Mahati Mokkarala

All Publications

• Identifying key CT features and clinical variables for predicting operative management of left ventricular assist device (LVAD) driveline infections. Emergency radiology Mokkarala, M., Ganapathy, A., Kalidindi, Y., Schmitt, C. R., Hoegger, M. J., Short, R. G., Raptis, D. A., Ballard, D. H. 2025; 32 (4): 533-543

  Abstract

  Despite technical advancements in left ventricular assist devices (LVADs), driveline infections (DLIs) remain a common complication evaluated by CT. The purpose of this study was to assess CT imaging features and clinical variables associated with operative versus non-operative management of LVAD DLIs.This study analyzed 129 patients with LVAD driveline infections evaluated using CT. Two radiologists assessed CT scans for superficial and deep soft tissue stranding and fluid collections. Logistic regression was used to identify predictors of operative management using imaging and clinical variables, guided by Akaike information criterion. Results were reported as odds ratios, and Interreader agreement was evaluated using Cohen's Kappa.Operative management was performed in 46.8% of patients. Positive driveline cultures (94.8% vs. 43.5%, p < 0.001) and new antibiotic use (98.3% vs. 72.7%, p < 0.001) were strongly associated with operative intervention. Mild subcutaneous fat stranding was the most frequent CT finding (62.6% and 66.9% by Readers 1 and 2, respectively), whereas deep fluid collections were rare (4.8-5.6%). Clinical predictors of operative management included new antibiotic use (p = 0.036), positive cultures (p < 0.001), and LVAD type. The resulting model achieved an AUC of 0.851 and overall accuracy of 78.6%. The absence of superficial fat stranding on CT significantly predicted non-operative management (p < 0.001).Positive driveline cultures, recent antibiotic initiation, and absence of skin or subcutaneous fat stranding on CT were associated with non-operative management in LVAD-related driveline infections. Absence of superficial fat stranding on CT may help distinguish suspected driveline infections that are unlikely to require surgical intervention.

  View details for DOI 10.1007/s10140-025-02363-0

  View details for PubMedID 40627235

  View details for PubMedCentralID 6597447

• The New American Board of Radiology Certifying Oral Examination: How Should Diagnostic Radiology Graduate Medical Education Evolve? Radiographics : a review publication of the Radiological Society of North America, Inc Mokkarala, M., Bentley, H., Gomez, C., Jiao, A., Zaki-Metias, K. M. 2024; 44 (6): e240016

  View details for DOI 10.1148/rg.240016

  View details for PubMedID 38722783

• Coronary-cameral fistula with double-chambered right ventricle: appearance on cardiac magnetic resonance imaging and 3D printed anatomic modeling. Clinical imaging Mokkarala, M., Ballard, D. H., Wesley, R. A., Gutierrez, F. R., Javidan-Nejad, C., Singh, G. K., Woodard, P. K., Lindley, K. J. 2020; 59 (1): 84-87

  Abstract

  The present case illustrates cardiac magnetic resonance imaging (MRI) and three-dimensional (3D) printed anatomic model findings of a coronary-cameral fistula (CCF) and double-chambered right ventricle (DCRV). A pregnant woman presented with palpitations and near syncope. A non-contrast cardiac MRI showed CCF connecting to a DCRV. Post-delivery, the patient had a contrast-enhanced MRI and 3D printed anatomic model to better evaluate her aberrant anatomy.

  View details for DOI 10.1016/j.clinimag.2019.10.003

  View details for PubMedID 31760282

  View details for PubMedCentralID PMC8077882

• Comparison of Response and Outcomes of Drug-eluting Bead Chemoembolization (DEB-TACE) Versus Radioembolization (TARE) for Patients With Colorectal Cancer Liver Metastases. Anticancer research Mokkarala, M., Noda, C., Malone, C., Ramaswamy, R., Akinwande, O. 2019; 39 (6): 3071-3077

  Abstract

  To compare outcomes for patients with colorectal cancer liver metastases (CRCLM) treated by drug-eluting bead chemoembolization (DEB-TACE) or radioembolization (TARE).A single-center retrospective review was carried out on 202 patients with CRCLM, treated by DEB-TACE (n=47) or TARE (n=155) patients. Propensity-matching yielded 44 pairs. Paired statistical analysis was performed on matched pair demographics, treatment response, and survival.Patients treated with DEB-TACE had worse extra-hepatic metastasis (68.1 vs. 47.7%, p=0.014) and ≥10 liver lesions (42.2 vs. 68.8%, p=0.001). Matched patients treated with DEB-TACE had a trend towards worse toxicity (27% vs. 9.1% (p=0.057). Index DEB-TACE treatment was not a prognostic factor for overall survival (hazard ratio=0.94, 95% confidence intervaI=0.54-1.65; p=0.83).In the matched CRCLM cohort, there was a trend towards worse toxicity post-DEB-TACE treatment, but it was not an independent prognostic factor for survival.

  View details for DOI 10.21873/anticanres.13442

  View details for PubMedID 31177151

• Finding Your Niche: Pursuing Uncommon Interests during Training and Shaping Your Career. Radiographics : a review publication of the Radiological Society of North America, Inc Zaki-Metias, K. M., Dixe de Oliveiro Santo, I., Páez-Carpio, A., Mokkarala, M. 2025; 45 (5): e240220

  View details for DOI 10.1148/rg.240220

  View details for PubMedID 40208811

• Bone Hydatidosis. Radiographics : a review publication of the Radiological Society of North America, Inc Gulati, A., Pishgar, F., Mokkarala, M., Jiao, A. D., Gulati, V. 2024; 44 (9): e240173

  View details for DOI 10.1148/rg.240173

  View details for PubMedID 39172708

• Splenogonadal Fusion. Radiographics : a review publication of the Radiological Society of North America, Inc Chu, J., Mokkarala, M., Zhang, M., Dixe de Oliveira Santo, I., Lanier, M. H. 2024; 44 (4): e230224

  View details for DOI 10.1148/rg.230224

  View details for PubMedID 38512727

• Renal Mass Imaging with MRI Clear Cell Likelihood Score: A User's Guide. Radiographics : a review publication of the Radiological Society of North America, Inc Shetty, A. S., Fraum, T. J., Ballard, D. H., Hoegger, M. J., Itani, M., Rajput, M. Z., Lanier, M. H., Cusworth, B. M., Mehrsheikh, A. L., Cabrera-Lebron, J. A., Chu, J., Cunningham, C. R., Hirschi, R. S., Mokkarala, M., Unteriner, J. G., Kim, E. H., Siegel, C. L., Ludwig, D. R. 2023; 43 (7): e220209

  Abstract

  Small solid renal masses (SRMs) are frequently detected at imaging. Nearly 20% are benign, making careful evaluation with MRI an important consideration before deciding on management. Clear cell renal cell carcinoma (ccRCC) is the most common renal cell carcinoma subtype with potentially aggressive behavior. Thus, confident identification of ccRCC imaging features is a critical task for the radiologist. Imaging features distinguishing ccRCC from other benign and malignant renal masses are based on major features (T2 signal intensity, corticomedullary phase enhancement, and the presence of microscopic fat) and ancillary features (segmental enhancement inversion, arterial-to-delayed enhancement ratio, and diffusion restriction). The clear cell likelihood score (ccLS) system was recently devised to provide a standardized framework for categorizing SRMs, offering a Likert score of the likelihood of ccRCC ranging from 1 (very unlikely) to 5 (very likely). Alternative diagnoses based on imaging appearance are also suggested by the algorithm. Furthermore, the ccLS system aims to stratify which patients may or may not benefit from biopsy. The authors use case examples to guide the reader through the evaluation of major and ancillary MRI features of the ccLS algorithm for assigning a likelihood score to an SRM. The authors also discuss patient selection, imaging parameters, pitfalls, and areas for future development. The goal is for radiologists to be better equipped to guide management and improve shared decision making between the patient and treating physician. © RSNA, 2023 Quiz questions for this article are available in the supplemental material. See the invited commentary by Pedrosa in this issue.

  View details for DOI 10.1148/rg.220209

  View details for PubMedID 37319026

• Integrative Imaging Informatics for Cancer Research: Workflow Automation for Neuro-Oncology (I3CR-WANO). JCO clinical cancer informatics Chakrabarty, S., Abidi, S. A., Mousa, M., Mokkarala, M., Hren, I., Yadav, D., Kelsey, M., LaMontagne, P., Wood, J., Adams, M., Su, Y., Thorpe, S., Chung, C., Sotiras, A., Marcus, D. S. 2023; 7: e2200177

  Abstract

  Efforts to use growing volumes of clinical imaging data to generate tumor evaluations continue to require significant manual data wrangling, owing to data heterogeneity. Here, we propose an artificial intelligence-based solution for the aggregation and processing of multisequence neuro-oncology MRI data to extract quantitative tumor measurements.Our end-to-end framework (1) classifies MRI sequences using an ensemble classifier, (2) preprocesses the data in a reproducible manner, (3) delineates tumor tissue subtypes using convolutional neural networks, and (4) extracts diverse radiomic features. Moreover, it is robust to missing sequences and adopts an expert-in-the-loop approach in which the segmentation results may be manually refined by radiologists. After the implementation of the framework in Docker containers, it was applied to two retrospective glioma data sets collected from the Washington University School of Medicine (WUSM; n = 384) and The University of Texas MD Anderson Cancer Center (MDA; n = 30), comprising preoperative MRI scans from patients with pathologically confirmed gliomas.The scan-type classifier yielded an accuracy of >99%, correctly identifying sequences from 380 of 384 and 30 of 30 sessions from the WUSM and MDA data sets, respectively. Segmentation performance was quantified using the Dice Similarity Coefficient between the predicted and expert-refined tumor masks. The mean Dice scores were 0.882 (±0.244) and 0.977 (±0.04) for whole-tumor segmentation for WUSM and MDA, respectively.This streamlined framework automatically curated, processed, and segmented raw MRI data of patients with varying grades of gliomas, enabling the curation of large-scale neuro-oncology data sets and demonstrating high potential for integration as an assistive tool in clinical practice.

  View details for DOI 10.1200/CCI.22.00177

  View details for PubMedID 37146265

  View details for PubMedCentralID PMC10281444

• Deep learning-based end-to-end scan-type classification, pre-processing, and segmentation of clinical neuro-oncology studies. Proceedings of SPIE--the International Society for Optical Engineering Chakrabarty, S., Abidi, S. A., Mousa, M., Mokkarala, M., Kelsey, M., LaMontagne, P., Sotiras, A., Marcus, D. S. 2023; 12469

  Abstract

  Modern neuro-oncology workflows are driven by large collections of high-dimensional MRI data obtained using varying acquisition protocols. The concomitant heterogeneity of this data makes extensive manual curation and pre-processing imperative prior to algorithmic use. The limited efforts invested towards automating this curation and processing are fragmented, do not encompass the entire workflow, or still require significant manual intervention. In this work, we propose an artificial intelligence-driven solution for transforming multi-modal raw neuro-oncology MRI Digital Imaging and Communications in Medicine (DICOM) data into quantitative tumor measurements. Our end-to-end framework classifies MRI scans into different structural sequence types, preprocesses the data, and uses convolutional neural networks to segment tumor tissue subtypes. Moreover, it adopts an expert-in-the-loop approach, where segmentation results may be manually refined by radiologists. This framework was implemented as Docker Containers (for command line usage and within the eXtensible Neuroimaging Archive Toolkit [XNAT]) and validated on a retrospective glioma dataset (n = 155) collected from the Washington University School of Medicine, comprising preoperative MRI scans from patients with histopathologically confirmed gliomas. Segmentation results were refined by a neuroradiologist, and performance was quantified using Dice Similarity Coefficient to compare predicted and expert-refined tumor masks. The scan-type classifier yielded a 99.71% accuracy across all sequence types. The segmentation model achieved mean Dice scores of 0.894 (± 0.225) for whole tumor segmentation. The proposed framework can automate tumor segmentation and characterization - thus streamlining workflows in a clinical setting as well as expediting standardized curation of large-scale neuro-oncology datasets in a research setting.

  View details for DOI 10.1117/12.2647656

  View details for PubMedID 39263425

  View details for PubMedCentralID PMC11389857

• Factors influencing selection of an interventional radiology training program. Clinical imaging Ramaswamy, R. S., Fung, D., Tiwari, T., Foltz, G., Akinwande, O., Mokkarala, M., Kim, S., Malone, C. 2019; 57: 30-34

  Abstract

  To understand factors influencing the choice and ranking of Interventional Radiology (IR) training programs among a cohort of medical students and diagnostic radiology residents pursuing careers in IR.An IRB approved, 34 question online survey (surveymonkey.com) evaluated the impact of twenty-two different factors and demographics on IR training program selection for medical students and residents. The factors analyzed included programmatic features, location characteristics, academic reputation, program size, benefits/financial incentives, emphasis on clinical care, and future job opportunities. Comparison of Likert scale responses between medical students and residents were performed by using unpaired two-sample t-tests.181 (145 male, 35 female) individuals responded to the survey, 74 medical students (40.9%) and 107 residents (59.1%). Medical students and residents both selected variety of IR cases as the most important and highest rated factor when choosing an IR program. Medical students ranked availability of a mentor (p = .03), inpatient consultation service (p = .003), outpatient clinic experience (p = .003), and ICU rotation experience (p < .001) significantly higher. Residents rated job placement/accomplishments of prior fellows (p = .03) and opinion of spouse/significant others (p = .002) significantly higher than medical students.The top rated factors are similar among medical students and residents however medical students value the clinical aspects of the program (ICU experience, inpatient consultation service, outpatient clinic) more than residents. Residents placed more value on job placement opportunities in selecting an IR program.

  View details for DOI 10.1016/j.clinimag.2019.05.001

  View details for PubMedID 31102780

• Outcomes and cost-minimization analysis of cement spacers versus expandable cages for posterior-only reconstruction of metastatic spine corpectomies. Annals of translational medicine Jordan, Y., Buchowski, J. M., Mokkarala, M., Peters, C., Bumpass, D. B. 2019; 7 (10): 212

  Abstract

  Reconstruction of the thoracolumbar spine after tumor corpectomy can be accomplished using either an expandable metallic cage (EC) or a polymethylmethacrylate (PMMA) cement spacer. Few studies have compared the relative successes between these two forms of reconstructions in the management of metastatic spine disease (MSD). The purpose of this study was to compare both the outcomes and costs of EC and PMMA spacers in the treatment of MSD. We hypothesized that the rate of complications and revision surgery when using PMMA spacers to reconstruct the spine after corpectomy for MSD would be equivalent to use of an EC, with lower implant and operating room (OR) costs.A single surgeon performed 65 vertebral corpectomies for MSD requiring anterior column reconstruction from 2007-2014. Charts were retrospectively reviewed and no patients were excluded. All resections were single-stage resections/reconstructions of the vertebral body through a posterior-only approach. Outcomes evaluated included perioperative complications, intraoperative time, postoperative survival, subsequent reoperations, and changes in radiographic spinal alignment.Thirty-six patients were treated with PMMA spacers; 29 were treated with EC. Baseline age, BMI, comorbidities, and disease severity as measured by Tokuhashi scores were equivalent between treatment groups. The cohorts had no significant differences in operative complications, blood loss, postoperative survival, number of subsequent reoperations, or changes in radiographic alignment. PMMA patients had a significantly shorter mean operative duration (328.6 vs. 241.1 min, P<0.001). Institutional implant cost savings were $4,355 favoring the PMMA cohort ($75 for cement vs. $5,000 for cage). Mean OR time savings were calculated to be $2,001 less for the PMMA cohort. Total cost minimization per PMMA case was thus $6,356, which was robust in 2-way sensitivity analyses varying both implant costs and time costs by 30%.In the largest series of posterior-only corpectomies for MSD reconstructed with PMMA, PMMA intervertebral spacers provided equivalent stability and longevity to EC, at a fraction of the cost. PMMA showed excellent durability while minimizing costs by $6,356 per case, an important consideration as reimbursement pressures increasingly influence surgical decision making.

  View details for DOI 10.21037/atm.2019.05.07

  View details for PubMedID 31297377

  View details for PubMedCentralID PMC6595212

• Percutaneous drainage and management of fluid collections associated with necrotic or cystic tumors in the abdomen and pelvis. Abdominal radiology (New York) Ballard, D. H., Mokkarala, M., D'Agostino, H. B. 2019; 44 (4): 1562-1566

  Abstract

  The purpose of the study was to evaluate the efficacy and safety of percutaneous drainage for palliation of symptoms and sepsis in patients with cystic or necrotic tumors in the abdomen and pelvis.This is a single center retrospective study of 36 patients (18 men, mean age = 51.1 years) who underwent percutaneous drainage for management of cystic or necrotic tumors in the non-postoperative setting over an 11-year period. Nineteen patients with intraabdominal fluid collections associated with primary malignancies included: cervical (n = 7), colorectal (n = 3), urothelial (n = 3), and others (n = 6). The 17 patients with fluid collections associated with intraabdominal metastases stemmed from the following primary malignancies: oropharyngeal squamous cell carcinoma (n = 3), colorectal (n = 3), ovarian (n = 2), lung (n = 2), melanoma (n = 2) along with others (n = 5). Indications for percutaneous drainage were as follows: pain (36/36; 100%); fever and/or leukocytosis (34/36; 94%), and mass effect (21/36; 58%). Seven patients underwent additional sclerosis with absolute alcohol. Criteria for drainage success were temporary or definitive relief of symptoms and sepsis control.Successful sepsis control was achieved in all patients with sepsis (34/34; 100%) and 30/36 (83%) patients had improvement in pain. Duration of catheterization ranged from 2 to 90 days (mean = 22 days). There were four cases of fluid re-accumulation and one patient developed catheter tract seeding. Alcohol ablation was successful in two patients (2/7; 29%). Nearly all patients (34/36; 94%) died during the follow-up period.Percutaneous drainage was effective for palliative treatment of symptomatic cystic and necrotic tumors in the majority of patients in this series.

  View details for DOI 10.1007/s00261-018-1854-z

  View details for PubMedID 30506143

  View details for PubMedCentralID PMC6440818

• Radiofrequency Ablation vs. Cryoablation for Localized Hepatocellular Carcinoma: A Propensity-matched Population Study. Anticancer research Xu, J., Noda, C., Erickson, A., Mokkarala, M., Charalel, R., Ramaswamy, R., Tao, Y. U., Akinwande, O. 2018; 38 (11): 6381-6386

  Abstract

  To compare overall survival (OS) and liver cancer-specific survival (LCSS) of Surveillance, Epidemiology and End Results (SEER) hepatocellular carcinoma (HCC) database patients treated with cryoablation (cryo) or radiofrequency ablation (RFA).This was a retrospective review of Stage I or II HCC patients from the SEER database treated with cryo and RFA from 2004-2013. Kaplan-Meier and Cox regressions were performed on pooled and propensity-matched cohort.Out of 3,239 patients, RFA showed a significant survival advantage over cryo in liver cancer specific survival (LCSS) (HR=1.634 p=0.0004). A total of 91 propensity-matched pairs had similar OS (HR=1.006 p=0.9768), but no difference in LCSS was observed between the groups [HR=1.412 (95%CI=0.933-2.137) p=0.1023]. Survival Cox models did not reveal treatment type as an independent prognostic factor.Propensity-matched cohort showed no significant difference in terms of OS and LCSS was found for patients treated with either cryo or RFA for localized HCC.

  View details for DOI 10.21873/anticanres.12997

  View details for PubMedID 30396961