wang2007

Frequency, Management, and
Outcome of Extravasation of
Nonionic Iodinated Contrast
Medium in 69 657 Intravenous
Injections1
Carolyn L. Wang, MD
Richard H. Cohan, MD
James H. Ellis, MD
Saroja Adusumilli, MD
N. Reed Dunnick, MD
Purpose: To determine retrospectively the frequency, management,
and outcomes of extravasations of intravenously injected
nonionic iodinated contrast medium.
Materials and
Methods:
Institutional review board approval was obtained, and the
requirement for informed consent was waived. The study
was HIPAA compliant. For 69 657 intravenous injections
of nonionic iodinated contrast medium for computed to-
mographic examinations between January 1, 2000, and
March 31, 2005, the incident reports, radiology reports,
and medical records of patients in whom contrast medium
extravasations occurred were reviewed. Data collected
included patient age, catheter gauge, injection site, volume
extravasated, patient symptoms, severity of injury, treat-
ment, whether or not the plastic surgery service was con-
sulted and any additional treatment that service instituted,
and patient outcome.
Results: Extravasations occurred in 475 (0.7%) of 69 657 patients,
and follow-up information was available for 442 adults
(280 women, 162 men; mean age, 57 years) and 17 chil-
dren (nine girls, eight boys; mean age, 6 years). Extrava-
sated volumes ranged from 3 to 150 mL. Symptoms usually
consisted of swelling and/or pain. The plastic surgery ser-
vice was consulted for 38 adults and six children and
provided additional treatment in eight patients (seven
adults, one child). Among adults, 432 had minimal or no
adverse effects, nine had moderate adverse effects, and
one had a severe complication (75 mL of contrast material
extravasated into the hand, causing compartment syn-
drome). Only one moderate or severe complication in an
adult resulted from an extravasation of less than 50 mL.
Fifteen children had minimal or no adverse effects, one
had moderate adverse effects, and one had a severe com-
plication (18 mL of contrast material extravasated into the
arm, causing brachial plexopathy).
Conclusion: Extravasation of nonionic iodinated contrast medium re-
sults only rarely in moderate or severe adverse effects, and
these usually occur only when large volumes of contrast
medium are involved.
娀RSNA, 2007
1From the Department of Radiology, University of Michi-
gan Health System, Room B1D502G, 1500 E Medical
Center Dr, Ann Arbor, MI 48109-0030. Received March
28, 2006; revision requested May 26; revision received
June 5; accepted June 21; final version accepted August
25. Address correspondence to R.H.C. (e-mail: rcohan
@umich.edu).
姝RSNA, 2007
ORIGINAL RESEARCH 䡲CONTRAST MEDIA
80 Radiology: Volume 243: Number 1—April 2007
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Extravasation of iodinated radio-
graphic contrast material is a well-
known complication of iodinated
radiographic contrast material injec-
tion, occurring even when appropriate
intravenous injection techniques are
used. In earlier series, the rate of ex-
travasation during computed tomogra-
phy (CT) was estimated to be 0.03%–
0.17% (1–3). Later reports with larger
numbers of patients, published after au-
tomated mechanical injectors began to
be routinely used for contrast material
injection, demonstrated higher extrava-
sation rates ranging from 0.25% to
0.9% (4–6).
The majority of extravasation injuries
resolve without adverse effects (7); how-
ever, severe extravasation injuries have
been reported after administration of
both ionic (8–12) and nonionic contrast
materials (13–16), and some have re-
sulted in tissue loss and neurovascular
and musculoskeletal compromise (8–16).
Multiple surgical procedures may be
needed to treat these complications in
some patients (8,9).
Few data exist on the frequency of
contrast medium extravasations and the
resulting complications. For example,
to our knowledge the three largest pub-
lished series (4–6) on this topic to date
included only 140 extravasations alto-
gether, 66 of which involved nonionic
contrast material. No severe complica-
tions from the extravasations were ob-
served in any of these series or reported
in a more recent study of 11 extravasa-
tions (17). The purpose of our study
was to determine retrospectively the
frequency, management, and outcome
of intravenous nonionic iodinated con-
trast medium extravasations.
Materials and Methods
Injection Technique and Extravasation
Management
At our institution, intravenous injections
for CT examinations are performed and
monitored by radiologic technologists, all
of whom have received training in intra-
venous injection technique. Injections are
performed with automated injectors (Stel-
lant; Medrad, Indianola, Pa) whenever
possible, through intravenous catheters
(Becton-Dickinson, Sandy, Utah) placed
preferentially in the antecubital fossa. If
venous access cannot be established in
the antecubital fossa, veins in the fore-
arm, hands, or, rarely, lower extremities
may be used. In adults, the technologists
are encouraged to use catheters that are
at least 20 gauge whenever possible; 22-
gauge intravenous catheters are reserved
for adult patients in whom intravenous
access is difficult and has to be established
in small veins. Occasionally, indwelling in-
travenous catheters are used after the
technologist establishes patency.
The policy at our children’s hospital is
to choose 22-gauge catheters, although
20-gauge catheters are preferred in young
adults and 24-gauge catheters are pre-
ferred in very young children. As in
adults, in young patients, the catheters
are preferentially placed in the antecubi-
tal fossa, with the hand the next most
preferred site.
At both hospitals, injections were
not made through peripherally inserted
central catheter lines, since the newer
ones that permit power injection (Pow-
erPICC power injection catheter; Bard
Access Systems, Salt Lake City, Utah)
were not used during the study period.
However, a nurse or physician can in-
ject contrast medium by hand through a
central line, arterial line, or port.
The technologists test each intrave-
nous catheter through which contrast
material is to be administered by briskly
hand injecting saline through it. Once
patency is established, the contrast me-
dium injection can be started. Unless
otherwise specified by the manufac-
turer, contrast material is warmed to
body temperature before injection;
this reduces viscosity. The technolo-
gist closely monitors the injection site
from the commencement of injection
to the beginning of scan acquisition.
This allows the technologist to remain
with the patient for 25–70 seconds af-
ter initiation of contrast material in-
jection. The patient is instructed to
report any injection site discomfort.
At completion of CT scanning, the in-
jection site is inspected by the technol-
ogist for swelling or erythema.
In November 1994, our radiology
department, in conjunction with the
section of plastic surgery of the depart-
ment of surgery, adopted a formal pol-
icy for documentation, management,
and follow-up of patients with contrast
material extravasation. Initial treatment
of a patient in whom an extravasation is
identified consists of application of ice
packs or cold compresses to the extrav-
asation site and elevation of the affected
extremity above the level of the heart. A
radiology resident or attending radiolo-
gist inspects each extravasation, and
the patient is then monitored in the ra-
diology department for up to 2–4 hours.
Published online
10.1148/radiol.2431060554
Radiology 2007; 243:80 – 87
Abbreviation:
EEV ⫽estimated extravasated volume
Author contributions:
Guarantors of integrity of entire study, C.L.W., R.H.C.,
N.R.D.; study concepts/study design or data acquisition or
data analysis/interpretation, all authors; manuscript draft-
ing or manuscript revision for important intellectual con-
tent, all authors; manuscript final version approval, all
authors; literature research, C.L.W., R.H.C., N.R.D.; clini-
cal studies, C.L.W., R.H.C., N.R.D.; and manuscript edit-
ing, all authors
Authors stated no financial relationship to disclose.
Advances in Knowledge
䡲In a single institution, extravasa-
tion of contrast material into the
subcutaneous tissues occurred
during attempted intravenous in-
jection in less than 1% of patients
(475 [0.7%] of 69 657 injections),
often involved large volumes of
contrast material (50–150 mL in
119 [26%] of 453 extravasations
for which estimated extravasation
volumes were available), and
nearly always resolved with con-
servative management.
䡲Moderate or severe extravasation
injuries developed in a small num-
ber of patients (10 [adults] and
two [children] of 459 patients
with sufficient follow-up data),
even when large volumes of con-
trast medium were involved.
CONTRAST MEDIA: Extravasation of Nonionic Iodinated Contrast Medium Wang et al
Radiology: Volume 243: Number 1—April 2007 81

A consultation from the plastic sur-
gery service is obtained if any of the
following five criteria are met: (a) Ex-
travasation volume is estimated to be
100 mL or more of nonionic contrast
medium, (b) skin blistering occurs,
(c) there is evidence of altered tissue
perfusion, (d) pain at the extravasation
site increases over time, and/or (e) there
is a change in sensation at or adjacent to
the extravasation site. The radiologist
completes a departmental incident data
form for contrast material extravasa-
tion, which includes patient identifying
information, type and estimated volume
of extravasated contrast material, site
of extravasation, gauge of catheter used
for the injection, patient signs and
symptoms after extravasation, treat-
ment instituted, and whether the plastic
surgery service was consulted. These
forms are filed in the radiology depart-
ment for quality assurance monitoring
and to facilitate follow-up.
Study Group
Institutional review board permission
was obtained to access pertinent imag-
ing and medical records of the patients
involved in this study. The submitted
institutional review board proposal was
deemed to be compliant with both insti-
tutional requirements and the Health In-
surance Portability and Accountability
Act. Waiver of informed consent was
granted.
Between January 1, 2000, and March
31, 2005, there were 69 657 intravenous
injections of nonionic contrast medium
for CT at our institution, 61 916 in adults
and 7741 in children. During this period,
nonionic iodinated contrast material was
used for all contrast material–enhanced
(iohexol 300 [Omnipaque 300; GE Health-
care, Waukesha, Wis]; iopromide 300 or
370 [Ultravist 300 or 370, respectively;
Berlex Laboratories, Montville/Wayne,
NJ]; or iodixanol 320 [Visipaque 320; GE
Healthcare]) CT examinations. For this
study, all of the contrast material extrava-
sation incident data forms completed be-
tween January 1, 2000, and March 31,
2005, were reviewed by one of two au-
thors (C.L.W. or R.H.C.). Data obtained
from these forms included patient sex,
patient age, type of contrast material
extravasated, injection site, intravenous
catheter gauge, contrast material injec-
tion rate, estimated extravasated volume
(EEV), immediate symptoms (if any), ini-
tial treatment, and whether or not plastic
surgery consultation was obtained. Medi-
cal records and radiology reports in the
same patients were also reviewed by one
of the same two authors (C.L.W. or
R.H.C.) to determine the duration of
symptoms, final outcome, and total dura-
tion of patient follow-up. Progress notes
generated on the day of the extravasation
and for at least 2 months after the extrav-
asation were reviewed for mention of any
adverse effects or treatment related to
the extravasation. When adverse conse-
quences were noted, additional progress
notes were examined until patient symp-
toms had resolved or the instituted treat-
ment was completed.
Each extravasation was classified by
consensus between two authors (C.L.W.
and R.H.C.) as producing mild, moder-
ate, or severe injury. Mild extravasation
injuries were those in which signs and
symptoms were absent or consisted of
only pain, swelling, and/or mild ery-
thema, which resolved with limited treat-
ment of elevation and administration of
ice packs or cold compresses. No addi-
tional treatment was administered, and
there was no mention of any adverse ef-
fects on the departmental extravasation
form, in the dictated radiology report, or
in any follow-up progress or clinic notes.
Moderate extravasation injuries were
those in which more severe initial mani-
festations were present, such as moder-
ate or severe erythema, blistering, or
marked pain or swelling, or injuries in
which additional treatment was insti-
tuted, regardless of initial manifestations.
However, to be considered moderate, all
signs and symptoms had to have resolved
within 2 weeks of the extravasation. Se-
vere extravasation injuries either pro-
duced long-term adverse effects (lasting
more than 2 weeks), such as unremitting
pain, swelling, and limitations in extrem-
ity movement, or required surgical inter-
vention. The medical records of patients
who experienced moderate or severe ex-
travasation were reviewed to assess for
the presence of any risk factors (such as a
history of diabetes mellitus or upper-ex-
tremity vascular or circulatory problems)
that might explain why only these patients
were affected adversely.
Results
Contrast material extravasation forms
were completed for 476 (0.7%) of 69 657
nonionic contrast material injections.
One patient was determined by the evalu-
ating radiologist and clinical service not to
have had contrast material extravasation
but rather to have experienced transient
pain at the injection site without extrava-
sation; this patient was therefore ex-
cluded. In 16 other patients, either the
follow-up was inadequate, so the severity
of the extravasation injury could not be
determined (n⫽13), or the extravasa-
tion was thought to involve only the pre-
liminarily injected saline flush (n⫽3).
These patients were also excluded from
further consideration. Therefore, com-
pleted extravasation forms were available
for 459 patients in whom there were ade-
quate follow-up data (mean follow-up, 18
months; range, 1 day to 67 months) and
in whom the extravasation was deemed
to involve nonionic iodinated contrast me-
dium. These patients included 442 adults
(280 women, 162 men; age range, 18–97
years; mean age, 57 years) and 17 chil-
dren (nine girls, eight boys; age range,
neonate to 17 years; mean age, 6 years).
The type of extravasated contrast
material was recorded for 454 of the
459 extravasations. Iohexol 300 was ex-
travasated in 387 patients (85%); iopro-
mide 300, in 44 (10%); iodixanol, in 12
(3%); and iopromide 370, in 11 (2%).
This distribution reflects the fact that
iohexol was used almost exclusively be-
tween January 2000 and October 2004,
with iopromide used between October
2004 and March 31, 2005. Iodixanol
was administered to only a small group
of patients with preexisting renal insuf-
ficiency. Precise data on the number of
times each type of contrast material was
injected were not available. No patient
experienced more than one extravasa-
tion episode.
Extravasations in Adults
Injection site, injection rate, catheter
gauge, and volume extravasated.—The
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82 Radiology: Volume 243: Number 1—April 2007

extravasation site was not mentioned
for five patients. The most common ex-
travasation site in the remaining 437
patients was the antecubital fossa (n⫽
196 [44.8%]). Other recorded extrava-
sation sites were the forearm (n⫽99
[22.6%]), hand (n⫽47 [10.8%]), arm
(n⫽41 [9.4%]), wrist (n⫽29 [6.6%]),
upper arm (n⫽16 [3.7%]), shoulder
(n⫽5 [1.1%]), foot (n⫽2 [0.5%]),
neck (n⫽1 [0.2%]), and groin (n⫽1
[0.2%]).
The injection rate was not recorded
for 21 adults. Of the remaining 421
adult patients, 113 (27%) were injected
at rates of less than 2 mL/sec; 212
(50%), at rates of 2–3 mL/sec; and 96
(23%), at rates exceeding 3 mL/sec.
The gauge of intravenous catheter
used was not specified for 16 adult pa-
tients. For the remaining 426 adults,
22-gauge catheters were used in 125
(29%) and 20-gauge catheters were
used in 284 (67%) patients. The re-
maining patients were injected through
18-gauge (n⫽14), 16-gauge (n⫽2), or
14-gauge (n⫽1) catheters.
The volume of contrast medium ex-
travasated was not recorded for six pa-
tients. The EEV was less than 10 mL in
45 (10%) of the remaining 436 patients,
10–49 mL in 276 (63%), 50–99 mL in
54 (12%), and 100–150 mL in 61
(14%).
Symptoms and initial treatment (in-
cluding plastic surgery consultation).—
The most commonly reported symptoms
in the 442 adult patients were swelling
(including descriptions of “bump,” edema,
or induration) in 350 patients (79%) and
pain in 106 (24%). The absence of symp-
toms was reported for 36 (8%) patients.
One of these patients was noted to be
unresponsive (due to a preexisting medi-
cal condition). For four patients the inci-
dent report sheet did not mention
whether or not symptoms were present.
Most patients (n⫽241) were
treated with cold compresses or ice
packs, and elevation. Some patients re-
ceived ice packs or cold compresses
alone (n⫽144) or elevation alone (n⫽
2). Although our policy was to use ice
rather than warmth, three patients
were treated with warm compresses
and elevation, while three others had
warm compresses applied without ele-
vation. One patient received ice packs
followed by warm compresses, and an-
other patient received ice and topical
hydrogen peroxide. In 38 patients the
radiology resident or staff deemed that
no treatment was necessary. In nine
cases, no treatment was recorded.
Although our policy requires plastic
surgery consultation for all patients
whose extravasations involve 100 mL or
more of contrast medium, the medical
records documented such a consulta-
tion for only 32 (52%) of the 61 patients
in this group. Plastic surgery consulta-
tions were also performed for six other
patients owing to symptoms. The 38
evaluations led to additional treatment
in seven patients. The additional treat-
ment consisted of hand splints (n⫽3),
topical silver sulfadiazine (Silvadene;
King Pharmaceuticals, Bristol, Tenn)
application to blisters or open arm
wounds (n⫽2), use of a stockingette (a
tubular bandage) (n⫽1), or surgery
(n⫽1). In two patients, additional ther-
apy was administered by another medi-
cal service already caring for the pa-
tient. One of the previously mentioned
patients who had received a splint also
received a subcutaneous injection of
colchicine administered by the clinical
inpatient service, as his extremity dis-
comfort was believed to be due to ag-
gravation of gout rather than extravasa-
tion. An additional patient (who was not
evaluated by the plastic surgery service)
received systemic antibiotics for pre-
sumed cellulitis.
Severity of extravasation injuries.—Of
the extravasation injuries, 432 were con-
sidered mild. Initial symptoms in these
patients, if any were present, resolved
without the need for any treatment other
than ice or cold compresses and eleva-
tion, and there were no short- or long-
term adverse consequences. There were
nine moderate extravasation injuries in-
volving a wide range of EEVs (10–150
mL). Symptoms that resulted in the clas-
sification of these reactions as moderate
included blistering (n⫽3); persistent
firmness, swelling, and/or pain (n⫽3);
ulceration (n⫽1); discrete areas of per-
sistent edema (n⫽1); numbness (n⫽1);
suspected inflammation in the affected
extremity, which was diagnosed 1 week
after the extravasation (n⫽1); “open
arm” wounds (n⫽1) (the term used in
the patient’s medical records); and ecchy-
mosis (n⫽1). In each of these patients,
symptoms had resolved completely at
2-week follow-up (Table 1).
There was a single severe extravasa-
tion injury, in a 48-year-old woman who
had an EEV of 75 mL of iohexol in the
dorsum of her left hand. Immediately
after the extravasation occurred, the
patient had swelling and pain, and
within 30 minutes progressive bluish
discoloration and numbness had devel-
oped in her fifth digit. The affected ex-
tremity was immediately elevated, and
cold compresses followed by ice packs
were applied. The plastic surgery ser-
vice was called to evaluate the patient
and measured elevated compartment
pressures. The patient subsequently un-
derwent a left-hand dorsal fasciotomy,
evacuation of subcutaneous contrast
medium and fluid, and placement of a
volar splint. At her 1-month follow-up,
she was noted to have minimal residual
injury, with a small healing scar on the
dorsum of her hand (Fig 1) but no func-
tional impairment.
The frequencies of the different se-
verities of extravasation injury were cal-
culated for different EEVs. All but one
of the moderate or severe injuries oc-
curred with extravasations of 60 mL or
more (Table 2). In one patient, an ex-
travasation of 10 mL into the forearm
led to a moderate injury consisting of
firmness, pain, numbness, and blister-
ing. When extravasations were grouped
according to volume, the largest differ-
ence in the frequency of moderate or
severe injuries occurred between vol-
umes smaller than 50 mL (total fre-
quency, 0.3%) and volumes of 50 mL or
more (total frequency, 8.0%) (Table 2).
There were three moderate extrav-
asation injuries in patients injected at
rates lower than 2 mL/sec, three mod-
erate or severe injuries in patients in-
jected at rates of 2–3 mL/sec, and four
moderate injuries in patients injected at
rates exceeding 3 mL/sec. Seven of the
10 patients with moderate or severe in-
juries were injected through 20-gauge
intravenous catheters, and one was in-
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Radiology: Volume 243: Number 1—April 2007 83

jected through a 22-gauge intravenous
catheter. Catheter size was not re-
corded in the remaining two patients
(including the patient with the severe
injury). The distribution in injection
rates and catheter sizes for patients
with moderate or severe extravasation
injuries was similar to that in the entire
group of 442 adults with extravasations.
Of the 10 patients with moderate or
severe injuries, six (60%) were injected
with iohexol 300; three (30%), with io-
promide 300; and one (10%), with io-
dixanol. This distribution reflects the
fact that iohexol was administered to
many more patients than were the other
agents during the study period.
The patients with moderate or se-
vere extravasation injuries had a large
number of medical conditions, but only
a few of these conditions might have
placed these patients at increased risk
of an adverse effect after extravasation.
Two of the 10 patients had connective
tissue diseases (one had rheumatoid ar-
thritis, and the other had systemic lupus
erythematosus), one had type II diabe-
tes mellitus, and one had had a single
episode of lower-extremity deep vein
thrombosis 1 year earlier. Other exist-
ing medical conditions in these patients
included a history of cancer (n⫽3),
pancreatitis (n⫽2), chronic lympho-
cytic leukemia, coronary artery disease,
dehydration, dementia, emphysema, hy-
pertension, hyperthyroidism, hypothy-
roidism, idiopathic thrombocytopenic
purpura, inflammatory bowel disease,
peptic ulcer disease, pneumonia, post-
operative state, pseudomembranous
colitis, and/or urinary tract infection
(each n⫽1).
Extravasations in Children
Injection site, injection rate, catheter
gauge, and extravasated volume.—A
variety of extravasation sites were ob-
served in children: the antecubital
fossa (n⫽4), arm (n⫽4), hand (n⫽
3), and six other sites (shoulder, fore-
arm, wrist, groin, ankle, and foot;
each n⫽1). One of these extravasa-
tions occurred from an indwelling
catheter placed in the left upper arm,
the tip of which was located near the
shoulder. The remaining extravasa-
tions occurred from catheters placed
specifically for the injection of con-
trast material. Eleven of the pediatric
injections were performed at slow
rates by hand. Automated injectors
were used in five other patients, with a
rate of 1.5 mL/sec used in three of
these patients; 2 mL/sec, in one; and
2.5 mL/sec, in one. The injection
method and rate were not recorded
for the last patient. Catheters used for
contrast material injection were 24
gauge (n⫽4), 22 gauge (n⫽6), 20
gauge (n⫽2), and 16 gauge (n⫽1).
For four children, the catheter gauge
was not recorded.
EEVs ranged from 4 to 125 mL. Vol-
umes of 0–9 mL were seen in three
children; volumes of 10–49 mL, in 10;
volumes of 50–99 mL, in one; and vol-
umes of 100–150 mL, in three. The five
largest extravasation volumes (125,
100, 100, 80, and 40 mL) were in chil-
dren older than 12 years. The largest
extravasation volume in a young child
was 24 mL into the antecubital fossa of a
1-year-old patient, which resolved with-
out adverse effects.
Symptoms and initial treatment (in-
cluding plastic surgery consultation).—
The most commonly encountered clini-
cal sign was swelling (13 children). Only
four children reported having pain, in
part because many children were too
young to communicate with the health
care providers. Initial treatment con-
sisted of ice packs or cold compresses
along with elevation in six patients, ice
packs or cold compresses alone in six,
and warm compresses in one. No treat-
ment was mentioned for the remaining
four patients. Plastic surgery consulta-
tion was documented in six instances. In
two, the admitting service was notified
of the extravasation and advised to con-
sult the plastic surgery service; how-
ever, there were no notes indicating
that these patients were subsequently
examined by plastic surgery personnel.
Table 1
Moderate and Severe Extravasation Injuries in Adults
Patient No./
Age (y)/Sex EEV (mL)
Location of
Extravasation
Severity of
Injury Symptoms Treatment*
Follow-up
Duration
1/59/M 150 Forearm Moderate Four areas of edema Silver sulfadiazine 5 mo
2/74/F 134 Antecubital Moderate Hardened mass over biceps, 1-cm area of blistering Silver sulfadiazine 11 mo
3/45/F 125 Antecubital Moderate Swelling, mild edema in biceps Splint 16 mo
4/69/F 100 Antecubital Moderate Ecchymosis, tense arm Splint 1 mo
5/40/F 80 Antecubital Moderate Tense forearm, pain with motion Stockingette 16 mo
6/70/M 80 Arm Moderate Delayed swelling at 1 week, no definite cellulitis Antibiotics 9 d
7/71/M 75 Antecubital Moderate Skin ulceration, erythema Splint, colchicine 1 mo
8/48/F 75 Hand Severe Paresthesias, numbness, blue discoloration in fifth digit Fasciotomy 49 mo
9/30/M 60 Forearm Moderate Three blisters 2 days later None 40 mo
10/41/F 10 Forearm Moderate Firmness, blisters, pain, and numbness None 36 mo
Note.—Patients (10 of 442 patients) are listed in order of decreasing EEV. Symptoms resolved within 2 weeks in all patients except patient 8, who had a severe injury that necessitated surgery
and in whom functional impairment resolved within 1 month of the injury.
* Treatment other than ice or cold compresses and elevation.
CONTRAST MEDIA: Extravasation of Nonionic Iodinated Contrast Medium Wang et al
84 Radiology: Volume 243: Number 1—April 2007