Right lower lobe pulmonary AVM

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This is an incidental pulmonary AVM in a patient with reported venous sinus thrombosis. Presumably this is related to HHT and another AVM may be implicated in the sinus thrombosis.

https://radiopaedia.org/articles/hereditary-haemorrhagic-telangiectasia

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Beluga whale sign

This elderly patient must have taken a serious header to get that whopper of a forehead and scalp hematoma. Fortunately, there is no intracranial hemorrhage. Just the the usual “brain rot” aka atrophy and underlying chronic ischemic white matter disease.ezgif-5-47bd3735e3

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Beluga whales can change the shape of their hump for use in tuning echolocation,  however, I don’t think elderly patients have that luxury, but wouldn’t it be cool if they did?!

Intestinal Ischemia aka Dead Bowel

The superior mesenteric artery was densely calcified. Although the Iliocolic region is frequently spared in the watershed areas are commonly affected, this unfortunate man had classic findings of intestinal ischemia with pneumatosis coli and portal venous gas extending to the periphery of the liver.

This case also demonstrates the importance of looking for pneumatosis and portal venous gas on the lung windows of the abdomen.

One of the Burlington radiologists employed at Greensboro radiology missed an obvious case of intestinal ischemia at CT that was far worse than this case.

It is important to note that intestinal ischemia is not the only cause of portal venous gas and pneumatosis. This can be associated with COPD and other less malignant causes than intestinal infarction or ischemia.

A common perceptual mistake is not noting the location of the portal venous gas in the liver. Portal venous gas follows the flow of blood to the periphery while pneumobilia goes to the non-dependent portions of the liver and is almost always seen at the porta hepatis even in cases where it is not seen in the common bile duct.

 

 

 

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When the abdomen is viewed on lung windows, the portal venous gas and pneumatosis coli can be seen in the right lower quadrant.

Greensboro Radiology and Martinsville: Lessons Learned

GR contracted to provide subspecialty reads for Martinsville around 2013. Initially there was not much volume but soon a pattern emerged where 4-5 studies were sent around 5pm. Approximately, 20% of these studies had critical values and all of them were “disaster area” cases which were highly complex postoperative spines, epidural abscesses, tumors, necrotizing fasciitis, and even acute stroke.

Adding insult to injury, try getting a physician on the phone for the mandated critical value notification after 5 for a case from Martinsville, VA.

It became a very painful arrangement to which GR leadership was deaf; all they cared for was the RVU, not the inconvenience associated with the cases. As an MSK rad, I could read 3-4 shoulder/knee MRIs in the same time it took to take 1 Martinsville case. We never saw a case of “routine” pathology from them. GR had incentivized the Martinsville radiologists to cherry pick the easy studies while sending anything remotely painful to GR.

Seriously, why wouldn’t you send anything potentially litigious or complex out?  You can be  halfway into a workout or beverage of choice while those poor saps at GR are slogging through your detritus.

From this, I learned that the following are considerations:

  • Right of refusal for a case must be available.
  • A complexity modifier for payment, either based on pathology or technical factors.
  • Increased pay for pre & post studies. Particularly post studies where the pre has been interpreted and the patient called back for contrast, which leads to re-interpretation of the original study. The additional RVU for pre/post is generally 0.5-1 versus a nonconstrast study alone.
  • Collaborative input on protocols.

Spleen Size by Age

Spleen

Ultrasound: Normal Spleen Size vs. Age¹

Age Spleen Length (cm)*
0-3 months ≤ 6
3-6 months ≤ 6.5
6-12 months ≤ 7
1-2 years ≤ 8
2-4 years ≤ 9
4-6 years ≤ 9.5
6-8 years ≤ 10
8-10 years ≤ 11
10-12 years ≤ 11.5
12-15 years ≤ 12
15-20 years (female) ≤ 12 (female)
15-20 years (male) ≤ 13 (male)

*Measurement obtained in the coronal longitudinal plane

References

  1. Rosenberg HK, Markowitz RI, Kolbeg H, et al.  Normal splenic size in infants and children: sonographic measurements.  AJR 1991; 157:119-121.  Table modified and used with permission.

Monteggia fracture dislocation

Typically, Monteggia fracture-dislocations occur as the result of a fall onto an outstretched hand (FOOSH).

The Bado classification is used to subdivide the fracture-dislocation into four types which all have different treatment options and prognoses and is based on the principle that the direction in which the apex of the ulnar fracture points is the same direction as the radial head dislocation 3. The direction of radial head dislocation depends on whether abduction or adduction forces were applied during the fall.

As is usually the case, in everyday practice, describing the fracture-dislocation is far more important than remembering the grade.