ElEctronic Exhibits - American Roentgen Ray Society

Transcription

Electronic Exhibits
Room 312, Level 3
Hours:
Sunday, April 26: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1:00 pm - 7:00 pm
Monday-Wednesday, April 27-29: . . . . . . . . . . . . . . . . . . . 7:00 am - 10:00 pm
Thursday, April 30: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7:00 am - 4:15 pm
Exhibit Topics:
Breast Imaging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . pages 175-185
Cardiopulmonary Imaging.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . pages 185-207
Efficacy, Education, Administration and PACS. . . . . . . . . . . . . . . pages 207-213
General and Emergency Radiology . . . . . . . . . . . . . . . . . . . . . . . pages 213-222
Gastrointestinal/Liver/Biliary/Pancreas Imaging. . . . . . . . . . . . . pages 223-258
Genitourinary/OB/GYN Imaging. . . . . . . . . . . . . . . . . . . . . . . . . . pages 259-275
Musculoskeletal Imaging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . pages 275-309
Neuroradiology/Head and Neck. . . . . . . . . . . . . . . . . . . . . . . . . pages 309-332
Nuclear Medicine/Molecular Imaging. . . . . . . . . . . . . . . . . . . . . pages 333-339
Pediatric Imaging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . pages 339-344
Vascular and Interventional Radiology. . . . . . . . . . . . . . . . . . . . . pages 345-356
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Electronic Exhibits: Breast
Breast
E001. 64-Slice MDCT and 3D Image Postprocessing to Depict
Deep Inferior Epigastric Artery Perforators for the
Preoperative Planning of Breast Reconstructive Surgery
(CME Credit Available)
Mitsumori, L.; Warren, B.; Dighe, M.; Kolokythas, O.; Cuevas,
C.; Shuman, W.; Dubinsky, T. University of Washington, Seattle, WA
Address correspondence to L. Mitsumori ([email protected].
edu)
Background Information: Recently, MDCT angiography has
been applied for the preoperative planning of abdominal perforator flap breast reconstruction surgery. The newer generations of
CT platforms that can achieve near-isotropic voxel acquisitions
now permit the use of numerous 3D image postprocessing techniques to these data sets to best define the number and distribution of rectus perforating arteries. This information facilitates the
selection and resection of the best rectus flap, thereby reducing
operative time (average saving 100 minutes), and decreasing
postsurgical complications. The purpose of this abstract is to
describe our MDCT protocol for a 64-slice scanner; and illustrate the use of different 3D image postprocessing techniques to
depict the small perforating vessels for the surgeon.
Educational Goals/Teaching Points: All exams are done on a
64-slice scanner. Images are acquired from 4 cm above the
umbilicus to the lesser trochanters of the femurs. Studies are
acquired at 120 kVp, with auto-smart mA. Image timing is
achieved with a timing bolus monitored in the right external iliac
artery. Scan acquisition at timing bolus peak + 10 seconds. The
0.625 mm axial images are sent to an independent 3D workstation and a second axial image set is reconstructed at 2.5 mm for
viewing the abdominal/pelvic viscera and bones. For these
exams, a postprocessing protocol was defined that consists of:
axial and sagittal oblique maximum intensity projection reconstruction (MIP) images to define the course and measure the
size of the proximal superficial inferior epigastric arteries; axial
and sagittal oblique MIP images of the three dominant deep
inferior epigastric rectus perforating (DIEP) arteries on the right
and then left sides, and a volume rendered view of the skin surface of the anterior abdominal wall to depict the location of the
origins of each DIEP arteries in relation to the umbilicus.
Key Anatomic/Physiologic Issues and Imaging Findings/
Techniques: A 64-slice MDCT protocol is used to generate nearisotropic imaging data sets to allow 3D image postprocessing.
Image postprocessing permits creation of volume rendered, multiplanar reformations, and MIP reconstructions to depict the variability in the size, number and distribution of DIEP arteries.
Conclusion: Near-isotropic MDCT data sets are used with 3D
image postprocessing to create rendered images of the small
abdominal perforating arteries. This preoperative imaging shortens the operative time and reduces the number of complications
of this type of breast reconstructive surgery.
E002. Nonincidental and Incidental Disorders of the Breast:
CT Diagnosis
Katz, D.1; Rausch, D.2; Ring, B.3; Levin, G.4; Bergstrom, R.5;
Kranz, A.1; Fuchs, S.1 1. Winthrop-University Hospital, Mineola,
NY; 2. Mount Sinai Medical Center, New York, NY; 3. Memorial
Sloan Kettering Cancer Center, New York, NY; 4. Beth Israel
Medical Center, New York, NY; 5. Palo Alto Medical Foundation,
Palo Alto, CA
Address correspondence to D. Katz ([email protected])
Background Information: The purpose of this exhibit is to
review our experience with the identification of nonincidental
and incidental breast pathology at several institutions over the
past decade, on CT examinations of the chest and/or abdomen. Educational Goals/Teaching Points: We have diagnosed a
wide variety of benign and to a much lesser extent malignant
incidental breast pathology on CT of the abdomen and/or
chest. Representative examples of incidental and non-incidental
breast pathology will be shown, including calcifications, cysts,
masses, gynecomastia, asymmetric tissue, infection, implants,
trauma, skin lesions, and postsurgical/postradiation
change. Regionally advanced breast cancer will also be
shown. Selected cases of PET-CT will also be demonstrated
where incidental or nonincidental breast pathology was identified.
Techniques: CT cases will be demonstrated, along with mammographic correlation if appropriate. The relevant literature will be
briefly reviewed. Similarly, selected examples of incidental and
non-incidental breast pathology as demonstrated on PET-CT will
also be shown, with a brief review of the literature. The approach
to incidental breast pathology on CT will also be reviewed.
Conclusion: A wide variety of disorders of the breast may be
identified on CT of the chest and/or abdomen, whether intentionally or not, especially with MDCT and thin sections used for
routine imaging. Such findings can be missed if the radiologist
does not include the breasts in her/his search pattern. We have
seen numerous such cases and call this to the attention of all
radiologists interpreting body CT examinations. Less commonly,
CT may be specifically performed for breast evaluation. Similarly,
such findings may also be seen on PET-CT examinations performed intentionally for staging breast cancer or for other reasons.
E003. Radiologic, Cytologic and Histologic Correlation of
Ultrasound-Guided Fine Needle Aspiration Biopsies of the
Breast: Analysis of Discordant Cases (CME Credit Available)
Durand, A.1; Flowers, C.1; Ljung, B.1; Jensen, K.2; Wolverton, D.1;
Brenner, R.2 1. University of California, San Francisco, San
Francisco, CA; 2. No Institutional Affiliation
Address correspondence to A. Durand ([email protected])
Objective: Increased use of mammographic screening has resulted in improved detection of nonpalpable breast lesions, many of
which are initially sampled under ultrasound guidance. Using
cytological analysis, imaging and clinical findings (the “triple
test”), accurate diagnoses can be made provided concordance is
present between the diagnostic modalities. The purpose of this
study was to examine concordance rates between ultrasound
classification, cytologic rapid review, cytologic final diagnosis and
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histologic diagnosis on ultrasound-guided fine needle aspiration
(US FNA) from a large cancer center with on-site cytology support, and to critically review all discordant cases.
Materials and Methods: Consecutive US FNAs with histologic
follow-up from January, 1999 to June, 2006 were identified from
the radiology procedure log and the pathology database at the
University of California-San Francisco (UCSF) Comprehensive
Cancer Center (total of 298 cases). Imaging and pathology
reports were reviewed, summarized and entered into a database
for analysis. FNA and histologic slide material was examined
when necessary, and for all discordant cases.
Results: Concordance rates for rapid review (on-site immediate
evaluation) to final cytologic diagnosis and for cytologic to histologic diagnosis were very high (90% or greater).Concordance
rates between ultrasound impression and cytologic diagnosis
were highest for atypical and malignant lesions.
Conclusion: Ultrasound-guided fine needle aspirations with on-site
immediate cytologic evaluation show high concordance rates
between cytologic and histologic diagnoses. With expert on-site
immediate cytologic evaluation, initially non-diagnostic or discordant cases can be converted to core biopsy during the same procedure (22% of cases in this series) to avoid a delay in diagnosis. Use
of the “triple test” algorithm allows for accurate, rapid diagnosis.
E004. Underestimation of Ductal Carcinoma In Situ – Is
“Possible Invasion” More Predictive of Invasive Carcinoma
Than Pure Ductal Carcinoma In Situ?
Arazi-Kleinman, T.1,2; Causer, P.2; Nofech Mozes, S.2; Jong, R.2 1.
Sourasky Medical Center, Tel Aviv, Israel; 2. Sunnybrook Health
Science Centre, Toronto, Canada
Address correspondence to T. Arazi-Kleinman (t_arazikleinman@
yahoo.com)
Objective: The objective was to compare the likelihood of
underestimation of ductal carcinoma in situ (DCIS) vs. DCIS with
“possible invasion” at percutaneous breast biopsy.
Materials and Methods: Of 3,836 consecutive lesions that
underwent percutaneous biopsy, 132 lesions revealed DCIS without frank invasion. Subsequent resection pathology results were
retrospectively compared with needle biopsy results according to
a diagnosis of DCIS or DCIS with “possible invasion” on needle
biopsy and presence of invasive carcinoma on resection pathology. Fisher’s exact test was used to determine differences between
the groups.
Results: Of 132 lesions, 114 were DCIS vs. 18 DCIS with “possible invasion” at percutaneous biopsy. Thirty-nine of 132 lesions
(29.5%) revealed invasive cancer at subsequent resection pathology [32/114 (28%) DCIS and 7/18 (39%) DCIS with possible
invasion, p=0.5]. The likelihood of underestimation was higher
when DCIS with possible invasion was diagnosed compared with
DCIS when stereotactic biopsy using an automated 14 gauge
needle was performed [3/6 (50%) vs. 18/74 (24%), p=0.37] and
when <=6 samples were obtained [7/15 (47%) vs. 26/85 (31%),
p=0.26]. The likelihood of underestimation was also higher in
clinically vs. screen detected lesions [3/6 (50%) vs. 5/14 (35%)
respectively, p=0.55] for lesions yielding DCIS with “possible
invasion” on biopsy pathology. The likelihood of DCIS underesti-
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mation slightly increased using stereotactic guidance with an
automated 14 gauge needle compared with an 11 gauge vacuum-assisted device [18/74 (24%), vs. 1/7 (14%), p=0.86] and
when =<6 samples were obtained compared with >6 samples
[24/85 (28%) vs. 6/29 (21%), p=0.43]. The likelihood of DCIS
underestimation markedly increased using ultrasound guidance
with an automated 14 gauge needle, however there was no difference between lesions yielding DCIS (11/27, 41%) vs. DCIS
with “possible invasion” (4/10, 40%). Among the 114 lesions
that yielded pure DCIS, 49 (37%) yielded high grade DCIS, 50
(38%) yielded intermediate grade DCIS, 12 (9%) yielded low
grade DCIS and in three (2%) lesions DCIS grading was not
known. Underestimation occurred in 37% (18/49) for high grade
DCIS, 22% (11/50) for intermediate grade DCIS and 25% (3/12)
for low grade DCIS.
Conclusion: DCIS with “possible invasion” at percutaneous
breast biopsy is a stronger predictor of invasive disease at surgery
than the diagnosis of DCIS only. Given the higher risk of underestimation a sentinel node biopsy should be considered in this
subset of patients.
E005. Imaging Evaluation of Breast Implants: Complications
and Implant-Associated Pathology (CME Credit Available)
Tyler, E.; March, D.; Hansen, A.; Miller, V. Baystate Medical Center,
Springfield, MA
Address correspondence to E. Tyler ([email protected])
Background Information: Breast augmentation has been in
practice since the late 19th century. The first such procedure in
1895 involved the autologous transplant of a lipoma. Subsequent
techniques have included free injection of paraffin and silicone.
Silicone gel implants were first used in 1962. Since then, an estimated 1-2 million women have undergone silicone breast augmentation both for cosmesis and for reconstruction following
mastectomy. Saline implants gained popularity in 1992 when the
FDA temporarily restricted the use of silicone implants. Patients
with implants can provide a challenge in screening and diagnostic breast imaging due to implant related complications as well
as unrelated, concomitant breast disease. Implant complications
include rupture, capsular contracture, and herniation through the
fibrous capsule, migration, and peri-implant fluid collections. In
addition, implants may be affected by benign and malignant neoplasms. Hematologic and inflammatory conditions may also
involve breast implants and affect their imaging appearance.
Educational Goals/Teaching Points: The goals are to review
the imaging appearance of different types of implants and their
potential complications; review the imaging appearance of other
pathologic entities that may affect breast implants; and describe
how the use of different imaging modalities may narrow the differential diagnosis of implant-related breast pathology and contribute to patient management.
Techniques: Imaging modalities will include mammography,
sonography, and MRI. The different types of implants will be discussed and examples provided. The imaging findings of intraand extracapsular implant rupture and other complications, along
with potential diagnostic pitfalls will be reviewed. Pathologic entities that can affect breast implants, other than those related to
implant complications, will also be reviewed and discussed.
Examples will be provided of both benign and malignant breast
lesions. Strategies for imaging these patients will be provided.
artifact is of little consequence or representative of a major problem that may require input from service and/or engineering staff.
Conclusion: Familiarity with the imaging appearance of breast
implants, their associated complications, and the appearance of
concurrent breast disease are important elements of breast imaging, and will aid in accurate diagnosis.
Techniques: In this exhibit, artifacts will be classified as due to
patient factors, gantry factors, and/or detector factors, including
lag, ghosting, pixel drop out, excessive noise, and gray scale
inversion. Examples of common artifacts will be presented along
with descriptions of the artifacts, their causes, and their remedies.
E006. Spectrum of Disease in the Male Breast (CME Credit
Available)
Iuanow, E.1; Fein-Zachary, V.1; Mehta, T.1; Kettler, M.2; Slanetz,
P.1 1. Beth Israel Deaconess Medical Center, Boston, MA; 2.
Oregon Health and Science University, Portland, OR
Address correspondence to P. Slanetz ([email protected])
Conclusion: Artifacts identified on selenium-based digital mammography may be due to patient factors, gantry factors, and/or
detector factors. Understanding artifacts is an important component of maintaining high image quality.
Background Information: Although pathology within the male
breast is less commonly encountered compared to the female
breast, an understanding of various conditions affecting the male
breast remains essential to the practice of breast imaging. Using
mammography, ultrasound, and/or magnetic resonance imaging,
the imaging findings of various diseases and conditions affecting
the male breast will be reviewed. These conditions will include
breast cancer, gynecomastia, epidermoid inclusion cysts, metastatic disease, and other rare benign tumors such as glomus
tumors, inflammatory pseudotumor, and rhabdomyosarcoma.
The pathophysiology and management of these conditions will
also be discussed.
E008. Relationship Between the Age, Breast Density on
Digital Mammography and the Risk of Breast Cancer and
Benign Lesions in Chinese Women
Du, T.; Wang, Y.; Zhang, C.; Yu, S.; Yan, Y.; Wang, X.; Zhang, W.;
Zhang, Y. Fuxing Hospital Affiliated to Capital University of
Medical Sciences, Beijing, China
Address correspondence to T. Du ([email protected])
Educational Goals/Teaching Points: The purpose of this exhibit
is to review the anatomy of the male breast; and describe imaging findings of a variety of diseases that affect the male breast.
Materials and Methods: The mammographic images of 1,621
subjects were independently interpreted by two experienced
radiologists. Sixty-two patients with breast cancer among the
total group were proved by surgical histopathology and 192
cases with benign breast lesion have the evidence of pathology
or other imaging methods including MR and ultrasound (US).
According to their age, all subjects were divided into five groups,
including <30, 31-40, 41-50, 51-60 and >61 years. All mammograms were measured using the semiquantitative planimetry by
drawing regions of interest to obtain the percentage of fibroglandular tissue occupying the total area of the breast. According to
the percentage of mammographic density, they were divided into
four groups, including <25%, 25-50%, 51-75% and >75%.
Techniques: This exhibit will review mammographic, ultrasonographic, and MRI of male breast disease and correlate it with
pathophysiology.
Conclusion: Radiologists will better understand the imaging findings and the underlying pathophysiology of various diseases and
conditions affecting the male breast.
E007. Digital Mammography Artifacts: What the Radiologist
Needs to Know (CME Credit Available)
Geiser, W.; Stephens, T.; Santiago, L.; Haygood, T.; Whitman, G.
The University of Texas M. D. Anderson Cancer Center, Houston, TX
Address correspondence to G. Whitman ([email protected])
Background Information: The purpose of this educational
exhibit is to demonstrate common artifacts encountered in selenium-based digital mammography. As the number of digital
mammography units continues to increase, it is important that
radiologists be able to recognize common artifacts and understand the causes of the artifacts.
Educational Goals/Teaching Points: The educational goals of
this exhibit are to categorize digital mammographic artifacts as
patient-related, gantry-related, and/or detector-related. The radiologist should become familiar with the causes of common digital mammography artifacts. In addition, the radiologist should
gain familiarity in troubleshooting and understand whether the
Objective: The purpose of this study was to establish whether a
correlation exists between the factors including age, the percentage of mammographic density and the risk of breast cancers and
benign lesions in Chinese women.
Results: A statistically significant difference was seen in mammographic density among various age groups. Mammographic density decreased with increasing age. The difference of breast density between the two groups of 41-50 years and 51-60 years was
most significant (Z=-11.7, p<0.001). The detection rate of 62
breast cancers in the five age groups from youngest to oldest
was 2.1%, 1.1%, 3.3%, 4.3% and 10.9%, respectively. In 62
breast cancers the proportion of patients in four mammographic
density groups from low to high density was 17.7%, 16.1%, 21%
and 45.2% respectively. Multinomial logistic regressive analysis
displayed that the detection rate of breast cancer trends increase
with age (Wald chi-square value=40.9, p<0.001) and breast density (Wald chi-square value=17.6, p<0.001). The detection rate of
breast cancer was three times more in the older age group compared with the younger age group (OR value=3) and 1.9 times
more in the higher breast density group compared with the
lower density group (OR value=1.9). The detection rate of breast
benign lesions increased with increasing age, but the mammographic density had no correlation with the detection rate of
benign breast lesions.
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Conclusion: Age and mammographic density are important risk
factors of breast cancer in Chinese women. The effect of age on
risk of breast cancer is more significant than that of breast density. The relationship between the mammographic density and the
risk of breast cancer is more predominant in postmenopausal
older women.
E009. Does Isolated Flat Epithelial Atypia on VacuumAssisted Breast Core Biopsy Require Surgical Excision?
Dialani, V.; Venkataraman, S.; Fein-Zachary, V.; Littlehale,
N.; Mehta, T. Beth Israel Deaconess Hospital, Brookline, MA
Address correspondence to V. Dialani ([email protected].
edu)
Objective: The objective was to determine if surgical excision is
warranted when flat epithelial atypia is diagnosed in isolation of
other atypia on breast core biopsy.
Materials and Methods: Using an IRB approved protocol, a retrospective analysis was performed on all patients referred to our
department for a breast stereotactic core biopsy from January,
2005 through December, 2007. All biopsies performed were for
calcifications. An 11 or eight gauge vacuum-assisted device was
used. Pathology reports were reviewed and only patients with
isolated flat epithelial atypia on core biopsy were included in our
study population. Any cases with associated ductal carcinoma in
situ, atypical ductal or lobular hyperplasia, or lobular carcinoma
in situ on core biopsy were excluded. Surgical pathology of the
study population was reviewed when available, to assess for
association with worse pathology on excision.
Results: There were 264 stereotactic core biopsies performed
during our study period. Of these, 16 (6%) had isolated flat epithelial atypia on pathology. Pathology from surgical excision was
available for 12 of the 16 (12/16; 75%). None of the 12 (0/12;
0%) had change in diagnosis to carcinoma. A change in diagnosis to atypia was noted in three patients (3/12; 25%; one atypical ductal hyperplasia and two atypical lobular hyperplasia), who
also had a change in management and were started on hormonal therapy. Of the remaining nine, six (6/12; 75 %) had calcifications associated with benign breast tissue and three had more
flat epithelial atypia on excision. Of the four patients without
available surgical excision pathology, two were lost to follow up
and two declined surgery and had stable mammographic findings on follow up (one for six months and one for 18 months).
Conclusion: Data from our small series suggests that if isolated
flat epithelial atypia is found on core biopsy, surgical excision
should be performed, since management changes. Though none
of our cases were upgraded to carcinoma, 25% (3/12) had a
change in diagnosis to atypia with change in management. In a
small subset if hormonal therapy is not contemplated or contraindicated a close mammographic follow-up could be considered.
E010. Percutaneously Diagnosed Benign Papillary Lesions of
the Breast: Pathological Upgrade Frequency at Subsequent
Surgical Excision (CME Credit Available)
Chetlen, A.; Schetter, S.; Van Hook, D.; Han, B. Penn State Milton
S. Hershey Medical Center, Hershey, PA
Address correspondence to A. Chetlen ([email protected])
Objective: The purpose of this research was to evaluate the
pathologic upgrade frequency of benign papillary lesions of the
breast discovered on stereotactic or ultrasound-guided core biopsy that proceeded to excisional biopsy and to evaluate the clinical stability of nonexcised lesions with long-term radiological follow-up.
Materials and Methods: A retrospective review was undertaken
of 37 ultrasound-guided large core breast biopsies or stereotactic
core breast biopsies performed in the last nine years (September,
1999-September, 2008) at our institution which yielded a diagnosis of intraductal papilloma or papillomatosis. Surgical pathologic follow-up was available in 28 cases and at least 24 months
mammographic follow-up was available in the remaining nine
cases. Office notes, radiologic imaging studies, and histologic
results were reviewed.
Results: The 28 cases of either intraductal papilloma or papillomatosis which proceeded to excisional biopsy or mastectomy
revealed a benign diagnosis in 24 (85.7%) cases, atypical ductal
hyperplasia in three cases (10.7%), and ductal carcinoma in situ/
atypical ductal hyperplasia/lobular carcinoma in situ in one case
(3.6%). No invasive carcinoma was found. The remaining nine
cases with initial diagnosis of intraductal papilloma or papillomatosis which had a minimum of 24 months mammographic follow-up were assigned BIRADS category I or II on all subsequent
mammograms.
Conclusion: In our study of percutaneously diagnosed intraductal papillomas or papillomatosis, surgery revealed associated high
risk lesions in 14% of cases and no invasive carcinomas. Our
patients without surgical excision who underwent only mammographic follow-up remained asymptomatic and had subsequent
BIRADS category I or II mammograms. However, due to the association with high risk lesions, surgical excision of benign papillary
lesions may be warranted.
E011. Effectiveness of Screening Women at High Risk for
Breast Cancer with Alternating Mammography and MRI
Le-Petross, H.; Atchley, D.; Whitman, G.; Hortobagyi, G.; Arun, B.
University of Texas M.D. Anderson Cancer Center, Houston, TX
Address correspondence to H. Le-Petross (huong.le-petross@di.
mdacc.tmc.edu)
Objective: MRI has been found to be more sensitive than mammography (M) in the detection of breast cancer (BC), and has
been introduced as an adjunct to an annual screening mammogram and clinical examination (CE) in women at high risk for
developing BC. We investigated the efficacy of alternating screening M with MRI every six months in women at high risk for developing BC.
Materials and Methods: A retrospective chart review was performed on 334 patients from the high risk clinic at one institu-
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tion, from 1997 to 2007. Patients with increased risk for BC and
had an MRI were included in this study. Women with hereditary
breast and ovarian cancer syndrome, personal breast cancer history, a biopsy of atypia or lobular carcinoma in situ (LCIS), or a
20% or higher lifetime risk of developing BC by the Gail model
were included. M, ultrasound (US), MRI findings, and biopsy
results were reviewed.
disorders which increase lifetime risk of breast cancer. There is
insufficient evidence currently regarding screening in women with
heterogeneously dense or very dense breasts. Here we present a
series of cases where mammographically occult malignancies
were discovered only through breast MR imaging. We will review
the indications for breast MRI and the kinetic curves and morphology of malignant vs. benign breast masses found on MRI. Results: Eighty-six of 334 (26 %) patients underwent annual
screening M and MRI, with M and MRI alternating every six
months. The remaining 248 patients underwent prophylactic
mastectomies or were treated with chemoprevention. CE was
performed every six months. A total of 47% of 86 patients completed the first round of MRI surveillance, 32% completed the
second round, 15% completed the third round, and 6% completed the fourth round. Of 86 patients who underwent MRI screening, 70 had BRCA mutations, and 16 had a history of BC, a biopsy
of atypia or LCIS, or a 20% or higher lifetime risk of developing
BC. The median follow-up period was two years (range, one to
four years). Nine cancers (six invasive ductal, one invasive lobular,
and two ductal carcinoma in situ [DCIS]) were detected in seven
of 86 (8.1%). Two women had bilateral cancers. Among the nine
cancers, four (44%) were identified by MRI but not by M, four
(44%) were identified by both M and MRI, and one (11%) was
not identified by M or MRI. No cancer was seen by M only. Of the
nine tumors, eight cancers were detected by MRI (sensitivity of
89%). One cancer was identified by mastectomy only (1 mm
focus of DCIS). In four of the eight MRI detected-cancers, M performed six months earlier was normal or demonstrated benign
findings. The mean size of the cancers was 10.4 mm (range, 1 to
25 mm). Metastatic ipsilateral axillary adenopathy was seen
in three of the nine cancer cases.
Educational Goals/Teaching Points: The teaching points will
include: indications for breast MRI as indicated by the recent literature; kinetic curves of malignant vs. benign breast masses on
MRI, and morphologic appearance of suspicious enhancing
lesions on MRI.
Conclusion: In women at high risk for developing BC, alternating
M and MRI at six month intervals demonstrated that no cancers
were detected by M only. Future prospective studies should be
performed to evaluate screening with annual M and MRI, alternating at six month intervals, vs. annual MRI alone.
E012. MRI Detected Breast Cancers with False Negative
Mammograms
Merchant, K.; Masuda, E.; Fundaro, G.; Beydoun, N. Henry Ford
Hospital, Detroit, MI
Address correspondence to E. Masuda ([email protected])
Background Information: Mammography is the standard of
care for detecting breast cancer with annual screening beginning
in women at age 40. However, 10% of malignancies are mammographically occult and are only found clinically. Evaluation for
breast cancer on mammography, in particular, is limited by the
density of the fibroglandular tissue. Contrast-enhanced MRI has
been shown to have high sensitivity for detecting breast cancer
with its excellent soft tissue contrast, as well as uptake and washout characteristics with gadolinium contrast-enhanced breast MRI.
Mammographically occult lesions seen by MRI have been reported in 27 to 37% of patients. Sensitivity for MRI for breast cancer
ranges from 88 to 95% in larger single center studies. There are
various indications for breast MRI including evaluation of known
breast cancer, and as screening for patients with a BRCA gene
mutation, a 20 to 25% or greater lifetime risk of breast cancer as
defined by the BRCAPRO or BOADICEA model, history of chest
irradiation between ages 10 to 30 years, and certain hereditary
Techniques: The exhibit will cover strengths and weaknesses of
mammography vs. breast MRI; indication for breast MRI imaging,
and enhancement kinetics and morphology of breast malignancies.
Conclusion: Detecting breast cancer on mammography may be
difficult in certain cases. MRI as an adjunct to mammography has
been shown to be valuable in the evaluation of breast cancer, as
some breast malignancies are only detected on MR imaging.
Understanding current indications for breast MRI, characteristics
of suspicious lesions on MRI, and the limitations of imaging with
breast MRI are vital for cancer detection.
E013. Mammary Fibromatosis (CME Credit Available)
Conners, A.; Glazebrook, K.; Reynolds, C.; Boughey, J. Mayo Clinic,
Rochester, MN
Address correspondence to K. Glazebrook (glazebrook.katrina@
mayo.edu)
Background Information: Mammary fibromatosis is a rare,
benign stromal tumor of the breast, comprising less than 0.2% of
all breast tumors. Although benign, this tumor is locally aggressive and may recur in up to 29% of cases. It presents clinically as
a palpable mass, suspicious for malignancy. Dimpling or retraction of the skin may be present and the mass may be adherent
to the chest wall. Mammary fibromatosis may occur sporadically
but also may occur after trauma or a previous surgical procedure,
such as breast reduction or breast augmentation with saline or
silicone implants. It is may also be associated with familial adenomatosis polyposis syndrome. This exhibit illustrates the imaging findings and the clinical presentation, with pathologic correlation, of mammary fibromatosis.
Educational Goals/Teaching Points: The educational goal of
this exhibit is to describe the imaging findings and clinical presentation, with pathologic correlation, of mammary fibromatosis.
Techniques: Mammographically, mammary fibromatosis may
present as a spiculated mass that is suspicious for malignancy
BIRADS 5. On sonography, fibromatosis appears as a solid, spiculated, irregular hypoechoic mass that is highly suspicious for
malignancy (BIRADS 5). Involvement of the pectoralis muscle or
intercostal muscles may be identified. MRI is the best imaging
technique for evaluating tumor extent and, in particular, chest
wall involvement. The masses are typically irregular and are isointense to muscle on T1-weighted images and of variable high-signal intensity on T2-weighted images. After treatment, areas of
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decreased T1 and T2 signal intensity develop, suggesting
decreased cellularity and increased dense fibrosis. The enhancement pattern is generally one of a benign progressive enhancement, as opposed to the typical wash-out kinetics of breast carcinoma.
Conclusion: Mammary fibromatosis is a rare, benign, nonmetastasizing stromal tumor. It is locally aggressive with infiltrative margins and has a high recurrence rate. Clinically and on imaging, it
mimics malignancy. MRI is helpful for determining tumor extent
and chest wall invasion. The histopathologic differential diagnosis
is broad and ranges from reactive processes to malignant ones.
Complete surgical excision is the treatment of choice.
E014. Pearls and Pitfalls in MRI-Guided Breast Biopsy
Ojeda-Fournier, H.; Comstock, C.; Middleton, M. University of
California, San Diego, San Diego, CA
Address correspondence to H. Ojeda-Fournier (ojeda-lowy@
sbcglobal.net)
Background Information: Contrast-enhanced breast MRI finds
lesions not visible by other modalities. The ability to perform MR
intervention is essential for any facility that performs high quality
contrast-enhanced breast MR. In summary, the technique, procedure, pitfalls and pearls are illustrated in this educational exhibit.
Educational Goals/Teaching Points: This exhibit will discuss
the indications for MR guided interventional procedures; illustrate
how to perform MR-guided intervention with photographs, diagrams and short cine clips and review pearls and pitfalls associated with MR-guided breast intervention.
Techniques: The exhibit will describe MRI-guided vacuum-assisted core biopsy and needle localization techniques of lesions
found at contrast-enhanced dynamic MRI of the breast, and not
seen by mammography, ultrasound, or clinical evident.
Conclusion: Contrast-enhanced breast MRI finds lesions not visible by other modalities. The ability to perform MR intervention is
essential for any facility that performs high quality contrast-enhanced breast MR. In summary, the technique, procedure, pitfalls
and pearls are illustrated in this educational exhibit.
E015. Review of Probably Benign Lesions Detected at Breast
MRI (CME Credit Available)
Mango, V.; Mercado, C.; Lee, J.; Toth, H.; Moy, L. New York
University, New York, NY
Address correspondence to V. Mango (victoria.mango@gmail.
com)
Background Information: BIRADS 3 “probably benign” imaging
characteristics for mammography are well defined and reflect an
expected cancer yield of < 2%. Specific imaging features for MRI
detected lesions placed in this category are not clearly defined.
The ACR describes MR BIRADS 3 lesions as having a “very high
probability of being benign” and states most approaches to this
category are currently “intuitive”. Our objectives are to identify
lesions classified as “probably benign” on MRI, review the followup compliance and frequency of subsequent malignancy.
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Educational Goals/Teaching Points: This exhibit will review the
MRI features that lead to the classification of a lesion as “probably benign”, and review how frequently this classification is utilized. In the literature, the frequency of “probably benign” interpretations range from 6.6 to 24% of MR exams receiving at least
one recommendation for a six-month follow-up MR. It will also
review follow-up recommendations and patient compliance
rates. Follow-up recommendations include MR in six months or
mammography or targeted ultrasound with short-term follow-up
MR if the lesion is sonographically occult. Compliance is variable,
ranging from 63 to 86% of patients returning for follow-up MR. It
will review outcome of follow-up imaging, including review if the
findings were downgraded to a BIRADS 1 or 2 based on resolution or stability of MR findings, unchanged as BIRADS 3 or
upgraded to a BIRADS 4 with biopsy recommended, and it will
identify the cancer yield in lesions initially assessed as BIRADS
3.The cancer yield exhibits ranges from 0.6-10%, with the highest
cancer yield in high-risk women. The pathology of these cancers
includes ductal carcinoma in situ (DCIS) and infiltrating ductal
carcinoma.
Techniques: This exhibit will review the literature to determine
the morphologic and kinetic features of lesions that were classified as “probably benign”. Specific features include: solitary vs.
multiple lesions, mass vs. non-mass lesions, margin characteristics, internal enhancement patterns, and time-signal intensity
curves. It will identify which features were most frequently seen
with true benign lesions and those associated with a malignancy.
Conclusion: A “probably benign” interpretation is assigned to 6.6
to 24% of breast MR exams with 63 to 86% of patients returning
for follow-up MR. The cancer yield ranges from 0.6-10%.
Evidenced-based criteria for “probably benign” lesions on breast
MRI needs to be established to decrease the chance of a falsenegative lesion being assigned a MR BIRADS 3 classification.
E016. MRI-Guided Breast Procedures in Less than 45
Minutes: Practical Tips and Tools for Troubleshooting
Chhor, C.; Chang, B.; Tso, H.; Proctor, E.; Hylton, N.; Joe, B.
University of California, San Francisco, San Francisco, CA
Address correspondence to B. Chang ([email protected])
Background Information: Increasing numbers of breast MRI
studies are being performed for screening of high risk women
and pre-operative evaluation of extent of disease. Given the limited specificity of breast MRI, this has led to an increased number
of breast procedures, which include wire-localization and biopsies. Efficient, safe, and accurate methods of performing MRIguided breast procedures of lesions not visible by mammography
or second-look ultrasound are needed. The purpose of this
exhibit is to describe efficient techniques for performing MRIguided breast procedures, particularly when there are multiple
sites or bilateral breasts are involved. Practical tips for troubleshooting problems with imaging or biopsy equipment will be
presented with case examples.
Educational Goals/Teaching Points: We will review indications
for MRI-guided breast procedures and how to perform MRIguided breast procedures utilizing various methods, needle
devices, and targeting software. In addition we will suggested
workflow for a safe, efficient, and successful procedure; and how
to troubleshoot common imaging pitfalls including: a) fat-saturation problems with water-saturation of breast tissue; b) what to
do when your targeting software fails, when grid obstructs needle placement, and if lesion is outside of grid; and c) how to
sequence procedures involving different means of guidance, such
as MRI, mammographic, and ultrasound, required in the same
patient.
Techniques: We will illustrate safe, efficient, and accurate techniques for performing MRI-guided breast procedures with the following case examples: 1) biopsy at three different sites in the
same breast (performed under 60 minutes); 2) positioning tricks
to reach far posterior breast lesions; 3) wire localization of
lesions outside of the grid; 4) fat-saturation failure with watersaturation of breast tissue (presentation of troubleshooting tips
and resultant improved images); 5) targeting lesions when software fails; and 6) sequencing of procedures when MRI, US and
mammographic guidance is required in the same patient.
Conclusion: MRI-guided breast procedures are an important
adjunct to the diagnosis and management of breast cancer. They
can be performed efficiently, safely, and accurately using techniques presented here.
E017. Optimal Timing of Breast MRI Examinations for
Premenopausal Women Who Do Not Have a Normal
Menstrual Cycle
Ellis, R. Gundersen Lutheran Medical Center, La Crosse, WI
Address correspondence to R. Ellis ([email protected])
Objective: The purpose of the study was to determine whether
our practice of using serum progesterone concentrations corresponding to the follicular phase of the menstrual cycle to time
breast MRI examinations in premenopausal women without
cyclical menses reduced the number of nondiagnostic and falsepositive results. Delille et al. found that performing scans during
the follicular phase of the menstrual cycle (days 3-14 of a normal
28-day menstrual cycle) minimized uptake of gadolinium in normal breast tissue that can render dynamic breast MRI examinations difficult to interpret, resulting in significant numbers of
false-positive results or in nondiagnostic examinations. Women
lacking a normal cyclical menses upon which to base optimal
timing of MRI examinations include, (a) premenopausal women
who have undergone a hysterectomy but retain normally functioning ovaries; (b) premenopausal women with induced irregular menstrual cycle due to oral or injectable contraceptives; (c)
premenopausal women undergoing chemotherapy with induced
perimenopausal status; and (d) perimenopausal women with
irregular menstrual cycles.
Materials and Methods: We conducted a retrospective, singleinstitution review of our center for breast care database to identify all patients who had breast MRI scans between February 5,
2006 (the date we first used progesterone concentrations to time
breast MRI scans in premenopausal women without cyclical
menses) and July 16, 2008. We further identified those patients
for whom serum progesterone concentrations had been obtained
and used to time the breast MRI examination. All the breast MRI
examinations were performed using a 1.5T scanner and software
(Siemens Medical Solutions, Erlangen, Germany) Scanning
sequences included pre- and postcontrast-enhanced (0.1 mmol
gadobenate dimeglumine/kg) 3D axial gradient-recalled echo
dynamic examinations.
Results: Serum progesterone concentration of < 1.5 ng/mL was
used to define the follicular phase of the menstrual cycle and
appropriately time the breast MRI examination for all 11 premenopausal women without cyclical menses. None of the women
required a repeat examination because of disproportionate
enhancement of normal glandular tissue.
Conclusion: Serum concentrations of progesterone corresponding to the follicular phase of a normal menstrual cycle can aid in
optimal scheduling of breast MRI examinations for premenopausal women who do not have a normal menstrual cycle.
E018. Preoperative Breast MRI for Prediction of Occult
Invasive Disease (CME Credit Available)
Jakubowski Wisner, D.; Chang, B.; Flowers, C.; Joe, B.; Lessing, J.;
Gibbs, J.; Itakura, K.; Hwang, S.; Hylton, N. University of California,
San Francisco, San Francisco, CA
Address correspondence to D. Jakubowski Wisner ([email protected])
Objective: The objective was to assess utility of preoperative MRI
for evaluation of occult invasive disease in women with an initial
core-biopsy diagnosis of ductal carcinoma in situ (DCIS).
Materials and Methods: A comprehensive search of University
of California-San Francisco pathology and radiology archives
spanning 2000-2007 was performed in order to identify all
women with a core biopsy revealing pure DCIS, who also
obtained preoperative MRI prior to surgery at UCSF. Neoadjuvant
therapies were excluded. Patients with a biopsy diagnosis of
microinvasive disease, history of ipsilateral invasive cancer in the
past two years, or recent (within six months) ipsilateral breast
surgery were also excluded. In order to avoid the possibility of
disease progression, inclusion required that final surgery occur
within six months of the core biopsy. A breast MRI-trained radiologist blinded to the surgical results was given the location of the
primary lesion as marked by biopsy clip or estimated biopsy location, and asked to categorize the lesion. Radiologist prediction of
invasive disease was compared to surgical pathology.
Results: To date, 36 MRI studies have been evaluated. In this
study group, 58% (21) proceeded to lumpectomy and 42% (15)
proceeded to mastectomy. Of the original 36 cases initially diagnosed as DCIS, nine (25%) were found to have invasive disease
and three patients (8%) had no remaining disease at surgery. In
the remaining 24 cases, 13 (36% of total population) were found
to have intermediate-high or high grade DCIS and 11 (31% of
the total population) had low to intermediate grade DCIS. When
asked to rate probability of invasive disease on the preoperative
MRI, the reader categorized 17 cases (47%) as “no invasive cancer,” 16 of which were accurately categorized and one of which
contained a 2 mm invasive ductal carcinoma. All other cases of
invasive disease were captured within “possible” (five) or “probable” (three) categories. Radiologist sensitivity for invasive disease
was 89% (CI: 52-100%), specificity 59% (38-78%), positive predictive value 42% (20-66%), and negative predictive value 94%
(71-100%).
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Conclusion: Initial results suggest radiologist prediction is sensitive for presence of occult invasive disease, although specificity is
poor. As negative predictive value is high (94%), a negative preoperative MRI may be very helpful for stratifying patients into low
and high risk groups for occult invasive disease, ultimately assisting the decision of whether to proceed to sentinel lymph node
biopsy.
E019. Fat Suppression for Breast MRI Improves by Fast 3D
Dual Echo Dixon Technique (CME Credit Available)
Le-Petross, H.; Kundra, V.; Szklaruk, J.; Wei, W.; Andreopoulou, E.;
Ma, J. University of Texas M.D. Anderson Cancer Center, Houston,
TX
Address correspondence to H. Le-Petross (huong.le-petross@di.
mdacc.tmc.edu)
Objective: MRI is becoming an important imaging modality in
the detection and diagnosis of breast diseases. The fat suppression quality of the imaging sequences used in a breast MRI exam
(bMRI) is essential to allow differentiation of enhancing lesions
from the background fatty tissue. The purpose of our study is to
compare the images of the contrast-enhanced dual echo Dixon
(cDixon) technique with the standard 3D spoiled gradient echo
technique or volume imaging for breast assessment (VIBRANT),
commonly used for breast MRI.
Materials and Methods: The institutional review board
approved this Health Insurance Portability and Accountability Actcompliant study. Informed consent was obtained from all
patients. The VIBRANT and the cDixon techniques were performed of both breasts, after IV gadolinium-enhanced dynamic
series of a standard bMRI exam. Three radiologists independently
reviewed the deidentified images. The radiologists rated the
image quality in five categories (scale: 1 poor, 2 fair, 3 good, 4
excellent): quality of the fat saturation, the uniformity of fat saturation, the visibility of the index lesion, the margin clarity of the
index lesion, and the visibility of the axillary region. For quantitative assessment, the signal-to-noise ratio (SNR), contrast-to-noise
ratio (CNR) of lesion to breast, SNR efficiency (SNReff), and CNR
efficiency (CNReff) were calculated.
Results: Nineteen patients agreed to participate in this study;
13/19 patients had a primary breast malignancy (11 invasive carcinoma and two ductal carcinoma in situ) and 6/19 patients had
benign lesions or negative exams. The Dixon images were rated
higher in four of the five qualitative categories: quality of fat saturation, uniformity of fat saturation, margin clarity of index lesion,
and visibility of the axilla (p<0.0001). The cDixon images yielded
significant higher SNR (43.8) and CNR (40.1), compared to the
VIBRANT images (SNR=34.8, CNR=25.3), p<0.05. The SNR and
CNR efficiency for the cDixon (SNR=36.3, CNR=33.79) were also
higher than the VIBRANT (SNR eff=25.7, CNR eff=19.1), p<0.05.
Furthermore, the Dixon technique required shorter scan time to
achieve these improvements.
Conclusion: The images of the Dixon technique were superior to
the standard VIBRANT technique in both qualitative and quantitative assessment of 19 breast MRI cases. The Dixon technique
could replace the standard VIBRANT technique, for improved
contrast-enhanced breast MRI, in future studies with larger sample size.
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E020. Ultrasound of the Pregnant and Immediate
Postpregnant Breast: Frequent and Less Common
Conditions (CME Credit Available)
Majewski, S.; O’Connell, A. University of Rochester Medical Center,
Rochester, NY
Address correspondence to S. Majewski (Sara_Majewski@urmc.
rochester.edu)
Background Information: Normal breast findings in pregnancy
and postpregnancy are secondary to hormonal stimulation. The
majority of entities affecting the breasts at these times are similar
to those in the nonpregnant state. Several findings are only seen
in the pregnant, postpregnant and lactating states. Ultrasound is
the best modality for evaluating the breast in pregnancy and
postpregnancy.
Educational Goals/Teaching Points: The exhibit will describe
ultrasound findings exclusive to pregnant and postpregnant
patients, including galactocele, cellulitis, mastitis, abscess and lactating adenoma; describe ultrasound findings of other abnormalities common in pregnancy such as fibroadenoma, pseudoangiomatous stromal hyperplasia (PASH) and diabetic mastopathy,
and emphasize the awareness of carcinoma which, although rare,
is the most devastating diagnosis to be made in pregnancy.
Techniques: The viewer of the exhibit will be learn the normal
anatomy of the breast, be able to describe the physiologic changes occurring in the pregnant and postpregnant breast and learn
advantages and disadvantages of ultrasound in imaging the pregnant and postpregnant breast compared to other modalities.
Conclusion: The pregnant and postpregnant breast presents with
both unique findings, as well as common entities seen in all
women, which are best imaged by ultrasound.
E021. Mixed Echogenicity Breast Masses: A Pictorial Review
of Imaging Findings with Pathologic Correlation (CME
Credit Available)
Guelfguat, M.; Hazany, S.; Wrzolek, M.; Buchbinder , S. Staten
Island University Hospital, Staten Island, NY
Address correspondence to S. Hazany ([email protected])
Background Information: Ultrasound is an established modality
employed for characterization of breast masses.
Educational Goals/Teaching Points: In this educational exhibit
we hope to: 1. illustrate sonographic features of different benign
and malignant mixed echogenicity breast lesions; 2. review imaging features and histopathologic correlation of several common
and rare mixed echogenicity breast masses, and 3. emphasize
diagnostic difficulties, potential pitfalls, and differential diagnoses
of these entities.
Techniques: Sonographic features of mixed echogenicity breast
lesions will be reviewed and correlated with mammographic
appearance and pathologic characteristics of various cancers, such
as metaplastic carcinoma, tubular carcinoma, metastatic cancer to
the breast, phylloides tumor, granular cell tumor, tubular adenoma, nodular lobular hyperplasia, complex sclerosing papillary
lesion, lipoma, epidermal inclusion cyst, sclerosing adenosis, fibro-
sis, fat necrosis, proteinaceous cyst, pseudoangiomatous stromal
hyperplasia (PASH), epidermal inclusion cyst, fibroadenoma.
Conclusion: The main teaching point of this exhibit is to provide
a pictorial review of diverse pathologic entities, benign and
malignant, appearing as mixed echogenicity breast lesions. The
exhibit will discuss specific imaging and pathologic characteristics
of several rare and common mixed echogenicity breast masses.
Familiarity with mixed echogenicity breast lesions aids in the formulation of complete differential diagnosis. Appropriate biopsy
strategies will be discussed.
E022. Preoperative Axillary Ultrasound and Biopsy in the
Evaluation of Women Diagnosed with Breast Cancer
Larsen, L.1; Kuo, J.1; Bickell, K.1; Soetaert, A.1; Fraley, J.1;
Andrews-Tang, D.2; Yamashita, M.1; 1. University of Southern
California School of Medicine, La Canada, CA; 2. Olive ViewUniversity of California-Los Angeles Medical Center, Sylmar, CA
Address correspondence to L. Larsen ([email protected])
Background Information: Axillary lymph node status is the single most important prognostic factor in women with invasive
breast cancer. Currently, the standard of reference for evaluating
the axilla is axillary lymph node dissection (ALND). However,
since this procedure can cause many postoperative problems,
ALND has largely been replaced by sentinel lymph node biopsy
(SNB) in clinically-determined node-negative women. More
recently, ultrasound (US) has been used as a noninvasive method for evaluating the axilla and has been successful in predicting
nodal status. Ultrasound-guided biopsy (UGB) is often performed
when a suspicious lymph node is identified. Women who have a
positive UGB will directly undergo an ALND without SNB, avoiding the additional cost and time of SNB.
This study is a retrospective review of 270 women diagnosed
with invasive breast cancer at our centers from January, 2006
to October, 2008. Our goal is to assess the accuracy of ultrasound in predicting nodal status in these women in order to
improve detection and decrease the number of operative procedures required for staging. Each woman had a preoperative axillary ultrasound and biopsy if the lymph node was suspicious. The
nodal status assessed by ultrasound with or without biopsy is
compared with final pathology results. Sonographic parameters
for each lymph node being evaluated include shape, hilar and
cortical morphology, vascularity, and dimensions (longitudinal,
transverse, and hilar diameters). We will determine the sonographic features that best correlate with metastatic lymph nodes
and describe the percutaneous biopsy techniques most accurate
for diagnosis.
Educational Goals/Teaching Points: In this educational exhibit,
we will compare the results of preoperative axillary ultrasound
and biopsy with final pathology in women diagnosed with breast
cancer. The sonographic features of benign and malignant axillary
lymph nodes will be described. We will discuss the different
biopsy techniques used for staging the axilla.
Techniques: We will correlate the preoperative axillary ultrasound findings with the pathology results in women with breast
cancer. We will determine which sonographic paraments correlate best with metastatic axillary lymph nodes.
Conclusion: Our goal is to demonstrate a decrease in the
number of sentinel node biopsies due to preoperative axillary
ultrasound evaluation and biopsy and to assess the sensitivity
of ultrasound-guided biopsy in preoperative staging across a
range of tumor sizes.
E023. 3D and 4D Ultrasound of the Breast: What Kind of
Additional Information Can it Provide Over Conventional 2D
Ultrasound in the Diagnosis and Intervention of Breast
Lesions?
Lee K.1; Woo O.1; Cho K.2; Seo B.3; Yong H.1; Kim A.1; Kang E.1
1. Korea University Guro Hospital, Seoul, South Korea; 2. Korea
University Anam Hospital, Seoul, Korea; 3. Korea University Ansan
Hospital, Seoul, Korea
Address correspondence to O. Woo ([email protected])
Background Information: 3D and 4D ultrasound may provide
new perspectives in the field of breast ultrasound. Consequently,
we look forward to offering new diagnostic information and
potentially improved characterization of breast lesions.
Educational Goals/Teaching Points: The goals are to present
variable techniques and differences in 3D and 4D ultrasound of
the breast; demonstrate various breast lesions with pathologic
correlation, and to evaluate the diagnostic accuracy of 3D and 4D
ultrasound in comparison with 2D ultrasound.
Techniques: This exhibit will focus on 3D and 4D ultrasound,
and techniques and differences and 3D and 4D ultrasound images related normal anatomy. It will provide an overview of 3D
and 4D breast ultrasound imaging, including information on
benign tumor: morphology, volume calculation; papillary neoplasm: in association with adjacent duct and malignant tumor:
morphology, extent including adjacent duct involvement, staging.
Additional information will be provided over 2D ultrasound that
aids in the diagnosis and intervention of breast lesions
Conclusion: Major advantages of 3D and 4D ultrasound of the
breast is its capability to generate multisectional planes and provide volumetric data of the lesion. Furthermore, the coronal
plane provides additional information that assists in differentiating benign and malignant tumors and in 3D targeting, it can provide precise location of biopsy needles in all planes thus providing reassurance to the radiologist.
E025. Value of Ultrasound-Guided Aspiration of Complicated
Breast Cysts in Identifying Malignant Lesions: Retrospective
Review (CME Credit Available)
Ansari, F.; Kaplan, S. Mount Sinai Medical Center, Miami Beach,
FL
Address correspondence to F. Ansari ([email protected])
Objective: The objective was to retrospectively review ultrasound-guided aspiration of complicated breast cysts to determine
the percentage that are solid masses upon aspiration, and to
determine incidence of malignancy.
Materials and Methods: The breast imaging database at our
institution was reviewed. A total of 449 ultrasound-guided cyst
aspiration procedures were performed during a one-year period
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between September 1, 2007 and August 31, 2008. The number
of aspirations that led to ultrasound-guided core needle biopsy
was determined retrospectively. The pathology database was
then reviewed to identify the number of benign, high risk, and
malignant entities resulting from the ultrasound-guided core
biopsies.
Results: Of the 449 ultrasound guided cyst aspiration procedures, 35 led to ultrasound-guided needle biopsies of the presumed complicated cysts. Twenty-nine of these apparent complicated cysts were benign, four proved to be malignant, and two
revealed high-risk atypical findings on pathology. The incidence
of malignancy of a complicated breast cyst unresolved with ultrasound-guided cyst aspiration in our study is 11.5%.
Conclusion: The risk of malignancy for apparent complicated
cysts that do not resolve upon aspiration attempt is 11.5% in this
retrospective review. Ultrasound-guided cyst aspiration should be
performed for masses that appear cystic and do not meet the
sonographic criteria for a simple cyst.
E026. Sonographic Features of Extranodal Extension in
Axillary Lymph Nodes (CME Credit Available)
Misselt, P.; Glazebrook, K.; Reynolds, C.; Degnim, A.; Morton, M.
Mayo Clinic, Rochester, MN
mayo.edu)
Objective: The objective was to assess the diagnostic accuracy of
several sonographic features in the prediction of extranodal
extension (ENE) in axillary lymph nodes of patients with biopsyproven breast cancer.
Materials and Methods: A query of our institutional surgical
and pathologic database was performed looking for breast cancer patients with axillary node sampling between January, 2003
and September, 2007. Patients without sonographic imaging or
surgical follow-up were excluded. We also excluded patients
whose surgical nodal biopsies revealed only isolated tumor cells
or micrometastases (N0(i)). The remaining patients (n=131)
were separated into two groups based on the pathology-proven
presence or absence of extranodal extension (ENE). A blinded,
fellowship trained breast imager then reviewed the sonographic
images of the axillary lymph nodes with specific attention to the
following imaging features: lymph node margins, matting, perinodal edema, and hilar effacement or replacement. The sensitivity
and specificity of predicting a positive pathology for ENE were
calculated for each imaging feature. Univariate and multivariable
association between these imaging features and ENE were
assessed using logistic regression, reporting the results as odds
ratios.
Results: Our search yielded 131 patients, 64 patients with
extranodal extension and 67 patients without extension. The sensitivity and specificity estimates for each sonographic feature as a
predictor of positive ENE on pathology are as follows: matting
52% and 84%, perinodal edema 34% and 87%, unclear node
margins 64% and 75%, hilar replacement 71% and 42%, and
hilar effacement 74% and 60%. Univariate analysis revealed a
statistically significant association between each sonographic feature and pathologically proven extranodal extension with odds
ratios (OR) as follows: matting 5.4, perinodal edema 3.4, unclear
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node margins 5.2, hilar replacement 4.3. Results of univariate
logistic regression predictive a positive pathology.
Variable
Sensitivity
Specificity
Odds
Ratio
P-value
Matting
51.6%
83.6%
5.4
<0.001
Perinodal
34.4%
86.6%
3.4
0.006
Unclear
Margins
64.1%
74.6%
5.2
<0.001
Fatty Hilar
Replacement
71.4%
42.3%
4.3
0.004
Fatty Hilar
Effacement
74.4%
59.5%
1.8
0.20
Conclusion: The sonographic features of unclear lymph node
margins, matting, perinodal edema, and hilar replacement have a
statistically significant association with ENE. The sonographic features of unclear node margins, lymph node matting, and perinodal edema are predictors of ENE with high specificity (75%,
84%, 87%).
E027. The Efficacy of Follow-Up Ultrasound in Asymptomatic
Patients with Mastectomy
Bae, J.; Kim, H.; Choi, J.; Ryeom, H. Kyungpook national university
hospital, Daegu, Korea
Address correspondence to H. Kim ([email protected])
Objective: The objective was to evaluate the efficacy of ultrasonographic (US) follow-up in detecting locoregional recurrences
in asymptomatic patients who had mastectomy for breast cancer
and to evaluate US findings and clinical variables associated with
a recurrence.
Materials and Methods: Between February, 2004 and
December, 2006, we reviewed 1,855 breast US examinations of
899 asymptomatic patients, who showed no clinical evidence of
recurrence after mastectomy for breast cancer in our hospital.
US-guided intervention or excision was taken to confirm the suspicious lesions on US. The US findings of lesions on mastectomy
site and the clinical variables were correlated with pathologic or
follow-up results. The overall survival for asymptomatic vs. symptomatic recurrent patients was estimated using Kaplan-Meier survival analysis.
Results: US found 124 lesions (65 masses and 59 lymph nodes)
on mastectomy site in 118 patients. Among them, 44 lesions in
43 patients showed suspicious US findings. Pathologic results
revealed 19 malignant lesions (43.2%) in 18 patients and 25
benign lesions (56.8%) in 25 patients. The US detection rate of
occult recurrence was 2%, (18 of 899 patients) and the overall
recurrence rate was 2.6% (23 of 899 patients), including five
false negative cases. The not circumscribed margin and thick halo
of the mass, the larger size, irregular shape, not circumscribed
margin, calcifications, increased vascularity of the lymph node,
and the number of positive lymph nodes at the time of surgery
were significantly associated with recurrence (p<0.05). There
was significant difference in the overall survival between asymptomatic and symptomatic recurrent groups by Kaplan-Meier survival analysis (p=0.049).
Electronic Exhibits: Cardiopulmonary
Conclusion: Regular US follow-up in asymptomatic patients who
had mastectomy for breast cancer is helpful for the early detection of recurrence and this may lead to better prognosis.
E028. Nodal Mapping for Radiation Planning in Primary
Breast Cancer Using Cross Modality Fusion
Islam, T.1; MacDonald, S.2; Oliveira, G.2; Wolfgang, J.2; Taghian,
A.2; Harisinghani, M.1 1. Center for Molecular Imaging Research/
Massachusetts General Hospital, Boston, MA; 2. Massachusetts
General Hospital, Boston, MA
Address correspondence to T. Islam ([email protected].
edu)
Background Information: The purpose of this exhibit is to demonstrate the use of cross modality registration techniques to
develop radiation planning maps for lymph nodes in patients
with primary breast cancer.
Educational Goals/Teaching Points: There is currently a lack of
robust guidelines and consensus among radiation oncologists
about anatomical distribution of regional nodes in primary breast
cancer. This exhibit demonstrates the use of pooled MRI data
from multiple patients who had undergone lymphotropic nanoparticle-enhanced MRI with ferumoxtran-10 (AMAG
Pharmaceutical, Inc., Lexington, MA) for nodal staging for developing a comprehensive nodal map and subsequently fusing this
to conventional CT for radiation planning purposes.
Techniques: Nodal staging is important for prognosis and therapy in patients with primary breast cancer. Evolving technologies
such as lymphotropic nanoparticle-enhanced MRI with ferumoxtran-10 (AMAG Pharmaceutical, Inc., Lexington, MA) allow us to
improve the accuracy in distinguishing benign from malignant
lymph nodes.
Conclusion: After reading this exhibit the viewer will understand
the nodal drainage sites for primary breast cancer and how this
information can be useful for accurate radiation therapy planning.
Cardiopulmonary
E029. Use of 3D Imaging Algorithms to Demonstrate the
Congenital Abnormalities of the Coronary Arteries
Oliveira, G.; Branch , K.; Dubinsky, T.; Shuman, W.; Warren, B.
University of Washington, Seattle, WA
Address correspondence to G. Oliveira ([email protected].
edu)
Background Information: The purpose of this exhibit is to demonstrate the congenital abnormalities of the coronary arteries
using detailed anatomic illustrations with corresponding reconstructed 3D MR and CT images.
Educational Goals/Teaching Points: Anomalous origins of the
coronary arteries may be clinically benign but may cause arrhythmias or myocardial ischemia and result in sudden death, particularly in young athletes. Understanding the clinical implications of
the normal anatomy and variants and anomalous origins of coronary arteries is very important for the radiologist and clinicians to
understand. The use of 2D and 3D reconstructions and real time
movies of the coronary arteries provides a clearer understanding
of this important anatomy.
Techniques: In this exhibit, we will show how 3D reconstructions in different anatomic planes with associated diagrams and
movies can provide a noninvasive demonstration of anatomy that
can be easily correlated with cross-sectional images.
Conclusion: After reviewing this exhibit the observer will have a
clear understanding of how state-of-the-art 3D imaging techniques are beneficial in the study of cross-sectional anatomy of
congenital abnormalities of the coronary arteries.
E030. Coronary Artery Noninvasive Imaging in Adult
Kawasaki Disease (CME Credit Available)
Cantin, L.1; Chartrand-Lefebvre, C.1; Marcotte, F.2; Pressacco, J.2;
Ducharme, A.2; Lapierre, C.3 1. University of Montreal Medical
Center, Montreal, Canada; 2. Montreal Heart Institute, Montreal,
Canada; 3. Sainte-Justine hospital, Montreal, Canada
Address correspondence to C. Chartrand-Lefebvre (chartrandlef@
videotron.ca)
Background Information: Coronary artery aneurysms, stenoses
and thromboses are significant complications of Kawasaki disease (KD). While appearing in childhood, coronary complications
are often left unrecognized until early and mid-adulthood. Along
with the increasing capacity of noninvasive coronary artery
imaging modalities, especially CT and MRI, radiologists are more
likely to face the diagnosis of KD in adults.
Educational Goals/Teaching Points: The goal is to review the
clinical aspects of KD for radiologists, and to compare coronary
imaging modalities in the diagnosis of KD.
Techniques: Echocardiography (US) is particularly useful in
young patients with KD, since aneurysms usually occur in proximal coronary arteries, which is an accessible region in children.
Abnormal findings include an artery diameter > 3 mm, lack of
normal tapering and perivascular bright echoes. Chest X-ray in
185
the acute phase can demonstrate cardiomegaly consistent with
pericardial effusion, and calcification of coronary artery aneurysms during follow-up. MR angiography allows a safe evaluation
of proximal coronary arteries, reducing radiation dose in very
young patients. MR evaluation of coronary artery aneurysms in
patients with KD is good, but is less adequate in the evaluation
of stenosis or thrombosis. 64-slice MDCT coronary angiography
can depict complex abnormal morphology of the coronary tree,
as well as stenoses, occlusions and calcifications. It is especially
useful for visualization of the distal coronary tree, an often blind
area for US and MR. CT seems superior to MR for aneurysm
visualisation, and especially for stenosis and thrombosis detection. Imaging protocols using ECG-dose modulation or prospective ECG-gating, along with beta-blockade, should reduce radiation dose. Catheter angiography can be reserved for complicated
or inconclusive cases or for interventions.
Conclusion: Coronary artery imaging will become even more
important as we move beyond 64-slice CT to near real time
acquisition. The techniques described in this exhibit will be
important regardless of the advances in data acquisition and an
understanding of them is critical for clinical practice.
Conclusion: In the childhood acute phase, US is the modality of
choice for coronary artery imaging in KD. After childhood, CT and
MRI should be used. MR angiography allows a safe evaluation of
proximal coronary arteries, reducing radiation dose in very young
patients with KD. CT seems superior to MR for aneurysm
visualisation, and especially stenosis and thrombosis detection.
Reducing radiation dose is a primary concern and imaging protocols using ECG-dose modulation or prospective ECG-gating, along
with beta-blockade, should be considered. Catheter coronary
artery angiography can usually be reserved for complicated cases,
or when interventions are planned.
Materials and Methods: IVUS and dual-source MDCTA were
prospectively performed in 12 patients, resulting in identification
of 20 segments containing noncalcified plaque. Four of these
segments were used to establish reference measurements of 0.6
mm proximal wall thickness using a 0 HU cut-off between epicardial fat and outer wall; and an individually adjusted threshold
for the interface between wall and lumen. Using these data, consecutive circular layers of outer wall were subtracted from a 3D
volume to determine the plaque plus media and the actual
plaque volume in the remaining 16 segments. Accuracy of the
voxel technique was assessed by comparing the results with
IVUS. This study was IRB approved and patients provided written
consent.
E031. Evaluation of Coronary Artery CT Angiograms: A
Practical Approach (CME Credit Available)
Fishman, E. Johns Hopkins Hospital, Owings Mills, MD
Address correspondence to E. Fishman ([email protected])
Background Information: The evaluation of the coronary arteries with CTA is one of the hottest topics in radiology today. The
literature provides a success rate of nearly a 99% negative predictive value and an 89-92% positive predictive value. Some of
the criticism of this data is small study series and a lack of robust
criteria for data analysis. To date there is no clear published consensus on how to evaluate the studies and authors use techniques ranging from axial imaging to multiplanar reconstruction
to curved planar reconstruction to sliding MIPs, to volume rendering to analyze the data. In this exhibit we will review each of
the options and define the advantage and disadvantage of each
technique. Select case studies will be provided to illustrate each
of the points made and a scheme for a logical approach to these
datasets will be provided.
Educational Goals/Teaching Points: The viewer of the exhibit
will learn the advantages and disadvantages of axial imaging,
multiplanar reconstruction, curved planar reconstruction, sliding
MIPs and volume rendering for imaging the coronary arteries and
be able to develop a logical scheme for the analysis of coronary
artery datasets.
Techniques: Key issues include analysis of coronary anomalies;
analysis of coronary artery stenosis; the role of axial imaging, multiplanar reconstruction , curved planar reconstruction, sliding MIPs
and volume rendering for imaging the coronary arteries and how to
develop a logical approach to the analysis of the coronary arteries.
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E032. Coronary Plaque Quantification by Voxel Analysis
Using MDCTA: Validation with Intravascular Ultrasound
Khosa, F.; Sarwar, S.; Brodoefel, H.; Sabir, A.; Yam, C.; Clouse, M.
Beth Israel Deaconess Medical Center, Brookline, MA
Address correspondence to F. Khosa ([email protected])
Objective: The objective was to evaluate a voxel based analysis
technique for quantification of non-calcified coronary plaque,
using intravascular ultrasound (IVUS) as a standard of reference.
Results: Both the plaque plus media layer and the actual plaque
volume showed good concordance to IVUS (49.6 ± 20 mm3 vs.
56.7 ± 23.6 mm3, p=0.076; 26.5 ± 14.8 mm3 vs. 30.9 ± 15.3
mm3, p=0.09). Corresponding correlation coefficients were
r=0.76 and r=0.79. The method offered good reproducibility with
intraclass-correlation-coefficients being 0.93 for total plaque burden and 0.90 for the genuine plaque volume.
Conclusion: Voxel analysis provides accurate and reproducible
quantification not only for plaque plus media volume but also for
true plaque volume.
E033. Prevalence and Clinical Significance of Noncoronary
Ancillary Findings on Coronary Artery Calcium Scoring CT
Akhtar, N.; Aktay, R.; Ciancibello, L.; Orringer, C.; Sachs, P.;
Gilkeson, R. University Hospitals–Case Medical Center, Lakewood,
OH
Address correspondence to N. Akhtar ([email protected])
Objective: The objective was to estimate the prevalence and
clinical significance of noncoronary ancillary findings on coronary
artery calcium scoring CT.
Materials and Methods: A retrospective review was made of
1,000 consecutive patients who underwent coronary artery calcium scoring CT between October, 2007 and July, 2008 in our
institutional-wide screening initiative, “EDUCATE” (Early Detection
Using Calcium Scoring for Treatment and Elimination of Coronary
Heart Disease). Studies were performed on dual source CT or
16-slice or 64-slice MDCT scanners and interpreted by one of
three radiologists. Noncoronary ancillary findings and corresponding imaging and clinical recommendations and follow-up were
reviewed.
Results: A total of 775 of 1,000 (77.5%) patients had one or
more noncoronary findings. A total of 311 of 775 (40.1%)
patients received one or more recommendations for follow up
imaging and/or clinical correlation. There were a total of 315
diagnostic imaging recommendations; 178 of 315 (56.5%) were
pulmonary imaging recommendations, including 156 recommendations for pulmonary nodules; 68 of 315 (21.6%) were gastrointestinal imaging recommendations, including 41 recommendations for hepatic lesions and 27 recommendations for esophageal thickening or dilatation. Sixty-two of 315 (19.7%) were cardiovascular imaging recommendations, including 57 for aortic
aneurysm. Seven of 315 (2.2%) were other imaging recommendations. Twenty follow up imaging studies have been performed
to date. Follow up pulmonary imaging includes two of three PETCT scans positive for primary lung cancer, one chest x-ray for
pneumothorax, and four CT exams documenting stability of pulmonary nodules. Follow up cardiovascular imaging includes four
CT exams for aortic aneurysm and four transthoracic echocardiograms evaluating aortic valvular calcification or left ventricular
bulge. Follow up gastrointestinal imaging includes one ultrasound and three MRI studies diagnostic for hepatic cysts and/or
hemangiomas.
Conclusion: At the early stage of this program, determining the
true disease prevalence and clinical significance for our entire
patient population is limited by the small number of follow up
studies. It is clear, however, that the prevalence of noncoronary
ancillary findings on coronary artery calcium scoring CT is high.
The significance of ancillary findings can be substantial in cases
such as a newly diagnosed lung cancer. The prevalence and
diversity of the findings support continued meticulous interpretation by radiologists.
E034. Analysis of Artifacts in Myocardial Perfusion CT: A
Preliminary Experience (CME Credit Available)
Ghoshhajra, B.1; Blankstein, R.1; Rocha-Filho, J.1; Shturman, L.1;
Pien, H.1; Rogers, I.1; Okada, D.1; Brady, T.1; Cury, R.1,2 1.
Massachusetts General Hospital, Boston, MA; 2. Baptist Cardiac
and Vascular Institute, Miami, FL
Address correspondence to B. Ghoshhajra (ghoshhajra@gmail.
com)
Objective: Perfusion CT scanning is a new technique which can
allow the detection of myocardial perfusion defects. Several artifacts cause potential pitfalls for the radiologist. The exhibit will
review and explain artifacts seen when performing myocardial
perfusion CT.
Materials and Methods: Twenty-seven perfusion CT exams
were performed as part of in IRB-approved study. A variety of
scan artifacts have been encountered. These will be demonstrated with images, and the underlying CT physics will be explained.
Results: Artifacts will be classified based on the underlying etiology (attenuation/beam hardening-related, motion-related, gating
misregistration-related, temporal slab artifacts, and image noiserelated). Examples will be provided of each. Various processing
techniques to differentiate these artifacts from true perfusion
defects will be explained with images. Useful techniques for
identifying and compensating for these artifacts include verification of anatomic distribution and relation to coronary supply,
slice reconstruction thickness, appropriate window/level settings,
image reconstruction technique, multiphase assessment for persistence of a defect throughout the cardiac cycle, wall motion
analysis, and knowledge of common artifact locations. Future
directions for novel imaging reconstruction algorithms and possible changes to scan technique will be discussed as well.
Conclusion: Perfusion artifacts can complicate the interpretation
of perfusion CT scans, and can lead to false-positive identification
of perfusion defects if not recognized appropriately. Correctly
identifying these artifacts will allow the radiologist to increase
sensitivity and specificity, and will lead to improvements in scan
protocols.
E035. Gender Normalized Reference Values of Heart and
Great Vessel Dimensions in Cardiac CT (CME Credit
Available)
Nevsky, G.; Jacobs, J.; Kim, D.; Chandarana, H.; Donnino, R.; Lim,
R.; Srichai, M. New York University School of Medicine, Sunnyside,
NY
Address correspondence to G. Nevsky ([email protected])
Objective: The objective was to establish gender-normalized
ranges of cardiac chamber size, wall thickness, ejection fraction
(EF) and thoracic aorta and pulmonary artery (PA) diameter on
electrocardiographic (ECG)-gated cardiac CT angiography (CCTA).
Materials and Methods: Seventy-six consecutive patients [41
females (mean age 52.7 ± 10.3 years) and 36 males (mean age
41.2 ± 10.3 years)] who underwent CCTA on a 64-slice CT system between 2005 and 2008, without known history of diabetes,
hypertension, smoking, or CCTA evidence of structural heart, vascular, or coronary artery disease were studied retrospectively.
End-systolic left and right atrial size, left ventricular (LV) volumes
and EF was measured using cardiac postprocessing software.
Thoracic aorta and PA were measured biorthogonally on a 3D
workstation. Measurements were normalized to body surface
area.
Results: Normalized values for men (values/m2): left atrial size
10.5 ± 2.1 cm2; right atrial size 10.1 ± 1.7 cm2; LV end-diastolic
volume 71.4 ± 15.6 ml; LV end-systolic volume 23.8 ± 8.8 ml; LV
EF 67.5 ± 8%; LV basal wall thickness 4.2 ± 0.4 mm; LV mid wall
thickness 3.5 ± 0.7 mm; LV apex wall thickness 3.2 ± 0.6 mm;
aortic annulus 1.4 ± 0.2 cm; aortic sinus 1.6 ± 0.2 cm; aortic
sinotubular junction 1.4 ± 0.2 cm; ascending aorta at level of
right PA 1.4 ± 0.2 cm; descending aorta at level of left PA 1.1 ±
0.1 cm; aorta diaphragm level 1.0 ± 0.1 cm; main PA 1.3 ± 0.1
cm; right PA 1.0 ± 0.1 cm; left PA 1.0 ± 0.1 cm. Normalized values for women (values/m2): left atrial size 12.3 ± 2.1 cm2; right
atrial size 10.7 ± 1.7 cm2; LV end-diastolic volume 60.9 ± 13.3
ml; LV end-systolic volume 17.6 ± 6.7 ml; LV EF 71 ± 8.1%; LV
basal wall thickness 4.2 ± 0.6 mm; LV mid wall thickness 3.7 ±
0.6 mm; LV apex wall thickness 3.1 ± 0.6 mm; aortic annulus 1.4
± 0.2 cm; aortic sinus 1.7 ± 0.2 cm; aortic sinotubular junction
1.5 ± 0.2 cm; ascending aorta at level of right PA 1.6 ± 0.2 cm;
descending aorta at level of left PA 1.2 ± 0.1 cm; aorta diaphragm
level 1.1 ± 0.1 cm; main PA 1.4 ± 0.1 cm; right PA 1.1 ± 0.2 cm;
left PA 1.1 ± 0.2 cm. There were statistically significant differences
187
between normalized reference values for males and females for
left atrial size, LV end-systolic and end-diastolic volumes, aortic
diameters at all measured levels and left PA diameter.
Conclusion: Gender-normalized reference measurements for cardiac chambers, aorta and pulmonary arteries are determined
with CCTA in subjects free of cardiac risk factors or CCTAdetectible cardiac disease.
E036. Transthoracic Echocardiography Provided
Underestimation of Left Ventricular Outflow Tract Area and
Aortic Valve Area Compared to Measured by Planimetry in
Cardiac CT and Transesophageal Echocardiography
Puntawangkoon, C.; Entrikin, D.; Ntim, W.; Chen, M.; Johnson, T.;
Carr, J. Wake Forest University, Winston Salem, NC
Address correspondence to C. Puntawangkoon (jirapa2801@
yahoo.com)
Objective: The objective is to assess the geometry and area of
the left ventricular outflow tract (LVOT) in stenotic and nonstenotic aortic valves and to determine the aortic valve area by cardiac CT (CCT) using a planimetry compared with transthoracic echo
(TTE) using continuity equation and transesophageal echo (TEE)
using a planimetry.
Materials and Methods: Forty-six patients, ages 20-81 years,
had CCT and echocardiography (either TTE or TEE) within one
week of another. Cardiac CT was performed using a 64-slice
scanner (GE Healthcare, Waukesha, WI). Aortic valve area (AVA)
was assessed by planimetry using TEE in 19 cases (used as reference standard), using CCT in 46 cases and by continuity equation
using TTE in 40 cases. LVOT area was determined by planimetry
from CCT and by calculating a circular area using the LVOT diameter from the three-chamber view in echocardiography. To quantify the deviation from a perfect circle, eccentricity index (EI) was
calculated using the formula: 1-(minor LVOT diameter/major LVOT
diameter). Results: The LVOT area based on the LVOT diameter derived from
three-chamber TTE was significantly underestimated compared to
planimetry by CCT (3.48 ± 0.88 cm2 vs. 5.09 ± 1.20 cm2,
p<0.001; mean difference -1.6 ± 0.85 cm2 and percent of the
different LVOT area by TTE and CCT=31 ± 13%). The median EI
was 0.19 (0.01-0.30), indicating that half the subjects had at least
19% difference between the major and minor diameters. An
elliptic LVOT morphology has been established by CCT planimetry
in most patients, which potentially contributed to AVA underestimation provided by the circular assumption formula via TTE.
Planimetric AVA ranged from 0.9 to 4.3 cm2 (2.91 ±1 cm2) by
TEE. AVA calculated by TTE technique was smaller than that
measured by TEE (p=0.01) with the mean difference 0.69 ± 0.94
cm2, whereas AVA by CCT correlated well with TEE planimetry
(p=0.13) with good agreement (correlation coefficient, r=0.91;
the mean difference 0.16 ± 0.42 cm2).
Conclusion: Calculation of LVOT area from LVOT diameter results
in underestimation of LVOT area compared to area measured by
planimetry from CCT because of an elliptic morphology of LVOT.
This ultimately results in underestimation of AVA by continuity
equation.
188
E037. Imaging Features of Cardiac Assist Devices
Ginat, D.; Bhatt, S.; Singh, M.; Dogra, V. University of Rochester,
Rochester, NY
Address correspondence to D. Ginat ([email protected])
review the types of commercially available cardiac assist devices;
review the physiologic consequences of the cardiac assist devices; illustrate the normal imaging appearance of the variety of
assist devices, and discuss potential complications associated
with these devices.
Educational Goals/Teaching Points: The major teaching points
of this exhibit are: 1.Various cardiac assist devices are used in the
management of heart failure. Therefore, it is important to recognize the normal configuration and functional implications of
these devices. 2. X-ray and CT are well-suited for assessing their
positioning. 3. Main complications include malpositioning, hemorrhage and infection.
Techniques: This exhibit will describe the design and physiologic
impact of the various cardiac assist devices, including intra-aortic
balloon pumps and ventricular assist devices; illustrate the normal appearance of cardiac assist devices, and discuss the potential complications associated with cardiac assist devices and their
imaging features.
Conclusion: The radiologist must be familiar with the normal
imaging appearances of the various types of cardiac assist devices and be able to recognize associated complications.
E038. Cardiac MDCT in Adult Patients with Congenital Heart
Disease: Challenging Protocols and Common Pitfalls
Torres, F.; Nguyen, E.; Doyle, D.; Ayyappan, A.; Abadi, S.; Provost,
Y.; Crean, A.; Paul, N. Toronto General Hospital, University of
Toronto, Toronto, Canada
Address correspondence to F. Torres ([email protected])
Background Information: Increasing numbers of patients with
congenital heart disease (CHD) are surviving into adulthood due
to improvements in surgical techniques and clinical care. Several
imaging modalities play a critical role in the diagnosis and followup of these patients. The introduction of CT units with 64 rows of
detectors, submillimeter and subsecond isotropic imaging has
made cardiac-gated CT an excellent alternative for patients with
contraindications to MRI. However, the unique anatomy and
physiology of CHD patients poses challenges for optimal contrast
opacification in structures of interest. This review highlights the
fundamental principles governing targeted CT protocols using
clinical examples from a spectrum of CHD and illustrates the
imaging appearances of common pitfalls when the technique is
suboptimal.
Educational Goals/Teaching Points: The goals are to identify
subgroups of adult CHD and surgical corrections that benefit
from cardiac CT; describe the potential pitfalls and common mistakes when evaluating these patients with MDCT, and discuss the
modifications to MDCT protocols required to adequately assess
each condition.
Techniques: This exhibit demonstrates the anatomic and hemodynamic aspects of specific common adult congenital heart diseases that require detailed attention when designing MDCT contrast protocols. A variety of conditions including congenital and
surgical shunts, baffles and conduits that require specialized
MDCT contrast protocols designed to assess the pulmonary veins,
atrial anatomy and biventricular function will be discussed.
Common pitfalls and the resultant imaging appearances will also
be illustrated.
Conclusion: The supervising radiologist must be aware of the
complex anatomy and altered physiology in adult patients with
CHD to plan the most appropriate MDCT protocol to successfully
image these patients.
E039. Infective Endocarditis: Pathophysiology, Cardiac and
Extra-Cardiac Imaging Manifestations (CME Credit
Available)
Murillo, H.1; Lane, M.2; Palacio, F. 1; Marmol-Velez, J.1; Nagar, V.
1; Reddick, R.1; Restrepo, C.1 1. University of Texas Health
Science Center–San Antonio, San Antonio, TX; 2. South Texas
Radiology Imaging Centers, San Antonio, TX
Address correspondence to H. Murillo (horacio.murillo@gmail.
com)
Background Information: Infective endocarditis remains an
important clinical problem associated with high morbidity and
mortality. Common conditions complicated by infective endocarditis include intravenous drug abuse, degenerative valve disease
in the elderly, valve replacement and aortic root repair, vascular
instrumentations, and placement of intracardiac devices and central lines. Transesophageal or transthoracic echocardiography has
been instrumental in the imaging of valvular vegetations and the
identification of structural complications of endocarditis.
However, CT and MRI have become powerful tools for imaging of
infective endocarditis even in conditions where metallic, calcific,
and graft material are in or around an infectious nidus limiting
echocardiographic imaging. Additional CT and MR advantages
include 3D anatomic delineation of structures and complications.
Moreover, extracardiac manifestations of infective endocarditis
can be imaged simultaneously including thoracic, nervous system, musculoskeletal, and abdominal organs.
the spectrum of imaging findings of infective endocarditis by CT,
MR, and echocardiography; to better understand the strengths
and limitations of various imaging modalities and when use of
one modality is advantageous, and to recognize typical extracardiac imaging manifestations of infective endocarditis.
Techniques: The image spectrum of cardiac and extracardiac
infective endocarditis manifestations, including thoracic, nervous
system, musculoskeletal, and abdominal organs; diagnostic imaging of direct invasion and embolic complications of infective
endocarditis and pathologic correlations, and advantages, disadvantages, and limitations of echocardiography, CT, and MR imaging methods will be outlined.
Conclusion: Infective endocarditis remains an important clinical
problem associated with significant morbidity and mortality.
Recognizing the spectrum of imaging findings of cardiac and extracardiac complications of infective endocarditis is important for
diagnostic and optimal patient care management.
E040. Multidetector and Dual Source CT of Congenital Heart
Disease in Adults (CME Credit Available)
Wiant, A.1; Gilkeson, R.1; Nyberg, E.1; Siwik, E.1,2; Zahka, K.1,2 1.
University Hospitals–Case Medical Center, Cleveland, OH; 2.
Rainbow Babies and Children’s Hospital, Cleveland, OH
Address correspondence to A. Wiant ([email protected])
Background Information: Advances in surgical and medical
therapies have enabled increasing numbers of children with previously diagnosed and treated congenital heart disease (CHD)
survive into adulthood. Additionally, a growing number of
patients with significant congenital heart disease are first diagnosed in adulthood. Multidetector and dual-source CT are emerging technologies that have several advantages over multislice CT,
including decreased radiation dose and improvements in ECG
gating capabilities. These factors make multidetector and dualsource CT an ideal means to detect and characterize known and
suspected CHD in the adult.
Educational Goals/Teaching Points: Overarching goals are to
review the technical and clinical aspects of multidetector and
dual-source CT imaging; to improve radiologists’ skills in interpreting CT studies of adults with known CHD; and to improve the
sensitivity and recognition of CHD in the previously undiagnosed
adult. After having reviewed this educational exhibit, the reader
should be able to do the following: understand the principle and
technique of multidetector and dual-source CT; understand the
epidemiology, characteristics, and diagnostic challenges associated with adults with CHD; and appreciate the spectrum of MDCT
characteristics of CHD presenting in adulthood. Participants will
also be able to recognize important features of the postoperative
appearances of lesions in adults with corrected CHD.
Techniques: We review the unique features of multidetector and
dual-source CT that make these imaging options optimal for evaluating cardiopulmonary complaints and detecting unsuspected
CHD in the adult patient. Briefly, we compare these modalities to
other techniques, e.g. echocardiography and MRI, which have traditionally been used to follow adults with CHD. We also review
congenital lesions most likely to be encountered in the adult
with known CHD and the patient with unsuspected CHD.
Conclusion: Multidetector and dual-source CT are evolving technologies that have particular application in the imaging of adults
with known and previously undiagnosed CHD.
189
E041. Don’t Get Lost in LA: An Electrophysiologists Road
Map to the Left Atrium (CME Credit Available)
Seaman, D.; Meyer, C.; Strunk, R.; Attari, M. University of
Cincinnati Medical Center, Cincinnati, OH
Address correspondence to D. Seaman (seaman.danielle@gmail.
com)
Background Information: This exhibit will discuss normal and
variant left atrial anatomy at MDCT with emphasis on relevance
to the electrophysiology lab.
Educational Goals/Teaching Points: The left atrium (LA) is
divided into four components: the septum, the vestibule, the
appendage and the venous portion. This exhibit will emphasize
the important normal and variant vascular supply.
Techniques: The septum provides access to the LA and relevant
vascular and conducting system will be demonstrated. Common
septal abnormalities encountered at cardiac CT angiography
include patent foramen ovale, atrial septal defects and septal
aneurysms. The vestibule is the thinnest portion of the left atrium; it surrounds the mitral valve orifice and abuts the coronary
sinus posteriorly. The potential for perforation is high in this location and is critical in the placement of a mitral isthmus line for
atrial flutter. Normal and variant appendage anatomy and criteria
for distinguishing atrial thrombus from delayed enhancement will
be discussed. Accessory appendages and their importance on the
effectiveness of atrial roof line ablations will be considered along
with a commonly associated left to right atrial muscular bridge
(the Bachman’s Bundle). A brief review of pulmonary venous
anatomy and common venous variants will be illustrated.
Common congenital anomalies such as left superior vena cava
and partial anomalous pulmonary venous return will be reviewed
and the potential impact on electrophysiology planning. Left atrial access, common ablation techniques and deployable mechanical devices are discussed in the context of the described anatomy
and variants. The important concept of atrial transport will be
introduced.
Conclusion: Evaluation of left atrial anatomy by MDCT prior to
left atrial catheter interventions results in decreased fluoroscopy
times and improve clinical outcomes by decreasing complication
rates when the relevant atrial anatomy is recognized.
E042. Dose Stratification in CT Coronary Angiography: A
Comparison of 320-Row with 64-Row MDCT (CME Credit
Available)
Torres, F.; Ray, C.; Ayyappan, A.; Abadi, S.; Doyle, D.; Nguyen, E.;
Crean, A.; Menezes, R.; Paul, N. Toronto General Hospital,
University of Toronto, Toronto, Canada
Address correspondence to F. Torres ([email protected])
Objective: The purpose of this study is to document the effective
dose equivalent (EDE) for CT coronary angiography (CTCA) performed with 320-row and 64-row MDCT in order to provide
appropriate risk stratification and informed patient consent.
Materials and Methods: We retrospectively reviewed 171 consecutive CTCA studies (106 males, 65 females) mean age 58
years (27-83), mean body mass index (BMI) 27.5 kg/m2(18.558.6) performed on 320-row MDCT (Toshiba Medical Systems,
Tochigi-ken, Japan) from March 1, 2007 to June 30, 2007, all
190
using prospective EKG gating and 109 consecutive CTCA studies
(62 male, 47 female) mean age 59 years (24-84), mean BMI
27.8 kg/m2 (16.2-51.5) performed on 64-row MDCT (Toshiba
Medical Systems, Tochigi-ken, Japan) from March 1, 2007 to April
30, 2007, all using retrospective EKG gating. All patients were
clinical cardiology referrals for exclusion of native CAD. Patients
received oral ± intravenous metoprolol (50-150 mg) to achieve a
target heart rate (HR) of =65 bpm. The actual HR prior to CTCA
on 320 row MDCT determined the phase of the cardiac cycle
used for image reconstruction as follows: HR (bpm) (phase %next R wave) <60 (70%-R), 60-65 (60%-R), >65 (40%-R). The
EDE (mSv) for each study was calculated from the dose length
product (mGy, cm, CT console) and a thorax conversion factor
(k=0.017) and presented as mean (range).
Results: For 320-row MDCT patients mean EDE=8.9mSv.
Subgroup analysis: for one heart beat acquisition 157(91.8%)
patients, there were three groups; phase of R-R cycle used
(number of patients, %), mean EDE mSv (range mSv): Group
one, 70%-R (83, 48.5%), 7.7 (4.7-10.5); Group two, 60%-R (61,
35.7%), 8.3 ( 5.1-12.0), and Group three, 40%-R (13, 7.7%), 9.3
(6.3-12.7). There were 14 patients (8.2%) requiring acquisition
during =two heart beats, with corresponding mean EDE of 18.4
mSv (13.8- 22.2). For 64 row MDCT patients mean
EDE=24.7mSv. Sub-group analysis: Group four, in which EKG
tube current modulation was used (n=20, 17.2%), mean
EDE=15.3 mSv (10.6-22.8), and Group five, no EKG current modulation (n= 89, 81.7%), mean EDE=26.5 mSv (11.9-38).
Conclusion: Prospectively EKG gated acquisitions on 320-row
MDCT with a short X-ray exposure in patients with a slow (<60
bpm), steady heart rate achieves a reduction in EDE of 69%
compared to a retrospective gated EKG acquisition performed on
64-row MDCT.
E043. Evaluation of a Specific Variant of the Left Atrial
Appendage on 64-Slice Coronary Computed Tomographic
Angiography
Bailey, J.; Warren, P.; Ghosh, S.; Benson, R.; King, M. The Ohio
State University College of Medicine and Public Health,
Columbus, OH
Address correspondence to M. King ([email protected])
Objective: The objective was to evaluate the prevalence and
morphology of a specific variant of the left atrial appendage
(LAA) seen on 64-slice coronary computed tomographic angiography (CTA).
Materials and Methods: Two independent reviewers retrospectively evaluated 200 consecutive coronary CTA performed at our
institution from April to September, 2008 for a specific variant of
the LAA. This was defined as a contrast outlined projection off
the LAA which curved superior to the left atrium and medially
toward the aortic root. These were categorized based on the
presence or absence of pectinate muscles. Those with pectinate
muscles were further subclassified based on their size. Any
thrombus within the left atrial appendage was also noted.
Differences were resolved by consensus.
Results: Seven of 200 cases were nondiagnostic and excluded
from analysis (3.5%). Of the remaining 193 cases there were 112
males and 81 females with a mean age of 51.9 years. Twenty-six
of 193 cases demonstrated the variant LAA anatomy (13.4%). Of
the 26 positive cases, eight were devoid of pectinate muscles
(30.7%) and 18 contained pectinate muscles (69.2%). Of those
with pectinate muscles; four, eight and six cases were categorized as being small, moderate and large (22.2%, 44.4% and
33.3%), respectively. Of the 193 cases analyzed, thrombus was
identified in two (1.0%), of which one was in a LAA variant
devoid of pectinate muscles.
Conclusion: To our knowledge this variant of LAA anatomy has
not been previously reported in the CT literature. It is important
for radiologists to be aware of this variant to avoid misinterpretation as a mass or some other pathologic condition, and to understand its relationship to the left atrium in case of thrombus formation.
E044. Cardiac MR Evaluation of Repaired Tetralogy of Fallot:
Techniques, Findings, and Prognosis
Paes, F.; Thota, S.; Kardon , R.; Ghersin , E.; Siegel, Y.; Fishman, J.
University of Miami, Miami, FL
Address correspondence to F. Paes ([email protected])
Background Information: Tetralogy of Fallot is a common form
of cyanotic heart disease. Correction in infancy offers good longterm results. However, residual pulmonary regurgitation or stenosis, or both, is often present after total correction. For patients
with a dilated right ventricle (RV) caused by significant pulmonary valve regurgitation, pulmonary valve replacement (PVR) has
proved to be beneficial with respect to reverse remodeling of the
RV, decrease in QRS duration, and prevention of chronic right
heart failure. Cardiac magnetic resonance (CMR) allows precise
and reliable volumetric and flow analysis in addition to providing
a 3D geometry of the heart, and has therefore emerged as a
modality of choice in the decision-making process for evaluation
of right ventricular and pulmonary valve pathology and timing of
pulmonary valve replacement.
Educational Goals/Teaching Points: Our educational goals
include reviewing the indications and protocol for CMR in
patients with repaired Tetralogy of Fallot, illustrating common
pathologic changes of the right ventricle and pulmonary valve
identified by various CMR techniques, and recognizing its value
as a method for preoperative evaluation and follow-up of right
ventricular size, function, and pulmonary valve regurgitation in
those patients.
Techniques: We review the pathophysiology and common cardiac imaging findings of repaired Tetralogy of Fallot patients, with
particular attention to the known complications and prognostic
factors. CMR protocols and sequences are described with emphasis in the advantages and disadvantages of this method compared with echocardiography and CT. A detailed description of
pulmonary valve regurgitation and right ventricular pathology is
presented in a case review format demonstrating its unique
imaging findings.
Conclusion: CMR using cine and velocity encoded phase contrast sequences is an accurate and reproducible method for evaluation of pulmonary valve and right ventricular pathology before
and after intervention in Tetralogy of Fallot. CMR evaluation can
identify patients with chronic pulmonary valve regurgitation who
might benefit from early intervention. Corrected RV ejection fraction, indexed RV end-diastolic and end-systolic volumes, and pul-
monary regurgitant fraction are the key CMR measurements to
obtain.
E045. Review of Delayed Enhancement Cardiovascular MR
Imaging of Ischemic and Nonischemic Cardiomyopathies
Brown, M.1; Khalaf, O.1; Jeudy, J.2; Legasto, A.1 1. Beth Israel
Medical Center-Manhattan, New York, NY; 2. University of
Maryland Medical Center, Baltimore, MD
Address correspondence to M. Brown (brownm32003@yahoo.
com)
Background Information: Delayed enhancement cardiovascular
MRI (DE-CMRI) plays an important role in the assessment of cardiomyopathy and thus directly influences patient treatment and
survival. The purpose of this exhibit is to discuss the underlying
relationship between hyperenhancement and myocardial pathophysiology and to review the imaging findings on cardiovascular
MRI in ischemic and several nonischemic cardiomyopathies.
Educational Goals/Teaching Points: There is a significant relationship between hyperenhancement and myocardial pathophysiology which is based on gadolinium molecules in the extracellular space. Ischemic and nonischemic cardiomyopathies (including sarcoid, hypertrophic cardiomyopathy and viral myocarditis) have typical patterns of hyperenhancement on DE-CMRI and
thus allow for etiologic differentiation when the diagnosis is
uncertain.
Techniques: Subendocardial or transmural hyperenhancement
on DE-CMRI is consistent with the presence of coronary artery
disease (CAD) and ischemic cardiomyopathy (ICM) is the most
likely diagnosis. If the pattern of enhancement is not subendocardial, nonischemic cardiomyopathy is likely present and patterns
of enhancement may be used to differentiate several etiologies.
Conclusion: DE-CMRI is a noninvasive imaging modality that
helps differentiate between various etiologies of cardiomyopathy
and thus significantly impacts patient management. E046. Heartbreak Hotel: Pictorial Essay of Myocarditis and
Cardiomyopathy With Echocardiography Correlation (CME
Credit Available)
Borso, M.1; Lee, Y.1; Spokoyny, I.1; Sheehan, J.2; Dill, K.2; Carr, J.2
1. University of California-San Diego, San Diego, CA; 2.
Northwestern, Chicago, IL
Address correspondence to M. Borso ([email protected])
Background Information: Cardiomyopathies are a heterogeneous group of diseases with significant morbidity and mortality,
which often have an insidious onset. Imaging, especially cardiac
MR, is playing an ever increasing role in the diagnosis of cardiomyopathies. This exhibit will review the classification and imaging
findings of a variety of cardiomyopathies through a case based
approach, with emphasis on key differential diagnostic points. We
will discuss the MR sequences commonly employed. Lastly, we
will compare and contrast MR with echocardiography in the diagnosis of cardiomyopathies.
Educational Goals/Teaching Points: This exhibit will include:
1. Introduction—epidemiology, WHO classification, pathophysiology of specific cardiomyopathies; 2. MR findings of myocarditis
191
and cardiomyopathy—overview of MR sequences, cellular mechanisms for enhancement, limitations/benefits of MR; 3. presentation of cases grouped by WHO classifications. Specific cases
include: idiopathic familial dilated, alcoholic, ischemic, valvular,
amyloid, sarcoid, hemosiderosis, Chagas, peripartal, eosinophillic,
hypertrophic cardiomyopathy, arrhythmogenic right ventricular
displasia, noncompaction, and Tako-tsubo; 4. algorithm for narrowing a differential diagnosis, 5. comparison with echocardiography—comparison/companion echocardiography cases for the
above cases (when possible), and a review of current literature
comparing echocardiography and MR for diagnosis of cardiomyopathy.
Techniques: A review of cardiac anatomy will be implicit in the
exhibit. We will review the pathophysiology of the cardiomyopathies listed above and how that relates to the imaging findings.
Modalities utilized will include radiographs, MR, and echocardiography. We will review the various sequences utilized in cardiac
MR for the evaluation of myocarditis and cardiomyopathy as well
as the cellular mechanism for enhancement. Additionally we will
compare and contrast MR and echocardiography for the evaluation of myocarditis and cardiomyopathies.
Conclusion: At the conclusion of the exhibit the viewer should
accomplish the following: 1. be familiar with the classification of
cardiomyopathies; 2. recognize common MR imaging features of
myocarditis and cardiomyopathy and understand characteristic
findings for specific cardiomyopathies, 3. be able to compare and
contrast MR and echocardiographic findings in cardiomyopathies.
E048. CT and MR Appearances of Cardiac Pseudomasses:
Imaging Pearls and Pitfalls (CME Credit Available)
Rueff, L.; Srichai, M.; Jacobs, J.; Chandarana, H.; Axel, L.; Kim, D.;
Lim, R. New York University Langone Medical Center, New York,
NY
Address correspondence to L. Rueff ([email protected])
Background Information: The differential diagnosis for cardiac
mass is broad, including benign and malignant neoplasms along
with a variety of normal anatomic variants and pseudomass
lesions. Misdiagnosis can cause significant morbidity or potentially mortality if a benign finding is mistaken for a more aggressive
lesion, triggering inappropriate intervention or management.
While echocardiography remains the initial imaging tool for diagnosis and assessment of intracardiac lesions, CT and MRI offer
the potential for further characterization of true masses and
definitive identification of pseudomass lesions. Familiarity with CT
and MR appearances of normal structures, anatomic/embryologic
variants and pseudomass lesions is essential for differentiation
from cardiac neoplasms, accurate diagnosis and appropriate
management.
Educational Goals/Teaching Points: This exhibit will: 1. present
the relative advantages and disadvantages of CT and MR for cardiac mass and pseudomass evaluation; 2. discuss technique optimization for successful differentiation of cardiac masses from
pseudomass entities; 3. present and discuss anatomic and
embryologic variants that should be differentiated from pathologic entities, and 4. present pathologic entities that may masquerade as mass lesions and discuss their clinical significance and
appearance on CT and MR.
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Techniques: A number of normal cardiac anatomic variants may
be mistaken for neoplastic mass lesions. Correct differentiation is
dependent on good imaging quality and technique as well as
physician experience and knowledge of cardiac anatomy and
potential variants. These variants include crista terminalis, eustachian ridge, chiari network, prominent atrial-ventricular groove
fat, and normal structures such as the moderator band, trabeculations, and pectinate muscles. Additionally, a number of pathologic diagnostic entities may masquerade as cardiac masses.
Using CT and MR, these pseudomass lesions can be distinguished from true neoplasms on the basis of location, mobility,
tissue characteristics and contrast uptake. These entities include
interatrial septal aneurysm, lipomatous hypertrophy of the interatrial septum, thrombus, pericardial cyst, cardiac pseudoaneurysm
and coronary artery aneurysm.
Conclusion: Many cardiac anatomic variants and pseudomass
lesions exist that must be distinguished from neoplastic lesions.
Familiarity with their appearance on CT and MR is essential for
accurate differentiation from cardiac mass lesions and appropriate intervention and management.
E049. Delayed Enhancement Imaging–Patterns, Pitfalls and
Pathology–A Pictorial Review (CME Credit Available)
Rajiah, P. Cleveland Clinic Foundation, Cleveland, OH
Address correspondence to P. Rajiah ([email protected])
Background Information: Delayed enhancement imaging is an
integral component the armamentarium of cardiac imagers. K
space segmented Inversion recovery images are acquired 15-20
minutes after intravenous injection of 0.2 mmol/kg of gadolinium. Magnitude images require selection of optimal inversion
time, while phase sensitive reconstruction doesn’t require this,
saving time. It is very useful in detection and characterization of
myocardial infarction. Uptake of contrast in delayed enhancement is due to expansion of extracellular space in scars and
delayed washout. Delayed enhancement is also seen in a wide
spectrum of non ischemic abnormalities. Educational Goals/Teaching Points: 1) Delayed enhancement
is very useful in assessing presence of viable myocardium in
ischemic cardiomyopathy 2) Mid myocardial scar in hypertrophic
cardiomyopathy is an adverse prognostic indicator. 3) Scar is
seen in subepicardial location in myocarditis. 4) Diffuse subendocardial to subepicardial enhancement is seen in amyloidosis.
Techniques: In ischemic cardiomyopathy, subendocardial or
transmural scarring is seen in coronary artery distribution. Extent
of scarred myocardium is essential in determining patients suitable for revascularization. Specific patterns of enhancement are
seen in nonischemic cardiomyopathies such as hypertrophic cardiomyopathy (patchy, sand like, septal ), dilated cardiomyopathy
(mid wall, septal), arrhythmogenic right ventricular dysplasia
(right ventricle free wall), sarcoid (patchy, basal septal), amyloid
(diffuse subendocardial to epicardial) endocardial fibroelastosis
(diffuse subendocardial, noncoronary distribution), Fabry’s disease (mid myocardial, inferolateral wall), noncompaction
(trabecular recesses) and myocarditis (subepicardial, inferolateral).
Delayed enhancement is also seen in acute/subacute pericarditis
(pericardial enhancement) postablation (septum in hypertrophic
obstructive cardiomyopathy, left atrium after ablation), postcardiac surgeries, valvular diseases (fibrosis of valvular apparatus) and
tumors (differentiates from thrombus). Conclusion: Presence of scar is useful in risk stratification, therapeutic management and determining prognosis of cardiomyopathies. Knowledge of specific pattern of enhancement is essential
for determining cause of nonischemic cardiomyopathy. Scar is
often a substrate for the development of ventricular arrhythmias.
E050. MRI in Common and Uncommon Cardiac Masses–
A Pictorial Review
Background Information: MRI is the most important modality
in the evaluation of cardiac masses, due to its high spatial resolution, large field of view, multiplanar imaging capability and inherent contrast between flowing blood and cardiac chambers.
Cardiac masses include tumors (benign, primary malignant, secondary malignant) and nontumoral masses. MRI helps in characterization and differentiation from nontumoral masses and anatomical variants. Educational Goals/Teaching Points: Cardiac masses include
tumors and nontumoral masses and MRI is essential in differentiating these two, which are managed differently. Postcontrast
MRI is useful for delineating the tumor and characterizing tumor
neovascularity. Most tumors show enhancement in the delayed
phase, unlike thrombus which does not. Delayed enhancement
with high inversion time (600 milliseconds) is useful in differentiating thrombus (dark) from tumor (bright). Myxomas are more
common in the left atrium and often attached near fossa ovalis.
Lipomatous hypertrophy of interatrial septum spares the fossa
ovalis.
Techniques: In evaluation of cardiac masses, MRI is acquired in
multiple planes and various sequences are used such as –
Functional (cine balanced steady state free precession), anatomical (T1/T2/short tau inversion recovery spin echo sequences),
myocardial tagging (spatial modulation of magnetization), perfusion imaging and delayed enhancement (usual inversion time
and long inversion time). Analysis of signal in various spin echo
sequences helps in internal characterization of the mass. Cine
sequences evaluate mobility, effect on myocardial contraction,
site of implantation and obstruction. Tagging helps in differentiating contracting and noncontracting myocardium. The various
masses in the heart are – benign cardiac tumors (myxoma, lipoma, fibeoelastoma, fibroma, hemangioma, rhabdomyoma), primary malignant cardiac tumors (lymphoma, angiosarcoma, rhabdomyosarcoma, mesothelioma and malignant histiocytoma), secondary malignant tumors (hematogeneous metastasis, direct
extension from adjacent tumors) nontumoral cardiac masses
(thrombus, lipomatous hypertrophy of interatrial septum, valvular
vegetations, pericardial cyst, hydatid cyst). Conclusion: MRI is very useful in diagnosis, characterization and
delineating extent of cardiac masses. A combination of various
sequences in multiple planes is used. MRI is also useful in follow
up after treatment. E051. Left Atrium–A Pictorial Review of Embryology,
Anatomy and Pathology (CME Credit Available)
Background Information: The morphological left atrium is the
posterior most chamber in the heart and is formed by the fusion
of primitive left auricle and sinus venosus. The left atrium
receives pulmonary veins and pumps oxygenated blood into the
left ventricle through the mitral valve. There is a wide spectrum
of abnormalities affecting the left atrium. Knowledge of the
development, anatomy, normal measurements and hemodynamics is essential for proper diagnosis. MRI and CT plays a pivotal
role in evaluation of left atrial abnormalities.
Educational Goals/Teaching Points: MRI is very useful in evaluation of all pathologies in the left atrium. Volume rendered
reconstruction is useful in assessment of the left atrial anatomy
and pulmonary venous connections. Delayed enhancement
imaging is vital in differentiating left atrial thrombus and tumors.
In CT, delayed imaging is useful in differentiating slow flow and
thrombus.
Techniques: This review discusses the development, anatomy,
variants and normal measurements (diameter, area, volume) of
left atrium. MR imaging planes, sequences and protocols for evaluating left atrium are discussed. Abnormalities in left atrium
which are discussed in this pictorial review include: congenital
(situs inversus, situs solitus with dextrocardia, dextro and levo
transposition, cor triatriatum, unroofed coronary sinus, hypoplastic left heart syndrome, atrial septal defect [ostium primum,
ostium secundum, sinus venosus]), postsurgical (mustard procedure, senning procedure, maze procedure, left atrial appendage
closure), postinterventional (pulmonary venous ablation), abnormal size (large left atrium [LA], giant LA, small LA), vascular
(aneurysm, thrombus, slow flow), tumors (myxoma, lipoma, sarcoma, metastasis), and infiltrative disorders (amyloidosis). The
role of CT in differentiating thrombus and slow flow is also discussed. Volume rendered 3D images are useful in planning for
ablation of pulmonary venous ostia. Conclusion: MRI plays an important role in the assessment of
left atrial abnormalities. Knowledge of the development, anatomy, pathology and characteristic radiological features are essential in the diagnosis of abnormalities. MRI is very vital in differentiating tumor from thrombosis.
E052. Unusual Fistulas in the Cardiovascular System–A
Pictorial Review
Background Information: Arteriovenous (AV) fistula is an
abnormal communication between an artery and vein, which
results in shunting of blood from the high-pressure arterial side
to the low-pressure venous side. This creates an abnormal lowresistance circuit that steals from the high-resistance normal capillary bed, which can cause tissue ischemia. AV fistulas involving
the aorta and coronary arteries are rare and are usually secondary to surgeries or interventions. CT and MRI play an important
role in the diagnosis of these fistulas.
193
Educational Goals/Teaching Points: Most AV fistulas involving
aorta and coronary artery are acquired. AV fistulas can cause tissue ischemia. Coronary artery fistulas often drain into the right
side of heart.
Techniques: The fistulas that we discuss in this review include –
Coronary artery to coronary sinus fistulas, inadvertent anastomosis of a left internal mammary artery (LIMA) graft to anterior
interventricular vein, aorta to right atrial fistula, aorta to inferior
vena cava (IVC) fistula, right coronary to right atrium to superior
vena cava (SVC) fistula and complex coronary artery fistulas.
Fistulas from coronary artery are rare (right coronary artery [RCA]60 %, left coronary artery [LCA]-35%) and could be congenital,
traumatic or iatrogenic. It usually drains in right heart chambers
(RV-(40%), RA –(25%), PA (15–20%), coronary sinus (7%)},
which results in a left to right shunt. Small fistulas can be asymptomatic, but large fistulas develop complications like cardiac failure, myocardial ischemia or infarction, infective endocarditis and
rupture. In symptomatic patients, fistulas are closed by percutaneous device closure or by surgical repair. Aorta–IVC fistulas are
usually post-traumatic. Aorta–right atrial fistula usually results
from an intimal tear near the aortic root, especially in patients
with prior cardiac surgery. The dense pericardial adhesions resulting from the previous surgery probably contain the free rupture
and contribute to the formation of the aorta–right atrial fistula.
CT angiography is an excellent method to delineate the location
and extent of the AV fistulas. MRI offers high spatial resolution
and multiplanar imaging capabilities, which detect even tiny fistulas. MR angiography is more useful in accurate delineation. Conclusion: CT and MRI are very useful in determining the type
and connection of fistulas involving the aorta or coronary arteries.
Careful analysis in multiple planes is required for complete evaluation of fistulas. E053. MRI in Evaluation of Pericardial Lesions–A Pictorial
Review
Background Information: The pericardium is a flask shaped
sac, which is lined by an inner visceral layer and outer serous
layer. The pericardial sac contains 10-50 ml of fluid is normal
conditions. It has two sinuses (transverse, oblique) and multiple
recesses. Pericardium has mechanical, membranous and ligamentous functions. MRI is the most useful modality which is useful in assessing the morphology of pericardium and the functional consequences of pericardial abnormalities. The purpose of this
exhibit is to illustrate the MRI appearances of the various pericardial disease processes. Educational Goals/Teaching Points: MRI is useful in evaluation
of all pericardial pathologies, including morphological and functional abnormalities. Delayed enhancement is very useful in
assessing pericardial inflammation and differentiating pericardial
layers and fluid. Ventricular interdependence, diastolic restraint,
diastolic septal bounce, conical/ tubular deformity of ventricles
are features of pericardial construction. Pericardial disease is
often focal and imaging in multiple planes is essential for diagnosis. Normal thickness pericardium does not rule out constriction.
194
Techniques: MRI sequences useful in evaluation of pericardium
are – Cine steady state free precession (SSFP), T1- and
T2-weighted spin echo/gradient echo, postcontrast delayed
enhancement and quantitative flow ( SVC, pulmonary venous
flow). Normal pericardium is smooth and low signal intensity,
measuring up to 2 mm in systole. Features to be assessed in the
pericardium are thickness, contour, focal/diffuse abnormality,
enhancement pattern, pericardial motion/tethering, deptal
bounce, diastolic filling pattern, deformity of ventricles, superior
vena cava (SVC)/inferior vena cava (IVC) size, flow curves in SVC
and pulmonary veins, pleural effusion and chamber sizes. There
is a wide spectrum of abnormalities in the pericardium. The various abnormalities illustrated in this pictorial review include congenital (pericardial cyst, absence of pericardium); effusion (circumferential, focal, simple/complex, mild/moderate/severe, cardiac tamponade); hemopericardium; pneumopericardium; pericarditis (acute, chronic, focal); abscess; calcification; tumors
(extension of lung cancer, esophageal cancer, metastasis, lymphoma, sarcoma), and constriction (diffuse, focal).
Conclusion: MRI is very pivotal in the diagnosis of various pericardial abnormalities. Imaging is done in multiple planes with
black blood sequences, cine MRI and delayed enhancement. E054. Right Ventricular Involvement in Patients With Acute
and Chronic Myocardial Infarction: A Cardiac Magnetic
Resonance Study
Algeri, E.; Francone, M.; Carbone, I.; Vasselli, F.; Cannavale, G.;
Iacucci, I.; Catalano, C.; Passariello, R. La Sapienza University of
Rome, Rome, Italy
Address correspondence to E. Algeri (emanuela_algeri@yahoo.
com)
Objective: Right ventricular (RV) involvement occurs in about
one-half of patients with inferior acute myocardial infarction
(AMI) and its identification is relevant as it defines a significant
clinical entity, associated with considerable immediate morbidity
and mortality and has a well-delineated set of priorities for its
management. Diagnosis of this condition is challenging as it
requires a high degree of suspicion based on clinical findings and
the early recording of the electrocardiogram through right precordial leads, as well as elevated right-sided filling pressures;
echocardiographic assessment of RV also remains technically difficult. Present study sought to assess feasibility of late enhancement (LE) cardiac MR (CMR) to detect RV infarctions and to evaluate its prevalence in a population of pts with acute and chronic
myocardial infarction (MI).
Materials and Methods: Ninety-seven patients with acute
(n=58) or chronic MI (n=31) were retrospectively assessed. All
patients previously underwent CMR using a 1.5T scanner
(Siemens Medical Solutions, Forchheim, Germany); imaging protocol included in all cases steady state free precession (SSFP)
cine-MR sequences, turbo spin-echo (TSE) T2-weighted short tau
inversion recovery (STIR), 1st pass perfusion and LE imaging
acquired after gadobenate dimeglumine administration (Bracco,
Milan, Italy). Images were analyzed dividing right ventricle into
nine segments and assessing presence of LE enhancement for
each segment; data were matched with both electrocardiogram
(ECG) and transthoracic echo which were previously recorded in
all patients.
Results: Among our study population, 31/97 patients had inferior MI, 62/97 had anterior wall MI and the remaining four had
extensive chronic scarring involving both anterior and inferolateral walls. Overall, RV LE was observed in 22/97 cases (22%):
13/31 (41%) inferior MI; 9/62 (14%) anterior MIs. In the subgroup of inferior MI, ECG with right precordial leads + echocardiography showed signs of RV involvement in 12/22 cases (54%);
no hints of RV involvement were observed in the anterior MI pts.
Additionally, RV infarctions showed larger RV EDV volumes as
compared to others (163 ± 27 mL vs. 132 ± 11 mL p=0.37).
Educational Goals/Teaching Points: MRI is the best modality
in evaluation of HOCM. MRI is accurate in assessing the septal
thickness. Systolic anterior motion of mitral valve (SAM) can be
seen. In-plane phase contrast flow imaging is useful for assessing
the flow gradient in left ventricular outflow tract. Delayed
enhancement indicates presence of scar, which has adverse prognostic significant and requires an implantable cardioverter defibrillator. Abnormal papillary muscle morphology is assessed with
3D sequences. In apical hypertrophic cardiomyopathy, a spade
like configuration of distal cavity is noted.
Conclusion: Detection of RV is feasible with LE CMR and very
often misdiagnosed with conventional clinical-instrumental data.
Techniques: MRI sequences used in evaluation of HOCM are
cine steady state free precession (functional abnormalities, systolic anterior motion of mitral valve.), myocardial tagging (abnormalities in contraction and strain), spin echo sequences (for
edema and differentiating from other lesions), phase contrast
flow imaging (gradient across the high velocity jets, flow patterns
in superior vena cava, inferior vena cava), 3D navigator gated
whole heart imaging (anatomy of papillary muscles, apical displacement of anterolateral papillary muscle and bifid posterior
muscle are abnormal) and delayed enhancement (presence of
scar is confined to hypertrophied areas, is a substrate for arrhythmia and indicates adverse prognosis). MRI is useful in classifying
the hypertrophic cardiomyopathy (concentric, eccentric, basal,
mid ventricular, apical, Takusubo). Delayed enhancement is confined to hypertrophied area and is due to myofibrillar disarray
and expansion of interstitial space or due to presence of
ischemia. E055. Cardiac MR Imaging: A Concise Review of Basic
Anatomy, Imaging Planes, and Pulse Sequences (CME
Credit Available)
Vyas, R.; Tuttle, D.; Ginat, D. University of Rochester, Rochester, NY
Address correspondence to D. Tuttle ([email protected].
edu)
Background Information: Cardiac MR imaging can be challenging for the resident and novice radiologist. The purpose of this
exhibit is to discuss the cardiac pulse sequences, familiarize the
viewer with the standard cardiac MR imaging planes, and provide
an interactive review of basic cardiac MR anatomy.
Educational Goals/Teaching Points: The standard cardiac pulse
sequences for cardiac morphology, function, perfusion, and viability assessment will be demonstrated. Standard imaging planes
of the heart, great vessels, and coronary arteries will be shown.
Basic cardiac anatomy will be reviewed and presented in an
interactive quiz format. Key Anatomic/Physiologic Issues and Imaging Findings/
Techniques: An interactive format integrating cardiac anatomy on MRI in standard imaging planes will be presented.
Conclusion: After the exhibit the viewer will be familiar with
basic cardiac MR imaging sequences; understand cardiac imaging
planes, identify basic cardiac anatomy on MR. E056. Role of MRI in Evaluation of Hypertrophic
Cardiomyopathy–A Pictorial Review (CME Credit Available)
Background Information: Hypertrophic cardiomyopathy is an
inherited disorder characterized by inappropriate myocardial
hypertrophy in the absence of obvious cause of hypertrophy such
as systemic hypertension or aortic stenosis. It is the most common cause of sudden death in young patients. Pathologically it is
characterized by myofibrillar disarray and endothelial dysfunction.
The various types are concentric, eccentric, basal, mid ventricular,
apical (Yamaguchi) and Takotsubo. It may also involve the right
ventricle and can be associated with atrial dilation. MRI is a very
important tool in the diagnosis and characterization of hypertrophic obstructive cardiomyopathy (HOCM). The purpose of this
exhibit is to illustrate the typical MRI findings and variants in
HOCM.
Conclusion: MRI is a very useful modality in evaluation of hypertrophic cardiomyopathy. MRI is used in diagnosis, determining
the type, evaluation of function, estimating flow gradient and
most importantly for presence of scar.
E057. Brain Natriuretic Peptide’s Emerging Supplemental
Role in Improving the Diagnosis of Congestive Heart Failure
in Conjunction with Chest Radiograph (CME Credit
Available)
Di Poce, J.; Salvatore, M.; Geha, F.; Abi Rafeh, N.; Ahern, K. Staten
Address correspondence to J. DiPoce ([email protected])
Objective: The objective was to evaluate the supplemental role
of brain natriuretic peptide (BNP) in improving diagnosis of congestive heart failure (CHF) utilizing chest radiographs.
Materials and Methods: Institutional review board approval,
HIPPAA compliance and informed consent were obtained. A total
of 355 patients (172 females and 183 males, average age 70.9
years old, range 28-102) were included if their emergency department chief complaint was dyspnea. Participants were over 18
years old and not pregnant. Patients were not included if their dyspnea was clearly not related to pulmonary edema such as from
pneumothorax. A research assistant documented the BNP value.
The radiograph was then interpreted by a board certified radiologist without other patient knowledge, including lab data and/or
preliminary diagnosis. Radiographs were evaluated for presence
and severity of CHF. After at least one week passed, the same radiographs were reviewed by the same radiologist with BNP. Two
separate clinicians reviewed the history, physical exam, diagnostic
tests and laboratory data to establish the final diagnosis.
195
Results: Sensitivity increased from 82.6% without BNP to 94.5%
with BNP significant at p.02, Chi Square, Yates corrected. ANOVA
showed that BNP levels for radiograph diagnoses of negative,
mild, moderate and severe CHF were significantly different at
p.000. Tukey-Kramer Multiple Comparison test indicated that the
BNP levels were significantly lower in the negative or mild group
compared to the moderate or severe group. ROC curves showed
that AUC for radiograph diagnosis with BNP was 0.784 and without BNP was 0.669. This difference was 0.114, Z value 3.94 and
p=0.0001.
Conclusion: CHF diagnosis with chest radiograph significantly
improved with the addition of BNP. Additionally, BNP values are
significantly different between chest radiograph severity groups.
BNP should be available to radiologists when evaluating the
chest radiographs of patients short of breath because BNP
improves congestive heart failure diagnosis.
E058. Volume Visualization of Isotropic CT Data: Role in
Imaging the Ascending Aorta (CME Credit Available)
Johnson, P.; Horton, K.; Fishman, E. Johns Hopkins University
School of Medicine, Baltimore, MD
Address correspondence to P. Johnson ([email protected])
Background Information: Contrast-enhanced CT is the primary
imaging modality used for suspected aortic pathology. In the past
decade, dataset quality has been improved by both advances in
scanner technology and display techniques. Because of the anatomic configuration of the ascending aorta, characterization of
pathology is facilitated by interactive multiplanar display of a
high-resolution dataset acquired during maximum enhancement.
protocol optimization for 64-MDCT of the thoracic aorta and the
utility of interactive multiplanar display for this anatomic region.
It will demonstrate the CT appearance of a range of pathology
that affects this section of the thoracic aorta.
Techniques: The exhibit will include protocol optimization (isotropic data acquisition, contrast infusion technique and timing,
the importance of cardiac gating); postprocessing and display
(2D multiplanar reconstructions, 3D maximum intensity and volume rendering), and pathology of the ascending aorta (aortic
valve disease, supravalvular aortic stenosis, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, and
concomitant coronary artery disease).
Conclusion: Pathology that affects the ascending aorta must be
evaluated in conjunction with assessment of the aortic valve, as
well as the coronary arteries since many of these patients are
managed surgically. As shown by the cases presented in this
exhibit, MDCT interpretation is optimized by attention to acquisition technique, including cardiac gating, and the use of interactive multiplanar display techniques. 196
E059. MDCT in the Preoperative Evaluation and Surveillance
of Endovascular Repair of the Thoracic Aorta
Godoy, M.; Cayne, N.; Ko, J. New York University, New York, NY
Address correspondence to M. Godoy ([email protected])
Background Information: Endovascular techniques have recently emerged as a less invasive alternative for repair of descending
thoracic aortic pathology (aneurysm, pseudoaneurysm, aortic dissection, penetrating aortic ulcer, intramural hematoma and traumatic aortic rupture). The purpose of this educational exhibit is
to discuss and illustrate the role of MDCT and CT reformations in
the preoperative assessment of the aorta and postendograft follow up.
Educational Goals/Teaching Points: MDCT protocol for assessing the pre- and postsurgical aorta will be addressed along with
inclusion criteria for endovascular repair of the thoracic aorta
(TEVAR). The postoperative appearance after TEVAR will be
reviewed with emphasis placed on complications, including
endoleak (Types I to IV), endotension; graft kinking, migration,
and infection; embolism; iatrogenic aortic dissection or rupture.
Techniques: Noncontrast CT prior to contrast-enhanced CT imaging enables easier identification of acute intramural hematoma,
aortic calcification and differentiation of pre contrast high attenuation areas from areas that enhance on post contrast imaging
(endoleaks). Preoperative CT evaluation requires precise characterization of pathology using post-processing techniques such as
curved multiplanar reconstructions. Important information to be
contained in the radiology report includes: measures of the maximal true cross-sectional diameters of the aorta at and immediately proximal, and distal to the pathological segment(s); presence of excessive angulation of the aortic arch; and distance of
the proximal and distal aspects of the aortic pathology from anatomical landmarks such as the left subclavian artery and celiac
artery, respectively. Circumferential thrombus, calcification at the
planned endograft landing zones, aortic, femoral, and/or iliac
artery tortuosity may affect candidacy for endograft therapy. 3D
volume rendered techniques readily enable assessment of the
position and integrity of the stent graft. MPRs play a major role in
the identification and characterization of endoleaks, change in
size of the aorta, or other complications.
Conclusion: MDCT with reformations serve an important role in
the preoperative and postoperative evaluation of the thoracic
aorta. Familiarity with the criteria used for determining the candidacy or exclusion of patients for TEVAR is essential. An understanding of the normal appearance of the postoperative thoracic
aorta enables identification and timely treatment of potentially
fatal complications.
E060. Thoracic-Vascular Anomalies: Recognition on CT Imaging
Kakarla, R.; Weiss, J.; Kirshenbaum, K. Illinois Masonic Medical
Center, Chicago, IL
Address correspondence to R. Kakarla ([email protected])
Conclusion: Radiologists should be familiar with the MDCT
appearances and clinical importance of these rare venous disorders of the thorax.
Background Information: Advances in MDCT technology have
allowed for accurate visualization of thoracic vasculature and rare
associated anomalies. MDCT and CT angiography (CTA) techniques allow for accurate depiction of such anomalies and obviate need for conventional angiography for their visualization. As
thoracic vascular anomalies have significant clinical implications,
especially in the pediatric population, it is essential to be aware
of their presentation of cross-sectional imaging.
E062. Back to Basics: The Language of Signs in Thoracic
Radiology
Choi, E.1; Patel, M.2; Batra, P.3; Verma, R.2; Jude, C.2 1. University
of California-Los Angeles Medical Center, Los Angeles, CA; 2.
Olive View – University of California-Los Angeles Medical Center,
Los Angeles, CA; 3. West Los Angeles Veterans Affairs Medical
Center, Los Angeles, CA
Address correspondence to C. Jude ([email protected])
various thoracic vascular anomalies recognized on CT imaging;
emphasize proper recognition of thoracic vascular variants in
order to avoid misdiagnosis of pathology and facilitate proper
intervention, and delineate the clinical implications of each of the
thoracic vascular variants commonly encountered.
Background Information: The purpose of this educational
exhibit is to review the classic radiological signs in thoracic imaging on chest radiographs and CT based on anatomic location. Recognition of these signs in thoracic imaging is important
for describing abnormalities, understanding pathological processes and formulating a differential diagnosis.
Techniques: Thoracic vascular variants encountered on our
review include: left sided superior vena cava, partial anomalous
pulmonary venous return, azygous vein fissure, anomalous left
brachiocephalic vein, left sided aortic arch with aberrant right
subclavian artery, right sided aortic arch with aberrant left subclavian artery, scimitar syndrome, arteriovenous malformations, and
left pulmonary artery sling. There will be a discussion of other
vascular anomalies and their clinical implications.
Educational Goals/Teaching Points: The educational goals of
this exhibit are to review the definition of classic signs in thoracic
radiology; to illustrate these signs by examples on chest radiographs and CT, and to describe the significance and limitation of
each sign.
Conclusion: Anomalies of intrathoracic vessels can alter radiographic anatomy of the mediastinum. CT is an excellent tool in
illustrating the variant thoracic vascular anatomy. It is essential to
recognize these entities in order to avoid misdiagnosis of pathology and assist in proper intervention if necessary.
E061. Unusual Thoracic Venous Abnormalities: Appearance
on MDCT (CME Credit Available)
Hendi, J.; Maldjian, P. University of Medicine and Dentistry of New
Jersey-New Jersey Medical School, Montvale, NJ
Address correspondence to J. Hendi ([email protected])
Background Information: Radiologists are confronted by unanticipated venous abnormalities of the thorax during interpretation
of CT studies. Correct diagnosis of these disorders may affect
patient management and avoid further unnecessary imaging. The
purpose of this exhibit is to demonstrate the MDCT appearance
of some of the more unusual thoracic venous abnormalities.
Educational Goals/Teaching Points: Some of the rare venous
abnormalities discussed in this exhibit include: pulmonary vein
varix, retroaortic left subclavian vein, atypical venous drainage of
pulmonary sequestration, “escape” of the azygos vein from the
azygos fissure, uncommon variants of partial anomalous pulmonary venous return (before and after surgical repair) and systemic
venous to pulmonary venous shunt.
Techniques: We emphasize the vital role of multiplanar image
reformatting and volume rendering in distinguishing among
these anomalies and making the correct diagnosis.
Techniques: The proposed exhibit will be organized based on
the location of the radiological signs. The following signs will be
discussed: Parenchyma and Airways -air bronchogram, silhouette,
air crescent, gloved finger, Golden S, Luftsichel, flat waist, fallen
lung, CT angiogram, halo, signet-ring, tree-in-bud, comet tail;
Mediastinum and Hila-cervicothoracic, hilum convergence or
overlay, doughnut, continuous diaphragm, ring around the artery,
double density, fat pad; Vascular-Fleischner, Hampton’s hump,
Westermark, figure 3, scimitar; and Pleura and Chest Wall-deep
sulcus, tapered margins, split pleura.
Conclusion: At the end of reviewing this exhibit, readers will be
able to recognize the common signs in thoracic radiology; relate
the signs to anatomical structures and pathological processes,
and understand the significance and limitations of each sign.
E063. Chest Imaging in the Intensive Care Unit: Evaluation
of Tubes, Lines, Catheters and Monitors (CME Credit
Available)
Godoy, M.; Leitman, B.; Vlahos, I.; deGroot, P.; Naidich, D. New
York University, New York, NY
Background Information: The evaluation of portable chest radiographs of patients in the intensive care unit is a challenging task
due to technical limitations as well as the inability of patients to
cooperate. However, it is essential to evaluate the multiple support
and monitoring devices used in these patients. As a component of
accurate interpretation of portable chest radiographs, it is necessary to stay abreast of newer devices and potential complications.
Educational Goals/Teaching Points: In this educational exhibit
we discuss and illustrate normal and aberrant positioning of
support and monitoring devices, as well as their inherent
complications.
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Techniques: The support and monitoring devices illustrated in
this exhibit include endotracheal and tracheostomy tubes,
nasogastric/feeding tubes, central venous and Swan-Ganz catheters, intra-aortic counter-pulsation balloon pumps, thoracic
drains, cardiac pacemakers/automatic implantable cardioverter
defibrillators, as well as an assortment of other less commonly
used devices.
Conclusion: The recognition of complications arising from the
introduction and use of these devices is often not clinically
apparent; therefore radiologists are critical in the detection and
confirmation of these issues.
E064. Imaging Manifestations of Chest Lesions in Patients
with HIV/AIDS (CME Credit Available)
Ferguson, E.1; Berkowitz, E.2 1. The University of Texas Medical
School at Houston, Houston, TX; 2. Emory University School of
Medicine, Atlanta, GA
Address correspondence to E. Ferguson (ecferguson@hotmail.
com)
Background Information: Many abnormalities are encountered
on chest radiographs and computed tomographic images of
patients with HIV/AIDS. Distinguishing among these various entities and rendering appropriate differential diagnoses is crucial for
directing patient care. Examples include opportunistic infections
such as fungal, mycobacterial, Pneumocystis jiroveci and other
atypical pneumonias, malignancies such as lymphoma and
Kaposi sarcoma, lymphoid interstitial pneumonia, as well as
other abnormalities such as bronchiectasis and adenopathy in
certain settings. Each type of abnormality, its imaging appearance, and distinguishing features will be reviewed.
Educational Goals/Teaching Points: The exhibit viewer will
review the many intrathoracic imaging abnormalities encountered in patients with HIV/AIDS; learn to distinguish and render
appropriate differential diagnoses of pulmonary and other
intrathoracic lesions associated with HIV/AIDS, and understand
the importance of each abnormality, its pathophysiology, and
treatment, as well as prognosis.
Techniques: The radiographic manifestations, pathophysiology,
and clinical outcome of each type of intrathoracic abnormality
associated with HIV/AIDS will be explained. The importance of
distinguishing among these lesions will be discussed, especially
since many of these lesions are treated differently and have different clinical implications.
Conclusion: Many chest imaging abnormalities associated with
HIV/AIDS are first diagnosed radiologically, making it crucial to
distinguish among these various abnormalities in order to optimize patient care. This exhibit will serve to review the diverse
imaging lesions found in the lungs and other parts of the chest
in patients with HIV/AIDS, to render diagnostic clues that aid in
distinguishing among these various diseases, and to explain the
pathophysiology and prognosis of each disease. Understanding
these diseases, their imaging manifestations, and clinical relevance will improve patient outcome.
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E065. Potential Clinical Applications of Dual-Energy CT in
Thoracic Imaging (CME Credit Available)
Godoy, M.1; Naidich, D.1; Leidecker, C.2; Assadourian, B.1;
Schmidt, B.2; Vlahos, I.1 1. New York University, New York, NY; 2.
Siemens Medical Solutions, Malvern, PA
Background Information: Recent advances in dual-source
MDCT technology have allowed simultaneous acquisition of CT
images at two different tube voltage settings during a single
acquisition. The advantages of dual-energy CT (DECT) technique
are twofold. Low kilovoltage imaging in CT angiographic studies
results in increased iodine conspicuity, due to increased photoelectric interactions. The use of simultaneously acquired low and
high kVp data permits the calculation of material specific images
based on the differential CT attenuation of selected substances at
two different energies. The purpose of this educational exhibit is
to review and illustrate potential clinical applications of DECT for
thoracic imaging.
Educational Goals/Teaching Points: The potential clinical
applications of DECT for thoracic imaging include evaluation of
the thoracic aorta, pulmonary arteries, pulmonary nodules and
masses, nodes, pleural disease and airway disease.
Techniques: The increased conspicuity of iodine at low tube
voltage images improves vascular opacification at CT angiography
of the aorta or pulmonary arteries. Consequently, the number of
inconclusive pulmonary artery studies may be reduced. In aortic
imaging, material specific DECT imaging has the potential to
eliminate the necessity to perform precontrast images by the use
of virtual noncontrast images. Material specific pulmonary blood
flow maps allow for detection of iodine perfusion defects in the
pulmonary parenchyma in patients with pulmonary emboli. For
pulmonary nodules, masses, pleural disease and nodes DECT can
be used for the detection of calcification and enhancement on
postcontrast studies alone by depicting the presence of calcium
and iodine, respectively. Characterization of large and small airways disease may be improved by the use of DECT subtraction
techniques comparable to ventilation/perfusion imaging. DECT
identification and removal of osseous structures is another application, which is particularly useful for 3D imaging and significantly reduces postprocessing time.
Conclusion: Dual-source DECT is a new technique with a variety
of potential clinical applications for thoracic imaging.
E066. Road Rules: Evaluation of Lesions in the Thoracic Inlet
Covarrubias, D.1; Surapaneni, K.1; Reede, D.1; Smoker, W.2;
Holliday, R.3; Gentry, L.4 1. Long Island College Hospital,
Brooklyn, NY; 2. University of Iowa Hospitals and Clinics, Iowa
City, IA; 3. The New York Eye and Ear Infirmary, New York, NY; 4.
University of Wisconsin Hospitals, Madison, WI
Address correspondence to D. Covarrubias (dcovarru@chpnet.
org)
Background Information: The purpose of this computer-based
exhibit is to review the anatomy of the thoracic inlet (TI); review
the clinical and radiographic findings of lesions encountered in
this region.; illustrate common pathways of disease spread, and
demonstrate a systematic approach for the interpretation of
cross-sectional images of the TI.
learn the anatomy of the TI; develop an understanding of the
anatomic spaces that cross the TI (carotid, visceral, danger, and
perivertebral); learn pathology encountered in this region with an
emphasis on the space of origin, and be able to demonstrate a
systematic approach for the evaluation of lesions in the TI based
on the space and/or organ of origin.
Techniques: Lesions in the various anatomic spaces of the neck
will be illustrated, including the following: 1) Carotid Space:
carotid and jugular venous thrombosis, aortic dissection with
extension into the carotid artery; 2) Visceral Space: thyroid
lesions, esophageal lesions, infection, and central airway pathology (i.e., tracheal stenosis, saber-sheath trachea, tracheoceles, and
Mounier-Kuhn syndrome); 3) Retropharyngeal Space: infection;
4) Perivertebral Space: location and pathology affecting major
nerves (recurrent laryngeal, phrenic, sympathetic chain, cervical
nerve roots and brachial plexus).
Conclusion: The TI is a busy intersection between the neck and
the chest, containing a number of structures from several organ
systems. An understanding of the pertinent anatomy and pathology that involves this region is essential for accurate interpretation of radiologic studies. This exhibit presents this anatomic and
pathologic information in an organized, algorithmic fashion in
order to allow the viewer to develop a systematic approach for
the interpretation of these studies.
E067. Will the Real Sarcoid Please Stand Up: How to
Differentiate Sarcoidosis from Common Mimics Seen in
Thoracic Imaging
Flamini, D.; Song, Y.; Covarrubias, D.; Martino, J.; Leonardo, R.;
Reede, D. Long Island College Hospital, Brooklyn, NY
Address correspondence to D. Flamini ([email protected])
Background Information: Sarcoidosis can be perplexing to residents and practicing radiologists who may be asked to interpret
cases on call or as part of their general coverage. Given that there
is overlap in the radiographic appearance of many disease entities in the lung, we propose a method of review that directly compares cases of sarcoid with other disease entities that may have
similar appearances, in order to emphasize the correct findings.
Educational Goals/Teaching Points: The goals are to increase
the general radiologist’s ability to make a confident diagnosis in
straightforward and more atypical cases of sarcoidosis, and to
emphasize the distinguishing characteristics of sarcoid from similar appearing, but different disease entities.
Techniques: The exhibit will review typical imaging findings of
sarcoidosis at various stages of appearance and present case
pairs of sarcoid with a closely matched nonsarcoid mimic accompanied by a discussion of the salient imaging features for distinction. Both typical and atypical appearances will be included.
Cases will be presented as unknowns to allow the participant to
test themselves.
Conclusion: Upon completion of this exhibit the viewer will have
become familiarized with common and uncommon thoracic radiographic manifestations of sarcoidosis; learned what CT imaging
findings to look for that can help identify or exclude sarcoidosis
when faced with a challenging case, and have the ability to offer
a more focused differential diagnosis when appropriate.
E068. A Radiologist’s Guide to the Revised Staging System
for Nonsmall Cell Lung Cancer (CME Credit Available)
Kligerman, S.; Abbott, G.; Fidias, P.; Neal, J. Massachusetts
General Hospital, Boston, MA
Address correspondence to S. Kligerman (skligerman@partners.
org)
Background Information: On January 1, 2009, the American
Joint Committee on Cancer (AJCC) will adopt a revised TNM staging system for nonsmall cell lung cancer as proposed by the
International Association for the Study of Lung Cancer (IASLC).
This new staging system will alter management and treatment in
many patients diagnosed with nonsmall cell lung cancer.
Educational Goals/Teaching Points: The goal of this educational exhibit is to describe and illustrate the new staging revisions
using a series of graphic illustrations and case-based examples.
Additionally, the exhibit will explain the rationale behind these
revisions so the radiologist can better understand their clinical
implications.
Techniques: Some important changes to the TNM classification
of nonsmall cell lung cancer include the subdivision of the T1
and T2 cancers based on the size of the tumor. Satellite lesions
in the same lobe, once staged as T4, and in a different lobe,
once staged as M1, will now be considered T3 and T4 lesions,
respectively. The M staging system will also be subdivided into
M1a and M1b, where M1a disease represents nodules in the
contralateral lung and M1b disease represents distant metastatic
disease. Malignant pleural effusions or pleural nodules will now
be classified as M1a disease instead of T4.
Conclusion: Given the multiple changes to the TNM staging system for nonsmall cell lung cancer, it is integral that radiologists
learn the revised staging system and understand the reasons for
the changes so that we can continue to provide the best care for
the patient.
E069. Screen Detected Lung Cancer – Retrospective Analysis
of CT Appearance (CME Credit Available)
Dhopeshwarkar, M.; Menezes, R.; Dong, Z.; Sitartchouk, I.;
Keshavjee, S.; Boerner, S. University Health Network, Toronto,
Canada
Address correspondence to M. Dhopeshwarkar ([email protected])
Objective: The objective was to retrospectively evaluate characteristics of cancers diagnosed in a low dose CT lung cancer
screening study.
Materials and Methods: As part of I-ELCAP we screened a
cohort of 4,738 at risk current and former smokers, 2,601 (55%)
women and 2,137 (45%) men. Seventy-seven cancers in 75 indi-
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viduals were detected and evaluated for time point of detection,
location, morphology, histology, stage at diagnosis, treatment and
survival. In 37 cases PET was available for correlation. Follow-up
imaging for computation of growth rates was available in 57
cases.
Results: Seventy-seven cancers were found in 74 individuals, 56
women and 19 men, ranging in age from 50-79 years (mean 63
years). Only five (6.5%) cancers were not seen on baseline scan.
Histology revealed 56 (73%) adenocarcinoma, 11 (14%) squamous cell cancer (SCC), five (6%) small cell lung cancer (SCLC),
two (3%) large cell carcinoma and three (4%) carcinoid. The
most common location was left upper lobe (34%) and right
upper lobe (31%). Forty-four cancers were solid (57%), 14 (18%)
nonsolid and 19 (25%) part solid. Thirty-two (40%) lung cancers
had spiculations and 54 (70%) irregular margins. Mean tumor
size was 17 x 13 mm. Fifty-three (69%) cancers were Stage I (IA
51%, IB 18%). Most of the cancers (n=57, 74%) were treated
surgically. To date 65 patients are alive, with a median observation time of 26 months, survival is 87%. Only nine cases were
central masses: two extensive stage SCLC, one large cell (3A) and
three SCC (stage 4, 3B and 1B each) one stage 4 adenocarcinoma and two stage 1A carcinoid, all others were peripheral. Of 37
cancers evaluated by PET scan, 20 (54%) were metabolically
active: all of the squamous, SCLC and large cell cancers but only
12 (48%) of the adenocarcinoma were active. Of the 57 cases
with follow up CT scans, 34 nodules increased in size. Mean doubling time (DT) for all cancers was 232 days (median 113). In 26
women, mean DT was 239 days (median 131), while in eight
males, mean was 110 days (median 87). DT of >400 days was
present in five cases, all women and all adenocarcinoma. The
mean and median DT for adenocarcinoma was 237 and 123 days
respectively, for SCLC 136 and 148 days respectively and for SCC
73 and 63 days, respectively.
Conclusion: Screening detects lung cancer in an early treatable
stage. Central tumors are less common in screen-detected cancers and more often detected at late stage. Women have a higher
prevalence of lung cancers and have more slow-growing adenocarcinoma. Most cancers can be surgically resected and survival is
high after a medium observation time of 26 months.
E070. Mimickers of Lung Cancers, Spectrum of CT Findings
with Pathological Correlation (CME Credit Available)
Furuya, K.1; Yaumori, K.1; Sakino, I.2; Takeo, S.1; Sakai, M.1;
Uesugi, N.1; Kiyohisa, H.1; Seiya, M.1; Muranaka, T.1 1. National
Hospital Organization Kyushu Medical Center, Fukuoka, Japan; 2.
Saiseikai Yahata General Hospital, Kitakyushu-City, Japan
Address correspondence to K. Furuya ([email protected])
Background Information: Miscellaneous pulmonary conditions
produce tumor-like imaging findings that mimic primary lung
cancers and are difficult to distinguish from them. The purpose of
this exhibit is to present a wide variety of chest radiographs and
CT features of pulmonary conditions that mimic lung cancers and
to assess the image clues and clinical background for differentiation from cancers. Pathological findings will also be demonstrated in actual cases.
Educational Goals/Teaching Points: The goal is for the learner
to recognize miscellaneous pulmonary conditions that cause
imaging findings that mimic lung cancers; be familiar with the
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underlying pathological features, and understand the role of
chest radiographs and updated CT and other imaging modalities
in making the correct diagnosis.
Techniques: The pathologies presented are atypical adenomatous hyperplasia, focal fibrosis, nodular lymphoid hyperplasia,
malignant lymphoma, inflammatory myofibroblastic tumor,
tumorlet, pulmonary amyloidosis, round atelectasis, focal organizing pneumonia, intrapulmonary lymph node, tuberculoma, cryptococcosis, Wegener’s granulomatosis, parasitic infection, foreign
body granuloma in the peripheral lung, sarcoidosis, actinomycosis, invasive aspergillosis, and other types of miscellaneous infectious disease and granulomas.
Conclusion: Awareness of miscellaneous pulmonary conditions
that produce radiological findings that mimic lung cancers with
an understanding of their pathological background and careful
attention to the clinical information will help in achieving correct
diagnoses.
E071. CT Staging of Lung Cancer: The Role of 3D Imaging
Park, K.; Sun, J. Ajou University, Suwon, South Korea
Address correspondence to K. Park ([email protected])
Background Information: MDCT maximizes the advantages of
multiplanar reformat (MPR) and 3D volumetric images providing
useful information for staging in lung cancer. The purpose of this
exhibit is to explain optimal CT techniques and reconstruction
methods, and to discuss the advantages and pitfalls of 3D imaging in CT staging of patients with lung cancer.
Educational Goals/Teaching Points: The goals of this exhibit
are to learn optimal imaging techniques and reconstruction
methods for CT imaging of patients with lung cancer; to understand advantages and pitfalls of MPR, 3D, virtual bronchoscopy,
and angioscopy for T-staging of lung cancer related with airway,
mediastinal vessels, fissure and chest wall, and to recognize possible application of MPR imaging for N- and M- staging of lung
cancer.
Techniques: The use of a narrow detector collimation and overlapping reconstruction intervals is mandatory for a high z-axis resolution in MDCT imaging. MPR and 3D volume-rendering images
are useful for staging of airway and vascular involvement. Virtual
bronchoscopy and angioscopy have a limited value, but are
potentially useful for a group of particular cases. MPR images are
accurate for the detection of transfissural, chest wall, and diaphragmatic extension of tumors. Vertebral and sternal metastases
are easily depicted on coronal or sagittal reconstruction images.
Conclusion: 3D imaging using MDCT provides more accurate information, higher diagnostic confidence, and better communication in staging of patients with lung cancer.
E072. A Single Center Review of CT Pulmonary Angiogram
Findings and Patient Risk Factors (CME Credit Available)
Murphy, G.; Saliti, U.; Knox, M.; Keogan, M. St James’s Hospital,
Dublin 6, Ireland
Address correspondence to G. Murphy (gillianmurphy78@hotmail.
com)
Objective: Certain patient groups are felt to be at high risk of
developing pulmonary embolism (PE). An audit was performed
to establish if patients most at risk were those with a malignancy,
intravenous drug users, pregnant, postoperative or immobile
patients.
Materials and Methods: A retrospective study was performed
during a 12-month period in 2007 in our institution. Clinical data
was collected on all patients who underwent a CT pulmonary
angiogram (CTPA) from the hospital PACS system. Analysis was
performed using statistical package for the social sciences software.
Results: A total of 659 patients (283 males, 376 females) had a
CTPA. Overall 70/659 (10.6%) were positive for PE. These included 25/172 (14.5%) postoperative/immobile patients, 7/57
(12.3%) pregnant patients, 17/161 (10.6%) patients with malignancy and 2/33 (6.1%) intravenous drug users. Of the patients
who were without these risks, 24/306 (7.8%) had a PE. Thirtyseven of 37 (100%) patients with normal D-dimers had a negative CTPA; 11/43(25%) of patients with a concurrent deep
venous thrombosis (DVT) and 11/84 (13%) of patients with previous thromboembolic disease had a positive scan. A total of
172/659 (26.1%) had a normal scan. The most common abnormal findings included 165/659 (25%) with consolidation, with
99 (67%) of these already evident on chest X-ray (CXR). A total
of 34/659 (5.2%) had indeterminate pulmonary nodules that
required followup CT scans.
Conclusion: Patients within high risk groups and those with concurrent/previous thromboembolic disease had a higher rate of PE
than patients not in these groups. D-dimers had 100% negative
predictive value. CXRs are mandatory, frequently suggesting an
alternate diagnosis. A combination of medical history, clinical
findings, CXR +/- D-dimers (as per Well’s criteria) are necessary
when deciding who should have CTPA.
E073. World Health Organization/International Association
for the Study of Lung Cancer Classification of Lung and
Pleural Tumors: Radiological and Pathological Correlation
El-Sherief, A.; Xu, H.; Wandtke, J. University of Rochester,
Rochester, NY
Address correspondence to A. El-Sherief (ahmed_elsherief@urmc.
rochester.edu)
Background Information: This exhibit will review the World
Health Organization/International Association for the Study of
Lung Cancer histological classification of lung and pleural tumors
for the general radiologist.
Educational Goals/Teaching Points: This review of lung and
pleural pathological categories includes epithelial tumors, soft tissue tumors, mesothelial tumors, miscellaneous tumors, lymphoproliferative disease, secondary tumors, unclassified tumors, and
tumor-like lesions.
Techniques: Imaging techniques include: chest radiographs, CT,
PET-CT.
Conclusion: Lung tumors can be classified as epithelial tumors,
soft tissue tumors, mesothelial tumors, miscellaneous tumors,
lymphoproliferative disease, secondary tumors, unclassified
tumors, and tumor-like lesions.
E074. CT Halo Sign and Reversed Halo Sign: The Spectrum of
Pulmonary Diseases
Jeon, K.; Bae, K. Gyeongsang National University Hospital, Jinju,
South Korea
Address correspondence to K. Jeon ([email protected])
Background Information: The CT halo sign may be seen in a
wide spectrum of pulmonary diseases; it is most commonly
associated with hemorrhagic nodules and is more rarely associated with tumor cell or inflammatory infiltrate. The reversed halo
sign refers to a CT finding that consists of a focal ground-glass
attenuation surrounded by denser airspace consolidation. This
sign was known to be relatively specific for cryptogenic organizing pneumonia. The purpose of this study was to present various
pulmonary diseases showing the CT halo sign and the reversed
halo sign.
Educational Goals/Teaching Points: The goals are for the viewer of this exhibit to understand pathologic basis of the CT halo
sign and the reversed halo sign; review the imaging findings of
various pulmonary diseases with the CT halo sign and the
reversed halo sign, and know differential points of pulmonary
diseases showing the same signs.
Techniques: The CT halo sign and the reversed halo sign are
seen in more various pulmonary diseases than previously reported. We demonstrate the spectrum of pulmonary diseases showing the CT halo sign and the reversed halo sign and discuss their
clinical and radiological features with an emphasis on differential
diagnosis.
Conclusion: The CT halo sign and the reversed halo sign are
seen in more various pulmonary diseases than previously
reported.
E075. High-Resolution CT Findings of the Pulmonary
Vasculitities (CME Credit Available)
Chowdhry, A.; Mohammed, T. Cleveland Clinic, Cleveland, OH
Address correspondence to A. Chowdhry ([email protected])
Background Information: The purpose of this exhibit is to discuss the high-resolution CT (HRCT) findings of some of the most
common pulmonary vasculitities, including Wegener’s granulomatosis, Goodpasture’s syndrome, Churg-Strauss syndrome, and
Polyarteritis nodosa. This exhibit will also discuss some unique
features of each of these diseases.
of this exhibit are: HRCT is the imaging modality of choice in
evaluating patients with pulmonary vasculitis, and imaging is useful and important in guiding treatment and future management.
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Typical imaging findings in patients who have pulmonary vasculitis, include pulmonary nodules (with or without cavitation), airspace consolidation, and tracheobronchial abnormalities will be
discussed.
Techniques: This exhibit will outline the frequency of pulmonary
vasculitities in the general population; discuss the role that HRCT
has in evaluating patients with these diseases; review the most
common imaging findings, and discuss how imaging can be used
to evaluate treatment response and guide management. Sample
cases will be provided.
Conclusion: HRCT is the imaging modality of choice in evaluating patients with pulmonary vasculitis. Typical imaging findings in
patients who have pulmonary vasculitis, include pulmonary nodules (with or without cavitation), airspace consolidation, and tracheobronchial abnormalities. Imaging is useful and important in
guiding treatment and future management.
E076. Lymphangioleiomyomatosis: Radiological Findings
and Pitfalls
Pauls, S.1; Katenkamp, D.2; Brambs, H.1; Possekel, A.1 1.
University of Ulm, Ulm, Germany; 2. University of Jena, Jena,
Germany
Address correspondence to S. Pauls ([email protected])
E077. From Solitary Pulmonary Nodule to Diffuse Pulmonary
Consolidations: Spectrum of Chest CT Findings Associated
with Bronchoalveolar Carcinoma (CME Credit Available)
Cuthbertson, E.1; Duncan, D.2; Spektor, M.2; Lebowitz,Y.2; Khan,
A.2 1. No Institutional Affiliation; 2. Long Island Jewish Medical
Center, Glen Oaks, NY
Address correspondence to D. Duncan ([email protected])
Background Information: This exhibit will showcase an array of
CT findings associated with bronchoalveolar carcinoma (BAC)
with pertinent differential diagnosis. Histopathologic correlation
and the association of BAC with adenocarcinoma will also be
described.
Educational Goals/Teaching Points: The exhibit will outline the
demographics and natural history of BAC and the various chest
CT appearances of BAC which include: Focal Disease (80%)—
small peripheral nodule(s) or masses, focal ill defined airspace
opacities simulating pneumonia (30%), lobar consolidations
causing lobar expansion and fissural bulging, and elongated
opacities simulating mucoid impaction (rare); Diffuse Disease
(20%)—diffuse pulmonary consolidations simulating pneumonia,
and diffuse nodules, miliary or larger in size.
Techniques: Multislice CT and plain film will be used to demonstrate CT findings in BAC.
Background Information: The symptoms of patients with lymphangioleiomyomatosis (LAM) are often uncharacteristic. The
average time between the first clinical manifestation and the
diagnosis is about five to six years. Therefore, imaging methods
play a key role in making a definitive diagnosis.
Conclusion: At this presentation’s conclusion, the participant
should have learned the various chest CT manifestations of bronchoalveolar carcinoma with pertinent differential diagnosis and
histopathologic correlation.
Educational Goals/Teaching Points: The viewer of the exhibit
will learn about the etiology of LAM, about the association with
other diseases, about the clinical presentation and the differential
diagnosis in imaging methods (for example congenital cysts, centrilobular emphysema, Langerhans cell histiocytosis, lymphomas,
lymphocele, pseudomyxoma peritonei) and new therapeutic
regimes. In addition, the viewer will gain knowledge of typical
radiological findings in LAM with thoracic and abdominal manifestation. Rare imaging findings and pitfalls are demonstrated.
E078. Pulmonary Nodule Evaluation: Current Concepts
Godoy, M.; Nonaka, D.; Naidich, D. New York University, New
York, NY
Techniques: LAM is characterized by typical pulmonary cystic
lung lesions and lymphatic disorders. An abdominal manifestation – especially without pulmonary disorders – is very rare.
Multidetector row CT as an imaging method of choice is able to
detect lymph node enlargement, cystic changes including multiple intrahepatic cystic lesions and a cisterna chyli. Mesenterial
masses can be fatty or liquid presenting different types of lymphangioleimyomas, which can be distinguished with the measurement of Hounsfield units on CT. Intramural cystic formations
in the small bowel wall and the colonic wall are extremly rare
findings. In association with tuberous sclerosis complex, meningeomas and renal or hepatic angiomyolipoma are observed.
Conclusion: Radiologists should not only know the typical findings of LAM. To make a correct diagnosis, it is also necessary to
recognize rare radiological findings of the pulmonary and abdominal manifestation of LAM and regard them before making a final
diagnosis.
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Background Information: New reported data in the literature is
currently redefining lung nodule characterization, particularly
regarding subsolid pulmonary nodules and its correlation to adenocarcinoma of the lung. The purpose of this educational exhibit
is to review and illustrate clinical, radiological and pathological
aspects of adenocarcinoma of the lung. In addition, we review
current approach to pulmonary nodules detected by CT, and we
discuss the optimal approach to diagnosis and management
of subsolid nodules.
Educational Goals/Teaching Points: Subsolid pulmonary nodules include pure ground-glass opacity (GGO) and mixed part
solid/part ground-glass nodules. Subsolid nodules are now
known to frequently represent adenocarcinoma and its spectrum
of disease, including premalignant atypical adenomatous hyperplasia (AAH), bronchoalveolar carcinoma (BAC), mixed BAC/invasive adenocarcinoma and pure invasive adenocarcinoma.
Correlation between Noguchi pathological classification and CT
appearance of pulmonary nodules has been established. CT findings, in particular growth and relative contribution of groundglass to solid elements, have been demonstrated to predict
malignancy and prognosis. Evaluation of serial CT findings has
demonstrated stepwise progression of ground-glass lesions,
showing increase in size, appearance of solid component and
subsequent increase of the extent of the solid component.
Differential diagnosis for subsolid nodules includes benign
lesions, such as nodular fibrosis. Recognition of suspicious morphology and accurate measurements of volume doubling time
should aid in the management of these lesions.
Techniques: Based on current knowledge, we suggest that pure
GGO’s larger than 1 cm in size should be assumed as BAC/adenocarcinoma provided stability for at least three months, although
up to 20-25% will prove to be benign. Mixed solid/GGO lesions
should also be presumed as malignant. Surgical resection should
be considered for mixed solid/GGO nodules, especially if larger
than 1 cm or growing, and for pure GGO’s larger than 1 cm if
growing or if they develop solid components. For GGO’s larger
than 5 mm and smaller than 1 cm long term follow-up is requisite pending better definition of its true significance.
Conclusion: While controversial, reassessment of our approach
to small pulmonary nodules is necessary as we increase our
knowledge of the natural history and CT appearance of small
adenocarcinomas of the lung.
E079. Acute Pulmonary Embolism in Patients With Chronic
Obstructive Pulmonary Disease Exacerbation
Talanow, R.1; Timofte, I.2 1. The Cleveland Clinic, Cleveland, OH;
2. Huron Hospital, East Cleveland, OH
Address correspondence to R. Talanow ([email protected])
E080. Pulmonary Manifestations of Pneumocystis Carinii
Pneumonia in HIV: A Pictorial Essay
Morgan, J.; Allmendinger, A.; Krauthamer, A.; Hwang, B.; Perone,
R. St. Vincent’s Hospital and Medical Center, New York, NY
Address correspondence to J. Morgan ([email protected])
Background Information: Pneumocystis carinii pneumonia
(PCP) is a common opportunistic infection associated with
human immunodeficiency virus (HIV) disease. Although the incidence of pulmonary infection has decreased in the past few
years secondary to antiretroviral therapy, prompt identification of
the pulmonary manifestations are important for early initiation of
therapy. The typical and atypical as well as acute and chronic
manifestations of PCP in the lung will be discussed.
Educational Goals/Teaching Points: The exhibit will review
both acute and chronic as well as typical and atypical roentgenographic manifestations of PCP and discuss important emergency
plain film findings and the added value of CT to aid in diagnosis.
It will also discuss the sensitivity and specificity of various diagnostic modalities in disease detection and characterization.
Techniques: The exhibit will review the etiology and pathophysiology of pulmonary PCP; apply the pathophysiology of the disease process both in its acute and chronic forms to the imaging
manifestations on chest radiographs and CT, and provide cases of
less typical manifestations of PCP and potential complications.
Objective: Acute pulmonary embolism and chronic obstructive
pulmonary disease (COPD) exacerbation are difficult to distinguish by clinical signs and symptoms. Lung CT angiography (CTA)
and ventilation-perfusion (VQ) scans are currently used in the
evaluation of pulmonary embolism (PE). The objective of the
study was to investigate the incidence of PE in patients with
acute COPD exacerbation and to assess the necessity of performing CTA or VQ scans in these patients.
Conclusion: Although the incidence of PCP has been decreasing
in recent years in the HIV population, early imaging identification
and characterization remains critical for expedient diagnosis and
treatment crucial to patient survival. In this pictorial essay, we
hope to summarize the imaging findings of both acute and
chronic, as well as typical and atypical pulmonary PCP to help
facilitate the above goal.
Materials and Methods: We retrospectively reviewed 3,282
charts of all patients that presented to Cleveland Clinic emergency department between January, 2001 and December, 2006 with
acute COPD exacerbation. We selected the cases that had a lung
CTA or a VQ scan as the initial investigation for a possible PE.
E081. MDCT Evaluation of Large Airway Disease
Kakarla, R.; Gelshenen, K.; Kirshenbaum, K. Illinois Masonic
Medical Center, Chicago, IL
Results: VQ scans were initially done in five patients with COPD
exacerbation and were all low probability for PE. CTA was performed in 74 of the 3,282 patients with acute COPD exacerbation and was negative and indeterminate for pulmonary embolism in 68 and five patients, respectively. There were no positive
CTA results. From the six patients that had an indeterminate CTA,
two patients had a normal VQ scan, one patient had extensive
lung metastasis, one patient had extensive pneumonia, and one
patient had a mucus plug.
Conclusion: Our study did not reveal an increased incidence of
PE in patients with acute COPD exacerbation. None of the
patients had a positive CT for pulmonary embolism. Thus, pulmonary embolism in the acute setting of COPD exacerbation is
extremely unlikely.
Background Information: Trachea and main stem bronchi are
affected by a variety of disease entities. MDCT is a powerful tool
is assessment of large airway disease that can provide complementary information to clinical findings and bronchoscopy. Educational Goals/Teaching Points: The exhibit will delineate
normal appearance of trachea and main stem bronchi on MDCT;
present imaging features of pathologic entities involving large airways, and discuss the utility of 3D imaging and reconstruction
algorithms in diagnosis and follow-up of patients.
Techniques: The exhibit will focus on: Focal Large Airway
Disease, including tracheal stricture and neoplasm (primary or
secondary); Diffuse Large Airway Diseases, including tracheobronchopathia osteochondroplastica, infections, inflammatory diseases, relapsing polychondritis, saber sheath trachea, granulomatous
disease, sarcoidosis, Wegener’s, Mounier-Kuhn syndrome, and
amyloidosis; and tracheobronchomalacia. It will feature 3D
imaging/reconstruction techniques.
203
Conclusion: Tracheal and bronchial wall thickening and narrowing have a wide variety of causes. Recognizing locations of abnormalities can allow one to narrow differential diagnosis. As one
incorporates clinical and bronchoscopy findings, when available,
CT patterns allow for accurate diagnosis even when symptomatology is nonspecific.
E082. Cystic Lung Disease Spectrum: CT and HRCT Imaging
Patterns
Kakarla, R.; Bhatia, S.; Kirshenbaum, K. Illinois Masonic Medical
Center, Chicago, IL
Background Information: The wide range of the disease spectrum that present as diffuse cystic lung disease can pose a diagnostic dilemma for the clinician and diagnostic radiologist. CT
and specifically high resolution CT (HRCT) is an invaluable tool in
assessment of structural changes that occur in pulmonary parenchyma in the diffuse interstitial lung diseases.
Educational Goals/Teaching Points: The goals are to illustrate
a spectrum of common and rare cystic diseases involving the
lung and to delineate patterns of presentation on CT and HRCT
of diffuse cystic lung disease and outline an approach to narrow
the differential diagnosis through incorporation of clinical findings.
Techniques: This is a retrospective review of thoracic CT and
HRCT database and correlation with literature review to delineate
imaging patterns of cystic lung disease. It will focus on: Adult
Diffuse Cystic Disease, including Langerhans cell histiocytosis,
pulmonary lymphangioleiomyomatosis, tuberous sclerosis, lymphoid interstitial pneumonia, congenital cystic adenomatoid malformation, and idiopathic pulmonary fibrosis with honeycombing;
Pediatric Diffuse Cystic Disease, including congenital cystic adenomatoid malformation and bronchopulmonary dysplasia; and
mimics, including cystic bronchiectasis, emphysema, and congenital diaphragmatic hernias.
widely used to exclude PE in patients with a low probability of
having a PE. Patterns of referral related to D-dimer results have
been variable. As clinicians have become more reliant on CTPA for
the diagnosis of PEs, weighing the risk and benefit of CTPA and
determining the frequency of positive studies is important.
However, given the variable clinical presentation of PEs, evaluation of other pathologies seen would be helpful for clinicians and
radiologists. It would also be of value to correlate dD results with
the results of CTPA studies.
Materials and Methods: A retrospective review of 398 CTPAs at
HHSC from May, 2004 to December, 2005 was completed.
Studies with the heading “CT-Pulmonary Angiogram” were
included. There were no exclusion criteria. Data was collected by
two independent reviewers. Clinical history from the referring clinician, risk factors for PE, patient age and gender, PE positive,
and dD status were recorded. Broad categories for other thoracic
findings (pleural/pericardial effusion, airspace disease, adenopathy, tumor, metastases, emphysema, congestive heart failure)
were also included. A Chi squared analysis was completed between dD findings/other pathologies in relation to positive
PE findings.
Results: The frequency of PE in the reviewed studies was 23%.
Shortness of breath was the most common symptom at presentation. A trend for positive CTPAs were seen in older patients
(>60 years). A total of 41% had dDs performed with 73% positive and 27% negative. 18% and 2.4% of patients had PEs,
respectively. The most common other pathologies were air space
disease (71%) and pleural effusions (47%); 13% of patients had
no other pathology; 2% of patients had PE only and 11% had no
pathology at all.
Conclusion: Given that only 11% of patients had no pathology
at all, CTPA remains a useful test in evaluating not only for the
presence of PE, which occurred in almost a quarter of the
patients, but also for the presence of other significant pathologies. The usual symptoms associated with PE were not significant
predictors of a positive CTPA. In the setting of a negative dD in a
low probability patient, CTPA should be used judiciously.
Conclusion: CT and HRCT are invaluable tools in the approach
to assessment of cystic lung disease. Recognition of patterns of
presentation on HRCT, including size, location, distribution, and
associated findings is essential for accurate diagnosis. Correlation
of HRCT findings with clinical information allow one to narrow
the differential diagnosis.
E084. Revisiting Arteriovenous Malformations: Radiologic
and CT Imaging Characteristics and Corresponding
Treatment Options
Poole, P.; Ferguson, E. University of Texas at Houston, Houston, TX
Address correspondence to P. Poole ([email protected])
E083. CT Pulmonary Angiograms: Pulmonary Emboli,
Pulmonary Emboli Plus or No Pulmonary Emboli–A
Canadian Experience
Muhn N.1,2; Choudur H.1,2 1. Hamilton Health Sciences–General
Site, Hamilton, Canada; 2. McMaster University, Hamilton,
Canada
Address correspondence to N. Muhn ([email protected])
Background Information: Pulmonary arteriovenous malformations (PAVM) are quite uncommon. However, they are an important part of the differential diagnosis in patients with solitary pulmonary nodule or hemoptysis. PAVMs can be congenital,
acquired or associated with a genetic syndrome. The imaging
characteristics vary greatly in size, distribution and associated
findings, and can be overlooked or mistaken for common mimicking processes.
Objective: CT of the pulmonary arteries (CTPA) has replaced
invasive angiography for diagnosing pulmonary emboli (PE)
but carries with it a significant radiation dose and possible
adverse contrast reaction. The increased use and lower threshold
in ordering CTPA in the Hamilton Health Science Corporation
(HHSC) has been noticeable. D-dimer (dD) testing has been
plain film and CT characteristics most useful for establishing the
diagnosis of PAVM; define some of the associated findings that
suggest a congenital, acquired or genetic etiology; discuss common mimics of PAVMs and how they can be distinguished from
PAVMs on plain film and CT; discuss the plain film and CT imag-
204
ing characteristics most useful for differentiating simple from
complex lesions, including size, distribution, and associated findings, and review the treatment of PAVMs and how imaging findings contribute to treatment plans.
Techniques: This presentation will discuss the plain film and CT
imaging findings of PAVMs, including what processes can mimic
them and the approach to single or multiple lesions. We will
identify what defines a simple vs. complex lesion and the corresponding imaging characteristics most useful in diagnosing and
categorizing the PAVM. In addition, we will discuss how the imaging findings contribute to treatment decisions and what the radiologist should communicate to the clinician regarding the findings.
Conclusion: At the end of this presentation the radiologist will
be able to recognize the imaging characteristics found with simple and complex PAVMs and how the pattern of findings suggest
the etiology. In addition, the radiologist will be able to recognize
the associated imaging findings commonly found with congenital, acquired and genetic causes of PAVMs. Currently there are
many treatment options for PAVMs, including percutaneous
embolization using coils or balloons, surgical techniques including local excision, segmental resection, lobectomy, ligation, pneumonectomy, or video assisted thoracoscopy. The decision for no
treatment vs. invasive treatment and what form of invasive treatment is often based on the clinical status, as well as the reported
imaging findings. Therefore, this presentation will aid radiologist
in how to report imaging findings, including the importance of
size, distribution, feeding vessels, and possible complications
from the lesions that commonly affect the treatment plan.
E085. 16-Row MDCT of the Chest and Postprocessing
Techniques: Assessment of Pleural Effusion and Correlation
with Clinical and Biochemical Analysis
Theodorou, D.1; Theodorou, S.1; Kakitsubata, Y.2; Tsampoulas,
C.1,3 1. University of California, San Diego; San Diego, CA; 2.
Miyazaki Shakaihoken Hospital, Miyazaki, Japan; 3. University of
Ioannina, Greece, Ioannina, Greece
Address correspondence to S. Theodorou (rjtheodorou@hotmail.
com)
Results: The predominant symptoms were dyspnea (n=161),
cough (n=114), and chest pain (n=76). The most common cause
of PE was congestive heart failure/pericarditis (n=75; 30%) followed by malignant tumor (n=44; 17.6%), infection (n=38;
15.2%), idiopathic (n=35; 14%), paraneoplastic (n=26; 10.4%),
pancreatitis (n=13; 5.2%), postradiation (n=8; 3.2%), pulmonary
embolism (n=7; 2.8%), connective tissue diseases (n=2; 0.8%),
myxedema (n=1; 0.4%), and sarcoidosis (n=1; 0.4%). A total of
127 PEs were transudates and 123 were exudates. Small to moderate (n=132; 52.8%), large (n=80; 32%), and massive (n=38;
15.2%) PEs were seen. Congestive heart failure/pericarditis was
associated with bilateral small (n=70) or unilateral large PEs
(n=5). Malignant PEs were unilateral massive (n=27), or large
(n=17). Infectious PEs were unilateral small (n=33) or massive
(n=5). Idiopathic PEs were most commonly unilateral large
(n=30) or small (n=5). Paraneoplastic PEs were unilateral large
(n=20) or massive (n=6). PEs due to pancreatitis, pulmonary
embolism and myxedema were unilateral small (n=21) collections, whereas postradiation PEs were exclusively unilateral large
collections (n=8). Connective tissue diseases and sarcoidosis
were associated with bilateral small PEs (n=3).
Conclusion: MDCT combined with postprocessing tools proves
particularly useful in defining the location, morphology and
extent of PE. CT findings coupled with clinical and laboratory
data can suggest or establish a specific cause for the PE.
E086. Imaging of Broken Sternal Sutures: Evaluation of
Findings and Clinical Implications (CME Credit Available)
Gerard, P.1; Lefkovitz, Z.2; Kupfer Y.1; Hersh, J.1; Nikac, V.1 1.
Maimonides Medical Center, Brooklyn, NY; 2. Mount Sinai
Medical Center, New York, NY
Address correspondence to P. Gerard ([email protected])
Background Information: This exhibit will discuss the importance in the recognition and reporting of broken sternal sutures
in the interpretation of plain chest radiographs and imaging procedures and the potential complications of broken sternal
sutures, including local and intravascular migration and potential
fatal outcomes.
Objective: MDCT scanners with increased volume coverage and
thin detector collimation provide high-resolution multiplanar
reformatted (MPR) images, with or without application of maximum intensity projection (MIP) techniques. We assessed the role
of postprocessing techniques using 16-row MDCT in patients
with pleural effusion (PE).
Educational Goals/Teaching Points: Sternal sutures are routinely encountered on a daily basis in poststernotomy patients, in
both hospital and private imaging settings. When broken sternal
sutures are encountered, they are frequently not reported. We
discuss our experience in the reporting of these findings, and
report potential complications of broken sutures, possible life
threatening consequences, and why they should be reported routinely in all cases where they are recognized.
Materials and Methods: A total of 250 patients with 321 PEs
were evaluated with 16-row MDCT and diagnostic thoracentesis.
There were 152 male and 98 female patients, with an age range
of 35-84 years (mean age, 59.5 years). The medical records with
special attention to history and symptoms, biochemical parameters, culture, and cytologic examination of the pleural fluid were
reviewed. CT axial and multiplanar reconstructions with or without MIP images were created. CT scans were evaluated for localization, distribution, and size of PE. The CT protocol that allowed
acquisition of high-quality 2D reformations is presented.
Techniques: A wide array of case examples will be presented,
including a pictorial of plain film and CT appearance of broken
sutures, discussion of why sternal sutures break, cases of local
and distant suture migration, local skin reactions to broken
sutures, and show the critical reasons why these broken sutures
should be recognized and reported. The role and importance of
the radiologist reporting these findings will be emphasized. Cases
will be correlated with other imaging modalities, including the CT
identification of critical findings.
205
Conclusion: We will demonstrate the various plain film findings
and imaging appearances of broken sternal sutures. We believe
that every case of broken sternal wires should be documented
and reported by the radiologist, which is not currently routinely
performed. The postoperative chest radiograph and CT study
enables the radiologist to issue the earliest warning of possible
impending complications. This reporting would allow the treating
clinician to take appropriate measures in both the prevention
and management of unexpected emergencies.
nary nodules is important in decreasing morbidity and mortality.
Recent studies indicate that computer-aided detection (CAD)
software is a useful adjunct to the interpreting radiologist in
improving sensitivity and specificity of early nodule detection on
plain film radiography. Recently, dual energy subtraction (DES)
radiography has emerged and studies have demonstrated
improved detection of subtle lung nodules using this technique.
We therefore hypothesize that the combined use of computeraided detection software with dual energy radiography will have
an additive benefit in nodule detection.
E087. Congenital Vascular Anomalies of the Mediastinum
Sartip, K.; Gakhal, M. Christiana Care Health Services, New
Castle, DE
Address correspondence to K. Sartip ([email protected])
Materials and Methods: We compiled a set of 36 patients with
a total of 56 CT-proven and pathology-proven malignant lung
nodules who underwent DES radiography (GE Medical Systems,
Milwaukee, WI) at our institution. Twenty-five DES exams without
positive findings were also included as a control set. We utilized
a computer-aided detection program (Riverain Medical,
Miamisburg, OH) to identify and mark regions of interest (ROI’s)
on the DES images. These ROI’s were compared with actual findings (“truths”) as determined by an experienced chest radiologist.
Sensitivity, specificity, and false positives per case (FPPC) values
were obtained for both the plain film (PA) and bone subtracted
images (BSI). Differences in sensitivity between the PA and BSI
images were measured by the Chi-square and proportional differences test.
Background Information: Various congenital vascular anomalies of the mediastinum may be encountered during interpretation of thoracic studies. Some of these anomalies may be clinically significant such as those causing extrinsic impression of
adjacent structures or changes in cardiovascular physiology. This
exhibit will review, through case example, various congenital vascular anomalies of the mediastinum while discussing their clinical
significance.
congenital arterial and venous anomalies of the mediastinum
through case example and discuss clinical significance of congenital mediastinal vascular anomalies such as extrinsic impression
of adjacent structures, associated syndromes and organ abnormalities, changes in cardiovascular physiology, and relevant
issues regarding interventional procedures.
Techniques: Cross-sectional imaging with radiographic/fluoroscopic correlation, maximum intensity projection, and volume
rendered images will be utilized. Mediastinal arterial anomalies
involve the aortic arch and include right sided aortic arch with
aberrant left subclavian artery, mirror image right aortic arch,
double aortic arch, aberrant right subclavian artery with diverticulum of kommerell, pulmonary sling, coarctation, and pseudocoarctation. Examples of venous anomalies include persistent left
superior vena cava, azygous and hemiazygos continuation of inferior vena cava, and total or partial anomalous pulmonary venous
return. The authors will describe these anomalies through case
example while emphasizing their clinical significance
Conclusion: Congenital vascular anomalies of the mediastinum
can be incidental or clinically significant discoveries during radiologic examinations. Knowledge and recognition of their clinical
significance is essential for image interpretation.
E088. Analysis of Computer-Aided Detection Software with
Dual Energy Subtraction Radiography in the Assessment of
Malignant Pulmonary Nodules on Chest X-Ray (CME Credit
Available)
Mehandru, S.; Novak, R.; Gilkeson, R. University Hospitals Case
Medical Center, Cleveland, OH
Address correspondence to S. Mehandru (smehandru@gmail.
com)
Objective: Lung cancer remains the most common cancer diagnosis in the United States. Early detection of neoplastic pulmo-
206
Results: The use of the bone subtracted image with CAD significantly improved sensitivity of nodule detection (47.1% vs. 66.7
%: p=0.022) when compared to the PA image. In addition, FPPC
was significantly reduced from 1.69 to 0.67 when the PA image
was compared to BSI (Chi squared=6.92, p=0.008).
Conclusion: Dual energy subtraction radiography in conjunction
with computer-aided detection software significantly improves
detection of subtle malignant pulmonary nodules. In addition,
there is a significant reduction in false positive findings. This technique is therefore a promising advancement in the early detection of lung cancer.
E089. A Free and Customized Online Tool to Facilitate Quick
and Accurate Staging of Common Mediastinal Malignancies
Talanow, R.1; Timofte, I.2; Giesel, F.3 1. The Cleveland Clinic,
Cleveland, OH; 2. Huron Hospital, East Cleveland, OH; 3. German
Cancer Research Center (DKFZ) Heidelberg, Heidelberg, Germany
Background Information: Complex cancer staging systems
describe the anatomic spread of a particular malignancy. Staging
provides prognostic information and is vital in guiding appropriate therapy. However staging can be difficult to perform for the
inexperienced physician and inaccurate staging can lead to an
adverse patient outcome. The author provides a free, comprehensive, Web-based, on-the-fly solution which is easy to use and aids
in accurate staging of common mediastinal malignancies.
Educational Goals/Teaching Points: The goal was to create a
free, Web-based and customized staging tool for common mediastinal cancers, which easily integrates into the radiologist’s daily
work from any monitor or PACS station.
Techniques: The tumor classification information is based on the
Collaborative Staging Network. On-the-fly staging is done by cal-
Electronic Exhibits: Efficacy, PACS
culating and comparing the information provided by the user with
the tumor classification database saved on the server. The staging
tool can be used in several modes for the user’s convenience.
Output of information is also offered in several modes to increase
flexibility and better integration into the reader’s workflow.
Conclusion: This software is an intuitive, user friendly educational program which makes staging of mediastinal malignancies
easy and accurate.
E090. Determination of Central Line Position in the Superior
Vena Cava or Azygous Vein on Frontal Chest Radiographs
Haygood, T.1; O’Sullivan, P.1; Yamal, J.1; Liles, L.2; Madewell, J.1;
Chasen, B.1; Fitzgerald, N.1; Costelloe, C.1; Ng, C.1; Sandler, C.1;
Lano, E.1; McEnery, K.1; Murphy, Jr. W.1 1. U. T. MD Anderson
Cancer Center, Houston, TX; 2. Harvard University, Cambridge, MA
Address correspondence to T. Haygood (tamara.haygood@di.
mdacc.tmc.edu)
Objective: Many malpositions of central venous lines are obvious
on a frontal chest radiograph (PA CXR). Clinical observation suggests that the most common malposition that is difficult to perceive on PA CXR is the tip of the line in the azygous vein. We tested radiologists’ ability to distinguish placement in the superior
vena cava (SVC) from placement in the azygous using the PA CXR.
Materials and Methods: Nine radiologists viewed 80 randomlyordered PA CXRs of patients with central lines, in two batches of
40, with each batch consisting of 20 PA CXRs common to both,
and 20 unique PA CXRs. They graded the position of the line:
definitely, probably or possibly in the SVC, or definitely, probably
or possibly in the azygous. Each batch of PA CXRs included 20
central lines in the SVC and 20 in the azygous. Half of the 20 that
were in both batches were in the SVC and half in the azygous.
Five of nine readers looked first at cases 1-40. Four of nine readers looked first at cases 41-80. Truth was determined by independent review by 2 investigators who consulted lateral views
and other imaging as needed and available. Only cases on which
both investigators agreed were included in the study images.
These investigators did not serve as readers.
Results: If the cutoff dividing a correct from an incorrect answer
was between “possibly SVC” and “possibly azygous,” images
were correctly classified between 76% and 97.5%, with mean
90% for the nine readers. Only 39% of “possibly SVC” readings
were correct. 86% of “possibly azygous” readings were accurate. If we omit all “possibly” readings, correct classification is
between 80% and 97.5%, with mean 92%. For the 20 cases
included in both batches of readings, in 125 of 180 readings
(69%) readers gave the same response both times. For 38 of 180
readings (21%) readers gave the same catheter location but
changed their confidence level. For 17 of 180 readings (9%)
readers changed the location of the catheter.
Conclusion: Accuracy was 90% or 92% if we ignore the “possibly” answers and evaluate only those showing a higher level of
confidence. Thus, though accuracy was not bad, there was room
for improvement. Readers were fairly consistent in their decisions
for the 20 PA CXRs that were included in both batches of images.
We intend next to investigate the influence of specific training on
accuracy of interpretation of the central line position and also to
investigate the contribution of the lateral CXR to accuracy.
Efficacy, Education,
Administration and PACS
E091. The Role of Oral and IV Contrast in CT Scanning:
Advantages, Risks and Complications–A Practical Approach
for the Nonradiologist (CME Credit Available)
Fishman, E. Johns Hopkins Hospital, Owings Mills, MD
Address correspondence to E. Fishman ([email protected])
Background Information: The use of oral and IV contrast is critical in body CT. Yet many of the individuals who are part of the
clinical process have minimal knowledge of contrast including
why it is used, potential contraindications and the importance of
contrast in clinical applications. This computer program is
designed to be both a teaching and reference tool for our referring clinicians, nursing staff in and outside of radiology as well as
a resource for technologists and radiologists. The format of this
program is a “how to guide” with more than 100 specific questions which are answered with references when possible. Select
images are also provided to make key points (i.e. positive vs.
neutral oral contrast agents). The program is designed as an easy
to use Web-based program making it accessible on a 24/7/365
basis.
Educational Goals/Teaching Points: This exhibit will answer
the following questions: 1. why do we use oral contrast and
what are its advantages and disadvantages? how, when and why
do we give it? 2. why do we use IV contrast agents and what are
its potential risks? 3. how do we handle patients with suspected
contrast allergies? premedication schemes, selection of agent,
alternatives? 4. what about the role of creatinine and glomerular
filtration rate in patient selection? 5. what do we do with the diabetic, the patient with myeloma, the patient with sickle cell disease, etc.? 6. what about rectal, and intravesical contrast? 7. what
about informed consent?
Techniques: The role of oral and IV contrast in body CT, risks of
contrast, management of risks, decisions in select patients
like the diabetic, the patient with myeloma, the patient with sickle cell disease, etc. and the importance of oral and IV contrast in
patient care will be discussed.
Conclusion: This exhibit provides a handy online how to guide
for the use of oral and IV contrast as well as answering 100 of
the most common questions on the use of contrast by our colleagues in and outside of radiology.
E092. Learning Radiology: Introduction to the Imaging
Modalities (CME Credit Available)
McNulty, N. Dartmouth-Hitchcock Medical Center, Lebanon, NH
Address correspondence to N. McNulty ([email protected])
Background Information: Utilizing radiographs, CTs and MRIs
to teach normal anatomy is playing an increasing role in the education of first-year medical students during the anatomy courses,
however, the busy curriculum at most institutions does not allow
for dedicated lectures on these imaging modalities prior to the
students being exposed to them. This leads to student frustration
and suboptimal learning, as they often do not understand what
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they are looking at. “Introduction to Radiology” is a Web-based
learning module created to introduce the common imaging
modalities to the learner. The target audience is those with no
prior exposure to radiology; this was created primarily for the
education of first year medical students.
Educational Goals/Teaching Points: The goal of this learning
module is to educate the first time user about common imaging
modalities; radiography, CT, MRI, ultrasound, and fluoroscopy.
Teaching points include the technique of image creation, the factors which influence the appearance of the images, what structures and organs are seen well with the modality, and limited
indications for use of the modality. To further achieve these goals,
there is a quiz at the end of each module to ensure a thorough
understanding of the material covered.
Techniques: Key points include discussion of how images are
displayed and viewed, the strengths and limitations of each
modality with regard to displaying normal structures, and the factors influencing the appearance of structures on the images. This
enables the learner to predict what structures will look like on a
given modality and to recognize normal anatomy. This basic
knowledge will also aid in determining when pathology is
present, and what the pathophysiologic basis for that pathology
is. This program is interactive and has numerous pictorial examples which demonstrate the concepts, including normal and
abnormal clinical images, images of fruit, vegetables and inorganic matter. The quiz at the end of each module allows for interactive assessment of the understanding of the concepts presented.
Conclusion: Despite its nearly ubiquitous use in clinical medicine and increasing use in teaching anatomy, there is typically no
formal instruction in radiology at accredited US medical schools,
however, students begin looking at these images as early as the
first year of medical school. This instructional module, primarily
created for the anatomy courses taken during medical school,
allows self-directed learning of the imaging techniques commonly used in teaching and clinical practice.
E093. Prepared for Call? A Web-Based, Interactive Tutorial
and Reference Database for On Call Radiology Findings
Talanow, R. The Cleveland Clinic, Cleveland, OH
Background Information: Junior residents who have not yet
started their emergency room rotations and have limited experience with emergency cases may encounter unknown case scenarios, leading to incorrect interpretation and potentially resulting
in wrong management and patient’s harm.
Educational Goals/Teaching Points: An interactive tutorial is
desired which prepares the junior radiology resident for the first
call.
Techniques: This online tutorial consists of more than 100 pages
and thousands of images with emergency cases. Multiple chapters cover chest, abdomen/pelvis, musculoskeletal, neuroradiology and OB/GYN. Interactive tools adapt to the user’s needs. Case
presentations mimic real scenarios at the workstation, offering
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scroll functions through CT image stacks and window/level
functions. Pre- and post-tests evaluate the learning progress. Free
text search and predefined menus allow individual display of
contents.
Conclusion: We present an interactive tutorial which serves junior radiology residents and also clinical residents as a comprehensive learning tool as well as a quick reference to become
familiar with on call and emergency findings. Free online access
makes it constantly and quickly available and interactivity helps
to accommodate the user’s needs to enhance the learning experience.
E094. Chestradiology.net–A Valuable Educational Interactive
Chest Anatomy Tutorial for Residents and Medical Students
Talanow, R.1; Timofte, I.2; Jend, H.3 1. The Cleveland Clinic,
Cleveland, OH; 2. Huron Hospital, East Cleveland, OH; 3. Klinikum
Bremen Ost, Bremen, Germany
Background Information: It can be difficult particularly for internal medicine residents and less experienced physicians who are
not specialized in chest radiology to differentiate between physiological thoracic structures and normal variants from pathological
findings on plain film and CT. We designed an interactive, stepby-step tutorial in order to teach residents and refresh information about benign and malignant findings in chest imaging.
Educational Goals/Teaching Points: This online chest tutorial
(“chestradiology.net”) consists of more than 150 pages and more
than 80 images covering plain film and CT. Chapters offer learning material about techniques, standard exams, projections, airways, lung parenchyma, heart and vessels, mediastinum, diaphragm, pleura, pathology. Pre- and post-tests evaluate the educational experience. Twenty-seven internal medicine residents
and medical students were asked to answer ten different questions on the topic covered in the Website. After a one hour tutorial the same questions were given to them in order to evaluate
the learning progress. The educational value of this chest tutorial
was then assessed using the results of the pretutorial and posttutorial questionnaire.
Techniques: Pre- and post-tests evaluated the learning progress
before and after reviewing the tutorial, respectively. Initially most
residents and students were able to answer only 2-3 basic questions out of ten regarding chest anatomy (20%-30%). After
spending one hour on this Web-based interactive tutorial that
briefly presented the radiology Web site the same residents and
medical students were asked to answer the same questions.
Most residents answered 6-7 questions 60%-70%.
Conclusion: We present an interactive tutorial which serves clinical residents and medical students as a comprehensive learning
tool as well as a quick reference to become familiar with physiologic and pathologic findings in chest imaging. Junior radiology
residents might also benefit from this program. Free online
access makes it constantly and quickly available and interactivity
helps to accommodate the user’s needs to enhance the learning
experience as demonstrated in our study. Our study demonstrates that the interactive tutorial is a valuable educational method, teaching medical students and residents to differentiate
between physiological and pathological findings on chest x-ray
and CT.
E095. Lymphoma Staging Made Easy! A Free and Customized
Online Tool to Facilitate Quick and Accurate Lymphoma
Staging (CME Credit Available)
Talanow, R. The Cleveland Clinic, Cleveland, OH
for any questions encountered during the study period. Over a
six-month period, we analyzed the ordering pattern for medical
interns who did not receive the intervention (July through
December, 2006), and compared it to those who had received
the lecture, (July through December, 2007).
Background Information: Complex cancer staging systems
describe the anatomic spread of a particular malignancy. Staging
provides prognostic information and is vital in guiding appropriate therapy. However staging can be difficult to perform for the
inexperienced physician and inaccurate staging can lead to
unnecessarily adverse patient’s outcome. The author provides a
free, comprehensive, Web-based, on-the-fly solution which is
easy to use and aids in accurate staging of lymphoma.
Results: There was an overall reduction of 26% in the studies
ordered per discharge when comparing 2007 to 2006 (p<0.001).
There was a consistent decrease in CTs per discharge, averaging
a reduction of 18% over the study period. MRI and nuclear medicine studies performed per discharge were also reduced 38%
and 22%, respectively. Over the study period, 1101 advanced
imaging studies were ordered in a six-month period in 2006 by
medical interns, compared to 827 in 2007. The number of discharges from July to December in 2006 compared to 2007 was
not significantly different, 10,658 vs. 10,819, respectively.
Educational Goals/Teaching Points: The goal is to create a
free, Web-based and customized lymphoma staging tool, which
easily integrates into the radiologist’s daily work from any monitor or PACS station.
Techniques: The tumor classification information is based on the
Collaborative Staging Network. On-the-fly staging is done by calculating and comparing the information provided by the user
with the tumor classification database saved on the server. The
staging tool can be used in several modes for the user’s convenience. Output of information is also offered in several modes to
increase flexibility and better integration into the reader’s workflow.
Conclusion: This free, Web-based and customized program easily integrates into the radiologist’s daily work from any monitor or
PACS station. The interface is flexible and easily adapts to the
individual physician’s preferences by seamlessly incorporating
into the workflow. It is an intuitive, user friendly educational program which makes staging of lymphoma easy and accurate.
E096. Overutilization of Advanced Imaging in the Hospital
Setting: An Educational Approach to Reduce Unnecessary
Inpatient Studies
Platnick, J.; Voutsinas, L.; Wetz, R.; Madero, G.; Raden, M. Staten
Address correspondence to J. Platnick ([email protected])
Objective: The use of diagnostic imaging, particularly, advanced
imaging including: CT, MRI and nuclear medicine, for the diagnosis and management of patients has been dramatically increasing. This study aimed to decrease the number of examinations
ordered by medical interns through targeted education.
Materials and Methods: In our 703 bed, tertiary care center,
medical residents, under attending supervision, order the majority of tests and treatments for inpatients. The medical interns
were given a lecture by a senior radiologist at the outset of their
internship year in late June, 2007. The conference, developed in
conjunction with the internal medicine program director,
described the risks, benefits and alternatives of the various imaging modalities. The discussion emphasized the radiation exposure
of various modalities and the increasing costs related to unnecessary imaging. The goal of the lecture was to educate the interns
about radiologic studies and their appropriate usage. The radiologist emphasized the department’s availability to the medical staff
Conclusion: Unnecessary advanced imaging of inpatients was
significantly reduced by an easily replicated and cost-effective
intervention of an informative lecture to the ordering physicians.
E097. Improving Cycle Time for Diagnostic Mammography:
Results from Mayo Clinic Quality Academy (CME Credit
Available)
Friese, J.; Maxwell, R.; Krecke, K.; Aakre, K. Mayo Clinic, Rochester,
MN
Address correspondence to J. Friese ([email protected])
Objective: The goal is to show the significance of process
improvement projects in improving patient care and satisfaction
of diagnostic mammography patients and staff satisfaction.
Materials and Methods: A multidisciplinary team of physicians
and staff from breast imaging conducted a 100 day quality
improvement project under the guidance of a quality advisor.
Using the define, measure, analyze, improve, and control
(DMAIC) framework, time studies were performed, patient and
staff surveys conducted, current and future value stream maps
developed, and tests of change implemented.
Results: Comprehensive value stream map and timing studies
showed that 72 minutes were required for diagnostic mammography prior to implementation of process changes. Two process
changes (i.e. tests of change) were undertaken. First, a technologist and radiologist were assigned to each patient who conducted the entire study from planning to interpretation. Second,
imaging parameters were given the same day as the diagnostic
mammogram rather than at the time of screening mammography. Exams going through a redo loop decreased from 17 to 7%
for radiologists and from 32 to 20% for technologists.
Consolidation and elimination of process steps resulted in
decreased time in the department from 54 to 38 minutes. Patient
satisfaction regarding wait time improved from 87 to 96%.
Employee satisfaction related to communication improved from
2.95 to 4.19 (out of five).
Conclusion: Process improvement projects in radiology can yield
positive results despite small incremental changes. The value of
mapping the process and including paraprofessional staff are paramount to success. While extra time and effort is necessary to
participate in quality improvement projects, changes can yield
benefits in patient and staff satisfaction.
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E098. Creating an Improved Radiology Resident: Techniques
to Help Detect Critical Findings (CME Credit Available)
Gerard, P1; Lefkovitz, Z. 2; Moonthungal, S1. 1. Maimonides
Medical Center, Brooklyn, NY; 2. Mount Sinai Medical Center,
New York, NY
Background Information: The goal is to demonstrate a variety
of visual and cognitive techniques to help enhance a radiology
residents observational skills which can be applied to the everyday interpretation of plain films and imaging procedures. The
result is enhanced observations, interpretation skills and performance, more accurate readings and ultimately better patient care.
Educational Goals/Teaching Points: Radiology residents are
accepted into residency positions based on certain criteria including academic performance, without a well defined method of
evaluating the ability to assess and interpret radiographic studies,
which have become increasingly more complex and demanding.
Lectures convey important information however may not
enhance the ability to identify critical findings. We will display a
pictorial of different visual techniques and exercises that will help
train residents in increasing their observation skills.
Techniques: We will demonstrate a variety of techniques and
exercises to help promote better observational skills. These have
been utilized at our institution with better performance by residents. Techniques that will be included in our presentation
include: use of images containing various scenarios for interpretation, location of objects on films, use of corner signs in interpretation, subliminal images, diagnosis on lateral projections, and
a variety of other techniques will be demonstrated.
Conclusion: We have identified specific issues in resident observation and interpretation skills of plain films and imaging procedures and have developed a series of visual techniques to help
train radiology residents in enhancing cognitive and perceptual
analysis skills. This can help prevent interpretation errors and significant misses. We hope that when applied during a radiology
resident’s training years, they can be helpful in enhancing a resident’s ability to detect important and critical findings and promote better patient care.
E099. Nobel Prize Winners Who Have Made Significant
Contributions to Radiology
Dunn, D.; Mansfield, L. Brooke Army Medical Center, San Antonio,
TX
Address correspondence to L. Mansfield (liem_mansfield@
hotmail.com)
Background Information: Nobel Laureates have made significant contributions to the establishment of radiology as an important branch of medicine. Roentgen and the Curies are the most
obvious; their revolutionary discoveries formed the basis of diagnostic radiology, radiation therapy and nuclear medicine.
However, there have been others. The purpose of this educational exhibit is to honor these Nobel Laureates and their ideas,
inventions and discoveries which laid the foundation of radiology
as we know it today.
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Educational Goals/Teaching Points: Twenty-eight Nobel
Laureates have made important discoveries or invented machines
that have contributed significantly to the advancement of radiology. The majority (86%) are scientists and engineers. Most of the
Nobel Prize winners’ research was in the basic sciences. Only
four (14%) of these individuals were physicians. In contrast, of
the 175 laureates of the Nobel Prize in Physiology and Medicine,
54% were physicians.
Techniques: The revolution in radiology over the last three decades has occurred due to the invention of ultrasound, CT, PET
and MR scanners. The invention and advancement of these imaging techniques could not have been possible without key discoveries in physics, electrical engineering and computer technology.
Conclusion: There is a historic bond between physics, engineering, and medicine in the advancement of medical knowledge.
Revolutionary progress in medicine requires synergy between the
physical and biological sciences. Therefore, while incremental
advances within our field will continue, resources must be allocated to collaboration outside radiology to lay the groundwork
for future ground-breaking discoveries.
E100. Collaborative Radiology Resources: Radiopaedia.org
as an Example of a Web 2.0 Radiology Resource
Gaillard, F. 1; Jones, J. 2 1. Vancouver General Hospital,
Vancouver, Canada; 2. Leeds General Infirmary, Leeds,United
Kingdom
Address correspondence to F. Gaillard ([email protected])
Background Information: Radiopaedia.org is a free online radiology resource built and maintained by its users. The idea is to
gather a small fraction of our collective knowledge in a single site
which can act as a valuable digital reference. There are no subscription fees and no restrictive copyright–all material is available
under the Creative Commons 3.0 license. It is a true peer
reviewed site–where errors can be found and corrected, discussion on difficult or controversial topics can be shared, and images
submitted and used. It is basically like a specialist version of
Wikipedia, aimed at the radiology community.
Educational Goals/Teaching Points: The goal of this exhibit is
to introduce Radiopaedia.org and how it works; review the features and purpose of Creative Commons Licenses (CCLs), and
outline how these features differ from those of traditional copyright; give examples of how images (radiological images, as well
as medical illustrations) can be licensed under CCLs and the benefits of CCLs over traditional copyright, and demonstrate how
small contributions by multiple users yields a comprehensive
resource ideal to teaching and reference.
Conclusion: Collaborative resources have been shown to work
remarkably well in other settings. Radiopaedia.org offers a mechanism to generate a free and copyright free resource for radiology. Distributing radiology/medical images under Creative
Commons Licenses offers significant advantages to both the general radiology community, as well as the individual owner of the
material. The combination of user created content and Creative
Commons Licenses is of great potential benefit to the whole
radiological community.
E101. Using “Hyperlinks” in PowerPoint Presentations as a
Teaching Tool for Radiology Trainees–An Interactive Tutorial
Stacy, G.; Thiel, S. University of Chicago Medical Center, Chicago,
IL
Address correspondence to G. Stacy ([email protected])
Background Information: PowerPoint software (Microsoft,
Redmond, Wash) has become a popular tool for creating and
showing electronic presentations. Such presentations typically
consist of a series of “slides” that are presented in sequential
order by a lecturer to his or her audience. The “hyperlink” function in PowerPoint, however, allows a user to advance from one
slide to any other slide in the presentation when he or she clicks
on a pre-determined word or image. The hyperlink can also “connect” the word or picture to a slide in a completely different
presentation, as well as a Web page, e-mail address, or another
type of file.
to showcase how the hyperlink function can enhance PowerPoint
presentations by making these presentations more interactive
and informative. For example, potential answers to a multiplechoice question can each be linked to specific slides, providing
instant feedback to the user. A similar process can be used to
create “games” in which a “contestant” can pick from a list of
“categories”, each of which would be linked to a particular slide
with a text- or image-based question. Hyperlinks can also be
made “invisible” and placed on an image, creating an educational tool whereby the user would be instructed to “point” to a particular anatomic structure or pathologic process with appropriate
feedback. Links to other documents or Websites can also be created, providing additional detail regarding a particular disease
process, if desired by the user. This exhibit will provide an interactive tutorial which demonstrates the necessary steps to create
such presentations.
Conclusion: The use of hyperlinks in PowerPoint presentations
allows for a much more dynamic and interactive educational
experience than can be obtained with serial presentation of
slides alone.
E102. A Radiology Information System Search-Based
Approach to Rare Case Interpretation
Green, A.; Kowal, D.; Garg, N. St Vincent, Worcester, MA
Address correspondence to A. Green ([email protected])
Objective: This exhibit will discuss rapid and real time automatic
work list generation from a full text radiology information service
(RIS) as a reference resource for uncommon diagnostic cases
and procedures, on call comparison cases, and end of resident
rotation unknown exams. Materials and Methods: The development of this program
involved the creation of a Wizard in our PACS system. This Wizard
initiated a Google desktop based search of the RIS database
using methods published by Erinjeri (Erinjeri 2008: Development
of a Google-Based Search Engine for Data Mining Radiology
Reports; Journal of Digital Imaging). AJAX search results were
then mined for relevant exam accession numbers. A custom work
list was then automatically generated using auto hotkey string
processing, thus enabling the list of pertinent exams to be
brought up in the PACS system for end user review. This program
was made accessible to all users and was deployed to the radiology residents and attendings in our department. Data collected
included log of uses and subsequent work list generation.
Results: The program has demonstrated its ability to reliably and
quickly search through the entire hospital database of radiological exams and generate work lists of exams based on user
defined search parameters. Over a period of 27 days, 106 separate uses of the program have been documented. Examples of
work lists generated have included acute epiglottis, neurofibroma
and aortic dissection. These uses have occurred at all times of
the day and night.
Conclusion: With the use of the program, any user can, in real
time, generate a work list of cases that fit his/her specific clinical
question. These cases can then be reviewed on the local PACS
system, allowing “real world” manipulation of images. This process has been used at our program prior to uncommon procedures, such as elbow arthrograms, and also in generating examples of important findings for residents on call to compare with
the case they are currently interpreting. For case conferences or
board review, instead of accessing online or pre-built case files, a
user could generate a new work list of cases of recent, institutional examples. As these cases are then displayed in the local
PACS, exams can be presented as unknowns and manipulated
utilizing the standard PACS tools. For end of rotation in-service
exams, instead of written questions or static images, actual PACScentered cases can be used, allowing for realistic evaluation of
clinical performance.
E103. Thin Client Servers: Technical Aspects, Applications,
Advantages and Limitations (CME Credit Available)
Jagtiani, M.1; Kalra, M.1; Dreyer, K.1; Schirmacher, H.2; Sack, D.1;
Saini, S.1 1. Massachusetts General Hospital, Boston, MA; 2. No
Institutional Affiliation
Address correspondence to M. Jagtiani Sangwaiya (mjagtiani@
partners.org)
Background Information: Routine interpretation of digital radiology imaging is adequate on PACS workstations. However, many
conventional PACS lack advanced postprocessing 3D and 4D
viewing, reconstruction abilities and remote access. In these circumstances, Web-based thin client servers can help, with not
only routine radiology image interpretation, but can also provide
interactive 3D and 4D reconstruction.
Educational Goals/Teaching Points: A thin client is software in
client-server architecture networks which depends primarily on
the central server for processing activities, and mainly focuses on
conveying input and output between the user and the remote
server. Recently thin clients have become available as fast viewers for 2D, 3D, and 4D images. The purpose of this exhibit is to
highlight the technical aspects, advantages, and limitations for a
thin client based radiology image interpretation and 3D reconstruction.
Techniques: This exhibit will outline the technical aspects and
fundamentals of thin client Web-based PACS and describe the
differences between thin client based PACS and conventional
PACS, advantages of thin client based PACS with suitable exam-
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ples from different radiology subspecialties (for example, in
emergency, chest and abdominal imaging) and current limitations of both Web and conventional PACS with appropriate clinical examples.
Conclusion: This exhibit describes the technical aspects and fundamentals of thin client servers in modern day radiology practice
with help of suitable radiology examinations. A thin client may
help off-lying radiology interpretation from conventional PACS in
daily radiology practice.
E104. How to Select the Best PACS Solution for Your
Institution
Dang, P.; Kalra, M.; Sack, D.; Schweitzer, A.; Dreyer, K.
Massachusetts General Hospital, Boston, MA
Address correspondence to P. Dang ([email protected],
[email protected])
Background Information: The advent of PACS has resulted in
improving the workflow, workload, and productivity of radiology
departments and the healthcare enterprise as a whole. Given the
multiple PACS options available, choosing a vendor can be difficult.
Educational Goals/Teaching Points: PACS enables easy availability of digital images virtually on all clinical workstations
throughout the healthcare institution, which helps to improve the
workflow, report turn around time, productivity, and clinical care.
A careful selection of the type of PACS solution should be based
on the institution’s demands, workflow, and infrastructure.
Successful selection of the PACS vendor involves making an
appropriate needs assessment plan, identifying the critical stakeholders, writing an effective request for proposal, making comprehensive site visits and effectively negotiating the terms and
conditions. The exhibit will include steps for PACS vendor selection, including: A) Developing an appropriate business plan: 1.
Perform a cost-benefit analysis considering various factors such
as dollars saved, liabilities, improved workflow, decreased workload, and improved patient care. 2. Develop a strategic business
plan to survey the facility, the existing resources and infrastructure, and the views of the administration and critical stakeholders. 3. Determine a clear set of goals and key objectives for PACS
implementation. 4. Define the principle criteria for evaluating the
different vendors. B) Writing an effective request for proposal
(RFP) should include goals and objectives of the institution;
information on the health care enterprise and radiology department including general information and specific information
about: operations, workflow, workload, hardware and software
requirements for acquiring, archiving and viewing of images, networking requirements, and training requirements, and other
requirements such as maintenance, security, support, warranties,
image and data management, timelines, financial terms, and payment options. It will also provide details on reviewing responses
to the RFP, performing detailed site visits, negotiating the contract and tallying the return of investment in spreadsheets,
graphs, and figures.
Conclusion: Choosing an appropriate PACS vendor that meets
the requirements for an institution is very important to realize the
true benefits from PACS implementation and avoid the unnecessary costs and expenses. This exhibit describes the steps for successful selection of a PACS vendor.
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E105. Integrating PACS and the Hospital Information System
Using Open Source Software (CME Credit Available)
Gentili, A.1,2 1. VA San Diego Healthcare System, San Diego, CA;
2. University of California, San Diego,, San Diego, CA
Address correspondence to A. Gentili ([email protected])
Background Information: Referring physicians often provide
incomplete clinical history on radiology requests. Having better
clinical histories improve the ability of radiologists to provide better interpretations and make correct diagnosis. Often more clinical information is available in the Hospital Information System
(HIS), but in most cases the patient records in HIS are not available from PACS. Integrating PACS and HIS is technically possible,
as most modern PACS and HIS systems can communicate using
HL-7, but it is often not easy to do, and requires a knowledge of
both systems and cooperation of both manufacturers. We have
used an open source program, AutoHotkey, to synchronize the
HIS client application, with the patient displayed on PACS on the
client machine.
Educational Goals/Teaching Points: AutoHotkey is a free,
open-source utility for Windows. With AutoHotkey, it is possible
to automate almost any program by sending keystrokes and
mouse clicks. With this program, it is possible to write a macro
that can be compiled into a small executable file that can be run
from any directory without any need for installation, or registry
modification. We have created a simple macro to synchronize HIS
with PACS. Radiologists, while working on PACS, at the press of a
shortcut key, can activate this macro. The macro opens the HIS
client, if not already running, once the HIS client is running, and
the radiologist is logged in, the macro transfer the hospital
number of the current patient from the PACS display window
into the HIS client, simulating the keyboard, to display the
patient’s medical records. This is all done using Windows functions, without the need to know about HL-7 or how the PACS
and HIS function.
Techniques: This macro facilitates reviewing the patient clinical
history and has increased the frequency with which radiologists
review the patient medical records. This method has several
advantages; it is free, works with PACS and HIS of different manufacturers and does not require complex installations. A limitation of this approach is that works only on Windows based systems.
Conclusion: Using Autohotkey, it is possible to synchronize PACS
and HIS, and have HIS display the clinical history of the patient
displayed on PACS.
E106. An Overview of the Economics of Radiology (CME
Credit Available)
Liu, R. New York Presbyterian Hospital, New York, NY
Address correspondence to R. Liu ([email protected])
Background Information: The economics of radiology represents a broad field, with multiple levels of complexity. Traditional
training of radiologists offers limited education in this increasingly
important facet of radiology. This exhibit aims to offer an initial
perspective of the economics of radiology, introducing the audience to fundamental concepts that can help facilitate a deeper
understanding of the field.
Electronic Exhibits: General, Emergency
Educational Goals/Teaching Points: The exhibit offers three
major areas of conceptual learning, including 1) an understanding of the current economic landscape in radiology 2) an overview of the revenue stream of a radiology practice and 3) how
the convergence of macroeconomic and microeconomic factors
are affecting the current radiology employment market in both
academic and private practice settings.
Techniques: An examination of the current economic landscape
will take a broad view of the historic relationship of the role of
imaging within the national health care system. Further analysis
focuses on recent trends in imaging costs, with an emphasis on
understanding how differences in modality and specialty affect
procedure volume and spending. In addition, the major current
disruptive forces which are changing the field of radiology are
examined, utilizing the economics of teleradiology as a case
study. The overview of the revenue stream of a radiologist is
accomplished by focusing on the history of the Medicare payment system, with a flow chart analysis of key criteria necessary
for successful revenue generation by a radiology practice. Finally,
the employment market is reviewed over a ten-year period, with
current differences in subspecialty and practice model variances
highlighted.
Conclusion: While the economics of radiology is a multilayered
complex field, an initial overview serves the purpose of introducing key concepts that can serve as a springboard for a more comprehensive education on this increasingly critical aspect of the
radiology practice.
E107. Radiology Malpractice: An Illustrated Presentation of
the Problem and Possible Solutions to Reduce Risk (CME
Credit Available)
Tu, R.; Kori, G.; Zeman, R.; Akin, E.; Kambhampati, S. George
Washington University, Washington, DC
Address correspondence to R. Tu ([email protected])
Background Information: The purpose of this study was to
illustrate examples of malpractice risk. We reviewed malpractice
cumulative and indemnity data from 2002-2007. We analyzed malpractice in all reported medical specialties in comparison to radiology. Examples of risk are presented as an opportunity for improvement.
Educational Goals/Teaching Points: A review of claims and
indemnity data from the Physicians Insurance Association of
America from 2002-2007 was completed. Radiology had a disproportionate high number of claims. The categories of high radiology malpractice claims were reviewed. Brain and diseases of
the breast were the majority of malpractice claims. Issues of
communication were also cited in the claims. Examples of the
subtle and not so subtle brain lesions and breast lesions are presented so the reader may gain insight to reduce misinterpretation. Communication strategies are also provided to help reduce
misunderstands and escalation to a malpractice event.
Techniques: Target regions of errors in brain imaging interpretation are illustrated. Typical problematic regions of the cerebral
convexity, inferior frontal lobe and fourth ventricle are illustrated.
The skull base and infratemporal fossa lesions in cranial imaging
studies not necessarily related to the initial study are presented.
Subtle examples on CT that may aid the reader in identifying
ischemia with MR correlation are presented. Target areas of
errors in breast imaging are presented. Cancers in dense breasts
and the edge of the film are presented. Communication strategies are presented designed to reduce misunderstanding.
Conclusion: Radiology is a high malpractice specialty in both
number of claims and payment/claim compared to other specialties. The majority of radiology malpractice claims were related to
the breast and brain. We present strategies through examples in
image interpretation to provide a vehicle for improvement to
reduce malpractice risk.
General, Emergency
E108. An Assessment of Ordering Physician’s Knowledge
and Attitudes Regarding Risk from CT Associated Radiation
Exposure (CME Credit Available)
McBride, J.1; Paxton, B.2; Wardrop, R.3 1. Mayo Clinic–Rochester,
Rochester, MN; 2. Duke University, Durham, NC; 3. Carilion Clinic,
Roanoke, VA
Address correspondence to J. McBride (mcbride.jeremy@mayo.
edu)
Objective: Medical literature suggests that ionizing radiation
from CT can significantly alter a patient’s lifetime attributable risk
of developing neoplasms. It is our hypothesis that ordering physicians have limited knowledge of CT-related radiation exposure with its associated risks.
Materials and Methods: An internet-based, anonymous survey
was sent to the ordering physicians of a regional tertiary care
teaching hospital. The survey was designed to evaluate their
knowledge, attitudes and self-assessed practice behaviors as
related to the potential increased risk of cancer from CT-related
radiation exposure. Both faculty and residents were invited to
respond to the survey. Complete and incomplete surveys were
included.
Results: Respondents to the survey were primarily faculty (63%)
and the largest represented specialty was internal medicine
(43%). When asked to rate a list of factors as influential when
ordering CT scans, 100% responded that the ability of CT to rule
in/rule out a diagnosis was influential and 85% reported that the
speed and ease with which a clinical answer could be obtained
influenced their decision. A total of 46% reported that the potential risk of litigation from not ordering the exam was influential. Concern regarding the radiation exposure from the exam and
the cumulative radiation that a patient had received from prior
exams influenced only a minority of respondents, 22% and 19%
respectively. When asked to identify the equivalent radiation
exposure a CT scan represents, in plain radiographs 64% underestimated. When asked if the lifetime risk for developing cancer
from one pediatric CT scan was increased, 75% reported affirmatively and 26% correctly identified the estimated risk; 58%
believed the same to be true in adults; 59% of respondents
admitted that they do NOT discuss the potential risks of CT with
patients and only 20% discuss the risk of radiation specifically.
Postsurvey free text comments included many admissions of
ignorance and a desire to “know the answers.”
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Conclusion: Physicians who order CT scans have limited knowledge of the impact of ionizing radiation exposure and its potential for increasing cancer risk in patients. Our results suggest that
radiation education for ordering physicians is needed and would
likely be welcomed by most. Radiologists have an opportunity to
positively impact patient care by educating ordering physicians of
the potential risks of ionizing radiation and providing consultation
on appropriate alternative imaging.
E109. Determining Fetal Radiation Dose on 4-, 16- and
64-Slice CT Scanners for Pulmonary Angiograms and
Abdomen Examinations Throughout Pregnancy (CME Credit
Available)
Gilet, A.; Dunkin, J.; Fernandez, T.; Moore, W.; Budorick, N. SUNY
Stony Brook University Medical Center, Stony Brook, NY
Address correspondence to A. Gilet ([email protected])
Objective: The objective was to determine an estimated dose
range for fetal exposure during four different stages of pregnancy
for both computed tomographic (CT) pulmonary angiogram and
CT abdomen/pelvis examinations on a 4-, 16- and 64-slice CT
scanner.
Materials and Methods: Simulated pulmonary angiograms and
abdomen/pelvic studies were performed on an anthropomorphic
phantom on 4-, 16- and 64-detector CT scanners using both consistent parameters and current institutional standard protocols for
abdominal and pelvic imaging of pregnant patients. Different
stages of pregnancy were reproduced by adding soft tissue
equivalent material (TX151) to create a pregnant phantom
model. Fetal positioning and mean fetal depth were determined
using previously published data from ultrasound examinations of
a large cohort of patients. Thermoluminescent dosimeters (TLDs)
were placed at appropriate positions for different gestational
ages. Scans were performed for early pregnancy, ten, 18 and 36
weeks gestational age fetal doses and entrance skin exposure
were measured. Effective dose was calculated using International
Commission on Radiological Protection methods. These were
compared with the dose–length product (DLP) and CT dose
index (CTDI) that were generated by the scanners.
Results: When using constant parameters for CT pulmonary angiograms we found the fetal radiation dose was not significantly
associated with gestational age. For the 4-, 16- and 64-detector
scanners the fetal dose averaged .063 cGy and the 16-slice scanner was the most dose efficient (average dose .044 cGy). For CT
abdomen we found the highest radiation dose was recorded in
early pregnancy; this was 1.15 cGy, 0.99 cGy and 1.56 cGy on the
4-, 16- and 64-slice scanners respectively. There was an average
20% higher radiation dose to the fetus with all three scanners
then was measured at the anterior abdomen skin entry
site which underestimates fetal exposure. When scanning parameters were kept constant between machines gestational age and
fetal dose were not significantly related, however when the institutional protocols (manufacturer recommended) for pregnant
patients were used the dose was significantly higher in the third
trimester on the 64-slice scanner.
Conclusion: Radiation doses to a fetus for pulmonary angiograms with shielded abdomen and abdominal CTs are higher
than what has been reported in the earlier literature performed
on single slice scanners. Optimal parameters for maximiz-
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ing image quality while minimizing radiation risk will vary
between machines depending on detector number.
E110. Safety of the Gadolinium Chelates (CME Credit
Available)
Runge, V. Scott and White Clinic and Hospital, Temple, TX
Address correspondence to V. Runge ([email protected])
Background Information: Magnetic resonance contrast agents,
specifically the gadolinium chelates, are very safe and lack the
nephrotoxicity (when injected intravenously) associated with
iodinated contrast media. Minor adverse reactions occur infrequently and include nausea, taste perversion, and hives. Whereas
these agents cannot be differentiated on the basis of mild
adverse effects, they do differ in regard to chelate stability, with
clinical lab abnormalities known with the less stable agents. The
issue of nephrogenic systemic fibrosis (NSF) and its relationship
to the gadolinium chelates (and specifically their in vivo stability)
have drawn widespread attention in the last two years to the
subject of safety of these agents. These topics are discussed in
depth in this educational exhibit, together with current updates
and recommendations for clinical practice.
Educational Goals/Teaching Points: The educational goals are
to discuss the clinical safety of the gadolinium chelates, as contrast media for MRI and provide a basis of knowledge upon
which appropriate guidelines for clinical use can be drawn, and
appropriate differentiation made between the approved agents.
Techniques: Topics to be discussed include: minor adverse reactions and their incidence (nausea, hives); severe anaphylactoid
reactions; physicochemical characteristics; stability – thermodynamic and kinetic; transmetallation/dechelation; interference
with laboratory tests (in particular serum calcium), and nephrogenic systemic fibrosis – origin, incidence, prevention.
Conclusion: The gadolinium chelates, widely used in MR clinical
practice, are in general a very safe class of contrast media. The
safety basis of these agents rests fundamentally with the stability
of the metal chelate in the body and rapid excretion. Knowledge
of NSF has led to re-examination of this topic, with the trend in
utilization being toward the more stable chelates and the likely
long-term outcome being the withdrawal of several agents from
clinical use.
E111. Role of an Advanced Statistical Iterative
Reconstruction Technique for Improving the Image Quality
of Low Radiation Dose CT (CME Credit Available)
Singh, S.1; Jagtiani, M.1; Blake, M.1; Thomas, S.1; Joshi, M.2;
Kalra, M.1 1. Massachusetts General Hospital, Boston, MA; 2.
General Electric Company, Giles, United Kingdom
Address correspondence to S. Singh ([email protected])
Background Information: In current CT scanners, images are
reconstructed using filtered back projection reconstruction algorithm. Filtered back projection techniques have higher image
noise, streak artifacts as well as beam hardening artifacts. Image
reconstruction algorithms such as iterative reconstruction help to
improve image quality of low dose CT examinations, as these
reconstruction techniques have much lower image noise.
Educational Goals/Teaching Points: This exhibit will describe
the implications of low dose CT images on image noise and
diagnostic acceptability with filtered back projection reconstruction technique; the effect of advanced statistical iterative reconstruction (ASIR) (GE Healthcare, Milwaukee, WI) technique on
low dose CT data reconstruction; the fundamental basics of iterative image reconstruction techniques, and CT dose reduction with
advanced statistical iterative reconstruction in different body
regions.
Techniques: The exhibit will focus on the fundamental basics of
ASIR of CT image reconstruction; the difference between ASIR
and filtered back projection reconstruction techniques; the effect
of advanced statistical iterative reconstruction on image quality of
low dose CT images; the use of ASIR to reduce radiation dose
with CT in different body regions, and the application of ASIR in
clinical scanners or clinical image reconstruction with suitable
examples and illustrations.
Conclusion: This exhibit describes the role of ASIR to improve
the image quality of low radiation dose CT examination by reducing image noise and thus making them diagnostically acceptable.
E112. Benign Mimics of Neoplasia. Can We Avoid a Wrong
Diagnosis? List of the Uncommon Lesions and Findings
Misdiagnosed as Malignancies
Choudhary, S.; Restrepo, C.; Prasad, S.; Chintapalli, K. University
of Texas Health Science Center–San Antonio, TX
Address correspondence to S. Choudhary ([email protected])
Background Information: Multiple benign imaging findings and
lesions may mimic malignancy on imaging and lead to unnecessary surgery, biopsy and patient anxiety. The most commonly
described lesion in this category is the inflammatory pseudotumor which consists of a proliferation of plasma cells and other
inflammatory cells, a fibrous stroma, and spindle cells that are
sometimes associated with a granulomatous reaction. This entity,
which has the gross appearance of a malignant tumor but has a
benign histological appearance and course, has been found in
many locations. Most frequently found in the lung, inflammatory
pseudotumors also have been reported in the stomach, retroperitoneum, orbit, and central nervous system. However there are
multiple other benign lesions that may mimic a malignant tumor
radiologically and misdiagnosed. These lesions not only mimic
malignant tumors radiologically but also clinically. The radiologist
should be well aware and acquainted with these entities to help
avoid improper management.
Educational Goals/Teaching Points: In this pictorial essay, a
selection of inflammatory pseudotumors and their imaging findings are discussed. Multiple other lesions/imaging findings that
may be incorrectly diagnosed as malignancy in multiple locations
and their characteristic radiological features are illustrated. A
review of the radiological features that may assist in the correct
interpretation of the benign nature are discussed.
Techniques: The purpose of this exhibit is to illustrate multiple
benign pathologies including the inflammatory pseudotumor that
mimic neoplasms on imaging.
Conclusion: Many benign lesions may mimic neoplasia both
clinically as well as on radiologic imaging. These can involve
diverse anatomical sites. A high index of suspicion for these
pathologies in the correct clinical context and correct interpretation by using characteristic radiological findings may lead us to
the correct diagnosis and help avoid unnecessary anxiety, incorrect treatment and surgical procedures.
E113. Abdominal Manifestations of Cystic Fibrosis as Seen
on MDCT: A Pictorial Review (CME Credit Available)
Morgan, J.; Gupta, S.; Sadler, M. St. Vincent’s Hospital and
Address correspondence to J. Morgan ([email protected])
Background Information: Cystic fibrosis is an inherited autosomal recessive condition that has multiple well-identified pulmonary manifestations. Radiologists should also be well-familiar
with manifestations seen in the abdomen, some of which have
serious implications. As the life-expectancy of individuals with
cystic fibrosis continues to increase, it is important for these
abdominal manifestations to be recognized and promptly managed in order to achieve optimization of the patient’s overall
well-being and health.
Educational Goals/Teaching Points: The goal is to highlight the
various manifestations of cystic fibrosis in the abdomen, including the hepatobiliary system, gastrointestinal tract and genitourinary system; illustrate the imaging findings associated with these
manifestations, including typical and atypical features, and provide the viewer with a basic understanding of cystic fibrosis in
the abdomen and the ability to appropriately convey relevant
findings to the referring physician.
Techniques: Abdominal manifestations will be discussed and
grouped according to system, and MDCT findings will be demonstrated as follows: Hepatobiliary System: hepatic steatosis, gallbladder and biliary system pathology, cirrhosis; Pancreas: fatty
replacement, calcifications, acute pancreatitis, neoplastic conditions; Gastrointestinal Tract: gastroesophageal reflux, peptic ulcer
disease, distal intestinal obstruction syndrome (DIOS), intussusception, appendicitis, malignancies, pseudomembranous colitis,
and Renal: nephrolithiasis.
Conclusion: As the lifespan of patients with cystic fibrosis
increase, extrapulmonary manifestations are now more prevalent.
With the advent of MDCT, more patients undergo abdominal
imaging for complaints such as abdominal pain or abnormal liver
function tests. It is important for radiologists to recognize the
manifestations of abdominal cystic fibrosis and to then convey
these findings, allowing for appropriate intervention as necessary
E114. The “Six Pack” in Black and White. Imaging Review of
the Rectus Abdominus
Chaudhary H.1; Choudhary, S.2; Fasih, N.1; Sunnapwar, A.2 1.
The Ottawa Hospital, Ontario, Canada; 2. University of Texas
Health Science Center–San Antonio, TX
Background Information: The rectus abdominis is a paired postural muscle of the anterior abdominal wall separated by a mid-
215
line band of connective tissue called the linea alba. It extends
from the pubic symphysis inferiorly to the xiphisternum and
lower costal cartilages. It is enclosed within the rectus sheath,
except below the arcuate line where it is separated from the peritoneum only by the transversalis fascia. The rectus muscle can
be involved by diverse disease processes, including infection,
tumor both primary and secondary, and hemorrhage. Multiple
unusual lesions affecting the muscle such as lipoma and
endometriomas are also described. Inferior to the arcuate line,
the area is also more susceptible to herniation. Spigelian hernia
is an acquired ventral hernia through the linea semilunaris. The
close proximity of the epigastric artery is the usual suspect for
cases with spontaneous and postprocedural active bleeding and
hematomas.
the essential anatomy of the rectus abdominis and the rectus
sheath; describe the common pathologies involving this compartment and their imaging features on multiple modalities including
ultrasound, CT and MRI, and describe an algorithmic approach
for correct diagnosis using imaging and percutaneous biopsy in
equivocal cases.
Techniques: Ultrasound as well as CT provides a noninvasive way
of visualizing the presence and extent of diseases involving the
rectus abdominis. MR imaging is a helpful adjunct however should
be used selectively. The imaging features of infection, tumor, and
hemorrhage may be similar however accurate diagnosis can be
achieved with a thorough knowledge of the anatomy, pertinent
clinical data and imaging features. In equivocal cases, ultrasound
can be used to guide biopsy and drainage procedures.
Conclusion: Knowledge of the normal anatomy of the rectus
abdominis muscle and the rectus sheath is important for the
diagnostic radiologist because of the associated clinical relevance. These muscles are also affected by diverse conditions with
a spectrum of imaging features. A systematic approach helps in
reaching a reasonable diagnosis.
E115. Lines and Circles: Cross-Sectional Imaging of Active
Bleeding and Pseudoaneurysms (CME Credit Available)
Choudkary, S.1,2; Fraser-Hill, M.1 1. The Ottawa Hospital, Ottawa,
Canada; 2. University of Texas Health Science Center – San
Antonio, TX
Background Information: In 1989, the “sentinel clot sign” was
recognized as an accurate indication of hemorrhage from
abdominal organs. Modern imaging techniques including MDCT
and color Doppler imaging (CDI) permit accurate recognition of
potentially life-threatening active hemorrhage and pseudoaneurysm which occur when vascular integrity is breached. While
active hemorrhage is uncontained, pseudoaneurysms are at least
temporarily contained by a false wall. Most reported cases of
imaging-detected active hemorrhage occur in the setting of trauma. Other causes include iatrogenic instrumentation, anticoagulation, aortic disease, and neoplasia. Clinical management depends
on patient factors, the cause, location and extent of bleeding and
comprises several therapeutic options including conservative
management, ultrasound-guided compression, angiographic
embolization and surgery.
216
Educational Goals/Teaching Points: After viewing this exhibit,
radiologists will recognize active bleeding and pseudoaneurysm
on MDCT and CDI in a variety of clinical scenarios; differentiate
active vascular contrast extravasation from pseudoaneurym, and
understand clinical management of active bleeding and pseudoaneurysm.
Techniques: This exhibit will review the literature concerning the
imaging signs of active hemorrhage and pseudoaneurysm;
describe the imaging features of active hemorrhage and pseudoaneurysm on contrast-enhanced MDCT and color Doppler
ultrasound in a variety of clinical conditions including iatrogenic
instrumentation, anticoagulation, vascular disease, spontaneous,
acute gastrointestinal and neoplasia, and discuss clinical management of active hemorrhage and pseudoaneurysm with description of noninvasive therapies including embolotherapy and ultrasound guided compression.
Conclusion: This educational exhibit reviews the MDCT and CDI
appearance of active bleeding and pseudoaneurysm in a variety
of conditions including trauma, iatrogenic instrumentation, anticoagulation, and pancreatitis, and reviews the appropriate clinical
management of such cases.
E116. Dose Preoperative Localization of the Appendix using
3D CT Affect on the Incision of Choice from the McBurney’s
Point in Acute Appendicitis? (CME Credit Available)
Bae, K.; Jeon, K.; Hong, S. Gyeongsang National University
Hospital, Jinju, South Korea
Address correspondence to K. Bae ([email protected])
Objective: The aim of this prospective study was to determine
the site of appendix using preoperative 3D CT and to examine
the usefulness of this 3D CT information on a surgeon’s choice of
incision for appendectomy.
Materials and Methods: After exclusion of all patients with
complicated appendicitis or previous intra-abdominal surgery, the
study population included 100 consecutive patients who underwent appendectomy during 2006. Volume rendering reconstruction of the MDCT data using 3D software was performed for each
patient before surgery. The location of the base of the appendix
and the McBurney’s point were marked on a single 3D image
that allowed the skin surface to be displayed. The distance
between the base of the appendix and the Mc Burney’s point
was measured. The surgeons performed appendectomies with
the 3D CT information and measured the length of the incision
and the distance between the surgical incision and the
McBurney’s point.
Results: The mean distance between the base of the appendix
and the McBurney’s point was 2.7 cm on 3D CT. The appendix
base was located within 1 cm from the McBurney’s point in 18%
of the patients. The appendix was within 3 cm and 5 cm from
the McBurney’s point in 64% and 86% of patients, respectively.
During the operation, the surgeons altered incision site from the
McBurney’s point in 33% of the patients. The distance between
the center of the incision and the McBurney’s point was more
than 3 cm in 8% of the patients.
Conclusion: Since the location of the appendix base has a wide
individual variation, the McBurney’s point has a limited use as a
surgical landmark for an appendectomy. The localization of the
appendix using 3D CT will provide useful information to surgeons
and enable them to make a precise and minimal incision during
an appendectomy.
E117. “Where is the Air?” Pattern Recognition on Abdominal
Plain Films: A Lost Art (CME Credit Available)
Chandrasekhar, C1; Hancock, J. 1; Guthrie, A. 2 1. University of
Texas Health Science Center Houston, Houston, TX; 2. LBJ
General Hospital, Houston, TX
Address correspondence to A. Chandrasekhar ([email protected])
Background Information: The abdominal series still remains a
fast and reliable method of evaluating the abdomen. It provides
a roadmap in establishing the etiology of abdominal pain prior to
a CT scan. With the advent of modern techniques for evaluation
of the acute abdomen, recognition of classic abnormal air patterns on abdominal series has fallen by the wayside.
Educational Goals/Teaching Points: The goals are to demonstrate classic plain film signs of abnormal gas patterns in the
diagnosis of abdominal pain; review the plain film features of
free intra- and retroperitoneal air, air fluid levels, small and large
bowel obstruction, ischemia, pneumobilia and infection on
abdominal series, and to correlate with findings on abdominal CT
where possible.
Techniques: A plain film of the abdomen provides a template
that can help to identify an abnormal air pattern prior to a CT
evaluation. An abdominal series provides valuable information as
to the presence of free intra- or retroperitoneal air. It can also
determine the presence of small or large bowel obstruction, air
fluid levels, pneumobilia or the presence of intramural air in
bowel loops as well as in the gall bladder or urinary bladder.
Conclusion: In spite of more sophisticated methods of evaluation of abdominal pain, a plain film of the abdomen or abdominal series can contribute towards making a definitive diagnosis to
determine the underlying cause of abdominal pain. The art of
plain film diagnosis is gradually being effaced out by other methodologies. Recognition of key findings on an abdomen series still
plays a crucial role in evaluating the acute abdomen.
E118. Impact of Multiplanar Reconstruction of CT Images in
the Evaluation of Acute Abdomen (CME Credit Available)
Malaty, R.; Hadley, W.; Paspulati, R. Case Western Reserve
University, Solon, OH
Address correspondence to R. Paspulati ([email protected])
Objective: The objective was to assess the efficacy of usefulness
of multiplanar reconstruction of CT of the abdomen in patients
with acute abdomen; discuss the technique of multiplanar reconstruction of CT images in the evaluation of acute abdomen, and
illustrate various examples, where multiplanar reconstruction has
helped in arriving at a diagnosis in patients with acute abdomen.
Materials and Methods: This is a four year review from 2004 to
2008 of 124 cases of acute abdomen from the emergency
department who had CT scans of the abdomen and pelvis. All
these patients were scanned with 5 mm thick slices at 5 mm
intervals initially and subsequently reconstructed at 2 mm thick
slices at 1 mm intervals from the original data and multiplanar
reconstructions are generated by the radiologist at a separate
workstation. The clinical indications included right lower quadrant
pain, left lower quadrant pain, bowel obstruction, and renal colic
and diffuse abdominal pain without localization. There were 84
female patients and 40 male patients with ages ranging from 18
years to 85 years.
Results: Multiplanar reconstruction images were able to identify
the appendix in its entirety and differentiate it from small bowel
and other adnexal structures, identify the transition zone definitively in small and large bowel obstruction, identify the cause of
bowel obstruction, display any associated abnormality of the
mesenteric vessels, display associated pneumatosis intestinalis
and differentiate from pseudopneumatosis, abdominal hernias
and associated complications, adnexal abnormalities such as
tubo-ovarian mass lesions and ovarian vein thrombosis.
Conclusion: Multiplanar reconstruction of the CT images is a
simple and useful technique and aids the radiologist in arriving at
a confident diagnosis in most of the patients with acute abdomen. E119. MDCT in the Evaluation of Extraperitoneal Pelvis for
Blunt and Penetrating Trauma: Review of Anatomy and
Tomographic Findings
Ballester, G.; Cortes, C.; Garcia, L.; Gomez, A.; Colon, E.; LopezAlvarez, Y.; Alvarado, E. University of Puerto Rico, Guaynabo, PR
Address correspondence to G. Ballester (goryballester@gmail.
com)
Background Information: Trauma related injuries are common
and are the leading cause of death and disability among the ages
of one to 44 years. It is estimated that 150,000 people die each
year as a result of such injuries. Pertaining to pelvic trauma, there
are usually two major categories: blunt and penetrating. Blunt
pelvic trauma is usually related to motor vehicle collisions,
assaults, recreational accidents, or falls. Penetrating pelvic trauma
is commonly related to gun shot wounds and stab wounds
(homicides or suicides). For the surgeon, the precise localization
of the injury is vital and will dictate further management decisions. Nowadays, MDCT with multiplanar reconstructions (MPR)
allows for better delimitation of the peritoneal and extraperitoneal compartments. The radiologist should have a thorough
knowledge of the complex anatomy of the extraperitoneal pelvic
spaces in order to accurately describe and localize the extension
of the injury.
of this exhibit are to review the normal anatomy of the extraperitoneal pelvic spaces; to understand the value of MDCT in depicting these spaces in pelvic trauma; to differentiate intraperitoneal
from extraperitoneal injuries in pelvic trauma, and to emphasize
the importance of accurate compartment localization in patient
treatment (i.e. surgical vs. conservative management).
217
Techniques: This exhibit will review the anatomy of the extraperitoneal pelvic spaces, which includes the following: prevesical
space, including retropubic retzius space; perivesical space; presacral space; femoral vascular sheath space; perirectal space;
ischiorectal space; ischioanal space, and pelvic sidewall. We will
present case examples from our trauma level 1 institution to
highlight findings along the previously described anatomical compartments. We will discuss common pitfalls of interpretation. Conclusion: Trauma is the leading cause of mortality and morbidity in the young population. The radiologist plays an important
role in the evaluation of patients with pelvic trauma. It is imperative for the radiologist to have a thorough knowledge of the
anatomy of the extraperitoneal pelvic spaces since it can have
significant impact on patient care.
E121. Imaging Ventral Hernias: Anatomy, Surgical
Techniques and Complications of Mesh Repair
Rowell, A.; Rau, B.; Heldmann, M.; Sangster, G.; Richardson, K.
Louisiana State University Health Sciences Center, Shreveport, LA
Address correspondence to M. Heldmann ([email protected])
Background Information: Abdominal wall hernias are a common malady in the general surgeon’s practice, and nearly
100,000 ventral hernia repairs are performed annually in the
United States. Traditional open hernia repair and newer laparoscopic methods are both associated with complications, and a
range of mesh products are commercially available for onlay,
suture or tack fixation. The evolution of radiologic techniques
from herniography, through ultrasound (US), to isotropic voxel CT
has afforded imaging greater contribution in the detection of
clinically occult hernias, characterization of complex defects for
preoperative planning, and detection of postoperative complications. The infinite multiplanar reformat (MPR) series and volume
rendered (VR) techniques of MDCT are powerful tools with
which the general or subspecialist radiologist can become familiar with and display expected and unanticipated findings after
anterior abdominal wall herniorrhaphy.
Educational Goals/Teaching Points: This educational exhibit
will review the anatomy of the anterior abdominal wall with
imaging and clinical correlation; illustrate the imaging appearance of congenital and acquired abdominal wall hernias relate
basic surgical techniques of ventral hernia repair; depict the
uncomplicated postoperative appearance of ventral hernia repair
with mesh, and present the common perioperative and postoperative complications, with an emphasis on MDCT.
Techniques: The exhibit will include operative images, MDCT
and US of the normal abdominal wall; operative images, MDCT
and US of ventral hernias, and MDCT with MPR and VR of postoperative abscess, hematoma, seroma, extrusion and fistula formation.
Conclusion: Abdominal hernia and hernia repair procedures are
ubiquitous, and as such are commonly encountered in the busy
radiology practice. Familiarity with basic surgical techniques,
materials and expected postoperative findings promote the
detection of complications and allow imagers to communicate
with and assist the surgeon performing abdominal herniorrhaphy.
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E123. Retroperitoneal Infectious Processes: A Pictorial Review
Arnold, G.1; Jafri, Z.1; Werder, G.1; Amendola, M.2; Francis, I.3;
Amin, M.1 1. William Beaumont Hospital, Royal Oak, MI; 2.
University of Miami, Coral Gables, FL; 3. University of Michigan,
Ann Arbor, MI
Address correspondence to G. Arnold ([email protected])
describe the basic anatomy of the retroperitoneum and to illustrate some of the infectious processes which occur there. Educational Goals/Teaching Points: Specific examples of retroperitoneal infectious processes illustrated include mycobacterium
tuberculosis (TB), histoplasmosis, mycobacterium avium-intracellulare (MAI), xanthogranulomatous pyelonephritis (XGP), diverticulitis with psoas abscess, discitis, mycotic aneurysm (aortitis),
and brucellosis.
Techniques: CT findings are emphasized.
Conclusion: This exhibit will aid the radiologist in forming a
basic differential diagnosis for infectious processes of the retroperitoneum.
E124. Identification and Clinical Significance of Twinkling
Artifact (CME Credit Available)
Wang, D.; Kamaya, A. Stanford University, Stanford, CA
Address correspondence to D. Wang ([email protected])
Background Information: Twinkling artifact is a commonly seen
artifact in abdominal and pelvic imaging. This artifact is a rapidly
alternating red, blue, green, yellow, and orange focus of aliasing
seen posterior to a highly reflective or rough surface on color
Doppler imaging. Accurate recognition of this artifact is important
as this artifact is commonly seen in daily practice.
Educational Goals/Teaching Points: The goals of the exhibit
are to demonstrate the range of appearances and locations of
twinkling artifact; to illustrate ways in which twinkling artifact can
be useful as a problem solving tool to lead to a correct diagnosis;
to provide methods to distinguish Twinkling artifact from true
vascularity, and demonstrate pitfalls in which twinkling artifact
may be artifactually seen.
Techniques: Twinkling artifact can be a very helpful tool in evaluating many entities: renal stones (ureterovesicular junction [UVJ]
stones which may otherwise be missed on grayscale imaging,
staghorn calculi which may be difficult to delineate from adjacent
echogenic fat, milk of calcium in calyceal diverticulum, simple
renal stones in which posterior acoustic shadowing is not clearly
demonstrable); gallbladder (adenomyomatosis, gallstones), and
bladder wall calcifications. Twinkling artifact associated with foreign bodies, and twinkling artifact seen in other areas such as
calcified uterine fibroids, prostate, carotid artery plaque, etc. will
be discussed. Techniques to distinguish twinkling from vascularity, such as recognition of twinkling artifact on spectral Doppler
tracings and understanding how changing pulse repetition frequency affects the appearance of twinkling artifact plus pitfalls
(confusing twinkling artifact with hypervascularity such as in the
gallbladder or uterus, confusing twinkling artifact for an arterial-
venous fistula in the kidney; confusing twinkling artifact with a
hemodynamically significant stenosis in vascular imaging and setting machine parameters too low such that a truly vascular lesion
is called twinkling artifact will be discussed.
and discuss the histopathologic correlation in order to have better understanding and correct usage of halo signs.
Conclusion: Correct identification of twinkling artifact is important in Doppler ultrasound and allows for more precise diagnostic accuracy.
Educational Goals/Teaching Points: The various entities associated with halo signs will be reviewed in terms of their key imaging
findings and histopathology. The goal of this pictorial review is to
have a clear understanding of the various halo signs in wide spectrum of pathologic processes and different imaging modalities.
E125. CT Appearance of Juxtacaval Fat Mimicking as IVC
Lipoma
Sidhu, R.; Bhatt, S.; Dogra, V. University of Rochester, Rochester, NY
Address correspondence to R. Sidhu (ravinder_sidhu@urmc.
rochester.edu)
Techniques: This exhibit will review pathologic processes and
imaging findings of a variety of diagnostic entities that halo signs
are associated with, and illustrate and emphasize key imaging
findings that constitute halo signs in those diagnostic entities.
Background Information: Fatty mass in the intrahepatic portion
of inferior vena cava (IVC) is unusual. This fat can be mistaken
for IVC lipoma on axial CT images. Multiplanar CT especially with
coronal images helps to demonstrate extraluminal nature of fat.
Conclusion: A halo sign is described in a variety of pathologic
processes at multiple imaging modalities. In order to improve its
diagnostic value, it is important to have a clear understanding of
the imaging findings and histopathology of the sign associated
with a variety of diagnostic entities.
Educational Goals/Teaching Points: Appearance of intraluminal fat within the intrahepatic portion of the IVC at or above the
level of confluence of the hepatic veins is often misinterpreted as
IVC lipoma. This extraluminal fat actually represents a close association of pericaval, extraluminal adipose tissue with the medial aspect of the immediately subdiaphragmatic IVC. Multiplanar
CT reconstruction is helpful in demonstrating the extraluminal
nature of juxtacaval fat collections, thereby avoiding misinterpretation and further unnecessary follow-up examinations.
Techniques: The axial and reconstruction CT images of fat in the
juxtacaval region will be shown. The key features as how to differentiate normal juxtacaval fat from IVC lipoma, and fat thrombus will be discussed. Conclusion: Juxtacaval fat mimics lipoma in the IVC. Special consideration will be made so as to be familiar with their normal
appearances of fat in this location which is an anatomical variant.
It is important to identify this particular entity which is much less
talked about so as to avoid further unnecessary investigations.
E126. Halos in the Bellows, Hallows and Others (CME Credit
Available)
Hwang, S.; Ginsberg, M.; Gollub, M. Memorial Sloan-Kettering
Cancer Center, New York, NY
Address correspondence to S. Hwang ([email protected])
Background Information: A halo sign has been described in a
variety of pathologic processes of multiple organ systems. In the
lung, the sign was initially introduced to describe hemorrhagic
nodules of invasive pulmonary aspergillosis at CT. Now the sign is
also linked to multiple infectious pathogens, pulmonary neoplasm and noninfectious inflammatory processes. In the liver, a
periportal halo sign at CT and MRI is associated with neoplastic
and non-neoplastic processes which expand periportal spaces. A
halo sign in the liver and spleen at ultrasound is often indicative
of neoplasm. Within the gastrointestinal tract, the sign is associated with infectious and inflammatory processes affecting intestinal
mural layers. In the bones, the halo sign at MRI is highly specific
for osteoblastic metastases. The goal of this review is to illustrate
imaging findings of halo signs of various pathologic processes
E127. Tumor Response Criteria: What Should a Radiologist
Know? (CME Credit Available)
Braschi , M.1; Ramaiya, N.2; Zondervan, R.1; Urban ,T.1; Van Den
Abbeele, A.2; Harris, G.1 1. Massachusetts General Hospital,
Boston, MA; 2. Dana Farber Hospital, Boston, MA
Address correspondence to M. Braschi ([email protected])
Background Information: When imaging is used to monitor the
efficacy of cancer treatment, radiologists are facing an increasing
demand from oncologists to use imaging assessment criteria
such as RECIST (Response Evaluation Criteria for Solid Tumors),
WHO (World Health Organization), and Cheson. In order to provide objective and consistent scan reviews, radiologists should
become familiar with the guidelines utilized by these standard
imaging assessment criteria. The goal of this exhibit is to familiarize viewers with these important measurement guidelines using
test cases and quizzes.
Educational Goals/Teaching Points: Longitudinal imaging
assessment in the evaluation of patients with cancer and in clinical trials plays an integral role in patient treatment decisions. The
above-mentioned criteria incorporate both quantitative and qualitative methods to assess tumor response to therapy. However, in
order to obtain the most accurate study results, the readers
require training, experience and knowledge on measurement criteria guidelines.
Techniques: In this exhibit, we will provide a synopsis of each
criteria and corresponding test cases and quizzes to demonstrate
a variety of teaching points such as lesion selection (“target” vs.
“nontarget”), methods of measurement (CT and MRI), consistency across imaging time points, and response evaluation: stable
disease (SD), partial response (PR), progression disease (PD),
complete response (CR), complete response unconfirmed (Cru),
relapse disease (RD), unknown.
Conclusion: At the conclusion of this presentation, the viewers
will gain confidence and knowledge about three of the most
common measurement criteria utilized in radiology to assess
response to therapy.
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E128. Sternoclavicular Joint Dislocations: Imaging Findings
With Intraoperative Correlation (CME Credit Available)
Chakarun, C.; Tumyan, L.; Demetriades, D.; Wolfson, N.; White, E.
University of Southern California, Los Angeles, CA
Address correspondence to C. Chakarun ([email protected])
Background Information: Our purpose is to describe the plain
radiographic and CT imaging findings in patients with sternoclavicular joint dislocations at our Level I trauma center, and correlate these findings with intraoperative reports and photographs.
Educational Goals/Teaching Points: Sternoclavicular joint dislocations usually cannot be diagnosed on plain radiographs, and
contrast-enhanced CT is often necessary. Anterior dislocations are
nine times more common than posterior dislocations, however,
posterior dislocations can be life-threatening due to compromise
of the trachea, esophagus, and great vessels. Herein, we provide
examples of both anterior and posterior sternoclavicular joint dislocations from our Level I trauma center, demonstrating plain
radiographic and CT imaging findings. These findings are correlated with emergency department photographs, intraoperative photographs, and intraoperative reports. Our goal is for the reader to
understand the serious sequelae that can result from sternoclavicular joint dislocation, and to have a better understanding of
the anatomy and associated imaging findings.
Techniques: Both anterior and posterior sternoclavicular joint
dislocations indicate high-energy trauma. Anterior dislocations
result from direct trauma that causes separation of the anterior
sternoclavicular ligament. Posterior sternoclavicular joint dislocations are caused by posterolateral compressive forces in the
shoulder that dislocate the medial aspect of the clavicle posterior
to the sternum. Cases have also been reported in which posterior
dislocation results from direct blunt trauma at the medial clavicular head. Contrast-enhanced CT is the imaging modality of choice,
since the great vessels need to be evaluated and plain radiography may not adequately assess joint alignment. Closed reduction
is the preferred treatment, but patients presenting more than 48
hours after injury often require surgical intervention.
Conclusion: Sternoclavicular joint dislocation can be life-threatening, and understanding the anatomy and imaging findings of
the associated injured structures is crucial to prompt diagnosis
and treatment. Through intraoperative photographs and images
from our Level I trauma center, the radiologist will become more
familiar with this important diagnosis.
E129. Traumatic Injury of the Head and Neck: Imaging of the
“Not-So-Obvious” that Can Make a Big Difference (CME
Credit Available)
Zeinati, C.1; Poon, C.1,2; Chang, J.1; Kubal, W.2 1. SUNY Upstate
Medical University, Syracuse, NY; 2. Yale University School of
Medicine, New Haven, CT
Address correspondence to C. Poon ([email protected])
Background Information: Imaging of traumatic injury of the
head and neck is often considered a straightforward task in radiological practice. Nevertheless, there are many subtle findings in
traumatic imaging that are often overlooked, but failure to recognize them may affect patient management significantly. An example is venous sinus thrombosis associated with injury of the dural
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venous sinuses. Traumatic dural venous sinus thrombosis may
mislead an inexperienced radiologist to interpret the findings as
simply hemorrhage from the traumatic injury. Yet the failure to
recognize the difference has significant implication in patient
management. Many other abnormalities, such as blunt vascular
injury or chronic injuries from child abuse, also can potentially be
associated with dire consequences. These injuries can be isolated, subtle and confusing, making them easy to be misinterpreted.
The purpose of this educational exhibit is to increase the awareness of these entities in the general radiology community, so that
improved patient care can be attained.
under-recognized traumatic injuries and their potentially serious
complications in the head and neck; to review the criteria and
algorithms for radiological workup in traumatic injuries of the
head and neck, with an emphasis on the value of advanced studies such as MRI, MR angiography (MRA), CT angiography (CTA)
and susceptibility weighted imaging, and to review the patient
management issues related to diagnosis of uncommon injuries in
the head and neck and their complications, as pertinent for a
radiologist.
Techniques: Cases related to traumatic injuries of the head and
neck from our institutions are reviewed systematically. Imaging
features of uncommon injuries, injuries with subtle findings or
unexpected complications are reviewed. Measures to avoid diagnostic pitfalls, guidelines for diagnostic workup in particular the
use of advanced imaging techniques such as CT venography, CTA,
MR venography, MRA and susceptibility weighted imaging are
discussed. A brief discussion on the impact of the radiological
diagnosis on patient management is also included.
Conclusion: Although imaging evaluation of traumatic injuries of
the head and neck are often considered straightforward, uncommon injuries or injuries with subtle findings are not as well recognized. These injuries can be associated with severe complications. Prompt recognition of these injuries and their potential
complications can affect patient management substantially.
E130. Blast and Ballistic Trajectory Analysis with MDCT:
Applications of Volume Acquisition and Complex Planar
Reformats in Trauma Diagnosis (CME Credit Available)
Folio, L.; Backus, C. Uniformed Services University of the Health
Sciences, Bethesda, MD
Address correspondence to L. Folio ([email protected])
Objective: The authors describe and quantify complex anatomic
planes that are now possible with volumetric MDCT imaging. We
propose more objective nomenclature labeled para-axial, paracoronal and parasagittal image reconstructions. A brief overview
of trajectory analysis using volumetric imaging and resultant multiplanar reconstruction will also be introduced. The authors also
introduce a quantifiable methodology for more accurately
describing these complex planes for consistency of reporting
penetrating trauma and showing how the radiologist can be
helpful in incident analysis.
Materials and Methods: Several penetrating trauma CT studies
from a deployed military hospital in Iraq were reviewed and
selected to apply this more objective planar description. A few of
the cases reviewed are presented demonstrating application of
the complex anatomic planes described. Detailed anatomic artwork tailored to the cases highlight application of more clearly
defined planes. Lastly, a methodical trajectory analysis system
and numerically descriptive plane combination using an anatomic reference point is proposed.
Results: The cases reviewed consistently identify and more effectively communicate the complex intersecting planes along the
trajectory of various missile fragments. Finding a trajectory of one
fragment often increases conspicuity of other fragments that may
have otherwise gone undetected. Parallel para-axial interpretation based on reference fragments helps find other missiles.
Quantification of intersecting planar angles and magnitude from
a reference point allows localization of remaining fragments. This
is especially helpful in blast injuries that have multiple fragments.
Conclusion: The authors demonstrate application of a novel trajectory analysis by more objectively defining complex planes with
a proposed lexicon and anatomic modeling. The authors further
quantify locations by a proposed anatomical polar coordinate
system based on a single reference point. The authors believe
this may be useful in consistent recording and communicating
the location of multiple blast and ballistic fragments. Determining
and describing trajectory angles using standard polar coordinates
may help the study of individual incidents as well as for an epidemiologic baseline in recording and comparing gunshot and
blast trajectories for years to come. Since image data is occasionally not available during evacuation up the echelons, more accurate recording of trajectories and quantified planes is paramount.
E131. North American Blastomycosis
Demos, T.; Brylka, D.; Posniak, H. Loyola University Medical
Center, Maywood, IL
Address correspondence to T. Demos ([email protected])
Background Information: North American blastomycosis is a
fungal disease that involves multiple organ systems. Initial infection is due to inhalation of B. dermatitidis from soil, vegetation or
rotting wood. In North America, the disease is most common in
the central and southeast US and southern Canada. Most
patients present with acute to chronic pulmonary symptoms and
85% have chest imaging findings that can have the appearance
of pneumonia, tuberculosis, or malignancy. Hematogenous
spread to other organs may not be evident for weeks to years.
Organ involvement includes skin (30%), bones and joints (20%),
prostate and genitourinary organs (10%), and meninges and
brain (3%), but all organs have been affected. Variable finding on
chest imaging can make diagnosis difficult. When patients
present with extrapulmonary disease, diagnosis can be even
more difficult. The informed radiologist can be instrumental in
contributing to the early diagnosis in these patients. Early diagnosis can avoid lengthy evaluations and invasive procedures, and
early treatment can be crucial to survival in immune compromised patients.
Educational Goals/Teaching Points: The exhibit will illustrate
the spectrum of findings of blastomycosis in the chest as shown
by various imaging modalities. Extrathoracic involvement will be
discussed and lesions of the bones and joints, prostate and genitourinary organ, meninges, brain, and abdomen and pelvis will
be illustrated. The association of lesions in a patient suggesting
the diagnosis will be discussed.
Techniques: The spectrum of thoracic blastomycosis will be
discussed and illustrated by radiography, CT, MR, and PET. The
incidence and presentation of extrapulmonary blastomyosis
will be discussed. Prostate and genitourinary lesions will be illustrated by CT and MR imaging. Meningeal and brain lesions will be
discussed and illustrated by MR and CT imaging. Bone and joint
lesions will be shown by radiography and MR imaging. Abdominal
and pelvis involvement will be illustrated by CT imaging.
Conclusion: North American blastomycosis is common in the
central and southeast US. Most patients present with
chest abnormalities but extrapulmonary lesions are common.
Chest lesions have a wide variety of appearances. The most common extrapulmonary lesions are to skin, bone, prostate, and
meninges. Knowledge of the spectrum of chest and extrapulmonary lesions will put the radiologist in a position to suggest the
diagnosis. Early diagnosis and treatment improve the prognosis,
especially in immune compromised patients.
E133. Incidentalomas: A Case-Based Review (CME Credit
Available)
Nehme, T. Radia, E Wenatchee, WA
Address correspondence to T. Nehme ([email protected])
Background Information: With the ever increasing accuracy of
cross-sectional imaging, more incidental findings are being recognized that are unrelated to the problem being evaluated. This has
created a dilemma for both the radiologist and referring physician in evaluating these abnormalities. The purpose of this exhibit
is to familiarize the audience with the different incidentalomas
visualized on cross-sectional imaging and to provide an algorithm
for their work up based on the current literature.
Educational Goals/Teaching Points: The goals are to familiarize the audience with the different incidentalomas detected on
cross-sectional imaging and to present algorithms in the work up
of incidentalomas based on current literature.
Techniques: Incidentalomas in neuroradiology on cross-sectional
imaging, incidentalomas in the chest on cross-sectional imaging,
and incidentalomas in the abdomen and pelvis on cross- sectional imaging will be discussed.
Conclusion: Incidentalomas on cross-sectional imaging are frequently encountered by radiologists. The work up of such findings however remains a dilemma. The exhibit presented will
hopefully help the interpreting radiologist in the work up of these
findings with algorithms based on current literature.
E134. Ciliary Disease: From the Ultrastructure Level to the
Imaging Manifestations
Escalante, B.1; Restrepo, C.1; Prasad , S.1; Varon, C.2; Varon, H.2;
Murcia, S.2 1. University of Texas Health Sciences Center at San
Antonio, San Antonio, TX; 2. Universidad Nacional de Colombia,
Bogota, Colombia
Address correspondence to B. Escalante ([email protected])
Background Information: The dysfunction of one type of cilium,
called motile cilia, leading to manifestations of primary ciliary dyskinesia and Karatagener’s syndrome is well studied. Recent studies
221
suggest the role of another type of cilium, called primary cilium, in
development of polycystic kidney disease and laterality defects.
The purpose of this exhibit is to discuss the two types of cilia and
illustrate the imaging characteristics of their associated diseases.
Educational Goals/Teaching Points: The exhibit will discuss
the difference between the two types of cilia: motile and primary;
review and help the learner understand the pathophysiology of
motile cilia dysfunction in the mucosa of the respiratory airways
leading to primary ciliary dyskinesia and Karatagener’s syndrome;
discuss the emerging evidence of the role of another type of cilia,
the primary cilia, in development of polycystic kidney disease and
laterality defects such as situs inverus and heterotaxias, and illustrate imaging characteristics of diseases associated with dysfunction of the two types of cilia.
Techniques: Cilia are organelles that are present in most human
cells and are classified based on their microtubular configurations. The motile type has a 9+2 microtubule configuration. Well
known are the abnormalities within motile cilia causing cellular
dysfunction leading to respiratory disease and infertility. The primary type has a 9+0 microtubule configuration and was traditionally thought of as a vestigial cellular structure. However,
recent discoveries have suggested that the absence or dysfunction of embryonic primary cilia may affect human development.
These discoveries extend the list and imaging characteristics of
ciliary diseases to include those that involve abnormal organ
form and location such as polycystic kidney disease, situs inversus, and heterotaxias. The imaging characteristics of the associated diseases of these two types of cilia will be presented.
Conclusion: Well known are the abnormalities of motile ciliary
function leading to tissue and cellular dysfunction as in primary ciliary dyskinesia and Karatagener’s syndrome. Recent studies have
linked another type of cilium, the primary cilium, in diseases such as
polycystic kidney disease, situs inverus, and heterotaxias. With these
new discoveries, imaging characteristics of ciliary disease encompass, not only those that are the consequences of abnormal organ
function, but also those of abnormal organ form and location.
E135. Non-Hodgkin’s Lymphoma: The Great Masquerader
Warsofsky, I.; Enochs, W. Bryn Mawr Hospital, Bryn Mawr, PA
Address correspondence to I. Warsofsky ([email protected])
Background Information: Lymphoma is a broad classification of
neoplastic processes which includes Hodgkin’s lymphoma, nonHodgkin’s lymphoma (NHL), and other related disorders.
Lymphomas are solid malignancies which typically occur in
lymph nodes and primary lymphoid tissue. However, atypical
appearances have found in other organs, particularly for NHL,
and it is important to be knowledgeable of both its common and
uncommon appearance. Such knowledge may expedite a
patient’s diagnostic workup as often the symptoms and/or physical examination are not sufficiently revealing.
Educational Goals/Teaching Points: Familiarity with the evaluation of NHL is necessary to ensure that staging is done correctly as
this has a direct impact on the treatment. Case examples of both
typical and atypical presentations of lymphoma will be illustrated.
The educational goals of this project include: review of the normal
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lymph node groups, evaluation of lymphomas with typical and
atypical presentations and assessment of other diagnoses in the
differential for the demonstrated imaging findings will be reviewed.
Techniques: A strong background in normal anatomy is required
in order to identify pathologic lymphoid tissue. While evaluation
of scans typically incorporates size criteria of nodes, it is important to use PET in conjunction for identification of metabolically
active nodes. Imaging modalities including plain film radiography, cross-sectional imaging (CT and MRI) as well as PET will be
depicted for specific cases from the standpoint of both diagnosis
and follow-up. Cases exemplifying typical presentations of lymphoma in the mediastinum and in the spleen will be shown.
Development of lymphoma in extranodal sites such as in the
adrenal gland, in breast tissue, kidney, brain, and in lung parenchyma will be illustrated.
Conclusion: There have been tremendous strides in the treatment of NHL with many patients achieving remission and/or
cure. However, it is not only the improved understanding of the
pathophysiology and treatments that are responsible for these
outcomes; but also, the improved imaging techniques for diagnosis. Lymphoma is often described at the reading board as “the
great masquerader.” Knowledge of its typical and atypical presentations will provide the radiologist with tools to carefully
review scans and offer the possible diagnostic considerations so
that a diagnosis is not missed.
E137. Emergency Radiographs: What all First Year Residents
Should Know (CME Credit Available)
Lee, B.; Whitehead, M.; Scheel, J.; Dowell, J.; Lambert, D.
University of Virginia, Charlottesville, VA
Address correspondence to B. Lee ([email protected])
Background Information: Certain findings on radiographs warrant a timely intervention. Often, these images are initially
encountered by a less experienced radiology resident. Prompt
recognition of these findings are essential to patient care.
Educational Goals/Teaching Points: The goal is to present various radiographic findings of “do not miss on call” lesions. (These
will be presented in case-quiz format.)
Techniques: The following cases will be presented in quiz format
with images and answers with explanation (with treatment in
selected cases). 1. Chest—pneumothorax, tension; pneumothorax
on supine radiograph (deep sulcus sign); pneumomediastinum;
pneumopericardium, and lobar collapse secondary to bronchial
occlusion; 2. Musculoskeletal—compound (open) fracture; knee,
segond fracture; foot, Lis Franc fracture-dislocation; hand, game
keeper’s thumb; hand, Bennet’s fracture; elbow, epicondylar fracture; spine, flexion tear drop; spine, posterior spinal ligamentous
injury; skull/spine, craniocervical dissociation, and spine, anklyosing spondylitis with fracture; 3. Abdomen—pneumoperitoneum;
retroperitoneal air; necrotizing enterocolitis; pneumobilia; pneumotosis intestinalis; portal venous gas; emphysematous cholecystitis; emphysematous cystitis, and small bowel obstruction
Conclusion: Described above are some of the plain radiographic
findings which require prompt attention and treatment.
Electronic Exhibits: Gastrointestinal
GI/Liver/Biliary/Pancreas
E138. Postgadolinium MR Imaging With Multiplanar
Reconstruction of Fistula In Ano
Dalal, T.; Paspulati, R. Case Western Reserve University, Solon, OH
Address correspondence to R. Paspulati (prajmohan@hotmail.
com)
Objective: The goals are for the learner to understand the anatomy, pathogenesis and types of fistula in ano; understand the
technique of MR imaging of fistula in ano, and understand the
role of MR imaging in treatment of fistula in ano.
Materials and Methods: This is a review of MR imaging of the
pelvis for diagnosis and lay out of peri anal fistulae. From 2005
to 2008, 56 cases of suspected fistula in ano had MR imaging.
Ten of them had known inflammatory bowel disease and five of
them had hematological malignancy under treatment with neutropenia and perianal abscess. The remaining large number of
cases are without a predisposing cause. MR protocol included
high resolution T2 fast spin echo (FSE) in three orthogonal
planes, Axial T2 FSE with fat suppression and 1.5 mm thin postgadolinium T1-weighted images. Multiplanar reconstructions are
obtained in all patients to demonstrate the fistulous tract.
Results: MR imaging findings are correlated with operative findings. The entire length of the fistula is well documented in
T2-weighted images and confirmed with postgadolinium images
in all patients. The wall of the fistula is well demonstrated on
postgadolinium images due to dense enhancement of inflammatory tissue. The fistulas are classified into intersphincteric and
trans-sphincteric types. Associated branching side tracks and
abscess are well demonstrated, which helped the surgeon in surgical management.
Conclusion: MR imaging with high resolution T2-weighted images and postgadolinium images provide an anatomical lay out of
the peri anal fistula for surgical management. The complex fistulous tracts are very well displayed in the multiplanar reconstructed postgadolinium images.
E139. Test Your Appendicitis IQ: Atypical Appearances and
Potential Mimickers on CT (CME Credit Available)
Mooney, S.; Rubens, D.; Fultz, P.; Jones, L. University of Rochester,
Rochester, NY
Address correspondence to S. Mooney (scott_mooney@urmc.
rochester.edu)
Background Information: Acute appendicitis is the most common indication for emergent surgery. CT is the primary imaging
modality used for evaluating abdominal pain in suspected
appendicitis, with ultrasound and MRI usually reserved for children and pregnant women. The classic appearance of appendicitis has been described on CT, however, atypical appearances of
appendicitis and its mimickers can create difficulty in interpretation. These confounding diagnostic challenges will be presented.
Techniques: Atypical appearances of appendicitis including tip
appendicitis, air-filled appendicitis, nondilated appendicitis, and
appendicitis masquerading as nonsurgical bowel disease will be
presented with CT. Potential CT mimickers of appendicitis including Meckel’s diverticulum, appendiceal mucocele, appendiceal
carcinoma, and secondary appendiceal inflammation will also be
presented.
Conclusion: Although CT has high negative and positive predictive value in the evaluation of acute appendicitis, atypical appearances and potential mimickers of appendicitis on CT can be confusing. Knowledge of these entities can aid in clarifying the diagnosis.
E140. Pitfalls in CT Diagnosis of Appendicitis (CME Credit
Available)
Tappouni, R.; Sarwani, N.; Chamarthi, S.; Peterson, C. Penn State,
Hershey, PA
Address correspondence to R. Tappouni ([email protected])
Background Information: Acute appendicitis is a common
cause of acute abdominal pain requiring emergent abdominal
surgery. CT of the abdomen and pelvis is increasingly used in
making the diagnosis and therefore avoiding delay in management. While the overall accuracy of CT is high, numerous pitfalls
exist which may deceive radiologists, resulting in a false negative
or false positive diagnosis. These pitfalls include atypical locations
of the appendix, inflammation of the appendiceal tip or postappendectomy stump, presence of coexisting lower abdominal
pathology and technical factors.
Educational Goals/Teaching Points: The goals are to demonstrate radiologic pitfalls in CT diagnosis of appendicitis; review
the differential diagnosis of appendicitis and right lower quadrant
pain; review the significance of various CT findings in the diagnosis of appendicitis, and illustrate the pitfalls in the diagnosis of
appendicitis.
Techniques: An auto-tutorial will consist of cases divided into
four categories: 1.Variants: tip appendicitis, abnormal location,
and stump appendicitis; 2.Technical Pitfalls: effect of oral and IV
contrast use in establishing the diagnosis of appendicitis; 3.
Conditions Leading to Misdiagnosis of Appendicitis: false negatives: ovarian pathology, small bowel obstruction, terminal ileitis;
coexisting inflammatory and neoplastic processes: appendicitis
coexisting with diverticulitis, and appendiceal carcinoma, and 4.
Conditions Leading to False Positive Diagnosis of Appendicitis:
wall thickening of appendix in an amyand hernia, Crohn’s disease, and appendiceal carcinoid.
Conclusion: In order to achieve a high degree of accuracy in the
CT diagnosis of appendicitis, careful attention to technique and
interpretation are required. The radiologist should be aware of
the features leading to false positive and negative diagnosis, in
addition to anatomic variants.
the normal appearance of the appendix, and present typical and
atypical appearances of appendicitis, and potential mimickers.
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E141. The Vermiform Appendix: The Worm That Turned
Goud, N.1; Jati, A.1; Goud, A.1; Ramaiya, N.2 1. VA Boston Health
Care System, West Roxbury, MA; 2. Dana Farber Cancer Institute,
Boston, MA
Address correspondence to A. Jati ([email protected])
Background Information: The objective is to describe and illustrate multimodality imaging findings of appendiceal pathology
and to identify differentiating imaging features in both neoplastic
and non-neoplastic conditions of the appendix.
Educational Goals/Teaching Points: This exhibit will provide a
concise and comprehensive review of appendiceal pathology,
and case examples with specific features that help to differentiate these disease processes. Persons who view the exhibit will
learn to identify the imaging findings of these conditions.
Techniques: Acute appendicitis is the most common pathology
involving the appendix. This may present with a myriad of typical
or atypical imaging findings. Primary tumors of the appendix are
rare and most tumors are incidentally detected on routine imaging. It is important to recognize the underlying tumor to allow for
optimal treatment. Benign tumors involving appendix include
lipoma, leiomyoma, adenoma, and neuroma. Malignant tumors
include carcinoid tumor, adenocarcinoma, lymphoma and gastrointestinal stromal tumor (GIST). Appendiceal luminal obstruction is a common manifestation of most appendiceal disease
entities including appendicitis, mucocele and appendiceal
tumors. Mucocele implies abnormal accumulation of mucus and
is caused by appendiceal obstruction. It can be seen in non-neoplastic and neoplastic conditions. Pseudomyxoma peritonei
results from the perforation of mucocele and it is important to
differentiate it from complicated ascitis and peritoneal carcinomatosis. Appendiceal tumors may have a greater soft tissue component in the pericecal area compared to appendicitis. Nodes
may be larger but not necessarily more numerous. Appendiceal
lymphoma usually have even more marked soft tissue thickening
with maintained vermiform morphology of appendix. Carcinoid
tumor is seen in distal appendix in young patients, because of
the small size the primary tumor may be difficult to image.
Conclusion: On completing this exhibit the reader should be
able to list the common and uncommon pathology that affects
the appendix and understand the role of imaging in making the
diagnosis of appendiceal pathology. The reader should also be
aware of the specific imaging findings that differentiate these various pathologic entities.
E142. Oh No! Did I Miss That? On-Call Acute Appendicitis
Lee, J.; Chen, C.; Suh, R.; Kadell, B.; Lee, E. University of
California-Los Angeles Medical Center, Los Angeles, CA
Address correspondence to E. Lee ([email protected])
Background Information: Acute appendicitis has extremely varied clinical presentations. A delayed or missed diagnosis of acute
appendicitis may result in severely detrimental consequences.
Acute appendicitis cases seen during on-call can be especially
difficult and challenging. This comprehensive pictorial review will
demonstrate the spectrum of radiological findings and CT
224
appearances of occult/missed appendicitis during on-call at a
single institution over the last six years.
Educational Goals/Teaching Points: The goals are to provide a
pictorial review of various presentations of missed acute appendicitis, and to review the complications and outcomes of missed
acute appendicitis.
Techniques: The exhibit will include MDCT and ultrasound (US)
presentations of missed acute appendicitis; radiological-pathological correlation of acute appendicitis; background information on
acute appendicitis ; meta-analysis of literature on delayed diagnosis of acute appendicitis and its outcomes, and outcome and
complication analysis of patients with missed acute appendicitis.
Conclusion: Diagnosis of acute appendicitis with MDCT or US
can be challenging. Missed acute appendicitis increases patient
healthcare cost, morbidity and mortality. Radiologists need to be
aware of the variety of presentations of acute appendicitis for
optimal patient care and prognosis.
E143. MDCT in Imaging of Epiploic Appendagitis: A Pictorial
Essay (CME Credit Available)
Gupta, S.; Tatineny, K.; Sadler, M.; Yeghiayan, P. St Vincent’s
Catholic Medical Center, NY, New York, NY
Address correspondence to S. Gupta ([email protected])
Background Information: The goals of the exhibit are to illustrate the radiological findings of epiploic appendagitis as seen on
MDCT; discuss the main differential diagnoses of epiploic
appendagitis, and to discuss the impact of imaging findings on
management.
Educational Goals/Teaching Points: Teaching points include
normal anatomy, signs and symptoms, epiploic appendagitis
(MDCT findings including hyperattenuating rim sign), and discussion on the importance of accurately diagnosing this condition
and its impact on management.
Techniques: The exhibit will distinguish the following differential
diagnoses from epiploic appendagitis: acute diverticulitis, omental infarction, acute appendicitis, panniculitis, and a fat-containing
tumor (liposarcoma).
Conclusion: In an era of increased imaging for acute abdominal
pain, radiologists are more likely to encounter the entity of epiploic appendagitis. Identifying its characteristic imaging features is
important, because it may avoid unnecessary antibiotic therapy
and possible surgery, as this entity is conservatively managed.
E144. Endoscopic Retrograde Cholangiopancreaticogram: A
Review of Normal Anatomy and Common Pathologies (CME
Credit Available)
Lee, B.; Whitehead, M.; Durst, C.; Shaffer, H.; Lambert, D.
Address correspondence to B. Lee ([email protected])
Background Information: Endoscopic retrograde cholangiopancreatography (ERCP) is a technique that combines endoscopy
and fluoroscopy to identify and treat diseases within the biliary
and pancreatic ductal systems. It is the test of choice in patients
with obstructive jaundice. Though most radiologists no longer
perform these procedures directly, fluoroscopic images are often
submitted for review. Knowledge of normal anatomy and recognition of abnormalities vs. abnormality is essential.
normal anatomy (diagram, picture, and fluoroscopic images are
included) of the biliary and pancreatic ductal system; identify
common pathology within the biliary and pancreatic ductal system, and recognize artifacts which may mimic disease.
Techniques: Fluoroscopic images from ERCP will be presented.
In selected case additional imaging modalities are presented
(endoscopic ultrasound, MR cholangiopancreatography [MRCP],
CT, cholangiogram). The exhibit will focus on the biliary ductal
system (cholelithiasis and choledocolithiasis, pseudolithiasis [air
bubbles, etc.], cholangiocarcinoma, primary sclerosing cholangitis,
bile leak, postoperative T-tube cholangiogram, and biliary stricture, benign and malignant) and the pancreatic ductal system
(pancreatic ductal stone; pancreatic ductal stricture, benign
[chronic pancreatitis] and malignant, intraductal papillary mucinous neoplasms [IPMN] and pancreas divisum).
Conclusion: ERCP is the test of choice in patients with obstructive jaundice. Though most radiologists no longer perform these
procedures directly, identification of normal biliary and pancreatic
ductal anatomy and recognition of common pathology on fluoroscopic images are essential.
E145. Radiographic Appearance of Endoscopic Retrograde
Cholangiopancreatography Instruments with Pictorial and
Functional Correlation
Kaplan, K.; Hartman, D. Penn State Milton S. Hershey Medical
Center, Harrisburg, PA
Address correspondence to K. Kaplan ([email protected])
Background Information: Endoscopic retrograde cholangiopancreatography (ERCP) is invaluable in the evaluation of disorders
of the pancreaticobiliary system. The interpretation of these images can be challenging as there is often uncertainty pertaining to
the type and purpose of the various endoscopic instruments
being used.
Educational Goals/Teaching Points: The exhibit is an auto-tutorial. A series of slides will review the various instruments within
a typical ERCP endoscope. Gross photographs of the individual
components will be presented along with corresponding radiographic images. Details regarding the function of the individual
instruments will be provided while radiographs from actual ERCP
cases will be used to correlate the structure and function.
Examples of the instruments that will be discussed include guide
wire, biliary extraction balloon, triple lumen needle knife, papillatome/sphincterotome, stone basket, pancreatic sized dilation
balloon, biopsy forceps and wire cytology brush.
Conclusion: This interactive exhibit will enable users to familiarize themselves with the endoscopic instruments that are used in
ERCP cases and the reasons why they are used. This will allow
the radiologist to provide a more accurate and meaningful report.
E146. Ultrasound Analysis of the Biliary System in Normal
and Diseased States
Matcuk, G.1; Vaseghi, M.2; Ralls, P.1 1. University of Southern
California, West Los Angeles, CA; 2. University of California, Los
Angeles, Los Angeles, CA
Address correspondence to G. Matcuk ([email protected])
Objective: The objective is to determine the normal size and
range of the intrahepatic and extrahepatic (common) bile ducts
and gallbladder, adjusted for demographic data, and to assess
the effects of a variety of pathologic states on these values.
Materials and Methods: Data from 4,119 abdominal ultrasounds were retrospectively analyzed. Normal patients were considered to be those without sonographic evidence of liver, gallbladder, biliary, or pancreatic disease. The values for the extrahepatic bile duct (EHD), left (LIHD) and right (RIHD) intrahepatic
ducts, gallbladder wall thickness, and gallbladder volume in normal patients were evaluated with respect to age, gender, ethnicity, and cholecystectomy status. These values were compared
using multivariate analysis to those in a variety of diseased states,
including cirrhosis, fatty liver, gallstones, sludge, cholecystitis, and
biliary obstruction.
Results: A total of 1,484 of the 4,119 abdominal ultrasounds
were classified as normal. The frequency of cirrhosis was 9.6%,
fatty liver 30.0%, gallstones 23.9%, sludge 8.5%, cholecystitis
1.0%, and biliary obstruction 2.0%. The EHD, RIHD, LIHD, and
gallbladder wall thickness and volume in normal patients were
3.8 ± 1.6 mm, 1. 9± 1.9 mm, 1.9 ± 1.1 mm, 2.6 ± 1.6 mm, and
242 ± 234 mL, respectively. Increasing EHD values correlated
with increasing RIHD, LIHD, and gallbladder volume measurements (p<0.0001). There were small but statistically significant
differences in normal EHD diameter with age (increase of 0.02 ±
0.11 mm/year, p<0.001), gender (0.3 ± 1.6 mm greater in
females than males, p<0.0001), and cholecystectomy status (1.0
± 1.6 mm greater in cholecystectomy patients, p<0.0001).
Patients with fatty liver had smaller mean EHD measurements
(difference of 0.4 ± 1.6 mm, p=0.0003) compared to normals. The gallbladder wall was thicker in patients with gallstones,
sludge, and cholecystitis by 0.4 ± 1.4 mm (p=0.0049), 0.5 ± 1.4
mm (p=0.0019), and 3.1 ± 1.6 mm (p<0.0001), respectively,
after adjusting for interdependence, age, and gender. In the presence of biliary obstruction, the mean values for EHD, RIHD, LIHD,
and gallbladder volume were significantly higher compared to
normal subjects by 6.0 ± 2.1 mm, 4.2 ± 1.4 mm, 4.1 ± 1.4 mm,
and 171 ± 207 mL, respectively (p<0.0001 for all values).
Conclusion: Ultrasound is an excellent tool for the evaluation of
the biliary system. This study clarifies normal values and ranges
for bile duct and gallbladder measurements, adjusted for demographic data, and evaluates these measurements in a variety of
common pathologic states. Key Anatomic/Physiologic Issues and Imaging Findings/
Techniques: Bile ducts, pancreatic ducts, biliary diseases, and
pancreatic diseases will be discussed.
225
E147. Biliary Ductal Plate Malformations: From the
Embryology to the Imagiology
Castro, M.; Almeida, A.; Silva, N.; Melao, L.; Pereira, J. Hospital de
São João, Porto, Portugal
Address correspondence to M. Castro ([email protected])
Background Information: The ductal plate is a cylindric layer of
cells that surrounds the branches of the portal veins that will form
the biliary ducts after remodeling and partial involution. Ductal
plate malformation disorders can result in biliary atresia and in
fibropolicystic liver diseases, when the ductal plates are insufficiently reabsorbed. The timing or stage of development arrest
determines the resulting clinicopathologic disorder such as congenital hepatic fibrosis, biliary hamartomas, autosomal dominant
polycystic liver disease, Caroli disease and choledochal cysts. Educational Goals/Teaching Points: The goals are to discuss
the pathogenesis of the disorders related with biliary ductal plate
malformation and review their clinical significance and to
describe the imaging findings of fibropolicystic liver diseases and
biliary atresia.
Techniques: CT and MR findings of the different clinical disorders related with ductal plate malformation are extensively discussed and illustrated with particular emphasis in the findings
that can assist in the differential diagnosis.
Conclusion: Knowledge of these disorders and the differences
between is fundamental to the correct diagnosis and proper
management.
E148. Cholangiocarcinoma: Diagnosis and Preoperative
Evaluation with MDCT and Dynamic Contrast-Enhanced MRI
with Pathologic Correlation
Rezvani, M.1; Kash, N. 1;Shaaban, A. 1; Olpin, J. 1; Sommers, D.
1; Woodward, P. 1. University of Utah, Salt Lake City, UT; 2. Texas
A & M University, College Station, TX
Address correspondence to M. Rezvani (maryam.rezvani@
hsc.utah.edu)
Background Information: This exhibit will familiarize the reader
with the MDCT and MRI features of cholangiocarcinoma for accurate diagnosis with emphasis on pathologic correlation and treatment planning.
Educational Goals/Teaching Points: Teaching points include:
pathophysiology and classification of cholangiocarcinoma;
imaging surveillance–optimizing MDCT and dynamic contrast-enhanced MRI protocols; imaging characteristics of cholangiocarcinoma with pathologic correlation, and preoperative imaging evaluation.
Techniques: Key to understanding the imaging characteristics of
cholangiocarcinoma and thereby optimizing MDCT and MRI protocols is an understanding of the pathologic basis of the disease.
Predisposing factors and the patient population requiring surveillance is reviewed. Key pathologic features and their corresponding imaging findings are illustrated. Advanced imaging techniques
will be reviewed to optimally visualize tumor and enable accurate preoperative evaluation.
226
Conclusion: This exhibit will be a comprehensive review of the
imaging features of intrahepatic and extrahepatic cholangiocarcinoma on MDCT and dynamic contrast-enhanced MRI. Pathologic
correlates for the characteristic imaging findings will be discussed
and illustrated. Features that determine resectability and impact
surgical planning will be reviewed.
E149. Primary Sclerosing Cholangitis: Imaging Features
Shaikh, A.1; Hammond, N.2; Berggruen, S.2; Harmath, C.2;
Nikolaidis, P.2 1. Chicago Medical School, North Chicago, IL; 2.
Northwestern University Feinberg, Chicago, IL
Address correspondence to S. Berggruen (senta.berggruen@nmff.
org)
Background Information: The goal is to review the imaging
characteristics of primary sclerosing cholangitis seen on ultrasound, CT, MRI, and MRCP that aid in the diagnosis of this
inflammatory disorder of the biliary tract.
are accurate characterization of the multimodality imaging features of primary sclerosing cholangitis.
Techniques: This educational exhibit will utilize case examples of
primary sclerosing cholangitis to demonstrate the characteristic
imaging findings that aid in the diagnosis and monitoring of this
disease. Ultrasound, CT, MRI, and MRCP will be the primary
modalities covered. ERCP will be also addressed. We will review
the imaging features of a variety of complications associated with
primary sclerosing cholangitis.
Conclusion: Primary sclerosing cholangitis is a chronic inflammatory disorder of the biliary tract. Recognizing the radiographic
findings on multiple modalities is essential in the diagnosis and
monitoring of patients with this disorder.
E150. The Effect of Positive Enteric Contrast Administration
on IV Contrast-Enhanced MDCT in Choledocholithiasis
Detection
Ajlan, A.; Mesurolle, B.; Stein, L.; Kao, E.; Giovanni , A.; Reinhold,
C. McGill University Health Centre, Montreal, Canada
Address correspondence to A. Ajlan ([email protected])
Objective: The objective is to retrospectively asses the accuracy
of IV-contrast-enhanced MDCT with and without oral contrast
administration in choledocholithiasis detection.
Materials and Methods: Among 1,580 endoscopic retrograde
cholangiopancreatography (ERCP) studies performed over a
three-year period, only patients with portal venous (PV)enhanced 4- and 64-MDCT examinations acquired within a week
prior to the ERCP study were selected (n=129). Of those, only
patients in whom the entire common bile duct (CBD) length was
visualized comprised the final study population (n=48, 19 males,
29 females; mean age, 68 years). We identified two groups
according to the absence (n=31) or presence (n=17) of positive
intraduodenal contrast. Section thickness ranged from 1.25-5
mm. Two radiologists, blinded to clinical information and ERCP
results, independently evaluated the CT images. Direct CBD stone
visualization was assessed according to predefined criteria. The
ERCP findings were used as the standard of reference. A third
reader retrospectively reviewed all discordant results. The diagnostic performances of both observers and interobserver agreement were calculated for both groups.
mechanisms include bradykinin associated vasodilatation and
increased vascular permeability, drug induced deficiency of C1
esterase and possible induction of auto-antibodies leading to an
immunologic response resulting in angioedema.
Results: Moderate (0.55) and good (0.66) interobserver agreements were obtained depending on the presence or absence of
duodenal contrast, respectively. There were 27 stone-positive and
21 stone-negative ERCP studies. Using MDCT, a stone was detected by at least one of the two observers in 23/27(85%). The
stone size ranged from 3-18.3 mm (mean=11.2). According to
the third reader, the major reasons for the false results were volume averaging and stone isoattenuation. A 77-88% sensitivity,
50-71% specificity and 71-74% accuracy were obtained in the
group without positive intraduodenal contrast, vs. 50-80% sensitivity, 57-71% specificity and 59-71% accuracy in the group with
positive intra-duodenal contrast. With exception of the positive
predictive value, all the diagnostic performance parameters
decreased when assessing the group with positive intraduodenal
contrast. This was more pronounced with the negative predictive
value (71-78% vs. 50-67%).
Conclusion: Angioedema involving the upper airway and oral
cavity is a rare, but known complication of ACE-I. Visceral
angioedema related to ACE-I without upper aerogastric angioedema is a rare and less recognized entity. Although there may be
an obvious temporal relationship with initiation of antihypertensive therapy, symptoms may commence many years into the use
of an ACE-I. Optimal management of this entity entails attention
to good clinical and medication history, recognition of common
imaging features, a high index of suspicion, and timely discontinuation of the offending medication.
Conclusion: PV-enhanced 4- and 64-MDCT have an overall moderate diagnostic performance in CBD stone detection. There was
a trend to decreasing accuracy with positive intraduodenal contrast. Thus, a normal enhanced MDCT in the context of a suspected CBD stone does not exclude the diagnosis and the use of precontrast scans or negative enteric contrast is still recommended
in such cases.
E151. Cross-Sectional Imaging of Angiotensin Converting
Enzyme Inhibitor Induced Visceral Angioedema: A Case
Series and Pictorial Review
Vallurupalli, K.; Coakley, K. Southern Illinois University, Springfield, IL
Address correspondence to K. Vallurupalli ([email protected])
Background Information: Abdominal pain of acute onset is one
of the most common complaints of patients presenting to the
emergency department (ED). Visceral angioedema induced by
angiotensin converting enzyme inhibitor (ACE-I) is a rare etiology
of acute onset or intermittent acute abdominal pain .We present
the salient CT findings in four patients with ACE-I induced visceral
angioedema.
Educational Goals/Teaching Points: The goals are to describe
CT features of visceral angioedema, correlate the imaging findings with patient symptoms and medication history, and recognize ACE-I induced visceral angioedema as a rare, but reversible
cause of acute abdominal pain.
Techniques: Examinations were performed with a 64-row MDCT
scanner (Siemens Medical Solutions, Malvern, PA) at 5 mm and
1.5 mm slice width with multiplanar reformatting in four patients.
Imaging characteristics include presence of ascites and mesenteric edema (n=4) and mural thickening of duodenum and jejunum
(n=2) and ileum (n=2). Engorgement of the vasa recta was seen
in two cases. All patients improved clinically after discontinuation
of the ACE-I. Resolution of abnormal findings was documented in
two patients on follow up imaging. The actual mechanism of visceral angioedema induced by ACE-I remains unknown. Proposed
E152. Value of CT Enterography in Evaluation of Focal and
Diffuse Small Bowel Pathology: A Radiologic-Pathologic
Correlation (CME Credit Available)
Gerasymchuk, G.; Sokhandon, F.; Shirkhoda, A. William
Beaumont Hospital, Royal Oak, MI
Address correspondence to G. Gerasymchuk ([email protected])
Background Information: Evaluation of disorders of the small
intestine has been notoriously frustrating and difficult due to its
relative inaccessibility to endoscopic evaluation and the poor
sensitivity of barium studies. CT enterography (CTE) is a relatively
new technique that since its introduction in late 1990s has quickly become standard of care for evaluation of small bowel (SB)
pathology. It has significantly improved visualization of SB mucosa, folds, wall and contents (including focal lesions).
Educational Goals/Teaching Points: The goals are to discuss
the technique and indications for CTE; to present the normal
anatomy and abnormal radiographic signs as demonstrated by
CTE; to review potential pitfalls; to explain the advantages of CTE
over traditional contrast studies, and to address some concerns
and precautions during performing CTE.
Techniques: CTE utilizes a low density oral and IV contrast to
distend the lumen and enhance visualization of the SB wall and
mucosa. With proper technique and knowledge of imaging
appearance of SB pathologies, CTE provides an excellent tool to
evaluate the entire SB plus the solid abdominal organs and vasculature all at the same time. This will help our clinical colleagues
to make the diagnosis and planning for treatment without any
need for further tests or invasive procedures in most situations. In
review of more than 300 CTEs in our institution, we present
many typical as well as unusual cases of SB pathology including,
but not limited to, new onset, recurrence and complications of
Crohn’s disease (fistulas, abscesses, strictures); partial bowel
obstruction; mesenteric ischemia; infectious and noninfectious
enteritis; congenital variants; arteriovenous malformation; gastrointestinal bleed; benign and malignant tumors (adenocarcinoma, lymphoma, carcinoid, melanoma, etc.). Also, we are able to
provide surgical and pathological, and in some cases endoscopic
correlation. Additionally, there will be a short discussion on diagnostic approach, patient selection, and frequency in performing
follow up CTE, with the consideration of radiation exposure and
the need for IV contrast. Given the advantages of CTE, we antici-
227
pate that the new modality has a good potential to replace traditional SB barium studies, enteroclysis, staging CT scans, and to
compliment capsule endoscopy in many instances.
Conclusion: Knowledge of standard CTE techniques, normal anatomical appearance of the SB, possible artifacts, and pitfalls as well
as radiographic signs of SB diseases and extraintestinal pathology
will help widely integrate the method in general practice.
E153. Isolated Intestinal and Multivisceral Transplantation:
Radiological Evaluation of the Normal and Abnormal
Transplanted Small Bowel
Lall, C.; Hoff, A.; Vianna, R.; Fridell, J. Indiana University Medical
Center, Indianapolis, IN
Address correspondence to C. Lall ([email protected])
Background Information: This exhibit will discuss indications
for small bowel transplantation and the role of new immunosuppressive agents; describe the latest surgical techniques used in
intestinal and multivisceral transplantation; describe the unique
cross-sectional imaging appearance of the normal transplanted
bowel, and discuss imaging of the abnormal intestinal transplant
and unique complications in this subgroup.
types of intestinal transplantation, including isolated intestinal
transplant, intestinal-liver and multivisceral transplantation and
surgical techniques in the donor and recipient; new aspects of
immunosuppression and breakthrough agents, and unique normal appearances of transplanted bowel on cross-sectional imaging in view of lack of lymphatics and neural innervations. It will
illustrate appearances of the abnormal intestinal transplant and
unique complications in this group after transplantation.
Techniques: The exhibit will discuss CT imaging and CT enteroclysis of intestinal transplantation and unique appearance of transplanted small bowel, and illustrate unique complications that
beset this transplant population and appearances of the abnormal transplanted small bowel.
Conclusion: This exhibit will illustrate the unique imaging appearance of transplanted small bowel as well as specific
complications like rejection, infection, post-transplantation lymphoproliferative disorder and graft-versus-host disease among
others. It will discuss advancements in the field of intestinal
transplantation and future developments in this field and discuss
refinement in surgical techniques and the latest aspects of immunosuppression as well as experience in living related intestinal
transplantation.
been postulated to result in various motility disorders in both
pediatric and adult patients.
the central role of the ICC in modulating gut motility; describe
the spectrum of gastrointestinal disorders linked to abnormalities
of ICC, and review the cross-sectional imaging findings of nonneoplastic entities related to the abnormalities of ICC.
Techniques: Pediatric disorders linked to ICC include idiopathic
hypertrophic pyloric stenosis, meconium ileus and Hirshsprung’s
disease. A wide spectrum of adult gut disorders such as achalasia, gastroparesis, chronic idiopathic intestinal pseudo-obstruction, diabetic gastroenteropathy, afferent loop syndrome, and
Chagas disease are hypothesized to be related to abnormal ICC
morphology and/or function. Cross-sectional and projectional
imaging findings of adult and pediatric disorders of ICC will be
discussed.
Conclusion: ICC play an important role in gut motility.
Abnormalities of ICC may lead to a gamut of motility disorders in
pediatric and adult patients. Many of these disorders have specific imaging findings that help in diagnosis and management.
E155. Small Bowel Imaging: Have We Overcome the
Challenge? A Review of MDCT Appearances of Small Bowel
Pathology
Mumtaz, H.1; Kalra, N.1; Khandelwal, N.1; Choudhary, S.2;
Sunnapwar, A.2 1. Post Graduate Institute of Medical Education
and Research, Chandigarh, India; 2. University of Texas Health
Science Center–San Antonio, San Antonio, TX
Background Information: A few years ago small bowel follow
through (SBFT) was the primary and only method for evaluation
of diseases of the small bowel, which also remained inaccessible
to the traditional endoscope. However with the introduction of
the MDCT, imaging of the small bowel has undergone a paradigm shift. Faster acquisition of a large volume of data with thin
collimation with use of MDCT allows multiplanar reformatting as
well as use of multiple enhancement phases after intravenous
contrast administration. MDCT has the advantage of being the
one step modality for diagnosis of common as well as uncommon bowel pathologies as it can evaluate not only the lumen
but also the wall, extramural changes, mesentery, nodes as well
as the vasculature.
E154. Non-Neoplastic Disorders of the Interstitial Cells of
Cajal: A Comprehensive Review
Katabathina, V.; Nagar, A.; Prasad, S.; Choudhary, S.; Ojili, V.;
Chintapalli, K. University of Texas Health Science Center at San
Antonio, San Antonia, TX
Address correspondence to V. Katabathina ([email protected])
Educational Goals/Teaching Points: The goals are to give an
update on the current protocols and techniques of MDCT of the
small bowel including the CT enteroclysis; provide a brief overview of various pathologies involving the small bowel. The
pathologies can be classified as: congenital, inflammatory, infectious, malabsorption syndromes, vascular, post-traumatic and
neoplastic; review the radiological imaging features of various
pathologies affecting the small bowel, and emphasize the distinctive radiological patterns and an algorithmic approach that may
help distinguish specific entities.
Background Information: Interstitial cells of cajal (ICC), found
in the walls of the gastrointestinal tract, are thought to play an
important role in gut neurotransmission and pacemaker activity.
Abnormalities of ICC (decrease in cell number or function) have
Techniques: With the advent of MDCT, imaging of the small
bowel has undergone a major change. The important advantages
of CT over the traditional small bowel follow through include
228
evaluation of not only the lumen but also the wall, extramural
changes, mesentery, nodes as well as the vasculature.
Conclusion: Early detection of small bowel pathologies is desirable for the clinicians but challenging for the radiologists. MDCT,
with high sensitivity and specificity, is becoming the one step
imaging modality for evaluation of the small bowel. Various
pathologies show characteristic radiologic features that allow us
to establish a specific diagnosis with confidence and an unnecessary biopsy or surgery can be avoided.
E156. CT Significance of Bowel Wall Thickening
Saenz, R.1,2; Rucks, A.1; Patel, A.1 1. Botsford Hospital,
Farmington Hills, MI; 2. Michigan State University, Lansing, MI
Address correspondence to R. Saenz ([email protected])
Background Information: During CT studies, bowel wall thickening is often seen. There are many different etiologies of this
finding. Clinically, the signs and symptoms of abdominal pain are
overlapping. Therefore, it is often the radiologist that diagnoses
the pathologic process as involving the gastrointestinal tract.
Educational Goals/Teaching Points: The exhibit will review the
CT findings of bowel wall thickening in order to allow the radiologist to understand its significance and discriminate certain etiologies. Persons who view this exhibit will be able to recognize the
key CT findings; review clinical and pathological relevant information related to the diagnoses of bowel wall thickening, and
improve overall CT diagnostic ability.
Techniques: Multiple cases will be reviewed utilizing CT.
Correlation will be made with the imaging findings and the EGD,
colonoscopy, and biopsy results.
Conclusion: Bowel wall thickening is an important CT finding.
Many different etiologies exist. At times, it is possible for the radiologist to narrow the differential diagnosis based on the specific
CT findings of the wall thickening.
E157. Bowel Transit Delay? Switch Planes! Utilizing MDCT
and Multiplanar Reformations to Identify Transition Points
in Small Bowel Obstruction (CME Credit Available)
Goud, A.; Goud, N.; Jati, A.; Manuel, D. VA Boston Healthcare
System, Boston, MA
Address correspondence to A. Goud ([email protected])
Background Information: The goal is to demonstrate the usefulness of multiplanar reformations (MPR) and MDCT capability
as a quick and effective way to identify transition points in cases
of small-bowel obstruction (SBO).
indications MPR in cases of small bowel obstruction; demonstrate the usefulness of MPR in identifying transition points
obscured in the standard axial plane; review the findings of
MDCT findings of small bowel obstruction; review the potential
causes of SBO and surgical implications, and discuss how to optimize your report: A checklist for including useful and critical key
points in cases of small bowel obstruction for our surgical colleagues.
Techniques: The increased utilization of MDCT has made postprocessing MPR a quick, efficient, and useful adjunctive imaging
strategy in diagnostic imaging. This is an especially useful tool in
the evaluation of small bowel obstructions. Accurately identifying
a transition point or multiple transition points provides useful
information to the surgeon in operative cases. By maximizing the
ability of MDCT to reformat the bowel in different planes quickly
and efficiently, transition points and potential causes of small
bowel obstruction can be identified with increased accuracy and
diagnostic confidence.
Conclusion: MDCT and MPR reformations of the bowel in different planes allow quick and efficient identification of transition
points and potential etiology of small bowel obstructions, otherwise often obscured in standard axial planes.
E158. Spectrum of Small Bowel Masses on CT Enterography
and CT Enteroclysis (CME Credit Available)
Ruan, D.; Hough, D.; Fidler, J.; Barlow, J.; Trenkner, S.; Fletcher, J.;
Huprich, J. Mayo Clinic, Rochester, MN
Address correspondence to D. Ruan ([email protected])
Background Information: CT enterography and CT enteroclysis
have recently emerged as alternative techniques to image the
small bowel. Traditional methods of small bowel imaging are
suboptimal. Conventional CT suffers from lack of small bowel distension whereas fluoroscopic techniques provide limited information. CT enterography and CT enteroclysis address these limitations. In this essay, we discuss the advantages and limitations of
these new techniques. We also present a pictorial review of small
bowel masses and how these masses can be optimally imaged.
Educational Goals/Teaching Points: The exhibit will review CT
enterography and CT enteroclysis techniques; highlight advantages and limitations of these techniques for detection of small
bowel masses, and illustrate the spectrum of small bowel pathology identified using these techniques.
Techniques: CT enterography and CT enteroclysis differ from
conventional CT in that better luminal distention is achieved. Two
different types of enteric agents are available: neutral and positive. The enteric agent used should be chosen based on clinical
indication to improve contrast between bowel lumen and mass.
Neutral contrast agents are useful for detecting hypervascular
masses whereas positive contrast agents may improve detection
of minimally enhancing masses. We performed a retrospective
search of our radiology and pathology databases for patients
with small bowel masses shown on CT enterography and CT
enteroclysis. Imaged small bowel masses included adenocarcinoma, gastrointestinal stromal tumor, carcinoid tumor, metastasis,
lymphoma, paraganglioma, vascular malformation, polyp, and
lipoma. Representative images are selected to illustrate typical
imaging features for each. Special focus will be made upon those
cases that illustrate the specific advantages (luminal distension
and enteric agent choice) that these new techniques confer.
Conclusion: Recent advances in small bowel imaging address
the limitations of conventional CT with imaging of the small
bowel. Knowledge of these new techniques will help the radiologist to improve detection and characterization of small bowel
masses.
229
E159. CT Enterography vs. Fluoroscopic Small Bowel FollowThrough in Inflammatory Bowel Disease: Is CT Enterography
up to the Task? (CME Credit Available)
Shin, K.; Ho, C.; Stay, R.; Carr, T.; Choudhri, A.; Lambert, D.
Address correspondence to C. Ho ([email protected])
Background Information: The mainstay for the evaluation of
the features and complications of inflammatory bowel disease
(IBD) has been fluoroscopic examination. With improvements in
CT technique and availability, CT enterography (CTE) has become
a viable option for the evaluation of inflammatory bowel disease.
This presentation will compare and correlate CTE and small
bowel follow-through (SBFT) findings of IBD in a group of
patients receiving both examinations.
Educational Goals/Teaching Points: The exhibit will review CTE
technique and protocol ; discuss both CTE and SBFT findings and
complications of IBD, and give a retrospective comparison and
review of findings in patients who have undergone both CTE and
SBFT examinations.
Techniques: CTE is comparable to SBFT in identifying findings of
IBD. Over a two-year period, 112 CTE studies were performed at
our institution with 41 of the patients having had recent comparison small bowel fluoroscopic examinations. CTE is able to delineate secondary findings and complications of IBD such as fistulas,
abscesses, perienteric inflammation, and strictures, some of
which are not detectable on SBFT.
Conclusion: CT enterography can be a stand-alone or complementary tool in the evaluation of patients with inflammatory
bowel disease. Because of its cross-sectional nature, CTE can
identify additional secondary findings and complications of IBD
that can be difficult or impossible to identify on SBFT exams.
E160. Imaging Intra-Abdominal Burkitt Lymphoma: From
Discrete Bowel Wall Thickening to Diffuse Soft Tissue
Infiltration
Martin, N.; Harris, A.; Chang, S. University of British Columbia,
Vancouver, Canada
Address correspondence to N. Martin (nancyma@interchange.
ubc.ca)
Background Information: Burkitt lymphoma (BL) is a highly
aggressive lymphoproliferative malignancy classified under the
WHO umbrella of non-Hodgkin lymphomas (NHL). Intraabdominal involvement is extremely common, and demonstrates
the NHL predilection for extranodal involvement, reflected in a
broad spectrum of clinicopathology. The purpose of this exhibit is
to increase awareness of the clinical and imaging manifestations
of intra-abdominal BL, enabling early suspicion and an expedited
tissue diagnosis.
Educational Goals/Teaching Points: The exhibit will define BL
within the WHO lymphoma classification system; briefly describe
the subclassification of BL; review the clinicopathology of BL,
with emphasis on sporadic and immunodeficiency variants and
their intra-abdominal presentation; review the spectrum of intraabdominal BL, with sample cases illustrating solid organ, bowel,
and soft tissue (ST) involvement, and briefly discuss the role of
230
complementary imaging modalities and image-guided biopsy in
expediting a prompt tissue diagnosis.
Techniques: Abdominal involvement predominates at presentation in the nonendemic variants. Pathologic and imaging findings
range from discrete bowel wall thickening to diffuse soft tissue
and organ infiltration. Despite its diverse appearance, BL demonstrates some characteristic sites of involvement (terminal ileum
and mesentery) and appearance (nephromegaly) .The relative
prevalence of BL is amplified in children and immune-compromised patients. BL is a highly aggressive malignancy, characterized by rapid doubling time with prognosis dictated by the burden of disease at presentation. BL demonstrates a dramatic
response to chemotherapy. Early diagnosis, aided by imagingguided biopsy techniques, and prompt management yield high
remission and overall survival rates.
Conclusion: BL is a highly aggressive form of NHL with a predilection for intra-abdominal and extranodal involvement. Although
there is no one finding diagnostic of BL, familiarity with its common and diverse radiological manifestations, as well as its
aggressive clinical behavior, will enable prompt diagnosis and
management of this potentially curable malignancy.
E161. Small Bowel Perforation: Differential Diagnosis and
Spectrum of CT Findings
Duncan, D.1; Wattamwar, A.2; Hines, J.1; Katz, D.2; Friedman, B.1
1. Long Island Jewish Medical Center, Glen Oaks, NY; 2. Winthrop
University Hospital, Mineola, NY
Address correspondence to D. Duncan ([email protected])
Background Information: Small bowel perforation is an infrequently encountered entity during abdominal imaging. The goal
of this exhibit will be to exemplify, using CT examples, the various pathological states which ultimately result in small bowel
perforation.
Educational Goals/Teaching Points: CT combined with history
can often define the site and etiology of small bowel perforation.
CT examinations will be utilized to demonstrate small bowel perforations which can occur as the result of: anastomotic leak,
Crohn’s disease, diverticular disease, foreign body, iatrogenic,
ischemia, malignancy, and trauma.
Conclusion: At the conclusion of this presentation the participant should be able to provide a comprehensive differential diagnosis and be able to identify the CT findings associated with
small bowel perforation.
E162. Fistulizing Crohn’s Disease: Correlation Between
MDCT Enterography and Surgical Findings (CME Credit
Available)
Ballester, G.; Labat, E.; Badillo, K.; Colon, E.; Gomez, A.; LopezAlvarez, Y. University of Puerto Rico, Guaynabo, PR
Address correspondence to G. Ballester ([email protected])
Background Information: Crohn’s disease is a chronic inflammatory condition of unknown etiology, which may involve any
part of the gastrointestinal tract. Transmural inflammation extending into adjacent bowel and organs through fistulous tracts is one
of the most common complications in Crohn’s disease. The
cumulative risk for fistulas in patients with Crohn’s disease is 33%
after 10 years and 50% after 20 years. The location and severity
of fistulous disease is critical in determining treatment. MDCT
enterography is an excellent tool for this purpose. Small fistulas
are first treated medically. On the other hand, large or multiple
fistulas, may need surgical treatment, particularly if they are
accompanied by persistent symptoms, such as fever or abdominal
pain or if they are related to abscess formation. The purpose of
this exhibit is: to describe an optimal protocol for MDCT enterography; to understand the utility of MDCT enterography for the
diagnosis of fistulizing Crohn’s disease, and to correlate the tomographic findings of fistulizing Crohn’s with the surgical findings.
Educational Goals/Teaching Points: Fistulas are a common
complication of Crohn’s disease. MDCT enterography plays a
major role in the diagnosis of fistulizing Crohn’s disease, providing great benefit for surgical planning.
Techniques: We will review the pathophysiology of Crohn’s disease; describe MDCT enterography protocol in the evaluation of
Crohn’s disease, and will discuss pitfalls in the diagnosis of fistulizing Crohn’s disease. We will also describe the different types of
surgery available for patients with Crohn’s disease, including strictureplasty, small bowel resection and colectomy. Cases of fistulizing Crohn’s disease with surgical correlation will be presented. Conclusion: MDCT enterography has become a very important
tool in the evaluation of Crohn’s disease. Radiologists play a
major role in the diagnosis of the disease and its complications,
including fistulizing disease. Therefore, their recognition and demonstration in MDCT is paramount for the management of patients
with this condition. Patients with Crohn’s disease need a multidisciplinary approach, with close collaboration between radiologists,
gastroenterologists and surgeons for the accurate assessment and
management of the disease and its complications.
E163. Diagnosis of Mesenteric Ischemia: Pearls and Pitfalls
Wasnik, A.1; Kaza, R.1; Surabhi, V.2; Al-Hawary, M.1; Liu, P.1 1.
University of Michigan, Ann Arbor, MI; 2. University of Texas
Medical School at Houston, Houston, TX
Address correspondence to R. Kaza ([email protected])
Background Information: Diagnosis of mesenteric ischemia in
patients presenting with nonspecific abdominal pain is a challenge to the radiologist. The early detection of subtle signs helps
in correct patient management. At the same time there are several pitfalls which one should avoid in making a misdiagnosis of
mesenteric ischemia.
Educational Goals/Teaching Points: The goal is for the learner
to make a correct and confident diagnosis of mesenteric
ischemia on all imaging modalities and be able to identify the
mimics of mesenteric ischemia to avoid a wrong diagnosis of
mesenteric ischemia.
radiographs, ultrasound, CT and MRI. Identification of pathognomonic features of mesenteric ischemia such as pneumatosis and
portal venous gas on abdominal radiographs, ultrasound and CT
scan will be discussed with examples. Identification of other signs
of early mesenteric ischemia such as subtle bowel wall thickening
and decreased enhancement will be discussed. Technique of CT
angiography and MR angiography and their value in diagnosing
acute and chronic mesenteric ischemia will be discussed.
Potential pitfalls in diagnosing mesenteric ischemia will be discussed including nonischemic causes of bowel wall thickening,
benign causes of pneumatosis and portal venous gas and mimics
of pneumatosis on abdominal radiographs and CT scan.
Conclusion: Radiologists should be able to identify the manifestations of mesenteric ischemia on all imaging modalities to make
an accurate diagnosis to aid proper patient management. There
are also several potential pitfalls in diagnosing mesenteric
ischemia which radiologists should be aware of to avoid a misdiagnosis of mesenteric ischemia as well.
E164. Variants of Gastric Carcinoma and its Mimicking
Diseases
Cho, O.; Kim, Y.; Jeong, W.; Song, S.; Koh, B.; Cho, Y. Hanyang
University Kuri Hospital, Kuri City, Kyunggido, South Korea
Address correspondence to Y. Kim ([email protected])
Background Information: Usually gastric lesions are detected as
wall thickening on the CT scans. Gastric wall thickening is nonspecific to diagnosis of specific disease. Most common gastric wall
thickenings are adenocarcinoma in malignant disease. However,
variant carcinoma and other tumor mimicking diseases are occasionally encountered. These diseases are very different from prognosis and treatment each other. We illustrate differential diagnostic points and characteristic CT findings of these diseases. Educational Goals/Teaching Points: The goals are to review
the clinical and radiologic characteristics of gastric carcinoma
classified by its variants, and to discuss the differences between
these gastric carcinomas, and to distinguish between these gastric carcinomas and some diseases which mimic them.
Techniques: We reviewed MDCT and pathologic findings of typical gastric adenocarcinoma. We correlated MDCT findings of variants of gastric carcinoma (mucin producing adenocarcinoma,
squamous carcinoma, hepatoid adenocarcinoma, lymphoepithelial carcinoma and carcinoid tumor) and the mimicking diseases of
gastric carcinoma (lymphoma, stromal tumor, gastric metastasis,
metastasis adjacent to stomach, severe gastritis, tuberculous gastritis, and parasite infestation) on the pathologic basis.
Conclusion: It is possible to know the clinical and radiologic key
points that explain each variant. It is also possible to discriminate
other diseases from gastric carcinomas to make a correct treatment plan.
Techniques: The etiology and pathophysiology of mesenteric
ischemia will be discussed. Role of imaging in diagnosing
mesenteric ischemia will be discussed with findings on abdominal
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E165. Imaging Manifestations and Mimics of Ischemic
Bowel (CME Credit Available)
Murphy, G.; Beddy, P.; Knox, M.; Keogan, M.; Wilson, G. St.
James’s Hospital, Dublin, Ireland
Address correspondence to G. Murphy (gillianmurphy78@hotmail.
com)
Background Information: Ischemic bowel is caused by insufficient blood flow to the bowel and ranges from localized transient
ischemia to catastrophic necrosis of the gastrointestinal tract.
MDCT with the benefit of multiplanar reconstruction is the most
commonly used modality for this diagnosis. However, as CT findings in ischemic bowel are nonspecific and variable, the diagnosis of ischemic bowel provides a challenge for radiologists. This
exhibit reviews patients with a CT diagnosis of ischemic bowel
from January to December, 2007 outlining positive and false positive imaging findings.
the pathophysiology of ischemic bowel; illustrate the common
imaging manifestations of ischemic bowel; present imaging findings of ischemic bowel based of a series of 50 patients, and provide examples of mimics of ischemic bowel emphasizing the
challenge this diagnosis presents to radiologists.
Techniques: Plain films of the abdomen demonstrate the nonspecific findings in early bowel ischemia. The CT imaging findings
of ischemic bowel include: bowel wall thickening with or without
the target sign; intramural pneumatosis; mesenteric or portal
venous gas; mesenteric arterial or venous thromboembolism;
engorgement of mesenteric veins and mesenteric edema; lack of
bowel wall enhancement; increased enhancement of the thickened bowel wall; bowel obstruction, and infarction of other
abdominal organs.
Conclusion: This comprehensive case series illustrates the spectrum of imaging findings of ischemic bowel and highlights mimics of this diagnosis.
E166. Computed Tomographic Enterography: Principles and
Recent Interpretation Trends of Imaging Findings (CME
Credit Available)
Elsayes, K.; Al-Hawary, M.; Platt, J. University of Michigan, Ann
Arbor, MI
Address correspondence to K. Elsayes ([email protected])
Background Information: Recent improvements in computed
tomographic enterography (CTE) technique have increased its
utility as an effective, efficient, and noninvasive tool aiding in the
diagnosis and management of a variety of gastrointestinal disorders. As more and more CTE examinations are performed, it is
important to be able to recognize and interpret the relevant
imaging findings as they pertain to various gastrointestinal diseases.
the imaging techniques of CTE; describe the clinical indications
for CTE; discuss the clinical utility of CTE in diagnosis of various
gastrointestinal diseases; and illustrate the imaging characteristics
of these diseases. Special emphasis will be placed on the recent
232
trends in interpretation of the imaging findings. The major teaching points of this exhibit are: 1. CTE can be easily performed with
modern equipment. 2. When CTE is performed appropriately, it is
a powerful tool capable of characterizing small bowel pathology,
identifying lesions within the stomach, duodenum and colon,
and providing an opportunity to evaluate both the extraluminal
and extraintestinal tissues. The exhibit will also provide a review
of the recent trends in interpretation of the imaging findings; for
example diagnosing the active component of Crohn’s disease.
Techniques: The exhibit begins with a short introduction of CTE
followed by discussion of the imaging parameters, patient preparation, and types of negative oral contrast. We then discuss the
utility of CTE in diagnosing various gastrointestinal diseases and
review the imaging findings according to the recent trends in
interpretation. The exhibit concludes with sample cases illustrating the diagnostic role of CTE and imaging findings of a spectrum
of diseases including inflammatory bowel disease, mesenteric
ischemia, gastrointestinal bleeding, small bowel obstruction, and
gastrointestinal tumors.
Conclusion: CTE can be easily performed with modern equipment and, when performed appropriately, is a powerful tool
capable of characterizing small bowel pathology, identifying
lesions within the stomach, duodenum and colon, and providing
an opportunity to evaluate both extraluminal and extraintestinal
tissues. Radiologists need to be able to recognize and interpret
the relevant findings in CTE and apply them to the various gastrointestinal diseases.
E167. Duodenal Abnormalities at MR Small-Bowel FollowThrough
Cronin, C.; Lohan, D.; DeLappe, E.; Roche, C.; Murphy, J. University
College Hospital Galway, Galway, Ireland
Address correspondence to C. Cronin ([email protected])
Background Information: Cross-sectional characterization of
duodenal pathology is plagued with inadequacy, a reflection of
the meandering course of this segment. We consider the imaging
appearance of such pathology at MR small bowel follow-through
(MRSBFT), illustrating the typical manifestations of each pathologically-confirmed condition.
Educational Goals/Teaching Points: Many of the duodenal
pathologies we illustrate were found incidentally, reminding us
not to forget the duodenum and highlighting the need for a thorough assessment. Undoubtedly many of the duodenal pathologies are well known to the reader; however we consider the
imaging manifestations at MRSBFT, illustrating features that may
aid in their differentiation. Such a description has not previously
been undertaken, making this a valuable addition to the current
literature.
Techniques: Through our institutional experience and a review
of literature we will provide a diverse review of MRSBFT’s role in
duodenal disease diagnosis and management. We will provide a
thorough, informative and concise guide.
Conclusion: MRSBFT allows confident duodenal evaluation
owing to a combination of sufficient luminal distension and multiplanar versatility. Diseases of the duodenum may have a variety
of manifestations at MRSBFT, a knowledge of which may aid in
confident noninvasive patient diagnosis.
E168. Evaluation of Crohn’s Disease In The Era of Radiation
Saftey: MR Enterography Technique and Spectrum of
Disease
Grand, D.; Shah, S.; Beland, M.; Mayo-Smith, W. Warren Alpert
School of Medicine/Brown University, Providence, RI
Address correspondence to D. Grand ([email protected])
describe the technique and demonstrate the feasibility and efficacy of evaluation of patients with known or suspected Crohn’s
disease using MR enterography. First, we demonstrate the technique of MR enterography including the rationale for each
sequence, optimized protocols for bowel distension with oral
contrast and mucosal enhancement with intravenous contrast.
Additionally, we demonstrate the spectrum of Crohn’s disease as
visualized on MR enterography from varying degrees of active
small bowel inflammation, colonic disease, skip lesions, fistulae
and abscess formation and differentiation of chronic from active
changes.
Educational Goals/Teaching Points: The exhibit will focus on :
1) Technique—coil choice and positioning, scan coverage, pulse
sequences, oral contrast protocol, and IV contrast protocol;
2) Spectrum of Disease—active inflammation (terminal ileitis –
mild, moderate, severe; skip lesions; colonic disease); chronic
inflammation (differentiation from active disease; stricture formation); and complications (fistula formation; abscess) and 3)
Future Directions—real-time cine bowel imaging and monitoring
response to new immunomodulatory therapies.
intrinsic contrast resolution, faster imaging times, and decreased
artifacts. MRI can suppress intra-abdominal fat signal, expand the
dynamic range of abdominal tissue signal intensities, and distinguish between intraluminal bowel contents and the bowel wall. Educational Goals/Teaching Points: Persons who view the
exhibit will be able to define the comprehensive protocol used
for bowel imaging on MRI, including methods for rapid imaging,
timing of postgadolinium sequences, and bowel preparation and
distension; understand the anatomical involvement of the bowel
wall and identify the involved segments of bowel. Differentiate
mucosal/submucosal involvement from transmural disease on
unenhanced and enhanced sequences; differentiate acute disease from chronic processes, and identify complications of
inflammatory processes, including abscesses and fistulae.
Techniques: Applications of MRI in the evaluation of bowel wall
thickening include diagnosing and monitoring severity of inflammatory bowel disease, including the identification of acute disease from chronic inflammation; diagnosing inflammatory processes such as enteritis, appendicitis, diverticulitis; identifying
enteric abscesses and fistulae; depicting abnormalities in the
arterial supply and venous outflow of the bowel with unenhanced and postgadolinium sequences; and elucidating the
source and extent of neoplastic disease. Acute inflammation
alters the appearance of the bowel wall, fat and mesentery
around the abdominal bowel on fat suppressed T2 sequences. Chronic disease will demonstrate progressive enhancement after
intravenous gadolinium but without a similar degree of T2 signal
change. MRI is well suited for directing therapeutic management
of patients with Crohn’s disease and complements the information derived from endoscopy.
Techniques: This exhibit illustrates the technique of small bowel
MRI for the detection and characterization of changes of inflammatory bowel disease, an exquisitely sensitive technique without
ionizing radiation.
Conclusion: With the implementation of modern MRI techniques
in bowel imaging, bowel wall thickening can be reliably depicted.
The differential diagnosis, which runs the gamut of inflammatory,
infectious, ischemic, and neoplastic diseases, can be narrowed
based on pertinent positive and negative MRI findings.
Furthermore, the ability of MRI to identify acute processes is vital
to formulating the optimal treatment plan and assessing
response to therapy. Conclusion: MR enterography is technically feasible and efficacious for routine evaluation of the full spectrum of pathology in
patients with Crohn’s disease without exposure to ionizing radiation. As readers become more comfortable with the techniques
and appearances presented in this educational exhibit, we
believe MR enterography may replace fluoroscopy and CT in the
evaluation of Crohn’s disease.
E170. Normal Small Bowel Wall Characteristics on MR Small
Bowel Follow-Through
Cronin, C.; DeLappe, E.; Lohan, D.; Roche, C.; Murphy, J. University
College Hospital Galway, Galway, Ireland
E169. Demystifying Bowel Wall Thickening With MRI (CME
Credit Available)
Krishnamoorthy, S.; Sebastian, S.; Kalb, B.; Rostad, B.; Li, J.;
Salman, K.; Sitaraman, S.; Sarmiento, J.; Martin, D. Emory
University, Atlanta, GA
Address correspondence to S. Krishnamoorthy (saravanan.
[email protected])
Background Information: Bowel wall thickening is a commonly
encountered question in clinical practice. Advances in MRI have
allowed for detailed visualization of the bowel due to improved
Objective: The objective was to assess the normal small bowel
parameters, namely bowel diameter, bowel wall thickness,
number of folds (valvulae connivientes) per 2.5 cm (inch), fold
thickness and interfold distance per small bowel segment (duodenum, jejunum, proximal ileum, distal ileum and terminal
ileum) on MR small bowel follow-through/enterography.
Materials and Methods: Between September, 2003 and
January, 2008, 280 MR small bowel follow-through examinations
were performed for investigation of known or suspected small
bowel pathology. A total of 120 of these examinations were normal. Sixty-five (29 males, 36 females, mean age=34years,
233
range=17-73years) of 120 examinations without a prior small
bowel diagnosis, with no prior or subsequent abnormal radiology
or endoscopy examinations, no prior small bowel surgery and
with a minimum three years follow-up demonstrating normality
were retrospectively evaluated for the described small bowel
parameters.
Results: We found the mean diameter of the duodenum to be
24.8 mm (SD=4.5 mm), jejunum to be 24.5 mm (SD=4.2 mm),
proximal ileum to be 19.5 mm (SD=3.6 mm), distal ileum to be
18.9 mm (SD=4.2 mm) and terminal ileum to be 18.7 mm
(SD=3.6 mm). The number of folds per 2.5 cm varied from 4.6 in
the jejunum to 1.5 in the terminal ileum. The fold thickness varied from 2.1 mm in the duodenum to 1.8 mm in the terminal
ileum. The small bowel parameters gradually decreased in size
from the duodenum to the smallest measurements which were
in the terminal ileum. The bowel wall is similar in size throughout the small bowel measuring 1.5 mm +/-0.5 mm.
Conclusion: These results provide the mean, range of normality
and standard deviation of the small bowel parameters per segment on the current population on MR Small bowel follow
through. From our experience, knowledge of these parameters is
extremely helpful and essential in the everyday assessment of
MR small bowel follow through studies.
E171. Small Bowel Obstruction: Radiologic Evaluation and
Imaging Selection (CME Credit Available)
Caserta, M.; Ott, D.; Oliphant, M.; Leyendecker, J. Wake Forest
University Medical Center, Winston Salem, NC
Address correspondence to D. Ott ([email protected])
Background Information: Small bowel obstruction (SBO)
remains a common clinical problem, which is difficult to diagnose accurately and to decide on a treatment option. Plain film
imaging is still performed often as the initial examination, but
has low specificity in distinguishing functional vs. mechanical
obstruction, and a diagnostic accuracy of only 50%-60%.
Traditional peroral contrast studies of the small bowel (SB) often
provide little improvement in accuracy; however, enteroclysis
with intubated ‘large volume’ infusion of the SB provides a much
more accurate examination. In more recent years, both CT and
MR have been applied to the evaluation of SBO; these techniques can be perform using ‘standard’ methods or with a volume challenge as enterography or enteroclysis variations. Thus,
current imaging assessment of SBO has changed and expanded
dramatically, and clinicians and radiologists must be aware of
these various options and choose appropriately.
clinical overview of the current etiology and status of SBO; discuss the various imaging options now available for evaluating the
SB; review and illustrate the advantages and limitations of these
imaging methods, and outline algorithms for specific clinical
presentations and imaging recommendations.
Techniques: In this exhibit, the current clinical status of SBO
regarding etiology, clinical assessment, and potential treatment
options are first reviewed. The various imaging modalities for
evaluating SBO are presented, and include: 1) plain abdominal
imaging; 2) SB contrast studies (both peroral and enteroclysis);
234
3) CT examinations (standard, CT enterography, and CT enteroclysis; and 4) MR methods (same as the CT categories). The basic
techniques of these radiologic studies are discussed and normal
examinations presented. Also, common causes of SBO seen on
radiologic imaging are illustrated. The advantages and limitations
of radiologic imaging relative to the methods used are outlined.
Finally, recommendations are made regarding selecting one or
more imaging studies for assessing specific clinical problems.
Conclusion: SBO remains a common problem. Radiologic imaging of the SB has expanded exponentially in recent years, and
selecting a specific imaging examination has become more difficult. This exhibit will hopefully update and clarify this selection
process.
E174. The Usefulness of MRI in the Evaluation of Acute
Sigmoid Diverticulitis
Halpenny, D.; McNeill, G.; Snow, A.; Buckley, O.; Geoghegan, T.;
Torreggiani, W. Adelaide + Meath Hospitals Incorporating the
National Childrens Hospital, Dublin, Ireland
Address correspondence to D. Halpenny ([email protected])
Objective: The aim of the study was to evaluate the usefulness
of MRI in the detection and characterization of acute sigmoid
diverticulitis.
Materials and Methods: Twenty-six patients (15 women, 11
men; mean age 58 years, range 42-74) with acute sigmoid diverticulitis diagnosed at CT, underwent MR imaging. The examinations were evaluated independently by two radiologists on a
monitor in a PACS (Siemens Medical Solutions, Forchheim,
Germany) environment. Each radiologist attempted to identify the
features of diverticulitis and grade the severity of disease on both
CT and MRI at different sittings. Results were recorded on coded
forms which were entered in a computerized database. The data
was statistically analysed using SPSS software. Correlation analysis
was performed with Speaman’s rank correlation coefficient. The
inter-rater agreement was measured with Cohen’s kappa test for
each imaging modality between the two observers.
Results: The sensitivity of MRI for diagnosing acute diverticulitis
MRI was 100% and specificity was 100%. The relative sensitivity
of MRI for diagnosing the severity of diverticulitis was derived;
93.5% for mild disease, 41.5% for moderate disease and 50%
for severe disease. The correlation between CT and MRI was analyzed using Speaman’s rank correlation coefficient. The ρ (rho)
value was 0.73 with p<0.01 which was statistically significant,
demonstrating good correlation between CT and MRI in the diagnosis of acute diverticular disease. The reliability or internal consistency of each imaging modality (CT and MRI) was assessed
with the Cronback alpha (a) test between the two observers. The
a value for CT was 0.84, the a value for MRI was 0.75. Each of
the a values is statistically significant implying that both imaging
modalities are reliable in diagnosing acute diverticulitis. The interrater agreement was measured with Cohen’s kappa test for each
imaging modality between the two observers. The kappa value
for CT was 0.44, considered significant; the kappa value for MRI
was 0.549, considered highly significant. There was higher agreement between the observers when MRI was used to assess
patients with acute diverticulitis.
Conclusion: This comparative study of CT and MR demonstrates
that MRI is a fast, safe and accurate imaging modality for diagnosing acute sigmoid diverticulitis, with a sensitivity and specificity of 100% in comparison to the “gold-standard” CT. MRI may
provide an alternative to CT in this clinical setting when CT cannot be performed.
E176. Can CT Replace MRI in Preoperative Assessment of
the Circumferential Resection Margin in Rectal Cancer?
Maizlin, Z.1; Brown, J.2; So, G.1; Phang, T.2; Brown, C.2; Kirby, J.1;
Walker, M.1; Maizels, L.3; Coblentz, C.1; Vora, P.1; Tiwari, P.2 1.
McMaster University Medical Centre, Burlington, Canada; 2. St.
Paul’s Hospital, Vancouver, Canada; 3. Technion, Haifa, Israel
Address correspondence to Z. Maizlin ([email protected])
E175. The Role of Functional Imaging in Colorectal Cancer
Garcia Figueiras, R.1; Goh, V.2; Gómez, A.1; Villalba Martín, C.1;
Armesto, V.3; Baleato, S.4; Martínez Alegría, A.1; Padhani, A.2 1.
Complexo Hospitalario Universitario de Santiago de Compostela,
Santiago De Compostela, Spain; 2. Paul Strickland Scanner
Centre, Northwood, United Kingdom; 3. Complexo Hospitalario de
Lugo, Lugo, Spain; 4. Complejo Hospitalario de Pontevedra,
Pontevedra, Spain
Address correspondence to R. Garcia Figueiras (roberto.garcia.
[email protected])
Objective: The goal was to evaluate the efficiency of MDCT in
identification of the mesorectal fascia (MRF) and the relationship
of rectal carcinoma and lymph nodes to MRF within the MRF
envelope.
Background Information: Conventional imaging techniques in
colorectal cancer (CRC) can depict morphologic features of the
tumors but they cannot provide the full information to characterize or monitor lesions. Functional imaging techniques such as diffusion-weighted (DW) MRI, perfusion techniques, PET-CT, or
MR-lymphography are increasingly being used to image CRC for
diagnosis, staging, and evaluating tumoral response and in posttreatment follow-up. More recently, these techniques may offer
the potential to establish a tumoral prognosis.
the indications and technical features for performing functional
imaging in CRC; describe their relevant imaging findings; show
the additional information gained by functional imaging in reference to conventional techniques in CRC, and understand what
the benefits are in combining different functional imaging techniques in CRC.
Techniques: Perfusion imaging may be used to improve detection and characterization of CRCs, to monitor tumor response to
therapeutic intervention, to improve delineation of residual or
recurrent tumor, to evaluate liver metastatic involvement, and to
assess patient prognosis before and after treatment. DWI provides indirect information about tissue structure and intra/extracellular space and can be used to diagnosis CRCs, estimate
tumor cellularity, and detect early changes following therapeutic
intervention. Lymph node imaging is of great importance for the
staging of CRCs. Assessment of lymph nodes based on structural
imaging features alone is limited in sensitivity and specificity for
microscopic metastatic disease. Functional lymph node imaging
can be performed using ultrasmall superparamagnetic iron oxidebased nanoparticles. Metabolic imaging, based on FDG-PET provides complementary information to structural imaging techniques for diagnosis, staging, and treatment planning. Blood oxygen level-dependent (BOLD) functional MRI depicts tumor oxigenation. Whole-body MRI, including DW sequences, may be
useful for staging CRC.
Conclusion: Structural imaging alone can not provide all the
information necessary for CRC management. Functional imaging
techniques in CRC represent a noninvasive and quantitative
opportunity to study tumoral physiology.
Materials and Methods: Institutional approval was obtained for
this study. Ninety-two patients with a biopsy proven rectal carcinoma were evaluated with MDCT scan of the abdomen and pelvis and MRI of the pelvis. Rectal tumors were defined as tumors
within 15 cm of the anal verge as measured with a rigid sigmoidoscope. Tumor downsizing following neoadjuvant therapy
made the histopathology (the traditional gold standard) invalid.
Hence, MRI was used as the only available reference standard for
the evaluation of the accuracy of MDCT for the prediction of
tumor invasion of the MRF. All examinations were reviewed independently by two dedicated abdominal radiologists who were
blinded to each other, to the findings from another technique
and to clinical information. MRF at three levels, tumor position,
lymph nodes and relation of the tumor and lymph nodes to MRF
were analyzed. Categorical agreement between MRI and MDCT
and the interobserver agreement were determined by using
Intraclass Correlation weighted kappa statistics.
Results: Strong correlation was found between MDCT and MRI
in identification of MRF, tumor and lymph nodes size, location
and relationship to MRF on the upper level. Moderate agreement
was identified on mid level and only fair correlation on the lower
level. These tendencies were present in both reviewers.
Interobserver agreement was strong in all the evaluated parameters except visualization of mesorectal fascia on lower and mid
levels.
Conclusion: The results of this study differ from those previously
published demonstrating substantial agreement between the
readers in assessment of the tumor, MRF and lymph nodes on
MDCT. With exception of MRF assessment on lower rectal level
and the distance of the nodes to MRF, other evaluated parameters were assessed with moderate and substantial agreement on
MDCT as compare to MRI. However, in such a high stake situation, excellent agreement should probably be required between
the findings on MDCT compared with MRI in characterization of
tumor relationship to the MRF and MRF invasion in order to recommend MDCT as MRI replacement for preoperative assessment
of the circumferential resection margin in rectal cancer.
E177. Mechanisms of Spread of Rectal Tumors (CME Credit
Available)
Oliphant, M.; Ott, D. Wake Forest University, Winston-Salem, NC
Address correspondence to M. Oliphant ([email protected])
Background Information: Recent advances in the combined
trimodality therapy for rectal cancer, neoadjuvant radiation therapy and chemotherapy along with surgery, has decreased the rate
of local, regional, and distant recurrences. This treatment regi-
235
men and more aggressive surgery (total mesorectal resection)
has placed greater demands on the imaging of rectal tumors.
Pretreatment imaging for staging of disease is required to aid in
management decisions. Essential for the interpreting of modern
imaging is a knowledge of normal anatomy and an understanding of the pathways of spread of rectal cancer.
Educational Goals/Teaching Points: The anatomy of the rectum, mesorectum, and pelvic organs is reviewed emphasizing the
vasculature and lymphatic supply of the rectum and the relationship of the rectum to its contiguous organs. The goal is the
understanding of the anatomy as it relates to disease spread.
The patterns of spread of rectal cancer are described to
include local, lymphatic, and contiguous spread. Emphasis will be
placed on the different patterns of spread from different regions
of the rectum. The teaching point is the knowledge of the patterns of spread aids in the radiologist’s search pattern. The exhibit correlates imaging findings with the staging of disease. The
teaching point is the correlation of imaging with staging and its
affect on patient management. The integration of multiple imaging modalities (MRI, MDCT, PET-CT) as they relate to evaluation
of the patient in the staging of disease is discussed. The goal is
to learn the value and limitations of each technique.
Techniques: The anatomy of the rectum, the mesorectum, and
contiguous structures; the pathophysiology of the spread of rectal
cancer with emphasis on mesenteric, lymphatic, and contiguous
spread; MRI, MDCT, PET-CT imaging findings and how they relate
to staging of disease, and the impact of the imaging evaluation
on patient treatment will be discussed.
Conclusion: Trimodality treatment and more aggressive surgery
of rectal cancer have made it imperative that the radiologist
use modern imaging modalities to delineate the extent of disease spread. In order to best achieve this goal search patterns
based on anatomy and the knowledge of patterns of disease
spread is essential. The accurate assessment of pretreatment
extent of disease greatly impacts patient management.
E178. The Duodenum: An Often Neglected Segment Despite
its Important Anatomic Location and Related Various
Disease Entities
Kim, Y.1; Jeong, W.1; Cho, O.2; Song, S.2; Koh, B.2; Cho, Y.1 1.
Hanyang University Kuri Hospital, Kuri City, Kyunggido, South
Korea; 2. Hanyang University Hospital, Seoul, South Korea
Background Information: The duodenum is the shortest segment of the intestinal tract, so it is often overlooked by radiologists. However, it is located at both the intraperitoneal and retroperitoneal space and has a close relationship with various
organs. As a result, the duodenum is involved in diverse primary
and secondary disease processes.
Educational Goals/Teaching Points: The goals are to review its
anatomic location and relationship among various adjacent
organs; review primary and secondary disease entities involving
the duodenum, and understand the importance of the duodenum which radiologists and clinicians often neglect.
236
Techniques: This presentation displays the anatomic location
and relationship of the duodenum with other organs such as
stomach, pancreas, gallbladder, liver, and other segments of the
gastrointestinal tract. Furthermore, it also demonstrates diverse
disease entities of the duodenum classified as developmental,
traumatic, inflammatory, neoplastic, and postsurgical conditions
with conventional imaging modalities.
Conclusion: It is possible to understand the anatomy and
diverse disease category of the duodenum. Knowledge about the
duodenum can result in early and accurate diagnosis.
E179. Esophageal Rupture: A Pictorial Review of Common
and Unusual Causes (CME Credit Available)
Ferguson, E.1; Berkowitz, E.2; Goldman, S.1 1. The University of
Texas Medical School at Houston, Houston, TX; 2. Emory
University School of Medicine, Atlanta, GA
Address correspondence to E. Ferguson ([email protected])
Background Information: Esophageal perforation may occur in
a variety of settings. Examples of different causes of esophageal
perforation will be discussed and their classic radiological
appearances on CT, plain film, and/or esophagram will be shown
and explained. Sources of esophageal perforation to be demonstrated include Boerhaave’s syndrome from vomiting, iatrogenic
causes such as Dobbhoff tube insertion and balloon dilatation,
acute rupture from trauma, malignant destruction, and an unusual variant of “esophageal” perforation involving a colonic interposition, as well as an example of chronic perforation. Each type of
perforation and its cause as well as imaging manifestations will
be discussed, diagnostic clues to aid in distinguishing among
them will be offered, and the natural outcome of each will be
explained along with current treatment options. Moreover, radiological findings in both acute and chronic perforations will
be demonstrated.
Educational Goals/Teaching Points: Persons who view this
exhibit will become familiar with the various entities that may
cause esophageal perforation; recognize important imaging
abnormalities associated with esophageal perforation and diagnostic clues which aid in making that diagnosis, and will understand the pathophysiology of each type of perforation and why it
occurs, the sequela of esophageal perforation and its treatment.
Techniques: Each type of esophageal perforation will be discussed and plain film, fluoroscopic, and/or computed tomographic imaging of each will be shown. The pathophysiology and
radiographic findings of each type of perforation will be
explained.
Conclusion: This exhibit will review the many causes for esophageal perforation. Showing examples of the radiological findings in
esophageal perforation is useful since seeing how each type of
perforation manifests will aid in future diagnosis. This exhibit
includes common and rare as well as unusual causes for perforation. Understanding these causes and recognizing patterns of
perforation is important because this affects patient care, outcome and prognosis. Acute and chronic manifestations and their
sequela will be discussed.
E180. Acute Esophageal Emergencies Encountered During
the “Ides of July”: One Hospital’s Experience from Late June
through Labor Day With the Arrival of the New House Staff
Ferguson, E.; Goldman, S. The University of Texas Medical School
at Houston, Houston, TX
Address correspondence to E. Ferguson (ecferguson@hotmail.
com)
Background Information: Most teaching-affiliated hospitals
experience a variety of changes during the month of July with
the arrival of the new house staff. This manifests in a number of
ways, particularly with new residents and medical students who
may occasionally make inadvertent and unintentional errors
while in the process of learning to care for their patients. Many
of these examples are captured radiologically. This exhibit focuses on acute iatrogenic esophageal emergencies encountered
with the arrival of the new house staff in and around the month
of July. Examples include iatrogenic esophageal perforation from
tube placement and other interventions, perforation of a colonic
interposition acting as an esophagus, and malpositioned
Dobbhoff feeding tubes placed into the airway, the lung, and the
pleural space. This pictorial review will serve to familiarize the
radiologist with possible iatrogenic esophageal trauma that may
be encountered during this time and will be useful for the new
house staff to caution them of potential errors that may occur so
that they may be avoided in the future. Each type of esophageal
emergency, its imaging manifestations, and sequelae will be discussed.
Educational Goals/Teaching Points: Radiologists should be
acquainted with the various types of iatrogenic esophageal trauma that may occur with the annual arrival of the new house staff
in July, at a time when new residents and medical students are
learning to take care of their patients. They should be familiar
with the appearance of malpositioned esophageal tubes, esophageal perforation, and other iatrogenic esophageal trauma and
instruct new house staff about causes of potential iatrogenic
esophageal trauma and ways to avoid it.
Techniques: This exhibit will focus on plain film, CT, and some
fluoroscopic findings associated with acute iatrogenic esophageal
emergencies that are encountered with the arrival of the new
house staff.
Conclusion: A review of the radiographic manifestations of iatrogenic esophageal emergencies that may occur with the arrival of
the new house during the “Ides of July” is helpful for the radiologist, especially since esophageal trauma and malpositioned
tubes may at times be overlooked or can mimic other abnormalities. It is also beneficial for the house staff to learn of some
inadvertent errors to be avoided. When they occur, medical errors
should be used as teaching tools, which is the goal of this exhibit, and, more importantly, to spare future patients of some of
these mistakes.
E181. Gallbladder Cancer: Imaging Findings and Mechanism
of Spread (CME Credit Available)
Olsen, K.; Oliphant, M. Wake Forest University Baptist Medical
Center, Winston Salem, NC
Address correspondence to K. Olsen ([email protected])
Background Information: Gallbladder carcinoma is the most
common malignancy of the biliary tract. The prognosis is greatly
altered with detection of disease beyond local involvement. It
spreads by several routes and the MDCT detection of metastatic
spread is crucial for initial staging and treatment planning. The
purpose of this exhibit is to review the pertinent anatomy of the
gallbladder; highlight key imaging findings of gallbladder cancer,
and discuss patterns of gallbladder cancer spread, with the intention to enable the radiologist to develop a focused search pattern.
Educational Goals/Teaching Points: Educational goals of this
exhibit include developing a heightened awareness of the imaging appearances of gallbladder cancer and its mechanisms of
spread; understanding the nuances of gallbladder anatomy and
how they determine the direct, subperitoneal, and intraperitoneal routes of spread, and developing a search pattern in cases
of gallbladder cancer.
Techniques: Gallbladder carcinoma spreads by several routes
determined by its anatomy. Direct spread occurs early to the liver
especially segment four due to venous drainage. Other direct
spread includes the duodenum and hepatic flexure due to anatomic proximity and along the bile ductules. Subperitoneal
spread occurs early via the lymphatics. The drainage is to the
cystic node and pericholedochal nodes then to the anterior and
posterior periportal nodes within the hepatoduodenal ligament, and to the celiac node and para-aortic nodes. Spread also
occurs within the hepatoduodenal ligament along the bile ducts.
Hematogenous spread is usually a late occurrence.
Intraperitoneal spread is from the peritoneal surface of the gallbladder. The gallbladder anatomy including gallbladder venous
and lymphatic drainage, anatomic relations to the liver and
other adjacent organs, and the patterns of cancer spread are discussed and illustrated.
Conclusion: The understanding of gallbladder anatomy and the
patterns of gallbladder tumor spread are the keys for developing
a logical and focused search pattern. Malignancy of the gallbladder has a poor prognosis. Localized tumor is generally associated
with longer survival. The detection of spread to the liver and
regional lymph nodes greatly alters prognosis and influences
treatment planning. The radiologist plays an essential role in the
detection of disease and the treatment of these patients.
E182. Meckel’s Diverticulum Revisited: Imaging
Manifestations of its Many Faces (CME Credit Available)
Shanbhogue, A1; Papadatos, D.1; Prasad, S.2; Ojili, V.2; Fasih, N1.
1. The Ottawa Hospital, Ottawa, Canada; 2. University of Texas
Health Science Center-San Antonio, San Antonio, TX
Address correspondence to A. Shanbhogue (shanbhogue_kp@
yahoo.com)
Background Information: Meckel’s diverticulum which results
from improper closure of the omphalomesenteric duct is the
most common congenital anomaly of the gastrointestinal tract,
237
occurring in 2–3% of the population. It occurs with equal frequency in both sexes and the majority of them are asymptomatic. Complications occur in approximately 4–40% of patients and
include diverticulitis, hemorrhage from peptic ulceration, intussusception, small intestinal obstruction, stone formation and neoplasm. Diagnosis of Meckel diverticulum and these complications
is difficult to establish in a substantial number of cases. The purpose of this exhibit is to review the multimodality imaging of
complicated and uncomplicated Meckel’s diverticulum.
the radiological spectrum of various clinical presentations of
Meckel’s diverticulum; identify the distinctive imaging features of
each of these relatively uncommon entities, and describe imaging features that help differentiate them from various other causes that may mimic them.
Techniques: In this exhibit, we will review the anatomy and
embryology of Meckel’s diverticulum. A comprehensive multimodality imaging review of various presentations and complications
like diverticulitis, hemorrhage, stone formation, intussusception
and intestinal obstruction will also be presented. Certain salient
features of these entities are described for reliable and accurate
diagnosis.
Conclusion: Meckel’s diverticulum can present with a wide
range of clinical and radiological manifestations ranging from
being benign and indolent to acute and life threatening.
Familiarity with these appearances allows an accurate diagnosis
to initiate an accurate management.
E183. CT Findings of Adult Intussusception (CME Credit
Available)
Borghei, P.; Lockhart, M.; Morgan, D.; Clements, R. University of
Alabama Birmingham, Birmingham, AL
Address correspondence to P. Borghei ([email protected])
Conclusion: Knowledge of the imaging features produced by different etiologies of intussusception in adults is a key element for
accurate radiologic diagnosis, can aid in predicting the clinical
course, and may help avoid unnecessary surgical explorations.
E184. Imaging of Budd-Chiari Syndrome
Kalra, N.; Virmani, V.; Singh, P.; Kang, M.; Anand, A.; Chawla, Y.;
Khandelwal, N. Postgraduate Institute of Medical Education and
Research, Chandigarh, India
Address correspondence to N. Kalra ([email protected])
Background Information: Budd-Chiari syndrome is a manifestation of hepatic venous outflow obstruction. It can be classified
according to etiology as primary or secondary or according to the
duration of disease as acute, subacute and chronic. The obstruction can occur at any level from the hepatic venules to the
cavoatrial junction. Prompt diagnosis of Budd-Chiari syndrome
and detection of the cause of obstruction, level of obstruction
and stage of the disease is essential for appropriate management
of the patient.
Educational Goals/Teaching Points: 1.The goals are for the
viewer of this exhibit to know the current status of various imaging modalities in the diagnosis of Budd-Chiari syndrome and
understand the various imaging features helpful in diagnosing
and classifying Budd-Chiari syndrome.
Techniques: Imaging modalities like Doppler sonography, MDCT,
MRI, MR venography and conventional inferior vena cavagraphy
are used for the diagnosis of Budd-Chiari syndrome. Each of
these modalities has its advantages and pitfalls. Doppler sonography, MDCT, MR venography and inferior vena cavagraphy are
useful for the evaluation of the hepatic veins and inferior vena
cava. On the other hand, dynamic CT and dynamic MRI provide
information about the hepatic parenchymal changes and can be
used for staging the disease.
Background Information: Unlike childhood intussusception that
is typically idiopathic, adult intussusception often has an identifiable cause. At times, diagnosis of this condition and identification
of underlying pathology can be challenging, but the latter is
important for directing therapy. The purpose of this exhibit is to
demonstrate the variety of imaging features of intussusception
that may be produced by different underlying etiologies.
Conclusion: This didactic exhibit depicts the imaging features of
Budd-Chiari syndrome and in a case format illustrates the various
stages and level of obstruction of Budd-Chiari syndrome. Primary
as well as secondary Budd-Chiari syndrome cases will be discussed. The advantages and disadvantages of various modalities
including their current status will be highlighted.
Educational Goals/Teaching Points: CT diagnostic criteria of
intussusception will be reviewed. Classification according to location (gastric, enteroenteric, ileocolic, ileocecal, or colocolic) and
cause (benign, malignant, or idiopathic) will be demonstrated.
Imaging features of transient intussusception without a lead
point will be contrasted with those that have a lead point. Based
on these findings, the decision process for surgical vs. conservative management will be discussed.
E185. The Caudate Lobe Revisited: Cross-Sectional Imaging
Findings of Caudate Lobe Pathologies and Implications for
Surgery
Nagar, A.; Katabathina, V.; Prasad, S.; Ojili, V.; Choudhary, S.;
Chintapalli, K. University of Texas Health Science Center at San
Antonio, San Antonio, TX
Address correspondence to A. Nagar ([email protected])
Techniques: CT is the most common imaging modality utilized
to identify intussusception. Factors such as clinical demographics,
size or length of the intussusception, and location are important
to the prognosis. In some cases, small bowel series, barium
enema and pathology results will be correlated with CT findings
to better understand pathophysiology.
238
Background Information: Accurate knowledge of the surgical
anatomy of the caudate lobe is essential for planning liver transplantation or hepatobiliary surgery. Surgical approach to segmental or total resection of caudate lobe lesions depends on the size,
type and precise location of the lesion as well as on the volume
of the caudate lobe itself. Caudate hepatectomy is the most difficult and technically challenging procedure due to complex vascular supply and deep location. Caudate lobe accounts for 9% of
the total mass of the liver and is used in transplantation. A spectrum of lesions affects the caudate lobe either in isolation or as a
part of multifocal process. A spectrum of pathologies, imaging
and surgical anatomy of the caudate with their surgical implications will be discussed in this exhibit.
embryology and applied anatomy of the caudate lobe with special emphasis on lobar changes in diffuse liver diseases, and
review the spectrum of pathologies involving the caudate lobe
with implications on liver surgery.
Techniques: Caudate lobe, the first segment of the liver is functionally a part of the left lobe. The caudate lobe is characterized
by separate vasculature and biliary ducts. The significance of caudate anatomy is reflected in major hepatic resections for various
neoplastic and non-neoplastic conditions. Diffuse caudate lobe
enlargement is the most common abnormality of the caudate
lobe, which occurs commonly in cirrhosis and Budd chiari syndrome. The caudate lobe is also a target site for a wide spectrum
of focal pathologies including primary and secondary malignant
neoplasms, benign tumors and infections. Malignant tumors of
the caudate lobe manifest advanced disease and thus portend
poor prognosis. Microscopic involvement of the caudate lobe is
commonly seen in hilar cholangiocarcinomas; resection of caudate is thus performed with right hepatectomy. Disorders in the
porta hepatis may displace the papillary process of the caudate
lobe and thus simulate an extrahepatic/retroperitoneal mass.
Variations in the anatomy of the papillary process may give a
pseudotumor like appearance. MDCT/MRI findings of focal/diffuse abnormalities of the caudate lobe are presented with implications for surgery.
Conclusion: In this exhibit, we discuss the relevant surgical anatomy and spectrum of pathologies that involve the caudate lobe
and their implications on surgery.
E186. Fat Containing Extrahepatic Intra-Abdominal
Neoplastic and Non-neoplastic Disorders: Cross-Sectional
Imaging Findings with Pathological Correlation (CME Credit
Available)
Chang, K.; Surabhi, V. University of Texas Houston Health Science
Center, Pearland, TX
Address correspondence to K. Chang ([email protected])
Background Information: A wide spectrum of fat containing
neoplastic and non-neoplastic diseases may occur in the abdomen. Our aim is to review the various fat containing extrahepatic
neoplastic and non-neoplastic disorders and examine salient
imaging findings then confirm with histopathology.
the fat containing extrahepatic neoplastic and non-neoplastic disorders; discuss salient imaging findings of the broad spectrum of
fat containing extrahepatic intra-abdominal neoplastic and nonneoplastic pathologies; discuss the differential diagnosis based
on radiologic findings, and correlate the above findings with
gross histopathology. Key Anatomic/Physiologic Issues and Imaging Findings/
Techniques: We will examine the following radiologic-pathologic
correlations: 1. Radiologic-pathologic correlation of the fat containing non-neoplastic extrahepatic intra-abdominal conditions –
mesenteric panniculitis, omental infarction, and mesenteric lipodystrophy; 2. Radiologic-pathologic correlation of the fat containing extrahepatic intra-abdominal neoplasms- lipoma, AML, clear
cell RCC, PECOma, liposarcoma, adrenal adenoma, myelolipoma,
teratoma and lipoleiomyoma .We will then present a differential
diagnoses for various radiologic findings and discuss methods to
distinguish various entities based on microscopic or macroscopic
fat histopathologic presentations.
Conclusion: A wide spectrum of fat containing neoplastic and
non-neoplastic diseases may occur in the abdomen. These disorders may either arise from the intra-abdominal organs or surrounding mesenchyme. In this exhibit, we enumerate and review
the fat containing extra hepatic neoplastic and non-neoplastic
diseases. Salient imaging findings of various conditions and
methods to distinguish based on microscopic vs. macroscopic fat
and organ of origin are discussed. E187. Avoiding Pitfalls in Hepatocellular Carcinoma: MDCT
Spectrum of Imaging Findings (CME Credit Available)
Rowell, A.; Sangster, G.; Heldman, M.; Zibari, G.; Shokouh-Amiri,
H.; Roberts, K. Louisiana State University Health Science Center,
Shreveport, Shreveport, LA
Address correspondence to A. Rowell ([email protected])
Background Information: Hepatocellular carcinoma (HCC) is
increasing in incidence in the US as the number of patients with
hepatitis B and C infection rises. MDCT, along with ultrasound
and MRI, plays an important role in the diagnosis and staging of
HCC. Because these tumors most often arise in liver parenchyma
that is already altered by pathology, their identification and differentiation from other lesions may represent a diagnostic challenge. Hypervascular tumors and nontumoral vascular conditions
may mimic HCC. MDCT is the modality of choice in differentiating
between these various entities.
Educational Goals/Teaching Points: After reviewing this exhibit
the reader should be able to differentiate the HCC from other
benign and malignant hepatic conditions; recognize the MDCT
imaging findings on typical and atypical HCC, and identify pitfalls
and false positive findings that may mimic HCC on MDCT.
Techniques: This presentation will discuss the MDCT imaging
findings of hepatocellular carcinoma and similar appearing
hepatic processes.
Conclusion: The aim of this presentation is to demonstrate the
MDCT imaging findings that are typical for HCC as well as to
illustrate MDCT features that help distinguish HCC from other
similar appearing conditions.
239
E188. Liver Involvement in Hereditary Hemorrhagic
Telangiectasia: A Multimodality Approach using CT, MR and
Color Doppler Sonography
Kantawala, K.; Robinson, K.; Dahiya, N.; Middleton, W.; Menias,
C.; Mallinckrodt Institute of Radiology, St. Louis, MO
Address correspondence to K. Kantawala ([email protected].
edu)
Background Information: Hereditary hemorrhagic telangiectasia
(HHT), also known as Rendu-Osler-Weber disease, is an autosomal dominant vascular disease characterized by mucocutaneous or
visceral angiodysplasias (telangiectases and arteriovenous malformations) that may be distributed throughout the body. The reported prevalence is estimated to be around 1:100,000 to 200,000.
Liver, lungs and brain, in order of prevalence, are the most frequently involved visceral organs of the body. The aim of this exhibit is to describe the multimodality imaging features of the hepatic
manifestations of HHT using Ultrasound (US), CT and MR.
Educational Goals/Teaching Points: Familiarity with the hepatic manifestations of HHT on multiple modalities results in more
accurate and early diagnosis and allows for better therapeutic
options if necessary.
Techniques: Our experience with a large group of HHT patients,
with symptomatic and asymptomatic liver involvement, indicates
that it is far more frequent than reported. It is characterized by
intrahepatic vascular shunts, disseminated intraparenchymal telangiectases, and other vascular lesions. These lesions can cause
serious complications, including congestive cardiac failure, portal
hypertension, portosystemic encephalopathy, cholangitis, and
atypical cirrhosis. Thus, a correct diagnosis is important, and diagnostic imaging has a fundamental role in detecting vascular alterations in the liver. Grey-scale and Doppler sonography are noninvasive, highly accurate and relatively low cost procedures for the
screening of liver involvement in patients with hereditary hemorrhagic telangiectasia. Multiphasic contrast-enhanced CT and MRI
provide high quality multiplanar and angiographic reconstructions, allowing for detection and characterization of the complex anatomopathologic alterations typical of this disease.
Conclusion: Diagnostic imaging based on ultrasound (US), CT
and MRI has a fundamental role in evaluating hepatic involvement in patients with HHT.
E189. Fat-Containing Hepatic Nodules: Ultrasound, CT, MR
and Pathologic Correlation
Cho, Y.; Kim, Y.; Jeong, W.; Cho, O.; Song, S. Hanyang University
Kuri Hospital, Kuri City, Kyunggido, South Korea
Background Information: Nowadays we can easily detect fatcontaining hepatic lesions by various image modalities. There are
various histologic types of hepatic nodules that contain fat. Those
nodules have similar sonographic findings: hyperechoic nodules,
well circumscribed margin, and occasionally posterior attenuation. However, their CT and MR findings make it easy to diagnose
among them. These radiologic findings are well correlated with
pathologic findings and we can differentiate these fat-containing
hepatic nodules.
240
Educational Goals/Teaching Points: The goal is to differentiate
radiologic findings of various fat-containing hepatic nodules with
pathologic correlation.
Techniques: We reviewed many cases of fat containing hepatic
lesions (multifocal fatty infiltration, hepatic angiomyolipoma,
nodular regenerative hyperplasia of the liver, hepatocellular adenoma, dysplastic nodules, and hepatocellular carcinoma with
fatty metamorphosis) and correlated between their radiologic
and pathologic findings.
Conclusion: Fat containing hepatic lesions were very diverse,
ranging from completely benign to malignant. By knowing the
additional features of fat containing hepatic nodules, we could
make more precise diagnoses. E190. Higher Concentration Contrast Media for MDCT of the
Liver
Lepanto, L. CHUM Hospital of St. Luc, Montreal, Canada
Address correspondence to L. Lepanto ([email protected])
Objective: The goal was to evaluate whether the use of contrast
media with a higher iodine concentration provide a benefit for
rapid MDCT of the liver.
Materials and Methods: A number of studies have demonstrated that the use of high concentration contrast media (HCCM;
370-400 mgI/mL solution) provides improved enhancement during multiphasic MDCT of the liver and associated vasculature.
However, in studies comparing various contrast media (CM) concentrations in which the injection rate and/or total grams of
iodine delivered varied between study groups, it has been difficult to assess the benefit of HCCM. Two recently conducted studies compared a moderate concentration CM (320 mgI/mL) with
a HCCM for first pass angiography and equilibrium phase MDCT
imaging of the liver. In both trials, all patients received equiiodine
(40 gI) doses of CM injected at 4 mL/second, improving the likelihood that any observed differences can be ascribed solely to
the CM concentration.
Results: In the IMPACT trial [1], 121 patients undergoing liver
MDCT received iodixanol-320 (n=61) or iopamidol-370 (n=60).
Here, the HCCM iopamidol-370 also provided significantly higher
HU values in abdominal aorta during the arterial phase of
enhancement for both readers (reader 1: 301.3 vs. 273.6 HU,
p=0.02; reader 2: 302.0 vs. 275.1 HU, p=0.03). In this study, no
significant difference was observed between the two CM during
the portal-venous phase of enhancement. In the ACTIVE trial [2],
183 patients undergoing liver MDCT received iodixanol-320
(n=92) or iomeprol-400 (n=91). In this study, iomeprol-400 produced significantly greater enhancement of the aorta during the
arterial phase for both blinded readers (reader 1: 337.3 vs. 294.9
HU, p=0.0004; reader 2: 325.7 vs. 295.3 HU, p=0.01) and greater
enhancement of liver parenchyma during the portal-venous
phase (reader 1: 115.1 vs. 108.6 HU, p=0.04; reader 2: 115.2 vs.
109.3 HU, p=0.05). No significant difference was noted between
the two study groups regarding enhancement of the inferior vena
cava or portal vein.
Conclusion: In well-designed comparative trials, the use of CM
with higher iodine concentration (370-400 mgI/mL) results in
greater enhancement for vascular phase imaging. The finding that
parenchymal phase imaging may also be improved with the use
of HCCM deserves further clinical evaluation. The use of HCCM
provides the ability to reduce CM volumes, potentially minimizing
patient exposure to CM while reducing examination costs.
1. Sahani DV, et al. Invest Radiol. 2007; 42:856-861.
2. Romano L, et al. Br J Radiol. 2008; In Press.
E191. Portal Vein Thrombosis: A Multimodality Approach to
the Diagnosis of Bland vs. Malignant Thrombi (CME Credit
Available)
Masuda, E.; Myers, D. Henry Ford Hospital, Detroit, MI
Address correspondence to E. Masuda ([email protected])
Background Information: Portal vein thrombus is a frequently
encountered finding in hepatic imaging. Bland thrombosis of the
portal vein can occur secondary to numerous benign etiologies
such as infection, surgical intervention, nonspecific parenchymal
disease, and secondary to malignancy; particularly hepatocellular
carcinoma (HCC). Portal vein thrombosis has been shown to
occur in up to 30% of cases of HCC, and in up to 5% of patients
with cirrhosis or portal hypertension. Malignant tumor thrombus,
however, is much less common, and usually is discovered incidentally during cancer staging. Malignant tumor thrombosis of
the portal vein occurs most commonly secondary to HCC. It is
therefore of value to differentiate bland vs. malignant thrombus,
as this plays a crucial role in the correct staging and appropriate
treatment for these patients, as well as avoiding unnecessary
risks involved in anticoagulation therapy if a malignant thrombus
is misdiagnosed. This exhibit will discuss the imaging characteristics of various modalities used to differentiate bland vs. malignant thrombus, including findings on CT, ultrasound, PET-CT, and
MRI. This exhibit will also discuss the potential pitfalls in the
diagnosis of bland vs. malignant portal vein thrombosis with
these various imaging modalities. A short series of challenge
cases will be presented at the end of our exhibit.
Educational Goals/Teaching Points: The exhibit will differentiate imaging characteristics on CT, ultrasound, PET-CT and MR,
which can be used by the radiologist to confidently distinguish
between bland vs. malignant portal vein thrombus (PVT);
describe the sensitivity and specificity of malignant portal vein
thrombus detection by various modalities as described by the
current literature, and identify artifacts that can falsely present as
portal vein thrombus.
Techniques: CT characteristics of malignant portal vein thrombus
include: intrathrombus neovascularity, venous expansion, and
direct invasion of the portal vein. Generalized enhancement on
CT strongly suggests malignant PVT. Hypermetabolism on PET-CT
may suggest either malignant tumor or septic thrombophlebitis.
The exhibit will discuss the identification of neovascularity and
Doppler flow characteristics of malignant thrombus on ultrasound.
Conclusion: Portal vein thrombus is a common finding in hepatic imaging. The distinction of bland vs. malignant thrombus by
the radiologist through the imaging characteristics discussed in
this exhibit plays a crucial role in correct staging and therapy.
E192. MR Cholangiopancreatography of Liver Transplant
Biliary Complications With Radiographic Cholangiographic
Correlation (CME Credit Available)
Alsheik, N.; Taylor, A.; Sadowski, E.; Paul, R.; Pfau, P.; Reeder, S.
University of Wisconsin Hospitals and Clinics, Madison, WI
Address correspondence to N. Alsheik ([email protected])
Background Information: Post liver transplant biliary complications occur commonly (19-30%) and are usually evaluated with
ultrasound, liver biopsy and/or direct cholangiography (endoscopic retrograde cholangiopancreatography [ERCP] or percutaneous cholangiography [PTC]]. Direct cholangiography is considered the diagnostic gold standard for post-transplant complications and can provide treatment at the time of diagnosis.
However, direct cholangiography is invasive and confers a risk of
pancreatitis, ascending cholangitis and duodenal perforation.
Although these complications are infrequent, they are devastating
in the immune-compromised transplant patient. MR cholangiopancreatography (MRCP) offers a viable, noninvasive means to
directly visualize postoperative biliary strictures and bile ducts
above the stricture, which ERCP does not demonstrate. MRCP
offers the benefit of diagnosing postoperative biliary complications (anastomotic stricture, intrahepatic nonanastomotic stricture
and extrahepatic nonanastomotic stricture) as well as extrabiliary
complications (recurrence of preoperative hepatitis, biloma, vascular compromise).
Educational Goals/Teaching Points: The aim of this exhibit is
to review the physics of our current MRCP protocol, which has
enhanced background suppression secondary to the addition of
a T2-prep pulse sequence module, and demonstrate the utility of
MRCP as a viable, noninvasive alternate means of direct visualization of the biliary tree in post liver transplant patients.
Techniques: Our current MRCP imaging protocol will be
reviewed. The diagnostic efficacy of MRCP for postoperative biliary and extrabiliary complications is compared to direct cholangiography (ERCP, PTC). Delayed images with gadobenate dimeglumine determine which strictures are physiologically significant.
Complications following orthotopic liver transplantation
include anastomotic and nonanastomotic strictures, bile leak, and
biliary recurrence of pre-existing preoperative conditions.
Conclusion: MRCP detects and characterizes biliary strictures as
accurately as direct cholangiography (ERCP, PTC) and serves as an
indispensable roadmap for interventional procedures. Also, MRCP
images the biliary tree in patients in whom direct cholangiography
is unsuccessful. A negative MRCP examination may obviate the
need for diagnostic ERCP or PTC in patients with elevated liver
enzymes following liver transplantation, limiting direct cholangiography to patients who require therapeutic intervention alone.
E193. MR Cholangiography for Evaluation of Orthotopic
Liver Transplant Complications: A Viable Noninvasive
Alternative to Radiographic Direct Cholangiography
Alsheik, N.; Taylor, A.; Sadowski, E.; Paul, R.; Pfau, P.; Reeder, S.
University of Wisconsin Hospitals and Clinics, Madison, WI
Address correspondence to N. Alsheik ([email protected])
Objective: Although direct cholangiography (endoscopic retrograde cholangiopancreatography [ERCP] and percutaneous
cholangiography [PTC]) is the diagnostic gold standard of
241
postorthotopic liver transplant complications, it confers a multitude
of risks in immunocompromised patients. Post-transplantation
biliary complications occur between 19-30%. MR cholangiopancreatography (MRCP) offers a viable, noninvasive means of direct
visualization of the biliary tree, vasculature and liver. Our current
MRCP protocol has enhanced background suppression secondary
to a T2-prep pulse sequence module. Delayed images with gadobenate dimeglumine offer crucial physiologic information regarding the significance of biliary strictures. The purpose of this study
is to establish the efficacy of MRCP compared to direct cholangiography in liver transplant patients. Materials and Methods: Fourteen liver transplant patients were
referred for both MRCP and direct cholangiography. These studies were independently interpreted by two radiologists. At MRCP,
strictures were graded as mild, moderate, or severe based on
radiographic size of stricture and physiology of delayed gadobenate dimeglumine excretion. At ERCP, strictures were graded
as mild, moderate or severe based on fluoroscopic size of stricture and resistance with balloon sweep of the stricture. Also
recorded were the presence of upstream and downstream dilatation, intrahepatic or extrahepatic strictures, bile leak/biloma, and
transplant vascular complications. Results: MRCP had a sensitivity and specificity of 100% in the
detection of six anastomotic strictures and three cases of multifocal intrahepatic strictures. MRCP was particularly useful in demonstrating the biliary tree in patients in whom direct cholangiography was unsuccessful. Six patients received delayed imaging. In
each case with delayed imaging, the grading of strictures as mild,
moderate or severe correlated with ERCP grading of strictures.
Conclusion: MRCP detects and characterizes biliary strictures as
accurately as direct cholangiography and serves as an indispensable roadmap for interventional procedures. A negative MRCP
examination may obviate the need for diagnostic ERCP or PTC in
patients with elevated liver enzymes following liver transplantation, limiting invasive cholangiography to patients requiring therapeutic intervention alone.
E194. The Varied MRI Appearances of Diffuse and Focal
Hepatic Steatosis
Yang, N.1; Goodwin, M.2; Chang, S.1; Schelleman, A.2; Elser, S.1
1. Vancouver General Hospital, Vancouver, Canada; 2. Austin
Health, Heidelberg, Victoria, Australia
Address correspondence to N. Yang ([email protected])
Background Information: As the rates of obesity, diabetes and
alcohol use increase in the community, so too does the incidence of diffuse and focal hepatic steatosis. In addition, nonalcoholic steatohepatitis (NASH) is now known to be a major cause
of cirrhosis. The varied appearances of fat in the liver can lead to
diagnostic confusion, in turn leading to unnecessary invasive procedures. MRI is highly sensitive and specific for intrahepatic fat,
and we aim to review its varied appearances.
the risk factors, pathophysiology, epidemiology and MR imaging
appearances of diffuse and focal hepatic steatosis. In addition,
the MRI physics will be reviewed.
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Techniques: Normal liver parenchyma has similar signal intensity
on gradient echo in-phase and opposed-phase images. Hepatic
steatosis can be detected if there is signal intensity loss on
opposed-phase images and the severity of steatosis can be graded by the degree of signal loss. Fat deposition can also be diagnosed with the application of other fat suppression techniques,
but this is less sensitive than chemical shift imaging. The signal
changes caused by focal steatosis can give rise to pseudolesions
in the liver, and the presence of steatosis can also complicate the
characterization of focal liver lesions. We will present recent
examples to illustrate the varied appearances.
Conclusion: MRI is sensitive and specific for detection of fat in
the liver, but hepatic steatosis has many manifestations and the
radiologist must be aware of these varied appearances to avoid
misdiagnosis.
E195. Liver Imaging at 3T: Technical Optimization
Mwangi, I.; Shiehmorteza, M.; Sirlin, C. University of CaliforniaSan Diego, San Diego, CA
Address correspondence to I. Mwangi ([email protected])
Background Information: MR imaging at 3T provides higher
signal to noise ratio and higher sensitivity to contrast agents than
at 1.5T. In principle, this makes 3T MR imaging suited for detection of small cancers and difficult lesions, both in cirrhotic and
noncirrhotic livers. However, consistently high image quality may
be difficult to achieve at 3T. This exhibit demonstrates how optimization of liver imaging at 3T can be achieved, by selection of
appropriate sequences and adjustment of technical parameters.
Basic physics and technical concepts, schematic diagrams, and
clinical illustrations are presented.
Educational Goals/Teaching Points: The learning objectives are
to review basic concepts of MR imaging of the liver at 1.5T and
3T; understand theoretical and practical advantages and disadvantages of liver imaging at 3T, and learn how to optimize 3T examinations of the liver.
Techniques: High field strength MRI (3T) accentuates motion,
standing wave, susceptibility and chemical shift artifacts. Also,
obtaining in- and out-of-phase sequences with appropriate echo
spacing to characterize lipid accumulation may be challenging.
Conclusion: By applying basic technical concepts it is possible to
formulate robust and reliable 3T sequences that generate consistently high image quality, avoid artifacts, and delineate liver
lesions with high conspicuity.
E196. Liver Lesion Characterization: “The Good, the Bad and
the Ugly” (CME Credit Available)
Shanbhogue, A.1; Cao, L.2; Papadatos, D.1 1. The Ottawa
Hospital, Ottawa, Canada; 2. No Institutional Affiliation
yahoo.com)
Background Information: Characterization of liver lesions is
one of the commonest indication for which an outpatient MRI is
indicated. The differential diagnosis of liver nodules is wide and
depends on presence or absence of underlying liver parenchymal
disease, age and sex of the patient and a number of other risk
factors. The diagnosis is effortless when classical imaging manifestations are present, but may be more challenging and difficult
when the imaging manifestations are not classic. The purpose of
this exhibit is to review the imaging spectrum of a diverse group
of benign and malignant liver nodules which demonstrate atypical imaging characteristics. Educational Goals/Teaching Points: The goals are to discuss
imaging features of liver lesions on ultrasound, CT and MRI with
emphasis on making a specific diagnosis, and to discuss potential
pitfalls using a standard algorithmic approach.
Techniques: In this exhibit, we will review the classic algorithmic
approaches to various liver nodules in cirrhotic and noncirrhotic
livers and highlight the pitfalls of using a classic algorithmic
approach. We will also present numerous simple and
benign (“The Good”), difficult (“The Bad”) and very complex
(“The Ugly”) liver nodules using ultrasound (US), CT and MRI.
internal fat. Cystic bile duct hamartomas have been mistaken for
malignancy. When treatment is required, these masses respond
favorably to simple deroofing procedures, thereby avoiding hepatectomy. Hepatocellular carcinoma and cholangiocarcinoma
appear differently on pre- and postcontrast sequences. Properly
timed arterial phase imaging and subsequent multiphasic imaging are vital in this discrimination. Metastases have a different
pattern of enhancement after gadolinium than primary hepatocellular carcinoma.
Conclusion: By implementing a comprehensive yet rapid MRI
protocol for abdominal imaging and employing an algorithmic
approach, the radiologist can confidently tackle hepatic masses. E198. Delayed Enhancing Hepatic Lesions on MR Imaging
Morani, A.; Elsayes, K.; Liu, P.; Hussain, H.; Weadock, W.; Caoili, E.
University of Michigan, Ann Arbor, MI
Address correspondence to A. Morani ([email protected])
Conclusion: Liver nodules can vary from benign to malignant
causes. Imaging features can be nonspecific. We plan on exposing the audience to a classic algorithmic approach, with review of
imaging findings on US, CT and significant emphasis on MRI, in
an attempt to properly characterize liver nodules. We will expose
the audience to classic and nonclassic appearances of both
benign and malignant liver nodules. Finally, we will present more
challenging cases to interpret.
Background Information: Many pathologic entities in the liver
enhance on delayed postgadolinium imaging. This enhancement
pattern may be due to fibrous tissue, edema or vascular spaces
within these entities.
E197. Hepatic Masses: An Algorithmic Approach (CME Credit
Available)
Krishnamoorthy, S.; Sebastian, S.; Salman, K.; Rostad, B.; Li, J.;
Sharma, P.; Kalb, B.; Spivey, J.; Sarmiento, J.; Martin, D. Emory
[email protected])
Techniques: Benign entities such as intrahepatic fibrosis, postradiotherapy changes, peliosis hepatis, pseudotumor, abscesses
and hemangiomas, and malignant entities such as hemangioendotheliomas, cholangiocarcinomas, combined hepatocellular carcinoma-cholangiocarcinoma, and hypovascular metastases show
characteristic delayed enhancement. These lesions have variable
morphologic features, signal intensities and early enhancement
pattern. MR imaging can help distinguish between these entities.
Background Information: The superlative soft tissue contrast
and depiction of hepatic vasculature, makes MRI ideal for characterization of hepatic masses. Modern MRI sequences allow for
faster scanning and greater resistance to motion artifacts. In order
to thoroughly exploit the advantages of MRI, proper unenhanced
and postgadolinium sequences are mandatory. Once such a system is established, the radiologist must understand the imaging
features of masses to determine the optimal course of action.
Educational Goals/Teaching Points: The goals are to define a
protocol for hepatic imaging by MRI; differentiate common
benign hepatic masses, including cyst, cystic bile duct hamartoma, hemangioma, focal nodular hyperplasia, and hepatic adenoma; identify MRI features of hepatic metastases and primary
hepatic malignancies; outline a followup protocol for dysplastic
nodules and hepatocellular carcinoma, and describe the imaging
criteria for hepatic transplantation as a treatment for hepatocellular carcinoma. Key Anatomic/Physiologic Issues and Imaging Findings/
Techniques: Hemangiomas demonstrate increased T2 signal.
They have nodular peripheral enhancement on the arterial phase
with subsequent progressive enhancement with time. Hepatic
adenoma features arterial enhancement and frequently contains
the spectrum of delayed enhancing hepatic lesions on MRI, and
to describe their temporal enhancement characteristics and signal intensities on current comprehensive pulse sequences.
Conclusion: Delayed enhancing hepatic lesions can be diagnosed and differentiated on MRI by assessing their temporal
enhancement and signal characteristics.
E199. Diffusion-Weighted MRI Findings of Diffuse Liver
Disease in Patients with Orthotopic Liver Transplant
Momtahen, A.; Balci, N.; Fattahi, R.; Wolverson, M. Saint Louis
University, Saint Louis, MO
Address correspondence to A. Momtahen ([email protected])
Objective: The goal was to evaluate the role of diffusion-weighted MRI (DWI) in the assessment of diffuse liver parenchymal disease in patients with orthotopic liver transplants (OLT).
Materials and Methods: DWI of 31 OLT patients (20 men and
11 women; mean age 53 years) and 20 patients without liver diseases (11 men and nine women; mean age 49 years) were retrospectively evaluated. All liver transplant patients had histopathologically proven diffuse liver disease. Patients with pathologic
diagnosis of transplant rejection were excluded from the study.
DWI was acquired on a 1.5T MR scanner with b=0, 300, and 600
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seconds/mm2. Apparent diffusion coefficient (ADC) maps were
created on all patients and ADC values of the liver were displayed
on a color map. Quantitative measurement of ADC values was
performed for each segment of the liver separately. Effects of
fibrosis, cholestasis, and necroinflammatory activity grade according to the Scheuer classification on the mean ADC value of the
liver were evaluated using linear regression analysis.
Results: Three patients had hepatitis, two patients had cholestasis and hepatitis, two patients had cholestasis and fibrosis, 14
patients had hepatitis and fibrosis, and ten patients revealed
cholestasis, hepatitis, and fibrosis. The grade of necroinflammatory changes and cholestasis did not have any effects on the ADC
values. ADC values were lower than the control group when
fibrosis was present. In the patient group, the mean ADC value of
the liver was 1.72 mm2/second in the absence of fibrosis and
1.21 mm2/second in grade 4 fibrosis. Mean ADC value of the
liver in the control group was 1.77 mm2/second. ADC color
maps in patients with diffuse liver changes revealed distinctly different patterns as compared to the control group.
Conclusion: DWI with color ADC map can reveal the presence of
liver fibrosis in patients with OLT.
E200. Early Contrast Enhancement of the Liver: Exact
Description of Phases Using MRI
Neto, J.1; Ramachandran, S.2; Semelka, R.2; Troy, J.2 1. No
Institutional Affiliation; 2. University of North Carolina Hospital,
Chapel Hill, NC
Address correspondence to S. Ramachandran ([email protected])
Objective: The purpose was to classify early postcontrast
enhancement of the liver into subtypes, using vessel enhancement patterns; and correlate these findings with quantitative
abdominal organ enhancement.
Materials and Methods: All abdominal MRI studies performed
between June 1, 2007 and June 18, 2007 were retrospectively
reviewed. The final study population comprised 114 studies. MR
studies were performed by using a set delay of 18 seconds
between the initiation of contrast injection and image acquisition. Subjective determination of phases of enhancement was
made by evaluating the presence of contrast in various abdominal vascular structures and the perceived extent of organ
enhancement. Correlation was made between the subjective
assessment and quantitative percentage enhancement of pancreatic, liver, spleen and kidney parenchyma.
Results: Five patterns of early postcontrast enhancement were
determined subjectively which included: early hepatic arterial
(EHA) [14 studies], mid hepatic arterial (MHA) [23 studies], late
hepatic arterial (LHA) [33 studies], splenic vein only hepatic arterial dominant (SVHAD) [20 studies], and hepatic arterial dominant (HAD) [24 studies]. Percentage pancreatic enhancement
was over 70% for LHA, SVHAD, and HAD, which was significantly
different than for the EHA and MHA phases (p<0.001).
Percentage liver enhancement was 33.4% in the HAD, which was
significantly greater than at any of the earlier phases, (p<0.001).
Conclusion: Vascular landmarks can be used to classify the specific early phases of enhancement. Using pancreatic parenchyma
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as a surrogate for liver lesion enhancement the LHA, SVHAD and
HAD all had greater enhancement than earlier phases. These
landmarks may be useful to predict adequacy of timing for early
dynamic liver imaging. Assessment of the subtype of early
enhancement may allow better judgment of liver lesions
enhancement and characterization, which may prove valuable
when assessing the response of liver lesions to treatment interventions.
E201. Ferumoxides Shift to the Spleen During MR Imaging
of the Cirrhotic Liver
Mwangi, I.; Shiehmorteza, M.; Mantrawadi, L.; Sirlin, C. University
of California-San Diego, San Diego, CA
Address correspondence to I. Mwangi ([email protected])
Objective: The objective was to retrospectively identify and
describe imaging features of ferumoxides shift to spleen in cirrhotic patients undergoing MR imaging.
Materials and Methods: In this IRB-approved, HIPAA-compliant,
descriptive study, patients with ferumoxides shift to spleen were
identified retrospectively by searching the abdominal imaging
teaching file of an academic hospital. Ferumoxides shift was
defined as reduced signal of the spleen relative to liver on T2*weighted gradient-recalled-echo images. Two radiologists in consensus evaluated the images. Patients’ medical records were
reviewed.
Results: Ten patients (five women, five men; mean age, 50
years; range, 39-63 years) with cirrhosis (hepatitis C (n=4), alcohol (n=4), nonalcoholic steatohepatitis (n=1), unknown (n=1))
and ferumoxides shift to spleen were identified. All had abnormal liver function tests. Two underwent liver transplantation after
imaging (three and 12 months respectively). All had splenomegaly, two with Gamna Gandi bodies. In three, liver parenchyma
cloaking hepatic vessels was hypointense to background liver,
suggesting preferential perivascular uptake of ferumoxides.
Conclusion: This is the first study to our knowledge to describe
ferumoxides shift to spleen as an entity in cirrhotic patients,
undergoing MR imaging. Further studies are needed to establish
the prevalence and clinical significance of this finding.
E202. The Varied Imaging Appearances of Fat Containing
Lesions of the Liver: A Pictorial Review to Aid Differential
Diagnosis (CME Credit Available)
Yang, N.; Zwirewich, C.; Chang, S. Vancouver General Hospital,
Vancouver, Canada
Address correspondence to N. Yang ([email protected])
Background Information: Fat may be present in a variety of
benign and malignant liver lesions. The detection of fat within a
liver lesion can be critical in the characterization of the lesion,
and coupled with the other imaging characteristics, can be helpful in narrowing the differential diagnosis. Ultrasound (US), CT,
and MRI can be used to detect intralesional fat. In particular,
MRI is both sensitive and specific for demonstrating both macroscopic fat and/or intracellular lipid within a liver lesion.
both benign and malignant types of fat containing liver lesions
and to describe and demonstrate the imaging appearances of
various fat containing liver lesions across a range of modalities,
including US, CT and MRI, to aid in narrowing the differential
diagnosis.
ground of high hepatic parenchymal signal. Additionally, the biliary excretion of the agent is best seen between 20-40 minutes
postinjection and can be used to assess the patency and caliber
of the intrahepatic and extrahepatic biliary ductal system. Key Anatomic/Physiologic Issues and Imaging Findings/
Techniques: Although the presence of fat can be documented
on US and CT, MRI is the most specific imaging technique for
demonstrating both an admixture of fat and soft tissue within a
lesion as well as pure macroscopic fat. A variety of MR techniques can be used to detect intralesional fat, but most commonly chemical shift opposed phase gradient echo sequences
and fat saturation sequences are used. Intracellular lipid-containing lesions include focal hepatic steatosis, hepatic adenoma,
focal nodular hyperplasia, regenerative nodules and hepatocellular carcinoma. Macroscopic fat-containing liver lesions include
hepatic adenoma, hepatocellular carcinoma, angiomyolipoma,
lipoma, hydatid cyst, metastases and pericaval fat.
Conclusion: Hepatobiliary specific contrast agents are important
for a variety of reasons. These could allow for improved diagnostic accuracy in liver lesion detection and characterization over
existing extracellular contrast media. In addition, this has the
potential to be used for functional imaging of the hepatobiliary
system, including evaluation for acute cholecystitis. The biliary
excretion helps evaluate the cystic duct patency, providing similar
functional information as a nuclear medicine cholescintigraphic
scan, while still providing the anatomic detail of a conventional
MR study.
Conclusion: The recognition of fat within a focal liver lesion is an
important finding, as this coupled with other imaging characteristics, aids in narrowing the differential diagnosis of these liver
lesions. US, CT and MRI can be used to further characterize these
lesions, but in particular, MRI is the most specific tool for demonstrating both macroscopic and microscopic fat deposition within
lesions.
E203. MRI of the Hepatobiliary System with a Liver-Specific
Contrast Agent
Gupta, R.; Brady, C.; Massey, C.; Merkle, E. Duke University
Medical Center, Durham, NC
Address correspondence to R. Gupta ([email protected])
Background Information: Recently, hepatobiliary specific agents
have become commercially available. One such agent is gadoxetate disodium. It is unique in that it has a dual route of excretion
with approximately 50% hepatic excretion and 50% renal excretion. Most MRI contrast agents currently in use are extracellular
agents and have negligible amounts of excretion through the
hepatobiliary system, primarily being excreted by the kidneys.
Hepatocyte-specific agents can be used in a wide range of hepatobiliary applications and the purpose of this exhibit is to show
cases in which the unique properties of liver-specific contrast
agents can be utilized effectively.
Educational Goals/Teaching Points: The goals of this exhibit
are to familiarize the reader with MR imaging protocols and
sequences utilized with liver-specific contrast agents and how
they differ from protocols used with extracellular contrast agents;
illustrate the impact that the liver-specific contrast has on
T2-weighted imaging; help understand how the hepatocyte-specific nature of these agents can help with liver lesion detection
and characterization, illustrate specific imaging features of liver
lesions with these agents, and learn how the biliary excretion of
such agents can be used to evaluate for biliary ductal system
pathology on delayed images.
Techniques: Using a hepatocyte-specific agent, the liver reaches
maximal enhancement approximately 15-30 minutes postinjection. This allows for lesions such as hepatocellular carcinoma,
adenomas, and cysts to be more conspicuous against the back-
E204. Quantitative Hepatic Imaging: Current and Emerging
Trends
Bajpai, S.; Singh, A.; Kambadakone R. A.; Catalano, O.; Blake, M.;
Sahani, D. Massachusetts General Hospital, Boston, MA
Address correspondence to S. Bajpai ([email protected])
Background Information: With the evolution of medicine coupled with imaging advances, expectations from radiology have
increased substantially. The liver is a target organ for several focal
and diffuse disease processes. Quantification in liver has many
important clinical applications ranging from the estimation of
total hepatic fat, iron, preoperative evaluation of normal liver volumes in hepatic transplantation and increasingly in functional
evaluation such as perfusion imaging. The purpose of this exhibit
is to study the current role of imaging in the quantification of
normal liver, diffuse hepatic diseases and focal liver lesions and
its impact on patient management, and to discuss the emerging
trends in volumetric evaluation of the liver by imaging.
imaging methods and techniques in the quantification of liver fat
and iron; highlight the role of CT and MR in liver volumetric estimation prior to hepatic transplantation; describe the clinical
applications and role of imaging in tumor volumetry, and discuss
imaging techniques such as perfusion CT, MR, PET for the quantitative evaluation of functional aspects of liver.
Techniques: The exhibit will outline the performance of current
and novel techniques such as ultrasound, CT, MRI and MR spectroscopy in hepatic fat quantification; technique and protocols of
imaging techniques such as MR in hepatic iron quantification;
volumetric assessment of functional and anatomical liver volume
in hepatic donors for presurgical evaluation; tumor volumetry
and its impact on planning surgery and treatment strategies such
as for proton beam therapy and selective internal radiation therapy (SIRT), and discuss perfusion imaging of the liver by CT and
MRI for quantification of hepatic microvascular physiology and
angiogenesis.
Conclusion: This exhibit highlights established hepatic quantitative imaging techniques and their pitfalls as well as novel
methods also capable of providing useful liver quantification
information.
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E205. Postoperative Diagnostic Workup of Orthotopic Liver
Transplantation: Impact of Recent Advances of CrossSectional Imaging (CME Credit Available)
Kanaan, Y.; Elsayes, K.; Trout, A.; Hussain, H.; Bude, R.; Dasika, N.;
Francis, I. University of Michigan, Ann Arbor, MI
Address correspondence to Y. Kanaan ([email protected])
Background Information: Orthotopic liver transplant (OLT) is a
common procedure and its complications should be identified
quickly to avoid problematic outcomes. Familiarity with multimodality imaging findings is extremely important for the radiologist
and consulting surgeon. In this presentation we will review the
surgical procedures and anatomic sequelae of liver transplantation; discuss the current diagnostic workup and utility of various
cross-sectional modalities and interventional radiology in revealing the complications of liver transplantation, and describe what
the surgeon needs to know when complications occur.
Educational Goals/Teaching Points: The exhibit provides a diagrammatic demonstration of OLT surgery, with imaging correlation; outlines the complications of OLT including pathophysiology
and incidence; discusses imaging strategies post OLT, including
diagnostic workup and utility of various imaging techniques in
the postoperative evaluation of orthotopic liver transplantation,
and reviews the imaging features of OLT complications and what
the surgeon needs to know when complications occur.
Techniques: A retrospective analysis of orthotopic liver transplants performed at the University of Michigan Health Systems
was reviewed and the sensitivities and specificities of the radiologic work-up was determined. Examinations that were evaluated
included: ultrasound, CT, MRI, interventional radiology and nuclear medicine. The surgical and pathologic findings were used as
the standard for imaging accuracy.
Conclusion: There is a wide spectrum of complications following
OLT. Clinical evaluation and multimodality imaging can be used
in conjunction to diagnose these complications.
E206. Perihepatitis: Various Causes and CT Findings
Kim, Y.1; Oh, S.1; Rha, S.1; Lee, Y.1; Jung, S.2; Byun, J.1; Lee, J.2
1. Kangnam St. Mary’s Hospital, Catholic University, Seoul, South
Korea; 2. St. Mary’s Hospital, Catholic University, Seoul, South
Korea
Objective: The objective is to review the pathophysiology of perihepatitis caused by various inflammatory processes and to demonstrate the imaging findings of the perihepatitis on dynamic
contrast-enhanced CT (CECT).
Materials and Methods: This study included 38 patients (15
men, 23 women; age range, 15-72 years) with hepatic capsular
enhancement identified by dynamic CECT. We analyzed the presence and pattern of hepatic capsular enhancement, presence of
subcapsular enhancement, presence of ascites and associated
abnormalities in abdomen and pelvis on dynamic CECT. Imaging
findings were correlated with medical records and pathological
reports.
246
Results: The associated diseases with perihepatitis were various; Fitz-Hugh-Curtis (FHC) syndrome (n=13), gastrointestinal
inflammation or perforation (n=10), hepatobiliary problem
(n=6), trauma (n=6), carcinomatosis peritonei (n=1), dialysis-related peritonitis (n=1), and pyelonephritis (n=1). In cases of
FHC syndrome and cholangitis, subcapsular parenchymal
enhancement was also noted. In cases of FHC syndromes, right
upper quadrant (RUQ) pain was the main complaint, however in
other associated diseases, pain in the primary inflammatory foci
was the main complaint.
Conclusion: Perihepatitis is a relatively nonspecific finding not
only seen in FHC syndrome but also seen in other inflammatory
processes. RUQ pain is less commonly associated in patients
with perihepatitis other than FHC syndrome.
E207. The Radiological Spectrum of Peritoneal
Carcinomatosis (CME Credit Available)
Vummidi, D.; Kolokythas, O.; Bush, W.; Lee, J.; Dighe, M. University
of Washington School of Medicine, Seattle, WA
Address correspondence to D. Vummidi ([email protected])
Background Information: The peritoneum is a complex serous
membrane with a visceral component that envelopes the organs
and a parietal component lining the abdominal wall . The peritoneal cavity is a potential space between these two layers that can
be affected by various pathological processes including neoplasia. Secondary or metastatic involvement is more commonly
encountered with ovarian cancer being the prototypical causative
lesion.
the anatomy of the peritoneum and describe its various compartments; describe the various pathways of spread of malignant
tumor; depict the multimodality approach to imaging peritoneal
carcinomatosis, and illustrate with suitable examples primary and
secondary peritoneal neoplasms.
Techniques: The peritoneal reflections and mesenteries divide
the peritoneal cavity into various compartments. The circulation
of the peritoneal fluid and rich blood supply provide an excellent
vehicle for the dissemination of neoplasia. Peritoneal carcinomatosis can be primary or secondary (metastatic).The latter which is
more common occurs by direct spread, lymphatic dissemination,
hematogenous embolic spread and peritoneal seedling. It is
commonly associated with ascites and can cause bowel/ureteral
obstruction. In this exhibit we shall illustrate the characteristic
involvement of the peritoneum including fat stranding, omental
masses/nodules, peritoneal thickening, mesenteric nodules/
masses, scalloping of visceral surface by peritoneal nodules and
Krukenberg’s tumor. Cross-sectional imaging affords the best
imaging option with both CT and MR providing excellent results.
Conclusion: This educational exhibit will illustrate the radiological spectrum of peritoneal carcinomatosis with emphasis on anatomical aspects and etiopathogenesis. It is necessary for all practicing radiologists to accurately identify often subtle peritoneal
carcinomatosis due to its far reaching implications on diagnosis
and treatment.
E208. MDCT of Retroperitoneal Air: What Lies Beneath?
Ojili, V.1; Shanbhogue, A.2; Nagar, A.1; Surabhi, V.3; Katabathina,
V.1; Prasad, S.1 1. University of Texas Health Science Center at
San Antonio, San Antonio, TX; 2. The Ottawa Hospital, Ottawa,
Canada; 3. University of Texas Health Science Center at Houston,
Houston, TX
Address correspondence to V. Ojili ([email protected])
Background Information: Retroperitoneal air is an uncommon finding of significant clinical importance. It is most commonly the result of bowel perforation secondary to inflammatory, ischemic or neoplastic causes, blunt or penetrating trauma, foreign body, iatrogenic injury or a gas-producing infection
originating in retroperitoneal organs. As the fascial planes of
the retroperitoneum are in continuity with those of the mediastinum through the diaphragmatic hiatus, air from the neck
and the mediastinum can also track into the retroperitoneum
or vice versa. Plain radiographs are the initial modality in evaluation of acute abdomen and can depict retroperitoneal air
and predict the possible cause with CT being the definite
investigation. The purpose of this exhibit is to provide a
detailed review of various causes of retroperitoneal air and to
discuss the role of MDCT in the evaluation of patients with
pneumoretroperitoneum.
Educational Goals/Teaching Points: The goals are to provide
comprehensive review of various common and uncommon
causes of retroperitoneal air; provide an overview of the anatomy of the extraperitoneal fascial planes and the retroperitoneal
compartments, and discuss the role of MDCT in identifying the
likely primary source of retroperitoneal air.
Techniques: Retroperitoneal tissues do not react as acutely and
severely to bacterial contamination as the peritoneal cavity. So it
is not until retroperitoneal gas is recognized on MDCT that
attention is directed to an acute process in the abdomen.
Imaging features of the distribution and localization of the retroperitoneal air provides an important clue to the identification of
the primary source. MDCT is both highly sensitive and specific in
the detection of abnormal gas and is well suited for reliable
depiction of the anatomic location, the extent of the gas and the
underlying cause. The various causes discussed in this exhibit
include the pathologies of retroperitoneal bowel and solid
organs as well as rare conditions including aortitis, necrotic metastatic lymphadenopathy with air and retroperitoneal perforation
of gallbladder.
Conclusion: Though pneumoretroperitoneum by itself is not
dangerous, prompt recognition of its origin is essential to unveil
an underlying serious etiology. Distribution and location of the
retroperitoneal gas on CT provides an important clue to the
identification of the likely source. MDCT plays a major role in
evaluating patients with pneumoretroperitoneum.
E209. When Pieces of the Pancreatic Puzzle Don’t Fit:
Discrepancies Between Multiphasic MDCT, 3D Datasets,
Endoscopic Ultrasound, and Surgery (CME Credit Available)
Shulman, D.; Lockhart, M.; Eloubeidi, M.; Arnoletti, J.; Morgan, D.
University of Alabama at Birmingham, Birmingham, AL
Address correspondence to D. Morgan ([email protected])
Background Information: The only potentially curative treatment for patients with pancreatic adenocarcinoma is complete
surgical resection. Using multiphasic MDCT, the sensitivity for
detection of tumors and positive predictive value for determination of unresectability approach 100%. However, detection of
tumors and accurate staging to properly select surgical candidates remains a challenge in some patients. The purpose of this
exhibit is to demonstrate persistent pitfalls encountered despite
using state-of-the-art pancreatic imaging techniques.
Educational Goals/Teaching Points: Sources of false positive
and false negative interpretations of resectable pancreatic tumors
will be demonstrated, including detection of isoattenuating noncontour-altering tumors or tiny hepatic and peritoneal metastases, as well as inaccuracies in estimation of vascular involvement
prior to or following neoadjuvant therapy. Emphasis will be
placed on relative roles of multiphasic MDCT and MRI of the
pancreas vs. endoscopic ultrasound (EUS), using surgically proven case material. The evolving issue of venous reconstructive surgery and the impact that surgical technique variability has on the
imaging determination of “resectable” vs. “unresectable” disease
will be discussed.
Techniques: “3D surgical planning” pancreatic protocols have
been proposed following the advances in isometric voxel acquisition using MDCT. In addition to standard thin section axial images
acquired during the pancreatic and portal venous phases, these
postprocessed images including thin section maximum intensity
projection coronal and axial reformations, 3D volume rendered
CT angiography and CT venography, as well as curved multiplanar
coronal reformations may help in assessment of tumor stage and
thus more accurate prediction of resectability. We reviewed our
experience enacting a “3D surgical planning pancreatic protocol”
and found inconsistencies between EUS, MDCT, and 3D images;
these case examples will be used to stress the persistent difficulty
in imaging of pancreatic cancer patients.
Conclusion: Knowledge of the potential pitfalls for accurate evaluation of pancreatic cancer patients is critical. This exhibit will
demonstrate these imaging pitfalls encountered despite using
state-of-the-art techniques.
E210. Imaging of Pancreatitis: Prognostic Value of CT Findings
Trout, A.; Elsayes, K.; Ellis, J.; Francis, I. University of Michigan, Ann
Arbor, MI
Address correspondence to A. Trout ([email protected])
Background Information: Pancreatitis has multiple associated
complications and findings that are apparent on CT evaluation.
Several classification schemes have been developed to attempt
to categorize outcomes in acute pancreatitis. In this exhibit, we
will review CT findings of various subtypes and complications of
acute pancreatitis with emphasis on the prognostic significance
of these findings.
247
epidemiology, pathophysiology and public health burden of
acute pancreatitis; briefly review the classification schemes used
to stratify patients with acute pancreatitis; review the CT findings
of various subtypes of acute pancreatitis, including: uncomplicated acute pancreatitis, groove pancreatitis, necrotizing pancreatitis,
and emphysematous pancreatitis, and review complications of
acute pancreatitis including: pseudocyst formation, peripancreatic/pancreatic abscess formation, and vascular complications such
as pseudoaneurysm formation and venous thrombosis. Special
emphasis will be placed on the clinical context and prognostic
significance of these findings to highlight those which are particularly significant.
Techniques: Necrosis is the common pathway for most of the
prognostically significant imaging findings. It is important that
contrast-enhanced CT is employed to identify the presence of
necrosis identified by a lack of parenchymal enhancement following contrast administration. The presence of gas within a peripancreatic fluid collection is a relatively specific sign of super-infection. Hemorrhage and pseudoaneurysm formation are typically
delayed effects of pseudocyst formation and can result in significant blood loss.
Conclusion: Although pancreatitis is a common entity evaluated
by CT, findings of necrosis and infection warrant special attention
due to their clinical significance and association with poor prognosis.
E211. Non-Neoplastic Cysts of the Pancreas (CME Credit
Available)
Molvar, C.; Oto, A. University of Chicago, Chicago, IL
Address correspondence to C. Molvar ([email protected])
Background Information: Cystic lesions of the pancreas encompass a wide spectrum of pathologic entities with variable morphology, clinical behavior and pathogenesis. Familiarity with these
lesions is essential since they are increasingly identified with the
more widespread use and the improved resolution of cross-sectional imaging. Cystic pancreatic masses are broadly classified into
neoplastic and non-neoplastic cysts. Neoplastic cysts are considered malignant or premalignant, except for serous cystadenomas,
which are almost always benign. Conversely, non-neoplastic cysts
have no malignant potential. Management strategies for many
pancreatic cysts are controversial due to their uncertain natural
history and the frequent lack of a preoperative diagnosis. Although
preoperative differentiation of neoplastic and non-neoplastic
lesions is often not possible, awareness with the disease spectrum and key features of cystic pancreatic masses is important.
Educational Goals/Teaching Points: This review describes
the clinical presentation, histology, and imaging findings of nonneoplastic cystic lesions of the pancreas. In addition, treatment
options for several of these lesions are explored.
Techniques: We report the CT and MRI findings of non-neoplastic pancreatic cysts; specifically, pseudocysts, retention cysts,
benign epithelial cysts, abscesses, duodenal wall cysts (diverticula), lymphoepithelial cysts and the recently described mucinous
non-neoplastic cyst.
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Conclusion: Non-neoplastic cystic tumors of the pancreas are
rare lesions, aside from pseudocysts, which are increasingly identified due to the more routine use and improved resolution of
cross-sectional imaging. While an imaging diagnosis is often not
possible, familiarity with the features of these benign lesions is
essential in forming a complete differential and guiding treatment.
E212. Heterotopic Pancreas in Various Locations:
Multimodality Imaging Features with Clinical and Pathologic
Correlation
Lee, J.1; Shin, K.1; Han, H.2; Cho, J.1; Kang, D.1 1. Chungnam
National University Hospital, Daejeon, South Korea; 2. Eulji
University Hospital, Daejeon, South Korea
Address correspondence to K. Shin ([email protected])
Background Information: Heterotopic pancreas (HP) is seen
incidentally in approximately 2-5% of autopsies. The most frequent sites are the stomach and the duodenum. The jejunum is
a less common site. It is rarely seen in the esophagus, mediastinum, gallbladder, omentum, spleen, fallopian tubes, and lymph
nodes. It is usually asymptomatic. However, some patients have
epigastric pain, upper gastrointestinal bleeding, and occasional
gastric outlet obstruction. In a few cases, the complications such
as pancreatitis, pseudocyst, cyst formation, insulinoma, adenoma,
and malignant transformation, have been reported. Sometimes it
is mistaken for a submucosal neoplasm. Therefore, It should be
part of the differential diagnosis for a variety of abnormalities
found at diagnostic imaging.
is to illustrate multimodality imaging features of heterotopic pancreas in various locations with clinicopathologic correlation,
and to understand advantage and limitation of each imaging
modality.
Techniques: Thirty-seven patients (14 women, 23 men; mean
age, 42 years; age range, 6-75 years) with pathologically (n=33)
or clinically (n=4) proven heterotopic pancreas (HP) were identified through a computerized search of radiologic and pathologic
records at our institution from May, 1994 to August, 2008. A retrospective review of radiologic and clinical findings was performed. The locations of HP were as follows: 25 at stomach, six at
duodenum, three at jejunum, two at ileum, and one at urachus.
The clinical presentations were as follows: pancreatitis (n=3),
intussusception (n=1), epigastric pain (n=11) melena (n=2), and
jaundice (n=1). The remaining 19 patients were asymptomatic.
In two cases, HP showed malignant transformation pathologically.
Imaging modalities such as MDCT, upper gastrointestinal series,
hypotonic duodenography, barium enema, Meckel’s scan, MRI
and endoscopic ultrasound were used. We performed a retrospective review of radiologic findings of HP in various locations
with clinicopathologic correlation and review of literature.
Conclusion: This exhibit will enhance the radiologists understanding regarding pathophysiology and radiologic features of
HP. Familiarity with this anomaly, the imaging techniques available for its study, and its variable imaging manifestations may be
useful in making the correct diagnosis.
E213. Severe and Unusual Forms of Acute Pancreatitis:
Spectrum of CT Findings with Emphasis on Complication
Shin, K.1; Lee, J.1; Han, H.2; Cho, J.1 1. Chungnam National
University Hospital, Daejeon, South Korea; 2. Eulji University
Hospital, Daejeon, South Korea
Address correspondence to K. Shin ([email protected])
the normal anatomy and related structures on imaging; illustrate
the array of disease processes affecting the pancreatic groove on
imaging; assess utility of reformatted images; propose an imaging based approach, and understand the role of imaging in management planning.
Background Information: Acute pancreatitis is a self-limited
disease in many patients. At the other end of the spectrum, it is
an unpredictable illness with an appreciable incidence of severe
complications and death. Accurate diagnosis is not easy in some
unusual forms. Early recognition of pancreatitis and its complication is critical, because proper management of the patient
remains a formidable challenge. CT is the imaging technique of
choice for confirming the diagnosis and detecting complication.
Techniques: The exhibit includes normal anatomy; imaging
appearance of various pathologies affecting the pancreas, duodenum, lymph nodes, common bile duct, vascular structures, miscellaneous; imaging modalities, reformatted images and optimal
applications; pitfalls and mimics on imaging; imaging algorithm
to various disease processes, and the role of imaging in management planning.
and assess the imaging findings of acute pancreatitis with
emphasis on its complication in severe and unusual forms, and
illustrate and assess the imaging findings of acute pancreatitis
with emphasis on its complication in severe and unusual forms.
Conclusion: A spectrum of aggressive and nonaggressive pathological processes can affect the pancreatic groove. Imaging has a
potential role to play in differentiating structure of origin and disease processes. Various imaging modalities can be used prudently and optimally to elucidate this gray zone and guide appropriate management.
Techniques: We retrospectively reviewed the imaging findings of
severe acute pancreatitis. CT allows the detection of pancreatic
necrosis, hemorrhage and abscess and demonstrates the spread
of inflammatory process into adjacent retroperitoneal and subperitoneal spaces. Hemorrhagic pseudocyst, pseudocyst mimicking cystic tumor, pseudocyst with calcification are demonstrated.
CT is helpful determining the route of percutaneous drainage of
deeply located pseudocyst. Extensive inflammatory extension
toward adjacent organs (i.e., spleen, stomach, duodenum, colon,
and gallbladder) results in tissue destruction, severe mural
edema, and fistula formation into various sites (mediastinum,
peritoneal cavity, hollow viscus). Unusual form of acute pancreatitis include post-traumatic or endoscopic retrograde cholangiopancreatography, pancreatitis, pancreatitis related to choledochal
cyst and tumor, pancreatitis mimicking carcinoma, and groove
pancreatitis. Other significant complications include biliary
obstruction mimicking common bile duct, cancer, thrombosis in
splenic vein, and splenic arterial aneurysm.
Conclusion: CT is able to delineate the spreading route of
inflammatory process and accurately identify the complications of
acute pancreatitis. In some unusual form, malignancy should be
differentiated. Familiarity with these imaging findings is necessary
for the proper management and thus to avoid catastrophic clinical outcomes.
E214. Imaging Approach to Lesions of Pancreatic Groove
With Radiologic-Pathologic Correlation
Sainani, N.; Catalano, O.; Mino-Kenudson, M.; Forcione, D.;
Sahani, D. Massachusetts General Hospital, Boston, MA
Address correspondence to N. Sainani ([email protected])
Background Information: Pancreatic groove or pancreatoduodenal groove is a narrow potential space bordered by important
structures. A spectrum of aggressive and nonaggressive pathological processes can affect the pancreatic groove. Imaging has a
potential role to play in differentiating structure of origin and disease processes. Imaging can be used prudently and optimally to
elucidate this gray zone and guide appropriate management.
E216. MRI of the Pancreas: State-of-the-Art
Sebastian, S.; Krishnamoorthy, S.; Kalb, B.; Rostad, B.; Li, J.;
Salman, K.; Sharma, P.; Adsay, V.; Sarmiento, J.; Martin, D. Emory
[email protected])
Background Information: Common pancreatic diseases range
from infectious or inflammatory conditions to benign or malignant neoplastic masses. With superior soft tissue detail and high
sensitivity to acute as well as chronic processes, MRI allows the
radiologist to elucidate pancreatic diseases.
Educational Goals/Teaching Points: The goals are to define a
comprehensive MRI protocol for pancreatic imaging; differentiate
acute from chronic pancreatitis and delineate complications of
pancreatitis; understand the features of benign pancreatic masses
on MRI, including masses that require followup imaging, and
identify malignant pancreatic masses, including features that correlate with the histologic diagnosis, and patterns of metastatic
disease.
Techniques: Fast sequences with reproducible and homogenous
fat suppression are vital for pancreatic imaging. Proper timing of
the arterial phase post gadolinium sequences in conjunction with
subsequent multiphasic postgadolinium sequences are integral
to identifying chronic pancreatitis and pancreatic adenocarcinoma. Acute pancreatitis alters the appearance of the pancreatic
parenchyma and surrounding retroperitoneal fat on T2 fat suppressed sequences. Acute complications can be discerned by
similar inflammatory changes. Metastatic disease to the liver has
characteristic appearances that often correlate with the type of
pancreatic malignancy. Vascular encasement limits surgical treatment options for pancreatic adenocarcinoma.
Conclusion: With superlative soft tissue contrast, fast updated
MRI techniques, and a comprehensive protocol, MRI can delineate pancreatic diseases with high sensitivity and reproducibility.
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E218. Multimodality Imaging of the Pancreas Transplant: A
Pictorial Review of the Expected Postoperative Imaging
Appearance and Complications
Downey, R.; Dillman, J.; Elsayes, K.; Bude, R.; Platt, J.; Francis, I.
University of Michigan Health Center, Ann Arbor, MI
Address correspondence to R. Downey ([email protected].
edu)
Background Information: A growing number of pancreas transplantations are being performed in the United States for the
treatment of insulin-dependent diabetes mellitus. Consequently,
the radiologist must be well-acquainted with the normal imaging
appearance of the post-transplant pancreas along with the spectrum of possible transplant-related complications.
Educational Goals/Teaching Points: To discuss the utility of
various imaging modalities in the assessment of the post-transplant pancreas and to provide representative examples of normal
and abnormal postoperative radiological findings.
Techniques: Indications for pancreatic transplantation along with
transplantation surgical technique are reviewed. The various
imaging modalities used to evaluate pancreas transplants as well
as the indications for each are discussed. The uncomplicated
post-transplantation appearance of the pancreas by ultrasound,
CT and MRI is described. Radiological findings of post-transplantation complications, including graft vascular thrombosis, graft
vessel compression, graft rejection, peritransplant fluid collections, pancreatic duct anastomotic leak/pseudocyst formation,
pseudoaneurysm and post-transplant lymphoproliferative disorder are also provided.
Conclusion: Pancreatic transplantation has become more commonplace over the past several decades, and as such, familiarity
with the expected postoperative graft appearance as well as possible transplant-related complications is increasingly important.
Ultrasound, CT and MRI are useful in the evaluation of pancreas
transplants.
E219. Pancreatic Cancer: A Review of the Radiology of
Diagnosis, Staging, and Treatment (CME Credit Available)
Schabel, A.; Shaaban, A. University of Utah, Salt Lake City, UT
Address correspondence to A. Schabel ([email protected].
edu)
Background Information: Pancreatic cancer is the fourth leading cause of cancer mortality in the United States with 34,290
fatalities in 2008. Additionally, with a five year survival rate of less
than 5%, it has one of the worst prognoses of any cancer secondary to the generally advanced stage at the time of diagnosis.
Radiology plays an essential role in prompt diagnosis, staging,
and therapy monitoring. This presentation will provide a review
of the regional anatomy, pathophysiology, diagnosis, staging,
management, and therapy of pancreatic adenocarcinoma.
the regional anatomy; pathophysiology of pancreatic adenocarcinoma; radiological methods and findings in the diagnosis and
staging (CT, MRI, PET-CT) of pancreatic adenocarcinoma; routes
of disease spread (local invasion, lymphatic, hematogenous,
intraperitoneal); specifics of disease staging; therapy based on
disease staging, and complications related to disease and/or
therapy.
250
Techniques: The exhibit will describe the location of the primary
neoplasm within the pancreas (head, neck, body, tail, and/or
uncinate); enhancement characteristics on contrast-enhanced
MRI and CT; vascular involvement (portal vein, superior
mesenteric vein, splenic vein, hepatic artery, celiac axis, superior
mesenteric artery, gastroduodenal artery) and the relationship to
surgical respectability; invasion of adjacent organs (common bile
duct, stomach, duodenum, colon) and the relationship to surgical
respectability, and metastatic spread (liver, lungs, lymph nodes,
intraperitoneal).
Conclusion: Pancreatic adenocarcinoma is a significant cause of
cancer morbidity and mortality in the United States. Radiology
plays an important role in the team approach to prompt diagnosis, staging, and approach to therapy. Knowledge of the typical,
as well as atypical, radiographic findings of disease and their
impact on therapeutic decision making is a necessary skill for
practicing radiologists.
E220. PET-CT of the Pancreas: Lesion Detection,
Characterization, Surgical Planning and Response
Assessment
Cronin, C.; Catalano, O.; Blake, M.; Mueller, P.; Sahani, D.
Massachusetts General Hospital, Boston, MA
Background Information: The goals are to provide an educational and pictorial review of the PET-CT imaging manifestations,
distribution and classification of pancreatic malignancy namely
pancreatic adenocarcinoma, metastasis, lymphoma, islet cell
tumors, and less common pancreatic malignancies such as intraductal papillary mucinous neoplasms, and to illustrate and
describe PET-CT’s impact on surgical planning and disease
response assessment of these pancreatic malignancies.
Educational Goals/Teaching Points: PET-CT has revolutionized
disease understanding, disease assessment, staging, treatment
and response assessment. In this pictorial review we consider the
range of neoplastic pathologies that may be detected by this
imaging modality and review their clinical, pathological and PETCT imaging manifestations. We discuss differentials where appropriate, in particular in differentiating the various pancreatic malignancies.
Techniques: Through our institutional experience and a review
of literature we will provide a diverse review of PET-CT’s role in
pancreatic disease diagnosis and management.
Conclusion: The important factors of better disease staging and
more accurate response assessment offered by PET-CT imaging
allows for more appropriate disease management and treatment
of pancreatic disease. We provide an interesting, informative and
concise radiological guide.
E221. Pelvic MRI for Perineal Crohn’s Disease: A Pictorial
Essay (CME Credit Available)
Labat, E.; Ballester, G.; Colon, E.; Gomez, A.; Devesa, N.; LopezAlvarez, Y. University of Puerto Rico, Guaynabo, PR
Address correspondence to G. Ballester ([email protected])
Background Information: Crohn’s disease (CD) is a chronic,
transmural inflammatory process of the gastrointestinal tract. The
most common perineal manifestations are perianal fistulas and
abscesses. In up to 25% of patients, fistulas may precede the
intestinal manifestations. MRI with its high soft tissue contrast,
multiplanar capabilities and spatial resolution, is the most specific and sensitive tool for the diagnosis of perineal complications in
fistulizing Crohn’s disease. MRI can reveal the location, extent,
and severity of the inflammatory reaction. Assessment for the
presence and severity of perianal fistulas in Crohn’s disease is
important for patient management and prognosis. The purpose
of this exhibit is to review the anatomy of the pelvic floor and
perineum; described an MRI protocol for the evaluation of the
pelvic floor and perineum in patients with CD in a 1.5T magnet,
and emphasize the role of MRI for the demonstration of perineal
complications in CD.
Educational Goals/Teaching Points: The complex pelvic floor
anatomy can be accurately evaluated with MRI. Pelvic MRI is the
most useful imaging technique for accurate assessment of perineal CD. Pelvic MRI plays a major role in the diagnosis and classification of fistulas in CD, which is used to guide therapeutic
interventions and is very useful for prognosis.
Techniques: The exhibit will include a brief discussion of the
pathophysiology in perineal Crohn’s disease; a description of the
pelvic floor MRI protocol for the evaluation of perineal CD; a
review the anatomy of the pelvic floor and the perineal compartments, and a review the classifications of perianal fistulas and its
MRI correlation.
Conclusion: The role of MRI to evaluate perineal disease activity
in CD has been investigated extensively, as MRI has intrinsic
advantages over other techniques, including noninvasiveness, the
absence of ionizing radiation and a superb contrast resolution.
Noncontrast and contrast-enhanced MRI evaluation of the pelvic
floor and perineal region can define the localization and extent
of fistulas. MRI can accurately show the pelvic and perineal complications of CD and help to establish the best patient management. Ultimately, radiologists should have a thorough knowledge
of the pelvic floor anatomy and the common MRI findings in
perineal CD.
58.2 years) with 25 SHs (size range: 0.8-10.1; mean: 2.2 cm)–
confirmed by splenectomy (n=2), CT (n=18) and/or MRI
(n=13)–evaluating baseline and contrast-enhanced findings of
each lesion in comparison with adjacent spleen parenchyma.
Results: At baseline US, 19/25 (76%) lesions showed homogeneous echo texture, mainly hyperechoic (n=14). In all cases
round contours were observed with well-defined borders in
24/25 (96%) SHs. Color-Doppler imaging did not show any signal in 20/25 (80%) hemangiomas. At CEUS, nine out of 25 SHs
showed an isoechoic appearance throughout the vascular phase;
two out of 25 were hypoechoic in arterial phase becoming isoechoic in the remaining phase, whereas one out of 25 SH was isoechoic in the arterial phase but became hypoechoic in portal-venous and delayed phases. Four out of 25 SHs showed a rapid
and complete fill-in in the arterial phase, but appeared isoechoic
(n=2) and hypoechoic (n=2) in delayed phase respectively. Two
out of 25 SHs showed peripheral hyperechoic nodules in the
arterial phase, followed by progressive centripetal fill-in. Finally,
seven out of 25 hemangiomas appeared constantly hypovascular.
Conclusion: When a splenic mass is discovered during an US
performed for other reasons, in the absence of history of cancer,
a primary benign vascular neoplasm should be considered and
hemangioma is the most common focal splenic lesion. At CEUS,
the majority of SHs presents contrast-enhancement patterns similar to that of liver hemangiomas.
E223. Submucosal Tumors of the Stomach: Differentiation of
Gastric Schwannoma from Gastrointestinal Stromal Tumor
With CT
Choi, J.1; Choi, D.1; Liu, W.2 1. Samsung Medical Center, Seoul,
South Korea; 2. Wooridul Spine Hospital, Seoul, South Korea
Address correspondence to C. Jin Wook ([email protected])
Objective: The goal is to describe CT findings of gastric schwannoma (GS) and determine characteristics that distinguish GS
from gastrointestinal stromal tumor (GIST).
Materials and Methods: A total of 130 patients who underwent
contrast-enhanced CT and were confirmed to have GS (n=5) or
GIST (n=105) were assessed retrospectively. Two experienced
radiologists reviewed CT findings of those patients in consensus.
The size, contour (round or lobulated), surface (regular or irregular), location with respect to the bowel wall (intraluminal, mixed,
or exophytic), enhancement degree (poor, moderate, or well),
enhancement pattern (homogeneous or heterogeneous) were
documented. We also evaluated for the presence of necrosis,
hemorrhage, calcification or ulceration.
Objective: The goal is to illustrate contrast-enhancement patterns of splenic hemangiomas (SH) at contrast-enhanced ultrasound (CEUS).
Results: There were significant differences in surface and location with respect to the bowel wall between GS and GIST.
Irregular surface is seen in no patient (0%) with GS and 22
patients (21.4%) with GIST, respectively. Intraluminal growing
masses were seen in no patient with GS (0%) and 24 patients
(23.3%) with GIST, respectively. There were no significant differences in size, contour, enhancement degree, enhancement pattern, presence of necrosis, hemorrhage, calcification or ulceration
between GS and GIST.
Materials and Methods: Two experienced radiologists retrospectively reviewed baseline and sulphur hexafluoride-enhanced
ultrasound (US) of 25 patients (14 women, 11 men; mean age:
Conclusion: GS and GIST showed similar imaging findings.
Location with respect to the bowel wall and surface irregularity
may helpful to differentiate GS from GIST.
E222. Role of Contrast-Enhanced Ultrasound in the
Assessment of Splenic Hemangiomas
Bartolotta, T.; Taibbi, A.; Galia, M.; Lo Re, G.; La Grutta, L.; Bova,
V.; Midiri, M.; De Maria, M. University Hospital, Palermo, Italy
Address correspondence to A. Taibbi ([email protected])
251
E224. Gastrointestinal Carcinoid Tumors and Mesenteric
Abnormalities: The Spectrum of Radiological Appearances
Bharwani, N.; Druce, M.; Grossman, A.; Reznek, R.; Rockall, A.
Barts and The London NHS Trust, London, United Kingdom
Address correspondence to N. Bharwani (nishatbharwani@gmail.
com)
Objective: One of the hallmarks of mid-gut carcinoid tumors is
the occurrence of fibrosis both locally and distant from the primary tumor. In the mesentery this can result in a marked desmoplastic reaction. Fibrosis can also occur at other sites, for example, the retroperitoneum, pleura, skin and cardiac valves. The etiology of carcinoid fibrosis is thought to involve serotonin probably via the 5HT2B receptor and downstream pathways. Although
features of carcinoid heart disease have been well documented,
the prevalence and clinical significance of intra-abdominal fibrosis has been reported in very few series. Our study aims to evaluate this further.
Materials and Methods: We included all patients with mid-gut
carcinoid tumors and available imaging over the past eight years.
Notes were reviewed for demographic characteristics, history of
small bowel obstruction and biochemical investigations. The
available imaging was reviewed for mesenteric abnormalities, in
particular those characteristically associated with carcinoid
tumors. Where imaging of other sites was also available the
occurrence of extra-abdominal fibrosis was sought.
Results: Thirty-two patients were included in the study, 16 men
and 16 women. Sixteen patients (50%) had a mesenteric mass.
The mass was associated with coarse calcification in seven
patients, surrounding soft tissue stranding in 11 patients and
“indrawing” of tissues in nine patients. Five of the 16 patients
had all three of these associated features. One further patient
had soft-tissue stranding without a visible mass. Eleven of 32
patients (34%) had small bowel thickening and one had small
bowel separation. Two patients had a “misty” mesentery and two
patients had early retroperitoneal fibrosis. Three patients had
incidental evidence of extra-abdominal fibrosis (pleural thickening). In 27 of 32 patients (78%), imaging confirmed the presence
of liver metastases. There was no correlation of mesenteric
involvement with gender or with mean 24-hour urinary 5-hydroxyindole acetic acid value. Of the patients with radiological fibrosis, 31% had a history of small bowel obstruction, in comparison
to 7% in the group without fibrosis (p>0.05).
Conclusion: Intra-abdominal fibrosis is a hallmark of mid-gut
carcinoid and can be detected radiologically in approximately
50% of patients. This is more common in association with a previous clinical presentation of small bowel obstruction.
E225. Gastrointestinal Stromal Tumors: A Review of the
Imaging Findings
Knox, M.; Beddy, P.; Murphy, G.; Ryan, J.; McDermott, R.; Meaney,
J. St. James’s Hospital, Dublin, Ireland
Address correspondence to M. William ([email protected])
Background Information: Gastrointestinal stromal tumors
(GISTs) are mesenchymal tumors arising from the muscularis
propria layer, which can occur throughout the gastrointestinal
(GI) tract. They comprise less than 1% of all GI tumors. GISTs
commonly arise in the stomach, small intestine and colon. Less
common sites include the esophagus and mesentery.
252
Educational Goals/Teaching Points: The goal is to illustrate
the imaging characteristics of GISTs across the range of imaging
modalities and describe in detail the use of embolization in the
treatment of GIST.
Techniques: We have performed a retrospective review of more
than 45 cases of GIST over a ten-year period. Cases of GIST arising in the esophagus, stomach, small intestine and colon are discussed. The typical imaging characteristics on CT, MRI, ultrasound
and barium studies are reviewed. We also present a case of a
rare duodenal GIST embolized with micro-particles.
Conclusion: GISTs are well demonstrated using a number of
imaging modalities. These can be used both for initial diagnosis
and staging and for follow-up. In addition, interventional radiology plays a role in the active management of some cases of GIST.
E226. Imaging Evaluation for Internal Hernia in
Laparoscopic Roux-en-Y Gastric Bypass Patients – A
Difficult but Essential Diagnosis (CME Credit Available)
Umphrey, H.; Lockhart, M.; McArthur, T.; Clements, R.; Robbin, M.;
Canon, C. University of Alabama at Birmingham, Birmingham, AL
Address correspondence to H. Umphrey ([email protected])
Background Information: Obesity is an important public health
problem in the United States and is associated with significant
morbidity. Surgical approaches to therapy, bariatric procedures,
are routinely used to treat patients with morbid obesity (body
mass index [BMI] greater than 40 or BMI>35 with comorbidity).
Internal hernia after laparoscopic Roux-en-Y gastric bypass
(LRGB) is an uncommon but clinically significant complication, as
it can progress to volvulus and small bowel infarction. It is more
common after LRGB as opposed to open procedures. It is a challenging diagnosis both clinically and with imaging, and ideally
should be identified before patients present with obstruction to
assure best outcome.
pertinent abdominal anatomy post LRGB; prescribe appropriate
imaging evaluation of these patients; list complications after
LRGB, and analyze imaging findings associated with internal
hernia.
Techniques: CT findings of internal hernia post LRGB include: 1)
swirled appearance of the mesenteric fat or vessels at the
mesenteric root, 2) clustered loops of small bowel, 3) small
bowel obstruction, 4) mushroom shape of herniated mesenteric
root with crowding and stretching of the mesenteric vessels, 5)
round shape of the herniated mesenteric fat closely surrounded
by bowel loops, 6) small bowel other than duodenum passing
posterior to the superior mesenteric artery, and 7) distal jejunal
anastomosis located in the right aspect of the abdomen.
Conclusion: Internal hernia is an ominous complication of
LRGB; therefore, it is essential to have a commanding knowledge
of the postsurgical anatomy and be skilled in identification of the
axial imaging signs of internal hernia unique to this patient population.
E227. The Roux-en-Y Gastric Bypass: Normal Anatomy and
Complications; A Comparison of Operative and Radiographic
Findings (CME Credit Available)
Cardoza, S.; Tsai, L.; Angus, L.; Scarmato, V. Nassau University
Medical Center, East Meadow, NY
Address correspondence to S. Cardoza (supriyacardoza@yahoo.
com)
Background Information: Morbid obesity is one of the common and debilitating health problems in the United States. The
increasing prevalence, especially in a younger age group, and
associated increased morbidity and mortality, continues to have a
significant impact on overall healthcare costs. Nonsurgical treatments like education, diet, exercise, and pharmacological intervention have had disappointing results. Bariatric surgery has
emerged as a reliable method of weight reduction. Roux-En-Y
gastric bypass surgery, introduced by Mason and Ito in 1967, has
seen an exponential increase in the number of procedures performed. It is now imperative for the radiologist to become familiar with normal postsurgical anatomy and the spectrum of possible complications.
Educational Goals/Teaching Points: Our goals in this presentation are to correlate key surgical anatomy of the most common
bariatric surgery, the Roux-En-Y gastric bypass, using intraoperative photographs with the radiologic findings on MDCT upper
gastrointestinal studies. We will also illustrate the spectrum of
postoperative complications of this surgery.
Techniques: We will illustrate key surgical steps of Roux-en-Y
gastric bypass surgery; the gastric reservoir creation, Roux limb
creation, gastrojejunostomy anastomosis, and distal Roux to biliopancreatic limb anastomosis. Both intraoperative photographs
and post operative radiological images will be used to correlate
the normal post surgical anatomy. We retrospectively reviewed
400 Roux-en-Y gastric bypass surgeries performed at our institution for postoperative complications, both immediate and long
term. We demonstrate examples of anastomotic leaks, strictures,
marginal ulcers, acute gastric distention, gastrogastric fistulas,
small bowel obstruction and internal hernias.
Conclusion: With the steadily increasing number of bariatric surgeries performed in the United States, the probability of a radiologist encountering a postoperative patient, either in routine or
emergency settings, has similarly increased. It is essential to
understand the normal postsurgical anatomy, clinical course and
common complications so as not to misinterpret radiological
examinations. Understanding the surgical process will allow the
radiologist to better understand the normal anatomy, diagnose
complications and communicate with the referring clinicians.
E228. Laparoscopic Gastric Banding: Techniques,
Complications, and Imaging (CME Credit Available)
Ott, D.; Oliphant, M.; Fernandez, A. Wake Forest University
Medical Center, Winston Salem, NC
Address correspondence to D. Ott ([email protected])
Background Information: Obesity has become an epidemic
health problem and bariatric surgical procedures are now being
performed commonly and at increasing frequency. In addition to
historic surgeries for obesity, the current spectrum of procedures
includes Roux-en-Y gastric bypass, laparoscopic adjustable gastric
banding, vertical-banded gastroplasty, gastric sleeve bypass, and
lesser used surgical procedures. Laparoscopic adjustable gastric
banding is being performed increasingly in the United States
since FDA approval in 2001.
the epidemic problem of obesity and the surgical options available; describe the technical details of laparoscopic adjustable gastric banding; identify the early and late complications of adjustable gastric banding, and review the role of imaging in patients
following gastric banding.
Techniques: At our institution, laparoscopic adjustable gastric
banding has become a popular alternate to other bariatric surgical procedures. Gastric banding is a pure ‘restrictive’ procedure,
and the degree of restriction can be easily altered or the band
removed, if necessary. In this exhibit, the indications and techniques of laparoscopic adjustable gastric banding are discussed
and illustrated. The normal appearances of gastric banding are
shown on plain abdominal imaging, and on standard contrast
and CT examinations. In addition, potential early and late complications are reviewed and the role of imaging in identifying and
managing these problems is discussed and illustrated.
Conclusion: Laparoscopic adjustable gastric banding is one of
the newly approved bariatric ‘restrictive’ surgeries in the United
States. The procedure has gained in popularity in recent years,
but is not without potential complications. Radiologic imaging
plays an important role in evaluating patients following gastric
banding to assess both normal and abnormal anatomy.
E230. The “O” Sign, a Helpful Tool in the Diagnosis of
Laparoscopic Gastric Band Slippage.
Pieroni, S.; Sommer, E.; Burch, M.; Tkacz, J. Boston University
Medical Center, Boston, MA
Address correspondence to S. Pieroni ([email protected])
Objective: The purpose of this scientific exhibit is to describe a
sign on plain film radiography for gastric band slippage, a known
complication of the laparoscopic adjustable gastric banding surgery and to emphasize the importance of this finding to radiologists and clinicians. Materials and Methods: We reviewed the radiological findings
in 55 consecutive patients who underwent the laparoscopic gastric banding surgery. Between March, 2007 and September, 2008,
four patients were diagnosed at our institution with gastric band
slippage. All patients underwent a barium upper gastrointestinal
(UGI) examination at the time of presentation to the emergency
room. Based on radiographic findings and/or clinical concern, all
patients were explored in the operating room.
Results: On the initial scout abdominal plain film image, all four
of the patients with surgically proven gastric band slippage demonstrated an “O” shaped configuration of the gastric band, (the
“O” sign). In all 4 cases, a baseline UGI examination was available for comparison. In all of these cases, the “O” configuration of
the slipped gastric band was a change from the proper band
position, a rectangular appearance with the long axis of the band
oriented at an acute angle with respect to the spine.
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Conclusion: As laparoscopic adjustable gastric banding surgery
becomes increasingly used, more and more patients are presenting to the emergency room with complications of the procedure,
particularly as a result of slippage of the gastric band. As the consequences of slippage may require acute surgical intervention, it
is imperative that the radiologist be familiar with the surgical
technique and appearance of the correct and incorrect positioning of the gastric band. Identification of the “O” sign on plain film
radiography can potentially aid the radiologist, surgeon or emergency room physician to the early detection of gastric band slippage and appropriate patient triage.
E231. Signs in Gastrointestinal Radiology: An Interactive
Teaching File Part I Plain Film and Barium Studies (CME
Credit Available)
Bloomer, C.1; Hartman, D.1; Hartman, M.2 1. Penn State,
Harrisburg, PA; 2. Allegheny General Hospital, Pittsburgh, PA
Address correspondence to C. Bloomer ([email protected])
Background Information: Metaphorical signs are commonly
used in the day-to-day practice of all aspects of diagnostic radiology. These signs frequently serve as a mnemonic to suggest a
specific diagnosis or limited differential diagnosis.
Educational Goals/Teaching Points: The exhibit is auto-tutorial.
A series of cases demonstrating a sign encountered in gastrointestinal radiology will be presented. This will be followed by an
explanation of the sign, a metaphorical illustration and the most
common diagnosis or differential diagnosis associated with that
sign. Some of the signs will include: bird’s beak (esophagus and
colon), reverse three (esophagus and duodenum), feline esophagus, football, leather bottle, stalactite, Carmen’s meniscus, ram’s
horn, pad, soap bubble, windsock, cloverleaf, hidebound appearance, cobblestone, apple peal, picket fence, bull’s-eye, aneurysmal dilatation, coiled spring, stacked coin, stripe, northern exposure, southern exposure, bowler hat, collar button, apple core,
thumb printing, and double track.
Techniques: The exhibit will include: anatomy (the hollow viscera of the gastrointestinal tract—esophagus, stomach, small
intestine, large intestine) and imaging techniques (plain film and
barium studies of the organs listed above).
Conclusion: This exhibit will enable users to familiarize themselves with signs in gastrointestinal radiology as well as a limited
differential diagnosis for each sign.
E232. Postoperative Gastrointestinal Tract: Leaks, Fluid
Collections and Foreign Bodies
Smith, J.; Lockhart, M.; Canon, C. University of Alabama at
Birmingham, Birmingham, AL
Address correspondence to C. Canon ([email protected])
Background Information: The number of gastrointestinal surgeries continues to grow. Patients are increasingly complex and
difficult to clinically evaluate. As a result, imaging has moved to
the forefront of postoperative patient care. Simply diagnosing
postoperative fluid collections is no longer adequate. Imagers
must be facile in postsurgical anatomy, expected imaging findings, and complications.
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Educational Goals/Teaching Points: The goals are to accurately
protocol CT and contrast fluoroscopy examinations in complex postoperative gastrointestinal patients; identify radiographic
findings of postoperative leaks and fluid collections; avoid contrast fluoroscopy pitfalls, including failure of adequate patient
positioning, and accurately identify foreign bodies.
Techniques: Protocoling of imaging studies remains an integral
process in accurate and timely postoperative imaging. Selection
of appropriate examination technique and contrast agent is
imperative. In contrast fluoroscopy, the importance of patient
positioning and repositioning cannot be underscored enough.
Conclusion: The radiologist’s role in the increasingly complex
postoperative patient continues to grow. If we are to remain integral in this process, we must provide timely, accurate imaging
diagnoses.
E233. Spectrum of Findings on Defecography Using High
Quality Digital Fluoroscopy
Ruma, J.; Al-Hawary, M.; Kaza, R.; Liu, P.; Cohan, R.; Weadock, W.;
Sonda, P. University of Michigan, Ann Arbor, MI
Address correspondence to M. Al-Hawary ([email protected])
Background Information: Observation of the normal and
abnormal findings found during defecography relies on the
dynamic observation of the pelvic structures motion during realtime fluoroscopy in order to make the appropriate diagnosis.
Both radiologic diagnostic observation and communication of the
abnormal findings to the referring physician is difficult using still
images or even videotape from defecography procedures.
Interpretation efficiency can be enhanced using digital fluoroscopy with improved image quality edited for physician review in a
format suitable for transmission to both the PACS and subsequently through the Internet.
Educational Goals/Teaching Points: The goal is to demonstrate
the normal anatomy and different abnormalities noted on defecography using digital fluoroscopy format for enhanced visualization
of the dynamic findings observed during real-time fluoroscopy.
Techniques: The normal anatomy and different types of abnormal defecation causing either constipation or incontinence as
observed during defecography will be illustrated. Emphasis will be
placed on the relationship and movement of the different pelvic
structures during the different dynamic phases of fecal control and
evacuation. Pathognomonic features of common disorders such
as rectoceles, enteroceles, rectal prolapse and intussusception
which can be identified during defecography will be presented.
Conclusion: Understanding of pelvic motion during defecation is
enhanced using high quality digital fluoroscopic formatting. Such
formatting enhances the detection of pathologic conditions leading to constipation or fecal incontinence, thus improving the ability to communicate findings to the referring physician for subsequent treatment decisions.
E234. MR Imaging of Organ Iron Deposition: Physical
Principles and Clinical Utility
Romano, P.; Stephenson, M.; Hanley, M.; Hardie, A. Medical
University of South Carolina, Charleston, SC
Address correspondence to A. Hardie ([email protected])
the spectrum of iron containing abdominal pathology, and demonstrate the effects of, including the pitfalls caused by, variable
echo-time used for out-of-phase and in-phase MR imaging on
characterizing these entities.
Background Information: Iron deposition in the abdominal
organs occurs in congenital disorders of iron metabolism as well
as in patients receiving chronic blood transfusions, often termed
secondary hemosiderosis. However, it is increasingly being appreciated that patients with liver cirrhosis also can have abnormal
iron deposition, not only in the liver but other abdominal organs.
Some authors suggest that the presence of hepatic iron in cirrhosis may increase the risk for hepatocellular carcinoma and may
need to be treated. The purpose of this educational exhibit is to
present the physical principles of MRI that can allow for not only
iron detection but quantification. Also, case examples will be presented which demonstrate how iron deposition can be quantified in the liver and other abdominal organs.
Techniques: On dual phase gradient echo sequences, a shorter
echo time for out-of-phase imaging can help distinguish between
lipid containing lesions (lose signal on out-of-phase) and iron
containing lesions (lose signal on in-phase). But, if the out-ofphase sequence is acquired with a longer echo time than the inphase sequence, it will be difficult to distinguish signal loss
caused by the coexistence of lipid and water in the same voxel,
and that due to susceptibility effect from iron.
the MR physics of T2* decay and demonstrate how lengthening
of the time to echo (TE) can be used to identify regional field
inhomogeneity caused by metal ion deposition, and present
example cases including: quantitatively mild, moderate, and
severe liver iron deposition (with pathology correlation), examples of iron deposition in the liver, pancreas, and spleen resulting
from primary hemochromatosis, porphyria cutanea tarda, secondary hemosiderosis, and cirrhosis alone, and an example of another type of metal deposition in the liver (manganese).
Techniques: Iron deposition in the abdominal organs results in a
progressively shortened T2* decay which is proportional to the
amount of iron deposited. This deposition can be measured quantitatively by performing a sequence with a progressively lengthened TE. An automated calculation of the T2 slope can be performed for an image slice and a region of interest can be measured. A lower T2 value in that region of interest indicates a greater
amount of iron deposition, which can be correlated with histology.
Conclusion: MRI is able to diagnose and also quantify the degree
of iron deposition in the abdominal organs. Not only can MRI
assess iron deposition in hemochromatosis patients and patients
with iron overload, but the presence of iron deposition in the
abdominal organs in patients with cirrhosis is increasingly being
recognized as clinically important and may require treatment.
E235. Iron Containing Abdominal Pathologies: Exploiting the
Magnetic Susceptibility Artifact on MRI
Morani, A.; Elsayes, K.; Liu, P.; Weadock, W.; Hussain, H.; Caoili, E.
University of Michigan, Ann Arbor, MI
Address correspondence to A. Morani ([email protected])
Background Information: A multitude of abdominal pathologic
entities such as hemochromatosis, siderotic liver nodules, gamna
gandy bodies, and hemorrhagic lesions, as well as paroxysmal
nocturnal hemoglobinuria etc. contain iron. These lesions drop
signal on longer echo time (TE) MRI sequences due to T2* effect,
called as magnetic susceptibility artifact. Magnetic susceptibility
and chemical shift artifacts can be used to diagnose iron and fat
containing lesions, respectively on MRI.
Conclusion: Magnetic susceptibility artifact is useful to diagnose
iron containing lesions on MRI. The echo time used for out-ofphase imaging relative to in-phase is important to distinguish
between lipid-containing and iron-containing lesions.
E236. A Pictorial Tour of Abdominal Manifestations in
Neurocutaneous Syndromes (CME Credit Available)
Shanbhogue, A.1,2; Fasih, N.1; Ojili, V.2; Surabhi, V.3;
Shanbhogue, D.2; Prasad, S.2; Khandelwal, A.4 1. The Ottawa
Hospital, Ottawa, Canada; 2. University of Texas Health Science
Center at San Antonio, San Antonio, TX; 3. University of Texas
Health Sciences Center at Houston, Houston, TX; 4. Post Graduate
Institute of Medical Education and Research, Chandiagrh, India.
yahoo.com)
Background Information: Neurocutaneous syndromes form a
broad group of hereditary or congenital conditions which have
many features in common. They can present with a wide spectrum of abdominal manifestations, ranging from benign incidental findings to aggressive malignancies. Although these syndromes are relatively uncommon and often diagnosed clinically,
they can pose a diagnostic challenge and may lead to complications which may occasionally be fatal. Radiology plays a pivotal
role in the diagnosis when the classical clinical manifestations
are not apparent, in the surveillance of clinically diagnosed
patients and also can alert the clinician to the development of
various unsuspected complications.
the radiology of common and uncommon abdominal manifestations of various neurocutaneous syndromes, and discuss the
imaging features of various complications associated with them.
Techniques: A comprehensive multimodality imaging review of
common and uncommon abdominal manifestations of tuberous
sclerosis complex, neurofibromatosis, Sturge-Weber syndrome
and Von Hippel-Lindau disease in the various organ systems
within the abdomen will be presented with emphasis on differential diagnosis. Abdominal manifestations of tuberous sclerosis
including hepatic and renal angiomylipoma, renal cysts, renal cell
cancer, retroperitoneal lymphangioma, and a variety of gastrointestinal tumors will be presented. Manifestations of Von Hippel
Lindau disease including pancreatic and renal cysts, renal cell
cancer, pheochromocytoma, pancreatic serous cystadenoma,
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neuroendocrine tumors and adenocarcinoma of the pancreas will
be described with attention to lesions that may undergo malignant transformation. Manifestations of neurofibromatosis and
Sturge-Weber syndrome including various complications are also
highlighted.
imaging findings in acute appendicitis, and review limitations of
the exam, and alternative diagnoses to consider in patients with
a similar clinical presentation.
Conclusion: Imaging of the abdomen in neurocutaneous syndromes can be challenging given the wide spectrum and diverse
nature of involvement. Knowledge of the constellation of findings
specific to a syndrome helps in pinpointing the diagnosis.
Regular surveillance and follow-up guides in appropriate and
timely management.
Techniques: MRI is often pursued at our institution if a pregnant
patient presents with right lower quadrant pain worrisome for
acute appendicitis after a negative ultrasound or if suspicion is
high. In a retrospective analysis, 50% of pregnant patients with
suspected appendicitis had positive findings on MRI. Of those
patients that had surgery 80% had confirmed acute appendicitis
on surgical pathology.
E237. Fat Containing Lesions of the Abdomen and Pelvis: CT
and MRI
Jati, A. VA Boston Health Care System, West Roxbury, MA
Address correspondence to A. Jati ([email protected])
Conclusion: Diagnosing and appropriately managing a pregnant
patient with right lower quadrant pain can place one in a diagnostic dilemma. MR imaging sans intravenous contrast during pregnancy has no known harmful effects on the fetus or mother, and
has been proven effective in the diagnosis of acute appendicitis.
Background Information: Demonstration of fat within the
abdominal lesions can significantly narrow the differential diagnosis. CT and MRI can help identify macroscopic fat while MRI is
usually required to identify the microscopic fat.
Educational Goals/Teaching Points: The exhibit will outline the
importance of CT and MRI to identify microscopic and macroscopic fat in the various abdominal lesions; the major differential
diagnosis on the basis of location and imaging findings, and further imaging or followup recommendations.
Techniques: Fat containing abdominal lesions include congenital, inflammatory, post-traumatic and neoplastic lesions. The anatomical location, imaging features and clinical history plays an
important role in narrowing the differential diagnosis. These
lesions can contain macroscopic fat (lipoma, liposarcoma, angiomyolipoma, omental infarct, mesenteric panniculitis, epiploic
appendagitis, pseudolipoma, teratoma, pericaval fat, extramedullary hematopoiesis, and metastases) or intracellular lipid (focal
steatosis, adenoma, focal nodular hyperplasia, regenerative nodules, and hepatocellular carcinoma).
Conclusion: CT and MRI lesions can help in characterization of
fat containing abdominal lesions by allowing specific diagnosis or
narrowing the differential diagnosis.
E238. Right Lower Quadrant Pain in the Pregnant Patient: Is
MRI Appropriate?
Ho, C.; Shin, K.; Carr, T.; Stay, R.; Lambert, D. University of
Virginia, Charlottesville, VA
Address correspondence to C. Ho ([email protected])
Background Information: Appendicitis is the most common
cause of the acute abdomen in pregnant female patients that
requires emergent surgical intervention. The purpose of this
exhibit will be to review normal gastrointestinal anatomy and the
radiographic appearance of appendicitis on MRI in the pregnant
patient.
MR techniques and sequences utilized in evaluation of suspected
appendicitis; review normal gastrointestinal anatomy, and MR
256
E239. Imaging Findings in Patients with Succinate
Dehydrogenase Gene Mutations
Bharwani, N.; Sahdev, A.; Rockall, A.; Srirangalingam, U.; Chew,
S.; Reznek, R. Barts and The London NHS Trust, London, United
Kingdom
com)
Background Information: Mutations in genes encoding succinate dehydrogenase (SDH) are responsible for the majority of
familial paragangliomas and also a significant proportion of “sporadic” cases. Paragangliomas associated with SDH mutations
tend to occur in diverse anatomical locations and have a greater
potential for malignancy. Theories for tumorigenesis include
mitochondrial resistance to apoptosis and failure to inactivate
hypoxic inducible factors resulting in unsuppressed angiogenic
stimulation.
Educational Goals/Teaching Points: The goals are for the
learner to be familiar with the range of appearances of paragangliomas in patients with SDH gene mutations and to understand
how they differ from nonfamilial tumors and to appreciate
diverse distribution of paragangliomas and potential for malignancy associated with this mutation.
Techniques: The distribution of tumors and the various imaging
modalities that can be used in their detection will be discussed
and illustrated in this pictorial review. At our institution screening
of carriers is performed using MRI to avoid use of ionizing radiation. Lesions are typically high signal intensity on T2-weighted
imaging, a feature which is accentuated with the use of fat-suppressed sequences. The tumors are generally intermediate signal
intensity on T1-weighted imaging and enhance avidly with
administration of contrast. Functional imaging using meta-iodobenzylguanidine and PET-CT can be used to detect metastatic
disease and help identify patients suitable for treatment with
radiopharmaceuticals.
Conclusion: This pictorial review describes the spectrum of disease associated with SDH gene mutations and highlights the typical sites of paragangliomas and imaging features.
E240. Lumps and Bumps of the Abdominal Wall: CrossSectional Imaging Findings
Nagar, A.1; Katabathina, V.1; Prasad, S.1; Choudhary, S.1; Raut,
A.2; Chintapalli, K.1 1. University of Texas Health Science Center
at San Antonio, San Antonio, TX; 2. King Edward Memorial VII
Hospital, Mumbai, India
Address correspondence to A. Nagar ([email protected])
approach to diagnosis—an approach to the differential diagnosis
of gastrointestinal disease based on the MDCT reading of the
bowel wall, localizing the segments involved, the extent of
involvement, and associated mesenteric, nodal, and/or peritoneal
involvement, and the correlation with the clinical setting (drug
treatment, time of onset, type and severity of symptoms, use of
antibiotics, laboratory data).
Background Information: Abdominal wall ‘lumps and bumps’
are commonly found in clinical practice and often present early
due to easy detection by the patients themselves. Common
abdominal wall tumors include soft tissue desmoids, lipomas,
neurofibromas, sarcomas, and hemangiomas. Most mesenchymal
tumors of the abdominal wall show a wide spectrum of biological behavior with a high incidence of recurrence. Metastasis to
the abdominal wall is rare and commonly results from iatrogenic
seeding of tumor. Rare primary tumors of the abdominal wall
include lymphoma, fibrous histiocytoma and peripheral nerve
sheath tumors. A wide variety of abdominal wall non-neoplastic
entities that mimic tumors include endometriosis, infections, herniations, and lesions arising from skin and its appendages like
sebaceous cysts. Iatrogenic entities are being increasingly seen as
a result of surgery or percutaneous interventions.
Techniques: The disease categories described in this exhibit
are: drug related inducing the mucosal barrier syndrome, its
pathophysiology and phases; neutropenic colitis (typhlitis); infectious enterocolitis to include pseudomembranous colitis, bacterial, viral, and fungal etiologies; graft-versus-host disease and
spontaneous perforation. Correlation of the imaging findings to
suggest a specific diagnosis or limited differential diagnosis will
be discussed.
and classify common tumors and pseudotumors of the abdominal wall, and discuss the cross-sectional imaging findings of common neoplastic and non-neoplastic lesions of the abdominal wall.
Techniques: Cross-sectional imaging techniques, particularly CT
helps in accurate detection, localization and characterization of
abdominal wall tumors. MR is useful in tissue characterization of
select abdominal wall lesions. Complications of iatrogenic nature
including hematoma, seroma, secondary infection, wall dehiscence, fistula formation are easily recognized using CT imaging.
Secondary spread of the disease process into the peritoneum or
the extraperitoneal spaces are accurately assessed using CT.
Imaging findings dictate institution of appropriate management.
Conclusion: In this exhibit, we discuss the cross-sectional imaging findings of the common tumors and pseudotumors of the
abdominal wall.
E241. MDCT of Gastrointestinal Complications Associated
With a Compromised Host
Oliphant, M.; Ott, D. Wake Forest University, Winston-Salem, NC
Address correspondence to M. Oliphant ([email protected])
Background Information: Recent advances in the treatment of
a variety of hematologic and nonhematologic diseases has lead
to potential cures. The morbidity related to treatment has
decreased, however, complications secondary to drug toxicity,
infections, and graft-versus-host disease persist. The new and
aggressive treatment modalities and their attendant morbidity
and mortality make it essential that the radiologist be familiar
with the potential complications.
Educational Goals/Teaching Points: The MDCT appearance of
the various causes of gastrointestinal disease (for example, drug
related, neutropenic colitis, infectious enterocolitis, and graft-versus-host) will be illustrated. The exhibit will offer a twofold
Conclusion: It is imperative that the radiologist be familiar with
and have an approach to the potential gastrointestinal complications in the compromised patient. Due to the overlap of MDCT
findings of gastrointestinal inflammation an approach stressing
the MDCT findings and correlating them with the clinical setting in which a disorder arises is essential in suggesting a specific
diagnosis or a limited differential diagnosis. E242. Spectrum of Stomach Pathology Demonstrated by MDCT
McSweeney, M.; Siegel, S. Maine Medical Center, Portland, ME
Address correspondence to M. McSweeney ([email protected])
Background Information: With the advent of thinner collimation, negative oral contrast, and multiplanar reformats, MDCT has
improved the evaluation of gastric disease. Findings regarding the
stomach on MDCT are often found incidentally. However, their
clinical relevance can be significant. Through prompt identification
of these abnormalities, appropriate follow-up studies can be recommended. The purpose of this exhibit is to give an overview of
the spectrum of stomach pathology that can be seen by MDCT.
pictorial review of primary and systemic entities that can affect
the stomach, as seen by MDCT, and increase the radiologist’s
ability to recognize these findings. Increased detection will help
the radiologist make appropriate follow-up recommendations,
which will ultimately improve patient care.
Techniques: This educational exhibit showcases a wide variety of
pathologic abnormalities of the stomach as seen by MDCT
through a didactic and image-rich format. Topics include, but are
not limited to benign and malignant gastric neoplasms, metastatic disease to the stomach, inflammatory conditions such as gastritis and peptic ulcer disease, portal gastropathy, stomach findings in polyposis syndromes, stomach involvement in a systemic
vasculitis, and trauma to the stomach. Each case will be accompanied by a detailed description of the image findings.
Conclusion: The advances in MDCT have improved the evaluation of gastric disease. By viewing this exhibit, the radiologist will
become familiar with the spectrum of stomach pathology that is
seen by MDCT, ultimately leading to better patient care.
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E243. Ride the Wave: Doppler Ultrasound Waveforms and
Their Essential Role in the Evaluation of the Abdominal
Vasculature (CME Credit Available)
Stay, R.; Sarti, M. University of Virginia, Charlottesville, VA
Address correspondence to R. Stay ([email protected])
Conclusion: Hernias of the abdomen and pelvis can be easily
identified with cross-sectional imaging. Often they are incidental
findings but hernias can be the etiology of the patients symptoms related to abdominal pain, obstruction and/or gastroesophageal reflux.
Background Information: Although a lot of information can be
obtained from the patency and direction of flow of the abdominal vasculature, the Doppler waveforms also play a key role in
the evaluation of these vessels. The purpose of this exhibit is to
describe the normal and abnormal Doppler waveforms in the
abdomen, with emphasis on the clinical relevance of each.
E245. A Vascular Road Map of Groin Hernias on MDCT
Bayanati, H.; Abdeen, N.; Shabana, W. University of Ottawa,
Ottawa, Canada
Address correspondence to H. Bayanati (hbayanati@hotmail.
com)
examples of normal and abnormal waveforms in several abdominal vessels including those of the liver, spleen, and kidneys, and
in liver and kidney transplants, and show such abnormal waveforms as tardus parvus, reversal of diastolic flow, dampened flow,
monophasic venous flow, turbulence, venous flow of transjugular
intrahepatic portosystemic shunt, pseudoaneurysm and arteriovenous fistulous flow.
Techniques: Proper ultrasound technique, including correct use
of the transducer frequency, gain, field of view, and Doppler
angle, can help optimize visualization of the waveforms. Potential
artifacts, including aliasing, incorrect Doppler gain, incorrect wall
filter, spurious spectral broadening, and vessel motion artifact,
must be recognized. An abnormality within the Doppler waveform may be the only clue to an underlying pathologic process.
Conclusion: Every abdominal imager should have a thorough
understanding of the varied Doppler waveforms of the abdominal vasculature, as they are crucial in diagnosing many disease
processes.
E244. Pictorial Review of Abdominal/Pelvic Hernias
Simpson, W.; Lewis, S.; Aggerwal, A.; Rausch, D. Mount Sinai
Address correspondence to W. Simpson (william.simpson@
mountsinai.org)
Background Information: To illustrate common and uncommon abdominal/pelvic hernias that can be encountered during
routine cross-sectional imaging.
Educational Goals/Teaching Points: Abdominal/pelvic hernias
can be an incidental finding or the cause of abdominal pain.
Hernias can lead to bowel obstruction or other symptoms such
as chest pain and gastroesophageal reflux.
Techniques: The anatomy of the abdominal and pelvic cavities
will be reviewed with attention to the location of hernias. In this
pictorial essay we will describe various common hernias such as
hiatal, inguinal and ventral. More unusual hernias will also be
reviewed to include lumbar, obturator, trochar site, Spigelian
and internal hernias as well as appendicitis in an inguinal hernia.
258
Background Information: Groin hernias are the most common
type of hernias. These might be incidental findings, present with
complication or mimics other diseases. Clinical diagnosis of complicated inguinal hernia can be difficult and due to the complex
anatomy of the groin, specific diagnosis of hernias in this region
on axial imaging can be challenging for an inexperienced observer.
Educational Goals/Teaching Points: In this exhibit we review
the groin anatomy, and the different types of groin hernias. The
diagnostic approach to inguinal hernia will be explained. The aim
is to enhance the radiologists’ confidence to diagnosis, detection
of the type and any related complications of groin hernias. We
will provide a pictorial review of groin anatomy including the
inguinal canal, femoral triangle as well as vascular landmarks
with a simple and easy algorithm for diagnostic approach.
Techniques: Groin hernias are direct inguinal in 1/3 of the cases
and indirect in 2/3 of the cases or femoral hernias. The latter are
much less frequent, have a 10:1 female to male ratio and higher
risk for incarceration (20-25%) compare to inguinal hernias
(3%). The inferior epigastric artery (IEA) and femoral vein are
important anatomic landmarks. If the hernia sac is located lateral
the IEA, the hernia is indirect inguinal hernia. If the hernia sac is
located medial to the IEA, and doesn’t compress on the femoral
vein, the hernia is direct. If the femoral vein is compressed by the
hernia sac, a femoral hernia is present.
Conclusion: The vascular roadmap with an easy two-step algorithm using the IEA and the femoral vein provides a practical
diagnostic approach to femoral and inguinal hernias.
Electronic Exhibits: GU/OB/GYN
GU/Ob/Gyn
E246. Gastrointestinal Tract Involvement in Gynecological
Disease
Balgude, A.; Samaroo, T.; Paspulati, R.; Pinchofsky, H. Case
Western Reserve University, Solon, OH
Address correspondence to R. Paspulati ([email protected])
Objective: The objective is to discuss the gynecologic diseases
that can involve the gastrointestinal (GI) tract, discuss the imaging methods in evaluation of the GI tract in patients with gynecologic disease, and to illustrate the various imaging findings of GI
tract involvement in gynecologic diseases.
Materials and Methods: This is a four-year review from 2004 to
2008 of all patients with various gynecologic diseases who had
GI tract involvement on imaging. The imaging methods included
barium enema, small bowel follow through, CT of the abdomen
and pelvis, PET imaging and MRI. Emphasis is made on crosssectional imaging with multiplanar reconstructions for demonstration of the GI tract in these patients.
Results: There were 57 patients in this study who had secondary
GI tract involvement from a primary gynecologic disease. These
included benign entities such as endometriosis, pelvic inflammatory disease, cervical, endometrial and ovarian cancer. The GI
tract involvement varied from serosal implants without and with
obstruction, strictures, fistulas and adhesions.
Conclusion: GI tract involvement in gynecologic diseases is not
uncommon and can be seen in both benign and malignant diseases. Knowledge of the pathology and imaging features will
help the radiologist in choosing an appropriate imaging technique in arriving at a correct diagnosis.
E247. Imaging Appearance of Primary and Recurrent
Ovarian Cancer and its Mimics
Ma, W.; Pandit-Taskar, N. Memorial Sloan Kettering Cancer
Center,New York, NY
Address correspondence to W. Ma ([email protected])
Background Information: This exhibit will describe radiological
staging of ovarian cancer: imaging findings and contribution of
CT, MRI, ultrasound and PET-CT. It will illustrate imaging findings
of primary and recurrent ovarian cancer and its mimics and discuss the importance of differentiating primary ovarian or recurrent ovarian cancers from other etiologies.
Educational Goals/Teaching Points: The goals are to familiarize radiologists with primary and recurrent ovarian cancer: pattern and spectrum of imaging findings, and their mimics such as
metastatic ovarian diseases, from other primary cancers, or some
benign etiologies; clues on imaging; sample cases and pitfalls. It
is clinically important for the radiologist to correlate with clinical
history, and consider differential diagnoses in order to make a
correct diagnosis. Sometimes, biopsy is necessary when the
imaging findings of primary or recurrent ovarian cancer and its
mimics are overlapping or confusing so that appropriate treatment can be undertaken.
Techniques: CT is the imaging modality of choice for staging
ovarian cancers. The role of MRI in staging ovarian cancer
remains a problem-solving modality. Sonography is excellent in
detection of ovarian masses and ascites. However, it is limited in
assessing peritoneal implants or abdominal lymphadenopathy.
The exhibit will discuss imaging pattern of primary ovarian cancer
spread (local, peritoneal, lymph node, or heterogeneous dissemination) and imaging of recurrent ovarian cancer (pelvic and/or
lymph node recurrence, peritoneal carcinomatosis, and other
organ recurrence including very rare skeletal recurrence).
Metastatic disease involving the ovary from other primary cancers
may mimic primary or recurrent ovarian cancers. Some of the
benign diseases with unusual imaging appearance may also
mimic primary or recurrent ovarian cancer, such as benign metastasizing leiomyoma presenting with a pelvic mass, or endometriosis presenting with abdominal and/or pelvic implants.
Conclusion: Some of the benign diseases with unusual imaging
appearance and metastatic disease involving the ovary from other
primary cancers may mimic primary or recurrent ovarian cancer
on imaging. It is important for the radiologist to make the correct
diagnoses so that appropriate treatment can be undertaken.
E248. CT of the Adrenal Glands in Patients With Congenital
Adrenal Hyperplasia: Correlation With Volume
Measurements and Hormonal Profile (CME Credit
Available)
Avila, N.1,2; Finkielstain, G.3; VanRyzin, C.4; Dwyer, A. 2; Williams,
D.2; Hanna, R.4; Thomas, F.2; Merke, D.3 1. Washington DC
Veterans Affairs Medical Center, Washington, DC; 2. Warren G.
Magnuson Clinical Center, Radiology and Imaging Sciences,
National, Bethesda, MD; 3. Warren G. Magnuson Clinical Center,
Reproductive Biology and Medicine Branch, Bethesda, MD; 4.
Warren G. Magnuson Clinical Center, Bethesda, MD
Address correspondence to N. Avila ([email protected])
Objective: The objective was to evaluate the CT findings in
patients with congenital adrenal hyperplasia (CAH) and correlate
them with volume measurements and levels of 17-hydroxyprogesterone (17-OHP).
Materials and Methods: Twenty-three adult patients (20-57
years, mean 34 years) with CAH had nonenhanced and
enhanced CT of the adrenal glands with 2.5 mm sections using
helical scanners. Adrenal enlargement was assessed from CT
using established criteria that include: increased AP diameter,
thickening, and increased length. Other CT features evaluated
included nodular appearance, and focal masses. Masses were
determined to contain fatty elements if they contained material
that measured less than -10 HU. Image processing was performed using the CT images to obtain volume measurements of
the adrenal glands. The CT findings and volume measurements
were correlated with levels of 17-OHP, a biomarker commonly
used to assess adrenal androgen control.
Results: Ten patients had normal adrenal glands by CT criteria;
volumes were 1.4-6.8 cc, mean 3.8 cc; all had normal levels of
17-OHP. Nine patients had diffusely hypertrophied adrenal glands
without nodularity; their volumes were 4.6-36.2 cc, mean 10.7
cc; 4/9 had normal levels of 17-OHP and their volumes ranged
from 6.0-9.1 cc, mean 7.6 cc; while 5/9 had elevated levels of
17-OHP and their volumes ranged from 4.6-36.2 cc, mean 12.4
cc. Four patients had diffusely hypertrophied and nodular glands;
their volumes were 12.7-32.5 cc, mean 22.8 cc; 1/4 had normal
259
levels of 17-OHP and the volumes ranged from 12.7-13.1 cc,
mean 12.9 cc; while 3/4 had elevated levels of 17-OHP and their
volumes ranged from 19.5-32.5 cc, mean 25.3 cc. Three patients
had fatty adrenal masses; one had a 2.5 cm mass, no evidence
of hypertrophy, and normal 17-OHP; the second patient had had
a 1.5 mm fatty mass, hypertrophied and nodular glands, and elevated 17-OHP; the third patient had six separate fatty masses in
the left adrenal gland that ranged from 0.7-2.5 cm, hypertrophied
and nodular glands, and elevated levels of OHP. Conclusion: Increased volume of the adrenal glands was associated with hypertrophy of the glands and elevated levels of
17-OHP. Volume measurements of the adrenal glands are useful
in the evaluation of patients with CAH and may be helpful during
follow-up to assess the efficacy of therapy. Three of 23 (13 %) of
the patients had adrenal myelolipomas; the increased frequency
may relate to metaplasia of adrenocortical cells and chronic
adrenocorticotropic hormone elevation in patients with CAH.
E249. Adrenal Masses: Imaging Characteristics (CME Credit
Available)
Rekhtman, K.; Fawwaz, R.; Newhouse, J. Columbia University
Address correspondence to K. Rekhtman (katyarekhtman@yahoo.
com)
Background Information: Adrenal masses are identified in up to
5% of CT scans. Characterization of these lesions is of great importance, since adrenal glands are frequently involved in metastatic
and benign disease processes. There are numerous studies that
characterize adrenal lesions with CT, MRI and PET imaging,
attempting to differentiate benign from malignant imaging features.
Educational Goals/Teaching Points: The optimal evaluation of
the adrenal glands depends on the thorough understanding of
the available imaging modalities and knowledge of the imaging
features that differentiate malignant from benign processes.
Imaging findings of normal adrenal and pathologic entities
including adenoma, hemorrhage, cyst, hemangioma, histoplasmosis, hyperplasia, lymphangioma, lymphoma, adrenal cortical
cancer, myelolipoma, metastatic disease, neuroblastoma, pheochromocytoma, pseudotumor and oncocytoma will be addressed.
In addition, imaging algorithms for work-up of adrenal masses
will be discussed.
Techniques: This educational exhibit will review the varied findings depicted on CT, MRI and PET in adrenal gland pathology. In
addition, state-of-the-art of imaging techniques for characterization of commonly encountered adrenal lesions will be reviewed.
Conclusion: Following review of this exhibit, the viewer should
be able to offer a broad differential for both common and
uncommon adrenal lesions; understand the imaging, pathologic
and clinical features of adrenal masses and discuss imaging algorithms for the work up of adrenal masses.
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E250. The Postoperative Kidney: Interpreting Images After
Nephron-Sparing Renal Therapies (CME Credit Available)
Allen, B.; Remer, E. Cleveland Clinic, Cleveland, OH
Address correspondence to B. Allen ([email protected])
describe the procedural steps key to understanding nephronsparing renal therapies, including partial nephrectomy and renal
tumor ablation, and to provide a pictorial review of normal and
abnormal postprocedural imaging findings following nephronsparing renal therapies.
Educational Goals/Teaching Points: Early postoperative imaging after partial nephrectomy is only obtained if a complication is
suspected. Complications after partial nephrectomy or ablation
include acute fluid collections such as abscess, hematoma, collecting system injury, or pseudoaneurysm. After partial nephrectomy, the intensity of follow-up is based on a risk-stratified
approach, based on original tumor stage and other demographic
factors. In some centers, baseline imaging is performed on the
day after tumor ablation, especially if contrast is not given during
the procedure. After tumor ablation, imaging should be performed every 3-4 months during the first year.
Techniques: In partial nephrectomy perinephric changes are
common, but sometimes have unusual appearances, oxidized
cellulose in the operative site may be mistaken for abscess, and
recurrent disease is suspected with new enhancement at the
operative site. In tumor ablation ablated tumors are expected to
decrease in size over time, to a greater degree after cryoablation
than radiofrequency ablation, peripheral rim enhancement may
be seen early and lesion growth and internal enhancement are
suspicious for tumor recurrence.
Conclusion: Nephron-sparing therapies are common techniques
in the treatment of low-stage renal tumors. Complications are
rare, and imaging plays an important role in identifying these
complications and assessing for residual or recurrent disease.
E251. The Radiological Diagnosis and Treatment of
Angiomyolipoma – An Update (CME Credit Available)
Halpenny, D.; Snow, A.; McNeill, G.; Torreggiani, W. Adelaide +
Meath Hospitals Incorporating the National Childrens Hospital,
Dublin, Ireland
Address correspondence to D. Halpenny ([email protected])
Background Information: Angiomyolipoma (AML) is the most
common benign renal neoplasm. They cause significant morbidity
due to their ability to mimic neoplastic disease and their propensity to bleed. The classical imaging findings are well described,
but there have been several recent developments in both the
diagnostic imaging of these tumors and in their radiologicallybased treatment.
Educational Goals/Teaching Points: The classical imaging findings will be briefly outlined. The most recent developments in
the radiological diagnosis and treatment of AML will be discussed
in detail.
Techniques: Regarding the use of MR, in phase/out of phase
MRI using the India ink artifact has been recently used to accurately diagnose AML’s, while various sequences utilizing chemical
shift (double-echo chemical shift FLASH ad chemical shift
GRE) have demonstrated utility in differentiating minimal fat AML
from renal cell carcinoma (RCC). Using CT sections of 1.5 mm
are now able to characterize lesions <1 cm. The use of CT pixel
mapping is more accurate than conventional CT algorithms in
AML diagnosis and CT histogram analysis is more accurate than
conventional methods for differentiation of AML from RCC. CT
angiography is now being used to noninvasively assess for aneurysm formation (a risk factor for bleeding). Power Doppler
increases the diagnostic accuracy of grey scale ultrasound in the
assessment of small AMLs from 21% to 82.4% and contrast-enhanced ultrasound has shown initial promise in the assessment
of AML. Several materials have demonstrated utility in AML
embolization in both the acute and elective setting. Most recently
the combination of particles and coils has allowed the effective
embolization of both the vascular bed and the source vessel.
Radiofrequency ablation is a potential novel technique for elective AML management.
Conclusion: AMLs represent an important diagnostic dilemma.
The most recent developments in the imaging of AML should
allow an accurate diagnosis in the majority of cases. The radiologist should be at the forefront of the management of this disease. E252. Renal Embolization Utilizing Hydrophilic
Microspheres–Experience in 50 Patients
Snow, A.; McNeill, G.; Halpenny, D.; Geoghegan, T.; Torreggiani,
W. Adelaide + Meath Hospital, Dublin, Ireland
Address correspondence to A. Snow ([email protected])
Objective: Renal embolization has become an increasingly common procedure over the last 30 years. Embolization coils have
traditionally been the material of choice when performing renal
embolization. The purpose of this study is to determine whether
renal embolization with microspheres is a viable alternative with
potentially fewer side effects.
Materials and Methods: A total of 52 patients underwent renal
embolization using a combination of 700-900 µm and 900-1200
µm Embosphere microspheres over a period of four years.
Twenty-six patients underwent embolization prior to elective
nephrectomy for renal cell carcinoma (RCC). Twenty-three
patients underwent the procedure for palliation of the symptoms
of metastatic RCC. We also performed embolization on two
patients with polycystic kidney disease (prior to elective nephrectomy) and one patient with renal trauma. Transfemoral aortography was performed in all cases, followed by selective renal angiography using a Cobra catheter. This was followed by flow-directed selective injection of microspheres and a follow-up flush aortogram to ensure occlusion.
Results: No procedure-related complications were encountered.
All patients who underwent renal embolization prior to nephrectomy for RCC subsequently underwent surgery successfully, without the need for blood transfusion. Those patients who were
embolized due to symptomatic metastatic RCC obtained satisfactory palliation of their symptoms, with no patients in this group
requiring patient-controlled analgesia for longer than 24 hours
postprocedure.
Conclusion: Our experience suggests that renal embolization can
be easily, safely and successfully performed using microspheres,
with limited postembolization toxicity.
E253. Renal incidentalomas -The Unusual Suspects (CME
Credit Available)
Vummidi, D.1; Adamson, K.1; Bush, W.1; Lalani, T.2; Dighe, M.1
1. University of Washington School of Medicine, Kirkland, WA; 2.
No Institutional Affiliation
Address correspondence to D. Vummidi ([email protected])
Background Information: The advances in cross-sectional imaging have resulted in better spatial resolution and in the incidental
detection of smaller renal masses or incidentalomas. The prototypical renal mass is the renal cell carcinoma. This exhibit is
devoted to the characterization of the other more unusual masses both neoplastic and inflammatory that can affect the kidney.
Educational Goals/Teaching Points: The goals are to list the
unusual neoplastic and non-neoplastic lesions that can affect the
kidney; briefly describe the imaging technique necessary to produce optimum multimodality images, and describe the characteristic imaging appearances of these lesions to enable an accurate
diagnosis.
Techniques: The vast majority of renal masses are detected incidentally on ultrasound, CT and MRI due to either contour abnormality or abnormal echogenicity/enhancement/signal. The
benign lesions are angiomolipoma, chronic hematoma, xanthogranulomatous pyelonephritis, perinephric abscess, and oncocytoma. The malignant lesions are transitional cell carcinoma,
liposarcoma, spindle cell carcinoma, squamous cell carcinoma,
lymphoma and metastases. Their characteristic imaging appearances will be depicted with histopathological, hematological and
biochemical correlation where appropriate.
Conclusion: The multimodality cross-sectional imaging appearances of unusual renal masses will be illustrated in this educational exhibit. It is important for radiologists to be aware of their
appearances to enable a confident diagnosis in the appropriate
clinical circumstances. The benefits include earlier treatment, reducing unnecessary surgical intervention, shorter hospital
stays and alleviating patient anxiety.
E254. Value of Quantitative and Qualitative MDCT Indices
Differentiating Oncocytoma from Clear Cell Renal Cell
Carcinoma
Bahrami, S.; Sauk, S.; Chow, D.; Raman, S. University of
California, Los Angeles, Los Angeles, CA
Address correspondence to S. Bahrami (simin_bahrami@yahoo.
com)
Objective: The goal is to characterize the differentiating imaging
features of oncocytomas vs. clear cell renal cell carcinoma (RCC).
Materials and Methods: Following IRB approval, query of the
department of pathology database identified 116 oncocytomas
and clear cell RCC in 105 consecutive patients who underwent
preoperative multiphasic single or multidetector helical CT scans
over a seven year period. In consensus blinded readers characterized lesion features including: shape (lobulated, smooth, irregu-
261
lar), hetero- or homogeneous enhancement, calcifications, exophytic growth pattern, size and maximal attenuation in the noncontrast (NC), corticomedullary (CM), nephrographic (N) and
excretory phases (E) (0, 30-45 seconds, 65-85 seconds, and five
minutes postcontrast, respectively). Presence of enhancement of
>100 HU was noted in the CM phase. Absolute and relative contrast wash-out characteristics were calculated.
Results: The majority of oncocytomas (20/24, 83%) had a
smooth shape while 49/92 (53%) clear cell were either lobulated or irregular, p=0.006. No oncocytoma was irregular in shape.
A heterogeneous enhancement pattern was found significantly
more often in clear cell RCC (83/92, 90%) than in oncocytomas
(15/24, 63%), p=0.001. Calcifications were present in 23/91
(25%) clear cell and 2/24 (8%) oncocytomas, p=0.077. The difference in growth pattern and maximal enhancement in CM, N
and E phases was not significantly different. More clear cell RCC
had enhancement >100 HU (80/92, 87%) than oncocytomas
(17/24, 71%), p=0.057.
Conclusion: Clear cell RCC were more likely to have lobulated
contour and heterogeneous enhancement. The presence of calcification and enhancement >100HU was more common in clear
cell RCC than oncocytomas with a trend toward significance.
Clear cell RCC and oncocytomas have significantly different clinical prognosis. The ability to preoperatively distinguish oncocytoma from clear cell RCC can help improve patient care.
E255. Nonvascular Renal Transplant Complications: It’s Not
Always Colorful
Sayah, A.; Allison, S. Georgetown University Hospital, Washington,
DC
Address correspondence to A. Sayah ([email protected])
Background Information: There is disproportionate emphasis
placed on vascular complications of renal transplantation. The
purpose of this activity is to review pathology found on the nonDoppler portion of a transplant study by exposing radiologists to
a series of cases.
Educational Goals/Teaching Points: The goals are to discuss a
variety of nonvascular complications of renal transplantation
including collections, parenchymal disease, as well as collecting
system abnormalities; present ultrasound case images of various
nonvascular renal transplant complications; emphasize the significance of nonvascular renal transplant complications and to
stress that they should be addressed with each renal transplant
evaluation.
Techniques: Cases will be presented in a quiz format. Key differential diagnostic points will be discussed with each case. The list
of cases includes but is not limited to ultrasound images of calculi, pyonephrosis, collections, neoplasm, and ureteral stricture.
Conclusion: With emphasis routinely placed on evaluating
for more common or dreaded vascular complications such as
renal vein thrombosis and renal artery stenosis, non vascular
complications are frequently overlooked. The gray scale portion
of the transplant study is often abbreviated. Complications demonstrated with gray scale imaging are significant and can be
detected, evaluated and followed with ultrasound.
262
E256. Primary Retroperitoneal Masses: RadiologicPathologic Correlation (CME Credit Available)
Choi, Y.; Kim, Y.; Jeong, W.; Cho, O.; Song, S. Hanyang University
Background Information: The retroperitoneum is the space
behind the abdominal cavity without specific delineating anatomical structures. The retroperitoneal space contains the urinary system, greater vessels, uterus and part of gastrointestinal tract in
adipose tissue. Masses arising in retroperitoneal space are rare
but include a broad spectrum of pathologic entities, including
benign and malignant, solid and cystic lesions.
Educational Goals/Teaching Points: The goals are that the
exhibit viewer will understand anatomy of retroperitoneal space,
and recognize the imaging findings that can be used to differentiate various retroperitoneal masses.
Techniques: Retroperitoneal masses are classified into solid and
cystic mass. Cystic masses are divided into pure cystic mass and
cystic mass with nodular portion. Pure cystic retroperitoneal
masses include simple cyst, mucinous cystadenoma, and cystic
lymphangioma. Cystic masses with nodular portion include teratoma, endometrioma, and hematoma. Solid retroperitoneal
masses are divided by vascularity into highly vascularized, intermediate vascularized and poorly vascularized masses. Highly vascularized retroperitoneal masses include extra-adrenal pheochromocytoma. Intermediate vascularized retroperitoneal masses
include leiomyosarcoma, malignant fibrous histiocytoma. Poorly
vascularized retroperitoneal tumor include ganglioneuroma,
liposarcoma, idiopathic retroperitoneal fibrosis, lymphoma, metastatic lymph node.
Conclusion: Differential diagnoses of retroperitoneal mass still
remains a challenge, but certain specific findings are helpful for
diagnosis, further treatment strategy and follow up.
E257. Uncommon Urinary Bladder Tumors; Different Imaging
Features for Urothelial Carcinoma
Kim, Y.; Jeong, W.; Cho, O.; Song, S.; Koh, B. Hanyang University
Background Information: The most common subtype of urinary
bladder tumor, urothelial carcinoma, accounts for about 85% of
all bladder tumors. About 5% of bladder tumors are composed
of nonepithelial tumor including mesenchymal origin tumor.
Most bladder tumors have overlapping clinical symptoms whether benign or malignant. It is critical that radiologists know about
discrete different imaging findings among various bladder
tumors, including rarer subtypes and tumor mimicking lesions.
Educational Goals/Teaching Points: This exhibit will provide an
understanding of the classification of bladder tumors and their
frequency, and characterize image features correlated with cystoscopic and pathological features.
Techniques: We describe the characteristic features of rare forms
of bladder tumors with cystoscopic, pathological and imaging fea-
tures, including squamous cell carcinoma, adenocarcinoma, small
cell carcinoma of epithelial origin; leiomyoma of mesenchymal
origin; metastasis or lymphoma as secondary involvement, and
bladder tumor mimicking lesions such as actinomycosis.
Conclusion: Despite similar clinical features of bladder tumor,
some diseases have characteristic imaging findings and different
growing patterns. According to tumor subtypes, treatment strategy and prognosis is different. Characterization of variable tumors
contributes to distinguishing each subtype, and affects the decision on performing the next imaging technique and adequate
patient management.
E258. Virtual Cystoscopy Using 3D Ultrasound: A New
Dimension in the Evaluation of Urinary Bladder Pathologies
Kantawala, K.; Dahiya, N.; Robinson, K.; Middleton, W.; Teefey, S.
Mallinckrodt Institute of Radiology, St. Louis, MO
Address correspondence to K. Kantawala ([email protected].
edu)
Background Information: While 3D ultrasound (3D US) is commonly used in prenatal imaging and screening, its use for clinical
applications beyond obstetrics is being increasingly explored. The
purpose of this exhibit is to review the current role of 3D US
using volume rendering parameters to look at the bladder lumen.
3D US, virtual cystoscopy as it is commonly called, simulates the
endoluminal view seen in conventional cystoscopy and represents a promising new approach for the noninvasive evaluation
of bladder pathologies.
Educational Goals/Teaching Points: At the end of this presentation, the viewer will be familiar with 1) the basic physics and
technique of acquiring 3D US images of the bladder and, 2) the
3D US imaging features of common bladder pathologies.
Techniques: 3D US virtual cystoscopy provides an endoluminal
image of the urinary bladder without using endoscopy, ionizing
radiation or contrast media. This exhibit will illustrate the basic
physics and technique of acquiring 3D US images of the bladder.
Various rendering parameters available for postprocessing will be
reviewed. 3D images of several pathologically proven lesions will
be shown, including, but not limited to: 1) bladder tumors,
including transitional cell cancer, 2) bladder diverticula, 3) bladder calculi, 4) endometriotic deposits in bladder wall and 5) cystitis. The role of 3D US as a problem solving tool in detecting and
characterizing bladder lesions will be discussed. Artifacts and pitfalls exclusive to 3D US will also be covered.
Conclusion: 3D ultrasound by virtue of its volume rendering
capabilities, facilitates visualization of the urinary bladder lumen
in a manner closely simulating conventional cystoscopy. Virtual
cystoscopy using perspective, volume rendered, 3D data represents a promising new approach for the noninvasive evaluation
of bladder pathologies.
E259. Beyond the “Usual” Pyelonephritis: Imaging of
Uncommon Urinary Tract Infections and Their Mimics
Shanbhogue, A.1,2; Fasih, N.1; McInnes, M.1; Prasad, S.2; Kielar,
A.1; Shanbhogue, D.3 1. The Ottawa Hospital, Ottawa, Canada;
2. University of Texas Health Sciences Center at San Antonio, San
Antonio, TX; 3. No Institutional Affiliation
yahoo.com)
Background Information: Urinary tract infection is the most
common urologic disease affecting an estimate of 600,000
patients per year, the majority being uncomplicated and bacterial
in origin. Only a small percentage of these are of interest to radiologists with suspected pyelonephritis being the most common
indication for imaging in adults. Radiologists are well versed with
imaging of the usual bacterial pyelonephritis and associated
complications. Correlative clinical and laboratory evidence is also
helpful in diagnosing bacterial pyelonephritis. However, tuberculosis, fungal infections, hydatid cysts, emphysematous and xanthogranulomatous pyelonephritis, infected renal cysts and a variety of other urinary bladder and prostatic infections, albeit less
common, can pose diagnostic problems. A substantial number of
noninfectious etiologies also mimic renal infections.
various urinary tract infections apart from the commonly encountered pyelonephritis; identify the distinctive imaging features of
each of these relatively uncommon entities, and describe imaging features that help differentiate them from various noninfectious causes that closely mimic them.
Techniques: In this exhibit, we will present imaging of various
urinary tract infections including renal tuberculosis, hydatid cyst,
fungal infections, a spectrum of emphysematous infections and
xanthogranulomatous pyelonephritis, infected renal cysts and various vesical and prostatic infections. Imaging of their mimics
including but not limited to lymphoma, renal cell cancer, urothelial malignancy, renal necrosis and graft-versus-host disease will
also be presented. Salient features of these entities will be
described which will facilitate reliable and accurate diagnosis.
Conclusion: Uncommon types of urinary infections should be
kept in mind in imaging evaluation of the urinary tract.
Knowledge of the various noninfectious mimics is essential to
avoid misdiagnosis and implement timely management.
E260. Urolithiasis: Imaging Essentials and What the
Urologist Wants to Know (CME Credit Available)
Moin, P.; Dunn, M.; Boswell, W.; Duddalwar, V. University of
Southern California, Glendale, CA
Address correspondence to P. Moin ([email protected])
Background Information: Urolithiasis is a relatively common
entity and can have several different clinical and imaging manifestations. Identification, evaluation and reporting of urolithiasis
and its potential complications are important subjects for the
diagnostic radiologist to be familiar with both due to its prevalence and the need to effectively communicate findings to the
treating urologist.
263
Educational Goals/Teaching Points: This presentation aims to
present an overview of the etiologies of urolithiasis; review imaging findings of urolithiasis and its secondary effects, primarily on
noncontrast-enhanced CT; suggest a standard format for the
reporting of urolithiasis to facilitate relevant and clear communication of findings, and highlight relevant findings which are
important for the urologist to know in order to decide upon further management.
Techniques: With urologist collaboration, this presentation will
include relevant anatomy, including surgical anatomy; a review of
findings and their significance; differentiation of types of calculi
as suggested by imaging findings, and review of treatment
options and factors that determine treatment choice.
Conclusion: It is hoped that this multidisciplinary effort with provide an effective review of the imaging findings of urolithiasis
and its complications, an education and reference tool for radiologists to report findings in a clinically relevant manner to facilitate the determination of appropriate treatment options, and a
foundation for further endeavors to standardize the reporting of
urolithiasis.
E261. Prostate Imaging at 1.5T With Surface Body Coils:
Feasibility of Technique With Potential Widespread Use to
Stage Prostate Cancer
Sarwani, N.; Tappouni, R.; Pagano, M. Penn State Milton Hershey
Medical Center, Hummelstown, PA
Address correspondence to N. Sarwani (doctor@nabeelsarwani.
com)
Background Information: Accurate staging of prostate cancer is
important for deciding treatment options, as well as to predict
prognosis. Also accurate localization of prostate cancer is
now being used in novel approaches for targeted radiation therapy treatment planning. A review of the radiology literature reveals
the majority of prostate MR imaging involve the use of endorectal coils, with the current trend to use 3T magnets. Such requirements may deter prostate imaging from being performed on a
wide spread basis. We demonstrate the feasibility to perform
accurate prostate MR imaging at 1.5T, including advanced imaging techniques such as diffusion-weighted imaging (DWI) and
MR spectroscopy (MRS), using surface body coils only.
the zonal anatomy of the prostate using surface body coils in a
1.5T magnet; delineate prostate cancer staging on MR including
capsular invasion, neurovascular spread, as well as local invasion;
demonstrate the technical feasibility of performing DWI and MRS
of the prostate, using surface body coils in a 1.5T magnet, and
describe the advantages and disadvantages of DWI and MRS in
prostate cancer.
Techniques: The presentation will be an auto-tutorial, with all
cases showing prostate MR images obtained using only surface
body coils. Imaging findings of the various stages of prostate cancer will be shown. Examples will be shown demonstrating the
effective role of DWI as a tool to aid in prostate cancer localization. Similarly, MRS will also be shown, and how the altered citrate/choline ratio, when combined with conventional prostate
264
imaging, can help define malignant lesions. These examples will
be correlated with pathology results.
Conclusion: Accurate local staging of prostate cancer is possible
using surface body coils and a 1.5T magnet. In addition, it is possible to perform advanced imaging techniques, such as DWI and
MRS of the prostate at the same time, without the use of an
endorectal coil. This has the potential to allow more wide-spread
use of MR imaging of prostate cancer, availing tumor localization
and staging information to referring urologists and radiation
oncologists. This information can be used in treatment planning,
and hence can result in improved patient care. E262. Evaluation of Dynamic Contrast-Enhanced MRI for
Detection of Bone Metastasis in Patients With Prostate
Cancer
Oto, A.; Kulkarni, K.; Yang, C.; Karczmar, G.; Stadler, W. University
of Chicago, Chicago, IL
Address correspondence to A. Oto ([email protected].
edu)
Objective: The objective is to evaluate the role of dynamic contrast-enhanced (DCE) MRI in detection of bone metastasis in
patients with prostate cancer.
Materials and Methods: Sixteen prostate cancer patients with
proven bone metastasis (median age 65, ranges from 49 to 64),
were included in the study. T1-weighted axial images were
obtained through the bone metastases and normal bones were
obtained at two second resolution for one minute before and
seven minutes after bolus injection of 0.1 mmol/kg gadodiamide. 2D fast spoiled gradient-echo pulse sequence with TR/TE
=7.8/1.7 milliseconds, flip angle 60° was used. The regions of
interest were placed over bone metastases, normal bone and
muscles by an experienced radiologist. Using a multiple reference tissue method, the contrast agent arterial input function
was estimated and used to calculate contrast agent transfer rate
Ktrans (volume transfer constant between blood plasma and the
extravascular extracellular space (EES)), and Ve (the fractional
volume of EES) applying the Tofts model. Kinetic perfusion
parameters of normal and abnormal bone were compared using
student t-test.
Results: All bone metastases showed significant enhancement,
with median Ktrans=0.079 minute-1 (range from 0.028 to 0.319,
mean 0.100) and median Ve=0.136 (range from 0.055 to 0.234,
mean 0.133). In normal bones, 12 patients showed slightly negative enhancement which might be due to T2* effect. Three
patients showed statistically insignificant and negligible enhancement with Ktrans less than 0.008 minute-1; only one patient
showed strong enhancement in normal bones, with Ktrans 0.080
and Ve 0.0477. Student t-test showed that both Ktrans and Ve
were significantly larger in bone metastases than in normal
bones.
Conclusion: DCE-MRI can easily distinguish prostate cancer
metastases from normal bone marrow. Decreased or lack of normal bone marrow enhancement in the elderly patients facilitates
the detection of bone metastasis from prostate cancer. Our
results also suggest that pulse sequences that separate T1 and
T2* effects of contrast media may improve sensitivity and specificity for detection of bone metastasis.
E263. 3D Doppler Sonography and Dynamic ContrastEnhanced MRI of Recurrent Prostate Cancer Following High
Intensity Focused Ultrasound Therapy
Bard, R.1; Barentsz, J.2 1. Biofoundation for Angiogenesis
Research and Development, New York, NY; 2. UMC St. Raboud,
Nijmegen, Netherlands
Address correspondence to R. Bard ([email protected])
Objective: The goal is to compare the value of 3D power
Doppler sonography (3D-PDS) with dynamic contrast-enhanced
(DCE)-MRI in the evaluation of prostate cancer recurrence following high intensity focused ultrasound (HIFU) treatment.
Materials and Methods: Seventy-nine patients with prostate
cancer treated by HIFU were prospectively scanned with an 18
MHz endorectal probe (GE Healthcare, Milwaukee, WI) with
power Doppler image reconstruction. All patients were scanned
within one week with a 1.5T MRI using large field T1-weighted
images and axial, sagittal and coronal small field T2-weighted
images and DCE-MRI evaluation in the axial plane with computer-assisted time point software. Eighteen patients with Gleason
4 or 5 disease had biochemical recurrence within six months and
were reimaged by 3D-PDS and DCE-MRI. No patients with
Gleason 3 disease had PSA elevations in that time frame.
Results: Four of 18 recurrences were correctly imaged by standard MRI. This is expected due to the signal irregularity caused by
HIFU tissue ablation. Sixteen of 18 tumors were imaged by
3D-PDS and 16/18 were imaged by DCE-MRI. 3D-PDS correlation with DCE-MRI was strong with two patients missed by each
modality.
Conclusion: Noncontrast MRI and gray scale sonography are not
accurate in detecting tumor recurrence in the thermally ablated
prostate. 3D-PDS and DCE-MRI appear equally sensitive in detection of cancer regrowth and offer the possibility of image-guided
biopsy and treatment.
E264. 3T MRI of Prostate Cancer without an Endorectal Coil:
A Radiological-Pathological Correlation (CME Credit
Available)
Sammet, S.; Takayama, Y.; Jia, G.; Wang, W.; Shah, Z.; Dangle, P.;
Jimenez, R.; Patel, V.; Knopp, M. The Ohio State University,
Columbus, OH
Address correspondence to S. Sammet ([email protected])
Objective: The purpose of this study was to correlate preoperative 3T MR imaging of prostate cancer with postoperative pathological results. Discrepant cases and mismatched lesions were
retrospectively analyzed to determine the best imaging sequences for the detection of prostate cancer in-vivo at 3T.
Materials and Methods: Twenty-nine patients (age=46-72
years, mean=57.9 years, average PSA=7.1 ng/ml, average Gleason
score=7) with biopsy-proven prostate cancer were scanned on a
3T MR system (Philips Healthcare, Cleveland, OH) in an 8-channel phased-array coil before surgery. Lesion locations and numbers were assessed on T2-weighted, dynamic contrast-enhancedMRI (DCE-MRI) and ADC maps. DCE-MRI was quantitatively analyzed with in-house software. Preoperative tumor volumes were
measured from axial T2-weighted using medical image processing, analysis and visualization (released by the National Institutes
of Health). After surgery, all prostates were examined by pathologists. Postoperative tumor volumes were calculated from pathological sections of the prostates. Tumor volumes calculated from
the preoperative MRIs and the postoperative pathological measurements were statistically analyzed using a Student’s t-test.
Results: Lesion Locations and Numbers: In 18 of the 29
patients up to small five lesions were not detected by MRI,
because the MRI resolution was not sufficient enough.
Additional discrepancies were seen in lesions in the inner
gland (8/18) and lesions masked by postbiopsy changes (4/18).
In a correlative review with pathology, time to signal-intensity
curves and DCE-MRI parameter color maps were helpful to
detect additional small lesions in seven cases. DCE-MRI helped
to delineate lesions in the inner gland in three of eight patients
and in one of four patients with postbiopsy changes. Tumor
Volumes: Preoperative MR estimations (20.8 ± 16.3) ml and
postoperative pathologic findings (16.6 ± 12.9) ml were significantly different (p<0.01).
Conclusion: Radiological–pathological correlation of prostate
cancer reveals limitations of standard MRI sequences and provides a roadmap for the development of advanced MRI techniques for prostate cancer. Small lesions and lesions in the inner
gland are often not detected even with high-field MRI. Tumor volumes measured on T2-weighted images are often underestimated. Therefore, DCE-MRI might have the potential to better delineate lesions in the prostate and to improve volume measurement
of prostate cancer with parameter color maps. Quantitative
approaches in DCE-MRI can help to improve the radiological
diagnosis of prostate cancer especially for small lesions and
lesions in the inner gland.
E265. Correlation of Dynamic Contrast-Enhanced MR
Imaging with Histopathological Tumor Grade in Prostate
Cancer: Percent Enhancement a Novel Technique
McClure, T.; Margolis, D.; Gomez, A.; Raman, S. University of
Address correspondence to T. McClure ([email protected].
edu)
Objective: The objective is to determine whether strength of
enhancement on DCE-MR can predict the grade of prostate
cancer.
Materials and Methods: IRB approval was obtained prior to
this study. On a 1.5T magnet with endorectal coil, dynamic contrast-enhanced imaging was performed in 23 men with biopsy
proven prostate cancer that then underwent radical prostatectomy. The percent peak enhancement was calculated. The region of
highest tumor grade identified at pathology was then localized
on MR and compared to contralateral normal prostate tissue
using paired student’s t-test. These patients were further stratified
into either Gleason score= 6 or Gleason score >6.
Results: Of the 23 patients evaluated the average value of
enhancement in the region of prostate cancer was 355%, whereas normal prostate cancer was 139% (p<0.001). When comparing low-grade vs. higher grade prostate cancer the average value
of percent enhancement for low-grade disease was 337% and
384% for higher grade disease (p=0.03).
265
Conclusion: Clinical preoperative diagnostic tools are limited in
assessing tumor grade, yet tumor grade determines management
in prostate cancer. On DCE-MRI the maximal percent peak
enhancement correlates with highest tumor grade in prostatic
adenocarcinoma. DCE-MRI may noninvasively help determine
highest tumor grade.
E266. Dynamic Contrast-Enhanced MR Imaging of Prostate
Adenocarcinoma: Novel Application of Wash-In and WashOut Maps–Indicators of High-Grade Disease
McClure, T.; Margolis, D.; Gomez, A.; Raman, S. University of
Address correspondence to T. McClure ([email protected].
edu)
Objective: The objective was to evaluate dynamic contrast-enhanced MRI wash-in and wash-out for the discrimination of lowgrade vs. high-grade cancer.
Materials and Methods: On a 1.5T magnet with endorectal coil,
dynamic contrast-enhanced imaging was performed in 23 men
with prostate cancer who underwent radical prostatectomy.
Contrast wash-in and wash-out color maps were generated on a
dedicated workstation. The region of highest tumor grade identified on pathology was then localized on MR and compared to
contralateral normal prostate tissue using paired student’s t-test.
These patients were further stratified into either Gleason score=
6 or Gleason score >6.
cer as defined by current state-of-art imaging techniques including CT, MR and bone scintigraphy, and to understand pathways
and patterns of disease spread. The exhibit will demonstrate typical and atypical manifestation of disease and discuss the role of
state-of-art imaging techniques on patient management and
treatment decision.
Techniques: This exhibit will illustrate the spectrum of prostate
cancer as defined by state-of-art imaging modalities including the
appearance of primary tumor, local staging, pathways of the locoregional and lymphatic spread, as well as distant metastases.
Both typical and atypical disease presentation will be discussed.
The limitations and pitfalls of these imaging modalities will also
be addressed. Finally, the roles of these state-of-art multimodality
imaging techniques on patient management decision will be
carefully defined based on different therapeutic options.
Conclusion: This exhibit will comprehensively review the radiologic spectrum of prostate cancer in all stages with emphasis on
pathways and patterns of disease spread. Understanding of typical and atypical prostate cancer may facilitate better detection of
disease, accurate diagnosis and optimal treatment.
Results: Focal areas of high wash-in were conspicuous in seven
of 14 patients with Gleason score 6 prostate cancer patients and
eight of nine patients with higher grade disease. This approached
statistical significance (p=0.086). The difference between
Gleason score 6 and higher-grade tumors’ wash-out was significant (p=0.028).
E268. Prostate Cancer Imaging: What, Why, and When
Garcia Figueiras, R.1; Vilanova, J.2; Patel, S.3; Gómez Caamaño,
A.1; Baleato González, S.4; Villalba Martin, C.1; Bermúdez, A.1;
Padhani, A.3 1. Complexo Hospitalario Universitario de Santiago
de Compostela, Santiago De Compostela, Spain; 2. RM Clínica
Girona, Girona, Spain; 3. Paul Strickland Scanner Centre,
Northwood, Middlesex, United Kingdom; 4. Complexo
Hospitalario de Pontevedra, Pontevedra, Spain
Address correspondence to R. Garcia Figueiras (roberto.garcia.
[email protected])
Conclusion: Clinical preoperative diagnostic tools are limited in
assessing tumor grade, yet tumor grade determines management
in prostate cancer. On DCE-MRI wash-out correlates with highest
tumor grade. DCE-MRI may noninvasively help determine highest
tumor grade. Thus, these techniques may be used to stratify
patients with in situ prostate cancer.
Background Information: Appropriate imaging for prostate cancer (PC) patients depends on clinical situation and disease state.
Actually, no consensus exists regarding the use of imaging for
evaluating PC. Improvements in PC diagnosis and treatment will
depend on new imaging modalities such as functional imaging
techniques. E267. State-of-Art Imaging Approach to the Prostate Cancer:
Special Emphasis on the Pattern of Locoregional and
Distant Metastasis (CME Credit Available)
Lee, J.; Dighe, M.; Bush, W. University of Washington, Seattle, WA
Address correspondence to J. Lee ([email protected])
Background Information: Prostate cancer is the second most
common cause of cancer-related death in men. Since more than
25,000 men die of distant metastasis per year, multimodality
imaging including state-of-art CT, MR and bone scintigraphy plays
a major diagnostic role in detecting and defining the extent of
disease. The prognosis and management decisions are based on
the knowledge of true extent of disease. Therefore, the accurate
staging is crucial in determining and planning surgical respectability as well as detecting recurrent or persistent disease.
Educational Goals/Teaching Points: The goals are for the viewer of the exhibit to learn radiographic spectrum of prostate can-
266
the role of different imaging methods in diagnosis, cancer localization, staging, treatment planning, evaluation of tumoral
response, and follow-up in PC; introduce the emerging role of
functional imaging in PC; discuss the functional anatomy of the
prostate and periprostatic area; present the possible role of computer-aided diagnosis (CAD) software in prostate imaging;
present the utility of fusion processing tools for joint analysis of
conventional and functional images, and discuss imaging guidelines in different clinical situations: detection of suspected PC,
staging, and surveillance.
Techniques: Relevant imaging findings are shown with different
imaging techniques: transrectal ultrasonography (US), dynamic
contrast-enhanced US, elastography, CT, MR imaging techniques,
such as diffusion-weighted imaging (DWI), dynamic contrast-enhanced MRI, MR spectroscopy (MRS), and MR-lymphography,
radionuclide bone scanning, and PET-CT. The key points in PC
imaging with these techniques are discussed, including detection
of small cancer foci; central gland tumors; T2 vs. T3 patients; N+
patients; metastatic disease, and treatment planning and tumoral
response evaluation.
Conclusion: The synthesis of anatomic, functional, and molecular imaging techniques will be the key point in the management
of patients with prostate cancer. Improvements in PC diagnosis
and treatment depend on improved imaging, mainly functional
imaging techniques. Advanced functional tools will enable us to
detect earlier stages of PC, identify poor prognosis tumors, detect
central gland tumors, and guide focal therapies.
E270. Sonography of Unusual Benign Intratesticular Masses
Huang, B.; Bhatt, S.; Dogra, V. University of Rochester Medical
Center, Rochester, NY
Address correspondence to B. Huang (brady_huang@urmc.
rochester.edu)
describe the sonographic features of uncommon and common
benign intratesticular pathologies. Some of these will include
congenital adrenal rests, hamartomas, splenogonadal fusion,
tuberculous gummas, vascular lesions, fibrous pseudotumor, sarcoidosis, postradiation fibrosis, and spontaneous intratesticular
hemorrhage. Other common entities such as epidermoids and
benign cystic lesions will also be reviewed.
the clinical and sonographic features of unusual benign intratesticular entities and more commonly encountered benign lesions,
and understand some features that may help distinguish true testicular neoplasms from benign tumor-like entities.
Techniques: After viewing the exhibit, the learner will understand the normal sonographic appearance and anatomy of the
testes.
Conclusion: Unusual testicular pathologies are uncommon, but
may be encountered in clinical practice. Familiarity with these
entities and their clinical presentations may help to avoid more
invasive interventions.
E271. CT Assessment of the Abdominal Fat Distribution in
Endometrial Cancer
Knox, M.; Beddy, P.; Murphy, G.; McMahon, C.; Keogan, M. St.
James’s Hospital, Dublin, Ireland
Objective: The risk of endometrial cancer is 2-3 times higher in
overweight and obese women. Obesity also adversely affects survival in most studies. The aim of this study was to assess the fat
distribution in patients with a new diagnosis of endometrial cancer.
Materials and Methods: Patients with a histologically confirmed
diagnosis of endometrial cancer were included. The visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT) were
calculated from the patient’s initial staging CT scan. The VAT and
SAT were calculated by measuring their respective cross-sectional
area at the level of the L3-L4 intervertebral disc. The technique
used for fat tissue measurements in CT cross-sectional images
has been previously standardized and validated. An age matched
control group was recruited from patients referred for a CT scan
to investigate abdominal pain.
Results: Thirty patients with a mean age of 62, and 30 control
patients were retrospectively assessed. Patients with endometrial
cancer had significantly higher VAT area than the control group
(130 vs. 57 cm2; p<0.01). They also had a significantly higher
SAT area than the control group (265 vs. 145 cm2; p<0.01).
There is however no significant increase in the ratio of VAT to
total adipose tissue (0.33 vs. 0.28) in patients with endometrial
cancer. We also found the VAT area was significantly higher in the
patients presenting with late stage disease (stage 3 and 4), than
in the control group (187 vs. 57 cm2) or the patients with early
stage disease (187 vs. 122cm2).
Conclusion: Obesity is associated with an increased risk of
endometrial cancer. Both subcutaneous and visceral adipose tissue is increased in patients with endometrial cancer. Visceral adipose tissue is increased in patients presenting with late stage disease compared to patients with early stage. This has possible
implications for disease prognosis and future treatment options.
E272. The Many Faces of Endometriosis, Typical and Atypical
Findings. CT, Ultrasound and MRI with Pathological
Correlation: A Pictorial Essay
Onyiuke, I.; Scoutt, L.; McCarthy, S. Yale University Hospital, New
Haven, CT
Address correspondence to I. Onyiuke ([email protected])
Background Information: Endometriosis is the presence of
ectopic functioning within the peritoneal cavity. While this is a
common disease, symptoms may be nonspecific and associated
with considerable morbidity, including pain and infertility.
Educational Goals/Teaching Points: Though the common
imaging findings in endometriosis are well known, there are a
variety of atypical findings which can mislead the radiologist on
ultrasound, CT and MR. Typical locations in the pelvis around the
ovaries and uterus are easy to diagnose but atypical locations like
the rectovaginal septum and caesarian section scar can be more
challenging.
Techniques: Ultrasound, the most easily accessible screening
tool is limited because endometriosis is often nonspecific on
ultrasound. Adhesions and implants on bowel and peritoneal
surfaces may be missed. CT, which may be the first imaging
test performed in women who present with abdominal or pelvic
pain lacks pathognomic features. MRI is more sensitive and specific for atypical manifestations of endometriosis such as glandular endometriosis, adhesions, muscular involvement as well as
complications like rupture and malignant degeneration.
Conclusion: While ultrasound and CT may exhibit nonspecific
findings, it is important to recognize these to guide the clinician
to obtain an MRI which is a more definite test. MRI should then
be carefully reviewed for the more atypical presentations of this
fairly common disease. 267
E273. Recent Imaging and Interpretation Advances in
Diagnostic Workup of Ovarian Cystic Lesions (CME Credit
Available)
Wasnik, A.1; Elsayes, K.1; Caoili, E.1; Platt, J.1; Menias, C.2 1.
University of Michigan Hospital, Ann Arbor, MI; 2. Mallinckrodt
Institute of Radiology, St. Louis, MO
Address correspondence to A. Wasnik ([email protected])
Background Information: The diagnosis of ovarian cystic
lesions continues to represent a daily challenge despite the
recent advances in cross-sectional imaging. Different diagnostic
algorithms in pre and postmenopausal females have been developed over the past decade. These algorithms however, need to
be modified according to recent trends in interpretation of images particularly on MRI, with its current spectrum of pulse
sequences. Particular imaging findings are used to differentiate
benign from malignant lesions. We found, however, that radiologists need to be more familiar with some lesions which can be
quite confusing. For instance, cystadenofibroma which can be
seen as complex ovarian predominantly cystic lesion is often
diagnosed as malignant despite its benign nature.
Educational Goals/Teaching Points: The goal is to discuss the
current diagnostic work up of ovarian cystic lesions. Special
emphasis will be placed on problem solving pathways and interpretation advances of ovarian cystic lesions. Diagnostic algorithms will be discussed and suggested.
Techniques: The exhibit begins with an introduction on techniques and various modalities used for evaluation of ovarian cystic lesions. Spectrum of imaging features of these lesions will be
illustrated. Representative examples of each entity will be presented.
Conclusion: Ovarian cystic lesions are a commonly encountered
entity on imaging. Diagnostic algorithm and utility of various
imaging modalities, with knowledge of the interpretation and
familiarity of the radiologist to these lesions are of paramount
significance in differentiating benign from malignant lesions.
E274. Ovarian Torsion: CT Diagnosis in Children and Adults
Saxon, P.; Luongo, J.; Badler, R.; Katz, D. Winthrop-University
Hospital, Mineola, NY
Background Information: Ovarian torsion is occasionally identified prospectively on CT examinations of the abdomen and pelvis
in girls and women presenting with pelvic pain, where CT (performed either with or without IV contrast) is the initial modality
utilized because a gynecologic condition is not specifically suspected. We have seen multiple patients where this scenario
occurred, in patients ranging from the preteen years to postmenopausal women, and have either established or suggested the
diagnosis prospectively. The purpose of this exhibit is to demonstrate our experience with CT in this situation, to correlate with
subsequent sonographic examinations if performed, and to
review the relevant radiology literature on ovarian torsion.
Educational Goals/Teaching Points: Radiologists may not necessarily suspect ovarian torsion when an abnormal ovary is identified on CT. The spectrum of appearances includes a simple cyst
268
or a mass such as a dermoid without specific evidence for torsion, to a highly specific appearance with multiple peripheral follicles in an enlarged ovary with a twisted appearance of the associated adnexal structures and edema of the adjacent fat. In certain cases the CT findings are all that are needed prior to operative intervention, whereas in other cases emergent sonographic
correlation is very helpful for confirmation. The goals of this
exhibit are to educate the radiologist as to this spectrum as well
as to review the current CT, ultrasound, MR, and clinical literature
on ovarian torsion.
Techniques: Multiple CT examples will be shown from our practice, including simple cysts which led to torsion; torsion without
an underlying lesion (typically in perimenarchal girls); ovarian
dermoids with and without specific evidence for associated torsion; noncontrast CT of ovarian torsion; and ovarian lesions such
as cystadenomas in middle-aged to older women which presented with torsion. Correlative sonographic imaging studies will be
shown, and pitfalls will be discussed, e.g. cases with preservation
of ovarian flow on sonography despite other findings of torsion
on CT.
Conclusion: The radiologist should recognize the spectrum of
appearances of ovarian torsion on CT, as the diagnosis may be
established prospectively in girls and women imaged without an
initial clinical suspicion for this specific diagnosis.
E275. Solid Ovarian Masses: Cross-Sectional Imaging With
Emphasis on MRI
Shanbhogue, A.1,2; Fasih, N.1; Ojili, V.2; McInnes, M.1;
Shanbhogue, D.2; Prasad, S.2 1. The Ottawa Hospital, Ottawa,
Canada; 2. University of Texas Health Science Center at San
Antonio, San Antonio, TX
yahoo.com)
Background Information: The majority of the ovarian masses
(>60%) are epithelial in origin and cystic. Solid masses form only
a small subset. Time and again, radiologists focus on cystic ovarian masses with emphasis on early diagnosis of ovarian malignancy which is well justified. However, solid ovarian masses,
albeit less commonly encountered, can cause serious and sometimes life-threatening complications. Although diagnosis can be
fairly straight forward in some cases, it can be more challenging
when unusual presentations and complications are encountered.
The purpose of this exhibit is to describe the imaging spectrum
of a histologically diverse group of benign and malignant solid
ovarian masses with special emphasis on MRI.
various solid benign and malignant masses encountered in the
ovaries; identify their distinctive imaging features on pelvic MRI
and to define a diagnostic approach; and discuss the imaging
features of various complications associated with them.
Techniques: In this exhibit we present imaging (with emphasis
on MR imaging) of solid ovarian masses including the sex cordstromal neoplasms (fibroma, thecoma and fibrothecoma), germ
cell tumors (teratoma, dysgerminoma, and endodermal sinus
tumors), mesenchymal tumors (leiomyoma), solid epithelial-stro-
mal neoplasms (Brenner tumor) and metastases. Uncommon
manifestations and complications are also highlighted and a
diagnostic approach is defined.
Conclusion: A knowledge of the varied appearances of the wide
spectrum of solid ovarian masses helps in timely diagnosis and
management of these relatively uncommon and usually benign
lesions. One needs to be well versed with characteristic imaging
features of various complications associated with them to initiate
an immediate management.
E276. MR Imaging Features of Ovarian Stromal Tumors
Bharwani, N.; Dilks, P.; Sahdev, A.; Reznek, R.; Rockall, A. Barts
and The London NHS Trust, London, United Kingdom
com)
Background Information: Ovarian stromal tumors arise from
primitive sex cord and stromal components of the ovary and
account for most hormonally active tumors. They comprise
approximately 8% of all ovarian tumors and can be further subclassified according to their histological components. The most
common types are granulosa cell tumors (GCTs), fibrothecomas/
thecomas, and Sertoli-Leydig cell tumors.
the pathophysiology of ovarian stromal tumors, and discuss and
illustrate the characteristic MRI features and secondary signs
associated with the various tumor subtypes.
Techniques: This pictorial review will demonstrate characteristic
MR features of ovarian stromal tumors and associated secondary
signs of excess hormone production, e.g. endometrial hyperplasia. Each subtype of stromal tumor has characteristic imaging features. GCTs are multiloculated cystic masses with variable solid
portions which can be associated with endometrial abnormalities. Fibromas and thecomas are usually solid masses with low
signal intensity on T1- and T2-weighted MRI and a variable
degree of calcification or degeneration. Sertoli-Leydig cell tumors
are generally well-defined, enhancing solid masses with intratumoral cysts of varying sizes.
Conclusion: Knowledge of the clinical signs and characteristic
MR features of ovarian stromal tumors can be used by the interpreting radiologist to differentiate these tumors from the more
common ovarian epithelial tumors. This information can help clinicians to guide further investigation, plan the extent of surgery
and assess prognosis.
E277. Characterization of Undetermined Ovarian Masses
with MRI: Discriminant Imaging Features and Pathologic
Correlation
Missere, M.; Restaino, G.; Occhionero, M.; Cucci, E.; Ciuffreda, M.;
Sallustio, G. Catholic University of Sacred Heart, Campobasso,
Italy
Address correspondence to G. Restaino ([email protected])
Background Information: Preoperative characterization and
determination of a degree of suspicion for malignancy of ovarian
masses (OM) is critical and depends largely on imaging appearance. Ultrasound can usually diagnose and characterize most of
OM, but some cases remain undetermined because of atypical or
a specific appearance. MRI is the best imaging modality for diagnosis and characterization of OM. The purpose of this exhibit is
to describe a systematic imaging approach to correct diagnosis
through depicting discriminant MRI features of OM and their
pathologic counterpart Educational Goals/Teaching Points: The goals are to review
the classification of OM; describe the epidemiology, pathophysiology, and clinical features of OM; demonstrate the utility of MRI
in the diagnosis and characterization of OM; describe MR examination technique for a comprehensive evaluation of OM, depict
and suggest a systematic MRI approach to correct diagnosis
through depicting discriminant MRI features of OM and their
pathologic counterpart. Key Anatomic/Physiologic Issues and Imaging Findings/
Techniques: MRI for evaluation of OM is better performed with a
high field magnet (1.5T) using a phased-array surface coil. A
myorelaxant agent is intramuscularly injected before starting the
procedure in order to reduce artifacts caused by intestinal peristalsis. The imaging protocol includes two 8 mm-thick/1 mm
spaced, T1-and T2-weighted fast spin echo (FSE) sequences with
elevated matrix and large field of view, followed by three highresolution FSE T2-weighted sequences in three orthogonal spatial
orientations and by an axial T1-weighted sequence with fat suppression. After IV contrast agent administration, a 3D T1-weighted
fast spoiled gradient echo dynamic acquisition is achieved in
order to better evaluate lesion vascularity and peritoneal carcinomatosis. Mature cystic teratomas, cysts, endometriomas, leiomyomas, fibromas, tecomas, germinomas and other OM can be accurately diagnosed and characterized on the basis of T1-weighted,
T2-weighted, and fat-saturated T1-weighted MRI findings and
through evaluation of their enhancement after IV contrast agent
administration.
Conclusion: MRI is the best imaging modality for diagnosis and
characterization of ovarian masses. Once the clinical and pathologic features of ovarian masses are known, MRI allows a systematic approach to correct diagnosis by analyzing their discriminant
imaging features: morphology, signal intensity and enhancement
patterns.
E278. An Illustrative Review of Cross-Sectional Imaging
Appearances After Uterine Fibroid Embolization (CME Credit
Available)
Verma, S.1; Bergin, D.1; Baltarowich, O.1; Gonsalves, C.1;
Lev-Toaff, A.2; Mitchell, D.1; Nazarian, L. 1. Thomas Jefferson
University Hospital, Philadelphia, PA; 2. Hospital of the University
of Pennsylvania, Philadelphia, PA
Address correspondence to S. Verma ([email protected])
Background Information: Uterine fibroid embolization (UFE) is
an effective treatment for symptomatic uterine fibroids, and a
good alternative to surgical management. Major complications
following UFE are rare. There is about an 8.5% short term and
1.25% serious complication rate. Postprocedural imaging is routinely performed to evaluate effectiveness of treatment and to
identify potential post UFE complications.
the spectrum of findings on MRI and CT performed after UFE; to
illustrate common and uncommon MRI and CT features after
269
successful, unsuccessful and complicated UFE, and to discuss
post UFE complications that requires urgent medical or surgical intervention.
Techniques: Imaging findings include typical post UFE appearances, fibroid location changes, fibroid vascularity, patterns of calcification, fibroid recurrence and regrowth, gas after UFE: sterile and infectious, adenomyosis following UFE, intermittent urinary retention, uterine necrosis, and pulmonary embolism.
Conclusion: The MRI and CT appearances vary depending upon
the time interval after UFE and success of the procedure. CT following UFE may be requested because of acute pelvic pain or
chest discomfort or pyrexia or for an unrelated indication.
Awareness of expected and abnormal imaging findings is essential for correct diagnosis and treatment. Radiologists should be
familiar with the range of post UFE appearances on MRI and CT
to better aid clinicians in correct diagnosis and treatment.
E279. Uterine Cervical Carcinoma after Therapy: MR Imaging
Findings
Restaino, G.; Missere, M.; Ciuffreda, M.; Cucci, E.; Occhionero, M.;
Sallustio, G. Catholic University of Sacred Heart, Campobasso,
Italy
Address correspondence to G. Restaino ([email protected])
Background Information: Cervical carcinoma (CC) is the third
most common gynecologic malignancy. Although patients now
survive longer due to radiation therapy and more effective chemotherapy, CC is also one of the most frequent causes of death in
women. The choice of primary treatment demands clinical judgment and depends on patient’s age and FIGO stage at diagnosis,
ranging from conization in stage IA, to surgery or radiation therapy in stages IB to IIA and to radiation therapy combined with
chemotherapy in stages from IIB to IVA. After primary treatment,
patients are usually followed up with MR. Deep knowledge of
imaging findings after therapy is crucial in order to accurately
evaluate the patient’s response and the potential complications
of treatments, and in order to correctly differentiate normal posttreatment findings from recurrence of disease.
the MR imaging appearances of post-therapy changes in patients
with CC, that is, anatomic changes resulting from surgery and
those changes induced by radiation therapy; illustrate the complications of hysterectomy or pelvic irradiation performed for treatment of CC, and review the imaging features of recurrent CC in
the pelvis and lymph nodes and of distant metastases.
Techniques: A normal vaginal cuff after hysterectomy appears as
a smooth, low-signal-intensity muscular wall on T2-weighted MR
images. In some cases, however, fibrotic scar tissue is present at
the vaginal vault. Metallic clips along the pelvic side wall can be
detected at the site of lymph node dissection as low-signal-intensity foci. Early and significant decreases in the signal intensity and
volume of the tumor at MR imaging indicate a good response to
radiation therapy. Reconstitution of the normal zonal anatomy of
the cervix and the presence of homogeneous low signal intensity
cervical stroma at MR imaging are reliable indicators of a tumorfree postirradiation cervix. The major complications of radical hys-
270
terectomy are ureteral fistula, lymphocele, pelvic infection, and
hemorrhage. Late complications of radiation therapy include rectovesical fistula, sigmoiditis, rectal stricture, ureteral stricture, and
sacral insufficiency fracture. Sites of recurrence are the pelvis,
lymph nodes, and distant sites.
Conclusion: Knowledge of the normal therapeutic changes and
the spectrum of recurrent tumor in patients with cervical carcinoma is important for accurate interpretation of follow-up MR
images.
E280. Utilization of Novel Extended Echo Train Acquisition
3D MRI Sequence for Investigation of Uterine Anomalies
Agrawal, G.; Riherd, J.; Hinshaw, J.; Sadowski, E. University of
Wisconsin, Madison, Madison, WI
Address correspondence to G. Agrawal ([email protected])
Objective: The objective is to compare 3D fast spin echo (FSE)
eXtended Echo Train Acquisition (XETA) and 2D fast-recovery fast
spin echo (FRFSE) MR imaging sequences and their respective 3D
reconstructions in the evaluation of congenital uterine anomalies.
Materials and Methods: This retrospective study received institutional review board exemption, and informed consent was not
required. The study was compliant with the HIPAA. Between
June, 2006 and May, 2008, both 2D FRFSE and 3D-FSE-XETA
imaging was performed on all female patients referred to our
department for a noncontrast MRI of the pelvis to assess for uterine anomalies. T2-weighted 2D FSE acquisitions were performed
in axial, sagittal and oblique (coronal to uterus) planes. (Time to
repeat [TR]=2,500 milliseconds, time to echo [TE]=85 milliseconds, FOV=24-36 cm, matrix=320 x 256, 12-24 slices 5 mm thick
with 1.5 mm skips, scan time 4.5 minutes per plane ~13 minutes for three planes.) 3D-FSE-XETA sequence was performed for
a volumetric T2-weighted acquisition (TR=2,500 milliseconds,
TE=105 milliseconds, FOV=24 cm, matrix=256 x 224 x 128, slab
coverage=18 cm, slice thickness=1.6 mm, scan time five minutes). Zero filling (since interpolation) in three dimensions was
used to reconstruct 0.5 x 0.6 x 0.7 mm voxels, allowing reconstructions of the 3D data in multiple planes. A retrospective
review of all pelvic MRI’s yielded 16 patients with uterine anomalies. Curvilinear 3D reconstructions were performed on these 16
studies utilizing both the 2D FRFSE and 3D-XETA images.
Evaluation for image quality based on tissue contrast, edge
sharpness, image blurring and motion artifact was performed by
a radiologist, who was blinded to the type of sequence used for
reconstructions. Each assessment was given a score using a scale
of 1-5 (1=poor; 5=excellent). Overall image quality and diagnostic confidence was determined by the mean of all scores and single tailed paired student’s t test was performed.
Results: Mean overall image quality of the 3D reconstructions
was significantly better (p<0.000002) for FSE XETA (4.03) compared to FRFSE (2.55). The level of diagnostic confidence though
statistically insignificant (p=0.21), was better for FSE XETA (4.31)
compared to FRFSE (4.18). Additionally, the XETA volume data for
reformat could be acquired in approximately five minutes as
opposed to more than 13 minutes required to obtain the 2D
FRFSE data in necessary three plane acquisition.
Conclusion: 3D FSE XETA provides superior image quality and
improved 3D reconstruction in less acquisition time compared to
2D FRSFE in the evaluation of uterine anomalies.
E281. MR Imaging Features of Uterine Sarcomas
Bharwani, N.1; Jelbert, A.1; Tunariu, N.2; Babar, S.2; Sahdev, A.1;
Rockall, A.1; Reznek, R.1 1. Barts and The London NHS Trust,
London, United Kingdom; 2. Imperial College HealthCare NHS
Trust, London, United Kingdom
com)
Background Information: Uterine sarcomas are uncommon,
aggressive tumors of mesenchymal origin accounting for 5-8% of
all uterine malignancies. Although uterine sarcomas can be indistinguishable from endometrial carcinoma or atypical fibroids on
MRI, there are certain features that can suggest these rare tumors
preoperatively. The distinction between atypical fibroids and sarcomas significantly alters the patient’s treatment strategy.
Although distinction between endometrial cancer and endometrial sarcomas can be made on endometrial biopsy, MR features
may also be helpful where the biopsy is inconclusive.
Preoperative diagnosis of a sarcoma, may avoid inappropriate
surgery and potentially affect patient outcome.
the pathology of uterine sarcomas, and illustrate typical MRI
appearances of common histological variants.
Techniques: The most common histological variants are: leiomyosarcoma (LMS), carcinosarcoma/malignant mixed müllerian
tumor (MMMT) and endometrial stromal sarcoma (ESS). Other
rarer sarcomas containing tissues foreign to normal uterine tissue
include rhabdomyosarcoma. LMS are characteristically large intermediate T2-weighted signal intensity masses replacing normal
uterine architecture with pockets of high T2-weighted signal representing areas of hemorrhage or cystic degeneration. MMMT are
endometrial-based tumors, heterogeneously hyperintense on T2,
homogenously hypointense on T1 and enhance with gadolinium.
Appearances of ESS vary with grade of tumor ranging from a simple endometrial mass to large, irregular infiltrative, aggressive
tumors.
Conclusion: Knowledge of typical MR features associated with
uterine sarcomas enables the reporting radiologist to suggest this
rare diagnosis preoperatively. This is advantageous to gynecological oncology surgeons allowing more radical surgical planning
and influences patient’s subsequent management.
E282. Images from the Under Belly: Pattern Recognition in
the Adnexa
Cornejo, S.; Chandrasekhar, C. University of Texas Health Science
Center Houston, Houston, TX
Address correspondence to A. Chandrasekhar ([email protected])
Background Information: Acute pelvic pain is a common presentation in the female patient on an emergent and nonemergent
basis. Ultrasound remains in the forefront of female pelvic imaging and is easily available on an emergent basis. Pattern recognition of adnexal sonographic findings is crucial to recognize and
understand normal physiologic changes vs. adnexal pathology as
the cause for pelvic pain. A subjective pattern recognition
approach has been shown to have high sensitivity and specificity
for differentiation of benign vs. malignant disease. Differentiation
between emergent and nonemergent entities based on sonographic findings is essential for patient management in clinical
practice.
and understand normal physiologic changes in the ovaries and to
differentiate sonographic presentations of normal physiology
from underlying pathologic entities; demonstrate typical physiologic sonographic imaging patterns in the adnexa, and to distinguish abnormal sonographic imaging patterns in different pathologic states.
Techniques: Classic sonographic imaging findings in the pelvis
form the cornerstone of diagnosis in female patients with pelvic
pain. Pattern recognition based on the sonographic spectrum of
different pathological entities vs. normal physiologic changes provides the roadmap for diagnosis, treatment and follow up in
the clinical setting. A pelvic ultrasound is the basic and ideal
method of investigation in the reproductive or postmenopausal
age groups. Besides providing the foundation for diagnosis, easy
follow up can also be obtained. This educational exhibit will elucidate the sonographic patterns that provide the basis of recognition of various physiologic and abnormal patterns in common
and uncommon pathological conditions.
Conclusion: Ultrasound has remained the gold standard in
female pelvic imaging both on an emergent and nonemergent
basis while providing a safe modality for follow up of pelvic
pathology or to confirm normal physiologic findings. Patient
management and triage is dependent on the sonographic findings based on pattern recognition and their clinical implication. E283. Female Pelvic Pain...Beyond the Adnexal Mass
Shively, A.; Kasales, C.; Collins, B.; Neutze, J. Penn State Hershey
Medical Center, Lewisburg, PA
Address correspondence to C. Kasales ([email protected])
Background Information: Women and adolescent girls with
acute pelvic pain make up a large percentage of patients seen in
the diagnostic ultrasound practice. Although making the appropriate diagnosis of adnexal processes such as ectopic pregnancy
and ovarian masses/ovarian torsion is important in these
patients, there is a far wider variety of pathology that may
present with acute pelvic discomfort. Our goal is to educate the
viewer as to the broad spectrum of common and not-so-common causes of pain that are encountered when evaluating young
girls and women with acute pelvic discomfort.
Educational Goals/Teaching Points: Our cases stress the
importance of combining a firm knowledge of pelvic anatomy as
well as the various pathophysiologic processes that may be
present. A systematic imaging approach to the ultrasound evaluation of females with pelvic pain is key to accurate diagnosis.
Close correlation of imaging findings with age, reproductive/surgical history, available clinical and laboratory data, and a firm
knowledge of the types of pathology commonly affecting the
uterus and adnexa is also important. In many patients, the source
for pain may be from the ovary. However the fallopian tube, uterus or even unexpected organs such as a transplanted kidney can
also be the source of symptoms. 271
Techniques: The uterus is a frequently forgotten source of pelvic
pain. Knowledge of the various pathologic processes affecting the
uterus in different age ranges (such as cervical stenosis, malignancy, and scar ectopic) is the key to differentiating the imaging
findings, which may otherwise not be very specific. Familiarity
with less common surgical procedures, such as supracervical hysterectomy, is also prudent, and may allow the sonographer or
sonologist to more readily recognize postoperative processes
such as stump abscess. Women who have undergone assisted
reproduction are at risk for less frequently seen complications
such as interstitial and heterotopic ectopic pregnancies. Finally,
as clinicians we need to remember that pathology from other
pelvic organs, such as transplanted kidneys, may be a source for
pelvic pain.
Conclusion: By thinking “beyond the ovary” and correlating the
imaging findings with available clinical and laboratory data, each
clinician can be better prepared to evaluate common and less
common causes of pelvic pain.
E286. Challenges and Pitfalls in the Diagnosis of Ectopic
Pregnancy: Multimodality Imaging Evaluation (CME Credit
Available)
Chaudhri, Y.1; Mauch, E.2; Oto, A.2; Slywotzky, C.1; Timor-Tritsch,
I.1; Bennett, G.1 1. New York University Medical Center, New York,
NY; 2. University of Chicago, Chicago, IL
Address correspondence to G. Bennett (genevieve.bennett@med.
nyu.edu)
Background Information: Ectopic pregnancy is one of the leading causes of maternal morbidity and mortality. There may be
unusual sites of pregnancy implantation which present a diagnostic challenge, both clinically and at imaging. Intra- and extrauterine pregnancy may coexist, and this may also present a diagnostic challenge. The location of the pregnancy may not be identified (pregnancy of unknown location [PUL]), and the patient
may be treated on the basis of clinical and laboratory findings.
Conventional gray scale and color Doppler ultrasound serve as
the cornerstone of imaging of the ectopic pregnancy; however,
3D ultrasound and MRI may serve as problem-solving tools.
Occasionally CT may be performed in the setting of an unsuspected ectopic or unusual intra-abdominal location. The purpose
of this exhibit is to review the imaging findings in ectopic pregnancy with an emphasis on unusual sites of pregnancy implantation. The role of 3D ultrasound, MRI and CT in the diagnosis of
unusual or complicated cases will be discussed.
Educational Goals/Teaching Points: The diagnosis of ectopic
pregnancy, especially when the site of implantation is unusual,
may be challenging. Familiarity with the imaging appearance of
unusual types of ectopic pregnancy is essential for appropriate
diagnosis. Although 2D ultrasound remains the initial imaging
study of choice, 3D ultrasound, MRI and CT may serve as important problem solving tools in unusual or complicated cases.
Techniques: In this exhibit, the epidemiology, pathophysiology
and clinical features of ectopic pregnancy will be discussed. This
will be followed by examples of ultrasound findings of ectopic
pregnancy with an emphasis on less common sites of pregnancy
implantation. Examples of unusual types of ectopic pregnancy
272
which will be demonstrated through the use of cases include:
C-section scar, cornual, cervical, abdominal, intrasplenic, and heterotopic pregnancy. Differentiation from mimics, such as pregnancy in the anomalous uterus and other adnexal masses, as
well as other pitfalls in diagnosis will be discussed. The role of
3D ultrasound, MRI and CT as an adjunct to 2D ultrasound for
problematic cases will be discussed. The role of imaging in guiding treatment and management of the pregnancy of unknown
location will also be presented.
Conclusion: Familiarity with the imaging appearance of unusual
types of ectopic pregnancy will allow for accurate and prompt
diagnosis. Multimodality imaging may play an important role in
differentiation of ectopic pregnancy from other acute disorders.
E287. Cesarean Section: Not Only a Convenience.
Multimodality Imaging Review of Complications
McLean, L.; Kennedy, A.; Shaaban, A.; Woodward, P. University of
Utah, Salt Lake City, UT
Address correspondence to L. McLean ([email protected].
edu)
review the multimodality imaging appearance of cesarean section complications; illustrate diagnostic criteria for both common
and rare complications seen in the pregnant and postpartum
patient, and discuss appropriate indications for supplemental
imaging in these patients.
Educational Goals/Teaching Points: The major educational
goals of this exhibit include multimodality imaging review of the
key diagnostic findings in pregnancy complications—placenta
accreta, increta, percreta, uterine rupture, and operative bladder,
bowel and vascular injury; postpartum complications—infection
(endometritis, pyelonephritis), bowel (ileus, perforation), pelvic
vein thrombosis, uterine scar dehiscence, uterine scar ectopic
pregnancy, and IUD malposition.
Techniques: The exhibit will include uterine anatomy—endometritis, placenta accreta, increta and percreta and uterine
scars status postcesarean section, and adjacent pelvic anatomy—
bladder and vascular structures.
Conclusion: Both common postpartum complications and unusual cesarean section scar-related complications are more frequently imaged due to the increased incidence of operative
deliveries. MRI and CT may be supplemental for further characterization. Accurate and timely diagnosis of the accreta spectrum
is imperative due to the potential for life-threatening maternal
hemorrhage and fetal demise.
E288. Cesarean Section: Imaging of Acute and Chronic
Complications
Horrow, M.; Rodgers, S.; Lee, J.; Larrauri, D. Albert Einstein
Medical Center, Philadelphia, PA
Address correspondence to M. Horrow ([email protected])
Background Information: In 2005 Cesarean delivery accounted
for approximately 1/3 of all births in the USA. Despite its safety, a
variety of acute complications, often more frequent with obesity
and repeat C-section can ensue. In addition there is a growing
population of women with a prior history of C-sections, who
require pelvic imaging. Uterine adhesions may cause difficulty
with sonographic imaging. The C-section scar also leaves the
patient vulnerable to several rare, but unique diagnoses that are
now made with increasing frequency. Review of post C-section
imaging over the past 3.5 years yielded examples of normal and
abnormal acute appearances and a variety of chronic complications. Familiarity with the “normal” appearance of the immediate
and chronic post C-section pelvis is necessary to appreciate true
pathologic findings and to understand complications related to
the C-section scar.
Educational Goals/Teaching Points: Unique acute bleeding
complications after C-section can include bladder flap and subfascial hematomas. Wound complications after C-section may
include uterine dehiscence. Scarring from C-sections may cause
adhesions that tether the uterus to the anterior abdominal wall
making sonographic imaging extremely difficult. Complications of
the uterine scar include: ectopic pregnancy, IUD malposition,
repository for menstrual blood and endometrial implants.
Techniques: This didactic exhibit uses CT and ultrasound to
demonstrate normal acute C-section appearance; examples of
acute complications: superficial collections and hematomas, cellulitis, subfascial hematomas, wound dehiscence, bladder flap
hematomas, uterine rupture, endometritis, pelvic vein thrombosis
and abscess; normal chronic C-section appearance: adhesions
resulting in abnormal uterine position and the uterine scar, and
examples of chronic C-section scar complications: repository for
menstrual blood, ectopic pregnancy, IUD malposition and
endometrial implants.
Conclusion: This exhibit will demonstrate acute and chronic complications of C-section using CT and ultrasound. Discussion of the
procedure and display of normal immediate findings will allow
appreciation of the unique types of hematomas and abscesses,
and wound complications in the acute situation. In the chronic
phase imaging will demonstrate the appearance of the normal
C-section scar, difficulties with ultrasound imaging related to
adhesions, and complications related to the C-section scar.
E289. Color Doppler Evaluation of Retained Products of
Conception: Potential Guide to Clinical Management (CME
Credit Available)
Kamaya, A.; Petrovitch, I.; Chen, B.; Jeffrey, R. Stanford University,
Stanford, CA
Address correspondence to A. Kamaya ([email protected])
Objective: The objective was to characterize color Doppler
imaging features of retained products of conception (RPOC)
with grayscale correlation.
Materials and Methods: Clinically suspected cases of RPOC
between January, 2005 and February, 2008 were reviewed.
Patient data and relevant color Doppler and grayscale features
were recorded.
Results: A total of 269 patients referred for sonographic evaluation for RPOC were identified. Thirty-four patients had confirmed
pathologic diagnosis, 27 of whom had RPOC. In those with RPOC,
19% were avascular (type 0), 19% had minimal vascularity (type
I), 37% had moderate vascularity (type II), 7% had marked vascularity (type III), and 19% had a single feeding vessel or focus of
vascularity (type IV). Peak velocities ranged from 10 to 108 cm/
second (average 35.7 cm/second). Resistive indices in arterial
waveforms ranged from 0.33 to 0.7 (average 0.5). Of those type 0
vascularity, 45% had RPOC. 83% of Type I had RPOC and 100%
of types II-IV had RPOC. An echogenic mass had moderate specificity (78%) but low sensitivity (26%) for RPOC.
Conclusion: We identified five types of color Doppler appearance of RPOC that provide additional information of the likelihood of the presence of RPOC. The presence of any vascularity
is highly correlated with retained products of conception while
the lack of vascularity can be seen in both intrauterine clot as
well as avascular RPOC.
E290. Diagnosis of Postpartum Complications
Ro, K.; Kamaya, A.; Desser, T.; Chang, P.; Benedetti, N. Stanford
University, Stanford,CA
Address correspondence to K. Ro ([email protected])
Background Information: Postpartum complications are reported to occur in up to 10% of all deliveries and include post-partum hemorrhage, obstetrical trauma, thromboembolic complications and puerperal infections. This exhibit will review the diagnostic considerations in the evaluation of postpartum complications, and the correlative radiological imaging findings and treatment options.
Educational Goals/Teaching Points: The educational goals
include demonstrating the range of normal findings in the postpartum uterus by ultrasound, CT and MRI; illustrating the spectrum of postpartum complications, their clinical presentation and
the correlative imaging findings relevant to the diagnosis; highlighting the preferred imaging modality that best illustrates a specific diagnosis, and describing specific radiologic pearls that can
aid in making an accurate diagnosis as well as the potential pitfalls to avoid.
Techniques: The imaging techniques and findings relevant to the
following postpartum complications will be described and
include postpartum hemorrhage—uterine atony, retained products of conception; obstetrical trauma—uterine dehiscence/rupture, postsurgical trauma including small bowel obstruction and
uterovesicular fistula, delayed postpartum complication including
cesarean section scar, ectopic and endometriosis in a cesarean
section scar; thromboembolic complications—ovarian vein thrombosis, amniotic fluid embolism; puerperal infection—endometritis, abscess formation, postpartum appendicitis, pyelonephritis,
and other postpartum complications—posterior reversible
encephalopathy syndrome, HELLP syndrome.
Conclusion: The accurate diagnosis of various postpartum complications requires both an understanding of the normal postpartum appearance of the uterus and the range of potential complications in order to choose the most accurate diagnostic modality
to confirm a suspected diagnosis.
273
E291. Doppler Evaluation of the Fetal Middle Cerebral
Artery (CME Credit Available)
Hogan, L.; Gaudier, F. Mayo Clinic, Jacksonville, FL
Address correspondence to L. Hogan ([email protected])
Background Information: Fetal Doppler applications are expanding at a rapid rate. Of particular interest is Doppler interrogation of
the fetal middle cerebral artery. The right and left middle cerebral
arteries are relatively straight branches of the circle of Willis that
carry more than 80% of the cerebral blood flow. Careful measurement of the velocity, resistive indices and evaluation of the waveform can provide useful information to the obstetrician regarding
fetal anemia, intrauterine growth restriction and fetal hypoxemia
which can in turn guide management of the pregnancy.
is to discuss the utility of Doppler evaluation of the middle cerebral artery including applications in fetal anemia, intrauterine
growth restriction and hypoxemia/placental insufficiency and
how this affects the obstetricians management of the patient;
discuss the appropriate technique for measurement of velocity,
resistive indices and waveform capture with special attention to
potential pitfalls and expected changes to the above parameters
as the gestation progresses, and review real life normal and
abnormal cases as seen in the maternal fetal medicine clinic.
Techniques: The cerebral circulation is normally a high resistance
circulatory system with continuous forward flow throughout the
cardiac cycle. When fetal hypoxemia is present, the fetus compensates by redistributing blood flow to the brain, heart and
adrenals while reducing flow to the remainder of the body, a
phenomenon known as “brain sparing”. The middle cerebral
artery is easily insonated in both the near and far field in the
fetus making this vessel an ideal choice for evaluation. In the
transverse plane of the fetal head near the base of the skull, the
proximal and distal middle cerebral arteries course almost parallel to the ultrasound beam. Measurements and waveforms
obtained near the origin of the vessel from the internal carotid
artery have been shown to be the most reproducible between
operators. Careful attention to technique, specifically the angle of
insonation, is paramount to ensure accurate evaluation.
Conclusion: The Doppler evaluation of the middle cerebral artery
in the fetus is a powerful tool for the obstetrician and when serially measured may obviate the need for more invasive tests/
monitoring, such as amniocentesis.
E292. Fetal Ultrasound and MRI: Practical Roles in Clinical
Management of the Neonate (CME Credit Available)
Bennett, B.; Johnson, K.; Angtuaco, T. University of Arkansas for
Medical Sciences, Little Rock, AR
Address correspondence to B. Bennett (bennettbrittonm@uams.
edu)
Objective: The goal was to explore clinical situations in which
MRI played a complementary role to ultrasound and instances in
which MRI did not add any additional information to sonographic
diagnosis and was therefore redundant. Materials and Methods: A review of medical records over the
past five years identified 53 patients who had both fetal ultra-
274
sound and MRI within one week of each other. Images from
both examinations were reviewed and correlated with prenatal
diagnosis and postnatal outcome. A comparison was made to
determine in which cases MRI provided complementary vs.
redundant information. Results: In 31 patients (58%), MRI findings did not provide additional information to ultrasound findings. In 15 patients (28%),
MRI findings were complementary to the ultrasound examination
but did not significantly change the clinical management. In
seven patients (13%), the clinical management was changed due
to MRI findings. Our experience suggests that the majority of fetal
MRI studies yield redundant information. In most of the clinical
situations we analyzed, prenatal ultrasound provided adequate
information to diagnose fetal abnormalities in high risk pregnancies and guide subsequent management decisions. In a minority
of cases MRI did yield additional information but did not change
clinical management. In the few cases where management was
changed, the complications were more related to maternal factors than fetal concerns. There is a fine line of distinction
between scenarios in which MRI may make a difference in management and when it does not add to what is already known
from prior fetal ultrasound. The benefits of doing fetal MRI
should therefore be carefully weighed before performing an
expensive and frequently redundant exam.
Conclusion: As the utilization of fetal MRI increases, an objective
evaluation of its perceived and actual benefits vs. traditional
ultrasound evaluation is necessary in each clinical scenario. E293. Fetal MRI: Basic Technique, Fetal Anomalies and
Maternal Abdomen (CME Credit Available)
Lee, H.1; Prince, M.1,2; Prowda, J.1; Laifer-Narin, S.1 1. Columbia
University College of Physicians and Surgeons, New York, NY; 2.
Weill Cornell Medical College, New York, NY
Address correspondence to H. Lee ([email protected])
Background Information: Fetal MR imaging is continuing to
gain popularity as it offers operator-independent imaging in any
image plane with excellent soft tissue contrast and fine detail, as
well as a large field of view. MR imaging also avoids exposure of
the mother and fetus to ionizing radiation and does not require
intravenous contrast material. With the development of faster MR
imaging sequences, greater anatomic detail of the fetus can be
visualized without the need for sedation to reduce fetal motion
artifact. Thus, it is necessary to understand the MR imaging techniques and to recognize fetal anomalies for optimal examination and image interpretation.
aims to familiarize radiologists with basic technique of fetal MR
imaging, a variety of fetal anomalies and complications involving
the maternal abdomen.
Techniques: A variety of anomalies involving the fetus will be
discussed: bronchopulmonary sequestration, conjoined twins,
sacrococcygeal teratoma, gastroschisis, omphalocele, congenital
diaphragmatic hernia, limb body wall complex, central nervous
system teratoma, vein of Galen aneurysm, myelomeningocele,
tuberous sclerosis, etc. Complications involving the maternal
abdomen, such as a pregnancy in the rudimentary horn of a uni-
Electronic Exhibits: Musculoskeletal
cornuate uterus, ectopic pregnancy, acute appendicitis during
pregnancy and placental abnormalities will be discussed.
Conclusion: While still evolving, fetal MR imaging contributes to
the decision-making processes regarding pregnancy, patient
counseling, delivery management, and planning for prenatal or
postnatal care.
Musculoskeletal
E294. Tarsal Coalitions
Brown, K.; Walker, E. Penn State Hershey Medical Center,
Hershey, PA
Address correspondence to K. Brown ([email protected])
Background Information: Tarsal coalition is an entity that can
be overlooked in patients with foot and ankle pain. Awareness of
the common types of tarsal coalitions and their radiographic
appearance is important for diagnosis and treatment planning.
is to demonstrate multimodal findings in the diagnosis of tarsal
coalition and to delineate the secondary findings important for
guiding management. At the conclusion of this exhibit, the radiologist should be able to 1) understand key findings and anatomic
structures involved in tarsal coalition, 2) document joint involvement and type of coalition, and 3) document secondary findings
and degenerative changes pertinent to clinical management.
Techniques: Tarsal coalitions may be fibrous, cartilaginous, or
osseous. Calcaneonavicular and talocalcaneal coalitions are most
common, and approximately 50% are bilateral. Calcaneonavicular
coalitions are often detectable on 45° internal oblique radiographs as an irregular broad apposition of the calcaneus and
navicular and an elongated anterior calcaneal process on the lateral view (“anteater” sign). Talocalcaneal coalitions frequently
involve the middle subtalar facet and often require CT or MRI for
conformation. Secondary signs of talocalcaneal coalition on plain
film include absent middle facet sign, C sign, talar beak or curved
undersurface of the sustentaculum tali. Sequelae of tarsal coalition, including degenerative changes, are important to recognize
and document for patient management and preoperative planning. In general, resection is indicated for symptomatic talocalcaneal coalitions involving <50% of the joint. For >50% involvement, subtalar arthrodesis is preferred. Calcaneonavicular coalitions are generally resected. For patients with secondary degenerative changes, triple arthrodesis may be required. CT and MR
imaging of the ankle and hindfoot should include imaging/reconstruction in the axial coronal and sagittal planes. T1 and proton
density-weighted images with T2-weighted images are generally
sufficient for MRI evaluation. Subarticular bone marrow edema at
the coalition can be seen on short-tau inversion recovery (STIR)
or T2 fat saturation sequences.
Conclusion: The diagnosis of tarsal coalition is often overlooked
in the clinical differential diagnosis of foot and ankle pain. Thus,
it is important for the radiologist to recognize the key anatomic
abnormalities and pertinent secondary findings of tarsal coalition
to help guide management.
E295. Off on the Right Foot: A Pictorial Exhibit on
Conventional Radiography and MDCT of Talar Injuries
Wibskov, J.; Rahal, A.; Loredo, R.; Garcia, G. University of Texas
Health Science Center at San Antonio, San Antonio, TX
Address correspondence to J. Wibskov ([email protected])
Background Information: Reportedly, 3-5% of foot fractures
involve the talus. As the bone responsible for both supporting the
tibia and communicating directly with the calcaneus and navicular,
fractures here are likely under-reported. Indeed, while both radiography and MDCT are consistently sensitive to ankle and calcaneal fractures, talar fractures tend to be radiographically occult.
Variability amongst detection of talar fractures depends greatly on
fracture location. The purpose of this exhibit is to first review the
anatomy of the talus and illustrate the classification of talar fractures. Secondly, a description of the mechanisms of injury and
patterns of talar trauma will demonstrate these classifications.
Finally, a comparison of plain film and MDCT presentations of talar
injuries will highlight cases of radiographically occult fractures.
pictorial illustration and review the anatomy and classification of
common talar fractures and provide an understanding of mechanisms of injury to the foot and ankle helps direct attention to the
probable sites of injury. MDCT is a useful adjunct to radiography
for the evaluation of complex or occult talar injuries.
Techniques: Talar fractures are divided into types based on the
three main anatomical regions of the talus: the body, head and
neck. Injuries to the body can be further categorized as belonging to the dome, to the medial, lateral and posterior processes,
or the main body, extending from the upper articular surface
through the subtalar joint. Talar neck fractures are historically very
clear on radiography. The three processes of the body, however,
are difficult to detect on plain film, and their fractures should be
suspected based on the mode of injury and clinical presentation.
Conclusion: Anatomy of the talus, mechanisms of injury and
types of talar fractures are reviewed. Imaging findings of different
talar injuries are depicted, comparing plain film radiography and
MDCT findings.
E296. Ankle and Foot Fractures, MDCT Imaging vs. Plain
Film Evaluation
Wibskov, J.; Rahal, A.; Loredo, R.; Garcia, G. University of Texas
Health Science Center at San Antonio, San Antonio, TX
Address correspondence to J. Wibskov ([email protected])
Objective: The purpose of our study was to assess the accuracy
of detection of foot and ankle fractures using radiographs as
compared to MDCT in patients with acute trauma. We further
aimed to identify which types of injury specifically warrant evaluation with MDCT.
Materials and Methods: Radiographic records were retrospectively analyzed for this IRB-approved study. Between January 1,
2006 and July 7, 2007, a total of 559 patients received MDCT following radiographic examination of the ankle or foot. Inclusion
criteria were met by 303 patients (317 extremities; 214 male,
103 female) with acute ankle and/or foot trauma. We recorded
the location of fractures diagnosed on plain films at the time of
275
injury, and compared it with the MDCT results as the gold standard. Agreement of the presence and the exact location of
fracture(s) in each bone was calculated. The frequency of fractures on plain films vs. MDCT images, the sensitivity for fracture
detection, and the correlation between radiographic and CT
results were summarized using descriptive statistics. Detailed
agreement for findings in each bone was assessed using contingency tables and Fisher’s exact tests.
Results: Exams of 317 extremities showed a total of 783 fractures in 292 extremities (92%): ankle (137), calcaneus (123),
talus (69), midfoot (93) and forefoot (77). The most common
modes of injury were motor-vehicle-related trauma 39%
(118/303) and falls 38% (116/303). The most common undetected fractures on initial radiographs were of the cuboid, intermediate and lateral cuneiforms, and the lateral and medial processes
of the talus. The sensitivity of plain film reports for talar and midfoot fractures was 31% (21/68) and 29% (26/90), respectively.
The calcaneus was the most commonly fractured bone; radiographs were sensitive to 77% (87/113) of these fractures. Five
out of 14 (36%) Lisfranc injuries were radiographically occult.
The sensitivity of radiography for fractures of the tibia and fibula
was 85% (115/136) and, for metatarsal fractures, 73% (45/62).
Overall, positive plain film findings in the foot and ankle were
moderately sensitive and highly specific for the different fractures
described in the ankle and calcaneus. Conclusion: In high-impact trauma patients with foot or ankle
injuries suspicious for fractures or Lisfranc joint injuries, MDCT
can improve diagnostic accuracy. MDCT imaging is especially
warranted in trauma patients with negative plain film exams.
E297. The Utility of Contrast-Enhanced MRI for the Detection
and Characterization of Foot and Ankle Pathology
Abrahamian, H.1; Kier, R.1; Siroka, P.2; Feldman, A.1; Eterno, R.1;
Davis, D.1 1. Bridgeport Hospital, Bridgeport, CT; 2. Stamford
Hospital, Stamford, CT
Address correspondence to H. Abrahamian (harry.abrahamian@
gmail.com)
Background Information: Few articles have evaluated the benefit of adding contrast enhancement for MR images to diagnose
and characterize pathologies of the foot and ankle. Existing publications have differing opinions. One shows that there is no difference in diagnosing bone marrow abnormalities when comparing
STIR images vs. T1-weighted contrast-enhanced fat-suppressed
MR images. Other articles report increased sensitivity and specificity in diagnosing osteomyelitis, syndesmotic injury, and bone
healing by adding gadolinium-enhanced fat-suppressed MR
images to nonenhanced MR images.
Educational Goals/Teaching Points: Diagnosis of synovitis and
tenosynovitis utilizing MRI images without contrast relies on
detection of either abnormal fluid or secondary soft tissue
edema. Intravenous gadolinium adds assessment of hyperemia
and hypervascularity which are more consistent with synovitis.
Contrast enhancement is beneficial for many other pathologies
such us infection, sprains, fibromas, capsular tears, adventitial
bursitis, tumors, and foreign bodies.
276
Techniques: Contrast-enhanced MR images help delineate a
variety of painful conditions in the foot and ankle: For infection,
noncontrast T1-weighted and short tau inversion recovery imaging can detect areas of abnormal edema, while contrast enhancement defines abscess and fistulous tracts as signal voids within
areas of hyperemia, guiding surgical treatments. For subacute
and chronic sprains, noncontrast MRI may show only heterogeneous signal that could be either healing or scarring, while contrast enhancement may show either intense enhancement indicating chronic tears with hyperemia or old scar with absence of
enhancement. Adjacent synovitis may also be detected. For tenosynovitis, contrast enhancement distinguishes bland fluid from
inflamed tendon sheaths. For plantar fibromas, focal enhancement delineates multifocal lesions that may be undetected without dye. For the forefoot, contrast detects tears of the metatarsophalangeal joint capsule, areas of enhancement in adventitial
bursitis, and acute synovitis that can appear normal without dye.
For rounded tumors that appear homogeneous, contrast distinguishes cystic (i.e. ganglion) from solid (i.e. neuroma). For foreign
bodies, contrast may outline abscess or focal foreign body reactions that help detect otherwise inconspicuous foreign bodies.
Conclusion: Gadolinium-based contrast agents, when not contraindicated, improve detection and characterization of a variety
of conditions of the foot and ankle.
E298. Low T2 Signal in the Foot and Ankle: Classic Lesions
and Less Familiar Entities
Wilde, G.1; Gakhal, M.1; Awan, O.2; 1. Christiana Care Health
System, Newark, DE; 2. No Institutional Affiliation
Address correspondence to G. Wilde ([email protected])
Background Information: The purpose of this exhibit is to illustrate the spectrum and appearance of T2 hypointense disease
entities that can be encountered on MRI of the foot and ankle in
everyday clinical practice. We present several frequently encountered lesions as well as a few less common entities.
Educational Goals/Teaching Points: Illustrative cases have
been selected from our institution and will be presented to the
viewer in a quiz format, followed by didactic material. Specific
distinguishing MRI features of entities that narrow the differential
diagnosis are highlighted. Pathologic features leading to MRI signal characteristics are reviewed when this information is known.
Correlation with plain radiographs is emphasized when these are
available.
Techniques: Entities covered include: systemic disorders, bone
and soft tissue tumors, tumor-like conditions, foreign bodies,
technical issues, coalition, and postsurgical findings.
Conclusion: Although most pathologic entities present with
hyperintense T2 signal in foot and ankle imaging, the differential
diagnosis for lesions with hypointense T2 signal is much less
expansive. In some cases, knowledge of distinctive features can
lead to a specific diagnosis. After review of this exhibit, the viewer will gain a firm appreciation of the common and uncommon
lesions of the foot and ankle that result in decreased T2 signal
intensity on MRI.
E299. MRI Spectrum of Soft Tissue Changes in the Diabetic
Foot (CME Credit Available)
Pierre-Jerome, C.1,2; Albastaki, U.1; Kkarala, A.2; Gothlin, J.1;
Terk, M.2; Moncayo, V. 2 1. Sahlgrenska-Molndal University
Hospital, Gothenborg, Sweden; 2. Emory University Hospital,
Atlanta, GA
Address correspondence to C. Pierre-Jerome (cpierrejerome@msn.
com)
Background Information: The incidence of diabetes mellitus
has tremendously increased in the last decade. Complications
can arise at any age, as the disease affects several systems in the
body. Its predilection for the appendicular skeleton, especially the
lower extremity, is well known. Radiologists are most familiar
with the bony changes seen in the diabetic foot, but the damages to the soft tissues still remain a dilemma due to their multiplicity and unpredictability. The purpose of this exhibit is
to present the myriad of soft tissues changes in the diabetic foot
visualized on MR images. Educational Goals/Teaching Points: The goals are to present a
bilateral MR imaging protocol for the diabetic foot; systematically
review the soft tissues changes taking place in the diabetic foot
at different stages of the disease; emphasize the use of gradient
echo sequences with water excitation to evaluate the cartilage,
and discuss the criteria for using intravenous contrast in patients
with advanced disease. Key Anatomic/Physiologic Issues and Imaging Findings/
Techniques: The soft tissues changes seen in the diabetic foot
are: 1) tendenopathy (tendinosis, tendenitis, tendon tear), 2)
myopathy (myositis, muscle ischemia, muscle necrosis), 3) ligament pathology (substance edema, tear), 4) bursa pathology
(bursitis), 5) synovial changes (synovitis), 6) fascia changes (fasciitis), 7) subcutaneous fat changes (cellulitis, necrosis), 8) chondropathy (chondral lesions). Conclusion: This exhibit presents a large spectrum of soft tissue
changes in the diabetic foot. It is still not clear whether the diversity of these changes reflects the severity of the disease or not.
Also, further research is needed to determine the clinical significance of these changes in predicting the evolution of the deformity of the foot.
E300. Comparison of Early and Delayed Postcontrast MR
Imaging for the Detection of Foot and Ankle Pathology
Shin, P.; Kier, R. Bridgeport Hospital, Bridgeport, CT
Address correspondence to P. Shin ([email protected])
Objective: MRI of the forefoot is sometimes performed after the
administration of gadolinium-based contrast agents as an
attempt to improve detection or characterization of various foot
pathology. In certain cases, some pathology may not be fully visualized with only early postcontrast imaging. Delayed imaging
after three minutes may improve detection and characterization
of both osseous and soft tissue abnormalities in the forefoot. This
study was designed to determine whether 30 second or three
minute delay after contrast injection was superior for demonstrating enhancement in pathologic tissue.
Materials and Methods: Fifty patients aged 19 to 65 underwent
MRI at 1.5T before and after the intravenous administration of
0.1mmol/kg of gadolinium-DTPA, with total volume of injection
ranging from 8 to 20 cc. Regions of interest in the area of pathology were obtained prior to injection, scanning began 30 seconds
after injection, and three minutes after injection, respectively. In
each case, all imaging sequences were reviewed and the area of
highest signal intensity on the delayed postcontrast images were
measured with the average of three elliptical regions of interest.
The corresponding areas of pathology on early postcontrast and
precontrast imaging planes were identified and the signal intensities were measured in identical fashion. The average of two
measurements was used to assess background noise signal
intensity. Congruence of imaging planes was confirmed by using
anatomic landmarks as well as external markers, when available.
Results: Postcontrast scans showed mean enhancement of 69%
early and 90% late. Delayed postcontrast scans showed an average of 21% greater enhancement than early post contrast scans,
with a standard deviation of 13%. In 42% of cases, delayed scanning showed at least 50% greater enhancement than early scans
and in 18% of cases, twice the enhancement of early scans. Conclusion: We conclude that MR imaging of the foot and ankle
three minutes after contrast injection shows significantly
increased enhancement when compared to imaging 30 seconds
after injection. This greater intensity of enhancement may
improve the detection and characterization of enhancing pathologic conditions of the foot and ankle.
E301. Lisfranc Fracture-Dislocation: Imaging Findings With
Intraoperative Correlation and Postoperative Imaging
Follow-Up
Chakarun, C.; Tumyan, L.; Wolfson, N.; White, E.; Forrester, D.
University of Southern California, Los Angeles, CA
Address correspondence to C. Chakarun ([email protected])
Background Information: Our purpose is to demonstrate the
plain radiography, CT and MR imaging findings in cases of
Lisfranc fracture-dislocation, and to correlate with intraoperative
photographs and surgical reports.
Educational Goals/Teaching Points: Lisfranc fracture-dislocation is a commonly overlooked diagnosis often due to the subtlety of findings on plain radiographs. Missed diagnosis can result in
significant morbidity. An understanding of the normal Lisfranc
joint is important in determining abnormalities and making the
correct diagnosis. Herein, we present cases of Lisfranc fracturedislocation from our institution, some of which were initially
overlooked. Through our exhibit, the reader will become familiar
with the imaging findings on plain radiography CT, and MRI correlated with intraoperative photographs and surgical reports.
Techniques: The Lisfranc ligament forms an oblique connection
between the first cuneiform and the base of the second metatarsal. Diastasis between the first and second metatarsals is the
main finding, however, without stress views this can be subtle. If
the patient is unable to bear weight on both feet for stress views,
CT imaging is recommended. Other imaging findings include
shear fracture at the second metatarsal, and impaction fractures
of the navicular, cuboid, and medial cuneiform. Lisfranc fracture-
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dislocation usually results from crush injury or high energy trauma. Missed diagnosis often leads to significant morbidity.
Nondisplaced injuries can be treated with cast immobilization,
and unstable injuries are treated by open reduction and internal
fixation.
Conclusion: The imaging findings of Lisfranc fracture-dislocation
can be subtle, and suspicion warrants stress views or further
evaluation by CT or MRI. Through examples from our institution,
the reader will become familiar with these imaging findings correlated with intraoperative photographs and surgical reports.
E302. My Foot Hurts Doc... What Do You Think?
Mazzie, J.1; Smith, S.2; Scalcione, L.1; Katz, D.1; Grossman, M.1;
Luchs, J.1 1. Winthrop-University Hospital, Mineola, NY; 2.
University of Maryland, Baltimore, MD
Background Information: Foot pain is a common clinical complaint heard by our orthopedic and podiatric colleagues, and by
primary care physicians. The purpose of this exhibit is to present
the imaging findings of a wide range of traumatic and non-traumatic conditions which can cause foot pain.
Educational Goals/Teaching Points: Common traumatic fractures such as Jones fracture, Lisfranc injury, talar neck fracture,
and calcaneal fractures will be shown and discussed, as well as
infectious processes, neuropathic disease, and overuse injuries.
Additionally, chronic causes of foot pain, including plantar fibromas, plantar spurs, osteochondral lesions within the talus, and
osteonecrosis (i.e. Frieberg’s necrosis) will be shown and discussed. Painful conditions associated with foot ossicles will also
be briefly covered (i.e., sesamoiditis).
Techniques: Radiographs, ultrasound, CT, MR, and nuclear medicine imaging will be shown and the relevant literature reviewed.
Conclusion: Foot pain is a common clinical complaint heard by
our clinical colleagues in orthopedic and podiatric medicine as
well as in primary care. A wide range of traumatic and nontraumatic conditions can cause foot pain, which may be identified on
imaging studies. Following review of this exhibit, the radiologist
should have a concise knowledge of the imaging appearances of
entities which may cause foot pain.
E303. Interactive 3D CT for Teaching Anatomy and Pathology
in Complex Foot and Ankle Trauma (CME Credit Available)
Goodman, M.; Richardson, M.; Bush, L.; Mulcahy, H.; Chew, F.
Address correspondence to M. Goodman (goodmm@
u.washington.edu)
Background Information: Early recognition and treatment of
foot and ankle problems are imperative for avoiding associated
morbidities. The ankle represents an anatomically complex region
that can be quite challenging. We present an interactive computer exhibit to demonstrate the utility of interactive 3D reconstructions in the preoperative evaluation of complex ankle and foot
trauma. This will help the user understand not only normal anatomy, but also fracture patterns and mechanism of injury. Other
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modalities such as conventional radiographs and MR will be
included where complementary.
Educational Goals/Teaching Points: The objectives of this educational activity are for the participant to learn complex ankle and
foot anatomy utilizing interactive 3D models; learn fracture patterns and mechanisms of injury in foot and ankle fractures;
develop a systematic method for interpreting diagnostic images
of foot and ankle trauma, and understand postoperative imaging
evaluation.
Techniques: The interactive 3D images will be used for demonstration of normal anatomy. Models of various ankle and foot
injuries will be presented illustrating mechanisms of injury of the
foot and ankle.
Conclusion: Interactive 3D reformations of the foot and ankle
are useful in teaching anatomy and pathology of the injured foot
and ankle to medical students, residents and practicing radiologists.
E304. The Lateral Ankle: What is There and What Can Go
Wrong (CME Credit Available)
Doshi, S.; Edwards, A. William Beaumont Hospital, Royal Oak, MI
Address correspondence to A. Edwards ([email protected])
Background Information: Lateral ankle pain related to both
chronic etiologies and acute injury account for a significant
number of emergency room, primary care, and orthopedic visits.
MRI can play a vital part in determining the etiology and planning the treatment, surgical or conservative, of lateral ankle
pathology. Advances in technology and improved access to MRI
have resulted in its increased utilization. The purpose of this
exhibit is to create familiarity and comfort with MRI evaluation of
the lateral ankle with respect to the relevant anatomy and types
of pathology.
Educational Goals/Teaching Points: The goals are to define
the lateral ankle for the purpose of this educational exhibit;
review relevant MRI anatomy; discuss common and less common types of pathology; detail the primary and secondary MRI
findings related to various types of pathology, and relate mechanism of injury.
Techniques: In order to diagnose the etiology of lateral ankle
pain, one must be familiar with the structures and mechanics.
Pathology related to the tendons, such as tendinosis, tenosynovitis, various types of tears, subluxation, and dislocation, is relatively common and can be readily evaluated with MRI. Additionally,
the pathology related to the ligaments, such as mild or moderate
sprains as well as complete tears, is also relatively common and
can be readily evaluated with MRI. MRI also provides osseous
structural detail and increases sensitivity for detecting bone marrow edema and radiographically occult fractures. Although a
diagnosis of anterolateral impingement syndrome, nerve entrapment, or tendon entrapment can be determined after a thorough
physical examination, MRI can serve as an invaluable noninvasive
tool if there is an understanding of the anatomy and symptomatology.
Conclusion: With the excellent spatial resolution, soft tissue contrast, and improved field strength of newer MRI units, the lateral
ankle can be thoroughly evaluated for the various etiologies of
lateral ankle pain. In addition to allowing excellent visualization
of the tendons, ligaments, and nerves, MRI readily provides
osseous structural and bone marrow detail. Although the lateral
ankle consists of a well defined and anatomically confined space,
there is a wide variety of etiologies for both acute and chronic
lateral ankle pain. We hope that this exhibit will provide a high
yield and simplified approach for the evaluation of the lateral
ankle anatomy and pathology.
E305. Painful Ankle Syndromes – MRI Evaluation (CME
Credit Available)
Chhabra A.1; Yadav, S.2; Carrino, J. 1 1. Johns Hopkins,
Baltimore, MD; 2. Dr RML Hospital,Delhi, India;
Address correspondence to A. Chhabra (avneesh.chhabra@
yahoo.com)
Techniques: The exhibit will include MRI evaluation of normal
and abnormal peroneal tendons, peroneal retinacula and Os peroneum.
Conclusion: It is important for the radiologist to understand normal peroneal tendon anatomy and key MR imaging features of
various pathologies and associated syndromes. The differentiation between such lesions is useful to direct appropriate patient
management.
E307. Deltoid Ligament: MRI Evaluation
Chhabra, A.1; Carrino, J.1;Batra K.2,3; 1. Johns Hopkins,
Baltimore, MD; 2. Drexel, Philadelphia, PA; 3. University of Texas
Medical Branch, Galveston, TX
yahoo.com)
Background Information: Painful ankle syndromes have a
broad differential based on clinical evaluation. MRI provides excellent depiction of the abnormality and the underlying etiology.
Background Information: Deltoid ligament injuries are commonly missed on ankle MR evaluation. Partial tears and sprains
are more common than complete tears. We will present a spectrum of deltoid ligament abnormalities in this exhibit.
learn optimal ankle MR technique for musculotendinous and ligament evaluation; gain knowledge of various painful ankle syndromes, such as, painful os peroneum syndrome, painful os
naviculare syndrome, Os Trigonum syndrome, Haglund’s syndrome, Henry’s knot syndrome, sinus tarsi syndrome, tarsal tunnel syndrome and ankle impingement syndromes, and become
familiar with key MR imaging features of these syndromes.
learn optimal ankle MR techniques for ankle ligament evaluation;
gain knowledge of MR anatomy of various components of superficial and deep deltoid ligament with case examples, and become
familiar with various pathologies, such as partial tear, complete
tear, secondary degenerative changes, ganglion formation anteromedial and posteromedial impingement and association with
spring ligament pathology.
Techniques: The exhibit will address the painful accessory ossicles and evaluate other anatomic confined spaces of ankle where
abnormalities leading to painful ankle can be detected on MRI.
Techniques: The goal is for exhibit viewer to learn various components of superficial and deep portions of deltoid ligament and
their abnormalities.
Conclusion: MRI is an excellent tool to evaluate painful ankle
syndromes. The differentiation between these lesions is important to direct appropriate patient management.
Conclusion: It is important for the imager to recognize the deltoid ligament abnormalities for early management and prevention of long term morbidity.
E306. MR Evaluation of Peroneal Tendon Pathology
Chhabra, A.1; Sayed, A.2; Carrino, J. 1 1. Johns Hopkins,
Baltimore, MD; 2. Temple University Hospital, Philadelphia, PA; 3.
yahoo.com)
E308. MRI of the Achilles Tendon: Normal Anatomy, Pitfalls
and Common Pathology
Pierre-Jerome, C.1; Albastaki, U.1; Gothlin, J.1; Terk, M.2 1.
Sahlgrenska University Hospital, Molndal, Sweden; 2. Emory
University Hospital, Atlanta, GA
Address correspondence to U. Albastaki ([email protected])
Background Information: Peroneal tendon pathology is a common problem. MR imaging depicts various abnormalities related
to peroneal tendons and peroneal retinacula in an exquisite
manner.
Educational Goals/Teaching Points: The viewer of this exhibit
will learn optimal MR technique for evaluation of peroneal tendons; gain knowledge of normal MRI anatomy of peroneal tendons and associated variations with case examples, and become
familiar with MRI appearances of various pathologies, such as
longitudinal split tears, complete tears, tendon dislocations, tenosynovitis, deficient and abnormal peroneal retinacula, and painful
Os peroneum syndrome.
Background Information: The Achilles tendon is named after
the Greek hero Akhilleus whose damage to the tendon lead to
his fatal apprehension. The tendon runs from the musculotendinous junction of the gastrocnemius muscle to the bony cortex of
the calcaneus. Contrarily to most tendons, the Achilles tendon
does not cross over the joint space to reach its insertion point;
but it runs posterior to the ankle joint. The Achilles tendinopaties,
if not properly diagnosed and managed, can carry serious clinical
and biomechanical consequences leading to disability. This
exhibit will present the MR characteristics of the normal Achilles
tendon and imaging pitfalls, and present the common pathologies of the Achilles tendon as seeing on MRI.
279
Materials and Methods: The materials are from the radiological
archives of Emory University and Sahlgrenska University. The MR
images of the lower leg and ankle joint are reviewed. The imaging protocols from the two institutions are fairly similar for most
examinations. The imaging sequences include: SET1W sagittal
and coronal, STIR sagittal and STIR axial. The normal anatomy of
the tendon is analysed from images of the lower leg and ankle
from three asymptomatic volunteers. First, we study the normal
configuration–shape, size, signal intensity, origin and insertion of
the normal tendon. Secondly, we review images of patients with
different pathologies of the tendon and pathologies of the surroundings tissues affecting the tendon. The findings are classified
into two groups: nonoperative tendinopaties and operative
changes of the tendon.
Conclusion: Knowledge of the anatomy and pathology frequently encountered in conjunction with improved understanding of
the clinical features can aid in accurate diagnosis of impingement
syndromes at the ankle and hindfoot. Results: The normal anatomy of the Achilles tendon is illustrated
in three planes along with some pitfalls. The non-operative tendinopaties include: degenerative tendinosis, inflammatory tendonitis, infectious tendonitis, partial tendon tear, full tendon tear, tendonitis with bursitis, tenosynovitis, Achilles tendinopaties of the
diabetic foot associated with myositis and cellulitis. Of the operated tendon, we present the postoperative changes without tear
and postoperative changes with re-tear. There is one case of
transplanted tendon with re-tear.
Background Information: Baxter’s nerve, a branch of the posterior tibial nerve, supplies the plantar fascia and can be a source
of chronic heel pain.
the normal anatomy of the tendon, and to have a comprehensive
understanding of the tendon’s pathology.
Conclusion: This exhibit presents a didactic review of the anatomy and pathologies of the Achilles tendon.
E309. Impingement Syndromes of the Ankle and Hindfoot: A
Case-Based Review
Zbojniewicz, A.; Nguyen, T.; Mace, A. West Virginia University,
Morgantown, WV
Address correspondence to A. Zbojniewicz ([email protected])
Background Information: Impingement syndromes of the ankle
and hindfoot are a well recognized cause of chronic pain.
Understanding the clinical features, pathophysiology, and expected imaging features can improve the accuracy of reports and aid
in clinical management of patients.
Educational Goals/Teaching Points: The goal of this presentation is to review the anatomy and pathology of the ankle joint
and hindfoot, which may contribute to development of impingement. The presentation will consist of a brief review of the clinical features and anatomy, including normal variations that may
contribute to impingement, followed by reinforcement by multiple case presentations.
Techniques: Impingement syndromes can be divided based on
location and include anterior, anterolateral, and posterior
impingement as well as impingement at the sinus tarsi. Multiple
imaging modalities including MRI, CT, SPECT-CT and plain radiography can be useful in conjunction with the clinical history to aid
in diagnosis.
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E310. MRI of Baxter’s Nerve: Anatomy, Variations and
Pathology
Brooks-Sienkiewicz, S.1; Morrison, W.1; Zoga, A.1; Elias, I.2;
Carneiro, C.3 1. Thomas Jefferson University Hospital, Havertown,
PA; 2. Rothman Institute, Philadelphia, PA; 3. No Institutional
Affiliation
Address correspondence to S. Brooks-Sienkiewicz ([email protected])
Educational Goals/Teaching Points: Knowlege of anatomy and
normal variation, and recognition of pathology of Baxter’s nerve
(and the tarsal tunnel that it courses through) is important in
patients with heel pain.
Techniques: Baxter’s nerve courses through the tarsal tunnel and
can be affected by pathology within it.
Conclusion: This exhibit will depict the range of findings seen on
MRI.
E311. Multimodality Imaging of Calcaneal Lesions (CME
Credit Available)
Motamedi, D.1; Young, S.1; Bauer, A.2; Modarresi, S. 3; Dym, J.1;
Learch,T.1 1. Cedars-Sinai Medical Center, Los Angeles, CA; 2. No
Institutional Affiliation; 3. West Los Angeles Wadsworth VA
Medical Center
Address correspondence to D. Motamedi ([email protected])
review various usual and unusual cases of calcaneal pain; provide a multimodality pictorial presentation of various entities
affecting the calcaneus, and delineate a practical approach to differential diagnosis of calcaneal abnormalities.
Educational Goals/Teaching Points: The exhibit will include an
overview of various usual and unusual causes of calcaneal pain
on plain film, CT, and MRI; a review of imaging findings with
emphasis on pattern-based approach to differential diagnosis,
and sample cases (including coalition, Haglund’s deformity, stress
fracture, lover’s fracture, diabetic ankylosis, rheumatoid arthritis,
reactive arthritis, gout, retrocalcaneal bursitis, osteomyelitis, unicameral bone cyst, intraosseous lipoma, osteoid osteoma, giant
cell tumor, and metastases).
Techniques: The exhibit will prove an anatomic review of the
calcaneus and common normal variants; a physiological review
of calcaneal vascularity, articulations, and stress distribution, and
a multimodality review of various usual and unusual pathologic
entities affecting the calcaneus.
Conclusion: After reviewing this exhibit, radiologists will identify
various causes of calcaneal pain seen on plain film, CT, and MR
imaging and provide valid differential diagnosis using a patternbased approach; recognize the appearance and expected distribution of calcaneal lesions and fractures to aid in the evaluation
of challenging cases, and understand the importance of recommending appropriate cross-sectional imaging such as MRI in
appropriate cases for further evaluation or biopsy planning.
E312. Calcaneus Fracture: What Should the Radiologist
Communicate to the Referring Clinician? (CME Credit
Available)
Bodiwala, R.; West, O.; Kumaravel, M. University of Texas Health
Science Center at Houston, Houston, TX
Address correspondence to R. Bodiwala (ravibodiwala@gmail.
com)
Background Information: Calcaneus is the most commonly
fractured tarsal bone, accounting for 2% of overall fractures and
60% of major tarsal injuries. The aim of this exhibit is to review
the anatomy of the calcaneus, describe the pathomechanics of
calcaneal injury, enlist the common and uncommon fracture patterns, and to provide the radiologist with knowledge of certain
key fracture characteristics that have significant prognostic implications. In achieving this purpose, we will use images acquired
using conventional radiography, CT, MRI, and 3D volume renderings.
Educational Goals/Teaching Points: The presentation is in a
case-based format. Multiple cases are presented that describe the
calcaneal fracture patterns, for example, intra-articular, extra-articular, joint depression type, and tongue fracture type. Sanders’
and Munichs CT classification of calcaneal fractures will also be
reviewed. We will also discuss management of these different
fracture patterns, as well as potential complications.
Techniques: The calcaneus has three articulating surfaces with
the talus, namely the anterior facet, middle facet, and the posterior facet. The fourth calcaneal articulating surface is between the
calcaneus and cuboid. We will use 3D volume rendered images
to depict the normal calcaneal anatomy. Most calcaneal fractures
result from axial loading, which produces compression and shear
type fracture lines. We will illustrate these fracture lines using
graphics.
Conclusion: Sanders’ and Munichs CT classification of calcaneal
fractures has provided a road map for a consensus in reporting
calcaneal injuries, and has been helpful in planning treatment
and determining prognosis. Continued advancement in CT and
MR technology has enabled the radiologist to provide the referring clinician with key knowledge to avoid certain management
pitfalls. For instance, injury to the peroneal tendon or the neurovascular bundle that runs along the medial border of the calcaneus may occur directly from trauma, or as an unintended consequence of fracture reduction. The radiologist should play an
important role in not only diagnosing these injuries, but also
forewarning the treating clinician about the possibility of these
injuries.
E313. Down at the Heel: The Radiology of Calcaneal Injuries
Carr, R.; Nett, M.; Sadro, C.; Chew, F. University of Washington,
Seattle, WA
Address correspondence to F. Chew ([email protected])
Background Information: Injuries of the calcaneus occur
through a variety of mechanisms and may range in radiologic
conspicuity from the obvious to the truly occult. Some fractures
are devastating in their sequelae, while others may progress to
functional recovery following proper treatment. The radiologist
should be able to detect and fully characterize these injuries in
order to optimize patient care. Educational Goals/Teaching Points: Following the completion
of this educational activity participants should be able to discuss
the normal imaging anatomy of the calcaneus and its articulations; recognize and distinguish among the various types of calcaneal injuries and their mechanisms, and summarize the typical
treatment and outcome of various calcaneal injuries.
Techniques: Emphasis is placed on the normal calcaneal anatomy, common and uncommon injury patterns, epidemiology,
treatment, and expected outcomes. The appropriate use of radiography, CT, and MRI is discussed.
Conclusion: Calcaneal injuries are common and accurate detection and full characterization is imperative for appropriate management. Understanding the surgical treatment of these injuries
will allow the radiologist to detect complications. E314. The “Dreaded Black Line” and Other Stress Fractures
of the Tibia
Manzoul, S.; Brindle, K. George Washington University, Bethesda,
MD
Address correspondence to K. Brindle ([email protected])
Background Information: The tibia is one of the most common
locations of stress fractures. Occurring in runners and other athletes, stress fractures of the tibia are seen most frequently at the
posteromedial cortex of the proximal to mid tibial shaft. Tibial
stress fractures though can, in fact, occur anywhere along the
tibia. They can also be of the insufficiency type. One unusual
stress fracture that is commonly missed occurs along the anterior
cortex of the tibia. It is frequently multiple and can be bilateral.
Called the “dreaded black line” by some, the term refers to the
propensity for delayed healing and associated complications.
X-ray evaluation of stress fractures is usually negative early on.
The diagnosis can be made at this stage with radionuclide bone
scan, MRI or sometimes CT scan. Radiographs typically become
positive after several weeks.
Educational Goals/Teaching Points: It is the goal of this exhibit
to review the radiologic findings of tibial stress fractures. Because
their location and imaging appearance can vary and findings are
typically subtle, they can be easily overlooked or mistaken for
other pathology. The clinical features, radiographic findings, and
follow-up of the “dreaded black line” type stress fracture will be
emphasized but other types of tibial stress fractures will be discussed. The focus will be on x-ray analysis, but radionuclide bone
scan, MRI, and CT features of stress fractures will also be
addressed.
281
Techniques: Radiographically, tibial stress fractures can present
as cortical thickening, periosteal reaction, or a linear band of sclerosis. A fracture line may or may not be present. When seen, the
fracture line can be horizontal or vertical. A bone scan will demonstrate focal increased uptake of radiotracer at the site of the
fracture and can be used to distinguish them from shin splints.
Bone marrow edema, periosteal edema, and a fracture line are
findings that can be seen on MRI. CT findings include endosteal
and periosteal reaction as well as a lucent fracture line through
the cortex of the bone.
Conclusion: The variable and often subtle findings of fatigue and
insufficiency type tibial stress fractures will be reviewed. The
review will encompass the unique features of stress fractures of
the anterior tibial cortex including clinical presentation and outcome.
E315. Functional Joint Imaging Using 256-Detector Row CT:
Technical Feasibility (CME Credit Available)
Kalia, V.1; Obray, R.2; Filice, R.2; Fayad, L.2; Murphy, K.2; Carrino,
J.2 1. Johns Hopkins University School of Medicine, Baltimore,
MD; 2. Johns Hopkins University Medical Center, Baltimore, MD
Address correspondence to V. Kalia ([email protected])
Objective: Musculoskeletal functional imaging should encompass the real-time (dynamic) depiction of joints in motion (kinematic). Our goal was to determine the technical feasibility of performing dynamic-kinematic imaging of the knee and wrist joints
using a new modality, 256-slice MDCT.
Materials and Methods: After informed consent was obtained,
six adult nonpregnant volunteer subjects were enrolled for 256detector row CT imaging of the knee and wrist, with three subjects allocated to bilateral knee imaging for patellofemoral evaluation (n=6 knees) and three subjects allocated to bilateral wrist
imaging for supination-pronation (n=6 wrists) and radioulnar
deviation (n=6 wrists). Participants had no history of joint pathology or surgery in the examined joints. All examinations were performed using a prototype FDA approved 256-multidetector row
CT (Toshiba Medical Systems, Tochigi-ken, Japan). The x-ray
detector is composed of 256 x 0.5 mm detectors delivering 12.8
cm of coverage in the z-axis. A single rotation of the detector
takes 0.5 seconds. Image acquisition time was 10 seconds for
each volume. 2D multiplanar reformations, 3D surface shaded,
volume rendered, and 4D cine loop images were reconstructed
from the source data.
Results: No device malfunctions or complications occurred. Knee
cine images showed normal translation of the patella from multiple angles and the extensor mechanism tendons throughout
knee flexion. Regarding radioulnar deviation, wrist cine images
showed normal “fluid-like” movement of the carpus at multiple
angles and positions of associated soft tissues throughout the
range of motion. Regarding pronation/supination, wrist cine
images showed normal rotation of the radius with respect to the
ulna and positions of associated soft tissues throughout the
range of motion. The alignment of the carpus and the distal radioulnar joint were well depicted and qualitatively showed normal
motion without an instability pattern.
282
Conclusion: In this pilot investigation, we found that 256-MDCT
dynamic-kinematic imaging adequately depicted by subjective
visualization real time unconstrained joint motion of the knee
and wrist bilaterally from a single acquisition. We chose the knee
joint because patellofemoral maltracking is a common disorder.
We choose the wrist because it is a complex joint with multiple
small articulations and degrees of freedom with subtle ranges of
motion. 256-MDCT may be useful in diagnosing patellar tracking
disorders and instabilities of the distal radioulnar joint (DRUJ).
E316. Patterns and Significance of Bone Marrow Edema in
the Knee: A Case Based Review
Nicola, R.1; Dheer, S.2; Zoga, A.3; Morrison, W.3 1.University of
Medicine and Dentistry of New Jersey-Robert Wood Johnson
Medical School, Cooper University Hospital, Camden, NJ; 2. South
Jersey Regional Medical Center, Cherry Hill, NJ; 3. Thomas
Jefferson University Hospital, Philadelphia, PA
Address correspondence to S. Dheer ([email protected])
Background Information: MRI studies are a mainstay in the
diagnosis and management of common musculoskeletal disorders affecting the knee. It is important for the radiologist and
treating physician to recognize various patterns of disease and
their significance on knee MRI’s.
Educational Goals/Teaching Points: The goals are to inform
and review with participants the patterns and significance of
bone marrow edema encountered on MRI examinations of the
knee. This will be done in an interactive, case review format.
Techniques: Specific cases to be shown include: pivot shift injury
with anterior cruciate ligament tear, transient patellar dislocation,
occult fracture, osteochondral fracture, subenthesial marrow
edema in the setting of quadriceps and patellar tendinosis/tears,
reactive edema as a sign of meniscal tear, femoral and tibial
subchondral insufficiency fractures (formerly referred to as spontaneous osteonecrosis of the knee/tibia) and osteomyelitis.
Conclusion: Following the conclusion of this activity, the participant should have a better understanding of the various patterns
of bone marrow edema encountered on knee MRI’s, any associated injuries and the prognostic significance of various injury patterns.
E317. MRI of Cystic Lesions In and Around the Knee
Lien, L. 1; August, D. 1; Santa Maria, J. 1; Burns, J.; Hunter, J. 2;
Tehranzadeh, J. 1 1. University of California-Irvine, Orange, CA;
2. Lawrence J. Ellison Ambulatory Care Center, Sacramento, CA
Address correspondence to L. Lien ([email protected])
Background Information: Cystic lesions are common in knee
joint MR interpretation which include bursa, ganglion cyst, meniscal cyst, abscess, cystic neoplasm, and cystic adventitial disease
of the artery, etc. It is important to be familiar with MR appearance of these lesions to avoid unnecessary surgery and guide
appropriate treatment.
Educational Goals/Teaching Points: The goal is to review common and less common cystic lesions in/around the knee joint
and the characteristic MR imaging findings.
Techniques: Imaging classification is as follows: 1.
Compartment: intracapsular vs. extracapsular. 2. Location: anterior, medial, lateral, and posterior. 3. Related Anatomic Structure:
bursa, ganglion, cruciate ligament, meniscus, bone, proximal tibiofibular joint, peroneal nerve, and popliteal artery. 4. Pathologic
Nature: neoplastic vs. non-neoplastic.
Conclusion: The current exhibit will review the MR appearance
of common and less common cystic lesions of the knee based
on anatomic compartment, location, related anatomic structures,
and pathologic nature.
E318. Imaging of Meniscal Tear and Cartilage Damage at
1.5T, 3T, and 7T
Sammet, S.1; Wassenaar, P.1; Zalewski, S.2; Stoez, M.2; Knopp,
M.1 1. The Ohio State University, Columbus, OH; 2. Philips
Medical Systems, Highland Heights, OH
Objective: Meniscal injuries and cartilage abnormalities are often
difficult to diagnose in MRI at conventional field strengths due to
their small sizes and low contrast. Imaging may benefit from high
signal to noise ratios and contrast mechanisms at ultra high field
strengths. The objective of this study was to compare image
quality of a knee injury at 1.5T, 3T, and 7T based on contrast and
artifacts.
Materials and Methods: Four healthy volunteers (age 25-32
years old) and one patient with a known meniscal tear (51 year
old male) were imaged at 1.5T, 3T, and 7T (Philips Healthcare,
Cleveland, OH) using 8-channel knee coils. The subjects were
scanned in a prone position with their knee in dedicated knee
coils at similar positions relative to the coil walls. MR sequences
were optimized at 7T on the healthy volunteers, after which
imaging was performed on the patient with the meniscal tear
across all field strengths using the same protocol. Images were
acquired in both sagittal and coronal planes, using a turbo spin
echo sequence (TSE), both with and without fat saturation. The
sequences used repetition time/echo time=3,000/25 milliseconds, echo train lengths 13, with an inplane resolution of 0.3 x
0.3mm2 and a slice thickness of 2.5 mm.
Results: In a patient with a knee injury a meniscal tear could be
identified in the same anatomical location on coronal
MR-images acquired at 1.5T, 3T and 7T. Fat saturation did not
add to the visualization of the injury. An increase in contrast of
cartilage signal compared to that of surrounding tissue can be
seen at 7T. This increase aids in the depiction of the lesion in the
meniscus, as well as potential cartilage damage. A stronger susceptibility effect can be observed as hypointense regions at the
intersection of cartilage and cortical bone. A slight shift in the
cartilage signal causes the susceptibility effects to be less visible
caudal to the joint.
Conclusion: At ultra high field strengths (7T), a higher contrast is
produced in the meniscus and knee cartilage compared to lower
field strengths. This contrast not only allows better depiction of
meniscal tears, but is promising in the depiction of cartilage
damage in human knees.
E319. Neoplastic Disease About the Knee:
Radiologic-Pathologic Correlation
Zbojniewicz, A.; Nguyen, T.; Mace, A.; Wilks, K.; Ward, J. West
Virginia University, Morgantown, WV
Address correspondence to A. Zbojniewicz ([email protected])
Background Information: Imaging of the knee, primarily MRI, is
performed frequently and on a daily basis in most imaging centers. This exhibit aims to review both common and uncommon
neoplastic disease encountered while imaging the knee with
illustration using multiple modalities and pathologic correlation.
to provide an improved ability to describe, characterize and diagnose neoplastic disease that may be encountered when imaging
the knee.
Techniques: Neoplastic disease about the knee can occur both
within the bones as well as in extraskeletal soft tissues including
within the joint and the surrounding soft tissues. Discussion of
pathology will be divided into these three areas with emphasis
on differential diagnoses, key imaging features, and pathologic
correlation with the aim to improve understanding of the imaging appearances.
Conclusion: Neoplastic disease about the knee may be encountered more frequently than expected given the large number of
knee MRIs performed in daily practice. This exhibit allows the
interpreting radiologist increased confidence in interpreting these
findings when something other than the expected sports medicine diagnoses are encountered.
E320. Relationship Between Medial Femoral Condyle
Osteochondral Defects and Tibial Spine Morphology
Brooks-Sienkiewicz, S.1; Morrison, W.1; Zoga, A.1; Carneiro, C.2 1.
Thomas Jefferson University Hospital, Philadelphia, PA; 2. No
Address correspondence to S. Brooks-Sienkiewicz ([email protected])
Objective: The objective is to evaluate whether there is an association between tibial spine morphology and osteochondral
defects (OCDs) at the medial femoral condyle.
Materials and Methods: MRI of 29 knees with OCDs at the
medial femoral condyle were evaluated by two musculoskeletal
radiologists. This group included nine patients with healed OCDs.
The size and morphology of the medial tibial spine were noted,
assessed on coronal images at midline and at the center of the
OCD. Size was evaluated relative to lateral spine size
(medial:lateral) with categories including 1:>1 (I), 1:1 (II), 1-2:1
(III), and >2:1 (IV). Absolute medial tibial spine height was measured at the midline with respect to the tibial plateau. Morphology
was evaluated as pointed (I), round (II), partial facet (III), and
complete facet (IV). These findings were compared with 29 MRI
knees of age-matched patients without OCDs. Comparison was
also made between healed and nonhealed OCDs.
Results: In the OCD group, 3% of patients had type I size, 14%
type II, 24% type III, and 59% type IV. Morphology in the OCD
group included 28% type I, 28% type II, 24% type III, and 21%
type IV. In the healed OCD subset, 11% of patients had type I
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size, 22% type II, 33% type III, and 33% type IV. Morphology in
the healed subset included 33% type I, 22% type II, 22% type III,
and 22% type IV. In the control group, 0% of patients had type I
size, 7% type II, 34% type III, and 59% type IV. Morphology in
the control group included 24% type I, 10% type II, 66% type III,
and 10% type IV. Average tibial spine height measured 8.4 mm
in the OCD group, 9.4 mm in the healed subset, and 7.8 mm in
the controls. There was no significant difference in any of the
parameters measured.
Conclusion: There is no evidence of an association between
medial femoral condyle OCDs and tibial spine morphology. There
is also no difference in tibial spine characteristics in healed and
nonhealed OCDs.
E321. The Spectrum of Chondral, Osteochondral and
Subchondral Abnormalities of the Knee
Borzykowski, R.1,2; Friedman, S.1,2; Finkelstein, M.1,2; Thornhill,
B.1,2; Shi, A.1 1. Montefiore Medical Center, Bronx, NY; 2. Albert
Einstein College of Medicine, Bronx, NY
Address correspondence to B. Thornhill ([email protected])
Background Information: The spectrum of abnormalities involving the articular cartilage, the osteochondral junction and the
subchondral region of the knee includes injuries, degenerative
changes, ischemic changes, tumor and infection. Awareness of
the importance of these abnormalities, the sometimes confusing
nomenclature surrounding this area, and the radiographic and
MRI appearances of the various lesions is essential for accurate
diagnoses.
Educational Goals/Teaching Points: The structure of cartilage
and types of cartilage will be briefly reviewed. Acute and chronic
chondral and osteochondral injuries will be explained and illustrated. The importance of assessing the cartilage on all knee MRI
examinations will be stressed. Various subchondral abnormalities
including fractures, post-traumatic sequelae, degenerative changes and classic osteonecrosis will be included. The terminology
referable to these areas will be reviewed, including osteochondral injury, osteochondrosis dissecans, and the misnomer of
“spontaneous” osteonecrosis, a term no longer thought to be
accurate. Application of the various terms according to the age of
the patient, presumed etiology and chronicity of the abnormalities will be included.
Techniques: The histology of cartilage, the osteochondral junction and the subchondral bone will be illustrated using diagrams.
The abnormalities will be demonstrated using radiography and
MRI. Commonly used MRI techniques available on a widespread
basis will be emphasized.
Conclusion: The viewer should come away from the exhibit with
an understanding of the various abnormalities of the articular
and subarticular regions of the knee including etiologies, imaging
appearances and terminology. The knowledge regarding these
relatively common findings will be readily applicable to routine
diagnostic studies.
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E322. Bisphosphonate-Related Femoral Insufficiency
Fractures
Bush, L.; Chew, F.; Richardson, M., Ott, S.; Goodman, M.; Mulcahy,
H. University of Washington, Seattle, WA
Address correspondence to L. Bush ([email protected])
Background Information: Osteoporosis, metabolic conditions
that predispose to low energy fractures, and lytic metastases are
important indications for the administration of bisphosphonate
medications. Bisphosphonates increase bone mineral density by
decreasing osteoclast activity. It is well documented that
bisphosphonates reduce fracture morbidity and mortality, and
they are widely used. Ironically the very mechanism by which
these medications suppress osteoclast activity can adversely
affect normal bone remodeling. Recent literature demonstrates a
rare, but concerning, pattern of bisphosphonate-related femoral
insufficiency fractures. Unresolved areas of microscopic damage
may accumulate at critical sites of mechanical bending stress to
form an insufficiency fracture; particularly in the subtrochanteric
region of the proximal femoral shaft. These insufficiency fractures
have a characteristic clinical presentation and imaging appearance and can progress with minimal force into a complete, transverse, potentially life-threatening femoral shaft fracture.
Educational Goals/Teaching Points: After completing this educational activity the participant will be able to discuss the potential for patients on bisphosphonate medications to develop femoral insufficiency fractures; recognize the characteristic appearance of bisphosphonate-related insufficiency fractures in multiple
modalities prior to fracture completion, and recommend expedient intervention to reduce the life-threatening risk of fracture
completion.
Techniques: Normal biomechanics of bone remodeling requires
a balance of osteoclast and osteoblast activity to respond to
microscopic injury and mechanical stress. Bisphosphonate medications can overly suppress the osteoclast component of bone
remodeling allowing formation of insufficiency fractures at sites
of critical mechanical stress. We demonstrate these lesions with
nuclear scintigraphy, radiography, CT, and MRI.
Conclusion: This interactive computer-based educational exhibit
presents a rare complication of bisphosphonate therapy with a
characteristic imaging appearance. Radiologists who are aware of
this entity and recognize the characteristic lesion of an insufficiency fracture in this setting can alert and educate the referring
provider; thereby reducing the risk of life-threatening fracture
completion in these patients.
The views expressed in this manuscript are those of the authors
and do not reflect the official policy or position of the
Department of the Army, Department of Defense or the U.S.
Government.
E323. Femoral Head Fractures: Review of Imaging Features
with a Focus on Management (CME Credit Available)
Spence, S.; Kumaravel, M. University of Texas Health Science
Center at Houston, Houston, TX
Address correspondence to S. Spence (Susanna.C.Spence@uth.
tmc.edu)
Background Information: Femoral head fractures are a common injury in the setting of posterior acetabular fractures. While
the acetabular fracture is generally well described, the femoral
head fracture is frequently missed, potentially with devastating
consequences. The typical imaging features of femoral head fractures are reviewed in this presentation, including the Pipkin classification, however the focus of this exhibit is to demonstrate the
appropriate management of these injuries, based on the severity
of the injury as classified by the interpreting radiologist. The
expected postoperative appearance as well as potential complications will be illustrated.
Educational Goals/Teaching Points: After completing this educational activity the participant will be able to recognize that femoral head fractures are common in the setting of posterior acetabular fractures, and the interpreting radiologist must immediately
institute a dedicated search for femoral head fractures upon recognition of an acetabular fracture; recognize the types of femoral
head fractures; recognize the implications of the femoral head
fracture pattern for patient management; recognize the postoperative appearance of femoral head fracture repair, and recognize
the potential late complications of femoral head fractures.
Techniques: The femoral head is often injured in a patient with
multiple additional distracting injuries. Large portions of the femoral head constitute weight bearing portions of the hip joint, and
unrecognized injury may have devastating functional consequences. Femoral head fractures may be difficult, or impossible,
to see by plain film radiography. An appropriate search pattern
must be instituted. The Pipkin classification has important implications for patient management. Followup of the postoperative
patient is important to recognize complications or issues requiring further intervention
Conclusion: An appropriate search pattern for femoral head fractures, particularly when cued by the presence of acetabular fractures, allows for a rapid identification and accurate categorization
of these injuries. While there remains some controversy as to the
management of these injuries, surgical intervention is often indicated for injuries to the weight bearing surface of the femoral
head. Inadequate management may result in decreased mobility
and even joint replacement, and it is further important for the
radiologist to recognize the postoperative appearance and potential complications.
E324. Review of Iliopsoas Anatomy and Patholody as Seen
on MDCT (CME Credit Available)
Gupta, S.; Morgan, J.; Sadler, M. St. Vincent’s Catholic Medical
Center, New York, NY
Address correspondence to S. Gupta ([email protected])
Background Information: The exhibit will review anatomy of
the iliopsoas compartment as visualized on MDCT; discuss the
methods by which disease can spread to this compartment; illustrate different types of pathology involving the iliopsoas compart-
ment, and provide radiologists with the knowledge necessary for
accurate and rapid identification of these pathological processes.
Educational Goals/Teaching Points: The iliopsoas compartment acts as a mechanism of spread of pathology in the body.
Knowledge of its anatomy and the pathological processes that
can occur in this region is important for early identification of
potentially fatal etiologies.
Techniques: The exhibit will include normal anatomy of the iliopsoas muscle and its appearance on MDCT; mechanisms by
which disease can spread to the iliopsoas compartment and
abnormalities involving the iliopsoas compartment including
infection (including various examples of psoas abscesses secondary to organisms such as tuberculosis), hemorrhage, and neoplastic disease.
Conclusion: The iliopsoas compartment is an important location
of pathology in the body. Spread of pathology to this area can
occur via a variety of methods. Understanding the types of
pathology that can spread to this region, as well as their appearance on MDCT imaging, is important in early diagnosis.
E325. Femoroacetabular Impingement Syndrome: An
Overview (CME Credit Available)
Bathala, E.; Peterson, J. Mayo Clinic, Jacksonville, FL
Address correspondence to E. Bathala (bathala.elizabeth@mayo.
edu)
Background Information: Femoroacetabular impingement
(FAI) is a major factor in the early development of debilitating
osteoarthritis of the hip. The syndrome is caused by abnormal
contact between the osseous protrusions of the acetabulum and
the femur during hip movement. There are two types which can
overlap, the cam type and the pincer type. Each type of FAI is characterized by a different clinical picture as well as different imaging
features. The purpose of this exhibit is to educate radiologists on
the clinical syndrome and the imaging findings of FAI in order to
allow earlier detection and treatment. Additionally, there will be
specific education concerning the types of treatment for FAI.
the clinical findings in patients with FAI; distinguish the two types
of FAI, both anatomically and clinically; review the etiology of
each type of FAI; review the imaging findings of FAI on radiography, CT and MRI including specific signs and diagnostic criteria,
and discuss the various treatment options available to decrease
the overall risk of severe early osteoarthritis of the hip necessitating joint replacement.
Techniques: Cam type FAI is primarily a femoral abnormality. It is
caused by an abnormal femoral head-neck morphology which
can be identified on lateral hip radiographs by visualizing an offset. MR imaging can be useful by evaluating the anterior alpha
angle on sagittal oblique imaging which is used to determine the
sphericity of the femoral head. The Pincer type of FAI is primarily
an acetabular abnormality and is caused by acetabular over-coverage. It can be seen as a “crossover” or “figure-of-eight” sign on
radiography. On MR imaging, pincer type FAI can demonstrate a
deep acetabulum and signs of osseous impaction along the femoral neck as well as cartilage damage.
285
Conclusion: In conclusion, early diagnosis of FAI is important
because of the debilitating nature of the advanced disease and
the fact that there are treatment options which can prevent the
progression of the disease.
E327. Hardware Failure in Total Hip Arthroplasty: What the
Orthopedic Surgeon Needs to Know (CME Credit Available)
Roberts, K.; Simoncini, A.; Hollister, A. Louisiana State University
Health Sciences Center-Shreveport, Shreveport, LA
Address correspondence to K. Roberts ([email protected])
E326. Femoroacetabular Impingement: Can Indirect MR
Arthrography be Considered a Valid Method in Detection of
Endoarticular Damages?
Background Information: Total hip replacement is the arthroplasty most frequently encountered by the radiologist. According
to the National Hospital Discharge Survey 1998-2005, more than
230,000 total hip replacements were documented in 2005 and
more than 30,000 total hip replacement revisions were documented in the same year. This number continues to rise with the
aging of the American population. Frequent radiographic followup is indicated to assess the alignment and stability of these
prostheses, and orthopedic surgeons use certain criteria to determine if radiographic findings are of clinical significance in the
management of total hip arthroplasty. This exhibit will showcase
common imaging findings in several cases of total hip arthroplasty failure along with a detailed discussion of which parameters must be assessed for optimal interpretation in order to provide the most clinically useful information to referring orthopedists. When possible, correlation with intraoperative findings will
be provided.
Zerbi, A.1; Stradiotti, P.2; Pozzi ,G.3; Sironi, S.3 1. Istituto
Ortopedico Galeazzi, Milano, Italy; 2. A.O. San Carlo Borromeo,
Milano, Italy; 3. Univerisità Degli Studi Milano-Bicocca, Azienda
Ospedaliera San Gerardo, Monza, Italy
Address correspondence to A. Zerbi ([email protected])
Objective: Femoroacetabular impingement (FAI) results from an
abnormal relationship between the proximal femur and the acetabulum. Two distinct types of FAI can be distinguished: “cam
FAI” caused by jamming of an abnormal femoral head and “pincer FAI”, that results from acetabular abnormality. That leads to
abutment of the femoral neck against the acetabular rim and can
cause labral and/or chondral lesion. Direct MR arthrography
(d-MRa) is actually considered as the gold-standard in detecting
intra-articular damages. The aim of this study is to evaluate a
new method for detecting intra-articular damages correlated to
FAI, based on an indirect MR arthrography (i-MRa) performed
after endovenous injection of contrast medium and patient’s
physical activity. All patients underwent MR, d-MRa and i-MRa;
results were then compared.
Materials and Methods: Between October, 2007 and July,
2008, 21 hip joints (nine left, 12 right) in 17 patients (eight
women, nine men; age range, 15–47 years; mean age, 32 years)
with clinical suspicion of FAI were examined either at MR imaging, i-MRa and d-MRa. All the patients had previously had an
anteroposterior radiograph of the pelvis and a lateral frog-leg
radiograph of the affected hip. Sensitivity and accuracy of the two
methods have been calculated. Interobserver agreement has
been also evaluated with Cohen’s K statistic.
the structure of the basic total hip arthroplasty prostheses frequently encountered by the radiologist; present and describe
common imaging findings associated with total hip replacement
failure, providing correlation with intraoperative findings when
possible, and detail the information which should be included in
radiologic reports to optimize their utility to the referring clinician.
Techniques: Key imaging findings will be displayed in electronic
format, providing correlation with intraoperative findings when
possible.
Conclusion: Orthopedic hardware failure in total hip arthroplasty
is frequently documented by radiographic imaging. Referring
orthopedists require detailed information acquired by imaging
studies in order to optimize management of the failed prosthesis.
The radiologist’s report should contain certain clinically relevant
information to aid the referring clinician in his or her management decisions when considering possible revision of total hip
arthroplasty.
Results: Eleven out of 21 hips analyzed had cam-type alterations
(52%), two pincer-type and two mixed cam/pincer-type. The values of sensitivity calculated in detection of the labral lesions
were 29% for standard MR and 76% for i-MRa (confidence level:
95%=0.2).The values of sensitivity in detection of late osteoarthritic changes were 100% for both the methods. The accuracy of
standard MR was 67% in detection of condral defects and 38%
for labral defects. For the i-MRa the values of accuracy were of
100% in condral defects detection, 76% in labral defects and
100%. Both the methods have shown the same accuracy in
detection late osteoarthritic changes (100%).Direct MRa did not
show a significantly higher sensitivity in comparison to indirect
MRa (p<0.05).
E328. My Hip Hurts Doc! How Can We Help Referring
Clinicians?
Smith, S.1; Mazzie, J.2; Scalcione, L.2; Math, K.3; Grossman, M.2;
Katz, D.2 1. University of Maryland, Baltimore, MD; 2. WinthropUniversity Hospital, Mineola, NY; 3. Beth Israel Medical Center,
New York, NY
Conclusion: MR arthrography is an indispensable instrument for
the detection of condral and labral lesions and it gives important
data in patient surgical planning. Indirect MRa has a significantly
higher sensitivity compared to traditional MR and sensitivity
equal to that of direct MRa. Indirect MRa is also easily reproducible and might be the imaging modality of choice in detecting
condral lesions in FAI.
Background Information: The history accompanying radiographs of the pelvis and hip from the emergency department will
often state simply “hip pain”. What does that mean for the radiologist, and what should be assessed on every hip and pelvic radiograph? The purpose of this exhibit is to present the imaging
findings of common and uncommon causes of hip pain using a
variety of imaging modalities.
286
Educational Goals/Teaching Points: Fractures, both traumatic
and pathologic, inflammatory processes, and femoral acetabular
impingement syndrome, will be presented and reviewed.
Additionally, findings such as bursitis, labral tears, and
osteonecrosis will be reviewed. Other nonprimary hip pathologies will be shown, including sacral insufficiency fractures, disc
herniations which can cause referred pain, and unanticipated
abdominal pathology such as hernias, renal and ureteral calculi,
and vascular lesions. Herniation pits, which are associated with
femoral acetabular impingement syndrome, will also be discussed.
Techniques: The emphasis will be on plain radiographic findings
and the differential diagnosis, but cross-sectional imaging findings of hip pathology in patients presenting with pain will also be
presented, including CT and MR examinations.
Conclusion: The radiologist needs to keep in mind the spectrum
of pathology, musculoskeletal or otherwise, which may cause
patients to present with hip/pelvic pain and to undergo plain
radiographic studies, particularly in the emergency department
setting.
E330. Sacral Pathology Revisited: A Multimodality Approach
Cao, M.1; Masih, S.1,2; Modarresi, S.1,2 1. University of California,
Los Angeles, Los Angeles, CA; 2. Veterans Administration West Los
Angeles Medical Center, Los Angeles, CA
Address correspondence to M. Cao ([email protected])
review the ligamentous, nervous and bony anatomy of the sacrum; discuss key radiographic findings in a spectrum of pathologic conditions involving the sacrum, and highlight the use of multiple imaging modalities in the diagnosis of sacral conditions.
Educational Goals/Teaching Points: The exhibit will include a
review of sacral anatomy (including bones, ligaments, joints, and
nerves) ; congenital lesions of the sacrum ; infection of the sacrum; trauma in the sacrum, and neoplastic tumors of the sacrum (including sacral canal tumors, benign bony lesions, malignant bony neoplasms).
Techniques: A multimodality approach including plain radiography, CT, and MRI is taken in the study of the bony and soft-tissue
components of the sacrum. Key radiographic findings will be
highlighted for various pathologies.
Conclusion: After the review of this exhibit, the participant
should be able to describe the anatomy of the sacrum, discuss
the imaging findings of a variety of congenital, infectious, traumatic and neoplastic sacral conditions, and recognize the value
of x-ray, CT and MRI in the diagnosis of sacral pathologies.
E331. Cervical Spine Trauma: Correlation Between MDCT
and MRI (CME Credit Available)
Cortes, C.; Garcia, L.; Ballester, G.; Gomez, A.; Colon, E.; Vidal, J.;
Rivera, G. University of Puerto Rico, San Juan, PR
Address correspondence to C. Cortes ([email protected])
Background Information: About 12,000 to 13,000 cervical
spine injuries occur yearly in the United States, of which an estimated 6,000 result in death and 5,000 in quadriplegia.
Approximately 80% of these patients are between the ages of 18
to 25 years. The premature death or disability of these individuals
has a large economical and social impact. The radiologist plays
an important role in identifying these injuries and providing information that will influence clinical management. Given the
increased role of MDCT and MRI in the evaluation of the trauma
patient, it is imperative for the radiologist to be familiar with the
normal cervical spine anatomy, as well as to be able to identify
the most common cervical spine injuries using these modalities.
Educational Goals/Teaching Points: After completing this educational activity the participant will be able to describe the normal cervical spine anatomy (MDCT and MRI); review the most
common patterns of cervical spine injuries; understand the
importance of using multiplanar reconstructions (MPR); understand the complementary role of cervical MRI to MDCT, particularly for evaluation of soft tissues, ligaments and the spinal cord,
and correlate post-traumatic findings in MDCT and MRI.
Techniques: We will review the normal osseous and ligamentous anatomy of the cervicocranium and lower cervical spine as
seen on MDCT and MRI modalities. We will show selected cases
from our trauma level 1 center facility including cervicocranial
injuries, such as dislocations, subluxations, and fractures. Injuries
of the lower cervical spine, including hyperflexion, axial compression, and hyperextension injuries will also be included.
Conclusion: Post-traumatic cervical spine injuries are very common and are a major cause of disability. MDCT plays a primary
role in the evaluation of patients with cervical spine trauma.
Cervical MRI is a useful complement to MDCT, particularly for
evaluation of ligamentous and spinal cord injuries. Therefore, a
thorough knowledge of the normal cervical spine anatomy, as
well as familiarity with the findings of the most common patterns
of post traumatic injury to the cervical spine are needed to adequately contribute to patient care.
E333. Using Reformatting Algorithms for Optimum
Thoracolumbar Spine Imaging
Merchant, N.; Jaffer, N.; Ghai, S. University of Toronto, Toronto,
Canada
Address correspondence to N. Merchant (neesha.merchant@
gmail.com)
Background Information: With the introduction of multislice CT
scans, isotropic or near-isotropic reformatting of axial images
from raw data has enhanced the interpretation of abdominal
imaging studies. The use of sagittal reconstruction has been routinely used in chest imaging; however, with the exception of CT
angiographic assessment of the splanchnic circulation, sagittal
reconstruction is not commonly utilized for abdominal imaging
studies. The bony structures of abdomen are difficult to evaluate
on CT studies with axial and coronal imaging alone.
287
Educational Goals/Teaching Points: This exhibit will demonstrate the value of sagittal reformatting of abdominal imaging
studies to evaluate osseous abnormalities that are often overlooked with the current axial and coronal image formats.
Techniques: Many osseous pathologies, such as disc disease,
focal metastasis, spinal trauma, lumbar canal stenosis, spondylolisthesis, and subtle findings of early ankylosing spondylitis are
best evaluated on sagittal views.
Conclusion: In adjunct to axial and coronal views, examination
of the sagittal view allows for a thorough evaluation of abdominal imaging studies, especially for the detection of osseous abnormalities. Reformatting programs are built into all multislice CT
scanners and accordingly, it is recommended that sagittal
reformatting be routinely used as part of a complete abdominal
imaging study.
E334. ABCS: A Systematic Approach to the Radiographic
Interpretation of the Thoracolumbar Spine with Illustration
of Its Usefulness
Kim, Y.; Mansfield, L. Brooke Army Medical Center, San Antonio, TX
Address correspondence to L. Mansfield ([email protected])
Background Information: Low back pain is a common clinical
complaint. Radiography remains the primary initial imaging evaluation of back pain.
Educational Goals/Teaching Points: The purposes of this
exhibit are to review the pertinent anatomy of the spine; introduce a systematic approach to the radiographic interpretation of
the thoracolumbar spine; illustrate the effectiveness of this
approach, and present a summary of the most common disorders affecting the thoracolumbar spine.
Techniques: Denis traditionally described three columns of the
spine: anterior, middle and posterior. Recently, Berg described a
possible fourth column of the thoracic spine, the sternal-rib complex. A systematic approach to the radiographic interpretation of
the thoracolumbar spine is summarized by the abbreviation
ABCS: Alignment—Disorders with abnormal alignment include
burst fracture, Chance fracture, thoracic and costovertebral fracture dislocations, scoliosis, and spondylolisthesis due to either
spondylolysis or facet arthropathy. Bone—The vertebral bodies
are evaluated for density and shapes, such as bullet, corduroy,
“H”, hooked, humped, ivory, picture frame, plana, rugger-jersey,
sandwich, scalloping, and squaring which can be pathognomonic
for certain diseases. Cartilage—The intervertebral disc spaces and
facet joints are evaluated for discitis and calcification. “S” is for
soft tissue, sacroiliac joints, and sacral foraminal lines which may
be abnormal due to neoplasm, sacroiliitis, or fracture.
Conclusion: Radiography remains the initial imaging evaluation
of the spine, which has complex anatomy. This educational
exhibit reviews the pertinent anatomy of the spine, introduces a
systematic approach to interpreting radiographs of the thoracolumbar spine (the ABCS method), and illustrates the pathognomonic radiographic appearance of the most common disorders
affecting the spine.
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E335. CT Fluoroscopy-Guided Percutaneous Sacroplasty for
the Treatment of Sacral Insufficiency Fractures: Results of
19 Patients
Kim, H.; Lee, S. Seoul Wooridul Hospital, Seoul, South Korea
Address correspondence to H. Kim ([email protected])
Objective: The objective is to describe the efficacy and safety of
percutaneous sacroplasty under CT-fluoroscopy guidance, and to
illustrate the technique and results of the method based on a
series of 19 patients.
Materials and Methods: From June, 2006 to June, 2008, we
performed CT-fluoroscopy guided percutaneous sacroplasty in 19
female patients who had sacral fracture and suffered from severe
back and buttock pain. Their mean age was 76.1 years (range,
66-83 years), mean body mass index (BMI) was 147.2 (range,
137-160), and mean bone mineral density (BMD) was -4.1
(range, -0.4 to -6.7) in L-spine and -4.3 (range, -3.2 to -5.9) in
femur. All procedures were performed under local anesthesia
using aseptic technique with the patient positioned prone on the
CT table. Vital signs were monitored by the radiology nursing
staff. We injected PMMA using an 11gauge or 13 gauge trocar
needle(s) with beveled tip under CT-fluoroscopy guidance. After
the procedures, a CT scan of the sacrum and pelvis was performed to confirm whether or not there was a leak of the PMMA
solution especially into the neural foramens, vascular lumens and
retroperitoneal spaces. All patients were assessed for relief of
pain with VAS score (0 to 10), before and one day after the procedure, and were followed for 4-27 months.
Results: Technical success with adequate distribution of PMMA
cement into the marrow spaces of the sacrum on imaging was
achieved in 18 patients (95%) of the 19 patients. One patient
had mild numbness and tingling sensation of her lower leg during the procedure because of a small cement leak into the ipsilateral L5-S1 neural foramen through the fracture crack. We
immediately performed an epidural steroid injection into the
neural foramen under CT-guidance, and the patient’s symptom
was relieved. Two to five trocar needles were placed (mean, 2.9)
and 2.5 cc to 11.5 cc (mean, 5.71 cc) of PMMA was injected for
the treatment. Before the treatment, 15 patients could not walk
by themselves, and others had difficulty in walking to the bathroom. Initial mean VAS score improvement was six (range, 2-7),
and following was 6.4 (range, 4-7). One day after the procedure,
all patients could walk to the bathroom by themselves. One
patient had the procedure twice because of refracture three
weeks after the first procedure with temporary relief of her
symptoms.
Conclusion: Under CT-fluoroscopy guidance, sacroplasty is an
effective and safe method in the treatment of sacral insufficiency
fractures that can provide substantial pain relief within a short
time.
E336. Pictorial Review of Current Lumbar Interbody Fusion
Techniques–Radiographic and Clinical Correlation (CME
Credit Available)
Chen, L.; Regev, G.; Gentili, A. University of California-San Diego
Medical Center, San Diego, CA
Address correspondence to L. Chen ([email protected])
Background Information: The goal of this educational exhibit is
to present state-of-the-art lumbar interbody fusion techniques
including indications, surgical techniques and radiographic
appearance.
Educational Goals/Teaching Points: Imaging is an important
complement to clinical evaluation which can provide accurate
morphologic information of the spine to guide therapeutic decisions and provide postsurgical evaluations.
Techniques: The most common surgical indication for spinal
fusion is segmental instability. Common causes for instability
include degenerative disc disease, facet arthropathy, iatrogenic
causes such as previous excessive surgical decompression with
removal of more than 50% of the facet joints, and post-traumatic
and congenital etiology. Current widely used surgical techniques
include anterior (ALIF), posterior (PLIF), and transforaminal lumbar interbody fusion (TLIF). Minimally invasive extreme lateral
interbody fusion (XLIF) is an increasingly promising new technique. Additionally, new technologies include polyetheretherketone (PEEK) composite radiolucent cages, recombinant human
bone morphogenetic protein-2 (rh-BMP-2), and artificial disc
replacement.
Conclusion: By the end of this educational exhibit, the reader
will be able to identify the most common indications for spinal
fusion, better understand the various current surgical techniques,
and provide more accurate interpretation of preoperative and
postoperative imaging for lumbar spinal fusion.
E337. Nerve Root Enhancement on Contrast-Enhanced MR:
Differential Considerations
Choo, H.; Lee, S.; Kim, M. Inje University Pusan Paik Hospital,
Busan, Korea
Address correspondence to H. Choo ([email protected])
Background Information: Single or multiple extramedullary
enhancing lesions along cauda equina of the lumbosacral intradural space on contrast-enhanced MRI are often encountered. It
can be the normal anatomy of spine or the true abnormality. This
exhibit describes the normal anatomy to mimic the enhancement
of true nerve roots and the various diseases manifested as nerve
roots enhancement.
normal anatomy to mimic the enhancement of the nerve root,
and describe the various disorders manifested as nerve root
enhancement.
Techniques: The normal anatomy of great radicular vein or filum
terminale can mimic nerve root enhancement. However the tendency of typical location of normal anatomy is helpful for the differential diagnosis from true nerve root enhancement. There are
the various disorders manifested as nerve root enhancement.
These can be the degenerative, inflammatory, infectious, and
malignant conditions. The radiologic features and its differential
diagnosis of each disease will be illustrated.
Conclusion: Normal structures of spine can mimic nerve roots
enhancement. There are various disorders manifested as nerve
roots enhancement. Recognition of these diseases entities would
help direct patient management.
E338. Granulocytic Sarcoma of the Spine: MR Imaging and
Clinical Review
Park, J.1; Seok, J.2; Kim, S.2; Choi, J.3 1. St. Mary’s Hospital,
Seoul, South Korea; 2. The Catholic University of Korea, Seoul,
South Korea; 3. St. Paul’s Hospital, Seoul, South Korea
Address correspondence to J. Park ([email protected])
Background Information: Granulocytic sarcoma (chloroma) is a
tumor formed by myeloid precursors in an extramedullary site
and is associated with myeloid leukemias and other myeloproliferative disorders. We present the MR imaging findings and clinical manifestations of 33 cases of spinal chloroma.
Educational Goals/Teaching Points: The average age of the
patients (22 males and 11 females) was 32 years. There were 24
acute myelogenous leukemias, four acute lymphocytic leukemias
and five chronic myelogenous leukemias. Nine patients manifested with granulocytic sarcoma as a presenting sign and the
remaining 24 were diagnosed during remission phase or relapse
period. All patients received radiotherapy with combined chemotherapy and three patients underwent surgical decompression.
MR imaging of spine was performed in all patients with follow
up MR imaging in 24 patients.
Techniques: All patients complained of lower back pain, with
other complaints including radioculathies, numbness and pain in
the extremities, and paraplegia. The lumbosacral (15 cases) and
thoracic (13 cases) spines were commonly involved, and three of
the 33 patients exhibited multiple noncontiguous areas of
involvement. MR imaging demonstrated multiple epidural masses
and obliteration of the spinal canal with parameningeal extension mainly through the neural foramina, resulting in thickening
of multiple nerve roots. Lesions were isointense to bone marrow
on both T1- and T2-weighted MR images with homogeneous
enhancement after injection of contrast medium.
Conclusion: Increased awareness of imaging findings of granulocytic sarcoma will facilitate early diagnosis and minimize potentially preventable neurological morbidity.
E339. Resolving Spontaneous Spinal Epidural Hematoma:
Evolution of MR Signal Characteristics
C.3 1. University of California, San Diego; San Diego, CA; 2.
Address correspondence to S. Theodorou ([email protected])
Objective: Spontaneous spinal epidural hematoma (SSEH) is a
rare condition that can result in rapidly progressive and severe
289
neurological deficits requiring urgent intervention. Although treatment of SSEH mandates early decompression of the spinal canal,
in case of progressive neurologic improvement, nonsurgical management may be warranted. We describe the MR signal characteristics of resolving SSEH that ensure accurate diagnosis and
monitoring of the former condition.
Materials and Methods: Three patients with acute onset of spinal pain, with (n=2) or without (n=1) associated radiculopathy
developed motor dysfunction (n=1) or sensory disturbances (n=1)
in the lower limbs. There was no history of antecedent blunt trauma, bleeding disorder or anticoagulant therapy. All patients underwent initial and repeat MR imaging studies until complete neurologic recovery and resolution of SSEH on MR images.
Results: MR imaging studies demonstrated a cervical (n=1) or
thoracolumbar (n=2) mass located in the dorsal (n=2) or dorsolateral (n=1) aspect of the epidural space. The craniocaudal
extent of the SSEH varied from two to three vertebral levels. All
three SSEHs closely conformed to contours of bone. There were
no concomitant disk herniations or annular tears. The MR imaging signal characteristics of the epidural mass were variable and
appeared to depend on the time interval between imaging and
the age of hematoma. On T1-weighted images the mass
appeared isointense to the spinal cord, with increasing signal
intensity over time. On T2-weighted images, the mass was heterogeneously hyperintense to spinal cord with focal regions of low
signal intensity. There was compression of the adjacent spinal
cord with no signal changes within it.
Conclusion: The clinical findings in SSEH are similar to those in
acute disk herniation, with acute onset of pain and rapid progression of symptoms. The MR imaging appearance of SSEH is that of
a relatively large dorsal or dorsolateral mass that is usually situated in the thoracolumbar region, compressing the adjacent thecal
sac and traversing nerve roots. Increasing MR signal intensity
within the epidural mass with time on T1-weighted images is
suggestive of the diagnosis. MR imaging may provide additional
information regarding the extent of SSEH and the degree of spinal canal compromise. Also, MR imaging proves well-suited in
the determination of the age of the hematoma, and for monitoring conservative treatment of SSEH.
E340. Symptomatic Epidural Gas Cyst Associated With
Vacuum Disk: Evaluation With CT and MR Imaging
C.3 1. University of California, San Diego, San Diego, CA; 2.
com)
Objective: The vacuum disk phenomenon refers to gaseous collections in intervertebral disk spaces. Although vacuum phenomenon has generally been equated with the presence of degenerative disk disease, gaseous collections may accompany other disorders of the disk and adjacent vertebrae. Less commonly, gas can
be localized to the spinal canal. Intraspinal gas can be asymptomatic; however, it is a well recognized, albeit rare cause of lumbar
radiculopathy. We report the CT and MR imaging findings in
patients with lumbar nerve root compression associated with a
vacuum disk, which was communicating with the epidural space.
290
Furthermore, we attempt to give an insight into the mechanism
of nerve root compression seen in vacuum disk phenomenon.
Materials and Methods: The medical records, cross-sectional
imaging studies (CT, MR imaging, CT myelography and CT discography), and available surgical findings in four symptomatic
patients (two men, two women; ages 51-72 years) with epidural
and intradiskal gas collections were reviewed. Three patients
underwent surgery and one patient was treated conservatively.
Results: In all cases, clinical symptoms of epidural gas collection
were identical to those of other more common causes of nerve
root compression. CT and MR imaging studies disclosed intraspinal and intradiskal gas accumulation. On CT images, gas bubbles
appeared hypodense, while on MR images gas was of low signal
intensity on both the T1- and T2- weighted images. Epidural gas
cysts were present at the L4 or L4-L5 level in two patients and at
the L5-S1 level in the other two patients. In two cases, there was
filling of the epidural gas cyst with contrast material on CT diskography indicating free communication between intradiskal and
epidural gas. Needle aspiration of epidural gas resulted in complete relief of radicular symptoms in three patients. The gas disappeared spontaneously in the other patient. One year later, all
patients were completely free of symptoms.
Conclusion: Although the vacuum disk is considered to be a
common finding of no or little pathologic significance, our results
show that intradiskal gas may occasionally leak into the spinal
canal and cause clinical symptoms. Epidural gas collections can
be a cause of lumbar radiculopathy and should be considered in
the differential diagnosis of low back pain. MR imaging complemented with CT permits confident diagnosis of the condition that
may eliminate remnant neurologic abnormalities.
E341. MR Findings of Pyogenic Facet Joint Infection
Fujisawa, H.; Kushihashi, T.; Baba, M.; Ukisu, R.; Takenaka, H.;
Fukushita, T.; Yagi, S. Showa University Northern Yokohama
Hospital, Kanagawa-Ken, Japan
Address correspondence to H. Fujisawa ([email protected])
Objective: Pyogenic arthritis of spinal facet joints is a rare condition. The purpose of this study is to analyze the clinical presentation, diagnostic laboratory tests, and radiological characteristics
especially on MR images, of pyogenic lumbar facet joint infections (PLFJI).
Materials and Methods: This was a retrospective review of 11
cases of PLFJI at our institution from April, 2004 through July,
2008. There were seven men and eight women, with age range
49-85 years (mean 69.3 years). All 15 patients had laboratory
tests, plain lumbar spine radiographs (frontal and lateral view),
and MRI. Gd-contrast enhancement MR was performed in 13
patients. We analyzed clinical features, laboratory findings, plain
radiograph findings, and MR images. On MR images, we evaluated the findings of infected facet joint, a presence of paraspinal
extension, paraspinal abscess, epidural abscess, psoas abscess,
and spondylodiscitis.
Results: All 15 patients complained of lumbar pain. Fever was
present in 14 patients. White blood cell counts and C-reactive
protein were elevated in all cases. We could not diagnose PLFJI
on plain radiographs in all cases. MR findings in PLFJI were high
signal intensity on T2WI and enhancement on fat-saturation
Gd-T1WI at infected facet joint in all cases, unilateral was nine
and bilateral was six, paraspinal extension was 15, paraspinal
abscess was six, epidural abscess was three. Psoas abscess and
spondylodiscitis were none.
E343. Evaluation of Rotator Cuff Tear Arthropathy by MRI
and Radiography
Ashikyan, O.; Motamedi, K.; Seeger, L.; Motamedi, A. University
of California Los Angeles, Los Angeles, CA
Address correspondence to O. Ashikyan ([email protected])
Conclusion: The clinical features and laboratory data in PLFJI
were not specific. The PLFJI may spread to paraspinal and epidural spaces easily. MRI is the most suitable diagnostic modality to
detect not only facet joint changes but also complications in paraspinal and epidural extension and abscess formation.
Objective: The objective is to characterize and compare MRI and
radiographic findings in patients with rotator cuff tear arthropathy.
E342. Illustrative Review of Superior Labral AnteriorPosterior Lesions of the Shoulder: Patterns and Pitfalls
Motamedi, D.1; Modarresi, S.2; Masih, S.2 1. Cedars-Sinai
Medical Center, Los Angeles, CA; 2. University of California, Los
Angeles/Veterans Administration of Greater Los Angeles, Los
Angeles, CA
Address correspondence to D. Motamedi ([email protected])
Background Information: Shoulder pain in young athletes can
be nonspecific and originate from various causes. Superior labral
anterior-posterior (SLAP) lesions are prevalent cause of such
pain. The purpose of this presentation is to review anatomy of
the glenoid labrum and related structures, to describe the mechanism of injury, to show different types and severity of labral
tears and to show MRI approach to these lesions. The ability to
accurately diagnose these conditions is necessary for the radiologist to recommend appropriate study such as MR arthrogram and
lead the referring physician to reaching the correct diagnosis and
appropriate treatment.
Educational Goals/Teaching Points: This exhibit will provide an
overview of various causes of nonspecific shoulder pain in young
athletes, and a pictorial review of different types of SLAP tears
and show extension of these tears to different areas of the
labrum, to middle glenohumeral ligament and to rotator interval.
It will also review the mechanism of injuries leading to superior
labral anterior-posterior tear; review the related anatomical structures such as glenohumeral ligaments, rotator interval and the
bicipitolabral complex, and describe the appropriate imaging
technique, positioning and pulse sequences for detection of
superior labral tears.
Techniques: This will be a didactic presentation of SLAP lesions
resulting in chronic pain in active individuals and young athletes
organized by anatomy, mechanism of injury and imaging characteristics. The role of MRI, indications for MR arthrogram, anatomical
variations and pitfalls of the superior labral tears will be discussed.
The value of clinical correlation, appropriate positioning and MR
sequences for reaching the correct diagnosis are emphasized.
Materials and Methods: We have reviewed 30 MRIs and radiographs in 28 patients with full-thickness rotator cuff tears, which
measured more than 3 cm. The acromiohumeral distance, glenoid concavity, and glenohumeral distance were measured on
MRIs and radiographs. We also evaluated rotator cuff tendons
and muscles, biceps tendon, labrum, and osseous structures.
Results: The radiographs were normal in nine patients and
demonstrated Stage Ia cuff tear arthropathy in 13 patients. Stage
IIa arthropathy was present in five patients and stage IIb in one.
Mean cuff tear measurements were 3.5 cm in anteroposterior
dimension and 3.5 cm in mediolateral dimension. The supraspinatus was torn on all studies (100%). An infraspinatus tear was
present in 87% of studies. A subscapularis tear was seen in
30% of studies. A teres minor tear was present on one study
(3%). Biceps tendon pathology was present in 80% of studies.
The mean acromiohumeral distance was 3 mm on MRI, and 5.9
mm on radiographs. Rounding of greater tuberosity was present
in 33% of studies and greater tuberosity marrow edema and
subcortical cysts were present in 63% and 70% of scans, respectively. Two findings of an “acetabularized” appearance of acromial undersurface included undersurface remodeling and undersurface spurs. Acromial marrow edema was present in 70%
of cases. The mean glenohumeral distance was 3.1 mm on MRI
and 4.5 mm on radiographs. The mean glenoid concavity was
measured 4.2 mm on MRI and 7.2 mm on radiographs. Glenoid
osteophytes were present in 50% of cases. Glenoid marrow
edema was seen in 20% of cases and subchondral cysts were
seen in 10% of cases. Maceration of the glenoid labrum was evident in 53% of cases. Humeral head osteophytes were demonstrated in 60% of cases. Humeral head marrow edema and subarticular cysts were present in 23% and 13% of cases, respectively.
Conclusion: In addition to radiography, MRI is a valuable tool in
evaluation of arthropathy in patients with large cuff
tears. “Acetabularization” of acromion may be present due to
hypertrophic changes or due to undersurface erosions. The
glenohumeral and acromiohumeral distances, and glenoid concavity were smaller when measured on MRI compared to radiographs. Acromial marrow edema and osteophytes, edema and
subcortical cysts in greater tuberosity, glenohumeral osteophytes,
maceration of glenoid labrum and biceps tendon pathology were
the most common findings in our study.
Conclusion: After reviewing this educational exhibit, radiologists
will recognize the MR appearance and distinguish different types
of SLAP tears with or without extension to adjacent structures;
recognize the value of a systematic approach to MR diagnosis of
SLAP lesions, imaging technique, and clinical and arthroscopic
correlation; recognize the importance of recommending MR
arthrogram in nonconclusive MRI cases in the appropriate age
group and clinical setting, and understand treatment options
available for different types of superior labral tears.
291
E344. Lesser Tuberosity Cysts: Incidence and Associated
Rotator Cuff Pathology
Wissman, R.1; Kapur, S.1; Akers, J.1; Crimmons, J.2; Ying, J.1;
Meganathan, K.1; Laor, T.3 1. University of Cincinnati , Cincinnati,
OH; 2. Radiology Associates of Northern Kentucky, Crestview Hills,
KY; 3. Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
Address correspondence to R. Wissman (wissmaRD@healthall.
com)
Objective: Humeral head cysts have a known association with
rotator cuff disease. Cysts of the greater tuberosity have been
well studied, however relatively little is known of the clinical significance of lesser tuberosity cysts. The purpose of our study is to
determine the incidence of cysts of or near the lesser tuberosity
and their association with rotator cuff pathology and impingement.
Materials and Methods: A retrospective review of 1,000 consecutive MRI exams of the shoulder was performed by consensus
by two radiologists. Lesser tuberosity cysts were grouped by their
location into type 1 (superior to the lesser tuberosity) and type
2 (at the insertion site of the subscapularis on the lesser tuberosity). If cysts were found at both locations they were included in
the type 2 group. The rotator cuff was defined as intact, partial or
completely torn. Severe tears of the supraspinatus included high
grade and complete tears. Severe tears of the subscapularis
included moderate and high grade tears. Partial tears were further subdivided into mild, moderate and high grade tears. The
shortest distance from the coracoid to the humeral head was
measured on axial images. These findings were compared to an
age and gender matched control without evidence of lesser
tuberosity cysts on MRI exams of the shoulder.
Results: A total of 48 patients (age range 35-79 years, mean 61
years) were found with lesser tuberosity cysts. Thirty-two had
type 1 cysts and 16 (33%) type 2 cysts. There was no significant
difference in severe subscapularis or severe supraspinatus tears
in type 1 cysts when compared to controls. Type 2 cysts were
found to be significantly associated with severe subscapularis
tears (69%) as compared to controls (38%, p=0.035) and type 1
cysts (22%, p=0.003). Type 2 cysts were also significantly associated with severe supraspinatus tears (81%) as compared to controls (44%, p=0.007) and type 1 cysts (31%, p=0.001).
Coracohumeral distance of less than 10 mm was noted in 63%
of type 2 cysts as compared to controls (33%, p=0.045) and type
1 cysts (31%, p=0.043) respectively.
Conclusion: Cysts of or near the lesser tuberosity cysts are not
uncommonly seen in shoulder MRI exams. Cysts just superior to
the lesser tuberosity (type 1) are more common than cysts at the
insertion site of the subscapularis tendon (type 2) and are not
associated with cuff pathology. Type 2 cysts are associated with
severe subscapularis and supraspinatus tendon pathology as well
as a decreased subcoracoid distance.
292
E345. The Rotator Interval: MR Arthrographic Anatomy and
Signs of Injury
Huang ,W.1; Masih, S.1,2; White, E.3 1. University of California,
Los Angeles, Los Angeles, CA; 2. VA West Los Angeles, Los
Angeles, CA; 3. University of Southern California, Los Angeles, CA
Address correspondence to W. Huang ([email protected])
Background Information: The rotator interval (RI) is an incompletely characterized region of the anterior shoulder joint between
the supraspinatus and subscapularis tendons which is increasingly
recognized as an important contributor to glenohumeral stability.
Injuries to the rotator interval are becoming an increasingly recognized source of inferoposterior shoulder instability.
Educational Goals/Teaching Points: This exhibit will review MR
arthrographic anatomy of RI structures; diagram mechanisms of
RI injury, and illustrate radiologic signs of RI injury.
Techniques: Important structures in the rotator interval include
the coracohumeral ligament, superior glenohumeral ligament,
joint capsule, and biceps brachii tendon. A review of rotator interval anatomy using images from shoulder MR arthrography is presented, with anatomic correlation with nonarthrographic shoulder MR images. Radiological signs including an obliterated subcoracoid fat pad and landmarks important for recognition of rotator interval injuries will be demonstrated using images from
patients demonstrating evidence of shoulder instability and damage to rotator interval structures on MR arthrography.
Conclusion: Injury to the rotator interval may be a cause of
shoulder instability. Evaluation of the rotator interval is performed
with MR arthrography. Important structures to evaluate in the
rotator interval are the coracohumeral ligament, superior glenohumeral ligament, joint capsule, and biceps brachii tendon.
E346. Current Imaging Options for Shoulder Injuries Related
to Golf
Pinchcofsky, H.; Young, P. Case Western Reserve University,
Cleveland, OH
Address correspondence to H. Pinchcofsky ([email protected])
Background Information: Multiple injuries of the shoulder have
been found to be attributable to golf. In some cases, the injury
pattern varies between professional golfers and amateurs. In
order to familiarize practicing radiologists with injuries of the
shoulder specific to golf, we review the literature which discusses
such injuries. We also discuss imaging findings and techniques
Educational Goals/Teaching Points: The golf swing involves
cross-body adduction in the backswing and follow-through portions. This predisposes golfers to subacromial impingement,
acromioclavicular and glenohumeral joint osteoarthritis, and
glenohumeral instability. The nondominant, leading shoulder in
the golf swing is usually the affected shoulder. Rotator cuff tendinosis and tearing are also common injuries in golf. Age is an
important factor in predicting the etiology of diseases in the
shoulder joint. In older individuals, subacromial impingement
and rotator cuff disease is caused by acromioclavicular osteophytes. For younger golfers, subacromial impingement is caused
by hyperlaxity of the glenohumeral joint, weak or imbalanced
rotator cuff muscles, or a tight posterior capsule.
Techniques: Rotator cuff tears may be evaluated with either MRI
or ultrasound. Rotator cuff tears are characterized by areas of
hyperintensity on T2-weighted images in the area of abnormality
on MRI. Retraction of the musculotendinous junction may also
be seen with full thickness rotator cuff tears. MRI remains the
most comprehensive method of assessing rotator cuff and shoulder pathology. On ultrasound, areas of pathology correspond to
anechoic areas. Tendinosis is characterized by thickened tendons
with intermediate signal on MRI. This same entity appears hypoechoic and heterogenous on ultrasound. Although unenhanced
MR sequences, particularly T2-weighted images, are the convention for diagnosing rotator cuff pathology, some authors now
advocate using MR arthrography for this purpose because of an
increased diagnostic yield. MR arthrography using T1-weighted
sequences with fat suppression can also be very helpful in
assessing shoulder pathology. Glenohumeral instability and labral
pathology are best evaluated with such imaging methods.
Conclusion: The shoulder is susceptible to injuries from the golf
swing. Although ultrasound can be helpful in diagnosing shoulder pathology, MRI remains the most comprehensive and commonly used modality to evaluate the shoulder. MR arthrography
can aid in a higher diagnostic yield for shoulder pathology when
used appropriately.
E347. The Injured Patient’s Shoulder: Clinical Correlation
and MR Findings (CME Credit Available)
Mazzie, J.1; Chang, W.2; Smith, S.2; Luchs, J.1; Lazzara, B.1; Katz,
D.1; Grossman, M.1 1. Winthrop-University Hospital, Mineola, NY;
2. University of Maryland, Baltimore, MD
Background Information: The shoulder is one of the most
common MR examinations encountered in a busy musculoskeletal imaging practice. The interpreting radiologist should be aware
of the variety of physical examination tests which patients may
have undergone by our clinical colleagues prior to seeing the
doors of a radiology department/practice.
Educational Goals/Teaching Points: This exhibit will be an
interactive PowerPoint presentation that will demonstrate a visual
correlation between the specific orthopedic physical examination
tests or maneuvers of the shoulder and the MR findings of the
shoulder, with that specific injury. Clinical tests to be discussed
will be organized according to the anatomic region for which it is
used for, in evaluating the shoulder (i.e., labrum, rotator cuff,
acromioclavicular disease, etc.).
Techniques: The emphasis will be on clinical evaluation tests
used by orthopedists and other clinicians, correlating with the
MR findings for positive injuries to the specific region(s) being
evaluated. Conclusion: While MR is the reference standard with regards to
possible glenohumeral disease, sometimes subtle abnormalities
can be missed by the radiologist. Interpreting radiologists should
be aware of the types of physical examination techniques utilized
prior to MR imaging, so as to better understand the clinical and
imaging correlation.
E348. The MR Arthrographic Anatomy of the Biceps Labral
Insertion and its Morphological Significance With Labral
Tears in Patients With Shoulder Instability
Jakanani, G.; Rennie, W. Leicester Royal Infirmary, Leicester,
United Kingdom
Address correspondence to G. Jakanani ([email protected])
Objective: The attachment of the long head of biceps tendon is
described in traditional anatomy texts as being at the supraglenoid tubercle of the scapula. There are however differing views
with reports in the literature of cadaveric work that has shown
that most of the tendon fibers attach just posterior to the tubercle and the labrum. We aim to define the anatomic biceps labral
attachment as demonstrated by MR arthrography of the shoulder,
and to determine the relationship between the attachment site
and type of labral tears seen in patients with recurrent shoulder
dislocation.
Materials and Methods: This was a retrospective study of MR
shoulder arthrograms performed during a two-year period by a
fellowship trained musculoskeletal radiologist at a university
teaching hospital. Forty-eight patients (33 males and 15 females,
age range 17-72 years, mean 32 years) were included in this
study. Postcontrast sagittal oblique proton density fat saturated
images were reviewed on a PACS workstation by two readers to
determine the attachment of the biceps tendon in relation to the
12 o’ clock position of the glenoid fossa.
Results: Twenty-two patients (46%) had a completely posterior
attachment. In 11 patients (23%) the tendon attachment was
predominantly posterior but with some fibers attaching to the
tubercle. Fifteen patients (31%) had the traditional 12 o’clock
configuration. Further results on associated labral tears are under
analysis and will be presented.
Conclusion: This study presents radiological evidence to support
previous cadaveric work that has shown that the attachment of
the tendon of the long head of biceps is not directly onto the
glenoid tubercle, but most commonly posterior. The type of
attachment may have important implications on the injury pattern seen in glenoid labral tears in patients with recurrent shoulder dislocation.
E349. Ultrasound-Guided Glenohumeral Injection Using the
Rotator Cuff Interval for MR Arthrography
Andrews, T.1,2; Ali, K.1,3; Knudtson, J.1; Joshi, A.1 1. University of
Kansas School of Medicine, Wichita, KS; 2. Wesley Medical
Center, Wichita, KS; 3. Cypress Imaging, Wichita, KS
Address correspondence to T. Andrews (tylerandrews2003@
yahoo.com)
Background Information: Glenohumeral joint injection is a
common procedure performed primarily in the outpatient setting.
Various techniques have been described in the past, the majority
of which involve fluoroscopy and iodinated contrast agents. It
was only in the past 5-10 years that ultrasound emerged as a
practical alternative for accessing the shoulder. To our knowledge,
only a posterior approach using ultrasound guidance has been
described in the literature. Our purpose is to describe a safe and
effective ultrasound-guided anterior approach using the rotator
cuff interval.
293
Educational Goals/Teaching Points: There are several advantages to performing shoulder injections under ultrasound guidance as opposed to the more traditional fluoroscopic techniques.
Ultrasound tends to be faster and eliminates exposure to ionizing
radiation. It may be performed portably or in the office setting. It
eliminates the need for iodinated contrast agents and the needle
can be directly observed and manipulated in real time as it
traverses the rotator cuff interval. Finally, patients tend to be
more comfortable on an ultrasound exam table as opposed to a
hard fluoroscopy unit.
Techniques: The rotator cuff interval is created by the coracoid
process of the scapula. It separates the supraspinatus and subscapularis tendons, contains the coracohumeral and superior
glenohumeral ligaments, and allows the long head of the biceps
tendon to pass from the bicipital groove to it’s insertion on the
superior glenoid. Our technique employs the use of a 5-12 megahertz linear array transducer, depending on patient size and
body habitus. With the patient in the supine, semirecumbent
position, the affected shoulder is externally rotated to protect the
biceps tendon. The shoulder is then prepped and draped in the
usual aseptic fashion. The transducer is positioned anteriorly so
that the coracoid process and medial aspect of the humeral head
are both visible. The articular cortex of the humeral head appears
as a spherically curved echogenic line. After local anesthesia, a 20
to 22 gauge spinal needle is then advanced in to the glenohumeral joint space under direct visualization. Intra-articular
injection of gadolinium is confirmed using loss of resistance technique and by directly observing adequate distension of the joint
capsule. The patient may then proceed to MR.
Conclusion: Ultrasound-guided glenohumeral joint injection
using the rotator cuff interval is a safe and effective alternative for
MR arthrography that can be performed in the outpatient setting.
E350. MR Imaging of Annular Ligament Injuries of the
Elbow: The Overlooked Isolated Annular Ligament Tear
Brouha, S.; Cardoso, F.; Pathria, M.; Resnick, D.; Chung, C.
University of California San Diego, San Diego, CA
Address correspondence to S. Brouha ([email protected])
Objective: In this study, we review the normal MR appearance of
the annular ligament and describe the MR appearance of annular
ligament injuries.
Materials and Methods: We reviewed all 336 elbow MR imaging reports from two institutions performed between January,
2006 and March, 2008 and one institution during 2007 to identify cases with annular ligament pathology. The selected cases
were reviewed by two musculoskeletal-trained radiologists for
elbow pathology. In addition, the patient histories were reviewed
to evaluate for symptoms including snapping of the elbow.
Results: We identified 15 MRI elbow studies in 14 patients with
annular ligament pathology. Five studies in four patients demonstrated isolated annular ligament injuries without concurrent ligamentous injuries of the elbow. All these patients encountered
either posterior elbow pain or snapping elbow. Pathology
encountered includes one patient with bilateral partial tears of
the annular ligament; two patients with isolated annular ligament
injuries, including a rupture of the posterior band of the annular
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ligament; and one patient with subluxation of the annular ligament to the level of the radiohumeral articulation. In ten cases,
the annular ligament injury was associated with other ligamentous and/or osseous injuries within the elbow.
Conclusion: Isolated annular ligament injuries may occur more
frequently than reported in the literature. The posterior attachment of the annular ligament is most susceptible to injury.
Furthermore, isolated annular ligament injuries may be demonstrated by MRI of the elbow and possibly to better advantage
with MR arthrography. Reports of isolated annular ligament tears
without concomitant elbow pathology are rare in the radiology
and orthopedic literature. In all but one reported case the annular ligament injury was not identified at the time of MRI but at
subsequent arthroscopy. These lesions should be suspected in
patients who present with snapping or clicking of the elbow.
Recognition of this entity and its clinical presentation may enable diagnosis at the time of imaging and potentially impact
management.
E351. Cadaveric Elbow Allograft and Prosthetic Arthroplasty:
Indications and Imaging Findings (CME Credit Available)
Tumyan, L.1; Chakarun, C.1; Itamura, J.1; Learch,T.2; White, E.1.
1.University of Southern California-Keck School of Medicine, Los
Angeles, CA; 2. Cedars Sinai Medical Center, Los Angeles, CA
Address correspondence to L. Tumyan ([email protected])
Background Information: The purpose of the exhibit is to
understand the role of radiologic studies in evaluating cadaveric
allograft transplantation and prosthetic elbow arthroplasties, and
to familiarize the radiologist with examples of both normal and
pathologic imaging findings in postoperative patients. The exhibit
will improve the relevance of radiology reporting of elbow
pathology for surgical decision-making by discussing the findings
in the language used by orthopedic surgeons.
Educational Goals/Teaching Points: The exhibit will review
and present relevant elbow pathology that leads to elbow transplantation or arthroplasty. Examples and cases of elbow arthroplasties including elbow transplantation, linked and unlinked
arthroplasties, elbow arthroplasty revision, and radial head prosthesis will be demonstrated. We will discuss and present imaging
findings of complications in elbow transplantations and arthroplasties.
Techniques: Prosthetic elbow surgery includes linked and
unlinked arthroplasties, elbow arthroplasty revision, and radial
head prosthetic replacement. The most common postoperative
complications include instability, polyethylene linear wear, osteolysis, loosening, infection, fracture, heterotopic ossification, and
failure of transplantation.
Conclusion: Evolving surgical and reconstruction techniques for
treatment of elbow pathology require the radiologist to become
familiar with novel imaging findings associated with these procedures. This presentation will include a complete discussion of
imaging studies in assessing appropriateness for surgery, proper
postoperative positioning, common and uncommon complications of cadaveric elbow allografts and prosthetic arthroplasties.
E352. Sonographic Evaluation of the Painful Elbow
Kim, M.; Choo, H.; Lee, S. Inje University Pusan Paik Hospital,
Busan, Korea
Address correspondence to H. Choo ([email protected])
Background Information: The elbow is an important synovial
hinge joint of the upper extremity and a common site of musculoskeletal symptomatology, affecting all age groups. Elbow ultrasound (US) has the advantage because it is cost-effective, widely
available, beautifully demonstrates superficial soft tissue structures, and it is able to perform a dynamic examination while
obtaining patient feedback and.
Educational Goals/Teaching Points: The goals of the exhibit
are to illustrate the sonographic anatomy of elbow, and describe
the various disorders to induce the painful elbows.
Techniques: This article describes the use of ultrasound in the
evaluation of the elbow. First, normal US anatomy of elbow will
be illustrated. Then, common pathologies about the elbow are
demonstrated, including tear of biceps tendon, common extensor
tendon and flexor tendon, medial and lateral epicondylitis, cubital
tunnel syndrome, dislocation of ulnar nerve, olecranon bursitis,
inflammatory and infectious arthritis, and so on. In addition, specific imaging techniques and positions are described for optimum
visualization of the various structures around the elbow.
Conclusion: There are variable diseases resulting in elbow pain
and US is a valuable imaging tool for assessment of disorders of
the elbow joint.
E353. Ultrasound of the Elbow: Surface Anatomy, Common
Pathology and Positioning of the Ultrasound Transducer
Fourgas, E.; Craig, J.; Bouffard, A.; van Holsbeeck, M. Henry Ford
Hospital, Detroit, MI
Address correspondence to E. Fourgas ([email protected])
Background Information: Ultrasound of the elbow is a noninvasive modality for the diagnosis of joint, tendon, ligament and
soft tissue pathology. It is a flexible, dynamic and low cost
modality making it an excellent choice.
Educational Goals/Teaching Points: After completing this educational activity, the participant will understand the normal anatomy of the elbow as seen by ultrasound; be able to identify common elbow pathology by ultrasound, and will become familiar
with optimal transducer positioning.
Techniques: Normal surface anatomy and appearance of the
major structures of the elbow will be reviewed. Common pathology around the elbow including long head of biceps and triceps
tears, medial and lateral epicondylitis, tears of the anterior band
of the ulnar collateral ligament, olecranon bursitis, inflammatory
arthritis and joint bodies will be reviewed. Some of the cases will
have MR correlation. Optimal positioning of the transducer will
be demonstrated and the corresponding normal anatomy will be
displayed. The format will be didactic. The presentation will
include images of the normal surface anatomy, common pathology and optimal ultrasound transducer positioning.
Conclusion: Ultrasound is an excellent modality for evaluation of
the normal and abnormal elbow.
E354. Masses of the Hand
Killam, J.; Benitez, C. St. Luke’s Roosevelt Hospital, New York, NY
Address correspondence to J. Killam ([email protected])
Background Information: Masses of the hand are often recognized early by patients who encounter them during routine everyday activities. Although radiographs should be the initial diagnostic study, MRI examinations are invariably used for further
evaluation. The superior contrast resolution allows distinction of
various tissue types and the use of intravenous gadolinium provides information about vascularity and perfusion patterns.
Location is another important characteristic in assessment. As
hand masses are not routinely encountered in clinical practice, it
is necessary to be familiar with the above characteristics in order
to generate a reasonable differential diagnosis.
Educational Goals/Teaching Points: The goals are to present a
review of hand anatomy, and describe imaging characteristics of
various masses including vascularity and enhancement patterns as
well as common locations. All hand masses are not neoplastic.
Etiologies are broadly divided into post-traumatic, related to
degenerative joint disease and other arthridities, and spontaneous.
Techniques: Cysts occur near joints and are related to degenerative processes and ligament tears. A finger tip is a common location of glomus tumors and inclusion cysts. Nerve sheath tumors
and pseudoaneurysms occur in the region of the neurovascular
bundles.
Conclusion: Evaluation of hand masses requires intimate familiarity with the anatomy. Systematic evaluation of signal characteristics, location and clinical history allows the differential diagnosis
to be narrowed. Many will ultimately require histologic evaluation. In addition to providing information about the mass itself,
the MRI provides valuable information to the surgeon for surgical
planning related to involvement of structures around the mass.
E355. Hurt Hands: Fractures and Other Injuries (CME Credit
Available)
Bush, L.; Gerson, R.; Chew, F.; Goodman, M.; Mulcahy, H.
Address correspondence to L. Bush ([email protected])
Background Information: Interpreting injuries of the hand can
be an intimidating task because of the complex anatomy, the
intricate biomechanics, and the broad range of pathology. Injuries
to the hand can also result in long-term dysfunction with emotional and economic impact. It is important for radiologists to
recognize a variety of injury patterns and their appearance in
multiple imaging modalities with awareness of features significant to treatment options and urgency of triage. This educational
exhibit demystifies this difficult region and presents an approach
to accurately interpreting hand injuries in a variety of modalities
to facilitate optimal and expedient patient care.
Educational Goals/Teaching Points: The objectives of this educational activity are for the participant to review the normal
295
appearance of the hand; evaluate the relation of mechanism of
trauma to patterns of injury; develop a pattern of assessing critical structures in the hand for injury; assess various cases of traumatic injuries to the hand with a variety of imaging modalities,
and appropriately emphasize findings that are of importance to
optimizing patient treatment and triage.
Techniques: The normal appearance of osseous, articular, ligamentous, musculotendinous, neurovascular, and soft tissue anatomy of the hand are reviewed. Case examples with a multimodality approach including radiographs, CT, ultrasound, and MRI
are used to illustrate the relationship of mechanism of trauma to
the pattern of injury. Critical injury findings that impact treatment
options or necessitate urgent management are emphasized.
Conclusion: This interactive computer-based educational exhibit
presents an approach to interpretation of hand trauma to facilitate recognition and description of a variety of injury patterns and
emphasizes findings which impact treatment. Participants may
take an interactive self-assessment module to facilitate and reinforce their learning.
The views expressed in this manuscript are those of the authors
and do not reflect the official policy or position of the Department
of the Army, Department of Defense or the US Government.
E356. Imaging of the Thumb and First Metacarpal: A
Multimodality Pictorial Review of Anatomy and Pathology
With Emphasis on Musculoskeletal Ultrasound (CME Credit
Available)
Friedkin, A.; Jacobson, J.; Livermore, J.; Brandon, C.; Girish, G.;
Jebson, P. University of Michigan, Ypsilanti, MI
Address correspondence to A. Friedkin (aaron.friedkin@gmail.
com)
Background Information: Imaging of the thumb and first metacarpal warrants specific attention given the unique mechanics of
these structures and their importance in daily activities. Our goal
is to review thumb anatomy and demonstrate the imaging characteristics of thumb pathology, including traumatic, neoplastic,
infectious, vascular, and inflammatory processes. Review of
thumb anatomy will rely on both cadaveric dissection as well as
imaging findings.
Educational Goals/Teaching Points: The exhibit will include
anatomy and mechanics of the thumb and first metacarpal
including examples of cadaveric dissection and imaging findings;
imaging modalities of the thumb (limitations and advantages of
radiographs, CT, MRI, ultrasound; indications for each modality
and techniques of thumb/metacarpal ultrasound), and examples
of thumb/metacarpal pathology with discussion of management.
Techniques: Examples will focus on ultrasound, although radiographic and MRI correlation will be included. Trauma, neoplasms,
infections, inflammation, and vascular malformations will be discussed.
Conclusion: After reviewing the exhibit, the participant of this
educational activity will understand the unique anatomy and
296
mechanics of the thumb and first metacarpal; understand the
advantages and limitations of various imaging modalities in evaluating thumb/first metacarpal pathology including radiography,
MRI and ultrasound; understand the basic technique of ultrasound of the thumb, and be able to review the imaging characteristics of common and unusual pathology involving the thumb
and first metacarpal including traumatic, neoplastic, infectious,
inflammatory and vascular etiologies.
E357. Radiological Evaluation of Partial (Functional) Wrist
Arthrodesis
Turecki, M.; Taljanovic, M.; Sheikh, S.; Sheppard, J.; Holden, D.;
Enoki, N. University of Arizona Health Sciences Center, Tucson, AZ
Address correspondence to M. Turecki ([email protected])
Background Information: Partial wrist arthrodesis is performed
to provide arthritic pain relief by eliminating movement in affected joints while preserving maximal function of the wrist and
hand. Other indications include previous tumor resection, spasticity, paralysis, or revision of prior unsuccessful arthrodesis.
Educational Goals/Teaching Points: We will attempt to familiarize the reader with key points of the current surgical techniques and radiographic evaluation of partial wrist arthrodesis.
Current approaches to wrist arthrodesis include total (nonfunctional) arthrodesis which will not be further discussed here and
partial or functional arthrodesis. Partial wrist arthrodesis is usually
achieved by combination of internal plates and screws which
have quickly replaced older techniques such as pin fixation, decortication, and corticocancellous bone grafts.
Techniques: The most common types of partial wrist arthrodesis
include scaphoid-trapezium-trapezoid, corticocancellous and
scaphoid-capitate-lunate arthrodesis with variable screw fixation
and two types of four corner fusion including the trapezium-trapezoid-capitate-scaphoid and lunate-triquetral-capitate-hamate
arthrodesis with four corner compression plate and variable
screws fixation. Isolated dual carpal bone fusion such as capitolunate may be used. Initial radiographic follow-up concentrates
on hardware assessment and exclusion of infection, especially
important in patients with postoperative pain. Subsequent studies evaluate for later complications including nonunion, fractures,
pseudoarthrosis, hardware loosening or fracture, reflex sympathetic dystrophy, or impingement syndrome. Neuroma formation,
transient nerve palsy, tendon adhesions, or skin necrosis are
other less common complications.
Conclusion: The techniques of partial wrist arthrodesis are still
evolving with controversies remaining as to which bones should
be fused to provide the best residual functional outcome.
Radiologists should be familiar with the normal radiographic
findings of partial wrist arthrodesis and their potential complications.
E358. Radiology of Carpal Trauma (CME Credit Available)
Goodman, M.; Bush, L.; Chew, F.; Mulcahy, H. University of
Washington, Seattle, WA
Address correspondence to M. Goodman ([email protected])
Background Information: Early diagnosis and treatment of carpal bone trauma is of paramount importance to avoid poor outcomes and disability. The complex anatomy of the carpus and
the importance of both bony and soft tissue structures pose challenges for the radiologist. Different imaging modalities are
employed for accurate and unambiguous diagnosis of carpal injuries. Postoperative evaluation is equally important because nonanatomic reduction and positioning may lead to functionally disabling results.
Educational Goals/Teaching Points: The objectives of this educational activity are for the participant to learn the mechanisms
of traumatic carpal injuries; develop a systematic method for
interpreting diagnostic images of carpal injuries, and recognize
the different patterns of injury as demonstrated by imaging.
Techniques: Accurate interpretation of conventional radiographs,
cross-sectional imaging and wrist arthrography coupled with
knowledge of critical factors that alter treatment decisions is
important for appropriate patient outcome. These factors include
developing a systematic method of interpreting radiographs, CTs
and MRI, knowing mechanisms of traumatic carpal injuries and
recognizing these mechanisms on imaging. Knowledge of mechanisms also allows for appropriate imaging modality selection.
Conclusion: This computer-based educational exhibit reviews
radiology of traumatic carpal injuries so that the practicing radiologist can recognize and accurately describe them. Cases are presented interactively as unknowns so that participants may self-assess their knowledge.
E359. The Carpal Bones in Poland Syndrome
Friedman, T.; Reed, M.; Elliot, A. University of Manitoba, Winnipeg,
Canada
Address correspondence to T. Friedman ([email protected])
Objective: The objective was to examine the carpal bones in
Poland syndrome in local patients and patients from the literature.
Materials and Methods: Hand radiographs from local patients
and patients identified from the literature with confirmed Poland
syndrome were examined for evidence of carpal bone involvement. Only cases with radiographs of adequate quality were
included in the analysis. In total, seven local patients and 23
patients from the literature were evaluated.
Results: Of the 23 literature patients, 12 patients (52%) had
abnormal findings. Of the abnormal patients, 4/12 (33%) had
carpal fusions, 8/12 (67%) showed disharmonious ossification
between the carpal and tubular bones and 7/12 (58%) showed
delay of carpal ossification. Of the local cohort, three patients
were too young to characterize carpal involvement. Of the four
remaining patients, two (50%) had abnormal carpal morphology,
3/4 had disharmonious ossification and 4/4 had delay of ossifica-
tion of carpal bones. Carpal fusions, particularly of the scaphoid
and trapezium, were common in both groups.
Conclusion: Carpal bone involvement anomalies (delay, disharmony and/or fusions) are frequent in Poland syndrome and can
occur in patients with mild or severe hand involvement. This
characteristic of Poland syndrome has not been fully appreciated
previously.
E360. Classic and Alternative Approaches for Extremity
Arthrography (CME Credit Available)
Hom, B.; Anderson, M.; Gaskin, C.; Fox, M.; Barr, M. University of
Virginia, Charlottesville, VA
Address correspondence to B. Hom ([email protected])
Background Information: Arthrography is commonly used prior
to MR and CT to distend the joint capsule and allow for
improved visualization of intra-articular structures. Contrast or
saline arthrography improves diagnosis of labral tears, postoperative meniscal tears, and ligamentous tears. It also allows for better assessment of hyaline cartilage defects, stability of osteochondral lesions, and the presence of loose bodies. Each of the major
appendicular joints can be accessed by more than one approach,
and knowledge of the advantages and disadvantages of each is
important when performing these procedures.
Educational Goals/Teaching Points: In this exhibit we will
review approaches to arthrography of each of the major appendicular joints including the shoulder, elbow, wrist, hip, knee and
ankle. The classic approach for each joint will be discussed followed by alternative approaches. We will discuss the advantages
and potential disadvantages of each approach and when, in our
clinical experience, one is preferred over another.
Techniques: The following will be discussed: shoulder (anterior,
rotator cuff interval, posterior); elbow (lateral, posterior); wrist
(distal radial ulnar joint, mid carpal, radiocarpal); hip (anterior,
anterolateral); knee (anterior lateral, anterior medial, anterior),
and ankle (direct anterior, anterolateral).
Conclusion: Arthrography is a useful technique in conjunction with MR and CT for improved assessment of intra-articular
structures. A knowledge of the spectrum of fluoroscopic
approaches to each joint is useful for providing the most efficient
and advantageous examination for a given clinical situation.
E361. Ultrasound Appearance of Metastatic and Recurrent
Extremity Tumors with MR Correlation
Woodrow, A.; Jacobson, J.; Girish, G.; Dong, Q.; Jiang, Y.; Jamadar,
D. University of Michigan, Ann Arbor, MI
Address correspondence to A. Woodrow ([email protected].
edu)
Background Information: New extremity masses in the patient
status post removal of an extremity tumor present a difficult clinical challenge. Ultrasound can be used as a primary and a complementary modality to MR in the differentiation of recurrent or
metastatic disease from benign postoperative changes. The purpose of this educational exhibit is to review the sonographic
appearance of pathology proven recurrent and metastatic
297
extremity tumors and compare and contrast these findings with
the sonographic appearance of postsurgical changes after tumor
removal.
the ultrasound characteristics of metastatic and recurrent extremity tumors; review the ultrasound characteristics of postsurgical
changes in the extremity; review the ultrasound characteristics of
primary extremity tumors; compare and contrast the above characteristics; describe key ultrasound findings in differentiation of
metastatic/recurrent extremity tumors from postsurgical change,
and demonstrate correlation with MR imaging.
Techniques: Metastatic and recurrent extremity tumors demonstrate ultrasound findings such as a discrete mass, hypoechogenicity and hypervascularity. Lymphoma may appear as a hypoechoic infiltrative mass. Benign postsurgical ultrasound findings
after tumor removal include lack of a defined mass, heterogeneity, hypoechogenicity, and variable hyperemia. Although findings
in these two groups demonstrate significant overlap, findings of a
discrete mass and hypervascularity tend to correlate more strongly with recurrent or metastatic disease. Primary tumors demonstrate findings similar to metastatic disease, notably a discrete
mass, hypoechogenicity, and hypervascularity.
Conclusion: Although ultrasound findings in pathologically proven recurrent and metastatic extremity tumors and ultrasound
findings in benign postsurgical changes demonstrate significant
overlap, ultrasound can be a valuable modality in evaluating a
new mass in a patient status post surgical removal of an extremity tumor.
E363. Sonographic Evaluation in the Clinical Setting of
Xiphoid Area Pain and/or Palpable Mass
Macatol, J.; Fessell, D.; Jamadar, D.; Girish, G.; Dong, Q.;
Jacobson, J. University of Michigan, Ann Arbor, MI
Address correspondence to J. Macatol ([email protected])
Objective: The objective was to investigate the clinical entity of
pain and/or palpable mass in the region of the xiphoid by ultrasound and discuss the sonographic findings as well as spectrum
of possible diagnoses.
Materials and Methods: This was a retrospective review of 31
consecutive patients whom were evaluated with ultrasound for
xiphoid area complaints from 2002 through 2008. Sonographic
findings were reviewed. Clinical/imaging follow-up was also
reviewed, when available.
Results: Of the 31 patients, the spectrum of diagnoses include:
lipoma, ventral hernia, variant shape of the xiphoid, thickening of
adjacent fascia, rectus abdominus injury, and normal appearing
xiphoid. Seven patients had follow-up CT imaging for correlation.
Conclusion: The clinical entity of xiphoid area palpable mass
and/or pain is not uncommon. No aggressive or malignant masses were found in this series. This data supports that this clinical
entity may be considered a “pseudo-mass”.
298
E364. Imaging Features of Lucent Lesions of the Face: What
Every Radiologist Must Know to Develop a Workable
Differential Diagnosis
Jiang, J.; Daffner, R. Allegheny General Hospital, Pittsburgh, PA
Address correspondence to J. Jiang ([email protected])
Background Information: Radiologists frequently encounter
dental and oral abnormalities. This exhibit will familiarize the
reader with a wide range of normal variant, benign and malignant lucent lesions of the face with the aid of a variety of imaging modalities, and define an approach to analyze the lesion
based on imaging features and forming a differential diagnosis.
normal anatomy of the face emphasizing the mandible and the
oral cavity. General imaging characteristics associated with lucent
lesions are illustrated. Clear case examples of normal variant,
developmental, acquired including cysts, infectious, inflammatory,
benign and malignant neoplasms, metabolic and traumatic
lucent lesions are explored. Imaging appearances and common
pitfalls regarding benign and its “evil twin” lesions are discussed.
Techniques: Imaging modalities employed include Panelipse, CT,
MRI and pathology. Detailed illustrations and explanation of the
dental and oral abnormalities are provided. Common pitfalls and
“evil twins” are provided side by side for detailed comparison.
Conclusion: The same principles for lucent bone lesions elsewhere can be applied to the face. Familiarity with a lesion’s location, epicenter, borders, internal contents, and its effect on adjacent structures can provide the radiologists with a tremendous
amount of information at reaching an accurate diagnosis and
ultimately effecting patient management.
E365. CT and MRI Findings of Chondroblastoma of the
Temporal Bone in 31 Patients With Pathologic Correlation
Brickner, M.; Glazebrook, K.; Inwards, C. Mayo Clinic, St. Louis
Park, MN
Address correspondence to M. Brickner ([email protected])
Objective: The purpose is to describe and characterize the radiologic appearance of chondroblastoma of the temporal bone
through CT and MRI.
Materials and Methods: One musculoskeletal radiologist and
one musculoskeletal fellow retrospectively reviewed 31 pathologically proven cases of chondroblastoma of the temporal bone.
Radiologic studies reviewed by consensus included CT (n=31)
and MRI (n=16). Evaluation included patient’s age and sex. CT
evaluation included size, location, expansion, matrix including the
presence of mineralization, aggression, and presence of a soft tissue mass. MRI evaluation included intrinsic T1 and T2 signal
along with the presence of contrast enhancement.
Results: Chondroblastoma of the temporal bone patients included 22 males and nine females with age ranges of 27-81 years
old. The average tumor size was 3.0 cm x 3.0 cm and located
predominately in the squamosal portion of the temporal bone
(n=26 or 84%). Bony expansion of the tumor was identified in
the vast majority of cases (n=29 or 94%) with a lytic (n=29 or
94%) matrix and presence of some mineralization (n=24 or
77%). Over half of the tumors were aggressive in nature (n=18
or 58%) and had an associated soft tissue mass (n=16 or 52%).
Of the cases with soft tissue involvement, 14/16 had a soft tissue
mass or soft tissue thickening within the external auditory canal.
Most lesions had predominately low signal characteristics on
both T1-weighted imaging (90%) and T2-weighted imaging
(67%) when MRI images were included. Most tumors with postcontrast T1-weighted imaging displayed some degree of
enhancement (93%).
Conclusion: Typical CT findings of chondroblastoma of the temporal bone include an expansile, lytic tumor with the presence of
mineralization located predominately in the squamosal portion of
the temporal bone. External auditory canal involvement was frequently identified in cases in which a soft tissue mass was
present. MRI findings typically demonstrate a mass with low signal on T1- and T2-weighted images with some degree of
enhancement.
E366. Imaging Characteristics of Mandibular Lesions (CME
Credit Available)
Meyer, K.1; Bancroft, L.2; Dietrich, T.3; Berquist, T.1; Kransdorf, M.1;
Peterson, J.1 1. Mayo Clinic, Jacksonville, Jacksonville, FL; 2. Florida
Hospital, Orlando, FL; 3. University of Louisville, Louisville, KY
Address correspondence to K. Meyer ([email protected])
Background Information: Jaw pathology is common, yet it is
not encountered by the radiologist on a daily basis. It is important for radiologists to recognize jaw pathology to ensure appropriate, timely patient care. A common site of complaint is the
temporomandibular joint (TMJ). MRI can evaluate displaced
disks, inflammation and osteoarthritis. Infection and trauma are
typically diagnosed based on clinical findings. However, imaging
studies are usually needed to assess the extent of disease as well
as to aid in treatment planning. Imaging studies may not provide
a specific diagnosis, yet they should narrow the differential and
guide further work-up. Additionally, jaw pathology may present in
a nonspecific manner, making imaging of the utmost importance
in elucidating the etiology of the patients symptoms.
Educational Goals/Teaching Points: After review of this educational exhibit, viewers will be able to recognize the indications
and appropriate imaging studies for various mandibular lesions
(radiographs as first line imaging, CT for evaluation of osseous
lesions, MRI for characterization of soft tissue lesions, and CT 3D
surfacing reformats for surgical planning); describe the imaging
findings of relatively common jaw pathology including, but not
limited to differentiation of benign vs. malignant tumor characteristics, infectious processes (abscesses, osteomyelitis, odontogenic
infections, necrotizing fascitis), osteonecrosis, TMJ disorders and
expected trauma patterns to help to avoid overlooking occult
fractures; formulate a differential diagnosis based on clinical
presentation and imaging characteristics, and understand appropriate treatment options (simple excision, excision with reconstruction, joint repair with or without joint prosthesis and surgical
debridement).
Techniques: This exhibit will address the anatomy, physiology,
clinical imaging, characteristic imaging, suggested imaging
modalities, and surgical treatment for neoplasms (benign and
malignant); congenital disorders (Treacher-Collins, cherubism);
infection (osteomyelitis, abscess, odontogenic infection, necrotizing fascitis); bisphosphonate osteonecrosis; sialolithiasis; temporomandibular joint disorders and replacement, and trauma.
Conclusion: In summary, proper characterization of jaw pathology is essential to ensure appropriate patient care and reduce
morbidity. Imaging plays a key role in the characterization of a
variety of jaw lesions and radiologists must be familiar with these
imaging findings.
E367. The Cortical Groove Sign: A Newly Described Finding
Associated With Osteoid Osteomas
Liu, P.; Kujak, J.; Roberts, C. Mayo Clinic, Scottsdale, AZ
Address correspondence to P. Liu ([email protected])
Objective: Osteoid osteomas have been shown on CT, MR
nuclear bone scintigraphy and arteriography to be hypervascular
tumors. We introduce a new finding seen on CT exams of osteoid
osteomas, the “cortical groove” sign, consisting of one or more
thin curvilinear or serpiginous lucencies coursing through adjacent bone cortex into the tumor nidus. These lucencies have the
appearance of vascular grooves containing vessels feeding these
hypervascular tumors. We performed this study to determine the
sensitivity and specificity of the cortical groove sign for osteoid
osteomas.
Materials and Methods: In this IRB approved retrospective
study, radiology records were searched to identify cases of pathologically proven osteoid osteomas imaged with CT over the past
ten years. Forty-one cases were identified. For control cases, radiology records were searched to identify 29 bone lesion biopsy
cases with pathologic diagnoses. Two musculoskeletal radiologists performed independent, blinded review of these CT exams,
grading for the appearance of the cortical groove sign.
Interobserver agreement was calculated, and Fisher’s exact test
was used to examine for statistical significance.
Results: For readers 1 and 2 respectively, sensitivity of the cortical groove sign for detection of osteoid osteoma was 0.74 and
0.76; specificity was 0.97 and 0.90. Using Fisher’s exact test,
p<0.0001 for both readers. Interobserver agreement was very
good, with kappa=0.85.
Conclusion: The cortical groove sign is a moderately sensitive
but very specific CT finding for osteoid osteomas. Our findings
correlate with recently reported histologic findings of multiple
prominent arteries and arterioles supplying these hypervascular
tumors.
E368. Soft Tissue Calcifications: What Am I Looking At and
What Should I Do About It? (CME Credit Available)
Callahan, B.; Wu, J.; Hall, F.; Hochman, M. Beth Israel Deaconess
Medical Center, Boston, MA
Address correspondence to B. Callahan (bcallaha@caregroup.
harvard.edu)
Background Information: Soft tissue calcifications are frequently encountered during routine radiographic evaluation and are
often associated with local underlying pathology, systemic disease, or, occasionally, malignancy. Radiographs often demonstrate distinct imaging features for different types of soft tissue
299
calcification. Familiarity with characteristic features of soft tissue
calcifications can help the radiologist generate more accurate —
and more clinically relevant — differential diagnoses.
Educational Goals/Teaching Points: The exhibit will include a
discussion of calcification vs. ossification and etiology and composition of different types of soft tissue calcification; presentation
of a spectrum of illustrative cases, with emphasis on distinctive
imaging characteristics, and a discussion of clinical implications
of the various forms of soft tissue calcification, including the presence of local pathology, systemic disease, and potential malignancy. It will discuss an analytic algorithm for assessment of soft
tissue calcification or ossification, and provide recommendations
for tailored work-up of findings that may be indicative of systemic disease or tumor.
Techniques: The exhibit will review the spectrum of soft tissue
calcifications and their imaging (predominantly radiographic)
appearance. The role of secondary findings and additional imaging work-up will be addressed. It will discuss the importance of
recognizing atypical and or aggressive features of these entities,
and describe the pathophysiology and underlying biochemical
perturbations leading to these various manifestations.
Conclusion: A broad spectrum of soft tissue pathologies demonstrates calcification. This exhibit will offer to help readers develop
an approach to the radiographic evaluation of soft tissue calcifications and heighten awareness regarding soft calcifications that
are indicative of systemic disease or malignancy.
E369. Sonographic Features of Subfascial Lipomas
Paunipagar, B.; Griffith, J. Chinese University of Hong Kong, New
Territories, Hong Kong
Address correspondence to B. Paunipagar ([email protected])
Objective: The objective was to describe the sonographic features of subfascial lipomas.
Materials and Methods: This was a retrospective review of
sonographic features of 60 subfascial lipomas in 60 patients (41
females, 19 males, mean age 46.5, range 16-77 years) seen over
an eight-year period (1998–2006). Features evaluated were location, size, shape, marginal definition, internal echogenicity,
including the presence of intermingled muscle fibers and linear
internal echoes, acoustic transmission and vascularity.
Confirmation was made histologically in 33 (55%) cases and by
typical MRI appearances in 27 (45%) cases. MRI proceeded
sonographic examination in only one patient.
Results: Of 60 subfascial lipomas, location was supramuscular
(7%), intermuscular (27%), intramuscular (56%) or submuscular
(7%), others (3%). Maximum diameter ranged from 1 cm to 15
cm. Shape was fusiform in seven (12%), rounded in 25 (42%),
oblong in 20 (33%) or geographical in eight (13%). Margin was
well-defined in 48 (80 %) or ill-defined in 12 (20%). Main lesion
echogenicity was hypoechoic to muscle in 14 (23%), isoechoic in
13 (22%) or hyperechoic in 37 (55%). Linear internal echoes
were present in 59 (98%). Acoustic transmission compared to
muscle was increased in 24 (40 %). Twenty (33 %) lipomas
revealed mild internal vascularity, eight (13 %) minimal internal
vascularity and 36 (60%) no internal vascularity. In all cases sub-
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fascial lipoma was reported as the most likely diagnosis on sonographic examination.
Conclusion: Although the features of subfascial lipoma are more
variable than those reported for subcutaneous lipomas, the presence of thin internal echoes in conjunction with other less specific features should enable a correct diagnosis.
E370. Acoustoelastography of the Tendon: Applying a New
Method for Evaluating Tissue Property and Deformation of
the Musculoskeletal System
Lee, K.; Kobayashi, H.; Vanderby, R. University of WisconsinMadison, Madison, WI
Address correspondence to K. Lee ([email protected])
Objective: Diagnosing tendon or ligament injury can be a difficult task despite recent advances in medical imaging. Ultrasound
has distinctive advantages over other imaging modalities (no
radiation, portability, low cost, accessibility), but its musculoskeletal use has been limited, particularly in the United States.
Innovative developments in ultrasound technology may expand
diagnostic capabilities of musculoskeletal ultrasound and thereby
increase its usage. The goal of this scientific exhibit is to introduce a new method that evaluates the tissue mechanical properties of a porcine tendon using A-mode ultrasound.
Materials and Methods: Our research group has developed an
innovative ultrasound wave analysis method termed “acoustoelastography.” It is based on a mathematical theory called acoustoelasticity (AE) that relates mechanical properties to wave propagation (acoustic) characteristics in a deformed medium. The
concept of AE can be envisioned with a guitar string. When the
string is stretched, a geometric change (reduction in string diameter) and an acoustic change occurs (pitch increases), which are
inter-related. AE was never applied to biological tissues, although
this wave velocity change has been observed in stretched animal
tendons. We measured reflected echo magnitude using an
A-mode 2.25 MHz Olympus-NDT V323-SU ultrasound device
from stretched porcine flexor tendons in vitro (n=8). Given a
measured reflected echo magnitude, the reflection coefficient
was evaluated as the magnitude ratio of the reflected echo to the
incident echo. Tendon stiffness in the transverse direction was
evaluated from the reflection coefficient. In order to remove the
influence of variation in tissue density, normalized tendon stiffness was evaluated as the ratio of stiffness in a deformed state
to stiffness in a nondeformed state.
Results: We have found that the normalized stiffness of the porcine flexor tendon is linearly related to applied force (mean
slope—4.6 x 10-4 SD—8.1 x 10-5). That is, as the tendon was
stretched, a predictable measure of increasing stiffness could be
obtained. Wave velocity increased as the flexor tendon was
stretched (increased stiffness), which can also be correlated with
its echogenicity.
Conclusion: Acoustoelastography is a new application that can
evaluate tissue mechanical properties of a tendon, which has
promising potential in enhancing diagnostic musculoskeletal
ultrasound. Future studies will use B-mode evaluation.
E371. You Ache, Therefore I Scan: The Use of Ultrasound for
Rheumatologic Disorders
Hoots, J.1; Shepherd, S.1; Strauss, D.2; Allison, S.1 1. Georgetown
University Medical Center, Washington, DC; 2. No Institutional
Affiliation
Address correspondence to J. Hoots ([email protected])
Conclusion: Image-guided techniques can be used in the diagnosis and treatment of bursitis. Familiarity with the normal and
abnormal appearances of bursae will enable radiologists to correctly identify bursal pathology and differentiate it from other
entities.
Background Information: Musculoskeletal ultrasound is an
underutilized modality in evaluating rheumatologic disorders. The
purpose of the exhibit it to review pathologic findings in rheumatologic disorders; demonstrate the sonographic appearance of
these findings, and demonstrate the utility of ultrasound in evaluating rheumatologic disorders.
E373. Imaging Features of Hemophilic Arthropathy (CME
Credit Available)
Brennan, I.; Murphy, G.; McEniff, N. St. James’s Hospital, Dublin,
Ireland
Address correspondence to I. Brennan ([email protected])
rheumatologic disorders present with joint pathology; types of
joint pathology (effusions and synovitis); sonographic features of
joint pathology, and other applications of ultrasound (joint aspiration, biopsy, injections).
Conclusion: Ultrasound may be used to detect and diagnose
joint pathology associated with rheumatologic disease.
Ultrasound is a cost effective, efficient modality in assessing disease activity in patients with rheumatologic disease. Ultrasound
may also provide additional diagnostic and treatment capabilities
in assisting with joint aspiration, synovial biopsy and tendon
injection in patients with rheumatologic disease. E372. Bursae, Bursae, Everywhere: A Radiologist’s Guide to
Bursal Anatomy, Imaging, and Image-Guided Intervention
Melenevsky, Y.1; Newman, J.2; Perry, L.1; Wu, J.1; Hochman, M.1
1. Beth Israel Deaconess Medical Center, Boston, MA; 2. New
England Baptist Hospital, Boston, MA
Address correspondence to Y. Melenevsky ([email protected])
Background Information: Deficiency of factor VIII or IX leads to
the clinical conditions of Hemophilia A and B respectively. Such
patients are prone to recurrent joint hemorrhage leading initially
to joint effusion and synovial proliferation. Late sequelae include
joint deformity, contracture and degenerative arthritis.
Hemophilia affects 1 in 5000 Irish men with hemarthrosis occurring in 75-90%. Up to 50% of patients will progress to develop
permanent joint deformity.
the radiographic appearance of early and established hemophilic
arthropathy in a variety of anatomical locations and to compare
plain radiography and MRI in the assessment and classification of
joint disease progression and treatment response.
Materials and Methods: Imaging from patients registered at the
National Centre for Hereditary Coagulation Disorders (NCHCD)
incorporating the National Haemophilia Centre based in St
James’s hospital were reviewed (n=236 cases ). Plain radiograph
and MR cases demonstrating the full spectrum of joint disease
were identified. Examples illustrating the established ArnoldHilgartner classification system were noted.
Background Information: Bursitis is a common cause of musculoskeletal pathology, and can be a manifestation of an injury or systemic disease. We will review bursal anatomy, function, and pathology using radiography, bursography, sonography, CT and MRI.
Conclusion: Hemophilia is an important cause of potentially
debilitating joint disease in young people. Knowledge of the
plain film and MR features of early and late hemophilic arthropathy is essential to enable timely identification and monitoring of
this disease process.
Educational Goals/Teaching Points: The goals are to familiarize the reader with bursal anatomy and function; outline imaging
characteristics of normal bursae throughout the body; describe
common and uncommon bursal pathology, and provide an overview of common image-guided diagnostic and therapeutic bursal
interventions.
E374. Dual-Energy CT for Evaluation of Gout
Black, D.; Glazebrook, K.; Michet, C.; Berger, R.; Kavros, S.;
McCollough, C. Mayo Clinic, Rochester, MN
mayo.edu)
Techniques: Bursae are small spaces lined by the synovium, typically interposed between bony surfaces and ligaments or tendons and may communicate with the joint. Usually bursae contain a small amount of fluid, alleviating friction between surfaces.
Normal bursae are not seen on radiographs, trace fluid can be
detected by cross-sectional modalities. MR is superior in evaluation of bursal pathology and extent of soft tissue inflammation;
sonography offers advantages of real-time exam, availability and
lower cost, but can be operator dependent. Bursitis can mimic
other entities; imaging can provide valuable information in addition to clinical findings. Imaging may be used to guide diagnostic
needle aspiration of bursal fluid in bursitis. Intrabursal glucocorticoid injections can be utilized in the management of bursitis.
Objective: The objective was to evaluate the technique of dualenergy CT (DECT) scanning in demonstrating uric acid crystals in
the extremities of patients with inflammatory arthropathies.
Materials and Methods: Fifteen patients with inflammatory
arthropathies were scanned using the DECT scanner. Eleven
ankles and feet and four hands and wrists were scanned. There
were seven males and eight females with age range of 38 to 80,
mean age of 63 years. All patients were clinically suspected of
having gout. DECT scanners have two, orthogonal X-ray tube/
detector array pairs. This design allows simultaneous acquisition of the 80kVp and 140 kVp data sets used in dual energy
processing. The use of a different kVp for each tube exploits the
kV-dependent nature of CT numbers, allowing differentiation of
301
materials having different effective atomic numbers. Off line postprocessing was performed using a commercial software program
to create material selective images, where uric acid crystals were
color coded as green and calcium as pink.
Results: Eight patients had dual source CT scans positive for uric
acid crystals. Of these, six patients had longstanding tophaceous
gout, two of whom were participating in a polyethylene glycol
uricase study for treatment of symptomatic tophaceous gout. In
the remaining two patients, one patient had insufficient fluid on
joint aspiration to assess for uric acid crystals. She was treated for
gout following the positive DECT with clinical improvement. The
other patient, diagnosed as seronegative arthritis at an outside
institution, was treated for gout following the positive DECT scan
with clinical improvement. Seven cases were negative for uric
acid crystals on DECT scans. Two patients with hyperuricemia had
joint aspirations with no uric acid crystals seen. One patient had
extensive periarticular calcification seen on the DECT. She was
thought to have calcium pyrophosphate deposition from chronic
renal failure. One patient had an ankle joint aspiration negative
for uric acid three months before the negative DECT scan.
Clinically, the remaining three patients were felt to have a flare of
seronegative arthritis following the negative DECT exam.
Conclusion: DECT scanning appears to be a very useful technique to noninvasively demonstrate uric acid deposition in
patients with gout. A negative DECT appears to have a high negative predictive value for gout in our small, pilot series.
E375. Approach to Arthritis: ABC’s and Beyond
Rehani, B.; Wissman, R. University of Cincinnati, West Chester, OH
Address correspondence to R. Wissman (wissmaRD@healthall.
com)
Background Information: Learning the arthridities is challenging and sometimes confusing. There are a myriad of arthridities
that can produce a host of radiographic findings. Generating a
reasonable differential requires a systematic approach. Therefore
we propose an approach to arthritis which categorizes arthridities
into three categorizes- hypertrophic, inflammatory and deposition
diseases.
Educational Goals/Teaching Points: The goals are to review an
approach to the radiographic findings which has previously been
described as the “ABC’S” of arthritis; use the radiographic findings to categorize arthritis into one of three categories- hypertrophic, inflammatory and deposition diseases; suggest ways to
differentiate seronegative arthridities from rheumatoid arthritis;
suggest ways to differentiate inflammatory arthritis from deposition diseases, and suggest a simple method to remember the
arthridities in each category.
Techniques: Hypertrophic arthridities such as osteoarthritis and
diffuse idiopathic skeletal hyperostosis predominantly produce
bone or osteophytes. Inflammatory arthridities such as rheumatoid arthritis and infection produce early joint space narrowing
and erosions often with little or no bone production. Deposition
diseases such as pigmented villonodular synovitis, gout and other
crystal deposition diseases, often spare the joint space until late
in the disease.
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Conclusion: A systematic approach to the arthridities is essential
for accurate diagnosis. We suggest this approach be considered.
E376. Imaging Characteristics of Skeletal Coccidioidomycosis
Kujak, J.; Lorans, R.; Chivers, S.; Liu, P. Mayo Clinic, Scottsdale, AZ
Address correspondence to R. Lorans ([email protected])
Background Information: Coccidioiodomycosis infection is
caused by a dimorphic fungus (coccidioides immitis) which lives
in the soil of semiarid locations and is endemic to the American
southwest, Mexico and South America. Exposure to the fungus is
usually through inhalation and when symptomatic, most usually
causes a flu-like illness with pulmonary and systemic symptoms
also known as “valley fever”. Infection of the bone by this organism is a relatively infrequent occurrence. Our purpose is to present
the imaging features of several cases of pathologically proven
musculoskeletal and isolated soft tissue coccidioidomycosis.
reviews the clinical presentation, demographics and musculoskeletal imaging features of coccidioidomycosis so that the practicing
radiologist can recognize this entity more readily in the appropriate clinical context and place it in the differential diagnosis. In
today’s mobile society, the ease of international travel and travel
to endemic locations in the American southwest emphasizes the
need to increase awareness and diagnostic consideration of this
infection, especially in nonendemic areas. The objectives of this
educational activity are for the participant to learn the various
radiologic features of musculoskeletal and soft tissue coccidioidomycosis infection; review the clinical presentation and demographics of patients with coccidioidomycosis infection, and to
become more aware of this entity and consider the diagnosis in
patients who have traveled to endemic areas.
Techniques: There are a broad range of appearances of musculoskeletal coccidioidomycosis and it can affect both the axial and
appendicular skeleton. It may mimic inflammatory arthritis,
osteomyelitis, myeloma, sarcoma and pigmented villonodular
synovitis. In our series, only 29% of patients were immunocompromised and close to half of the patients presented with a systemic illness.
Conclusion: As the imaging features of musculoskeletal coccidioidomycosis infection are nonspecific, this diagnosis should be
considered in patients with recent travel to endemic areas who
present with bone/joint erosion, destruction or mass-like lesions.
E377. Whole-Bone Osteomyelitis: Imaging Findings With
Pathologic Correlation
Roberts, K.; Simoncini, A.; Hollister, A.; Primeaux, T.; Rowell, A.;
Sessions, D. Louisiana State University Health Sciences CenterShreveport, Shreveport, LA
Address correspondence to K. Roberts ([email protected])
Background Information: Very few cases of whole-bone osteomyelitis are described in the current literature. Submitted for
presentation are several cases of whole-bone osteomyelitis collected over the last three years at our institution. This exhibit will
showcase the MRI and radiographic imaging findings of this enti-
ty along with pathologic correlation when possible. Clinical correlation as well as surgical and medical management will be outlined in a case-by-case format. Follow-up images documenting
outcome of these rare cases will be presented when available.
Educational Goals/Teaching Points: Osteomyelitis rarely affects
the entirety of the long bone. Well-planned MRI protocols are
highly sensitive and specific in diagnosing the extent of osteomyelitis. Therapeutic management of whole-bone osteomyelitis is
heavily dependant upon the findings reported from radiographic
imaging.
Techniques: Multimodality imaging findings will be displayed
in an electronic format, providing pathologic correlation when
possible.
Conclusion: Osteomyelitis of the entire long bone presents
certain diagnostic and therapeutic challenges which will be
addressed in this educational exhibit. The clinician’s decision to
pursue surgical vs. medical management in these cases is often
impacted heavily by radiographic imaging findings. As very few
cases have been described, this exhibit will serve to provide an
overview of the clinical and radiologic manifestations of this condition.
E378. Spectrum of Imaging Findings in Paget Disease of
Bone and its Musculoskeletal Complications (CME Credit
Available)
C.3 1. University of California, San Diego; San Diego, CA; 2.
com)
Background Information: Paget disease, or osteitis deformans,
is a chronic skeletal disorder characterized by exaggerated and
abnormal bone remodeling. It is the second most common bone
disease after osteoporosis that affects the elderly in the United
States. Paget disease of bone demonstrates a plethora of imaging patterns and variable appearances related to the pathologic
stage of the disease. In the initial or active phase there is well
defined osteolysis in the skull (osteoporosis circumscripta) or
subchondral bone (blade-of-grass appearance), in the appendicular skeleton. In the mixed phase of disease, characteristic
trabecular and cortical thickening (i.e., picture frame vertebra)
occurs in conjunction with bone enlargement; and, in the late or
inactive phase of Paget’s there is predominant bone sclerosis (i.e.,
ivory vertebra). Despite the development of new therapies that
may diminish morbidity, patients with Paget are at risk of developing various musculoskeletal complications.
Educational Goals/Teaching Points: In this educational exhibit,
we revisit Paget disease of bone and illustrate the gamut of
imaging findings associated with this skeletal disorder. Although
we emphasize the radiographic appearance of Paget disease, a
multimodality approach including scintigraphy, CT, and MR imaging is employed. Overall, this exhibit illustrates the imaging characteristics of Paget disease of bone, both uncomplicated and
complicated.
Techniques: Traditionally, conventional radiography has been the
mainstay in the imaging evaluation of Paget disease affecting the
skeleton. Because CT may provide superior cortical and trabecular detail and better depiction of osseous deformity (i.e. bowing)
it has been helpful in evaluating pagetic bone. MR imaging,
owing to its exquisite soft tissue resolution and multiplanar imaging capabilities, can facilitate early and accurate diagnosis of
musculoskeletal complications, including osseous deformity, fracture, spinal stenosis, neoplastic degeneration, and osteoarthrosis.
Finally, radionuclide scanning is well suited for defining the
extent and activity of polyostotic disease especially in those sites
with overlapping structures.
Conclusion: Recognition of the key imaging features of Paget
disease as derived from different imaging methods, coupled with
information about the site or distribution of lesions, allows prospective diagnosis of the disease and its associated musculoskeletal complications and can preclude biopsy.
E379. Surface Lesions of Bone–What to Do With Them
Malhotra, A.; Dhillon, G.; Cesarz, M.; Seo, G.; Monu, J. University
of Rochester, Rochester, NY
Address correspondence to J. Monu ([email protected])
Background Information: Many bone neoplasms occur either
in the medullary space or cortex of bone. Lesions occurring on
the surface of bone may pose a diagnostic dilemma as it may be
difficult to decide the site of origin and hence the true nature of
the lesion.
a simple and organized approach way to analyze surface neoplasm of bone; differentiate lesions that occur in proximity of
bone from those that are intimately related to surface of bone,
and have a working knowledge of the more common surface
lesions of bone and their management.
Techniques: Selected images from our radiology data bank will
be used to illustrate the usual features of surface neoplasm of
bone. Correlative pathology images will be presented to buttress
the diagnoses. The differential diagnoses for the various lesions
presented will be discussed and key diagnostic imaging and histopathologic features will be highlighted. Management of the various disease entities will be addressed using illustrative cases.
Conclusion: Surface neoplasms of bone are not uncommon. An
organized and informed analysis of the images will frequently
enable an accurate diagnosis.
E380. Applications of SPECT-CT in Bone Imaging
Yilmaz, Z.; Brown, R.; Frey, K. University of Michigan, Ann Arbor, MI
Address correspondence to R. Brown ([email protected])
Background Information: Nuclear scintigraphy is a highly sensitive technique for the detection of bone pathology, however, it
lacks specificity. Correlation with anatomic imaging can be useful
in improving the diagnostic accuracy of the study. This exhibit
303
demonstrates clinical examples where hybrid imaging improves
the detection and characterization of bone pathology.
Educational Goals/Teaching Points: The goals are for the participant in this educational activity to learn how fusion imaging
can improve the diagnostic accuracy of nuclear scintigraphy; gain
a better understanding of what specific questions are best
answered with fusion imaging, and gain a better understanding
of what CT protocols are used for evaluating bone pathology in
fusion imaging.
Techniques: The exhibit demonstrates the problem solving capabilities of SPECT-CT in pathology that are subtle, occult or indeterminate on standard planar imaging. Examples of fractures,
osteochondral injuries, osteomyelitis, avascular necrosis, metastases and degenerative changes simulating disease are demonstrated. The utility of viewing studies in a fusion mode is discussed.
Conclusion: By correlating the location of uptake with the findings on the coregistered anatomic images the diagnostic accuracy
of bone scans can be improved. SPECT-CT also enables the
detection of tissue abnormalities which are not usually detected
on nuclear scintigraphy. In cases of suspected osteomyelitis this
technology can obviate the need for 24 hour delayed views in
patients with delayed blood pool clearance. Both sensitivity and
specificity can be improved with the utilization of hybrid imaging.
E382. Clinical Dyads: Traumatic Lesions that Commonly
Occur Together (CME Credit Available)
Dunn, D.; Mansfield, L. Brooke Army Medical Center, San Antonio,
TX
Address correspondence to L. Mansfield ([email protected])
Background Information: In the United States, trauma is
the leading cause of death in persons under 40 years old and
third most common overall. Mortality and morbidity are due to
polytrauma, where multiple long bone fractures are seen in association with vascular, visceral and soft tissue injuries, arising from
a common mechanism of injury.
is for the participant of this activity to understand the concept of
polytrauma; to be familiar of the common clinical dyads, traumatic injuries that frequently occur together, and to understand
the mechanism of injury accounting for the common clinical
dyads.
Techniques: Examples of musculoskeletal-vascular dyads include
knee dislocation and popliteal artery injury, pelvic fracture and
iliac artery laceration, skull fracture and epidural hematoma,
scapulothoracic dissociation and axillary artery injury, posterior
sternoclavicular dislocation and great vessels injury, and cervical
spine fracture and vertebral artery dissection. Examples of fractures-visceral dyads include pelvic fracture and bladder or urethral rupture, pelvic fracture and diaphragmatic rupture, lower
ribs fracture and liver/spleen/kidney laceration, Chance fracture
and small bowel injury, rib fractures and pneumothorax, and frac-
304
ture-dislocation of spine and esophageal or tracheal rupture.
Fractures that occur together are calcaneus and thoracolumbar
spine, femoral shaft and hip fracture dislocation, tibia and hip
dislocation, pelvis and sacrum or sacroiliac joint dislocation, chest
wall and scapula, spine and sternum, and fracture-dislocation of
spine and costovertebral joint. Fractures-soft tissue dyads include
Segond fracture and anterior cruciate ligament (ACL) tear, arcuate
sign and cruciate ligament rupture, osteochondral fracture of the
patella and medial patellofemoral ligament tear, kissing bone
contusions in ACL rupture, kissing bone contusions in posterior
cruciate ligament tear, orbital blow-out fracture entrapping inferior rectus muscle, ankle fracture and superior peroneal retinaculum avulsion resulting in peroneal tendon subluxation, and ankle
fracture entrapping ankle tendon. Fractures-dislocation dyads
include Monteggia, Galeazzi, Essex-Lopresti and Maisonneuve
fracture dislocation.
Conclusion: Certain traumatic lesions occur together due to the
mechanism of injury. Therefore, radiologists must be aware of
the common clinical dyads seen in patients with multiple injuries
to avoid delay in diagnosis and prevent avoidable morbidity and
mortality.
E383. Musculoskeletal Corticosteroid Injections: A Step-byStep Guide to Common and Innovative Applications for the
Practicing Radiologist
Koo, J.1; Tumyan, L.2; Chakarun, C.2; White, E.2; Wolfson, N.2 1.
University of California, Los Angeles, Los Angeles, CA; 2.
University of Southern California-Keck School of Medicine, Los
Angeles, CA
Address correspondence to L. Tumyan ([email protected])
Background Information: The purpose of the exhibit is to
review the indications, key imaging findings, and the appropriate
technique for common and novel applications of musculoskeletal
corticosteroid injections.
Educational Goals/Teaching Points: Corticosteroid injections
for arthritides affecting the knee and shoulder have remained
some of the most common procedures for the practicing orthopedist, rheumatologist, and general practitioner. More recently,
novel imaging-guided techniques using fluoroscopy, ultrasound,
and CT have been utilized for therapeutic injection in a variety of
muscular and intra-articular locations. The exhibit will review the
literature and discuss the indications, relative contraindications,
plain film and MRI findings in patients referred for diagnostic and
therapeutic joint injections. Our exhibit will provide step-by-step
instructions and common pitfalls for fluoroscopic-, CT- and ultrasound-guided musculoskeletal injections. This will include injection of the flexor hallucis longus tendon sheath, as well as injection of the pubic symphysis, hip, os trigonum, calcaneocuboid,
talonavicular, tibiotalar, subtalar joints, sacroiliac, elbow, and
shoulder joints.
Techniques: Differentiating between the various inflammatory
and noninflammatory arthritides requires a combination of clinical, imaging, and laboratory findings. Imaging evaluation should
begin with conventional radiography, but the radiologist must
also be familiar with normal and pathophysiologic features on
other imaging modalities such as CT and MRI. Innovative imaging-guided techniques have led to successful injection of the flex-
or hallucis longus tendon sheath, as well as multiple joints
including the sacroiliac, pubic symphysis, elbow, talonavicular,
calcaneocuboid, and subtalar joints.
Conclusion: Corticosteroid injections of the musculoskeletal system involve minimally invasive procedures that play a significant
therapeutic role. Our exhibit will review the indications, imaging
findings, and provide a detailed guide with step-by-step instructions of common and novel techniques for musculoskeletal injections. The viewer of the exhibit will be able to incorporate these
techniques into their practice.
E384. Phase Sensitive Fat-Water Separation for
Musculoskeletal Imaging: Core Concepts and Methodologies
Yao, L.; Gai, N. National Institutes of Health, Bethesda, MD
Address correspondence to L. Yao ([email protected])
Background Information: Radiologists commonly employ spectral fat suppression when performing MRI of the body and musculoskeletal system. The fundamentals and methods of phase sensitive fat water separation are less familiar to radiologists and
practitioners. Phase sensitive fat water separation is potentially
more robust than spectral fat suppression, and confers advantages for quantitative imaging approaches, but requires processing
of acquired images. Potential clinical applications for image
quantitation include assessment of muscle atrophy, bone marrow
infiltration, and body composition.
Educational Goals/Teaching Points: This exhibit reviews fundamental concepts underlying Dixon (Dixon WT. Radiology 1984)
fat-water separation methodology. Potentially confusing core concepts are highlighted and explained. The exhibit emphasizes
newer phase correction strategies. Methods and principles of fat
water separation are illustrated in clinical thigh muscle MR studies to make the concepts visually accessible and more intuitive to
radiologists.
Techniques: The exhibit discusses and illustrates these concepts
and methods: complex image data, image phase, and phase
arithmetic; image acquisition considerations for Dixon-based
spectroscopic imaging; determinants and ranges of phase ambiguity; two point vs. three point Dixon methods; phase correction
(Ma J. Magn Reson Med 2004) vs. phase unwrapping; region
growing strategies and enhancements (Schmidt MA, Fraser KM. J
Magn Reson Imaging 2008). Conclusion: Newer region growing phase correction strategies
are robust, efficient, and easy to implement. These approaches
may raise the practical utility of Dixon fat water separation methodologies. Associated scan techniques are time efficient, particularly on current, high gradient performance scanners. Phase sensitive methods may improve fat suppression in clinical imaging
and could be particularly helpful for contrast-enhanced studies.
The same strategies may also facilitate quantitative clinical MRI
measurements of fat fraction.
E385. Imaging of the Musculoskeletal System in HIV (CME
Credit Available)
Allmendinger, A.; McLaughlin, V. St. Vincent’s Catholic Medical
Address correspondence to A. Allmendinger (amallmendinger@
gmail.com)
Background Information: Musculoskeletal abnormalities are not
as common as pulmonary or central nervous system abnormalities
in patients with HIV, however a wide spectrum of musculoskeletal
abnormalities (soft tissue and bony) does occur. HIV disease
decreases the body’s defense mechanisms, predisposing the body
to common and opportunistic infections, anemia and HIV-related
malignancies. Additionally, avascular necrosis may occur secondary
to HIV therapy. Musculoskeletal involvement generally is more
common in the later stages of HIV infection, although arthritis can
occur at any stage. Our purpose is to provide a case-based, pictorial essay of musculoskeletal pathology in HIV disease.
the common MR sequences utilized in imaging musculoskeletal
pathology in HIV; discuss the common and opportunistic infections as well as HIV-related malignancies; discuss the various
manifestations of avascular necrosis related to HIV therapy, and
discuss bone marrow signal abnormalities commonly found in
HIV patients.
Techniques: HIV infected patients may demonstrate a wide variety of musculoskeletal abnormalities not commonly encountered
in every day practice. This exhibit is a case-based, pictorial essay
discussing HIV disease and manifestations demonstrated on MR
imaging. Soft tissue and bony pathology will be presented with a
focus on common and opportunistic infections, bone marrow
pathology and HIV-related malignancies.
Conclusion: Although musculoskeletal manifestations are not as
common as pulmonary or central nervous system abnormalities,
recognition of these conditions is important for early and appropriate initiation of therapy. After completing this exhibit, the viewer will be confident identifying infectious, neoplastic and bone
marrow pathology commonly encountered in the HIV patient.
E386. Malignant “Triton” Tumor: An Imaging Perspective
Sunnapwar, A.1; Lemos, J.2; Lemos, D.2; Choudhary, S.1;
Restrepo, C.1 1. University of Texas Health Science Center at San
Antonio, San Antonio, TX; 2. University of Vermont, Burlington, VT
Address correspondence to A. Sunnapwar ([email protected])
Background Information: Malignant Triton tumor is a rare
malignant peripheral nerve sheath tumor with rhabdomyosarcomatous differentiation. It is a type of aggressive sarcoma consisting of both malignant schwannoma cells and malignant rhabdomyoblasts. We present imaging features of five cases of this
rare tumor with systematic review of the literature.
the histopathology of malignant Triton tumor (MTT); give an
overview of the demographics and clinical presentation of MTT;
present imaging features of five cases of MTT that were proven
by histopathology, and to briefly review management and prognostic issues of MTT.
305
Techniques: Over a period of seven years five cases of histopathologically proven MTT were observed. Three patients had
imaging with CT scans and two patients had MRI. Each patient
had tumor in different locations. A systematic search of the literature was made.
Conclusion: Malignant tumors arising from peripheral nerve
sheath or in neurofibromas may contain other mesenchymal elements such as rhabdomyosarcoma. These tumors are also commonly referred in pathology literature as “Triton” tumor. These
tumors can arise anywhere in the body from the neck region to
the foot. Because of aggressive behavior they have a worse prognosis than classic malignant peripheral nerve sheath tumors. A
preoperative diagnosis is important as more radical surgery and
aggressive management is necessary.
E387. Imaging Features of Recurrent Giant Cell Tumors:
Review of Radiographic, Ultrasound, CT, and MRI Findings
Aagesen, M.; Jacobson, J.; Girish, G.; Morag, Y.; Kalume Brigido,
M.; Sabb, B. University of Michigan, Ann Arbor, MI
Address correspondence to M. Aagesen ([email protected])
Background Information: Giant cell tumor is a relatively common tumor of the osseous structures, comprising 18-23% of all
benign skeletal neoplasms. Orthopedic surgeons will commonly
treat giant cell tumors with a combination of curettage, bone
grafting, and cement placement. Radiologists should be familiar
with the common postoperative appearance after giant cell
tumor resection. The recurrence rate for giant cell tumors after
placement of graft and cement is 2-25%, therefore familiarity
with the imaging appearance of recurrent giant cell tumors on
multiple different modalities is essential for the general and musculoskeletal radiologist.
Educational Goals/Teaching Points: This exhibit will detail the
appearance of giant cell tumors; the postoperative appearance of
treated giant cell tumors, (including bone graft and cement), and
the findings of recurrence giant cell tumors in the surgical field
and adjacent soft tissues.
Techniques: We queried our RIS database and electronic medical records to identify patients who had undergone surgery for
giant cell tumors and had follow-up imaging at our institution.
We identified 77 patients who had undergone surgery for pathologically proven giant cell tumors. Out of these patients, 13 subjects had biopsy proven recurrences, and three had biopsy proven second recurrences. We reviewed the imaging findings of
giant cell tumor recurrences on radiographs, ultrasound, CT, and
MRI for these patients and characterized the most common locations, appearances, signal characteristics, and presence or
absence of involvement of cement/bone graft.
Conclusion: This presentation will provide the reviewer with the
most common imaging findings of recurrent giant cell tumors
after surgical treatment and resection of the primary lesion with
bone graft or cement placement. The radiographic, ultrasound,
CT, and MRI features of giant cell tumor recurrence will be discussed and illustrated.
306
E388. MR Safety and Compatibility of Silver-Based Wound
Dressings at 7T
Sammet, S.; Chaudhry, Z.; Coffey, R.; Crockett, A.; Miller, S.; Yuh,
W.; Knopp, M. The Ohio State University, Columbus, OH
Objective: Silver containing products are an integral part of topical wound care for burn patients. Silver-based burn wound dressings are applied to the wound and left in place until the wound
is closed. Package inserts for silver-based burn wound dressings recommend their removal prior to any MRI procedures.
Repeated dressing removal is associated with a disruption of the
wound bed which may delay wound healing, increased patient
pain, analgesia use, anxiety, and stress. The purpose of this study
was to determine whether silver-based wound dressings are
compatible with MRI imaging by investigating if ultra high field
MRI and silver-based dressings produce either increased body
surface temperature and/or caused distortions in the resulting
MR image.
Materials and Methods: On three limbs of euthanized pigs,
wounds were created in the porcine skin with a scalpel. The
depth of the wound varied from superficial skin wound to the
surface of the fascia of the muscle. Three standard silver containing burn wound dressings were placed in a dry application on
the wounds. Four fiber optic temperature probes were placed in
four different locations [(A) on the superficial skin wound, (B) on
the deep fascial wound and two under the wound dressing: (C)
in an area with a superficial skin wound and (D) in an area with
a deep fascial wound). The limbs were scanned in a 7T whole
body MR scanner (Philips Healthcare, Cleveland, OH) using
standard MRI sequences. The temperature in the four locations
was recorded every 20 seconds. All MR images were graded
independently for distortion.
Results: All three examined silver containing wound dressings
didn’t increase the surface temperature of porcine skin wounds
significantly when the rf-sequences of Table 1 were used to scan
the pig limbs at 7T. The maximum temperature increase of 0.2°C,
for areas covered with the wound dressings, was similar to areas
without wound dressings, and was within the measurement
accuracy of fiber optics thermometer. The dry and wet application
of the silver containing wound dressings at 7T showed no temperature differences during the MRI exam. Image distortions in
all images were graded as minimal by two independent readers.
Conclusion: The maximum measured temperature increases of
the skin with silver containing wound dressings are within the
allowed temperature-rise guidelines of The Food and Drug
Administration (FDA). Based on these results, all tested wound
dressings are both safe and compatible with MRI at 7T.
E389. Orthopedic Implants and Complications: What the
Radiologist Must Know (CME Credit Available)
Arnold, G.; Yadavalli, S.; Werder, G. William Beaumont Hospital,
Bloomfield Hills, MI
Address correspondence to S. Yadavalli ([email protected])
Background Information: With an aging demographic and
advances in orthopedic surgery, newer prostheses and implants
are being used daily. In the past radiographs were the mainstay
of postoperative follow-up. However, with advances in CT and
MRI techniques, cross-sectional imaging has become an important part of the diagnostic tools for orthopedic hardware followup. The radiologist plays an important role, not only in accurate
interpretation of the postoperative studies, but also in the development, optimization and protocoling of imaging exams for the
evaluation of the hardware, the osseous structures and the surrounding soft tissues. Familiarity with the commonly used orthopedic procedures, devices and possible complications is essential
for the radiologist.
the normal appearance of commonly used prostheses and orthopedic fixation hardware, including alignment and positioning;
familiarize the viewer with possible complications related to the
hardware and in the surrounding osseous structures and soft tissues, and illustrate with multiple examples how various imaging
modalities can be used to optimize assessment of orthopedic
hardware and the associated musculoskeletal structures.
Techniques: The exhibit will have a case-based-learning type of
format. Various diagnostic modalities including radiographs, CT,
MRI, nuclear scintigraphy, ultrasound and arthrography will be
used to present cases that illustrate many of the complications
seen with orthopedic hardware placement. Complications related
to the prostheses or fixation hardware and cement, including
abnormal positioning, fracture, polyethylene wear, dislocation
and loosening will be discussed. Abnormalities due to infection,
particle disease, heterotopic ossification, tendon failure and muscle atrophy will also be described.
Conclusion: Awareness of normal and abnormal appearances of
various types of joint replacements and fixation devices being
used with advances in surgical techniques enables the radiologist
to play an essential role in the care of the postoperative patient.
The well-informed radiologist is able to optimize the most appropriate exam to evaluate the problem and accurately interpret any
complications that may be present.
E390. CT of the Postoperative Trauma Patient: Added Value
of 3D CT Imaging in Defining Skeletal Complications
Fayad, L.; Patra, A.; Fishman, E. Johns Hopkins University,
Baltimore, MD
Address correspondence to L. Fayad ([email protected])
Background Information: Effective imaging methods are necessary when evaluating the postoperative trauma patient with
metal hardware. Although radiographs are utilized frequently,
they generally provide an inadequate postoperative assessment,
as they cannot evaluate bones and joints in three dimensions.
Cross-sectional imaging with MR imaging is often not effective in
the postoperative setting, since ferromagnetic metals distort magnetic fields and result in severe artifact on MR images. Hence, CT
has emerged as an important tool for the postoperative evaluation of the skeleton. In recent years, advances in CT technology
and optimization of protocols have resulted in high quality postoperative 3D CT images that enable the identification of pathology, despite the presence of metal.
indications for performing CT in trauma patients who have
undergone surgical fixation or joint replacement; examine technical aspects and benefits of generating 3D CT images in postoperative patients, and demonstrate postoperative skeletal complications with 3D CT imaging.
Techniques: The exhibit will be organized as follows: a) indications for CT imaging of the postoperative trauma patient; b) technique (acquisition of CT imaging isotropic datasets, construction
of 3D CT images); c) advantages of 3D CT imaging in the postoperative setting; d) expected postoperative appearance; e) postoperative complications (hardware failure, particle disease [osteolysis], nonunion, new fracture, infection, heterotopic ossification).
Conclusion: 3D CT imaging plays an important role in diagnosing abnormalities of the postoperative skeleton. The creation of
3D CT images minimizes artifacts related to the presence of
metal in the postoperative patient and the demonstration of
postoperative complications with 3D CT imaging is often superior
to that of traditional axial CT imaging alone.
E391. Epidermolysis Bullosa: Imaging Manifestations of a
Rare Disorder (CME Credit Available)
Knox, M.; Beddy, P.; Dunne, R.; Meaney, J.; Wilson, G. St. James’s
Hospital, Dublin, Ireland
Background Information: Epidermolysis bullosa (EB) is a group
of inherited bullous disorders characterized by blister formation
in response to mechanical trauma. It has a wide spectrum of
presentations from the relatively minor simplex form through to
the severe recessive dystrophic type.
Educational Goals/Teaching Points: The aim of this exhibit is
to illustrate the array of imaging findings and highlight the problems faced with interventional procedures in patients with EB.
Techniques: We have performed a retrospective review of over
40 cases of EB. Cases include multilevel esophageal strictures,
feet and hand contractures with associated characteristic skeletal
abnormalities and squamous cell cancer formation in areas of
repetitive trauma. We also present three cases of the rare
‘inverse’ form of EB. We describe the interventional radiology
procedures performed on some of our patient cohort, including
peripheral access and feeding tube placement, and the challenges faced in this particular group of patients.
Conclusion: Radiology has an important role in the multidisciplinary management of patients with EB, from diagnosis of the multiple manifestations to the treatment of specific complications.
307
E392. Accessory Ossicles and Sesamoid Bones from Head to
Toe: Innocent Bystanders or Mischievous Neighbors? (CME
Credit Available)
Mazzie, J.1; Smith, S.2; Ramas, C.1; Math, K.3; Katz, D.1; Luchs,
J.1 1. Winthrop-University Hospital, Mineola, NY; 2. University of
Maryland, Baltimore, MD; 3. Beth Israel Medical Center, New
York, NY
Background Information: Accessory ossicles and sesamoid
bones are routinely encountered and may be the source of a
patient’s pain. The purpose of this exhibit is to remind radiologists that these bones are not always as innocent as they appear,
and to help them decipher amongst fractures, dislocations, foreign bodies, and such ossicles/sesamoids.
Educational Goals/Teaching Points: The common and uncommon accessory ossicles and sesamoid bones of the body will be
reviewed in an organized fashion from head to toe by anatomic
region, with possible associated complications related to their
presence if applicable. Examples will be shown of the os acetabuli- and os acromiale-related impingement syndromes, as well as
os styloideum and os trigonum syndromes. Additionally, complications of the accessory navicular bone will be presented.
Fractures and osteonecrosis will be shown.
Techniques: Multimodality imaging will be used to demonstrate
the relevant findings of symptomatic and problematic accessory
ossicles and sesamoid bones and their mimics, including plain
films, CT, MR, and bone scan. The differential diagnosis will be
reviewed, as well as the relevant imaging and clinical literature.
Conclusion: Inevitably, while interpreting imaging studies on a
given day, general and musculoskeletal radiologists will encounter accessory ossicles and sesamoid bones. These ossicles are not
without consequence, and can often contribute to patient symptoms of pain and discomfort. This exhibit will remind the radiologist that these bones are not always as innocent as they appear,
and that imaging is critical in the differentiation of incidental ossicles and sesamoid bones from clinically relevant ones.
E393. Complications of Orthopedic Fixation Hardware—A
Pictorial Review (CME Credit Available)
Katzen, J.; Brindle, K.; George Washington University, Bethesda, MD
Address correspondence to K. Brindle ([email protected])
Background Information: The goal of fracture fixation is to provide stability in addition to restoring anatomic alignment and
function. This can be accomplished by internal or external methods. Internal fixation implies the use of some type of hardware,
whether it is pins, wires, plates and screws, or intramedullary
rods or nails to maintain the reduction. After the initial reduction,
follow-up imaging is performed in order to assess for healing
and to evaluate for complications. It is important to recognize
complications early because failure to do so can result in devastating consequences for the patient.
Educational Goals/Teaching Points: Radiographs play an
important role in the assessment of orthopedic fixation hardware
and the potential complications associated with it. Most often, it
is the only imaging modality used to evaluate patients with frac-
308
ture fixation. The purpose of this exhibit is to review the radiographic findings of these complications including, among others,
hardware misplacement, postoperative infection, hardware loosening, and failure of fracture union.
Techniques: A review of general types of orthopedic appliances
used for fracture fixation will be provided. Important technical
considerations including imaging the entire length of the hardware and comparing to prior films will be discussed. Multiple
examples of hardware complications will be shown to illustrate
the variety of problems that can be diagnosed radiographically. In
some cases, the method of treating the complication will also be
included.
Conclusion: Internal fracture fixation devices are commonly evaluated radiographically and it is important to be able to recognize
complications associated with the hardware. This review will
illustrate a variety of problems that can be encountered.
E394. The Nuts and Bolts of Fracture Management
Carr, R.; Mulcahy, H.; Chew, F. University of Washington, Seattle,
WA
Address correspondence to F. Chew ([email protected])
Background Information: Advances in fracture management
have resulted in an ever-increasing array of surgical innovations.
Recognizing the normal and abnormal appearances of specialized hardware and other implants presents a continuing challenge for the radiologist.
Educational Goals/Teaching Points: Following the completion
of this educational activity participants should be able to recognize the normal appearance of fracture treatment devices;
explain and discuss their indications and mechanisms of action,
and identify treatment-related complications of fracture healing.
Techniques: It is important to understand the function and normal appearance of these devices so that complications can be
detected. Presurgical, intraoperative, and postsurgical images are
provided with biomechanical and physiological correlations, as
well as examples of complications.
Conclusion: As techniques for fracture management evolve, the
radiologist must keep pace with these advancements. By understanding the indications, functions, and potential complications
of these newer devices, the radiologist will be able to provide
optimal imaging care for patients undergoing fracture treatment. E395. Name the Mechanism: Pattern Recognition of
Musculoskeletal Injuries (CME Credit Available)
Smith, S.1; Mazzie, J.2; Luchs, J.2; Lazzara, B.2; Scalcione, L.2;
Math, K.3; Katz, D.2 1. University of Maryland, Baltimore, MD; 2.
Winthrop-University Hospital, Mineola, NY; 3. Beth Israel Medical
Background Information: There is a long list of named or unnamed fractures and/or dislocations on imaging studies, all of
which are associated with specific mechanisms of injury. The pur-
Electronic Exhibits: Neuroradiology
pose of this exhibit is to present diverse examples of multiple
fractures on plain radiographs and CT as well as bone contusion
patterns on MRI, from several centers which routinely image
trauma patients.
will also be provided. US studies are obtained without additional
charge to the patient whose MRI studies were interpreted as
positive by radiologists at our institution specializing in MSK
imaging, and subsequently confirmed by orthopedic evaluation.
Educational Goals/Teaching Points: Using an interactive program, the exhibit will not only test but also reinforce the different
mechanisms which are responsible for each injury. This will be
organized according to anatomic structures in order to enhance
learning and review of the material. Mechanisms of injuries and
their associated types of fracture/dislocations that will be
reviewed include many different anatomic regions, such as the
cervical spine, pelvis, wrist, and forearm. The treatment options
will be briefly reviewed.
Conclusion: A Web-based US anatomy atlas will provide a useful
and quick online reference of MSK pathology diagnosed with US
for both radiologists and nonradiologists. The atlas will hopefully
foster a better understanding and increased utility of US in conjunction with MRI when diagnosing MSK pathology.
Techniques: The roles of plain films as well as of CT and MR for
the recognition of patterns of musculoskeletal injuries will be
emphasized.
E397. A Hardware Store for the Brain – An Introduction to
Advanced Intracranial Monitoring and Therapeutic Devices
on Current Neuroimaging
Tsappidi, S.; Narayanan, S.; Mullins, M. Emory University, Decatur,
GA
Address correspondence to S. Tsappidi ([email protected])
Conclusion: There is a long list of named as well as un-named
fractures and/or dislocations on imaging studies, all of which are
associated with specific mechanisms of injury. The clinical severity of the injuries, the causative mechanisms, and the specific significant urgent radiographic findings which should be made, all
need to be considered by the radiologist interpreting trauma
imaging studies. The role of CT and MR in the trauma setting also
needs to be considered.
E396. Web-Based Musculoskeletal Ultrasound Anatomy
Atlas
Kovalenko, B.; Karol, I.; Cohen, S. Bridgeport Hospital-Yale
University, Bridgeport, CT
Address correspondence to B. Kovalenko ([email protected])
Background Information: Ultrasound (US) is increasingly being
recognized as an adjunctive modality to MRI in diagnosing musculoskeletal (MSK) pathologies. However, understanding US anatomy and recognizing pathognomonic signs on US images can be
a challenging task, particularly for nonradiologists. A Web-based
MSK US anatomy atlas, which presents normal and abnormal
anatomy in an interactive user friendly interface would be invaluable for correlating clinical findings.
Educational Goals/Teaching Points: Physicians, physicians-intraining and medical students, will have a Web-based resource
that is quickly accessible online. The Web-based atlas will contain
a series of images of normal and abnormal findings,
which are navigated in a scrollable fashion, with enabled mouse
and cursor label cross referencing. Cross referencing of images
between different imaging planes will allow for better correlation
and understanding of US findings. Embedded Web links will also
direct users to electronic online literature and references.
Techniques: The Web-based atlas will concentrate on typical US
imaging findings with respect to tendonopathy particularly within
the rotator cuff and Achilles tendon. Ligamentous, joint, muscle
and nerve anatomy and pathology will also be demonstrated.
Dynamic scanning and extended field of view images will be presented where applicable. Interactive scrollable series of arthrogram images with labeled anatomy of common MSK pathologies
Neuroradiology/Head and Neck
Background Information: Advances in neurocritical care, neurosurgical and neuroendovascular therapy have led to a new era in
understanding and managing brain injury. Modern intracranial
monitoring devices (tools) provide previously unprecedented
monitoring strategies. Neurosurgical and endovascular hardware
has trended toward newer, lighter and smaller materials. We
present a summary of many such advanced devices currently in
use, with corollary descriptions and neuroimaging features.
Educational Goals/Teaching Points: A pictorial essay demonstrating common and uncommon intracranial surgical devices
supplanted by expected normal appearance on neuroimaging,
intended function and a review with literature search on each
device will be provided.
Techniques: Until the last decade, most monitoring intracranial
hardware included the intraparenchymal Camino bolt to measure
intracranial pressure (ICP) and the external ventricular drainage
(EVD) catheter to drain cerebrospinal fluid. Better understanding
of brain injury pathophysiology has led to newer devices with
multimodality monitoring capability. Measurement of cerebral
blood flow (CBF) and ICP with qualitative laser Doppler and
quantitative thermal diffusion flowmetry is still considered experimental but active in current practice. Brain tissue oxygenation
(pBtO2), coupled with intracranial temperature (ICT) and ICP is
commonplace in many centers. Cerebral microdialysis (CMD) is
another monitoring system involving a tiny intraparenchymal
probe for injecting and collecting dialysate towards multiple neurochemical marker analysis. Continuous EEG (electroencephalography) monitoring (cEEG) typically utilizes MRI compatible leads
placed on the scalp and sometimes in the subdural space.
Endovascular liquid embolizing radio-opaque agents, platinumbased coils, nitinol-based intracranial stents, combination intracranial monitoring devices, programmable ventriculoperitoneal
shunts, deep brain stimulator (DBS) electrodes, among other
newer advances, will also be reviewed.
Conclusion: A review of intracranial “tools” and their imaging
characteristics is provided, likely helpful for neuroimagers to provide the most reliable interpretations towards quality patient care.
309
E398. Complicated Migration of Ventriculoperitoneal Shunt
Catheter into the Heart With its Successful Retrieval by an
Interventional Procedure Using the Transfemoral Approach
Park, D.; Jung, W.; Ryu, J.; Heo, J.; Kim, Y.; Park, C.; Hahm, C.
Hanyang University Guri Hospital, Guri, South Korea Address correspondence to D. Park ([email protected])
Objective: A ventriculoperitoneal (VP) shunt is the most common treatment for hydrocephalus. Cervicothoracic complications
with VP shunts are rare, but we present extremely rare case of
the distal migration of distal catheter of a VP shunt into the
heart, via the internal jugular vein, which is successfully retrieved
by an interventional procedure using a transfemoral approach.
Materials and Methods: A 68-year-old woman, who underwent
the placement of right frontal VP shunt due to hydrocephalus
that developed after aneurysmal clipping, presented with mental
declination.
Results: Serial plain chest X-rays and CT revealed the distal catheter to be gradually pulled into the internal jugular vein, and
finally into the right ventricle of the heart. A right lower neck incision was performed to access the distal catheter, which was then
slowly pulled up out of the heart, but failed to pass through the
superior vena cava because the large size of the distal catheter
knotted. After cutting the catheter at lower neck level, it was
ensnared and pulled out through the femoral vein by an interventional procedure.
Conclusion: The migration of the distal catheter of a VP shunt
probably occurred with the perforation of the internal jugular
vein near the distal catheter tract. Slow venous flow and negative
inspiratory pressure may have gradually pulled the catheter up
into the right atria and ventricle of the heart. It can be extracted
safely in the interventional procedure with transfemoral venous
approach.
E399. Effect on Renal Function from High Contrast Load in
Subarachnoid Hemorrhage Patients Having Both CT
Angiography and Catheter Cerebral Angiography Within 24
Hours (CME Credit Available)
Sharma, A.; Wang, H. University of Rochester Medical Center,
Strong Memorial Hospital, Rochester, NY
Address correspondence to A. Sharma ([email protected])
Objective: At many institutions including ours, CT angiography
(CTA) has replaced catheter angiography as the initial evaluation
of patients presenting with subarachnoid hemorrhage. However,
catheter angiography is still obtained soon afterwards either for
further evaluation or for embolization. In this study, we investigate whether contrast induced nephropathy may develop from
the high contrast load from the two procedures in the acute setting. We hypothesis that there should be no significant compromise of renal function from the additional contrast because cerebral catheter angiography does not expose the kidneys to large
bolus of contrast and is performed over a period of one to several hours.
Materials and Methods: We retrospectively studied 50 patients
who presented with subarachnoid hemorrhage and underwent
CT angiography and catheter angiography/embolization within
24 hours. We assessed creatinine, before and at least two days
310
after administration of contrast agent. In addition, the risk factors
for contrast induced nephropathy (CIN) were recorded .We also
assessed the amount of contrast injected. CIN was defined as an
increase of the serum creatinine-level of > 25% above baseline
within 48 hours after contrast agent administration.
Results: The male:female ratio was 3:2, with age ranging from
10 years to 88 years. The mean amount of contrast injected for
CTA was 80 cc (Iohexol 350) and for angiography/embolization it
ranged from 60 cc to 200 cc (Iohexol 300) with mean of 110 cc.
All had normal initial values. Compared to their initial values, the
serum creatinine after the two procedures did not increase significantly in any of the patients. Mean serum creatinine value before
CTA was 0.68 with standard deviation of 0.27 and mean on second day after catheter angiography/embolization was 0.27 with
standard deviation of 0.27.
Conclusion: Even though CT angiography shortly followed by
catheter angiography represents a high contrast load to the kidneys, this appears to have no adverse affect on renal function.
E400. A Simplified Algorithmic Approach to the Posterior
Fossa: A Compendium of the Commonplace, the Curious and
the Confounding (CME Credit Available)
Ferretti, J.; Grossman, J.; Velayudhan, V.; Lev, S. Nassau University
Medical Center, Copiague, NY
Address correspondence to V. Velayudhan ([email protected])
Background Information: We provide a framework to analyze
the complex anatomy and pathology of the posterior fossa,
which may present in the emergent setting.
a location-based approach to posterior fossa lesions and review
the characteristics of radiological mimics. The participant in this
educational activity will learn how assessment of the fourth ventricle can pinpoint the abnormality.
Techniques: Analysis of a posterior fossa lesion should begin by
noting whether it projects inwardly from the bordering dura or
skull base or originates from the contents within. Dural lesions
may be tentorial (meningioma, metastases) or involve the
venous sinuses (thrombosis). Skull base lesions may be midline
(clivus) or lateral (petrous apex) and can be destructive (chordoma, glomus tumors) or benign (fibrous dysplasia, cholesterol
granuloma). Intraparenchymal pathology can be localized by noting the position of the fourth ventricle. Brainstem lesions (gliomas, central pontine myelinolysis) compress the fourth ventricle
posteriorly. Vermian lesions compress the fourth ventricle anteriorly. Lesions of the cerebellar hemispheres, such as the “lookalikes” hemangioblastoma, juvenile pilocytic astrocytoma and
cystic metastases, deviate the ventricle laterally. An unusual
necrotic glioblastoma multiforme and atypical medulloblastoma
are also shown. The extra-parenchymal spaces can be subdivided
into cisternal or intraventricular. Effacement of the quadrigeminal
and ambient cisterns may indicate impending herniation.
Prepontine cistern lesions are primarily midline (basilar tip aneurysm, dermoid). Cerebellopontine angle lesions (epidermoids,
meningiomas and schwannomas) are at the anterolateral posterior fossa. A trigeminal schwannoma and a cystic vestibular
schwannoma are demonstrated. Fourth ventricular lesions may
be solid (medulloblastoma, ependymoma) or cystic (echinococcus, neurocystercercosis). Vascular lesions occur anywhere.
Unusual lesions include a giant vein of Galen malformation, a
posterior inferior cerebellar artery aneurysm presenting as a ventricular bleed, superficial siderosis, and a dense basilar artery sign
(prelude to a massive pontine hemorrhage). Venous thrombosis
may imitate subdural hemorrhage. Infectious/inflammatory processes are great mimickers. Meningitis can resemble a focal dural
lesion. Rhomboencephalitis can mimic a brainstem glioma.
Conclusion: A systematic approach to the posterior fossa can
assist the radiologist in localizing and defining both common and
unusual entities, allowing for prompt and confident diagnosis.
E401. Masses of the Posterior Cranial Fossa: Spectrum of
Disease Among Children With Pathogic Correlation (CME
Credit Available)
Devenney-Cakir, B. 1; Nadgir, H. 1; Castro-Aragon, I. 1; Delalle, I.
1; Golja, A. 2; Sakai, O. 1 1. Boston University Medical Center,
Boston, MA; 2. Children’s Hospital Boston, Boston, MA
Address correspondence to B. Devenney-Cakir ([email protected])
Background Information: The aim is to present the CT and MRI
appearances and differential diagnosis of posterior cranial fossa
masses in the pediatric and young adult patient population with
pathologic correlation.
Educational Goals/Teaching Points: The exhibit will include an
overview of anatomy of the posterior cranial fossa; a discussion
of the differential diagnosis of posterior cranial fossa masses in
the pediatric and young adult patient population; imaging presentation of a variety of posterior cranial fossa masses in children
and young adults with discussion of typical and atypical features,
and direct correlation of imaging findings, pathologic specimen
and histopathologic features. Key Anatomic/Physiologic Issues and Imaging Findings/
Techniques: This exhibit will present examples of the large spectrum of benign and malignant neoplasms that occur in the posterior cranial fossa, with emphasis on both classic and atypical
imaging findings. Pathologic correlation will be included where
appropriate.
Conclusion: The posterior cranial fossa is a common site for
intracranial neoplasms, including intra-axial, extra-axial, and
osseous lesions. The differential diagnosis can be commonly narrowed based on CT and MR imaging characteristics and patient
age demographics. Many imaging features of posterior cranial
fossa masses can be correlated to histopathologic findings.
Princeton, NJ). After the switch, some of the radiologists and MRI
technologists thought the postcontrast images more frequently
showed patient motion artifact, possibly from patient discomfort
related to contrast injection. In this study, we reviewed the MRI
postcontrast images of patients just before we switched contrast
to those of patients after the switch to see if there was a statistical difference between the two contrast agents.
Materials and Methods: We collected the data of 300 consecutive patients who underwent brain MRI consisting of 150 patients
receiving gadodiamide and the other 150 receiving gadoteridol.
Patients scanned under anesthesia or sedation, children below
10 years of age and patients with significant motion on the precontrast images were excluded. Only brain MR images were
reviewed. The doses of the two contrast agents were the same,
being 0.1–0.2 mmol/kg. The author who analyzed the MRI images for motion was blinded to the type of contrast used.
Results: Of the patients meeting the criteria, there were 80
patients in Group 1 who received gadodiamide and another 80
in Group 2 who received gadoteridol. No major adverse reaction
was reported in either group. Group 1 did not show any significant motion after contrast injection, whereas Group 2 showed
motion in four patients. Because of the low incidence of motion,
we used the Fisher exact test which gave a P value of 0.12 indicating no significant difference between the two groups.
Conclusion: In reviewing our cases, we found the incidence of
motion in those patients receiving gadoteridol was low but higher than those receiving gadodiamide. However, this difference
was not statistically significant.
E403. Imaging Features of Neuromyelitis Optica and Review
of Recent Advances in Diagnosis and Treatment (CME Credit
Available)
Sidhu, G.; Glastonbury, C. University of California, San Francisco,
San Francisco, CA
Address correspondence to G. Sidhu ([email protected])
Background Information: Until recently, neuromyelitis optica
(NMO), also known as Devic’s disease, was considered a variant
of multiple sclerosis (MS). With the discovery in 2004 of an
autoantibody relatively specific for NMO, however, there has
been great progress in characterizing NMO as a unique disease
with different pathophysiology to MS, and different therapeutic
implications. As such, early diagnosis of NMO has become
increasingly important, expediting confirmatory antibody testing
and enabling earlier treatment.
E402. Patient Motion on Brain MRI in Patients Receiving
Gadoteridol Compared to Those Receiving Gadodiamide
Sykes, J.; Malhotra, A.; Kumar, V.; Wang, H. University of Rochester
Medical Center, Rochester, NY
Address correspondence to H. Wang ([email protected])
Educational Goals/Teaching Points: The principal educational
goal of this exhibit is to highlight the imaging findings of antibody-positive NMO through a review of cases identified at our
institution. Updates in the pathology, diagnosis, and treatment of
NMO are also emphasized with comparison to other disease
states that have similar presentations, such as optic neuritis and
transverse myelitis. In addition we describe distinguishing features of NMO as characterized by newer advanced imaging techniques such as diffusion tensor imaging (DTI).
Objective: Due to recent concern of nephrogenic systemic fibrosis, our MRI center made a complete switch from gadodiamide
(GE Healthcare, Princeton, NJ) to gadoteridol (Bracco Diagnostics,
Techniques: For decades NMO was considered an aggressive variant of MS, relatively resistant to treatment and offering a dismal
311
prognosis. In 2004 a specific IgG autoantibody targeting a waterconducting membrane channel (Aquaporin 4) at the blood-brainbarrier was found. This has been shown to be quite specific for
NMO and is not typically present in MS patients. Many other
distinctions have been identified since that discovery which led
to a revision of the clinical diagnostic criteria of NMO in 2006. Concomitant optic pathway and cervical cord involvement
remains the cornerstone of radiologic diagnosis on NMO as demonstrated by the cases at our institution, though various limited
forms have now been identified. DTI offers the possibility of early
recognition and discrimination from MS, through assessment of
the corpus callosum and otherwise-normal appearing brain tissue.
Conclusion: The discovery of NMO IgG has permitted rapid
advances in diagnosis and treatment of neuromyelitis optica.
Recognition of the imaging features of NMO including the classic
optic pathway-cervical cord lesions as well as newly described
limited forms has therefore become increasingly important in the
care of these patients. E404. Neuroimaging of Pediatric Stroke (CME Credit
Available)
Acharya, D.; Holder, C. Emory University, Atlanta, GA
Address correspondence to D. Acharya (darshan.acharya@gmail.
com)
Background Information: Stroke in children is uncommon, but
has potentially devastating morbidity and mortality. This exhibit
will guide the student through the imaging appearances of the
intracranial complications of pediatric stroke, demonstrate the
various imaging techniques involved, and discuss therapeutic
options.
the anatomy and pathophysiology of pediatric stroke; demonstrate characteristic imaging techniques for evaluating the disease
process; show relevant imaging techniques, and demonstrate
treatment options and their follow-up imaging appearance.
Techniques: The exhibit will include an overview of underlying
diseases and presentations, including cardiac, sickle cell, moya
moya, vasculitis, dissection and thrombophilic states; an overview
of the role of and applications for transcranial Doppler, CT, CT
angiography, MRI, MR angiography, and angiography. The potential role of other advanced imaging techniques will be discussed.
Conclusion: Stroke in the pediatric population is an uncommon
but increasingly recognized problem. Various causative disease
states are responsible, and several have characteristic imaging
findings delineated above. Treatment options are available and
with improving understanding of the disease course and imaging
findings, can be applied earlier, limiting associated morbidity.
E405. Susceptibility Imaging and Stroke
Small, J.1; Haacke, E.2; Schaefer, P.1 1. Massachusetts General
Hospital, Boston, MA; 2. Wayne State University, Detroit, MI
Address correspondence to J. Small ([email protected])
Background Information: Susceptibility refers to the property or
tendency of a substance to get magnetized when exposed to a
magnetic field. Magnetic resonance sequences that take advantage of susceptibility effects to demonstrate pathology are powerful and sensitive aids for diagnostic imaging. One of the key
applications of susceptibility sequences is the identification of
hemorrhage and blood products, an essential component in the
evaluation of hemorrhagic and ischemic stroke.
Educational Goals/Teaching Points: In the setting of hemorrhagic stroke, susceptibility sequences can identify a pattern of
hemorrhage that may indicate a specific stroke etiology. In the
setting of acute ischemic stroke, these images can reveal hemorrhagic transformation of infarcts and/or the presence of chronic
microbleeds. They can also detect acute intra-arterial clot or intravenous clot and they contribute to the improved safety and efficacy of MR-based selection criteria for thrombolytic therapy.
Importantly, they can also lend important information for the
exclusion of hemorrhage mimics such as hyperdense lesions on
CT, cavernomas, or hemorrhagic and melanotic metastasis.
Techniques: Although the term susceptibility-weighted imaging
(SWI) has been used in the past to refer to T2* gradient echo
(GRE) techniques, the more recent convention has been to
reserve this term for a distinct new sequence utilizing both magnitude and phase information. Already, several clinical applications of SWI for both adults and children have emerged including
the improved delineation of cerebral venous microvasculature,
hemorrhage detection, and depiction of low flow vascular malformations as well as adding information to the evaluation of trauma, brain tumors, cavernous malformations and neurodegenerative conditions. In the setting of acute stroke, SWI has been
shown to be much more sensitive that T2* GRE sequences in the
detection of both acute and chronic intracranial hemorrhage. The
added sensitivity and anatomic detail of SWI imaging may perhaps be able to depict previously unseen lacunar infarctions.
Conclusion: Susceptibility images are an essential component of
the imaging armamentarium in the evaluation of hemorrhagic
and ischemic stroke. In addition, susceptibility sequences and
susceptibility-weighted imaging techniques promise to improve
our understanding, diagnosis and treatment of acute stroke.
E406. Diffusion Tensor Imaging of Brainstem Disorders
Kessler, J.; Salamon, N. University of California, Los Angeles, Los
Angeles, CA
Address correspondence to J. Kessler ([email protected])
Background Information: Diffusion tensor imaging (DTI) is a
powerful technique that allows one to image white matter tracts
in the brain. Although a great deal of work has evaluated the
supratentorial brain, DTI tractography of the brainstem is a relatively new endeavor. Furthermore, little published research has
utilized DTI to examine the anatomical changes seen in various
diseases that affect the brainstem. The assessment of these ana-
312
tomical alterations may provide insight into new methods of
both diagnosis and treatment. Educational Goals/Teaching Points: The goals are to provide
an overview of the anatomy of the brainstem as seen on DTI;
provide an overview of various disorders that manifest as anatomical aberrations in the brainstem, and demonstrate DTI’s utility in elucidating these brainstem abnormalities. Key Anatomic/Physiologic Issues and Imaging Findings/
Techniques: Numerous disorders may affect the brainstem
including tumors, congenital disease, degenerative diseases, and
Wallerian degeneration. The way in which these disorders affect
normal white matter tracts can be better seen using DTI, as
opposed to standard MRI techniques. This exhibit will display
normal white matter tracts of the brainstem including the pyramidal tract, medial lemniscus, decussation of the superior cerebellar peduncles, middle cerebellar peduncles, inferior cerebellar
peduncles, and transverse pontine fibers. Additionally, it will display how these tracts are either invaded, displaced or diminished
in various pathological processes including glioma, cavernous
malformation, multisystem atrophy, spinocerebellar atrophy, progressive supranuclear palsy, horizontal gaze palsy and scoliosis
syndrome, Chiari malformation, and infarction. Conclusion: Diffusion tensor imaging is a powerful technique
that may better demonstrate the integrity of the white matter fibers in the different disorders of the brainstem. E407. Misnomer of Posterior Reversible Encephalopathy
Syndrome—Not Only Posterior and Not Always Reversible
Maizlin, Z.1; Shewchuk, J.2; Gandehari ,H.1; Kirby, J.1; Coblentz,
C.1; Maizels, L.1; Clement, J.3 1. McMaster University Medical
Centre, Burlington, Canada; 2. Royal Columbian Hospital, New
Westminster, Canada; 3. St. Paul’s Hospital, Vancouver, Canada
Address correspondence to Z. Maizlin ([email protected])
Background Information: In 2000 the term of posterior reversible encephalopathy syndrome (PRES) was suggested. Since then
the acronym of PRES has become very popular in imaging and
clinical literature due to its shortness, easy to remember configuration, outlining the frequent localization of neuroimaging findings along with the clinical and radiological outcome of this syndrome. Another possible reason for the popularity of the acronym PRES in clinical circles is the connotation of PRES with (elevated blood) PRESsure, since it is generally believed among clinicians that this diagnosis is specific for cases of hypertension.
However, a few problems exist with the interpretation and common understanding of PRES, questioning the legacy of “P” and
“R” in the acronym. Moreover, the entire mechanism responsible
for the imaging appearance remains unclear and controversial.
Educational Goals/Teaching Points: The goal is to analyze the
controversial issues related to the acronym PRES. Cases of reversible
encephalopathy in predominantly anterior distribution of the findings and PRES in patients without hypertension are demonstrated.
Techniques: Although, reversibility is a frequent evolution of
PRES when promptly treated, it is not a rule and some patients
have an unfavorable outcome, in spite of prompt therapy.
Frequent frontal lobe involvement, cases of PRES affecting brain-
stem or basal ganglia and sparing the parieto-occipital region, or
abnormal findings in anterior portions of the brain along with the
parieto-occipital and cerebellum confirms that “P” standing for
the “posterior” in PRES makes it a misnomer. Hypertension is
absent in 25% of patients and, when present, does not typically
reach the level of failed auto-regulation.
Conclusion: Considering the popularity of the acronym PRES in
both radiological and clinical circles, it seems to be reasonable to
substitute “posterior” with “potentially” standing for “P” in the
PRES acronym, as proposed by Narbone et al. This acronym modification, altering its meaning but saving its appearance, may be
justified since it emphasizes that reversibility is not spontaneous.
Elimination of the term posterior enables proper inclusion of
cases in which parieto-occipital involvement is not prominent and
avoids the use of the prefix “atypical” for such cases. It is likely
that expansion of our knowledge regarding this syndrome, will
result in a future redefinition or creation of a pseudoacronym. E408. Diagnostic Performance of MR Perfusion and 18F-FDG
PET in Differentiating Tumor Recurrence from PostTreatment Necrosis (CME Credit Available)
Mangla, R.; Ekholm, S.; Zhong, J. University of Rochester School of
Medicine and Dentistry, Rochester, NY
Address correspondence to R. Mangla ([email protected])
Objective: Differentiation of tumor recurrence from treatment-related necrosis may be difficult with conventional MR imaging
when newly enhancing lesions appear. Our aim was to determine the value of perfusion-sensitive dynamic susceptibility contrast MR imaging and 18F-FDG PET for differentiating recurrent
neoplasm from non-neoplastic contrast-enhancing tissue.
Materials and Methods: Thirty-six patients in whom new
enhancing lesions developed within irradiated regions were
examined with perfusion-sensitive dynamic susceptibility contrast
MR imaging. Nineteen of them also underwent 18F-FDG PET
within a period of one to 25 days. Relative cerebral blood volume (rCBV) ratios and standardized uptake value (SUV) and the
tumor-to-normal tissue (T/N) ratio were evaluated to determine
whether the new enhancing lesions were recurrent or not. The
examinations limited due to artifacts were excluded from the
study. The findings on perfusion findings were confirmed histopathologically in 20 patients and PET findings were confirmed
in seven patients. In other cases, tumor recurrence was distinguished by lesions that progressively increased in size on serial
MR examinations over at least six months, and necrosis was distinguished by lesions that disappeared or decreased in size on
serial MR studies over at least nine months.
Results: The receiver operating characteristic curve analysis of
each modality was performed. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of
dynamic susceptibility contrast imaging that was calculated to
diagnose recurrence were 83.5%, 75%, 76.1%, and 64.4%,
respectively. Sensitivity, specificity, PPV, and NPV for determining
recurrence on 18F-FDG PET were 78.2%, 55%, 62.1%, and 49.2
%, respectively.
Conclusion: Perfusion-sensitive dynamic susceptibility contrast
(DSC) MR imaging and 18F-FDG PET are clinically useful tools to
differentiate the tumor recurrence from treatment related necro-
313
sis. The rCBV measurements on MR perfusion had better diagnostic performance than the 18F-FDG PET. The major limitation
of perfusion imaging is susceptibility artifacts, in such cases 18F
-FDG PET may be more useful.
E409. Brainstem: Anatomy and Pathology (CME Credit
Available)
Kanekar, S.; Creutzburg, G.; Koconis, K.; Moshiri, S. Penn State
Milton S Hershey Medical Center, Hershey, PA
Address correspondence to S. Kanekar ([email protected])
Background Information: CT has a major limitation in evaluation of posterior fossa pathologies. With MR, due to its high soft
tissue differentiation capability, we are able to image in detail the
brainstem structures in detail and noninvasively. Several major
internal structures like substantia nigra, inferior olivary nuclei, red
nuclei, cerebral peduncles, decussation of cerebellar peduncles,
and medial lemnisci can be easily identified making radiologists
compelled to learn the detailed internal anatomy and their function. As diffusion tensor imaging (DTI) becomes more widely
available it has become more important to understand the tract
anatomy and their function and direction on routine MR scans.
Educational Goals/Teaching Points: The goals are to familiarize the viewer with normal anatomy of the brainstem and various
tracts and cranial nerve nuclei it harbors (the knowledge of
which is of vital importance as we move toward higher modalities like DTI), and illustrate various pathologies involving the
brainstem and clinical signs and symptoms associated with it.
Techniques: In this exhibit we illustrate the detailed anatomy of
the brainstem on conventional MRI sequences which will help
the radiologist in understanding the position of the vital structures, tracts and location of various cranial nerve nuclei. We also
present the spectrum of lesions involving the brainstem, which
are classified as: infection (meningitis, encephalitis, acute disseminated encephalomyelitis); trauma (axonal injury, Duret’s
hemorrhages); tumors (primary like glioma, glioblastoma multiforme, lymphoma and metastatic lesions); demyelinating conditions (multiple sclerosis, myelinolysis); vascular pathologies (cavernoma, arteriovenous malformation and stroke); metabolic diseases and degenerative diseases. Conclusion: As DTI becomes more widely available it has
become more important to understand the normal anatomy of
the brainstem, white matter tracts and their function on conventional routine MR scans.
E410. Strategies for Partitioning the Human Brain in Three
Dimensions With a Review of Methodological Approaches
Used for Quantitative Imaging Analysis (CME Credit
Available)
Watanabe, M.; Saito, N.; Jara, H.; Sakai, O. Boston Medical
Center, Boston, MA
Address correspondence to M. Watanabe ([email protected])
Objective: Neuroscientists divide the brain into anatomically
defined regions. Tomographic imaging modalities such as MRI
and CT generate volumetric data sets. Consequently quantitative
imaging analysis requires defining volumetric partitions. Various
314
approaches have been described in the literature such as manual
tracing (Jernigan et al., 2001; Tisserand et al., 2002), semiautomatic plane segmentation (Giedd et al., 1996; DeCarli et al.,
2005) and automatic atlas-based segmentation (Tisserand et al.,
2002). Currently, universally accepted consensus for brain partitioning has not been established. Therefore, easily reproducible
standardized technique is anticipated. The purpose of this exhibit
is to describe a semiautomatic segmentation algorithm based on
dual-clustering and plane partitioning, that is highly automated,
reliable and reproducible; review various strategies for brain partitioning as described in the literature, and discuss the specific
technological advantages and difficulties of each method.
Materials and Methods: Segmentation was performed using a
high level programming environment. After image segmentation
of intracranial volume, sagittal plane was placed through the
interhemispherical fissure. Coronal plane was placed through
internal auditory canals. The posterior part was divided with the
axial plane, which was placed through the top of the cerebellum
tentorium. Thus, the whole brain was divided semiautomatically
into six subsegments: right and left anterior cerebrum, posterior
cerebrum and cerebellum. We also review previously reported
methods, and discuss advantages and disadvantages of each
method.
Results: Segmentation with common landmarks and planes is
relatively easy, quick and reproducible however it has a limitation
that each region is not based on sulcal/gyral patterns. Voxelbased automatic segmentation software provides perfectly reproducible segmentation. It is also applicable to large datasets.
According to the study by Allen et al (Neuroimage 2008), the
quantitative effects of spatial transformation on regional brain
volume estimates are subtle. They also suggested that meta-analyses should take into account whether volumes are determined
using spatially-transformed images and/or specific automated
methods. Manual tracing is still the most accurate method,
though it requires anatomical expertise, and it is highly labor
intensive and time consumptive.
Conclusion: We describe a semiautomatic segmentation method,
and review methods for partitioning brain. Various segmentation
methods from manual to automatic are described and discussed
in terms of advantages and disadvantages. Learning the various
strategies should contribute to reaching consensus for a standard
brain partitioning method. Furthermore, it may contribute to translating quantitative imaging analyses to routine clinical practice.
E411. MR Imaging Findings of a Large Meningioma in a
Three-Year Old Child: A Case Report (CME Credit Available)
Angileri, T.1; Verderame, F.1; Bartolotta, T.2; Taibbi, A.2; De Pietro,
A.1; Banco, A.2 1. Villa Santa Teresa, Bagheria, Palermo, Italy; 2.
University Hospital, Palermo, Italy
Address correspondence to A. Taibbi ([email protected])
Objective: The objective is to describe MR imaging findings of a
large atypical meningioma found in a 3-year-old child.
Materials and Methods: The pediatric patient with a clinical
history of epilepsy, lower limb tremble and psychomotor deficit,
underwent a 1.5 MR examination before and after intravenous
administration of 0.2 mL/kg of gadoteric acid under sedation.
The definitive diagnosis was obtained by means of histological
analysis of a resected specimen. The child was followed-up by CT
and/or MR examination after surgery.
Results: MR imaging showed a huge mass in the left frontal
lobe, with unsure intra- or extra-axial origin, sized 10.6 cm x 7.4
cm. The tumor presented as solid in the upper part and cystic in
the lower. The mass – with solid part mainly isointense on
T1-weighted sequences, isohyperintense on T2-weighted
sequences and presenting a strong and inhomogeneous contrast-enhancement–showed huge relationships with dura mater
and determined severe mass-effect with mid line shift, subfalcine
herniation of left lateral ventriculus and hypertensive dilatation of
the contralateral ventriculus. Histological examination characterized the mass as atypical meningioma WHO grade II. No evidence of recurrence was observed at least up to the last MR follow-up performed six months after surgery.
Conclusion: Meningiomas, although common in adults, are rare
in infancy and childhood. In our case surgical resection allowed a
strong and progressive improvement of neurological deficits. MR
imaging is useful and mandatory for surgical planning and follow-up.
DTI using SENSE mitigates susceptibility artifacts and can be used
for neurosurgical planning.
E413. Diffusion Tensor Imaging as a Diagnostic Tool in
Evaluating Brain Pathologies: Review Of Clinical Experience
With Over 170 Cases
Hochberg, A.; Booya, F.; Bhadilia, R.; Rojas, R. Beth Israel
Deaconess Medical Center, Jamaica Plain, MA
Address correspondence to F. Booya ([email protected])
Background Information: The white matter tracts cannot be
individually identified by MRI or postmortem slices due to similar
chemical composition. White matter tracts variable orientation
gives them different diffusion properties which is applied by diffusion tensor imaging (DTI). DTI is the technique which measures
diffusion in a series of different spatial directions in order to evaluate white matter cytoarchitecture. We perform DTI routinely in
all brain MRI performed in one of our new MRI scanners. We
reviewed all the cases which were performed from June, 2008 to
September, 2008. There were 179 cases which had DTI. Tumor
(21), hemorrhage (15), infarction (27), demyelinating disease
(12) and postoperative brain (10) had different manifestation on
DTI with useful clinical interpretation.
E412. Postoperative Fiber Assessment Using Diffusion
Tensor Imaging in a Brain Tumor Patient at 7T (CME Credit
Available)
Sammet, S.; Irfanoglu, O.; Koch, R.; Wassenaar, P.; Schmalbrock,
P.; Yuh, W.; Knopp, M. The Ohio State University, Columbus, OH
Educational Goals/Teaching Points: DTI offers an overall view
of brain anatomy, including the degree of connectivity between
different regions of the brain. We will demonstrate the usefulness
of daily clinical application of DTI in the evaluation of the common brain pathologies.
Objective: Diffusion tensor imaging (DTI) measures molecular
diffusion in the human brain to assess white matter fibers in vivo.
At low field strengths DTI with single excitation protocols faces
limited spatial resolution and low signal-to-noise ratio (SNR).
These shortcomings can be effectively mitigated by the transition
to high magnetic field strengths and by using parallel imaging
technology such as SENSitivity encoding (SENSE). The purpose of
this study was to investigate the potential of 7T MRI to assess
white matter fiber tracts in a patient after the resection of a brain
tumor for a follow-up surgery.
Techniques: DTI is a helpful adjunct in daily practice.
Characterization of sensorimotor pathways or language center
involvement by acute ischemic insults has strong correspondence
to clinical symptoms, prognosis and long-term management. DTI
improves tumor margin delineation, particularly in radiologically
ambiguous lesions such as T2 hyperintense peritumoral voxels.
DTI provides anatomic guidance for preoperative planning and
demonstrates displacement and disruption of the white matter
tracts by tumor or hemorrhage.
Materials and Methods: DTI of the human brain of a 37-year
old female patient after the resection of a brain tumor (oligodendroglioma) was performed on a 7T whole body MR-scanner
(Philips Healthcare, Cleveland, OH) using a 16-channel SENSE
head coil (Nova Medical, Wilmington, MA). Acquisition parameters: repetition time=3, 000 milliseconds; echo time=86 milliseconds; field of view=230 mm2; matrix size=128 x 128; b=0, 1,000
seconds/mm2; slice thickness=2 mm; SENSE=4 and number of
signal averages=1. To reduce motion artifacts in the DTI images
the datasets were postprocessed and tracts representing nerve
fibers were reconstructed on the MRI scanner.
Conclusion: Although the full potential of DTI will probably not
be realized until it is integrated with other modalities such as
functional imaging, there are advantages of DTI in every day practice such as determining prognosis, improving characterization of
white matter lesions and preoperative planning.
Results: SENSE-DTI at 7T allows acquisition of diffusion-weighted images with high signal-to-noise ratio and mitigates susceptibility artifacts successfully. Postoperative analysis of fractional anisotropy (FA) maps and fiber tracts in a patient after resection of a
brain tumor showed the course of the remaining fibers and
helped in planning a follow-up surgery.
Conclusion: Advanced MRI techniques such as diffusion tensor
imaging open new vistas in brain tumor research. Ultra high field
E414. Seizures! Neurocysticercosis: A Diagnostic Puzzle for
the Emergency Physician and the Importance of Imaging
Bollepalli, S.; Yost, A.; Gridley, D.; Hedayati, P. Maricopa Medical
Center, Gilbert, AZ
Address correspondence to S. Bollepalli (srigayatri2000@yahoo.
com)
Background Information: Neurocysticercosis (NC) is the most
common reported neuroparasitosis worldwide. Once an exotic
disease in the US, NC has increased in reported incidence due to
the impact of globalization and increased tourism. Maricopa
Medical Center, serving a Latino rich population, has extensive
experience with polymorphic neurologic and neuropsychiatric
manifestations of NC and the clinical course. Cysticercosis may
315
present as neurocysticercosis or extraneural cysticercosis, the
former being a more common form. NC has a myriad of clinical
presentations, mostly as the convulsive form and less often as
headaches, obstructive hydrocephalus, cysticercotic encephalitis,
ataxia, and dementia or very rarely as isolated optic nerve cysticercosis. 80% of the affected patients are asymptomatic. NC represents the leading cause of adult onset seizures, constituting
approximately 10 % of seizure cases seen in the emergency setting. Pathologic manifestations of NC include parenchymal forms
which exist as cysts of varying stages, typically at the gray white
junction of brain parenchyma. Meningeal, intraventricular and
spinal cysticercosis constitute the extra parenchymal forms. Its
interesting characteristics enable an active cyst to remain viable
in the human tissue for months to years. Imaging with CT or MR
plays a pivotal role in evaluating NC, as the diagnosis is virtually
impossible based on clinical grounds. Serologic markers only
assist in confirmation of imaging findings when necessary. An
early diagnosis at the time of initial presentation may avoid
unwarranted tests, invasive biopsy, and patient anxiety.
ple of DWI sequence for the practicing radiologist. In the second
half of the exhibit we show various pathologies which can show
restricted diffusion and how DWI can be some times help in
reaching the specific diagnosis. We categorize these pathologies
under following: hemorrhagic and non-hemorrhagic stroke, infection, trauma, hemorrhage, demyelination, and extra and intra-axial neoplasm. The importance of DWI and its usefulness in differentiating and yet times giving specific diagnosis is highlighted.
Educational Goals/Teaching Points: The goals are to familiarize the reader with the variable imaging presentation of NC; correlate the imaging pattern with clinical sequelae, and inform the
reader to consider NC as a differential in the relevant setting.
Background Information: The clinical picture of brainstem and
cerebellar infarctions is variable and mainly depends on the area
involved. The anatomy of the brainstem is complex due to the
presence of numerous tracts, vital structures and cranial nerve
nuclei. Unlike supratentorial infarcts, a small stroke in the posterior fossa can potentially be disastrous clinically. Infarction of the
cerebellum and brainstem can produce characteristic clinical patterns or syndromes. CT has a major limitation in the posterior
fossa due to poor soft tissue differentiation and beam hardening
artifact. MR, especially diffusion-weighted imaging (DWI) and thin
high resolution T2-weighted imaging has revolutionized the diagnosis of posterior fossa stroke. For best clinicocorrelation understanding the anatomy of the posterior fossa structures and vascular pattern is important.
Conclusion: NC is emerging as a more common disease than
once thought in the US. Imaging plays an important role in diagnosis and treatment of the disease, particularly in cases with perplexing clinical presentations.
E415. Diffusion-Weighted Imaging: Physics and Its
Applications in Nonstroke Brain Pathologies (CME Credit
Available)
Kanekar, S. Penn State Milton S Hershey Medical Center, Hershey,
PA
Background Information: Diffusion-weighted imaging (DWI)
provides viability information of the brain. The role of DWI in
stroke has been well established due to its capability to diagnose
stroke as early as 10-30 minutes. From its introduction in the mid
1990s, clinical application has been widespread. In the last few
years, DWI has been found to be increasingly useful in diagnosing or excluding the various nonstroke intra- and extra-axial
pathologies of the brain. Restricted diffusion, though once considered specific for stroke, can also be seen in various other
pathologies ranging from infection, neoplasms, trauma, and
blood products to demyelinating condition.
Educational Goals/Teaching Points: We simplify and make
understandable the relevant physics and principles of DWI to the
practicing radiologist. DWI has an established role in imaging of
stroke. However there are various intracranial pathologies where
this sequence can be extremely helpful in reaching the specific
diagnosis. We highlight this concept with illustrations.
Techniques: To understand application and usefulness of DWI
sequence, knowledge of physics and principle behind this
sequence is mandatory. We divide this exhibit into two parts. In
the first half of this exhibit we simplify the physics and the princi-
316
Conclusion: This exhibit will be a core learning tool for DWI
sequence.
E416. Posterior Fossa Stroke: Vascular Syndromes and MRI
Correlation
Kanekar, S.; Thamburaj, K.; Popeliansky, E.; Creutzburg, G. Penn
State Milton S Hershey Medical Center, Hershey, PA
Address correspondence to S. Kanekar (sankan2000@yahoo.
com)
Educational Goals/Teaching Points: We illustrate the normal
vascular anatomy, anatomical variations, and territorial distribution of the posterior fossa structures. We illustrate, with examples, various brainstem vascular syndromes with clinical and MR
correlation.
Techniques: We retrospectively reviewed MR images of 154
patients from our archive system with clinical and MR diagnosis
of posterior fossa stroke. Axial T2, DWI/apparent diffusion coefficient, fluid attenuated inversion recovery, gradient-echo, MR angiogram and perfusion images from these patients form the basis
of this exhibit. We first illustrate in detail the normal vascular
anatomy and territorial distribution of the various major and
minor branches. We also review the vascular anatomical variation
of the posterior fossa. We present the various brainstem vascular
syndromes with clinical and imaging correlation, knowledge of
which is very essential for the practicing radiologist.
Conclusion: This exhibit will be a core learning module to
understand the normal vascular anatomy of the posterior fossa
and various clinical syndromes associated with stroke.
E417. Pearls and Pitfalls in Perfusion CT for Imaging of
Acute Ischemic Stroke (CME Credit Available)
Allmendinger, A.; Spektor, V. St. Vincent’s Catholic Medical Center,
New York, NY
Address correspondence to A. Allmendinger (amallmendinger@
gmail.com)
Background Information: Perfusion CT is increasingly utilized
as a diagnostic tool for evaluation of acute ischemic stroke.
Perfusion CT has the ability to detect ischemic stroke before it is
evident on noncontrast CT and can detect the infarct penumbra
representing viable parenchyma. If viable parenchyma is identified, vascular recanalization therapy may be initiated given the
patient meets additional criteria. Vascular recanalization therapy
is not without risks, as severe intracranial hemorrhage is a potential outcome. This emphasizes the importance in not only identifying the presence or absence of acute ischemic stroke, but also
identifying potential pitfalls and limitations of perfusion CT. Our
purpose is to provide an overview on imaging techniques, interpretation pearls and discuss common pitfalls and limitations we
encountered with CT perfusion.
the perfusion CT technique and perfusion CT parameters including; time-to-peak (TTP), cerebral blood volume (CBV), cerebral
blood flow (CBF) and mean transit time (MTT); review the findings in acute ischemic stroke and how to differentiate between
the core infarct (dead tissue) vs. the penumbra (hypoperfused
tissue); discuss common imaging pitfalls and limitations of perfusion CT, and provide a case-based pictorial essay discussing the
effects of acetazolamide in perfusion CT.
Techniques: In this exhibit, a total of 11 cases (one normal and
10 abnormal) of perfusion CT are reviewed. We present two
cases of hyperacute/acute stroke, two cases demonstrating mismatch defects identifying the penumbra, five cases of common
pitfalls in perfusion CT imaging and one case demonstrating the
effects of acetazolamide in perfusion CT for a patient with middle
cerebral artery stenosis. An overview of the perfusion CT technique, parameters utilized and image interpretation pearls will
also be discussed.
Conclusion: Perfusion CT is proven to be a valuable tool in the
diagnosis of acute ischemic stroke. The knowledge provided by
these cases will not only allow the viewer to confidently identify
the presence of acute ischemic stroke, but also recognize the
common pitfalls and limitations in perfusion CT.
E418. Imaging Review of the Trigeminal Pathway,
Emphasizing Effects of Pathology on Anatomy and Resultant
Clinical Compromise
Palacios, E.; Rodgers, B. Tulane University, New Orleans, LA
Address correspondence to B. Rodgers ([email protected])
Background Information: The trigeminal pathway is long, and
abnormalities along its route can lead to a variety of sensory and
motor problems. Learning its course is the first step in understanding the effects of disease. We will also review the clinical
impact of CN V pathology on the patient. This presentation is
also prepared as a teaching module for the general radiologist
and those in training.
Educational Goals/Teaching Points: Our goals are to review
normal CN V anatomy; review common lesions, trauma, and
syndromes that affect all or part of its course, and demonstrate
how abnormalities along specific portions of the trigeminal nerve
will lead to certain clinical manifestations. We will discuss these.
This will improve patient assessment interactions with referring
clinicians.
Techniques: MRI and MR angiography (and to a lesser extent CT
and CT angiography) are major imaging techniques used for
assessment of these types of suspected CN V pathology. Each
technique has its own set of advantages and disadvantages.
Location of lesions often leads to likely pathologic and clinical findings.
Conclusion: The trigeminal nerve can be adversely affected by a
wide variety of abnormalities. We review these along with the
clinical presentations to be expected. Preferred methods for
imaging and diagnosis are assessed. By combining clinical and
imaging data, optimal patient outcome is enhanced due to
improved communication between physicians.
E419. Unusual and Usual Presentations of an Uncommon
Entity: Tuberous Sclerosis
Sathyakumar ,V.1; Shah, C.1,2; Ramakrishnaiah, R.1,2; Glasier,
C.2 1. University of Arkansas for Medical Sciences, Little Rock, AR;
2. Arkansas Children’s Hospital, Little Rock, AR
Address correspondence to V. Sathyakumar (veenadoc@yahoo.
co.in)
Background Information: The purpose is to illustrate various
presentations of tuberous sclerosis, show progression of disease,
compare and contrast various phakomatosis and provide differential diagnosis of radiological findings seen in tuberous sclerosis. Tuberous sclerosis is a phakomatosis condition. This neurocutaneous disease involves the brain, eye, kidney, heart, skin, bone
as well as lung. Typical presentation is subependymal nodules
and cortical tubers in a child with infantile spasm. We display
images showing different findings of tuberous sclerosis including
cardiac rhabdomyoma. The exhibit includes a case that we have
followed for years, which demonstrates increasing size of subependymal giant cell astrocytoma that caused obstructive hydrocephalus. We also show a case of lymphangioleiomyomatosis of
the lung. We present various radiological findings seen in tuberous sclerosis patients on CT, MRI and ultrasound. We also discuss
differential diagnosis of various lesions seen in tuberous sclerosis.
Furthermore, we compare and contrast subependymal nodules
and subependymal heterotopias. In addition, we briefly discuss
other phakomatosis conditions like neurofibromatosis, Sturge
Weber syndrome, Von Hippel Lindau syndrome. We compare and
contrast these various phakomatosis conditions.
Educational Goals/Teaching Points: The goals are to display
multiorgan involvement with tuberous sclerosis; discuss differential diagnosis of various radiological findings of tuberous sclerosis, and compare and contrast various phakomatosis conditions.
Techniques: The exhibit will provide a description and pictorial
illustration of CT, MRI and ultrasound findings in tuberous sclerosis: cerebral findings (periventricular subependymal nodules,
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cortical/subcortical tubers and subependymal giant cell astrocytomas), renal angiomyolipoma, cardiac rhabdomyoma, pulmonary lymphangiomyolipoma, and display salient radiological features of other phakomatosis conditions.
Conclusion: Revisiting radiological findings of tuberous sclerosis
and other phakomatosis conditions in a pictorial way may aid
residents and general diagnostic radiologists in becoming more
comfortable at diagnosing these conditions.
E420. The Limbic System: Anatomy of the Emotions (CME
Credit Available)
Whitehead, M.; Lee, B. University of Virginia, Charlottesville, VA
Address correspondence to M. Whitehead ([email protected])
Background Information: The limbic system is a complex area
of brain, intimately involved in emotional and autonomic equilibrium, memory, motivation, and personality. Despite its functional intricacies, the genesis of many of these intangible concepts
have been mapped and localized to specific parts of the brain
which are visible with MR imaging. The purpose of this exhibit is
to review the anatomy and basic physiology of the seemingly
mystical limbic system with emphasis on MR anatomy.
Educational Goals/Teaching Points: The function and location
of the various limbic system components visible on MR imaging
will be reviewed. Knowledge of limbic system anatomy enables
the radiologist to offer more specific diagnoses in specific symptomatic clinical scenarios.
Techniques: The limbic system is intimately involved in the emotional experiences and human personality. It has a direct effect
on the diencephalon, influencing such things as homeostasis and
the fight or flight response. Some neuropsychiatric afflictions are
directly related to limbic system disturbances. The functional and
anatomic components of the limbic system including the limbic
lobe and certain subcortical structures will be reviewed. The limbic lobe primarily includes the uncus, parahippocampal gyrus,
cingulate gyrus, hippocampus, dentate gyrus, fornix, and fimbria.
Subcortical limbic structures include the mammillary bodies,
amygdala, and septal nuclei. T1-weighted, T2-weighted, and
fluid attenuation inversion recovery (FLAIR) MR images have traditionally been the mainstay in evaluation and analysis of limbic
system pathology. Diffusion tensor imaging provides exquisite
anatomic detail.
Conclusion: The limbic system is a key component of the
brain, important in human emotions, memory, motivation, and
personality. Familiarity with its various anatomic components and
functions helps the radiologist prescribe more specific diagnoses.
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E421. Differential of Pineal Lesions Based on the New WHO
2007 Classification: Radiologic-Pathologic Correlation (CME
Credit Available)
Juakiem, W.1; Smith, A.1,2; Smirniotopoulos, J.1; Rushing, E.2 1.
Uniformed Services University, Bethesda, MD; 2. Armed Forces
Institute of Pathology, Washington, DC
Address correspondence to A. Smith ([email protected])
Background Information: In 2007 the WHO modified its classification of lesions of the pineal region. We will illustrate the radiologic-pathologic features of neoplasms of the pineal region
based on the new classification using images selected from an
archive of pathologically proven cases.
Educational Goals/Teaching Points: The educational goal of
this is exhibit is for the viewer to develop a better understanding
of the various types of lesions that involve the pineal region, and
to recognize the imaging characteristics of these lesions in order
to narrow the differential diagnosis.
Techniques: Lesions of the pineal region have a limited differential diagnosis, which can be narrowed based on imaging findings
along with the patient’s age, gender and laboratory values. Germ
cell neoplasms (including germinoma, teratoma, and choriocarcinoma) account for 60% of the neoplasms occurring in the pineal
region. The differential also includes the primary pineal neoplasms (pineocytoma, pineal parenchymal tumor of intermediate
differentiation, pineoblastoma, and papillary tumor of the pineal
gland) that make up 15% of pineal lesions, as well as astrocytoma, lipoma, meningioma and metastasis. The exhibit will focus
on the CT and MR imaging findings with pathologic correlation.
Conclusion: Pineal gland lesions present a differential that can
be refined by knowledge of their specific imaging characteristics
along with patient history.
E422. Temporal Bone Anatomy: A Pictorial Essay (CME
Credit Available)
Smith, A.1,2; Smirniotopoulos, J.1,2 1. Uniformed Services
University, Bethesda, MD; 2. Armed Forces Institute of Pathology,
Washington, DC
Address correspondence to A. Smith ([email protected])
Background Information: The temporal bone has complex
gross and imaging anatomy. When evaluating for pathology, this
can be especially confusing to neophytes. However, an organized
review of this anatomy can help simplify the process, and provides a greater understanding of the associated abnormalities
seen in disease.
to enhance the viewer’s knowledge of the temporal bone anatomy in order to improve recognition of pathologic processes
involving this region.
Techniques: This interactive review of the normal anatomy of
the temporal bone, utilizing thin slice CT imaging in both the
coronal and axial planes, will simplify and enhance understanding of this complex region. In addition, examples of both developmental and pathological process will be highlighted by comparison to normal images.
Conclusion: Understanding of the anatomy of the temporal bone
simplifies the detection and analysis of pathology in this region.
E423. CT Evaluation of Chamberlain’s, McGregor’s and
McRae’s Skull Base Lines (CME Credit Available)
Cronin, C.; Lohan, D.; Ni Mhuircheartaigh, J.; Meehan, C.; Murphy,
J.; Roche, C. University College Hospital Galway, Galway, Ireland
Objective: The distance of the tip of the normal odontoid peg
from Chamberlain‘s line was established on plain radiographs in
1943. To date these measurement have only been quantified on
MRI. CT’s technological ability has excelled over recent years. It
now has excellent spatial resolution, speed and ability to perform
high quality multiplanar reformats. It offers excellent bony detail,
which many consider superior to that of plain radiographs and
MRI. The purpose of this study is to evaluate the mean distance
from the odontoid process of C2 to the standard skull base line:
Chamberlain’s, McGregor’s and McRae’s lines on CT imaging, and
to compare these measurements to previously documented plain
radiograph and MRI measurements.
Materials and Methods: We retrospectively evaluated reformatted midline sagittal CT images of 150 adults. The shortest perpendicular distance was measured from the Chamberlain,
McGregor and McRae baselines for each subject to the odontoid
tip and statistical analysis was performed to compare the CT data
with the previously obtained MRI and plain film data.
Results: The mean position of the odontoid process was 1.4 mm
below Chamberlain’s line (median=1.2 mm, standard deviation
[SD] of 2.4 mm), 0.8 mm (median=0.9 mm, SD=3 mm) below
McGregor’s line and 5 mm (median 5 mm, SD of 1.8 mm) below
McRae’s line. There is no significant difference between male and
female results (p>0.05) or between these CT and previous MRI
measurements (p>0.05).
Conclusion: These results provide the mean and range of normal
distance from the odontoid process to the most frequently used
skull base lines on the current population on CT. Knowledge of
the normal values will be of benefit to each radiologist in their
everyday diagnosis and assessment of the skull base and aid
establishment of the diagnosis of basilar impression.
E424. Head and Neck Infections: Patterns of Spread and
Complications
Surapaneni, K.1; Reede, D.1; Smoker, W.2; Holliday, R.3; Gentry,
L.4; Shatzkes, D.5 1. Long Island College Hospital, Brooklyn, NY;
2. University of Iowa Hospital and Clinics, Iowa City, IA; 3. New
York Eye and Ear Infirmary, New York, NY; 4. University of
Wisconsin Hospital and Clinics, Madison, WI; 5. St. LukesRoosevelt Hospital Center, New York, NY
Address correspondence to K. Surapaneni ([email protected])
Background Information: This exhibit reviews the clinical presentation, potential complications, imaging appearance, and basic
anatomy as it pertains to the spread and/or containment of
inflammatory processes in the head and neck. Educational Goals/Teaching Points: The goals are to review
the relevant anatomy pertaining to infections involving the orbit,
ear, sinuses, and superficial/deep neck spaces; discuss the characteristic imaging features and clinical presentations of common
and uncommon head and neck infections, and illustrate key anatomic structures in the head and neck that determine the potential patterns of disease spread and complications.
Techniques: Selected cases of infections involving the pretracheal, masticator, parapharyngeal, retropharyngeal, carotid and buccal spaces will be presented, in addition to infections involving
the orbit, paranasal sinuses and tympanomastoid cavities.
Complications discussed include: cavernous and sigmoid sinus
thrombosis, intracranial abscess, Lemierre’s syndrome,
Gradenigo’s syndrome, Pott’s Puffy tumor and Bezold’s abscess.
Conclusion: The imaging diagnosis of infections in the head and
neck requires an understanding of the anatomic basis for the
spread of infection and potential associated complications. Upon
the completion of this teaching module, the user will have
learned a systematic approach for the evaluation of patients with
head and neck infections based on an understanding of key anatomic structures in the various regions of the head and neck. The
use of this approach will improve the ability for cross-sectional
localization of infections and facilitate early detection of associated complications. E425. Utility of PET-CT in the Surgical Management of Head
and Neck Cancers: Combining Imaging Data With Images at
Surgery
Rodgers, B.; Friedlander, P.; Palacios, E.; Wasilewska, E. Tulane
University, New Orleans, LA
Background Information: In head and neck imaging, there is
often a disconnect between what we see on a computer monitor
and what the ENT surgeon sees in the operating room (OR). This
module should help imagers correlate our findings to surgical
findings in the OR. Precise and accurate localization is vital as
part of surgical planning and intervention.
Educational Goals/Teaching Points: For those imaging physicians whose expertise lies outside of neuroradiology, head and
neck anatomy can be very challenging. This is compounded by
the challenges of interpreting both anatomic and physiologic
data from PET-CT. Understanding the true needs of your referring
ENT surgeon will lead to more optimal therapy for the patient.
Techniques: The multiplanar anatomy of the head and neck with
emphasis on PET and CT imaging will be reviewed. The importance of accurate and precise interpretation will be demonstrated. However, what does the ENT surgeon do with this information while performing a neck dissection? We have intraoperative
photos from surgical cases that will provide additional examples
of how we move from imaging to optimal surgical planning and
management.
Conclusion: Surgeons and imagers do not always speak the same
language. Patient care will be optimized when both types of physicians understand each others needs. Just saying where a mass or
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node is located may be enough in many cases to guide a successful surgery. In other cases, further communication and understanding is required to avoid unnecessary dissection and fruitless surgery. This will lead to improved patient care and more referrals.
E426. Petrous Apex: Anatomy and Pathologies
Powell, A.; Kanekar, S.; Ghossaini, S.; Policare, C. Penn State
Milton S Hershey Medical Center, Hershey, PA
Background Information: Anatomically petrous apex is a portion of temporal bone lying anteromedial to the inner ear
between the sphenoid bone anteriorly and occipital bone posteriorly. The tip of the petrous apex terminates at the foramen
lacerum. It has a close anatomic relationship with the carotid
canal and internal carotid artery, midbrain, pons and cranial
nerves. Any pathology in the petrous apex could manifest into
various neurological and cranial nerve deficits.
Educational Goals/Teaching Points: The goal is that the participant in this educational activity will learn the radiological anatomy of petrous apex and its relationship with surrounding brain
structures and cranial nerves. The exhibit will highlight the importance and salient differentiating points between the various
petrous apex pathologies.
Techniques: We retrospectively reviewed the imaging studies
from our PACS system of 22 patients with petrous apex lesion. All
patients had a high resolution CT scan of the temporal bone and
contrast-enhanced high resolution MRI of the internal auditory
canal. Clinical features included cranial neuropathies, vertigo, dizziness and fullness in the ear. Lesions are classified into anatomic
variation (asymmetric fatty marrow, trapped fluid); infection
(petrous apicitis, Gradenigo’s syndrome); cholesteatoma and
cholesterol granuloma; neoplastic lesions (primary involving the
bone and secondary/metastasis to apex, and vascular. We illustrate the imaging appearances of the various processes and discuss the clinical significance.
Conclusion: Due to anatomical relations with internal carotid
artery, brainstem, and cranial nerves, pathologies involving
petrous apex may cause a variety of neurological symptoms
which are difficult to localize clinically and therefore imaging
plays a vital role. E427. MDCT Evaluation of Otosclerosis (CME Credit
Available)
Rivas Rodriguez, F.; Gujar, S.; Shah, G.; Mukherji, S. University of
Michigan Health System., Ann Arbor, MI
Address correspondence to F. Rivas ([email protected])
Background Information: Otosclerosis is a unique disease of the
optic capsule and results from deposition of hypo-attenuating
spongy vascular bone. Lesions are most frequently seen in the
anterior aspect of the oval window involving the fissula antefenestrum (fenestral) with advanced cases involving the pericochlear
bone (retrofenestral). Surgery for otosclerosis consists of stapedectomy and prosthesis insertion. We illustrate the spectrum of preand postsurgical MDCT findings with multiplanar reformats (MPR)
in a series of 30 patients with surgically proven otosclerosis.
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Educational Goals/Teaching Points: The goal is for the participant of this educational activity to understand physiopathology,
natural history, imaging presentation and differential imaging
diagnosis of otosclerosis; be able to formulate a differential diagnosis for patients presenting with conductive hearing loss and
normal otoscopy; identify critical CT findings affecting presurgical
planning or predicting poor postsurgical outcome, and be aware
of differential diagnosis in patients with poor postsurgical outcome.
Techniques: Preoperatively MDCT with MPR is accurate for identifying hypoattenuating otospongiotic plaques as well as known
predictors of less successful postsurgical outcomes, such as
round window involvement and dehiscent tympanic facial nerve.
In patients with poor poststapedectomy outcome, MDCT evaluates for prosthesis displacement, intratympanic fibrosis, obliterative otosclerosis, malleoincudal dislocation, malleous ankylosis to
the tympanic wall, intravestibular prosthesis protrusion and
reparative oval window granuloma.
Conclusion: MDCT is useful in the diagnosis, pretreatment planning and postoperative evaluation of otosclerosis.
E429. CT Perfusion Changes in Normal Tissues in Head and
Neck Cancer Patients During a Course of Radiotherapy (CME
Credit Available)
Saito, N.1; Truong, M.1; Wang, J.1; Lee, R.2; Tanabe, K.1; Ozonoff,
A.2; Sakai, O.1 1. Boston Medical Center, Boston University
School of Medicine, Boston, MA; 2. Boston University School of
Medicine, Boston, MA
Address correspondence to N. Saito ([email protected])
Objective: The objective is to evaluate CT perfusion (CTP)
parameters changes in the normal tissues during a course of concurrent chemoradiotherapy in head and neck cancer patients.
Materials and Methods: Nine patients with biopsy proven primary head and neck cancer undergoing primary chemoradiation
with curative intent were included in this study. Patients were
treated with conformal radiotherapy (RT) to a total dose of 70-72
Gy over 6-7 weeks. CTPs were obtained before RT, weeks two,
four, and six of RT, and six weeks after completion of RT.
Perfusion parameters including blood flow (BF), blood volume
(BV), mean transit time (MTT), and capillary permeability (CP)
were measured in the normal tissues (parotid gland, submandibular gland, sternocleidomastoid muscle, pharyngeal constrictor
muscle, pharyngeal mucosa, and subcutaneous fat) within the
treated area using a deconvolution-based analysis.
Results: Nine patients completed five serial CTP studies according to the protocol. Primary tumor sites included: oropharynx
(three patients), larynx (two), oral cavity (one), nasopharynx
(one), hypopharynx (one), and auricle (one). At weeks two, four,
and six during RT and six weeks after RT, all CTP parameters
were expressed as a percentage of the baseline values. For the
parotid gland, the mean percentage change of BF was 171.5%
(range: 130.3-235.4), BV was 162.0% (139.3-223.2), MTT was
104.1% (57.9-130.9), and CP was 155.5% (101.4-221.3). For the
sternocleidomastoid muscle, the mean percentage change of BF
was 171.3% (114.3-193.5), BV was 152.4% (122.2-174.1), MTT
was 113.4% (101.0-124.4), and CP was 545.9% (178.3-1240.9).
For the pharyngeal mucosa, the mean percentage change of BF
was 324.4% (263.8-371.1), BV was 270.5% (239.7-314.1), MTT
was 137.9% (111.1-171.5), and CP was 4433.2% (2,912.16798.4). In the parotid gland, muscles, BV demonstrated peak
increase at six weeks after RT and showed the lowest values at
2-4 weeks during RT. In the mucosa, however, BV increased at a
median of six weeks during RT and showed the lowest values at
six weeks after RT. BF increased the most at 4-6 weeks during RT
in all the tissues. Peak increase in MTT in salivary glands was at
six weeks, and 2-4 weeks during RT in all other normal tissues.
CP showed peak increase at six weeks after RT in salivary glands
and muscles.
Conclusion: Normal tissues such as parotid gland, muscle, fat,
and mucosa demonstrated the increases in CTP parameters.
These changes may reflect the onset of acute side effects of RT
such as acute mucositis and acute changes in salivary flow.
E430. The Retroantral Fat Pad: Important Landmark for
Accurate Staging of Disease Extension Beyond the Maxillary
Sinus and Infratemporal Fossa
Kori, G.; Tu, R.; Brenner, C.; Jones, R.; Tanna, N.; Kambhampati, S.;
George Washington University, Washington, DC
Address correspondence to R. Tu ([email protected])
Background Information: The early detection of pathology
beyond the margins of the maxillary sinus laterally and infratemporal fossa craniad to Level II can be elusive. An understanding
of normal anatomic boundaries of the pterygopalatine fossa and
retroantral space provides clues for accurate staging. We review
normal anatomic landmarks of the infratemporal fossa and retroantral space.
Educational Goals/Teaching Points: The reader will learn the
normal landmarks of the infratemporal fossa and relationships of
the retroantral fat pad. Variation of the retroantral fat pad will be
illustrated. Heightened understanding of subtle changes will aid
in accurate detection of early disease and prevent misinterpretation and understating of disease.
Techniques: The normal relationships of the retroantral fat pad
space, the pterygopalatine fossa and infratemporal fossa are
reviewed. Complex sinonasal inflammatory processes beyond the
maxillary wall may be easily detected before extension into the
pyerygoid muscles and infratemporal fossa occur. Level II inflammatory and neoplastic processes toward the skull base and
sinuses may be identified by understanding the retroantral space
before the inevitable extension intracranially.
Conclusion: The retroantral space is a normal anatomic space.
The loss of normal fat is an early sign of disease. Various examples of the retroantral space are reviewed. An understanding of
the relationships of the space will aid in accurate interpretation
of sinonasal and head/neck pathology.
E431. Paranasal Sinus Disease in Multiple Sclerosis–
Possible Links to Periodontal Disease and Parallels to this
in Other Autoimmune Diseases (CME Credit Available)
Rosenthal, P. Ralph H Johnson VA Medical Center, Charleston, SC
Address correspondence to P. Rosenthal ([email protected])
Objective: The objective is to present the findings of paranasal
sinus disease in a cluster of patients with imaging features of
multiple sclerosis (MS) and correlate these findings with comparable appearances in patients with other autoimmune diseases.
Materials and Methods: This was a retrospective imaging
review of a cluster of multiple sclerosis patients at a small southeast center in the US showing variants of paranasal sinus disease.
There was correlation of these findings with MS disease activity
in this group, and correspondence of the sinus findings to imaging findings in a sampling of cases with other known autoimmune diseases. Results: There was sequential findings in a patient with lupus
and advanced osseous resorption around a maxillary tooth on CT,
with documentation of progression of sinus inflammation over a
few weeks as confirmed with MR. This shows the morphology of
inferior maxillary sinus disease resulting from known periodontal
disease. Correspondence of the above findings in patients with
multiple sclerosis and other patients with other autoimmune diseases is demonstrated. The pattern and form of the inferior maxillary sinus disease is analyzed. This shows inferiorly-localized or
inferior-predominant maxillary sinusitis, with features of undulant
and /or polypoid cystic changes of the sinus mucosa, and examples of mild, moderate and severe, limited and extensive sinus
involvements. The relationship of the sinus changes to MS disease activity is not linear in this small sample, but the findings
suggest an increased prevalence of this form of sinus disease in
patients with MS.
Conclusion: The findings suggest that this variant of undulent or
polypoid, inferiorly-limited, or inferior-predominant, maxillary
sinus disease may be significantly more prevalent in patients with
MS than previously reported, and may be a marker of underlying maxillary ridge periodontal /gingival disease, even when the
maxillary bone separating the dental ridge from the nasal sinus
has not been formally breached.
E432. Experience with a Standard Head CT Trauma Report in
a Deployed Military Hospital in Iraq (CME Credit Available)
Mackett, K.1; Sanghi, A.2; Folio, L.1 1. Uniformed Services
University of Health Sciences, Bethesda, MD; 2. Walter Reed Army
Medical Center, Washington, DC
Address correspondence to K. Mackett ([email protected])
Objective: A standard radiology reporting format is presented for
penetrating head injuries based on recent deployed military
experience. Standard reporting techniques helped communicate
complex CT findings to our deployed neurosurgeons in Iraq. The
image severity findings of penetrating trauma on CT exhibited a
predictable parallel clinical prognosis spectrum. Quantification
and prognosis scores similar to Glasgow coma scale (GCS) and
injury severity score (ISS) may be possible with similar standard
formats used over time.
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Materials and Methods: Penetrating head trauma CT studies
were reviewed and correlated with example reports using a format that proved successful in a deployed military hospital in Iraq.
The CT report format was compared to neurosurgical procedures
and findings with other predictability measures to include GCS
and clinical follow-up of patients. Parameters on the standard
report included presence or absence of the following: pneumocephalus, missile path (bihemispheric, multilobar, transventricular), skull fracture, evidence of elevated intracranial pressure
(effaced sulci, basal cisterns, midline shift), hemorrhage (location
choices: cisternal, subarachnoid hemorrhage, intraventricular
hemorrhage, extra-axial), and intraparenchymal hemorrhage.
These parameters were arranged in a consistent table format
with checklist type responses.
the volume transfer constant (ktrans), exchange rate (kep), elimination rate (kel) and arterial input function decomposed kep_adj
and kpe_adj from an redefined Brix’s model. The results were
correlated with prognostic tumor biomarkers, such as serum calcitonin level and tumor diameter, after RECIST measurement.
Results: Experiences in our deployed setting were positive as
neurosurgeons, emergency department physicians and ICU medical staff could quickly assess the findings important to them.
Prior to this, neurosurgeons had to search for information buried
in a nonstandard report. Standardized reporting of penetrating
head injuries provided more efficient communication to neurosurgeons and other hospital medical staff over several months.
Conclusion: DCE-MRI of medullary thyroid carcinoma provides
better signal to noise ratio, and spatial and temporal resolution
compared to previous studies at 1.5T. Therapy monitoring of MTC
using DCE-MRI at 3T provides a possibility to evaluate the biologic therapeutic responses by a clinically readily available approach.
DCE-MRI at 3T is a valuable diagnostic tool for monitoring the
microvascular properties of malignant tumors during therapy.
Conclusion: Standard reporting formats ensure evaluation of all
significant penetrating head injury findings on CT and display
pertinent negative findings at a glance. Fast and efficient communication is essential to patient care in the chaotic setting of
deployed medicine. More objective severity determination and
prognostic indicators on CT may be possible in the near future.
This reporting format may be generalizable to busy civilian trauma centers as well. Epidemiologic trends and preventive measures can be better evaluated and refined. Lastly, standard report
mechanisms can make prospective research on CT grading scales
possible for more consistent data mining of standard lexicon.
E434. Dynamic Contrast-Enhanced MR Imaging of Medullary
Thyroid Carcinoma at 3T (CME Credit Available)
Sammet, S.; Liang, J.; Koch, R.; Yang, X.; Jia, G.; Shah, M.; Knopp,
M. The Ohio State University, Columbus, OH
Objective: The purpose of this study was to investigate the
microcirculation changes of medullary thyroid carcinoma (MTC)
during antiangiogenic therapy with dynamic contrast-enhanced
MR imaging (DCE-MRI) at 3T.
Materials and Methods: Thirteen patients (10 males, three
females) with metastatic medullary thyroid carcinoma in a Phase
II clinical trial of an RAF/VEGF-R kinase inhibitor underwent DCEMRI using Gd-chelate (0.1 mmol/kg band width, flow 0.5 ml/
second) on a 3T clinical MRI system. One baseline scan was performed prior to treatment and follow up scans (from one to eight
times, average three times) were scheduled after every eightweeks of therapy. A 3D radio frequency spoiled fast field echo
sequence was used for the dynamic scans: repetition time/echo
time: 8/4 milliseconds, fractional anisotropy: 20º, field of view:
250 mm; matrix: 256 × 256; slice thickness: 5 mm; 20 slices;
temporal resolution: 6.7seconds with 70 time points. Contrast
enhancement in a region of interest (ROI) was evaluated by
quantitative pharmacokinetic parameters applying a two-compartment model, which characterizes the angiogenic and microcirculatory properties of the lesion, and enables quantification of
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Results: A total of 28 target lesions from 13 patients were evaluated. In 11 of 13 patients, follow-up scans after first treatment
revealed significant decrease of ktrans, kep, kep_adj and kpe_
adj (p<0.01) with an average decrease of -47%, -37%, -36%
and -21%, respectively, which agreed with other biological readouts. Two patients had increased follow-up values in the pharmacokinetic parameters, which also revealed either increased calcitonin level or increased tumor diameter.
E435. MR Imaging of Orbital Inflammatory Pseudotumor: A
Review and Update
Sepahdari, A.; Aakalu, V.; Kapur, R.; Valvassori, G. University of
Illinois at Chicago, Chicago, IL
Address correspondence to A. Sepahdari ([email protected])
Background Information: Orbital inflammatory syndrome (OIS),
also known as orbital inflammatory pseudotumor, can present
with varied clinical and imaging findings. OIS can be difficult to
distinguish from infectious lesions, from various benign and
malignant neoplasms, and from other inflammatory lesions such
as sarcoid or thyroid ophthalmopathy. We will present 15 cases
of proven OIS, with companion cases comprising infectious,
inflammatory, and neoplastic lesions that mimic OIS. The purpose of our exhibit is to review the MRI findings of OIS, with a
focused description of key imaging findings and clinical context.
Educational Goals/Teaching Points: The student should
become familiar with the range of clinical and imaging presentation of OIS. The student should be able to identify key features
that can help distinguish OIS from mimicking lesions.
Techniques: OIS can have a broad range of imaging findings,
which will be reviewed. Diffuse orbital inflammation, preseptal
inflammation, periscleritis, lacrimal gland enlargement, myositis,
and orbital mass with or without sclerosis have all been identified as presentations of OIS. We will show high quality MRI
examples of each, including a range of subtle to striking abnormalities and companion cases of mimicking lesions. Several features may distinguish OIS from mimicking lesions. Sparing of the
myotendinous junction may suggest an alternative diagnosis of
thyroid ophthalmopathy. Presence of an encapsulated, peripherally enhancing fluid intensity lesion would indicate infectious cellulitis complicated by abscess. Diffusion-weighted imaging may
also be helpful, as intense diffusion restriction suggests a lymphoid lesion whereas facilitated diffusion may suggest infectious
cellulitis. High quality orbital MRI can be rapidly performed with
the use of a multichannel head coil. Excellent fat-suppressed
postcontrast sequences with homogeneous fat suppression are
readily obtained with the head coil, and are useful for identifying
subtle disease.
Conclusion: Orbital inflammatory syndrome can have a broad
range of imaging and clinical findings which overlap with numerous other lesions. Awareness of the range of MRI findings in OIS
and key features that may distinguish OIS from mimicking lesions
is essential in providing an accurate differential diagnosis.
E436. MR Evaluation of Orbital Pathology: A Pictorial
Review Utilizing Knowledge of the Normal Structures of the
Orbit
Yousefzadeh-Grunin, N.; Lignelli, A. New York Presbyterian
Hospital- Columbia University, New York, NY
Address correspondence to N. Yousefzadeh-Grunin (noy9001@
nyp.org)
Background: The orbit is a relatively small anatomic space, but
the site of a wide range of pathology, which can be distinguished
with dedicated MR imaging. In the approach to orbital pathology,
it can be helpful to consider the structures normally located within the orbit. These include the globe, optic and oculomotor
nerves, extraocular muscles, vascular structures, and mucosal
associated lymphoid tissue. The intent of this presentation is to
give an organized and illustrated approach to pathology encountered in the orbit to make this small space a more welcome one
to the practicing radiologist.
Educational Goals/Teaching Points: Educational Goals: The
goals are to briefly describe the normal anatomy of the orbit;
describe the distinguishing MR appearance of pathology of the
globe including retinoblastoma, melanoma, retinal detachment,
and coloboma; describe the distinguishing MR appearance of
pathology of the optic and oculomotor nerves including optic
nerve infarct, optic neuritis, optic nerve glioma, meningioma,
neurofibroma and schwannoma; describe the distinguishing MR
appearance of diseases affecting the extraocular muscles including thyroid ophthalmopathy and myositis; describe the distinguishing MR appearance of orbital vascular lesions including
hemangioma, varix and lymphangioma; describe the distinguishing MR appearance of lymphoid tissue related lesions including
lymphoma, and leukemic infiltrate, and describe the distinguishing MR appearance of additional lesions which may not fit neatly
in the above categories including rhabdomyosarcoma and dermoid/epidermoid.
Techniques: MR imaging is optimally suited for evaluation of
pathology of the orbit. Reasons include the capability of multiplanar imaging, the anatomic resolution, ability to differentiate tissue types, sensitivity to blood flow, and detection of phases of
hemorrhage. Fat suppression techniques and contrast administration are tools that improve accuracy of differential diagnosis.
Conclusion: Diagnosing pathology of the orbit can be a challenging but satisfying process for the radiologist. Consideration of
the structures of the orbit can help in arriving at a differential
diagnosis. After locating a lesion within the orbit, specific imaging
characteristics aid in making particular diagnoses within each
compartment.
E437. Postoperative Imaging in Carcinoma of Buccal Mucosa
Shah, S.; Walvekar, V.; Parekh, K.; Goswami, K. The Gujarat
Cancer and Research Institute, Ahmedabad, India
Address correspondence to K. Parekh (keyurparekh1983@yahoo.
com)
Objective: The objective is to illustrate subtle changes pointing
to recurrence and to highlight postoperative changes other than
recurrence.
Materials and Methods: Thirty postoperative cases of malignancy of buccal mucosa were studied with CT and MRI. Characteristic
features found on the images will be provided. Features will focus
predominantly on the changes noted in the postoperative period.
Findings pointing to early recurrence at the operated site, like the
abnormal mucosal pattern and enhancement of the suspected
lesion as compared to normal mucosa, are emphasized. The
exhibit will include various postoperative cases, including those
following wide excision and marginal resection.
Results: The presence of new lesions at previously operated site
shows more enhancement than surrounding normal mucosa.
Inhomogeneous enhancement of lesion favors early recurrence.
The presence of enhancing soft tissue density lesions noted in
skin and subcutaneous plane indicates flap site recurrence.
Lesions mimicking recurrence in immediate postoperative period
either enhance similar or less than that of normal mucosa and
points more in favor of postoperative changes like edema/inflammation. In the late postoperative period resected bone margins
appearing sharp and the mucosa not showing any enhancement
or irregularity rules out recurrence.
Conclusion: In cases where clinical examination is not fruitful in
postoperative evaluation, imaging has an important role. Imaging,
immediate following the operation or later, holds due importance in terms of identifying altered but normal anatomical findings and early recurrence. Imaging can also guide the clinician for
further management options in terms of biopsy site to confirm
recurrence and adjuvant therapy.
E438. The Facial Nerve: An Anatomic Review for the
Radiologist
Whitehead, M.; Lee, B. University of Virginia, Charlottesville, VA
Address correspondence to M. Whitehead ([email protected])
Background Information: The facial nerve (CN VII) serves several important functions: motor innervation for muscles of facial
expression, taste sensation from the anterior tongue, and lacrimal
gland parasympathetic supply. The purpose of this exhibit is
to review the normal anatomic MRI appearance and course of
the facial nerve and its major branches.
the normal course of the facial nerve, highlighting intra-axial, cisternal, intratemporal, and extracranial segments; to outline the
normal enhancement pattern of CN VII, and to review the muscular innervation and sensory input of CN VII.
Techniques: For evaluation of the facial nerve temporal segment,
thin collimation temporal bone CT is the imaging modality of
choice. For all remaining facial nerve segments, MRI is preferred, because of the better contrast resolution. At our institu-
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tion, T1-weighted, T2-weighted, fluid attenuation inversion recovery, contrast-enhanced T1-weighted, and constructive interference
in a steady state (CISS), a heavily T2-weighted imaging sequences are used (images will be included). The facial nerve emerges
from the brainstem at the pontomedullary junction. After an
abbreviated trip through the cerebellopontine angle cistern, it
courses in the anterosuperior compartment of the internal auditory canal, superior to the falciform crest and anterior to Bill’s bar.
It then enters the labyrinthine, intratympanic, and mastoid segments of the temporal bone, giving off the greater superficial
petrosal nerve, stapedial nerve, and chorda tympani. Finally, after
exiting the skull via the stylomastoid foramen, it terminates radicular branches supplying muscles of facial expression. Portions of
the facial nerve, including the labyrinthine segment, geniculate
ganglion, and proximal intratympanic segment may demonstrate
variable degrees of enhancement in normal situations.
and results in significant morbidity and mortality. Long term
sequelae include but are not limited to learning disabilities, mental
retardation, epilepsy, diplegia or quadriplegia and cerebral
palsy. Reduced cerebral perfusion can occur from many factors
which may be prenatal, perinatal and postnatal. The pattern of cerebral injury will depend on both the severity of ischemia and the
gestational age of the infant at the time of insult. In addition, different patterns of injury have been shown to have differing long
term sequelae involving motor function and cognitive impairment.
Conclusion: The facial nerve has multiple functions and a complex course. Familiarity of normal anatomy and appearance enables better recognition of CN VII pathology.
Techniques: Different patterns of injury are observed that
depend on the degree of brain maturity and severity of the
ischemic/hypoxic event. Patterns of injury in premature neonates
(less than 34 weeks of gestational age) differ from term infants.
Premature infants with mild events demonstrate periventricular
white matter injury, while those with severe HIE demonstrate
injury to thalami, basal ganglia and brainstem. Term neonates
with mild HIE demonstrate predominantly watershed areas of
injury, whereas patients with severe HIE demonstrate injury to
the thalami, basal ganglia, perirolandic cortex and brainstem.
Echoencephalography is a convenient, low cost and noninvasive
modality for recognition of periventricular leukomalacia, hemorrhage and hydrocephalus. CT is a rapid modality for evaluation of
hemorrhage and hydrocephalus. MRI is the most sensitive and
specific modality for imaging of neonates with HIE. Modern imaging techniques like MR spectroscopy, diffusion-weighted imaging
and perfusion weighted imaging with relative cerebral blood flow
(rCBF) and relative cerebral blood volume (rCBV) further potentiate the effectiveness of MR as a diagnostic and prognostic tool.
E439. Intracranial Manifestations of HIV-Related Diseases
Vaghani, A.; Kakarla, R.; Gorelick, G. Illinois Masonic Medical
Center, Chicago, IL
review the spectrum of intracranial diseases seen in HIV patients;
to explain the utility of CT and MRI in differentiating these
pathologies, and to discuss the potential pitfalls and implications
of imaging findings in the patient care plan.
Educational Goals/Teaching Points: The exhibit will include:
intracranial manifestations of HIV-related diseases (atrophy, mass
lesions, white matter disease, leptomeningeal and ependymal
disease); imaging characteristics (CT, MRI); imaging pitfalls; clinical implications of imaging, and future directions.
Techniques: The exhibit will discuss intracranial manifestations
of HIV-related disease and atrophy, mass lesions, white matter
disease, and eptomeningeal and ependymal disease.
Conclusion: Familiarity with the various intracranial manifestations
of HIV-related disease is essential to the workup and management
of HIV patients. The large overlap in the radiographic appearances
of these various diseases can make their differentiation difficult. An
algorithmic approach based on radiographic signs of disease aids
the radiologist in offering a more reliable list of differential diagnoses to the clinician to further direct patient management.
E440. Multimodality Imaging Findings of Neonatal HypoxicIschemic Encephalopathy Using Conventional and Modern
Techniques (CME Credit Available)
Akhter, N.; Saigal, G.; Lopez Arberola, R. Jackson Memorial
Hospital/University of Miami, Miami, FL
Address correspondence to N. Akhter ([email protected])
Background Information: Neonatal hypoxic ischemic encephalopathy (NIE or HIE) results from systemic hypoxemia, reduced
cerebral perfusion or both. It affects 2-9 of every 1,000 live births
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the imaging characteristics of HIE with ultrasound, CT and MRI;
emphasize the imaging findings on MR spectroscopy and perfusion weighted imaging; and discuss the strengths and weaknesses of available imaging modalities in evaluation of various
patterns of HIE.
Conclusion: Prompt, comprehensive and accurate evaluation of
HIE is essential as different patterns of injury may be predictive
of future motor and cognitive development and may guide rehabilitation.
E441. Role of MDCT in Predicting Pre-Epiglottic Fat Invasion
in Supraglottic Malignancy (CME Credit Available)
Shah, S.; Parekh, K.; Walvekar, V.; Goswami, K. The Gujarat
Cancer and Research Institute, Ahmedabad, India
Address correspondence to K. Parekh (keyurparekh1983@yahoo.
com)
Objective: The objective is to signify the role of MDCT in accurately predicting pre-epiglottic fat invasion., and to illustrate findings favoring invasion of pre-epiglottic fat.
Materials and Methods: Thirty cases of supraglottic malignancies were studied on MDCT. Changes in pre-epiglottic fat suggesting malignant involvement were looked for. Findings were presence of abnormal soft tissue enhancement in pre-epiglottic
space, mass lesion invading pre-epiglottic space, cartilage
involvement, and altered pattern compared to opposite site in
cases with hemilaryngeal involvement. Findings were correlated
and confirmed by pathological and preoperative findings.
Results: Our study revealed that involvement of pre-epiglottic fat
involvement was confidently reported based on the following:
comparison with opposite side; presence of enhancing soft tissue
in pre-epiglottic space; mass lesion invading space or cartilage
involvement in relation to pre-epiglottic space. In early cases of
malignant involvement of pre-epiglottic space comparison with
opposite side turned out to be very simple and the most sensitive finding. Various false positive situations to be kept in mind
include: change in pre-epiglottic space by external pressure
impression of mass lesion; presence of mucosal tissue within
pre-epiglottic space; bilateral changes in pre-epiglottic space in
early malignant lesions, and edematous epiglottis due to inflammatory changes. A mass lesion involving lateral walls can lead to
misdiagnosis. Small vascular channels noted in pre-epiglottic
space turned out to be a nonspecific finding.
Conclusion: Invasion of pre-epiglottic fat in cases of supraglottic
malignancy is significant in terms of the treatment protocol
selected by the clinician. Accurate prediction on CT can prevent
further investigation in the form of an MRI study. Various situations can mimic malignant involvement and careful evaluation
can prevent such pitfalls.
E442. Chondrosarcoma of the Larynx: A Case Series
Theoret, C.1; Harder, S.2 1. Royal University Hospital, Saskatoon,
Canada; 2. Loma Linda University Medical Center, Loma Linda, CA
Address correspondence to C. Theoret ([email protected])
Background Information: Although rare, laryngeal chondrosarcoma is the most common sarcoma of the larynx. The purpose of
this case series is to draw attention to this condition and to highlight some of the associated clinical and imaging features.
Educational Goals/Teaching Points: After reading this exhibit,
the reader should have an increased awareness of this entity;
understand the importance of cross-sectional imaging in the
diagnosis, surgical planning, and postoperative follow-up of laryngeal chondrosarcoma, and understand that although imaging
findings are variable, classic features of chondrosarcoma seen in
other locations may be identified in laryngeal chondrosarcoma.
Techniques: The condition involves the components of the larynx
consisting of hyaline cartilage, including the cricoid cartilage, the
thyroid cartilage, and the arytenoid cartilages. Laryngeal carcinoma may be suspected clinically in a patient presenting with
hoarseness, dyspnea, dysphagia, or a neck mass. Endoscopic and
histologic evaluation may be unremarkable or reveal vocal cord
paralysis, a submucosal mass, or mucosal abnormality. Crosssectional imaging may demonstrate the classic findings of chondrosarcoma seen in other locations (stippled calcification, increased
signal on T2-weighted imaging). Imaging also has a role in the
evaluation of the extent of involvement of adjacent structures.
Further, imaging studies may direct subsequent biopsy or may
influence surgical management (conservative vs. radical resection), and are important in disease monitoring post-treatment.
Conclusion: Radiologic imaging is important in the initial diagnosis and the postoperative follow-up of laryngeal chondrosarcoma, which can at times be a difficult endoscopic diagnosis. This
rare entity may show the classic imaging characteristics of chondrosarcoma seen elsewhere in the body.
E443. Imaging of Intradural Extramedullary Spinal Lesions
Tuttle, D.; Sarang, T.; Ginat, D.; Meyers, S. University of Rochester,
Rochester, NY
Address correspondence to D. Tuttle ([email protected].
edu)
Purpose: The purpose is to review the spectrum of intradural/
extramedullary spinal lesions.
Educational Goals/Teaching Points: The goals are to demonstrate the imaging features of various intradural/extramedullary
lesions involving the spine to aid the formulation of appropriate
differential diagnosis. Key Anatomic/Physiologic Issues and Imaging Findings/
Techniques: An image-rich slide format will be employed to
address the range of intradural/extramedullary spinal lesions,
including common and rare diseases. Some of the diseases that
will be covered include congenital/developmental (arachnoid
cyst, epidermoid cyst, dermoid cyst, teratoma, neurenteric cyst,
dural ectasia, meningocele, dorsal dermal sinus, conjoined nerve
roots); neoplastic (ependymoma [sporadic, neurofibromatosis
Type II], schwannoma [sporadic, neurofibromatosis Type II], neurofibroma [sporadic, neurofibromatosis Type I], meningioma [sporadic, neurofibromatosis Type II], paraganglioma, primitive neuroectodermal tumor, malignant nerve sheath tumor, disseminated
metastatic disease [central nervous system tumors, non-central
nervous system metastases], leukemia, lymphoma); infectious
disease (pyogenic meningitis, granulomatous meningitis [TB, fungal], parasitic meningitis [cystercosis, etc.]); noninfectious inflammatory disease (adhesive arachnoiditis, sarcoidosis, inflammatory
reaction from subacute subarachnoid hemorrhage); vascular
(dural arteriovenous fistula, arteriovenous malformation), and
traumatic (subarachnoid hemorrhage, avulsed nerve roots).
Conclusion: The attendee will gain familiarity with the imaging
characteristics of various intradural/extramedullary abnormalities
involving the spine that will allow the formulation of an appropriate differential diagnosis. E444. Imaging of Spinal Cord Lesions (CME Credit
Available)
Sarang, T.; Tuttle, D.; Meyers, S. University of Rochester, Rochester,
NY
Address correspondence to T. Sarang (trushar_sarang@hotmail.
com)
Background Information: A wide variety of lesions can occur in
the spinal cord. Familiarity with the common types of lesions
involving the spinal cord is useful to narrow the differential diagnosis for intramedullary abnormalities. This presentation will
begin with a review of spinal cord anatomy. The bulk of the
exhibit will review the spectrum of intramedullary spinal cord
lesions including congenital anomalies, neoplastic disease, infectious and noninfectious inflammatory disease, vascular and traumatic lesions, and metabolic disorders. The presentation will be
image-rich with an emphasis on MRI and CT characteristics used
to distinguish between disease entities.
Educational Goals/Teaching Points: After viewing the exhibit
the participant will be familiar with common intramedullary
325
spinal cord disease with specific emphasis on key MRI and CT
findings; be able to distinguish different disease entities, and be
able to formulate a concise differential for a given lesion.
Techniques: An image-rich slide format will be employed to
cover the intramedullary spinal cord lesions. Some of the diseases that will be covered include congenital (myelocele/myelomeningocele, myelocystocele, lipomyelocele/lipomyelomeningocele, spinal cord lipoma, tethered spinal cord, split spinal cord
malformations/diastematomyelia, syringohydromyelia [with Chiari
1 malformation], neurenteric cyst, terminal ventricle); neoplastic
lesions (astrocytoma, pilocytic astrocytoma, anaplastic astrocytoma, glioblastoma multiforme, ependymoma [sporadic, associated
with neurofibromatosis type II], hemangioblastoma [sporadic,
multiple lesions in von Hippel Landau disease], ganglioglioma/
gangliocytoma, metastasis, malignant glioneuronal tumor); infections (pyogenic, granulomatous infection, including tuberculosis
and fungal infections, sarcoidosis, parasitic, viral [cytomegalovirus,
herpes, polio], vacuolar myelopathy in AIDS); noninfectious
inflammatory lesions (multiple sclerosis, transverse myelitis, systemic lupus myelitis); vascular lesions (spinal cord infarct, venous
congestion in spinal cord/intradural vascular malformation, arteriovenous malformation with or without intramedullary hematoma, cavernous hemangioma); traumatic lesions (spinal cord contusion, spinal cord transaction, traumatic intramedullary hematoma, post-traumatic syrinx), and metabolic (subacute combined
degeneration).
Conclusion: The attendee will be able to recognize the characteristics of various spinal cord abnormalities to enable formulation of an appropriate differential diagnosis.
enhancement. Flow voids related to abnormal enlarged vessels
may also be seen, and are a more specific finding for vascular
anomalies. In particular, identifying the site of a nidus or shunt
can aid in distinguishing the type of vascular lesion. Angiography
permits confirmation of the pattern of abnormal vessels and is
vital to treatment planning.
Conclusion: Acute or chronic myelopathy may be due to vascular lesions, including spinal cord infarct, spinal dural arteriovenous fistula, spinal cord arteriovenous malformation, and spinal
cord arteriovenous fistula. In these clinical scenarios, vascular
lesions of the spinal cord may or may not be suspected by
the referring physician. It is important that radiologists be familiar
with these entities and their MR appearance, and that they recommend angiography when necessary to ensure appropriate
diagnosis and treatment.
E446. Cystic Lesions of the Spine: Location-Based
Differential Diagnosis with Emphasis on Key Distinguishing
Imaging Features
El-Sherief, A.1; Malhotra, A.1; Westesson, P.1; Kathuria, S.2 1.
University of Rochester, Rochester, NY; 2. Johns Hopkins,
Baltimore, MD
Address correspondence to A. El-Sherief (ahmed_elsherief@urmc.
rochester.edu)
Background Information: The purpose of this education exhibit
is to review the macroanatomy of the spine: meninges, spaces/
compartments and contents; review location-based differential
diagnosis of cystic lesions of the spine, and review key imaging
findings that aid one in arriving at an accurate pathoanatomic
diagnosis.
E445. Vascular Lesions of the Spinal Cord: MR Imaging with
Angiographic Correlation (CME Credit Available)
Yousefzadeh-Grunin, N.; Reig, B.; Silver, J. New York Presbyterian
Hospital-Columbia University, New York, NY
Address correspondence to N. Yousefzadeh-Grunin (noy9001@
nyp.org)
Educational Goals/Teaching Points: The viewer will be able to
apply macroanatomy of the spine with special attention to its
compartments and contents; develop a location-based differential diagnosis when encountering a cystic lesion in the spine, and
recognize key imaging findings that aid one in arriving at an
accurate pathoanatomic diagnosis.
Background Information: Vascular lesions of the spinal cord
include spinal cord infarct, spinal dural arteriovenous fistula, spinal
cord arteriovenous malformation, and spinal cord arteriovenous
fistula. Patients with these lesions may present clinically with
acute or chronic-progressive myelopathy. A spectrum of clinical
and radiographic findings of these lesions is presented, highlighting features which favor each diagnosis. Additional intramedullary
lesions, which may mimic vascular lesions are also discussed.
Techniques: The exhibit will focus on macroanatomy (meninges,
spaces/compartments and contents); intramedullary (syringomyelia, hydromyelia, ventriculus terminalis, cystic spinal tumor
[astrocytoma, ependymoma, hemangioblastoma]); intradural
extramedullary (spinal meningeal cyst, nerve sheath tumor
[schwannoma], neurenteric cyst); extradural (spinal meningeal
cyst, sacral meningomyelocele, facet joint synovial cyst, idiopathic
spinal cord herniation, aneurysmal bone cyst).
Teaching Points: The exhibit will describe the vascular supply to
the spinal cord and how it affects the distribution and appearance of vascular lesions of the spinal cord; review the clinical
presentation of vascular lesions of the spinal cord and how the
presentation can help to differentiate the various types; illustrate
the MR features of vascular lesions of the spinal cord with angiographic correlation, and identify additional intramedullary lesions
which can mimic some of the MR features of vascular lesions.
Key Imaging Findings: The primary imaging finding of vascular
lesions of the spinal cord is intramedullary hyperintensity on
T2-weighted MR imaging from cord ischemia and edema. This
may also be associated with expansion of the cord and/or
326
E447. Imaging Complications of Epidural Injections
Silbergleit, R.; Greene, R.; Khan, N.; Krishnan, A. William
Beaumont Hospital, Royal Oak, MI
Address correspondence to R. Silbergleit (rsilbergleit@beaumont.
edu)
Background Information: Epidural injections are commonly
used for treatment and occasionally diagnosis of back pain and/
or radiculopathy. These injections are usually safe, however, a
variety of serious complications can occur.
Educational Goals/Teaching Points: The objectives are to demonstrate that a variety of serious conditions can result as a complication of epidural injections and to demonstrate the imaging
appearance of these conditions.
Techniques: Epidural Injections can be complicated by a variety
of conditions including epidural hematoma, epidural abscess,
epidural granulomatous processes, and discitis/osteomyelitis.
MRI is usually the best imaging modality for diagnosing these
complications and guiding further therapy. CT myelography can
be used if there is a contraindication to MRI.
Conclusion: It is important to be aware of the potential for serious complications as a result of epidural injections. MRI is useful
in identifying these complications.
E448. Lipomatous Lesions of CNS and Spine
Midia, M.; Ribeiro, L.; Kirby, J.; Miller, E.; Maizlin, Z. McMaster,
Burlington, Canada
Address correspondence to M. M idia ([email protected])
Background Information: This exhibit will classify and describe
the imaging pattern of lipomatous lesions in the central nervous
system (CNS) and spine. We aim to provide essential background
information necessary and focus on a practical approach and key
imaging findings that are pertinent to the clinician and patient
management.
the lipomatous lesions based on origin, location, clinical significance, associated lesions and imaging pitfalls, and to offer a
practical algorithm to image and assess these lesions.
Techniques: Fat could be found in a variety of neoplastic and
non-neoplastic lesions. Understanding the embryology and tissue
differentiation/transformation is essential in being able to interpret such lesions accurately in the CNS and spine. Also utilizing a
multimodality approach and paying attention to locations of
these lesions are the key factors that need to be considered by
every radiologist.
Conclusion: Detecting fat continues to be a helpful feature in
interpretation of a variety of lesions and disorders of the brain
and spine. Here we have outlined the key information necessary
to image and assess fatty lesions of the CNS and spine with the
modern tools and techniques available.
E449. Histiocytosis: Imaging Spectrum in the Central
Nervous System
Midia, M.; Kirby, J.; Miabi, Z.; Chhibber, S.; Jeddyian, S.; Miller, E.;
Haider, E. McMaster University Hospital, Hamilton, Canada
Address correspondence to M. Midia ([email protected])
the pathophysiology and imaging findings of LCH in CNS including craniofacial structures; meninges and other extra-axial structures, and intra-axial (direct involvement, indirect/neurodegenerative lesions).
Techniques: The etiology of LCH-CNS remains poorly understood. The majority of patients display more than one type of
lesion. Often diabetes insipidus with structural changes in the
hypothalamic-pituitary region heralds the involvement of other
parts of the brain, sometimes by years. The clinical presentation
is largely dependent on the predominant type of lesion.
Conclusion: LCH is a systemic disease that could involve multiple systems and organs in the body. Here we provide a comprehensive spectrum of imaging findings of LCH applicable to CNS.
E450. Analysis of Ulcerated Carotid Plaque: Comparison
Between MDCT Angiography and Color Doppler Ultrasound
Saba, L.; Mallarini, G. A.O.U, Cagliari Sardegna, Italy
Address correspondence to L. Saba ([email protected])
Objective: The purpose of our work was to assess the diagnostic
efficacy of MDCT angiography (MDCTA) in the study of patients
with carotid plaque complicated by ulceration, through the comparison with the color Doppler ultrasound (CD-US) and the surgical observation in a cohort of 180 patients.
Materials and Methods: From January, 2004 to December,
2007, 198 patients for a total of 396 carotid arteries were analyzed by using MDCTA, studied at first through CD-US. We measured the degree of stenosis based on North American
Symptomatic Carotid Endarterectomy Trial criteria. In each patient
we evaluated plaque composition and presence of ulcerations.
Maximum intensity projection, multiplanar reconstruction and
volume rendering postprocessing were performed. Obtained data
were compared with the surgical results.
Results: MDCTA detected 73 ulcerations; the surgical confirmation has underlined a 92.6% sensitivity, clearly superior to 61.7%
detected by color Doppler ultrasound. We observed that the
number of ulcerations increased with the severity of stenosis.
Ulcerations of the carotid plaque occur more often proximal than
distal to the point of maximum stenosis. Moreover, we found
that fatty plaques are more likely affected by ulcerations whereas
calcified plaques are rarely ulcerated.
Conclusion: MDCTA is a very good technique in detecting plaque
ulcerations whereas CD-US shows suboptimal results. MDCTA
allows for adequate assessment of the morphology of the ulcerated plaque, defining dimension, position and the structure of
plaque.
Background Information: Langerhans cell histiocytosis (LCH) is
a clonal proliferative disease of the dendritic cell system.
We present the imaging pattern of LCH involving the craniofacial
structures and the central nervous system (CNS).
327
E451. Carotid Artery Wall Thickness and Enhancement
Patterns of the Vascular Wall by Using MDCT Angiography
Saba, L.; Caddeo, G.; Mallarini, G. A.O.U, Cagliari Sardegna, Italy
Results: Measurements of the distal common CAWT varied from
0.5 to 1.5 mm. We observed that hypertension and diabetes mellitus are associated with increased CAWT (p=0.016 and p= 0.0188
respectively). We did not find a significant association between
increased CAWT with dyslipidemia and a history of smoking.
Objective: The purpose of this study was to evaluate the correlation between the carotid artery wall thickness (CAWT) and the
enhancement patterns of the vascular wall by using MDCT angiography (MDCTA).
Conclusion: Results of our study suggest that an increased CAWT
is associated with the cardiovascular risk factors hypertension
and diabetes. This data should be considered in the stratification
risk and for the follow up of these patients.
Materials and Methods: Forty-three patients (31 males, 12
female; mean age 60 years; age range 45-82 years), for a total of
86 carotids were prospectively analyzed by using a four-detector
row CT. Contrast material was injected into the antecubital vein
and arterial phase images were obtained by using a 4 mL\second flow rate. In each patient CAWT was measured by using a
digital caliper. Differential enhancement of the vascular wall was
measured after and before contrast material administration by
using the same region of interest area in all patients; absolute
enhancement was also recorded. The normality of each continuous variable group was tested using the Kolmogorov-Smirnov Z
test. Concordance correlation coefficients were calculated by
using Pearson statistics. Results: In our study CAWT ranged from 0.54 to 1.57 mm, with
a mean value of 0.914 mm. In the Kolmogorov-Smirnov Z test,
normality of variable was accepted for the CAWT values
(p=0.368). Correlation coefficient r between CAWT and absolute
enhancement values was 0.0729 (95% CI from -0.1412 to
0.2804) with p=0.5048. Correlation coefficient r between CAWT
and differential enhancement values was 0.1738 (95% CI from
-0.0396 to 0.3720) with p=0.1096.
Conclusion: Our results indicated that there is not a statistically
significant correlation between CAWT, absolute carotid wall
enhancement and differential carotid wall enhancement by using
MDCTA.
E452. Association Between Carotid Artery Wall Thickness
and Vascular Risk Factors (CME Credit Available)
Saba, L.; Sanfilippo, R.; Montisci, R.; Mallarini, G. A.O.U, Cagliari
Sardegna, Italy
Objective: Carotid artery wall thickness was indicated as a marker of atherosclerosis. The aim of this paper was to determine if
carotid artery wall thickness (CAWT) evaluated by using MDCT
angiography (MDCTA) is associated with the classic vascular risk
factors (hypertension, diabetes mellitus, dyslipidemia, history of
smoking).
Materials and Methods: This was a retrospective study and we
analyzed 168 patients by using a multidetector row CT scanner.
In each patient we measured CAWT and measurements were
made with an internal digital caliper. Continuous data were
described as the mean value ± standard deviation (SD) and they
were compared with Student t test. We performed simple logistic
regression in order to evaluate the association between hypertension, diabetes mellitus, dyslipidemia, a history of smoking and
IMT. P<0.05 was considered to indicate statistical significance.
328
E453. Incidence of Carotid Artery Disease in Patients
Screened for Liver Transplantation: Assessing Risk Factors
and Clinical Significance (CME Credit Available)
Jurasic, M.; Broderick, D. Mayo Clinic Jacksonville, Jacksonville, FL
Address correspondence to M. Jurasic ([email protected])
Objective: The objective is to determine the incidence of carotid
artery disease detected on screening carotid Doppler ultrasound
in liver transplantation candidates. Risk factors will be evaluated
in order to optimize screening techniques. Post- transplant clinical outcomes will also be assessed, with a focus on cerebral vascular events, to determine the incidence of these events following liver transplantation in patients with carotid artery disease.
Materials and Methods: A total of 744 patients evaluated for
liver transplantation between 1998 and 2006 were randomly
selected. Patients who received prescreening carotid Doppler
ultrasound were included in this study, and retrospectively evaluated for risk factors for carotid artery disease, including age, sex,
smoking history, hypertension (HTN), diabetes (DM), abnormal
lipid panels, and carotid bruits. Clinical outcomes, including pretransplant carotid artery surgery or stenting, and cerebral vascular
events occurring during and following transplantation, were also
investigated.
Results: Of the 744 patients evaluated, 440 underwent pretransplant screening carotid Doppler ultrasound. Of these 440, 384
received liver transplants. 5.7% of screened patients had significant findings on carotid Doppler: 19 had moderate narrowing, two
of which also had vertebral artery disease; six had severe narrowing, of whom one underwent pretransplant carotid endarterectomy (CEA). Of these patients, 72% were male, 60% smoked, 8%
had HTN, 28% had DM, 16% had HTN and DM, and 8% had
abnormal lipid ratios. The average age of patients with greater
than mild carotid disease was 62 years, vs. 59 for those with mild
or no disease. Of patients without significant carotid disease, 70%
were male, 73% smoked, 18% had HTN, 20% had DM, 13% had
HTN and DM, and 13% had an abnormal lipid ratio.
Conclusion: The incidence of significant carotid artery disease
with >70% narrowing was low (1%) in this population of individuals being evaluated for liver transplantation, despite the high
frequency of risk factors conditions, including tobacco use, diabetes, and hypertension. Only one person with significant disease
and a history of transient ischemic attacks underwent CEA prior
to transplantation, and none of the patients with moderate or
severe stenosis or vertebral artery disease experienced intra- or
immediate postoperative ischemic events. These findings suggest
that narrower screening with carotid ultrasound, focusing on
patients with bruits, multiple risk factors, and prior cerebral vascular events, may be reasonable and safe.
E454. Artery of Adamkiewicz Evaluated by Using MDCT
Saba, L.; Mallarini, G. A.O.U, Cagliari Sardegna, Italy
the stereotaxic space icbm152. Finally, lesion probability maps
voxel by voxel were generated for each MS subgroup. These
were then compared visually.
Objective: Arteries of Adamkiewicz (AKA) feed the anterior spinal artery (ASA) and the anterior two thirds of the spinal cord
receive blood supply from the ASA. It is extremely important to
study the AKA in order to avoid ischemic complication of spinal
cord after surgery of the thoracoabdominal aorta. Our purpose
was to evaluate the visualization of the AKA by using MDCT angiography (MDCTA).
Results: The lesion load was higher in SP (range 4.8-74.97 cm3;
mean ± SD of 28.49 ± 19.7) than RR (0.82-53.93 cm3; 14.59 ±
12.9) and PP (2.5-35.33 cm3; 10.27 ± 11.4), p<0.001, and no
difference was seen between RR and PP. Except for higher lesion
load in the posterior fossa and basal ganglia/internal capsules in
SP patients, there was no evident visual difference in the spatial
distribution of MS plaques in the different clinical groups.
Materials and Methods: We retrospectively studied CT data set
of 80 patients that underwent an MDCTA examination of the thoracoabdominal aorta, and we analyzed the AKA presence and
characteristics. Contrast material was injected into the antecubital
vein and arterial phase images were obtained by using a 4-6 mL\
second flow rate. For each patient we generated postprocessed
images by using maximum intensity projection (MIP), multiplanar
reconstruction (MPR) and volume rendering (VR) techniques.
Each exam was evaluated by two radiologist independently .
Conclusion: The spatial distribution of MS plaques differs exclusively in the basal ganglia, internal capsules and posterior fossa
of SP when compared with RR/PP patients. This suggests that
spatial distribution may play a role, at least in SP patients, but it
is not the determinant factor in the clinical long-term evolution of
MS patients. Invisible white matter disease, as well as cortical
and spinal involvement may be more important factors for chronic progression.
Results: We visualized at least a single AKA in 63 (78.75%) of
the 80 patients. We identified two arteries of Adamkiewicz in
nine (11.25%). The most number of AKA had their origin
between T9 and L1: 57 arteries (80.3%). Forty-eight AKA originated from the left side (67.6%).
E456. T1 and T2 Relaxation Times in Multiple Sclerosis
Patients Before and After GadodiamideContrast Injection at
3T (CME Credit Available)
Sammet, S.; Koch, R.; Liang, J.; Jia, G.; Knopp, M. The Ohio State
University, Columbus, OH
Conclusion: MDCT angiography may depict artery of
Adamkiewicz in a high percentage of patients and its sensitivity is
comparable to MR and digital subtraction angiography.
E455. Visual Assessment of the Spatial Distribution of
Multiple Sclerosis Plaques and its Impact in the Clinical
Presentation of Multiple Sclerosis Patients (CME Credit
Available)
Ribeiro, L.1; Matos, A.2; Narayanan, S.3; Arnold, D.3; Santos, A.4
1. McMaster University, Hamilton, Ontario, Canada; 2. No
Institutional Affiliation; 3. McGill University, Montreal, Canada; 4.
Faculty of Medicine Ribeirao Preto, USP, Ribeirao Preto, Brazil
Address correspondence to L. Ribeiro ([email protected])
Objective: Multiple sclerosis (MS) is the most common demyelinating disorder affecting the central nervous system (CNS) in
adults. A total of 85% of the patients will present with a relapsing remitting course (RR), and 10 years after disease onset, up to
50% of these will develop progressive neurological decline, i.e.,
secondary progressive phase (SP). Fifteen percent of patients will
present with primary progressive MS (PP). The factors that determine which subtype of disease evolution a patient will have are
not well understood. It is reasonable to believe that the white
matter lesion load, which is higher in SP, could at least partially
explain the disease course seen in these patients. There have
been few attempts to investigate if the spatial distribution of MS
plaques differs between different MS groups. The objective of
this study is to assess whether there is a significant difference in
the spatial distribution of MS plaques among the different MS
clinical groups. Materials and Methods: Retrospective images from 50 MS
patients were analyzed. MS plaques were automatically segmented and manually corrected, producing lesion labels. Intra- and
intersubject linear and nonlinear registration was applied using
Objective: The purpose of this study was to evaluate T1 and T2
relaxation time changes in white matter lesions and in normal
appearing white matter (NAWM) in multiple sclerosis (MS)
patients before and after the injection of a Gd-chelate at 3T.
Materials and Methods: In this ongoing study 42 patients (37 ±
9 years) with prior diagnosed multiple sclerosis were scanned in
a 3T clinical MR scanner (Philips Healthcare, Cleveland, OH) with
an 8-channel SENSE head coil. T1 measurements with a multiflip
angle sequence (flip angle=5, 10, 15 and 20o; TR=50 0milliseconds; TE=10 milliseconds) and T2 measurements with a multishot turbo spin echo sequence (10 TE values from 12 to 120 milliseconds; TR=2,000 milliseconds) were performed before and
after injection of a single dose of gadodiamide (GE Healthcare,
Princeton, NJ). T1 and T2 parameter maps were generated to
determine pixel-wise MR relaxation times in the brain tissue of
the patients. Average relaxation times in MS lesions were calculated by drawing regions of interest and compared to normal
appearing white matter before and after contrast injection.
Results: Average T1 in enhancing MS lesions before contrast
injection was 1,204 ± 238 milliseconds and 1,354 ± 265 milliseconds in nonenhancing lesions. Gadodiamide shortened T1 to
an average of 755 ± 164 milliseconds after contrast injection in
enhancing lesions and to 1,300 ± 254 milliseconds in nonenhancing lesions. Before contrast injection, NAWM in MS patients
showed a T1 of 867 ± 62 milliseconds and T1 shortened to 840
± 62 milliseconds after contrast injection in MS patients. T2
before contrast injection was 116 ± 23 milliseconds in enhancing
and 122 ± 27 milliseconds in nonenhancing MS lesions. After
contrast injection T2 changed to 117 ± 28 milliseconds in
enhancing MS lesions and to 122 ± 26 milliseconds in nonenhancing lesions.
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Conclusion: Relaxation time changes in the normal appearing
white matter of MS patients after the injection of gadodiamide
-contrast media at 3T could help to attribute the changes to
either diffuse abnormality or to small lesions undetected at lower
field strengths. Evaluating MR relaxation time changes after gadodiamide injections at 3T can potentially contribute to an earlier
detection of MS lesions and help to better understand the pathogenesis of the disease.
E457. Evaluation of a New CT Metal Artifact Correction
Postprocessing Algorithm in Neuroradiology: Preliminary
Results (CME Credit Available)
Douglas-Akinwande, A.1; Brown, K.2; Jennings, S.1; Ho, C.1 1.
Indiana University School of Medicine, Indianapolis, IN; 2. No
Address correspondence to A. Douglas-Akinwande (andougla@
iupui.edu)
Objective: The objective is to evaluate a new postprocessing
algorithm on metal related artifacts on MDCT images in head,
neck and spine studies.
Materials and Methods: Nine MDCT examinations of the brain,
ear, nose and throat (ENT), and spine in which metal was
present were studied. The image data was postprocessed with a
new image based metal artifact reduction algorithm that does
not require raw data and is applied following CT image reconstruction. The original and postprocessed images were independently compared by two neuroradiologists in a nonblinded manner using a five-point scale (1=definitely better, 2= better, 3=no
change, 4= worse, and 5=definitely worse). The parameters rated
included the visualization of bone and soft tissues within 1cm
and 5 cm of metal, reduction of artifacts from metal, and
improvement in diagnostic quality. The presence of new artifacts
and the demonstration of new anatomy were assessed.
Results: The CT images from four ENT, three brain, and two
spine examinations were studied. Processing revealed new anatomy in 8/9 cases; reduced metallic artifacts in 4/9 cases;
improved visualization of soft tissue within 1 cm and 5 cm in
4/9 and 5/9 cases respectively. The visualization of bone within
1cm and 5 cm improved in 2/9 and 1/9 cases. The diagnostic
quality of the study improved in 3/9 cases. The metal artifact
correction technique was most effective in ENT cases where visualization of soft tissue within 5 cm and 1 cm of metal was better
in 4/4 and 3/4 cases respectively. The visualization of bone, soft
tissue and the appearance of artifacts were rated as unchanged
or worse in most brain and spine cases. New artifacts were introduced in all cases.
Conclusion: This preliminary study demonstrates the usefulness
of this new metal correction algorithm which revealed new anatomy in 89% of cases; and was most effective in ENT cases where
the visualization of soft tissue improved in 75-100% of cases
within 1cm and 5 cm of metal. The algorithm is novel because it
can be applied retrospectively following image reconstruction
and may reduce radiation dose to ENT patients by replacing the
current practice of repeat scanning of the oral cavity at a different
angle to avoid dental hardware. Despite revealing new anatomy,
the generation of new artifacts in brain and spine cases did not
result in improved diagnostic quality and further optimization of
this algorithm is needed for brain and spine examinations.
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E458. Advanced MRI Techniques in Neuroradiology:
Principles, Applications and Future Directions
Srinivasan, A.; Wesolowski, J.; Shah, G.; Chenevert, T.; Mukherji, S.
University of Michigan Health System, Canton, MI
Address correspondence to A. Srinivasan ([email protected])
Background Information: This exhibit will review the principles
of advanced MRI techniques in neuroradiology including diffusion and perfusion imaging, tractography, functional diffusion
mapping, MR spectroscopy, dynamic MRA and functional MRI;
discuss their clinical applications with supporting data from the
literature, and teach about the potential future applications.
Educational Goals/Teaching Points: The participant in this
activity will learn the principles of advanced MRI techniques in
neuroradiology, including diffusion and perfusion imaging, tractography, functional diffusion mapping, MR spectroscopy, dynamic MRA and functional MRI; gain awareness of their clinical applications in multiple neurologic disorders including but not restricted to stroke, demyelinating disease, vascular diseases, brain
tumors and epilepsy, and be exposed to the latest research applications of these techniques.
Techniques: The principles included in this exhibit include diffusion-weighted and diffusion tensor imaging including tractography, functional diffusion mapping, perfusion-weighted imaging,
dynamic MR angiography, MR spectroscopy, and functional MRI.
The clinical applications discussed include acute stroke, brain
tumors, demyelinating disorders, epilepsy, degenerative disorders,
eg., Parkinson’s disease, vascular diseases, and miscellaneous.
Future directions include the use of advanced MRI in cognitive
disorders and exploring impaired consciousness.
Conclusion: Advanced MRI techniques are becoming increasingly important in the diagnosis, prognostication and follow-up of
multiple neurological diseases. Knowledge of the principles and
applications of these techniques in the clinical setting will be
helpful for both radiologists-in-training and practising radiologists.
E460. “CHAFT” A Differential Diagnosis of Low T2 Signal
Intensity Lesions in Neuroimaging (CME Credit Available)
Hsu, J.; York, G.; Mansfield, L.; Lisanti, C. Brooke Army Medical
Cneter, Fort Sam Houston, TX
Address correspondence to J. Hsu ([email protected])
Background Information: 1. To review MR physics of low signal
intensity on T2 weighted imaging. 2. To introduce mnemonic
“CHAFT” to guide differential when evaluating lesions with low
signal intensity on T2WI. 3. To give a comprehensive list of
lesions that have dark signal on T2WI with selected examples
seen in neuro-imaging.
Educational Goals/Teaching Points: Review MR physical basis
for low T2 signal. Present “CHAFT” mnemonic for lesions with
low signal intensity on T2WI (Calcifications, Hemosiderin/High
iron, Air and Artifact, Fibrous lesions and Flow voids, and gouty
Tophi). This exhibit will review selected illustrative cases of more
common causes of low T2 lesions in neuro-imaging and application of the “CHAFT” mnemonic
Techniques: Low T2 signal on MR are seen in tissues with low
proton density, superparamagnetic effect, and low cellularity.
There are a number of pathologic conditions which can result in
decreased T2 signal. The use of “CHAFT” mnemonic is helpful in
neuroimaging by providing a list of differential diagnoses when
presented with lesions demonstrating low T2 signal. Imaging
examples of each of the mnemonic components will be presented.
Conclusion: Low signal intensity on T2 weighted MR images is a
helpful tool in narrowing differential diagnosis in neuroimaging.
“CHAFT” is a mnemonic to facilitate rapid recall of different MRI
etiologies for low signal on T2WI. This exhibit presents common
T2 dark lesions and application of the “CHAFT” mnemonic in
neuroimaging.
E461. Results of Intraindividual Crossover Comparisons of
Gadobenate Dimeglumine with Other Gadolinium Contrast
Agents for MRI of the Central Nervous System
Kuhn, M.1; Rowley, H.2; Colosimo, C.3; Essig, M.4; Maravilla, K. 5
1. Southern Illinois University School of Medicine, Springfield, IL;
2. University of Wisconsin, Madison, WI; 3. Catholic University of
Sacred Heart, Rome,Italy; 4. German Cancer Research Center,
Heidelberg, Germany; 5. University of Washington, Seattle, WA
Address correspondence to M. Kuhn ([email protected])
Background Information: The objective is to summarize intraindividual crossover comparison studies of gadobenate dimeglumine vs. comparator agents for MRI of central nervous system
(CNS) lesions.
Educational Goals/Teaching Points: All patients (n=336)
underwent two separate MR exams within 2-14 days of each
other. In a randomized order, all patients received 0.1 mmol/kg
of gadobenate dimeglumine and either gadolinium diethylenetriaminepentaacetic acid (n=191), gadolinium diethylenetriaminepentaacetic acid bismethylamide, (n=117), or gadoterate
meglumine, (n=28). Expert neuroradiologists assessed both sets
of T1-weighted spin echo postcontrast images qualitatively
assessed in a blinded manner. Quantitative region of interest
measurements of lesion to normal background brain data were
also derived by blinded readers. Differences in study populations
were assessed with the Wilcoxon signed rank test.
Techniques: Gadobenate dimeglumine resulted in significantly
greater (p<0.05) lesion-to-brain contrast than comparator agents
in all five studies. In blinded reader evaluations, a highly significant (p<0.001) preference for gadobenate dimeglumine over the
other three gadolinium based contrast agents was noted for
lesion detection and global diagnostic preference. In patients
with poorly enhancing lesion such as metastases, gadobenate
dimeglumine resulted in the detection of lesions not seen on the
comparator exams.
Conclusion: Results from intraindividual studies involving 336
patients undergoing MRI of the CNS show that gadobenate
dimeglumine is more efficacious than other gadolinium agents at
an equivalent dose. In general, images produced following administration of gadobenate dimeglumine demonstrated greater contrast enhancement, provided more diagnostic information, and
were highly-significantly preferred by experienced, blinded readers.
These findings may be attributed to the approximately 25-30%
greater enhancement seen with this agent due to weak binding to
serum proteins. References: 1) Colosimo C, Invest Radiol
2001;36:72-81. 2) Colosimo C, Neuroradiology 2004;46:655-665.
3) Knopp MV, Radiology 2004;230:55-64. 4) Maravilla KR,
Radiology 2006:289-400. 5) Rowley H, AJNR 2008. In Press.
E462. Contrast-Enhanced MR Neuroimaging Protocols at
1.5T and 3T: Results of an Expert Consensus Panel
Kuhn, M.1; Rowley, H.2; Tanenbaum, L.3; Enterline, D.4 1.
Southern Illinois University School of Medicine, Springfield, IL; 2.
University of Wisconsin, Madison, WI; 3. Mt. Sinai School of
Medicine, New York, NY; 4. Duke University Medical Center,
Durham, NC
Address correspondence to M. Kuhn ([email protected])
Background Information: The objective is to develop state-ofthe-art contrast-enhanced MR neuroimaging protocols that are
optimized for the specific examination being performed and the
field strength being used.
Educational Goals/Teaching Points: A multi-institutional panel
of expert neuroradiologists was convened to evaluate and discuss MR neuroimaging protocols at 1.5 and 3T. All participants
used 1.5T as well as 3T machines in their research and clinical
practice. Together, the experts developed protocols for commonly
performed studies (whole brain, spine, neurovascular, acute
stroke, and multiple sclerosis) as well as for several more specialized indications (IAC and cranial nerve, orbits, pituitary, and seizures). For each technical parameters (ie, FOV, TR, TE, ETL, NEX,
etc), an absolute value or range of values was specified. Each
protocol also included a recommended slice thickness and gap,
plane(s) of reconstruction, and notes on any special sequences
(IR, fat saturation, magnetization transfer) the group felt should
be recommended or discouraged. In the absence of a complete
consensus on a particular exam, annotations captured possible
variations on approaches suggested by the panel. All recommended protocols were subsequently tested and further optimized as necessary prior to finalization.
Techniques: Optimized neuroimaging protocols which are applicable at multiple institutions were developed and will be presented. Protocols at 3T were optimized to take advantage of the
high SNR provided by these systems while considering SAR
issues. For the majority of contrast-enhanced MR examinations, a
standard dose of 0.1 mmol/kg bodyweight is recommended
however, this dose may be reduced with the use of a high-relaxivity contrast agent. For certain exams at 1.5T (for example, pituitary lesions and acoustic neuromas) and for many studies performed on a 3T scanner, a half dose of 0.05 mmol/kg bodyweight was felt to be adequate, particularly when a higher-relaxivity contrast agent was used.
Conclusion: Neuroimaging protocols optimized for the type of
examination being performed and for the coil and field strength
of the scanner being used have been developed. The use of
high-relaxivity contrast agents provides adequate enhancement
at a lower dose, maximizing contrast enhancement and patient
safety.
331
E463. Pros and Cons of Cone-Beam CT: What the Radiologist
Has to Know (CME Credit Available)
Tanabe, K.1; Nishikawa, K.1; Otonari-Yamamoto, M.1; Sano, T.1;
Wang, J.2; Nadgir, R.2; Saito, N.2; Sakai, O.2 1. Tokyo Dental
College, Chiba, Japan; 2. Boston University/Boston Medical
Center, Boston, MA
Address correspondence to K. Tanabe ([email protected])
Background Information: Cone-beam CT is an imaging technique utilized worldwide, particularly in the field of dental medicine, but remains unfamiliar to radiologists in the United States.
The purpose of this exhibit is to review the principle of conebeam CT; to review use of cone-beam CT for dental implant
planning; to review common dental pathologies on cone-beam
CT, and to discuss pros and cons of cone-beam CT.
of this exhibit are to learn the principle of cone-beam CT; to
understand advantages and limitations of cone-beam CT, and to
be familiar with cone-beam CT findings of common dental
pathologies.
Techniques: The exhibit will include principles of cone-beam CT
(techniques, spatial resolution, radiation dose, limitations); a
review of cone-beam CT findings of odontogenic and nonodontogenic lesions with sample cases (periodontal disease, such as
periapical granuloma, periapical abscess or periapical cyst, trauma, such as fracture, tooth subluxation, odontogenic cysts, odontogenic tumors, nonodontogenic cysts, nonodontogenic tumors);
dental implant planning with cone-beam CT (scan and reconstruction techniques, interpretation: pertinent findings–what the
dentist wants to know, pitfalls), and discussion of advantages
and disadvantages of cone-beam CT .
Conclusion: Cone-beam CT has been utilized worldwide, particularly in the field of dental medicine. Understanding its advantages and limitations is crucial for optimal patient care.
E465. Multiple Sclerosis Lesion Characterization with MRI at
7T (CME Credit Available)
Sammet, S.; Schmalbrock, P.; Shah, J.; Boster, A.; Chakeres, D.;
Racke, M.; Knopp, M. The Ohio State University, Columbus, OH
Objective: The objective is to evaluate 7T MRI for visualizing and
characterizing multiple sclerosis (MS) lesion substructure with
the long-term goal to bring 7T MRI into clinical practice thus
expanding capabilities for early diagnosis and treatment assessment.
Materials and Methods: Ten MS patients (33-53 years) were
studied at 7T (Philips Healthcare, Cleveland, OH) using the following sequences: 2D-susceptibility weighted imaging (SWI: repetition time [TR]/ echo time [TE]/flip=1,600/12/50°); 2D-white
matter attenuated inversion recovery turbo spin echo (WHAT: TR/
TI/ TE=8,000/500/14) and T2-weighted gradient spin echo
(GraSE: TR/TE=4,000/70). Phase images were reconstructed from
the SWI data. All 7T MR images were visually compared and the
numbers of lesions seen with each sequence were counted.
332
Results: Overall, lesions had highest contrast on WHAT. The high
spatial resolution and excellent grey matter/white matter contrast
allowed depicting a number of juxtacortical lesions and a few
GM lesions. WHAT images also provided excellent depiction of
perivascular spaces. SWI magnitude images depicted only 93% of
the lesions seen on WHAT. This is due to the decreased contrast
in the weakly proton density weighted SWI magnitude images
compared to WHAT. SWI phase images showed several interesting features. Some lesions were seen on the magnitude images,
but not on the phase images indicating that contrast in these
lesions is due to free water increase. Other lesions were seen
only on phase but not magnitude images. These lesions must
have significant presence of paramagnetic material, e.g. iron.
Furthermore, a dark outer ring was observed on some lesions on
SWI phase images that was not visible in SWI magnitude or
WHAT images, and most lesions visible on SWI magnitude and
phase images were associated with venous vasculature.
Conclusion: This ongoing study indicates that 7T MRI provides
several novel contrast mechanisms not typically visible at 1.5T for
detailed characterization of MS lesions and depiction of their
internals structure. Future studies are needed to correlate the variable 7T MRI appearance of MS lesions with clinical findings.
High resolution MR imaging at 7T MRI enables to differentiate
substructures in MS lesions. Therefore, ultra-high field MRI of
MS might help to better understand the course of the disease
and monitor treatment.
E466. Imaging of Neurocutaneous Syndromes (CME Credit
Available)
Parmar, H.; Ibrahim, M. University of Michigan, Ann Arbor, MI
Address correspondence to H. Parmar ([email protected])
Background Information: Neurocutaneous malformations or
phakomatoses constitute a wide and often complex spectrum of
congenital abnormalities affecting multiple structures, especially
of ectodermal origin like the nervous system, skin and retina.
Some other visceral organs are involved to a lesser degree.
Imaging, especially MRI, is extremely helpful in the workup of
these patients and in certain cases can be vital for accurate diagnosis before the clinical features become apparent. Secondly,
identification of many of the responsible genes has vastly
improved our understanding of these entities. The purpose of
this exhibit is to discuss and describe the common and some of
the uncommon types of neurocutaneous syndromes; to review
the imaging findings of these entities using a variety of imaging
modalities with particular focus on MRI, and to develop an imaging based approach to these complex entities.
Educational Goals/Teaching Points: After completing this
exhibit, the viewer will be able to recognize the typical imaging
features associated with various neurocutaneous malformations
and understand their underlying pathology.
Techniques: This exhibit will provide an overview of clinical and
imaging features of various neurocutaneous syndromes seen in
regular radiology and neuroradiology practice. They will be divided into the first group of relatively common entities like: neurofibromatosis type I and type II, tuberous sclerosis, Sturge-Weber
syndrome and von Hippel Lindau syndrome. Next we will present
Electronic Exhibits: Nuclear Medicine
imaging findings in some of the rare and uncommon types of
neurocutaneous syndromes like neurocutaneous melanosis,
Proteus syndrome, basal cell nevus syndrome (Gorlin’s syndrome), hereditary hemorrhagic telangiectasia (Osler-WeberRendy syndrome) and hypomelanosis of Ito.
E467. The New Great Mimicker: Disseminated
Coccidiomycosis (CME Credit Available)
Yost, A.; Gridley, D.; Bollepalli, S.; Keehn, B. Maricopa Medical
Center, Phoenix, AZ
Address correspondence to A. Yost ([email protected])
Background Information: Coccidioidomycosis (valley fever) is a
systemic fungal infection caused by Coccidioides immitis endemic to Arizona, Southern California and Northern Mexico. The clinical syndrome presents as community-acquired pneumonia with various immunologic manifestations such as rashes and
skeletal discomfort. Although, most infections resolve without
complications or antifungal therapy, coccidioidomycosis may
spread hematogenously to other parts of the body in approximately 1% of infected individuals-higher in the immunocompromised. Disseminated coccidiomycosis (DC) is defined as coccidioidal disease that spreads beyond the pulmonary parenchyma or
hilar nodes. Few studies exist that examine DC’s imaging presentation and morbidity. The purpose of this exhibit is to define
our experience with DC from a county hospital’s perspective. The
Phoenix hospital’s population is composed of the incarcerated,
illegal aliens, and the severely mentally ill. These individuals generally receive inadequate health care and are often immunocompromised. DC is a mimicker in its presentation often involving the
neuroaxis, musculoskelatal system, and abdomen much the
same way that syphillis and tuberculosis can present in confounding patterns. Its indolent characteristics make it complex to
diagnose. For two primary reasons, DC is a differential to consider across the United States, despite its proclivity and concentration in the San Juaquin Valley. Our mobile society allows for
exposure to occur with presentation months to years later, when
a person resides in a nonendemic area. Secondly, the increasing
life expectancy of those who are immunocompromised continues
to expand. Consideration of disseminated cocci in the differential for a patient may be a life-saving measure as a radiologist.
Educational Goals/Teaching Points: The goals are to delineate
the complex and myriad imaging presentations of DC; review
DC’s epidemiology, serology, treatment, and sequelae, and utilize
a case-based, interactive learning model to enhance user retention.
Techniques: The exhibit will demonstrate imaging characteristics
of DC presentation with MR and CT; review the optimum imaging sequences utilizing MRI, and discuss important diffential considerations.
Conclusion: Disseminated coccidiomycosis is indolent and myriad in presentation. Its increasing incidence and necessity to
treat make it an important diagnosis to consider from an imaging
perspective.
Nuclear Medicine/Molecular
Imaging
E468. Common Artifacts in Nuclear Medicine: Diagnosis,
Prevention and a Pictorial Review
Girard, P. 1; Lefkovitz, Z2; Finestone, H. 1; Elgort, S1. 1.
Maimonides Medical Center, Brooklyn, NY; 2. Mount Sinai
Background Information: It is important to be aware of the
various artifacts encountered in nuclear medicine as they can
result in misdiagnosis. We present a pictorial of commonly
encountered nuclear medicine artifacts that can result in misdiagnosis and decrease diagnostic accuracy. Awareness of these artifacts will result in better patient care and outcomes.
Educational Goals/Teaching Points: We will discuss the common causes for encountering artifacts in nuclear medicine, discuss artifact presentations on the nuclear study, and provide
ways to avoid the pitfalls when it comes to interpretation of
these studies. We will discuss how quality control plays an
important role in the production of artifacts. With improved
detection and understanding of these artifacts, patient care can
be improved.
Techniques: We will review a variety of commonly encountered
artifacts in nuclear medicine including: artifacts produced by
attenuation and technical problems, contamination artifacts,
instrument malfunction, operator error, artifacts produced by
overlying objects, patient related artifacts, problems with radiopharmaceuticals, nuclear cardiology artifacts, etc.
Conclusion: Artifacts remain an issue in the correct interpretation of nuclear medicine studies. Distinction of artifacts from normal variants and pathologic entities may be a difficult task. If an
artifact is not recognized during acquisition and interpretation of
a study, it can simulate a pathologic process and lead to a misdiagnosis. We will display and discuss a variety of commonly
encountered artifacts, discuss how to recognize these artifacts
and demonstrate techniques in awareness and prevention to
enhance patient care.
E469. Outside the Box: Unexpected Crucial Findings In The
Daily Practice of Nuclear Medicine
Gerard, P.1; Lefkovitz, Z. 3; Kleyn, M.1; Geller, M.2; Desai, K.1 1.
Maimonides Medical Center, Brooklyn, NY; 2. Winthrop University
Hospital, Mineola, NY; 3. Mount Sinai Medical Center, New York,
NY
Background Information: The objective is to discuss the identification of crucial incidental findings on nuclear medicine studies
that can have devastating consequences if they are not detected. To show clinicians how thinking “outside the box,” can help
solve these critical problems from a new perspective.
Educational Goals/Teaching Points: There are many different
studies that are performed daily in a busy nuclear medicine
department. In the early evaluation of the patient, the nuclear
333
medicine study may be the initial diagnostic examination as it
offers both anatomic and functional information. Although performed for other reasons, there may be crucial incidental findings
that require prompt diagnosis and communication to the referring physician. These findings can have devastating consequences
if not detected. We discuss our experience in a variety of nuclear
medicine studies, including PET-CT where incidental critical findings were diagnosed changing patient management, and we
elaborate on key points to help diagnose these important findings.
Techniques: Many nuclear medicine studies are requested as
they convey both anatomic and functional information on a variety of disease entities. A variety of nuclear medicine studies
obtained from our nuclear medicine department will be presented which demonstrate crucial incidental findings, requiring
prompt communication to the referring physician. These cases
include abdominal aortic aneurysms on gastrointestinal bleeding
studies, pneumothorax or tumor on VQ lung and PET-CT scans,
DVT and pericardial effusions on PET-CT, compartment syndrome
on bone scan, pancreatitis and aneurysms and diverticulitis on
PET-CT scans, the misdiagnosis of brown fat in the cancer
patient, lung tumors on cardiac scans, technical artifacts and
attenuation defects, etc.
They are phagocytozed by macrophages which accumulate within lymph nodes. Disturbances in lymph flow or in nodal architecture caused by metastases lead to abnormal patterns of accumulation of the particles, which are detectable by MRI. On postcontrast T2- and T2*-weighted MRI benign lymph nodes show a
drop in signal intensity and homogenous darkening whereas
areas of malignant infiltration show lack of nanoparticle uptake
and remain signal-intense.
Conclusion: By taking this quiz the viewer will acquire confident
knowledge of the features of benign vs. malignant lymph nodes
in lymphotropic nanoparticle-enhanced MRI.
E471. Pictorial Review of Unexpected Extraosseous Findings
on Skeletal Scintigraphy (CME Credit Available)
Webb, H.; Oza, U.; Latifi, H.; Grossman, S.; Joyner, K.; Griffeth, L.
Baylor University Medical Center, Rockwall, TX
Address correspondence to H. Webb ([email protected])
Background Information: The goal of this exhibit is to show the
reader unexpected and often unusual findings when interpreting
skeletal scintigraphy. The categorized format of this presentation
will aid the reader in establishing a broad classification of etiologies for these extraosseous findings.
Conclusion: Nuclear medicine procedures are performed daily to
diagnose a variety of clinical conditions. It is important to be
aware of unexpected crucial findings that are encountered that
require prompt identification and communication of the findings
to the referring physician. We demonstrate how thinking “outside
the box” can help demonstrate a variety of these incidental
nuclear findings and show how it affects diagnosis and patient
management issues.
Educational Goals/Teaching Points: Although the exact mechanism for extraosseous uptake on skeletal scintigraphy is not fully
understood, the cases presented will be organized into separate
categories based on underlying etiology. These categories include
artifact, excretory abnormalities, neoplastic conditions, hormonal
conditions, inflammation, ischemia/infarction, and trauma.
Correlative radiologic imaging as well as histopathologic and clinical findings will be incorporated in several cases. Key teaching
points will be highlighted in each case.
E470. Quiz Yourself in Lymph Node Characterization With
Lymphotropic Nanoparticle-Enhanced MRI Using
Superparamagnetic Iron Oxides! (CME Credit Available)
Islam, T.1; Braschi, M.1; Oliveira, G.2; Harisinghani, M.1 1. Center
for Molecular Imaging Research/Massachusetts General Hospital,
Boston, MA; 2. Massachusetts General Hospital, Boston, MA
Address correspondence to T. Islam ([email protected].
edu)
Techniques: This exhibit will address the incidental extraosseous
uptake of tracer on skeletal scintigraphy, focusing on the common and uncommon imaging findings with pathologic correlation.
Background Information: The purpose of this education exhibit
is to familiarize viewers with various patterns of enhancement
in lymphotropic nanoparticle-enhanced MRI (LNMRI) with ferumoxtran-10 using test cases.
Educational Goals/Teaching Points: Evolving technologies
such as LNMRI with ferumoxtran-10 improve the accuracy in distinguishing benign from malignant lymph nodes. However accurate nodal characterization requires reader training and experience. This exhibit will showcase the variations in signal intensity
changes with ferumoxtran-10 in benign and malignant nodes.
Multiple histologically proven lymph nodes from various primary
tumors will be shown pre- and postcontrast enhancement in a
quiz manner followed by the correct answers.
Techniques: This technique employs superparamagnetic iron
oxide nanoparticles targeted at the reticuloendothelial system.
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Conclusion: Unexpected extraosseous skeletal scintigraphic findings often cause diagnostic dilemmas. Participating in a pictorial
review of several examples in multiple broad categories of diagnostic etiologies should allow the reader to create more accurate
interpretations.
E472. The Utility of Bone Scintigraphy in Pediatric Patients
Zukotynski, K.1,2; Treves, S.1,2; Grant, F.1,2 1. Harvard Medical
School, Brookline, MA; 2. Children’s Hospital Boston, Boston, MA
Address correspondence to K. Zukotynski (katherine.zukotynski@
utoronto.ca)
Background Information: Bone scintigraphy is a sensitive imaging modality for the detection of osseous abnormalities. It may be
used to detect initial changes that can not be identified with anatomic imaging, such as early bone stress in patients actively
involved in sports. It may complement findings identified on radiographs, CT or MRI such as in the evaluation of patients with neoplastic disease. A three-phase bone scan may be an effective
approach in the evaluation of suspected septic arthritis or osteomyelitis. Bone scintigraphy offers advantages compared with anatomic imaging in that it provides a practical way of imaging the
entire skeleton and typically does not require sedation. However,
interpretation of pediatric bone scintigraphy may pose particular
challenges, such as those related to developmental change and
disease distribution in children. This exhibit will review the utility
of bone scintigraphy in modern pediatric musculoskeletal imaging.
the utility of bone scintigraphy in pediatric musculoskeletal imaging with emphasis on the appearance of tracer uptake associated
with specific pathology and pitfalls encountered in imaging children.
Techniques: Whole-body planar bone scans, pinhole images and
SPECT will be shown for the evaluation of traumatic, neoplastic
and infectious abnormalities in children. Imaging protocols used
will be reviewed.
Conclusion: This is a didactic exhibit illustrating key imaging
findings and the utility of pediatric bone scintigraphy.
E473. Skeletal Scintigraphy of Benign Bone Lesions
Velayudhan, V.; Ferretti, J.; Cardoza, S.; Rosen, J. Nassau
University Medical Center, Copiague, NY
Address correspondence to V. Velayudhan ([email protected])
Background Information: Skeletal scintigraphy with methylene
diphosphonate is most commonly performed in evaluation for
metastatic disease. Frequently, benign conditions are incidentally
detected. Bone scintigraphy can be helpful in the differentiation
of these benign abnormalities.
Educational Goals/Teaching Points: The goals are for the participant in this educational activity to differentiate benign conditions from metastatic disease that may be present on bone scintigraphy; understand the presentation and differential diagnosis
of benign bony lesions on bone scan, and understand findings
on additional imaging modalities that provide successful diagnosis of benign conditions.
Techniques: Radiopharmaceuticals in bone scintigraphy can elucidate more lesions and provide earlier diagnosis than conventional radiography. We present several cases of primary benign
bony lesions demonstrating positive scintigraphic findings including a calvarial based hemangioma, nonossifying fibroma, cortical
desmoids of the femur and a large sclerotic lesion thought to represent a metastasis demonstrating no increased uptake on bone
scintigraphy, the classic appearance of a bone island. Paget disease characteristically displays increased uptake and expansion of
the involved bone. Systemic diseases may also show increased
activity, such as bone infarction in sickle cell anemia, cortical
uptake in hypertrophic pulmonary osteoarthropathy, and
increased activity in sarcoidosis related arthropathy. Bone imaging
can be useful to evaluate patients with bone pain and equivocal
radiographs, trauma that is difficult to evaluate on radiographs
and subtle injuries such as insufficiency fractures and medial tibial
stress syndrome (shin splints). These can be seen earlier than on
radiography, often at presentation. Reflex sympathetic dystrophy
classically demonstrates increased blood flow to the affected limb
with periarticular uptake. Prosthetic joints can also be evaluated
for aseptic loosening. This however needs to be distinguished
from osteomyelitis and septic arthritis, which can be achieved
with radiolabeled leukocyte and bone marrow imaging. Soft tissue uptake can also be demonstrated in nonmalignant lesions,
including post-traumatic myositis ossificans, heterotopic ossification and soft tissue calcification in a patient with scleroderma.
Conclusion: Skeletal scintigraphy has numerous applications
beyond evaluation for metastatic disease. Knowledge of the variety of non-neoplastic bony processes along with their typical distribution and differentiating features can aid radiologists in accurate interpretation and diagnosis.
E474. F-18 FDG PET-CT Imaging of Benign and Malignant
Musculoskeletal Diseases (CME Credit Available)
Nguyen, B.; Roarke, M.; Ram, P. Mayo Clinic, Scottsdale, AZ
Address correspondence to B. Nguyen ([email protected])
Background Information: F-18 FDG PET-CT is a well-established
imaging modality for the staging and post-therapeutic surveillance of lymphoma, melanoma, and cancer of the lung, esophagus, colon and breast. The imaging is based on uptake and
retention of glucose-analog radiotracer by highly metabolic
tumors and related metastases. During this combined anatomic
and functional evaluation of malignancy, musculoskeletal pathology may be purportedly or fortuitously demonstrated. In this
exhibit, the authors present the spectrum of benign and malignant musculoskeletal processes encountered during PET-CT
imaging.
Educational Goals/Teaching Points: This exhibit reviews the
PET-CT features of benign and malignant musculoskeletal diseases. Emphasis is on the differentiation between benign lesions
requiring no intervention and malignant tumors necessitating tissue sampling. Strengths and limitations of PET-CT in the diagnostic and staging of bone malignancy are also discussed.
Techniques: This exhibit is a pictorial essay describing PET-CT
patterns of inflammatory, infectious, traumatic, iatrogenic, and
neoplastic musculoskeletal diseases. The presented pathologic
processes include arthroplasty wear-induced granuloma, bursitis,
hemangioma, hibernoma, elastofibroma dorsi, aneurysmal bone
cyst, oncogenic osteomalacia, schwannoma, sarcoidosis, pigmented villonodular synovitis, multiple myeloma, lymphoma, sarcomas, and bone metastasis from different primary neoplasms.
Each entity will be reviewed and discussed in correlation/comparison with other imaging modalities.
Conclusion: After viewing this education exhibit, the participants
will learn different features of benign and malignant musculoskeletal diseases demonstrated by PET-CT, and understand
potential clinical applications, pitfalls and limitations of PET-CT in
musculoskeletal imaging.
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E475. Qualitative Patterns of FDG Uptake Seen in the Brain
PET-CT Scan for Different Dementias (CME Credit Available)
Nasoodi, A.; Hughes, S. Belfast Trust, Belfast, United Kingdom
Address correspondence to A. Nasoodi ([email protected])
Background Information: Combined PET-CT with F-18 FDG is
well established for routine oncological investigations but not for
the assessment of early dementia. FDG PET is better than perfusion scintigraphy for the assessment of early dementia. The patterns of disease seen in early dementia assessment in FDG PETCT are sometimes different from those seen in perfusion studies.
Educational Goals/Teaching Points: The goals are for the participant in this activity to understand the difference in perfoming
a PET-CT scan for dementia and oncology; to understand the patterns seen in the normal aging brain, and to understand the patterns seen in the common and uncommon dementias.
Techniques: We will show the indicators of a high quality FDG
PET-CT brain scan. We will show normal brain patterns and patterns seen in the normal aging brain. We will show the patterns
of disease seen in Alzheimer’s disease, frontotemporal dementia,
Lewy body dementia, vascular dementia, mixed dementia and
Creutzfelt-Jacob disease. We will discuss the possible benefit of
the combined findings of the FDG distribution and the unenhanced CT which can be obtained from the PET-CT scan. We will
discuss the accuracy and reliability of this scanning technique in
these different diseases. We will discuss the problems with using
this technique in mild cognitive impairment (MCI) as opposed to
early dementia.
Conclusion: The delegate should feel more confident in recognizing the patterns of disease seen in dementia scanned with
FDG PET-CT and realize the advantages and shortcomings of this
exciting technique.
E476. PET Imaging in MRI Negative Epilepsy (CME Credit
Available)
Bahl, G.1; Juhasz ,C.2; Chugani, H.2 1. Wayne State Univ/Detroit
Medical Center, Madison Heights, MI; 2. Wayne State University,
Detroit, MI
Address correspondence to G. Bahl ([email protected])
Background Information: Between 15-20% of epileptic seizures are intractable and may require surgical resection.
Presurgical imaging is very important to identify the epileptogenic
region to be removed for seizure-free surgical outcome. In cases
where standard imaging fails to demonstrate an epileptogenic
lesion, functional imaging with PET is a powerful tool for surgical
planning. This exhibit will discuss the use of PET in intractable,
MRI negative epilepsy.
Educational Goals/Teaching Points: The exhibit will provide a
brief overview of the uses of other modalities, primarily MRI and
EEG, and limitations of these techniques in localizing the epileptogenic region and a brief introduction to PET imaging and F-18
FDG as a tracer. After viewing this exhibit, the participant in this
activity will be be able to recognize the imaging findings of FDG
PET in common types of epilepsies. Multiple examples of typical
findings of interictal FDG PET will be displayed and put into clini-
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cal context. The participant will also understand the limitations
of FDG PET and compare it with ictal SPECT, another common
functional imaging modality to understand which technique is
preferred and when they provide complementary localizing information in different types of partial epilepsies.
Techniques: Functional imaging with PET provides valuable
information regarding the epileptogenic region in MRI negative
intractable seizures. The most commonly used tracer is F-18 FDG,
a glucose analogue, which provides functional information about
uptake of glucose in the brain. Interictal FDG PET provides valuable localizing information, showing hypometabolism in the epileptogenic region, in a variety of partial epilepsies, including temporal lobe epilepsy, extratemporal epilepsy, and some pediatric
epilepsy syndromes. There are limitations to this technique, such
as overestimation of the epileptogenic focus. In some cases, ictal
SPECT imaging can provide additional localizing information. In
this exhibit, we will compare interictal PET, scalp and intracranial
EEG, in multiple examples, and discuss the clinical impact of PET
in each case.
Conclusion: The reader should understand the basics of PET
imaging in epilepsy, recognize the most common abnormal patterns of glucose hypometabolism and become familiar with the
optimal clinical use of FDG PET in presurgical localization of epileptic foci.
E478. PET-CT in Head and Neck Cancer: Physiologic and
Pathologic Uptakes (CME Credit Available)
Kanekar, S.; Goldenburg, D.; Otto, N. Penn State Milton S.
Hershey Medical Center, Hershey, PA
Background Information: CT and MRI are commonly used
imaging modalities in evaluation of patients with head and neck
cancer. Diagnosis or exclusion predominantly rely on nodal size,
or contrast enhancement pattern which are nonspecific. Nodal
metastasis specificity is very low for the two routinely used
modalities CT (39%) and MR (48%). Diagnosis could be further
challenging after radical surgery or radiation therapy where the
normal anatomical morphology gets distorted. Today combined
PET-CT permits the synchronous images acquisition of anatomy
and metabolic data.
Educational Goals/Teaching Points: The goals are to learn the
PET-CT appearances of various histiologic types of head and neck
tumors at different spaces of the neck, and to highlight the physiologic uptake and mimics of the tumor.
Techniques: We retrospectively assembled a cohort of 95
patients with surgically and/or biopsy proven cases of head and
neck cancer. We have divided this exhibit into two major categories. The first half of the exhibit illustrates and describes the various physiologic uptakes and their mimics while in the second
half we discuss and describe the various pathologies. We illustrate the variety of primary and secondary head and neck tumors
involving the various spaces (oral, parapharyngeal, masticator,
parotid, carotid and base of the skull). We also illustrate the limitations following postsurgical and postradiotherapy changes.
Normal anatomical structures of the neck, such as glands, muscle, fat, lymphoid tissue and mucosa can show increased uptake.
Comprehensive knowledge of this physiologic uptake is important to avoid false positives.
the spectrum of artifacts in cardiac rest/stress studies using 99mTc
Sestamibi which mimic real ischemic disease and to present the
information as a desktop algorithm for easy reference.
Conclusion: PET-CT has revolutionized the imaging of head and
neck cancer.
Techniques: We illustrate a spectrum of common and lesser
known artifacts; explain their usual etiology and provide simple
tools by which to differentiate real from artifactual findings of
ischemia. We provide a ‘desktop algorithm’ that can be used by
trainees and non-nuclear specialists for guidance.
E479. PET-CT in Breast Cancer: Clinical Applications
Akin, E.; Katzen, J. George Washington University Hospital,
Bethesda, MD
Address correspondence to J. Katzen ([email protected])
Background Information: In conjunction with review of the literature, we catalogued common PET-CT findings in detection,
staging, and recurrent breast cancer.
Educational Goals/Teaching Points: Interpretation of PET-CT
requires knowledge of the staging scheme and understanding of
the pattern of spread of breast cancer. The audience will see
multiple examples of breast cancer in a variety of stages and
become familiar with the PET-CT findings in these stages. This
review also aims to demonstrate the added benefit and accuracy
of PET-CT in detection of recurrent and metastatic breast cancer
over other less sensitive imaging modalities. We will demonstrate
common pitfalls in PET-CT interpretation of breast cancer.
Techniques: This review, using specific case examples, emphasizes the superior accuracy of PET-CT in the detection of internal
mammary nodal metastases, as well as metastatic lesions to the
thoracic wall, and subtle lytic skeletal metastases not evident by
conventional imaging modalities. In addition, imaging examples
are presented where PET-CT may be limited in detection of
recurrence, so alternative imaging modalities can be selected,
such as bone scans in the setting of nonhypermetabolic sclerotic
metastases. Conclusion: PET-CT is the superior modality in detecting local
and regional nodal recurrence and distant metastases in breast
cancer. PET-CT should not replace histopathologic sampling for
establishment of axillary nodal stage. PET-CT helps in deciding
which therapy regimen works. Additionally, PET-CT is able to help
determine when to discontinue a therapy regimen that the tumor
is unresponsive to. Ongoing development of new imaging agents
will likely be important in tailoring therapy of breast cancer to the
specific tumor type and behavior.
E480. Pitfalls of Nuclear Medicine Sestamibi Cardiac
Imaging: A Pictorial Essay and Desktop Algorithm for
Sorting Out Artifacts (CME Credit Available)
Zentner, L.; Sivaratnam, D.; Better, N.; Lichtenstein, M. Royal
Melbourne Hospital, Parkville, Australia
Address correspondence to L. Zentner ([email protected])
Background Information: Many artifacts have been identified in
cardiac stress studies in nuclear medicine. When the artifact is in
an arterial territory it often closely mimics ischemia.
Conclusion: Breast attenuation, adjacent hot or cold areas,
reconstruction algorithm used, number of counts in image and
attenuation correction with CT can all produce artifacts that
mimic real cardiac ischemia. Knowing how to differentiate these
from real pathology can save unnecessary cardiac catherization
and significant patient anxiety.
E481. Malignant Peritoneal Mesothelioma: Characterization
by CT, PET and PET-CT (CME Credit Available)
Rasiej, M.1; Uldrick, T.2; Joffe, R.1; Austin, J.1; Taub, R.1; Ichise,
M.1 1. NewYork-Presbyterian Hospital Columbia University, New
York, NY; 2. National Cancer Institute, Bethesda, MD
Address correspondence to M. Rasiej ([email protected])
Background Information: Malignant peritoneal mesothelioma
is a rare, aggressive tumor, which is known to show FDG uptake
on PET and is commonly imaged with CT. The use of combined
PET-CT in the evaluation of malignant peritoneal mesothelioma
has not been extensively described. This exhibit will illustrate the
imaging of malignant peritoneal mesothelioma, primarily focusing on CT, PET and PET-CT with selected MRI correlations.
Implications of imaging for the diagnosis and assessment of
treatment of peritoneal mesothelioma, and also for future
research directions will be discussed.
epidemiology, pathophysiology, histopathology and spectrum of
CT, PET and PET-CT imaging characteristics of peritoneal mesothelioma, using representative cases; discuss the potential
advantages of various cross-sectional imaging methods of peritoneal mesothelioma in the context of current multimodality
approach to treatment, and provide differential diagnosis for peritoneal abnormalities on cross-sectional imaging.
Techniques: Malignant peritoneal mesothelioma is a rare,
aggressive tumor, which demonstrates F-18 FDG uptake. FDG PET
features include diffuse and nodular peritoneal uptake. CT features include several characteristic imaging findings, some also
shared by other peritoneal neoplasms. Cross-sectional anatomic
and physiologic imaging techniques may provide complimentary
information in the diagnosis and treatment of malignant peritoneal mesothelioma.
Conclusion: F-18 FDG PET-CT is a valuable imaging modality in
the characterization of malignant peritoneal mesothelioma in
addition to traditional cross-sectional imaging methods. Further
evaluation of test characteristics and imaging response criteria of
PET-CT in the setting of peritoneal mesothelioma is warranted.
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E482. Frequency, Significance and Management of
“Incidentalomas” Found on PET-CT (CME Credit Available)
Scotti, S.2; Kassis, C.1; Staab, E.2 1. State University of New York
at Buffalo, Buffalo, NY; 2. North Carolina Baptist Hospital,
Winston Salem, NC
Address correspondence to S. Scotti ([email protected])
Background Information: The hybrid modality of PET-CT is an
exciting development in imaging, as it combines the advantages
of each respective modality — the highly sensitive detection of
metabolic activity by PET scan and the accurate anatomic localization of CT. However, while exciting, it is important to determine
the incidence and significance of so-called ‘incidentalomas’, or
tumors (-omas) found by coincidence (incidental) without clinical symptoms or suspicion, discovered serendipitously by PET-CT.
Such findings occur with a small but significant frequency, and
their incidence and significance vary by anatomic location. In one
study of thyroid incidentalomas the incidence was 4.8% with
3.8% of patients having diffuse thyroid uptake and 1% having
focal thyroid uptake. 100% of the diffuse uptake cases were
benign and 38% of the focal lesions were found to be malignant.
In another study of colorectal incidentalomas 2.4% of patients
were found to have colorectal lesions satisfying strict criteria for
an incidentaloma and 67% of these were found to be cancerous
or precancerous. We review similar data from the literature from
multiple anatomic sites with examples. Being aware of this information should help with generating more accurate diagnoses
and with improving patient care.
Educational Goals/Teaching Points: We review the literature
and provide examples with PET-CT images of incidentalomas
from multiple anatomic locations, including the adrenal gland,
bowel, brain, kidney, lung, ovary, pancreas, prostate, salivary
glands, thyroid, thymus, and several others. The goal is to educate the reader about the frequency, PET-CT appearance and significance of these incidentalomas by anatomic site so that these
can be initially recognized and appropriate recommendations can
be made for the care of patients having these findings. Conclusion: Although incidentalomas on PET-CT are relatively
infrequent, they occur frequently enough to be seen with some
regularity in a busy practice. It is therefore important to be familiar with their incidence and significance by anatomic location,
their PET-CT appearance and their management. A review of the
literature with example clinical cases with PET-CT images is one
way of accomplishing this educational goal. Example cases are
provided for multiple anatomic locations, including the adrenal
gland, bowel, brain, kidney, lung, ovary, pancreas, prostate, salivary glands, thyroid, thymus, and several others, with recommendations regarding management and care provided from the
literature.
E483. How Should You Deal With Unusual Radioactive
Exposure and Poisoning Situations (CME Credit Available)
Rodgers, B.1; Johnston, RN, MSN, M.2; Wasilewska, E.1; Palacios,
E.1 1. Tulane University, New Orleans, LA; 2. The Johns Hopkins
Hospital, Baltimore, MD
Background Information: We face many threats to society,
some are man made; some are not. Following in the wake of hurricane related damage in the Gulf region, threats of “dirty” bombs,
338
and the previously reported polonium poisoning case, radiologists
and nuclear medicine professionals need to know how to help
assess and manage such situations. We may also have to bear
responsibility in our communities to protect other healthcare
workers, possibly exposed citizens, handle the press, and deal
with law enforcement personnel. All are possibly involved in such
circumstances. Having experienced several devastating hurricanes
over the past few years, physicians along the Gulf have been
forced to learn and be skillful in disaster situations.
Educational Goals/Teaching Points: We will review methods of
containment and assessment. Also we will review how to handle
the media appropriately, so as to inform and not cause any
panic.
Techniques: Planning and discipline are key factors in handling
unusual or crisis situations. To be effective a straightforward plan
will help.
Conclusion: As first responders in any “nuclear” event we must
be professional, helpful, and organized in our approach to any
unusual or potentially dangerous situation. If radiologists and
nuclear medicine professionals in the community do not provide
such assistance, who will?
E484. What to Do Before, During, and After a Catastrophe
Involving Your Hospital’s Radiation Oncology and Nuclear
Medicine Departments: Special Considerations for
Protecting and Retrieving Nuclear Materials (CME Credit
Available)
Rodgers, B.1; Johnston, RN, MSN, M.2; Hafner, MHSA, RT, S.1;
Reindl, MS, C.1; Brookes Ezell, M.1; Jacobs, A.1 1. Tulane
University, New Orleans, LA; 2. The Johns Hopkins Hospital,
Baltimore, MD
Background Information: Nuclear materials can be found in
most all radiation therapy and nuclear medicine departments. In
radiation therapy (and in some pathology departments), lethal
amounts are often present. Both current and spent (waste)
materials require supervised storage, use and disposal. They
require special handling. Multiple hurricanes, including Katrina,
Rita, and more recently, Gustav, have taught us that updates to
our disaster plan were required, especially pertaining to access
and the aftermath of flooding (cleanup).
Educational Goals/Teaching Points: Tulane University Hospital
and Clinic had regulated nuclear imaging and therapeutic materials in multiple locations and floors of our complex. Where flooding occurred during Hurricane Katrina on our first floor, issues of
breakage or leaking–contamination–had to be addressed during
our recovery and rebuilding phase. Adding to our problems,
many of the recovery workers had little training or knowledge in
handling nuclear materials. Other hospitals throughout the gulf
region have faced similar or worse issues in recent years. Some
problems could have been prevented with a better predisaster
plan. A highly coordinated approach with multiple areas of
redundancy is required to best cope with such a crisis.
Electronic Exhibits: Pediatrics
Techniques: With an improved disaster plan, we should be better able to survive the next potential disaster situation. Such planning should be readily applicable to other potential disaster situations, for example tornado or earthquake damage.
Conclusion: By carefully planning what to do if the structural
integrity of your building is compromised by a natural or man
made event, potential serious consequences of unshielded nuclear materials can be avoided. Special consideration must be given
to recovery workers who might be insufficiently trained in handling nuclear materials, especially for therapy sources and agents.
Planning is required to ensure that all nuclear materials remain
safe and shielded during a catastrophe. Unsealed and unshielded
sources can be life threatening otherwise.
E485. Nuclear Regulatory Commission Knowledge: ABR Oral
Exam Preparation Tutorial (CME Credit Available)
Amin, A.; Burns, N.; Colletti, P. University of Southern California,
Los Angeles, CA
Address correspondence to P. Colletti ([email protected])
Background Information: In 2005, the Nuclear Regulatory
Commission (NRC) established guidelines for physicians who
would like to be designated with the status of auxiliary user. In
order to meet these criteria, residents in diagnostic radiology
must undergo more than 700 hours of education and training
that includes a review of adequate handling of radionuclide substances that are used in the imaging and treatment of patients.
The written and oral radiology board examinations nuclear medicine sections includes specific questions related to NRC regulations, including the safe handling of unsealed radiopharmaceuticals for diagnosis and therapy.
is to provide residents in radiology with a concise overview tutorial so that they can satisfactorily pass the nuclear medicine
aspect of their radiology board examination as well as assist
them to practice in compliance with the NRC requirements. The
presentation consists of radiation physics, monitoring personal
exposure, methods for proper decontamination, effective handling of radioactive materials and the maintenance of overall
radiation safety while working in a nuclear medicine department.
The tutorial will contain exhibits detailing how a radionuclide spill
should be properly assessed and decontaminated as well as
cases and questions that will test and provide adequate explanations for maintaining safety in the nuclear medicine department.
Techniques: The exhibit will include information on safe acquisition, storage, and administration of radiopharmaceuticals;
response to radioactive spills; appropriate handling of radioactive
waste; quality assurance for radiopharmaceuticals, and quality
assurance for nuclear medicine equipment.
Conclusion: This exhibit will provide residents in diagnostic radiology with an educational program in nuclear medicine so that
residents will be able to meet the guidelines set forth by the
Nuclear Regulatory Commission and American Board of
Radiology.
Pediatric Imaging
E486. Benign Enlargement of the Subarachnoid Spaces in
Infants: Truly Benign? (CME Credit Available)
DiDomenico, P.; Palka, P. David Grant Medical Center, Travis AFB,
CA
Address correspondence to P. DiDomenico (paul.didomenico1@
travis.af.mil)
Background Information: Benign enlargement of the subarachnoid spaces (BESS) in infants is often discovered incidentally or
when patients undergo neuroimaging in the workup of macrocephaly. These patients are usually neurologically normal and
have no history of trauma. Studies have shown a correlation
between this finding and an increased risk of subdural hematoma occurring either spontaneously or following minor, accidental trauma. Confusion may arise in such cases due to the association of subdural hematoma in infants with nonaccidental trauma.
A review of the literature cautions against this association, however, in the absence of known high-specificity stigmata of nonaccidental trauma. There is also a risk of communicating hydrocephalus which may develop in a low percentage of patients. We
present cases illustrating these findings in patients who developed normally without incident, and in patients who did have
subdural hemorrhage although without concurrent evidence of
nonaccidental trauma.
Educational Goals/Teaching Points: BESS may be benign but
also may confer increased risk of subdural hemorrhage and communicating hydrocephalus. The finding may also be misinterpreted as representing chronic subdural hematomas. When subdural
hematoma is discovered in a patient with enlarged subarachnoid
spaces, this finding is not specific for nonaccidental trauma.
Treatment may be warranted if hydrocephalus develops.
Techniques: Ultrasound, CT, and MRI imaging of the brain may
demonstrate findings seen in BESS, as well as complications of
subdural hematomas. A triad of symmetric extra-axial fluid overlying the cerebral hemispheres with extension into the interhemispheric fissure with mild compensatory dilatation of the anterior
horns is most consistent with BESS and essentially excludes subdural hematomas.
Conclusion: BESS in infants may be encountered in routine
practice by general, pediatric, and neuroradiologists. While this
finding is benign in many cases, there is an increased risk of subdural hemorrhage either spontaneously or following minor trauma. A low percentage of patients may develop communicating
hydrocephalus, which may warrant treatment. Radiologists may
better serve patients and referring clinicians through the recognition that the presence of subdural hematoma in patients with
BESS is not specific for nonaccidental trauma and should be correlated with the presence or absence of higher-specificity lesions
for this diagnosis.
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Electronic Exhibits: Pediatrics
E487. Shedding Light on Echogenic Neonatal Brain Lesions
Wolfman, D.; Khianey, A.; Allison, S. Georgetown University
Hospital, Washington, DC
Address correspondence to D. Wolfman ([email protected])
requires no contrast or sedation. Cranial sonography is an indispensable tool for the diagnosis, followup, and prediction of outcome in infants with subependymal, intraventricular, and parenchymal hemorrhage.
Background Information: The purpose of this presentation is to
review the differential diagnosis of an echogenic brain lesion on
neonatal brain ultrasound; review the ways to differentiate
between the different echogenic brain lesions on neonatal brain
ultrasound, and discuss pertinent imaging findings of the different echogenic brain lesions on neonatal brain ultrasound.
E489. Shaking Out the Causes of Pediatric Seizures by
Imaging (CME Credit Available)
Taheri, M.1; Chung, J.1; Richardson, R.1,2; Patterson, K.2; Ishak,
G.1,2 1. University of Washington, Seattle, WA; 2. Children’s
Hospital and Medical Center, Seattle, WA
Address correspondence to M. Taheri ([email protected])
Educational Goals/Teaching Points: The goals of this presentation include reviewing the optimal technique to perform neonatal
brain ultrasound; reviewing the differential diagnosis of an echogenic brain lesion on neonatal brain ultrasound, including imaging findings for each lesion, and reviewing ways to distinguish
between echogenic brain lesions on neonatal brain ultrasound,
including pitfalls and mimics.
Background Information: The goals are to review the role of
imaging in the work-up of children with seizures, as only a small
fraction of children with seizures require imaging; to discuss the
spectrum of imaging findings associated with pediatric seizures,
and to provide examples of pathologic correlates with images of
selected cases.
Techniques: The ability to accurately diagnose echogenic brain
lesions on neonatal ultrasound significantly impacts patient care.
This review will help the physician better understand the differential diagnosis of echogenic brain lesions on ultrasound, including its limitations.
guidelines on how to approach a child with seizures; sample
cases along with pathological appearances of common tumors,
cortical dysplasia, and sclerosis/gliosis with or without vascular
causes associated with pediatric seizures, and sample cases of
other potential etiologies of pediatric seizures such as infections,
developmental malformations, and dysmyelinating disorders.
Conclusion: After viewing the exhibit the physician should be
able to discuss the differential diagnosis of an echogenic lesion
on neonatal brain ultrasound; describe the imaging findings of
the different echogenic lesions on neonatal brain ultrasound, and
describe imaging pitfalls and mimics of echogenic lesions on
neonatal brain ultrasound.
Techniques: The exhibit will discuss the CT and/or MR imaging
findings that can assist in formulating a differential diagnosis in
the setting of pediatric seizures; introduce the complementary role
of spectroscopy in diagnosis of specific dysmyelinating diseases,
and discuss the microscopic appearance of common tumors, cortical dysplasia, and sclerosis/gliosis that assist in their diagnosis.
E488. Sonography of the Infant Brain: Anatomy,
Hemorrhage, Hypoxic/Ischemic Disease (CME Credit
Available)
Rosenberg, H.; Mehta, A.; Chaudhry, H. Mount Sinai Medical
Address correspondence to H. Rosenberg (henrietta.rosenberg@
mountsinai.org)
Conclusion: Many children with seizures do not require imaging.
Various cerebral abnormalities can cause seizures; each has distinctive imaging characterisitics. Pathological correlation helps
confirm the diagnosis in a fraction of the cases.
Background Information: The advent of high-resolution realtime sonography in the 1980s revolutionized the imaging
approach to the infant brain. This noninvasive, nonionizing imaging modality with portable and repeatable capabilities is not only
cost effective but is readily available and reliable for the evaluation and follow-up of intracranial hemorrhage in infants. This
education exhibit reviews the ultrasound appearance of brain
hemorrhage and its sequelae in premature and full-term infants. Educational Goals/Teaching Points: The goal of this exhibit is
to provide the reader with information regarding the risk factors
for and the sonographic findings of intracranial hemorrhage in
premature and full-term infants, to present the classification of
intracranial hemorrhage in the premature infant and to contrast
the patterns seen in the full-term infant, as well as to elaborate
on the anticipated sequelae of these insults to the infant brain.
Conclusion: High-resolution ultrasound is a sensitive, accurate,
noninvasive, nonionizing portable imaging modality which
340
E490. An Array of Common Pediatric Breast Abnormalities
Kim, A.; Woodfield, C.; Donegan, L. The Warren Alpert Medical
School of Brown University/Rhode Island Hospital, Providence, RI
Address correspondence to A. Kim ([email protected])
Background Information: Most palpable masses in the pediatric and adolescent patients are benign. However, due to the
increased awareness of breast cancer, a breast lump in a child or
adolescent may alarm both the parent and the child. Physical
examination should be the initial examination, followed by an
ultrasound examination of the palpable mass. It is important to
recognize both benign and malignant findings to aid in patient
management.
the stages of normal breast development; review the different
entities that manifest as palpable breast masses in the pediatri

ElEctronic Exhibits - American Roentgen Ray Society

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