Vesicourachal Diverticulum: An Uncommon Incidental Finding on Staging 18F-FDG PET/CT in a Patient with Suspected Malignant Transformation of Neurofibromatosis.

In a 32-y-old man with neurofibromatosis type 1, 18F-FDG PET/CT incidentally revealed a vesicourachal diverticulum, a rare anatomic variant. The PET/CT, performed for staging a malignant peripheral nerve sheath tumor, highlighted a distinctive 18F-FDG-avid pattern crucial for accurate diagnosis. Recognizing such features enhances disease assessment and clarifies distinctions between benign urogenital anomalies and malignancies in 18F-FDG PET/CT staging.

Slow-Flow Venous Vascular Malformation in the Carotid Sheath.

Slow-flow venous vascular malformation is a benign lesion characterized by an abnormal but non-cancerous growth of capillaries. In the carotid space, a slow-flow venous vascular malformation is an exceptionally uncommon occurrence. Here, we present the case of a 58-year-old man who had been experiencing a slow-growing lump on the left side of his neck for the past four years. Upon conducting magnetic resonance imaging (MRI) of the neck soft tissues and computed tomography angiography (CTA) of the neck, imaging findings revealed a venous vascular malformation within the carotid sheath. Venous vascular malformation in the carotid space is rarely reported in the medical literature. The unique imaging findings for venous vascular malformation make our case distinct, which deviates from the more common entities usually encountered in this area, such as schwannoma or carotid body tumor. The atypical presentation of this case has brought about greater awareness among the medical community and readers alike.

MRI Findings Reflecting Ongoing Cardiac Arrest While Being on an MRI Scanner.

Sudden cardiac arrest (SCA) is the abrupt loss of cardiac function that results in acute cardiovascular collapse and subsequent decreased or loss of various organ perfusion. Here, we present an interesting case of a 58-year-old man who developed abnormal brain MRI findings reflecting ongoing cardiac arrest due to pulseless electric activity (PEA) during an MRI scan. To our knowledge, this is the first case describing the MRI findings of ongoing cardiac arrest due to PEA. Our case is unique in imaging findings, which are not routinely encountered in day-to-day practice. This case raised awareness among the readers.

Role of 18F-Fluorocholine Positron Emission Tomography (PET)/Computed Tomography (CT) in Diagnosis of Elusive Parathyroid Adenoma.

Accurate localization of parathyroid adenomas is paramount in hypercalcemia and elevated parathyroid hormone (PTH) levels. This narrative of a 56-year-old female diagnosed with primary hyperparathyroidism underscores the intricacies faced when conventional imaging falls short. Despite a series of diagnostic and surgical endeavors, including an initial nuclear sestamibi scan and diverse imaging examinations like ultrasound, 4D CT, and MRI, it was the 18F-Fluorocholine positron emission tomography (PET)/computed tomography (CT) scan that illuminated the presence of the elusive adenoma in the left para esophageal superior mediastinum. The surgical outcome reinforced the diagnosis, marking the resolution of the adenoma. This case accentuates the necessity of a multifaceted diagnostic methodology, especially in convoluted primary hyperparathyroidism presentations. It highlights the yet-to-be widely adopted 18F-Fluorocholine PET/CT scan, emphasizing its prospective significance awaiting Food and Drug Administration (FDA) endorsement.

Choriocarcinoma-Driven Uterine Perforation in a Bicornuate Anatomy: An Elusive Encounter.

Choriocarcinoma, an aggressive gestational trophoblastic disease, infrequently manifests with spontaneous uterine perforation. We report the case of a 22-year-old female with five months of amenorrhea presenting with acute abdominal pain. Ultrasound and MRI assessment highlighted a uterine perforation with choriocarcinoma. Subsequent total abdominal hysterectomy revealed choriocarcinoma in the bicornuate uterus with uterine perforation. Histopathological analysis confirmed the diagnosis of choriocarcinoma in the cornu of the uterus. Timely diagnosis is vital to reduce mortality. Notably, choriocarcinoma in a bicornuate uterus is exceptionally rare. Radiological evaluations are critical for diagnosis, staging, and follow-up.

Sinogram: A Valuable Diagnostic Tool for an Adult Male With Discharging Heel Ulcer and Suspected Calcaneal Osteomyelitis.

This report highlights the clinical significance of a sinogram in diagnosing osteomyelitis in resource-poor areas. We report a case in which a sinogram was used successfully for the diagnosis of calcaneal osteomyelitis. A 25-year-old male patient sought medical attention for persistent pain in the right ankle joint and heel, accompanied by a discharging ulcer over the right heel. He had a history of foot trauma involving vegetative matter sustained during a farming injury one month prior to the onset of symptoms. An ankle radiograph revealed an osteolytic lesion involving the calcaneum, prompting further investigation with a sinogram, which indicated a subcutaneous sinus tract with intramedullary extension into the calcaneum. Despite the clinical necessity for a magnetic resonance imaging (MRI) or computed tomography (CT) evaluation to precisely assess the lesion's extent and aid in formulating an appropriate treatment plan, the patient faced significant financial constraints that hindered him from undergoing the essential imaging procedure.

Artificial Intelligence (AI) in Radiology: A Deep Dive Into ChatGPT 4.0's Accuracy with the American Journal of Neuroradiology's (AJNR) "Case of the Month".

The advent of artificial intelligence (AI), particularly large language models (LLMs) such as ChatGPT 4.0, holds significant potential in healthcare, specifically in radiology. This study examined the accuracy of ChatGPT 4.0 (July 20, 2023, version) in solving diagnostic quizzes from the American Journal of Neuroradiology's (AJNR) "Case of the Month." We evaluated the diagnostic accuracy of ChatGPT 4.0 when provided with a patient's history and imaging findings weekly over four weeks, using 140 cases from the AJNR "Case of the Month" portal (from November 2011 to July 2023). The overall diagnostic accuracy was found to be 57.86% (81 out of 140 cases). The diagnostic performance varied across brain, head and neck, and spine subgroups, with accuracy rates of 54.65%, 67.65%, and 55.0%, respectively. These findings suggest that AI models such as ChatGPT 4.0 could serve as useful adjuncts in radiological diagnostics, thus potentially enhancing patient care and revolutionizing medical education.

Pericardial Cyst at an Unusual Location: The Role of CT Imaging.

The pericardial cyst is a benign, uncommon congenital cystic lesion of pericardial origin located in the anterior and middle mediastinum. Most commonly, pericardial cysts are located in the right anterior cardiophrenic angle. Computed tomography (CT) and magnetic resonance imaging (MRI) of the chest are the non-invasive imaging modalities for the diagnosis of the pericardial cyst. Here we present a case of a 55-year-old male who presented with coughing and chest pain for two weeks. A chest X-ray revealed a soft-tissue opacity mass in the left lower zone. A CT of the chest showed a fluid-density cystic lesion in close proximity to the pericardium, located along the left posterior cardiophrenic angle, an uncommon location for a pericardial cyst.

Merkel Cell Carcinoma of the Left Cheek With Testicular Metastasis: An Uncommon Occurrence.

Merkel cell carcinoma (MCC) is an infrequent and aggressive neuroendocrine tumor of the skin. 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) is an effective imaging technique with good diagnostic accuracy that may be used to help stage MCC and for detecting unexpected recurrences and distant metastatic disease. Other causes of testicular neoplasms, such as primary testicular tumors, lymphomas, or anaplastic small cell melanomas, are difficult to differentiate from MCC testicular metastases on imaging, and tumor markers and histopathology will help confirm it. The current case is a 65-year-old non-immunocompromised male with Merkel cell carcinoma who was incidentally identified with testicular metastases on PET/CT and confirmed on histopathology.

Large Chorioangioma in Triplets: An Uncommon Occurrence.

A 25-year-old primigravida presented at 26 weeks of gestation by dates, the first time for the routine antenatal checkup. No histories were suggestive of pregnancy-induced hypertension (PIH) and edema. On physical examination, pallor was present with microcytic hypochromic anemia. Raised beta-human chorionic gonadotropin (HCG) and alpha-fetoprotein (AFP) levels were present. Ultrasonography revealed triples with two thin echogenic intertwining membranes. Anomaly scan did not reveal any abnormality in fetuses. The placenta showed a large oval hypoechoic mass arising from its edge and bulge into the amniotic fluid. A central feeding vessel with a branching pattern and pulsatile color flow like that of the umbilical artery is noted on the color Doppler. She was spontaneously preterm delivered vaginally at 28 weeks of gestation. All three fetuses were stillborn. Histopathological diagnosis of angiomatous chorioangioma was confirmed. This case classically represents a grave complication of the large chorioangioma.

Case 317.

HISTORY: A 44-year-old previously healthy man with a 9-month history of progressive cognitive decline, depression, urinary incontinence, and inability to perform tasks of daily living presented to the emergency department with worsening cognitive and neuropsychiatric symptoms. He had become more distressed, and his family noticed him departing the house without closing doors, leaving water faucets running, and sending his children to school on Sundays. History taken from the patient's wife revealed that his brother had passed away in his late 30s after a slowly progressing functional and cognitive decline over the course of 5 years. No further detailed family history could be obtained. The review of systems was negative; he had no prior medical, psychiatric, or surgical history; and he denied any history of recent travel, camping, hiking, or vaccination. The patient was not taking any dietary supplements, nor was he taking any over-the-counter or prescription medication. Examination revealed vital signs were within normal limits. Neurocognitive assessment revealed a conscious, coherent, and alert patient with impaired memory and concentration. He showed poor attention, depressed mood, and restricted affect. He was unable to spell the word world forward, nor was he able to understand a request to spell it backward. The rest of the physical and neurologic examination revealed no abnormalities. Extensive laboratory work-up was conducted and included the following: toxicology screening; screening for HIV-1, HIV-2, and syphilis treponemal antibodies; COVID-19 polymerase chain reaction; and measurement of B1 and B12 levels. The results of screening were negative. Cerebrospinal fluid (CSF) assays, including CSF oligoclonal bands and CSF flow cytometry, revealed values within normal limits. CT of the brain without intravenous contrast material was performed in the emergency department to rule out acute intracranial abnormality (Fig 1). Multiplanar multisequence MRI of the brain without and with intravenous contrast material was ordered for further assessment (Figs 2-4). CT images of chest, abdomen, and pelvis were unremarkable (images not shown).

Human parechovirus meningoencephalitis.

Human parechovirus-3 (HPeV-3) infection is one of the differential diagnoses of neonatal meningoencephalitis. A 13-day-old full-term female neonate presented with a seizure. Brain MRI showed classic imaging findings of the meningoencephalitis which was confirmed on cerebrospinal fluid analysis. Contribution: The HPeV-3 is an emerging pathogen for neonatal meningoencephalitis. The case in this study is unique with classic imaging findings, which are not routinely encountered in day-to-day practice. This case raises reader awareness.

Uncommon Presentation of Craniopharyngioma: A Case Report of Post-traumatic Intratumoral Hemorrhage Leading to Cerebral Infarct.

Craniopharyngiomas emanate from squamous cell remnants in the hypophyseal/pharyngeal duct region. This report details the unprecedented case of a 29-year-old male with adamantinomatous craniopharyngioma, who, following a motor vehicle collision (MVC), presented with post-traumatic intratumoral hemorrhage leading to acute basal ganglia infarct. The patient, previously subjected to subtotal resection, exhibited focal neurological deficits attributed to compression of lenticulostriate arteries due to the sudden increase in tumor volume. The patient, ineligible for thrombolysis or thrombectomy, was conservatively managed post-MVC. Subtotal resection occurred four months later. After one year, persistent right-sided weakness (2/5 motor power) remained, and the recommended stereotactic radiotherapy was declined by the patient. Notably, this instance represents the first documented case of post-traumatic intratumoral hemorrhage in adamantinomatous craniopharyngioma. This report distinguishes between adamantinomatous and papillary subtypes, noting their prevalence in different age groups. While these tumors commonly present with gradual vision changes, fatigue, and endocrine dysfunction, complications such as intra-tumoral hemorrhage remain rare. This report serves as an educational tool, shedding light on potential complications and urging increased vigilance in managing craniopharyngiomas.

18F-FDG PET/CT Imaging Features of Cardiac Arrhythmia in a Patient Treated with Panitumumab.

Panitumumab is a new humanized antiepidermal growth factor receptor monoclonal antibody (mAb) approved for the treatment of advanced colorectal cancer. There is an increase in the use of this drug due to a good response rate and possible secondary resection in advanced colorectal cancer. Here, we present 18F-FDG PET/CT imaging findings of cardiac arrhythmia in a patient receiving panitumumab for the treatment of metastatic infiltrating rectal adenocarcinoma. Cardiotoxicity is a known adverse effect associated with panitumumab. So far, to our knowledge, no documented imaging findings for the same are available in the literature.

A Rare Case of Schistosomiasis (Bilharzia) of the Bladder in a Non-Endemic Area.

BACKGROUND: Schistosomiasis or snail fever is an endemic parasitic infection caused by various trematodes of the genus Schistosoma. People acquire the disease through contact with water containing infected snails. It is one of the most widespread human parasitic infections in tropical and subtropical regions of the world such as Africa, South America, the Middle East, Asia and the Caribbean. In 1996, the World Health Organisation estimated that more than 200 million people living in rural areas are affected by this disease. However, the diagnosis is difficult in low prevalence areas because of a low index of suspicion. CASE REPORT: Herein, we present a case of a 14-year old boy who had intermittent passage of blood in urine for the past 3 years. Clinical examination and initial investigations did not reveal any abnormality. Bladder schistosomiasis was suspected after contrast-enhanced computed tomography and later confirmed by cystoscopic biopsy. CONCLUSIONS: Bladder schistosomiasis is a prevalent disease in the developing countries, but in non-endemic areas diagnosis may be often missed. The diagnosis should be considered in patients presenting with sporadic episodes of haematuria who have immigrated from or travelled to areas where this disease is endemic.

An Unusual Case of a Metallic Foreign Body per Urethra.

BACKGROUND: Foreign body in the lower urinary tract has a low incidence. Here we discuss a case of a safety pin within the bulbar urethra inserted by a young boy for sexual gratification, which was successfully removed under cysto-urethroscopic guidance. CASE REPORT: Herein we present a case of a 14-year-old boy who presented with complaints of perineal pain and dysuria. On evaluation in detail and from clinical history, we came to know that he had inserted a safety pin within the urethra. Urine analysis revealed microscopic haematuria and few pus cells. X-ray of the pelvis and computerised tomography helped in confirming the presence of the safety pin within the urethra. CONCLUSIONS: The method of extraction of a foreign body per urethra depends on the size and shape of the foreign body. Cysto-urethroscopic removal is successful depending on the physical characteristics of the foreign body. It has the advantage of minimising urothelial trauma and also helps in assessing any previous mucosal injury or thickening. Psychological evaluation and counselling may help to prevent further such episodes.

Radiological Features of Long-Standing Hypoparathyroidism.

BACKGROUND: Idiopathic hypoparathyroidism is an extremely rare endocrinal disorder with a prevalence of 37 per 100,000. Herein we presented a case of a 30-year-old male who came with symptoms of muscle weakness, carpopedal spasms and limitation of movement which gradually progressed over 8 years. CASE REPORT: A 30-year-old male patient presented in an outpatient department of a tertiary care centre with a complaint of severe pain in both hip joints. He had generalized muscle weakness, facial discomfort, recurrent episodes of carpopedal spasms and crampy abdominal pains. On clinical examination, the patient had Chvostek sign and Trousseau sign. Biochemical tests revealed hypocalcemia, hyperphosphatemia and hypomagnesemia with low plasma parathyroid hormone level. X-ray of the pelvis and spine revealed spondylarthropathic changes of long-standing hypoparathyroidism. Computed Tomography of the brain revealed bilateral basal ganglia calcifications. The patient was treated with intravenous calcium gluconate, magnesium and oral vitamin D3. On follow-up the patient showed improvement of muscle weakness and carpopedal spasm with near-normal biochemical parameters. However, there was no improvement in symptoms related to spondyloarthropathy. CONCLUSIONS: Idiopathic hypoparathyroidism is a rare endocrine disorder with clinic and biochemical features of hypocalcemia. Long- standing hypoparathyroidism can cause spondyloarthropathic changes closely resembling ankylosing spondylitis and DISH. Skeletal changes of long-standing hypoparathyroidism are irreversible. If left untreated, life-threatening complications like cardiac arrhythmias and broncholaryngospasm may occur.

A Classic Case of Tuberous Sclerosis with Multisystem Involvement Including Giant Bilateral Renal Angiomyolipomas Presenting as Massive Hematuria.

BACKGROUND: Tuberous Sclerosis (TSC) also known as Bourneville disease is a neurocutaneous syndrome having an autosomal dominant inheritance pattern, though the condition has a high rate of spontaneous mutation. It is the second most common neurocutaneous syndrome after neurofibromatosis. This disease demonstrates a widespread potential for hamartomatous growths in multiple organ systems. CASE REPORT: We report a case of a 36-year-old female with TSC presenting as massive hematuria with underlying giant bilateral renal angiomyolipomas (AML) with estimated total tumor burden of more than 8 kg which is to the best of our knowledge the highest ever reported. The patient also had lymphangioleiomyomatosis and lesions in the brain, skin, teeth and bones. CONCLUSIONS: TSC has a wide variety of clinical and radiologic manifestations. It should be suspected when some of the common radiological manifestations are found, including CNS involvement, renal and hepatic AMLs and LAM, even if clinical signs are not obvious. Renal AMLs in setting of TSC may reach giant proportions and may present with massive hematuria.