Imaging Pearls ❯ November 2025
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3D and Workflow
- With the rise of artificial intelligence (AI), we are now beginning to see another shift in which jobs and industries will face disruption by highly efficient, highly sophisticated intelligent systems that possess tremendous capabilities. Indeed, the inflection point that occurred with the origin of generative AI methods suggests the rise of the technological singularity and portends the difficulties in predicting the ultimate capabilities of machine intelligences.
Can Obsolescence Be Cured?
Smith J, Fishman EK, Rowe SP, Chu LC, Crawford CK.
J Am Coll Radiol. 2025 Aug 21:S1546-1440(25)00463-6. - As the capabilities of AI grow, it will spark disruption and opportunity across many industries. Now is the time for individuals to prepare for that shift. As it stands, AI is highly effective in large-scale, routine cognitive tasks and is showing potential in generative tasks— threatening not only blue-collar jobs but white-collar jobs as well. Individuals must take the initiative to look outwardly and embrace the key steps to “future-proof” themselves from career obsolescence.
Can Obsolescence Be Cured?
Smith J, Fishman EK, Rowe SP, Chu LC, Crawford CK.
J Am Coll Radiol. 2025 Aug 21:S1546-1440(25)00463-6. - Although the prospect of AI disrupting industries can be daunting, it is important to approach that incipient change with a mind-set of resilience and adaptability. Embracing learning as a lifelong journey will help mitigate the fear of obsolescence and empower individuals to take control of their futures. In essence, those who constantly are leading the charge treat every day as a chance to learn and are proactively searching for new skills, techniques, and ideas. It is essential to use each day to continuously update and hone skills so that when necessary changes come, adapting to those changes is just as easy as routine maintenance. Human-machine collaboration is already transforming industries, so it is vital to identify and focus on areas in which workers can transform, meanwhile embracing the aspects that make us uniquely human, such as creativity, strategy, and cross-domain thinking.
Can Obsolescence Be Cured?
Smith J, Fishman EK, Rowe SP, Chu LC, Crawford CK.
J Am Coll Radiol. 2025 Aug 21:S1546-1440(25)00463-6. - As AI continues to evolve, the role of adaptive radiologists will likely transition from image interpretation to a more strategic position. The radiologist that is truly at the cutting edge will constantly be incorporating traditional and generative AI solutions into their clinical practice to “level themselves up”. Therefore, as labor-intensive processes become more automated, such as reading or dictating, radiologists will need to embrace the role of information managers, being responsible for overseeing AI-driven processes, making critical decisions based on the data provided, and coordinating care across medical teams.
Can Obsolescence Be Cured?
Smith J, Fishman EK, Rowe SP, Chu LC, Crawford CK.
J Am Coll Radiol. 2025 Aug 21:S1546-1440(25)00463-6. - That transition will highlight the growing importance of human expertisein managing AI tools, ensuring that they are used effectively to enhance patient outcomes. Whether AI outperforms the traditional radiologist capabilities in the next 6 months or not for another 20 years, it is important to remain receptive and adaptive as new technology revolutionizes radiology and medicine as a whole.
Can Obsolescence Be Cured?
Smith J, Fishman EK, Rowe SP, Chu LC, Crawford CK.
J Am Coll Radiol. 2025 Aug 21:S1546-1440(25)00463-6.
Adrenal
- Purpose To identify interpretable CT-based radiomics features that can differentiate adrenal pheochromocytomas from adenomas.
Methods An institutional database was used to identify patients with pathologically proven adrenal pheochromocytomas 5/1/05–5/1/23. To be included, patients needed to have a contrast-enhanced abdominal CT with an adrenal mass within 12 months of pathology (n = 95). For comparison, 57 adenomas were identified from a set of consecutive CT examinations. The final dataset included 152 adrenal masses (95 pheochromocytomas; 57 adenomas) with 121 used in the development set and 31 in the test set. Following confirmation of accurate automated segmentation, 463 radiomic features were evaluated and used to create an interpretable artificial intelligence (AI) rule-learning model. Model performance was reported using F1 score.
Conclusion A rule-learning AI model identified the smallest optimal set of interpretable CT radiomics features, sufficient to achieve 96% accuracy in differentiating adrenal pheochromocytomas from adenomas on contrast-enhanced CT.
Using interpretable rule-learning artificial intelligence to optimally differentiate adrenal pheochromocytomas from adenomas with CT radiomics
Daniel I. Glazer · Melissa Viator · Andrew Sharp et al.
Abdominal Radiology (2025) 50:4722–4730 
Using interpretable rule-learning artificial intelligence to optimally differentiate adrenal pheochromocytomas from adenomas with CT radiomics
Daniel I. Glazer · Melissa Viator · Andrew Sharp et al.
Abdominal Radiology (2025) 50:4722–4730- Our study also demonstrates that rule-learning AI validates using attenuation-based thresholds to differentiate adenomas from pheochromocytomas in routine clinical practice, when radiomics data is not available. The attenuation threshold suggested by our AI model (125 HU) is similar to that utilized by Northcutt et al. who found that a threshold of 130 HU could differentiate pheochromocytomas from adenomas with a 100% specificity but 38% sensitivity.
Using interpretable rule-learning artificial intelligence to optimally differentiate adrenal pheochromocytomas from adenomas with CT radiomics
Daniel I. Glazer · Melissa Viator · Andrew Sharp et al.
Abdominal Radiology (2025) 50:4722–4730 - In conclusion, a simple radiomics model utilizing only three features, quantifying grey scale intensity, roundness, and boundary intensity, can differentiate between adrenal pheochromocytomas and adenomas with high (96%) accuracy. The use of this interpretable rule-based model and the clinical features it discovers could be a useful adjunct to biochemical testing or additional diagnostic imaging in most patients.
Using interpretable rule-learning artificial intelligence to optimally differentiate adrenal pheochromocytomas from adenomas with CT radiomics
Daniel I. Glazer · Melissa Viator · Andrew Sharp et al.
Abdominal Radiology (2025) 50:4722–4730 - Future studies would be necessary to determine the performance of the models in a population of patients with incidental adrenal nodules where the prevalence of pheochromocytomas is lower. Fourth, pheochromocytomas were larger and found in younger patients. This could have influenced the results; however size alone was not identified as a significant factor at multivariable analysis.
Using interpretable rule-learning artificial intelligence to optimally differentiate adrenal pheochromocytomas from adenomas with CT radiomics
Daniel I. Glazer · Melissa Viator · Andrew Sharp et al.
Abdominal Radiology (2025) 50:4722–4730
- The most common laboratory findings were low cortisol (51.9%), elevated ACTH (43.2%), hyponatremia (88.2%) and anemia (83.3%). Adrenal cultures were positive in 86.4% cases, with Histoplasma capsulatum (37.3%) being the leading causative agent. Blood cultures were positive in 30% of patients. The majority of the adrenal infections occurred through secondary dissemination from other infectious foci and abscesses were more commonly bilateral (70%). A total of 46.4% of patients developed long-term adrenal insufficiency requiring treatment. Abscess drainage was performed in 7 patients (8.3%) and adrenalectomy was performed in 18 (21.4%) patients. The survival rate was 92.9%.
Adrenal Abscesses: A Systematic Review of the Literature.
Gligorijevic N, et al.
J Clin Med. 2023 Jul 11;12(14):4601. - Our review shows that adrenal abscesses are usually caused by fungal pathogens, and among these, Histoplasma capsulatum is the most common. The adrenal glands are usually involved in a bilateral fashion and become infected through dissemination from other primary sources of infection. Long-term adrenal insufficiency develops in 46% of patients, which is more common than what is observed in non-infectious etiology of adrenal gland disorders. Mortality is about 7%, and the presence of thrombocytopenia is associated with worse prognosis.
Adrenal Abscesses: A Systematic Review of the Literature.
Gligorijevic N, et al.
J Clin Med. 2023 Jul 11;12(14):4601. - The most common CT findings were bilateral diffuse adrenal enlargement, heterogeneously enhancing adrenal lesions, nodular changes and diffuse adrenal thickening with peripheral enhancement. An advantage of using the CT scan in the cases of suspected adrenal involvement was detecting potential intrabdominal and intrathoracic infection dissemination without the need to utilize additional imaging studies.
Adrenal Abscesses: A Systematic Review of the Literature.
Gligorijevic N, et al.
J Clin Med. 2023 Jul 11;12(14):4601.
Chest
- Acute aortic dissection, intramural hematoma, and penetrating aortic ulcer are three distinct entities encompassed by the clinical diagnosis of an acute aortic syndrome. Aortic dissection starts with a tear in the intima, which might be preceded by medial degeneration and followed by separation and lifting of the intima from the media in an antegrade and retrograde manner. This sequence of events creates two (or occasionally more) channels where the blood can flow outside the true lumen of the aorta, and complications arise if the blood flow into the aortic side branches becomes compromised by the dissection.
Management of Acute Type B Aortic Dissection.
Mussa FF, Kougias P.
N Engl J Med. 2025 Sep 4;393(9):895-905. - The incidence rate of sporadic aortic dissection is 3 to 4 cases per 100,000 persons per year.5 The mean age at presentation is 63 years, and men are predominantly affected. There is also a trend toward older age, and among older adults, the incidence among men is similar to that among women. The risk profile for patients with aortic dissection is related to uncontrolled hypertension. Other contributing factors include connective-tissue diseases, genetic aortopathy, smoking, blunt trauma, and use of illicit drugs, such as cocaine or amphetamines. Delayed diagnosis of acute aortic dissection is not uncommon and is associated with female sex, non-White race, previous cardiac surgery, transfer from another center, and normal blood pressure at presentation.
Management of Acute Type B Aortic Dissection.
Mussa FF, Kougias P.
N Engl J Med. 2025 Sep 4;393(9):895-905. - Genetically triggered thoracic aortic disease is a term that encompasses several syndromic and nonsyndromic conditions, including Marfan’s syndrome, the Loeys–Dietz syndrome, vascular Ehlers–Danlos syndrome, and nonsyndromic heritable thoracic aortic disease. Traditionally, TEVAR was considered to be contraindicated in patients with genetically triggered thoracic aortic disease because of arterial-wall fragility, the risk of creating a retrograde type A dissection during or after the procedure, and the high rates of short- and long-term failure. For these reasons, uncomplicated type B aortic dissection in patients with genetically triggered thoracic aortic disease is typically treated conservatively with medical therapy. Complicated type B aortic dissection poses distinct treatment challenges, with open repair favored over endovascular repair.
Management of Acute Type B Aortic Dissection.
Mussa FF, Kougias P.
N Engl J Med. 2025 Sep 4;393(9):895-905. - The open-repair strategy for acute, complicated type B aortic dissection is reserved for patients deemed to be anatomically unsuitable for endovascular repair and those in whom malperfusion persists after TEVAR. In-line or extraanatomical arterial bypass grafts to occluded visceral or extremity vessels are occasionally placed to restore flow and address end-organ ischemia. For patients undergoing extensive open replacement or stent-graft coverage of the aorta (the entire thoracic aorta to the celiac trunk), as well as those who have previously undergone aortic surgery or who have occluded collateral vessels, the targets for postoperative systolic blood pressure are often higher than those for patients without these risk factors.
Management of Acute Type B Aortic Dissection.
Mussa FF, Kougias P.
N Engl J Med. 2025 Sep 4;393(9):895-905.
- Purpose Artificial Intelligence (AI) algorithms in radiology are currently deployed as tools to augment radiologists rather than autonomous readers. An augmentative tool should improve performance above and beyond the baseline performance achieved by the user alone. We conducted a meta-analysis to elucidate the added value of augmentative AI to radiologists for detecting Pulmonary Embolism (PE) on CT scan. Methods Using PRISMA guidelines, studies in which both AI and Human Interpreter (HI) assessed CT scans for pulmonary emboli were selected. Data extracted from these studies were used to compare diagnostic performance of AI and HI with an emphasis on the performance of AI above and beyond that of HI.
Value assessment of augmentative artificial intelligence for assessment of pulmonary emboli on CT - a meta-analysis comprising 15,963 CT scans.
Kitanovski IM, Buetow A, Schoettler-Woll SC, Zafar AM.
Emerg Radiol. 2025 Oct;32(5):731-736.. - Results Both HI and AI performed similarly with no statistically significant difference in the pooled estimates of sensitivity, specificity, PPV, NPV and accuracy. Subsequent analysis focusing on the differences between performance of AI and HI within each study, followed by pooled estimate, also did not demonstrate any significant difference (p < 0.05). Conclusions In a meta-analysis of nearly sixteen thousand CTs, AI and HI had similar performance for detection of pulmonary emboli. On one hand, this buttresses AI’s use for triaging and for second reads. On the other hand, the outcomes may or may not be different when AI is added-on. The findings of this meta-analysis can be used to re-examine the use-scenarios of AI and to re-calibrate its value proposition.
Value assessment of augmentative artificial intelligence for assessment of pulmonary emboli on CT - a meta-analysis comprising 15,963 CT scans.
Kitanovski IM, Buetow A, Schoettler-Woll SC, Zafar AM.
Emerg Radiol. 2025 Oct;32(5):731-736.. - The current meta-analysis including nearly sixteen thousand CT scans did not demonstrate any statistically significant increment or decrement in sensitivity, specificity, PPV, NPV or accuracy when studies were assessed for PE by AI and HI. Except for specificity, the pooled estimates of all diagnostic metrices were very similar for AI and HI. If the clinical question was limited to presence or absence of pulmonary arterial emboli, the current meta-analysis suggests that AI could replace HI. However, CT scan performed for PE is also meant to assess for a number of additional disease entities including but not limited to pneumonia, pulmonary edema, lung masses, pleural effusions, pneumothorax, pericardial effusion, and fractures. All of these disease entities require assessment by an HI. This means that, currently, AI can only be deployed as an augmentative tool.
Value assessment of augmentative artificial intelligence for assessment of pulmonary emboli on CT - a meta-analysis comprising 15,963 CT scans.
Kitanovski IM, Buetow A, Schoettler-Woll SC, Zafar AM.
Emerg Radiol. 2025 Oct;32(5):731-736..
Colon
- Stercoral colitis is an inflammatory reaction secondary to fecal impaction and almost always occurs in the setting of chronic constipation. Luminal distention caused by dense and dehydrated stool compresses the vascular supply of the distal colon, resulting in bowel ischemia and ulceration. Stercoral colitis primarily affects elderly patients, but it can be seen in any patient with decreased bowel motility, with risk factors including neurodegenerative disorders, chronic medical diseases, malignancy, immobility, and the use of narcotic or anticholinergic medications.
Stercoral Colitis: Review of Imaging Features and Complications.
Karkala N, Mathai B, Hines JJ Jr, Byun S, Katz DS.
Radiographics. 2025 Apr;45(4):e240085. - The overlap of findings between stercoral colitis and other colonic diseases, particularly diverticulitis and malignancy, can sometimes make diagnosis challenging. Identification of fecal impaction and associated inflammatory changes helps in distinguishing stercoral colitis from other pathologic conditions. Prompt diagnosis of stercoral colitis and its complications allows appropriate management, which can range from preventive measures to emergent surgical treatment.
Stercoral Colitis: Review of Imaging Features and Complications.
Karkala N, Mathai B, Hines JJ Jr, Byun S, Katz DS.
Radiographics. 2025 Apr;45(4):e240085. - Stercoral Colitis: Facts
The short segment of the colon between the branches of the inferior mesenteric and superior rectal arteries, known as the Sudeck point,marks the junction of the rectum and sigmoid colon. This region is a watershed territory with a relatively reduced blood supply and is susceptible to ischemia. - Stercoral Colitis: Facts
The pathophysiology of stercoral colitis is primarily driven by bowel-wall ischemia caused by luminal stool impaction. CT is the primary imaging modality to aid in diagnosing stercoral colitis and its potential complications. Identification of fecal impaction is essential for diagnosis. Inflammatory changes such as wall thickening and fat stranding typically are associated with the area affected by fecal impaction - The pathophysiology of stercoral colitis is primarily driven by bowel wall ischemia caused by luminal stool impaction. impacted fecal material in the colon causes compression of the colonic vasculature due to increased pressure on the wall. This results in ischemic injury and can lead to necrosis,ulceration, and colonic wall perforation in a stepwise fashion.
Stercoral Colitis: Review of Imaging Features and Complications.
Karkala N, Mathai B, Hines JJ Jr, Byun S, Katz DS.
Radiographics. 2025 Apr;45(4):e240085. - On CT images, stool typically has a “soap bubble” appearance. In stercoral colitis, inspissated stool forms hard masses known as fecalomas. These fecalomas are more dense compared with normal stool and often contain calcifications or have a laminated appearance. The impacted stool collects in the affected colon and rectum, resulting in the characteristic fecal loading observed in stercoral colitis. Distention of the rectal diameter beyond 6–6.5 cm is generally considered abnormal, but this should be compared with that of the proximal portions of the colon.
Stercoral Colitis: Review of Imaging Features and Complications.
Karkala N, Mathai B, Hines JJ Jr, Byun S, Katz DS.
Radiographics. 2025 Apr;45(4):e240085. - Extramural findings are associated with complications and are usually manifestations of ischemia leading to perforation. Stercoral perforation is associated with a mortality rate of 32%–59% due to extraluminal spillage of feces and the often rapid onset of feculent peritonitis . CT is particularly useful in the identification of direct sites of transmural injury or secondary signs of perforation, including mural discontinuity, extraluminal air, and perirectal fluid collection or abscess. . Extraluminal gas is easily identifiable on noncontrast CT images, but mural discontinuity may not be evident.
Stercoral Colitis: Review of Imaging Features and Complications.
Karkala N, Mathai B, Hines JJ Jr, Byun S, Katz DS.
Radiographics. 2025 Apr;45(4):e240085. - Perirectal inflammatory changes favor stercoral colitis, as diverticula rarely form in the rectum. Perforated diverticulitis can resemble the extraluminal stool observed in perforated stercoral colitis, especially in cases in which a large diverticulum ruptures. However, the absence of colonic distention typically associated with fecal impaction favors diverticulitis as the likely underlying cause. Furthermore, stercoral ulcers and perforation sites commonly occur at multiple locations, in contrast to diverticulitis.
Stercoral Colitis: Review of Imaging Features and Complications.
Karkala N, Mathai B, Hines JJ Jr, Byun S, Katz DS.
Radiographics. 2025 Apr;45(4):e240085. - Stercoral colitis is essentially a form of ischemic colitis that is precipitated by chronic constipation. Although stercoral colitis is considered to be relatively rare in the literature, the authors believe this may be related to underdiagnosis due to nonspecific clinical presentations and overlap with other inflammatory bowel disorders. Stercoral colitis primarily affects the elderly, but the diagnosis should be considered in any patient with decreased bowel motility and appropriate imaging findings. CT is the standard modality for diagnosis, allowing accurate identification of characteristic findings as well as potential complications. Awareness of this condition and its findings allows appropriate management, ranging from supportive measures to surgical treatment.
Stercoral Colitis: Review of Imaging Features and Complications.
Karkala N, Mathai B, Hines JJ Jr, Byun S, Katz DS.
Radiographics. 2025 Apr;45(4):e240085. 
Stercoral Colitis: Review of Imaging Features and Complications.
Karkala N, Mathai B, Hines JJ Jr, Byun S, Katz DS.
Radiographics. 2025 Apr;45(4):e240085.
Deep Learning
- With the rise of artificial intelligence (AI), we are now beginning to see another shift in which jobs and industries will face disruption by highly efficient, highly sophisticated intelligent systems that possess tremendous capabilities. Indeed, the inflection point that occurred with the origin of generative AI methods suggests the rise of the technological singularity and portends the difficulties in predicting the ultimate capabilities of machine intelligences.
Can Obsolescence Be Cured?
Smith J, Fishman EK, Rowe SP, Chu LC, Crawford CK.
J Am Coll Radiol. 2025 Aug 21:S1546-1440(25)00463-6. - As the capabilities of AI grow, it will spark disruption and opportunity across many industries. Now is the time for individuals to prepare for that shift. As it stands, AI is highly effective in large-scale, routine cognitive tasks and is showing potential in generative tasks— threatening not only blue-collar jobs but white-collar jobs as well. Individuals must take the initiative to look outwardly and embrace the key steps to “future-proof” themselves from career obsolescence.
Can Obsolescence Be Cured?
Smith J, Fishman EK, Rowe SP, Chu LC, Crawford CK.
J Am Coll Radiol. 2025 Aug 21:S1546-1440(25)00463-6. - Although the prospect of AI disrupting industries can be daunting, it is important to approach that incipient change with a mind-set of resilience and adaptability. Embracing learning as a lifelong journey will help mitigate the fear of obsolescence and empower individuals to take control of their futures. In essence, those who constantly are leading the charge treat every day as a chance to learn and are proactively searching for new skills, techniques, and ideas. It is essential to use each day to continuously update and hone skills so that when necessary changes come, adapting to those changes is just as easy as routine maintenance. Human-machine collaboration is already transforming industries, so it is vital to identify and focus on areas in which workers can transform, meanwhile embracing the aspects that make us uniquely human, such as creativity, strategy, and cross-domain thinking.
Can Obsolescence Be Cured?
Smith J, Fishman EK, Rowe SP, Chu LC, Crawford CK.
J Am Coll Radiol. 2025 Aug 21:S1546-1440(25)00463-6. - As AI continues to evolve, the role of adaptive radiologists will likely transition from image interpretation to a more strategic position. The radiologist that is truly at the cutting edge will constantly be incorporating traditional and generative AI solutions into their clinical practice to “level themselves up”. Therefore, as labor-intensive processes become more automated, such as reading or dictating, radiologists will need to embrace the role of information managers, being responsible for overseeing AI-driven processes, making critical decisions based on the data provided, and coordinating care across medical teams.
Can Obsolescence Be Cured?
Smith J, Fishman EK, Rowe SP, Chu LC, Crawford CK.
J Am Coll Radiol. 2025 Aug 21:S1546-1440(25)00463-6. - That transition will highlight the growing importance of human expertisein managing AI tools, ensuring that they are used effectively to enhance patient outcomes. Whether AI outperforms the traditional radiologist capabilities in the next 6 months or not for another 20 years, it is important to remain receptive and adaptive as new technology revolutionizes radiology and medicine as a whole.
Can Obsolescence Be Cured?
Smith J, Fishman EK, Rowe SP, Chu LC, Crawford CK.
J Am Coll Radiol. 2025 Aug 21:S1546-1440(25)00463-6.
- Radiology and pathology have traditionally operated in silos, each with distinct workflows and expertise. Merging these disciplines requires a cultural shift toward interdisciplinary collaboration, mutual respect, and shared clinical goals. This transformation can foster a new generation of diagnosticians trained to integrate imaging and tissue analysis, enhancing diagnostic accuracy and clinical relevance. E pluribus unum: The Diagnostician
Will Artificial Intelligence prompt a merger of radiology and pathology into one specialty
Sala E, Goyen M
European Journal of Radiology Artificial Intelligence 4(2025) 100045 - In our view, AI is not a replacement for human expertise but a powerful augmentation. The future diagnostician will be a hybrid professional equipped to interpret imaging, analyze tissue, understand molecular signatures, and apply AI-driven insights to clinical care. Achieving this vision, however, demands systemic change, new training programs, redefined roles, and a reimagined healthcare infrastructure. The merger of radiology and pathology into a unified specialty is not just a technological possibility, it is a clinical necessity. It promises to improve diagnostic precision, accelerate treatment planning, and support the development of personalized therapies. Yet, realizing this vision requires overcoming challenges in data integration, interdisciplinary collaboration, infrastructure development, and ethical governance. E pluribus unum: The Diagnostician
Will Artificial Intelligence prompt a merger of radiology and pathology into one specialty
Sala E, Goyen M
European Journal of Radiology Artificial Intelligence 4(2025) 100045
- Purpose Artificial Intelligence (AI) algorithms in radiology are currently deployed as tools to augment radiologists rather than autonomous readers. An augmentative tool should improve performance above and beyond the baseline performance achieved by the user alone. We conducted a meta-analysis to elucidate the added value of augmentative AI to radiologists for detecting Pulmonary Embolism (PE) on CT scan.
Methods Using PRISMA guidelines, studies in which both AI and Human Interpreter (HI) assessed CT scans for pulmonary emboli were selected. Data extracted from these studies were used to compare diagnostic performance of AI and HI with an emphasis on the performance of AI above and beyond that of HI.
Value assessment of augmentative artificial intelligence for assessment of pulmonary emboli on CT - a meta-analysis comprising 15,963 CT scans.
Kitanovski IM, Buetow A, Schoettler-Woll SC, Zafar AM.
Emerg Radiol. 2025 Oct;32(5):731-736.. - Results Both HI and AI performed similarly with no statistically significant difference in the pooled estimates of sensitivity, specificity, PPV, NPV and accuracy. Subsequent analysis focusing on the differences between performance of AI and HI within each study, followed by pooled estimate, also did not demonstrate any significant difference (p < 0.05).
Conclusions In a meta-analysis of nearly sixteen thousand CTs, AI and HI had similar performance for detection of pulmonary emboli. On one hand, this buttresses AI’s use for triaging and for second reads. On the other hand, the outcomes may or may not be different when AI is added-on. The findings of this meta-analysis can be used to re-examine the use-scenarios of AI and to re-calibrate its value proposition.
Value assessment of augmentative artificial intelligence for assessment of pulmonary emboli on CT - a meta-analysis comprising 15,963 CT scans.
Kitanovski IM, Buetow A, Schoettler-Woll SC, Zafar AM.
Emerg Radiol. 2025 Oct;32(5):731-736.. - The current meta-analysis including nearly sixteen thousand CT scans did not demonstrate any statistically significant increment or decrement in sensitivity, specificity, PPV, NPV or accuracy when studies were assessed for PE by AI and HI. Except for specificity, the pooled estimates of all diagnostic metrices were very similar for AI and HI. If the clinical question was limited to presence or absence of pulmonary arterial emboli, the current meta-analysis suggests that AI could replace HI. However, CT scan performed for PE is also meant to assess for a number of additional disease entities including but not limited to pneumonia, pulmonary edema, lung masses, pleural effusions, pneumothorax, pericardial effusion, and fractures. All of these disease entities require assessment by an HI. This means that, currently, AI can only be deployed as an augmentative tool.
Value assessment of augmentative artificial intelligence for assessment of pulmonary emboli on CT - a meta-analysis comprising 15,963 CT scans.
Kitanovski IM, Buetow A, Schoettler-Woll SC, Zafar AM.
Emerg Radiol. 2025 Oct;32(5):731-736.. - Artificial Intelligence (AI) is a transformative force that is reshaping the very foundations of diagnostic medicine. As AI-driven technologies increasingly blur the boundaries between image interpretation and tissue analysis, the rationale for maintaining radiology and pathology as separate specialties becomes less compelling. A merger into a unified specialty - diagnostic medicine - could offer new opportunities for synergy, enabling clinicians to deliver more accurate, timely, and personalized care. This paper argues that the convergence of radiology and pathology is not only a likely development but also important for the future of precision medicine. The integration of imaging, histopathology, and molecular diagnostics will support a new generation of diagnosticians equipped to navigate complex data landscapes and guide clinical decision-making with deeper insight. E pluribus unum: The Diagnostician
Will Artificial Intelligence prompt a merger of radiology and pathology into one specialty
Sala E, Goyen M
European Journal of Radiology Artificial Intelligence 4(2025) 100045
- Background This study aimed to preoperatively predict Ki-67 proliferation levels in patients with pancreatic solid pseudopapillary neoplasm (pSPN) using radiomics features extracted from arterial phase helical CT images.
Results Seven key radiomics features were selected via LASSO regression with cross-validation. The deep learning model demonstrated improved accuracy with demographics and CTscore, with key features such as Morphology and CTscore contributing significantly to predictive accuracy. The best-performing models, including GBM and deep learning algorithms, achieved high predictive performance with an AUC of up to 0.946 in the training cohort.
Conclusions We developed a robust deep learning-based radiomics model using arterial phase CT images to predict Ki-67 levels in pSPN patients, identifying CTscore and Morphology as key predictors. This non-invasive approach has potential utility in guiding personalized preoperative treatment strategies.
Arterial phase CT radiomics for non-invasive prediction of Ki-67 proliferation index in pancreatic solid pseudopapillary neoplasms.
Liu J, Wu H, Ren D, et al.
Abdom Radiol (NY). 2025Oct;50(10):4635-4645. 
Arterial phase CT radiomics for non-invasive prediction of Ki-67 proliferation index in pancreatic solid pseudopapillary neoplasms.
Liu J, Wu H, Ren D, et al.
Abdom Radiol (NY). 2025Oct;50(10):4635-4645.
Arterial phase CT radiomics for non-invasive prediction of Ki-67 proliferation index in pancreatic solid pseudopapillary neoplasms.
Liu J, Wu H, Ren D, et al.
Abdom Radiol (NY). 2025Oct;50(10):4635-4645.- This study highlights the potential of interpretable machine learning and radiomic analysis in developing a non-invasive predictive model for preoperative Ki-67 assessment in pSPN. By leveraging arterial phase CT radiomics, our model enables patient stratification based on tumor proliferation potential, aiding surgical planning and postoperative surveillance. Preoperative Ki-67 assessment may help identify high-risk tumors, informing decisions on surgical extent, imaging strategies, and follow-up protocols.
Arterial phase CT radiomics for non-invasive prediction of Ki-67 proliferation index in pancreatic solid pseudopapillary neoplasms.
Liu J, Wu H, Ren D, et al.
Abdom Radiol (NY). 2025Oct;50(10):4635-4645. - While multi-center validation is needed, these findings underscore the role of radiomics-driven artificial intelligence in precision oncology. Continued advancements in deep learning and multi-modal imaging could further refine predictive models, enhancing risk stratification, treatment optimization, and patient outcomes in pancreatic neoplasms and beyond.
Arterial phase CT radiomics for non-invasive prediction of Ki-67 proliferation index in pancreatic solid pseudopapillary neoplasms.
Liu J, Wu H, Ren D, et al.
Abdom Radiol (NY). 2025Oct;50(10):4635-4645.
Pancreas
- Background This study aimed to preoperatively predict Ki-67 proliferation levels in patients with pancreatic solid pseudopapillary neoplasm (pSPN) using radiomics features extracted from arterial phase helical CT images.
Results Seven key radiomics features were selected via LASSO regression with cross-validation. The deep learning model demonstrated improved accuracy with demographics and CTscore, with key features such as Morphology and CTscore contributing significantly to predictive accuracy. The best-performing models, including GBM and deep learning algorithms, achieved high predictive performance with an AUC of up to 0.946 in the training cohort.
Conclusions We developed a robust deep learning-based radiomics model using arterial phase CT images to predict Ki-67 levels in pSPN patients, identifying CTscore and Morphology as key predictors. This non-invasive approach has potential utility in guiding personalized preoperative treatment strategies.
Arterial phase CT radiomics for non-invasive prediction of Ki-67 proliferation index in pancreatic solid pseudopapillary neoplasms.
Liu J, Wu H, Ren D, et al.
Abdom Radiol (NY). 2025Oct;50(10):4635-4645.
Arterial phase CT radiomics for non-invasive prediction of Ki-67 proliferation index in pancreatic solid pseudopapillary neoplasms.
Liu J, Wu H, Ren D, et al.
Abdom Radiol (NY). 2025Oct;50(10):4635-4645.
Arterial phase CT radiomics for non-invasive prediction of Ki-67 proliferation index in pancreatic solid pseudopapillary neoplasms.
Liu J, Wu H, Ren D, et al.
Abdom Radiol (NY). 2025Oct;50(10):4635-4645.- This study highlights the potential of interpretable machine learning and radiomic analysis in developing a non-invasive predictive model for preoperative Ki-67 assessment in pSPN. By leveraging arterial phase CT radiomics, our model enables patient stratification based on tumor proliferation potential, aiding surgical planning and postoperative surveillance. Preoperative Ki-67 assessment may help identify high-risk tumors, informing decisions on surgical extent, imaging strategies, and follow-up protocols.
Arterial phase CT radiomics for non-invasive prediction of Ki-67 proliferation index in pancreatic solid pseudopapillary neoplasms.
Liu J, Wu H, Ren D, et al.
Abdom Radiol (NY). 2025Oct;50(10):4635-4645. - While multi-center validation is needed, these findings underscore the role of radiomics-driven artificial intelligence in precision oncology. Continued advancements in deep learning and multi-modal imaging could further refine predictive models, enhancing risk stratification, treatment optimization, and patient outcomes in pancreatic neoplasms and beyond.
Arterial phase CT radiomics for non-invasive prediction of Ki-67 proliferation index in pancreatic solid pseudopapillary neoplasms.
Liu J, Wu H, Ren D, et al.
Abdom Radiol (NY). 2025Oct;50(10):4635-4645.
Small Bowel
- The severity of arterial vascular narrowing (ie, >70% stenosis, complete occlusion) and pneumatosis intestinalis are predictors of transmural necrosis. Bowel dilatation and extreme bowel wall thinning with an imperceptible paper-thin appearance are predictive of transmural necrosis and related to irreversible injury to the deep muscle layers and myenteric plexus. Wall thinning is 38% sensitive and 98% specific for transmural necrosis. Bowel dilatation is more common in arterial occlusion than in venous occlusion or NOMI; importantly, bowel dilatation should be recognized as a predictor of transmural bowel necrosis in arterial occlusive AMI, not misinterpreted as simple ileus.
Acute Mesenteric Ischemia: Pathophysiology-based Approach to Imaging Findings and Diagnosis.
Lee MH, Pickhardt PJ, Sorensen AM, et al.
Radiographics. 2025 Oct;45(10):e250012. doi: 10.1148/rg.250012. PMID: 40996899. 
- “Decreased or absent bowel wall enhancement (diagnostic odds ratio [DOR] = 8.2, P = .00) and bowel dilatation (DOR = 3.1, P = .00) are statistically significant predictors of transmural necrosis in venous AMI. Decreased or absent wall enhancement reflects cessation of arterial flow related to later-stage ischemia. Importantly, the degree of wall thickening and extraintestinal findings do not correlate with the severity of ischemic bowel injury.”
Acute Mesenteric Ischemia: Pathophysiology-based Approach to Imaging Findings and Diagnosis.
Lee MH, Pickhardt PJ, Sorensen AM, et al.
Radiographics. 2025 Oct;45(10):e250012. doi: 10.1148/rg.250012. PMID: 40996899. - In patients with NOMI, CT features associated with transmural necrosis were absent wall enhancement (P < .001), wall thinning (P < .001), bowel dilatation (P = .041), pneumatosis (P = .003), mesenteric gas (P = .005), and portal venous gas (P = .002). Using clinical and imaging findings associated with irreversible transmural necrosis, Calame et al identified four predictive factors—absent bowel enhancement, bowel thinning, plasma bicarbonate concentration of 15 mmol/L or less, and prothrombin rate less than 40%—to devise a system for risk stratification whereby 88% and100% of patients with three or four of these features, respectively, had irreversible transmural bowel necrosis.
Acute Mesenteric Ischemia: Pathophysiology-based Approach to Imaging Findings and Diagnosis.
Lee MH, Pickhardt PJ, Sorensen AM, et al.
Radiographics. 2025 Oct;45(10):e250012. doi: 10.1148/rg.250012. PMID: 40996899. - Mesenteric ischemia occurs when blood flow is insufficient to meet the metabolic demands of bowel. The causal mechanisms of AMI can be distilled into four basic underlying causes: inadequate inflow (eg, arterial occlusion), inadequate outflow (eg, mesenteric venous occlusion), global hypoperfusion (eg, nonocclusive mesenteric ischemia [NOMI]), and strangulating bowel obstruction. Practically speaking, the first three flow-related causes are primary causes of AMI, whereas strangulating bowel obstruction can be thought of as secondary AMI. A confident understanding of the relationships between the arterial and mesenteric vasculature, vascular territories, and bowel is foundational to understanding the pathophysiology and imaging features of the different forms of AMI.
Acute Mesenteric Ischemia: Pathophysiology-based Approach to Imaging Findings and Diagnosis.
Lee MH, Pickhardt PJ, Sorensen AM, et al.
Radiographics. 2025 Oct;45(10):e250012. doi: 10.1148/rg.250012. PMID: 40996899. - There are no specific laboratory measures or serum biomarkers for diagnosing early, potentially reversible AMI in routine clinical practice. Levels of conventional serologic markers such as serum lactate are elevated late in the disease course after transmural infarction and the serum lactate level is often normal early, which may be misleading and harmful because normal lactate level is an independent predictor of delayed AMI diagnosis.
Acute Mesenteric Ischemia: Pathophysiology-based Approach to Imaging Findings and Diagnosis.
Lee MH, Pickhardt PJ, Sorensen AM, et al.
Radiographics. 2025 Oct;45(10):e250012. doi: 10.1148/rg.250012. PMID: 40996899. - Treatment paradigms for AMI depend on the underlying cause and severity of bowel ischemia, requiring a multidisciplinary approach . Although beyond the scope of this review, the treatment aims in AMI are to (a) restore compromised blood flow to the bowel and (b) resect nonviable segments of bowel while preserving as much functional bowel as possible. Typically, arterial embolism or thrombosis is treated with endovascular or open thrombectomy (14); NOMI with supportive care, catheter-directed mesenteric artery papaverineinjection, and anticoagulation; mesenteric venous thrombosis with anticoagulation; and strangulated bowel obstruction with operative management and resection of nonviable bowel.
Acute Mesenteric Ischemia: Pathophysiology-based Approach to Imaging Findings and Diagnosis.
Lee MH, Pickhardt PJ, Sorensen AM, et al.
Radiographics. 2025 Oct;45(10):e250012. doi: 10.1148/rg.250012. PMID: 40996899. - A systematic interpretive approach to AMI based on underlying Pathophysiology is imperative . Assessing the vasculature for the presence or absence of clot (ie, embolus or thrombosis) is the first crucial step to distinguish the type of AMI. If clot is identified in the SMA or SMV and there are no findings of strangulating bowel obstruction, the diagnosis of arterial or mesenteric venous occlusive AMI can be established. If there is no clot, the diagnosis of NOMI, occult clot, or small-vessel ischemia is possible. Next, assessment proceeds with bowel and extraintestinal findings to determine the distribution, extent, and severity of end-organ injury. Of course, the approach is flexible and bidirectional between the steps, since bowel and extraintestinal findings may be most conspicuous.
Acute Mesenteric Ischemia: Pathophysiology-based Approach to Imaging Findings and Diagnosis.
Lee MH, Pickhardt PJ, Sorensen AM, et al.
Radiographics. 2025 Oct;45(10):e250012. doi: 10.1148/rg.250012. PMID: 40996899. - Arterial embolism is the most common cause of primary AMI overall, accounting for the majority of arterial occlusive AMI cases. Arterial emboli are typically located several centimeters beyond the SMA origin but can involve any part of the SMA , with classic pathognomonic sparing of the proximal SMA and middle colic arterial branch. The SMA is susceptible due to its angulation from the aorta, and emboli typically lodge 3–15 cm from the SMA origin. Patients tend to be younger and have underlying cardiac disease such as ischemic heart disease or atrial fibrillation. Less common causes include emboli from endocarditis, valvular disease, or aortic atheroma.
Acute Mesenteric Ischemia: Pathophysiology-based Approach to Imaging Findings and Diagnosis.
Lee MH, Pickhardt PJ, Sorensen AM, et al.
Radiographics. 2025 Oct;45(10):e250012. doi: 10.1148/rg.250012. PMID: 40996899. - Importantly, 20%–68% of patients will have synchronous emboli involving other organs . An accurate description of the precise location of arterial occlusion is imperative for treatment planning purposes in the setting of arterial embolism. In a recent retrospective review of original reports in 39 patients with arterial occlusive AMI, the location of occlusion was not mentioned in 62%, incorrect in 13%, incomplete in 8%, and appropriate in 18% .
Acute Mesenteric Ischemia: Pathophysiology-based Approach to Imaging Findings and Diagnosis.
Lee MH, Pickhardt PJ, Sorensen AM, et al.
Radiographics. 2025 Oct;45(10):e250012. doi: 10.1148/rg.250012. PMID: 40996899. - Decreased bowel wall enhancement is the hallmark feature of bowel ischemia in arterial occlusive AMI, with reported specificity of 97%–99%. Diminished or absent wall enhancement and thinning are specific to arterial causes of AMI not seen in venous causes. In early arterial occlusion, diminished wall enhancement is known as pale ischemia. Most of the time, ischemia is segmental and there are discrete transitions between ischemic and nonischemic bowel, which can be difficult to recognize unless one is aware and vigilant. Comparing suspected ischemic segments to adjacent normal loops can help to confidently identify decreased enhancement ..
Acute Mesenteric Ischemia: Pathophysiology-based Approach to Imaging Findings and Diagnosis.
Lee MH, Pickhardt PJ, Sorensen AM, et al.
Radiographics. 2025 Oct;45(10):e250012. doi: 10.1148/rg.250012. PMID: 40996899. - Mesenteric venous occlusion, namely mesenteric venous thrombosis (MVT), accounts for 5%–20% of AMI cases . MVT typically occurs in younger patients who present with acute abdominal pain; acute MVT is symptomatic in about 90% of patients. MVT often results from a combination of hypercoagulability, endothelial injury, and venous stasis related to local or systemic processes. Risk factors include underlying hypercoagulable states. The typical manifestation is different from that of arterial occlusive AMI; symptoms are more gradual and develop over days to weeks.
Acute Mesenteric Ischemia: Pathophysiology-based Approach to Imaging Findings and Diagnosis.
Lee MH, Pickhardt PJ, Sorensen AM, et al.
Radiographics. 2025 Oct;45(10):e250012. doi: 10.1148/rg.250012. PMID: 40996899. - The authors of this article have shown how to contextualize imaging findings of AMI through a pathophysiology- rather than semiology-based approach emphasizing the imaging features predictive of transmural necrosis, which are different based on the underlying cause of AMI and are important for establishing a critical diagnosis and informing prognosis. The sentiment that AMI encompasses processes for which the “diagnosis is impossible, the prognosis hopeless, and the treatment useless”—expressed by Cokkinis nearly a hundred years ago—reverberates today, with undoubted room for improvement, although the authors hope that this work will empower interpreting radiologists with interpretive skills to make an important diagnosis and point toward a more hopeful future.
Acute Mesenteric Ischemia: Pathophysiology-based Approach to Imaging Findings and Diagnosis.
Lee MH, Pickhardt PJ, Sorensen AM, et al.
Radiographics. 2025 Oct;45(10):e250012. doi: 10.1148/rg.250012. PMID: 40996899.
- “Tyrosine kinase inhibitors are a form of targeted therapy, and they have unique adverse effects. Tyrosine kinase inhibitor–related intestinal lymphangiectasia has a significantly higher incidence in younger patients and those receiving multitarget tyrosine kinase inhibitors (eg, pazopanib, sunitinib, cabozantinib) as opposed to single-target tyrosine kinase inhibitors (eg, afatinib, osimertinib) . Tyrosine kinase inhibitor–related lymphangiectasia most commonly involves the small bowel (71.4%), followed by the large bowel (42.9%). Appearance of submucosal fat attenuation is attributed to dilated lymphatic channels containing low-density chylous fluid.”
Tyrosine Kinase Inhibitor-related Intestinal Lymphangiectasia.
Awiwi MO, Naik S.
Radiology. 2022 Nov;305(2):294. - Tyrosine Kinase Inhibitor Related Lymphangiectasia
A condition characterized by lymphatic vessel dilation due to tyrosine kinase inhibitors (TKIs).
Often associated with cancer treatments that inhibit tyrosine kinase activity.
Symptoms may include protein-losing enteropathy, edema, and gastrointestinal issues.
Spleen
- ”Spontaneous or atraumatic rupture of the spleen is an uncommon but potentially fatal abdominal emergency, often overshadowed by trauma-related etiologies. However, a wide range of infectious, neoplastic, vascular, autoimmune, and iatrogenic conditions can predispose the spleen to rupture without direct trauma. Multidetector computed tomography (MDCT) is the preferred modality for evaluating these cases, offering rapid, high-resolution assessment of hemorrhage—with or without active bleeding—and associated parenchymal abnormalities. This pictorial review highlights the diverse spectrum of underlying causes and characteristic imaging findings through 13 cases. It also outlines CT acquisition protocols, postprocessing techniques, and key clinical features that radiologists must be aware of to reach timely diagnoses and guide management. Early recognition and identification of the underlying pathology are critical in improving patient outcomes and directing appropriate interventions. ”
CT of spontaneous atraumatic splenic rupture: etiologies and imaging findings.
Yasrab M, Rahmatullah ZF, Chu LC, Kawamoto S, Fishman EK
Emerg Radiol. 2025 Sep 30. doi: 10.1007/s10140-025-02383-w. Epub ahead of print. - Epidemiologically, only 7% of atraumatic splenic ruptures are idiopathic, while the rest are due to one or more underlying etiological factors that include neoplastic processes, inflammatory or autoimmune disorders, viral infections, and hematological conditions. Patients typically present with vague to sharp abdominal pain and tenderness, nausea and vomiting, referred left shoulder pain (Kehr’s sign) that is seen in up to half of all patients, drop in hemoglobin, and sudden hemodynamic instability and shock in cases of more severe bleeding. The presence of splenomegaly, which has been seen in up to 55% of patients with atraumatic splenic rupture, and age above 40 are significantly associated with a higher mortality rate.
CT of spontaneous atraumatic splenic rupture: etiologies and imaging findings.
Yasrab M, Rahmatullah ZF, Chu LC, Kawamoto S, Fishman EK
Emerg Radiol. 2025 Sep 30. doi: 10.1007/s10140-025-02383-w. Epub ahead of print. - Infectious disorders are the second most common cause of pathologic atraumatic splenic rupture, following neoplastic processes that we will discuss below. Infectious mononucleosis is a common cause of splenomegaly, occurring nearly all cases of infectious mononucleosis, typically caused by Ebstein Barr Virus (EBV) and cytomegalovirus (CMV). The incidence of splenic rupture in infectious mononucleosis ranges between 0.1%−0.5%, and over 85% of ruptures occur in the absence of any explicit trauma or injury . Other infections that rarely result in splenic hemorrhage or rupture include varicella zoster virus (VZV), CMV, dengue virus, malaria, babesia, and bacterial infections like tuberculosis, brucellosis, salmonella typhi, and tularemia.
CT of spontaneous atraumatic splenic rupture: etiologies and imaging findings.
Yasrab M, Rahmatullah ZF, Chu LC, Kawamoto S, Fishman EK
Emerg Radiol. 2025 Sep 30. doi: 10.1007/s10140-025-02383-w. Epub ahead of print. - Aneurysms and pseudoaneurysms of the splenic artery make up nearly 70% of all visceral aneurysms. True aneurysms are most commonly idiopathic, but associated causes include portal hypertension, chronic liver disease, atherosclerosis, and acute or chronic pancreatitis. Atypical intraparenchymal pseudoaneurysms, which tend to be more saccular in morphology, are less frequent and almost always secondary to an underlying cause, commonly pancreatitis, iatrogenic injury, or infection. They pose a particularly high risk of rupture (up to 37%) and are nearly always fatal when untreated.
CT of spontaneous atraumatic splenic rupture: etiologies and imaging findings.
Yasrab M, Rahmatullah ZF, Chu LC, Kawamoto S, Fishman EK
Emerg Radiol. 2025 Sep 30. doi: 10.1007/s10140-025-02383-w. Epub ahead of print. - Malignant hematologic disorders are the most common cause of spontaneous splenic rupture, including acute myelogenous leukemia (AML), acute lymphoblastic leukemia (ALL), chronic myeloid leukemia (CML), lymphoma (discussed in the next section), myeloproliferative disorders such as polycythemia vera or myelofibrosis, and myelodysplastic syndromes. The presence of splenomegaly and age above 40 are significantly associated with increased mortality when ruptured . While the pathophysiology remains unclear, infiltrative processes and infarction are thought to be responsible for spontaneous splenic rupture. Apart from an enlarged spleen, sites of splenic infarcts and perisplenic fluid collections can be appreciated in cases of spontaneous splenic rupture.
CT of spontaneous atraumatic splenic rupture: etiologies and imaging findings.
Yasrab M, Rahmatullah ZF, Chu LC, Kawamoto S, Fishman EK
Emerg Radiol. 2025 Sep 30. doi: 10.1007/s10140-025-02383-w. Epub ahead of print. - Malignant masses can be primary or metastatic lesions. Lymphoid neoplasms are the most common primary malignant splenic neoplasms, including Hodgkin and non-Hodgkin lymphoma subtypes. They often present as part of systemic disease commonly with associated adenopathy, and rarely as primary site of disease (less than 2% of all lymphomas). CT findings range from homogenous splenomegaly to solitary or multiple nodules or masses. Splenomegaly is present in two-thirds of patients and the lesions are frequently hypoenhancing. Another major primary splenic malignancy is angiosarcoma. Primary angiosarcomas of the spleen are rare (less than 5% of all angiosarcomas) and present as single or multiple complex masses or nodules with irregular borders in the background of splenomegaly.
CT of spontaneous atraumatic splenic rupture: etiologies and imaging findings.
Yasrab M, Rahmatullah ZF, Chu LC, Kawamoto S, Fishman EK
Emerg Radiol. 2025 Sep 30. doi: 10.1007/s10140-025-02383-w. Epub ahead of print. - Splenic Rupture: Background
Splenic rupture, a rare but life-threatening condition, leads to internal bleeding and acute abdominal distress.
Pathologic Ruptures: Arise from underlying splenic disease. (93%)
Infections
Inflammatory or autoimmune disorders
Vascular abnormalities
Hematological abnormalities and thromboembolism
Benign lesions
Neoplastic processes
Idiopathic Ruptures: No identifiable cause. (7%) - Background
Clinical Signs and Symptoms:
Abdominal Pain and Tenderness: Vague or sharp.
Kehr's Sign: Referred left shoulder pain (present in ~50% of patients).
Nausea and vomiting.
Hemodynamic instability and shock (in severe bleeding).
Drop in hemoglobin.
Associated Risk Factors:
Presence of splenomegaly (55% of cases).
Age > 40 years, linked to higher mortality rates. - Splenic Rupture :Utility of CT Imaging
Contrast enhanced CT imaging gold standard for diagnosis:
Provides detailed evaluation of:
- Splenic parenchyma (e.g., hematomas, infarcts, hyperdensity).
- Active bleeding and extravasation of contrast.
- Associated complications (e.g., hemoperitoneum, splenomegaly).
Rapid acquisition for emergency presentations
Widely accessible
High spatial resolution
Arterial, venous, delayed phase acquisition
Ability for post-processing (e.g. 3D cinematic rendering) - Splenic Rupture : Infectious Causes
Epstein–Barr virus (EBV) or cytomegalovirus (CMV) most common.
Other Viral: Varicella zoster virus (VZV), dengue virus.
Parasitic: Malaria, babesia.
Bacterial: Tuberculosis, brucellosis, salmonella typhi, tularemia.
Pathophysiology:
Involves splenic sequestration, splenomegaly, hemorrhage, ± abscess or hematoma formation.
Abscesses may appear as centrally low-density lesions with possible peripheral enhancement (if encapsulated). - Splenic Rupture: Other Inflammatory Causes
Acute or chronic pancreatitis-associated rupture. Direct extension of peripancreatic inflammation to the spleen.
Vasculitis-associated rupture (polyarteritis nodosa, granulomatosis with polyangiitis). Involve splenic vessels, increasing hemorrhage risk.
Autoimmune diseases (systemic lupus erythematosus, rheumatoid arthritis, and Behçet disease). - Splenic Rupture Vascular Causes
True Aneurysms of Splenic Artery:
Most commonly idiopathic.
Associated causes: portal hypertension, chronic liver disease, atherosclerosis, acute/chronic pancreatitis.
Pseudoaneurysms of Splenic Artery:
Less common and typically saccular in morphology.
Nearly always secondary to underlying causes: pancreatitis, iatrogenic injury, or infection.
Significantly higher risk of rupture (up to 37%) and often fatal without treatment. - Splenic Rupture: Vascular Causes
Connective Tissue Disorders: Ehlers-Danlos, Marfan syndrome → Increased rupture risk; rare fibromuscular dysplasia cases.
Hypercoagulability: From malignancy/pancreatitis → Vessel occlusion, infarction, rupture.
Emboli: Endocarditis or atrial fibrillation → Infarcts, hemorrhaging, mycotic pseudoaneurysms.
Medications: Anticoagulants (e.g., apixaban, rivaroxaban) → Higher risk of atraumatic bleeding. - Splenic Rupture: Benign Masses
Hemangiomas: Most common benign splenic neoplasm (seen in up to 14% of autopsies). Risk of rupture in up to 25%. Imaging: Persistent homogeneous enhancement, or early peripheral enhancement with delayed fill-in.
Splenic Hamartomas: Contour abnormalities, fat deposition, calcifications, cystic changes.
Epidermoid and Mesothelial Cysts: Hypoattenuating, fluid-filled, well-circumscribed lesions with possible calcifications and no enhancement. - Splenic Rupture: Malignant Causes
Hematologic Malignancies:
Acute myelogenous leukemia (AML), acute lymphoblastic leukemia (ALL), chronic myeloid leukemia (CML), lymphoma, polycythemia vera, myelofibrosis, and myelodysplastic syndromes.
Primary Malignant Splenic Neoplasms:
Lymphoid Neoplasms (e.g., Hodgkin and non-Hodgkin lymphoma). Presents with homogenous splenomegaly, solitary/multiple nodules or masses, hypoenhancing lesions.
Angiosarcoma: presents as heterogeneously enhancing masses with necrotic or hemorrhagic areas; highly aggressive. - Splenic Rupture: Metastatic Lesions
Common Primary Cancers
- Lung
- Melanoma
- Breast
- Ovarian
- GI malignancies.
Features: Solitary or multiple hypoenhancing lesions, cystic or necrotic components.
Complications: Bleeding, rupture, vessel occlusion, infarcts.
Vascular
- Acute aortic dissection, intramural hematoma, and penetrating aortic ulcer are three distinct entities encompassed by the clinical diagnosis of an acute aortic syndrome. Aortic dissection starts with a tear in the intima, which might be preceded by medial degeneration and followed by separation and lifting of the intima from the media in an antegrade and retrograde manner. This sequence of events creates two (or occasionally more) channels where the blood can flow outside the true lumen of the aorta, and complications arise if the blood flow into the aortic side branches becomes compromised by the dissection.
Management of Acute Type B Aortic Dissection.
Mussa FF, Kougias P.
N Engl J Med. 2025 Sep 4;393(9):895-905. - The incidence rate of sporadic aortic dissection is 3 to 4 cases per 100,000 persons per year.5 The mean age at presentation is 63 years, and men are predominantly affected. There is also a trend toward older age, and among older adults, the incidence among men is similar to that among women. The risk profile for patients with aortic dissection is related to uncontrolled hypertension. Other contributing factors include connective-tissue diseases, genetic aortopathy, smoking, blunt trauma, and use of illicit drugs, such as cocaine or amphetamines. Delayed diagnosis of acute aortic dissection is not uncommon and is associated with female sex, non-White race, previous cardiac surgery, transfer from another center, and normal blood pressure at presentation.
Management of Acute Type B Aortic Dissection.
Mussa FF, Kougias P.
N Engl J Med. 2025 Sep 4;393(9):895-905. - Genetically triggered thoracic aortic disease is a term that encompasses several syndromic and nonsyndromic conditions, including Marfan’s syndrome, the Loeys–Dietz syndrome, vascular Ehlers–Danlos syndrome, and nonsyndromic heritable thoracic aortic disease. Traditionally, TEVAR was considered to be contraindicated in patients with genetically triggered thoracic aortic disease because of arterial-wall fragility, the risk of creating a retrograde type A dissection during or after the procedure, and the high rates of short- and long-term failure. For these reasons, uncomplicated type B aortic dissection in patients with genetically triggered thoracic aortic disease is typically treated conservatively with medical therapy. Complicated type B aortic dissection poses distinct treatment challenges, with open repair favored over endovascular repair.
Management of Acute Type B Aortic Dissection.
Mussa FF, Kougias P.
N Engl J Med. 2025 Sep 4;393(9):895-905. - The open-repair strategy for acute, complicated type B aortic dissection is reserved for patients deemed to be anatomically unsuitable for endovascular repair and those in whom malperfusion persists after TEVAR. In-line or extraanatomical arterial bypass grafts to occluded visceral or extremity vessels are occasionally placed to restore flow and address end-organ ischemia. For patients undergoing extensive open replacement or stent-graft coverage of the aorta (the entire thoracic aorta to the celiac trunk), as well as those who have previously undergone aortic surgery or who have occluded collateral vessels, the targets for postoperative systolic blood pressure are often higher than those for patients without these risk factors.
Management of Acute Type B Aortic Dissection.
Mussa FF, Kougias P.
N Engl J Med. 2025 Sep 4;393(9):895-905.
- The severity of arterial vascular narrowing (ie, >70% stenosis, complete occlusion) and pneumatosis intestinalis are predictors of transmural necrosis. Bowel dilatation and extreme bowel wall thinning with an imperceptible paper-thin appearance are predictive of transmural necrosis and related to irreversible injury to the deep muscle layers and myenteric plexus. Wall thinning is 38% sensitive and 98% specific for transmural necrosis. Bowel dilatation is more common in arterial occlusion than in venous occlusion or NOMI; importantly, bowel dilatation should be recognized as a predictor of transmural bowel necrosis in arterial occlusive AMI, not misinterpreted as simple ileus.
Acute Mesenteric Ischemia: Pathophysiology-based Approach to Imaging Findings and Diagnosis.
Lee MH, Pickhardt PJ, Sorensen AM, et al.
Radiographics. 2025 Oct;45(10):e250012. doi: 10.1148/rg.250012. PMID: 40996899. - “Decreased or absent bowel wall enhancement (diagnostic odds ratio [DOR] = 8.2, P = .00) and bowel dilatation (DOR = 3.1, P = .00) are statistically significant predictors of transmural necrosis in venous AMI. Decreased or absent wall enhancement reflects cessation of arterial flow related to later-stage ischemia. Importantly, the degree of wall thickening and extraintestinal findings do not correlate with the severity of ischemic bowel injury.”
Acute Mesenteric Ischemia: Pathophysiology-based Approach to Imaging Findings and Diagnosis.
Lee MH, Pickhardt PJ, Sorensen AM, et al.
Radiographics. 2025 Oct;45(10):e250012. doi: 10.1148/rg.250012. PMID: 40996899. - In patients with NOMI, CT features associated with transmural necrosis were absent wall enhancement (P < .001), wall thinning (P < .001), bowel dilatation (P = .041), pneumatosis (P = .003), mesenteric gas (P = .005), and portal venous gas (P = .002). Using clinical and imaging findings associated with irreversible transmural necrosis, Calame et al identified four predictive factors—absent bowel enhancement, bowel thinning, plasma bicarbonate concentration of 15 mmol/L or less, and prothrombin rate less than 40%—to devise a system for risk stratification whereby 88% and100% of patients with three or four of these features, respectively, had irreversible transmural bowel necrosis.
Acute Mesenteric Ischemia: Pathophysiology-based Approach to Imaging Findings and Diagnosis.
Lee MH, Pickhardt PJ, Sorensen AM, et al.
Radiographics. 2025 Oct;45(10):e250012. doi: 10.1148/rg.250012. PMID: 40996899. - Mesenteric ischemia occurs when blood flow is insufficient to meet the metabolic demands of bowel. The causal mechanisms of AMI can be distilled into four basic underlying causes: inadequate inflow (eg, arterial occlusion), inadequate outflow (eg, mesenteric venous occlusion), global hypoperfusion (eg, nonocclusive mesenteric ischemia [NOMI]), and strangulating bowel obstruction. Practically speaking, the first three flow-related causes are primary causes of AMI, whereas strangulating bowel obstruction can be thought of as secondary AMI. A confident understanding of the relationships between the arterial and mesenteric vasculature, vascular territories, and bowel is foundational to understanding the pathophysiology and imaging features of the different forms of AMI.
Acute Mesenteric Ischemia: Pathophysiology-based Approach to Imaging Findings and Diagnosis.
Lee MH, Pickhardt PJ, Sorensen AM, et al.
Radiographics. 2025 Oct;45(10):e250012. doi: 10.1148/rg.250012. PMID: 40996899. - There are no specific laboratory measures or serum biomarkers for diagnosing early, potentially reversible AMI in routine clinical practice. Levels of conventional serologic markers such as serum lactate are elevated late in the disease course after transmural infarction and the serum lactate level is often normal early, which may be misleading and harmful because normal lactate level is an independent predictor of delayed AMI diagnosis.
Acute Mesenteric Ischemia: Pathophysiology-based Approach to Imaging Findings and Diagnosis.
Lee MH, Pickhardt PJ, Sorensen AM, et al.
Radiographics. 2025 Oct;45(10):e250012. doi: 10.1148/rg.250012. PMID: 40996899. - Treatment paradigms for AMI depend on the underlying cause and severity of bowel ischemia, requiring a multidisciplinary approach . Although beyond the scope of this review, the treatment aims in AMI are to (a) restore compromised blood flow to the bowel and (b) resect nonviable segments of bowel while preserving as much functional bowel as possible. Typically, arterial embolism or thrombosis is treated with endovascular or open thrombectomy (14); NOMI with supportive care, catheter-directed mesenteric artery papaverineinjection, and anticoagulation; mesenteric venous thrombosis with anticoagulation; and strangulated bowel obstruction with operative management and resection of nonviable bowel.
Acute Mesenteric Ischemia: Pathophysiology-based Approach to Imaging Findings and Diagnosis.
Lee MH, Pickhardt PJ, Sorensen AM, et al.
Radiographics. 2025 Oct;45(10):e250012. doi: 10.1148/rg.250012. PMID: 40996899. - A systematic interpretive approach to AMI based on underlying Pathophysiology is imperative . Assessing the vasculature for the presence or absence of clot (ie, embolus or thrombosis) is the first crucial step to distinguish the type of AMI. If clot is identified in the SMA or SMV and there are no findings of strangulating bowel obstruction, the diagnosis of arterial or mesenteric venous occlusive AMI can be established. If there is no clot, the diagnosis of NOMI, occult clot, or small-vessel ischemia is possible. Next, assessment proceeds with bowel and extraintestinal findings to determine the distribution, extent, and severity of end-organ injury. Of course, the approach is flexible and bidirectional between the steps, since bowel and extraintestinal findings may be most conspicuous.
Acute Mesenteric Ischemia: Pathophysiology-based Approach to Imaging Findings and Diagnosis.
Lee MH, Pickhardt PJ, Sorensen AM, et al.
Radiographics. 2025 Oct;45(10):e250012. doi: 10.1148/rg.250012. PMID: 40996899. - Arterial embolism is the most common cause of primary AMI overall, accounting for the majority of arterial occlusive AMI cases. Arterial emboli are typically located several centimeters beyond the SMA origin but can involve any part of the SMA , with classic pathognomonic sparing of the proximal SMA and middle colic arterial branch. The SMA is susceptible due to its angulation from the aorta, and emboli typically lodge 3–15 cm from the SMA origin. Patients tend to be younger and have underlying cardiac disease such as ischemic heart disease or atrial fibrillation. Less common causes include emboli from endocarditis, valvular disease, or aortic atheroma.
Acute Mesenteric Ischemia: Pathophysiology-based Approach to Imaging Findings and Diagnosis.
Lee MH, Pickhardt PJ, Sorensen AM, et al.
Radiographics. 2025 Oct;45(10):e250012. doi: 10.1148/rg.250012. PMID: 40996899. - Importantly, 20%–68% of patients will have synchronous emboli involving other organs . An accurate description of the precise location of arterial occlusion is imperative for treatment planning purposes in the setting of arterial embolism. In a recent retrospective review of original reports in 39 patients with arterial occlusive AMI, the location of occlusion was not mentioned in 62%, incorrect in 13%, incomplete in 8%, and appropriate in 18% .
Acute Mesenteric Ischemia: Pathophysiology-based Approach to Imaging Findings and Diagnosis.
Lee MH, Pickhardt PJ, Sorensen AM, et al.
Radiographics. 2025 Oct;45(10):e250012. doi: 10.1148/rg.250012. PMID: 40996899. - Decreased bowel wall enhancement is the hallmark feature of bowel ischemia in arterial occlusive AMI, with reported specificity of 97%–99%. Diminished or absent wall enhancement and thinning are specific to arterial causes of AMI not seen in venous causes. In early arterial occlusion, diminished wall enhancement is known as pale ischemia. Most of the time, ischemia is segmental and there are discrete transitions between ischemic and nonischemic bowel, which can be difficult to recognize unless one is aware and vigilant. Comparing suspected ischemic segments to adjacent normal loops can help to confidently identify decreased enhancement ..
Acute Mesenteric Ischemia: Pathophysiology-based Approach to Imaging Findings and Diagnosis.
Lee MH, Pickhardt PJ, Sorensen AM, et al.
Radiographics. 2025 Oct;45(10):e250012. doi: 10.1148/rg.250012. PMID: 40996899. - Mesenteric venous occlusion, namely mesenteric venous thrombosis (MVT), accounts for 5%–20% of AMI cases . MVT typically occurs in younger patients who present with acute abdominal pain; acute MVT is symptomatic in about 90% of patients. MVT often results from a combination of hypercoagulability, endothelial injury, and venous stasis related to local or systemic processes. Risk factors include underlying hypercoagulable states. The typical manifestation is different from that of arterial occlusive AMI; symptoms are more gradual and develop over days to weeks.
Acute Mesenteric Ischemia: Pathophysiology-based Approach to Imaging Findings and Diagnosis.
Lee MH, Pickhardt PJ, Sorensen AM, et al.
Radiographics. 2025 Oct;45(10):e250012. doi: 10.1148/rg.250012. PMID: 40996899. - The authors of this article have shown how to contextualize imaging findings of AMI through a pathophysiology- rather than semiology-based approach emphasizing the imaging features predictive of transmural necrosis, which are different based on the underlying cause of AMI and are important for establishing a critical diagnosis and informing prognosis. The sentiment that AMI encompasses processes for which the “diagnosis is impossible, the prognosis hopeless, and the treatment useless”—expressed by Cokkinis nearly a hundred years ago—reverberates today, with undoubted room for improvement, although the authors hope that this work will empower interpreting radiologists with interpretive skills to make an important diagnosis and point toward a more hopeful future.
Acute Mesenteric Ischemia: Pathophysiology-based Approach to Imaging Findings and Diagnosis.
Lee MH, Pickhardt PJ, Sorensen AM, et al.
Radiographics. 2025 Oct;45(10):e250012. doi: 10.1148/rg.250012. PMID: 40996899.