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We are pleased to announce Global Radiology CME's Kevin Rice, MD is a semifinalist for 2021 AuntMinnie.com 's Most Effective Radiology Educator. Dr. Kevin Rice, Vice Chief of the Medical Staff at Valley Presbyterian Hospital, a 21 year radiologist at RIMA, a proud member of Radiology Partners, a member of the Radiology Partners Advocacy Board, and President of Global Radiology CME, is honored to be named a semi finalist in the " 2021 edition of the Minnies, AuntMinnie.com's campaign to recognize the best and brightest in medical imaging ". 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 . This is Dr. Rice's second nomination for the prestigious award having been nominated and becoming a semifinalist for a Minnie in 2016 . Always looking for new challenges and opportunities for outreach, in 2020 Dr. Rice began a program of mentoring medical students interested in radiology residencies. In the inaugural year of his mentoring program all 6 of his medical students successfully matched in top radiology programs including Indiana University, Thomas Jefferson University, Vanderbilt, Amita Health, and Northwestern. The mentoring program was so successful Dr. Rice will be working with 12 medical students for the 2021 academic year. The only love that supersedes his passion for radiology is time spent with his family. With over 2 million page views per month and close to 150,000 members, Aunt Minnie is the premiere radiology information website catering to radiologists and professionals in the medical imaging field from across the globe. According to AuntMinnie.com the Minnie's seek to recognize the "Best and Brightest in Medical Imaging". Now in their 22th year, the Minnie awards provide a forum for radiology professionals to acknowledge the contributions of their peers to the field of medical imaging. Minnies candidates are nominated by AuntMinnie.com members and the winner will be selected by a panel of experts in the field through two rounds of voting. Semifinalists for AuntMinnie.com's 2021 Most Effective Radiology Educator: Dr. Ryan Avery, Northwestern University Dr. Omer Awan, University of Maryland Dr. Tessa Cook, PhD, University of Pennsylvania Dr. Carolynn DeBenedectis, University of Massachusetts Dr. Christine Glastonbury, University of California, San Francisco Dr. Paula Gordon, University of British Columbia Dr. David Kim, University of Wisconsin Dr. Nicholas Koontz, Indiana University Dr. Christine Menias, Mayo Clinic Arizona Dr. Rendon Nelson, Duke University Dr. Alexander Norbash, University of California, San Diego Dr. Reed Omary, Vanderbilt University Dr. Amy Patel, University of Missouri-Kansas City Dr. Victor Pizzitola, Mayo Clinic Arizona Dr. Kevin Rice, Valley Presbyterian Hospital Dr. Bradley Spieler, Louisiana State University Dr. Richard Wiggins, University of Utah Dr. Jeremy Wortman, Lahey Hospital & Medical Center Dr. Stephanie Yen, Dartmouth-Hitchcock Health Dr. Greg Zaharchuk, Stanford University from AuntMinnie.com Logo courtesy of Brian Casey , Editor in chief of AuntMinnie.com 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 Figure 1 Features Dr. Kevin Rice Kevin Rice, MD - One of the #HumansOfRadiology

We are pleased to announce Global Radiology CME's Kevin Rice, MD is a semifinalist for 2016 AuntMinnie.com 's Most Effective Radiology Educator. Kevin Rice, MD Dr. Kevin Rice, radiologist at Renaissance Imaging Medical Associates and Chair of Radiology at Valley Presbyterian Hospital in Los Angeles, California is one of 17 radiologists from around the world to be a semifinalist in the category of Most Effective Radiology Educator. Dr. Rice is "extremely honored to be nominated and be part of such an extraordinary group of radiologists from renowned teaching centers." With over 2 million page views per month and close to 150,000 members, Aunt Minnie is the premiere radiology information website catering to radiologists and professionals in the medical imaging field from across the globe. According to AuntMinnie.com, t he Minnie's seek to recognize the "Best and Brightest in Medical Imaging". Now in their 17th year, the Minnies awards provide a forum for radiology professionals to acknowledge the contributions of their peers to the field of medical imaging. Minnies candidates are nominated by AuntMinnie.com members and selected by a panel of experts in the field through two rounds of voting. Logo courtesy of Brian Casey , Editor in chief of AuntMinnie.com Semifinalists for AuntMinnie.com 's 2016 Most Effective Radiology Educator: Dr. Stephen Amis , Albert Einstein College of Medicine/Montefiore Medical Center Dr. Sanjeev Bhalla , Mallinckrodt Institute of Radiology Dr. Kevin Chang , Brown University Dr. Frank Gaillard , Radiopaedia - Australia Dr. Carol Geer , Wake Forest Baptist Medical Center Dr. Pamela Johnson , Johns Hopkins University Dr. Frank Lexa , Drexel University Dr. Tan-Lucien Mohammed , University of Florida Dr. Mark Mullins , PhD, Emory University Dr. Gregory Nicola , Hackensack Radiology Group Dr. François Pontana , Lille University Hospital - France Dr. Elizabeth Rafferty , Lawrence General Hospital Dr. Parvati Ramchandani , University of Pennsylvania Dr. Kevin Rice , Renaissance Imaging Medical Associates Dr. Mary Scanlon , University of Pennsylvania Dr. Kitt Shaffer , PhD, Boston University Dr. Stacy Smith , Brigham and Women's Hospital Dr. Rice serves as the Chair of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates . Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA and writing the popular Xray of the Week for radiology social media. 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. Dr. Rice is on Twitter posting what matters to radiologists @KevinRiceMD All posts by Kevin Rice, MD Related articles: Figure 1 Features Dr. Kevin Rice Kevin Rice, MD - One of the #HumansOfRadiology

Blocked Tube • Xray of the Week To prevent obstruction, it is best to exchange nephrostomy tubes every 3 months. However, long term indwelling nephrostomy tubes may become occluded by urinary crystal deposition which can lead to encrustation and obstruction. What if the patient still needs the tube and you can't get a guide-wire through the tube? Can you still exchange it? Yes you can! Below is a step by step approach with diagrams that I drew myself. Figure 1. A. Cut existing nephrostomy tube (in blue). B. Suture (in orange) through tube. C. Advance sheath (in red) over tube and the suture. Figure 2. A. Keep advancing sheath (in red) over tube. B. Now sheath in collecting system. C. When sheath in collecting system, pull nephrostomy tube. Figure 3. A. Keep pulling nephrostomy tube while holding sheath (in red) in place. B. Now sheath in collecting system. C. Advance wire (in black) through sheath. Figure 4. A. Remove sheath, leaving wire in collecting system. B. Advance new nephrostomy tube (in purple) over the wire. C. Remove wire. Discussion: Indications for percutaneous nephrostomy include urinary diversion for urinary tract obstruction secondary to calculi, malignancy, or inflammation. It may also be requested by urologists for urinary fistula and/or leaks which may be due to traumatic or iatrogenic injury. I usually use a 10F tube as smaller tubes are more likely to become occluded. In the event of nephrostomy tube occlusion, the above technique has been very effective. References: 1. Dagli M, Ramchandani P. Percutaneous nephrostomy: technical aspects and indications. Semin Intervent Radiol. 2011;28 (04): 424-437 . 2. Ramchandani P, Cardella J F, Grassi C J, et al. Society of Interventional Radiology Standards of Practice Committee Quality improvement guidelines for percutaneous nephrostomy. J Vasc Interv Radiol. 2003;14(9 Pt 2):S277–S281. 3. Farrell TA, Hicks ME. A review of radiologically guided percutaneous nephrostomies in 303 patients. J Vasc Interv Radiol. 1997 Sep-Oct; 8(5):769-74. 4. Pollack HM, Banner MP. Replacing blocked or dislodged percutaneous nephrostomy and ureteral stent catheters. Radiology. 1982 Oct;145(1):203-5. https://pubs.rsna.org/doi/pdf/10.1148/radiology.145.1.7122880 5. Huang SY, MD, Engstrom BI, Lungren MP, et al.. Management of Dysfunctional Catheters and Tubes Inserted by Interventional Radiology. Semin Intervent Radiol. 2015 Jun; 32(2): 67–77.doi: 10.1055/s-0035-1549371 6. Lee WJ, Patel U, Patel S, Pillari GP. Emergency percutaneous nephrostomy: results and complications. J Vasc Interv Radiol. 1994 Jan-Feb; 5(1):135-9. Kevin M. Rice, MD is president of Global Radiology CME and serves as the Chief of staff and Chair of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates . Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. Dr. Rice co-founded Global Radiology CME with Natalie Rice to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

63 yr old otherwise healthy male in Northern Italy with syncope • Xray of the Week The patient presented to the Emergency Department with syncope. He denied contact with COVID-19 positive people in the Italian “red zones”. Vital signs including temperature were normal. Physical exam was normal. EKG: negative LABORATORY: CBC: Lymphopenia, otherwise normal. D-dimer: Elevated. LDH: Elevated at 365. Oxygen saturation: Low at 92. Influenza virus: Negative. Respiratory syncytial virus: Negative. Chlamydia serology: Negative. ABG:↓PaO2 = 60 mm Hg (N=80-100 mm Hg) RADIOLOGY: CT brain: Normal Chest X-ray: Bilateral linear consolidation, in left upper and lower lobes. No pleural effusion. Normal heart size. Due to the syncope, elevated D-Dimer, and chest X-ray the patient underwent a CT pulmonary angiogram which demonstrated no pulmonary embolism. However, there was bilateral subpleural consolidation and two small areas of ground glass opacification in the left upper lobe and lingula. The patient was admitted with a diagnosis of nonspecific pulmonary inflammation and treated with ceftriaxone and azithromycin. During hospitalization the patient’s condition worsened with the onset of respiratory distress. Non-contrast chest CT was then performed and demonstrated widespread bilateral mosaic crazy paving pattern, resolution of sub-pleural consolidations and no pleural effusion or lymphadenopathy. Figure 1. Chest CT scan upper chest. Initial images show bilateral subpleural linear consolidation and two small areas of ground glass opacification in the left upper lobe and lingula. One week later, there is crazy paving pattern with ground glass opacities. Figure 2. Chest CT scan lower chest. Initial images show bilateral subpleural linear consolidation and two small areas of ground glass opacification in the left upper lobe and lingula. One week later, there is crazy paving pattern with ground glass opacities. Discussion: This case demonstrates how the lack of epidemiological criteria and atypical clinical presentation led to the hospitalization of a COVID-19 positive patient without standard quarantine precautions. Unfortunately, this led to a delayed diagnosis and the subsequent spread of the disease in the Hospital. It is felt that the initial radiological studies were too non-specific for an early diagnosis of COVID-19, especially given that the city was in the early phase of the pandemic. The CT chest performed one week after admission did have the typical pattern of COVID-19 with crazy paving pattern with peripheral ground glass opacities. After this experience and due to the high prevalence in the community, during this pandemic most of the non-traumatic patients triaged in the Ospedale Castelli di Verbania Emergency Department have since been considered COVID-19 positive until proven otherwise. ​​​​ COVID-19 Information as of February 5, 2021: Epidemiology and Etiology In December of 2019, there was a large outbreak of a new coronavirus (part of the Coronaviridae family) in Wuhan, Hubei Province, China. This novel virus was termed SARS-CoV-2 and the corresponding disease caused by the virus, coronavirus disease, has been termed COVID-19. Although possibly originating in bats with an intermediate host, the virus spreads through human-to-human contact and has been shown to be transmissible during the incubation period which is up to 14 days following exposure. It is likely that 40% of infected individuals remain asymptomatic. It has been estimated that the Ro of the virus is 2.5, thus each carrier of the virus goes on to infect 2-3 other individuals and the CDC estimates that 50% of transmission occurs before symptom onset (23). Based on data from New York City where on 5/2/20, they found 20% of the sampled population was positive for antibodies, the the case fatality rate is estimated at 0.5%-1%. Due to the high rate of transmissibility of SARS-CoV-2, some epidemiologists estimate that herd immunity will be only be achieved when about 60-70% of the population has been infected and has antibodies (22). Current Best Estimate of Infection Fatality Ratio (ref. 23): 0-19 years: 0.003% 20-49 years: 0.02% 50-69 years: 0.5% 70+ years: 5.4% Confirmed COVID-19 cases of February 5, 2021 (ref. 7): Seen in 192 territories and six continents. Global: >105 Million cases. >2.3 Million deaths. USA: >26 Million cases. >460,000 deaths. Brazil: >9 Million cases. >230,000 deaths. UK: >3.9 Million cases. >111,00 deaths. Spain: >2.9 Million cases. >61,00 deaths. Italy: >2.6 Million cases. >90,000 deaths. Ireland: >201,000 cases. >3600 deaths. Fatality rate per million people by country. Source: https://ourworldindata.org/grapher/total-covid-deaths-per-million?year=latest Excess mortality during COVID-19: The number of deaths from all causes compared to previous years. Source: https://ourworldindata.org/grapher/excess-mortality-p-scores Share of people who received at least one dose of COVID-19 vaccine. This may not equal the share that are fully vaccinated if the vaccine requires two doses. Source: https://ourworldindata.org/covid-vaccinations Clinical manifestations Most cases manifest approximately four to five days after exposure and symptoms described in 138 patients with COVID-19 pneumonia in Wuhan included fever (99%), fatigue (70%), dry cough (59%), anorexia (40%), myalgias (35%), dyspnea (31%), sputum production (27%). In an Italian survey of 59 patients with COVID-19, 34% self-reported either olfactory dysfunction such as anosmia or taste aberration. Recent reports also indicate that the virus may cause nausea, abdominal pain or diarrhea and occasionally patients may present with gastrointestinal symptoms. Rare cases have also been associated with myocarditis or encephalopathy. A recent paper out of Ireland found that patients admitted to hospital with severe COVID-19 infection may develop an unusual coagulopathy resulting in micro-thrombosis within the pulmonary vasculature (19). Imaging Features Plain radiograph features are less sensitive than computed tomography and are highly variable and non-specific. Within infected individuals, chest radiography most often shows bilateral involvement with patchy or diffuse asymmetric opacities within the lungs, and ground glass opacification. Involvement is most often in the lower lung zones. CT findings include interstitial thickening, crazy paving pattern, progressive ground glass opacification which may be rounded, consolidation with air bronchograms and the reverse halo sign. The findings are more likely to be bilateral, have a peripheral distribution, and involve the lower lobes. Pleural effusion and lymphadenopathy are uncommon. Follow up CT’s often illustrate progressive worsening. Mild ground glass opacities may be seen incidentally in asymptomatic patients. While imaging findings are useful for showing disease activity, the findings are nonspecific and many mimic those seen in influenza, cytomegalovirus pneumonia, SARS or MERS pneumonia, pulmonary edema, various interstitial lung diseases, and atypical bacterial pneumonia. Management of COVID-19 patients and persons under investigation in the radiology department are evolving and vary depending on the needs and resources of each facility. Priorities center around early detection and limiting exposure of healthcare workers, employees and patients, as well as maintenance of radiology department operations. Labs The diagnosis is made by a nasopharyngeal swab specimen collected for reverse-transcription polymerase chain reaction (RT-PCR) testing for SARS-CoV-2. In a study conducted on 138 hospitalized COVID-19 positive patients, the most common laboratory findings were increased PT, increased LDH, and lymphopenia. Laboratory features which have been associated with worse outcomes include lymphopenia and acute kidney injury. Elevated blood work including liver enzymes, LDH, CRP, D-dimer, PT, troponin, CPK also portend a worse prognosis. Treatment While many different treatment modalities are currently in the pipeline, no regimen has yet to be shown to effectively treat COVID-19. On March 28, 2020 in the United States, the FDA issued an emergency use authorization (EUA) to allow the use of hydroxychloroquine and chloroquine for COVID-19. However, this EUA was revoked on June 15, 2020 stating "Based on its ongoing analysis of the EUA and emerging scientific data, the FDA determined that chloroquine and hydroxychloroquine are unlikely to be effective in treating COVID-19." An emergency-use authorization is a lower regulatory bar than full FDA approval. The antiviral drug remdesivir, which was developed to treat the Ebola virus has shown promise in laboratory settings to inhibit the ability of Coronavirus to infect cells in vitro. It has been effective in treating coronavirus within animals. Large randomized clinical trials with the antiviral are currently underway. The FDA issued an EUA on May 1, 2020 to treat hospitalized patients with severe COVID-19 stating the benefits of the drug outweigh its risks in patients (20). COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU) Source: https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6 References: Xiong Y, Sun D, Liu Y, et al. Clinical and High-Resolution CT Features of the COVID-19 Infection: Comparison of the Initial and Follow-up Changes. Investigative Radiology. 2020;Publish Ahead of Print. doi: 10.1097/RLI.0000000000000674 CDC. Coronavirus Disease 2019 (COVID-19) – Symptoms. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html . Published March 29, 2020. Accessed April 5, 2020. CDC. Coronavirus Disease 2019 (COVID-19). Information for Clinicians on Therapeutic Options for COVID-19 Patients. https://www.cdc.gov/coronavirus/2019-ncov/hcp/therapeutic-options.html#r7 . Accessed April 5, 2020. Li Y, Xia L. Coronavirus Disease 2019 (COVID-19): Role of Chest CT in Diagnosis and Management. American Journal of Roentgenology. March 2020:1-7. doi: 10.2214/AJR.20.22954 Publishing HH. Coronavirus Resource Center. Harvard Health. https://www.health.harvard.edu/diseases-and-conditions/coronavirus-resource-center . Accessed April 5, 2020. Bell DJ. COVID-19 | Radiology Reference Article | Radiopaedia.org. Radiopaedia. https://radiopaedia.org/articles/covid-19-3?lang=us . Accessed April 5, 2020. Coronavirus COVID-19 Global Cases by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins. Interactive online map. https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6 Accessed April 8, 2020. Hosseiny M, Kooraki S, Gholamrezanezhad A, Reddy S, Myers L. Radiology Perspective of Coronavirus Disease 2019 (COVID-19): Lessons From Severe Acute Respiratory Syndrome and Middle East Respiratory Syndrome. American Journal of Roentgenology. February 2020:1-5. doi: 10.2214/AJR.20.22969 Gautret P, Lagier J, Parola P, Hoang V, Meddeb L, Mailhe M, et al. Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial. International Journal of Antimicrobial Agents. In Press. Hu Z, Song C, Xu C, et al. Clinical characteristics of 24 asymptomatic infections with COVID-19 screened among close contacts in Nanjing, China. Sci China Life Sci. 2020 Mar 4. doi: 10.1007/s11427-020-1661-4 . [Epub ahead of print] Shi H, Han X, Jiang N, et al. Radiological findings from 81 patients with COVID-19 pneumonia in Wuhan, China: a descriptive study. Lancet Infect Dis. 2020 Apr;20(4):425-434. doi: 10.1016/S1473-3099(20)30086-4 . Epub 2020 Feb 24. Zhao W, Zhong Z, Xie X. et al. Relation Between Chest CT Findings and Clinical Conditions of Coronavirus Disease (COVID-19) Pneumonia: A Multicenter Study. AJR Am J Roentgenol. 2020 Mar 3:1-6. doi: 10.2214/AJR.20.22976 . [Epub ahead of print] Poyiadji N, Shahin G, Noujaim D, et al. COVID-19–associated Acute Hemorrhagic Necrotizing Encephalopathy: CT and MRI Features. Published Online: Mar 31 2020 https://doi.org/10.1148/radiol.2020201187 Mossa-Basha M, Meltzer CC , Kim DC, et al. Radiology Department Preparedness for COVID-19: Radiology Scientific Expert Panel. Published Online: Mar 16 2020 https://doi.org/10.1148/radiol.2020200988 RSNA COVID-19 Resources. Radiological Society of North America. Published online. Accessed April 5, 2020. https://www.rsna.org/covid-19 Wang D, Hu B, Hu C, et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. JAMA. 2020 Feb 7. doi: 10.1001/jama.2020.1585 . [Epub ahead of print] Up to Date online. Coronavirus disease 2019 (COVID-19). https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19 Giacomelli A, Pezzati L, Conti F, et al. Self-reported olfactory and taste disorders in SARS-CoV-2 patients: a cross-sectional study. Clin Infect Dis. 2020 Mar 26. pii: ciaa330. doi: 10.1093/cid/ciaa330 . [Epub ahead of print] Fogarty H, Townsend L, Ni Cheallaigh C, et al. COVID-19 Coagulopathy in Caucasian patients. British Journal of Haematology, 2020; First published online:24 April 2020 DOI: https://doi.org/10.1111/bjh.16749 Coronavirus (COVID-19) Update: FDA Issues Emergency Use Authorization for Potential COVID-19 Treatment. Online FDA news release. Accessed May 2, 2020. https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-issues-emergency-use-authorization-potential-covid-19-treatment 21 Percent Of NYC Residents Tested In State Study Have Antibodies From COVID-19. Date of publication April 23, 2020. https://gothamist.com/news/new-york-antibody-test-results-coronavirus​ Kwok KO, Lai F, Wei WI, et al. Herd immunity – estimating the level required to halt the COVID-19 epidemics in affected countries. J Infect. 2020 Mar 21.[Epub ahead of print] doi: 10.1016/j.jinf.2020.03.027 CDC. Coronavirus Disease 2019 (COVID-19) – COVID-19 Pandemic Planning Scenarios. https://www.cdc.gov/coronavirus/2019-ncov/hcp/planning-scenarios.html#definitions Gianluca Firullo is a Radiologist at Ospedale Castelli di Verbania (Maggiore Lake), Azienda Sanitaria Locale Verbano-Cusio-Ossola Italy. He graduated from the ancient Alma Ticinensis Univesitas of Pavia , after experiences in Northern Italy Public Hospitals of Pavia and Cuneo with responsibility roles of CT body and MSK MRI. Dr. Firullo currently carries out his radiology practice at Ospedale Castelli of Verbania (Maggiore Lake) with body MRI responsibility role. He is author and coauthor of scientific works on MRI, mammography, lung screening X-ray tomo. He has also lectured at several congresses and conferences, and is a past docent at the degree course for radiologist technicians. 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 @nealshah95 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 Fabio Di Stefano was proudly born in Sicily in 1964. A specialist in geriatrics, he has been the Director of Internal Medicine Department of Ospedale Castelli of Verbania since 2017. He has authored many publications on geriatrics,with a special interest in Alzheimer’s disease and osteoporosis management. Currently he is strongly committed in the struggle with SARS-CoV-2 since his department was changed into a sub-intensive COVID-19 unit. Dr. Gabriella Traballi is in the Department of Internal Medicine at Ospedale Castelli di Verbania (Maggiore Lake), Azienda Sanitaria Locale Verbano-Cusio-Ossola Italy.

21 yo F Cough. Nodule on CXR. Had a CT chest to evaluate the nodule. • Xray of the Week Figure 1. What is the diagnosis? Figure 2. CT scan of the chest demonstrating multiple peripheral regions of ground glass opacification. Discussion: This case demonstrates pneumonia in a patient diagnosed with COVID-19. In this case, CXR shows a nodule while the chest CT shows extensive disease that is not seen on CXR. CXR is less sensitive than CT in detecting COVID-19 lung disease (1). It is important to note that RT-PCR, not chest CT, is the gold standard in diagnosis of COVID-19. ACR guidelines state that CT should not be used to screen for COVID-19 and should not be the first-line test for diagnosis of COVID-19 (2). ACR guidelines also state that CT should be used “sparingly and reserved for hospitalized, asymptomatic patients with specific clinical indications for CT.” (2). COVID-19, like other viral pneumonias, causes lung opacities in more than one lobe bilaterally (1,3). These opacities typically occur in the peripheral lung, which can be seen on CXR (1). CXR can show diffuse lung opacities similar to those seen in inflammatory conditions such as acute respiratory distress syndrome (1). Common lung findings on CT include ground glass opacities (GGO) with or without consolidation, which can be accompanied by interstitial or interlobular septal thickening (1,4). GGO may also have thickened interlobular septa and intralobular lines appearing as a “crazy paving” pattern (5,6). GGO is not typically perceived on chest radiography so CT is especially important (3). Consolidation due to cellular fibromyxoid exudates in alveoli may occur after 2 weeks and is used to estimate disease progression (6). Appearance on imaging varies based on stage and severity. Asymptomatic patients with COVID-19 pneumonia show lesions on CT in the peripheral and subpleural areas of the lung, involving one or two lung lobes (4,5). In critical cases, bronchiectasis and bronchial wall thickening are also common with proliferation of fibrous tissue (6). Less common findings have also been reported in the literature, including pleural effusions, lung cavitation, pneumothorax, nodules, diffuse chest wall subcutaneous emphysema, pneumomediastinum, and diffuse alveolar damage (1). In this case, a solitary nodule was observed on CXR (Figure 2). Nodules are defined as round or irregular opacities measuring less than 3 cm in diameter with well or poorly defined edges (6). They are common in viral pneumonia and 3-13% of COVID-19 patients may have multifocal solid irregular nodules or nodules with visible halo sign (6). Some patients with COVID-19 have only presented with a single small sub-centimeter ground glass nodule with peripheral halo on baseline CT images which could be misdiagnosed (7,8). Multiple drugs have been investigated as possible treatments. Dexamethasone has been suggested to improve outcomes in patients who are dependent on ventilation, but there is only limited evidence supporting its role in reducing mortality rates (8,9). Remdesevir has been found to shorten recovery time for patients on supplemental oxygen therapy from 15 days in the placebo group to 11 days in the Remdesivir group (10). Although mortality was lower in the Remdesivir group (7.1%) than in the placebo group (11.9%), the difference was not statistically significant (10). An investigational vaccine known as mRNA-1273 has been effective in protecting mice from infection with SARS-CoV-2, and it is now in Phase 3 trials (11). There are several similar vaccine candidates currently in Phase 1-3 trials; however, it is uncertain how long it will take for a vaccine to be FDA approved (12). ​​​​ References: Jacobi A, Chung M, Bernheim A, Eber C. Portable chest X-ray in coronavirus disease-19 (COVID-19): A pictorial review. Clin Imaging. 2020; 64:35-42. doi: 10.1016/j.clinimag.2020.04.001 acr.org. 2020. ACR Recommendations For The Use Of Chest Radiography And Computed Tomography (CT) For Suspected COVID-19 Infection. [online] Available at: https://www.acr.org/Advocacy-and-Economics/ACR-Position-Statements/Recommendations-for-Chest-Radiography-and-CT-for-Suspected-COVID19-Infection [Accessed 10 August 2020]. Hu L, Wang C. Radiological role in the detection, diagnosis and monitoring for the coronavirus disease 2019 (COVID-19). Eur Rev Med Pharmacol Sci. 2020;24(8):4523-4528. doi: 10.26355/eurrev_202004_21035 Meng H, Xiong R, He R, et al. CT imaging and clinical course of asymptomatic cases with COVID-19 pneumonia at admission in Wuhan, China. J Infect. 2020;81(1):e33-e39. doi: 10.1016/j.jinf.2020.04.004 Verdecchia, Paolo, et al. The Pivotal Link between ACE2 Deficiency and SARS-CoV-2 Infection. European Journal of Internal Medicine, vol. 76, June 2020, pp. 14–20. PubMed Central, doi: 10.1016/j.ejim.2020.04.037 Ye, Zheng, et al. Chest CT Manifestations of New Coronavirus Disease 2019 (COVID-19): A Pictorial Review. European Radiology, Mar. 2020, pp. 1–9. PubMed Central, doi: 10.1007/s00330-020-06801-0 Rasekhi, Alireza, et al. COVID-19 Pneumonia Presenting as a Single Pulmonary Nodule in a Kidney Transplant Recipient: A Case Report and Literature Review. Radiology Case Reports, vol. 15, no. 9, July 2020, pp. 1587–90. PubMed Central, doi: 10.1016/j.radcr.2020.06.054 Xia, Tianyi, et al. Small Solitary Ground-Glass Nodule on CT as an Initial Manifestation of Coronavirus Disease 2019 (COVID-19) Pneumonia. Korean Journal of Radiology, vol. 21, no. 5, May 2020, pp. 545–49. PubMed Central, doi: 10.3348/kjr.2020.0240 Yang, J. W., et al. Corticosteroid Administration for Viral Pneumonia: COVID-19 and Beyond. Clinical Microbiology and Infection: The Official Publication of the European Society of Clinical Microbiology and Infectious Diseases, June 2020. PubMed, doi: 10.1016/j.cmi.2020.06.020 Beigel, John H., et al. Remdesivir for the Treatment of Covid-19 — Preliminary Report. New England Journal of Medicine, vol. 0, no. 0, May 2020, p. null. Taylor and Francis+NEJM, doi: 10.1056/NEJMoa2007764 Corbett, K.S., Edwards, D.K., Leist, S.R. et al. SARS-CoV-2 mRNA vaccine design enabled by prototype pathogen preparedness. Nature (2020). doi: 10.1038/s41586-020-2622-0 NIH-Moderna Investigational COVID-19 Vaccine Shows Promise in Mouse Studies. National Institutes of Health (NIH), 5 Aug. 2020. https://www.nih.gov/news-events/news-releases/nih-moderna-investigational-covid-19-vaccine-shows-promise-mouse-studies 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 All posts by Amara Ahmed 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

Abdominal pain with incidental lung abnormality on CT • Xray of the Week No SOB, cough or fever. Figure 1. CT abdomen and pelvis showing peripherally distributed bibasilar ground-glass opacities (red and blue arrows) Discussion: On January 7, 2020, a novel coronavirus was isolated and named as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by the International Committee on Taxonomy of Viruses (ICTV) in the wake of an outbreak of pneumonia of unknown cause in Wuhan city, China[1, 2]. This pneumonia was called Coronavirus Disease 2019 (COVID-19) by the World Health Organization on February 11, 2020. Globally, more than 20 million confirmed cases of COVID-19 have been reported. An outbreak at Wuhan, identified an initial association of human with a seafood market that sold live animals. However, as the outbreak progressed, person-to-person spread through the airborne route became the main mode of transmission. SARS-CoV-2 has been detected in non-respiratory specimens, including stool, blood, ocular secretions, and semen, but the role of these sites in transmission is uncertain [3-6]. Most commonly seen in adults than in children. The incubation period for COVID-19 is up to 14 days, with most cases occurring four to five days after exposure. [7, 8]. Infectivity is high during earlier stages of illness, when viral RNA levels from upper respiratory specimens are the highest [9-12]. The duration of viral RNA shedding is variable and may increase with the severity of illness and does not indicate prolonged infectiousness [11, 13-15].Transmission of SARS-CoV-2 from individuals with infection but no symptoms (including those who later developed symptoms and thus were considered presymptomatic) has been documented [16-18]. As per CDC in United States, pneumonia is the most frequent serious manifestation of infection, characterized primarily by fever ( in 43%), cough (in 50%), dyspnea (in 29%), and bilateral infiltrates on chest imaging. Other features includes sore throat (in 20%), myalgias (in 36%), diarrhea (in 19%), headache (in 34%), nausea/vomiting (in 12 %) and smell or taste disorders, abdominal pain, and rhinorrhea (in <10 % each) [8, 19, 20]. SARS-Cov-2 has high affinity to angiotensin converting enzyme 2 (ACE2) receptors, leading to cytokine-mediated immune response and inflammation, thereby affecting organs posing ACE2 receptors i.e. brain, heart, arterial and venous endothelial cells, kidneys, liver (hepatocytes and cholangiocytes), gastrointestinal tract, and gallbladder giving atypical symptoms of COVID-19 pneumonia [3-5]. The optimal time to test for COVID-19 following exposure is uncertain as the time to detectable RNA following exposure is unknown, hence five to seven days post exposure is recommended and a negative viral test following exposure, still necessitates quarantine. Nucleic acid amplification testing (NAAT), most commonly with a reverse-transcription polymerase chain reaction (RT-PCR) assay, to detect SARS-CoV-2 RNA from the upper respiratory tract is the preferred initial diagnostic test for COVID-19 [21]. Table 1: Diagnostic tests for COVID-19 [36]. COVID-19: coronavirus disease 2019; RT-PCR: real-time polymerase chain reaction; IgG: immunoglobulin G; CDC: United States Centers for Disease Control and Prevention.* single positive test generally confirms the diagnosis. If initial testing is negative and clinical suspicion remains, performing a second test can enhance diagnostic yield. In the United States, the CDC recommends collection of one of the upper respiratory specimens: nasopharyngeal/ nasal swab specimen from both anterior nares, nasal or nasopharyngeal wash/aspirate, oropharyngeal swab (has lower sensitivity) (Table 1) Multisystem involvement leads to the following laboratory findings; lymphopenia, elevated aminotransaminase levels, elevated lactate dehydrogenase levels, elevated inflammatory markers (eg, ferritin, C-reactive protein, and erythrocyte sedimentation rate), and abnormalities in coagulation tests [8, 20, 22]. Table 2: Proposed reporting language for CT findings related to COVID-19 [23]. COVID-19: coronavirus disease 2019; CT: computed tomography; GGO: ground-glass opacity; PUI: person under investigation; RT-PCR: reverse transcription polymerase chain reaction. CXR findings in COVID-19 pneumonia include consolidation and ground glass opacities, with bilateral, peripheral, and lower lung zone distributions. According to the American College of Radiology (ACR), Chest CT is more sensitive than CXR and is reserved for hospitalized patients under treatment. We present a case of 47-year-old female with atypical presentation with abdominal pain and fever but no respiratory symptoms. CT abdomen/pelvis demonstrated bibasilar, peripherally distributed crazy paving pattern (ground-glass opacifications with superimposed septal thickening), which was later diagnosed as COVID-19 pneumonia on further laboratory evaluation (Fig. 1). The Radiological Society of North America has categorized chest CT features as typical, indeterminate, or atypical for COVID-19 (Table 2) [23]. Other chest CT findings includes bronchiectasis, pleural effusion, pericardial effusion, and lymphadenopathy. Acute respiratory distress syndrome (ARDS) is a serious complication that can manifest shortly after the onset of dyspnea. [20, 24]. Other complications include thromboembolic events [25-27], acute cardiac injury [20, 28], kidney injury, and inflammatory complications [19, 29] The risk of transmission after contact with an individual with COVID-19 increases with the closeness and duration of contact and appears highest with prolonged contact in indoor settings i.e. household contacts, cruise ships [30], homeless shelters [31, 32], and detention facilities [33], in health care settings like hospitals [20] when personal protective equipment are not used, and after social or work gatherings. Hence transmission can be reduced by wearing masks (with NO exhalation valves) in public, washing hands, social or physical distancing. For patients with non-severe disease, primarily supportive care, with close monitoring for disease progression is recommended. For patients with severe disease requiring supplemental oxygen, mechanical ventilation/ECMO, low dose Dexamethasone and/or Remdesivir has had some success in early clinical trials. [34, 35] ​​​​ References: 1. Phelan, A.L., R. Katz, and L.O. Gostin, The Novel Coronavirus Originating in Wuhan, China: Challenges for Global Health Governance. JAMA, 2020. 323(8): p. 709-710 DOI: 10.1001/jama.2020.1097 2. Wu, Y., et al., SARS-CoV-2 is an appropriate name for the new coronavirus. Lancet, 2020. 395(10228): p. 949-950 DOI: 10.1016/s0140-6736(20)30557-2 3. Wang, W., et al., Detection of SARS-CoV-2 in Different Types of Clinical Specimens. Jama, 2020. 323(18): p. 1843-4 DOI: 10.1001/jama.2020.3786 4. Colavita, F., et al., SARS-CoV-2 Isolation From Ocular Secretions of a Patient With COVID-19 in Italy With Prolonged Viral RNA Detection. Ann Intern Med, 2020. 173(3): p. 242-243 DOI: 10.7326/m20-1176 5. Cheung, K.S., et al., Gastrointestinal Manifestations of SARS-CoV-2 Infection and Virus Load in Fecal Samples From a Hong Kong Cohort: Systematic Review and Meta-analysis. Gastroenterology, 2020. 159(1): p. 81-95 DOI: 10.1053/j.gastro.2020.03.065 . Retrieved from http://www.sciencedirect.com/science/article/pii/S0016508520304480 6. Li, D., et al., Clinical Characteristics and Results of Semen Tests Among Men With Coronavirus Disease 2019. JAMA Netw Open, 2020. 3(5): p. e208292 DOI: 10.1001/jamanetworkopen.2020.8292 7. Li, Q., et al., Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus-Infected Pneumonia. N Engl J Med, 2020. 382(13): p. 1199-1207 DOI: 10.1056/NEJMoa2001316 8. Guan, W.J., et al., Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med, 2020. 382(18): p. 1708-1720 DOI: 10.1056/NEJMoa2002032 9. Zou, L., et al., SARS-CoV-2 Viral Load in Upper Respiratory Specimens of Infected Patients. N Engl J Med, 2020. 382(12): p. 1177-1179 DOI: 10.1056/NEJMc2001737 10. To, K.K., et al., Temporal profiles of viral load in posterior oropharyngeal saliva samples and serum antibody responses during infection by SARS-CoV-2: an observational cohort study. Lancet Infect Dis, 2020. 20(5): p. 565-574 DOI: 10.1016/s1473-3099(20)30196-1 11. Wölfel, R., et al., Virological assessment of hospitalized patients with COVID-2019. Nature, 2020. 581(7809): p. 465-469 DOI: 10.1038/s41586-020-2196-x 12. Kujawski, S.A., et al., Clinical and virologic characteristics of the first 12 patients with coronavirus disease 2019 (COVID-19) in the United States. Nature Medicine, 2020. 26(6): p. 861-868 DOI: 10.1038/s41591-020-0877-5 13. Zheng, S., et al., Viral load dynamics and disease severity in patients infected with SARS-CoV-2 in Zhejiang province, China, January-March 2020: retrospective cohort study. BMJ, 2020. 369: p. m1443 DOI: 10.1136/bmj.m1443 . Retrieved from http://www.bmj.com/content/369/bmj.m1443.abstract 14. Liu, Y., et al., Viral dynamics in mild and severe cases of COVID-19. Lancet Infect Dis, 2020. 20(6): p. 656-657 DOI: 10.1016/s1473-3099(20)30232-2 15. Xu, K., et al., Factors Associated With Prolonged Viral RNA Shedding in Patients with Coronavirus Disease 2019 (COVID-19). Clin Infect Dis, 2020. 71(15): p. 799-806 DOI: 10.1093/cid/ciaa351 16. Rothe, C., et al., Transmission of 2019-nCoV Infection from an Asymptomatic Contact in Germany. N Engl J Med, 2020. 382(10): p. 970-971 DOI: 10.1056/NEJMc2001468 17. Bai, Y., et al., Presumed Asymptomatic Carrier Transmission of COVID-19. Jama, 2020. 323(14): p. 1406-7 DOI: 10.1001/jama.2020.2565 18. Wang, Y., et al., Characterization of an asymptomatic cohort of SARS-COV-2 infected individuals outside of Wuhan, China. Clin Infect Dis, 2020 DOI: 10.1093/cid/ciaa629 19. Huang, C., et al., Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet, 2020. 395(10223): p. 497-506 DOI: 10.1016/s0140-6736(20)30183-5 20. Wang, D., et al., Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. Jama, 2020. 323(11): p. 1061-9 DOI: 10.1001/jama.2020.1585 21. Patel, A. and D.B. Jernigan, Initial Public Health Response and Interim Clinical Guidance for the 2019 Novel Coronavirus Outbreak - United States, December 31, 2019-February 4, 2020. MMWR Morb Mortal Wkly Rep, 2020. 69(5): p. 140-146 DOI: 10.15585/mmwr.mm6905e1 22. Goyal, P., et al., Clinical Characteristics of Covid-19 in New York City. N Engl J Med, 2020. 382(24): p. 2372-2374 DOI: 10.1056/NEJMc2010419 23. Simpson, S., et al., Radiological Society of North America Expert Consensus Statement on Reporting Chest CT Findings Related to COVID-19. Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA - Secondary Publication. Journal of Thoracic Imaging, 2020. 35(4): p. 219-227 DOI: 10.1097/rti.0000000000000524 . https://journals.lww.com/thoracicimaging/Fulltext/2020/07000/Radiological_Society_of_North_America_Expert.2.aspx 24. Richardson, S., et al., Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. Jama, 2020. 323(20): p. 2052-9 DOI: 10.1001/jama.2020.6775 25. Mao, L., et al., Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China. JAMA Neurol, 2020. 77(6): p. 1-9 DOI: 10.1001/jamaneurol.2020.1127 26. Klok, F.A., et al., Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res, 2020. 191: p. 145-147 DOI: 10.1016/j.thromres.2020.04.013 27. Merkler, A.E., et al., Risk of Ischemic Stroke in Patients With Coronavirus Disease 2019 (COVID-19) vs Patients With Influenza. JAMA Neurology, 2020 DOI: 10.1001/jamaneurol.2020.2730 28. Arentz, M., et al., Characteristics and Outcomes of 21 Critically Ill Patients With COVID-19 in Washington State. JAMA, 2020. 323(16): p. 1612-1614 DOI: 10.1001/jama.2020.4326 29. Mehta, P., et al., COVID-19: consider cytokine storm syndromes and immunosuppression. Lancet, 2020. 395(10229): p. 1033-1034 DOI: 10.1016/s0140-6736(20)30628-0 30. Kakimoto, K., et al., Initial Investigation of Transmission of COVID-19 Among Crew Members During Quarantine of a Cruise Ship - Yokohama, Japan, February 2020. MMWR Morb Mortal Wkly Rep, 2020. 69(11): p. 312-313 DOI: 10.15585/mmwr.mm6911e2 31. Baggett, T.P., et al., Prevalence of SARS-CoV-2 Infection in Residents of a Large Homeless Shelter in Boston. JAMA, 2020. 323(21): p. 2191-2192 DOI: 10.1001/jama.2020.6887 32. Kuehn, B.M., Homeless Shelters Face High COVID-19 Risks. Jama, 2020. 323(22): p. 2240 DOI: 10.1001/jama.2020.8854 33. Saloner, B., et al., COVID-19 Cases and Deaths in Federal and State Prisons. JAMA, 2020. 324(6): p. 602-603 DOI: 10.1001/jama.2020.12528 . 34. Horby, P., et al., Dexamethasone in Hospitalized Patients with Covid-19 - Preliminary Report. N Engl J Med, 2020 DOI: 10.1056/NEJMoa2021436 35. Wang, M., et al., Remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro. Cell Research, 2020. 30(3): p. 269-271 DOI: 10.1038/s41422-020-0282-0 36. Weissleder, R., et al., COVID-19 diagnostics in context. Science Translational Medicine, 2020. 12(546): p. eabc1931 DOI: 10.1126/scitranslmed.abc1931 . Retrieved from https://stm.sciencemag.org/content/scitransmed/12/546/eabc1931.full.pdf Shama Jaswal is an International Medical Graduate, currently doing research at Mallinckrodt Institute of Radiology (MIR), Saint Louis. She aims at pursuing Diagnostic Radiology residency and poses a keen interest in research alongside academics. At MIR, she has been fortunate to work on various oncology projects including the project in which they studied how the difference in fat metabolism in both sexes can affect the cancer survival and outcome, and how this study can further improve prognosis through treatment modification. Shama is both an accomplished sprinter and singer having won several national competitions in in each discipline in India. She also has a strong passion for cooking and gardening. Follow Shama Jaswal on Twitter @Jaswal_Shama All posts by Shama Jaswal Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice is a radiologist with 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

41-year old female. COVID-19 positive. Left side weakness. • Xray of the Week Figure 1. CT scan and CT perfusion scan in 41 year old COVID-19 positive female with left side weakness. Figure 2. CT scan and CT perfusion scan of brain with color mapping. A. Non-contrast CT. Hyperdense M1 segment of right MCA (red arrow) indicating acute thrombus in the artery. B. Post contrast perfusion CT brain. Large area of decreased blood flow in the right MCA distribution (orange arrows). Normal perfusion of the left MCA distribution (green arrows). C,D. Cerebral blood volume (CBV) and cerebral blood flow (CBF) maps. Large area of decreased blood flow and decreased cerebral blood volume in the right MCA distribution (orange arrows) with no significant penumbra suggesting large area of core infarction without evidence of reversible ischemia. Normal perfusion of the left MCA distribution (green arrows). Figure 3. CT angiogram shows occlusion of the M1 segment of the right MCA near its origin without reconstitution of flow distally indicating acute thrombus (white arrow). There is some reconstitution of flow in distal cortical branches via leptomeningeal collaterals. Right ACA, ophthalmic artery and intracranial ICA are patent without significant narrowing. This confirms the findings on the non-contrast CT scan and the CT perfusion scan (Fig.2). Discussion: Strokes are the second leading cause of death worldwide, particularly within the middle cerebral artery (MCA) which supplies deep structures of the brain in addition to the frontal, temporal and parietal lobes (1,2). SARS-CoV-2 is a viral disease typically presenting with pulmonary complications. Recently, case studies have found COVID-19 to be linked to neurologic manifestations and an increased risk of cryptogenic large vessel ischemic stroke (4). Such arterial thrombotic complications may be due to inflammation-induced hypercoagulability, cytokine storm, and direct viral-induced endotheliitis (5,7,8). Additional studies also demonstrate abnormalities in fibrinogen, D-dimer, interleukin-6, and troponin levels (5,7). Presentations of an MCA stroke secondary to COVID-19 have included contralateral hemiparesis, contralateral hemisensory loss, aphasia, dysarthria, and reduced level of consciousness (3, 10). This is in addition to typically seen pulmonary and systemic manifestations of COVID-19 such as fever, cough, and hypoxia (11). Typical risk factors for ischemic stroke include hypertension, diabetes mellitus, cardiovascular disease, hypercholesterolemia, smoking, age, family history, and inflammatory conditions (9). Thus, patients with high risk factors may be at higher risk for mortality. However, patients with minimal or no risk factors with COVID-19 have also presented with ischemic stroke, particularly those under 50 years of age (10,11). Imaging findings of ischemic stroke in the acute setting on non-contrast CT scan may include hyperdense MCA sign as seen in this case (Fig. 2A) (6). CT may also show decreased attenuation and loss of grey/white matter differentiation due to cytotoxic cerebral edema (6). Perfusion scans are able to differentiate penumbra (potentially reversible with reperfusion therapy) from the core (non-reversible) infarct (6). Core infarct demonstrates increased mean transit time (MTT), markedly decreased CBF and markedly decreased CBV; whereas penumbra demonstrates increased MTT, moderately reduced CBF and near-normal or increased CBV (Fig. 2B-D). The increased CBV is due to autoregulatory vasodilatation. Large vessel occlusion may be identified on CT angiogram (Fig. 3) (6). On chest x-ray, associated COVID-19 findings are predominantly peripheral with patchy or diffuse ground glass and reticulonodular opacities (12). The true association between COVID-19 and increased risk of stroke is still under study, with new evidence-based guidelines underway (5,8). Typical treatment and management of an ischemic stroke include restoration of vascular supply via IV tPA, thrombectomy, or stent placement (2). With the added uncertainty and hypercoagulable state associated with COVID-19, anticoagulation and further management should be individualized on a case by case basis (5). References: Khaku AS, Tadi P. Cerebrovascular Disease (Stroke) [Updated 2020 Aug 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430927/ Nogles TE, Galuska MA. Middle Cerebral Artery Stroke. [Updated 2020 Aug 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK556132 R. Kollmar, S. Schwab, Ischaemic stroke: acute management, intensive care, and future perspectives, BJA: British Journal of Anaesthesia, Volume 99, Issue 1, July 2007, Pages 95–101, https://doi.org/10.1093/bja/aem138 Merkler AE, Parikh NS, Mir S, et al. Risk of Ischemic Stroke in Patients With Coronavirus Disease 2019 (COVID-19) vs Patients With Influenza. JAMA Neurol. Published online July 02, 2020. doi: 10.1001/jamaneurol.2020.2730 Tsivgoulis G, Katsanos AH, Ornello R, Sacco S. Ischemic Stroke Epidemiology During the COVID-19 Pandemic: Navigating Uncharted Waters With Changing Tides. Stroke. 2020;51(7):1924-1926. doi: 10.1161/STROKEAHA.120.030791 Lin MP, Liebeskind DS. Imaging of Ischemic Stroke. Continuum (Minneap Minn). 2016;22(5, Neuroimaging):1399-1423. PubMed full text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5898964/ doi: 10.1212/CON.0000000000000376 Fifi JT, Mocco J. COVID-19 related stroke in young individuals. Lancet Neurol. 2020;19(9):713-715. doi: 10.1016/S1474-4422(20)30272-6 Ntaios G, Michel P, Georgiopoulos G, et al. Characteristics and Outcomes in Patients With COVID-19 and Acute Ischemic Stroke: The Global COVID-19 Stroke Registry. Stroke. 2020;51(9):e254-e258. doi: 10.1161/STROKEAHA.120.031208 “Stroke.” National Heart Lung and Blood Institute, U.S. Department of Health and Human Services, www.nhlbi.nih.gov/health-topics/stroke Oxley TJ, Mocco J, Majidi S, et al. Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young. N Engl J Med. 2020;382(20):e60. doi: 10.1056/NEJMc2009787 Yaghi S, Ishida K, Torres J, et al. SARS-CoV-2 and Stroke in a New York Healthcare System [published correction appears in Stroke. 2020 Aug;51(8):e179]. Stroke. 2020;51(7):2002-2011. doi: 10.1161/STROKEAHA.120.030335 Cozzi D, Albanesi M, Cavigli E, et al. Chest X-ray in new Coronavirus Disease 2019 (COVID-19) infection: findings and correlation with clinical outcome. Radiol Med. 2020;125(8):730-737. doi: 10.1007/s11547-020-01232-9 Rabab Zaidi is an aspiring radiologist and fourth year medical student at the Loyola University Chicago Stritch School of Medicine (SSOM) . She currently serves as the Community Support Co-Lead for the Loyola University COVID-19 Response Team and Co-President of the Radiology Interest Group at SSOM. At the Stritch School of Medicine, she has also worked with the Department of Radiation Oncology to study prostate cancer imaging and adaptive radiotherapy techniques, where she learned about the intersection of patient care and radiology. Rabab graduated magna cum laude with a degree in Economics from Loyola University Chicago in 2016. She is further passionate about mentorship, advocacy, and photography. Follow Rabab Zaidi on Twitter @ZaidiRabab All posts by Rabab Zaidi 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

The Imaging in Dublin 2022 conference will be held in Dublin, Ireland from June 5 to June 8, 2022, at the Westin Dublin Hotel . 1. World Class Faculty : Ella Kazerooni, Elizabeth Morris, Donald Resnick, Neil Rofsky. 2. Dublin- Ranked one of the 10 top cities to visit in Europe. 3. Friendly people. Find out why Ireland is consistently ranked one of the friendliest countries in the world . We met Zack Gallagher - Ireland's Food Guide at Boxty Restaurant in Dublin. 4. Trinity College - Established in 1592, under the Tudor Monarch. Trinity is modeled after Oxford and Cambridge and home to the Book of Kells and the Old Library . Located across the street from Westin Dublin Hotel, the Imaging in Dublin 2020 conference venue. 5. Epic Museum - Winner of Europe's Leading Tourist attraction 2019 . Learn about the history of Ireland, Irish immigration, and why 70 million people worldwide claim Irish ancestry. Every Person Is Connected . 6. Guinness Storehouse - Discover through interactive exhibits the history of beer and stop by the Gravity Bar to watch the city buzzing below as you enjoy your pint of Guinness or soft drink . 7. Butlers Irish Chocolates - Founded in 1932 in Dublin by Marion Bailey-Butler, these award winning chocolates are addictive! 8. Fade Street Social - Restaurant courtesy of Irish renowned chef Dylan McGrath- in the Grafton Street district. Dublin is a renowned foodies destination. 9. Temple Bar District - The hub of the Irish Pub Culture and Celtic music in Dublin. Located along side the Liffey River. Adjacent to Westin Dublin. 10. Emerald Island- The breathtaking, rugged, beauty of the Irish countryside. This is a unique opportunity to meet radiologists from all corners of the globe in an intriguing location, and learn from some of the best specialists in their field. Indulge all your senses and join Global Radiology CME for the trip of a lifetime to Dublin, Ireland in June, 2022! We have had registrants from: Australia, Austria, Belgium, Brazil, Bulgaria, Canada, China, Denmark, France, Germany, Greece, Hong Kong, Hungary, India, Indonesia, Ireland, Israel, Lithuania, Malaysia, Netherlands, New Zealand, Norway, Philippines, Saudi Arabia, Singapore, Slovenia, South Africa, Spain, Sweden, Switzerland, Thailand, Turkey, Uruguay, United Kingdom, United States of America, and Zambia.

Register now for Imaging in Israel 2023 , then check out all the amazing things to do in Israel! We made a top ten list for some our favorite activities in the holy land. You can also register for guided tours of these historic locations and more on our website here . 1. Jerusalem, The city of Gold, has been the religious epicenter for the 3 major monotheistic religions, Christianity, Judaism, and Islam. Visit the Western Wall, Church of the Holy Sepulcher, and Dome of the Rock. 2. Float in the Dead Sea, the lowest point on Earth. Rejuvenate yourself immersing in the warm waters of the Dead Sea. Visit one of the many spas doting the shores of this natural wonder. 3. Enjoy a day at the Ramon Crater, the world's largest "erosion cirque", in the awe inspiring Negev Desert. Spend the day viewing wildlife on a jeep tour, or take a ride on a camel, imagining what life was like traveling along these trading routes 1,000 years ago. When the sun goes down, enjoy the hospitality of dinner in a Bedouin tent but don't forget to stop to do do a little stargazing before heading to bed. 4. Take a drive up to the Galilee and enjoy the afternoon in the mystical City of Safed. Walk along the ancient streets. Known as the center of Jewish Mysticism, Safed is the home to a multitude of ancient synagogues, an eclectic mix of inhabitants, a unique artist colony, and breathtaking views of the Galilee. 5. Spend a day soaking in the sun, along the beaches in the coolest city in the Mediterranean, Tel Aviv. When the sun sets over the Mediterranean, the celebrity chef restaurants open up, and visitors and locals alike party till the morning hours in the bars and clubs. 6. Travel back in time 2,000 years and imagine life on the top of Masada. Climb or take a cable car to visit this archeological wonder. If you climb, try to time it to witness the spectacular sun rising over the Dead Sea. When you reach the top, tour the ruins of the ancient castle built by Herod The Great, King of Judea between 37 BCE and 37 CE. 7. From ancient times the "Holy Land" was renowned for its grape vineyards and olive trees. Today, the abundance of world class wineries in the Galilee, Golan Heights, and Judean Hills has put Israel on the top of the list for "Wine Tourism" connoisseurs. 8. A trip to Israel and Jerusalem would not be complete without taking the time to wander through the 250 vendors in Mahane Yehuda, your senses will be awakened as you explore everything from exotic spices to unique wares. 9. Israel will celebrate its 75th Birthday in 2023! The country will be alive with unique festivities to mark this milestone! 10. Enjoy all of the above networking with radiologists from around the world at a Global Radiology CME conference featuring a line up of world renowned speakers, including Neil Rofsky, Donald Resnick, Paul Parizel, Ella Kazerooni, and many others.

Register now for Imaging in Copenhagen 2024 , and check out all the amazing things to do in Denmark! We made a top ten list of some our favorite activities in and around the Danish Capital. 1. Global Radiologists - We know your primary reason for joining us is our outstanding faculty, scientific program, and the opportunity to meet radiologists from around the globe! At the helm of our distinguished award winning faculty is our Scientific Director, Dr. Neil Rofsky , recently awarded the 2023 SABI Gold Medal. Pictured above is the ACR Gold Medalist, Dr. Donald Resnick presenting the coveted Global Radiology CME annual Resnick MSK Quiz Award to Dr. Nancy Prendergast . 2. Embrace Hygge - Denmark really is the friendliest and happiest country I have ever visited! Michelle Exarhos , Chief Concierge in charge of Responsible Business, Spirit and Culture at the Radisson Collection Royal, taught me first hand the meaning of hygge and she looks forward to welcoming all Global Radiology CME registrants to Copenhagen with the same warmth! 3. Architecture - Copenhagen was named the UNESCO WORLD CAPITAL OF ARCHITECTURE in 2023 ! It only made sense when selecting a conference venue for Imaging in Copenhagen, The Radisson Collection Royal, the first design hotel, created by renowned Danish designer and architect, Arne Jacobsen was the ideal choice! The floating staircase pictured above leads to the Imaging in Copenhagen 2024 conference room! 4. Tivoli Gardens - Across the street from the Radisson Collection Royal we found the perfect place to host the Welcome to Copenhagen 2024 dinner. The historic Groften Restaurant, serving traditional Danish delicacies has been welcoming guests since 1874 and is located in the beautiful Tivoli Gardens ! Emil Rud Nielson, pictured above, Manager of Groften Restaurant, looks forward to welcoming you this June! The dinner at Groften and entrance into Tivoli Gardens are included in your registration. 5. Nyhavn - Beautiful canals meander throughout this gorgeous city but the old port of Nyhavn lined with brightly colored 17th and early 18th century townhouses with lively restaurants, and bars is the quintessential place to meet up with colleagues and enjoy a drink or meal while watching the ships sailing in and out of the harbor. 6. Bicycles - Upon arrival to the Danish Capital we quickly realized there are more bicycles than people in Copenhagen ! There are actually 5 times as many bikes as cars on the road. You can rent a bike at the Radisson Collection Royal Hotel. Be sure to save time to experience the city like a local. 7. Vikings - I love Vikings and one of the highlights of my site visit was a visit to the Viking Ship Museum and learning to sail a replica Viking ship. Yes, that is me at the helm! You too can sign up and become part of the crew for an afternoon sail in Roskilde Fjord! 8. Castles and Shakespeare - The Danish monarchy is one of the oldest in the world and there are a plethora of castles to explore in Denmark. My favorite was Kronborg Castle , pictured above. It is a UNESCO World Heritage site, and the setting for Shakespeare's Hamlet. The Castle is located in the quaint town of Helsingor, only a 60 minute drive from Copenhagen. Global Radiology registrants will also have an opportunity to eat like Royalty at the gala dinner in the beautiful Odd Fellow Palace, included in your registration. 9. Signature Social Events - When you are outside the conference room its time to have some fun and get to know the faculty and your fellow registrants in an informal setting. Global Radiology is renowned for our unique and engaging social and networking opportunities! We have gone punting in Oxford, on a musical pub crawl in Dublin, camel riding and Israel, and look forward to many more shared experiences in Copenhagen! 10. A Gastronomic Journey - Copenhagen is currently home to 15 Michelin star restaurants , and the world famous Torvehallerne Food stalls . No wonder it is a culinary destination! Torvehallerne and many of the Michelin star restaurants are only a short walk from the conference hotel.

8 yo F with trauma. Diagnosis? • Xray of the Week Figure 1. Trauma in a 8 year old female. Diagnosis? Figure 2. Cuboid Bone Fracture. Fracture indicated by orange arrow. (A) Dorsoplantar radiograph of the foot demonstrating an isolated fracture of the cuboid with possible extension into the tarsometatarsal joint. (B) Medial oblique radiograph of the foot demonstrating an isolated fracture of the cuboid. Introduction: Fracture of the cuboid or disturbance of its articular relationships can lead to profound disruption of the movement and biomechanics of the foot [1,2]. Significant foot dysfunction can result from cuboid injury since the cuboid bone acts as a crucial supporting structure within the lateral column of the midfoot, and the articulation between the cuboid and the fourth and fifth metatarsals makes the largest contribution to dorsiflexion and plantar flexion of the midfoot [1]. Epidemiology: Cuboid fractures are uncommon, occurring in 5% of all tarsal fractures [3]. The most common pattern of cuboid injury involves avulsion types. These occur with inversion of the hindfoot and adduction of the forefoot combined with external rotation of the tibia resulting in avulsion of the calcaneocuboid portion of the bifurcate ligament [1,3]. Diagnosis: The diagnosis of a cuboid fracture can be established when there is a high index of suspicion secondary to significant swelling of the midfoot region and a positive history of direct or indirect trauma to the foot accompanied by local tenderness [3]. Radiographic evidence can support the diagnosis. A standard three view foot series (lateral, dorsoplantar, and medial oblique) should be obtained to evaluate a midfoot fracture. A fracture of the cuboid is best appreciated on the medial oblique view because as the foot is rolled medially, the cuboid comes into full, unobstructed view, which allows visualization of the joints in question, swelling of the surrounding soft tissues, or avulsion [2]. More sophisticated imaging, such as computed tomography or magnetic resonance imaging, should be obtained if plain film is unrevealing but there is high suspicion of fracture. Figure 3. Diagram showing the types of fracture of the cuboid [1]. Cuboid Fracture Classification: In 2016, Fenton et al. proposed a classification system for fractures of the cuboid based on the fracture pattern and the mechanism of injury (Fig. 3) [1]. The treatment of these fractures was also described. Table 1. Summary of the types of fracture of the cuboid, the frequency, mechanism of injury, treatment and outcomes from the literature [1]. Treatment: A cuboid fracture with comminution, significant ligamentous injuries, or greater than 2mm of step-off at any articular surface should be recommended for surgery [1,4]. An isolated cuboid fracture without these concerning features can be treated nonoperatively. Simple body fractures and nondisplaced avulsion fractures are treated with a below-the-knee weightbearing cast for 6 to 8 weeks or until there are radiographic signs of a bony union [2]. Complications: Cuboid fractures are frequently associated with other fractures, dislocations, or ligamentous injuries, and missed or mismanaged cuboid fractures can lead to significant complications [2,3,5]. Malunion, degenerative joint disease, persistent subluxation, and prolonged pain are complications of mismanaged cuboid fractures [2]. Degenerative arthritis and disruption of the midfoot biomechanics can result from untreated cuboid fracture [3]. References: Fenton P, Al-Nammari S, Blundell C, Davies M. The patterns of injury and management of cuboid fractures: a retrospective case series. Bone Joint J . 2016;98-B(7):1003-1008. DOI: 10.1302/0301-620X.98B7.36639 Miller SR, Handzel C. Isolated cuboid fracture. A rare occurrence. J Am Podiatr Med Assoc . 2001;91(2):85-88. DOI: 10.7547/87507315-91-2-85 Grivas TB, Vasiliadis ED, Koufopoulos G, Polyzois VD, Polyzois DG. Midfoot fractures. Clin Podiatr Med Surg . 2006;23(2):323-vi. DOI: 10.1016/j.cpm.2006.01.001 Pinney SJ, Sangeorzan BJ. Fractures of the tarsal bones. Orthop Clin North Am . 2001;32(1):21-33. DOI: 10.1016/s0030-5898(05)70191-7 Khatri Chhetri KM, Acharya P, Rokaya Chhetri DR. Combined fracture dislocation of the navicular bone along with cuboid, cuneiform and longitudinal split fracture of the lateral malleolus: a rare combination of fractures. Chin J Traumatol . 2014;17(6):358-360. PMID: 25471434. https://pubmed.ncbi.nlm.nih.gov/25471434/ Corey Brown is a medical student at Meharry Medical College in Nashville, TN. He is vice-president of his school’s radiology interest group and a member of Rad Boot Camp. Prior to medical school, he attended Queens University of Charlotte and the University of Toronto . He graduated with degrees in biochemistry and biomedical engineering. As a graduate student, Corey volunteered at Milestone Christian Ministries and worked with Maple Leaf Sports and Entertainment as a Soccer Senior Sport Lead Coach. He enjoys barbering and watching sports in his free time. UPDATE Oct. 2025: Dr. Brown is a third year Radiology Resident at Brigham and Women's Hospital / Harvard Medical School. Follow Corey Brown on Twitter @coreybrwn Corey Brown on LinkedIn: https://www.linkedin.com/in/corey-brown-md-meng-514536a8/ All posts by Corey Brown 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

25-Year-Old Female with Abdominal Pain and Weight Loss. Diagnosis? • Xray of the Week Figure 1. 25-Year-Old Female with Abdominal Pain and Weight Loss. Diagnosis? Figure 2. CTA through the thoracic and abdominal aorta. A. Axial image through descending thoracic aorta demonstrates concentric mural thickening and mild stenosis (yellow arrow). B. Axial image through infra-renal abdominal aorta demonstrates mild concentric mural thickening and severe stenosis (red arrow). C. CTA 3D Image demonstrates severe stenosis of the infra-renal abdominal aorta and very severe stenosis of the origin of the common iliac arteries (green arrow). Takayasu Arteritis Epidemiology Takayasu arteritis is named after Mikito Takayasu, a Japanese ophthalmologist who first presented the case of a young patient with a peculiar "wreathlike" pattern of arteriovenous anastomosis in the retina at the 1908 Japanese Ophthalmology Society Meeting. also known as pulseless disease, Takayasu arteritis (TAK) is a rare large-vessel vasculitis, with global prevalence ranging between 3.2 and 40 cases per million and an annual incidence of 0.4–2.6 per million, varying by geography. [1] It predominantly affects young women, with a female-to-male ratio of approximately 8–9:1. [1] Clinical Findings Patients commonly present with constitutional symptoms, such as weight loss, fever, and malaise, evolving insidiously. Over time, vascular symptoms emerge: abdominal pain may reflect mesenteric ischemia due to abdominal aortic or branch stenosis. Physical exam may reveal diminished peripheral pulses, discrepant blood pressures between arms, bruits over major arteries, and elevated inflammatory markers (ESR, CRP). [2] Pathology TAK is characterized histologically by granulomatous inflammation of the adventitia and media, with giant cells, lymphocytic infiltration, and intimal hyperplasia. Progressive fibrosis leads to concentric wall thickening and subsequent stenosis, occlusion, or aneurysmal change. [2,5] Classification The widely adopted Hata/Numano angiographic classification divides TAK into five types based on arterial involvement: Type I:  Branches of the aortic arch Type IIa:  Ascending aorta, arch, branches Type IIb:  Type IIa + thoracic descending aorta Type III:  Thoracic descending and abdominal aorta Type IV:  Abdominal aorta and/or renal arteries Type V:   Entire aorta and its branches. This classification correlates with clinical presentation and guides treatment strategy. [3] Radiographic Features CT Angiography (CTA):CTA is the modality of choice for mapping vascular anatomy, delineating stenosis severity, occlusion, aneurysms, and collateral pathways. In active disease, CTA reveals long-segment concentric mural thickening with homogeneous enhancement. Chronic stages demonstrate fixed luminal narrowing, post-inflammatory calcifications, and aneurysmal changes. [5,6,9] Characteristic CTA Signs: Double-ring sign: Inner low-attenuation ring within an enhancing vessel wall, correlating with mural edema and inflammation. [7,8] Diffuse narrowing: Seen in both thoracic and abdominal aorta with ostial stenoses of branch vessels, particularly renal and mesenteric arteries. Collateral development: Seen in chronic disease, providing indirect evidence of long-standing vascular compromise. MRI and PET/CT: MRI detects mural edema and enhancement on vessel wall imaging, and FDG-PET/CT demonstrates increased metabolic activity in inflamed vessels. These modalities are superior to CTA for monitoring disease activity and guiding immunosuppressive therapy, as emphasized in EULAR guidelines. [4,10] Treatment and Prognosis High-dose corticosteroids remain first-line therapy, often combined early with steroid-sparing immunosuppressants. Tocilizumab and other biologics have demonstrated efficacy in refractory disease. [11,12] Surgical or endovascular revascularization is reserved for severe, flow-limiting lesions and ideally performed when inflammation is controlled. Relapses are common, and long-term follow-up with multimodality imaging is essential to monitor disease progression and therapeutic response. [12] ​​​​ References Rutter M, Bowley J, Lanyon PC, Grainge MJ, Pearce FA. A systematic review and meta-analysis of the incidence rate of Takayasu arteritis. Rheumatology (Oxford).  2021;60(11):4982-4990. doi: https://doi.org/10.1093/rheumatology/keab406 . Kerr GS, Hallahan CW, Giordano J, et al. Takayasu arteritis. Ann Intern Med.  1994;120(11):919-929. doi: https://doi.org/10.7326/0003-4819-120-11-199406010-00004 . Hata A, Noda M, Moriwaki R, Numano F. Angiographic findings of Takayasu arteritis: new classification. Int J Cardiol.  1996;54 Suppl:S155-S163. doi: https://doi.org/10.1016/S0167-5273(96)02813-6 . Dejaco C, Ramiro S, Duftner C, et al. EULAR recommendations for the use of imaging in large vessel vasculitis in clinical practice. Ann Rheum Dis.  2018;77(5):636-643. doi: https://doi.org/10.1136/annrheumdis-2017-212649 . Matsunaga N, Hayashi K, Sakamoto I, Ogawa Y, Matsumoto T. Takayasu arteritis: protean radiologic manifestations and diagnosis. Radiographics.  1997;17(3):579-594. doi: https://doi.org/10.1148/radiographics.17.3.9153698 . Yamada I, Nakagawa T, Himeno Y, Numano F, Shibuya H. Takayasu arteritis: evaluation of the thoracic aorta with CT angiography. Radiology.  1998;209(1):103-109. doi: https://doi.org/10.1148/radiology.209.1.9769819 . Park JH, Chung JW, Im JG, Kim SK, Park YB, Han MC. Takayasu arteritis: evaluation of mural changes in the aorta and pulmonary artery with CT angiography. Radiology.  1995;196(1):89-93. doi: https://doi.org/10.1148/radiology.196.1.7784596 . Kim SY, Park JH, Chung JW, et al. Follow-up CT evaluation of the mural changes in active Takayasu arteritis. Korean J Radiol.  2007;8(4):286-294. doi: https://doi.org/10.3348/kjr.2007.8.4.286 . Zhu FP, Luo S, Wang ZJ, Jin ZY, Zhang LJ, Lu GM. Takayasu arteritis: imaging spectrum at multidetector CT angiography. Br J Radiol.  2013;85(1020):e1282-e1292. doi: https://doi.org/10.1259/bjr/25536451 . Bois JP, Anand V, Anavekar NS. Detection of inflammatory aortopathies using multimodality imaging. Circ Cardiovasc Imaging.  2019;12(7):e008471. doi: https://doi.org/10.1161/CIRCIMAGING.118.008471 . Nakaoka Y, Isobe M, Takei S, et al. Efficacy and safety of tocilizumab in patients with refractory Takayasu arteritis: results from a randomized, double-blind, placebo-controlled, phase 3 trial in Japan (the TAKT study). Ann Rheum Dis.  2018;77(3):348-354. doi: https://doi.org/10.1136/annrheumdis-2017-211878 . Hellmich B, Agueda A, Monti S, et al. 2018 update of the EULAR recommendations for the management of large-vessel vasculitis. Ann Rheum Dis.  2020;79(1):19-30. doi: https://doi.org/10.1136/annrheumdis-2019-215672 . 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