BACKGROUND: Epidural hematoma (EDH) can result in a catastrophic outcome of traumatic brain injury. Current management guidelines do not consider the source of hemorrhage in decision making. The purpose of this study was to examine the relationship between EDH location and the source of hemorrhage. METHODS: We report retrospectively reviewed, prospectively obtained surgical data of patients with acute traumatic cranial EDH treated between 2007 and 2018. Computed tomography (CT) scans were used to categorize EDH location as lateral or medial. The source of hemorrhage was identified intraoperatively by a single surgeon. RESULTS: Overall, of 92 evacuated EDHs (in 87 patients), 71 (77.2%) were in the lateral location. Arterial bleeding was the cause of EDH in 63.4% of the lateral EDHs and 9.2% of the medial EDHs (P < 0.0001). In the cases where surgery was done primarily to treat EDH, 65.3% had an arterial bleed source (P < 0.0001). In those treated for primary reasons other than EDH evacuation, 75% had a venous bleed source (P = 0.002). CONCLUSIONS: The location of EDH correlates with the source of hemorrhage. The decision to operate on EDH may be influenced by this factor.

Abstract PURPOSE Ommaya reservoirs are frequently inserted in patients requiring regular delivery of intrathecal medications. The incidence of intracranial hemorrhage following insertion ranges from 1–3% and is typically associated with thrombocytopenia. However, the exact platelet count at which it is considered safe to insert an Ommaya reservoir has not been previously reported. The purpose of this study is to investigate the nature of the relationship between thrombocytopenia and post-operative hemorrhage following insertion of Ommaya reservoirs for intrathecal chemotherapy. METHODS Consecutive patients requiring insertion of an Ommaya reservoir were enrolled in the study with no minimum platelet count as an exclusion criterion. Patients data were retrospectively reviewed with thrombocytopenia defined as platelet count < 100,000. All thrombocytopenic patients received at least one unit of intraoperative platelet transfusion. Post-operative incidence of hemorrhage, determined through CT scan, was compared between the thrombocytopenic group and normal platelet group. RESULTS 53 patients were enrolled within the study with 23 patients determined to be thrombocytopenic at the time of insertion. Thrombocytopenic patients were found to have 18.6 times the odds of post-operative bleeding when compared to patients with normal platelet counts (p< 0.001). However, no patient in the thrombocytopenic group had a clinically significant bleed, defined as being symptomatic or requiring intervention. CONCLUSIONS Although thrombocytopenia increases the risk of post-operative hemorrhage associated with Ommaya reservoir placement, there is no increase in clinically significant bleeding. With concurrent platelet transfusion and use of neuronavigation, Ommaya reservoir may be safely placed in thrombocytopenic patients.

OBJECTIVE The objective of our study was to assess utilization of the Family and Medical Leave Act (FMLA) in radiology practices in 2016 and compare with 2015 utilization. MATERIALS AND METHODS The Practice of Radiology Environment Database was used to identify practice leaders, and these leaders were asked to complete the annual American College of Radiology Commission on Human Resources workforce survey. The 2017 survey, which asked about 2016 experiences, again included questions about the number of radiologists in each practice who took FMLA, reasons why, and how absences were covered. RESULTS Twenty-six percent (477/1811) of practice leaders responded to the survey. Of these respondents, 73% (346/477) answered FMLA questions, and 23% (80/346) of those answered affirmatively that a radiologist in their practice had taken FMLA leave in 2016 (previously 15% in 2015; p = 0.15). The reasons for FMLA leave included taking care of a newborn or adopted child (57%, previously 49%; p = 0.26), personal serious health condition (35%, previously 42%; p = 0.31), caring for an immediate family member (8%, unchanged), and engaging in active military duty (< 1%, unchanged). Although more women (72%) than men (32%) took FMLA leave for the first reason (p < 0.01), more men (63%) than women (18%) took FMLA leave for the second (p < 0.01), and there was no significant difference between women (10%) and men (5%) taking leave to care for an immediate family member (p = 0.18). Most practices (80%) again made no workforce changes to cover absences due to FMLA leave (previously 82%). CONCLUSION Utilization of FMLA leave in radiology practices in 2016 was similar to that in 2015 and represents the beginning of longitudinal accrual of data on this important topic for both male and female radiologists.

The transition of leadership within radiology practices is often not a planned replacement process with formal development of potential future leaders. To ensure their ongoing success, however, practices need to develop comprehensive succession plans that include a robust developmental program for potential leaders consisting of mentoring, coaching, structured socialization, 360-degree feedback, developmental stretch assignments, job rotation, and formal education. Succession planning and leadership development will be necessary in the future for a practice to be successful in its business relationships and to be financially viable.

Phosphaturic mesenchymal tumor (mixed connective tissue variant) (PMT-MCT) are tumors that may cause tumor-induced osteomalacia and rarely appear intracranially. The authors describe the case of an 8-year-old girl who was found to have PMT-MCT with involvement of the cerebellar hemisphere and a small tumor pedicle breaching the dura mater and involving the skull. This was removed surgically in gross-total fashion without further complication. Histologically the tumor was confirmed to be a PMT-MCT. There was no evidence of tumor-induced osteomalacia. At the 42-month follow-up, the patient is doing well, has no abnormalities, and is free of recurrence. PMT-MCTs are rare tumors that may involve the brain parenchyma. A gross-total resection may be effective to cure these lesions.

Superior Mesenteric Artery (SMA) Syndrome, also known as Cast syndrome or Wilkie syndrome, is an acutely presenting condition of nausea and intractable bilious vomiting due to compression of the transverse duodenum by the overlying superior mesenteric artery (SMA) typically as a result of recent weight loss and a thinning of the mesenteric fat pad. This mechanical obstruction results in radiographic megaduodenum and stomach dilation due to retention of bowel contents and a visible aorto-mesenteric angle ≤ 25°. We report a 30 year-old Persian male with a history of opiate, benzodiazepine, marijuana and tobacco abuse resulting in an 80 pound weight loss over the last 5 years, the last 40 pounds lost in the past year. He presented with mild nausea, vomiting, shortness of breath, and chest pain. He was diagnosed with spontaneous pneumothorax, acute kidney injury and drug withdrawal after positive urine drug screen of the aforementioned substances. Later on during this admission, nausea and copious bilious vomiting began, thought to be due to viral gastroenteritis and associated with leukocytosis. After considering recent weight loss, lack of diarrhea and emaciated appearance, CT angiography of the abdomen was done, confirming suspected SMA syndrome with duodenal compression and SMA-aortic angle of approximately 20, figure (1) and (2). Symptoms resolved immediately with positional eating in left lateral decubitus and prone positions with nasogastric suction. Patient was discharged two days after tolerating full diet. Although the majority of reported cases in literature are associated with rapid weight loss, other confounding variables such as drug use, socioeconomic factors, recent orthopedic surgeries and psychiatric disorders lead to challenges in diagnosis. SMA syndrome is rare with limited reported cases since it was first descried in 1842. Urgent radiologic diagnosis is imperative. With the initial medical management of SMA syndrome being positional eating, quick diagnosis may lead to decreased hospital stays and better outcomes. Patients may need gastric decompression, fluid resuscitation and correction of electrolyte abnormalities. Inirial therapy includes weight loss reversal, which may be through enteral nutritional support but some patients may require parenteral nutrition. This case highlights the high index of suspicion needed to make the proper diagnosis of SMA syndrome in patients with comorbidities and/or confounding symptomatology.Figure 1Figure 2

PURPOSE:To assess gender utilization of the Family and Medical Leave Act (FMLA) in radiology practices across the United States.METHODS:The Practice of Radiology Environment Database was utilized to identify U.S. practice leaders, who were asked to complete an electronic survey developed by the ACR Human Resources (HR) Commission. In 2016, new survey questions asked about number of radiologists in each practice who took FMLA, the reasons why, the average number of weeks taken, and how such absences were covered.RESULTS:Thirty-two percent (579/1815) of practice group leaders responded to the survey and of these, 73% (432/579) answered FMLA questions, with 15% of those (64/432) answering affirmatively that a radiologist in their practice had taken FMLA leave. Reasons for this in 2015 included to care for a newborn/adopted child (49%), because of a personal serious health condition (42%), to care for an immediate family member (8%), or for active military duty (1%). Women took a greater number of weeks of FMLA leave than men for all reasons (care of newborn/adopted child: 10.7 versus 4.7; personal serious health condition: 10.3 versus 8.0; care of immediate family member: 9.7 versus 8.7) except for military duty (24 weeks taken, all by men). At least 69% of leave time was paid, irrespective of reason for leave or gender of person taking it. Most practices (82%) made no workforce changes to cover FMLA leave.CONCLUSIONS:Both genders of radiologists needed absences from work for FMLA-sanctioned reasons.

We report the case of a 33-year-old HIV-infected man who presented with a recurrent, nonhealing perianal fistula. After multiple benign biopsies, the diagnosis of plasmablastic lymphoma (PBL) eventually was made. The patient underwent chemotherapy and radiation with a complete response. Perianal fistulas are frequent in HIV-positive patients, but PBL as a cause is extremely rare. This often delays the diagnosis and treatment of this highly aggressive disease. We review the literature and discuss the pitfalls in the diagnosis and management of the disease.

Purpose: To determine whether thromboembolic risk factor assessment could accurately indicate the pretest probability for pulmonary embolism (PE), and if so, computed tomographic (CT) angiography might be targeted more appropriately than in current usage, resulting in decreased costs and radiation exposure.Materials and Methods: Institutional review board approval was obtained. Electronic medical records of 2003 patients who underwent CT angiography for possible PE during 1 years (July 2004 to February 2006) were reviewed retrospectively for thromboembolic risk factors. Risk factors that were assessed included immobilization, malignancy, hypercoagulable state, excess estrogen state, a history of venous thromboembolism, age, and sex. Logistic regressions were conducted to test the significance of each risk factor.Results: Overall, CT angiograms were negative for PE in 1806 (90.16%) of 2003 patients. CT angiograms were positive for PE in 197 (9.84%) of 2003 patients; 6.36 % were Emergency Department patients, and 13.46% were inpatients. Of the 197 patients with CT angiograms positive for PE, 192 (97.46%) had one or more risk factors, of which age of 65 years or older (69.04%) was the most common. Of the 1806 patients with CT angiograms negative for PE, 520 (28.79%) had no risk factors. The sensitivity and negative predictive value of risk factor assessment in all patients were 97.46% and 99.05%, respectively. All risk factors, except sex, were significant in the multivariate logistic regression (P < .031).Conclusion: In the setting of no risk factors, it is extraordinarily unlikely (0.95% chance) to have a CT angiogram positive for PE. This selectivity and triage step should help reduce current costs and radiation exposure to patients. (C) RSNA, 2010