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Everything you need to know about Computed Tomography (CT) & CT Scanning

November 2017 Imaging Pearls - Learning Modules | CT Scanning | CT Imaging | CT Scan Protocols - CTisus
Imaging Pearls ❯ November 2017

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    • Purpose: To develop a machine learning model that allows high- risk breast lesions (HRLs) diagnosed with image-guided needle biopsy that require surgical excision to be distinguished from HRLs that are at low risk for upgrade to cancer at surgery and thus could be surveilled. 

      Conclusion: This study provides proof of concept that a machine learn- ing model can be applied to predict the risk of upgrade of HRLs to cancer. Use of this model could decrease unnecessary surgery by nearly one-third and could help guide clinical decision making with regard to surveillance versus surgical excision of HRLs.

      
High-risk Breast lesions: A Machine Learning Model to Predict Pathologic Upgrade and Reduce Unnecessary Surgical Excision 
Manisha Bahl et al.
Radiology (in press)
    • “Instead of surgical excision of all HRLs, if HRLs categorized with our model to be at low risk for upgrade to cancer were sur- veilled and the remainder were excised, then 97.4% (37 of 38) of malignancies would be diag- nosed at surgery, and 30.6% (91 of 297) of surgeries of benign lesions could be avoided.” 


      High-risk Breast lesions: A Machine Learning Model to Predict Pathologic Upgrade and Reduce Unnecessary Surgical Excision 
Manisha Bahl et al.
Radiology (in press)
    • “Machine learning could inform shared decision making by the patient and the provider re- garding surveillance versus sur- gical excision of HRLs and thus could support more targeted, personalized approaches to patient care.”

      
High-risk Breast lesions: A Machine Learning Model to Predict Pathologic Upgrade and Reduce Unnecessary Surgical Excision 
Manisha Bahl et al.
Radiology (in press)
    • “In conclusion, machine learning can be applied as a risk prediction method to identify patients with biopsy-proven HRLs that have the potential for follow-up rather than surgical excision. Future work includes incorporation of mammographic images and histopathologic slides into the machine learning model.Use of our model based on tra- ditional structural features with an additional feature of biopsy pathologic report text has the potential to decrease unnecessary surgery by nearly one-third in women with HRLs and supports shared decision making regarding surveillance versus surgical excision of HRLs.” 


      High-risk Breast lesions: A Machine Learning Model to Predict Pathologic Upgrade and Reduce Unnecessary Surgical Excision 
Manisha Bahl et al.
Radiology (in press)
Adrenal

    • When do we operate on an Adrenal Myelolipoma?
      - Size (usually over 8cm)
      - Patient has pain and discomfort
      - Atypical CT appearance (not certain it is a AML)
    • “Laparoscopic adrenalectomy may be appropriate for patients with a presumptive diagnosis of AM and abdominal or flank pain, large tumor size, and/or uncertain diagnosis after imaging.”

      
Adrenal Myelolipoma: Operative Indications and Outcomes
Victoria M. Gershuni et al.
J Laparoendosc Adv Surg Tech A. 2014 Jan 1; 24(1): 8–12.
    • “ According to Olsson et al., the incidence of myelolipoma at autopsy ranges from 0.08% to 0.4%. Males and females are affected equally, and the peak age range at diagnosis is between 50 and 70 years of age.Although most AMs are small and asymptomatic, larger tumors may present with symptoms ranging from nonspecific abdominal pain to spontaneous retroperitoneal hemorrhage.”


      Adrenal Myelolipoma: Operative Indications and Outcomes
Victoria M. Gershuni et al.
J Laparoendosc Adv Surg Tech A. 2014 Jan 1; 24(1): 8–12.
    • “ A potentially interesting observation in our AM patients is the incidence of obesity. Mean BMI was 36 kg/m2, and most patients were obese; 6 of 13 patients for whom BMI data were available had BMI values >39 kg/m2. These BMI values were also significantly higher than for the rest of our adrenalectomy population. Because fat is a major component of AM, this raises the question of whether AM may be seen more commonly in the era of the obesity epidemic.”


      Adrenal Myelolipoma: Operative Indications and Outcomes
Victoria M. Gershuni et al.
J Laparoendosc Adv Surg Tech A. 2014 Jan 1; 24(1): 8–12.
    • “Management of adrenal myelolipoma should be considered on an individual basis. Although it is a benign tumor, surgery plays an important role for symptomatic cases and those lesions that cannot be distinguished reliably from malignancy.”

      
Adrenal myelolipoma: To operate or not? A case report and review of the literature
Mary Ramirez1 and  Subhasis Misra⁎
Int J Surg Case Rep. 2014; 5(8): 494–496.
    • “Although traditionally treated conservatively, some studies suggest surgical intervention for symptomatic tumors, growing tumors, or tumors larger than 6 cm in order to reduce the risk of developing abdominal pain or life threatening rupture and hemorrhage.”


      Adrenal myelolipoma: To operate or not? A case report and review of the literature
Mary Ramirez1 and  Subhasis Misra⁎
Int J Surg Case Rep. 2014; 5(8): 494–496.
    • “These lesions can be classi ed by their cause: congenital (eg, discoid adrenal gland, horseshoe adrenal gland, and epithelial cysts), vascular and/ or traumatic (eg, adrenal hemorrhage), infectious (eg, granulomatous diseases), enzyme deficiency disorders (eg, congenital adrenal hyperplasia [CAH] and Wolman disease), benign neoplasms (eg, pheochromocytomas, ganglioneuromas, adrenal adenomas, and myelolipomas), and adrenal mass mimics (eg, extralobar seques- tration and extramedullary hematopoiesis).”


      Imaging of Nonmalignant Adrenal Lesions in Children 
Sargar KM et al.
RadioGraphics 2017; 37:1648–1664
    • “Infradiaphragmatic extralobar sequestration may mimic an adrenal mass at imaging. Suprarenal extralobar sequestration may be seen as a well-de fined radiopacity in the upper paraspinal region on chest and abdominal radiographs. US demonstrates a heterogeneous suprarenal mass, often pyramidal. The increased echogenicity is related to multiple tissue interfaces within the lesion. A thin and highly echogenic rim around the lesion may also be seen. The blood supply is from the aorta or branches of the aorta.”

      
Imaging of Nonmalignant Adrenal Lesions in Children 
Sargar KM et al.
RadioGraphics 2017; 37:1648–1664
    • “An adrenal hemorrhage is the most common cause of an adrenal mass in a neonate, and it usually occurs in the rst few days of life. In the newborn period, adrenal hemorrhage occurs in two of 1000 patients, and they are nearly four times more common than neuroblastomas. Ten percent of adrenal hemorrhage cases are bilateral, and 70% are on the right side . The reason for the right side preponderance is unclear, although one theory suggests that this is due to the compression of the right adrenal gland between the liver and right kidney.”

      
Imaging of Nonmalignant Adrenal Lesions in Children 
Sargar KM et al.
RadioGraphics 2017; 37:1648–1664
    • “Adrenal calci cations carry a broad differential diagnosis and commonly occur as a sequel of prior adrenal hemorrhage or old granulomatous infections, such as histoplasmosis and tubercu- losis. Rarely, viral infections of childhood, such as disseminated neonatal herpes simplex and cytomegalovirus infections, may cause calci- cations. Wolman disease is a rare autosomal recessive disorder with acid lipase de ciency that causes adrenal gland calcifications. In addition, lipid deposition is seen in the liver, adrenal gland, spleen, and lymph nodes in patients with Wolman disease.”


      Imaging of Nonmalignant Adrenal Lesions in Children 
Sargar KM et al.
RadioGraphics 2017; 37:1648–1664
    • “On nonenhanced CT images, low attenuation less than 10 HU is characteristic of lipid-rich adenomas. Lipid-poor adenomas show higher attenuation values. Calci cations are less common in adenomas than in adrenocortical carcinomas. At contrast-enhanced CT, adenomas show moderate homogeneous contrast enhancement with rapid washout at delayed imaging. At MR imaging, the lipid-rich adenomas show a signal intensity drop on opposed-phase chemical shift images, due to the presence of microscopic fat.”


      Imaging of Nonmalignant Adrenal Lesions in Children 
Sargar KM et al.
RadioGraphics 2017; 37:1648–1664
    • “The formerly used “10% rule” has been challenged. According to the 10% rule, 10% of the pheochromocytomas are hereditary. In children, approximately 40% of pheochromocytomas are associated with known genetic mutations, 8%–43% are extra-adrenal, and 19%–38% are bilateral adrenal. Multiple tumors may be seen in 30%–70% of cases, especially in those with a familial predisposition.”

      
Imaging of Nonmalignant Adrenal Lesions in Children 
Sargar KM et al.
RadioGraphics 2017; 37:1648–1664
    • “Pheochromocytomas occur in von Hippel– Lindau syndrome, multiple endocrine neoplasia syndrome type 2, neuro bromatosis type 1, and familial paraganglioma syndromes. Familial paraganglioma syndromes are caused by muta- tions in the succinate dehydrogenase (SDH) gene.”


      Imaging of Nonmalignant Adrenal Lesions in Children 
Sargar KM et al.
RadioGraphics 2017; 37:1648–1664
    • “A ganglioneuroma is a primary neural crest neoplasm of sympathetic nerve origin, which most commonly arises from the posterior mediastinum or retroperitoneum .Other locations include the adrenal gland, skin, tongue, appendix, and lymph nodes Ganglioneuromas occur in the adrenal glands in 21% of cases. It is the most mature and benign form of the neural crest cell tumors. It contains mature ganglion cells and encapsulated nerve bers, but it does not contain neuroblasts or increased mitotic figures.”

      
Imaging of Nonmalignant Adrenal Lesions in Children 
Sargar KM et al.
RadioGraphics 2017; 37:1648–1664
    • “At CT, the mass is well-defined with homo- geneous low attenuation, similar to or slightly less attenuated than muscle. There is usually mild enhancement after 
intravenous contrast material administration. The enhancement may be homogeneous or heterogeneous. About 50% of ganglioneuromas demonstrate calci cation at CT. The calci cations are more often small and punctate, unlike the more coarse calcifications typically seen in a neuroblastoma.”


      Imaging of Nonmalignant Adrenal Lesions in Children 
Sargar KM et al.
RadioGraphics 2017; 37:1648–1664
    • “Extramedullary hematopoiesis (EMH) is de ned as the production of blood cells outside nor-
mal bone marrow. It is most commonly seen in chronic hemolytic anemias such as thalassemia, sickle cell anemia, and hereditary spherocytosis, as well as in lymphoma and leukemia. EMH is less common in children than adults, and it is most commonly seen in adolescents. In most patients, EMH is usually asymptomatic; however, patients may present with symptoms secondary to mass effect. In the abdomen, EMH may be seen involving the perirenal space, kidney, and adrenal gland.”

      
Imaging of Nonmalignant Adrenal Lesions in Children 
Sargar KM et al.
RadioGraphics 2017; 37:1648–1664
Colon

    • “Cecal volvulus is torsion of the cecum and ascending colon, accounting for 1–3% of cases of large-bowel obstruction. The progression of cecal volvulus can result in bowel ischemia, necrosis, or perforation, as well as death. Rapid surgical treatment can treat, or even prevent, these complications. Abdominal radiography is suboptimal for the diagnosis, having a re- ported sensitivity of 75%, and being diagnostic in only 17% of patients.”

      
Utility of CT Findings in the Diagnosis of Cecal Volvulus 
Dane B et al.
AJR 2017; 209:762–766
    • “The readers also assessed images for a proposed new potential finding of cecal volvulus that we designate as the “central appendix” sign. The central appendix sign was defined as an abnormal position of the appendix near mid- line, whereby the appendix is rotated toward the right side of the cecum and is on the same side as the terminal ileum.”


      Utility of CT Findings in the Diagnosis of Cecal Volvulus 
Dane B et al.
AJR 2017; 209:762–766
    • “The radiologists evaluated the CT examinations for the presence or absence of the following features; whirl sign (previously defined as collapsed loops of cecum with swirling strands of soft tissue, vessels, and fat attenuation centrally, abnormal cecal position (defined as cecum located outside the right lower quadrant), “bird beak” sign (previously defined as progressive tapering of afferent and efferent loops at the site of torsion), severe cecal distention, and mesenteric engorgement.”


      Utility of CT Findings in the Diagnosis of Cecal Volvulus 
Dane B et al.
AJR 2017; 209:762–766
    • “CT exhibited excellent diagnostic performance and very high sensitivity for cecal volvulus for readers of varying experience. Secondary imaging ndings may be useful in interpretation given that oral contrast material often fails to reach the transition point in patients with this 
diagnosis. The previously described whirl sign was a signi cant independent predictor of cecal volvulus for both readers. The newly proposed central appendix sign may also have potential value for less experienced readers.”


      Utility of CT Findings in the Diagnosis of Cecal Volvulus 
Dane B et al.
AJR 2017; 209:762–766
Contrast

    • 24 vs 13 vs 5 Hour Contrast Prep
      “Accelerated intravenous premedication with corticosteroids beginning 5 hours before contrast-enhanced CT has a breakthrough reaction rate noninferior to that of a 13- hour oral premedication regimen.”

      Intravenous Corticosteroid Premedication Administered 5 Hours before CT Compared with a Traditional 13-Hour Oral Regimen Benjamin M. Mervak et al. Radiology (in press)
    • “Our data support the replacement of a 13-hour oral premedication regimen with a 5-hour intravenous premedication regimen in patients with competing medical priorities (eg, inpatients, those in emergency departments).”


      Intravenous Corticosteroid Premedication administered
5 hours before CT compared with a Traditional 13-hour Oral regimen 
Mervak PM et al.
Radiology 2017; 285:425–433
    • “Faster premedication should reduce the indirect harms of pre- medication in hospitalized patients at high risk for reactions to contrast media.”


      Intravenous Corticosteroid Premedication administered
5 hours before CT compared with a Traditional 13-hour Oral regimen 
Mervak PM et al.
Radiology 2017; 285:425–433 

Incidentaloma

    • “The incidence of INs has increased over time with the latest imaging techniques. For example, it is known that pulmonary nodules may be identified in up to 50% of chest computed tomography (CT) studies in smoking individuals and up to 25% of studies of non-smokers. Renal and hepatic findings occur in about 15% of individuals. In a study examining 1192 asymptomatic patients receiving a whole-body CT scan, 86% had an abnormal finding, and 37% of patients were referred for follow-up or treatment. Increased access to medical imaging and the propensity of physicians to favour over-investigating to avoid medical litigation can be identified as contributing factors to the in- creased frequency of Ins”. 


      The incidence and management of non-head and neck incidentalomas for the head and neck surgeon 
 Sahovaler A et al.
 Oral Oncology; Volume 74, November 2017, Pages 98–104
    • “The incidence of INs has increased over time with the latest imaging techniques. For example, it is known that pulmonary nodules may be identified in up to 50% of chest computed tomography (CT) studies in smoking individuals and up to 25% of studies of non-smokers. Renal and hepatic findings occur in about 15% of individuals. In a study examining 1192 asymptomatic patients receiving a whole-body CT scan, 86% had an abnormal finding, and 37% of patients were referred for follow-up or treatment”. 


      The incidence and management of non-head and neck incidentalomas for the head and neck surgeon 
 Sahovaler A et al.
 Oral Oncology; Volume 74, November 2017, Pages 98–104
    • “Advances in medical imaging technology have provided more sensitive, detailed and higher resolution images. Consequently, the frequency of INs has increased. A considerable volume of our referrals emerges from colleagues that seek our expertise in managing unexpected imaging findings in the head and neck region. Similarly, head and neck surgeons can encounter incidental findings in regions outside their “comfort zone”. Many times, we rely on the radiology report to suggest the next step in work-up. On other occasions, we initiate an immediate referral to another specialist without knowing if it is the most appropriate next step in management.”.

      The incidence and management of non-head and neck incidentalomas for the head and neck surgeon 
 Sahovaler A et al.
 Oral Oncology; Volume 74, November 2017, Pages 98–104
    • “The incidence of INs has increased over time with the latest imaging techniques. For example, it is known that pulmonary nodules may be identified in up to 50% of chest computed tomography (CT) studies in smoking individuals and up to 25% of studies of non-smokers. Renal and hepatic findings occur in about 15% of individuals. In a study examining 1192 asymptomatic patients receiving a whole-body CT scan, 86% had an abnormal finding, and 37% of patients were referred for follow-up or treatment. Increased access to medical imaging and the propensity of physicians to favour over-investigating to avoid medical litigation can be identified as contributing factors to the increased frequency of INs.”. 


      The incidence and management of non-head and neck incidentalomas for the head and neck surgeon 
 Sahovaler A et al.
 Oral Oncology; Volume 74, November 2017, Pages 98–104
Musculoskeletal

    • ”In the following pictorial essay, we provide a number of clinical examples of the use of CR in musculoskeletal imaging, including the evaluation of complex fractures, the delineation of the relationship of fractures to adjacent vasculature and overlying soft tissues, and the visualization of vascular and soft tissue injuries.”
CT evaluation of musculoskeletal trauma: initial experience with cinematic rendering.
Rowe SP, Fritz J , Fishman EK
Emerg Radiol. 2017 Sep 12. [Epub ahead of print]
Neuroradiology

    • “The incidence of INs has increased over time with the latest imaging techniques. For example, it is known that pulmonary nodules may be identified in up to 50% of chest computed tomography (CT) studies in smoking individuals and up to 25% of studies of non-smokers. Renal and hepatic findings occur in about 15% of individuals. In a study examining 1192 asymptomatic patients receiving a whole-body CT scan, 86% had an abnormal finding, and 37% of patients were referred for follow-up or treatment. Increased access to medical imaging and the propensity of physicians to favour over-investigating to avoid medical litigation can be identified as contributing factors to the in- creased frequency of Ins”. 


      The incidence and management of non-head and neck incidentalomas for the head and neck surgeon 
 Sahovaler A et al.
 Oral Oncology; Volume 74, November 2017, Pages 98–104
    • “The incidence of INs has increased over time with the latest imaging techniques. For example, it is known that pulmonary nodules may be identified in up to 50% of chest computed tomography (CT) studies in smoking individuals and up to 25% of studies of non-smokers. Renal and hepatic findings occur in about 15% of individuals. In a study examining 1192 asymptomatic patients receiving a whole-body CT scan, 86% had an abnormal finding, and 37% of patients were referred for follow-up or treatment”. 


      The incidence and management of non-head and neck incidentalomas for the head and neck surgeon 
 Sahovaler A et al.
 Oral Oncology; Volume 74, November 2017, Pages 98–104
    • “Advances in medical imaging technology have provided more sensitive, detailed and higher resolution images. Consequently, the frequency of INs has increased. A considerable volume of our referrals emerges from colleagues that seek our expertise in managing unexpected imaging findings in the head and neck region. Similarly, head and neck surgeons can encounter incidental findings in regions outside their “comfort zone”. Many times, we rely on the radiology report to suggest the next step in work-up. On other occasions, we initiate an immediate referral to another specialist without knowing if it is the most appropriate next step in management.”. 


      The incidence and management of non-head and neck incidentalomas for the head and neck surgeon 
 Sahovaler A et al.
 Oral Oncology; Volume 74, November 2017, Pages 98–104
    • “The incidence of INs has increased over time with the latest imaging techniques. For example, it is known that pulmonary nodules may be identified in up to 50% of chest computed tomography (CT) studies in smoking individuals and up to 25% of studies of non-smokers. Renal and hepatic findings occur in about 15% of individuals. In a study examining 1192 asymptomatic patients receiving a whole-body CT scan, 86% had an abnormal finding, and 37% of patients were referred for follow-up or treatment. Increased access to medical imaging and the propensity of physicians to favour over-investigating to avoid medical litigation can be identified as contributing factors to the increased frequency of INs.”.

      The incidence and management of non-head and neck incidentalomas for the head and neck surgeon 
 Sahovaler A et al.
 Oral Oncology; Volume 74, November 2017, Pages 98–104
Pancreas

    • “Acute pancreatitis (AP) is the third leading cause of hospitalization in the United States among gastrointestinal diseases, resulting in 275,170 hospitalizations at a cost of nearly 2 billion dollars in 2012. Approximately 90% of patients with AP have acute interstitial pancreatitis (AIP) that is typically mild in severity with full clinical recovery commonly seen within 1 week. Severe acute pancreatitis (SAP), which is typically defined as persistent organ failure (POF) and/or infected pancreatic necrosis, occurs in about 5–10% of AP patients and is associated with increased mortality, morbidity and length of hospital stay.”
    • “Acute pancreatitis (AP) is the third leading cause of hospitalization in the United States among gastrointestinal diseases, resulting in 275,170 hospitalizations at a cost of nearly 2 billion dollars in 2012. Approximately 90% of patients with AP have acute interstitial pancreatitis (AIP) that is typically mild in severity with full clinical recovery commonly seen within 1 week.”

      
Persistent SIRS and acute fluid collections are associated with increased CT scanning in acute interstitial pancreatitis
Kamal A1, Faghih M1, Moran RA1, Afghani E1, Sinha A1, Parsa N1, Makary MA2, Zaheer A3,4, Fishman EK4, Khashab MA1, Kalloo AN1,3, Singh VK1,3
Scand J Gastroenterol. 2017 Oct 11:1-6
    • “Severe acute pancreatitis (SAP), which is typically defined as persistent organ failure (POF) and/or infected pancreatic necrosis, occurs in about 5–10% of AP patients and is associated with increased mortality, morbidity and length of hospital stay.”


      Persistent SIRS and acute fluid collections are associated with increased CT scanning in acute interstitial pancreatitis
Kamal A1, Faghih M1, Moran RA1, Afghani E1, Sinha A1, Parsa N1, Makary MA2, Zaheer A3,4, Fishman EK4, Khashab MA1, Kalloo AN1,3, Singh VK1,3
Scand J Gastroenterol. 2017 Oct 11:1-6
    • “An AFC on initial CT and persistent SIRS are associated with increased CT imaging in AIP patients. However, these additional CT scans did not change clinical management.”


      Persistent SIRS and acute fluid collections are associated with increased CT scanning in acute interstitial pancreatitis
Kamal A1, Faghih M1, Moran RA1, Afghani E1, Sinha A1, Parsa N1, Makary MA2, Zaheer A3,4, Fishman EK4, Khashab MA1, Kalloo AN1,3, Singh VK1,3
Scand J Gastroenterol. 2017 Oct 11:1-6
    • Systemic inflammatory response syndrome (SIRS) was defined as two or more of the following:
      (1) temperature >38 °C or <36 °C;
      (2) respiratory rate >20 breaths/minutes or PaCO2 <32 mmHg;
      (3) pulse >90 beats/min and
      (4) WBC <4000 cells/mm3 or 12,000 cells/mm3 or >10% immature bands. Persistent SIRS was defined as presence of SIRS for >48 hours
    • “The present study has shown that persistent SIRS and AFC are independent factors associated with repeat CT imaging in patients hospitalized with AIP. However, repeat CT imaging was not associated with a change in clinical management or a subsequent evolution from AIP to ANP. Clinicians may be compelled to obtain additional CT scans for AIP patients with persistent SIRS and/or an AFC on the premise that these patients might be developing ANP or other local complications.”


      Persistent SIRS and acute fluid collections are associated with increased CT scanning in acute interstitial pancreatitis
Kamal A1, Faghih M1, Moran RA1, Afghani E1, Sinha A1, Parsa N1, Makary MA2, Zaheer A3,4, Fishman EK4, Khashab MA1, Kalloo AN1,3, Singh VK1,3
Scand J Gastroenterol. 2017 Oct 11:1-6
    • “In summary, additional CT imaging in AIP patients was more commonly pursued in those with persistent SIRS and/or an AFC; however, this did not result in the detection of ANP or a change in clinical management. Greater efforts will need to be expended to reduce unnecessary CT imaging in patients with AIP.”


      Persistent SIRS and acute fluid collections are associated with increased CT scanning in acute interstitial pancreatitis
Kamal A1, Faghih M1, Moran RA1, Afghani E1, Sinha A1, Parsa N1, Makary MA2, Zaheer A3,4, Fishman EK4, Khashab MA1, Kalloo AN1,3, Singh VK1,3
Scand J Gastroenterol. 2017 Oct 11:1-6
    • “Residual inflammatory changes were present in 19.8% of cases, with a median time period lasting 86 days since the initial episode of acute pancreatitis. Residual fluid collections were seen in 27.2% and persisted for a median of 132 days. Three patients had residual solid-appearing inflammatory masses, which could be mistaken for neoplasms.”


      The diagnostic challenge of the sequelae of acute pancreatitis on CT imaging: a pictorial essay.
Hughey M et al.
Abdom Radiol (NY). 2017 Apr;42(4):1199-1209
    • “Recognizing the spectrum of residual findings of acute pancreatitis, some of which can be long term, is important in the correct interpretation of a pancreatic CT. These findings can mimic acute pancreatitis or a pancreatic/peripancreatic neoplasm and often cause diagnostic confusion, especially in the absence of prior CT imaging.”


      The diagnostic challenge of the sequelae of acute pancreatitis on CT imaging: a pictorial essay.
Hughey M et al.
Abdom Radiol (NY). 2017 Apr;42(4):1199-1209
Practice Management

    • “To be successful, we need curiosity and the willingness to reach out to people from other disciplines who know things we do not know and are smarter than us. I subscribe to the 50- 50 rule: at least half of what I read is in fields unrelated to my own work.”

      
From Academia to Government to
Industry: A Strange Journey and Its Lessons Elias Zerhouni, Elliot K. Fishman, Karen M. Horton, Sheila Sheth
Journal of the American College of Radiology (in press)

    • “Leadership requires heart, spine, and brains, as well as dominating one’s fear. When I first came to the United States, I had big dreams; I knew I could not put a full life in a small dream box. The ability of this country to attract the best is what makes America great.”


      From Academia to Government to
Industry: A Strange Journey and Its Lessons Elias Zerhouni, Elliot K. Fishman, Karen M. Horton, Sheila Sheth
Journal of the American College of Radiology (in press)

    • “For radiology to flourish in the world of precision medicine, our specialty must reach out and collaborate with other disciplines. Remaining sheltered in our imaging silo could hamper success. For example, the development of deep learning as applied to medical imaging depends on radiologists’ working closely with computer scientists to identify the most promising applications and algorithms as well as with our colleagues in oncology and surgery to identify key clinical questions we need to address.”


      From Academia to Government to
Industry: A Strange Journey and Its Lessons Elias Zerhouni, Elliot K. Fishman, Karen M. Horton, Sheila Sheth
Journal of the American College of Radiology (in press)
Small Bowel

    • “Small bowel gastrointestinal stromal tumors (SB-GISTs) account for 8% to 15% of all primary small bowel neoplasms. They are thought to arise from a precursor of interstitial cells of Cajal found through the gastrointestinal tract. They involve the duodenum, jejunum, and ileum in order of decreasing frequency. Small SB-GISTs can be found incidentally or part of a surgical specimen to resect another tumor (eg, duodenal GIST found in a Whipple specimen). Larger tumors can present with obstruction, pain, or GI bleeding.”

      
Small Bowel Gastrointestinal Stromal Tumors: Multidetector Computed Tomography Enhancement Pattern and Risk of Progression 
Franco Verde, Ralph H. Hruban, Elliot K. Fishman
J Comput Assist Tomogr 2017;41: 407–411
    • “This study demonstrated interesting significant associations between heterogeneous enhancement pattern and presence of necrosis and also histologic risk of tumor progression. The difference in enhancement reflects the underlying pathologic change which is thought to be necrosis. As tumors enlarge, they outstrip their blood supply and become necrotic which is suggested by the significant association between heterogeneous enhancement, necrosis, and increasing size.”


      Small Bowel Gastrointestinal Stromal Tumors: Multidetector Computed Tomography Enhancement Pattern and Risk of Progression 
Franco Verde, Ralph H. Hruban, Elliot K. Fishman
J Comput Assist Tomogr 2017;41: 407–411
    • “Heterogeneous enhancement was significantly associated with non-low (ie, moderate or high) risk of tumor progression. This association was expected as heterogeneity reflects necrosis which is associated with increasing size. Size is a determinant in risk of progression hence the assumption can be made that 
heterogeneous enhancement indirectly reflects risk.”

      
Small Bowel Gastrointestinal Stromal Tumors: Multidetector Computed Tomography Enhancement Pattern and Risk of Progression 
Franco Verde, Ralph H. Hruban, Elliot K. Fishman
J Comput Assist Tomogr 2017;41: 407–411
    • “Heterogeneous 
enhancement was significantly associated with the presence of necrosis, larger size, and non-low (ie, moderate or high) risk of tumor progression. Radiologists can preoperatively offer prognostic information which may help surgical planning.”


      Small Bowel Gastrointestinal Stromal Tumors: Multidetector Computed Tomography Enhancement Pattern and Risk of Progression 
Franco Verde, Ralph H. Hruban, Elliot K. Fishman
J Comput Assist Tomogr 2017;41: 407–411
Trauma

    • ”In the following pictorial essay, we provide a number of clinical examples of the use of CR in musculoskeletal imaging, including the evaluation of complex fractures, the delineation of the relationship of fractures to adjacent vasculature and overlying soft tissues, and the visualization of vascular and soft tissue injuries.”
CT evaluation of musculoskeletal trauma: initial experience with cinematic rendering.
Rowe SP, Fritz J , Fishman EK
Emerg Radiol. 2017 Sep 12. [Epub ahead of print]
Vascular

    • ACR Appropriateness Criteria® 
Abdominal Aortic Aneurysm: Interventional Planning and Follow-up (2017)

    • ACR Appropriateness Criteria® 
Abdominal Aortic Aneurysm: Interventional Planning and Follow-up

    • ACR Appropriateness Criteria® 
Abdominal Aortic Aneurysm: Interventional Planning and Follow-up

    • ACR Appropriateness Criteria® 
Abdominal Aortic Aneurysm: Interventional Planning and Follow-up

      Computed tomography (CT) is a cross-sectional imaging modality that offers excellent spatial resolution, fast image acquisition times, and widespread availability. However, without contrast material administration, its ability to assess vascular structures is limited. Evaluation of the vessel lumen is accomplished through CT angiography (CTA), a technique that utilizes the administration of iodinated contrast material. The addition of 3- D volumetric postprocessing techniques allow the abdominal aorta and associated vasculature to be viewed in any obliquity and affords quantification of luminal diameter, cross-sectional area, and sac volume. A disadvantage of CTA includes potential nephrotoxicity from administered contrast material.

    • ACR Appropriateness Criteria® 
Abdominal Aortic Aneurysm: Interventional Planning and Follow-up

      Due to its superior spatial resolution and rapid image acquisition, CTA with 3-D volumetric reconstruction and vessel analysis has gained wide acceptance as the gold standard for pre-EVAR evaluation. The utilization of 3-D reconstruction software has become paramount in EVAR planning, as it diminishes the impact of vessel tortuosity on diameter and length measurements, in addition to reducing intraobserver variability. One author found that routine 3-D analysis of pre-EVAR images led to a significant reduction in Type I endoleaks. Reformatted CTA images in the coronal and sagittal planes should be utilized for increased diagnostic accuracy. In most cases, a CTA of the abdomen and pelvis is appropriate to ensure coverage of the entire aneurysm and vascular access.

    • Abdominal Aortic Aneuurysm: Facts
      Every year, 200,000 people in the U.S. are diagnosed with an abdominal aortic aneurysm (AAA).
      A ruptured AAA is the 15th leading cause of death in the country, and the 10th leading cause of death in men older than 55.
      Aneurysms run in families. If a first-degree relative has had an AAA, you are 12 times more likely to develop an abdominal aortic aneurysm. Of patients in treatment to repair an AAA, 15–25% have a first-degree relative with the same type of aneurysm.

    • Abdominal Aortic Aneurysm: Risk Factors Include;
      Smoking (strongest risk factor)
      Hypertension
      Older age (peak incidence at age 70 to 80)
      Family history (in 15 to 25%)
      Race (more common in whites than in blacks)
      Male sex

    • Abdominal Aortic Aneurysm: Facts
      Defined as aorta larger than 3 cm
      4 - 5.4 cm can be monitored
      Fusiform > 5.4 cm warrants repair

    • AAA: Rupture Risk
      Aortic aneurysm rupture 77-94% mortality rate
         - Risk factors for AAA rupture
         - female gender
         - larger baseline AAA diameter
         - hypertension
         - continued tobacco use
         - cardiac or renal transplant

    • AAA Size and Risk


    • Impending AAA Rupture
      Clinical diagnosis difficult
      CT indicators of aneurysm instability
         - Rapid increase in size
         - Lumen: plaque ulceration
         - Wall: Intramural hematoma
         - Periaortic: retroperitoneal or intraperitoneal hemorrhage
      Guide emergent surgical management

    • What should repair be done?
      Elective surgical repair is recommended for
         - Aneurysms > 5 to 5.5 cm (when risk of rupture increases to > 5 to 10%/yr), unless coexisting medical conditions contraindicate surgery
         - Additional indications for elective surgery include
         - Increase in aneurysm size by > 0.5 cm within 6 mo regardless of size
         - Chronic abdominal pain
         - Thromboembolic complications
         - Iliac or femoral artery aneurysm that causes lower-limb ischemia 

    • What if an AAA ruptures?
      Ruptured abdominal aortic aneurysms require immediate open surgery or endovascular stent grafting. Without treatment, mortality rate approaches 100%. With open surgical treatment, mortality rate is about 50%. Mortality with endovascular stent grafting is generally lower (20 to 30%).
      Merck Manual

    • ACR Appropriateness Criteria® 
Abdominal Aortic Aneurysm: Interventional Planning and Follow-up
      Computed tomography (CT) is a cross-sectional imaging modality that offers excellent spatial resolution, fast image acquisition times, and widespread availability. However, without contrast material administration, its ability to assess vascular structures is limited. Evaluation of the vessel lumen is accomplished through CT angiography (CTA), a technique that utilizes the administration of iodinated contrast material. The addition of 3- D volumetric postprocessing techniques allow the abdominal aorta and associated vasculature to be viewed in any obliquity and affords quantification of luminal diameter, cross-sectional area, and sac volume. A disadvantage of CTA includes potential nephrotoxicity from administered contrast material.

    • ACR Appropriateness Criteria® 
Abdominal Aortic Aneurysm: Interventional Planning and Follow-up
      Due to its superior spatial resolution and rapid image acquisition, CTA with 3-D volumetric reconstruction and vessel analysis has gained wide acceptance as the gold standard for pre-EVAR evaluation. The utilization of 3-D reconstruction software has become paramount in EVAR planning, as it diminishes the impact of vessel tortuosity on diameter and length measurements, in addition to reducing intraobserver variability. One author found that routine 3-D analysis of pre-EVAR images led to a significant reduction in Type I endoleaks. Reformatted CTA images in the coronal and sagittal planes should be utilized for increased diagnostic accuracy. In most cases, a CTA of the abdomen and pelvis is appropriate to ensure coverage of the entire aneurysm and vascular access.

© 1999-2017 Elliot K. Fishman, MD, FACR. All rights reserved.