Case 324: CHANTER Syndrome.

HISTORY: A 69-year-old right-handed man with a history of substance use disorder, hypertension, and diabetes presented to the emergency department in an unresponsive state. Upon examination, apart from tachycardia (heart rate, 108 beats per minute), vital signs were within normal ranges (blood pressure, 134/102 mm Hg; temperature, 97.9 ºF (36.6 ºC); respiratory rate, 16 per minute; oxygen saturation, 96%). The patient had a Glasgow coma scale score of 8. Otherwise, the physical examination revealed no abnormalities. Prior psychiatric and surgical histories were unremarkable. There was no history of recent travel, camping, hiking, or vaccination. No family history could be obtained. Laboratory work-up revealed an elevated creatine kinase level (49 006 U/L [818.4 µkat/L]; normal reference range, 10-205 U/L [0.17-3.42 µkat/L]). An electrocardiogram showed sinus tachycardia without evidence of cardiac ischemia. An echocardiogram was unremarkable. Alanine aminotransferase (126 U/L [2.10 µkat/L]; normal reference range, 0-40 U/L [0-0.67 µkat/L]) and aspartate aminotransferase (488 U/L [8.15 µkat/L]; normal reference range, 3-44 U/L [0.05-0.74 µkat/L]) levels were elevated. Polymerase chain reaction results were negative for HIV-1, HIV-2, syphilis treponemal, and COVID-19 antibodies. The remaining routine laboratory work-up findings were within normal limits. Urine drug screening was positive for cocaine, marijuana, fentanyl, and benzodiazepines. Naloxone was administered, but the patient remained unresponsive. Intubation was performed for airway protection. Noncontrast and contrast-enhanced CT of the head and CT angiography were performed in the emergency department to rule out an acute intracranial abnormality. Multisequence MRI of the brain with administration of intravenous contrast material was ordered for further assessment. CT of the abdomen and pelvis was unremarkable (images not shown).

Case 324.

HISTORY: A 69-year-old right-handed man with a history of substance use disorder, hypertension, and diabetes presented to the emergency department in an unresponsive state. Upon examination, apart from tachycardia (heart rate, 108 beats per minute), vital signs were within normal ranges (blood pressure, 134/102 mm Hg; temperature, 97.9°F [36.6°C]; respiratory rate, 16 breaths per minute; oxygen saturation, 96%). He had a Glasgow coma scale score of 8. Otherwise, the physical examination revealed no abnormalities. His prior psychiatric and surgical histories were unremarkable. There was no history of recent travel, camping, hiking, or vaccination. No family history could be obtained. Laboratory work-up revealed an elevated creatine kinase level (49 006 U/L [818.4 µkat/L]; normal reference range, 10-205 U/L [0.17-3.42 µkat/L]). An electrocardiogram showed sinus tachycardia without evidence of cardiac ischemia. An echocardiogram was unremarkable. Alanine aminotransferase (126 U/L [2.10 µkat/L]; normal reference range, 0-40 U/L [0-0.67 µkat/L]) and aspartate aminotransferase (488 U/L [8.15 µkat/L]; normal reference range, 3-44 U/L [0.05-0.74 µkat/L]) levels were elevated. Polymerase chain reaction results were negative for HIV-1, HIV-2, syphilis treponemal, and COVID-19 antibodies. The rest of the routine laboratory work-up findings were within normal limits. Urine drug screening was positive for cocaine, marijuana, fentanyl, and benzodiazepines. Naloxone was administered, but the patient remained unresponsive. Intubation was performed for airway protection. Noncontrast and contrast-enhanced CT of the head (Fig 1) and CT angiography were performed in the emergency department to rule out an acute intracranial abnormality. Multisequence MRI of the brain with administration of intravenous contrast material was ordered for further assessment (Figs 2-4). CT of the abdomen and pelvis was unremarkable (images not shown).

Automatic Ventriculomegaly Detection in Fetal Brain MRI: A Step-by-Step Deep Learning Model for Novel 2D-3D Linear Measurements.

In this study, we developed an automated workflow using a deep learning model (DL) to measure the lateral ventricle linearly in fetal brain MRI, which are subsequently classified into normal or ventriculomegaly, defined as a diameter wider than 10 mm at the level of the thalamus and choroid plexus. To accomplish this, we first trained a UNet-based deep learning model to segment the brain of a fetus into seven different tissue categories using a public dataset (FeTA 2022) consisting of fetal T2-weighted images. Then, an automatic workflow was developed to perform lateral ventricle measurement at the level of the thalamus and choroid plexus. The test dataset included 22 cases of normal and abnormal T2-weighted fetal brain MRIs. Measurements performed by our AI model were compared with manual measurements performed by a general radiologist and a neuroradiologist. The AI model correctly classified 95% of fetal brain MRI cases into normal or ventriculomegaly. It could measure the lateral ventricle diameter in 95% of cases with less than a 1.7 mm error. The average difference between measurements was 0.90 mm in AI vs. general radiologists and 0.82 mm in AI vs. neuroradiologists, which are comparable to the difference between the two radiologists, 0.51 mm. In addition, the AI model also enabled the researchers to create 3D-reconstructed images, which better represent real anatomy than 2D images. When a manual measurement is performed, it could also provide both the right and left ventricles in just one cut, instead of two. The measurement difference between the general radiologist and the algorithm (p = 0.9827), and between the neuroradiologist and the algorithm (p = 0.2378), was not statistically significant. In contrast, the difference between general radiologists vs. neuroradiologists was statistically significant (p = 0.0043). To the best of our knowledge, this is the first study that performs 2D linear measurement of ventriculomegaly with a 3D model based on an artificial intelligence approach. The paper presents a step-by-step approach for designing an AI model based on several radiological criteria. Overall, this study showed that AI can automatically calculate the lateral ventricle in fetal brain MRIs and accurately classify them as abnormal or normal.

Case 313: Cerebral Venous Infarct Due to Internal Cerebral Vein Thrombosis in the Setting of COVID-19 Infection.

HISTORY: A 45-year-old woman presented to the emergency department of an outside hospital with shortness of breath and cough. Five days after initial presentation, the patient presented again to the same emergency department with worsening headache and progressive left arm and left leg weakness. She was transferred to the neuroscience intensive care unit of our hospital with concern for an intracranial abnormality based on her work-up at the outside hospital. Her past medical history was notable only for a large uterine fibroid. In our hospital, CT of the brain and chest and MRI of the brain, including perfusion studies, were performed. Additionally, CT venography of the brain was performed.

Case 313.

HISTORY: A 45-year-old woman presented to the emergency department of an outside hospital with shortness of breath and cough. Five days after initial presentation, the patient presented again to the same emergency department with worsening headache and progressive left arm and left leg weakness. She was transferred to the neuroscience intensive care unit of our hospital with concern for an intracranial abnormality based on her work-up at the outside hospital. Her past medical history was notable only for a large uterine fibroid. In our hospital, CT of the brain and chest (Figs 1, 2) and MRI of the brain, including perfusion studies (Figs 3, 4), were performed. Additionally, CT venography of the brain was performed (Fig 5).

Shear wave elastography evaluation of brachial plexus in multiple sclerosis.

BACKGROUND: Multiple sclerosis (MS) is a chronic neuroinflammatory disease characterized by inflammation involving the peripheral nerves. Shear wave elastography (SWE) is potentially a method of choice for detecting peripheral nerve involvement. PURPOSE: To compare the degree of thickening and nerve elasticity of brachial plexus (BP) nerve roots and evaluate the usefulness of sonoelastography in patients with clinically diagnosed MS without brachial plexopathy. MATERIAL AND METHODS: Thirty-two patients with MS and 32 controls were included in the study. Bilateral C5, C6, and C7 mean nerve root diameters, and mean elasticity values in kiloPascal (kPa) were measured in the patient and control groups. The relationship between the age, height, and weight values and nerve diameter-elasticity values of the patient and control groups was compared. RESULTS: The elasticity values of the C5 and C6 nerve roots were increased, and the nerve root thickness was decreased in the MS group compared to that in the control (P < 0.05). There was no difference between the C7 mean nerve root elasticity (kPa) and diameter measurements in the patient and control groups (P > 0.05). CONCLUSION: Our study showed an increase in the BP nerve root elasticity values (kPa) in patients with MS compared to that of the control group and a decrease in diameter values thought to be related to the possible chronic atrophic process. The results are consistent with the demyelinating process of the peripheral nervous system (PNS) due to MS.

Shear wave elastography evaluation in predicting the success of ultrasound-guided saline enema hydrostatic reduction technique in ileocolic intussusception.

BACKGROUND: Intussusception is the invagination of the proximal intestinal segment into the distal portion. Reduction procedures with fluid or air have been used as the primary treatment of choice in clinically stable children. PURPOSE: To evaluate the role of intestinal wall elasticity measurements by shear wave elastography (SWE) to predict the success of ultrasound-guided saline enema (USGSE) reduction. METHODS: USGSE was performed, if not contraindicated otherwise, after the diagnosis of ileocecal intussusception via the ultrasound (US). The length and diameter of the intussusception and the median stiffness of the intestine were measured before USGSE. RESULTS: Seventeen children were diagnosed with ileocolic intussusception via grayscale US assessment. Two children whose SWE images became artifacts due to inadaptability were excluded from the study. Thus, the study involved 15 patients (9 boys, 6 girls; age range = 11-48 months). There was no statistically significant association between age and median stiffness measurement in kilopascal (kPa). (P > 0.05). A moderate positive correlation was observed between the median stiffness measurement (kPa) and the length of intussusception (r = 0.547; P = 0.035). There was no statistically significant relationship between median stiffness measurement (kPa) and short-axis diameter of intussusception (P > 0.05). CONCLUSIONS: Stiffness assessment of the intestinal wall in ileocolic intussusception during the US examination, which is the gold standard in the intussusception assessment, can be used as a new criterion for predicting the performance of the USGSE technique and might be useful in making decisions regarding the clinical management of ileocolic intussusception.

Diaphragmatic Mesothelial Cyst: Radiological Appearance and Follow-Up Results During Childhood.

ABSTRACT: To identify radiological findings of diaphragmatic mesothelial cysts (DMC) in the pediatric age group and to assess follow-up outcomes.In this study, 27 pediatric age group patients were evaluated with ultrasonography (US), computed tomography (CT), or magnetic resonance imaging due to various clinical indications and diagnosed with DMC from May 2014 to September 2018. Age, sex, imaging indications and DMC localization, volumes in the first diagnosis, and follow-ups were retrospectively evaluated. Descriptive statistics were used for age, sex, imaging indications, and volume are presented as numbers and percentages.Ages range from 5 months to 13 years. Nine girls and 18 boys included in this study. The most common imaging indications were abdominal pain, diarrhea, and obesity. The mean volume of DMC was at first 2.62 and 2.45 mL during the follow-ups. There was volume reduction in 24 cases, and no change in 3 cases. Mean follow-up duration was 22.4 months. The US imaging findings were similar for all cases, bilobular cystic lesion with fat indentation between the cyst and liver parenchyma.The typical localization and lateral fat sign are useful in differential diagnosis of DMC from cystic lesions of liver. The US is a very effective and beneficial radiological method for diagnosis and follow-up. Routine clinical and sonographic follow-ups may be sufficient for asymptomatic patients with stable cyst volume.

Shear Wave Elastography Evaluation of Meniscus Degeneration with Magnetic Resonance Imaging Correlation.

RATIONALE AND OBJECTIVES: The objective of the study was to assess the diagnostic efficiency of shear wave elastography in the grading of meniscal degeneration compared to magnetic resonance imaging (MRI) as a reference standard. MATERIALS AND METHODS: Fifty patients were included in the study (who had bilateral knee MRI). Tissue elasticity was measured in the coronal plane from the meniscus body in kilopascal. Nonparametric testing (Mann-Whitney U) was utilized to assess the differences between mean elasticity of the meniscus tissue, gender. The inter-intraobserver agreement was determined by the intraclass correlation coefficient. The correlations between the mean elasticity of the meniscus versus age, height, and body mass index were calculated via the "Pearson Correlation Coefficient Test." The relationship between MRI meniscal degeneration grading and elastography elasticity module was determined via the "Spearman Correlation Test." A p value less than 0.05 was considered statistically significant. RESULTS: Inter-intraobserver intraclass correlation coefficient of the lateral and medial meniscus mean stiffness values were good or excellent (>0.8). A statistically significant increase in stiffness of meniscus tissue was observed with an increase in age (p = 0.003 for medial menisci, 0.006 for lateral menisci). Tissue stiffness was higher in the medial meniscus than the lateral meniscus (p < 0.001). A positive correlation was observed between the MRI meniscal degeneration grade and tissue stiffness (p < 0.05). Additionally, mean stiffness values from lateral and medial menisci were higher in the group with degeneration (p < 0.0001). CONCLUSION: Meniscus stiffness is increased with aging. There was a statistically significant positive correlation between meniscal stiffness and degeneration grading in MRI.

The evaluation of the use of 2D shear-wave ultrasound elastography in differentiation of clinically insignificant and significant liver fibrosis in pediatric age group.

OBJECTIVE: To determine the accuracy of 2D shear-wave elastography (2D-SWE) in pediatric age group patients in differentiating clinically insignificant and significant liver fibrosis using METAVIR fibrosis scoring system as the gold standard. INTRODUCTION: Liver biopsy has long been the gold standard in liver fibrosis diagnosis. However, due to probable complications and sampling variabilities, the need for more accurate and non-invasive techniques has increased. 2D-SWE is a non-invasive technique used in the evaluation of liver stiffness and utilized more and more in routine clinical practice with recent advances and researches. MATERIALS AND METHODS: In this retrospective single-center study, we included 46 pediatric age group patients who had a liver parenchymal biopsy and 2D-SWE evaluation regardless of etiology. For 2D-SWE, the LOGIQ E9 system (GE Medical Systems, Wisconsin, USA) and, for histopathological evaluation, METAVIR fibrosis scoring system were utilized. Patients were further subgrouped as clinically insignificant (METAVIR Score F0-1) and significant (METAVIR Score F2-4). The Kolmogorov-Smirnov and Mann-Whitney U tests were employed for statistical analysis. The diagnostic accuracy of 2D-SWE was assessed, and cutoff values were set by ROC curve analysis. RESULTS: kPa values were statistically different between clinically significant and insignificant fibrosis patient groups (p < 0.001). kPa value of 8.92 was designated as the best cutoff value according to the Youden Index. CONCLUSION: 2D-SWE is one of the non-invasive techniques in the evaluation of liver fibrosis. Our findings suggest that 2D-SWE accurately differentiate clinically insignificant and significant liver fibrosis.

The Change in the Renal Pelvis Anterior-Posterior Diameter Between Prevoiding and Postvoiding Status, and Its Correlation With Vesicoureteral Reflux.

In this study, our aim was to evaluate the significance of the change in renal pelvis anterior-posterior diameter (RPAPD) before and after micturition between vesicoureteral reflux (VUR)-positive and -negative patients to whom had voiding cystourethrography (VCUG) was performed.In this study, 69 children, age ranging from 0 to 12 years, were included. Before the VCUG imaging, the RPAPD was measured first with a full bladder and then after urination via ultrasound (US). The differences between in RPAPD measurements were noted and values compared made among VUR-positive and -negative children. Data distribution was inhomogeneous, and the Wilcoxon Sign Rank test was utilized instead of Student t test. There was no statistically significant difference in prevoiding and postvoiding RPAPD in VUR (+) and VUR (-) patients (P = 0.672). There was no statistically significant relation between VUR and the presence of hydronephrosis (P = 0.126). Vesicoureteral reflux is more common in patients with urinary tract infections (UTI) (P = 0.001). There was no statistically significant relationship between prevoiding and postvoiding RPAPD change and VUR diagnosis (P = 0,164).Ultrasound is the modality of choice for urinary system evaluation. Diagnosis of hydronephrosis via US is not sufficient in predicting VUR; however, indirect findings may reveal the diagnosis. A decrease in RPAPD in postvoiding US evaluation may not rule out the VUR diagnosis for this reason further imaging modalities, such as VCUG, should be taken into consideration for the patients with clinical suspicion.

Evaluation of a two-image technique consisting of an axial and a coronal image generated by using the rib-flattening application: effect on reading time and diagnostic validity

Background/aim: When reading a chest CT, a radiologist needs to evaluate each rib one by one due to complex curvy shape, which makes reporting a tiresome and time-consuming task. A new curved planar reformat application that flattens ribs on a single plane may find a place in the radiology reporting room. This study aimed to evaluate the effect of a two-image set created by using the rib-flattening application on the performance of a radiologist in detecting sclerotic rib lesions in cancer patients. Materials and methods: The local Institutional Review Board approved this retrospective study. Two radiologists with different experience levels reviewed chest CT examinations of 106 patients (76 men, 30 women). We divided the patients into group A (n = 54), reviewed by a standard method, and group B (n = 52), reviewed by a standard method and the two-image set created on the rib- flattening application. Reading times, validity indices, and agreement levels with reference data were evaluated for both readers. Results: The median reading time of the junior examiner significantly decreased with the rib-flattening method (160.5 s vs. 70.0 s; P < 0.001). Diagnostic indices of the senior reader were improved significantly at per patient level (group A, AUC: 0.867; group B, AUC: 0.982; P = 0.046). The new method showed better agreement levels (kappa: 0.69 to 0.96) than the general method (kappa: 0.53 to 0.91). Conclusion: Based on improved agreement levels, reading times, and diagnostic validity indices we conclude that a two-image set consisting of an axial and a coronal flattened-rib image may be used in conjunction with an ordinary exam.