Claire K. Sandstrom

Diaphragmatic hernias: a spectrum of radiographic appearances.

Diaphragmatic hernias are common, and although frequently incidental, recognition of both benign and life-threatening manifestations of diaphragmatic hernias is necessary to guide appropriate management. Congenital fetal diaphragmatic hernias, traumatic diaphragmatic rupture, and large symptomatic Bochdalek, Morgagni, and hiatal hernias are typically repaired surgically, while eventration, diaphragmatic slips, and small diaphragmatic hernias do not require intervention or imaging follow-up but should be recognized to avoid confusion with other diagnoses that require additional attention. This pictorial essay will explore the imaging findings and clinical characteristics of these entities.

Variability in Management Recommendations for Incidental Thyroid Nodules Detected on CT of the Cervical Spine in the Emergency Department

PURPOSE Incidental thyroid nodules are common on CT. Variability in management recommendations for these nodules due to a lack of accepted CT base guidelines has not been demonstrated. METHODS Consecutive CT cervical spine radiology reports describing thyroid nodules performed in an emergency department from January 1, 2009, to December 31, 2011, were retrospectively reviewed. Number of nodules, nodule size, and type of recommended management were recorded. RESULTS Three hundred fifteen examinations met the inclusion criteria. The mean study age was 64 ± 20 years. Fifty-eight percent were women. Thirty percent (n = 95) of thyroid nodules measured <10 mm, 20% (n = 63) were ≥10 but <15 mm, 11% (n = 36) were ≥15 but <20 mm, and 15.5% (n = 49) were ≥20 mm. Size was not reported for 22.9% (n = 72). Two hundred twenty-seven recommendations were made in 181 (57.5%) studies. Recommendations were made for 51.6% (49 of 95) of nodules <10 mm, for 52.4% (33 of 63) of those ≥10 but <15 mm, for 83.3% (30 of 36) of those ≥15 but <20 mm, and for 81.6% (40 of 49) of those ≥20 mm. Management was recommended in 40.0% (29 of 72) of nodules with no size reported. Fifty-four percent (123 of 227) of recommendations were for ultrasound, followed by no follow-up recommended (17.2% [39 of 227]), clinical correlation (13.7% [31 of 227]), thyroid serology (6.2% [14 of 227]), clinical follow-up (4.8% [11 of 227]), comparison with prior studies (2.2% [5 of 227]), fine-needle aspiration (1.3% [3 of 227]), and nuclear scintigraphy (0.4% [1 of 227]). Nodule size was significantly associated with the likelihood of recommendation (odds ratio, 1.79; 95% confidence interval, 1.37-2.35). CONCLUSIONS Management recommendations for incidental thyroid nodules detected on cervical spine CT are made inconsistently, and the type of management recommended is variable.

Current Concepts in Imaging Evaluation of Penetrating Transmediastinal Injury

Penetrating transmediastinal injuries (TMIs) are injuries that traverse the mediastinum. These injuries are most commonly caused by firearms and knives. The investigation and management algorithms for TMI have undergone changes in recent years due to increasing evidence that computed tomography (CT) in useful in the evaluation of hemodynamically stable TMI patients. Initial investigation of TMI patients depends on the question of hemodynamic stability. In unstable patients, imaging (if any) should be limited to bedside radiography and focused ultrasonography. In hemodynamically stable patients in whom a mediastinal trajectory of injury is suspected, the primary imaging modality after radiography should be multidetector CT. CT is invaluable in the assessment of TMI due to its capacity to depict the injury track as well as demonstrate both direct and indirect signs of organ injury. On the basis of the suspected trajectory and specific findings, radiologists can play an essential role in determining future patient management and investigations for each mediastinal organ, thereby expediting appropriate investigation and treatment and avoiding unnecessary and sometimes invasive tests or surgery. The authors provide an up-to-date and evidence-based approach for the management of hemodynamically unstable and stable patients with suspected TMI, discuss management algorithms and CT protocols, and highlight common and uncommon imaging findings and diagnostic pitfalls associated with vascular, cardiac, esophageal, tracheobronchial, pleural, and pulmonary injuries. Online supplemental material is available for this article.

Renal angiomyolipoma with nontraumatic pulmonary fat embolus.

W275 Angiomyolipoma is the most common benign renal mesenchymal neoplasm arising from the perivascular epithelioid cells (also known as PEComas) and contains a variable proportion of blood vessels, smooth muscle, and adipose tissue [1]. Angiomyolipoma can degenerate into a malignant form known as epithelioid angiomyolipoma; this rare subtype does not contain macroscopic fat and radiographically resembles renal cell carcinoma [2]. Growth into the renal vein is an unusual, but known, complication of benign angiomyolipoma and does not imply malignant potential or degeneration. A review by Islam et al. [3] in 2004 of 26 patients with renal angiomyolipoma invading the IVC suggested that angiomyolipomas are usually found incidentally in middle-aged patients, either as sporadic, often symptomatic, solitary tumors or in association with tuberous sclerosis, in which they are more likely to be multiple, small, and asymptomatic. Tumors with IVC invasion are generally larger than noninvasive angiomyolipomas and are more likely to be symptomatic. Renal Angiomyolipoma With Nontraumatic Pulmonary Fat Embolus

Imaging of Urinary System Trauma

Computed tomography (CT) imaging of the kidney, ureter, and bladder permit accurate and prompt diagnosis or exclusion of traumatic injuries, without the need to move the patient to the fluoroscopy suite. Real-time review of imaging permits selective delayed imaging, reducing time on the scanner and radiation dose for patients who do not require delays. Modifying imaging parameters to obtain thicker slices and noisier images permits detection of contrast extravasation from the kidneys, ureters, and bladder, while reducing radiation dose on the delayed or cystographic imaging. The American Association for the Surgery of Trauma grading system is discussed, along with challenges and limitations.

Identification of Superior Mesenteric Artery Syndrome from Vascular Angle Measurements

A 55-year-old man presented to the Emergency Department by medics with sudden-onset constant, severe, generalized abdominal pain and distention 1 h prior to presentation. The pain was made worse with any movement. Associated symptoms included persistent nausea and vomiting of stomach contents. Specifically, he had no change in bowel or bladder function, difficulty breathing, chest pain, change in diet, or recent weight loss. The patient had no medical history and took no medications. He drank alcohol and smoked cigarettes intermittently and denied drug use. On arrival his vital signs were normal, but he was in severe distress. His abdomen was rigid and distended with involuntary guarding and rebound tenderness. Bowel sounds could not be heard. The rest of the examination was within normal limits. Laboratory studies were within normal limits except for a mild leukocytosis, mild lactic acidosis, and mild lipase elevation. A one-view upright abdominal x-ray study showed no abnormalities other than a relative paucity of bowel gas in the upper and right abdomen. A computed tomography (CT) scan of the abdomen and pelvis was performed with intravenous contrast showing

Acute Shoulder Trauma: What the Surgeon Wants to Know

Many excellent studies on shoulder imaging from a radiologic perspective have been published over the years, demonstrating the anatomy and radiologic findings of shoulder trauma. However, it may not always be clear what the surgeon, who bears the responsibility for treating the injured patient, really needs to know about the injury to predict outcomes and plan management. The authors review the relevant osseous, soft-tissue, and vascular anatomy and describe the clinically relevant concepts that affect management. Familiarity with the Neer classification system for proximal humerus fractures can have a significant impact on treatment. The length and displacement of the medial humeral metaphyseal fragment helps predict the risk of ischemia in proximal humerus fractures. The Nofsinger approach for measuring the area of glenoid fossa bone loss can help the surgeon determine the need for surgical repair of a bony Bankart lesion. The size of Hill-Sachs and reverse Hill-Sachs lesions is also an important predictor of stability. The Ideberg classification system for intraarticular fractures of the glenoid fossa, combined with information on instability and joint incongruity, helps determine the need for surgical fixation of glenoid fossa fractures. Awareness of what matters to the surgeon can help radiologists better determine where to focus their attention and efforts when describing acute shoulder trauma.

Core curriculum illustration: anterior process fracture of the calcaneus

This is the 28th installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at http://www.aseronline.org/curriculum/toc.htm.

Core curriculum illustration: acute pyelonephritis

This is the 26th installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online please visit the ASER Core Curriculum and Recommendations for Study online at: http://www.aseronline.org/curriculum/toc.htm.

Beyond decreased bowel enhancement: acute abnormalities of the mesenteric and portal vasculature.

Acute mesenteric ischemia (AMI) is a potentially life-threatening condition with an associated high mortality. Prompt diagnosis is crucial to achieve a favorable outcome. The radiologist plays a central role in the initial evaluation of a patient with suspected AMI. In this pictorial essay, we review the appropriate imaging evaluation of a patient with suspected AMI, and we review both the common and uncommon etiologies of mesenteric ischemia. With each etiology presented, relevant clinical and imaging findings, as well as potential treatments, are reviewed.