Author: Logan Young

A landmark California Court of Appeal decision is shielding out-of-state remote professionals from Golden State taxation. In Garcia-Rojas v. California Franchise Tax Board, the court ruled that a Texas teleradiologist is not subject to California income tax, despite serving California patients.

So, California attempted to use a complex corporate tax theory to claim income from a contractor who never physically entered the state.

• The Provider: Dr. Xavier Garcia-Rojas, a Texas-based radiologist, performed contract reads for San Diego-based StatRad from 2018 to 2020.
• The Dispute: The Franchise Tax Board (FTB) claimed Dr. Garcia-Rojas owed taxes because he used StatRad’s software, was licensed in California, and served Cali patients.
• The Numbers: The doctor originally paid roughly $48,000 in taxes, penalties, and interest under protest before suing for a refund.

Legal Pivot: The court rejected FTB’s attempt to apply the unitary business doctrine (usually reserved for multi-state corporations) to a single-person sole proprietorship.

• The Rule: A nonresident providing remote professional services does not automatically become part of a unitary business just because their client is in California.
• The Result: Because the actual labor (i.e., image interpretation) happened at a desk in Texas, the income is not California-sourced.

As Bloomberg noted, Garcia-Rojas v. CAFTB sets a binding precedent for thousands of remotely contracted lawyers and consultants, as well as the surfeit of tech sector labor, working for California firms. Indeed, it confirms that location of labor—not the location of the client—is the deciding factor for individual income sourcing.

The “football sign” is a pathognomonic indicator of massive pneumoperitoneum on supine abdominal radiographs, characterized by a large, oval radiolucent area shaped like an American football.

SIP: In extremely low birth weight infants, this finding often signals spontaneous intestinal perforation (SIP), a condition distinct from necrotizing enterocolitis (NEC). Recognizing the difference is critical because SIP is often an isolated vascular insult, and as Susan D. John, MD, illustrated during Mastering Radiology: A Comprehensive Board Review for Residents and Refresher for Radiologists in Practice, some cases may heal without surgical intervention.

Three Tips from Dr. John:

1. Radiolucent Oval—Massive free air collects anterior to the abdominal viscera, distending the peritoneal cavity and creating a sharp interface with the parietal peritoneum.
2. Laces Out—The air outlines longitudinal structures of the anterior abdominal wall, most commonly the falciform ligament in the right upper abdomen. It may also outline the median umbilical ligament (urachal vestige) or medial umbilical ligaments (umbilical arteries).
3. Bowel Appearance—A key clue for SIP is that the bowel often appears normal in caliber without evidence of pneumatosis intestinalis, which would typically be present in NEC.

Bottom Line: While frequently associated with spontaneous perforation in premature infants (ca. 24 weeks gestation), the football sign can also be seen in cases of iatrogenic trauma, such as rectal perforation resulting from the placement of a rectal tube. If the sign is suspected on a supine film, a decubitus view can be used to confirm the presence of free air.

Distinguishing between oligodendroglioma and IDH-mutant astrocytoma is a high-yield challenge for neurorads, as both typically present as infiltrative, T2-hyperintense masses with variable enhancement.

1p/19q: While both tumors fall under the umbrella of IDH-mutant adult gliomas, their molecular signatures—and, consequently, imaging phenotypes—offer specific smoking guns for diagnosis.

• Oligodendroglioma: Defined by IDH mutation and 1p/19q codeletion.
• Astrocytoma: IDH-mutant but 1p/19q intact.

As part of the dynamic, rapid-fire Neuroradiology Case Review during the 2026 ARRS Annual Meeting, Susana Calle, MD, pointed out some key discriminators…

T2-FLAIR Mismatch: This is the strongest predictor for IDH-mutant astrocytoma, boasting a specificity of 90–100%.

• The lesion shows homogeneous high signal on T2-weighted images but complete or near-complete signal suppression on T2-FLAIR.
• The presence of this sign virtually rules out oligodendroglioma (although its absence does not exclude an astrocytoma diagnosis).

Worm-like: If you see gyroform cortical calcifications, think oligodendroglioma.

• Calcification occurs in up to 90% of oligodendrogliomas.
• These tumors have a strong frontal lobe predominance and tend to be more cortically based than astrocytomas.
• Astrocytomas are far less likely to calcify.

Perfusion Paradox: Typically, high cerebral blood volume (CBV) indicates high-grade malignancy, but oligodendrogliomas are the exception.

• Elevated CBV is often seen in oligodendrogliomas, regardless of grade, due to their characteristic “chicken-wire” fine intratumoral capillaries, rather than true neoangiogenesis.

Bottom Line: Calcified cortical tumor in the frontal lobe? Sway toward oligodendroglioma. T2-FLAIR mismatch sign identified? Think IDH-mutant astrocytoma. Accurate noninvasive identification of these genotypes is critical because 1p/19q codeletion in oligodendrogliomas is associated with a better response to chemoradiation and significantly improved overall survival.

For patients with severe aortic stenosis and a life expectancy greater than one year, the choice between transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) is a complex decision made by a multidisciplinary heart team.

Three Things: Although TAVR was initially the standard for patients with high surgical risk, its use is rapidly increasing. Today, TAVR’s approved for low-risk patients, too. However, as noted by Matthew Stib, MD, of Mayo Clinic Arizona during the ARRS Online Course Mastering CT for TAVR and TMVR, the choice still hinges on three primary features: age, surgical risk, and life expectancy.

• <65 years: SAVR is preferable. Surgical valves have established longevity, whereas TAVR has only been in use for about a decade, and its long-term durability is less certain.
• 65–80 years: Both are viable options; the choice depends on patient preference and specific clinical or anatomical factors.
• >80 years: TAVR is the preferred approach.
• High Surgical Risk: TAVR is favored, regardless of age.

Two Tips: Pre-procedural CT remains the reference standard for TAVR planning, serving two critical roles: sizing the prosthesis at the aortic root and evaluating vascular access in the thorax, abdomen, and pelvis.

Beyond the Valve: Recent research indicates that rads should look at more than just the valve to predict patient outcomes. Features of right heart failure identified on pre-procedure CT are independent predictors of 1-year mortality after TAVR:

• Pulmonary Artery Dilation: A median main size of 3.2 cm was associated with death within 1 year, compared to 2.9 cm in survivors.
• Pericardial Effusion: The presence of a moderate-to-large pericardial effusion is a strong predictor of mortality, even when adjusting for the Society of Thoracic Surgeons clinical risk score.

Bottom Line: As TAVR becomes more common, the rad’s role is expanding from procedural planning to risk stratification. Identifying signs of right heart failure—like a dilated PA or pericardial effusion—can help identify high-risk candidates who may have poor outcomes, despite a technically successful procedure.

In small capacity joints, septic arthritis doesn’t stay contained—it bursts! Apropos, William Morrison, MD, of Thomas Jefferson University Hospital coined a very specific, Saturday Night Live-forward metaphor to help rads recognize the larger-than-life presentation of infection in tiny spaces.

The Chris Farley Finding: Just as the late physical comedy genius would don one-size-too-small outfits to accentuate his larger frame, septic arthritis in small joints creates an angry effusion that so often appears too big for its britches.

• The Mechanism: Because joints like the fingers, sternoclavicular, or sacroiliac (SI) have very small capacities, infection pops out of the capsule early on.
• The Look: Imaging reveals massive periarticular edema and enhancement disproportionate to the joint size.

Holy Schnikes! As Dr. Morrison described in MSK Infection Update: What Do I Need to Say and Do?, recognizing this bursting effect is critical for early diagnosis, especially in the sacroiliac joint.

• The Great Imitator: Septic sacroiliitis often presents as sciatica because the inflammation irritates the sciatic nerve sitting directly in the sciatic notch.
• The Diagnostic Trap: Clinicians may mistake the pain for a disc herniation and order a lumbar spine MRI.
• The Rad’s Role: Looking all the way to the edge of the image for SI joint edema, you may be the first to catch the infection.

Bottom Line: Beyond the Chris Farley finding, you’ll also want to watch for three more classic signs of septic arthritis in small joints:

• Erosions: Destruction of the joint surface.
• Loss of subchondral white line: A key indicator of joint space infection.
• Disproportionate soft-tissue involvement: Massive edema surrounding a tiny joint.

No, it’s not yet another template. ACR’s Neck Imaging Reporting and Data System (NI-RADS) is really about a strategic sales pitch and local adaptation. Paul Bunch, MD, ACR NI-RADS Committee Chair, explained to AJR Neuroradiology Imaging Senior Editor Carlos Zamora, MD, PhD, in this Video Article how he successfully integrated NI-RADS MRI version 2025 recommendations at Wake Forest by focusing on clinical buy-in and implementation science.

How Concerned Are You? Standardized reporting like NI-RADS MRI v2025 eliminates ambiguity. Before implementation, tumor boards often struggled with reports where the rad’s level of concern was unclear. Post-implementation, 100% of surveyed referring physicians agreed that the numeric scoring system was valuable for patient management.

Steps for Success: Dr. Bunch followed a four-point roadmap to move NI-RADS from a white paper to daily clinical practice:

1. ID Your Champs—The push at Wake Forest actually began with a request from clinical colleagues at multidisciplinary tumor boards who saw the potential benefit.
2. Pitch Perfect—Dr. Bunch presented to his neuro group, framing NI-RADS not as a radical change to their interpretation skills, but as a tool for uniform communication.
3. 90 Days—The department ran an optional 3-month trial, using surveys and data mining to track usage and satisfaction alike among both rads and referring doctors.
4. Adaptation & Context—Following principles of implementation science, the team kept the core identity of NI-RADS (e.g., suspicion levels and linked recommendations), while modifying peripheral details to fit local needs. 

Local Mods: Dr. Bunch was quick to note that rigid adherence can hinder adoption. To gain full buy-in, his colleagues made two key adjustments:

1. Flexible Follow-Up: They removed that 3-month timeframe for short-interval follow-up to prevent insurance authorization issues and allow clinicians more flexibility.
2. Worst-First Lead: To ensure referring MDs didn’t stop reading after a NI-RADS 1 primary site score, Bunch et al. added an overall assessment score at the top of the report reflecting the most concerning finding in the entire study.

Bottom Line: By treating implementation as a collaborative effort rather than a top-down mandate, Dr. Bunch’s team turned NI-RADS into a templated tool that virtually eliminated “how worried are you?” questions during tumor boards.

During the Wellness Symposium at ARRS 2026, Sherry S. Wang, MBBS, from the University of Cincinnati shared her own, hard-won framework for identifying and navigating toxic professional environments.

Working Definition: A toxic workplace is defined by poor leadership, lack of transparency, unreasonable work volumes, and a culture of fear or retaliation. Because these factors can directly erode a rad’s confidence and performance right there at the workstation, addressing them is a professional necessity.

Dr. Wang’s 5-Step Manual:

1. Pattern Recognition—Differentiate between a one-time misunderstanding and repeated patterns of toxic behavior.
2. People vs. Process—Determine if you are facing a people problem or a process problem, then assess if the organization is actually open to change.
3. To Engage or Nah? Evaluate if the issue is worth the effort to fix and whether you can effectively protect yourself from retaliation.
4. Writing & Speaking—If you feel safe, present documented evidence of the behavior to leadership. [N.B. If you’re too afraid to do so, you likely already have your answer.]
5. Plan B, Always—Having an exit strategy is a courageous act of self-preservation. If you decide to leave, do so cordially, but prepare for potential retaliation during your notice period.

Maybe It’s Me? Toxicity isn’t just an HR issue; it eats away at our wellbeing, impacting a rad’s sensitivity and specificity alike. And since we all contribute to institutional culture—be it a primary instigator or simply as silent bystanders who allow toxicity to persist—Dr. Wang challenged us to keep looking inward.

Bottom Line: Merely surviving your reading room shift is no longer enough. Going forward, the goal should be detoxing our workplaces to make them that much more productive for each and every rad.

In patients presenting with renal failure, certain MRI patterns in the basal ganglia provide a leading history for a diagnosis of uremic encephalopathy. Specifically, the lentiform fork sign helps ID metabolic distress in the deep brain nuclei, particularly in the context of metabolic acidosis.

Big Picture: While uremic encephalopathy most commonly affects the posterior parietooccipital cortical and subcortical regions, as Atul Agarwal, MD, of Indiana University duly noted during the ARRS Web Lecture Abnormalities of the Basal Ganglia, it can involve the basal ganglia, extensively, too.

• Subcortical Structures: MRI typically shows expansile, abnormal signals on T1 and T2-weighted imaging involving the putamen and globus pallidus.
• Brain Fork: The signature fork appears due to FLAIR hyperintensity in the external and internal capsules—those white matter pathways surrounding the lentiform nucleus.
• Restrictions Apply: Imaging often reveals anticipated abnormal restricted diffusion in these regions.

What to Watch For: This pattern is not exclusive to uremia; therefore, rads must consider several high-stakes mimics:

• Metformin-Associated Encephalopathy: This can have a nearly identical appearance, making it a vital consideration for diabetic patients with renal impairment.
• Atypical PRES: Whereas posterior reversible encephalopathy syndrome usually follows a standard pattern, acute hypertensive encephalopathy can present in this atypical form.
• Metabolic/Ischemic Insults: Both hypoglycemia and ischemia share similar mechanisms that can produce comparable basal ganglia findings.

Bottom Line: When you see the lentiform fork sign in a renal patient, metabolic acidosis is the likely culprit, but always cross-check for metformin use or hypertensive crisis.

Cryoablation is becoming the hottest tool for managing complex osseous metastases, utilizing alternating cycles of rapid freezing and thawing to achieve reliable cell death. And as Anderanik Tomasian, MD, of UC Irvine explained during the ARRS Online Course Minimally Invasive Musculoskeletal Interventional Oncology Masterclass, cryoablation is uniquely suited for tumors where heat-based methods like radiofrequency ablation (RFA) often fail.

Why It Matters: Unlike RFA, which is ineffective for purely osteoblastic lesions due to high electrical impedance, cryoablation excels in treating these dense bone tumors. It also offers less intraprocedural pain and allows for the simultaneous use of multiple probes to cover large, complex geometries.

Freezing is Believing: The Ice Ball

• CT Visual: The primary advantage is your ability to see the hypoattenuating ice ball in real time.
• Precision on the Margins: The visible edge of the ice ball typically represents 0°C; to guarantee cell death (which requires –40°C), the ice ball must extend 3–5 mm beyond the tumor boundary.
• Heavy Caveat: While highly visible in soft tissue, the ice ball can be difficult to distinguish within the dense bone of a blastic lesion or normal bone.

Targeted Case: In Dr. Tomasian’s case of a patient with non-small cell lung cancer, cryoablation was successfully used to target a painful L4 osteoblastic lesion. Because RFA cannot effectively penetrate such dense lesions, cryoablation was the preferred modality for pain palliation and local tumor control.

Thermal Protection: Since bone cortex does not stop the expansion of an ice ball, adjacent vital structures are at risk.

• Active: Techniques like pneumodissection or even hydrodissection are used to displace and insulate nerves or the spinal cord.
• Passive: Strategies include placing thermocouples to monitor temperatures near sensitive structures, with active protection recommended if the temperature drops to 10°C.

Bottom Line: Cryoablation is a versatile, less painful, and highly visible intervention that provides a critical alternative for patients with refractory bone pain—particularly those with large soft-tissue components or blastic disease.

At some point of inflection, every new imaging modality will require its own image-guided biopsy capabilities. Why? Because as Haydee Ojeda-Fournier, MD, of UC San Diego Health reminded us in her ARRS Quick Byte video, suspicious findings may be occult on all other systems.

Yes, and … Contrast-enhanced mammography (CEM) is transitioning from diagnostic instrument to a functional intervention platform—addressing Dr. Ojeda-Fournier’s “what next?” query for findings seen only on recombined images.

Percentage Points:

• 62% of CEM-detected lesions can be identified during a second look at digital breast tomosynthesis (DBT).
• 76% of CEM findings have an ultrasound correlate; these correlates are more likely to be malignant.
• ~60% of MRI-guided biopsies could potentially be performed via CEM, providing a faster, lower-cost alternative for impacted MR units.

Case in Point: CEM-guided intervention remains a game-changer for patients who cannot tolerate MRI. For example, in the 83YO patient above with invasive lobular carcinoma who was not an MRI candidate, CEM-guided localization successfully targeted a contralateral mass that was mammographically and sonographically occult.

In the projection below, you’ll notice some artifact from the needle. And after Dr. Ojeda-Fournier’s team deployed their wireless localizing device (based on geography), pathology came back benign. She’ll need a follow up, regardless.

Final Points of Order:

• Search in Teams: Using a combined scout (CEM+DBT) provides the most flexibility for choosing the optimal guidance modality.
• Needle Up! While both horizontal and vertical approaches are possible, typically, the vertical needle approach is preferred because it samples a larger tissue volume in the z-axis and is less reliant on precise depth estimation.
• Singular Sensation: A successful biopsy is defined as obtaining tissue within one procedure under a single compression, whether guided by recombined CEM, DBT, or stereotactic techniques.

More than isolated findings, pancreatic cystic lesions can be a cry for help from the entire organ. In fact, the field defect suggests that the presence of a cyst indicates an increased risk of developing pancreatic ductal adenocarcinoma elsewhere in the gland.

Look Around You! Rads frequently focus on the stability of a cystic lesion, but malignancy can arise in the surrounding pancreatic parenchyma—even when the cyst, itself, remains unchanged for months, even years.

• Crying Metaphor: In his ARRS Quick Byte video, Atif Zaheer, MD, of Johns Hopkins dubs these lesions “tears of the pancreas,” warning of synchronous or metachronous cancer development.
• Surveillance Trap: Whereas some guidelines suggest stopping surveillance for stable cysts after 5 years, Dr. Zaheer’s research indicates a continued risk of malignancy beyond the 5–10 year mark.
• What’s the Protocol Here? Abbreviated MRI protocols designed for cyst follow-up must include sequences that specifically evaluate the parenchyma to avoid missing cancers arising in the uncinate process of the pancreatic head.

Under New Management: Managing pancreatic cysts is shifting from a disease of technology toward a more personalized, multi-faceted approach, including:

• Beyond Imaging: Effective risk stratification now involves clinical data, biochemical markers, and cyst fluid DNA sequencing for mutations in genes like PIK3CA and TP53.
• AI Edge: Emerging deep-learning algorithms and radiomics are helping to create automated risk-prediction models to differentiate high-risk lesions from benign ones.
• Patient Empowerment: With the 2020 Cures Act, patients have immediate access to their reports, increasing the need for structured, recommendation-based reporting that tracks imaging features over time.

Bottom Line: Don’t just look at the cyst. Evaluating the health of the entire pancreatic gland is critical to detecting early invasive cancer that the field defect may be denying.

In matters of the heart, truth matters all the more. And identifying the real lumen remains critical for planning endovascular repairs, ensuring branch vessels are correctly supplied to prevent end-organ ischemia. Sure, continuity with the normal aorta remains the gold standard for sussing things out. But as Ferco Berger, MD, pinpointed during the ARRS Online Course “Imaging in the Emergency Department,” tracing it can be difficult in cases involving the aortic root or when only limited abdominal scans are available.

False Witnesses:

• Beak Sign: Acute angle formed where dissection flap meets outer wall, it’s the most useful and reliable indicator (present in nearly 100% of acute and chronic cases).
• Larger Size: A false lumen typically distends and has a larger cross-sectional area than the real deal.
• Cobweb Sign: Thin, linear defects representing remnants of media layer. Albeit rare, they are highly specific to false lumen.

Truth Tellers:

• Calcification: Generally, hardening along outer wall or eccentric flap is indicative of true lumen. [N.B. In chronic cases, false lumen can occasionally calcify.]
• Wraparound: In transverse aortic arch, if one lumen appears to wrap around another, that inner lumen is invariably the truer one.
• Density: In arterial phase, true lumen frequently show higher contrast density.

Supply Chain: Differentiating the supply side here helps predict which organs are at risk:

• True Lumen: Usually supplies celiac trunk, superior mesenteric artery, right renal artery.
• False Lumen: Often supplies left renal artery and more prone to thrombus formation.

Bottom Line: When continuity is unclear, look for the beak sign and larger caliber to identify the false lumen; double-check the arch wraparound and calcification patterns to confirm the true lumen.