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Emergency Radiology : ISSN: 2165-3259 JAOCR Official Journal of the American Osteopathic College of Radiology EMERGENCY RADIOLOGY Guest Editor: Hemang Kotecha, D.O. Editor-in-Chief: Daniel J. Wale, D.O. April 2020, Vol. 9, Issue 2 JAOCR About the Journal JAOCR Official Journal of the American Osteopathic College of Radiology Aims and Scope The Journal of the American Osteopathic College of Radiology (JAOCR) is designed to provide practical up-to-date reviews of critical topics in radiology for practicing radiologists and radiology trainees. Each quarterly issue covers a particular radiology subspecialty and is composed of high-quality review articles and case reports that highlight differential diagnoses and important teaching points. Access to Articles All articles published in the JAOCR are open access online. Subscriptions to the journal are not required to view or download articles. Reprints are not available. Copyrights Materials published in the JAOCR are protected by copyright. No part of this publication may be reproduced without written permission from the AOCR. Guide for Authors Submissions for the JAOCR are by invitation only. If you were invited to submit an article and have questions regarding the content or format, please contact the appropriate Guest Editor for that particular issue. Although contributions are invited, they are subject to peer review and final acceptance. Editor-in-Chief Daniel J. Wale, D.O., Ann Arbor, MI Editor Emeritus William T. O’Brien, Sr., D.O., Cincinnati, OH Editorial Board Abdominal/Body Radiology Neuroradiology Sharon A. Kreuer, D.O., Monroeville, PA Robert Koenigsberg, D.O., F.A.O.C.R., Philadelphia, PA Rocky C. Saenz, D.O., F.A.O.C.R., Farmington Hills, MI Alysha Vartevan, D.O., Scottsdale, AZ Breast Radiology Nuclear Medicine Matthew Tommack, D.O., Eugene, OR Timothy McKnight, D.O., Farmington Hills, MI Michelle C. Walters, D.O., Dallas, TX Daniel J. Wale, D.O., Ann Arbor, MI Chest and Cardiac Radiology Pediatric Radiology Mark Guelfguat, D.O., Bronx, NY Brooke S. Lampl, D.O., Cleveland, OH Douglas Johnson, D.O., Charlotte, NC Emily Janitz, D.O., Akron, OH Musculoskeletal Radiology Vascular and Interventional Radiology Christopher Cerniglia, D.O., M.Eng., Westborough, MA Aaron T. Rucks, D.O., M.S., Erie, PA Matthew Tommack, D.O., Eugene, OR Donald von Borstel, D.O., Tulsa, OK Page 2 J Am Osteopath Coll Radiol 2020; Vol. 9, Issue 2 Table of Contents JAOCR EMERGENCY RADIOLOGY Guest Editor: Hemang Kotecha, D.O. From the Editor In this Issue ...............................................................................................................................................4 Hemang Kotecha, D.O. Review Articles Neck Infections: What the Radiologist Needs to Know ................................................................................5 Roberto Kutcher-Diaz, M.D., David Radcliffe, M.D., Hao Lo, M.D., Hemang Kotecha, D.O., Gabriela Santos-Nunez, M.D Oncologic Emergencies of the Abdomen and Pelvis ..................................................................................11 Evan Ruppell, D.O., Hemang Kotecha, D.O., Lacey McIntosh, D.O. Differential-Based Case Reviews New Saccular Abdominal Aortic Aneurysm ..............................................................................................21 Alex Pavidapha, M.D., Hemang Kotecha, D.O. Pulmonary Nodules Following Renal Transplant ........................................................................................24 Uday Malhotra, M.D., Gabriela Santos-Nunez, M.D. JAOCR at the Viewbox Spontaneous Renal Artery Dissection .......................................................................................................26 David Radcliffe, M.D., Hemang Kotecha, D.O. Distal Intestinal Obstruction Syndrome (DIOS) ..........................................................................................27 Derek M. Chicarilli, M.D., M.A., Byron Chen, M.D. Calcific Tendinitis of the Longus Colli Muscle ...........................................................................................28 Tina Shiang, M.D., Christopher Cerniglia, D.O., M.Eng. J Am Osteopath Coll Radiol 2020; Vol. 9, Issue 2 Page 3 Letter from the Editor In this Issue Hemang Kotecha, D.O. Assistant Professor, University of Massachusetts, Worcester, MA UMass Memorial Medical Center, Worcester, MA am frequently met with confused expres- genitourinary, musculoskeletal, and head to toe Hemang Kotecha, D.O. sions when I tell other physicians, including trauma imaging utilizing conventional radiog- Iradiologists, that I am an emergency radiolo- raphy, CT, MRI, ultrasound, fluoroscopy, and gist. Most people are not aware that such a sub- nuclear medicine. “ Above all, don’t specialty exists within radiology, and almost all In this emergency radiology issue of the inquire as to what the profession entails. JAOCR, our goal was to complement the re- fear difficult The field of emergency radiology initially cent issue on trauma imaging by highlighting moments. emerged to meet demands for 24/7 diagnostic several stimulating nontrauma topics encoun- radiology coverage and has grown as imag- tered in emergency radiology. Our review The best comes ing utilization has skyrocketed in emergency articles emphasize common oncologic emer- from them.” departments, both in academic and private gencies in the abdomen and pelvis and lay the practices. Our academic institution covers five foundation for approaching neck infections emergency departments, including a level 1 — two daunting conditions encountered in the Rita Levi-Montalcini trauma and comprehensive stroke center, and emergency department. Our case reviews and emergency radiologists provide final reports Viewbox articles feature a variety of muscu- on all imaging studies 24 hours a day, 7 days loskeletal, vascular, gastrointestinal, and pul- a week, 365 days a year. Our residents and monary conditions that may cause diagnostic fellows are trained in emergency pathology, dilemmas for radiologists. department-specific imaging workflow, best I am privileged to serve as guest editor for protocols and practices, utilization of advanced this issue, and I would like to thank my mentor imaging techniques including dual-energy CT and colleague Christopher Cerniglia, D.O., for and rapid protocol MRI, as well as incorporat- nominating me for this role, and Daniel Wale, ing artificial intelligence into daily practice. D.O., for his guidance and support throughout We work closely with emergency medicine this project. Residents from our program were physicians and acute-care/trauma surgeons to heavily involved in each article, and I am in- care for adult and pediatric patients with both debted to all our department faculty for their traumatic and nontraumatic acute illnesses, mentorship. We hope these articles will both with an emphasis on rapid, comprehensive, and educate our readership on the selected clinical accurate diagnoses. This includes stroke, head subjects and provide a glimpse into the scope and neck, thoracic, vascular, gastrointestinal, of emergency radiology. Page 4 J Am Osteopath Coll Radiol 2020; Vol. 9, Issue 2 Neck Infections: What the Radiologist Needs to Know Neck Infections: What the Radiologist Needs to Know Roberto Kutcher-Diaz, M.D., David Radcliffe, M.D., Hao Lo, M.D., Hemang Kotecha, D.O., Gabriela Santos-Nunez, M.D. Department of Radiology, UMass Memorial Medical Center, Worcester, MA eck infections represent common radiologists as it is a connective layer the infrahyoid, geniohyoid, and mylo- clinical emergencies. While diag- interposed between the skin and deep hyoid muscles with superior attachment Nnosis and treatments are often merely fascia. By comparison, the deep fascia to the hyoid and thyroid cartilage and clinical, approximately 10% to 20% of is significant to radiologists as under- inferior continuity with the clavipec- deep neck infection complications are standing fascial boundaries allows for toral fascia. The visceral division of the potentially life threatening.1 Common easier detection of disease, more re- pretracheal layer encircles the thyroid, etiologies for head and neck infection fined differential diagnoses, anticipated parathyroid glands, trachea, and esopha- include pharyngitis, mastoiditis, and routes of disease spread and subsequent gus. The posterior aspect of the visceral odontogenic infections. Localization complications.3,4 division, also named the buccopharyn- and patterns of spread, especially in- The first layer of the deep cervi- geal fascia, extends from the skull base volving the deep cervical spaces, can cal fascia, the superficial layer, is also to the thoracic cavity where it attaches be challenging for the treating clinician. known as the investing layer. The su- to the pericardium. This layer is of Clinical manifestations vary based on the perficial layer of the deep cervical fas- particular clinical significance given age of presentation and infection site. CT cia (SLDCF) encircles the neck with that the retropharyngeal spaces lies of the neck is the first line of imaging in attachment to the spinous processes and directly posterior to the buccopharyngeal the acute setting.2 Although anatomy of ligamentum nuchae posteriorly; hyoid fascia.3,4 the head and neck is challenging, knowl- bone anteriorly; the mandible, tempo- The deep layer of the deep cervi- edge of common imaging patterns and ral, and occipital bones superiorly; and cal fascia (DLDCF), also known as the complications is critical for prompt and the manubrium, clavicles, and scapulae prevertebral
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  • Rare Case of Plunging Ranula with Parapharyngeal Extension and Absent Submandibular Gland: Excision by Transcervical Approach
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