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Reduced Intravenous Contrast Dose Portal Venous Phase Photon-Counting Computed Tomography Compared With Conventional Energy-Integrating Detector Portal Venous Phase Computed Tomography

Dane, Bari; Mabud, Tarub; Melamud, Kira; Ginocchio, Luke; Smereka, Paul; Okyere, Mabel; O'Donnell, Thomas; Megibow, Alec
OBJECTIVE:The aim of this study was to compare portal venous phase photon-counting CT (PCCT) using 20 cc less than weight-based contrast dosing with energy-integrating detector CT (EID-CT) using weight-based dosing by quantitative and qualitative analysis. METHODS:Fifty adult patients who underwent a reduced intravenous contrast dose portal venous phase PCCT from May 1, 2023, to August 10, 2023, and a prior portal-venous EID-CT with weight-based contrast dosing were retrospectively identified. Hounsfield units (HU) and noise (SD of HU) were obtained from region-of-interest measurements on 70-keV PCCT and EID-CT in 4 hepatic segments, the main and right portal vein, and both paraspinal muscles. Signal-to-noise and contrast-to-noise ratios were computed. Three abdominal radiologists qualitatively assessed overall image quality, hepatic enhancement, and confidence for metastasis identification on 5-point Likert scales. Readers also recorded the presence/absence of hepatic metastases. Quantitative variables were compared with paired t tests, and multiple comparisons were accounted for with a Bonferroni-adjusted α level of .0016. Ordinal logistic regression was used to evaluate qualitative assessments. Interreader agreement for hepatic metastases was calculated using Fleiss' κ. RESULTS:Fifty patients (32 women; mean [SD] age, 64 [13] years) were included. There was no significant difference in hepatic HU, portal vein HU, noise, and signal-to-noise or contrast-to-noise ratio between reduced contrast dose portal venous phase PCCT versus EID-CT (all Ps > 0.0016). Image quality, degree of hepatic enhancement, and confidence for metastasis identification were not different for reduced dose PCCT 70-keV images and EID-CT (P = 0.06-0.69). κ Value for metastasis identification was 0.86 (95% confidence interval, 0.70-1.00) with PCCT and 0.78 (95% confidence interval, 0.59-0.98) with EID-CT. CONCLUSION/CONCLUSIONS:Reduced intravenous contrast portal venous phase PCCT 70-keV images had similar attenuation and image quality as EID-CT with weight-based dosing. Metastases were identified with near-perfect agreement in reduced dose PCCT 70-keV images.
PMID: 38595174
ISSN: 1532-3145
CID: 5645932

Imaging of Antepartum and Postpartum Hemorrhage

Melamud, Kira; Wahab, Shaun A; Smereka, Paul N; Dighe, Manjiri K; Glanc, Phyllis; Kamath, Amita; Maheshwari, Ekta; Scoutt, Leslie M; Hindman, Nicole M
Severe obstetric hemorrhage is a leading cause of maternal mortality and morbidity worldwide. Major hemorrhage in the antepartum period presents potential risks for both the mother and the fetus. Similarly, postpartum hemorrhage (PPH) accounts for up to a quarter of maternal deaths worldwide. Potential causes of severe antepartum hemorrhage that radiologists should be familiar with include placental abruption, placenta previa, placenta accreta spectrum disorders, and vasa previa. Common causes of PPH that the authors discuss include uterine atony, puerperal genital hematomas, uterine rupture and dehiscence, retained products of conception, and vascular anomalies. Bleeding complications unique to or most frequently encountered after cesarean delivery are also enumerated, including entities such as bladder flap hematomas, rectus sheath and subfascial hemorrhage, and infectious complications of endometritis and uterine dehiscence. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material. See the invited commentary by Javitt and Madrazo in this issue.
PMID: 38547034
ISSN: 1527-1323
CID: 5645142

Photon-counting CT urogram: optimal acquisition potential (kV) determination for virtual noncontrast creation

Dane, Bari; Freedman, Daniel; Qian, Kun; Ginocchio, Luke; Smereka, Paul; Megibow, Alec
PURPOSE/OBJECTIVE:To quantitatively and qualitatively compare the degree of iodine removal in the collecting system from PCCT urographic phase-derived virtual noncontrast (VNC) images obtained at 140 kV versus 120 kV. METHODS:A retrospective PACS search identified adult patients (>18 years) who underwent a PCCT urogram for hematuria from 4/2022 to 4/2023 with available urographic phase-derived VNC images in PACS. Tube voltage (120 kV, 140 kV), body mass index, CTDIvol, dose length product (DLP), and size-specific dose estimate (SSDE) were recorded. Hounsfield Unit (HU) in both renal pelvises and the urinary bladder on urographic-derived VNC were recorded. Three radiologists qualitatively assessed the degree of iodine removal (renal pelvis, urinary bladder) and diagnostic confidence for urinary stone detection. Continuous variables were compared for 140 kV versus 120 kV with the Wilcoxon rank sum test. A p < .05 indicated statistical significance. RESULTS:63 patients (34 male; median (Q1, Q3) age: 30 (26, 34) years; 140 kV/120 kV: 30 patients/33 patients) were included. BMI, CTDIvol, DLP, and SSDE were not different for 140 kV and 120 kV (all p > .05). Median (Q1, Q3) collecting system HU (renal pelvis and bladder) was 0.9 (- 3.6, 4.4) HU at 140 kV and 10.5 (3.6, 26.7) HU at 120 kV (p = .04). Diagnostic confidence for urinary calculi was 4.6 [1.1] at 140 kV and 4.1 [1.4] at 120 kV (p = .005). Diagnostic confidence was 5/5 (all readers) in 82.2% (74/90) at 140 kV and 59.6% (59/99) at 120 kV (p < .001). CONCLUSION/CONCLUSIONS:PCCT urographic phase-derived VNC images obtained at 140 kV had better collecting system iodine removal than 120 kV with similar patient radiation exposure. With excellent PCCT urographic phase iodine removal at 140 kV, consideration can be made to utilize a single-phase CT urogram in young patients.
PMID: 38006415
ISSN: 2366-0058
CID: 5611222

Comparison of a Deep Learning-Accelerated vs. Conventional T2-Weighted Sequence in Biparametric MRI of the Prostate

Tong, Angela; Bagga, Barun; Petrocelli, Robert; Smereka, Paul; Vij, Abhinav; Qian, Kun; Grimm, Robert; Kamen, Ali; Keerthivasan, Mahesh B; Nickel, Marcel Dominik; von Busch, Heinrich; Chandarana, Hersh
BACKGROUND:Demand for prostate MRI is increasing, but scan times remain long even in abbreviated biparametric MRIs (bpMRI). Deep learning can be leveraged to accelerate T2-weighted imaging (T2WI). PURPOSE/OBJECTIVE:To compare conventional bpMRIs (CL-bpMRI) with bpMRIs including a deep learning-accelerated T2WI (DL-bpMRI) in diagnosing prostate cancer. STUDY TYPE/METHODS:Retrospective. POPULATION/METHODS:Eighty consecutive men, mean age 66 years (47-84) with suspected prostate cancer or prostate cancer on active surveillance who had a prostate MRI from December 28, 2020 to April 28, 2021 were included. Follow-up included prostate biopsy or stability of prostate-specific antigen (PSA) for 1 year. FIELD STRENGTH AND SEQUENCES/UNASSIGNED:. ASSESSMENT/RESULTS:CL-bpMRI and DL-bpMRI including the same conventional diffusion-weighted imaging (DWI) were presented to three radiologists (blinded to acquisition method) and to a deep learning computer-assisted detection algorithm (DL-CAD). The readers evaluated image quality using a 4-point Likert scale (1 = nondiagnostic, 4 = excellent) and graded lesions using Prostate Imaging Reporting and Data System (PI-RADS) v2.1. DL-CAD identified and assigned lesions of PI-RADS 3 or greater. STATISTICAL TESTS/METHODS:Quality metrics were compared using Wilcoxon signed rank test, and area under the receiver operating characteristic curve (AUC) were compared using Delong's test. SIGNIFICANCE/CONCLUSIONS:P = 0.05. RESULTS:Eighty men were included (age: 66 ± 9 years; 17/80 clinically significant prostate cancer). Overall image quality results by the three readers (CL-T2, DL-T2) are reader 1: 3.72 ± 0.53, 3.89 ± 0.39 (P = 0.99); reader 2: 3.33 ± 0.82, 3.31 ± 0.74 (P = 0.49); reader 3: 3.67 ± 0.63, 3.51 ± 0.62. In the patient-based analysis, the reader results of AUC are (CL-bpMRI, DL-bpMRI): reader 1: 0.77, 0.78 (P = 0.98), reader 2: 0.65, 0.66 (P = 0.99), reader 3: 0.57, 0.60 (P = 0.52). Diagnostic statistics from DL-CAD (CL-bpMRI, DL-bpMRI) are sensitivity (0.71, 0.71, P = 1.00), specificity (0.59, 0.44, P = 0.05), positive predictive value (0.23, 0.24, P = 0.25), negative predictive value (0.88, 0.88, P = 0.48). CONCLUSION/CONCLUSIONS:Deep learning-accelerated T2-weighted imaging may potentially be used to decrease acquisition time for bpMRI. EVIDENCE LEVEL/METHODS:3. TECHNICAL EFFICACY/UNASSIGNED:Stage 2.
PMID: 36651358
ISSN: 1522-2586
CID: 5419182

Structured versus non-structured reporting of pelvic MRI for ileal pouch evaluation: clarity and effectiveness

Ginocchio, Luke A; Dane, Bari; Smereka, Paul N; Megibow, Alec J; Remzi, Feza H; Esen, Eren; Huang, Chenchan
PURPOSE/OBJECTIVE:Given that ileal pouch-anal anastomosis (IPAA) surgery is a technically challenging and high-morbidity procedure, there are numerous pertinent imaging findings that need to be clearly and efficiently communicated to the IBD surgeons for essential patient management and surgical planning. Structured reporting has been increasingly used over the past decade throughout various radiology subspecialties to improve reporting clarity and completeness. We compare structured versus non-structured reporting of pelvic MRI for ileal pouch to evaluate for clarity and effectiveness. METHODS:164 consecutive pelvic MRI's for ileal pouch evaluation, excluding subsequent exams for the same patient, acquired between 1/1/2019 and 7/31/2021 at one institution were included, before and after implementation (11/15/2020) of a structured reporting template, which was created with institutional IBD surgeons. Reports were assessed for the presence of 18 key features required for complete ileal pouch assessment: anastomosis (IPAA, tip of J, pouch body), cuff (length, cuffitis), pouch body (size, pouchitis, stricture), pouch inlet/pre-pouch ileum (stricture, inflammation, sharp angulation), pouch outlet (stricture), peripouch mesentery (position, mesentery twist), pelvic abscess, peri-anal fistula, pelvic lymph nodes, and skeletal abnormalities. Subgroup analysis was performed based on reader experience and divided into three categories: experienced (n = 2), other intra-institutional (n = 20), or affiliate site (n = 6). RESULTS:57 (35%) structured and 107 (65%) non-structured pelvic MRI reports were reviewed. Structured reports contained 16.6 [SD:4.0] key features whereas non-structured reports contained 6.3 [SD:2.5] key features (p < .001). The largest improvement following template implementation was for reporting sharp angulation of the pouch inlet (91.2% vs. 0.9%, p < .001), tip of J suture line and pouch body anastomosis (both improved to 91.2% from 3.7%). Structured versus non-structured reports contained mean 17.7 versus 9.1 key features for experienced readers, 17.0 versus 5.9 for other intra-institutional readers, and 8.7 versus 5.3 for affiliate site readers. CONCLUSION/CONCLUSIONS:Structured reporting of pelvic MRI guides a systematic search pattern and comprehensive evaluation of ileal pouches, and therefore facilitates surgical planning and clinical management. This standardized reporting template can serve as baseline at other institutions for adaptation based on specific radiology and surgery preferences, fostering a collaborative environment between radiology and surgery, and ultimately improving patient care.
PMID: 36871233
ISSN: 2366-0058
CID: 5428752

Rectal and perirectal CT findings in patients with monkeypox virus infection

Ola, David; Dane, Bari; Shanbhogue, Krishna; Smereka, Paul
OBJECTIVE:To analyze the findings of proctitis in patients with laboratory-confirmed Mpox and correlate the patient clinical presentation and laboratory findings. METHODS:21 patients with PCR-positive Mpox who obtained abdominopelvic CT were retrospectively identified by electronic medical record search. Three radiologists independently evaluated CT images, measuring rectal wall thickness (cm), degree of perirectal fat stranding on a 5-point Likert scale, and size of perirectal lymph nodes (cm, short axis). Mann-Whitney U-test (Wilcoxon rank sum test) was used to assess the association of rectal wall thickness and perirectal fat standing between patients with rectal symptoms and patients without rectal symptoms. RESULTS:20 of 21 patients presented with perirectal fat stranding, with mean Likert score of 3.0 ± 1.4, indicating moderate perirectal stranding. Mean transverse rectal wall thickness was 1.1 ± 0.5 cm (range 0.3-2.3 cm); it was thicker among patients with HIV (1.2 cm vs 0.7 cm; p = .019). Mean perirectal fat stranding was greater among patients presenting with HIV, and with rectal symptoms, though not significantly so. 17/21 (81%) patients had abnormal mesorectal lymph nodes by at least two of three readers, with mean short-axis measurement 1.0 ± 0.3 cm (range 0.5-1.6 cm). Multiple linear regression showed no significant correlation between rectal thickness and laboratory values or HIV status. CONCLUSION/CONCLUSIONS:Nearly all patients with Mpox who presented with additional symptoms warranting a CT demonstrated proctitis. Degree of proctitis varied greatly within the cohort, with greatest thickening among patients with HIV. Physicians should have a high suspicion for proctitis in patients with suspected Mpox.
PMID: 37148320
ISSN: 2366-0058
CID: 5472462

How We Got Here: The Legacy of Anti-Black Discrimination in Radiology

Goldberg, Julia E; Prabhu, Vinay; Smereka, Paul N; Hindman, Nicole M
Current disparities in the access to diagnostic imaging for Black patients and the underrepresentation of Black physicians in radiology, relative to their representation in the general U.S. population, reflect contemporary consequences of historical anti-Black discrimination. These disparities have existed within the field of radiology and professional medical organizations since their inception. Explicit and implicit racism against Black patients and physicians was institutional policy in the early 20th century when radiology was being developed as a clinical medical field. Early radiology organizations also embraced this structural discrimination, creating strong barriers to professional Black radiologist involvement. Nevertheless, there were numerous pioneering Black radiologists who advanced scholarship, patient care, and diversity within medicine and radiology during the early 20th century. This work remains important in the present day, as race-based health care disparities persist and continue to decrease the quality of radiology-delivered patient care. There are also structural barriers within radiology affecting workforce diversity that negatively impact marginalized groups. Multiple opportunities exist today for antiracism work to improve quality of care and to apply standards of social justice and health equity to the field of radiology. An initial step is to expand education on the disparities in access to imaging and health care among Black patients. Institutional interventions include implementing community-based outreach and applying antibias methodology in artificial intelligence algorithms, while systemic interventions include identifying national race-based quality measures and ensuring imaging guidelines properly address the unique cancer risks in the Black patient population. These approaches reflect some of the strategies that may mutually serve to address health care disparities in radiology. © RSNA, 2023 See the invited commentary by Scott in this issue. Quiz questions for this article are available in the supplemental material.
PMID: 36633971
ISSN: 1527-1323
CID: 5410492

Accelerated T2-weighted MRI of the liver at 3 T using a single-shot technique with deep learning-based image reconstruction: impact on the image quality and lesion detection

Ginocchio, Luke A; Smereka, Paul N; Tong, Angela; Prabhu, Vinay; Nickel, Dominik; Arberet, Simon; Chandarana, Hersh; Shanbhogue, Krishna P
PURPOSE/OBJECTIVE:Fat-suppressed T2-weighted imaging (T2-FS) requires a long scan time and can be wrought with motion artifacts, urging the development of a shorter and more motion robust sequence. We compare the image quality of a single-shot T2-weighted MRI prototype with deep-learning-based image reconstruction (DL HASTE-FS) with a standard T2-FS sequence for 3 T liver MRI. METHODS:41 consecutive patients with 3 T abdominal MRI examinations including standard T2-FS and DL HASTE-FS, between 5/6/2020 and 11/23/2020, comprised the study cohort. Three radiologists independently reviewed images using a 5-point Likert scale for artifact and image quality measures, while also assessing for liver lesions. RESULTS:DL HASTE-FS acquisition time was 54.93 ± 16.69, significantly (p < .001) shorter than standard T2-FS (114.00 ± 32.98 s). DL HASTE-FS received significantly higher scores for sharpness of liver margin (4.3 vs 3.3; p < .001), hepatic vessel margin (4.2 vs 3.3; p < .001), pancreatic duct margin (4.0 vs 1.9; p < .001); in-plane (4.0 vs 3.2; p < .001) and through-plane (3.9 vs 3.4; p < .001) motion artifacts; other ghosting artifacts (4.3 vs 2.9; p < .001); and overall image quality (4.0 vs 2.9; p < .001), in addition to receiving a higher score for homogeneity of fat suppression (3.7 vs 3.4; p = .04) and liver-fat contrast (p = .03). For liver lesions, DL HASTE-FS received significantly higher scores for sharpness of lesion margin (4.4 vs 3.7; p = .03). CONCLUSION/CONCLUSIONS:Novel single-shot T2-weighted MRI with deep-learning-based image reconstruction demonstrated superior image quality compared with the standard T2-FS sequence for 3 T liver MRI, while being acquired in less than half the time.
PMID: 36171342
ISSN: 2366-0058
CID: 5334382

Factors affecting MRI scanner efficiency in an academic center

Smereka, Paul; Weng, Jonathan; Block, Kai Tobias; Chandarana, Hersh
PURPOSE/OBJECTIVE:To determine which patient characteristics influence MRI scan time and how. METHODS:A database search of outpatient MRI liver examinations on 1.5T and 3T scanners from 1/1/2019 to 4/4/2019 was performed using an in-house developed software tool. Mean and median scan times were calculated. Patients who had difficulty following breathing instructions or completing breath-hold sequences were identified. Twenty-one additional patient characteristics were obtained from an Electronic Medical Record (EMR) search. RESULTS:Scan times were significantly increased for patients with breath-holding issues during the exam (N = 43, median = 23.98 min) versus not (N = 179, median = 17.5 min, p < 0.001). Among patients who had difficulty following breathing instructions/completing breath-hold sequences, a significant number were non-native English speakers (23/43, 53%) compared to those whose first language was English (48/179, 27%, p < 0.001). Breath-holding issues were also significantly more frequent for patients requiring a translator during the exam (15/43, 35%) versus those who did not (24/179, 13%, p < 0.001). No other patient characteristics showed a significance difference between those with breathing issues and those without. Patient characteristics that caused a significant number of scan times to be one standard deviation or more above the median were as follows: Breath-holding issues during exam (21/43 ≥ one SD above, 51%, versus 22/189 < one SD above, 12%, p < 0.001); and first language not English (16/71 ≥ one SD above, 23%, versus 55/189 < one SD above, 29%, p = 0.03). CONCLUSION/CONCLUSIONS:The ability to follow breathing instructions and complete breath-hold sequences had a significant impact on patient scan time. Patients who were not native English speakers had more frequent breathing issues during scans and significantly longer scans times compared native English speakers.
PMID: 35918543
ISSN: 2366-0058
CID: 5287982

Correlation between imaging findings on outpatient MR enterography (MRE) in adult patients with Crohn disease and progression to surgery within 5 years

Dane, Bari; Qian, Kun; Krieger, Rachel; Smereka, Paul; Foster, Jonathan; Huang, Chenchan; Chang, Shannon; Kim, Sooah
PURPOSE/OBJECTIVE:To retrospectively evaluate which key imaging features described by SAR-AGA on outpatient surveillance MRE correlate with progression to surgery in adults with CD. METHODS:52 CD patients imaged with outpatient MRE from 10/2015 to 12/2016 and with available clinical information were included. Two abdominal radiologists reviewed the MRE for the presence of active inflammation, intramural edema, restricted diffusion, stricture, probable stricture, ulceration, sacculation, simple fistula, complex fistula, sinus tract, inflammatory mass, abscess, perienteric inflammation, engorged vasa recta, fibrofatty proliferation, and perianal disease. Bowel wall thickness, length of bowel involvement, and degree of upstream dilation in strictures were quantified. Subsequent bowel resection, prior bowel surgery, and available laboratory values were recorded. The association between progression to surgery and imaging features was evaluated using a logistic regression model adjusting for demographics, prior bowel surgery, medication usage, and body mass index. RESULTS:19.2% (10/52) of patients progressed to surgery. Restricted diffusion, greater degree of upstream dilation from stricture, complex fistula, perienteric inflammation, and fibrofatty proliferation were significantly more common in patients progressing to surgery (all p < 0.05). κ for these significant findings ranged 0.568-0.885. Patients progressing to surgery had longer length bowel involvement (p = 0.03). Platelet count, ESR, and fecal calprotectin were significantly higher, and serum albumin was significantly lower in patients progressing to surgery. Prior bowel surgery, sex, age, and all other parameters were similar. CONCLUSION/CONCLUSIONS:Radiologists should carefully describe bowel dilation upstream from strictures, penetrating and perienteric findings on outpatient MRE in CD patients, as these findings may herald progression to surgery.
PMID: 35916941
ISSN: 2366-0058
CID: 5286132