Renal and splanchnic artery aneurysms are clinically significant vascular abnormalities with potential for life-threatening complications, including rupture. Accurate imaging is essential for initial detection, risk stratification, treatment planning purposes, and longitudinal surveillance. This document provides evidence-based recommendations for imaging evaluation of suspected and known renal and/or splanchnic artery aneurysms across four clinical scenarios: adults undergoing initial evaluation, adults under active surveillance, pregnant patients with suspected aneurysm, and pregnant patients undergoing surveillance. The roles of CTA, MRA, ultrasound (including duplex Doppler and contrast-enhanced techniques), and catheter angiography are reviewed with attention to diagnostic performance and safety considerations. CTA and MRA are generally preferred in nonpregnant adults, whereas ultrasound and noncontrast MRA are favored in pregnancy to minimize radiation and contrast exposure. These document aims to optimize imaging utilization, enhance diagnostic accuracy, and support safe, patient-centered management of renal and/or splanchnic artery aneurysms.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.

Renovascular hypertension is the most common cause of secondary hypertension and occurs in 0.5% to 5% of individuals with hypertension. This is more common in individuals who have difficulty controlling their pressure or elderly patients with end-stage kidney disease. An evaluation for renovascular hypertension is indicated if there is a high level of clinical suspicion. The primary imaging modalities for assessing renovascular hypertension are ultrasound, CT, and MRI, and these options can vary depending on the patient's current renal status. Although ultrasound is beneficial since it uses nonionizing radiation, CT with contrast provides excellent spatial resolution. In patients with decreased renal function, MRI is a reliable alternative. 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.

Rationale: Coronary artery disease (CAD) is a major cause of morbidity and mortality. Elevated coronary artery calcium (CAC) levels are common among individuals eligible for CT lung screening (CTLS), Agatston scores >400 indicate high CAD risk. Identifying CAC on CTLS offers an opportunity to detect high-risk individuals who may benefit from closer monitoring and targeted interventions. This study explored associations between Agatston scores >400, adverse outcomes and modifiable risk factors. Methods: This retrospective, multi-center CTLS cohort study included 4,673 patients from Lahey Hospital and Medical Center (LHMC) and 1,271 scans from Mount Auburn Hospital (MAH). Baseline scans (2012-2017 at LHMC; 2015-2019 at MAH) utilized the 4DMedical CAC algorithm to calculate Agatston scores. Follow-up extended through 2019 at LHMC and 2020 at MAH. A subset of 1,384 LHMC and 419 MAH patients with Agatston scores >400 and primary care within the health system were analyzed for risk factor modification and gender disparities. Chi-square tests examined group differences, and Cox proportional hazards models assessed associations with mortality, lung cancer incidence, and hospital admissions (all-cause, myocardial infarction, and congestive heart failure), with significance at p < 0.05. Results: Of the scans, 4,637 (99.2%) at LHMC and 1,251 (98.4%) at MAH successfully generated Agatston scores. A score >400 was associated with increased lung cancer risk at both LHMC (HR 2.11, CI 1.19-3.73, p = 0.01) and MAH (HR 1.75, CI 1.03-2.96, p = 0.037), and correlated with all-cause hospitalization at LHMC (HR 3.16, CI 1.43-6.99, p = 0.004) and MAH (HR 1.70, CI 1.17-2.48, p = 0.005). High scores were also linked to greater myocardial infarction events at LHMC (HR 2.8, CI 1.47-5.27, p = 0.002) and MAH (HR 2.8, CI 1.2-6.7, p = 0.017), as well as congestive heart failure admissions at LHMC (HR 1.99, CI 2.17-3.39, p = 0.011) and MAH (HR 7.87, CI 2.84-21.8, p < 0.001). Among those with Agatston scores >400, tobacco use was prevalent in 49% at LHMC and 58% at MAH. Elevated LDL (>100 mg/dL) was more common in women than men at both LHMC (55.2% vs. 40.25%, p < 0.001) and MAH (38.5% vs. 27.8%, p = 0.028). Conclusion: An Agatston score >400 on CTLS exams reliably indicates elevated risks for adverse outcomes. Targeted interventions, including smoking cessation and LDL management, are essential, with gender disparities in LDL among women warranting focused attention to improve outcomes in this high-risk group.

OBJECTIVE:To identify imaging utilization patterns and radiologically evident injuries suggestive of intimate partner violence (IPV). METHODS:This retrospective case-control study analyzed historical imaging reports from women reporting physical IPV between 2013 and 2018 ("cases"; n = 265; 6,401 imaging studies) and age- and race-matched controls not reporting IPV (n = 875; 13,462 imaging studies). Adjusted incidence rate ratios (aIRRs) were calculated using Poisson regression to compare imaging utilization by organ system or modality. Logistic regression calculated adjusted odds ratios (aORs) for canceled studies and studies conducted in the emergency department (ED), overnight, or on weekends. Injury patterns were assessed by calculating aIRRs of injury by anatomic site and comparing synchronous and asynchronous injury detection. A time-to-event analysis using Cox proportional hazards regression compared the cumulative incidence of asynchronous injury in patients with at least one injury. RESULTS:Patients experiencing IPV underwent imaging at a higher rate than controls (aIRR: 1.5, 95 confidence interval [CI]: 1.5-1.6). They were more likely to cancel screening mammograms (aOR: 3.2, 95% CI: 1.8-5.7) and undergo imaging in the ED (aOR: 3.8, 95% CI: 2.9-5.0), overnight (aOR: 1.6, 95% CI: 1.3-1.9) and on weekends (aOR: 1.3, 95% CI: 1.1-1.5). The injury rate was higher in cases (aIRR: 15.1, 95% CI: 12.5-18.1), particularly for cranial (aIRR: 104.5, 95% CI: 14.2-770.1), facial (aIRR: 47.0, 95% CI: 18.9-117.0), and thoracic (aIRR: 32.6, 95% CI: 11.5-92.2) injuries. Cases were more likely to have multiple injuries in a single encounter (aOR: 4.7, 95% CI: 1.5-14.1) or multiple encounters with unique injuries (hazard ratio: 4.9, 95% CI: 2.6-9.3). CONCLUSION:Patients experiencing IPV had higher rates of imaging studies, imaging utilization in the ED, weekend, and overnight settings, screening examination cancellation, and radiologically evident injuries than controls.

Background:Chronic obstructive pulmonary disease (COPD) remains underdiagnosed and undertreated. Because screening asymptomatic individuals for COPD is not recommended, several case-finding tools have been explored. The COPD Assessment in Primary Care to Identify Undiagnosed Respiratory Disease and Exacerbation Risk (CAPTURE) questionnaire and peak expiratory flow (PEF) rate (CAPTURE tool) have been tested in the primary care setting, with disappointing results. We hypothesized that these tools could yield better results in a computed tomography lung screening (CTLS) program, where individuals have a history of cigarette smoking and higher prevalence of COPD. Methods:We recruited 67 patients referred to a CTLS program at a single institution. Participants completed the CAPTURE and COPD Assessment Test (CAT) questionnaires. Spirometric testing was completed with a portable device and low-dose chest computed tomography (CT) was performed according to a standard protocol. Results:The group's mean age was 66 ±7 years, 43% were male, with a 37 pack-year smoking history. Eighteen (27%) had COPD (forced expiratory volume in 1 second of 60 ±22% predicted) and a higher CAT score (12 [interquartile range (IQR) 6-15]) compared to the nonobstructed group (CAT=7 [IQR 3-10]), p<0.02. Combining the CAPTURE questionnaire with PEF generated the best COPD diagnostic criteria (sensitivity=0.82, specificity=0.73, area under the receiver operating curve [AUROC]=0.784), followed by combining the CAPTURE questionnaire and emphysema presence (sensitivity=0.73, specificity=0.71, AUROC=0.779). The CAPTURE questionnaire alone had a sensitivity=0.766, specificity=0.616, and AUROC=0.669. Conclusions:The CAPTURE tool is an effective method to find COPD cases in lung cancer screenings. A CT diagnosis of emphysema can substitute peak flow in this population.

Diseases of the thoracic aorta include two broad categories: aneurysmal dilation involving all three layers of the intact aortic wall, and acute aortic syndromes, wherein at least one layer of the aortic wall is disrupted, such as in aortic dissection. These diseases carry a variable risk of subsequent aortic rupture, which is associated with high morbidity and mortality. Imaging is critical in the diagnosis, surveillance, and treatment of this constellation of diseases. 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.

Pulmonary arteriovenous malformations (PAVMs) occur in 30% to 50% of patients with hereditary hemorrhagic telangiectasia. Clinical presentations vary from asymptomatic disease to complications resulting from the right to left shunting of blood through the PAVM such as paradoxical stroke, brain abscesses, hypoxemia, and cardiac failure. Radiology plays an important role both in the diagnosis and treatment of PAVM. Based on different clinical scenarios, the appropriate imaging study has been reviewed and is presented in this document. 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.

Li-Fraumeni syndrome (LFS) is a rare autosomal dominant familial cancer syndrome caused by germline mutations of the tumor protein p53 gene (TP53), which encodes the p53 transcription factor, also known as the "guardian of the genome." The most common types of cancer found in families with LFS include sarcomas, leukemia, breast malignancies, brain tumors, and adrenocortical cancers. Osteosarcoma and rhabdomyosarcoma are the most common sarcomas. Patients with LFS are at increased risk of developing early-onset gastric and colon cancers. They are also at increased risk for several other cancers involving the thyroid, lungs, ovaries, and skin. The lifetime risk of cancer in individuals with LFS is greater than 70% in males and greater than 90% in females. Some patients with LFS develop multiple primary cancers during their lifetime, and guidelines have been established for screening these patients. Whole-body MRI is the preferred modality for annual screening of these patients. The management guidelines for patients with LFS vary, as these individuals are more susceptible to developing radiation-induced cancers-for example, women with LFS and breast cancer are treated with total mastectomy instead of lumpectomy with radiation to the breast. The authors review the role of imaging, imaging guidelines, and imaging features of tumors in the setting of LFS.

Abdominal aortic aneurysm (AAA) is a significant vascular disease found in 4% to 8% of the screening population. If ruptured, its mortality rate is between 75% and 90%, and it accounts for up to 5% of sudden deaths in the United States. Therefore, screening of AAA while asymptomatic has been a crucial portion of preventive health care worldwide. Ultrasound of the abdominal aorta is the primary imaging modality for screening of AAA recommended for asymptomatic adults regardless of their family history or smoking history. Alternatively, duplex ultrasound and CT abdomen and pelvis without contrast may be appropriate for screening.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.

Introduction: In pediatric trauma patients, 60-80% of spinal cord injuries involve the cervical vertebrae. While the American College of Radiology offers guidelines for best imaging practices in the setting of acute pediatric trauma, there is a lack of uniformity in imaging-decision protocols between institutions. Magnetic resonance imaging (MRI) has been shown to demonstrate high sensitivity for both bony and ligamentous injuries while also avoiding unnecessary radiation exposure in the pediatric patient population. However, the efficacy of flexion-extension (FE) radiography following initial MRI has not been evaluated in the pediatric population. Our hypothesis is that FE radiography does not contribute significant diagnostic information after an initial MRI and can be removed from institutional protocols in order to avoid unnecessary testing and reduce pediatric radiation exposure. Methods: Trauma data were collected for pediatric patients presenting with acute cervical spine (c-spine) injury between 2014-2021. A total of 108 patients were subdivided into 41 patients who received “MRI Only” and 67 patients who received both “MRI and FE” diagnostic c-spine imaging. Chi-square testing and t-tests were performed to determine differences between MRI and FE radiographic detection rates of bony and ligamentous injuries in the subgroups. Results: In patients for whom FE did not find any injury, MRI detected bony and ligamentous injuries in 9/59 and 11/60 cases, respectively. In 3/21 (14.3%) cases in which MRI detected a bony and/or ligamentous injury and FE did not, patients eventually required surgical intervention for c-spine stabilization. No patients required surgical fixation when FE radiography showed an abnormality and MRI was normal. Addition of follow-up FE radiography after initial MRI did not have a significant effect on overall hospital length of stay (MRI Only vs. MRI + FE: 9.2 ± 12.0 days vs. 8.6 ± 13.5 days, p=0.816), or on rates of collar removal at discharge or greater than 48 hours after imaging (MRI Only vs. MRI + FE: 35.1% vs. 52.2%, p=0.106). Conclusions: FE radiography following initial MRI did not have a significant effect on clearance for c-collar removal or in reducing hospital length of stay. In addition, FE radiography missed ~10% of bony and ligamentous injuries detected on MRI.

To recognize the imaging patterns of thoracic injuries in survivors of intimate partner violence (IPV). A retrospective radiological review of 688 patients self-reporting IPV to our institution’s violence intervention and prevention program between January 2013 and June 2018 identified 30 patients with 89 thoracic injuries. Imaging and demographic data were collected. Thirty survivors with 89 injuries to the thorax were identified with a median age of 43.5 years (21–65 years). IPV was reported or disclosed as the direct cause of injury in 50 Recognizing common injuries to the thorax will prompt the radiologists to suspect IPV and discuss it with the clinicians.

ObjectiveThe aim of the study is to analyze the imaging findings and injury patterns seen on head computed tomography (CT) examinations performed on survivors of intimate partner violence (IPV).MethodsAn institutional review board-approved retrospective analysis of 668 patients reporting IPV to our institution's violence intervention and prevention program between January 2013 and June 2018 identified 40 unique patients with radiological findings visible on head CT. All injuries visible on head CT were analyzed based on the anatomic location and injury type. Demographics, IPV screening at the time of injury, concomitant, prior, and subsequent injuries to the index head injury were also recorded.ResultsOur study cohort had 36 women and 4 men with a mean age at presentation of 43 +/- 13 years (mean +/- SD), 91 unique injuries with 57 (62.6%) isolated soft tissue injuries, 4 (3.2%) fractures, 13 (14.3%) intra-axial, and 17 (18.7%) extra-axial injuries. Soft tissue injuries and intra-axial injuries occurred most commonly in the frontal region (45.6% and 38.5%), followed by the parietal region (22.8% and 23.1%), while most extra-axial injuries were subdural hematomas (41.2%). Left-sided injuries accounted for 49% (45/91) with 29/91 right-sided (32%) and 17/91 bilateral (19%) injuries. The IPV screening occurred in 44% of injury visits (22/50). Concomitant injuries were seen in 14/50 injury visits (28%), most commonly being in the lower extremity (6/14, 42.9% [% of visits with concomitant injuries]) followed by the upper extremity (5/14, 35.7%), while 52% of visits (26/50) were preceded by prior injuries and 68% of events (34/50) were followed by subsequent injuries.ConclusionsIsolated soft tissue swelling is the most common manifestation of IPV on head CT scans with frontoparietal region being the most common site. Synchronous and metachronous injuries are frequent.

Arterial claudication is a common manifestation of peripheral artery disease. This document focuses on necessary imaging before revascularization for claudication. Appropriate use of ultrasound, invasive arteriography, MR angiography, and CT angiography are discussed. 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 where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Cancer therapy has evolved from being broadly directed towards tumor types, to highly specific treatment protocols that target individual molecular subtypes of tumors. With the ever-increasing data on imaging characteristics of tumor subtypes and advancements in imaging techniques, it is now often possible for radiologists to differentiate tumor subtypes on imaging. Armed with this knowledge, radiologists may be able to provide specific information that can obviate the need for invasive methods to identify tumor subtypes. Different tumor subtypes also differ in their patterns of metastatic spread. Awareness of these differences can direct radiologists to relevant anatomical sites to screen for early metastases that may otherwise be difficult to detect during cursory inspection. Likewise, this knowledge will help radiologists to interpret indeterminate findings in a more specific manner.

To evaluate the imaging findings of facial injuries in patients reporting intimate partner violence (IPV). A retrospective review of radiology studies performed for 668 patients reporting IPV to our institution’s violence prevention support program identified 96 patients with 152 facial injuries. Demographics, imaging findings, and clinical data obtained from a review of the electronic medical records (EMR) were analyzed to categorize injury patterns. The study cohort consisted of 93 women and 3 men with a mean age of 35 years (range 19–76; median 32). At the time of presentation, 57 (59.3%) patients reported IPV as the mechanism of injury. The most frequent site of injury was the midface, seen in 65 (67.7%) patients. The most common fracture sites were the nasal bones (45/152, 29.6%), followed by the mandible (17/152, 11.1%), and orbits (16/152, 10.5%). Left-sided injuries were more common (90/152; 59.2%). A vast majority of fractures (94.5%) showed minimal or no displacement. Over one-third of injuries (60/152, 39.4%) demonstrated only soft tissue swelling or hematoma without fracture. Associated injuries were seen most frequently in the upper extremity, occurring synchronously in 11 (11.4%) patients, and preceding the index facial injury in 20 (21%) patients. /advances in knowledge. The midface was the most frequent location of injury in victims of intimate partner violence, and the nasal bone was the most commonly fractured facial bone. Recognizing these injury patterns can help radiologists suspect IPV and prompt them to discuss the possibility of IPV with the clinical providers.

Novel anticancer agents have replaced conventional chemotherapy as first line agents for many cancers, with continued new and expanding indications. Small molecule inhibitors act on cell surface or intracellular targets and prevent the downstream signaling that would otherwise permit tumor growth and spread. Anticancer antibodies can be directed against growth factors or may be immunotherapeutic agents. The latter act by inhibiting mechanisms that cancer cells use to evade the immune system. Hormonal agents act by decreasing levels of hormones that are necessary for the growth of certain cancer cells. Cancer therapy protocols often include novel anticancer agents and conventional chemotherapy used successively or in combination, in order to maximize survival and minimize morbidity. A working knowledge of anti-cancer drug classification will aid the radiologist in assessing response on imaging.