May 2017

Vol. 46, No. 5

Guest Editorial:
Don’t shoot the messenger

THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT

Imaging evaluation of acute pelvic pain in the

emergency department
JD Egusquiza and AM Durso, University of Miami/Jackson Memorial Hospital,
Miami, FL

Peripheral arteriovenous malformations:

Classification and endovascular treatment
K Lam; A Pillai; and M Reddick; University of Texas Southwestern, Dallas, TX

MRI in pregnancy: Gastrointestinal and genitourinary

pathology
JA Steinkeler and KS Lee, Beth Israel Deaconess Medical Center, Boston, MA

Technology Trends: Time for radiology to get ready for

MACRA and MIPS
Mary Beth Massat

Radiological Case
Giant hypothalamic hamartoma

WWW.APPLIEDRADIOLOGY.COM
D IF FERE N T N A M E
SAME GREAT
EXPERIENCE

Bringing you Speed, Comfort, and Quality

inspired by your patients
Hitachi Medical Systems America and Hitachi Aloka Medical America have joined forces to provide
a more customer focused approach to doing business. As of April 1, 2017, Hitachi Healthcare
Americas will be the new home of the high quality, patient centric medical imaging portfolio you’ve
come to expect with the superior service we want to deliver.

To learn more about Hitachi Healthcare, log on to www.hitachihealthcare.com.

RUNNING HEAD
EDITOR-IN-CHIEF
Stuart E. Mirvis, MD, FACR

Stuart E. Mirvis, MD, FACR

PRESIDENT Editor-in-Chief
O. Oliver Anderson University of Maryland Medical Center
EDITORIAL ADVISORY BOARD
Baltimore, MD
PUBLISHER
Kieran N. Anderson Theodore E. Keats, MD MUSCULOSKELETAL
Editor Emeritus Thomas Lee Pope, Jr., MD, FACR
EXECUTIVE EDITOR 1989-2011 Radisphere National Radiology Group
Joseph F. Jalkiewicz Beachwood, OH and Westport, CT
BREAST IMAGING
ADMINISTRATIVE EDITOR Phan T. Huynh, MD Jamshid Tehranzadeh, MD
Linda Cohen Mirvis St. Luke’s Episcopal Hospital University of California Medical Center
Texas Medical Center Orange, CA
ART DIRECTOR/PRODUCTION
Barbara A. Shopiro CARDIOVASCULAR IMAGING NEURORADIOLOGY
Elliot K. Fishman, MD Blake A. Johnson, MD, FACR
CIRCULATION DIRECTOR Johns Hopkins Hospital Center for Diagnostic Imaging
Cindy Cardinal Baltimore, MD Minneapolis, MN

TEL: 908-301-1995 FAX: 908-301-1997 CHEST IMAGING C. Douglas Phillips, MD

EMAIL: info@appliedradiology.com Jeanne B. Ackman, MD Weill Cornell Medical College/
Director of Thoracic MRI (non-vascular) New York-Presbyterian Hospital
Massachusetts General Hospital New York, NY

CIRCULATION, COVERAGE, ADVERTISING RATES: Com-

Charles S. White, MD NUCLEAR MEDICINE
plete details regarding circulation, coverage, advertising
rates, space sizes, and similar information are available to University of Maryland Wengen Chen, MD, PhD
prospective advertisers. Closing date is 30 days preced-
ing date of issue. School of Medicine University of Maryland Medical Center
Baltimore, MD Baltimore, MD
EDITORIAL CONTRIBUTIONS may be submitted by
email to our editor-in-chief at smirvis@umm.edu.If sent
by regular mail, they must be accompanied by stamped GASTROINTESTINAL IMAGING ENTERPRISE IMAGING
return envelopes and will be handled with reasonable
care; however, the publishers assume no responsibil- Marc S. Levine, MD Rasu Shrestha, MD, MBA
ity for safety of artwork, photographs, or manuscripts.
University of Pennsylvania School of Medicine University of Pittsburgh Medical Center
The opinions and recommendations expressed herein,
in articles or columns, are not necessarily those of the Philadelphia, PA Pittsburgh, PA
publishers. Every precaution is taken to ensure accu-
racy, but the publishers cannot accept responsibility for
the correctness or accuracy of the information supplied INTERVENTIONAL RADIOLOGY Eliot Siegel, MD
or for any opinion expressed. Before using procedures
or treatments discussed or suggested by authors, clini- Jeffrey C. Hellinger, MD VA Maryland Healthcare System
cians should evaluate their patients’ condition, compare Lenox Hill Radiology University of Maryland School of Medicine
the recommendations of other authorities, consider
possible contraindications or dangers, and review New York, NY Baltimore, MD
applicable manufacturer’s product information. Editorial
closing date is first day of the month 3 months prior to
issue date. Articles should be geared to the practitioner MEDICAL INDUSTRY PEDIATRIC RADIOLOGY
and should reflect practical everyday clinical applica-
tion rather than research activity. Articles may pertain Sarah Conway, MD Erin Simon Schwartz, MD
to clinical management, administration, fiscal, techni- Delphi Radiology Associates University of Pennsylvania School of Medicine
cal, and medicolegal issues. Review articles also are
solicited. Papers should be original and unpublished, Lake Forest, IL The Children’s Hospital of Philadelphia
approximately 1,500 to 2,500 words. Images should be Philadelphia, PA
original prints, slides, or electronic files (saved at a res-
olution of at least 300 dpi). Complete author guidelines Ronald B. Schilling, PhD
are available at www.appliedradiology.com. Authors
RBS Consulting Group Marilyn J. Siegel, MD, FACR
will be notified of any major recommended revisions.
Prior to publication, galleys will be sent to the author for Los Altos Hills, CA Washington University School of Medicine
final approval. Manuscripts should be sent to Stuart E.
Mirvis, MD, FACR, Editor-in-Chief, Applied Radiology, Mallinckrodt Institute of Radiology
Department of Radiology, University of Maryland Medi- MEDICOLEGAL ISSUES St. Louis, MO
cal Center, 22 South Greene Street, Baltimore, MD
21201-1595 (or smirvis@umm.edu). Michael M. Raskin, MD, MPH, JD
©2017 Anderson Publishing, Ltd. All rights University Medical Center ULTRASOUND
reserved. Reproduction in whole or part without Tamarac, FL John P. McGahan, MD
written permission is strictly prohibited.
University of California
Anderson Publishing, Ltd.
MR/CT Davis, CA
180 Glenside Avenue
Scotch Plains, NJ 07076
Lawrence N. Tanenbaum, MD, FACR
Director of CT, MR & Advanced Imaging

USPS: 0943-180
RadNet, Inc.

May 2017 1
©

www.appliedradiology.com APPLIED RADIOLOGY n

 May 2017
Vol. 46, No. 5

THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT

9 Imaging evaluation of acute pelvic pain in the

emergency department
Acute pelvic pain is a common presenting complaint in women
and determining the etiology can be difficult. There is a broad
differential diagnosis that includes causes arising from multiple
organ systems, with overlapping signs and symptoms decreas-
ing specificity. This article focuses on the imaging characteris-
tics of acute obstetric and gynecologic causes of pelvic pain
in reproductive-age women that radiologists are commonly
asked to evaluate in the emergency department.
Julio Daniel Egusquiza, MD, and Anthony M. Durso, MD
15
15 Peripheral arteriovenous malformations:
Classification and endovascular treatment
This review covers the classification and endovascular man-
agement of arteriovenous malformations (AVMs). We begin
by viewing AVMs in relation to the broader class of congenital
vascular malformations and subsequently go into more depth
on the clinical and pathologic characteristics that define AVMs.
We then focus on the endovascular treatment options for
peripheral AVMs and summarize the functional characteristics
of the sclerosants and embolic agents available to clinicians.
Kenrick Lam, MD; Anil Pillai, MD; and Mark Reddick, MD 23

23 MRI in pregnancy: Gastrointestinal and

genitourinary pathology
The presentation of abdominal pain in pregnancy is a diag-
nostic challenge for clinicians and in the setting of a confus-
ing clinical picture, imaging is a crucial tool for the evaluation
of pregnant patients with abdominal pain. MRI is beneficial in
pregnancy as it allows for excellent soft tissue contrast resolution
and the evaluation of multiple organ systems without exposure
to ionizing radiation.
Jennifer A. Steinkeler, MD, and Karen S. Lee, MD

Applied Radiology (ISSN 0160-9963, USPS 943180) is published in print 6 times a year, January, March, May, July, September, November, by Anderson Pub-
lishing Ltd at 180 Glenside Ave., Scotch Plains NJ 07076. Periodicals postage paid at Scotch Plains, NJ and additional mailing offices. Digital issues will also be
released in February, April, June, August, October, and December. Free subscriptions for US-based qualified radiology professionals. Subscriptions for the US and
its territories and possessions: $115 per year, $225 for two years. Foreign and Canadian subscriptions $215 for one year payable in US funds, international money
orders, or by credit card only. Postmaster: Please send address changes to Applied Radiology, PO Box 1317, Lowell, MA 01853-1317 (978-671-0449).

2 May 2017
©

n APPLIED RADIOLOGY www.appliedradiology.com

 ABDOMINAL DUAL-SOURCE DUAL-ENERGY CT: USES IN CLINICAL PRACTICE

May 2017
Vol. 46 No.5
DE P AR TMEN TS

RADIOLOGICAL CASE

4 GUEST EDITORIAL RADIOLOGICAL CASE

The impending “3D transformation” Giant hypothalamic hamartoma

External iliac artery pseudoaneurysm

of radiology informatics Mougnyan Cox, MD; Julia Ahn, DO; Vinay Kandula, MD; and Joseph Piatt, MD
in patient with history of failed kidney
transplant
Neil Patel; Satyam Veean; Eran Rotem, MD, MPH; and Hoang Vo, MD

Shella Farooki, MD, MPH; Jonas Almeida, PhD; CASE SUMMARY

A 9-year-old girl was referred to our
effect on the optic chiasm, and supero-
lateral displacement of the bilateral
of central precocious puberty.3 Treat-
ment is usually medical, with a focus

and Mary Morrison Saltz, MD

endocrinology service for short stature.
She was otherwise well without a his-
tory of headaches or visual symptoms.
She was a full-term baby with normal
birth weight and no prenatal abnormal-
ities. Upon endocrinologic evaluation,
she was found to have central growth
hormone deficiency and hypothyroid-
ism. She was referred to radiology for a
brain MRI to rule out a structural cause
for her multiple endocrinopathies.
IMAGING FINDINGS
MR imaging of the brain without
and with contrast was performed, and
showed a large, slightly heterogeneous
mass in the suprasellar region. The
internal carotid arteries. There was no
hydrocephalus or vascular encasement/
narrowing. The pituitary gland was sep-
arate from the mass, and the sella was
not expanded.
DIAGNOSIS
Giant hypothalamic hamartoma.
Differential diagnosis includes cranio-
pharyngioma, pituitary macroadenoma,
and germ cell tumor.
DISCUSSION
Hypothalamic hamartomas are con-
genital malformations characterized by
disorganized but normal neural tissue in
the hypothalamic region.1 Patients with
on correcting any associated endocri-
nologic abnormalities or controlling CASE SUMMARY DIAGNOSIS developed a pseudoaneurysm at the
seizures. Surgery is usually reserved forA 66-year-old African-American Multiple bilateral hypervascular anastomotic site.2 This is the case in
medically refractory seizures, or preco-
male presented with a four-month his- masses were suspected to be the source the patient presented in this report. The
cious puberty in some cases.4,5 tory of asymptomatic hematuria. Inter- of the hematuria. Angiogram also incidental pseudoaneurysm discovered
On imaging, hypothalamic ham- ventional Radiology was consulted for showed an incidental finding of a pseu- in this patient was at the site of anasto-
artomas are similar in appearanceembolization
to of bilateral native arter- doaneurysm in the right external iliac moses of the right external iliac artery to
distorted but normal brain tissue. 6
ies in this patient on hemodialysis. His artery. the graft renal artery.
Hypothalamic hamartomas arise from past medical history was significant It is also important to note that this
the floor of the third ventricle and proj-
for end-stage renal disease secondary DISCUSSION patient’s pseudoaneurysm was not
ect into the suprasellar cistern. Whento polycystic kidney disease. Patient A pseudoaneurysm occurs due to associated with some of the common
large, these lesions can distort underwent
the right kidney transplantation a disruption in an arterial wall. The symptoms that are seen in patients
suprasellar cistern and compress or dis-
21 years ago, which ultimately failed 15 high-pressure arterial blood stretches with pseudoaneurysms. These com-
place multiple structures includingyears
the ago. the weakened arterial wall and creates mon symptoms include but are not lim-
optic chiasm and prechiasmatic optic a communicating sac within the lumen ited to pain, swelling, pulsatile mass,
nerves, internal carotid arteries, andIMAGING FINDINGS of the artery. The sac is surrounded by and symptoms associated with nerve
pituitary stalk. On CT, these lesionsCT scan of the pelvis showed multi- the adventitia and media of the vessel. and vein compression, such as venous

29
mass was isointense to the brain on hypothalamic hamartomas classically appear isodense to the normal brain ple avidly enhancing lesions of various There are many causes of pseudoaneu- thrombosis and neuropathy.3

TECHNOLOGY TRENDS
the unenhanced T1- and T2-weighted
images (Figures 1 and 2), without
abnormal enhancement (Figure 3). The
mass had a cerebriform appearance,
resembling a ‘brain-within-a-brain’
architecture. There was associated mass
present with gelastic seizures (laughing
seizures), but other seizures types may
also occur.2 Hypothalamic hamartomas
are also an important structural cause
of precocious puberty, and have been
reported to be the most common cause
parenchyma, and do not enhance after sizes throughout bilateral native kid- rysms with the most common being due In the few instances that a pseudo-
contrast administration. Hemorrhage neys (Figure 1). Subsequently, angiog- to inflammation, iatrogenic surgical or aneurysm has been described at the
and calcification within hypothalamic raphy was done in order to evaluate for catheterization injuries, and trauma.1 anastomotic site of a failed renal trans-
hamartomas are exceedingly rare. MRI embolization. A digitally subtracted There have also been a few rare inci- plant, the discovery of the pseudoan-
imaging shows a soft tissue mass inoblique
the image of the right external dences where pseudoaneurysms have eurysm has been within several weeks
hypothalamic region that is isointenseiliac artery demonstrated a pseudoan- been discovered in patients with failed of transplantation or at the time of fail-

Industry perspectives on the

eurysm (Figure 2). Finally, a digitally
subtracted image after covered stent
2 APPLIED RADIOLOGY Month 2017
placement showed no pseudoaneurysm
©
renal transplants. One particular study ure. In one particular case, bruits were
looked at 843 renal transplants per- heard over an anastomotic site only five
formed over a 37-year period. Only weeks after transplantation. Further

n www.appliedradiology.com
filling (Figure 3). three, or 0.35 percent, of those patients investigation using arteriography in this

2 APPLIED RADIOLOGY Month 2017

©

www.appliedradiology.com

future of medical imaging

n

Mary Beth Massat ONLINE RADIOLOGICAL CASE

Giant hypothalamic hamartoma
Mougnyan Cox, MD; Julia Ahn, DO; Vinay
32 WET READ Kandula, MD; and Joseph Piatt, MD
Reading room treats ONLINE RADIOLOGICAL CASE
C. Douglas Phillips, MD, FACR Ruptured cholecystitis with
intrahepatic biloma
Jignesh Patel, MD; John Chang, MD, PhD;
and Rizvan Mirza, MD

Erratum
“Safety of Gadolinium-Based Contrast Agents in Adult & Pediatric Patients,” a supplement that accompanied the March
2017 issue of Applied Radiology, inadvertently contained an outdated ACR table which included a misstatement regard-
ing the status of gadoterate meglumine (Dotarem®)— “as of this writing not FDA-approved for use in the U.S.” Gadoterate
meglumine (Dotarem®) was approved by the U.S. FDA in 2013 for MRI of the CNS in adults and pediatric patients (2 years
of age and older). Applied Radiology regrets the error.
A corrected Table 2 is displayed here which has also been modified to reflect that gadoversetamide (OptiMARK™) has
since been acquired by Guerbet.

Table 2. ACR Classification of GBCAs in Terms of NSF Risk6

Group 1: Agents associated with the greatest number of NSF cases

Gadodiamide (Omniscan® — GE Healthcare)
Gadopentetate dimeglumine (Magnevist® — Bayer HealthCare Pharmaceuticals)
Gadoversetamide (OptiMARK® — Guerbet)
Group II: Agents associated with few, if any, unconfounded cases of NSF
Gadobenate dimeglumine (MultiHance® — Bracco Diagnostics)
Gadobutrol (Gadevist® — Bayer HealthCare Pharmaceuticals)
Gadoterate meglumine (Dotarem® — Guerbet)
Gadoteridol (ProHance® — Bracco Diagnostics)
Group III: Agents that have only recently appeared on the market
Gadofosveset trisodium (Ablavar® — Lantheus Medical Imaging)
Gadoxetate disodium (Eovist® —Bayer HealthCare Pharmaceuticals)

November
May 2017 2013 3
©

www.appliedradiology.com APPLIED RADIOLOGY n

GUEST
EDITORIAL
Don’t shoot the messenger
Michael M. Raskin, MD, MPH, JD
When creating
I
your reports, try recently learned that a radiologist was
found liable in a malpractice lawsuit
to put yourself after a lung cancer patient perceived his
report as “bad news” and died as the result
in the patient’s of suicide.1 The radiologist was aware that
shoes and think: the patient was undergoing psychiatric treat-
ment for depression and was receiving radia-
How would I or tion following lung resection.
“Don’t shoot the messenger” is a cliché
one of my family often used to avoid blaming or punishing the
bearer of bad news. We have all heard this
members respond cliché; many of us have probably used it
many times over, and even though the law-
to the same suit was not a case from the United States,
it raises the question: Could it happen here?
news? Could a radiologist in the United States
be held liable for medical malpractice for
reporting “bad news”?
Historically, radiology reports have been
sent only to treating physicians, not to their
patients. Radiologists and other clinicians
were not comfortable with patients receiv-
ing their reports, especially in the event of
abnormal findings. This attitude has soft-
Dr. Raskin is a Clinical Associate Professor of Radiology at the University of Miami School of Medicine, and a neu-
roradiologist at University Medical Center, Tamarac, FL. He is also a member of the Applied Radiology Editorial
Advisory Board.
4 May 2017
©
n APPLIED RADIOLOGY www.appliedradiology.com
ened over the years, especially after the
Mammography Quality Standards Act of
1999, which mandated that patients receive
a plain-language summary of their report
within 30 days of their mammogram.
And despite physician concerns that
receiving certain abnormal test results could
place patients at risk for psychological harm,
federal law has made it mandatory since
2014 for physicians and hospitals to provide
patients with copies of their medical records
upon request.
To date, there has not been a malpractice
case in the U.S. because a radiologist sent a
report that was considered to be bad news by
a patient. But that doesn’t mean that it can’t
occur. Now that patients have the right to
their medical records, including radiology
reports, they may receive “bad news” before
the ordering physician has explained the
results to them. Radiologists should expect
that their reports will be increasingly read by
patients. The potential for patients acting on
perceived “bad news” will increase with time.
continued on page 8

Global clinical experience with over 60 million doses administered worldwide.2
INDICATION1
DOTAREM is a gadolinium-based contrast agent indicated for intravenous use with
magnetic resonance imaging (MRI) in brain (intracranial), spine and associated tissues
in adult and pediatric patients (2 years of age and older) to detect and visualize areas
with disruption of the blood brain barrier (BBB) and/or abnormal vascularity.
IMPORTANT SAFETY INFORMATION1
WARNING: NEPHROGENIC SYSTEMIC FIBROSIS (NSF)
Gadolinium-based contrast agents (GBCAs) increase the risk for NSF among
patients with impaired elimination of the drugs. Avoid use of GBCAs in these
patients unless the diagnostic information is essential and not available with
non-contrasted MRI or other modalities. NSF may result in fatal or debilitating
fibrosis affecting the skin, muscle and internal organs.
• The risk for NSF appears highest among patients with:
– Chronic, severe kidney disease (GFR < 30 mL/min/1.73m2), or
– Acute kidney injury.
• Screen patients for acute kidney injury and other conditions that may
reduce renal function. For patients at risk for chronically reduced renal
function (for example, age > 60 years, hypertension or diabetes), estimate
the glomerular filtration rate (GFR) through laboratory testing
[see Warnings and Precautions].
• For patients at highest risk for NSF, do not exceed the recommended DOTAREM
dose and allow a sufficient period of time for elimination of the drug from the
body prior to any re-administration [see Warnings and Precautions].
Contraindicated in patients with a history of clinically important hypersensitivity
reactions to DOTAREM.
The possibility of serious or life-threatening anaphylactoid/anaphylactic reactions
with cardiovascular, respiratory or cutaneous manifestations, ranging from mild to
severe, including death, should be considered. Monitor patients closely for need of
emergency cardiorespiratory support.
Macrocyclic and Ionic...
DOTAREM
...There is only One.
The first and only macrocyclic and
ionic gadolinium agent in its class.1
Representative images. Individual results may vary.
In patients with chronically reduced renal function, acute kidney injury
requiring dialysis has occurred with the use of GBCAs. The risk of acute
kidney injury may increase with increasing dose of the contrast agent;
administer the lowest dose necessary for adequate imaging. Screen all
patients for renal impairment by obtaining a history and/or laboratory
tests. Consider follow-up renal function assessments for patients with a
history of renal dysfunction.
Ensure catheter and venous patency before the injection of DOTAREM.
Extravasation into tissues during DOTAREM administration may result in
tissue irritation.
The most common adverse reactions associated with DOTAREM in
clinical studies were nausea, headache, injection site pain, injection site
coldness, and burning sensation.
For more information about DOTAREM, including Boxed WARNING,
please see the Full Prescribing Information.
Please see adjacent Brief Summary of Prescribing Information.
DOTAREM is a registered trademark of Guerbet and is available by
prescription only.
GU01171000
References: 1. DOTAREM® [package insert]. Bloomington, IN: Guerbet
LLC; 2014. 2. Data on file, Guerbet LLC.
www.guerbet-us.com
DOTAREM® (gadoterate meglumine) sufficient period of time for elimination of the drug prior to re-administration. For patients 7 DRUG INTERACTIONS
Injection for intravenous use receiving hemodialysis, physicians may consider the prompt initiation of hemodialysis DOTAREM does not interfere with serum and plasma calcium measurements determined by
Initial U.S. Approval: 2013 following the administration of a GBCA in order to enhance the contrast agent’s colorimetric assays. Specific drug interaction studies with DOTAREM have not been conducted.
elimination. The usefulness of hemodialysis in the prevention of NSF is unknown [see
FULL PRESCRIBING INFORMATION Dosage and Administration (2) and Clinical Pharmacology (12)]. 8 USE IN SPECIFIC POPULATIONS
WARNING: NEPHROGENIC SYSTEMIC FIBROSIS (NSF) 5.2 Hypersensitivity Reactions Anaphylactic and anaphylactoid reactions have 8.1 Pregnancy
Gadolinium-based contrast agents (GBCAs) increase the risk for NSF among patients been reported with DOTAREM, involving cardiovascular, respiratory, and/or cutaneous
with impaired elimination of the drugs. Avoid use of GBCAs in these patients unless manifestations. Some patients experienced circulatory collapse and died. In most cases, Pregnancy Category C
the diagnostic information is essential and not available with non-contrasted MRI or initial symptoms occurred within minutes of DOTAREM administration and resolved with Risk Summary
other modalities. NSF may result in fatal or debilitating fibrosis affecting the skin, prompt emergency treatment [see Adverse Reactions (6)]. There are no adequate and well-controlled studies with DOTAREM conducted in pregnant
muscle and internal organs. • Before DOTAREM administration, assess all patients for any history of a reaction to women. Limited published human data on exposure to other GBCAs during pregnancy did
• The risk for NSF appears highest among patients with: contrast media, bronchial asthma and/or allergic disorders. These patients may have an not show adverse effects in exposed neonates. No effects on embryo fetal development
- Chronic, severe kidney disease (GFR < 30 mL/min/1.73m2), or increased risk for a hypersensitivity reaction to DOTAREM. were observed in rats or rabbits at doses up to 10 mmol/kg/day in rats or 3 mmol/
- Acute kidney injury. • Administer DOTAREM only in situations where trained personnel and therapies are kg/day in rabbits. The doses in rats and rabbits were respectively 16 and 10 times the
• Screen patients for acute kidney injury and other conditions that may reduce renal promptly available for the treatment of hypersensitivity reactions, including personnel recommended human dose based on body surface area. DOTAREM should be used during
function. For patients at risk for chronically reduced renal function (e.g. age > 60 trained in resuscitation. pregnancy only if the potential benefit justifies the potential risk to the fetus.
years, hypertension, diabetes), estimate the glomerular filtration rate (GFR) • During and following DOTAREM administration, observe patients for signs and symptoms
through laboratory testing (5.1). of hypersensitivity reactions. Human Data
• For patients at highest risk for NSF, do not exceed the recommended DOTAREM While it is unknown if DOTAREM crosses the human placenta, other GBCAs do cross the
dose and allow a sufficient period of time for elimination of the drug from the body 5.3 Acute Kidney Injury In patients with chronically reduced renal function, acute kidney injury placenta in humans and result in fetal exposure.
prior to any re-administration [see Warnings and Precautions (5.1)]. requiring dialysis has occurred with the use of GBCAs. The risk of acute kidney injury may increase
with increasing dose of the contrast agent; administer the lowest dose necessary for adequate Animal Data
1 INDICATIONS AND USAGE imaging. Screen all patients for renal impairment by obtaining a history and/or laboratory tests. Reproductive and developmental toxicity studies were conducted with gadoterate
DOTAREM is a gadolinium-based contrast agent indicated for intravenous use with Consider follow-up renal function assessments for patients with a history of renal dysfunction. meglumine in rats and rabbits. Gadoterate meglumine was administered intravenously in
magnetic resonance imaging (MRI) in brain (intracranial), spine and associated tissues in doses of 0, 2, 4 and 10 mmol/kg/day (or 3.2, 6.5 and 16.2 times the recommended
5.4 Extravasation and Injection Site Reactions Ensure catheter and venous patency human dose based on body surface area) to female rats for 14 days before mating
adult and pediatric patients (2 years of age and older) to detect and visualize areas with before the injection of DOTAREM. Extravasation into tissues during DOTAREM administration throughout the mating period and until gestation day (GD) 17. Pregnant rabbits were
disruption of the blood brain barrier (BBB) and/or abnormal vascularity. may result in tissue irritation [see Nonclinical Toxicology (13.2)]. intravenously administered gadoterate meglumine at the dose levels of 0, 1, 3 and 7
2 DOSAGE AND ADMINISTRATION 6 ADVERSE REACTIONS mmol/kg/day (or 3.3, 10 and 23 times the human doses based on body surface area)
2.1 Dosing Guidelines For adult and pediatric patients (2 years and older), the GBCAs have been associated with a risk for NSF [see Warnings and Precautions (5.1)]. from GD6 to GD19. No effects on embryo fetal development were observed in rats or
recommended dose of DOTAREM is 0.2 mL/kg (0.1 mmol/kg) body weight NSF has not been reported in patients with a clear history of exposure to DOTAREM alone. rabbits at doses up to 10 mmol/kg/day in rats or 3 mmol/kg/day in rabbits. Maternal
administered as an intravenous bolus injection, manually or by power injector, at a flow toxicity was observed in rats at 10 mmol/kg/day (or 16 times the human dose based on
rate of approximately 2 mL/second for adults and 1-2 mL/second for pediatric patients. Hypersensitivity reactions and acute kidney injury are described in other sections of the body surface area) and in rabbits at 7 mmol/kg/day (23 times the human dose based
Table 1 provides weight-adjusted dose volumes. labeling [see Warnings and Precautions (5.2) and (5.3)]. on body surface area).
Table 1: Volumes of DOTAREM Injection by Body Weight 6.1 Clinical Studies Experience Because clinical trials are conducted under widely 8.3 Nursing Mothers
varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be It is not known whether DOTAREM is excreted in human milk. Limited case reports on use
Body Weight Volume directly compared to rates in the clinical trials of another drug and may not reflect the rates of GBCAs in nursing mothers indicate that 0.01 to 0.04% of the maternal gadolinium
Pounds (lb) Kilograms (kg) Milliliters (mL) observed in clinical practice.
22 10 2 dose is excreted in human breast milk. Because many drugs are excreted in human milk,
44 20 4 The data described below reflect DOTAREM exposure in 2813 patients, representing 2672 exercise caution when DOTAREM is administered to a nursing woman. Nonclinical data
66 30 6 adults and 141 pediatric patients. Overall, 55% of the patients were men. In clinical trials show that gadoterate meglumine is excreted into breast milk in very small amounts
88 40 8 where ethnicity was recorded the ethnic distribution was 74% Caucasian, 12% Asian, 4% (< 0.1% of the dose intravenously administered) and absorption via the gastrointestinal
110 50 10 Black, and 10% others. The average age was 53 years (range from 0.1 to 97 years). tract is poor.
132 60 12 Overall, 3.9% of patients reported at least one adverse reaction, primarily occurring 8.4 Pediatric Use
154 70 14 immediately or several days following DOTAREM administration. Most adverse reactions The safety and efficacy of DOTAREM at a single dose of 0.1 mmol/kg have been
176 80 16 were mild or moderate in severity and transient in nature. established in pediatric patients from 2 to 17 years of age. No dosage adjustment
198 90 18 according to age is necessary in this population [See Dosage and Administration (2.1) and
220 100 20 Table 2 lists adverse reactions that occurred in ≥ 0.2% patients who received DOTAREM.
Clinical Studies (14)]. The safety and efficacy of DOTAREM have not been established in
242 110 22 Table 2: Adverse Reactions in Clinical Trials pediatric patients below 2 years of age. GFR does not reach adult levels until 1 year of age
264 120 24 [see Warnings and Precautions (5.1)].
286 130 26 Reaction Rate (%) n=2813
308 140 28 Nausea 0.6% 8.5 Geriatric Use
330 150 30 Headache 0.5% In clinical studies of DOTAREM, 900 patients were 65 years of age and over, and 312
Injection Site Pain 0.4% patients were 75 years of age and over. No overall differences in safety or efficacy were
To ensure complete injection of DOTAREM the injection may be followed by normal saline Injection Site Coldness 0.2% observed between these subjects and younger subjects. In general, use of DOTAREM
flush. Contrast MRI can begin immediately following DOTAREM injection. Burning Sensation 0.2% in elderly patients should be cautious, reflecting the greater frequency of impaired renal
2.2 Drug Handling Visually inspect DOTAREM for particulate matter prior to Adverse reactions that occurred with a frequency < 0.2% in patients who received function and concomitant disease or other drug therapy. No age-related dosage adjustment
administration. Do not use the solution if particulate matter is present or if the container DOTAREM include: feeling cold, rash, somnolence, fatigue, dizziness, vomiting, is necessary.
appears damaged. DOTAREM should be a clear, colorless to yellow solution. Do not mix pruritus, paresthesia, dysgeusia, pain in extremity, anxiety, hypertension, palpitations, 8.6 Renal Impairment
with other drugs or parenteral nutrition. Discard any unused portions of the drug. oropharyngeal discomfort, serum creatinine increased and injection site reactions, including No DOTAREM dosage adjustment is recommended for patients with renal impairment.
site inflammation, extravasation, pruritus, and warmth. Gadoterate meglumine can be removed from the body by hemodialysis [see Warnings and
When DOTAREM is to be injected using plastic disposable syringes, the contrast medium
should be drawn into the syringe and used immediately. Adverse Reactions in Pediatric Patients Precautions (5.1) and Clinical Pharmacology (12.3)].
During clinical trials, 141 pediatric patients (7 aged < 24 months, 33 aged 2 - 5 years, 58 10 OVERDOSAGE
3 DOSAGE FORMS AND STRENGTHS DOTAREM 0.5 mmol/mL is a sterile, aged 6 - 11 years and 43 aged 12 - 17) received DOTAREM. Overall, 6 pediatric patients
clear, colorless to yellow, aqueous solution for intravenous injection containing 376.9 mg/ (4.3%) reported at least one adverse reaction following DOTAREM administration. The most DOTAREM administered to healthy volunteers and to patients at cumulative doses up
mL gadoterate meglumine and is available in vials and pre-filled syringes. to 0.3 mmol/kg was tolerated in a manner similar to lower doses. Adverse reactions
frequently reported adverse reaction was headache (1.5%). Most adverse events were mild in to overdosage with DOTAREM have not been reported. Gadoterate meglumine can be
4 CONTRAINDICATIONS History of clinically important hypersensitivity reactions to severity and transient in nature, and all patients recovered without treatment. removed from the body by hemodialysis [See Clinical Pharmacology (12.3)].
DOTAREM [see Warnings and Precautions (5.2)]. 6.2 Postmarketing Experience The following additional adverse reactions have been 11 DESCRIPTION
5 WARNINGS AND PRECAUTIONS identified during postmarketing use of DOTAREM. Because these reactions are reported DOTAREM (gadoterate meglumine) is a paramagnetic macrocyclic ionic contrast agent
5.1 Nephrogenic Systemic Fibrosis Gadolinium-based contrast agents (GBCAs) increase voluntarily from a population of uncertain size, it is not always possible to reliably estimate administered for magnetic resonance imaging. The chemical name for gadoterate
the risk for nephrogenic systemic fibrosis (NSF) among patients with impaired elimination their frequency or establish a causal relationship to drug exposure. meglumine is D-glucitol, 1-deoxy-1-(methylamino)-,[1,4,7,10-tetraazacyclododecane-
of the drugs. Avoid use of GBCAs among these patients unless the diagnostic information is Table 3: Adverse Reactions in the Postmarketing Experience 1,4,7,10-tetraaceto(4-)-.kappa.N1, .kappa.N4, .kappa.N7, .kappa.N10, .kappa.O1,
essential and not available with non-contrast MRI or other modalities. The GBCA-associated .kappa.O4, .kappa.O7, .kappaO10]gadolinate(1-)(1:1); it has a formula weight of
NSF risk appears highest for patients with chronic, severe kidney disease (GFR < 30 System Organ Class Adverse Reaction 753.9 g/mol and empirical formula of C23H42O13N5Gd (anhydrous basis).
mL/min/1.73m ) as well as patients with acute kidney injury. The risk appears lower
2
Cardiac Disorders bradycardia, tachycardia, arrythmia
for patients with chronic, moderate kidney disease (GFR 30 - 59 mL/min/1.73m ) 2 The structural formula of gadoterate meglumine in solution is as follows:
and little, if any, for patients with chronic, mild kidney disease (GFR 60 - 89 mL/ Immune System Disorders hypersensitivity / anaphylactoid reactions including cardiac
min/1.73m2). NSF may result in fatal or debilitating fibrosis affecting the skin, muscle arrest, respiratory arrest, cyanosis, pharyngeal edema, CAS Registry No. 92943-93-6
and internal organs. Report any diagnosis of NSF following DOTAREM administration to laryngospasm, bronchospasm, angioedema, conjunctivitis,
Guerbet LLC (1-877-729-6679) or FDA (1-800-FDA-1088 or www.fda.gov/medwatch). ocular hyperemia, eyelid edema, lacrimation increased,
hyperhidrosis, urticaria
Screen patients for acute kidney injury and other conditions that may reduce renal function. Nervous System Disorders coma, convulsion, syncope, presyncope, parosmia, tremor
Features of acute kidney injury consist of rapid (over hours to days) and usually reversible
decrease in kidney function, commonly in the setting of surgery, severe infection, injury or Musculoskeletal & muscle contracture, muscle weakness
drug-induced kidney toxicity. Serum creatinine levels and estimated GFR may not reliably Connective Tissues Disorders
assess renal function in the setting of acute kidney injury. For patients at risk for chronically Gastrointestinal Disorders diarrhea, salivary hypersecretion
reduced renal function (e.g., age > 60 years, diabetes mellitus or chronic hypertension), General Disorders & malaise, fever
estimate the GFR through laboratory testing. Administration Site Conditions
Skin & Subcutaneous Tissue NSF, in patients whose reports were confounded by the
Among the factors that may increase the risk for NSF are repeated or higher than Disorders receipt of other GBCAs or in situations where receipt of other DOTAREM Injection is a sterile, nonpyrogenic, clear, colorless to yellow, aqueous solution of
recommended doses of a GBCA and the degree of renal impairment at the time of GBCAs could not be ruled out. No unconfounded cases of 0.5 mmol/mL of gadoterate meglumine. No preservative is added. Each mL of DOTAREM
exposure. Record the specific GBCA and the dose administered to a patient. For patients NSF have been reported with DOTAREM. contains 376.9 mg of gadoterate meglumine, 0.25 mg of DOTA and water for injection.
at highest risk for NSF, do not exceed the recommended DOTAREM dose and allow a Vascular Disorders superficial phlebitis DOTAREM has a pH of 6.5 to 8.0.
The main physiochemical properties of DOTAREM are provided below: 13 NONCLINICAL TOXICOLOGY Each single dose vial is closed with a rubber stopper and sealed with an aluminum cap and
the contents are sterile. Vials are individually packaged in a shrink wrapped package of 10,
Table 4: Physicochemical Properties 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility in the following configurations:
Long-term animal studies have not been performed to evaluate the carcinogenic potential 10 mL in glass vial (NDC 67684-2000-1)
Parameter Value of gadoterate meglumine. 15 mL in glass vial (NDC 67684-2000-2)
Density @ 20°C 1.1753 g/cm3 Gadoterate meglumine did not demonstrate mutagenic potential in in vitro bacterial reverse 20 mL in glass vial (NDC 67684-2000-3)
mutation assays (Ames test) using Salmonella typhimurium, in an in vitro chromosome • DOTAREM Injection is supplied in 10 mL pre-filled syringes containing 10 mL of solution
Viscosity @ 20°C 3.4 mPa s . aberration assay in Chinese hamster ovary cells, in an in vitro gene mutation assay in and 20 mL pre-filled syringes containing 15 mL or 20 mL of solution.
Viscosity @ 37°C 2.4 mPa s . Chinese hamster lung cells, nor in an in vivo mouse micronucleus assay.
Each syringe is sealed with rubber closures and the contents are sterile. Syringes,
Osmolality 1350 mOsm/kg water No impairment of male or female fertility and reproductive performance was observed in including plunger rod, are packaged in a shrink wrapped package of 5, in the following
rats after intravenous administration of gadoterate meglumine at the maximum tested configurations:
The thermodynamic stability constants for gadoterate (log Ktherm and log Kcond at pH 7.4) are dose of 10 mmol/kg/day (16 times the maximum human dose based on surface area), 10 mL in glass pre-filled syringe (NDC 67684-2000-5)
25.6 and 19.3, respectively. given during more than 9 weeks in males and more than 4 weeks in females. Sperm 15 mL in glass pre-filled syringe (NDC 67684-2000-6)
counts and sperm motility were not adversely affected by treatment with the drug. 20 mL in glass pre-filled syringe (NDC 67684-2000-7)
12 CLINICAL PHARMACOLOGY
13.2 Animal Toxicology and/or Pharmacology Storage
12.1 Mechanism of Action Local intolerance reactions, including moderate irritation associated with infiltration of
Gadoterate is a paramagnetic molecule that develops a magnetic moment when placed in inflammatory cells were observed after perivenous injection in rabbits suggesting the Store at 25°C (77°F); excursions permitted to 15°C to 30°C (59°F to 86°F) [see USP,
a magnetic field. The magnetic moment enhances the relaxation rates of water protons in possibility of local irritation if the contrast medium leaks around the veins in a clinical Controlled Room Temperature (CRT)].
its vicinity, leading to an increase in signal intensity (brightness) of tissues. setting [see Warnings and Precautions (5.4)]. Pre-filled syringes must not be frozen. Frozen syringes should be discarded.
In magnetic resonance imaging (MRI), visualization of normal and pathological tissue Should solidification occur in the vial because of exposure to the cold, DOTAREM should be
depends in part on variations in the radiofrequency signal intensity that occurs with: 14 CLINICAL STUDIES
Efficacy and safety of DOTAREM were evaluated in a multi-center clinical trial (Study brought to room temperature before use. If allowed to stand at room temperature for a
1) differences in proton density minimum of 90 minutes, DOTAREM should return to a clear, colorless to yellow solution.
2) differences of the spin-lattice or longitudinal relaxation times (T1) A) that enrolled 364 adult and 38 pediatric patients (aged ≥ 2 years) with known
or suspected CNS lesions. Adults were randomized 2 to 1 to receive either DOTAREM Before use, examine the product to assure that all solids are redissolved and that the
3) differences in the spin-spin or transverse relaxation time (T2) container and closure have not been damaged. Should solids persist, discard the vial.
or gadopentetate dimeglumine, each administered at a dose of 0.1 mmol/kg. All
When placed in a magnetic field, gadoterate shortens the T1 and T2 relaxation times in pediatric patients received DOTAREM, also at a dose of 0.1 mmol/kg. In the trial, Directions for Use of the DOTAREM (gadoterate meglumine) Injection glass pre-filled syringe:
target tissues. At recommended doses, the effect is observed with greatest sensitivity in the patients first underwent a baseline (pre-contrast) MRI examination followed by the
T1-weighted sequences. assigned GBCA administration and a post-contrast MR examination. The images 1) Screw the threaded tip of the plunger rod clockwise into the cartridge plunger and
(pre-contrast, post-contrast and “paired pre- and post-contrast”) were interpreted by push forward a few millimeters to break any friction between the cartridge plunger and
12.2 Pharmacodynamics three independent off-site readers blinded to clinical information. The primary efficacy syringe barrel.
Gadoterate affects proton relaxation times and consequently the MR signal, and the analysis compared three patient-level visualization scores (paired images) to baseline
contrast obtained is characterized by the relaxivity of the gadoterate molecule. The 2) Holding the syringe vertically so the rubber cap is pointed upward, aseptically remove
MRI (pre-contrast images) for adults who received DOTAREM. The three primary
relaxivity values for gadoterate are similar across the spectrum of magnetic field strengths visualization components were: contrast enhancement, border delineation and internal the rubber cap from the tip of the syringe and attach either a sterile, disposable needle or
used in clinical MRI (0.2-1.5 T). compatible needleless luer lock tubing set using a push-twist action. At this point, the tubing
morphology. For each of these components there was a pre-defined scoring scale. set is not attached to a patient’s intravenous connection.
Gadoterate does not cross the intact blood-brain barrier and, therefore, does not enhance Lesion counting (up to five per patient) was also reflected within each component’s • If using a needleless luer lock tubing set, check the connection between the syringe and
normal brain or lesions that have a normal blood-brain barrier, e.g. cysts, mature patient-level visualization score. the tubing as the fluid flows. Ensure that the connection is successful before
post-operative scars. However, disruption of the blood-brain barrier or abnormal vascularity Among the adult patients, 245 received DOTAREM and their data comprised the primary administration of DOTAREM Injection.
allows distribution of gadoterate in lesions such as neoplasms, abscesses, and infarcts. efficacy population. There were 114 (47%) men and 131 (53%) women with a mean • If using a needle, hold the syringe vertically and push plunger forward until all of the
12.3 Pharmacokinetics age of 53 years (range 18 to 85 years), the racial and ethnic representations were 84% air is evacuated and fluid either appears at the tip of the needle or the tubing is filled.
The pharmacokinetics of total gadolinium following an intravenously administered 0.1 Caucasian, 11% Asian, 4% Black, and 1% other. Following the usual venous blood aspiration procedure, complete the DOTAREM injection.
mmol/kg dose of DOTAREM in normal subjects conform to a one-compartment open- Table 6 displays a comparison of paired images (pre-and post-contrast) to pre-contrast 3) To ensure complete delivery of the contrast medium, the injection may be followed by
model with a mean elimination half-life (reported as mean ± SD) of about 1.4 ± 0.2 hr images with respect to the proportion of patients who had paired image scores that were a normal saline flush.
and 2.0 ± 0.7 hr in female and male subjects, respectively. Similar pharmacokinetic profile greater “better”, or same/worse “not better” than the pre-contrast scores and with
and elimination half-life values were observed after intravenous injection of 0.1 mmol/kg respect to the difference in the mean patient level visualization score. Across the three 4) Properly dispose of the syringe and any other materials used.
of DOTAREM followed 20 minutes later by a second injection of 0.2 mmol/kg (1.7 ± 0.3 readers 56% to 94% of patients had improved lesion visualization for paired images
hr and 1.9 ± 0.2 hr in female and male subjects, respectively). compared to pre-contrast images. DOTAREM provided a statistically significant improvement
Distribution for all three primary visualization components. More lesions were seen on the paired
The volume of distribution at steady state of total gadolinium in normal subjects is images than the pre-contrast images.
179 ± 26 and 211 ± 35 mL/kg in female and male subjects respectively, roughly Table 6: Study A. Improvement in Patient-level Lesion Visualization Scores,
equivalent to that of extracellular water. Paired versus Pre-contrast Images(a)
Gadoterate does not undergo protein binding in vitro. The extent of blood cell partitioning Reader 1 Reader 2 Reader 3
of gadoterate is not known. Lesion Scores n = 231 n = 232 n = 237
Metabolism Border Delineation
Gadoterate is not known to be metabolized. Better 195 (84%) 215 (93%) 132 (56%) 17 PATIENT COUNSELING INFORMATION
Not Better 28 (12%) 7 (3%) 88 (37%) 17.1 Nephrogenic Systemic Fibrosis
Elimination Missing 8 (4%) 10 (4%) 17 (7%)
Following a 0.1 mmol/kg dose of DOTAREM, total gadolinium is excreted primarily in the Instruct patients to inform their healthcare provider if they:
urine with 72.9 ± 17.0% and 85.4 ± 9.7% (mean ± SD) eliminated within 48 hours, Difference in Mean Score (b)
2.26* 2.89* 1.17* 1. have a history of kidney disease, or
in female and male subjects, respectively. Similar values were achieved after a cumulative Internal Morphology 2. have recently received a GBCA.
dose of 0.3 mmol/kg (0.1 + 0.2 mmol/kg, 20 minutes later), with 85.5 ± 13.2% and Better 218 (94%) 214 (93%) 187 (79%)
GBCAs increase the risk for NSF among patients with impaired elimination of the drugs. To
92.0 ± 12.0% recovered in urine within 48 hrs in female and male subjects respectively. Not Better 5 (2%) 8 (3%) 33 (14%)
Missing 8 (4%) 10 (4%) 17 (7%) counsel patients at risk for NSF:
In healthy subjects, the renal and total clearance rates of total gadolinium are comparable Difference in Mean Score (b) • Describe the clinical manifestations of NSF.
2.74* 2.75* 1.54* • Describe procedures to screen for the detection of renal impairment.
(1.27 ± 0.32 and 1.74 ± 0.12 mL/min/kg in females; and 1.40 ± 0.31 and Contrast Enhancement
1.64 ± 0.35 mL/min/kg in males, respectively) indicating that the drug is primarily Better 208 (90%) 216 (93%) 208 (88%) Instruct the patients to contact their physician if they develop signs or symptoms of NSF
cleared through the kidneys. Within the studied dose range (0.1 to 0.3 mmol/kg), the Not Better 15 (6%) 6 (3%) 12 (5%) following DOTAREM administration, such as burning, itching, swelling, scaling, hardening
kinetics of total gadolinium appear to be linear. Missing 8 (4%) 10 (4%) 17 (7%) and tightening of the skin; red or dark patches on the skin; stiffness in joints with trouble
Special Populations Difference in Mean Score (b)
3.09* 3.69* 2.92* moving, bending or straightening the arms, hands, legs or feet; pain in the hip bones or
ribs; or muscle weakness.
Renal Impairment (a) Better: number of patients with paired (pre-and post-contrast) score greater than the
A single intravenous dose of 0.1 mmol/kg of DOTAREM was administered to 8 patients (5 pre-contrast score. Not better: number of patients with paired score same as or worse than 17.2 Common Adverse Reactions
men and 3 women) with impaired renal function (mean serum creatinine of the pre-contrast score. Missing: number of patients with missing score Inform patients that they may experience:
498 ± 98 µmol/L in the 10-30 mL/min creatinine clearance group and 192 ± 62 µmol/L (b) Difference = paired mean score minus pre-contrast mean score • Reactions along the venous injection site, such as mild and transient burning or pain or
in the 30-60 mL/min creatinine clearance group). Renal impairment delayed the elimination *Statistically significant improvement by paired t-test feeling of warmth or coldness at the injection site.
of total gadolinium. Total clearance decreased as a function of the degree of renal impairment. In secondary analyses, post-contrast images were improved in comparison to pre-contrast • Side effects of headache, nausea, abnormal taste and feeling hot.
The distribution volume was unaffected by the severity of renal impairment (Table 5). No images. DOTAREM lesion visualization scores were similar to those for gadopentetate 17.3 General Precautions
changes in renal function test parameters were observed after DOTAREM injection. The mean dimeglumine. DOTAREM imaging results in the pediatric patients were also similar to those Instruct patients receiving DOTAREM to inform their physician if they:
cumulative urinary excretion of total gadolinium was approximately 76.9 ± 4.5% in 48 hrs in seen in adults. • Are pregnant or breastfeeding.
patients with moderate renal impairment, 68.4 ± 3.5% in 72 hrs in patients with severe renal • Have a history of allergic reaction to contrast media, bronchial asthma or allergy.
±
impairment and 93.3 4.7% in 24 hrs for subjects with normal renal function. In a second clinical trial (Study B), MR images were reread from 150 adult patients with • Are taking any medications.
known CNS lesions who had participated in previously conducted clinical trial. DOTAREM
Table 5: Pharmacokinetic Profile of Total Gadolinium in Normal and Renally administration and image interpretation was performed in the same manner as in Study Rx Only
Impaired Patients A. Similar to Study A, this trial also demonstrated improved lesion visualization with
Population Elimination Plasma Clearance Distribution DOTAREM.
Half-Life (hr) (L/h/kg) Volume (L/kg) Guerbet LLC
Healthy volunteers 1.6 ± 0.2 0.10 ± 0.01 0.246 ± 0.03 16 HOW SUPPLIED/STORAGE AND HANDLING 120 W. 7th Street, Suite 108
DOTAREM Injection is a clear, colorless to yellow solution containing 0.5 mmol/mL of Bloomington, IN 47404
Patients with moderate
renal impairment 5.1 ± 1.0 0.036 ± 0.007 0.236 ± 0.01 gadoterate meglumine. It is supplied in vials and prefilled syringes. Pre-filled syringes manufactured by Catalent, Belgium for Guerbet
Vials manufactured by Recipharm, France for Guerbet
Patients with severe • DOTAREM Injection is supplied in 10 mL vials containing 10 mL of solution, in 20 mL
renal impairment 13.9 ± 1.2 0.012 ± 0.001 0.234 ± 0.01 vials containing 15 mL or 20 mL of solution. Revised 3/2014
GUEST
EDITORIAL
continued from page 4
Another potential but highly unlikely pitfall could be the
tort of intentional infliction of emotional distress. However,
to prevail on such a charge, it would have to be proved that
a radiologist acted intentionally or recklessly, and the con-
duct of the radiologist was extreme and outrageous. The tort
of negligent infliction of emotional distress is a controversial
cause of action, which is available in nearly all U.S. states but
is severely constrained and limited in most. The underlying
concept is that the radiologist has a legal duty to use reason-
able care to avoid causing emotional distress to the patient.
As I mentioned previously, there have not been any
malpractice lawsuits filed against a radiologist in the U.S.
because the report contains findings that may be considered
bad news. The legal pathway to prevailing on such a tract is
murky at best. Nevertheless, it would be foolish to believe
that it couldn’t happen here. As a result, it pays to follow the
example of the Boy Scouts and to be prepared.
Delivering bad news, either in person or in writing, is
difficult. Radiologists should be aware that a written report
may contain findings that some patients may consider to be
bad news; e.g., a report that is “suspicious for malignancy,”
or a report that describes a “recurrence” or “progression of a
known tumor.” What constitutes “bad news” is based on the
patient’s viewpoint, not what is actually contained within
the report; i.e., “Perception is reality,” as the saying goes.
When creating your reports, try to put yourself in the
patient’s shoes and think: How would I or one of my family
members respond to the same news?
8 May 2017
©
n APPLIED RADIOLOGY www.appliedradiology.com
Carefully choose your words. Be careful in your choice of
the adjectives and adverbs. However, it’s equally important
to remember not to gloss over or hide facts. This can result in
an incorrect diagnosis. Say what must be said with compas-
sion and in a considerate way. Strive to be more deliberate in
the wording of your reports. Realize that many patients who
are undergoing cancer treatment may already be depressed.
Be honest and direct.
Dictate your report without unreasonable delay. For us,
dictating these reports is a routine part of our job, but for
patients, even if there is no bad news, waiting for the result is
a nerve-racking experience from beginning to end. Patients
tend to think the worst.
Proofread your report for accuracy, especially if you think
you will become the bearer of bad news, and make sure it
reads honestly as well as compassionately.
Finally, consider directly communicating with the order-
ing or treating physician to provide a “heads’ up” so he or
she can have the opportunity to discuss the findings with the
patient before the patient has received the report.
Besides reducing your risk of being sued, it is the consid-
erate and compassionate thing to do for your patient. And
should the news be truly bad, your patients will appreciate
being handled with a human touch.
Reference
1. Berlin L, Sosna J, Halevy D. Radiologist found liable for malpractice in Israel
for causing a patient’s suicide by sending a “bad news” report: Can this happen
in the United States? AJR 2017;208:241-244.
Imaging evaluation of acute pelvic
pain in the emergency department
Julio Daniel Egusquiza, MD, and Anthony M. Durso, MD
A
cute pelvic pain is a common
presenting complaint in women
and determining the etiology
can be difficult. There is a broad differ-
ential diagnosis that includes causes aris-
ing from multiple organ systems (Table
1), with overlapping signs and symptoms
decreasing specificity. Initial assess-
ment is usually centered on evaluating
for emergent and life threatening condi-
tions such as ruptured ectopic pregnancy,
ovarian torsion, ruptured ovarian cysts,
and appendicitis. A thorough history and
physical (H&P) along with basic labo-
ratory analyses such as complete blood
count, urinalysis, and pregnancy test can
help narrow the differential. In women
of reproductive age, the pregnancy test
is paramount, as this will determine if
pregnancy and its complications need to
be considered in the differential, most
importantly informing the suspicion for
ectopic pregnancy.
This article will focus on the im-
aging characteristics of acute obstet-
ric and gynecologic causes of pelvic
pain in reproductive-age women that
radiologists are commonly asked to
evaluate in the emergency department
(Table 2). While the H&P and labora-
tory tests constitute the initial clinical
Dr. Egusquiza and Dr. Durso are
Radiologists at the University of Miami/
Jackson Memorial Hospital, Miami, FL.
May 2017
evaluation generating the differential
diagnosis, the first-line imaging test
usually obtained is pelvic ultrasound
(US), followed by selective use of com-
puted tomography (CT) as indicated
by sonographic findings. In some sit-
uations CT may be the initial imaging
study, as it is generally more available
than sonography, and provides more
extensive coverage of the abdomen and
pelvis if the differential diagnosis ini-
tially is very broad.
Table 1. Differential diagnosis
for acute pelvic pain in
a reproductive-age female
Menstrual-related pain
Ovarian cysts
Rupture of ovarian cysts
Threatened abortion
Ectopic pregnancy
Appendicitis
Endometriosis
Adenomyosis
Pelvic inflammatory disease
Adnexal torsion
Placental abruption
Uterine rupture
Urolithiasis
Cystitis/pyelonephritis
Diverticular disease
Bowel obstruction
www.appliedradiology.com
Pregnancy: Ectopic, unknown
location, and nonviable intrauterine
Ectopic pregnancy occurs when a
fertilized oocyte implants outside the
endometrial cavity. They account for
approximately 2% of all pregnancies,
with a 9-14% mortality rate.1 The di-
agnosis should be considered in any
reproductive age woman who presents
with acute pelvic pain and has a positive
urine or serum pregnancy test.
When evaluating for ectopic preg-
nancy, it is important to be familiar with
the sonographic findings of a normal
intrauterine pregnancy (IUP), as this
essentially rules out an ectopic preg-
nancy due to the statistical rarity of a
heterotopic pregnancy (a concurrent
intrauterine and ectopic pregnancy). An
intrauterine gestational sac with a fetal
pole or yolk sac is the best sign of an
IUP. The earliest sonographic evidence
Table 2. Common obstetric
and gynecologic causes of
acute pelvic pain evaluated in
the emergency department
Pregnancy and its complications
Ruptured/hemorrhagic cysts
Pelvic inflammatory disease and
tubo-ovarian abscess
Ovarian torsion
9
©
APPLIED RADIOLOGY n
IMAGING EVALUATION OF ACUTE PELVIC PAIN IN THE EMERGENCY DEPARTMENT

A B C

D E F

G H I

J
of a normal IUP is the intradecidual
sign, which is a small fluid collection
surrounded by an echogenic ring that is
eccentrically located within the endo-
metrium. The sac should be visualized
in two planes and have a stable appear-
ance. At about 5 weeks’ gestation, the
double decidual sac should be seen.
This is described as two echogenic rings
with a hypoechoic region between them
surrounding the anechoic sac. Shortly
thereafter a yolk sac can be visual-
FIGURE 1. Varied appearance on transvaginal US of ectopic pregnancy in patients presenting
with pelvic pain. (A, B) 26-year-old with live ectopic pregnancy in the right adnexa. (C, D) 33
year-old with gestational sac with yolk sac in the right adnexa and an “empty” uterus. (E, F)
32-year-old presenting with cystic mass in the right adnexa and an IUD in situ. (G, H) 24-year-
old with heterogeneous solid mass in the left adnexa and free fluid in the pelvis. (I, J) 28-year-
old presenting with gestational sac in the right cornua of the uterus. (I) peripheral location of
the gestation sac with thin myometrium covering it (solid arrow) and the endometrial stripe
extending to it (open arrow) reveals the interstitial line sign. 3D sonographic image (J) con-
firms the cornual ectopic pregnancy.
ized. Recent guidelines state that any an ectopic pregnancy is an extrauterine
fluid collection with rounded edges in gestational sac with a yolk sac or em-
the uterus in a pregnant patient is most bryo (Figure 1).3 However, in a patient
likely a gestational sac.2 without an IUP and elevated b-hCG,
Lack of an IUP should trigger a care- any extraovarian adnexal mass, sepa-
ful search for an ectopic pregnancy. Up rate from the ovary, is concerning for
to 95% of ectopic pregnancies are tubal, ectopic pregnancy (Figure 1). In some
with most occurring in the ampulla.1 cases, free intraperitoneal fluid or he-
Locations for ectopic pregnancies in- moperitoneum may be the only finding.
clude the ovary, cervix, myometrial Interstitial, or cornual, ectopic preg-
scars, or in the peritoneal cavity. The nancies are clinically important to
most specific sonographic finding of recognize because they are associated

10 May 2017
©

n APPLIED RADIOLOGY www.appliedradiology.com

 IMAGING EVALUATION OF ACUTE PELVIC PAIN IN THE EMERGENCY DEPARTMENT

IUP or an ectopic pregnancy in a patient

A B
with a positive pregnancy test. Histori-
cally in pregnancies of unknown loca-
tion, a threshold hCG level (commonly
used levels ranged from 1500-2000
mIU/ml) was used to aid in diagnosis
of an ectopic pregnancy.5 Newer data
questions the validity of these thresh-
old values6 and has led to newer recom-
FIGURE 2. A 22-year-old woman presented with mendations regarding the assessment
pelvic discomfort initially was evaluated with ultra- of pregnancies of unknown location.2
sound and then with CT. Transvaginal US (A) and The data has shown that a single mea-
coronal CT image (B) demonstrate similar findings
of a ruptured left ovarian cyst with extensive hemo-
surement of HCG regardless of its value
peritoneum. does not reliably distinguish between
an ectopic and a viable or nonviable
intrauterine pregnancy. Even at levels
A B ranging from 2000 to 3000mIU/mL
there is a risk of interrupting a viable
pregnancy with presumptive treatment.
Above 3000 mIU/mL, the more likely
diagnosis is a nonviable uterine preg-
nancy, followed by ectopic pregnancy,
with an early viable IUP not excluded,
and continued clinical and imaging
follow-up is needed. In those recent
guidelines, Doubilet et al2 believe there
is limited risk in waiting 48 hours to
C D measure progression of hCG values in a
hemodynamically stable patient with no
signs or symptoms of rupture and no ul-
trasound evidence of an IUP or ectopic
pregnancy.
It is also important to be able to ap-
propriately triage a viable or nonviable
IUP. It is not uncommon during the
FIGURE 3. A 25-year-old woman presented with pelvic pain and ultrasound was obtained evaluation for ectopic pregnancy to en-
to evaluate for ovarian torsion. Transabdominal US (A) with a hemorrhagic cyst in the right counter an “empty” gestational sac or a
adnexa, transvaginal US (B) with debris with free fluid in the cul-de-sac, and transabdominal fetal pole without cardiac activity. Most
US (D) with fluid tracking to the right upper quadrant. CT (d) obtained after ultrasound with
radiologists will be familiar with the
extensive hemoperitoneum in the pelvis from the ruptured cyst.
old adage “5 alive,” referring to a 5mm
with higher morbidity and mortality pic gestation sac is often not surrounded crown rump length (CRL) at which
compared to other ectopic pregnancy by at least 5 mm of myometrium in all point fetal cardiac activity is expected.
sites.4 They are located in the intersti- planes (Figure 1), as is expected for a They may also be familiar with criteria
tial portion of the fallopian tube sur- normal IUP.1 that at 16 or 20 mm mean sac diame-
rounded by myometrium and represent A radiologist or sonographer also has ter (MSD) a fetal pole should be seen.
2-4% of all ectopic implanatations.4 to be prepared for other imaging scenar- The newer consensus guidelines2 also
Due to the surrounding myometrium, ios that can be encountered in ectopic updated these criteria based on newer,
these ectopic pregnancies can grow pregnancy. They include pregnancies of more robust data.7 Those guidelines
painlessly for quite some time leading unknown location and nonviable intra- now adopt criteria to diagnose a nonvi-
to a later presentation and higher risk uterine pregnancies. Though these may able IUP on an initial transvaginal US
of large hemorrhage. An interstitial ec- not be a direct cause of acute pelvic pain, as absent fetal cardiac activity at a CRL
topic pregnancy should be suspected on they are frequently encountered and have of 7 mm or greater and an anembryonic
transvaginal ultrasound when an IUP is important clinical implications. gestational sac at an MSD of 25 mm or
visualized high in the fundus. An ecto- Ultrasound may not reveal either an greater. Absent cardiac activity below a

May 2017 11
©

www.appliedradiology.com APPLIED RADIOLOGY n

IMAGING EVALUATION OF ACUTE PELVIC PAIN IN THE EMERGENCY DEPARTMENT

A B C

FIGURE 4. A 40-year-old woman presenting with pelvic pain underwent transvaginal US, demon-
strating ovarian torsion. Gray scale image (A) reveals an enlarged right ovary with a singular uniloc-
ular cyst, and color flow (B) and pulsed Doppler (C) images without flow in the right ovary.

A B cysts are the most common gyneco-

C ated symptoms.
FIGURE 5. A 20-year-old presenting with right lower quadrant pain. Initial evaluation with con-
trast-enhanced CT (A,B) demonstrates an enlarged right ovary (white arrow). Follow-up trans-
vaginal US (C,D) confirmed lack of flow in the enlarged, torsed right ovary.
CRL of 7mm is suspicious for, but not
diagnostic of, a failed pregnancy and
should have follow-up US to reassess
viability.2 Likewise, an anembryonic
gestational sac with MSD between 16
and 24 mm is suspicious for, but not di-
agnostic of, a failed IUP, and deserves
follow-up imaging to reassess the preg-
nancy’s viability.2
In the emergency department setting,
the most common clinical concern for a
D has completely ruptured and the fluid
pregnant patient presenting with acute
pelvic pain is an ectopic pregnancy.
However, there are numerous other
complications of pregnancy spanning
all trimesters that can present with acute
pelvic pain, ranging from subchorionic
hemorrhage to placental abruption.
Ruptured and hemorrhagic
ovarian cysts
Ruptured or hemorrhagic ovarian
logic cause of acute onset pelvic pain in
a non-pregnant female of reproductive
age presenting to the emergency depart-
ment.3 They are infrequently seen at
the extremes of age; however, they can
rarely occur in postmenopausal women
receiving hormonal treatments. Patients
typically present with only unilateral
acute pelvic pain without other associ-
Ruptured ovarian cysts may have a
crenulated appearance containing low
level echoes with adjacent free fluid
(Figure 2). At times it may be a diagno-
sis of exclusion on ultrasound if the cyst
reabsorbed. Findings of cyst rupture in-
clude free fluid and hemoperitoneum,
typically seen in the cul-de-sac (Figure
3). On CT, hemorrhagic cysts appear
as heterogeneous ovarian masses with
internal attenuation of 25-100 HU. Flu-
id-fluid levels and hemoperitoneum
may be seen after cyst rupture (Figure
3). Treatment is usually conservative
unless the patient is hemodynamically
unstable from massive bleeding.
The ultrasound appearance of a hem-
orrhagic cyst is highly variable based
on its acuity and amount of clot forma-
tion. The typical acute appearance is of
a thin-walled mass with internal echoes,
increased through transmission, and no
internal vascularity. Over time fibrin
strands form and innumerable retic-
ular or linear echoes with a fishnet or
lace like appearance can be seen. This
reticular pattern is considered diagnos-

12 May 2017
©

n APPLIED RADIOLOGY www.appliedradiology.com

 IMAGING EVALUATION OF ACUTE PELVIC PAIN IN THE EMERGENCY DEPARTMENT

A B C

FIGURE 6. A 40-year-old woman with right lower quadrant pain initially evaluated by CT (A,B) for appendicitis with hyperenhancement of the left
fallopian tube and a small posterior collection concerning for pyosalpinx and TOA. Transvaginal US image (C) demonstrated features of pyosal-
pinx with thickened irregular walls of the left fallopian tube with echogenic debris filling the lumen.

A B C

FIGURE 7. A 47-year-old woman presenting with lower abdominal pain and clinical concern for appendicitis. Initial CT of the abdomen (A)
demonstrates a complex cystic mass surrounding the uterine fundus representing TOA. Follow-up transvaginal US (B,C) confirms the complex
collection around the uterus.
tically specific. Given further time, the
clot coalesces and retracts presenting as
clumped avascular echoes with concave
or sharp angular borders in the margin
of the lesion.
Hemorrhagic cysts typically are
self-limiting and most resolve within
two menstrual cycles. Recommenda-
tions for imaging follow-up of hemor-
rhagic cysts are based on the size of the
cyst, appearance, and hormonal status
of the patient.8 If the patient is of repro-
ductive age and the cyst is greater than
5 cm, then follow-up US in 6-12 weeks
is recommended to ensure resolution.
For postmenopausal women, follow-up
US (in early menopause) or surgical
consultation (late menopause) is rec-
ommended.8
Ovarian torsion
Ovarian torsion is the twisting of an
ovary on its ligamentous support, which
can lead to compromised blood supply.
It is a rare but concerning presentation of
acute pelvic pain in women, accounting
for 2.7% of gynecologic emergencies.9
Early diagnosis and surgical intervention
are important to avoid morbidity; how-
ever, nonspecific symptoms and varying
imaging features can lead to a delay in
identification.
Torsion can occur in women of all
ages. However, the highest incidence is
in reproductive age women and during
pregnancy.10 This is believed to be due
to the higher prevalence of physiologic
and pathologic ovarian masses in this
age group. In adults, 50-90% of patients
are found to have a coexisting ovarian
mass that acts as the lead point for the
torsion.10 The classic presentation in-
cludes a sharp, unremitting, unilateral,
lower abdominal pain with waves of
nausea and vomiting. A tender adnexal
mass may or may not be palpable.
The most common imaging finding in
ovarian torsion is unilateral ovarian en-
largement (>4cm in longest dimension),
which can be present even before infarc-
tion has occurred.10 Typically, the ovary
is displaced to the midline and superior
to the fundus. Ovarian stroma may ap-
pear heterogeneous and echogenic due to
edema and hemorrhage (Figure 4). Ultra-
sound may demonstrate multiple uniform
cysts in the periphery of the enlarged
ovary, the “string of pearls” sign. Doppler
ultrasound findings have classically been
described as a lack of arterial flow (Fig-
ures 4, 5). However, Doppler evaluation
alone for torsion has been shown to be
unreliable with variability in the presence
or absence of arterial and venous flow in
surgically proven cases of torsion.9-13
Diagnostic criteria for torsion on CT
have not been well defined or confirmed
in large studies. Common findings are
nonspecific and include unilateral ovar-
ian displacement and enlargement with
deviation of the uterus to the side of
torsion. Similar to ultrasound, stroma
may appear hypodense with peripheral,
hypoattenuating cysts (Figure 5). Other
findings include free fluid in the pelvis,
lack of contrast enhancement of the
ovary, and loss of fat planes.
Pelvic inflammatory disease/tubo-
ovarian abscess
Pelvic inflammatory disease (PID)
is an ascending infection of the female
genital tract that begins as cervicitis, and
can spread upwards to cause endometritis

May 2017 13
©

www.appliedradiology.com APPLIED RADIOLOGY n

IMAGING EVALUATION OF ACUTE PELVIC PAIN IN THE EMERGENCY DEPARTMENT
A B
FIGURE 8. A 25-year-old woman with cervical motion tenderness originally sent for CT of the abdomen (A,B) with small collections of free fluid
in the right upper quadrant and pelvis (white arrows) consistent with Fitz-Hugh-Curtis syndrome. Transvaginal US (C) demonstrates changes of
pyosalpinx. The patient tested positive for gonorrhea.
and salpingitis. Untreated, it eventually
may lead to involvement of the ovaries
and formation of a tubo-ovarian abscess
(TOA). It is caused by a wide spectrum
of sexually transmitted diseases, but most
commonly Neisseria gonorrhoeae and
Chlamydia trachomatis. PID accounts
for as many as 24% of ED visits for acute
gynecological pain.14 Symptoms range
from none to severe; classic symptoms
include pelvic pain, cervical motion ten-
derness, vaginal discharge, fever, and ele-
vated white blood cell count. PID is most
often a clinical diagnosis with the role of
imaging to evaluate for complications
and treatment planning.
Imaging findings can be normal in
early or uncomplicated PID. As in-
fection worsens, findings continue to
be nonspecific with possible uterine
enlargement, obscure uterine mar-
gins, endometrial thickening, and fluid
within the endometrial canal. Involve-
ment of the fallopian tubes is typically
bilateral and can lead to pyosalpinx. In
pyosalpinx, ultrasound can show a dis-
tended fallopian tube filled with com-
plex fluid and debris. The walls can
also be thickened and echogenic with in-
creased flow on color Doppler (Figure 6).
As the ovary becomes involved, it en-
larges and acquires more edema. Even-
tually a TOA may form, characterized
by a complex thick-walled, multilocular
cystic collection in the adnexa. The walls
and septations are typically hypervas-
cular due to inflammation. There is loss
of differentiation of the ovary and tubal
architecture. On CT, tubo-ovarian ab-
scesses appear as complex fluid-atten-
uating collections with thickened and
14
©
n APPLIED RADIOLOGY
irregularly enhancing walls (Figure 7).
Thickening of the uterosacral ligament
and fat stranding can also be seen.
Other intraperitoneal structures can
also be affected by PID. Abdominal US
or CT can be used to evaluate for ex-
tra-pelvic extension. Some of these man-
ifestations include small or large bowel
ileus or obstruction, uretral and renal col-
lecting system obstruction, peritonitis,
or Fitz-Hugh-Curtis (FHC) syndrome.15
Fitz-Hugh-Curtis syndrome describes
an inflammation of the right upper quad-
rant caused by bacterial spread along
the right paracolic gutter or through the
lymphatic system (Figure 8). This causes
inflammation of the right upper quadrant
peritoneum and the right hepatic lobe.
On contrast CT, FHC classically pres-
ents with intense enhancement along the
anterior surface of the liver and gallblad-
der wall thickening.
Conclusion
Acute pelvic pain is a frequent present-
ing complaint in women and often will
lead to imaging evaluation on presenta-
tion to the emergency department. The
differential is broad, spanning multiple
organ systems, due to the overlap in pre-
sentation of many of the causes of pel-
vic pain. US is typically the first choice
in imaging, although due to the clinical
challenge in diagnosis and 24-hour avail-
ability, CT may initially be requested.
The emergency department or on-call ra-
diologist needs to be able to recognize the
US and CT appearance of the most com-
monly encountered causes of acute pelvic
pain, particularly those that relate to the
female reproductive tract.
www.appliedradiology.com
C
References
1. Lin EP, Bhatt S, Dogra V. Diagnostic clues to ecto-
pic pregnancy. RadioGraphics. 2008;289:1661-1671.
2. Doubilet PM, Benson CB, Bourne T, et al. Diag-
nostic criteria for nonviable pregnancy early in first
trimester. N Engl J Med. 2013;369(15):1443-1451.
3. Cicchiello LA, Hamper UM, Scoutt LM. Ultra-
sound evaluation of gynecologic causes of pelvic
pain. Obstet Gynecol Clin Am. 2001;38(1):85-114.
4. Levine D. Ectopic Pregnancy. Radioogy.
2007;245(2):385-397.
5. Barnhart K, Mennuti MT, Benjamin I, et al.
Prompt diagnosis of ectopic pregnancy in an
emergency department setting. Obstet Gynecol.
1994;84(6):1010–1015.
6. Mehta TS, Levine D, Beckwith B. Treatment of
ectopic pregnancy: is a human chorionic gonado-
tropin level of 2000 mIU/ml a reasonable threshold?
Radiology. 1997;205(2):569-573.
7. Abdallah Y, Daemen A, Kirk E, et al. Limitations
of current definitions of miscar- riage using mean
gestational sac diameter and crown–rump length
measurements: a multicenter observational study.
Ultrasound Obstet Gynecol. 2011; 38(5): 497–502.
8. Levine D, Brown DL, Andreotti RF, et al. Man-
agement of asymptomatic ovarian and other
adnexal cysts imaged at US Society of Radiologists
in Ultrasound consensus conference statement.
Radiology. 2010; 256(3):943-954.
9. Swenson DW, Lourenco AP, Beaudoin FL, et al.
Ovarian torsion: case-control study comparing sen-
sitivity and specificity of ultrasonography and com-
puted tomography for diagnosis in the emergency
department. Eur J Radiol. 2012; 83(4): 733-738.
10. Chang HC, Bhatt S, Dogra VS. Pearls and pit-
falls in diagnosis of ovarian torsion. RadioGraphics.
2008; 28(5):1355-1368.
11. Pena JE, Ufberg D, Cooney N, et al. Usefulness
of Doppler sonography in the diagnosis of ovarian
torsion. Fertil Steril. 2000;73(5):1047-1050.
12. Bar-On S, Mashiach R, Stockheim D, et al.
Emergency laparascopy for suspected ovarian
torsion: are we too hasty to operate? Fertil Steril.
2010; 93(6): 2012–2015.
13. Shadinger LL, Andreotti RF, Kurian RL. Pre-
operative sonographic and clinical characteristics
as predictors of ovarian torsion. J Ultrasound Med.
2008;27(1):7-13.
14. Potter AW, Chandrasekhar CA. US and CT
Evaluation of acute pelvic pain of gynecologic ori-
gin in nonpregnant premenopausal patients. Radio-
Graphics. 2008; 28(6):1645-1659.
15. Sam JW, Jacobs JE, Birnbaum BA. Spectrum
of CT findings in acute pyogenic pelvic inflammatory
disease. RadioGraphics. 2002; 22(6):1327-1334.
May 2017
Peripheral arteriovenous
malformations: Classification and
endovascular treatment
Kenrick Lam, MD; Anil Pillai, MD; and Mark Reddick, MD
I
n this review we cover the classifica-
tion and endovascular management
of arteriovenous malformations
(AVMs). We begin by viewing AVMs
in relation to the broader class of con-
genital vascular malformations and
subsequently go into more depth on the
clinical and pathologic characteristics
that define AVMs. We then focus on the
endovascular treatment options for pe-
ripheral AVMs and summarize the func-
tional characteristics of the sclerosants
and embolic agents available to clini-
cians today.
Vascular malformations and their
classification
Arteriovenous malformations
(AVMs) are abnormal shunts between
arteries and veins that result from dis-
turbances in angiogenesis. They are
high-flow malformations that are radio-
graphically characterized by a central
nidus, a tangle of blood vessels where
the abnormal arterial-venous commu-
nication exists without a normal inter-
vening capillary bed. They can arise
anywhere in the body and therefore
Dr. Lam, Dr. Pillai, and Dr. Reddick are
Radiologists at the University of Texas
Southwestern, Dallas, TX.
May 2017
have a wide range of presentations,
from an asymptomatic birthmark to a
life-threatening impingement on vital
structures. Typically present at birth,
they grow concomitantly with the pa-
tient and may be stimulated to grow fur-
ther after periods of trauma, hormonal
change, infection or spontaneous hem-
orrhage. Historically, surgical resection
has been considered the treatment of
choice. However, due to the significant
morbidity and high rate of recurrence
associated with surgical resection, en-
dovascular therapy has emerged as a
less invasive alternative with compara-
ble efficacy.1
AVMs fall within the broader cate-
gory of congenital vascular malforma-
tions (CVMs), which are any abnormal
blood vessels arising from disturbed an-
giogenesis. CVMs can involve any por-
tion of the vascular tree, including veins,
arteries, capillaries, lymphatics or any
combination thereof. Unlike vascular
tumors, CVMs generally do not exhibit
abnormalities in cellular proliferation.
Two main classification systems are
used to describe CVMs: Mulliken and
Hamburg. The Mulliken system divides
CVMs into either high flow or low flow.
This is a practical and useful classifica-
tion since high flow lesions are treated
www.appliedradiology.com
with catheter-directed embolization and
low flow lesions are treated with percu-
taneous sclerotherapy. The Hamburg
system distinguishes vascular malfor-
mations based on their predominant
histological components (lymphatic, ar-
terial, venous, etc.). It divides each type
into truncular, arising from the normal
vascular tree, or extra-truncular, arising
from outside the vascular tree. Trun-
cular lesions arise from disturbances
later in angiogenesis than extra-truncu-
lar and, in regard to treatment, tend to
be higher flow than extra-truncular. In
2014, the International Society for the
Study of Vascular Anomalies combined
the Hamburg and Mulliken systems and
also expanded on each of them (Table
1).2 CVMs are now separated into four
categories based on clinical context and
vessel involvement.
Clinical staging
The Schobinger classification is a
clinical assessment of vascular shunt-
ing that is predictive of treatment suc-
cess (Table 2).3 This classification has
four stages, with stage 1 lesions being
asymptomatic and stage 4 representing
high-output heart failure. Stages 2 and
3 are intermediate, with stage 3 lesions
demonstrating ulceration, bleeding,
15
©
APPLIED RADIOLOGY n
PERIPHERAL ARTERIOVENOUS MALFORMATIONS

Table 1. 2014 ISSVA Classification of Vascular Malformations

Simple Capillary, Venous, Lymphatic, Arteriovenous*, Arteriovenous Fistula*

Combined Any combination of simple malformations (eg. Capillary – Venous, Venous – Lymphatic,
Capillary – Lymphatic – Venous)

Involves Major Vessels Vessel Involved (Artery, Vein or Lymphatic)

(Truncular) Anomaly of: Origin, Course, Number, Length, Diameter, Valves, Communication,
Persistence (embryonal)

Part of Clinical Syndrome Klippel-Trenaunay, Parkes Weber, Servelle-Martorell, Sturge-Weber, Mafucci, Cloves,
Proteus, Bannayan-Riley
Simple malformations involve one type of vessel including vessel shunts such as AVMs. There are no longer arterial malformations. The
star (*) indicates high-flow lesions. Combined malformations are any combination of simple malformations and can involve more than two
different types. Truncular malformations are distinguished by the name of the vessel involved as well its anomalous characteristics. Clinical
syndromes have a typical set of malformations that accompany them; thus, they are considered a single clinical entity.

four distinct nidal architectures and

Table 2. Schobinger Clinical Grading System found that AVMs consisting of multi-
of Arteriovenous Malformations ple feeders emptying into a single vein,
Stage 1 Warm, pink-blue stain type 1 and 2, have the best response to
Stage 2 Stage 1 + Enlargement, pulsatile, bruit, thrill treatment (Figure 3). AVMs with mul-
Stage 3 Stage 2 + Ulceration, bleeding, pain, necrosis tiple inflows and outflows, types 3a and
Stage 4 Stage 3 + Heart failure
3b, have the worst response.11

pain, and necrosis. In general, Scho-
binger stage 3 lesions and above should
receive treatment.4 Whether lower stage
AVMs should be treated is still up for
debate. One study found that almost all
AVMs at Schobinger stage 1 eventually
progressed, with nearly half becoming
stage 3 and above. The authors, there-
fore, recommended early treatment re-
gardless of stage.4
Imaging findings in AVMs
Initial imaging tests should include
Doppler ultrasound and CT with con-
trast, or MRI. On Doppler, one may
observe arterial waveforms and high
flows in venous structures which are
indicative of vascular shunting.5 MRI
will often show a conglomerate of flow
voids on T1- and T2-weighted images
that may not respect soft tissue planes
(Figure 1.6 Time-resolved MRA has
emerged as a useful tool, not only to de-
lineate nidal anatomy, but also to assess
treatment efficacy through the measure-
ment of venous filling times.7 CT angi-
ography is an alternative to MRA that
gives comparable images; however,
the 3D reconstruction lacks temporal
resolution.8 4D-CT angiography is an
emerging technology that may be able
to overcome this barrier and has shown
to be useful for brain AVMs.9 In gen-
eral, MRI and MRA are the preferred
primary imaging modalities as they de-
liver both excellent anatomical resolu-
tion of the AVM and surrounding soft
tissue, which are necessary for analyz-
ing the extent of peripheral AVMs.
Diagnostic angiography should be
performed on almost all AVMs and is
absolutely required prior to treatment
to assess flow rate, visualize anatomy
of the nidus in greater detail than MRA
and identify vessels required for distal
circulation (Figure 2).10 AVMs can be
identified as a tangled mass of blood
vessels with early venous filling. If per-
formed during embolization, accessory
feeder vessels may begin to be visual-
ized as primary feeder vessels are em-
bolized.7 The architecture of the nidus
on angiography has implications for
treatment and outcomes. Cho described
Endovascular treatment options
Embolic materials
Several embolic materials are avail-
able for endovascular treatment of
peripheral AVMs. These embolic ma-
terials include: ethanol, N-butyl cyano-
acrylate (NBCA), poly-vinyl-alcohol
(PVA) particles, ethylene vinyl alcohol
copolymer (Onyx), and endovascular
coils and vascular plugs. Each one has
specific handling criteria and learning
curves. It is often the case that multi-
ple different embolics are used to treat
a single AVM. Detergents such as eth-
anoloamine oleate, polidocanol, and
sotradecol have been reported, but are
generally avoided because of increased
recurrence risk.
Ethanol is widely regarded as the
most effective liquid embolic. It di-
rectly damages the endothelium by act-
ing as a protein denaturant, denuding
the vessel to the internal elastic lamina.
It is cost effective, but carries higher
rates of complications such as signif-
icant edema, skin necrosis and nerve
damage. Therefore, it should be diluted

16 May 2017
©

n APPLIED RADIOLOGY www.appliedradiology.com

 PERIPHERAL ARTERIOVENOUS MALFORMATIONS

to 50% or not used at all in AVMs in-

A B volving significant portions of skin.12,
13
The most-feared complication from
ethanol is the dose-dependent risk of
pulmonary hypertension and cardio-
vascular collapse, which necessitates
intraprocedural pulmonary arterial
pressure (PAP) monitoring.14 PAP be-
gins to increase with doses higher than
0.14mL/kg and the maximum recom-
mended dose per treatment session is
0.5 – 1mL/kg administered in small
1 – 3cc aliquots; many administer less
than 0.5mL/kg.15 PAP above 25mmHg
systolic merit treatment with nitroglyc-
C D erin infusion at 1mcg/kg/min.16 PAP is
found to peak 10 to 15 minutes post-op-
eratively; therefore patients must be
monitored closely.17 Outflow occlusion
reduces the increase of PAP and should
be employed whenever possible. Fi-
nally, ethanol is very painful and gen-
eral anesthesia is required. Ethanol can
be mixed with iodized oil (Lipiodol) if
visualization is desired.6
FIGURE 1. (A,C) Axial T1-weighted images of an AVM obtained prior to embolization. Note N-butyl cyanoacrylate is a liquid
the large flow voids on the anterior portion of the arm. (B,D) T1-weighted images obtained casting adhesive agent generally consid-
after staged embolization display decreased flow; however, with significant residual AVM. ered to be safer than ethanol. It may be

A D

B E

C F

FIGURE 2. (A,B,C) Arterial, capillary, and venous phases of angiogram performed prior to embolization. (D,E,F) Arterial, capillary, and venous
phases of postembolization angiography. Although flow is significantly reduced and the patient’s clinical symptoms have greatly improved, there
is still a significant portion of residual AVM.

May 2017 17
©

www.appliedradiology.com APPLIED RADIOLOGY n

PERIPHERAL ARTERIOVENOUS MALFORMATIONS
FIGURE 3. The four types of AVM architecture described by Cho et al. Type I AVMs are
defined by no more than three arterial feeders with one outflow vein. Type II AVMs contain
multiple arterioles leading to a single outflow vein. Type III lesions are the most common and
consist of two subtypes: IIIa, which are multiple non-dilated shunts, and IIIb, which consist of
multiple dilated shunts.
preferred in AVMs with large, draining
veins that would require great amounts
of ethanol or Onyx, or in the pediatric
population where ethanol dosing needs
to be limited.18 ,19 It polymerizes quickly
and irreversibly when exposed to anions
and is effective in the setting of coagu-
lopathy.20 To administer, ingredients
are mixed in a glass vial and only poly-
propylene syringes and catheters (Tru-
Fill recommends the Prowler, Prowler
Select or Transit family of catheters)
may be used. To minimize premature
polymerization, NBCA should diluted
with non-ionic solvent (Lipiodol) and
the catheter flushed with 5% dextrose
solution. The catheter used for angi-
ography may also be used for embo-
lization if perfectly flushed, but some
opt to use a new catheter. The ratio of
NBCA to Lipiodol is determined based
18
©
n APPLIED RADIOLOGY
on lesion flow dynamics, with more
concentrated NBCA being used for
higher flow lesions. In our experience,
an NBCA-to-Lipiodol ratio of 1:3 is a
good starting point with an expected
polymerization time of 1-4 seconds.
Exact casting time is difficult to predict
and may lead to complications such as
embolizing too proximal or having the
catheter become glued into the vessel
lumen. 21 Operators should allow an
adequate buffer zone so the catheter
can be slowly withdrawn during ad-
ministration. Adequate visualization is
paramount as the operator must watch
for any reflux of the embolic. Another
method to prevent reflux is to “push”
an aliquot of n-BCA out of the catheter
with D5W allowing deeper penetration
into the AVM and away from the cathe-
ter tip. If the catheter becomes adhered,
www.appliedradiology.com
a quick tug followed by prolonged trac-
tion often will remove it. However, if
unsuccessful, an open removal may be
necessary.
Ethylene vinyl alcohol copolymer
(Onyx) is another liquid casting agent
with an extensive track record for safety
and efficacy in treatment of central ner-
vous system AVMs. It has many of the
same applications as nBCA and is gain-
ing in popularity because it is easier to
use.22, 23 Solubilized in DMSO, it polym-
erizes from outside in allowing further
penetration into the nidus. It is injected
slowly; the maximum injection rate is
0.1mL/min to avoid vasospasm caused
by DMSO. Like NBCA, the viscos-
ity and casting time can be changed by
varying the concentration. 6-8% are the
typical concentrations for adequate dis-
tal penetration from intra-arterial access.
However in high flow fistulous malfor-
mations concentrations as high as 20%
may be needed to achieve adequate cast-
ing time.22 Using a test injection of con-
trast to determine the amount of Onyx to
use is inaccurate due to the differences in
viscosity and changes in flow rate during
injection of the embolic. If reflux is
seen around the catheter, administration
should be stopped for up to 2 minutes to
allow the refluxed Onyx to solidify. Af-
terward administration can be resumed.
In the event of reflux, the catheter may be
dislodged by aspirating whilst applying
constant, gentle traction. It may take sev-
eral seconds to dislodge and the cast may
stretch up to 3 cm during this period, but
this is normal. The primary advantage of
Onyx over NBCA is the slow flow and
longer casting time, giving the operator
greater control over administration. The
downside is longer treatment times and
greater expense. In superficial lesions, it
may cause “tattooing” of the skin.
PVA particles may be used on rare
occasions to de-vascularize a lesion ei-
ther as a pre-surgical adjunct or in the
management of an acutely bleeding
AVM. However, this carries a high risk
of complications related to non-target
embolization due to selection of im-
proper particle size. Authors have used
particle sizes from 150 – 500 um.24,25
May 2017
 PERIPHERAL ARTERIOVENOUS MALFORMATIONS

FIGURE 4. Endovascular AVM embolization treatment techniques include: Arterial balloon occlusion (A), Venous outflow balloon occlusion (B),
Superselective embolization (C), Retrograde balloon-assisted embolization (D), Venous outflow coil embolization (E), Direct nidal puncture (F),
Arterial pruning (coiling of arterial feeders) (G), and the use of blood pressure cuffs to occlude venous outflow (H).

There are several reported cases of pul-
monary embolism after PVA emboli-
zation 26 , 27. We do not recommend the
use of PVA particles in the management
of AVMs except for in the most expe-
rienced hands and only for the above
mentioned indications.
Endovascular coils and vascular
plugs have a limited role in the treat-
ment of peripheral AVMs. Their major
drawback is their size which may limit
future vascular access if subsequent em-
bolization is required. They have been
used as stand-alone therapy exclusively
in pulmonary and renal AVMs where
the large diameter and simple architec-
ture are amenable to such treatment.21
As an adjunct, coils and vascular plugs
are useful agents for outflow occlusion,
especially in nidi with a dominant out-
flow vein.19, 28 Especially in very high
flow AVMs, coils may sometimes may
be displaced and migrate, posing a po-
tential embolic risk; however, this is not
commonly reported.29
Treatment techniques
The goal of AVM embolization is to
obliterate the nidus while simultaneously
minimizing non-target embolization.
This can be best achieved by slowing
the flow to improve operator control
and intra or juxtanidal positioning of

May 2017 19
©

www.appliedradiology.com APPLIED RADIOLOGY n

PERIPHERAL ARTERIOVENOUS MALFORMATIONS

Table 3. Selected review of results of AVM embolization in

various clinical situations and regions of the body.

Author Patients Embolic (patients) Response (patients) Complications (number of patients)

Acute Bleeding
Churojana, 201238 5 NBCA (33 - 50%) Recurrence (3) Infection (2)

McGrath, 201225 9 PVA (355 - 500 um, Requiring second None

150 - 250 um) embolization for control (1)
Pre-surgical
Pompa, 201139 11 PVA (7), Coils (4) > 90% Flow reduction None Reported
in 7 cases

Lee, 200440 16 NBCA (13), Ethanol (3) Cure (16) Pulmonary Embolism (1)

Head and Neck

Kim, 2015 41 45 Ethanol, NBCA (15), No response (3), Cure (8), Skin necrosis (18 - 3 require grafting),
Onyx (1) Recurrence (5) bullae (12), Stroke (1), swelling requiring
decompression (1)

Dmytriw, 201432 89 PVA (96), NBCA (103), Cure (52 - 28 w/combined Swelling requiring intubation (1),
(244 sessions) Coils (5) surgery, mostly small post-operative bleeding (5), vision loss (1),
AVMs), Recurrence (2) stroke (1)

Pekkola, 201313 19 Ethanol 6 with residual symptoms, Skin necrosis (5 - 2 with secondary
1 recurrence, 1 progression infection, 1 requiring surgery),
of symptoms mucosal necrosis (2), tissue necrosis (2),
transient paresthesia (1), blindness (1)

Srinivasan, 201423 7 Onyx 18 Partial response Skin necrosis (1), ankle stiffness (1),

Trunk, Pelvis, Extremities

Wohlgemuth, 201534 11 Onyx, Coils (4) Cure (8), Partial (3), No complications
Recurrence (1)

Tan, 200442 13 NBCA (11), PVA No response (4), Cure (2), Fracture (1), transient paralysis (1)
(5, 300 - 500um) Recurrence (2)

Cho, 200630 66 Ethanol Cure (21), No relief (17) Skin necrosis (31), bullae (10),
paresthesias (2), stroke (1), embolism (3),
permanent nerve injury (2), infection (2),
tissue necrosis (1)

Rockman, 200343 50 PVA (11) NBCA (22), Unchanged (4), Cured (14) hematoma (1), recurrence requiring
(30 avm) ibca (6), coils (1) amputation (1)

Yakes, 201044 48 Ethanol, coils Cured (36) Transient nerve (4), blistering (4), PE (1),
tissue necrosis requiring bowel diversion (1)
Pulmonary
Mager, 200429 112 Coils Recanalization (19) TIA (3), cerebral abscess (2), coil migration
(5 - 3 requiring retrieval), pulmonary infiltrate
(1), angina (1), DVT (1)

Letourneau, 201045 24 Vascular Plug Recanalization No complications

(2 - of 19 pt f/u),
all had sx improvement
Renal
Murata, 201446 12 Coils, NBCA (3), Gel Recurrence (2 - treated No complications
Sponge (1), Ethanol (3) with coils only), Cure (10)

Dominant Outflow Vein Architecture

Conway, 201519 14 Plug and coils (13), No response (1), Cure (5)
Ethanol (2), NBCA (11 - 1:1) No complications

Sung, 200831 19 Ethanol, coil (13) Cure (13) Embolism (3), stroke (1), bladder necrosis (1),
skin necrosis (3)

20 May 2017
©

n APPLIED RADIOLOGY www.appliedradiology.com


the catheter (Figure 4). The techniques
to achieve these goals depend on AVM
nidal architecture as well as anatomic
location. We will organize treatment ap-
proaches based on the angiographic clas-
sification developed by Cho (Figure 3).30
In AVMs with a dominant outflow
vein, types one and two, retrograde or
direct puncture have become the pre-
ferred methods of access. Flow is first
reduced either via manual occlusion
of the draining vein or blood pressure
cuff. For lesions not amenable to the
above methods, such as those in the
trunk, balloon occlusion of the inflow
or outflow may be useful. In large an-
eurysmal draining veins, coils and glues
have been successfully used to occlude
the outflow.28, 31 In small AVMs of this
type NBCA alone has been shown to
be potentially curative.32 In most cases
though, after the outflow is occluded,
retrograde filling of the nidus can be
achieved either with ethanol or Onyx.19
,28, 33, 34
Operators are cautioned when
using high amount of outflow occlusion
as sclerosant can reflux into the arterial
system if injected too quickly.
For AVMs with multiple feeders and
outflows, types 3a and 3b, a trans-arterial
or direct puncture approach is recom-
mended.30 Direct puncture may be nec-
essary in situations where the tortuosity
of the arterial feeder precludes juxtani-
dal positioning or when the operator is
unable to assess proper positioning of
the catheter in very complex AVMs.12
This may be difficult and time-consum-
ing for small vessels and runs the risk of
sclerosant .35, 36 Flow occlusion contin-
ues to be paramount to ensure adequate
contact time with the nidus. Manual
compression of the draining vein or a
blood pressure cuff should be employed
when possible. A combination approach
has been described using a trans-arterial
NBCA injection to slow flow followed
by direct puncture of sclerosant into
nidal vessels.35
At our institution, we first perform
catheter-based diagnostic angiogra-
phy with selective and super-selective
catheter positioning using compression
adjuncts when appropriate. For all but
May 2017
PERIPHERAL ARTERIOVENOUS MALFORMATIONS
the most simple AVMs, we then bring
the patient back for staged treatment. In
the interim, the patient’s history, physi-
cal exam findings and MRI and angio-
graphic images are reviewed by a team
that includes interventional radiology,
diagnostic radiology, plastic surgery
and vascular surgery.
Postoperative pain and swelling
should be expected and can sometimes
be significant. The use of perioperative
corticosteroids to control postoperative
swelling is not well studied, but is rec-
ommended by those with considerable
experience treating these lesions. 37 Pa-
tients are typically seen in clinic once a
month after treatment begins, sooner if
indicated, until the primary endpoint of
symptomatic relief is reached or further
endovascular treatment is precluded due
to anatomical or clinical considerations.
Outcomes
There is limited data on the treatment
of peripheral AVMs with most reports
being small case series. Outcomes vary
considerably mostly due to the hetero-
geneous nature of AVMs. Large, dif-
fuse AVMs are often not curable and
embolotherapy is merely palliative.11
Small AVMs, especially those with a
single outflow vein, have a high chance
of cure with embolotherapy alone.32
However, if treated correctly, most
patients will experience at least symp-
tomatic improvement after endovascu-
lar therapy. Recurrence is a common
problem, especially if prior treatment
resulted in loss of preferred methods of
access. Table 3 provides a selected re-
view of the literature on various AVMs.
Conclusion
Peripheral AVMs have myriad mani-
festations, and treatment depends on the
acuity of the situation, nidal architecture
and anatomic location. Treatment is
often a long process requiring multiple
rounds of embolization and lifelong fol-
low up. We emphasize the use of a mul-
tidisciplinary team and to personalize
treatment to the patient’s wishes, as cur-
rently there is no cure. We have provided
a description of treatment techniques,
www.appliedradiology.com
complications and outcomes associated
with various sclerosants. We also de-
scribe our institutional techniques and
literature based techniques for treating
these lesions. Larger, controlled studies
are needed to provide more robust data
on the safety, efficacy, treatment tech-
niques, and periprocedural management
of these patients.
References
1. Hyodoh H, Hori M, Akiba H, et al. Peripheral
vascular malformations: Imaging, treatment
approaches, and therapeutic issues. Radiograph-
ics. 2005;25 Suppl 1:S159-171.
2. ISSVA Classification of Vascular Anoma-
lies ©2014 International Society for the Study
of Vascular Anomalies. https://s3.amazonaws.
c o m / C l u b E x p r e s s C l u b F i l e s / 2 9 8 4 3 3 / d o c u-
ments/issva_classification_2014_final_trial.
pdf?AWSAccessKeyId=AKIAIB6I23VLJX7E-
4J7Q&Expires=1436810557&response-con-
tent-disposition=inline%3B%20
filename%3Dissva_classification_2014_final_trial.
pdf&Signature=k0PV0BKQ7%2FGhsys8%2Flz-
1kRqsV0I%3D. Accessed May 1, 2017.
3. Kohout MP, Hansen M, Pribaz JJ, et al. Arterio-
venous malformations of the head and neck: Natu-
ral history and management. Plast Reconstr Surg.
1998;102(3):643-654.
4. Liu AS, Mulliken JB, Zurakowski D, et al. Extra-
cranial arteriovenous malformations: Natural pro-
gression and recurrence after treatment. Plast
Reconstr Surg. 2010;125(4):1185-1194.
5. Dubois J, Garel L. Imaging and therapeutic
approach of hemangiomas and vascular malfor-
mations in the pediatric age group. Pediatr Radiol.
1999;29(12):879-893.
6. Legiehn GM, Heran MK. Classification, diag-
nosis, and interventional radiologic management
of vascular malformations. Orthop Clin North Am.
2006;37(3):435-474, vii-viii.
7. Mulligan PR, Prajapati HJS, Martin LG, et al.
Vascular anomalies: classification, imaging char-
acteristics and implications for interventional
radiology treatment approaches. Br J Radiol.
2014;87(1035):20130392.
8. Bittles MA, Sidhu MK, Sze RW, et al. Multi-
detector CT angiography of pediatric vascular
malformations and hemangiomas: utility of 3-D
reformatting in differential diagnosis. Pediatr
Radiol. 2005;35(11):1100-1106.
9. Willems PW, Taeshineetanakul P, Schenk B, et
al. The use of 4D-CTA in the diagnostic work-up
of brain arteriovenous malformations. Neuroradiol-
ogy. 2012;54(2):123-131.
10. Herborn CU, Goyen M, Lauenstein TC, et al.
Comprehensive time-resolved MRI of peripheral
vascular malformations. AJR Am J Roentgenol.
2003;181(3):729-735.
11. Park KB, Do YS, Kim DI, et al. Predictive fac-
tors for response of peripheral arteriovenous mal-
formations to embolization therapy: Analysis of
clinical data and imaging findings. J Vasc Interv
Radiol. 2012;23(11):1478-1486.
12. Vogelzang RL, Atassi R, Vouche M, et al. Eth-
anol embolotherapy of vascular malformations:
clinical outcomes at a single center. J Vasc Interv
Radiol. 2014;25(2):206-213; quiz 214.
21
©
APPLIED RADIOLOGY n
PERIPHERAL ARTERIOVENOUS MALFORMATIONS
13. Pekkola J, Lappalainen K, Vuola P,et al. Head
and neck arteriovenous malformations: Results of
ethanol sclerotherapy. AJNR Am J Neuroradiol.
2013;34(1):198-204.
14. Ko JS, Kim JA, Do YS, et al. Prediction of the
effect of injected ethanol on pulmonary arterial
pressure during sclerotherapy of arteriovenous
malformations: Relationship with dose of ethanol.
J Vasc Interv Radiol. 2009;20(1):39-45.
15. Shin BS, Do YS, Cho HS, et al. Effects of repeat
bolus ethanol injections on cardiopulmonary hemo-
dynamic changes during embolotherapy of arterio-
venous malformations of the extremities. J Vasc
Interv Radiol. 2010;21(1):81-89.
16. Lee BB, Do YS, Byun HS, et al. Advanced
management of venous malformation with etha-
nol sclerotherapy: Mid-term results. J Vasc Surg.
2003;37(3):533-538.
17. Ko JS, Kim CS, Shin BS, et al. Changes in
pulmonary artery pressures during ethanol sclero-
therapy for arteriovenous malformations: iden-
tifying the most vulnerable period. Clin Radiol.
2011;66(7):639-644.
18. Lungren MP, Patel MN. Endovascular manage-
ment of head and neck vascular malformations.
Curr Otorhinolaryngol Rep. 2014;2(4):273-284.
19. Conway AM, Qato K, Drury J. Embolization tech-
niques for high-flow arteriovenous malformations
with a dominant outflow vein. J Vasc Surg. 2015.
20. Morishita H, Yamagami T, Matsumoto T, et al.
Transcatheter arterial embolization with N-butyl
cyanoacrylate for acute life-threatening gastroduo-
denal bleeding uncontrolled by endoscopic hemo-
stasis. J Vasc Interv Radiol. 2013;24(3):432-438.
21. Rosen RJ, Nassiri N, Drury JE. Interventional
management of high-flow vascular malformations.
Tech Vasc Interv Radiol. 2013;16(1):22-38.
22. Numan F, Omeroglu A, Kara B, et al. Embo-
lization of peripheral vascular malformations with
ethylene vinyl alcohol copolymer (Onyx). J Vasc
Interv Radiol. 2004;15(9):939-946.
23. Srinivasan KG, Vidyadharan R, Patel N, et al.
Embolisation of high flow extracranial/peripheral
arteriovenous malformations (AVMs) with ethylene
vinyl alcohol copolymer (ONYX®) in children - Bir-
mingham Children’s Hospital experience. Eur J
Plast Surg. 2014;37(3):129-134.
24. Chen WL, Ye JT, Xu LF, et al. A multidis-
ciplinary approach to treating maxillofacial
arteriovenous malformations in children. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod.
2009;108(1):41-47.
25. McGrath S, Harding V, Lim AK, et al. Embo-
lization of uterine arteriovenous malformations
22
©
n APPLIED RADIOLOGY
in patients with gestational trophoblastic tumors:
A review of patients at Charing Cross Hospital,
2000-2009. J Reprod Med. 2012;57(7-8):319-324.
26. Kjellin I, Boechat M, Vinuela F, et al. Pulmo-
nary emboli following therapeutic embolization of
cerebral arteriovenous malformations in children.
Pediatr Radiol. 2000;30(4):279-283.
27. Kline JN, Ryals TJ, Galvin JR, et al. Pulmonary
embolization and infarction: An iatrogenic compli-
cation of transcatheter embolization of a cerebral
arteriovenous malformation with polyvinyl alcohol
sponge. Chest. 1993;103(4):1293-1295.
28. Wang D, Su L, Han Y, et al. Ethanol embo-
lotherapy of high-flow auricular arteriovenous
malformations with electrolytically detachable
coil-assisted dominant outflow vein occlusion. Eur
J Vasc Endovasc Surg. 2014;48(5):576-584.
29. Mager JJ, Overtoom TT, Blauw H, et al. Embo-
lotherapy of pulmonary arteriovenous malforma-
tions: Long-term results in 112 patients. J Vasc
Interv Radiol. 2004;15(5):451-456.
30. Cho SK, Do YS, Shin SW, et al. Arteriovenous
malformations of the body and extremities: Anal-
ysis of therapeutic outcomes and approaches
according to a modified angiographic classifica-
tion. J Endovasc Ther. 2006;13(4):527-538.
31. Sung KC, Young SD, Dong IK, et al. Peripheral
arteriovenous malformations with a dominant out-
flow vein: Results of ethanol embolization. Korean
Radiol. 2008;9(3):258-267.
32. Dmytriw AA, Ter Brugge KG, Krings T, et
al. Endovascular treatment of head and neck
arteriovenous malformations. Neuroradiology.
2014;56(3):227-236.
33. Hernandez D. Transvenous embolization of
arteriovenous malformation. 2012 http://www.
nursinglibrary.org/vhl/handle/10755/243371?-
mode=full. Accessed May 1, 2017.
34. Wohlgemuth WA, Müller-Wille R, Teusch VI,
et al. The retrograde transvenous push-through
method: A novel treatment of peripheral arterio-
venous malformations with dominant venous out-
flow. Cardiovasc Intervent Radiol. 2015; 38(3);
623-631.
35. Kitagawa A, Izumi Y, Hagihara M, et al. Eth-
anolamine oleate sclerotherapy combined with
transarterial embolization using n-butyl cyanoacry-
late for extracranial arteriovenous malformations.
Cardiovasc Intervent Radiol. 2014;37(2):371-380.
36. van der Linden E, van Baalen JM, Pattynama
PM. Retrograde transvenous ethanol embolization
of high-flow peripheral arteriovenous malforma-
tions. Cardiovasc Intervent Radiol. 2012;35(4):
820-825.
www.appliedradiology.com
37. Lee BB, Baumgartner I, Berlien HP, et al.
Consensus document of the International Union
of Angiology (IUA)-2013 current concepts on the
management of arterio-venous malformations. Int
Angiol. 2013;32(1):9-36.
38. Churojana A, Khumtong R, Songsaeng
D, Chongkolwatana C, Suthipongchai S.
Life-threatening arteriovenous malformation of
the maxillomandibular region and treatment out-
comes. Interventional neuroradiology: Journal
of peritherapeutic neuroradiology, surgical pro-
cedures and related neurosciences. 2012;18(1):
49-59.
39. Pompa V, Valentini V, Pompa G, Di Carlo S,
Bresadola L. Treatment of high-flow arteriovenous
malformations (AVMs) of the head and neck with
embolization and surgical resection. Annali italiani
di chirurgia. 2011;82(4):253-259.
40. Lee BB, Do YS, Yakes W, Kim DI, Mattassi R,
Hyon WS. Management of arteriovenous malfor-
mations: a multidisciplinary approach. Journal of
vascular surgery. 2004;39(3):590-600.
41. Kim B, Kim K, Jeon P, Kim S, Kim H, Byun JH,
Kim D, Kim Y. Long-term results of ethanol sclero-
therapy with or without adjunctive surgery for head
and neck arteriovenous malformations. Neurora-
diology.2015 Apr;57(4):377-86. doi: 10.1007/
s00234-1483. Epub 2015 Jan 7.
42.Tan KT, Simons ME, Rajan DK, Terbrugge K.
Peripheral high-flow arteriovenous vascular mal-
formations: a single-center experience. Journal
of vascular and interventional radiology:JVIR.
2004;15(10):1071-1080.
43. Rockman CB, Rosen RJ, Jacobowitz GR,
Weiswasser J, Hofstee DJ, Fioole B, Lamparello
PJ, Adelman MA, Gagne PJ, Riles TS. Tran-
scatheter embolizationof extremity vascular mal-
formations: The long-term success of multiple
interventions. Ann Vasc Surg. 2003 Jul;17(4):
417-23
44. Yakes W. Abstract No. 200: Ethanol embo-
lotherapy management of pelvic arteriovenous
malformations. Journal of vascular and interven-
tional radiology: JVIR. 2010;21(2):S77.
45. Letourneau-Guillon L, Faughnan ME, Soulez
G, et al. Embolization of pulmonary arteriove-
nous malformations with amplatzer vascular
plugs: safety and midterm effectiveness. Journal
of vascular and interventional radiology: JVIR.
2010;21(5):649-656.
46. Murata S, Onozawa S, Nakazawa K, et al.
Endovascular embolization strategy for renal
arteriovenous malformations. Acta Radiol.
2014;55(1):71-77.
May 2017
MRI in pregnancy: Gastrointestinal
and genitourinary pathology
Jennifer A. Steinkeler, MD, and Karen S. Lee, MD
T
he presentation of abdominal
pain in pregnancy is a diag-
nostic challenge for clinicians.
Often, intra-abdominal pathology in
pregnancy can be masked by maternal
physiologic and anatomic changes in-
cluding leukocytosis, displacement of
abdominal organs by a gravid uterus,
nausea and vomiting, and a difficult
physical exam. 1,2 When true pathol-
ogy does exist, a delayed diagnosis can
lead to unfavorable outcomes for both
mother and fetus. In the setting of a con-
fusing clinical picture, imaging is a cru-
cial tool for the evaluation of pregnant
patients with abdominal pain.
Magnetic resonance imaging (MRI)
is beneficial in pregnancy as it allows
for excellent soft tissue contrast resolu-
tion and for the evaluation of multiple
organ systems without exposure to ion-
izing radiation.3 In this review, we will
discuss the safety of MRI in pregnancy
Dr. Steinkeler and Dr. Lee are Radiolo-
gists at Beth Israel Deaconess Medical
Center, Boston, MA.
May 2017
and our institution’s technique for im-
aging pregnant patients with abdomi-
nal pain by MRI. We will focus on the
MRI appearance of common abdominal
pathologies seen in pregnancy with at-
tention to the gastrointestinal and geni-
tourinary systems.
MRI technique
The American College of Radiol-
ogy (ACR) approves the use of MRI in
pregnancy. Although MRI is performed
without ionization radiation, radiofre-
quency pulses utilized in MRI deposit
energy in patients in the form of heat.
The amount of energy deposited is re-
ferred to as the specific absorption rate
(SAR) and is monitored on all mod-
ern MRI systems. The predicted fetal
temperature rise caused by this energy
deposition, to this point, has never been
demonstrated to cause fetal teratogenic-
ity in any trimester of pregnancy.4 MRI
in pregnancy is, therefore, felt to be safe
in all trimesters. As with any interven-
tion in pregnancy, however, the ACR
stresses that a risk-benefit analysis be
www.appliedradiology.com
performed, and in our institution, in-
formed consent is always obtained in
pregnant patients prior to undergoing
MRI. If an MRI is deemed non-urgent,
the study should be delayed until the pa-
tient is no longer pregnant.4
The ACR recommends against the
routine use of MRI contrast agents in
pregnant patients. Studies have demon-
strated that at least some of the gado-
linium chelate traverses the placenta
and may accumulate in the amniotic
cavity, with contrast cycling through
the fetal gastrointestinal and genito-
urinary tracts for an indefinite period
of time. 5 Although the risk of using
gadolinium in pregnancy remains un-
known, there is a potential for chelate
dissociation and the formation of toxic
gadolinium ions.4,5,6 The decision to use
contrast should therefore be made after
a risk-benefit analysis and on a case-to-
case basis.
At our institution, pregnant patients
are imaged supine on a 1.5 T magnet
with a phased-array body coil. No intra-
venous or oral contrast agent is admin-
23
©
APPLIED RADIOLOGY n
MRI IN PREGNANCY

istered. Image coverage extends from

A B the superior aspect of the gallbladder
through the pelvis. Key components
of our protocol are multiplanar, T2-
weighted steady-state fast spin echo
(SSFSE) sequences, which are useful
for localization of anatomic structures
and for highlighting edema and fluid,
particularly when fat-suppression tech-
nique is applied. Axial T1-weighted
in-phase and opposed-phase gradient
echo imaging is performed for soft tis-
sue characterization, including identify-
ing the presence of bulk or microscopic
C D fat, hemorrhage or protein, and sus-
ceptibility artifact, which can aid in the
identification of a normal air-containing
appendix. Diffusion-weighted imaging
can highlight areas of inflammation, in-
fection, or neoplasm, and provide value,
especially in the setting of a noncon-
trast study. Finally, 2D time-of-flight
imaging is utilized to help differentiate
a normal appendix from other tubular
mimickers such as pelvic varices.

Gastrointestional pathologies
While the most common cause of
acute abdominal pain in pregnancy is
FIGURE 1. Acute appendicitis in a 5-week pregnant patient presenting with right lower quad- appendicitis, other frequently encoun-
rant abdominal pain. (A) Axial T2-weighted SSFSE sequence demonstrating a dilated appen- tered gastrointestinal causes include
dix with hyperintense intraluminal material and extensive periappendiceal stranding (arrow). bowel obstruction and inflammatory
(B) Axial T2-weighted SSFSE image with fat suppression demonstrates extensive edema bowel conditions.7
centered about an enlarged appendix (arrow). (C,D) Coronal and sagittal T2-weighted SSFSE
images showing an enlarged, inflamed appendix (arrow). Acute appendicitis was confirmed at
surgery. Appendicitis
Appendicitis is the most common
non-obstetric cause for emergency sur-
A B gery in pregnancy.8 Acute appendicitis
in pregnancy, particularly perforated
appendicitis, has been linked to prema-
ture labor and maternal death, making
early diagnosis essential. 9 Studies have
demonstrated that MRI can reliably di-
agnose acute appendicitis during preg-
nancy with sensitivity and specificity of
100% and 94%, respectively.3, 9
Localization of the appendix can be
challenging in pregnant patients due to
changes in abdominal organ position
FIGURE 2. A 30-year-old woman with a history of Roux-en-Y gastric bypass presenting with caused by the gravid uterus. One means
severe left upper quadrant pain at 7 weeks’ gestation. (A) Coronal T2-weighted SSFSE image to localize the appendix is a cecal tilt
demonstrates dilated fluid-filled loops of jejunum in a left upper quadrant (thick arrows). (B)
Axial T2-weighted SSFSE image demonstrating one of the multiple transition points (thin
angle of at least 90° or greater on sagit-
arrow) with surrounding dilated small bowel. At surgery, a closed-loop obstruction secondary tal T2-weighted imaging, which predicts
to an internal adhesive band was confirmed. localization of the appendix to the right

24 May 2017
©

n APPLIED RADIOLOGY www.appliedradiology.com

 MRI IN PREGNANCY

A B C

FIGURE 3. A 37-year-old woman presenting with abdominal pain while 24-weeks pregnant. The patient has a history of Crohn’s disease. (A)
Coronal T2-weighted SSFSE image shows a markedly thickened distal ileum (thin arrows) with more normal adjacent bowel medially. (B) Axial
T2- weighted SSFSE image with thickened loops of distal ileum (thin arrows) and mesenteric inflammatory change (thick arrow). (C) Axial T2-
weighted SSFSE image with fat suppression demonstrates thickened distal ileal loops with mural stratification (thin arrow).

upper quadrant regardless of gestational

age.10 MR imaging features of a nor-
A B mal appendix include a diameter of less
than 6 mm, a collapsed or partially air-
filled lumen, and lack of periappendiceal
stranding. T1-weighted in-phase and
opposed-phase gradient echo imaging is
especially useful for identifying luminal
gas in the appendix, seen as susceptibility
artifact on the longer echo time in-phase
sequence compared to the opposed-phase
sequence. When gas is seen throughout
the appendiceal lumen, the diagnosis of
appendicitis is essentially excluded, re-
gardless of appendix diameter.
Features of acute appendicitis on
MRI include a dilated appendix greater
than 7 mm in diameter, hyperintense
intraluminal fluid on T2-weighted im-
aging, and a thickened, edematous wall
appearing brighter on T2-weighted
C D images compared to bowel wall else-
where. Restricted diffusion can also be
seen in acute appendicitis, and when
apparent, increases the sensitivity for
accurate diagnosis.11 Secondary signs
of appendicitis include periappendiceal
inflammation appearing as hyperintense
signal on T2-weighted images made
particularly apparent with the use of
FIGURE 4. Physiologic hydronephrosis at week 16 of pregnancy in a patient presenting with fat-suppression techniques (Figure 1).
right lower quadrant pain. (A) Coronal T2-weighted SSFSE sequence demonstrating moder- Appendicoliths, when present, may ap-
ate hydronephrosis of the right kidney. (B) Sagittal T2-weighted SSFSE sequence demon-
strating right hydronephrosis with gradual smooth tapering of the ureter in its distal portion
pear as focal hypointense structures on
(arrow). (C, D) Sequential axial T2-weighted SSFSE images through the pelvis showing com- T1- and T2-weighted imaging and can
pression of the ureter between the psoas muscle and the gravid uterus (arrow). demonstrate susceptibility artifact.

May 2017 25
©

www.appliedradiology.com APPLIED RADIOLOGY n

MRI IN PREGNANCY

A B C

FIGURE 5. Obstructive hydronephrosis in a pregnant patient presenting with right lower quadrant pain.
(A) Sagittal T2-weighted SSFSE sequence demonstrating severe right hydronephrosis (thick arrow).
The ureter is dilated below the level of the sacral promontory with abrupt decompression (thin arrows).
(B,C) Two subsequent axial FIESTA sequences demonstrate dilation of the right distal ureter (thick
arrow) with abrupt decompression. Susceptibility artifact (thin arrow) at the site of decompression is
consistent with an obstructing distal ureteral stone.

A B C

FIGURE 6. Ovarian torsion at 25 weeks’ gestation in a patient presenting with right lower quadrant pain. (A) Axial T2-weighted images showing
a gravid uterus with an enlarged edematous right ovary (arrow). (B) ADC image demonstrating low signal in the right ovary, with corresponding
DWI image showing hyperintense signal (not shown), consistent with restricted diffusion. (C) Axial T1-weighted opposed-phase gradient echo
image demonstrates a rim of high signal in the right ovary (arrow), consistent with hemorrhage. At surgery the right ovary was found to be torsed
and necrotic.

Bowel obstruction
Bowel obstruction in pregnancy
has an incidence of approximately 1 in
1,500 to 1 in 66,000.12 The frequency of
mechanical obstruction increases with
older gestational age.13 Common symp-
toms of pregnancy including nausea,
vomiting, and constipation mimic those
symptoms classic for bowel obstruc-
tion, making diagnosis a challenge.
Causes of obstruction are similar to
those seen in non-pregnant patients,
with adhesions being most common,
accounting for 58% of obstructions
in pregnant patients.14 Volvulus is the
second most common cause of obstruc-
tion in pregnancy occurring in approxi-
mately 25% versus only 3-5% of cases
in non-pregnant patients.15, 16 A unique
cause of bowel obstruction in preg-
nancy results from bowel compression
by a gravid uterus.17
MRI is excellent for the evaluation of
bowel obstruction and can be performed
without oral or IV contrast. Although
motion caused by amniotic fluid, ma-
ternal breathing, and peristalsis may
limit the evaluation of maternal bowel
on MRI, utilization of fast acquisition
imaging techniques helps compensate
for this limitation. Multiplanar T2-
weighted SSFSE imaging has demon-
strated particular utility in evaluating
the severity of obstruction and identify-
ing the transition point. Obstruction on
MRI appears as dilated loops of bowel,
often fluid-filled, leading to a transition
point, with decompressed downstream
bowel loops. Secondary signs, which
can help determine the severity of ob-
struction, such as bowel wall edema,
mesenteric edema, and ascites are also
well depicted by MRI (Figure 2).
Inflammatory bowel disease
Inflammatory bowel disease (IBD) is
a common cause of abdominal pain in
pregnancy both in women who already
carry the diagnosis and those who do
not, as both the age of presentation for
Crohn’s disease and ulcerative colitis
(UC) overlaps with reproduction. IBD
often mimics other surgical conditions
in pregnancy. For example, Crohn’s
disease frequently affects the terminal
ileum, making it a common mimicker
of acute appendicitis in pregnancy.1
On MRI active Crohn’s disease ap-
pears as segments of circumferentially
thickened, edematous bowel often with

26 May 2017
©

n APPLIED RADIOLOGY www.appliedradiology.com

 MRI IN PREGNANCY

A B

FIGURE 7. A 29-year-old woman at 16 weeks’ gestation, presenting with left lower quadrant pain. (A) Axial T2-weighted SSFSE sequence
demonstrating a gravid uterus. There is an exophytic hypertense mass in continuity with the uterus (arrow) with a thick hypointense rim, consis-
tent with a leiomyoma. (B) T1-weighted out-of-phase gradient echo image demonstrates that the rim of the leiomyoma is higher in signal inten-
sity then surrounding uterine parenchyma (arrow). Findings are consistent with a leiomyoma undergoing hemorrhagic degeneration

mural stratification on T2-weighted im-
ages, frequently with skip lesions and
involvement of the terminal ileum (Fig-
ure 3). Luminal narrowing is seen both
in the acute phase of inflammation, and
as a sequela of fibrosis in chronic dis-
ease. In addition to stricturing, bowel
in chronic disease often demonstrates
fatty mural infiltration, well differenti-
ated from wall edema by T2-weighted
fat-suppression sequences.
Extraluminal complications of
Crohn’s disease such as sinus and/or fis-
tulous tracts, phlegmon, and abscesses
are also well evaluated by MRI. The
former appear as fluid-filled linear areas
of signal abnormality on T2-weighted
sequences arising from bowel loops,
often with a stellate configuration and
associated bowel tethering.18 Phlegmon
appears as a mass-like area of hyperin-
tensity on T2-weighted imaging within
the mesenteric fat, while abscesses are
walled-off extraluminal fluid collec-
tions, sometimes containing suscepti-
bility due to the presence of gas.
In contrast to Crohn’s disease, in-
flammation in UC involves the rectum
and spreads proximally in a contiguous
manner. Even in the most severe cases,
wall thickening in UC is less dramatic
then in Crohn’s disease, as inflamma-
tion is not transmural and spares the
serosal surface. As in acute Crohn’s dis-
ease, secondary signs of active inflam-
mation such as free fluid and edema in
the surrounding soft tissues are well de-
picted by MRI. Chronic changes of UC
include a featureless, ahaustral colon
with fibrofatty proliferation of sur-
rounding soft tissues.
Genitourinary pathologies
Various genitourinary pathologies
can manifest as abdominal pain in
pregnancy, including obstructing cal-
culi, ovarian torsion, and degenerating
fibroids.
Obstructive hydronephrosis
The most frequent cause of obstruc-
tive hydronephrosis in pregnancy is uri-
nary tract calculi. Acute urolithiasis is
the most common cause of nonobstetric
hospital admission during pregnancy.19,
20
Potential complications of urolithiasis
include infection and premature labor,
highlighting the importance of differ-
entiating between physiologic and ob-
structive hydronephrosis.
Physiologic hydronephrosis occurs
in 90% of pregnant patients and is most
often asymptomatic, but has been a re-
ported cause of abdominal pain.21 Phys-
iologic hydronephrosis is caused by a
combination of extrinsic compression
of the ureter and hormonal-induced
ureteral relaxation, occurring most fre-
quently on the right (Figure 4).22 Phys-
iologic hydronephrosis manifests as
gradual tapering of the mid/distal ureter
due to compression between a gravid
uterus and the iliopsoas muscle.23 In
physiologic hydronephrosis, no filling
defect is seen, the ureter is not dilated
distal to the sacral promontory and only
rarely is there associated renal enlarge-
ment or perinephric fluid.
MRI features of obstructive uropa-
thy include an abrupt change in ureteral
caliber, renal enlargement, perinephric
fluid, and when visible, a low-signal
intensity ureteral filling defect on T2-
weighted imaging, which reflects the
obstructing calculus (Figure 5). Dila-
tation of the ureter caudal to the sacral
promontory also strongly suggests
pathologic, rather than physiologic,
ureteral dilatation. MRI, however, is
limited in the visualization of small cal-
culi in the ureter owing to poor spatial
resolution.
Ovarian torsion
Ovarian torsion occurs when the ad-
nexa twists on its pedicle, leading to
vascular compromise. There is a five-
fold increase in the rate of ovarian tor-
sion in pregnant women, occurring
most frequently in the first trimester.24
While ovarian torsion in pregnancy can
occur in a normal ovary due to increased

May 2017 27
©

www.appliedradiology.com APPLIED RADIOLOGY n

MRI IN PREGNANCY
ligamentous laxity, the more common
scenario involves an ovarian mass, such
as an enlarged corpus luteal cyst, predis-
posing to torsion.1
MRI features of ovarian torsion in-
clude an enlarged ovary, peripheral-
ization of follicles, and hyperintense,
edematous, ovarian stroma on T2-
weighted imaging. Fallopian tube thick-
ening and a swirled vascular pedicle can
also be seen (Figure 6).
Degenerating leiomyoma
The majority of leiomyomas remain
asymptomatic during pregnancy. How-
ever, as the uterus enlarges in pregnancy,
the blood flow to preexisting leiomyo-
mas is altered. When draining veins be-
come obstructed, hemorrhagic infarction
or so called red degeneration ensues.
This occurs in approximately 8% of leio-
myomas during pregnancy and can pres-
ent with an acute abdomen.25
The appearance of red degenera-
tion on MRI is variable depending on
the stage of necrosis. On T1-weighted
imaging, diffuse high signal inten-
sity is commonly seen and reflects T1
shortening effects of methemoglobin
or proteinaceous contents of blood.
There may also be an isolated hyper-
intense rim on T1-weighted imaging
surrounding the acutely degenerating
leiomyoma, thought to be secondary to
blood product confined to thrombosed
vessels. 25,26 T2-weighted sequences
demonstrate variable signal intensity
depending on the age of blood products
(Figure 7).
Conclusion
Abdominal pain in pregnancy can
be a diagnostic challenge for clinicians
28
©
n APPLIED RADIOLOGY
and MRI can serve as a critical imag-
ing tool. MRI is considered a safe im-
aging modality in pregnancy at any
gestational age. The benefits of MRI in
pregnancy include multiorgan system
evaluation without the cost of ionizing
radiation. Utilizing a standardized MRI
approach, many common gastrointesti-
nal and genitourinary causes of abdom-
inal pain in pregnancy, such as those
reviewed in this article, can be accu-
rately diagnosed.
References
1. Spalluto LB, Woodfield CA, DeBenedictis CM,
et al. MR imaging evaluation of abdominal pain
during pregnancy: Appendicitis and other non-
obstetric causes. Radiographics. 2012;32(2):
317-334.
2. Cappell MS, Friedel D. Abdominal pain
during pregnancy. Gastroenterol Clin North Am.
2003;32(1):1-58.
3. Pedrosa I, Levine D, Eyvazzadeh AD, et al. MR
imaging evaluation of acute appendicitis in preg-
nancy. Radiology. 2006;238(3):891-899.
4. Kanal E, Barkovich J, Bell C, et al. ACR guid-
ance document on MR safe practices:2013. J
Magn Reson Imaging. 2013;37(3): 501-530.
5. Tremblay E, Thérasse E, Thomassin-Naggara
I, et al. Guidelines for the use of medical imaging
during pregnancy and lactation. Radiographics.
2012;32(3):897-911.
6. Webb JA, Thomsen HS, Morcos SK, et al. The
use of iodinated and gadolinium contrast media
during pregnancy and lactation. Eur Radiol.
2005;15(6):1234-1240.
7. Bendeck SE, Nino-Murcia M, Berry GJ, et al.
Imaging for suspected appendicitis: negative
appendectomy and perforation rates. Radiology.
2002;225(1):131-136.
8. Woodfield CA, Lazarus E, Chen KC, et al.
Abdominal pain in pregnancy: Diagnosis and
imaging unique to pregnancy—Review. AJR Am J
Roentgenol. 2010;194(6 Suppl):14-30.
9. Cobbon LP, Groot I, Haans L, et al. MRI for clin-
ically suspected appendicitis during pregnancy.
AJR Am J Roentgenol. 2004;183(3):671-675.
10. Lee KS, Rofsky NM, Pedrosa I, et al. Local-
ization of the appendix at MR imaging during
pregnancy: utility of the cecal tilt angle. Radiology.
2008;249(1):134-141.
11. Leeuwenburgh MM, Wiarda BM, Bipat S, et
al. Acute appendicitis on abdominal MR images:
www.appliedradiology.com
training readers to improve diagnostic accuracy.
Radiology. 2012;264(2):455-463.
12. Perdue PW, Johnson HW, Stafford PW. Intes-
tinal obstruction complicating pregnancy. Am J
Surg. 1992;164(4):384-388.
13. Stukan M, Kruszewski WJ, Dudziak M, et al.
Intestinal obstruction in pregnancy. Ginekol Pol.
2013; 84(2):137-141.
14. Unal A, Sayharman SE, Ozel L, et al. Acute
abdomen in pregnancy requiring surgical man-
agement: A 20-case series. Eur J Obstet Gynecol
Repro Biol. 2011;159(1):87-90.
15. Vassiliou I, Tympa A, Derpapas M, et al. Small
bowel ischemia due to jejunum volvulus in preg-
nancy: a case report. Case Rep Obstet Gynecol.
2012;2012:1-2.
16. Gaikwad A, Ghongade D, Kittad P. Fatal mid-
gut volvulus: a rare cause of gestational intesti-
nal obstruction. Abdom Imaging. 2010;35:(3)
288-290.
17. McKenna DA, Meehan CP, Alhajeri AN, et
al. The use of MRI to demonstrate small bowel
obstruction during pregnancy. Br J Radiol.
2007;80(949):e4-11.
18. Martin DR, Danrad R, Herrmann K, et al.
Magnetic resonance imaging of the gastrointesti-
nal tract. Top Magn Reson Imaging. 2005;16(1):
77-98.
19. Semins MJ, Matlaga BR. Management of
urolithiasis in pregnancy. Int J Womens Health.
2013;5:599-604.
20. Horowitz E, Schmidt JD. Renal calculi in preg-
nancy. Clin Obstet Gynecol. 1985;28(2):324-338.
21. Puskar D, Balagović I, Filipović A, et al. Symp-
tomatic physiologic hydronephrosis in pregnancy:
incidence, complications, and treatment. Eur Urol.
2001;39(3)260-263.
22. Mayer IE, Hussain H. Abdominal pain
during pregnancy. Gastrienterol Clin North Am.
1998;27(1):1-36.
23. Spencer JA, Chahal R, Kelly A, et al. Eval-
uation of painful hydronephrosis in pregnancy:
Magnetic resonance urographic patterns in phys-
iological dilation versus calculous obstruction. J
Urol. 2004;171(1):256-260.
24. Masselli G,Brunelli R, Monti R, et al. Imaging
for acute pelvic pain in pregnancy. Insights Imag-
ing. 2014;5(2):165-181.
25. Kawakami S, Togashi K, Konishi I, et al. Red
degeneration of uterine leiomyoma: MR appear-
ance. J Comput Assist Tomogr. 1994;18(6):
925-928.
26. Ueda H, Togashi J, Konishi I, et al. Unusual
appearances of uterine leiomyomas: MR imaging
findings and their histopathologic backgrounds.
Radiographics. 1999;19(1):131-145.
May 2017
TECHNOLOGY
TRENDS
Time for radiology to get
ready for MACRA and MIPS
Mary Beth Massat
B
y signing into law the Medicare Acces-
sibility and CHIP Reauthorization Act
(MACRA) in 2015, President Barack
Obama replaced the Sustainable Growth Rate
formula with a method that incentivizes value
and quality over volume.
Under the Quality Payment Program (QPP),
the Centers for Medicare and Medicaid Ser-
vices (CMS) has two payment tracks: the Mer-
it-based Incentive Payment System (MIPS) or
the Alternative Payment Models (APMs). MIPS
has absorbed three existing quality improvement
programs: Physician Quality Reporting Systems
(PQRS), Value-Based Payment Modifier and
Medicare EHR Incentive Program.
Ezequiel Silva III, MD, Chair of the ACR
Economics Commission, says that most radiol-
ogy practices will be judged under the MIPS
payment pathway. “The good news is CMS says
the first two years of the program are transitional
years. The potential for downside risk is fairly
low, so groups don’t have to do a whole lot to be
neutral, and not a lot more to get that bonus.”
If they haven’t already, radiology managers
should become acquainted with the new scoring
system and criteria, and understand that radiol-
ogists and radiology groups are being scored
against other physicians. There are four perfor-
mance categories: Quality (60%); Advancing
Care Information (25%); Improvement Activi-
ties (15%); and Cost (0%). CMS has exempted
the cost category from the performance criteria
in 2017.
Mary Beth Massat is a freelance writer based
in Crystal Lake, IL.
May 2017
www.appliedradiology.com
The first step is to determine whether or not
the radiologist and/or group is patient facing
or non-patient facing. Dr. Silva points out that
non-patient facing radiologists will have fewer
requirements and measures to report and there-
fore have a higher chance of fulfilling those
requirements.
“From a purely risk-averse perspective of
avoiding penalties, it is better to be non-patient
facing,” says Dr. Silva, who understands and
agrees with the movement within radiology to be
more involved in patient care and a visible con-
tributor to a patient’s health. However, from a
reporting and billing perspective, patient-facing
radiologists and groups will have more require-
ments.
For example, non-patient-facing radiologists
are likely to be automatically reweighted to zero
for the Advancing Care Information category;
non-patient-facing, hospital-based eligible cli-
nicians may have to apply for this exemption.
Within Improvement Activities, most clinicians
are required to complete up to four improvement
activities; yet, non-patient-facing MIPS clini-
cians must meet half that requirement.
Another piece of good news for radiology
is that the 2017 MACRA Final Rule stated
that physicians would need more than 100
patient-facing encounters in order to be desig-
nated as patient-facing, which includes addi-
tional performance criteria.
Danny R. Hughes, PhD, Senior Director,
Health Policy Research, and Senior Research
Fellow at the Harvey L. Neiman Health Policy
Institute (HPI); Judy Burleson, ACR Senior
Director for Quality Management Programs,
29
©
APPLIED RADIOLOGY n
TECHNOLOGY
TRENDS
and HPI’s Wenyi Wang, MS, research associate,
explored the impact of the patient-facing desig-
nation on radiologists.
In a Jan. 5, 2017, blog post, Dr. Hughes wrote,
“10 percent of all radiologists and 9 percent of
diagnostic radiologists would receive the patient
facing designation under CMS’ definition.”
The three also evaluated the publicly available
Physician and Other Supplier Data from CMS to
see if this percentage has been consistent over the
last three years of available data. While there has
been a slight increase in patient-facing radiologists
from 2012 to 2014, Dr. Hughes expects this num-
ber to remain fairly consistent.
Dr. Hughes further noted that even if an indi-
vidual radiologist is patient facing, “Under the
group reporting option, if 75 percent of a group’s
clinicians meet the non-patient-facing criteria,
then the group does as well.”
Radiology groups have a few options for
reporting in 2017, explains Lea Halim, Senior
Consultant, Research, at Advisory Board. In
theory, groups that report on the required MIPS
measures across all categories for at least 90
days will be eligible for some positive payment.
“One option for all physicians who are not
prepared to fully report on all the criteria is
they can report on a smaller set of measures—
at least one MIPS metric in each category—for
90 days,” Halim says. “Or, minimally to avoid a
MIPS penalty, they can report one metric in one
of the categories for any period of time.”
While groups will be better off if they can report
the full metrics, Halim says, “If you haven’t done
anything, figure out one metric to report this year
for 90 days.”
Erin Lane, Senior Analyst, Research, at Advi-
sory Board, adds that because there are options
for reporting and the possibility to reduce the
number of reported metrics, groups can use this
transition year to put the systems and infrastruc-
ture in place for the following year.
Registries
Practices that have been participating in
PQRS and Meaningful Use will be well suited
for MACRA, Dr. Silva adds. “They will have the
operational procedures in place to do well in this
new paradigm, so practices that tackle this now
are well positioned to thrive.”
A challenge for some radiology groups is that
they have outsourced their PQRS to their billing
company, explains Halim. Now with the more
complete metrics and performance measures
30
©
n APPLIED RADIOLOGY www.appliedradiology.com
closely tied to reimbursement payment and penal-
ties, practices may want to explore either bringing
that function back inside or working more closely
with the billing company.
Another issue is that some groups and billing
companies have deduced PQRS through billing
claims. “The challenge with MIPS is that claims-
based reporting is not an option for all categories,”
Halim adds. “Groups may need to rethink their
reporting and invest in a different method, such as
using a registry.”
The ACR’s PQRS Qualified Clinical Data
Registry (QCDR) is an example of a robust
reporting option that radiologists can utilize. It has
been approved for the CMS PQRS for 2016 and
became fully functional for 2017 MIPS report-
ing as of March 31, 2017. And, with 60 percent
to 85 percent of a radiologists’ or groups’ score
based on quality performance, depending on
patient-facing or non-patient-facing designation,
the registry can help groups to benchmark out-
comes and process-of-care measures as well as
develop quality improvement programs.
“With claims-based reporting, reaching the
required six MIPS measures is challenging.
However, with the ACR QCDR, we have a list
of registry-based measures that we can report,”
says Dr. Silva. “It is not plug and play and is
fairly involved—it’s not easy but doable. In my
opinion a good business manager can put the
processes into place to get six measures for all
their radiologists.”
Some facilities may already be participat-
ing in a registry, such as the ACR Lung Cancer
Screening Registry. Dr. Silva explains that when
CMS began to cover lung cancer screening ser-
vices, one of the requirements was participation
in a registry.
“It is possible for practices to translate their
experience with one registry to other registries,”
Dr. Silva adds. “The Dose Index Registry is a
good registry to start with as most practices can
manage it effectively. They may also want to
look at the National Mammography Database
and the CT Colonography Registry.”
There is another advantage to participation
in the registries. Advisory Board’s Lane says,
“Through the QCDR, practices can see what
they are doing best in and adjust their reporting
based on their performance for MIPS. So the
ability to track, select and adjust will be key.”
Lane adds that it is also important to note
that the trend toward evidence-based medicine
began before MACRA and MIPS. Utilizing
May 2017

FIGURE 1. Axial T1-weighted MR of the
brain in this patient with a giant hypotha-
lamic hamartoma shows a large mass (blue
arrow) that is isointense to brain paren-
chyma centered in the suprasellar cistern.
to brain on T1 and T2, without abnor-
mal enhancement.
The differential diagnosis for a
suprasellar mass in a pediatric patient
is extensive,7 but the majority of the
lesions are uncommon. Major consid-
erations for a solid suprasellar mass
would include a craniopharyngioma,
pituitary macroadenoma, or a germ
cell tumor (including teratomas). Cra-
niopharyngiomas in pediatric patients
are usually of the adamantinomatous
type. These lesions are typically cys-
tic, contain calcifications, and enhance
after contrast administration.8 Pituitary
macroadenomas usually expand the
sella, and may extend into the suprasel-
lar cistern when large. These lesions
have a propensity to invade the cavern-
ous sinus, and may encase the internal
carotid artery without causing signifi-
cant narrowing. Suprasellar germ cell
tumors (most commonly germinomas)
arise from the hypothalamic region and
grow along the pituitary stalk. When
large, they present as heterogeneous
May 2017
FIGURE 2. Coronal T2-weighted image of the
same patient with a giant hypothalamic hamartoma
shows that the mass is slightly heterogeneous in
appearance, with components that are isointense
to gray matter (red arrow) and white matter (white
arrow). The area immediately subjacent to the red
arrow shows a cerebriform architecture with gray
and white matter, mimicking normal brain.
masses with enhancement and mild
restricted diffusion. These tumors have
a tendency for cerebrospinal fluid dis-
semination, and additional enhancing
foci elsewhere in the ventricles should
be viewed with suspicion and consid-
ered to be metastases until proven oth-
erwise.
CONCLUSION
Hypothalamic hamartomas are an
important cause of precocious puberty
and epilepsy in young patients. When
small in size, these lesions can be sub-
tle and easily overlooked due to their
similarity to normal brain tissue. When
large, a cerebriform or ‘brain-within-
a-brain’ appearance helps to clinch the
diagnosis of a hypothalamic hamartoma
and distinguish this lesion from other
pediatric suprasellar masses.
REFERENCES
1. Coons S, Retake H, Prenger E, et al. The histo-
pathology of hypothalamic hamartomas: Study of
57 cases. Journal of Neuropathology and Experi-
mental Neurology. 2007;66:131-141.
www.appliedradiology.com
RADIOLOGICAL CASE
FIGURE 3. Coronal fat-suppressed post-
contrast T1-weighted image shows that the
mass remains isointense to brain paren-
chyma without abnormal enhancement.
2. Mullati N, Selway R, Nashef L, et al. The clin-
ical spectrum of epilepsy in children and adults
with hypothalamic hamartoma. Epilepsia.
2003;44:1310-1319.
3. Kornreich L, Horev G, Blaser S. et al. Central
precocious puberty: Evaluation by neuroimaging.
Pediatric Radiology. 1995;25:7-11.
4. Albright A, Lee P. Neurosurgical treatment of
hypothalamic hamartomas causing precocious
puberty. Journal of Neurosurgery. 1993;78:77-82
5. Nishio S, Morioka T, Fukui M, et al.Surgical
treatment of Intractable Seizures Due To Hypotha-
lamic Hamartomas. Epilepsia. 1994;35:514-519.
6. Barkovich JA, Raybaud C. Pediatric Neuroimag-
ing, 5th Edition.
7. Rheinboldt M, Blasé J. Exophytic hypothalamic
cavernous malformation mimicking an extra-ax-
ial suprasellar mass. Emergency Radiology.
2011;18:363-367.
8. Kollias S, Barkovich A, Edwards M. Magnetic
resonance analysis of suprasellar tumors of child-
hood. Pediatric Neurosurgery. 1991;17:284-303.
Prepared by Dr. Cox while a third-year
Radiology Resident at Thomas Jefferson
University in Philadelphia, PA.; Dr. Ahn
while a second-year Radiology Resi-
dent at Christiana Hospital in Newark,
DE.; and Dr. Kandula while a Pediatric
Neuroradiologist, and Dr. Piatt while
a Pediatric Neurosurgeon at Nemours
Hospital in Wilmington, DE.
31B
©
APPLIED RADIOLOGY n
RADIOLOGICAL CASE
Giant hypothalamic hamartoma
Mougnyan Cox, MD; Julia Ahn, DO; Vinay Kandula, MD; and Joseph Piatt, MD
CASE SUMMARY
A 9-year-old girl was referred to our
endocrinology service for short stature.
She was otherwise well without a his-
tory of headaches or visual symptoms.
She was a full-term baby with normal
birth weight and no prenatal abnormal-
ities. Upon endocrinologic evaluation,
she was found to have central growth
hormone deficiency and hypothyroid-
ism. She was referred to radiology for a
brain MRI to rule out a structural cause
for her multiple endocrinopathies.
IMAGING FINDINGS
MR imaging of the brain without
and with contrast was performed, and
showed a large, slightly heterogeneous
mass in the suprasellar region. The
mass was isointense to the brain on
the unenhanced T1- and T2-weighted
images (Figures 1 and 2), without
abnormal enhancement (Figure 3). The
mass had a cerebriform appearance,
resembling a ‘brain-within-a-brain’
architecture. There was associated mass
31A
©
n APPLIED RADIOLOGY
effect on the optic chiasm, and supero-
lateral displacement of the bilateral
internal carotid arteries. There was no
hydrocephalus or vascular encasement/
narrowing. The pituitary gland was sep-
arate from the mass, and the sella was
not expanded.
DIAGNOSIS
Giant hypothalamic hamartoma.
Differential diagnosis includes cranio-
pharyngioma, pituitary macroadenoma,
and germ cell tumor.
DISCUSSION
Hypothalamic hamartomas are con-
genital malformations characterized by
disorganized but normal neural tissue in
the hypothalamic region.1 Patients with
hypothalamic hamartomas classically
present with gelastic seizures (laughing
seizures), but other seizures types may
also occur.2 Hypothalamic hamartomas
are also an important structural cause
of precocious puberty, and have been
reported to be the most common cause
www.appliedradiology.com
of central precocious puberty.3 Treat-
ment is usually medical, with a focus
on correcting any associated endocri-
nologic abnormalities or controlling
seizures. Surgery is usually reserved for
medically refractory seizures, or preco-
cious puberty in some cases.4,5
On imaging, hypothalamic ham-
artomas are similar in appearance to
distorted but normal brain tissue. 6
Hypothalamic hamartomas arise from
the floor of the third ventricle and proj-
ect into the suprasellar cistern. When
large, these lesions can distort the
suprasellar cistern and compress or dis-
place multiple structures including the
optic chiasm and prechiasmatic optic
nerves, internal carotid arteries, and
pituitary stalk. On CT, these lesions
appear isodense to the normal brain
parenchyma, and do not enhance after
contrast administration. Hemorrhage
and calcification within hypothalamic
hamartomas are exceedingly rare. MRI
imaging shows a soft tissue mass in the
hypothalamic region that is isointense
May 2017

FIGURE 1. Axial T1-weighted MR of the
brain in this patient with a giant hypotha-
lamic hamartoma shows a large mass (blue
arrow) that is isointense to brain paren-
chyma centered in the suprasellar cistern.
to brain on T1 and T2, without abnor-
mal enhancement.
The differential diagnosis for a
suprasellar mass in a pediatric patient
is extensive,7 but the majority of the
lesions are uncommon. Major consid-
erations for a solid suprasellar mass
would include a craniopharyngioma,
pituitary macroadenoma, or a germ
cell tumor (including teratomas). Cra-
niopharyngiomas in pediatric patients
are usually of the adamantinomatous
type. These lesions are typically cys-
tic, contain calcifications, and enhance
after contrast administration.8 Pituitary
macroadenomas usually expand the
sella, and may extend into the suprasel-
lar cistern when large. These lesions
have a propensity to invade the cavern-
ous sinus, and may encase the internal
carotid artery without causing signifi-
cant narrowing. Suprasellar germ cell
tumors (most commonly germinomas)
arise from the hypothalamic region and
grow along the pituitary stalk. When
large, they present as heterogeneous
May 2017
FIGURE 2. Coronal T2-weighted image of the
same patient with a giant hypothalamic hamartoma
shows that the mass is slightly heterogeneous in
appearance, with components that are isointense
to gray matter (red arrow) and white matter (white
arrow). The area immediately subjacent to the red
arrow shows a cerebriform architecture with gray
and white matter, mimicking normal brain.
masses with enhancement and mild
restricted diffusion. These tumors have
a tendency for cerebrospinal fluid dis-
semination, and additional enhancing
foci elsewhere in the ventricles should
be viewed with suspicion and consid-
ered to be metastases until proven oth-
erwise.
CONCLUSION
Hypothalamic hamartomas are an
important cause of precocious puberty
and epilepsy in young patients. When
small in size, these lesions can be sub-
tle and easily overlooked due to their
similarity to normal brain tissue. When
large, a cerebriform or ‘brain-within-
a-brain’ appearance helps to clinch the
diagnosis of a hypothalamic hamartoma
and distinguish this lesion from other
pediatric suprasellar masses.
REFERENCES
1. Coons S, Retake H, Prenger E, et al. The histo-
pathology of hypothalamic hamartomas: Study of
57 cases. Journal of Neuropathology and Experi-
mental Neurology. 2007;66:131-141.
www.appliedradiology.com
RADIOLOGICAL CASE
FIGURE 3. Coronal fat-suppressed post-
contrast T1-weighted image shows that the
mass remains isointense to brain paren-
chyma without abnormal enhancement.
2. Mullati N, Selway R, Nashef L, et al. The clin-
ical spectrum of epilepsy in children and adults
with hypothalamic hamartoma. Epilepsia.
2003;44:1310-1319.
3. Kornreich L, Horev G, Blaser S. et al. Central
precocious puberty: Evaluation by neuroimaging.
Pediatric Radiology. 1995;25:7-11.
4. Albright A, Lee P. Neurosurgical treatment of
hypothalamic hamartomas causing precocious
puberty. Journal of Neurosurgery. 1993;78:77-82
5. Nishio S, Morioka T, Fukui M, et al.Surgical
treatment of Intractable Seizures Due To Hypotha-
lamic Hamartomas. Epilepsia. 1994;35:514-519.
6. Barkovich JA, Raybaud C. Pediatric Neuroimag-
ing, 5th Edition.
7. Rheinboldt M, Blasé J. Exophytic hypothalamic
cavernous malformation mimicking an extra-ax-
ial suprasellar mass. Emergency Radiology.
2011;18:363-367.
8. Kollias S, Barkovich A, Edwards M. Magnetic
resonance analysis of suprasellar tumors of child-
hood. Pediatric Neurosurgery. 1991;17:284-303.
Prepared by Dr. Cox while a third-year
Radiology Resident at Thomas Jefferson
University in Philadelphia, PA.; Dr. Ahn
while a second-year Radiology Resi-
dent at Christiana Hospital in Newark,
DE.; and Dr. Kandula while a Pediatric
Neuroradiologist, and Dr. Piatt while
a Pediatric Neurosurgeon at Nemours
Hospital in Wilmington, DE.
31B
©
APPLIED RADIOLOGY n
RADIOLOGICAL CASE
Intrahepatic biloma from ruptured
cholecystitis
Jignesh Patel, MD; John Chang, MD, PhD; and Rizvan Mirza, MD
CASE SUMMARY:
A 78-year-old man with a past
medical history of rectal cancer pre-
sented to the emergency department
with upper abdominal pain, increasing
confusion, and urinary incontinence.
A physical exam was unremarkable
with temperature of 97.7 F. Laboratory
data revealed a normal white blood cell
count of 10.9 and cloudy urine positive
for leukocyte esterase and WBC >50.
Patient was admitted for urinary tract
infection and given intravenous anti-
biotics. On hospital day 2, a CT of the
abdomen was obtained for persistent
low grade fevers.
IMAGING FINDINGS:
Contrast enhanced CT of the abdo-
men with coronal reconstructions dem-
onstrates a 3.5 cm intrahepatic fluid
collection in the right hepatic lobe
(Figure 1). Multiple gallstones are pres-
ent within this fluid collection. Review
of the axial images reveals a direction
communication between the poste-
rior inferior wall of the gallbladder and
the fluid collection (Figure 2). Addi-
tionally, there is mild heterogeneous
enhancement of the surrounding liver
parenchyma from localized inflamma-
31C
©
n APPLIED RADIOLOGY
tion (Figures 1 and 2). The gallbladder
was not visualized on HIDA scan (Fig-
ure 3), confirming acute cholecystitis.
DIAGNOSIS:
Ruptured cholecystitis with intrahe-
patic biloma containing multiple gall-
stones.
DISCUSSION:
Gallbladder perforation is uncommon
but well described in the literature. This
complication occurs in 2-10% of cases of
acute cholecystitis.(1)  With the increase
in cholecystectomies in modern surgi-
cal practice, gallbladder perforation is
becoming rare with a reported incidence
of 0.8%.(2) The pathophysiology lead-
ing to perforation involves obstruction
of the cystic duct, biliary stasis causing
increase in the intravesicular pressure,
leading to gallbladder dilatation and
eventual perforation.1,3 Niemeier clas-
sified gallbladder perforation as acute
(type I) if there is generalized peritoni-
tis, subacute (type II) if the peritonitis is
localized or if there is a pericholecystic
abscess, and chronic (type III) if there
is a cholecystoenteric fistula.4 If the
rupture occurs along the under surface
of the gallbladder then peritonitis with
www.appliedradiology.com
extraluminal fluid collection occurs. If
the rupture occurs along the liver surface
of the gallbladder then an intrahepatic
biloma or abscess may form. Intraheptic
bilomas secondary to gallbladder perfo-
ration have rarely been described in the
literature.1,3 Our case is the first to dem-
onstrate back filling of the intrahepatic
biloma with multiple gallstones follow-
ing the perforation.
Both uncomplicated and com-
plicated cholecystitis have overlap-
ping symptoms which can make early
diagnosis difficult but have important
implications for patient management.
Complicated cases may require open
cholecystectomy rather than laparo-
scopic cholecystectomy. 1,5 Others
have advocated elective removal of the
gallbladder with percutaneous decom-
pression via a cholecystostomy tube
used as a bridge to surgery.2, 5
This patient underwent percuta-
neous ultrasound-guided cholecys-
tostomy tube placement because the
patient was deemed a high risk surgi-
cal candidate. Patient was discharged
after resolution of fevers and improved
mental status. Elective cholecystec-
tomy was planned for after the percuta-
neous drain was removed.
May 2017
 RADIOLOGICAL CASE

FIGURE 1. Contrast-enhanced CT of the abdomen with coronal reconstructions FIGURE 2. Direction communication between the poste-
demonstrated a 3.5 cm intrahepatic fluid collection in the right hepatic lobe. rior inferior wall of the gallbladder and the fluid collection.

FIGURE 3. The gallbladder was not visualized on HIDA scan, confirming acute cholecystitis.

CONCLUSION REFERENCES graphic signs and correlation with computed tomog-

Intrahepatic biloma is a rare com-
plication of perforated acute chole-
cystitis. Early and accurate detection
has significant impact on clinical man-
agement. Imaging and interventional
1. Taneja S, Sharma A, Duseja AK, et al. Sponta-
neous perforation of gallbladder with intrahepatic
bilioma. JCEH. 2011;1:210–211.
2. Kochar K, Vallance K, Mathew G, et al. Intra-
hepatic perforation of the gall bladder presenting
as liver abscess: case report, review of literature
raphy. Radiol Bras [online]. 2013;46:320-322.
4. Neimeier OW. Acute Free Perforation of Gall-
bladder. Ann Surg. 1934;99:922-44.
5. Date RS, Thrumurthy SG, Whiteside S, et al.
Gallbladder perforation: case series and system-
atic review. Int J Surg. 2012;10:63–68.

radiology play an important role in the
diagnosis and management of compli-
cated perforated acute cholecystitis.
and Niemeier’s classification. Eur J Gastroenterol
Hepatol. 2008;20:240–244.
3. Hollanda E, et al. Spontaneous perforation of
gallbladder with intrahepatic biloma formation: sono-
Prepared by Dr.Patel, Dr, Chang,
and Dr. Mirza while at Banner MD
Anderson Cancer Center, Gilbert, AZ.

May 2017 31D

©

www.appliedradiology.com APPLIED RADIOLOGY n

RADIOLOGICAL CASE
Intrahepatic biloma from ruptured
cholecystitis
Jignesh Patel, MD; John Chang, MD, PhD; and Rizvan Mirza, MD
CASE SUMMARY:
A 78-year-old man with a past
medical history of rectal cancer pre-
sented to the emergency department
with upper abdominal pain, increasing
confusion, and urinary incontinence.
A physical exam was unremarkable
with temperature of 97.7 F. Laboratory
data revealed a normal white blood cell
count of 10.9 and cloudy urine positive
for leukocyte esterase and WBC >50.
Patient was admitted for urinary tract
infection and given intravenous anti-
biotics. On hospital day 2, a CT of the
abdomen was obtained for persistent
low grade fevers.
IMAGING FINDINGS:
Contrast enhanced CT of the abdo-
men with coronal reconstructions dem-
onstrates a 3.5 cm intrahepatic fluid
collection in the right hepatic lobe
(Figure 1). Multiple gallstones are pres-
ent within this fluid collection. Review
of the axial images reveals a direction
communication between the poste-
rior inferior wall of the gallbladder and
the fluid collection (Figure 2). Addi-
tionally, there is mild heterogeneous
enhancement of the surrounding liver
parenchyma from localized inflamma-
31C
©
n APPLIED RADIOLOGY
tion (Figures 1 and 2). The gallbladder
was not visualized on HIDA scan (Fig-
ure 3), confirming acute cholecystitis.
DIAGNOSIS:
Ruptured cholecystitis with intrahe-
patic biloma containing multiple gall-
stones.
DISCUSSION:
Gallbladder perforation is uncommon
but well described in the literature. This
complication occurs in 2-10% of cases of
acute cholecystitis.(1)  With the increase
in cholecystectomies in modern surgi-
cal practice, gallbladder perforation is
becoming rare with a reported incidence
of 0.8%.(2) The pathophysiology lead-
ing to perforation involves obstruction
of the cystic duct, biliary stasis causing
increase in the intravesicular pressure,
leading to gallbladder dilatation and
eventual perforation.1,3 Niemeier clas-
sified gallbladder perforation as acute
(type I) if there is generalized peritoni-
tis, subacute (type II) if the peritonitis is
localized or if there is a pericholecystic
abscess, and chronic (type III) if there
is a cholecystoenteric fistula.4 If the
rupture occurs along the under surface
of the gallbladder then peritonitis with
www.appliedradiology.com
extraluminal fluid collection occurs. If
the rupture occurs along the liver surface
of the gallbladder then an intrahepatic
biloma or abscess may form. Intraheptic
bilomas secondary to gallbladder perfo-
ration have rarely been described in the
literature.1,3 Our case is the first to dem-
onstrate back filling of the intrahepatic
biloma with multiple gallstones follow-
ing the perforation.
Both uncomplicated and com-
plicated cholecystitis have overlap-
ping symptoms which can make early
diagnosis difficult but have important
implications for patient management.
Complicated cases may require open
cholecystectomy rather than laparo-
scopic cholecystectomy. 1,5 Others
have advocated elective removal of the
gallbladder with percutaneous decom-
pression via a cholecystostomy tube
used as a bridge to surgery.2, 5
This patient underwent percuta-
neous ultrasound-guided cholecys-
tostomy tube placement because the
patient was deemed a high risk surgi-
cal candidate. Patient was discharged
after resolution of fevers and improved
mental status. Elective cholecystec-
tomy was planned for after the percuta-
neous drain was removed.
May 2017
 RADIOLOGICAL CASE

FIGURE 1. Contrast-enhanced CT of the abdomen with coronal reconstructions FIGURE 2. Direction communication between the poste-
demonstrated a 3.5 cm intrahepatic fluid collection in the right hepatic lobe. rior inferior wall of the gallbladder and the fluid collection.

FIGURE 3. The gallbladder was not visualized on HIDA scan, confirming acute cholecystitis.

CONCLUSION REFERENCES graphic signs and correlation with computed tomog-

Intrahepatic biloma is a rare com-
plication of perforated acute chole-
cystitis. Early and accurate detection
has significant impact on clinical man-
agement. Imaging and interventional
1. Taneja S, Sharma A, Duseja AK, et al. Sponta-
neous perforation of gallbladder with intrahepatic
bilioma. JCEH. 2011;1:210–211.
2. Kochar K, Vallance K, Mathew G, et al. Intra-
hepatic perforation of the gall bladder presenting
as liver abscess: case report, review of literature
raphy. Radiol Bras [online]. 2013;46:320-322.
4. Neimeier OW. Acute Free Perforation of Gall-
bladder. Ann Surg. 1934;99:922-44.
5. Date RS, Thrumurthy SG, Whiteside S, et al.
Gallbladder perforation: case series and system-
atic review. Int J Surg. 2012;10:63–68.

radiology play an important role in the
diagnosis and management of compli-
cated perforated acute cholecystitis.
and Niemeier’s classification. Eur J Gastroenterol
Hepatol. 2008;20:240–244.
3. Hollanda E, et al. Spontaneous perforation of
gallbladder with intrahepatic biloma formation: sono-
Prepared by Dr.Patel, Dr, Chang,
and Dr. Mirza while at Banner MD
Anderson Cancer Center, Gilbert, AZ.

May 2017 31D

©

www.appliedradiology.com APPLIED RADIOLOGY n


registries and solutions such as clinical deci-
sion support solutions can help practices adapt
to value-based reimbursement models and help
improve quality.
Image sharing
Another area that is also appropriate and
sensible to pursue is image sharing—not just
for MIPS but for interoperability. However,
Dr. Silva cautions while it is not a significant
component of the quality program, it should
not be overlooked because image sharing has
the potential to lower costs by helping to avoid
duplicate or inappropriate exams.
As a specialty, Dr. Silva encourages radiology
groups to expand their use of certified EHR sys-
tems. “We had an exemption from Meaningful
Use for five years, and the consequence of that
exemption is that many radiology groups didn’t
participate. The secondary consequence is that
TECHNOLOGY
TRENDS
vendors didn’t take the steps through ONC to
become certified.”
Why does this matter now? Because, Dr. Silva
says, the Advancing Care Information category
and the quality measures behind it are evolv-
ing; while these measures may not be dependent
upon the use of certified EHR systems, their use
can enhance them.
“As the landscape changes and hospital or
multi-specialty groups embrace new payment
models tied to quality improvements, there is
no question radiology has to be a part of that,”
says Dr. Silva. “These changes are more than
scoring and protecting payments … . Practice
and industry leaders need to prepare radiologists
and groups to implement the quality payment
program and to understand the processes that
impact payments. The practices that want to do
well in the next chapter will have to do well now,
or the opportunity may pass them by.”

EXPERT FORUMS
A L I V E W E B C A S T

MACRA Readiness
Tuesday, June 6, 2017
11AM PT | 12PM MT | 1PM CT | 2PM ET
Summary
This Expert Forum Webcast will cover the strategic importance of MACRA and what it means to the
radiology community. We will provide an overview of what MACRA involves and define which providers
must begin planning immediately. In addition, the program will describe the Merit-based Incentive
Payment System (MIPS) and the four performance categories, which will ultimately determine how
radiologists and other physicians are reimbursed for their services.
Faculty

Gregory N. Nicola, MD, FACR Danny R. Hughes, PhD Theodore Long, MD, MHS
Vice President Senior Director, Health Policy Senior Medical Officer for the
Hackensack Radiology Group Research and Senior Research Fellow, Quality Measurement and
Harvey L. Neimen Health Policy Institute Value-Based Incentives Group at
the Centers for Medicare and
Medicaid Services (CMS)
Credits Available
One (1) AMA/PRA Category 1 CME Credits (TM)
One (1) ARRT Category A CE Credits
One (1) AHRA CRA Credits
Commercial Support
This activity has been supported by an unrestricted educational grant from Bracco Diagnostics, Inc. 

REGISTER TODAY — APPLIEDRADIOLOGY.COM/WEBCASTS

 Reading room treats
C. Douglas Phillips, MD, FACR
The superiority of chocolate, both for
health and nourishment, will soon give it
the same preference over tea and coffee in
America which it has in Spain.
Pavlov would —Thomas Jefferson,
in a letter to John Adams, 1785
have certainly
My career and medical training started
understood. in Virginia. In Charlottesville, townspeo-
I know what their ple still talk about Mr. Jefferson like he’s
just gone away for the weekend and will
priority is before be back in the office on Monday. Everyone
acts like he is still involved in everything.
a word is spoken. You hear things like, “Man, TJ is not going
to be happy with that new building going up
downtown.” TJ had a pretty serious love of
good food, wine, and chocolate.
We radiologists often spend the day in our
reading rooms; for the majority of us, they
are our workplace. We may have offices,
and we may occasionally get to them, pick
up mail, or answer a call, but the fact is, we
work in the reading room. And, as we have all
found of late, we rarely leave. We eat lunch
there, we drink coffee and get snacks without
a step from the desk, and usually spend very
little time not in direct contact with the key-
board and monitor. You want us? Come to the
Dr. Phillips is a Professor of Radiology, Director of Head and Neck Imaging, at Weill Cornell Medical College, NewYork-
Presbyterian Hospital, New York, NY. He is a member of the Applied Radiology Editorial Advisory Board.
32
©
n APPLIED RADIOLOGY www.appliedradiology.com
reading room. So, late in the afternoon, work
is still piling up, you’re starting to fade a little
… it’s time for a pick-me-up. Candy. Maybe,
candy and some caffeine. What do you keep
in your reading room?
We go for chocolate. We keep bags of it.
I have learned what true strength is: It’s just
eating one or two of those things and not
ruining my dinner by gorging on them. The
other benefit of this chocolate-infusion sys-
tem is the camaraderie that we experience
with clinicians who visit to “consult” with
us. I know why they come to the reading
room. They are returning for the chocolate. It
is a pilgrimage. They filled their pockets the
day before and the day before that, and they
are coming back for more.
Pavlov would have certainly understood.
I know what their priority is before a word
is spoken. If they look to the chocolate bag
before they announce they want to review
something, they are on the chocolate hunt.
The case they want to look at is subsidiary.
I think this is fine and I don’t mind shar-
ing (too much). And, when I venture to their
clinics or space to do a conference or look
at images, I find their stash as well. I have
pockets, too.
Keep doing that good work. Mahalo
May 2017
 The consistent quality of connected radiology

Seamlessly connect your team to enterprise-wide data and analytics, and

the power of integrated radiation-dose and contrast-dose* management:
• Compliance – dose tracking, Dose Reference Level alerts and benchmarking
• Efficiency – automated documentation and user-focused dashboards
• Reproducible quality – actionable analytics and protocol management

Find it all in the Radimetrics™ Enterprise Platform and our

dedicated teams of implementation and solutions specialists.

It’s our commitment to helping your team become seamlessly smart.

* Requires Medrad® Stellant® CT injection system with Certegra® Workstation.

Bayer, the Bayer Cross, Medrad®, Stellant®, Certegra® and Radimetrics™ are trademarks of the Bayer group of companies. ©2015 Bayer PP-REP-US-0074 March 2015