Osteoma in the upper cervical spine: A case report and comprehensive literature review

INTRODUCTION AND IMPORTANCE

Osteoma is a benign, and usually asymptomatic bone tumor normally found in the skull and facial bones, although it can occasionally occur in the long bones and spine.

CASE PRESENTATION

In this article, we present a 49-year-old male patient who experienced progressive neck pain accompanied by left-sided radicular pain symptoms. Clinical investigation using various imaging techniques confirmed a bone-forming lesion located within the C1 vertebrae region. Treatment involved performing hemilaminectomy of C1 along with resection for complete removal of this extradural bone lesion, ultimately achieving symptom relief. Histopathological examination of the resected specimen leads to the diagnosis of osteoma. Along with reporting this case, we conducted a comprehensive literature review of the previously reported spinal osteoma cases.

CLINICAL DISCUSSION

Histopathological examination confirmed the diagnosis of osteoma. A comprehensive literature review was conducted, revealing 16 previously reported cases of spinal osteoma. Among these, only one case involved the C1 vertebra and presented similar neurological symptoms. The review underscores the rarity of spinal osteomas and the importance of surgical intervention for symptom relief.

CONCLUSION

Spinal osteomas are rare but should be considered in the differential diagnosis of patients presenting with neck pain and radicular symptoms. Surgical removal of the lesion is often necessary for symptom relief, as highlighted by our case and supported by the literature review. This case adds to the limited body of evidence on spinal osteomas and emphasizes the importance of a multidisciplinary approach for optimal patient outcomes.

Mechanism of action and therapeutic potential of dimethyl fumarate in ischemic stroke

Dimethyl fumarate (DMF) is an immunomodulatory drug currently approved for the treatment of multiple sclerosis and psoriasis. Its benefits on ischemic stroke outcomes have recently come to attention. To date, only tissue plasminogen activators (tPAs) and clot retrieval methods have been approved by the FDA for the treatment of ischemic stroke. Ischemic conditions lead to inflammation through diverse mechanisms, and recanalization can worsen the state. DMF and the nuclear factor erythroid-derived 2-related factor 2 (Nrf2) pathway it regulates seem to be important in postischemic inflammation, and animal studies have demonstrated that the drug improves overall stroke outcomes. Although the exact mechanism is still unknown, studies indicate that these beneficial impacts are due to the modulation of immune responses, blood-brain barrier permeability, and hemodynamic adjustments. One major component evaluated before, during, and after tPA therapy in stroke patients is blood pressure (BP). Recent studies have found that DMF may impact BP. Both hypotension and hypertension need correction before treatment, which may delay the appropriate intervention. Since BP management is crucial in managing stroke patients, it is important to consider DMF's role in this matter. That being said, it seems further investigations on DMF may lead to an alternative approach for stroke patients. In this article, we discuss the mechanistic roles of DMF and its potential role in stroke based on previously published literature and laboratory findings.

Effect of the COVID-19 Pandemic on Seizure Control Status in Patients with Epilepsy

BACKGROUND

Previous studies have shown that patients with epilepsy (PWE) perceived significant disruption in the quality and provision of care due to the coronavirus disease 2019 (COVID-19) pandemic. The present study aimed to investigate the effect of this pandemic on seizure control status and changes in seizure frequency in PWE.

METHODS

A consecutive sample of adult PWE registered in the database of Shiraz Epilepsy Center (Shiraz, Iran) was included in the study. In July 2021, phone interviews were conducted with all selected patients. Information such as age, sex, last seizure, seizure type, and frequency during the 12 months before the study, and history of COVID-19 contraction was extracted. The seizure control status of the patients in 2019 (pre-pandemic) was compared with that during the COVID-19 pandemic. Data were analyzed using SPSS software with the Fisher's exact test and Pearson's Chi squared test. P<0.05 was considered statistically significant.

RESULTS

A total of 158 patients were included in the study, out of which 62 (39.2%) patients had a stable seizure control status, 47 (29.7%) had fewer seizures, and 50 (31.6%) had more seizures. Breakthrough seizures were reported by 32 (34.4%) patients. Seizure frequency increased in 18 (27.7%) and decreased in 46 (70.7%) patients.

CONCLUSION

Overall, the COVID-19 pandemic has not been a major precipitating factor nor has it affected the seizure control status of PWE. In treated epilepsy, a fluctuating course with periods of seizure freedom followed by relapses is part of its natural history.

Pharmacotherapeutic approach toward urological medications and vaccination during COVID-19: a narrative review

One year after the prevalence of the novel coronavirus pandemic, some aspects of the physiopathology, treatment and progression of coronavirus 2019 disease (COVID-19) have remained unknown. Since no comprehensive study on the use of urological medications in patients with COVID-19 has been carried out, this narrative review aimed to focus on clinically important issues about the treatment of COVID-19 and urologic medications regarding efficacy, modifications, side effects and interactions in different urologic diseases. In this review, we provide information about the pharmacotherapeutic approach toward urologic medications in patients with COVID-19 infection. This study provides an overview of medications in benign prostatic hyperplasia, prostate cancer, impotence and sexual dysfunction, urolithiasis, kidney transplantation and hypertension as the most frequent diseases in which the patients are on long-term medications. Also, the effect of urologic drugs on the efficacy of vaccination is briefly discussed.

Psychological Problems Among Patients With Chronic Medical Disorders During the COVID-19 Pandemic

The aim of the current study was to investigate the rates of stress, anxiety, and depression among people in south Iran (a group from the general population without a history of any chronic medical problems, and cohorts of patients were recruited from epilepsy, diabetes, and cardiac disease clinics). We surveyed a sample of people during September 2020: a group of the general population without a history of any chronic medical problems, people with epilepsy, people with diabetes mellitus (DM), and people with cardiac problems. The survey included four general questions and two COVID-19 specific questions [contracting COVID-19, relatives with COVID-19]. Furthermore, the survey included the DASS (Depression-Anxiety-Stress Scale)-21 questionnaire. 487 people were surveyed (154 people with epilepsy, 127 patients with DM, 98 people with cardiac problems, and 108 healthy individuals). Among people without a history of any chronic medical illnesses, 14% had any psychological problems. The highest rates of depression and anxiety were observed among patients with DM (52% and 57%, respectively), and the highest rate of increased stress was observed among people with cardiac problems (40%). The existence of any underlying medical problem was significantly associated with higher rates of depression, anxiety, and stress among the participants. While many patients with underlying chronic medical conditions suffer from depression, anxiety, and stress during the COVID-19 pandemic, we cannot establish a cause and effect relationship between the COVID-19 pandemic and increased psychological problems among these patients.

Surgical approach is associated with complication rate in sinonasal malignancy: A multicenter study

BACKGROUND

Management of sinonasal malignancy (SNM) often includes surgical resection as part of the multimodality treatment. Treatment-related surgical morbidity can occur, yet risk factors associated with complications in this population have not been sufficiently investigated.

METHODS

Adult patients with histologically confirmed SNM whose primary treatment included surgical resection were prospectively enrolled into an observational, multi-institutional cohort study from 2015 to 2020. Sociodemographic, disease, and treatment data were collected. Complications assessed included cerebrospinal fluid leak, orbital injury, intracranial injury, diplopia, meningitis, osteoradionecrosis, hospitalization for neutropenia, and subsequent chronic rhinosinusitis. The surgical approach was categorized as endoscopic resection (ER) or open/combined resection (O/CR). Associations between factors and complications were analyzed using Student's t test, Fisher's exact test, and logistic regression modeling.

RESULTS

Overall, 142 patients met the inclusion criteria. Twenty-three subjects had at least 1 complication (16.2%). On unadjusted analysis, adjuvant radiation therapy was associated with developing a complication (91.3% vs 65.5%, p = 0.013). Compared with the ER group (n = 98), the O/CR group (n = 44) had a greater percentage of higher T-stage lesions (p = 0.004) and more frequently received adjuvant radiation (84.1% vs 64.4%, p = 0.017) and chemotherapy (50.0% vs 30.6%, p = 0.038). Complication rates were similar between the ER and O/CR groups without controlling for other factors. Regression analysis that retained certain factors showed O/CR was associated with increased odds of experiencing a complication (odds ratio, 3.34; 95% confidence interval, 1.06-11.19).

CONCLUSIONS

Prospective, multicenter evaluation of SNM treatment outcomes is feasible. Undergoing O/CR was associated with increased odds of developing a complication after accounting for radiation therapy. Further studies are warranted to build upon these findings.

Detection of Angiographically Occult Ruptured Basilar Sidewall Perforator Aneurysm by Vessel Wall MR Imaging

Basilar artery perforator aneurysms are rare with a prevalence of less than 1%. These are particularly challenging to detect given their small size and tendency to intermittently thrombose. We describe a case of a ruptured basilar artery sidewall perforator aneurysm that was angiographically occult on computed tomographic angiogram and cerebral catheter angiogram. One day after the initial diagnostic work-up, intracranial vessel wall MR imaging (VWI) was performed which revealed a small outpouching along the right posterolateral basilar arterial wall with a punctate enhancing focus suggestive of a thrombosed basilar perforator artery aneurysm. Thrombus within the small aneurysm sac likely contributed to the poor opacification of the aneurysm sac on conventional lumen-based imaging techniques. Ruptured aneurysms have high morbidity and mortality due to their tendency to rebleed, making their expedient detection and treatment imperative. This case highlights the role VWI can play in detecting small ruptured aneurysms that intermittently thrombose and are otherwise challenging to diagnose with conventional vessel imaging.

Is the risk of COVID-19 contraction increased in patients with epilepsy?

OBJECTIVE

The aim of the current study was to investigate the rates of contracting COVID-19 in various populations to provide evidence on the susceptibility of patients with epilepsy (PWE) to contracting symptomatic COVID-19.

METHODS

We surveyed a random sample of three groups of people: patients with epilepsy, people with psychiatric problems, and a group of the general population. The survey included four general questions (age, sex, education, and medical/psychiatric problem) and four COVID-19 specific questions (contracting COVID-19, relatives with COVID-19, wearing a face mask, and frequent hand washings).

RESULTS

Three hundred and fifty -eight people were surveyed (108 healthy individuals, 154 patients with epilepsy, and 96 patients with psychiatric problems). Thirty-eight (11%) people had a history of COVID-19 contraction. The only factor that had a significant association with COVID-19 contraction was a relative with COVID-19 (Odds Ratio: 5.82; 95% Confidence Interval: 2.85-11.86; p = 0.0001). Having epilepsy did not increase the risk of COVID-19 contraction.

CONCLUSION

Symptomatic COVID-19 does not seem to be more likely in PWE. The single most important factor associated with contracting COVID-19 is a close relative with this infection. Isolation of people with SARS-CoV-2 infection and observation of their close contacts may reduce the risk of secondary infections.

Association of plasma cell-free DNA with survival in patients with IDH wild-type glioblastoma

BACKGROUND

We aimed to determine whether plasma cell-free DNA (cfDNA) concentration is associated with survival in patients with isocitrate dehydrogenase (IDH) wild-type glioblastoma (GBM).

METHODS

Pre-operative and post-chemoradiotherapy blood samples were prospectively collected from patients with newly diagnosed IDH wild-type GBM. Patients underwent surgical resection or biopsy and received adjuvant radiotherapy with concomitant temozolomide. Cell-free DNA (cfDNA) was isolated from plasma and quantified using SYBR Green-based q polymerase chain reaction (qPCR).

RESULTS

Sixty-two patients were enrolled and categorized into high vs. low cfDNA groups relative to the pre-operative median value (25.2 ng/mL, range 5.7-153.0 ng/mL). High pre-operative cfDNA concentration was associated with inferior PFS (median progression-free survival (PFS), 3.4 vs. 7.7 months; log-rank P = .004; hazard ratio [HR], 2.19; 95% CI, 1.26-3.81) and overall survival (OS) (median OS, 8.0 vs. 13.9 months; log-rank P = .01; HR, 2.43; 95% CI, 1.19-4.95). After adjusting for risk factors, including O6-methylguanine-DNA methyltransferase (MGMT) promoter methylation status, pre-operative cfDNA remained independently associated with PFS (HR, 2.70; 95% CI, 1.50-4.83; P = .001) and OS (HR, 2.65; 95% CI, 1.25-5.59; P = .01). Post-hoc analysis of change in cfDNA post-chemoradiotherapy compared to pre-surgery (n = 24) showed increasing cfDNA concentration was associated with worse PFS (median, 2.7 vs. 6.0 months; log-rank P = .003; HR, 4.92; 95% CI, 1.53-15.84) and OS (median, 3.9 vs. 19.4 months; log-rank P < .001; HR, 7.77; 95% CI, 2.17-27.76).

CONCLUSIONS

cfDNA concentration is a promising prognostic biomarker for patients with IDH wild-type GBM. Plasma cfDNA can be obtained noninvasively and may enable more accurate estimates of survival and effective clinical trial stratification.

Anatomical Variations, Mimics, and Pitfalls in Imaging of Patients with Epilepsy

Epilepsy is among one of the most common neurologic disorders. The role of magnetic resonance imaging (MRI) in the diagnosis and management of patients with epilepsy is well established, and most patients with epilepsy are likely to undergo at least one or more MRI examinations in the course of their disease. Recent advances in high-field MRI have enabled high resolution in vivo visualization of small and intricate anatomic structures that are of great importance in the assessment of seizure disorders. Familiarity with normal anatomic variations is essential in the accurate diagnosis and image interpretation, as these variations may be mistaken for epileptogenic foci, leading to unnecessary follow-up imaging, or worse, unnecessary treatment. After a brief overview of normal imaging anatomy of the mesial temporal lobe, this article will review a few important common and uncommon anatomic variations, mimics, and pitfalls that may be encountered in the imaging evaluation of patients with epilepsy.

NIMG-22. INTEGRATION OF A RADIOMIC SIGNATURE, CLINICAL VARIABLES AND PLASMA CELL-FREE DNA IN ADULT PATIENTS WITH NEWLY DIAGNOSED GLIOBLASTOMA PREDICTS PATIENT SURVIVAL AND IMPROVES DISEASE STRATIFICATION

PURPOSE

We have previously demonstrated the potential role of liquid biopsy, specifically plasma cell-free DNA (cfDNA), as a non-invasive biomarker for prognostication in patients with glioblastoma. In separate prior studies, we have also developed MRI-based radiomic signatures to predict survival outcomes in glioblastoma. In this study, for the first time, we evaluated the potential of combining radiomic signatures, epidemiological and clinical variables, and plasma cfDNA quantification for upfront prediction of overall survival (OS) in patients with newly diagnosed glioblastoma.

METHODS

Quantitative radiomic features were extracted from multiparametric MRI (T1, T1Gd, T2, T2-FLAIR) scans of a discovery cohort of 505 and an independent replication cohort of 50 IDH-wildtype glioblastoma patients. For the independent replication cohort, pre-surgical plasma cfDNA was extracted and quantified. In the first stage, a radiomic signature was created for stratification of patients into categories of short (OS ≤ 6 months) and long (OS ≥ 18 months) survivors using a cross-validated XGBoost method based on the discovery cohort, which was tested independently on the replication cohort. In the second stage, the radiomic signature and clinical variables were integrated to build a second-stage signature using a cross-validated support vector machine (SVM) classifier to stratify the patients into short and long survivor categories. In the third stage, the value of the second-stage signature integrated with cfDNA concentration was assessed through a cross-validated SVM regression method.

RESULTS

The combination of radiomic, clinical, and cfDNA variables resulted in the best overall predictive accuracy, with Pearson’s correlation coefficient of 0.59 (p&lt; 0.0001) between actual and predicted OS.

CONCLUSION

In this study, we evaluated the value of combining plasma cfDNA, radiomic, and clinical variables for predicting OS, and showed that it could act as an effective non-invasive prognostic and patient stratification tool in patients with newly diagnosed glioblastoma.

A prospective validation cohort study of baseline plasma cell-free DNA (cfDNA) as a prognostic biomarker in newly diagnosed glioblastoma (GBM)

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Background: Due to significant interpatient heterogeneity, survival outcomes vary widely in patients with GBM. Novel prognostic biomarkers are needed. We aimed to determine the prognostic impact of baseline plasma cfDNA concentration in patients with GBM. Methods: We analyzed 84 patients with newly diagnosed GBM and at least 7 months of follow-up time. The first 41 patients comprised a previously published derivation cohort (Bagley, Clin Cancer Res 2020). The subsequent 43 patients served as an independent validation cohort. cfDNA was extracted from plasma collected prior to initial surgical resection and quantified by qPCR for a 115 bp amplicon of the human ALU repeat element. Receiver operating characteristic (ROC) curve analysis was used in the derivation cohort to (1) assess the accuracy of plasma cfDNA concentration for predicting progression-free survival status at 7 months (PFS-7), a landmark based on the median PFS for newly diagnosed GBM (Stupp, N Engl J Med 2005), and (2) derive the optimal cutoff for dichotomizing patients into high- and low-cfDNA groups. In the validation cohort, logistic regression was used to measure the association of plasma cfDNA concentration (high vs. low) with PFS-7, adjusted for age, isocitrate dehydrogenase ( IDH) 1/2 mutational status, 0-6-methylguanine-methyltransferase ( MGMT) methylation, extent of resection, and performance status. Multivariate Cox regression was used for overall survival (OS) analysis. Results: In the derivation cohort, the optimal cutoff for plasma cfDNA was 25.0 ng/mL (area under the curve [AUC] = 0.663), with inferior PFS and OS in patients with cfDNA above this cutoff (PFS, median 4.9 vs. 9.5 months, log-rank p = 0.001; OS, median 8.5 vs. 15.5 months, log-rank p = 0.03). In the validation cohort, baseline plasma cfDNA concentration over the cutoff was independently associated with a lower likelihood of being alive and progression-free at 7 months (adjusted OR 0.13, 95% CI 0.02 – 0.75, p = 0.02). OS was also worse in in the validation cohort in patients with high plasma cfDNA (adjusted HR 3.0, 95% CI 1.1 – 8.0, p = 0.03). Conclusions: In patients with newly diagnosed GBM, high baseline plasma cfDNA concentration is associated with worse survival outcomes independent of other prognostic factors. Further validation in a larger, multicenter study is warranted.

Epilepsy Lesion Localization is not Predicted by Developmental Venous Anomaly Location or its FDG-PET Metabolic Activity

BACKGROUND AND PURPOSE

This study's purpose is to correlate location and metabolic activity of developmental venous anomalies (DVAs) in epilepsy patients to the seizure focus as determined by ictal/interictal encephaloelectrogram (EEG).

METHODS

A retrospective search was performed for epilepsy patients with DVAs who underwent brain ¹⁸ F-fluorodeoxyglucose positron emission tomography (¹⁸ F-FDG-PET) and magnetic resonance imaging (MRI). MRI exams were analyzed to characterize DVA location and associated structural findings. MRI and PET images were co-registered and assessment of ¹⁸ F-FDG uptake in the DVA territory was performed. The electronic medical record was reviewed for each subject to determine seizure semiology and site of seizure focus by ictal/interictal EEG.

RESULTS

Twenty-eight DVAs in 25 patients were included. Twelve DVAs demonstrated regional metabolic abnormality on ¹⁸ F-FDG-PET. There was no significant correlation between DVA site and seizure focus on EEG. DVA location was concordant with EEG seizure focus in three subjects, and all three demonstrated hypometabolism on ¹⁸ F-FDG-PET. This significance remains indeterminate, as one of these DVAs was associated with cavernoma, which could serve as the true seizure focus, and one of the patients underwent resection of the DVA without decrease in seizure frequency. Furthermore, there was no statistically significant relationship between DVA metabolic activity and DVA-EEG lobar or laterality concordance.

CONCLUSIONS

In this sample, there is no significant correlation between location of DVA and seizure focus, and hypometabolism within the DVA territory is not predictive of EEG/DVA co-localization. As use of ¹⁸ F-FDG-PET for evaluation of epilepsy increases, knowledge of this poor correlation is important to avoid diagnostic confusion and potentially unnecessary surgery in epilepsy patients.

Imaging and histopathologic correlates of plasma cell-free DNA concentration and circulating tumor DNA in adult patients with newly diagnosed glioblastoma

Background

Plasma cell-free DNA (cfDNA) concentration is lower in glioblastoma (GBM) compared to other solid tumors, which can lead to low circulating tumor DNA (ctDNA) detection. In this study, we investigated the relationship between multimodality magnetic resonance imaging (MRI) and histopathologic features with plasma cfDNA concentration and ctDNA detection in patients with treatment-naive GBM.

Methods

We analyzed plasma cfDNA concentration, MRI scans, and tumor histopathology from 42 adult patients with newly diagnosed GBM. Linear regression analysis was used to examine the relationship of plasma cfDNA concentration before surgery to imaging and histopathologic characteristics. In a subset of patients, imaging and histopathologic metrics were also compared between patients with and without a detected tumor somatic mutation.

Results

Tumor volume with elevated (>1.5 times contralateral white matter) rate transfer constant (K_ep, a surrogate of blood–brain barrier [BBB] permeability) was independently associated with plasma cfDNA concentration (P = .001). Histopathologic characteristics independently associated with plasma cfDNA concentration included CD68+ macrophage density (P = .01) and size of tumor vessels (P = .01). Patients with higher (grade ≥3) perivascular CD68+ macrophage density had lower volume transfer constant (K_trans, P = .01) compared to those with lower perivascular CD68+ macrophage density. Detection of at least 1 somatic mutation in plasma cfDNA was associated with significantly lower perivascular CD68+ macrophages (P = .01).

Conclusions

Metrics of BBB disruption and quantity and distribution of tumor-associated macrophages are associated with plasma cfDNA concentration and ctDNA detection in GBM patients. These findings represent an important step in understanding the factors that determine plasma cfDNA concentration and ctDNA detection.

Significance of the absent vertebral artery T2 flow void on cervical spine MRI in atraumatic patients without acute neurological symptoms

PURPOSE

Loss of the T2 vertebral artery flow void can be an ominous sign in patients with trauma. However, the significance of an absent vertebral artery flow void is less clear when discovered incidentally in patients without trauma or acute neurological symptoms. The purpose of this study was to review retrospectively the results of additional imaging and clinical evaluation in atraumatic patients without acute neurological symptoms found to have an incidentally discovered absent vertebral artery flow void on magnetic resonance imaging.

MATERIALS AND METHODS

An imaging database was reviewed for absent vertebral artery flow voids in atraumatic cervical spine magnetic resonance images. Imaging and long-term clinical follow-up were recorded.

RESULTS

Fifty-four patients were included in the study. All patients had clinical follow-up and 22 patients (40% of cases) had vascular imaging follow-up. Nine patients had a hypoplastic but patent vertebral artery on follow-up vascular imaging, and no further action was taken. Ten patients had evidence of stenosis or occlusion of the vertebral artery on follow-up imaging, none with acute neurological symptoms or new symptoms/subsequent change in management during follow-up. Three additional patients had vertebral artery dissections on follow-up imaging, but all of them had acute neurological symptoms at the time of imaging and acute infarcts on current or subsequent magnetic resonance imaging. The other 32 patients had clinical follow-up and remained asymptomatic throughout the study period, without change in management.

CONCLUSION

In the absence of trauma or acute neurological symptoms an absent vertebral artery flow void has a low likelihood of altering patient management.

Reversible Dilation of the Superior Ophthalmic Vein in Intubated Patients

BACKGROUND AND PURPOSE

Superior ophthalmic vein enlargement has typically been associated with increased intracranial or orbital pressure. This study evaluates the incidence of superior ophthalmic vein enlargement in intubated patients without pre-existing intracranial or intraorbital pathologies.

MATERIALS AND METHODS

Two cohorts (patients with trauma and epilepsy patients undergoing stereotactic intracranial lead placement) who underwent CT while intubated and shortly following extubation and a cohort of 30 outpatients with a history of headache and normal head CT findings (healthy controls) were included. The superior ophthalmic vein diameter was measured on all scans.

RESULTS

Seventy patients intubated for trauma and 45 patients with intraoperative CT were included (n = 115). While intubated, 66% of the total sample had at least unilateral superior ophthalmic vein dilation of >2.5 mm and 48% had bilateral dilation. Fifty-seven percent of patients with trauma and 84% of intraoperative patients with dilated superior ophthalmic veins showed reversal of mean superior ophthalmic vein dilation to <2.5 mm on postextubation CT. The mean superior ophthalmic vein diameter decreased an average of 1.2 mm following extubation. Changes in superior ophthalmic vein diameter between intubated and extubated states were statistically significant (P < .001). Differences between the control group and the extubated subjects were not statistically significant (P = .21).

CONCLUSIONS

Bilateral dilation of the superior ophthalmic vein is common in intubated patients and usually reverses following extubation. In the appropriate clinical setting, this knowledge will prevent misinterpretation of prominent superior ophthalmic veins as automatically indicative of an underlying pathology.

Chapter 6 Non-Squamous Cell Causes of Cervical Lymphadenopathy

Cervical lymphadenopathy is a common indication for imaging evaluation of the neck. Besides metastatic squamous cell carcinoma of the head and neck, cervical lymphadenopathy can be due to many causes, with simple reactive lymphadenopathy on one end of the spectrum and malignant lymphadenopathy due to a distant infraclavicular primary, on the other end. A systematic approach to the cause of cervical lymphadenopathy, which includes pattern of lymph node enlargement, lymph node characteristics, systemic symptoms, and extranodal abnormalities, can be very useful in arriving at the correct diagnosis. In this article, various patterns of cervical lymphadenopathy due to non-squamous cell causes are discussed.

Chapter 8 On the Horizon: Advanced Imaging Techniques to Improve Noninvasive Assessment of Cervical Lymph Nodes

Conventional imaging modalities are limited in the evaluation of lymph nodes as they predominantly rely on size and morphology, which have suboptimal sensitivity and specificity for malignancy. In this review we will explore the role of "on the horizon" advanced imaging modalities that can look beyond the size and morphologic features of a cervical lymph node and explore its molecular nature and can aid in personalizing therapy rather than use the "one-size-fits-all" approach.

Wallerian Degeneration Beyond the Corticospinal Tracts: Conventional and Advanced MRI Findings

Wallerian degeneration (WD) is defined as progressive anterograde disintegration of axons and accompanying demyelination after an injury to the proximal axon or cell body. Since the 1980s and 1990s, conventional magnetic resonance imaging (MRI) sequences have been shown to be sensitive to changes of WD in the subacute to chronic phases. More recently, advanced MRI techniques, such as diffusion-weighted imaging (DWI) and diffusion tensor imaging (DTI), have demonstrated some of earliest changes attributed to acute WD, typically on the order of days. In addition, there is increasing evidence on the value of advanced MRI techniques in providing important prognostic information related to WD. This article reviews the utility of conventional and advanced MRI techniques for assessing WD, by focusing not only on the corticospinal tract but also other neural tracts less commonly thought of, including corticopontocerebellar tract, dentate-rubro-olivary pathway, posterior column of the spinal cord, corpus callosum, limbic circuit, and optic pathway. The basic anatomy of these neural pathways will be discussed, followed by a comprehensive review of existing literature supported by instructive clinical examples. The goal of this review is for readers to become more familiar with both conventional and advanced MRI findings of WD involving important neural pathways, as well as to illustrate increasing utility of advanced MRI techniques in providing important prognostic information for various pathologies.

Temporal patterns of 18 F-fluorodeoxyglucose positron emission tomography/computed tomography sinonasal uptake after treatment of sinonasal malignancy

BACKGROUND

Current guidelines have identified 10 to 12 weeks posttreatment as the ideal time-point for improved diagnostic accuracy of positron emission tomography/computed tomography (PET/CT) for deep tissue sites of the head and neck. After treatment, the sinonasal skull base is predisposed to prolonged inflammation that may render this time-point inappropriate for initial posttreatment imaging surveillance for sinonasal malignancies. The purpose of this study is to evaluate temporal trends in ¹⁸ F-fluorodeoxyglucose (¹⁸ FDG) sinonasal uptake after treatment for sinonasal malignancies to better elucidate the optimal time-point for initial PET/CT posttreatment evaluation in this patient population.

METHODS

A retrospective analysis of all successfully treated and non-locally recurrent sinonasal malignancies over a 15-year study period (2000 to 2015) was performed at our institution. Posttreatment ¹⁸ FDG PET/CT standardized uptake value data were collected and compared between various time-points (2 to 4 months, 5 to 12 months, 5 to 24 months, and 13 to 24 months) using an independent-samples t test.

RESULTS

A statistically significant difference was noted between the posttreatment time windows 2 to 4 and 5 to 12 months (p = 0.048) as well as 2 to 4 and 5 to 24 months (p = 0.02). A trend toward significance was seen when comparing 2 to 4 and 13 to 24 months (p = 0.083).

CONCLUSION

Our analysis of PET/CT in patients previously treated for sinonasal malignancy suggests that the posttreatment sinonasal skull base is characterized by a prolonged period of hypermetabolism that endures beyond the period previously described for deep tissue sites of the head and neck. These findings prompt a reevaluation of the previously described 10- to 12-week cutoff point for initial posttreatment PET/CT for head and neck squamous cell carcinoma as applied to sinonasal malignancies.

Utility of fat-suppressed sequences in differentiation of aggressive vs typical asymptomatic haemangioma of the spine

OBJECTIVE

While haemangiomas are common benign vascular lesions involving the spine, some behave in an aggressive fashion. We investigated the utility of fat-suppressed sequences to differentiate between benign and aggressive vertebral haemangiomas.

METHODS

Patients with the diagnosis of aggressive vertebral haemangioma and available short tau inversion-recovery or T2 fat saturation sequence were included in the study. 11 patients with typical asymptomatic vertebral body haemangiomas were selected as the control group. Region of interest signal intensity (SI) analysis of the entire haemangioma as well as the portion of each haemangioma with highest signal on fat-saturation sequences was performed and normalized to a reference normal vertebral body.

RESULTS

A total of 8 patients with aggressive vertebral haemangioma and 11 patients with asymptomatic typical vertebral haemangioma were included. There was a significant difference between total normalized mean SI ratio (3.14 vs 1.48, p = 0.0002), total normalized maximum SI ratio (5.72 vs 2.55, p = 0.0003), brightest normalized mean SI ratio (4.28 vs 1.72, p < 0.0001) and brightest normalized maximum SI ratio (5.25 vs 2.45, p = 0.0003). Multiple measures were able to discriminate between groups with high sensitivity (>88%) and specificity (>82%).

CONCLUSION

In addition to the conventional imaging features such as vertebral expansion and presence of extravertebral component, quantitative evaluation of fat-suppression sequences is also another imaging feature that can differentiate aggressive haemangioma and typical asymptomatic haemangioma.

ADVANCES IN KNOWLEDGE

The use of quantitative fat-suppressed MRI in vertebral haemangiomas is demonstrated. Quantitative fat-suppressed MRI can have a role in confirming the diagnosis of aggressive haemangiomas. In addition, this application can be further investigated in future studies to predict aggressiveness of vertebral haemangiomas in early stages.

Correlation of prenatal and postnatal MRI findings in schizencephaly

BACKGROUND AND PURPOSE

Schizencephaly is a rare malformation of the brain characterized by a gray matter-lined defect extending from the pial surface to the lateral ventricles. The purpose of this study was to correlate imaging findings of schizencephaly and associated anomalies on fetal and postnatal MR imaging and assess possible changes that may occur from the prenatal-to-postnatal state.

MATERIALS AND METHODS

A retrospective review of subjects with schizencephaly who had both pre- and postnatal MR imaging was performed. Subject age, cleft type, number, location, and features of the defects and associated anomalies were recorded. Normalized dimensions of the defect and ipsilateral ventricle were measured and correlated to changes in the clefts between pre- and postnatal imaging.

RESULTS

Ten subjects with 18 clefts (8 bilateral) were included. Most defects (83%) were open on prenatal MR imaging, but 47% of those were found to have subsequently closed on postnatal imaging. Evidence of prior hemorrhage was seen in 83%. Prenatal MR imaging detected all cases of an absent septum pellucidum but detected a fraction of gross polymicrogyria and missed all cases of optic nerve hypoplasia. The normalized ipsilateral ventricular and inner and middle width dimensions of the defects were significantly decreased at postnatal imaging (P < .05). The widths of the defects, ventricular width, and presence of hemorrhage were not predictors of closure of prenatally diagnosed open defects (P > .05).

CONCLUSIONS

In our series, nearly half of prenatally open schizencephaly defects had closed on postnatal imaging. Prenatal MR imaging was only able to demonstrate some of the associated anomalies.

High-resolution 3-T MR imaging of the temporal part of the caudate tail in children

BACKGROUND AND PURPOSE

This study aims to investigate the high-resolution 3-T MRI appearance and morphological variation of the temporal part of the caudate tail in pediatric subjects with normal brain MR examinations.

PATIENTS AND METHODS

One hundred pediatric patients were retrospectively evaluated using a high-resolution 3-T imaging protocol. Different morphological parameters including shape, size, and symmetry were evaluated. The appearance and shape of the caudate tail were classified into nodular, linear, or imperceptible. The location and relation of the caudate tail to the temporal horn and adjacent brain parenchyma were categorized. Relationships between age, gender, shape, location, side, and the cross-sectional area of the caudate tail were investigated.

RESULTS

The caudate tail was imperceptible in 22 %, had a nodular shape in 66.5 %, and was flat in 11.5 %. There was asymmetry of the caudate tail between the two sides in 37 % of subjects. The caudate tail was completely embedded within the temporal lobe parenchyma in 8.3 %, completely protruding into the temporal horn in 27.5 %, or intermediate in 64.1 %. The mean cross-sectional area of the caudate tail was constant across ages despite the varied age range of the subjects. There was no difference in overall mean cross-sectional area of the caudate tail between the two sides.

CONCLUSION

There is a wide variation in the appearance of the caudate tail adjacent to the temporal horn of the lateral ventricle. Identification of anatomical variation of the caudate tail may prevent potential diagnostic pitfalls, especially with respect to subependymal heterotopia.

Imaging findings of patients with metastatic neuroblastoma to the brain

RATIONALE AND OBJECTIVES

Metastatic involvement of brain is rare in neuroblastoma (NB). We retrospectively evaluated conventional and advanced imaging and clinical findings of seven patients with secondary intra-axial brain NB metastases.

MATERIALS AND METHODS

Magnetic resonance imaging and computed tomography examinations of patients with metastatic brain NB were reviewed. Recent iodine-123 metaiodobenzylguanidine ((123)I-MIBG) scans were also reviewed. A medical record review was performed for relevant clinical, laboratory, histopathologic, and genetic data.

RESULTS

Mean age at the time of primary tumor diagnosis was 35 months, and all were considered high-risk NB at diagnosis. Mean time interval between diagnosis and brain involvement was 23.2 months. Extensive prior extra-central nervous system (CNS) disease was present in all patients, but concomitant extra-CNS disease at the time of brain involvement was absent in three (43%) patients. Various forms of disease, including intraparenchymal, intraventricular, and leptomeningeal lesions were detected. Most intraparenchymal lesions were supratentorial and hemorrhagic; however, hemorrhage was absent in multiple leptomeningeal nodules in one patient. Contrast enhancement of lesions was present on all contrast-enhanced studies. Restricted diffusion of lesions was present in two patients. Arterial spin labeling (ASL) perfusion in two patients also revealed increased cerebral blood flow. Recent (123)I-MIBG scans were available in four patients and showed lesions in two patients with larger metastases but failed to demonstrate lesions in another two patients with smaller lesions.

CONCLUSIONS

Brain metastases of NB are often supratentorial and hemorrhagic and demonstrate contrast enhancement. Diffusion-weighted imaging can show restricted diffusion. ASL images may reveal increased perfusion. MIBG scans may not show smaller brain metastases.

CT and MRI of pediatric skull lesions with fluid-fluid levels

Fluid-fluid levels can occur whenever different fluid densities are contained within a cystic or compartmentalized lesion, usually related to the evolution of hematoma or necrosis. Review of the literature demonstrated that throughout the skeletal system, the most common etiology for fluid-fluid levels is aneurysmal bone cyst, but there are no dedicated studies of the pediatric calvaria, to our knowledge. In this report, we present clinicopathologic characteristics and CT and MR imaging of 11 patients with pediatric skull mass lesions demonstrating fluid-fluid levels. MR imaging demonstrated more fluid-fluid levels compared with CT in all cases. The etiologies of skull lesions with fluid-fluid levels were Langerhans cell histiocytosis in 4 (36.6%), aneurysmal bone cysts in 3 (27.2%), cephalohematoma in 3 (27.2%), and metastatic neuroblastoma in 1 (9%). Radiologists should be aware of the other etiologies of calvarial lesions with fluid-fluid levels in the pediatric skull.

Aortic arch vessel anomalies associated with persistent trigeminal artery

Developmental anomalies of the aortic arch vessels and persistent trigeminal artery that is the most common of the four anomalous carotid-basilar anastomoses are repeatedly reported in the literature as separate entities. Herein we report a previously undescribed variant including the coexistence of persistent trigeminal artery, truncus bicaroticus and direct origin of left vertebral artery from aortic arch.

Hydatid cyst of the parotid gland

Primary hydatid cyst of the parotid gland is extremely rare, even in the endemic areas. A 23-year-old woman presented with slowly progressive swelling in the right periauricular region. Computed tomography (CT) scan of the head and neck revealed a round, well-demarcated water-density mass in the right parotid gland. At the operation, the cystic mass replacing most of the superficial part of right parotid gland was demonstrated. Superficial parotidectomy was carried out. Histopathological examination confirmed the diagnosis of hydatid disease. CT scan is a valuable imaging method for diagnosis of parotid cystic lesions; however, other acquired and congenital cystic lesions of parotid gland may have similar appearance and should be differentiated. Where the incidence of the disease is high, hydatid cyst of parotid gland should be considered in the differential diagnosis of lesions causing swelling of the parotid area.

Retroesophageal aortic arch in a patient with pulmonary embolism

The authors report an interesting case of right retroesophageal aortic arch (REAA) with pulmonary embolism that presented like the dissection of the aortic aneurysm but eventually diagnosed by means of spiral CT. Right REAA should be considered as a rare cause of mediastinal widening in the patients in whom significant difference between the blood pressure and pulse intensity of both extremities is evident to prevent the erroneous diagnosis and treatment.

Ultrasonographic assessment of the prevalence of cholelithiasis and biliary sludge in beta-thalassemia patients in Iran

BACKGROUND

Thalassemia is a hereditary disease related to hemoglobin synthesis. The aim of this study was to determine the prevalence of gallbladder sludge and stones in beta-thalassemic children.

MATERIAL/METHODS

One hundred fifty-three beta-thalassemia patients on a long-term transfusion/chelation program were selected by a cluster randomized method and were evaluated ultrasonographically for the presence of sludge and biliary lithiasis. Relationships between the prevalence of gallbladder sludge and stones with age, sex, age at the start and the frequency of transfusion, mean pretransfusion Hb and ferritin levels, age at start of deferoxamine injection, splenectomy, and degree of splenomegaly were evaluated statistically.

RESULTS

Gallstones and biliary sludge were detected in 12.4% and 13.1% of the patients, respectively. There was a significant increase in the prevalence of gallstones with increasing age, transfusion periods of <21 days, severe splenomegaly, splenectomy, and deferoxamine injection started after 5 years of age. Such a relationship was not detected for hemoglobin and ferritin levels. Multiple logistic regression analysis revealed that the frequency of transfusions and age at the start of deferoxamine injections were the only positive factors that predicted the subsequent development of gallstones.

CONCLUSIONS

Longer survival of beta-thalassemic patients leads to a higher prevalence gallbladder sludge and stones. Therefore a proper follow-up of patients with abdominal ultrasonography and improving the transfusion/chelation program should be mandatory.

Foley catheter entrapment resulting from the formation of a true knot in a female infant: sonographic findings

One of the rarest complications of bladder Foley catheter insertion is knotting of the catheter. We present a case of Foley entrapment secondary to formation of a true knot at the proximal end of the catheter in a 6-month-old female infant who was referred to our center for voiding cystourethrograthy. Sonography of the bladder revealed the knotted catheter in the urinary bladder.

Bilateral renal lymphangiomatosis: sonographic findings

Renal lymphangiomatosis is an exceedingly rare disorder characterized by developmental malformation of the lymphatic system surrounding the kidneys. We report a case of bilateral renal lymphangiomatosis in a 21-year-old man who underwent abdominal sonographic examination that revealed numerous cystic areas of various sizes around both kidneys with extension along the renal hilum. Subsequent abdominal CT examination demonstrated bilateral, multilocular, fluid-filled cystic masses with thin walls in the perirenal and peripelvic region. MRI of the patient revealed bilaterally enlarged kidneys with multiple hyperintense lesions in both perirenal spaces and the peripelvic area on T2-weighted images. These cystic spaces appeared hypointense on T1-weighted images with no enhancement in postcontrast images. The diagnosis of renal lymphangiomatosis was made based on typical imaging findings.

Percutaneous transhepatic venous angioplasty and stenting in a 9-month-old patient with hepatic vein obstruction after partial liver transplantation

Hepatic venous outflow obstruction is a rare but serious complication after liver transplantation. We report ultrasound-guided percutaneous transhepatic stent placement in a 9-month-old infant with a left lateral split liver transplantation with near-complete hepatic vein obstruction.

Iatrogenic venous pseudoaneurysm following venipuncture: case report and review of the literature

We report the case of a venous pseudoaneurysm that developed after a venipuncture made during a blood donation in an otherwise healthy 43-year-old man. The patient presented 3 years later with a mass in the antecubital fossa that was successfully treated with surgical resection. The clinical features of this exceptionally rare lesion are discussed.

Methanol poisoning: acute MR and CT findings in nine patients

INTRODUCTION

Methanol poisoning is an uncommon but potent central nervous system toxin. We describe here the CT and MR findings in nine patients following an outbreak of methanol poisoning.

METHODS

Five patients with a typical clinical presentation and elevated anion and osmolar gaps underwent conventional brain MRI with a 1.5-T Gyroscan Interna scanner. In addition nonenhanced CT was performed in another three patients with more severe toxicity.

RESULTS

Bilateral hemorrhagic or nonhemorrhagic necrosis of the putamina, diffuse white matter necrosis, and subarachnoid hemorrhage were among the radiological findings. Various patterns of enhancement of basal ganglial lesions were found including no enhancement, strong enhancement and rim enhancement.

CONCLUSION

A good knowledge of the radiological findings in methanol poisoning seems to be necessary for radiologists. The present study is unique in that it enables us to include in a single report most of the radiological findings that have been reported previously.