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Prior Duodenal Surgery and Jaundice • Xray of the Week 2016 • Week #32 This 54 year old female had prior duodenal surgery and presented with jaundice. What is the diagnosis and treatment? Fig. 1 CT scan. Mass in the porta hepatis region, surgical staples in the duodenum, and biliary dilatation. Bottom right: Severe biliary dilatation also seen on the Percutaneous Transhepatic Cholangiogram (PTC). Note that no contrast enters the duodenum, despite distention with contrast, indicating high grade obstruction. Fig 2. Left: MRI Coronal FSE T2WI demonstrates a mass in the porta hepatis region and biliary dilatation. Right: Severe biliary dilatation seen on the 3D MRCP image. Video showing how I placed a stent in the common bile duct (CBD) and relieved the biliary obstruction. Duodenal Carcinoma is a rare gastrointestinal malignancy, comprising 0.3% of all GI tract cancers. (1,2) Almost always adenocarcinoma, the neoplasm is the most common malignant tumor of the duodenum. Symptoms are nonspecific and include weight loss, abdominal pain, and later in the process jaundice and vomiting due to gastric outlet obstruction. (1,2) As in this case CT shows a mass or asymmetric thickening of the duodenum, with invasion of fat planes, pancreatic and biliary duct dilatation, and vascular encasement. (1) The overall 5 year survival in one study of 89 patients was 25% (4) with improved outcome following radical surgery. If diagnosed late as in this case, there is a very poor prognosis. (4) References: 1. Jayaraman MV, Mayo-Smith WW, Movson JS et-al. CT of the duodenum: an overlooked segment gets its due. Radiographics. 2001;21 Spec No (suppl 1) 2. Markogiannakis H, Theodorou D, Toutouzas KG et-al. Adenocarcinoma of the third and fourth portion of the duodenum: a case report and review of the literature. Cases J. 2008;1 (1): 98. 3. Imaging Features of Benign and Malignant Ampullary and Periampullary Lesions. RadioGraphics 2014; 34:624–641 4. Santoro E, Sacchi M, Scutari F, Carboni F, Graziano F: Primary adenocarcinoma of the duodenum: treatment and survival in 89 patients. Hepatogastroenterology. 1997, 44 (16): 1157-1163. Kevin Rice, MD serves as the Medical Director of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a Member of Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice launched Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. Follow Dr. Rice on Twitter @KevinRiceMD All Posts by Kevin M. Rice, MD

Frequent palpitations and SOB • Xray of the Week This patient complained of frequent palpitations and shortness of breath. Chest x-ray was performed, and subsequent device examination revealed inability to reliably depolarize the right atrium. Fig. 1 RA lead (red arrow) of dual chamber pacemaker shows a slight curve on the initial post- placement image, and a straight vertical course on the 30 day image. The right ventricular (RV) lead is normally positioned at the RV apex (blue arrow). Images courtesy of my friend and colleague Marcelo Spector, MD. In this case, the lead is floating freely in atrium, resulting in the inability to reliably depolarize the right atrium. This is probably due to placement with not enough "slack" in the lead to allow for motion during inspiration and standing erect. Fig. 2 Dual lead pacemaker. RA lead (red arrow) of dual chamber pacemaker shows a normal "J" curve with the tip in the right atrial appendage. The right ventricular (RV) lead (blue arrow) is normally positioned at the RV apex. Fig 3A. ICD–biventricular pacemaker combination. Frontal view. The shock coils of the ICD lead appear as thickened metallic sections visualized in the superior vena cava (SVC) and RV (blue arrows). The RA lead (red arrow) demonstrates a J-shaped appearance and curves superiorly and anteriorly with the tip in the right atrial appendage. The left ventricular (LV) lead is placed through the coronary sinus into a cardiac vein, usually along the lateral or posterior free wall of the LV (yellow arrow). The LV lead courses inferiorly and laterally on the frontal radiograph and posteriorly on the lateral view. Fig 3B. ICD–biventricular pacemaker combination. Lateral view. The shock coils of the ICD lead appear as thickened metallic sections visualized in the superior vena cava (SVC) and RV (blue arrows). The RA lead (red arrow) demonstrates a J-shaped appearance and curves superiorly and anteriorly with the tip in the right atrial appendage. The left ventricular (LV) lead is placed through the coronary sinus into a cardiac vein, usually along the lateral or posterior free wall of the LV (yellow arrow). The LV lead courses inferiorly and laterally on the frontal radiograph and posteriorly on the lateral view. Fig 4. ICD–biventricular pacemaker combination. Frontal view on another patient. The shock coils of the ICD lead appear as thickened metallic sections visualized in the superior vena cava (SVC) and RV (blue arrows). The RA lead (red arrow) demonstrates a J-shaped appearance and curves superiorly and laterally with the tip in the right atrial appendage. The left ventricular (LV) lead is placed through the coronary sinus into a cardiac vein, along the lateral or posterior free wall of the LV (yellow arrow). The LV lead courses inferiorly and laterally on this frontal radiograph References: 1. Aguilera, AL MD, et al. Radiography of Cardiac Conduction Devices: A Comprehensive Review. RadioGraphics 2011; 31:1669–1682 2. Sigakis CJG, Mathai SK, et. al. Radiographic Review of Current Therapeutic and Monitoring Devices in the Chest. RadioGraphics 2018; 38:1027–1045 3. Brixey AG, Fuss C. Innovative Cardiac Devices on Chest Imaging An Update. J Thorac Imaging 2017;32:343–357 4. Costelloe, CM, MD, et al. Radiography of Pacemakers and Implantable Cardioverter Defibrillators. AJR 2012; 199:1252–1258 Related posts: Bicuspid Aortic Valve and Aortic Stenosis Implanted Cardiac Loop Recorder Cardiac Tamponade Following Coronary Artery Rotational Atherectomy Papillary Fibroelastoma of Aortic Valve Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice serves as the Medical Director of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice launched Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

Thoracic Foreign Body • Xray of the Week This patient had a chest Xray for shortness of breath. Is the foreign body a new type of USB drive left in his shirt pocket? Fig. 1 A. CXR. Foreign body overlying the left side of chest. Fig 1 B. Magnification view showing the detail of the foreign body. Fig. 2 Radiograph of the Medtronic Reveal LINQ implantable cardiac loop recorder. Note the morphology of the device is the same as the device implanted in this patient. Image courtesy of Medtronics. Fig. 3. Medtronic Reveal XT implantable cardiac loop recorder compared to the Medtronic Reveal LINQ implantable cardiac loop recorder. Note the Linq is about one tenth the size of the XT. Images courtesy of John Mandrola, MD and Medtronics. Fig 4. Radiograph (A) and picture (B) of 2 types of USB flash drives. Note the two holes in the A plug on the standard USB flash drive. There are no holes in the compact version. Fig 5. Chest radiograph of patient with Medtronic Reveal XT implantable cardiac loop recorder. The implantable cardiac loop recorder is used in patients with recurrent unexplained episodes of palpitations or syncope, for long-term monitoring in patients at risk for or with documented atrial fibrillation, and for risk stratification in patients who have had a myocardial infarction. (1,2,3) The device is implanted subcutaneously in the left parasternal region and stores EKG data automatically in response to a significant arrhythmia. (1,2,3) It is useful either when symptoms are infrequent or when long-term data are required. The internal loop recorder devices are MRI conditional. (1,4,5,6) The electrical data stored in the loop recorder may be erased or corrupted by the strong magnetic field. Therefore, it is essential for the patient's electrophysiologist to download the data prior to any MRI exam. Since all loop recorders contain ferromagnetic components, there may be motion of the device during a scan. Following MRI, artifacts mimicking arrhythmias are frequently seen internal loop recorder data sets (6). References: 1. Medtronic REVEAL LINQ™ LNQ11 Insertable Cardiac Monitor. MRI procedural information Manual. 2. Vikas Shah MD: xrayoftheweek 43: that's not a USB stick...is it? The XRay Doctor Blog 3. Medtronic Website. http://manuals.medtronic.com/manuals/main/en_US/manual/index?findby=brandmodel&model=LNQ11 4. Wong JA, Gula LJ, Skanes AC, et al. Feasibility of Magnetic Resonance Imaging in Patients with an Implantable Loop Recorder. Pacing Clin Electrophyisol 2008; 31(3): 333-337. 5. Hilbert S, Jahnke C, Loebe S, et al. Cardiovascular magnetic resonance imaging in patients with cardiac implantable electronic devices: a device-dependent imaging strategy for improved image quality. Eur Heart J Cardiovasc Imaging. 2018 Sep 1;19(9):1051-1061. doi: 10.1093/ehjci/jex243. 6. Medtronic Reveal Loop Recorder information at MRIsafety.com Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice serves as the Medical Director of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a Member of Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

Incidental Finding on CT Chest • Xray of the Week 2016 • Week #34 What is the clinical significance of this finding? Fig. 1 CT scan demonstrating marked calcification of the aortic valve. The patient later had an aortic valve replacement. Fig. 2 Image from intra-operative trans-esophageal cardiac echo on this patient demonstrating aortic valve stenosis with marked calcification. Bicuspid aortic valve is an uncommon congenital condition, usually due to fusion of 2 of the 3 leaflets of the aortic valve. High pressure across the valve results in calcification. One of the most common causes of aortic stenosis, bicuspid aortic valve may be present in up 2% of the population. [1,2] Visualization of dense calcification of the aortic valve on imaging studies should prompt the reader to think of bicuspid aortic valve and aortic stenosis. [3] Definitive treatment is aortic valve replacement. Due to dilation of the proximal aorta related to high pressures, aortic root replacement is required in 30% of patients undergoing valve replacement. [4] References: 1. Ko SM, Song MG, Hwang HK. Bicuspid aortic valve: spectrum of imaging findings at cardiac MDCT and cardiovascular MRI. AJR Am J Roentgenol. 2012;198 (1): 89-97. 2. Spindola-franco H, Fish BG, Dachman A et-al. Recognition of bicuspid aortic valve by plain film calcification. AJR Am J Roentgenol. 1982;139 (5): 867-72. 3. Chen JJ, Manning MA, Frazier AA et-al. CT angiography of the cardiac valves: normal, diseased, and postoperative appearances. Radiographics. 29 (5): 1393-412. 4. Siu SC, Silversides CK. Bicuspid aortic valve disease. J. Am. Coll. Cardiol. 2010;55 (25): 2789-800. Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice serves as the Medical Director of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a Member of Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice launched Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

RLQ Pain in 56M with Ruptured Appendix 15 Years Ago • Xray of the Week 2016 • Week #35 This 56 year old male complained of chronic right lower quadrant pain and tenderness. He had a ruptured appendix 15 years ago, followed by appendectomy. CT guided biopsy was performed. What is the diagnosis? Fig. 1 CT: Fatty mass in the right abdominal mesentery with a thin high attenuation capsule. Pathologic analysis of the biopsy specimen demonstrated fat necrosis, and the patient was treated conservatively. Fig. 2 CT: Fatty mass in the right abdominal mesentery with a thin high attenuation capsule (blue arrow). My biopsy needle (red arrow). Encapsulated fat necrosis is due to necrotic fatty tissue organizing within a thin or thick fibrous capsule (1,2). It may cause pain and tenderness as it can be associated with inflammation and calcification (3). Since the imaging appearance may be similar with fatty tissue surrounded by a weakly enhancing capsule, and mild mass effect on adjacent structures (Fig. 2 blue arrows), the main concern in the differential diagnosis is liposarcoma (4-6). However, unlike liposarcoma, fat necrosis does not invade adjacent structures. As in this case, the history of prior surgery in the vicinity gives a clue to the correct diagnosis, as patients with encapsulated fat necrosis usually have a history of surgery (1,2). In addition, encapsulated fat necrosis remains stable or becomes smaller over time, whereas liposarcomas usually enlarge. The condition is considered a type of intraperitoneal focal fat infarction (7) along with omental infarction and epiploic appendagitis. As I did in this case, biopsy (Fig. 2 red arrow) can be performed to be certain of the diagnosis. References: 1. Kamaya A, Federle MP, Desser TS. Imaging manifestations of abdominal fat necrosis and its mimics. Radiographics 2011. 31 (7): 2021-34. 2. Chan LP, Gee R, Keogh C, Munk PL. Imaging features of fat necrosis. AJR Am J Roentgenol 2003; 181(4):955–959. 3. Kiryu H, Rikihisa W, Furue M. Encapsulated fat necrosis: a clinicopathological study of 8 cases and a literature review. J Cutan Pathol 2000;27(1):19–23. 4. Takao H, Yamahira K, Watanabe T. Encapsulated fat necrosis mimicking abdominal liposarcoma: computed tomography findings. J Comput Assist Tomogr 2004;28(2):193–194. 5. Chen H, Tsang Y, Wu C, Su C, Hsu JC. Perirenal fat necrosis secondary to hemorrhagic pancreatitis, mimicking retroperitoneal liposarcoma: CT manifestation. Abdom Imaging 1996;21(6):546–548. 6. Andaç N, Baltacioglu F, Cimşit NC, Tüney D, Aktan O. Fat necrosis mimicking liposarcoma in a patient with pelvic lipomatosis: CT findings. Clin Imaging 2003;27(2):109–111. 7. Coulier B. Contribution of US and CT for diagnosis of intraperitoneal focal fat infarction (IFFI): a pictorial review. JBR-BTR. 2010;93 (4): 171-85. Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice serves as the Chair of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances and given 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 launched 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

"Found Down" • Xray of the Week 2016 • Week #37 This 53 year old male known abuser of oxycodone was found down. Urine was positive for opiates and benzodiazepines. Arterial blood gas results: pH 6.89 (N = 7.38 - 7.42), pCO2 126 mmHg (N = 38 - 42), pO2 19 mmHg (N = 75 - 100), O2 sat 24% (N = 94 - 100) What are the arrows pointing to? Why this appearance? Figure 1: CT Scan of the brain. A & B. high attenuation in the basal cisterns and subarachnoid spaces. C. Diffuse edema with loss of grey and white matter differentiation. The history compatible with anoxic brain injury and the diffuse cerebral edema on the CT scan should indicate that the findings are not due to subarachnoid hemorrhage (SAH). The increased attenuation in the basal cisterns and subarachnoid spaces is due to diffuse cerebral edema related to anoxic encephalopathy. The high attenuation appearance may be due to a combination of diffuse decreased attenuation of the brain as a result of edema, and the subarachnoid space with less low attenuation CSF and a larger proportion of meninges and blood vessels than usual. Differential diagnosis of pseudo-subarachnoid hemorrhage on CT: •Meningitis •Leptomeningeal carcinomatosis •Artifacts on CT: anoxic encephalopathy, Spontaneous intracranial hypotension •Iatrogenic causes: recently administered intrathecal or IV contrast material; and following endovascular procedures such as aneurysm coiling and stroke intervention. Highly proteinaceous material in the subarachnoid space causes increased attenuation which may be due to purulent fluid seen with meningitis or leptomeningeal carcinomatosis, mimicking SAH. Anoxic encephalopathy and spontaneous intracranial hypotension both cause a perceptual error due to relatively higher attenuation of the basal cisterns related to the low attenuation seen with these conditions. Iodinated contrast in the subarachnoid space either due to IV or intrathecal administration causes high attenuation in the subarachnoid space which should be easily differentiated from SAH if the history is known. Likewise, endovascular procedures may result in leakage of iodinated contrast which could be confused with SAH, especially given that the procedures are often done for patients with SAH or aneurysms. Follow up CT scan within 3-4 hours after the procedure will show clearing of the contrast, whereas SAH will persist. References: 1. Carrie P. Marder, et al. Subarachnoid Hemorrhage: Beyond Aneurysms. American Journal of Roentgenology. 2014;202: 25-37. 10.2214/AJR.12.9749 2. Mendelsohn DB, Moss ML, Chason DP, Muphree S, Casey S. Acute purulent leptomeningitis mimicking subarachnoid hemorrhage on CT. J Comput Assist Tomogr 1994; 18:126–128 3. Tsuchiya K, Katase S, Yoshino A, Hachiya J. FLAIR MR imaging for diagnosing intracranial meningeal carcinomatosis. AJR 2001; 176:1585–1588 4. al-Yamany M, Deck J, Bernstein M. Pseudo-subarachnoid hemorrhage: a rare neuroimaging pitfall. Can J Neurol Sci 1999; 26:57–59 5. Given CA, Burdette JH, Elster AD et-al. Pseudo-subarachnoid hemorrhage: a potential imaging pitfall associated with diffuse cerebral edema. AJNR Am J Neuroradiol. 2003;24 (2): 254-6. AJNR Am J Neuroradiol (full text) 6. Yuzawa H, Higano S, Mugikura S et-al. Pseudo-subarachnoid hemorrhage found in patients with postresuscitation encephalopathy: characteristics of CT findings and clinical importance. AJNR Am J Neuroradiol. 2008;29 (8): 1544-9. 7. Zhang J1, Li Q1, Zhang Z2, Sun X1. Pseudo-subarachnoid hemorrhage in a patient with hypoxic encephalopathy. Neurochirurgie. 2015 Feb;61(1):35-7. Kevin Rice, MD serves as the Medical Director of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice launched Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. Follow Dr. Rice on Twitter @KevinRiceMD All Posts by Kevin M Rice, MD

Headache and Frontal Mass • Xray of the Week 2016 • Week #36 16 year old male with headache and right frontal palpable mass. What is the diagnosis? What is the eponymous name for the condition at the site of the blue arrow? Figure 1. A: CT axial image. Large osseous defect of posterior wall of the right frontal sinus and a small region of lysis in the anterior right frontal sinus. Figure 1. B: MRI- T1 weighted axial with contrast. Mild right frontal dural enhancement adjacent to the peripherally enhancing abscess in the right frontal sinus/epidural space. Enhancement of the edematous frontal scalp indicates Pott puffy tumor. Figure 1. C: MRI- T2 weighted axial. Abscess in the right frontal sinus/epidural space. Figure 1. D: MRI- T1 sagittal with contrast. Mild right frontal dural enhancement adjacent to the peripherally enhancing abscess in the right frontal sinus/epidural space. Figure 1. E: MRI- Diffusion weighted axial image. Restricted diffusion centered in the right frontal sinus. Figure 1. F: MRI- ADC map axial image. Confirms restricted diffusion centered in the right frontal sinus due to abscess. In 1760, English surgeon Sir Percival Pott, described the condition of frontal sinusitis with subperiosteal abscess and osteomyelitis. Inflammatory extension into the scalp soft tissues results in the non-neoplastic "tumor" in the frontal region. Most commonly seen in adolescents, this is now a rare complication of sinusitis due to early treatment with antibiotics. Of note, Sir Pott also first described arthritic tuberculosis of the spine, now known as Pott disease. As seen in this case, CT scan and MRI demonstrate fluid in the frontal sinus with edema of the adjacent scalp, and a lytic portion of the anterior wall of the sinus. (Fig. 1A) In this case, there is also dural enhancement (Fig. 1D) and an epidural abscess. (Fig. 1B-F) Contrast enhanced CT or MRI may demonstrate other intracranial complications such as, subdural empyema, dural sinus thrombosis, and cerebral abscess. Dural enhancement is seen better on MRI than CT and is indicative of meningitis. A scalp abscess with rim enhancement may also be visualized. The clinical appearance is a frontal palpable erythematous painful mass (Fig. 2). Surgical treatment is required with drainage of the abscess and 6 weeks of IV antibiotics. Figure 2: Tweet from @CMAJ showing the clinical appearance of Pott Puffy Tumor. References: 1. Masterson L, Leong P. Pott's puffy tumour: a forgotten complication of frontal sinus disease. Oral Maxillofac Surg. 2009 Jun;13(2):115-7. 2. Karaman E, Hacizade Y, Isildak H et-al. Pott's puffy tumor. J Craniofac Surg. 2008;19 (6): 1694-7. 3. Durur-subasi I, Kantarci M, Karakaya A et-al. Pott's puffy tumor: multidetector computed tomography findings. J Craniofac Surg. 2008;19 (6): 1697-9. 4. Morón FE, Morriss MC, Jones JJ et-al. Lumps and bumps on the head in children: use of CT and MR imaging in solving the clinical diagnostic dilemma. Radiographics. 24 (6): 1655-74. Kevin M. Rice, MD serves as the Medical Director of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice launched Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. Follow Dr. Rice on Twitter @KevinRiceMD All Posts by Kevin M Rice, MD

Screening OB Ultrasound • Xray of the Week 2016 • Week #39 This 28 year old had a routine OB ultrasound. What is the abnormality? What is the significance of this finding? Fig 1A: Prenatal ultrasound. Coronal head. Absence of the calvarium and brain with associated bulging orbits giving the "frog eye" appearance. Fig 1B: Prenatal ultrasound. Sagittal head and neck. Absence of the calvarium and brain. Anencephaly is the most severe neural tube defect (NTD) with complete absence of most of the cranium, meninges, and calvarium due to failure of closure of the rostral neural tube. All women of child-bearing age should consume 0.4 mg of folic acid daily, especially those attempting to conceive or who may possibly conceive, as this can reduce the risk of anencephaly from 0.1 % to 0.03%. Genetics may play a role in the cause of anencephaly as women with a prior pregnancy with NTD have a 3% risk of having another child with a NTD. Other possible factors include insulin-dependent diabetes, exposure to anticonvulsants, and toxins such as lead, chromium, mercury, and nickel. Antenatal screening for NTD’s with ultrasound and maternal serum alpha-fetoprotein is essentially 100% effective. With ultrasound, no brain parenchymal tissue is seen above the orbits and the calvarium is largely absent. As in this case, coronal ultrasound of the head demonstrates absence of the calvarium and brain with associated bulging orbits giving the "frog eye" appearance. [Fig.1A] Associated findings on ultrasound may include: other neural tube defects such as spina bifida, congenital heart defects, cleft lip/palate, diaphragmatic hernia, spinal dysraphism, clubfoot, omphalocele, and urinary tract anomalies such as hydronephrosis. Prognosis is dismal with 100% fatality, most within the first few hours after delivery. References: 1. Cameron M, Moran P. Prenatal screening and diagnosis of neural tube defects. Prenat Diagn. 2009 Apr;29(4):402-11 2. Goldstein RB, Filly RA. Prenatal diagnosis of anencephaly: spectrum of sonographic appearances and distinction from the amniotic band syndrome. AJR Am J Roentgenol. 1988;151 (3): 547-50. 3. Morbidity and Mortality Weekly Report (MMWR). Effectiveness in Disease and Injury Prevention Use of Folic Acid for Prevention of Spina Bifida and Other Neural Tube Defects -- 1983-1991 http://www.cdc.gov/mmwr/preview/mmwrhtml/00014915.htm 4. Timor-tritsch IE, Greenebaum E, Monteagudo A et-al. Exencephaly-anencephaly sequence: proof by ultrasound imaging and amniotic fluid cytology. J Matern Fetal Med. 5 (4): 182-5. Kevin Rice, MD serves as the Medical Director of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a Member of Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice launched Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. Follow Dr. Rice on Twitter @KevinRiceMD All Posts by Kevin M Rice, MD

Screening OB Ultrasound • Xray of the Week 2016 • Week #40 This 26 year old had a routine OB ultrasound. What is the abnormality? What is the treatment? Figure 1: Gastroschisis on prenatal ultrasound. Note the herniated small bowel to the right of the cord insertion. The bowel is freely floating in the amniotic fluid. Gastroschisis is a sporadic congenital anomaly characterized by herniation of fetal abdominal contents, usually small bowel, and occasionally stomach, colon and/or liver into the amniotic cavity through a para-umbilical abdominal wall defect. The incidence is approximately 1 per 10,000 live births. With the defect almost always on the right side and typically 2-4 cm long, unlike omphalocele, there is no covering membrane. Associated anomalies (usually malrotation) are seen only in 10% of cases; however, omphalocele has associated anomalies in 27-91% of cases. Figure 2: Omphalocele. The cord inserts at the apex of the abdominal wall defect and the abdominal contents are covered by a membrane. Case courtesy of Dr Ahmed Mahrous Saied, Radiopaedia.org. From the case https://radiopaedia.org/cases/34001 On prenatal ultrasound, the fetal abdominal circumference is small for gestational age due to the herniated abdominal contents. The small bowel is seen to be free floating in the amnionic fluid to the right of the umbilical cord insertion [Figure 1]. With omphalocele, the cord inserts at the apex of the abdominal wall defect and the herniated abdominal contents are covered by a membrane [Figure 2]. Most infants with gastroschisis are treated surgically on the first day of life, however, 90% of cases require multiple operations. The prognosis is good with a survival rate of greater than 90%. References: 1. Morrow RJ, Whittle MJ, McNay MB, Raine PA, Gibson AA, Crossley J (1993). "Prenatal diagnosis and management of anterior abdominal wall defects in the west of Scotland". Prenat Diagn. 13(2): 111–5. 2. Shaw, Anthony (1975). "The myth of gastroschisis". Journal of Pediatric Surgery. 10 (2): 235–44. 3. Devries, Pieter A. (1980). "The pathogenesis of gastroschisis and omphalocele". Journal of Pediatric Surgery. 15 (3): 245–51. 4. Santiago-Munoz PC, McIntire DD, Barber RG, Megison SM, Twickler DM, Dashe JS (2007)."Outcomes of pregnancies with fetal gastroschisis". Obstet Gynecol. 110 (3): 663–8. 5. Baerg J, Kaban G, Tonita J, Pahwa P, Reid D (2003). "Gastroschisis: A sixteen-year review". J Pediatr Surg. 38 (5): 771–4. 6. http://www.cdc.gov/ncbddd/birthdefects/gastroschisis.html 7. Blazer S, Zimmer EZ, Gover A et-al. Fetal omphalocele detected early in pregnancy: associated anomalies and outcomes. Radiology. 2004;232 (1): 191-5. 8. Durfee SM, Downard CD, Benson CB et-al. Postnatal outcome of fetuses with the prenatal diagnosis of gastroschisis. J Ultrasound Med. 2002;21 (3): 269-74. 9. Giulian, BB. Prenatal Ultrasonographic Diagnosis of Fetal Gastroschisis. Radiology 129:473-475, November 1978 10. Daltro P, Fricke BL, Kline-fath BM et-al. Prenatal MRI of congenital abdominal and chest wall defects. AJR Am J Roentgenol. 2005;184 (3): 1010-6. Kevin Rice, MD serves as the Medical Director of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a Member of Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice launched Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. Follow Dr. Rice on Twitter @KevinRiceMD All Posts by Kevin M Rice, MD

Vote for the Correct Spine Labeling • Xray of the Week 2016 • Week #46 RADIOLOGISTS - It's not too late to vote! This could have serious consequences for several years. If you do not like either of the major candidates, please pick C. To vote, reply with A or B, or C in the comments. Sorry, but there are no secret ballots. The votes will be tallied, and the winner announced on Friday. Fig. 1. A & B: Two ways of labeling the same image. Either one could be correct Fig. 1. C: "I do not know" is the correct answer. Transitional lumbosacral vertebrae are a relatively common variant and can be seen in 15-35% of the general population [1-3]. If this variant is not recognized or not correctly described in the report, there is a risk of wrong level surgery or other spine intervention such as injection [3,4]. It is essential to evaluate all preoperative imaging modalities before reporting the levels on intraoperative images. If preoperative images are not available and the surgeon is insistent on providing a level in the report, we use the following preamble: "For the purposes of this report, the last apparent true disc level is considered to be L5-S1. Based on this, the posterior surgical instrument is present overlying the ___ level." If there is no absolute requirement to state a level in the report, one can use the following verbiage: "This ia a limited lateral intraoperative radiograph for the purpose of localization. Please refer to the operative report including designation of the operative levels by the surgeon." Fig. 2. The iliolumbar ligaments (blue arrows). The iliolumbar ligament is fairly reliable anatomic structure which can be used to determine the lumbosacral numbering scheme (Fig. 2). Best seen on CT scan, the iliolumbar ligament frequently arises from the transverse process of L5. However, due to wide variability in the number of vertebral segments, the iliolumbar ligament does not always indicate the L5 level. It actually merely identifies the lowest lumbar-type vertebral segment [1]. References: 1. Carrino JA, Campbell PD, Lin DC et-al. Effect of Spinal Segment Variants on Numbering Vertebral Levels at Lumbar MR Imaging. Radiology. 2011;259 (1): 196-202. 2. Uçar D, Uçar BY, Coşar Y et-al. Retrospective cohort study of the prevalence of lumbosacral transitional vertebra in a wide and well-represented population. Arthritis. 2013;2013: 461425. 3. Konin GP, Walz DM. Lumbosacral transitional vertebrae: classification, imaging findings, and clinical relevance. AJNR Am J Neuroradiol. 2010;31 (10): 1778-86. AJNR Am J Neuroradiol. 4. Bron JL, van Royen BJ, Wuisman PI. The clinical significance of lumbosacral transitional anomalies. Acta Orthop Belg. 2008;73 (6): 687-95. Kevin Rice, MD serves as the Chair of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice launched 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

Left Scrotal Pain in 64M • Xray of the Week 2016 • Week #50 This 64 year old male presented with left scrotal pain. There is a history of undescended left testicle and orchiopexy at age 5. What is the diagnosis? Video 1: Ultrasound demonstrating slow flow in an intratesticular varicocele. Video 2: Zoomed ultrasound demonstrating slow flow in an intratesticular varicocele. The flow is too slow to be seen with color Doppler. Figure 1. Intratesticular varicocele in a different patient. Color Doppler shows the dilated vein within the testis. Case courtesy of Dr Rupesh Namdev, Radiopaedia.org. From the case rID: 27305 Intratesticular varicocele is a rare cause of testicular pain seen in less than 2% of cases. Although usually associated with extratesticular varicocele, as seen in this case it is not invariable. Testicular pain is due to stretching of the tunica albuginea related to congestion and dilatation of veins [1]. Approximately 9% of men who have had prepubertal orchiopexy for undescended testis eventually develop an intratesticular varicocele [2]. Slightly more than half of the cases occur on the left side [1,2,3]. In 1992, Weiss et al reported the first 2 cases of intratesticular varicocele, describing straight or serpentine hypoechoic structures within the mediastinum testis radiating into the testicular parenchyma, identified as veins with color Doppler sonography [3]. However, slow flow may preclude Doppler signal, and as seen in the videos above, flow can be appreciated with real time sonography [Videos 1 and 2]. Approximately 80% of the testes affected with intratesticular varicocele demonstrate atrophy [4]. References: 1. Das KM, Prasad K, Szmigielski W et-al. Intratesticular varicocele: evaluation using conventional and Doppler sonography. Abstract: AJR Am J Roentgenol. 1999;173 (4): 1079-83. Full Text PDF 2. Meij-de Vries A, den Bakker FM, van der Wolf-de Lijster FS et-al. High prevalence of intratesticular varicocele in a post-orchidopexy cohort. J Pediatr Urol. 2013;9 (3): 328-33. doi:10.1016/j.jpurol.2012.04.004 - Pubmed citation 3. Weiss AJ, Kellman GM, Middleton WD, Kirkemo A. Intratesticular varicocele: sonographic findings in two patients. AJR Am J Roentgenol 1992; 158:1061–1063 4. Tétreau R, Julian P, Lyonnet D, et al. Intratesticular Varicocele: An Easy Diagnosis But Unclear Physiopathologic Characteristics. J Ultrasound Med 2007; 26:1767–1773 Kevin Rice, MD serves as the Medical Director of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a Member of Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice launched 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

6 Month Old with Abdominal Pain • Xray of the Week History: There was a baby from Cali, who had a pain in his belly. For a BE, it's time; 'cause of a target sign, and his stool looks like currant jelly. Figure 1. Left image: Target sign on ultrasound due to intussusception. Right image: Spot view from water soluble contrast enema showing the filling defect in the transverse colon due to ileo-colic intussusception. Figure 2. The pseudokidney sign. Long axis ultrasound image of intussusception showing the layers of ileum inside the cecum in the right lower quadrant. Figure 3. Intussusception is reduced with contrast in the terminal ileum. Figure 4. Actual currant jelly Figure 5. Bloody stool in diaper (aka nappy) that looks like currant jelly Intussusception is a common cause of abdominal pain in children and is caused by a segment of bowel pulled into itself by peristalsis. The classic triad of intermittent abdominal pain, vomiting and right upper quadrant mass, plus occult or gross blood on rectal examination is seen in less than 20% of intussusception cases. Bloody stool may have the appearance of currant jelly due to the presence of mucus in the stool [Fig. 4,5]. If prolonged, ischemia and necrosis with eventual perforation may occur. 90% of cases in children aged less than 2 years old have no lead point. Ultrasound demonstrates the target sign in the short axis view [Fig. 1] and the pseudokidney sign in the long axis view [Fig.2] due to alternating bands of hyperechoic mucosa and hypoechoic submucosa. Definitive diagnosis and treatment is reduction with water soluble contrast or air enema [Fig. 3]. When seen in adults, there is almost invariably a neoplasm as a pathologic lead point, thus requiring surgery. References: 1. Lioubashevsky N, Hiller N, Rozovsky K, et al. Ileocolic versus Small-Bowel Intussusception in Children: Can US Enable Reliable Differentiation? Radiology. 269 (3): 266-271 2. Kim YH, Blake MA, Harisinghani MG et-al. Adult intestinal intussusception: CT appearances and identification of a causative lead point. Radiographics. 26 (3): 733-44 3. Anderson DR. The pseudokidney sign. Radiology. 1999;211 (2): 395-7. 4. del-Pozo G, Albillos JC, Tejedor D, et al. Intussusception in children: current concepts in diagnosis and enema reduction. RadioGraphics 1999;19(2):299–319. 5. Swischuk LE, Hayden CK, Boulden T. Intussusception: indications for ultrasonography and an explanation of the doughnut and pseudokidney signs. Pediatr Radiol 1985;15(6):388–391. 6. Rubinstein JC, Lucy Liu L, Caty MG. Pathologic Leadpoint Is Uncommon in Ileo-Colic Intussusception Regardless of Age. J Pediatr Surg. 2015 Oct;50(10):1665-7. DOI: 10.1016/j.jpedsurg.2015.03.048 7. McDermott VG, Taylor T, Mackenzie S, et al. Pneumatic Reduction of Intussusception: Clinical Experience and Factors Affecting Outcome. Clin Radiol. 1994 Jan;49(1):30-4. doi: 10.1016/s0009-9260(05)82910-1. Related case: Intussusception in melanoma Kevin Rice, MD serves as the Chair of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice 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