Publications

BACKGROUND: Breast cancer screening with dynamic contrast-enhanced MRI (DCE-MRI) is recommended for high-risk women but has limitations, including variable specificity and difficulty in distinguishing cancerous (CL) and high-risk benign lesions (HRBL) from average-risk benign lesions (ARBL). Complementary non-invasive imaging techniques would be useful to improve specificity.

PURPOSE: To evaluate the performance of a previously-developed breast-specific diffusion-weighted MRI (DW-MRI) model (BS-RSI3C) to improve discrimination between CL, HRBL, and ARBL in an enriched screening population.

STUDY TYPE: Prospective.

SUBJECTS: Exactly 187 women, either with mammography screening recommending additional imaging (N = 49) or high-risk individuals undergoing routine breast MRI (N = 138), before the biopsy.

FIELD STRENGTH/SEQUENCE: Multishell DW-MRI echo planar imaging sequence with a reduced field of view at 3.0 T.

ASSESSMENT: A total of 72 women had at least one biopsied lesion, with 89 lesions categorized into ARBL, HRBL, CL, and combined CLs and HRBLs (CHRLs). DW-MRI data were processed to produce apparent diffusion coefficient (ADC) maps, and estimate signal contributions (C1, C2, and C3-restricted, hindered, and free diffusion, respectively) from the BS-RSI3C model. Lesion regions of interest (ROIs) were delineated on DW images based on suspicious DCE-MRI findings by two radiologists; control ROIs were drawn in the contralateral breast.

STATISTICAL TESTS: One-way ANOVA and two-sided t-tests were used to assess differences in signal contributions and ADC values among groups. P-values were adjusted using the Bonferroni method for multiple testing, P = 0.05 was used for the significance level. Receiver operating characteristics (ROC) curves and intra-class correlations (ICC) were also evaluated.

RESULTS: C1, √C1C2, and log C 1 C 2 C 3 were significantly different in HRBLs compared with ARBLs (P-values < 0.05). The log C 1 C 2 C 3 had the highest AUC (0.821) in differentiating CHRLs from ARBLs, performing better than ADC (0.696), especially in non-mass enhancement (0.776 vs. 0.517).

DATA CONCLUSION: This study demonstrated the BS-RSI3C could differentiate HRBLs from ARBLs in a screening population, and separate CHRLs from ARBLs better than ADC.

TECHNICAL EFFICACY STAGE: 2.

BACKGROUND: Variations of hand and forearm lymphatic drainage to upper-arm lymphatic pathways may impact the route of melanoma metastasis. This study compared rates of lymphatic drainage to epitrochlear nodes between anatomic divisions of the hand and forearm to determine whether the anatomic distribution of hand and forearm melanomas affects the likelihood of drainage to epitrochlear lymph nodes.

METHODS: Using a single-institution lymphoscintigraphy database, we identified all patients with cutaneous melanoma on the hand and forearm. A body-map two-dimensional coordinate system was used to classify cutaneous melanoma sites between radial-ulnar and dorsal-volar divisions. Sentinel lymph nodes (SLNs) visualized on lymphoscintigraphy were recorded. Proportions of patients with epitrochlear SLNs were compared between anatomic divisions using χ2 analysis.

RESULTS: Of 3628 upper extremity cutaneous melanoma patients who underwent lymphatic mapping with lymphoscintigraphy, 1400 met inclusion criteria. Twenty-one percent of patients demonstrated epitrochlear SLNs. Epitrochlear SLNs were observed in 27% of dorsal forearm melanomas and 15% of volar forearm melanomas (p < 0.001). Epitrochlear SLNs were observed in 31% of ulnar forearm melanomas and 17% of radial forearm melanomas (p < 0.001).

CONCLUSIONS: Higher proportions of dorsal and ulnar forearm melanomas have epitrochlear SLNs. Metastasis to epitrochlear SLNs may be more likely from melanomas in these respective forearm regions.

OBJECTIVES: There is a burgeoning discrepancy between the procedural competency of graduating diagnostic radiology residents and the needs of our patient population. The causes of this mismatch and opportunities for improvement are explored by the APDR Procedural Competency of Graduating DR Residents Task Force.

MATERIALS AND METHODS: The APDR convened a task force consisting of diverse broad stakeholder viewpoints, drawing from organized radiology, academic and private practices. The task force conducted structured analyses of the drivers contributing to the current state and reviewed relevant resources, conducted membership surveys, and developed consensus statements regarding solutions to the identified problem.

RESULTS: A defined list of procedures a graduating resident is expected to competently perform is established. Key domain-based drivers of the currents state were identified including the ABR initial certification exam structure and content, ACGME practices, creation of the IR-DR residency and ESIR tracks, residency and fellowship training paradigms, and secular trends. The task force offers several best practice recommendations for improving procedural training in DR residency to better meet the needs of the marketplace and our patients.

CONCLUSION: Armed with a defined list of procedures expected of a general radiologist and best practices for enhancing procedural training in diagnostic residencies, the task force presents a national game-plan for improving our ability to deliver high value diagnostic and interventional services to the communities that need it most.

OBJECTIVE: The clinical significance of incidentally detected pancreatic duct (PD) dilatation at ultrasound (US) without a visualized underlying cause is unclear. We aimed to assess the role of subsequent MRI (including MRCP) and to identify US imaging and laboratory findings predictive of underlying pancreaticobiliary malignancy at the time of initial US.

MATERIALS AND METHODS: Patients with incidentally detected PD dilatation at ultrasound from 2011 to 2019 that had an ensuing MRI were included. Based on MRI results patients were divided into three groups: malignant pancreaticobiliary causes, benign causes and idiopathic PD dilatation. Subsequently the diagnostic ability of MRI was assessed. Initial ultrasound findings and laboratory results were compared between groups to identify predictors of underlying pancreaticobiliary pathology. A p-value < .05 was considered statistically significant.

RESULTS: In 37/59 (63%) patients PD dilatation was confirmed on MRI. MRI demonstrated malignant 7/59 (12%) and benign 10/59 (17%) causes of PD dilatation detected at initial ultrasound. Sensitivity, specificity, negative predictive value, positive predictive value and accuracy of MRI to ascertain the cause of PD dilatation was 89%, 100%, 95%, 100% and 97% respectively. Patients with a larger magnitude of PD dilatation, concomitant CBD dilatation and elevated lipase values were more likely to have underlying pancreaticobiliary malignancy (p < 0.05). No patient with initial negative MRI had pancreaticobiliary malignancy on subsequent work-up.

CONCLUSION: Incidentally detected PD dilatation on ultrasound is an important finding and should prompt referral to MRI. MRI is an accurate, noninvasive method for identifying the underlying cause of PD dilatation in these patients and in excluding pancreaticobiliary malignancy.

PURPOSE: To evaluate the outcomes of early primary stent placement (within 30 days of liver transplantation) for hepatic artery stenosis (HAS).

MATERIALS AND METHODS: Patients who underwent liver transplantation between February 2001 and February 2024 were evaluated for HAS. Patients who underwent primary stent placement were selected and stratified based on the time from anastomosis to intervention. Early intervention was defined as primary stent placement within 30 days of surgical anastomosis. Kaplan-Meier analysis was performed for primary patency.

RESULTS: HAS occurred in 83 of 779 (11%) patients (median age, 55 years; interquartile range, 48-63 years; 27 [48%] women), with 56 patients meeting inclusion criteria. Stent placement was performed within 0-6 days of the anastomosis in 11 (20%), 7-14 days in 11 (20%), 15-30 days in 7 (12%), 31-70 days in 9 (16%), and >70 days in 18 (32%) patients. Technical success was 100%. Primary patency rates were 89%, 87%, and 87% at 1, 3, and 5 years, respectively. Primary assisted patency rates were 100% at 1, 3, and 5 years. Early interventions at 0-6 days, 7-14 days, and 15-30 days showed primary patency rates of 100%, 90%, and 86%, respectively, at 1 year (P = .58). There was no difference in primary patency between the early (<30 days) and late (>30 days) cohorts (P = .88). There was 1 Grade 4 adverse event. There were no cases of anastomotic rupture, hepatic artery dissection, or graft failure.

CONCLUSIONS: Hepatic artery stent placement within 30 days of liver transplantation is safe and technically successful with excellent long-term primary patency.

PURPOSE: To evaluate the safety and efficacy of ultrasound-guided percutaneous thrombin injection for the treatment of upper extremity pseudoaneurysms.

METHODS: An institutional database containing 8,316,467 radiology reports was searched for suitable cases over a 241-month period. Fourteen female and 10 male patients, average age of 69.7 years (range 29-93) underwent a total of 26 procedures for the management of upper extremity pseudoaneurysms, involving the radial (n = 9), brachial (n = 9) or other upper extremity arteries (n = 6). Baseline demographic and pseudoaneurysm characteristics were documented, together with primary and secondary success, failures, and complications. All procedures were performed with real-time ultrasound guidance.

RESULTS: The mean pseudoaneurysm volume was 9.93 cm3 (range 0.06-111.62 cm3). Twelve cases were related to central line placement or arterial access. Primary success was obtained in 50% (n = 12) after a single ultrasound-guided thrombin injection, and secondary success was achieved in an additional six (for a total success of 75%). Success was highest for the treatment of brachial artery pseudoaneurysms (87.5%), and in those who were diagnosed within 7 days of the inciting event, findings that were statistically significant (p-value 0.046 and 0.002, respectively).

CONCLUSIONS: Ultrasound-guided percutaneous thrombin injection is safe and effective for managing upper extremity pseudoaneurysms.

PURPOSE: To evaluate how the implementation of superior hypogastric nerve block (SHNB) during uterine artery embolization (UAE) for uterine fibroids impacts same-day discharge and healthcare encounters (HCEs) within 30 days.

MATERIALS AND METHODS: A total of 240 patients who underwent successful UAE for fibroids between January 2018 and December 2022 were retrospectively reviewed. HCEs within 30 days, including emergency department and urgent care visits, admissions, and readmissions, were categorized as early (0-7 days of discharge) and late (8-30 days of discharge) and related or unrelated to interventional radiology (IR) care. Factors associated with same-day discharge and HCE were identified using univariate analyses. Rates of HCE based on SHNB status were compared using the chi-square tests.

RESULTS: The mean age of the patients was 46 years (SD ± 5); 125 patients received UAE with SHNB. Patients who underwent SHNB were significantly more likely to undergo same-day discharge (113/125, 90%) than those without SHNB (55/115, 48%) (P < .001). No factors were associated with rates of all-cause 30-day HCE, including SHNB status (SHNB, 17% [21/125], versus no SHNB, 10% [12/115]; P = .20). A majority of HCEs were due to an IR-related cause (26/33, 79%), including abdominal or pelvic pain (22/33, 67%); nausea, vomiting, or poor oral intake (18/33, 55%); and vaginal bleeding (4/33, 12%). Comparison of patients who underwent SHNB with those without SHNB showed no difference in the proportion of IR-related HCE (17/21 [81%] versus 9/12 [75%], P = .69).

CONCLUSIONS: UAE with SHNB was associated with significantly higher rates of same-day discharge but similar rates of 30-day HCEs compared with UAE alone.

Cognitive biases are systematic thought processes involving the use of a filter of personal experiences and preferences arising from the tendency of the human brain to simplify information processing, especially when taking in vast amounts of data such as from imaging studies. These biases encompass a wide spectrum of thought processes and frequently overlap in their concepts, with multiple biases usually in operation when interpretive and perceptual errors occur in radiology. The authors review the gamut of cognitive biases that occur in radiology. These biases are organized according to their expected stage of occurrence while the radiologist reads and interprets an imaging study. In addition, the authors propose several additional cognitive biases that have not yet, to their knowledge, been defined in the radiologic literature but are applicable to diagnostic radiology. Case examples are used to illustrate potential biases and their impact, with emergency radiology serving as the clinical paradigm, given the associated high imaging volumes, wide diversity of imaging examinations, and rapid pace, which can further increase a radiologist's reliance on biases and heuristics. Potential strategies to recognize and overcome one's personal biases at each stage of image interpretation are also discussed. Awareness of such biases and their unintended effects on imaging interpretations and patient outcomes may help make radiologists cognizant of their own biases that can result in diagnostic errors. Identification of cognitive bias in departmental and systematic quality improvement practices may represent another tool to prevent diagnostic errors in radiology. ©RSNA, 2024 See the invited commentary by Larson in this issue.

BACKGROUND: The glymphatic system represents an extravascular network of astrocytic channels responsible for interstitial fluid and solute transit through the brain parenchyma. Its dysfunction has been considered as a possible cause of idiopathic intracranial hypertension (IIH).

METHODS: We enrolled participants with active IIH, treated or cured IIH, and controls. The active IIH group was divided into untreated participants with recently developed (<6 mo) and chronic (6+ mo) disease. Glymphatic function was assessed using diffusion tensor imaging along the paravascular space (DTI-ALPS) to generate an ALPS-index, hypothesized to measure glymphatic function. Participants were imaged before lumbar puncture (LP) if IIH was suspected and following LP when possible.

RESULTS: ALPS indices were higher in participants with chronically present, active IIH than in those either with recently developed IIH or control participants. ALPS-indices correlated with papilledema but did not correlate significantly with age, BMI, or intracranial pressure (ICP).

CONCLUSIONS: Our findings suggest that DTI-ALPS-indices of glymphatic function may be influenced by the chronicity of intracranial hypertension but do not support the hypothesis that glymphatic dysfunction causes IIH. Though these findings are preliminary, glymphatic imaging may be a useful radiographic biomarker in IIH.

The rapid advancement of medical technology has introduced a plethora of innovative devices designed for use within the thoracic cavity. Familiarity with the characteristic imaging features of these devices, their purpose and desired positioning is crucial for radiologists to identify them promptly and accurately assess any associated complications. This pictorial review provides a comprehensive overview of the radiologic findings associated with various new chest devices, aiming to equip radiologists with the knowledge required for effective clinical management.