Radiology Literature Research Articles

Damage control surgery: use of diagnostic CT after life-saving laparotomy.

Damage control surgery (DCS) is a limited exploratory laparotomy that is performed in unstable trauma patients who, without immediate intervention, would acutely decompensate. Patients usually present with shock physiology and metabolic derangements including acidosis, hypothermia, and coagulopathy. Delayed medical correction of these metabolic derangements leads to an irreversible state of coagulopathic hemorrhagic shock and inevitable patient demise. Therefore, once a patient meets DCS criteria, a limited exploratory laparotomy is performed to stabilize life-threatening injury and expedite initiation of medical resuscitation in the intensive care unit (ICU). The surgeon plans to return to the operating room for definitive surgical treatment once the patient is hemodynamically stabilized and the metabolic derangements have been corrected. DCS patients are frequently sent to the ICU with an open abdomen and purposefully retained surgical equipment. The lack of response to resuscitation efforts, persistent hypotension, tachycardia, and/or the development of sepsis are common indications for this patient population to undergo CT imaging. The indications and findings of multi-detector CT (MDCT) in patients post-DCS have not been thoroughly evaluated in the radiology literature. A radiologist's knowledge of the DCS protocol and pre-imaging surgical interventions helps optimize the MDCT protocol. This enhances the radiologist's ability to evaluate for failure of surgical interventions performed prior to imaging and to search for injuries in areas that were not explored or that were missed during the initial surgical exploration.

Groove pancreatitis—a great mimicker

Groove pancreatitis is an uncommon form of chronic pancreatitis affecting the “groove” between the pancreatic head, duodenum and common bile duct. Many radiologists remain unfamiliar with this entity, with only a few descriptions of it existing in the radiology and pathology literature. The exact underlying cause of groove pancreatitis is unclear, although there are strong associations with peptic ulcer disease, smoking, long-term alcohol abuse, functional obstruction of the duct of Santorini and Brunner gland hyperplasia. This entity mimics pancreatic carcinoma and often ultimately leads to surgery. Hence it is important for radiologists to be familiar with imaging findings of groove pancreatitis to avoid diagnostic dilemma. Imaging findings in our case showed a soft tissue mass in the pancreaticoduodenal groove with enhancement, consistent with scar tissue and cystic changes within the lesion. It was associated with adjacent duodenal wall thickening with smooth and regular tapering of the pancreatic and common bile ducts.

Postmortem Changes as Documented in Postmortem Computed Tomography Scans.

The benefits and uses of postmortem computed tomography (PMCT) have been well documented in the forensic pathology and radiology literature in recent years and research into its utility continue in earnest. Opinions and policies regarding who actually interprets the PMCT scans vary between institutions, but in general, scans will be read by a forensic pathologist, a clinical radiologist, or a clinical radiologist with a special interest or training in postmortem imaging. Differences between clinical computed tomography scans and PMCT scans have been well documented and knowledge of these differences, typically those due to postmortem changes, is essential to the reader of the PMCT scan so as to minimize the risk of misinterpretation and, potentially, misdiagnoses.

Artifacts Affecting Musculoskeletal Magnetic Resonance Imaging: Their Origins and Solutions

Among articles within the radiology literature, few present the manifestations of magnetic resonance imaging artifacts in a clinically oriented manner. Recognizing such artifacts is imperative given the increasing clinical use of magnetic resonance imaging and the emphasis by the American Board of Radiology on practical physics applications. The purpose of this article is to present magnetic resonance physics principles visually and conceptually in the context of common musculoskeletal radiology artifacts and their solutions, described using nonmathematical explanations.

Willingness to Pay for CT Colonography: A Survey of Patient Preferences.

CT colonography (CTC) has received mixed reviews both in the radiology literature and in clinical practice. CTC is less invasive than optical colonoscopy (OC), is better for identifying polyps, and does not require sedation. However, its cost-effectiveness has been called into question, and there is a residual need for OC if the CTC findings are positive. Some radiologists are hesitant to perform CTC because of the time-intensive nature of its interpretation. Results of willingness-to-pay surveys can be informative about preferences and value placed on intangibles. The purpose of this study was to use such a survey to elicit the preferences of radiologists about CTC versus OC. A vignette was presented in which the insurer covered OC at no charge but required out-of-pocket payment for CTC. The strengths and weaknesses of OC and CTC were listed. The respondents were asked how much they would be willing to pay for CTC; for CTC with perfect sensitivity, specificity, and accuracy; and for CTC that required no bowel preparation. Twenty-eight of 42 radiologists preferred OC to CTC. One radiologist was indifferent. Four radiologists would reverse their preference and choose CTC if it had 100% sensitivity. Sixteen radiologists said they would prefer CTC if it had 100% specificity. If CTC eliminated the need for bowel preparation, 57% would prefer it to OC. Thirty-one (74%) radiologists preferred perfect sensitivity to perfect specificity. Despite the less invasive nature of CTC, most radiologists who responded to the survey preferred OC for colorectal cancer screening, mostly because of the definitive nature of OC due to the capability of immediate biopsy of suspicious lesions and the lack of requirement for a second round of bowel preparation.

Fine-needle aspiration of axillary lymph nodes: a change of paradigm in the approach to axillary compromise?

Radiol Bras. 2016 Jan/Fev;49(1):IX Breast cancer is the most common malignant tumor in women. Recently, the Brazilian radiological literature has been extremely concerned with the relevance of the role played by imaging methods in the improvement of breast cancer diagnosis. In the last decades, the treatment for breast cancer has undergone major changes, with more conservative surgeries demonstrating no influence on overall survival. However, despite the recent developments, axillary compromise still remains as the most relevant isolated prognostic factor. Additionally, it may determine the indication for the most appropriate treatment such as chemotherapy and radiotherapy in a significant number of patients. Until recently, sentinel lymph node biopsy has been a game changer in the assessment of the axilla and definition of the necessity of axillary dissection. The latter, however, was responsible for the major part of the morbidity associated with breast cancer surgery. Avoiding such a measure in cases where it is unnecessary, i.e. in cases of negative sentinel lymph node was the main focus of the oncologic breast surgery over the last decades. Thus, the application of a minimally invasive, simple and effective diagnostic method in the prediction of axillary compromise could be helpful to reduce the surgical time, so the surgeon could avoid the sentinel lymph node biopsy, proceeding directly to axillary dissection. Would it be so simple? Such a rationale would be perfect up to four years ago, before the publication of the clinical essays ACOSOG Z0011 and AMAROS. Such studies have demonstrated that patients eligible for conservative surgery (T1-T2), with less than three positive lymph nodes and submitted to axillary dissection, presented the same survival and local management as those who had not undergone dissection. Then, on the basis of the ACOSOG Z0011 and AMAROS results, in which situations could the findings by Rocha et al. be useful? The great relevance of the study developed by Rocha et al. is in the high degree of sensitivity of fine needle aspiration biopsy (FNAB) observed in cases of lymph nodes considered to be suspicious and indeterminate (87.1%), allowing to avoid the sentinel lymph node procedure in 70.1% of patients. And, in the cases where

Current Practice vs. Guideline Based Imaging in Abdominal Radiology in the German Speaking Area: Results of an Online Survey.

The working group for abdominal imaging within the German Roentgen Society (DRG) performed an online survey amongst radiologist concerning the current status of techniques for abdominal imaging. The results of this survey were compared with the most recent guidelines. We performed an online survey open for all members of the DRG during a 76-day period with 65 questions and an overall estimated time for finishing the questionnaire of 15 minutes concerning technical specifications for abdominal radiological imaging. The results were evaluated using descriptive statistics. 90 of all participants, who filled out the survey covering more than 80% of the questions, were included in the statistical evaluation. 27% of all participants were registered radiologists while 73% represented radiologists working in a hospital. Most participants worked in a managerial position. The participants gave detailed information regarding the radiological techniques used in dedicated organ systems (esophagus, stomach, pancreas, liver, small intestines, colon) regarding acquired contrast phases and oral and intravenous administration of contrast medium. The results confirm that most radiologists participating in this survey perform their examinations and choose their modalities in conformity with the current existing clinical guidelines. Because most clinical guidelines do not specify radiological examinations in detail, there is a noteworthy heterogeneity of the acquired contrast phases and major divergence in terms of technical parameters. Therefore a joint radiological effort should be initiated for developing and publishing updated radiological parameters for abdominal imaging. • In German speaking countries indications for abdominal radiological examinations are performed with a high compliance to published guidelines. • There is a significant heterogeneity regarding the acquisition of different contrast phases for parenchymal abdominal organs. • There is an urgent need to publish radiological recommendations and guidelines based on current radiological literature for radiological abdominal imaging.

CT Appearance of Adrenal Cystic Lymphangioma: Radiologic-Pathologic Correlation.

Cystic lymphangioma is an uncommon lesion in the adrenal gland. Because of the lesion's rarity, few descriptions of it can be found in the radiology literature. We therefore describe a series of these lesions with a focus on CT characteristics with correlation to gross and microscopic pathology features. Retrospective review identified seven patients with definitive pathologic findings of cystic lymphangioma of the adrenal gland and available diagnostic CT examinations. CT examinations were reviewed for key imaging features and correlated to gross and microscopic pathology. Lesions were generally described in corresponding reports as likely representing adenomas or hematomas based on CT findings. All cystic lymphangiomas included in this series were well-circumscribed lesions with low-attenuation internal contents and thin walls, without evidence of solid components or nodularity. No measurable contrast enhancement was seen in these lesions. Six of the seven lesions contained calcifications with one of two patterns: either thick, curvilinear, and dystrophic-appearing or thin and scattered. On gross and microscopic pathology, the lesions were composed of dilated cystic spaces containing serous fluid and lined by bland endothelial cells. Though rare, an adrenal cystic lymphangioma should be suspected on CT when a unilocular or multilocular, low-attenuation, nonenhancing lesion is present in the region of the adrenal gland, particularly if the lesion contains either of the above-noted calcification patterns. Recognition of these findings may allow more conservative treatment of selected patients harboring these lesions.

Gender Trends in Radiology Authorship: A 35-Year Analysis.

The purpose of this study was to describe trends over time in female authorship in the radiology literature and to investigate the tendency of female first authors to publish with female senior authors. Data on the gender of academic physician authors based in the United States for all major articles published in three general radiology journals--Radiology, AJR, and Academic Radiology--were collected and analyzed for the years 1978, 1988, 1998, 2008, and 2013. Multivariate logistic regression was used to identify significant trends over time, and a chi-square test of independence was performed to determine significant relations between the genders of first and senior authors. The gender of 4182 of 4217 (99.17%) authors with MD degrees was determined. The proportion of original research articles published by women as first authors increased from 8.33% in 1978 to 32.35% in 2013 (p < 0.001). The proportion of original research articles with women as senior authors increased from 6.75% in 1978 to 21.90% in 2013 (p < 0.001). Female first and senior authorship increased significantly over time (first author, p < 0.001; senior author, p < 0.001). There was a statistically significant relation between the genders of first and senior authors of original research articles and guest editorials (p < 0.001). Over 35 years, there was a statistically significant upward linear trend of female physician participation in authorship of academic radiology literature. Female first authors were more likely to publish with female senior authors.

MRI of Labral and Chondral Lesions of the Hip.

Unenhanced MRI, indirect MR arthrography, and direct MR arthrography have been used in the radiologic evaluation of patients with suspected labral tears and chondral lesions of the hip. The purpose of this article is to examine the existing evidence for the use of these techniques in patients with hip pain and suspected labral or chondral abnormalities. Evidence from a review of the radiologic literature supports the use of direct MR arthrography over unenhanced MRI and indirect MR arthrography for the detection of labral and cartilage abnormalities in the hip. Although high-resolution unenhanced 3-T MRI appears promising, limited information in the literature supports its use in the detection and characterization of chondrolabral lesions.

MRI appearance of the superior transverse scapular ligament.

The superior transverse scapular ligament (STSL) forms the roof of the suprascapular notch, which is the most common location of entrapment of the suprascapular nerve, a cause of shoulder pain and weakness. The purpose of this study is to determine the frequency of visualization of the STSL on routine shoulder MRIs, to identify the sequences and imaging planes on which it is visualized most frequently, and to describe its typical MRI appearance, none of which have been previously addressed in the radiologic literature. One hundred twenty-one consecutive shoulder MRIs were reviewed for the presence or absence of the STSL, including the imaging plane and sequence that best depicted the ligament. Dimensions of the ligament were recorded. Fifty four of 121 shoulder MRIs were technically adequate for visualization of the STSL, and it was identified on 51 of these studies (94%). There was no statistically significant difference between 1.5-T and 3-T systems. The best individual sequence for visualizing the STSL was the sagittal T1-weighted sequence, in which the STSL was visible on 75/80 technically adequate sequences (94%). The sagittal plane was the best plane for visualizing the STSL, in which it was visible on 65/69 technically adequate studies (94%). The STSL on average measured 12.8 ± 1.5 mm in transverse dimension. The STSL can be visualized on the majority of shoulder MRIs and is best seen on sagittal T1-weighted images on our imaging protocol. Evaluation of the STSL can potentially help in identifying pathologic conditions affecting the suprascapular nerve.

Correlation of computed tomographic signs of hypoperfusion and clinical hypoperfusion in adult blunt trauma patients.

The computed tomographic signs of hypoperfusion (CTSHs) have been reported in radiology literature as preceding the onset of clinical shock in children, but its correlation with tenuous hemodynamic status in adult blunt trauma patients has not been well studied. We hypothesized that these CT findings represent a clinically hypoperfused state and predict patient outcomes. We retrospectively reviewed 52 adult blunt trauma patients who presented to our Level I trauma center with an Injury Severity Score (ISS) greater than 15 and a systolic blood pressure less than 90 mm Hg and who underwent torso CT scans during a period of 5.5 years. Patient's demographics and clinical data were recorded. All CT scans were assessed by our radiologist (J.M.) for 25 CTSHs. Seventy-nine percent of the patients studied exhibited CTSH. The mean number of signs identified per patient was 4. Patient with the most common CTSH, that is, free peritoneal fluid, small bowel enhancement, flattened inferior vena cava (IVC), and flattened renal veins, had a significantly higher intensive care unit admission rate than those without (all p < 0.05). Patient with signs of small bowel abnormal enhancement/dilation, flattened IVC/renal vein had worse acidosis (all p < 0.05). A significantly lower admission hemoglobin and an increased need for red blood cell transfusion were found in patient with flattened IVC (p < 0.05), flattened renal vein (p < 0.01), and active contrast extravasation (p < 0.01). Univariate analysis identified small bowel dilatation and splenic injury as factors associated with mortality and laparotomy, respectively. Logistic regression model revealed that splenic injury is a significant independent predictor of laparotomy (odd ratio, 7.50; 95% confidence interval, 1.67-33.71; p < 0.01). CTSH correlates with clinical hypoperfusion in blunt trauma patients and has important prognostic and therapeutic implications. The presence of CTSH in blunt trauma patients should draw immediate attention and require prompt intervention. Trauma surgeons should be familiar with these signs and include them in the clinical decision-making paradigms to improve outcomes in blunt trauma. Diagnostic study, level III.

Assessing the Gap in Female Authorship in Radiology: Trends Over the Past Two Decades

PurposeThe aim of this study was to retrospectively identify trends in the representation of female authorship in prominent general radiology journals over the past 2 decades. MethodsA comprehensive search was conducted for all articles published in 1993, 2003, and 2013 in Radiology, the American Journal of Roentgenology (AJR), European Radiology, and Investigative Radiology. The genders of the first and last authors were collected. Chi-square tests were used for statistical analysis, and P values < .05 were considered to indicate statistical significance. ResultsA total of 3,786 articles were reviewed. Overall, women constituted 20.0% authorship, 24.7% of first authors, and 15.2% of senior authors. The average overall female first and senior authorship grew from 19.7% to 32.1% and from 13.6% to 19.1%, respectively from 1993 to 2013. Female first authorship grew over the past 2 decades in the journals reviewed, with significant growth in AJR and Radiology (P < .0001). Female first authorship in the individual journals grew from 16.4%-29.1% in 1993, to 29.1%-34.8% in 2013. Female senior authorship also demonstrated growth in the past 2 decades, growing from 4.3%-17.5% in 1993 to 15.5%-23.2% in 2013. There was significant growth in senior female authorship in Radiology (from 12.1% to 19.2%, P = .004) and European Radiology (from 4.3% to 15.5%, P = .0433). Female senior authorship remained significantly lower than first authorship over the past 2 decades (P = .002, P < .001, and P < .0001). ConclusionsAlthough women’s growth in first authorship in radiology literature is proportional to their growth in the specialty, they continue to remain a minority, especially in senior authorship, and demonstrate similar participation to other medical specialties.

Histomorphologic Features of Biopsy Sites Following Excisional and Core Needle Biopsies of the Breast.

Mammographic studies have documented a number of architectural changes occurring around breast biopsy sites. These changes are well described in the radiological literature, but similar studies do not appear to be present in the pathology literature. We reviewed 100 consecutive mastectomy specimens from women who had undergone prior core needle or excisional biopsies. Multiple sections of the needle tract or excisional biopsy site were reviewed and morphologic findings reported. Hemorrhage, fat necrosis, granulation tissue, necrosis of fibrous tissue, and epithelium along with fibrosis and foreign body type giant cells were common features. Less frequent were areas of synovial metaplasia, atypical spindle cells, atypical duct-like structures, single atypical cells, squamous metaplasia, proliferations of abnormal blood vessels, and hemosiderin deposition. The misinterpretation of atypical spindle cells, single atypical cells, atypical duct-like structures and squamous metaplasia could result in the false-positive diagnosis of residual malignancy. Careful attention to the reactive nature of these changes aids in their distinction from carcinoma.

Retroperitoneal Liposarcoma

Retroperitoneal liposarcomas are rare mesenchymal tumors of the retroperitoneum that typically present with advanced disease and often carry a poor prognosis. Because of their rarity and anatomic location, these malignant tumors can cause a diagnostic dilemma and present several therapeutic challenges. They are usually associated with a high rate of recurrence despite grossly complete resection, thus requiring long-term and often indefinite follow-up. Relevant data on this topic was procured and synthesized with the aid of a comprehensive Medline search in addition to oncologic, pathologic, urologic, radiologic, and surgical literature review on retroperitoneal sarcomas. This article provides an in-depth review into the natural history, pathology, clinical manifestations, and prognostic features of retroperitoneal liposarcomas. It also discusses the reliability of diagnostic procedures and novel curative approaches that are currently being evaluated for the disease.

CBCT Findings of Complete Calcification of the Stylohyoide Ligament: Case Reports

Calcification of the stylohyoide ligament or Eagle syndrome, which cause is still unclear, is a group of symptoms caused by an elongated ossified styloid process. It can occur unilaterally or bilaterally and most frequently results in symptoms of dysphagia, headache, pain on rotation of the neck, pain on extension of the tongue, change in voice, and a sensation of hyper salivation. This finding is well documented in otolaryngology literature and dentistry literature but has not been sufficiently reported in the radiology literature, although it often goes undetected in the absence of radiographic studies. In these report, we will present some radiographic evidences on a series of CBCT views and 3D reconstructions of three cases with clinical evidence of Eagle syndrome.

Mesenteric panniculitis: still an ambiguous condition.

To study the possible relationship between mesenteric panniculitis (MP) visible on computed tomography (CT) and the presence of an underlying neoplastic disease. A retrospective analysis of 158 patients with CT examinations that revealed the presence of MP was performed. CT images were analyzed by two different radiologists using morphological criteria validated in the radiological literature. The presence, frequency and type of neoplastic lesions associated with MP were assessed. MP was asymptomatic in 96/158 patients (61%). Fat halo sign and pseudocapsule were visible on CT in 89/158 (56%) and 93/158 (59%) patients, respectively. Underlying neoplastic disease was present in 88/158 patients (56%). The neoplastic diseases most often associated with MP were lymphoma (28%), melanoma (18%), colorectal cancer (15%) and prostate cancer (13%). MP has typical CT appearance and is associated with underlying neoplastic disease in 56% of patients. Such levels of association might suggest that MP may be considered as a paraneoplastic condition. Hence, incidental depiction of MP on CT in a patient without known neoplastic disease should incite radiologists to further scrutinize CT examination for presence of synchronous neoplastic lesions.

Giant pilomatrixoma presenting in the posterior thorax, a rare location and the largest described.

Pilomatrixoma is a common benign soft tissue neoplasm arising from hair follicle cells, typically not exceeding 3 cm and located mainly within the head and neck regions. Lesions greater than 3 cm or those located elsewhere are rare and are often not thought of or high on a differential diagnosis. Moreover, the radiographic features of pilomatrixoma are very nonspecific making the diagnosis even more difficult and rarely described in the radiology literature. We present the largest reported case of pilomatrixoma measuring 24 cm arising from the posterior thorax. Our hope is to increase awareness of this diagnosis for slow-growing soft tissue masses not located in the classically described locations of head and neck, explore the radiographic features on various imaging modalities, and review the current radiology literature.

Persistent Epidural Fluid at the Cervical Spine Level, Lessons from Radiology

Following an accidental dural puncture during the placement of epidural anesthesia, leakage of cerebrospinal fluid occurs. This leads to tugging on intracranial pain-sensitive structures and causes a headache that is postural in nature. According to radiology literature, the presence of retro spinal fluid collections has been associated with the diagnosis of spontaneous intracranial hypotension. The characteristic C1-C2 radiographic sign, called the C1-C2 false localizing sign, can be found on magnetic resonance (MR) images as a focal area of fluid-like signal intensity and on CT myelograms as a CSF collection between the spinous processes of C1 and C2. As our case report demonstrates, this sign is also associated with intracranial hypotension after lumbar puncture.

Intestinal and appendiceal paracoccidioidomycosis.

Dear. Editor,A male, 20-year-old patient with hematochezia and enteror-rhagia associated with weight loss. Colonoscopy demonstratednonspecific rectitis, and histopathological analysis was compat-ible with Crohn’s disease. The treatment was initiated and remis-sion was observed.After five months, the medication was interrupted withoutmedical advice, and recurrence of the same initial symptoms wasobserved after one month, in addition to papular lesions, some ofthem pustular, scattered throughout the body and scalp. After fivedays of immunosuppressive therapy, progression of the papularlesions, onset of intensely painful, hemorrhagic lesions in the oralmucosa, and painful lymph nodes enlargement in cervical chainswere observed. Then, the patient was transferred to the authors’institution where the assessment by the Unit of Dermatology raisedthe suspicion of paracoccidioidomycosis (PCM), confirmed by orallesions smear and silver staining demonstrating the typical pin-wheel cells. Rectosigmoidoscopy demonstrated granulomatousproctosigmoiditis and biopsy confirmed the diagnosis. Abdomi-nal computed tomography (CT) identified ileocecal mass, appen-diceal thickening with parietal contrast enhancement, adjacentperitoneal fat infiltration, mesenteric and retroperitoneal lymphnodes enlargement, besides parietal thickening of the rectum withpararectal gaseous foci at right, caused by fistulas, and perirectalfat blurring (Figure 1).He was treated with amphotericin B which, after four days,resulted in improvement of the dermatological and painful condi-tion. The tomographic follow-up revealed involution of the ileoce-cal, appendicular and rectal involvement.The Brazilian radiological literature has recently highlightedthe relevance of imaging methods in the diagnosis of the diges-tive system diseases