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Educational cases in MR spinal imaging
S8
Abstract / Clinical Radiology 72 (2017) S1eS13
Portable CT head imaging: an assessment of dose, quality and utility Authors: Drew Maclean, Dafydd Ifan, Ben Johnson, Omar Siddique, Roger Lightfoot, Andrea Romsauerova, Jason Macdonald Purpose: The emerging practice of portable computed tomography (CT) head imaging is set to rapidly increase in the UK. However, questions remain over the dose implication to staff and patients, the quality of images, and the degree of logistical and patient safety benefits, which we therefore aimed to evaluate. Methods and materials: From September 2015eMarch 2017 all patients from neuro intensive care unit (NICU) undergoing an unenhanced CT head were included. Portable imaging was assessed using a prospectively established criteria relating to the clinical question. Dose was assessed through a three-month non-inferiority analysis (d¼75 mSv), comparing the dose in NICU against general ICU (GICU). Logistical requirements were prospectively recorded and compared for both portable and departmental scans. Results: 741 non-contrast CT head scans were performed, 18.2% (135/741) being portable studies (patient age 45.3+/18.4, M:F 5.6:1), most (66.2%) conducted following trauma admissions with a mean patient dose length product of 699.8 mGy.cm. No significant increase in radiation level was detected in NICU compared with GICU (mean dose differential 2.5+/0.5 mSv, d¼75 mSv, p<0.05), and the dose recorded at the operator’s console was also low (10 mSv). All studies allowed the clinical question to be answered with 67/135 also enabling a good overall assessment. Total transfer and imaging time was reduced with portable CT (median 36 versus 53 mins) and doctors were required less frequently (5.9% versus 84.3%, Chi2 p<0.001). Conclusion: Portable CT head imaging offers significant logistical and patient safety benefits, while minimising background dose and simultaneously maintaining practical image quality. Heterotopic ossification in neurological injury: a pictorial review Authors: Richard McCormack, Brian McGlone Purpose: Heterotopic ossification (HO) is a condition whereby there is bone formation in a non-anatomical site, most commonly the peri-articular muscles in spinal cord and traumatic brain injury patients. It causes pain and restricts movement, most commonly at the hip joints. Though it may cause significant morbidity, it is a diagnosis not always considered when reporting imaging in susceptible individuals. This review aims to highlight its key features in order to promote better recognition. Methods and materials: We reviewed four of the best available cases of patients previously discussed at the NRH radiology multidisciplinary meeting (MDM). The imaging findings across various modalities are discussed, along with recommendations. Results: Through our four cases we saw that once HO has developed it responds poorly to medical therapies. Its key features in various modalities were examined. Recognition of these features in the acute setting prior to transfer to rehab services may facilitate earlier diagnosis of this condition, preventing further clinical sequelae including urinary tract infection, pressure sores and pneumonia. In patients with polytrauma and ischaemic muscular injuries HO may often be apparent on subsequent imaging of large joints. Conclusion: We conclude that heterotopic ossification is very prevalent in certain populations, especially those presenting with spinal cord injury and traumatic brain injury. One should always be aware of this potentially significant finding when reporting imaging on such patients, as there are practical rehabilitation challenges and management issues to be considered. In particular, HO should be considered in the differential for patients with spinal cord injury and leg swelling who are referred for Doppler ultrasound. Educational cases in MR spinal imaging Authors: Jenny Walsh, Peter Brown, Ian Craven Purpose: Following the initiation of a registrar (StR) on-call service for spinal magnetic resonance imaging (MRI) at our tertiary neurosciences
centre, we present an educational overview of the commonly misinterpreted pathologies seen on call. Methods and materials: We performed a review of 174 on call spinal cases performed in our centre over 12 months to identify cases with significant discrepancy between the provisional on-call report and the final report from the consultant neuroradiologist. Overall there was a 93% concordance between the on call and formal reports. Results: The most common indication to perform on call spinal MRI was for possible acute cord compression secondary to disc disease. Other referrals were received to investigate spinal infection, characterise trauma and assess for possible complications from spinal surgical intervention. We shall expand on areas of discordance between StR and consultant reports. This will emphasise common trends in discrepancy with themes of report structure, failure to make the relevant observations and interpretative error. The most commonly perceived difficulties encountered by StRs were postoperative infection, new diagnosis metastatic disease and trauma. Conclusion: By retrospectively reviewing our on-call performance we have been able to identify cases where StRs genuinely have difficulty in reading cases. Consequently this educational exhibit will prove useful to anyone interpreting acute spinal imaging.
In what context are radiologists most prone to error? A systematic review of discrepancies in a tertiary neuroradiology service Authors: Andrew Nanapragasam, Daniel Birchall, Priya Bhatnagar Purpose: It is well recognised that errors occurring in radiology reporting are a recurring and seemingly inevitable aspect of radiology practice. Discrepancies have serious and far-reaching consequences, not only in terms of clinical mal-outcome, but also in relation to organisational and personal professional reputation and to medico-legal liability. The purpose of this study was to assess the context in which errors occur in clinical practice. Methods and materials: A retrospective analysis of 100 consecutive cases referred to a discrepancy forum in a tertiary neuroradiology service was performed to assess the context in which erroneous consultant reports were issued, including reference to time of day, scan type, and nature of consultant report. Comparison was made with overall service data for each of these fields. Results: The following inter-connected factors were associated with a higher prevalence of error: reporting of computed tomography (CT) scans (48% of errors, versus 30% of overall service output); out-of-hours reports (36% of errors, versus 18% of overall service output); and consultant checking of trainee reports (52% of errors, versus 18% of overall consultantverified scans). Conclusion: The most striking pattern of error prevalence is in the context of consultants checking trainees’ out-of-hours CT scan reports. This is likely to relate to a combination of cognitive heuristics, including anchoring and framing bias, in which knowledge of clinical presenting details and of the trainee report appears to result in a high incidence of inattentional blindness in the checking consultants’ report. Awareness of this phenomenon is important for the reduction of error in this specific and widely underestimated reporting context. The trainees become the trainers: a specialty trainee-led introduction to an undergraduate radiology placement Authors: Adrian Hood, Taryn Kalami, Mark Phillips, Ian Craven Purpose: To assess a teaching session designed and delivered by radiology trainees that introduces undergraduates to radiology, radiologists and The Royal College of Radiologists’ (RCR) undergraduate curriculum. Methods and materials: The session is delivered entirely by specialist trainees to third-year undergraduates at the start of a one-week clinical placement in radiology. A combination of slideshow and picture archiving and communications system (PACS) image viewing takes the undergraduates through a single admission during which a notional patient undergoes multiple common investigations. Approaches to plain film and computed tomography (CT) reporting are introduced. An ultrasound (US) scan is viewed and discussed. Indications for common investigations and
Abstract / Clinical Radiology 72 (2017) S1eS13
Portable CT head imaging: an assessment of dose, quality and utility Authors: Drew Maclean, Dafydd Ifan, Ben Johnson, Omar Siddique, Roger Lightfoot, Andrea Romsauerova, Jason Macdonald Purpose: The emerging practice of portable computed tomography (CT) head imaging is set to rapidly increase in the UK. However, questions remain over the dose implication to staff and patients, the quality of images, and the degree of logistical and patient safety benefits, which we therefore aimed to evaluate. Methods and materials: From September 2015eMarch 2017 all patients from neuro intensive care unit (NICU) undergoing an unenhanced CT head were included. Portable imaging was assessed using a prospectively established criteria relating to the clinical question. Dose was assessed through a three-month non-inferiority analysis (d¼75 mSv), comparing the dose in NICU against general ICU (GICU). Logistical requirements were prospectively recorded and compared for both portable and departmental scans. Results: 741 non-contrast CT head scans were performed, 18.2% (135/741) being portable studies (patient age 45.3+/18.4, M:F 5.6:1), most (66.2%) conducted following trauma admissions with a mean patient dose length product of 699.8 mGy.cm. No significant increase in radiation level was detected in NICU compared with GICU (mean dose differential 2.5+/0.5 mSv, d¼75 mSv, p<0.05), and the dose recorded at the operator’s console was also low (10 mSv). All studies allowed the clinical question to be answered with 67/135 also enabling a good overall assessment. Total transfer and imaging time was reduced with portable CT (median 36 versus 53 mins) and doctors were required less frequently (5.9% versus 84.3%, Chi2 p<0.001). Conclusion: Portable CT head imaging offers significant logistical and patient safety benefits, while minimising background dose and simultaneously maintaining practical image quality. Heterotopic ossification in neurological injury: a pictorial review Authors: Richard McCormack, Brian McGlone Purpose: Heterotopic ossification (HO) is a condition whereby there is bone formation in a non-anatomical site, most commonly the peri-articular muscles in spinal cord and traumatic brain injury patients. It causes pain and restricts movement, most commonly at the hip joints. Though it may cause significant morbidity, it is a diagnosis not always considered when reporting imaging in susceptible individuals. This review aims to highlight its key features in order to promote better recognition. Methods and materials: We reviewed four of the best available cases of patients previously discussed at the NRH radiology multidisciplinary meeting (MDM). The imaging findings across various modalities are discussed, along with recommendations. Results: Through our four cases we saw that once HO has developed it responds poorly to medical therapies. Its key features in various modalities were examined. Recognition of these features in the acute setting prior to transfer to rehab services may facilitate earlier diagnosis of this condition, preventing further clinical sequelae including urinary tract infection, pressure sores and pneumonia. In patients with polytrauma and ischaemic muscular injuries HO may often be apparent on subsequent imaging of large joints. Conclusion: We conclude that heterotopic ossification is very prevalent in certain populations, especially those presenting with spinal cord injury and traumatic brain injury. One should always be aware of this potentially significant finding when reporting imaging on such patients, as there are practical rehabilitation challenges and management issues to be considered. In particular, HO should be considered in the differential for patients with spinal cord injury and leg swelling who are referred for Doppler ultrasound. Educational cases in MR spinal imaging Authors: Jenny Walsh, Peter Brown, Ian Craven Purpose: Following the initiation of a registrar (StR) on-call service for spinal magnetic resonance imaging (MRI) at our tertiary neurosciences
centre, we present an educational overview of the commonly misinterpreted pathologies seen on call. Methods and materials: We performed a review of 174 on call spinal cases performed in our centre over 12 months to identify cases with significant discrepancy between the provisional on-call report and the final report from the consultant neuroradiologist. Overall there was a 93% concordance between the on call and formal reports. Results: The most common indication to perform on call spinal MRI was for possible acute cord compression secondary to disc disease. Other referrals were received to investigate spinal infection, characterise trauma and assess for possible complications from spinal surgical intervention. We shall expand on areas of discordance between StR and consultant reports. This will emphasise common trends in discrepancy with themes of report structure, failure to make the relevant observations and interpretative error. The most commonly perceived difficulties encountered by StRs were postoperative infection, new diagnosis metastatic disease and trauma. Conclusion: By retrospectively reviewing our on-call performance we have been able to identify cases where StRs genuinely have difficulty in reading cases. Consequently this educational exhibit will prove useful to anyone interpreting acute spinal imaging.
In what context are radiologists most prone to error? A systematic review of discrepancies in a tertiary neuroradiology service Authors: Andrew Nanapragasam, Daniel Birchall, Priya Bhatnagar Purpose: It is well recognised that errors occurring in radiology reporting are a recurring and seemingly inevitable aspect of radiology practice. Discrepancies have serious and far-reaching consequences, not only in terms of clinical mal-outcome, but also in relation to organisational and personal professional reputation and to medico-legal liability. The purpose of this study was to assess the context in which errors occur in clinical practice. Methods and materials: A retrospective analysis of 100 consecutive cases referred to a discrepancy forum in a tertiary neuroradiology service was performed to assess the context in which erroneous consultant reports were issued, including reference to time of day, scan type, and nature of consultant report. Comparison was made with overall service data for each of these fields. Results: The following inter-connected factors were associated with a higher prevalence of error: reporting of computed tomography (CT) scans (48% of errors, versus 30% of overall service output); out-of-hours reports (36% of errors, versus 18% of overall service output); and consultant checking of trainee reports (52% of errors, versus 18% of overall consultantverified scans). Conclusion: The most striking pattern of error prevalence is in the context of consultants checking trainees’ out-of-hours CT scan reports. This is likely to relate to a combination of cognitive heuristics, including anchoring and framing bias, in which knowledge of clinical presenting details and of the trainee report appears to result in a high incidence of inattentional blindness in the checking consultants’ report. Awareness of this phenomenon is important for the reduction of error in this specific and widely underestimated reporting context. The trainees become the trainers: a specialty trainee-led introduction to an undergraduate radiology placement Authors: Adrian Hood, Taryn Kalami, Mark Phillips, Ian Craven Purpose: To assess a teaching session designed and delivered by radiology trainees that introduces undergraduates to radiology, radiologists and The Royal College of Radiologists’ (RCR) undergraduate curriculum. Methods and materials: The session is delivered entirely by specialist trainees to third-year undergraduates at the start of a one-week clinical placement in radiology. A combination of slideshow and picture archiving and communications system (PACS) image viewing takes the undergraduates through a single admission during which a notional patient undergoes multiple common investigations. Approaches to plain film and computed tomography (CT) reporting are introduced. An ultrasound (US) scan is viewed and discussed. Indications for common investigations and