Vasculitides are disorders characterized by inflammation of blood vessels and are typically classified by their size. Large vessel vasculitis (LVV) is divided into two main categories of giant cell arteritis (GCA) and Takayasu arteritis (TA). Although there are key distinguishing factors in their presentation, in reality, both conditions can behave nonspecifically with generalized symptoms making diagnosis challenging. Noninvasive imaging has a role in identifying, classifying, and staging LVV; often with a multimodality approach including US, CT and MRI with angiography, and fluorine 18 (F)-fluorodeoxyglucose (FDG) PET/CT. The choice of imaging examination may vary according to patient presentation and local protocols, but international guidance recommends US as a first-line alternative to temporal artery biopsy in diagnosing GCA and mandates extracranial imaging when initial images are negative. In TA, cross-sectional body imaging is advised, ideally with MRI with angiography, owing to the lower radiation doses and effectiveness of structural assessment. Functional imaging with F-FDG PET/CT and advancements in vessel wall and diffusion-weighted MRI show promise in monitoring activity and assessing treatment response but require validation. The authors describe the epidemiology, presentation, pathogenesis, and management of the primary large vessel vasculitides; outline generic and specific multimodality imaging findings alongside technical aspects; and consider the role of imaging in monitoring disease activity and treatment response. Variable vessel and secondary vasculitides, which can involve large vessels, are briefly reviewed. RSNA, 2025.

MRI is an essential tool in diagnosis and management of prostate cancer. However, image quality and interpretation variability continue to hinder its broader adoption in clinical practice. To address the challenge of inconsistent image quality, the American College of Radiology (ACR) launched the Prostate MR Image Quality Improvement Collaborative, an initiative within the ACR Learning Network. To date, three cohorts comprising 14 organizations have participated in the program, which was built on the ACR ImPower continuous improvement framework. The organizations identified four main key drivers for prostate MR image quality: protocol optimization, patient preparation, personnel training, and performance monitoring and feedback. Examples of interventions designed to address these areas included incorporating protocol adjustments to comply with the Prostate Imaging Reporting and Data System version 2.1, changing the phase-encoding direction of diffusion-weighted and T2-weighted images, including artifact-resistant and artificial intelligence-enhanced sequences in the MRI protocol, developing and implementing patient preparation instructions regarding use of saline enema and dietary restrictions, training technologists on the importance of image quality and how to troubleshoot imaging artifacts, and performing systematic audits of the MRI examinations using the Prostate Imaging Quality System. The Collaborative also fostered a culture of continuous improvement and teamwork, which led to operational efficiencies and improved job satisfaction among frontline staff. The authors outline the Collaborative's framework and lessons learned, offering a practical road map for institutions aiming to achieve and sustain high-quality prostate MRI. RSNA, 2025 Supplemental material is available for this article.

The scaphoid is the largest and most significant bone in the proximal carpal row and is essential for wrist biomechanics and stability. Its intricate anatomy and unique blood supply render it vulnerable to overlooked fractures and postfracture complications, often making for an exceptionally challenging radiologic appraisal. Radiographic diagnosis of a scaphoid fracture is particularly difficult because of the bone's complex geometric structure. Its numerous sulci, apices, ridges, and facets can resemble fractures, which may lead to unnecessary immobilization. A significant portion of the scaphoid is also encased in cartilage that restricts its capacity to develop callus, an imaging clue enduringly relied on in follow-up trauma radiography to confirm a fracture. There is no established agreement on the number of radiographic views. A minimum of three views is recommended, with most institutions adding a fourth. Both CT and MRI provide specific benefits for assessing cortical fractures and trabecular injuries, respectively, and can clarify cases for which clinical suspicion remains high. The scaphoid's distinctive distal-to-proximal blood flow increases the risk of osteonecrosis and abnormal healing following a fracture. Diagnosing osteonecrosis remains the radiologist's greatest challenge when evaluating the scaphoid. There are myriad studies proposing one imaging technique over another, without definite consensus on which is best. Currently, low signal intensity at T1-weighted MRI for osteonecrosis is the only generally accepted criterion. Among all complications, scaphoid osteonecrosis with nonunion is arguably the most difficult to treat. Both nonvascularized and vascularized bone grafts have been proposed, yielding mixed outcomes, and further high-quality randomized trials are necessary to establish which approach is superior. RSNA, 2025 Supplemental material is available for this article.

Screening US for developmental dysplasia of the hip in infants with risk factors should optimally be performed after 6 weeks corrected gestational age (CGA). Scanning before this age leads to higher false-positive rates and the potential need for repeat examination, which creates waste and undue stress on the child and family. Pediatric radiologists at the authors' institution observed that many premature infants were being scheduled too early for their screening US. This quality improvement project aimed to decrease incorrectly scheduled screening examinations from a baseline rate of 50% to less than 25% within 6 months. Key drivers and interventions addressed the lack of clarity regarding whether the examination was screening or diagnostic (physical examination finding), poor visibility and manual calculation of CGA by schedulers, and lack of automated scheduling guidance. Ordering clinicians were educated, and an electronic health record (EHR) report was created to prospectively identify examinations that may need rescheduling. Next, a mandatory order question was added in the EHR to clearly identify which examinations were ordered for screening, with embedded guidance for schedulers to time these examinations after 6 weeks CGA. Finally, a special work queue was created to leverage the expertise of certain schedulers assigned to this task. After the final plan-do-study-act cycle, incorrectly scheduled examinations decreased from 50% to 10%. By using people- (specialized scheduling team), process- (dedicated work queue), and system-related (EHR order question with scheduling guidance) interventions, the group was able to create and sustain change and decreased incorrectly scheduled pediatric hip US examinations by 80%. RSNA, 2025.

Despite technical advances and careful preparation, motion artifacts are commonly encountered in cardiac CT. Artifacts due to patient motion or breathing are not correctable and may necessitate repeat scanning; however, cardiac motion artifacts may be mitigated without repeating the scan. Cardiac motion artifacts may manifest as blur, transition, interpolation, or duplication. Blur artifact due to mismatch between cardiac motion speed and the scanner's temporal resolution can be mitigated by using a different cardiac phase, a motion-correction algorithm, or multisegment reconstruction. Transition artifact at the interface between different scanned segments with different R-R interval lengths may be mitigated by using a different cardiac phase or edge-correction algorithms. Interpolation artifact results when the pitch is too high for the heart rate (HR) at some point of a retrogated scan, either due to the patient taking a deep breath, missing electrocardiographic (ECG) synchronization (sync)-points, or long ECG pauses after premature atrial contractions (PACs) or premature ventricular contractions (PVCs). The scanner fills the data gaps by interpolating (ie, "smearing") data from above and below the gap. Duplication artifact results when the pitch is too low for the HR at some point of a retrogated scan, due to contrast material injection, medications, premature or extra beats, or spurious ECG sync-points. Interpolation and duplication artifacts can often be mitigated by manipulating ECG sync-points. In sync-point editing, sync-points are added (eg, for a missed R wave) or deleted (eg, tagging of a tall T wave, exercise spike, or bifid R waves) such that every R wave (and only R waves) are tagged. In sync-point composing, sync-points are artificially manipulated to improve image quality in arrhythmias with variable R-R intervals (eg, PACs or PVCs, atrial fibrillation). RSNA, 2025 Supplemental material is available for this article. See the invited commentary by Ufuk and Landeras in this issue.

US is an important diagnostic tool in evaluation of the pancreas, as it is noninvasive, does not require irradiation, and offers real-time imaging capability and broad accessibility. Despite the utility of pancreatic US, it often has limited effectiveness due to the complex anatomy of the pancreas and peripancreatic structures, which inevitably leads to diagnostic errors. The authors summarize the lessons learned from quality assurance rounds at a high-volume tertiary care center. The errors are systematically categorized as perceptual, interpretive, information transfer, and process errors. Each error type is discussed with detailed case studies from clinical practice to underscore common pitfalls and their impact on patient management. Perceptual errors occur when the operators overlook subtle pathologic signs due to the complex anatomy. Interpretive errors arise from misjudgments regarding the clinical significance of visible abnormalities, while information transfer errors stem from inadequate communication of patient history or suboptimal review of previous imaging findings. Process errors reflect systemic issues related to US protocol and scanning techniques. The authors advocate having a thorough understanding of the US appearances of normal and variant pancreatic anatomy and emphasize the importance of correlating US findings with findings of complementary imaging modalities to improve diagnostic accuracy. They also highlight the need to use high-resolution US transducers, embrace new technologies, and adopt meticulous scanning techniques as valuable practical strategies to mitigate diagnostic errors. By providing a detailed analysis of cases, this review demonstrates how structured quality assurance measures and continuous education can significantly reduce diagnostic errors. These efforts are crucial in ensuring accurate diagnoses and optimizing patient outcomes. RSNA, 2025 Supplemental material is available for this article.

Surgical approaches to lung cancer resection are rapidly evolving, particularly for early-stage lung cancer. Advances in chest CT technology and increasing use of CT in patient care have led to detection of smaller nodules, many with ground-glass attenuation that do not require lobectomy for resection. Lung-sparing and minimally invasive techniques have been shown to result in improved patient outcomes compared with those of traditional open thoracotomy and are noninferior in terms of cancer recurrence. As more patients undergo these surgeries, it is important for radiologists to be aware of useful information for surgeons before the operation. It is helpful for radiologists to understand the indications for lung-sparing surgery and have a basic understanding of the techniques involved in video-assisted and robotic thoracic operations. Identification of the location and morphology of the tumor, as well as the pulmonary vasculature that feeds and drains the segment of lung containing the tumor is important. Also, the presence of emphysema, pulmonary fibrosis, and incomplete fissures is useful information. In addition, chest imaging is also progressing, with improvements in multiplanar reformations and three-dimensional imaging allowing for more detailed and accurate image-based localization of tumors and visualization of anatomy. Nodule localization for surgery plays an even larger role given the limited ability to palpate nodules during surgery with minimally invasive surgery approaches. Methods can involve imaging and in vivo localization, with transthoracic and bronchoscopic methods used to label a nodule. Finally, radiologists should be aware of postoperative complications and their imaging characteristics, such as suture line granulomas and bronchopleural fistulas. RSNA, 2025.

(MASLD) is the new name for (NAFLD). MASLD continues to be a significant global health care problem, commensurate with the increased prevalence of obesity and metabolic syndrome. The study of MASLD has intensified over the past 5 years, with major breakthroughs in understanding the pathogenesis and natural history. The American Association for the Study of Liver Diseases (AASLD) published practice guidance in 2023 to incorporate changes in diagnosis and management. A new nomenclature for MASLD, with updated definitions, has been approved through a global multisociety-led Delphi consensus to replace with and (NASH) with (MASH). AASLD practice guidelines on blood-based and imaging-based noninvasive liver disease assessments of hepatic fibrosis and steatosis have also been recently published. The latest advances in US and MRI techniques have allowed radiologists to play a pivotal role in early detection, accurate assessment, and monitoring of diseases, thus enabling timely intervention and lifestyle changes. Resmetirom has recently been approved for treating noncirrhotic adult patients with MASLD and moderate to severe hepatic fibrosis, along with diet and exercise. The authors review the role of imaging in the new guidelines as the current evaluation of MASLD transitions from invasive tests to advanced imaging-based diagnostics. The article will serve as a reference for radiologists, who play a critical role in managing and prognosticating MASLD. RSNA, 2025 Supplemental material is available for this article.

Low-dose-rate (LDR) brachytherapy with iodine 125 (I) seeds is an effective treatment of localized prostate cancer, delivering targeted doses to the prostate while minimizing radiation exposure to adjacent tissues. I seeds implanted under transrectal US guidance provide tailored radiation distribution through loose or stranded configurations. Loose seeds allow flexible placement but carry a higher migration risk than stranded seeds. Optimal placement strategies involve targeting the peripheral zone near the prostate capsule to achieve adequate dose coverage for potential extracapsular extensions, with careful consideration to minimize toxicity to adjacent organs. Seed migration, primarily to the lungs, typically occurs through venous pathways due to the extensive periprostatic venous plexus. Less common migration sites include the heart, vertebral venous plexus, kidneys, liver, and testicular veins. Migration mechanisms involve retrograde venous flow and, in rare cases, arterial pathways through pulmonary arteriovenous malformations or intracardiac shunts. These seed migrations are typically incidental findings at imaging and rarely necessitate intervention because of the gradual radioactive decay of the seeds. Hydrogel spacers composed of polyethylene glycol are increasingly used during brachytherapy to reduce rectal toxicity by creating a separation between the prostate and rectum. Although these spacers are generally effective, complications such as asymmetric distribution, intraprostatic or intrarectal injection, and fistula formation can compromise radiation safety and efficacy. These complications can be identified at postprocedural imaging. Accurate imaging assessment is crucial for evaluating seed placement, detecting seed migration, and identifying complications related to hydrogel spacers, ultimately contributing to improved patient outcomes in prostate cancer treated with LDR brachytherapy. RSNA, 2025 Supplemental material is available for this article.

Reverse total shoulder arthroplasty (RTSA) is increasingly used for a variety of complex shoulder abnormalities, particularly in patients with rotator cuff deficiency. Design improvements with better biomechanics have led to improved clinical outcomes, but the radiographic appearance and complication profile of contemporary RTSA implants differ from those of a decade ago. Plain radiographs can be used to identify whether the prosthesis is medialized (primarily older prostheses) or lateralized. A standardized imaging protocol and a reporting checklist are vital for the identification of complications. Although most complications can be identified with standard radiography, CT and MRI performed with dedicated protocols to reduce metallic artifacts are helpful problem-solving adjuncts. US can be used to assess the surrounding muscles before and after RTSA, to evaluate for postoperative complications such as fluid collections, and to provide guidance for aspiration. Complications such as periprosthetic fracture, instability, loosening, scapular notching, and implant failure require focused search patterns for identification. More chronic complications such as stress fractures and tuberosity fragmentation require comparison with previously acquired images. Implant disassembly, rarely seen with other arthroplasties, can occur and requires familiarity with the expected appearance of the prosthesis components. A downloadable checklist for imaging evaluation of the prosthesis is provided, and imaging examples of common and uncommon complications are presented. After reviewing this article, the reader will have an improved understanding of the RTSA prosthesis and will be able to recognize the normal and abnormal imaging appearances of this increasingly popular type of shoulder replacement. RSNA, 2025 Supplemental material is available for this article.

Due to longer survival of patients with cancer, better recognition and understanding of immunocompromising conditions, and emerging immune-modulating therapies for malignant and nonmalignant diseases, the number of immunocompromised individuals has increased. Immunocompromised patients require complex, often individualized, evaluation and treatment of an expanded spectrum of pathogens. Pneumonia is a leading cause of death due to infectious disease in these patients, and identification of the pathogen is key to providing appropriate therapy. One important factor in evaluating an immunocompromised patient with pneumonia is the type of immunocompromise, because this will help determine the potential opportunistic agents that should be included in the differential diagnosis. Radiologists can play a vital role in the diagnosis of a wide range of pulmonary diseases associated with immunocompromise, including many opportunistic pulmonary infections, by recognizing key imaging features. The authors summarize the types of immunocompromise encountered in different clinical settings and associate these with specific opportunistic organisms, describe patterns of disease seen in patients with HIV infection with different CD4 cell counts, and describe the imaging appearance of viral and fungal infections in patients with neutropenia. RSNA, 2025.

Renovascular hypertension (RVH) results from activation of the renin-angiotensin system by renal arterial stenosis (RAS). RAS can result from either intrinsic narrowing or extrinsic compression. Intrinsic narrowing may be caused by atherosclerosis, fibromuscular dysplasia, vasculitis, dissection, thrombus, aneurysm, arteriovenous fistula, neurofibromatosis type 1, or midaortic syndrome. Extrinsic compression can be from retroperitoneal fibrosis, neoplasm, or subcapsular hematoma or fluid. Diagnostic evaluation for RVH is triggered by either a high index of suspicion in a patient with hypertension or incidental detection of RAS at noninvasive imaging. Renal US, primarily with Doppler, is a common modality used for initial screening of RVH, especially when renal function is decreased. US can be used to evaluate hemodynamically significant RAS, including in stents, and also for parenchymal evaluation. MR angiography (MRA) is an excellent modality for RVH evaluation, typically used following US. In patients with decreased renal function, MRA can be performed without contrast material or with ferumoxytol, but group 2 gadolinium-based contrast agents are safe. CT angiography offers excellent spatial resolution that is ideal for the evaluation of distal small renal arterial branches and for assessment of in-stent stenosis following intervention. Conventional angiography is the reference standard, now reserved only for interventional procedures. Imaging also plays an important role in excluding other causes of secondary hypertension and evaluating complications of RVH. The management of RVH depends on the cause and involves a combination of medical treatment and surgical or interventional procedures. Interventional options include angioplasty, stent placement, and embolization. RSNA, 2025 Supplemental material is available for this article.

The authors present a framework for integrating trauma-informed care principles into radiologic procedures. Trauma-informed care is an approach that acknowledges the widespread impact of psychological trauma, incorporating this understanding into health care practices to prioritize patient safety, trust, and support while minimizing the risk of retraumatization. Given the high prevalence of psychological trauma among patients, radiologic procedures-some of which can be physically and emotionally distressing, such as breast biopsies, hysterosalpingography, and fluoroscopic enemas-must be approached with sensitivity. However, despite the growing awareness of trauma-informed care in health care, there is limited literature specifically addressing its application in the field of radiology. Without established frameworks, radiologists and imaging staff may unintentionally overlook critical aspects of patient-centered care, increasing the risk of psychological retraumatization. The authors aim to bridge that gap by providing a structured approach to implementing trauma-informed care in radiology. They outline key principles, including clear communication, patient autonomy, environmental modifications, and procedural adjustments, to foster a sense of safety and control. Additionally, they offer actionable recommendations for before, during, and after imaging examinations-the START, CARES, and FOLLOW framework-to enhance patient comfort and trust. By incorporating trauma-informed strategies and considering barriers to implementation, radiologists and imaging teams can improve patient experiences, foster stronger provider-patient relationships, and ultimately contribute to more compassionate, patient-centered care. Given the integral role of radiology in modern medicine, these considerations are crucial to ensuring equitable and supportive health care for all patients, particularly those with a history of psychological trauma. RSNA, 2025 Supplemental material is available for this article.

Budd-Chiari syndrome (BCS) results from the obstruction of hepatic venous outflow and can occur anywhere from the level of the small hepatic veins (HVs) to the junction of the inferior vena cava (IVC) and the right atrium. The obstruction of the HVs can be global or segmental. This results in sinusoidal congestion, which leads to portal hypertension and subsequent centrilobular fibrosis, nodular regenerative hyperplasia, and ultimately cirrhosis. Treatment is aimed at restoring HV or IVC outflow by angioplasty, stent placement, or creating a portosystemic shunt, which in turn drastically reduces hepatic sinusoidal pressure. Thus, treatment strategies should be based on detailed knowledge of the underlying causal factors, lesion classification, clinical presentation, and baseline liver function. The BCS classification system is divided into types and subtypes that can guide interventional therapy, with the aim of standardizing the imaging diagnosis and interventional therapy of BCS. Intravascular US (IVUS) aids in BCS lesion characterization as described by the BCS classification system. It can help determine the need for stent placement following angioplasty and is helpful in portosystemic shunt creation. Additionally, IVUS can reduce radiation dose, contrast agent volume, and procedure time and increase the technical success rate of procedures. It is essential for the radiologist to understand the BCS classification system as a useful tool to guide interventional therapy. RSNA, 2025