The impact of installing an MR scanner in the emergency department for patients presenting with acute stroke-like symptoms.

PURPOSE: We examined the impact of an MR scanner in the emergency department (ED) on ED length of stay (LOS), hospital (H) LOS, hospital admission rate, hospitalization costs, and ED re-presentation rate of patients presenting with stroke-like symptoms (SLS). We hypothesized that the ED MR would increase efficiency of patient care. METHODS: The number of MRIs performed in the ED vs. inpatient setting, EDLOS, HLOS, hospitalization charges, admission rate, discharge diagnoses, and 30-60-day ED re-presentation rates were determined for ED patients with SLS six months before (2011) and after (2012) ED MR installation. RESULTS: 362 and 448 patients with SLS presented to the ED, and 196 and 176 patients were admitted in 2011 and 2012 respectively. In 2011, 36 (18.4%) admitted patients, and, in 2012, 68 (38.6%) had MRIs in the ED, p<0.001. In 2011, 74 (37.8%) admitted patients were diagnosed with ischemic stroke, compared to 92 (52.3%) in 2012, p=0.007. HLOS was longer and charges higher for patients with stroke. No patients returned with a confirmed diagnosis of CVA or TIA within 0-60days after being discharged from the ED with negative MR. CONCLUSIONS: With the ED MR, more admitted patients 1) got scanned in the ED and 2) were diagnosed with stroke. Because this led to more patients on the stroke service actually suffering from strokes (and not other diagnoses), the overall HLOS and charges of patients presenting with SLS were not reduced by ED MR screening. Discharge after a negative ED MR did not incur risk of TIAs or strokes over the ensuing 60days. Therefore, not only does a dedicated MR scanner in the ED aid in the acute diagnosis of a CVA or other neurologic disorder, but it does so without the risk of under-diagnosing TIAs or evolving strokes in the presence of a negative MRI.

Opportunities for Targeted Education: Critical Neuroradiologic Findings Missed or Misinterpreted by Residents and Fellows.

OBJECTIVE: We reviewed neuroradiology cases in which a resident or fellow missed a significant finding, to identify potential areas of deficiency that could be strengthened through targeted education. MATERIALS AND METHODS: Included in the study were all neuroradiology reports from 2011 through 2013 that were marked with an electronic flag to indicate a significant modification between the preliminary and final versions. The reports were examined to determine whether a critical finding (CF) or a non-CF was missed, with the use of a hospital-approved list of 17 neuroradiology CFs. Results were analyzed for all trainees. RESULTS: A total of 978 modified reports were found among reports from 225,628 neuroradiology examinations. Of these modified reports, 891 (91.1%) contained an addendum that identified the discrepancy: 658 (73.8%) contained a CF,192 (21.7%) contained a non-CF, and 41 (4.6%) were changed from containing a CF to not containing a CF. A total of 725 missed CFs were found in the 658 modified reports. The CF miss rate for all trainees was 6.0% (95% CI, 5.6-6.4%), whereas that for residents was 8.6% and that for fellows was 4.8%. Residents missed hydrocephalus, intracranial pressure or edema, new hemorrhage, and new infarction more frequently than did fellows. The five most frequently missed CFs were congenital variation, infection, misplaced hardware, a new or enlarging mass, and vascular abnormality. CONCLUSION: Our trainees' overall CF miss rate was 6.0%. Five CFs had miss rates of approximately 10% or more, and residents missed four of the CFs more frequently than did fellows. With the use of these data, our curriculum could potentially be strengthened and our trainee error rates decreased, leading to improved patient care.

Continuous practice quality improvement initiative for communication of critical findings in neuroradiology.

The authors examined faculty's compliance with a hospital-approved neuroradiology critical findings (CFs) policy, which requires urgent verbal communication with the clinical team when 17 specific critical pathologies are identified. During June 2011 to July 2013, 50 random neuroradiology reports were sampled monthly for the presence of CFs and appropriate action. Faculty were provided ongoing feedback, and at the end of 2 years, the medical records for cases with noncommunicated CFs were reviewed to identify potential adverse outcomes. Of the 1200 reviewed reports, 195 (16.3%) had and 1005 (83.8%) did not have a CF. A total of 176 of 195 (90.3%) cases with CFs were communicated, and compliance increased from 77.4% to 85.6% (P = .027) since the monthly sampling was instituted; 1 of 19 (5.3%) noncommunicated CFs resulted in a potential adverse event. The ongoing monthly feedback resulted in improved faculty compliance with the CF policy. However, a small number of cases with CFs are still not being communicated.

Hand sanitizer-dispensing door handles increase hand hygiene compliance: a pilot study.

Improving rates of hand hygiene compliance (HHC) has been shown to reduce nosocomial disease. We compared the HHC for a traditional wall-mounted unit and a novel sanitizer-dispensing door handle device in a hospital inpatient ultrasound area. HHC increased 24.5%-77.1% (P < .001) for the exam room with the sanitizer-dispensing door handle, whereas it remained unchanged for the other rooms. Technical improvements like a sanitizer-dispensing door handle can improve hospital HHC.

Reporting of critical findings in neuroradiology.

OBJECTIVE: The objective of our study was to assess compliance among academic neuroradiologists in reporting institutionally derived critical findings. MATERIALS AND METHODS: We analyzed 3054 neuroradiology CT and MRI reports generated in 1 month. Reports were categorized by whether or not they contained a critical finding based on a previously established list. The reports were subcategorized by whether the reporting neuroradiologist flagged the report as containing a critical finding and whether the radiologist verbally communicated the critical finding to the referring clinician. Reports were divided into day or night categories and the frequency of critical findings for each time period was calculated. RESULTS: Of the 3054 reports included in this study, 301 (9.9%) had critical findings. Of those 301 reports, 233 (77.4%) were flagged and the referring clinician was called. Of the remaining 68 reports with critical findings, the reporting radiologist did not call the clinician about 35.3% of them (24/68). Of the 2753 reports without critical findings, 2658 (96.5%) were appropriately not flagged and the clinician was not called. However, radiologists called clinicians about 3.5% (95/2753) of the reports without critical findings and erroneously flagged 68.4% (65/95) of those reports as critical. A majority of the cases with critical findings were reported at night (55.1%) despite the fact that 67.2% of the studies occurred during the day. CONCLUSION: Compliance with reporting and communicating critical findings must be monitored. Calling clinicians to report noncritical findings may result in unnecessary interruptions in work flow for radiologists and referring health care providers.

Determination and communication of critical findings in neuroradiology.

PURPOSE: The aims of this study were to analyze reporting of critical findings among neuroradiologists in a university setting and to revise a list of critical findings reflecting an academic clinical practice as part of a practice quality improvement project. MATERIALS AND METHODS: Neuroradiologic studies performed between January 1 and February 28, 2011, containing "critical finding" notations were searched. Reports were matched with an institutionally approved list of critical findings. These findings and unlisted items that were labeled critical were analyzed for frequency, clinical severity, and diagnosis category. The list was revised on the basis of frequency and severity results. RESULTS: A total of 12,607 reports contained 871 critical findings, 608 of which (69.8%) matched the preexisting list. One-third of the findings (263 of 871) labeled critical were not found on the list. Facial, spinal, and calvarial fractures (76 of 263 [28.9%]) and neurovascular injuries (38 of 263 [14.4%]) were the most frequent unlisted findings. A revised list encompassed 86.7% of all communicated neuroradiologic critical findings. CONCLUSIONS: Clinician-approved and neuroradiologist-approved standardized sets of critical findings can facilitate the communication of important results without "overcalling" and decreasing efficiency. Physician judgment of what constitutes a critical finding supersedes any such list, as clinical scenarios are highly variable from patient to patient. Critical findings lists require intermittent revision to reflect practice patterns and changing incidence of disease. Such a review can constitute a practice quality improvement initiative.

Who collects professional fees for neuroradiology interpretation, radiologists or nonradiologists?

PURPOSE: An increasing portion of imaging studies are performed by nonradiologists, especially for modalities with the highest relative value units. The aim of this study was to examine the trends in neuroradiologic interpretation among radiologists, neurologists, neurosurgeons, and other specialists within the Medicare population. METHODS: The number of neuroradiologic studies interpreted by radiologists, neurologists, neurosurgeons, and other specialists in the inpatient, hospital outpatient, and private office settings was determined from the CMS Physician/Supplier Procedure Summary Master Files for 1996 to 2010. Studies billed through professional and global charges were aggregated. Utilization rates and utilization rate compound annual growth rates were computed by specialty and by imaging study. RESULTS: In 1996, radiologists interpreted 4,802,490 (93.7%) CMS neuroradiologic procedures, neurologists 77,312 (1.5%), neurosurgeons 9,825 (0.19%), and other specialists 234,423 (4.6%). In 2010, radiologists interpreted 11,476,376 (93.5%) procedures, neurologists 101,172 (0.8%), neurosurgeons 20,697 (0.17%), and other specialists 680,786 (5.5%). Neurology and neurosurgery lost market share at all sites. Radiology's share increased in the inpatient (from 94.8% to 98.7%) and hospital outpatient (from 95% to 98.7%) settings but decreased in the private office setting (from 88.2% to 73.1%). Lost market share was captured by the other CMS specialty categories, including independent diagnostic testing facilities and multidisciplinary groups, many of which included radiologists. CONCLUSIONS: There was marked growth (140%) in neuroradiologic studies between 1996 and 2010 in the Medicare patient population. Radiologists' share of the total neuroradiologic interpretations remained unchanged and constituted 93.5% in 2010. Radiology's market share has shown growth in the inpatient and hospital outpatient sectors but not the private office sector, where independent diagnostic testing facilities, multidisciplinary groups, and other specialists have seen increases.

Volume of neuroradiology studies read by neurologists: implications for fellowship training.

PURPOSE: The ACGME recognizes radiology's neuroradiology fellowship programs as the pathway to neuroradiology expertise. Members of the American Society of Neuroimaging have called for the expansion of neuroradiology fellowships for neurologists with informal accreditation through the United Council for Neurologic Subspecialties. The aim of this study was to investigate the number of neuroradiologic studies read by neurologists to assess their capacity to support fellowship positions at ACGME training criteria. METHODS: The numbers of neuroradiologic studies interpreted by radiologists and neurologists in the inpatient and hospital outpatient settings were determined from the CMS Physician/Supplier Procedure Summary Master Files for 1996 to 2008. The ACGME requirements of 1,500 neuroradiologic CT and 1,500 neuroradiologic MR scans per fellow per year were used to calculate the number of fellowship positions that could be supported by each specialty. RESULTS: In 2008, in the inpatient and hospital outpatient setting, radiologists interpreted 9,287,768 (98.3% of the total) and neurologists interpreted 43,107 (0.5% of the total) neuroradiologic examinations on Medicare patients. Per ACGME requirements, on the basis of CT volumes, radiologists could potentially train 4,256 neuroradiology fellows, compared with neurologists' 12 fellows, assuming a single fellow was exposed to every Medicare case. On the basis of MR volumes, radiologists and neurologists could train 1,935 and 16 fellows, respectively. CONCLUSIONS: Radiologists are responsible for interpreting the vast majority (98.3%) of neuroradiologic studies. Neurologists have a limited exposure to neuroradiologic CT and MR and could support only 12 fellowship positions by ACGME criteria on the basis of reading available 1996 to 2008 Medicare cases.

Arterial wall enhancement overlying carotid plaque on CT angiography correlates with symptoms in patients with high grade stenosis.

BACKGROUND AND PURPOSE: The degree of internal carotid artery (ICA) stenosis is an established primary risk factor for embolic stroke. Recent publications suggest that inflammatory features may also play an important role. Our purpose was to correlate acute neurological symptoms with either carotid artery wall enhancement or plaque calcification, on axial CT angiographic source images (CTA-SI) of patients with severe (>or=70%) ICA stenosis. METHODS: 75 consecutive patients with >or=70% ICA stenosis on CTA-SI were identified. Each case was classified as symptomatic (n=37) or asymptomatic (n=38), and as having either calcified or noncalcified plaque. The latter group was stratified into those with versus without arterial wall enhancement, measured in absolute and relative Hounsfield Units (HU). RESULTS: Calcified plaque was present in 39% (15/38) of the symptomatic patients and in 62% (23/37) of the asymptomatic patients (P=0.065). Of the 37 patients without calcified plaque, carotid wall enhancement was observed in 83% (19/23) of the symptomatic, but only in 57% (8/14) of the asymptomatic patients (P=0.041). When the "calcified plaque" and "no carotid wall enhancement" groups were pooled, versus the "carotid wall enhancement" group, enhancement was more likely in symptomatic patients (OR 3.625, CI 95% 1.3229 to 9.93, P=0.01 Fisher Exact test). CONCLUSIONS: In patients with severe ICA stenosis, additional stratification of stroke risk may be possible based on the presence of carotid wall enhancement on CTA-SI. Patients with carotid wall enhancement are more likely to be symptomatic, compared to those with either calcified plaque or no enhancement.

Comparison of gadolinium-enhanced cardiovascular magnetic resonance angiography with high-resolution black blood cardiovascular magnetic resonance for assessing carotid artery stenosis.

PURPOSE: Carotid angiography is used to assess stroke risk, but it cannot reliably characterize plaque burden because the vessel remodels during plaque formation. High-resolution black blood cardiovascular magnetic resonance (BBCMR) depicts the outer wall thereby providing a truer estimate of plaque size. We compared carotid stenosis by gadolinium enhancement cardiovascular magnetic resonance angiography (CMRA) versus high-resolution BBCMR. METHODS: Twenty-four subjects (M:F = 20:4; ages 57-83 years) with carotid atherosclerosis underwent CMRA and transaxial BBCMR through the stenosis. Area and diameter stenosis measurements by NASCET criteria using CMRA images were compared to area stenosis measurements based on outer wall and lumen contours drawn on corresponding BBCMR images. RESULTS: Area stenosis by CMRA correlated with area stenosis by BBCMR (r = 0.77; 95% CI: 0.58, 0.89). BBCMR values exceeded corresponding CMRA area measurements in 20 of 24 cases, with the remainder being highly stenotic (> 90%). CONCLUSION: CMRA yields lower estimates of luminal narrowing compared to BBCMR, which delineates the outer wall and accounts for vascular remodeling. BBCMR could serve as a new measure of narrowing to guide management, but prospective studies are needed to better understand the clinical implications of this new scale of disease.

Middle cerebral artery infarction: relationship of cavernous carotid artery calcification.

BACKGROUND AND PURPOSE: This study was designed to determine whether calcification of the cavernous carotid artery (CCA) is associated with cerebrovascular infarcts in the same way that coronary artery calcification scores indicate myocardial infarctions. We sought to correlate the grade of CCA calcification with infarctions in the middle cerebral artery (MCA) distribution. METHODS: Nonenhanced brain CT scans of 40 patients with MCA-distribution strokes, 34 with non-MCA-distribution strokes, and 94 age-matched control subjects were reviewed. Circumferential calcification and thickness of calcification were graded for the CCAs on head CT scans. Scores were determined for the left and right CCAs. Mann-Whitney tests and Spearman correlation coefficients were used to detect differences between patients and control subjects and between patients with MCA and those with non-MCA strokes. RESULTS: CCA calcification scores did not significantly differ in the groups compared. The manner in which calcification was scored (by using circumference, thickness, or both) did not affect the results. No difference was noted between scores ipsilateral and those contralateral to the stroke. CONCLUSION: Circumferential degree or thickness of cavernous artery calcification was not correlated with MCA or non-MCA infarctions. CCA calcification scores did not differ between patients with stroke and those without stroke.

Cavernous carotid artery calcification and white matter ischemia.

BACKGROUND AND PURPOSE: The relevance of cavernous carotid artery calcification on unenhanced CT scans of the brain has recently been investigated against the backdrop of the widespread implementation of coronary artery calcification scoring. We sought to determine whether the degree of cavernous carotid artery calcification correlated with scores of white matter hyperintensity seen on MR images. In so doing, we sought to establish a relative risk for future stroke on the grade of carotid calcification. METHODS: Neuroradiologic findings in 187 patients who underwent CT and MR imaging examinations within 1 month of each other were retrospectively reviewed. The degree of circumferential calcification and thickness of calcification were graded for the cavernous carotid arteries on the basis of CT findings. Using the scale developed by the Cardiovascular Health Study, the white matter was graded for degree of disease on the basis of MR findings. Correlation tests and regression analyses were performed to determine the impact of age, race, and sex on results. RESULTS: Although the cavernous carotid calcification scores and the MR imaging white matter scores showed good correlation (P <.001), the effect was mediated by age. With age factored in as a covariant, no correlation was shown between CT calcification scores and MR imaging white matter scores. Sex had no effect, but African American study participants had worse MR imaging white matter scores than did white participants. CONCLUSION: After adjusting for age, cavernous carotid calcification grades and MR imaging white matter scores do not show a significant correlation. The relative risk for future stroke cannot be predicted from cavernous carotid calcifications.