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 3
JAMLIK- OMARI JOHNSON
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Emergency Imaging
Case Review Series
Series Editor
David M. Yousem, MD, MBA
Associate Dean for Professional Development
Johns Hopkins University School of Medicine
Vice Chairman of Program Development
Department of Radiology
Johns Hopkins Medical Institution
Baltimore, Maryland

Volumes in the CASE REVIEW Series

Brain Imaging
Breast Imaging
Cardiac Imaging
Duke Review of MRI Physics
Emergency Radiology
Gastrointestinal Imaging
General and Vascular Ultrasound
Genitourinary Imaging
Head and Neck Imaging
Imaging Physics
Musculoskeletal Imaging
Neuroradiology
Non-Interpretive Skills for Radiology
Nuclear Medicine and Molecular Imaging
Obstetric and Gynecologic Ultrasound
Pediatric Radiology
Spine Imaging
Thoracic Imaging
Vascular and Interventional Imaging
Emergency Imaging
Case Review Series
SECOND EDITION

JAMLIK-OMARI JOHNSON, MD, FASER

Associate Professor
Radiology and Imaging Sciences
Chief of Radiology and Imaging Sciences, Emory University Hospital Midtown
Director of Emergency and Trauma Imaging, Emory Healthcare
Atlanta, Georgia
1600 John F. Kennedy Blvd.
Ste 1600
Philadelphia, PA 19103-2899

EMERGENCY IMAGING: CASE REVIEW SERIES, SECOND EDITION

ISBN: 978-0-323-42875-0

Copyright © 2020 by Elsevier, Inc. All rights reserved.

Previous edition copyrighted 2009.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
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This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).

Notice
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using any information, methods, compounds or experiments described herein. Because of rapid advances
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Content Development Manager: Kathryn DeFrancesco
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Printed in China

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

 List of Contributors

Farhan Ahmed Iqra Khan, BA, MD Wertheim College of Medicine

Medical Student Department of Emergency Medicine Miami, Florida
St. George’s University School of Medicine Saint Louis University School of Medicine
Meir Scheinfeld, MD, PhD
Grenada, West Indies St. Louis, Missouri
Director of Emergency Radiology
Maher Ahmed Taleef R. Khan, MBA, MD Montefiore Medical Center
Windsor University School of Medicine Resident Associate Professor
St. Kitts, West Indies Department of Orthopaedics and Sports Albert Einstein College of Medicine
Medicine Bronx, New York
Rizwan Ahmed, DO
University of Washington
Resident Shoaib Shariff, MBBS
Seattle, Washington
Department of Diagnostic and Interven- Baqai Medical University
tional Radiology Tahuriah Khan, DO Karachi, Pakistan
Advocate Illinois Masonic Medical Center Instructor
Haris Shekhani, MD, MBID
Chicago, Illinois Department of Emergency Medicine
Clinical Research Associate
Western Michigan University
Amanda Batten, DO, Capt USAF Interventional Radiology,
Homer Stryker, MD School of Medicine
Assistant Professor Emergency Radiology, MR Imaging
Kalamazoo, Michigan
Division of Emergency and Trauma Imaging Emory University
San Antonio Uniformed Services Health Marshall Kong, MD Atlanta, Georgia
Education Consortium Assistant Professor
Frank Taddeo, MD
San Antonio, Texas Department of Radiology
Resident, Family Medicine
University of Cincinnati Medical Center
Ferdia Bolster, MBBCh, BAO Piedmont Columbus Regional
Cincinnati, Ohio
UW Medicine Harborview Medical Center Columbus, Georgia
Seattle, Washington Kiran Maddu, MBBS
Darren Transue, MD
Emory University School of Medicine
Naga Ramesh Chinapuvvula, MD Attending Radiologist
Atlanta, Georgia
Assistant Professor Radiology Specialists of Florida
Emergency and Trauma Radiology Braham Malghani Florida Hospital Department of Radiology
UTHealth Assistant Professor
The University of Texas Health Science Faroukh Mehkri, DO University of Central Florida College of
Center, Houston/McGovern Medical School Resident Medicine
Houston, Texas Department of Emergency Medicine Orlando, Florida
Aprile Gibson, MD University of Connecticut Nupur Verma, MD
Teleradiologist Hartford Hospital Assistant Professor
Virtual Radiologics Hartford, Connecticut Abdominal and Cardiac Imaging
Eden Prairie, Minnesota Sarah McCord Director of Abdominal CT
Medical Student Director or Critical Care Imaging
Ibad Haider
Emory University School of Medicine University of Florida
CEO, BWell Pharmacy
Atlanta, Georgia Gainsville, Florida
CFO, Autism & Behavioral Spectrum
Autism and Behavioral Spectrum Leonora Mui, MD Brianna Vey, MD
St. Louis, Missouri Assistant Professor of Clinical Radiology Resident Physician
Zucker School of Medicine at Hofstra/ Emory University School of Medicine
Tarek Hanna, MD
Northwell Atlanta, Georgia
Associate Director, Division of Emergency
and Trauma Imaging Manhasset, New York Jason D. Weiden, MD
Program Director, Emergency Radiology Nabeel Mumtaz Assistant Program Director, Emergency
Fellowship Alabama College of Osteopathic Medicine Radiology Fellowship Program
Assistant Professor, Department of Class of 2021 Candidate Assistant Professor, Division of Emergency
Radiology and Imaging Sciences Dothan, Alabama and Trauma Imaging
Emory University School of Medicine Columbia University IHN Class of 2015 Department of Radiology and Imaging
Atlanta, Georgia New York, New York Sciences
Illinois Wesleyan Class of 2014 Emory University School of Medicine
Gayatri Joshi, MD
Bloomington, Illinois Atlanta, Georgia
Assistant Professor, Division of
Emergency Radiology Justin Rafael, MD Yara Younan, MD
Emory University School of Medicine Associate Radiologist Resident, Diagnostic Radiology
Atlanta, Georgia Radiology Associates of South Florida Department of Radiology
Baptist Health South Florida University of Massachusetts Medical School
Florida International University Herbert Worcester, Massachusetts

v
 Foreword

I am very happy to see the latest edition of Emergency Radiology For those of us who read within our specialty, the ED cases are
Case Review edited by Dr. Jamlik-Omari Johnson with cases writ- often challenging and foreboding. Lots of images, lots of recon-
ten by a number of talented radiologists. This is a burgeoning field structions, lots of nuances. All of us could learn from this well-
with ever increasing demand. Some of that demand has been written book.
assumed by NightHawk services, which provides off-hours imag- With this philosophical bent and admiration for those who
ing review for many practices. I have seen several of my Johns choose this field, I congratulate Dr. Johnson on this edition of
Hopkins residents and neuroradiology fellows take advantage of the Case Review Series in Emergency Radiology. I know that it
this entrepreneurial opportunity, as a permanent commitment, will be quite popular and well read. Best of luck and many thanks
as a moonlighting opportunity, or as a transition between jobs. to those people who specialize in this arena: thank you for allowing
Emergency department (ED) radiology is not like other fields many of us to sleep safely and securely at night!
of radiology which may be dominated by oncologic imaging. Obvi- Welcome Emergency Radiology, 2nd edition to our Case
ously, there are more vascular, traumatic, and infectious disease Review Series.
that are represented. However, the real challenge is the need to
master all organ systems, something that is daunting to a “narrow” David M. Yousem, MD, MBA
subspecialist such as myself. In fact, I always say that I admire the Case Review Series
“jack-of-all-trades” generalist much more so than the specialist. Associate Dean for Professional Development
Keeping up with all branches of the radiology literature is an enor- Johns Hopkins University School of Medicine
mous task—I only have to know my tiny field of neuroradiology. I Vice Chairman of Program Development
do very few things very well. I also recognize that, in this branch Department of Radiology
of radiology, communication skills are paramount. Emergency Johns Hopkins Medical Institution
radiologists are our voice. Baltimore, Maryland

vi
 Preface

Across the United States, 260 patients present to an emergency resonance, nuclear medicine), multiple disciplines, and multiple
department (ED) every minute. Taken in aggregate, 137 million body regions. We provide a one-stop shop for emergent imaging
patients were seen in EDs in 2015 according to the CDC.1 These and interpretation. We operate in the chaos and the quickly paced
numbers reflect a trend of sustained growth in ED visits year after emergency setting. Often times as a first responder, a gatekeeper, a
year. Imaging patients, as a vital tool not only to triage, but also to consultant, or a clinician—and always—as an advocate for patients.
plan treatment, is now commonplace. An estimated 70% of ED As the field of Emergency and Trauma Imaging continues to grow
patients receive imaging during their encounter.2 The sustained and mature, we hope the understanding and appreciation for the
growth within the ED setting and the importance of imaging have role of the Emergency Radiologist keeps pace.
fostered not only the growth of Emergency Radiology or, as I now My colleagues from around the country and I have compiled
refer to it, Emergency and Trauma Imaging, but also the Emer- this series of cases, not as an exhaustive compendium of every pos-
gency Radiologist. sible ED clinical scenario, but as a reflection of our broad daily
But who is the Emergency Radiologist? The question begs an practices. It is intended not just for the Emergency Radiologist,
answer. Although the answers may vary slightly, a common core but for individuals who may find themselves in the unfamiliar
exists. At Emory University our dedicated team of radiologists pro- territory of providing imaging support for the ED. We have
vide around-the-clock coverage for some of our sickest and most highlighted pertinent clinical and background information, imag-
vulnerable patients as they pass through the ED gateways. We also ing findings, management consideration, and reference material.
partner with our Emergency, Trauma, Medicine, Obstetrical and We hope that the entities you will encounter will rekindle and
Gynecological, and Oncologic colleagues to quickly, comprehen- augment your knowledge and reignite or spark a passion for this
sively, and appropriately evaluate patients answering the emergent exciting, growing, and dynamic subspeciality.
clinical queries and helping to triage patients to the next station.
The breadth and scope of our practice spans multiple modalities
(radiography, ultrasound, computed tomography, magnetic Jamlik-Omari Johnson, MD

1
National Hospital Ambulatory Medical Care Survey: 2015 Emergency
Department Summary Tables, tables 1, 4, 15, 25, 26 (https://www.cdc.gov/
nchs/data/nhamcs/web_tables/2015_ed_web_tables.pdf).
2
National Hospital Ambulatory Medical Care Survey: 2010 Emergency
Department Summary Tables. http://www.cdc.gov/nchs/data/ahcd/
nhamcs_emergency/2010_ed_web_tables.pdf.

vii
 To ACH—Thank you for the love and support
during not only this journey but over all these many
happy years.
To my colleagues-in-arms—Every day and through
the night, we fight the good fight. We strengthen our
discipline and make a difference at every level. I could not
be prouder of the work we do.
—Jamlik-Omari Johnson, MD
 Contents

Part I
Opening Round, 1

Part II
Fair Game, 74
Part III
Challenge, 149

PART IV
Answers, 177

Index of Cases 237

Index 238

ix
 PART
I Opening Round

Case 1
History: 22-year-old female patient presents with right lower 3. What is the most common tool to diagnose acute appendicitis
quadrant pain. in the adult population?
A. Computed tomography (CT)
1. Which of the following would be included in the differential
B. Ultrasonography (US)
diagnosis for the images presented? (Choose all that apply.)
C. Exploratory laparotomy
A. Pelvic inflammatory disease (PID)
D. Radiography
B. Acute cholecystitis
4. Which of the following statements regarding the pathogenesis
C. Acute appendicitis
of acute appendicitis is false?
D. Irritable bowel syndrome (IBD)
A. Increased pressure and distention of the appendix can be
2. Which of the following is a common symptom in acute
caused by luminal obstruction.
appendicitis?
B. Lumen obstruction is always the cause of acute appendicitis.
A. Pain in the right upper quadrant
C. Viral or bacterial infections can occur after an
B. Inability to pass gas
appendectomy.
C. Abdominal swelling
D. Obstruction of venous outflow and then arterial inflow can
D. Increased appetite
result in gangrene.

Fig. 1.1
Fig. 1.2

1
 Case 2
History: 72-year-old male with acute right-sided hemiparesis. 3. On CT perfusion imaging, which combination describes the
characteristic blood flow within the penumbra?
1. Which of the following would be included in the differential
A. Decreased mean transit time (MTT), decreased cerebral
diagnosis for the images presented? (Choose all that apply.)
blood volume (CBV), increased cerebral blood flow (CBF)
A. Transient ischemic attack (TIA)
B. Increased MTT, decreased CBV, increased CBF
B. Meningitis
C. Decreased MTT, increased CBV, decreased CBF
C. Acute middle cerebral artery (MCA) infarction
D. Increased MTT, normal CBV, decreased CBF
D. Hypertensive intracranial hemorrhage
4. What time frame and percentage of MCA territory involve-
2. Which of the following is the most likely cause of the salient
ment pair is desired for a patient to receive intravenous (IV)
finding in Fig. 2.1?
tissue plasminogen activator (tPA) therapy?
A. Hemoconcentration
A. 4.5 hours or less; <33%
B. Intravascular thrombus
B. 8 hours or less; <66%
C. Atherosclerotic calcification
C. 4.5 hours or less; >33%
D. Contrast material
D. 8 hours or less; >66%

Fig. 2.1

Fig. 2.2

2
 Case 2 3

Fig. 2.4

Fig. 2.3
 Case 3
History: 69-year-old female presenting with right lower 3. Which of the following treatments should be considered for
extremity pain. patients with a DVT if anticoagulation is contraindicated?
A. Low-molecular-weight heparin
1. Which of the following differential diagnoses is rarely associ-
B. Warfarin
ated with the imaging presented? (Choose all that apply.)
C. Inferior vena cava filter
A. Baker’s cyst
D. tPA
B. Cellulitis
4. Which of these patients with DVT is the best candidate for an
C. Lymphedema
inferior vena cava (IVC) filter?
D. Chronic venous insufficiency
A. 32-year-old with second occurrence of DVT and protein S
E. Superficial thrombosis
deficiency
2. Which of the following can be a symptom seen in patients with
B. 45-year-old with DVT and pulmonary embolism (PE)
deep venous thrombosis (DVT)?
C. 22-year-old pregnant women with first-time DVT
A. Deep pain and swelling in both arms
D. 76-year-old on warfarin develops atrial fibrillation, pul-
B. Frequent redness and swelling in left hand
monary embolus, and DVT
C. Leg pain on right side of calf
D. Leg pain on the back of the calf

Fig. 3.1

Fig. 3.2

4
 Case 4
History: 30-year-old male presenting with dull chest pain and 4. How would the CT finding of right ventricular strain alter
dyspnea. immediate clinical management?
A. Shock and death are a risk; patient should receive intense
1. Which of the following would be included in the differential
monitoring.
diagnosis for the imaging presented? (Choose all that apply.)
B. Shock and death are a risk; patient should receive throm-
A. Pulmonary embolism (PE)
bolytic therapy.
B. Intrinsic intraluminal tumor
C. There is a high risk for recurrent PE; patient should receive
C. Esophagitis
heparin rather than warfarin.
D. Angina
D. There is a high risk for ongoing embolization; patient
2. Which of the following symptoms is most commonly associated
should receive an IVC filter.
with PE?
A. Cyanosis
B. Mastalgia
C. Cephalgia
D. Delusional disorders
3. What is the most appropriate examination to evaluate a
30-week pregnant patient with suspected PE?
A. Lung scintigraphy
B. Transthoracic echocardiography (TTE)
C. Pulmonary angiography
D. CT pulmonary angiography (CTPA)
E. Venous duplex ultrasound

Fig. 4.2

Fig. 4.1

Fig. 4.3

5
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