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January 2017 Imaging Pearls - Learning Modules | CT Imaging | CT Scan Protocols - CTisus
Imaging Pearls ❯ January 2017
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    • “The combination of big data and artificial intelligence, referred to by some as the fourth industrial revolution, will change radiology and pathology along with other medical specialties. Although reports of radiologists and pathologists being replaced by computers seem exaggerated, these specialties must plan strategically for a future in which artificial intelligence is part of the health care workforce.”

      
Adapting to Artificial Intelligence 
Radiologists and Pathologists as Information Specialists 
Jha S, Topol EJ
JAMA. Published online November 29, 2016. doi:10.1001/jama.2016.17438
    • “Watson has a boundless capacity for learning—and now has 30 billion images to review after IBM acquired Merge. Watson may become the equivalent of a general radiologist with super-specialist skills in every domain—a radiologist’s alter ego and nemesis.”


      Adapting to Artificial Intelligence 
Radiologists and Pathologists as Information Specialists 
Jha S, Topol EJ
JAMA. Published online November 29, 2016. doi:10.1001/jama.2016.17438
    • “For example, a radiologist typically views 4000 images in a CT scan of multiple body parts (“pan scan”) in patients with multiple trauma. The abundance of data has changed how radiologists interpret images; from pattern recognition, with clinical context, to searching for needles in haystacks; from inference to detection. The radiologist, once a maestro with a chest ra- diograph, is now often visually fatigued searching for an occult fracture in a pan scan.”

      
Adapting to Artificial Intelligence 
Radiologists and Pathologists as Information Specialists 
Jha S, Topol EJ
JAMA. Published online November 29, 2016. doi:10.1001/jama.2016.17438
    • “Radiologists should identify cognitively simple tasks that could be addressed by artificial intelligence, such as screening for lung cancer on CT. This involves detecting, measuring, and characterizing a lung nodule, the management of which is standardized. A radiology residency or a medical degree is not needed to detect lung nodules.”

      
Adapting to Artificial Intelligence 
Radiologists and Pathologists as Information Specialists 
Jha S, Topol EJ
JAMA. Published online November 29, 2016. doi:10.1001/jama.2016.17438
    • “Because pathology and radiology have a similar past and a common destiny, perhaps these specialties should be merged into a single entity, the “information specialist,” whose responsibility will not be so much to extract information from images and histology but to manage the information extracted by artificial intelligence in the clinical context of the patient.”

      
Adapting to Artificial Intelligence 
Radiologists and Pathologists as Information Specialists 
Jha S, Topol EJ
JAMA. Published online November 29, 2016. doi:10.1001/jama.2016.17438
    • “The information specialist would interpret the important data, advise on the added value of another diagnostic test, such as the need for additional imaging, anatomical pathology, or a laboratory test, and integrate information to guide clinicians. Radiologists and pathologists will still be the physician’s physician.”

      
Adapting to Artificial Intelligence 
Radiologists and Pathologists as Information Specialists 
Jha S, Topol EJ
JAMA. Published online November 29, 2016. doi:10.1001/jama.2016.17438
    • “If artificial intelligence becomes adept at screening for lung and breast cancer, it could screen populations faster than ra- diologists and at a fraction of cost. The information specialist could ensure that images are of sufficient quality and that artificial intelligence is yielding neither too many false-positive nor too many false- negative results. The efficiency from the economies of scale because of artificial intelligence could benefit not just developed countries, such as the United States, but developing countries hampered by access to specialists. A single information specialist, with the help of artificial intelligence, could potentially manage screening for an entire town in Africa.”


      Adapting to Artificial Intelligence 
Radiologists and Pathologists as Information Specialists 
Jha S, Topol EJ
JAMA. Published online November 29, 2016. doi:10.1001/jama.2016.17438
    • “There may be resistance to merging 2 distinct medical specialties, each of which has unique pedagogy, tradition, accreditation, and reimbursement. However, artificial intelligence will change these diagnostic fields. The merger is a natural fusion of human talent and artificial intelligence. United, radiologists and pathologists can thrive with the rise of artificial intelligence.”


      Adapting to Artificial Intelligence 
Radiologists and Pathologists as Information Specialists 
Jha S, Topol EJ
JAMA. Published online November 29, 2016. doi:10.1001/jama.2016.17438
    • “Information specialists should train in the traditional sciences of pathology and radiology. The training should take no longer than it presently takes because the trainee will not spend time mastering the pattern recognition required to become a competent radiologist or pathologist. Visual interpretation will be restricted to perceptual tasks that artificial intelligence cannot perform as well as humans. The trainee need only master enough medical physics to improve suboptimal quality of medical images. Information special- ists should be taught Bayesian logic, statistics, and data science and be aware of other sources of information such as genomics and bio- metrics, insofar as they can integrate data from disparate sources with a patient’s clinical condition.”


      Adapting to Artificial Intelligence 
Radiologists and Pathologists as Information Specialists 
Jha S, Topol EJ
JAMA. Published online November 29, 2016. doi:10.1001/jama.2016.17438
    • “For both readers, there was no significant difference in agreement with the reference standard for per-vessel stenosis scores using either the 3D workstation or the iPad. In a multivariable logistic regression analysis including reader, workstation, and vessel as co-variates, there was no significant association between workstation type or reader and agreement with the reference standard (p > 0.05). Both readers identified 100 % of coronary anomalies using each technique.Reading of coronary CT angiography examinations on the iPad had no influence on stenosis assessment compared to the standard clinical workstation.”


      Remote reading of coronary CTA exams using a tablet computer: utility for stenosis assessment and identification of coronary anomalies 
Stefan L. Zimmerman, Cheng T. Lin, Linda C. Chu, John Eng, Elliot K. Fishman
Emerg Radiol (2016) 23:255–261
    • “When agreement with the reference was assessed per vessel for the presence of significant CAD, overall agreement in- creased to 87 and 90 % for the iPad and clinical workstations, respectively (difference, p > 0.05). There was 100 % agreement between readers and the reference for identification of coronary anomalies and aneurysms for both the iPad and clinical workstation.”


      Remote reading of coronary CTA exams using a tablet computer: utility for stenosis assessment and identification of coronary anomalies 
Stefan L. Zimmerman, Cheng T. Lin, Linda C. Chu, John Eng, Elliot K. Fishman
Emerg Radiol (2016) 23:255–261
    • “The multivariate analysis showed the use of the iPad had no significant impact on the accuracy of coronary CTA reads. In a multivariable logistic regression analysis including reader, workstation, and vessel as co-variates, there was no significant association between workstation type or reader and agreement with the reference scores for presence of significant CAD (p > 0.05).”


      Remote reading of coronary CTA exams using a tablet computer: utility for stenosis assessment and identification of coronary anomalies 
Stefan L. Zimmerman, Cheng T. Lin, Linda C. Chu, John Eng, Elliot K. Fishman
Emerg Radiol (2016) 23:255–261
    • “Coronary CTA imaging requires considerable training and expertise. Mobile devices can be used to expand avail- ability of these expert readers by allowing them to perform evaluations anywhere with a reliable internet connection. If implemented in the clinical routine, it is important to consider how these results will be communicated to the covering physicians. In our practice, when a remote study is performed, the reading physician is provided the contact information of the ordering physician and discusses the case directly with the referring. A preliminary verbal report is then stored in our electronic medical record by the ED provider until the formal report can be dictated by the cardiac imager.”

      
Remote reading of coronary CTA exams using a tablet computer: utility for stenosis assessment and identification of coronary anomalies 
Stefan L. Zimmerman, Cheng T. Lin, Linda C. Chu, John Eng, Elliot K. Fishman
Emerg Radiol (2016) 23:255–261
    • “Coronary CTA with using a tablet computer is feasible with results that are no different from reading of cardiac exams on standard clinical workstations. On multivariate analysis, we found no significant relationship between the type of reading modality and accuracy of interpretation. Remote reading with a tablet computer could be used to expand availability of coronary CTA in the ED.”


      Remote reading of coronary CTA exams using a tablet computer: utility for stenosis assessment and identification of coronary anomalies 
Stefan L. Zimmerman, Cheng T. Lin, Linda C. Chu, John Eng, Elliot K. Fishman
Emerg Radiol (2016) 23:255–261
Cardiac

    • “When agreement with the reference was assessed per vessel for the presence of significant CAD, overall agreement in- creased to 87 and 90 % for the iPad and clinical workstations, respectively (difference, p > 0.05). There was 100 % agreement between readers and the reference for identification of coronary anomalies and aneurysms for both the iPad and clinical workstation.”


      Remote reading of coronary CTA exams using a tablet computer: utility for stenosis assessment and identification of coronary anomalies 
Stefan L. Zimmerman, Cheng T. Lin, Linda C. Chu, John Eng, Elliot K. Fishman
Emerg Radiol (2016) 23:255–261
    • “The multivariate analysis showed the use of the iPad had no significant impact on the accuracy of coronary CTA reads. In a multivariable logistic regression analysis including reader, workstation, and vessel as co-variates, there was no significant association between workstation type or reader and agreement with the reference scores for presence of significant CAD (p > 0.05).”


      Remote reading of coronary CTA exams using a tablet computer: utility for stenosis assessment and identification of coronary anomalies 
Stefan L. Zimmerman, Cheng T. Lin, Linda C. Chu, John Eng, Elliot K. Fishman
Emerg Radiol (2016) 23:255–261
    • “Coronary CTA imaging requires considerable training and expertise. Mobile devices can be used to expand avail- ability of these expert readers by allowing them to perform evaluations anywhere with a reliable internet connection. If implemented in the clinical routine, it is important to consider how these results will be communicated to the covering physicians. In our practice, when a remote study is performed, the reading physician is provided the contact information of the ordering physician and discusses the case directly with the referring. A preliminary verbal report is then stored in our electronic medical record by the ED provider until the formal report can be dictated by the cardiac imager.”

      
Remote reading of coronary CTA exams using a tablet computer: utility for stenosis assessment and identification of coronary anomalies 
Stefan L. Zimmerman, Cheng T. Lin, Linda C. Chu, John Eng, Elliot K. Fishman
Emerg Radiol (2016) 23:255–261
    • “Coronary CTA with using a tablet computer is feasible with results that are no different from reading of cardiac exams on standard clinical workstations. On multivariate analysis, we found no significant relationship between the type of reading modality and accuracy of interpretation. Remote reading with a tablet computer could be used to expand availability of cor- onary CTA in the ED.”


      Remote reading of coronary CTA exams using a tablet computer: utility for stenosis assessment and identification of coronary anomalies 
Stefan L. Zimmerman, Cheng T. Lin, Linda C. Chu, John Eng, Elliot K. Fishman
Emerg Radiol (2016) 23:255–261
    • “For both readers, there was no significant difference in agreement with the reference standard for per-vessel stenosis scores using either the 3D workstation or the iPad. In a multivariable logistic regression analysis including reader, workstation, and vessel as co-variates, there was no significant association between workstation type or reader and agreement with the reference standard (p > 0.05). Both readers identified 100 % of coronary anomalies using each technique.Reading of coronary CT angiography examinations on the iPad had no influence on stenosis assessment compared to the standard clinical workstation.”

      
Remote reading of coronary CTA exams using a tablet computer: utility for stenosis assessment and identification of coronary anomalies 
Stefan L. Zimmerman, Cheng T. Lin, Linda C. Chu, John Eng, Elliot K. Fishman
Emerg Radiol (2016) 23:255–261
    • “When agreement with the reference was assessed per vessel for the presence of significant CAD, overall agreement in- creased to 87 and 90 % for the iPad and clinical workstations, respectively (difference, p > 0.05). There was 100 % agreement between readers and the reference for identification of coronary anomalies and aneurysms for both the iPad and clinical workstation.”


      Remote reading of coronary CTA exams using a tablet computer: utility for stenosis assessment and identification of coronary anomalies 
Stefan L. Zimmerman, Cheng T. Lin, Linda C. Chu, John Eng, Elliot K. Fishman
Emerg Radiol (2016) 23:255–261
    • “The multivariate analysis showed the use of the iPad had no significant impact on the accuracy of coronary CTA reads. In a multivariable logistic regression analysis including reader, workstation, and vessel as co-variates, there was no significant association between workstation type or reader and agreement with the reference scores for presence of significant CAD (p > 0.05).”


      Remote reading of coronary CTA exams using a tablet computer: utility for stenosis assessment and identification of coronary anomalies 
Stefan L. Zimmerman, Cheng T. Lin, Linda C. Chu, John Eng, Elliot K. Fishman
Emerg Radiol (2016) 23:255–261
    • “Coronary CTA imaging requires considerable training and expertise. Mobile devices can be used to expand avail- ability of these expert readers by allowing them to perform evaluations anywhere with a reliable internet connection. If implemented in the clinical routine, it is important to consider how these results will be communicated to the covering physicians. In our practice, when a remote study is performed, the reading physician is provided the contact information of the ordering physician and discusses the case directly with the referring. A preliminary verbal report is then stored in our electronic medical record by the ED provider until the formal report can be dictated by the cardiac imager.”


      Remote reading of coronary CTA exams using a tablet computer: utility for stenosis assessment and identification of coronary anomalies 
Stefan L. Zimmerman, Cheng T. Lin, Linda C. Chu, John Eng, Elliot K. Fishman
Emerg Radiol (2016) 23:255–261
    • “Coronary CTA with using a tablet computer is feasible with results that are no different from reading of cardiac exams on standard clinical workstations. On multivariate analysis, we found no significant relationship between the type of reading modality and accuracy of interpretation. Remote reading with a tablet computer could be used to expand availability of cor- onary CTA in the ED.”


      Remote reading of coronary CTA exams using a tablet computer: utility for stenosis assessment and identification of coronary anomalies 
Stefan L. Zimmerman, Cheng T. Lin, Linda C. Chu, John Eng, Elliot K. Fishman
Emerg Radiol (2016) 23:255–261
    • BACKGROUND: Recent guidelines for the workup of patients with chest pain and suspected coronary artery disease include coronary computed tomography angiography (CTA). However, its diagnostic value may be limited in patients with severe coronary calcification.

      CONCLUSION: In the largest patient series evaluated so far, we identified an "Agatston Score" of 287 to represent a threshold above which coronary CTA permits to rule out coronary artery stenoses in less than 50% of cases.
Influence of the coronary calcium score on the ability to rule out coronary artery stenoses by coronary CT angiography in patients with suspected coronary artery disease.
Schuhbaeck A et al
J Cardiovasc Comput Tomogr. 2016 Sep-Oct;10(5):343-50
    • “ The median coronary calcium score was 12, with calcium present in 60.5% of all patients. Coronary CTA ruled out stenoses in 82% of patients, while in 18% of patients at least one stenosis was found or could not be excluded. The threshold above which coronary CTA permitted to rule out stenoses in less than 50% of patients was an "Agatston Score" of 287. This threshold was significantly lower for male patients (213 vs. 330), for patients with a heart rate >65 beats/min (157 vs. 317) and for patients with a body mass index ≥25 kg/m(2) (208 vs. 392). The evaluability of coronary arteries decreased with increasing amounts of calcium and differed significantly between heart rates ≤65 beats/min and >65 beats/min (p < 0.0001).”


      Influence of the coronary calcium score on the ability to rule out coronary artery stenoses by coronary CT angiography in patients with suspected coronary artery disease.
Schuhbaeck A et al
J Cardiovasc Comput Tomogr. 2016 Sep-Oct;10(5):343-50
    • “The evaluability of coronary arteries decreased with increasing amounts of calcium and differed significantly between heart rates ≤65 beats/min and >65 beats/min (p < 0.0001).”


      Influence of the coronary calcium score on the ability to rule out coronary artery stenoses by coronary CT angiography in patients with suspected coronary artery disease.
Schuhbaeck A et al
J Cardiovasc Comput Tomogr. 2016 Sep-Oct;10(5):343-50
    • “The presence of pronounced coronary calcification has been identified as a limitation of coronary CTA, and in some guidelines, the use of coronary CTA is not encouraged for individuals above a certain amount of coronary calcium, e.g. an “Agatston Score” of 400.”


      Influence of the coronary calcium score on the ability to rule out coronary artery stenoses by coronary CT angiography in patients with suspected coronary artery disease.
Schuhbaeck A et al
J Cardiovasc Comput Tomogr. 2016 Sep-Oct;10(5):343-50
    • “First of all, with increasing amounts of coronary calcium, the prevalence of coronary stenoses increases making a “negative” coronary CTA unlikely and increasing the likelihood for the requirement of further downstream testing. Second, calcium might render coronary CTA data sets difficult to interpret or even unevaluable. Finally, extensive calcifications frequently cause overestimation of coronary stenosis severity, again leading to subsequent and potentially unnecessary testing.”


      Influence of the coronary calcium score on the ability to rule out coronary artery stenoses by coronary CT angiography in patients with suspected coronary artery disease.
Schuhbaeck A et al
J Cardiovasc Comput Tomogr. 2016 Sep-Oct;10(5):343-50
    • “We were able to demonstrate in a relative large cohort of 2614 patients with suspected coronary artery disease who were investigated by dual source computed tomography that this threshold was an “Agatston Score” of 287 for an overall all-comer patient group. In subgroup analyses with respect to gender, heart rate, body weight or body mass index, we found that the threshold can be substantially higher – both due to a lower prevalence of stenosis (e.g. in female patients) and due to a higher rate of fully evaluable data sets (e.g. in patients with low heart rate or low body weight, the former reducing motion artifacts and the latter leading to lower image noise.”


      Influence of the coronary calcium score on the ability to rule out coronary artery stenoses by coronary CT angiography in patients with suspected coronary artery disease.
Schuhbaeck A et al
J Cardiovasc Comput Tomogr. 2016 Sep-Oct;10(5):343-50
    • “Our study revealed that an “Agatston Score” > 287 represents a threshold above which coronary CTA, when performed with state-of-the-art technology and careful patient preparation, permits to rule out coronary stenoses in less than 50% of patients. However, there is substantial influence of other factors that determine image quality and hence that threshold, namely body weight or BMI (surrogate markers of image noise) as wells as heart rate (since motion aggravates artifacts caused by coronary calcium).”


      Influence of the coronary calcium score on the ability to rule out coronary artery stenoses by coronary CT angiography in patients with suspected coronary artery disease.
Schuhbaeck A et al
J Cardiovasc Comput Tomogr. 2016 Sep-Oct;10(5):343-50
    • “Despite of the limitations, the threshold identified in our study, an “Agatston Score” of 287, may be a useful value above which physicians performing coronary CTA may expect to be unable to rule out coronary artery stenoses in more than 50% of cases. If all imaging conditions are optimal, this threshold is 454.”


      Influence of the coronary calcium score on the ability to rule out coronary artery stenoses by coronary CT angiography in patients with suspected coronary artery disease.
Schuhbaeck A et al
J Cardiovasc Comput Tomogr. 2016 Sep-Oct;10(5):343-50
    • Calcium Score and CCTA

    • “ First of all, with increasing amounts of coronary calcium, the prevalence of coronary stenoses increases making a “negative” coronary CTA unlikely and increasing the likelihood for the requirement of further downstream testing. Second, calcium might render coronary CTA data sets difficult to interpret or even unevaluable. Finally, extensive calcifications frequently cause overestimation of coronary stenosis severity, again leading to subsequent and potentially unnecessary testing.” 


      Influence of the coronary calcium score on the ability to rule out coronary artery stenoses by coronary CT angiography in patients with suspected coronary artery disease 
Annika Schuhbaeck et al. 
Journal of Cardiovascular Computed Tomography 10 (2016) 343-350
    • “Despite of the limitations, the threshold identified in our study, an “Agatston Score” of 287, may be a useful value above which physicians performing coronary CTA may expect to be unable to rule out coronary artery stenoses in more than 50% of cases. If all imaging conditions are optimal, this threshold is 454. This may prompt preference of other clinical tests for patient evaluation.” 


      Influence of the coronary calcium score on the ability to rule out coronary artery stenoses by coronary CT angiography in patients with suspected coronary artery disease 
Annika Schuhbaeck et al. 
Journal of Cardiovascular Computed Tomography 10 (2016) 343-350
    • “The median coronary calcium score was 12, with calcium present in 60.5% of all patients. Cor- onary CTA ruled out stenoses in 82% of patients, while in 18% of patients at least one stenosis was found or could not be excluded. The threshold above which coronary CTA permitted to rule out stenoses in less than 50% of patients was an “Agatston Score” of 287. This threshold was significantly lower for male patients (213 vs. 330), for patients with a heart rate >65 beats/min (157 vs. 317) and for patients with a body mass index !25 kg/m2 (208 vs. 392). The evaluability of coronary arteries decreased with increasing amounts of calcium and differed significantly between heart rates 65 beats/min and >65 beats/min (p < 0.0001).” 


      Influence of the coronary calcium score on the ability to rule out coronary artery stenoses by coronary CT angiography in patients with suspected coronary artery disease 
Annika Schuhbaeck et al. 
Journal of Cardiovascular Computed Tomography 10 (2016) 343-350
    • “Cardiovascular risk assessment has assumed a prominent role in the course of preventive care of all adults. Traditionally cardiovascular risk assessment has been performed using risk factors including gender, age, smoking history, lipid status, diabetes status, and family history. Increasingly, imaging has been deployed to directly detect coronary atherosclerotic disease. Quantification of coronary calcium (e.g., Agatston method, calcium mass and volume) is readily detected using helical CT scanners. Large multicenter cohort studies have enabled a better understanding of the relevance of coronary calcium detection. The purpose of this review is to review the methods for quantification of coronary artery calcium, as well as to present current and future perspectives on calcium scoring for cardiovascular risk stratification.”


      CT calcium scoring. History, current status and outlook.
Sandfort V, Bluemke DA
Diagn Interv Imaging. 2016 Aug 5.
    • Question: Diameters of coronary artery aneurysms (CAAs) complicating acute phase KD can strongly predict the long-term prognosis of coronary artery lesions (CAL). Recently, computed tomographic angiography (CTA) has been used to detect CAL, and the purpose of this study was to determine whether coronary artery diameters measurements by CTA using dual-source computed tomography (DSCT) can be used instead of coronary angiogram (CAG) measurements.


      Measurements of Coronary Artery Aneurysms Due to Kawasaki Disease by Dual-Source Computed Tomography (DSCT)
Tsujii N et al.
Pediatr Cardiol. 2016 Mar;37(3):442-7. doi: 10.1007/s00246-015-1297-z. Epub 2015 Oct 29.

    • “Diagnostic accuracy was expressed as κ coefficient. A Bland-Altman analysis was also used to assess the intra-observer, inter-observer and inter-modality agreement. The diagnostic quality of CTA was excellent (κ = 0.93). Excellent inter-observer agreement for the diameters of CAAs was obtained for MIP, MPR and CAG and for the intra-observer agreement. The inter-modality agreement was also excellent in measurements of CAA (MPR-CAG: y = 0.9x + 0.40, r = 0.97, p < 0.0001 MIP-CAG: y = x + 0.1, r = 0.94, p < 0.0001). These values in normal coronary arteries were also obtained. We found a significant correlation between CTA and CAG in measuring the coronary arteries. We conclude that measuring coronary artery diameters by CTA is reliable and useful.”


      Measurements of Coronary Artery Aneurysms Due to Kawasaki Disease by Dual-Source Computed Tomography (DSCT)
Tsujii N et al.
Pediatr Cardiol. 2016 Mar;37(3):442-7. doi: 10.1007/s00246-015-1297-z. Epub 2015 Oct 29.

    • “Excellent inter-observer agreement for the diameters of CAAs was obtained for MIP, MPR and CAG and for the intra-observer agreement. The inter-modality agreement was also excellent in measurements of CAA (MPR-CAG: y = 0.9x + 0.40, r = 0.97, p < 0.0001 MIP-CAG: y = x + 0.1, r = 0.94, p < 0.0001). These values in normal coronary arteries were also obtained. We found a significant correlation between CTA and CAG in measuring the coronary arteries. We conclude that measuring coronary artery diameters by CTA is reliable and useful.”


      Measurements of Coronary Artery Aneurysms Due to Kawasaki Disease by Dual-Source Computed Tomography (DSCT)
Tsujii N et al.
Pediatr Cardiol. 2016 Mar;37(3):442-7..

    • PURPOSE:“ Coronary-pulmonary arterial fistulas (CPAFs) are rare coronary artery anomalies that have been described only in limited case reports. This study aims to evaluate the clinical presentation and imaging findings of CPAFs collected from 6 participating medical centers along with CPAFs reported in the literature, to discern any general trends present in CPAFs.”

      
Coronary-Pulmonary Artery Fistulas: A Systematic Review.
Verdini D et al.
J Thorac Imaging. 2016 Nov;31(6):380-390.

    • CONCLUSIONS: “ CPAFs are seen in a variety of clinical settings, from infants with advanced congenital heart disease to elderly patients who have undergone revascularization surgery. Although coronary artery fistulas have previously been described as rarely involving multiple coronary arteries, with the right coronary artery being most often involved, our series demonstrates that multiple fistulas are commonly present, with the most common pattern being between the left main/left anterior descending and the main pulmonary trunk.”


      Coronary-Pulmonary Artery Fistulas: A Systematic Review.
Verdini D et al.
J Thorac Imaging. 2016 Nov;31(6):380-390.
    • “Kawasaki disease (KD) is the most recognized vasculitis of childhood. The condition's characteristic high fever, rash, mucositis, conjunctivitis, lymphadenopathy, and extremity changes are superficially unexceptional, and resolve spontaneously within a mean of 12 days. It is the acuity and the potential for life-changing damage to the coronary arteries that distinguish KD from conditions that mimic it and exemplify the unique aspects and challenges of vascular inflammation in children.”

      
Kawasaki Disease at 50 Years.
Cohen E, Sundel R
JAMA Pediatr. 2016 Nov 1;170(11):1093-1099.
    • “Kawasaki disease is a hybrid condition at the junction of infectious diseases, immunology, rheumatology, and cardiology. Rather than being left an orphan disease, KD is bringing disciplines together to identify its genetic, pathophysiological, and hemodynamic features. In turn, this work promises to shed light on many other inflammatory conditions as well.”

      
Kawasaki Disease at 50 Years.
Cohen E, Sundel R
JAMA Pediatr. 2016 Nov 1;170(11):1093-1099.
    • “Inter-observer agreement between the study reviewers was moderate to good (0.4–0.73) for most of the incidental cardiovascular findings. At least one incidental cardiovascular finding not documented in the original report was identified by the study reviewers in 225/409 (55 %) of chest CT examinations. A total of 168/266 (63.2 %) potentially clinically significant cardiovascular findings were unreported in the original reports of 177/447 (39.6 %) subjects (p < 0.0001). Senior radiologists tended to more frequently report coronary artery calcification (p = 0.0006), cardiac valves calcification (p = 0.0003), and ascending aorta enlargement (p = 0.01) compared to junior radiologists.”


      Under‐reporting of cardiovascular findings on chest CT 
Nicola Sverzellati et al.
Radiol med (2016) 121:190–199
    • “In keeping with our study, local radiologists only seldom specified which coronary artery was calcified. However, it was shown that visually scoring CAC on ungated CT is feasi- ble and of prognostic value. We could not stratify the prognostic value of CAC in our study cohort as the study observers applied a different CAC classification system.”

      
Under‐reporting of cardiovascular findings on chest CT 
Nicola Sverzellati et al.
Radiol med (2016) 121:190–199
    • “For both readers, there was no significant difference in agreement with the reference standard for per-vessel stenosis scores using either the 3D workstation or the iPad. In a multivariable logistic regression analysis including reader, workstation, and vessel as co-variates, there was no significant association between workstation type or reader and agreement with the reference standard (p > 0.05). Both readers identified 100 % of coronary anomalies using each technique.Reading of coronary CT angiography examinations on the iPad had no influence on stenosis assessment compared to the standard clinical workstation.”

      
Remote reading of coronary CTA exams using a tablet computer: utility for stenosis assessment and identification of coronary anomalies 
Stefan L. Zimmerman, Cheng T. Lin, Linda C. Chu, John Eng, Elliot K. Fishman
Emerg Radiol (2016) 23:255–261
Chest

    • “Multidetector CT and dynamic contrast en- hanced techniques have been used to study features of malignancy in breast tumors. Ir- regular margins, irregular shape, and rim en- hancement are the most highly predictive features for malignancy in these studies. A spiculated and irregular margin is the most accurate sign for malignancy.”


      Breast Lesions Incidentally Detected with CT: What the General Radiologist Needs to Know
Harish MG et al.
RadioGraphics 2007; 27:S37–S51 

    • “A washout pattern on postcontrast images had high positive predictive value and sensitivity, although low negative predictive value and specificity. Diffuse regional en- hancement is also shown to have high positive predictive value for malignancy.”


      Breast Lesions Incidentally Detected with CT: What the General Radiologist Needs to Know
Harish MG et al.
RadioGraphics 2007; 27:S37–S51 

    • “At CT, invasive ductal carcinoma appears as a dense, spiculated mass with marked early and/or peripheral enhancement. The presence of rim enhancement and internal enhancing septations can be suggestive signs. In advanced cases, associated skin thickening, lymphadenopathy, or pleural effusions may be seen.”


      Breast Lesions Incidentally Detected with CT: What the General Radiologist Needs to Know
Harish MG et al.
RadioGraphics 2007; 27:S37–S51 

    • “Inflammatory carcinoma is an uncommon, aggressive tumor with early dermal lymphatic invasion and poor prognosis. Clinical diagnosis is based on increased warmth, induration of breast skin, erysipeloid edge (peau d’orange), and nipple retraction. In some cases, inflammatory carcinoma may be indistinguishable from mastitis and abscess but fails to respond to antibiotics. Inflammatory carcinoma should be considered in the differential diagnosis when breast edema is accompanied by clinical signs of infection.”


      Breast Lesions Incidentally Detected with CT: What the General Radiologist Needs to Know
Harish MG et al.
RadioGraphics 2007; 27:S37–S51 

    • “Breast hematomas and seromas can be seen after biopsy, trauma, or surgery . Their diagnosis can be made by correlating the finding to the clinical history. Immediately after surgery or biopsy, the surrounding edema may obscure a hematoma. Hematomas will become smaller over time and eventually resorb and therefore can be 
distinguished from other masses.”


      Breast Lesions Incidentally Detected with CT: What the General Radiologist Needs to Know
Harish MG et al.
RadioGraphics 2007; 27:S37–S51 

    • “If the scar can be shown to occupy a surgical site, then the spiculated appearance is not of concern. In differentiating a scar from cancer, correlating prior biopsy locations from the patient history, reviewing prior images, and noting linear scar markers in the locations of prior biopsy are very important. Masses not corresponding to a postbiopsy scar should be considered suspicious. In addition, any new tissue growth in a previously identified postoperative scar (particularly after cancer resection) should be viewed with suspicion.”


      Breast Lesions Incidentally Detected with CT: What the General Radiologist Needs to Know
Harish MG et al.
RadioGraphics 2007; 27:S37–S51 

    • “In general, larger round or oval calcifications that are uniform in size and shape have a higher probability of being associated with a benign process, whereas smaller, irregular, polymorphic, clustered calcifications heterogeneous in size and morphology are more often associated with a malignant process. Nearly all calcifications currently seen at CT are benign, on the basis of size alone, due to the limited spatial resolution .”
Breast Lesions Incidentally Detected with CT: What the General Radiologist Needs to Know
Harish MG et al.
RadioGraphics 2007; 27:S37–S51 

    • “CT is very sensitive for the detection of coarse calcifications. When calcifications are identified in the breast at CT, they are nearly all benign. They should be characterized when resolution allows as lucent-centered calcifications, eggshell or rim calcifications, coarse or popcornlike calcifications, large rodlike calcifications, or round calcifications.”

      
Breast Lesions Incidentally Detected with CT: What the General Radiologist Needs to Know
Harish MG et al.
RadioGraphics 2007; 27:S37–S51 

    • “In our experience, breast abnormalities at CT are frequently overlooked or inaccurately assessed. Our aim has been to expose the general radiologist to the imaging characteristics of a range of breast abnormalities in addition to providing a succinct and accurate method of describing and classifying these findings. It is important that general radiologists pay attention to the breasts on CT scans and that they are trained to recognize and report abnormal findings with confidence.”

      
Breast Lesions Incidentally Detected with CT: What the General Radiologist Needs to Know
Harish MG et al.
RadioGraphics 2007; 27:S37–S51
    • “Inter-observer agreement between the study reviewers was moderate to good (0.4–0.73) for most of the incidental cardiovascular findings. At least one incidental cardiovascular finding not documented in the original report was identified by the study reviewers in 225/409 (55 %) of chest CT examinations. A total of 168/266 (63.2 %) potentially clinically significant cardiovascular findings were unreported in the original reports of 177/447 (39.6 %) subjects (p < 0.0001). Senior radiologists tended to more frequently report coronary artery calcification (p = 0.0006), cardiac valves calcification (p = 0.0003), and ascending aorta enlargement (p = 0.01) compared to junior radiologists.”


      Under‐reporting of cardiovascular findings on chest CT 
Nicola Sverzellati et al.
Radiol med (2016) 121:190–199
    • “In keeping with our study, local radiologists only seldom specified which coronary artery was calcified. However, it was shown that visually scoring CAC on ungated CT is feasi- ble and of prognostic value. We could not stratify the prognostic value of CAC in our study cohort as the study observers applied a different CAC classification system.”

      
Under‐reporting of cardiovascular findings on chest CT 
Nicola Sverzellati et al.
Radiol med (2016) 121:190–199
Esophagus

    • “Spontaneous esophageal perforation (Boerhaave syndrome) is a very uncommon, life-threatening surgical emergency that should be suspected in all patients presenting with lower thoracic-epigastric pain and a combination of gastrointestinal and respiratory symptoms. Variable clinical manifestations and subtle or unspecific radiographic findings often result in critical diagnostic delays. Multidetector computed tomography complemented with CT-esophagography represents the ideal “one-stop shop” investigation technique to allow a rapid, comprehensive diagnosis of BS, including identification of suggestive periesophageal abnormalities, direct visualization of esophageal perforation and quantification of mediastinitis.”


      Spontaneous esophageal perforation (Boerhaave syndrome): Diagnosis with CT-esophagography
Massimo Tonolini, Roberto Bianco
J Emerg Trauma Shock. 2013 Jan-Mar; 6(1): 58–60
    • “Multidetector computed tomography complemented with CT-esophagography represents the ideal “one-stop shop” investigation technique to allow a rapid, comprehensive diagnosis of BS, including identification of suggestive periesophageal abnormalities, direct visualization of esophageal perforation and quantification of mediastinitis.”


      Spontaneous esophageal perforation (Boerhaave syndrome): Diagnosis with CT-esophagography
Massimo Tonolini, Roberto Bianco
J Emerg Trauma Shock. 2013 Jan-Mar; 6(1): 58–60
    • “Unless specifically considered in the differential diagnosis, spontaneous esophageal perforation is often unsuspected or misdiagnosed, since its manifestations closely mimic other more common intrathoracic diseases, including myocardial infarction and pericarditis, acute aortic disease or even abdominal emergencies such as perforated peptic ulcer or acute pancreatitis. Unfortunately, diagnostic work-up delays may hinder timely treatment with a negative effect on patients’ outcome.”

      
Spontaneous esophageal perforation (Boerhaave syndrome): Diagnosis with CT-esophagography
Massimo Tonolini, Roberto Bianco
J Emerg Trauma Shock. 2013 Jan-Mar; 6(1): 58–60
    • “Although controversy exists about appropriate therapy, surgical management is currently considered the gold standard for ruptures diagnosed within 24 hours from onset and allows a 75% chance of recovery. Surgery should include pleural cavity drainage, perforation debridement and primary repair through an open thoracotomic or laparoscopic approach. Conservative management with resuscitation and broad-spectrum antibiotics should be reserved for patients with minimal sepsis and mediastinal abnormalities, and for those too unstable to undergo surgery. After 24 hours, survival rates as low as 20% have been reported, therefore a high index of clinical suspicion and prompt diagnostic assessment are needed.”


      Spontaneous esophageal perforation (Boerhaave syndrome): Diagnosis with CT-esophagography
Massimo Tonolini, Roberto Bianco
J Emerg Trauma Shock. 2013 Jan-Mar; 6(1): 58–60
    • “ Mediastinal findings suggestive of esophageal injury and associated mediastinitis (such as periesophageal and mediastinal gas and/or mediastinal fluid collections, esophageal wall thickening, pleural effusion or hydrothorax) are reliably identified on thoraco-abdominal emergency CT examinations performed under alternative clinical diagnoses.”


      Spontaneous esophageal perforation (Boerhaave syndrome): Diagnosis with CT-esophagography
Massimo Tonolini, Roberto Bianco
J Emerg Trauma Shock. 2013 Jan-Mar; 6(1): 58–60
    • “Clinical or CT features suggesting the diagnosis of BS should be further investigated by means of CT-esophagography with oral ingestion or administration through the nasogastric tube of 10% diluted iodinated contrast medium, and reconstruction of multiplanar images. Easily performed as a complement of initial CT acquisition, CT-esophagography allows to confirm and visually document the perforation through the direct identification of extraluminal contrast leakage. The time spared without transferring the patient from the CT scanner table to the fluoroscopic suite may prove prognostically important.”


      Spontaneous esophageal perforation (Boerhaave syndrome): Diagnosis with CT-esophagography
Massimo Tonolini, Roberto Bianco
J Emerg Trauma Shock. 2013 Jan-Mar; 6(1): 58–60
Kidney

    • “Genitourinary tuberculosis almost always starts in the kidney, which is infected by hematogenous dissemination from primary pulmonary tuberculosis. Ureteral and bladder involvement is almost always secondary to renal involvement, arising from seeding of the ureter and bladder from the infected kidney.”

      
Imaging Findings of Urinary Tuberculosis on Excretory Urography and Computerized Tomography
Wang LJ et al.
The Journal of Urology Volume 169, Issue 2, February 2003, Pages 524–528
    • “On CT renal parenchymal scarring was the most common finding (76% of cases), followed by hydrocalycosis, hydronephrosis or hydroureter due to stricture (67%) and thick walls of the renal pelvis, ureters or bladder (61%). The stricture site on CT was the infundibulum in 12 cases, ureteropelvic junction in 6 and ureter in 22. Thick walls were visualized on CT in the renal pelvis in 15 images, ureters in 16 and bladder in 7. Renal calcifications were identified on CT at the renal parenchyma in 10 cases, renal collecting system wall in 2 and at each site.”

      
Imaging Findings of Urinary Tuberculosis on Excretory Urography and Computerized Tomography
Wang LJ et al.
The Journal of Urology Volume 169, Issue 2, February 2003, Pages 524–528
    • “IVP and CT showed a wide spectrum of imaging findings of urinary tuberculosis in our study. Of these findings renal parenchymal masses and scarring, thick urinary tract walls and extra-urinary tubercular manifestations were more common on CT than on IVP. Although each imaging finding may be nonspecific, multiple findings on IVP and CT were common in our study. When the 3 patterns of multiple findings are shown on IVP and CT, tubercular cultures or biopsy specimens are suggested to make the definite diagnosis.”


      Imaging Findings of Urinary Tuberculosis on Excretory Urography and Computerized Tomography
Wang LJ et al.
The Journal of Urology Volume 169, Issue 2, February 2003, Pages 524–528
    • “The 3 imaging patterns were hydrocalycosis, hydronephrosis or hydroureter due to multiple strictures, hydrocalycosis, hydronephrosis or hydroureter due to a single stricture with at least 1 other imaging finding and autonephrectomy with another imaging finding other than stricture.”


      Imaging Findings of Urinary Tuberculosis on Excretory Urography and Computerized Tomography
Wang LJ et al.
The Journal of Urology Volume 169, Issue 2, February 2003, Pages 524–528
    • “ Moreover, although standard axial image review may be sufficient in most other parts of the abdomen and pelvis, evaluation of the collecting systems and ureters presents a prime example of an application for which standard axial images may not be sufficient to identify many subtle urothelial tumors, and for which the use of multiplanar reformations and three-dimensional (3D) imaging techniques may be helpful (or even necessary) for the identification of small or difficult-to-see lesions.”


      Upper and Lower Tract Urothelial Imaging Using Computed Tomography Urography 
Siva P. Raman, Elliot K. Fishman 
Radiol Clin N Am - (2016)
    • “Urothelial carcinoma of the upper urinary tract (including the intrarenal collecting systems, renal pelvis, and ureters) is uncommon, although the renal pelvis is probably the second most common location for urothelial carcinoma following the bladder. Although exact numbers are difficult to obtain for the incidence of upper urinary tract tumors given their rarity, it is thought that roughly 2300 patients in the United States were diagnosed with transitional cell carcinoma of the ureter (with 700 deaths) in 2008. Upper tract tumors account for only 5% of all urothelial carcinomas and w15% of all renal tumors.”


      Upper and Lower Tract Urothelial Imaging Using Computed Tomography Urography 
Siva P. Raman, Elliot K. Fishman 
Radiol Clin N Am - (2016)
    • “A study by Dillman and colleagues found inferior urinary tract distension with the split-bolus technique. In our own experience, this protocol is particularly problematic when evaluating the ureters, with poor distention of the distal ureters. Another potential disadvantage of this protocol is decreased sensitivity for small or subtle renal cell carcinomas, because only 2 postcontrast phases are available for evaluation of the renal parenchyma, as opposed to 3 phases in the single-bolus technique.”


      Upper and Lower Tract Urothelial Imaging Using Computed Tomography Urography 
Siva P. Raman, Elliot K. Fishman 
Radiol Clin N Am - (2016)
    • “At our own institution, in patients who present with hematuria, we have made the decision that our primary goal is to maximize sensitivity for all renal malignancies (ie, both renal cell carcinoma and transitional cell carcinoma), and to make the diagnosis on the first attempt (rather than having patients be imaged repeatedly without a clear diagnosis being made). Accordingly, at our own institution we have decided to use the single- bolus technique, and in patients more than 35 years of age (at maximal risk for the development renal malignancies), we acquire 4-phase studies with separate noncontrast, arterial, venous, and delayed phase acquisitions.”


      Upper and Lower Tract Urothelial Imaging Using Computed Tomography Urography 
Siva P. Raman, Elliot K. Fishman 
Radiol Clin N Am - (2016)
    • “Subsequently, the source axial images (0.5 mm) are sent to an independent workstation for generation of 2 separate sets of 3D reconstructions, including maximum intensity projection (MIP) images and volume-rendered re- constructions. The MIP technique involves taking the highest attenuation voxels in a data set and projecting these voxels into a 3D display, which can be interactively rotated or manipulated by the interpreting radiologist.”


      Upper and Lower Tract Urothelial Imaging Using Computed Tomography Urography 
Siva P. Raman, Elliot K. Fishman 
Radiol Clin N Am - (2016)
    • “MIP images are particularly useful in evaluating the collecting systems and ureters, providing a good global overview of the high-density contrast within the collecting systems, and highlighting subtle sites of urothelial thickening, luminal narrowing, calyceal destruction, or asymmetric hydronephrosis/hydroureter. In particular, our own experience has suggested that these reconstructions are particularly helpful in evaluating the ureters, where subtle urothelial thickening or even ureteral strictures are easy to overlook on the source axial images (and are commonly missed), whereas these abnormalities tend to be more conspicuous using a coronal MIP reconstruction.”


      Upper and Lower Tract Urothelial Imaging Using Computed Tomography Urography 
Siva P. Raman, Elliot K. Fishman 
Radiol Clin N Am - (2016)
    • “In particular, MIP images allow the entirety of the collecting systems and ureters to be viewed at a single glance (providing a global overview of the collecting systems), which is a great advantage compared with standard axial image review, in which the intrarenal collecting systems and ureters are constantly moving in and out of plane, making careful evaluation difficult.”

      
Upper and Lower Tract Urothelial Imaging Using Computed Tomography Urography 
Siva P. Raman, Elliot K. Fishman 
Radiol Clin N Am - (2016)
    • “This is one area in which the use of MIP images can be helpful in terms of providing a global overview of the ureters and collecting systems, and highlighting subtle differences in ureteral distention. Whenever asymmetric hydronephrosis or hydroureter is identified, the ureter should then be followed along its course to identify a potential transition point or change in caliber that might suggest an obstructing tumor.”

      
Upper and Lower Tract Urothelial Imaging Using Computed Tomography Urography 
Siva P. Raman, Elliot K. Fishman 
Radiol Clin N Am - (2016)
    • “Given this overlap between benign and malignant entities, it is not surprising that the positive predictive value of CT urography for up- per tract urinary malignancy may be as low as 53% (with a positive predictive value of only 46% for urothelial thickening), although this increases in patients with a discrete mass, for which the positive productive value may be as high as 83%.”


      Upper and Lower Tract Urothelial Imaging Using Computed Tomography Urography 
Siva P. Raman, Elliot K. Fishman 
Radiol Clin N Am - (2016)
    • “The identification of transitional cell carcinomas throughout the upper and lower urinary tract (including the intrarenal collecting systems, ure- ters, and bladder) can be very difficult, and relies on several subtle imaging features. However, it is important to be cognizant that the identification of these imaging features is heavily contingent on proper imaging technique and protocol design. Failure to acquire the correct contrast enhance- ment phases, or, alternatively, failure to adequately distend the collecting system, can make identification of even large tumors difficult.”

      
Upper and Lower Tract Urothelial Imaging Using Computed Tomography Urography 
Siva P. Raman, Elliot K. Fishman 
Radiol Clin N Am - (2016)
Liver

    • “Communication between a hepatic arterial branch and the portal vein at the level of the trunk, sinusoids, or peribiliary venules results in redistribution of arterial flow into a focal region of portal venous flow. Arterioportal shunts may be posttraumatic, occurring after blunt or penetrating injury, biopsy, or instrumentation (eg, placement of a transhepatic biliary drainage catheter).”


      CT of Nonneoplastic Hepatic Vascular and Perfusion Disorders
Torabi M et al. 
RadioGraphics 2008; 28:1967–1982 

    • “The prevalence of arterioportal shunts in patients with large hepatocellular carcinomas is as high as 63%. In patients with cirrhosis, the majority of small arterioportal shunts are pseudolesions; that is, they involve no pathologic alteration.”

      
CT of Nonneoplastic Hepatic Vascular and Perfusion Disorders
Torabi M et al. 
RadioGraphics 2008; 28:1967–1982 

    • “Contrast-enhanced arterial phase CT usually shows small, peripheral, nonspherical, enhancing foci, which become isoattenuating to the liver and vasculature in the portal venous phase. Early enhancement of the peripheral portal vein occurs during the hepatic arterial phase and before the opacification of the main portal vein.”


      CT of Nonneoplastic Hepatic Vascular and Perfusion Disorders
Torabi M et al. 
RadioGraphics 2008; 28:1967–1982 

    • “It may be difficult to distinguish an arterioportal shunt from a small hepatocellular carcinoma. In such situations, repeat imaging in 6 months usually demonstrates the resolution or stability of an arterioportal shunt, as opposed to growth for a hepatocellular carcinoma. Moreover, on portal venous and delayed phase images, a hepatocellular carcinoma usually becomes hypoattenuated to liver and vessels, but an arterioportal shunt has the same attenuation as the vessels.”

      
CT of Nonneoplastic Hepatic Vascular and Perfusion Disorders
Torabi M et al. 
RadioGraphics 2008; 28:1967–1982
Musculoskeletal

    • “Fibrous dysplasia is a noninherited bone disease in which abnormal differentiation of osteoblasts leads to replacement of normal marrow and cancellous bone by immature bone and fibrous stroma. It is usually an incidental imaging finding, generally not requiring further investigation. However, fibrous dysplasia may be complicated by pathologic fracture, and rarely by malignant degeneration.”

      
Imaging Findings of Fibrous Dysplasia with Histopathologic and Intraoperative Correlation 
Fitzpatrick KA et al.
AJR 2004;182:1389–139
    • “Fibrous dysplasia is categorized as either monostotic or polyostotic and may occur as a component of McCune-Albright syndrome or the rare Mazabraud syndrome.”


      Imaging Findings of Fibrous Dysplasia with Histopathologic and Intraoperative Correlation 
Fitzpatrick KA et al.
AJR 2004;182:1389–139
    • “The polyostotic form of fibrous dysplasia may involve many or few bones, most commonly the skull and facial bones, pelvis, spine ,and shoulder. Polyostotic fi- brous dysplasia is often unilateral, some- times showing a monomelic pattern. It tends to involve larger segments of bone and is frequently associated with fractures and severe deformities.”


      Imaging Findings of Fibrous Dysplasia with Histopathologic and Intraoperative Correlation 
Fitzpatrick KA et al.
AJR 2004;182:1389–139
    • “McCune-Albright syndrome is an endocrin- opathy occurring mainly in girls, consisting of the triad of precocious puberty, polyostotic fi- brous dysplasia, and characteristic cutaneous pigmentation. The cutaneous lesions are flat pigmented macules, often referred to as “café au lait” spots and likened to the coast of Maine because of their irregular contour. Fibrous dysplasia lesions associated with McCune-Albright syndrome tend to be more disabling than those of pure polyostotic disease.”

      
Imaging Findings of Fibrous Dysplasia with Histopathologic and Intraoperative Correlation 
Fitzpatrick KA et al.
AJR 2004;182:1389–139
    • “Lesions predominantly composed of fibrous tissue are usually of intermediate density similar to that of muscle. Benign fibrous masses include nodular fasciitis, fibromas, and fibromatoses, the last of which can recur and be locally aggressive. Uncommon in the extremities, solitary fibrous tumors are a type of spindle cell neoplasm originally described in the pleura but now recognized to be anatomically ubiquitous and of uncertain malignant potential; their CT appearance is typically that of a well-defined mass nearly isodense to muscle.”


      Soft-Tissue Masses and Masslike Conditions: What Does CT Add to Diagnosis and Management?
Ty K. Subhawong Elliot K. Fishman,Jennifer E. Swart,John A. Carrino,Samer Attar, Laura M. Fayad
AJR Am J Roentgenol. 2010 Jun; 194(6): 1559–1567
    • “CT angiography may aid in the characterization of soft-tissue masses by revealing arterial or venous lesion vascularity, which is characteristic of certain tumors or vascular malformations. CT angiography is especially useful for preoperative planning by depicting vascular structures with a high degree of spatial resolution in multiple planes and in 3D reconstructions.”


      Soft-Tissue Masses and Masslike Conditions: What Does CT Add to Diagnosis and Management?
Ty K. Subhawong Elliot K. Fishman,Jennifer E. Swart,John A. Carrino,Samer Attar, Laura M. Fayad
AJR Am J Roentgenol. 2010 Jun; 194(6): 1559–1567
    • “The primary role of CT in the evaluation of soft-tissue masses is adjunctive to that of MRI for the characterization of the masses. With CT, subtle areas of matrix mineralization may be detected that are diagnostic for a specific entity when minute areas of ossification or calcification are undetectable by MRI or radiography. Lesion density can suggest a histologic diagnosis, and careful evaluation of the adjacent bone often reveals clues regarding the potential for aggressive behavior.”


      Soft-Tissue Masses and Masslike Conditions: What Does CT Add to Diagnosis and Management?
Ty K. Subhawong Elliot K. Fishman,Jennifer E. Swart,John A. Carrino,Samer Attar, Laura M. Fayad
AJR Am J Roentgenol. 2010 Jun; 194(6): 1559–1567
OB GYN

    • “Imaging has limited utility in the diagnosis of endometriosis, as it lacks adequate resolution to identify adhesions or superficial peritoneal implants. Ultrasound is cheap and easy to perform, but user-dependent; MRI is more accurate but considerably more expensive. As CT of the pelvis does not visualize pelvic organs well, it is not useful in the diagnosis of endometriosis. An important role for the CT scan with contrast is to detect ureteral involvement and possible renal insufficiency.”

      
Invasive and non-invasive methods for the diagnosis of endometriosis
Albert L Hsu et al.
Clin Obstet Gynecol. 2010 Jun; 53(2): 413–419.
    • “Endometriosis is a common benign gynecologic disorder, defined by endometrial glands and stroma outside of the endometrial cavity. Endometriosis can be associated with infertility or pain symptoms, including cyclic pelvic pain, dysmenorrhea, dyspareunia, dysuria, and dyschezia. The correlation between lesions and pain symptoms or infertility in endometriosis is poorly understood. There is a wide spectrum of symptom severity, and the stage of endometriosis on laparoscopy correlates poorly with the extent and severity of pain. Some patients with minimal disease have debilitating pain, while other women with severe stage III–IV disease are asymptomatic.”


      Invasive and non-invasive methods for the diagnosis of endometriosis
Albert L Hsu et al.
Clin Obstet Gynecol. 2010 Jun; 53(2): 413–419.
    • “Endometriomas contain a dense, brown, chocolate-like fluid and are pseudocysts formed by the invagination of endometriosis within the ovarian cortex. Adhesions are usually associated with endometriomas and attach them to nearby pelvic structures. Deep infiltrating endometriosis (DIE) is a nodular blend of fibromuscular tissue and adenomyosis. These lesions are primarily found in the uterosacral ligaments or cul de sac, but may also involve the rectovaginal septum. Patients with DIE may present with deep dyspareunia and various bowel symptoms from diarrhea to dyschezia during menses, depending on the location of the deep lesions.-.”


      Invasive and non-invasive methods for the diagnosis of endometriosis
Albert L Hsu et al.
Clin Obstet Gynecol. 2010 Jun; 53(2): 413–419.
    • “At laparoscopy, endometriosis may be visualized as peritoneal implants, peritoneal windows, endometriomas, and deep infiltrating nodules of endometriosis which may each be associated with adhesions. The color, size, and morphology of endometriotic lesions are highly variable from person to person. Endometriotic implants in the pelvis occur more often on the left side, although the reason for this asymmetry is not known.”


      Invasive and non-invasive methods for the diagnosis of endometriosis
Albert L Hsu et al.
Clin Obstet Gynecol. 2010 Jun; 53(2): 413–419.
    • “ Mature cystic teratomas, often referred to as dermoids, are the most common benign ovarian neoplasm and the most common neoplasm responsible for ovarian torsion. They frequently present with acute pain owing to rupture or torsion. If free fluid is present in the setting of a dermoid and acute pain, rupture should be considered. Pain re- sults from a chemical peritonitis secondary to leak- ing of the oily material of dermoids.”


      Acute Gynecologic Disorders
Carolyn K. Donaldson  
Radiol Clin N Am 53 (2015) 1293–1307
    • “Tip of the iceberg” is a term used to describe the ultrasonographic findings of a dermoid. Dermoids can contain large fatty components that absorb the sound beam, preventing adequate evaluation of the lesion. Therefore, only the anterior margin of a lesion may be imaged with US. The posterior margin is obscured. Thus, large lesions are often undermeasured. The same lesion on CT is much larger.”


      Acute Gynecologic Disorders
Carolyn K. Donaldson  
Radiol Clin N Am 53 (2015) 1293–1307
    • “Dermoids do not contain internal vascularity. This is an important feature that distinguishes dermoids from malignant lesions. Dermoids are usually benign. Malignant transformation in up to 2% occurs in older women (>50 years) and in large dermoids (>10 cm). Dermoids are usually removed because of the risk of rupture, or torsion. They can grow slowly and destroy ovary. They are bilateral in 12% to 20% of cases. Dermoids may elude detection by US, but are subsequently seen on CT.”


      Acute Gynecologic Disorders
Carolyn K. Donaldson  
Radiol Clin N Am 53 (2015) 1293–1307
Small Bowel

    • “In particular, CT enterography has proven to be effective in identifying involvement of the small and large bowel (including active inflammation, stigmata of chronic inflammation, and Crohn’s-related bowel neoplasia) by Crohn’s disease, as well as the extra-enteric manifestations of the disease, including fistulae, sinus tracts, abscesses, and urologic/hepatobiliary/osseous complications. Moreover, the proper use of 3-D technique (including volume rendering and maximum intensity projection) as a routine component of enterography interpretation can play a vital role in improving diagnostic accuracy.”

      
Computed tomography of Crohn’s disease: The role of three dimensional technique
Siva P Raman,Karen M Horton,Elliot K Fishman
World J Radiol. 2013 May 28; 5(5): 193–201
    • “Crohn’s disease, a form of transmural inflammatory bowel disease affecting over 1.5 million Americans and Europeans, remains a difficult entity to diagnose clinically: While involvement of any segment of the gastrointestinal tract is possible, the disease most often affects the mesenteric small bowel, making direct endoscopic evaluation and biopsy difficult. Moreover, symptoms tend to be nonspecific, and there are no clinical symptoms or laboratory markers which allow a specific diagnosis.”

      
Computed tomography of Crohn’s disease: The role of three dimensional technique
Siva P Raman,Karen M Horton,Elliot K Fishman
World J Radiol. 2013 May 28; 5(5): 193–201
    • “Crohn’s disease can involve any portion of the gastrointestinal tract from the mouth to the anus, although the small bowel is the most commonly affected portion of the bowel, particularly the distal and terminal ileum. The earliest phases of small bowel inflammation may be characterized only by subtle mucosal hyperenhancement on the arterial phase images, with little or no wall thickening or venous phase enhancement abnormalities. However, as the degree of inflammation progresses, thickening of the bowel wall is typically visualized (in addition to frank mucosal hyperemia on the venous phase images), with evidence of mural stratification (“target” or “double-halo appearance”). This mural stratification most often represents the juxtaposition of avidly enhancing mucosa with hypodense submucosal edema in the bowel wall itself, and in some cases, hyperemia of the serosal surface of the bowel.”


      Computed tomography of Crohn’s disease: The role of three dimensional technique
Siva P Raman,Karen M Horton,Elliot K Fishman
World J Radiol. 2013 May 28; 5(5): 193–201
    • “Crohn’s disease can involve any portion of the gastrointestinal tract from the mouth to the anus, although the small bowel is the most commonly affected portion of the bowel, particularly the distal and terminal ileum. The earliest phases of small bowel inflammation may be characterized only by subtle mucosal hyperenhancement on the arterial phase images, with little or no wall thickening or venous phase enhancement abnormalities. However, as the degree of inflammation progresses, thickening of the bowel wall is typically visualized (in addition to frank mucosal hyperemia on the venous phase images), with evidence of mural stratification (“target” or “double-halo appearance”).”


      Computed tomography of Crohn’s disease: The role of three dimensional technique
Siva P Raman,Karen M Horton,Elliot K Fishman
World J Radiol. 2013 May 28; 5(5): 193–201
    • “Patients with Crohn’s disease are at increased risk for both small bowel and colonic adenocarcinoma and lymphoma . Corresponding to the most common sites of inflammation in Crohn’s disease patients, the most common sites of small bowel adenocarcinoma are in the distal and terminal ileum, as opposed to the general population, where small bowel adenocarcinomas are most common in the duodenum. The overall risk of small bowel adenocarcinoma may be 15-50 times greater than in the general population, and are most commonly seen at the sites of greatest inflammation in each specific patient.”


      Computed tomography of Crohn’s disease: The role of three dimensional technique
Siva P Raman,Karen M Horton,Elliot K Fishman
World J Radiol. 2013 May 28; 5(5): 193–201
    • “Originally described by Rokitansky in 1861, superior mesenteric artery syndrome (SMAS) is a relatively rare condition caused by obstruction of the third portion of the duodenum between the SMA and aorta. The condition has also been called cast syndrome, Wilke syndrome, or arteriomesenteric duodenal compression syndrome. Because of its relative infrequency, the incidence of the disorder is not well known. However, estimated incidence rates based on gastrointestinal barium series are from 0.01% to 0.33%.”


      Multidetector Row CT of Superior Mesenteric Artery Syndrome 
Gautam A. Agrawal, Pamela T. Johnson, Elliot K. Fishman 
J Clin Gastroenterol 2007;41:62–65

    • “As opposed to traditional imaging modalities like upper gastrointestinal and mesenteric arteriography, which depict either the bowel or vasculature respectively, CT enables direct visualization of obstructed bowel owing to duodenal compression by the SMA. Multiplanar MDCT with 3-dimen- sional rendering provides sagittal reconstructions that can be used to confirm the CT criteria of decreased aortomesenteric angle and distance in SMAS.”


      Multidetector Row CT of Superior Mesenteric Artery Syndrome 
Gautam A. Agrawal, Pamela T. Johnson, Elliot K. Fishman 
J Clin Gastroenterol 2007;41:62–65

    • “When conservative management fails, surgical treatment is employed. Surgical management includes duodenojejunostomy, gastrojejunostomy, or lysis of the ligament of Treitz with derotation of the bowel (Strong’s operation). After unsuccessful conservative management, surgical correction was required in 2/3 of patients in 1 small series.”

      
Multidetector Row CT of Superior Mesenteric Artery Syndrome 
Gautam A. Agrawal, Pamela T. Johnson, Elliot K. Fishman 
J Clin Gastroenterol 2007;41:62–65

    • An entity first described almost 150 years ago, ‘‘superior mesenteric artery (SMA) syndrome’’ represents a unique set of clinical symptoms caused by compression of the duodenum between the aorta and SMA. Classically described in young women, patients experience early post-prandial satiety, abdominal pain, nausea, and vomiting, often resulting in chronic anorexia and weight loss.


      Superior mesenteric artery syndrome: spectrum of CT findings with multiplanar reconstructions and 3-D imaging 
Siva P. Raman, Edward G. Neyman, Karen M. Horton, Frederic E. Eckhauser, Elliot K. Fishman 
 Abdom Imaging (2012) 37:1079–1088 

    • “SMA syndrome is thought to result from an abnormally short distance between the aorta and SMA, which results in compression of the duodenum. Patients with SMA syndrome usually present with nonspecific symptoms, making diagnosis extremely difficult. Typically seen in young women, their chronic anorexia, nausea, vomiting, and post- prandial abdominal pain are often blamed on non-anatomic, psychosocial causes, resulting in a delayed diagnosis. Nevertheless, when carefully questioned, these patients often have a characteristic history, with their symptoms relieved by changes in posture, such as turning to their left side, bringing their knees up to their chest, or the prone position.”


      Superior mesenteric artery syndrome: spectrum of CT findings with multiplanar reconstructions and 3-D imaging 
Siva P. Raman, Edward G. Neyman, Karen M. Horton, Frederic E. Eckhauser, Elliot K. Fishman 
 Abdom Imaging (2012) 37:1079–1088 

    • “In a normal patient, the distance between the aorta and SMA (‘‘aortomesenteric distance’’) should range from 10 to 34 mm, and the normal angle between the aorta and SMA (‘‘aortomesenteric angle’’) should be between 28° to 65°. Angiographic studies have shown that patients with SMA syndrome clearly have an abnormal aortomesenteric angle (6°–22°), and a shortened aorto-mesenteric distance (2–8 mm) compared to normal patients.”


      Superior mesenteric artery syndrome: spectrum of CT findings with multiplanar reconstructions and 3-D imaging 
Siva P. Raman, Edward G. Neyman, Karen M. Horton, Frederic E. Eckhauser, Elliot K. Fishman 
 Abdom Imaging (2012) 37:1079–1088
Spleen

    • “EMH occurs secondary to deficient bone marrow cells and arises from pluripotential stem cells distributed throughout the body. EMH can occur in congenital hemolytic disorders, with EMH presenting adjacent to hematopoietically active bones. When EMH occurs in patients with acquired marrow replacement disorders such as myeloproliferative diseases, the marrow space is nonfunctional and EMH can occur in organs such as the spleen or liver and lymph nodes. EMH in the spleen is usually diffusely infiltrative but can present as a focal masslike lesion with reported sizes ranging from 2.5 to 7.0 cm.” 


      Nonneoplastic, Benign, and Malignant Splenic Diseases: Cross-Sectional Imaging Findings and Rare Disease Entities 
Thipphavong S et al.
AJR 2014; 203:315–322
    • “Splenic metastases can occur with wide- spread disease, and parenchymal disease is caused by hematogenous dissemination. The most common primary cancers with splenic metastases include melanoma and cancers of the breast, lung, ovary, stomach, and prostate. 
On ultrasound and CT, splenic metastases are typically hypoechoic and hypodense, respectively, but can vary depending on the primary tumor. On MRI, metastases usually have low signal intensity on T1-weighted imaging and high signal intensity on T2-weight- ed imaging. Metastases show varying degrees of enhancement. Peritoneal disease can deposit on the capsular surface of the spleen, which is most commonly seen with gynecologic malignancies.” 


      Nonneoplastic, Benign, and Malignant Splenic Diseases: Cross-Sectional Imaging Findings and Rare Disease Entities 
Thipphavong S et al.
AJR 2014; 203:315–322
    • “The most common primary benign vascular neoplasm of the spleen is hemangioma. Other benign vascular neoplasms of the spleen include hamartoma, lymphangioma, EMH, and SANT. Primary splenic angiosarcoma is the most common malignant nonhematolymphoid malignancy of the spleen. Lymphoma, myeloma, and metastases are the other malignant entities involving the spleen.”

      
Nonneoplastic, Benign, and Malignant Splenic Diseases: Cross-Sectional Imaging Findings and Rare Disease Entities 
Thipphavong S et al.
AJR 2014; 203:315–322
    • “Pyogenic abscesses are most commonly caused by hematogenous spread of infection. Other causes include penetrating trauma and prior splenic infarction. On ultrasound, ab- scesses appear as poorly defined hypoecho- ic or cystic lesions. On CT, microabscesses are multiple ill-defined low-attenuation lesions. Lesions are usually small, 5–10 mm. A central focus of higher attenuation and ring enhancement can also be seen. Fungal microabscesses usually occur in immunocom- promised patients.” 


      Nonneoplastic, Benign, and Malignant Splenic Diseases: Cross-Sectional Imaging Findings and Rare Disease Entities 
Thipphavong S et al.
AJR 2014; 203:315–322
    • “Splenic hemangiomas are the most fre- quently occurring benign tumor of the spleen, with a rate of occurrence in autopsy series of 0.03–14%. Splenic hemangiomas are thought to be congenital in origin, arising from sinusoidal epithelium, and most are the cavernous type. Most hemangiomas are small (reported size range, 0.5–7.0 cm), incidental, and asymptomatic.” 


      Nonneoplastic, Benign, and Malignant Splenic Diseases: Cross-Sectional Imaging Findings and Rare Disease Entities 
Thipphavong S et al.
AJR 2014; 203:315–322
    • “Lymphangiomas are slow-growing benign tumors that are usually found in the soft tissues of the neck, axilla, mediastinum, retroperitoneum, or extremities. Lymphangiomas can also involve the liver, spleen, kidney, or gastrointestinal tract. Three histologic sub- types are described: simple lymphangiomas, cavernous lymphangiomas, and cystic hygromas. Splenic lymphangiomas can be seen with lymphangiomatosis or systemic cystic angiomatosis (lymphangiomas and hemangi- omas) involving several body parts or organs in the body. Diffuse lymphangiomatosis with splenic involvement is rare, and most cases have been reported in children.” 


      Nonneoplastic, Benign, and Malignant Splenic Diseases: Cross-Sectional Imaging Findings and Rare Disease Entities 
Thipphavong S et al.
AJR 2014; 203:315–322
    • “On CT, multiple discrete, nonenhancing low-attenuation lesions are present. Lymph- 
angiomas are usually subcapsular in location. Curvilinear peripheral mural calcifications can be seen. On MRI, well-circumscribed fluid-signal-intensity lesions are present on T2- weighted images. High signal intensity can be seen on T1-weighted imaging if there has been internal bleeding or if there is a large amount of intracystic proteinaceous material.” 


      Nonneoplastic, Benign, and Malignant Splenic Diseases: Cross-Sectional Imaging Findings and Rare Disease Entities 
Thipphavong S et al.
AJR 2014; 203:315–322
    • “Splenic hamartomas are tumors composed of a varying mixture of tumor tissue and normal splenic tissue, with reported sizes ranging from 0.3 to 20.0 cm. Hamartomas are solid lesions that may contain a cystic or necrotic component. Splenic hamartomas can be associated with syndromes—namely, tuberous sclerosis and Wiskott-Aldrich-syndrome. Two subtypes of splenic hamartomas can occur: white pulp lesions, which are composed of aberrant lymphoid tissue, and red pulp lesions, which are composed of an aberrant complex of sinuses. Most hamartomas are a mixture of the two subtypes.”

      
Nonneoplastic, Benign, and Malignant Splenic Diseases: Cross-Sectional Imaging Findings and Rare Disease Entities 
Thipphavong S et al.
AJR 2014; 203:315–322
    • “On unenhanced CT, hamartomas are usually isodense to splenic parenchyma. Depending on size, splenic hamartomas can cause distortion of the splenic con- tour. Sometimes the contour abnormality is the only noticeable feature on unenhanced CT. Calcification, cystic change, and fat can occasionally be seen.” 


      Nonneoplastic, Benign, and Malignant Splenic Diseases: Cross-Sectional Imaging Findings and Rare Disease Entities 
Thipphavong S et al.
AJR 2014; 203:315–322
Vascular

    • “Originally described by Rokitansky in 1861, superior mesenteric artery syndrome (SMAS) is a relatively rare condition caused by obstruction of the third portion of the duodenum between the SMA and aorta. The condition has also been called cast syndrome, Wilke syndrome, or arteriomesenteric duodenal compression syndrome. Because of its relative infrequency, the incidence of the disorder is not well known. However, estimated incidence rates based on gastrointestinal barium series are from 0.01% to 0.33%.”


      Multidetector Row CT of Superior Mesenteric Artery Syndrome 
Gautam A. Agrawal, Pamela T. Johnson, Elliot K. Fishman 
J Clin Gastroenterol 2007;41:62–65

    • “As opposed to traditional imaging modalities like upper gastrointestinal and mesenteric arteriography, which depict either the bowel or vasculature respectively, CT enables direct visualization of obstructed bowel owing to duodenal compression by the SMA. Multiplanar MDCT with 3-dimen- sional rendering provides sagittal reconstructions that can be used to confirm the CT criteria of decreased aortomesenteric angle and distance in SMAS.”


      Multidetector Row CT of Superior Mesenteric Artery Syndrome 
Gautam A. Agrawal, Pamela T. Johnson, Elliot K. Fishman 
J Clin Gastroenterol 2007;41:62–65

    • “When conservative management fails, surgical treatment is employed. Surgical management includes duodenojejunostomy, gastrojejunostomy, or lysis of the ligament of Treitz with derotation of the bowel (Strong’s operation). After unsuccessful conservative management, surgical correction was required in 2/3 of patients in 1 small series.”


      Multidetector Row CT of Superior Mesenteric Artery Syndrome 
Gautam A. Agrawal, Pamela T. Johnson, Elliot K. Fishman 
J Clin Gastroenterol 2007;41:62–65

    • An entity first described almost 150 years ago, ‘‘superior mesenteric artery (SMA) syndrome’’ represents a unique set of clinical symptoms caused by compression of the duodenum between the aorta and SMA. Classically described in young women, patients experience early post-prandial satiety, abdominal pain, nausea, and vomiting, often resulting in chronic anorexia and weight loss.

      
Superior mesenteric artery syndrome: spectrum of CT findings with multiplanar reconstructions and 3-D imaging 
Siva P. Raman, Edward G. Neyman, Karen M. Horton, Frederic E. Eckhauser, Elliot K. Fishman 
 Abdom Imaging (2012) 37:1079–1088 

    • “SMA syndrome is thought to result from an abnormally short distance between the aorta and SMA, which results in compression of the duodenum. Patients with SMA syndrome usually present with nonspecific symptoms, making diagnosis extremely difficult. Typically seen in young women, their chronic anorexia, nausea, vomiting, and post- prandial abdominal pain are often blamed on non-anatomic, psychosocial causes, resulting in a delayed diagnosis. Nevertheless, when carefully questioned, these patients often have a characteristic history, with their symptoms relieved by changes in posture, such as turning to their left side, bringing their knees up to their chest, or the prone position.”


      Superior mesenteric artery syndrome: spectrum of CT findings with multiplanar reconstructions and 3-D imaging 
Siva P. Raman, Edward G. Neyman, Karen M. Horton, Frederic E. Eckhauser, Elliot K. Fishman 
 Abdom Imaging (2012) 37:1079–1088 

    • “In a normal patient, the distance between the aorta and SMA (‘‘aortomesenteric distance’’) should range from 10 to 34 mm, and the normal angle between the aorta and SMA (‘‘aortomesenteric angle’’) should be between 28° to 65°. Angiographic studies have shown that patients with SMA syndrome clearly have an abnormal aortomesenteric angle (6°–22°), and a shortened aorto-mesenteric distance (2–8 mm) compared to normal patients.”


      Superior mesenteric artery syndrome: spectrum of CT findings with multiplanar reconstructions and 3-D imaging 
Siva P. Raman, Edward G. Neyman, Karen M. Horton, Frederic E. Eckhauser, Elliot K. Fishman 
 Abdom Imaging (2012) 37:1079–1088
All images on this site are © 2017 Elliot K. Fishman, MD.