24-year-old male with leg pain. Diagnosis? • Xray of the Week Figure 1. Radiographs of the left knee. (A) Frontal radiograph demonstrates an aggressive lesion centered in the distal left femur with a large mineralized soft-tissue component (yellow arrows). (B) Lateral radiograph further demonstrates the densely mineralized lesion and associated soft-tissue mass arising from the distal femur (yellow arrows). Figure 2. Postoperative CT Scan of the left femur. (A) Frontal CT Scout image demonstrates postoperative changes with metallic endoprosthetic reconstruction of the distal femur extending across the knee (yellow arrow). (B) Coronal CT image demonstrates the postoperative femoral reconstruction and prosthetic components (yellow arrow). Figure 3. Pulmonary metastatic disease in osteosarcoma. Axial CT image of the chest demonstrates peripheral pulmonary nodules (red arrows), consistent with pulmonary metastatic disease in this patient. Figure 4. Recurrent osteosarcoma with calcified pulmonary metastases in a different patient. (A) Coronal CT image demonstrates densely calcified pulmonary metastatic nodules (yellow arrows). (B) Postoperative radiograph demonstrates mineralized recurrent soft-tissue disease adjacent to the distal femoral endoprosthesis (red arrow). (C) Magnified radiograph further demonstrates the mineralized recurrent tumor adjacent to the prosthesis (black arrow). Epidemiology Osteosarcoma is the most common primary malignant bone tumor in children and adolescents, with an incidence of approximately 3–5 cases per million persons per year in younger populations [1,2]. Incidence peaks during adolescence and is slightly higher in males [1]. Osteosarcoma most commonly arises in the metaphyses of long bones, particularly around the knee. The distal femur is the most frequent site, followed by the proximal tibia and proximal humerus [1]. Clinical Findings Pain is the most common presenting symptom of osteosarcoma and may initially be intermittent before becoming persistent. Local swelling, a palpable mass, restricted joint movement, and limp may occur as the tumor enlarges. Pathological fracture is an uncommon presentation, while systemic symptoms are generally unusual [2,3]. In the primary case, the 24-year-old male presented with left leg pain. Pathology Osteosarcoma is a malignant mesenchymal neoplasm characterized by production of osteoid or immature bone directly by malignant tumor cells [2,3]. Conventional osteosarcoma is typically a high-grade intramedullary tumor composed of malignant pleomorphic cells with variable production of osteoid and other extracellular matrix. Tumor osteoid is often irregular and disorganized and may undergo mineralization. Histological response following neoadjuvant chemotherapy, particularly the degree of tumor necrosis, has important prognostic significance [2]. Classification Osteosarcoma comprises seven recognized primary subtypes: conventional, telangiectatic, low-grade central, small cell, parosteal, periosteal, and high-grade surface osteosarcoma [3,4]. Conventional osteosarcoma is the most common subtype, accounting for approximately 75–80% of cases, and may demonstrate osteoblastic, chondroblastic, or fibroblastic differentiation according to the predominant matrix [3,4]. Surface osteosarcomas include parosteal, periosteal, and high-grade surface variants, which differ in histologic grade, imaging appearance, treatment, and prognosis [4]. Radiographic Features Plain radiography is usually the initial imaging modality. Conventional osteosarcoma typically appears as an aggressive metaphyseal lesion with mixed lytic and sclerotic components, cortical destruction, an ill-defined zone of transition, mineralized osteoid matrix, and an associated soft-tissue mass (Fig. 1) . Aggressive periosteal reactions, including sunburst-type spiculation and a Codman triangle, may occur [2,4,5]. CT better depicts cortical destruction and mineralized tumor matrix and is important for assessment of pulmonary metastatic disease [4,5]. MRI is the preferred modality for local staging, defining intramedullary and soft-tissue extent, relationship to neurovascular structures and joints, and the presence of skip lesions [2,4]. Pulmonary metastases usually appear as solid pulmonary nodules on chest CT and may be multiple and bilateral. Calcification or ossification can occur (Figs. 3,4) and represents a recognized atypical appearance of osteosarcoma lung metastases [6]. Postoperative imaging provides a baseline for assessment of the reconstruction and subsequent surveillance. Comparison with prior examinations is important when evaluating for suspected local recurrence, with MRI particularly useful for assessing recurrent soft-tissue disease [7]. Treatment and Prognosis Treatment of high-grade osteosarcoma generally combines systemic chemotherapy with complete surgical resection of the primary tumor. Limb-salvage surgery (Fig. 2) is feasible in many patients when adequate oncologic margins and a functional extremity can be achieved; amputation remains necessary in selected cases [8-10]. Histologic response to chemotherapy and the presence of metastatic disease are important prognostic factors [9]. Contemporary series report 5-year survival of approximately 70–75% for patients with localized extremity osteosarcoma, whereas outcomes are substantially poorer in patients with metastatic or recurrent disease. The lungs are the predominant site of distant metastasis. In patients with resectable pulmonary metastatic disease, complete surgical removal of metastases is an important component of management and is associated with better outcomes in selected patients [7]. Conclusion Osteosarcoma is an aggressive primary bone malignancy that predominantly affects adolescents and young adults. Imaging plays a central role in diagnosis, local staging, treatment planning, and surveillance. Recognition of characteristic aggressive osseous features and careful assessment for pulmonary metastatic and recurrent disease are essential because disease stage and treatment response strongly influence prognosis. References Ottaviani G, Jaffe N. The epidemiology of osteosarcoma. Cancer Treat Res. 2009;152:313. https://doi.org/10.1007/978-1-4419-0284-9_1 Durfee RA, Mohammed M, Luu HH. Review of osteosarcoma and current management. Rheumatol Ther. 2016;3(2):221-243. https://doi.org/10.1007/s40744-016-0046-y Fox MG, Trotta BM. Osteosarcoma: review of the various types with emphasis on recent advancements in imaging. Semin Musculoskelet Radiol. 2013;17(2):123-136. https://doi.org/10.1055/s-0033-1342969 Yarmish G, Klein MJ, Landa J, Lefkowitz RA, Hwang S. Imaging characteristics of primary osteosarcoma: nonconventional subtypes. Radiographics. 2010;30(6):1653- 1672. https://doi.org/10.1148/rg.306105524 Crombé A, et al. Imaging of osteosarcoma: presenting findings, metastatic patterns, and features related to prognosis. J Clin Med. 2024;13(19):5710. https://doi.org/10.3390/jcm13195710 Silva JAM, Marchiori E, Amorim VB, Barreto MM, et al. CT features of osteosarcoma lung metastasis: a retrospective study of 127 patients. J Bras Pneumol. 2023;49(2):e20220433. https://doi.org/10.36416/1806-3756/e20220433 Garner HW, Kransdorf MJ, Peterson JJ. Posttherapy imaging of musculoskeletal neoplasms. Radiol Clin North Am. 2011;49(6):1307-1323. https://doi.org/10.1016/j.rcl.2011.07.011 Bielack SS, Kempf-Bielack B, Delling G, et al. Prognostic factors in high-grade osteosarcoma of the extremities or trunk: an analysis of 1,702 patients treated on neoadjuvant Cooperative Osteosarcoma Study Group protocols. J Clin Oncol. 2002;20(3):776-790. https://doi.org/10.1200/JCO.2002.20.3.776 Luetke A, Meyers PA, Lewis I, Juergens H. Osteosarcoma treatment—where do we stand? A state of the art review. Cancer Treat Rev. 2014;40(4):523-532. https://doi.org/10.1016/j.ctrv.2013.11.006 Briccoli A, Rocca M, Salone M, Guzzardella GA, Balladelli A, Bacci G. High grade osteosarcoma of the extremities metastatic to the lung: long-term results in 323 patients treated combining surgery and chemotherapy, 1985-2005. Surg Oncol. 2010;19(4):193-199. https://doi.org/10.1016/j.suronc.2009.05.002 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. All posts by Umaiza Ihsan, MD 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

Dizziness and syncope. Diagnosis? • Xray of the Week Figure 1. What is this foreign body in the chest? Figure 2. Dislodged leadless pacemaker within the left pulmonary arterial circulation. (A) Frontal chest radiograph demonstrates the radiopaque leadless pacemaker projecting over the left hilar region (red arrow), rather than its expected position within the right ventricle. (B) Axial CT image confirms the leadless pacemaker within the left pulmonary arterial circulation (red arrow). Figure 3. Frontal and lateral CXR. Normal position of leadless pacemaker in a different patient (A) in the right ventricle. Incidental cardiac loop recorder (B). Epidemiology Leadless pacemaker dislodgement is an uncommon complication of implantation. In the Micra Post-Approval Registry, device dislodgement occurred in 0.13% of patients within 30 days [1]. More recent post-market data reported dislodgement and/or embolization in 0.29% of 72,237 Micra VR implants and 0.88% of 5,990 AVEIR VR implants [2]. Migration into the pulmonary arterial circulation is particularly rare and has predominantly been described in case reports [3-5]. Clinical Findings Leadless pacemaker dislodgement may be clinically silent or associated with pacemaker malfunction [3-5]. Device displacement may result in abnormal pacing parameters or loss of capture [3-6]. In this case, the patient presented with dizziness and syncope. Pulmonary artery embolization itself may remain asymptomatic, although serious vascular complications can rarely occur [5-7]. Pathology Leadless pacemakers are implanted directly into the right ventricular endocardium and use dedicated fixation mechanisms to maintain device stability [8]. Inadequate fixation or device release problems may result in dislodgement and subsequent embolization into the pulmonary arterial circulation [2,5]. Once dislodged from the right ventricle, the device may pass through the right ventricular outflow tract and pulmonary valve and lodge within a pulmonary arterial branch [3-5]. Radiographic Features On chest radiography, a normally positioned leadless pacemaker appears as a radiopaque device implanted within the right ventricular wall [9,10]. Device dislodgement should be suspected when the pacemaker is no longer seen in its expected intracardiac position and instead projects over the pulmonary arterial circulation (Figure 1A). Serial radiographs, when available, may demonstrate interval migration [5]. CT provides cross-sectional anatomic localization of an embolized device within the pulmonary vasculature and can delineate its relationship to adjacent pulmonary arterial branches (Figure 1B) [10]. Published cases demonstrate embolization into both central and more peripheral pulmonary arterial branches [3-5]. Treatment and Prognosis Management of an embolized leadless pacemaker depends on device location, clinical status, duration since implantation, and feasibility of retrieval [3,11]. Percutaneous retrieval may be performed using snare-based techniques introduced through a large-bore delivery catheter or steerable sheath [3,4,7,11]. When complete endovascular removal is not technically feasible, a surgical component may occasionally be required [4]. Following successful retrieval, further pacing therapy can be provided when clinically indicated [3,11]. Conclusion Leadless pacemaker dislodgement with pulmonary arterial embolization is a rare complication that may be clinically silent or result in pacemaker dysfunction and potentially serious vascular complications. Chest radiography can identify abnormal device position, while CT provides more precise anatomic localization within the pulmonary arterial circulation. Prompt recognition of device migration is important for guiding subsequent management. References 1. Roberts PR, Clementy N, Al Samadi F, et al. A leadless pacemaker in the real-world setting: the Micra Transcatheter Pacing System Post-Approval Registry. Heart Rhythm. 2017;14(9):1375-1379. https://doi.org/10.1016/j.hrthm.2017.05.017 2. Bahbah A, Sengupta J, Witt D, et al. Device dislodgement and embolization associated with a new leadless pacemaker. J Cardiovasc Electrophysiol. 2024;35(12):2483 2486. https://doi.org/10.1111/jce.16485 3. Terricabras M, Khaykin Y. Successful leadless pacemaker retrieval from the left pulmonary artery: a case report. HeartRhythm Case Rep. 2020;6(10):798-799. https://doi.org/10.1016/j.hrcr.2020.08.004 4. Barbieri F, Kranewitter C, Frech A, Hintringer F, Stühlinger M. Lost but not lost—embolization of a leadless pacemaker to the pulmonary artery with consecutive endovascular recovery. J Cardiovasc Dev Dis. 2021;8(4):37. https://doi.org/10.3390/jcdd8040037 5. Sugiura K, Baba Y, Hirota T, Kubo T, Kitaoka H. A drifting dislodged leadless pacemaker in the bilateral pulmonary arteries. JACC Case Rep. 2022;4(14):844-846. https://doi.org/10.1016/j.jaccas.2022.03.034 6. Amin MI, Saif S, Shivappa S, Noor H. Leadless pacemaker dislodgment: difficulty in release as a predictor for dislodgment and tools for successful retrieval. Heart Rhythm O2. 2024;5(10):739-740. https://doi.org/10.1016/j.hroo.2024.08.010 7. Abraham H, Assar MD, Chugh Y. A novel technique for percutaneous retrieval of an embolized atrial leadless pacemaker from the pulmonary artery. JACC Cardiovasc Interv. 2026;19(10):1333-1335. https://doi.org/10.1016/j.jcin.2026.02.025 8. El-Chami MF, Roberts PR, Kypta A, Omdahl P, Bonner MD, Kowal RC, Duray GZ. How to implant a leadless pacemaker with a tine-based fixation. J Cardiovasc Electrophysiol. 2016;27(12):1495-1501. https://doi.org/10.1111/jce.13092 9. Mathew RP, Alexander T, Patel V, Low G. Chest radiographs of cardiac devices (Part 1): cardiovascular implantable electronic devices, cardiac valve prostheses and Amplatzer occluder devices. S Afr J Radiol. 2019;23(1):1730. https://doi.org/10.4102/sajr.v23i1.1730 10. Conyers JM, Rajiah P, Ahn R, Abbara S, Saboo SS. Imaging features of leadless cardiovascular devices. Diagn Interv Radiol. 2018;24(4):203-208. https://doi.org/10.5152/dir.2018.17462 11. Afzal MR, Daoud EG, Cunnane R, et al. Techniques for successful early retrieval of the Micra transcatheter pacing system: a worldwide experience. Heart Rhythm. 2018;15(6):841-846. https://doi.org/10.1016/j.hrthm.2018.02.008 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. All posts by Umaiza Ihsan, MD 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

A 15-year-old female Gymnastics injury. Diagnosis? • Radiology Case of the Week Figure 1. A 15-year-old female Gymnastics injury. Diagnosis? Figure 2. A. Cross-table lateral radiograph of the left knee. The patella (red arrows) is projected over the anterior femoral condyles (yellow arrow). B. Anteroposterior radiograph of the left knee. The patella (red arrows) is displaced laterally and lies beside the lateral femoral condyle (yellow arrow). C. Axial patellofemoral view of the left knee. The patella (red arrow) lies lateral to the lateral femoral condyle (yellow arrow), outside the trochlear groove (green arrow).. Epidemiology Lateral patellar dislocation is a common knee injury, particularly in children and adolescents. Acute patellar dislocation affects approximately 1 in 1000 healthy children aged 9–15 years, with the highest incidence occurring during adolescence. The injury is frequently associated with acute trauma or sporting activity [1,2]. Clinical Findings Patients typically present with acute knee pain, swelling, and limited range of motion following trauma. The patella frequently reduces spontaneously during knee extension. When persistent, the patella remains displaced laterally. Joint effusion and tenderness along the medial retinaculum are common, and the patellar apprehension test may be positive [2]. In the present case, the patient is a 15-year-old female and presents with lateral patellar dislocation following trauma. Pathology Lateral patellar dislocation results from displacement of the patella from the trochlear groove, with injury to the medial patellar stabilizers, particularly the medial patellofemoral ligament (MPFL) [3,5]. The patella may impact the lateral femoral condyle during dislocation, resulting in chondral or osteochondral injury. Predisposing anatomic factors include trochlear dysplasia, patella alta, lateral patellar tilt or subluxation, increased Q angle, femoral anteversion, and lateralization of the patellar tendon insertion [3,5]. Classification Patellar dislocations are classified according to the direction of displacement as lateral, medial, superior, or inferior. Lateral dislocation is the most common and typically occurs when the patella is displaced laterally from the trochlear groove. They may also be categorized as acute, recurrent, or chronic based on the clinical course [4]. Radiographic Features The standard radiographic series includes anteroposterior (AP), true lateral, and axial (sunrise) views. In this case, the patella is laterally displaced on the AP view and lies outside the trochlear groove on the axial view, consistent with lateral patellar dislocation (Fig. 2 C). Radiographs may also demonstrate joint effusion, lipohemarthrosis, osteochondral fracture of the medial patella, lateral patellar tilt or subluxation, and a deep lateral sulcus sign resulting from impaction of the lateral femoral condyle [5]. MRI is useful for further evaluation of associated soft-tissue and osteochondral injuries. Typical MRI findings include injury or disruption of the medial patellofemoral ligament (MPFL), bone marrow edema or contusions involving the medial patella and lateral femoral condyle, and predisposing anatomic abnormalities such as trochlear dysplasia and patella alta [3,5]. Treatment and Prognosis Initial management of a first-time lateral patellar dislocation generally involves reduction when necessary, followed by nonoperative treatment with bracing and rehabilitation focused on restoring range of motion and strengthening the quadriceps and medial stabilizers [6,7]. Surgical treatment may be considered in the presence of an associated osteochondral fracture, recurrent instability, or significant predisposing anatomic abnormalities [6,7]. Although many patients recover with conservative treatment, recurrent instability remains an important complication. Conclusion Lateral patellar dislocation is a common injury in adolescents and should be recognized promptly on radiographs. Assessment of patellar alignment, associated osteochondral injury, and underlying anatomic risk factors is important for appropriate management and prediction of recurrence. References: Sanders TL, Pareek A, Hewett TE, Stuart MJ, Dahm DL, Krych AJ. Incidence of First-Time Lateral Patellar Dislocation: A 21-Year Population-Based Study. Sports Health. 2018;10(2):146-151. DOI: 10.1177/1941738117725055 Gao B, Shi Y, Zhang F. Pediatric patellar dislocation. Minerva Pediatr. 2020;72(1):65-71. DOI: 10.23736/S0026-4946.17.04882-4 Earhart C, Patel DB, White EA, Gottsegen CJ, Forrester DM, Matcuk GR Jr. Transient lateral patellar dislocation: review of imaging findings, patellofemoral anatomy, and treatment options. Emerg Radiol. 2013;20(1):11-23. DOI: 10.1007/s10140-012-1073-9 Parikh SN, Lykissas MG. Classification of Lateral Patellar Instability in Children and Adolescents. Orthop Clin North Am. 2016;47(1):145-152. DOI: 10.1016/j.ocl.2015.08.016 5.Kim HK, Parikh S. Patellofemoral Instability in Children: Imaging Findings and Therapeutic Approaches. Korean J Radiol. 2022;23(6):674-687. DOI: 10.3348/kjr.2021.0577 Smith TO, Song F, Donell ST, Hing CB. Operative versus non-operative management of patellar dislocation. A meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2011;19(6):988-998. DOI: 10.1007/s00167-010-1355-2 Parikh SN, Schlechter JA, Veerkamp MW, et al. Consensus-Based Guidelines for Management of First-Time Patellar Dislocation in Adolescents. J Pediatr Orthop. 2024;44(4):e369-e374. DOI: 10.1097/BPO.0000000000002616 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. All posts by Umaiza Ihsan, MD 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

A 70-year-old female fell off her bed while changing a light bulb and complains of left shoulder pain. What is the diagnosis? • Xray of the Week Figure 1. Non-contrast CT of the cervical spine. What is the diagnosis? Figure 2. Non-contrast CT of the cervical spine (sagittal reconstructions): Bilateral facet dislocation at C7-T1 with anterior subluxation of C7 on T1. The inferior facets of C7 are locked anterior to the superior facets of T1 (yellow and green arrows), with anterior vertebral body translation present. There are associated fractures of C7 and T1 (red arrows). Figure 2. Non-contrast axial CT of the cervical spine: Bilateral facet dislocation at C7-T1 with naked facet sign (green arrow) and reverse hamburger bun sign (red arrow). Discussion The cervicothoracic junction (C7–T1) represents a biomechanical transition between the mobile cervical spine and the rigid thoracic spine, making it particularly vulnerable to traumatic instability. Bilateral facet dislocation at this level is a highly unstable injury most commonly associated with high-energy trauma but may also occur after low-energy falls in elderly patients due to osteopenia and degenerative stiffness. [1] The injury involves both facets "jumping" anteriorly, disrupting ligamentous stability and risking cord compression.[2] Delayed diagnosis can occur due to poor visualization of C7-T1 on plain films, emphasizing the need for CT in suspected cases.[3] As seen in this case, "teardrop" fragment on C7 or T1 represents a highly unstable flexion-compression or flexion-distraction injury; it is not a minor avulsion and signifies severe ligamentous damage.[5] Imaging Findings CT is the imaging modality of choice for evaluating suspected cervicothoracic junction trauma, as plain radiographs frequently fail to visualize C7–T1 due to shoulder overlap. Multiplanar CT reformations are essential for assessing alignment, facet integrity, and associated fractures. [1] Key CT findings include: High-grade anterior translation of C7 relative to T1 Bilateral jumped or locked facets with loss of normal facet articulation Widening of the interspinous distance indicating posterior ligamentous complex disruption Small anterior vertebral body fracture fragments at C7 and T1 consistent with flexion teardrop fractures Marked narrowing of the spinal canal at the C7–T1 level Axial CT images demonstrate bilateral reverse hamburger bun and naked facet signs, which are pathognomonic for facet dislocation. [2,3] Differential Diagnosis Traumatic bilateral facet dislocation must be distinguished from degenerative spondylolisthesis, which is common in geriatric patients but lacks joint capsule disruption and typically involves less than 4 mm of translation. Unilateral facet dislocation involves a rotational component and manifests as a "bow-tie" sign on lateral radiographs with less than 25% anterior translation. Isolated flexion teardrop fractures involve significant three-column injury but lack the mechanical "locking" of the facet joints seen in dislocations. Traumatic dislocation is favored when there is facet joint disruption, significant translation, and associated ligamentous injury. [1] Management and Prognosis Bilateral facet dislocation at C7–T1 represents a surgical emergency due to profound instability and high risk of neurologic deterioration. Initial management includes cervical immobilization and urgent neurosurgical consultation. Most cases require operative fixation, often via posterior or combined anterior-posterior approaches. Prognosis depends largely on neurologic status at presentation. [1] Key Learning Points C7–T1 injuries are frequently missed on plain radiographs Low-energy falls can cause severe cervical instability in elderly patients Reverse hamburger bun and naked facet signs are key CT indicators Anterior teardrop fractures signify severe ligamentous injury Early recognition and surgical management are critical Correlate with MRI for soft tissue/cord assessment. References Raniga SB, Menon V, Al Muzahmi KS, Butt S. MDCT of acute subaxial cervical spine trauma: a mechanism-based approach. Insights Imaging. 2014;5(3):321–338. doi: 10.1007/s13244-014-0311-y Daffner SD, Daffner RH. Computed tomography diagnosis of facet dislocations: the hamburger bun and reverse hamburger bun signs. J Emerg Med. 2002;23(4):387–394. DOI: 10.1016/s0736-4679(02)00577-2 Lingawi SS. The naked facet sign. Radiology. 2001;219(2):366–367. DOI: 10.1148/radiology.219.2.r01ma06366 Kim KS, Chen HH, Russell EJ, Rogers LF. Flexion teardrop fracture of the cervical spine: radiographic characteristics. AJR Am J Roentgenol. 1989;152(2):319–326. DOI: 10.2214/ajr.152.2.319 Kim KS, Chen HH, Russell EJ, Rogers LF. Flexion teardrop fracture of the cervical spine: radiographic characteristics. AJR Am J Roentgenol. 1989;152(2):319-326. DOI: 10.2214/ajr.152.2.319 Nishad Kosaraju is a second-year osteopathic medical student (OMS-II) at the Edward Via College of Osteopathic Medicine–Carolinas Campus (VCOM Carolinas). He has a strong interest in diagnostic imaging and interventional radiology, with particular enthusiasm for case-based learning and understanding how imaging directly informs clinical decision-making. Nishad did his undergraduate education at UNC Chapel Hill, where he studied Exercise and Sports Science. Nishad enjoys contributing educational radiology cases that highlight classic imaging findings, uncommon presentations of common conditions, and high-yield diagnostic pearls for trainees. Outside of medicine, he enjoys golf, classical music, and technological advances in medicine. 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 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

Lung mass. Diagnosis? • Xray of the Week Figure 1. What is the lung mass? Figure 2. Pulmonary hamartoma Figures 2A and 2B: Axial CT chest demonstrating well-demarcated, solitary peripheral, and inhomogeneous pulmonary mass arising from right lower lung lobe (yellow arrows). Note the low attenuation fat in the mass which is diagnostic of hamartoma. Small calcifications are also present. Figure 2C: Sagittal CT chest demonstrates posteriorly located well-demarcated solitary peripheral pulmonary mass. The mass is above the intact diaphragm (red arrow). Figure 2D: Coronal CT chest and abdomen demonstrates solitary lung mass arising from the right lung superior to the diaphragm with evidence of calcification. The mass is above the intact diaphragm (red arrow). Discussion: A hamartoma is a noncancerous focal proliferation of cells that is typically found in the organ or surrounding structures from which it arises (1). Hamartomas are commonly composed of mesenchymal tissue such as adipose tissue, epithelium, fibrous tissue, and cartilaginous tissue (2,3). Pulmonary hamartomas, dominantly composed of cartilaginous and adipose tissue, are the most common benign lung neoplasm, accounting for approximately 6% of solitary pulmonary nodules (3). They are commonly incidental findings found in the fourth to sixth decades of life with a male predilection and no current identifiable risk factors (3,9). Though often incidentally diagnosed as most patients are asymptomatic, symptoms can present depending on the location of the hamartoma (5). If located within the endobronchial structures, patients can present with cough, hemoptysis, or endobronchial obstruction with associated fever and dyspnea (5). Pulmonary hamartomas are found on diagnostic imaging; however, some cases may require definitive diagnosis with cytological evaluation after biopsy. On imaging, computed tomography (CT) is more sensitive to detecting pulmonary hamartomas compared to chest radiographs (4). Findings on CT demonstrate solitary, well-defined, round or lobulated masses or lobules that are predominantly peripherally located in the lungs (3,4). The size of the mass or nodule can be variable, typically around 2 to 5 cm. However, pulmonary hamartomas can also be larger than 10 cm, as seen in Figure 1 and 2 (8). Approximately 60% of the masses or nodules contain adipose tissue and 30% contain popcorn-like calcifications (6,7). A well-circumscribed solitary pulmonary nodule which contains fat and remains stable in size is virtually pathognomonic of a pulmonary hamartoma (7). If asymptomatic, patients with pulmonary hamartomas do not require treatment. Surgical resection is reserved for rapidly proliferating or symptomatic masses for which malignancy cannot be ruled out (9). Prognosis is typically excellent as hamartomas are commonly slow growing with rare malignant transformation (9). ​​​​ References: Batsakis JG. Pathology consultation. Nomenclature of developmental tumors. Ann Otol Rhinol Laryngol. 1984 Jan-Feb;93(1 Pt 1):98-9. doi: 10.1177/000348948409300122. PMID: 6703601 Leiter Herrán F, Restrepo CS, Alvarez Gómez DI, Suby-Long T, Ocazionez D, Vargas D. Hamartomas from head to toe: an imaging overview. Br J Radiol. 2017;90(1071):20160607. doi:10.1259/bjr.20160607 Singh H, Khanna SK, Chandran V, Jetley RK. PULMONARY HAMARTOMA. Med J Armed Forces India. 1999;55(1):79-80. doi:10.1016/S0377-1237(17)30328-3 Radosavljevic V, Gardijan V, Brajkovic M, Andric Z. Lung hamartoma--diagnosis and treatment. Med Arch. 2012;66(4):281-2. doi: 10.5455/medarh.2012.66.281-282. PMID: 22919888 Thomas JW, Staerkel GA, Whitman GJ. Pulmonary hamartoma. AJR Am J Roentgenol. 1999 Jun;172(6):1643. doi: 10.2214/ajr.172.6.10350308. PMID: 10350308 Chai JL, Patz EF. CT of the lung: patterns of calcification and other high-attenuation abnormalities. AJR Am J Roentgenol. 1994;162 (5): 1063-6 doi:10.2214/ajr.162.5.8165982 Klein JS, Braff S. Imaging evaluation of the solitary pulmonary nodule. Clin. Chest Med. 2008;29 (1): 15-38, v. doi:10.1016/j.ccm.2007.11.007 Siegelman SS, Khouri NF, Scott WW Jr, Leo FP, Hamper UM, Fishman EK, Zerhouni EA. Pulmonary hamartoma: CT findings. Radiology. 1986 Aug;160(2):313-7. doi: 10.1148/radiology.160.2.3726106. PMID: 3726106 Lundeen KS, Raj MS, Rajasurya V, et al. Pulmonary Hamartoma. [Updated 2020 Jul 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan. https://www.ncbi.nlm.nih.gov/books/NBK539806/ UPDATE: 2022 - Dr. Zidi is a Radiology Resident at Northwestern University, in Chicago, Illinois. Rabab Zaidi is an aspiring radiologist and fourth year medical student at the Loyola University Chicago Stritch School of Medicine (SSOM). She currently serves as the Community Support Co-Lead for the Loyola University COVID-19 Response Team and Co-President of the Radiology Interest Group at SSOM. At the Stritch School of Medicine, she has also worked with the Department of Radiation Oncology to study prostate cancer imaging and adaptive radiotherapy techniques, where she learned about the intersection of patient care and radiology. Rabab graduated magna cum laude with a degree in Economics from Loyola University Chicago in 2016. She is further passionate about mentorship, advocacy, and photography. Follow Rabab Zaidi on Twitter @ZaidiRabab All posts by Rabab Zaidi 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