Emerg Radiol (2014) 21:279–297 DOI 10.1007/s10140-014-1213-5


Highlights from the scientific and educational abstracts presented at the ASER 2013 Annual Scientific Meeting and Postgraduate Course Lee A. Myers & Keith Herr & Sravanthi Reddy

Received: 10 March 2014 / Accepted: 12 March 2014 / Published online: 23 March 2014 # Am Soc Emergency Radiol 2014

Abstract The American Society of Emergency Radiology (ASER) 2013 Annual Scientific Meeting and Postgraduate Course offered dedicated learning sessions, oral presentations, and digital exhibits on a broad spectrum of topics in emergency radiology, including traumatic and nontraumatic emergencies, quality, communication, education, and technology. This article highlights the scientific and educational abstracts presented at the meeting (Emergc Radiol 20:345–378, 2013). Keywords American Society of Emergency Radiology (ASER) . Emergency . Radiology . Imaging . 2013 . Highlights

Introduction This year, the American Society of Emergency Radiology (ASER) celebrated its silver anniversary with a homecoming in Boston, the site of the first Scientific Meeting and Postgraduate Course that took place in 1990. Over 400 professional attendees from across the globe were present this year, reflecting a growing interest in the field and success in the organization and reflecting its current standing and relevance as the pre-eminent international scientific body within the subspecialty of emergency radiology. As usual, the main event of the program was the 2-day Trauma Head-to-Toe review L. A. Myers (*) : K. Herr : S. Reddy University of Southern California LAC+USC Medical Center, 1200 N. State Street, Room D&T 3D321, Los Angeles, CA 90033-1029, USA e-mail: [email protected] K. Herr e-mail: [email protected] S. Reddy e-mail: [email protected]

course, which featured high-yield topics in musculoskeletal, neurological, pediatric, thoracic, and spine imaging, and presented by leading experts in trauma imaging. Included in the course was a half-day session focused on quality and safety in emergency radiology, with presentations on radiation dose reduction, quality assurance, and interdisciplinary communication. This year, a special module on combat and forensic radiology was offered, underscoring a role that emergency radiology can play even in the current domestic and international geopolitical landscape. The Saturday session featured a range of general emergency radiology imaging topics and included sessions on radiology informatics. Self-assessment modules in traumatic abdominopelvic and nontraumatic neuroradiologic emergencies were made available for CME credit. In special recognition of the achievements of ASER over the past 25 years, four Founders’ sessions highlighting advances in trauma imaging were presented by past presidents of the organization. This year’s oral scientific sessions and educational poster exhibits again covered the full range of subjects in emergency radiology. Nearly 150 poster exhibits were presented in this year’s program, offering a concise, practical, and evidencebased approach to common and uncommon emergency imaging scenarios. The ten oral scientific sessions presented some nearly 6,000 patient-derived data points in evaluating outcomes. Most of the abstracts of the oral scientific session and electronic poster exhibits presented at the 2013 meeting were published in the October 2013 edition of Emergency Radiology, and a synopsis of these presentations follows. Traumatic emergencies People (5.8 million) die each year from injuries and violence worldwide, representing only a fraction of the overall tens of millions of people who receive medical attention for accidents and violence annually. Death by traffic injury alone is projected


to become the fifth leading cause of death globally in 2030, whereas today, it stands in ninth position [1]. Given the trend toward an increase in imaging utilization overall, emergency radiologists can expect to encounter a high volume of imaging related to trauma. Accordingly, there were a large number of presentations that summarized the current state-of-the art of trauma imaging as well those that added to the growing body of knowledge through original independent research. Neuroradiological trauma Gunshot wounds to the craniofacial region can be difficult to evaluate due to the streak artifact arising from embedded ballistic fragments. Wang et al. discussed how iterative reconstruction and dual-energy computed tomography (CT) techniques could reduce image degradation from metal artifact and thereby improve visualization of adjacent structures. Iterative reconstruction assumes data collected through metal are incorrect or missing and are accordingly rejected, with image production generated from surrogate data and iterative reconstruction technique. Dual-energy CT simultaneously acquires two different kVp settings through the use of rapid kVp switching or dual- tube potential sources. These two data sets are combined to generate a single monochromatic image reconstruction [2]. Focusing specifically on the orbit, Hoshmand and colleagues examined the role of CT in the evaluation and management of intra-orbital foreign bodies, such as knife blades, bullet fragments, glass, plastic, and wood. Note was also made of intra-orbital foreign bodymimics, including drusen, scleral calcifications, trochlear calcifications, lens implant dislocation, and surgical clips. Management depends on location of the foreign body within the orbit, its composition, and the presence of complications [3]. Beckman et al. discussed the validity of initial head CT for mild traumatic brain injury from the OCTOPUS (Observation or Computed Tomography for Mild Head Injury in Sweden) Study. This study demonstrated similar clinical outcomes in cohorts randomized to noncontrast head CT or hospital admission; however, CT was more cost-effective. After reviewing the head CTs in the imaged group for accuracy, reassessment yielded a sensitivity of only 49.1 %, stressing the need for improvement in interpreting head CTs in this group [4]. Trauma to the neck and spine In trauma patients, source images from torso CT are often reformatted for multiplanar evaluation of the thoracolumbar spine. Robinson et al. evaluated the minimal acceptable slice thickness of source torso CT images for use in reconstructing the thoracolumbar spine. Using 1-, 2-, 3-, and 5-mm slice thickness, sagittal reformations from soft tissue axial source images of CT chest, abdomen, and pelvis were assessed for diagnostic adequacy. The results indicated that slice thickness

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≤2 mm was optimal, whereas 3-mm slice thickness received mixed reviews and 5-mm slice thickness was generally unacceptable [5]. Several authors presented on traumatic cervical spine injury. Kang et al. focused on indications for cervical spine imaging, comparing the National Emergency X-Radiography Utilization Study (NEXUS) criteria with the Canadian C-Spine Rule (CCR) as well as reviewing the indications for the use of radiography, CT, and magnetic resonance imaging (MRI) in the setting of cervical spine trauma [6]. The Subaxial Injury Classification (SLIC) and Severity Score were also described in this presentation and further elaborated on by Spence and colleagues in a separate exhibit, with a detailed description of the SLIC classification. The three major components comprising the SLIC scoring include injury morphology, discoligamentous complex integrity, and neurological status. These authors concluded that the use of SLIC scoring will improve inter-observer correlation as well as provide a unified terminology for clinicians [7]. Discoligamentous injury of the cervical spine is best evaluated with MRI, according to Cheekatla et al., but subtle signs can be assessed on CT, including facet joint widening, malalignment, posterior interspinous widening, and disc signs, including disc space widening, height loss, or herniation [8]. Moving down into the thoracic spine, Cheekatla et al. also discussed the spectrum of combined thoracic spine injury morphology and offered an approach to classifying these injuries, emphasizing that it is not uncommon for thoracolumbar spine fractures to demonstrate more than one type of injury morphology [9]. The Cheekatla group also presented on injury patterns in the rigid spine, such as those affected by ankylosing spondylitis. The most common injury morphology in rigid spines is the distraction injury, which is manifested on imaging as intervertebral disc space widening, horizontal vertebral fractures, and widening of the facet joints. Other injuries include combination distraction and translation and occasionally pure translation [10]. Trauma to the thorax, abdomen, and pelvis In the trauma setting, patients with extensive, potentially lifethreatening internal bleeding may not present clinically with signs of hypovolemic shock, which stresses the important role the emergency radiologist plays in evaluating such patients with CT [11]. Wang et al. depicted CT findings of the hypovolemic shock complex including the “slit sign” of the inferior vena cava (IVC), diminished caliber of the aorta, abnormal enhancement of the liver and spleen, “shock” pancreas, and bowel as well as gallbladder wall and intense adrenal gland enhancement [12]. Lemos et al. conducted a study on the relationship between the presence of secondary traumatic injuries and treatment decision time and patient outcomes. The authors concluded that

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the detection of secondary injuries increases decision time and death rates, which appears to emphasize the value of real-time interpretation in trauma patients as images are being acquired to assess for immediately life-threatening injuries [13]. In penetrating trauma, the majority of skin wounds are not always readily visible on imaging, irrespective of injury type. Bellou et al. proposed using vitamin E capsules placed at wound entry sites on the patient’s skin surface prior to CT to allow for a more rapid and accurate assessment of penetrating trauma, focusing the reader’s attention on the region of primary injury [14]. Traumatic injury to the gastrointestinal tract and mesentery received particular attention at this year’s conference. Several authors elaborated on CT findings of bowel injury, most notably, perforation. Bowel wall thickening, discontinuity and abnormal enhancement, luminal dilatation, extraluminal accumulation of enteric contrast, intramural hematoma, pneumoperitoneum, and free intraperitoneal fluid are findings to suggest bowel injury [15–18]. Blazak et al. correlated CT findings of bowel and mesenteric injury with corresponding intraoperative photographs [17]. Wong et al. examined the significance of low-attenuating peritoneal fluid in males in the trauma setting, and concluded that free fluid measuring ≤43 Hounsfield units (HU) is significantly associated with bowel perforation, suggesting that this phenomenon can be diagnosed in this patient population without the use of gastrointestinal tract opacification [19]. Mesenteric injury is often co-morbid with gastrointestinal injury, and its CT appearance was discussed by Beckmann et al., Blazak et al., and Shin et al. The findings include mesenteric infiltration and hematoma, direct visualization of mesenteric vascular injury, such as abrupt cutoff, extravasation, or pseudoaneurysm, and hemoperitoneum [15–17]. Renal trauma was the subject of several exhibitors’ presentations. Although the American Association for the Surgery of Trauma (AAST) classification system of organ injury is primarily designed to predict patient outcomes based on operative findings, the emergency radiologist is often tasked with approximating these findings on CT as a guide for intervention [20]. Stibbe et al. provided imaging examples of the range of AAST renal injuries, from grade 1 to grade 5. These findings include subscapular hematoma, perirenal hematoma, laceration, renal infarct, renal vein pseudoaneurysm, collecting system injury, and shattered kidney [21]. Orton and colleagues also expounded the AAST classification system of renal injury and discussed management options based on grade. Grades 1 and 2 injuries are nonoperative; grades 3 and 4 injuries are often nonoperative, and grade 5 injuries usually require nephrectomy. Renal angioembolization improves nonoperative management and may represent an alternative to nephrectomy in 78–83 % of cases with high-grade injuries [22]. The AAST classification of hepatobiliary trauma was reviewed by Wang et al., who provided an imaging-based management algorithm


for blunt trauma to the liver and biliary system along with examples of CT correlates of each grade [23]. Complications from partial nephrectomy and thermal ablation were explored by Ryan et al. Vascular complications are most common and include perinephric hematoma, active extravasation, and pseudoaneurysm formation. Other complications can involve injury to the urinary collecting system and bowel, tumor seeding, and pneumothorax [24]. Body wall trauma was discussed by two groups. Lee et al. proposed the “pseudowall sign,” representing the spurious appearance of an intact abdominal wall in cases of a traumatic abdominal wall defect caused by soft tissue hematoma [25]. In a retrospective review by Lonsord et al., a direct relationship between traumatic lumbar hernias size and associated bowel or mesenteric injury was established. Delayed complications from these types of hernias include bowel incarceration and strangulation. Although the study sample was relatively small, these findings suggest that, when traumatic lumbar hernia is detected at CT in the setting of trauma, a close inspection of the bowel and mesentery is warranted for associated injury and vice versa [26]. Lemos et al. introduced a new classification scheme for treating blunt aortic injuries using curved planar reformations (CPR) in the emergency setting. This classification scheme is based on the presence (pseudoaneurysm or rupture) or absence (intimal tear/flap) of external contour abnormality of the traumatized aorta. Intimal tears 10 mm can be reimaged in 7 days to assess for progression. Progression should be managed with endovascular repair when possible. All patients with aortic external contour abnormality should be considered for semielective endovascular repair if there is a high likelihood of survival from other associated injuries [27]. Staying within the chest, Kon et al. discussed life-threatening nonaortic injuries from blunt chest trauma. These included pulmonary contusion/laceration with intraparenchymal extravasation, hemothorax with extravasation, tracheobronchial injury, vertebral fracture with extravasation, and rib fracture with sharp-edged fragments. Although aortic and cardiac injuries are indicators for emergent care, other injuries can be equally severe and require urgent management [28]. DeFoe et al. reviewed imaging features of pneumopericardium and discussed associated injuries. Causes of pneumopericardium include penetrating and blunt trauma and iatrogenic and infectious causes as well as fistula formation. An illustration of tension pneumopericardium was provided [29]. Trauma to the musculoskeletal system Musculoskeletal trauma played prominently in this year’s conference, and particular attention was paid to trauma to the bony pelvis. Kang et al. discussed the clinical relevance of acetabular fracture imaging with a review of the Judet-


Letournel classification. Accurate classification guides the decision to proceed to surgery and informs the appropriate surgical approach. A succinct review of the Harris and Coupe classification was also provided [30]. Cheekatla et al. reviewed the various patterns of pelvic ring disruption and delineated the Young and Burgess classification. The discussion centered on the lateral and anteroposterior compression and vertical shear-type injuries. Lateral compression and anteroposterior compression injuries can be further subclassified into three different types. Recognizing and accurately classifying the patterns of pelvic ring disruption play an important role in surgical planning [31]. Imaging of the hip deserves special attention in the emergency setting, as hip fractures can be difficult to detect on plain radiography and a delay in treatment from missed diagnosis can result in increased morbidity, particularly in the elderly [32, 33]. Hicks et al. discussed acetabular fractures and the use of roof and CT subchondral arc determinations, important measurements in the radiographic evaluation of acetabular fractures. These values are useful in the T-shaped, transverse, and transverse with posterior wall acetabular fractures and can inform surgical versus nonsurgical management [34]. As the challenges of diagnosing hip fracture on plain radiography in certain situations are being recognized and availability of MRI is increasing, occult fractures are more frequently being assessed with MRI. Daftaribesheli et al. contributed to the growing volume of data lending support to the utility of MRI in diagnosing hip fractures. The authors conducted a retrospective study on all adult patients who had MRI evaluation for suspected pelvic/hip fractures in the emergency department over a 5-year period. Comparison was made with radiography and, occasionally, CT. Radiography and CT demonstrated relatively poor sensitivity and specificity as compared to MRI [35]. In a separate study, the Daftaribesheli group sought to identify the minimal MRI sequences needed to accurately diagnose a nondisplaced pelvic/hip fracture. T2weighted images yielded the highest sensitivity followed by coronal T1-weighted images. The authors emphasized the importance of diagnosing hip fractures in the acute setting, as a delay of just 2 days in surgical treatment of an acute hip fracture doubles the mortality rate and proposed that MRI should be considered early in suspected pelvic/hip fracture. Following a negative radiograph of the pelvis/hip, the imaging modality of choice appears to be MRI in patients with persisting clinical concern for fracture [36]. Turning our attention to the younger population, Sivit et al. discussed apophyseal injuries of the pelvis and hip, including anterior superior and inferior iliac spine, ischial tuberosity, iliac crest, and greater and lesser trochanter injuries. Apophyseal trauma results from forceful contraction of a muscle attachment. Most commonly associated athletic activities include soccer, gymnastics, tennis, and track and usually occur in 14- to 25-year age group [37].

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A number of presenters highlighted the spectrum of extremity injuries. Avutu et al. reviewed trauma to the hand and fingers. Fractures that were described included Bennett, Rolando, Reversed Bennett, and boxer’s fractures. Ligamentous and tendinous injuries were also illustrated, such as Gamekeeper’s thumb, Jersey finger, mallet finger, and boutonniere deformity. If unrecognized, these seemingly minor injuries can lead to serious dysfunction and deformity [38]. Distal radial fractures account for approximately one sixth of all fractures treated in US emergency departments. Bunch et al. summarized “what the orthopedic surgeon wants to know” about these fractures. The widely used and clinically significant Fernandez and Jupiter classification was detailed [39]. Reddy and Flink presented the anatomy, pathology, and radiographic appearance of perilunate dislocations, noting that greater arc injuries are twice as common as lesser arc injuries. The Mayfield Classification was also reviewed with a description of the four stages of ligamentous disruption about the lunate [40]. Continuing on with the wrist, Flug et al. discussed wrist pain with clinical correlation and MRI findings. The discussion focused on median neuropathy, ulnar impaction syndrome, scaphoid fracture, scapholunate ligament tear, Dequervain’s tenosynovitis, triangular fibrocartilage complex tear, and intersection syndrome. Physical examination techniques reviewed included Phalen’s sign, snuffbox tenderness, Watson test/scaphoid shift test, Finkelstein test, and tenderness to palpation over Lister’s tubercle in intersection syndrome [41]. Common causes of acute elbow pathology were reviewed by Wilson and Doshi with an emphasis on MRI in the emergency setting. The discussion included the anterior compartment, citing biceps tendon tears (partial and complete), and biceps intramuscular hematoma as the major offenders. The posterior compartment discussion included triceps tendon tears and olecranon bursitis. Common flexor tendinosis and medial apophysitis occur in the medial compartment, and radial collateral ligament tears and common extensor ligament tears occur in the lateral compartment. Additionally, osteochondritis dissecans and capitellar osteochondral fracture were reviewed [42]. In the lower extremity, Fulwadhva and colleagues examined tibial plateau fractures and reviewed the Schatzker classification. Treatment depends on degree of displacement and comminution as well as associated soft tissue and ligamentous or neurovascular injury. Complications of tibial plateau fractures include malunion, post-traumatic arthritis, ligamentous pathology, meniscal lesions, stiffness, infection and avascular necrosis [43]. Spence et al. discussed CT evaluation of pilon fractures with a review of the Ruedi-Allgower classification and the Arbeitsgemeinschaft für Osteosynthesefragen classification and an extensive review of the Topliss Classification, which

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concerns the pattern of articular surface involvement of the tibial plafond. Simple and complex fracture patterns are seen in sagittal and coronal fracture families [44]. A review by Sarah M. Yu and Joseph S. Yu centered on calcaneal avulsion fractures, which are often difficult to diagnose, but recognition of their very specific locations and characteristic radiographic appearances can aid in the diagnosis. The avulsion fracture types that were described included the Achilles tendon-posterior calcaneal tuberosity, plantar fascia-medial process of the calcaneal tuberosity, bifurcate ligament-anterior calcaneal process, extensor digitorum brevis muscle-dorsolateral anterior calcaneus, and calcaneocuboid ligament-distal anterolateral cortex [45]. Acknowledging that the assessment for rib fractures on CT in trauma is a frustrating task for radiologists, Puig et al. introduced automated 3-D rendering and rib labeling for evaluation of rib fractures in WBCT data sets of polytrauma patients. The main advantage of this post-processing technique is that the virtually rendered, unfolded view of all ribs are linked with standard orthogonal views, which allows the reader to interrogate suspicious regions on additional views without changing the hanging protocol, application, or workstation. With the use of the Syngo-CT Bone-Reading® platform, it is possible to achieve a higher detection rate of rib fractures compared to conventional reading in a relatively shorter period of time [46]. Nontraumatic emergencies The Patient Protection and Affordable Care Act of 2010 is expected to provide insurance coverage to 23 million currently uninsured Americans by 2021 [47]. This sudden expansion in health insurance coverage is expected to result in a paradoxical explosion in emergency department utilization, presumably related, in part, to financially empowering a population accustomed to resorting to emergency services for medical conditions without addressing pre-existing barriers to seeking traditional primary care [48]. Whatever the reasons, it is projected that there will be more visits to emergency departments in the USA for nontraumatic emergencies in the coming years and, consequently, an increasing reliance on emergency imaging for evaluating these conditions. Nontraumatic neurologic emergencies Due to cumulative advances in stroke prevention and management in recent years, stroke is now the fourth leading cause of death in the USA, having decidedly dropped from third place in 2008 [49]. Imaging remains a critical component in the early work-up of stroke. Chaudhry et al. compared whole brain perfusion CT with diffusion-weighted (DWI) MRI for the assessment of acute brain infarct. According to their work, the detection of acute transcortical infarct on dynamic volume


whole brain CT perfusion images using 320-detector row CT is equivalent to DWI for transcortical infarct with sensitivity of 100 % and negative predictive value of 100 %. The detection of lacunar infarcts is lower, with sensitivity of only 56 %. Additionally, perfusion CT can detect perfusion defects, which do not have correlative DWI abnormality [50]. Lawhn-Heath et al. discussed the utility of head CT in the evaluation of acute vertigo and dizziness in the emergency department. This study demonstrated that CT misses 46.2 % of all emergent findings in the setting of acute vertigo and dizziness, all of which were detected on follow-up MRI as acute ischemic ischemia. These authors suggest that patients believed to be at high risk for a central cause of vertigo or dizziness bypass CT altogether and proceed to MRI. Explanations provided by polled emergency physicians for not initially ordering an MRI in this setting are as follows: lack of availability (100 %), length of procedure (61.5 %), patient preference (30.8 %), and difficulty interpreting MRI scans (15.4 %). When asked to reflect on the utilization of medical imaging in emergency departments, 76.9 % of emergency medicine physicians thought that imaging was overused, and 92.3 % cited liability concerns as the most important explanation for overutilization [51]. Unenhanced CT of the head is the most common imaging exam performed in the assessment of suspected stroke [49]. Without the use of intravenous contrast, however, incidental brain findings are often equivocal. Grechushkin et al. provided guidance in recognizing incidental cerebrovascular abnormalities on noncontrast head CT in their presentation entitled, “How to recognize incidental cerebrovascular abnormalities on noncontrast head CT.” Arteriovenous malformations will generally demonstrate surrounding edema and, occasionally, calcifications. Cavernous malformations are benign vascular hamartomas, are inconsistently visible on unenhanced CT (50–70 %), and may appear hyperdense with surrounding edema. Arterial thrombosis may be demonstrated by increased attenuation and can often be the earliest sign of arterial occlusion. The emergency radiologist should be adept at recognizing the occasionally subtle signs of nonischemic cerebrovascular conditions and the implications for prognosis and patient outcome [52]. Chaudhry et al. focused on another incidental finding that may be seen at noncontrast head imaging for stroke and other neurologic conditions. By measuring the attenuation value of the dural venous sinuses on noncontrast head CT, they found a direct positive correlation with the patient’s hemoglobin and hematocrit values with good interobserver agreement. The confluence of sinuses demonstrated the most reliable correlation. Identification of HU2 mm for small bowel), diverticulitis, epiploic appendagitis, appendicitis, small bowel obstruction, obstructed hernia, colonic obstruction, and enteroenteric intussusception. Sonographic imaging of acute hepatobiliary-pancreatic pathologies included liver abscess, ruptured liver tumor, dengue hemorrhagic fever, gangrenous and emphysematous cholecystitis, and acute and infected necrotizing pancreatitis [75]. Two groups reviewed sonography of ovarian torsion. Swenson et al. discussed findings of ovarian torsion when CT is the initial study performed in the emergency department. The most sensitive finding associated with ovarian torsion was asymmetric ovarian enlargement in the setting of acute lower abdominal or pelvic pain. Fifteen (100 %) of the torsed ovaries had a single measurement greater than 5 cm and a volume greater than 20 mL [76]. Baker et al. reviewed sonographic features of ovarian torsion and common mimickers. Color Doppler imaging can be helpful in suggesting ovarian torsion when there is absent or significantly

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decreased blood flow; however, normal flow does not exclude torsion. Though CT findings are nonspecific, a thickened or tortuous fallopian tube, peripheral hypodense cystic structures, and lack of enhancement suggest torsion in the appropriate context. Other sources of pelvic pain that may be mistaken for ovarian torsion at imaging are isolated fallopian tube torsion, ectopic gestation, hemorrhagic ovarian cyst, and extra-genitourinary diseases, such as appendicitis, epiploic appendagitis, and terminal ileitis [77]. Glass et al. reviewed imaging of the ectopic gestation with a discussion on the role of human chorionic gonadotropin levels. Sonographic findings of normal early intrauterine pregnancy include the intradecidual sign (4.5 weeks), double decidual sac sign (5 weeks), and normal intrauterine pregnancy with yolk sac (5.5 weeks) and fetal pole (approximately 6 weeks). Ectopic pregnancy was subsequently reviewed with established risk factors and locations by frequency (95 % fallopian tube). Extrauterine pseudosac and decidual cyst, adenexal mass with a “ring of fire,” live extrauterine ectopic pregnancy, and hemoperitoneum are sonographic findings with known association with an ectopic gestation [78]. Ultrasound is almost always the first imaging modality in the setting of scrotal pain [79]. Walter et al. discussed pitfalls in emergent scrotal ultrasound, including failure to diagnose testicular torsion presenting with subtle asymmetric blood flow, imaging findings of testicular appendage torsion, failure to detect focal epididymitis, and mistaking testicular neoplasm for hematoma or orchitis. Testicular torsion is not an all-ornone phenomenon: it can be complete, partial, or transient. Testicular salvage is time dependent. Torsion lasting less than 6 h is associated with a nearly 100 % salvage rate, but if greater than 12 h, viability drops to 20 %. Ten to 15 % of testicular tumors present after an instance of testicular trauma, which can be misinterpreted as testicular hematoma [80]. Ronald H. Wachsberg pointed out that not all scrotal pain is attributable to the scrotum, as an obstructing ureteral calculus can present as an acute scrotum and the use of sonographic imaging can aid in the diagnosis. A ureteral calculus can present with referred pain to the scrotum in a minority of cases, and in such cases, irritation of the genitofemoral nerve is implicated. The author suggests that men who present with unilateral scrotal pain with normal scrotal ultrasound undergo limited ultrasound of the ipsilateral kidney and ureter to evaluate for an unsuspected diagnosis of ureteral colic [81]. Though sonography remains the imaging examination of choice when gynecologic pathology is specifically suspected in a female patient with acute abdominal or pelvic pain, CT is frequently performed as the initial examination, as discussed by Katz et al., with their exposition of CT of the acute pelvis in females. Examples of ovarian torsion, ovarian cyst, endometrioma, ectopic pregnancy, ovarian vein thrombosis, pelvic inflammatory disease, complicated uterine leiomyomas, ovarian hyperstimulation, and uterine rupture

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were displayed [82]. Elamir et al. also reviewed common causes of pelvic pain in females in the emergency department. Several imaging correlates of causes of pelvic pain were featured, including ruptured corpus luteal cyst with hemoperitoneum, ovarian torsion, hydrosalpinx, tuboovarian abscess, pelvic abscess, endometrioma, fibroids, dermoid, and abnormal pregnancy related conditions [83]. With growing attention to radiation exposure in medical imaging, ultrasound and MRI are competing with CT as imaging modalities of first choice in certain situations. This is particularly the case in pregnant patients. Maddu et al. discussed the utility of MRI in the acute abdomen and pelvis in pregnancy. When sonographic imaging is inconclusive or equivocal, MRI can be effective in evaluating the cause of acute abdominopelvic pathology. An MRI compendium of common causes of acute abdominal and pelvic pain in pregnancy was illustrated with images of acute cholecystitis, spontaneous adrenal hemorrhage, acute appendicitis, cystic degeneration of intramural fibroid, renal abscess, hepatic adenoma, inflammatory bowel disease, ovarian dermoid, ectopic gestation, and placenta increta as well as retained products of conception [84]. This group also offered a comprehensive MRI review of hepatobiliary emergencies. Although CT and ultrasound are often sufficient in evaluating right upper quadrant or epigastric pain, occasionally, further imaging is needed with MRI. The authors reviewed MRI of many hepatobiliary emergencies, including acute, subacute and chronic liver abscesses, acute Budd-Chiari syndrome, acute hepatitis, hepatic infarct and hematoma, acute and chronic cholecystitis, choledocholithiasis, hilar cholangiocarcinoma with biliary obstruction, and gall bladder perforation as well as hemorrhage of neoplastic processes, including angiosarcoma, hepatic adenoma, and hepatocellular carcinoma [85]. Appendicitis is one of the most common causes of the acute abdomen worldwide, and emergency radiologists have to be vigilant to the various imaging appearances of appendicitis and its complications [86]. Seol and Adduci analyzed the diagnostic performance of ultrasound in suspected acute appendicitis. They found that ultrasound was relatively insensitive (sensitivity 43.1 %) in acute appendicitis and false positives were disappointingly common (21.7 %). The authors conclude that patients without definite findings of appendicitis on ultrasound and a normal white blood cell count may be considered at low risk for acute appendicitis and, absent symptoms warranting surgery, these patients may be managed expectantly with active clinical observation before undergoing additional imaging [87]. CT is still more often used for the evaluation of appendicitis in most centers and is rated higher than ultrasound for appropriateness in the assessment of acute appendicitis according to the ACR Appropriateness Criteria (2013) [88]. Grechushkin et al. evaluated the utility and accuracy of CT in distinguishing perforated from nonperforated acute appendicitis without


evidence of abscess or phlegmon. This retrospective study including 102 patients with appendicitis demonstrated a sensitivity of 38 %, specificity of 96 %, and positive predictive value of 90 % for diagnosing perforated appendicitis without abscess or phlegmon. The presence of extra-luminal air locules, increased wall thickness, and intraluminal fecalith correlated positively with perforation at surgery [89]. Andrew Del Gaizo discussed patterns and pathologic bases of referred abdominal pain. Of patients presenting to emergency departments with abdominal pain, 45 % undergo crosssectional imaging. Three types of abdominal pain exist, namely, somatic, visceral, and referred. Somatic pain results from irritation of any layer of the abdominal wall and is well localized on physical exam. Visceral pain results from irritation of an organ, mesentery, or visceral peritoneum, and is often dull and poorly localized. Referred pain is pain perceived as originating from a site distant from the affected organ and can be referred from either visceral or somatic structures. Causes of referred pain to the abdomen include pneumonia in the lung bases, pulmonary embolus, pericarditis, and discitis/osteomyelitis. Causes of referred abdominal pain included splenic rupture, acute pancreatitis, ureteral stone, and duodenal perforation [90]. Goldman et al. discussed the revised Atlanta classification for acute pancreatitis. The presentation highlighted the recent changes between the Atlanta classification of 1993 and the recently revised version of the Atlanta classification of 2013. Two clinical periods exist, an early phase (1st week) and a late phase (weeks to months). In addition, two discrete clinical patterns were described as follows: interstitial edematous acute pancreatitis, seen in approximately 90 % of patients and usually resolving within a week, and necrotizing acute pancreatitis, which can last weeks or months. The revised Atlanta classification instructs that if the diagnosis of acute pancreatitis is clear based on symptoms and elevation of amylase/lipase is greater than 3 times normal, then imaging is not indicated unless there is clinical concern for local complications, in particular, the presence of fluid collections [91]. Although the spleen often takes center stage in the traumatic setting, Alabousi et al. emphasized the range of nontraumatic splenic emergencies that may be seen at imaging, including hydatid disease, splenic abscess, splenic torsion, spontaneous splenic rupture, splenic vein thrombosis, aneurysm or pseudoaneurysm of the splenic artery, malignant splenic masses, and splenic infarcts. When follow-up scans of splenic infarcts show progressive liquefaction or outward expansion, secondary infection or impending rupture should be considered [92]. Baer et al. discussed spontaneous adrenal and renal emergencies with an imaging review of infection, inflammation, and vascular abnormalities. Adrenal hemorrhage is the most frequent cause of acute adrenal insufficiency and most commonly due to overwhelming sepsis (Waterhouse-Friderichson


syndrome). Adrenal infection is the second most common cause of primary adrenal insufficiency in the USA with causative agents including mycobacteria and fungus (histoplasmosis or blastomycosis). Over time, the adrenal glands will atrophy and develop calcifications. Renal emergencies that were discussed were urolithiasis, acute pyelonephritis, emphysematous pyelonephritis, xanthogranulomatous pyelonephritis, renal infarction, spontaneous renal hemorrhage, renal artery dissection, and renal vein thrombosis [93]. Nontraumatic gastrointestinal pathology was presented by many exhibitors. Bagherpour et al. discussed common and rare gastric emergencies and the imaging manifestations of these entities. Gastric volvulus is divided into two subtypes, organoaxial and mesenteroaxial. In organoaxial volvulus, the stomach rotates around its long axis, while mesenteroaxial volvulus involves rotation along the short axis. Other gastric emergencies include perforated peptic ulcer, gastric necrosis, perforated gastric adenocarcinoma, Dieulafoy lesion with active bleeding and jejuno-gastric intussusception in patients with a history of gastric surgery. Helicobacter pylori gastritis and traumatic diaphragmatic hernia were also addressed [94]. Katz et al. reviewed regional and diffuse small bowel disorders. The appearance of small bowel can depend on the degree of luminal distention. Acute peritonitis presents as variable degrees of segmental or diffuse bowel dilatation and mural thickening on CT. Infection of the small bowel by Clostridium difficile, tuberculosis, MAI, Tropheryma whipplei (Whipple disease), cryptosporidiosis, and cytomegalovirus was shown. Chemotherapy and radiation therapy-related enteritis, celiac disease, small bowel angioedema, eosinophilic enteritis, systemic lupus erythematosus, small intestinal amyloidosis, and spontaneous intramural small bowel hematoma were also illustrated [95]. Maddu et al. reviewed imaging findings of colorectal emergencies and associated complications related to colitis. Colorectal emergencies that were discussed included infection, inflammation, ischemia, bowel obstruction, lower gastrointestinal hemorrhage, large bowel trauma, foreign body, and fecal impaction. Complications related to colitis include perforation, pericolonic abscess, fistulas, peritonitis, portal vein thrombophlebitis, gangrene/necrotic bowel, and bowel obstruction. Identifying these complications is crucial in determining patient management [96]. Hashmi and Chandrasekhar reviewed colonic pathologies as a cause acute abdominal pain. These diseases include focal infectious etiologies such as appendicitis, diverticulitis, typhlitis, neoplastic, and epiploic appendagitis as well as more diffuse processes such as pseudomembranous colitis, Crohn colitis, and ulcerative colitis. Mechanical causes of acute abdominal pain include volvulus or colon-containing hernias [97]. Acord and Shah presented an imaging primer for large-bowel obstruction in adults. Large-bowel obstruction (LBO) accounts for 20 % of all bowel obstructions and 20 % of colon cancers present with

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obstruction. Neoplasm is the most common cause of large bowel obstruction, accounting for 55 % of all LBOs, followed by diverticulitis. Neoplasm, volvulus, inflammatory and postinflammatory strictures, and hernias were reviewed. Mimics of LGO include Ogilvie syndrome, adynamic ileus, and toxic megacolon [98]. Kumar et al. reviewed the spectrum of colonic diverticular disease at imaging, including diverticulosis, acute uncomplicated diverticulitis, abscess, perforation, and fistula formation, including the enterocutaneous, colovesical, coloenteric and colovaginal varieties, and fistulas between sigmoid diverticulitis and the fallopian tube, leading to pyosalpinx, tubo-ovarian abscess, and endometritis [99]. Iatrogenic emergencies in the abdomen and pelvis were highly represented this year. Troy and Leverson discussed complications of colonscopy. Most complications present to the emergency department within hours to days after the procedure. These complications include perforation from direct trauma from the colonoscope, barotrauma from colonic overinflation, and perforation from therapeutic interventions. Postpolypectomy syndrome, which can be due to electrocagulation injury to the bowel wall with transmural burn, can be seen in the absence of perforation. Other complications include splenic injury, post-procedural bleeding, appendicitis, and diverticulitis [100]. Often a complication of antibiotic treatment, C. difficile colitis was discussed by Wong et al., who evaluated CT parameters to stratify severe patients requiring surgical intervention. Length of affected colon, colon wall thickness, and presence of megacolon helped identify severe C. difficile colitis requiring surgical intervention [101]. Two groups discussed complications of bariatric surgery. Maddu and Zygmont discussed complications of bariatric surgeries with a pictorial review of CT imaging findings. The bariatric procedures that were discussed included Rouxen-Y gastric bypass, laparoscopic adjustable gastric banding, and sleeve gastrectomy. Complications of Roux-en-Y gastric bypass included anastomotic leak, stricture, obstruction, mesocolic window stenosis, intussusception, hernia, and blind pouch syndrome. Laparoscopic adjustable gastric banding complications included band malposition and gastric perforation as early complications and pouch dilatation, band slippage, intraluminal band penetration, and esophageal widening as late complications. Early complications seen in sleeve gastrectomy include gastric leak and dehiscence, abscess formation, hemorrhage, and obstruction, and late complications include obstruction to stenosis and dilatation of the remnant stomach. Imaging plays an important role in evaluating and managing postoperative bariatric surgery complications [102]. Kim at el. also discussed the spectrum of acute imaging findings of internal hernias after Roux-en-Y gastric bypass. The major types of internal hernias include transmesocolic, Petersen, and mesojejunal hernias. Internal hernia is a relatively common and important late complication of Roux-en-Y gastric bypass surgery [103].

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Vecchione et al. evaluated the role of 64-slice multidetector CT in the diagnosis of vascular and nonvascular complications of percutaneous lithotripsy. These complications include urinary tract perforation, perirenal hematoma, and vascular lesions [104]. Nontraumatic injury to the musculoskeletal system While emergency radiologists are often well versed in fractures and dislocations, the incidental bone finding can often present a diagnostic challenge. Chaudhry et al. reviewed imaging characteristics of benign and malignant lytic and sclerotic bone lesions. This review also linked common locations to patient age. Lytic lesions that were illustrated included enchondroma in the digits, focal fat, unicameral bone cyst, aneurysmal bone cyst, osteomyelitis, nonossifying fibroma, chondroblastoma, giant cell tumor, B cell lymphoma, and metastatic disease. Sclerotic lesions caused by Paget’s disease, HIV-induced osteonecrosis, chronic recurrent multifocal osteomyelitis, renal osteodystrophy, enostosis, fibrous dysplasia, osteosarcoma, early and healed eosinophilic granuloma, osteoid osteoma, and metastasis were reviewed. Lytic and sclerotic osseous lesions are a common finding in emergency radiology, and benign lesions must be differentiated from malignant ones to the extent possible. Using anatomical location and patient age as discriminating factors, the radiologist can often correctly assign benignity or malignancy to a majority of these lesions [105, 106]. The medication effect on bone appearance was discussed by Souza et al. Examples include insufficiency fractures from bisphosphate use, flouroquinolone-associated tendinopathy, and avascular necrosis secondary to chemotherapy and exogenous steroid. The first radiological sign of bisphosphonateassociated insufficiency fracture appears to be an asymmetric lateral diaphyseal focus of cortical thickening of the subtrochanteric femur [107]. Yu and Yu reviewed skeletal “holes, clefts, and notches.” The rhomboid fossa is located in the inferomedial aspect of the clavicle and corresponds to the insertion of the costoclavicular ligament. It is 10 times more common in males than females. The Saupe classification of three types of bipartite patellae was described. Additionally, sternal foramina and clefts, os acromiale, deltoid tubercle, supratrochlear foramina, midline fusion defects, enlarged sacral foramina, paraglenoidal sulcus, and dorsal defect of the patella were illustrated [108] Kothary et al. reviewed painful musculoskeletal conditions of the gluteal region, including the piriformis syndrome, which is caused by compression and entrapment of the sciatic nerve at the greater sciatic notch. This condition can be secondary to post-traumatic inflammation and hypertrophy of the piriformis muscle, reflex muscle spasm, or abnormal course of the sciatic nerve. Many other etiologies exist that can cause pain in the gluteal region. These include the following:


hamstring avulsion or tear, sacral insufficiency fracture, lumbosacral disc herniation, sacroilititis, Morel-Lavallèe lesion, subcutaneous cellulitis/fasciitis, dermatomyositis, and neoplastic processes, such as sacral giant cell tumor, soft-tissue sarcoma, and metastatic tumoral implants [109]. Gul-E-Khanda et al. offered a reminder that not all that is imaged with ultrasound in the lower extremity is vascular. This group reviewed sonographic imaging of common pathologies seen in the lower extremities, including hematoma, ruptured Baker cyst, foreign bodies, abscess, and bursitis as well as tears of soleus, gastrocnemius, and Achilles tendons. Sonographic imaging in the musculoskeletal system can be useful in the emergency radiology setting to evaluate muscular, tendon, soft tissue, and vascular abnormalities [110]. Pediatric imaging Pomeranz and Babagbemi discussed common nontraumatic neonatal and infant emergencies that every radiology resident should recognize. Necrotizing enterocolitis and congenital diaphragmatic hernia occur in the newborn and may be detected within the first few days of life. Later in infancy, intussusception, congenital malrotation, and pyloric stenosis are more common [111]. Fujikawa and colleagues emphasized that children are not just “little adults” when it comes to trauma. This group performed a retrospective study on the differences between pediatric and adult splenic and hepatic injuries. In the pediatric group, the grade of splenic injury resulting from low-energy mechanism was greater than that in adults, whereas hepatic injury severity was similar to that of adults. The authors also reported that pediatric patients with high-grade injury do not always require aggressive therapy [112]. Not surprisingly, presentations related to ultrasound imaging in the pediatric population were in abundance this year. Von Herrmann et al. reviewed common pediatric pathologies that can be seen on pediatric ultrasound, including appendicitis, intussusception, hypertrophic pyloric stenosis, testicular torsion, and ovarian torsion [113]. Other authors centered in on the right lower quadrant. Parmet et al. presented a synopsis of sonographic imaging of acute appendicitis. The normal appendix should be a noncompressible and nonperistaltic blind-ending tubular structure measuring less than 6 mm in axial dimension. Common clinical mimickers of acute appendicitis are intussucception, mesenteric adenitis, viral colitis, and ovarian torsion [114]. Ma et al. discussed imaging updates for pediatric acute right lower quadrant pain. The results of their retrospective study included 843 pediatric patients and used a staged imaging protocol proposed by Krishnamoorthi et al. in Radiology 2011, in which ultrasound is performed first in suspected cases of acute appendicitis and, if findings are definitive, CT is not performed. Retrospective adoption of this protocol yielded a sensitivity of 99 % and specificity of


89 %, similar to published measures of performance [115]. Ellermeier et al. discussed emergent MRI of the right lower quadrant in children. This pictorial review displayed uncomplicated and complicated appendicitis with common mimickers, including Crohn ileitis, infectious ileitis, omental infarct, and epiploic appendagitis as well as rectus abdominis strain, cholelithtiasis, ovarian cyst, adnexal torsion, and hematometrocolpos. MRI is also effective in differentiating appendicitis from other conditions in pediatric patients [116]. In keeping with the spirit of radiation dose minimization in this population, Thompson et al. discussed dose reduction in the pediatric population for the diagnosis of appendicitis using highly focused CT based on bony landmarks. The bony landmarks used in this retrospective study of 111 patients with pathologically proven appendicitis were the superior endplate of L3 (superior landmark) and the femoral heads (inferior landmark). Five of the 105 diagnostic scans would have missed only a portion of the appendix using these anatomical references; however, the diagnosis of appendicitis would have been possibly using other imaging features. Highly focused CT scanning in this manner would have led to an average radiation dose reduction of 50 % [117]. Who should be interpreting pediatric ultrasound for suspected acute appendicitis was studied by Moriarity et al. by comparing the performance of emergency radiologists and subspecialty trained pediatric radiologists in the evaluation of acute appendicitis. This study revealed that overnight radiologists were less likely to report visualization of the appendix (26 versus 67 %) and more likely to recommend a follow-up CT (77 versus 37 %) when compared to pediatric radiologists. Given that abdominal pain is one of the most common presentations in pediatric emergency department encounters, these findings suggest the potential value of enhanced pediatric training in the practice of emergency radiology to bolster diagnostic confidence in diagnosing acute appendicitis in children [118]. Michaelides et al. reviewed plain film findings and management of intussusception, the most common cause of bowel obstruction in the first two years of life. Peak incidence is in the 4- to 12-month age group with 2:1 male-to-female predominance. Plain radiography can demonstrate a soft tissue density or mass with surrounding mesenteric fat resulting in a target sign or a meniscus or crescent sign caused by the intussusceptum protruding into a segment of gas-filled colon. Prolonged intussusception can lead to small-bowel obstruction. On ultrasound, intussusception may appear as alternating hyperechoic and hypoechoic concentric rings of bowel wall signature, representing the “doughnut” sign. Treatment of intussusception by enema under fluoroscopic visualization can be performed with contrast or air. Perforation risk is 1 % or less [119]. Two groups discussed musculoskeletal imaging in the pediatric group. Sivit et al. reviewed pediatric hand injuries. The most common mechanism of injury in younger children is the crush injury, whereas most fractures in teenagers result from

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recreational sports. Metacarpal fractures are the most common hand fractures in children. The fracture patterns that were discussed were the boxer’s fracture, epibasal fracture, and Bennett and reverse Bennett fractures. Proximal and middle phalangeal injuries were included, with an examination of volar plate injuries and central slip avulsion fractures. Distal phalangeal injuries, including distal tuft fractures, are common and are often associated with nail bed injury [120]. Lee et al. offered an imaging review of ossification centers and fracture/dislocations in the pediatric elbow. Lack of familiarity of the ossification centers of the pediatric elbow can lead to misdiagnosis, and an understanding of the temporal development of ossification centers of the elbow is essential. In addition, recognizing the secondary signs of elbow fracture, such as soft tissue swelling and joint effusion, can provide additional clues and alert the radiologist to scrutinize the bones more thoroughly [121]. Nuclear medicine in the emergency setting Despite the fact that nuclear medicine imaging is not as widely used or universally available as anatomic imaging in the emergency setting, nuclear medicine has the potential to occupy a unique position in emergency departments with the functional data it provides as a complement to conventional imaging or, in some cases, as an essential component of diagnostic evaluation [122]. Elman et al. and Glazer et al. reviewed some of the nuclear medicine studies that should be considered in the emergency department setting. These include ventilation/ perfusion (VQ) scans for pulmonary embolus, myocardial perfusion imaging shown to decrease length of hospitalization and overall cost, and cholescintigraphy for acute cholecystitis and bile leaks, bone scintigraphy for occult fractures, osteomyelitis, complex regional pain syndrome, and hip arthroplasty loosening, Tc 99-m-tagged red blood cell scans to evaluate for gastrointestinal hemorrhage [123, 124]. Glazer et al. also discussed scintigraphy in the emergency setting [124]. Konwinski et al. revisited the perennial controversy regarding the appropriate imaging modality to assess for pulmonary embolism in young female patients due to a concern for radiation exposure to breast to tissue. In their retrospective cohort study, they concluded that young females have very few intermediate VQ scans, pointing to the utility of this modality in this patient population. Although the VQ scan is comparable to CT pulmonary angiography in excluding pulmonary embolus, there is significantly less breast radiation and may, therefore, be a more appropriate diagnostic test in young females [125]. Quality Hippocrates instructed, “First, do no harm.” This principle of nonmaleficence is embodied in the practice of quality assurance and improvement. Acknowledging our own limitations

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and learning how to overcome them are basic tenets of modern medical science. Several presenters explored quality in emergency radiology. Connolly et al. discussed the top five emergency radiology abdominal ultrasound quality assurance issues. These related to acute cholecystitis, renal transplant, liver lesions and certain operator-dependent factors [126]. Wang et al. discussed commonly missed fractures in the emergency department. Between 1 and 4 % of all emergency department visits result in a missed fracture diagnosis, and 3.1 % of all fractures are missed on initial presentation. The fractures reviewed mostly involved not only the extremity and include Chopart, Lisfranc, femoral neck, acetabular, scaphoid, Segond and reverse Segond, and talar neck fractures, but also include posterior shoulder dislocation. These fracture types, if not identified, can lead to significant long-term patient morbidity and functional disruption [127]. Brunner et al. performed a retrospective analysis of radiology report discrepancies from a teleradiology service within an academic hospital. This study found off-hour attending teleradiology interpretations demonstrate a very low discrepancy rate and short turnaround time [128]. Image interpretation by nonradiologist was a subject of investigation by two groups. Mangano et al. examined the interpretation of radiologic studies by emergency department physicians and how confidence in their interpretive ability might affect patient management. A survey was conducted that demonstrated highest confidence among emergency physicians in rendering preliminary interpretations on radiographs and CTs, but less confidence with ultrasound and MRI. Emergency physicians are relatively uncomfortable discharging patients without a finalized radiology report, except in the case of plain radiography and, even so, they preferred to make patient management decisions following review of a preliminary radiology report. Emergency radiologists should consider these data and their potential effects on both clinical and departmental workflow [129]. Bedside ultrasound is used in the emergency department for triage and rapid evaluation of acutely ill patients. Incidental findings are occasionally encountered, which can impact clinical management. Tewari et al. performed a study of 200 patients in whom 51 had incidental findings on emergent bedside ultrasound. The bedside ultrasound was performed and interpreted by emergency medicine residents under the supervision of emergency medicine fellows and faculty. Emergency medicine residents detected more overall incidental findings than did radiologists who retrospectively reviewed these studies in a blind fashion; however, radiologists were more accurate in initial diagnosis when these findings were correlated with follow-up imaging [130]. In “Think outside the box: CT pathology on the image periphery in the emergency setting,” Hanley-Knutson and her colleagues warned against the hazards of “search satisfaction” in reviewing how important diagnoses can be missed by straying from a dedicated search pattern, including glancing


at the scout, which may include a larger field of view than the CT images otherwise relied on [131]. Education and communication Noninterpretive skills are often given short shrift at major scientific conferences, but a number of presenters addressing education and communication emphasized their importance in emergency radiology training and practice. Brown et al. investigated the performance of first-year radiology residents before and following a 12-week pre-call training program focusing on key conditions in the emergency setting, demonstrating the value of intensive training prior to taking independent call. After completing these training sessions, first-year radiology residents outperformed emergency medicine clinicians in terms of diagnostic accuracy [132]. Keller et al. and Roden et al. outlined the various roles radiologist assistants can fill in enhancing patient care, such as dictating some examinations, triaging phone calls, taking part in quality improvement projects, and performing imageguided procedures. The Roden group conducted a 16question anonymous online survey to 28 radiology residents on the impact of the radiology assistant on resident education in the emergency department. They ewported that residents felt that the implementation of a radiologist assistant program in the emergency radiology setting significantly improved the overall educational experience, particularly by decreasing the amount of time the resident spends on the phone and protocoling studies, thereby allowing more time for image interpretation [133, 134]. A handful of posters took up the issue of communication between the emergency radiologist and the emergency department and even with the patient directly. O’Connell et al. discussed using patient status displays in the emergency department to facilitate locating a patient within the radiology department workflow, i.e., unread, under review, preliminary, or final status. Such a mechanism would identify the interpreting radiologist, allowing the clinician to contact that specific radiologist, which helps reduce interruptions of other radiologists in the reading room [135]. Although image interpretation results are typically communicated to the patient in the emergency department by a nonradiologist clinician, some advocate that this type of communication should occur between the interpreting radiologist and the patient directly. Gunn et al. created an online survey for emergency physicians to poll opinions on this matter. The survey revealed that 89 % of emergency physicians preferred the conventional mode of directly communicating radiology results to the patients under their care. The remainder of the emergency physicians felt that the optimal method of communication of results was through a patient-accessible online portal. No respondents favored direct communication from the radiologist. Other questions addressed in the survey were whether a radiologist should use


lay language in their reports in anticipation of patient access to these reports. Twenty-six percent felt that radiologists should, indeed, adjust their language in a way to make findings and impressions understandable to the layperson [136]. Radiology reports often include additional imaging recommendations to ensure stability or resolution of findings. Shuaib et al. performed a retrospective study to identify the risk factors associated with patient noncompliance of recommendations made by emergency radiologists. This study included 20,000 consecutive emergency department patients receiving some form of imaging. They observed a decline in the compliance rate for recommended additional imaging as the recommended period for follow-up increased. Contributing factors included increasing age, male gender, non-Caucasian race, lack of a primary care physician or medical insurance, non-English primary language, and residence more than 20 mi from the hospital. Clinicians are advised to take these factors into consideration in identifying patients at risk for not following up on recommended additional imaging [137]. Miscellaneous Technology is the cornerstone of the practice of radiology and integral to the education of radiology trainees. Two groups addressed the impact of technology on radiology resident training. Jeanmenne and Becker introduced “Must See Radiology,” an interactive mobile application for novice radiology residents that simulates emergency cases. This application makes use of “scrollable” case studies, which offer an obvious advantage over conventional single-image teaching resources [138]. Using a web-based survey, Chng et al. reported that, although the majority of radiology residents utilize mobile devices in some capacity while on call, a large majority of residents (93 %) resorted to the desktop computer to access electronic resources to aid in interpreting studies while on call [139]. Man versus nature was the theme of two presentations this year at the ASER. Tewari et al. reviewed images from tornado-related trauma during the April 2011 tornado outbreak in the southeast of the USA, which claimed 324 lives [140]. Gerard et al. reviewed injuries caused by animals, including motorcycle collision versus deer, dog bites, and injuries incurred from being thrown from a horse [141]. Familiarity with the imaging appearance of vascular injury and extravascular blood is an invaluable skill in emergency radiology. Keith Herr presented a pictorial review of hemoperitoneum from the most common causes, providing an approach for determining the likely source of bleeding, such as with the “sentinel clot” sign and suggesting a time course based on the various time-dependent appearances of free blood [142]. Shinjo et al. discussed how to promptly and accurately identify thrombus and hematoma on nonenhanced CT. They proposed the use of a window setting width of 40 HU and center level of 60 HU on body CT and 40 HU for the window width and center

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level for head CT, which will allow thrombus to appear highly attenuated (>50 HU), hence more readily detectable on nonenhanced CT. Examples included in this presentation were diverticular bleeding, subarachnoid hemorrhage, middle cerebral artery, posterior cerebral artery and superior mesenteric artery thrombus, spinal epidural hemorrhage, pulmonary embolism, aortic dissection, small-bowel hemorrhagic necrosis, and perisplenic hemorrhage [143]. The CT appearance of traumatic venous injuries, including the intimal flap, pseudoaneurysms, portocaval fistula, arteriovenous fistula, and active contrast extravasation, was reviewed by Cheekatla and colleagues. The signs that suggest venous injury include hematoma, stranding, perivascular fluid, contour irregularity, and luminal narrowing [144]. Whitesell and Steenburg reviewed imaging findings of acute intravascular thrombus on nonenhanced CT, which included cerebrovascular thrombus, aortic intramural hematoma and coronary artery thrombus, deep vein thrombus in the common and superficial femoral, and internal jugular veins and thrombosis of the right gonadal and superior mesenteric veins. Acute intravascular thrombosis and thromboembolism are critical diagnoses, which may be made or suggested on nonenhanced CT by identifying hyperdense clot [145]. In severely injured blunt trauma patients, the presence of paraspinal extravasation of contrast predicts underlying coagulopathy, according to Sato and colleagues, with their review of 389 CT trauma scans. Recognizing the potential for coagulopathy in the traumatized patient is critical as anticoagulation therapy increases risk for death and morbidity by a factor of four [146]. In “Cutting the tension: Imaging findings, clinical manifestations and treatment of acute tension physiology in the body,” Hegde and Keiper discussed and illustrated compartment syndrome, tension pneumothorax, tension hydrothorax, tension pneumocephalus, and tension pneumoperitoneum. Tension physiology is important to recognize early, as these are potentially life threatening and response to treatment dramatic [147]. The far reach of coccidioides was described by Goud and Patel, who discussed the spectrum of imaging manifestations of coccidiodmycosis, commonly known as valley fever. Case presentations included cavitary pulmonary, intraocular, CNS, and disseminated coccidioidomycosis. This fungus can cause chronic pneumonia, meningitis, osteomyelitis, and septic arthritis [148]. Huang and Asrani reminded us to keep infection in the differential, as infection can be confused with neoplasm and brain infarction at imaging [149]. As a testament to the expanse of human ingenuity and misfortune, Baker et al. reviewed the imaging appearance of unusual foreign body locations and scenarios, including transurethral placement of NuvaRing® into the urinary bladder, insertion of a flashlight into the rectum, gossypiboma, foley catheter with balloon inflation in the ureter, an ingested dental implant, and a wire from a grill brush lodged in the esophagus [150].

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Emergent interventional radiology Ierardi et al. reported results from three studies on the topic of vascular interventional radiology. In a retrospective study of transcatheter embolization of iatrogenic renal vascular injuries, embolization was performed with microcoils, polyvinyl alcohol particles, embospheres, Spongostan emulsion, and vascular plug with a technical success rate of 100 % and a clinical success rate of 95 %. The findings lend support to employing percutaneous strategies as an alternative to more invasive procedures for management of iatrogenic renal arterial injuries [151]. A second study investigated the safety and technical and clinical success rate of positioning endovascular endografts (EG) in the treatment of ruptured abdominal aneurysms [152]. In a third study, endovascular treatment of acute arterial injuries after orthopedic surgery was examined. The group concluded that percutaneous treatment is a feasible and safe option for arterial injuries with rapid and definitive hemostasis [153]. Senoo et al. described diagnostic and interventional strategies in the management of gastrointestinal bleeding. The vast majority of upper gastrointestinal bleeding is due to peptic ulcer disease (31–67 %). CT can effectively locate the source of hemorrhage and can delineate the precise vascular anatomy of the gastrointestinal tract. Transcatheter embolization enjoyed a 100 % success rate in all patients with upper and lower intestinal hemoarrhage when bleeding was established by extravasation of intravenous contrast on CT. Transcatheter embolization performed more poorly (30 % success rate) in upper gastrointestinal bleeding in patients without extravasation on CT [154]. Ojili et al. discussed acute complications of image-guided nonvascular abdominal interventions. Iatrogenic complications of image-guided interventional procedures are uncommon but can rarely be life threatening. The examples included abscess formation after gastrostomy and posthepatic radiofrequency ablation (RFA), pseudoaneurysm following liver biopsy and renal biopsy, and arteriovenous fistula after hepatic RFA [155].

Conflict of interest The authors declare that they have no conflict of interest.

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295 96. Maddu K, Mittal P, Shuaib W, Ibraheem O, Tewari A, Khosa F (2013) Imaging review of colorectal emergencies and associated complications. Emerg Radiol 20:366 97. Hashmi SS and Chandrasekhar C (2013) The Er colon: the plethora of colonic pathologies as a cause of acute abdominal pain 98. Acord M, Shah S (2013) An imaging primer on large bowel obstruction in adults. Emerg Radiol 20:374–375 99. Kumar G, Ahmad R, Tremblay M, Agarwala R (2013) From tics to perf to Pus and Gas: angry diverticulitis at its best: a look at the common and uncommon complications of diverticulitis. Emerg Radiol 20:377 100. Troy K and Levenson RB (2013) acute abdominal pain following colonoscopy: what could it be? 101. Wong KK, Paranjape C, Shah SN, Fawley R, Clanton J, Bonilla H, Tanner JR, Cawthon L, Duggal A, Haller N (2013) CT parameters stratify severe Clostridium difficile colitis patients requiring surgical intervention. Emerg Radiol 20:362 102. Maddu K, Zygmont M (2013) Complications of bariatric surgeries: a pictorial review of helical CT findings. Emerg Radiol 20:366 103. Kim JY, Bennett AE, Shah S, Ni Mhuircheartaigh JM, Levenson RB (2013) Internal hernia after Roux-En-Y gastric bypass: spectrum of acute imaging findings. Emerg Radiol 20:376 104. Vecchione D, Ponticiello G, Nicotra S, Russo G, Pinto A, Romano L (2013) Role of 64-slice MDCT in the diagnosis of vascular and Non-vascular complications of percutaneous lithotripsy. Emerg Radiol 20:366 105. Chaudhry A, Grechushkin V, Gul M, Chaudhry A, Dunkin J, Abbasi A (2013) Another lytic lesion! benign and malignant causes of lytic lesions. Emerg Radiol 20:360 106. Chaudhry A, Gul M, Mikhail G, Chaudhry A, Abbasi A (2013) Common and uncommon causes of benign and malignant osteosclerosis. Emerg Radiol 20:360–361 107. Souza L, Hill A, Stella M, Khurana B (2013) Imaging of adult patients presenting to the emergency department with acute druginduced musculoskeletal complications. Emerg Radiol 20:361 108. Yu SM and Yu JS (2013) Pitfalls in diagnosis: skeletal holes, clefts, and notches 109. Kothary S, Math KR, Irish R, Gardner J, Katz DS (2013) Pains in the tuchus: imaging review of painful musculoskeletal conditions of the gluteal region 110. Gul-E-Khanda SML, Dheikh AM (2013) Imaging of lower Leg: what to look for in an ER setting. Emerg Radiol 20:358 111. Pomeranz C, Babagbemi K (2013) Common non-traumatic neonatal and infant emergencies that every resident should know. Emerg Radiol 20:366 112. Fujikawa A, Matsumoto J, Lohman BD, Ode S, Miyakawa T, Shinjo Y, Kitagawa H, Nakajima Y (2013) Pediatric splenic and hepatic injuries in Japan: differences from injuries in adults. Emerg Radiol 20:374 113. Von Herrmann PF, Challa H, Braithwaite K, Richer E (2013) Abnormal or not? Test your emergency pediatric sonographic know-how. Emerg Radiol 20:353 114. Parmet PN, Johnston SK, Davis HC, Johnston JH (2013) Sonographic evaluation of acute appendicitis: a review of imaging technique, findings, and common mimics in pediatric RLQ ultrasound. Emerg Radiol 20:356 115. Ma M, Krishnarao P, Kang YS, Ha BY (2013) Imaging updates for pediatric acute right lower quadrant pain in a new gentle imaging world 116. Ellermeier A, Swenson DW, Lourenco AP, Herliczek TW (2013) Emergent MR imaging of right lower quadrant pain in children: appendicitis and its mimics. Emerg Radiol 20:351 117. Thompson B, Ehrlich L, Eutsler E, Goodman TR (2013) Highly focused CT based on bony landmarks for dose reduction in the pediatric population for the diagnosis of appendicitis. Emerg Radiol 20:357–358 118. Moriarity AK, Warner JN, Baki N, Halabi S (2013) Does subspecialty training matter? Measuring radiologic management and



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Emerg Radiol (2014) 21:279–297 outcomes of suspected pediatric appendicitis among pediatric and emergency radiologists. Emerg Radiol 20:374 Michaelides C, Kaproth-Johnson K, Nicola R, Nina K (2013) Intussusception: review of plain film findings and management of a pediatric emergency. Emerg Radiol 20:349 Sivit AP, DuPont ET, Sivit CJ (2013) Pediatric hand injuries: essentials you need to know. Emerg Radiol 20:351 Lee SC, Gupta R, Balsam D (2013) The pediatric elbow: fracture or ossification center? Emerg Radiol 20:355 McGlone BS, Balan KK (2001) The Use of nuclear medicine techniques in the emergency department. Emerg Med J 18(6):424–429 Elman S, Mannelli L, Clark T, Lewis D, Mann FA (2013) What’s “hot” in the ED: nuclear medicine studies you should be recommending. Emerg Radiol 20:361–362 Glazer D, Chong S, Brown R, Hoff C, Chen P Jr, Khuu A (2013) Scintigraphy in the emergency setting: from A to V/Q Konwinski R, Luttenton C, Close O, Davis AT (2013) Should V/Q scan be the primary modality to exclude PE in young females? Emerg Radiol 20:353–354 Connolly C, Levenson RB, Lee KS (2013) Top Emergency radiology ultrasound QA issues Wang J, Liang T, Nicolaou S (2013) Commonly missed fractures in the ER: what should I look for? Emerg Radiol 20:348 Brunner JF, Adduci AJ, Prevedello LM, Stella MH, Sodickson AD (2013) A retrospective analysis of radiology report discrepancies from a teleradiology service run out of an academic, tertiary care hospital. Emerg Radiol 20:375 Mangano MD, Gunn AJ, Pugmire BS, Sahani DV, Binder WD, Choy G (2013) Interpretation of radiologic examinations by emergency department physician: does confidence in interpretive ability change patient management? Emerg Radiol 20:356 Tewari A, Shuaib W, Park JS, Thomas P, Beck S, Maddu K, Johnson JO, Khosa F (2013) Incidental findings on emergent bedside ultrasonography. Emerg Radiol 20:370 Hanley-Knutson K, Chang J, Stevens WR, Gaizo AD (2013) Think outside the box: CT pathology on the image periphery in the emergent setting. Emerg Radiol 20:368 Brown N, Leschke P, Cleland P (2013) Pre-oncall key conditions training for first year radiology registrars. Emerg Radiol 20:378 Keller J, Blanchette S, Rolen M, Gonzalez R, Nunez D, Bokhari S (2013) The radiologist assistant’s (RRA) role in emergency radiology. Emerg Radiol 20:359 Rolen M, Jordan K, Blanchette S, Michalski M, Nunez D, Bokhari S (2013) The impact of the radiologist assistant (RA) on the resident educational experience in emergency radiology. Emerg Radiol 20: 366–367 O’Connell T, Wortman J, Khorasani R, Sodickson A (2013) Patient status displays for emergency radiology departments: helping us, helping our clinicians Gunn AJ, Mangano MD, Pugmire BS, Sahani DV, Binder WD, Choy G (2013) Breaking the news: toward improved communication of examination results to emergency physicians and patients. Emerg Radiol 20:356 Shuaib W, Johnson JO, Salestekar N, Maddu KK, Khosa F (2013) Risk factors for non-compliance with recommendations by emergency radiologist. Emerg Radiol 20:367 Jeanmenne A, Becker J (2013) Development and implementation of an interactive mobile application for novice radiology. Emerg Radiol 20:357 Chng Y, Price A, Belfi L (2013) The role of technology in emergency radiology: resident experience. Emerg Radiol 20:364 Tewari A, Shuaib W, Khosa F, Groves A (2013) Tornado associated trauma: imaging a natural disaster. Emerg Radiol 20:352 Gerard P, Shaish H, Acharya J, Patel B, Lefkovitz Z (2013) “Man vs wild:” radiologic imaging of trauma caused by contact with animals: a pictorial review. Emerg Radiol 20:361

142. Herr KD (2013) Looking for blood in All the wrong places: an imaging synopsis of hemoperitoneum and its causes. Emerg Radiol 20:378 143. Shinjo Y, Sato F, Lohman BD, Matsumoto J, Taira Y, Nakajima Y (2013) Glow in the dark! how to promptly and accurately identify thrombus and hematoma on non-enhanced CT 144. Cheekatla S, Chinapuvvula R, Spence S, West OC (2013) CT appearance of traumatic venous injuries. Emerg Radiol 20:370–371 145. Whitesell RT, Steenburg SD (2013) Imaging findings of acute intravascular thrombus on non-enhanced computed tomography (NECT). Emerg Radiol 20:358–359 146. Sato R, Matsumoto J, Lohman BD, Yokoi T, Nakajima Y, Taira Y (2013) CT scan: a tool to assess coagulation status in the severe blunt trauma patient. Emerg Radiol 20:375–376 147. Hegde A, Keiper M (2013) Cutting the tension: imaging findings, clinical manifestations and treatment of acute tension physiology in the body. Emerg Radiol 20:365 148. Goud A, Patel N (2013) Valley fever: spectrum of imaging manifestations. Emerg Radiol 20:371 149. Huang D, Asrani A (2013) Calor, dolor, rubor, tumor: why “abscess” can mimic any pathology in the ER. Emerg Radiol 20:355–356 150. Baker KS, Cherian V, Dunkin J (2013) How did that get there?!? A review of unusual foreign body locations and scenarios. Emerg Radiol 20:374 151. Ierardi AM, Fontana F, Floridi C, Petrillo M, Kehagias E, Tsetis D, Carrafiello G (2013) Transcatheter embolization of iatrogenic renal vascular injuries. Emerg Radiol 20:364 152. Ierardi AM, Fontana F, Mangini M, Floridi C, Petrillo M, Carrafiello G (2013) Endovascular treatment of ruptured abdominal aortic aneurysms: aorto-uni-iliac or bifurcated endograft. Emerg Radiol 20:365 153. Ierardi AM, Fontana F, Mangini M, Floridi C, Petrillo M, Carrafiello G (2013) Endovascular treatment in emergency setting of acute arterial injuries after orthopedic surgery. Emerg Radiol 20:365 154. Senoo S, Matsumoto J, Lohman BD, Hattori T, Yokoi T, Sato R, Miyakata M, Muto A, Kato H, Ichinose Y, Morimoto K (2013) Diagnostic and IR strategies in gastrointestinal bleeding. Emerg Radiol 20:364 155. Ojili V, Vassa R, Gunabushanam G, Nagar A, Chintapalli K (2013) Acute complications of image-guided non-vascular abdominal interventions. Emerg Radiol 20:369

ASER 2013 Annual Meeting Awards Gold medalist and Founder’s lecturer Stephen Frederick Hatem, MD Cleveland Clinic Cleveland, OH 2013 ASER Fellows Joseph S. Yu, MD Wexner Medical Center at The Ohio State University Columbus, OH Ronald J. Zagoria, MD, FACR University of California San Francisco, CA Harris Award Jeremy Wortman, MD, Brigham and Women’s Hospital, for Structured physician order entry for trauma ct

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scans improves clinical information transfer and billing efficiency in the emergency department Novelline Award Yasumoto Shingo, MD, St. Marianna University, for Glow in the dark! How to promptly and accurately identify thrombus and hematoma on non-enhanced CT Scientific paper presentation winners Summa cum laude Jeremy Wortman, MD, Brigham and Women’s Hospital, for Structured physician order entry for trauma ct scans improves clinical information transfer and billing efficiency in the emergency department Magna cum laude Elizabeth George, MBBS, Brigham and Women’s Hospital, for Evaluation of CT pulmonary angiography and transthoracic echocardiography for correlation of imaging findings and prognosis in 785 patients with acute pulmonary embolism Cum laude Anjali Agrawal, MD, Teleradiology Solutions, for Potential benefit of focused contemporaneous dual read in emergency teleradiology


Scientific and educational exhibit winners Summa cum laude Douglas S. Katz, MD, FACR, State University of New York at Stony Brook, for CT of the acute female pelvis Magna cum laude Yasumoto Shinjo, MD, St. Marianna University School of Medicine, for Glow in the dark! How to promptly and accurately identify thrombus and hematoma on non-enhanced CT Cum laude Susanna Spence, MD, UT Health at Houston, for Be slick with the slic: a common language for cervical spine trauma Certificates of merit Douglas S. Katz, MD, FACR, State University of New York at Stony Brook, for Pains in the tuchus: imaging review of painful conditions of the gluteal region Sirote Wongwaisayawan, MD, Ramathibodi Hospital and Mahidol University, for Sonography of acute abdomen in adults: gastrointestinal and hepatobiliary-pancreatic pathologies Case of the day winner Gustav Blomquist, MD, University of Kentucky Lexington, KY

Highlights from the scientific and educational abstracts presented at the ASER 2013 Annual Scientific Meeting and Postgraduate Course.

The American Society of Emergency Radiology (ASER) 2013 Annual Scientific Meeting and Postgraduate Course offered dedicated learning sessions, oral pr...
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