Mortality After Adolescent Firearm Injury: Effect of Trauma Center Designation.

PURPOSE: To determine the incidence and outcomes of firearm injuries in adolescents and the effect of trauma center (TC) designation on their mortality. METHODS: The National Trauma Data Bank (2010-2016) was queried for all encounters involving adolescents aged 13-16 years with firearm injuries. Multivariable logistic regression was employed to determine the association of covariates with mortality (α = .05). Propensity score matching was also used to explore the relationship between TC designation and mortality. RESULTS: A total of 9,029 adolescents met inclusion criteria. Patients aged 15 and 16 years compromised 77.8% of the cohort and were more often male (87.9% vs. 80.6%, p < .001), black (63.8% vs. 56.1%, p < .001), injured in the abdomen (25.4% vs. 22.4%, p = .007) or extremities (62.3% vs. 56.7%, p < .001), and incurred severe injuries (54.5% vs. 50.9%, p = .004) versus 13- and 14-year-old patients. Younger patients were more often injured in the head/neck (23.8% vs. 20.5%, p = .001). Multivariable logistic regression demonstrated no difference in mortality between age groups. Poor neurologic presentation, severe injury, abdominal, chest, and head injuries were all associated with an increased odds of death. Odds of mortality were 2.88 times higher at adult TCs compared to pediatric TCs (CI: 1.55-5.36, p = .001). However, using a 1:1 propensity score matching model, no difference in mortality was found between TC types (p = NS). CONCLUSIONS: Variability exists in outcomes for adolescents after firearm injuries. Understanding and identifying the potential differences between pediatric and adult TCs managing adolescent firearm victims may improve survival in all treatment venues, but these data support patients being treated at the closest available TC.

Intra-arterial contrast-enhanced ultrasound (IA CEUS) for localization of hepatocellular carcinoma (HCC) supply during transarterial chemoembolization (TACE): a case series.

Transarterial chemoembolization (TACE) is a proven catheter-based locoregional therapy for treatment of hepatocellular carcinoma (HCC). Drug-eluting bead TACE involves delivering micrometer-sized particles preloaded with doxorubicin directly to the tumor via its arterial blood supply and results in vascular embolization with intra-tumoral drug release. Effective therapy requires mapping of the tumor arterial supply, which in some cases cannot be accomplished with conventional angiographic techniques alone. Contrast-enhanced ultrasound (CEUS) is an imaging technique which utilizes microbubble contrast agents to demonstrate blood flow and tissue perfusion, enabling tumor visualization in real time. CEUS with intravenous contrast administration is well established for evaluation of HCC. Intra-arterial (IA) CEUS, on the other hand, is an emerging technique that allows more selective evaluation of the arterial supply to the tumor. The three cases in this report illustrate the utility of intra-procedural IA CEUS during TACE. Specifically, IA CEUS aided TACE in cases where the HCC showed poor arterial enhancement, an extrahepatic arterial supply, and a portal venous supply, respectively.

Atypical central neurocytoma with metastatic craniospinal dissemination: a case report.

Central neurocytomas comprise nearly half of adult intraventricular neoplasms. The median age of onset is 34 years. It is typically a low-grade neoplasm (World Health Organization grade II), although some cases of malignant neurocytomas have been described. We present a rare case of an atypical central neurocytoma with craniospinal dissemination, including both imaging and pathologic findings.

Active Surveillance of Small Renal Masses: A Review on the Role of Imaging With a Focus on Growth Rate.

OBJECTIVE: This study aimed to systematically summarize the current literature in the field of active surveillance for small renal masses, with the primary focus being the role of imaging in the primary decision-making and subsequent follow-up. MATERIALS: A systematic review of the electronic databases PubMed and Web of Knowledge was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analysis statement guidelines. Variables were extracted from the data set and included the following: (1) patient demographics, (2) tumor characteristics, and (3) study design. RESULTS: Twenty-one articles studying imaging in active surveillance of small renal masses were selected. Seventy-two percent (15/21) of studies were retrospective; 19% (4/21) were prospective; and 9% (2/21) studies were bidirectional. Mean age of patients was 69 years (range, 57-81 years). A total of 1386 patients were in the study; 59% of patients were men. Mean follow-up was 39 months (range, 18.8-91.5 months). Sixty-seven percent of masses discussed in this review were followed up using more than one imaging modality; 19% consistently used computed tomography for follow-up whereas the remaining 14% did not specify what imaging modality was used. Imaging studies were reviewed by the investigators centrally in 86% (18/21). In 14% of the studies, only imaging report was reviewed. Biopsy was performed in 24% of masses. Mean growth rate for all tumors was 0.27 cm/y (range, 0.06-0.7 cm/y). For studies where growth rate of benign and malignant masses were differentiated, mean growth rate for benign masses was 0.3 cm/y and mean growth rate for malignant masses was 0.35 cm/y. CONCLUSIONS: Growth rate is often used as a discriminant in following up a small renal mass in patients undergoing active surveillance. However, there is great variability in growth rate and it alone is not an adequate marker for determining whether the tumor is malignant. Because very few studies specified radiological characteristics of small renal masses, future studies can be done to better characterize masses.

Role of contrast-enhanced ultrasound (CEUS) in evaluation of thermal ablation zone.

PURPOSE: Thermal ablation has emerged as a mainstay therapy for primary and metastatic liver malignancy. Percutaneous thermal ablation is usually performed under CT and/or ultrasound guidance. CT guidance frequently utilizes iodinated contrast for tumor targeting, with additional radiation and contrast required at the end of the procedure to ensure satisfactory ablation margins. Contrast-enhanced ultrasound (CEUS) is an imaging technique utilizing microbubble contrast agents to demonstrate blood flow and tissue perfusion. In this study, we performed a retrospective review to assess the utility of CEUS in the immediate post ablation detection of residual tumor. METHODS: Sixty-four ablations were retrospectively reviewed. 6/64 ablations (9.4%) had residual tumor on the first follow-up imaging after thermal ablation. There were two groups of patients. Group 1 underwent standard protocol thermal ablation with CT and/or ultrasound guidance. Group 2 not only had thermal ablation with a protocol identical to group 1, but also had CEUS assessment at the conclusion of the procedure to ensure satisfactory ablation zone. RESULTS: The residual tumor rate in group 1 was 16.7% and the residual tumor rate in group 2 was 0%. The difference between the groups was statistically significant with a p value of 0.023. The results suggest that using CEUS assessment immediately after the ablation procedure reduces the rate of residual tumor after thermal ablation. CONCLUSION: CEUS evaluation at the end of an ablation procedure is a powerful technique providing critical information to the treating interventional radiologist, without additional nephrotoxic contrast or ionizing radiation.

Cross-sectional imaging following surgical interventions for stress urinary incontinence in females.

Stress urinary incontinence (SUI) is a condition in which the weakness of the pelvic floor muscles causes unintentional loss of urine. For patients who are unable to achieve symptomatic improvement from lifestyle modification and pharmacotherapy, surgical placement of the pelvic slings or the use of urethral bulking agents has been shown to provide tremendous symptomatic improvement. Learning to recognize the pelvic slings and to identify their complications on imaging is invaluable; however, this is challenging because of the change in the local anatomy after surgical placement of the sling. In this paper, we present CT and MR imaging to demonstrate the surgical and non-surgical treatments of female SUI and their complications. Through this pictorial essay, our goal is to familiarize radiologists with recognizing the various forms of treatment for SUIs, the relevant pelvic anatomy, and complications that may occur secondary to the surgical placement of the pelvic slings.

Assessing the clinical utility of color Doppler ultrasound for ovarian torsion in the setting of a negative contrast-enhanced CT scan of the abdomen and pelvis.

PURPOSE: The purpose of this study is to evaluate the utility of color Doppler ultrasound (CDU) in the assessment of ovarian torsion following a negative contrast-enhanced computed tomography (CT) examination. METHODS: This is a retrospective study of women who presented to the ED with abdominal pain and received both a contrast-enhanced CT and CDU within a 24-h period. The abdominal/pelvic CT examinations were evaluated for findings specific to torsion, including ovarian size greater than 5 cm, the presence of free fluid, uterine deviation, fallopian tube thickening, ovarian fat stranding, smooth wall thickening, the presence of the "twisted pedicle" sign, and abnormal ovarian enhancement. The results were compared to the presence or absence of ovarian torsion on the concurrent US. RESULTS: The initial query yielded 834 cases among 789 women. Of those 834 cases, 283 cases in 261 women received both imaging modalities within a 24-h period. The CT examinations demonstrated 48 cases with an ovarian size greater than 5 cm. 84 cases showed the presence of free fluid. Three cases of fallopian tube thickening were identified. One case of smooth wall thickening and a "twisted pedicle" sign were noted. Fifteen cases demonstrated stranding of the peri-ovarian fat. Twenty nine cases showed abnormal ovarian enhancement. A total of 111 cases showed at least one positive finding. Fourteen positive cases were identified on the CDU studies. Of the 14 positive cases, 11 had ovarian size greater than 5 cm. Twelve cases demonstrated the presence of free fluid. There was no uterine deviation or smooth wall thickening. One twisted pedicle was noted. Seven cases showed peri-ovarian fat stranding. Ten cases showed abnormal enhancement. Abnormalities on CT were noted in all cases suspicious for ovarian torsion on CDU. No negative CT examinations were associated with a positive CDU. In this small sample size, the negative predictive value of a negative CT examination was 100%. CONCLUSION: A negative contrast-enhanced CT examination of the abdomen and pelvis is sufficient to rule out ovarian torsion. Therefore, there is no utility in the addition of CDU specifically to evaluate for ovarian torsion following a negative contrast-enhanced CT scan of the abdomen and pelvis.

CT prediction of the Fuhrman grade of clear cell renal cell carcinoma (RCC): towards the development of computer-assisted diagnostic method.

PURPOSE: There are distinct quantifiable features characterizing renal cell carcinomas on contrast-enhanced CT examinations, such as peak tumor enhancement, tumor heterogeneity, and percent contrast washout. While qualitative visual impressions often suffice for diagnosis, quantitative metrics if developed and validated can add to the information available from standard of care diagnostic imaging. The purpose of this study is to assess the use of quantitative enhancement metrics in predicting the Fuhrman grade of clear cell RCC. MATERIALS AND METHODS: 65 multiphase CT examinations with clear cell RCCs were utilized, 44 tumors with Fuhrman grades 1 or 2 and 21 tumors with grades 3 or 4. After tumor segmentation, the following data were extracted: histogram analysis of voxel-based whole lesion attenuation in each phase, enhancement and washout using mean, median, skewness, kurtosis, standard deviation, and interquartile range. RESULTS: Statistically significant difference was observed in 4 measured parameters between grades 1-2 and grades 3-4: interquartile range of nephrographic attenuation values, standard deviation of absolute enhancement, as well as interquartile range and standard deviation of residual nephrographic enhancement. Interquartile range of nephrographic attenuation values was 292.86 HU for grades 1-2 and 241.19 HU for grades 3-4 (p value 0.02). Standard deviation of absolute enhancement was 41.26 HU for grades 1-2 and 34.66 HU for grades 3-4 (p value 0.03). Interquartile range was 297.12 HU for residual nephrographic enhancement for grades 1-2 and 235.57 HU for grades 3-4 (p value 0.02), and standard deviation of the same was 42.45 HU for grades 1-2 and 37.11 for grades 3-4 (p value 0.04). CONCLUSION: Our results indicate that absolute enhancement is more heterogeneous for lower grade tumors and that attenuation and residual enhancement in nephrographic phase is more heterogeneous for lower grade tumors. This represents an important step in devising a predictive non-invasive model to predict the nucleolar grade.

Multidimensional Interactive Radiology Report and Analysis: Standardization of workflow and reporting for renal mass tracking and quantification.

A conventional radiology report primarily consists of a large amount of unstructured text, and lacks clear, concise, consistent and content-rich information. Hence, an area of unmet clinical need consists of developing better ways to communicate radiology findings and information specific to each patient. Here, we design a new workflow and reporting system that combines and integrates advances in engineering technology with those from the medical sciences, the Multidimensional Interactive Radiology Report and Analysis (MIRRA). Until recently, clinical standards have primarily relied on 2D images for the purpose of measurement, but with the advent of 3D processing, many of the manually measured metrics can be automated, leading to better reproducibility and less subjective measurement placement. Hence, we make use this newly available 3D processing in our workflow. Our pipeline is used here to standardize the labeling, tracking, and quantifying of metrics for renal masses.

Composite liver tumors: a radiologic-pathologic correlation.

Bi-phenotypic neoplasm refers to tumors derived from a common cancer stem cell with unique capability to differentiate histologically into two distinct tumor types. Bi-phenotypic hepatocellular carcinoma-cholangiocarcinoma (HCC-CC), although a rare tumor, is important for clinicians to recognize, since treatment options targeting both elements of the tumor are crucial. Imaging findings of bi-phenotypic HCC-CC are not specific and include features of both HCC and CC. A combination of imaging and immuno-histochemical analysis is usually needed to make the diagnosis.