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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.

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.

Background The ratio of the transmitral early inflow wave velocity (E wave velocity) and the velocity of the septal (or lateral) mitral annulus as measured by tissue Doppler (the e’ wave velocity) can be used to estimate left atrial pressure on echocardiographic examination. An elevated E/e’ (more than 15 when using the septal mitral annular velocity) is an established measure of elevated LAP. Furthermore when the left atrial pressure rises, simultaneous changes take place in the pulmonary venous flow. The normal flow pattern in the pulmonary veins consist of a prominent systolic and a smaller diastolic component with the ratio of the peak systolic to diastolic velocities more than 1. With elevated left atrial pressure the ratio drops to below 1.

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.

s of Theses Approved for the MSc and PhD Degrees at the Faculty of Medicine, Health Sciences Centre, Kuwait University, Kuwait IL-8 levels and the IL-8/IL-10 ratio promise to be good indicators of irreversible pulpitis. An important and potentially very useful outcome of this study is the demonstration that cytokine estimation in pulpal blood may help in the diagnosis of pulpal inflammation. Supported by a Fellowship from the College of Graduate Studies. Raj Raghupathy (Supervisor) Kefah Barrieshi (Co-Supervisor)

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.

Objectives:We present our institutional experience with dynamic time-resolved magnetic resonance angiography (DTR MRA) with delayed venous imaging for free fibula flap (FFF) patient selection. We sought to (1) determine the sensitivity of the test for vascular anomalies predisposing to limb-threatening complications and (2) assess the impact of the venous phase findings in patient selection.Methods:Retrospective review of 46 patients considered for mandibular reconstruction with FFF in an academic tertiary setting from 2009-2012. A DTR MRA was performed preoperatively in all cases. Both imaging and physical examination findings were used to determine patient eligibility for the procedure.Results:Thirteen patients (28.2%) had findings on DTR MRA excluding flap harvesting from the preferred leg, with atherosclerosis (n = 8) and anatomic variations (n = 4) being the most common findings. Eight of these patients (61.5%) underwent harvesting from the opposite leg, while 5 underwent reconstruction with a differ...

Objectives:Dynamic time-resolved magnetic resonance angiography (DTR MRA) is a novel imaging algorithm that allows for better visualization of small-caliber vessels when compared with standard MRA. We sought to estimate the technique sensitivity when compared with intraoperative findings.Methods:Retrospective review of 25 patients undergoing reconstruction with free fibula flap at an academic tertiary setting from 2009 to 2013. Preoperative DTR MRA was performed in all cases. Two radiologists performed blind reviews of the images and their findings were compared with surgical descriptions of the perforator anatomy.Results:Surgical exploration identified 32 perforators while DTR MRA identified 45 vessels. The technique confirmed the presence of perforators in 22 out of 23 patients with at least one perforator, and their absence in 1 out of 2 patients who had a negative exploration. There was a significant correlation in the number of perforators identified clinically and radiologically in each case (P = .0...

An accessory lobe of the liver is a rare congenital anomaly that can undergo torsion and present as an acute surgical emergency. It is rarely diagnosed preoperatively. We report the preoperative utility of CT scan and MRI in the diagnosis and surgical planning of a case of intermittent accessory hepatic lobe torsion.

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.

It is an opportune time for radiologists to focus on personal productivity. The ever increasing reliance on computers and the Internet has significantly changed the way we work. Myriad software applications are available to help us improve our personal efficiency. In this article, the authors discuss some tools that help improve collaboration and personal productivity, maximize e-learning, and protect valuable digital data.

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.

Increasing use of smartphones and handheld computers is accompanied by a rapid growth in the other related industries. Electronic books have revolutionized the centuries-old conventional books and magazines markets and have simplified publishing by reducing the cost and processing time required to create and distribute any given book. We are now able to read, review, store, and share various types of documents via several electronic tools, many of which are available free of charge. Additionally, this electronic revolution has resulted in an explosion of readily available Internet-based educational resources for the residents and has paved the path for educators to reach out to a larger and more diverse student population.

We are in the midst of an evolving educational revolution. Use of digital devices such as smart phones and tablet computers is rapidly increasing among radiologists who now regularly use them for medical, technical, and administrative tasks. These electronic tools provide a wide array of new tools to the radiologists allowing for faster, more simplified, and widespread distribution of educational material. The utility, future potential, and limitations of some these powerful tools are discussed in this article.

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).

We submit a case of intrapancreatic accessory spleen.A 33-year-old patient with history of dyspepsia underwent imaging studies suggestive of a neuroendocrine tumor. After referral to our institute, endoscopic ultrasound guided fine needle aspiration (EUS-FNA) confirmed diagnosis as intrapancreatic accessory spleen.An accessory spleen may develop from estranged mesenchymal cells due to fusion failure of the splenic anlage. The prevalence of an accessory spleen is 10-30% with 80% of them present at the splenic hilum and 17% in the pancreatic tail. Intrapancreatic accessory spleen is commonly misdiagnosed as a pancreatic tumor. Since, the differential diagnosis includes pancreatic neuroendocrine tumors, additional investigation with EUS-FNA should be considered when radiological diagnosis is not definitive.For diagnosis of intrapancreatic accessory spleen, radiographic imaging is useful, but lacks specificity without tissue diagnosis. Diagnosis can be safely and reliably established with EUS-FNA, leading to a benign prognosis and avoidance of unnecessary surgical intervention.

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.

Flexor digitorum tendon entrapment is a known complication of proximal phalangeal fractures and is commonly diagnosed clinically. However, it can sometimes be subtle and may not be suspected initially. A case of proximal phalangeal fracture of the index finger complicated by entrapment of the flexor digitorum profundus tendon is presented in which the diagnosis was made based on sonographic findings subsequently confirmed by CT and later surgical findings. This case demonstrates that tendon entrapment complicating phalangeal fractures can be diagnosed using sonography. © 2008 Wiley Periodicals, Inc. J Clin Ultrasound, 2008.

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.

To describe the imaging findings of two cases of cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) mimicking multiple sclerosis.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 T(2)-weighted images (T(2)WI)/fluid-attenuated inversion recovery (FLAIR) images, hypointense on T(1)-weighted images (T(1)WI) and 'diffuse' white matter lesions, hyperintense on T(2)WI/FLAIR sequences and isointense to hypointense on T(1)WI. 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.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.