Hepatic Encephalopathy Secondary to Non-cirrhotic Portosystemic Shunt.

Hepatic encephalopathy is uncommon in the absence of cirrhosis. We report a 71-year-old woman who presented with altered mental status in the setting of hyperammonemia for the second time in 6 months. Magnetic resonance imaging of the abdomen revealed an uncommon portosystemic shunt involving an enlarged posterior branch of the right portal vein and an accessory right hepatic vein, with no features of cirrhosis. Appropriate management of these patients with ammonia-lowering therapy can reduce repeat episodes and improve quality of life. This case demonstrates the importance of diagnosing non-cirrhotic hepatic encephalopathy in patients with altered mental status.

Staged repair of concomitant rectovaginal fistula and pelvic organ prolapse after removal of a neglected pessary.

Rectovaginal fistulas are a rare complication of neglected pessaries and can pose challenges in managing pelvic organ prolapse. We describe a 66-year-old woman with uterine procidentia who presented with a neglected Gellhorn pessary in place for 5 years. She complained of constipation and persistent vaginal bulge. On examination, the pessary stem eroded through the mid-posterior vaginal wall and anterior rectal wall. Staged surgical treatment included (1) pessary removal and development of ileostomy, (2) rectovaginal fistula repair, and (3) vaginal hysterectomy, uterosacral ligament suspension, and ileostomy reversal. Short-term follow-up did not demonstrate evidence of fistula or recurrence of prolapse. Rectovaginal fistulae resulting from neglected pessaries pose challenges in managing concomitant vaginal prolapse. A staged approach to fistula and prolapse repair is possible with the potential for good outcomes.

Giant cell tumor of the talus: A case report.

Giant cell tumor is a benign primary bone neoplasm which most often occurs in a periarticular location. Involvement of the bones of the foot and ankle is rare, and there have been a limited number of previous case reports involving the talus. Here we report a case of giant cell tumor of the talus, which was initially radiographically occult in a 43-year-old female, with emphasis on MRI imaging characteristics. The patient underwent surgical excision and curettage. Histological examination revealed the presence of spindle cells admixed with giant cells, confirming GCT. We further provide an overview of the radiological findings of GCT. Giant cell tumor is a benign bone neoplasm of mesenchymal origin, identified by multinucleated giant cells [1]. GCT is locally aggressive and can destroy adjacent bone and articulations. The most commonly affected bones are the distal femur, proximal tibia, and distal radius, with an epiphyseal predominance in 90% of cases [2]. Presentations are mostly mono-ostotic, however multicentricity may occur in younger patients [3]. Very few cases have been reported in the bones of the feet, an incidence of 1%-2% have been previously reported [4]. GCT is seen between ages 20 and 40 years, with a 56% predominance in females [3]. Although benign, 1%-9% cases may "metastasize" to the lungs. The initial treatment is surgical removal, either en bloc, or more commonly intralesional curettage and the use of adjuvants. Even after resection, GCT has a high recurrence rate [2]. The trigger for GCT is currently unknown. However, a majority of cases have cytogenetic abnormalities of telomeric associations (tas). Involvement of the RANK pathway is also believed to contribute to the pathogenesis of GCT [2].

Digital imaging evaluation of the scapula for prediction of endosteal implant placement in reconstruction of oromandibular defects with scapular free flaps.

OBJECTIVE: Dental implant placement in scapular free flaps is challenging. This study examines the scapula with computed tomography to identify ideal locations for predictable implant placement during preoperative planning. METHODS: Sixty-eight adult patient chest CT scans (34 men, 34 women) captured for various medical indications, were analyzed for age, height, weight, and scapula length. The lateral border of the scapula was divided into six equal segments; the midpoints of each segment (labeled proximally to distally as 1M-6M) were analyzed in cross-section as potential recipient sites for 3.5 × 8 mm implants. Also, we present a case of a 77-year-old male with ameloblastoma of the mandible who underwent patient specific planning and received a scapular free flap with dental implant placement. RESULTS: There was greater bone availability in males with a mean depth of 8.3 ± 2.8 versus 5.1 ± 3.3 mm in females (p < .01). The proximal portion (1M) of the scapula in males and females had depths of 11.3 ± 1.5 and 9.5 ± 2.3 mm, respectively. Males had depths of 8.4 ± 3.0 in M3, 9.7 ± 1.7 in M4, and 8.9 ± 1.2 mm in M6. Depth of bone available for patients with heights ≥165 cm versus <165 cm had means of 10.4 ± 1.3 and 8.0 ± 1.6 mm (p < .01), respectively; but showed no significant differences between BMI (BMI <25 vs. ≥25) and bone availability (6.8 ± 1.7 vs. 6.8 ± 1.6, p = .07), or age (<55 years vs. ≥55 years) and bone availability (9.8 ± 1.6 vs. 9.8 ± 1.6, p = .11). In our case, the patient received 6 cm length of scapular bone with four 4.1 × 14 mm endosteal implants, which upon osseointegration was able to receive a fixed dental prosthesis. Three years after the initial surgery, the patient has had no difficulty with his prosthesis. CONCLUSION: In females the most proximal portion of the scapula will predictably accommodate a dental implant, while males have multiple sites including the proximal, middle, and distal portions.

Core curriculum illustration: acute traumatic aortic injury.

This is the 34th installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at http://www.aseronline.org/curriculum/toc.htm .

Developing Trans-Affirming Health Services in an Underserved Area: An Intersectional Approach.

Purpose: Gender-nonconforming patients are at higher risk for medical problems that require prompt medical and mental health intervention. Barriers to healthcare for transgender individuals have been well characterized in the literature, but not in low resource settings. The purpose of this paper is to present the barriers encountered when bringing healthcare to transgender children, adolescents, and adults in a medically underserved, predominantly Hispanic area of the United States. Methods: In this medically underserved area on the U.S.-Mexico border, there is a severe shortage of medical expertise for transgender individuals at both the primary- and specialty-care levels. Further, given the mainly Hispanic population, there is an additional culturally based barrier to obtaining medical care for transgender patients. Results: It is important for academic centers in these regions to collaborate to overcome these barriers through a multidisciplinary approach that includes providing education for medical students and physicians in training and identifying medical providers who are able and willing to provide transgender-competent care adapted to local culture and gender norms. Conclusion: In this manuscript, we will describe the efforts of various groups to address the needs of the transgender community in the region.

Imaging of endoscopic cystogastrostomy in pancreatic walled-off necrosis: what the radiologist needs to know.

Acute pancreatitis is a frequent entity encountered by radiologists. In 2012, the Atlanta criteria were revised to help radiologists use a common nomenclature when describing acute pancreatitis and its complications. One delayed complication of acute necrotizing pancreatitis in walled-off necrosis, a collection seen at least 4 weeks after an episode of acute pancreatic necrosis and/or acute peripancreatic necrosis. Multiple treatments have been adapted in the setting of walled-off necrosis, including endoscopic cystogastrostomy. The focus of this article is to familiarize the radiologist with the imaging appearance of this procedure as well as, review the outcomes and potential complications of endoscopic cystogastrostomy.

Intermetatarsal bursa primary synovial chondromatosis: case report and review of the literature.

Primary synovial chondromatosis is a benign neoplastic process, occurring mostly in large joints, more rarely in tendon sheaths, and extremely uncommonly in bursae. We describe a patient with primary synovial chondromatosis arising in the fourth intermetatarsal bursa. Knowledge of the bursal anatomy of the forefoot, and of characteristic imaging findings and the pathogenesis of synovial chondromatosis, is essential in including this uncommon entity in the differential when occurring in unusual locations.

Spontaneous Rupture of the Uterine Artery in an Otherwise Normal Pregnancy.

Spontaneous rupture of a uterine artery in pregnancy is associated with a high rate of mortality. Although uterine artery rupture has been associated with postpartum hemorrhage, it is rarely found during pregnancy. Unfortunately, clinical signs and symptoms are usually vague and nonspecific. We report a case of a 36-year-old woman at 20 weeks gestation presenting with abdominal pain who was found to have a spontaneous uterine artery rupture. To our knowledge, this is the first case report demonstrating imaging findings in a patient with this condition. Our patient underwent successful ligation of the uterine vessel with preservation of both mother and fetus. We will discuss possible etiologies of uterine artery rupture during pregnancy, associated imaging findings, and management options.

Inferior vena cava thrombus secondary to blunt abdominal trauma.

A 15-year-old female presented to the emergency department of a level 1 trauma centreafter being involved in a high-speed motor vehicle accident. The patient underwent a contrast-enhanced CT scan of the abdomen and pelvis obtained with a 60-70 s delay as part of the institution's polytrauma protocol. The CT scan demonstrated multiple hepatic lacerations and a filling defect in the suprahepatic inferior vena cava adjacent to the cavoatrial junction. Inferior vena cava thrombus secondary to blunt abdominal trauma is extremely rare, and to our knowledge, this is the first reported case of acute thrombus diagnosed by CT at the time of initial injury. There is limited literature on management of this entity. Possible treatments range from conservative approaches to anticoagulation and placement of IVC filters.

Comparative Outcome of Computed Tomography-guided Percutaneous Radiofrequency Ablation, Partial Nephrectomy or Radical Nephrectomy in the Treatment of Stage T1 Renal Cell Carcinoma.

Renal cell carcinoma (RCC) accounts for 3% of all cancers in adults. The indications for Radiofrequency Ablation (RFA) for renal carcinomas include T1a (tumor 4 cm or less, limited to the kidney), elderly patients, renal impairment, comorbidities, poor surgical candidate, and multiple bilateral renal masses. We retrospectively reviewed medical records, specifically investigating the indications, complications and outcomes of RFA and nephrectomy for treatment of RCC in a tertiary medical center with a predominantly Hispanic patient population. Forty-nine patients with RCC were evaluated. Nine patients had RFA, 9 had partial nephrectomy and 31 had radical nephrectomy. All patients among the 3 groups had stage T1N0M0 RCC at diagnosis. Tumor recurrence was observed in 2 (22%) patients that had RFA, one (11%) patient that had partial nephrectomy and no patients that had radical nephrectomy. One patient had recurrence of the tumor at the opposite kidney pole from the initial RFA site 4 years later. This particular patient did not have any tumor recurrence at the site of the initial RFA. A second RFA was performed on the recurrent tumor with no recurrence upon subsequent follow up visits. The second patient had recurrence of the RCC on 1 year follow that was discovered to be sarcomatoid RCC, which is an aggressive type with a poor prognosis. Our results support the clinical utility of RFA in patients with stage T1 RCC who are poor surgical candidates or those with reduced renal function. The clinical utility of RFA as an equally effective approach when compared to partial nephrectomy in patients with stage T1 RCC that meet strict indications for the procedure. The treatment choice should be individualized and based on the characteristics of the renal tumor such as size, location and histological type of RCC. We conclude that RFA presents a safe treatment choice for patients with RCC if long term follow up is maintained.

Coccidioidomycosis osteomyelitis of the knee in a 23-year-old diabetic patient.

Coccidioidomycosis is a pulmonary infection caused by the dimorphic fungi Coccidioides immitis and Coccidioidomycosis posadasii. This disease is endemic to the southwestern United States and has a predilection for immunocompromised patients. Diabetes mellitus has been shown to be a strong risk factor for acquiring this infection in these states. Most cases are asymptomatic or present with mild pulmonary symptoms. However, untreated pulmonary mycosis can lead to disseminated infection, most often involving meningitis, osteomyelitis, or skin and soft-tissue infections. When there is arthritis, the knee is the most common site of infection. We present a case of a 23-year-old male with longstanding, uncontrolled Type 1 diabetes mellitus who was found to have pulmonary coccidioidomycosis following diagnosis of coccidioidomycosis osteomyelitis of the knee.

Dual-energy computed tomography imaging of the aorta after endovascular repair of abdominal aortic aneurysm.

Endovascular repair is increasingly considered a less-invasive alternative to open repair of abdominal aortic aneurysm. However, there are still many potential complications of endovascular repair, including endoleaks, graft migration, thrombosis, and fistula formation. Endoleak is the most common complication for which these patients undergo long-term imaging surveillance. Most centers acquire computed tomographic (CT) data before contrast administration and during an arterial and delayed phase of aortic enhancement after the administration of intravenous contrast material to optimize detection of endoleaks. Although this technique works well, the downside is significant patient radiation exposure. Although the carcinogenic risk of ionizing radiation because of CT exposure is low, it has been linked to an increase in the lifelong risk of developing fatal cancers. Furthermore, this risk is cumulative and increases with multiple radiation exposure, as is true in surveillance after endovascular repair. As a result, considerable research is being performed to optimize CT protocols in an effort to decrease radiation dose. One such approach is to image these patients with recently introduced dual source dual-energy CT system. Using this technique, virtual noncontrast data may be generated from a postcontrast acquisition which may obviate the routine acquisition of noncontrast acquisition, thus decreasing radiation dose. In this article, we discuss the role of dual energy CT imaging in evaluation of patients after endovascular repair of abdominal aortic aneurysm.

Pelvic cake kidney drained by a single ureter associated with unicornuate uterus.

The pelvic cake kidney in which there is complete fusion of both kidneys into a single renal parenchymal mass has been described as the rarest of renal fusion anomalies. Pelvic cake kidney most commonly drains via 2 separate ureters, with fewer than 10 reports demonstrating a cake kidney drained by a single ureter. We present the first ever reported case of a pelvic cake kidney drained by a single ureter in association with a unicornuate uterus. These findings were identified in a young female patient who underwent pelvic magnetic resonance imaging for pelvic pain.

Significance of missed polyps at CT colonography.

OBJECTIVE: Our purpose was to determine the clinical significance of polyps missed on CT colonography using histologic analysis and the natural history of colorectal polyps and to propose guidelines for follow-up colon surveillance based on CT colonographic findings. SUBJECTS AND METHODS. One hundred eighty-six men (age range, 40-87 years; mean, 62.3 years) underwent CT colonography immediately before conventional colonoscopy. All polyps detected on CT colonography were measured and imaged, and their segmental location was documented. All polyps detected on colonoscopy were measured, photographed, biopsied, and histologically analyzed. Results of CT colonography and conventional colonoscopy were compared with the final pathology reports. Conventional colonoscopy was used as the gold standard unless CT colonography showed a lesion measuring 10 mm or more that was not detected on conventional colonoscopy and had characteristics of a polyp. In these cases, follow-up conventional colonoscopy was offered. RESULTS: One hundred ninety-one polyps were detected on conventional colonoscopy. CT colonography prospectively detected 53 polyps. Histologic analysis of the polyps not detected on CT colonography showed that of those 5 mm or smaller, 58.1% were not adenomas, and of those measuring 6-9 mm, 42.8% were not adenomas. Both missed polyps at CT colonography of 10 mm or more were adenomas. Of the 22 polyps measuring 10 mm or more, three were not detected on conventional colonoscopy. Of these three, CT colonography showed a lesion having characteristics of a polyp, follow-up endoscopy confirmed the presence of the lesion, and histologic analysis showed a villous adenoma, a tubulovillous adenoma, and a tubular adenoma. CONCLUSION: If CT colonography shows no abnormality, follow-up screening in 5 years is recommended. If CT colonography detects a lesion smaller than 5 mm, follow-up imaging in 3-5 years is recommended. If CT colonography detects a lesion measuring 6 mm or more, endoscopy and polypectomy should be offered unless contraindicated.

Positional change in colon polyps at CT colonography.

PURPOSE: To determine the frequency with which polyps change positions with respect to the bowel surface and the cause of this movement. MATERIALS AND METHODS: From December 2001 to March 2003, 113 patients underwent computed tomographic (CT) colonography prior to colonoscopy. For all confirmed polyps that were 5 mm and larger, images obtained with CT colonography were retrospectively analyzed by one author to determine if the polyp was present on both data sets or on only one data set. Retrospective evaluation of these polyps for ventral or dorsal location within the colonic lumen was performed for data sets obtained with patients in the prone and the supine position. The data sets were further reviewed by another author to determine the cause of positional change, when present. RESULTS: Twenty-six patients had a total of 49 histologically proved colorectal polyps that were 5 mm and larger. Eight of 49 colorectal polyps were depicted only on images obtained with the patient in the supine or prone position. Of the remaining 41 polyps that were depicted on images obtained with the patient in the supine and the prone position, 11 moved from a dorsal to a ventral location or vice versa relative to the colonic surface when the patient changed position. Five of these polyps were pedunculated on a stalk. Six were sessile; two were located in the sigmoid colon, two in the transverse colon, one in the ascending colon, and one in the cecum. In these cases, polyp mobility was related to positional changes of the colon in the mesentery, as opposed to true mobility of the polyp. CONCLUSION: In this series, 27% of polyps moved from a ventral location to a dorsal location relative to the colonic surface when the patient was turned from the supine to the prone position; thus, polyps appeared to be mobile. Thus, a mobile filling defect cannot be assumed to be residual fecal material at CT colonography.

FRS2 family docking proteins with overlapping roles in activation of MAP kinase have distinct spatial-temporal patterns of expression of their transcripts.

FRS2alpha and FRS2beta, two members of the FRS2 family of docking proteins, become tyrosine phosphorylated in response to fibroblast growth factor (FGF) or nerve growth factor (NGF) stimulation. Tyrosine phosphorylated FRS2alpha serves as a platform for the recruitment of multiple signaling proteins for activation of the Ras-mitogen-activated protein (MAP) kinase signaling cascade. We report that Frs2alpha and Frs2beta have distinct spatio-temporal expression patterns in mouse embryos. We further show that FRS2beta can compensate for the loss of FRS2alpha for activation of MAP kinase when expressed in fibroblasts from Frs2alpha(-/-) mouse embryos. We propose that the FRS2 family proteins have distinct roles in vivo through activation of common signaling proteins including MAP kinase.