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IgG4 aortitis is a recently recognized entity that can have clinical and imaging features that mimic acute aortic syndrome. Therefore, it is imperative for radiologists to be aware of how to potentially differentiate the two. Although this entity has been previously described via case reports and meta-analysis in the context of inflammatory abdominal aortic aneurysm, very few cases of ascending aortic involvement have been reported. In this case report, we present a case of a 60-year-old female transferred from another facility for an initial diagnosis of intramural hematoma of the ascending aorta and later found to have IgG4 aortitis post aortic root repair. This is a histologically confirmed case of multi-segmented IgG4 aortitis with rare involvement of both ascending and infra-renal aorta. We will briefly discuss the pathophysiology of IgG4 aortitis, along with review of literature.

Medical imaging plays a crucial role in the evaluation of patients in the acute setting. Radiology, primarily CT, provides safe, rapid, and accurate information that is helpful in diagnosis management and triage of patients. This chapter will focus on the indications and type of medical imaging available in the elderly populations, risks and contraindications, and hallmark imaging features to be aware of. It will highlight the imaging role in the setting of mesenteric ischemia, vascular compromise, trauma, and acute bowel.

Pancreatic cancer is an aggressive disease with rising incidence and high mortality despite advances in imaging and therapeutic options. Surgical resection is currently the only curative treatment, with expanding roles for adjuvant and neoadjuvant chemoradiation. Accurate detection, staging, and post-treatment monitoring of pancreatic cancer are critical to improving survival and imaging plays a central role in the multidisciplinary approach to this disease. This article will provide a broad overview of the imaging and management of pancreatic cancer with a focus on diagnosis and staging, operative and nonoperative treatments, and post-therapeutic appearances after surgery and chemoradiation therapy.

A lack of well-defined postoperative imaging guidelines for bariatric patients may lead to false-positive findings, radiation exposure, additional cost, and patient anxiety. We investigated our institutional usage and utility of nonroutine postoperative abdominal imaging.Laparoscopic gastric bypass and sleeve gastrectomy patients over a 5-year period were retrospectively identified. All bariatric-related nonroutine initial and all subsequent prompted abdominal and pelvic imaging was included.A total of 578 patients were included (399 gastric bypass, 179 sleeve gastrectomy); 907 nonroutine studies in 69% of patients were performed, and 36% patients underwent computed tomography (CT). Only 20.3% of findings were symptom-related, 26% had benign incidental findings, and 50% were negative. Incidental findings prompted 71 additional studies. Bypass procedure (sleeve versus bypass, odds ratio [OR] .3), older age (median 43 versus 48 years), and lower initial body mass index (BMI) (median 43 versus 45) increased the likelihood of imaging. History of prior abdominal surgery and dyspepsia increased the probability of undergoing CT by an odds ratio of 1.8 and 2.0, respectively (P.05). History of ulcer (OR .6) or reflux on routine upper gastrointestinal imaging (OR .3) decreased probability (P.05). Patients who underwent CT were more likely to undergo other abdominal imaging (3 versus 1 study per patient, P.01).Postoperative abdominal imaging in the bariatric population is common, with almost 70% of patients undergoing imaging and 70% of findings not related to patient symptoms. Bypass procedure, older age, and lower initial BMI were associated with a higher likelihood of patients undergoing imaging. Heightened understanding of this important subject is necessary to help streamline cost-effective imaging protocols for these patients.

The Medicare Access and CHIP Reauthorization Act of 2015 was signed into law on April 16, 2015, fundamentally altering the way clinicians are reimbursed for the treatment of Medicare patients starting in 2017. Under this new pay-for-performance model, reimbursement will be tied to multiple metrics related to quality and cost of care. A scaled scoring system will require providers to compete for positive reimbursement adjustments, while also penalizing poor performers with negative adjustments. A firm understanding of this new system will be essential for all physicians looking to maximize their reimbursement, particularly diagnostic radiologists and members of other highly focused fields where special considerations lead to alterations in the scoring system.

A 61-year-old Asian man presented with severe right upper quadrant pain which had been worsening for several months. Laboratory results indicated elevated aspartate aminotransferase and alanine aminotransferase. The subsequent ultrasound, CT and MRI showed a large cystic mass with solid components and severe intrahepatic and extrahepatic biliary ductal dilatation. The mass was resected and pathology showed a well-demarcated mucinous cystic lesion with polygonal cells containing ovoid nuclei and abundant pink oncocytic cytoplasm. These findings are characteristic of intraductal oncocytic papillary neoplasm (IOPN), a rare subtype of intraductal papillary neoplasm of the liver. IOPN occurs most frequently in the Asian regions endemic to clonorchiasis and hepatolithiasis; however, cases have been reported in the Western world as well. Patients with IOPN are male or female and typically middle-aged. Treatment is typically resection. Prognosis is favourable and recurrence is rare. The 5-year survival rate is upwards of 80%.

Gallbladder varices are a rare form of collateralization that develop in patients with portal hypertension. We present here a case of gallbladder varices accurately diagnosed by contrast enhanced CT imaging of the abdomen and confirmed by Color Doppler Sonography. A 76-year-old patient with hepatocellular carcinoma developed portal vein thrombosis due to tumor extension during the course of treatment and was incidentally discovered to have gallbladder varices. While most commonly asymptomatic, gallbladder varices are associated with increased risk of massive bleeding, either spontaneously or during cholecystectomy. As a result, the existence of such varices should be well documented if the patient is to undergo any abdominal surgical procedures. In addition, because of a particular association with portal vein thrombosis, patients with portal hypertension that are found to possess gallbladder varices should be evaluated for portal vein thrombosis.

RadioGraphics continues to publish radiologic-pathologic case material selected from the American Institute for Radiologic Pathology (AIRP) "best case" presentations. The AIRP conducts a 4-week Radiologic Pathology Correlation Course, which is offered five times per year. On the penultimate day of the course, the best case presentation is held at the American Film Institute Silver Theater and Cultural Center in Silver Spring, Md. The AIRP faculty identifies the best cases, from each organ system, brought by the resident attendees. One or more of the best cases from each of the five courses are then solicited for publication in RadioGraphics. These cases emphasize the importance of radiologic-pathologic correlation in the imaging evaluation and diagnosis of diseases encountered at the institute and its predecessor, the Armed Forces Institute of Pathology (AFIP).

Salmonella osteomyelitis is seen most commonly in patients with sickle cell disease and in those with compromised immune systems. We report on the clinical, histological and imaging findings of salmonella osteomyelitis with intraosseous abscess formation occurring in a non-sickle cell patient receiving anti-tumor necrosis factor (TNF) alpha therapy.

Ultrasound Quarterly & Volume 24, Number 2, June 2008 93 Received for publication February 1, 2008; accepted February 2, 2008. Division of Body Imaging, Department of Radiology, Stony Brook University Medical Center, Stony Brook, NY. Reprints: Anthony G. Gilet, MD, Department of Radiology, HSC Level 4, Rm 120, Stony Brook, NY (e-mail: anthonygilet@gmail.com). Copyright * 2008 by Lippincott Williams & Wilkins

In evaluating the gastrointestinal tract, whether in the emergency room setting, the inpatient setting or the outpatient setting, the radiologist may encounter a myriad of intraluminal radio-opaque, non-anatomic entities. It is the radiologist’s role to distinguish between true foreign bodies and medical paraphernalia. Further, the later must be evaluated for proper positioning vs. improper, potentially detrimental positioning. While many foreign bodies from the community may be distinctly familiar to the radiologist, the large variety of medical tools in existence may not be. Furthermore, many medical devices are designed to transiently traverse, or interact with the gastrointestinal tract, requiring the radiologist to become familiar with their natural history. We explore a select group of common and uncommon intraluminal foreign bodies and will divide them into medical paraphernalia that are properly positioned; medical paraphernalia that are in abnormal locations and miscellaneous foreign bodies from the community. For each medical tool, we will discuss its development and medical utility, natural history as it relates to the gastrointestinal tract, optimal positioning as assessed radiologically, malpositioning, and subsequent complications. A small selection of unusual foreign bodies from the community will be presented. Finally, a selection of medical conditions which produce symptoms due to acquired intraluminal objects will be reviewed.

Unlike TAVR with balloon expandable valve, standard co-planar “3-cusp” view may not be ideal for deploying self-expanding valve (e.g.CoreValve) as it requires elimination of parallax ofvalve frame during deployment. A co-planar view by overlapping right and left cusps may be a useful approach in

A 32-year-old woman was referred to the liver transplant centre, for pretransplant evaluation. Her medical history revealed portal hypertension diagnosed at the age of 6 years, oesophageal varices with history of banding and sclerotherapy by the age of 12 years, as well as multiple episodes of pneumonia. Contrast-enhanced CT of the thorax was performed as part of the routine preoperative workup for liver transplant, which demonstrated unilateral absence of the right pulmonary artery (UAPA) associated with a small right lung and rightward mediastinal shift (figure 1). Additionally, numerous right subpleural cysts were present with diffuse pleural thickening (figure 1). Collateral vessels were noted along the right hemidiaphragm supplied by a single branch coming off the aorta at the level of the coeliac trunk, …

The purpose of this study is to determine fetal dose during four different stages of pregnancy for both pulmonary CT angiogram and abdominal and pelvic CT examination on 4-, 16-, and 64-MDCT scanners measured in an anthropomorphic phantom simulating a pregnant patient.Pulmonary angiograms and abdominal and pelvic studies were performed on a phantom on 4-, 16-, and 64-MDCT scanners. Fetal positioning and mean fetal depth were determined using data from ultrasound examinations of a large cohort of patients. Scans were performed for early pregnancy and for 10, 18, and 36 weeks. Gestational age, fetal dose, and entrance skin exposure were measured.When constant parameters were used for pulmonary CT angiograms, the fetal radiation dose was not significantly associated with gestational age. For abdominal examinations, the 64-MDCT scanner imparted a 20% higher dose during the third trimester than did the other scanners. When scanning parameters were kept constant between machines, gestational age and fetal dose were not significantly different. However, when the manufacturer-recommended protocols for pregnant patients were used, the dose was significantly higher in the third trimester on the 64-MDCT scanner.The 64-MDCT scanner is the most dose-efficient machine when the fetus is outside the direct scan volume, as in the case of pulmonary angiograms. For abdominal examinations, the 64-MDCT scanner imparted the highest fetal dose. This finding is attributable to the increased tube current used to penetrate the larger amount of soft tissue in late pregnancy. Abdominal shielding may reduce fetal dose without affecting diagnostic ability.

To assess the utility of diffusion-weighted imaging (DWI) findings as an indirect marker of side-specific risk of extracapsular extension (ECE) of prostate cancer.Fifty-one patients underwent 3T magnetic resonance imaging (MRI) before prostatectomy. Radiologists 1 and 2 (4 and 1 years experience) assessed each side for ECE using T2-weighted imaging (T2WI) and evaluated apparent diffusion coefficient (ADC) maps for the presence of apparent tumor in each lobe and to measure peripheral zone ADC. A uropathologist measured the extent of any ECE.In all, 28/102 lobes had ECE, of which 12 measured ≤1 mm, 11 measured1 mm and ≤2 mm, and five measured2 mm. Side-specific accuracies for detection of ECE for readers 1 and 2 were respectively: T2WI 68.6% and 74.5%; presence of apparent tumor on ADC map 66.7% and 60.8%; ADC value 75.5% and 69.6%. For ECE2 mm, both readers achieved 100% sensitivity based on apparent tumor on ADC map or ADC values and 80% sensitivity using T2WI. For detection of ECE ≤2 mm, sensitivity for all combinations of the three methods and two readers ranged from 58.3%-81.8%, aside from assessment for ECE using T2WI by the less experienced reader, which exhibited sensitivity of 17.4%. Interreader agreement for the presence of ECE was 0.18 using T2WI, 0.37 using apparent tumor on ADC map, and 0.60 using ADC values.Compared with T2WI, DWI had comparable accuracy for side-specific assessment of ECE, greater sensitivity for ECE2 mm for the less-experienced radiologist, and greater interreader agreement.

We present the case of a 48-year-old woman with hypothenar hammer syndrome. Hypothenar hammer syndrome is caused by chronic repetitive trauma to the ulnar artery and superficial palmar arch. This syndrome was originally described in males working in occupations that involved repetitive blunt trauma including working with jackhammers. It is believed that the ulnar artery is repetitively damaged by blunt compression against the hamate. Our patient was a postal worker who frequently used a rubber stamper.

Diagnosis of appendicitis during pregnancy can be challenging because of atypical clinical presentations such as abdominal pain, nausea and vomiting, which can also appear in normal pregnancy. According to the American College of Radiology appropriateness criteria, ultrasound of the right lower quadrant with graded compression is the most appropriate initial imaging test in suspected appendicitis in a pregnant patient, especially during the first and early second trimester.1 Ultrasound with graded compression technique, although the first line investigation modality for suspected appendicitis in pregnancy, depends on variability in operator skills and may result in equivocal or indeterminate findings.2 If ultrasound is non-diagnostic, MRI (if available), which lacks ionisation …

We present the case of a 33-year-old woman who presented with a slowly enlarging mass over the volar aspect of the wrist that had been present since infancy which for the previous year had been causing progressive pain. The lesion was proven to be a fibrolipomatous hamartoma, a rare benign tumor that most commonly affects the median nerve. We discuss the characteristic radiologic appearance of this entity that is often pathognomonic and allows a confident diagnosis without the need for biopsy.