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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.

"I am delighted to join my good friend Phillip Tirman in England!" - Blake A. Johnson, MD, FACR​ We are honored to have Blake A. Johnson join the panel of expert speakers at Imaging in Oxford in June, 2018. 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.

Skin lesions and kidney masses • Xray of the Week What is the diagnosis? Figure 1. What are the important findings seen on these CT images? Figure 2. Figure 2A: Axial CT image of abdomen with angiomyolipomas (orange arrows). Figure 2B: Axial CT image with sclerotic bone lesions (green arrows). Figure 2C: Coronal CT image of abdomen with angiomyolipomas (orange arrow) and renal cysts (yellow arrows). Figure 2D: Axial CT of brain with subependymal tubers (red arrows). Discussion: Tuberous sclerosis complex (TSC) aka Bourneville Disease is a multisystem autosomal dominant neurocutaneous syndrome that is usually diagnosed in childhood but may present at any age [1]. It is due to mutation in the genes TSC1 or TSC2. Diagnosis of TSC can be achieved with genetic analysis, however, it may not identify a mutation in up to 25% of patients [2]. This leads to the use of clinical diagnostic criteria, which is separated into major and minor features. Definitive diagnosis is defined as the presence of at least two major features, or one major and two minor features [2]. Major Features Hypomelanotic macules (>2 at least 5 mm in diameter) Angiofibromas (>2) or a fibrous cephalic plaque Ungual fibromas (>1) Shagreen patch Multiple retinal hamartomas Cortical dysplasias Subependymal nodules Subependymal giant cell astrocytoma Cardiac rhabdomyoma Lymphangioleiomyomatosis Angiomyolipomas (>1) Minor Features Confetti skin lesions Dental enamel pits (>3) Intraoral fibromas (>1) Retinal achromic patch Multiple renal cysts Nonrenal hamartomas TSC may affect any human organ with well demarcated benign and noninvasive lesions [3]. Organs often involved include the skin, brain, retina, heart, kidneys, and lungs [3]. TSC is often associated with neurologic disorders, including epilepsy, mental retardation, and autism [4]. However, TSC has a wide clinical spectrum and many patients may have minimal symptoms with no neurologic disability [4]. Some characteristic findings that are appreciable on imaging include angiomyolipomas, cysts, sclerotic bone lesions, and subependymal tubers. Renal angiomyolipomas occur in about 75 to 80% of patients over the age of 10 years [5]. A majority of these lesions are benign and typically are bilateral and multiple. Renal cysts are also common findings of TSC and the combination of renal cysts and angiomyolipomas is characteristic of TSC [5], (Figs. 2A and 2C). Sclerotic bone lesions can appear as collection of dense, compact bone within the medullary cavity [6], (Figure 2B). Subependymal tubers are seen in up to 90% of patients, while about up to 20% develop subependymal giant cell astrocytomas [7] . Subependymal tubers are calcified nodules that are adjacent to the ventricular wall and tend to extend into the ventricular lumen [5]. These nodules are commonly observed in the anterior aspects of the lateral ventricles [5], (Fig. 2D). Currently, there is no cure for TSC, however, the International Tuberous Sclerosis Complex Consensus Group proposes the following recommendations for clinical management. For asymptomatic growing renal angiomyolipomas measuring greater than 3 cm in diameter, first-line treatment consists of mTOR inhibitors [8]. Furthermore, a patient’s blood pressure should be evaluated and those with hypertension should be started on a renin-aldosterone-angiotensin system inhibitor, while avoiding angiotensin converting enzyme inhibitor in those treated with mTOR inhibitors [8]. Renal angiomyolipomas have abnormal blood vessels that are prone to aneurysm formation and rupture [9]. Hemorrhage from angiomyolipomas can be life-threatening, so treatment is advised in symptomatic patients and those with lesions larger than 4 cm [9]. Treatment of renal angiomyolipomas includes the use of selective or super-selective transcatheter arterial embolization which has clinical success rates approaching 100% [9,10]. Brain surveillance by MRI is recommended every 1-3 years in individuals with TSC under 25 years of age and should be continued for life if the patient develops a subependymal giant astrocytoma [8]. Patients with TSC are also at risk for lymphangioleiomyomatosis and should have a baseline high-resolution chest CT with assessment for symptoms of exertional dyspnea and shortness of breath [8]. If no lung cysts are appreciated on CT, then repeat imaging is done every 5-10 years [8]. If a cyst is detected, then imaging is done every 2-3 years along with annual pulmonary function testing and 6-minute walk test [8]. Asymptomatic patients with cardiac rhabdomyomas require follow-up echocardiogram every 1-3 years along with 12-lead ECG every 3-5 years to monitor for conduction defects [8]. Thus, radiology plays an essential role as part of the multidisciplinary team in the surveillance and management of tuberous sclerosis complex. ​​​​ References: Randle, Stephanie Carapetian. "Tuberous sclerosis complex: a review." Pediatric annals 46.4 (2017): e166-e171. doi: 10.3928/19382359-20170320-01 Von Ranke, Felipe Mussi et al. “Imaging of tuberous sclerosis complex: a pictorial review.” Radiologia brasileira vol. 50,1 (2017): 48-54. doi: 10.1590/0100-3984.2016.0020    Curatolo, P., and B. L. Maria. "Tuberous sclerosis." Handbook of clinical neurology. Vol. 111. Elsevier, 2013. 323-331. doi: 10.1016/B978-0-444-52891-9.00038-5 Crino, Peter B., Katherine L. Nathanson, and Elizabeth Petri Henske. "The tuberous sclerosis complex." New England Journal of Medicine 355.13 (2006): 1345-1356. doi: 10.1056/NEJMra055323 Roach, E. Steve, and Steven P. Sparagana. "Diagnosis of tuberous sclerosis complex." Journal of child neurology 19.9 (2004): 643-649. doi: 10.1177/08830738040190090301 Avila, Nilo A., et al. "CT of sclerotic bone lesions: imaging features differentiating tuberous sclerosis complex with lymphangioleiomyomatosis from sporadic lymphangioleiomymatosis." Radiology 254.3 (2010): 851-857. doi: 10.1148/radiol.09090227 Luo C, Ye WR, Shi W, et al. Perfect match: mTOR inhibitors and tuberous sclerosis complex. Orphanet J Rare Dis . 2022;17(1):106. Published 2022 Mar 4. doi : 10.1186/s13023-022-02266-0 Krueger, Darcy A., et al. "Tuberous sclerosis complex surveillance and management: recommendations of the 2012 International Tuberous Sclerosis Complex Consensus Conference." Pediatric neurology 49.4 (2013): 255-265. doi: 10.1016/j.pediatrneurol.2013.08.002 Wang, Chengen et al. “Transarterial embolization for renal angiomyolipomas: A single centre experience in 79 patients.” The Journal of international medical research vol. 45,2 (2017): 706-713. doi: 10.1177/0300060516684251 Hatano, Takashi, and Shin Egawa. "Renal angiomyolipoma with tuberous sclerosis complex: How it differs from sporadic angiomyolipoma in both management and care." Asian Journal of Surgery (2020). doi: 10.1016/j.asjsur.2019.12.008 Update 2024: Amer Ahmed is a Class of 2026 Radiology Resident at University of Illinois Chicago College of Medicine , after having done an internship at Indiana University School of Medicine . Amer Ahmed is a fourth-year medical student at Midwestern University Chicago College of Osteopathic Medicine . There, he has served as the President for the Medical Business Association and Secretary for the Radiology Interest Group. Before medical school, Amer earned a degree in Economics at Loyola University Chicago and spent some time as an Investment Specialist at Merrill Edge before deciding to pursue his interest in medicine. Radiology intrigued Amer following a back injury requiring him to get an MRI. That is when he was able to appreciate the eye for detail Radiologists possess. Amer is passionate about finance, medicine, and technology. Follow Amer Ahmed on Twitter @amer_ahmed401 All posts by Amer Ahmed 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

What can you determine about this patient's blood work? • Xray of the Week Figure 1. A. Axial CT. B. Coronal CT. Figure 2. A. Axial CT. Note the “interventricular septum sign” with hyperattenuating interventricular septum against relatively hypodense blood pool (red arrow). B. Coronal CT. Also demonstrating the interventricular septum sign (red arrow). Figure 3. Axial CT. Note the ROI in the LV is 20 HU. Figure 4. This patient's blood work indicating severe anemia with Hemoglobin of 3.0 g/dL (N= 12-16 g/dL) and Hematocrit of 8.4% (N=36-46%) Discussion: Differences in density on CT of the thorax can be helpful in diagnosis of anemia, especially when complete blood count data is not available. Anemia is thought to be associated with low CT attenuation of blood in the lumen of the left ventricle (Figs. 1-3) (1). The patient in this case has pancytopenia which is a deficiency in red blood cells (anemia), white blood cells, and platelets (Fig. 4) (2). This patient's LV lumen has a measurement of 20 HU (Fig. 3) Studies suggest that CT attenuation of 35 HU corresponding to a hemoglobin level of 10 g/dL can distinguish between anemic and non-anemic patients with a sensitivity of 76% and specificity of 81% (1,3). Foster et al. found that visualization of the hyperdense interventricular septum against the hypodense left ventricular cavity, also known as the interventricular septum sign (Figs. 1-3), on unenhanced CT of the thorax is specific for anemia with a positive predictive value of 100% for males and 89% for females (1,3). Hyperattenuation of the aortic wall against the hypodense aortic blood pool, also known as the aortic ring sign, is more sensitive than the interventricular septum sign (84% vs 72%) in diagnosis of anemia (4,5). However, it has lower specificity because faint calcification in atherosclerotic mural plaques appear dense on unenhanced CT which may occur in other cardiac abnormalities such as Takayasu’s arteritis and intramural aortic hematoma (5). Kamel et al. suggest that the best diagnostic approach to identifying anemia on unenhanced CT of the thorax is a combination of inspection for aortic ring sign, interventricular septum sign, and measurement of aortic CT attenuation values to account for the sensitivity, specificity, and accuracy of these indicators (5). ​​​​ References: Foster M, Nolan RL, Lam M. Prediction of anemia on unenhanced computed tomography of the thorax. Can Assoc Radiol J. 2003;54(1):26-30. https://pubmed.ncbi.nlm.nih.gov/12625080/ Yokuş, Osman, and Habip Gedik. “Etiological Causes of Pancytopenia: A Report of 137 Cases.” Avicenna Journal of Medicine, vol. 6, no. 4, 2016, pp. 109–12. PubMed Central, doi: 10.4103/2231-0770.191447 MedPix Topic - Assessing Anemia on Thoracic CT. https://medpix.nlm.nih.gov/topic?id=795fffaa-34a2-46bc-87f4-9b77c00e3989 . Accessed 21 Aug. 2020. Collins AJ, Gillespie S, Kelly BE. Can computed tomography identify patients with anaemia?. Ulster Med J. 2001;70(2):116-118. https://pubmed.ncbi.nlm.nih.gov/11795761/ Kamel, Ehab M., et al. “Radiological Profile of Anemia on Unenhanced MDCT of the Thorax.” European Radiology, vol. 18, no. 9, Sept. 2008, pp. 1863–68. PubMed, doi: 10.1007/s00330-008-0950-9 Updated: 08/25/2024: Amara Ahmed is a Radiology Resident at The University of Florida . She did her medical school 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 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 Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

36 M with RLQ pain, R inguinal swelling and fever. What is the diagnosis? • Xray of the Week Figure 1. CT scan of the pelvis on 36 year old male with right lower quadrant pain, right inguinal swelling, and fever. Figure 2. CT scan of the pelvis demonstrating acute infective vasitis. A. Axial CT- Inflammation of the right vas deferens (yellow arrows) with mild adjacent edema in the right side of pelvis. B. Axial CT- Thickening of the right spermatic cord extending into the inguinal canal with mild adjacent edema (red arrows). C. Coronal CT -Thickening of the right spermatic cord extending into the inguinal canal with mild adjacent edema (red arrows). Figure 3. Acute infective vasitis. Video going through the axial images on this case. Figure 4. Ultrasound of acute vasitis shows a heterogenous and thickened vas deferens. Figure 5. Color Doppler ultrasound of the same section as Figure 4. Note the marked increased blood flow within the spermatic cord. Discussion: Vasitis refers to a rare inflammatory disease of the vas deferens (1). There are two forms: acutely painful infectious vasitis and asymptomatic vasitis nodosa (2). The infectious form is typically caused by retrograde spread of organisms such as Neisseria gonorrhoeae, Chlamydia sp., or Escherichia coli from the prostatic urethra or seminal vesicle while vasitis nodosa results from vasectomy (1). Vasitis often presents as painful swelling in the groin with a palpable mass in the scrotal region (3). It can include urinary tract infection-like symptoms, so it is often misdiagnosed as epididymitis, orchitis, testicular torsion, or prostatitis (4). Due to the inguinal pain and swelling, it is frequently misdiagnosed as an acute inguinal hernia (4). It can also present with leukocytosis, fever, and right lower quadrant pain as seen in this patient (3). Imaging is important in vasitis as it can prevent unnecessary surgical intervention for other causes of acute groin pain (5-7). The inguinal canal edema can be seen on CT with thickening of the spermatic cord and vas deferens (4) (Figs. 1-3). CT is especially helpful in differentiating between vasitis and acute inguinal hernia. With ultrasound, acute vasitis shows a heterogenous, hypoechoic and thickened vas deferens with hyperemia on color Doppler (3-6)(Figs. 4, 5). Ultrasound can help exclude orchitis, epididymitis, and testicular torsion by color Doppler but it is still difficult to differentiate acute inguinal hernia from vasitis so CT or MRI is recommended (3-5). On MRI, fluid-sensitive sequences show edema of the inguinal canal and spermatic cord (3,7). With appropriate treatment including antibiotics and anti-inflammatory drugs, prognosis is excellent (3). ​​​​ References: Yang DM, Kim HC, Lee HL, Lim JW, Kim GY. Sonographic findings of acute vasitis. Journal of Ultrasound in Medicine. 2010;29(12):1711-1715. doi: https://doi.org/10.7863/jum.2010.29.12.1711 Lin C, Huang TY. Vasitis: a clinical confusion diagnosis with inguinal hernia. Int Braz J Urol. 2019;45(3):637-638. doi:10.1590/S1677-5538.IBJU.2018.0457 Chen C-W, Lee C-H, Huang T-Y, Wang Y-M. Vasitis: a rare diagnosis mimicking inguinal hernia: a case report. BMC Urology. 2019;19(1):27. doi:10.1186/s12894-019-0460-xoi:10.1590/S1677-5538.IBJU.2018.0457 Eddy K, Piercy GB, Eddy R. Vasitis: clinical and ultrasound confusion with inguinal hernia clarified by computed tomography. Can Urol Assoc J. 2011;5(4):E74-E76. doi:10.5489/cuaj.10116 Eddy K, Connell D, Goodacre B, Eddy R. Imaging findings prevent unnecessary surgery in vasitis: An under-reported condition mimicking inguinal hernia. Clinical Radiology. 2011;66(5):475-477. doi:10.1016/j.crad.2010.12.006 Yang DM, Kim HC, Lee HL, Lim JW, Kim GY. Sonographic findings of acute vasitis. J Ultrasound Med . 2010;29(12):1711-1715. doi: 10.7863/jum.2010.29.12.1711 Patel K, Lamb B, Pathak S, Peters J. Vasitis: the need for imaging and clinical acumen. BMJ Case Rep . 2014;2014:bcr2014206994. Published 2014 Oct 17. doi: 10.1136/bcr-2014-206994 Updated 08/25/2023: Amara Ahmed is a Radiology Resident  at The University of Florida . She did her medical school 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 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 Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

Register now for the Imaging in Greece radiology conference scheduled to take place from June 1-5, 2025. This event will feature world-renowned experts in radiology who will share their knowledge and insights. Beyond the conference sessions, take the opportunity to discover the top ten activities recommended by our team. From the historical wonders of Athens to the picturesque landscapes of the Greek islands, there is no shortage of amazing things to do and see during your stay. 1. Spend an unforgettable week with world class faculty , networking with radiologists from around the globe, while educating your mind, and rejuvenating your body and soul in Athens, the birthplace of Democracy.  2. "Island Hop"! Our main CME program will be held at the Divani Palace, Athens with the option to attend an add on course, June 5, 2025 focusing on wellness/business. After the conference you will be free to explore the nearby island in the Aegean Sea. 3. Focus on your wellness! Join one of our early morning guided "brisk walks" offered by a local tour guide . The walks will commence at 7:00 am bringing you back to the hotel in time for the scientific program. 4. Explore the Acropolis and marvel at the Parthenon. Step back in time as you wander through ancient ruins and stand in awe of the iconic Parthenon, a symbol of classical Greece only a 7 minute walk from the conference hotel, Divani Palace. You can see this and other historic gems on the Greek Mythology Walking Tour . 5. A short walk from the conference venue will bring you to the historic Plaka district. Immerse yourself in the charming streets lined with neoclassical buildings, quaint shops, and cozy cafes offering a glimpse into Athens' past. 6. Visit the Acropolis Museum for a deeper insight into Greek history and Mythology. Discover a treasure trove of artifacts and sculptures that bring to life the rich history and culture of ancient Greece. 7. Indulge in delicious Greek cuisine at local tavernas. Treat your taste buds to an array of mouthwatering Greek dishes, from souvlaki and moussaka to fresh seafood, all served in cozy tavernas filled with local charm. 8. Enjoy a glass of wine at one of the local vineyards while overlooking the sea! 9. Get Wet! Enjoy an afternoon sail on a Catamaran. Embark on a thrilling adventure and immerse yourself in the refreshing experience of sailing on a Catamaran. Feel the gentle breeze against your skin as you glide through the crystal-clear waters, surrounded by stunning views of the Greek islands. Whether you're a seasoned sailor or a first-time seafarer, the Catamaran offers a unique and exhilarating way to explore the Aegean sea. 10. Take a day trip to Delphi to explore ancient ruins. Embark on a journey to Delphi, home to the legendary Oracle of Apollo, and explore the well-preserved archaeological site surrounded by stunning mountain scenery. Register for this unforgettable conference HERE: https://www.globalradiologycme.com/imagingingreece2025/registration