Emergency Radiology ER001-EB-X Diagnostic Limits, Blindspots and Pitfalls in CT Imaging of Blunt Abdominal Trauma All Day Location: ER Community, Learning Center Participants Michael R. Cline, MD, Ann Arbor, MI (Presenter) Nothing to Disclose Suzanne T. Chong, MD, Ann Arbor, MI (Abstract Co-Author) Nothing to Disclose William J. Weadock, MD, Ann Arbor, MI (Abstract Co-Author) Owner, Weadock Software, LLC Jill Cherry-Bukowiec, Ann Arbor, MI (Abstract Co-Author) Nothing to Disclose David Machado-Aranda, Ann Arbor, MI (Abstract Co-Author) Nothing to Disclose TEACHING POINTS 1. To emphasize the critical role of multidetector CT in identifying injuries in the polytrauma patient2. To discuss the diagnostic limitations, potential blindspots and pitfalls of MDCT in imaging blunt abdominal trauma3. To reinforce the understanding of these concepts through the use of illustrative cases and quiz questions TABLE OF CONTENTS/OUTLINE MDCT studies from a 10-year search of the radiology information system of our quaternary care, academic teaching hospital with a Level 1 trauma center were reviewed for the contents of this exhibit. With unparalleled diagnostic performance, MDCT plays a critical role in imaging injuries sustained from blunt abdominal trauma for expediting clinical/surgical treatment to improve clinical outcomes. But MDCT is not perfect, with known diagnostic limits for imaging injuries to the diaphragm, pancreas, bowel and mesentery, ureters and bladder, and thoracolumbar spine. These, along with potential blindspots and imaging pitfalls, will be discussed. Concepts will be reinforced with illustrative cases and quiz questions. An awareness of the "dark side" of MDCT in blunt abdominal trauma is crucial for the trauma radiologist to reduce the likelihood of missed findings. ER002-EB-X Advantages of a State-of-the-Art Dual Source Computed Tomography (DSCT) System in an ED Setting All Day Location: ER Community, Learning Center Participants Rick R. Layman, PhD, Columbus, OH (Presenter) Nothing to Disclose Joshua K. Aalberg, DO, Columbus, OH (Abstract Co-Author) Nothing to Disclose Gabriel A. Chiappone, MBA, RT, Columbus, OH (Abstract Co-Author) Nothing to Disclose Chad Greulich, BS, ARRT, Columbus, OH (Abstract Co-Author) Nothing to Disclose Kelly J. Corrigan, MD, Xenia, OH (Abstract Co-Author) Nothing to Disclose Richard D. White, MD, Columbus, OH (Abstract Co-Author) Nothing to Disclose TEACHING POINTS Advantages of DSCT in the ED with high pitch and dual energy modes of operation. Benefits of DSCT to minimize radiation dose. TABLE OF CONTENTS/OUTLINE Objective of this presentation is to explain technical and applications advancements of a DSCT (Siemens Somatom Definition Force) and advantages in an ED.DSCT technical description Configuration High pitch Dual energyTeaching Point: DSCT can improve axial sampling as compared to single source CT. Table speeds up to 737 mm/s, temporal resolution up to 66 ms and pitches > 3 can be achieved.Clinical Examples DSCT high pitch mode obtained free-breathing without gating to reduce scan time Non-cooperative patient Pediatrics Involuntary motion DSCT dual energy mode for functional and quantitative imaging Iodine lung perfusion Teaching Point: Perfusion images offer valuable additional information in the diagnosis of pulmonary embolism eliminating the need for repeat or additional imaging.Radiation Safety Hardware Z-axis collimators Detectors and electronics for improved efficiency Iterative reconstruction Acquisition kV and mA modulation Shuttle mode Lower kV Teaching Point: Effective mAs=pitch/mAs. The mAs compensates for a higher pitch to maintain image quality and does not result in dose savings. ER003-EB-X The Emergent Aorta: Multi-modality Imaging Review in an Emergent Setting for Emergency Department Clinicians and Junior Radiology Residents "Cannot Miss Lesions" All Day Location: ER Community, Learning Center Participants Rami Eldaya, MD, Galveston, TX (Presenter) Nothing to Disclose Andrew Z. Chow, MD, Galveston, TX (Abstract Co-Author) Nothing to Disclose Matthew Ditzler, MD, Galveston, TX (Abstract Co-Author) Nothing to Disclose Jason R. Ross, MD, Galveston, TX (Abstract Co-Author) Nothing to Disclose Devon M. Divito, MD, Galveston, TX (Abstract Co-Author) Nothing to Disclose Omar S. Eissa, MD, Galveston, TX (Abstract Co-Author) Nothing to Disclose Poyan Rafiei, MD, Jackson, MS (Abstract Co-Author) Nothing to Disclose TEACHING POINTS Traumatic Aortic Injuries are relatively common in the setting of the emergency department. Prompt diagnosis is essential for prompt management and can be lifesaving in multiple instances. Radiology plays an integral role in diagnosis of this injury, in particular junior residence in the emergency department. Therefore, familiarity with the imaging appearance of the normal aortic anatomy, normal variants, and emergencies is essential to all emergency department personal. This exhibit aims to provide a thorough review of the aorta and its acute/chronic with potential acute component with target audience of junior residence early in their call experience and for emergency department faculty and residents. Anatomy of the aorta, its branches, and normal variants on CTA,MRA, and angiogram Through review of acute aortic pathologies with emphasis on differentiating between act now and watch lesions TABLE OF CONTENTS/OUTLINE Introduction of normal aorta and its branches anatomy on CTA/MRA and angiogramMulti-modality imaging review of normal variants that could present potential diagnostic uncertainty.Detailed chart summarizing the main acute aortic injuries including pathophysiology/mechanism of injury and multi-modality imaging findings with classification into act now/watch lesionImaging case review of multiple acute aortic pathologies ER004-EB-X Post-mortem CT Angiography (PMCTA): Potential Benefits in Forensic Practice All Day Location: ER Community, Learning Center Participants Jisun Hwang, MD, Seoul, Korea, Republic Of (Presenter) Nothing to Disclose Heon Lee, MD, PhD, Bucheon, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose Jang Gyu Cha, MD, Bucheon, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose Sookyoung Lee, Wonju, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose Kyungmoo Yang, Wonju, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose TEACHING POINTS SUMMARYAlthough the use of PMCT (post-mortem CT) is being increased primarily to guide subsequent forensic dissection, recently, PMCT angiorgaphy (PMCTA) has been introduced to provide more detailed information concerning the vascular structures. We herein describe the PMCTA findings with the special emphasis on the potential roles of PMCTA in forensic medicine.TEACHING POINTS1. Vascular injury.PMCTA allows the detailed and objective assessment of important vascular structures in the postoperative and traumatic condition which would otherwise be extremely difficult and time consuming using standard autopsy dissection.2. Natural cardiac death:PMCT cannot define the hemodynamic significance of the identified vascular stenosis especially in natural cardiovascular death. This is the same as with autopsy findings. However, evaluation of organ perfusion with PMCTA may be useful in estimating the functional relevance of the vascular lesion in selected cases, providing more confident diagnosis of ischemia as a cause of death. TABLE OF CONTENTS/OUTLINE TABLE OF CONTENTS / OUTLINE 1. Technical background2. PMCTA acquisition3. Review of cases A. Trauma - Detection and precise localization of vascular injury B. Natural cardiac death - More confident diagnosis of ischemia4. Discussion ER005-EB-X Blunt Diaphragmatic Lesions: Imaging Findings and Possible Pitfalls All Day Location: ER Community, Learning Center Participants Matteo Bonatti, MD, Bolzano, Italy (Presenter) Nothing to Disclose Norberto Vezzali, Bolzano, Italy (Abstract Co-Author) Nothing to Disclose Fabio Lombardo, MD, Verona, Italy (Abstract Co-Author) Nothing to Disclose Federica Ferro, Bolzano, Italy (Abstract Co-Author) Nothing to Disclose Giampietro Bonatti, Bolzano, Italy (Abstract Co-Author) Nothing to Disclose TEACHING POINTS -Blunt diaphragmatic lesions (BDL) may occur in up to 7% of major traumas and are often associated with other abdominal and/or thoracic injuries.-FAST and chest X-ray may rise the suspicion of BDL. -Multidetector-row CT (MDCT) is able to clearly depict, in the majority of the cases, the presence of BDL; anyway, radiologists in an emergency setting often overlook them, mainly because of the presence of distracting lesions to other organs.-Delayed diagnosis of BDL represents a relatively common event and is associated with increased morbidity and mortality rates.-Coronal and sagittal multiplanar reconstruction images (2-3 mm thick) are the most useful for detecting BDL. TABLE OF CONTENTS/OUTLINE 1. Review of epidemiology, trauma dynamics and pathogenesis of blunt diaphragmatic lesions.2. Review of FAST signs and anomalies associated with BDL.3. Review of chest X-ray signs associated with BDL.4. Review of MDCT signs of BDL, highlighting the ones that are more difficult to appreciate.5. Examples of false negative cases of BDL (slight diaphragmatic alterations with no viscera herniation, mechanical ventilation,…).6. Examples of false positive cases of BDL (relaxatio). ER006-EB-X Code Stroke! Not Everything that Restricts Diffusions is Acute Ischemia All Day Location: ER Community, Learning Center Participants Matthew Osher, MD, Royal Oak, MI (Presenter) Nothing to Disclose Dominic Semaan, MD, JD, Southfield, MI (Abstract Co-Author) Nothing to Disclose Eric A. Liao, MD, Novi, MI (Abstract Co-Author) Nothing to Disclose Mathew N. Chakko, MD, Farmington Hills, MI (Abstract Co-Author) Nothing to Disclose Roger L. Gonda JR, MD, Southfield, MI (Abstract Co-Author) Nothing to Disclose TEACHING POINTS To review the basic physics and evaluation of diffusion weighted imaging To review the typical findings of acute ischemia including cause of restricted diffusion, morphology and location, contributory MR findings and evolution To review the differential diagnoses for intracranial lesions that demonstrate restricted diffusion and imaging pearls for differentiation TABLE OF CONTENTS/OUTLINE Basic physics of diffusion weighted imaging Identifying restricted diffusion Why we see restricted diffusion in acute ischemia Imaging appearance of acute and evolving ischemia Differential diagnosis of intracranial restricted diffusion, image findings and differentiating from acute ischemia Ischemic Arterial Venous Inflammatory/Infectious Abscess Empyema Encephalitis Granulomatous Creutzfeldt-Jakob Disease Neoplastic Glioma Meningioma Lymphoma Metastatic Disease Demyelinating Hemorrhage Epidermoid Cyst Diffuse Axonal Injury ER007-EB-X Near Death Imaging: Understanding the Radiologic Predictors of Cause, Cost, and Course unto Death All Day Location: ER Community, Learning Center Awards Certificate of Merit Participants Efren J. Flores, MD, Boston, MA (Presenter) Nothing to Disclose Aishwarya Bhadouria, Boston, MA (Abstract Co-Author) Nothing to Disclose Atul Padole, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose Alexi Otrakji, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose Laura L. Avery, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose Subba R. Digumarthy, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose Jo-Anne O. Shepard, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose Kalra K. Mannudeep, Boston, MA (Abstract Co-Author) Nothing to Disclose TEACHING POINTS Medical autopsies provide critical information on evolution of disease and cause of death. Combined with postmortem CT and MR, autopsy studies can help establish cause of death. With these postmortem exams as ground truth, antemortem, or near death imaging (NDI) can assist in identifying imaging predictors of mortality that can potentially change management for better outcome. We use our experience to highlight the following teaching points: Define the concept of NDI (imaging studies at terminal hospital visit or admission) and analyze patients with antemortem and postmortem imaging studies to identify early predictors of the final cause of death based on autopsy results. Illustrate evolution of disease processes associated with high mortality based on antemortem and postmortem imaging and pathology findings. Discuss the role of NDI and provide possible changes in patient management that could potentially prevent mortality. TABLE OF CONTENTS/OUTLINE Discuss NDI concept and its role as mortality predictor and identify useful signs on imaging. Case based review of different causes of death with ante-mortem and post-mortem imaging, with correlation of admission diagnosis, hospital course and causes of death. All cases have autopsy correlation. Briefly discuss predictive models and outcomes research addressing this breach in mortality. Honored Educators Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality educational content in their field of study. Learn how you can become an honored educator by visiting the website at: https://www.rsna.org/Honored-Educator-Award/ Subba R. Digumarthy, MD - 2013 Honored Educator ER100-ED-X Abdominal and Pelvic Trauma: Misses and Misinterpretations on Multidetector Computed Tomography All Day Location: ER Community, Learning Center Awards Certificate of Merit Identified for RadioGraphics Participants Michael N. Patlas, MD,FRCPC, Hamilton, ON (Presenter) Nothing to Disclose Savvas Nicolaou, MD, Vancouver, BC (Abstract Co-Author) Institutional research agreement, Siemens AG Christine O. Menias, MD, Scottsdale, AZ (Abstract Co-Author) Nothing to Disclose Sanjeev Bhalla, MD, Saint Louis, MO (Abstract Co-Author) Nothing to Disclose Nataly Farshait, MS, Toronto, ON (Abstract Co-Author) Nothing to Disclose Douglas S. Katz, MD, Mineola, NY (Abstract Co-Author) Nothing to Disclose TEACHING POINTS To illustrate common diagnostic errors in the interpretation of abdominal and pelvic Multidetector Computed Tomography (MDCT) in trauma patients. To analyze the factors leading to these mistakes. To discuss the potential advantages of utilizing multiple phases of imaging and multiplanar reconstructions (MPRs) for the accurate detection and characterization of traumatic injuries. TABLE OF CONTENTS/OUTLINE Multiple abnormalities are frequently encountered on the initial MDCT examinations of critically ill trauma patients. Such traumatic findings can be easily overlooked due to numerous concomitant injuries. MDCT abdominal and pelvic imaging findings of the following missed abnormalities will be illustrated and reviewed: penetrating diaphragmatic injury; penetrating and blunt bowel injury; blunt pancreatic injury; gallbladder hematoma; penetrating and blunt adrenal injury; renal vascular injury; blunt ureteral injury; bladder rupture.The value of multiphasic MDCT techniques, MPRs, intraluminal contrast in selected cases, follow-up imaging examinations using a multimodality approach and management options will all be discussed and demonstrated. This exhibit offers an opportunity to review common mistakes in the evaluation of abdominal and pelvic MDCT trauma scans and emphasizes the solutions to avoid the misinterpretation of these life-threatening entities. Honored Educators Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality educational content in their field of study. Learn how you can become an honored educator by visiting the website at: https://www.rsna.org/Honored-Educator-Award/ Christine O. Menias, MD - 2013 Honored Educator Christine O. Menias, MD - 2014 Honored Educator Christine O. Menias, MD - 2015 Honored Educator Sanjeev Bhalla, MD - 2014 Honored Educator Douglas S. Katz, MD - 2013 Honored Educator Douglas S. Katz, MD - 2015 Honored Educator ER101-ED-X Imaging Scrotal Pathology in the Emergency Department - Beyond Testicular Torsion All Day Location: ER Community, Learning Center Participants Arash Bedayat, MD, Worcester, MA (Presenter) Nothing to Disclose Byron Y. Chen, MD, Worcester, MA (Abstract Co-Author) Nothing to Disclose Jean-Marc Gauguet, MD, PhD, Worcester, MA (Abstract Co-Author) Nothing to Disclose Nancy A. Resteghini, DO, MS, Worcester, MA (Abstract Co-Author) Nothing to Disclose Monique M. Tyminski, DO, Worcester, MA (Abstract Co-Author) Nothing to Disclose Hao S. Lo, MD, Worcester, MA (Abstract Co-Author) Nothing to Disclose TEACHING POINTS 1. Learn an appropriate standardized sonographic technique for evaluating the acute scrotum. 2. Discuss relevant differential diagnoses pertaining to the emergency department patient. 3. Review typical sonographic and CT/MRI findings for each pathology. TABLE OF CONTENTS/OUTLINE 1. Anatomy of the scrotum and testicle2. Standard sonographic approach using grayscale, color spectral Doppler, and cine techniques3. Differential diagnosis in the emergency department patient - Trauma - testicular rupture, contusion, hematocele - Vascular - testicular torsion, infarct, parenchymal edema - Infection - necrotizing fasciitis, epididymo-orchitis, cellulitis/abscess - Mass/tumor - benign and malignant neoplasms, intestinal hernia - Incidental, normal variant - cystic dilatation of rete testis, varicocele, intratesticular adrenal rests4. For each disease category, review typical sonographic and CT/MRI findings with selected gross pathology or histology correlation