Modern advances in the medical imaging layered onto sophisticated trauma resuscitation strategies in highly organized regionalized trauma systems have created a paradigm shift in the management of severely injured patients. Although immediate exploratory surgery to identify and control life-threatening injuries still has its place, accelerated image acquisition and interpretation procedures now make it rare for trauma surgeons in major centers to venture into damage control surgery unaided by computed tomography (CT) or other imaging, particularly in cases of blunt trauma. Indeed, because of the high incidence of clinically occult injuries associated with major mechanism trauma, and even lower energy trauma in frail or elderly patients, CT imaging has become as invaluable as physical examination, if not more so, in critical decision-making in support of optimal outcomes. In particular, whole-body computed tomography (WBCT) completed promptly after initial assessment of a major trauma provides a quick, comprehensive survey of injuries that enables better surgical planning, obviates the need for multiple subsequent studies, and permits specialized reconstructions when needed. For those at risk for problematic occult injury after modest trauma, WBCT facilitates safer discharge planning and simplified follow-up. Through standardized guidelines, streamlined protocols, synoptic reporting, accessible web-based platforms, and active collaboration with clinicians, radiologists dedicated to trauma and emergency imaging enable clearer understanding of complex injuries in high-risk patients which leads to superior clinical decision-making. Whereas dated dogma has long warned that the CT scanner is the last place to take a challenging trauma patient, modern practice suggests that, more often than not, early comprehensive imaging can be done safely and efficiently and is in the patient’s best interest. This article outlines how the role of diagnostic imaging for major trauma has evolved considerably in recent years.

Background Surveillance of sporadic renal angiomyolipomas is a growing issue for physicians and radiologists. Current treatment recommendations favor active surveillance. However, the evidence underlying these is based on small case series, which also typically include angiomyolipomas associated with tuberous sclerosis. Purpose To evaluate the natural growth pattern of sporadic renal angiomyolipomas in patients without tuberous sclerosis. Material and Methods A retrospective review was performed in three separate tertiary referral centers. A keyword search of each institutions PACS history was performed. Inclusion criteria were angiomyolipomas > 1 cm in size, three years of follow-up, and lesions requiring treatment before reaching three years of follow-up. Exclusion criteria included a diagnosis of tuberous sclerosis, pregnancy, prior treatment with embolization without any prior imaging, and lesions which were treated on presentation. Growth of the angiomyolipomas was evaluated on the basis of maximum dimension on initial and follow-up images. Results Sixty-three patients were identified in total, with 64 lesions eligible for inclusion. The majority of patients were women (55/63). The mean age at which the angiomyolipomas discovered was 56.4 years. Mean total growth was 0.085 mm and mean follow-up was 65.5 months. At initial measurement, the mean maximum dimension of the lesions in our cohort was 2.08 cm. After follow-up, this was 2.16 cm. The average rate of growth was 0.015 cm per year. Conclusion Sporadic angiomyolipomas exhibit minimal, if any, natural growth. Current surveillance strategies could be relaxed.

CT in Differentiating Complicated From Uncomplicated Appendicitis: Role of Dual-Energy CTCiaran E. Redmond1, Brian Gibney2 and Savvas Nicolaou2Audio Available | Share

HomeRadioGraphicsVol. 40, No. 1 Previous Letters to the EditorFree AccessRole of Dual-Energy CT in Emergency NeuroradiologyBrian T. Gibney , Ciaran E. Redmond, Savvas NicolaouBrian T. Gibney , Ciaran E. Redmond, Savvas NicolaouAuthor AffiliationsDepartment of Radiology, Vancouver General Hospital, 899 W 12th Ave, Vancouver, BC, Canada V5Z 1L5 (B.T.G, C.E.R, S.N.)Department of Radiology, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada (S.N.)e-mail: [email protected]Brian T. Gibney Ciaran E. RedmondSavvas NicolaouPublished Online:Jan 9 2020https://doi.org/10.1148/rg.2020190202MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In Editor:It is with great interest that we read the excellent articles in the RadioGraphics October 2019 monograph entitled “Emergency Neuroradiology.” We particularly wish to acknowledge the articles by Ghodasara et al and Potter at al for their inclusion of the role of dual-energy CT. Ghodasara et al (1) discuss the utility of high-energy virtual monoenergetic techniques for reduction of beam hardening when combined with metal artifact reduction algorithms in postoperative imaging of the spine. Potter at al (2) review some of the uses of dual-energy CT in acute stroke, such as improved gray-white matter differentiation, bone subtraction for three-dimensional angiographic reconstruction, and iodine maps to assess for hemorrhage in the setting of postthrombectomy iodine leakage. We wish to highlight some of the many additional uses of dual-energy CT in the assessment of patients with emergency neurologic presentations, which we believe are important omissions from other articles in this monograph.An editorial in the September 2019 issue of Radiology entitled “Is Dual-Energy CT Ready for Prime Time in Traumatic Brain Injury?” by Talbott and Hess (3) expands on the emerging role of dual-energy CT in head trauma. The authors discuss recent findings using dual-energy CT, including iodine quantification methods as the best CT predictors of inpatient mortality and short-term outcome measures; differentiation of subdural hematomas from enhancing subdural effusions; and improved detection of subdural, epidural, and subarachnoid hemorrhages.For imaging of the neck, among other uses for dual-energy CT, virtual nonenhanced images from single-phase contrast-enhanced dual-energy CT allow assessment of sialolithiasis akin to that at nonenhanced CT, with a fraction of the radiation dose compared with that of dual-phase contrast-enhanced single-source CT (4).While MRI remains crucial in acute spinal imaging, dual-energy CT allows diagnoses traditionally made with MRI to be made at CT, which can be more rapidly and readily available in the emergency department. Virtual noncalcium dual-energy CT images have been found to have higher overall sensitivity and specificity (91% and 92%, respectively) than standard CT for detecting lumbar disk herniation, when MRI was used as a reference standard (5). A recent meta-analysis of the performance of dual-energy CT for detection of bone marrow edema found that dual-energy CT showed excellent diagnostic performance for the spine and appendicular skeleton (sensitivity, 84% and 84%, respectively; specificity, 98% and 93%, respectively) (6).At our institution, dual-energy CT has become standard practice for assessing many acute neurologic manifestations, including traumatic brain injuries, aneurysmal hemorrhage, and spinal trauma, as we feel it improves accuracy and reader confidence. We suggest that dual-energy CT should be considered in the assessment of a wide spectrum of emergency neurologic manifestations.Disclosures of Conflicts of Interest.—S.N. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: institution (University of British Columbia) has a master research agreement with Siemens Healthineers. Other activities: disclosed no relevant relationships.References1. Ghodasara N, Yi PH, Clark K, Fishman EK, Farshad M, Fritz J. Postoperative spinal CT: what the radiologist needs to know. RadioGraphics 2019;39(6):1840–1861. Link, Google Scholar2. Potter CA, Vagal AS, Goyal M, Nunez DB, Leslie-Mazwi TM, Lev MH. CT for treatment selection in acute ischemic stroke: a code stroke primer. RadioGraphics 2019;39(6):1717–1738. Link, Google Scholar3. Talbott JF, Hess CP. Is dual-energy CT ready for prime time in traumatic brain injury? Radiology 2019;292(3):739–740. Link, Google Scholar4. Pulickal GG, Singh D, Lohan R, Chawla A. Dual-source dual-energy CT in submandibular sialolithiasis: reliability and radiation burden. AJR Am J Roentgenol 2019;213(6):1291–1296. Crossref, Medline, Google Scholar5. Booz C, Nöske J, Martin SS, et al. Virtual noncalcium dual-energy CT: detection of lumbar disk herniation in comparison with standard gray-scale CT. Radiology 2019;290(2):446–455. Link, Google Scholar6. Suh CH, Yun SJ, Jin W, Lee SH, Park SY, Ryu CW. Diagnostic performance of dual-energy CT for the detection of bone marrow oedema: a systematic review and meta-analysis. Eur Radiol 2018;28(10):4182–4194. Crossref, Medline, Google ScholarArticle HistoryPublished online: Jan 09 2020Published in print: Jan 2020 FiguresReferencesRelatedDetailsRecommended Articles Spinal Hematomas: What a Radiologist Needs to KnowRadioGraphics2018Volume: 38Issue: 5pp. 1516-1535Traumatic Brain Injury: Imaging Patterns and ComplicationsRadioGraphics2019Volume: 39Issue: 6pp. 1571-1595Pediatric Central Nervous System Imaging of Nonaccidental Trauma: Beyond Subdural HematomasRadioGraphics2018Volume: 39Issue: 1pp. 213-228Dual-Energy CT in Emergency Neuroimaging: Added Value and Novel ApplicationsRadioGraphics2016Volume: 36Issue: 7pp. 2186-2198Construction of a Machine Learning Dataset through Collaboration: The RSNA 2019 Brain CT Hemorrhage ChallengeRadiology: Artificial Intelligence2020Volume: 2Issue: 3See More RSNA Education Exhibits Twenty Known and Emerging DECT Applications in Emergency NeuroradiologyDigital Posters2019Postoperative Non-Contrast CT for Ruptured Subarachnoid Hemorrhage: Utility of Dual-Energy CT ApplicationsDigital Posters2019Dual-Energy CT for the Pediatric Radiologist: Tools to Incorporate into Daily PracticeDigital Posters2019 RSNA Case Collection Terson syndromeRSNA Case Collection2020Vertex epidural hematoma RSNA Case Collection2021Intracranial hypotension syndromeRSNA Case Collection2021 Vol. 40, No. 1 Metrics Altmetric Score PDF download

Dual-energy computed tomography (CT) is a promising tool with increasing availability and multiple emerging and established clinical applications in neuroradiology. With its ability to allow characterization of materials based on their differential attenuation when imaged at two different energy levels, dual-energy CT can help identify the composition of brain, neck, and spinal components. Virtual monoenergetic imaging allows a range of simulated single energy-level reconstructions to be created with postprocessing. Low-energy reconstructions can aid identification of edema, ischemia, and subtle lesions due to increased soft tissue contrast as well as increasing contrast-to-noise ratios on angiographic imaging. Higher energy reconstructions can reduce image artifact from dental amalgam, aneurysm clips and coils, spinal hardware, dense contrast, and dense bones. Differentiating iodine from hemorrhage may help guide management of patients after thrombectomy and aid diagnosis of enhancing tumors within parenchymal hemorrhages. Iodine quantification may predict hematoma expansion in aneurysmal bleeds and outcomes in traumatic brain injury. Calcium and bone subtraction can be used to distinguish hemorrhage from brain parenchymal mineralization as well as improving visualization of extra-axial lesions and vessels adjacent to dense plaque or skull. This article reviews the basics of dual-energy CT and highlights many of its clinical applications in the evaluation of acute neurological presentations.

PURPOSE:Prospective radiology fellows often rely on the internet to obtain information with regard to the application process for and the unique qualities of different fellowship programs. The aim of this study was to analyze the content of websites of the United States' and Canadian cardiothoracic radiology fellowships.METHODS:All active Cardiothoracic Radiology fellowship websites as of July 2019 were evaluated and compared using 25 criteria in the following domains: Application, Recruitment, Clinical Training, Education/Research, and Incentives. Program website information availability was compared by geographic region.RESULTS:There were 60 active cardiothoracic radiology fellowships, and 59 of these fellowships had a dedicated fellowship website. Websites, on average, had 9.3 of the 25 criteria (37.2%). The mean number of schools that satisfied the criterion in the "Incentives" domain ([7.75/59] 10.5%±2.8%) was significantly lower than that for the "Application Process" domain ([40.50/59]; 68.7%±40.6%) (P=0.01). There was no significant difference in the information content of programs in different geographic regions (P=0.246).CONCLUSION:Most cardiothoracic radiology fellowship websites were lacking content relevant to prospective fellows. Provision of more relevant and easily accessible online content may support programs to better inform and recruit residents and to promote the specialty of cardiothoracic radiology.

Objective: A radiology sign that references a resemblance to something which is not actually present within an image has been termed a 'metaphoric' sign. Metaphoric signs are widely described in the literature and commonly used in teaching as a form of pattern recognition, or 'pareidolia'. However, the educational benefit of metaphoric signs has not been previously assessed. We aimed to assess the utility of metaphoric signs in medical student teaching. Materials and Methods: Fifteen radiology cases were prepared into two lecture formats for medical student education. A 'test' lecture uti-lizing metaphoric radiology signs to describe the appearance of the cases and a 'control' lecture where pathology was compared to nor-mal anatomical appearances without reference to metaphoric signs. Forty-nine volunteer medical students were randomized with cluster sampling to receive either the test or control lecture. Four days later, students were quizzed to determine retention of knowledge and to assess interest in the lecture on a visual analogue scale from 0 to 100. Results: The median interest level of the test group (69.5) was higher than the control group (50) (p = 0.001). The mean quiz score was higher in the test group (34.5) than in the control group (29) (Difference 5.5, 95% confidence interval 0.08-10.92, p = 0.047). Conclusion: The use of metaphoric signs in radiology education of medical students increased interest, descriptive ability and short-term knowledge retention, compared to the same material taught with normal anatomy correlation. Metaphoric signs should be considered as a useful radiology teaching tool.

Traumatic lower urinary tract injuries are uncommon and mainly occur in patients with severe trauma and multiple abdominopelvic injuries. In the presence of other substantial injuries, bladder and urethral injuries may be overlooked and cause significant morbidity and mortality. Therefore, it is important that radiologists are familiar with mechanisms and injuries that are high risk for bladder and urethral trauma. We review the imaging findings associated with these injuries and the appropriate modalities and techniques to further evaluate the patient and accurately diagnose these injuries. Computed tomography cystography and conventional retrograde urethrography are effective tools in identifying injuries to the lower urinary tract and play a crucial role in patient care and prognosis.

Purpose: In recent years, there has been increased recognition of the benefits of teaching by active learning. However, there is a paucity of experimental studies utilizing active learning in undergraduate radiology rotations, which is traditionally a passive learning experience. We designed a new radiology rotation that integrated teaching by active learning. We prospectively examined the efficacy of this new rotation compared to our standard rotation in terms of students' radiological competency and attitudes toward radiology, as well as impact on departmental efficiency. Methods: This was a prospective cohort study involving fourth year medical students completing a 1-week radiology rotation at our department between January and April 2018. One cohort completed a rotational model which incorporated active learning sessions (integrated cohort) while the remainder were taught using traditional passive learning methods (standard cohort). All participants completed a radiology examination before and after the rotation and were surveyed on their attitudes toward radiology. Results: A total of 105 students enrolled in the study. The mean postrotation competency score obtained by the integrated cohort was significantly higher than that obtained by the standard cohort (82% vs 62%; P < 0.001). The integrated rotation freed up 7 hours of radiologists' time per week. While the students completing the integrated rotation had a more positive perception of radiology, they were no more likely to express a desire to pursue a career in radiology. Conclusions: The integration of active learning sessions into an undergraduate radiology rotation results in an improvement in students' postrotation radiological competency and attitudes toward radiology. (C) 2019 Elsevier Inc. All rights reserved.

Coronavirus Disease 2019 (COVID-19) is the disease caused by the novel coronavirus officially named the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), declared as a pandemic by the World Health Organization on March 11, 2020. The COVID-19 pandemic presents an unprecedented challenge to emergency radiology practice. The continuity of an effective emergency imaging service for both COVID-19 and non-COVID-19 patients is essential, while adhering to best infection control practices. Under the direction of the Board of the Canadian Association of Radiologists, this general guidance document has been synthesized by collaborative consensus of a group of emergency radiologists. These recommendations aim to assist radiologists involved in emergency diagnostic imaging to help mitigate the spread of COVID-19 and continue to add value to patient care in the emergency setting.

This Emergency Radiology Special Issue of Canadian Association of Radiologists Journal comes at a critical conjuncture in the short history of the subspecialty of emergency radiology (ER). Since the emergence of the novel coronavirus (SARSCoV-2) in December 2019, the subsequent rapid escalation of COVID-19 disease to a pandemic has massively disrupted our normal way of life and places previously unimaginable strain on health-care services worldwide. A common theme emanating from the medical response to the COVID-19 pandemic thus far has been collaboration: The ongoing tremendous collective effort to create and share new knowledge related to COVID-19 by the radiology community deserves recognition. Several of the largest radiology journals have taken the initiative to create dedicated open access sections on their websites for COVID-19 articles. We now have grasp of the imaging features of COVID-19, as well as the diagnostic performance of computed tomography (CT). Indeed, the precise role(s) of radiological imaging for COVID-19 is currently in a state of evolution and is reviewed in this issue by Nasir et al. These unprecedented and extraordinary times present unique challenges to how we as emergency radiologists operate our workflow and help facilitate the most efficient possible care to patients imaged in the emergency department. We must use appropriate infection control measures while imaging patients with confirmed or suspected COVID-19 disease to mitigate the risk of transmission to other patients and staff. In this regard, the advice offered by Lei et al in this edition from their experience at a high-volume COVID-19 imaging unit will provide valuable foresight to radiologists preparing for a COVID-19 surge. Other radiologists have been equally forthcoming: In one of the first radiology department preparedness articles, Cheng et al reflected on the lessons learnt by their department during the SARS epidemic of 2003 and how this has informed their response to COVID-19. These protective measures involve time-consuming decontamination protocols and result in reduced patient throughput—the ability of emergency radiologists to triage and prioritize studies has never been more essential. The ongoing risk of transmission among staff within the ER division is also forcing us to rethink our usual work practices: The implementation of physical distancing and staff segregation measures in reporting rooms can limit opportunities for feedback, collaboration, and mentoring between colleagues. Furthermore, several national and international ER conferences this year have had to be canceled and it is perceivable that further scheduled conferences may need to be canceled. In these challenging times, it is essential that the ER community harnesses communication technologies to somewhat compensate for the potential loss of these vital research, educational, and networking events. We must continue to look out for and support our colleagues—the COVID-19 pandemic is threatening our mental as well as our physical health. These challenging and uncertain times require guidance and leadership; the establishment of a dedicated American Society of Emergency Radiology (ASER) COVID-19 Task Force is a welcomed initiative. Teleradiology is an important tool in ER which was growing in importance due to increasing expectations for 24/7/365 access to advanced imaging of emergent presentations, including smaller and more peripheral hospitals without the ability to fully staff an overnight roster. This tool will likely further grow in importance and utility in response to COVID-19, as needs increase in all hospitals at a time when health-care workers are particularly at risk of infection. However, moves to teleradiology must be balanced with the valuable role of the radiologist for on-table review of the most acute patients, as well as preand postimaging discussion and review.

Identifying citation classics is a valuable metric of research performance. Ireland has a distinguished history of medical research, although Ireland's top-cited articles are unknown. The SCOPUS database identified all medical and surgical articles published by journals in the Republic of Ireland or Northern Ireland. The 100 top-cited articles were analysed. The most cited article received 240 citations. There is an observed trend of increasing number of authors over time (p<0.05). General medicine and public health are the most common topics. The majority of works originate from Irish institutions. Collaborative research and non-Irish research are poorly represented among the citation classics. The Irish medical literature contains multiple highly cited and influential articles.

We read with great interest the recent article ( 1 Gaetke-Udager K. Magid D. Smith M. et al. Recruiting Future radiologists: how can we do better?. Acad Radiol. 2019; https://doi.org/10.1016/j.acra.2019.08.001 Abstract Full Text Full Text PDF Scopus (18) Google Scholar ) by Gaetke-Udager et al. entitled “Recruiting Future Radiologists: How Can We Do Better?”. We share the sentiments of the authors that there is a need for radiologists to improve recruitment efforts and address the potential barriers for medical students who may be interested in radiology. We wish to express our gratitude to the authors for sharing their well-considered advice on this pertinent issue.

AIMS AND OBJECTIVES:Varicocele embolization is a growing treatment modality owing to the safety, efficacy, and quick return to work following the procedure. The internet is the most dominant source of information for many. We aimed to assess the quality of information accessible by patients considering treatment.MATERIALS AND METHODS:A list of applicable, commonly used searchable terms was generated. Each term was assessed across the five most-used English language search engines to determine the two most commonly used terms. These two terms were then investigated across each search engine, with the first 25 web pages returned by each engine included for analysis. Duplicate web pages, nontext content such as video or audio, and web pages behind paywalls were excluded. Web pages were analyzed for quality and readability using validated tools including DISCERN score, JAMA Benchmark Criteria, HONcode Certification, Flesch Reading Ease Score, Flesch-Kincaid Grade Level, and Gunning-Fog Index. Secondary features including age, rank, author, and publisher were recorded.RESULTS:The most common applicable terms were "Testicular embolization" (378,300 results) and "Varicocele embolization" (375,800 results). Mean DISCERN quality of information provided by websites is "fair"; Adherence to JAMA Benchmark Criteria was 13.5%. Flesh-Kincaid readability tests demonstrated an average "9th grade" reading level. Scientific journals showed the highest quality scores, but were least up to date with an average web page age of 11.2 years. Web pages produced by "for-profit" organizations were the second most current (average age 2.7 years), but displayed the lowest quality of information scores.CONCLUSION:While quality of online information available to patients is "fair," adherence to JAMA benchmark criteria is poor. "For-profit" organization websites are far more numerous and significantly more up-to-date, yet showed significantly lower quality of information scores. Scientific journals were unsurprisingly of higher quality, yet more challenging for the general public to read. These findings call for the production of high-quality and comprehensible content regarding interventional radiology, where physicians can reliably direct their patients for information.

Background: Detection of optic neuropathy on MRI has potential implications for the diagnosis and management of Multiple Sclerosis (MS). Objective: This study assessed the accuracy of T2 sagittal MRI brain for detection of optic neuropathy, compared to coronal STIR orbit. Methods and materials: Retrospective single-center blinded diagnostic accuracy study of 100 consecutive patients who underwent both T2 sagittal brain and coronal STIR orbit MRI. All were performed on 1.5T scanners. T2 sagittal slice thickness was 4 mm for the first 50 patients (group') and 3 mm for the second 50 (group2). The MRIs were reviewed in a blinded fashion to determine the presence of optic neuropathy. Coronal STIR orbit sequences were considered the diagnostic reference standard. Results: The sensitivity of T2 sagittal brain imaging for ON was 44% in group 1 and 85% in group 2 (p = 0.007). The specificities were 98% and 97% respectively (p = 0.9). Sensitivity was poorest for evaluation of the intraorbital nerve segment (56% grpl, 69% grp2, p = 0.4). Conclusion: T2 sagittal MRI brain has high specificity for the detection of optic neuropathy when compared to coronal STIR orbit. Sensitivity is increased when slice thickness is reduced, but remains poor for evaluation of the intraorbital segment.