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Name the Cardiac Device • Xray of the Week Figure 1. Name the cardiac device. Figure 2. A: Plain radiograph demonstrating the TMVR (red arrows). Note on the plain xray that the long axis of the TMVR replacement is more horizontal than seen with TAVR B: Axial CT image of the chest showing TMVR (yellow arrows). C: Coronal CT image of the chest showing TMVR (green arrows). Figure 3. Video demonstrating transapical placement technique for Transcatheter Mitral Valve Replacement (Neovasc). Figure 4. A: Plain radiograph demonstrating TAVR (red arrows). Note on the plain xray that the long axis of the TAVR replacement is more vertical than seen with TMVR B: Axial CT image of the chest showing TAVR (green arrow). Note the location of the normal mitral valve (yellow arrows) C: Coronal CT image of the chest showing TAVR (green arrow). Discussion: Mitral regurgitation (MR) is the most common type of mitral valve disease in developed nations, and mitral valve disease itself is the second most common valvular heart disease within adults. Untreated MR can lead to systolic and diastolic congestive heart failure (CHF) with an annual mortality rate of 5%. Treatment options for MR include both surgical and minimally invasive approaches. The latter of these approaches includes both the MitraClip (transcatheter mitral valve repair technique or TMVr) or transcatheter mitral valve replacement (TMVR) (Figs. 1-3). Currently only TMVr via MitraClip is FDA approved and remains the standard of care, but this approach is limited in use due to the small proportion of suitable patients. Unlike the MitraClip, TMVR has been mostly experimental and while over 30 different systems are in development, only a few of these technologies have reached early feasibility studies in humans including but not limited to the Tendyne MV system, Sapien 3 and Highlife Valve. Transseptal, transapical and transfemoral approaches have been used for placement of these prosthetic valves (Fig. 3). All of the valves are comprised of 3 bovine or porcine leaflets in an expandable stentframe (Fig. 3). Imaging for mitral valve replacement falls into 3 main categories, pre-procedural, intra-procedural, and post-procedure. Due to the complex anatomical structure of the mitral valve, placement is more complicated than that of the aortic valve (Fig. 4). Intra-procedural imaging via fluoroscopy is used to ensure proper placement and deployment of the prosthesis. Due to the limitations of fluoroscopy, pre-procedural imaging via 2D echocardiography and angiography are crucial for success. Multidetector CT (MDCT), which provides a 3D reconstruction of the valve allowing for detailed measurements, has gained use in pre-procedural imaging as well. Recent studies have shown that even 3D TEE compared to 2D echo allow for better evaluation and flow convergence. In addition to its complex geometry, the mitral valve in identifying soft tissue structures, imaging will be inadequate in a mitral valve with a lack of calcifications. Thus, TEE also plays a role in intra-procedural imaging as well as immediately following deployment and identifying potential complications such as tamponade, septal rupture, and coronary sinus trauma. While crossover of Transcatheter Aortic Valve Replacement TAVR technologies and approaches continue to aid in the development of similar TMVR devices, several key differences do exist that limit this. Included within these differences are patient age in that MR patients tend to be much younger than Aortic Stenosis (AS) patients, disease etiology, and the benefit of conservative therapy. Complications of TMVR include left ventricular outflow tract valve displacement, cardiovascular mortality, device malfunction, and stroke. On plain radiographs a TMVR prosthesis can easily be misidentified as a TAVR and that studies have shown that the “imaginary line method” may not be a reliable method of discerning between the two. Rather use of the “valve orifice” or “perceived direction of blood flow” methods should be employed. As seen in this case, CT is definitive in discerning the valve location (Fig. 4). ​​​​ References: 1. Kelley C, Lazkani M, Farah J, Pershad A. Percutaneous mitral valve repair: A new treatment for mitral regurgitation. Indian Heart J. 2016;68(3):399-404. doi:10.1016/j.ihj.2015.08.025 2. Meng Z, Zhang E-L, Wu Y-J. Current Status and Future Direction of Transcatheter Mitral Valve Replacement. Chin Med J (Engl). 2018;131(5):505-507. doi:10.4103/0366-6999.226080 3. Alkhouli M, Alqahtani F, Aljohani S. Transcatheter mitral valve replacement: an evolution of a revolution. J Thorac Dis. 2017;9(Suppl 7):S668-S672. doi:10.21037/jtd.2017.05.60 4. Ramlawi B, Gammie JS. Mitral Valve Surgery: Current Minimally Invasive and Transcatheter Options. Methodist Debakey Cardiovasc J. 2016;12(1):20-26. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4847963/ 5. Foot CL, Coucher J, Stickley M, Mundy J, Venkatesh B. The imaginary line method is not reliable for identification of prosthetic heart valves on AP chest radiographs. Crit Care Resusc. 2006;8(1):15-18. https://www.ncbi.nlm.nih.gov/pubmed/16536714 6. del Val D, Ferreira‐Neto AN, Wintzer‐Wehekind J, et al. Early Experience With Transcatheter Mitral Valve Replacement: A Systematic Review. Journal of the American Heart Association. 2019;8(17):e013332. doi:10.1161/JAHA.119.013332 7. Natarajan N, Patel P, Bartel T, et al. Peri-procedural imaging for transcatheter mitral valve replacement. Cardiovasc Diagn Ther. 2016;6(2):144-159. doi:10.21037/cdt.2016.02.04 Related posts: Mitraclip Cardiac Device Transcatheter Aortic Valve Replacement (TAVR) CardioMEMS Device Malposition of Right Atrial Lead of Permanent Pacemaker Implanted Cardiac Loop Recorder Wearable Cardiac Defibrillator Impella Left Ventricular Assist Device Micra Intracardiac Pacemaker Neal Shah is a medical student at The Edward Via College of Osteopathic Medicine (VCOM)–Carolinas and intends on completing his residency within the field of radiology. Prior to medical school, he completed his undergraduate studies at the University of North Carolina at Chapel Hill where he majored in economics and chemistry. During his 4 years there he worked in UNC’s Biomedical Research Imaging Center where he helped develop formulations for iron-oxide nanoparticles used for MRI; it was here that his love for the field of radiology developed. He eventually wishes to also pursue his MBA and hopes to use it to help advance the field of medicine in terms of medical innovation. Follow Neal Shah on Twitter @neal_shah17 All posts by Neal Shah Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice is a radiologist with Renaissance Imaging Medical Associates. and is currently the Vice Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

Name the Cardiac Device • Xray of the Week Figure 1. Name the cardiac device. Figure 2. A: Plain radiograph demonstrating the TAVR (red arrows). Note on the plain xray the TAVR aligning with the expected location of the aortic root. B: Axial CT image of the chest showing TAVR (green arrow). Note the location of the normal mitral valve (yellow arrows) C: Coronal CT image of the chest showing TAVR (green arrow). Figure 3. Video demonstrating placement technique for TAVR (Edwards Sapien 3). Discussion: Aortic valve replacement via surgical (surgical aortic valve replacement or SAVR) and minimally invasive approaches (transcatheter aortic valve replacement or TAVR) have become the gold standard in treatment for patients with severe aortic stenosis (AS). Prior to TAVR, which was FDA approved in 2011 for severe AS, the only nonsurgical options available to patients were diuretics and balloon valvuloplasty – neither of which effected long term events. Indications for aortic aalve (AV) replacement include patients with symptoms, and those who are asymptomatic with LVEF less than 50%. Imaging plays a crucial role before, during and after the procedure, and especially with TAVR as there is decreased visualization with this procedure compared to SAVR. Pre-op imaging remains a crucial aspect to TAVR as the aortic valve maintains a complex geometrical structure making measurements a hard task. Additionally, in severe AS the valve annulus may morph in shape which can lead to an underestimation of size. Thus, 3D transesophageal echocardiography (TEE) and multi-detector computed tomography (MDCT) remain the modalities of choice. Studies have specifically shown that TEE measurements are best obtained during mid-systole and while MDCT measurements can be obtained at any point during the cycle, they best correspond to those of TEE when obtained during diastole. There does remain some concern though that 3D TEE tends to underestimate to the tune of 9-12% compared to MDCT, thus overall MDCT tends to be utilized more in practice. Peri-procedural imaging has traditionally relied upon guidance via TEE requiring general anesthesia but as the shift from general anesthesia towards conscious sedation is being made for the procedure, imaging is now largely done via fluoroscopic guidance. Each modality, TEE, TTE with fluoroscopy, and fluoroscopy alone have all been used for real time imaging during the procedure, and each has its own benefits and downfalls. Post-procedural imaging relies strongly on a multi-modal imaging approach by way of echocardiography, cardiac CT, and cardiac magnetic resonance imaging, all of which play important roles in discerning between various post-op complications. Suspected paravalvular leak and valvular thrombosis are best imaged via echo and CMR or echo and CCT, respectively. Structural deterioration is best seen via CCT. ​​​​ References: 1. Corrigan FE, Gleason PT, Condado JF, et al. Imaging for Predicting, Detecting, and Managing Complications After Transcatheter Aortic Valve Replacement. JACC Cardiovasc Imaging. 2019;12(5):904-920. doi:10.1016/j.jcmg.2018.07.036 2. Xu B, Mottram PM, Lockwood S, Meredith IT. Imaging Guidance for Transcatheter Aortic Valve Replacement: Is Transoesophageal Echocardiography the Gold Standard? Heart Lung Circ. 2017;26(10):1036-1050. doi:10.1016/j.hlc.2017.02.018 3. Bleakley C, Monaghan MJ. The Pivotal Role of Imaging in TAVR Procedures. Curr Cardiol Rep. 2018;20(2). doi:10.1007/s11886-018-0949-z 4. Ramlawi B, Anaya-Ayala JE, Reardon MJ. Transcatheter Aortic Valve Replacement (TAVR): Access Planning and Strategies. Methodist Debakey Cardiovasc J. 2012;8(2):22-25. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3405802/ 5. Mahmaljy H, Tawney A, Young M. Transcatheter Aortic Valve Replacement (TAVR/TAVI, Percutaneous Replacement). In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2020. http://www.ncbi.nlm.nih.gov/books/NBK431075/. Accessed March 20, 2020. Related posts: Bicuspid Aortic Valve and Aortic Stenosis Transcatheter Mitral Valve Replacement (TMVR) CardioMEMS Device Malposition of Right Atrial Lead of Permanent Pacemaker Implanted Cardiac Loop Recorder Wearable Cardiac Defibrillator Impella Left Ventricular Assist Device Micra Intracardiac Pacemaker Neal Shah is a medical student at The Edward Via College of Osteopathic Medicine (VCOM)–Carolinas and intends on completing his residency within the field of radiology. Prior to medical school, he completed his undergraduate studies at the University of North Carolina at Chapel Hill where he majored in economics and chemistry. During his 4 years there he worked in UNC’s Biomedical Research Imaging Center where he helped develop formulations for iron-oxide nanoparticles used for MRI; it was here that his love for the field of radiology developed. He eventually wishes to also pursue his MBA and hopes to use it to help advance the field of medicine in terms of medical innovation. Follow Neal Shah on Twitter @neal_shah17 All posts by Neal Shah Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice is a radiologist with Renaissance Imaging Medical Associates. and is currently the Vice Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

45 year old male with chest pain, tachypnea and shortness of breath • Xray of the Week Figure 1. Name the important findings on this CT Scan. Figure 2. CT Scan demonstrating saddle pulmonary embolism with RV strain. A: Saddle embolism (red arrow). Large bilateral emboli in right and left main pulmonary arteries (yellow and green arrows). B: RV strain with dilated RV, bowing of the interventricular septum to the left (blue arrows). Figure 3. CT Scan demonstrating saddle pulmonary embolism with RV strain. A: Saddle embolism and dilated main pulmonary artery which is larger than the ascending aorta. B: RV strain with dilated RV, measuring larger than LV. C: Bowing of the interventricular septum to the left (yellow arrows). Discussion: Due to its high sensitivity and specificity, CT pulmonary angiography (CTPA) has become the imaging modality of choice in diagnosis of pulmonary embolism (PE) and has replaced VQ scanning within treatment algorithms (1,2). CTPA allows for a more accurate evaluation of clot size, extent of clot, underlying lung disease and evaluation of potential right ventricular (RV) strain. In addition, in up to 40% of patients CT demonstrates other pathology responsible for the patient's clinical picture (3-5). CT findings of PE include a central filling defect, vessel cut off, and rim sign. Multiple emboli are more common than solitary and lower lobes are usually more affected than upper lobes. Secondary findings on CT may include pulmonary infarct, hemorrhage, upper extremity DVT, hypoperfusion, atelectasis, and RV strain. An RV/LV ratio greater than one and leftward bowing of the ventricular septum are indicative of RV strain (5). A dilated RV is the most accurate and reproducible method of evaluating RV strain (5). Although, leftward bowing of the ventricular septum and inferior vena cava contrast reflux are also predictive of adverse outcomes (3). After myocardial infarction and stroke, pulmonary embolism is the 3rd leading cause of mortality due to cardiovascular disease. Mortality from RV failure is most often due to PE (4). Mortality rate is as high as 50-58% in those with hemodynamic instability and 8-15% in those without (4). The mainstay of treatment is cardiopulmonary support and anticoagulation; however, thrombolysis may play a role in cases with massive PE and cardiovascular compromise (6). Patients who can not be anticoagulated require an IVC filter. ​​​​ References: 1. Ghaye B, Ghuysen A, Bruyere P-J, D’Orio V, Dondelinger RF. Can CT Pulmonary Angiography Allow Assessment of Severity and Prognosis in Patients Presenting with Pulmonary Embolism? What the Radiologist Needs to Know. RadioGraphics. 2006;26(1):23-39. doi:10.1148/rg.261055062 2. He H, Stein MW, Zalta B, Haramati LB. Computed tomography evaluation of right heart dysfunction in patients with acute pulmonary embolism. J Comput Assist Tomogr. 2006;30(2):262-266. doi:10.1097/00004728-200603000-00018 3. Kang DK, Thilo C, Schoepf UJ, et al. CT Signs of Right Ventricular Dysfunction: Prognostic Role in Acute Pulmonary Embolism. JACC: Cardiovascular Imaging. 2011;4(8):841-849. doi:10.1016/j.jcmg.2011.04.013 4. Kostadima E, Zakynthinos E. Pulmonary Embolism: Pathophysiology, Diagnosis, Treatment. Hellenic J Cardiol 48: 94-107, 2007 5. Kang DK, Ramos-Duran L, Schoepf UJ, et al. Reproducibility of CT Signs of Right Ventricular Dysfunction in Acute Pulmonary Embolism. American Journal of Roentgenology. 2010;194(6):1500-1506. doi:10.2214/AJR.09.3717 6. Araoz PA, Gotway MB, Harrington JR, et al. Pulmonary Embolism: Prognostic CT Findings. Radiology 2007;242:889-897 https://doi.org/10.1148/radiol.2423051441 Related posts: Transcatheter Mitral Valve Replacement (TMVR) CardioMEMS Device Malposition of Right Atrial Lead of Permanent Pacemaker Implanted Cardiac Loop Recorder Wearable Cardiac Defibrillator Impella Left Ventricular Assist Device Micra Intracardiac Pacemaker Neal Shah is a medical student at The Edward Via College of Osteopathic Medicine (VCOM)–Carolinas and intends on completing his residency within the field of radiology. Prior to medical school, he completed his undergraduate studies at the University of North Carolina at Chapel Hill where he majored in economics and chemistry. During his 4 years there he worked in UNC’s Biomedical Research Imaging Center where he helped develop formulations for iron-oxide nanoparticles used for MRI; it was here that his love for the field of radiology developed. He eventually wishes to also pursue his MBA and hopes to use it to help advance the field of medicine in terms of medical innovation. Follow Neal Shah on Twitter @neal_shah17 All posts by Neal Shah Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice is a radiologist with Renaissance Imaging Medical Associates. and is currently the Vice Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

Name the finding on bladder ultrasound and related complication • Xray of the Week Figure 1. Bladder ultrasound. Figure 2. Bladder ultrasound- sagittal image. Note the intra-vesicular ureterocele seen as a cystic dilation of the distal ureter bulging into the bladder. There is also a dilated distal ureter due to obstruction. Discussion: Ureteroceles form due to the cystic dilation and out-pouching of the distal ureter and may result in ureteral obstruction and impaired renal function. Patients may present asymptomatically or with signs related to obstructed urine outflow such as recurrent urinary tract infections, and renal failure. Classification of ureteroceles is based on location as either intra or extra vesicular. Any child with a urinary tract infection should undergo screening with bladder ultrasound (US) which will typically help identify this congenital anomaly. If US fails to show any deformities, voiding cystourethrogram (VCUG) should be considered and especially in cases of colonization by organisms other than E.coli and in cases of recurrent UTI (1,2). Ultrasound characteristics of ureteroceles include identification of an ectopic cystic mass, typically near the vesicoureteral junction (VUJ). Radiologic characteristics of ureteroceles consist of a round filling defect near the VUJ and the classical ‘cobra head sign’ that resembles a snake’s head bulging into the bladder. The ‘cobra head sign’ is typically seen with intravesical ureteroceles and is characterized by dilation of the distal ureter (cobra head) with a surrounding radiolucent halo that is seen within contrast-filled bladders on intravenous urograms (1,3). Symptomatic ureteroceles are typically managed via cystoscopic transurethral incision (4). ​​​​ References: 1. Adesiyun. Bilateral giant orthotopic ureterocele appearing as kissing cobra in a Nigerian child. Accessed May 8, 2020. http://www.wajradiology.org/article.asp?issn=1115-3474;year=2015;volume=22;issue=1;spage=42;epage=44;aulast=Adesiyun 2. Schultza K, Todab LY. Genetic Basis of Ureterocele. Curr Genomics. 2016;17(1):62-69. doi:10.2174/1389202916666151014222815 3. Genitourinary Radiology. Accessed May 8, 2020. https://www.med-ed.virginia.edu/courses/rad/gu/embryology/ureterocele.html 4. Gottlieb C, Beranbaum SL, Hamilton RH. Radiographic Features of Ureterocele. Radiology. 1953;60(1):64-67. doi:10.1148/60.1.64 Neal Shah is a medical student at The Edward Via College of Osteopathic Medicine (VCOM)–Carolinas and intends on completing his residency within the field of radiology. Prior to medical school, he completed his undergraduate studies at the University of North Carolina at Chapel Hill where he majored in economics and chemistry. During his 4 years there he worked in UNC’s Biomedical Research Imaging Center where he helped develop formulations for iron-oxide nanoparticles used for MRI; it was here that his love for the field of radiology developed. He eventually wishes to also pursue his MBA and hopes to use it to help advance the field of medicine in terms of medical innovation. Follow Neal Shah on Twitter @neal_shah17 All posts by Neal Shah Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice is a radiologist with Renaissance Imaging Medical Associates. and is currently the Vice Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

46 year old female with right upper quadrant pain and jaundice. Diagnosis? • Xray of the Week Figure 1. What are the important findings? Figure 2 A: Transverse ultrasound of RUQ. Hyperechoic shadowing gallstone within lumen of gallbladder (green arrow) with diffuse irregular wall thickening (red arrows). B: T1 weighted axial MRI with contrast. Irregularly thickened enhancing gallbladder wall (red arrows). C: CT Abdomen with contrast, coronal reconstruction. Irregular mass with heterogenous enhancement (red arrows). Gallstone within lumen of gallbladder (green arrow). D: T1 weighted coronal MRI. Irregularly thickened enhancing gallbladder wall (red arrows). Gallstone in fundus of gallbladder (green arrow). Discussion: Gallbladder carcinoma is the most common malignancy of the biliary tract and is associated with a mean survival of 6 months from diagnosis (1). The poor prognosis is due to late diagnosis, often with advanced disease as a result of the nonspecific symptoms with which the cancer may present. Risk factors include, Native American and Southeast Asian descent, female gender, and history of inflammation of the gallbladder, from gallstones, parasitic illness or primary sclerosing cholangitis (1,2). Figure 3. Porcelain gallbladder in a different patient. Plain radiograph Endoscopic ultrasonography is the optimal modality for staging (1). However, symptomatic patients may get an initial abdominal radiograph, which can show gas production from invasion into bowel or fistula formation or a heterogenous pattern from tumor necrosis (3). Findings suggestive of malignancy can include porcelain gallbladder, characterized by calcium deposition in the gallbladder wall, which is associated with underlying carcinoma in 25% of patients (Fig. 3). Furthermore, wall thickness greater than 3 mm should raise an index of suspicion, although diffuse wall thickening can be associated with other inflammatory conditions such as cholecystitis and adenomyomatosis (4). Focal or diffuse asymmetric wall thickening greater than 3 mm can be concerning for underlying carcinoma, with increased likelihood of malignancy when there is marked enhancement of the wall during the arterial phase and isointensity in the venous phase on CT and MRI (5). Increased vascularity and the presence of polyps are most often benign and secondary to cholesterol or inflammation, but may have malignant potential (6,7). Resection is indicated for polyps greater than 1 cm (5). CT can be utilized to depict lymphadenopathy, regional spread to liver or metastasis (1). CT can also serve in highlighting regions of the gallbladder that may be poorly visualized on ultrasound, when there are gallstones or mural calcification present (5). A CT demonstrating a weakly enhancing outer layer and thicker inner layer of gallbladder wall is highly suggestive of malignancy (4). On CT, gallbladder carcinoma can present as a polyploid mass within the lumen, focal or diffuse thickening or with a mass replacing the gallbladder (2,3). MRI/MRCP can show vascular or bile duct invasion (3). ​​​​ References: Hundal, R., & Shaffer, E. A. (2014). Gallbladder cancer: epidemiology and outcome. Clinical epidemiology, 6, 99–109. doi:10.2147/CLEP.S37357 Kanthan R, Senger JL, Ahmed S, Kanthan SC. Gallbladder Cancer in the 21st Century. J Oncol. 2015;2015:967472. doi:10.1155/2015/967472 Levy AD, Murakata LA, Rohrmann CA Jr. Gallbladder carcinoma: radiologic-pathologic correlation [published correction appears in Radiographics 2001 May-Jun;21(3):766]. Radiographics. 2001;21(2):295-555. doi:10.1148/radiographics.21.2.g01mr16295 Kim SJ, Lee JM, Lee JY, et al. Analysis of enhancement pattern of flat gallbladder wall thickening on MDCT to differentiate gallbladder cancer from cholecystitis. AJR Am J Roentgenol. 2008;191(3):765-771. doi:10.2214/AJR.07.3331 Andrén-Sandberg Å. Diagnosis and management of gallbladder cancer. North Am J Med Sci 2012;4:293-299. doi:10.4103/1947-2714.98586 Mitchell CH, Johnson PT, Fishman EK, Hruban RH, Raman SP. Features suggestive of gallbladder malignancy: analysis of T1, T2, and T3 tumors on cross-sectional imaging. J Comput Assist Tomogr. 2014;38(2):235-241. doi:10.1097/RCT.0b013e3182aafb6b Rooholamini SA, Tehrani NS, Razavi MK, et al. Imaging of gallbladder carcinoma. Radiographics. 1994;14(2):291-306. doi:10.1148/radiographics.14.2.8190955 Usha Trivedi is a medical student at Rutgers New Jersey Medical School with aspirations to become a diagnostic radiologist. She completed her undergraduate education at The College of New Jersey with a major in Biology and a minor in Art History. She is drawn to radiology due its unique blend of technology, art and medicine that is rooted in patient care. Her first exposure to radiology was through clerkships in medical school, where she saw how crucial imaging can be for patient care. She is currently involved as a director for one of her medical school’s student-run clinics and with her medical school’s humanities-themed magazine. She aspires to become a radiologist with specific interests in mentorship, education and advocacy. In her spare time, she enjoys hiking, reading, art and board games. Follow Usha Trivedi on Twitter @UshaTrivedi11. All posts by Usha Trivedi Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice is a radiologist with Renaissance Imaging Medical Associates. He has held several leadership positions including Chair of Radiology, Board of Directors, 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. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

8 Year Old Male With Trauma Due To A Fall. Diagnosis? • Xray of the Week Figure 1. What is the important finding? Figure 2 A: AP view radiograph of right forearm. Acute transverse fracture of distal radius visualized (green arrow). B: Lateral radiograph view of right forearm. Angulation of ulna visualized (red arrows). Discussion: The above imaging findings occurred in an 8-year-old child with a trauma after a fall. An angulated fracture of the distal midshaft radius is also visualized, but there is also bowing of the ulna that is more appreciated on the lateral radiograph view. Forearm fractures are common in pediatric populations, likely due to the intrinsic elasticity and uniquely thinner cortex as compared to adult bones [1]. Radiographically, bowing fractures may show visible bending on radiographic imaging, however, as in this case if the bending occurs within the same plane of the radiograph, there may be no visible deformities on radiographic imaging [2]. Unlike other fractures, plastic bowing fractures do not produce a characteristic fracture line, but rather can produce subtle angular changes that appear as “bending” of the bone [3]. Additionally, in contrast to other fractures, the subsequent healing process for a bowing fracture does not involve a periosteal reaction [4]. As seen in this patient, bowing fractures can also be associated with a conventional fracture in the paired bone. The fracture often manifests in children who present with localized symptoms of pain and swelling after falls on an outstretched hand, and in many cases, the child is playing or participating in common childhood activities like climbing monkey bars or jumping. Plastic bowing fractures most commonly occur in the forearm, but may also be found in the clavicle, fibula, and other long bones. The mechanism of injury often entails an angulated force on the bone producing longitudinal compression, that exceeds the intrinsic elasticity of the bone [4] . Most fractures that disrupt the cortical makeup of a bone exceed intrinsic plasticity, which produces classical fractures [4]. However, due to the natural growth patterns of the bone in pediatric populations, the response of the bone to a force exceeding the elastic injury is a response of bowing, which occurs proportionally to the force [4]. Microscopically, there are microfractures occurring along the bowing edge of the bone, but this is often not appreciated on the radiograph [3]. The bowing often appears fluid-like. Intervention is often not required in most cases, unless when angulation is measured to more than 10 degrees or in children older than 10 years [5, 6]. The decision for reduction may be a dilemma for clinicians, as increased angulation and older age of children may be associated with long-term osteoarthritis [7]. Other differentials that may be considered are buckle fractures, physiological bowing, stress fractures, and greenstick fractures. Due to the subtle presentations of these fractures on radiographs, clinicians need to maintain a high index of suspicion for these injuries in susceptible pediatric populations. ​​​​ References: Kalkwarf HJ, Laor T, Bean JA. Fracture risk in children with a forearm injury is associated with volumetric bone density and cortical area (by peripheral QCT) and areal bone density (by DXA). Osteoporos Int. 2011;22(2):607-616. doi:10.1007/s00198-010-1333-z Sawkar, A.; Swischuk, L; Jadhav, S. Plastic Bending Fractures in Children, Contemporary Diagnostic Radiology: 2011; (34): 1-6. doi:10.1097/01.CDR.0000406379.59531.8d Crowe JE, Swischuk LE. Acute bowing fractures of the forearm in children: a frequently missed injury. AJR Am J Roentgenol. 1977;128(6):981-984. doi:10.2214/ajr.128.6.981 Borden S 4th. Roentgen recognition of acute plastic bowing of the forearm in children. Am J Roentgenol Radium Ther Nucl Med. 1975;125(3):524-530. doi:10.2214/ajr.125.3.524 Vorlat P, De Boeck H. Bowing fractures of the forearm in children: a long-term followup. Clin Orthop Relat Res. 2003;(413):233-237. doi:10.1097/01.blo.0000072901.36018.25 Vervaecke AJ, Nuyts R, Sys J. The importance of adequate diagnosis of pediatric forearm bowing fractures: A case report. Trauma Case Rep. 2021;34:100508. doi:10.1016/j.tcr.2021.100508 Dhillon PS, Currall V, Shannon MN. Traumatic plastic deformation of the tibia: case report and literature review. Ann R Coll Surg Engl. 2012;94(1):e30-e32. doi:10.1308/003588412X13171221498947 Usha Trivedi is a medical student at Rutgers New Jersey Medical School with aspirations to become a diagnostic radiologist. She completed her undergraduate education at The College of New Jersey with a major in Biology and a minor in Art History. She is drawn to radiology due its unique blend of technology, art and medicine that is rooted in patient care. Her first exposure to radiology was through clerkships in medical school, where she saw how crucial imaging can be for patient care. She is currently involved as a director for one of her medical school’s student-run clinics and with her medical school’s humanities-themed magazine for her medical school. She aspires to become a radiologist with specific interests in mentorship, education and advocacy. In her spare time, she enjoys hiking, reading, art and board games. Follow Usha Trivedi on Twitter @UshaTrivedi11. All posts by Usha Trivedi Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice is a radiologist with Renaissance Imaging Medical Associates and is currently the Vice Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

Global Radiology CME is honored to announce Ella Kazerooni,MD will be speaking at this year's Global Radiology CME course in Dublin, Ireland - Imaging in Dublin 2022. Ella Kazerooni, MD MS is a Professor of Radiology & Internal Medicine, Associate Chair for Clinical Affairs & Director of Cardiothoracic Radiology at the University of Michigan. With a Master’s degree in Clinical Research Design & Statistical Analysis, her research focuses on the development and evaluation of advanced imaging technologies applied to the heart and lungs, including lung cancer, coronary artery and aortic disease, pulmonary embolism, and diffuse lung disease. She has given over 400 lectures, has over 300 peer-reviewed manuscripts, 30 book chapters and 4 books. She began the Radiology Service Excellence Program at U of M, with the department achieving the highest patient satisfaction scores in the health system. She is a frequently invited speaker on the topics of patient centered care & service excellence, lung cancer screening and lung disease, and is passionate about mentoring and coaching faculty and trainees as clinicians & scientists and as leaders. She is past president of the American Roentgen Ray Society, Association of University Radiologists, Society of Thoracic Radiology and Radiology Alliance for Health Services Research and past Trustee of the American Board of Radiology. Dr. Kazerooni currently Chairs the American Cancer Society’s National Lung Cancer Roundtable, is Vice Chair of the National Comprehensive Cancer Center’s Lung Cancer Screening panel, and Chairs the American College of Radiology’s Lung-RADS committee and the Lung Cancer Screening Registry (LCSR). These efforts are focused on bringing quality lung cancer screening to high risk individuals, and reduce the mortality from the #1 cancer killer.

Dr O’Keeffe MB, MRCP(UK), FFR RCSI, FRCR (UK) is a consultant radiologist in St James’s Hospital Dublin since 2010. She completed her undergraduate medical training in Trinity College Dublin and her postgraduate Radiology training in St James’s Hospital in Dublin before undertaking fellowships in Oncology Imaging in the Mater Hospital, Dublin and Breast Radiology and Women’s Imaging in Cambridge, UK. She was appointed as a Senior Lecturer in Trinity College in 2010. She has since spent two years as a Consultant Radiologist in St Bartholomew’s Hospital, London with a special interest in Breast Radiology including breast screening. Her other special interest is in Women’s Imaging including infertility and gynaecological cancer. She serves on university and national bodies including the National Cancer Control Programme.

Global Radiology CME is pleased to announce Niall Sheehy, FFR RCSIwill be speaking at this year's Global Radiology CME course in Dublin, Ireland - Imaging in Dublin 2022. Dr. Niall Sheehy is a consultant radiologist in St James's Hospital Dublin. He trained in radiology as part of the Faculty of Radiologists Radiology Training Scheme between 2002 and 2006. He did fellowships in PET/CT and Nuclear Medicine in The Dana Farber Cancer Institute and the Joint Programme in Nuclear Medicine in Harvard Medical School. He is a Clinical Senior Lecturer in Trinity College Dublin and the current Dean of the Faculty of Radiologists of the Royal College of Surgeons in Ireland.

Dr. Martina Morrin FFR RCSI, FRCR is a Consultant Radiologist in Beaumont Hospital Dublin. She trained in Radiology at the Mater Misericordiae hospital Dublin as part of the Faculty of Radiologists Radiology Training Scheme between 1994 and 1997. She did a fellowship in Abdominal Imaging at Beth Israel Deaconess Medical Center, Harvard Medical School(1997-1999) and subsequently spent 7 years on staff at that institution. She is associate Clinical Professor in radiology in the Royal College of Surgeons in Ireland. Her main research interests are in the field of abdominal imaging particularly CT colonography, gastrointestinal and urinary tract imaging.Dr. Morrin has lectured extensively at national and international conferences (including ESGAR, SGR, ARRS and RSNA) on a range of topics including CT colonography,rectal cancer and hepatobiliary imaging. She has authored and co-authored numerous articles and book chapters. She has contributed to national and international guideline development for colorectal cancer management, CT colonography and perianal fistula imaging. She acted as Irish National Coordinator Radiology training scheme 2009-2011. She acted as National Radiology Lead for Irish Bowel Screen colorectal cancer screening programme (2014-17). She acts as reviewer for several radiology and clinical journals.

"I look forward to the meeting and traveling to Dublin." - Donald Resnick, MD, FACR Global Radiology CME is honored to have ACR Gold Medalist, Donald Resnick, join us in Dublin for Imaging in Dublin 2019. Donald L. Resnick, MD, Professor Emeritus of Radiology and Former Chief of Osteoradiology at the University of California, San Diego (UCSD), has devoted more than 30 years to musculoskeletal radiology education. Dr. Resnick has written over 1100 scientific and educational articles (more than 100 published in Radiology), 72 book chapters, and 16 books on musculoskeletal radiology. Dr Resnick is a renowned lecturer, having given over 50 named lectures throughout the world including the Wilhelm Conrad Roentgen Honorary Lecture at the European Congress of Radiology and the Ho Hung Chiu Medical Education Foundation Lecture in Hong Kong. His list of dozens of awards and honors includes the American Roentgen Ray Gold Medal, Diagnostic Imaging Magazine’s 20 Most Influential People in Radiology, Medical Imaging Industry’s Top 10 Radiologists, twice-awarded AuntMinnie.com Most Effective Radiology Educator, and an Honorary Doctorate from the University of Zurich.Dr Resnick is a member of 9 radiology societies, and is a past president of the International Skeletal Society. In addition, he is an Honorary Fellow of 6 radiology societies in Europe and Asia. He serves on a multitude of departmental, hospital/medical school, and national committees. He has served on editorial boards and as a manuscript reviewer for 18 leading journals including AJR, Radiology, and RadioGraphics. More than 150 clinical fellows and 400 international research fellows, from over 20 countries throughout the world, have received one-on-one training through his fellowship programs. Amazingly, 70% of these fellows pursued academic careers after their training. More than 1000 visitors have come to his base of operations, formerly known as “The Bone Pit”, and now aptly dubbed "The Bone Palace." Dr. Resnick presenting the Global Radiology CME Resnick MSK Quiz Award to Andrew Kingzett Taylor from New Zealand at Imaging in Prague 2019

James Meaney FRCP, FFR RCSI, FRCPI is a Radiologist at St. James’s Hospital and a Clinical Professor in Trinity College Dublin. After undergraduate training in NUI Galway, he specialized in Radiology working in Liverpool, UK, University of Michigan, Ann Arbor and University of Leeds, UK before returning to Dublin in 2001. Prof. Meaney is director of the Thomas Mitchell Centre for Advanced Medical Imaging, which hosts a 3T MRI research scanner. His clinical and research interests span all areas of body CT and MRI, particularly magnetic resonance angiography. He has published over 80 papers in peer reviewed international journals and owns 8 patents related to MRI technology, is a former Trustee of the ISMRM and has been awarded Fellowship of the ISMRM. He is a former president of the MRA Club (now The Society4MRA). He has published 2 textbooks, numerous chapters and two radiology educational Apps.