Iatrogenic breast pseudoaneurysm in a lactating female: A rare breast emergency treated with ultrasound guided thrombin administration.

Pseudoaneurysm development is a well-recognized consequence of arterial injury, frequently observed in procedures involving arterial groin access. Breast emergencies are infrequent but need prompt attention. We present a notable case of breast pseudoaneurysm postcore needle biopsy, incidentally, identified through subsequent magnetic resonance imaging. Remarkably, the patient's lactating status emerged as a unique risk factor. Our report thoroughly explores the pathogenesis, etiology, preventive measures, and treatment strategies specific to breast pseudoaneurysms. A comprehensive understanding of this phenomenon is essential for radiologists at large, with particular importance for specialists in breast imaging.

C2 Synchondrosal Injuries: A Case Report and Anatomic Review.

Developmental succession in the pediatric patient requires special consideration in post-traumatic assessment. An understanding of the sequential development of this region and common patterns of injury can provide an accurate initial assessment before proceeding to further management and prognostic evaluation. Primarily, this article focuses on the synchondrosal development of C2 and its role in the craniocervical junction, as well as its common patterns of injury. This article presents two sample cases and offers a review of treatment options with added prognostic factors.

Cervical MRI assessment of traumatic anterior atlanto-occipital membrane complex injuries with evaluation of ancillary findings.

BACKGROUND AND PURPOSE: The purpose of this study was to identify and classify the different types of anterior atlanto-occipital membrane complex injuries on MRI and evaluate for the presence, size, and location of a prevertebral effusion on the preceding CT exams. MATERIALS AND METHODS: Patients who suffered an anterior atlanto-occipital membrane complex injury were identified retrospectively utilizing Nuance mPower software. An anatomic-based description of the location of the anterior atlanto-occipital membrane complex injury was recorded along with any additional osteoligamentous trauma of the craniocervical junction. The preceding cervical CT exams for these patients were reviewed for the presence and location of a prevertebral effusion. RESULTS: Fifty patients were identified with an acute, post-traumatic anterior atlanto-occipital membrane complex injury. Three distinct patterns of anterior atlanto-occipital membrane complex injury were observed. Nineteen patients demonstrated increased STIR signal with disruption of the anterior atlanto-occipital membrane, ten patients demonstrated increased STIR signal with disruption of the anterior atlanto-axial membrane, and twenty-one patients demonstrated increased STIR signal with disruption of both the anterior atlanto-occipital membrane and anterior atlanto-axial membrane. An effusion at the C1-C2 level was present in greater than 90% of patients with anterior atlanto-occipital membrane complex injury. CONCLUSIONS: The presence of a craniocervical prevertebral effusion on CT in trauma patients may raise suspicion for an injury to the anterior atlanto-occipital membrane complex and potentially trigger additional investigation with cervical MRI.

Utility of Anterior Atlantodens Interval Widening on Cervical Spine CT for Assessing Transverse Atlantal Ligament Injury.

STUDY DESIGN: Retrospective, cross-sectional. OBJECTIVES: To identify trauma patients with confirmed tears of the transverse atlantal ligament on cervical MRI and measure several parameters of atlanto-axial alignment on cervical CT, including the anterior atlantodens interval, to determine which method is most sensitive in predicting transverse atlantal ligament injury. METHODS: Adult trauma patients who suffered a transverse atlantal ligament tear on cervical MRI were identified retrospectively. The cervical CT and MRI exams for these patients were reviewed for the following: anterior and lateral atlantodens interval widening, lateral C1 mass offset, C1-C2 rotatory subluxation, and transverse atlantal ligament injuries on cervical MRI. RESULTS: Twenty-six patients were identified with a tear of the transverse atlantal ligament on cervical MRI. Twelve percent of these patients demonstrated an anterior dens interval measuring greater than 2 mm, 26% of patients demonstrated lateral mass offset of C1 on C2 (average offset of 2.4 mm), 18% of patients demonstrated an asymmetry greater than 1 mm between the left and right lateral atlantodens interval, and one patient demonstrated atlanto-axial rotation measuring greater than 20%. Ten patients had an accompanying C1 burst fracture and eight patients had a C2 fracture. One patient demonstrated widening of the atlanto-occipital joint space greater than 2 mm indicative of craniocervical dissociation injury. CONCLUSIONS: An anterior atlantodens interval measuring greater than 2 mm is an unreliable methodology to screen trauma patients for transverse altantal ligament injuries and atlanto-axial instability. Moreover, C1 lateral mass offset, lateral atlantodens asymmetry, and atlanto-axial rotation were all poor predictors of transverse atlantal ligament tears.

Interrelationship Between Craniocervical Dissociation Spectrum Injuries and Atlantoaxial Instability on Trauma Cervical MRI Examinations.

Background and purpose Craniocervical dissociation injuries encompass a spectrum of osteoligamentous injuries between the skull base and C1-C2 that may be treated via prolonged external immobilization versus occipital cervical fusion depending on the risk of persistent craniocervical instability. However, the presence of atlantoaxial instability (AAI) at C1-C2, as determined by transverse atlantal ligament (TAL) integrity with or without a C1 fracture, may guide the neurosurgical management of craniocervical dissociation spectrum injuries (CDSI) since it implies an overall greater degree of instability at the craniocervical junction (CCJ). Materials and methods Adult trauma patients who suffered a transverse atlantal ligament injury on cervical magnetic resonance imaging (MRI) were identified retrospectively. The cervical computed tomography (CT) and magnetic resonance imaging examinations for these patients were reviewed for additional traumatic findings. Demographic information, treatment, and outcome information were recorded. Results Twenty-nine trauma patients presented to the emergency department (ED) with an acute, midsubstance transverse atlantal ligament tear on cervical magnetic resonance imaging. Thirty-one percent of patients demonstrated a tear in at least one major craniocervical ligament (atlanto-occipital capsular ligaments, alar ligaments, and tectorial membrane {TM}) with 14% demonstrating a tear in two major craniocervical ligaments and no patients demonstrating a tear in all three major craniocervical ligaments. Minor craniocervical ligament injuries (anterior atlanto-occipital membrane complex {AAOMc} and posterior atlanto-occipital membrane complex {PAOMc}) were common and observed in 76% of patients. Conclusions Our study suggests that multiple major craniocervical junction ligamentous injuries on cervical magnetic resonance imaging are relatively uncommon in the setting of transverse atlantal ligament injury.

Appropriateness of Cervical Magnetic Resonance Imaging in the Evaluation and Management of C1 Jefferson Fractures.

BACKGROUND: Traditionally, C1 fractures have been designated as stable or unstable based on the inherent integrity of the transverse altantal ligament. The purpose of our study was to identify adult trauma patients with C1 fractures on cervical computed tomography and evaluate whether C1-C2 alignment differed in patients with and without an associated transverse atlantal ligament injury on follow-up cervical magnetic resonance imaging. METHODS: Adult trauma patients who suffered a C1 fracture were identified retrospectively. The cervical computed tomography examinations for these patients were reviewed for the following: C1 fracture classification, anterior atlantodens interval (ADI) widening, asymmetry in the lateral atlantodens interval, C1 lateral mass offset, and atlantoaxial rotation. RESULTS: Acute C1 fractures were grouped into those with an unequivocal transverse atlantal ligament injury (n = 12), and patients with an unequivocally intact transverse atlantal ligament (n = 20). Three patients were classified as indeterminate for transverse atlantal ligament injury. Statistically significant increases in lateral ADI asymmetry and combined C1 lateral mass offset were identified in patients with transverse atlantal ligament tears. CONCLUSIONS: Lateral ADI asymmetry (using a cutoff of >3 mm), combined C1 lateral mass offset, and anterior ADI demonstrate robust specificity to "rule in" transverse atlantal ligament injury. Atlantoaxial alignment was overall relatively insensitive as a screening test although sensitivity can be improved using a cutoff of >2 mm for lateral ADI asymmetry. Our findings reinforce the role of cervical magnetic resonance imaging in the diagnostic workup and clinical management of trauma patients with an acute burst fracture of the C1 vertebra.

Occult craniocervical dissociation on cervical CT: an under-appreciated presentation of craniocervical trauma requiring occipital cervical fusion.

BACKGROUND AND PURPOSE: Craniocervical dissociation is a rare and life-threatening injury that results from a significant hyperflexion-hyperextension force. Occult craniocervical dissociation is defined as an unstable craniocervical injury in the absence of atlanto-occipital joint space widening or other skull base line abnormality. The early and accurate diagnosis of craniocervical dissociation is crucial since the early diagnosis and subsequent stabilization with occipital-cervical fusion has been shown to reduce neurologic morbidity and mortality. Several normative skull base lines have been developed to predict craniocervical dissociation. The purpose of our study was to measure the atlanto-occipital joint space and four other common skull base lines in patients who underwent occipital-cervical fusion for post-traumatic craniocervical instability. MATERIALS AND METHODS: Patients who underwent occipital-cervical fusion for craniocervical injury were identified retrospectively using a keyword search of radiology reports using Nuance mPower software. The cervical CT and MRI exams for these patients were reviewed and the atlanto-occipital joint space, Powers ratio, Wackenheim line, posterior axial line, and basion dens interval were measured. Detailed descriptions of craniocervical ligament injuries on MRI were recorded along with patient demographic information, clinical history, management, and outcome. RESULTS: Nine adult patients who underwent occipital-cervical fusion for an acute craniocervical injury were identified. Six patients demonstrated an atlanto-occipital joint space measuring 2 mm or less on cervical spine CT with no additional abnormality in the Powers ratio, Wackenheim line, posterior axial line, or basion-dens interval. Three patients demonstrated widening of the atlanto-occipital joint space with two patients demonstrating an abnormality in at least two additional skull base lines. Clinical outcomes were variable with nearly half of the patients demonstrating persistent neurologic deficits, including one quadriplegic patient. CONCLUSIONS: A normal atlanto-occipital joint space and skull base line measurements on cervical CT demonstrated a low predictive value for detecting unstable craniocervical injuries. Occult craniocervical dissociation was present in two-thirds of patients who underwent occipital cervical fusion for acute, craniocervical trauma. A high clinical and radiologic index of suspicion for craniocervical trauma with subsequent follow-up cervical MRI to directly evaluate ligamentous integrity is necessary to accurately diagnose and triage patients with high velocity trauma.

Radiologic utility of the Gehweiler and AO spine classification systems for C1 Trauma: A retrospective review from a Level I trauma center.

Objective: The purpose of our study was to identify adult trauma patients with an acute C1 burst fracture, evaluate for concomitant transverse atlantal ligament (TAL) injury, and apply the modified Gehweiler and AO spine classification systems to determine the utility of these classification systems in accurately defining C1 trauma. Materials and Methods: Adult trauma patients with an acute C1 fracture were identified retrospectively using Nuance mPower software. The C1 fracture was described based on whether the fracture involved the anterior arch, posterior arch, lateral mass, medial tubercle, and/or transverse process. If follow-up cervical magnetic resonance imaging (MRI) was performed, the presence and location of an associated TAL injury was recorded. The anatomic location of the C1 burst fracture and TAL injury, if present, were compared with the descriptive classification systems outlined by Gehweiler/Dickman (modified) and the AO Spine society. Any additional osseous trauma of the skull base and C1-C2 was also recorded along with relevant clinical history and management. Results: Thirty-nine patients were identified with an acute C1 burst fracture on cervical computed tomography (CT) with seventy-seven percent of patients undergoing follow-up cervical MRI. Observed fracture patterns were divided into five distinct types based on CT findings and further subdivided based on the integrity of the transverse altantal ligament on MRI. TAL tears were observed exclusively in type 3 fractures (anterior and posterior arch fractures) and type 4 fractures (anterior arch, posterior arch, and lateral mass fractures). The modified Gehweiler classification system failed to accurately describe the anatomic location of the C1 fracture in forty-four percent of patients, whereas the AO spine was too broad and failed to accurately describe fracture location in our cohort. Conclusions: The Gehweiler and AO spine classifications demonstrated significant shortcomings in the accurate description of patients with C1 trauma. Whereas the Gehweiler system did not accurately describe the anatomic location of the various C1 fractures, the AO spine system was too broad and failed to radiologically classify fracture location. Moreover, there was a high number of patients with AO spine type B injuries without atlantoaxial translation that nevertheless required C1-C2 fusion for atlantoaxial instability. We suggest the need for an updated classification system that takes into account both the CT (fracture location) and MRI (TAL integrity) appearance of C1 trauma. An updated classification strategy will offer a radiologic standardization of C1 trauma that will aid in future research studies and help optimize patient management.

C1-C2 Dorsal Epidural Hematoma on Cervical Spine CT: A Novel Imaging Sign of Posterior Atlanto-Occipital Membrane Stripping Injury.

BACKGROUND AND PURPOSE:  Identify patients with a dorsal epidural hematoma at C1-C2 and examine the major craniocervical junction ligaments for injury on follow-up magnetic resonance imaging. MATERIALS AND METHODS:  Adult and pediatric trauma patients who suffered a dorsal epidural hematoma at C1-C2 were identified using Nuance mPower software (Nuance Communications, United States). The cervical computed tomography and magnetic resonance imaging exams for these patients were reviewed for craniocervical junction osteoligamentous injuries. An age-matched control group was obtained. RESULTS:  Eight trauma patients were identified with a dorsal epidural fluid collection at C1-C2. All patients with a dorsal epidural hematoma, who underwent follow-up cervical magnetic resonance imaging demonstrated a stripping injury of the posterior atlanto-occipital membrane from the C1 posterior arch with increased short tau inversion recovery signal in the posterior atlanto-occipital membrane complex. Disruption of additional major craniocervcial ligaments on magnetic resonance imaging was relatively common with the most frequently associated ligamentous injuries involving the tectorial membrane (five patients) followed by the alar ligaments and anterior altanto-occiptial membrane (four patients each).  Conclusions: A C1-C2 dorsal epidural hematoma is a rare injury that may be identified on cervical spine computed tomography but may be easily overlooked by the radiologist. We propose that a C1-C2 dorsal epidural hematoma is a direct result of a significant hyperflexion-hyperextension force with subsequent stripping of the posterior atlanto-occipital membrane from the posterior C1 arch. Trauma patients with a C1-C2 dorsal epidural hematoma on cervical spine computed tomography should undergo a cervical magnetic resonance imaging examination to evaluate the integrity of the posterior atlanto-occipital membrane complex and remaining craniocervical junction ligaments for injury.

Current Management and Image Review of Skull Base Chordoma: What the Radiologist Needs to Know.

Chordomas of the skull-base are typically slow-growing, notochord-derived tumors that most commonly originate along the clivus. Skull base chordoma is treated with surgery and radiotherapy. Local recurrence approaches 50% at 10 years. Radiologists play a critical role in diagnosis, treatment planning, and follow-up. Surgeons and radiation oncologists rely on radiologists for pre-operative delineation of tumor and adjacent anatomy, identification of post-treatment changes and disease recurrence, and radiation treatment effects. This review provides an overview of clinical characteristics, surgical anatomy, indications for radiotherapy, identification of treatment complications, and patterns of disease recurrence for radiologists to provide value in the management of these lesions.

Occipital condylar avulsion fractures in the acute trauma setting: Stable or unstable injury?

BACKGROUND AND PURPOSE: Occipital condylar avulsion fractures are considered potentially unstable, associated with craniocervical dissociation spectrum injuries, and thought to carry a relatively high mortality rate based on the current literature. The purpose of this study was to identify patient with acute, occipital condylar avulsion fractures and evaluate for the incidence of concomitant cervical osteoligamentous trauma and craniocervical dissociation spectrum injury on cervical spine CT and MRI. MATERIALS AND METHODS: Patients who suffered an inferomedial occipital condylar avulsion fracture were identified retrospectively using Nuance mPower software. Cervical spine CT and MRI reports performed within 48 h for this patient cohort were then reviewed by two CAQ certified neuroradiologists. Confirmation of an occipital condylar avulsion fracture was recorded along with any concomitant craniocervical junction injury. Relevant clinical history, including management and outcomes, was recorded for each patient. RESULTS: Thirty-four patients were identified with an inferomedial fracture of the occipital condyle. Of the 85% of patients who underwent cervical MRI, all but one patient demonstrated a 'negative' MRI without major craniocervical junction ligamentous injury. These patients were treated conservatively with external bracing without persistent neurologic deficits upon 4-month follow-up. CONCLUSIONS: Inferomedial fractures of the occipital condyle are currently classified as potentially unstable fractures based on the Anderson classification system. Our data suggest that an isolated occipital condylar avulsion fracture without an additional C1-C2 fracture or widening of the atlanto-occipital joint space is likely a stable injury that can be treated conservatively with excellent clinical outcomes.

Inferior Vena Cava Syndrome as a Manifestation of Metastatic Carcinoid Tumor.

Small bowel-origin carcinoid tumor is indolent but may metastasize relentlessly to various sites, including the liver. Over the past 9 years, we have treated a 69-year-old woman who has undergone 5 percutaneous liver ablations, 5 hepatic intra-arterial chemoembolizations, an ovarian cryoablation, and a trans-ventral hernia mesenteric cryoablation. These interventions are all related to her inoperable carcinoid malignancy. After the patient presented with swelling of the abdomen and both lower extremities, computed tomography (CT) angiography was performed, revealing a circumferential hepatic metastatic mass encasing the intrahepatic inferior vena cava (IVC) and extensive third spacing of fluids specific to the IVC distribution below the diaphragm. A venogram of the intrahepatic IVC revealed extrinsic compression causing 95% narrowing of the vessel. A balloon was advanced to the level of the lesion and inflated, increasing the caliber of the vessel. Subsequently, 2 covered aortic stent graft cuffs were deployed in an overlapping fashion within the lumen of the IVC, traversing the area of narrowing. Next, an open-cell aortic dissection stent was placed across both overlapping aortic stents from the renal veins to the hepatic veins. Following this, three 17-gauge cryoablation probes were inserted into the segment 1 intrahepatic lesions encasing the newly stented IVC via an anterior percutaneous approach. Two 10-min freeze cycles were performed with intraoperative CT imaging, demonstrating circumferential coverage of the lesions. Posttreatment venogram revealed patent stent grafts within the intrahepatic IVC, and restoration of vessel patency. No immediate postoperative complications were noted. The patient's abdominal and lower extremity swelling resolved completely within 1 week after procedure. Two-month follow-up CT demonstrated markedly decreased size of the metastatic lesions and no adverse effects. Six- and 9-month PET-CT scans demonstrated maintained patency of the IVC stent. This palliative procedure allowed the patient to maintain good performance status and alleviated her symptoms of IVC syndrome. The radial force generated by the multiple aortic stents will ostensibly maintain the patency of the intrahepatic IVC. Cryoablation of the encasing metastatic lesion was performed with markedly decreased size of the tumor on the 2-month follow-up.

Tectorial Membrane Injury, Frequently Identified in Adult Trauma Patients Who Undergo Occipital-Cervical Fusion for Craniocervical Instability.

Background In the absence of frank craniocervical dissociation, there is a lack of consensus regarding what patterns of craniocervical junction ligamentous injuries require occipital-cervical fusion. This study was undertaken to examine the integrity of the craniocervical junction ligaments and analyze clinical outcomes in patients who underwent occipital-cervical fusion for craniocervical junction injury. Methods Adult patients requiring occipital-cervical fusion were identified retrospectively utilizing keyword searches in cervical computed tomography and magnetic resonance imaging reports between 2012 and 2020 using Nuance mPower software (Nuance, Burlington, MA). The cervical magnetic resonance imaging examinations for these patients were reviewed for craniocervical ligamentous injury by two neuroradiologists. Descriptions of craniocervical junction injuries, demographic information, clinical history, surgical management, and global outcomes were recorded. Results Nine adult patients were identified with an acute, post-traumatic craniocervical junction injury requiring occipital-cervical fusion. All nine patients demonstrated a ligamentous tear in at least one of the four major craniocervical junction ligaments - the occipital condylar-C1 capsular ligaments, alar ligaments, tectorial membrane, and posterior atlantooccipital membrane. The tectorial membrane was the most commonly torn ligament followed by the alar ligament(s), posterior atlantooccipital membrane, and capsular ligament(s). There was wide variability in the number of major craniocervical junction ligaments torn, ranging from one ligament to all four ligaments. Four patients suffered persistent neurologic deficits following surgery. Conclusion Craniocervical injury is best evaluated by cervical magnetic resonance imaging. In the absence of overt craniocervical dissociation, we propose that an injury of the tectorial membrane in the adult population may indicate patients with significant craniocervical instability, possibly necessitating occipital-cervical fusion.

Proposed Grading System for Posterior Atlantooccipital Membrane Complex Injuries on Cervical Magnetic Resonance Imaging.

BACKGROUND: The posterior atlantooccipital membrane complex consists of the posterior atlantooccipital membrane and posterior atlantoaxial membrane. Posttraumatic, posterior atlantooccipital membrane complex injuries may have varied appearances on cervical magnetic resonance imaging. The purpose of this study was to identify the different types of posterior atlantooccipital membrane complex injuries that occur in trauma patients. METHODS: Patients who suffered a posterior atlantooccipital membrane complex injury were identified retrospectively using key word searches of cervical magnetic resonance imaging reports between 2013 and 2020 using Nuance mPower software. All relevant imaging studies were reviewed by 2 neuroradiologists. A description of the location and type of posterior atlantooccipital membrane complex injury was recorded, along with additional osteoligamentous trauma of the craniocervical junction and relevant clinical history. RESULTS: Forty-one patients were identified with acute posterior atlantooccipital membrane complex injury. Four distinct patterns of posterior atlantooccipital membrane complex injury were observed. CONCLUSIONS: A grading system for posterior atlantooccipital membrane complex injuries is proposed on the basis of these data: grade 1-edema confined to the posterior atlantooccipital and atlantoaxial membrane; grade 2-edema confined to the posterior atlantooccipital and atlantoaxial membrane and ligamentum nuchae; grade 3-stripping injury of the posterior atlantooccipital membrane with C1-C2 dorsal epidural hematoma; and grade 4-frank disruption of the posterior atlantooccipital membrane at C1 with edema in the remaining posterior atlantooccipital membrane complex.

"Supradental space sign" on cervical spine CT-a sign of tectorial membrane injury in adults trauma patients.

BACKGROUND AND PURPOSE: The supradental space is a small, predominantly fat-filled recess superior to the atlanto-axial joint and inferior to the basion of the clivus that contains a small venous plexus. The posterior boundary of the supradental space is formed by the tectorial membrane, a stabilizing ligament of the craniocervical junction. The purpose of our study was to examine the imaging appearance of the supradental space in patients with tectorial membrane injury. MATERIALS AND METHODS: Adult patients with tectorial membrane injury were identified utilizing keyword searches of radiology reports using Nuance mPower software. Age-matched positive and negative control groups were obtained. Two CAQ-certified neuroradiologists evaluated the cervical CT exams of these patients for supradental fat pad effacement from hematoma formation. The integrity of the osteoligamentous structures of the craniocervical junction was recorded on CT and MRI exams along with demographic information, clinical history, surgical management, and global outcome. Statistical analysis was performed. RESULTS: Sixteen adults were diagnosed with tectorial membrane injury on cervical MRI. All patients with a visible supradental space demonstrated fat pad effacement and Hounsfield units consistent with hematoma formation. The positive and negative control groups demonstrated supradental fat pad effacement in 2/16 and 1/16 patients, respectively. A p-value of < 0.001 was obtained. CONCLUSION: The "supradental space sign," defined as hematoma formation in the supradental space with effacement of the supradental fat pad is associated with tectorial membrane injury in adult trauma patients with sensitivity of 93.75% (95% confidence interval 69.77 to 99.84%) and specificity of 90.62% (95% confidence interval 74.98 to 98.02%).

Anatomic, functional, and radiographic review of the ligaments of the craniocervical junction.

The craniocervical junction (CCJ) is a complex and unique osteoligamentous structure that balances maximum stability and protection of vital neurovascular anatomy with ample mobility and range of motion. With the increasing utilization and improved resolution of cervical magnetic resonance imaging, craniocervical injury is being more accurately defined as a spectrum of injury that ranges in severity from overt craniocervical disassociation to isolated injuries of one more of the craniocervical ligaments, which may also lead to craniocervical instability. Thus, it is vital for the radiologist and neurosurgeon to have a thorough understanding of the imaging anatomy and function of the CCJ.

Pediatric Retroclival Epidural Hematoma in the Acute Trauma Setting: A Sign of Tectorial Membrane Stripping Injury.

OBJECTIVE. A traumatic retroclival epidural hematoma is a rare imaging finding of severe cervical flexion-extension injury in the pediatric population. The purpose of our study was to identify pediatric patients with a retroclival epidural hematoma, record the hematoma size and extent, and examine the major craniocervical ligaments for injury. MATERIALS AND METHODS. Pediatric patients who suffered a retroclival epidural hematoma were identified retrospectively using the keywords "clivus," "epidural hematoma," and "retroclival" included in head CT reports between 2012 and 2019. The cervical and brain MRI examinations for these patients were reviewed for craniocervical ligament injury by two certified neuroradiologists. Detailed descriptions of patient injuries were recorded along with demographic information, clinical history, patient management, and outcome. RESULTS. Eleven pediatric patients were identified with an acute posttraumatic retroclival epidural hematoma with a mean anteroposterior dimension of 4.4 mm and craniocaudal dimension of 4.3 cm. All patients with a retroclival epidural hematoma who underwent subsequent cervical MRI had a stripping injury of the tectorial membrane (TM). Disruption of additional major craniocervical ligaments on MRI (alar ligament, transverse ligament, longitudinal ligaments, and ligamentum flavum) was relatively rare with the most common associated ligamentous injuries involving the anterior atlantooccipital membrane, apical ligament, and interspinous ligaments. None of the patients suffered a cervical cord or severe intracranial injury. The majority of the patients were managed conservatively with excellent clinical outcomes. CONCLUSION. A posttraumatic retroclival epidural hematoma in the pediatric population is a rare injury often identified initially by head CT and easily overlooked by the radiologist. We propose that a retroclival epidural hematoma in the pediatric population is a direct result of a significant flexion-extension force, with a subsequent stripping injury of the TM from the posterior clivus. Pediatric patients with a posttraumatic retroclival epidural hematoma on initial head CT should undergo a cervical MRI to evaluate the integrity of the TM and other craniocervical ligaments.

Diffusion Weighted Imaging in Unilateral Adrenal Infarction: A Case of Colicky Right Upper Quadrant Pain in a Pregnant Female.

Diffusion weighted imaging (DWI) is a magnetic resonance imaging (MRI) non-contrast sequence that can indicate tissue ischemia or infarction. Adrenal infarct may present similarly to biliary or gallbladder pathologies, and the differential diagnosis during emergency work-up can be narrowed utilizing DWI sequences. In this paper, we describe the usefulness of DWI for urgent diagnosis in a case of non-hemorrhagic adrenal infarct of a pregnant female presenting with right upper quadrant pain. Although uncommon, adrenal infarct may occur in patients with hypercoagulability and localizing pain that is unexplained by other imaging modalities. We outline the imaging features of DWI in evaluating adrenal infarct as a safe and time effective application for patients with contraindications to imaging with ionizing radiation.

Expanding the Frontiers of Treatment: Cryoablation of an Ovarian Mass.

The ovaries are a common site of metastasis from a variety of solid organ malignancies. These tumors most commonly originate from the gastrointestinal tract. Neuroendocrine tumors of the small bowel are unrelenting in their tendency to exhibit this type of distant spread, which poses a challenge for curative treatment. Whether metastatic disease to the ovary or primary ovarian malignancy, this is a major cause of morbidity and mortality for women of various ages. Currently, a mainstay of palliative treatment for advanced-stage disease resides in surgical debulking and chemotherapy. At times, these patients may not be surgical candidates due to various reasons which may include a large disease burden. Computed tomography-guided percutaneous cryoablation is a minimally invasive technique that has shown promise in treating solid organ metastatic lesions by exposing them to lethal temperatures. We describe a novel technique of palliative cryoablation of a primary small bowel carcinoid tumor that metastasized to the ovary. Hydrodissection was utilized to create a window for safe percutaneous treatment. At the end of freeze cycles, intraoperative CT was performed, demonstrating greater than 90% incorporation of the ovarian tumor within the margins of the lethal ice zone. Our team decided that this was a maximum percentage of freeze due to neighboring vessels and bowel. The patient tolerated this treatment well, and there were no reported post-operative complications. The procedure was clinically successful at shrinking the tumor as demonstrated on a nine-month follow-up CT. Percutaneous cryoablation is already a widely utilized method for treating tumors in various locations including the kidneys and liver. The application of cryoablation can be expanded as an effective and safe palliative technique for treating ovarian tumors. This may be especially useful in patients that are not surgical candidates.