A 23-Year-Old female at First-Trimester Ultrasound. Diagnosis? • Xray of the Week Figure 1. Transabdominal first-trimester pelvic ultrasound. 23-year-old patient presenting with vaginal bleeding: Diagnosis? Figure 2. A. Magnified sagittal-plane view of the cystic structure shows a thin, complete outer wall (red arrow) and an internal septation (yellow arrow) crossing the cyst; ultrasound calipers measure 1.6 x 1.2 cm. Fetal pole (green arrow) is seen with the cystic structure (yellow arrow) immediately dorsal to it, at the craniocervical junction (blue arrow). B. Calipers placed across the dorsal nuchal region measure an additional, smaller 0.5 cm focus, in keeping with a markedly thickened/septated nuchal translucency. Note the midline septum representing the nuchal ligament (white arrow). Epidemiology Fetal cystic hygroma is identified in approximately 1 in 285 pregnancies undergoing first trimester nuchal translucency screening, with an estimated overall prenatal prevalence of 0.2-3%. It is far less common as a postnatal diagnosis, with an incidence at birth of only about 1 in 6000, since most affected pregnancies end in miscarriage, intrauterine fetal death, or elective termination (1). A chromosomal abnormality is identified in roughly half of prenatally detected cases overall, most commonly monosomy X (Turner syndrome), trisomy 21, trisomy 18, and triploidy (2,3). Clinical Manifestations Cystic hygroma is usually an incidental finding on first- or early second-trimester sonography, typically identified as a markedly increased and septated nuchal translucency. Severe lymphatic obstruction may progress to nonimmune hydrops fetalis, with generalized skin edema, pleural or pericardial effusion, and ascites, a combination associated with a markedly worse outcome. If it persists after birth, it can present as a soft, compressible, transilluminant neck mass (1). Pathology Cystic hygroma is a macrocystic lymphatic malformation resulting from failure of the paired jugular lymphatic sacs to establish normal communication with the internal jugular veins and the remainder of the venous system during the fifth to ninth week of gestation. The resulting obstruction causes progressive dilation of the sequestered sacs, producing thin-walled, multiloculated cystic spaces filled with proteinaceous lymphatic fluid within the posterior soft tissues of the fetal neck. Histologically, the cyst walls are lined by a single layer of flattened endothelium with scant surrounding stroma (1). Classification Cystic hygromas are classified sonographically as septated or nonseptated, a distinction with direct prognostic importance. The nonseptated form is a simple, markedly thickened nuchal translucency without an internal dividing line. The septated form, as in this case, shows a midline septum representing the nuchal ligament, flanked by paired symmetric cystic spaces. This distinction carries prognostic weight: in one comparative series, septated lesions had a 72% aneuploidy rate, a 40% rate of hydrops, and only a 12% livebirth rate, compared with 5.7%, under 2%, and 94%, respectively, for nonseptated lesions (3). Pathologically, lymphatic malformations are further categorized by cyst size as macrocystic (individual cysts greater than 2 cm), microcystic (less than 2 cm), or mixed. Radiographic Features On prenatal ultrasound, cystic hygroma appears as a thin-walled, anechoic to hypoechoic cystic structure in the soft tissues dorsal to the fetal craniocervical junction, frequently traversed by one or more internal septa (Figures 1-2) (4). Caliper measurements are used to document lesion size and to distinguish it from a simple increased nuchal translucency. Color Doppler characteristically shows no internal flow. Postnatally, MRI is the modality of choice for defining the full extent and its relationship to adjacent neurovascular structures before surgical planning. Treatment and Prognosis Once identified, cystic hygroma warrants karyotype, microarray testing (chorionic villus sampling or amniocentesis), a detailed fetal anatomic and cardiac survey, and serial sonographic surveillance for hydrops. Prognosis is governed chiefly by septation status, karyotype, and the presence of hydrops (5,6); pregnancies reaching the second trimester without these adverse features generally do well. Postnatally, a persistent or isolated lymphatic malformation is managed with intralesional sclerotherapy as first-line treatment, with surgery reserved for lesions that fail sclerotherapy, recur, or threaten the airway; an ex utero intrapartum treatment (EXIT) procedure may be needed when a large lesion is expected to obstruct the airway at delivery (7). Conclusion Fetal cystic hygroma is an important early sonographic marker of aneuploidy and adverse pregnancy outcome. Its recognition should prompt genetic counseling, karyotype testing, and close sonographic follow-up. References: Rangel V, Having K. Cystic Hygroma. J Diagn Med Sonogr. 2008;24(4):218-222. DOI: https://doi.org/10.1177/8756479308319969 Malone FD, Ball RH, Nyberg DA, et al. First-trimester septated cystic hygroma: prevalence, natural history, and pediatric outcome. Obstet Gynecol. 2005;106(2):288-294. DOI: 10.1097/01.AOG.0000173318.54978.1f Bronshtein M, Bar-Hava I, Blumenfeld I, Bejar J, Toder V, Blumenfeld Z. The difference between septated and nonseptated nuchal cystic hygroma in the early second trimester. Obstet Gynecol. 1993;81(5 ( Pt 1)):683-687. https://pubmed.ncbi.nlm.nih.gov/8469454/ Sepúlveda WH, Ciuffardi I. Early sonographic diagnosis of fetal cystic hygroma colli. J Perinat Med. 1992;20(2):149-152. DOI: 10.1515/jpme.1992.20.2.149 Chen HY, Zheng JQ, Zhang HP. A case report of Turner syndrome associated with fetal nuchal cystic hygroma and bilateral syndactyly of the hands and feet. Ital J Pediatr. 2019;45(1):85. Published 2019 Jul 18. DOI: 10.1186/s13052-019-0680-4 Rosati P, Guariglia L. Transvaginal ultrasound detection of septated and non-septated cystic hygroma in early pregnancy. Fetal Diagn Ther. 1997;12(3):132-135. DOI: 10.1159/000264452 Gowda M, Godipelli L, Gangadhar L, Jindal B, Deodar K, Yadav M. Management of isolated fetal lymphangiomas following prenatal diagnosis: case series. J Fetal Med. 2021;8(1):39-43. DOI: https://doi.org/10.1007/s40556-021-00288-5 Umaiza Ihsan, MD is a medical graduate of King Edward Medical University, Pakistan. She completed her internship at Mayo Hospital, Lahore, including a three- month rotation in Radiology, which further strengthened her interest in diagnostic imaging. She has gained additional clinical exposure in Radiology through observerships at Mon Health Morgantown and the University of Maryland, Baltimore. She has a strong interest in Radiology, particularly diagnostic imaging and its role in clinical decision-making, and is actively interested in clinical research, with experience in systematic reviews and medical research. Kevin M. Rice, MD is the president of Global Radiology CME and is a radiologist with Cape Radiology Group. He has held several leadership positions including Board Member and Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator by AuntMinnie.com. He has continued to teach by mentoring medical students interested in radiology. Everyone who he has mentored has been accepted into top programs across the country including Harvard, UC San Diego, Northwestern, Vanderbilt, and Thomas Jefferson. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

Adolescent with Chronic Neck Pain and Suboccipital Discomfort: Diagnosis? • Xray of the Week Figure 1. CT images of the cervical spine (A) sagittal view and (B) coronal view. What is the important finding on this CT scan? Figure 2. A. Sagittal CT shows a small, round, well-corticated ossicle (yellow arrow) representing the os odontoideum separated from the underlying body of C2 (green arrow). Note the smooth, radiolucent gap between the body of C2 and the os odontoideum (red arrow). Also note the thickening and abnormal rounding of the anterior arch of C1 (blue arrow). B. Coronal CT section again demonstrates the well-corticated ossicle representing the os odontoideum (yellow arrow) positioned symmetrically between the lateral masses of C1 (blue arrows) and separated from the underlying body of C2 (green arrow). C. Axial CT through the ring of C1 shows the os odontoideum (yellow arrow) situated just posterior to the anterior arch of C1 (blue arrow). Note the thickening and abnormal rounding of the anterior arch of C1 (blue arrow). Feature Os Odontoideum Chronic Fracture Dens (Nonunion) Ossicle Margins Smooth, distinct, and completely well-corticated. Often irregular, sclerotic, but lack a uniform smooth outer cortex of an independent ossicle. Gap / Interface Wide, smooth, radiolucent gap with corticated margins on both opposing surfaces. Jagged or sharply angulated lucent cleft matching the original fracture line (typically Type II base). Morphology of Dens Hypoplastic, foreshortened, or round/oval ossicle located superiorly. Normal height/shape of the residual dens base, matching the displaced fragment size. C1 (Atlas) Remodeling Frequently shows hypertrophy and rounding of the anterior arch. Anterior arch of C1 is usually normal in morphology unless secondary degenerative changes exist. Location of Gap Typically well above the superior articulating facets of C2. Typically at the base of the dens (classic Type II location). Clinical Context May be an unrecognized childhood injury or congenital variant; highly prone to atlantoaxial instability. Known prior acute trauma history with documented failure of bony union. Table 1. Differentiating Os odontoideum from a chronic nonunited Type 2 dens fracture on a CT scan relies on margin characteristics, gap appearance, and associated bony remodeling as summarized here. Epidemiology Os odontoideum is a rare anomaly of the craniocervical junction. Its true prevalence and incidence are unknown, since most cases are discovered incidentally or only after symptoms develop; reported prevalence on adult imaging series is well under 1%. Diagnosis spans a wide age range, from early childhood through late adulthood, although many patients present within the first three decades of life. An increased frequency has been reported in patients with Down syndrome, spondyloepiphyseal dysplasia, Morquio syndrome, and other skeletal dysplasias, supporting a multifactorial rather than a single unifying etiology (1,2). Clinical Findings Many cases are asymptomatic and are identified incidentally on imaging obtained for unrelated indications. When symptomatic, neck pain is the most common complaint, followed by mechanical or intermittent neurologic symptoms related to atlantoaxial instability, including myelopathy, transient quadriparesis after minor trauma, and vertebrobasilar symptoms such as vertigo or syncope from vertebral artery compromise. Because an unstable ossicle may be tolerated for years before a seemingly trivial injury precipitates catastrophic cord compression, even an incidentally detected os odontoideum warrants further clinical and radiographic evaluation (3,4). Pathology The etiology of os odontoideum remains debated. The congenital theory attributes the anomaly to failure of fusion between the odontoid process and the body of the axis at the subdental synchondrosis. Growing evidence instead favors an acquired origin: an unrecognized fracture through the odontoid synchondrosis before ossification is complete (roughly before 5-6 years of age), with subsequent avascular remodeling of the separated fragment into a smooth, independently corticated ossicle (5). Both mechanisms likely contribute in different patients. Because the transverse atlantal ligament inserts on the mobile ossicle rather than on a fixed dens, it is rendered ineffective at restraining atlantoaxial translation. Classification Os odontoideum is divided into two types based on the position of the ossicle relative to the atlas and clivus. In the orthotopic type, the more common pattern, the ossicle lies in the normal anatomic position of the odontoid tip and moves together with the anterior arch of C1. In the dystopic type, the ossicle is displaced, most often superiorly, and may fuse to the basion/clivus, moving with the occiput rather than the atlas; this pattern is more frequently associated with instability and neurologic injury (6). Radiographic Features CT best depicts the bony morphology of os odontoideum and is the modality of choice for surgical planning. The ossicle appears round-to-oval, roughly half the size of a normal dens, with a smooth and completely corticated margin. It is separated from the hypoplastic dens/axis body by a wide, smooth, radiolucent gap located above the level of the superior articular facets of C2 (Figures 1-2). Compensatory hypertrophy and rounding of the anterior arch of C1 is a recognized associated finding. Dynamic flexion-extension radiographs or CT, together with MRI, are used to quantify atlantoaxial instability and to assess for cord compression or signal change (6,7). Differentiating os odontoideum from a chronic nonunited (Type II) dens fracture on CT relies on margin characteristics, gap appearance, and associated bony remodeling (Table 1). Treatment and Prognosis Management depends on symptoms and the degree of instability rather than on the mere presence of the ossicle. Asymptomatic patients without instability on flexion-extension imaging can be managed with observation and serial radiographic surveillance. Operative posterior C1-C2 fusion is favored for patients with neurologic deficits, myelopathy, or significant instability, given the risk of delayed neurologic deterioration, which has been documented even after a period of apparent clinical stability (7). Fusion rates and symptomatic improvement after surgery are high, although the timing of surgery in asymptomatic patients remains controversial. Conclusion Os odontoideum is an important, often incidental, cause of atlantoaxial instability that must be reliably distinguished from a chronic ununited dens fracture, as the two entities carry different implications for surveillance and treatment. Recognizing the smooth, corticated ossicle, the wide suprafacetal gap, and the hypertrophied anterior arch of C1 on CT allows a confident diagnosis and appropriate management, helping to avert neurologic catastrophe. References: Fielding JW, Hensinger RN, Hawkins RJ. Os Odontoideum. J Bone Joint Surg Am. 1980;62(3):376-383. https://pubmed.ncbi.nlm.nih.gov/7364809/ Sankar WN, Wills BP, Dormans JP, Drummond DS. Os odontoideum revisited: the case for a multifactorial etiology. Spine (Phila Pa 1976). 2006;31(9):979-984. DOI: 10.1097/01.brs.0000214935.70868.1c Fagan AB, Askin GN, Earwaker JW. The jigsaw sign. A reliable indicator of congenital aetiology in os odontoideum. Eur Spine J. 2004;13(4):295-300. DOI: 10.1007/s00586-004-0732-2 Klimo P Jr, Kan P, Rao G, Apfelbaum R, Brockmeyer D. Os odontoideum: presentation, diagnosis, and treatment in a series of 78 patients. J Neurosurg Spine. 2008;9(4):332-342. DOI: 10.3171/SPI.2008.9.10.332 Cho S, Shlobin NA, Dahdaleh NS. Os odontoideum: A comprehensive review. J Craniovertebr Junction Spine. 2022;13(3):256-264.DOI: 10.4103/jcvjs.jcvjs_71_22 Nelson C, Mujahed T, Tedford NJ. Adolescent male with neck pain. J Am Coll Emerg Physicians Open. 2024;5(3):e13222. Published 2024 Jun 16.DOI: 10.1002/emp2.13222 Menezes AH. Os odontoideum: database analysis of 260 patients regarding etiology, associated abnormalities, and literature review. Front Surg. 2023;10:1291056. Published 2023 Dec 5. DOI: 10.3389/fsurg.2023.12910561 Umaiza Ihsan, MD is a medical graduate of King Edward Medical University, Pakistan. She completed her internship at Mayo Hospital, Lahore, including a three- month rotation in Radiology, which further strengthened her interest in diagnostic imaging. She has gained additional clinical exposure in Radiology through observerships at Mon Health Morgantown and the University of Maryland, Baltimore. She has a strong interest in Radiology, particularly diagnostic imaging and its role in clinical decision-making, and is actively interested in clinical research, with experience in systematic reviews and medical research. Kevin M. Rice, MD is the president of Global Radiology CME and is a radiologist with Cape Radiology Group. He has held several leadership positions including Board Member and Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator by AuntMinnie.com. He has continued to teach by mentoring medical students interested in radiology. Everyone who he has mentored has been accepted into top programs across the country including Harvard, UC San Diego, Northwestern, Vanderbilt, and Thomas Jefferson. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

61-year-old male with abdominal pain 15 days after capsule endoscopy. • Xray of the Week Figure 1. What are the important findings in this case. Figure 2. Frontal abdomen radiograph demonstrates foreign body consistent with capsule endoscopy device (pill cam) in descending colon. Capsule Retention and Risk Factors: Capsule endoscopy is used for evaluating small-bowel disorders, such as bleeds and Crohn disease.[1] This diagnostic procedure involves swallowing a pill-sized camera that records thousands of images of the alimentary canal including the small intestine, an area difficult to examine via traditional endoscopy. Retention of the camera-containing capsule is the main complication of capsule endoscopy. Traditionally, capsule retention (CR) is defined as the presence of a capsule in the digestive tract for a minimum of 2 weeks. Approximately 2% of all capsule endoscopies result in CR [2] The clinical indication for capsule endoscopy is correlated with different rates of CR. Retention rates for patients post-capsule endoscopy for chronic diarrhea or abdominal pain is approximately 2%.[3] For patients with a greater likelihood of small bowel strictures, retention rates increase to 13%.[4] The highest CR rates of 10-20% are in patients being evaluated for subacute small bowel obstructions.[5,6] Capsule retention can be often be prevented by assessment of functional patency with a Patency Capsule. Use of high-dose non-steroidal anti-inflammatory drugs, previous abdominal radiation therapy, and history of small bowel restrictions generally increase the risk of CR post-capsule endoscopy.[2] Figure 3. Capsule endoscopy camera​ (pill cam) on CT Scan in a different patient. A and B: Coronal Images. C: Axial Image. ​ Imaging: In asymptomatic patients, plain abdominal x-ray 15-days following capsule ingestion is the preferred confirmation imaging of CR (Figs. 1,2). If capsule endoscopy findings suggest potential CR, then performing an abdominal x-ray 7-days post-capsule ingestion is advisable, since most capsules are excreted within 3-7 days. Capsules that reach the cecum generally are secreted as cases of colonic CR accounting for less than 1% of all retention [7]. Computed tomography (CT) could be used to determine the capsule’s location if it is difficult to do so via x-ray (Fig. 3). Treatment: Asymptomatic patients are monitored initially, given that 35-50% of patients with CR naturally excrete the capsule after more than 15 days.[8,9] Surgical or device-assisted enteroscopy retrieval of the capsule is indicated for asymptomatic patients 3-6 months following capsule ingestion. For patients with inflammatory bowel disease, the use of steroids has been shown to assist the excretion of capsules in up to 20-30% of all CR cases.[2] Importance of Prompt Management: Patients with missed CR could develop bowel obstruction and perforation.[2] Disintegration of the capsule could expose the camera’s lithium battery to the digestive tract, increasing the risk of mucosal damage. Identifying and managing CR is important to prevent avoidable gastrointestinal complications. ​​​​ References: 1. Lee HS, Lim YJ, Kim KO, et al. Outcomes and Management Strategies for Capsule Retention: A Korean Capsule Endoscopy Nationwide Database Registry Study. Dig Dis Sci. 2019;64(11):3240-3246. doi:10.1007/s10620-019-05659-7 2. Rondonotti E. Capsule retention: prevention, diagnosis and management. Ann Transl Med. 2017;5(9):198. doi:10.21037/atm.2017.03.15 3. Rezapour M, Amadi C, Gerson LB. Retention associated with video capsule endoscopy: systematic review and meta-analysis. Gastrointest Endosc. 2017;85(6):1157-1168.e2. doi:10.1016/j.gie.2016.12.024 4. Cheifetz AS, Lewis BS. Capsule endoscopy retention: is it a complication? J Clin Gastroenterol. 2006;40(8):688-691. doi:10.1097/00004836-200609000-00005 5. Cheifetz AS, Sachar DB, Lewis BS. Small Bowel Obstruction — Indication or Contraindication for Capsule Endoscopy. Gastrointest Endosc. 2004;59(5):P102. doi:10.1016/S0016-5107(04)00509-7 6. Yang XY, Chen CX, Zhang BL, et al. Diagnostic effect of capsule endoscopy in 31 cases of subacute small bowel obstruction. World J Gastroenterol. 2009;15(19):2401-2405. doi:10.3748/wjg.15.2401 7. Sachdev MS, Leighton JA, Fleischer DE, et al. A prospective study of the utility of abdominal radiographs after capsule endoscopy for the diagnosis of capsule retention. Gastrointest Endosc. 2007;66(5):894-900. doi:10.1016/j.gie.2007.06.066 8. Fernández-Urién I, Carretero C, González B, et al. Incidence, clinical outcomes, and therapeutic approaches of capsule endoscopy-related adverse events in a large study population. Rev Esp Enferm Dig. 2015;107(12):745-752. doi:10.17235/reed.2015.3820/2015 9. Rondonotti E, Soncini M, Girelli C, et al. Small bowel capsule endoscopy in clinical practice: a multicenter 7-year survey. Eur J Gastroenterol Hepatol. 2010;22(11):1380-1386. doi:10.1097/MEG.0b013e3283352ced Eric Errampalli is a passionate medical student at the University of Missouri – Kansas City Six-Year BA/MD Program, with a steadfast commitment to becoming a radiologist. His fascination with the field stems from its integral role in healthcare and the endless possibilities for technological advancements waiting to be made. At UMKC, Eric has made significant contributions to the Radiology Interest Group, serving in various executive roles and currently as the interventional radiology chair. His leadership has inspired his peers to explore the field and discover the boundless opportunities for growth and impact. Beyond UMKC, Eric's interests have risen to a national level, as he serves on the Society of Interventional Radiology Medical Student Council Education Committee and TheRadRoom IR Team. Through these platforms, he has been instrumental in shaping the future of interventional radiology education and promoting awareness of the field among medical students. Eric's passion for innovation extends beyond the classroom, as he strives to help drive change in the field of radiology through his medical entrepreneurial ventures. He believes that entrepreneurship can unlock untapped potential in the field and pave the way for transformative breakthroughs that can improve patient outcomes and revolutionize healthcare. To stay up to date on Eric's journey and learn more about his work, follow Eric on Twitter @EricErrampalli and connect with him on LinkedIn www.linkedin.com/in/eric-errampalli/ All posts by Eric Errampalli Kevin M. Rice, MD is the president of Global Radiology CME and is a radiologist with Cape Radiology Group. He has held several leadership positions including Board Member and Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator by AuntMinnie.com. He has continued to teach by mentoring medical students interested in radiology. Everyone who he has mentored has been accepted into top programs across the country including Harvard, UC San Diego, Northwestern, Vanderbilt, and Thomas Jefferson. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

An Interactive Session with Martyna Kosciesza, MD Martyna's personalized approach to yoga Radiology is a demanding and highly sedentary profession. Long hours at the workstation, sustained concentration, static posture, and repetitive computer use can make it difficult to incorporate movement into the working day. [1,2] At Imaging in Switzerland 2027, we will address this challenge with a practical session designed specifically for radiologists as part of our Wellness & Business Mini-Conference. The Evidence Behind the Session Sedentary behavior and workstation ergonomics are important concerns in radiology.[1,2] A 2016 study found that 78% of surveyed radiologists estimated sitting for at least six hours during the workday.[2] An AJR review highlighted the health implications of prolonged sitting and recommended incorporating intermittent movement and stretching into the workday.[2] More recently, a 2025 ergonomics audit found that only 48% of radiology staff reported taking regular breaks, despite increased awareness.[3] Together, these findings highlight the importance of simple, practical ways to interrupt prolonged sitting and incorporate movement into the radiologist's workday. Meet Martyna Kosciesza On Friday, June 11, 2027, at the Grand Hotel Suisse Majestic in Montreux, we are pleased to welcome Martyna Kosciesza, a yoga teacher and medical doctor based in the Swiss Riviera. Through her practice at Private Yoga Vevey, Martyna combines her background in medicine with extensive yoga training. Her approach emphasizes anatomy, physiology, movement and, breathing exercises—an especially relevant perspective for a session focused on the physical demands of the radiology workstation. Radiologist Wellness at the Workstation Martyna will lead an approximately 60-minute session focusing on practical techniques that participants may incorporate into their everyday routines, including: Posture and alignment at the workstation Stretching and mobility for prolonged sitting Breathing techniques and brief opportunities to reset Simple movement that can be incorporated between cases Greater awareness of tension and physical fatigue Our goal is to provide radiologists with practical tools they can use long after the conference to improve well-being in the reading room. Join us in Montreux for Radiologist Wellness at the Workstation: Posture, Stretching, Breathing & Movement on Friday. June 11, 2027. References Yadav S, Goel CL. Optimizing Ergonomic Practices in Radiology: A Closed-Loop Audit of Workstation Standards and Staff Wellbeing. Cureus. 2025;17(12):e99149. PMCID: PMC12795620 PMID: 41531581 Hoffmann JC, Mittal S, Hoffmann CH, Fadl A, Baadh A, Katz DS, Flug J. Combating the Health Risks of Sedentary Behavior in the Contemporary Radiology Reading Room. AJR Am J Roentgenol. 2016;206(6):1135-1140. doi: 10.2214/AJR.15.15496 Lamar DL, Chou SH, Medverd JR, Swanson JO. Sedentary Behavior in the Workplace: A Potential Occupational Hazard for Radiologists. Curr Probl Diagn Radiol. 2016;45(4):253-257. doi: 10.1067/j.cpradiol.2015.10.007 Martyna Kosciesza, MD About Martyna Kosciesza Martyna Kosciesza is a dedicated yoga teacher, medical doctor, and Vipassana meditator with firsthand experience working in high-stress environments. Her medical background has given her a deep understanding of the physical and mental effects of prolonged stress, including fatigue, sleep difficulties, back pain, stiffness, muscle tension, digestive issues, and irritability. Martyna discovered yoga as a holistic practice combining physical postures, breathing exercises, and relaxation techniques and has experienced its benefits personally. Her experience as both a physician and yoga student has also shaped her strong commitment to safe practice. Having experienced several yoga-related injuries herself, Martyna places particular emphasis on alignment, anatomy, physiology, and individualized adjustments. She follows the medical principle of “first, do no harm,” with a mission to make yoga safe, accessible, and meaningful for people of all levels. Through her teaching, Martyna hopes to share the benefits of yoga and help others discover practical ways to improve their physical and mental well-being. The TRUTH About Yoga: Dr. Martyna Kosciesza

An Interactive Roundtable with Karen S. Lee, MD FACR Boston Marathon - April 13, 2013 Image credit: John Tlumacki Boston Globe - www.cnn.com/interactive/2023/04/us/boston-marathon-bombing-anniversary/ What happens when your radiology department suddenly cannot operate as usual? A disaster might take the form of a mass casualty event, but it can just as easily stem from a PACS outage, hospital flooding, major power failure, cyberattack, or another sudden disruption that brings normal clinical workflow to a complete halt. Disaster Radiology: Ready or Not? Lessons from the Boston Marathon Bombing is an interactive roundtable led by Karen S. Lee, MD, FACR, who was on the front lines managing the radiologic response to the Boston Marathon bombing. Her experience highlights a fundamental lesson: disaster preparedness is not just about managing mass casualties. It requires established communication channels, decisive leadership, operational flexibility, and resilient backup systems long before an emergency strikes. A Global Perspective on Disaster Readiness Rather than a traditional lecture, Dr. Lee invites radiologists from around the world to participate in an open, practical discussion on real-world preparedness, lessons learned, and different regional approaches to crisis management: IT & System Disruptions: How does your department maintain imaging workflows when PACS goes down, EHRs crash, or a cyberattack takes networks offline? Physical Infrastructure Failures: What are your contingency protocols when hospital flooding, major power outages, or equipment failures make key facilities inaccessible? Mass Casualty Surges: How are imaging services prioritized when patient volume spikes, and how are CT, MRI, ultrasound, and radiography operations adapted under pressure? Crisis Leadership & Communication: Who makes key operational decisions during a shutdown, and how does radiology communicate effectively with emergency medicine, trauma teams, IT, and hospital leadership? Disaster resilience cannot be built in the middle of a crisis. This session provides a collaborative platform to compare international strategies, pressure-test your department's contingency plans, and sharpen your operational response before the unexpected occurs. Karen Lee, MD, FACR About Karen Lee Karen S. Lee, MD FACR is an Assistant Professor of Radiology at Harvard Medical School and a radiologist specializing in Emergency Radiology and Body MRI at Beth Israel Deaconess Medical Center (BIDMC). She serves as Associate Chief of the Emergency Radiology section, Director of Radiology Fellowship Training Programs, and Program Director for both the Body MRI and Cross-Sectional Imaging Fellowships. Dr. Lee earned her medical degree from Harvard Medical School and completed her radiology residency at BIDMC, where she served as Chief Resident. She remained at BIDMC to complete a fellowship in Body MRI. Her research interests include imaging of acute abdominal pain in pregnancy, evaluating cognitive biases in emergency radiology, and reducing redundant imaging in the emergent setting. She has authored numerous scientific articles, review publications, and book chapters, and has been invited to speak nationally and internationally on abdominal MRI and gastrointestinal and genitourinary emergency imaging. Dr. Lee is an active member of several professional societies, including the Radiological Society of North America (RSNA), American Roentgen Ray Society (ARRS), American College of Radiology (ACR), American Society of Emergency Radiology (ASER), and Society of Abdominal Radiology (SAR). She serves on the Scientific Program Committees for RSNA and ASER, and is a member of both the RSNA Multisystem Subcommittee and the RadioGraphics General Imaging Panel. A dedicated educator and mentor, Dr. Lee is a peer reviewer for several journals, including Abdominal Imaging, Journal of Magnetic Resonance Imaging, RadioGraphics, and The New England Journal of Medicine. She has received multiple consecutive teaching and mentorship awards at BIDMC, and her educational and scientific exhibits have been recognized with honors by RSNA, ARRS, and ASER. Dr. Lee is a Fellow of both the American College of Radiology and the Society of Abdominal Radiology.

34 M. Trauma due to falling off a roof. Diagnosis? • Xray of the Week Figure 1. Trauma due to falling off a roof. Diagnosis? Figure 2. Type B2 Lisfranc injury. (A) AP radiograph demonstrates the circled “fleck sign” or Lisfranc ligament avulsion fracture fragment. (B) Arrow demonstrates the increase in distance between the first and second metatarsals. The red lines show the misalignment or lateral displacement of the 2nd metatarsal bone over the second cuneiform bone and the preserved alignment of the first metatarsal with the first cuneiform bone. The first cuneiform bone is also fractured and there is lateral shift of the 2nd, 3rd, 4th, and 5th metatarsals. (C) Lateral radiograph demonstrates dorsal sub dislocation of the metatarsal base (red circle). Introduction A Lisfranc Fracture is a relatively rare injury, with an incidence of 1 per 55,000 persons per year and 0.2% of all diagnosed fractures. More commonly seen in male patients during the third decade of life, it is a fracture/dislocation of the tarsometatarsal (TMT) joint between the first, second, and third metatarsal bones, which articulate with three cuneiform bones [1,2]. The trapezoidal shape between these bones, the transverse arch, provides stability. Injury can encompass minor ligamentous lesions and fracture dislocations with more severe trauma, as in this case [2]. Other risk factors include patients with diabetes or chronic neuropathy and repetitive wear and tear [1]. A shallow second TMT joint also contributes to increased risk of injury. Fracture often occurs due to intense medial or lateral forces acting as the foot is plantar flexed, such as in a motor vehicle collision or while playing sports [2]. With over 20% of Lisfranc fractures missed upon presentation, it is important to diagnose these injuries promptly, as delayed diagnosis may lead to chronic foot deformity, midfoot arthritis, pain, chronic instability, and disability [1,2]. History and Physical Exam: Severe injuries present with difficulty bearing weight, pain, swelling, and an obvious deformity [1]. However, some patients may only present with pain and no obvious deformity [2]. Patients commonly hear or feel a midfoot pop when acutely injuring the Lisfranc joint. Symptoms may also include plantar ecchymosis, neuropathy, and decrease of sensation and two-point discrimination over the medial terminal branch of the deep peroneal nerve. There may also be abnormal increased distance between the first and second toes [2]. Imaging and Case Analysis: Radiographic images demonstrate misalignment of the medial side of the second metatarsal with the medial side of the middle cuneiform bone, as seen in this case. (Fig.1B) [3]. An increased distance between the first and second metatarsals can be seen. (Fig.1B) [1]. It may demonstrate a more pronounced cavus midfoot, findings highly suggestive of a Lisfranc fracture [2]. A distance of greater than 2 mm between the first cuneiform bone and second metatarsal is also suggestive of a Lisfranc injury [2]. A bone fragment is often observed between the first and second metatarsals, indicating an avulsion of the Lisfranc ligament or “fleck sign” as demonstrated here (Fig.1A) [2]. The lateral side of the first metatarsal base and the lateral side of the medial cuneiform may also be visualized and misaligned due to injury [3]. Figure 3. Hardcastle & Myerson Classification system for Lisfranc Injury. [2, 4] The Hardcastle & Myerson Classification system categorizes injuries as type A when all the metatarsals are displaced laterally with total incongruity, with M1-M5 dislocated in the same direction [2]. In a type B injury, one or more metatarsals are displaced without total incongruity. The M1 joint will be medially dislocated, or any of the M2-M4 joints will be laterally dislocated [2]. A type C injury has a divergent pattern or a complete dislocation of M1 and all metatarsals [2]. Myerson further subdivided type B and type C injuries into a modified classification system. For B1 injuries, there is a first metatarsal medial dislocation [4]. For B2 injuries, there is a lateral dislocation of M2-M5. Type C1 demonstrates a divergent pattern in some of the tarsometatarsal joints, and type C2 includes all the tarsometatarsal joints [4]. This case demonstrates severe trauma, and although there is preserved alignment of the first metatarsal with the first cuneiform bone, the first cuneiform bone itself is fractured. There is also a lateral shift or displacement of the 2nd, 3rd, 4th, and 5th metatarsals (Fig. 1A). Using this description and the flowchart (Fig. 4), this patient has a type B2 Lisfranc injury. Figure 4. Flow chart of Hardcastle & Myerson Classification system for Lisfranc Injury. [2, 4] One should also evaluate the oblique view to check the medial side of the fourth metatarsal base lining up with the medial side of the cuboid bone [1]. The lateral view is useful to check for plantar misalignment and the dorsal cortex of the first metatarsal lining up with the medial side of the cuneiform bone [2]. In this case the lateral view shows a dorsal sub dislocation of the metatarsal base (Fig. 1C). A CT scan will better assist with diagnosis and help with planning if surgery is necessary [5]. It is useful when measuring M2-C1 distance and comparing the sides of the foot [6]. However, some argue it has limited benefit for subtle injuries as radiographs are 82% sensitive and 90% specific [7]. Magnetic resonance imaging will help to evaluate ligamentous involvement and provides a 94% predictive value for diagnosing Lisfranc injury [2]. Treatment: Non-surgical treatment can only be considered for stable, non-displaced injuries. Those patients will be treated with immobilization for six weeks and subsequent gradual return to physical activity [2]. For patients with displaced (rupture or detachment of Lisfranc ligament) or unstable while weight-bearing Lisfranc injuries, surgery is required [1]. Although the Hardcastle and Myerson is the most commonly used classification system for Lisfranc injuries, it does not fully determine the treatment plan [8]. Standard treatment is open reduction and internal fixation, with non-weight-bearing for six to eight weeks for most types of Lisfranc injuries, commonly type B [2,9]. However, a primary partial arthrodesis may also be considered as it has shown optimal results for purely ligamentous Lisfranc injuries, patients with delayed presentation or chronic deformity, or patients with complete Lisfranc fracture dislocations such as those with type A or C2 Lisfranc injuries [2,4,8,10]. A combination of both procedures can be considered for a complex Lisfranc injury, such as in this case. There is conflicting evidence on which surgical procedure is more effective as both have similar pain intensity scores. However, primary arthrodesis has lower complication rates [10]. References: Buchanan BK, Donnally III CJ. Lisfranc Dislocation. In: StatPearls. Treasure Island (FL): StatPearls Publishing; August 29, 2022. PMID: 28846306. Bookshelf ID: NBK448147. https://pubmed.ncbi.nlm.nih.gov/28846306/. Moracia-Ochagavía I, Rodríguez-Merchán EC. Lisfranc fracture-dislocations: current management. EFORT Open Rev. 2019;4(7):430-444. Published 2019 Jul 2. DOI: 10.1302/2058-5241.4.180076. Shazadeh Safavi P, Weiss W, Panchbhavi V. Gravity Stress Radiograph Revealing Instability at the First Metatarso-Cuneiform Joint in Lisfranc Injury. Cureus. 2017;9(2):e1015. Published 2017 Feb 7. DOI: 10.7759/cureus.1015. Albert S, Bliss J, Nithyananth M. Lisfranc fracture dislocation: A Review. Journal of Foot and Ankle Surgery (Asia Pacific). 2022;10(1):234-241. doi:10.5005/jp-journals-10040-1236. Kennelly H, Klaassen K, Heitman D, Youngberg R, Platt SR. Utility of weight-bearing radiographs compared to computed tomography scan for the diagnosis of subtle Lisfranc injuries in the emergency setting. Emerg Med Australas. 2019;31(5):741-744. DOI: 10.1111/1742-6723.13237. Falcon S, McCormack T, Mackay M, et al. Retrospective chart review: Weightbearing CT scans and the measurement of the Lisfranc ligamentous complex. Foot Ankle Surg. 2023;29(1):39-43. DOI: 10.1016/j.fas.2022.08.011. Chen C, Jiang J, Wang C, Zou J, Shi Z, Yang Y. Is the diagnostic validity of conventional radiography for Lisfranc injury acceptable?. J Foot Ankle Res. 2023;16(1):9. Published 2023 Mar 1. DOI: 10.1186/s13047-023-00608-0. Padki A, Cheok GJ, Mehta KV. Outcomes of surgical fixation of Lisfranc injuries: A 2-Year review. Journal of Foot and Ankle Surgery (Asia Pacific). 2022;9(S1). doi: 10.5005/jp-journals-10040-1192. Mascio A, Greco T, Maccauro G, Perisano C. Lisfranc complex injuries management and treatment: current knowledge. Int J Physiol Pathophysiol Pharmacol. 2022;14(3):161-170. Published 2022 Jun 15. PMCID: PMC9301181. https://pubmed.ncbi.nlm.nih.gov/35891929/. Levy CJ, Yatsonsky D 2nd, Moral MZ, Liu J, Ebraheim NA. Arthrodesis or Open Reduction Internal Fixation for Lisfranc Injuries: A Meta-analysis. Foot Ankle Spec. 2022;15(2):179-184. DOI: 10.1177/1938640020971419. Rebeca Santos is a Class of 2025 medical student at Indiana University School of Medicine in Indianapolis, IN. She graduated summa cum laude with a Bachelor of Business Administration degree in Finance and International Business with honors college completion and an international bank management certificate in 2014. During medical school, she volunteered at the IU student outreach clinic and participated in Kids in Nutrition, teaching healthy habits, and providing nutritional education to elementary students. She also conducted laboratory research on the FOXP3 isoform to establish its role in autoimmunity and presented the poster at the Harvard 2022 New England Science Symposium. She is now pursuing a career in Diagnostic Radiology with interests in Breast imaging. She strives to achieve innovation in the field of radiology, utilizing breakthrough detection methods to make an impact in women’s health. All posts by Rebeca Santos Kevin M. Rice, MD is the president of Global Radiology CME and is a radiologist with Cape Radiology Group. He has held several leadership positions including Board Member and Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator by AuntMinnie.com. He has continued to teach by mentoring medical students interested in radiology. Everyone who he has mentored has been accepted into top programs across the country including Harvard, UC San Diego, Northwestern, Vanderbilt, and Thomas Jefferson. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

This is a detailed post, meant for radiologists who want concrete steps for optimizing Nuance's Powerscribe 360. Templates improve outward service and help in meeting metric reporting (MIPS) criteria. I am going to jump into some details for Powerscribe 360 that might be helpful for struggling radiologists. This may assist some practices in making the rubber meet the road to realize the promises of the pitch. I will end with a few comments in regards to internal workflow, billing, and quality. TECHNICAL BUILD: Make 1 base general template (PS360 “Autotext”) for each radiology CPT code. Do this initially at the top tier “Site” level. You can start by setting up a basic shell template (“Text Fields” for typical section headers – findings, etc.). You then “clone” this “Autotext” as many times as you need, rename to each study type you need (each CPT). Spend the time to make L and R versions. Trust me. Working at the “Site” level requires “Admin” rights. Link each Autotext to the appropriate line item/s of your system’s chargemaster. PS360 calls this assigning “Categories” and it makes the templates “Relevant”. This is an IMPERATIVE step, and should be done with the root “Site” level Autotext. So many useful things tumble from this, I cannot stress it enough. Unfortunately, this is system specific and needs to be done whether you build Autotexts from scratch or get your hands on a set from Nuance or elsewhere. Base content: PS360 has “Merge fields” that your IT staff can set up (interface) for certain types of information. Date of service and indication are two obvious basic ones to pull from your RIS or EMR. (US measurements and NM doses are still out of reach for us, but desired.) “Pick Lists”: These are fields that nest in the template. You can invoke a chunk of text with a single key word. We use this for “Technique” section (e.g. CT AP w/wo is still 1 template, with 5 different options in the pick list for panc, renal mass, etc…). We also use it for the set of projections on plain films (e.g. variations on a 3-view knee). “Findings” #1: Careful of a breakdown here. You will need buy-in, especially if working with a herd of cats, I mean brilliant radiologists who have not previously used VR or who love their own template verbiage. I chose to have very basic formulaic normal findings for CR studies. I left MR/CT findings as an empty text field. US and NM were variously built out. “Findings” #2: Only when you complete the above, THEN you “Clone” all of the “Site Autotexts” to each user’s account. Each user will have a full set of “Relevant Personal Autotexts”. We were not authoritarian in “Findings” content, in order to preserve buy-in during our transition. (Aside: There is plenty of structure to the above steps, without a line item per-organ findings section. I really can’t stand reading articles about “structured vs unstructured” reporting. It is a spectrum.). This allows your rads the autonomy to alter or add findings to take ownership of the templates without having to accept “your” way of dictating, while PRESERVING all of the structured content you embedded. WORKFLOW: By having 1 root Autotext tied to each Category chargemaster line item, you can make it a “Default” that blows in when you launch the dictation, whether the study is normal or not. 100% of the time. “Cloning” is key. Once you have a default set up, you can clone the autotext as many times as you want. The key here is that cloning will PRESERVE the categories that make the templates “relevant”. These clones will not be defaults. There are two huge benefits (stay with me here): 1. You can invoke and nest another autotext within your default autotext dictation. Specifically, you can have as many simple or complex variations for a “Findings” section for a given study type as you want, and they will be easy to find (and remember!) when you use the Autotext preview pane set to “Relevant Personal” at the bottom of the dictation window. The sky is the limit here, and I will admit that finding the time to create these iterations is hard. 2. You can use this same cloning approach to set up as many “tips” (i.e. crib sheets) Autotexts as you want. When you single click on an autotext in the bottom of the dictation screen you will see it in the preview pane, without dumping the content into your actual dictation. I LOVE THIS. I use this daily for various things such as Lung-RADS, adnexal consensus recommendations, Fleischner, aortic root limits, etc. It occurs to me that this could be a really handy educational tool at point of care at a teaching institution. BILLING: By having only 1 template pinning back to each CPT code, and having fixed text descriptions at the top of your report, you can avoid human error in what you do or do not dictate. Conversely, you can spot the occasional IT/Registration/Tech mix up quickly when whatever flows through from RIS/EMR/written order does not match what you are seeing in PACS. A stitch in time for a clean claim… QUALITY: Similar and related to the above, you can quickly spot if the PACS study does not match what is in your default template (CR 2 views vs 3 views, L spine complete or not, CT w vs w/wo, L/R mismatch, etc…). Also, having discrete, non-generic, technique sections for your complex cross sectional studies also communicates a level of service and attention to referring specialists (e.g. all “CT w/wo” are not the same!). This is painless with a pick list and a single spoken word, but is not going to happen if you are dictating the entire protocol every case. Helps demonstrate our expertise. This was article was originally posted on ACR Engage on February 11, 2017. Below are YouTube videos with tips on how to use Powerscribe 360: By Jason Mullinix - 11 videos above. By University of South Florida above. Matthew Brady, MD is the Alternate Councilor for the South Carolina Chapter of the ACR and Treasurer of the South Carolina Radiological Society. After obtaining a BA at The Woodrow Wilson School of Public and International Affairs at Princeton in 1997, he earned his MD at Dartmouth in 2002. Dr. Brady then went on to a Radiology Residency with subsequent combined Nuclear Medicine and Body Imaging at Duke University from 2003 to 2008. Dr. Brady is dual boarded by the ABR and ABNM and is now is in private practice at Roper Radiologists, PA in Charleston, South Carolina.

New Left Breast Thickening in 67F • Xray of the Week 2017 • Week #4 This 67 year old asymptomatic woman was called back from mammography screening for assessment of the finding detected on the mammograms of her left breast. In addition, there was a slight palpable thickening in the lateral portion of the left breast at clinical breast examination. What two processes are present? Figure 1. a-d. Mediolateral (a,b) and craniocaudal (c,d) mammograms of the previous screening examination, 24 months before diagnosis and treatment. This examination was read as normal. The subtle contour change of the fibroglandular tissue seen retrospectively on the left CC projection was not appreciated at this examination. Figure 2. a-d. MLO (a,b) and CC (c,d) projections. The patient was called back from screening for further assessment of the asymmetric density with slight architectural distortion seen in the lateral portion of the left breast. The <10 mm, low density, oval lesion in the medial portion of the right breast is a mole (nevus). Figure 3 a,b. Microfocus magnification mammograms, MLO (a) and CC (b) projections. The architectural distortion is seen best on the craniocaudal projection (b): There is no central tumor mass and the radiating structure consists of drooping linear radiolucencies, characteristic for a radial scar (“black star”). No mammographic signs of malignancy are demonstrable. Figure 4: ABUS multislice series, images 7-12/18. There is an obvious tissue defect in the upper half of the breast in images 7-10/18 (encircled), suggesting the presence of a pathologic lesion. Figure 5 a,b. Placing the cursor over the tissue defect on ABUS image 9/18 produces a reconstructed 2D ultrasound image, showing a small malignant lesion. However, there is a discrepancy between the finding on ABUS and the finding on the mammogram. Figure 6 a-f. Breast MRI examination using a body-coil. MIP reconstructions showing bilateral moderate background enhancement. In the upper portion of the left breast there is a 5x4 cm area with many small enhancing areas and architectural distortion within the fibroglandular tissue. In the central portion there are a few lesions, having rapid washin and washout in the delayed phase. In addition, there is a small post biopsy hematoma adjacent to the above described lesions (Figs d-f) d (T2w) e (STIR) f (T1w pre contrast). Figure 7. Microfocus magnification radiograph of specimen slice # 1. Numerous stellate lesions and architectural distortion can be found in this specimen radiograph. No malignant type calcifications are demonstrable. Figure 8. The corresponding large format, subgross (3D) histopathology image of slice #1 shows the stellate lesions and the radiating structures. There are three invasive cancer foci (within white circles) and several radial scars (within black circles). Histology images are courtesy of Tibor Tot, MD PhD - Associate Professor, Department of Pathology and Clinical Cytology, Central Hospital Falun, Falun, Sweden Discussion Final histopathology: Multifocal invasive breast cancer (8x7 mm, 6x4 mm, 2x2 mm, 2x1 mm) associated with cancer in situ over a region measuring 30x25 mm. pN 0/2. Biomarkers: ER/PR+ve, Ki67 15%, HER2-ve. Several radial scars can be seen in the segmentectomy specimen. Comment: Perception of architectural distortion on the mammograms is a difficult task. Once perceived, history helps us rule out traumatic fat necrosis, a common cause of architectural distortion. Clinical breast examination is mandatory when the finding on the mammogram is architectural distortion. Radial scar, the second most common benign lesion causing architectural distortion is seldom palpable, regardless of its size or location. However, radial scars can be associated with carcinoma in situ and/or small invasive carcinoma or even with multifocal invasive cancers. When the analysis of the mammograms suggests a radial scar, but there is a “thickening” upon clinical breast examination (such as in this case), then the lesion may be a radial scar associated with invasive carcinoma. The alternative diagnoses are either neoductgenesis (duct forming invasive carcinoma) or diffusely infiltrating cancer of apparent mesenchymal origin. The multimodality approach and thorough histopathologic examination using large format histopathology is needed to arrive at the correct diagnosis. Learn more about early detection of breast cancer and radiologic/pathologic correlation from one of the world's leading experts, Dr. László Tabár and Israeli breast imager Dr. Tamar Sella at Imaging in Israel - 2017. Other breast imaging cases: Invasive Ductal Carcinoma of the Breast in 27 Year Old Phyllodes Tumor Medullary Breast Cancer Hemangioma of Breast References: 1. Orel SG, Evers K, Yeh IT et-al. Radial scar with microcalcifications: radiologic-pathologic correlation. Radiology. 1992;183 (2): 479-82. 2. Tabár L, Dean PB, Tot T. Teaching atlas of mammography. George Thieme Verlag. (2001) ISBN:0865779627. Find it at Amazon 3. Alleva DQ, Smetherman DH, Farr GH et-al. Radial scar of the breast: radiologic-pathologic correlation in 22 cases. Radiographics. 1999;19 Spec No : S27-35. 4. Carder PJ, Liston JC. Will the spectrum of lesions prompting a "B3" breast core biopsy increase the benign biopsy rate? J. Clin. Pathol. 2003;56 (2): 133-8. 5. Mokbel K, Price RK, Carpenter R. Radial scars and breast cancer. N. Engl. J. Med. 1999;341 (3): 210. 6. Wolfe JN. Breast patterns as an index of risk for developing breast cancer. AJR Am J Roentgenol. 1976;126 (6): 1130-7. László Tabár, MD, FACR (Hon) the Professor Emeritus of Radiology Uppsala University, Faculty of Medicine, Sweden and the Medical Director Emeritus of the Department of Mammography, Falun Central Hospital, Sweden. Through his company, Mammography Education, Inc, he has also been the course director and principal lecturer at more than 300 mammography courses on 6 continents. His pioneering research has laid the foundation for early detection through modern mammographic screening. Dr. Tabár is the recipient of numerous awards including the Gold Medal from the Society of Breast Imaging, American Cancer Society's Distinguished Service Award, and the first Alexander Margulis Award for Scientific Excellence from the Radiological Society of North America (RSNA). Dr. Tabár will be sharing his vast knowledge of breast imaging at Imaging in Israel - 2017. All Posts by László Tabár, MD All Breast Imaging Posts

Radiology PowerPoint Tip • Xray of the Week • Week #49 Have you ever wondered how to get a scrollable image stack of CT or MR images on a single PowerPoint slide. There is a way to do it! Australian Emergency Medicine Specialist Dr. Andy Buck shares how to get a scrollable image stack on a single PowerPoint slide on a Mac. The basic steps on Mac: 1. Export the image stack from PACS as JPEG images. If your PACS can not export as JPEG, use Osirix to convert from DICOM to JPEG. Make sure the images are de-identified either with PACS or Osirix. 2. Resize all images to 630 x 630 pixels. 3. Copy and paste the entire set of JPEG images to a single blank slide. 4. Select all and click Animate> Appear. 5. On the right side, where the list of "Play Selected" is, select all (with Ctrl-A) 6. Below under "Timing", click Start> On Click. 7. Save. 8. In presentation mode, use mouse or wheel to scroll through the images. Here is a video of the Windows version by senior editor at Radiopaedia.org, Dr. Matt Skalski: How to add scrollable stack of CT or MRI Images on Microsoft PowerPoint 365 (2020) from Chris Nguyen: Basic steps for Windows: 1. Export the image stack from PACS as JPEG images. If your PACS can not export as JPEG, use DICOM Converter to convert from DICOM to JPEG. Make sure the images are de-identified in PACS prior to download. 2. Resize all images to 630 x 630 pixels. 3. Copy and paste the entire set of JPEG images to a single blank slide. 4. Click animations on the toolbar, click on Custom Animation 5. Click the little triangle on Add Effect>Entrance> Appear. 6. On the right side, where the list of "Play Selected" is, select all (with Ctrl-A) 7. Above at "Start" select "On Click". 8. Save. 9. In presentation mode, use mouse or wheel to scroll through the images. How to export a perfect size and format for Carestream PACS users: 1. First make an empty new folder in your documents folder called "CT stack" or something else related to the case. You will use this to save the images. 2. In PACS, use layout 4 on 1 in stack mode. Make sure this box is selected. 3. Click "hide DICOM Annotations" to de-identify the images. 4. Click Export > Save > Save as File 5. In the dialogue box -File Name: Browse back to your empty folder called "CT stack" select and make a name for the images -Save as type: JPEG -Selection: Current Selection -Size: As displayed on screen 5. Click Save 6. Navigate back to your images and import to PowerPoint as described above in the basic steps for Windows or Mac starting at step #3. This is a PowerPoint PPT file I did as a demo: Click here to download Kevin M. Rice, MD serves as the Chair of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a Radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

Name the Cardiac Device • Xray of the Week Fig. 1. A. Frontal chest xray showing the Amulet® over the expected location of the left atrial appendage (LAA). Fig. 1. B. Magnified chest xray. The self-expanding distal lobe (blue arrow) and proximal disc (red arrow) are seen. Fig. 2. Amulet® is very similar to the Amplatzer™ Cardiac Plug (ACP) device. Fig. 3 Video demonstrating percutaneous placement technique for the Amplatzer™ Cardiac Plug (ACP) and Amulet® device for LAA closure. Fig. 4. Watchman™ LAAC device from Boston Scientific shows the self-expanding nitinol frame and fabric covering the face of the device. Fig. 5. CT scan of Watchman™ LAAC device in the left atrial appendage on axial and coronal images. Fig. 6 Video explaining percutaneous placement technique for the Watchman™ LAAC device. Fig. 7. AtriClip® Left Atrial Appendage Exclusion System. A. The AtriClip® in the deployment device. B. The layers of the AtriClip®. Fig. 8. AtriClip® Left Atrial Appendage Exclusion System. A. Frontal CXR with yellow arrow pointing to the device. B. Lateral CXR with red arrow pointing to the AtriClip®. Note the parallel tubes and Nitinol springs at each end. Discussion: LAA closure or occlusion devices are indicated for patients with atrial fibrillation in whom oral anticoagulation is contraindicated or an alternative to oral anticoagulation therapy for stroke prevention in patients with atrial fibrillation. Percutaneous LAA closure devices include the Watchman, Amplatzer Amulet, Amplatzer Cardiac Plug (ACP), and the PLAATO system. The Amulet and ACP both consist of a self-expanding distal lobe and proximal disc made of nitinol mesh with an articulating waist (Figs 1,2,3). The Watchman consists of a self-expanding nitinol frame, with a fabric covering the face of the device (Figs 4-6). Placed by open surgery or minimally invasive techniques, the AtriClip (Fig 7,8) is a self-closing clip placed on the epicardial surface of the heart on the base of the LAA . It is visualized on radiographs as a metallic structure with parallel tubes over the expected location of the LAA (Fig 6,7). Complications of percutaneous LAA closure devices include malposition, migration, or embolization. The Watchman, AtriClip, Amplatzer Amulet, and Amplatzer Cardiac Plug LAA closure devices are MR imaging conditional at 1.5 T and 3 T. References: 1. Swaans MJ, Wintgens LI, Alipour A, Rensing BJ, Boersma LV. Percutaneous left atrial appendage closure devices: safety, efficacy, and clinical utility. Med Devices (Auckl). 2016;9:309-316. Published 2016 Sep 2. doi:10.2147/MDER.S65492 Full Text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5015878/ 2. Onalan O, Crystal E. Left atrial appendage exclusion for stroke prevention in patients with nonrheumatic atrial fibrillation. Stroke. 38 (2 Suppl): 624-30. Full Text: doi:10.1161/01.STR.0000250166.06949.95 3. Sigakis CJG, Mathai SK, Suby-Long TD, Restauri NL, Ocazionez D, Bang TJ, Restrepo CS, Sachs PB, Vargas D. Radiographic Review of Current Therapeutic and Monitoring Devices in the Chest. (2018) Radiographics : a review publication of the Radiological Society of North America, Inc. 38 (4): 1027-1045. doi:10.1148/rg.2018170096 Full Text: https://pubs.rsna.org/doi/10.1148/rg.2018170096 4. Bedeir K, Warriner S, Kofsky E, Gullett C, Ramlawi B. Left Atrial Appendage Epicardial Clip (AtriClip): Essentials and Post-Procedure Management. (2019) Journal of atrial fibrillation. 11 (6): 2087. doi:10.4022/jafib.2087 Full Text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6652788/ 5. Moussa Pacha H, Al-Khadra Y, Soud M, Darmoch F, Moussa Pacha A, Alraies MC. Percutaneous devices for left atrial appendage occlusion: A contemporary review. World J Cardiol. 2019;11(2):57–70. doi:10.4330/wjc.v11.i2.57 Full Text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6391622/ 6. Sick PB, Schuler G, Hauptmann KE, et al. Initial worldwide experience with the WATCHMAN left atrial appendage system for stroke prevention in atrial fibrillation. J Am Coll Cardiol. 2007;49(13):1490-1495. doi:10.1016/j.jacc.2007.02.035. Full Text: https://www.sciencedirect.com/science/article/pii/S0735109707007474 Related posts: CardioMEMS Device Bicuspid Aortic Valve and Aortic Stenosis Implanted Cardiac Loop Recorder Cardiac Tamponade Following Coronary Artery Rotational Atherectomy Papillary Fibroelastoma of Aortic Valve Micra Intracardiac Pacemaker Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

Trauma due to motor vehicle collision. Diagnosis? • Xray of the Week Figure 1. CT images of the cervical spine (A) sagittal view and (B) coronal view. What is the important finding on this CT scan? Figure 2. CT scan of a Type I dens fracture. Red arrows point to the fracture line at the tip of the dens. Figure 3. Anderson and D’Alonzo dens fracture classification system. Diagram by Neal Joshi. Type I is an oblique avulsion fracture involving the upper tip of the dens, usually at the alar ligament insertion, and is generally considered stable when isolated. Type II occurs at the junction of the dens and the body of C2 and has a greater risk of displacement and nonunion. Type III extends from the base of the dens into the body of C2 and generally has better healing potential because the fracture extends into cancellous bone. Introduction: The odontoid process, or dens, is a superior projection of C2 that articulates with the anterior arch of C1 and functions as the pivot for atlantoaxial rotation. The alar ligaments arise from the upper dens and attach to the medial aspects of the occipital condyles, contributing to stability of the craniocervical junction (1,2). The Anderson and D'Alonzo classification is the most widely used system for classifying odontoid fractures according to the location of the fracture (3,4) (Fig. 3). Type I fracture is usually stable, however, an apparent Type I avulsion fracture may be associated with injury to the alar or other craniocervical ligaments; therefore, the surrounding ligamentous structures and craniocervical alignment should be assessed (5). Epidemiology Odontoid fractures are among the most common fractures of the upper cervical spine, particularly in older adults. Type I odontoid fractures are rare, representing approximately 2–3% of odontoid fractures. In a prospective study from the Swedish Fracture Register, 30 of 1,154 odontoid fractures were classified as Type I, compared with 583 Type II and 541 Type III fractures. Odontoid fractures in older adults are commonly associated with low-energy falls, whereas higher-energy mechanisms such as motor vehicle collisions are more frequent in younger patients (6,7). Clinical Manifestation Patients with Type I dens fractures typically present with upper cervical or posterior neck pain and tenderness following trauma. Pain may be aggravated by cervical movement and may be associated with restricted range of motion. Neurological deficits are uncommon but may occur in the presence of associated cervical or craniocervical injuries. Because Type I fractures are uncommon and may be associated with ligamentous injury, careful clinical and radiologic assessment for craniocervical instability is important (3). Radiographic Features Plain radiographs, including lateral and open-mouth odontoid views, may demonstrate a small avulsion fragment at the tip of the dens; however, a negative examination does not exclude fracture. When clinical suspicion persists, thin-section CT with sagittal and coronal reformations is the preferred imaging modality, allowing accurate assessment of fracture location, displacement, and atlantoaxial and craniocervical alignment (Fig. 1). In this patient, CT performed following a motor vehicle collision demonstrated a type I dens fracture (Fig. 2). Associated fractures of C1 and C2 should also be carefully evaluated (5). CT is also useful in distinguishing a type I odontoid fracture from os odontoideum. MRI may be useful when there is concern for associated ligamentous injury or craniocervical instability and can provide additional evaluation of the spinal cord. Treatment and Prognosis Isolated, nondisplaced Type I dens fractures are generally considered stable and are treated conservatively with external immobilization, most commonly with a rigid cervical collar. Current recommendations support immobilization with a hard collar for approximately 6–8 weeks, with clinical and radiographic follow-up to confirm stability and healing; duration may be extended based on follow-up imaging (8). Surgical treatment is rarely required for an isolated Type I fracture. However, operative stabilization may be considered when there is significant displacement, craniocervical instability, or associated ligamentous injury. The prognosis of an isolated Type I fracture is generally favorable with appropriate immobilization. In elderly patients specifically, rigid immobilization methods such as halo-vest bracing carry an increased mortality risk and should be weighed carefully against a rigid collar alternative when isolated Type I injuries are stable (9). Conclusion Type I dens fractures are rare avulsion injuries involving the superior tip of the odontoid process, usually at the site of alar ligament attachment. Although generally stable when isolated, they require careful evaluation for associated ligamentous injury and craniocervical instability. CT is the imaging modality of choice for defining the fracture and assessing alignment, while MRI may provide additional evaluation of ligamentous and neural structures. Recognition of this uncommon fracture pattern is important for appropriate management and favorable outcome. References: Clark CR, White AA 3rd. Fractures of the dens. A multicenter study. J Bone Joint Surg Am. 1985;67(9):1340-1348. https://pubmed.ncbi.nlm.nih.gov/4077905/ O'Brien WT Sr, Shen P, Lee P. The Dens: Normal Development, Developmental Variants and Anomalies, and Traumatic Injuries. J Clin Imaging Sci. 2015;5:38. Published 2015 Jun 30. DOI: 10.4103/2156-7514.159565 Anderson LD, D'Alonzo RT. Fractures of the odontoid process of the axis. J Bone Joint Surg Am. 1974;56(8):1663-1674. https://pubmed.ncbi.nlm.nih.gov/4434035/ Nouri A, Da Broi M, May A, et al. Odontoid Fractures: A Review of the Current State of the Art. J Clin Med. 2024;13(20):6270. Published 2024 Oct 21. DOI: 10.3390/jcm13206270 Jain N, Verma R, Garga UC, Baruah BP, Jain SK, Bhaskar SN. CT and MR imaging of odontoid abnormalities: A pictorial review. Indian J Radiol Imaging. 2016;26(1):108-119. DOI: 10.4103/0971-3026.178358 Baranto D, Steinke J, Blixt S, et al. The epidemiology of odontoid fractures: a study from the Swedish fracture register. Eur Spine J. 2024;33(8):3034-3042. DOI: 10.1007/s00586-024-08406-3 Hashem M, Surur S, Hamad AS. Clinical and Radiological Outcomes of Halo Vest Application for Type II and III Odontoid Fractures. Int J Gen Med. 2024;17:457-469. Published 2024 Feb 5. DOI: 10.2147/IJGM.S440126 Gonschorek O, Vordemvenne T, Blattert T, Katscher S, Schnake KJ; Spine Section of the German Society for Orthopaedics and Trauma. Treatment of Odontoid Fractures: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU). Global Spine J. 2018;8(2 Suppl):12S-17S. DOI: 10.1177/2192568218768227 Tashjian RZ, Majercik S, Biffl WL, Palumbo MA, Cioffi WG. Halo-vest immobilization increases early morbidity and mortality in elderly odontoid fractures. J Trauma. 2006;60(1):199-203. DOI: 10.1097/01.ta.0000197426.72261.17 Umaiza Ihsan, MD is a medical graduate of King Edward Medical University, Pakistan. She completed her internship at Mayo Hospital, Lahore, including a three- month rotation in Radiology, which further strengthened her interest in diagnostic imaging. She has gained additional clinical exposure in Radiology through observerships at Mon Health Morgantown and the University of Maryland, Baltimore. She has a strong interest in Radiology, particularly diagnostic imaging and its role in clinical decision-making, and is actively interested in clinical research, with experience in systematic reviews and medical research. Kevin M. Rice, MD is the president of Global Radiology CME and is a radiologist with Cape Radiology Group. He has held several leadership positions including Board Member and Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator by AuntMinnie.com. He has continued to teach by mentoring medical students interested in radiology. Everyone who he has mentored has been accepted into top programs across the country including Harvard, UC San Diego, Northwestern, Vanderbilt, and Thomas Jefferson. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

Name the implant and potential complications • Xray of the Week Figure 1. What is the name of this implant? Discussion: Mentoplasty refers to cosmetic chin augmentation that is often used to treat deficient chin projection caused by soft-tissue atrophy and retrusion of the chin (1). Chin retrusion may be further classified as underdevelopment of mandibular symphysis (microgenia) or mandibular retrusion (retrognatia) (2). Augmentation mentoplasty can be performed using various implant materials, autografts, and homografts, and silicone as in this case (1,2). Silicone rubber is preferred over other materials for its resistance to changes in body temperature, calcification, absorption, and degeneration as well as its pliability (2). The silicone implant is typically positioned inferior to the mental foramen in a subperiosteal pocket via an extraoral approach (1,2). Silicone implants are best seen on CT using bone windows, and there is typically variable attenuation with density that is higher than soft tissue but less than bone (1). On MRI, there is very low signal intensity on T1- and T2- weighted sequences (1). Complications include infection, migration, heterotopic bone formation, and foreign body giant cell reaction (1). Mandibular bone erosion is also a common complication and can be evaluated on CT with dental CT software (3). ​​​​ References: Schatz CJ, Ginat DT. Imaging of cosmetic facial implants and grafts. AJNR Am J Neuroradiol. 2013;34(9):1674-1681. doi: 10.3174/ajnr.A3214 PMID: 22878009 Vuyk HD. Augmentation mentoplasty with solid silicone. Clin Otolaryngol Allied Sci. 1996;21(2):106-118. doi: 10.1111/j.1365-2273.1996.tb01312.x Abrahams JJ, Caceres C. Mandibular erosion from silastic implants: evaluation with a dental CT software program. AJNR Am J Neuroradiol. 1998;19(3):519-522. PMCID: PMC8338244 2026 UPDATE: Dr. Ahmed is a Radiology Resident at The Department of Radiology in the College of Medicine at the University of Florida in Gainesville. https://residency.xray.ufl.edu/residents/class-of-2028/ Amara Ahmed is a medical student at the Florida State University College of Medicine. She serves on the executive board of the American Medical Women’s Association and Humanities and Medicine. She is also an editor of HEAL: Humanism Evolving through Arts and Literature, a creative arts journal at the medical school. Prior to attending medical school, she graduated summa cum laude from the Honors Medical Scholars program at Florida State University where she completed her undergraduate studies in exercise physiology, biology, and chemistry. In her free time, she enjoys reading, writing, and spending time with family and friends. Follow Amara Ahmed on Twitter @Amara_S98 All posts by Amara Ahmed Kevin M. Rice, MD is the president of Global Radiology CME and is a radiologist with Cape Radiology Group. He has held several leadership positions including Board Member and Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator by AuntMinnie.com. He has continued to teach by mentoring medical students interested in radiology. Everyone who he has mentored has been accepted into top programs across the country including Harvard, UC San Diego, Northwestern, Vanderbilt, and Thomas Jefferson. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD