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Purpose: To analyze the change in utilization of healthcare resources through a review of ultrasound examinations performed in the emergency department of an urban healthcare system in NYC during the time of peak COVID-19 outbreak., Methods: This is a retrospective review analyzing ED ultrasound exams performed by the radiology department of an urban healthcare system during the 8-week time period of the peak COVID-19 outbreak in NYC, compared to a time-matched period one year prior. Data regarding the examination type and indication were obtained in addition to patient demographics and indicators of outcomes including admission, length of stay, and mortality., Results: There was a 58% decrease in ED ultrasounds performed by the radiology department during the COVID-19 time period. Exams performed during the pandemic compared to the pre-pandemic period were more likely to be performed on men (28.3 vs 18.0%, p < 0.01), older patients (36 vs. 35 years, p = 0.02), and patients subsequently admitted (17.8 vs. 13.4%, p = 0.03). There was also a difference in the distribution of exam type (p = 0.01). There was no difference in death, rate of surgery/intervention performed, or distribution of clinical indication. When correcting for gender, there was only an increase in studies leading to hospital admission in the female-only group (14.9 vs. 10.7%, p = 0.05)., Conclusion: COVID-19 had a drastic impact on the utilization of emergency department ultrasounds performed by the radiology department, with a decrease in total exams performed and changes in patient demographics, including a higher proportion of male patients and increases in some markers of disease severity, including rate of hospital admission., (© 2021. American Society of Emergency Radiology.)

Rationale and Objectives: Our goal was to determine whether use of the iPad would increase the students' radiologic knowledge, aid in their interpretation of imaging exams, and increase learner satisfaction., Material and Methods: iPads were pre-populated with ten image data sets, which included plain film, ultrasound, and CT of the head, chest, abdomen, and pelvis. The students, working in small groups, were charged with identifying the salient imaging findings, formulating a differential diagnosis, and choosing the most appropriate imaging modality, if further work-up was necessary. After the student group problem-solved for an hour, a faculty facilitator joined the group and reviewed the cases with them in an interactive fashion. Pre- and post- intervention tests were administered, and statistical analysis was performed., Results: Student satisfaction surveys were administered to 125 students in the first 2 years of the study. These scores rated their assessment of the iPad exercise and ranged from 4.6 to 4.9 out of 5. The knowledge evaluation group included 219 students, 110 in the study group and 109 in the control group, in the latter 3 years of the study. The average improvement from the initial to the second test was 1.04 points among the control group and 2.32 among the study group, which was statistically significant ( p  = 0.0001)., Conclusion: We demonstrate increased learner satisfaction, as well as improved knowledge acquisition and interpretive skills of third year medical students engaged in hands-on learning using iPads., Competing Interests: Conflict of InterestThe authors declare that they have no conflict of interest., (© International Association of Medical Science Educators 2020.)

Purpose: After encouraging results from a single-institution pilot, a novel case-based education portal using integrated clinical decision support at the simulated point of order entry was implemented at multiple institutions to evaluate whether the program is scalable and results transferable. The program was designed to fill key health systems' science gaps in traditional medical education curricula, ultimately aiding the transition from volume to value in health care. The module described uses commonly encountered medical vignettes to provide learners with a low-stakes educational environment to improve their awareness and apply curricular content regarding appropriate resource utilization, patient safety, and cost., Methods: In 2016 and 2017, the team implemented the modules at eight US medical schools. A total of 199 learners participated in this institutional review board-approved study; 108 completed the module, and 91 were in the control group., Results: The module group had higher posttest scores than their control group peers, after controlling for pretest scores (β = 4.05, P < .001). The greatest knowledge gains were on questions related to chest radiography (22% improvement) and adnexal cysts (20.33% improvement) and the least on items related to pulmonary embolism (0.33% improvement). The majority of learners expressed satisfaction with the educational content provided (70.4%) and an increased perception to appropriately select imaging studies (65.2%)., Conclusions: This program is promising as a standardized educational resource for widespread implementation in developing health systems science curricula. Learners at multiple institutions judged this educational resource as valuable and, through this initiative, synthesized practice behaviors by applying evidence-based guidelines in a cost-effective, safe, and prudent manner., (Copyright © 2019 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Ultrasound contrast agents have been used for decades in Europe and Asia for cardiac and abdominal imaging and are now being more commonly utilized in the United States for radiology applications. Our article reviews the basics of contrast-enhanced ultrasound including how the contrast agent works, advantages and disadvantages, as well as pearls and pitfalls to help the radiologist efficiently integrate this technology into day-to-day clinical practice. We also discuss the diagnosis of focal hepatic lesions as well as off-label applications such as evaluation of renal masses., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Colostomies are commonly created in conjunction with colorectal surgery performed for both malignant and benign indications. Familiarity with the different types of colostomies and their normal imaging appearance will improve radiologic detection and characterization of colostomy complications. The radiologist plays a large role in assessment of colostomy patients either via fluoroscopic technique or multidetector computed tomography (CT) in order to help identify ostomy complications or to aid the surgeon prior to colostomy reversal. In this article, we will review: (1) the types of colostomies and indications for their creation; (2) the proper radiographic technique of ostomy evaluation; and (3) the potential complications of colostomies and their imaging manifestations., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Obesity has become an epidemic in the United States, and bariatric surgery is being increasingly performed for its management. There has been an increased number of laparoscopic sleeve gastrectomies performed for the treatment of morbid obesity due to its efficacy and lower complication rate compared to other bariatric surgical techniques. The authors discuss the surgical technique, review the imaging of normal and complicated sleeve gastrectomy, and highlight radiographic pitfalls., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Focal atraumatic splenic lesions often pose a diagnostic challenge on cross-sectional imaging. They can be categorized based on etiology, as nonneoplastic, benign neoplastic, and malignant neoplastic (discussed in Part III) lesions, or on prevalence, as common, uncommon, and rare lesions. Familiarity with pertinent clinical parameters, etiology, pathology, prevalence, and ancillary features such as splenomegaly, concomitant hepatic involvement, and extrasplenic findings, in addition to knowledge of imaging spectra of the lesions, can improve diagnostic confidence. Consideration of these factors together can arm the radiologist with the necessary tools to render a more confident diagnosis and thus better aid management., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Solid organ abdominal ischemia commonly presents with acute pain prompting radiologic evaluation and often requires urgent treatment. Despite different risk factors and anatomic differences, most solid organ ischemia is due to arterial or venous occlusion and, less frequently, a low-flow state. Radiologic diagnosis is critical, as clinical presentations are often nonspecific. Contrast-enhanced computed tomography (CT) is the modality of choice (except in adnexal torsion) with magnetic resonance imaging (MRI) useful in equivocal cases or follow-up of ischemic disease. This article will provide a pictorial review of the CT and MRI features of solid abdominal organ ischemia while highlighting key clinical features, etiology, and management., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Focal atraumatic splenic lesions often pose a diagnostic challenge on cross-sectional imaging. They can be categorized based on etiology as nonneoplastic (reviewed in Part I), benign neoplastic, and malignant neoplastic lesions. Lesions can also be characterized based on prevalence as common, uncommon, and rare. Familiarity with pertinent clinical parameters, etiology, pathology, prevalence, and ancillary features such as splenomegaly, concomitant hepatic involvement, and extrasplenic findings, in addition to knowledge of imaging spectra of these lesions, can improve diagnostic confidence. Since the nonneoplastic lesions are usually easily recognized, it is critical that the radiologist identifies them avoiding unnecessary work up., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Acute hollow organ ischemia commonly presents with acute pain prompting radiologic evaluation and almost always requires urgent treatment. Despite different risk factors and anatomic differences, ischemia is commonly due to low flow states but can also be due to arterial and venous occlusion. Radiologic diagnosis is critical as many present with nonspecific symptoms. Contrast-enhanced computed tomography (CT) is the modality of choice. Magnetic resonance imaging (MRI) is preferred in suspected appendicitis in pregnant patients and is superior in biliary necrosis. This article provides a pictorial review of the CT/MRI features of hollow abdominal organ ischemia while highlighting key clinical features, pathogenesis, and management., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Focal atraumatic splenic lesions often pose a diagnostic challenge on cross-sectional imaging. They can be categorized based on etiology as nonneoplastic, benign neoplastic (discussed in Part II), and malignant neoplastic lesions or on prevalence as common, uncommon, and rare lesions. Familiarity with pertinent clinical parameters, etiology, pathology, prevalence and ancillary features such as splenomegaly, concomitant hepatic involvement, and extrasplenic findings, in addition to knowledge of imaging spectra of the lesions, can improve diagnostic confidence. Consideration of these factors together can arm the radiologist with the necessary tools to render a more confident diagnosis and, thus, better aid management., (Copyright © 2016. Published by Elsevier Inc.)

The aim of this study was to evaluate the feasibility and acceptance of a model of direct interaction between radiologist and patients in the emergency department (ED) setting. The study population was comprised of pregnant patients accrued in a non-consecutive prospective manner from June 2014 to September 2015, who had an obstetrical ultrasound performed in the radiology department of an inner-city tertiary care hospital at the request of the ED. The feasibility and approval of direct communication between radiologist and patient were evaluated by means of a questionnaire presented by an independent observer to the ED provider, patient, and radiologist. The exam enrolled 54 patients. Ultrasound (US) exam results were divided into (31) normal live intrauterine gestation (group 1), (7) abnormal failed intrauterine gestation or ectopic pregnancy (group 2), and (16) indeterminate pregnancies that could not be placed in the former categories and may require a follow-up exam (group 3). Forty-five (83 %) ED providers approved of the radiologist's direct communication with patients. Fifty (93 %) patients stated a better understanding of the radiologist's role in their care after than before the interaction. The radiologists found the interaction with patients to be positive in 52 (96 %) cases. Direct communication between radiologist and patient yielded a good acceptance by the radiologist, ED provider, and patient. More importantly, after the encounter, the vast majority of patients reported a better understanding of the radiologist's role in their care.

Purpose: The aim of this study was to determine whether group-based or didactic teaching is more effective to teach ACR Appropriateness Criteria to medical students., Methods: An identical pretest, posttest, and delayed multiple-choice test was used to evaluate the efficacy of the two teaching methods. Descriptive statistics comparing test scores were obtained., Results: On the posttest, the didactic group gained 12.5 points (P < .0001), and the group-based learning students gained 16.3 points (P < .0001). On the delayed test, the didactic group gained 14.4 points (P < .0001), and the group-based learning students gained 11.8 points (P < .001). The gains in scores on both tests were statistically significant for both groups. However, the differences in scores were not statistically significant comparing the two educational methods., Conclusions: Compared with didactic lectures, group-based learning is more enjoyable, time efficient, and equally efficacious. The choice of educational method can be individualized for each institution on the basis of group size, time constraints, and faculty availability., (Copyright © 2016 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Objectives: To describe the imaging findings in a series of patients with mesothelioma of the tunica vaginalis testis., Methods: We reviewed clinical data, imaging findings and follow-up information in a series of 10 pathology-proven cases of mesothelioma (all had US; 2 had MR) of the tunica vaginalis., Results: A variety of patterns could be observed, the most common (5/10) being a hydrocele with parietal, solid and hypervascular vegetations; one patient had a septated hydrocele with hypervascular walls; one had multiple, solid nodules surrounded by a small, physiological quantity of fluid; one a cystic lesion with thick walls and vegetations compressing the testis; two had a solid paratesticular mass. MR showed multiple small nodules on the surface of the tunica vaginalis in one case and diffuse thickening and vegetations in the other one; lesions had low signal intensity on T2-w images and were hypervascular after contrast injection., Conclusions: A preoperative diagnosis of mesotheliomas presenting as solid paratesticular masses seems very difficult with imaging. On the contrary, the diagnosis must be considered in patients in whom a hydrocele with parietal vegetations is detected, especially if these show high vascularity., Key Points: Mesotheliomas of the tunica vaginalis are rare, often challenging to diagnose preoperatively. Most common finding is a complex hydrocele with hypervascular parietal vegetations. Septated hydrocele, nodules without hydrocele, a thick-walled paratesticular cyst are less common. Preoperative diagnosis may allow aggressive surgical approach and, possibly, a better prognosis.

Objectives: We aimed to determine the prevalence of hydronephrosis in patients who underwent renal sonography for new-onset acute kidney injury (AKI) and to identify clinical factors predictive of hydronephrosis. In patients with hydronephrosis, we sought to investigate how routine renal sonography affects patient treatment, including performance of interventional procedures., Methods: A retrospective chart review identified 274 adults with AKI who underwent renal sonography at an urban teaching hospital from January through July 2011. The prevalence of hydronephrosis was determined. Electronic medical records were reviewed for comorbidities, including risk factors for hydronephrosis such as a pelvic mass, prior renal or pelvic surgery, and neurogenic bladder, and for subsequent interventions and outcomes., Results: Sonography showed hydronephrosis in 28 patients (10%); 5 (18%) had subsequent interventions. In a multivariable logistic regression model with the outcome being hydronephrosis, all considered risk factors (pelvic mass, prior renal or pelvic surgery, and neurogenic bladder) were significantly associated with hydronephrosis (odds ratio, 6.4; 95% confidence interval, 2.7-15.4; P < .001) when adjusting for age and diabetes mellitus. Diabetes had a negative predictive value for hydronephrosis. No diabetic patients younger than 85 years and without clinical risk factors had hydronephrosis., Conclusions: Hydronephrosis is infrequently seen on sonograms in hospitalized patients with AKI who lack risk factors for urinary tract obstruction. Deferral of sonography pending a trial of medical treatment is safe and will reduce medical costs. Adoption of clinical guidelines to assess patients' risk levels for hydronephrosis is critical to avoid unnecessary imaging., (© 2015 by the American Institute of Ultrasound in Medicine.)

Ultrasound is the primary imaging modality used in the evaluation of first-trimester vaginal bleeding and pelvic pain. This article will summarize the ultrasound findings in normal first-trimester pregnancy, failed pregnancy, ectopic pregnancy, subchorionic hemorrhage, retained products of conception, and gestational trophoblastic disease. Mastery of the spectrum of sonographic findings in the normal and abnormal first-trimester pregnancy allows the radiologist to make accurate diagnoses and helps to appropriately guide patient management., (Copyright © 2015 Elsevier Inc. All rights reserved.)

In this review, we illustrate the computed tomographic features of thoracoabdominal soft-tissue abnormalities, which may be easily overlooked and often can provide important information regarding systemic processes. Examples include necrotizing fasciitis, heterotopic ossification, fat necrosis, benign and malignant neoplasms, endometriosis, and collagen vascular disease as well as systemic and congenital pathology., (Copyright © 2014 Canadian Association of Radiologists. Published by Elsevier Inc. All rights reserved.)

Familiarity with the imaging appearance and potential complications of buttocks aesthetic surgery is important for radiologists. In this review, we illustrate the spectrum of imaging features after buttocks implants, liposuction, fat injections and silicone injections. Complications such as fat necrosis, abscess, and silicone migration are also presented.

This white paper describes adnexal (ovarian and paraovarian) incidental findings found on CT and MRI in nonpregnant postmenarchal patients in whom no adnexal disorder is clinically known or suspected. This represents the first of 4 such papers from the ACR Incidental Findings Committee II, which used a consensus method based on repeated reviews and revisions and a collective review and interpretation of relevant literature. Recommendations for the management of incidental adnexal findings are organized into 4 main categories: benign-appearing cysts, probably benign cysts, adnexal masses with characteristic features, and all other adnexal masses, with pathways on the basis of patient menstrual status or age (when last menstrual period is unknown). A table and flowchart are provided for reference., (Copyright © 2013 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

In this review, we illustrate the spectrum of imaging features after plastic surgical procedures including transverse rectus abdominis myocutaneous flap, deep inferior epigastric perforators flap, latissimus dorsi flap, liposuction, abdominoplasty, and buttocks augmentation. Examples of complications, including seromas, abscesses, fat necrosis, abdominal hernia, and flap necrosis, will also be discussed., (Copyright © 2012 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Background: Abdominal pain is often evaluated using imaging, most often with computed tomography (CT). While CT is sensitive and specific for certain diagnoses, small bowel thickening is a nonspecific finding on CT with a broad differential diagnosis including infection, inflammation, ischemia and neoplasm., Method: A review of medical records of patients who underwent CT scans of the abdomen and pelvis over a one-year period and exhibited small bowel thickening were retrospectively evaluated to determine the final diagnosis., Results: The etiologies of small bowel thickening on CT were as follows: infection (113 of 446 [25.34%]); reactive inflammation (69 of 446 [15.47%]); primary inflammation (62 of 446 [13.90%]); small bowel obstruction (38 of 446 [8.52%]); iatrogenic (33 of 446 [7.40%]); neoplastic (32 of 446 [7.17%]); ascites (30 of 446 [6.73%]); unknown (28 of 446 [6.28%]); ischemic (24 of 446 [5.38%]); and miscellaneous (17 of 446 [3.81%])., Conclusion: Infectious and inflammatory (primary or reactive) conditions were the most common cause of small bowel thickening in the present series; these data can be used to formulate a more specific differential diagnosis.

Purpose: To evaluate the utility of chest radiography in demonstrating clinically significant pacemaker complications that required reoperation., Methods: In this retrospective case-controlled series, we identified 14 consecutive adults who required pacemaker reoperation and who had chest radiographs available for review (6 men, 8 women; mean age, 71 years [range, 43-95 years]). Ten patients had pacemakers implanted at our institution, and 4 were referred for reoperation. Forty-two controls, 3 for each patient, had postoperative chest radiographs and normal device function (25 men, 17 women; mean age 76 years [range, 37-96 years]). All postoperative chest radiographs, including 1-year follow-ups, were blindly reviewed by at least 2 of 4 radiologists for lead perforation and position of right atrial and right ventricular leads. Follow-up radiographs were assessed for lead perforation, lead displacement, and lead fracture. Data were analysed by using the Fisher exact test., Results: Of the patients, 1.7% (10/581) required reoperation for pacemaker dysfunction (noncapture, oversensing, abnormal atrial and ventricular thresholds, failing impedance), extracardiac stimulation, and lead perforation and/or displacement. There were no lead fractures. Chest radiographs demonstrated pacemaker complications in 57% of patients (8/14) at a median of 2 days (<1-32 days) after implantation and in 5% of the controls (2/42) (P < .0001). None of the abnormalities were noted on the official reports. Among subgroups, chest radiographs were abnormal for the following indications: pacemaker dysfunction in 4 of 7 patients versus 0 of 21 controls (P = .0017), extracardiac stimulation in 1 of 3 patients vs 0 of 9 controls (P = .25), and lead perforation and/or displacement in 3 of 4 patients vs 2 of 12 controls (P = .06)., Conclusions: Chest radiographs are useful after pacemaker placement and demonstrate the majority of complications that require reoperation. Familiarity with the expected normal position of the leads, appearances of pacemaker complications, and comparison with prior radiographs is crucial in rendering a correct diagnosis that guides patient management., (Copyright © 2011 Canadian Association of Radiologists. Published by Elsevier Inc. All rights reserved.)

Orthotopic liver transplantation is an important treatment option for patients with end-stage liver disease. Advances in surgical technique, along with improvements in organ preservation and immunosuppression have improved patient outcomes. Post-operative complications, however, can limit this success. Ultrasound is the primary imaging modality for evaluation of hepatic transplants, providing real-time information about vascular flow in the graft. Graft vascular complications are not uncommon, and their prompt recognition is crucial to allow for timely graft salvage. A multimodality approach including CT angiography, MRI, or conventional angiography may be necessary in cases of complex transplant vascular anatomy or when sonography and Doppler are inconclusive to diagnose the etiologies of these complications. The purpose of this article is to familiarize radiologists with the normal post-transplant vascular anatomy and the imaging appearances of the major vascular complications that may occur within the hepatic artery, portal vein, and venous outflow tract, with an emphasis on ultrasound.

Objective: The purpose of our study was to determine the efficacy of contrast-enhanced CT in detecting a thickened endometrium. We used transvaginal sonography as the reference standard., Materials and Methods: Between March 2005 and January 2007, data from 259 patients (mean age, 47 years; age range, 18-90 years) who underwent transvaginal sonography and contrast-enhanced CT of the pelvis were analyzed retrospectively. The endometrium was quantitatively measured in millimeters on sonography. On CT it was qualitatively categorized as normal, thickened, indeterminate, or not visualized and compared with the sonography findings and original radiology reports. When the endometrium was indeterminate (thickened or triangular in shape on axial images), sagittal reconstructions were performed for final categorization. Two reviewers evaluated the CT scans and sonograms jointly with differences resolved by consensus. Kappa, Wilcoxon's rank sum test, and intraclass correlation statistics were derived., Results: The overall sensitivity and specificity of CT in detecting the thickened endometrium was 53.1% and 93.5%, respectively, relative to transvaginal sonography. The positive and negative predictive values were 66.7% and 89.1%, respectively. Kappa, the statistical measure of agreement between CT and sonography data, was 0.5049. All cases of a triangular endometrium were normal in size on sagittal reconstruction images., Conclusion: Routine pelvic CT correctly identifies a normal endometrium in most patients. Sagittal reconstruction images are helpful to further evaluate the endometrium on CT in cases with a prominent or triangular endometrium because these are often related to uterine version. CT is relatively insensitive in detecting the thickened endometrium but better able to identify gross rather than subtle thickening, which must be further characterized by transvaginal sonography.

Objectives: Replacement of the myocardium by fat is a feature of arrythmogenic right ventricular dysplasia (ARVD). Pathology literature describes ventricular myocardial fat to be present not only in ARVD, but much more frequently related to aging, prior myocardial infarction (MI), and chronic ischemia. We noted focal ventricular myocardial fat in a group of patients who underwent chest computed tomography (CT) for varied indications. The aim of this study is to describe the noncontrast CT findings and clinical correlates of ventricular myocardial fat in this population., Materials and Methods: We prospectively identified 26 patients whose noncontrast chest CT (5/03 to 6/04) demonstrated ventricular myocardial fat and whose clinical charts were available. There were 14 men and 12 women with a mean age of 70 years. Twenty-three percent (6/26) had prior CTs. Each CT was reviewed by 3 radiologists in consensus. The site of the ventricular fat was noted. Each patient was categorized based on the location of the fat as follows: group 1-right ventricle (RV) only, group 2-left ventricle (LV) only, group 3-biventricular. Results of cardiac history, laboratory tests, and cardiac imaging were noted., Results: The distribution of ventricular myocardial fat was: group 1 RV-27% (7/26), group 2 LV-46% (12/26), and group 3 biventricular-27% (7/26). Echocardiographic, nuclear cardiology, or electrocardiographic data localizing a prior MI to a specific site were available in 35% (9/26) of patients: 14% (1/7) of group 1, 50% (6/12) of group 2, and 29% (2/7) of group 3. Myocardial fat corresponded to the site of MI in 89% (8/9). The presence and distribution of ventricular fat on CT was unchanged from prior CT in 100% (6/6). When comparing group 1 and group 2, group 1 was older (77 vs. 64 y, P=0.005), more often female (57% vs. 17%, P=0.13) and had fewer prior MI (14% vs. 50%, P=0.17) than group 2. Only 1 patient in this series had ARVD. He was in group 3., Conclusions: The significance of ventricular myocardial fat varies by location. Fat in the RV is most often related to aging. Prior RV MI and ARVD are less common etiologies. Fat in the LV is frequently related to prior MI. Recognition of myocardial fat on a noncontrast chest CT may be the first opportunity to diagnose a silent MI.

Objective: The purpose of this study was to define the sonographic characteristics of the vaginal cuff and cervical remnant after hysterectomy and to establish normal measurements of each after each type of surgery., Materials and Methods: One hundred twenty-one women who had undergone hysterectomy (mean age, 51 years; range, 31-80 years) were studied using transabdominal or transvaginal sonography. Seventy-six patients were acquired retrospectively and 45 prospectively. Hysterectomy types included abdominal, 52% (63/121); supracervical, 17% (20/121); vaginal, 17% (20/121); and unknown, 15% (18/121). Two reviewers, who were blinded to clinical information, evaluated each cuff or remnant in consensus. Transabdominal anteroposterior, transvaginal anteroposterior, and transvaginal length measurements before and after transducer compression, and amount of color Doppler flow as shown by percentage of color pixels (n = 36 patients) were correlated with hysterectomy type and patient age., Results: Supracervical cuffs were larger (p < 0.01) than abdominal and vaginal hysterectomy cuffs (transabdominal sonography anteroposterior, 2.8 vs 1.5 and 1.6 cm; transvaginal sonography anteroposterior, 3.3 vs 1.8 and 1.7 cm; and transvaginal length, 3.0 vs 2.1 and 1.9 cm). Anteroposterior measurements, but not length, decreased significantly with advancing age. Transvaginal length decreased with compression (mean, 0.84 cm; p < 0.0001). Color Doppler flow scores (minimum, 56% [20/36]; mild, 28% [10/36]; moderate, 14% [5/36]; and absent, 3% [1/36]) did not vary with age, time since surgery, or type of surgery., Conclusion: The remnant is larger in every dimension after supracervical hysterectomy compared with both abdominal and vaginal hysterectomy and commonly shows some color Doppler flow.

Objective: Despite the dual blood supply to the lung, acute pulmonary embolism (PE) can lead to a spectrum of ischemic injury to the lung resulting in infarction and hemorrhage. In this series we systematically describe the spectrum of CT findings and clinical correlates of pulmonary infarction in patients with PE., Methods: We retrospectively identified 24 consecutive adults with pulmonary infarction on multidetector CT between July 2002 and March 2004. There were 13 women and 11 men, with a mean age of 59 years. The cases were identified by review of 74 consecutive CTs demonstrating PE. Each CT was evaluated by 2 of 3 reviewers in consensus for presence and characteristics of peripheral parenchymal opacities and extent of PE. Peripheral opacities were evaluated for degree of enhancement, internal air lucencies, and contour. The presence of adjacent vessels and linear strands were noted. At the end of interpreting each case, the reviewers determined whether or not an infarct was present based on the constellation of previously described imaging features. The extent of pulmonary vascular obstruction was graded using the CT clot burden scoring system. Each chart was reviewed for predisposing factors for PE and infarction, presenting clinical symptoms/signs, and co-existing pulmonary or cardiac conditions., Results: Thirty-two percent (24/74) of patients with PE had pulmonary infarction. Thirty-three percent (8/24) of patients had more than 1 infarct. Seventy-three percent (27/37) of infarcts were in the lower lobes. The CT findings of pulmonary infarction included: focal decrease in parenchymal enhancement in 95% (35/37), broad pleural base in 65% (24/37), truncated apex in 57% (21/37), convex border in 46% (17/37), internal air lucencies in 32% (12/37), linear stranding from the apex toward the hilum in 24% (9/37), and a thickened vessel leading to the apex of the infarct in 14% (5/37). There was a trend toward a higher mean clot burden (12.3 vs. 10.5) between the patients with PE with and without infarction. Ninety-six percent (23/24) of patients with pulmonary infarction had predisposing factors for infarction, including PE involving more than 1 lobe (n = 21), malignancy (n = 5), and heart failure (n = 3). Pleuritic chest pain was significantly more frequent in patients with infarction (P = 0.0064)., Conclusion: Pulmonary infarction occurred in nearly 1/3 of patients with PE in this series. The infarcts were peripheral parenchymal opacities characterized by a distinctive complex of findings on CT reflecting ischemic injury in the setting of a dual blood supply to the lung. Pleuritic chest pain was significantly associated with infarction.

Purpose: To evaluate the role of qualitative assessment of right heart dysfunction on multidetector computed tomography (CT) in patients with acute pulmonary embolism., Methods: Seventy-four consecutive adults with pulmonary embolism diagnosed on multidetector nongated CT were identified between July 2002 and March 2004. There were 47 women and 27 men, with a mean age of 62 years. Each CT scan was jointly reviewed by 2 of 3 reviewers in consensus. The CT scans were qualitatively assessed for dilatation of the right ventricle and the position of the interventricular septum. Scans were considered positive for right heart dysfunction if, on visual integration of multiple axial images, the right ventricle was dilated or the interventricular septum was straightened or bowed into the left ventricle. The extent of pulmonary vascular obstruction was graded using the CT clot burden scoring system. Reports of echocardiograms (n = 30) were reviewed when available. The sensitivity and specificity of CT and echocardiography in demonstrating right heart dysfunction were calculated and compared using pulmonary vascular obstruction of > or =30% as the reference standard., Results: Sixty-six percent (49 of 74 patients) with pulmonary embolism had right heart dysfunction on CT, with right ventricular dilatation in 38 patients and septal straightening or bowing in 44 patients. Forty-nine percent (36 of 74 patients) had pulmonary vasculature obstruction of > or =30%. There was a significant difference between the mean clot burden of patients with (12.8) and without (7.5) right heart dysfunction on CT (P = 0.0021). The sensitivity and specificity of CT in demonstrating right heart dysfunction were 81% (29 of 36 patients) and 47% (18 of 38 patients), respectively. Forty-one percent (30 of 74 patients) had technically adequate echocardiograms within 48 hours of CT. Fifty-seven percent (17 of 30) of the echocardiograms were positive for right heart dysfunction. There was no significant difference between the mean clot burden of patients with (12.7) and without (10.3) right heart dysfunction on echocardiography. Echocardiography had a sensitivity of 56% (10 of 17 patients) and a specificity of 42% (5 of 13 patients) in demonstrating right heart dysfunction., Conclusion: Qualitative assessment of the cardiac chambers is a quick and practical means of evaluating for right heart dysfunction on CT. Computed tomography findings of right heart dysfunction in patients with acute pulmonary embolism compare favorably with echocardiography and correlate with a higher mean pulmonary arterial clot burden. Because most patients do not undergo echocardiography, chest CT often provides the only opportunity to evaluate for right heart dysfunction in patients with acute pulmonary embolism.

Objective: Pregnant patients without a sonographically visible intrauterine pregnancy and with a thick-walled cystic adnexal structure present a dilemma. This study compared the utility of various sonographic features in differentiating between the tubal ring of ectopic pregnancy and the corpus luteum., Methods: Retrospective review of first-trimester transvaginal sonograms revealed a cystic adnexal structure in 79 women. Each structure was evaluated for 6 specific sonographic characteristics: echogenicity of its wall compared with that of the ovary and endometrium, wall thickness in 2 planes, color Doppler flow distribution and percentage of wall circumference, and internal texture., Results: Forty-one (52%) of the 79 women had ectopic pregnancies, and 38 (48%) had corpora lutea. Eleven (32%) of 35 ectopic walls were more echogenic than the endometrium, compared with none of the corpora lutea. A cyst wall less echogenic than the endometrium was more likely in corpora lutea (84% versus 31%; P < .0001). More than twice as many ectopic rinds were more echogenic than ovarian tissue compared with corpora lutea (76% versus 34%; P < .0001). The only predictive internal texture feature was a clear pattern, which was more common in the corpora lutea (P < .01, Fisher exact test). There was no significant difference in mural flow distribution or extent between the 2 groups., Conclusions: Ancillary sonographic signs to distinguish between an ectopic pregnancy and a corpus luteum include decreased wall echogenicity compared with the endometrium and an anechoic texture, which suggests a corpus luteum.

Purpose: The purpose of this article was to describe the CT finding of dilated thoracoabdominal veins in patients with renal failure who have arteriovenous fistulas or grafts (AVF/G) for hemodialysis., Materials and Methods: The authors retrospectively identified nine women and nine men on hemodialysis with a mean age of 62 (range, 20-88) years. Inclusion criteria for the series were functioning AVF/G, imaging with chest or abdominal CT, and access to clinical charts. Each clinical chart was evaluated for AVF/G function, diagnosis of cirrhosis or central venous obstruction, hepatitis B and C serology, and liver function as reflected by serum SGOT/SGPT. Each CT was reviewed for evidence of cirrhosis as follows: nodular liver contour, prominent left and caudate lobes, splenomegaly, and ascites. The CT scans were also evaluated for the presence of dilated thoracic or abdominal veins. The contrast-enhanced scans were evaluated for obstruction of the visualized central veins., Results: Fifty percent (9 of 18) of patients had dilated thoracoabdominal veins involving the following sites: chest wall, internal mammary, inferior phrenic, left gastric, gastric, portal, periportal, preaortic, mesenteric, splenorenal, periumbilical, and omental. None of these patients had clinical or CT evidence of cirrhosis. Eighty-nine percent (eight of nine patients) had normal serum SGOT/SGPT. Hepatitis B serology was normal in all seven patients tested, and hepatitis C serology was normal in 86% (six of seven patients). Eighty-nine percent (eight of nine patients) had no clinical or CT evidence of central venous obstruction. Among the nine patients without dilated veins, none had the clinical diagnosis of cirrhosis, although 56% (five of nine) had one or more CT findings associated with cirrhosis. None was diagnosed with central venous obstruction. Sixty-seven percent (six of nine patients) of those tested had normal serum SGOT/SGPT. Hepatitis B serology was normal in 88% (seven of eight) and 63% (five of eight) of patients tested, respectively. The authors did not find statistically significant differences between the patients with and without dilated veins with respect to the above parameters., Conclusion: Dilated thoracoabdominal veins were present in 50% of patients on hemodialysis with functioning AVF/G in this series. The venous dilatation appears to be independent of cirrhosis and central venous obstruction and is likely related to complex physiologic changes that are known to occur in patients on hemodialysis with functioning AVF/G.

A 5-year-old girl presented with hypertension, with no perceived blood pressure differential between the lower and upper extremities. Doppler ultrasound revealed a tardus-parvus pattern with diminished systolic acceleration and peak systolic velocities in the abdominal aorta and both main renal arteries. Doppler interrogation of the suprasternal aorta showed a normal waveform, suggesting a partial obstruction distally. Echocardiography and aortography confirmed severe discrete aortic coarctation with transverse arch hypoplasia. Because classic findings of aortic coarctation may not be present, especially in the older child, the radiologist must be aware that a tardus-parvus Doppler waveform in the abdominal aorta and bilateral renal arteries is suggestive of proximal aortic stenosis, which may be localized by spectral Doppler of the aortic arch.

Epidermoid cyst of the testis is a rare benign testicular tumor with varied sonographic appearances. We present a case in which two specific ultrasonographic patterns were seen: (1) an "onion ring" configuration of alternating hyperechoic and hypoechoic regions, described previously as being characteristic of this lesion, and (2) a heterogeneous region with multiple punctate hyperechoic foci.