CT-guided Native Medical Renal Biopsy: Cortical Tangential versus Non-Tangential Approaches-A Comparison of Efficacy and Safety.

Purpose To review a single-center experience with the cortical tangential approach during computed tomography (CT)-guided native medical renal biopsy and to evaluate its efficacy and safety compared with those of a non-cortical tangential approach. Materials and Methods This retrospective study received institutional review board approval, with a waiver of the HIPAA requirement for informed consent. The number of cores, glomeruli, and complications were reviewed in 431 CT-guided medical renal biopsies performed between July 2007 and September 2015. A biopsy followed a cortical tangential approach if the needle path was parallel to the renal cortical surface, at a depth closer to the renal capsule than the renal pelvic fat. A sample was considered adequate if the biopsy yielded at least 10 glomeruli at light microscopy, one glomerulus at immunofluorescence microscopy, and one glomerulus at electron microscopy. The χ2 test, the t test, the Mann-Whitney test, and logistic regression modeling of sample adequacy were performed. Results One hundred fifty-six (36%) of 431 biopsies were performed with the cortical tangential approach. More cores were obtained for the cortical tangential group (2.6 vs 2.4, P = .001); biopsy needle gauge was not significantly different (P = .076). More adequate samples were obtained in the cortical tangential group (66.7% vs 49.8%, P = .001), with more glomeruli (23 vs 16, P = .014). Results were significant after controlling for needle gauge and number of cores (P = .008). The cortical tangential group had fewer complications (1.9% vs 7.3%, P = .018). Conclusion The cortical tangential approach, when applied to CT-guided native medical renal biopsies, results in higher rates of sample adequacy and lower rates of postprocedural complications. © RSNA, 2016.

Safety of CT-Guided Bone Marrow Biopsy in Thrombocytopenic Patients: A Retrospective Review.

PURPOSE: To test the hypothesis that computed tomography (CT)-guided bone marrow biopsy in patients with a platelet count between 20,000/uL and 50,000/uL is safe and that preprocedure platelet transfusion is unnecessary. MATERIALS AND METHODS: This single-center retrospective study included bone marrow biopsies performed between May 2009 and May 2016. The study population included 981 patients-age range, 15-93 years; average age, 57 years; 505 (51.5%) men; and 476 (48.5%) women. One hundred eighty-seven biopsies were performed in patients with a platelet count of 20,000-50,000/µL; 33 were performed in patients with a platelet count of < 20,000/µL. The primary endpoint was hemorrhagic complications, Society of Interventional Radiology (SIR) complication class C or above. The complication rates in thrombocytopenic patients were compared to patients with a platelet count of ≥ 50,000/uL. Ninety-five percent confidence intervals (CIs) for the complication rate in each group were also calculated. RESULTS: There were no SIR class C or above postprocedure bleeding-related complications, including interventions or transfusions. For patients with a platelet count of < 20,000/µL and of 20,000-50,000/µL, hemorrhagic complications rates were 0% (95% CI: 0-9.1%) and 0% (95% CI: 0-1.6%), respectively. CONCLUSIONS: CT-guided bone marrow biopsy is safe in thrombocytopenic patients, with a hemorrhagic complication rate below 1.6% for patients with a platelet count of 20,000-50,000/µL. Routine preprocedure platelet transfusion may not be necessary for patients with a platelet count of 20,000-50,000/µL.

Fecal Impaction and Nonperforated Stercoral Colitis: Red Flags for Poor Outcomes.

Fecal impaction and stercoral colitis are common, yet little research has been performed on the associated mortality risk. We performed a retrospective cohort study of 970 hospital encounters representing 885 unique patients in which fecal impaction or stercoral colitis was identified in CT reports. Among the 535 patients with fecal impaction, 13.3% died or were discharged to hospice, compared to 13.1% among the 428 patients with nonperforated stercoral colitis (p = 0.93). Of the seven patients with perforation, five died or were discharged to hospice. The risk of death or discharge to hospice for patients with fecal impaction or nonperforated stercoral colitis aged 18-49 was 2.9% and rose approximately 4% each decade thereafter to 21.9% for patients 90 and older (p< 0.001). Patients with a body mass index of 25-30 had an 8.1% risk of death or discharge to hospice, compared to 23.4% for those with a BMI < 18.5 (p< 0.001). Patients with at least one ICD-10 code for dementia, paralysis/neuromuscular disease, or malnutrition/failure to thrive had a risk of death or discharge to hospice of 21.6%, compared to 1.9% among patients with none of these risk factors (p< 0.001). ICD-10 codes for sepsis were associated with 90.0% of the deaths and 44.3% of the discharges to hospice. Patients diagnosed in less than three hours had a risk of death or discharge to hospice of 8.0%, compared to a risk of 20.1% for those diagnosed in ≥ 12 hours (p< 0.001).

Fat-Finding Mission: Primary Pleomorphic Liposarcoma of the Heart and Pericardium.

Primary cardiac liposarcomas are rare tumors with a poor prognosis and no well-defined imaging characteristics or treatment guidelines. Here, we present a case of primary pleomorphic liposarcoma of the heart and pericardium with multimodality imaging findings and our institution's treatment approach. (Level of Difficulty: Intermediate.).

Anomalous Coronary Anatomy with Fistula Diagnosed on Coronary Computed Tomography Angiography.

Anomalous coronary vasculature is a rare finding among the general population. Identifying such cases is important for preventing adverse outcomes such as sudden cardiac death. We present two rare cases of aberrant coronary anatomy. In Case 1, a 4-year-old male who presented with non-exertional chest pain was found to have anomalous coronary architecture on echocardiogram. Coronary computed tomography angiogram (CCTA) confirmed an anomalous origin of the left coronary artery from the right coronary sinus with a malignant interarterial course and myocardial bridging of the left anterior descending (LAD) artery. The patient underwent a successful surgical correction of the defects. In Case 2, a full-term infant female was born with a hypoplastic right ventricle and pulmonary atresia. CCTA showed a large fistula originating from the coronary sinus on the left that drained into the superior aspect of the mid right ventricular cavity, an anomalous bridge between the left and right atrial appendages, and five fistulous connections between various vessels. The patient was transferred to another facility for cardiac transplant.

A Case of Supernumerary Kidney.

A supernumerary kidney is extremely rare, with less than 100 cases currently reported in the literature. When this variant is present, the additional renal parenchyma demonstrates its own collecting system, vascular supply, and distinct encapsulated parenchyma. Herein, we discuss the case of a supernumerary kidney in a 20-year-old male.

Catastrophic Prosthetic Valve Endocarditis Caused by Rare Black Fungi.

Fungal infection of prosthetic heart valves is rare and can lead to severe complications including death. Dematiaceous mold, also known as "black fungi," are an extremely rare cause of endocarditis that usually affect immunocompromised hosts. The infection is usually chronic and can lead to heart failure and embolic complications. These fungi have limited antifungal treatment modalities. We present a rare case of prosthetic aortic valve, root, and graft infection in an immunocompetent host that revealed itself through renal, mesenteric, and cerebral embolic phenomenon. The patient underwent removal and replacement of the aortic graft followed by small bowel resection for mesenteric infarction. Patient had a successful postoperative course and underwent a long-term antifungal treatment with amphotericin B and voriconazole.

Imaging Manifestations of Creutzfeldt-Jakob Disease and Case Series.

Sporadic Creutzfeldt-Jakob disease (CJD) is the most common prion disease, resulting in rapid neurocognitive decline, and is universally lethal. CJD has a confounding clinical presentation with similarities which overlap with many other neurodegenerative disorders. Brain biopsy is the current gold standard; however, less-invasive initial screening tests are also utilized. These include brain magnetic resonance imaging (MRI), electroencephalography (EEG), and cerebrospinal fluid (CSF) laboratory studies. Five patients presented to our facility with varying levels of nonspecific cognitive impairment and movement disorders. CJD was initially suggested after review of each patient's brain MRI. The T2-weighted fluid attenuation inversion recovery and diffusion-weighted images in each case demonstrated varied classic patterns of signal abnormality involving the cortex, basal ganglia, thalami, and brainstem. EEG and CSF studies were confirmatory in three and four patients, respectively (EEG not performed in one patient). One death occurred two months after initial presentation, and the other four patients were transferred to hospice three, four, nine, and 20 months after initial presentation. Radiological evaluation is an invaluable component of the workup for nonspecific neurodegenerative disorders because brain MRI may suggest the initial diagnosis of CJD, as demonstrated in our presented cases. Familiarity with the spectrum of classic MRI findings suggestive of sporadic CJD can improve radiologists' role in early detection of the most common prion disease. Clinicians may benefit from understanding the utility of the newer CSF laboratory studies (Real-time quaking-induced conversion, T-tau, and 14-3-3 protein), which are far less invasive than the gold standard of brain biopsy. Early diagnosis can help save medical resources and guide clinicians to form appropriate plans of care with the patient and family.

Complex Vascular Ring Diagnosed on Cardiovascular MR in a 3-Day-Old Infant.

Prenatal ultrasonography in the early third trimester showed an unusual branching pattern of the right aortic arch. Echocardiography performed 4 h after birth showed the right aortic arch with mirror-image branching, patent ductus arteriosus, and patent foramen ovale. Because the location of the ductus arteriosus was unclear on echocardiography, cardiovascular magnetic resonance imaging was performed 3 days after birth. Advanced techniques including contrast-enhanced time-resolved magnetic resonance angiography and 3D time-of-flight magnetic resonance angiography allowed accurate diagnosis of a vascular ring comprising ascending and descending aorta, right aortic arch with mirror-image branching, and diverticulum of Kommerell giving rise to a left ligamentum arteriosum. The infant had hiccups, but no other symptoms. The esophagram was negative for obstruction. The infant was closely monitored; however, she developed esophageal obstruction at 7 months of age because of the vascular ring. She underwent lysis of the left ligamentum arteriosum followed by aortopexy for relief of esophageal obstruction. This report shows the utility of neonatal cardiovascular magnetic resonance imaging to evaluate complex congenital aortic arch anomalies.

Leukemic Ischemia: A Case of Myocardial Infarction Secondary to Leukemic Cardiac Involvement.

We report a case of a 39-year-old male who presented to the emergency department with acute chest pain while being in remission from T-cell acute lymphoblastic leukemia (T-ALL). Cardiac markers were elevated and EKG revealed ischemic changes compatible with acute myocardial ischemia. Coronary computed tomography angiography (CCTA) showed calcium-free coronary arteries and soft tissue myocardial infiltration suggestive of cardiac leukemia. A bone marrow biopsy confirmed recurrence of T-ALL, and patient was successfully treated with chemotherapy. We discuss the prospective diagnosis of myopericardial leukemic involvement and the role of CCTA in diagnosis and perform a literature review.

Liddle Syndrome in Association with Aortic Dissection.

Liddle syndrome is a rare form of autosomal dominant monogenic hypertension manifested as an early onset of resistant hypertension with either no response or suboptimal response to conventional antihypertensive therapy. If there is a delay in diagnosis, uncontrolled hypertension can lead to end organ damage. To our knowledge, aortic dissection has not been reported in association with this disease. We report a case of a dissecting aortic aneurysm occurring in association with Liddle syndrome.​.

Synovial cutaneous fistula complicating a reverse total shoulder arthroplasty.

Reverse total shoulder arthroplasty is becoming a common form of shoulder arthroplasty that is often performed in the setting of rotator cuff pathology. Infection is a rare complication but is more common in reverse total shoulder arthroplasty than in hemiarthroplasty or anatomic total shoulder arthroplasty. We present the case of a 69-year-old patient with a reverse total shoulder arthroplasty who presented with purulent drainage from the skin of his anterior shoulder. Computed tomography arthrogram confirmed the presence of a synovial cutaneous fistula. Synovial cutaneous fistula is a rare variant of periprosthetic infection that, to our knowledge, has not been described previously in the setting of a reverse total shoulder arthroplasty. Computed tomography arthrogram proved to be a reliable method for confirming the diagnosis and was used for operative planning to remove the hardware.

B-Cell Lymphoma in the Tricuspid Valve.

Lymphoma can involve any organ or tissue that contains lymphoid tissue and the heart is no exception. A few prior case reports have described lymphoma encasing a coronary artery or involving one or more cardiac valves. We present a rare case of diffuse large B-cell lymphoma (DLBCL) involving the tricuspid valve and right coronary artery diagnosed on coronary CT angiography. The clinical and imaging characteristics of cardiac lymphoma are discussed.

Recurrent radiation-induced osteosarcoma of the sternum in a patient with remote radiation therapy for breast cancer.

BACKGROUND: Recurrent radiation-induced osteosarcoma of the sternum following remote radiation therapy for breast cancer and sternal reconstruction. CASE: A 51-year-old woman presents with recurrent, radiation-induced sternal osteosarcoma 11 years after receiving both radiation therapy for breast cancer and sternal reconstruction. The case details both her work-up and subsequent course, including reconstructive and curative efforts. DISCUSSION: An uncommon side effect of radiation therapy for breast cancer is development of osteosarcoma of the chest wall. Even rarer is recurrence of the osteosarcoma following sternal reconstruction.