Radiological Imaging Research Articles

The potential of federated learning for self-configuring medical object detection in heterogeneous data distributions

Medical Object Detection (MOD) is a clinically relevant image processing method that locates structures of interest in radiological image data at object-level using bounding boxes. High-performing MOD models necessitate large datasets accurately reflecting the feature distribution of the corresponding problem domain. However, strict privacy regulations protecting patient data often hinder data consolidation, negatively affecting the performance and generalization of MOD models. Federated Learning (FL) offers a solution by enabling model training while the data remain at its original source institution. While existing FL solutions for medical image classification and segmentation demonstrate promising performance, FL for MOD remains largely unexplored. Motivated by this lack of technical solutions, we present an open-source, self-configuring and task-agnostic federated MOD framework. It integrates the FL framework Flower with nnDetection, a state-of-the-art MOD framework and provides several FL aggregation strategies. Furthermore, we evaluate model performance by creating simulated Independent Identically Distributed (IID) and non-IID scenarios, utilizing the publicly available datasets. Additionally, a detailed analysis of the distributions and characteristics of these datasets offers insights into how they can impact performance. Our framework’s implementation demonstrates the feasibility of federated self-configuring MOD in non-IID scenarios and facilitates the development of MOD models trained on large distributed databases.

Evaluating Explainable Artificial Intelligence (XAI) techniques in chest radiology imaging through a human-centered Lens.

The field of radiology imaging has experienced a remarkable increase in using of deep learning (DL) algorithms to support diagnostic and treatment decisions. This rise has led to the development of Explainable AI (XAI) system to improve the transparency and trust of complex DL methods. However, XAI systems face challenges in gaining acceptance within the healthcare sector, mainly due to technical hurdles in utilizing these systems in practice and the lack of human-centered evaluation/validation. In this study, we focus on visual XAI systems applied to DL-enabled diagnostic system in chest radiography. In particular, we conduct a user study to evaluate two prominent visual XAI techniques from the human perspective. To this end, we created two clinical scenarios for diagnosing pneumonia and COVID-19 using DL techniques applied to chest X-ray and CT scans. The achieved accuracy rates were 90% for pneumonia and 98% for COVID-19. Subsequently, we employed two well-known XAI methods, Grad-CAM (Gradient-weighted Class Activation Mapping) and LIME (Local Interpretable Model-agnostic Explanations), to generate visual explanations elucidating the AI decision-making process. The visual explainability results were shared through a user study, undergoing evaluation by medical professionals in terms of clinical relevance, coherency, and user trust. In general, participants expressed a positive perception of the use of XAI systems in chest radiography. However, there was a noticeable lack of awareness regarding their value and practical aspects. Regarding preferences, Grad-CAM showed superior performance over LIME in terms of coherency and trust, although concerns were raised about its clinical usability. Our findings highlight key user-driven explainability requirements, emphasizing the importance of multi-modal explainability and the necessity to increase awareness of XAI systems among medical practitioners. Inclusive design was also identified as a crucial need to ensure better alignment of these systems with user needs.

Concordance of Chest Radiography and Chest Computed Tomography Findings in Patients with Hematologic Malignancy and Invasive Mucormycosis: What Are the Prognostic Implications?

Invasive pulmonary mucormycosis (IPM) is a deadly opportunistic mold infection in patients with hematological malignancies (HM). Radiologic imaging is essential for its timely diagnosis. Here, we compared IPM lesions visualized by chest computed tomography (CCT) and chest X-ray (CXR) and determined the prognostic significance of discordant imaging. Therefore, we reviewed 44 consecutive HM patients with probable/proven IPM at MD Anderson Cancer Center in 2000-2020 who had concurrent CCT and CXR studies performed. All 44 patients had abnormal CCTs and 39 (89%) had anormal CXR findings at IPM diagnosis. However, only 26 patients (59%) showed CCT-matching IPM-suspicious lesions on CXR. Acute Physiology and Chronic Health Evaluation II score > 18 at IPM diagnosis and breakthrough infection to Mucorales-active antifungals were the only independent risk factors for 42-day and/or 84-day mortality. Absence of neutropenia at IPM diagnosis, neutrophil recovery in neutropenic patients, and surgical revision of mucormycosis lesions were protective factors. Although not reaching significance on multivariable analysis, visualization of CCT-matching lesions on CXR was associated with significantly increased 84-day mortality (log-rank test, p = 0.033), possibly as a surrogate of extensive lesions and tissue necrosis. This observation supports the exploration of radiologic lesion kinetics as a prognostic staging tool in IPM patients.

Chemoradiotherapy treatment increases cardiac and aortic [18F]FDG uptake ratios in lung cancer patients

[18F]Fluorodeoxyglucose (FDG) positron emission tomography (PET) is an indispensable non-invasive imaging tool to aid diagnosis, prognostication, and therapeutic monitoring in oncology, but it can also evaluate cardiovascular inflammation1,2. Previously, cardiac metabolic changes using [18F]FDG with chemoradiotherapy have been explored3 but changes in the rest of the cardiovascular system remain undetermined. To investigate the cardiovascular metabolic changes pre- and post-chemoradiotherapy in stage 3b non-small cell lung cancer (NSCLC) patients. A retrospective analysis of 26 patients (43-82 years) with stage 3b NSCLC from the American College of Radiology Imaging Network (ACRIN 6668) trial was performed3. All available pre- and post-treatment imaging were retrieved from the Cancer Imaging Archive (TCIA)4 and regions of interest for the left ventricle and calcified large arteries were contoured on all PET-CT scans using PMOD version 4.0 software. The mean, maximum standard uptake value (SUVmean and SUVmax) and target-to-background ratio (TBR) were quantified on PMOD. At approximately 14 weeks post-chemoradiotherapy, there was a higher SUVmean (mean difference 0.81, p=0.01) and SUVmax (mean difference 2.20, p=0.006) in the left ventricle compared with pretreatment scans. TBR for aorta was higher post-treatment (mean difference 0.06, p=0.005). However, SUVmean for carotid arteries and right brachiocephalic artery was reduced post-chemoradiotherapy (mean difference 0.15, p=0.008 and mean difference 0.28, p=0.03). A reduction in SUVmax was also seen for aortic arch (mean difference 0.58, p=0.03) and right brachiocephalic artery (mean difference 0.42, p=0.03 and mean difference 0.42, p=0.03). Cardiovascular glucose metabolism is selectively increased in the left ventricle and aorta post-chemoradiotherapy. Changes in glucose metabolism of atherosclerotic plaques vary across different vessels throughout the body. Please click on the 'PDF' for the full abstract!

Risk Factors for Bone Cement Displacement After Percutaneous Kyphoplasty in Osteoporotic Vertebral Fractures: A Retrospective Analysis.

BACKGROUND Bone cement displacement (BCD), which has received increasing attention from scholars, is a serious complication following vertebroplasty in patients with osteoporotic vertebral fractures (OVFs), and percutaneous kyphoplasty (PKP) might promote its occurrence. However, few studies have systematically explored the risk factors of BCD after PKP. This research aimed to study the risk factors for BCD following PKP. MATERIAL AND METHODS The clinical data of patients with OVFs treated with PKP from June 2016 to August 2022 in our department were retrospectively reviewed. Patients were categorized into the bone cement displacement group and the bone cement non-displacement group. Data on the subjects and their radiologic images were gathered for univariate analysis and binary logistic regression analysis. The receiver operating characteristic (ROC) curve and confusion matrix were utilized to assess the discrimination ability. RESULTS We included 181 patients, of which 12 had BCD after PKP. Binary logistic regression analysis revealed that independent risk factors associated with BCD after PKP were: high BMI, high restoration rate of the Cobb angle, high distance between the bone cement and the vertebral endplates, and presence of bone cement leakage. The ROC curve and confusion matrix indicates that logistic regression exhibited a strong predictive value for BCD. CONCLUSIONS Patients with a high BMI, a high restoration rate of the Cobb angle, a high distance between the bone cement and the vertebral endplates, and bone cement leakage have an increased risk of BCD after PKP.

Forensic Radiology and the Testimony of Shadows

This article examines how radiological images became accepted by courts as visual evidence of death in the 20th century. Initially conceived as a speciality of photography, X-rays confounded courts, eliciting a range of judicial responses, from outright refusal to consider the images as any kind of evidence, to mocking them as cheap parlour tricks for an unwitting public, to recognising them as more reliable than the testimony of the expert witness. The article contends that courts moved towards recognising X-rays as proof of death only by both affirming forensic radiology's promise of ‘mechanical objectivity’ while acknowledging its reliance on the fallibility of ‘human subjectivity’. We suggest that this history has broader implications in socio-legal studies for comprehending how the invention of novel optical techniques continues to problematise legal epistemologies of death in the 21st century.

Continent urinary diversion and management of pouch calculi as a late complication: A case series

Objective: Following cystectomy, there are several reconstructive options. A continent cutaneous urinary diversion (CUD) avoids an ileal conduit if patients are unsuitable for an orthotopic neobladder. Reservoir stone formation is common, and management is challenging. Our data present incidence and management of calculi following Indiana pouch reconstruction after radical cystectomy. Patients and Methods: Prospective database review identified 30 patients with Indiana pouch CUD in our series of 450 open cystectomies. Paper, electronic medical records, and radiological imaging were reviewed. Results: Six (20%) patients with up to 15 years follow-up were identified with stones. At cystectomy, all patients were stone free with normal renal function and electrolytes. Time to first stone formation was 29–60 months. Eighty percent became recurrent stone formers. Management involved a combination of endoscopic LASER litholapaxy, percutaneous and open access. All patients had a functioning CUD following stone treatment. Time to stone recurrence improved with assessment for metabolic abnormalities, timed pouch emptying, pouch irrigation and treatment of urine infections. Conclusion: The risk of stone formation and requirement for rigorous post-operative prevention protocols should be discussed with patients. Follow-up for this group should be lifelong to include imaging and metabolic monitoring. Management requires a multimodal, multi-disciplinary approach. Level of evidence: Not applicable

A Case of Chronic Back Pain: Revealing Complete Ureteral Duplicity in an Adult Woman

Ureteral duplication is a rare congenital anomaly, often diagnosed incidentally, characterized by the presence of two distinct ureters draining a single kidney. This condition can lead to complications such as vesicoureteral reflux or upper pole obstruction, often due to ectopic ureteral insertion or ureterocele. We report the case of a 40-year-old woman presenting with left-sided chronic low-back pain. Imaging studies, including ultrasound and CT urography, revealed bilateral ureteral duplication with significant left ureterohydronephrosis due to dysplasia and ectopic insertion of the upper ureter. Radiological imaging, especially CT urography, is essential for diagnosing ureteral duplication and identifying its complications. Timely imaging and intervention are critical for preserving renal function, with treatment options depending on the extent of renal impairment. These may include partial or total ureteronephrectomy or ureteral reimplantation.

6529 The Risk of Hypophysitis Following Treatment With Relatlimab+Nivolumab Appears Higher Than Expected

Abstract Disclosure: N. Chamorro-Pareja: None. A.T. Faje: None. K.K. Miller: Stock Owner; Self; Bristol-Myers Squibb. Hypophysitis is a recognized complication of immune checkpoint inhibitor therapy; the risk of developing hypophysitis in patients receiving nivolumab (an anti-programmed death-ligand 1 [anti-PD-1]) is estimated to be < 1%. Relatlimab is a human monoclonal antibody targeting lymphocyte activation gene 3 (LAG-3) recently approved in combination with nivolumab for the treatment of unresectable or metastatic melanoma. The risk of hypophysitis as a complication of relatlimab therapy is not well-defined. Objective: To examine the prevalence, identify risk factors, and characterize the clinical presentation of hypophysitis in patients receiving relatlimab+nivolumab. Methods: 159 patients received relatlimab+nivolumab at the Mass General Brigham health care system between 6/2015 and 11/2023. Twenty-seven patients were excluded because they were either diagnosed with adrenal insufficiency (AI) before receiving relatlimab+nivolumab or AI was secondary to other factors, primarily exogenous glucocorticoid administration, leaving a total of 122 patients. The medical records of these patients, including provider encounters, laboratory results, medication records, and radiologic images were reviewed. Data are presented as mean ± SD. Results: Central AI was diagnosed in 10 patients (7.5% of the cohort) after relatlimab+nivolumab administration. The mean age was 64.5±13.8 vs. 67.1±14.4 in patients with AI vs. patients without AI (p= 0.58). Sixty percent of patients in the AI group were male compared to 53% of patients without AI (p= 0.68). The development of AI was not related to the cumulative dose of relatlimab+nivolumab (mean number of cycles 6.4±3.2 vs. 4.9±5.0, p=0.35). The most common presenting symptoms of AI were fatigue, anorexia, nausea, and vomiting. No patients were diagnosed with additional anterior pituitary hormone deficiencies, though not all patients were evaluated for these diagnoses; none had diabetes insipidus. Nine patients had MRIs performed after the diagnosis of central AI; 7 of these patients had pre-treatment MRIs for comparison. Diffuse pituitary enlargement was seen on MRI after initiation of relatlimab+nivolumab in 3 patients up to 8 weeks prior to the diagnosis of hypopituitarism. All patients had persistent hypopituitarism at the most recent evaluation. Conclusions: This study is the first cohort analysis of hypophysitis in patients treated with relatlimab+nivolumab. A significant portion of patients were diagnosed with central AI, presumptively due to hypophysitis given the lack of an identifiable alternative etiology. Although the clinical phenotype of these patients paralleled published studies analyzing anti-PD-1 monotherapy, combination treatment with relatlimab+nivolumab appeared to confer a significantly higher risk of developing hypophysitis. Presentation: 6/3/2024

7090 The Largest Study on Asymptomatic Primary Hyperparathyroidism (APHPT) Conducted at the Tertiary Care Riga East Clinical University Hospital (RECUH)— Three Years of Data

Abstract Disclosure: D. Stūrīte: None. I. Rasa: None. Background: Primary hyperparathyroidism (PHPT) is the third most common endocrine disorder and a leading cause of hypercalcemia in the outpatient setting. The study aimed to assess the characteristics, management and outcomes of pts with APHPT. Methods: A retrospective analysis of data from 168 pts with APHPT, evaluated at RECUH from January 2021 to November 2023 was conducted. Information obtained included medical records, laboratory data, imaging results, surgical protocols, histopathology data. Statistical analysis was performed using IBM SPSS 29.0. Results: From the 168 pts (mean age: 63.7±11.8 years), 86.3% (n=145) were females. Predominantly, 67.3% (n=113) exhibited mild hypercalcemia (2.6-3.0mmol/L), while 22.6% (n=38) had moderate hypercalcemia (3.0-3.49mmol/L), and 4.8% (n=8) -severe hypercalcemia (≥3.5mmol/L). 5.3% (n=9) had normocalcaemic PHPT. The mean preoperative maximal calcium level was 2.9±0.3mmol/L, iPTH level - 247.6±224.9pg/mL, minimal phosphorus - 1.3±6.7mmol/L and 25-OH vitamin D level - 28.3±14.7ng/mL. The mean preoperative eGFR was 90.6±28.2 ml/min/1.73m2, creatinine - 72.5±23.9μmol/L. Parathyroid adenoma sizes ranged from 0.3x0.4cm to 5.3x3.7cm. Calcium levels positively correlated with adenoma cross-sectional area (ρ=0.187, p=0.029) and maximal adenoma dimension (ρ=0.215, p=0.011). Ultrasonography convincingly detected parathyroid adenomas in 63.9% (107/168), SPECT/CT - 68.4% (52/76), 99mTc-sestamibi scintigraphy - 65.6% (61/93), 3D-CT - 70.6% (24/34), contrast-enhanced ultrasonography - 84% (21/25) and MRI in - 40% (2/5) cases. 12.5% (n=21) pts had unlocated parathyroid adenoma. 34.5% (n=58) of pts had osteoporosis, 47.6% (n=80) osteopenia, 12.5% (n=21) had a history of osteoporotic fracture, 17.3% (n=29) had gallstones and 22.0% (n=37) - kidney stones. 80.4% (n=135) of pts had thyroid nodules, 48.2% (n=81) - nontoxic goitre, 24.4% (n=31) - autoimmune thyroiditis, 41.7% (n=70) - hypertension, 10.5% (n=18) - type 2 diabetes. 18.5% (n=31) pts were found to have a diagnosis of malignancy. 61.9% (n=104) of pts underwent parathyroidectomy. Histopathology and radiologic imaging revealed single parathyroid adenoma in 95.2% (n=99), double parathyroid adenomas in 1.9% (n=2), parathyroid hyperplasia in 2.9% (n=3) and parathyroid carcinoma in 1.9% (n=2) pts. The mean maximal postoperative calcium level (n=103) was 2.4±0.1mmol/L, iPTH (n=101) - 63.5±27.7pg/mL, 25-OH vitamin D - 41.5±13.3ng/mL, and the mean minimal phosphorus (n=56) - 1.1±0.2mmol/L. Conclusions: APHPT remains frequently encountered and often showcases bone manifestations. It's crucial to consider the diverse clinical manifestations and associated conditions in patients with APHPT. Presentation: 6/2/2024

Correlation of Radiological and Pedobarographic Evaluations in the Presence of Foot Sole Pain

Objective: One of the reasons for foot pain is the changes in the structure of the medial longitudinal arch. Assessment of medial longitudinal arch height is often made with foot radiographs and pedobarographic measurements. The relationship between these methods in the presence of foot sole pain has not been examined yet. This study aims to investigate the relationship among these measurement methods in adults with foot sole pain. Materials and Methods: 60 adults with foot sole pain were included in this study. The talohorizontal, talocalcaneal, talo1.metatarsal, and calcaneal inclination angles were measured in the lateral weight bearing foot radiographs. The arch index was calculated in static, dynamic pedobarographic measurements. The agreement of radiological and pedographic measurements among themselves and with each other was determined. Results: The mean age of 60 participants was 45.32 ±13.64. Agreement among foot classifications of radiologic measurements was poor Gwet’s agreement coefficient =-0.198 with a 95% confidence interval (-0.315,-0.080); percent agreement = 0.167 with a 95% confidence interval (0.099,0.234) and Kappa =-0.047 with a 95% confidence interval (-0.083,-0.01) were found. The agreement between pedobarographic classifications was fair Gwet’s agreement coefficient =0.486 with a 95% confidence interval (0.355,0.617); percent agreement =0.65 with 95% confidence interval (0.563,0.737) and Kappa=0.453 with a 95% confidence interval (0.324,0.583) were found. Among radiological measurements, the calcaneal inclination angle showed the highest coefficients of agreement with pedobarographic measurements. The extent of its agreement was fair. Conclusion: Pedobarography is a simple, reliable, inexpensive, and noninvasive method. The calcaneal inclination angle which is used in radiological imaging can give an idea about the height of the medial longitudinal arch.

4D-Flow MRI and Vector Ultrasound in the In-Vitro Evaluation of Surgical Aortic Heart Valves - a Pilot Study.

The aim of this study was the initial investigation of 4D-Flow MRI and Vector Ultrasound as novel imaging techniques in the in-vitro analysis of hemodynamics in anatomical models. Specifically, by looking at the hemodynamic performance of state-of-the-art surgical heart valves in a 3D-printed aortic arch. The mock circulatory loop simulated physiological, pulsatile flow. Two mechanical and three biological aortic valves prostheses were compared in a 3D-printed aortic arch. 4D magnetic resonance imaging and vector flow Doppler ultrasound served as imaging methods. Hemodynamic parameters such as wall shear stress, flow velocities and pressure gradients were analyzed. The flow analysis revealed characteristic flow-patterns in the 3D-printed aortic arch. The blood-flow in the arch presented complex patterns, including the formation of helixes and vortices. Higher proximal peak velocities and lower flow volumes were found for biological valves. The mock circulatory loop in combination with modern radiological imaging provides a sufficient basis for the hemodynamic comparison of aortic valves.

Intramyocardial and intra-atrial courses in the right coronary artery: prevalence and characteristics.

We aimed to determine the prevalence and radiological characteristics of myocardial bridging (MB) and intra-atrial course anomaly (IARCA), which are rare course variations of the right coronary artery (RCA), in the adult patient population. Radiological images of cases over the age of 18 who underwent coronary CT angiography (CTA) examination in our clinic were scanned from the archives retrospectively, and cases with MB of the RCA and IARCA detection were included in the study. The number, age and gender distribution of the cases, whether there were any other accompanying vascular anomalies, whether there was atherosclerosis in the coronary arteries (calculation of Agatston total calcium score, calculation of atherosclerotic stenosis as a percentage, if any) were evaluated. The prevalence of MB in the RCA was 2.06%, and the prevalence of IARCA was 0.44%. In one case, both anomalies were detected together. The average MB segment length in RCA was 21.9mm, and the average IARCA segment length was 37.9mm. There was no atherosclerotic disease in the RCA segment where anomaly was detected. Recognition of rare course anomalies of RCA before treatment procedures such as ablation and surgery is important to prevent complications that may have potentially fatal consequences.

Pneumatosis cystoides intestinalis in granulomatosis with polyangiitis: a case report.

This study aims to investigate the clinical manifestations, imaging features, and treatment considerations in the rare occurrence of pneumatosis cystoides intestinalis (PCI) within the context of granulomatosis with polyangiitis (GPA). We present the case of a 71-year-old Chinese woman diagnosed with GPA, who, despite exhibiting fatigue, knee pain, and nasosinusitis, remained asymptomatic for PCI. Regular follow-up revealed laboratory and imaging evidence indicative of clinical relapse. The patient received GPA treatment but was not specifically managed for PCI. Serial abdominal CT scans were performed to monitor the progression of PCI. Radiological diagnosis confirmed the presence of gas within the colon wall, indicating pneumatosis cystoides intestinalis. Notably, the patient remained asymptomatic for abdominal complaints. Despite ongoing GPA treatment, a follow-up CT scan 2months later revealed persistent gas within the colon wall, suggesting a persistent state of PCI. Patient consent was obtained for the publication of this case report, and ethical approval was not obtained as this study constitutes a retrospective review. This case underscores the importance of recognizing pneumatosis cystoides intestinalis as a potential complication in GPA patients, even in the absence of typical abdominal symptoms. Further research is warranted to elucidate the underlying mechanisms and optimal management strategies for this rare association. Key points • Rare association: This case report sheds light on the uncommon occurrence of pneumatosis cystoides intestinalis (PCI) within the context of granulomatosis with polyangiitis (GPA), adding to the understanding of the spectrum of manifestations of GPA. • Clinical manifestations: Despite being diagnosed with GPA and experiencing symptoms such as fatigue, knee pain, and nasosinusitis, the patient remained asymptomatic for PCI, emphasizing the importance of vigilant clinical monitoring in GPA patients. • Imaging features: Radiological imaging, including serial abdominal CT scans, played a crucial role in diagnosing and monitoring the progression of PCI in the absence of typical abdominal complaints, highlighting the utility of imaging modalities in detecting silent manifestations of gastrointestinal complications in GPA. • Treatment considerations: The case highlights the challenge of managing PCI in GPA patients, especially when asymptomatic, and raises questions about the optimal management strategies for such rare associations, underscoring the need for further research in this area.

Unique properties of clinical manifestation and magnetic resonance imaging for differential diagnosis of optic nerve hemangioblastoma.

To investigate the unique properties of clinical manifestation and radiological imaging for differential diagnosis of optic nerve hemangioblastoma (ONH) from adult optic nerve glioma (ONG) prior to surgical resection. ONH and adult ONG patients were recruited from 2012 to 2022. A total of seven ONH patients (8 eyes) and 23 adult ONG patients (24 eyes) were assessed. The median onset age of ONH patients was older than that of adult ONG patients (p = 0.007). There were 42.9% (3/7) of ONH patients closely associated with the diagnosis of Von Hippel-Lindau (VHL) syndrome. Notably in Magnetic Resonance Imaging (MRI), the retrobulbar hemangioblastomas in all ONH patients were primarily intraorbital (100%, 8/8), canalicular (87.5%, 7/8), and anterior intracranial (12.5%, 1/8), especially concentrated in the orbital apex, with little posterior optic pathway involvement. Nearly all affected parts of optic nerve in the ONH group (75.0%, 6/8) presented with circumscribed cystic-solid components, characterized by cystic lesions (peritumoral oedema) anteriorly and solid tumours posteriorly, with significant heterogeneous enhancement. Adult ONG lesions prior to extend from the anterior portion to the whole length of the optic nerve, with relatively innocent enlargement in the postcontrast study. Optic nerve tumours in those with older ages at diagnosis (>30 years) or those diagnosed with VHL syndrome are more likely to be indicative of ONH. In the absence of associated VHL syndrome, a distinguishing MRI feature is the concentration of tumours in the orbital apex, characterized by circumscribed cystic-solid components and heterogeneous enhancement of the solid portion.

SPIN-03 PROFILE OF MALIGNANT SPINAL CORD COMPRESSION AMONG CHILDREN AT A SINGLE CENTRE IN JOHANNESBURG, SOUTH AFRICA

Abstract OBJECTIVE Malignant spinal cord compression (MSCC) in children can lead to permanent neurological deficits and therefore warrants urgent referral, prompt diagnosis and treatment. There is limited data on paediatric MSCC in Sub-Saharan Africa. The objective was to assess the characteristics, aetiology, clinical presentation, treatment and long-term outcomes of MSCC. METHODS Records of 23 patients with MSCC were retrospectively assessed over a 15-year period (2008-2023) at Charlotte Maxeke Johannesburg Academic Hospital in Johannesburg, South Africa. RESULTS The median age of MSCC diagnosis was four years (range: 5 months to 15 years). The median interval between symptom onset and confirmed diagnosis was three months (1 week to 20 months). MSCC’s leading causes were central nervous system tumours (30%), lymphomas (22%), sarcomas (17%), germ cell tumours (9%), teratoid tumours (9%), neuroblastomas (9%) and leukaemias (4%). Commonest presenting symptoms were motor deficits (96%), pain (35%) and sphincter dysfunction (22%). Magnetic resonance imaging (MRI) of the spine was diagnostic in all cases. The primary tumour was managed using a multimodality approach: 70% underwent neurosurgical intervention and 39% received radiotherapy. The median follow-up duration was two years (1 month to 15 years). There were six deaths (two cases of ependymoma and a case each of glioblastoma multiforme, alveolar rhabdomyosarcoma, acute lymphoblastic leukaemia and Burkitt lymphoma) at a median interval of 4.5 months from diagnosis (1 month to 2 years). The commonest long-term sequelae were motor deficits (52%) and sphincter dysfunction (26%) and 22% of patients were asymptomatic. CONCLUSION We documented longer diagnostic delays than published in the literature and recommend increased awareness and rapid referral to decrease permanent sequelae. Patients presenting with new-onset neurological deficits suggestive of MSCC should have urgent radiological imaging; preferably MRI, followed by prompt referral to a specialised centre with an experienced multidisciplinary team.

Radiological perspective on earthquake trauma: differences in children and adults.

February 2023 saw major earthquakes in Pazarcık and Elbistan, causing significant devastation in Turkey. Patients were transferred to hospitals in neighboring provinces, with multiple traumas-especially fractures and organ injuries-forming the main reasons for hospital admissions. This study aimed to examine earthquake-related injuries in pediatric and adult populations to understand differences. This study analyzed 1,220 adults and 590 pediatric patients with radiological imaging out of 8,704 earthquake trauma cases. Radiological images were assessed independently by two radiologists. Statistical analysis using SPSS examined relationships between variables such as age group and injury type. Results showed 40% of adults and 64% of children had normal radiological findings. Cerebral and extremity traumas were most common in pediatrics, while adults showed more extremity, thoracic, and spinal traumas. Significant differences between adult and pediatric groups were observed in cranial fractures, thoracic and lumbar vertebral fractures, hemopneumothorax, lung contusions, rib fractures, femur and talocalcaneal fractures, and compartment syndrome (p<0.001). Earthquake-related injuries may vary between children and adults. Due to children's more flexible anatomical structure, it is believed that earthquake-related injuries occur less frequently in children. In this study, head traumas were more common in children compared to adults. The rate of cranial fractures was significantly higher in children, with a higher incidence of epidural hematoma compared to adults. Spinal traumas were more frequent in adults than in children, attributed to children's greater flexibility reducing the risk of entrapment under rubble. Pediatric thoracic compliance being significantly higher than in adults often resulted in milder chest traumas. However, compartment syndrome was more common in children, with a lower rate of accompanying bone fractures compared to adults. No significant difference was observed between children and adults in maxillofacial, abdominal, and pelvic traumas. These findings provide insights for future disaster healthcare planning and management.

E-scooter-related imaging: a new emerging high-energy trauma patient.

To quantify the volume and nature of radiological imaging performed for e-scooter related trauma presentations in a tertiary referral centre and to identify common radiological pattern of injuries. Our study received institutional review board approval. We retrospectively reviewed all anonymised radiological imaging studies performed in our institution for the term 'scooter' or 'e-scooter' between July 2020 and July 2021. The patient demographics, number of imaging studies performed and modality type as well as the nature of injuries identified were recorded. Within the study period, 147 patients with e-scooter-related injuries were referred for radiological imaging. Forty-two (29%) of those patients had positive radiological findings. The vast majority of injuries on radiographs were upper limb injuries typical of a fall on outstretched hand (FOOSH) pattern. Thirty-two patients (22%) required advanced diagnostics with CT or MRI with 11 of these patients having positive findings. Four patients suffered significant head injuries including skull fractures and/or intracranial haemorrhage. Five patients suffered facial bone fractures, and 2 suffered spinal fractures. One patient suffered a handlebar abdominal trauma with a resulting large bowel injury ultimately requiring bowel resection. E-scooter-related injuries represent a new and emerging high-energy trauma patient. These patients demonstrate injury patterns similar to other high-energy trauma such as road traffic accidents. Although the most common injuries are musculoskeletal upper limb injuries typical of FOOSH, a large proportion of these require advanced diagnostic imaging (CT, MRI) which were commonly positive for significant injuries.

Pelvic Stress Fractures Following Resection and Reconstruction of Pelvis Tumours—An Observational Study

Background and Aims: Pelvic bone tumours are rare, with a guarded prognosis despite advances in radiological imaging and surgical techniques. Despite this, limb salvage surgery has become the mainstay treatment for patients presenting with primary bone sarcomas, especially those with low histological grade variants. However, the rate of peri-operative-associated complications remains high in the form of local recurrence and surgical site infections (SSI). Objective: We highlight our experience from a tertiary referral oncology centre of incidence and clinical and radiological features, as well as discuss the risk factors for developing pelvic stress fractures (PSFs) in patients treated with hemipelvis resection. Materials and Methods: We performed a retrospective search from our radiology and oncology database at our tertiary orthopaedic oncology referral centre for patients referred, diagnosed and managed for stress fractures following an internal hemipelvectomy for pelvic tumours/Sarcoma through the service between 2007 and 2019. Patient demographics, clinical characteristics, complementary imaging, clinical management outcome and peri-operative complications were documented. A focussed evaluation of patients diagnosed and managed for PSFs in patients treated with hemipelvis resection. Results: We identified a total of six patients with stress fractures following internal hemipelvectomy. The sacrum was the most common anatomical region ( n = 3). Other areas identified with insufficiency stress fractures included the ischium and femoral neck. Conclusion: Stress fractures post pelvis resection and reconstruction is a rare complication. Radiologists and orthopaedic oncology surgeons need to be aware of this complication to aid with an early diagnosis and initiate appropriate management.

Beyond the womb: pontine hemorrhage’s impact on maternal and fetal outcomes: a case report from Nepal

Introduction: Strokes cause 37% of cardiovascular-related deaths in women, with 40% during delivery and 50% postpartum. Pontine hemorrhage, a rare cerebrovascular disease, can occur during pregnancy and postpartum, requiring complex diagnosis and management. Case presentation: A 33-year-old primipara female presented with headache, vomiting, and altered consciousness at 15 weeks and 5 days gestation. She had no history of head trauma, involuntary urine passage, cough, shortness of breath, palpitation, or per vaginal bleeding. Psychiatric and neurology consultations were conducted to address her symptoms. Discussion: Pontine hemorrhage is a rare condition affecting pregnant women, causing mild symptoms like vertigo, ataxia, and dysphagia. Our patient underwent an initial blood investigation with imaging of her brain (CT and MRI) to establish the diagnosis of pontine hemorrhage. It is believed to be caused by hormonal fluctuations, but studies have not proven it. Stroke during pregnancy is rare, with only 10% occurring during the antepartum period. Diagnosis requires a multidisciplinary approach with history, clinical examination, and radiological imaging like CT and MRI. Treatment involved antiplatelet therapy, which ensured favorable maternal and fetal outcomes for our patient. Conclusion: In summary, this case demonstrates the rare incidence of pontine hemorrhage during pregnancy. It highlights the diagnostic challenges and successful treatment with antiplatelet therapy, emphasizing the necessity for a comprehensive approach to ensure favorable maternal and fetal outcomes.