Homogeneous Contrast Enhancement Research Articles

Low-grade oncocytic tumor of the kidney: imaging features of a novel tumor entity.

Low-grade oncocytic tumor (LOT) is a rare renal tumor that has emerged from the spectrum of eosinophilic/oncocytic renal tumors and poses a diagnostic challenge due to its similarity to chromophobe renal cell carcinoma (CHRCC) and renal oncocytoma (RO). The imaging features of this novel tumor entity have not yet been clearly described. The purpose of this study was to describe the imaging features of LOT with radiologic-pathologic correlation. We conducted a retrospective observational study involving two expert centers. We identified 12 pathologically proven LOT with preoperative imaging available, including at least computed tomography (CT) or magnetic resonance imaging (MRI), from the past 12 years. Three experienced radiologists performed the imaging analysis independently. All tumors presented well-defined borders. Nine of the 12 LOT exhibited an early peripheral enhancement with complete or almost complete centripetal fill-in on nephrographic or delayed phases without any particular shape. Three showed a homogeneous contrast enhancement. Macroscopic fat and calcifications were not observed in any of the tumors. Early peripheral enhancement with complete or almost complete centripetal fill-in on nephrographic or delayed phases without any particular shape suggests a LOT diagnosis. Further analyses involving larger studies are needed to fully confirm these imaging characteristics. To date, a percutaneous biopsy should be performed before considering management.

Combining morphological and functional imaging parameters to diagnose primary bone neoplasms in the skull base, spine and sacrum.

Morphological magnetic resonance (MR) and computed tomography (CT) features are used in combination with histology for diagnosis and treatment selection of primary bone neoplasms. Isolated functional MRI parameters have shown potential in diagnosis. Our goal is to facilitate diagnosis of primary bone neoplasms of the skull base, mobile spine and sacrum, by a comprehensive approach, combining morphological and functional imaging parameters. Pre-treatment MR of 80 patients with histologically proven diagnosis of a primary bone neoplasm of the skull base, mobile spine and sacrum were retrospectively analyzed for morphological and functional MRI parameters. Functional parameters were measured in 4 circular regions of interest per tumor placed on non-adjacent scan slices. Differences in values of functional parameters between different histologies were analyzed with Dunn's test. Chordomas were the predominant histology (60.0%). Most neoplasms (80.0%) originated in the midline and had geographical (78.2%) bone destruction. Amorphous-type calcification (pre-existing bone) was seen only in chordomas. Homogeneous contrast enhancement pattern was seen only in chondrosarcoma and plasmacytoma. Ktrans and Kep were significantly lower in both chordoma, and chondrosarcoma compared to giant cell tumor of the bone (p = 0.006 - 0.011), and plasmacytoma (p = 0.004 - 0.014). Highest diffusion-weighted MRI apparent diffusion coefficient (ADC) values corresponded to chondrosarcoma and were significantly higher to those of chordoma (p = 0.008). We identified the most discriminating morphological parameters and added functional MR parameters based on histopathological features that are useful in making a confident diagnosis of primary bone neoplasms in the skull base, mobile spine and sacrum.

Intradural‐extramedullary inflammatory pseudotumour of the cervical spinal cord of a dog

AbstractAn 8‐year‐old mixed‐breed dog was presented with cervical hyperesthesia, tetraparesis, and mild proprioceptive ataxia in all four limbs. 3 Tesla MRI showed a dorsal compressive intradural‐extramedullary mass at the level of C1–C2, isointense to the gray matter with a hypointense ventral core on T2 weighted images (WI), isointense on T1WI, with a strong and homogeneous contrast enhancement. A C1–C2 partial dorsal laminectomy was performed, and the lesion was removed en bloc. The histopathological and immunohistochemical analysis defined the diagnosis of inflammatory pseudotumor.

Comparison of clinical and MRI features of brain metastases between ALK+ and ALK- NSCLC.

Non-small-cell lung cancer (NSCLC) is the primary cause of brain metastases (BM). This study aimed to investigate differences in clinical and magnetic resonance imaging (MRI) features of BM between anaplastic lymphoma kinase (ALK) gene fusion (ALK+) and ALK wild-type (ALK-) NSCLC, and to preliminarily assess the efficacy of radiotherapy for treating BM. A retrospective analysis included 101 epidermal growth factor receptor (EGFR)- NSCLC patients with BM: 41 with ALK gene fusion and 60 being ALK-. The brain MRI and clinical features were compared between different ALK status using the multivariate analysis, and a nomogram was constructed to predict ALK gene fusion. Fifty-six patients who did not undergo cerebral surgery and had complete pre- and post- treatment data were further divided based on whether they received radiotherapy. Log-rank test was used to compare the short-term effect of treatment between the two groups under different genotypes. ALK+ BM exhibited decreased peritumoral brain edema size, lower peritumoral brain edema index (PBEI), and a more homogeneous contrast enhancement pattern compared to ALK- BM. Age (OR = 1.04; 95%CI: 1.02-1.06), time to BM (OR = 1.50; 95% CI: 1.04-2.14), PBEI (OR = 1.26; 95% CI: 0.97-1.62), smoking status (smoking index >400 vs. non-smoking status: OR = 1.42; 95% CI: 0.99-2.04) and contrast enhancement pattern (OR = 1.89; 95% CI: 1.28-2.78) were associated with ALK gene fusion. A nomogram based on these variables demonstrated acceptable predictive efficiency (AUC = 0.844). In the ALK+ group, patients who received radiotherapy did not show increased disease control rate (DCR) or progression-free survival (PFS). In contrast, in the ALK- group, those who received radiotherapy had improved objective response rate (ORR), DCR, and PFS compared to those who were only treated with systemic therapy. The clinical and MRI features of BM can indicate the status of ALK in NSCLC. In the ALK- group, patients who received radiotherapy showed higher ORR, DCR, and PFS compared to those who did not.

Primary extraskeletal intradural Ewing sarcoma with acute hemorrhage: a case report and review of the literature

BackgroundSpinal cord tumors present a challenge in diagnosis and treatment due to their varied histopathological characteristics. While Ewing sarcoma is a rare malignant tumor typically originating from skeletal bone, cases of primary intradural extraskeletal Ewing sarcoma are exceptionally rare. The similarity of its presentation to other spinal tumors further complicates its identification and management.Case presentationWe report a case of a 58-year-old Palestinian male with intradural extraskeletal lumbar Ewing sarcoma. The patient initially presented with lower back pain and bilateral S1 radiculopathy, with more severe symptoms on the left side. Magnetic resonance imaging revealed a 7 cm oval-shaped mass with homogeneous contrast enhancement, obstructing the spinal canal from L3/L4 to L5/S1 levels. Initially, a myxopapillary ependymoma was suspected, but the patient’s sensory and motor functions suddenly deteriorated during hospitalization. Repeat magnetic resonance imaging indicated heterogeneous contrast enhancement, indicating acute intratumoral hemorrhage. Consequently, the patient underwent emergent L3–L5 laminotomy, with successful gross total resection of the tumor. Histopathological and immunohistochemical analyses confirmed the diagnosis of intradural extraskeletal Ewing sarcoma. Adjuvant therapy was administered to minimize the risk of local recurrence or distant metastasis. A systematic review of relevant literature, along with retrospective analysis of medical records, operative reports, radiological studies, and histopathological findings of similar cases, was also conducted.ConclusionsIntradural extraskeletal Ewing sarcoma is an infrequently encountered condition in adult patients, emphasizing the importance of considering it in the differential diagnosis of spinal tumors. Surgeons must possess a comprehensive understanding of this rare entity to ensure accurate staging and optimal management, particularly in the early stages when prompt intervention may improve prognosis.

CASE REPORT : OLFACTORY GROOVE MENINGIOMA

Abstract
 Background: Olfactory Groove Meningiomas (OGM) are a rare cause of olfactory dysfunction. OGMs are benign, slow-growing tumors that cause non-specific symptoms, such as headaches, olfactory impairment, and psychiatric symptoms, such as depression, personality changes, decreased cognitive function, visual problems, or seizures.
 Aim: In this case report we would like to discuss about a rare case of olfactory groove meningioma with non-spesific symptoms presented in 47-year old female patient
 Case report: A 47-year old female with progressive blurred vision in the right eye for 3 months. Negative light perception in the right eye and fundus of the right eye indicated papillary atrophy. The direct and indirect light reflexes were negative in the right eye. We found Strong homogenous contrast enhancement extraaxial lesion accompanied by multiple dural tails in the left frontal convexity UK approximately 3.2 x 2.8 x 3.1 cm, Tuberculum sellae approximately 2.7 x 2.9 x 3 cm. Cranial decompression, frontal bone reconstruction, and tumor removal were performed. It was found that there was microcystic growth of tumor tissue, consisting of proliferation of meningoethelial cells, round to oval nuclei, smooth chromatin, visible intranuclear inclusions
 Discussion: OGM is a rare, benign tumor. Female patients were more likely to develop OGM than male patients. The ciliary ganglion of cranial nerve III may be affected by compression of the tumor, resulting in the absence of direct and indirect pupillary reflexes in the affected eyes.
 Conclusion: OGM is a slow-growing tumor that does not show significant symptoms at an early stage, making early detection difficult.
 Keyword: Olfactory Groove Meningioma, Blurred Vision, Meningioma

Isolated fourth ventricle craniopharyngioma: Representative case illustration and review of literature

Background: Sella and suprasellar areas are frequently affected by craniopharyngiomas. In this article, eight occurrences have been documented. One is new, and the remaining seven are from previously published articles. Their prevalence in the posterior fossa without expansion from the suprasellar area is unusual. Case Description: We present a case of a primary 4th ventricular craniopharyngioma of the posterior fossa in a 16-year-old male with no association with Gardner’s syndrome. He presented with sudden deterioration of consciousness level and was diagnosed as having a homogeneously contrast enhancing lesion occupying the 4th ventricle with obstructive hydrocephalus. The patient underwent emergency placement of external ventricular drain followed by complete removal of the tumor on the next day by midline suboccipital craniotomy with telovelar approach. Histopathological features were consistent with the adamantinomatous variety of craniopharyngioma. He had complete neurological recovery and no evidence of tumor recurrence in 1-year follow-up. Conclusion: The craniopharyngioma in our case was distinct because it was a solid tumor with no cystic component, exhibited homogeneous contrast enhancement in neuroimaging, developed in the fourth ventricle, and reached the level of foramen magnum, features that had rarely been documented previously. We also reviewed the literature on reported cases of 4th ventricular craniopharyngioma to strengthen knowledge in this area and highlight the embryological basis of ectopic craniopharyngioma.

Compressive Myelopathy Caused by Arachnoid Cyst and Extramedullary Hematopoietic Tissue in a Patient with Thalassemia Major

AbstractThalassemias, inherited diseases of hemoglobin synthesis, are characterized by the presence of deficient hemoglobin chains that deposit in red blood cells, inducing hemolytic anemia. Extramedullary hematopoiesis represents a compensatory picture that usually affects the liver, the spleen, and lymph nodes. The involvement of the epidural space with spinal cord compression is extremely rare. Our objective was to describe the case of RMS, 31 years old, male, β-thalassemia major carrier, admitted with 2-month progressive paraparesis and urinary retention due to medullary compression by extramedullary hematopoietic tissue and thoracic arachnoid cyst, and to discuss therapeutic options. Magnetic resonance imaging (MRI) showed an extensive intraspinal and extramedullary lesion with homogeneous contrast enhancement of T3-T11 in addition to a T1-T3 cystic lesion isointense to cerebrospinal fluid (CSF). After the presumed diagnosis of spinal cord compression by proliferative hematopoietic tissue, a 10-session fractional radiotherapy treatment was immediately performed. After the radiotherapy treatment, the neurological deficits of the patient persisted despite the excellent image response with almost complete disappearance of the intraspinal mass. However, the MRI showed a persistent T1-T3 cystic lesion with significant mass effect on the spinal cord. The patient was submitted to microsurgery for total resection of this cystic lesion. In the postoperative period, the patient improved his sphincter control and motor deficits. Medullary compression by extramedullary epidural hematopoiesis is a rare complication in thalassemic patients and may be treated with surgery and/or radiotherapy. There are successful cases with the exclusive use of radiotherapy, especially in extensive lesions.

Predicting the prognosis of primary orbital lymphoma by clinical characteristics and imaging features.

To analyze the 5-year disease-free survival (DFS) of primary orbital lymphoma (POL) by clinical characteristics and imaging features. A total of 72 patients, 43 males and 29 females, with histologically confirmed POL, were retrospectively recruited between January 2012 and May 2017. The information on clinical characteristics, imaging features, and 5-year DFS was obtained. Univariate and multivariate forward logistic regression analyses were used to identify the variables significantly associated with 5-year DFS. Kaplan-Meier was applied for survival analysis. Univariate analysis revealed that uni- or bilateral orbital involvement, single or multiple lesions, treatment methods, and contrast enhancement pattern on images were significant for 5-year DFS (P=0.022, 0.042, <0.001, and 0.028, respectively), while in multivariate logistic regression analysis, only uni- or bilateral orbital involvement, treatment methods and contrast enhancement pattern on images were significant (r=0.453, 0.897, and 0.556, P=0.038, <0.001 and 0.022, respectively). The survival curves for DFS were obtained. The majority of POL are B-cell lymphomas. Unilateral orbital involvement, homogeneous contrast enhancement on images, and the appropriate treatment schemes result to be significant factors for a good prognosis for POL.

THE ASSOCIATION BETWEEN MRI AND INTRA OPERATIVE FINDINGS WITH ESTROGEN RECEPTOR/PROGESTERON RECEPTOR STATUS IN PATIENTS OPERATED FOR INTRA CRANIAL MENINGIOMA IN TERTIARY CARE HOSPITAL

Background: Meningiomas constitute about 13-26% of primary intracranial tumours. Women are affected twice. Common in 5th to 6th decades. Meningiomas mostly are asymptomatic but presents with variety of symptoms related due to compression of adjacent structures. The World Health Organization (WHO) has divided the meningioma into three grades: typical, atypical, and anaplastic. Consideration of Pre operative MRI ndings, macroscopic factors (intraoperative meningioma factors), such as tumor size and shape, and the rate of local invasion of this tumor, like bone invasion, can also be useful in determining the prognosis of patients because of differences in brain meningioma in different parts of the brain. Objectives: 1. To study the association between MRI ndings with Estrogen receptor/progesteron receptors status in patients operated for meningioma in Tertiary Care Hospital 2. To study the association between intra operative ndings with Estrogen receptor/progesteron receptors status in patients operated for meningioma in Tertiary Care Hospital Materials and Methods:ADescriptive study was conducted Department of Neurosurgery, Government medical college Thiruvananthapuram between September 2021 to march 2022. 74 cases of meningioma were included in the study. Results: In majority 43(58.11%)), hormonal receptor status was PR+ followed by ER and PR negative 17(22.97%)). Hormonal receptor status was ER+ in only 14 out of 74 patients (18.92%) with no signicant association between them. (p value=0.499) according to age. ER+ most commonly seen in postmenopausal women as compared to PR+(34.15%). MRI Brain in majority of patient with ER +status presented with single tumour commonly at convexity(50%), hard in consistency(29.41%), moderate edema,( 42.86%) commonly calcication not present, diffusion restriction, homogeneous contrast enhancement, sinus involvement with atypical grade (57.14%,) whereas with PR+ presented with single tumor, commonly arises from convexity but spenoid wing is specic site for this receptor, tumor was rm in consistency, had mild edema, moderate vascularity, no calcication, diffusion restriction, homogeneous contrast enhancement, no sinus involvement with typical grade(95.35%). Intraoperative ndings with ER+ patient had single tumor, convexity, hard in consistency (29.41%), moderate edema, mild vascularity, suckable, cusable, maximum patient had calcication (71.43%), maximum had no hyperostosis with Resectable Simpsons grade2. Maximum had no hyperostosis with Resectable Simpsons grade2 Proportion of patients with histopathological grading: - meningo-epithelial meningioma grade 1, psammomatous meningioma grade 1 was signicantly higher in PR+, atypical meningioma grade 2 was signicantly higher in ER+ as compared to PR+ and ER and PR negative. Conclusions: Meningioma expresses predominantly progesterone receptor followed by estrogen receptor. Postmenopausal females have estrogen receptor positive meningioma, in older age group, with MRI features of atypical meningioma, intraoperative hard consistency and higher grades of histopathology, whereas progesterone receptor positive meningioma is common in premenopausal women with typical features of meningioma with soft to rm consistency intraoperative and with lesser grades of histopathology. MRI and intraoperative ndings are associated with hormonal receptor status. Thus, aid in predicting nature and prognosis of meningioma.

CT features of rounded atelectasis in chronic inflammatory pleural effusions in cats and dogs.

Rounded atelectasis is well described in human medicine as focal lung deformation and collapse secondary to inflammatory pleural effusions and pleuritis. Specific CT features (round to ovoid soft tissue pulmonary attenuations, creation of an acute angle with the adjoining visceral pleura, and the presence of perinodular comet tail signs) support the diagnosis of rounded atelectasis in humans so that further diagnostic workup is not necessary in defining the nodules. In this retrospective case series, we described the CT characteristics of rounded atelectasis in eight cats and three dogs diagnosed with restrictive pleuritis secondary to either a chylothorax or pyothorax. Thirty-six soft tissue attenuating pulmonary nodular lesions were identified on CT. Comet tail signs, consisting of bundles of bronchi and vessels coalescing into the pulmonary nodules, were associated with 92% of the nodules (33/36), and 92% of the nodules abutted and created an acute angle with the pleura (33/36). Other prevalent features included location in gravity-dependent regions of the lung lobes (33/36, 92%), blurred hilar margins with sharper pleural margins of the nodules (33/36, 92%), presence of air bronchograms (30/36, 83%), homogeneous contrast-enhancement (23/36, 64%), and volume loss of the affected lung lobe (22/36, 61%). Pulmonary malignant neoplasms were not found cytologically (6/11 patients) or histologically (5/11 patients). To avoid a misdiagnosis of neoplasia, veterinary radiologists should be aware of the CT features of rounded atelectasis and consider it as a differential for pulmonary nodular lesions in patients with concurrent inflammatory pleural effusion and pleuritis.

Ectopic lingual thyroid tissue diagnosed in an elderly patient

Abstract Introduction Lingual thyroid (LT) is a rare ectopy of the gland characterized by residual thyroid tissue remaining along the thyroglossal duct, due to inability of the gland to descend from the foramen cecum into the lower part of the neck. Clinical Case A 65-year-old female patient presented with a long-standing difficulty in swallowing and sensation of a foreign body in the throat. Oropharyngeal examination revealed a well-circumscribed submucosal mass at the base of the tongue. Neck MRI detected 28×25×30 mm, lesion, isointense on T1WI and T2WI, showing prominent and homogeneous contrast enhancement located at the base of tongue, midline at the level of the vallecula, and narrowing towards the oropharynx anteriorly. Since normal thyroid tissue was not observed in the thyroid bed, the mass was suspected to be an ectopic lingual thyroid tissue. Tc99m pertechnetate thyroid scintigraphy revealed focal involvement at the base of the tongue rather than its anatomical region, confirming the diagnosis of LT. Thyroid function tests showed; serum TSH level of 4.25 mU/L (normal range: 0.27–4.20), free T4 12.1 pmol/L (11–22), free T3 4.1 pmol/ L (3.1–6.8), Anti-TPO &amp;lt;0.9 IU/ml, Anti-Tg: 14.9 IU/ml(0–115).Since the patient had difficulty swallowing, Levothyroxine was considered to be insufficient and time-consuming, surgical intervention was planned as a permanent solution. After surgical treatment, LT4 replacement was initiated, and the pathology confirmed normal thyroid tissue. The patient is being followed up with LT4 replacement therapy. Lingual thyroid (LT) is the most frequent ectopic location of the thyroid gland, its prevalence ranges between 1/100000 and 1/300000 being seven times more common in women. While the ectopy is often diagnosed at an early age, it may present at any age from birth to senility. Patients with ectopic LT are usually asymptomatic, hypothyroidism has been reported in 33% to 62% of patients. In proportion to the size of the lingual thyroid tissue, it can also cause complaints such as dysphonia, dysphagia, respiratory distress, foreign body sensation in the throat. Diagnosed with ectopic LT tissue at an advanced age, our patient had complaints of long-standing difficulty in swallowing solid foods, but hypothyroidism was not detected. After ENT examination, the diagnosis was confirmed by technetium (Tc99m) pertechnetate thyroid scintigraphy. Treatment of ectopic LT is either surgical or medical, depending on the size of the mass and patient's signs and symptoms. Ectopic lingual thyroid gland should always be considered, for the midline lesions, especially at the base of the tongue. Detailed assessment should be conducted to conclusively rule out obstruction and malignancy where the surgery is indicated. Levothyroxine could be a good solution for smaller, well defined benign lesions, which may stay stable or reduce in size under treatment.

Cervical ganglioneuroma arising from the dorsal root ganglion: illustrative case

Ganglioneuroma is a benign and well-differentiated tumor derived from neural crest cells, which occurs infrequently, with most patients being female and adolescents. While predilection sites are the posterior mediastinum and retroperitoneal cavity, ganglioneuroma originating from the dorsal root ganglion is very rare. Here the authors report a case with C2 dorsal root ganglion-derived ganglioneuroma with some literature review. A 45-year-old male patient complained of persistent right-side throbbing occipital headache for more than a year. Magnetic resonance imaging (MRI) of the cervical spine revealed a dumbbell-shaped intradural extramedullary tumor from the C2 posterior surface of the odontoid to right C1-2 intervertebral foramen with high T2- and low T1-weighted signal intensities. The tumor displayed homogeneous contrast enhancement by MRI. The authors suspected schwannoma and performed a tumorectomy for both diagnosis and treatment purposes. Intraoperative findings showed that the tumor originated from the dorsal root ganglion, and pathological examination revealed ganglioneuroma. Immediately after the tumorectomy, the throbbing occipital headache disappeared and the patient was discharged from the hospital without major complications. Although ganglioneuroma derived from the dorsal root ganglion is very rare, a differential diagnosis of the ganglioneuroma should be made, when schwannoma is suspected.

Comparison of MRI Findings among Osteofibrous Dysplasia, Fibrous Dysplasia, and NonOssifying Fibroma of the Long Bone.

Background The characteristics of magnetic resonance imaging (MRI) findings among osteofibrous dysplasia (OFD), fibrous dysplasia (FD), and nonossifying fibroma (NOF) have yet to be determined. Aims This study determines the differences of MRI features among OFD, FD, and NOF of the long bone. Patients and Methods This study included 39 patients including 10 OFD, 13 with FD, and 16 with NOF of the long bone. All patients underwent preoperative MRI and histological examination. We retrospectively reviewed the MRIs and compared the imaging findings among the three pathologies. Results The maximum diameter was significantly different among OFD (47.0 ± 18.6 mm), FD (59.0 ± 35.0 mm), and NOF (33.3 ± 15.0 mm) ( p < 0.05). Multiplicity (60%, p < 0.01), eccentric distribution (100%, p < 0.05), septation (70%, p < 0.01), homogeneous intensity on T2-weighted images (70%, p < 0.01), homogeneous contrast enhancement (63%, p < 0.05), and intense contrast enhancement (88%, p < 0.01) were significantly more frequent in OFD. Centric distribution (69%, p < 0.01), cyst formation (54%, p < 0.01), and fluid-fluid level formation (31%, p < 0.01) were significantly more frequent in FD. Eccentric distribution (100%, p < 0.01), heterogeneous on T2-weighted images (100%, p < 0.01), predominant hypointensity on T2-weighted images (44%, p < 0.01), and the presence of intralesional hypointensity on T2-weighted images (88%, p < 0.01) were significantly more frequent in NOF. Conclusion MRI features could differentiate OFD, FD, and NOF of the long bone.

Chordoid gliomas of the third ventricle

Chordoid glioma is a rare slow-growing tumor of the central nervous system. Available world experience includes no more than 200 cases (lesion of the third ventricle in absolute majority of cases). Recognition and treatment of chordoid glioma are currently difficult problems due to small incidence of this disease. To describe clinical manifestations and surgical treatment of chordoid glioma of the third ventricle considering literature data and own experience. There were 12 patients (6 men and 6 women) with chordoid glioma between 2004 and 2023 (10 patients with lesion of the third ventricle, 1 - lateral ventricle, 1 - pineal region). Only patients with tumors of the third ventricle were analyzed. Total and subtotal resection was performed in 1 and 3 cases, respectively. Five patients underwent partial resection, 1 patient underwent biopsy. The follow-up data were available in 7 out of 10 patients (mean 25 months). Radiotherapy was performed in 4 patients (continued tumor growth in 2 cases). One patient died. Chordoid glioma is a benign tumor predominantly localized in the third ventricle. Preoperative MRI and CT in some cases make it possible to suspect chordoid glioma and differentiate this tumor from craniopharyngioma, meningioma and pituitary adenoma by such signs as isointense signal in T1WI, hyper- or isointense signal in T2WI, homogeneous contrast enhancement and edema of basal ganglia in T2 FLAIR images. The only effective treatment for chordoid glioma is surgery. Total resection is often impossible or extremely dangerous due to location of tumor, large size and invasion of the third ventricle. Postoperative mental disorders and diabetes insipidus, including severe hypernatremia, are common that requires mandatory monitoring of water and electrolyte balance.

Spinal Epidural Cavernoma of the Thoracic Spine: a case report

BACKGROUND AND OBJECTIVE Cavernomas are well-circumscribed and multilobulated vascular malformations that can occur nearly anywhere in the body. Cavernomas are found 80% supratentorially, 15% in posterior fossa and only 5% in the spinal cord. Spinal cavernomas are most commonly intramedullar. Purely epidural spinal cavernoma constitute of less than 4% of all spinal epidural lesions. We report a case of histopathologically confirmed epidural cavernoma of the thoracic spine. CASE PRESENTATION A 24-year-old woman presented with a 6-month history of progressive chronic upper back pain. Physical examination revealed no neurological deficit. Her VAS pain scale was 6/10. Conservative treatments did not relieve her symptoms. Thoracal MRI without contrast shown a lesion that hyperintense on T2-weighted images and isointense on T1-weighted images. The lesion sized 14x13x7 mm at T5 vertebral level located at posterolateral spinal canal. Thoracal MRI with contrast showed extradural mass with homogenous contrast enhancement. The mass was located at left posterolateral spinal canal suspected extradural meningioma. The surgery was done via posterior approach. Left hemilaminectomy was done at T4-T5 vertebral level. Reddish soft tissue mass was observed at the epidural space. The mass was well defined and there were no signs of bony invasion. Gross tumor removal was done under the microscope. Histopathological examination of the mass showed large dilated vessel filled with erythrocyte and lined by endothelium which support the diagnosis of cavernoma. After the surgery, her pain symptom was improved. CONCLUSION Spinal epidural cavernomas are rare, but it should be considered as one of the differential diagnosis for spinal epidural lesions. Exact preoperative diagnosis is hard because there are no pathognomonic MRI findings of spinal epidural cavernoma. Total surgical resection of the lesions was the treatment of choice in symptomatic patients to prevent progressive neurological deficit and prospective hemorrhage.

Detecting immunoglobulin G4-related intracranial arteriopathy with magnetic resonance vessel wall imaging: a preliminary experience in two cases

BackgroundDetecting immunoglobulin G4 (IgG4)-related intracranial arteriopathy, a rare neurovascular complication of IgG4-related disease, is challenging. While magnetic resonance (MR) vessel wall imaging (VWI) can visualize various neurovascular pathologies, its application to this arteriopathy has not been reported as of this writing.Case presentationA 74-year-old male and a 65-year-old female manifested multiple cranial nerve palsy and neck pain, respectively. Both cases exhibited multiorgan masses with markedly elevated serum IgG4 levels and were clinically diagnosed with IgG4-related disease. Three-dimensional T1-weighted black blood VWI with and without contrast agent identified intracranial vascular lesions characterized as nearly-circumferential mural thickening with homogeneous contrast enhancement in the internal carotid and vertebral arteries; some of the lesions had been unrecognized with screening MR angiography due to expansive remodeling. The former patient underwent corticosteroid therapy, and VWI after treatment revealed decreased mural thickening and enhancement.ConclusionFurther studies to elucidate characteristic findings of VWI might contribute to early detection of this treatable pathology.

A Rare Case of Advanced Duodenal Cancer Infiltrating the Head of Pancreas and the Mesocolon of the Hepatic Flexure

Background Primary small bowel carcinoma is a very rare tumor, with non-specific symptoms that usually cause a delay in diagnosis and, consequently, a negative outcome. Duodenal carcinoma is on its own an uncommon tumor of the intestinal tract. Our case presented further local advancement with infiltration of the hepatic flexure mesocolon. En-block pancreaticoduodenectomy plus right hemicolectomy or Colo-Pancreatico- Duodenectomy (cPD) is feasible in highly selected patients if performed by experienced surgeons. Case presentation We are introducing the case of a 48 y/o male patient presenting with a dull pain of the lower abdomen and dark stools (melena) in the recent episodes of defecation; considerable weight loss; jaundice (total bilirubin level 10 mg/dL). In the radiologic investigations, IV contrast CT of the abdomen revealed the presence of a 7.7 cm x 8.5 cm mass of duodenum (D3) which infiltrates the head of pancreas as evidenced by homogeneous contrast enhancement. The pancreatic duct of Wirsung was dilated, 4.4 mm. Gastroduodenoscopy visualizes a non-circumferential ulcerative proliferation. Exploratory laparotomy was performed. Intraoperatively we encountered the presence of local progression of the primary duodenal lesion into head of the pancreas, the mesocolon of the hepatic flexure with infiltration of the right colic vessels. Colo-Pancreatico-Duodenectomy (cPD) and Whipple’s procedure was performed, with Blumgart type pancreatico-jejunal and ileo-colic anastomoses. Discussion En-block pancreaticoduodenectomy plus right hemicolectomy or Colo-Pancreatico-Duodenectomy (cPD) is feasible in highly selected patients if performed by experienced surgeons. The most common indication of cPD is locally advanced pancreatic head cancer that directly invades the colon or mesocolon, followed by locally invaded colon cancer at the duodenum and/or pancreatic head. The cPD procedure is rarely performed in gastrointestinal surgery. This is due to its complexity, difficulty, and high risks. In certain acute situations, cPD is the efficacious path forward. Conclusion Following a careful evaluation plan, along with necessary consults for accompanying disorders, the indications for colo-pancreatico-duodenectomy were clearly set for this patient with locally advanced duodenal adenocarcinoma infiltrating the pancreas head and hepatic flexure mesocolon. Our experience highlights the importance of meticulous and experienced perioperative care to minimize complications and mortality. Keywords: General surgery, Duodenal cancer, Whipple procedure, colo-pancreatico-duodenectomy, cPD, Blumgart pancreatico-jejunal anastomosis DOI: 10.7176/ALST/95-01 Publication date: November 30 th 2022

Deep learning reconstruction allows for usage of contrast agent of lower concentration for coronary CTA than filtered back projection and hybrid iterative reconstruction.

The demand for homogeneous and higher vascular contrast enhancement is critical to provide an appropriate interpretation of abnormal vascular findings in coronary computed tomography angiography (CTA). To evaluate the effect of various contrast media concentrations (Iohexol-370, Iohexol-300, Iohexol-240) and image reconstructions (filtered back projection [FBP], hybrid iterative reconstruction [IR], and deep learning reconstruction [DLR]) on coronary CTA. A total of 63 patients referred for coronary CTA between July and October 2021 were enrolled in this prospective study, and they randomly received one of three contrast media. CTA images were reconstructed with FBP, hybrid IR, and DLR. The CT attenuation, image noise, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR) were calculated for all three images. The images were subjectively evaluated by two radiologists in terms of overall image quality, artifacts, image noise, and vessel wall delineation on a 5-point Likert scale. The application of DLR resulted in significantly lower image noise; higher CT attenuation, SNR, and CNR; and better subjective analysis among the three different concentrations of contrast media groups (P < 0.001). There was no significant difference in the CT attenuation of the left ventricle (P = 0.089) and coronary arteries (P = 0.072) between hybrid IR at Iohexol-300 and DLR at Iohexol-240. Furthermore, application of DLR to the Iohexol-240 significantly improved SNR and CNR; it achieved higher subjective scores compared with hybrid IR at Iohexol-300 (P < 0.001). We suggest that using DLR with Iohexol-240 contrast media is preferable to hybrid IR with Iohexol-300 contrast media in coronary CTA.

Orbital Inflammatory Pseudotumor following mRNA COVID-19 Vaccination

ABSTRACT The authors present a case of orbital pseudotumor after mRNA COVID-19 vaccination. A 40-year-old otherwise healthy woman was referred to our oculoplastics unit because of left blepharoptosis of 2 months duration starting 1 week after she received her first Pfizer-BioNTech mRNA vaccination. On presentation, her best-corrected visual acuity was 20/20 in each eye. The external examination revealed left blepharoptosis and mild upper eyelid swelling. Orbital magnetic resonance imaging revealed left lacrimal gland enlargement with homogeneous contrast enhancement and diffuse mild enlargement of the left lateral and superior rectus muscles. The results of the extended workup for autoimmune and infectious etiologies and the systemic examination findings were normal. Systemic corticosteroids were started for the orbital pseudotumor. The presented case of orbital pseudotumor development after the mRNA vaccine may be considered to be an immunological process targeting the orbital tissue following immunization, although the cause–effect relationship remains uncertain.