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Left Scrotal Pain in 64M • Xray of the Week 2016 • Week #50 This 64 year old male presented with left scrotal pain. There is a history of undescended left testicle and orchiopexy at age 5. What is the diagnosis? Video 1: Ultrasound demonstrating slow flow in an intratesticular varicocele. Video 2: Zoomed ultrasound demonstrating slow flow in an intratesticular varicocele. The flow is too slow to be seen with color Doppler. Figure 1. Intratesticular varicocele in a different patient. Color Doppler shows the dilated vein within the testis. Case courtesy of Dr Rupesh Namdev, Radiopaedia.org. From the case rID: 27305 Intratesticular varicocele is a rare cause of testicular pain seen in less than 2% of cases. Although usually associated with extratesticular varicocele, as seen in this case it is not invariable. Testicular pain is due to stretching of the tunica albuginea related to congestion and dilatation of veins [1]. Approximately 9% of men who have had prepubertal orchiopexy for undescended testis eventually develop an intratesticular varicocele [2]. Slightly more than half of the cases occur on the left side [1,2,3]. In 1992, Weiss et al reported the first 2 cases of intratesticular varicocele, describing straight or serpentine hypoechoic structures within the mediastinum testis radiating into the testicular parenchyma, identified as veins with color Doppler sonography [3]. However, slow flow may preclude Doppler signal, and as seen in the videos above, flow can be appreciated with real time sonography [Videos 1 and 2]. Approximately 80% of the testes affected with intratesticular varicocele demonstrate atrophy [4]. References: 1. Das KM, Prasad K, Szmigielski W et-al. Intratesticular varicocele: evaluation using conventional and Doppler sonography. Abstract: AJR Am J Roentgenol. 1999;173 (4): 1079-83. Full Text PDF 2. Meij-de Vries A, den Bakker FM, van der Wolf-de Lijster FS et-al. High prevalence of intratesticular varicocele in a post-orchidopexy cohort. J Pediatr Urol. 2013;9 (3): 328-33. doi:10.1016/j.jpurol.2012.04.004 - Pubmed citation 3. Weiss AJ, Kellman GM, Middleton WD, Kirkemo A. Intratesticular varicocele: sonographic findings in two patients. AJR Am J Roentgenol 1992; 158:1061–1063 4. Tétreau R, Julian P, Lyonnet D, et al. Intratesticular Varicocele: An Easy Diagnosis But Unclear Physiopathologic Characteristics. J Ultrasound Med 2007; 26:1767–1773 Kevin Rice, MD serves as the Medical Director of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a Member of 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 launched 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

6 Month Old with Abdominal Pain • Xray of the Week History: There was a baby from Cali, who had a pain in his belly. For a BE, it's time; 'cause of a target sign, and his stool looks like currant jelly. Figure 1. Left image: Target sign on ultrasound due to intussusception. Right image: Spot view from water soluble contrast enema showing the filling defect in the transverse colon due to ileo-colic intussusception. Figure 2. The pseudokidney sign. Long axis ultrasound image of intussusception showing the layers of ileum inside the cecum in the right lower quadrant. Figure 3. Intussusception is reduced with contrast in the terminal ileum. Figure 4. Actual currant jelly Figure 5. Bloody stool in diaper (aka nappy) that looks like currant jelly Intussusception is a common cause of abdominal pain in children and is caused by a segment of bowel pulled into itself by peristalsis. The classic triad of intermittent abdominal pain, vomiting and right upper quadrant mass, plus occult or gross blood on rectal examination is seen in less than 20% of intussusception cases. Bloody stool may have the appearance of currant jelly due to the presence of mucus in the stool [Fig. 4,5]. If prolonged, ischemia and necrosis with eventual perforation may occur. 90% of cases in children aged less than 2 years old have no lead point. Ultrasound demonstrates the target sign in the short axis view [Fig. 1] and the pseudokidney sign in the long axis view [Fig.2] due to alternating bands of hyperechoic mucosa and hypoechoic submucosa. Definitive diagnosis and treatment is reduction with water soluble contrast or air enema [Fig. 3]. When seen in adults, there is almost invariably a neoplasm as a pathologic lead point, thus requiring surgery. References: 1. Lioubashevsky N, Hiller N, Rozovsky K, et al. Ileocolic versus Small-Bowel Intussusception in Children: Can US Enable Reliable Differentiation? Radiology. 269 (3): 266-271 2. Kim YH, Blake MA, Harisinghani MG et-al. Adult intestinal intussusception: CT appearances and identification of a causative lead point. Radiographics. 26 (3): 733-44 3. Anderson DR. The pseudokidney sign. Radiology. 1999;211 (2): 395-7. 4. del-Pozo G, Albillos JC, Tejedor D, et al. Intussusception in children: current concepts in diagnosis and enema reduction. RadioGraphics 1999;19(2):299–319. 5. Swischuk LE, Hayden CK, Boulden T. Intussusception: indications for ultrasonography and an explanation of the doughnut and pseudokidney signs. Pediatr Radiol 1985;15(6):388–391. 6. Rubinstein JC, Lucy Liu L, Caty MG. Pathologic Leadpoint Is Uncommon in Ileo-Colic Intussusception Regardless of Age. J Pediatr Surg. 2015 Oct;50(10):1665-7. DOI: 10.1016/j.jpedsurg.2015.03.048 7. McDermott VG, Taylor T, Mackenzie S, et al. Pneumatic Reduction of Intussusception: Clinical Experience and Factors Affecting Outcome. Clin Radiol. 1994 Jan;49(1):30-4. doi: 10.1016/s0009-9260(05)82910-1. Related case: Intussusception in melanoma Kevin 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 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

Here's all my 2016 cases in one quick video: Kevin 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 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

Let's stop the confusion! There is no Superficial Femoral Vein! Many ultrasound technologists are using the term "superficial femoral vein" or "SFV" on their images. In addition, radiologists often use this term in reports. To the best of my knowledge, there is actually no such anatomic structure. The name of the vein between the common femoral vein (CFV) and popliteal vein is the "femoral vein" (FV) [1-4]. Figure 1. A. The ultrasound technologist has incorrectly labeled the image "SFV". B. A different ultrasound technologist has correctly labeled the image "FV". This misnomer has real consequences - I have personally seen patients not treated for acute DVT as the report has indicated isolated thrombus in the superficial femoral vein. The clinician read the report and thought he did not need to treat the patient with anticoagulants as it was superficial thrombosis. I would encourage all ultrasound technologists and radiologists to abandon the term "Superficial Femoral Vein" and instead use the term used by the vast majority of anatomists [4], endorsed by The Society of Interventional Radiology (SIR) [3], The Australasia Society for Ultrasound in Medicine (ASUM) [5], and The Interventional Radiology Society of Australasia (IRSA) [6]: "Femoral Vein". Figure 2. Venous anatomy of the lower extremity demonstrating the femoral vein. Note that it is the vein between the common femoral vein and the popliteal vein. There is no superficial femoral vein. References: 1. Hammond I. The Superficial Femoral Vein [letter] Radiology. November 2003. Volume 229, Issue 2 p.604. 2. Thiagarajah R, Venkatanarasimha N, Freeman S. Use of the term "superficial femoral vein" in ultrasound. J Clin Ultrasound. 2011 Jan;39(1):32-4. 3. Caggiati A, Bergan JJ, Gloviczki P, Jantet G, Wendell-Smith CP, Partsch H, et al. Nomenclature of the veins of the lower limbs: an international interdisciplinary consensus statement. Journal of Vascular Surgery. 2002;36(2):416-222. 4. Bundens WP, Bergan JJ, Halasz NA, Murray J, Drehobi M. The superficial femoral vein: a potentially lethal misnomer. JAMA. 1995;274:1296–1298.3. 5. Australasia Society for Ultrasound in Medicine (ASUM). Statement on Use of ‘Superficial Femoral Vein’ Term. http://hosted.verticalresponse.com/1278897/74615a8ee1/545444629/804d8fbe22/ 6. Interventional Radiology Society of Australasia (IRSA). Use of the term “superficial femoral vein”. http://www.irsa.com.au/news/76-use-of-the-term-superficial-femoral-vein. Kevin Rice, MD serves as the Medical Director of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a Member of 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 launched Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. Due to his online teaching activities, Dr. Rice was nominated and became a semifinalist for a "Minnie" award for the Most Effective Radiology Educator in 2016. Follow Dr. Rice on Twitter @KevinRiceMD All Posts by Kevin M Rice, MD

Thyroid Nodule • Xray of the Week 2017 • Week #40 What is the TI-RADS Score of this nodule? What would you do next? Figure 1: Thyroid Ultrasound. TI-RADS Scoring Here is how I scored it: Composition: Solid or almost completely solid - 2 points Echogenicity: Hypoechoic - 2 points Shape: Taller-than-wide - 3 points Margin: Lobulated or irregular - 2 points Echogenic Foci: Punctate echogenic foci - 3 points TOTAL: 12 TIRADS 5 - Highly Suspicious, Needs FNA. Biopsy was performed and it showed thyroid papillary cancer. Figure 2: Thyroid Ultrasound. Arrows showing the punctate echogenic foci. The ACR Thyroid Imaging Reporting and Data System (TI-RADS) is a system that can take the guess work out of reading thyroid ultrasounds. The goal is to improve quality and decrease unnecessary biopsies. Figure 3: ACR TI-RADS System More TI-RADS Resources here: https://www.globalradcme.com/acr-tirads-resources References: 1. ACR TI-RADS ATLAS 2. Grant, E G, Tessler, FN, Hoang, JK, Langer, JE, Beland, MD, Berland, LL, Cronan JJ, Desser, TS, Frates, MC, Hamper, UM, Middleton, WD, Reading, CC, Scoutt, LM, Stavros, AT and Teefy, SA. (2015). Thyroid Ultrasound Reporting Lexicon: White Paper of the ACR Thyroid Imaging, Reporting and Data System (TIRADS) Committee. Journal of the American College of Radiology,12(12), 1272-1279. http://www.jacr.org/article/S1546-1440(15)00684-5/abstract 3. Franklin N. Tessler, MD, CMCorrespondence information about the author MD, CM Franklin N. TesslerEmail the author MD, CM Franklin N. Tessler, William D. Middleton, MD, Edward G. Grant, MD, Jenny K. Hoang, MBBS, Lincoln L. Berland, MD, Sharlene A. Teefey, MD, John J. Cronan, MD, Michael D. Beland, MD, Terry S. Desser, MD, Mary C. Frates, MD, Lynwood W. Hammers, DO, Ulrike M. Hamper, MD, Jill E. Langer, MD, Carl C. Reading, MD, Leslie M. Scoutt, MD, A. Thomas Stavros, MD ACR Thyroid Imaging, Reporting and Data System (TI-RADS): White Paper of the ACR TI-RADS Committee. http://www.jacr.org/article/S1546-1440(17)30186-2/fulltext Kevin Rice, MD serves as the Chair of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is the Chief Compliance Officer of 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 co-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

Transient Left Eye Blindness after Exercise • Xray of the Week This 73 year old male with a history of transient left eye blindness after exercise had a carotid doppler with evaluation of the ophthalmic arteries. What is the abnormality and what is the anatomic reason? Fig. 1A: No flow in the left internal carotid artery. Fig. 1B: Antegrade flow in the right ophthalmic artery. Note red color above the baseline in the ophthalmic artery. The pulsed Doppler signal is also above the baseline. Fig. 1C: Retrograde flow in the left ophthalmic artery. Note blue color below the baseline in the ophthalmic artery. The pulsed Doppler signal is also below the baseline. Fig. 2A. Normal flow direction shown with arrows in the arteries. There is normal antegrade flow in the ophthalmic artery (OA), signified by the red arrow. Fig. 2B Note the retrograde flow in the ophthalmic artery (OA), signified by the blue arrow. With occlusion of the internal carotid artery (ICA), peri-orbital collaterals from the ECA circulation open up, and flow is restored to the supra-clinoid segment of the ICA. Key: CCA: Common carotid artery ECA: External carotid artery ICA: Internal carotid artery FA: Facial artery AA: Angular artery STA: Superficial temporal artery STA (FA): Superficial temporal artery (Frontal artery-branch) OA: Ophthalmic artery STA: Supratrochlear artery Fig. 3. Neovascularization of the iris (NVI), also known as rubeosis iridis, is when small fine, blood vessels (black arrows) develop on the anterior surface of the iris in response to retinal ischemia. These changes most often develop at the pupillary border (yellow arrow). Ophthalmic Image by EyeRounds.org, The University of Iowa is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License. Discussion Retrograde flow in the ophthalmic artery can be seen with ICA occlusion or severe stenosis and may lead to transient orbital ischemia. (1,2,3) Due to the decreased flow to the globe, this may present as transient monocular blindness after exposure to bright light, position-induced visual loss, postprandial transient visual loss, exercise-induced visual loss, or visual loss following facial heating.(1,2,3) Patients with markedly diminished flow to the globe may eventually develop rubeosis iridis (Fig.3) which is defined as neovascularization of the iris in response to retinal ischemia.(3,4) This may in turn lead to the development of neovascular glaucoma. Therefore, these patients should be treated with superficial temporal artery to middle cerebral artery (STA-MCA) bypass to avoid this serious complication.(3) References: 1. Anupriya Arthur, et al. Ophthalmic masquerades of the atherosclerotic carotids. Indian Journal of Ophthalmology. 2014. Volume 62, Page 472-476 2. Yamamoto K, Mori T, Yasuhara M, et al. Ophthalmic artery blood flow in patients with internal carotid artery occlusion. Br J Ophthalmol. 2004 Apr; 88(4): 505–508. doi: 10.1136/bjo.2003.025809 3. CL Tsai, et al. Reversal of ophthalmic artery flow as a predictor of intracranial hemodynamic compromise: implication for prognosis of severe carotid stenosis. European Journal of Neurology Volume 20, Issue 3, pages 564–570, March 2013 4. Beebe, J and Haugsdal J. Rubeosis iridis or neovascularization of the iris in diabetes. Accessed 11/10/2018. EyeRounds.org. https://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/NVI/index.htm Kevin Rice, MD is the president of Global Radiology CME and serves as the Chief of Staff and Chair of the Radiology Department at 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 co-founded Global Radiology CME with Natalie Rice 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 Device • Xray of the Week Routine CXR for cough demonstrates metallic device. Name the cardiac implant. Fig. 1 Device is within the myocardium of the right ventricle and is an implanted cardiac pacemaker. Fig. 2 A different patient with 2 cardiac devices. Device A is within the myocardium of the right ventricle and is an implanted pacemaker. Device B is within the chest wall and is an implanted cardiac loop recorder. Fig. 3 CT scan of a different patient with a Micra intracardiac pacemaker within the myocardium of the right ventricle. Fig 4. The Micra intracardiac pacemaker. Fig 5. Video showing the technique for implantation of the leadless cardiac pacemaker. The Micra™ transcatheter pacing system (TPS) is the world’s smallest pacemaker, (1) delivered percutaneously via a minimally invasive approach, directly into the right ventricle and does not require the use of leads. It has a 99% implant success rate (2,3) and 63% fewer major complications than traditional pacemakers. (3) The Micra Pacing Capsule is 93% smaller than conventional pacemakers (4) and has an estimated average 12-year battery longevity.(2,5) The device is MRI safe up to 3 Tesla. (2). References: 1. Nippoldt D, Whiting J. Micra Transcatheter Pacing System: Device Volume Characterization Comparison. November 2014. Medtronic Data on File. 2. Reynolds DW, Duray GZ, Omar R, et al. A Leadless Intracardiac Transcatheter Pacing System. N Engl J Med. Published online November 9, 2015. 3. El-Chami M, et al. Leadless Pacemaker Implant in Patients with Pre-Existing Infections: Results from the Micra Post-Approval Registry. Presented at HRS May 2018. Boston, MA 4. Williams E, Whiting J. Micra Transcatheter Pacing System Size Comparison, November 2014, Medtronic Data on File. 5. Duray GZ. Ritter P, el-Chami M, et al. Long-term performance of a transcatheter pacing system: 12-Month results from the Micra Transcatheter Pacing Study. Heart Rhythm. Published online February 10, 2017. 6. Medtronic Micra Implant Manual, April, 2015 7. Eggen M, Grubac V, Bonner M. Design and Evaluation of a Novel Fixation Mechanism for a Transcatheter Pacemaker. IEEE Trans Biomed Eng. September 2015;62(9):2316-2323. 8. Eggen, M. FlexFix Tine Design. April 2015. Medtronic Data on File. 9. Bonner M, et al. Pacing Clin Electrophysiol. 2015;38:1248-1259. 10. Medtronic Micra Transcatheter Pacing System Website Related posts: Bicuspid Aortic Valve and Aortic Stenosis Implanted Cardiac Loop Recorder Cardiac Tamponade Following Coronary Artery Rotational Atherectomy Papillary Fibroelastoma of Aortic Valve CardioMEMS Device Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice 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. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

SOB and Hypotension Following Coronary Artery Rotational Atherectomy • Xray of the Week This 85 year old female became short of breath, hypotensive, and lethargic shortly after rotational atherectomy of the right coronary artery. The cardiologist was concerned that there may be a retroperitoneal hemorrhage related to the femoral artery puncture, and ordered a CT abdomen and pelvis. What is the diagnosis and treatment? Figure 1A: Axial CT of lower chest. Figure 1B: Axial CT at the level of the vascular sheaths in the RLQ. Figure 1C: Coronal CT abdomen and pelvis. Figure 2A: Axial CT showing pericardial effusion (white arrows). Figure 2B: Axial CT showing no abnormality at the level of the vascular sheaths in the RLQ (white arrow). Figure 2C: Coronal CT showing pericardial effusion (white arrows). The images demonstrate no retroperitoneal abnormality. However, the CT scan demonstrates a large pericardial effusion (Figs. 1A, 1C, 2A, 2C) and, based on the clinical findings cardiac tamponade is suspected. An echocardiogram was performed which demonstrates right ventricular collapse in early diastole and right atrial inversion in late diastole in addition to the moderate sized pericardial effusion. (Fig. 3) A dilated inferior vena cava without respiratory variation was also seen, all signs of cardiac tamponade. Emergent pericardiocentesis and pericardial drainage catheter placement was performed resulting in rapid improvement in the patient's condition, no longer requiring pressors. Figure 3: Apical 4 chamber view showing right ventricular collapse in early diastole and right atrial inversion in late diastole. There is also a moderate sized pericardial effusion. Discussion Rotational atherectomy is increasingly being used for percutaneous coronary intervention due to the of the expansion of indications to more complex lesions (1,2,3). However, the compared to angioplasty, percutaneous transluminal rotational atherectomy has four times the risk for coronary artery perforation (1,3). The incidence of important procedure-related complications from rotational atherectomy is 1.3%, and the incidence of tamponade is 0.64% (4). Beck's triad consisting of jugular venous distension, distant heart sounds, and hypotension is the classic presentation of cardiac tamponade. Other symptoms of tamponade include severe respiratory distress, tachycardia, and agitation. Pulsus paradoxus, low voltage QRS complex on EKG, and a chest x-ray with enlarged cardiac silhouette may also be seen with tamponade (5). Even a small amount of pericardial fluid may cause tamponade in the acute setting, whereas a large amount of fluid accumulated over a long period of time may not cause tamponade. Treatment is pericardiocentesis and placement of a pericardial drain preferably with ultrasound guidance. Rapid treatment is often life-saving, resulting in prompt improvement in the patient's condition. Thoracotomy may be required in severe trauma. (6) Cardiac tamponade is in the differential diagnosis of pulseless electrical activity (PEA). References: 1. Wasiak J, Law J, Watson P, Spinks A. Percutaneous transluminal rotational atherectomy for coronary artery disease. Cochrane Database Syst Rev. 2012 Dec 12 2. Lee MS. Rotational Atherectomy: An Invaluable Tool for Complex Lesions. Cath Lab Digest Issue Number: Volume 19 - Issue 6 - June 2011 3. Gunning, MG, et al. Coronary artery perforation during percutaneous intervention: incidence and outcome. Heart. 2002 Nov; 88(5): 495–498. 4. Sakakura K, Inohara T, Kohsaka S, et al. Incidence and Determinants of Complications in Rotational Atherectomy. Circulation: Cardiovascular Interventions. 2016;9:e004278 5. Spodick DH. Acute Cardiac Tamponade. N Engl J Med 2003; 349:684-690 August 14, 2003 6. Shekar PS, Leacche M ,Farnam KA, et al. Surgical Management of Complications of Percutaneous Coronary Rotational Atherectomy Interventions. Ann Thorac Surg 2004;78:e81–2 Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice has served in many leadership positions; he has been the Chair of the Radiology Department and Chief of Staff 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

RLQ Pain in 54 M • Xray of the Week This 54 year old male presented to the Emergency Department with right lower quadrant pain and vomiting. What is the diagnosis? Axial CT with contrast. There is a thick-walled diverticulum arising from the distal ileum with surrounding mesenteric edema, and mural enhancement diagnostic of Meckel diverticulitis. (blue arrow) Discussion Present in 2% of the population, Meckel diverticulum forms as a result of incomplete closure of the intestinal end of the omphalomesenteric duct, and is present within 40–100 cm of the ileocecal valve. The total lifetime complication rate of a Meckel diverticulum is approximately 4%. Complications include intestinal obstruction (40%) and diverticulitis (20%), torsion, intussusception, and hemorrhage. The symptoms are non specific and are most commonly attributed to appendicitis. CT scan demonstrates an inflamed diverticulum in the RLQ or midline with a normal appendix. The diverticulum may contain calcified enteroliths. Treatment is surgical excision. References: 1. Bennett GL, Birnbaum BA, Balthazar EJ. CT of Meckel's diverticulitis in 11 patients. AJR Am J Roentgenol. 2004;182 (3): 625-9. AJR Am J Roentgenol (full text) 2. Wong CS, Dupley L, Varia HN, Golka D, Linn T. Meckel's diverticulitis: a rare entity of Meckel's diverticulum. J Surg Case Rep. 2017;2017(1):rjw225. Published 2017 Jan 6. doi:10.1093/jscr/rjw225 3.Thurley PD, Halliday KE, Somers JM et-al. Radiological features of Meckel's diverticulum and its complications. Clin Radiol. 2009;64 (2): 109-18. DOI: https://doi.org/10.1016/j.crad.2008.07.012 4. Milam RA, Fonseca RB. Case 240: Meckel Diverticulitis. Radiology 2017; 283:303–307 https://pubs.rsna.org/doi/full/10.1148/radiol.2017150885 5. Elsayes KM, Menias CO, Harvin HJ et-al. Imaging manifestations of Meckel's diverticulum. AJR Am J Roentgenol. 2007;189 (1): 81-8. 6. Kotha VK, Khandelwal A, Saboo SS, et al. Radiologist's perspective for the Meckel's diverticulum and its complications. Br J Radiol. 2014;87(1037):20130743. doi:10.1259/bjr.20130743 7. Platon A, Gervaz P, Becker CD, Morel P, Poletti PA. Computed tomography of complicated Meckel's diverticulum in adults: a pictorial review. Insights Imaging. 2010;1(2):53–61. doi:10.1007/s13244-010-0017-8 Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice has served in many leadership positions; he has been the Chair of the Radiology Department and Chief of Staff of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances and given 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

50-year-old male in a motor vehicle collision (MVC) presenting with hypotension. What is the diagnosis? • Xray of the Week Figure 1. Abdominal CT. Name the significant findings. Figure 2. A) Axial CT - bilateral striated nephrogram (red arrows). B) Axial CT - retroperitoneal hematoma (yellow arrows). C) Coronal CT – bilateral striated nephrogram (red arrows). Discussion: As a result of trauma this patient is hypotensive due to a large retroperitoneal hematoma which is partially visualized on these images. Patients with blunt trauma who are hypotensive and tachycardic are deemed to be in hemorrhagic shock until proven otherwise [1]. A striated nephrogram refers to a mixture of alternating low-attenuating and normal-enhancing bands within the kidney arranged radially on CT [2]. The pattern is due to any process that causes inflammation or edema in the renal cortex or medulla [3]. Striated nephrograms can be unilateral or bilateral, depending on the underlying pathology. Common causes of unilateral striated nephrogram include ureteric obstruction, acute pyelonephritis, renal contusion, and renal vein thrombosis. Bilateral striated nephrogram can be seen with hypotension, autosomal recessive polycystic kidney disease, acute pyelonephritis, and acute tubular necrosis [2,4]. Retroperitoneal hematoma is frequently due to traumatic vascular injury but can be associated with ruptured aortic aneurysm, coagulopathy, or iatrogenesis [5]. Hypotension is the principal finding; yet some patients may present with abdominal tenderness, distension and/or flank pain. CT is the imaging modality of choice if retroperitoneal hematoma is suspected clinically [5]. Acute and subacute hematomas have high attenuation on CT whereas chronic hematomas are often low in attenuation [6]. Treatment is dependent on the cause of the hematoma and patient condition with supportive care including blood transfusion, reversal of any coagulopathy, and observation for stable patients. Angiography with embolization or rarely surgery may be required for unstable patients [5]. ​​​​ References: Barkin AZ, Fischer CM, Berkman MR, Rosen CL. Blunt abdominal trauma and a diaphragmatic injury. J Emerg Med. 2007;32(1):113-117. doi:10.1016/j.jemermed.2006.11.001 Wolin EA, Hartman DS, Olson JR. Nephrographic and pyelographic analysis of CT urography: differential diagnosis. AJR Am J Roentgenol. 2013;200(6):1197-1203. doi:10.2214/AJR.12.9692 Moinuddin I, Bracamonte E, Thajudeen B, Sussman A, Madhrira M, Costello J. Allergic Interstitial Nephritis Manifesting as a Striated Nephrogram. Case Rep Med. 2015;2015:250530. PMCID: PMC4667022 doi:10.1155/2015/250530 Saunders HS, Dyer RB, Shifrin RY, Scharling ES, Bechtold RE, Zagoria RJ. The CT nephrogram: implications for evaluation of urinary tract disease. Radiographics. 1995;15(5):1069-1088. doi:10.1148/radiographics.15.5.7501851 Mondie C, Maguire NJ, Rentea RM. Retroperitoneal Hematoma. [Updated 2020 Nov 12]. In: StatPearls https://www.ncbi.nlm.nih.gov/books/NBK558928/ Rajiah P, Sinha R, Cuevas C, Dubinsky TJ, Bush WH Jr, Kolokythas O. Imaging of uncommon retroperitoneal masses. Radiographics. 2011;31(4):949-976. doi:10.1148/rg.314095132 Deven Champaneri is a medical student at Edward Via College Osteopathic Medicine (VCOM) – Carolinas and plans to pursue residency in diagnostic radiology. While he was rotating through various specialties, he realized his passion for DR and valued its role in all aspects of medicine. He graduated from the University of South Carolina in 2017 with a degree in Business Marketing. During his undergraduate studies, he was involved with multiple volunteer organizations, such as Camp Kemo a summer camp for children with cancer and Palmetto Richland Children’s Hospital. Currently, he mentors at-risk high-school students and tutors students for Step 1/COMLEX 1. In his spare time he enjoys, golfing, backpacking, cooking, and spending time with family. Follow Deven Champaneri on Twitter @devenchampaneri All posts by Deven Champaneri Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice is a radiologist with Renaissance Imaging Medical Associates and is currently the Vice 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. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

Trauma in a 31 yo F due to a motor vehicle collision (MVC) • Xray of the Week Figure 1. What are the important findings on this CT scan. What is the diagnosis? Figure 2. A,B. Sagittal reformatted CT images. C-E. Axial CT images Images show horizontal fracture through the right lamina (orange arrows), right pedicle (green arrows) and left pedicle (red arrows). Fracture of the spinous process (blue arrows) is also present. Discussion: Chance fractures are horizontal spinal fractures that extend through the spinous process, pedicles, and vertebral body at the thoracolumbar junction [1]. They typically result from flexion-distraction injury of the spine and may be referred to as “seat belt fractures” because they can occur in motor vehicle collisions where rapid deceleration causes flexion of the spine over the seat belt [1]. This causes distraction of the middle and posterior elements of the spine [1]. Table 1. Francis Denis Spine Fracture Classification System Source: https://www.researchgate.net/figure/Column-involvement-in-major-Denis-fracture-types_tbl1_288817814 The Chance fracture is classified as an unstable flexion-distraction spinal injury according to the Francis Denis three-column concept (Table 1) because it involves two or more columns: a distraction-type injury of the middle and posterior columns; compression-type injury of the anterior column may also be present in some cases [1,2]. Chance fractures can be identified as pure osseous, pure ligamentous, or osteoligamentous [1,2]. Chance fractures are difficult to identify as they do not present with neurological deficits but can present with intra-abdominal injuries [1]. Delays in diagnosis can result in progressive kyphosis and pain, so early diagnosis is essential. Differential diagnosis includes burst fracture, compression fracture, and distraction injury [1,3]. Figure 3. Axial CT image demonstrating the seat belt sign in this patient with stranding in the subcutaneous fat of the abdominal wall (red arrows). CT shows the horizontal fracture as well as vertebral body compression [1]. Stranding in the subcutaneous fat of the abdominal wall results in the “seat belt sign” on CT [1] (Fig. 3). CT also shows “dissolving pedicle,” which refers to the progressive decrease in pedicle definition from anterior to posterior [3]. On MRI, there may be a bright T2 signal signifying edema with low signal intensity fracture lines, intervertebral disc injury, and spinal cord edema [1]. Plain radiograph shows empty vertebral body sign, which results from displacement of the spinous processes [3]. Increased distance between the pedicles and facet joints on plain X-ray may also be seen in a Chance fracture [3]. Treatment includes immobilization with a stabilizing brace in patients without neurological deficits [1]. Surgical stabilization may be required in patients who have neurological deficits or damage to the posterior ligaments [1]. ​​​​ References: Koay J, Davis DD, Hogg JP. Chance Fractures. In: StatPearls. Treasure Island (FL): StatPearls Publishing; December 2, 2020. https://pubmed.ncbi.nlm.nih.gov/30725611/ Raniga SB, Skalski MR, Kirwadi A, Menon VK, Al-Azri FH, Butt S. Thoracolumbar Spine Injury at CT: Trauma/Emergency Radiology. Radiographics. 2016;36(7):2234-2235. doi:10.1148/rg.2016160058 Bernstein MP, Mirvis SE, Shanmuganathan K. Chance-type fractures of the thoracolumbar spine: imaging analysis in 53 patients. AJR Am J Roentgenol. 2006;187(4):859-868. doi:10.2214/AJR.05.0145 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 Dr. Rice is a radiologist with Renaissance Imaging Medical Associates and is currently the Vice 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. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD