Tabassum A. Kennedy

ACR Appropriateness Criteria Low Back Pain.

Most patients presenting with uncomplicated acute low back pain (LBP) and/or radiculopathy do not require imaging. Imaging is considered in those patients who have had up to 6 weeks of medical management and physical therapy that resulted in little or no improvement in their back pain. It is also considered for those patients presenting with red flags raising suspicion for serious underlying conditions, such as cauda equina syndrome, malignancy, fracture, and infection. Many imaging modalities are available to clinicians and radiologists for evaluating LBP. Application of these modalities depends largely on the working diagnosis, the urgency of the clinical problem, and comorbidities of the patient. When there is concern for fracture of the lumbar spine, multidetector CT is recommended. Those deemed to be interventional candidates, with LBP lasting for > 6 weeks having completed conservative management with persistent radiculopathic symptoms, may seek MRI. Patients with severe or progressive neurologic deficit on presentation and red flags should be evaluated with MRI. 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 include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (the RAND/UCLA Appropriateness Method and the Grading of Recommendations Assessment, Development, and Evaluation) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Imaging of Temporal Bone Trauma

Temporal bone trauma is commonly seen in patients with craniofacial injury and can be detected using multidetector computed tomography. A thorough understanding of the different types of temporal bone fracture patterns is needed to accurately describe the trajectory of injury as well as anticipated complications. Fractures should be described based on direction, segment of temporal bone involved, as well as involvement of the otic capsule. More importantly, the radiologist plays an integral role in identifying complications of temporal bone injury, which often have significant clinical implications.

Simultaneous, unilateral plugging of superior and posterior semicircular canal dehiscences to treat debilitating hyperacusis.

OBJECTIVE To describe a case of bilateral superior and posterior semicircular canal dehiscences, and the use of a unilateral transmastoid approach to address both right-sided defects simultaneously. CASE REPORT In a patient with right-sided hyperacusis, bilateral dehiscence of both the superior and the posterior semicircular canals was identified, located adjacent to the common crus, together with a right-sided, anterosuperiorly positioned sigmoid sinus and a high-riding jugular bulb. Results for audiography and cervical vestibular evoked myogenic potential testing were consistent with right-sided semicircular canal dehiscence. At surgery, a right-sided transmastoid approach provided access to plug both defects simultaneously, following posterior mobilisation of the sigmoid sinus. The patients hyperacusis was completely resolved, with a 10-30 dB improvement in his right ear air conduction hearing, without decrement in bone conduction. CONCLUSION In properly selected patients, a transmastoid approach can be used to effectively manage superior semicircular canal dehiscence and posterior semicircular canal dehiscence simultaneously. Pre-operative computed tomography is recommended to evaluate the dehiscence sites and to identify complicating vascular anatomy.

ACR Appropriateness Criteria Dementia and Movement Disorders.

Neurodegenerative disease, including dementia, extrapyramidal degeneration, and motor system degeneration, is a growing public health concern and is quickly becoming one of the top health care priorities of developed nations. The primary function of anatomic neuroimaging studies in evaluating patients with dementia or movement disorders is to rule out structural causes that may be reversible. Lack of sensitivity and specificity of many neuroimaging techniques applied to a variety of neurodegenerative disorders has limited the role of neuroimaging in differentiating types of neurodegenerative disorders encountered in everyday practice. Nevertheless, neuroimaging is a valuable research tool and has provided insight into the structure and function of the brain in patients with neurodegenerative disorders. Advanced imaging techniques, such as functional neuroimaging with MRI and MR spectroscopy, hold exciting investigative potential for better understanding of neurodegenerative disorders, but they are not considered routine clinical practice at this time. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Radiographic Features of Superior Semicircular Canal Dehiscence in the Setting of Chronic Ear Disease

Objective To determine if radiologic chronic otitis media (COM), both with and without cholesteatoma, is associated with superior semicircular canal dehiscence (SSCD). Study Design Retrospective review of consecutive high-resolution computed tomography (HRCT) scans of the temporal bone. Setting Tertiary care medical center. Patients Two hundred consecutive patients undergoing HRCT of the temporal bone beginning January 1, 2012. Intervention Imaging was evaluated by 3 reviewers (2 neuroradiologists and 1 neurotologist). All scans were assessed for the presence of SSCD, cholesteatoma, chronic otomastoiditis, tegmen dehiscence, and for abnormalities of the cochlea, vestibule, facial nerve, and temporal bone vasculature. Main Outcome Measure Ears with COM associated with chronic otomastoiditis or cholesteatoma were compared with those without COM with respect to the presence of SSCD or other temporal bone abnormalities. Statistical analysis was performed to assess for differences between the groups studied. Results One-hundred ninety-four patients (388 ears) were included. Cholesteatoma was identified in 48 ears (12.4%) and chronic otomastoiditis in 62 ears (16%). Ten ears with cholesteatoma had ipsilateral SSCD, and 8 ears with chronic otomastoiditis had ipsilateral SSCD. In 340 ears without either cholesteatoma or chronic otomastoiditis, SSCD was found in 18 (5.3%). SSCD was found to occur significantly more often in patients with ipsilateral radiologic cholesteatoma. No cases of SSCD were associated with cochlear, facial nerve, or vascular abnormalities. Conclusion Our findings suggest that COM with cholesteatoma is associated with the presence of SSCD, although the nature of this association is unclear.

Bilateral Duplicated Internal Carotid Arteries Presenting as Middle Ear Masses: A Case Report and Review of the Literature

Objectives We seek to describe an individual with bilateral duplicated internal carotid arteries (ICAs) presenting as middle ear masses, to discuss the anatomy and characteristic imaging findings associated with this condition, and to familiarize clinicians with effective methods to prevent and manage complications related to this entity. Methods The clinical presentation of an individual with this unusual vascular anomaly was reviewed. A literature search was then performed to identify previously reported studies describing aberrant ICAs in order to characterize the presentation, anatomy, imaging findings, and management of this condition. Results An aberrant ICA presenting as a middle ear mass is uncommon; there are only approximately 45 reported cases to date. The majority of these cases presented as a unilateral anomaly without a duplication, were associated with pulsatile tinnitus and hearing loss, and were diagnosed during middle ear procedures. Bilateral aberrant ICAs are exceedingly rare, with only 14 existing reports. Only 1 of these cases presented with duplicated ICAs. Our report demonstrates an unusual presentation of aberrant ICAs, as pulsatile tinnitus was absent and previous middle ear surgery had been performed without establishing this diagnosis and without any resulting complications. Furthermore, this case represents the first known instance of a bilateral duplicated ICA system without persistent stapedial arteries. Although vascular middle ear anomalies are unusual, complications of surgical manipulation have been documented. Conclusions The clinician must have a high index of suspicion for vascular lesions in patients presenting with a retrotympanic mass. Appropriate diagnostic imaging studies should be performed to exclude this diagnosis before middle ear exploration. Should injury to the carotid artery occur, surgeons should follow specific guidelines to avoid potentially serious complications.

ACR Appropriateness Criteria® Cerebrovascular Disease

Diseases of the cerebral vasculature represent a heterogeneous group of ischemic and hemorrhagic etiologies, which often manifest clinically as an acute neurologic deficit also known as stroke or less commonly with symptoms such as headache or seizures. Stroke is the fourth leading cause of death and is a leading cause of serious long-term disability in the United States. Eighty-seven percent of strokes are ischemic, 10% are due to intracerebral hemorrhage, and 3% are secondary to subarachnoid hemorrhage. The past two decades have seen significant developments in the screening, diagnosis, and treatment of ischemic and hemorrhagic causes of stroke with advancements in CT and MRI technology and novel treatment devices and techniques. Multiple different imaging modalities can be used in the evaluation of cerebrovascular disease. The different imaging modalities all have their own niches and their own advantages and disadvantages in the evaluation of cerebrovascular disease. 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.

Radiology Workflow Dynamics: How Workflow Patterns Impact Radiologist Perceptions of Workplace Satisfaction

RATIONALE AND OBJECTIVES The study aimed to assess perceptions of reading room workflow and the impact separating image-interpretive and nonimage-interpretive task workflows can have on radiologist perceptions of workplace disruptions, workload, and overall satisfaction. MATERIALS AND METHODS A 14-question survey instrument was developed to measure radiologist perceptions of workplace interruptions, satisfaction, and workload prior to and following implementation of separate image-interpretive and nonimage-interpretive reading room workflows. The results were collected over 2 weeks preceding the intervention and 2 weeks following the end of the intervention. The results were anonymized and analyzed using univariate analysis. RESULTS A total of 18 people responded to the preintervention survey: 6 neuroradiology fellows and 12 attending neuroradiologists. Fifteen people who were then present for the 1-month intervention period responded to the postintervention survey. Perceptions of workplace disruptions, image interpretation, quality of trainee education, ability to perform nonimage-interpretive tasks, and quality of consultations (P < 0.0001) all improved following the intervention. Mental effort and workload also improved across all assessment domains, as did satisfaction with quality of image interpretation and consultative work. CONCLUSION Implementation of parallel dedicated image-interpretive and nonimage-interpretive workflows may improve markers of radiologist perceptions of workplace satisfaction.

Documenting Web-Based Learning Modules as Scholarly Activity for Promotion

Although Boyer’s and Glassick’s work focused on undergraduate education, this concept has also been applied to medical education [3]. Over the past 10 years, changes in the pedagogical framework in medical education have resulted in a greater emphasis on “flipped-classroom” models [4]. This, in turn, has resulted in the development of enduring learning objects (ELOs) to supplement educators’ in-person teaching. Educators are creating various electronic resources (websites, apps, interactive modules) that are being implemented within the medical curriculum to replace standard lecturebased teaching [4]. Many of these

ACR Appropriateness Criteria® Penetrating Neck Injury

In patients with penetrating neck injuries with clinical soft injury signs, and patients with hard signs of injury who do not require immediate surgery, CT angiography of the neck is the preferred imaging procedure to evaluate extent of injury. Other modalities, such as radiography and fluoroscopy, catheter-based angiography, ultrasound, and MR angiography have their place in the evaluation of the patient, depending on the specific clinical situation and question at hand. 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 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.