Neuritis ossificans mimicking a malignancy in a child: case report and literature review.

We present the case of a child with neuritis ossificans after acute trauma, treated conservatively. The aim of the review is to compare several parameters in this disease. Emphasis is placed on the clinical-radiological features distinguishing neuritis ossificans from malignancy to avoid unnecessary biopsy and surgery.A literature review was performed. Only 18 cases were described. Except for one, all describe adults, and none had acute trauma. Nearly all were treated surgically.Our 13-year-old patient presented with posterior knee pain after trauma. MRI demonstrated a mass within the tibial nerve with oedema, some lymph nodes and increased avidity on 18fluoro-2-deoxyglucose-positron emission tomography. These findings can be reactive but also associated with malignancy. However, eggshell-like calcifications in the periphery of the mass were seen on CT. Biopsy and resection were proposed. Follow-up visits over the next weeks showed remarkable clinical improvement. Wait-and-scan was advised after international discussion. Follow-up imaging after 2 months showed resolution of the oedema and volume reduction of the mass, suggesting a benign pathology. Diagnosis of neuritis ossificans was proposed based on the clinical and radiological features. There was a favorable course with no complaints after two months. Imaging after seven months showed an almost complete regression.Neuritis ossificans should be considered within a painfull (mono)neuropathy. The initial inflammatory phase may mimic malignancy, misleading clinicians toward biopsy or surgery with the risk of nerve damage. As seen in our case, neuritis ossificans can be a self-limiting process. Therefore, conservative therapy should be considered with a wait-and-scan approach.

Eye lens dosimetry in anesthesiology: a prospective study.

The eye lens is one of the most sensitive organs for radiation injury and exposure might lead to radiation induced cataract. Eye lens dosimetry in anesthesiology has been published in few clinical trials and an active debate about the causality of radiation induced cataract is still ongoing. Recently, the International Commission on Radiological Protection (ICRP) recommended a reduction in the annual dose limit for occupational exposure for the lens of the eye from 150 to 20 mSv, averaged over a period of 5 years, with the dose in a single year not exceeding 50 mSv. This prospective study investigated eye lens dosimetry in anesthesiology practice during a routine year of professional activity. The radiation exposure measured represented the exposure in a normal working schedule of a random anesthesiologist during 1 month and this cumulative eye lens dose was extrapolated to 1 year. Next, eye lens doses were measured in anesthesiology during neuro-embolisation procedures, radiofrequency ablations or vertebroplasty/kyphoplasty procedures. The eye lens doses are measured in terms of the dose equivalent H p(3) with the Eye-D dosimeter (Radcard, Poland) close to the right eye (on the temple). In 16 anesthesiologists, the estimated annual eye lens doses range from a minimum of 0.4 mSv to a maximum of 3.5 mSv with an average dose of 1.33 mSv. Next, eye lens doses were measured for nine neuro-embolisation procedures, ten radiofrequency ablations and six vertebroplasty/kyphoplasty procedures. Average eye lens doses of 77 ± 76 µSv for neuro-embolisations, 38 ± 34 µSv for cardiac ablations and 40 ± 44 µSv for vertebro-/kyphoplasty procedures were recorded. The maximum doses were respectively 264, 97 and 122 µSv. This study demonstrated that the estimated annual eye lens dose is well below the revised ICRP's limit of 20 mSv/year. However, we demonstrated high maximum and average doses during neuro-embolisation, cardiac ablation and vertebro-/kyphoplasty procedures. With radiation induced cataract being explained as a possible stochastic effect, without a threshold dose, anesthesiologists who regularly work in a radiological environment should remain vigilant and maintain radiation safety standards at all times. This includes adequately protective equipment (protection shields, apron, thyroid shield and leaded eye wear), keeping distance, routine monitoring and appropriate education.

Cone-beam CT to assess bony fusion following anterior cervical interbody fusion.

PURPOSE: Assessment of bony fusion following anterior cervical interbody fusion (ACIF) is usually done by plain film or CT. We present the first clinical application of Cone-Beam CT (CBCT) to evaluate bony fusion after ACIF. METHODS: A 56-year-old man with disc herniation at C6-C7 underwent ACIF surgery using a compressed nanocrystalline hydroxyapatite interbody device (nanOss-C, Pioneer Surgical Marquette, MI, USA) and a nanocrystalline hydroxyapatite bone graft filler (nanOss Bioactive, Pioneer Surgical Marquette, MI, USA). Imaging follow-up was performed by CBCT (NewTom 5G, QR Srl, Verona, Italy) at 1 day, 6 weeks, 3 and 9 months post-operatively. Two independent assessors quantitatively measured the greyscale changes of the bone graft filler and qualitatively evaluated the bony fusion process. RESULTS: Quantitative analysis of the images showed a steadily increasing matrix density of the bone graft filler over the 9 months follow-up, suggesting increasing calcification. Qualitative evaluation demonstrated different stages of the bone fusion process within the disc space around the cage, at the interface between cage and endplates, and at the interface between bone graft filler and the endplates. CONCLUSIONS: CBCT provides high-resolution cross-sectional imaging of the cervical spine after ACIF. For the first time, in vivo evaluation of the bone graft filler within the centre of the circumferentially radiodense cage and detailed cross-sectional evaluation of bone fusion was achieved. Confirmation of these promising outlooks of CBCT in a large cohort of ACIF patients is needed with regard to routine clinical application and evaluation of different interbody devices.

Bilateral anterior choroidal artery infarction presenting with progressive somnolence.

A 55-year-old woman was admitted with a 3 days history of increasing lethargy with bradyphrenia and apathy. She progressively developed severe somnolence with marked abulia, right hemiparesis, right hemianopsia, and pseudobulbar palsy. Brain magnetic resonance imaging showed the rare image of bilateral acute anterior choroidal artery infarction. Pseudobulbar mutism and in rare cases abulia have been described in acute anterior choroidal artery infarction contralateral to an older lesion in mirror position. Although neurologic deterioration is not infrequent in anterior choroidal artery territory infarcts, the absence of focal neurologic signs on admission is rare and did not raise suspicion of acute stroke.

MRI of Paraspinal Gossypiboma: Look for the Barium Sulfate Filament.

Gossypiboma is a rare post-surgical complication comprising a retained surgical gauze surrounded by a foreign body reaction. Although usually presenting on magnetic resonance imaging (MRI) with low T1 signal, high central and low peripheral signal on T2, and bandlike peripheral enhancement, MR appearance is often non-specific. The barium sulphate filament within a surgical gauze presents on MR as a curvilinear thread which is dark on both T1 and T2 sequences. Scrutinizing the MR images is critical to identify the filament and to pinpoint the diagnosis of gossypiboma. Teaching Point: A paraspinal mass on postoperative spine MRI should be carefully searched for a hypointense contorted wire (the barium sulfate filament), as it may be the characteristic finding to evocate the diagnosis of gossypiboma.

Migrating pseudomeningocele causing posterior fossa syndrome.

We present two cases of spontaneous intracerebellar migration of a pseudomeningocele. This is a rarely reported complication of posterior fossa surgery with possible life threatening cerebellar mass effect. The probable mechanism is a slow but progressive cerebrospinal fluid (CSF) movement (one-way valve mechanism) into the pseudomeningocele with secondary herniation or dissection through a weakened dura into the cerebellum causing progressive or acute cerebellar dysfunction. Evacuation and dural repair with or without CSF shunting or marsupialisation results in resolution of the symptoms.

CT-derived measurements of pulmonary blood volume in small vessels and the need for supplemental oxygen in COVID-19 patients.

Throughout the COVID-19 pandemic, a portion of those affected have evolved toward acute hypoxic respiratory failure. Initially, this was hypothesized to result from acute lung injury leading to acute respiratory distress syndrome (ARDS). In previous research, a novel quantitative CT post-processing technique was described to quantify the volume of blood contained within pulmonary blood vessels of a given size. We hypothesized that patients with lower BV5 blood flow would have higher supplemental oxygen needs and less favorable arterial blood gas profiles. From the initial data analysis, 111 hospitalized COVID-19 patients were retrospectively selected based on the availability of CT scans of the lungs with a slice thickness of 1.5 mm or less, as well as PCR-confirmed SARS-CoV2 infection. Three-dimensional (3-D) reconstructions of the lungs and pulmonary vasculature were created. Further analysis was performed on 50 patients. Patients were divided into groups based on their need for oxygen at the time of CT scan acquisition. Eighteen out of 50 patients needed >2 L/min supplemental oxygen and this group demonstrated a significantly lower median percentage of total blood flow in the BV5 vessels compared with the 32 patients who needed <2 L/min supplemental oxygen (41.61% vs. 46.89%, P = 0.023). Both groups had significantly less blood as a proportion in BV5 vessels compared with healthy volunteers. These data are consistent with the hypothesis that reduced blood volume within small (BV5) pulmonary vessels is associated with higher needs for supplemental oxygen and more severe gas exchange anomalies in COVID-19 infections.NEW & NOTEWORTHY This research provides, by using new imaging analysis on CT imaging, an insight into the pathophysiology of patients with COVID-19 infection. By visualizing and quantifying the blood in small vessels in the lung, we can link these results to the clinical need for oxygen in patients with COVID-19 infection.

Peroneal neuropathy after weight loss: a high-resolution ultrasonographic characterization of the common peroneal nerve.

OBJECTIVE: The objective of this study was to use in vivo ultrasonographic imaging to analyze the common peroneal nerve in controls and patients who were diagnosed with peroneal neuropathy (PN) due to significant weight loss. We also looked for a relationship between weight loss (magnitude) and the occurrence of PN. MATERIALS AND METHODS: Fifty controls and six patients who were diagnosed with PN after losing a significant amount of weight were examined by means of ultrasonography (US). On the US images, the structure and reflectivity of the nerve were analyzed. Correlations were made between the ultrasonographic measurements and the body mass index (BMI) of controls. In PN patients, these ultrasonographic parameters were compared between the normal and pathological legs. RESULTS: BMI was positively correlated with the transverse cross-sectional area of the nerve and fibular tunnel in controls. In controls with a high BMI, the peroneal nerve appeared thicker and the US reflectivity of the nerve was higher. A lower US reflectivity was observed in the pathological legs of the six patients who developed PN after weight loss. CONCLUSION: The transverse cross-sectional area and reflectivity of the peroneal nerve on the US images could be viable tools in the diagnosis of PN after weight loss.

Subacute combined degeneration of the cervical and dorsal spinal cord in a 40-year-old male patient: A case report.

Subacute combined degeneration of the spinal cord is a neurologic complication of vitamin B12 deficiency. It presents as a potentially reversible demyelination of the posterior and lateral columns of the cervical and dorsal spinal cord. We present the case of a 40-year-old male with progressive sensory and motor deficit from the lower extremities ascending to the mid-thoracic region. A combination of laboratory tests and magnetic resonance imaging confirmed the diagnosis of subacute degeneration of the spinal cord due to vitamin B12 deficiency.

Intraneural ganglion cyst of the common peroneal nerve causing foot drop in a 12-year old child.

OBJECTIVES: Intraneural ganglia are benign fluid-filled cysts contained within the subepineurial space of peripheral nerves. The common peroneal nerve at the fibular neck is by far the most frequently involved, although other nerves can be affected as well. Although the differential diagnosis of foot drop in adults and children show some differences, clinical presentation, diagnostic workup, treatment and follow-up of intraneural ganglia are quite similar in both groups. The primary objective was to create an overview of intraneural ganglia in children, with an emphasis on diagnostic workup and potential pitfalls during neurosurgical intervention, based on all available literature concerning this topic and own center experiences. As a secondary objective, we tried to raise the awareness concerning this unique cause of foot drop in childhood. PATIENTS AND METHODS: We performed a review of the literature, in which children who developed foot drop secondary to an intraneural ganglion cyst of the common peroneal nerve were examined. A total of eleven articles obtained from MEDLINE were included. Search terms included: "pediatric", "children", "child", "intraneural ganglia", "intraneural ganglion cysts", "foot drop", "peroneal nerve" and "fibular nerve". Additional studies were identified by checking reference lists. Furthermore, we present the case of a 12-year old girl with foot drop caused by an intraneural ganglion cyst. She underwent cyst decompression with evacuation of intraneural cyst fluid and articular branch disconnection. PRISMA and CARE statement guidelines were followed. RESULTS: We hypothesize that minor injury caused a breach in the joint capsule, resulting in synovial fluid egression along the articular nerve branch, corroborating the unifying articular theory and emphasizing the need for ligation of said branch. Foot drop is a predominant characteristic, explained by the proximity of the anterior tibial muscle motor branch near the articular branch nerve. In children, satisfactory motor recovery after surgical decompression is to be expected. CONCLUSION: Sudden or progressive foot drop in children warrants an exhaustive neurophysiological and radiological workup. The management of intraneural ganglia is specific, consisting of nerve decompression, articular branch ligation and joint disarticulation, if deemed necessary. Our surgical results support the unifying articular theory and emphasize the importance of ligation and transection of the articular branch nerve, distally from the anterior tibial muscle branch, in order to prevent intraneural ganglia recurrence. This well-documented case adds depth to the current literature on this sparsely reported entity.

Chest CT Diagnosis of COVID-19: Accuracy using CO-RADS and CT-Involvement Scoring.

OBJECTIVES: Both Reporting and Data System (CO-RADS) and CT-involvement scores (CTIS) have been proposed for evaluation of COVID-19 on chest CT. The purpose of this single-center, retrospective study was to evaluate both scoring systems to diagnose COVID-19 infection in a high-prevalence area. MATERIALS AND METHODS: Chest CT datasets (n = 200) and available reverse transcription polymerase chain reaction (RT-PCR) on nasopharyngeal swab were included. CT scans were assigned to four 'imaging groups' after scoring for both CO-RADS and CTIS. Diagnostic accuracy of chest CT was calculated respectively using RT-PCR and clinical diagnosis as gold standards: False-negatives and false-positives of chest CT regarding RT-PCR were studied in more depth using the medical files. RESULTS: The 'imaging group' including CO-RADS 4/5 scores reached the highest diagnostic values for COVID-19 considering either the initial RT-PCR or the final clinical diagnosis as the standard of reference: accuracies of 172/200 (86%) to 181/200 (90.5%), sensitivities of 60/80 (88.2%) to 70/79 (88.6%), specificities of 112/132 (84.9%) to 111/121 (91.7%), negative predictive values (NPV) of 112/120 (93.3%) to 111/120 (92.5%), respectively. False-negative CTs regarding RT-PCR were mainly explained by imaging very early in the disease course (5 out of 8 cases) or COVID-19 infection with no/minor respiratory symptoms (3 out of 8 cases). CONCLUSION: Assessing chest CT using CO-RADS is a valuable diagnostic approach for COVID-19 infection in a high-prevalence area, with a higher accuracy than CTIS.

Assessment of Small Pulmonary Blood Vessels in COVID-19 Patients Using HRCT.

RATIONALE AND OBJECTIVES: Mounting evidence supports the role of pulmonary hemodynamic alternations in the pathogenesis of COVID-19. Previous studies have demonstrated that changes in pulmonary blood volumes measured on computed tomography (CT) are associated with histopathological markers of pulmonary vascular pruning, suggesting that quantitative CT analysis may eventually be useful in the assessment pulmonary vascular dysfunction more broadly. MATERIALS AND METHODS: Building upon previous work, automated quantitative CT measures of small blood vessel volume and pulmonary vascular density were developed. Scans from 103 COVID-19 patients and 107 healthy volunteers were analyzed and their results compared, with comparisons made both on lobar and global levels. RESULTS: Compared to healthy volunteers, COVID-19 patients showed significant reduction in BV5 (pulmonary blood volume contained in blood vessels of <5 mm2) expressed as BV5/(total pulmonary blood volume; p < 0.0001), and significant increases in BV5-10 and BV 10 (pulmonary blood volumes contained in vessels between 5 and 10 mm2 and above 10 mm2, respectively, p < 0.0001). These changes were consistent across lobes. CONCLUSION: COVID-19 patients display striking anomalies in the distribution of blood volume within the pulmonary vascular tree, consistent with increased pulmonary vasculature resistance in the pulmonary vessels below the resolution of CT.

Fast MR arthrography using VIBE sequences to evaluate the rotator cuff.

PURPOSE: The purpose of this paper was to evaluate if short volumetric interpolated breath-hold examination (VIBE) sequences can be used as a substitute for T1-weighted with fat saturation (T1-FS) sequences when performing magnetic resonance (MR) arthrography to diagnose rotator cuff tears. MATERIALS AND METHODS: Eighty-two patients underwent direct MR arthrography of the shoulder joint using VIBE (acquisition time of 13 s) and T1-FS (acquisition time of 5 min) sequences in the axial and paracoronal plane on a 1.0-T MR unit. Two radiologists scored rotator cuff tendons on VIBE and T1-FS images separately as normal, small/large partial thickness and full thickness tears with or without geyser sign. T1-FS sequences were considered the gold standard. Surgical correlation was available in a small sample. RESULTS: Sensitivity, specificity, and positive and negative predictive values of VIBE were greater than 92% for large articular-sided partial thickness and full thickness tears. For detecting fraying and articular-sided small partial thickness tears, these parameters were 55%, 94%, 94%, and 57%, respectively. The simple kappa value was 0.76, and the weighted kappa value was 0.86 for agreement between T1-FS and VIBE scores. All large partial and full thickness tears at surgery were correctly diagnosed using VIBE or T1-FS MR images. CONCLUSION: Fast MR arthrography of the shoulder joint using VIBE sequences showed good concordance with the classically used T1-FS sequences for the appearance of the rotator cuff, in particular for large articular-sided partial thickness tears and for full thickness tears. Due to its very short acquisition time, VIBE may be especially useful when performing MR arthrography in claustrophobic patients or patients with a painful shoulder.

Glioblastoma with extracranial parotid, lymph node, and pulmonary metastases: a case report.

We present a rare case of an isocitrate dehydrogenase-wildtype glioblastoma with histologically proven parotid, cervical lymph node, and lung metastases. While recent therapy advances are likely to increase glioblastoma mid- and long-term survival, this will also increase the time window for extraneural glioblastoma spread. Radiologists should be aware of this risk, so they can accurately detect and interpret metastatic glioblastoma disease.

Retro-Odontoid Pseudotumor in a Patient with Atlanto-Occipital Assimilation.

A retro-odontoid pseudotumor is an uncommon non-neoplastic mass. They are mostly associated with rheumatoid arthritis and atlanto-axial subluxation. The pathogenesis is degeneration of the transverse ligament due to chronic mechanical stress. In this case report, an atlanto-occipital assimilation altered the biomechanics of the cervical spine, causing chronic mechanical stress on the transverse ligament and subsequently the development of a retro-odontoid pseudotumor. This is in accordance with previous studies that have attributed the development of retro-odontoid pseudotumor to a loss of mobility of the cervical spine, in cases without associated rheumatoid arthritis or atlanto-axial subluxation.

Imaging of Soft Tissue Tumors in the Pediatric Patient.

The presence of a soft tissue mass in children is of concern to parents and physicians. Fortunately, these masses are rare and usually benign or pseudotumoral. When dealing with malignant soft tissue tumors, therapeutic options and long-term survival are strongly related to the disease stage at the time of diagnosis. Therefore, when children present with indeterminate or persisting symptoms and posttraumatic, metabolic, or infectious disorders have been ruled out, one should perform dedicated imaging studies (conventional radiography, computed tomography [CT], or both; sonography; magnetic resonance [MR] imaging) to exclude the possibility of a nonpalpable soft tissue mass or to characterize the mass when present. An overview of the use of the different imaging modalities for evaluating soft tissue tumors in the pediatric patient is presented. Because of the numerous benign, malignant, and pseudotumoral soft tissue masses that are often encountered in children, clinical, histologic, and imaging features are presented as concise tables.

Dynamic magnetic resonance guided treatment of developmental dysplasia of the hip.

This study demonstrates the feasibility and advantages of near real-time, multiplanar, dynamic magnetic resonance image-assisted treatment of patients with developmental dysplasia of the hip. Pathoanatomy and dynamic blocks to reduction are visualized with anatomic clarity not otherwise possible. Continuous imaging allows accurate assessment and maintenance of optimum positioning throughout the casting procedure. Patient charges for this new technique are less than standard methods of treatment, and the child receives no ionizing radiation.

Interventional musculoskeletal procedures performed by using MR imaging guidance with a vertically open MR unit: assessment of techniques and applicability.

PURPOSE: To evaluate the safety of and time required for a broad range of musculoskeletal interventional procedures performed by using magnetic resonance (MR) imaging guidance with a vertically open 0.5-T unit. MATERIALS AND METHODS: Sixty-three MR imaging-guided procedures were performed. A vertically open MR unit equipped with in-room display monitors allowed interactive freehand MR guidance predominantly with fast spin-echo and gradient-echo sequences. Each procedure was classified in terms of the anatomic location, procedure type, and tissue type involved. The procedures were evaluated for success of needle placement, adequacy of tissue sampling, total procedural time, needle time, number of needle passes, and complications. RESULTS: Procedures consisted of tissue sampling with core-needle (n = 6) or fine-needle aspiration (n = 20) biopsy, corticosteroid or contrast agent injection (n = 19), joint cyst aspiration (n = 7), and drainage (n = 11). Successful needle placement was achieved in all 63 cases. Cytologic and histologic tissue samples were sufficient for pathologic diagnosis in 24 of 26 cases. In two cases, complications occurred: transient local bleeding and a brief vasovagal episode. The mean total procedural time was 64.8 minutes; the mean needle time, 26.2 minutes; and the mean number of needle passes per patient, 1.6. CONCLUSION: With use of a vertically open MR unit, MR-guided interventional procedures involving bone, soft tissue, intervertebral disks, and joints are safe and sufficiently rapid for use in clinical practice.

Subchondral fractures in osteonecrosis of the femoral head: comparison of radiography, CT, and MR imaging.

OBJECTIVE: Our objective was to compare the sensitivity of unenhanced radiography, CT, and MR imaging in revealing subchondral fractures. SUBJECTS AND METHODS: Forty-five subjects with stage I and stage II osteonecrosis of the femoral head were included in the study as part of a multicenter clinical trial to evaluate the effectiveness of recombinant human bone morphogenetic protein as an adjuvant treatment to core decompression. Patients were evaluated with radiography, CT, and MR imaging 6 and 12 months after surgery. RESULTS: At 6 months, 18 fractures were shown on CT scans, but only 12 were detected on radiographs and six, on MR images. At 12 months, 20 subchondral fractures were detected on CT scans, but only 17 were seen on radiographs and 11, on MR images. Compared with CT, MR imaging has a sensitivity and specificity of 38% and 100%, and unenhanced radiography has a sensitivity and specificity of 71% and 97%, respectively. On T2-weighted MR images, the subchondral fractures were visualized as crescentic high-signal-intensity lines, and in all patients, on the corresponding CT scans, the fracture clearly breached the femoral cortex. CONCLUSION: CT reveals more subchondral fractures in osteonecrosis of the femoral head than unenhanced radiography or MR imaging. The high-signal-intensity line seen on T2-weighted MR images appears to represent fluid accumulating in the subchondral fracture, which may indicate a breach in the overlying articular cartilage.