Emergency Radiology最新文献

Background: Appropriate utilization of imaging in the emergency department (ED) remains an important determinant of health care expenditures and patient throughput. LLMs have demonstrated potential as clinical decision support tools, and may aid in cost-conscious imaging triage in the ED. We aim to evaluate the effectiveness of LLMs in providing accurate, cost-conscious imaging recommendations for ED patients with lower back pain.

Methods: 422 patients presented between December 2017 and June 2018 to the ED of a ~ 1000-bed major urban academic medical center with a chief complaint of lower back pain and received a lumbar spine MRI. The primary outcomes were Hoy et al. (Best Pract Res Clin Rheumatol 24(6):769-781, 2010) alignment of Generative Pre-Trained Transformer 4 (GPT-4)-generated imaging recommendations with ACR criteria, by raw accuracy and Cohen's κ, and Hoy et al. (Arthritis Rheum 64(6):2028-2037, 2012) professional service resource utilization quantified in work relative value units (wRVUs) under real-world clinical decisions, GPT-4 recommendations, and hypothetical 100% ACR adherence scenarios. GPT-4 was compared with real-world clinical decisions for imaging of lower back pain based on ED triage notes. Resource utilization was analyzed to assess potential savings from GPT-4 recommendations.

Results: GPT-4 model generated ACR-concordant recommendations for 72.0% (304/422) of cases and demonstrated significant alignment with ACR criteria as measured by Cohen's κ (0.42,95% CI: [0.35,0.48], p < 0.05). Actual resource utilization was 629 wRVUs. GPT-4 would have used 481.74 wRVUs. 100% adherence to the ACR criteria would have used 481.86 wRVUs.

Conclusions: Our results support LLMs as possible tools for cost-conscious radiologic decision making in ED back pain evaluation.

Background: In this study, we examined the potential role of V/Q scintigraphy in distinguishing acute PE (APE) from chronic PE (CPE).

Materials and methods: From 2020 to 2023, 36 patients diagnosed with APE and 24 patients diagnosed with CPE were included in the study. Location (segmental, subsegmental, lobar), number and appearance (wedge/patch) of mismatch perfusion defects on V/Q scintigraphy were recorded, and data were compared between the two groups.

Results: The number of mismatch segmental defects on V/Q scintigraphy was higher in the APE group (p = 0.042). The number of wedge-shaped defects was higher in the APE group (p = 0.003), while patchy defects were more common in the CPE group (p < 0.001). A negative correlation (p = 0.002) was observed between CPE and the number of wedges, whereas a positive correlation (p < 0.001) was found between CPE and the number of patches. Pulse oxygen saturation negatively correlated with the number of patches (p = 0.012). A negative correlation also existed between the number of mismatch segmental defects and CPE (p = 0.041). APE was indicated when the number of wedges was ≥1.5 (75% sensitivity,62% specificity, p = 0.03), while CPE was indicated when the number of patches was ≥0.5 (88% sensitivity, 61% specificity, p < 0.001). Patchy defects were found to be an independent risk factor for CPE (p = 0.008, OR: 2.1, 95% CI: 1.2-3.7).

Conclusion: Patchy defects serve as an independent risk factor for CPE and correlate with the severity of hypoxemia.

Purpose: To understand the afterhours radiology workforce and views towards imaging volumes, compensation, overnight challenges, and work-from-home.  METHODS: Survey questions focusing on the afterhours radiology workforce were created. The survey was administered by the American College of Radiology (ACR) and the data analysis performed by the ACR in partnership with an independent market research agency. The confidence level was set at 95%, with an error rate of +/- 2.2%.  RESULTS: A total of 1109 out of 1844 (60.1%) survey participants responded to the afterhours survey. A majority of respondents (56%) had worked an afterhours shift while a minority had worked a late-evening (18%) or overnight shift (13%). Irrespective of practice type, the majority of radiologists thought afterhours volumes were not manageable, and afterhours compensation was not equitable. Less than half of those who worked overnight shifts believed they were given adequate compensatory time-off for recovery. The majority of respondents supported work-from-home for afterhours shifts.

Conclusions: As the largest survey to date on after-hours radiology, these findings should be carefully considered by practices aiming to successfully recruit and retain radiologists in this critical niche.

Orthopedic surgery is the most common intervention performed on the lower limb. Although rare (0.005-0.5%), the incidence of iatrogenic arterial injuries is increasing due to the rising use of prosthetic implants and broader surgical indications in aging populations. Imaging findings are diverse and include hemorrhage, pseudoaneurysm, hemarthrosis, endomedullary bleeding, retraction-induced microvascular injury, stenosis, and occlusion. However, evaluation is often complicated by artifacts from metallic hardware. This pictorial review illustrates the radiological spectrum of these injuries, offers practical tips to optimize imaging quality, and proposes a structured algorithm to guide timely and effective diagnosis and management.

Purpose: To evaluate the diagnostic utility of bile duct attenuation measured on contrast-enhanced computed tomography (CT) in differentiating choledocholithiasis, malignant biliary obstruction, benign biliary obstruction, and cholangitis.

Methods: This retrospective study included 208 patients who underwent contrast-enhanced abdominal CT followed by endoscopic retrograde cholangiopancreatography (ERCP) within three days. Intraductal bile attenuation was measured using two region of interest (ROI) techniques (elliptical and 4-point), with all measurements obtained strictly from bile-filled ductal segments. Secondary morphologic features were also assessed. Diagnostic performance was evaluated using receiver operating characteristic (ROC) analysis, and multivariate logistic regression identified independent predictors of malignancy.

Results: Mean attenuation values were significantly higher in malignant obstruction and choledocholithiasis than in benign biliary obstruction and cholangitis (p < 0.001). For malignant obstruction, the 4-point method yielded 96% sensitivity and 81% specificity at a cut-off of ≥ 29 HU (AUC: 0.97), while the elliptical method yielded 100% sensitivity and 80% specificity at ≥ 60 HU (AUC: 0.95). Elliptical ROI attenuation and bile duct wall thickness were independent predictors of malignancy (p = 0.010 and p < 0.001, respectively). Interobserver agreement was excellent for both techniques (ICC > 0.89).

Conclusion: When measured strictly within bile-filled ductal segments, CT-based attenuation provides useful quantitative information for differentiating common causes of biliary obstruction. Combined with ductal wall thickness and secondary morphologic features, attenuation analysis may enhance the diagnostic value of routine contrast-enhanced CT, particularly in settings where advanced imaging modalities are limited or delayed.

Background: Adnexal torsion diagnosis in children relies heavily on ultrasound, but existing literature lacks standardization of technique and handling of equivocal results.

Purpose: To assess the accuracy of transabdominal ultrasound (US) in diagnosing adnexal torsion in pediatric patients and evaluate optimal clinical decision-making for equivocal US reads.

Materials and methods: Retrospective review of pelvic US exams and surgical data for girls aged 1-18 years from 2015 to 2019 at a pediatric quaternary care hospital. US reports were coded as positive, negative, or equivocal for torsion. Surgical findings were used to confirm final diagnosis. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated under various scenarios for handling equivocal reads.

Results: This study included 4,396 ultrasound exams from 3,707 patients (median age, 15.2 years [IQR: 12.8-16.8]). Ovarian visualization rate was 97-98%. US was read as positive for torsion in 1% of adnexae, negative in 95%, and equivocal in 4%. Among 179 surgical cases, torsion was present in 52%. Sensitivity of US for torsion was highest (86.0%) when equivocal cases were considered positive (EqP), but PPV was lowest (29.9%) under this condition. Area under the ROC curve was greatest (0.8651) when equivocal US were counted as positive. US reads were more likely to be true positive for isolated ovarian torsion compared to when tubal torsion was present (p = 0.003).

Conclusion: A standardized transabdominal US protocol yields high ovarian visualization rates, and treating equivocal reads as positive can optimize diagnostic accuracy when combined with clinical decision-making. US maybe be less accurate in detecting tubal torsion compared to isolated ovarian torsion, but this finding should be interpreted with caution given the small sample size. Overall, these results provide clinically relevant insights to guide management and future research in pediatric adnexal torsion.

Purpose: To assess the appropriateness of emergency department (ED) on-call medical imaging requests and the corresponding radiology reports.

Methods: Two researchers reviewed all CT, MRI, and ultrasound scans ordered from January 1 to December 31, 2022 by ED physicians during on-call hours at a major Canadian hospital network (estimated 2.5 million catchment population). Scan indications were evaluated for: (1) containing any clinical history and (2) providing a clinical question and/or specific differential diagnosis. Radiology report impressions were categorized as either: (1) normal (including chronic and/or stable findings); (2) positive for the clinical question and/or differential diagnosis provided; (3) positive for a condition that could reasonably explain the provided clinical history/question; or (4) only containing incidental findings unrelated to the indication. Inter-rater reliability for the scoring was assessed with the κ statistic.

Results: Among 85,066 scans ordered during ED encounters in 2022, 18,201 met inclusion criteria including 248 (1.4%) MRI, 3587 (19.7%) US, and 14,366 (78.9%) CT scans. Most requests (74.2%) provided clinical history and a differential diagnosis; a minority provided only clinical history (15.0%) or only a clinical question/differential diagnosis (10.7%). Most imaging studies contained only normal or chronic findings (62.0%). Approximately 12.5% of studies were positive for the specified differential diagnosis, 4.1% were positive for a condition that could reasonably explain the provided clinical history/question, and 21.3% identified unrelated incidental findings.

Conclusion: The high percentage of negative scans may be an unavoidable consequence of modern medicine's growing dependence on imaging. However, ensuring that imaging tests are appropriately ordered and automating routine steps of the image acquisition workflow may mitigate strains on radiology departments.

Background: Traumatic brain injury (TBI) is a global health challenge associated with high morbidity and mortality. Non-contrast computed tomography (NCCT) remains the first-line imaging modality due to its accessibility and speed, yet its diagnostic and prognostic utility across diverse populations remains underexplored.

Purpose: To systematically evaluate and quantify the diagnostic accuracy and prognostic value of NCCT in acute TBI patients worldwide.

Evidence acquisition: Following PRISMA 2020 guidelines, a systematic literature search was conducted in PubMed, Embase, Cochrane Library, and Scopus up to April 2025. Studies assessing the diagnostic or prognostic performance of NCCT in acute TBI were included. QUADAS-2 was used for quality assessment. Meta-analyses were performed using random-effects models.

Evidence synthesis: Out of 2,132 articles screened, 41 studies met inclusion criteria, encompassing over 76,000 patients. The pooled sensitivity and specificity for NCCT detecting intracranial hemorrhage were 0.92 (95% CI: 0.89-0.95) and 0.87 (95% CI: 0.82-0.91), respectively. Prognostically, features like midline shift > 5 mm and compressed basal cisterns showed a significant association with in-hospital mortality (OR: 3.6, 95% CI: 2.4-5.1). Subgroup analyses by age, GCS, and scan timing confirmed robust diagnostic consistency.

Conclusion: NCCT demonstrates high diagnostic accuracy in detecting intracranial hemorrhage and offers substantial prognostic insights in acute TBI. It remains a cornerstone imaging tool, particularly valuable in time-sensitive emergency settings.

Clinical impact: NCCT should be prioritized in emergency protocols for early diagnosis and risk stratification in TBI, particularly in resource-constrained environments lacking advanced neuroimaging.

The growing demand for after-hours imaging and rapid turnaround times-particularly for trauma and acute care patients- as well as institutional moves toward requiring finalized attending reports overnight, has intensified reliance on emergency radiologists, leading to increased workloads, shift-related fatigue, and rising burnout rates. This review examines the multifaceted challenges faced by emergency radiologists, including disrupted circadian rhythms, cognitive decline, professional isolation, unpredictable spikes in imaging volume, and physical and psychological health risks. Additional concerns such as gender disparities, medico-legal pressures, and limited opportunities for career advancement further exacerbate these issues. The paper highlights both personal coping strategies and institutional reforms-such as optimized scheduling, improved staffing models, and wellness initiatives-aimed at enhancing job satisfaction, supporting long-term career sustainability, and ensuring high-quality patient care in emergency radiology.

Systemic vasculitides are rare, multi-organ inflammatory disorders involving blood vessels, classified by the size of the affected vessels. When abdominal arteries are involved, diagnosis becomes particularly challenging due to nonspecific symptoms such as fever, fatigue, and abdominal pain, which can mimic other acute conditions and hinder identification in emergency settings. Examples include Takayasu arteritis (large vessels), polyarteritis nodosa (medium vessels), and lupus-associated or drug-induced vasculitis (small vessels), each exhibiting distinct imaging features. Imaging techniques, particularly contrast-enhanced computed tomography (CECT) and computed tomography angiography (CTA), are vital for evaluating acute presentations and identifying characteristic abnormalities. Part 1 of this pictorial essay presents illustrative cases of abdominal vasculitis, incorporating advanced imaging modalities such as CECT, CTA, 3D volume rendering, and 3D cinematic rendering to emphasize key diagnostic features. Early recognition of these imaging findings by radiologists is crucial to ensure accurate diagnosis, guide appropriate treatment, and assess the need for surgical intervention. By enhancing awareness and understanding of these rare vascular pathologies, this review aims to facilitate timely diagnosis, improve clinical decision-making, and optimize patient outcomes.