Right Shoulder Pain in Throwing Athlete • Xray of the Week 2016 • Week #47 This 21 year old college baseball catcher had decreased velocity when throwing and right shoulder pain for 2 months. What is the diagnosis? Figure 1. Coronal and sagittal images shows mild atrophy in the inferior subscapularis muscle (yellow arrows) and teres major muscle (red arrows). Neuropraxia changes include atrophy and fatty replacement. Figure 2. Left image. Coronal image showing the neuropraxia changes with mild atrophy in the inferior subscapularis muscle (yellow arrow) and teres major muscle (red arrow). Neuropraxia changes include atrophy and fatty replacement. Figure 2. Right image. Axial image showing a “Kim’s” lesion with posterior bone buildup. This is often seen with Glenohumeral Internal Rotation Deficit (GIRD). Figure 3. Axial MRI image shows a posterior peelback SLAP lesion seen in throwing athletes (yellow arrow). The lower subscapular nerve innervates the lower (inferior) aspect of the subscapularis muscle as well as the teres major muscle. Denervation can occur with trauma to the nerve such as stretching (a.k.a.stretch neuropraxia), blunt trauma, laceration or transection of the nerve with penetrating trauma. The nerve can also be involved with inflammatory or inflammatory like conditions such as Parsonage Turner syndrome, denervation changes, and non specific brachial plexitis. Mass compression of the nerve may also cause denervation. Either adjacent neoplasia or scar entrapment from prior trauma can exert mass effect on the nerve, potentially causing ischemia and malfunction of the nerve. Lower subscapular nerve stretch neuropraxia is potentially reversible with the cessation of activities that lead to the neuropraxia or resolution of the swelling associated with a single traumatic event. MRI findings of lower subscapular nerve denervation involve the 2 muscles innervated by the nerve. Early findings are of muscle belly swelling (bright on T2 and fat sat PD or T2 images - see figure 1). Late findings are of atrophy, and the presence of atrophy indicates irreversibility. References: 1. Burkhart S, Morgan C, Kibler, W. The Disabled Throwing Shoulder: Spectrum of Pathology Part I: Pathoanatomy and Biomechanics. Arthroscopy: The Journal of Arthroscopic and Related Surgery. 2003;19 (4): 404-420 2. Gaskin C and Helms C. Parsonage-Turner Syndrome: MR Imaging Findings and Clinical Information of 27 Patients. Radiology. 2006;240 (2): 501-507. 2. Romeo AA, Rotenberg DD, Bach BR. Suprascapular neuropathy. J Am Acad Orthop Surg. 2001;7 (6): 358-67. 3. Yanny S, Toms AP. MR patterns of denervation around the shoulder. AJR Am J Roentgenol. 2010;195 (2): W157-63. 4. Linda DD, Harish S, Stewart BG et-al. Multimodality imaging of peripheral neuropathies of the upper limb and brachial plexus. Radiographics. 2010;30 (5): 1373-400. Phillip Tirman, MD is the Medical Director of Musculoskeletal Imaging at the Renaissance Imaging Center in Westlake Village, California. A nationally recognized expert in the applications of MRI for evaluating MSK and spine disorders, Dr. Tirman is the co-author of three textbooks, including MRI of the Shoulder and Diagnostic Imaging: Orthopedics. He is also the author or co-author on over sixty original scientific articles published in the radiology and orthopedic literature. All posts by Phillip Tirman, MD All posts by Kevin Rice, MD

New Right Breast Nodule in 58F • Xray of the Week 2016 • Week #45 This 58 year old woman was hospitalized for DVT and suspected pulmonary emboli. The chest CT showed no pulmonary emboli, but there was a lesion in the upper part of the right breast. What rare type of breast mass could this be? Figure 1. Bilateral mammogram 6 months ago was normal. Figure 2. Left image: MLO Mammogram, shows a nodule with lobular shape and circumscribed margins in the right breast superiorly. Right image: CC Mammogram, shows a nodule with lobular shape and circumscribed margins in the right breast posteriorly. Figure 3: Ultrasound images show a hypoechoic right breast nodule with angular margin, peripheral flow, parallel orientation, abrupt interface, neutral sound transmission, and complex echotexture. Figure 4: Axial MRI images show an enhancing mass in the right breast. The MRI features are suspicious for malignancy. MRI images courtesy of Nadja Lindhe, MD - Radiologist at Department of Mammography, Central Hospital Falun, Falun, Sweden Figure 5: Ultrasound images show biopsy of the mass. Histology is hemangioma. Histology images are courtesy of Tibor Tot, MD PhD - Associate Professor, Department of Pathology and Clinical Cytology, Central Hospital Falun, Falun, Sweden Due to the malignant appearance on MRI, ultrasound biopsy was performed [Fig.5] followed by excision of the nodule. Pathology was hemangioma of the breast. Figure 6: Specimen radiograph of excisional biopsy with associated large section histology. There is no invasive component. Histology images are courtesy of Tibor Tot, MD PhD - Associate Professor, Department of Pathology and Clinical Cytology, Central Hospital Falun, Falun, Sweden Figure 7: Histology demonstrated a partially fibrotic/hyalinized hemangioma containing dilated vessels with no evidence of malignancy. Note the dilated vascular channels of varying size (green arrow) and compact, dense aggregates of capillary structures (yellow arrow). Histology images are courtesy of Tibor Tot, MD PhD - Associate Professor, Department of Pathology and Clinical Cytology, Central Hospital Falun, Falun, Sweden Discussion Hemangioma of the breast is a rare vascular tumor of the breast which is usually extraparenchymal and for that reason is superficial [1-4]. According to an analysis of 15 cases, the mammographic appearance has an oval shape in 33% of cases and a lobular shape in 53% of cases; while the margins are circumscribed 53% of the time and microlobulated 46% of the time. Rarely the mammogram may show characteristic phleboliths [1,3,4,5]. Tangential views may show the mass to be superficial in location [1]. Sonography usually demonstrates a lobulated, superficial, well-circumscribed, solid mass. Due to the dilated blood vessels the nodules are often heterogeneous on ultrasound; however, hemangiomas may be difficult to visualize on ultrasound as about 11% are isoechoic [1,6]. MRI of the lesions is not well documented with one case showing slow, delayed enhancement within a capillary hemangioma [6]. A second report demonstrated avid early homogenous contrast enhancement with plateau formation seen on dynamic enhancement curve following initial early washout of contrast [7]. On occasions such as in this case when there are malignant features on imaging studies [Figs. 2-4], biopsy is indicated [8,9]. Jozefczyk and Rosen in their study of 62 angiosarcomas and 24 hemangiomas found that angiosarcomas were rarely smaller than 2 cm [10]. Histology of hemangiomas demonstrates unencapsulated aggregates of closely packed, thin-walled capillaries, with endothelial lining. Their lumens may be thrombosed and organized [10-12]. This case has the histologic appearance of a complex hemangioma [Figs. 5-7] with dilated vascular channels of varying size and compact, dense aggregates of capillary structures [12]. As in this case, when a hemangioma is diagnosed by core needle biopsy, complete excision is advised as low grade angiosarcoma may be indistinguishable and there is the remote possibility of malignant transformation to angiosarcoma [1, 10]. In conclusion, a superficial mass measuring less than 2 cm with oval or lobular shape and complex or isoechoic echotexture may give the radiologist a clue to this unusual diagnosis Other breast imaging cases: Invasive Ductal Carcinoma of the Breast in 27 Year Old Phyllodes Tumor Medullary Breast Cancer References: 1. Mesurolle B, Sygal V, Lalonde L, et al. Sonographic and Mammographic Appearances of Breast Hemangioma. AJR 2008; 191:W17–W22 www.ajronline.org/doi/full/10.2214/AJR.07.3153 2. Chung SY, Oh KK. Mammographic and sonographic findings of a breast subcutaneous hemangioma. J Ultrasound Med 2002; 21:585 –588. http://www.jultrasoundmed.org/content/21/5/585.long 3. Webb LA, Young JR. Case report: haemangioma of the breast—appearances on mammography and ultrasound. Clin Radiol 1996; 51:523 –524. https://www.ncbi.nlm.nih.gov/pubmed/8689834?dopt=Abstract 4. Tabar L, Dean PB. Teaching Atlas of Mammography. 2nd ed. New York, NY: Thieme; 1985:45. 5. Tabar L, Dean PB. Teaching Atlas of Mammography. 2nd ed. New York, NY: Thieme; 1985:209. 6. Glazebrook KN, Morton MJ, Reynolds C. Vascular tumors of the breast: mammographic, sonographic, and MRI appearances. AJR 2005; 184:331 –338 http://www.ajronline.org/doi/10.2214/ajr.184.1.01840331 7. Ameen R, Mandalia U, Marr A, et al. Breast Hemangioma: MR Appearance with Histopathological Correlation. J Clin Imaging Sci. 2012; 2: 53. Published online 2012 Aug 30. doi: 10.4103/2156-7514.100376 8. Mariscal A, Casas JD, Balliu E, Castella E. Breast hemangioma mimicking carcinoma. Breast 2002; 11:357–358. www.thebreastonline.com/article/S0960-9776(02)90453-4/abstract9 9. Hoda SA, Cranor ML, Rosen PP. Hemangiomas of the breast with atypical histological features: further analysis of histological subtypes confirming their benign character. Am J Surg Pathol 1992; 16:553 –560. www.ncbi.nlm.nih.gov/pubmed/1599035?dopt=Abstract 10. Jozefczyk MA, Rosen PP. Vascular tumors of the breast. II. Perilobular hemangiomas and hemangiomas. Am J Surg Pathol 1985; 9:491 –503 https://www.ncbi.nlm.nih.gov/pubmed/4091183?dopt=Abstract 11. Lesueur GC, Brown RW, Bhathal PS. Incidence of perilobular hemangioma in the female breast. Arch Pathol Lab Med 1983; 107:308 –310. https://www.ncbi.nlm.nih.gov/pubmed/6687795?dopt=Abstract 12. Hoda SA, Brogi E, Koerner F, Rosen PP. Rosen's Breast Pathology 4e. 2014. Lippincott, Williams, and Wilkins. (2014) ISBN-13: 978-1451176537 Buy it on Amazon László Tabár, MD, FACR (Hon) the Professor Emeritus of Radiology Uppsala University, Faculty of Medicine, Sweden and the Medical Director Emeritus of the Department of Mammography, Falun Central Hospital, Sweden. Through his company, Mammography Education, Inc, he has also been the course director and principal lecturer at more than 300 mammography courses on 6 continents. His pioneering research has laid the foundation for early detection through modern mammographic screening. Dr. Tabár is the recipient of numerous awards including the Gold Medal from the Society of Breast Imaging, American Cancer Society's Distinguished Service Award, and the first Alexander Margulis Award for Scientific Excellence from the Radiological Society of North America (RSNA). Dr. Tabár will be sharing his vast knowledge of breast imaging at Imaging in Israel - 2017. 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 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 All Posts by László Tabár, MD

Abdominal Pain and Acute Renal Failure • Xray of the Week This 88 yo female presented with abdominal pain and acute renal failure. Multiple co-morbidities (cardiac disease, old MI, cirrhosis, portal hypertension, asthma, hypertension, pancytopenia, diabetes) precluded surgery for the patient's condition. What is the diagnosis? Figure 1. CT scan of the abdomen and pelvis. Axial images (A and B) demonstrate bilateral hydronephrosis. Sagittal image (C) demonstrates global pelvic floor “failure” with prolapse of the vagina, uterus, bladder, and rectum. In this case, the hydronephrosis [Fig. 1 A,B] is caused by compression of the vesicoureteric junctions as the bladder has prolapsed below the pelvic floor. In the above sagittal image [Fig. 1C], it is apparent that the vagina, uterus and bladder have prolapsed, indicating that there is likely global pelvic floor “failure”. The incidence of pelvic organ prolapse (POP) has been difficult to estimate accurately, partially due to a relative lack of knowledge about the symptoms, diagnostic tools and therapeutic options amongst both the general population and the medical community. Options for imaging of POP include defecating x-ray/fluoroscopic proctography (aka defecography), or MRI. The major benefits of MRI are the ability to image the bladder, vagina, uterus and small bowel without additional contrast administration, due to the inherent soft tissue imaging capability of MRI. These structures can be imaged using x-ray defecography, but at the expense of a much more invasive test as it necessitates bladder catheterization and insertion of a vaginal swab, and also involves exposure to ionizing radiation. Both methods do require insertion of rectal contrast material to enable more accurate assessment of rectoanal mucosal prolapses and rectocele size. This week's Xray of the week is sponsored by Radiology Basics - Get it free on iTunes Dynamic pelvic floor MRI utilizes rapid sequences such as Siemens’ TRUE FISP (Fast Imaging with Steady-state free Precession), GE’s FIESTA (Fast Imaging Employing Steady-state Acquisition) or Philips’s Balanced-FFE (Fast Field Echo). The trade off for the rapidity of the exam acquisition is in image quality, but for the purposes of the study, this compromise is acceptable. The technique uses 100 ml of ultrasound gel inserted through the anal canal using bladder (catheter tip) syringes. Ultrasound gel is readily available and easy to place into the syringes; and the syringes have a nozzle shape and size ideal for anal insertion. After gel injection, the patient is asked to “push” the gel out and images are acquired at a frame rate of approximately 1 image per second. The images are viewed as a cine clip, and alongside a qualitative assessment, are analyzed using the pubococcygeal line (PCL) scoring system. By measuring the relative distances of the anterior, middle and posterior compartmental organs from the PCL, prolapses can be graded as mild, moderate or severe [Fig. 2]. The above video in a different patient is an example of a severe bladder prolapse (cystocele), severe anorectal junction descent and a moderate sized anterior rectocele. Figure 2. The PCL line on a still image from the above video, with the red arrow indicating the cystocele, and the green arrow indicating the anorectal descent and anterior rectocele. The pubococcygeal line (PCL) is the yellow line. References: 1. García del Salto L, de Miguel Criado J, et al. MR Imaging–based Assessment of the Female Pelvic Floor. RadioGraphics 2014; 34:1417–1439. http://pubs.rsna.org/doi/full/10.1148/rg.345140137 2. Chiara Colaiacomo M, Masselli G, et al. Dynamic MR Imaging of the Pelvic Floor: a Pictorial Review. RadioGraphics 2009, 10.1148/rg.e35. http://pubs.rsna.org/doi/abs/10.1148/rg.e35 3. Boyadzhyan L, Raman S, et al. Role of Static and Dynamic MR Imaging in Surgical Pelvic Floor Dysfunction. RadioGraphics 2008; 28:949–967. http://pubs.rsna.org/doi/pdf/10.1148/rg.284075139 4. Bitti G, Argiolas G, et al. Pelvic Floor Failure: MR Imaging Evaluation of Anatomic and Functional Abnormalities. RadioGraphics 2014; 34:429–448. http://pubs.rsna.org/doi/abs/10.1148/rg.342125050 Vikas Shah, MBBS FRCR is a Consultant Radiologist specializing in gastrointestinal and colorectal imaging at University Hospitals of Leicester NHS Trust. Dr. Shah did his Radiology training in London, England at Imperial College Hospitals NHS Trust, and subsequently did subspecialty training in oncologic imaging at Mount Vernon Hospital and in pelvic floor and colonic imaging at St. Mark's Hospital. Dr. Shah is passionate about teaching, and in particular the use of social media and mobile technology to enhance teaching and education. His expertise in pelvic floor imaging is underlined by his appointment to the Medical Advisory Committee of the Association of Pelvic Organ Prolapse Support (APOPS). The originator of #xrayofthewek, Dr. Shah blogs at www.thexraydoctor.co.uk Follow Dr. Shah on Twitter @DrVikasShah Kevin M. Rice, MD is president of Global Radiology CME and 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

Paresthesias • Xray of the Week 2016 • Week #42 This 60 year old caucasian male with stage 4 fibrosis of liver presented with unsteady gait and falls. He also had paresthesias including tingling and numbness of the wrists for one month. Laboratory values as follows: MMA = 24,600 (N 0-0.40 nmol/mL) B12 = 142 (N= 150 to 350 pg/mL.) Folate = 14.5 (N= 2-20 ng/mL) Hgb = 12.8 (N= 13-17 g/dL) MCV = 129 (N= 80-100 fL) MRI of cervical spine was done after the patient fell. What is the diagnosis? Figure 1.: Axial and sagittal T2-weighted images showing dorsal column T2 hyperintensity suspicious for subacute combined degeneration of the cord. In vitamin B12 deficiency, the methylmalonic acid (MMA) level may be elevated before the vitamin B12 level is low [1]. Elevated mean corpuscular volume (MCV) is a sign of B12 or folate deficiency, resulting in macrocytic anemia. This patient's markedly elevated MMA, low B12, and normal folate levels are diagnostic of vitamin B12 deficiency. Subacute combined degeneration of the cord is a metabolic disorder due to vitamin B12 deficiency which results in paresthesias of the hands and feet. Later in the disease, patients develop unsteady gait and weakness due to damage of the sensory tracts in the spinal cord[2]. The classic MRI appearance is abnormal high signal on T2 weighted images in the dorsal columns as well as lateral columns on T2-weighted images, leading to the "inverted V sign" [3-6]. Rarely the anterior columns may be involved [8]. The clinical symptoms and imaging findings are reversible with administration of vitamin B12 [2]. References: 1. How do we evaluate a marginally low B12 level? http://www.mdedge.com/jfponline/article/62530/how-do-we-evaluate-marginally-low-b12-level 2. Patten John P. Neurological Differential Diagnosis. Second Edition. London: Springer-Verlag, 1996. pg 234-235, Print. 3. Ravina B, Loevner LA, Bank W. MR findings in subacute combined degeneration of the spinal cord: a case of reversible cervical myelopathy. AJR Am J Roentgenol. 2000;174 (3): 863-5. 4. Kumar, Ashok, and Amar Kumar Singh. "Teaching NeuroImage: Inverted V sign in subacute combined degeneration of spinal cord." Neurology 72.1 (2009): e4-e4. 5. Naidich M, Ho S. Case 87: Diagnosis Please - Subacute Combined Degeneration. Radiology 2005; 237:101–105 6. Narra R, Mandapalli A, Jukuri N, Guddanti P. “Inverted V sign” in Sub-Acute Combined Degeneration of Cord. J Clin Diagn Res. 2015 May; 9(5) 7. Ketonen, Leena. Pediatric Brain and Spine: An Atlas of MRI and Spectroscopy. Berlin: Springer, 2005. pg 435, Print. 8. Karantanas AH, Markonis A, Bisbiyiannis G. Subacute combined degeneration of the spinal cord with involvement of the anterior columns: a new MRI finding. Neuroradiology. 2000;42 (2): 115-7. Danielle Rice, MD is a neurohospitalist at Gottlieb Memorial Hospital, a part of Loyola University Health System. Dr. Rice graduated cum laude from Kent State University and earned her medical degree from Northeastern Ohio Universities College of Medicine. Dr. Rice completed a residency in adult neurology from Rush University Medical Center and a fellowship in multiple sclerosis from the University of Chicago. Dr. Rice is board certified in Neurology and is an assistant professor in the Department of Neurology of Loyola University Chicago Stritch School of Medicine. Kevin Rice, MD is president of Global Radiology CME. Follow Dr. Kevin Rice on Twitter @KevinRiceMD All Posts by Kevin M Rice, MD All Posts by Danielle Rice, MD

Flat Foot and Pain with Walking • Xray of the Week 2016 • Week #41 56 y/o female with chronic anterior talofibular ligament (ATFL) tear, flat foot, and pain with walking. What is the diagnosis? Fig. 1. Images show loss of fatty tissue, edema as well as scarring (arrows). Fig. 2 Normal appearance of the sinus tarsi with preserved fatty tissue – 3T Fig. 3 Note pes planus and mid foot arthrosis on sagittal image. Coronal Fat Sat image shows edema and scar. Fig. 4 Axial fat sat (left image) and T1 image shows loss of fatty tissue, edema as well as scarring (orange arrows). Fig. 5 Edema and scarring and reactive osseous edema (blue arrows) Fig. 6 Normal ligaments of the sinus tarsi. Discussion Sinus Tarsi Syndrome usually presents with lateral foot pain and tenderness. There may be subtalar micro-instability; however, frank ankle instability is usually not present. Pathologically there is scarring and degenerative changes of soft-tissue structures in the sinus tarsi. Seventy percent of patients have a history of inversion injury with lateral ligament complex tears, and it is frequently associated with posterior tibial tendon injury. On MRI, in the acute setting there is increased signal in fat on T2 weighted images due to edema. [Fig. 3-5] There may also be reactive osseous edema with high signal on PD and T2 weighted fat saturation images[Fig.5] Treatment of sinus tarsi syndrome is usually conservative, with initial immobilization and anti-inflammatory drugs, followed by physiotherapy. References: 1. Helgeson K. Examination and intervention for sinus tarsi syndrome. N Am J Sports Phys Ther. 2009;4 (1): 29-37. 2. Lee KB, Bai LB, Park JG et-al. Efficacy of MRI versus arthroscopy for evaluation of sinus tarsi syndrome. Foot Ankle Int. 2008;29 (11): 1111-6. 3. Klein MA, Spreitzer AM. MR imaging of the tarsal sinus and canal: normal anatomy, pathologic findings, and features of the sinus tarsi syndrome. Radiology. 1993;186 (1): 233-40. 4. Herrmann M, Pieper KS. [Sinus tarsi syndrome: what hurts?]. Unfallchirurg. 2008;111 (2): 132-6. 5. Rosenberg ZS, Beltran J, Bencardino JT. From the RSNA Refresher Courses. Radiological Society of North America. MR imaging of the ankle and foot. Radiographics. 2000;20 Spec No : S153-79. Phillip Tirman, MD is the Medical Director of Musculoskeletal Imaging at the Renaissance Imaging Center in Westlake Village, California. A nationally recognized expert in the applications of MRI for evaluating MSK and spine disorders, Dr. Tirman is the co-author of three textbooks, including MRI of the Shoulder and Diagnostic Imaging: Orthopedics. He is also the author or co-author on over sixty original scientific articles published in the radiology and orthopedic literature. All posts by Phillip Tirman, MD All posts by Kevin Rice, MD

Headaches and confusion in 55F • Xray of the Week 2016 • Week #3 This 55 year old Hispanic female with past medical history of type 2 diabetes, hypertension, and hyperlipidemia, presented with 3 days of headaches and confusion. An MRI brain was performed, and due to the findings, genetic testing was performed. A mutation on chromosome 19q12 involving the Notch 3 gene was discovered. What is the diagnosis? Figure 1. CADASIL A: MRI- FLAIR axial image shows symmetric T2 hyperintensities in the anterior temporal lobes. B: MRI- DWI axial image shows no acute infarct. Figure 2. CADASIL Patient #2 A: MRI- FLAIR axial image shows symmetric T2 hyperintensities in the anterior temporal lobes in patient #2. B: MRI- FLAIR axial image shows confluent symmetric white matter T2 hyperintensity changes in patient #2. Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) is an autosomal dominant condition which has an onset of symptoms between ages 30 to 50. [1,2] The gene mutation causes small vessel and arteriole stenosis as a result of fibrotic thickening of the basement membrane of the vessels. Symptoms are non-specific but may include weakness, dementia, focal neurological defects, and seizures due to recurrent transient ischemic attacks (TIA's). [1,2,3] On MRI, the anterior temporal lobes are affected up to 86% of the time [Fig. 1] and the external capsule is affected in up to 93% of cases at presentation. There are often confluent white matter regions of increased signal intensity on T2 weighted images, with a predilection for the anterior temporal lobe [Fig 2]. More circumscribed lesions may also be visualized in the basal ganglia, thalamus and pons; however, there is usually sparing of the cortex and subcortical U-fibers. [1,2] Treatment is supportive, and prognosis is poor as symptomatology is progressive. [1,3] References: 1. Yousry TA, Seelos K, Mayer M et-al. Characteristic MR lesion pattern and correlation of T1 and T2 lesion volume with neurologic and neuropsychological findings in cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL). AJNR Am J Neuroradiol. 1999;20 (1): 91-100. 2. Auer DP, Pütz B, Gössl C et-al. Differential lesion patterns in CADASIL and sporadic subcortical arteriosclerotic encephalopathy: MR imaging study with statistical parametric group comparison. Radiology. 2001;218 (2): 443-51. 3. Bohlega S, Al Shubili A, Edris A et-al. CADASIL in Arabs: clinical and genetic findings. BMC Med. Genet. 2007;8 : 67. 4. Lotz PR, Ballinger WE, Quisling RG. Subcortical arteriosclerotic encephalopathy: CT spectrum and pathologic correlation. AJR Am J Roentgenol. 1986;147 (6): 1209-14. Danielle Rice, MD is a neurohospitalist at Gottlieb Memorial Hospital, a part of Loyola University Health System. Dr. Rice graduated cum laude from Kent State University and earned her medical degree from Northeastern Ohio Universities College of Medicine. Dr. Rice completed a residency in adult neurology from Rush University Medical center and a fellowship in multiple sclerosis from the University of Chicago. Dr. Rice is board certified in Neurology and is an assistant professor in the Department of Neurology of Loyola University Chicago Stritch School of Medicine. Kevin Rice, MD is president of Global Radiology CME. Follow Dr. Kevin Rice on Twitter @KevinRiceMD All Posts by Kevin M Rice, MD All Posts by Danielle Rice, MD

27 year old Female with Palpable Right Breast Mass • Xray of the Week 2016 • Week #30 A 27-year-old, African American female presented with a right breast mass, palpable for one year. Given the patient’s age, an ultrasound was performed. The findings prompted a mammogram. What is the diagnosis? Left: Medial lateral oblique (MLO) mammogram of right breast. Mammogram revealed two irregular, spiculated masses with pleomorphic calcifications involving the entire upper, outer quadrant of the right breast, corresponding to this patient’s region of palpable lesion. Right: Breast ultrasound showing an irregular, hypoechoic mass with posterior shadowing. There are also bright internal echoes consistent with microcalcifications. Mild increased flow is present with color Doppler sonography. Fig.2 Spot magnification views of right breast demonstrate pleomorphic calcifications and irregular, spiculated masses Fig.3 Ultrasound demonstrating dilated ducts with internal echos in the periareolar breast adjacent to the mass. DIAGNOSIS: An ultrasound core biopsy was performed. Pathology was invasive ductal (IDC), grade 2 and ductal carcinoma in situ (DCIS), comedo type with high nuclear grade, Estrogen and Progesterone Receptor Positivity (ER/PR +), and HER2/neu 2+ (equivocal). DISCUSSION: In younger women, palpable masses are often benign and related to hormonal influences, commonly fibroadenomas, and cysts, or galactoceles in pregnant or breastfeeding females. Fibroadenomas are the most common benign breast tumor, especially in African American women and women under the age of 30. However, ultrasound imaging of a fibroadenoma will typically reveal a circumscribed, hypoechoic mass which often has posterior acoustic enhancement. A cyst would demonstrate circumscribed margins, be anechoic, and have posterior acoustic enhancement. This patient’s mass did not demonstrate benign characteristics, thus prompting mammographic evaluation. The features of this patient’s mass, including the irregular margins, suspicious calcifications, hyperemia and associated dilated ducts with internal echos are all common appearances for IDC and DCIS on mammogram and ultrasound. The incidence of breast cancer is very low in young females. For women under the age of 40, the risk of developing breast cancer within 10 years is less than 2%. However, African American women have higher rates of premenopausal breast cancer in comparison to other groups. It is important to closely evaluate the ultrasound appearance of masses in women under the age of 30. Characteristics associated with malignancy include: spiculation, taller than wide, microlobulations, angular margins, markedly hypoechoic nodule, posterior acoustic shadowing, punctate calcifications, or duct extension. If there are any of these suspicious findings, further imaging with mammography is required. References: 1. American Cancer Society. Cancer Facts & Figures for African Americans: 2013-2014, 2013 2. Dogan BE, Ceyhan K, Tukel S, Saylisoy S, Whitman GJ. Ductal dilatation as the manifesting sign of invasive ductal carcinoma. J Ultrasound Med. 2005 Oct;24(10):1413-7. Available at: http://www.jultrasoundmed.org/content/24/10/1413.full#ref-1 doi:10.1148/radiol.2423051631 3. Jokich PM, Monicciolo DL, Adler YT: Breast ultrasonography. Radiol Clin North Am 30:993-1009, 1992. 4. Kaur, K. (2014, July 2). Breast Lumps in Young Women: Diagnostic Approaches. Retrieved July 9, 2016, from http://reference.medscape.com/features/slideshow/breastlumps#9 Dr. Anjali Malik received her B.A. in Public Health from The Johns Hopkins University and her MD from Tulane University. She completed her residency in Diagnostic Radiology at the University of Texas - Southwestern with Dr. Neil Rofsky. In 2013, Dr. Malik commenced a Breast Imaging Fellowship with Dr. Rachel Brem at George Washington University. Currently, she is a Breast Imaging and Intervention Specialist at Eastern Radiologists, Inc in Greenville, NC. She is passionate about breast imaging, women’s health issues, and preventive medicine. Follow Dr. Malik on Twitter @AnjaliMalikMD Shannon Maree Osborne is in the Class of 2019 at The Brody School of Medicine at East Carolina University Related Cases: Phyllodes Tumor Medullary Carcinoma of the Breast

Enlarging Painless Right Upper Thigh Mass • Xray of the Week This 26 y/o male presented with a right upper inner thigh mass for over a year. The mass was painless and growing. What is the differential diagnosis? (Left) T2 weighted coronal image demonstrating a high signal intensity lobulated medial right thigh mass. (Right) FSE PD weighted axial image with fat saturation demonstrating the markedly hyperintense mass. (yellow arrows) Above: T1 weighted coronal image demonstrating a low signal intensity lobulated subcutaneous right thigh mass. Discussion Biopsy of this mass demonstrated a schwannoma. The appearance of the mass is non-specific. However, there are multiple ring-like hypointense structures, consistent with the fascicular sign (1, 2,4). Although this mass is not located along the anatomic course of a peripheral nerve, the appearance is suspicious for peripheral nerve sheath tumor due to the presence of the fascicular sign. The fascicular sign is characterized by multiple small ring-like structures with peripheral hyperintensity on T2 weighted images representing the fascicular bundles within the nerves. Other signs of Schwannoma or neurofibroma include the tail, target, bag-of-worms, and split-fat signs. (4) The target sign is characterized by peripheral high T2 signal and central low signal on T2 weighted images. The split-fat sign is visualized as a thin peripheral rim of fat best seen on planes along long axis of the lesion in non-fat-suppressed images. The vast majority (approx 90%) of schwannomas are solitary. Multiple schwannomas are virtually diagnostic of Neurofibromatosis 2 (NF2). However up to 20% of solitary schwannomas are seen with NF2. Clinical presentation is usually a painless mass; however, there may be symptoms related to local mass effect or dysfunction of the nerve from which the tumor arises. Differential diagnosis for soft tissue masses is broad (1): Mesenchymal Tumors: Dermatofibrosarcoma protuberans, Lipoma, Angiomas (hemangioma, lymphangioma), Peripheral nerve sheath tumor (schwannoma, neurofibroma), Malignant fibrous histiocytoma, Liposarcoma, Leiomyosarcoma, Fibromatosis Skin Appendage Lesions: Epidermal inclusion cyst, Pilomatricoma, Cystadenoma Metastatic Tumors: Carcinoma, Melanoma, Myeloma Other Tumors and Tumor-like Lesions: Myxoma, Lymphoma Inflammatory Lesions: Cellulitis, Fasciitis, Adenitis, Abscess References: 1. F D Beaman, M J Kransdorf, et al. Superficial Soft-Tissue Masses: Analysis, Diagnosis, and Differential Considerations. RadioGraphics 2007; 27:509 –523 2. F D Beaman, MD, M J Kransdorf, MD. Schwannoma: Radiologic-Pathologic Correlation. RadioGraphics 2004; 24:1477–1481 3. A Chhabra and T Soldatos. Soft-Tissue Lesions: When Can We Exclude Sarcoma? AJR 2012; 199:1345–1357 4. Chandan Kakkar, et al. Telltale signs of peripheral neurogenic tumors on magnetic resonance imaging. Indian Journal of Radiology and Imaging. 2015, Volume 25 Page: 453-458 Phillip Tirman, MD is the Medical Director of Musculoskeletal Imaging at the Renaissance Imaging Center in Westlake Village, California. A nationally recognized expert in the applications of MRI for evaluating MSK and spine disorders, Dr. Tirman is the co-author of three textbooks, including MRI of the Shoulder and Diagnostic Imaging: Orthopedics. He is also the author or co-author on over sixty original scientific articles published in the radiology and orthopedic literature. All posts by Phillip Tirman, MD 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 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. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin Rice, MD

Nearly half of all radiologists have been sued at least once, according to an article published in the October 2012 issue of the Journal of the American College of Radiology. Having been on the credentials committee at several hospitals for the last 15 years, I have seen many errors which could have been easily prevented. Here are the top seven Do's and Don'ts if you have the misfortune of getting into a medical-legal matter. 1. DO NOT discuss the case with anyone except your attorney. 2. DO NOT alter the medical record. 3. Although tempting, DO NOT review the medical record or the images without your attorney present. If you look at any of the medical record or images, it is arguably discoverable in deposition and the courtroom and may be used against you. Reviewing the images with your attorney is likely protected by the attorney-client privilege and not discoverable by the attorney suing you. 4. If you get a 90 day letter with intent to sue, DO contact your insurance provider immediately. Often, they can obtain radiology or other experts and get their legal team to have the case dropped before it ever gets filed in court. 5. If a case does get filed in court, DO inform all the hospitals' medical staff services offices where you have privileges. It varies at different hospitals, but in general if you inform them within 30 days you will be safe. DO NOT wait until reappointment time to inform the hospitals. Most hospitals have an obligation to report any pending suits, settlements, or judgments in their bylaws. ____________________________ Although tempting, DO NOT review the images without your attorney present. ___________________________ 6. If you are applying for new hospital privileges, or are up for reappointment, make sure you answer the question about any pending suits, settlements, or judgments correctly. DO NOT just blindly sign the form without checking it carefully, especially if someone else has filled it out for you. A false statement on the application is your responsibility and has very serious consequences such as revocation of privileges or inability to obtain privileges. These events may also be reportable to the Medical Board of your state. 7. If you have a settlement or judgment against you, DO inform all the hospitals where you have privileges within 30 days. Again, don't wait until reappointment time to inform the hospitals. The good news is up to 80% of medical malpractice suits are dropped or dismissed without payment. Only approximately 15% are settled, and of the 5% that make it to court, the defendant prevails 80-90% of the time. Make it easier to defend yourself and carry the day by following the common sense tips in this article. Kevin Rice, MD is the Chief of Staff and the Chair of the Radiology at 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 Disclaimer: Kevin Rice, MD is not an attorney and the above should not be construed as legal advice. Check with your own attorney and insurance provider if you have any legal matters. Courtroom gavel photo courtesy of: https://www.flickr.com/photos/joegratz/117048243/ Creative Commons 01.0 Universal (CC0 1.0)

44 y/o Female with intermittent knee pain and swelling for several years • Xray of the Week Figure 1.a. T1 weighted sagittal image demonstrating a low signal intensity lobulated intra-articular mass. Figure 1.b. FSE PD weighted sagittal image with fat saturation demonstrating the markedly hyper-intense mass with characteristic low-signal-intensity linear structures, due to fibrous septa. Figure 2. Axial FSE PD weighted image with fat saturation demonstrating the markedly hyper-intense mass with characteristic low-signal-intensity linear structures, due to fibrous septa. Discussion: Synovial haemangiomas are rare benign vascular malformations that occur in synovial joints. They may be a form of soft tissue hemangioma and occasionally synovial haemangiomas may present with a hemarthrosis. However, symptoms are usually non-specific, consisting of pain, swelling and limited range of motion of the affected joint. Most synovial haemangiomas are seen in the knee. Phleboliths seen on plain radiographs may be diagnostic if present. As in this case, MRI typically shows a lobulated intra-articular mass which is usually low or intermediate signal intensity on T1 weighted images and markedly hyper-intense on T2 weighted images. In addition, the T2 weighted images characteristically demonstrate low-signal-intensity linear structures in the mass, due to fibrous septa or vascular channels. Since MRI demonstrates the precise location and extent of the tumor, it is essential for preoperative planning. Pedunculated and well-circumscribed lesions usually are resected arthroscopically. Diffuse hemangiomas require open wide excision and recurrence is common in cases of diffuse lesions. References: 1. Arslan H, Islamoglu N, Akdemir Z, et al. Synovial Hemangioma in the Knee: MRI Findings. J Clin Imaging Sci. 2015; 5: 23. Published online 2015 Apr 30. 2. Barakat MJ, Hirehal K, Hopkins JR et-al. Synovial hemangioma of the knee. J Knee Surg. 2007;20 (4): 296-8. 3. Sheldon PJ, Forrester DM, Learch TJ. Imaging of intraarticular masses. Radiographics. 25 (1): 105-19 4. Watanabe S, Takahashi T, Fujibuchi T et-al. Synovial hemangioma of the knee joint in a 3-year-old girl. 2010. Journal of Pediatric Orthopaedics B. 19(6):515-520, NOV 2010. 5. Rajni, Khanna G, Gupta A, Gupta V. Synovial hemangioma: A rare benign synovial lesion. Indian J Pathol Microbiol [serial online] 2008 [cited 2018 Feb 11];51:257-8. Available from: http://www.ijpmonline.org/text.asp?2008/51/2/257/41676 Phillip Tirman, MD is the Medical Director of Musculoskeletal Imaging at the Renaissance Imaging Center in Westlake Village, California. A nationally recognized expert in the applications of MRI for evaluating MSK and spine disorders, Dr. Tirman is the co-author of three textbooks, including MRI of the Shoulder and Diagnostic Imaging: Orthopedics. He is also the author or co-author on over sixty original scientific articles published in the radiology and orthopedic literature. All posts by Phillip Tirman Kevin 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 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. All posts by Kevin Rice, MD Follow Dr. Rice on Twitter @KevinRiceMD

Foot pain • Xray of the Week 54 year old male with pain and soft tissue masses of both feet. (Left) T1 weighted axial image demonstrating low signal intensity tophi adjacent to the first and second metatarsal phalangeal joints with associated bone erosions. Note the typical overhanging edges and sclerotic margins of the erosions. (Right) Sagittal FSE PD weighted image with fat saturation showing a large intermediate signal intensity tophus posterior to the tibio-talar joint. There is also synovial proliferation, erosions and tibialis anterior tendon tophus formation. T1 weighted sagittal image demonstrating low signal intensity tophi adjacent to the first metatarsal phalangeal joint. Axial FSE PD weighted image with fat saturation showing a large intermediate signal intensity tophus posterior to the tibio-talar joint. There is also synovial proliferation, erosions and tibialis anterior tendon tophus formation. A vitamin E capsule is at the site of the patient’s pain. T1 weighted sagittal image demonstrating low signal intensity tophi adjacent to the tibiotalar joint with associated bone erosions. Note the typical overhanging bone and sclerotic margins of the erosions. 1. Girish G, Glazebrook KN, Jacobson JA. Advanced Imaging in Gout. AJR Am J Roentgenol. 2013;201: 515-525. 2. Barnes CL and Helms CA. MRI of gout: a pictorial review. Int. J. Clin. Rheumatol. (2012) 7(3), 281–285. 3. Oaks J, Quarfordt SD, Metcalfe JK. MR features of vertebral tophaceous gout. AJR Am J Roentgenol. 2006;187 (6): W658-9. 4. Yu JS, Chung C, Recht M et-al. MR imaging of tophaceous gout. AJR Am J Roentgenol. 1997;168 (2): 523-7. 5. Perez-Ruiz F, Dalbeth N, Urresola A, et-al. Imaging of gout: findings and utility. Arthritis Res. Ther. 2009;11 (3): 232. 6. de Ávila Fernandes E, Kubota ES, Sandim GB, et-al. Ultrasound features of tophi in chronic tophaceous gout. Skeletal Radiol. 2011;40 (3): 309-15. Phillip Tirman, MD is the Medical Director of Musculoskeletal Imaging at the Renaissance Imaging Center in Westlake Village, California. A nationally recognized expert in the applications of MRI for evaluating MSK and spine disorders, Dr. Tirman is the co-author of three textbooks, including MRI of the Shoulder and Diagnostic Imaging: Orthopedics. He is also the author or co-author on over sixty original scientific articles published in the radiology and orthopedic literature. All Posts by Phillip Tirman, MD Kevin 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 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. All posts by Kevin Rice, MD Follow Dr. Rice on Twitter @KevinRiceMD

This how I do Clario zVision Peer Review: Above. Step 1. In "My Reading Queue", click on "Peer Review" (blue arrow), then click on "Peer Review Assigned to Me" (red arrow). Above. Step 2. Then this list of cases should pop up. Click on the arrow down for places you do not have privileges to remove the case from the list (orange box). Next, click on the first case in the list. Above. Step 3. Then the patient report will pop up. Click on the magnifying glass icon in the top right (red arrow), and that will open the images for that case. Step 4. Click on your Rating, Category and make a note if there is a discrepancy (blue arrow). Then click "Submit and Next" on the bottom right (orange box). This will automatically load the next case. Repeat Step 4 until you run out of cases, and you are done! More Clario zVision tips: Clario zVision Auto-Next Mode Tips How to Re-assign a Case While in Auto-Next Mode in Clario zVision Clario zVision Communication Notes Tips Clario zVision • How to Change Reading Queue Sorting Clario zVision • How to Not Enter Patient View All posts by Kevin M. Rice, MD