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

29M with right wrist pain and deformity after a motorcycle accident • Xray of the Week Figure 1. Describe the wrist injury. Figure 2. Transscaphoid perilunate dislocation. Frontal , lateral, oblique radiographs of the wrist. Red arrow points to scaphoid fracture and yellow arrow points to a normally positioned lunate bone. 2A. On the frontal view, the capitolunate joint space is obliterated as the bones overlap one another. 2B. On the lateral view the capitate (green arrow) is dislocated dorsal to the lunate (yellow arrow). Due to the fracture (red arrow), the proximal pole of the scaphoid has remained aligned with the lunate, whereas the distal pole has followed the capitate dorsally. The lunate and the distal radius remain normally aligned. Discussion: Of the eight carpal bones that make up the wrist, the scaphoid bone is fractured most often and accounts for 70% of all carpal fractures.[1] Less commonly, scaphoid fractures can be associated with perilunate dislocations. The injury mechanism in transscaphoid perilunate dislocations is typically “high energy” with wrist hyperextension (e.g. falling from a height, sports trauma, and motor vehicle accidents). These patients generally present with exquisite wrist pain and swelling, exacerbated by wrist motion.[2] Figure 3. Mayfield Classification of Carpal Dislocations from https://wikem.org/wiki/Perilunate_and_lunate_dislocations Carpal dislocations have been described to occur in 4 stages (Fig. 3) [3]. In a Stage I injury, the scapholunate joint is disrupted. A Stage II injury finds the capitolunate joint disrupted, and Stage III injury is disruption of the lunotriquetral joint. It is considered a Stage IV injury when there is complete lunate dislocation with volar displacement [2-4]. On PA radiographs, a Stage I scapholunate dissociation can be recognized by the ‘Terry-Thomas sign’ which refers to a gap greater than 2 mm between the scaphoid and lunate bones, and is due to scapholunate ligament rupture. In normal lateral wrist radiographs, the capitate bone is aligned with the lunate bone and sits right above it. As seen in this case, with Mayfield Stage II when perilunate dislocation occurs, the capitate can be identified dorsally with respect to the lunate (Figs. 1B, 2B). This case also has a fracture through the scaphoid which is seen in 60% of cases. With Mayfield Stage III, or midcarpal dislocation there is dislocation of the capitate from the lunate and subluxation of the lunate from the radius. A Stage IV lunate dislocation is characterized by the "spilled teacup" sign seen on lateral radiographs, indicating the volar displacement of the lunate bone resembling a teacup spilling forward [2,5]. (Fig. 4) Transscaphoid perilunate dislocations can be treated with initial closed reduction and splint followed by surgical repair of injured ligaments after swelling has decreased. However, in cases where progressive median nerve dysfunction is noted, immediate open reduction with internal fixation (ORIF) is the preferred treatment [2,6]. Figure 4. Stage IV lunate dislocation. A. PA radiograph of lunate dislocation with triangular, “piece of pie” lunate appearance (green arrows), disruption of carpal arcs, increased radiolunate space, and overlap of lunate with other carpals. B. Lateral radiograph showing the “spilled teacup” appearance of lunate dislocation (yellow arrows), with the concavity of the lunate facing anteriorly. The lunate has volar displacement and angulation, and has lost articulation with the radius and capitate. ​​​​ References: 1. Papp S. Carpal Bone Fractures. Hand Clinics. 2010;26(1):119-127. doi:10.1016/j.hcl.2009.08.014 2. Kannikeswaran N, Sethuraman U. Lunate and perilunate dislocations. Pediatr Emerg Care. 2010;26(12):921-924. doi:10.1097/PEC.0b013e3181fe915b 3. Mayfield JK, Johnson RP, Kilcoyne RK. Carpal dislocations: Pathomechanics and progressive perilunar instability. Journal of Hand Surgery. 1980;5(3):226-241. doi:10.1016/S0363-5023(80)80007-4 4. Kennedy A, Allan H. In Brief: Mayfield et al. Classification: Carpal Dislocations and Progressive Perilunar Instability. Clinical Orthopaedics and Related Research. 2012;470(4):1243-1245. doi:10.1007/s11999-012-2275-x 5. Bashir WA, Aziz A, Jidaal I. Imaging of skeletal extremity trauma: A review. Trauma. 2014;16(4):300-317. doi:10.1177/1460408614542920 6. Kloss B, Patierno S, Sullivan A. Transscaphoid perilunate dislocation. International Journal of Emergency Medicine. 2010;3(4):501-502.doi:10.1007/s12245-010-0212-x Nirali Dave is a medical student at Medical University of Lublin in Poland, currently doing clinical rotations in New York. Before that she completed her undergraduate education at Rutgers University, and worked as a medical scribe. Nirali was first exposed to basic radiologic imaging while scribing, and was very quickly taken by the field. Her passion for radiology comes from the bridging of anatomy, health technologies, and patient care. In the future, she hopes to complete a diagnostic radiology residency and stay committed to clinical research and patient education. UPDATE March 19, 2021: Nirali Dave is a resident in Radiology and Imaging Sciences at Indiana University School of Medicine. Follow Nirali Dave on Twitter @ndave08 All posts by Nirali Dave Kevin M. Rice, MD is the president of Global Radiology CME and is a radiologist with Cape Radiology Group. He has held several leadership positions including Board Member and Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator by AuntMinnie.com. He has continued to teach by mentoring medical students interested in radiology. Everyone who Dr. Rice has mentored has been accepted into top programs across the country including Harvard, UC San Diego, Northwestern, Vanderbilt, and Thomas Jefferson. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

Name the anatomic variant and why it is important • Xray of the Week Figure 1. CT Scan - Name the anatomic variant and why it is important. Figure 2. Celiacomesenteric trunk. CT Scan - 3D angiogram image shows a common trunk (red arrow) which gives rise to the superior mesenteric artery and the celiac axis. Axial and sagittal CTA images: Superior mesenteric artery (green arrow) and celiac axis (yellow arrow) originating a common trunk. Figure 3. Celiacomesenteric trunk. Sagittal CT Scan and 3D angiogram in a different patient which shows a large common trunk giving rise to the superior mesenteric artery and the celiac axis. Discussion: The celiac trunk classically gives off three main branches: the left gastric, splenic, and common hepatic arteries. In 30% of the population though variations exist and included within these is the incidence of a celiacomesenteric trunk (CMT) in which the superior mesenteric artery (SMA) also branches from a common trunk with the celiac artery (Figs.1-3). The incidence of this anomaly is reported to be 0.5-3.4% (1-3). In total there have been four different types of CMT with the classic type being recognized as a common trunk containing the 3 branches of the celiac artery along with the SMA (2). In even rarer cases, an embryonic anastomotic branch may persist between the celiac and SMA, known as the arc of Buhler (AOB). Enlargement of this anastomosis can occur as can formation of aneurysms leading to occlusion of the celiac artery (5). CTA is often performed in patients undergoing abdominal procedures, and especially those concerning pancreatic, hepatobiliary, and other gastric neoplasms and masses. Multidetector computed tomography angiography (MDCT) remains the superior method for recognizing anatomical variants within the arterial and venous systems (4). It is crucial to identify anatomical variants such as the one described here prior to any open surgical, laparoscopic, or interventional procedures in order to avoid potential complications. ​​​​ References: 1. D’Souza D. Celiac artery | Radiology Reference Article | Radiopaedia.org. Radiopaedia. https://radiopaedia.org/articles/coeliac-artery?lang=us. Accessed April 13, 2020. 2. Muzio BD. Celiacomesenteric trunk | Radiology Reference Article | Radiopaedia.org. Radiopaedia. https://radiopaedia.org/articles/coeliacomesenteric-trunk?lang=us. Accessed April 13, 2020. 3. Ramesh Babu CS, Joshi S, Gupta KK, Gupta OP. Celiacomesenteric trunk and its variants a multidetector row computed tomographic study. Journal of the Anatomical Society of India. 2015;64(1):32-41. doi:10.1016/j.jasi.2015.04.007 4. Winston CB, Lee NA, Jarnagin WR, et al. CT Angiography for Delineation of Celiac and Superior Mesenteric Artery Variants in Patients Undergoing Hepatobiliary and Pancreatic Surgery. American Journal of Roentgenology. 2007;189(1):W13-W19. doi:10.2214/AJR.04.1374 5. Kageyama Y, Kokudo T, Amikura K, Miyazaki Y, Takahashi A, Sakamoto H. The arc of Buhler: special considerations when performing pancreaticoduodenectomy. Surg Case Rep. 2016;2. doi:10.1186/s40792-016-0149-2 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. UPDATE: Dr. Shah is a radiology resident at Vanderbilt Radiology 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

Fifth finger pain with minor trauma • Xray of the Week Figure 1. Name the lytic lesion in the fifth proximal phalanx and the complication. Figure 2. Magnified view of the enchondroma with pathologic fracture. Note the typical ring and arc calcifications within the expansile, well-circumscribed metaphyseal lytic lesion with minor cortical thinning and endosteal scalloping. Discussion: Enchondromas are benign, cartilage-forming neoplasms of the medullary bone cavity. They are often discovered incidentally on routine imaging, most commonly found in metacarpal and phalanges bones of the hand.(1-4) Enchondromas are generally asymptomatic, however due to the typical location of the lesions even minor trauma may result in pathologic fractures causing pain and swelling.(2) Recognizing radiographic features of this benign bony tumor can help in excluding more aggressive bone malignancies. On radiographic imaging enchondromas are classically recognized as well-circumscribed, metaphyseal lytic lesions with minor cortical thinning and endosteal scalloping. Occasionally calcifications can be seen on xray, particularly in the ‘ring and arc’ or ‘popcorn’ pattern characteristic of chondroid lesions. When an enchondroma presents with a pathologic fracture, cortical expansion may also be seen on imaging.(2,3) Negative radiographic findings such as the absence of periosteal reactions or soft tissue extension distinguish enchondromas from low-grade osteosarcomas.(1) A higher index of suspicion for malignancy may warrant further evaluation with MRI and histopathologic evaluation. Enchondroma treatment is typically reserved for presence of a pathologic fracture, or if there is high risk of fracture in the future. The treatment options include surgical curettage followed by bone graft or filling with synthetic material, and follow-up xrays to detect any recurrence.(4,5)​ ​​​​ References: 1. Larbi A, Viala P, Omoumi P, et al. Cartilaginous tumours and calcified lesions of the hand: a pictorial review. Diagn Interv Imaging. 2013;94(4):395-409. doi:10.1016/j.diii.2013.01.012 2. Santini-Araujo E, Kalil RK, Bertoni F, Park Y-K. Tumors and Tumor-Like Lesions of Bone: Enchondroma. 2nd ed. 2020. Springer International Publishing; 2020. doi:10.1007/978-3-030-28315-5. https://www.springer.com/us/book/9781447172437#otherversion=9781447165774 3. Mcvey MJ, Kettner NW. Pathologic fracture of metacarpal enchondroma: Case study and differential diagnosis. Journal of Manipulative and Physiological Therapeutics. 2002;25(5):340-344. doi:10.1067/mmt.2002.124417 4. Douis H, Saifuddin A. The imaging of cartilaginous bone tumours. I. Benign lesions. Skeletal Radiol. 2012;41 (10): 1195-212. doi:10.1007/s00256-012-1427-0 5. Hakim DN, Pelly T, Kulendran M, Caris JA. Benign tumours of the bone: A review. J Bone Oncol. 2015;4(2):37-41. Published 2015 Mar 2. doi:10.1016/j.jbo.2015.02.001 Nirali Dave is a medical student at Medical University of Lublin in Poland, currently doing clinical rotations in New York. Before that she completed her undergraduate education at Rutgers University, and worked as a medical scribe. Nirali was first exposed to basic radiologic imaging while scribing, and was very quickly taken by the field. Her passion for radiology comes from the bridging of anatomy, health technologies, and patient care. In the future, she hopes to complete a diagnostic radiology residency and stay committed to clinical research and patient education. UPDATE March 19, 2021: Nirali Dave is a resident in Radiology and Imaging Sciences at Indiana University School of Medicine. Follow Nirali Dave on Twitter @ndave08 All posts by Nirali Dave Kevin M. Rice, MD is the president of Global Radiology CME and is a radiologist with Cape Radiology Group. He has held several leadership positions including Board Member and Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator by AuntMinnie.com. He has continued to teach by mentoring medical students interested in radiology. Everyone who Dr. Rice has mentored has been accepted into top programs across the country including Harvard, UC San Diego, Northwestern, Vanderbilt, and Thomas Jefferson. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

@GlobalRadCME and @KevinRiceMD are posting Free Open Access Medical education for radiology which is also known as #FOAMrad on Twitter. We are also posting interesting cases on LinkedIn and Facebook. According to a blog post on the largest and most visited FOAMrad site - Radiopaedia, the term FOAMrad was coined by the following group of radiologists and radiology trainees: Fiona Pathiraja (@dr_fiona) Matthew Bull (@mattdbull) Vikas Shah (@DrVikasShah) Andrew Dixon (@DrAndrewDixon) Jeremy Jones (@dr_jbj) David Little (@DrDLittle) Lynne Armstrong (@oscarella) Radiopaedia, the largest FOAMrad resource, was founded by Dr. Frank Gaillard in December 2005, and he remains Editor in Chief of Radiopaedia.org. Symplur Radiology Hashtag Ontology by Matt Hawkins (@MattHawkinsMD): Clinical Tags I have the most popular links in blue Hashtag Topic #AbdRad Abdominal Radiology #ChestRad Chest Radiology #CTRad Computed Tomography #CVRad Cardiovascular Imaging #EMRad Emergency Radiology #HNRad Head/Neck Radiology #IRad Vascular Interventional Radiology #IROnc Interventional Oncology #Mammo Mammography #MRI MRI #MSKRad Musculoskeletal Radiology #MSKUS MSK Ultrasound #NeuroRad Neuro Radiology #NucMed Nuclear Medicine #OBRad Obstetrics Radiology #oncorad Oncologic Radiology #PedsRad Pediatric Radiology #USRad Ultrasound Scientific Disciplines I have the most popular links in blue Hashtag Topic #FOAMRad Free and Open Access to Medical Education Radiology #FOAMus Free and Open Access to Medical Education Ultrasound #GlobalRad Global Radiology #HITRad Radiology Informatics #MolRad Molecular Imaging #POCUS Research Related to Point-of-Care US #RadCME CME Offerings in Radiology #RadEcon Radiology Economics #RadHSR Radiology Health Services Research #Radiology Radiology #RadLeaders Radiology Leadership #RadPhys Radiology Physics #RadPolicy Radiology Health Policy #RadQI Radiology Quality Improvement #RadRes Radiology Residency #RadSafety Radiation Safety #TeleRad Teleradiology #radpathmatch Radiologic - Pathologic correlation on Twitter #xrayoftheweek Interesting cases by Radiologists Vikas Shah, MD and Kevin Rice, MD on Twitter Did you see all my Xray of the Week - 2016 Cases? Here they are: Follow us on Twitter ​@GlobalRadCME Follow Dr. Rice on Twitter @KevinRiceMD Follow Dr. Rice on LinkedIn Follow Global Radiology CME on LinkedIn Follow Global Radiology CME on Facebook Kevin Rice, MD serves as the Medical Director of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a Member of Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice launched Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD FACR

Global Radiology CME is pleased to announce our President, Dr. Kevin Rice was recently elected a Fellow of The American College of Radiology for his exemplary service and dedication to the ACR and his profession. Dr. Rice is not only an outstanding practicing radiologist and the President of Global Radiology CME, he also devotes time to providing free radiology online education. He has also been mentoring medical students who are interested in pursuing radiology residencies. Author of an extensive online radiology teaching file produced by Global Radiology CME and followed in over 150 countries across the globe, Dr. Rice is well known for sharing his broad knowledge and extensive experience as a practicing radiologist. Dr. Rice has authored or co-authored over 200 radiology cases that can be accessed on the Global Radiology teaching file. As a testament to his broad knowledge base, Dr. Rice has authored cases in Breast Imaging, MSK Imaging, Body Imaging, Cardiac Imaging, Spine Imaging, Interventional Radiology, and Neuroradiology. The only love that supersedes his passion for radiology is time spent with his family. According to Dr. Rice, "I am honored to have been conferred the prestigious title: Fellow of the American College of Radiology (FACR) at ACR 2023. It is all possible due to my family, especially my loving wife Natalie Rice who has sacrificed so much over many years. She has been my guiding light, and I know that it would not have been possible without Natalie by my side." Dr. Rice is on Twitter @KevinRiceMD All posts by Kevin Rice, MD Related articles: Dr. Kevin Rice: Semifinalist for 2016 AuntMinnie.com's Most Effective Radiology Educator Dr. Kevin Rice: Semifinalist for 2021 AuntMinnie.com's Most Effective Radiology Educator Mentored Medical Students Match in Radiology

79 year old male. Back pain and lower extremity weakness after a fall • Xray of the Week Figure 1.What are the important findings in each image. Figure 2. Coronal CT (A) and sagittal CT (B) images demonstrate fracture at the T11-12 level with significant offset (red arrows) causing the neurologic deficit. Note also the extensive ankylosis throughout the spine. Axial CT image (C) demonstrates edema adjacent to the acute fracture (green arrows). Axial CT image (D) shows fused sacroiliac joints (yellow arrows). Ankylosing Spondylitis: Ankylosing spondylitis (AS) is a seronegative spondyloarthropathy and chronic inflammatory disease of the axial skeleton that leads to the partial or complete fusion and rigidity of the spine. The disease triggers the innate immune response to mobilize macrophages, CD4+ T cells, and CD8+ T cells into the paravertebral and sacroiliac entheses.1 Chronic enthesitis erodes the iliac component of the sacroiliac joints and forms vertical syndesmophytes along the spinal ligament or around the annulus fibrosus of intervertebral discs. These syndesmophytes may fuse at the intervertebral discs and vertebral bodies.2 Ossification of vertebral ligaments present as the dagger sign on X-ray, while ossification of the outer fibers of the annulus fibrosus presents as a bamboo spine.3 [Figs. 1,2] These inflammatory changes additionally lead to osteopenic vertebrae and reduced spinal mobility. Chalk stick fracture: Patients with AS should be monitored to prevent serious complications such as chalk stick fractures: a complete separation of fused vertebrae. The fused osteopenic bones in AS increase the rigidity of the bony spinal structure overall and the risk of patients experiencing low-energy fractures.4 Chalk stick fractures may lead to anterior subluxation and narrowing of the spinal canal.5 As in this case, nearly 67% of chalk stick fractures from AS present with neurologic deficits.6 They typically occur in the cervical spine (81%) followed by the thoracic (11%) and lumbar (8%) regions.7 Primary diagnosis of AS involves radiography of sacroiliac joints and symptomatic areas of the spine (Figs. 1,2). Because radiography may not detect early signs of AS, non-enhanced MRI is recommended in identifying early signs of disease.8 ​​​​ References: Van Praet L, Van den Bosch F, Mielants H, Elewaut D. Mucosal inflammation in spondylarthritides: past, present, and future. Curr Rheumatol Rep. 2011;13(5):409-415. doi:10.1007/s11926-011-0198-2 Ward MM, Deodhar A, Gensler LS, et al. 2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis Rheumatol. 2019;71(10):1599-1613. doi:10.1002/art.41042 Kumar RR, Jha S, Sharma A. Dagger sign of ankylosing spondylitis. Oxf Med Case Reports. 2019;2019(12):502-503. doi:10.1093/omcr/omz117 Chaudhary SB, Hullinger H, Vives MJ. Management of acute spinal fractures in ankylosing spondylitis. ISRN Rheumatol. 2011;2011:150484. doi:10.5402/2011/150484 Akhaddar A, Salami M. Fracture of the bamboo spine (chronic ankylosing spondylitis) after cervical injury. Pan Afr Med J. 2014;17:113. doi:10.11604/pamj.2014.17.113.3888 Westerveld LA, Verlaan JJ, Oner FC. Spinal fractures in patients with ankylosing spinal disorders: a systematic review of the literature on treatment, neurological status and complications. Eur Spine J. 2009;18(2):145-156. doi:10.1007/s00586-008-0764-0 Skarentzos K, Karamanou G, Chrysafis I, Papagoras C. Chalk-stick fracture in ankylosing spondylitis. Clin Rheumatol. 2020;39(8):2469-2470. doi:10.1007/s10067-020-05117-0 Bernard SA, Kransdorf MJ, Beaman FD, et al. ACR Appropriateness Criteria® Chronic Back Pain Suspected Sacroiliitis-Spondyloarthropathy. J Am Coll Radiol. 2017;14(5):S62-S70. doi:10.1016/j.jacr.2017.01.048 Eric Errampalli is a passionate medical student at the University of Missouri – Kansas City Six-Year BA/MD Program, with a steadfast commitment to becoming a radiologist. His fascination with the field stems from its integral role in healthcare and the endless possibilities for technological advancements waiting to be made. At UMKC, Eric has made significant contributions to the Radiology Interest Group, serving in various executive roles and currently as the interventional radiology chair. His leadership has inspired his peers to explore the field and discover the boundless opportunities for growth and impact. Beyond UMKC, Eric's interests have risen to a national level, as he serves on the Society of Interventional Radiology Medical Student Council Education Committee and TheRadRoom IR Team. Through these platforms, he has been instrumental in shaping the future of interventional radiology education and promoting awareness of the field among medical students. Eric's passion for innovation extends beyond the classroom, as he strives to help drive change in the field of radiology through his medical entrepreneurial ventures. He believes that entrepreneurship can unlock untapped potential in the field and pave the way for transformative breakthroughs that can improve patient outcomes and revolutionize healthcare. To stay up to date on Eric's journey and learn more about his work, follow Eric on Twitter @EricErrampalli and connect with him on LinkedIn www.linkedin.com/in/eric-errampalli/ All posts by Eric Errampalli 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

68M with headache • Xray of the Week Figure 1. What is the important finding on these images. Figure 2. CT of a planum sphenoidale meningioma. A. Axial non contrast CT showing subtle density in midline frontal region (red arrows). B. Coronal non contrast CT showing subtle density in midline frontal region (red arrows). C. Axial CT with contrast showing enhancing midline mass (green arrows). D. Coronal CT with contrast showing enhancing midline mass with a broad base along the planum sphenoidale (green arrows). Introduction: Meningiomas are extra-cranial tumors which are attached to the dura in most cases (1, 4). Around 5-10% of meningiomas are suprasellar, which are subclassified as arising from the planum sphenoidale, tuberculum sellae, diaphragma sellae, and anterior clinoid process (2). Planum sphenoidale meningiomas may have a poor surgical outcome due to the anatomic complexity as they can extend into nearby structures such as the sella turcica, posterior clinoid, and cavernous sinus (3). Discussion: CT is useful since it can demonstrate any meningiomas effect on adjacent bone and in detecting psammoma calcifications (1). On non-contrast CT, meningiomas appear isodense compared to adjacent brain tissue (Figs. 1A, B). On contrast CT, the meningioma will enhance and may or may not appear homogeneous (Fig. 1C, D) depending on the presence of calcium, fat, and tumor necrosis (2). Hyperostosis of adjacent bone suggests a benign meningioma. MRI has the ability to assess soft tissue characteristics including vascular supply and perfusion. On MRI with contrast, meningiomas and their dural tail/attachment will enhance, which reflects dural infiltration and/or reactive vascularity. Calcifications may appear as low signal intensity or areas void of vascular flow (2). On T1 weighted images, meningiomas appear isointense or hypointense and have signal variability on T2 weighted images. The use of diffusion-weighted imaging has been shown to aid in predicting the histological grade of meningiomas (3). Treatment: Depending on the tumor size and involvement of adjacent structures, planum sphenoidale meningiomas may be removed using approaches such as endonasal transsphenoidal resection. Early decompression of the optic canal and orbiotomy are critical for total resection with excellent outcomes (5). ​​​​ References: Ohba, S., Abe, M., Hasegawa, M., & Hirose, Y. (2016). Intraparenchymal Meningioma: Clinical, Radiologic, and Histologic Review. World neurosurgery, 92, 23–30. doi:10.1016/j.wneu.2016.04.098 Saloner D, Uzelac A, Hetts S, Martin A, Dillon W. Modern meningioma imaging techniques. J Neurooncol. 2010;99(3):333-340. doi:10.1007/s11060-010-0367-6 Ranabhat K, Bishokarma S, Agrawal P, et al. Role of MR Morphology and Diffusion-Weighted Imaging in the Evaluation of Meningiomas: Radio-Pathologic Correlation. JNMA; Journal of the Nepal Medical Association. 2019 Jan-Feb;57(215):37-44. https://europepmc.org/article/med/31080244 Finn JE, Mount LA. Meningiomas of the Tuberculum Sellae and Planum Sphenoidale: A Review of 83 Cases. Arch Ophthalmol. 1974;92(1):23–27. doi:10.1001/archopht.1974.01010010027007 Mortazavi MM, Brito da Silva H, Ferreira M Jr, Barber JK, Pridgeon JS, Sekhar LN. Planum Sphenoidale and Tuberculum Sellae Meningiomas: Operative Nuances of a Modern Surgical Technique with Outcome and Proposal of a New Classification System. World Neurosurg. 2016;86:270-286. doi:10.1016/j.wneu.2015.09.043 Neal Joshi is a medical student and aspiring diagnostic radiologist at Rowan University School of Osteopathic Medicine in New Jersey. Prior to medical school, he did research with mouse models for Parkinson’s disease and L-DOPA induced dyskinesias. He also did an internship at Kessler Institute for Rehabilitation in a stroke lab analyzing MR images in ischemic stroke patients with hemispatial neglect. During his time at Rowan, he did research with animal models for traumatic brain injury with an emphasis on electrophysiology of neurons. He graduated from William Paterson University where he completed his studies in biology and biopsychology. Apart from medical school, Neal loves to read, skateboard, go on hikes, and spend time with his friends. Update July 2022: Dr. Joshi is a Radiology Resident at Thomas Jefferson University in Philadelphia. All posts by Neal Joshi Kevin M. Rice, MD is the president of Global Radiology CME and is a radiologist with Cape Radiology Group. He has held several leadership positions including Board Member and Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator by AuntMinnie.com. He has continued to teach by mentoring medical students interested in radiology. Everyone who Dr. Rice has mentored has been accepted into top programs across the country including Harvard, UC San Diego, Northwestern, Vanderbilt, and Thomas Jefferson. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD