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"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

As the VP of Global Radiology CME, I am often asked the question, why attend a live radiology conference when there are so many CME options on line? It is often argued that online learning is more convenient and cost efficient. Why pack a suitcase and deal with the stresses of travel to engage in an activity you can do from the convenience and comfort of your home or office? Welcome dinner at Groften at Imaging in Copenhagen 2024 1. Get away from your computer. Most of us spend a tremendous amount of our day in front of the computer. We shop, socialize via social media, study and with the advances of teleradiology, often work, without ever leaving our home or office. While on line learning has revolutionized medical education and plays a critical role in keeping radiologists abreast in a rapidly changing field of medicine, it is a more passive form of study. Watch this video and hear what people are saying about Global Radiology CME. 2. Meet other radiologists from around the world. Learning is intensified from the synergy that can only occur from collaborative and interactive educational opportunities, experiences that cannot be achieved when sitting passively in front of a computer. When a group of radiologists from around the globe, meet away from the distractions of their offices, to share their knowledge, discuss advances, address concerns, network and socialize with their colleagues the takeaway is far greater than the number of CME credit hours earned. The radiologist not only comes away from the meeting with gained knowledge and skill sets, but also new colleagues that can offer fresh approaches and different perspectives to address shared goals. Registrants and Faculty at Imaging in Copenhagen 2024 Neuroradiology Quiz Winners and Neuroradiology Faculty: Left to right: Bob Chai -USA, Thomas Grieser - Germany, Faculty- Amish Dosi of Mount Sinai USA, Faculty- Pia Sundgren of Lund University Sweden, Nancy Shaffer -USA, James Fulton - New Zealand, Ky McGrillen - Australia. 3. Interact directly with the faculty. Live conferences provide opportunities to network with the faculty. Radiologists go back to their practices with a renewed energy and enthusiasm for their profession. The holistic educational experience only achieved through live education accelerates advances in radiology that most importantly benefits the patients, hospitals, and communities served. Oxford Bridge of Sighs and Radcliffe Camera - Photos by Kevin Rice 4. Visit interesting locations. The next question I am asked, is why should I choose Global Radiology CME, and what sets Global Radiology apart from online conference providers? Our motto is to “Go Global”! Our faculty is comprised of an internationally renowned group of award winning radiologists, that are not only leaders in their area of specialty, but outstanding educators, our conferences attract radiologists from around the globe. During the last 2 years in Oxford and Israel, we have hundreds of radiologists attending from 36 countries! We choose enriching off the beaten path destinations for our meetings and we provide opportunities to network with colleagues in informal settings during social events and tours. 5. Bring your family and friends. We are also family friendly. We appreciate radiologists often want to combine business with pleasure and we warmly welcome spouses/companions/children to our social programming. The experience you will have attending a Global Radiology CME conference can not be obtained online! So join us for one of our upcoming conferences in exciting and historic destinations. Natalie B. Rice Global Radiology CME Vice President of Finance and Operations Co-Founder of Global Radiology CME, Natalie B. Rice, was born in Winnipeg and graduated from the University of Manitoba majoring in Economics. After completing her economics degree she attended Business School, majoring in accounting. Her work experiences include Dunwoody Accounting Firm, The Conference Board of Canada, and Principal of a Religious School. Having sat on numerous community boards, she is well connected and knows how to see a project to completion. Natalie has planned numerous successful international events throughout Canada, Europe, the Middle East, and the USA. Most recently, Natalie spearheaded Global Radiology’s conference in Israel, successfully managing 250 delegates from 20 different countries and overseeing all aspects of the congress including faculty management, venue selection, registration, itinerary and social programming.

34 M. Trauma due to falling off a roof. Diagnosis? • Xray of the Week Figure 1. Trauma due to falling off a roof. Diagnosis? Figure 2. Type B2 Lisfranc injury. (A) AP radiograph demonstrates the circled “fleck sign” or Lisfranc ligament avulsion fracture fragment. (B) Arrow demonstrates the increase in distance between the first and second metatarsals. The red lines show the misalignment or lateral displacement of the 2nd metatarsal bone over the second cuneiform bone and the preserved alignment of the first metatarsal with the first cuneiform bone. The first cuneiform bone is also fractured and there is lateral shift of the 2nd, 3rd, 4th, and 5th metatarsals. (C) Lateral radiograph demonstrates dorsal sub dislocation of the metatarsal base (red circle). Introduction A Lisfranc Fracture is a relatively rare injury, with an incidence of 1 per 55,000 persons per year and 0.2% of all diagnosed fractures. More commonly seen in male patients during the third decade of life, it is a fracture/dislocation of the tarsometatarsal (TMT) joint between the first, second, and third metatarsal bones, which articulate with three cuneiform bones [1,2]. The trapezoidal shape between these bones, the transverse arch, provides stability. Injury can encompass minor ligamentous lesions and fracture dislocations with more severe trauma, as in this case [2]. Other risk factors include patients with diabetes or chronic neuropathy and repetitive wear and tear [1]. A shallow second TMT joint also contributes to increased risk of injury. Fracture often occurs due to intense medial or lateral forces acting as the foot is plantar flexed, such as in a motor vehicle collision or while playing sports [2]. With over 20% of Lisfranc fractures missed upon presentation, it is important to diagnose these injuries promptly, as delayed diagnosis may lead to chronic foot deformity, midfoot arthritis, pain, chronic instability, and disability [1,2]. History and Physical Exam: Severe injuries present with difficulty bearing weight, pain, swelling, and an obvious deformity [1]. However, some patients may only present with pain and no obvious deformity [2]. Patients commonly hear or feel a midfoot pop when acutely injuring the Lisfranc joint. Symptoms may also include plantar ecchymosis, neuropathy, and decrease of sensation and two-point discrimination over the medial terminal branch of the deep peroneal nerve. There may also be abnormal increased distance between the first and second toes [2]. Imaging and Case Analysis: Radiographic images demonstrate misalignment of the medial side of the second metatarsal with the medial side of the middle cuneiform bone, as seen in this case. (Fig.1B) [3]. An increased distance between the first and second metatarsals can be seen. (Fig.1B) [1]. It may demonstrate a more pronounced cavus midfoot, findings highly suggestive of a Lisfranc fracture [2]. A distance of greater than 2 mm between the first cuneiform bone and second metatarsal is also suggestive of a Lisfranc injury [2]. A bone fragment is often observed between the first and second metatarsals, indicating an avulsion of the Lisfranc ligament or “fleck sign” as demonstrated here (Fig.1A) [2]. The lateral side of the first metatarsal base and the lateral side of the medial cuneiform may also be visualized and misaligned due to injury [3]. Figure 3. Hardcastle & Myerson Classification system for Lisfranc Injury. [2, 4] The Hardcastle & Myerson Classification system categorizes injuries as type A when all the metatarsals are displaced laterally with total incongruity, with M1-M5 dislocated in the same direction [2]. In a type B injury, one or more metatarsals are displaced without total incongruity. The M1 joint will be medially dislocated, or any of the M2-M4 joints will be laterally dislocated [2]. A type C injury has a divergent pattern or a complete dislocation of M1 and all metatarsals [2]. Myerson further subdivided type B and type C injuries into a modified classification system. For B1 injuries, there is a first metatarsal medial dislocation [4]. For B2 injuries, there is a lateral dislocation of M2-M5. Type C1 demonstrates a divergent pattern in some of the tarsometatarsal joints, and type C2 includes all the tarsometatarsal joints [4]. This case demonstrates severe trauma, and although there is preserved alignment of the first metatarsal with the first cuneiform bone, the first cuneiform bone itself is fractured. There is also a lateral shift or displacement of the 2nd, 3rd, 4th, and 5th metatarsals (Fig. 1A). Using this description and the flowchart (Fig. 4), this patient has a type B2 Lisfranc injury. Figure 4. Flow chart of Hardcastle & Myerson Classification system for Lisfranc Injury. [2, 4] One should also evaluate the oblique view to check the medial side of the fourth metatarsal base lining up with the medial side of the cuboid bone [1]. The lateral view is useful to check for plantar misalignment and the dorsal cortex of the first metatarsal lining up with the medial side of the cuneiform bone [2]. In this case the lateral view shows a dorsal sub dislocation of the metatarsal base (Fig. 1C). A CT scan will better assist with diagnosis and help with planning if surgery is necessary [5]. It is useful when measuring M2-C1 distance and comparing the sides of the foot [6]. However, some argue it has limited benefit for subtle injuries as radiographs are 82% sensitive and 90% specific [7]. Magnetic resonance imaging will help to evaluate ligamentous involvement and provides a 94% predictive value for diagnosing Lisfranc injury [2]. Treatment: Non-surgical treatment can only be considered for stable, non-displaced injuries. Those patients will be treated with immobilization for six weeks and subsequent gradual return to physical activity [2]. For patients with displaced (rupture or detachment of Lisfranc ligament) or unstable while weight-bearing Lisfranc injuries, surgery is required [1]. Although the Hardcastle and Myerson is the most commonly used classification system for Lisfranc injuries, it does not fully determine the treatment plan [8]. Standard treatment is open reduction and internal fixation, with non-weight-bearing for six to eight weeks for most types of Lisfranc injuries, commonly type B [2,9]. However, a primary partial arthrodesis may also be considered as it has shown optimal results for purely ligamentous Lisfranc injuries, patients with delayed presentation or chronic deformity, or patients with complete Lisfranc fracture dislocations such as those with type A or C2 Lisfranc injuries [2,4,8,10]. A combination of both procedures can be considered for a complex Lisfranc injury, such as in this case. There is conflicting evidence on which surgical procedure is more effective as both have similar pain intensity scores. However, primary arthrodesis has lower complication rates [10]. References: Buchanan BK, Donnally III CJ. Lisfranc Dislocation. In: StatPearls. Treasure Island (FL): StatPearls Publishing; August 29, 2022. PMID: 28846306. Bookshelf ID: NBK448147. https://pubmed.ncbi.nlm.nih.gov/28846306/. Moracia-Ochagavía I, Rodríguez-Merchán EC. Lisfranc fracture-dislocations: current management. EFORT Open Rev. 2019;4(7):430-444. Published 2019 Jul 2. DOI: 10.1302/2058-5241.4.180076. Shazadeh Safavi P, Weiss W, Panchbhavi V. Gravity Stress Radiograph Revealing Instability at the First Metatarso-Cuneiform Joint in Lisfranc Injury. Cureus. 2017;9(2):e1015. Published 2017 Feb 7. DOI: 10.7759/cureus.1015. Albert S, Bliss J, Nithyananth M. Lisfranc fracture dislocation: A Review. Journal of Foot and Ankle Surgery (Asia Pacific). 2022;10(1):234-241. doi:10.5005/jp-journals-10040-1236. Kennelly H, Klaassen K, Heitman D, Youngberg R, Platt SR. Utility of weight-bearing radiographs compared to computed tomography scan for the diagnosis of subtle Lisfranc injuries in the emergency setting. Emerg Med Australas. 2019;31(5):741-744. DOI: 10.1111/1742-6723.13237. Falcon S, McCormack T, Mackay M, et al. Retrospective chart review: Weightbearing CT scans and the measurement of the Lisfranc ligamentous complex. Foot Ankle Surg. 2023;29(1):39-43. DOI: 10.1016/j.fas.2022.08.011. Chen C, Jiang J, Wang C, Zou J, Shi Z, Yang Y. Is the diagnostic validity of conventional radiography for Lisfranc injury acceptable?. J Foot Ankle Res. 2023;16(1):9. Published 2023 Mar 1. DOI: 10.1186/s13047-023-00608-0. Padki A, Cheok GJ, Mehta KV. Outcomes of surgical fixation of Lisfranc injuries: A 2-Year review. Journal of Foot and Ankle Surgery (Asia Pacific). 2022;9(S1). doi: 10.5005/jp-journals-10040-1192. Mascio A, Greco T, Maccauro G, Perisano C. Lisfranc complex injuries management and treatment: current knowledge. Int J Physiol Pathophysiol Pharmacol. 2022;14(3):161-170. Published 2022 Jun 15. PMCID: PMC9301181. https://pubmed.ncbi.nlm.nih.gov/35891929/. Levy CJ, Yatsonsky D 2nd, Moral MZ, Liu J, Ebraheim NA. Arthrodesis or Open Reduction Internal Fixation for Lisfranc Injuries: A Meta-analysis. Foot Ankle Spec. 2022;15(2):179-184. DOI: 10.1177/1938640020971419. Rebeca Santos is a Class of 2025 medical student at Indiana University School of Medicine in Indianapolis, IN. She graduated summa cum laude with a Bachelor of Business Administration degree in Finance and International Business with honors college completion and an international bank management certificate in 2014. During medical school, she volunteered at the IU student outreach clinic and participated in Kids in Nutrition, teaching healthy habits, and providing nutritional education to elementary students. She also conducted laboratory research on the FOXP3 isoform to establish its role in autoimmunity and presented the poster at the Harvard 2022 New England Science Symposium. She is now pursuing a career in Diagnostic Radiology with interests in Breast imaging. She strives to achieve innovation in the field of radiology, utilizing breakthrough detection methods to make an impact in women’s health. All posts by Rebeca Santos 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

51M with hypertension and chest pain • Xray of the Week Figure 1. Name the important findings on this CT Scan. Figure 2. CT of Stanford Type B aortic intramural hematoma. A. Normal ascending aorta (green arrow). Note the crescent-shaped, hyperdense region along the wall of the descending aorta (yellow arrow) indicating intramural hematoma. B. Normal ascending aorta (green arrow). The intramural hematoma is seen more inferiorly with an intramural blood pool demonstrated by contrast within the intramural hematoma without visualized connection to the lumen (blue arrow). C. The intramural hematoma extends into the abdominal aorta on sagittal oblique MPR image (red arrow). Figure 3. Diagram of Stanford classification for aortic intramural hematoma. Stanford A affects the ascending aorta, with or without descending aortic involvement and Stanford B affects the descending aorta, distal to the origin of the left subclavian artery. Diagram by Han Ngo. Discussion: Aortic dissection occurs when blood enters the aortic media due to an intimal tear. Aortic intramural hematoma (IMH), a variant form of the classic aortic dissection, originally was thought to occur due to hemorrhage within the aortic media from rupture of the vasa vasorum in the absence of an intimal tear (1,2). However, with the advent of high resolution imaging, intimal tears may be identified in patients with IMH. For this reason, it is postulated that aortic dissection has both an entry tear and an exit tear whereas IMH has only an entry tear (3) in the intima. Older patients with history of hypertension are at highest risk for aortic dissection and IMH (4). Aortic dissection and IMH usually present with hypertension and chest pain that radiates to the back (3-6). IMH may progress to dissection, rupture, or acute cardiac tamponade occurred in up to 32% of cases (7). Acute aortic regurgitation may occur in up to 35% of patients with IMH (4,6,8). The Stanford classification system is used to categorize both aortic dissection and IMH (Fig. 3). Stanford Type A affects the ascending aorta, with or without descending aortic involvement and Stanford Type B affects the descending aorta, distal to the origin of the left subclavian artery (4,5). Usually Stanford Type A is treated surgically or with stent-graft placement while Stanford Type B is managed medically- primarily with blood pressure control (5-9). On chest CT and MRI, aortic dissection is diagnosed by the presence of an intimal flap (1,2). With IMH, CT demonstrates a crescent-shaped hyperdense region along the aortic wall with no intimal flap (Fig. 2). This crescent sign represents the hematoma confined to the aortic media without visualized communication with the aortic lumen. As in this case, an intramural blood pool may be seen as enhancing blood in the aortic wall without visualized connection to the lumen, most often seen in the in the descending aorta (8, 10). Followup imaging in patients with IMH is similar to that in patients with aortic dissection: CT or MR imaging done while in hospital and at 1, 3, 6, and 12 months after the initial presentation and then annually to evaluate for the emergence of complications (9). ​​​​ References: 1. Song J-K. Diagnosis of aortic intramural haematoma. Heart. 2004;90:368-371. doi: 10.1136/hrt.2003.027607 2. Macura KJ, Corl FM, Fishman EK, et al. Pathogenesis in acute aortic syndromes: aortic dissection, intramural hematoma, and penetrating atherosclerotic aortic ulcer. AJR Am J Roentgenol. 2003;181 (2): 309-16. doi:10.2214/ajr.181.2.1810309 3. Gutschow SE, Walker CM, Martínez-Jiménez S, et al. Emerging Concepts in Intramural Hematoma Imaging. (2016) Radiographics : a review publication of the Radiological Society of North America, Inc. 36 (3): 660-74. doi:10.1148/rg.2016150094 4. Alomari IB, Hamirani YS, Madera G, et al. Aortic intramural hematoma and its complications. Circulation. 2014;129(6):711-716. doi:10.1161/CIRCULATIONAHA.113.001809 4. Herrán FL, Bang TJ, Thomas NR, et al. CT imaging of complications of aortic intramural hematoma: a pictorial essay. 2018. Diagn Interv Radiol. 2018 Nov; 24(6): 342–347. doi:10.5152/dir.2018.17261 5. Weis-Müller BT, Sandmann W. Aortic dissection. In: Vascular Surgery: Cases, Questions and Commentaries. Springer International Publishing; 2018:83-92. 6. Chao CP, Walker TG, Kalva SP. Natural history and CT appearances of aortic intramural hematoma. Radiographics. 2009;29 (3): 791-804. doi:10.1148/rg.293085122 7. Nienaber CA, von Kodolitsch Y, Petersen B, et al. Intramural Hemorrhage of the Thoracic Aorta Diagnostic and Therapeutic Implications. Circulation. 1995;92:1465–1472 doi:10.1161/01.CIR.92.6.1465 8. Gutschow SE, Walker CM, Martínez-Jiménez S, et al. Emerging Concepts in Intramural Hematoma Imaging. (2016) Radiographics : a review publication of the Radiological Society of North America, Inc. 36 (3): 660-74. doi:10.1148/rg.2016150094 9. Hiratzka LF, Bakris GL, Beckman JA et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: executive summary. J Am Coll Cardiol 2010;55(14):1509–1544. doi:10.1016/j.jacc.2010.02.010 10. Wu MT, Wang YC, Huang YL et al. Intramural blood pools accompanying aortic intramural hematoma: CT appearance and natural course. Radiology 2011;258(3):705–713. doi:10.1148/radiol.10101270 Han Ngo is a medical student at Oakland University William Beaumont School of Medicine (OUWB) in Rochester, Michigan. She graduated from UCLA, receiving her B.S. degree in Biochemistry. Prior to starting medical school, Han spent 4+ years (including her undergraduate years) working as a medical scribe for a psychiatrist at Ronald Reagan UCLA Medical Center. Interested in radiology, Han is now serving as the President of both diagnostic radiology and interventional radiology interest groups at OUWB. She is also a committee member on the Medical Student Council of the Society of Interventional Radiology (SIR). After deciding on her specialty, Han plans to continue learning and striving to make a difference in patients’ lives. Follow Han Ngo on Twitter @Han_Ngoo All posts by Han Ngo 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

58 F with left side weakness • Xray of the Week Figure 1. Name the important findings on this CT Scan. Figure 2. Stanford Type A aortic dissection. Blue arrows (A, C, E) pointing at intimal flaps in the ascending aorta, descending aorta, and common iliac arteries. The intimal flap separates the true lumen (smaller caliber) from the false lumen (larger caliber). Green arrows pointing at normal left common carotid artery (D, E). Red arrows pointing at the intimal flap in the right common carotid artery, indicating that dissection has extended into the arch vessels (B, D, E). Yellow arrows showing contrast in the right internal and external carotid arteries via retrograde flow (D). Figure 3: Diagram of Stanford classification for aortic dissection. Stanford Type A involves the ascending aorta with or without descending aortic involvement. Stanford Type B involves the descending aorta distal to the left subclavian artery. Intimal flap is the piece of teared intima that separates the true aortic lumen from false aortic lumen. Diagram by Han Ngo. Discussion: Aortic dissection occurs when there is a tear in the intima of the aortic wall, resulting in blood leaking from the true lumen into the media. The blood that travels to the media creates a false lumen, which is separated from the true lumen by a layer of defective intima called the intimal flap (1). Aortic dissection is most commonly seen in elderly patients with systemic hypertension. Connective tissue disorders (e.g. Marfan’s syndrome, Ehlers-Danlos syndrome), bicuspid aortic valve, aortic coarctation, smoking, hyperlipidemia, cocaine use, deceleration trauma, and iatrogenic injury are other risk factors that have been associated with aortic dissection (2,3). Patients with aortic dissection classically present with sudden onset of severe chest pain, often described as “sharp” or “tearing” in sensation. Depending on the location of aortic dissection, patients may also present with a blood pressure difference between the two arms (4,5). Neurological symptoms such as syncope and stroke may also present if dissection extends into the carotid arteries (2-4,7). If left untreated, aortic dissection can be fatal within the first 24-48 hours due to aortic rupture or insufficient blood flow to the heart (6). Aortic dissection can be categorized by the Stanford classification system (Figure 3). In Stanford Type A, aortic dissection occurs at the level of the ascending aorta, with or without descending aortic involvement. In Stanford Type B, aortic dissection affects the descending aorta distal to the left subclavian artery (3-6). Since Stanford type A has a higher risk of aortic rupture, it is treated more aggressively than Stanford Type B. Usually, Stanford Type A is treated surgically or with stent-graft placement while Stanford Type B is managed medically, primarily with blood pressure control (6). Medical imaging is imperative for the diagnosis and treatment of Stanford Type A aortic dissection. Common imaging modalities currently used to confirm aortic dissection include CT, transesophageal echocardiography, and MRI with CT being the most common due to its wide availability, high accuracy, and ability to produce images rapidly (3). The key diagnostic finding on chest CT and MRI for Stanford Type A aortic dissection is the presence of an intimal flap in the ascending aorta, with or without the involvement of the descending aorta and common iliac arteries (Figures 2A, 2C, 2E). The intimal flap separates the aortic lumen into true and false lumens that can be distinguished based on size and contrast density: the false lumen is larger and has lower contrast density than the true lumen (3,8). In some Stanford Type A cases, dissection may also extend into the common carotid arteries (Figures 2D, 2E) and cause stroke and other serious neurological symptoms (9,10). In summary, the key to successful management of Stanford Type A aortic dissection requires early clinical suspicion followed by correct choice of imaging tests to confirm the diagnosis and immediate surgical intervention. The dissected portion of aorta is replaced with a Dacron graft to prevent more blood flowing into the false lumen (6-8). For cases where the aortic dissection extends into the carotid artery, the ideal management is still unclear (10). ​​​​ References: 1. Juang D, Braverman AC, Eagle K. Aortic dissection. Circulation. 2008;118(14). doi:10.1161/CIRCULATIONAHA.108.7999082 2. Alfson DB, Ham SW. Type B Aortic Dissections: Current Guidelines for Treatment. Cardiol Clin. 2017;35(3):387-410. doi:10.1016/j.ccl.2017.03.0073 3. Kamalakannan D, Rosman HS, Eagle KA. Acute aortic dissection. Crit Care Clin. 2007;23(4):779-vi. doi:10.1016/j.ccc.2007.07.0024 4. Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 2000;283(7):897-903. doi:10.1001/jama.283.7.8975 5. Salameh MJ, Ratchford EV. Aortic dissection. Vasc Med. 2016;21(3):276-280. doi:10.1177/1358863X166328986 6. Hiratzka LF, Bakris GL, Beckman JA et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: executive summary. J Am Coll Cardiol 2010;55(14):1509–1544. doi:10.1016/j.jacc.2010.02.0108 7. Lee EW, Jourabchi N, Sauk SC, et al. An Extensive Stanford Type A Aortic Dissection Involving Bilateral Carotid and Iliac Arteries. Case Rep Radiol. 2013;2013.doi:10.1155/2013/607012 8. Nienaber CA, Clough RE. Management of acute aortic dissection. Lancet. 2015;385(9970):800-811. doi:10.1016/S0140-6736(14)61005-9 9. Bobelmann C, Poli S. Sonographic features of carotid artery dissection due to extension of aortic dissection: a case report. Ultrasound J. 2019;11(1):32. doi:10.1186/s13089-019-0147-2 10. Laser A, Drucker CB, Harris DG, et al. Management and outcomes of carotid artery extension of aortic dissections. J Vasc Surg. 2017;66(2):445-453. doi:10.1016/j.jvs.2016.12.137 Han Ngo is a medical student at Oakland University William Beaumont School of Medicine (OUWB) in Rochester, Michigan. She graduated from UCLA, receiving her B.S. degree in Biochemistry. Prior to starting medical school, Han spent 4+ years (including her undergraduate years) working as a medical scribe for a psychiatrist at Ronald Reagan UCLA Medical Center. Interested in radiology, Han is now serving as the President of both diagnostic radiology and interventional radiology interest groups at OUWB. She is also a committee member on the Medical Student Council of the Society of Interventional Radiology (SIR). After deciding on her specialty, Han plans to continue learning and striving to make a difference in patients’ lives. Follow Han Ngo on Twitter @Han_Ngoo All posts by Han Ngo 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

58 yo Male Chest pain. Abdominal and pelvic pain radiating to the back. Hypertension • Xray of the Week Figure 1. Name the important findings on this CT Scan. Figure 2. Stanford Type B aortic dissection. On chest CT, red arrows point at the true aortic lumen and yellow arrows point at the false aortic lumen at the levels: A- Mid ascending aorta B- Aortic root C- Upper abdomen D- Celiac axis E- Delineates the extent of dissection in the descending aorta. Intimal flap is the low attenuation linear region between the true and false lumen. Figure 3. Diagram showing a cross section of the aorta at the level of aortic dissection. A tear in the aortic intima leads to blood leaking from the true aortic lumen into the false lumen. The two lumens are separated by an intimal flap, the key diagnostic finding of aortic dissection on imaging. Diagram by Han Ngo. Figure 4: Diagram of Stanford classification for aortic dissection. Stanford Type A involves the ascending aorta with or without descending aortic involvement. Stanford Type B involves the descending aorta distal to the left subclavian artery. Intimal flap is the piece of teared intima that separates the true aortic lumen from false aortic lumen. Diagram by Han Ngo. Discussion: Aortic dissection occurs when there is a tear in the intima of the aortic wall, resulting in blood leaking from the true lumen into the media. The blood that travels to the media creates a false lumen, which is separated from the true lumen by a layer of defective intima called intimal flap (1) (Figure 3). Aortic dissection is most commonly seen in elderly patients with systemic hypertension. Connective tissue disorders (e.g. Marfan’s syndrome, Ehlers-Danlos syndrome), bicuspid aortic valve, aortic coarctation, smoking, hyperlipidemia, cocaine use, deceleration trauma, and iatrogenic injury are other risk factors that have been associated with aortic dissection (2,3). Patients with aortic dissection often present with sudden onset of severe chest pain, typically described as “sharp” or “tearing” in sensation. Depending on the location of aortic dissection, patients may also present with a blood pressure difference between the two arms (4,5). Other symptoms such as abdominal pain, syncope, stroke, or acute renal failure may also result due to decreased blood supply to organs (2-4). If left untreated, aortic dissection can be fatal within the first 24-48 hours due to aortic rupture or insufficient blood flow to the heart (6). Aortic dissection can be categorized by the Stanford classification system (Figure 4). In Stanford Type A, aortic dissection occurs at the level of the ascending aorta, with or without descending aortic involvement. In Stanford Type B, aortic dissection affects the descending aorta distal to the left subclavian artery. Usually, Stanford Type A is treated surgically or with stent-graft placement while Stanford Type B is managed medically, primarily with blood pressure control (3-7). Medical imaging is imperative for the diagnosis of aortic dissection and for the Stanford classification (which guides the disease treatment). Common imaging modalities currently used to confirm aortic dissection include CT, transesophageal echocardiography, and MRI with CT being the most common due to its wide availability, high accuracy, and ability to produce images rapidly. The key diagnostic finding on chest CT and MRI is the presence of an intimal flap separating the true and false aortic lumens. The two lumens can be distinguished based on size and contrast density: the false lumen is often larger and has lower contrast density than the true lumen (2,3,8) (Figures 1,2). In summary, the key to successful management of aortic dissection requires early clinical suspicion followed by correct choice of imaging tests to confirm the diagnosis and prompt initiation of treatment based on the Stanford classification system. Since the highest risk for complications (e.g. aneurysm, recurrent dissection) occurs in the first two years after the initial presentation, patients with aortic dissection should be followed up closely with CT or MRI imaging of the aorta at 1, 3, 6, and 12 months and then annually over the long term (6,7). ​​​​ References: 1. Juang D, Braverman AC, Eagle K. Aortic dissection. Circulation. 2008;118(14). doi:10.1161/CIRCULATIONAHA.108.7999082 2. Alfson DB, Ham SW. Type B Aortic Dissections: Current Guidelines for Treatment. Cardiol Clin. 2017;35(3):387-410. doi:10.1016/j.ccl.2017.03.0073 3. Kamalakannan D, Rosman HS, Eagle KA. Acute aortic dissection. Crit Care Clin. 2007;23(4):779-vi. doi:10.1016/j.ccc.2007.07.0024 4. Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 2000;283(7):897-903. doi:10.1001/jama.283.7.8975 5. Salameh MJ, Ratchford E V. Aortic dissection. Vasc Med. 2016;21(3):276-280. doi:10.1177/1358863X166328986 6. Juang D, Braverman AC, Eagle K. Aortic dissection. Circulation. 2008;118(14). doi:10.1161/CIRCULATIONAHA.108.7999087 7. Hiratzka LF, Bakris GL, Beckman JA et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: executive summary. J Am Coll Cardiol 2010;55(14):1509–1544. doi:10.1016/j.jacc.2010.02.0108 8. Nienaber CA, Clough RE. Management of acute aortic dissection. Lancet. 2015;385(9970):800-811. doi:10.1016/S0140-6736(14)61005-9 Han Ngo is a medical student at Oakland University William Beaumont School of Medicine (OUWB) in Rochester, Michigan. She graduated from UCLA, receiving her B.S. degree in Biochemistry. Prior to starting medical school, Han spent 4+ years (including her undergraduate years) working as a medical scribe for a psychiatrist at Ronald Reagan UCLA Medical Center. Interested in radiology, Han is now serving as the President of both diagnostic radiology and interventional radiology interest groups at OUWB. She is also a committee member on the Medical Student Council of the Society of Interventional Radiology (SIR). After deciding on her specialty, Han plans to continue learning and striving to make a difference in patients’ lives. Follow Han Ngo on Twitter @Han_Ngoo All posts by Han Ngo 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

40F with trauma and headache • Xray of the Week Figure 1. What is the important finding on this CT scan. Figure 2. A. Axial CT brain showing intraparenchymal hemorrhage (blue arrow) and subdural hemorrhage along tentorium (orange arrow) B. Axial CT brain showing subdural hemorrhage along falx (yellow arrow) and coup at site of subgaleal hematoma (red arrow) C. Coronal CT brain showing subdural hemorrhage along falx (yellow arrow) and tentorium (orange), subdural hematoma overlying left cerebral convexity (green arrows), and subgaleal hematoma at the coup (red arrows). Discussion: Contrecoup brain injury occurs when a force strikes the head and causes the brain to shift away from the site of impact, and inertia causes the brain to hit the opposite side of the intracranial cavity (1). Thus, the side of the brain opposite to the traumatic force is injured. Contrecoup brain injuries often occur in traumatic accidents where the moving brain strikes a stationary object (2). They typically occur in the frontal and temporal lobes of the brain (2,3). Contrecoup injuries are often associated with cerebral contusions and subdural hemorrhage due to increases in intracranial pressure (2,3). In coup injuries, damage occurs on the same side of the brain as the traumatic force (2,3). Contrecoup injuries can occur with coup injuries, but they may rarely occur alone (2). It is important to note that coup injuries tend to be more focal and easier to identify on imaging while contrecoup injuries are diffuse and can cause more damage (1,2). The initial site of injury, or the coup site, can often be found by soft tissue swelling on CT (3,4). In this case, the coup is located at the site of the subgaleal hematoma. The contrecoup site can show hemorrhagic contusions in the frontal and temporal lobes on CT, or with MRI on Gradient echo (GRE) sequences (3). The contrecoup site can also present with subdural hematoma (SDH) along the falx and tentorium as in this case. Treatment depends on the severity of the injury and presence of other injuries, but typically involves surgical decompression and evacuation of hematoma (2). Patients with neurological deficits and Glasgow coma score less than 9 require intracranial pressure monitoring (2,4). Follow up head CT at 12 hours is recommended (2). ​​​​ References: 1. Salyer, Steven W. “Care of the Multiple Trauma Patient.” Essential Emergency Medicine, Elsevier, 2007, pp. 1050–112. doi:10.1016/B978-141602971-7.10018-2 2. Payne WN, De Jesus O, Payne AN. Contrecoup Brain Injury. [Updated 2020 Jun 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK536965/ 3. Kim JJ, Gean AD. Imaging for the Diagnosis and Management of Traumatic Brain Injury. Neurotherapeutics 8, 39–53 (2011). doi:10.1007/s13311-010-0003-3 4. Le TH, Gean AD. Imaging of head trauma. Semin Roentgenol. 2006;41(3):177-189. doi:10.1053/j.ro.2006.04.003 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 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

29F with headache • Xray of the Week Figure 1. What is the important finding on this CT scan. Figure 2. CT scan of cerebral arteriovenous malformation. Arterial venous malformation in the left posterior periventricular region with draining veins extending to the internal cerebral veins A. Axial non contrast CT showing subtle density in left parietal lobe (red arrow). B. Coronal CT with contrast showing AVM nidus (green arrow) C. Coronal CT brain with contrast showing AVM nidus (yellow arrow). D. Axial CT brain with contrast showing AVM nidus (red arrow). E. Sagittal CT brain with contrast showing AVM draining vein (green arrow) F. Sagittal CT brain with contrast showing AVM with draining vein (yellow arrow). Introduction: Cerebral arteriovenous malformations (AVMs) are abnormal fistulas between feeding arteries and draining veins without a capillary bed. They can cause intracranial hemorrhage due to the high flow that goes into veins. As other vascular malformations, they can be found incidentally or present with seizures and chronic headaches depending on size, location and vessel involvement (1, 2). AVMs can be associated with genetic conditions or be sporadic. The incidence ranges from 1.12-1.42 cases per 100,000 with about 37% of new cases presenting with a hemorrhage (5). The most well-known classification system for AVMs is the Spetzler-Martin grading scale (3). Discussion: Although digital subtraction angiography (DSA) is the gold standard in diagnosing cerebral AVMs, a non-contrast CT (NCCT) is usually done first due to patients presenting for a suspected intracranial hemorrhage. CT and MRI are usually the initial modalities done on patients with AVMs. On NCCT, AVMs may appear as serpentine hyperattenuating structures and even curvilinear or speckled calcifications (5, 6). Conventional CTA can identify AVMs but has some limitations due to its static nature not allowing for flow-related changes. For this reason, DSA is superior and depicts AVMs with greater detail and information due to its spatial and temporal resolution. Also, MRI with an MRA can be more advantageous compared to a CTA due to better visualization of parenchymal changes (6). Sometimes small AVMs may be difficult to detect on any imaging modality if there is a hemorrhage, during which the hematoma can compress the AVM nidus. Here it is recommended that imaging be performed again 4-6 weeks after the hematoma (5). T1w and T2w-MR along with fluid-attenuated inversion recovery (FLAIR) sequences may also be used (5). Particularly, susceptibility-weighted imaging (SWI) is good at evaluating draining venous structures better than MRA and MRI. On SWI, AVMs may appear as a hyperintense venous signal (5). Treatment: Treatment modalities include endovascular embolization, surgical resection, and radiosurgical intervention. The risk of hemorrhage is high and randomized studies comparing these modalities are needed in ruptured AVMs and to determine if observation or surgical intervention provides better outcomes in unruptured AVMs (6). ​​​​ References: 1. Ozpinar A, Mendez G, Abla AA. Epidemiology, genetics, pathophysiology, and prognostic classifications of cerebral arteriovenous malformations. Handb Clin Neurol. 2017;143:5-13. doi:10.1016/B978-0-444-63640-9.00001-1 2. Hofmeister C, Stapf C, Hartmann A, et al. Demographic, morphological, and clinical characteristics of 1289 patients with brain arteriovenous malformation. Stroke. 2000;31(6):1307-1310. doi:10.1161/01.str.31.6.1307 3. Spetzler RF, & Martin NA (1986). A proposed grading system for arteriovenous malformations. Journal of Neurosurgery, 65(4), 476-483. doi:10.3171/jns.1986.65.4.0476 4. Abecassis IJ, Xu DS, Batjer HH, Bendok BR. Natural history of brain arteriovenous malformations: a systematic review. Neurosurg Focus. 2014;37(3):E7. doi:10.3171/2014.6.FOCUS14250 5. Mossa-Basha M, Chen J, Gandhi D. Imaging of cerebral arteriovenous malformations and dural arteriovenous fistulas. Neurosurgery Clinics of North America. 2012 Jan;23(1):27-42. doi:10.1016/j.nec.2011.09.007 6. Asif K, Leschke J, Lazzaro MA. Cerebral arteriovenous malformation diagnosis and management. Semin Neurol. 2013;33(5):468-475. doi:10.1055/s-0033-1364212 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 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