Homogeneous Contrast Enhancement Research Articles

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.

Pituicytoma: A Report of Two Cases and Literature Review

Abstract Introduction Pituicytoma is a rare form of primary benign tumor of the neurohypophysis and infundibulum. There have been 140 reported cases in world literature that could be found in our search. Here we discuss about the presentation, radiological features, treatment, histopathology, and immunohistochemical markers of two cases, along with a brief review of literature. Materials and Methods A 48-year-old female presented with headache and painless visual loss for 4 years. Examination revealed bitemporal hemianopia and normal fundus. Hormonal profile was normal. Magnetic resonance imaging (MRI) showed 2.6 × 2.8 × 3.3 cm, thin-walled, cystic sellar and suprasellar lesions stretching the optic chiasm superiorly. Endoscopic transnasal, transsphenoidal gross total excision was done. Histopathological examination (HPE) and immunohistochemistry (IHC) were suggestive of pituicytoma.A 55-year-old male presented with intermittent headache and vomiting for 3 months. Examination was unremarkable. Hormonal profile was normal. MRI showed lobulated mass of size 1.4 × 1.9 × 2.0 cm, arising from anterior pituitary and extending to the suprasellar cistern. Lesion was hyperintense in T1-weighted and heterointense in T2-weighted images, and Fluid attenuated inversion recovery images (FLAIR) with homogenous contrast enhancement pushed the optic chiasm superiorly. Endoscopic transnasal partial excision of the lesion was done. HPE and IHC were suggestive of pituicytoma. Results Total number of cases was 142, of which 71 were males (50%) and 71 were females (50%). Age ranged between 7 and 83 years (mean 49.2, median 48). Brain imaging was available in 110 cases. Size of the lesion varied from 4 to 72 mm (mean 27 mm). Location was either pure sellar (24.3%) or with extension into the suprasellar cistern (34.3%) and/or the cavernous sinuses (7.1%). Lesions in MRI were solid (84%) with few areas of cystic changes, while contrast enhancement of solid portion was in 92% (homogenous in 80% and heterogeneous in 20%) of the cases. One case showed features of hemorrhage while no case showed calcification. Treatment was primarily surgical (120 out of 130 cases): transsphenoidal excision in 70% of the cases and craniotomy and excision in 30%. Preoperative embolization of arterial feeders was done in two cases and postoperative radiation was given in one case. Gross total resection was done in 46.3%, subtotal resection in 40%, partial resection in 12.6%, and biopsy was done in 1.1% of the cases in the study. Follow-up ranged from 2 to 134 months (average 31.2, median 19). Recurrence or regrowth was documented in 23 patients, treatment in 18 patients, and resurgery was done in 12 cases, followed by radiotherapy in 5. In six cases, radiotherapy was used in isolation. Improvement in the visual deficit was seen in 26 patients, and remained unchanged in 3. Among the patients with preoperative endocrine dysfunction, 10 improved while 11 suffered a worsening. Ten patients had new postoperative endocrine alteration. Only one fatal case was registered. Conclusion Pituicytoma is a rare World Health Organization grade I tumor of the sellar and suprasellar region, presenting with varied clinical, radiological, and hormonal features. Histopathology and immunohistochemistry form the mainstay in diagnosis. Surgical excision with transsphenoidal approach is ideal. Prognosis in general is good after surgical resection alone or in conjunction with radiotherapy.

Malignant Gastrointestinal Neuroectodermal Tumor: A New Kid on the Block?

Also referred to as "osteoclast-rich, clear cell sarcoma-like tumor of the gastrointestinal tract (CCSLGT)," malignant gastrointestinal neuroectodermal tumor is a newly described, rare, aggressive sarcoma that commonly arises in the small bowel, stomach, and colon. Histogenesis is likely from an autonomous nervous system-related primitive cell of neural crest origin. The hallmark genetic finding of EWS-CREB1 or EWS-ATF1 fusion transcripts clinches the diagnosis. Annular constrictive lesions tend to be smaller, show homogenous contrast enhancement on computed tomography, and may present with bowel obstruction. Larger, expansile masses tend to be exophytic and show heterogeneous contrast enhancement. Surgical resection is the mainstay of treatment. Frequent recurrences, metastases, and death from disease in 75% of patients portend a poor prognosis. Targeted chemotherapy based on specific tumor pathways is being developed.

MEDB-77. Metastasic medulloblastoma: radiological features and its correlation with molecular subgroups and dissemination pattern

Medulloblastoma (MB) is the most frequent malignant childhood brain tumor. Four molecular subgroups have been described (WNT, SHH, group3, group4), which are associated with a different biological profile, prognosis, specific MRI characteristics and patterns of metastatic dissemination. We aimed to determine the imaging features of the metastatic MB and its molecular subgroup and their outcomes. Retrospective single-center analytic-observational study conducted from January 2004-January 2022 in a tertiary-care center. Pediatric patients with metastatic medulloblastoma at disease onset were included. We collected epidemiological and clinical characteristics, treatment received, and outcomes. The molecular subgroup was determined by its methylation profile. MRI were reviewed by the neuroradiologist. Sixty-three patients were diagnosed, 17 (26.9%) were metastatic. The median age at diagnosis was 5.1 years (range 2.1-17.5 years), 58.8% were male. According to histopathologic classification, fifteen patients (93.8%) were classic,1 (6.3%) desmoplastic. Molecular subgroup analysis showed 2 WNT (12.5%), 1 SHH (6.3%), 3 (18.8%) group 3 (G3) and 5 (31.2%) group 4 (G4). Four patients (25%) were classified as G3/G4 and 1 (6.3%) as mixed. Five patients (29.4%) were M2 and 12 patients (70.6%) were M3 according to Chang staging system. The location in the cerebellar hemispheres was only observed in SHH patient while G3 tumors presented homogeneous contrast enhancement. All WNT, G3 and G4 were located in IV ventricle. We found no association between molecular subgroup and metastatic site (intracranial vs spinal, Fisher test, p=0.45). All patients presented with metastasis in the third ventricular infundibular recess were G4. Four patients died, all of them were G3 or G3/G4. Our results supported the literature previously reported. According to the MRI imaging features, the molecular medulloblastoma subgroups could be suggested. The presence of metastasis in the infundibular recess suggested MB group 4. However, the dissemination pattern could not be associated with any subgroup in our series.

Prognostic and Predictive Markers of Limited (1–4) Brain Metastases in Patients with Lung Adenocarcinoma After Stereotactic Radiosurgery: A Retrospective Analysis

Owing to the complexities of brain metastases (BMs), accurate and reliable prognostic and predictive factors remain critical roadblocks in patients with lung adenocarcinoma (LUAD) BMs who undergo stereotactic radiosurgery (SRS). In total, 132 patients with LUAD BMs who underwent SRS were retrospectively analyzed; Cox proportional hazards analysis of imaging and clinical characteristics was used to identify independent predictors related to overall survival (OS) and progression-free survival (PFS). Our data indicated that initial brain metastasis velocity (iBMV), Karnofsky performance score (KPS), and Rvol (the sum of peritumoral edema volume/cumulative intracranial tumor volume) could potentially be independent prognostic factors for OS. iBMV ≥2 (P=0.000), KPS <80 (P=0.042), and Rvol ≥5.7 (P=0.017) were strongly associated with unsatisfactory OS. The KPS and BM contrast enhancement were also identified as independent prognostic factors for PFS. A higher KPS (P=0.004) and homogeneous BM contrast enhancement (P=0.026) were strongly associated with longer PFS. Collectively, iBMV and Rvol are highly related to OS and could be used as potential prognostic indices in patients with LUAD BMs who underwent SRS. Furthermore, we also revealed that the KPS and BM contrast enhancement could be potential indices of PFS in LUAD BMs.

Spinal epidural capillary hemangioma: A systematic literature review and an illustrative case

BackgroundSpinal hemangiomas are rare vascular malformations resulting from proliferation of vascular endothelial cells. The cavernous form is the most common and represents 5-12% of spinal vascular malformations, while the capillary form is rare. Case DescriptionA 56-year-old patient with no past medical history presented with progressive spinal cord compression symptoms localizing to the T10 level with MRC grade 4 proximal paraparesis. Preoperative MRI demonstrated a well-delineated, dumbbell-shaped, epidural lesion, without bony involvement, resulting in spinal cord compression at the T7 and T8 levels. The patient underwent gross total surgical resection of the lesion. At the one month follow up, the patient's strength improved to MRC grade 5, and sensation had fully returned. The histopathological diagnosis was a capillary hemangioma. Exclusively epidural capillary hemangiomas are extremely rare with only 26 cases reported in the literature. They are mainly located at the thoracic level (T4-T6). The MRI features include a well-circumscribed mass, hyperintense on T2-weighted sequence in 92% of cases, isointense on T1-weighted sequence in 88% of cases, and homogeneous contrast enhancement in 100% of cases. No tumor recurrence has been observed after gross total surgical removal. ConclusionsWhen evaluating progressive spinal cord compression by a purely epidural spinal lesion, the differential diagnosis should include capillary hemangioma, in addition to schwannoma, meningioma, and lymphoma. Early and complete surgical removal is the first line treatment.

Unicentric castleman disease located in the left popliteal fossa: a case report

BackgroundCastleman disease (CD) is a lymphoproliferative disease of unknown etiology, it can affect any lymph nodes of the body but rarely affects the popliteal fossa.Case presentationWe present a 67-year-old woman with touching solitary painless mass in the left popliteal fossa for one week. Imaging showed multiple soft-tissue masses of different sizes in the left popliteal muscle space, the T1 weighted image showed hypointense to isointense, the fat-suppressed T2 weighted images showed subtle hypersignal intermingled with linear of hypointense,and displayed homogeneous contrast enhancement after administration of gadolinium. Complete surgical resection was performed. Pathologically demonstrated plasma cell type CD.ConclusionWe described a rare case plasma cell type of UCD located in the popliteal fossa which might help to enrich the clinical spectrum of this rare site and unique subtype of UCD. This case illustrates that CD should be considered in the differential diagnosis of every hypervascularity soft tissue tumor in any anatomic location, especially when they occur in the region of lymph node distribution.

Imaging features of laryngeal chondrosarcomas: A case series and systematic review.

To comprehensively summarize the characteristics of radiological findings of laryngeal conventional chondrosarcomas. We included patients with pathologically proven laryngeal conventional chondrosarcomas with CT and /or MRI, including 41 cases from 31 publications recruited after a systematic review and 14 cases from our institution. Two board-certified radiologists reviewed and evaluated all the radiological images. The relationship between pathological grade and radiological findings was analyzed. The median long diameter of the lesion was 3.1 cm (range, 1.5-8.5 cm). The most common location was the cricoid (74.5%), followed by the thyroid (12.7%), cricoid and thyroid (7.3%), and arytenoid (5.5%). All lesions showed well-defined margins. Cortical defect/expansion (98.0%), internal low density (89.6%), and calcification (95.8%) with homogeneous and scarce contrast enhancement on contrast-enhanced CT (85.3%) were frequently observed. All cases showed high signal on T2-weighted imaging, low signal on T1-weighted imaging (T1WI), and heterogeneous and mild contrast enhancement on postcontrast T1WI. No significant differences were found between the pathological grades and radiological findings. In our summary of comprehensive CT and MRI findings of laryngeal conventional chondrosarcomas, we found that the knowledge of these radiological features may facilitate prompt diagnosis and appropriate management.

Augmented Reality-Assisted Craniotomy for Parasagittal and Convexity En Plaque Meningiomas and Custom-Made Cranio-Plasty: A Preliminary Laboratory Report.

Background: This report discusses the utility of a wearable augmented reality platform in neurosurgery for parasagittal and convexity en plaque meningiomas with bone flap removal and custom-made cranioplasty. Methods: A real patient with en plaque cranial vault meningioma with diffuse and extensive dural involvement, extracranial extension into the calvarium, and homogeneous contrast enhancement on gadolinium-enhanced T1-weighted MRI, was selected for this case study. A patient-specific manikin was designed starting with the segmentation of the patient’s preoperative MRI images to simulate a craniotomy procedure. Surgical planning was performed according to the segmented anatomy, and customized bone flaps were designed accordingly. During the surgical simulation stage, the VOSTARS head-mounted display was used to accurately display the planned craniotomy trajectory over the manikin skull. The precision of the craniotomy was assessed based on the evaluation of previously prepared custom-made bone flaps. Results: A bone flap with a radius 0.5 mm smaller than the radius of an ideal craniotomy fitted perfectly over the performed craniotomy, demonstrating an error of less than ±1 mm in the task execution. The results of this laboratory-based experiment suggest that the proposed augmented reality platform helps in simulating convexity en plaque meningioma resection and custom-made cranioplasty, as carefully planned in the preoperative phase. Conclusions: Augmented reality head-mounted displays have the potential to be a useful adjunct in tumor surgical resection, cranial vault lesion craniotomy and also skull base surgery, but more study with large series is needed.

P14.54 Primary central nervous system lymphoma of the spinal cord: a LOC network cohort study

Abstract BACKGROUND Primary central nervous system lymphoma (PCNSL) mainly affects the brain (&amp;gt;90% of the cases), Very little data can be found in the literature on PCNSL with spinal cord localization. MATERIAL AND METHODS We present a retrospective study based on the French LOC network database. We selected adult immunocompetentpatients, with a histological or cytological diagnosis of PCNSL, and a spinal cord localization at initial diagnosis. RESULTS Of the 2043 PCNSLof the LOC database newly diagnosed since 2011, 14 patients (9 men, median age 68, median Karnofsky performance status 50%)met the selection criteria. The median diagnostic delay was 82 days (min 15-max 1080) compared to 35 days in primary cerebral lymphomas. At diagnosis, walking was impossible in 7/14 patients and 5/14 had indwelling urinary catheter. On MRI, 100% had enlargement of the spinal cord with homogeneous contrast enhancement in 13/14 cases. Spinal cord lesions were unique in 9/14 patients and multiples in 5/14 patients. CSF IL10 level was increased in 6/7 patients. Brain lesions were found in 9/14 patients, located in the posterior fossa in 5/9 cases. The diagnosis was made either on a brain biopsy (N=6), a spinal cord biopsy or surgery (N=5) or the cytologic analysis of the CSF (N=3).4/5 patients had neurological sequel after spinal cord biopsy or surgery. All the patients were treated by high-dose methotrexate-based chemotherapy, followed by spinal cord irradiation (N=1) or autograft (N=2). There was an overall response rate of 71% (complete response in 8/14). 8/14 patients relapsed, 5 in the brain, 2 in the spinal cord, and 1 both in the spinal cord and in the brain. 2-year PFS and OS were 45% and 64%, respectively. Among the long-term responders, 50% remained in wheel chair, while only 10% could walk normally. CONCLUSION Considering the high risk of a spinal cord biopsy,the rarity of the disease, as well as the numerous differential diagnoses, the diagnosis of spinal cord lymphoma is difficult. Searching for other lymphomatous locations or assaying CSF IL10 may be helpful in this disease where delay in diagnosis is often prolonged et can cause irreversible handicap.

PROXIMAL FIBULAR AUTOGRAFT RECONSTRUCTION AFTER RESECTION GCT DISTAL FIBULA

Background: Giant cell tumor (GCT) is a destructive bone tumor. The predilection of the GCT is mostly on the epiphysial of long bones. GCT of the distal fibula is a very rare case that becomes challenging in surgical management. The chosen surgical management is crucial and still under debate.Case Report: A 38-years-old male complaint of a painful lump in the lateral side of his left ankle for three months. Plain radiographs demonstrate a lytic lesion involving distal fibula, appropriate with 2nd-grade Campanacci. MRI showed a mass centered on the distal fibula with intermediate to high T2 signal, low T1 signal, and homogenous contrast enhancement. The patient underwent a wide excision and reconstruction of the distal fibula with a fibular head graft from the ipsilateral side. After fifteen months of evaluation, the result was excellent. The patient can full-wight-bearing with a full range of ankle joint movement, return to daily activities without pain, and no signs of recurrence. Functional status measured by the MSTS and CAIT showed good results, with total scores was 28 and 27.Discussion: Ten centimeters distal fibula is a crucial component to form stability of the ankle. Reconstruction of the distal fibula after wide excision requires the bone graft and is considered to maintain ankle stability. It can be achieved using autograft from fibula or iliac crest.Conclusion: Reconstruction of distal fibula GCT with proximal fibular autograft showed a great result. This method is a viable option as it provides good pain relief and functional improvement.

Teaching NeuroImage: Abducens Nerve Palsy With Ipsilateral Excessive Eye Tearing Attributed to an Internal Carotid Artery Sympathetic Plexus Schwannoma.

A 65-year-old man developed subacute horizontal diplopia due to left abducens nerve (AN) palsy and excessive left eye tearing. Brain MRI revealed a hyperintense T2 lesion with an elongated course within the left carotid canal, presenting homogenous contrast enhancement (figure 1). The imaging findings were characteristic for an internal carotid artery sympathetic plexus (ICSP) schwannoma compressing the left AN. Subsequent irritation of the deep petrosal nerve originating directly from ICSP and continuing as the Vidian nerve may have led to the lacrimal gland edema and excessive left eye tearing (figure 2). Thorough case presentation and a figure demonstrating the relevant anatomy are available from Dryad at [doi.org/10.5061/dryad.pzgmsbck6][1]. [1]: https://doi.org/10.5061/dryad.pzgmsbck6

Idiopathic Hypophysitis

Introduction: Hypophysitis is a heterogeneous condition that leads to inflammation of the sella / suprasellar region, potentially resulting in hormonal deficiencies or mass effects. Prevalence of hypophysitis ranges from 0.2% to 0.88%. Annual incidence of hypophysitis is 1 case per 9 million individuals. We present an interesting case of idiopathic hypophysitis. Clinical Case: A 52-year-old female was evaluated for secondary hypothyroidism. Patient complained of excess fatigue, weight gain, headaches, polyuria with nocturia and vision changes. She was seen by ophthalmology for formal visual field testing revealing right superior quadrantanopia. Labs significant for TSH 4 uIU/mL (ref range 0.27-4.2uIU/mL), FT4 0.72ng/dL (ref range 0.93-1.7 ng/dL), Anti TPO ab negative, AM cortisol 8.9UG/dL, ACTH 18pg/mL, IGF1 127ng/mL, prolactin 7ng/mL, FSH 102MIU/mL, LH 41 MIU/mL. MRI sella revealed homogenous enhancement of the pituitary with convex superior margin - 0.8*1*0.9cm concerning for hyperplasia. Due to the concern for hypophysitis, an extensive inflammatory workup was pursued which was negative. She was started on thyroid hormone replacement and DDAVP. An empiric trial of high dose steroids failed to provide any relief. During workup, patient complained of transient right sided face and arm tingling, diagnosed with TIA and started on aspirin. Due to worsening headaches, a pituitary biopsy was pursued. Pathology significant for glandular tissue ruling out inflammatory, neoplastic, and infectious etiologies. Neurology diagnosed the patient with hemicrania continua. Patient is currently maintained on thyroid hormone replacement and DDAVP with close follow-up. Discussion: The incidence of hypophysitis has recently increased due to increased awareness and also due to the use of medications like ICI. Primary hypophysitis is mostly due to autoimmune etiology. Secondary hypophysitis could result from infections, neoplastic conditions or an adverse effect of medications. Clinical presentations ranges from being asymptomatic to having features of hypopituitarism. Usually presents with mass effect, visual symptoms due to the upward expansion of the pituitary gland impinging the dura mater and optic chiasm. This is followed by symptoms of hormone deficiency, central DI and hyperprolactinemia. Central AI has been reported in 20%-75%, central hypogonadism in 15%-60%, central hypothyroidism in 25%-58%, GH deficiency in 5%-41%, and prolactin deficiency in 13%-25%. Typical MRI findings include, homogeneous pituitary contrast enhancement, pituitary stalk thickening and loss of posterior pituitary bright spot, ‘figure of 8’ appearance, ‘dural tail’. Treatment consists of surgery, anti-inflammatory medications, and radiotherapy. Glucocorticoid treatment is the cornerstone for medical management; however, the overall recurrence rate is high.

Analysis of Clinical, Imaging, and Pathologic Features of 36 Patients with Primary Intraspinal Primitive Neuroectodermal Tumors: A Case Series and Literature Review.

Primary intraspinal primitive neuroectodermal tumors (PNETs) account for ∼0.4% of all intraspinal tumors, but information about these tumors in the medical literature is limited to single case reports. We report four cases of primary intraspinal PNETs and present a systematic literature review of the reported cases. We retrospectively reviewed and analyzed the clinical data of 4 patients with primary intraspinal PNETs who underwent neurosurgical treatment at our clinic between January 2013 and January 2020, and of 32 cases reported in the literature. The female-to-male ratio was 2.6:1. The mean patient age was 21.42 ± 15.76 years (range: 1-60 years), and patients <36 years of age accounted for 83.30% of the study cohort. Progressive limb weakness and numbness were the chief symptoms (accounting for ∼55.6%). The mean complaint duration was 0.89 ± 0.66 months for males and 2.72 ± 3.82 months for females (p = 0.028). Epidural (41.7%) was the most common site, and thoracic (47.3%) was the most frequent location. Most PNETs were peripheral, and magnetic resonance imaging (MRI) appearance was isointense or mildly hypointense on T1-weighted images and hyperintense on T2-weighted images. Homogeneous contrast enhancement was observed. The 1-year survival rate of patients who underwent chemoradiation after total or subtotal lesion resection was better compared with patients who did not undergo chemotherapy, radiotherapy, or total or subtotal resection. The modality of treatment was associated with survival time (p = 0.007). Primary intraspinal PNETs mainly occur in young people with a female preponderance. In patients with a rapid loss of lower limb muscle strength and large intraspinal lesions on MRI, PNETs should be considered. Surgical resection and adjuvant radio chemotherapy are key prognostic factors.

Case Report: Gastric Wall Thickening: Radiological Diagnostic Challenges in Gastric Malignancy

Gastric abnormalities show nonspecific gastrointestinal symptoms and similarly radiological findings. Intra and extra luminal gastric wall thickening are the most common finding in benign and malignant pathologic process. This aim of this case report was to describe several characteristics such as the location and size of the lesion, involvement of the gastric wall and surrounding structures, calcifications, and contrast enhancement pattern which can assist in radiological diagnosis. Several cases at our institution have similar gastrointestinal complaints, however, there were different lesions characteristic found in contrast enhanced abdominal CT scan. The first case 72-years-old man experienced hematemesis with radiologic finding diffuse gastric mucosal thickening as well as homogenous contrast enhancement but without calcification. The second case 37-years-old man complaint dizziness and melena with radiologic finding large tumor more than 10 cm in size, amorph calcification and heterogenous contrast enhancement. The last 60-years-old man case experienced melena and hematemesis, from abdominal CT scan showed irregular gastric mucosal thickening with heterogenous contrast enhancement and fat stranding around the lesion, without calcification. Methods used in these cases were contrast-enhanced abdominal CT scan, esophagogastroduodenoscopy (EGD), and biopsy in order to determine the diagnosis. Contrast-enhanced abdominal CT scan plays a vital role in describing the lesion characteristics which affects the determination of treatment options and future prognosis.

Intratumoral microhemorrhage detection on susceptibility-weighted imaging can help in preoperative differentiation of cerebellopontine angle vestibular schwannomas from meningiomas: Correlation with pathology findings

Objectives: In this study, we aimed to evaluate whether intratumoral microhemorrhage detection on susceptibility-weighted imaging (SWI) could help in preoperative differentiation of cerebellopontine angle (CPA) vestibular schwannomas (VSs) from meningiomas. Patients and Methods: A total of 75 patients (32 males, 43 females; mean age: 45.5±16.7 years; range, 17 to 68 years) consisting of 61 VSs and 14 meningiomas located in the CPA cistern were retrospectively analyzed. All patients underwent contrast-enhanced magnetic resonance imaging (MRI) using the SWI sequence. All images in our study were obtained with a 12-channel phased-array head coil on a 1.5-Tesla clinical scanner. The presence of intratumoral microhemorrhages on SWI sequence was evaluated by demonstrating blooming artifacts as punctate hypointense regions. Both magnitude and phase-contrast images were used to verify microhemorrhages. All patients in our patient cohort underwent surgery and resected tumor specimens were evaluated by pathology. Results: All VS cases in our cohort exhibited multiple hypointense small foci causing blooming artifact on magnitude and processed SWI images. In the meningioma population, typical MRI signal intensity characteristics, including an intense homogenous contrast enhancement, were observed. In all the meningioma cases, except for one, there was no blooming artifact due to intratumoral hemorrhage within the mass lesions on SWI images. In only one meningioma case, SWI revealed hypointense microhemorrhages within the mass lesion. Following surgical procedures and tumor resections, pathology specimens were evaluated and absence or presence of intratumoral microhemorrhages were detected. These results were significantly correlated with the SWI findings. We obtained 100% sensitivity, 92.8% specificity, and 98.6% accuracy in terms of differentiating VSs from meningiomas located in the CPA cistern by using the SWI sequence. Conclusion: Meningiomas and VSs are the two most common masses of the CPA cistern and, in some cases, it seems to be difficult to reach an accurate diagnosis with conventional MRI sequences. The SWI can be helpful to solve this problem by demonstrating whether intratumoral microhemorrhages are present or not within mass lesions and, thus, can help to assume a probable accurate diagnosis prior to surgery

Primary marginal zone B-cell lymphoma of the cavernous sinus: a case report and review of the literature

BackgroundPrimary lymphoma of the cavernous sinus is a rare form of extranodal non-Hodgkin lymphoma, of which very few cases have been reported in the published literature. This report presents the MRI findings with apparent diffusion coefficient (ADC) value in an exceedingly rare primary marginal zone B-cell lymphoma (MZBCL) of the cavernous sinus.Case presentationThe case in this study is a 59-year-old immunocompetent male patient with a 2-month history of right ptosis and blurred vision. Right third cranial nerve palsy and binocular diplopia were observed upon neurological examination. Preoperative brain CT showed an extra-axial enhancing mass lesion in the right cavernous sinus. On MRI, ipsilateral internal carotid arterial encasement was noted without causing stenosis of the vessel. Isointense signal on T1-weighted and T2-weighted images, homogeneous contrast enhancement, and diffusion restriction were also observed. The mean ADC value of the tumor is 0.64 × 10–3 mm2/s (b value = 1000 s/mm2). Subtotal resection of the tumor was performed, and improvement of clinical symptoms were observed. The pathologic diagnosis of MZBCL was established by immunohistochemical examinations.ConclusionsPrimary MZBCL of the cavernous sinus is exceedingly rare, and preoperative confirmation poses a major challenge with CT and conventional MRI only. In this case, preoperative quantitative ADC value is shown to offer valuable additional information in the diagnostic process.

Dural-based lesions: is it a meningioma?

Meningiomas are the most common extra-axial intracranial neoplasms with typical radiological findings. In approximately 2% of cases, histopathological reports reveal different neoplasms or non-neoplastic lesions that can closely mimic meningiomas. We describe radiological features of meningioma mimics highlighting imaging red flags to consider a differential diagnosis. A total of 348 lesions with radiological diagnosis of meningiomas which underwent to surgical treatment or biopsy between December of 2000 and September of 2014 were analyzed. We determined imaging features that are not a typical finding of meningiomas, suggesting other lesions. The following imaging characteristics were evaluated on CT and MRI: (a) bone erosion; (b) hyperintensity on T2WI; (c) hypointensity on T2WI; (d) bone destruction; (e) dural tail; (f) leptomeningeal involvement; (g) pattern of contrast enhancement; (h) dural displacement sign. We have a relatively high prevalence of meningioma mimics (7.2%). Dural-based lesions with homogeneous contrast enhancement (52%) are easily misdiagnosed as meningiomas. Most lesions mimic convexity (37.5%) or parafalcine (21.9%) meningiomas. We have determined five imaging red flags that can alert radiologists to consider meningioma mimics: (1) bone erosion (22.2%); (2) dural displacement sign (36%); (3) marked T2 hypointensity (32%); (4) marked T2 hyperintensity (12%); (5) absence of dural tail (48%). The most common mimic lesion in our series was hemangiopericytomas, followed by lymphomas and schwannomas. The prevalence of meningioma mimics is not negligible. It is important to have awareness on main radiological findings suggestive of differential diagnosis due to a wide range of differentials which lead to different prognosis and treatment strategies.