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Name the Device • Xray of the Week Routine CXR for cough demonstrates metallic device. Name the cardiac implant. Figure 1. The circled device is a CardioMEMS HF System used to measure and monitor pulmonary artery (PA) pressure and heart rate. The patient also has a biventricular pacemaker. (Image courtesy of Mark Beller, MD.) Figure 2. Video Explaining percutaneous placement technique for the CardioMEMS. Figure 3. The CardioMEMS HF System. A. Implantable monitoring device. B. RemoteCare external electronics unit. The CardioMEMS™ HF System is indicated for wirelessly measuring and monitoring pulmonary artery (PA) pressure and heart rate in New York Heart Association (NYHA) Class III heart failure patients who have been hospitalized for heart failure in the previous year. Using a percutaneous approach (Fig. 2), the sensor (Fig. 3A) is implanted in the pulmonary artery. Once the device is implanted, daily pressure readings are obtained with the external electronics unit (Fig. 3B) and wirelessly transmitted to the patient's physician for continuous monitoring. Fig 4. Magnified views of the CXR and CT Scan of a second patient with the CardioMEMS HF System in the right lower lobe pulmonary artery. References: 1. Abbott CardioMEMS Website 2. Chaudhry SI, Mattera JA, CurtisJP, et al., (2010). Telemonitoring in patients with heart failure. NEJM, 363(24), 2301-2309.  http://dx.doi.org/10.1056/NEJMoa1010029 3. Kohler F, Winker S, Schieber M, et al. (2010, November). Telemedical interventional monitoring in heart failure (TIM-HF), a randomized, controlled, intervention trial investigating the impact of telemedicine on mortality in ambulatory patients with chronic heart failure. Presented at the meeting of the American Heart Association, Chicago, IL. http://dx.doi.org/10.1161/CIR.0b013e318200c0b5 4. van Veldhuisen DJ, Braunschweig F, Conraads V, et al, for the DOT-HF Investigators. (2011). Intrathoracic impedance monitoring, audible patient alerts, and outcome in patients with heart failure. Circulation, 124(16), 1719-1726.  http://dx.doi.org/10.1161/circulationaha.111.043042 5. Adamson PB, Abraham WT, Bourge RC, et al. (2014). Wireless pulmonary artery pressure monitoring guides management to reduce decompensation in heart failure with preserved ejection fraction.Circulation: Heart Failure, 7(6), 935- 944. http://dx.doi.org/10.1161/circheartfailure.113.001229 6. Abraham WT, Stevenson L, Bourge RC, et al. (2016). Sustained efficacy of pulmonary artery pressure to guide to adjustment of chronic heart failure therapy: Complete follow-up results from the CHAMPION randomized trial. The Lancet, 387(10017), 453-461.  http://dx.doi.org/10.1016/S0140-6736(15)007233-0 7. Adamson PB, Abraham WT, Bourge RC, et al. (2010). CardioMEMS heart sensor allows monitoring of pressures to improve outcomes in NYHA class III heart failure patients (CHAMPION) Trial: Impact of hemodynamic guided care on patients with preserved ejection fraction. Journal of Cardiac Failure, 16(11), 913.  http://dx.doi.org/10.1016/j.cardfail.2010.09.012 8. Weiner S, Abraham WT, Adamson PB, et al. (2011). Effect of CRT on heart failure related hospitalizations in patients with reduced EF utilizing remote pulmonary artery pressures in the CHAMPION Trial. Heart Rhythm, 8(5S), S437. http://dx.doi.org/10.1016/j.hrthm.2011.03.033 9. Conyers JM, Rajiah P, Ahn R, Abbara S, et al. Imaging features of leadless cardiovascular devices. Diagn Interv Radiol. 2018 Jul; 24(4): 203–208. d oi: 10.5152/dir.2018.17462 10. How to Implant the CardioMEMS Heart Failure SensorA step-by-step review of the sensor implantation procedure, including pre- and postprocedural assessment.By David M. Shavelle, MD, FACC, FSCAI. https://citoday.com/2018/02/how-to-implant-the-cardiomems-heart-failure-sensor/ Related posts: Bicuspid Aortic Valve and Aortic Stenosis Implanted Cardiac Loop Recorder Cardiac Tamponade Following Coronary Artery Rotational Atherectomy Papillary Fibroelastoma of Aortic Valve Micra Intracardiac Pacemaker 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 M. Rice, MD

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

Radiology PowerPoint Tip • Xray of the Week • Week #49 Have you ever wondered how to get a scrollable image stack of CT or MR images on a single PowerPoint slide. There is a way to do it! Australian Emergency Medicine Specialist Dr. Andy Buck shares how to get a scrollable image stack on a single PowerPoint slide on a Mac. The basic steps on Mac: 1. Export the image stack from PACS as JPEG images. If your PACS can not export as JPEG, use Osirix to convert from DICOM to JPEG. Make sure the images are de-identified either with PACS or Osirix. 2. Resize all images to 630 x 630 pixels. 3. Copy and paste the entire set of JPEG images to a single blank slide. 4. Select all and click Animate> Appear. 5. On the right side, where the list of "Play Selected" is, select all (with Ctrl-A) 6. Below under "Timing", click Start> On Click. 7. Save. 8. In presentation mode, use mouse or wheel to scroll through the images. Here is a video of the Windows version by senior editor at Radiopaedia.org , Dr. Matt Skalski : How to add scrollable stack of CT or MRI Images on Microsoft PowerPoint 365 (2020) from Chris Nguyen: Basic steps for Windows: 1. Export the image stack from PACS as JPEG images. If your PACS can not export as JPEG, use DICOM Converter to convert from DICOM to JPEG. Make sure the images are de-identified in PACS prior to download. 2. Resize all images to 630 x 630 pixels. 3. Copy and paste the entire set of JPEG images to a single blank slide. 4. Click animations on the toolbar, click on Custom Animation 5. Click the little triangle on Add Effect>Entrance> Appear. 6. On the right side, where the list of "Play Selected" is, select all (with Ctrl-A) 7. Above at "Start" select "On Click". 8. Save. 9. In presentation mode, use mouse or wheel to scroll through the images. How to export a perfect size and format for Carestream PACS users: 1. First make an empty new folder in your documents folder called "CT stack" or something else related to the case. You will use this to save the images. 2. In PACS, use layout 4 on 1 in stack mode. Make sure this box is selected. 3. Click "hide DICOM Annotations" to de-identify the images. 4. Click Export > Save > Save as File 5. In the dialogue box -File Name: Browse back to your empty folder called "CT stack" select and make a name for the images -Save as type: JPEG -Selection: Current Selection -Size: As displayed on screen 5. Click Save 6. Navigate back to your images and import to PowerPoint as described above in the basic steps for Windows or Mac starting at step #3. This is a PowerPoint PPT file I did as a demo: Click here to download Kevin M. Rice, MD serves as the Chair of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a Radiologist with Renaissance Imaging Medical Associates . Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice 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

RUQ pain, septic, unstable BP • Xray of the Week Figure 1. What is the important finding on these images. Figure 2. A. HIDA scan showing liver, common bile duct, small bowel B. Magnified view HIDA scan showing common bile duct (green arrow) and duodenum (blue arrow). Note that tracer is not present in the gallbladder due to cystic duct obstruction. C. Abdominal CT showing enlarged gallbladder with gas in the gallbladder wall (yellow arrow) and cholelithiasis (red arrow). Discussion: Emphysematous cholecystitis is a rare, life-threatening form of acute cholecystitis that occurs when gas-producing bacteria invade the gallbladder wall and cause necrosis (1). Air accumulates in the wall as seen in figure 2C, which can be attributed to gallbladder ischemia, tissue infarction, drugs, abdominal trauma, or incompetence of the sphincter of Oddi (1). Emphysematous cholecystitis typically occurs in diabetic men and puts patients at increased risk of gallbladder perforation (2). Emphysematous cholecystitis has echogenic foci with reverberation artifact on ultrasound, but ultrasound is less sensitive and specific than CT scan (3). The appearance of air in the lumen on ultrasound is also known as the “ring-down artifact” or “dirty shadowing” (4). Emphysematous cholecystitis can be distinguished from acute cholecystitis on CT due to the presence of gas in the gallbladder wall or lumen (1,5). On CT, emphysematous cholecystitis may also demonstrate pericholecystic inflammatory changes, intrahepatic abscess, gallbladder wall thickening, cholelithiasis, and intraperitoneal free air (1,3). On MRI, emphysematous cholecystitis shows intraluminal gas and intramural necrosis as well as gallstones in the neck of the gallbladder (1). Emphysematous cholecystitis may also present with the “champagne sign” or effervescent gallbladder sign on MRI, which refers to the foci of gas in the wall (1). Treatment of emphysematous cholecystitis includes broad-spectrum antibiotics and emergency cholecystectomy, although patients not suitable for surgery may undergo temporary percutaneous cholecystostomy (2,3). Click here to see what was done for this patient: Treatment of Emphysematous Cholecystitis ​​​​ References: Safwan M, and Penny SM. Emphysematous Cholecystitis: A Deadly Twist to a Common Disease. Journal of Diagnostic Medical Sonography, vol. 32, no. 3, May 2016, pp. 131–37. doi: 10.1177/8756479316631535 Yen WL, Hsu CF, Tsai MJ. Emphysematous cholecystitis. Tzu Chi Medical Journal. 2016;28(1):37-38. doi: 10.1016/j.tcmj.2015.12.001 Sunnapwar A, Raut AA, Nagar AM, Katre R. Emphysematous cholecystitis: Imaging findings in nine patients. Indian J Radiol Imaging. 2011;21(2):142-146. doi: 10.4103/0971-3026.82300 Aherne A, Ozaki R, Tobey N, Secko M. Diagnosis of emphysematous cholecystitis with bedside ultrasound in a septic elderly female with no source of infection. J Emerg Trauma Shock. 2017;10(2):85-86. doi: 10.4103/JETS.JETS_75_16 Chen, Ming-Yu, et al. Emphysematous Cholecystitis in a Young Male without Predisposing Factors: A Case Report. Medicine, vol. 95, no. 44, Nov. 2016, p. e5367. doi: 10.1097/MD.0000000000005367 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 UPDATE: Dr. Ahmed will be a radiology resident at University of Florida in July 2024. All posts by Amara Ahmed Kevin M. Rice, MD  is the president of Global Radiology CME and is a radiologist with Cape Radiology Group . He has held several leadership positions including Board Member and Chief of Staff at Valley Presbyterian Hospital  in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide  innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator.  He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator  by AuntMinnie.com . He has continued to teach by mentoring medical students interested in radiology . Everyone who he has mentored has been accepted into top programs across the country including Harvard, UC San Diego, Northwestern, Vanderbilt, and Thomas Jefferson. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

Septic Shock and Abdominal pain • Xray of the Week 2018 A 57 yo M presented to the Emergency Department with septic shock and vague abdominal pain. What is the diagnosis and what is the treatment of choice? Figure 1. (A) Axial non-contrast CT of the upper abdomen. (B) Gallbladder ultrasound. Figure 2. (A) Axial non-contrast CT of the upper abdomen. (B) Gallbladder ultrasound. Red arrow: Thick-walled gallbladder with surrounding mesenteric fat stranding indicative of acute cholecystitis seen on CT scan. Green arrow: Edema in thickened gallbladder wall seen on ultrasound. Figure 3. CT images following placement of cholecystostomy tube (Green arrow). Discussion: Acute cholecystitis is the main complication of gallstones and is a common cause of acute right upper quadrant pain. While the vast majority are associated with gallstones, 5-10% of cases are due to acalculous cholecystitis. As in this case, if there are no gallstones, the diagnosis of acute acalculous cholecystitis can be suggested if there is gallbladder wall thickening and surrounding edema (Fig. 1-2). Adjacent fluid, abscess, and positive ultrasonographic Murphy sign may also be present. Severe trauma, critical illness, burn, diabetes, malignant disease, abdominal vasculitis, congestive heart failure, cholesterol embolization, shock, and cardiac arrest are all associated with acute acalculous cholecystitis. The most common indication for percutaneous cholecystostomy is with cases of known cholecystitis -either calculous or acalculous- in patients who are too high risk for surgery. However, the procedure should be considered in critically ill patients with unexplained sepsis. Complications of the procedure include bile leak, bleeding, and bowel injury. The most common cause of bile leak and recurrent sepsis is catheter dislodgement, which is why it is advised to coil the tube inside the gallbladder if possible. References: 1. Barie PS, Eachempati SR. Acute acalculous cholecystitis. Gastroenterol. Clin. North Am. 2010;39 (2): 343-57, x. 2. Mirvis SE, Vainright JR, Nelson AW et-al. The diagnosis of acute acalculous cholecystitis: a comparison of sonography, scintigraphy, and CT. AJR Am J Roentgenol. 1986;147 (6): 1171-5. 3. Joseph T, Unver K, Hwang GL et-al. Percutaneous cholecystostomy for acute cholecystitis: ten-year experience. J Vasc Interv Radiol. 2012;23 (1): 83-8.e1 . 4. Huang CC, Lo HC, Tzeng YM et-al. Percutaneous transhepatic gall bladder drainage: a better initial therapeutic choice for patients with gall bladder perforation in the emergency department. Emerg Med J. 2007;24 (12): 836-40 Kevin M. Rice, MD is president of Global Radiology CME and serves as the Chief of staff and Chair of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates . Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. Dr. Rice co-founded Global Radiology CME with Natalie Rice 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

Sepsis and hypotension. What procedure is indicated? • Xray of the Week Figure 1. What action should be taken for this patient with sepsis and hypotension? Figure 2. A. HIDA scan showing liver, common bile duct, small bowel B. Magnified view HIDA scan showing common bile duct (green arrow) and duodenum (blue arrow). Note that tracer is not present in the gallbladder due to cystic duct obstruction. C. Abdominal CT showing enlarged gallbladder with gas in the gallbladder wall (yellow arrow) and cholelithiasis (red arrow) indicating emphysematous cholecystitis. Figure 3. Percutaneous Cholecystostomy Abdominal CT showing percutaneous access needle (green arrow) entering the patient’s gallbladder via a transhepatic approach. The final CT image shows the drainage catheter (yellow arrow) correctly placed in the gallbladder with the tip coiled in the gallbladder fundus (red arrow). Discussion: Percutaneous cholecystostomy (PCS) is an image-guided, minimally invasive catheterization of the gallbladder [1]. It is indicated for gallbladder drainage in acute cholecystitis (including calculous, acalculous , gangrenous, and emphysematous varieties) or gallbladder perforation among high-risk patients with contraindications to surgical intervention. It can also be employed to allow percutaneous removal of biliary stones, or catheterization of the biliary tree to resolve obstruction [1,2]. Among patients treated for acute cholecystitis, PCS is commonly followed by cholecystectomy if the patient’s condition can be optimized, as its use as a definitive therapy in this population has not found consistent support [3]. PCS may be guided by US, CT, and/or fluoroscopy, and involves transhepatic or transperitoneal insertion of an access needle followed by gallbladder catheterization with either the Seldinger technique or a trocar system [1,4,5]. Figures 1 and 2 are imaging studies on a patient with sepsis and hypotension due to emphysematous cholecystitis who was too unstable to undergo surgery. The patient underwent a percutaneous cholecystostomy using the Seldinger technique and CT guidance, as illustrated in Figure 3. After stabilization and maturation of the tract, the patient had a surgical cholecystectomy and fully recovered. Though ultrasound is typically the favored imaging modality for needle insertion due to mobility, lack of ionizing radiation, and continuous visualization, CT may be necessary if the gallbladder lumen cannot be observed sonographically (e.g. cholecystitis, wall thickening; 1,5). Access needles can be clearly visualized on either US or CT. Following US-guided needle insertion, fluoroscopy is frequently used to aid catheter placement [1,5]. Choice of transhepatic or transperitoneal approaches should be employed according to patient anatomy and operator discretion, since there has been no demonstrated difference in outcome or complications [6]. The former method involves traversing the liver with intent to puncture the bare area of the gallbladder, while the latter simply accesses the gallbladder via the peritoneal cavity [1,6]. Rationales favoring the transhepatic approach include increased catheter stability, quicker fistula tract maturation, and a theoretically decreased risk of bile leakage [1,6]. It is also preferred in cases of ascites or bowel interposition [1]. A transperitoneal route is favored in patients with coagulopathy or diffuse liver disease [1]. Major complications of PCS include hemorrhage, pneumothorax, biliary leak, and peritonitis, with the transhepatic approach having increased risk of pleural or hepatic damage [1,2,4]. ​​​​ References: Ginat D and Saad W. Cholecystostomy and Transcholecystic Biliary Access. Tech Vasc Interv Radiol. 2008;11(1):2-13. DOI: 10.1053/j.tvir.2008.05.002 Hatzidakis A, Venetucci P, Krokidis M, Iaccarino V. Percutaneous biliary interventions through the gallbladder and cystic duct: What radiologists need to know. Clin Radiol. 2014;69(12):1304-1311. DOI: 10.1016/j.crad.2014.07.016 Gurusamy KS, Rossi M, Davidson BR. Percutaneous cholecystostomy for high risk surgical patients with acute calculous cholecystitis. Cochrane Database Syst Rev. 2013;(8): CD007088. DOI: 10.1002/14651858.CD007088.pub2 Little Mw. Percutaneous cholecystostomy: The radiologist’s role in treating acute cholecystitis. Clin Radiol. 2013;68(7): 654-660. DOI: 10.1016/j.crad.2013.01.017 Venara A, Carretier V, Lebigot J, E Lermite. Technique and indications of percutaneous cholecystostomy in the management of acute cholecystitis in 2014. J Visc Surg. 2014;151(6):435-439. DOI: 10.1016/j.jviscsurg.2014.06.003 Beland MD, Patel L, Ahn SH, Grand DJ. Image-Guided Cholecystostomy Tube Placement: Short- and Long-Term Outcomes of Transhepatic Versus Transperitoneal Placement. AJR Am J Roentgenol. 2019;212: 201-204. DOI: 10.2214/AJR.18.19669 Ian Rumball is a medical student and aspiring radiologist at the Zucker School of Medicine at Hofstra/Northwell in Hempstead, NY. He serves as chair for his school’s radiology interest group. Prior to medical school, he attended the University of Wisconsin - Madison and graduated with degrees in biology, history, global health, and African studies. As an undergraduate, he did research in the fields of oncology, hematology, and neuroendocrinology. He also published work in undergraduate journals of creative writing, history, and physiology. In his free time, Ian enjoys playing guitar, hiking his local state parks, and watching classic films. Follow Ian Rumball on Twitter @RumballIan All posts by Ian Rumball UPDATE: Dr. Rumball will be a radiology resident at Medical College of Wisconsin in July 2024, after his Transitional Year at Gundersen Health System in La Crosse, Wisconsin. Kevin M. Rice, MD  is the president of Global Radiology CME and is a radiologist with Cape Radiology Group . He has held several leadership positions including Board Member and Chief of Staff at Valley Presbyterian Hospital  in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide  innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator.  He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator  by AuntMinnie.com . He has continued to teach by mentoring medical students interested in radiology . Everyone who he has mentored has been accepted into top programs across the country including Harvard, UC San Diego, Northwestern, Vanderbilt, and Thomas Jefferson. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

86 F in motor vehicle collision . Neck pain • Xray of the Week Figure 1. What is the important finding on this CT scan. Figure 2. CT scan of Type 3 dens fracture. Red arrow is pointing to the fracture line at the junction of the dens and body of C2. Figure 3. Anderson and D’Alonzo dens fracture classification system. Diagram by Neal Joshi. Type I: Avulsion fracture of the tip of the dens, usually stable. Type II: Fracture of the base of the dens, usually unstable. Type III: Fracture involving the body of C2, usually stable. Introduction: The odontoid process, otherwise known as the dens, is a bony projection from C2 (axis). The most commonly utilized classification system for fracture of the odontoid process is the Anderson and D’Alonzo system, which identifies three types of fractures [1,2] (Fig. 3). C2 fractures can be classified into Odontoid and Hangman’s and most common C2 fractures are the type II odontoid fractures. These can pose issues due to a greater than 50% rate of non-union. Discussion: A type I odontoid fracture is described as an avulsion fracture of the tip of the dens. A type II fracture is one that occurs at the base of the dens and is considered unstable due to high rates of non-union. Type III fractures involve the body of C2 and may even involve the facets (Fig. 3). For odontoid fractures, radiographs can be very useful, but a negative result does not exclude a fracture. Therefore, if there is clinical suspicion a CT scan should be obtained (Figs. 1,2) [3,4]. Non-contrast MRI is useful for viewing ligamentous structures which may be injured. In non-displaced type II odontoid fractures for example, the transverse ligament needs to be intact for certain surgical procedures and would require an MRI for evaluation [5,6]. Complications of dens fractures include malunion, non-union, and pseudoarthrosis. Figure 4. Fluoroscopic guided placement of an odontoid screw. Treatment: For treatment of type I and III odontoid fractures, external fixation via a rigid cervical collar may be sufficient. For type II fractures, surgical fixation is usually required if there is greater than 4-5 mm of displacement due to high risk for non-union [5,6] (Fig. 4). ​​​​ References: Anderson LD, D'Alonzo RT. Fractures of the odontoid process of the axis. J Bone Joint Surg Am . 1974;56(8):1663-1674. https://pubmed.ncbi.nlm.nih.gov/4434035/ Korres DS, Chytas DG, Markatos KN, Efstathopoulos NE, Nikolaou VS. The "challenging" fractures of the odontoid process: a review of the classification schemes. Eur J Orthop Surg Traumatol. 2017;27(4):469-475. doi: 10.1007/s00590-016-1895-3 Montemurro N, Perrini P, Mangini V, Galli M, Papini A. The Y-shaped trabecular bone structure in the odontoid process of the axis: a CT scan study in 54 healthy subjects and biomechanical considerations [published online ahead of print, 2019 Feb 1]. J Neurosurg Spine. 2019;1-8. doi: 10.3171/2018.9.SPINE18396 Chutkan NB, King AG, Harris MB. Odontoid Fractures: Evaluation and Management. J Am Acad Orthop Surg. 1997;5(4):199-204. doi: 10.5435/00124635-199707000-00003 Nourbakhsh A, Hanson ZC. Odontoid Fractures: A Standard Review of Current Concepts and Treatment Recommendations. J Am Acad Orthop Surg . 2022;30(6):e561-e572. doi : 10.5435/JAAOS-D-21-00165 Löhrer L, Raschke MJ, Thiesen D, et al. Current concepts in the treatment of Anderson Type II odontoid fractures in the elderly in Germany, Austria and Switzerland. Injury. 2012;43(4):462-469. doi: 10.1016/j.injury.2011.09.025 Neal Joshi is a medical student and aspiring diagnostic radiologist at Rowan University School of Osteopathic Medicine in New Jersey. Prior to medical school, he did research with mouse models for Parkinson’s disease and L-DOPA induced dyskinesias. He also did an internship at Kessler Institute for Rehabilitation in a stroke lab analyzing MR images in ischemic stroke patients with hemispatial neglect. During his time at Rowan, he did research with animal models for traumatic brain injury with an emphasis on electrophysiology of neurons. He graduated from William Paterson University where he completed his studies in biology and biopsychology. Apart from medical school, Neal loves to read, skateboard, go on hikes, and spend time with his friends. Update July 2022: Dr. Joshi is a Radiology Resident at Thomas Jefferson University in Philadelphia. All posts by Neal Joshi Kevin M. Rice, MD is the president of Global Radiology CME and is a radiologist with Cape Radiology Group . He has held several leadership positions including Board Member and Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator by AuntMinnie.com . He has continued to teach by mentoring medical students interested in radiology . Everyone who Dr. Rice has mentored has been accepted into top programs across the country including Harvard, UC San Diego, Northwestern, Vanderbilt, and Thomas Jefferson. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

Biventricular Pacemaker Dysfunction • Xray of the Week Figure 1. Abnormal position of pacemaker. Figure 2. CXR done 19 days after pacemaker placement. A- Note the retracted right atrial lead (green arrow) and right ventricular lead with shock coil (yellow arrow). The coronary sinus lead is also partially retracted (blue arrow). B- Coiled up electrodes adjacent to the generator (red arrow). Figure 3. Immediate postoperative CXR obtained 19 days earlier demonstrating the correct position of the pacemaker. A- Note the correct position of the RA lead with the characteristic "J" shape (green arrow) as it curves superiorly and laterally with the tip in the right atrial appendage. The RV lead with shock coil has a gentle curve and the tip is at the RV apex (yellow arrow). The LV lead is also correctly positioned deep in the coronary sinus (blue arrow). B- Well positioned electrodes adjacent to the generator (red arrow). Figure 4. Fluoroscopy images from the time of placement of the left ventricular/coronary sinus lead initially show contrast in the coronary sinus (orange arrows), followed by positioning of the lead in the coronary sinus (blue arrow). Discussion: Biventricular pacing also known as cardiac resynchronization therapy (CRT) is a modality of cardiac pacing used in congestive heart failure (CHF) patients with left ventricular (LV) systolic dysfunction and dys-synchronous ventricular activation. Biventricular pacemakers provide simultaneous or nearly simultaneous electrical activation of the LV and right ventricle (RV) via leads placed in the coronary sinus and the RV. As seen in this case, a right atrium (RA) lead is often present as well [1]. CRT has been shown to reduce heart failure hospitalization and/or mortality by up to 34% in patients with less advanced, predominantly NYHA class II heart failure patients [2]. CRT devices are inserted via the subclavian vein and are attached to a pulse generator unit which is then implanted subcutaneously, over the pectoralis muscle. Gentle loops of leads into the heart and to the generator will avoid the problems of recoil from the ventricle or advancement into the pericardium. A snug pocket for the generator is desirable in order to avoid its motion with traction upon the catheter [3]. In this case, electrode dislodgement was caused by the patient twisting the pulse generator and coiling the electrode (red arrow- Image A & B) adjacent to the generator known as the “pacemaker twiddler’s syndrome” [4-6]. The tip of of the atrial lead (green arrow) is superior to level of right atrium and has come to rest in the superior vena cava (Figs. 1A, 2A). The right ventricle lead (yellow arrow) and coronary sinus lead (blue arrow) have also migrated proximally (Figs. 1A, 2A). Ventricular capture depends upon the intimate contact between the pacing electrode and the endocardium. Dislodged pacemakers may begin to pace the diaphragm due to phrenic-nerve stimulation resulting in the sensation of continuous abdominal pulsation. [6] Additional retraction of the wire may lead to brachial plexus stimulation with resultant upper extremity twitching. [6] Other complications of pacemaker placement include lead migration, improper initial placement, and perforation. Migration of the RV lead across the tricuspid valve and into the inferior vena cava or migration into the LV via the interventricular septum or the interatrial septum may have catastrophic clinical results [3]. RV leads may rarely pass through a patent foramen ovale or perforate in the area near the fossa ovalis or pass through a persistent sinus venosus. Left ventricular pacing has also been reported due to inadvertent trans arterial placement, which allows the lead to cross the aortic valve and enter the left ventricular cavity [7]. Close abutment of the tip against the ventricle can lead to perforation of the myocardium and entrance of the catheter into the pericardial space leading to failure of ventricular capture or tamponade [3]. Malposition of a transvenous pacing lead into the left ventricle can cause thromboembolism. Other electrode associated complications include fracture, pneumothorax, hematoma (pocket or mediastinal), hardware infection, and inappropriate shocks [3, 8]. It is essential that lead position be correct and verified on frontal and lateral imaging before the placement procedure is terminated. A frontal projection alone cannot define appropriate lead position [3]. This patient had his pacemaker replaced at which time additional sutures were used to secure the generator. References: Aguilera AL, Volokhina YV, Fisher KL. Radiography of cardiac conduction devices: a comprehensive review. Radiographics. 2011;31(6):1669-1682. doi: 10.1148/rg.316115529 Zaręba W. Comparison of clinical trials evaluating cardiac resynchronization therapy in mild to moderate heart failure. Cardiol J. 2010;17(6):543-548. https://pubmed.ncbi.nlm.nih.gov/21154255/ McHenry, M.M. and C.E. Grayson, Roentgenographic Diagnosis of Pacemaker Failure. American Journal of Roentgenology, 1970. 109(1): p. 94-100 DOI: 10.2214/ajr.109.1.94 . Tegtmeyer, C.J. and J.M. Deignan, The cardiac pacemaker: a different twist. AJR Am J Roentgenol, 1976. 126(5): p. 1017-8 DOI: 10.2214/ajr.126.5.1017 Bayliss CE, Beanlands DS, Baird RJ. The pacemaker-twiddler's syndrome: a new complication of implantable transvenous pacemakers. Can Med Assoc J . 1968;99(8):371-373. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1924435/ Nicholson WJ, Tuohy KA, Tilkemeier P. Twiddler's Syndrome. N Engl J Med . 2003;348(17):1726-1727. DOI: 10.1056/NEJM200304243481722 Bauersfeld, U.K., et al., Malposition of transvenous pacing lead in the left ventricle: radiographic findings. American Journal of Roentgenology, 1994. 162(2): p. 290-292 DOI: 10.2214/ajr.162.2.8310911 Costelloe, C.M., et al., Radiography of pacemakers and implantable cardioverter defibrillators. AJR Am J Roentgenol, 2012. 199(6): p. 1252-8 DOI: 10.2214/ajr.12.8641 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 Cape Radiology Group . Formerly the Chief of Staff at Valley Presbyterian Hospital  in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME  to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator.   He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator  by AuntMinnie.com . Follow Dr. Rice on X formerly Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

"In the field of breast cancer, there are a lot of difficult moments, but there is a lot of hope." - Tamar Sella, MD Tamar Sella, MD is the Director of The Marlene Greenebaum Multidisciplinary Breast Center at Hadassah Medical Center and Clinical Senior Lecturer at the Hebrew University Faculty of Medicine - Jerusalem, Israel Dr. Sella earned her MD at the Hebrew University-Hadassah School of Medicine in 1996, and was awarded the faculty prize for outstanding MD thesis. She completed her residency in diagnostic radiology at Hadassah-Hebrew University Medical Center in 2001 and was then appointed as an attending radiologist. In 2004, Dr. Sella completed a rotating fellowship in breast and body imaging in the Department of Diagnostic Radiology,Memorial Sloan Kettering Cancer Center of the Weill Medical College, Cornell University, New York. Dr. Sella returned to Hadassah in 2005 and was appointed Medical Director of oncologic imaging in the Department of Radiology at Hadassah and Lecturer at the Hebrew University Faculty of Medicine, rising to Clinical Senior Lecturer in 2012. She was named Director of Hadassah’s Diagnostic Breast Imaging Center in 2009 and is now the Director of The Marlene Greenebaum Multidisciplinary Breast Center at Hadassah Medical Center. Her research focuses on oncologic imaging, breast imaging and biopsy, breast and body MRI, prostate MRI, and women’s imaging. She serves as an expert radiologist on a number of teams developing innovative techniques for breast and prostate imaging.

"Medical imaging has revolutionized diagnosis and, with it, therapy." - Jacob Sosna, MD We are honored to have Jacob Sosna, President of ISRA, join us at Imaging in Israel in June, 2017. Dr Sosna is currently President of the Israel Radiological Association. Professor Sosna’s research focuses on advancing clinical applications in cutting edge CT technology in collaboration with other experts in image-based diagnosis and therapy in the US and Europe. He also conducts ongoing research in quality assurance in collaboration with the Beth Israel Deaconess Medical Center and the major radiological professional societies. Professor Jacob Sosna earned his MD from the Sackler Faculty of Medicine of Tel Aviv University with distinction in 1989. After an Internship at the Beilinson Medical Center in Petach Tikvah, he completed his residency in radiology at Hadassah in 2001. He traveled to Boston to the Beth Israel Deaconess Medical Center, Harvard Medical School, for research and clinical fellowships in abdominal imaging and advanced cross-sectional imaging. Professor Sosna returned to Hadassah as a Senior Radiologist, Head of CT, and Director of the 3D Imaging Laboratory in 2003. He has served as Radiology Research Coordinator since 2004, and he established and heads the Experimental CT and Applied Radiology Laboratories. In 2006, he advanced to Senior Lecturer at the Hebrew University-Hadassah School of Medicine and Adjunct Lecturer in Radiology at the Harvard Medical School, advancing to Associate Professor of Radiology at the Hebrew University in 2009. In December 2011 Professor Sosna was named Chairman of Radiology at Hadassah Hebrew University Medical Center. Professor Sosna has published over 90 articles in peer-reviewed journals and is an active speaker in international conferences on radiology and diagnostic imaging. He was selected by the Board of Directors of the Radiological Society of North America (RSNA) as the Eyler Editorial Fellow for 2006, and is an Associate Editor for Radiology.

GLOBAL RADIOLOGY CME, congratulates Dr. Phillip Tirman, Medical Director of Musculoskeletal Imaging at Renaissance Imaging and Co-Scientific Program Director at Global Radiology CME for being named a Minnie semifinalist candidate, in the category of "Most Effective Educator" . We also extend our congratulations to Dr. Neil Rofsky , Effie and Wofford Cain Distinguished Chair in Diagnostic Imaging at UT Southwestern, and a distinguished faculty member of Global Radiology CME on UT Southwestern being named a semi finalist in the category of Best Radiologist Training Program . Please join us in also extending our congratulations to Imaging in England faculty, Dr. Laszlo Tabar and Dr. Vikas Shah for their nominations as Semi-finalist candidates in the category of most effective educator. The Minnies "recognize the best and brightest in medical imaging." Along with Dr. Blake Johnson , we are thrilled to have Dr. Phillip Tirman head up the panel of amazing speakers at Imaging in Prague in June, 2019. Dr. Phillip Tirman is a nationally recognized expert in the applications of Magnetic Resonance Imaging for evaluating orthopedic, sports medicine, and spine disorders. He is the co-author of three textbooks, including MRI of the Shoulder and Diagnostic Imaging: Orthopaedics. He is also the author or co-author on over sixty original scientific articles published in the radiology and orthopedic literature. Dr. Tirman is a manuscript reviewer for Radiology, the American Journal of Roentgenology, and the Journal of Magnetic Resonance Imaging. He is a widely sought lecturer and has spoken at over fifty international meetings and has been a pioneer of continuing medical education utilizing webinar technology with OCAD MSK. Dr. Tirman is also a food and wine connoisseur and is the author of the popular book The Wine and Food Lover's Diet which was a James Beard award nominee. Click here to read Dr. Tirman's blog posts and interesting cases Semifinalists for AuntMinnie.com's 2018 Most Effective Radiology Educator: Dr. Soonmee Cha, University of California, San Francisco Dr. Kevin Chang, Newton-Wellesley Hospital Dr. Tessa Cook, PhD, Hospital of the University of Pennsylvania Dr. Saurabh Jha, University of Pennsylvania Dr. Emanuel Kanal, University of Pittsburgh Dr. Nicholas Koontz, Indiana University Dr. Vincent Mellnick, Mallinckrodt Institute of Radiology Dr. Tan-Lucien Mohammed, University of Florida Dr. William Morrison, Thomas Jefferson University Dr. Mark Mullins, PhD, Emory University Dr. Gregory Nicola, Hackensack Radiology Group Dr. Nayana Parange, University of South Australia Dr. Ryan Peterson, Emory University Dr. Stephen Pomeranz, ProScan MRI Online Dr. Sumer Sethi, Delhi Academy of Medical Sciences Dr. Vikas Shah, University Hospitals of Leicester Dr. Laszlo Tabar, Falun Central Hospital Dr. William Thorwarth, American College of Radiology Dr. Phillip Tirman, Global Radiology CME Dr. Amar Udare, Tata Memorial Centre Dr. Hebert Alberto Vargas, Memorial Sloan Kettering Cancer Center Dr. Marc Willis, Baylor College of Medicine Dr. Kevin Wong, Phoenix Children's Hospital Dr. Sanjay Yadav, Mysore Medical College

"I am delighted to join my good friend Phillip Tirman in Israel!" - Blake A. Johnson, MD, FACR​ We are honored to have Blake A. Johnson join the panel of expert speakers at Imaging in Israel in June, 2017. Blake A. Johnson, M.D., F.A.C.R. is the Twin Cities Medical Director and director of neuroimaging at Center for Diagnostic Imaging (CDI). Before joining CDI in 1997, Dr. Johnson was chief of neuroradiology at David Grant USAF Medical Center. He also served as assistant clinical professor of radiology at the University of California, San Francisco. Dr. Johnson has lectured at national and international conferences on a broad spectrum of central nervous system imaging topics and spine pain management. He is past president of the Clinical Magnetic Resonance Society and a Fellow of the American College of Radiology. Dr. Johnson has authored and co-authored numerous articles and book chapters on neuroradiology topics including brain and spine imaging. He also authored and coauthored several pieces on image-guided spine intervention. He lectures extensively on these areas of interest at several national and international forums. His contributions to organizations include serving on the ASSR Executive Committee, the ACR Committees on Economics, Human Resources, Coding and Nomenclature, the CMRS Board of Trustees, the ASNR Committee on Economics, ACR Commission on Neuroradiology and Magnetic Resonance, the ACR Expert Panel on Neuroimaging, the ASNR Research Committee, the ASNR Clinical Practice Committee, Chair of the ASNR Coding & Reimbursement Subcommittee and on the program committees of the ASNR and ASSR. Dr. Johnson is a three-time recipient of the Editor’s Recognition Award for Distinction in Reviewing for Radiology.