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What is the mechanism of injury? • Xray of the Week Figure 1. Frontal and lateral plain radiographs of the left hand and lateral plain radiograph of the left forearm. Figure 2. Frontal and lateral plain radiographs of the left hand and lateral plain radiograph of the left forearm demonstrating occupational sandblasting injury. A. Frontal x-ray of left hand showing radiopaque sand (red arrows) in the 1st metacarpal web space and extensive subcutaneous emphysema throughout the hand (yellow arrows). B. Lateral x-ray of left hand demonstrating radiopaque sand (red arrows) in the 1st metacarpal web space and around the adjacent proximal 1st phalanx. C. Lateral x-ray of left forearm showing subcutaneous emphysema (yellow arrows) extending along the anterior surface of forearm. Discussion: Sandblasting is a form of abrasive blasting that involves the propulsion of sand particles at high speeds to clean, smooth, or shape various industrial surfaces. Sandblasting injuries are classified as high-pressure injection injuries and can result in significant trauma that may require emergent surgery (1,2). Although there is widespread usage of these high-pressure tools, high-pressure injection hand injuries are rarely seen and account only for a small number of total hand trauma cases (1-3). In cases of limited exposure and small injection sites, the overlying soft tissue may look grossly intact, but the underlying tissue is where extensive damage can occur including tissue ischemia, chemical irritation, muscle destruction, compression effects, and widespread edema (3). Rarely, subcutaneous emphysema can occur due to communication with surrounding atmospheric air, injection of air from the high-pressure device, and creation of a one-way valve system (4). The specific imaging features of sandblasting injuries and foreign bodies in general ultimately is determined by the composition of the material. Plain radiography is usually the first step in imaging hand trauma with suspected foreign body as it allows for potential classification of the material and location relative to other structures. Materials such as metal, glass, and stone, including sand, are readily picked up on plain radiographs and will appear radiopaque (Figs. 1,2) (5). Of note, wood and acrylic-based materials exhibit the opposite and will appear radiolucent on x-ray making the visualization of these materials difficult (5). Subcutaneous emphysema can be further visualized on conventional radiographs due to its lower density compared to surrounding soft tissues and bone (Figs. 1,2). CT can provide higher resolution and a precise measurement of the foreign body’s size and shape, although cross sectional imaging is rarely sought after in most cases (5,6). When concerning radiolucent materials, CT has greater utility in their detection when compared to conventional radiographs (5). Both CT and MRI can be utilized when surgery is in question and for assessing soft tissue, muscular, ligamentous, and tendinous damage (5,6). Sonographic features of most foreign bodies including stone will appear hyperechoic, but any air introduced to the surveyed area will lead to difficulty visualizing the foreign body (5). Treatment of these high-pressure injection injuries involves prompt evaluation of the wound and emergent surgical debridement to ensure the patient maintains function of the affected area and to reduce the need for amputation (5,6). ​​​​ References: Amir A, Sagi A, Barr J, Rosenberg L. 'Sand-blaster' injuries. Injury. 1996;27(3):223-224. doi:10.1016/0020-1383(95)00206-5 Belsole RJ, Nolan M, Eichberg RD. Sandblasting injury of the hand. J Hand Surg Am. 1982;7(5):523-525. doi:10.1016/s0363-5023(82)80054-3 Verhoeven N, Hierner R. High-pressure injection injury of the hand: an often underestimated trauma: case report with study of the literature. Strategies Trauma Limb Reconstr. 2008;3(1):27-33. doi:10.1007/s11751-008-0029-9. PubMed Full Text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2291478/ Fox A, Sheick H, Ekwobi C, Ho-Asjoe M. Benign surgical emphysema of the hand and upper limb: gas is not always gangrene--a report of two cases. Emerg Med J. 2007;24(11):798-799. doi:10.1136/emj.2007.046755 PubMed Full Text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2658337/ Aras MH, Miloglu O, Barutcugil C, Kantarci M, Ozcan E, Harorli A. Comparison of the sensitivity for detecting foreign bodies among conventional plain radiography, computed tomography and ultrasonography. Dentomaxillofac Radiol. 2010;39(2):72-78. doi:10.1259/dmfr/68589458 Collins M, McGauvran A, Elhassan B. High-pressure injection injury of the hand: peculiar MRI features and treatment implications. Skeletal Radiol. 2019;48(2):295-299. doi:10.1007/s00256-018-3005-6 Corey Stump is a medical student and aspiring radiologist at the Marian University College of Osteopathic Medicine in Indianapolis, Indiana. Prior to medical school, he graduated summa cum laude from Wittenberg University where he received a B.S. degree in Biology. He is excited to pursue a career in Diagnostic Radiology with interests in medical education. He has produced a webinar titled “Navigating The Virtual Match; Program Directors vs. Medical Students” through the Academy of Online Radiology Education with other medical students and radiologists around the country in an effort to provide insight on the 2020 residency match. He is passionate about teaching and he hopes to provide a meaningful experience to medical students one day. Follow Corey Stump on Twitter @corey_stump All posts by Corey Stump Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice is a radiologist with Renaissance Imaging Medical Associates and is currently the Vice Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

56M with new chest mass after recent cardiac surgery • Xray of the Week 56 yo M with complaints of new chest mass, cough and chest pain. Patient recently had a minimally invasive secundum ASD and PFO closure. Patient noticed a mass bulging on his right side at the surgical site when coughing. What is the diagnosis? Figure 1. Patient with history of recent cardiac surgery presents with palpable right chest mass. What is the diagnosis? Figure 2. CT chest with contrast axial image shows a portion of the anterior basal segment right lower lobe herniating between two anterior ribs. Also noted is a large right hemothorax. Figure 3. CT chest oblique coronal image (A) with a volume rendered oblique coronal reconstruction image (B) again shows a portion of the anterior basal segment right lower lobe herniating between two anterior ribs. Figure 4. CT chest without contrast axial image after thoracotomy, lung herniation repair with pneumolysis of the anterior basal segment of the right lower lobe and drainage of a previous hemothorax with a chest tube (orange arrow). Discussion: Lung herniation occurs uncommonly, with 20% due to a congenital anomaly, and the remaining 80% acquired. Causes of acquired lung herniation include infection, neoplasm, trauma, and (as seen in this case) from recent or remote thoracic surgery [1]. Lung herniation most commonly occurs in the anterior region especially in the lower intercostal spaces due to less muscular support (Figs. 1-3) [1,2]. Postoperative lung herniations are more common during less extensive surgical procedures and minimally invasive surgeries compared to more extensive procedures that involve a thoracotomy due to technique in closure [1]. Congenital hernias result from a defect in the endothoracic fascia with absence of intercostal musculature or due to costal malformations [2]. Pathological causes of lung herniation usually include infections or neoplasms such as breast cancer or metastasis of the chest wall that erode and weaken the intercostal musculature [2]. History usually reveals a palpable mass and chest wall pain that worsen after coughing, sneezing or actions that increase intrathoracic pressure [3]. History and physical exam including examination of the chest wall with Valsalva maneuver are best at first diagnosing lung herniation as an initial chest radiograph may not reveal the diagnosis [3, 4]. Ultrasound can be used to easily differentiate herniated lung tissue that is filled with air compared to soft tissue, fat or fluid lesions such as a lipoma or hematoma [4]. Expiratory CT scans can exaggerate the lung herniation to improve diagnosis sensitivity and can provide additional information such as the possibility of lung strangulation to deduce viability of lung tissue before surgery [4]. Emergent indications for surgery include signs or increased risk of lung incarceration and strangulation [3]. This may include a non-reducible bulge on physical exam or narrowing of the pulmonary vasculature, small airways and neck of the hernia on imaging [3]. There is currently no consensus on management of nonemergent lung herniation. Conservative management such as compression is mostly reserved for high comorbid conditions, but long term complications may lead to reduced pulmonary compliance, atelectasis or infection [3,5]. Surgical management such as resection of incarcerated lung, pneumolysis (Fig. 4), pericostal fixation, reduction with mesh, or muscle flaps can be done with good long term outcomes [6, 7]. ​​​​ References: 1. Scelfo C, Longo C, Aiello M, Bertorelli G, Crisafulli E, Chetta A. Pulmonary hernia: Case report and review of the literature. Respirol Case Rep. 2018;6(8):e00354. Published 2018 Oct 2. doi:10.1002/rcr2.354 2. Moncada R, Vade A, Gimenez C, et al. Congenital and acquired lung hernias. J Thorac Imaging. 1996;11(1):75-82. doi:10.1097/00005382-199601110-00008 3. Chaturvedi A, Rajiah P, Croake A, Saboo S, Chaturvedi A. Imaging of thoracic hernias: types and complications. Insights Imaging. 2018;9(6):989-1005. doi:10.1007/s13244-018-0670-x 4. Detorakis EE, Androulidakis E. Intercostal lung herniation--the role of imaging. J Radiol Case Rep. 2014;8(4):16-24. Published 2014 Apr 1. doi:10.3941/jrcr.v8i4.1606 5. Mirza A, Gogna R, Kumaran M, Malik M, Martin-Ucar A. The surgical management of intercostal lung herniation using bioprosthesis. J Surg Case Rep. 2011;2011(2):6. Published 2011 Feb 1. doi:10.1093/jscr/2011.2.6 6. Chiang TY, Yin MF, Yang SM, Chen KC. Thoracoscopic management of incarcerated lung herniation after blunt chest trauma: a case report and literature review. J Thorac Dis. 2017;9(3):E253-E257. doi:10.21037/jtd.2017.03.41 7. Chu MW, Losenno KL, Fox SA, et al. Clinical outcomes of minimally invasive endoscopic and conventional sternotomy approaches for atrial septal defect repair. Can J Surg. 2014;57(3):E75-E81. doi:10.1503/cjs.012813 Steven M. Lee, MD is a diagnostic radiology resident at the John P. and Kathrine G. McGovern Medical School at UTHealth in Houston, Texas. The McGovern Radiology Residency program has a Trauma Level 1 Emergency Department at MHH-TMC, and a top cancer center at MDACC. The location in the Texas Medical Center, the largest in the world, provides a unique training experience with access to numerous faculty, resources, and research opportunities. Dr. Lee graduated from the University of Texas at Austin as a Psychology major and earned his medical degree from McGovern Medical School. All posts by Steven M. Lee Cihan Duran, MD is an Associate Professor of Radiology at The University of Texas McGovern Medical School in Houston. She received her medical degree from Hacettepe University in Turkey. After completing her residency at Istanbul University, she worked in Group Florence Nightingale/ Istanbul Bilim University as a body and cardiothoracic imaging faculty. After she came to the United States, she worked as a research fellow in Advanced Cardiovascular Imaging Laboratory at Harvard University. She completed her fellowship in Cardiovascular MRI at Baylor College of Medicine St. Luke’s Episcopal Hospital and Thoracic Radiology, Musculoskeletal Radiology, and Body Imaging fellowships in MD Anderson Cancer Center. Dr. Duran authored and co-authored over 65 peer-reviewed articles; multiple book chapters and over 100 abstracts and scientific and educational exhibits at National and International conferences on the topics of cardiothoracic and body imaging. She serves as a journal reviewer for several scientific journals.

84M with trauma, swollen upper lip, and epistaxis • Xray of the Week Figure 1. What is the important finding on this CT scan. Figure 2. Left: Axial CT showing fracture of the anterior and lateral maxillary sinus walls (yellow arrows) and pterygoid plates (red arrows). Right: 3D VR reconstruction showing bilateral Lefort 1 fractures traveling horizontally from the nasal septum to the lateral pyriform rims above the teeth (green arrows). Figure 3. Diagram of Lefort fractures. A. Frontal view of LeFort complex fractures 1-3. B. Lateral view of LeFort complex fractures 1-3. Source: University of Washington, Department of Radiology. https://rad.washington.edu/about-us/academic-sections/musculoskeletal-radiology/teaching-materials/online-musculoskeletal-radiology-book/facial-and-mandibular-fractures/ Discussion: Lefort fractures were named for Rene Le Fort, a French army surgeon who conducted experiments on cadaver skulls by applying blunt force trauma (1,2). As a result of these experiments, he was able to identify several “lines of weakness” in the maxilla that led him to develop a system of classifying facial fractures (2). Lefort fractures refer to complex fractures from blunt facial trauma that involve separation of the midface from the skull base, and include bilateral fractures of the pterygoid plates (1). There are three types of Lefort fractures; types I, II, and III which affect the maxillary, nasal, and zygomatic bones respectively (1) (Fig.3). This case illustrates the Lefort I fracture, which is a horizontal maxillary fracture through the lateral nasal wall and pterygoid plates (1). Lefort 1 fractures affect all three walls of the maxillary sinus and pterygoid processes due to a direct blow to the lower face in a downward direction against the upper teeth (2). Fractured bones typically include the lower nasal septum, pyriform apertures, canine fossae, zygomaticomaxillary buttresses, posterior maxillary walls, and pterygoid plates (3). Lefort I fractures present with swelling of the upper lip, nasopharyngeal bleeding, oral lacerations, and malocclusion (2,3). According to the Iowa Head and Neck Protocols, non-contrast, fine-cut (2 mm sections) CT is recommended for Lefort fractures, with axial cuts from the skull base to the mandible (4). Coronal cuts can also be used to visualize the orbital walls (4). Bilateral fractures of the pterygoid plates on CT are key in diagnosis as they are present in all three types of Lefort fractures (3). However, Lefort 1 fractures will also show fracture of the anterolateral margin of the nasal fossa (5). If the anterolateral margin of the nasal fossa is intact, type I fracture can be excluded (5). Type I Lefort fractures are the only type of Lefort fractures to involve the lateral pyriform aperture (3). Lefort fractures are not always symmetric, and trauma can result in multiple types of Lefort fractures on the same side of the face (5). It can also occur simultaneously with non-Lefort facial fractures, so it is important to consider these possibilities. CT scan of the facial bones, head, and angiography are also important in midface trauma for possible brain injury or vascular damage (2). Treatment involves surgical restoration of midfacial height and projection by reestablishing the midfacial buttresses (3). This can be done by using gingivobuccal sulcus incision to insert 1.5 - 2.0 mm L and J plates axial to the nasomaxillary and zygomaticomaxillary buttresses (3). ​​​​ References: Phillips BJ, Turco LM. Le Fort Fractures: A Collective Review. Bull Emerg Trauma. 2017;5(4):221-230. doi:10.18869/acadpub.beat.5.4.499 Patel BC, Wright T, Waseem M. Le Fort Fractures. [Updated 2020 Sep 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK526060/ Kim HS, Kim SE, Lee HT. Management of Le Fort I fracture. Arch Craniofac Surg. 2017;18(1):5-8. doi:10.7181/acfs.2017.18.1.5 Facial Fracture Management Handbook - LeFort Fractures | Iowa Head and Neck Protocols. Accessed November 15, 2020. https://medicine.uiowa.edu/iowaprotocols/facial-fracture-management-handbook-lefort-fractures Rhea JT, Novelline RA. How to simplify the CT diagnosis of Le Fort fractures. AJR Am J Roentgenol. 2005 May;184(5):1700-5. doi:10.2214/ajr.184.5.01841700 Amara Ahmed is a medical student at the Florida State University College of Medicine. She serves on the executive board of the American Medical Women’s Association and Humanities and Medicine. She is also an editor of HEAL: Humanism Evolving through Arts and Literature, a creative arts journal at the medical school. Prior to attending medical school, she graduated summa cum laude from the Honors Medical Scholars program at Florida State University where she completed her undergraduate studies in exercise physiology, biology, and chemistry. In her free time, she enjoys reading, writing, and spending time with family and friends. Follow Amara Ahmed on Twitter @Amara_S98 All posts by Amara Ahmed Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice is a radiologist with Renaissance Imaging Medical Associates and is currently the Vice Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

50 year old with cirrhosis and ascites. Diagnosis? • Xray of the Week Figure 1. What are the important findings? Figure 2. A: Contrast enhanced coronal CT scan showing thrombus in the portal vein (yellow arrow) as well as a cirrhotic liver with nodular surface (red arrow) surrounded by ascites (green arrow). B and C: Contrast enhanced axial CT images showing ascites (green arrows) as well as confirmation of the occlusion of the hepatic portal vein (yellow arrows). Figure 3. A: Color doppler ultrasound of portal vein thrombosis in a different patient. Note the echogenic thrombus in the dilated portal vein (PV). Color doppler shows no flow in the portal vein. https://www.slideshare.net/shaffar75/doppler-ultrasound-of-portal-vein-thrombosis Discussion: Portal vein thrombosis (PVT) (Figs. 1,2) is a common complication in patients with liver cirrhosis and is also associated with malignancies and inherited thrombophilia disorders [1]. The pathophysiology of hepatic PVT can be explained by the well-known Virchow’s triad, which explains the causes of thrombosis including stasis, endothelial injury and hypercoagulability. Hepatic PVT in liver cirrhosis patients typically is the result of portal hypertension and stagnation of blood in the portal system leading to partial or complete thrombosis of the portal vein [2]. Up to 43% of patients may be asymptomatic; however, many present with abdominal pain due to bowel ischemia and/or gastrointestinal bleeding due to varices [3]. Due to the high proportion of asymptomatic patients, PVT is often a missed diagnosis or an incidental finding, and when it becomes symptomatic can lead to deadly consequences. Therefore, it is important to diagnose PVT with imaging as early as possible. PVT is usually evaluated first by ultrasound which has a sensitivity and specificity greater than 80%. Ultrasound evaluation of PVT typically shows hyperechoic material in the portal vein and diminished flow with doppler (Fig. 3). Contrast CT and MRI can also be used in the evaluation of PVT and can provide additional information such as bowel ischemia, portal hypertension, portal hypertension, including ascites, splenomegaly, and portosystemic shunts [4-6]. On CT scan, PVT is depicted as a non-enhancing filling defect (Figs. 1, 2). Similar to CT, MR demonstrates abnormal signal within the lumen of the portal vein; however, signal intensity depends on the age of the clot [5,6]. Linear regions of calcification within the clot indicate chronic thrombosis [6]. Treatment of PVT depends on the cause of the PVT. Options for treatment of PVT can include observation, anticoagulation, shunt placement, and thrombectomy. Treatment of PVT in patients with liver cirrhosis is controversial due to lack of clinical trials. Some studies support the use of anticoagulants while others support the use of transjugular intrahepatic portosystemic shunts (TIPS). These both have risks including bleeding with anticoagulants and hepatic encephalopathy with TIPS [7]. When treating PVT in a liver cirrhosis patient, it is also important to evaluate for other life-threatening consequences including esophageal varices with endoscopy [4]. ​​​​ References: Nery F, Chevret S, Condat B, et al. Causes and consequences of portal vein thrombosis in 1,243 patients with cirrhosis: results of a longitudinal study. Hepatology. 2015;61(2):660-667. doi:10.1002/hep.27546 Intagliata NM, Caldwell SH, Tripodi A. Diagnosis, Development, and Treatment of Portal Vein Thrombosis in Patients With and Without Cirrhosis. Gastroenterology. 2019;156(6):1582-1599.e1. doi:10.1053/j.gastro.2019.01.265 Amitrano L, Guardascione MA, Brancaccio V, et al. Risk factors and clinical presentation of portal vein thrombosis in patients with liver cirrhosis. J Hepatol. 2004;40(5):736-741. doi:10.1016/j.jhep.2004.01.001 Chawla YK, Bodh V. Portal vein thrombosis. J Clin Exp Hepatol. 2015;5(1):22-40. doi:10.1016/j.jceh.2014.12.008 Parvey HR, Raval B, Sandler CM. Portal vein thrombosis: imaging findings. AJR Am J Roentgenol. 1994;162(1):77-81. doi:10.2214/ajr.162.1.8273695 Jha RC, Khera SS, Kalaria AD. Portal Vein Thrombosis: Imaging the Spectrum of Disease With an Emphasis on MRI Features. AJR Am J Roentgenol. 2018 Jul;211(1):14-24. doi:10.2214/AJR.18.19548 Sharma AM, Zhu D, Henry Z. Portal vein thrombosis: When to treat and how?. Vasc Med. 2016;21(1):61-69. doi:10.1177/1358863X15611224 Sai Kilaru is a medical student at Central Michigan University College of Medicine and plans to pursue a residency in diagnostic radiology. Sai first realized his interest in radiology while he was conducting research in radiomics at the University of Michigan, where he graduated from in 2018 with a Bachelor of Science degree in Neuroscience. As he progressed through his third year of medical school, Sai realized the very important role that radiology has in medicine and decided to take on the challenge of diagnosing patients in the future. Sai is also a member of the Gold Humanism Honor Society and is involved with giving back to the community at a local free clinic as a medical assistant. In his spare time, Sai enjoys playing basketball, board games, spending time with friends, and exploring new restaurants. Follow Sai Kilaru on Twitter @sai_kilaru All posts by Sai Kilaru Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice is a radiologist with Renaissance Imaging Medical Associates and is currently the Vice Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

32 year old male with sudden dysuria • Xray of the Week Figure 1. A. Axial, B. Sagittal, C. Coronal CT abdomen-pelvis. What is the abnormality? Figure 2. A. Axial, B. Sagittal, C. Coronal CT abdomen-pelvis showing large calculus in the prostatic urethra (red arrows). Discussion: Prostatic urethra calculi are uncommon accounting for less than 1% of all urinary stone disease. Usually seen in males over 50 years of age, the most common site of urethral calculi is the posterior urethra; however, calculi can be seen along the entire length of the urethra [1, 2]. Primary urethral calculi originate within the urethra and are usually the result of urinary stagnation and infection in poorly draining intra-urethral and paraurethral cavities such as abscesses, diverticula, and mucosal ulcerations [1, 2]. Urethral strictures may also lead to stagnation and primary urethral calculi formation [1]. Secondary calculi are those that originate in the upper urinary tract or bladder and are much more common than primary urethral calculi. While primary urethral calculi are often asymptomatic, secondary calculi often produce sudden obstruction resulting in dysuria, hematuria, or incontinence [1-3]. Urethral calculi may be seen as an incidental finding on radiographs or CT scan. They may also be visualized on transabdominal or transrectal ultrasound. Retrograde urethrogram can be utilized to define the anatomy when a urethral stricture or diverticulum is suspected [2]. In this case, CT scan was performed due to the patient’s symptoms and it revealed the large calculus in the prostatic urethra (Figs. 1,2). Treatment is dependent upon the size, shape, and location of the calculus and by the status of the urethra. Smaller calculi can often be treated with transurethral endoscopic techniques including laser and pneumatic lithotripsy. If the stone is large and immobile, it may require open surgery via a perineal or a suprapubic approach [1]. ​​​​ References: 1. Demir, O., et al., The giant calculus within the prostatic urethra. Urol Res, 2011. 39(4): p. 319-21 DOI: 10.1007/s00240-010-0350-x. Retrieved from https://link.springer.com/article/10.1007%2Fs00240-010-0350-x 2. Friedman, P.S., L. Solis-Cohen, and S.M. Joffe, Urethral Calculus: Its Roentgen Evaluation. Radiology, 1954. 62(2): p. 248-250 DOI: 10.1148/62.2.248. Retrieved from https://pubs.rsna.org/doi/abs/10.1148/62.2.248 3. Kamal, B.A., et al., Urethral calculi: presentation and management. BJU Int, 2004. 93 PubMed: https://pubmed.ncbi.nlm.nih.gov/15008727/ doi:10.1111/j.1464-410x.2003.04660.x Shama Jaswal is an International Medical Graduate, currently doing research at Mallinckrodt Institute of Radiology (MIR), Saint Louis. She aims at pursuing Diagnostic Radiology residency and poses a keen interest in research alongside academics. At MIR, she has been fortunate to work on various oncology projects including the project in which they studied how the difference in fat metabolism in both sexes can affect the cancer survival and outcome, and how this study can further improve prognosis through treatment modification. Shama is both an accomplished sprinter and singer having won several national competitions in in each discipline in India. She also has a strong passion for cooking and gardening. Follow Shama Jaswal on Twitter @Jaswal_Shama All posts by Shama Jaswal Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice is a radiologist with Renaissance Imaging Medical Associates and is currently the Vice Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

27 yo female with postpartum hemorrhage. Diagnosis? • Xray of the Week Figure 1. Sagittal ultrasound image of the uterus showing placement of Bakri balloon in the mid-uterine position. Figure 2. Diagram of Bakri balloon. A. 3D image showing correct placement of the Bakri balloon in the uterine cavity. B. Correct and incorrect placement of the Bakri balloon in the uterine cavity. The balloon should not traverse the cervix. C. Silicone catheter inflated to 500 ml. Note the distal drainage port. - Cook Medical. Figure 3. Video of placement of Bakri Postpartum Balloon - Cook Medical. Discussion: Postpartum hemorrhage is the leading cause of maternal mortality in developing countries (1). The Bakri balloon is an FDA-approved “minimally invasive intrauterine tamponade device” used to control and reduce postpartum hemorrhage when conservative management is required (1-4). It consists of a 24-French, 54-cm long silicone catheter that can be inflated to 500 mL (1) (Figs. 2,3). Contraction of the myometrium constricts the placental blood vessels and causes hemostasis (2). In postpartum hemorrhage, this vessel constriction does not occur. The Bakri balloon applies pressure directly on the myometrium and placental bed when the uterus contracts on the balloon, which causes hemostasis through a similar mechanism (2). When positioned correctly, the Bakri balloon can reduce the need for hysterectomy, uterine artery ligation, embolization, and other more invasive interventions (1). On imaging, the balloon appears as a round anechoic structure in the center of the uterus with a hyperechoic rim (1) (Fig. 1). Ultrasonography is the preferred imaging modality compared to CT and MRI due to cost, portability, and time efficiency (1,2). US guidance can also be used to determine the uterine volume, confirm that there are no retained products of conception, and ensure proper placement of the balloon past the cervical canal and internal ostium in the transvaginal approach (2-4). A transabdominal approach can also be used to position the balloon in cases of Cesarean section. US examination is used to determine the uterine volume, and the Cesarean incision is used to pass the inflation port through the uterus and cervix (2,3). This ensures that the balloon is in the uterus and limits the spread of vaginal flora into the peritoneal cavity (3). The balloon is then inflated with sterile liquid. The Bakri balloon is associated with serious complications due to migration of the balloon or uterine rupture via over-inflation of the balloon (1,3). It is contraindicated in cases of balloon material allergy, uterine rupture, uterine anomalies, cervical cancer, disseminated intravascular coagulation, or retained products of conception (1,3). Continuous patient monitoring is necessary as persistent bleeding may require more aggressive treatment. ​​​​ References: Katsinis BR. Bakri balloon displacement in the uterus: sonographic demonstration. Journal of Diagnostic Medical Sonography. 2015;31(6):386-389. doi:10.1177/8756479315611658 Cho Y, Rizvi C, Uppal T, Condous G. Ultrasonographic visualization of balloon placement for uterine tamponade in massive primary postpartum hemorrhage. Ultrasound Obstet Gynecol. 2008 Oct;32(5):711-3. doi:10.1002/uog.5408. Bakri YN, Amri A, Abdul Jabbar F. Tamponade-balloon for obstetrical bleeding. Int J Gynaecol Obstet. 2001 Aug;74(2):139-42. doi:10.1016/s0020-7292(01)00395-2. Suarez S, Conde-Agudelo A, Borovac-Pinheiro A, et al. Uterine balloon tamponade for the treatment of postpartum hemorrhage: a systematic review and meta-analysis. Am J Obstet Gynecol 2020;222:293.e1-52. doi:10.1016/j.ajog.2019.11.1287 Amara Ahmed is a medical student at the Florida State University College of Medicine. She serves on the executive board of the American Medical Women’s Association and Humanities and Medicine. She is also an editor of HEAL: Humanism Evolving through Arts and Literature, a creative arts journal at the medical school. Prior to attending medical school, she graduated summa cum laude from the Honors Medical Scholars program at Florida State University where she completed her undergraduate studies in exercise physiology, biology, and chemistry. In her free time, she enjoys reading, writing, and spending time with family and friends. Follow Amara Ahmed on Twitter @Amara_S98 All posts by Amara Ahmed Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice is a radiologist with Renaissance Imaging Medical Associates and is currently the Vice Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

A 46 year old male with hyponatremia, altered level of consciousness, and seizures. What is the diagnosis? • Xray of the Week Figure 1. Brain CT. What is the significant finding. Figure 2. A: Axial CT image obtained at the level of the 4th ventricle shows a centrally located region of low attenuation within the pons (red arrow). B: Midline sagittal CT image shows a centrally located region of low attenuation within the pons (red arrow). Discussion: Osmotic demyelination syndrome (ODS) is a symmetric, non-inflammatory condition where the myelin fibers are disrupted primarily in the pons. The neuronal cell bodies and axons in the pons are preserved as well as the peripheral fibers and axons of the corticospinal tract (1). This syndrome was previously referred to as central pontine myelinolysis, but early detection of this condition showed that extrapontine structures can be involved. Other common structures include cerebellum and the lateral geniculate body (3). This condition occurs because of electrolyte abnormalities, especially hyponatremia, being corrected too rapidly with patients deteriorating within 2-8 days. Symptoms are based on which tracts are affected in the brain: Corticobulbar involvement will cause dysarthria and dysphagia; corticospinal tract involvement will cause flaccid paralysis and possibly spastic quadriparesis depending on basis pontis damage. Widespread pontine damage can cause “locked-in” syndrome (5). Extrapontine symptoms such as psychiatric disorders, movement disorders, depression, and seizures (1) may also occur. Imaging findings in ODS can be delayed up to 2 weeks (2). Diffusion weighted MRI is recognized as the earliest and most sensitive imaging modality for ODS and is recommended to be performed on the initial day of symptoms (5). Characteristic MR findings include the symmetric trident pattern on T2-weighted and FLAIR MR images (2). T1-weighted images will show decreased signal intensity in affected areas with no mass effect; however findings on T1-weighted images are nonspecific (2, 4, 5, 6). MRI will not show demyelination of the ventrolateral pons and the pontine portion of the corticospinal tracts. CT scans are not the first line imaging study for ODS but can demonstrate regions of demyelination as low attenuation lesions in the basilar part of the pons without mass effect (Figs.1,2). Hypoattenuation can be seen in other parts of the brain such as the basal ganglia and thalamus and sparing of the pontine tegmentum (1,2). Lack of radiological findings does not rule out ODS. To prevent the devastating complications of ODS, sodium levels must be gradually corrected depending on the initial lab value and symptoms. The goal of patients with sodium levels above 120 is to first achieve euvolemic status and then balance the electrolyte levels. They must be monitored and may be treated with vasopressin antagonists. Patients with severe hyponatremia (Na <120) or neurological symptoms can be given hypertonic saline (4). ​​​​ References: Alleman AM. Osmotic demyelination syndrome: central pontine myelinolysis and extrapontine myelinolysis. Semin Ultrasound CT MR. 2014;35(2):153-159. doi:10.1053/j.sult.2013.09.009 Howard SA, Barletta JA, Klufas RA, Saad A, De Girolami U. Best cases from the AFIP: osmotic demyelination syndrome. Radiographics. 2009;29(3):933-938. doi:10.1148/rg.293085151 Kleinschmidt-Demasters BK, Rojiani AM, Filley CM. Central and extrapontine myelinolysis: then...and now. J Neuropathol Exp Neurol. 2006;65(1):1-11. doi:10.1097/01.jnen.0000196131.72302.68 Lambeck J, Hieber M, Dreßing A, Niesen WD. Central Pontine Myelinosis and Osmotic Demyelination Syndrome. Dtsch Arztebl Int. 2019;116(35-36):600-606. doi:10.3238/arztebl.2019.0600 Ruzek KA, Campeau NG, Miller GM. Early diagnosis of central pontine myelinolysis with diffusion-weighted imaging. AJNR Am J Neuroradiol. 2004;25(2):210-213. http://www.ajnr.org/content/25/2/210.abstract Yuh WT, Simonson TM, D'Alessandro MP, Smith KS, Hunsicker LG. Temporal changes of MR findings in central pontine myelinolysis. AJNR Am J Neuroradiol. 1995;16(4 Suppl):975-977. http://www.ajnr.org/content/16/4/975.abstract Austin Sanu is a 3rd year medical student at the New York Institute of Technology College of Osteopathic Medicine. He plans on pursuing a residency in Diagnostic Radiology. Austin discovered his passion for radiology during his clinical rotations and finds using imaging to diagnose patients very rewarding. During his medical school career, Austin is a clinic manager for NYITCOM’s Community Free Clinic in Central Islip, Old Westbury, and Harlem. This organization helps patients without insurance receive health care while letting medical students get hands on experience before clinical rotations. Austin graduated from the New York Institute of Technology in 2017 with a Bachelor of Science degree in Biology. Austin’s hobbies include weightlifting and playing sports, especially basketball. Follow Austin Sanu on Twitter @austinsanu All posts by Ausin Sanu Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice is a radiologist with Renaissance Imaging Medical Associates and is currently the Vice Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

Radiology nurses provide for continuity of safe, quality care in the imaging department. Every patient deserves the same level of care regardless of day of the week or time. In the radiology department radiology nurses help ensure that every patient gets the same quality of care. We care for patients across the lifespan in all modalities in imaging. Radiology nurses are there to accept, interview, assess and prep the patient prior to procedures. They monitor vital signs and administer analgesia and sedation during the procedure or assist anesthesia when their services are needed. Post procedure the nurse monitors the patient until they are at baseline to be discharged to home or transferred to an inpatient unit. Radiology nurses teach the patient and significant other what to expect and what to do for follow-up care. We form relationships with patients and help ease anxiety and fear that is often associated with diagnostic tests and procedures. Radiology nurses improve the quality of the patient experience in radiology. In addition to scheduled hours many are part of the "on-call" team for emergencies 24/7. Radiology nurses may also be involved in radiology clinics, quality initiatives in the department, research in radiology and teaching throughout the department and hospital. We are an integral part of the radiology team ensuring safety and quality. So how did we become so adept at doing this? We have adapted skills learned from working in other specialties such as the intensive care unit or emergency department and have developed our own special set of skills needed for radiology nursing. Examples include how to respond to a contrast reaction, oxygen de-saturation from sedation and management of a groin puncture site. Radiology nurses improve the quality of the patient experience in radiology. The Association for Radiologic and Imaging Nursing (ARIN), an international nursing association, now in its 40th year, is dedicated to enhancing patient care through continuing nursing education, publications (the Journal of Radiology Nursing, a monthly newsletter, a core curriculum for radiologic and imaging nursing, a scope and standards book, an orientation manual, position statements and more), virtual webinars and annual convention with continuing education credits. ARIN supports certification in radiology nursing as administered by the Radiologic Nursing Certification Board (RNCB), an accredited body, and offers a review course prior to sitting for the examination. Informal networks allow for communication among members when "hot topics" surface. Regional chapters of ARIN hold regular meetings with presentations on a variety of subjects relevant to practice. Radiology nurses understand that radiology is dynamic and so must our practice must be that, too. New procedures are constantly being added and adaptability is a key to our success. While we pioneer new nursing care, evidence based care is our goal so some radiology nurses are dedicated to outcomes research to improve practice. Continuing education has been another key to the advancement of radiology nursing. The new text, Advanced Practice and Leadership in Radiology Nursing (Springer, 2020) is a good example of meeting the new needs of the radiology nurse who has entered an advanced practice role as a clinician, manager or educator. Nurses become leaders in the department. Working collaboratively with the radiologists and technologists helps ensure the best safe patient care. The above mentioned text with an interdisciplinary group of authors shows how the radiology department is interdependent on the various team members toward the imaging goal. Radiology nurses are proactive, inquisitive, caring and uniquely positioned to serve the many needs of the patient in the imaging department. If your department is not currently utilizing radiology nurses, the time to start is now. Discover more about radiology nursing at The Association for Radiologic and Imaging Nursing and see the official publication here: Journal of Radiology Nursing. Information about the recent book by Kathleen A. Gross for US residents here: Advanced Practice and Leadership in Radiology Nursing or Springer Europe: https://www.springer.com/gp/book/9783030326784 Kathleen A. Gross, MSN, BS, RN, MEDSURG-BC,CRN, FAARIN Kathleen Gross is the Editor-in-Chief of the Journal of Radiology Nursing, an Elsevier publication. She resides in the greater Baltimore metropolitan area. Kathleen has over 21 years of clinical experience working in Interventional Radiology and other imaging modalities. She has edited the Core Curriculum for Radiologic and Imaging Nursing Core Curriculum, 3rd ed. and has authored chapters on radiology nursing in Alexander’s Care of the Patient in Surgery, 14th ed. and in Perianesthesia Nursing Care: A Bedside Guide for Safe Recovery 1st and 2nd editions in addition to authoring numerous articles. Kathleen is a Past President of the Association for Radiologic and Imaging Nursing (ARIN) and has served in many capacities for ARIN. Currently, she is a member of the Standards Committee for the Society of Interventional Radiology and also a member of the American College of Radiology Patient and Family Centered Care Education Committee. Kathleen is focused on advancing education for all radiology nurses regardless of modality or geographic location to improve patient care. She enjoys mentoring new authors. She also advocates for the best patient experience for those undergoing imaging. She enjoys studying medical humanities and its role in healthcare, for patients and providers.

What is the eponymous name of this anatomic finding? • Xray of the Week Figure 1. What is the eponymous name of this anatomic finding? Figure 2. A. Coronal abdomen and pelvis CT. B. Magnified view. Cecum (yellow arrows). Appendix in inguinal canal (red arrows) Figure 3. Coronal MIP CT abdomen and pelvis in a different patient. Note the opacified appendix in the right inguinal canal. There is also a left inguinal hernia containing a short segment sigmoid colon without obstruction. Discussion: A vermiform appendix in an inguinal hernia, inflamed or not is known as Amyand hernia. (Figs. 1-3) It is a rare disease seen in about 1% of all hernias where complications such as appendicitis and perforated appendix within an inguinal hernia sac are even rarer, approximately 0.07-0.13% and 0.01% respectively [1-4]. The term was coined in honor of Claudius Amyand, a French surgeon, who performed the first successful appendectomy in 1735 on a 11 year old boy who presented with an inflamed appendix in the right inguinal hernial sac, perforated secondary to a metallic pin [1-3]. Amyand hernia is seen 3 times more commonly in children than in adults due to the patency of the processus vaginalis in the pediatric population [1]. In adults, Amyand hernia is exclusively on the right side and more common in males [1]. However, left-sided Amyand hernias may be seen associated with situs inversus, intestinal malrotation, mobile cecum or a large appendix. It can be accompanied by cecum, bladder, ovary, fallopian tube, omentum or a Meckel diverticulum [4]. It is usually an incidental finding during surgery; however, patients may present with sudden onset epigastric or periumbilical pain with localized tenderness in the right lower quadrant along with a tender irreducible mass in the inguinal or inguino-scrotal region. This clinical presentation is similar to strangulated inguinal or femoral hernia making clinical diagnosis of Amyand hernia difficult [1,3]. Although often an incidental finding at surgery, preoperative diagnosis can be confirmed with CT scan in patients with a clinical suspicion of appendicitis [1-4]. The CT findings in this patient shows a blind ended tubular structure arising from the cecum and extending into the inguinal sac (Figs. 1,2). Usually acute appendicitis is seen as dilated lumen, wall enhancement and thickening with periappendiceal fat stranding. However, in this case, the the appendix is normal. When scrotal involvement is suspected, sonography is a readily available and safe imaging modality[1, 2]. Table 1. Losanoff and Basson classification of Amyand hernias. Treatment: Losanoff and Basson proposed a classification scale to identify and treat Amyand hernias (Table 1) [5]. The literature recommends hernia reduction followed by no tension hernia repair. If appendectomy is performed then primary hernia repair without a prosthetic mesh is the best option to prevent infection. Use of synthetic mesh is avoided in the repair of contaminated abdominal defects because prosthetic material can increase the inflammatory response and result in wound infection. [1, 3]. ​​​​ References: 1. Ivanschuk G, Cesmebasi A, Sorenson EP, et al. Amyand's hernia: a review. Med Sci Monit, 2014. 20: p. 140-6 doi:10.12659/msm.889873 2. Green J and Gutwein LG. Amyand's hernia: a rare inguinal hernia. J Surg Case Rep, 2013. 2013(9) doi:10.1093/jscr/rjt043 3. Luchs JS, Halpern D, Katz DS. Amyand's Hernia: Prospective CT Diagnosis. Journal of Computer Assisted Tomography, 2000. 24(6): p. 884-886. doi:10.1097/00004728-200011000-00011 4. Morales-Cárdenas A, Ploneda-Valencia CP, Sainz-Escárrega VH, et al. Amyand hernia: Case report and review of the literature. Ann Med Surg (Lond), 2015. 4(2): p. 113-5 doi:10.1016/j.amsu.2015.03.007 5. Losanoff JE and Basson M. Amyand hernia: A classification to improve management. Hernia : the journal of hernias and abdominal wall surgery, 2008. 12: p. 325-6 doi:10.1007/s10029-008-0331-y Shama Jaswal is an International Medical Graduate, currently doing research at Mallinckrodt Institute of Radiology (MIR), Saint Louis. She aims at pursuing Diagnostic Radiology residency and poses a keen interest in research alongside academics. At MIR, she has been fortunate to work on various oncology projects including the project in which they studied how the difference in fat metabolism in both sexes can affect the cancer survival and outcome, and how this study can further improve prognosis through treatment modification. Shama is both an accomplished sprinter and singer having won several national competitions in in each discipline in India. She also has a strong passion for cooking and gardening. Follow Shama Jaswal on Twitter @Jaswal_Shama All posts by Shama Jaswal Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice is a radiologist with Renaissance Imaging Medical Associates and is currently the Vice Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

76-year-old female presenting with abdominal pain for 11 days • Xray of the Week Figure 1. Describe the abdominal findings. Figure 2. A. Axial CT scan of the abdomen and pelvis demonstrating small bowel obstruction secondary to hernia with collapsed small bowel distal to obstruction (yellow arrow), collapsed colon distal to obstruction (orange arrows), and dilated small bowel proximal to the obstruction (green arrow). B. Axial CT scan of the abdomen and pelvis demonstrating small bowel obstruction secondary to hernia with collapsed small bowel distal to obstruction (yellow arrow), collapsed colon distal to obstruction (orange arrows), and dilated small bowel proximal to the obstruction (green arrow). C. Coronal CT abdomen and pelvis demonstrating dilated small bowel proximal to the obstruction (green arrow) and collapsed small bowel distal to obstruction (yellow arrow). Note the loop of small bowel herniated through the right inguinal canal. Discussion: An abdominal wall hernia occurs when a portion of the bowel or peritoneum extends beyond the abdominal wall, resulting in a sac containing tissue or abdominal organs. Hernias can further be classified as inguinal, femoral, incisional, umbilical, or epigastric (1). The most common complications of abdominal wall hernias include small bowel obstruction (SBO) (2). A SBO is defined as a complete or partial blockage of the small intestine due to a functional or mechanical pathology (Figs. 1,2). This clinically presents as abdominal pain, distension, nausea, vomiting, constipation, and high-pitched or absent bowel sounds. The obstructions are commonly secondary to hernia incarceration or hernia strangulation (2). Incarceration of the hernia occurs when the hernial sac can no longer be reduced (3). This poses a risk for strangulation, which results in constriction of the vascular supply to the hernia sac (4). Strangulated hernias can be life-threatening for the patient and requires prompt surgical intervention (1,4). CT imaging is helpful in identifying subtle signs of complications such as obstruction, incarceration, strangulation, and contents within the hernial sac (3). On CT imaging, key findings of SBO include small bowel dilation, a transition point from dilated to nondilated small bowel, colon compression, and air-fluid levels (5). The dilated bowel can be visualized as proximal to the obstruction, with reduced or collapsed bowel distal to the obstruction (Figs. 1,2) (2). Findings of ischemia secondary to strangulation include bowel wall thickening, mesenteric vessel engorgement, and ascites (2). If asymptomatic, abdominal wall hernias are typically not operated on. However, if the abdominal wall hernia presents with incarceration or strangulation surgical management is indicated. ​​​​ References: Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG); 2006-. Hernias: Overview. 2016 Sep 21 [Updated 2020 Jan 30]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK395554/ Aguirre DA, Santosa AC, Casola G, Sirlin CB. Abdominal wall hernias: imaging features, complications, and diagnostic pitfalls at multi-detector row CT. Radiographics. 2005;25(6):1501-1520. doi:10.1148/rg.256055018 Baiu I, Hawn MT. Small Bowel Obstruction. JAMA. 2018;319(20):2146. doi:10.1001/jama.2018.5834 Lassandro F, Iasiello F, Pizza NL, et al. Abdominal hernias: Radiological features. World J Gastrointest Endosc. 2011;3(6):110-117. doi:10.4253/wjge.v3.i6.110 Paulson EK, Thompson WM. Review of small-bowel obstruction: the diagnosis and when to worry. Radiology. 2015;275(2):332-342. doi:10.1148/radiol.15131519 Rabab Zaidi is an aspiring radiologist and fourth year medical student at the Loyola University Chicago Stritch School of Medicine (SSOM). She currently serves as the Community Support Co-Lead for the Loyola University COVID-19 Response Team and Co-President of the Radiology Interest Group at SSOM. At the Stritch School of Medicine, she has also worked with the Department of Radiation Oncology to study prostate cancer imaging and adaptive radiotherapy techniques, where she learned about the intersection of patient care and radiology. Rabab graduated magna cum laude with a degree in Economics from Loyola University Chicago in 2016. She is further passionate about mentorship, advocacy, and photography. Follow Rabab Zaidi on Twitter @ZaidiRabab All posts by Rabab Zaidi Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice is a radiologist with Renaissance Imaging Medical Associates and is currently the Vice Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

76 yo M acute right side weakness • Xray of the Week Figure 1. What is the diagnosis? Figure 2. A. T1 weighted image. Note the hyperintense nodules and masses with surrounding edema (red arrows). There is mass effect with narrowing of the left lateral ventricle and third ventricle, as well as rightward midline shift. B. T1 weighted image with contrast. Hyperintense nodules and masses with surrounding edema which also demonstrate contrast enhancement (yellow arrows) and large hemorrhagic lesion in left frontal lobe (green arrow) with hematocrit level compatible with hemorrhage. C. FLAIR image showing large hemorrhagic lesion in left frontal lobe with hematocrit level (green arrow). Discussion: Melanomas are skin cancers that develop in melanocytes, which are derived from the neural crest and produce melanin (1). If sufficient melanin is present in a melanoma, it can appear on T1-weighted magnetic resonance imaging as high signal intensity (1). Melanomas can metastasize to the regional lymph nodes, but hematogenous spread to other organs is most common in advanced stages (1). Advanced melanoma is commonly associated with brain metastases. Nearly 20% of patients have brain metastasis at time of diagnosis of metastatic melanoma while over 50% of patients develop brain metastasis after diagnosis (2). Intracranial melanoma metastases (IMM) can be classified as melanotic with more than 10% melanotic cells or amelanotic with less than 10% melanotic cells (3). They also commonly present with large hemorrhagic lesions as seen in this case. Most intracranial lesions are hypointense on T1-weighted images, but high signal intensity can occur with various substances including gadolinium contrast, intra- and extra-cellular methemoglobin, fat, proteins, minerals such as manganese copper and calcium, and melanin (4,5). The unique T-1 hyperintensity on MR can help in narrowing the differential diagnosis. Melanin pigment has stable free radicals which are paramagnetic and cause shortening of T1 and T2 relaxation times (3,6). Chelated metal ions in melanin and unpaired electrons in free radicals can also cause dipole-dipole interactions and proton relaxation enhancement (3,6). On MRI, melanotic IMM appears as hyperintense relative to the cortex in T1-weighted images due to melanin pigment and hemorrhage, as in this case. Contrast enhancement demonstrates a peripheral rim or diffusely heterogeneous pattern (3). Hypointensity can be seen on T2-weighted images and isointensity or hyperintensity can be seen on proton density-weighted images (3). Amelanotic melanomas show hypointensity or isointensity relative to the cortex on T1 and hyperintensity or isointensity on T2 (3). On CT, IMM can present as single or multiple nodules with increased attenuation and frequent ring-enhancement (5,7). Optical Coherence Tomography (OCT) can also be used to identify intracortical melanomas intraoperatively. This technique is similar to ultrasound B-imaging but it uses reflections of infrared light instead of sound (7). Increased optical backscatter suggests the presence of the tumor in this method (7). Prognosis of IMM is poor, and treatment is controversial (7-9). Current options include surgical resection, stereotactic radiosurgery, whole brain radiation therapy, and immune checkpoint inhibitors, but varying combinations of these methods are typically used (8,9). ​​​​ References: 1. Patnana M, et al. Multimethod Imaging, Staging, and Spectrum of Manifestations of Metastatic Melanoma. Clinical Radiology, vol. 66, no. 3, Mar. 2011, pp. 224–36. doi:10.1016/j.crad.2010.10.014 2. Vosoughi Elham, et al. Survival and Clinical Outcomes of Patients with Melanoma Brain Metastasis in the Era of Checkpoint Inhibitors and Targeted Therapies. BMC Cancer, vol. 18, no. 1, Apr. 2018, p. 490. BioMed Central, doi:10.1186/s12885-018-4374-x 3. Isiklar I, et al. Intracranial Metastatic Melanoma: Correlation between MR Imaging Characteristics and Melanin Content. American Journal of Roentgenology, vol. 165, no. 6, Dec. 1995, pp. 1503–12. doi:10.2214/ajr.165.6.7484597 4. Cakirer S, et al. Spontaneously T1-Hyperintense Lesions of the Brain on MRI: A Pictorial Review. Current Problems in Diagnostic Radiology, vol. 32, no. 5, Oct. 2003, pp. 194–217. PubMed, doi:10.1016/s0363-0188(03)00026-4 5. Zimny A, et al. Intracranial Lesions with High Signal Intensity on T1-Weighted MR Images – Review of Pathologies. Polish Journal of Radiology, vol. 78, no. 4, 2013, pp. 36–46. PubMed: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3908506/ 6. Ma, Mian, et al. Neurocutaneous Melanosis in an Adult Patient with Intracranial Primary Malignant Melanoma: Case Report and Review of the Literature. World Neurosurgery, vol. 114, June 2018, pp. 76–83. ScienceDirect. doi:10.1016/j.wneu.2018.02.007 7. Goulart CR, et al. Cerebral Melanoma Metastases: A Critical Review on Diagnostic Methods and Therapeutic Options. ISRN Surgery, vol. 2011, 2011. doi:10.5402/2011/276908 8. Ma YF, et al. Intracranial Malignant Melanoma: A Report of 7 Cases. Oncology Letters, vol. 10, no. 4, Oct. 2015, pp. 2171–75. PubMed Central, doi:10.3892/ol.2015.3537 9. Goyal S, et al. The Clinical Management of Multiple Melanoma Brain Metastases: A Systematic Review. JAMA Oncology, vol. 1, no. 5, Aug. 2015, pp. 668–76. doi:10.1001/jamaoncol.2015.1206 Amara Ahmed is a medical student at the Florida State University College of Medicine. She serves on the executive board of the American Medical Women’s Association and Humanities and Medicine. She is also an editor of HEAL: Humanism Evolving through Arts and Literature, a creative arts journal at the medical school. Prior to attending medical school, she graduated summa cum laude from the Honors Medical Scholars program at Florida State University where she completed her undergraduate studies in exercise physiology, biology, and chemistry. In her free time, she enjoys reading, writing, and spending time with family and friends. Follow Amara Ahmed on Twitter @Amara_S98 All posts by Amara Ahmed Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice is a radiologist with Renaissance Imaging Medical Associates and is currently the Vice Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

70F with abdominal pain • Xray of the Week Figure 1. Describe the abdominal findings. Figure 2. A. Axial CT scan of the abdomen demonstrating small bowel obstruction secondary to umbilical hernia with collapsed small bowel distal to obstruction (yellow arrow). B. Axial CT abdomen demonstrating dilated small bowel in C shape configuration (green arrow). C. Sagittal CT abdomen demonstrating umbilical hernia outpouching from the abdominal wall. Outline of the hernia follows a C-configuration with small bowel contained within the hernial sac with inflammatory changes (blue arrow). Discussion: An abdominal wall hernia occurs when a portion of the bowel or peritoneum extends beyond the abdominal wall, resulting in a sac containing tissue or abdominal organs. Hernias can be classified as inguinal, femoral, incisional, umbilical, or epigastric (1). The most common ventral hernia is the umbilical hernia (3). An umbilical hernia occurs due to a defect in the anterior abdominal wall 3 cm above or below the umbilicus, as seen in Figure 1 (2). This abdominal defect is common among patients with increased intra-abdominal pressure due to pregnancy, ascites, or obesity, which weakens the abdominal musculature (2). Common complications of abdominal wall hernias include small bowel obstruction (SBO) and bowel ischemia (3,4). An SBO is defined as a complete or partial blockage of the small intestine due to a functional or mechanical pathology as seen in Figure 1. This presents as abdominal pain, distension, nausea, vomiting, constipation, and high-pitched or absent bowel sounds. Further complications include hernia incarceration (irreducible sac) and strangulation (ischemia secondary to lack of blood supply) (3). The use of CT imaging helps identify subtle signs of complications such as obstruction, incarceration, and strangulation (4). On CT imaging, key findings of an SBO include small bowel dilation, a transition point from dilated to nondilated small bowel, colon compression, and air-fluid levels (3, 5). In Figure 1, CT imaging demonstrates the umbilical hernia containing a portion of the small bowel in a C-shaped configuration. Narrowing of the hernial sac neck in addition to fat stranding on CT imaging also suggests hernia incarceration and inflammatory changes (3). Other associated findings of SBO secondary to a strangulated umbilical hernia include discrete mesenteric engorgement, ascitic fluid within the hernia sac, and dilation of herniated bowel loops (3). If asymptomatic, abdominal wall hernias are typically not operated on. If complications arise, surgical treatment with laparoscopic repair or mesh is indicated (3, 4). ​​​​ References: Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG); 2006-. Hernias: Overview. 2016 Sep 21 [Updated 2020 Jan 30]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK395554/ Coste AH, Jaafar S, Parmely JD. Umbilical Hernia. [Updated 2020 Jun 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459312/ Aguirre DA, Santosa AC, Casola G, Sirlin CB. Abdominal wall hernias: imaging features, complications, and diagnostic pitfalls at multi-detector row CT. Radiographics. 2005;25(6):1501-1520. doi:10.1148/rg.256055018 Baiu I, Hawn MT. Small Bowel Obstruction. JAMA. 2018;319(20):2146. doi:10.1001/jama.2018.5834 Paulson EK, Thompson WM. Review of small-bowel obstruction: the diagnosis and when to worry. Radiology. 2015;275(2):332-342. doi:10.1148/radiol.15131519 Rabab Zaidi is an aspiring radiologist and fourth year medical student at the Loyola University Chicago Stritch School of Medicine (SSOM). She currently serves as the Community Support Co-Lead for the Loyola University COVID-19 Response Team and Co-President of the Radiology Interest Group at SSOM. At the Stritch School of Medicine, she has also worked with the Department of Radiation Oncology to study prostate cancer imaging and adaptive radiotherapy techniques, where she learned about the intersection of patient care and radiology. Rabab graduated magna cum laude with a degree in Economics from Loyola University Chicago in 2016. She is further passionate about mentorship, advocacy, and photography. Follow Rabab Zaidi on Twitter @ZaidiRabab All posts by Rabab Zaidi Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice is a radiologist with Renaissance Imaging Medical Associates and is currently the Vice Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD