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

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

86 F in motor vehicle collision. Neck pain • Xray of the Week Figure 1. What is the important finding on this CT scan. Figure 2. CT scan of Type 3 dens fracture. Red arrow is pointing to the fracture line at the junction of the dens and body of C2. Figure 3. Anderson and D’Alonzo dens fracture classification system. Diagram by Neal Joshi. Type I: Avulsion fracture of the tip of the dens, usually stable. Type II: Fracture of the base of the dens, usually unstable. Type III: Fracture involving the body of C2, usually stable. Introduction: The odontoid process, otherwise known as the dens, is a bony projection from C2 (axis). The most commonly utilized classification system for fracture of the odontoid process is the Anderson and D’Alonzo system, which identifies three types of fractures [1,2] (Fig. 3). C2 fractures can be classified into Odontoid and Hangman’s and most common C2 fractures are the type II odontoid fractures. These can pose issues due to a greater than 50% rate of non-union. Discussion: A type I odontoid fracture is described as an avulsion fracture of the tip of the dens. A type II fracture is one that occurs at the base of the dens and is considered unstable due to high rates of non-union. Type III fractures involve the body of C2 and may even involve the facets (Fig. 3). For odontoid fractures, radiographs can be very useful, but a negative result does not exclude a fracture. Therefore, if there is clinical suspicion a CT scan should be obtained (Figs. 1,2) [3,4]. Non-contrast MRI is useful for viewing ligamentous structures which may be injured. In non-displaced type II odontoid fractures for example, the transverse ligament needs to be intact for certain surgical procedures and would require an MRI for evaluation [5,6]. Complications of dens fractures include malunion, non-union, and pseudoarthrosis. Figure 4. Fluoroscopic guided placement of an odontoid screw. Treatment: For treatment of type I and III odontoid fractures, external fixation via a rigid cervical collar may be sufficient. For type II fractures, surgical fixation is usually required if there is greater than 4-5 mm of displacement due to high risk for non-union [5,6] (Fig. 4). ​​​​ References: Anderson LD, D'Alonzo RT. Fractures of the odontoid process of the axis. J Bone Joint Surg Am. 1974;56(8):1663-1674. https://pubmed.ncbi.nlm.nih.gov/4434035/ Korres DS, Chytas DG, Markatos KN, Efstathopoulos NE, Nikolaou VS. The "challenging" fractures of the odontoid process: a review of the classification schemes. Eur J Orthop Surg Traumatol. 2017;27(4):469-475. doi:10.1007/s00590-016-1895-3 Montemurro N, Perrini P, Mangini V, Galli M, Papini A. The Y-shaped trabecular bone structure in the odontoid process of the axis: a CT scan study in 54 healthy subjects and biomechanical considerations [published online ahead of print, 2019 Feb 1]. J Neurosurg Spine. 2019;1-8. doi:10.3171/2018.9.SPINE18396 Chutkan NB, King AG, Harris MB. Odontoid Fractures: Evaluation and Management. J Am Acad Orthop Surg. 1997;5(4):199-204. doi:10.5435/00124635-199707000-00003 Nourbakhsh A, Hanson ZC. Odontoid Fractures: A Standard Review of Current Concepts and Treatment Recommendations. J Am Acad Orthop Surg. 2022;30(6):e561-e572. doi: 10.5435/JAAOS-D-21-00165 Löhrer L, Raschke MJ, Thiesen D, et al. Current concepts in the treatment of Anderson Type II odontoid fractures in the elderly in Germany, Austria and Switzerland. Injury. 2012;43(4):462-469. doi:10.1016/j.injury.2011.09.025 Neal Joshi is a medical student and aspiring diagnostic radiologist at Rowan University School of Osteopathic Medicine in New Jersey. Prior to medical school, he did research with mouse models for Parkinson’s disease and L-DOPA induced dyskinesias. He also did an internship at Kessler Institute for Rehabilitation in a stroke lab analyzing MR images in ischemic stroke patients with hemispatial neglect. During his time at Rowan, he did research with animal models for traumatic brain injury with an emphasis on electrophysiology of neurons. He graduated from William Paterson University where he completed his studies in biology and biopsychology. Apart from medical school, Neal loves to read, skateboard, go on hikes, and spend time with his friends. Update July 2022: Dr. Joshi is a Radiology Resident at Thomas Jefferson University in Philadelphia. All posts by Neal Joshi 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 Dr. Rice 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

93 F with trauma from a fall. Neck pain • Xray of the Week Figure 1. What is the important finding on this CT scan. Figure 2. CT scan of Type 2 dens fracture. Red arrow is pointing to the fracture line at the base of the dens. Figure 3. Anderson and D’Alonzo dens fracture classification system. Diagram by Neal Joshi. Type I: Avulsion fracture of the tip of the dens, usually stable. Type II: Fracture of the base of the dens, usually unstable. Type III: Fracture involving the body of C2, usually stable. Introduction: The odontoid process, otherwise known as the dens, is a bony projection from C2 (axis). The most commonly utilized classification system for fracture of the odontoid process is the Anderson and D’Alonzo system, which identifies three types of fractures (1) (Fig. 3). C2 fractures can be classified into Odontoid and Hangman’s and most common C2 fractures are the type II odontoid fractures. These can pose issues due to a greater than 50% rate of non-union. These fractures occur during hyperextention and hyperflexion injuries to the cervical spine (falls, motor vehicle accidents). Type II odontoid fractures are most common and can occur at any age but mostly in the elderly due to increase risk of falls and decreased bone mineral density. Discussion: A type I odontoid fracture is described as an avulsion fracture of the tip of the dens. A type II fracture is one that occurs at the base of the dens and is considered unstable due to high rates of non-union. Type III fractures involve the body of C2 and may even involve the facets (Fig. 2). For odontoid fractures, radiographs can be very useful, but a negative result does not exclude a fracture. Therefore, if there is clinical suspicion a CT scan should be obtained (Fig. 1) (3). Non-contrast MRI is useful for viewing ligamentous structures which may be injured. In non-displaced type II odontoid fractures for example, the transverse ligament needs to be intact for certain surgical procedures and would require an MRI for evaluation (4). Complications of odontoid fractures include malunion, non-union, and pseudoarthrosis. Type II fractures are unstable and have a higher rate of nonunion mainly due to the lower surface area of the fractured bone compared to type III fractures. Radiological parameters such as displacement and angulation are important and can determine surgical planning of type II odontoid fractures. Using CT, it was determined that diagnostic classification of displacements and angulation had good observer reliability using review systems and tools in image processing software (5). Figure 4. Fluoroscopic guided placement of an odontoid screw. Treatment: For treatment of type I and III odontoid fractures, external fixation via a rigid cervical collar may be sufficient. For type II fractures, surgical fixation is usually required if there is greater than 4-5 mm of displacement due to high risk for non-union (3) (Fig. 4). ​​​​ References: Korres DS, Chytas DG, Markatos KN, Efstathopoulos NE, Nikolaou VS. The "challenging" fractures of the odontoid process: a review of the classification schemes. Eur J Orthop Surg Traumatol. 2017;27(4):469-475. doi:10.1007/s00590-016-1895-3 Montemurro N, Perrini P, Mangini V, Galli M, Papini A. The Y-shaped trabecular bone structure in the odontoid process of the axis: a CT scan study in 54 healthy subjects and biomechanical considerations [published online ahead of print, 2019 Feb 1]. J Neurosurg Spine. 2019;1-8. doi:10.3171/2018.9.SPINE18396 Chutkan NB, King AG, Harris MB. Odontoid Fractures: Evaluation and Management. J Am Acad Orthop Surg. 1997;5(4):199-204. doi:10.5435/00124635-199707000-00003 Löhrer L, Raschke MJ, Thiesen D, et al. Current concepts in the treatment of Anderson Type II odontoid fractures in the elderly in Germany, Austria and Switzerland. Injury. 2012;43(4):462-469. doi:10.1016/j.injury.2011.09.025 Karamian BA, Liu N, Ajiboye RM, Cheng I, Hu SS, Wood KB. Reliability of radiological measurements of type 2 odontoid fracture. Spine J. 2019;19(8):1324-1330. doi:10.1016/j.spinee.2019.04.020 Neal Joshi is a medical student and aspiring diagnostic radiologist at Rowan University School of Osteopathic Medicine in New Jersey. Prior to medical school, he did research with mouse models for Parkinson’s disease and L-DOPA induced dyskinesias. He also did an internship at Kessler Institute for Rehabilitation in a stroke lab analyzing MR images in ischemic stroke patients with hemispatial neglect. During his time at Rowan, he did research with animal models for traumatic brain injury with an emphasis on electrophysiology of neurons. He graduated from William Paterson University where he completed his studies in biology and biopsychology. Apart from medical school, Neal loves to read, skateboard, go on hikes, and spend time with his friends. Update July 2022: Dr. Joshi is a Radiology Resident at Thomas Jefferson University in Philadelphia. All posts by Neal Joshi 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 Dr. Rice 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

59 yo male who was assaulted and sustained blunt trauma to the left orbit. • Xray of the Week Figure 1. What are the important findings in each image. Figure 2. A: Coronal CT image demonstrates normal contour of the right globe (green arrow) and a shrunken left globe (orange arrow), which is suggestive of globe rupture. B: Axial CT image demonstrates normal contour of the right globe (green arrow) and abnormal contour left globe (orange arrow), suggestive of globe rupture. Note the mushroom shape due to extruded vitreous. The hyperattenuation of the left globe (orange arrow) is consistent with vitreous hemorrhage. C: Sagittal CT image demonstrates normal contour in the right globe (green arrow). D: Sagittal CT image demonstrates a shrunken left globe (orange arrow), which is suggestive of globe rupture. Globe Rupture: Ruptured globes are an ocular emergency that could lead to permanent vision loss if not treated quickly. Penetrating and blunt trauma, in addition to chemical exposure, account for the majority of cases (Figs. 3,4). High intraocular pressure leads to ruptures at weak areas in the eye wall, including rectus muscle insertion sites, the limbus, and the optic nerve.[1] Imaging: Computed tomography (CT) is the recommended imaging modality for evaluating orbital trauma. Thin-section axial CT scans followed by multiplanar reformations can visualize ruptured globe contour, which can present as a “mushroom” (Figs. 1-2) or “flat tire” shape.[2] Vitreous hemorrhage increases the attenuation of the vitreous on CT as well.[3] Other findings of open globe injuries include a thick posterior sclera, hazy globe contour outline, abnormal anterior chamber size, and the presence of intraocular gas or foreign bodies. CT detects open globe injuries with a sensitivity of 90-100%, specificity of 50-80%, and interrater reliability of κ > 60%. [4] Prompt identification of ruptured globes is necessary to guide management. Figure 3. Clinical image of ruptured globe in a different patient. This 49-year-old male was slapped in the face and a finger went into his left eye rupturing his globe at the superonasal limbus with iris prolapse through the wound. This slit-lamp photograph demonstrates disruption of his anterior segment anatomy with iridodialysis and hyphema. Image credit: https://eyerounds.org/atlas/pages/open-globe.html#gsc.tab=0 EyeRounds.org, The University of Iowa Figure 4. Ultrasound of ruptured globe. This 49-year-old male was slapped in the face and a finger went into his left eye rupturing his globe at the superonasal limbus with iris prolapse through the wound. The ultrasound demonstrates a vitreous hemorrhage without a retinal detachment. Image credit: https://eyerounds.org/atlas/pages/open-globe.html#gsc.tab=0 EyeRounds.org, The University of Iowa Treatment: Immediate surgery and empiric systemic antibiotics are needed to preserve vision and reduce the risk of intraocular infection.[3] Once an open globe rupture is suspected, the patient should remain NPO and wear a protective eye device on the affected eye.[5] Additionally, physicians should avoid maneuvers, including lid retraction and tonometry, or systemic medications that increase intraocular pressure.[6] A semi-recumbent head position, anti-emetics, pain management, and removal of other stressors help prevent increases in intraocular pressure. Patients with open globe injuries should receive a tetanus booster if their immunization history is uncertain. Surgery on the ruptured globe and removal of ocular foreign objects should be performed once patients are stabilized. Following surgery, patients should begin antibiotic coverage of pathogens associated with endophthalmitis per recommendations provided by their institution’s infectious disease specialist.[7] Prognosis: Ruptured globes maintain a poor prognosis. The patient’s presenting visual acuity is a major determinant of their post-surgical visual acuity. The Ocular Trauma Score (OTS) metric proposed by Kuhn et al can be used to determine the functional outcome of injured eyes.[8] ​​​​ References: Murata N, Yokogawa H, Kobayashi A, Yamazaki N, Sugiyama K. Clinical features of single and repeated globe rupture after penetrating keratoplasty. Clin Ophthalmol. 2013;7:461-465. doi:10.2147/OPTH.S42117 Kubal WS. Imaging of orbital trauma. Radiographics. 2008;28(6):1729-1739. doi:10.1148/rg.286085523 Zhou Y, DiSclafani M, Jeang L, Shah AA. Open Globe Injuries: Review of Evaluation, Management, and Surgical Pearls. Clin Ophthalmol. 2022;16:2545-2559. doi:10.2147/OPTH.S372011 Crowell EL, Koduri VA, Supsupin EP, et al. Accuracy of Computed Tomography Imaging Criteria in the Diagnosis of Adult Open Globe Injuries by Neuroradiology and Ophthalmology. Acad Emerg Med. 2017;24(9):1072-1079. doi:10.1111/acem.13249 Ritson JE, Welch J. The management of open globe eye injuries: a discussion of the classification, diagnosis and management of open globe eye injuries. J R Nav Med Serv. 2013;99(3):127-130. https://www.ncbi.nlm.nih.gov/pubmed/24511795 Bord SP, Linden J. Trauma to the globe and orbit. Emerg Med Clin North Am. 2008;26(1):97-123, vi - vii. doi:10.1016/j.emc.2007.11.006 Blair K, Alhadi SA, Czyz CN. Globe Rupture. StatPearls Publishing; 2022. Accessed June 5, 2023. https://www.ncbi.nlm.nih.gov/books/NBK551637/ Kuhn F, Maisiak R, Mann L, Mester V, Morris R, Witherspoon CD. The Ocular Trauma Score (OTS). Ophthalmol Clin North Am. 2002;15(2):163-165, vi. doi:10.1016/s0896-1549(02)00007-x UPDATE Sept. 2026: Eric Errampalli is now a resident in Interventional Radiology, Resident Class of 2031 at University of Illinois Chicago. 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

Don’t Miss This Unique Experience Imaging in Switzerland 2027 isn’t just a conference—it’s an opportunity to grow, connect, and be inspired in one of the most extraordinary countries in the world. 📅 Conference Dates: June 6–11, 2027 📍 Location: The Zurich Marriott Hotel + Optional Mini-Conference at Grand Hotel Suisse Majestic Montreux 🔗 View the full program and register now → https://www.globalradiologycme.com/imaging-in-switzerland-2027 Whether you are looking to earn premium Continuing Medical Education (CME) credits, learn from world-renowned leaders in diagnostic imaging, or explore alpine vistas and medieval architecture, this symposium offers an extraordinary blend of academic rigor and luxury travel. Here are the top 10 reasons you should attend Imaging in Switzerland 2027: 1. Leading edge, captivating Scientific Program delivered by a World-Class Faculty Led by Scientific Director Neil M. Rofsky, the 2025 program will feature topics in body imaging, cardiothoracic imaging, MSK, neuroradiology, and emergency radiology. Faculty include some of the most respected names in the field: Donald Resnick, Ella Kazerooni, Amish Doshi, Reto Sutter, and Karen Lee. 2. Zurich is ranked one of the top cities to visit in the world Zurich offers a distinctive blend of historic charm, cultural sophistication, and effortless Swiss elegance. From the boutiques of Bahnhofstrasse and the character of Zurich Old Town (Altstadt) to the beauty of Lake Zurich and the surrounding Alpine backdrop, the city provides an exceptional place to combine professional enrichment with memorable travel. 3. Interactive and engaging Lunch Round Tables Back by popular demand, our daily Round Table sessions offer a chance to discuss current imaging and leadership topics in an informal setting with the faculty. These sessions are often cited by attendees as a highlight of the educational program. 4. Explore Zurich’s Historic & Cultural Landmarks During your downtime in Zurich, step back in time in the medieval Old Town (Altstadt), admire the iconic stained-glass Chagall windows at Fraumünster Church, tour world-class collections at Kunsthaus Zürich, or stroll along the high-fashion avenues of Bahnhofstrasse. 5. Experience the World's #1 Ranked Country Switzerland isn’t just beautiful—it’s unmatched in safety, precision, efficiency, and quality of life. In the U.S. News Best Countries rankings, Switzerland was named the #1 Country in the World overall. From pristine mountain air to world-class hospitality, you will experience the gold standard of travel. 6. Dynamic Global Networking Opportunities Connect with an international cohort of radiologists, department leaders, and industry colleagues from around the globe. Share clinical perspectives, build professional relationships, and socialize at our welcoming Opening Reception on June 6 overlooking Lake Zurich. 7. A Premier Host Venue in Zurich Our primary host hotel, the Zurich Marriott Hotel, sits right along the pristine Limmat River with sweeping views toward the Swiss Alps. Offering state-of-the-art conference facilities, modern guest rooms, and an ideal central location, it provides a sophisticated setting for four days of immersive learning (June 6–9, 2027). 8. Exclusive Montreux Wellness & Business Mini-Conference Extend your conference experience with our 1-day Wellness & Business Mini-Conference on June 11, 2027, hosted at the historic Grand Hotel Suisse Majestic (Autograph Collection) on Lake Geneva. Set against a backdrop of Belle Époque elegance, this specialized program focuses on executive leadership, burnout reduction, and personal renewal for healthcare professionals. 9. Seamless Zurich-to-Montreux Inter-City Scenic Transfer & Tour Building on the wild success of our signature inter-city transfers in Japan, we are offering an exclusive, optional Zurich to Montreux Transfer & Day Tour. Enjoy effortless luggage logistics and stress-free travel while taking in Switzerland's breathtaking countryside, historic landmarks, and alpine scenery en route to the Swiss Riviera. 10. Perfect Gateway for Broader European Travel With Switzerland’s central European location and hyper-efficient rail network, extending your journey couldn't be easier. Take effortless day trips to Bern, Basel, Geneva, or Lucerne—or catch high-speed trains directly to Paris, Milan, or Munich! Experience an exceptional radiology education alongside a memorable cultural journey at this distinctive conference by Global Radiology CME. The Imaging in Switzerland 2027 event offers professional growth, networking opportunities, and wellness for radiologists worldwide in a culturally vibrant country that seamlessly integrates European traditions with contemporary innovations.

This prestigious award is presented by Professor Resnick to the winner of his annual MSK imaging quiz at the Global Radiology CME conference. Participants are challenged with complex MSK imaging cases at the start of the day, with answers revealed during the final time slot of the MSK session. Dr. Resnick's reputation for presenting captivating and often surprising cases adds an element of intrigue to the session, making it a highlight of the conference for many attendees. The trophy symbolizes not only excellence in MSK imaging but also the dedication and commitment of the winner to the field. Join us at our next conference to test your skills and compete for this coveted award. 2026 - Shown above is Dr. Christine Chung, Professor and Chair of the Department of Radiology at UC San Diego School of Medicine, presenting the prestigious Global Radiology CME Donald Resnick MSK Quiz Award to Andrew Kingzett Taylor of Pacific Radiology in New Zealand at Imaging in Japan 2026. This remarkable achievement marks Dr. Kingzett Taylor's third Donald Resnick MSK Quiz Award, having previously earned the honor in 2019 and 2024. Dr. Kingzett Taylor is one of New Zealand’s leading musculoskeletal radiologists, with a career dedicated to advanced MSK imaging, MRI, and sports-related radiology. A fellowship-trained musculoskeletal radiologist, Dr. Kingzett Taylor is widely recognized for his expertise in MSK imaging and his contributions to radiology education. His third Donald Resnick MSK Quiz Award underscores his exceptional diagnostic acumen and longstanding commitment to the field. 2025 - Shown above is Dr. Donald Resnick, the world's leading authority in musculoskeletal imaging, presenting the prestigious Global Radiology CME Resnick MSK Quiz Award to Dr. Andrew Whan of Barwon Medical Imaging in the Melbourne region of Australia during Imaging in Greece 2025. Dr. Whan completed his radiology training at Austin Hospital, earning the Gold Medal as the top candidate in the Royal Australian and New Zealand College of Radiologists (RANZCR) Fellowship Exam. In 2001, he undertook advanced fellowship training in MRI and breast imaging at Austin Hospital, followed by additional fellowship training in musculoskeletal MRI in Perth. Dr. Whan currently serves as an Examiner for RANZCR and holds the position of Associate Professor and Tutor at Deakin Medical School, Deakin University. 2024 - Pictured above is the authority in MSK imaging, Dr. Donald Resnick presenting the coveted Global Radiology CME annual Resnick MSK Quiz Award to Andrew Kingzett Taylor of Pacific Radiology in New Zealand at Imaging in Copenhagen 2024. This marks his second win, following his previous award in 2019. Dr. Kingzett Taylor was a visiting fellow to the musculoskeletal section at the University of California, San Francisco in 1998 and 1999. 2023 - Pictured above is the MSK radiology luminary and prolific writer, Dr. Donald Resnick presenting the much sought after Global Radiology CME annual Resnick MSK Quiz Award to Stuart Rubin of Windsong Radiology in Buffalo, New York at Imaging in Israel 2023. Dr. Rubin did a MSK fellowship at Columbia-Presbyterian Medical Center in New York, NY. He comes from a family of three generations of doctors. In addition to his father and grandfather, his siblings are all physicians. 2022 - Dr. Donald Resnick, the legendary MSK radiologist, is seen presenting the prestigious Global Radiology CME annual Resnick MSK Quiz Award to Nancy Prendergast of University Radiology Group in New Jersey, USA at Imaging in Dublin 2022. Following medical school at Brown University and radiology residency at New York University Medical Center, Dr. Prendergast completed a Musculoskeletal Radiology fellowship at New York University Medical Center in 1993. 2019 - Dr. Donald Resnick, the 2018 ACR Gold Medalist, is shown in the image awarding the inaugural Global Radiology CME Resnick MSK Quiz Award to Andrew Kingzett Taylor of Pacific Radiology in New Zealand at Imaging in Prague 2019. Seen above, Dr. Resnick expressed his admiration for Dr. Kingzett Taylor's exceptional performance in interpreting the complex cases.

We are pleased to announce two special industry-supported educational sessions sponsored by our Gold Sponsor Bayer during Imaging in Japan 2026, hosted at the beautiful Hotel Chinzanso Tokyo. These sessions will provide valuable opportunities for learning, discussion, and professional engagement with leaders in radiology. Bayer Lunch & Learn Integrating Next Generation Contrast Agents into Clinical Practice Date & Time: Monday, June 1, 2026 · 12:00 PM – 1:00 PM Location: ZUIKO Room, Hotel Chinzanso Tokyo Moderator: Neil Rofsky This Bayer-sponsored Lunch & Learn session is open to all registered conference attendees and will feature a premier educational session focused on Ambelvist (gadoquatrane). Ambelvist is a next-generation, low-dose, macrocyclic gadolinium-based contrast agent (GBCA) developed by Bayer for use in magnetic resonance imaging (MRI) scans. This session is particularly timely given recent regulatory milestones. In March 2026, Japan’s Ministry of Health, Labour, and Welfare granted the first global regulatory approval for Ambelvist, establishing Japan as the pioneer market for this high-relaxivity agent, which is designed to reduce gadolinium dose requirements while maintaining diagnostic efficacy. With marketing authorizations currently under active review by the U.S. FDA, European EMA, and other international authorities, this session offers an early look at its real-world clinical implementation. Our scientific program provides a direct bridge between global pharmaceutical innovation and frontline radiology practice by connecting Bayer's global R&D leadership with prominent clinical investigators in Japan. The session features two concise perspectives on this new agent: Clinical Practice & Workflows: Prof. Rintaro Ito, an expert in advanced clinical MRI contrast kinetics from Nagoya University, will discuss gadoquatrane within the context of Japan’s high-scan-density clinical environment. He will outline the clinical value of a "lower dose without diagnostic compromise," focusing on its relevance to longitudinal neuroradiology cohorts (such as MS and brain tumor surveillance) and pediatric imaging, while briefly exploring how AI may interact with low-dose contrast workflows. Product Fundamentals & Trial Evidence: Dr. Petra Palkowitsch, Head of Global Clinical Development for Ambelvist at Bayer AG, will review the core chemical properties and clinical evidence supporting this tetrameric macrocyclic agent. Supported by Dr. Hironori Taniguchi, a specialist in contrast media medical affairs at Bayer Japan, she will provide an overview of the global Phase 1–3 clinical program—including the pivotal QUANTI trials—highlighting key efficacy and safety outcomes that support its global regulatory submissions. The presentation will be followed by an interactive audience discussion mediated by Dr. Neil Rofsky, a leading authority in body MRI contrast techniques and the conference's Scientific Program Director. Attendees will have the opportunity to evaluate these latest developments in contrast media and engage in a peer-to-peer dialogue regarding their clinical implications. BAYER AG Bayer Focus Group Discussion The Decision Process for Adopting MR Contrast Agents: Global Perspectives Date & Time: Wednesday, June 3, 2026 · 12:00 PM – 1:00 PM Location: TSUZUMI Room, Hotel Chinzanso Tokyo Moderator: Neil Rofsky In addition to the Lunch & Learn, Bayer will host a focus group discussion bringing together approximately 12 invited radiologists for a moderated roundtable conversation. This small-group format is designed to encourage open dialogue and exchange of professional insights among key clinicians. These sponsored sessions reflect the important collaboration between industry innovators and the global radiology community, helping advance education, dialogue, and innovation in medical imaging. We thank Bayer for its support of Imaging in Japan 2026 and look forward to welcoming participants to these engaging events in Tokyo. About the Featured Experts Dr. Neil Rofsky Dr. Neil M. Rofsky, MD, MHA, FSABI, FISMRM, FACR, serves as the Scientific Program Director for Imaging in Japan 2026. He is the Dr. Charles M. and Marilyn Newman Professor and System Chair of the Department of Diagnostic, Molecular and Interventional Radiology at the Mount Sinai Health System and the Icahn School of Medicine at Mount Sinai in New York. A globally recognized luminary in contrast-enhanced MRI, Dr. Rofsky co-pioneered the VIBE sequence (volumetric interpolated breath-hold examination), a breakthrough 3D T1-weighted technique fundamental to evaluating contrast kinetics in modern body MRI. Throughout his distinguished career, he has been a leading investigator in the clinical translation, efficacy, and safety profiling of MRI contrast media. Dr. Rintaro Ito Prof. Rintaro Ito, MD, PhD, is a Designated Lecturer in the Department of Innovative Biomedical Visualization (iBMV) at the Nagoya University Graduate School of Medicine in Japan. He is a board-certified diagnostic radiologist and nuclear medicine specialist whose advanced clinical research spans MRI analysis—specifically glymphatic system imaging and brain macrostructure—and the clinical integration of medical artificial intelligence. Prof. Ito's work focuses on optimization methodologies, evaluating contrast kinetics alongside innovative diagnostic workflows, vision-language modeling, and advanced imaging modalities to streamline clinical practice. Dr. Petra Palkowitsch Dr. Petra Palkowitsch is the Global Clinical Lead for gadoquatrane at Bayer AG in Berlin, Germany. With over 25 years of extensive cross-functional leadership in radiology at Bayer, she has held senior-level positions spanning both Medical Affairs and Clinical Development. Dr. Palkowitsch has focused extensively on contrast media and diagnostic imaging research, driving the global clinical strategy, trial designs, and safety profiling for a wide range of contrast agents and medical devices, with an emphasis on next-generation macrocyclic innovations. Her profound contributions to next-generation macrocyclic contrast agent innovation earned her the prestigious RSNA Kuo York Chynn Neuroradiology Research Award. Dr. Hironori Taniguchi Dr. Hironori Taniguchi is an expert in Medical Affairs and clinical data evaluation based at Bayer Yakuhin, Ltd. (Bayer Japan). Specializing in the evidence-generation and post-development phase of MRI contrast media, he focuses on real-world safety surveillance, clinical efficacy data, and patient outcomes. Dr. Taniguchi plays a vital role in translating global contrast-agent R&D innovations into local medical practice, ensuring next-generation imaging agents successfully advance patient-centric, contrast-enhanced radiology across Japan.

34 year old male with chest pain and shortness of breath • Xray of the Week Figure 1. 34 year old male with chest pain and shortness of breath. Figure 2. A and B: Axial and coronal CT with cardiomegaly due to markedly dilated heart. Right pleural effusion (blue arrow). Low EF with contrast only in RA (red arrows) and RV (orange arrow). Reflux of contrast into the IVC (green arrow) and hepatic veins (white arrow) indicates tricuspid valve regurgitation. C: Echocardiogram apical 4 chamber view. Mitral regurgitation as evidenced by a regurgitant jet extending into the RA (yellow arrow). Discussion: Methamphetamine (MA) and related compounds are the most widely abused drugs in the world after cannabis. It is a psychostimulant that causes an increase in the synapse of monoamine neurotransmitters, including dopamine, norepinephrine, and serotonin [1]. Methamphetamines can be smoked, snorted, injected, or ingested orally. Methamphetamine is more potent, and its effects last longer than cocaine. Methamphetamine associated cardiomyopathy (MACM) is more common in younger age groups compared to patients with cardiomyopathy attributable to other causes. The development of MACM has been shown to be dose-dependent and amplified by repetitive use, binge pattern use, and concomitant use of other substances. Autopsy studies have shown MACM to be associated with extensive myocardial fibrosis, cellular vacuolization, and myocyte destruction [2, 3]. Cardiac complications of MA use include chest pain, hypertension, arrhythmia, aortic dissection, coronary vasospasm, cardiomyopathy, sudden cardiac death, and pulmonary arterial hypertension [2]. Figure 3. Axial (A) and coronal (B) contrast-enhanced CT images in the same patient demonstrate a dilated right ventricle containing a non-enhancing filling defect, consistent with a right ventricular thrombus. (red arrows). Imaging Findings Echocardiography typically shows severe multi-chamber dilatation, reduced ejection fraction (EF), mitral regurgitation (MR), tricuspid regurgitation (TR), and pericardial effusion [6-9]. Patients with MACM are also prone to developing intracardiac thrombi, with up to 33% for LV thrombus and 3.3% for RV thrombus [4, 5] (Fig. 3), with RV thrombi posing a significant risk for pulmonary embolism. Thrombus formation is driven by the triad of severe systolic stasis, drug-induced endocardial injury, and a prothrombotic state. [5]. In general, patients with MACM have significantly larger LA, LV, and RV size, lower LVEF, and a higher rate of mitral regurgitation (MR) compared to other causes of dilated cardiomyopathy [6]. Contrast-enhanced CT typically demonstrates severe biventricular dilatation and associated findings of pulmonary edema like pleural effusions or septal thickening. Contrast-enhanced CT may show a hallmark sign of severe tricuspid regurgitation: the reflux of intravenous contrast into the inferior vena cava and hepatic veins. Additionally, CT can help exclude other stimulant-related complications like aortic dissection or coronary artery calcification. Cardiac Magnetic Resonance (CMR) remains the gold standard for tissue characterization, identifying linear mid-wall septal fibrosis, but its use is often limited in the acute phase. On CMR, the presence of late gadolinium enhancement (LGE) is a key marker of irreversible myocardial damage and predicts poor functional recovery. In this case, there is severe tricuspid regurgitation (TR) with reflux of contrast into the inferior vena cava (IVC) and hepatic veins; pleural effusion is indicative of heart failure (Figs. 2 A, B). There is also MR visualized on the echocardiogram with a large regurgitant jet extending into the LA during systole (Fig. 2C). Differential Diagnosis MACM must be distinguished from idiopathic dilated cardiomyopathy, which typically occurs in older demographics and lacks the same potential for reversibility. Alcoholic cardiomyopathy presents similarly, but right heart involvement and intracardiac thrombus are often more pronounced in methamphetamine users. Viral myocarditis should also be considered, though it frequently presents with sub-epicardial LGE rather than the mid-wall or sub-endocardial patterns seen in MACM. Management and Prognosis The mainstay of management is complete drug abstinence, which can lead to dramatic structural and functional recovery. Treatment of MACM is aimed at the specific pathology such as anticoagulation for intracardiac thrombus and diuresis/venodilators for volume overload. Prognosis is largely dictated by the extent of myocardial fibrosis present at the time of diagnosis. Key Learning Points Suspect MACM in young patients with unexplained cardiomegaly and heart failure. CT findings include marked multi-chamber dilatation and contrast reflux into the hepatic veins. Intracardiac thrombi are highly prevalent (up to 33%) and can involve both ventricles. Cardiac MR is superior for tissue characterization and prognostication, but CT is vital in the emergency setting. Cardiac recovery is highly dependent on achieving sustained drug abstinence. ​​​​ References: Barr, A.M., et al., The need for speed: an update on methamphetamine addiction. J Psychiatry Neurosci, 2006. 31(5): p. 301-13. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1557685/ Reddy, P.K.V., et al., Clinical Characteristics and Management of Methamphetamine-Associated Cardiomyopathy: State-of-the-Art Review. J Am Heart Assoc, 2020. 9(11): p. e016704 DOI: 10.1161/jaha.120.016704. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7428977/ Karch, S.B., The unique histology of methamphetamine cardiomyopathy: a case report. Forensic Sci Int, 2011. 212(1-3): p. e1-4 DOI: 10.1016/j.forsciint.2011.04.028. Retrieved from https://pubmed.ncbi.nlm.nih.gov/21664081/ Janardhanan, R. and A. Kannan, Methamphetamine Cardiotoxicity: Unique Presentation with Multiple Bi-Ventricular Thrombi. The American Journal of Medicine, 2016. 129(1): p. e3-e4 DOI: 10.1016/j.amjmed.2015.08.006. Retrieved from https://www.amjmed.com/article/S0002-9343(15)00780-9/fulltext Schürer, S., et al., Clinical Characteristics, Histopathological Features, and Clinical Outcome of Methamphetamine-Associated Cardiomyopathy. JACC Heart Fail, 2017. 5(6): p. 435-445 DOI: 10.1016/j.jchf.2017.02.017. Retrieved from https://pubmed.ncbi.nlm.nih.gov/28571597/ Ito, H., et al., A comparison of echocardiographic findings in young adults with cardiomyopathy: with and without a history of methamphetamine abuse. Clin Cardiol, 2009. 32(6): p. E18-22 DOI: 10.1002/clc.20367. Retrieved from https://pubmed.ncbi.nlm.nih.gov/19330818/ Neeki, M.M., et al., Frequency of Methamphetamine Use as a Major Contributor Toward the Severity of Cardiomyopathy in Adults ≤50 Years. The American Journal of Cardiology, 2016. 118(4): p. 585-589 DOI: https://doi.org/10.1016/j.amjcard.2016.05.057. Retrieved from http://www.sciencedirect.com/science/article/pii/S0002914916309602 Wijetunga, M., et al., Crystal methamphetamine-associated cardiomyopathy: tip of the iceberg? J Toxicol Clin Toxicol, 2003. 41(7): p. 981-6 DOI: 10.1081/clt-120026521. Retrieved from https://pubmed.ncbi.nlm.nih.gov/14705845/ Yeo, K.K., et al., The association of methamphetamine use and cardiomyopathy in young patients. Am J Med, 2007. 120(2): p. 165-71 DOI: 10.1016/j.amjmed.2006.01.024. Retrieved from https://pubmed.ncbi.nlm.nih.gov/17275458/ Voskoboinik A, Ihle JF, Bloom JE, et al. Methamphetamine-associated cardiomyopathy: patterns and predictors of recovery. Intern Med J . 2016;46(6):723-727. doi:10.1111/imj.13050 https://doi.org/10.1111/imj.13050  PubMed: https://pubmed.ncbi.nlm.nih.gov/26929061/   Koo BH, et al. Recreational Drug-induced Cardiopulmonary Injury. RadioGraphics . 2025;45(10). doi:10.1148/rg.250013 https://doi.org/10.1148/rg.250013 Zuern CS, Sticherling C, Krisai P, et al. Methamphetamine-associated cardiomyopathy. Eur Heart J Cardiovasc Imaging . 2024;25(4):e147. doi:10.1093/ehjci/jead320 https://doi.org/10.1093/ehjci/jead320  PubMed: https://pubmed.ncbi.nlm.nih.gov/37983477/   Hagan IG, Burney K. Radiology of recreational drug abuse. RadioGraphics . 2007;27(4):919-940. doi:10.1148/rg.274065103 https://doi.org/10.1148/rg.274065103  PubMed: https://pubmed.ncbi.nlm.nih.gov/17620470/   Pujol-López M, Ortega-Paz L, Flores-Umanzor EJ, et al. Cardiac Magnetic Resonance as an Alternative to Endomyocardial Biopsy to Predict Recoverability of Left Ventricular Function in Methamphetamine-Associated Cardiomyopathy. JACC Heart Fail . 2017;5(11):853-854. doi:10.1016/j.jchf.2017.08.009 https://doi.org/10.1016/j.jchf.2017.08.009  PubMed: https://pubmed.ncbi.nlm.nih.gov/29096799/   Update 2026: Dr. Jaswal is a Nuclear Medicine Resident at New York Presbyterian/ Weill Cornell Medicine. Shama Jaswal is an International Medical Graduate, currently doing research at Mallinckrodt Institute of Radiology (MIR), Saint Louis. She aims at pursuing Diagnostic Radiology residency and poses a keen interest in research alongside academics. At MIR, she has been fortunate to work on various oncology projects including the project in which they studied how the difference in fat metabolism in both sexes can affect the cancer survival and outcome, and how this study can further improve prognosis through treatment modification. Shama is both an accomplished sprinter and singer having won several national competitions in in each discipline in India. She also has a strong passion for cooking and gardening. Follow Shama Jaswal on Twitter @Jaswal_Shama All posts by Shama Jaswal 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

Quick summary From Hotel Chinzanso Tokyo to Tokyo Station: Taxi (≈30 mins) ~ ¥5,000 ($34). Tokyo to Kyoto on Shinkansen: Nozomi train, ~ 2 hr 15 min, reserved seat ~ ¥14,500 ($95) per adult. Book early as the seats may be limited. Japan Rail Pass - JRailPass.comスマートEX Carry-On Rules for Shinkansen: Suitcases under 160 cm (sum of L+W+H) can be brought onboard. Larger luggage requires reservation or baggage forwarding. Baggage forwarding (Tokyo→Kyoto): Most services are next day delivery. If available, same-day service is ~ ¥4,000 - ¥6,000 (US$28 - $44) per bag depending on size and weight. Ask concierge or Yamato/Kuroneko counter for exact quote. Kyoto Station → Hyatt Regency: Taxi ~¥2000 (US$14) / ~10 min. Full details here: 1) From Hotel Chinzanso Tokyo → Tokyo Station By taxi (fastest): ~30 minutes (typical fare about ¥5000) depending on traffic. Most taxi drivers in Tokyo do not speak English, so be sure to have your destination written on a card in Japanese or have the hotel doorman arrange the service. By subway / bus (cheaper): walk ~10 min to Edogawabashi Station, then subway/bus connections to central Tokyo — fares ~¥170–¥310, journey 30–45 min depending on route. Tokyo Taxi 2) Tokyo Station → Kyoto Station (Shinkansen) Typical travel time: ~2 hours 15 minutes on Nozomi / fastest services; Hikari slightly slower. JR CentralJapan Rail Pass - JRailPass.com Typical one-way fare (ordinary car): broadly ¥13,000–¥14,500 (varies by train type—Nozomi, Hikari, reserved vs non-reserved). Book early for best fares (SmartEX, JR Central online). Japan Rail Pass - JRailPass.comスマートEX Booking tips Buy tickets or reserve seats in advance via SmartEX / JR Central / station ticket counters, especially if you travel with luggage. SmartEX offers advance discounts for some fares. スマートEXJR Central Shinkansen - Bullet Train Luggage on the Shinkansen — what you need to know Standard rule: Passengers may bring luggage, but large suitcases are regulated. Luggage with total dimensions over 160 cm should be managed (either use the designated oversized baggage area or make a reservation for a seat with an oversized baggage area). Items with total dimensions up to 250 cm may be allowed as carry items (subject to limits and seat/area availability). In practice, suitcases under 160 cm total (height+width+depth) travel without special arrangements. JR CentralWest Japan Railway Company Practical advice If your suitcase is ≤160 cm total (e.g., 65 cm × 40 cm × 30 cm ≈ 135 cm total), you can bring it on board and stow it in the overhead or behind seats. If >160 cm (but ≤250 cm total), you must reserve a seat with an oversized-baggage area (last-row seats on some cars) — no extra ticket surcharge, but reservation is required. Reserve early. West Japan Railway CompanyJR Central Kyoto Station 3) Kyoto Station → Hyatt Regency Kyoto Taxi: ~10 minutes, fare around ¥2000 depending on route and traffic. Local train + short walk: ~15–20 minutes (cheaper option). See hotel access instructions on arrival. hyattregency.hotel-kyoto.com Baggage-forwarding (takkyubin) — a popular option Why use it: Send your checked suitcases from Hotel Chinzanso Tokyo to Hyatt Regency Kyoto so you travel light on the train (highly recommended). Most hotels accept and drop off for kuroneko/Yamato or Japan Post takkyubin. Typical pricing / timing (examples & guidance) Next-day delivery (standard, widely available): typical range ¥3000–¥5000 per item depending on size (smaller bags cheaper; 160-size suitcase frequently ~¥2,000–¥3,000 Tokyo→Kyoto). Same-day delivery: available from selected Yamato / Kuroneko counters on some routes — prices vary and same-day service depends on pick-up time and destination (ask the provider or hotel concierge). Expect higher fees than next-day, in the ¥4000–¥6000 per item range. Video Guide To Luggage Delivery Service How to arrange Ask Hotel Chinzanso Tokyo concierge to reserve takkyubin pickup and confirm delivery date — they will handle forms in English. Contact the concierge team directly at concierge@hotel-chinzanso.com Provide your Hyatt Regency Kyoto reservation name and arrival date (note: confirm the hotel will accept forwarded bags). Keep a copy of the takkyubin receipt and tracking number; delivery is usually next-day, but confirm if you need same-day service. Conclusion Whether you choose the Global Radiology CME seamless Kyoto Transfer and 1 Day Tour, the Kyoto Transfer and 3 Day Tour, or plan your own trip we look forward to seeing you at the Business and Wellness mini-conference in Kyoto. --Natalie and Kevin Rice

Don’t Miss This Unique Experience Imaging in Japan 2026 isn’t just a conference—it’s an opportunity to grow, connect, and be inspired in one of the most extraordinary countries in the world. 📅 Conference Dates: June 1–5, 2026 📍 Location: Hotel Chinzanso Tokyo + Optional Mini-Conference at Hyatt Regency Kyoto 🔗 View the full program and register now → www.globalradiologycme.com/imaging-in-japan2026 Here are the top 10 reasons you should attend Imaging in Japan 2026: 1. Leading edge, captivating Scientific Program delivered by a World-Class Faculty Led by Scientific Director Neil M. Rofsky, the 2025 program will feature topics in body imaging, cardiothoracic imaging, MSK, neuroradiology, and emergency radiology. Faculty include some of the most respected names in the field: Donald Resnick, Ella Kazerooni, Amish Doshi, and Karen Lee. 2. Tokyo is ranked one of the top cities to visit in the world Travel + Leisure ranked Tokyo #3 in their readers favorite cities in the world in 2026. Forbes ranked Tokyo #3 of Best Cities in the world to visit in 2026. 3. Interactive and engaging Lunch Round Tables Back by popular demand, our daily Round Table sessions offer a chance to discuss current imaging and leadership topics in an informal setting with the faculty. These sessions are often cited by attendees as a highlight of the educational program. 4. Hotel Chinzanso Tokyo: A Hidden Gem in the Heart of Tokyo The conference venue, Hotel Chinzanso Tokyo, is a luxurious garden retreat tucked away in central Tokyo. You’ll attend sessions surrounded by centuries-old camellia trees, koi ponds, and stone paths—an inspiring and peaceful place to learn. 5. Kyoto: A Spiritual and Cultural Retreat Don’t miss the optional Wellness and Business Mini-Conference on June 5, 2026 at the Hyatt Regency Kyoto. Explore Japan’s former imperial capital, home to over 1,600 temples, zen gardens, and world-famous sites like the Fushimi Inari Shrine and Arashiyama Bamboo Forest. 6. Cruise and Dinner on Tokyo Bay Network with fellow registrants and faculty while enjoying a spectacular evening cruise on Tokyo Bay, complete with dinner, drinks, and panoramic views of the city skyline and Rainbow Bridge. 7. Explore Tokyo’s Contrasts From the bustling energy of Shibuya Crossing to the quiet elegance of the Meiji Shrine, Tokyo is a city of contrasts. Shop in Ginza, experience a traditional tea ceremony, take a ride in a rickshaw or marvel at the views from Tokyo Skytree—all just a short ride from the conference hotel. 8. Soak in a Traditional Onsen Experience the healing waters of a Japanese onsen. Whether in Tokyo or Kyoto, you’ll find beautifully designed public baths and hotel spas that offer the perfect post-conference wind-down. 9. Savor Michelin-Starred Cuisine and Street Food Japan has more Michelin-starred restaurants than anywhere else on earth—but the culinary scene goes far beyond fine dining. Don’t leave without trying fresh sushi at Tsukiji Market, sizzling yakitori in a local izakaya, or warm taiyaki from a street vendor. 10. Ride the Shinkansen (Bullet Train) Fast, efficient, and a uniquely Japanese experience, the Shinkansen connects Tokyo and Kyoto in just over two hours. Experience an exceptional radiology education alongside a memorable cultural journey at this distinctive conference by Global Radiology CME. The Imaging in Japan 2026 event offers professional growth, networking opportunities, and wellness for radiologists worldwide in a culturally vibrant country that seamlessly integrates ancient traditions with contemporary innovations.

Right upper quadrant pain in unstable patient. What procedure is indicated? • Xray of the Week Figure 1. What action should be taken for this patient with right upper quadrant pain who is also hemodynamically unstable? Figure 2. A. MRI of abdomen. The patient is pregnant (orange arrows), therefore ionizing radiation with CT scan or fluoroscopy can not be used for imaging guidance. Gallbladder with wall thickening (green arrow) and adjacent fluid (yellow arrow) indicate acute cholecystitis. A nuclear medicine hepatobiliary scan was also performed (not shown) and demonstrated no radiopharmaceutical present in the gallbladder due to cystic duct obstruction. B. Ultrasound of gallbladder used for guidance of percutaneous needle (red arrow) placement for cholecystostomy. C. Ultrasound of gallbladder demonstrating drainage catheter in the lumen (blue arrow). Discussion: Cholecystitis is the second most common surgical emergency seen in pregnancy after appendicitis. [1] Surgical intervention is typically safe for both the mother and fetus , due to improved morbidity when utilizing the laparoscopic approach rather than open cholecystectomy. [2]. In cases of high risk pregnancy or when treating an unstable peripartum patient, percutaneous cholecystostomy is an important important image-guided, minimally invasive alternative to surgical cholecystectomy [ 3-6 ]. This technique has proven effective for cases of acute cholecystitis occurring during the third trimester, allowing for management until delivery when surgery becomes safer. [7] . Percutaneous cholecystostomy is usually followed by laparoscopic cholecystectomy in the postpartum period once the patient has been stabilized [ 3,7 ]. In pregnancy, ultrasound is used for imaging guidance due to lack of ionizing radiation encountered with CT scan or fluoroscopy [5]. The transhepatic or transperitoneal insertion of an access needle is followed by gallbladder catheterization with either the Seldinger technique or a trocar system [8-11]. Figures 1 and 2 are imaging studies on a pregnant patient with acute cholecystitis and was too unstable to undergo surgery. The patient underwent a percutaneous cholecystostomy using the Seldinger technique and US guidance. After the patient delivered and was stable, the patient had a laparoscopic cholecystectomy and fully recovered. Major complications of percutaneous cholecystostomy include hemorrhage, pneumothorax, biliary leak, and peritonitis. The transhepatic approach may carry higher risk of pleural or hepatic injury, while transperitoneal avoids liver traversal but risks bowel injury. [8,9,11]. Prognosis is excellent with timely intervention, allowing safe maternal stabilization and fetal protection until definitive treatment. Key Learning Points Ultrasound-guided percutaneous cholecystostomy is a safe bridge in high-risk pregnant patients with acute cholecystitis, especially in the third trimester. Look for gallbladder distention and real-time needle/catheter placement on ultrasound to confirm access and decompression. Radiology plays a key role in avoiding radiation and guiding minimally invasive drainage—prefer transhepatic or transperitoneal based on anatomy. Prompt intervention stabilizes the patient; interval cholecystectomy is standard postpartum for definitive management. ​​​​ References: Angelini DJ. Obstetric triage revisited: update on non-obstetric surgical conditions in pregnancy. J Midwifery Womens Health . 2003;48(2):111-118. doi: 10.1016/s1526-9523(02)00417-8 . Knab LM, Boller AM, Mahvi DM. Cholecystitis. Surg Clin North Am . 2014;94(2):455-470. doi: 10.1016/j.suc.2014.01.005 Hojberg Y, Patel K, Shebrain S. Utilizing Percutaneous Cholecystostomy Tube as a Temporary Minimally Invasive Approach for Acute Cholecystitis during Third Trimester of a High-Risk Pregnancy. Case Rep Gastroenterol . 2022;16(1):49-54. Published 2022 Feb 14. doi: 10.1159/000522060 Baron   TH , Grimm   IS , Swanstrom   LL . Interventional approaches to gallbladder disease . N Engl J Med . 2015 ; 373 ( 4 ): 357 – 65 . doi: 10.1056/NEJMra1411372 Moirano J, Khoury J, Yeisley C, Noor A, Voutsinas N. Interventional Radiology and Pregnancy: From Conception through Delivery and Beyond. Radiographics . 2023;43(8):e230029. doi: 10.1148/rg.230029 Rana P, Gupta P, Chaluvashetty SB, et al. Interventional radiological management of hepatobiliary disorders in pregnancy. Clin Exp Hepatol . 2020;6(3):176-184. doi: 10.5114/ceh.2020.99508 Caliskan K. The use of percutaneous cholecystostomy in the treatment of acute cholecystitis during pregnancy. Clin Exp Obstet Gynecol . 2017;44(1):11-13. https://pubmed.ncbi.nlm.nih.gov/29714857/ Ginat D and Saad W. Cholecystostomy and Transcholecystic Biliary Access. Tech Vasc Interv Radiol. 2008;11(1):2-13. doi: 10.1053/j.tvir.2008.05.002 Little MW. Percutaneous cholecystostomy: The radiologist’s role in treating acute cholecystitis. Clin Radiol. 2013;68(7): 654-660. doi: 10.1016/j.crad.2013.01.017 Venara A, Carretier V, Lebigot J, E Lermite. Technique and indications of percutaneous cholecystostomy in the management of acute cholecystitis in 2014. J Visc Surg. 2014;151(6):435-439. doi: 10.1016/j.jviscsurg.2014.06.003 Beland MD, Patel L, Ahn SH, Grand DJ. Image-Guided Cholecystostomy Tube Placement: Short- and Long-Term Outcomes of Transhepatic Versus Transperitoneal Placement. AJR Am J Roentgenol. 2019;212: 201-204. doi: 10.2214/AJR.18.19669 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