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THE REQUISITES

Emergency
Radiology
SERIES EDITOR OTHER VOLUMES IN THE REQUISITES
RADIOLOGY SERIES
James H. Thrall, MD
Radiologist-in-Chief Emeritus Breast Imaging
Department of Radiology Cardiac Imaging
Massachusetts General Hospital Gastrointestinal Imaging
Distinguished Juan M.Taveras Professor of Radiology Genitourinary Imaging
Harvard Medical School Musculoskeletal Imaging
Boston, Massachusetts Neuroradiology
Nuclear Medicine
Pediatric Radiology
Thoracic Radiology
Ultrasound
Vascular and Interventional Radiology
 THE REQUISITES

Emergency
Radiology
SECOND EDITION
Jorge A. Soto, MD
Professor of Radiology
Department of Radiology
Boston University School of Medicine;
Vice Chairman
Department of Radiology
Boston Medical Center
Boston, Massachusetts

Brian C. Lucey, MD
Associate Professor
Department of Radiology
Boston University School of Medicine
Boston, Massachusetts;
Clinical Director
Department of Radiology
The Galway Clinic
Doughiska, County Galway, Ireland
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

EMERGENCY RADIOLOGY:THE REQUISITES, SECOND EDITION ISBN: 978-0-323-37640-2

Copyright © 2017 by Elsevier, Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical treatment
may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds, or experiments described herein. In using such
information or methods they should be mindful of their own safety and the safety of others, including
parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the
most current information provided (i) on procedures featured or (ii) by the manufacturer of each
product to be administered, to verify the recommended dose or formula, the method and duration
of administration, and contraindications. It is the responsibility of practitioners, relying on their own
experience and knowledge of their patients, to make diagnoses, to determine dosages and the best
treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume
any liability for any injury and/or damage to persons or property as a matter of products liability,
negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.

Previous edition copyright © 2009 by Mosby, Inc., an affiliate of Elsevier, Inc.

Library of Congress Cataloging-in-Publication Data

Soto, Jorge A., editor.

Lucey, Brian C., editor.
Emergency radiology / [edited by] Jorge A. Soto, Brian C. Lucey.
Emergency radiology (Soto) | Requisites in radiology. | Requisites series.
Second edition. | Philadelphia, PA : Elsevier, [2017] | Requisites |Requisites radiology series
Includes bibliographical references and index.
LCCN 2015037285
ISBN 9780323376402 (hardcover : alk. paper)
MESH: Diagnostic Imaging. | Emergency Medical Services.
LCC RC78 | NLM WN 180 | DDC 616.07/572--dc23 LC record available at http://lccn.loc.gov/2015037285

Executive Content Strategist: Robin Carter

Content Development Specialist: Amy Meros
Publishing Services Manager: Patricia Tannian
Project Manager: Stephanie Turza
Senior Book Designer: Amy Buxton

Printed in China

Last digit is the print number: 9 8 7 6 5 4 3 2 1

To my parents, Jorge Sr. and Socorro, for their example and guidance, and to my
wife, Ana, and children, Andrea and Alejandro, for their sustained support and
patience as I devote my time to academic radiology.
J.A.S.

To my parents, James and Anne; sister, Suzanne; wife, Ciara; and son, James.
Thanks for the unconditional support.
B.C.L.
This page intentionally left blank

     
Contributors
Carlos A. Anaya, MD Ana Maria Gomez, MD
Medical Director Department of Radiology
Cardiovascular Interventional Institute Manati Medical Center
Department of Radiology Manati, Puerto Rico
Manati Medical Center
Manati, Puerto Rico Rathachai Kaewlai, MD
Instructor
Stephan W. Anderson, MD Division of Emergency Radiology
Associate Professor of Radiology Department of Diagnostic and Therapeutic Radiology
Boston University Medical Center Ramathibodi Hospital
Boston, Massachusetts Faculty of Medicine
Mahidol University
Laura L. Avery, MD Bangkok,Thailand
Assistant Professor
Massachusetts General Hospital Russ Kuker, MD
Harvard Medical School Department of Radiology
Boston, Massachusetts University of Miami Hospital
Miami, Florida
Glenn D. Barest, MD
Assistant Professor of Radiology Christina A. LeBedis, MD
Boston Medical Center Assistant Professor
Boston, Massachusetts Boston University Medical Center
Boston, Massachusetts
Sarah D. Bixby, MD
Assistant Professor of Radiology Brian C. Lucey, MD
Harvard Medical School; Associate Professor
Pediatric Radiologist Department of Radiology
Department of Radiology Boston University School of Medicine
Boston Children’s Hospital Boston, Massachusetts;
Boston, Massachusetts Clinical Director
Department of Radiology
Anna K. Chacko, MD The Galway Clinic
Adjunct Professor of Radiology Doughiska, County Galway, Ireland
Boston University
Boston, Massachusetts; Asim Z. Mian, MD
Professor of Telemedicine Assistant Professor of Radiology
John A. Burns School of Medicine Boston Medical Center
University of Hawaii Boston University
Honolulu, Hawaii Boston, Massachusetts

Margaret N. Chapman, MD Sarah S. Milla, MD

Chief of Neuroradiology Associate Professor
Boston VA Healthcare System; Department of Radiology and Imaging Sciences
Assistant Professor of Radiology Emory University;
Boston Medical Center Attending Pediatric Radiologist and Neuroradiologist
Boston University School of Medicine Children’s Healthcare of Atlanta
Boston, Massachusetts Egleston Hospital
Atlanta, Georgia
Luis E. Diaz, MD
Associate Chief of Radiology Felipe Munera, MD
VA Boston Health Care System; Department of Radiology
Associate Professor of Radiology University of Miami Hospital
Boston University Miami, Florida
Boston, Massachusetts
Rohini N. Nadgir, MD
Alejandra Duran-Mendicuti, MD Assistant Professor of Radiology and Radiological Science
Department of Radiology Johns Hopkins Medical Institutions
Brigham and Women’s Hospital Baltimore, Maryland
Boston, Massachusetts
vii
viii Contributors

Osamu Sakai, MD, PhD Joshua W. Stuhlfaut, MD

Chief of Neuroradiology Beth Israel Deaconess Hospital
Professor of Radiology, Otolaryngology–Head and Neck Plymouth, Massachusetts
Surgery and Radiation Oncology
Boston Medical Center Jennifer C. Talmadge, MD
Boston University School of Medicine Department of Radiology
Boston, Massachusetts Children’s Hospital Boston
Boston, Massachusetts
Rashmikant B. Shah, MD
Diagnostic Radiology Salvatore G. Viscomi, MD
St. James Healthcare Clinical Instructor
Butte, Montana Harvard Medical School;
Attending Radiologist
Ajay Singh, MD Department of Radiology
Department of Radiology Brigham and Women’s Hospital
Massachusetts General Hospital Boston, Massachusetts;
Boston, Massachusetts Chairman
Department of Radiology
Aaron D. Sodickson, MD, PhD Cape Cod Hospital
Department of Radiology Hyannis, Massachusetts
Brigham and Women’s Hospital
Boston, Massachusetts Scott White, MD
Department of Radiology
Jorge A. Soto, MD Brigham and Women’s Hospital
Professor of Radiology Boston, Massachusetts
Department of Radiology
Boston University School of Medicine; Ryan T. Whitesell, MD
Vice Chairman St. Paul Radiology
Department of Radiology Regions Hospital
Boston Medical Center St. Paul, Minnesota
Boston, Massachusetts

Michael Stella, MD
Department of Radiology
Brigham and Women’s Hospital
Boston, Massachusetts
Foreword
Time passes quickly, and it is now time to introduce the THE REQUISITES books have become old friends to
second edition of Emergency Radiology: THE REQUI- imagers for over 25 years. We have tried to remain true
SITES. Drs. Soto and Lucey, along with their coauthors, to the original philosophy of the series, which was to pro-
have once again created an excellent text that captures vide residents, fellows, and practicing radiologists with
the fundamental building blocks of emergency radiology a text that might be read within several days. From feed-
practice. back I have received, many residents do exactly that at
Drs. Soto and Lucey have maintained the logical division the ­beginning of each rotation. During first rotations this
of their book by both body part and indication—trauma ­allows them to acquire enough knowledge to really ben-
versus nontrauma with separate chapters for special con- efit from their day-to-day exposure to clinical material and
siderations in children and for nuclear medicine applica- the conditions about which they have just read. During
tions.This allows the reader of Emergency Radiology: THE subsequent rotations, a rereading imprints the knowledge
REQUISITES to go immediately to the material of interest. they will need subsequently for upcoming certification
As a side note, only two or so decades ago, nontrauma emer- exams. For the practicing radiologist, it serves as a useful
gency patients were not imaged nearly as often as they are refresher, like a booster shot.At the workstation, the books
today.Today, emergency applications for the nontrauma pa- in THE REQUISITES series are useful as a first reference
tient are just as important as the historic role of imaging source and guide to differential diagnosis.
in trauma. Imaging is truly the “guiding hand” of medical THE REQUISITES books are not intended to be exhaus-
practice, making possible rapid diagnosis, triage, and dispo- tive. There are other large reference books to catalog rare
sition, which are vitally important given the time and re- and unusual cases and to present different sides of con-
source constraints faced by busy emergency departments. troversies. Rather, THE REQUISITES books are intended
In the years between the preparation of the first edition to provide information on the vast majority of conditions
and the current work, much has happened to enhance that radiologists see every day, the ones that are at the core
the role of radiology in the emergency department and of radiology practice. In fact, one of the requests to authors
to reshape our thinking. These changes affect every area is to not look up anything they do not know but to put
of application and include, among many others, optimiza- in the book what they teach their own residents at the
tion of computed tomographic (CT ) protocols in every workstation. Since the authors are experienced experts in
organ system for lower radiation exposure, taking advan- their respective areas, this is predictably the most impor-
tage of fast CT scanning capabilities to reduce contrast us- tant material.
age and an increasing appreciation for the potential roles Drs. Soto and Lucey and their coauthors have again
of MRI for both traumatic and nontraumatic indications. done an outstanding job in sustaining the philosophy
Conventional radiography continues to play an important and excellence of THE REQUISITES series and deserve
role, especially for extremity trauma and some thoracic congratulations. Their book reflects the contemporary
imaging applications such as pneumonia and congestive practice of emergency imaging and should serve radiolo-
heart failure. However, for most applications, radiography gists, emergency medicine specialists, and other physi-
is being inexorably replaced by cross-sectional imaging. cians who deal with emergencies as a concise and useful
Drs. Soto and Lucey have again assembled an outstand- foundation for understanding the indications for imaging
ing team of coauthors to help ensure that Emergency and the significance of imaging findings in the emergency
Radiology: THE REQUISITES is as up to date as possible. setting.
Thanks to all the authors for their contributions.
Each chapter presents a different challenge in present- James H. Thrall, MD
ing material. All share a rich opportunity for illustrations, Chairman Emeritus
and Emergency Radiology: THE REQUISITES is extremely Department of Radiology
well illustrated. Otherwise the use of outline lists, boxes, Massachusetts General Hospital
and tables has been dictated by the material requiring Distinguished Taveras Professor of Radiology
presentation. Harvard Medical School

ix
This page intentionally left blank

     
Preface
Emergency Radiology is a unique title in THE REQUI- including CT angiography in the emergency department
SITES series. Although both the organ system–based and for coronary, aorta, brain/neck, visceral, and extremity ar-
modality-based divisions of radiology have existed for
­ teries, updated CT protocols in trauma and nontraumatic
some time, this REQUISITES title is the first to embrace a emergencies, and new and better quality images obtained
multimodality, multisystem approach to radiology. There with the latest imaging technology. Stepping away from
is an ongoing paradigm shift in medical management over the organ- and modality-based divisions, we acknowledge
the past 25 years or so, away from inpatient-oriented health that there is potential for overlap among this text and
care toward an increasingly outpatient-based system. No- others in THE REQUISITES series. However, to avoid this,
where is this more apparent than in emergency depart- we have endeavored to confine the text to medical and
ments across the United States and around the world. The surgical conditions that commonly present through the
reliance on imaging for diagnosis and guiding management emergency department rather than including every imag-
decisions throughout medicine has been increasing, and ing possibility that may present. We apologize in advance
this is exemplified in the emergency setting. All imaging if any overlap is identified—it was included for complete-
modalities are available to the emergency physician. More ness—or for any deficiencies; some rare entities may have
than in any other modality, the massive increase in the use been omitted for the sake of brevity.The fundamental divi-
of computed tomograpy (CT ) has led to the development sion of the book is in two parts, one dealing with acute
and growth of the specialty of emergency radiology. The trauma and the other with nontraumatic acute processes,
value of CT in the setting of trauma, investigation of severe and the division of the chapters reflects this. This makes it
headache, abdominal pain, and the evaluation of patients possible to easily select those chapters relevant to an in-
with suspected pulmonary embolus forms the bedrock of dividual radiology practice. Some departments, especially
emergency imaging, although there is an increasing role large academic departments with residency programs, will
for MR and ultrasound imaging in the emergency setting, have trauma units, whereas some community practices
particularly for the rapid evaluation of musculoskeletal in- may run an emergency department without dealing with
jury and emergent neurologic evaluation. The book is an acute trauma.
attempt to collate all the radiology information required We are pleased with how this revision has developed
in today’s emergency department setting into one suc- from an abstract concept into reality and built upon the
cinct, practical, and current text that can be used by both first edition. It has taken substantial effort, and we fully ap-
residents in training and general radiologists in practice, preciate the contributions from the authors, all of whom
as well as emergency department physicians and trauma have considerable experience in emergency imaging. We
surgeons. hope that the revision will be as well received as the first
The goal of this revision is to provide updates to address edition and will act as an integral resource for all radiology
the rapid changes in emergency imaging requirements, departments and training programs.

xi
This page intentionally left blank

     
Acknowledgments
We would like to thank many people who helped trans- are experienced radiologists with extensive knowledge
form the concept of this book into a reality. First, we owe in the various aspects of emergency radiology. Each au-
thanks to innumerable individuals (staff, residents, fel- thor has added his or her own subspecialty e­xpertise
lows, technologists, and nurses) at the Boston University to the chapters, which has resulted in the final product,
Medical Center who helped us and our colleagues build a textbook that we believe they should all be proud of.
multidisciplinary groups for the care of the acutely ill Finally, thanks to all the staff at Elsevier, especially Amy
patient. This was the principal driving force behind our Meros and Robin Carter, who waited patiently for us to
growing interest in the field of emergency ­radiology. We deliver the various parts of the book, sometimes at a
would also like to thank Dr. James Thrall for insisting on slower-than-hoped-for pace.
the timeliness and necessity of this text to add to THE J.A.S.
REQUISITES series. We would also like to extend a sin- B.C.L.
cere thank you to the contributing authors, all of whom

xiii
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