Author: Logan Young

Back Report: Interventional rads really rely on diagnostic CT and MRI reporting to plan an effective percutaneous vertebral augmentation. As Dr. Monica Cooley warned during ARRS26, missed details can lead to cement leakage, incomplete pain relief, or severe canal compromise. And it’s often a DR’s own dictations that dictate whether a patient is a candidate for procedure, which access trajectory to choose, and just how much cement to safely infuse.

Critical CT Findings

• Fracture Plane Trajectory: Explicitly detail whether fracture lines extend into the posterior cortex or vertebral endplates. These serve as direct channels for cement migration toward at-risk neural structures.
• Intravertebral Clefts: Report fluid- or gas-filled fracture clefts. Bridging these clefts with cement is critical to eliminate pain-causing instability.
• Pedicle Integrity: Highlight the fractures, as well as underlying lytic lesions. Breached or weak pedicles require switching to a unipedicular approach using a curved cannula to avoid cement extrusion.
• Bony Retropulsion: Note retropulsed fragments causing spinal canal stenosis or cord compression. Retropulsion may disqualify the patient or demand a conservative posterior cement volume to prevent neural injury.

Essential MRI Findings

• Marrow Edema (STIR/T1): Confirm active edema along the fractured endplate, signaling inflammation and unhealed fracture motion.
• Healed vs. Acute: Fractures without marrow edema are considered healed and, generally, do not benefit from vertebral augmentation.
• Underlying Path: ID metastases, plasmacytoma, or epidural extension. Significant canal compromise or tumor involvement may redirect care toward surgical decompression or combined radiofrequency ablation with plasty.

RadFYI: A good diagnostic report becomes a great interventional roadmap. Explicitly calling out fracture planes, pedicle breaches, retropulsion, and STIR edema gives proceduralists the best blueprint for safe and targeted cement fill.

Summary: Evaluate relative complexity against adjacent normal tissue. If it looks identical to—or even simpler than—normal fat and lacks vascularity, your DDX is done.

Where’s Waldo? Subcutaneous lipomas are notoriously easy to miss on cross-sectional imaging because they match the exact density and signal intensity of surrounding tissue. During ARRS26, Dr. Mark Murphey detailed the diagnostic principles he uses to confidently spot subtleties.

• If you don’t see anything within the first 5 milliseconds, you’re almost certainly dealing with a subcutaneous lipoma.
  • And it’s not unlike searching for Waldo—trying to ID fat against a background of fat.

The Monotony of It All! Up to 71% of lipomas consist of simple, monotonous fat with no significant architectural complexity across CT, MRI, or US.

• Compare directly to adjacent normal subcutaneous fat on T1-weighted scans.
• On US, lipomas exhibit echotexture similar to fat and, crucially, show no evidence of significant blood flow on Doppler.

Ask Yourself: Is this lesion more, or less, complex than its counterpart? Normal fat consists of lobules divided by connective tissue septa (grossly, these appear as greasy, monotonous yellow tissue composed of adipocytes uniform in size/shape). Should that mass look less complex than its surroundings, “it can’t be very bad,” Dr. Murphey said.

• Ca. 85% of subcutaneous lesions can be diagnosed by physical exam alone, but rads are increasingly relied upon as the primary examinator.
• Markers placed by techs over the palpable point of concern do wonders for localization.

Summary: Adopting total SVD score in routine practice helps standardize the gauge of cumulative vascular injury, stratifying cerebrovascular and cognitive risks alike.

Four-ward Thinking: Crunching the total cerebral small vessel disease score can evaluate brain health writ large. Cobbling individual neuro markers into one, singular composite serves as a critical prognostic indicator for both dementia and recurrent stroke. And as Dr. Abdel Mahammedi noted during this ARRS Quick Byte video, total SVD ranges from 0 to 4, allocating one point for each of the following four markers:

• Lacunes: Presence of any subcortical lacunar cavities
• Microbleeds: Detection of one or more microbleeds on T2- or susceptibility-weighted MRI.
• EPVS: Observing >20 enlarged perivascular spaces in basal ganglia.
• WMH: Moderate-to-severe Fazekas score of 2 or 3.

Case in Point: Dr. Mahammedi’s high-risk patient exhibited each and every marker; two months later, that patient suffered an acute lacunar infarct, highlighting PPV of high SVD burden.

Summary: Although PVE remains the benchmark and LVD offers rapid growth, radiation lobectomy provides a dual-action option—albeit requiring further trials beyond existing retro data.

Kinetic Growth: When liver surgery candidates require resection but present with an insufficient future liver remnant, augmentation can stimulate contralateral hepatic growth a priori. It all works via the atrophy-hypertrophy complex—inducing atrophy in the diseased lobe while driving compensatory hypertrophy in the remaining segment.

As Dr. Sameer Gadani explained in this ARRS Quick Bytes video, selecting the optimal technique depends on whether the objective is rapid growth, long-standing procedural data, or concurrent tumor control during the hypertrophy phase.

• PVE: Portal vein embolization remains the traditional standard of care due to extensive clinical experience and historical safety data.
• LVD: Liver venous deprivation is the fastest emerging option for liver augmentation and highly safe when clinicians are experienced with embolic glue.
• Radiation Lobectomy: Deploys radioactive embolic beads to flood the target lobe, simultaneously treating the tumor while driving lobar fibrosis and contralateral hypertrophy.
  • A modified technique delivers a targeted high dose directly to the tumor-bearing segment before pulling back to flood the entire lobe, improving local tumor destruction and atrophy efficiency.

Test of Time: Whereas lobectomy needs more time to achieve target hypertrophy, this window acts as a natural filter; rapid tumor progression indicates resection was unlikely to be beneficial.

• Monitoring hypertrophy rate serves is a vital marker for both underlying liver health and overall tumor aggressiveness.

Summary: Timing determines outcome. When rads recognize subclinical involvement early and proceed to peds specialists, long-term functional outcomes improve dramatically.

Quiet Confidence: For JIA patients, the absence of symptoms doesn’t exclude active disease. A trio of what Dr. Hamza Alizai dubbed “clinically silent” joints in his ARRS Quick Bytes video harbor inflammation that only MRI can reliably detect.

• Cervical Spine: Early presentations of subtle edema in the dorsal aspect of the odontoid process on MRI (and dorsal dens erosions on CT), alongside facet joint inflammation.
  • Unchecked inflammation risks progression to severe atlanto-axial joint fusion.
• Sacroiliac Joints: Sacroiliitis remains an established marker of poor overall prognosis in JIA, leading to routine orders for screening MRI.
• Temporomandibular Joint: Since asymptomatic synovitis is so widespread, rheumatologists maintain an exceptionally low threshold for requesting TMJ MRI during everyday evals.

JIA fundamentally alters joint development, making early detection vital to preventing debilitating long-term sequelae. And because physical exams frequently fail to uncover subclinical synovitis in deep or complex articular structures, MRI—US, too—is essential to ID disease long before irreversible damage manifests on radiographs.

Numbers Game:

• 40%–87% of TMJ MRIs demonstrate positive findings in JIA, regardless of whether active symptoms are reported.
• 71% of JIA patients with active TMJ synovitis are completely asymptomatic.
• ~33% of patients suffer from sacroiliitis, with the highest prevalence seen in enthesitis-related arthritis and psoriatic subtypes.

Summary: Categorizing pancreatic cysts into benign, surgical, or surveillance buckets streamlines care and prevents unnecessary workups. Focus on key discriminators: demographics, location, central vs. peripheral calcification, rim enhancement, and ductal communication.

Pail Comparison: Subtyping allows rads to quickly bucket these cysts into one of three actionable management categories: clearly benign (stop workup), concerning with malignant potential (surgical consult), or non-specific (surveillance). Rather than getting bogged down by extensive differentials, as Dr. Chenchan Huang tipped us to at ARRS26, clinical workflow relies on mastering five core subtypes:

1. Serous Cystadenoma (SCA)—Clearly Benign
   • Classic honeycomb appearance composed of tiny microcystic foci, occasional larger peripheral lacules, and central coarse calcification or T2-hypointense scar.
   • Smooth, thin, enhancing internal septa on post-contrast.
   • Entirely benign and remains stable over years; however, large lesions in pancreatic head can compress main duct, causing upstream parenchymal atrophy or mild biliary dilation.
2. Mucinous Cystic Neoplasm (MCN)—Concerning
   • Occurs almost exclusively in middle-aged women (contains ovarian stroma) and is nearly always located in pancreatic body or tail.
   • Thickened outer wall, thin internal septations, and peripheral/mural calcification (differentiating it from SCA’s central calcification).
   • Warrants surgical consultation due to possible malignancy.
3. Cystic Neuroendocrine Tumor (NET)—Hyperenhancing Rim
   • Demonstrates distinct hyperenhancing outer rim on post-contrast scan.
   • Shows intense tracer uptake on 68Ga-DOTATATE.
   • Tends to follow favorable, indolent course.
4. Solid Pseudopapillary Neoplasm (SPN)—Malignant Potential in Young Females
   • Typically presents in women in their 20s.
   • Large, complex mass with mixed solid and cystic components, septations, and internal hemorrhage showing high signal intensity on T1 fat-saturated MRI.
   • Undergoes surgical resection due to malignant potential.
5. Branch Duct IPMN (BD-IPMN)—Presumed Non-Specific
   • Highly common, increases with age, and frequently multifocal. Classically forms a cluster of grapes or tubular fluid configuration.
   • High-quality MRCP frequently confirms direct communication with main pancreatic duct.
   • When non-specific in appearance, routine surveillance suffices.

Summary: Whereas lumen-only looks show overlapped narrowing in both conditions, high-res, contrast-enhanced VWI reveals fundamental differences in wall thickening, enhancement, as well as temporal persistence.

Against the Wall: Having to differentiate CNS vasculitis from reversible cerebral vasoconstriction syndrome (RCVS) is as common as it is critical. “That one comes up a lot,” Dr. Hediyeh Baradaran noted in her ARRS Quick Bytes video. Thankfully, intracranial vessel wall imaging (VWI) exists to aid in your DDX.

• Vasculitis
  • Enhancement & Thickening: Characterized by concentric vessel wall enhancement and marked wall thickening.
  • Longitudinal Persistence: Both arterial narrowing and contrast enhancement persist across multiple follow-up exams.
  • Remodeling Pattern: Typically demonstrates a higher negative remodeling index.
• RCVS
  • Enhancement & Thickening: Shows multifocal arterial irregularities with no enhancement (or only rare, subtle wall thickening without significant contrast uptake) on pre- and post-contrast VWI.
  • Longitudinal Resolution: Arterial narrowing does not persist over time, resolving on repeat imaging—“as the name implies,” said Dr. Baradaran.

Summary: Your primary objective when raising suspicion of IPV isn’t to force a confession or urge patients to get out. Instead, it is to provide repeated, safe opportunities so patients can recognize their circumstances, avail themselves of resources, and make decisions on their own timeline.

Turn, Turn, Turn: Imagers tend to treat IPV disclosure like a pathology report, expecting confirmation as soon as findings get flagged. When a patient denies abuse, it’s easy to feel disappointed or assume the assessment was incorrect.

In Episode 4 of the AJR Podcast Series on Extreme Radiology, Dr. Bharti Khurana spoke with hosts Drs. Lindsey Negrete and Amy Maduram about framing disclosure not as one, singular outcome, but rather as opening a too tight “pickle jar.” Each safe, compassionate conversation loosens that lid until your patient is finally ready and empowered to seek support.

• Team Effort: Opening a stubborn jar requires passing it from person to person.
  • The provider who hears that ultimate disclosure didn’t work alone—every preceding interaction turned the lid just a little bit further.
  • And even if a patient declined today, creating a supportive opportunity will help that lid loosen for tomorrow.

Obstacles to full disclosure are legion. Patients may not even ID their situation as IPV, much less realize that health care systems offer confidential resources.

• Concerns regarding safety, children, housing, financial security, or immigration status often compel the quiet.

Summary: The dark side of oral contrast offers a sharper, unambiguous window into GI disease—enhancing spatial visualization, optimizing radiation dosage, and uncovering hard-to-spot abdominal lesions.

Light in the Darkness: Traditional contrast too frequently obscures or imitates. Positive oral agents can hide hypervascular tumors or simulate GI bleeding, whereas the neutral water-like ones tend to blend in with bladder biology. More radiolucent than water and soft tissue, albeit less so for pure bowel gas, dark oral contrast agents provide a distinct attenuation profile—600 to −40 HU—that stands out. Clearly, said Benjamin Yeh, MD, in this ARRS Quick Bytes video.

Better Bowel Bets: Pure gas causes volume averaging artifacts and loss of mucosal detail, while dark agents provide just enough attenuation contrast to delineate fine mucosal folds sans blur.

• Maximizing Yeh’s “delta HU” against surrounding tissue, dark agents dramatically improve conspicuity for both hypervascular lesions and hypodense masses.
• Their uniqueness better detects bowel wall ischemia, abscesses, and enhancement subtleties (without confusion via IV contrast or intraluminal contents).
• Dark agents reduce bowel motion artifacts and lower radiation by optimizing automated exposure control systems.

Stay Tuned! Currently in Phase 2 clinical trials, these agents are advancing toward FDA, as well as EMA, review.

• Promising experiments include dark borosilicate suspensions, xanthan and egg albumin foams, and lipid/paraffin emulsions.

Summary: Expanding your search field from nipples to knees ensures accurate diagnosis, helping athletes avoid unnecessary surgery and return to peak competition faster.

Mimic Me: Athletic groin pain is oft misattributed to the classics—a hernia or lesion that delays return-to-play or speeds up surgical referral. In pro sports especially, the concept of the core extends far beyond the pubic symphysis—from the nipples to the knees, front and back, Adam C. Zoga, MD, reiterated at ARRS26. Did that MRI at the pubic symphysis come back negative? Time to evaluate your surroundings…

• Tennis Tear: Forceful contraction during the follow-through of an overhand serve can cause lower rectus abdominis tears.
• Knee to Know: An NFL quarterback diagnosed on the field with pubalgia actually suffered a distal adductor strain further down the thigh (requiring 2 weeks rest, instead of surgery.)
• Outfielder’s Back: A rare quadratus lumborum strain caused by tracking fly balls, presenting as diffuse pelvic pain.
• Weird Flex: A gymnast with suspect hernia was found to have a grade 2 iliacus muscle strain. Sartorius strains masquerade as core injuries, too.
• Hip Pointer: Direct impact to the anterior pelvis in quarterbacks, which represents an external oblique avulsion.
• SuperSonics: An NBA player flown across the country for specialized core surgery really had a rectus femoris avulsion from the AIIS.

Because standard pelvic protocols are blinded on the periphery, Dr. Zoga moves the phase-array torso coil directly over the localized area of maximal pain, rather than centering strictly on the pubic symphysis.

• Run both fat-suppressed and non-fat-suppressed sequences to delineate subtle avulsions and straining.

Postop Points:

• Aponeurotic Reinforcement: Verify structural support along the lateral margin of the rectus abdominis and external oblique aponeurosis.
• Cleft Sign & Osteitis Pubis: Confirm size reduction of the former, as well as improvement in the latter.
• Adductor Hematoma? If an adductor muscle release was performed, don’t be surprised to see a hematoma within that compartment.

Summary: Looking beyond non-specific LV hypertrophy, confirm post-contrast timing before diagnosing “myocardium-first” darkening.

Heart of Darkness: Noting myocardial involvement, characterizing LGE, measuring disease extent parametrically—CMR creates clarity for cardiac amyloidosis. Classically, Dr. Matthew D. Cham said at ARRS26, cardiac amyloidosis presents with concentric LV hypertrophy on initial cine or SSFP imaging.

• The Catch? Concentric LV hypertrophy is highly non-specific and easily mimics commoners (e.g., systemic hypertension).
• Cham’s Solution: Contrast kinetics vis-à-vis specialized sequence.

TI Scout: The Look-Locker sequence provides key contrast kinetics by observing the order of tissue nulling:

• Normal: Cavity nulls first; myocardium nullification afterwards.
• Amyloidosis: Myocardium nulls first, then the lumen darkens.

Patchy Involvement: When amyloid deposition is focal or non-uniform, distinguishing normal from diseased becomes quite challenging.

• And if a tech accidentally runs Look-Locker before contrast injection, healthy myocardium will null first—creating false-positive “amyloid pattern” in otherwise normal patient.