Author: Logan Young

_{Published March 1, 2022}

“This pandemic is really getting me down… I’m not sleeping well… Small things worry me constantly… My concentration drifts while interpreting studies… Antacids are taking care of my epigastric symptoms… Alcohol has become a necessary crutch to help me sleep… Everybody seems so needy around me… The media is driving me insane… The sense of loss overwhelms me at times… I cannot bear the thought of more Zoom meetings…”

Resilience. It’s a concept that predates the pandemic and one that we’ve heard about in personal development books, TED Talks, and leadership courses many times before. The word conjures a sense of unshakeable inner strength that’s impermeable to outside forces, like a giant African baobab tree—also known as the continent’s “tree of life”—during a torrential storm. You might define resilience as the capacity to recover and bounce back from adverse circumstances, such as those many of us are currently experiencing, as illustrated by the sampling of comments above.

It often feels like the pandemic swiftly derailed the pre-2020 tools and strategies we had introduced to our organizations to identify and combat employee burnout and support the collective health and wellness of our teams. While stressors have expanded and amplified, the concepts that were leading us on a path to healthier workplaces are still valid and valuable, particularly when it comes to resilience. With intention, practice, patience, and persistence, resilience can be learned, sustained, and strengthened; with resilience, we can emerge from our proverbial emotional basements, even during the most turbulent of weather.

Opening the Cookbook

While it’s not quite as simple as following a step-by-step recipe for your favorite meal, several key ingredients can help you develop resilience. Let’s explore 10 of them here.

1. Take care of yourself, first and foremost: If you’re a leader, remind yourself of the airline analogy to put on your own oxygen mask first. Learn to practice mindfulness to slow down and reduce anxiety. Learn to focus on being intensely aware of your senses and feelings in the moment, without interpretation or judgment. Be mindful, too, that you may be using unhelpful coping solutions. Try to eat healthily, sleep to rejuvenate, and exercise as best as you can, wisely. Doing so should boost your capacity for physical resilience. Consider strategies to boost your mental resilience, as well. How do you reignite your energy and creativity after challenging situations? Are you able to effectively disconnect? Build time into your schedule to recharge. Develop coping skills to help you manage stress, so that it doesn’t compound. One example of a valuable coping mechanism is laughter, which can reduce anxiety and increase our intake of fresh oxygen. Try to find ways to laugh each day, as part of your self-care practice. You can even find laughter yoga exercises on YouTube.
2. When something is not quite right, recognize, acknowledge, and call it what it is: Stress. Anxiety. Overwhelm. Depression. PTSD. Whether it is a formal diagnosis from a care provider or a gut instinct that you have, it’s OK not to be OK. The pandemic is amplifying our national mental health crisis. Recognize and mourn your losses, no matter how big or small you think they are. Communicate openly and honestly about your current state of mind; don’t minimize or ignore your symptoms until they become intolerable. Share your concerns with your primary care provider, a licensed therapist, a trusted family member or friend, or a 24/7 hotline. If you are in a potentially life-threatening situation, call 911, or go to your nearest emergency room. Opening up and asking for help can be terrifying, but you are worth it. No one is alone here. Seek the support and care that you deserve and need.
3. Find your sense of purpose: Develop your personal W-H-Y? Find intentional ways to connect to your larger life purpose and learn to savor them. What are your volunteer efforts? What does your charitable giving list look like? Altruism drives a sense of purpose and is a recognized trait of resilient individuals. Try to integrate your work and life effectively for you. Strive to be a realistic optimist and, rather than focusing on the negative, hone in on what you can contribute to your community, region, state, or country.
4. Get connected: Establish and nurture a supportive social network. Who comprises your safety net? Whose safety net are you in? Help others to support and nourish you by building a social resilience community. Never be afraid to lean on your support systems, even if virtually. How did you build your support group? Do you have an online community? Develop positive and trusting relationships in which you can work together to endure and recover from stressors. By listening and hearing, we can be kind and compassionate to others when they need it most. Do a proverbial mitzvah!
5. Find your resilience role models: On a personal level, I derive such joy and inspiration experiencing the resilience of my immediate family members. As a South African, it will also never cease to amaze me when I consider the remarkable resilience shown by Nelson Mandela. His endurance and persistence in the face of severe adversity were coupled with his ability to show emotional regulation, empathize, build connections, demonstrate self-efficacy, and stick to his guiding moral compass through authenticity. His favorite poem was “Invictus,” written by William Henley, which ends with the powerful line, “I am the master of my fate / I am the captain of my soul.”  
6. Seek to constantly learn and improve: Be coachable and seek feedback that you learn from and act upon. Seek this feedback from those sources most likely to be helpful to you. Recognize that change can be good, however inconvenient or uncomfortable. View so-called “failures” as learning and improvement opportunities and embrace them; activate your action plan, rather than dwelling on what might have been.
7. Know what emotional intelligence looks like: Practice self-awareness by knowing your stress levels and noticing your emotions. Train your brain—build emotional intelligence, moral integrity, and physical endurance. To boost your emotional resilience, work on understanding, appreciating, and regulating your emotions, while consciously choosing your feelings and responses to avoid being reactive. Learn to become self-aware. This includes recognizing what drives your stressors. What pushes your buttons? Finding and sticking to your moral center may aid this journey.   
8. Find ways to relax and decompress that work for you: Some examples include spending time with friends, pursuing hobbies, cooking, meditating, and listening to music. Each of these can be enjoyed in groups or individually, depending on what you prefer. As one example, photography is an art that can be practiced in mindful ways, shared with colleagues, and even used as a communication and connection tool. It might even influence your choice of travel locations and online connections. Surround yourself with positive energy. Misery doesn’t love company—find new ways to manage or even avoid adversities and adversaries. Have an executable plan to eliminate your blockages.
9. Practice gratitude and self-compassion: Hardwire this into your daily activities list; it will help you to feel content. This might simply include journaling things that you are grateful for. You already possess a series of resiliency tools and have likely overcome adverse situations that you learned from. Your journey has already begun, and you have endured 100% of your worst days. Congratulate yourself for this.
10. Reflect: This can go hand-in-hand with journaling. Simply put, sit quietly with the events and feelings of the day and see what comes up. Committing to creating the time for reflection allows one to build and increase self-awareness (an important component of emotional intelligence), encourages learning, and opens doors to being more adaptable. For events that occur, consider what happened, how it made you feel, and what lessons or new approaches you learned from the experience.

Sharing the Recipe

As a leader, your resilience impacts your performance, as well as the performance and engagement of your teams. Stressed leaders engage in fewer positive leadership behaviors, such as enunciating optimistic visions, setting and overseeing goals, communicating confidence, clarifying roles, showing genuine appreciation, and recognizing performance. Stressed leaders can become passive—they step in only when needed, tend to avoid decision-making, and can be emotionally absent. These attributes get noticed and impact teams. Resilient leaders can keep calm under pressure and develop additional skills (a component of posttraumatic growth) in the face of adversity. Through self-reflection and feedback, resilient leaders have a keen sense of the main components of emotional intelligence.

Resilient leaders can also regularly assess their leadership effectiveness and styles, more readily responding to change and unexpected situations. Striving to learn and grow continuously, resilient leaders are often purpose-driven individuals—they can visualize their work effort as being meaningful. Resilient leaders cultivate relevant and helpful relationships in their internal and external work environments that support them through tough times.

Why Is Resilience at Work Important?

Resilience shapes the way employees respond to the stress of change. It also relates to work engagement, job satisfaction, and organizational commitment. Resilience is inversely related to the frequency and manifestations of burnout and can improve organizational and employee performance.

How Do We Recognize Resilient Behaviors in Others?

A spectrum of characteristic behaviors and skills is recognized under the resilience rubric. Many of these are also included under a larger umbrella of effective leadership behaviors. A person who manifests resilient behavior communicates clearly, thoughtfully, and consistently. Moreover, effective leaders may design a strategy for communicating and managing change that accounts for different stakeholders and their communication preferences. Resilient individuals are coachable, regardless of their position in a hierarchy, and many seek opportunities for learning and improvement. They are willing to embrace change, and, ideally, they’re skilled at managing it. Resilient individuals are comfortable saying, “I don’t know” (and “I would like to learn”). They know how and when to take bold risks or when to initiate new ideas. Similar to effective leaders, resilient individuals are willing to and do invest in the development and advancement of others.

Those with high levels of resilience are better equipped to cope with stressful situations. They tend to see change as an opportunity, are optimistic, adaptable, and realistic about realities, and engage colleagues for support. Resilient individuals possess emotional regulation skills and don’t allow stress to impede their functioning. They practice self-compassion to reduce harsh self-criticism, soothe difficult emotions, and find sources of motivation. Resilient individuals show cognitive agility, a difficult skill to develop, which entails shifting how one thinks about negative situations.

Let’s face it: It’s really difficult learning to become resilient. It takes time, persistence, effort, commitment, energy, and a drive to succeed. We do know that resilient teams are best served by resilient leaders. Now more than ever before, we need our imaging teams to function effectively. Our teams should be equipped with resilience to face ever-changing challenges and unanticipated adversities, and whether they are or not begins with us as leaders.

What do you think? Tell us about your favorite resilience strategies and other interests. How do you nourish your mind and combat fatigue? How do you create mental breaks during the day? I’d love to hear from you: jkruskal@bidmc.harvard.edu.

_{Published March 1, 2022}

Presented as a featured Sunday Session at the 2022 ARRS Annual Meeting, “Cranial Nerve Imaging: From the Least to the Last” is specifically designed to explore the approaches to evaluating different symptomatology arising from cranial nerve pathologies.

Our sense of olfaction is a vital contribution to how we experience the world, both as the sense of smell and as a strong provider to the experience of “taste.” This session will investigate olfaction from sensory bodies in the olfactory mucosa to the olfactory cortex, along with an evaluation of the myriad causes of anosmia and dysosmia.  

Hearing loss can be caused by diseases of the external, middle, or inner ears leading to either a conductive, sensorineural, or mixed dysfunction. Imaging plays a central role in the management of these conditions by providing important diagnostic clues and detailed information to help medical and/or surgical treatment. This session offers an overview of these disease conditions and discusses important points that assist diagnosis. 

The facial nerve can be affected by a number of central and peripheral pathologies that result in weakness or paralysis of the facial musculature. Detailed knowledge of the normal course of the facial nerve is essential to recognize various pathologies. During “Cranial Nerve Imaging: From the Least to the Last,” we will review the complex imaging anatomy of the facial nerve in the brainstem, temporal bone, and extracranial soft tissues and review the characteristic imaging findings of common pathologies affecting the facial nerve. 

Hoarseness is a common clinical problem with a lifetime prevalence of 30%. Initial evaluation requires clinical assessment, with endoscopy reserved for hoarseness persisting more than 2 weeks in duration without benign etiology. Imaging is important to characterize and stage laryngeal masses and to investigate other structural lesions causing hoarseness, usually from vocal cord paralysis. Reviewing anatomy relevant to the workup of hoarseness, this session will also present classic imaging examples of pathology.

After attending this Sunday Session—presented in partnership with the American Society of Head and Neck Radiology—radiologists will have a more thorough understanding of both common and uncommon conditions affecting the cranial nerves, as well as updated insights regarding their imaging findings and treatment options.

_{Published February 16, 2022}

The temporal bone (TB) is a complex structure within the lateral skull base, often with difficult pathologies, including a wide range of congenital, infectious, inflammatory, vascular, and neoplastic processes. To correctly evaluate TB imaging, it is critical to understand TB anatomy—and then, how to use logic and rationality to objectively evaluate cross-sectional imaging findings of the TB. The correlation between clinical presentation and physical examination findings significantly alters TB imaging interpretation. Also, CT and MRI are complementary imaging modalities for evaluating TB abnormalities.

On Friday, March 4, 2022, “Temporal Bone Imaging Made Easy: Basic to Advanced (Everything You Ever Wanted to Know, But Were Afraid to Ask)” will offer imaging professionals a unique opportunity to interact with a diversity of expert head and neck radiologists from across North America. Relevant for a broad audience—practicing head and neck radiologists, neuroradiologists, otolaryngologists, neurologists, as well as allied residents and fellows—this ARRS Virtual Symposium offers up to 4 CME and 4 SA-CME credits during and after the live event, through March 3, 2023.

The symposium will begin with a complete review of TB anatomy (Fig. 1), care of Dr. Laura Eisenmenger from the University of Wisconsin School of Medicine, followed by an examination of the facial nerve by Dr. Luke Ledbetter from UCLA’s David Geffen School of Medicine.

Next, we will address the critical anatomy and pathology leading to both conductive hearing loss (CHL) and sensorineural hearing loss (SNHL) from Dr. Blair Winegar at the University of Utah Health Science Center and Dr. Kalen Riley from Indiana University Health, respectively. When imaging a patient with hearing loss, the clinical examination does not always include an accurate history of the hearing loss itself (unilateral, bilateral, slow or fast onset, conductive, sensorineural, or mixed) or the patient’s medical history, which may be significant. In general, we want to begin a CHL case using CT with focused imaging of the inner ear, middle ear, and external auditory canal, whereas an SNHL case may begin with MRI focusing on the inner ear, internal auditory canal, and cerebellopontine angle.

Following the break, Dr. Remy Lobo from University of Michigan Medicine will review imaging findings of pulsatile tinnitus pathologies. Infectious and Inflammatory processes of the TB will then be discussed by Dr. Nick Koontz from Indiana University School of Medicine. Thin-section CT and MRI provide complementary information in evaluating these TB pathologies (Fig. 2).

I will then analyze complex postoperative imaging findings of TB cases, pointing out key details for consideration. And for the final lecture, Dr. Kelly Dahlstrom from University of Kansas Health Systems will present interactive cases reviewing the top points from all our earlier presentations. As we will do before the break, we’ll end the symposium with another Q&A session, allowing faculty to address individual questions, comments, and concerns.

A thorough understanding of the TB’s anatomical complexities and cross-sectional imaging of pathologies can facilitate expert interpretation of these difficult cases. Because clinical presentation and physical examination findings can significantly change our interpretation of TB imaging studies, communication with referring health care providers is crucial to providing the best patient care.

_{Published on December 21, 2021}

CT colonography (CTC) is an abdominal/pelvic CT exam with the colon insufflated with room air or CO2, following a bowel preparation to optimize visualization of the mucosa. Postprocessed images of the colon include both 2D and 3D images for interpretation with or without a three-dimensional flythrough of a “virtual colonoscopic” view similar to optical colonoscopy. The American College of Radiology (ACR) appropriateness criteria list indications for diagnostic CTC exams in symptomatic patients. Importantly, CTC is also listed by the ACR appropriateness criteria and the United States Preventive Services Task Force (USPSTF) recommendations as an indicated exam for colorectal cancer (CRC) screening in asymptomatic people of an appropriate age. The sensitivity for detection of polyps 6 mm or greater in size and for advanced neoplasia equates to that of the optical colonoscopy (OC), which is the only other available direct visualization test of the entire colon that can lead to prevention of CRC, not just detection. This is an important distinction, as prevention of CRC can be achieved by finding precancerous polyps with the use of direct-visualization tests, enabling subsequent surgical removal. Considering CRC is the second-leading cause of cancer death in the United States, and it is mostly preventable through screening, the importance of prevention with CTC is amplified. Additional CRC screening options include stool-based tests, which have high cancer detection rates, but less sensitivity for detecting precancerous lesions.

Because CTC provides high sensitivity for polyp detection and doesn’t require anesthesia, it is an ideal service for radiology practices. Establishing a CTC service requires a simple, but organized plan that can be easily followed by those involved in the project, as well as understood by those who have financial responsibility. A practical starting point is finding a program champion who can drive three simple phases: visioning, analysis, and implementation.

Visioning Phase

During this aspirational phase, the radiologist champion collaborates with other interested parties to establish a vision, mission, and set of objectives for the endeavor. A clearly stated vision keeps everyone aligned to the goals in establishing a CTC service. For example, “By 2025, we will establish a CT colonography program to screen patients for colorectal cancer, inclusive of follow- up evaluations per recommendations by the USPSTF.” The champion is also responsible for identifying stakeholders, such as hospital administrators, ACO administrators, colleagues from within the practice and from external referring services, and, importantly, patients who value such an initiative.

Analytical Phase

During the analytical phase, the radiologist or project champion decides whether the project can or should be proceed. The project champion might consider conducting a “SWOT” analysis to determine current strengths and weaknesses, as well as potential opportunities and threats:

Strengths

• New multislice CT scanner
• CT scanner underutilized
• OC appointments backlogged
• Gastrointestinal (GI) service supports CTC initiative

Weaknesses

• One radiologist trained in CTC
• Insufflation device needed
• CT technologists untrained

Opportunities

• CTC technologists’ career advancement
• Federal incentive programs for hospitals include increased colon cancer screening
• Understaffed GI service
• Low CRC screening compliance

Threats

• Hospital aggressively recruiting new GI physicians
• Family practice MD training to perform OC
• Stool-based tests to resolve backlog, though less accurate for detecting precursor polyps

Another consideration is an assessment of the market using “Porter’s Five Forces”—a method for analysis taking into consideration the competition (other radiology practices, or medical specialties); suppliers of colon evaluation (gastroenterologists and colorectal surgeons); service purchasers (patients and insurance companies); and threats of substitutes (stool-based tests, fecal immunochemical tests, and blood tests). For example, “Are screening and diagnostic CTC already offered by gastroenterology or colorectal surgeons in the health system or nearby?” Asking such questions will drive an analysis of whether a successful CTC service can be achieved in the face of competition or whether it cannot be achieved due to market saturation or other forces. Moreover, can the CTC service synergize with current programs, resulting in an ideal collegial opportunity, with more specific direction of high-yield colonoscopies and improved resource allocation?

An added benefit to performing such an evaluation is the production of a financial analysis, which may guide stakeholders, such as hospital administrators or practice partners, in decision making. Such an analysis can be a simple income statement weighing the projected revenues, compared to the expenses. A financial analysis also shows downstream revenues to the affiliated hospital (e.g., increased early-stage as opposed to late-stage CRC surgeries, which may be a benefit to academic and private health systems and, ultimately, the patients).

“Heavy Lifting” Phase

Once the project has been approved by the various stakeholders, it is time to act. The first step is to identify gaps between the current and future states. Common tools include developing a timeline for implementation, creating a checklist, and determining milestones that need to be achieved to stay on target:

• 8 Months Out—Establish training plan for radiologists and CT technologists
• 7 Months Out—Purchase all equipment (insufflator device, rectal catheter, oral tagging solution)
• 6 Months Out—Create digital and paper patient instructions
• 5 Months Out—Create order sets in hospital EMR and version to send providers outside system
• 4 Months Out—Set scheduling rules
• 3 Months Out—Draft memo on “Go Live” date for marketing
• 2 Months Out—Complete training for radiologists and technologists
• 1 Month Out—Test “Go Live” with three pilot patients
• “Go Live”—First day of program launch

For many practices, defining the current state will be straightforward (i.e., where no CTC program exists, begin with whatever CT services are offered). It is also possible that the practice has no other competing or complimentary services that have surfaced during the analysis phase. The next step is to determine how a future state will look based on that vision. Finally, set up benchmarks that must be met within the desired time frame. This can be done using a Gantt chart or a simple timeline. Start by creating a task list:

• Inventory equipment
  • Identify location(s) and CT machine(s) that will be used for performance of procedure
  • Purchase CO2 insufflator and CO2 tank supply
• Establish imaging protocol
• Create bowel preparation protocol with patient instructions
• Obtain needed supplies, such as tagging solution and balloon-tip rectal catheter
• Perform information technology- and billing-related tasks, such as creating order form or electronic orderable, setting fees, and building dictation template
• Hire and train patient navigator
• Draft standard patient letters (normal, follow-up required, referral to specialist)
• Create scheduling template
• Train radiologists

Once these tasks and milestones are complete, a CTC service can begin, thus providing an excellent opportunity for patients to avoid a potentially preventable cancer through successful screening. The system will also be effective for necessary added value diagnostic CTC exams, benefiting patients who are unable to undergo OC for assessment.

The Next-Level Goal

Once a successful CTC service has been established, a next-level goal is to launch a multidisciplinary program in collaboration with gastroenterologists, surgeons, and oncologists to provide options for screening candidates and to provide swift follow-up action for abnormal findings. Prior to 2021, the age of recommended initial screening for those at average risk was 50. Approximately one-third of eligible screening candidates remained unscreened, and yet, there were access resource constraints. Now that the age for initial screening has been lowered to 45, access challenges to screening tests have continued to increase. The use of CTC as part of a multidisciplinary program, with options made readily available to screening candidates at first contact, may be more successful in reaching those who otherwise remain continually unscreened. As experts commonly say, “the best test is the one the candidate will do.”

Establishing a CTC service is not an insurmountable task, but one that can be more easily implemented with detailed organization, as is common to most initiatives in radiology involving cross-sectional imaging. This article is meant to provide one guiding template to establishing a CTC service, with room for variation as needed by the project champion. Establishing a CTC service is an excellent opportunity for radiologists to provide and demonstrate added value to a partner hospital or health system in today’s health care market, which is changing into a “fee for performance” model focused on quality outcomes. Metrics, such as the percentage of a population managed within a given health system that has undergone CRC screening, are valuable to hospitals competing for federal incentives (e.g., Health Care Effectiveness Data and Information Set metrics for CRC screening). Therefore, CTC programs are valuable to radiology practices in demonstrating added value to such institutions. The ability to provide a CTC service can serve as a unique bargaining chip for private radiology practices vying for new contracts, or for academic radiology practices in need of quality contributions meaningful to population health. Moreover, establishing a CTC service can provide a more convenient option for patients in need of CRC screening, which can result in fewer deaths from CRC.

CTC and COVID-19

A discussion of establishing a CTC service would be incomplete without discussing that service in the setting of the coronavirus disease (COVID-19) pandemic. The benefits of a CTC service in that context are multifold. CTC can be performed with less use of PPE, which may be in sparse supply; the risk of exposure for the radiologist and technologist are lower, compared to an anesthesiologist and colonoscopist in a positive pressure room; fewer health care workers are exposed per screening candidate, and those health care workers can remain socially distanced from respiratory exposure throughout the procedure. CRC screening should be considered a necessary ongoing service during the pandemic, given the high likelihood of increased cancer mortalities, if screening is not ongoing.

_{Published January 21, 2022}

Although these two populations—epilepsy patients and dementia patients—may seem very different at first glance, they share a number of important characteristics. Their clinical presentation is often myriad and varied, and early diagnosis leads to better long-term outcomes and more efficient health care utilization. Radiology is often critical for the proper diagnosis and management of these patients. To best utilize imaging resources and interpret studies, we will explore anatomic and functional considerations in these disease processes during our Sunday Featured Session, “Multimodality Approach to Epilepsy and Dementia,” at the 2022 ARRS Annual Meeting in New Orleans, LA.

In 2020, the estimated health care costs for Alzheimer treatment alone was estimated at $305 billion, not including other causes of dementia. It is even more difficult to quantify the monetary cost of epilepsy treatment, much less the cost of quality of life issues. Often times a combined approach with multiple imaging modalities is needed to accurately diagnosis these conditions—but where do we start, and how do we integrate the information?

Higher-resolution anatomic imaging, including diffusion tensor imaging, holds promise in both conditions, but it often serves as an entry point into the diagnostic algorithm. Artificial intelligence has gained traction in automatic segmentation of brain parenchyma, theoretically allowing a more precise localization of volume loss, which can be seen in selective areas in both conditions. This may allow stratification of patients in a community setting, before potential referral to a tertiary center for further evaluation.

Having a working understanding of available molecular imaging agents is also critical for optimizing patient evaluation. Although fluorine-18 fluorodeoxyglucose (¹⁸FDG) is in common use for oncologic PET, there is applicability in neurodegenerative imaging, potentially allowing the identification of relatively hypometabolic areas prior to the development of anatomic changes. Additional neurodegenerative PET imaging agents target amyloid and tau protein deposition. Brain perfusion nuclear medicine imaging, as well as ¹⁸FDG-PET, can also be helpful in the assessment and localization of epileptogenic foci.

The goal of our “Multimodality Approach to Epilepsy and Dementia” session is to explore a different utility of anatomic and molecular imaging in the evaluation of patients with these challenging neurological disorders, allowing radiologists to better understand potential imaging algorithms and advanced diagnostic tests.

_{Published December 21, 2021}

In the US, approximately 100–150 athletes each year die from sudden cardiac death (SCD) during competitive events. Though moderate exercise has been shown to be cardioprotective, vigorous exertion during sports can lead to abrupt hemodynamic changes, triggering ventricular tachycardia or fibrillation in the setting of an underlying cardiac abnormality. As a result, SCD is approximately twice as likely in athletes, compared with the general population. In most cases, the underlying cause can be diagnosed by imaging. Radiologists play a pivotal role in helping clear potential athletes before they begin playing sports and in the workup of athletes after a sudden cardiac arrest.

Causes of Cardiac Events and Patient Demographics

The most common causes of SCD in the US are hypertrophic cardiomyopathy (HCM) and anomalous coronary arteries. According to the US National Registry of Sudden Death in Athletes, from 1980 to 2011, HCM constituted 36% of SCD cases and anomalous coronary arteries constituted 19%. A variety of less common causes are responsible for the remainder of cardiac events and include arrhythmogenic cardiomyopathy (AC), noncompaction cardiomyopathy, myocarditis, valvular disease, and coronary artery disease. Additional causes that can be diagnosed without imaging findings include channelopathies, Wolff- Parkinson-White syndrome, and commotio cordis. Similar statistics have been found in series examining sudden cardiac arrest, in addition to SCD. The frequency of cause differs by age. For instance, coronary artery anomalies are more common in middle school athletes. In patients over 35 years old, coronary artery disease is the most common cause.

The vast majority of SCDs occur in male athletes. The reasons for this are not entirely clear, but it has been hypothesized that greater intensity of physical training, more frequent participation in contact sports, such as football and boxing, and undocumented protective metabolic mechanisms in female athletes may contribute [4]. More than half of patients with SCD are football and basketball players. African-American athletes are at higher risk for cardiovascular death than patients of other ethnicities, potentially related to a greater rate of participation in sports and a higher incidence of cardiomyopathy.

Imaging Two Common Causes of Sudden Cardiac Death

Hypertrophic Cardiomyopathy

HCM is the most common cause of death in athletes younger than 35 years old. The underlying cause is usually an inherited abnormality of the sarcomeres. Though HCM can be diagnosed on echocardiography, it is definitively evaluated on cardiac MRI (CMR), allowing complete anatomic and tissue characterization. CMR is also more sensitive for detection of apical aneurysm and thrombus, compared with echocardiography. The main diagnostic criterion for HCM is an end-diastolic wall thickness greater than or equal to 15 mm without left ventricular dilation or evidence of systemic disease to explain the degree of hypertrophy. The location of thickening can vary among patients, most often involving the septum (asymmetric septal hypertrophy) (Fig. 1A). Other types of hypertrophy include concentric (Fig. 1B), midcavity, apical (also known as spade-like) (Fig. 1C), and mass-like.

Left ventricular outflow obstruction in HCM can result in syncope, exercise limitation, or chest pain. MRI typically shows a thickened basal anteroseptum with a dephasing jet secondary to flow acceleration. The mitral valve is pulled into the left ventricular outflow tract as a result of flow acceleration, resulting in further obstruction (Fig. 1D). This systolic anterior motion of the mitral valve is best visualized on the three-chamber view of the left ventricle. Commonly, an associated mitral regurgitation is directed posteriorly because of incomplete coaptation of the mitral valve leaflets. Both 2D phase-contrast and 4D flow imaging techniques have been applied to assess the pressure gradient caused by obstruction, but this is generally better assessed with echocardiography because of improved temporal resolution for observing peak velocity. The criterion for obstruction is a gradient greater than or equal to 30 mm Hg.

Radiologists also have a role in identifying predictors of SCD. Implantable cardioverter-defibrillator (ICD) placement is dictated on the basis of individual risk. Myocardial thickening greater than 30 mm measured at end diastole constitutes massive hypertrophy, and its presence raises consideration for ICD placement. An apical aneurysm (Fig. 1C) also raises the risk for thromboembolism and SCD. LGE is typically hazy and observed in a midmyocardial distribution (Fig. 1E). The presence of LGE greater than or equal to 15% of the myocardial mass doubles the risk of a cardiac event, though current guidelines from the American College of Cardiology Foundation and American Heart Association (AHA) have yet to incorporate LGE. The presence of myocardial delayed enhancement also helps distinguish HCM from athlete’s heart.

Many patients with HCM have abnormal papillary muscles, which may be important to identify for presurgical planning. The identification of a hypertrophied anterolateral papillary muscle inserting directly into the anterior mitral leaflet can lead to greater obstruction. A long anterior mitral leaflet may necessitate mitral valve repair and has been defined as an anterior leaflet length greater than 30 mm. Additional abnormalities include accessory anterolateral papillary muscles and accessory left ventricular muscle bundles that can contribute to outflow obstruction. In such cases, the surgeon will need to adjust the surgical approach, including reduction of the papillary muscles.

Anomalous Coronary Arteries

Anomalous coronary arteries are the second-most common cause of SCD. Normally, the left main coronary artery arises from the left coronary sinus of the aortic root, and the right coronary artery arises from the right coronary sinus. Coronary anomalies consist of deviations of this usual anatomy.

Anomalous coronary arteries are often initially evaluated by echocardiography, followed by coronary CTA for patients with persistent concern for an anomalous coronary artery. In some patients, MRI is performed—such sequences can be performed without contrast material but can be difficult to perform in young patients without anesthesia. In addition, smaller vessels are more difficult to analyze because of lower spatial resolution.

When assessing the coronary arteries, a radiologist should evaluate the origin and course of the left main coronary artery, right coronary artery, left anterior descending artery, and left circumflex artery. Most coronary anomalies are asymptomatic. Examples include a retroaortic course of the left circumflex artery, separate origins of the left anterior descending and left circumflex arteries from the aortic root, and a prepulmonic course of the left anterior descending artery.

The most frequent types of potentially hemodynamic significant coronary artery anomalies are those with an interarterial course. An anomalous origin of the right coronary artery with an interarterial course between the aorta and the main pulmonary artery is the most common in young athletes; if symptomatic, repair is indicated. In the absence of symptoms, institutional policy may vary, but patients generally undergo a stress test to evaluate for inducible ischemia. An anomalous left coronary artery from the right coronary sinus (Fig. 2) has a higher risk of ischemia, and patients with this anomaly are recommended to undergo surgical repair regardless of symptoms. For any interarterial course, a slit-like origin suggests an intramural course with greater risk of SCD.

An important distinction from an interarterial course of the left main coronary artery is a transseptal course in which the anomalous coronary arteries pass through the septum, rather than between the aorta and main pulmonary artery. Unlike an interarterial course, a transseptal course is thought to be benign and rarely requires surgical correction, though an exercise stress test is still required.

An additional benign differential consideration is a highrising coronary artery, which arises 1 cm or more above the level of the sinotubular junction in the ascending aorta. The origin may be slightly rotated clockwise with respect to the right coronary sinus, but this is a benign entity without hemodynamic consequence.

Finally, anomalous left or right coronary arteries arising from the pulmonary arteries generally require surgical treatment in athletes. Because of the lower pressure of the pulmonary arteries, blood flow is actually reversed—this represents a steal phenomenon in which coronary artery blood flow shunts to the pulmonary arteries via collateral vessels.

The author thanks Seth Kligerman for review of this article and assistance with figures.