Atypical Imaging Findings Research Articles

An unusual case of cerebral autosomal-dominant arteriopathy with subcortical infarcts and leukoencephalopathy with occipital lobe involvement.

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is an autosomal dominant angiopathy caused by a mutation in the notch 3 gene on chromosome 19. Clinically, patients may be asymptomatic or can present with recurrent ischemic episodes and strokes leading to dementia, depression, pseudobulbar palsy, and hemi- or quadraplegia. Additional manifestations that have been described include migraine (mostly with aura), psychiatric disturbances, and epileptic seizures. Neuroimaging is essential to the diagnosis of CADASIL. On imaging CADASIL is characterized by symmetric involvement by confluent lesions located subcortically in the frontal and temporal lobes as well as in the insula, periventricularly, in the centrum semiovale, in the internal and external capsule, basal ganglia, and brain stem; with relative sparing of the fronto-orbital and the occipital subcortical regions. We describe a 49 year old male with CADASIL with absence of temporal lobe findings on MRI but predominant lesions within the periventricular white matter, occipital lobes with extension into the subcortical frontal lobes, corpus callosum and cerebellar white matter. Although CADASIL characteristically presents with anterior temporal lobe involvement, these findings may be absent and our case addresses the atypical imaging findings in CADASIL.

Hypertensive Encephalopathy with Atypical Imaging Findings

Received April 16, 2015 Revised June 19, 2015 Accepted June 19, 2015 Address for correspondence: Sang-Won Ha, MD Department of Neurology, Veterans Health Service Medical Center, 53 Jinhwangdo-ro 61-gil, Dunchon-dong, Gangdong-gu, Seoul 05368, Korea Tel: +82-2-2225-1324 Fax: +82-2-2225-1327 E-mail: hippocam@naver.com Figure. Radiologic findings of the patient. Apparent diffusion coefficients map of diffusion weighted images do not show diffusion restriction (A, B). Intracranial magnetic resonance angiography shows no significant steno-occulsive lesion (C). Fluid attenuated inversion recovery images (D, E) show T2 hyperintense lesions in the left corona radiata, left insula, left parieto-occipital lobes. Also present is abnormal low intense lesion in the left parietal lobe (F, white arrow). Computed Tomography image shows hyperdense lesion in the left insula (G, white arrow). Gradient recalled echo T2 weighted images (H) show multiple petechial hemorrhages in the left insula and left parietal lobe. Brain magnetic resonance imaging after 1 month of admission shows much improvement of lesions (I). 82세 여자가 수 일전 발생한 두통 및 의식변화로 내원하였다. 혈압은 202/140 mmHg이고, 다른 활력징후는 정상이었으며, 응 급실에서 전신강직간대발작을 하였으나, 국소신경학적결손은 없 었다. 혈액검사는 정상이었고, 뇌척수액검사에서 단백질 상승이 보였다(115 mg/dL). 증상 발생 20여 시간 만에 시행한 확산강 조영상에서 확산제한은 없었고(Fig. A, B) 두개내 자기공명혈관 조영술은 정상이었다(Fig. C). 액체감쇠역전회복영상에서 좌측

Pseudolymphoma of the liver: a case report and literature review.

Pseudolymphoma is a benign lymphocytic tumor-like lesion, and its occurrence in the liver is rare. Here, we report the case of a 78-year-old woman with pseudolymphoma of the liver. She had a history of tremors for several years. Therefore, she underwent computed tomography (CT) for screening, and liver tumors were incidentally identified. She did not have any history of liver disease. Liver function test results and tumor marker levels were all within normal limits, and viral markers for hepatitis were negative. Contrast-enhanced CT revealed four nodules measuring up to 13 mm in diameter with ring enhancement in both lobes of the liver. On magnetic resonance imaging, the lesions showed slightly high intensity on T2-weighted images and high intensity on diffusion-weighted images. Because of atypical imaging findings, the tumors could not be definitively diagnosed. Therefore, we performed laparoscopic limited resection of segments 2, 3, 4, and 8 of the liver. The final pathological diagnosis was pseudolymphoma of the liver. The patient has had no signs of recurrence for 6 months after the surgery. Although pseudolymphoma of the liver is rare, it is necessary to consider it in the differential diagnosis of a liver tumor.

Invasive urothelial carcinoma within a calyceal diverticulum associated with renal stones: A case report.

Calyceal diverticula are rare outpouchings of the upper collecting system lying within the renal parenchyma. These often contain stones, however, carcinoma within a calyceal diverticulum is uncommon. The present study reports a case of invasive urothelial carcinoma within a calyceal diverticulum associated with renal stones. A 70-year-old male with a left renal mass identified by abdominal computed tomography was referred to the Department of Urology, Kanazawa University Hospital. Pre-operative diagnosis was difficult owing to an atypical imaging finding of a hypovascular renal mass with calcification. A laparoscopic nephroureterectomy was performed, and the surgical specimens showed invasive high-grade urothelial carcinoma within a calyceal diverticulum, and the calcifications were renal stones consisting of 97% calcium oxalate. Urothelial carcinoma in calyceal diverticula is a rare condition, however, a pre-operative definite diagnosis is difficult and a high potential for invasion of the renal parenchyma is suspected in this disease.

Typical and Atypical Imaging Findings of Abdominal Teratomas

Teratomas are most commonly observed as lesions of ovarian origin. They can also be detected in extragonadal regions such as brain, face, neck, mediastinum, retroperitoneum, and sacrococcygeal region. Ovarian teratomas are usually in mature cystic form as benign, well-differentiated, and cystic lesions. Immature teratomas and monodermal teratomas (struma ovarii, carcinoid tumors and neural tumors) are rare forms. Mature cystic teratomas are usually diagnosed by ultrasound (US) and magnetic resonance (MR) imaging. On US, a variety of appearances including echogenic sebaceous material and calcification are observed. MR imaging can specifically demonstrate fat component by fat-saturation sequences. On the other hand, teratomas are usually incidentally detected on computed tomography (CT) and fat attenuation within a cyst is diagnostic. It may be difficult to characterize immature teratomas due to nonspesicific findings on US. However, CT and MR can provide diagnosis by identifying small foci of fat within a mass with irregular solid component containing coarse calcifications. A small proportion of mature cystic teratomas can undergo malignant transformation (carcinomas or sarcomas). The purpose of this paper is to review the imaging features of various types of abdominally located teratomas for differentiation and diagnosis. Keywords: Computed tomography, dermoid cyst, magnetic resonance, ovary, teratoma, tumor, ultrasonography.

Diagnosis and treatment of inflammatory breast cancer

Inflammatory breast cancer (IBC) is a rare disease in clinic, with rapid progression and poor prognosis. It is easy to be misdiagnosed in cases of atypical clinical symptoms and imaging findings. Combined with the medical record of IBC in our hospital, the author explores the causes of misdiagnosis of inflammatory breast cancer, based on clinical manifestations, diagnosis, imaging examination, treatment and so on, so as to improve the clinical physicians understanding and diagnosis of this disease.

Cryptococcosis mimicking lung cancer with brain metastasis

Cryptococcus neoformans is a ubiquitous organism that primarily nfects the lungs and subsequently spreads to the central nerous system (CNS) through the haematogenous route [1]. Although everal imaging patterns are well described in both CNS and pulonary cryptococcosis, the diagnosis of Cryptococcus infection can e confusing if there are atypical image findings. We report the ase of a patient with CNS and pulmonary cryptococcosis who preented with unusual imaging findings that mimicked lung cancer ith brain metastasis.

Atypical Magnetic Resonance Imaging Findings in Hepatocellular Carcinoma

Magnetic resonance imaging (MRI) is currently the modality of choice to evaluate liver lesions in patients with cirrhosis and hepatitis B and C. Hepatocellular carcinoma demonstrates typical imaging findings on contrast-enhanced MRI, which are usually diagnostic. Unfortunately, a subgroup of hepatocellular carcinoma presents with atypical imaging features, and awareness of these atypical presentations is important in ensuring early diagnosis and optimal patient outcomes. Herein, we review some of the more common atypical presentations with a focus on MRI.

Imaging and differential diagnosis of pediatric spinal tuberculosis

ObjectiveThis paper aimed to summarize imaging features of pediatric spinal tuberculosis. MethodsThe spinal X-ray, CT and MR presentations of 21 patients under 18 years old who were confirmed with tuberculosis by biopsy or pathological surgery were retrospectively analyzed. ResultsAmong the 21 cases, 14 cases (66.7%) had consecutive multi-vertebral lesions; 2 cases (9.5%) had nonconsecutive multi-vertebral lesions; and 5 cases (23.8%) had single vertebral lesion. Besides, 18 (85.7%) cases presented with typical imaging findings: well-defined bone destruction, intervertebral space stenosis and existence of marginal sclerosis, sequestrum and paravertebral soft tissue. The remaining 3 (14.3%) cases presented with atypical imaging findings, with two cases of single vertebral lesion misdiagnosed as Langerhans cell histiocytosis and one case of nonconsecutive multiple vertebral lesions and ill-defined bone destruction diagnosed as malignant neoplasm. ConclusionPediatric spinal tuberculosis often occurs in the cervical and thoracic vertebrae with typical imaging findings. The cases with atypical manifestations should be differentiated from other diseases such as Langerhans cell histiocytosis and metastatic neoplasm.

Creutzfeldt-Jakob Disease with a prion protein gene codon 180 mutation presenting asymmetric cortical high-intensity on magnetic resonance imaging

ABSTRACT. Here we report a genetically confirmed case of Creutzfeldt-Jakob disease with a prion protein gene codon 180 mutation presenting atypical magnetic resonance imaging findings. The present case exhibited an acute onset and lateralized neurologic signs, and progressive cognitive impairment. No myoclonus or periodic synchronous discharges on electroencephalography were observed. Diffusion-weighted images revealed areas of high signal intensity in the right frontal and temporal cortices at onset that extended to the whole cortex and basal ganglia of the right cerebral hemisphere at 3 months. Although the cerebrospinal fluid (CSF) was initially negative for neuron specific enolase, tau protein, 14–3–3 protein, and abnormal prion protein, the CSF was positive for these brain-derived proteins at 3 months after onset.

A pediatric case of multiple hepatic focal nodular hyperplasia-like lesions presenting as atypical imaging and histopathological findings

A pediatric case of multiple hepatic focal nodular hyperplasia-like lesions presenting as atypical imaging and histopathological findings

Postpartum hypernatremic cerebral encephalopathy with osmotic myelinolysis: Report of two cases and review with emphasis on magnetic resonance imaging findings

Postpartum complications are diverse. Electrolyte imbalance with hypernatremia can occur secondary to underlying postpartum complication or can arise de novo. Hypernatremia causes demyelination similar to hyponatremia but predominantly involves extra-pontine structures. Here, we present two cases, one classical and another a variant of a recently described entity called postpartum hypernatremic encephalopathy with osmotic demyelination. The more classical appearance is altered signal intensity changes in the posterior limb of internal capsules, external capsule, crus cerebri, corticopontine tracts, middle cerebellar peduncle, hippocampus, fornix, and cerebellar white matter with classical wine glass appearance on coronal T2-weighted images. The nonclassical case shows a different and atypical imaging finding of the same disease with small focal transient altered signal intensity changes in the splenium of corpus callosum. Both the patients recovered with conservative management of the electrolyte imbalance.

CN-09 * POSTERIOR REVERSIBLE ENCEPHALOPATHY SYNDROME AND PRIMARY BRAIN TUMORS

BACKGROUND: Posterior reversible encephalopathy syndrome (PRES) is a neurotoxic encephalopathic state associated with reversible cerebral vasogenic edema. It is an increasingly recognized occurrence in the oncology population. However, it is very uncommon in patients with primary brain tumors (PBT). The aim of this study is to analyze the clinical manifestations, radiological features and report clinical outcomes of PRES in PBT patients. METHODS: In this retrospective review, we identified 4 patients with PBTs who developed PRES at MDACC between 2012 and 2014. Clinical and radiographic data were abstracted from their records. In addition, we also solicited 2 cases from the literature. RESULTS: The median age at diagnosis of PRES was 47 years (range 5-62), the male:female ratio was 1:5 and occurred in patients with glioblastoma (N = 3), diffuse intrinsic pontine glioma (N = 1), anaplastic ependymoma (N = 1) and atypical meningioma (N = 1). The two cases from literature review had received bevacizumab, and only one case received chemotherapy (cisplatin/etoposide/temozolomide) before the symptoms onset. Clinical presentation included seizures (N = 3), altered mental status (N = 3), headache (N = 2) and focal neurologic deficits (N = 2). All of the patients presented with elevated blood pressure. Three patients had atypical imaging findings, one of them also developed infarctions in those areas. Three of our MDACC patients recovered completely in 3 to 4 weeks after the symptoms onset. One patient died due to active cancer and several comorbidities including PRES. CONCLUSIONS: HTN seems to be the most important co-existent risk factor for development of PRES. The clinical and radiological course of PRES in PBT patients did not vary from the classical descriptions of PRES found in other causes. Resolution of PRES was an independent process even to that of tumor progression. PRES distribution did not correlate with the brain tumor location. Delay in diagnosis can result in permanent residual deficits.

Chorea-ballism associated with ketotic hyperglycemia.

Chorea-ballism is a rare movement disorder characterized by irregular, poorly patterned, and involuntary movements, which are usually unilateral but may be bilateral or involve the extremities. The most common metabolic cause of transient chorea-ballism is nonketotic or ketotic hyperglycemia (NKHG or KHG, respectively). A meta-analysis and several reviews have identified clinical characteristics of NKHG-associated chorea-ballism; however, the characteristics of KHG-associated chorea-ballism remain unknown. We performed a search for studies of patients with KHG-associated chorea-ballism, published in MEDLINE between 1960 and May 2014, and identified 13 studies of 15 patients. Despite the limited number of cases, we identified some significant differences in the clinical and radiological characteristics between patients with KHG- or NKHG-induced chorea-ballism. Patients with KHG were significantly younger than patients with NKHG, and a higher percentage of patients with KHG had atypical or negative brain imaging findings for chorea-ballism compared to patients with NKHG. We recommend that blood glucose levels be tested on admission as a key diagnostic measure, to improve the early diagnosis of chorea-ballism. The best treatment for KHG-induced chorea-ballism is rapid glucose control with an insulin drip and, possibly, neuroleptics. The mechanisms of the disease are unclear, although the GABA theory, cerebrovascular insufficiency, and alterations of dopaminergic activity in the striatum might play important roles.

Localized pulmonary alveolar proteinosis: two case reports.

Pulmonary alveolar proteinosis (PAP) is a relatively rare disease characterized by abnormal accumulation of surfactant-like material in the alveolar spaces. The classic radiologic findings of PAP include bilateral, symmetric, diffuse ground-glass opacity (GGO) or consolidation. The most common computed tomography (CT) feature of PAP is widespread GGO with thickened interlobular septa, the so-called crazy-paving pattern, which strongly suggests the diagnosis. Here, we report the cases of two young male patients with unusual presentations of PAP. One patient showed localized PAP in the left lower lobe on CT images and the other patient presented with unilateral PAP involving the right lower lung field and recurrence in the same area with the same pattern as the initial manifestation. In conclusion, it is important for radiologists to be aware of potential atypical imaging findings of PAP in order to provide a correct diagnosis. Along these lines, PAP can present as a solitary nodular lesion or unilateral focal lesion, and can recur in the same pattern and location.

Neuroimaging Features and Predictors of Outcome in Eclamptic Encephalopathy: A Prospective Observational Study

Posterior reversible encephalopathy syndrome is associated with eclampsia. We assessed the distribution and nature of typical and atypical cranial MR imaging findings in these patients and their correlation with clinical and laboratory data and predictors of outcome. Forty-five clinically confirmed cases of eclampsia were included in this prospective observational study. Subjects with hemolysis, elevated liver enzymes, and low platelets syndrome (n = 9) and pre-existing neurologic conditions (1 with cerebral solitary cysticercus granuloma) were excluded. Patients underwent blood investigations and cranial MR imaging. Twenty-seven patients had abnormal while 8 had normal MR imaging findings. Involvement of brain regions was as follows: frontal, 88.89%; temporal, 44.44%; parietal, 100%; occipital, 100%; deep gray matter, 29.63%; cerebellum, 22.22%; brain stem, 14.81%. Cytotoxic edema was present in 33.33% of cases; 66.67% of patients had mild posterior reversible encephalopathy syndrome; 25.92% had moderate posterior reversible encephalopathy syndrome; and 7.41% had severe posterior reversible encephalopathy syndrome. Abnormal neuroimaging findings were significantly associated with altered sensorium; visual disturbances; status epilepticus; and elevated serum creatinine, uric acid, and lactate dehydrogenase (P=.006, P=.018, P=.015, P=.019, P=.003, and P=.001, respectively). Serum creatinine, uric acid, and lactate dehydrogenase values and the presence of moderate or severe posterior reversible encephalopathy syndrome were significantly associated with mortality (P<.001, P<.001, P=.009, and P=.027, respectively). Neuroimaging in eclampsia demonstrates a higher incidence of atypical distributions and cytotoxic edema than previously thought. Altered sensorium; visual disturbances; status epilepticus; and elevated serum uric acid, lactate dehydrogenase, and creatinine are associated with abnormal neuroimaging findings. Higher serum creatinine, uric acid, and lactate dehydrogenase levels and moderate and severe forms of posterior reversible encephalopathy syndrome are possible predictors of poor outcome.

Astrocitoma pilocítico. Formas de presentación

Our purpose is to illustrate and describe the typical and atypical imaging findings of supra and infratentorial pilocytic astrocytoma (PA) with computed tomography (CT) and magnetic resonance imaging (MRI). For this, 32 patients with PA from our case series were selected. Twenty-four patients had confirmed PA from histologic analysis. The remaining 8 patients presented optic pathway gliomas and PA was the most accurate presumptive diagnosis. All patients, 20 male and 12 female (age range 10 months-65 years), underwent unenhanced and enhanced MRI. Diffusion-weighted images and MR spectroscopy (MRS) were performed in 6 patients, and 6 patients underwent CT.The locations of the PA selected (n = 32) were: optic pathway and hipotalamous-quiasmatic region (n = 17), cerebellum (n = 7), talamous (n = 6) and cerebral hemisphere (n = 2).At MRI most PA appeared as solid-cystic masses, iso to hypointense in T1-weighted images and hyperintense in T2-weighted images and FLAIR, with post-contrast enhancement.Four patients presented atypical characteristics: 1 solid cerebellum PA with calcifications, 1 hypothalamus PA in a child without NF1 with no contrast enhancement and 1 cerebral hemisphere PA in a 65 year old woman.The PA are regarded as grade I tumors in the WHO classification. The optic pathway and the hypothalamic-quiasmatic region, as well as the posterior fossa are the most frequent locations. PA are typically well-circumscribed and solid-cystic lesions with low cellularity and slow growth.

Primary melanoma of the cochlea with cerebellopontine extension and leptomeningeal spread

Less than 1 per cent of tumours occurring in the region encompassing the internal auditory canal and the cerebellopontine angle are malignant. Primary central nervous system melanomas arising from this region are exceptionally rare and are often initially misdiagnosed as acoustic neuromas. We present a 71-year-old man with acute vestibular disturbance and unilateral hearing loss. Magnetic resonance imaging demonstrated a mass, thought to be a cochlear nerve schwannoma, involving the cochlea and the internal auditory canal. At surgery, a pigmented mass adherent to the facial nerve was visualised, and the observed histopathology was consistent with a malignant melanoma. No extracranial site for the primary tumour was found, suggestive of a primary central nervous system melanoma. Despite surgical resection and adjuvant radiotherapy, the patient re-presented with extensive leptomeningeal disease 16 months later. Malignant tumours in the internal auditory canal and cerebellopontine angle region are rare. Early diagnosis and management are aided by recognition of characteristic factors such as a history of prior malignancy, atypical magnetic resonance imaging findings and accelerated audiovestibular symptoms. Despite the presented patient's outcome, total surgical resection with post-operative radiotherapy remains the recommended treatment.

Diagnostic Algorithm for Autoimmune Pancreatitis in Korea

Autoimmune pancreatitis should be differentiated from pancreatobiliary cancers because they often have similar clinical features and images. Accurate and practical diagnostic algorithm for AIP is important to avoid unnecessary surgery and delayed treatment. International Consensus Diagnostic Criteria for AIP suggested that diagnostic algorithms and the practical patterns considerably vary worldwide. Patients with clinically suspected AIP can be categorized into patients with typical features of AIP and patients with indeterminate features based on CT findings. Serology and other organ involvement can be used as collateral evidence of AIP. If a patient presents with diffuse pancreatic enlargement but is lack of collateral evidence, pancreatogram could be useful. If a patient has obstructive jaundice, biliary drainage and endobiliary biopsy are recommended. Duodenal papillary biopsy for IgG4 immunostain can be used during ERCP. In case of atypical imaging findings, EUS-guided FNA/biopsy is recommended to exclude pancreatic cancer and to obtain the suggestive findings of AIP. If type 2 is clinically suspected, EUS-guided core biopsy is required for the definite diagnosis. Short-term steroid trial can be performed to confirm the diagnosis of AIP when pancreatobiliary cancer workup shows negative results. However, clinical practice in diagnosing AIP varies depending on the local expertise, facilities, cost, prevalence of AIP and its subtypes. Korean J Pancreatobiliary 2014;19(1):7-12

Unusual imaging of pancreatic metastasis: A case report of tumor-to-tumor metastasis

Introduction: Metastasis of one tumor to another tumor is a very rare and controversial phenomenon. Solitary renal cell carcinoma metastasis to a preexisting pancreatic endocrine tumor is distinctly uncommon. We report atypical imaging findings of pancreatic metastasis from renal cell carcinoma, due to tumor-to- tumor metastasis for presence of renal cell carcinoma metastasizing to a pancreatic endocrine tumor. Case Report: A 78-year-old male suffering from mild anemia underwent to multidetector computed tomography scan showing renal cell carcinoma and solid-cystic pancreatic mass, both resectable, treated with right radical nephrectomy and spleno-distal pancreatectomy. Histopathology of the resected renal and pancreatic specimens confirmed a clear cells right renal cell carcinoma metastatic to endocrine neoplasm of pancreatic bodytail. We compared multidetector computed tomography scan findings and histopathological pancreatic specimen. The imaging finding of peripheral rim enhancement coincided in pancreatic pathologic specimen with presence of pancreatic endocrine tumor. The imaging finding of solid trabeculae inside the mass corresponded in pancreatic pathologic specimen to presence of pancreatic endocrine tumor mixed with lobules of typical renal carcinoma metastatic cells. Finally, the imaging finding of hypoenhancing central area of lesion coincided in pancreatic pathologic specimen with presence of large necrotic component. Conclusion: We describe an unusual multidetector computed tomography scan finding of renal cell carcinoma metastasizing to pancreatic endocrine tumor and emphasize the knowledge of rare phenomena of tumor-to-tumor metastasis.