Medicine and Health Sciences Commons^™

Single Center Retrospective Review Of Post-Laparotomy Ct Abdomen And Pelvis Findings And Trends, Dylan C. Steffey, Emad A. Chishti, Maximo J. Acevedo, Luis F. Acosta, James T. Lee

Radiology Faculty Publications

Purpose: To identify common findings visualized on CT following damage control laparotomy, including post-surgical changes and additional injuries, and to determine change in frequency of post-laparotomy CT at our institution over time.

Methods: Single institution, IRB-Exempt, retrospective review of the University of Kentucky trauma registry from 1/2006 to 2/2019 for all trauma patients undergoing exploratory laparotomy initially and subsequently undergoing CT of the abdomen and pelvis within 24 hours. Operative findings from surgical operation notes and findings reported on post-laparotomy CT were recorded, including vascular and solid organ injuries, operative changes, free intraperitoneal fluid/air, and retroperitoneal findings. Next steps in …

Combined Transhepatic And Transjugular Approach For Mechanical Thrombectomy Of Massive Tips Thrombosis, Jack B. Newcomer, Emad A. Chishti, Driss Raissi

Radiology Faculty Publications

Transjugular intrahepatic portosystemic shunt (TIPS) is a well-validated decompressive therapy option to manage ascites and variceal bleeding secondary to portal hypertension. Complications following TIPS procedures include hepatic encephalopathy, liver failure, and TIPS dysfunction. TIPS dysfunction is due to occlusion or stenosis of the TIPS shunt and can be caused by acute or chronic thrombosis. TIPS thrombosis is often treated with mechanical thrombectomy or catheter-directed thrombolytic therapy. Most cases of in-stent occlusion can be treated via a transjugular approach with recanalization or placement of additional stents. We present a case of a 72-year-old female who presented with worsening ascites 17 months …

Aapm Medical Physics Practice Guideline 12.A: Fluoroscopy Dose Management, Ryan F. Fisher, Kimberly E. Applegate, Lindsey K. Berkowitz, Olav Christianson, Jaydev K. Dave, Lindsay Deweese, Nichole Harris, Mary Ellen Jafari, A. Kyle Jones, Robert J. Kobistek, Brendan Loughran, Loren Marous, Donald L. Miller, Beth Schueler, Bryan C. Schwarz, Adam Springer, Kevin A. Wunderle

Radiology Faculty Publications

No abstract provided.

Avoidable And Unavoidable Repeat Breast Core Needle Biopsies, Xiaoqin Wang, Fara Shikoh, Mauro Hanaoka, Aurela Clark

Radiology Faculty Publications

Background: Breast core needle biopsies are not perfect and could miss cancer. The need for a repeat breast core biopsy is not uncommon and can occur for a multitude of reasons. Radiologists should carefully correlate the pathology results with imaging features after each breast biopsy and must recognize why certain core biopsies must be repeated to avoid missed or delayed cancer diagnosis. In this review, we discuss the main reasons for repeat core biopsies via case presentation with radiological images and pathological correlation. This review will help multidisciplinary breast care team recognize when to repeat a biopsy to reduce false …

Bilateral Popliteal Entrapment Syndrome In A Young Athlete Diagnosed With Ultrasound, Hanna K. Thompson, Justin R. Montgomery, Paul J. Spicer

Radiology Faculty Publications

Popliteal artery entrapment syndrome (PAES) occurs when the popliteal artery is compressed by abnormally developed or hypertrophied muscles adjacent to the popliteal fossa. When symptomatic, it most frequently presents with leg cramping while walking or running. We describe the case of an 18-year-old female runner presenting with claudication and exercise intolerance. After MRI was non-diagnostic, diagnostic ultrasound demonstrated that she had functional (Type VI) PAES. She subsequently underwent popliteal artery release surgery. Type VI PAES should be considered in young, healthy patients who present with claudication, particularly athletes.

Rapid 3d Reconstruction Guided Embolization For Catastrophic Bleeding Following Vacuum Assisted Breast Biopsy; A Case Report And Review Of The Literature, Martin Halicek, Chenghao Qian, Driss Raissi, Xiaoqin Wang, Yevgen Chornenkyy, William B. Bates, Michael Winkler

Radiology Faculty Publications

The most clinically significant complication associated with stereotactic core needle biopsy of the breast is hematoma formation, which only occurs in less than 1% of biopsies and may require treatment. Cases of uncontrollable bleeding, refractory to repeated compression, resulting from biopsy are exceedingly rare. We present a case of catastrophic, uncontrollable bleeding and large hematoma formation resulting from stereotactic vacuum-assisted breast biopsy of a breast mass identified in screening mammography. Percutaneous embolization was planned and guided using 3D reconstructions from computed tomographic angiography, and bleeding was successfully controlled with micro-coil embolization.

Primary Bilateral Ovarian Artery Embolization For Uterine Leiomyomatosis In The Setting Of A Rare Anatomic Variant - Hypoplastic Uterine Arteries, Merve Ozen, Shezaan Momin, Charles Ben Myers, Mark Hoffman, Driss Raissi

Radiology Faculty Publications

We present the case of a 50-year-old female who underwent bilateral ovarian artery embolization for uterine fibroids in the setting of hypoplastic uterine arteries. Ovarian artery embolization is usually conducted during uterine artery embolization for fibroids to increase the procedure success when ovarian feeders are seen. The bilateral ovarian artery embolization is rarely performed due to fears of amenorrhea and early menopause from decreased blood supply to both ovaries. According to our knowledge, this the first case report describing primary bilateral ovarian artery embolization in the setting of a rare anatomic variant- hypoplastic uterine arteries. The patient had complete resolution …

Concurrent Covid-19 Infection In Children With Acute Appendicitis: A Report Of Three Cases, Maximo J. Acevedo, Dylan Steffey, Johanne E. Dillon, James T. Lee, David J. Worhunsky

Radiology Faculty Publications

Literature describing patients with concomitant COVID-19 infection with acute appendicitis in pediatric patients is growing, and understanding the clinical picture of such patients is relevant in their treatment. We report 3 male children who were surgically treated for acute appendicitis and had concomitant SARS-CoV-2 infection. Our first patient was a 12-year-old male who presented with symptoms indicative of appendicitis but no respiratory symptoms associated with COVID-19 (eg cough, shortness of breath). Laboratory evaluation revealed leukopenia and an elevated C-reactive protein; imaging was consistent with acute appendicitis and an acute pulmonary viral infection. Though he lacked diffuse peritonitis on physical examination …

Extrapulmonary Tuberculosis: A Case Report Involving The Spine And Soft Tissues, Aden Gunnar Miller, Paul J. Spicer

Radiology Faculty Publications

Tuberculosis (TB) is a major health concern worldwide, and its incidence is increasing in developed countries, especially among immigrant populations. Extrapulmonary TB with musculoskeletal involvement is often a difficult and delayed diagnosis, as the disease can mimic metastases or infection. We present a case of extrapulmonary TB affecting the spine and soft tissues of a Vietnamese-born patient living in the United States. We discuss the imaging findings associated with extrapulmonary TB of the spine. Familiarity with key imaging features of disease can lead to early suspicion and detection of the disease as well as timely treatment.

Opioid And/Or Psychotropic Use Increases Intraprocedural Sedation Drug Requirements, Sreeja Sanampudi, Ravi Jayavarapu, Trae C. Brooks, Driss Raissi

Radiology Faculty Publications

Objectives Acute pain management in opioid users can be challenging in the perioperative period. This study focuses on whether use of opioids increases sedation medication requirements in patients undergoing port placement under moderate sedation.

Materials and Methods A retrospective review was performed on all patients undergoing port placement between June 1, 2017, and June 30, 2019. Exclusion criteria included receiving general anesthesia, no sedation, and errors in data entry. Data collection included demographics, use of opioids, benzodiazepines, antidepressants, tobacco, alcohol, and sedation data.

Results Opioid, benzodiazepine, and selective serotonin reuptake inhibitors (SSRIs)/serotonin-norepinephrine reuptake inhibitors (SNRIs) use was significantly associated with …

Recurrent Breast Cancer Diagnosis Delayed By Covid-19 Pandemic, Hannah K. Thompson, Paul J. Spicer

Radiology Faculty Publications

We describe the case of a 65-year-old female with a history of left-sided ductal carcinoma in situ in 2008. Mammography in January 2020 demonstrated calcifications in the previously affected breast. Subsequent stereotactic biopsy results were benign. In the months that followed, the patient experienced breast changes but avoided returning to the facility as the COVID-19 pandemic worsened. In August of 2020, the patient returned for a repeat mammogram, which indicated 2 suspicious masses in the left breast. Further analysis through ultrasound-guided core biopsy ultimately led to a left mastectomy and lymph node biopsy, which were performed in September 2020. Pathology …

Duration Of Rheumatoid Arthritis And The Risk Of Developing Interstitial Lung Disease, Michael P. Mohning, Isabelle Amigues, M. Kristen Demoruelle, Evans R. Fernández Pérez, Tristan J. Huie, Rebecca K. Keith, Amy L. Olson, Zulma X. Yunt, Jonathan H. Chung, Stephen B. Hobbs, Jeffrey J. Swigris, Joshua J. Solomon

Radiology Faculty Publications

Age of ILD onset is similar in patients with RA-UIP and RA-NSIP but duration of RA before ILD onset differs.

Bone In The Breast: A Case Report Of A Metaplastic Breast Cancer With Osseous Differentiation, Kyle Luo, Xiaoqin Wang

Radiology Faculty Publications

Metaplastic breast carcinoma is an uncommon malignant tumor with various pathologic subtypes. Diagnosis is often challenging due to the wide spectrum of clinical and imaging presentations. Here, we present the case of a very rare subtype of metaplastic breast carcinoma-a mixed-type metaplastic breast cancer with osseous differentiation in a 55-year-old female patient. The clinical presentation, imaging-pathology diagnosis, and treatment options are reviewed. Knowing this rarely reported but aggressive breast cancer is very important for clinicians to establish a timely diagnosis for effective management.

Integrated Multiparametric Radiomics And Informatics System For Characterizing Breast Tumor Characteristics With The Oncotypedx Gene Assay, Michael A. Jacobs, Christopher B. Umbricht, Vishwa S. Parekh, Riham H. El Khouli, Leslie Cope, Katarzyna J. Macura, Susan Harvey, Antonio C. Wolff

Radiology Faculty Publications

Optimal use of multiparametric magnetic resonance imaging (mpMRI) can identify key MRI parameters and provide unique tissue signatures defining phenotypes of breast cancer. We have developed and implemented a new machine-learning informatic system, termed Informatics Radiomics Integration System (IRIS) that integrates clinical variables, derived from imaging and electronic medical health records (EHR) with multiparametric radiomics (mpRad) for identifying potential risk of local or systemic recurrence in breast cancer patients. We tested the model in patients (n = 80) who had Estrogen Receptor positive disease and underwent OncotypeDX gene testing, radiomic analysis, and breast mpMRI. The IRIS method was trained …

Lung Metastasis Postradioembolization Of Hepatocellular Carcinoma With Tumor In Vein, Harit Kapoor, Sreeja Sanampudi, Joseph W. Owen, Driss Raissi

Radiology Faculty Publications

Transarterial radioembolization (TARE) is one of the few treatment options available for infiltrative hepatocellular carcinoma with tumor in vein. This is backed by the published data showing marginally favorable toxicity profile compared with other locoregional and systemic therapies. Although lung shunt fraction studies are performed to prevent radiation injury to the lungs, TARE-induced embolization/metastasis to the lungs has not been reported before. We report an intriguing case of new lung metastases within 1 month after TARE for infiltrative hepatocellular carcinoma with a tumor in the vein, with only a slightly elevated but acceptable lung shunt fraction. This report brings to …

Parallel Transjugular Intrahepatic Portosystemic Shunt With Viatorr® Stents For Primary Tips Insufficiency: Case Series And Review Of Literature, Driss Raissi, Qian Yu, Michael Nisiewicz, Steven Krohmer

Radiology Faculty Publications

BACKGROUND

Transjugular intrahepatic portosystemic shunts (TIPS) can alleviate complications of portal hypertension such as ascites and variceal bleeding by decreasing the portosystemic gradient. In limited clinical situations, parallel TIPS may be only solution to alleviate either variceal bleeding or ascites secondary to portal hypertension when the primary TIPS fails to do so. Data specifically addressing the use of this partially polytetrafluoroethylene covered nitinol stent (Viatorr^®) is largely lacking despite Viatorr^® being the current gold standard for modern TIPS placement.

CASE SUMMARY

All three patients had portal hypertension and already had a primary Viatorr^® TIPS placed previously. …

Li-Rads: A Conceptual And Historical Review From Its Beginning To Its Recent Integration Into Aasld Clinical Practice Guidance, Khaled M. Elsayes, Ania Z. Kielar, Victoria Chernyak, Ali Morshid, Alessandro Furlan, William R. Masch, Robert M. Marks, Aya Kamaya, Richard K. G. Do, Yuko Kono, Kathryn J. Fowler, An Tang, Mustafa R. Bashir, Elizabeth M. Hecht, Kedar Jambhekar, Andrej Lyshchik, Shuchi K. Rodgers, Jay P. Heiken, Marc Kohli, David T. Fetzer, Stephanie R. Wilson, Zahra Kassam, Mishal Mendiratta-Lala, Amit G. Singal, Christopher S. Lim, Irene Cruite, James Lee, Ryan Ash, Donald G. Mitchell, Matthew D. F. Mcinnes

Radiology Faculty Publications

The Liver Imaging Reporting and Data System (LI-RADS^®) is a comprehensive system for standardizing the terminology, technique, interpretation, reporting, and data collection of liver observations in individuals at high risk for hepatocellular carcinoma (HCC). LI-RADS is supported and endorsed by the American College of Radiology (ACR). Upon its initial release in 2011, LI-RADS applied only to liver observations identified at CT or MRI. It has since been refined and expanded over multiple updates to now also address ultrasound-based surveillance, contrast-enhanced ultrasound for HCC diagnosis, and CT/MRI for assessing treatment response after locoregional therapy. The LI-RADS 2018 version was …

Waardenburg Syndrome And Left Persistent Superior Vena Cava, Driss Raissi, Alexander Christie, Kimberly Applegate

Radiology Faculty Publications

Waardenburg syndrome (WS) is a rare genetic disorder secondary to neural crest cell developmental abnormalities. It is predominantly described as an auditory-pigmentary syndrome with diverse patient presentation, typically involving congenital sensorineural hearing loss and pigmentation abnormalities of the skin, hair, and iris. Other developmental abnormalities that may be associated with this syndrome are Hirschsprung's disease and a myriad of cardiovascular congenital defects. We present a case of a young girl with WS who found to have a persistent left superior vena cava (PLSVC) draining into the coronary sinus. The prevalence of PLSVC is increased in patients with chromosomal and genetic …

Upper Gastrointestinal Bleed Embolization With Onyx®: The "Tattoo Effect", Driss Raissi, Qian Yu, S. Houssam Mardini

Radiology Faculty Publications

Endoscopic intervention is well validated for the control of upper gastrointestinal bleeding (UGIB). In cases of refractory bleeding, transarterial embolization is a safe and effective alternative. Ethylene vinyl alcohol (EVOH) commonly known as Onyx^® is an inherently black liquid embolic approved for use in cerebrovascular arteriovenous malformations and is increasingly used as an embolic agent in multiple peripheral and visceral territories. Onyx^® has a uniquely undesirable property of causing black color discoloration when used in peripheral applications adjacent to the skin akin to a "tattoo effect." Knowledge of the agents used by the interventional radiologist, clinical correlation, and …

The "Lightning Bolt" Sign On Computed Tomography During Percutaneous Renal Mass Cryoablation, Qian Yu, Driss Raissi

Radiology Faculty Publications

Ice‑ball fracture is a rare and often overlooked entity that may lead to intraprocedural hemorrhage after percutaneous cryoablation of renal masses. There is scant literature on ice‑ball fractures associated with percutaneous renal cryoablation. Immediate recognition of the lightning bolt sign during intraprocedural computed tomography can help identify patients who may have developed this complication.

Procedural Competency Training During Diagnostic Radiology Residency: Time To Go Beyond “See One, Do One, Teach One”!, Driss Raissi, Qiong Han, Michael A. Winkler, Edward J. Escott

Radiology Faculty Publications

Objectives: Achieving procedural competency during diagnostic radiology residency can impact the radiologist's future independent practice after graduation, especially in a private practice setting. However, standardized procedure competency training within most radiology residency programs is lacking, and overall procedural skills are still mainly acquired by the traditional “see one, do one, teach one” methodology. We report the development of a simple standardized procedural training protocol that can easily be adopted by residency programs currently lacking any form of structured procedural training.

Materials and Methods: An ad hoc resident procedural competency committee was created in our radiology residency program. A procedural certification …

Renal Granulomatosis Post Intravesical Bacillus Calmette-Guerin Therapy For Non-Muscle-Invasive Bladder Cancer, Karen Tran-Harding, Rashmi T. Nair, Halemane S. Ganesh

Radiology Faculty Publications

Intravesical Bacillus Calmette–Guerin (BCG) immunotherapy is a proven, effective treatment for intermediate- and high-risk non-muscle-invasive bladder cancer. Minor side effects are common and expected but systemic effects can occur in < 5% of treated patients. We present a rare case of a 49-year-old male that presented with fever and chills after 3 weeks of intravesical BCG therapy post transurethral resection of bladder tumor. New renal lesions were present on contrast-enhanced computed tomography scan which was histologically proven to be necrotizing renal granulomatosis.

Bleeding Stomal Varices In Portal Hypertension, Karen Tran-Harding, Michael A. Winkler, Driss Raissi

Radiology Faculty Publications

We report a case of a 50-year-old man with a history of liver cirrhosis and colon cancer post end colostomy presenting to the emergency department with stomal bleeding and passage of clots into the colostomy bag. The patient was treated with transjugular intrahepatic portosystemic shunt (TIPS) and concomitant embolization of the stomal varices via the TIPS shunt using N-butyl cyanoacrylate mixed with ethiodol. Although stomal variceal bleeding is uncommon, this entity can have up to 40% mortality upon initial presentation, given the challenges in diagnosis and management. Currently, there are no established standard treatments for stomal variceal bleeding. In addition, …

Radiation Dose Measurements In A 256-Slice Computed Tomography Scanner, Victor J. Weir, Jie Zhang

Radiology Faculty Publications

Purpose: The purpose of this study is to compare computed tomography (CT) radiation dose measurement methods proposed by TG111, International Electrotechnical Commission (IEC), and a direct dose profile integral (DPI) measurement method. Methods: Pencil and Farmer ion chambers are used for integrating dose profiles at different beam widths in a 60 cm long body phantom. Resulting DPI is used to calculate CT dose index (CTDI) at each beam width. Measurements are also done for a pencil chamber inserted into a 15 cm body phantom at the reference beam width. The reference measurement is scaled with pencil chamber measurements in air …

Patient And Hospital Characteristics Predictive Of Inferior Vena Cava Filter Usage In Venous Thromboembolism Patients: A Study From The 2013 To 2014 Nationwide Readmissions Database, Amie Goodin, Ming Chen, Driss Raissi, Qiong Han, Hong Xiao, Joshua Brown

Radiology Faculty Publications

To examine the association between patient and hospital characteristics and inferior vena cava filter (IVCF) utilization in patients with venous thromboembolism (VTE).

The 2013 to 2014 Nationwide Readmissions Database was used to define a cohort of patients with VTE aged ≥ 18 after a primary VTE diagnosis. Comorbidities of interest were classified via diagnosis codes and IVCF placement was identified via procedure code. Chi square analysis tested differences between patient and hospital-level characteristics and whether or not IVCFs were placed. A hierarchical logistic regression model estimated the relationship between patient-level factors (demographics, socioeconomic status, comorbidities), hospital-level factors (bed size, teaching …

Mri Of Suspected Appendicitis During Pregnancy: Interradiologist Agreement, Indeterminate Interpretation And The Meaning Of Non-Visualization Of The Appendix, Richard Tsai, Constantine Raptis, Kathryn J. Fowler, Joseph W. Owen, Vincent M. Mellnick

Radiology Faculty Publications

Objective: To determine the degree of interradiologist agreement between the MRI features of appendicitis during pregnancy, the outcomes associated with an indeterminate interpretation and the negative predictive value of non-visualization of the appendix.

Methods: Our study was approved by the institutional review board at the Washington University in St. Louis, Missouri (WUStL) and was HIPAA (Health Insurance Portability and Accountability Act of 1996)-compliant. The informed consent requirement was waived. Cases of suspected appendicitis during pregnancy evaluated using MRI were retrospectively identified using search queries. Scans were re-reviewed by two radiologists (7 and 9 years experience, respectively) to evaluate the interradiologist …

Gastrointestinal Bleeding From Supraduodenal Artery With Aberrant Origin, Qiong Han, Chenghao Qian, Gaby Gabriel, Steven Krohmer, Driss Raissi

Radiology Faculty Publications

Angiography and endovascular embolization play an important role in controlling acute arterial upper gastrointestinal hemorrhage, particularly when endoscopic intervention fails to do so. In our case, the patient presented with recurrent life-threatening bleed in spite of multiple prior endoscopic interventions and gastroduodenal artery embolization. Our teaching points focus on the role of angiography in acute upper gastrointestinal bleed and when to conduct empiric embolization, while reviewing the supraduodenal artery as an atypical but important potential culprit for refractory upper gastrointestinal bleed.

Breast Cancer Screening In Patients With Newly Diagnosed Lung And Colorectal Cancer: A Population-Based Study Of Utilization, Gelareh Sadigh, Ruth C. Carlos, Kevin C. Ward, Jeffrey M. Switchenko, Renjian Jiang, Kimberly E. Applegate, Richard Duszak Jr.

Radiology Faculty Publications

Purpose—To assess breast cancer screening utilization in Medicare beneficiaries with colorectal and lung cancer versus cancer-free controls.

Methods—Female fee-for-service Medicare beneficiaries who were ≥ 67 years old and diagnosed with lung or colorectal cancer between 2000 and 2011 and who reported to a Surveillance, Epidemiology, and End Results (SEER) registry (case group) were followed for 2 years after their diagnoses, unless death, a diagnosis of breast cancer, or the end of 2013 came first. A similar number of cancer-free controls were individually matched to cases by age, race, registry region, and follow-up time. Screening utilization was defined as …

Primary Lung Carcinoid Metastatic To The Breast, Marianna Zagurovskaya, Karen Tran-Harding, Richard Gibbs

Radiology Faculty Publications

Lung carcinoid tumors account for approximately 2% of lung cancers, with 10% of the tumors represented by the atypical type. While atypical carcinoids are metastatic to intrathoracic lymph nodes in approximately half of the cases on the initial presentation, distant metastases are seen in only 20% of the patients and are found most frequently in bones, liver, adrenal glands, and brain. We present a case of an unusual metastatic disease to the breast in 51-year-old female who developed a new breast mass 2 years after left lower lobectomy due to atypical carcinoid tumor. Atypical pulmonary carcinoid metastases to the breast …

The Use Of Intraosseous Needles For Injection Of Contrast Media For Computed Tomographic Angiography Of The Thoracic Aorta, Michael A. Winkler, Cynthia Talley, Connor Woodward, Alexander Kingsbury, Frank Appiah, Hossam Elbelasi, Kevin P. Landwehr, Xingzhe Li, Dominik Fleischmann

Radiology Faculty Publications

Background

The objective of this study is to evaluate the safety and quality of computed tomographic angiography of the thoracic aorta (CTA-TA) exams performed using intraosseous needle intravenous access (ION-IVA) for contrast media injection (CMI).

Methods

All CTA-TA exams at the study institution performed between 1/1/2013 and 8/14/2015 were reviewed retrospectively to identify those exams which had been performed using ION-IVA (ION-exams). ION-exams were then analyzed to determine aortic attenuation and contrast-to-noise ratio (CNR). Linear regression was used to determine how injection rate and other variables affected image quality for ION-exams. Patient electronic medical records were reviewed to identify any …