Atraumatic bilateral scapular spine fracture several months after bilateral reverse total shoulder arthroplasty.

We report an 89-year-old woman with bilateral atraumatic scapular spine fracture several months after bilateral reverse total shoulder arthroplasty (RTSA). Recently, RTSA has gained popularity in the surgical treatment of complex shoulder disorders such as cuff tear arthropathy. However, scapular fractures may occur several months after surgery as a late complication of this procedure. In this case report we focus on a relatively uncommon subtype, the scapular spine fracture. Although well-known in the orthopedic literature, radiologists are less familiar with this complication. To the best of our knowledge, bilateral scapular fractures have not yet been reported.

Conservative Treatment of a Floating Mural Thrombus in the Descending Aorta.

A 70-year-old woman was referred to the department of thoracic and vascular surgery after a floating mural thrombus was found in the distal aortic arch with extension into the proximal descending aorta. Imaging and clinical examination did not show signs of embolization and treatment with aspirin and low-molecular weight heparin was started. Follow-up after 2 weeks and 6 months showed a complete resolution of the aortic mural thrombus.

The Brain-Heart Link: A Case Report of a Critically Located Multiple Sclerosis Lesion in the Brainstem Leading to Recurrent Takotsubo Syndrome.

Various central nervous system (CNS) diseases, including neurovascular and neuroinflammatory diseases, can lead to stress cardiomyopathy, also known as Takotsubo syndrome (TTS). We present a case of a 69-year-old woman with cardiovascular comorbidities, suffering from repeated episodes of TTS and respiratory failure due to a critical lesion in the brainstem, leading to a diagnosis of multiple sclerosis (MS). Despite aggressive treatment, intractable and recurrent symptoms in our patient occurred. Repeated bouts of autonomic dysfunction and respiratory failure ultimately led to installment of palliative care and the patient passing away. TTS should raise suspicion for underlying neurological diseases. Thorough questioning of previous neurological symptoms and extensive neurological workup is warranted. MS should be considered as a trigger of TTS also in elderly patients with cardiovascular risk factors.

Correlation Between Apparent Diffusion Coefficient Value on MRI and Histopathologic WHO Grades of Neuroendocrine Tumors.

BACKGROUND: The correlation of diffusion-weighted MRI and tumor aggressiveness has been established for different tumor types, which leads to the question if it could also apply for neuroendocrine tumors (NET). PURPOSE: To investigate the possible correlation between apparent diffusion coefficient (ADC) value on magnetic resonance imaging (MRI) and histopathologic WHO-grades of NET. MATERIAL AND METHODS: Electronic patient records from patients presented at the multidisciplinary neuro-endocrine tumor board between November 2017 and April 2019 were retrospectively reviewed. Patients with both available MR imaging (primary tumor or metastasis) and known WHO tumor grade were included (n = 47). Average and minimum ADC values (avgADC; minADC) were measured by drawing a freehand ROI excluding only the outermost border of the lesion. The largest axial size (primary tumor) or most clearly delineated lesion (metastasis) was used. RESULTS: Forty seven patients met the inclusion criteria (mean age 59 ± 12 SD; 24F/23M). Twenty one patients (45%) were diagnosed with WHO G1 tumor, 17 seventeen with G2 (36%) and nine with G3 (19%) tumor. Twenty eight primary tumors and 19 metastases were measured. A significant difference was found between low-grade (G1+G2) and high-grade (G3) tumors (Mann-Whitney; avgADC: p < 0,001; minADC: p = 0,001). There was a moderate negative correlation between WHO-grade and avgADC/minADC (Spearman; avgADC: -0,606; 95% CI [-0,773; -0,384]; minADC: -0,581; 95% CI [-0.759; -0.353]). CONCLUSION: Our data show a significant difference in both average and minimum ADC values on MRI between low and high grade NET. A moderate negative correlation was found between histopathologic WHO grade and ADC value.

Diagnostic and clinical features of lung cancer associated with cystic airspaces.

"Lung cancer associated with cystic airspaces" is an uncommon manifestation, in which lung cancer presents on imaging studies with a cystic area with associated consolidation and/or ground glass. With the widespread use of computed tomography (CT), both in clinical practice and for lung cancer screening, these tumors are being more frequently recognized. An association of this entity with smoking has been established with the majority of cases reported being in former and current smokers. The true pathogenesis of the cystic airspace is not yet fully understood. Different causes of this cystic airspace have been described, including a check-valve mechanism obstructing the small airways, lepidic growth of adenocarcinoma on emphysematous lung parenchyma, cyst formation of tumor and tumor growth along the wall of a pre-existing bulla. Adenocarcinoma is the commonest histological type, followed by squamous cell carcinoma. Two classification systems have been described, based on morphological features of the lesion, taking into account both the cystic airspace as well as the morphology of the surrounding consolidation or ground glass. The cystic component may mislead radiologists to a benign etiology and the many different faces on imaging can make early diagnosis challenging. Special attention should be made to focal or diffuse wall thickening and consolidation or ground glass abutting or interspersed with cystic airspaces. Despite their atypical morphology, staging and management currently are still similar to that of other lung cancer types. Although the rarity of this entity will hamper larger studies, numerous aspects regarding this particular lung cancer type still need to be unraveled. This manuscript reviews the CT-imaging findings and gives an overview of available data in the English literature on pathogenesis, histopathology and clinical findings. Differential diagnosis and pitfalls are discussed as well as future directions regarding staging and management.

Lesion measurement on a combined "all-in-one" window for chest CT: effect on intra- and interobserver variability.

PURPOSE: A newly developed image processing technique fuses conventional windows into a single 'All-In-One' (AIO) window. This study aims to evaluate variability of CT measurement of lesions in thoracic oncology patients on this novel AIO-window. METHODS: Six radiologists with different levels of expertise measured 368 lesions of various size, origin and sharpness. All lesions were measured twice on the AIO-window and twice on the conventional window settings. Intraclass correlation coefficients and Bland-Altman plots were used to assess intra- and interobserver variability. RESULTS: Overall intra-observer agreement for lesion diameters on the AIO-window and conventional window settings was 0.986 (95% Confidence interval (CI): 0.983-0.989) and 0.991 (95% CI 0.989-0.993) respectively. For interobserver agreement this was 0.982 (95% CI 0.979-0.985) (AIO) and 0.979 (95% CI 0.957-0.982) (conventional). For both the AIO and conventional windows, intra- and interobserver agreement were dependent on size, sharpness and reader experience. Measurement variability decreased with increasing lesion size. Regarding sharpness, inter- and intra-observer agreement ranged from 0.986-0.989 (AIO) and 0.985-0.992 (conventional) for well-defined lesions and from 0.978-0.983 (AIO) and 0.974-0.991 (conventional) for ill-defined lesions. CONCLUSIONS: Lesion diameters were consistently smaller on the AIO-window compared to conventional window settings. Overall intra- and interobserver variability rates were similar for the AIO-window and conventional window settings. We conclude that the AIO-window offers a reliable and reproducible alternative for measurement of thoracic lesions.

CT imaging features of atrioventricular shunts: what the radiologist must know.

UNLABELLED: In the last decade, cardiac computed tomography (CT) has gained mainstream acceptance for the noninvasive exclusion of significant coronary disease in a selected population. Improvements in electrocardiogram (ECG)-triggered imaging techniques also allow, by extension, a proper evaluation of the complete heart anatomy. Given the increasing worldwide clinical implementation of cardiac CT for coronary artery evaluation, radiologists can, incidentally, be confronted with unfamiliar and previously unsuspected non-coronary cardiac pathologies, including congenital morphological defects. This presence of congenital heart disease (CHD) should not be overlooked, being the most common form of birth defect, with a total birth prevalence of 9.1 per 1000 live births worldwide [1]. The prevalence of adult patients with CHD is estimated to be 3000 per million adults [2]. Ventricular septal defects (VSDs) are the most frequent subtypes of CHD, accounting together with atrial septal defects (ASDs) for nearly half of all CHD cases [1]. While some small defects are rarely symptomatic and can go undetected for life, others are clinically significant and require adequate and timely medical intervention. In this article, we present the CT imaging features of atrioventricular (AV) shunts, highlighting both their embryological origins and associated relevant clinical features. TEACHING POINTS: • Congenital heart disease (CHD) is the most common birth defect. • Ventricular and atrial septal defects account for nearly half of CHD cases. • Atrioventricular defects can frequently be detected on a cardiac CT. • Radiologists must be able to identify clinically significant atrioventricular defects.

Aberrant internal carotid artery presenting as a retrotympanic vascular mass.

We report a case of a young woman with an aberrant right internal carotid artery (ICA) presenting as a retrotympanic reddish mass. This variant of the ICA represents the collateral pathway that is formed as a result of an embryological agenesis of the cervical segment of the ICA. The embryonic inferior tympanic artery is recruited to bypass the absent carotid segment. This hypertrophied vessel may be seen otoscopically and wrongfully considered to be a vascular middle ear tumor. Informing the otorhinolaryngologist of this important vascular variant not only obviates biopsy but also helps in careful preoperative planning of eventual middle ear procedures.

A case of a temporal bone meningioma presenting as a serous otitis media.

We report the imaging features of a case of a temporal bone meningioma extending into the middle ear cavity and clinically presenting as a serous otitis media. Temporal bone meningioma extending in the mastoid or the middle ear cavity, however, is very rare. In case of unexplained or therapy-resistant serous otitis media and a nasopharyngeal tumor being ruled out, a temporal bone computed tomography (CT) should be performed. If CT findings are suggestive of a temporal bone meningioma, a magnetic resonance imaging (MRI) examination with gadolinium will confirm diagnosis and show the exact extension of the lesion.