Incidental Radiological Finding Research Articles

Developmental disorders of the gastrointestinal tract

Developmental disorders of the gastrointestinal tract comprise abroad spectrum of congenital malformations of different etiologies and locations from the mouth to the anus. The authors present the most important malformations of the gastrointestinal tract on the basis of basic and current reviews. Gastrointestinal developmental disorders occur both sporadically and in connection with malformation syndromes. Symptoms are highly variable and range from postnatal emergencies to asymptomatic abnormalities, which may be incidental radiological findings. Prenatal ultrasound examinations can often identify gastrointestinal developmental disorders at an early stage. Here, fetal magnetic resonance imaging can be auseful addition to the diagnostic process. In the first few days of life, simple X‑ray overview images, supplemented by images after the administration of contrast medium, are often sufficient. Many patients with amalformation of the gastrointestinal tract require lifelong medical care, so that not only pediatric radiologists need specific knowledge about this group of diseases.

Diagnostic challenges and therapeutic implications of Hyperostosis Frontalis Interna (HFI) in a post-menopausal woman - A case report

This case report highlights the importance of recognizing Hyperostosis Frontalis Interna (HFI) in patients with a diverse clinical presentation, particularly in post-menopausal individuals with relevant risk factors. It emphasizes the need for maintaining a high index of suspicion in neurological settings. Timely identification and treatment of HFI can significantly improve patient outcomes and alleviate debilitating symptoms and comorbidities. HFI, often an under-diagnosed condition and an incidental radiological finding, calls for ongoing research and vigilance in clinical practice.

Hepatopulmonary syndrome: an incidental radiological finding in a child with signs of portal hypertension

Hepatopulmonary syndrome: an incidental radiological finding in a child with signs of portal hypertension

Sub-Septate Uterus: An Incidental Radiological Finding in a Woman with History of Recurrent Miscarriage. A Case Report

Background: The septate uterus, which is the most common Mullerian duct anomaly, results from the abnormal fusion of the Mullerian duct during embryonic life, and it is usually associated with poor obstetric outcomes such as recurrent spontaneous abortions, subfertility, preterm labour, and reproductive failure. A large proportion of the patients that are affected remain asymptomatic owing to lack of indication for abdominal ultrasound before conception, and the problems are mainly detected after several pregnancy losses. The exact aetiology of the septate uterus is unknown but is caused by incomplete resorption of the uterovaginal septum after fusion of the Mullerian duct during embryogenesis. Case Presentation: We present a 32-year-old Para 0+3 woman referred to the radiology department for ultrasonography and hysterosalpingography (HSG) on account of recurrent miscarriage, which occurs within the first trimester of gestation. She has had three (3) consecutive miscarriages within the last 4 years, of pregnancies which were achieved spontaneously and were lost between the gestational ages of 9-12 weeks. She was investigated with ultrasonography, which demonstrated a bulky uterine appearance with two endometrial cavities that is connected to one cervical canal. Hysterosalpingography (HSG) showed a contrast-filled partly divided uterus with inter-cornual angles of 34º and intercornual distance of 1.92cm. The patient had hysteroscopic septum resection with a satisfactory outcome given addressing other medical problems that could militate against conception and has been on monthly follow-up. Conclusion: Radiological investigation of patients with recurrent miscarriages is indispensable for optimal evaluation to achieve accurate diagnosis and identify women whose problems are amenable to specialized treatments.

The hidden epidemic: Uncovering incidental fatty liver disease and its metabolic comorbidities by datamining in a hospital data lake – A real-world cohort study

AimsTo identify individuals with incidental fatty liver disease (FLD), and to evaluate its prevalence, metabolic co-morbidities and impact on follow-up. MethodsWe leveraged the data-lake of Helsinki Uusimaa Hospital district (Finland) with a population of 1.7 million (specialist and primary care). A phrase recognition script on abdominal imaging reports (2008–2020) identified/excluded FLD or cirrhosis; we extracted ICD-codes, laboratory and BMI data. ResultsExcluding those with other liver diseases, the prevalence of FLD was 29% (steatosis yes/no, N=61,271/155,521; cirrhosis, N=3502). The false positive and negative rates were 5–6%. Only 1.6% of the FLD cases had the ICD code recorded and 32% had undergone full clinical evaluation for associated co-morbidities. Of the 35–65-year-old individuals with FLD, 20% had diabetes, 42% prediabetes and 28% a high liver fibrosis index. FLD was independently predicted by diabetes (OR 1.56, CI 1.46–1.66, p = 2.3 * 10^-41), BMI (1.46, 1.42–1.50, p = 1.7 * 10^-154) and plasma triglyceride level (1.5, 1.43–1.57, p = 3.5 * 10^-68). Alanine aminotransferase level mildly increased (1.12, 1.08–1.16, p = 2.2 * 10^-9) and high age decreased the risk (0.92, 0.89–0.94, p = 4.65*10^-09). Half of the cases had normal ALT. ConclusionsThe incidental radiological finding of FLD is reliable and associated with metabolic risks but largely ignored, although it should lead to metabolic and hepatic follow-up.

Impact of Early Direct Patient Notification on Follow-Up Completion for Nonurgent Actionable Incidental Radiologic Findings

PurposeThe aim of this study was to evaluate whether early direct patient notification in addition to an existing multistage recommendation-tracking system (Backstop) increases follow-up completion rates for actionable incidental findings (AIFs). Patient attitudes toward early notification were also assessed. MethodsThis prospective, randomized controlled trial recruited patients with AIFs requiring follow-up being enrolled into the Backstop system. Patients were randomized into four groups: those receiving additional early direct notification in a mailed letter (group 1, similar to Pennsylvania Act 112), by phone (group 2), or in an electronic portal message (group 3) and a control group (group 4) without additional notifications added to the existing Backstop system. Differences in follow-up completion rates among these groups were determined using χ2 tests. Patients were surveyed on binary yes/no and Likert-type scale questions, and descriptive statistics are reported. ResultsData from 2,548 randomized patients were analyzed for the study, including 593 patients notified by letter, 637 notified by phone, 701 notified by portal, and 617 control patients. Group 3 demonstrated the lowest rate of follow-up completion within 1 month of the follow-up due date at 36.4%, compared with 58.7% for group 1, 60.4% for group 2, and 53.2% for group 4 (P < .0001 for all). Group 2 was the only group to have a significantly higher completion rate than group 4 (P = .014). Patients responded positively regarding early notification and preferred electronic portal communication. ConclusionsEarly direct notification had a mixed impact on follow-up completion rates on the basis of communication modality but was positively received by patients and may have health care benefits when implemented within a recommendation-tracking system.

The hidden star: mastoiditis as a late sequela of retained foreign body in the nose

BackgroundAcute mastoiditis is an intratemporal complication due to acute otitis media (AOM). Common risk factors include young age (often < 24 months), high values of C-reactive protein and previous antibiotic therapy, previous middle ear infection, or history of ear surgery. The main factor of acute mastoiditis is obstruction of the aditus antrum by granulation tissue or mucosa edema, inhibiting purulent drainage from the mastoid. Retained foreign body in the nose is a rare indirect cause of acute mastoiditis. It may be due to mucosal inflammation and accumulation of secretion causing nasal tract or nasopharyngeal infection leading to otitis media and later manifesting as an intratemporal complication.Case presentationWe report a case of acute mastoiditis as a late sequela of retained foreign body in the nose, and we also emphasize the incidental radiological finding of a star-shaped foreign body in the nose, which was a miss during the initial presentation. Further questioning revealed a history of recurrent unilateral blood-stained, foul-smelling nasal discharge, which was left untreated for years, leading to a delayed presentation of acute mastoiditis. After removing the foreign body and broad-spectrum antibiotic administration, complete disease resolution was achieved.ConclusionAlthough rare, retained foreign bodies of the nose must be ruled out in certain cases of mastoiditis. A thorough history with a high index of clinical suspicion is recommended for early diagnosis to prevent complications.

Incidental radiological findings during clinical tuberculosis screening in Lesotho and South Africa: a case series

BackgroundChest X-ray offers high sensitivity and acceptable specificity as a tuberculosis screening tool, but in areas with a high burden of tuberculosis, there is often a lack of radiological expertise to interpret chest X-ray. Computer-aided detection systems based on artificial intelligence are therefore increasingly used to screen for tuberculosis-related abnormalities on digital chest radiographies. The CAD4TB software has previously been shown to demonstrate high sensitivity for chest X-ray tuberculosis-related abnormalities, but it is not yet calibrated for the detection of non-tuberculosis abnormalities. When screening for tuberculosis, users of computer-aided detection need to be aware that other chest pathologies are likely to be as prevalent as, or more prevalent than, active tuberculosis. However, non­-tuberculosis chest X-ray abnormalities detected during chest X-ray screening for tuberculosis remain poorly characterized in the sub-Saharan African setting, with only minimal literature.Case presentationIn this case series, we report on four cases with non-tuberculosis abnormalities detected on CXR in TB TRIAGE + ACCURACY (ClinicalTrials.gov Identifier: NCT04666311), a study in adult presumptive tuberculosis cases at health facilities in Lesotho and South Africa to determine the diagnostic accuracy of two potential tuberculosis triage tests: computer-aided detection (CAD4TB v7, Delft, the Netherlands) and C-reactive protein (Alere Afinion, USA). The four Black African participants presented with the following chest X-ray abnormalities: a 59-year-old woman with pulmonary arteriovenous malformation, a 28-year-old man with pneumothorax, a 20-year-old man with massive bronchiectasis, and a 47-year-old woman with aspergilloma.ConclusionsSolely using chest X-ray computer-aided detection systems based on artificial intelligence as a tuberculosis screening strategy in sub-Saharan Africa comes with benefits, but also risks. Due to the limitation of CAD4TB for non-tuberculosis-abnormality identification, the computer-aided detection software may miss significant chest X-ray abnormalities that require treatment, as exemplified in our four cases. Increased data collection, characterization of non-tuberculosis anomalies and research on the implications of these diseases for individuals and health systems in sub-Saharan Africa is needed to help improve existing artificial intelligence software programs and their use in countries with high tuberculosis burden.

Non‐ossifying fibroma of the mandible: A case report and review of the literature

AbstractThe case reported here is a large non‐ossifying fibroma (NOF) of the mandible presenting in a 24‐year‐old male patient. The lesion was diagnosed through radiological and histopathological assessment. It remains under observation without surgical intervention, despite its large size, as the extensive surgery to remove it is not currently justifiable. Whilst common at the metaphysis of the long bones in paediatric patients, NOFs are rarely observed in the jaw bones. These benign fibrous lesions are often asymptomatic and may be an incidental radiological finding. Most NOFs of the limbs presenting in children will not require any treatment, and spontaneously resolve when growth ceases. However, regarding mandibular lesions, the majority of historical cases have been successfully treated with curettage and do not recur. Due to their scarcity, the outcomes for untreated NOFs of the gnathic bones are not reliably known. We discuss the clinical, radiological and histopathological findings for this case. A thorough literature review of previous reports of this rare entity reveals the typical characteristics and behaviour of this lesion.

Sacral Tarlov cysts: Neurophysiology abnormalities and correlation with pelvic sensory and visceral symptoms.

Recent studies suggest a possible association between Tarlov cysts (TCs), usually considered as incidental radiological findings, and neurological symptoms such as pain, numbness and urogenital complaints. The aim was to explore the relationship between TCs and sacral nerve root functions using pelvic neurophysiology tests, and to correlate changes with clinical symptoms and magnetic resonance imaging (MRI) findings. Consecutive patients with sacral TCs, referred for pelvic neurophysiology testing and presenting with at least one symptom related to the pelvic area, participated in a cross-sectional review of symptoms using validated questionnaires. Findings of pelvic neurophysiology (pudendal sensory evoked potentials, sacral dermatomal sensory evoked potentials, external anal sphincter electromyography) and urodynamics testing were collected retrospectively. The relationship between neurophysiology, MRI findings and patients' symptoms was assessed using Fisher and ANOVA tests. Sixty-five females were included (mean age 51.2 ± 12.1 years). The commonest symptom was pain (92%). Urinary (91%), bowel (71%) and sexual (80%) symptoms were also frequently reported. Thirty-seven patients (57%) had abnormal neurophysiology findings reflecting sacral root dysfunction. No association was seen between MRI findings (size, location of the cysts, severity of compression) and neurophysiology. A negative association was observed between neurophysiology abnormalities and occurrence of urgency urinary incontinence (p = 0.03), detrusor overactivity (p < 0.01) and stress urinary incontinence (p = 0.04); however, there was no association with voiding difficulties. Contrary to current understanding, TCs are associated with injury to the sacral somatic innervation in the majority of patients with presumed symptomatic cysts. However, urinary incontinence is unlikely to be related to TC-induced nerve damage.

Paget’s Disease of the Bone in a Patient with Recurrent Falls. A Case Report.

Paget's disease of the bone (PDB) is a rare metabolic bone disease that is estimated to affect 1-2% of the general population in the United States, resulting in deformity and high disability. The disease is commonly misdiagnosed due to a diverse range of signs and symptoms. This case report summarizes a case of a 75-year-old man with multiple comorbidities and history of falls, was found to have multiple old and new fractures of the spine on imaging. Incidental radiologic findings were the first clue to the diagnosis. The patient was given zoledronic acid, which improved symptoms. Difficulty in ambulation, falls and subsequent fractures can easily be attributed to frailty and comorbid conditions. This case highlights the importance of keeping PDB on the list of differentials in an elderly patient presenting with recurrent falls and fractures.

Pneumorrhachis and pneumocephalus resulting from pneumothorax: illustrative case.

Pneumorrhachis and pneumocephalus are rare conditions in which air is found within the spinal canal and brain, respectively. It is mostly asymptomatic and can be located in the intradural or extradural space. Intradural pneumorrhachis should prompt clinicians to search and treat any underlying injury of the skull, chest, or spinal column. A 68-year-old man presented with a history of cardiopulmonary arrest together with pneumorrhachis and pneumocephalus following a recurrent pneumothorax. The patient reported acute headaches with no other neurological symptoms. He was managed conservatively with bed rest for 48 hours following thoracoscopic talcage of his pneumothorax. Follow-up imaging showed regression of the pneumorrhachis, and the patient reported no other neurological symptoms. Pneumorrhachis is an incidental radiological finding that self-resolves with conservative management. However, it can be a complication resulting from a serious injury. Therefore, close monitoring of neurological symptoms and complete investigations should be performed in patients with pneumorrhachis.

Sjögren’s Syndrome: An Incidental Radiologic Finding in a Patient with Aural Symptoms

Sjögren’s Syndrome: An Incidental Radiologic Finding in a Patient with Aural Symptoms

Quality Improvement Report: Adherence to Follow-up Recommendations for Incidental Abdominal Aneurysms

The use of national guidelines for the management of incidental radiologic findings remains low. Therefore, improving adherence to and consistency with follow-up recommendations for incidental findings was undertaken in a large academic practice. A gap analysis was performed, and incidental findings of abdominal aneurysms for which reporting management recommendations could be improved were identified. The Kotter change management framework was used, and institution-specific dictation macros were developed and implemented in February 2021 for the management of abdominal aortic aneurysms (AAAs), renal artery aneurysms (RAAs), and splenic artery aneurysms (SAAs). A retrospective medical record review was conducted for February through April in 2019, 2020, and 2021 to assess reporting adherence and imaging and clinical follow-up. Personal feedback was provided to radiologists in July 2021 with repeat data collection in September 2021. A significant increase in the number of correct follow-up recommendations was reported for incidental AAAs and SAAs after implementation of the macro (P < .001). However, there was no significant change for RAAs. Providing personal feedback to radiologists further improved adherence with standard recommendation macros for common findings and dramatically increased adherence for rare findings such as RAAs. New macros resulted in an increase in AAA and SAA imaging follow-up (P < .001). Institution-specific dictation macros were found to improve adherence to reporting recommendations for incidental abdominal aneurysms, with further improvement seen after feedback, which can have a significant effect on clinical follow-up. © RSNA, 2023.

Bowel Perforation Due to Complicated Jejunal Diverticulitis: A Rare Case Report and Literature Review

Small bowel diverticulosis is a rare and acquired disease usually diagnosed as an incidental radiological finding. We report the case of a 65-year-old man admitted to our Emergency Department with abdominal pain and fever. The CT-scan showed multiple jejunal diverticular eversions and oedema of the surrounding tissues. At urgent laparotomy the radiological finding was confirmed with microperforation of one diverticula. Bowel resection was performed and histology revealed erosive inflammation with ischemic mucosa. Small bowel diverticula do not require any treatment if asymptomatic, nevertheless cases like this could be life-threatening. Urgent surgical procedure must be the treatment of choice in these patients.

880: PULMONARY AMYLOIDOSIS ASSOCIATED WITH B CELL LYMPHOPROLIFERATIVE DISORDER: A CASE REPORT

Introduction: Amyloidosis is caused by the deposition of misfolded autologous proteins in various organs and can be systemic or localized. AL amyloidosis is often associated with plasma cell disorder but here we report a rare case of Isolated Nodular Pulmonary Amyloidosis associated with a B cell Lymphoproliferative Disorder. Description: An 89 year old female with a past medical history of pulmonary arterial hypertension presented to the clinic with chronic stable exertional dyspnea and no associated symptoms. Four years prior, a computed tomography (CT) of the chest showed multiple bilateral calcified and noncalcified lung nodules with no further work-up. Chest X-ray performed at current presentation revealed extensive pulmonary reticulonodular shadowing at the peripheries with extensive fibrotic changes and scattered nodules. Subsequent CT chest showed interval increase of several bilateral nodules. A PET-CT showed multiple mildly hypermetabolic nodules. A CT guided needle biopsy of an FDG avid right upper lobe nodule measuring 1.5 x 1.4 cm was performed. Pathology was significant for homogenous acellular amorphous material with an entrapped plasma cell infiltrate. Congo red stain confirmed the presence of apple green birefringence diagnostic of amyloidosis. Immunohistochemistry showed a mixture of kappa-positive and lambda-positive cells, with kappa-positive cell predominance suggestive of an atypical plasma cell population. Clonal gene rearrangements were detected in both the immunoglobulin heavy chain and light chain gene which highly suggested the presence of a B-cell Lymphoproliferative Disorder. The patient was subsequently referred to oncology for further management. Discussion: Pulmonary Amyloidosis is an incidental radiological finding with patients being asymptomatic. CT chest may show lung nodules with/without calcifications. Biopsy is required for diagnosis with radiology guided fine needle aspiration. Isolated pulmonary amyloidosis has a good prognosis but should trigger evaluation for autoimmune disorders and B cell lymphoproliferative disorders as in this case with early referral and treatment of the underlying disorder.

Academic patterns of practice regarding CT simulation scans and radiology review

ObjectiveCurrently, there are no consensus guidelines about handling incidental radiological findings on radiotherapy planning CT simulation scans. Retrospective studies analyzing incidental findings on CT simulations show a small, but not insignificant, rate of both oncologic and non-oncologic findings. These findings may have medico-legal, financial, and clinical implications. Given a lack of guidelines, we obtained a formal survey of multiple academic institutions to evaluate how CT simulations are handled in regard to incidental findings. MethodsA formal survey was developed consisting of 12 questions related to institutional practices regarding CT simulation scans. From 7/18/21 to 8/27/21 and 5/6/22 to 5/24/22, the survey was administered electronically by REDCap to key personnel at Academic Radiation Oncology Programs identified through the American Society for Radiation Oncology (ASTRO) with inclusion criteria including an active ACGME approved Radiation Oncology residency program. ResultsIn total, 88 academic radiation oncology programs were surveyed with total of 45 responses (51%). 1 out of 45 departments who responded has formal guidelines regarding workup of incidental findings. There is variability about sending CT simulation scans for official radiology review if an incidental finding is identified. ConclusionsBased on a measurable rate of incidental findings on radiotherapy planning CT simulations and their possible implications, our survey illustrates a likely need for consensus recommendations for handling such findings to improve patient care and safety.

Oncology Capture of ED Patients with Incidental Radiologic Findings

Oncology Capture of ED Patients with Incidental Radiologic Findings

Catching Those Who Fall Through the Cracks: Integrating a Follow-Up Process for Emergency Department Patients with Incidental Radiologic Findings

Abnormal findings unrelated to the indication for testing are identified on emergency department (ED) imaging studies. We report the design and implementation of an electronic health record-based interdisciplinary referral system and our experience from the first 13 months of ensuring that patients with incidental radiology findings were connected with the appropriate outpatient surveillance. Our informatics team standardized the contemporaneous reporting of critical radiology alerts using our ED trackboard and created a companion follow-up request form for the treating ED clinicians to complete. The forms were routed to nurse case managers, who arranged follow-ups based on the findings and clinical significance. The primary outcome was the proportion of ED patient visits with identified incidental findings that had documented communication of the incidental findings and surveillance plans. Over the first 13 months after implementation, 932 ED patient visits had critical radiology alert referrals, for a total of 982 incidental findings. The primary outcome (confirmed post-ED communication and documented follow-up plan) was attained in 888 (95.3%, 95% confidence interval [CI] 93.9% to 96.6%) ED patient visits with confirmed post-ED communication and documented follow-up plans. The team was unable to contact or confirm follow-up with 44 (4.7%, 95% CI 3.4 to 6.1) patients by telephone or through the health care system's electronic communication tools. We report the implementation of a standardized notification and referral system for ED patients with incidental radiology findings. The development of a reliable notification and follow-up system is an important patient safety intervention given the opportunity to potentially identify undiagnosed malignancies.

CT KUB evaluation of suspected urolithiasis

Introduction: Non-contrasted computed tomography scan for kidney, ureter, and bladder (CT KUB) for diagnosis of urolithiasis is important for accurate diagnosis, followup, and management. Unlike USG, CT KUB has more diagnostic yield in urolithiasis and other incidental findings. This study aims to evaluate the use of the CT KUB in suspected urolithiasis, presented with severe flank pain.&#x0D; Method: A retrospective observational study was carried out in the Department of Radiology and Imaging, Patan Hospital, Nepal.TheCT KUB reports of patients with suspected urolithiasis from a period of 3 years from Jan 2017 to Jan 2020 were analyzed for evidence of urolithiasis and secondary signs of obstruction as ‘diagnostic’ of CT KUB. Other incidental radiological findings were further analysed and categorized into urinary and extra-urinary. Ethical approval was obtained.Association of USG and CT KUBwas analysed using Chi-square test,with p value&lt;0.05considered statistically significant.&#x0D; Result: Total of 414 CT KUB reports were analysed, 230(55.6%) males, 314 patients had USG before CT KUB. Considering CT KUB as a gold standard for diagnois of urolithiasis, the accuracy of ultrasound was found to be 85.03% and sensitivity is 94.09% and specificity of 27.9%.&#x0D; Conclusion: Majority of the patients included in the study had ultrasound done before CT KUB. The sensitivity of ultrasound was significant considering CT KUB as a gold standard in diagnosis of urolithaisis.