21 yo F Cough. Nodule on CXR. Had a CT chest to evaluate the nodule. • Xray of the Week Figure 1. What is the diagnosis? Figure 2. CT scan of the chest demonstrating multiple peripheral regions of ground glass opacification. Discussion: This case demonstrates pneumonia in a patient diagnosed with COVID-19. In this case, CXR shows a nodule while the chest CT shows extensive disease that is not seen on CXR. CXR is less sensitive than CT in detecting COVID-19 lung disease (1). It is important to note that RT-PCR, not chest CT, is the gold standard in diagnosis of COVID-19. ACR guidelines state that CT should not be used to screen for COVID-19 and should not be the first-line test for diagnosis of COVID-19 (2). ACR guidelines also state that CT should be used “sparingly and reserved for hospitalized, asymptomatic patients with specific clinical indications for CT.” (2). COVID-19, like other viral pneumonias, causes lung opacities in more than one lobe bilaterally (1,3). These opacities typically occur in the peripheral lung, which can be seen on CXR (1). CXR can show diffuse lung opacities similar to those seen in inflammatory conditions such as acute respiratory distress syndrome (1). Common lung findings on CT include ground glass opacities (GGO) with or without consolidation, which can be accompanied by interstitial or interlobular septal thickening (1,4). GGO may also have thickened interlobular septa and intralobular lines appearing as a “crazy paving” pattern (5,6). GGO is not typically perceived on chest radiography so CT is especially important (3). Consolidation due to cellular fibromyxoid exudates in alveoli may occur after 2 weeks and is used to estimate disease progression (6). Appearance on imaging varies based on stage and severity. Asymptomatic patients with COVID-19 pneumonia show lesions on CT in the peripheral and subpleural areas of the lung, involving one or two lung lobes (4,5). In critical cases, bronchiectasis and bronchial wall thickening are also common with proliferation of fibrous tissue (6). Less common findings have also been reported in the literature, including pleural effusions, lung cavitation, pneumothorax, nodules, diffuse chest wall subcutaneous emphysema, pneumomediastinum, and diffuse alveolar damage (1). In this case, a solitary nodule was observed on CXR (Figure 2). Nodules are defined as round or irregular opacities measuring less than 3 cm in diameter with well or poorly defined edges (6). They are common in viral pneumonia and 3-13% of COVID-19 patients may have multifocal solid irregular nodules or nodules with visible halo sign (6). Some patients with COVID-19 have only presented with a single small sub-centimeter ground glass nodule with peripheral halo on baseline CT images which could be misdiagnosed (7,8). Multiple drugs have been investigated as possible treatments. Dexamethasone has been suggested to improve outcomes in patients who are dependent on ventilation, but there is only limited evidence supporting its role in reducing mortality rates (8,9). Remdesevir has been found to shorten recovery time for patients on supplemental oxygen therapy from 15 days in the placebo group to 11 days in the Remdesivir group (10). Although mortality was lower in the Remdesivir group (7.1%) than in the placebo group (11.9%), the difference was not statistically significant (10). An investigational vaccine known as mRNA-1273 has been effective in protecting mice from infection with SARS-CoV-2, and it is now in Phase 3 trials (11). There are several similar vaccine candidates currently in Phase 1-3 trials; however, it is uncertain how long it will take for a vaccine to be FDA approved (12). ​​​​ References: Jacobi A, Chung M, Bernheim A, Eber C. Portable chest X-ray in coronavirus disease-19 (COVID-19): A pictorial review. Clin Imaging. 2020; 64:35-42. doi: 10.1016/j.clinimag.2020.04.001 acr.org. 2020. ACR Recommendations For The Use Of Chest Radiography And Computed Tomography (CT) For Suspected COVID-19 Infection. [online] Available at: https://www.acr.org/Advocacy-and-Economics/ACR-Position-Statements/Recommendations-for-Chest-Radiography-and-CT-for-Suspected-COVID19-Infection [Accessed 10 August 2020]. Hu L, Wang C. Radiological role in the detection, diagnosis and monitoring for the coronavirus disease 2019 (COVID-19). Eur Rev Med Pharmacol Sci. 2020;24(8):4523-4528. doi: 10.26355/eurrev_202004_21035 Meng H, Xiong R, He R, et al. CT imaging and clinical course of asymptomatic cases with COVID-19 pneumonia at admission in Wuhan, China. J Infect. 2020;81(1):e33-e39. doi: 10.1016/j.jinf.2020.04.004 Verdecchia, Paolo, et al. The Pivotal Link between ACE2 Deficiency and SARS-CoV-2 Infection. European Journal of Internal Medicine, vol. 76, June 2020, pp. 14–20. PubMed Central, doi: 10.1016/j.ejim.2020.04.037 Ye, Zheng, et al. Chest CT Manifestations of New Coronavirus Disease 2019 (COVID-19): A Pictorial Review. European Radiology, Mar. 2020, pp. 1–9. PubMed Central, doi: 10.1007/s00330-020-06801-0 Rasekhi, Alireza, et al. COVID-19 Pneumonia Presenting as a Single Pulmonary Nodule in a Kidney Transplant Recipient: A Case Report and Literature Review. Radiology Case Reports, vol. 15, no. 9, July 2020, pp. 1587–90. PubMed Central, doi: 10.1016/j.radcr.2020.06.054 Xia, Tianyi, et al. Small Solitary Ground-Glass Nodule on CT as an Initial Manifestation of Coronavirus Disease 2019 (COVID-19) Pneumonia. Korean Journal of Radiology, vol. 21, no. 5, May 2020, pp. 545–49. PubMed Central, doi: 10.3348/kjr.2020.0240 Yang, J. W., et al. Corticosteroid Administration for Viral Pneumonia: COVID-19 and Beyond. Clinical Microbiology and Infection: The Official Publication of the European Society of Clinical Microbiology and Infectious Diseases, June 2020. PubMed, doi: 10.1016/j.cmi.2020.06.020 Beigel, John H., et al. Remdesivir for the Treatment of Covid-19 — Preliminary Report. New England Journal of Medicine, vol. 0, no. 0, May 2020, p. null. Taylor and Francis+NEJM, doi: 10.1056/NEJMoa2007764 Corbett, K.S., Edwards, D.K., Leist, S.R. et al. SARS-CoV-2 mRNA vaccine design enabled by prototype pathogen preparedness. Nature (2020). doi: 10.1038/s41586-020-2622-0 NIH-Moderna Investigational COVID-19 Vaccine Shows Promise in Mouse Studies. National Institutes of Health (NIH), 5 Aug. 2020. https://www.nih.gov/news-events/news-releases/nih-moderna-investigational-covid-19-vaccine-shows-promise-mouse-studies Amara Ahmed is a medical student at the Florida State University College of Medicine . She serves on the executive board of the American Medical Women’s Association and Humanities and Medicine. She is also an editor of HEAL: Humanism Evolving through Arts and Literature , a creative arts journal at the medical school. Prior to attending medical school, she graduated summa cum laude from the Honors Medical Scholars program at Florida State University where she completed her undergraduate studies in exercise physiology, biology, and chemistry. In her free time, she enjoys reading, writing, and spending time with family and friends. Follow Amara Ahmed on Twitter @Amara_S98 All posts by Amara Ahmed Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice is a radiologist with Renaissance Imaging Medical Associates and is currently the Vice Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

Abdominal pain with incidental lung abnormality on CT • Xray of the Week No SOB, cough or fever. Figure 1. CT abdomen and pelvis showing peripherally distributed bibasilar ground-glass opacities (red and blue arrows) Discussion: On January 7, 2020, a novel coronavirus was isolated and named as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by the International Committee on Taxonomy of Viruses (ICTV) in the wake of an outbreak of pneumonia of unknown cause in Wuhan city, China[1, 2]. This pneumonia was called Coronavirus Disease 2019 (COVID-19) by the World Health Organization on February 11, 2020. Globally, more than 20 million confirmed cases of COVID-19 have been reported. An outbreak at Wuhan, identified an initial association of human with a seafood market that sold live animals. However, as the outbreak progressed, person-to-person spread through the airborne route became the main mode of transmission. SARS-CoV-2 has been detected in non-respiratory specimens, including stool, blood, ocular secretions, and semen, but the role of these sites in transmission is uncertain [3-6]. Most commonly seen in adults than in children. The incubation period for COVID-19 is up to 14 days, with most cases occurring four to five days after exposure. [7, 8]. Infectivity is high during earlier stages of illness, when viral RNA levels from upper respiratory specimens are the highest [9-12]. The duration of viral RNA shedding is variable and may increase with the severity of illness and does not indicate prolonged infectiousness [11, 13-15].Transmission of SARS-CoV-2 from individuals with infection but no symptoms (including those who later developed symptoms and thus were considered presymptomatic) has been documented [16-18]. As per CDC in United States, pneumonia is the most frequent serious manifestation of infection, characterized primarily by fever ( in 43%), cough (in 50%), dyspnea (in 29%), and bilateral infiltrates on chest imaging. Other features includes sore throat (in 20%), myalgias (in 36%), diarrhea (in 19%), headache (in 34%), nausea/vomiting (in 12 %) and smell or taste disorders, abdominal pain, and rhinorrhea (in <10 % each) [8, 19, 20]. SARS-Cov-2 has high affinity to angiotensin converting enzyme 2 (ACE2) receptors, leading to cytokine-mediated immune response and inflammation, thereby affecting organs posing ACE2 receptors i.e. brain, heart, arterial and venous endothelial cells, kidneys, liver (hepatocytes and cholangiocytes), gastrointestinal tract, and gallbladder giving atypical symptoms of COVID-19 pneumonia [3-5]. The optimal time to test for COVID-19 following exposure is uncertain as the time to detectable RNA following exposure is unknown, hence five to seven days post exposure is recommended and a negative viral test following exposure, still necessitates quarantine. Nucleic acid amplification testing (NAAT), most commonly with a reverse-transcription polymerase chain reaction (RT-PCR) assay, to detect SARS-CoV-2 RNA from the upper respiratory tract is the preferred initial diagnostic test for COVID-19 [21]. Table 1: Diagnostic tests for COVID-19 [36]. COVID-19: coronavirus disease 2019; RT-PCR: real-time polymerase chain reaction; IgG: immunoglobulin G; CDC: United States Centers for Disease Control and Prevention.* single positive test generally confirms the diagnosis. If initial testing is negative and clinical suspicion remains, performing a second test can enhance diagnostic yield. In the United States, the CDC recommends collection of one of the upper respiratory specimens: nasopharyngeal/ nasal swab specimen from both anterior nares, nasal or nasopharyngeal wash/aspirate, oropharyngeal swab (has lower sensitivity) (Table 1) Multisystem involvement leads to the following laboratory findings; lymphopenia, elevated aminotransaminase levels, elevated lactate dehydrogenase levels, elevated inflammatory markers (eg, ferritin, C-reactive protein, and erythrocyte sedimentation rate), and abnormalities in coagulation tests [8, 20, 22]. Table 2: Proposed reporting language for CT findings related to COVID-19 [23]. COVID-19: coronavirus disease 2019; CT: computed tomography; GGO: ground-glass opacity; PUI: person under investigation; RT-PCR: reverse transcription polymerase chain reaction. CXR findings in COVID-19 pneumonia include consolidation and ground glass opacities, with bilateral, peripheral, and lower lung zone distributions. According to the American College of Radiology (ACR), Chest CT is more sensitive than CXR and is reserved for hospitalized patients under treatment. We present a case of 47-year-old female with atypical presentation with abdominal pain and fever but no respiratory symptoms. CT abdomen/pelvis demonstrated bibasilar, peripherally distributed crazy paving pattern (ground-glass opacifications with superimposed septal thickening), which was later diagnosed as COVID-19 pneumonia on further laboratory evaluation (Fig. 1). The Radiological Society of North America has categorized chest CT features as typical, indeterminate, or atypical for COVID-19 (Table 2) [23]. Other chest CT findings includes bronchiectasis, pleural effusion, pericardial effusion, and lymphadenopathy. Acute respiratory distress syndrome (ARDS) is a serious complication that can manifest shortly after the onset of dyspnea. [20, 24]. Other complications include thromboembolic events [25-27], acute cardiac injury [20, 28], kidney injury, and inflammatory complications [19, 29] The risk of transmission after contact with an individual with COVID-19 increases with the closeness and duration of contact and appears highest with prolonged contact in indoor settings i.e. household contacts, cruise ships [30], homeless shelters [31, 32], and detention facilities [33], in health care settings like hospitals [20] when personal protective equipment are not used, and after social or work gatherings. Hence transmission can be reduced by wearing masks (with NO exhalation valves) in public, washing hands, social or physical distancing. For patients with non-severe disease, primarily supportive care, with close monitoring for disease progression is recommended. For patients with severe disease requiring supplemental oxygen, mechanical ventilation/ECMO, low dose Dexamethasone and/or Remdesivir has had some success in early clinical trials. [34, 35] ​​​​ References: 1. Phelan, A.L., R. Katz, and L.O. Gostin, The Novel Coronavirus Originating in Wuhan, China: Challenges for Global Health Governance. JAMA, 2020. 323(8): p. 709-710 DOI: 10.1001/jama.2020.1097 2. Wu, Y., et al., SARS-CoV-2 is an appropriate name for the new coronavirus. Lancet, 2020. 395(10228): p. 949-950 DOI: 10.1016/s0140-6736(20)30557-2 3. Wang, W., et al., Detection of SARS-CoV-2 in Different Types of Clinical Specimens. Jama, 2020. 323(18): p. 1843-4 DOI: 10.1001/jama.2020.3786 4. Colavita, F., et al., SARS-CoV-2 Isolation From Ocular Secretions of a Patient With COVID-19 in Italy With Prolonged Viral RNA Detection. Ann Intern Med, 2020. 173(3): p. 242-243 DOI: 10.7326/m20-1176 5. Cheung, K.S., et al., Gastrointestinal Manifestations of SARS-CoV-2 Infection and Virus Load in Fecal Samples From a Hong Kong Cohort: Systematic Review and Meta-analysis. Gastroenterology, 2020. 159(1): p. 81-95 DOI: 10.1053/j.gastro.2020.03.065 . Retrieved from http://www.sciencedirect.com/science/article/pii/S0016508520304480 6. Li, D., et al., Clinical Characteristics and Results of Semen Tests Among Men With Coronavirus Disease 2019. JAMA Netw Open, 2020. 3(5): p. e208292 DOI: 10.1001/jamanetworkopen.2020.8292 7. Li, Q., et al., Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus-Infected Pneumonia. N Engl J Med, 2020. 382(13): p. 1199-1207 DOI: 10.1056/NEJMoa2001316 8. Guan, W.J., et al., Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med, 2020. 382(18): p. 1708-1720 DOI: 10.1056/NEJMoa2002032 9. Zou, L., et al., SARS-CoV-2 Viral Load in Upper Respiratory Specimens of Infected Patients. N Engl J Med, 2020. 382(12): p. 1177-1179 DOI: 10.1056/NEJMc2001737 10. To, K.K., et al., Temporal profiles of viral load in posterior oropharyngeal saliva samples and serum antibody responses during infection by SARS-CoV-2: an observational cohort study. Lancet Infect Dis, 2020. 20(5): p. 565-574 DOI: 10.1016/s1473-3099(20)30196-1 11. Wölfel, R., et al., Virological assessment of hospitalized patients with COVID-2019. Nature, 2020. 581(7809): p. 465-469 DOI: 10.1038/s41586-020-2196-x 12. Kujawski, S.A., et al., Clinical and virologic characteristics of the first 12 patients with coronavirus disease 2019 (COVID-19) in the United States. Nature Medicine, 2020. 26(6): p. 861-868 DOI: 10.1038/s41591-020-0877-5 13. Zheng, S., et al., Viral load dynamics and disease severity in patients infected with SARS-CoV-2 in Zhejiang province, China, January-March 2020: retrospective cohort study. BMJ, 2020. 369: p. m1443 DOI: 10.1136/bmj.m1443 . Retrieved from http://www.bmj.com/content/369/bmj.m1443.abstract 14. Liu, Y., et al., Viral dynamics in mild and severe cases of COVID-19. Lancet Infect Dis, 2020. 20(6): p. 656-657 DOI: 10.1016/s1473-3099(20)30232-2 15. Xu, K., et al., Factors Associated With Prolonged Viral RNA Shedding in Patients with Coronavirus Disease 2019 (COVID-19). Clin Infect Dis, 2020. 71(15): p. 799-806 DOI: 10.1093/cid/ciaa351 16. Rothe, C., et al., Transmission of 2019-nCoV Infection from an Asymptomatic Contact in Germany. N Engl J Med, 2020. 382(10): p. 970-971 DOI: 10.1056/NEJMc2001468 17. Bai, Y., et al., Presumed Asymptomatic Carrier Transmission of COVID-19. Jama, 2020. 323(14): p. 1406-7 DOI: 10.1001/jama.2020.2565 18. Wang, Y., et al., Characterization of an asymptomatic cohort of SARS-COV-2 infected individuals outside of Wuhan, China. Clin Infect Dis, 2020 DOI: 10.1093/cid/ciaa629 19. Huang, C., et al., Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet, 2020. 395(10223): p. 497-506 DOI: 10.1016/s0140-6736(20)30183-5 20. Wang, D., et al., Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. Jama, 2020. 323(11): p. 1061-9 DOI: 10.1001/jama.2020.1585 21. Patel, A. and D.B. Jernigan, Initial Public Health Response and Interim Clinical Guidance for the 2019 Novel Coronavirus Outbreak - United States, December 31, 2019-February 4, 2020. MMWR Morb Mortal Wkly Rep, 2020. 69(5): p. 140-146 DOI: 10.15585/mmwr.mm6905e1 22. Goyal, P., et al., Clinical Characteristics of Covid-19 in New York City. N Engl J Med, 2020. 382(24): p. 2372-2374 DOI: 10.1056/NEJMc2010419 23. Simpson, S., et al., Radiological Society of North America Expert Consensus Statement on Reporting Chest CT Findings Related to COVID-19. Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA - Secondary Publication. Journal of Thoracic Imaging, 2020. 35(4): p. 219-227 DOI: 10.1097/rti.0000000000000524 . https://journals.lww.com/thoracicimaging/Fulltext/2020/07000/Radiological_Society_of_North_America_Expert.2.aspx 24. Richardson, S., et al., Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. Jama, 2020. 323(20): p. 2052-9 DOI: 10.1001/jama.2020.6775 25. Mao, L., et al., Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China. JAMA Neurol, 2020. 77(6): p. 1-9 DOI: 10.1001/jamaneurol.2020.1127 26. Klok, F.A., et al., Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res, 2020. 191: p. 145-147 DOI: 10.1016/j.thromres.2020.04.013 27. Merkler, A.E., et al., Risk of Ischemic Stroke in Patients With Coronavirus Disease 2019 (COVID-19) vs Patients With Influenza. JAMA Neurology, 2020 DOI: 10.1001/jamaneurol.2020.2730 28. Arentz, M., et al., Characteristics and Outcomes of 21 Critically Ill Patients With COVID-19 in Washington State. JAMA, 2020. 323(16): p. 1612-1614 DOI: 10.1001/jama.2020.4326 29. Mehta, P., et al., COVID-19: consider cytokine storm syndromes and immunosuppression. Lancet, 2020. 395(10229): p. 1033-1034 DOI: 10.1016/s0140-6736(20)30628-0 30. Kakimoto, K., et al., Initial Investigation of Transmission of COVID-19 Among Crew Members During Quarantine of a Cruise Ship - Yokohama, Japan, February 2020. MMWR Morb Mortal Wkly Rep, 2020. 69(11): p. 312-313 DOI: 10.15585/mmwr.mm6911e2 31. Baggett, T.P., et al., Prevalence of SARS-CoV-2 Infection in Residents of a Large Homeless Shelter in Boston. JAMA, 2020. 323(21): p. 2191-2192 DOI: 10.1001/jama.2020.6887 32. Kuehn, B.M., Homeless Shelters Face High COVID-19 Risks. Jama, 2020. 323(22): p. 2240 DOI: 10.1001/jama.2020.8854 33. Saloner, B., et al., COVID-19 Cases and Deaths in Federal and State Prisons. JAMA, 2020. 324(6): p. 602-603 DOI: 10.1001/jama.2020.12528 . 34. Horby, P., et al., Dexamethasone in Hospitalized Patients with Covid-19 - Preliminary Report. N Engl J Med, 2020 DOI: 10.1056/NEJMoa2021436 35. Wang, M., et al., Remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro. Cell Research, 2020. 30(3): p. 269-271 DOI: 10.1038/s41422-020-0282-0 36. Weissleder, R., et al., COVID-19 diagnostics in context. Science Translational Medicine, 2020. 12(546): p. eabc1931 DOI: 10.1126/scitranslmed.abc1931 . Retrieved from https://stm.sciencemag.org/content/scitransmed/12/546/eabc1931.full.pdf 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 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

41-year old female. COVID-19 positive. Left side weakness. • Xray of the Week Figure 1. CT scan and CT perfusion scan in 41 year old COVID-19 positive female with left side weakness. Figure 2. CT scan and CT perfusion scan of brain with color mapping. A. Non-contrast CT. Hyperdense M1 segment of right MCA (red arrow) indicating acute thrombus in the artery. B. Post contrast perfusion CT brain. Large area of decreased blood flow in the right MCA distribution (orange arrows). Normal perfusion of the left MCA distribution (green arrows). C,D. Cerebral blood volume (CBV) and cerebral blood flow (CBF) maps. Large area of decreased blood flow and decreased cerebral blood volume in the right MCA distribution (orange arrows) with no significant penumbra suggesting large area of core infarction without evidence of reversible ischemia. Normal perfusion of the left MCA distribution (green arrows). Figure 3. CT angiogram shows occlusion of the M1 segment of the right MCA near its origin without reconstitution of flow distally indicating acute thrombus (white arrow). There is some reconstitution of flow in distal cortical branches via leptomeningeal collaterals. Right ACA, ophthalmic artery and intracranial ICA are patent without significant narrowing. This confirms the findings on the non-contrast CT scan and the CT perfusion scan (Fig.2). Discussion: Strokes are the second leading cause of death worldwide, particularly within the middle cerebral artery (MCA) which supplies deep structures of the brain in addition to the frontal, temporal and parietal lobes (1,2). SARS-CoV-2 is a viral disease typically presenting with pulmonary complications. Recently, case studies have found COVID-19 to be linked to neurologic manifestations and an increased risk of cryptogenic large vessel ischemic stroke (4). Such arterial thrombotic complications may be due to inflammation-induced hypercoagulability, cytokine storm, and direct viral-induced endotheliitis (5,7,8). Additional studies also demonstrate abnormalities in fibrinogen, D-dimer, interleukin-6, and troponin levels (5,7). Presentations of an MCA stroke secondary to COVID-19 have included contralateral hemiparesis, contralateral hemisensory loss, aphasia, dysarthria, and reduced level of consciousness (3, 10). This is in addition to typically seen pulmonary and systemic manifestations of COVID-19 such as fever, cough, and hypoxia (11). Typical risk factors for ischemic stroke include hypertension, diabetes mellitus, cardiovascular disease, hypercholesterolemia, smoking, age, family history, and inflammatory conditions (9). Thus, patients with high risk factors may be at higher risk for mortality. However, patients with minimal or no risk factors with COVID-19 have also presented with ischemic stroke, particularly those under 50 years of age (10,11). Imaging findings of ischemic stroke in the acute setting on non-contrast CT scan may include hyperdense MCA sign as seen in this case (Fig. 2A) (6). CT may also show decreased attenuation and loss of grey/white matter differentiation due to cytotoxic cerebral edema (6). Perfusion scans are able to differentiate penumbra (potentially reversible with reperfusion therapy) from the core (non-reversible) infarct (6). Core infarct demonstrates increased mean transit time (MTT), markedly decreased CBF and markedly decreased CBV; whereas penumbra demonstrates increased MTT, moderately reduced CBF and near-normal or increased CBV (Fig. 2B-D). The increased CBV is due to autoregulatory vasodilatation. Large vessel occlusion may be identified on CT angiogram (Fig. 3) (6). On chest x-ray, associated COVID-19 findings are predominantly peripheral with patchy or diffuse ground glass and reticulonodular opacities (12). The true association between COVID-19 and increased risk of stroke is still under study, with new evidence-based guidelines underway (5,8). Typical treatment and management of an ischemic stroke include restoration of vascular supply via IV tPA, thrombectomy, or stent placement (2). With the added uncertainty and hypercoagulable state associated with COVID-19, anticoagulation and further management should be individualized on a case by case basis (5). References: Khaku AS, Tadi P. Cerebrovascular Disease (Stroke) [Updated 2020 Aug 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430927/ Nogles TE, Galuska MA. Middle Cerebral Artery Stroke. [Updated 2020 Aug 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK556132 R. Kollmar, S. Schwab, Ischaemic stroke: acute management, intensive care, and future perspectives, BJA: British Journal of Anaesthesia, Volume 99, Issue 1, July 2007, Pages 95–101, https://doi.org/10.1093/bja/aem138 Merkler AE, Parikh NS, Mir S, et al. Risk of Ischemic Stroke in Patients With Coronavirus Disease 2019 (COVID-19) vs Patients With Influenza. JAMA Neurol. Published online July 02, 2020. doi: 10.1001/jamaneurol.2020.2730 Tsivgoulis G, Katsanos AH, Ornello R, Sacco S. Ischemic Stroke Epidemiology During the COVID-19 Pandemic: Navigating Uncharted Waters With Changing Tides. Stroke. 2020;51(7):1924-1926. doi: 10.1161/STROKEAHA.120.030791 Lin MP, Liebeskind DS. Imaging of Ischemic Stroke. Continuum (Minneap Minn). 2016;22(5, Neuroimaging):1399-1423. PubMed full text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5898964/ doi: 10.1212/CON.0000000000000376 Fifi JT, Mocco J. COVID-19 related stroke in young individuals. Lancet Neurol. 2020;19(9):713-715. doi: 10.1016/S1474-4422(20)30272-6 Ntaios G, Michel P, Georgiopoulos G, et al. Characteristics and Outcomes in Patients With COVID-19 and Acute Ischemic Stroke: The Global COVID-19 Stroke Registry. Stroke. 2020;51(9):e254-e258. doi: 10.1161/STROKEAHA.120.031208 “Stroke.” National Heart Lung and Blood Institute, U.S. Department of Health and Human Services, www.nhlbi.nih.gov/health-topics/stroke Oxley TJ, Mocco J, Majidi S, et al. Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young. N Engl J Med. 2020;382(20):e60. doi: 10.1056/NEJMc2009787 Yaghi S, Ishida K, Torres J, et al. SARS-CoV-2 and Stroke in a New York Healthcare System [published correction appears in Stroke. 2020 Aug;51(8):e179]. Stroke. 2020;51(7):2002-2011. doi: 10.1161/STROKEAHA.120.030335 Cozzi D, Albanesi M, Cavigli E, et al. Chest X-ray in new Coronavirus Disease 2019 (COVID-19) infection: findings and correlation with clinical outcome. Radiol Med. 2020;125(8):730-737. doi: 10.1007/s11547-020-01232-9 Rabab Zaidi is an aspiring radiologist and fourth year medical student at the Loyola University Chicago Stritch School of Medicine (SSOM) . She currently serves as the Community Support Co-Lead for the Loyola University COVID-19 Response Team and Co-President of the Radiology Interest Group at SSOM. At the Stritch School of Medicine, she has also worked with the Department of Radiation Oncology to study prostate cancer imaging and adaptive radiotherapy techniques, where she learned about the intersection of patient care and radiology. Rabab graduated magna cum laude with a degree in Economics from Loyola University Chicago in 2016. She is further passionate about mentorship, advocacy, and photography. Follow Rabab Zaidi on Twitter @ZaidiRabab All posts by Rabab Zaidi Kevin M. Rice, MD is the president of Global Radiology CME 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

The Imaging in Dublin 2022 conference will be held in Dublin, Ireland from June 5 to June 8, 2022, at the Westin Dublin Hotel . 1. World Class Faculty : Ella Kazerooni, Elizabeth Morris, Donald Resnick, Neil Rofsky. 2. Dublin- Ranked one of the 10 top cities to visit in Europe. 3. Friendly people. Find out why Ireland is consistently ranked one of the friendliest countries in the world . We met Zack Gallagher - Ireland's Food Guide at Boxty Restaurant in Dublin. 4. Trinity College - Established in 1592, under the Tudor Monarch. Trinity is modeled after Oxford and Cambridge and home to the Book of Kells and the Old Library . Located across the street from Westin Dublin Hotel, the Imaging in Dublin 2020 conference venue. 5. Epic Museum - Winner of Europe's Leading Tourist attraction 2019 . Learn about the history of Ireland, Irish immigration, and why 70 million people worldwide claim Irish ancestry. Every Person Is Connected . 6. Guinness Storehouse - Discover through interactive exhibits the history of beer and stop by the Gravity Bar to watch the city buzzing below as you enjoy your pint of Guinness or soft drink . 7. Butlers Irish Chocolates - Founded in 1932 in Dublin by Marion Bailey-Butler, these award winning chocolates are addictive! 8. Fade Street Social - Restaurant courtesy of Irish renowned chef Dylan McGrath- in the Grafton Street district. Dublin is a renowned foodies destination. 9. Temple Bar District - The hub of the Irish Pub Culture and Celtic music in Dublin. Located along side the Liffey River. Adjacent to Westin Dublin. 10. Emerald Island- The breathtaking, rugged, beauty of the Irish countryside. This is a unique opportunity to meet radiologists from all corners of the globe in an intriguing location, and learn from some of the best specialists in their field. Indulge all your senses and join Global Radiology CME for the trip of a lifetime to Dublin, Ireland in June, 2022! We have had registrants from: Australia, Austria, Belgium, Brazil, Bulgaria, Canada, China, Denmark, France, Germany, Greece, Hong Kong, Hungary, India, Indonesia, Ireland, Israel, Lithuania, Malaysia, Netherlands, New Zealand, Norway, Philippines, Saudi Arabia, Singapore, Slovenia, South Africa, Spain, Sweden, Switzerland, Thailand, Turkey, Uruguay, United Kingdom, United States of America, and Zambia.

Register now for Imaging in Israel 2023 , then check out all the amazing things to do in Israel! We made a top ten list for some our favorite activities in the holy land. You can also register for guided tours of these historic locations and more on our website here . 1. Jerusalem, The city of Gold, has been the religious epicenter for the 3 major monotheistic religions, Christianity, Judaism, and Islam. Visit the Western Wall, Church of the Holy Sepulcher, and Dome of the Rock. 2. Float in the Dead Sea, the lowest point on Earth. Rejuvenate yourself immersing in the warm waters of the Dead Sea. Visit one of the many spas doting the shores of this natural wonder. 3. Enjoy a day at the Ramon Crater, the world's largest "erosion cirque", in the awe inspiring Negev Desert. Spend the day viewing wildlife on a jeep tour, or take a ride on a camel, imagining what life was like traveling along these trading routes 1,000 years ago. When the sun goes down, enjoy the hospitality of dinner in a Bedouin tent but don't forget to stop to do do a little stargazing before heading to bed. 4. Take a drive up to the Galilee and enjoy the afternoon in the mystical City of Safed. Walk along the ancient streets. Known as the center of Jewish Mysticism, Safed is the home to a multitude of ancient synagogues, an eclectic mix of inhabitants, a unique artist colony, and breathtaking views of the Galilee. 5. Spend a day soaking in the sun, along the beaches in the coolest city in the Mediterranean, Tel Aviv. When the sun sets over the Mediterranean, the celebrity chef restaurants open up, and visitors and locals alike party till the morning hours in the bars and clubs. 6. Travel back in time 2,000 years and imagine life on the top of Masada. Climb or take a cable car to visit this archeological wonder. If you climb, try to time it to witness the spectacular sun rising over the Dead Sea. When you reach the top, tour the ruins of the ancient castle built by Herod The Great, King of Judea between 37 BCE and 37 CE. 7. From ancient times the "Holy Land" was renowned for its grape vineyards and olive trees. Today, the abundance of world class wineries in the Galilee, Golan Heights, and Judean Hills has put Israel on the top of the list for "Wine Tourism" connoisseurs. 8. A trip to Israel and Jerusalem would not be complete without taking the time to wander through the 250 vendors in Mahane Yehuda, your senses will be awakened as you explore everything from exotic spices to unique wares. 9. Israel will celebrate its 75th Birthday in 2023! The country will be alive with unique festivities to mark this milestone! 10. Enjoy all of the above networking with radiologists from around the world at a Global Radiology CME conference featuring a line up of world renowned speakers, including Neil Rofsky, Donald Resnick, Paul Parizel, Ella Kazerooni, and many others.

Register now for Imaging in Copenhagen 2024 , and check out all the amazing things to do in Denmark! We made a top ten list of some our favorite activities in and around the Danish Capital. 1. Global Radiologists - We know your primary reason for joining us is our outstanding faculty, scientific program, and the opportunity to meet radiologists from around the globe! At the helm of our distinguished award winning faculty is our Scientific Director, Dr. Neil Rofsky , recently awarded the 2023 SABI Gold Medal. Pictured above is the ACR Gold Medalist, Dr. Donald Resnick presenting the coveted Global Radiology CME annual Resnick MSK Quiz Award to Dr. Nancy Prendergast . 2. Embrace Hygge - Denmark really is the friendliest and happiest country I have ever visited! Michelle Exarhos , Chief Concierge in charge of Responsible Business, Spirit and Culture at the Radisson Collection Royal, taught me first hand the meaning of hygge and she looks forward to welcoming all Global Radiology CME registrants to Copenhagen with the same warmth! 3. Architecture - Copenhagen was named the UNESCO WORLD CAPITAL OF ARCHITECTURE in 2023 ! It only made sense when selecting a conference venue for Imaging in Copenhagen, The Radisson Collection Royal, the first design hotel, created by renowned Danish designer and architect, Arne Jacobsen was the ideal choice! The floating staircase pictured above leads to the Imaging in Copenhagen 2024 conference room! 4. Tivoli Gardens - Across the street from the Radisson Collection Royal we found the perfect place to host the Welcome to Copenhagen 2024 dinner. The historic Groften Restaurant, serving traditional Danish delicacies has been welcoming guests since 1874 and is located in the beautiful Tivoli Gardens ! Emil Rud Nielson, pictured above, Manager of Groften Restaurant, looks forward to welcoming you this June! The dinner at Groften and entrance into Tivoli Gardens are included in your registration. 5. Nyhavn - Beautiful canals meander throughout this gorgeous city but the old port of Nyhavn lined with brightly colored 17th and early 18th century townhouses with lively restaurants, and bars is the quintessential place to meet up with colleagues and enjoy a drink or meal while watching the ships sailing in and out of the harbor. 6. Bicycles - Upon arrival to the Danish Capital we quickly realized there are more bicycles than people in Copenhagen ! There are actually 5 times as many bikes as cars on the road. You can rent a bike at the Radisson Collection Royal Hotel. Be sure to save time to experience the city like a local. 7. Vikings - I love Vikings and one of the highlights of my site visit was a visit to the Viking Ship Museum and learning to sail a replica Viking ship. Yes, that is me at the helm! You too can sign up and become part of the crew for an afternoon sail in Roskilde Fjord! 8. Castles and Shakespeare - The Danish monarchy is one of the oldest in the world and there are a plethora of castles to explore in Denmark. My favorite was Kronborg Castle , pictured above. It is a UNESCO World Heritage site, and the setting for Shakespeare's Hamlet. The Castle is located in the quaint town of Helsingor, only a 60 minute drive from Copenhagen. Global Radiology registrants will also have an opportunity to eat like Royalty at the gala dinner in the beautiful Odd Fellow Palace, included in your registration. 9. Signature Social Events - When you are outside the conference room its time to have some fun and get to know the faculty and your fellow registrants in an informal setting. Global Radiology is renowned for our unique and engaging social and networking opportunities! We have gone punting in Oxford, on a musical pub crawl in Dublin, camel riding and Israel, and look forward to many more shared experiences in Copenhagen! 10. A Gastronomic Journey - Copenhagen is currently home to 15 Michelin star restaurants , and the world famous Torvehallerne Food stalls . No wonder it is a culinary destination! Torvehallerne and many of the Michelin star restaurants are only a short walk from the conference hotel.

8 yo F with trauma. Diagnosis? • Xray of the Week Figure 1. Trauma in a 8 year old female. Diagnosis? Figure 2. Cuboid Bone Fracture. Fracture indicated by orange arrow. (A) Dorsoplantar radiograph of the foot demonstrating an isolated fracture of the cuboid with possible extension into the tarsometatarsal joint. (B) Medial oblique radiograph of the foot demonstrating an isolated fracture of the cuboid. Introduction: Fracture of the cuboid or disturbance of its articular relationships can lead to profound disruption of the movement and biomechanics of the foot [1,2]. Significant foot dysfunction can result from cuboid injury since the cuboid bone acts as a crucial supporting structure within the lateral column of the midfoot, and the articulation between the cuboid and the fourth and fifth metatarsals makes the largest contribution to dorsiflexion and plantar flexion of the midfoot [1]. Epidemiology: Cuboid fractures are uncommon, occurring in 5% of all tarsal fractures [3]. The most common pattern of cuboid injury involves avulsion types. These occur with inversion of the hindfoot and adduction of the forefoot combined with external rotation of the tibia resulting in avulsion of the calcaneocuboid portion of the bifurcate ligament [1,3]. Diagnosis: The diagnosis of a cuboid fracture can be established when there is a high index of suspicion secondary to significant swelling of the midfoot region and a positive history of direct or indirect trauma to the foot accompanied by local tenderness [3]. Radiographic evidence can support the diagnosis. A standard three view foot series (lateral, dorsoplantar, and medial oblique) should be obtained to evaluate a midfoot fracture. A fracture of the cuboid is best appreciated on the medial oblique view because as the foot is rolled medially, the cuboid comes into full, unobstructed view, which allows visualization of the joints in question, swelling of the surrounding soft tissues, or avulsion [2]. More sophisticated imaging, such as computed tomography or magnetic resonance imaging, should be obtained if plain film is unrevealing but there is high suspicion of fracture. Figure 3. Diagram showing the types of fracture of the cuboid [1]. Cuboid Fracture Classification: In 2016, Fenton et al. proposed a classification system for fractures of the cuboid based on the fracture pattern and the mechanism of injury (Fig. 3) [1]. The treatment of these fractures was also described. Table 1. Summary of the types of fracture of the cuboid, the frequency, mechanism of injury, treatment and outcomes from the literature [1]. Treatment: A cuboid fracture with comminution, significant ligamentous injuries, or greater than 2mm of step-off at any articular surface should be recommended for surgery [1,4]. An isolated cuboid fracture without these concerning features can be treated nonoperatively. Simple body fractures and nondisplaced avulsion fractures are treated with a below-the-knee weightbearing cast for 6 to 8 weeks or until there are radiographic signs of a bony union [2]. Complications: Cuboid fractures are frequently associated with other fractures, dislocations, or ligamentous injuries, and missed or mismanaged cuboid fractures can lead to significant complications [2,3,5]. Malunion, degenerative joint disease, persistent subluxation, and prolonged pain are complications of mismanaged cuboid fractures [2]. Degenerative arthritis and disruption of the midfoot biomechanics can result from untreated cuboid fracture [3]. References: Fenton P, Al-Nammari S, Blundell C, Davies M. The patterns of injury and management of cuboid fractures: a retrospective case series. Bone Joint J . 2016;98-B(7):1003-1008. DOI: 10.1302/0301-620X.98B7.36639 Miller SR, Handzel C. Isolated cuboid fracture. A rare occurrence. J Am Podiatr Med Assoc . 2001;91(2):85-88. DOI: 10.7547/87507315-91-2-85 Grivas TB, Vasiliadis ED, Koufopoulos G, Polyzois VD, Polyzois DG. Midfoot fractures. Clin Podiatr Med Surg . 2006;23(2):323-vi. DOI: 10.1016/j.cpm.2006.01.001 Pinney SJ, Sangeorzan BJ. Fractures of the tarsal bones. Orthop Clin North Am . 2001;32(1):21-33. DOI: 10.1016/s0030-5898(05)70191-7 Khatri Chhetri KM, Acharya P, Rokaya Chhetri DR. Combined fracture dislocation of the navicular bone along with cuboid, cuneiform and longitudinal split fracture of the lateral malleolus: a rare combination of fractures. Chin J Traumatol . 2014;17(6):358-360. PMID: 25471434. https://pubmed.ncbi.nlm.nih.gov/25471434/ Corey Brown is a medical student at Meharry Medical College in Nashville, TN. He is vice-president of his school’s radiology interest group and a member of Rad Boot Camp. Prior to medical school, he attended Queens University of Charlotte and the University of Toronto . He graduated with degrees in biochemistry and biomedical engineering. As a graduate student, Corey volunteered at Milestone Christian Ministries and worked with Maple Leaf Sports and Entertainment as a Soccer Senior Sport Lead Coach. He enjoys barbering and watching sports in his free time. UPDATE Oct. 2025: Dr. Brown is a third year Radiology Resident at Brigham and Women's Hospital / Harvard Medical School. Follow Corey Brown on Twitter @coreybrwn Corey Brown on LinkedIn: https://www.linkedin.com/in/corey-brown-md-meng-514536a8/ All posts by Corey Brown 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

What is the diagnosis? • Xray of the Week Figure 1. What is the diagnosis? Figure 2. Frontal chest radiograph reveals a curvilinear radiopaque tubular structure paralleling the right cardiac border (red arrows) —the classic “scimitar vein.” The right lung is also mildly hypoplastic. Figure 3. (Contrast-Enhanced CT):  Coronal images demonstrate the anomalous right pulmonary vein (red arrows) draining into the inferior vena cava (yellow arrows), confirming the diagnosis. Scimitar Syndrome (Congenital Pulmonary Venolobar or Hypogenetic Lung Syndrome) Definition & Epidemiology Scimitar Syndrome is a rare congenital condition characterized by partial anomalous pulmonary venous return (PAPVR), where pulmonary veins from the right lung drain into systemic veins—most commonly the inferior vena cava. The condition derives its name from the characteristic curvilinear vascular shadow on chest radiography, which resembles a scimitar sword. The estimated incidence is approximately 1–3 per 100,000 live births [1,12]. Imaging Findings On chest radiography, the hallmark finding is a vertically oriented, curved opacity along the right cardiac border representing the anomalous pulmonary vein, the “scimitar sign.” Associated features may include right lung hypoplasia, dextroposition of the heart due to reduced right lung volume, and sometimes systemic arterial supply to the right lower lobe. These findings, although classic, are variably present and require confirmatory cross-sectional imaging. [2,3,10,13]. Contrast-enhanced CT better delineates the anomalous venous drainage, confirms the connection to the IVC, and demonstrates associated anomalies—such as right pulmonary artery hypoplasia, anomalous systemic arterial supply from the aorta, bronchial anomalies and atrial septal defects, which frequently coexist. [3,16,11]. Clinical Relevance & Classification Two clinical variants exist: the infantile form, which often presents with pulmonary hypertension, heart failure, and more complex anatomy; and the adult/adult-variant form, frequently asymptomatic and diagnosed incidentally in adulthood [5,12]. Treatment & Prognosis Management depends on symptom severity and associated anomalies. Asymptomatic patients with adequate right lung function may not require intervention. Symptomatic infants with recurrent infections, pulmonary hypertension, or significant left-to-right shunt often undergo surgical rerouting of the anomalous vein to the left atrium, or coil/embolization of anomalous systemic arterial supply [6,7]. Prognosis is variable, with better outcomes in isolated cases without pulmonary hypertension or cardiac malformations [7]. References Dupuis C, Charaf LA, Brevière GM, Abou P, Rémy-Jardin M, Helmius G. The "adult" form of the scimitar syndrome. Am J Cardiol . 1992;70(4):502-507. doi: 10.1016/0002-9149(92)91198-d Roehm JOF, Jue KL, Amplatz K. Radiographic features of the scimitar syndrome. Radiology . 1966;86(5):856-859. https://doi.org/10.1148/86.5.856 Canter CE, Martin TC, Spray TL, Weldon CS, Strauss AW. Scimitar syndrome in childhood. Am J Cardiol . 1986;58(7):652-654. doi: 10.1016/0002-9149(86)90296-1 Masrani A, McWilliams S, Bhalla S, Woodard PK. Anatomical associations and radiological characteristics of scimitar syndrome on CT and MR. J Cardiovasc Comput Tomogr . 2018;12(4):286-289. https://doi.org/10.1016/j.jcct.2018.02.001 Konen E, Raviv-Zilka L, Cohen RA, et al. Congenital pulmonary venolobar syndrome: spectrum of helical CT findings with emphasis on computerized reformatting. RadioGraphics . 2003;23(5):1175-1184. https://doi.org/10.1148/rg.235035004 Berrocal T, Madrid C, Novo S, Gutiérrez J, Arjonilla A, Gómez-León N. Congenital anomalies of the tracheobronchial tree, lung, and mediastinum: embryology, radiology, and pathology. RadioGraphics . 2004;24(1):e17. https://doi.org/10.1148/rg.e17 Ngai C, Freedberg RS, Latson L, et al. Multimodality imaging of scimitar syndrome in adults: A report of four cases. Echocardiography . 2018;35(10):1684-1691. DOI: 10.1111/echo.14124 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

What is this foreign body in the abdomen? • Xray of the Week Figure 1. What is this foreign body in the abdomen? Figure 2. Plain abdominal radiograph at approximately 30 hours after ingestion of patency capsule. A radio‑opaque foreign body (~2.6 cm × 1.1 cm) is noted in the abdomen, consistent with retained patency capsule. Figure 3. Enlarged and abdomen radiograph demonstrates foreign body consistent with Patency Capsule in the bowel. Patency Capsule: Imaging Appearance and Clinical Utility The patency capsule  is a dissolvable, radio-opaque capsule used to assess small bowel patency prior to capsule endoscopy (Figs. 1-3). It is particularly important in patients at risk for strictures, such as those with Crohn disease or a history of abdominal surgery [1,3]. The capsule is similar in size to a standard video capsule (approximately 26 mm × 11 mm ) and contains a barium-impregnated lactose core, sometimes with an RFID tag for scanner detection [1,2]. After oral ingestion, no specific bowel prep is typically required. Imaging is performed at ~28–30 hours  to confirm whether the capsule has passed [2,4]. If not seen on X-ray, functional patency is assumed. If visible, retention is suspected—though location (small bowel vs colon) can be difficult to determine on planar images alone [2,3]. If retained, CT can help confirm location and avoid false-positive findings [2,5]. Delayed imaging (e.g., at 72 hours) may further improve diagnostic yield without increasing risk [4]. The capsule begins to dissolve at ~30–33 hours, minimizing the risk of obstruction [1,2]. Conclusion The patency capsule is a valuable tool to assess small bowel patency and reduce the risk of capsule retention . Radiologists should recognize its appearance and assess for passage at ~30 hours post-ingestion, using adjunct imaging if needed. References Spada C, Spera G, Riccioni ME, et al. A novel diagnostic tool for detecting functional patency of the small bowel: the Given patency capsule. Endoscopy . 2005;37(9):793–800. https://doi.org/10.1055/s-2005-870246 Costigan C, O’Hara FJ, McNamara D. Patency testing improves capsule retention rates but at what cost? Front Med (Lausanne) . 2023;10:1046155. https://doi.org/10.3389/fmed.2023.1046155 Nemeth A, Kopylov U, Koulaouzidis A, et al. Use of patency capsule in patients with established Crohn’s disease. Endoscopy . 2016;48(4):373–379. https://doi.org/10.1055/s-0034-1393560 O’Hara FJ, Costigan C, McNamara D. Extended 72-hour patency capsule protocol improves functional patency rates in high-risk patients undergoing capsule endoscopy. World J Gastrointest Endosc . 2024;16(12):661–667. https://doi.org/10.4253/wjge.v16.i12.661 Kim YE, Kim YJ, Kim KO, et al. Patency Capsule and Cross-Sectional Imaging for Predicting Capsule Endoscopy Retention: A Systematic Review and Meta-Analysis. Dig Dis Sci . 2025;70(2):761–773. https://doi.org/10.1007/s10620-024-08835-6 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

63 year old male. Headache for 1 month and unsteady gait. What is the diagnosis? • Xray of the Week Figure 1. Brain CT. Name the significant findings. Figure 2. A, B, C: Non-contrast axial CT displaying subtle bilateral isodense subdural hematomas. There is medial displacement of gray matter with left (orange arrows) worse than right (red arrows). Shift of midline structures to the right is also a clue to the diagnosis. D: Non-contrast coronal CT indicating isodense subdural hematoma (orange arrows). Note again the midline shift to the right. Figure 3. Post op CT brain on same patient. Note the lower attenuation fluid after treatment. Partial evacuation of hematoma with hypodense regions indicating residual fluid and blood products (red and orange arrows). Discussion: Subacute subdural hematomas (SDH) are usually due to clinically undetected acute SDH. Two leading causes are tearing of the bridging vessels due to abrupt acceleration-deceleration of the head or accumulation around a parenchymal laceration (1). This trauma leads to blood accumulation between the arachnoid and dura layers of the brain (2). Risk factors include cerebral atrophy (elderly patients or chronic alcoholics), anticoagulation use, or recent thrombolysis (3). The patient may or may not have a history of head trauma. Common presenting features include headache, decreased memory, confusion, and motor dysfunction (4). SDH can cross suture lines since they occur deep to the dura mater; this differs from epidural hematomas which usually do not cross suture lines since blood cannot extend beyond the point where the dura attaches to the cranial sutures (5). Subacute subdural hematomas are categorized as isodense biconcavities on CT. When blood clots degrade, the density decreases and becomes more similar to the brain parenchyma. Furthermore, subacute (and chronic) SDHs may show septations within an iso/hypodense hematoma due to reactive granulation tissue formation (6). Subacute hemorrhages can be challenging to recognize because of the isodense characteristics. Therefore, one must also look for signs of mass effect such as asymmetry of the lateral ventricles, shifting of midline structures, sulcal effacement, and sulci that do not extend into the skull (Figs. 1-2) (7). Management of subacute SDH is determined by whether a patient is symptomatic or exhibiting signs of mass effect; those who are asymptomatic may be candidates for conservative treatment (8). Mainstay surgery modalities include twist-drill craniostomy, burr-hole craniostomy, and craniotomy (8). Figure 2 shows this patient following bilateral craniotomy. ​​​​ References: Williams KA Jr, Kouloumberis P, Engelhard HH. Subacute subdural hematoma in a 45-year-old woman with no significant past medical history after a roller coaster ride. Am J Emerg Med . 2009;27(4):. doi: 10.1016/j.ajem.2008.08.005 Pierre L, Kondamudi NP. Subdural Hematoma. [Updated 2019 Dec 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532970/ Lupescu IC, Stefanescu VC, Lupescu IG, Dulamea AO. Subacute Subdural Hematoma Presenting as Non-Fluent Aphasia. Maedica (Bucur) . 2019;14(1):63-66. doi: 10.26574/maedica.2019.14.1.63 Yadav YR, Parihar V, Namdev H, Bajaj J. Chronic subdural hematoma. Asian J Neurosurg . 2016;11(4):330-342. doi: 10.4103/1793-5482.145102 Heit JJ, Iv M, Wintermark M. Imaging of Intracranial Hemorrhage. J Stroke . 2017;19(1):11-27. doi: 10.5853/jos.2016.00563 Grainger and Allison. Adam Kenji Yamamoto and Ashok Adams: Grainger & Allison's Diagnostic Radiology, 54, 1387-1410 Emergency Radiology. Glenn D. Barest, Asim Z. Mian, Rohini N. Nadgir and Osamu Sakai: Emergency Radiology: The Requisites, Chapter 1, 1-60 Cai Q, Guo Q, Zhang F, et al. Evacuation of chronic and subacute subdural hematoma via transcranial neuroendoscopic approach. Neuropsychiatr Dis Treat . 2019;15:385-390. Published 2019 Jan 30. doi: 10.2147/NDT.S193548 Deven Champaneri is a medical student at Edward Via College Osteopathic Medicine (VCOM) – Carolinas and plans to pursue residency in diagnostic radiology. While he was rotating through various specialties, he realized his passion for DR and valued its role in all aspects of medicine. He graduated from the University of South Carolina in 2017 with a degree in Business Marketing. During his undergraduate studies, he was involved with multiple volunteer organizations, such as Camp Kemo a summer camp for children with cancer and Palmetto Richland Children’s Hospital . Currently, he mentors at-risk high-school students and tutors students for Step 1/COMLEX 1. In his spare time he enjoys, golfing, backpacking, cooking, and spending time with family. UPDATE 2025: Dr. Champaneri is now a radiology resident at Medical University of South Carolina Follow Deven Champaneri on Twitter @ devenchampaneri All posts by Deven C hampaneri 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

Global Radiology CME is pleased to congratulate the Award Winners for Best E-Posters and The Donald Resnick MSK Quiz at Imaging in Prague 2019. Awards were presented at The Gala Dinner at the Prague Municipal House on June 10, 2019. Neuroradiology E-Poster: Victor Teng - Flexion MRI in Hirayama Disease Dr. Teng is a radiologist at National University Health System Singapore. He was presented with the Award by Dr. Blake Johnson, Co-Scientific Director and Neuroradiology Faculty for Imaging in Prague 2019. Body Imaging E-Poster: Grace Rubin - Breast Tuberculosis - A review of 62 cases Dr. Rubin is Clinical Head of Radiology, at Helen Joseph Hospital in Johannesburg, a University of Witwatersrand affiliated academic hospital. She was presented with the Award by Dr. Neil Rofsky, Body Imaging Faculty at Imaging in Prague 2019. MSK Imaging E-Poster: Junsiyuan Li - Fibrolipomatous Hamartoma of the Median Nerve Dr. Li is a senior radiology resident at Singapore General Hospital, SingHealth. He was presented with the Award by Dr. Phillip Tirman, Co -Scientific Director and MSK Imaging Faculty at Imaging in Prague 2019. Donald Resnick MSK Quiz Award: Andrew Kingzett Taylor Dr. Kingzett Taylor serves as an MSK radiologist at Pacific Radiology, located in Wellington and Manawatu, New Zealand. He completed a visiting fellowship at the MSK Section of UCSF and the San Francisco MRI Centre. Dr. Donald Resnick, an ACR Gold Medalist and esteemed MSK Imaging faculty member of Global Radiology CME, is seen presenting him with the Award. More award winners here .

A 61-year-old female presented with left upper quadrant abdominal pain and hypotension following a motor vehicle collision. How would you grade this injury? • Xray of the Week Figure 1. Contrast enhanced CT of abdomen and pelvis. How would you grade this injury? What action should be taken for this patient who is hemodynamically unstable? Figure 2. Contrast enhanced CT of abdomen and pelvis demonstrating IV contrast extravasation from the spleen (red arrows). Note also the hematomas adjacent to the spleen and liver. Figure 3. Initial selective splenic artery angiogram and subsequent coil embolization. Discussion: Splenic trauma occurs frequently in patients who sustain blunt abdominal injury, especially following high-energy mechanisms such as motor vehicle collisions. The injury can range from capsular tears to complete devascularization of the spleen. The American Association for the Surgery of Trauma (AAST) Splenic Injury Scale is a standardized grading system ranging from Grade I to Grade V used to classify the severity of splenic injuries based on imaging and surgical findings [1]. Imaging criteria for a Grade I injury includes subcapsular hematomas involving less than 10% of the surface area, parenchymal lacerations <1cm in depth, and capsular tear. Grade II injuries include subcapsular hematomas covering 10% to 50% of the surface area, intraparenchymal hematomas under 5 cm, or 1-3 cm lacerations (do not involve the trabecular vessels). Grade III injuries are characterized by subcapsular hematomas greater than 50% of the surface area or ruptured subcapsular or intraparenchymal hematomas larger than 5 cm, or lacerations deeper than 3 cm (involve the trabecular vessels) [1]. Grade IV injuries include lacerations that extend into segmental or hilar vessels and result in major devascularization of more than 25% of the spleen and any injuries with the presence of a splenic vascular injury or active bleeding within the splenic capsule. Since there is contrast extravasation, this is case is considered a Grade IV injury (Figs. 1-2). Grade V injuries are the most severe form, involving a shattered spleen or hilar vascular injury leading to devascularization of the organ and active bleeding extending beyond the spleen into the peritoneum [1]. Prompt identification of the injury grade is essential for guiding treatment decisions. Higher-grade injuries (Grades IV and V), especially when accompanied by active contrast extravasation as in this case, typically indicate ongoing hemorrhage and necessitate urgent intervention, often through angioembolization or surgery. Lower-grade injuries (Grades I–III) can be managed non-operatively in hemodynamically stable patients [2]. Imaging: Computed tomography (CT) is the imaging modality of choice for evaluating blunt abdominal trauma and identifying splenic injury. Contrast-enhanced CT, particularly with arterial and portal venous phases, allows for accurate detection and grading of splenic lacerations, hematomas, and vascular injuries. Key findings on CT include subcapsular and intraparenchymal hematomas, depth and extent of lacerations, active contrast extravasation, pseudoaneurysms, and areas of devascularization. Multiphase imaging increases sensitivity for detecting active bleeding, which appears as hyperdense contrast pooling in the arterial phase and persistent enhancement in delayed images. The sensitivity and specificity of contrast-enhanced CT in identifying clinically significant splenic injuries are both high, with CT also serving as the basis for injury grading using the AAST Splenic Injury Scale. Prompt and accurate identification of injury grade and vascular involvement is essential in guiding appropriate management, ranging from non-operative observation to embolization or surgery [3]. Treatment: In this case, the patient presented with significant splenic trauma and active extravasation on imaging, which required urgent intervention. Given the hemodynamic instability and the severity of the injury, the patient underwent splenic embolization. Transcatheter arterial embolization (TAE) is considered the treatment of choice for high-grade splenic injuries and avoids the need for splenectomy in many cases. During embolization, selective catheterization of the splenic artery allows for precise delivery of embolic agents to the bleeding vessels, controlling the hemorrhage. It can successfully treat most splenic injuries with a low risk of complications. As an alternative to splenectomy, it is minimally invasive and effective in achieving hemostasis while preserving splenic function. However, patients with more severe injuries, such as complete splenic rupture or failure of embolization, may require splenectomy [4]. Prognosis: Prognosis after splenic injury is dependent on degree of injury and time until treatment. Low grade injuries often have a very favorable prognosis, though delayed splenic rupture may occur up to 10 days post injury. The prognosis for patients undergoing TAE is generally favorable, especially in cases of successful embolization. When embolization effectively controls the bleeding, the patient can recover without the need for splenectomy and typically experience a full recovery. In up to 20% of patients, splenic infarction may occur after embolization (defined as more than 25% devascularization of the spleen). The risk of other complications such as recurrence of bleeding or abscess formation is low. However, patients who undergo splenectomy due to failed embolization or more severe injury are at higher risk for post-splenectomy infection, particularly with encapsulated organisms. This risk is highest in the first 2 years after splenectomy but can occur at any time. Vaccinations and long-term follow-up are essential in these patients. Early diagnosis, timely embolization, and careful post-procedural monitoring contribute to favorable long-term outcomes for most patients with splenic injuries [5]. ​​​​ References: Injury scoring scale. The American Association for the Surgery of Trauma. (2025, Jan. 16). https://www.aast.org/resources-detail/injury-scoring-scale#spleen Coccolini F, Montori G, Catena F, et al. Splenic trauma: WSES classification and guidelines for adult and pediatric patients. World J Emerg Surg . 2017;12:40. Published 2017 Aug 18. DOI: 10.1186/s13017-017-0151-4 Steven R Klepac, M. (2023, September 14). Splenic trauma imaging. Practice Essentials, Radiography, Computed Tomography. https://emedicine.medscape.com/article/373694-overview Quencer KB, Smith TA. Review of proximal splenic artery embolization in blunt abdominal trauma. CVIR Endovasc . 2019;2(1):11. Published 2019 Mar 18. PMCID: PMC7224246 DOI: 10.1186/s42155-019-0055-3 Oelhaf RC, Sugumar K, King KC. Splenic Trauma. [Updated 2023 Jun 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430920/ Sriya Kosaraju is a medical student at University of Missouri-Kansas City (UKMC) School of Medicine and is pursuing radiology. Her interest is in the field radiology from its central role in patient care and the dynamic intersection of technology, innovation, and impactful clinical decision-making. At UMKC, she currently serves as the Director of Research Initiatives for UMKC’s Vascular and Interventional Radiology Interest Group, where she helps organize journal clubs, connects students with mentors, and supports research opportunities in interventional radiology. She also serves as a Student Ambassador, guiding and mentoring prospective students through tours, panels, and other recruitment efforts. On a national level, she currently serves on the Society of Interventional Radiology's membership committee and volunteers with both the Society of Interventional Radiology (SIR) and the American College of Radiology (ACR) Rad Reserves, contributing to projects to enhance radiology resources and outreach. Sriya is passionate about preventative health care and the role of radiology in improving clinical outcomes. She is the founder and president of Mam4Mom, a nonprofit dedicated to increasing access to women’s health services. Through Mam4Mom, she has led initiatives including free mammogram and Pap smear days, community awareness campaigns, and care baskets for hospitalized cancer patients. She hopes to continue to explore ways to bridge medicine, service, education, and advocacy in her future career. Follow Sriya Kosaraju on X (formerly Twitter) @sriyakosaraju All posts by Sriya Kosaraju 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 X (formerly Twitter) @KevinRiceMD All posts by Kevin M. Rice, MD