Beyond the Bony Fragment: A Review of Limbus Vertebra

Vertebral limbus is a condition characterized by the intraspongious herniation of a portion of the nucleus pulposus. It is often asymptomatic, but it can sometimes cause nonspecific symptoms such as local pain and muscle spasm, or, in rare cases, radiculopathies, which is why it can be confused with vertebral fractures, spondyloarthropathies, infectious or tumoral processes. Early recognition of this pathology is preferable for a correct diagnosis and adequate treatment, the latter ranging from conservative approaches (such as personalized exercise programs and physical therapy) to surgical interventions reserved for severe cases with nerve compression.

Clinical Management of Mantle Cell Lymphoma With Concurrent Vascular Complications: A Case Report

This is a case of a 70-year-old patient with no past medical history but a significant family history of cancer, who was admitted with acute pulmonary embolism and left lower extremity deep vein thrombosis concerning malignancy. Further investigations revealed mantle cell lymphoma. This case highlights the complex clinical management of patients presenting with concurrent hematological malignancy and vascular complications.

Acute Intratonsillar Abscess in an Adult: A Case Report and Literature Review

Intratonsillar abscess (ITA) is rarely reported. Here, we present an uncommon case of acute ITA in an adult, discuss the evaluation and treatment plan, and review the ITA literature.  The abscess reported in the present study was diagnosed through a combination of clinical findings and computed tomography imaging, and treatment included drainage, intravenous (IV) clindamycin, and IV dexamethasone. The literature reports 72 ITA cases with specified treatments: 21 (29.2%) in adults, 19 (26.4%) in children, and 32 (44.4%) in patients of unspecified ages. Among them, 25 (34.7%) responded to antibiotics alone, 11 (15.3%) to needle aspiration and antibiotics, and 36 (50.0%) needed further intervention. Based on the presented case and literature review, we suggest the use of IV antibiotics with needle aspiration as the primary treatment for acute ITA. Incision and drainage (I&D) with antibiotics should be reserved for cases unresponsive to initial measures, and tonsillectomy is recommended for recurrent post-I&D cases.

Complex Compression Fracture in the Thoracolumbar Junction: A Case Report

Compression fractures in the thoracolumbar junction are one of the most frequent types of spine injuries. They can be the result of trauma or underlying conditions of the vertebrae. We present a case report of a 68-year-old patient with pain and loss of mobility in the lumbar spine after sustaining a trauma via falling from a significant height. Lumbar spondylography and a following CT scan revealed a complex compression fracture of L1 with degenerative osteoporotic changes of lumbar vertebrae and several pathologies of the lumbosacral junction. A surgical intervention was performed in the form of posterior transpedicular vertebral stabilization with titanium rods and screws. Postoperatively, relief from the lumbar region pain was reported. No neurological deficit was observed. The patient was mobilized, rehabilitated, and discharged from the hospital. This case report emphasizes the use of reliable imaging methods for the diagnosis of thoracolumbar compression fracture and highlights the reliability of surgical treatment of the condition via posterior transpedicular vertebral stabilization.

Establishing Baseline Radiological Metrics of the Talus and Calcaneus: A Retrospective Analysis of Computed Tomography Imaging in an Irish Cohort

Introduction The subtalar joint anatomy is complex and heterogeneity in its morphology creates unique challenges for foot and ankle surgeons. Anatomical metrics used for prosthesis design are well established. However, there is a paucity of literature quantifying foot and ankle measurement techniques and metrics used for prosthesis design. The aim of this study was to document reproducible measurement techniques and quantify talar and calcaneal metrics in a sample of Irish patients on computed tomography imaging to aid in the design of a novel hindfoot plate. Methods A retrospective analysis of consecutive foot and ankle computed tomography images performed at our institution was undertaken. Five measurements were performed on each foot and ankle image. Statistical analysis was performed to identify if a correlation existed between measurements. Results Sixty-four CTs met the inclusion criteria. Talar body height 27.1 mm (SD 2.17 mm), talar neck width 32.7 mm (3.16 mm), talar head height 25.41 (SD 2.16 mm), lateral process to posterior talus 23.6 (2.64 mm), calcaneal height 43.8 mm (SD 3.9 mm). A positive correlation was identified between all measurements. Conclusion This study identified that there was a low degree of heterogeneity in talar and calcaneal measurements in an Irish cohort. Furthermore, the metrics used in this study will provide valuable information for the preliminary design of a novel hindfoot plate.

Osteomyelitis of the Clivus Secondary to Mucormycosis

Osteomyelitis of the clivus secondary to mucormycosis is a rare infection of the clivus bone due to infiltration by fungi of the genus Mucor. Immunocompromised patients and/or those with diabetes mellitus are most at risk of developing this disease. Here, we present the case of a 63-year-old male patient with findings of gas within the clivus on computed tomography angiography. Diagnosis of mucormycosis osteomyelitis was confirmed after endoscopic biopsy and histopathologic examination. Furthermore, as this condition is very difficult to detect on imaging, we emphasize the discussion of typical radiology findings associated with this disease based on this and other case reports in the literature.

Computerized Tomography Texture Analysis in the Differential Diagnosis of Intracranial Epidermoid and Arachnoid Cysts

PURPOSE

This study evaluated the differences between arachnoid and epidermoid cysts in computerized tomography (CT) texture analysis (TA).

MATERIAL AND METHODS

The study included 12 patients with intracranial epidermoid cysts and 26 patients with intracranial arachnoid cysts who were diagnosed with diffusion-weighted magnetic resonance imaging (DW-MRI) and who had undergone an unenhanced CT examination before treatment. The LIFEx application software was used to obtain texture features. Eighty-two texture features from 38 lesions were automatically calculated for each lesion. The Shapiro-Wilk test was used to test the normality of the scores, and the Mann-Whitney U Test was used to test the difference between the groups. Receiver operating characteristic (ROC) curves and multivariate logistic regression modeling examined the parameters' diagnostic performances.

RESULTS

The median age of the patients was 53 years (range: 19-88 years). Eighty-two texture parameters were evaluated in the first order: gray-level co-occurrence matrix (GLCM), gray-level run length matrix (GLRLM), neighbor gray-tone difference matrix (NGTDM), and gray-level size zone matrix (GLSZM) groups. There was a statistically significant difference between the arachnoid cyst and the epidermoid cyst in the variables of compacity, compactness 1, compactness 2, sphericity, asphericity, sum average, coarseness, and low gray-level zone (p<0.05). According to the multiple logistic regression model, it was determined that the sum average in the GLCM group (B=-0.11; p=0.015), coarseness (B= 869.5; p=0.044) in the NGTDM group, and morphological sphericity (B=24.18; p=0.047) were the radiomics variables that increased the probability of epidermoid diagnosis. According to the classification table of the model, the sensitivity rate was found to be 83%, and the specificity rate was found to be 96%. Therefore, the probability of accurate model classification was 92%.

CONCLUSION

CT TA is a method that can be applied with high diagnostic accuracy in the differential diagnosis of intracranial epidermoid and arachnoid cysts, especially in patients who cannot undergo an MRI examination.

Delayed Metastatic Cholangiocarcinoma to the Stomach With Imaging Characteristics Resembling Gastrointestinal Stromal Tumor: A Case Report and Review of the Literature

Intrahepatic cholangiocarcinoma (ICC) is a relatively rare subtype of cholangiocarcinoma, and there has been an increasing incidence of ICC in Western countries in recent years. Surgical resection is the most effective treatment for ICC. However, overall outcomes are extremely poor given that most patients are diagnosed at an advanced stage, and postoperative ICC recurrence is still very high despite hepatic resection. We report a case of metastatic ICC to the stomach presenting after resection of the original tumor, with imaging characteristics highly resembling gastrointestinal stromal tumor (GIST) on imaging. Reported cases of metastatic ICC to the liver are sparse. Given that there is a significant difference in the survival rate between metastatic cholangiocarcinoma and other tumors arising from the gastrointestinal tract, including GISTs, it is important to delineate the differences via imaging features. We further discuss the imaging characteristics of intrahepatic ICC, comparing and contrasting it to other gastric tumors.

Imaging Depiction of Hypoxic Pulmonary Vasoconstriction Using Dual-Energy CT

In this article, we aim to highlight the utility of dual-energy computed tomography (DECT) in demonstrating imaging changes due to hypoxic pulmonary vasoconstriction (HPV). DECT allows detailed image reconstructions that have been shown to better characterize cardiothoracic pathologies, as compared to conventional CT techniques. DECT simultaneously detects two different X-ray energies, which enables generation of iodine density maps, virtual monoenergetic images, and effective atomic number maps (Z_eff), among others. DECT has been shown to have utility in the assessment of benign versus malignant pulmonary nodules, pulmonary embolism, myocardial perfusion defects, and other conditions. Herein, we describe four cases of indeterminate pulmonary pathology when imaged with conventional CT in which subsequent use of DECT-derived image reconstructions demonstrated HPV as the underlying pathophysiological mechanism. The goal of this article is to understand the imaging appearance of HPV on DECT and discuss how HPV may mimic other causes of perfusion defects.

A Rare Presentation of Congenital Chilaiditi Syndrome: Symptomatic Hepatobowel Entrapment

The displacement and trapping of the colon between the liver and the right hemidiaphragm are known as the Chilaiditi sign or syndrome. The Chilaiditi sign presents in an asymptomatic patient, while Chilaiditi syndrome presents with symptoms such as abdominal pain, distension, and constipation, in addition to complications such as perforation, volvulus, and bowel obstruction. It is often misdiagnosed as pneumoperitoneum or free air under the diaphragm and liver, often seen on the abdomen and chest radiography. It more commonly presents in males than in females. Here, we present the case of a 37-year-old female who reported abdominal pain and persistent constipation. An abdominal CT scan showed entrapment of a bowel segment, which is referred to as the Chilaiditi sign. The patient's presentation with hepatobowel entrapment and persistent gastrointestinal symptoms was diagnosed as Chilaiditi syndrome. This presentation entails a conservative management approach. The aim of this report is to educate about the rare occurrence of Chilaiditi sign and Chilaiditi syndrome as a differential diagnosis to often misdiagnosed critical conditions such as pneumoperitoneum and intestinal perforation. Correctly identifying these patients will reduce overtreatment and help improve outcomes.

Wilkie Syndrome and Pseudo-Nutcracker Syndrome a Rare Combination: Description of a Case

Wilkie's syndrome is a very rare vascular alteration caused by congenital or acquired reduction of space between the superior mesenteric artery (SMA) and aorta. In acquired form, it is caused by perivascular adipose tissue reduction due to rapid weight loss and, if symptomatic, causes postprandial vomiting and weight loss. The left renal vein (LRV) when it has a retro-aortic course can be compressed in aorto-vertebral space (AVS); if the stenosis is severe it can cause venous congestion symptoms with left flank pain, microhematuria, and thrombosis, this vascular alteration is known as a pseudo-nutcracker syndrome. The combination of Wilkie's and pseudo-nutcracker's syndrome (PNCS) is very rare and has not yet been described in the literature. We describe a case of a 62-year-old woman who presented symptoms and alterations typical of two syndromes.

A Rare Case of Osteomyelitis Presenting as Cyst-Like Lesion in the Coronoid Process: A Diagnostic Challenge

Cyst-like lesion in the coronoid process of the mandible is a challenging diagnosis to make, as it may present with a range of non-specific symptoms. A middle-aged woman reported a one-year history of non-bloody, pus discharge from the right angle of the mandible. There was a history of prior surgery comprising teeth removal two years ago for a painful swelling on the right side of her face, following which her symptoms regressed but in the due course, she developed a chronic sinus with draining abscess. Radiographic findings, in combination with clinical symptoms, are critical in the diagnosis and evaluation of cysts and cyst-like lesions of the jaws. The orthopantomograph (OPG) revealed a cyst-like lesion in the coronoid process of the mandible with an extra-oral sinus tract leading to the epicenter of the cyst-like radiolucency, and so this, in combination with the patient's atypical symptoms, presented a diagnostic challenge. This case report explores the events which led to the diagnosis of osteomyelitis and shows several unique learning points.

Anomalous Circumrenal Inferior Vena Cava Associated With Horseshoe Kidney

A 69-year-old male presented with periumbilical pain radiating across his abdomen, with associated nausea and emesis. CT imaging of his abdomen and pelvis revealed calculi in the right and left ureterovesical junctions with hydroureteronephrosis bilaterally. Furthermore, the imaging revealed that the patient had a horseshoe kidney with an associated anomalous inferior vena cava (IVC) that split superiorly to the horseshoe kidney at the L1 level and rejoined inferior to the horseshoe kidney at the L5 level. The IVC took on a "circumrenal" course, as it traversed the right kidney with an anterior and posterior portion. Furthermore, the patient's right ureter was compressed between the anterior portion of the IVC and the right kidney. We hypothesize that the development of the horseshoe kidney around the 7 to 8th week of gestation created a path of resistance for the forming of IVC around the same time. While surgical correction is not warranted, recognition of this circumrenal IVC variant could have major implications for planning of procedures, such as IVC filter placement.

A Rare Case of Emphysematous Osteomyelitis of Femur in an Intravenous Drug User

Emphysematous osteomyelitis (EO) is a rare condition characterized by the appearance of gas locules within the bone on imaging, usually as a result of anaerobic bacterial infection. We present the case of a 46-year-old known intravenous (IV) drug user who was admitted to the emergency department with intractable pain in the right groin. He was febrile with elevated white cell count and C-reactive protein. He underwent an X-ray and CT of the pelvis which demonstrated intraosseous gas in the proximal right femur. A diagnosis of EO was made radiologically, allowing for prompt antibiotic treatment and a plan for surgical debridement. There are only a handful of published cases of EO in the literature, only one of which has described IV drug use as the underlying factor.

Bullet Appendicitis: An Unusual Cause to a Rather Straight-Forward Diagnosis

A 19-year-old male patient presented to the emergency department (ED) with pain in the right iliac fossa. Computed tomography (CT) scan of the abdomen and pelvis revealed signs of acute appendicitis, as a result of a metallic foreign body beyond the appendiceal orifice. Upon further questioning, the patient gave a history of ball bearing (BB) gun bullet ingestion in the past. Although rare, foreign body appendicitis occurs. A radiologist should be mindful to reporting such cases especially bizarre foreign bodies for example bullets as it may warrant psychiatric consultation or alter surgical management.

Ampullary Adenocarcinoma Causing Small Intestinal Obstruction

Ampullary adenocarcinoma is a malignant tumor that arises from the ampullary complex, distal to the confluence of common bile duct and pancreatic duct. It is a rare tumor and pathologically differentiated into intestinal or pancreaticobiliary in origin. Management is surgical resection. We report a case of a 67-year-old male who presented with abdominal pain, vomiting, and constipation. Computed tomography scan showed a cystic mass compressing the duodenum and causing small intestinal obstruction. Pathologic evaluation was consistent with ampullary adenocarcinoma.

Non-Infectious Diseases Compatible With COVID-19 Pneumonia

While the definitive diagnosis of the coronavirus disease 19 (COVID-19) is mainly made by the polymerase chain reaction (PCR), some PCR-negative cases are diagnosed typically by a computed tomography (CT) scan's radiology. However, there are many different infectious and non-infectious diseases that have radiology like COVID-19. We are presenting a case of a patient having symptoms and a CT scan radiology comparable to that of COVID-19 and also having eosinophilia. The patient was initially diagnosed and treated as a COVID-19 patient. The patient stated that she had always complained of having dyspnea and cough, but it had increased even more in the past few days. Her thorax CT revealed bilateral ground-glass opacities with upper lobe predominance, which was reported as highly compatible with COVID-19 by radiologists. COVID-19 PCR result was negative twice. In laboratory results, eosinophil count was 2,850/mm³ and total Ig was 768 IU/mL. However, when the laboratory values and the radiological findings were combined with the patient’s history, COVID-19 was excluded and the chronic eosinophilic pneumonia was accepted as a diagnosis. Clinicians more focused on COVID-19 while questioning the patients and while evaluating the laboratory and the radiological findings make it easier to miss other infectious and non-infectious diseases. Assessing the complete blood count result, focusing on the lymphocyte value, also makes it easy to skip eosinophilia.

Mucormycosis Following Tooth Extraction in a Diabetic Patient: A Case Report

Mucormycosis is a rare, opportunistic fungal infection, which can progress acutely or subacutely in immunosuppressed patients. It is a devastating disease in patients with poorly controlled diabetes mellitus and immunocompromised conditions. It causes decaying and extensive lesions of the soft tissue caused by fungi belonging to the order of Mucorales and is often fatal. Due to its aggressive nature, early detection and prompt management are of great importance for a good prognosis. We report a case of mucormycosis post-dental extraction in a patient with uncontrolled diabetes mellitus.