Trauma is a common indication for seeking medical treatment including falls, motor vehicle collision (MVC), and assault. Minor blunt trauma can be defined as minor nonfatal injury to a single body part or minor injury with a low-risk mechanism including limited assault, ground-level falls, low-speed MVC, fall from bicycle, and blunt sports injuries. Patients are assumed to be ambulatory without distracting injuries to limit physical examination with normal mental status. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Trauma remains the leading cause of mortality in the United States for those <45 years of age, and it is the fourth leading cause of death overall. Polytrauma is defined as an injury to at least two body parts, including the head, neck, chest, abdomen, pelvis, or an extremity, with any one or a combination of these injuries being potentially fatal. This document covers imaging of major blunt trauma or polytrauma resulting in multiple organ injuries. Burn injuries, and injuries to pediatric patients are excluded. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

This document assesses the appropriateness of various imaging studies for acute penetrating trauma to the torso. Penetrating trauma most commonly occurs from gunshots and stabbings, although any object can impale the patient. Anatomic location, type of penetrating trauma, and hemodynamic status are among the many important factors when deciding upon if, what, and when imaging is needed to further evaluate the patient. Imaging plays a critical role in the management of these patients. CT, in particular, aids in identifying and predicting internal injuries based upon trajectory of the object. Clinical variants are distinguished by ballistic versus nonballistic injuries, hemodynamic status, and compartment of the body injured. Ballistic trauma trajectory is less predictable, and imaging recommendations are adjusted for this unpredictability. Excluded from this document are penetrating traumatic injuries to pediatric patients and specific recommendations when the genitourinary system is clinically suspected to be injured, the latter of which is more specifically discussed in other Appropriateness Criteria documents.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are documented annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer documented journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer documented literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Establishing an emergency radiology division in a practice that has long-standing patterns of operational routines comes with both challenges and opportunities. In this article, considerations around scheduling and staffing, compensation, and equity and parity are provided with supporting literature references. Furthermore, a panel of experts having established, grown and managed emergency radiology divisions in North America and Europe share their experiences through a question and answer format.

HIV-associated dementia is commonly seen in older individuals and presents as a subcortical dementia associated with concentration, attention, and memory impairments. Motor signs, such as difficulty with gait, and mood changes are less prominent findings but are considered during diagnosis. We present a case of HIV-associated dementia in a young 29-year-old man who presented with progressive lower extremity weakness and difficulty ambulating.

This document focuses on imaging in the adult and pregnant populations with right lower quadrant (RLQ) abdominal pain, including patients with fever and leukocytosis. Appendicitis remains the most common surgical pathology responsible for RLQ abdominal pain in the United States. Other causes of RLQ pain include right colonic diverticulitis, ureteral stone, and infectious enterocolitis. Appropriate imaging in the diagnosis of appendicitis has resulted in decreased negative appendectomy rate from as high as 25% to approximately 1% to 3%. Contrast-enhanced CT remains the primary and most appropriate imaging modality to evaluate this patient population. MRI is approaching CT in sensitivity and specificity as this technology becomes more widely available and utilization increases. Unenhanced MRI and ultrasound remain the diagnostic procedures of choice in the pregnant patient. MRI and ultrasound continue to perform best in the hands of the experts. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Small-bowel obstruction is a common cause of abdominal pain and accounts for a significant proportion of hospital admissions. Radiologic imaging plays the key role in the diagnosis and management of small-bowel obstruction as neither patient presentation, the clinical examination, nor laboratory testing are sufficiently sensitive or specific enough to diagnose or guide management. This document focuses on the imaging evaluation of the two most commonly encountered clinical scenarios related to small-bowel obstruction: the acute presentation and the more indolent, low-grade, or intermittent presentation. This document hopes to clarify the appropriate utilization of the many imaging procedures that are available and commonly employed in these clinical settings. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

This review assesses the appropriateness of various imaging studies for adult major blunt trauma or polytrauma in the acute setting. Trauma is the leading cause of mortality for people in the United States <45 years of age, and the fourth leading cause of death overall. Imaging, in particular CT, plays a critical role in the management of these patients, and a number of indications are discussed in this publication, including patients who are hemodynamically stable or unstable; patients with additional injuries to the face, extremities, chest, bowel, or urinary system; and pregnant patients. Excluded from consideration in this review are penetrating traumatic injuries, burns, and injuries to pediatric patients. Patients with suspected injury to the head and spine are also discussed more specifically in other appropriateness criteria documents. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

This review summarizes the relevant literature regarding imaging of suspected diverticulitis as an etiology for left lower quadrant pain, and imaging of complications of acute diverticulitis. The most common cause of left lower quadrant pain in adults is acute sigmoid or descending colonic diverticulitis. Appropriate imaging triage for patients with suspected diverticulitis should address the differential diagnostic possibilities and what information is necessary to make a definitive management decision. Patients with diverticulitis may require surgery or interventional radiology procedures because of associated complications, including abscesses, fistulas, obstruction, or perforation. As a result, there has been a trend toward greater use of imaging to confirm the diagnosis of diverticulitis, evaluate the extent of disease, and detect complications before deciding on appropriate treatment. Additionally, in the era of bundled payments and minimizing health care costs, patients with acute diverticulitis are being managed on an outpatient basis and rapid diagnostic imaging at the time of initial symptoms helps to streamline and triage patients to the appropriate treatment pathway. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Acute pancreatitis (AP) is divided into two types: interstitial edematous and necrotizing. AP severity is classified clinically into mild, moderately severe, and severe, depending on the presence and persistence of organ failure and local or systemic complications. The revised Atlanta classification divides the clinical course of AP into an early (first week) and late phase (after first week) and the clinical phase determines the role of imaging. Imaging has a limited role in the early phase. In the early phase with typical presentations of AP, ultrasound is usually the only appropriate modality and is used for the detection of gallstones. CT and MRI are appropriate in the early phase in equivocal presentations. In the late phase (or at least 48-72 hours after presentation), CT and MRI play a primary role in the imaging of patients with AP for evaluation of etiology, complications, extent of disease, intervention, and follow-up; CT is particularly useful in patients with suspected acute hemorrhage. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

The range of pathology in adults that can produce abdominal pain is broad and necessitates an imaging approach to evaluate many different organ systems. Although localizing pain prompts directed imaging/management, clinical presentations may vary and result in nonlocalized symptoms. This review focuses on imaging the adult population with nonlocalized abdominal pain, including patients with fever, recent abdominal surgery, or neutropenia. Imaging of the entire abdomen and pelvis to evaluate for infectious or inflammatory processes of the abdominal viscera and solid organs, abdominal and pelvic neoplasms, and screen for ischemic or vascular etiologies is essential for prompt diagnosis and treatment. Often the first-line modality, CT quickly evaluates the abdomen/pelvis, providing for accurate diagnoses and management of patients with abdominal pain. Ultrasound and tailored MRI protocols may be useful as first-line imaging studies, especially in pregnant patients. In the postoperative abdomen, fluoroscopy may help detect anastomotic leaks/abscesses. While often performed, abdominal radiographs may not alter management. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Procedure Appropriateness Category Relative Radiation Level CT abdomen and pelvis with IV contrast Usually Appropriate ☢☢☢ CT abdomen and pelvis without IV contrast May Be Appropriate ☢☢☢ MRI abdomen and pelvis without and with IV contrast May Be Appropriate O MRI abdomen and pelvis without IV contrast May Be Appropriate O US abdomen transabdominal May Be Appropriate O CT abdomen and pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢ Fluoroscopy contrast enema Usually Not Appropriate ☢☢☢ Radiography abdomen and pelvis Usually Not Appropriate ☢☢☢ US pelvis transvaginal Usually Not Appropriate O

Procedure Appropriateness Category Relative Radiation Level CT abdomen and pelvis with IV contrast Usually Appropriate ☢☢☢ MRI abdomen and pelvis without and with IV contrast May Be Appropriate O US abdomen May Be Appropriate O CT abdomen and pelvis without IV contrast May Be Appropriate ☢☢☢ MRI abdomen and pelvis without IV contrast May Be Appropriate O CT abdomen and pelvis without and with IV contrast May Be Appropriate ☢☢☢☢ Radiography abdomen May Be Appropriate ☢☢ FDG-PET/CT skull base to mid-thigh Usually Not Appropriate ☢☢☢☢ WBC scan abdomen and pelvis Usually Not Appropriate ☢☢☢☢ Nuclear medicine scan gallbladder Usually Not Appropriate ☢☢ Fluoroscopy contrast enema Usually Not Appropriate ☢☢☢ Fluoroscopy upper GI series with small bowel follow-through Usually Not Appropriate ☢☢☢

Mesenteric ischemia is an uncommon condition resulting from decreased blood flow to the small or large bowel in an acute or chronic setting. Acute ischemia is associated with high rates of morbidity and mortality; however, it is difficult to diagnose clinically. Therefore, a high degree of suspicion and prompt imaging evaluation are necessary. Chronic mesenteric ischemia is less common and typically caused by atherosclerotic occlusion or severe stenosis of at least two of the main mesenteric vessels. While several imaging examination options are available for the initial evaluation of both acute and chronic mesenteric ischemia, CTA of the abdomen and pelvis is overall the most appropriate choice for both conditions. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Procedure Appropriateness Category Relative Radiation Level CTA abdomen and pelvis with IV contrast Usually Appropriate ☢☢☢ CT abdomen and pelvis with IV contrast May Be Appropriate ☢☢☢ Arteriography abdomen May Be Appropriate (Disagreement) ☢☢☢ MRA abdomen and pelvis without and with IV contrast May Be Appropriate (Disagreement) O Radiography abdomen May Be Appropriate ☢☢ US duplex Doppler abdomen May Be Appropriate O CT abdomen and pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢ CT abdomen and pelvis without IV contrast Usually Not Appropriate ☢☢☢ MRA abdomen and pelvis without IV contrast Usually Not Appropriate O

Procedure Appropriateness Category Relative Radiation Level CT abdomen and pelvis with IV contrast Usually Appropriate ☢☢☢ CT abdomen and pelvis without IV contrast May Be Appropriate ☢☢☢ MRI abdomen and pelvis without and with IV contrast May Be Appropriate O Radiography abdomen and pelvis May Be Appropriate (Disagreement) ☢☢☢ Fluoroscopy small bowel follow-through May Be Appropriate ☢☢☢ MRI abdomen and pelvis without IV contrast May Be Appropriate O CT abdomen and pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢ CT enteroclysis Usually Not Appropriate ☢☢☢☢ CT enterography Usually Not Appropriate ☢☢☢☢ MR enterography Usually Not Appropriate O US abdomen and pelvis Usually Not Appropriate O Fluoroscopy small bowel enteroclysis Usually Not Appropriate ☢☢☢ MR enteroclysis Usually Not Appropriate O

In our emergency department (ED), patients with flank pain often undergo non-enhanced computed tomography (NECT) to assess for nephroureteral (NU) stone. After immediate image review, decision is made regarding need for subsequent contrast-enhanced CT (CECT) to help assess for other causes of pain. This study aimed to review the experience of a single institution with this protocol and to assess the utility of CECT. Over a 6 month period, we performed a retrospective analysis on ED patients presenting with flank pain undergoing CT for a clinical diagnosis of nephroureterolithiasis. Patients initially underwent abdominopelvic NECT. The interpreting radiologist immediately decided whether to obtain a CECT to evaluate for another etiology of pain. Medical records, CT reports and images, and 7-day ED return were reviewed. CT diagnoses on NECT and CECT were compared. Additional information from CECT and changes in management as documented in the patient’s medical record were noted. Three hundred twenty-two patients underwent NECT for obstructing NU stones during the study period. Renal or ureteral calculi were detected in 143/322 (44.4 %). One hundred fifty-four patients (47.8 %) underwent CECT. CECT added information in 17/322 cases (5.3 %) but only changed management in 6/322 patients (1.9 %). In four of these patients with final diagnosis of renal infarct, splenic infarct, pyelonephritis and early acute appendicitis in a thin patient, there was no abnormality on the NECT (4/322 patients, 1.2 %). In the remaining 2 patients, an abnormality was visible on the NECT. In patients presenting with flank pain with a clinical suspicion of nephroureterolithiasis, CECT may not be indicated. While CECT provided better delineation of an abnormality in 5.3 % of cases, changes in management after CECT occurred only in 2 %. This included 1 % of patients in whom a diagnosis of organ infarct, pyelonephritis or acute appendicitis in a thin patient could only be made on CECT.

Background: Headache is a common complaint in emergency department (ED) patients. Nearly 15% of ED headache patients will have brain computed tomography (CT) done. One frequent finding on these scans is "chronic sinusitis." Assuming that "chronic sinusitis" is the cause of the patient's headache is a potential source of mis-diagnosis. Study Objective: We hypothesized that CT findings of chronic sinusitis occur with equal frequency in patients with atraumatic headache as in control patients with minor head injury. Methods: This is a retrospective, single-center medical record review of consecutive discharged patients who received noncontrast head CT scans in an urban ED for either minor closed head injury or atraumatic headache. Each patient's head CT radiologic report was reviewed for findings of sinusitis and classified as chronic sinusitis, indeterminate for sinusitis, air-fluid levels, or no findings of sinusitis. Results: We enrolled 500 patients (234 in the atraumatic headache group, 266 in the minor head injury group). The two groups were similar except that more women were enrolled in the atraumatic headache group. CT findings of chronic sinusitis in the atraumatic headache group (22.2%) and the minor head injury group (17.7%; difference 4.5%; 95% confidence interval of -2.5-11.6%). Conclusion: Prevalence of CT findings of sinusitis in ED patients with atraumatic headaches and mild head injury are similar. This strongly suggests that CT findings of chronic sinusitis in patients with atraumatic headache may be incidental, and are rarely the cause of a patient's acute headache. (C) 2014 Elsevier Inc.

Objective: To prospectively examine undifferentiated emergency department (ED) patients with dizziness to identify clinical features associated with acute stroke.Patients and Methods: We conducted a pilot study from November 1, 2009, through October 30, 2010, of adult patients with dizziness presenting to 3 urban academic EDs. Data collected included demographic characteristics, medical history, presenting symptoms, examination findings, clinician pretest probability of stroke, and neuroimaging results. Logistic regression was used to identify variables with a significant association with acute stroke (P <. 05).Results: During the study period, we enrolled 473 patients (mean +/- SD age, 56.7 +/- 19.3 years; 60% female; and 71% white). We found 30 acute, serious diagnoses (6.3%), including 14 ischemic strokes, 2 subarachnoid hemorrhages, 7 mass lesions, 2 demyelinating lesions, 2 severe vertebral artery stenoses, 2 acute coronary syndromes, and 1 case of hydrocephalus and meningitis). We identified 6 clinical variables associated with stroke: age (odds ratio [ OR], 1.04; 95% CI, 1.0-1.07), hyperlipidemia (OR, 3.62; 95% CI, 1.24-10.6), hypertension (OR, 4.91; 95% CI, 1.46-16.5), coronary artery disease (OR, 3.33; 95% CI, 1.0610.5), abnormal tandem gait test result (OR, 3.13; 95% CI, 1.10-8.89), and high or moderate physician pretest probability for acute stroke (OR, 18.8; 95% CI, 4.72-74.5).Conclusions: Most ED patients with dizziness do not have a serious cause of their symptoms. Although the small number of outcomes precluded development of a multivariate model, we identified several individual high-risk variables associated with acute ischemic stroke. Further study will be needed to validate the findings of this pilot investigation. (C) 2014 Mayo Foundation for Medical Education and Research

Dr. Matthew Bivens: Today's case is that of a 36-year-old woman who presented with a headache associated with neurological symptoms. She had a long history of chronic headaches, some of which had in past been associated with neurological symptoms.