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Soft-tissue sarcomas are a diverse group of rare mesenchymal malignancies accounting for only 1% of all solid adult malignancies. These have been categorized in 12 broad groups by the World Health Organization (WHO) with their recent update in 2013. Majority of them lack specific imaging features serving as imaging conundrums for a radiologist. These are often large masses at presentation as they are asymptomatic or cause vague clinical symptoms. These tumors are challenging for surgeons as well as they find it difficult to achieve complete resection because of complex intra-abdominal anatomy and their close relationship with critical structures. Often, a multidisciplinary approach is required to decide on the most appropriate management for these complex cases so as to provide optimal patient care. Knowledge of the WHO classification, pathologic features and available treatment options will help the radiologist make a meaningful contribution in multidisciplinary discussions of such cases and overall patient care. Liposarcoma (well-differentiated and dedifferentiated liposarcomas), leiomyosarcoma, and gastrointestinal stromal tumor are the 3 most common primary intra-abdominal sarcomas. In part 1 of this article, general features of soft tissue sarcomas and some of the common tumors from WHO category 1-4 found in abdomen and pelvis are discussed. Part 2 will focus on common tumors from remainder of the WHO categories.

High-resolution phased array external magnetic resonance imaging (MRI) is the first investigation of choice in rectal cancer for local staging, both in the primary and restaging situations. Use of MRI helps differentiate between those with good prognosis, which can be offered upfront surgery and the poor prognostic cases where treatment intensification is needed. MRI identified poor prognostic factors are threatened or involved mesorectal fascia, T3 tumors with >5 mm extramural spread, those with extramural vascular invasion, pelvic sidewall nodes and mucinous tumors. At restaging, use of MRI helps evaluate response and an MR tumor regression grading system is being evaluated. Complete response seen on clinical examination and endoscopy, needs confirmation on MRI using both T2-weighted and diffusion-weighted sequences to justify a "watch and wait" approach. In this subset of patients, MRI also plays a role in monitoring and detecting early regrowth. In those with partial response, MRI helps define surgical margins and can be used as a roadmap to decide between sphincter preserving surgeries and radical sphincter sacrificing surgeries; pelvic exenteration and pelvic sidewall lymph node dissection. Poor responders on MRI may benefit from adjuvant chemotherapy. Use of MRI thus helps in individualizing treatment in rectal cancer.

With the introduction of the coronavirus disease 2019 (COVID-19) mRNA vaccines, the incidence of severe infection has significantly decreased. While the vaccines have been shown to be effective and safe, there have been few case reports of acute myocarditis within 3-5 days following the second dose of the vaccine. We report a case of an elderly man who presented with acute-onset chest pain after three months of receiving the second dose of the mRNA vaccine. He was found to have acute myocarditis on cardiac magnetic resonance imaging (CMRI), which was attributed to exposure to the COVID-19 vaccine in the absence of any other risk factors. Our patient demonstrated quick resolution of symptoms and was discharged within 72 hours. We review the literature and summarize published case reports on COVID-19 vaccine-associated myocarditis. The present case report provides new evidence regarding the possible subacute presentation of myocarditis post-COVID-19 vaccine, and further highlights the favorable outcome in this newly described clinical entity.

Background and Aims: Parsonage Turner Syndrome is a well known clinical entity. Several excellent articles have succinctly described Magnetic Resonance Imaging (MRI) findings in PTS. However, these articles have inferred neural involvement in PTS based on the patterns of denervation of muscles in the shoulder region. The aim of this study is to directly visualize the distribution and extent of abnormality in MR Neurography (MRN) of the brachial plexus in known cases of brachial plexus neuritis or Parsonage-Turner Syndrome (PTS). Methods: 15 patients who were diagnosed with PTS based on clinical and electrophysiological findings participated in the study. MRN of the brachial plexus was done in a 1.5T system using a combination of T1W (T1-weighted), T2W (T2-weighted) fat-saturated, STIR (Short Tau Inversion Recovery), 3D STIR SPACE (Sampling Perfection with Application Optimized Contrasts) and 3D T2W SPACE sequences. Findings were recorded and assessed. Results: The age range of our patients was 7-65 years (mean 37.87 years). Most of the patients had unilateral symptoms. All patients had weakness in shoulder abduction. Other common associated complaints included pain in the shoulder/neck/arm and preceding fever. MRN revealed the percentage of involvement of roots, trunks, cords and terminal branches was 53.3%, 46.7%, 40% and 13.3% respectively. Evidence of muscle denervation in the form of edema, fatty infiltration and atrophy was noted in 8 (53.3%) patients. Conclusion: Most of the patients in this study had unilateral involvement on MRN. The roots were the commonest site of involvement followed by the trunks, cords and terminal branches. C5 was the most commonly involved root.

Inflammatory pseudotumor (IPT) is a rare lesion of unknown origin, characterized by proliferation of fibrous connective tissue and invasion of inflammatory cells. Although benign, it has the propensity to mimic malignant masses given its nonspecific symptoms and imaging manifestations. We present a case of hepatic IPT with variable interpretation on different imaging modalities, called as abscess on computed tomography (CT) and neoplasm on ultrasound and magnetic resonance imaging (MRI), thus posing a diagnostic dilemma. Hence it is important to recognize this as a distinct clinical entity and include it in the differential of liver masses with atypical imaging findings.

High-resolution magnetic resonance imaging (MRI) plays a pivotal role in the pretreatment assessment of primary rectal cancer. The success of this technique depends on obtaining good-quality high-resolution T2-weighted images of the primary tumor, orthogonal to rectal lumen. The goal of magnetic resonance staging is to identify patients who will benefit from neoadjuvant therapy prior to surgery to minimize postoperative recurrence and planning of optimal surgical approach. MRI also facilitates optimal identification of important prognostic factors, which improves both treatment selection and posttreatment follow-up. The objective of this article is to review the existing literature and provide a concise update on various aspects of rectal cancer imaging, discuss the current role of advanced imaging techniques such as diffusion-weighted and perfusion imaging in the evaluation of rectal cancer, and to assess response to therapy.

A 63-year-old female with a history of hypertension presented with progressively worsening shortness of breath. She underwent a cardiac catheterization and was found to have prominent Thebesian veins as well as anomalous connections between the proximal right coronary artery and the right ventricle. Cardiac computed tomography was ordered for further evaluation and showed a coronary fistula to the right ventricular outflow tract confirming the diagnosis of a coronary-cameral fistula (CCF). CCF are rare congenital anomalous communications that occur between coronary arteries and a cardiac chamber. They are usually an incidental finding and patients are rarely symptomatic. As the use of coronary computed tomography angiography is rapidly expanding, the detection of CCF will likely increase in the general population.

Soft-tissue sarcomas are a diverse group of rare mesenchymal malignancies accounting for only 1% of all solid adult malignancies. These have been categorized in 12 broad groups by the World Health Organization (WHO) with their recent update in 2013. Majority of them lack specific imaging features serving as imaging conundrums for a radiologist. These are often large masses at presentation as they are asymptomatic or cause vague clinical symptoms. These tumors are challenging for surgeons as well as they find it difficult to achieve complete resection because of complex intra-abdominal anatomy and their close relationship with critical structures. Often, a multidisciplinary approach is required to decide on the most appropriate management for these complex cases so as to provide optimal patient care. Knowledge of the WHO classification, pathologic features, and treatment options available helps the radiologist make a meaningful contribution in multidisciplinary discussions of such cases and overall patient care. Liposarcoma (well-differentiated and dedifferentiated liposarcomas), leiomyosarcoma, and gastrointestinal stromal tumor are the 3 most common primary intra-abdominal sarcomas. In part 1 of this article, general features of soft-tissue sarcomas and some of the common tumors from WHO category 1-4 found in abdomen and pelvis are discussed. Part 2 will focus on common tumors from remainder of the WHO categories.

To study the use of cardiac magnetic resonance (CMR) feature tracking technique in evaluation of myocardial amyloidosis.CMR scans of 28 patients with biopsy proven myocardial amyloidosis and 35 controls were reviewed. Conventional short axis, vertical long axis, and 4-chamber cine steady-state free precession images from CMR scans were used to generate radial, circumferential, and longitudinal myocardial strain maps using feature tracking software. Global and regional peak radial, circumferential, and longitudinal strain values were computed.There were significant decreases in radial, circumferential, and longitudinal strains in patients with myocardial amyloidosis globally and across layers (all P0.001). Strain was relatively preserved for the apex and most affected for the basal level. The area under the receiver operating characteristic curve for base peak radial, circumferential, and longitudinal strain 0.899, 0.884, and 0.866 and cut offs of 22.9, -13.3, and -10.9, respectively, were determined by receiver operating characteristic analysis. CMR feature tracking strain analysis of base-level strain parameters was able to differentiate patients with myocardial amyloidosis from those without myocardial amyloid with high sensitivity (82.5%) and specificity (82.9%) particularly for radial strain. The maximum sensitivity (89.3%) was achieved if any of the 3 parameters were abnormal, and the maximum specificity (88.6%) when all 3 parameters were abnormal.Myocardial amyloidosis produces significant changes in regional and global strain parameters, and the peak radial and circumferential strain are the most affected at the basal layer.

Objectives AL amyloidosis affects up to 30% of patients with multiple myeloma (MM), and cardiac involvement is associated with worse outcomes. Traditional screening modalities including EKG, echocardiography and biomarkers have limited value. The aim of this study was to evaluate the clinical and prognostic value of late gadolinium enhancement (LGE) by cardiovascular magnetic resonance (CMR) imaging in patients with plasma cell dyscrasias and suspected cardiac amyloidosis (CA). Methods A total of 251 consecutive patients with plasma cell dyscrasias who underwent CMR were enrolled in this study. Primary endpoint was all cause mortality. Clinical, ECG, echocardiographic, biomarker and CMR predictors of mortality were analyzed. Results Mean age of population was 63 ± 10 years, 36% females and 19% African Americans. During a median follow-up duration of 28 months (IQR 5–56), there were 97 deaths (39%). Patients who died were more likely to have diabetes (28% vs. 14%; P = 0.03), CAD (28% vs. 16%; P = 0.04) and CKD (33% vs. 21%; P = 0.04). With endomyocardial biopsy as the gold standard (42 (17%) patients), amyloid pattern on CMR (LGE+) had sensitivity and negative predictive values of 100%; specificity and positive predictive values of 80 and 81% with an AUC 0.9 for CA. History of CAD (HR 1.64, 95% CI 1.01–2.6; P = 0.04), brain natriuretic peptide (HR 1.0003 95% CI 1.0001–1.0006; P = 0.004) and LGE + (HR 1.72, 95% CI 1.05–2.8; P = 0.02) were independent predictors of mortality. LGE+ possessed incremental prognostic value over clinical, laboratory and echocardiographic variables for mortality prediction. Conclusions CMR is a clinically useful tool for diagnosis and prognostication in myeloma patients with suspected CA. [10.1093/ehjci/jew130][1] [1]: /lookup/doi/10.1093/ehjci/jew130

Sarcoidosis is a systemic granulomatous disorder with a variety of clinical presentations and radiological appearances. Although it primarily affects the lungs and lymphatics, sarcoidosis potentially involves essentially every organ system. On imaging, sarcoidosis can mimic different disease entities, including primary and metastatic neoplasms, vasculitis, and other granulomatous infections. Definitive diagnosis often requires a combination of clinical, radiological, and histologic information. Imaging plays a crucial role in diagnosis and evaluating response to therapy. This review covers imaging findings in sarcoidosis within each organ system, with an emphasis on the use of imaging in the diagnosis and management of this condition.

The posterior approach is a commonly employed exposure of the elbow that provides excellent visualization and efficacy for various orthopedic procedures, including total elbow arthroplasty (TEA) and fracture care. The posterior approach to the elbow has been associated with an increased rate of wound complications, including infection, skin necrosis, and wound dehiscence. Despite an association between these complications and decreased elbow perfusion, data regarding the intrinsic anatomic etiology for preferential complications in this area has been scarcely reported in the literature. This study characterizes the subdermal and cutaneous vascular perfusion about the elbow by describing the predominant direction of circulation, subdermal anastomoses, and volume of perfusion through cadaveric modeling using computed tomography angiography (CTA). Fifteen upper extremity cadaver specimens were prepared with injection of radiographic contrast directly into the axillary artery immediately preceding CTA imaging of each specimen. Sectra IDS7 software for Windows was used for analysis of all images to produce superimposed axial and 3-D reconstructions of each CTA series. From these images it was discerned that the predominant direction of flow in the posterior elbow integument is anterior medial to posterior lateral. Both the posterior medial and posterior lateral subdermal vascular networks emanate from proximally derived medial arterial sources with few anastomoses and minimal collateral perfusion from the anterolateral location. Consequently, it is important to preserve medial subdermal vascular structures to prevent ischemic wound complications. This is especially true in previously incised elbow integuments. Clin. Anat. 32:509-514, 2019. © 2019 Wiley Periodicals, Inc.

Crohn's disease (CD) is a chronic inflammatory bowel disease that often requires frequent imaging of patients in order to detect active disease and other complications related to disease activity. While endoscopy is the gold standard for diagnosis, it may be contraindicated in some patients and has a limited role in detecting deep submucosal/mesenteric diseases and intra abdominal complications. In recent years, magnetic resonance enterography (MRE) has evolved as a noninvasive, radiation free imaging modality in the evaluation of patients with CD. This review article will focus on role of MRE in imaging patients with CD with emphasis on technical considerations, systematic image interpretation, differential diagnoses, and the role of imaging in deciding treatment options for patients.

Sinus histiocytosis with massive lymphadenopathy (SHML) or Rosai-Dorfman disease is a non-neoplastic condition which typically presents as massive, bilateral cervical lymphadenopathy and can involve multiple extranodal organ systems such as skin, eyes, and upper respiratory tract in about 28% cases. Bone lesions in association with nodal disease are seen in less than 10% cases. Isolated bone involvement as the only manifestation of SHML is extremely rare, with less than 50 cases reported in the literature. We report a very uncommon case of Rosai-Dorfman disease with isolated multifocal osseous involvement as the only presenting feature, involving about 10 different sites with no lymphadenopathy or other organ system involvement.

The menisci play an important role in knee kinematics. Their unique anatomy allows them to channel forces generated during knee movements through the larger tibio-femoral condylar surfaces while simultaneously resisting deleterious hoop stresses. Although physiologic meniscal extrusion occurs with every knee joint movement, pathologic meniscal extrusion subjects the knee to persistent and excessive load transmission. This renders the knee structures susceptible to injury or exacerbates worsening of existing knee joint internal derangement. Detection and quantification of meniscus extrusion is important given its association with underlying pathological processes and internal derangements such as cartilage loss, osteoarthritis and meniscal tears. The medial and lateral menisci vary in size, attachments and load transmission, and the medial meniscus is more susceptible to injury. In this article, the authors illustrate the role of meniscus kinematics, and the identification and quantification of medial meniscal extrusion. Multimodality imaging appearances and implications of presence of medial meniscal extrusion in different knee joint pathologies are discussed with review of the relevant literature.

Musculoskeletal pathologies in the pelvis encompass a wide variety of lesions including femoroacetabular impingement, athletic pubalgia, ischiofemoral impingement, and apophyseal avulsion injuries. Magnetic resonance imaging is the noninvasive imaging modality of choice for the diagnosis and management of these lesions. In this article, the authors discuss the nonneoplastic musculoskeletal lesions in the pelvis, with illustrations and relevant case examples.

Stress urinary incontinence and pelvic organ prolapse are 2 common pelvic floor disorders that are important causes of pelvic pain and disability. Mesh and sling placement are some of the surgical treatment options available for treatment of these conditions. In addition to clinical assessment, imaging plays an important role in managing postoperative patients with complications such as recurrent organ prolapse and chronic pain. Role of high-resolution pelvic magnetic resonance imaging with additional advanced imaging techniques, such as magnetic resonance neurography that are invaluable in managing such patients, are discussed in this article.

Malignant peripheral nerve sheath tumor (MPNST) is a rare form of sarcoma arising from Schwann cells or pluripotent cells of the neural crest. Malignant triton tumor (MTT) is a subtype of MPNST with a component of malignant rhabdomyoblasts in addition to malignant Schwann cells. MPNST and MTT are both aggressive malignancies that most commonly arise from large deep neurofibromas in patients with neurofibromatosis type 1 (NF-1). However, sporadic non-NF-1 cases of MTT have also been reported in the literature. We present a case of a 50-year-old African American male with no stigmata of NF-1 who developed a large mass in a free flap on the right calf. The free flap had been placed by plastic surgery 15 years previously following open right tibial and fibular fractures associated with a large soft tissue defect. Biopsy of the enlarging mass, followed by wide surgical excision, confirmed the pathology to be MTT. Although the development of a high-grade soft tissue sarcoma has been previously reported as a late complication of radiation therapy following free flap reconstructions, we believe this is the first reported case of sarcomatous transformation arising in a vascularized, free muscle transfer.

Stem cell transplant has been the focus of clinical research for a long time given its potential to treat several incurable diseases like hematological malignancies, diabetes mellitus, and neuro-degenerative disorders like Parkinson disease. Hematopoietic stem cell transplantation (HSCT) is the oldest and most widely used technique of stem cell transplant. HSCT has not only been used to treat hematological disorders including hematological malignancies, but has also been found useful in treamtent of genetic, immunological, and solid tumors like neuroblastoma, lymphoma, and germ cell tumors. In spite of the rapid advances in stem cell technology, success rate with this technique has not been universal and many complications have also been seen with this form of therapy. The key to a successful HSCT therapy lies in early diagnosis and effective management of complications associated with this treatment. Our article aims to review the role of imaging in diagnosis and management of stem cell transplant complications associated with HSCT.

Diffuse infiltrative neurofibroma is a rare clinical entity that can pose a diagnostic challenge not only due to its rarity but also due to its varied clinical, radiological, and histological features. Our case illustrates how this entity may be misdiagnosed on clinical and pathological examination. Radiological imaging plays a critical and collaborative role in guiding clinicians and pathologists when faced with this challenging diagnosis.

Magnetic resonance imaging has become more frequently utilized for staging, preoperative planning, and post-neoadjuvant evaluation of rectal cancer. It offers detailed resolution of the layers of the rectal wall, visualization of the mesorectal fascia, and identification of locoregional nodal involvement. Many advances have been made since the original protocols and include the use of phased-array coils, orthogonally obtained images and 3-dimensional sequences, the use of diffusion-weighted and perfusion protocols to better evaluate the tumor before and after neoadjuvant therapy, and the development of techniques to better evaluate metastatic nodes. Magnetic resonance imaging shows similar accuracy to endorectal ultrasound when staging and offers a less invasive technique that is not limited by patient discomfort or decreased luminal size. This article is meant to provide an update on the recent advances in rectal cancer imaging while addressing the controversial issues that exist in staging, technique, and imaging protocol.

Radiologic procedures form one of the cornerstones of diagnosis in hematological malignancies. Various radiological procedures are essential for the diagnosis, assessment of the therapeutic response, to identify disease relapse, and to evaluate for complications pre- and post-transplantation. The significance of radiology and radiological procedures in stem cell transplantation is expected to grow. In this chapter, we discuss the radiologic procedures and review the key imaging modalities and implications related to pediatric hematopoietic stem cell transplant (HSCT). We will also discuss the role of radionuclide Imaging for patients undergoing hematopoietic stem cell transplantation with a brief review of use of radio-labeled MIBG imaging in children with Neuroblastoma.

Multiple myeloma (MM) is an incurable plasma cell malignancy in which abnormal plasma cells accumulate in the bone marrow manifesting as osteolytic lesions in approximately 80% of the patients. Since bone disease is a hallmark of MM, sensitive imaging techniques directed at the detection of early bone lesions may be predictive of MM progression. Even though the current guideline for assessment of MM involves traditional skeletal survey, its limitations are well documented. However, several techniques have evolved in the preclinical cancer drug discovery including molecular and non-invasive imaging techniques, such as, low dose CT, molecularly targeted PET, MRI, single positron emission computed tomography, ultrasound and approaches like bioluminescence and fluorescence imaging. These techniques hold great promise in early diagnosis and monitoring of the disease and each has its share of advantages and disadvantages. An ideal technique should not alter the subject, should allow repeated measurements during the time course of the disease, should be sensitive enough to detect early disease and should have reasonably high specificity. However such technique is difficult to devise and test directly in human subjects due to technical challenges and ethical considerations and most of the pre-clinical research is done on the small animals.

To evaluate the utility of inversion scout (TI-scout) obtained during cardiac magnetic resonance imaging (CMR) in diagnosing myocardial amyloid infiltration. A retrospective analysis of CMR exams in 39 patients (24 males, age range 29–77 years) was performed. Imaging was performed on a 1.5T system, and included steady state cine, post contrast TI-scout and delayed enhancement images. Evaluations included studies in 13 patients with myocardial amyloidosis and 26 patients without myocardial amyloidosis. To characterize abnormal nulling, the time to myocardial nulling on the TI scout was compared to the null times of the blood pool and spleen for each scan. The sensitivity and specificity of different tissue nulling abnormalities for myocardial amyloidosis were computed. The null times of tissues in 18/26 (69 %) patients in the non-amyloid group followed a consistent order with the blood pool null time preceding the myocardial nulling which was equal to that of splenic nulling (Type 1 pattern). This order differed in all 13 patients with myocardial amyloidosis described as three non-mutually exclusive nulling categories: 10 patients had myocardial null time preceding or coincident with blood pool (Type 2 pattern); in 11 patients myocardial null time was non-coincident with splenic nulling (Type 3 pattern); and in 8 patients myocardial null time was non-coincident with both blood pool AND splenic nulling (Type 4 pattern). While no patient exhibited Type 4 nulling pattern in the non-amyloid group, 1/26 patient had a Type 2 and 7/26 patients had a Type 3 nulling pattern. A sensitivity of 100 % was obtained when either Type 2 OR Type 3 nulling was present while a specificity of 100 % was obtained when both Type 2 AND Type 3 nulling were present together (Type 4 pattern). Our study demonstrates that the pattern of nulling on the TI scout sequence CMR has potential diagnostic utility for the presence of myocardial amyloidosis. The temporal pattern of myocardial, blood pool and splenic nulling needs to be carefully evaluated on the TI scout sequence and could prove useful in other infiltrative cardiomyopathies.

We describe the efficacy of time-resolved MR angiography in diagnosing a case of pelvic congestion syndrome (PCS). MR angiography, using four-dimensional (4D) TRAK (Time-Resolved Angiography using Keyhole) technique was used in an 81-year-old woman presenting with low backache, pelvic pain, and left pelvic fullness. Dynamic images were obtained in multiple vascular phases including arterial, arteriovenous, and venous phases. The high temporal resolution of 4D TRAK could demonstrate early retrograde left ovarian vein filling as well as multiple dilated pelvic varices, allowing the prospective diagnosis of PCS to be made. Although uncommon in this age group, the diagnosis was subsequently confirmed on conventional catheter venography with symptomatic relief after successful embolization of the incompetent left ovarian vein. The MRA and correlative catheter venography images are presented in this case report. J. Magn. Reson. Imaging 2010;32:700–704. © 2010 Wiley-Liss, Inc.

The familial cases of dysplasia epiphysealis hemimelica (DEH), or Trevor's disease, are thought to represent dominant carpotarsal osteochondromatosis (DCO). Only three families affected by DCO have been reported so far in the literature. We report a fourth family: a 10-year-old girl, her father, and his cousin. Unlike the other reported cases of DCO this family had no carpal or upper limb epiphyseal osteochondromas and many of the other reported associations. The only consistent associated finding in our cases was the presence of multiple parosteal osteochondromatous proliferations. The findings of our cases are, therefore, unique in many ways. These cases may represent a variant of dominant carpotarsal osteochondromatosis or may represent a new entity.

Magnetic resonance angiographic evaluation of the intracranial vasculature has been predominantly carried out using conventional angiographic techniques such as time of flight and phase contrast sequences. These techniques have good spatial resolution but lack temporal resolution. Newer faster angiographic techniques have been developed to circumvent this limitation. Elliptical centric time-resolved imaging of contrast kinetics (EC-TRICKS) is one such technique which has combined the use of elliptical centric ordering of the k-space with multiphase 3D digital subtraction MR angiogram (MRA) to achieve excellent temporal resolution of the arterial and venous circulations. Its applications have been mainly in the peripheral vasculature. We report the use of this technique in a case of a high-flow, direct carotid-cavernous fistula to demonstrate its potential in intracranial MR angiography.

Objectives The aim of this study was to access the prognostic implication of late gadolinium enhancement (LGE) in patients with systemic amyloidosis undergoing cardiac magnetic resonance (CMR). Background Cardiac amyloidosis confers significantly worse prognosis in patients with systemic amyloidosis. CMR imaging has emerged as an attractive noninvasive modality to diagnose cardiac involvement in patients with systemic amyloidosis. We performed a systemic review and meta-analysis to evaluate the prognostic role of LGE-CMR imaging in patients with systemic amyloidosis. Methods Electronic databases MEDLINE, PubMed, Embase, and Cochrane were systematically searched to identify studies evaluating the association between LGE-CMR and prognosis in systemic amyloidosis with cardiac involvement. The present study was designed to systematically review and assess the association between LGE and the primary endpoint of all-cause mortality. A random effects model was used to calculate a pooled odds ratio using inverse-variance weighting. Results Data were included from 7 studies with a total of 425 patients and a mean follow-up of 25 months. Patients had a weighted average age of 64 years and left ventricular ejection fraction of 59.2%; 67% were male. Endomyocardial biopsy was positive for amyloidosis in 20%, whereas LGE was present in 73% of patients. LGE-positive patients had increased overall mortality compared with those without LGE (pooled odds ratio: 4.96; 95% confidence interval [CI]: 1.90 to 12.93; p = 0.001). For the LGE group, the pooled death rate was 0.07 (95% CI: 0.03 to 0.19) events per year and for the LGE+ group, the rate was 0.25 (95% CI: 0.16 to 0.39 per year; p = 0.001). The proportion of patients with cardiac biopsy within each study ranged from 3% to 68%, and the relationship between LGE status and death did not vary according to cardiac biopsy proportion across studies. Conclusions LGE on CMR in patients with systemic amyloidosis with known or suspected cardiac amyloidosis is associated with increased risk of all-cause mortality.

Objective and Importance: To describe the imaging findings of two cases of cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) mimicking multiple sclerosis. Clinical Presentation and Intervention: Two cases presenting with neurological signs and symptoms were referred for magnetic resonance imaging (MRI) evaluation of the brain. Case 1 was a 36-year-old female patient presenting with recurrent headaches and recent onset numbness in the fingers of the right hand. Neurological examination showed a mild sensory deficit in the right hand. Case 2 was a 31-year-old female patient presenting with attacks of right-sided numbness of the face and body. The neurological examination revealed a sensory loss in the face and brisk deep tendon reflexes. Routine MRI sequences showed two types of lesions in both cases: ‘punctate’ hyperintense lesions on T2-weighted images (T2WI)/fluid-attenuated inversion recovery (FLAIR) images, hypointense on T1-weighted images (T1WI) and ‘diffuse’ white matter lesions, hyperintense on T2WI/FLAIR sequences and isointense to hypointense on T1WI. All lesions showed no contrast enhancement. Both cases were previously clinically and radiologically diagnosed as multiple sclerosis. There was a strong family history consistent with recurrent infarctions in other family members of both patients. Both cases were later diagnosed as CADASIL by skin biopsy/genetic linkage studies and follow-up. Conclusion:The cases showed that CADASIL causes stroke-like episodes in adults and can mimic multiple sclerosis on imaging. Clinical evaluation and MRI findings allow a differentiation of the two entities.

Lymphoma is the most common malignancy of the spleen. The imaging features of splenic lymphoma are nonspecific and mostly lymphomas present as a diffusely enlarged spleen. Focal lesions are described but remain of low density or intensity on CT or MRI, respectively. We describe a histologically proven case of splenic lymphoma that showed an atypical hyperdense/hyperenhancing appearance on imaging suspicious for a vascular pathology. To the best of our knowledge and based on review of English literature, such an appearance of splenic lymphoma is extremely unusual and rare.

Full article available online at Healio.com/Orthopedics Figure: Coronal computed tomography scan (A) showing a large hypervascular intramuscular mass. Coronal (B) and axial (C) magnetic resonance T2 fatsaturated images showing diffuse increased signal of the adductor magnus muscle, with fluid in the perimuscular fascial planes. Coronal T1-weighted image showing subtle diffuse hypointensity of the muscle (D). Diabetic myonecrosis is a rare complication of long-standing diabetes mellitus that presents as acute onset of swelling and pain of the affected muscles. The differential diagnosis includes cellulitis/pyomyositis, necrotizing fasciitis, neoplasm, and deep venous thrombosis (DVT). Missed diagnoses can lead to unnecessary invasive diagnostic procedures and inappropriate treatment. The diagnosis is established by the clinical presentation and findings on magnetic resonance imaging (MRI) scan. A 30-year-old African-American man presented with a painful mass affecting the medial aspect of the right thigh for several months. Initial laboratory studies showed white blood cell count of 8800 cells/mm 3 , D-dimer value of 0.55 µg/mL, HgBA1c level of 15.1%, glucose level of 352 mg/dL, erythrocyte sedimentation rate of 22 mm/h, and C-reactive protein level of 222 mg/L. An MRI scan was obtained, and diabetic myonecrosis was diagnosed and treated. One year later, the patient had similar symptoms of pain in the contralateral thigh. Repeat workup and MRI scan were obtained. The MRI abnormalities originally seen in the right thigh 1 year earlier were present in the left thigh, with complete resolution of the abnormalities seen in the right thigh. Treatment with bed rest and analgesics resulted in symptom resolution. Patients with diabetic myonecrosis typically have no fever, normal white blood cell count, mildly increased erythrocyte sedimentation rate, and elevated C-reactive protein level in 50% of cases. They lack the radiologic signs of fascial enhancement or well-defined, rim-enhancing collections that are seen in necrotizing fasciitis and pyomyositis/abscess. The onset of severe pain and the lack of mass effect on imaging differentiate diabetic myonecrosis from tumor-like conditions such as vascular malformations or soft tissue tumors. Normal D-dimer levels and ultrasound Doppler examination of the extremity help to rule out DVT. The typical MRI scan findings and clinical presentation can lead to the diagnosis of diabetic myonecrosis, allowing the physician to avoid invasive tests, such as muscle biopsy, and to reassure patients that this condition is self-limiting with appropriate treatment.

The purpose of this article is to report brain MRI findings of merosin-negative congenital muscular dystrophy (CMD) in two cases and to discuss its differentiation from other CMD subtypes. The cases were investigated by 1.5 Tesla MRI equipment using T1-weighted, T2-weighted, fluid-attenuated inversion recovery (FLAIR), 3D fast spoiled gradient recalled (SPGR) and post-contrast gadolinium enhanced sequences and the diagnosis was confirmed by muscle biopsy with immunohistochemical staining for merosin. Magnetic resonance imaging showed bilateral subcortical U-fibre white matter changes with periventricular sparing in the first case. Though this imaging finding is non-specific and could be seen in other white matter diseases like Canavan disease, the absence of other distinguishing MRI and clinical features of those conditions allowed a proper diagnosis. The second case showed diffuse subcortical and deep white matter involvement and cerebellar cysts. There was no brainstem involvement, polymicrogyria or cobblestone lissencephaly in both of our cases which allowed differentiation of merosin-negative CMD from other CMDs. Muscle biopsy in both these patients showed dystrophic changes with absent staining for merosin confirming the diagnosis. Merosin-negative CMD should be considered in the imaging differential diagnosis of white matter diseases. In a patient presenting with features of CMD, MRI can be of help in further differentiation of the various CMD subtypes.

A 33-year-old woman was admitted to the hospital with an abdominal pregnancy at a gestational age of 20 weeks. An initial MRI mapping of fetal location and placental vascular invasion was obtained. The patient refused surgical intervention until fetal survival would be possible. Serial MRIs were essential in timing delivery and avoiding an emergency surgical situation. The baby was delivered at 24 weeks with the assistance of a multidisciplinary surgical team. The mother as well as the baby survived. This case report highlights the role of serial MRI evaluations in the diagnosis and expectant management of an abdominal pregnancy. It also highlights the importance of interdisciplinary communication for a successful outcome.

Lung cancer screening programs for high-risk populations using low-dose computed tomography (LDCT) have been shown by a class I clinical trial to reduce lung cancer mortality by 20%. We present an overview of randomized and nonrandomized lung cancer screening trials and review some of the arguments advocating for or against the widespread implementation of such a screening program. Concerns regarding the use of LDCT screening for lung cancer include increased risk from radiation exposure, overdiagnosis of indolent tumors, and high numbers of false-positive results, which may increase patient anxiety and result in unnecessary procedures with potential complications. Current recommendations regarding diagnostic criteria and workup of positive screens as well as the risks and benefits of using LDCT for lung cancer screening are provided.

Plasmablastic lymphoma (PBL) is an aggressive diffuse large B-cell lymphoma (DLBCL) with plasmablastic features that was initially described in the oral cavity of HIV-infected individuals. PBL remains a diagnostic challenge given its close morphologic resemblance and overlapping immunophenotypic patterns to other B-cell lymphoid malignancies and plasmablastic plasma cell myeloma (PCM) with extramedullary involvement. The presence of serum monoclonal protein and radiographic evidence of lytic bone lesions favors the diagnosis of plasma cell myeloma over PBL. Distinguishing PBL from PCM is important as PBL is treated with a completely different chemotherapy regimen compared to PCM. PBL carries a guarded prognostic profile among DLBCLs with high relapse rate and poor median survival. We present a case of a 44-year-old HIV-positive man who presented with a large retroperitoneal mass associated with obstructive uropathy, sacral radiculopathy, and inferior vena caval compression. The mass was initially mistaken to be a PCM on histopathology; however, subsequent investigations revealed an extra-oral PBL with plasmacytic differentiation. To our knowledge, this will be the first case of PBL of the retroperitoneum in an HIV- and HCV-positive patient and the second one at this location in the English-language literature. In this report, key differentiating points between PBL versus PCM and newer therapeutic agents such as proteasome inhibitors have been discussed along with related review of literature.

Cardiac magnetic resonance imaging (CMRI) plays an important role in the diagnosis and follow-up of apical ballooning syndrome (takotsubo syndrome), a recently described cardiac condition characterised by transient dyskinesia of the left ventricle secondary to an acute emotional event. We present the CMRI findings in a 53-year-old female diagnosed with apical ballooning syndrome and discuss its value in the diagnosis and follow-up of this condition.

Etiological classification of diabetes insipidus is as follows. 1. Central Diabetes Insipidus (CDI) A. Idiopathic B. Familial C. Structural Causes i. Congenital: Septo-optic dysplasia Tuber cinereum Hamartoma ii. Traumatic: Iatrogenic, head trauma iii. Inflammatory: Tuberculous Meningitis Sarcoidosis Wegener’s granulomatosis Lymphocytic Hypophysitis iv. Neoplastic: a. Pediatric: Hypothalamic glioma Craniopharyngioma Intracranial Germ Cell Tumors Teratoma Langerhans Histiocytosis b. Adult: Metastasis 2. Psychogenic: Compulsive intake of large amounts of fluid leading to inhibition of normal vasopressin (2).

Acetaminophen (APAP) toxicity is responsible for approximately half of all cases of acute liver failure in the United States. The mouse model of APAP toxicity is widely used to examine mechanisms of APAP toxicity. Non-invasive approaches would allow for serial measurements in a single animal to study the effects of experimental interventions on the development and resolution of hepatocellular necrosis. The following study examined the time course of hepatic necrosis using small animal magnetic reasonance imaging (MRI) following the administration of 200 mg/kg ip APAP given to B6C3F1 male mice. Mice treated with saline served as controls (CON). Other mice received treatment with the clinical antidote N-acetylcysteine (APAP+NAC). Mouse liver pathology was characterized using T1 and T2 weighted sequences at 2, 4, 8 and 24 h following APAP administration. Standard assays for APAP toxicity (serum alanine aminotransaminase (ALT) levels and hemotoxylin and eosin (H&E) staining of liver sections) were examined relative to MRI findings. Overall, T2 sequences had a greater sensitivity for necrosis and hemorrhage than T1 (FLASH) images. Liver injury severity scoring of MRI images demonstrated increased scores in the APAP mice at 4, 8 and 24 h compared to the CON mice. APAP+NAC mice had MRI scores similar to the CON mice. Semi-quantitative analysis of hepatic hemorrhage strongly correlated with serum ALT. Small animal MRI can be used to monitor the evolution of APAP toxicity over time and to evaluate the response to therapy.

Patients on long term lithium therapy for affective disorders may develop renal toxicity. It may manifest as nephrogenic diabetes insipidus with renal biopsy showing interstitial fibrosis, sclerotic glomeruli and cyst formation. Magnetic resonance imaging demonstrates the presence of microcysts in patients on long-term lithium therapy, suggesting a possible cause for their nephrotoxicity. We describe the typical magnetic resonance imaging appearance of renal microcysts in a 53 year old woman on chronic lithium therapy.

Intracranial calcification is a known but extremely rare complication of diabetes insipidus. To date, only 16 patients have been reported and all had the peripheral (nephrogenic) type of diabetes insipidus. We report a child with intracranial calcification complicating central diabetes insipidus. We also report a child with nephrogenic diabetes insipidus, and compare the patterns of intracranial calcification.