Category: Articles

_{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.

By the time you read this, results from the United States Medical Licensing Examination (USMLE) Step 1 exam will have changed from a numeric score to pass or fail. As students, medical schools, and residency programs anticipate this upcoming change, many are left wondering if and how this update will affect applicant selection for radiology residencies. Our study used an anonymous and voluntary 14-question online survey to assess program directors’ views on the scoring change of Step 1 from numeric to pass or fail, while assessing if other metrics, such as Step 2 Clinical Knowledge (CK) scores, may become more important during application review. Eighty-eight of 308 (29%) members of the Association of Program Directors in Radiology (APDR) completed the survey.

Our study found that more than two-thirds of survey respondents indicated their programs currently use a Step 1 screen before sending interview invitations. Specific to radiology, previous studies have demonstrated a correlation between Step 1 performance and both the number of interpretive errors made as a radiology resident and future success on the American Board of Radiology Core Exam. Our study also found that more than 90% of survey respondents anticipate their programs may or definitively will require Step 2 CK scores before application review, once Step 1 becomes pass or fail; in contrast, many radiology programs presently do not require Step 2 CK scores before reviewing applications. In addition, our study found that regardless of the current use of a Step 1 screen, survey respondents did not significantly differ in their anticipation of requiring Step 2 CK scores (p=0.71) or extending later interviews to accommodate Step 2 CK scores (p=0.64). This finding may reflect hesitancy from programs to place significant weight on Step 2 CK before more research is done. There may be increased utility of using Step 2 CK scores over Step 1 scores as a marker of clinical knowledge, as the material covered in Step 2 CK has greater clinical relevance than that of Step 1. Through faculty, peer, and patient-level evaluations, previous studies from internal medicine have shown that Step 2 CK scores correlate better to clinical performance both during and after residency than Step 1 scores. It could be informative to examine whether this correlation exists with Step 2 CK scores and performance in radiology residency, as more residency applicants may include Step 2 CK scores with their initial application in upcoming years.

Although making Step 1 pass or fail may help mitigate the significant distress surrounding the examination, there are valid concerns that the stress surrounding Step 1 will simply be transferred to Step 2 CK, when Step 2 CK becomes the only remaining standardized metric among applications. In an ideal world, all applications would receive a thorough and holistic review with consideration of both qualitative and quantitative characteristics. However, many selection committees do not have enough resources to do so, given the growing number of applications each program receives for the same number of residency spots. Some specialties have implemented preference signaling and supplemental applications to highlight an applicant’s top programs of interest and specific program characteristics (location, patient population, research, etc.) a particular applicant is seeking. Some studies have suggested more drastic measures, such as application caps, to reduce the usage of standardized test scores as a filter during application review and allow for more holistic application reviews. While changing Step 1 to pass or fail does not resolve all the challenges associated with the residency selection process, it does pave the way for additional meaningful changes to the system in the future.

_{Published January 4, 2022}

Acute ischemic stroke (AIS) results from occlusion of a cervical or cerebral artery, and it is the leading cause of disability in the US. The most severe forms of AIS result from thrombo- or thromboembolic occlusion of the internal carotid artery or proximal (M1 segment) of the middle cerebral artery, and these occlusions are termed large vessel occlusions (LVOs). LVOs are amenable to thrombectomy, which is a minimally invasive endovascular surgery that removes the thrombus from the affected artery (Fig. 1).

Thrombectomy treatment of AIS due to LVO has exploded, following the publication of multiple randomized trials that demonstrated superior outcomes with thrombectomy treatment in patients presenting in both early (0–6 hours from last known well) and late (6–24 hours from last known well) time windows. These studies not only found thrombectomy to be superior to medical treatment, but they also fundamentally changed the evaluation and treatment triage of AIS-LVO patients.

Previously, the best medical therapy for AIS was intravenous thrombolysis with tissue plasminogen activator (tPA), but tPA treatment was limited to patients who present within 3–4.5 hours from symptom onset. The time-sensitive nature of tPA treatment was a significant barrier, and it limited the number of patients eligible for treatment. The success of the thrombectomy trials has shattered the stopwatch that governs tPA treatment in LVO patients, and we have now entered an era in which imaging guides stroke treatment, rather than the time from symptom onset.

The imaging evaluation of AIS patients has moved beyond the non-contrast head CT (NCCT) that has guided intravenous thrombolysis treatment decisions since 1995. Thrombectomy has the greatest impact when it is performed in a patient with minimal ischemic brain injury and an LVO, and these patients are identified at a minimum with an NCCT and a CT angiogram (CTA). Most of the index randomized thrombectomy trials also used CT perfusion (CTP) to characterize brain tissue that was likely permanently injured (the ischemic core) and the presence of underperfused, but salvageable, brain tissue (the penumbra). Due to the success of these trials, there has been a marked increase in CTP utilization for the evaluation of AIS patients with LVO. The increased use of CTA and CTP is making a meaningful impact on stroke treatment, but this usage has the potential to significantly strain radiology practice resources, given that AIS LVO patients should be screened for thrombectomy candidacy up to 24 hours after they were last known to be well.

The need for timely evaluation of AIS patients and the increased utilization of CTA and CTP is being aided by the integration of automated image processing and artificial intelligence (AI) techniques that identify thrombectomy treatment candidates. The emergence and implementation of these disruptive software platforms has integrated into clinical practice at a pace seldom seen in medicine, demonstrating the potential value of AI to the practice of radiology.

The success of thrombectomy and the increased use of CTA and advanced brain imaging, such as CTP, requires that radiologists are well aware of AIS patient evaluation and treatment workflows. Apropos, A RRS is offering an exciting and timely Sunday Featured Session with leading stroke experts during the 2022 Annual Meeting in New Orleans, LA. Join us for “Code Stroke: What Every Radiologist Should Know Early.”

_{Published on December 21, 2021}

Feeling stuck, joyless, or “meh?” You, like many others, might be languishing. In fact, it might be the dominant emotion of 2021.

Sociologist Corey Keyes describes mental health as a continuum: ranging from flourishing, that state of wellbeing we all seek to achieve, to languishing, the absence of wellbeing, and a lower state of mental health. Languishing is distinct from depression, yet individuals who are languishing are at a higher risk of future mental illness (such as depression and anxiety disorders), as shown by Keyes et al..

Simply put, languishing is a series of emotions, rather than a mental illness. Adam Grant, writing in the New York Times, refers to languishing as “the neglected middle child of mental health” and “the void between depression and flourishing.” Given the negative impacts on productivity, morale, innovation, team building, retention, and engagement, nonprofit organizations and corporations alike must take this widespread state seriously.

The pandemic has impacted almost every structural framework of our lives, such as socializing, working, vacationing, traveling, and exercising—and, in turn, compromised our sources of joy. With no clear path as to when and how our “future state” will present itself, we continue to exist in an ongoing and indefinite interim state. As uncertainties persist and routines remain in flux, many people are being shuffled into a state of languishing.

You Might Be Languishing if You Are:

• overwhelmed or emotionally numb
• distracted and unfocused
• depleted, empty, and/or disinterested
• unmotivated or procrastinating
• not functioning at your full capacity
• unable to feel excited about upcoming events
• cynical about your colleagues and leaders

How Can We Shift From Languishing to Flourishing?

Below, I share a compilation of suggestions from the experiences of many. If the symptoms of languishing seem familiar to you, perhaps one or more of these strategies might help. If even one person finds solace in these ideas, it would bring me joy.

• Prioritize your health: Do your best to eat healthily, drink plenty of water, sleep well, and incorporate movement into your life. Schedule and keep your annual health appointments. Consider alternative medicine modalities, such as acupuncture and chiropractic medicine. Find moments to sit in silence and simply breathe. Use your personal time and plan vacations, including memorable “staycations.” Disconnect from work and social media during your time off. Set boundaries and learn how to respectfully say “no,” when needed. Take your first small step toward doing something you’ve always wanted to do for your health today.
• Protect your time: Manage your time intentionally and purposefully. Detach, disconnect, and learn how to engage your personal reset button. You might try scheduling uninterrupted time for yourself to recharge your batteries, even if this means “doing nothing.” Limit social media scrolling and email checking. Consider recapturing your prepandemic experiences; for example, create a virtual “commute” that includes a home spin class, podcast episodes, reading, music, or another element that helps you transition from the waking to working hours.
• Make positive connections: Reengage or recreate your personal and professional network. Recall who once might have lifted you up. Walk and chat, gather and eat, find and embrace, and explore commonalities with positive people. When possible, spend less time with those who drain your energy and spirits. Seek a peer support buddy with whom you can share your experiences and feelings. Look for authentic and uplifting connections to replenish yourself emotionally.
• Reflect on the current situation: Acknowledge the loss and anxiety and frustrations and grief. What have you lost? What have others lost? What has everybody lost? Recognize that you’re not alone here.
• And then, practice gratitude: Recognize what you do have, rather than focusing on what you don’t. Appreciate what is working, rather than focusing on what isn’t. Try keeping a daily gratitude journal or using a meditation app, like Calm or Headspace, for guided gratitude practices.
• Find flow and motivation: What’s on your music playlist, and when did you last update the content? Step out of your comfort zone by trying a new recipe, exercise, podcast, app, or online class. Get better at something, whether it’s dance, yoga, art, reading, writing, meditation, music, composting, or gardening. Explore mindful crafting, photography, collecting, and other hobbies. Reconnect with and walk barefoot in nature for additional grounding.
• Celebrate small successes: Rethink what constitutes success, however small. It may be someone else’s success or happiness that you contributed to. When overwhelmed, rethink your goal-setting strategy. Set simpler goals that are achievable, and enjoy the successes that you are contributing to. It’s OK to start small. Perhaps also schedule achievable self-care activities each day.
• Rethink your possessions: What would you like to keep or surround yourself with? These items might include things that bring you joy, inspiration, hope, confidence, or calm. Consider decluttering a room or maybe even your entire living space over a period of time. According to a recent Psychology Today article, decluttering can be very beneficial.
• Change your scenery: Breaking from a stagnant routine is challenging. I encourage all of us to find ways to get out of our emotional basement and head up to our proverbial sunroom. Take a stroll through your memory banks to recall what may have once ignited your passions. Learn the art of introspection—what does your perfect day look like?—and consciously do something new or different to refresh your spirits. Check out your local museum, gallery, or library with a friend. Sign up for an online class or enjoy a virtual comedy show. You never know what you may discover.
• Find joy in giving: When did you last wrap a small gift? Who can you help today? What causes would you like to reengage with? Have you discussed and explored different options with your friends and family? Try to get back to your talents and gifts. Learn to be a peer supporter. Research volunteer opportunities in your community. Contemplate your purpose and remember what truly drives you. Helping others can bring a tremendous sense of inner fulfillment.
• Activate your personal coping strategies: For some, the average workday may seem filled with one stressful encounter after another. Meetings may not go as planned. Your workflow may be interrupted. The dominant sentiment might be that this is just another tough day. Is it possible that you are being too hard on yourself and in your judgments? For example, while you may feel that a meeting, interaction, or event didn’t quite go as planned, perhaps that is from your perspective. Maybe others had a different perspective and felt more positive about the encounter. Activate your personal coping strategies to decompress, relax, boost your energy, stay focused, gain perspective, and reflect on the bigger picture.
• Explore therapy. It’s a strength to recognize when we need professional help. According to a recent Value Penguin survey of more than 1,300 US adults, “nearly 30% of Americans have seen a therapist during the coronavirus pandemic, and 86% say it’s helped them cope.” Psychiatrists, psychologists, social workers, therapists, and other licensed practitioners are trained to help patients construct a personal repertoire of coping strategies. There are many forms of therapy to consider, including psychodynamic, cognitive behavioral, dialectical behavioral, mindfulness-based, and art. One or more of these modalities could help you address and manage stressful life events.

The journey from languishing to flourishing is of indeterminate length, and some of the “travel aids” listed above may be more effective than others. What we need is a means of sharing best practices—what worked well and what didn’t—multigenerational preferences and impacts, as well as other solutions that have been identified along the path. I can only wish each of you who may be experiencing a state of languishing a very safe, healthy, memorable, and rewarding trip back!