Cerebral syphilitic gumma presenting with intracranial gumma and pathologic vertebrae fractures.

A 37-year-old female was admitted with worsening neurologic function. On arrival from an outside hospital, the patient was obtunded and intubated. Magnetic resonance imaging of the brain revealed nodular enhancement of the leptomeninges, intracranial osteolytic lesions, and diffuse vasogenic edema causing mass effect. Imaging of the thoracic spine revealed pathologic compression fractures of 4 thoracic vertebrae. On review of the patient's electronic medical record, the patient had previously received treatment for secondary syphilis with intramuscular benzathine penicillin G. Surgical biopsies of the frontal bone and dura showed diffuse, chronic inflammation while a biopsy of the adjacent brain parenchyma revealed replicating spirochetes. The patient was subsequently prescribed dexamethasone and benzathine penicillin G. She regained neurologic function but later signed out against medical advice without completing her treatment regimen.

Investigation of Whole Spine MRI in the Emergency Department at Two Large Tertiary Care Academic Medical Centers in the United States.

RATIONALE AND OBJECTIVES: The impact of emergent whole spine magnetic resonance imaging (WS-MRI) on patient management has not been extensively studied to date. Here, we explore indications, results, and outcomes associated with WS-MRI performed through the emergency departments (EDs) of 2 large tertiary care, academic medical centers in the Northeastern United States. We hypothesize that given a relatively low barrier to entry, coupled with lack of appropriateness guidelines, a sizeable proportion of WS-MRI studies performed emergently do not result in spine findings necessitating inpatient admission for immediate treatment. MATERIALS AND METHODS: We retrospectively studied 335 adult patients (≥18 years) who underwent WS-MRI through the ED between 2016 and 2019. The demographic data collected included, age, sex, chief complaint, history of spine disease, and date and type of last spine imaging prior to ED presentation. Data compiled from the time of ED visit included WS-MRI result and patient disposition, including reason for hospital admission, by which patients were categorized into groups to allow for ease of comparisons. Hypergeometric tests were used to determine statistically significant associations between random discrete variables. RESULTS: Trauma was the most frequent chief complaint, comprising 35% (n = 117) of all presentations, followed by pain (25%, n = 84), motor deficit (16%, n = 55), sensory disturbance (12%, n = 41), bowel, and/or bladder dysfunction (9%, n = 30), and subjective or objective fevers with suspicion for spine infection (2%, n = 8). The largest proportion of WS-MRI studies revealed degenerative disc disease (DDD) as the principal result (41%, n = 139). 52% of all patients were either discharged directly from the ED (41%) or admitted for a non-spine issue after WS-MRI (11%); of these numbers, 61% underwent WS-MRI and no other imaging study in the ED. In patients who presented with a chief complaint of pain, DDD was often the principal WS-MRI finding (54%), albeit this association was not statistically significant. DDD, nonetheless, was positively associated with a discharge from the ED (P <0.001). Trauma was positively associated with fracture or ligamentous/soft tissue injury (P <0.001) on WS-MRI and hospital admission for a spine issue (P <0.01). CONCLUSION: That just under half of patients in our study were admitted for spine-related pathology suggests that WS-MRI is valuable in the emergent setting. At the same time, however, that over half of patients were not subsequently admitted for a spine-related issue points to the possibility of further refining which patients would benefit most from WS-MRI. WS-MRI may be less helpful in patients presenting with pain, though may be higher-yield in those with trauma, motor deficits, and bowel/bladder complaints. Although MRI is highly sensitive in ruling out emergent central nervous system pathology, given the resource-intensive nature of the test, it is prudent to carefully select which patients should undergo emergent WS-MRI, especially in instances when more cost-effective, alternative diagnostic approaches, including detailed neurological exam, computed tomography, or localized/targeted MRI, are possible.

Complications of Ileal Conduits after Radical Cystectomy: Interventional Radiologic Management.

Since their introduction into clinical practice in the 1950s, ileal conduits have been the most common type of urinary diversion used after radical cystectomy worldwide. Although ileal conduits are technically simpler to construct than other forms of urinary diversion, a variety of complications can occur in the early and late postoperative periods. Early complications include urine leakage, urinary obstruction, postoperative fluid collection (eg, urinoma, hematoma, lymphocele, or abscess), and fistula formation. Late complications include ureteroileal anastomotic stricture, stomal stenosis, conduit stenosis, and urolithiasis. Although not directly related to ileal conduits, ureteroarterial fistula can occur in patients with an ileal conduit. Interventional radiologists can play a pivotal role in diagnosis and management of these complications by performing image-guided minimally invasive procedures. In this article, the authors review the surgical anatomy of an ileal conduit and the underlying pathophysiology of and diagnostic workup for complications related to ileal conduits. The authors also discuss and illustrate current approaches to interventional radiologic management of these complications, with emphasis on a collaborative approach with urologists or endourologists to best preserve patients' renal function and maintain their quality of life. ©RSNA, 2020.

Case 284: Posterior Quadrantic Dysplasia.

History A 36-year-old left-handed woman with a history of developmental delay and medical refractory seizures since birth most recently presented with continuous simple partial seizures and occasional breakthrough complex partial seizures with postictal migraines. These were described as the patient "becoming pale with sinking to the floor and staring for approximately 1 minute with confusion thereafter." The patient had years of reported seizure freedom until 2010 when she was evaluated for intractable headaches, and electroencephalography revealed her focal subclinical status. At that time, ambulatory electroencephalography findings showed asymmetric left parietal-occipital high-amplitude spike-and-wave discharges in her best awake and alert state. Since that time, the patient developed and continues to have complex partial seizures every 2-3 months that are persistent despite the implementation of several medical regimens. At the time of recent presentation, the patient initially underwent unenhanced head CT in the emergency department followed by unenhanced MRI of the brain due to increased seizure activity at the patient's group home despite continued compliance with her antiepileptic regimen. Contrast material-enhanced imaging was not available at the time of recent presentation, so comparison was made with gadolinium-enhanced brain MRI performed approximately 9 years earlier.

Intraluminal hyperdense appearance of the small bowel on high resolution computed tomography of the abdomen and pelvis secondary to use of Calcium Carbonate tablets (Tums) mimicking a small bowel fistula.

Hyperdensity within the small bowel is most commonly seen with positive oral contrast agents, intraluminal hemorrhage and less likely an abnormal fistulous connection with the colon containing rectally administered contrast. We present the case of a 57-year-old female with a complex history of breast cancer and multiple abdominal surgeries presenting with intraluminal hyperdense small bowel on computed tomography (CT) performed with rectal contrast. Postsurgical CT with rectal contrast, and no oral contrast, showed multifocal regions of intraluminal hyperdensity with the small bowel anterior to and close to the surgical anastomosis. This raised concerns for a fistula between the colon and small bowel; however, surgical exploration demonstrated an intact anastomosis without a coloenteric fistula. Additional history notes that the patient consumed an increased dose of calcium carbonate tablets for a few days prior to obtaining the scan and this intraluminal hyperdense appearance of the small bowel was then attributed to this. We conclude that ingested over the counter medications can pose an imaging dilemma for radiologists as their appearance on CT could falsely mimic pathology. It is imperative to obtain a thorough clinical history in such cases to provide accurate diagnoses and decrease unwanted imaging and clinical intervention. It is also important for radiologists to be aware of the appearances of commonly consumed over the counter medications that can mimic pathology as demonstrated by this case.

Case 284.

History A 36-year-old left-handed woman with a history of developmental delay and medical refractory seizures since birth most recently presented with continuous simple partial seizures and occasional breakthrough complex partial seizures with postictal migraines. These were described as the patient "becoming pale with sinking to the floor and staring for approximately 1 minute with confusion thereafter." The patient had years of reported seizure freedom until 2010 when she was evaluated for intractable headaches, and electroencephalography revealed her focal subclinical status. At that time, ambulatory electroencephalography findings showed asymmetric left parietal-occipital high-amplitude spike-and-wave discharges in her best awake and alert state. Since that time, the patient developed and continues to have complex partial seizures every 2-3 months that are persistent despite the implementation of several medical regimens. At the time of recent presentation, the patient initially underwent unenhanced head CT in the emergency department followed by unenhanced MRI of the brain due to increased seizure activity at the patient's group home despite continued compliance with her antiepileptic regimen. Contrast material-enhanced imaging was not available at the time of recent presentation, so comparison was made with gadolinium-enhanced brain MRI performed approximately 9 years earlier (Figs 1-5).

Incidental finding of renal pseudoaneurysm in child with tuberous sclerosis presenting with atypical clinical symptoms.

Tuberous sclerosis (TS) is a complex medical disorder with multisystemic clinical manifestations. Although the renal manifestations of this disease are well researched, the complexities of clinical diagnosis are raised significantly in patients with cognitive impairments, particularly in the pediatric population. We present a case of a 12-year-old male with intellectual disabilities and renal angiomyolipomas associated with his TS complex presenting with subtle cognitive and behavioral changes leading to the eventual diagnosis of a renal pseudoaneurysm. The purpose of this case report is to highlight the subtleties of diagnosis and management of patients with TS and cognitive impairments and maintaining a high clinical index of suspicion for life threatening complications when presenting symptoms are nonspecific. This case also demonstrates the importance of obtaining a thorough clinical history from parents and caregivers of these children and educating them on significance of recognizing changing behavior patterns. The healthcare responsibility for diagnosis and management must be shared by all levels of personnel that participate in the care to allow for improved morbidity, mortality, and quality of lives for these patients.