An Interactive Roundtable with Karen S. Lee, MD FACR Boston Marathon - April 13, 2013 Image credit: John Tlumacki Boston Globe - www.cnn.com/interactive/2023/04/us/boston-marathon-bombing-anniversary/ If a mass casualty event happened at your hospital tomorrow, would your radiology department be ready? Mass casualty events are rare—but when they happen, they can overwhelm a hospital in minutes. For radiologists, the challenge is not simply interpreting images. It is knowing how to keep imaging moving when the emergency department is suddenly flooded with critically injured patients, resources are stretched, and the usual workflow no longer applies. Disaster Radiology: Ready or Not? is an interactive roundtable led by Karen S. Lee, MD, FACR, who was involved in the radiologic response to the Boston Marathon bombing. Rather than a traditional lecture, the session will put participants into the middle of mass casualty scenarios and ask a simple question: What would you do? How do you prioritize imaging when dozens of patients arrive simultaneously? Who decides which studies get performed first? How do you adapt CT, MRI, ultrasound, and radiography operations when demand suddenly exceeds capacity? And how does the radiology department communicate effectively with the emergency department, trauma teams, and hospital leadership? Most radiologists will never experience a disaster on the scale of the Boston Marathon bombing. But that is precisely why preparedness matters. You cannot develop disaster experience by waiting for a disaster to happen. This roundtable offers an opportunity to learn from someone who has been there—and to think through how your own department would respond before the moment arrives. Karen Lee, MD, FACR About Karen Lee Karen S. Lee, MD is an Assistant Professor of Radiology at Harvard Medical School and a radiologist specializing in Emergency Radiology and Body MRI at Beth Israel Deaconess Medical Center (BIDMC). She serves as Associate Chief of the Emergency Radiology section, Director of Radiology Fellowship Training Programs, and Program Director for both the Body MRI and Cross-Sectional Imaging Fellowships. Dr. Lee earned her medical degree from Harvard Medical School and completed her radiology residency at BIDMC, where she served as Chief Resident. She remained at BIDMC to complete a fellowship in Body MRI. Her research interests include imaging of acute abdominal pain in pregnancy, evaluating cognitive biases in emergency radiology, and reducing redundant imaging in the emergent setting. She has authored numerous scientific articles, review publications, and book chapters, and has been invited to speak nationally and internationally on abdominal MRI and gastrointestinal and genitourinary emergency imaging. Dr. Lee is an active member of several professional societies, including the Radiological Society of North America (RSNA), American Roentgen Ray Society (ARRS), American College of Radiology (ACR), American Society of Emergency Radiology (ASER), and Society of Abdominal Radiology (SAR). She serves on the Scientific Program Committees for RSNA and ASER, and is a member of both the RSNA Multisystem Subcommittee and the RadioGraphics General Imaging Panel. A dedicated educator and mentor, Dr. Lee is a peer reviewer for several journals, including Abdominal Imaging, Journal of Magnetic Resonance Imaging, RadioGraphics, and The New England Journal of Medicine. She has received multiple consecutive teaching and mentorship awards at BIDMC, and her educational and scientific exhibits have been recognized with honors by RSNA, ARRS, and ASER. Dr. Lee is a Fellow of both the American College of Radiology and the Society of Abdominal Radiology.

24-year-old male with leg pain. Diagnosis? • Xray of the Week Figure 1. Radiographs of the left knee. (A) Frontal radiograph demonstrates an aggressive lesion centered in the distal left femur with a large mineralized soft-tissue component (yellow arrows). (B) Lateral radiograph further demonstrates the densely mineralized lesion and associated soft-tissue mass arising from the distal femur (yellow arrows). Figure 2. Postoperative CT Scan of the left femur. (A) Frontal CT Scout image demonstrates postoperative changes with metallic endoprosthetic reconstruction of the distal femur extending across the knee (yellow arrow). (B) Coronal CT image demonstrates the postoperative femoral reconstruction and prosthetic components (yellow arrow). Figure 3. Pulmonary metastatic disease in osteosarcoma. Axial CT image of the chest demonstrates peripheral pulmonary nodules (red arrows), consistent with pulmonary metastatic disease in this patient. Figure 4. Recurrent osteosarcoma with calcified pulmonary metastases in a different patient. (A) Coronal CT image demonstrates densely calcified pulmonary metastatic nodules (yellow arrows). (B) Postoperative radiograph demonstrates mineralized recurrent soft-tissue disease adjacent to the distal femoral endoprosthesis (red arrow). (C) Magnified radiograph further demonstrates the mineralized recurrent tumor adjacent to the prosthesis (black arrow). Epidemiology Osteosarcoma is the most common primary malignant bone tumor in children and adolescents, with an incidence of approximately 3–5 cases per million persons per year in younger populations [1,2]. Incidence peaks during adolescence and is slightly higher in males [1]. Osteosarcoma most commonly arises in the metaphyses of long bones, particularly around the knee. The distal femur is the most frequent site, followed by the proximal tibia and proximal humerus [1]. Clinical Findings Pain is the most common presenting symptom of osteosarcoma and may initially be intermittent before becoming persistent. Local swelling, a palpable mass, restricted joint movement, and limp may occur as the tumor enlarges. Pathological fracture is an uncommon presentation, while systemic symptoms are generally unusual [2,3]. In the primary case, the 24-year-old male presented with left leg pain. Pathology Osteosarcoma is a malignant mesenchymal neoplasm characterized by production of osteoid or immature bone directly by malignant tumor cells [2,3]. Conventional osteosarcoma is typically a high-grade intramedullary tumor composed of malignant pleomorphic cells with variable production of osteoid and other extracellular matrix. Tumor osteoid is often irregular and disorganized and may undergo mineralization. Histological response following neoadjuvant chemotherapy, particularly the degree of tumor necrosis, has important prognostic significance [2]. Classification Osteosarcoma comprises seven recognized primary subtypes: conventional, telangiectatic, low-grade central, small cell, parosteal, periosteal, and high-grade surface osteosarcoma [3,4]. Conventional osteosarcoma is the most common subtype, accounting for approximately 75–80% of cases, and may demonstrate osteoblastic, chondroblastic, or fibroblastic differentiation according to the predominant matrix [3,4]. Surface osteosarcomas include parosteal, periosteal, and high-grade surface variants, which differ in histologic grade, imaging appearance, treatment, and prognosis [4]. Radiographic Features Plain radiography is usually the initial imaging modality. Conventional osteosarcoma typically appears as an aggressive metaphyseal lesion with mixed lytic and sclerotic components, cortical destruction, an ill-defined zone of transition, mineralized osteoid matrix, and an associated soft-tissue mass (Fig. 1) . Aggressive periosteal reactions, including sunburst-type spiculation and a Codman triangle, may occur [2,4,5]. CT better depicts cortical destruction and mineralized tumor matrix and is important for assessment of pulmonary metastatic disease [4,5]. MRI is the preferred modality for local staging, defining intramedullary and soft-tissue extent, relationship to neurovascular structures and joints, and the presence of skip lesions [2,4]. Pulmonary metastases usually appear as solid pulmonary nodules on chest CT and may be multiple and bilateral. Calcification or ossification can occur (Figs. 3,4) and represents a recognized atypical appearance of osteosarcoma lung metastases [6]. Postoperative imaging provides a baseline for assessment of the reconstruction and subsequent surveillance. Comparison with prior examinations is important when evaluating for suspected local recurrence, with MRI particularly useful for assessing recurrent soft-tissue disease [7]. Treatment and Prognosis Treatment of high-grade osteosarcoma generally combines systemic chemotherapy with complete surgical resection of the primary tumor. Limb-salvage surgery (Fig. 2) is feasible in many patients when adequate oncologic margins and a functional extremity can be achieved; amputation remains necessary in selected cases [8-10]. Histologic response to chemotherapy and the presence of metastatic disease are important prognostic factors [9]. Contemporary series report 5-year survival of approximately 70–75% for patients with localized extremity osteosarcoma, whereas outcomes are substantially poorer in patients with metastatic or recurrent disease. The lungs are the predominant site of distant metastasis. In patients with resectable pulmonary metastatic disease, complete surgical removal of metastases is an important component of management and is associated with better outcomes in selected patients [7]. Conclusion Osteosarcoma is an aggressive primary bone malignancy that predominantly affects adolescents and young adults. Imaging plays a central role in diagnosis, local staging, treatment planning, and surveillance. Recognition of characteristic aggressive osseous features and careful assessment for pulmonary metastatic and recurrent disease are essential because disease stage and treatment response strongly influence prognosis. References Ottaviani G, Jaffe N. The epidemiology of osteosarcoma. Cancer Treat Res. 2009;152:313. https://doi.org/10.1007/978-1-4419-0284-9_1 Durfee RA, Mohammed M, Luu HH. Review of osteosarcoma and current management. Rheumatol Ther. 2016;3(2):221-243. https://doi.org/10.1007/s40744-016-0046-y Fox MG, Trotta BM. Osteosarcoma: review of the various types with emphasis on recent advancements in imaging. Semin Musculoskelet Radiol. 2013;17(2):123-136. https://doi.org/10.1055/s-0033-1342969 Yarmish G, Klein MJ, Landa J, Lefkowitz RA, Hwang S. Imaging characteristics of primary osteosarcoma: nonconventional subtypes. Radiographics. 2010;30(6):1653- 1672. https://doi.org/10.1148/rg.306105524 Crombé A, et al. Imaging of osteosarcoma: presenting findings, metastatic patterns, and features related to prognosis. J Clin Med. 2024;13(19):5710. https://doi.org/10.3390/jcm13195710 Silva JAM, Marchiori E, Amorim VB, Barreto MM, et al. CT features of osteosarcoma lung metastasis: a retrospective study of 127 patients. J Bras Pneumol. 2023;49(2):e20220433. https://doi.org/10.36416/1806-3756/e20220433 Garner HW, Kransdorf MJ, Peterson JJ. Posttherapy imaging of musculoskeletal neoplasms. Radiol Clin North Am. 2011;49(6):1307-1323. https://doi.org/10.1016/j.rcl.2011.07.011 Bielack SS, Kempf-Bielack B, Delling G, et al. Prognostic factors in high-grade osteosarcoma of the extremities or trunk: an analysis of 1,702 patients treated on neoadjuvant Cooperative Osteosarcoma Study Group protocols. J Clin Oncol. 2002;20(3):776-790. https://doi.org/10.1200/JCO.2002.20.3.776 Luetke A, Meyers PA, Lewis I, Juergens H. Osteosarcoma treatment—where do we stand? A state of the art review. Cancer Treat Rev. 2014;40(4):523-532. https://doi.org/10.1016/j.ctrv.2013.11.006 Briccoli A, Rocca M, Salone M, Guzzardella GA, Balladelli A, Bacci G. High grade osteosarcoma of the extremities metastatic to the lung: long-term results in 323 patients treated combining surgery and chemotherapy, 1985-2005. Surg Oncol. 2010;19(4):193-199. https://doi.org/10.1016/j.suronc.2009.05.002 Umaiza Ihsan, MD, is a medical graduate of King Edward Medical University, Pakistan. She completed her internship at Mayo Hospital, Lahore, including a three- month rotation in Radiology, which further strengthened her interest in diagnostic imaging. She has gained additional clinical exposure in Radiology through observerships at Mon Health Morgantown and the University of Maryland, Baltimore. She has a strong interest in Radiology, particularly diagnostic imaging and its role in clinical decision-making, and is actively interested in clinical research, with experience in systematic reviews and medical research. Kevin M. Rice, MD is the president of Global Radiology CME and is a radiologist with Cape Radiology Group. He has held several leadership positions including Board Member and Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator by AuntMinnie.com. He has continued to teach by mentoring medical students interested in radiology. Everyone who he has mentored has been accepted into top programs across the country including Harvard, UC San Diego, Northwestern, Vanderbilt, and Thomas Jefferson. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

A 30-year-old female, after a motor vehicle collision, presented with chest pain, abdominal pain, shortness of breath, and rib fractures. Diagnosis? • Xray of the Week Figure 1. Coronal and axial CT Scan. Diagnosis? Figure 2. CT scan of traumatic left hemi-diaphragmatic rupture. (A) Coronal CT images demonstrate abdominal viscera herniating into the left hemithorax (yellow arrow pointing to colon), consistent with traumatic disruption of the left hemidiaphragm. (B) Axial CT image also demonstrates abdominal organs including spleen (red arrow) in the chest. Figure 3. Prior CT examination. Coronal CT image obtained one year earlier demonstrates the pre-trauma thoracoabdominal anatomy in the same patient without the left-sided intrathoracic visceral herniation seen on the current examination. Normal left hemidiaphragm (yellow arrow). Epidemiology Traumatic diaphragmatic rupture is uncommon, occurring in approximately 0.5% of all trauma patients and around 1–2% of patients with blunt trauma [1]. Motor vehicle collisions are a major cause of blunt diaphragmatic rupture. Left-sided injuries predominate, accounting for approximately 65–80% of cases, while right-sided and bilateral ruptures are less frequent. Diaphragmatic rupture commonly occurs in the setting of high-energy thoracoabdominal trauma and is frequently accompanied by other traumatic injuries [1,2]. Clinical Findings Clinical presentation of traumatic diaphragmatic rupture is variable and may be obscured by associated thoracic or abdominal injuries. Patients may present with chest or abdominal pain, dyspnea, tachypnea, or respiratory distress. Physical examination may demonstrate decreased breath sounds or, when abdominal viscera have herniated into the thorax, bowel sounds within the chest. Some injuries may initially be clinically occult, contributing to delayed diagnosis [1,2]. In this case, the 30-year-old woman presented following a motor vehicle collision with chest pain, abdominal pain, and shortness of breath; associated rib fractures were also documented. Pathology Traumatic diaphragmatic rupture results from disruption of the musculotendinous diaphragm following blunt or penetrating thoracoabdominal trauma. In blunt trauma, sudden elevation of intra-abdominal pressure and shearing forces can produce diaphragmatic tears, which commonly involve the posterolateral diaphragm [2]. The resulting defect may permit abdominal viscera to herniate into the thoracic cavity because of the pressure gradient between the abdomen and chest. If unrecognized, progressive herniation may lead to incarceration or strangulation of herniated viscera. Classification Traumatic diaphragmatic injuries are graded according to the American Association for the Surgery of Trauma (AAST) Organ Injury Scale. Grade I represents diaphragmatic contusion; Grade II, a laceration <2 cm; Grade III, a laceration 2–10 cm; Grade IV, a laceration >10 cm with tissue loss <25 cm²; and Grade V, a laceration with tissue loss >25 cm². Bilateral injuries are advanced by one grade up to Grade III [3]. This classification describes the anatomical severity of diaphragmatic injury. Radiographic Features Chest radiography may demonstrate an elevated or irregular hemidiaphragm, intrathoracic abdominal viscera, abnormal diaphragmatic contour, or associated pleural and pulmonary abnormalities; however, findings may be subtle or nonspecific [4]. Multidetector CT is the principal imaging modality for evaluating suspected traumatic diaphragmatic injury [5]. Direct CT findings include focal diaphragmatic discontinuity and the dangling diaphragm sign, representing inward curling of the torn diaphragmatic edge [6]. Indirect findings include intrathoracic herniation of abdominal viscera, the collar sign from waist-like constriction of herniated viscera at the defect, and the dependent viscera sign, in which herniated abdominal organs lie against the posterior thoracic wall [7]. Coronal and sagittal multiplanar reformations may facilitate identification of diaphragmatic defects and visceral herniation. Associated thoracoabdominal injuries, including rib fractures, may also be identified. Treatment and Prognosis Traumatic diaphragmatic rupture requires surgical repair once the patient's condition permits. Herniated abdominal viscera are reduced and the diaphragmatic defect is usually closed primarily with sutures; mesh may be required for larger defects that cannot be closed without tension [8]. The operative approach may be abdominal, thoracic, or minimally invasive depending on clinical stability, associated injuries, and timing of presentation [1,8]. Prognosis is largely determined by the severity of associated traumatic injuries rather than the diaphragmatic defect itself. Delayed or missed diagnosis may result in visceral incarceration, strangulation, or respiratory compromise [8]. Conclusion Traumatic diaphragmatic rupture is an uncommon but important complication of thoracoabdominal trauma that may be difficult to recognize clinically. Awareness of characteristic imaging findings, particularly on multidetector CT, is essential for prompt diagnosis and appropriate management, helping to reduce complications associated with delayed or missed injury. References Furák J, Athanassiadi K. Diaphragm and transdiaphragmatic injuries. J Thorac Dis. 2019;11(Suppl 2):S152-S157. doi:https://doi.org/10.21037/jtd.2018.10.76 Petrone P, Asensio JA, Marini CP. Diaphragmatic injuries and post-traumatic diaphragmatic hernias. Curr Probl Surg. 2017;54(1):11-32. doi:https://doi.org/10.1067/j.cpsurg.2016.11.001 Moore EE, Malangoni MA, Cogbill TH, et al. Organ injury scaling IV: thoracic vascular, lung, cardiac, and diaphragm. J Trauma. 1994;36(3):299-300. doi:https://doi.org/10.1097/00005373-199403000-00002 Desir A, Ghaye B. CT of blunt diaphragmatic rupture. Radiographics. 2012;32(2):477-498. doi:https://doi.org/10.1148/rg.322115082 Nchimi A, Szapiro D, Ghaye B, et al. Helical CT of blunt diaphragmatic rupture. AJR Am J Roentgenol. 2005;184(1):24-30. doi:https://doi.org/10.2214/ajr.184.1.01840024 Desser TS, Edwards B, Hunt S, Rosenberg J, Purtill MA, Jeffrey RB. The dangling diaphragm sign: sensitivity and comparison with existing CT signs of blunt traumatic diaphragmatic rupture. Emerg Radiol. 2010;17(1):37-44. doi:https://doi.org/10.1007/s10140-009-0819-5 Bergin D, Ennis R, Keogh C, Fenlon HM, Murray JG. The “dependent viscera” sign in CT diagnosis of blunt traumatic diaphragmatic rupture. AJR Am J Roentgenol. 2001;177(5):1137-1140. doi:https://doi.org/10.2214/ajr.177.5.1771137 Giuffrida M, Perrone G, Abu-Zidan F, et al. Management of complicated diaphragmatic hernia in the acute setting: a WSES position paper. World J Emerg Surg. 2023;18(1):43. doi:https://doi.org/10.1186/s13017-023-00510-x Umaiza Ihsan, MD, is a medical graduate of King Edward Medical University, Pakistan. She completed her internship at Mayo Hospital, Lahore, including a three- month rotation in Radiology, which further strengthened her interest in diagnostic imaging. She has gained additional clinical exposure in Radiology through observerships at Mon Health Morgantown and the University of Maryland, Baltimore. She has a strong interest in Radiology, particularly diagnostic imaging and its role in clinical decision-making, and is actively interested in clinical research, with experience in systematic reviews and medical research. Kevin M. Rice, MD is the president of Global Radiology CME and is a radiologist with Cape Radiology Group. He has held several leadership positions including Board Member and Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator by AuntMinnie.com. He has continued to teach by mentoring medical students interested in radiology. Everyone who he has mentored has been accepted into top programs across the country including Harvard, UC San Diego, Northwestern, Vanderbilt, and Thomas Jefferson. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

Dizziness and syncope. Diagnosis? • Xray of the Week Figure 1. What is this foreign body in the chest? Figure 2. Dislodged leadless pacemaker within the left pulmonary arterial circulation. (A) Frontal chest radiograph demonstrates the radiopaque leadless pacemaker projecting over the left hilar region (red arrow), rather than its expected position within the right ventricle. (B) Axial CT image confirms the leadless pacemaker within the left pulmonary arterial circulation (red arrow). Figure 3. Frontal and lateral CXR. Normal position of leadless pacemaker in a different patient (A) in the right ventricle. Incidental cardiac loop recorder (B). Epidemiology Leadless pacemaker dislodgement is an uncommon complication of implantation. In the Micra Post-Approval Registry, device dislodgement occurred in 0.13% of patients within 30 days [1]. More recent post-market data reported dislodgement and/or embolization in 0.29% of 72,237 Micra VR implants and 0.88% of 5,990 AVEIR VR implants [2]. Migration into the pulmonary arterial circulation is particularly rare and has predominantly been described in case reports [3-5]. Clinical Findings Leadless pacemaker dislodgement may be clinically silent or associated with pacemaker malfunction [3-5]. Device displacement may result in abnormal pacing parameters or loss of capture [3-6]. In this case, the patient presented with dizziness and syncope. Pulmonary artery embolization itself may remain asymptomatic, although serious vascular complications can rarely occur [5-7]. Pathology Leadless pacemakers are implanted directly into the right ventricular endocardium and use dedicated fixation mechanisms to maintain device stability [8]. Inadequate fixation or device release problems may result in dislodgement and subsequent embolization into the pulmonary arterial circulation [2,5]. Once dislodged from the right ventricle, the device may pass through the right ventricular outflow tract and pulmonary valve and lodge within a pulmonary arterial branch [3-5]. Radiographic Features On chest radiography, a normally positioned leadless pacemaker appears as a radiopaque device implanted within the right ventricular wall [9,10]. Device dislodgement should be suspected when the pacemaker is no longer seen in its expected intracardiac position and instead projects over the pulmonary arterial circulation (Figure 1A). Serial radiographs, when available, may demonstrate interval migration [5]. CT provides cross-sectional anatomic localization of an embolized device within the pulmonary vasculature and can delineate its relationship to adjacent pulmonary arterial branches (Figure 1B) [10]. Published cases demonstrate embolization into both central and more peripheral pulmonary arterial branches [3-5]. Treatment and Prognosis Management of an embolized leadless pacemaker depends on device location, clinical status, duration since implantation, and feasibility of retrieval [3,11]. Percutaneous retrieval may be performed using snare-based techniques introduced through a large-bore delivery catheter or steerable sheath [3,4,7,11]. When complete endovascular removal is not technically feasible, a surgical component may occasionally be required [4]. Following successful retrieval, further pacing therapy can be provided when clinically indicated [3,11]. Conclusion Leadless pacemaker dislodgement with pulmonary arterial embolization is a rare complication that may be clinically silent or result in pacemaker dysfunction and potentially serious vascular complications. Chest radiography can identify abnormal device position, while CT provides more precise anatomic localization within the pulmonary arterial circulation. Prompt recognition of device migration is important for guiding subsequent management. References 1. Roberts PR, Clementy N, Al Samadi F, et al. A leadless pacemaker in the real-world setting: the Micra Transcatheter Pacing System Post-Approval Registry. Heart Rhythm. 2017;14(9):1375-1379. https://doi.org/10.1016/j.hrthm.2017.05.017 2. Bahbah A, Sengupta J, Witt D, et al. Device dislodgement and embolization associated with a new leadless pacemaker. J Cardiovasc Electrophysiol. 2024;35(12):2483 2486. https://doi.org/10.1111/jce.16485 3. Terricabras M, Khaykin Y. Successful leadless pacemaker retrieval from the left pulmonary artery: a case report. HeartRhythm Case Rep. 2020;6(10):798-799. https://doi.org/10.1016/j.hrcr.2020.08.004 4. Barbieri F, Kranewitter C, Frech A, Hintringer F, Stühlinger M. Lost but not lost—embolization of a leadless pacemaker to the pulmonary artery with consecutive endovascular recovery. J Cardiovasc Dev Dis. 2021;8(4):37. https://doi.org/10.3390/jcdd8040037 5. Sugiura K, Baba Y, Hirota T, Kubo T, Kitaoka H. A drifting dislodged leadless pacemaker in the bilateral pulmonary arteries. JACC Case Rep. 2022;4(14):844-846. https://doi.org/10.1016/j.jaccas.2022.03.034 6. Amin MI, Saif S, Shivappa S, Noor H. Leadless pacemaker dislodgment: difficulty in release as a predictor for dislodgment and tools for successful retrieval. Heart Rhythm O2. 2024;5(10):739-740. https://doi.org/10.1016/j.hroo.2024.08.010 7. Abraham H, Assar MD, Chugh Y. A novel technique for percutaneous retrieval of an embolized atrial leadless pacemaker from the pulmonary artery. JACC Cardiovasc Interv. 2026;19(10):1333-1335. https://doi.org/10.1016/j.jcin.2026.02.025 8. El-Chami MF, Roberts PR, Kypta A, Omdahl P, Bonner MD, Kowal RC, Duray GZ. How to implant a leadless pacemaker with a tine-based fixation. J Cardiovasc Electrophysiol. 2016;27(12):1495-1501. https://doi.org/10.1111/jce.13092 9. Mathew RP, Alexander T, Patel V, Low G. Chest radiographs of cardiac devices (Part 1): cardiovascular implantable electronic devices, cardiac valve prostheses and Amplatzer occluder devices. S Afr J Radiol. 2019;23(1):1730. https://doi.org/10.4102/sajr.v23i1.1730 10. Conyers JM, Rajiah P, Ahn R, Abbara S, Saboo SS. Imaging features of leadless cardiovascular devices. Diagn Interv Radiol. 2018;24(4):203-208. https://doi.org/10.5152/dir.2018.17462 11. Afzal MR, Daoud EG, Cunnane R, et al. Techniques for successful early retrieval of the Micra transcatheter pacing system: a worldwide experience. Heart Rhythm. 2018;15(6):841-846. https://doi.org/10.1016/j.hrthm.2018.02.008 Umaiza Ihsan, MD, is a medical graduate of King Edward Medical University, Pakistan. She completed her internship at Mayo Hospital, Lahore, including a three- month rotation in Radiology, which further strengthened her interest in diagnostic imaging. She has gained additional clinical exposure in Radiology through observerships at Mon Health Morgantown and the University of Maryland, Baltimore. She has a strong interest in Radiology, particularly diagnostic imaging and its role in clinical decision-making, and is actively interested in clinical research, with experience in systematic reviews and medical research. Kevin M. Rice, MD is the president of Global Radiology CME and is a radiologist with Cape Radiology Group. He has held several leadership positions including Board Member and Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator by AuntMinnie.com. He has continued to teach by mentoring medical students interested in radiology. Everyone who he has mentored has been accepted into top programs across the country including Harvard, UC San Diego, Northwestern, Vanderbilt, and Thomas Jefferson. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

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

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

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

A 70-year-old female fell off her bed while changing a light bulb and complains of left shoulder pain. What is the diagnosis? • Xray of the Week Figure 1. Non-contrast CT of the cervical spine. What is the diagnosis? Figure 2. Non-contrast CT of the cervical spine (sagittal reconstructions): Bilateral facet dislocation at C7-T1 with anterior subluxation of C7 on T1. The inferior facets of C7 are locked anterior to the superior facets of T1 (yellow and green arrows), with anterior vertebral body translation present. There are associated fractures of C7 and T1 (red arrows). Figure 2. Non-contrast axial CT of the cervical spine: Bilateral facet dislocation at C7-T1 with naked facet sign (green arrow) and reverse hamburger bun sign (red arrow). Discussion The cervicothoracic junction (C7–T1) represents a biomechanical transition between the mobile cervical spine and the rigid thoracic spine, making it particularly vulnerable to traumatic instability. Bilateral facet dislocation at this level is a highly unstable injury most commonly associated with high-energy trauma but may also occur after low-energy falls in elderly patients due to osteopenia and degenerative stiffness. [1] The injury involves both facets "jumping" anteriorly, disrupting ligamentous stability and risking cord compression.[2] Delayed diagnosis can occur due to poor visualization of C7-T1 on plain films, emphasizing the need for CT in suspected cases.[3] As seen in this case, "teardrop" fragment on C7 or T1 represents a highly unstable flexion-compression or flexion-distraction injury; it is not a minor avulsion and signifies severe ligamentous damage.[5] Imaging Findings CT is the imaging modality of choice for evaluating suspected cervicothoracic junction trauma, as plain radiographs frequently fail to visualize C7–T1 due to shoulder overlap. Multiplanar CT reformations are essential for assessing alignment, facet integrity, and associated fractures. [1] Key CT findings include: High-grade anterior translation of C7 relative to T1 Bilateral jumped or locked facets with loss of normal facet articulation Widening of the interspinous distance indicating posterior ligamentous complex disruption Small anterior vertebral body fracture fragments at C7 and T1 consistent with flexion teardrop fractures Marked narrowing of the spinal canal at the C7–T1 level Axial CT images demonstrate bilateral reverse hamburger bun and naked facet signs, which are pathognomonic for facet dislocation. [2,3] Differential Diagnosis Traumatic bilateral facet dislocation must be distinguished from degenerative spondylolisthesis, which is common in geriatric patients but lacks joint capsule disruption and typically involves less than 4 mm of translation. Unilateral facet dislocation involves a rotational component and manifests as a "bow-tie" sign on lateral radiographs with less than 25% anterior translation. Isolated flexion teardrop fractures involve significant three-column injury but lack the mechanical "locking" of the facet joints seen in dislocations. Traumatic dislocation is favored when there is facet joint disruption, significant translation, and associated ligamentous injury. [1] Management and Prognosis Bilateral facet dislocation at C7–T1 represents a surgical emergency due to profound instability and high risk of neurologic deterioration. Initial management includes cervical immobilization and urgent neurosurgical consultation. Most cases require operative fixation, often via posterior or combined anterior-posterior approaches. Prognosis depends largely on neurologic status at presentation. [1] Key Learning Points C7–T1 injuries are frequently missed on plain radiographs Low-energy falls can cause severe cervical instability in elderly patients Reverse hamburger bun and naked facet signs are key CT indicators Anterior teardrop fractures signify severe ligamentous injury Early recognition and surgical management are critical Correlate with MRI for soft tissue/cord assessment. References Raniga SB, Menon V, Al Muzahmi KS, Butt S. MDCT of acute subaxial cervical spine trauma: a mechanism-based approach. Insights Imaging. 2014;5(3):321–338. doi:  10.1007/s13244-014-0311-y Daffner SD, Daffner RH. Computed tomography diagnosis of facet dislocations: the hamburger bun and reverse hamburger bun signs. J Emerg Med. 2002;23(4):387–394. DOI:  10.1016/s0736-4679(02)00577-2 Lingawi SS. The naked facet sign. Radiology. 2001;219(2):366–367. DOI:  10.1148/radiology.219.2.r01ma06366 Kim KS, Chen HH, Russell EJ, Rogers LF. Flexion teardrop fracture of the cervical spine: radiographic characteristics. AJR Am J Roentgenol. 1989;152(2):319–326. DOI:  10.2214/ajr.152.2.319 Kim KS, Chen HH, Russell EJ, Rogers LF. Flexion teardrop fracture of the cervical spine: radiographic characteristics. AJR Am J Roentgenol . 1989;152(2):319-326. DOI: 10.2214/ajr.152.2.319 Nishad Kosaraju is a second-year osteopathic medical student (OMS-II) at the Edward Via College of Osteopathic Medicine–Carolinas Campus ( VCOM-Carolinas ). He has a strong interest in diagnostic imaging and interventional radiology, with particular enthusiasm for case-based learning and understanding how imaging directly informs clinical decision-making. Nishad did his undergraduate education at UNC Chapel Hill , where he studied Exercise and Sports Science. Nishad enjoys contributing educational radiology cases that highlight classic imaging findings, uncommon presentations of common conditions, and high-yield diagnostic pearls for trainees. Outside of medicine, he enjoys golf, classical music, and technological advances in medicine. Kevin M. Rice, MD is the president of Global Radiology CME and is a radiologist with Cape Radiology Group . He has held several leadership positions including Board Member and Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state-of-the-art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator by AuntMinnie.com . He has continued to teach by mentoring medical students interested in radiology . Everyone he has mentored has been accepted into top programs across the country, including Harvard, UC San Diego, Northwestern, Vanderbilt, and Thomas Jefferson. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

34 year old male with chest pain and shortness of breath • Xray of the Week Figure 1. 34 year old male with chest pain and shortness of breath. Figure 2. A and B: Axial and coronal CT with cardiomegaly due to markedly dilated heart. Right pleural effusion (blue arrow). Low EF with contrast only in RA (red arrows) and RV (orange arrow). Reflux of contrast into the IVC (green arrow) and hepatic veins (white arrow) indicates tricuspid valve regurgitation. C: Echocardiogram apical 4 chamber view. Mitral regurgitation as evidenced by a regurgitant jet extending into the RA (yellow arrow). Discussion: Methamphetamine (MA) and related compounds are the most widely abused drugs in the world after cannabis. It is a psychostimulant that causes an increase in the synapse of monoamine neurotransmitters, including dopamine, norepinephrine, and serotonin [1]. Methamphetamines can be smoked, snorted, injected, or ingested orally. Methamphetamine is more potent, and its effects last longer than cocaine. Methamphetamine associated cardiomyopathy (MACM) is more common in younger age groups compared to patients with cardiomyopathy attributable to other causes. The development of MACM has been shown to be dose-dependent and amplified by repetitive use, binge pattern use, and concomitant use of other substances. Autopsy studies have shown MACM to be associated with extensive myocardial fibrosis, cellular vacuolization, and myocyte destruction [2, 3]. Cardiac complications of MA use include chest pain, hypertension, arrhythmia, aortic dissection, coronary vasospasm, cardiomyopathy, sudden cardiac death, and pulmonary arterial hypertension [2]. Figure 3. Axial (A) and coronal (B) contrast-enhanced CT images in the same patient demonstrate a dilated right ventricle containing a non-enhancing filling defect, consistent with a right ventricular thrombus. (red arrows). Imaging Findings Echocardiography typically shows severe multi-chamber dilatation, reduced ejection fraction (EF), mitral regurgitation (MR), tricuspid regurgitation (TR), and pericardial effusion [6-9]. Patients with MACM are also prone to developing intracardiac thrombi, with up to 33% for LV thrombus and 3.3% for RV thrombus [4, 5] (Fig. 3), with RV thrombi posing a significant risk for pulmonary embolism. Thrombus formation is driven by the triad of severe systolic stasis, drug-induced endocardial injury, and a prothrombotic state. [5]. In general, patients with MACM have significantly larger LA, LV, and RV size, lower LVEF, and a higher rate of mitral regurgitation (MR) compared to other causes of dilated cardiomyopathy [6]. Contrast-enhanced CT typically demonstrates severe biventricular dilatation and associated findings of pulmonary edema like pleural effusions or septal thickening. Contrast-enhanced CT may show a hallmark sign of severe tricuspid regurgitation: the reflux of intravenous contrast into the inferior vena cava and hepatic veins. Additionally, CT can help exclude other stimulant-related complications like aortic dissection or coronary artery calcification. Cardiac Magnetic Resonance (CMR) remains the gold standard for tissue characterization, identifying linear mid-wall septal fibrosis, but its use is often limited in the acute phase. On CMR, the presence of late gadolinium enhancement (LGE) is a key marker of irreversible myocardial damage and predicts poor functional recovery. In this case, there is severe tricuspid regurgitation (TR) with reflux of contrast into the inferior vena cava (IVC) and hepatic veins; pleural effusion is indicative of heart failure (Figs. 2 A, B). There is also MR visualized on the echocardiogram with a large regurgitant jet extending into the LA during systole (Fig. 2C). Differential Diagnosis MACM must be distinguished from idiopathic dilated cardiomyopathy, which typically occurs in older demographics and lacks the same potential for reversibility. Alcoholic cardiomyopathy presents similarly, but right heart involvement and intracardiac thrombus are often more pronounced in methamphetamine users. Viral myocarditis should also be considered, though it frequently presents with sub-epicardial LGE rather than the mid-wall or sub-endocardial patterns seen in MACM. Management and Prognosis The mainstay of management is complete drug abstinence, which can lead to dramatic structural and functional recovery. Treatment of MACM is aimed at the specific pathology such as anticoagulation for intracardiac thrombus and diuresis/venodilators for volume overload. Prognosis is largely dictated by the extent of myocardial fibrosis present at the time of diagnosis. Key Learning Points Suspect MACM in young patients with unexplained cardiomegaly and heart failure. CT findings include marked multi-chamber dilatation and contrast reflux into the hepatic veins. Intracardiac thrombi are highly prevalent (up to 33%) and can involve both ventricles. Cardiac MR is superior for tissue characterization and prognostication, but CT is vital in the emergency setting. Cardiac recovery is highly dependent on achieving sustained drug abstinence. ​​​​ References: Barr, A.M., et al., The need for speed: an update on methamphetamine addiction. J Psychiatry Neurosci, 2006. 31(5): p. 301-13. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1557685/ Reddy, P.K.V., et al., Clinical Characteristics and Management of Methamphetamine-Associated Cardiomyopathy: State-of-the-Art Review. J Am Heart Assoc, 2020. 9(11): p. e016704 DOI: 10.1161/jaha.120.016704. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7428977/ Karch, S.B., The unique histology of methamphetamine cardiomyopathy: a case report. Forensic Sci Int, 2011. 212(1-3): p. e1-4 DOI: 10.1016/j.forsciint.2011.04.028. Retrieved from https://pubmed.ncbi.nlm.nih.gov/21664081/ Janardhanan, R. and A. Kannan, Methamphetamine Cardiotoxicity: Unique Presentation with Multiple Bi-Ventricular Thrombi. The American Journal of Medicine, 2016. 129(1): p. e3-e4 DOI: 10.1016/j.amjmed.2015.08.006. Retrieved from https://www.amjmed.com/article/S0002-9343(15)00780-9/fulltext Schürer, S., et al., Clinical Characteristics, Histopathological Features, and Clinical Outcome of Methamphetamine-Associated Cardiomyopathy. JACC Heart Fail, 2017. 5(6): p. 435-445 DOI: 10.1016/j.jchf.2017.02.017. Retrieved from https://pubmed.ncbi.nlm.nih.gov/28571597/ Ito, H., et al., A comparison of echocardiographic findings in young adults with cardiomyopathy: with and without a history of methamphetamine abuse. Clin Cardiol, 2009. 32(6): p. E18-22 DOI: 10.1002/clc.20367. Retrieved from https://pubmed.ncbi.nlm.nih.gov/19330818/ Neeki, M.M., et al., Frequency of Methamphetamine Use as a Major Contributor Toward the Severity of Cardiomyopathy in Adults ≤50 Years. The American Journal of Cardiology, 2016. 118(4): p. 585-589 DOI: https://doi.org/10.1016/j.amjcard.2016.05.057. Retrieved from http://www.sciencedirect.com/science/article/pii/S0002914916309602 Wijetunga, M., et al., Crystal methamphetamine-associated cardiomyopathy: tip of the iceberg? J Toxicol Clin Toxicol, 2003. 41(7): p. 981-6 DOI: 10.1081/clt-120026521. Retrieved from https://pubmed.ncbi.nlm.nih.gov/14705845/ Yeo, K.K., et al., The association of methamphetamine use and cardiomyopathy in young patients. Am J Med, 2007. 120(2): p. 165-71 DOI: 10.1016/j.amjmed.2006.01.024. Retrieved from https://pubmed.ncbi.nlm.nih.gov/17275458/ Voskoboinik A, Ihle JF, Bloom JE, et al. Methamphetamine-associated cardiomyopathy: patterns and predictors of recovery. Intern Med J . 2016;46(6):723-727. doi:10.1111/imj.13050 https://doi.org/10.1111/imj.13050  PubMed: https://pubmed.ncbi.nlm.nih.gov/26929061/   Koo BH, et al. Recreational Drug-induced Cardiopulmonary Injury. RadioGraphics . 2025;45(10). doi:10.1148/rg.250013 https://doi.org/10.1148/rg.250013 Zuern CS, Sticherling C, Krisai P, et al. Methamphetamine-associated cardiomyopathy. Eur Heart J Cardiovasc Imaging . 2024;25(4):e147. doi:10.1093/ehjci/jead320 https://doi.org/10.1093/ehjci/jead320  PubMed: https://pubmed.ncbi.nlm.nih.gov/37983477/   Hagan IG, Burney K. Radiology of recreational drug abuse. RadioGraphics . 2007;27(4):919-940. doi:10.1148/rg.274065103 https://doi.org/10.1148/rg.274065103  PubMed: https://pubmed.ncbi.nlm.nih.gov/17620470/   Pujol-López M, Ortega-Paz L, Flores-Umanzor EJ, et al. Cardiac Magnetic Resonance as an Alternative to Endomyocardial Biopsy to Predict Recoverability of Left Ventricular Function in Methamphetamine-Associated Cardiomyopathy. JACC Heart Fail . 2017;5(11):853-854. doi:10.1016/j.jchf.2017.08.009 https://doi.org/10.1016/j.jchf.2017.08.009  PubMed: https://pubmed.ncbi.nlm.nih.gov/29096799/   Update 2026: Dr. Jaswal is a Nuclear Medicine Resident at New York Presbyterian/ Weill Cornell Medicine. Shama Jaswal is an International Medical Graduate, currently doing research at Mallinckrodt Institute of Radiology (MIR), Saint Louis. She aims at pursuing Diagnostic Radiology residency and poses a keen interest in research alongside academics. At MIR, she has been fortunate to work on various oncology projects including the project in which they studied how the difference in fat metabolism in both sexes can affect the cancer survival and outcome, and how this study can further improve prognosis through treatment modification. Shama is both an accomplished sprinter and singer having won several national competitions in in each discipline in India. She also has a strong passion for cooking and gardening. Follow Shama Jaswal on Twitter @Jaswal_Shama All posts by Shama Jaswal Kevin M. Rice, MD  is the president of Global Radiology CME and is a radiologist with Cape Radiology Group . He has held several leadership positions including Board Member and Chief of Staff at Valley Presbyterian Hospital  in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state-of-the-art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide  innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator.  He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator  by AuntMinnie.com . He has continued to teach by mentoring medical students interested in radiology . Everyone he has mentored has been accepted into top programs across the country, including Harvard, UC San Diego, Northwestern, Vanderbilt, and Thomas Jefferson. Follow Dr. Rice on Twitter @KevinRiceMD   All posts by Kevin M. Rice, MD

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

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

Right upper quadrant pain in unstable patient. What procedure is indicated? • Xray of the Week Figure 1. What action should be taken for this patient with right upper quadrant pain who is also hemodynamically unstable? Figure 2. A. MRI of abdomen. The patient is pregnant (orange arrows), therefore ionizing radiation with CT scan or fluoroscopy can not be used for imaging guidance. Gallbladder with wall thickening (green arrow) and adjacent fluid (yellow arrow) indicate acute cholecystitis. A nuclear medicine hepatobiliary scan was also performed (not shown) and demonstrated no radiopharmaceutical present in the gallbladder due to cystic duct obstruction. B. Ultrasound of gallbladder used for guidance of percutaneous needle (red arrow) placement for cholecystostomy. C. Ultrasound of gallbladder demonstrating drainage catheter in the lumen (blue arrow). Discussion: Cholecystitis is the second most common surgical emergency seen in pregnancy after appendicitis. [1] Surgical intervention is typically safe for both the mother and fetus , due to improved morbidity when utilizing the laparoscopic approach rather than open cholecystectomy. [2]. In cases of high risk pregnancy or when treating an unstable peripartum patient, percutaneous cholecystostomy is an important important image-guided, minimally invasive alternative to surgical cholecystectomy [ 3-6 ]. This technique has proven effective for cases of acute cholecystitis occurring during the third trimester, allowing for management until delivery when surgery becomes safer. [7] . Percutaneous cholecystostomy is usually followed by laparoscopic cholecystectomy in the postpartum period once the patient has been stabilized [ 3,7 ]. In pregnancy, ultrasound is used for imaging guidance due to lack of ionizing radiation encountered with CT scan or fluoroscopy [5]. The transhepatic or transperitoneal insertion of an access needle is followed by gallbladder catheterization with either the Seldinger technique or a trocar system [8-11]. Figures 1 and 2 are imaging studies on a pregnant patient with acute cholecystitis and was too unstable to undergo surgery. The patient underwent a percutaneous cholecystostomy using the Seldinger technique and US guidance. After the patient delivered and was stable, the patient had a laparoscopic cholecystectomy and fully recovered. Major complications of percutaneous cholecystostomy include hemorrhage, pneumothorax, biliary leak, and peritonitis. The transhepatic approach may carry higher risk of pleural or hepatic injury, while transperitoneal avoids liver traversal but risks bowel injury. [8,9,11]. Prognosis is excellent with timely intervention, allowing safe maternal stabilization and fetal protection until definitive treatment. Key Learning Points Ultrasound-guided percutaneous cholecystostomy is a safe bridge in high-risk pregnant patients with acute cholecystitis, especially in the third trimester. Look for gallbladder distention and real-time needle/catheter placement on ultrasound to confirm access and decompression. Radiology plays a key role in avoiding radiation and guiding minimally invasive drainage—prefer transhepatic or transperitoneal based on anatomy. Prompt intervention stabilizes the patient; interval cholecystectomy is standard postpartum for definitive management. ​​​​ References: Angelini DJ. Obstetric triage revisited: update on non-obstetric surgical conditions in pregnancy. J Midwifery Womens Health . 2003;48(2):111-118. doi: 10.1016/s1526-9523(02)00417-8 . Knab LM, Boller AM, Mahvi DM. Cholecystitis. Surg Clin North Am . 2014;94(2):455-470. doi: 10.1016/j.suc.2014.01.005 Hojberg Y, Patel K, Shebrain S. Utilizing Percutaneous Cholecystostomy Tube as a Temporary Minimally Invasive Approach for Acute Cholecystitis during Third Trimester of a High-Risk Pregnancy. Case Rep Gastroenterol . 2022;16(1):49-54. Published 2022 Feb 14. doi: 10.1159/000522060 Baron   TH , Grimm   IS , Swanstrom   LL . Interventional approaches to gallbladder disease . N Engl J Med . 2015 ; 373 ( 4 ): 357 – 65 . doi: 10.1056/NEJMra1411372 Moirano J, Khoury J, Yeisley C, Noor A, Voutsinas N. Interventional Radiology and Pregnancy: From Conception through Delivery and Beyond. Radiographics . 2023;43(8):e230029. doi: 10.1148/rg.230029 Rana P, Gupta P, Chaluvashetty SB, et al. Interventional radiological management of hepatobiliary disorders in pregnancy. Clin Exp Hepatol . 2020;6(3):176-184. doi: 10.5114/ceh.2020.99508 Caliskan K. The use of percutaneous cholecystostomy in the treatment of acute cholecystitis during pregnancy. Clin Exp Obstet Gynecol . 2017;44(1):11-13. https://pubmed.ncbi.nlm.nih.gov/29714857/ Ginat D and Saad W. Cholecystostomy and Transcholecystic Biliary Access. Tech Vasc Interv Radiol. 2008;11(1):2-13. doi: 10.1053/j.tvir.2008.05.002 Little MW. Percutaneous cholecystostomy: The radiologist’s role in treating acute cholecystitis. Clin Radiol. 2013;68(7): 654-660. doi: 10.1016/j.crad.2013.01.017 Venara A, Carretier V, Lebigot J, E Lermite. Technique and indications of percutaneous cholecystostomy in the management of acute cholecystitis in 2014. J Visc Surg. 2014;151(6):435-439. doi: 10.1016/j.jviscsurg.2014.06.003 Beland MD, Patel L, Ahn SH, Grand DJ. Image-Guided Cholecystostomy Tube Placement: Short- and Long-Term Outcomes of Transhepatic Versus Transperitoneal Placement. AJR Am J Roentgenol. 2019;212: 201-204. doi: 10.2214/AJR.18.19669 Kevin M. Rice, MD  is the president of Global Radiology CME and is a radiologist with Cape Radiology Group . He has held several leadership positions including Board Member and Chief of Staff at Valley Presbyterian Hospital  in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide  innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator.  He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator  by AuntMinnie.com . He has continued to teach by mentoring medical students interested in radiology . Everyone who he has mentored has been accepted into top programs across the country including Harvard, UC San Diego, Northwestern, Vanderbilt, and Thomas Jefferson. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD