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

52 year old Male on dialysis. What are the devices? • Xray of the Week Figure 2:  Frontal chest radiograph in a dialysis patient . What are the devices? Figure 2: Frontal chest radiograph in a dialysis patient with bilateral HeRO grafts. The green arrow indicates the proximal aspect of the right-sided nitinol-reinforced venous component entering the central circulation via the internal jugular vein. The red arrow highlights the left-sided system entering via the subclavian vein. The yellow arrow identifies the convergence of the dual mesh-like tubes as they cross the cavoatrial junction. Figure 3:   Anatomical diagram of a right-sided HeRO graft implantation. The arterial graft component (with cannulation area indicated) is anastomosed to the brachial artery and tunneled subcutaneously in the upper arm, connecting via the titanium connector to the venous outflow component. The venous outflow component bypasses central venous stenosis, entering the central circulation (typically via the internal jugular vein) and terminating in the right atrium for continuous outflow. Radiologic Evaluation and Management of Bilateral HeRO Grafts in Access-Challenged Patients Discussion The clinical course of patients with end-stage kidney disease (ESKD) is often limited by "vascular access exhaustion." Central venous stenosis (CVS) or occlusion (CVO) occurs in up to 40% of patients who have had prior central venous catheters, leading to venous hypertension and the failure of standard arteriovenous fistulas or grafts.[3] For these access-challenged patients, the Hemodialysis Reliable Outflow (HeRO) graft provides a critical salvage option by bypassing central obstructions to drain blood directly into the right atrium.[1][2] System Components and Radiographic Appearance The HeRO system is a hybrid device consisting of three subcutaneous parts that a general radiologist must recognize on routine imaging (see Figure 1 for anatomical overview): Arterial Graft Component: A 6-mm inner diameter expanded polytetrafluoroethylene (ePTFE) graft. On radiographs, it is poorly radiopaque, but it features distinctive PTFE beading near its distal end to provide kink resistance.[2] Titanium Connector: This is a highly radiopaque, tapered junctional device typically located in the deltopectoral groove. It joins the arterial graft to the venous outflow component.[2] Venous Outflow Component (VOC): This is a 19-French radiopaque silicone tube reinforced with a 48-braid nitinol mesh. It produces a dense, mesh-like "necklace" appearance on chest radiographs, which is the hallmark of the device.[2] Imaging Findings In the provided frontal chest radiograph, a rare bilateral HeRO graft configuration is visualized. This setup is typically reserved for patients with total, bilateral central venous occlusions who have exhausted all other upper-extremity options.[3][8] The green arrow identifies the right-sided system, where the reinforced nitinol component enters the central circulation via the right internal jugular vein. The red arrow points to the contralateral left-sided system entering via the left subclavian vein. The yellow arrow points to the central convergence of the two nitinol-reinforced components at the cavoatrial junction. The distal tips of these components should ideally reside in the mid-to-upper right atrium to ensure optimal flow and minimize the risk of thrombus formation.[2] See Figure 3 for a labeled anatomical diagram illustrating the right-sided access, including the cannulation area on the arterial graft component, the venous outflow path, and overall subcutaneous routing. While radiographs are used for routine surveillance, contrast-enhanced CT venography (CTV) or ferumoxytol-enhanced MR venography (MRV) is the gold standard for preoperative mapping of occlusions and collateral pathways.[9] Ultrasound is primarily used to evaluate the superficial arterial graft segment for patency and volume flow (typically 800–1,000 mL/min).[2] Differential Diagnosis Radiologists must differentiate the HeRO system from other common thoracic devices: Standard Tunneled Dialysis Catheters (TDCs): These are non-reinforced, less radiopaque, and lack the titanium connector and nitinol mesh "necklace" appearance.[2] Central Venous Stents: While mesh-like, stents are entirely intravascular and are not connected to a subcutaneous arterial graft.[3] Pacemaker and AICD Leads: These are much thinner and terminate in specific cardiac chambers (e.g., right ventricular apex). They do not feature the wide-caliber mesh seen in HeRO components.[2]   Management and Prognosis The HeRO graft offers a major clinical advantage over standard catheters by being entirely subcutaneous, which reduces the risk of bacteremia by approximately 69%.[5] Patency rates are comparable to conventional ePTFE grafts, with secondary patency—the ability to maintain function through interventions—reported at 80% to 90% at one year.[4][6] However, the device requires frequent maintenance. On average, patients require 1.5 to 2.2 radiologic interventions per year to treat complications such as graft thrombosis or component migration.[7] Migration of the nitinol component (either retracting into the SVC or advancing into the IVC) is a serious complication that can lead to device dysfunction or atrial injury.[7] Evolving therapies for underlying AVF/graft dysfunction (e.g., drug-coated balloons, endovascular AVF creation) may complement HeRO in select cases.[11] Key Learning Points Recognition: Identify the HeRO graft by its dense nitinol-braid "necklace" appearance and the highly radiopaque titanium connector in the deltopectoral groove.[2] Bilateral Configuration: Bilateral grafts represent a salvage strategy for patients with total thoracic central vein obstruction (TCVO).[3][8] Clinical Value: The subcutaneous design significantly lowers infection rates compared to tunneled catheters.[5] Radiologist's Role: General radiologists are often the first to identify device complications like kinking at the connector or tip migration on routine chest films.[7] Advanced Imaging: Ferumoxytol-enhanced MRV is a safe alternative for venous mapping in patients with severe renal impairment.[9] References: Katzman HE, McLafferty RB, Ross JR, Glickman MH, Peden EK, Lawson JH. Initial experience and outcome of a new hemodialysis access device for catheter-dependent patients. J Vasc Surg . 2009;50(3):600-607. doi: 10.1016/j.jvs.2009.04.014 Tabriz DM, Arslan B. HeRO Graft: Indications, Technique, Outcomes, and Secondary Intervention. Semin Intervent Radiol . 2022;39(1):82-89. doi: 10.1055/s-0042-1742391 Fitzgerald KM, Newell KR, Shin DS, et al. Thoracic Central Vein Obstruction: Endovascular Recanalization and Reconstruction. Radiographics . 2024;44(1):e240178. doi: 10.1148/rg.240178 Gage SM, Katzman HE, Ross JR, et al. Multi-center experience of 164 consecutive Hemodialysis Reliable Outflow graft implants for hemodialysis treatment. Eur J Vasc Endovasc Surg . 2012;44(1):93-99. doi: 10.1016/j.ejvs.2012.04.011 Kim Y, Cui CL, Eze AN, et al. Perioperative and long-term outcomes after Hemodialysis Reliable Outflow (HeRO) graft surgery. J Vasc Surg . 2025;82(4):1458-1466.e1. doi: 10.1016/j.jvs.2025.05.042 Gebhard TA, Bryant JA, Adam Grezaffi J, et al. Percutaneous interventions on the hemodialysis reliable outflow vascular access device. J Vasc Interv Radiol . 2013;24(4):543-549. doi: 10.1016/j.jvir.2012.12.027 Cline BC, Zuchowski A, Gage SM, et al. Hemodialysis Reliable Outflow (HeRO) graft creation in upper extremities abandoned due to stent obstruction via recanalization and HeRO outflow component insertion across stent interstices. J Vasc Access . 2021;24(5):989-993. Published 2021 Dec 10. doi: 10.1177/11297298211048061 Medjahed O, Jha AK, Ahmed A, Shaat A. Point-of-Care Ultrasound in the Diagnosis of Pulmonary Embolism With Right Heart Strain: A Case Report of Dialysis Line-Related Complications. Cureus . 2025;17(11):e96273. Published 2025 Nov 7. doi: 10.7759/cureus.96273 Takahashi EA, Kilari S, Misra S. Novel Clinical Therapies and Technologies in Dialysis Vascular Access. Kidney360 . 2021;2(8):1373-1379. Published 2021 Jun 10. doi: 10.34067/KID.0002962021 Lok CE, Huber TS, Lee T, et al. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis . 2020;75(4 Suppl 2):S1-S164. doi: 10.1053/j.ajkd.2019.12.001 Ekanem AA, Eze AN, Eze AN, Cui CL, Kim Y, Southerland KW. A rare case of hemorrhage from spontaneous disconnection of super-HeRO adapter and early-cannulation graft: A case report. J Vasc Access . 2026;27(1):361-365. doi: 10.1177/11297298251326970 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

50-year-old female presenting with short 5th finger . What is the diagnosis? • Xray of the Week Figure 1. Frontal bilateral hand X-ray. What is the diagnosis? Figure 2. Frontal bilateral hand X-ray:  Severe shortening of the middle phalanx of the fifth digit (red arrows). The phalanx measures less than 50% of the length of the adjacent fourth middle phalanx, satisfying the Hertzog criteria for Brachydactyly Type A3. A mild radial clinodactyly is present, secondary to the wedge-shaped morphology of the middle phalanx. Discussion Brachydactyly (BD) refers to disproportionately short fingers and toes, classified by the Julia Bell system into five primary types (A–E) based on anatomical involvement. Type A3 (BDA3), also known as brachymesophalangy V, is the most common isolated hand anomaly.[1]   Imaging Findings and Analysis Radiographs of this 50-year-old female (Fig 1, 2) reveal isolated, bilateral shortening of the middle phalanx of the fifth digit. The definitive diagnosis is established using the Hertzog criterion, which mandates that the longitudinal length of the fifth middle phalanx must be less than 50% of the longitudinal length of the fourth middle phalanx.[1] Morphologically, the affected phalanx exhibits a characteristic rhomboid or wedge-shaped configuration. The radial side of the phalanx is significantly shorter than the ulnar side, creating a slanted distal articular surface that drives radial clinodactyly (radial deflection of the distal phalanx toward the fourth digit).   Pathophysiological and Genetic Mechanisms BDA3 is an autosomal dominant disorder arising from disrupted cartilage ossification during early embryonic development (blastogenesis), with some cases mapped to the chromosome 13q33 region.[1]   Epidemiology and Biocultural Insights The prevalence of BDA3 varies significantly by ethnicity; it is a common variant in Asian populations, occurring in 21% to 25.6% of Japanese children, but remains rare in populations of European or African descent (<2%).[7][8]   Growth and Development Although BDA3 is more frequently identified in children with short stature, it does not negatively impact the efficacy of growth hormone therapy, indicating that the local physis disruption does not represent global resistance to growth signals.[4]   Syndromic Associations and Differentials Radiologists should view BDA3 as a clinical marker for broader genetic conditions, most notably Down syndrome (present in ~60%) and Turner syndrome.[9] Differential considerations include Kirner deformity (palmo-radial bowing of the distal phalanx shaft) and Camptodactyly (a soft-tissue flexion contracture of the PIP joint).[5]   Genetic Counseling Inheritance is typically autosomal dominant with a 50% recurrence risk for offspring; however, for isolated cases, patients should be reassured that BDA3 is a benign anatomical variant.[1]   Management and Prognosis Isolated BDA3 is almost universally asymptomatic and requires no medical or surgical intervention. The functional prognosis is excellent, as the shortening of the little finger does not typically affect manual dexterity or grip strength.[5] Corrective surgical procedures, such as osteotomy, are extremely rare and indicated only for severe clinodactyly that causes functional impairment or significant cosmetic distress.[1]   Key Learning Points Diagnostic Standard : BDA3 is confirmed when the fifth middle phalanx length is <50% of the fourth (Hertzog criterion) .[1]   Radiographic Features : Look for a wedge-shaped middle phalanx and associated radial clinodactyly.   Population Variant : High prevalence in Japanese and other Asian populations should be noted as a common anatomical variation .[7][8] Clinical Marker : Identification of BDA3 warrants screening for Down and Turner syndromes, particularly if associated with metacarpal shortening .[9]   Management : Isolated BDA3 is benign; functional impairment is rare, though corrective options exist for severe cases .[5]   References Temtamy SA, Aglan MS. Brachydactyly. Orphanet J Rare Dis . 2008;3:15. doi: 10.1186/1750-1172-3-15 Garn SM, Hertzog KP, Poznanski AK, Nagy JM. Metacarpophalangeal length in the evaluation of skeletal malformation. Radiology . 1972;105(2):375-381. doi: 10.1148/105.2.375 Wu H, Wu H, Li Y, Li H. Brachydactyly Type A3 Is More Commonly Seen in Children With Short Stature But Does Not Affect Their Height Improvement by Growth Hormone Therapy. Front Endocrinol (Lausanne) . 2022;13:824315. doi: 10.3389/fendo.2022.824315 Nguyen ML, Jones N. Undergrowth: brachydactyly. Hand Clin . 2009;25(2):247-255. doi: 10.1016/j.hcl.2009.02.003 Everman DB. The brachydactylies. In: Stevenson RE, Hall JG, eds. Human Malformations and Related Anomalies . 2nd ed. Oxford University Press; 2006:968-983. Zhang W, Li K, Zhang Q, et al. Epidemiology of brachydactyly type A3 in China: a nationwide multicentre population-based study among children aged 3–17 years. BMJ Open . 2025;15(11):e099166. doi: 10.1136/bmjopen-2025-099166 Wu HH, Zhang YQ, Yu CD, et al. Brachydactyly type A3 may be associated with shorter stature: An observation from a Chinese pediatric sample. PLoS One . 2025;20(11):e0336913. doi: 10.1371/journal.pone.0336913 Kang MJ, Kanakatti Shankar R, Jee YH. Phalangeal bone growth and implications in Turner syndrome. Front Endocrinol (Lausanne) . 2026;16:1735962. doi: 10.3389/fendo.2025.1735962 . Castriota-Scanderbeg A, Dallapiccola B. Abnormal Skeletal Phenotypes: From Sameness to Differential Diagnosis . Springer; 2006. doi: 10.1007/3-540-30361-8   Cleveland Clinic. Brachydactyly. Accessed January 20, 2026. https://my.clevelandclinic.org/health/diseases/24081-brachydactyly   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

An 74-year-old male with chronic low back pain and progressive lower extremity weakness. What is the diagnosis? • Xray of the Week Figure 1. Non-contrast CT of the lumbar spine. What is the diagnosis? Figure 2. Non-contrast CT of the lumbar spine (axial, sagittal, and coronal reconstructions): Central pattern of arachnoiditis ossificans demonstrating dagger-like ossification within the central spinal canal at the L5 level (red arrows). The linear, hyperdense bony bar courses longitudinally along the central canal, causing focal narrowing and potential cauda equina compression. No peripheral or circumferential involvement is seen, consistent with the central ossification pattern. Diagnosis Arachnoiditis ossificans. Discussion Arachnoiditis ossificans is a rare end-stage manifestation of chronic adhesive arachnoiditis, characterized by ossification of the arachnoid membrane within the spinal canal.[1][2] It typically occurs in the thoracolumbar region and is associated with prior spinal surgery, trauma, infection, subarachnoid hemorrhage, or oil-based myelography.[3][4] Patients often present with progressive myelopathy or radiculopathy due to nerve root compression or tethering.[5] The condition represents metaplastic ossification of inflamed arachnoid tissue, leading to intrathecal calcified or ossified plaques that can encase the spinal cord or cauda equina.[6] Imaging Findings Computed tomography (CT) is the modality of choice for diagnosing arachnoiditis ossificans due to its superior depiction of ossified structures, with sensitivity for detecting intrathecal ossification approaching 100% in symptomatic cases.[2][7] On CT, hyperdense bone attenuation plaques are seen within the thecal sac, with patterns varying by type of ossification [2]: Central pattern : Linear or dagger-like hyperdense ossification centered within the spinal canal, often appearing as a solitary midline bony bar or rod on axial views. (Figs. 1,2) Nerve root encasing pattern : Tubular or circumferential hyperdense ossifications surrounding individual or clumped nerve roots (cauda equina), with roots appearing embedded or passing through the ossified tissue. Weblike pattern : Interlacing, mesh-like hyperdense strands or trabeculae filling or crisscrossing the thecal sac, creating a reticular appearance between nerve roots. Peripheral pattern : Rim-like or discontinuous hyperdense plaques along the inner walls of the thecal sac, often circumferential or partially encircling, potentially narrowing the canal without central involvement. These patterns frequently coexist, leading to thecal sac deformity, nerve root clumping, and varying degrees of central canal stenosis. Multiplanar reconstructions (sagittal/coronal) help confirm the distribution and extent. Patterns of intrathecal ossification can guide prognosis and surgical planning. Management and Prognosis Management is primarily conservative, focusing on pain control and physical therapy, as surgical decompression carries high risks of reossification or worsening symptoms.[3][5] Laminectomy with duraplasty may be considered for severe cord compression, with variable success rates (30-50% improvement in symptoms).[4] Prognosis is guarded, with many patients experiencing progressive disability; early detection via imaging can facilitate timely intervention to prevent irreversible myelopathy.[6] Key Learning Points CT is essential for identifying hyperdense intrathecal ossifications in arachnoiditis ossificans, outperforming MRI for bony detail. Look for circumferential or patterned ossified plaques encasing nerve roots on multiplanar reconstructions to differentiate from mimics like dural calcifications. Radiology plays a critical role in classifying ossification patterns, which influence surgical feasibility and prognosis. Prompt recognition on CT can guide multidisciplinary management and prevent complications like syringomyelia—always correlate with clinical history of prior spinal insult. References Frizzell B, Kaplan P, Dussault R, Sevick R. Arachnoiditis ossificans: MR imaging features in five patients. AJR Am J Roentgenol . 2001;177(2):461-464. doi: 10.2214/ajr.177.2.1770461 Thejeel B, Greditzer-Sobeck C, Ciacci J, Siddiqi I. Patterns of intrathecal ossification in arachnoiditis ossificans: a retrospective case series. AJNR Am J Neuroradiol . 2023;44(2):228-234. doi: 10.3174/ajnr.A7764 Donalisio M, Cadosch D. Arachnoiditis ossificans. Skeletal Radiol . 2024;53(5):1019-1021. doi: 10.1007/s00256-023-04465-7 Junewick JJ. Clinical image. Arachnoiditis ossificans in a pediatric patient. Pediatr Radiol . 2010;40(2):228. doi: 10.1007/s00247-009-1350-2 Jaspan T, Preston BJ, Mulholland RC, Webb JK. The CT appearances of arachnoiditis ossificans. Spine (Phila Pa 1976) . 1990;15(2):148-151. doi: 10.1097/00007632-199002000-00022 Chan CC, Lau PY, Sun LK, Lo SS. Arachnoiditis ossificans. Hong Kong Med J. 2009;15(2):146-148. https://pubmed.ncbi.nlm.nih.gov/19342743/ Kumaran SP, Gupta K, Maddali A, Viswamitra S. Post traumatic arachnoiditis ossificans. J Emerg Trauma Shock . 2012;5(3):250-252. doi: 10.4103/0974-2700.99701 Sefczek RJ, Deeb ZL. Case report: computed tomography findings in spinal arachnoiditis ossificans. J Comput Tomogr . 1983;7(3):315-318. doi: 10.1016/0149-936x(83)90099-1 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

Pt fell and his eye hit a metal object. What is the diagnosis? • Xray of the Week Figure 1. Non-contrast CT orbits – axial and sagittal images. What is the diagnosis? Figure 2. Non-contrast CT orbits – axial and sagittal images. Hyperdense material consistent with blood fills the anterior chamber of the left eye (red arrows), indicating hyphema. Hyperdense material is also present in the vitreous chamber posteriorly (yellow arrows), consistent with acute vitreous hemorrhage. The right globe shows a normal lens separating anterior and posterior chambers (green arrows) for comparison. Diagnosis Traumatic hyphema with concurrent vitreous hemorrhage in the left eye. Discussion Hyphema is hemorrhage into the anterior chamber, most commonly from blunt or penetrating ocular trauma, but also possible from surgery, coagulopathy, or spontaneous causes (e.g., iris neovascularization).[1][2] Vitreous hemorrhage involves bleeding into the vitreous cavity, often linked to trauma, proliferative diabetic retinopathy, retinal tears, or vascular occlusions.[3] In this traumatic case, both findings coexist due to shearing forces disrupting iris/ciliary body vessels (hyphema) and posterior structures (vitreous hemorrhage). Hyphemas are graded clinically by the volume of layered blood in the anterior chamber (Table below). Grading helps predict complications like rebleeding (highest in grades III–IV) and secondary glaucoma.[4][5][6] Hyphema Grade Approximate Volume of Blood in the Anterior Chamber Risk of IOP elevation/ secondary glaucoma Grade 0: Microhyphema <1% (slit-lamp only) <10% Grade I <33% ~10% Grade II 33–50% ~10% Grade III >50% but not full ~25% Grade IV 100% >50% "Eight ball" hyphema 100% & dark color due to poor circulation 100% Figure 3. Traumatic hyphema c linical image:   Note the layering blood in the anterior chamber in this patient following blunt eye trauma. Contributor : Jesse Vislisel, MD - EyeRounds.org The University of Iowa. Creative Commons 3.0 https://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/Hyphema/index.htm#gsc.tab=0 Imaging Findings Non-contrast orbital CT is the preferred initial imaging for acute ocular trauma when direct exam is limited by swelling, pain, or suspected open globe.[7][8] Hyphema appears as hyperdense (blood attenuation ~40–70 HU) material layering or filling the anterior chamber, anterior to the lens.[7] Vitreous hemorrhage shows increased attenuation in the posterior segment, often homogeneous acutely or heterogeneous if clotted/organized.[3][9] Reported sensitivity for detecting hyphema on CT is ~77%, specificity ~88%.[7] CT excels at identifying associated injuries (e.g., lens dislocation, globe rupture, foreign bodies, orbital fractures) and is safer than ultrasound if open globe is suspected (to avoid pressure on the eye).[8] Ultrasound is superior for posterior segment details (e.g., retinal detachment ) when media opacity from hemorrhage limits fundus view, but CT is first-line for trauma screening.[3][9] Management & Prognosis Management is primarily ophthalmology-directed. For traumatic hyphema: conservative measures include protective eye shielding, head elevation (30–45°), limited activity/bed rest, avoiding aspirin/NSAIDs/anticoagulants, and serial IOP monitoring to prevent rebleeding (peak risk days 3–5) or secondary glaucoma.[4][5][6][10] Topical corticosteroids reduce inflammation; cycloplegics (e.g., atropine) relieve ciliary spasm/pain. Antifibrinolytics (e.g., tranexamic acid or aminocaproic acid) may reduce rebleeding risk but lack strong evidence for improving final visual acuity and can prolong clot clearance—use is controversial per recent reviews.[10] There are ongoing debates regarding optimal approaches due to the absence of standardized guidelines, including medical agents, surgical techniques, and special situations (e.g., sickle-cell disease).[8] Surgical evacuation (e.g., anterior chamber washout) is indicated for large/persistent hyphema causing corneal blood staining, uncontrolled IOP, or active rebleeding. Vitreous hemorrhage often resolves spontaneously but may require vitrectomy if non-clearing or associated with retinal pathology.[3] Prognosis is generally good for isolated/low-grade cases (most resolve within days to weeks), but worse with higher grades, rebleeding, secondary glaucoma, sickle cell trait/disease, or extensive posterior involvement (e.g., retinal detachment). Approximately 5% of traumatic hyphemas require surgery.[4][5] Key Learning Points Look for hyperdense anterior chamber fluid on non-contrast CT to diagnose hyphema in trauma. Vitreous hyperdensity indicates posterior hemorrhage; always assess for associated globe/orbital injuries. CT is valuable when clinical exam is limited; ultrasound complements for posterior evaluation. Grade hyphema clinically to guide prognosis and intervention—prompt ophthalmology consultation is essential to prevent vision loss. References Sung EK, Nadgir RN, Fujita A, et al. Injuries of the globe: what can the radiologist offer? Radiographics . 2014;34(3):764-776. doi: 10.1148/rg.343135120 Hallinan JTPD, Pillay P, Koh L, Goh K, Yu W. Eye globe abnormalities on MR and CT in adults: an anatomical approach. Korean J Radiol . 2016;17(5):664-673. doi: 10.3348/kjr.2016.17.5.664 Spraul CW, Grossniklaus HE. Vitreous hemorrhage. Surv Ophthalmol . 1997;42(1):3-39. doi: 10.1016/S0039-6257(97)84041-6 Hartness E, Garza Reyes A, Yu C, Sears N. Hyphema: diagnosis and management. EyeRounds.org . February 20, 2024. Accessed January 14, 2026. https://eyerounds.org/cases/345-hyphema.htm Chen EJ, Fasiuddin A. Management of traumatic hyphema and prevention of its complications. Cureus . 2021;13(6):e15771. doi: 10.7759/cureus.15771 Miller SC, Meeralakshmi P, Fliotsos MJ, et al. Global current practice patterns for the management of hyphema. Clin Ophthalmol . 2022;16:3135-3144. doi: 10.2147/OPTH.S372273 Chazen JL, El-Sayed IH, Vance S, et al. CT in the evaluation of acute injuries of the anterior eye segment. AJR Am J Roentgenol . 2018;210(3):W107-W113. doi: 10.2214/AJR.17.18279 Bansal S, Gunasekaran PK, Azad S, Agrawal R. Controversies in the pathophysiology and management of hyphema. Surv Ophthalmol . 2016;61(3):297-308. doi: 10.1016/j.survophthal.2015.11.005 Rabinowitz R, Yagev R, Shoham A, Lifshitz T. Comparison between clinical and ultrasound findings in patients with vitreous hemorrhage. Eye (Lond) . 2004;18(3):253-256. doi: 10.1038/sj.eye.6700632 Woreta FA, Lindsley KB, Gharaibeh A, et al. Medical interventions for traumatic hyphema. Cochrane Database Syst Rev . 2023;2023(3):CD005431. doi: 10.1002/14651858.CD005431.pub5 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 83-year-old male with rectal bleeding. What is the diagnosis? • Xray of the Week Figure 1. CTA abdomen/pelvis. What is the diagnosis? Figure 2. CT angiogram: A. Non-contrast images are normal (yellow arrow) . B. Arterial phase image: Hyperdense extravasation of contrast within the lumen of the ascending colon (blue arrow), indicating active bleeding. C and D. Note the dependent layering of contrast on portal venous phase images, confirming active extravasation. Diagnosis Active gastrointestinal bleeding in the ascending colon. Discussion Gastrointestinal (GI) bleeding is a common clinical problem, particularly in the elderly, where lower GI sources predominate. Common etiologies include diverticulosis, angiodysplasia, neoplasms, ischemia, and inflammatory conditions.[1][2] In this case, the ascending colon involvement suggests a right-sided colonic source, often angiodysplasia or diverticular bleed, which can present with painless hematochezia.[3] Active bleeding is defined as extravasation of contrast into the bowel lumen on imaging, distinguishing it from pseudo-extravasation mimics like hyperdense pills or fecal material.[4] Imaging Findings Multiphase computed tomography angiography (CTA) is the preferred initial imaging for hemodynamically stable patients with suspected acute GI bleeding, offering high sensitivity (85-89%) and specificity (85-95%) for detecting active extravasation.[5][6] It is rapid, widely available, and guides subsequent interventions like endoscopy or embolization.[7] On non-contrast phase: No extravasation; may show hyperdense sentinel clot (40-70 HU) or bowel wall abnormalities. On arterial phase: Active extravasation appears as hyperdense focus (>90 HU) within the lumen, often eccentric or jet-like, increasing in size or density compared to non-contrast. On portal venous/delayed phase: Extravasation persists or enlarges, confirming active bleed; helps differentiate from venous sources. Reported detection rates for active bleeding exceed 0.3-0.5 mL/min, superior to nuclear medicine in many settings.[8] CTA also identifies structural causes (e.g., diverticula, tumors) even without active bleeding.[4] Management and Prognosis Management begins with hemodynamic resuscitation. For active lower GI bleeding confirmed on CTA, options include urgent colonoscopy (if stable), interventional radiology embolization (targeted to the bleeding vessel), or surgery for refractory cases.[1][3][7] Embolization success rates are 70-90%, with low rebleeding if superselective.[2] Prognosis depends on bleed severity, comorbidities, and etiology; elderly patients have higher mortality (10-20% for severe bleeds). Rebleeding risk is 10-25% for diverticular sources.[6] Key Learning Points Multiphase CTA is first-line for localizing active GI bleeding in stable patients, with high accuracy for extravasation. Look for hyperdense intraluminal contrast on post-contrast phases that is absent on non-contrast to confirm active bleed. CTA guides therapy by identifying the site and potential etiology; always assess for mimics like hyperdense foreign material. Prompt radiology interpretation is crucial to expedite embolization or endoscopy and improve outcomes. References Artigas JM, Martí M, Soto JA, Esteban H, Pinilla I, Guillén E. Multidetector CT angiography for acute gastrointestinal bleeding: technique and findings. Radiographics . 2013;33(5):1453-1470. doi: 10.1148/rg.335125072 Wells ML, Hansel SL, Bruining DH, et al. CT for evaluation of acute gastrointestinal bleeding. Radiographics . 2018;38(4):1089-1107. doi: 10.1148/rg.2018170138 Wortman JR, Landman W, Fulwadhva UP, Viscomi SG, Sodickson AD. CT angiography for acute gastrointestinal bleeding: what the radiologist needs to know. Br J Radiol . 2017;90(1075):20170076. doi: 10.1259/bjr.20170076 Di Serafino M, Iacobellis F, Schillirò ML, et al. The role of CT-angiography in the acute gastrointestinal bleeding: a pictorial essay of active and obscure findings. Tomography . 2022;8(5):2369-2402. doi: 10.3390/tomography8050198 Wu LM, Xu JR, Yin Y, Qu XH. Usefulness of CT angiography in diagnosing acute gastrointestinal bleeding: a meta-analysis. World J Gastroenterol . 2010;16(31):3957-3963. doi: 10.3748/wjg.v16.i31.3957 García-Blázquez V, Vicente-Bártulos A, Olavarria-Delgado A, Plana MN, van der Winden D, Zamora J. Accuracy of CT angiography in the diagnosis of acute gastrointestinal bleeding: systematic review and meta-analysis. Eur Radiol . 2013;23(5):1181-1190. doi: 10.1007/s00330-012-2721-x Kim BS, Li BT, Engel A, Samra JS, Clarke S, Norton ID, Li AE. Diagnosis of gastrointestinal bleeding: a practical guide for clinicians. World J Gastrointest Pathophysiol . 2014;5(4):467-478. doi: 10.4291/wjgp.v5.i4.467 Parekh PJ, Buerlein RC, Shams R, Vingan H, Johnson DA. Evaluation of gastrointestinal bleeding: update of current radiologic strategies. World J Gastrointest Pharmacol Ther. 2014;5(4):200-208. doi: 10.4292/wjgpt.v5.i4.200 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

25-Year-Old Female with Abdominal Pain and Weight Loss: Diagnosis? • Xray of the Week Figure 1. 25-Year-Old Female with Abdominal Pain and Weight Loss: Diagnosis? Figure 2. CTA through the thoracic and abdominal aorta. A. Axial image through the descending thoracic aorta demonstrates concentric mural thickening and mild stenosis (yellow arrow). B. Axial image through the infra-renal abdominal aorta demonstrates mild concentric mural thickening and severe stenosis (red arrow). C. CTA 3D Image demonstrates severe stenosis of the infra-renal abdominal aorta and very severe stenosis of the origin of the common iliac arteries (green arrow). Takayasu Arteritis Epidemiology Takayasu arteritis, named after Mikito Takayasu, is a rare large-vessel vasculitis. This condition is also known as pulseless disease. The global prevalence ranges from 3.2 to 40 cases per million, with an annual incidence of 0.4 to 2.6 per million, depending on geographic location. It predominantly affects young women, with a female-to-male ratio of approximately 8 to 9:1. Clinical Findings Patients with Takayasu arteritis often present with constitutional symptoms. These may include weight loss, fever, and malaise, which develop gradually. As the disease progresses, vascular symptoms can emerge. Abdominal pain may indicate mesenteric ischemia due to stenosis in the abdominal aorta or its branches. A physical examination may reveal diminished peripheral pulses, differing blood pressures between arms, bruits over major arteries, and elevated inflammatory markers such as ESR and CRP. Pathology Histologically, Takayasu arteritis is characterized by granulomatous inflammation of the adventitia and media. This includes giant cells, lymphocytic infiltration, and intimal hyperplasia. Over time, progressive fibrosis leads to concentric wall thickening, which can result in stenosis, occlusion, or aneurysmal changes. Classification The Hata/Numano angiographic classification is widely used to categorize Takayasu arteritis into five types based on arterial involvement: Type I: Branches of the aortic arch Type IIa: Ascending aorta, arch, branches Type IIb: Type IIa + thoracic descending aorta Type III: Thoracic descending and abdominal aorta Type IV: Abdominal aorta and/or renal arteries Type V: Entire aorta and its branches. This classification correlates with clinical presentation and guides treatment strategies. Radiographic Features CT Angiography (CTA) CTA is the preferred modality for mapping vascular anatomy. It helps delineate the severity of stenosis, occlusions, aneurysms, and collateral pathways. In active disease, CTA reveals long-segment concentric mural thickening with homogeneous enhancement. In chronic stages, fixed luminal narrowing, post-inflammatory calcifications, and aneurysmal changes are evident. Characteristic CTA Signs: Double-ring sign: This sign features an inner low-attenuation ring within an enhancing vessel wall, correlating with mural edema and inflammation. Diffuse narrowing: This is observed in both the thoracic and abdominal aorta, particularly with ostial stenoses of branch vessels like the renal and mesenteric arteries. Collateral development: This occurs in chronic disease, providing indirect evidence of long-standing vascular compromise. MRI and PET/CT MRI is useful for detecting mural edema and enhancement on vessel wall imaging. FDG-PET/CT can demonstrate increased metabolic activity in inflamed vessels. These modalities are superior to CTA for monitoring disease activity and guiding immunosuppressive therapy, as emphasized in EULAR guidelines. Treatment and Prognosis High-dose corticosteroids remain the first-line therapy. They are often combined early with steroid-sparing immunosuppressants. Tocilizumab and other biologics have shown efficacy in refractory cases. Surgical or endovascular revascularization is reserved for severe, flow-limiting lesions and is ideally performed when inflammation is controlled. Relapses are common, making long-term follow-up with multimodality imaging essential to monitor disease progression and therapeutic response. Conclusion Understanding Takayasu arteritis is crucial for timely diagnosis and effective management. By recognizing the clinical features and utilizing appropriate imaging techniques, we can improve patient outcomes. References Rutter M, Bowley J, Lanyon PC, Grainge MJ, Pearce FA. A systematic review and meta-analysis of the incidence rate of Takayasu arteritis. Rheumatology (Oxford). 2021;60(11):4982-4990. doi: https://doi.org/10.1093/rheumatology/keab406 . Kerr GS, Hallahan CW, Giordano J, et al. Takayasu arteritis. Ann Intern Med. 1994;120(11):919-929. doi: https://doi.org/10.7326/0003-4819-120-11-199406010-00004 . Hata A, Noda M, Moriwaki R, Numano F. Angiographic findings of Takayasu arteritis: new classification. Int J Cardiol. 1996;54 Suppl:S155-S163. doi: https://doi.org/10.1016/S0167-5273(96)02813-6 02813-6). Dejaco C, Ramiro S, Duftner C, et al. EULAR recommendations for the use of imaging in large vessel vasculitis in clinical practice. Ann Rheum Dis. 2018;77(5):636-643. doi: https://doi.org/10.1136/annrheumdis-2017-212649 . Matsunaga N, Hayashi K, Sakamoto I, Ogawa Y, Matsumoto T. Takayasu arteritis: protean radiologic manifestations and diagnosis. Radiographics. 1997;17(3):579-594. doi: https://doi.org/10.1148/radiographics.17.3.9153698 . Yamada I, Nakagawa T, Himeno Y, Numano F, Shibuya H. Takayasu arteritis: evaluation of the thoracic aorta with CT angiography. Radiology. 1998;209(1):103-109. doi: https://doi.org/10.1148/radiology.209.1.9769819 . Park JH, Chung JW, Im JG, Kim SK, Park YB, Han MC. Takayasu arteritis: evaluation of mural changes in the aorta and pulmonary artery with CT angiography. Radiology. 1995;196(1):89-93. doi: https://doi.org/10.1148/radiology.196.1.7784596 . Kim SY, Park JH, Chung JW, et al. Follow-up CT evaluation of the mural changes in active Takayasu arteritis. Korean J Radiol. 2007;8(4):286-294. doi: https://doi.org/10.3348/kjr.2007.8.4.286 . Zhu FP, Luo S, Wang ZJ, Jin ZY, Zhang LJ, Lu GM. Takayasu arteritis: imaging spectrum at multidetector CT angiography. Br J Radiol. 2013;85(1020):e1282-e1292. doi: https://doi.org/10.1259/bjr/25536451 . 10. Bois JP, Anand V, Anavekar NS. Detection of inflammatory aortopathies using multimodality imaging. Circ Cardiovasc Imaging. 2019;12(7):e008471. doi: https://doi.org/10.1161/CIRCIMAGING.118.008471 . 11. Nakaoka Y, Isobe M, Takei S, et al. Efficacy and safety of tocilizumab in patients with refractory Takayasu arteritis: results from a randomized, double-blind, placebo-controlled, phase 3 trial in Japan (the TAKT study). Ann Rheum Dis. 2018;77(3):348-354. doi: https://doi.org/10.1136/annrheumdis-2017-211878 . 12. Hellmich B, Agueda A, Monti S, et al. 2018 update of the EULAR recommendations for the management of large-vessel vasculitis. Ann Rheum Dis. 2020;79(1):19-30. doi: https://doi.org/10.1136/annrheumdis-2019-215672 . 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

What is the significance of this anomaly? • Xray of the Week Figure 1. What is the significance of this anomaly? Figure 2. Axial and coronal CT images of the cervical spine along with 3D CT reconstruction demonstrating a right cervical rib. A. Axial CT of the cervical spine detailing a unilateral, right cervical rib at the level of C7 (red arrow) B. Axial CT image further demonstrating the unilateral right cervical rib (red arrow) C. 3D CT reconstruction of a right cervical rib arising from the transverse process of C7 (red arrow). D. Coronal CT image of the cervical spine showing unilateral cervical rib on the right (red arrow). Discussion: There is a total of 12 pairs of ribs that articulate with each segment of the thoracic vertebrae posteriorly and function to protect the thoracic viscera and help promote respiration. In regards to rib anatomy, the first seven pairs are considered true ribs as they attach directly to the sternum via their costal cartilage while the 8th-10th ribs are considered false ribs since their cartilages fuse and then join at the 7th rib costal cartilage to attach indirectly to the sternum. Finally, there are also ribs 11 and 12 which are considered floating due to their lack of connection to the sternum in any fashion. Another classification regarding rib structure is typical vs atypical ribs, which separates ribs 1, 11, and 12 from 2-10 due to specific anatomical features. Cervical ribs are a rare occurrence in the population with an incidence of under 1% and are often an incidental finding on radiographic imaging (1). A cervical rib is defined as an accessory rib that develops most commonly at the level of C7, but some cases have been reported at C6, C5, and as high as C4 (1). To classify a cervical rib, there must be evidence of a supernumerary rib that attaches to the transverse process of a cervical vertebra (Figs. 1,2) (1,2). When they are bilateral, they are often asymmetric, however, when they are unilateral, they tend to be found on the right (1). Cervical ribs are normally clinically silent, and individuals may never know that they have one. However, this becomes clinically relevant and warrants investigation when patients start to develop symptoms of thoracic outlet syndrome due to compression of the brachial plexus, subclavian artery, or subclavian vein in the extremity on the side of the cervical rib (2,3). In rare cases, cervical ribs have been shown to cause recurrent strokes in younger individuals, subclavian artery aneurysms, subclavian artery thromboses, and significant ischemia leading to gangrene of the distal phalanges (4). Without clinical manifestations of a cervical rib, there is no dedicated imaging protocol to detect them. They will most likely be picked up incidentally on plain radiographs for other medical indications (1,2). When there are clinical manifestations of thoracic outlet syndrome, an initial plain radiograph would be an appropriate first study. In the setting of unilateral ischemic arm pain, paresthesia, weakened pulse, and numbness, CT scan will definitively demonstrate a rib articulating with the transverse process of C7 if it is present (Figs. 1,2) (3). Three-dimensional computed tomography is especially useful for surgical planning purposes (Figs. 1,2 C) (5). With 3D CT, anatomical detail is significantly enhanced, especially the attachment sites of the rib, presence of pseudoarthrosis, and the location of nearby vasculature and neural structures (5). ​​​ References: Spadliński Ł, Cecot T, Majos A, et al. The Epidemiological, Morphological, and Clinical Aspects of the Cervical Ribs in Humans. Biomed Res Int. 2016;2016:8034613. DOI: 10.1155/2016/8034613 Jeung MY, Gangi A, Gasser B, et al. Imaging of chest wall disorders. Radiographics. 1999;19(3):617-637. DOI: 10.1148/radiographics.19.3.g99ma02617 Viertel VG, Intrapiromkul J, Maluf F, et al. Cervical ribs: a common variant overlooked in CT imaging. AJNR Am J Neuroradiol. 2012;33(11):2191-2194. DOI: 10.3174/ajnr.A3143 Kataria R, Sharma A, Srivastava T, Bagaria H, Sharma A. Cervical rib, a rare cause of recurrent stroke in the young: case report. Neurologist. 2012;18(5):321-323. DOI: 10.1097/NRL.0b013e31826754a9 Chandak S, Kumar A. Usefulness of 3D CT in Diagnosis of Cervical Rib Presenting as Supraclavicular Swelling of Short Duration. J Clin Diagn Res. 2014;8(5):RD01-RD2. DOI: 10.7860/JCDR/2014/7977.4374 Corey Stump is a medical student and aspiring radiologist at the Marian University College of Osteopathic Medicine in Indianapolis, Indiana. Prior to medical school, he graduated summa cum laude from Wittenberg University where he received a B.S. degree in Biology. He is excited to pursue a career in Diagnostic Radiology with interests in medical education. His current project involves a webinar titled “Navigating The Virtual Match; Program Directors Vs Medical Students” through the Academy of Online Radiology Education with other medical students and radiologists around the country in an effort to provide insight on the upcoming residency match. He is passionate about teaching and he hopes to provide a meaningful experience to medical students one day. Follow Corey Stump on Twitter @corey_stump All posts by Corey Stump Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice is a radiologist with Renaissance Imaging Medical Associates and is currently the Vice Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

Trauma. What is the diagnosis? • Xray of the Week Figure 1. What is the diagnosis? Figure 2 :  Coronal CT Images display a fracture through the right cervical rib (red arrows). Figure 3 :  Axial and Coronal CT Images display edema in the soft tissues adjacent to the fracture (yellow arrows). Fracture of the Right Cervical Rib Overview Cervical ribs are true supernumerary ribs arising from the C7 transverse process and are a common congenital variant on cross-sectional imaging; on large CT series they are present in roughly 2.0% of adults and are under-reported unless actively sought. [1] A fracture of a cervical rib is an exceedingly uncommon event described only in isolated case reports and small case series; reported mechanisms include direct trauma, falls, and repetitive occupational load (eg, heavy backpack use). [2,3] Clinical Findings Patients typically present with focal supraclavicular or neck pain, a palpable tender mass at the thoracic inlet, or delayed symptoms of thoracic outlet syndrome (TOS) — most often neurogenic (paresthesia/weakness in the ulnar distribution) and occasionally vascular (upper-extremity ischemia, digital emboli). Many reported fractures initially present as atraumatic swelling or delayed neurogenic symptoms after a remote injury. [2,3] Imaging CT is the modality of choice for identifying cervical ribs and confirming fracture because plain radiographs frequently miss fractures at the cervicothoracic junction due to overlap and suboptimal projection. [4] Post-processing strategies that improve detection and reporting accuracy include coronal/oblique reformats through the rib axis, curved planar or “unfolded” rib reconstructions, and single-in-plane rib-cage reformations — all of which increase sensitivity for osseous injury and streamline preoperative planning. [5] When neurovascular compromise is suspected clinically or when the fracture lies close to the subclavian vessels/brachial plexus, CT angiography (CTA) with neutral and provocative/postural maneuvers (abduction or elevation of the ipsilateral arm) can demonstrate dynamic arterial or venous compression, stenosis, aneurysm, thrombosis, or abnormal vessel course related to the fractured cervical rib. Helical CTA protocols and multiplanar 3-D reformations are particularly helpful for surgical planning. [6,7] Imaging Findings — What to look for • Cervical rib identification:  a continuous osseous structure originating from the C7 transverse process that may articulate (partially or fully) with the first rib or clavicle. [1] • Acute fracture:  sharp cortical break or lucent fracture line with surrounding soft-tissue swelling, displaced fragments, and occasionally small adjacent hematoma. [4] • Subacute/chronic healing:  sclerotic margins, callus formation or pseudoarthrosis at an articulation site that can mimic chronic nonunion. [2,3] • Relationship to neurovascular structures:  focal narrowing or indentation of the subclavian artery/vein, abnormal vessel angulation/arching, or proximity to the lower brachial plexus should be documented; dynamic imaging may demonstrate postural exacerbation. [6,7] • Associated findings:  first-rib abnormalities, anomalous fibrous bands, or concurrent first-rib or clavicular fractures may alter management. [7] Differential diagnosis Differentiate true acute fracture from: unfused ossification centers or congenital pseudoarthrosis, chronic nonunion/pseudarthrosis of a cervical rib, an anomalous elongated C7 transverse process, or osteophyte. Cortical irregularity plus focal bone marrow/soft-tissue edema on MRI (if obtained) or clear cortical disruption on CT favor acute fracture. [5] Treatment & Prognosis Initial management of isolated, uncomplicated cervical-rib fractures is conservative: activity modification, short-term immobilization/analgesia, and physiotherapy. Surgical referral is indicated when there is persistent pain, symptomatic nonunion/callus mass, or objective neurovascular compromise (TOS) attributable to the fractured rib. Surgical options include supraclavicular or transaxillary resection of the cervical rib (with ± scalenectomy and addressing fibrous bands), and preoperative vascular imaging is recommended when arterial or venous involvement is suspected. Outcomes are generally favorable after appropriate decompression; durable symptom relief is reported in series where resection was indicated. [8,9] References Viertel VG, Intrapiromkul J, Maluf F, Patel NV, Zheng W, Alluwaimi F, Walden MJ, Belzberg A, Yousem DM. Cervical ribs: a common variant overlooked in CT imaging. AJNR Am J Neuroradiol . 2012;33(11):2191-2194. doi: https://doi.org/10.3174/ajnr.A3143 . PubMed Kamath GS, Borkar S, Chauhan A, Chidanand B, Kashyap N, Warrier R. Isolated cervical rib fracture. Ann Thorac Surg . 2010;89(6):e41-e42. doi: https://doi.org/10.1016/j.athoracsur.2010.02.035 . PubMed Dar RA, Wani SH, Mushtaque M. Isolated cervical rib fracture: a rare etiology of thoracic outlet syndrome. Case Rep Surg . 2011;2011:163792. doi: https://doi.org/10.1155/2011/163792 . PubMed Jelly LM, Evans DR, Easty MJ, Coats TJ, Chan O. Radiography versus spiral CT in the evaluation of cervicothoracic junction injuries in polytrauma patients who have undergone intubation. Radiographics . 2000;20(Spec No):S251-S259. doi: https://doi.org/10.1148/radiographics.20.suppl_1.g00oc20s251 . PubMed Dankerl P, Seuss H, Ellmann S, Cavallaro A, Uder M, Hammon M. Evaluation of rib fractures on a single-in-plane image reformation of the rib cage in CT examinations. Acad Radiol . 2017;24(2):153-159. doi: https://doi.org/10.1016/j.acra.2016.09.022 . PubMed Remy-Jardin M, Remy J, Masson P, Bonnel F, Debatselier P, Vinckier L, Duhamel A. Helical CT angiography of thoracic outlet syndrome: functional anatomy. AJR Am J Roentgenol . 2000;174(6):1667-1674. doi: https://doi.org/10.2214/ajr.174.6.1741667 . PubMed Raptis CA, Sridhar S, Thompson RW, Fowler KJ, Bhalla S. Imaging of the patient with thoracic outlet syndrome. RadioGraphics . 2016;36(4):984-1000. doi: https://doi.org/10.1148/rg.2016150221 . PubMed Sanders RJ, Hammond SL. Management of cervical ribs and anomalous first ribs causing neurogenic thoracic outlet syndrome. J Vasc Surg . 2002;36(1):51-56. doi: https://doi.org/10.1067/mva.2002.123750 . PubMed Moridzadeh RS, Gelabert MC, Rigberg DA, Gelabert HA. A novel technique for transaxillary resection of fully formed cervical ribs with long-term clinical outcomes. J Vasc Surg . 2021;73(2):572-580. doi: https://doi.org/10.1016/j.jvs.2020.07.064 . PubMed 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

We are pleased to announce Global Radiology CME's Kevin Rice, MD is a semifinalist for 2021 AuntMinnie.com's Most Effective Radiology Educator. Dr. Kevin Rice, Vice Chief of the Medical Staff at Valley Presbyterian Hospital, a 21 year radiologist at RIMA, a proud member of Radiology Partners, a member of the Radiology Partners Advocacy Board, and President of Global Radiology CME, is honored to be named a semi finalist in the "2021 edition of the Minnies, AuntMinnie.com's campaign to recognize the best and brightest in medical imaging". Author of an extensive online radiology teaching file produced by Global Radiology CME and followed in over 150 countries across the globe, Dr. Rice is well known for sharing his broad knowledge and extensive experience as a practicing radiologist. Dr. Rice has authored or co-authored over 200 radiology cases that can be accessed on the Global Radiology teaching file. As a testament to his broad knowledge base, Dr. Rice has authored cases in Breast Imaging, MSK Imaging, Body Imaging, Cardiac Imaging, Spine Imaging, Interventional Radiology, and Neuroradiology. This is Dr. Rice's second nomination for the prestigious award having been nominated and becoming a semifinalist for a Minnie in 2016. Always looking for new challenges and opportunities for outreach, in 2020 Dr. Rice began a program of mentoring medical students interested in radiology residencies. In the inaugural year of his mentoring program all 6 of his medical students successfully matched in top radiology programs including Indiana University, Thomas Jefferson University, Vanderbilt, Amita Health, and Northwestern. The mentoring program was so successful Dr. Rice will be working with 12 medical students for the 2021 academic year. The only love that supersedes his passion for radiology is time spent with his family. With over 2 million page views per month and close to 150,000 members, Aunt Minnie is the premiere radiology information website catering to radiologists and professionals in the medical imaging field from across the globe. According to AuntMinnie.com the Minnie's seek to recognize the "Best and Brightest in Medical Imaging". Now in their 22th year, the Minnie awards provide a forum for radiology professionals to acknowledge the contributions of their peers to the field of medical imaging. Minnies candidates are nominated by AuntMinnie.com members and the winner will be selected by a panel of experts in the field through two rounds of voting. Semifinalists for AuntMinnie.com's 2021 Most Effective Radiology Educator: Dr. Ryan Avery, Northwestern University Dr. Omer Awan, University of Maryland Dr. Tessa Cook, PhD, University of Pennsylvania Dr. Carolynn DeBenedectis, University of Massachusetts Dr. Christine Glastonbury, University of California, San Francisco Dr. Paula Gordon, University of British Columbia Dr. David Kim, University of Wisconsin Dr. Nicholas Koontz, Indiana University Dr. Christine Menias, Mayo Clinic Arizona Dr. Rendon Nelson, Duke University Dr. Alexander Norbash, University of California, San Diego Dr. Reed Omary, Vanderbilt University Dr. Amy Patel, University of Missouri-Kansas City Dr. Victor Pizzitola, Mayo Clinic Arizona Dr. Kevin Rice, Valley Presbyterian Hospital Dr. Bradley Spieler, Louisiana State University Dr. Richard Wiggins, University of Utah Dr. Jeremy Wortman, Lahey Hospital & Medical Center Dr. Stephanie Yen, Dartmouth-Hitchcock Health Dr. Greg Zaharchuk, Stanford University from AuntMinnie.com Logo courtesy of Brian Casey, Editor in chief of AuntMinnie.com Dr. Rice is on Twitter @KevinRiceMD All posts by Kevin Rice, MD Related articles: Dr. Kevin Rice: Semifinalist for 2016 AuntMinnie.com's Most Effective Radiology Educator Figure 1 Features Dr. Kevin Rice Kevin Rice, MD - One of the #HumansOfRadiology

We are pleased to announce Global Radiology CME's Kevin Rice, MD is a semifinalist for 2016 AuntMinnie.com 's Most Effective Radiology Educator. Kevin Rice, MD Dr. Kevin Rice, radiologist at Renaissance Imaging Medical Associates and Chair of Radiology at Valley Presbyterian Hospital in Los Angeles, California is one of 17 radiologists from around the world to be a semifinalist in the category of Most Effective Radiology Educator. Dr. Rice is "extremely honored to be nominated and be part of such an extraordinary group of radiologists from renowned teaching centers." With over 2 million page views per month and close to 150,000 members, Aunt Minnie is the premiere radiology information website catering to radiologists and professionals in the medical imaging field from across the globe. According to AuntMinnie.com, t he Minnie's seek to recognize the "Best and Brightest in Medical Imaging". Now in their 17th year, the Minnies awards provide a forum for radiology professionals to acknowledge the contributions of their peers to the field of medical imaging. Minnies candidates are nominated by AuntMinnie.com members and selected by a panel of experts in the field through two rounds of voting. Logo courtesy of Brian Casey , Editor in chief of AuntMinnie.com Semifinalists for AuntMinnie.com 's 2016 Most Effective Radiology Educator: Dr. Stephen Amis , Albert Einstein College of Medicine/Montefiore Medical Center Dr. Sanjeev Bhalla , Mallinckrodt Institute of Radiology Dr. Kevin Chang , Brown University Dr. Frank Gaillard , Radiopaedia - Australia Dr. Carol Geer , Wake Forest Baptist Medical Center Dr. Pamela Johnson , Johns Hopkins University Dr. Frank Lexa , Drexel University Dr. Tan-Lucien Mohammed , University of Florida Dr. Mark Mullins , PhD, Emory University Dr. Gregory Nicola , Hackensack Radiology Group Dr. François Pontana , Lille University Hospital - France Dr. Elizabeth Rafferty , Lawrence General Hospital Dr. Parvati Ramchandani , University of Pennsylvania Dr. Kevin Rice , Renaissance Imaging Medical Associates Dr. Mary Scanlon , University of Pennsylvania Dr. Kitt Shaffer , PhD, Boston University Dr. Stacy Smith , Brigham and Women's Hospital Dr. Rice serves as the Chair of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates . Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA and writing the popular Xray of the Week for radiology social media. In 2015 Dr. Rice launched Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. Dr. Rice is on Twitter posting what matters to radiologists @KevinRiceMD All posts by Kevin Rice, MD Related articles: Figure 1 Features Dr. Kevin Rice Kevin Rice, MD - One of the #HumansOfRadiology