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Cholangiocarcinoma (CC) is the most frequent malignant tumor of the biliary tract. The vast majority of cholangiocarcinomas are adenocarcinomas with a high proportion of fibrous stroma. Based on the macroscopic growth pattern, CC is classified as mass-forming, periductal infiltrating, or intraductal, with each type having its own characteristic imaging findings and prognostic outcome. The recently proposed pathological classification of cholangiocarcinoma into two types: perihilar large duct type and peripheral small duct and/or ductular type helps in better understanding of the morphology and the imaging appearances. Computed tomography (CT) and magnetic resonance imaging (MRI) remain the main tools of imaging. We aim to provide a comprehensive outline of the different subtypes and the rationale behind various imaging features of these subtypes. Cholangiocarcinoma is one of the more difficult tumors to treat and till date, surgery remains the only definitive curative treatment.

Each of the 3 morphological subtypes of cholangiocarcinoma has a different set of imaging differentials. Emulators of mass-forming cholangiocarcinoma include other primary and secondary hepatic malignancies, benign tumors and tumor-like mimics such as abscess, hemangioma and confluent hepatic fibrosis. Benign inflammatory biliary strictures constitute the major differential of periductal-infiltrative type and intraductal calculi are the main consideration for intraductal-growth type. CT and MRI are the standard imaging tools for characterization of cholangiocarcinoma and differentiating it from close mimics. Here we will describe the various tumoral and non-tumoral mimics of cholangiocarcinoma and discuss specific imaging features useful in differentiation.

Foreign-body ingestion is a rare cause for acute appendicitis. The authors report a case of a 48-year-old man who presented with abdominal pain for 3 days. Computed tomography (CT) revealed a foreign body in the appendix with peri-appendicular inflammatory changes. The patient underwent a successful appendectomy with complete recovery.

Calf pain or swelling is a common presentation to the emergency department. The differential diagnoses are wide. Deep vein thrombosis (DVT) is often the first diagnosis to be excluded given its potentially fatal complications. Musculoskeletal causes of calf pain or swelling such as Baker's cyst, muscle or tendon tear, soft tissue infection, and inflammation are not uncommon and can often be confidently diagnosed with ultrasonography (US). Familiarity with these conditions and the sonographic findings would be useful in making timely and correct diagnosis.

Background In ST-segment elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (PPCI), current oral P2Y12 platelet inhibitors do not provide maximal platelet inhibition at the time of reperfusion. Furthermore, administration of cangrelor prior to reperfusion has been shown in pre-clinical studies to reduce myocardial infarct (MI) size. Therefore, we hypothesize that cangrelor administered prior to reperfusion in STEMI patients will reduce the incidence of microvascular obstruction (MVO) and limit MI size in STEMI patients treated with PPCI. Methods The platelet inhibition to target reperfusion injury (PITRI) trial, is a phase 2A, multi-center, double-blinded, randomized controlled trial, in which 210 STEMI patients will be randomized to receive either an intravenous (IV) bolus of cangrelor (30 μg/kg) followed by a 120-minute infusion (4 μg/kg/min) or matching saline placebo, initiated prior to reperfusion (NCT03102723). Results The study started in October 2017 and the anticipated end date would be July 2020. The primary end-point will be MI size quantified by cardiovascular magnetic resonance (CMR) on day 3 post-PPCI. Secondary endpoints will include markers of reperfusion, incidence of MVO, MI size, and adverse left ventricular remodeling at 6 months, and major adverse cardiac and cerebrovascular events. Summary The aim of the PITRI trial is to assess whether cangrelor administered prior to reperfusion would reduce acute MI size and MVO, as assessed by CMR.

A 44-year-old man presented with breathlessness and episodes of palpitations for the last one year. The imaging diagnosis of cardiac sarcoidosis was made based on chest radiography and cardiac magnetic resonance (MR) imaging findings, and was further confirmed by biopsy. Cardiac sarcoidosis is an uncommon entity, yet is potentially fatal with nonspecific clinical manifestations, including sudden cardiac death. Hence, it is important to diagnose and treat this entity at an early stage to improve morbidity and mortality. Cardiac MR imaging plays a pivotal role in facilitating diagnosis and monitoring therapeutic response. We describe the MR imaging features of cardiac sarcoidosis and discuss imaging features of other cardiomyopathies that may mimic cardiac sarcoidosis.

From conventional radiograph to magnetic resonance urography, imaging of urinary system has evolved with variety of investigations over the past several decades with each of them having advantages and limitations of their own. In the current era, computed tomography (CT) has emerged as a preferred investigations for evaluation of the urinary tract. There are various techniques involved in performing CT urography (CTU) with triple bolus technique (TB-CTU) currently drawing a special attention because of its low radiation exposure. This article aims to discuss the current techniques, indications, and clinical applications of CTU with illustrations.

Conductive hearing loss (CHL) is caused by the disruption of the sound conductive chain that, in turn, may be due to diseases of the external and middle ear. High-resolution computed tomography (CT) is the imaging modality of choice to evaluate CHL because of its excellent spatial resolution. Along with clinical and otoscopic findings, CT also helps in the diagnosis and preoperative planning. This pictorial review aims to illustrate the CT features of common conditions causing CHL that may arise from the external and middle ear, as well as highlights some of the key imaging features that are helpful in management.

Wunderlich syndrome is a rare entity characterised by spontaneous retroperitoneal haemorrhage with renal origin. We present a case of Wunderlich syndrome secondary to clotting dyscrasia in a 64-year-old woman. The patient experienced a second Wunderlich haemorrhagic event with metachronous pseudoaneurysm formation, which was likely secondary to the large subcapsular haematoma stripping the renal capsule and tearing the cortical arteries. Selective pseudoaneurysm embolisations were successfully performed on both occasions. This clinical entity, its imaging differential diagnoses and management are discussed.

Patients presenting with a painful swollen leg are not infrequently encountered at the emergency department and can pose a diagnostic dilemma for attending physicians. The potential causes of leg pain and swelling include trauma, infection, inflammation, and neurogenic, vascular, and iatrogenic conditions; with magnetic resonance imaging (MRI) being an important tool in evaluation. We describe the MRI features of various conditions causing painful swollen legs. We also discuss the differential diagnosis and the useful clinical and laboratory findings that radiologists should be aware of, in order to arrive at an accurate diagnosis.

A 64-year-old woman presented to the emergency department complaining of sudden onset of right side neck pain radiating to the right scapula and right sided weakness. There was no history of headache or similar episode in the past. No past history of diabetes mellitus, hypertension or cardiac disease was present. On physical examination, there was loss of power in right upper and lower limbs (right upper limb: 2/5 and right lower limb: 1/5). There was no loss of power in the left limb. Patient's blood pressure was 124/82 mmHg, heart rate of 90/minute and oxygen saturation was 99% on room air. There was no difference of blood pressure in the arms. Glasgow coma scale (GCS) was 15 and initial laboratory investigations were within normal limits. A 12-lead ECG showed no acute changes. Urgent non-enhanced computed tomography (CT) of the brain followed by a CT angiogram of neck and circle of Willis was performed as patient complained of severe neck pain. After discussion with the neurosurgeons, the patient underwent a Magnetic Resonance Imaging (MRI) of the whole spine.

A 56-year-old Chinese man presented with giddiness and vertigo. Subsequent chest radiography showed the classic scimitar sign of an abnormal pulmonary venous return. Further evaluation with non-contrast computed tomography substantiated the finding of a partial anomalous venous drainage pattern and identified an associated rare lung anomaly, horseshoe lung. The imaging findings of scimitar syndrome and its association with horseshoe lung are reviewed.

AIP Acute interstitial pneumonia COP Cryptogenic organizing pneumonia CTD Connective tissue disease CTD-ILD Connective tissue disease-related ILD DIP Desquamative interstitial pneumonia GGO Ground-glass opacity HP Hypersensitivity pneumonitis IIP Idiopathic interstitial pneumonia ILD Interstitial lung disease IPF Idiopathic pulmonary fibrosis LIP Lymphocytic interstitial pneumonia NSIP Nonspecific interstitial pneumonia OP Organizing pneumonia PPFE Pleuroparenchymal fibroelastosis RB Respiratory bronchiolitis UIP Usual interstitial pneumonia

Radiology investigations play an important role in the assessment of pulmonary artery. Imaging is utilized in the diagnosis of pulmonary embolism (PE) and in the evaluation of a patient with pulmonary artery hypertension (PAH). PE is the third most common cardiovascular disease after coronary artery disease and stroke. The precise incidence of PE is not well known, but European guidelines estimated the incidence from 0.5 to 1 in 1000 [1]. Acute PE is associated with mortality rates as high as 30% [1, 2]. The clinical presentation of acute PE is variable accounting for its underdiagnoses. Most of the patients present with sudden onset of dyspnea, while a significant proportion may present with chest pain indistinguishable from more common coronary artery disease [3]. A small subset of patients may present with nonspecific symptoms like cough, hemoptysis, or syncope. Since the majority of the PEs are due to deep venous thrombosis (DVT) in the legs, one must be aware of predisposing conditions for DVT and PE that include advanced age, overweight, coagulation disorders, underlying malignancy, hormone replacement therapy, and oral contraception.

Nodules by definition are lung opacities less than 3 cm in size [1]. Subcentimeter pulmonary nodules always pose a dilemma to reporting radiologist. Radiologist’s role doesn’t get over by just describing the number and size of the nodules. It is important to guide the referring physician and patient about the next course of action that may range from follow-up CT to percutaneous CT-guided intervention. In certain cases, CT can provide additional clues for the underlying diseases accounting for pulmonary nodules.

The imaging appearances of pulmonary pathologies can be classified into various patterns for the ease of description and to narrow down the differential diagnoses. Imaging pattern refers to a finding or multiple findings suggesting one or more specific conditions [1, 2]. Many characteristic signs have also been described in computed tomography (CT) and radiographs. Along with the clinical features, these signs help in localizing the lesion or in arriving at a diagnosis.

Mediastinal abnormalities are generally uncommon—the most frequently encountered abnormality being mediastinal masses. Chest radiograph still remains the initial investigation of choice in patients with mediastinal abnormalities. Rarely, a mediastinal mass may be identified in an asymptomatic patient on routine screening chest radiograph. Hence, the radiologist must be aware of the signs of identifying and localizing mediastinal masses. The signs may not be specific; hence a sign in isolation is inadequate in diagnosis. However, a combination of imaging signs helps in accurate localization of a mediastinal mass on a chest radiograph. The absence of a sign is equally important in localization of an abnormality. CT is the investigation of choice for further characterization, assessing the extent of disease, and staging of mediastinal masses. Similarly, mediastinitis and pneumomediastinum are initially evaluated by chest radiographs and usually followed by a CT examination.

Computed tomography and magnetic resonance imaging are widely used for evaluation of patients with nasal masses, playing an integral role in their diagnosis and treatment. Inverted papilloma is a rare tumor of the sinonasal region that demonstrates characteristic imaging appearances. Preoperative diagnosis and precise tumor extent are essential for surgical planning as this tumor grows centrifugally and has high potential to recur following incomplete surgery. This pictorial review aims to illustrate the spectrum of imaging features of inverted papilloma and highlight the key features that are useful for making an accurate diagnosis of this condition. Common differential diagnoses are also discussed.

This editorial is discussing about the indiscriminate use of abdominal radiographs in the emergency department in general, with focus on value of the erect abdominal radiograph for the diagnosis of mechanical bowel obstruction and paralytic ileus.

Computed tomography (CT) is widely used for evaluation of patients with otologic conditions. External auditory canal cholesteatoma (EACC), although rare, demonstrates characteristic CT appearance. Moreover, the accurate extent of involvement cannot be accurately assessed clinically. This pictorial review aims to illustrate the spectrum of CT features of EACC and highlight the key features that are useful for making an accurate diagnosis of this condition. We have also discussed the radiological and clinical differential diagnoses of external auditory canal lesions that can be mistaken for an EACC.

Cardiovascular and noncardiovascular conditions are commonly encountered in the emergency department. While the majority of patients have underlying cardiovascular aetiologies, such as acute myocardial infarction, congestive heart failure, aortic dissection and pulmonary embolism, a small subset of patients have underlying noncardiovascular conditions, although they present with similar symptoms of chest pain, dyspnoea, cough, haemoptysis and haematemesis. This article aims to describe the imaging findings in common noncardiovascular conditions of the chest that are frequently encountered in the emergency department, with a review of the existing literature.

Acute cholecystitis is a common cause of right upper quadrant pain in patients presenting at the emergency department. Early diagnosis and recognition of associated complications, though challenging, are essential for timely management. Imaging studies, including ultrasonography, computed tomography and magnetic resonance imaging, are increasingly utilised for the evaluation of suspected cases of cholecystitis. These investigations help in diagnosis, identification of complications and surgical planning. Imaging features of acute cholecystitis have been described in the literature and are variable, depending on the stage of inflammation. This article discusses the spectrum of cholecystitis-associated complications and their imaging manifestations. We also suggest a checklist for the prompt and accurate identification of complications in acute cholecystitis.

A 21-year-old woman presented with acute onset of upper abdominal pain. A diagnosis of Peutz-Jeghers syndrome (PJS) was made based on the clinical picture of perioral pigmentation with imaging findings of transient jejunojejunal intussusceptions and small bowel polyps, and confirmed by characteristic histopathological appearances of Peutz-Jeghers polyps. PJS is a rare hereditary condition characterised by unique hamartomatous polyps, perioral mucocutaneous pigmentations, and increased susceptibility to gastrointestinal and extraintestinal neoplasms. Patients usually present with recurrent abdominal pain due to intussusception caused by polyps. Other modes of presentations include rectal bleeding and melaena. We describe the imaging findings of PJS and provide a brief review of bowel polyposis syndromes. The latter are relatively rare disorders characterised by multiple polyps in the large or small intestine, with associated risk of malignancies and other extraintestinal manifestations. Awareness of the manifestations and early diagnosis of these syndromes is crucial to prevent further complications.

The current usual interstitial pneumonitis (UIP)/idiopathic pulmonary fibrosis CT scan classification system excludes probable UIP as a diagnostic category. We sought to determine the predictive effect of probable UIP on CT scan on histology and the effect of the promoter polymorphism in MUC5B (rs35705950) on histologic and CT scan UIP diagnosis. METHODS The cohort included 201 subjects with pulmonary fibrosis who had lung tissue samples obtained within 1 year of chest CT scan. UIP diagnosis on CT scan was categorized as inconsistent with, indeterminate, probable, or definite UIP by two to three pulmonary radiologists. Tissue slides were scored by two expert pulmonary pathologists. All subjects with available DNA (N = 200) were genotyped for rs35705950. RESULTS The proportion of CT scan diagnoses were as follows: inconsistent with (69 of 201, 34.3%), indeterminate (72 of 201, 35.8%), probable (34 of 201, 16.9%), and definite (26 of 201, 12.9%) UIP. Subjects with probable UIP on CT scan were more likely to have histologic probable/definite UIP than subjects with indeterminate UIP on CT scan (82.4% [28 of 34] vs 54.2% [39 of 72]; P = .01). CT scan and microscopic honeycombing were not associated with each other ( P = .76). The minor (T) allele of the MUC5B polymorphism was associated with concordant CT scan and histologic UIP diagnosis ( P = .03). CONCLUSIONS Probable UIP on CT scan is associated with a higher rate of histologic UIP than indeterminate UIP on CT scan suggesting that they are distinct groups and should not be combined into a single CT scan category as currently recommended by guidelines. CT scan and microscopic honeycombing may be dissimilar entities. The T allele at rs35705950 predicts a UIP diagnosis by both chest CT scan and histology.

Interstitial lung abnormality was found in about 10% of lung cancer screening participants.

An environmental-friendly radiology department should be a requirement of the future era. The aim of this article is to make radiologists aware of their responsibilities for a greener world. We have suggested a number of minor but important changes in various sections of a radiology department that can make the radiology department more environmentally friendly. These small steps require relatively little effort on our part but cumulatively, may have a huge positive impact on our environment.

Abdominal apoplexy due to short gastric artery rupture following vomiting is an exceedingly rare condition. It results from non-traumatic and non-iatrogenic causes. This entity has variable clinical presentation and patients usually present with non-specific abdominal pain . Imaging plays a vital role in early diagnosis, as immediate exploratory laparotomy is the treatment of choice for successful outcome and helps to reduce mortality rate. We report the case of a 27-year-old male patient who presented to the emergency department with acute-onset abdominal pain after multiple episodes of vomiting following binge alcohol drinking. Contrast-enhanced CT revealed intraperitoneal haemorrhage secondary to vessel rupture, probably from a short gastric artery. Intraoperatively, the short gastric artery was identified as the bleeding source and ligated. The patient had an uneventful postoperative course.

A nutcracker (Fig. 1) has been used as an imaging metaphor to describe the compression of the left renal vein, as it passes between the abdominal aorta and the superior mesenteric artery (SMA). This appearance classically is seen on sagittal reconstruction of computed tomography (CT) scans (Fig. 2A). The resultant effects lead to ‘‘nutcracker syndrome’’, a term first used by de Schepper in 1972 [1] to characterize this vascular anatomical relationship described by Grant in 1937 [2]. The nutcracker phenomenon, also known as ‘‘left renal vein entrapment,’’ can be asymptomatic and merely detected as an incidental finding on a CT scan done for unrelated reasons [3]. When symptomatic it is termed nutcracker syndrome, and can cause hematuria or left flank or pelvic pain. The hematuria is thought to be due to small varices rupturing into the collecting system because of renal venous hypertension. The left flank or pelvic pain and discomfort, especially in young women, could reflect pelvic congestion caused by a distended left ovarian vein and resultant adnexal varices [1, 2]. On axial CT views, the left renal vein is compressed between the SMA and the aorta with the abrupt change in its caliber (Fig. 2B). The left renal vein proximally is dilated. To characterize the orientation of the vasculature, various measurements have been suggested, including the ratio of the left renal vein diameter at the hilum and at its narrowest segment, and the distance/angle between the aorta and SMA on sagittal reconstructions (aorto-mesenteric angle) [1, 2]. In addition to CT, Doppler ultrasound examination can be helpful in evaluating cases with suspected nutcracker syndrome [4]. The historical ‘‘gold standard’’ diagnostic test, retrograde venography, rarely is used to make a diagnosis, rather only performed when endovascular treatment is planned [2].

A 73-year-old woman presented to the ED with non-radiating right sided chest pain, since 1 week. The pain was progressively worsening and was not associated with vomiting and there was no preceding history of trauma. She denied prior episode of chest pain. History was significant for hypertension, hyperlipidaemia and iron deficiency anaemia. There was no history of coughing or smoking. Physical examination and ECG were unremarkable. A frontal chest radiograph was obtained (figure 1). Figure 1 Frontal chest radiograph. Which organ is the most …

Computed tomographic (CT) pulmonary angiography is widely used for evaluation of pulmonary embolism. Intraluminal filling defects in the contrast enhanced pulmonary arteries are considered diagnostic of pulmonary emboli. We report a false-positive case where filling defects in the pulmonary artery were due to mixing of blood from a complex shunt or vascular malformation between the systemic arteries and pulmonary artery.

To determine the effect of the MUC5B promoter polymorphism (rs35705950) on the CT imaging appearance of pulmonary fibrosis.High-resolution CT scans of 1,764 subjects were scored as part of a, genomewide association study with institutional review board approval; 1,491 of these had pulmonary fibrosis on CT scans and were included in the study. Two thoracic radiologists independently scored CT scans systematically. Discrepancies were resolved by a third thoracic radiologist. All patients were genotyped specifically for the rs35705950 single-nucleotide polymorphism (SNP). Two-tailed Fisher exact or χ(2) tests and Student t tests or Mann-Whitney U tests were used to compare proportions and means, respectively.The major and minor alleles at the rs35705950 SNP are guanine (G) and thymine (T), respectively: 514 were homozygous for the major allele (G group), and 977 were heterozygous or homozygous for the minor allele (T group). The G group had a higher proportion than the T group with ground-glass opacity (62.1% vs 54.2%; P = .04). There was no significant difference between the G and T groups regarding presence of honeycombing. The T group showed a significantly higher subpleural axial distribution of fibrosis than did the G group (62.3% vs 42.2%; P .0001). The T group showed a lower proportion of diagnoses inconsistent with usual interstitial pneumonitis (UIP; 20.3% compared with 30.5% for the G group) and a greater proportion of confident (probable UIP and UIP) UIP diagnoses (43.8% compared with 32.6% for the G group).The MUC5B promoter polymorphism identifies a pattern of fibrosis that is different from other causes of fibrosis and may respond differently to potential therapies.

Object The use of unilateral dural sinus stent placement in patients with idiopathic intracranial hypertension (IIH) has been described by multiple investigators. To date there is a paucity of information on the angiographic and hemodynamic outcome of these procedures. The object of this study was to define the clinical, angiographic, and hemodynamic outcome of placement of unilateral dural sinus stents to treat intracranial venous hypertension in a subgroup of patients meeting the diagnostic criteria for IIH. Methods Eighteen consecutive patients with a clinical diagnosis of IIH were treated with unilateral stent placement in the transverse-sigmoid junction region. All patients had papilledema. All 12 female patients had headaches; 1 of 6 males had headaches previously that disappeared after weight loss. Seventeen patients had elevated opening pressures at lumbar puncture. Twelve patients had opening pressures of 33–55 cm H2O. All patients underwent diagnostic cerebral arteriography that showed venous outflow compromise by filling defects in the transverse-sigmoid junction region. All patients underwent intracranial selective venous pressure measurements across the filling defects. Follow-up arteriography was performed in 16 patients and follow-up venography/venous pressure measurements were performed in 15 patients. Results Initial pressure gradients across the filling defects ranged from 10.5 to 39 mm Hg. Nineteen stent procedures were performed in 18 patients. One patient underwent repeat stent placement for hemodynamic failure. Pressure gradients were reduced in every instance and ranged from 0 to 7 mm Hg after stenting. Fifteen of 16 patients in whom ophthalmological follow-up was performed experienced disappearance of papilledema. Follow-up arteriography in 16 patients at 5–99 months (mean 25.3 months, median 18.5 months) showed patency of all stents without in-stent restenosis. Two patients had filling defects immediately above the stent. Four other patients developed transverse sinus narrowing above the stent without filling defects. One of these patients underwent repeat stent placement because of hemodynamic deterioration. Two of the other 3 patients had hemodynamic deterioration with recurrent pressure gradients of 10.5 and 18 mm Hg. Conclusions All stents remained patent without restenosis. Stent placement is durable and successfully eliminates papilledema in appropriately selected patients. Continuing hemodynamic success in this series was 80%, and was 87% with repeat stent placement in 1 patient.

The lateral neck radiograph is widely utilized for the evaluation of common neck conditions in the emergency department. The anatomy of the neck is complex and it can be difficult to differentiate between soft tissue structures on a lateral radiograph. We suggest a schematic pattern of interpreting the lateral neck radiograph with case images of various pathologies that can present in the emergency setting.

Although pathologies affecting stomach are commonly encountered in computed tomography imaging of the abdomen, they are frequently overlooked. Their etiologies are often diverse; however, most of them have certain well-documented imaging characteristics. Conventionally the stomach abnormalities were classified according to their etiopathogenesis. This article aims at providing the readers with an easy approach by categorizing abnormalities of stomach using a novel image appearance-based classification. An attempt to illustrate various gastric pathologies using this new classification by means of pictorial examples is made. Basic computed tomography imaging anatomy of the stomach and imaging techniques that need to be adapted are also emphasized in the outset of the discussion.

Diverticular disease of the appendix is rare and is usually diagnosed during surgery. We report a case of a 50-year-old man who presented to the emergency department with right lower quadrant pain of 1-day duration. A preoperative diagnosis of appendiceal diverticulitis was made by computed tomography of the abdomen. The patient underwent emergency laparoscopic appendectomy, which confirmed the diagnosis.