Weighing the risks and benefits of anticoagulation in atrial fibrillation: a case report of left atrial appendage absence in a patient referred for procedural occlusion.

Background: The absence of the left atrial appendage is an exceedingly rare structural variant that could have important implications for anticoagulation regimens in patients with atrial fibrillation. Case summary: We report the case of a 63-year-old Puerto Rican female with a history of hypertension, cerebral artery aneurysms, and type 2 diabetes mellitus who suffered multiple haemorrhagic strokes. The patient had never received anticoagulation therapy. During the indicated stroke work-up, the patient was found to have paroxysmal atrial fibrillation. Given the patients high risk for thromboembolism and contraindications to anticoagulation therapy, the patient was referred for left atrial appendage occlusion. Pre-procedural transoesophageal echocardiography failed to identify the left atrial appendage. Evaluation by way of cardiac computed tomography confirmed absence of the left atrial appendage. Left atrial appendage occlusion could not be carried out. The patient had been deemed being at high risk of bleeding, was not anticoagulated, and was instead closely followed. The patient has not had thrombo-embolic events nor has she experienced a haemorrhagic stroke recurrence at follow-up appointments. Discussion: To our knowledge, this is the first such case report that reports left atrial appendage absence in the setting of multiple haemorrhagic strokes. Given the rarity of the condition and lack of available guidelines, the most viable way to currently manage this patient population is on a case-to-case basis. However, we propose that absence of the left atrial appendage could confer a decreased risk of thrombo-embolic phenomena in patients with atrial fibrillation.

Radiology Education and Clinical Service during the COVID-19 Pandemic - the Puerto Rico Medical Center Experience.

Residency training programs have faced the dual challenge of providing continuous and effective clinical services and graduate medical education during the Coronavirus Disease 2019 (COVID-19) pandemic. This article outlines the changes incorporated by the University of Puerto Rico School of Medicine Diagnostic Radiology Program during the COVID-19 pandemic, including incorporating a virtual approach for read-out sessions, didactic conferences and additional learning experiences for the radiology residents. By means of collaboration and unity in the noble goal of public service, the faculty and residents of the Diagnostic Radiology Program at UPR-SOM have shown resilience throughout the many challenges faced during the current COVID-19 pandemic.

Delayed Spontaneous Resolution of a Traumatic Middle Meningeal Artery Pseudoaneurysm.

BACKGROUND Middle meningeal artery (MMA) aneurysms are a very rare entity, comprising less than 1% of all intracranial aneurysms. In particular, traumatic MMA pseudoaneurysms (MMAP) are reported in the literature to have a poor outcome in about 20% of cases. Moreover, in extremely rare cases, MMAPs can spontaneously thrombose. CASE REPORT We present the case of a 42-year-old Hispanic man with multiple craniofacial hemangiomas and history of chronic migraines that increased in frequency after blunt head trauma 1 month prior to initial evaluation. CTA and brain MRI showed a right-sided MMAP adjacent to the foramen spinosum with a pan-hemispheric subdural hematoma and no associated skull fractures. The MMAP was not visualized 2 days later on digital subtraction angiography (DSA) and was therefore presumed to be thrombosed. CTA at 3 months showed interval progression of the MMAP with subsequent spontaneous resolution on CTA at 10 months. CONCLUSIONS Knowledge regarding MMAPs is limited since it is based on a small number of cases and literature reviews. Additional studies are needed to elucidate the true incidence and natural course of this entity and produce adequate treatment guidelines.

Radiologic Features with Pathologic Correlation of an Unusual Large Intraosseous Skull Cavernous Hemangioma.

BACKGROUND Intraosseous cavernous skull hemangiomas are rare benign vascular tumors that are usually found incidentally on imaging, with an asymptomatic and slow-growing course. We present a case in which the patient had a mass on her forehead for many years, which began to grow rapidly after head trauma. Imaging characteristics play a crucial role in the diagnosis and description of this disease, and in differentiating it from other more common calvarial lesions that may present with a similar clinical picture. Here, we report an unusual presentation of a large skull hemangioma and discuss the different radiologic imaging findings and pathologic correlations. CASE REPORT A 58-year-old female with history of a lump on her forehead since childhood, which began to grow rapidly after experiencing a closed-head injury. Due to its large size, she went on to seek further management. Radiologic images revealed a frontal skull lesion suggestive of an intraosseous hemangioma. She underwent embolization of the tumor, and 2 days later underwent bilateral frontal craniectomy and cranioplasty. Histopathologic findings confirmed this diagnosis. CONCLUSIONS Intraosseous skull hemangioma may be confidently diagnosed and differentiated from other skull lesions by its imaging characteristics. An accurate diagnosis is essential to selecting correct management and avoiding complications.