An Update in Imaging of Blunt Vascular Neck Injury

Traumatic injuries of the cervical carotid and vertebral arteries, collectively referred to as blunt cerebrovascular injury (BCVI), can result in significant patient morbidity and mortality, with one of the most feared outcomes being cerebrovascular ischemia. Systematic imaging-guided screening for BCVI aims for early detection to guide timely management. In particular, accurate detection of the severity and grade of BCVI is paramount in guiding initial management. Furthermore, follow-up imaging is required to decide the duration of antithrombotic therapy. In this article, classification of the grades of BCVI and associated imaging findings will be outlined and diagnostic pitfalls and mimickers that can confound diagnosis will be described. In addition, updates to existing screening guidelines and recent efforts of criteria modification to improve detection of BCVI cases will be reviewed. The advent of postprocessing tools applied to conventional computed tomography (CT) angiograms and new diagnostic tools in dual energy CT for improved detection will also be discussed.

Giant mixed Sertoli-Leydig-Granulosa sex cord tumor of the testis; clinical, histopathological, and radiological features: a case report

Sex cord tumors of the testis in post pubertal men are rare. Mixed leydig-Sertoli-Granulosa sex cord tumors are exceptionally rare. To the best of our knowledge there are only three reported similar cases in the literature. We reported a case of a 27-year-old male who presented with huge left scrotal mass of 6-years duration. The gross tumor specimen after resection measured 11 cm in diameter. Histological examination revealed mixed sex cord stromal tumor. This case demonstrates the limited ability of accurate diagnostic determination preoperatively, with pathologic examination and immune-histochemical staining post-orchiectomy representing the only definitive means of diagnosis. It also highlights the unique radiological appearances of this tumor, which were not previously reported in literature.

Overnight attending radiologist coverage decreases imaging-related emergency department recalls by at least 90

PURPOSE

Benefits of overnight attending radiologist final reports are debated, often stating low resident discrepancy rates, usually assessed retrospectively. The objective of this study was to assess the impact of overnight final reporting on the recall rates for patients in the emergency department (ED) receiving overnight imaging.

METHODS

Retrospective matched cohorts of two separate years prior (prior-16 and prior-17) and 1 year after (post-18) introduction of overnight attending radiologist final reporting. Patients receiving imaging between 22:00 and 07:00 h and returned to ED within 48 h of initial visit discharge were electronically identified. String matching identified return visits possibly related to imaging completed on first visit. Identified return visit notes were scored by three observers individually. Unclear and discrepant cases were resolved by consensus meeting, using full patient charts where needed. Incidences were provided and logistic regression analysis defined if coverage model was a predictor for recall. Odds ratios were calculated.

RESULTS

ED patient count with imaging completed overnight in prior-16 was 9200, in prior-17 was 9543, and in post-18 was 9992. The number of overnight imaging studies performed was respectively 13,883, 14,463, and 15,112. Imaging-related ED recalls were respectively 54, 61, and 7, a decrease with the new coverage model of 89% to true and at least 90% of expected recalls.Logistic regression demonstrated that coverage model was a significant predictor of ED recalls with chi-square of 59.86 and p < 0.001, an R² of 0.03 (Hosmer and Lemeshow). Compared to post-18, ED patients had an odds ratio of 8.42 (prior-16) and 9.18 (prior-17) to be called back to ED.

CONCLUSION

Overnight final reporting significantly decreases ED recalls for patients receiving diagnostic imaging overnight. While numbers are low even prior to rollout, the number should be minimized wherever possible to diminish patient anxiety and discomfort, reduce ED overcrowding and expedite definitive management.

KEY MESSAGES/WHAT THIS PAPER ADDS

Section 1: What is already known on this subject • Radiology resident preliminary report discrepancy rates are low. • Overnight attending radiologist coverage is a model increasingly applied in academic and large non-academic centers. • Patient recalls to the ED are a burden to the patient and impact patient throughput in (over)crowded EDs. Section 2: What this study adds • First study to look at the impact of overnight attending final reports on the recall rate for ED patients with overnight imaging performed. • While absolute numbers are low, there is a significant decrease in patients returning to ED for imaging related issues after introducing overnight attending coverage. • Resident autonomy can be preserved and training enhanced while increasing patient safety and comfort.

Evaluation of Bowel and Mesentery in Abdominal Trauma

Since the advent of multidetecter computed tomography (CT), radiologist sensitivity in detection of traumatic bowel and mesenteric abnormalities has significantly improved. Although several CT signs have been described to identify intestinal injury, accurate interpretation of these findings can remain challenging. Early detection of bowel and mesenteric injury is important as it alters patient management, disposition, and follow-up. This article reviews the common imaging findings of traumatic small bowel and mesenteric injury.

Conservative treatment for Brucella testicular abscesses: A case report and literature review

Brucellosis is a multi-organ infectious disease that can cause genitourinary manifestations.1-4 The most common genitourinary manifestation is orchitis;2,4 however, intratesticular abscesses are a rare complication. Although surgery is the standard treatment for intratesticular abscesses, medical therapy alone can be successful. We report the case of a 36-year-old man with multiple testicular abscesses caused by relapse of systemic brucellosis. The patient presented after a history of treated systemic brucellosis with left testicular swelling and pain. An ultrasound showed multiple small testicular abscesses, and the repeat diluted brucella titer demonstrated the causative pathogen. The patient was successfully treated with 3 months of oral targeted antibiotics, with no need for drainage or orchiectomy.

Upward migration of a ureteric stone in a military trainer: a case report

Retrograde ureteric stone migration is an extremely rare phenomenon with only one previously reported case in the literature. We report on a case of upward spontaneous migration of a ureteric stone in a 39-year-old male military trainer in Saudi Arabia who was diagnosed with upper left ureteric stone based on non-contrast spiral computerized tomography kidney ureter bladder (CT-KUB) scan. The plan was to treat the patient conservatively with alpha blockers and oral hydration. Two weeks after treatment started, repeated CT-KUB scan revealed an upward migration of the stone to the left renal calyx. Accordingly, we highly recommend performing a prior stone localizing imaging test to avoid unnecessary procedures or operations.

Starting an Emergency Radiology Division: Scheduling and Staffing, Compensation, and Equity and Parity

Establishing an emergency radiology division in a practice that has long-standing patterns of operational routines comes with both challenges and opportunities. In this article, considerations around scheduling and staffing, compensation, and equity and parity are provided with supporting literature references. Furthermore, a panel of experts having established, grown and managed emergency radiology divisions in North America and Europe share their experiences through a question and answer format.

Tuberculous peritonitis post orchiectomy for testicular tuberculosis; a case report and literature review

Tuberculous peritonitis, though rare, is a serious condition and its diagnosis is challenging due to nonspecific clinical symptoms and imaging findings. Likewise, tuberculous epididymo-orchitis is a clinical dilemma, as it often mimics testicular tumors. We report a case of a 62-year-old patient diagnosed to have TB peritonitis, following tuberculous epididymo-orchitis with review of the imaging features of both entities. A high index of suspicion and careful clinical assessment will help in early diagnosis and treatment of TB peritonitis, preventing potential complications. Moreover, testicular tuberculosis should be considered in the differential diagnosis of scrotal mass.

Overnight emergency radiologist coverage model with preserved resident autonomy: impact on report turnaround times and resident experience

PURPOSE

To evaluate the impact of overnight in-house emergency radiologist coverage on turnaround time (TAT) for emergent imaging of ED and inpatients, during the night and following morning, in a coverage model tailored to preserving resident autonomy.

METHODS

Retrospective analysis of TAT for all emergent imaging of ED and inpatients at an academic Level-1 trauma center from September 2015 to August 2019, two years before and after changing coverage model. Median and 90th percentile were assessed for overnight (22:00-07:00 h.) and morning (07:00-10:00 h.) emergent imaging TAT for both the 'First report' and 'Final report'. Statistical significance of TAT changes between study years was assessed with quantile regression. Trainee report volumes and their rotation evaluations were assessed.

RESULTS

128,433 emergent ED and inpatient imaging studies (82,482 overnight and 45,951 morning) were included; 40,136 CTs, 83,993 X-rays, 2018 US and 2286 MRIs. Imaging volumes increased over time. Except 90th percentile MRI First report TAT, all overnight TAT metrics statistically significantly improved with the new coverage model. For example, ED CT median Final report TAT decreased from 8.45 h to 1.38 h. Morning imaging showed statistically significant reduction for all TATs, except for MRI TATs and 90th percentile US Final report TAT. For example, ED CT median Final report TAT decreased from 1.56 h to 1.19 h. Absolute imaging volume reported by trainees increased by 14% in the 4-year period and weighted average rotation evaluation on a 5-point scale was 3.9 in the post-implementation cohort.

CONCLUSION

Introduction of a tailored in-house overnight emergency radiologist coverage model can preserve resident autonomy and productivity while achieving statistically significant reduction of emergent imaging report turnaround time for emergent imaging overnight and the following morning. It may help mitigate ED overcrowding while preserving trainee educational experience.

Initial Imaging of Pregnant Patients in the Trauma Bay-Discussion and Review of Presentations at a Level-1 Trauma Centre

Trauma is the leading non-obstetric cause of maternal and fetal mortality and affects an estimated 5-7% of all pregnancies. Pregnant women, thankfully, are a small subset of patients presenting in the trauma bay, but they do have distinctive physiologic and anatomic changes. These increase the risk of certain traumatic injuries, and the gravid uterus can both be the primary site of injury and mask other injuries. The primary focus of the initial management of the pregnant trauma patient should be that of maternal stabilization and treatment since it directly affects the fetal outcome. Diagnostic imaging plays a pivotal role in initial traumatic injury assessment and should not deviate from normal routine in the pregnant patient. Radiographs and focused assessment with sonography in the trauma bay will direct the use of contrast-enhanced computed tomography (CT), which remains the cornerstone to evaluate the potential presence of further management-altering injuries. A thorough understanding of its risks and benefits is paramount, especially in the pregnant patient. However, like any other trauma patient, if evaluation for injury with CT is indicated, it should not be denied to a pregnant trauma patient due to fear of radiation exposure.