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The craniofacial manifestations of beta thalassaemia are widely reported, and occur as a result of inadequate haematopoiesis leading to marrow space expansion. Secondarily, extramedullary haematopoiesis can occur throughout the body, although this is rarely reported in the paranasal sinuses. We discuss the systemic and craniofacial manifestations of beta thalassaemia major, with a focus on the radiological findings, as illustrated in a case of a 55-year-old male patient who was referred to the dental hospital as a result of complications of thalassaemia. This case report focuses on the effects of thalassaemia that may be encountered in a dental setting and highlights the radiological findings that clinicians should be aware of. CPD/Clinical Relevance: Dental and craniofacial manifestations, and their management, are discussed for patients with beta thalassaemia.

Neurofilament light chain (NfL) is an accepted biomarker of disease activity in multiple sclerosis (MS), but its relationship with magnetic resonance imaging (MRI) activity particularly in reference to lesion location and recurrent activity is not well understood.In 139 MS patients who underwent lumbar punctures with follow-up in 25, the relationship between cerebrospinal fluid (CSF) NfL and cranial MRI based on lesion location and lesion number was evaluated. Spearman rank correlation was used to assess the association between CSF NfL and MRI lesion location and lesion counts at baseline and follow-up at 1 year. Multiple linear regression analysis was performed to assess which lesion location was most strongly associated with CSF NfL values.The associations between baseline CSF NfL and lesion location and follow-up lesions were modest, whilst those between baseline MRI and follow-up CSF NfL were greater: periventricular (r = 0.31, p = 0.141), juxtacortical (r = 0.47, p = 0.022), infratentorial (r = 0.71, p ≤ 0.001) and cord lesions (r = 0.60, p = 0.002). All associations, however, improved following adjustment for disease duration and type of MS. Modelling revealed 53% of (log) CSF NfL could be explained by variance in baseline MRI lesion location.Baseline CSF NfL did not correlate with current or future MRI activity and lesion location. However, baseline MRI activity explained around 53% of the variation in the follow-up CSF NfL, suggesting that the relationship between MRI and CSF NfL is mainly precedent rather than an association, that is one occurring before the other.

Cone beam computed tomography (CBCT) is a popular and often indispensable imaging modality used for the dento-alveolar tissues and immediate surrounding structures. It can be used across several dental disciplines including endodontics, implant planning, oral surgery and orthodontics. Furthermore, it is commonly used in the medical specialties of oral and maxillofacial surgery (OMFS) and ear, nose and throat (ENT) surgery. In part 1 of this series, we described some of the common incidental findings found in the dento-alveolar complex and immediate neighbouring structures. Part 2 looks further afield and depicts some common and important incidental findings and anatomical variants that can be found on larger fields of view. CPD/Clinical Relevance: Many incidental findings are innocuous, yet their recognition and documentation are essential because some will warrant medical or surgical intervention.

This article provides an overview of the patterns of skull base trauma and provides a review of the pertinent soft tissue injuries and complications that can ensue. A brief review of skull base anatomy is provided with subsequent focus on the important findings in anterior, central, and posterior skull base trauma.

BackgroundThe coronavirus disease 2019 pandemic requires urgent modification to existing head and neck cancer diagnosis and management practices. A protocol was established that utilises risk stratification, early investigation prior to clinical review and a reduction in aerosol generating procedures to lessen the risk of coronavirus disease 2019 spread.MethodsTwo-week wait referrals were stratified into low, intermediate and high risk. Low risk patients were referred back to primary care with advice; intermediate and high risk patients underwent investigation. Clinical encounters and aerosol generating procedures were minimised. A combined diagnostic and therapeutic surgical approach was undertaken where possible.ResultsForty-one patients were used to assess feasibility. Thirty-one per cent were low risk, 35 per cent were intermediate and 33 per cent were high risk. Thirty-three per cent were discharged with no imaging.ConclusionImplementing this protocol reduces the future burden on tertiary services, by empowering primary care physicians to re-refer low risk patients. The protocol is applicable across the UK and avoids diagnostic delay.

Objective: To report on safety and effectiveness of subcutaneous cladribine (Litak®) in multiple sclerosis (MS) patients. Methods: Litak® was offered to MS-patients irrespective of disease course. Litak® 10 mg was administered for 3–4 days during week 1. Based on lymphocyte count at week 4, patients received another 0–3 doses at week 5. A second course was administered 11 months later. Follow-up included adverse events, relapses, expanded disability status scale (EDSS), 9-hole-peg and Timed-25-foot-walking tests, no-evidence-of-disease-activity (NEDA), no-evidence-of-progression-or-active-disease (NEPAD), MRI, cerebrospinal fluid (CSF) neurofilament light chain (NfL), and lymphocyte counts. Results: In all, 208 patients received at least one course of treatment. Age at baseline was 44 (17–72) years and EDSS 0–8.5. Cladribine was generally well tolerated. One myocardial infarction, one breast cancer, and three severe skin reactions occurred without long-term sequelae. Two patients died (one pneumonia, one encephalitis). Lymphopenia grade 3 occurred in 5% and grade 4 in 0.5%. In 94 out of 116 pwMS with baseline and follow-up (BaFU) data after two treatment courses, EDSS remained stable or improved. At 18 months, 64% of patients with relapsing MS and BaFU data ( n = 39) had NEDA. At 19 months, 62% of patients with progressive MS and BaFU data ( n = 13) had NEPAD. Of n = 13 patients whose CSF-NfL at baseline was elevated, 77% were normalised within 12 months. Conclusions: Litak® was well tolerated. Effectiveness in relapsing MS appeared similar to cladribine tablets and was encouraging in progressive MS. Our data suggest cladribine may be safe and effective in MS-patients irrespective of their disease stage.

Context Differentiated thyroid cancer (DTC) is usually treated by thyroidectomy followed by radioiodine ablation and generally has a good prognosis. It may now be possible to limit the amount of treatment without impacting on efficacy. It is not known whether coexistent thyroiditis impacts on radioiodine uptake or on its potential efficacy, but this could provide a rationale for modification to current therapeutic protocols. Design This was a retrospective cohort study of radioiodine uptake on imaging after radioiodine ablation for DTC in patients with and without concurrent thyroiditis. All patients with histologically confirmed DTC treated with radioiodine ablation after thyroidectomy in a single centre from 2012 to 2015 were included. The primary outcome assessed was the presence of low or no iodine uptake on post-ablation scan, as reported by a nuclear medicine physician blinded to the presence or absence of thyroiditis. Results One hundred thirty patients with available histopathology results were included. Thyroiditis was identified in 42 post-operative specimens and 15 of these patients had low or no iodine uptake on post-ablation scan, compared to only 2 of 88 patients without thyroiditis (P Conclusions Concurrent thyroiditis may impair the uptake of radioactive iodine in management of DTC. Given that patients with DTC and thyroiditis already have a good prognosis, adopting a more selective approach to this step in therapy may be indicated. Large, longitudinal studies would be required to determine if omitting radioactive iodine therapy from those patients with concurrent thyroiditis has a measurable impact on mortality from thyroid cancer.

Highlights • Adenoma, carcinoma and hyperplasia cause parathyroid gland enlargement. • Mimics include thyroid nodules and cystic structures in the head and neck. • Enlarged parathyroid glands can enhance variably following contrast administration. • Hyperparathyroidism can present acutely with respiratory compromise. • Syndromic associations., Primary hyperparathyroidism is associated with significant morbidity and mortality. It is in this day and age, an eminently treatable condition which relies heavily on preoperative imaging to localise enlarged parathyroid glands. The imaging appearances of parathyroid gland enlargement are varied; this paper seeks to address some of its more unusual manifestations with an emphasis on its atypical enhancement patterns, mimics and associations. An enlarged glands may also present as an ‘incidentaloma’ in head and neck imaging performed for entirely different indications, or as part of sporadic or familial syndrome. Radiologists are in a good position to expedite the relevant investigations and curative treatment, and knowledge of the spectrum of imaging appearances is crucial.

IntroductionCladribine tablets (Mavenclad®) are licensed for treating people with relapsing multiple sclerosis (pwRMS). We treated people with relapsing (pwRMS) and progressive MS (pwPMS) using sub- cutaneously administered cladribine (SCAC) since 2014. Here, we present up to five year follow-up on safety and efficacy.MethodsSCAC 10mg was given on 3–4 days during week 1. 0–3 doses were administered at week 5, according to week 4 lymphocyte count. A second cycle of SCAC was administered 11 months later. Follow-up included clinical outcome evaluation and pharmacovigilance. The proportion of pwMS with no evidence of (i) disease activity (NEDA) and (ii) progression or active disease (NEPAD) was calculated.Results211 pwMS received SCAC. 154/211 completed two treatment cycles. At baseline age was 44 (17–72) years, EDSS 1–8.5. Tolerability was good. One myocardial infarction and one breast cancer occurred. Two severely disabled pwMS died (one of influenza, one of encephalitis). Lymphopenia grade 3 was detected in ConclusionsSCAC was well tolerated. Frequency of significant lymphopenia was low. Efficacy in pwRMS corresponds with trial data. NEPAD rates in pwPMS were similar to licensed DMT.k.allen-philbey@nhs.net

Imaging has an important role in the investigation of patients with sicca symptoms. There are a number of imaging modalities and techniques available in order to aid diagnosis of Sjögren’s syndrome (SS) and attempt to differentiate from other potential causes. Imaging techniques form part of the various diagnostic criteria proposed for the diagnosis of both primary and secondary SS. The aim of this chapter is to highlight the benefits and limitations of the various imaging techniques and provide a spectrum of the imaging findings encountered in clinical practice. The chapter will also identify potential areas for future development that may assist with diagnosis and treatment of patients with SS.

The olfactory pathway is composed of peripheral sinonasal and central sensorineural components. The wide variety of different pathologies that can affect the olfactory pathway reflect this complex anatomical relationship. Localising olfactory pathology can present a challenge to the reporting radiologist. This imaging review will illustrate the normal anatomy of the olfactory system and describe a systematic approach to considering olfactory dysfunction. Key concepts in image interpretation will be demonstrated using examples of olfactory pathway pathologies.

Objective: In dentistry, imaging is the most frequently used diagnostic tool. As a result, a steady increase in the use of imaging modalities are leading to an increase in healthcare cost and in patients’ radiation exposure. Results: 67-year-old patient attended for a surgical removal of lower left third molar. A sectioned panoramic radiograph showed an incidental finding of a well-defined, unilocular radiolucency apical to the lower left second and third molars. This was partially superimposed over the outline of the ID canal. A Stafne’s bone cavity was considered as the most likely diagnosis. Further imaging was considered due to location not being fully below the ID canal as usually described in the literature. Reviewing previous imaging on PACS revealed the patient has had a CT angiogram of the head and neck 5 years prior. This showed a lingual bone defect of the surface of the mandible in the region of interest. The extension of the submandibular gland into the defect confirmed the likely nature of Stafne’s bone cavity. Conclusion: This case highlights the essential role of reviewing (if in the same practice) or requesting (from a different practice) previous images. The international Commission for Radiological Protection regularly publishes data relating to the principles of dose reduction; Justification, Optimisation and Limitation. All examinations have to be justified to ensure the benefit to the patient outweigh the risk and radiation should be kept as low as reasonably achievable.

Penetrating neck injury can have potentially devastating consequences due to the many vital structures contained within the neck. In patients who do not require immediate surgery, computed tomography angiography of the neck is the test of choice to characterize the injury. A systematic approach to assessment will ensure a thorough evaluation and give the reporting radiologist the best chance of identifying the significant findings, which can often be subtle. Clear communication with the trauma team at both the time of request and after the imaging has been evaluated to relay any significant findings is vital to ensure the best outcome for the patient.

ObjectiveTo review the management of temporal bone fractures at a major trauma centre and introduce an evidence-based protocol.MethodsA review of reports of head computed tomography performed for trauma from January 2012 to July 2018 was conducted. Recorded data fields included: mode of trauma, patient age, associated intracranial injury, mortality, temporal bone fracture pattern, symptoms and intervention.ResultsOf 815 temporal bone fracture cases, records for 165 patients met the inclusion criteria; detailed analysis was performed on the records of these patients.ConclusionTemporal bone fractures represent high-energy trauma. Initial management focuses on stabilisation of the patient and treatment of associated intracranial injury. Acute ENT intervention is directed towards the management of facial palsy and cerebrospinal fluid leak, and often requires multidisciplinary team input. The role of nerve conduction assessment for immediate facial palsy is variable across the UK. The administration of high-dose steroids in patients with temporal bone fracture and intracranial injury is not advised. A robust evidence-based approach is introduced for the management of significant ENT complications associated with temporal bone fractures.

Background Evidence suggests people with non-relapsing deteriorating (“progressive”) multiple sclerosis (pwPMS) may benefit from disease-modifying immune therapy (DMT). However, only one such treatment (ocrelizumab) has been licensed and is highly restricted to pwPMS suffering from the primary progressive phenotype. The difficulties assessing treatment outcome in pwPMS is one important reason for the lack of respective DMT. The concentration of neurofilaments in the cerebrospinal fluid (CSF) provides a biomarker of neuro-axonal damage, and both neurofilament light (NfL) and heavy chain (NfH) levels have been used as outcome indices and to guide treatment choices. Methods We report on two pwPMS, who were treated with subcutaneous cladribine undergoing CSF NfL testing, alongside MRI and clinical follow-up, before and after treatment. Results Cladribine treatment was well tolerated without any side effects. CSF NfL after treatment revealed significant reduction (by 73% and 80%, respectively) corroborating the MRI detectable drop in disease activity. Disability mildly progressed in one, and remained stable in the other pwPMS. Conclusions pwPMS with detectable disease activity (MRI, elevated NfL) should be considered for DMT. NfL appears to be a sensitive index of treatment effect in pwPMS, and may be a useful outcome in clinical trials targeting this patient group. Over and above its licensed indication (relapsing MS), cladribine may be an effective treatment option for pwPMS.

Background Whilst the dangers of ‘legal highs’ have been widely publicised in the media, very few cases of the neurological syndrome associated with the inhalation of nitrous oxide (N2O) have been reported. Here we set out to raise awareness of subacute degeneration of the spinal cord arising from recreational N2O use so that formal surveillance programs and public health interventions can be designed. Methods Case series documenting the clinical and investigational features of ten consecutive cases of subacute degeneration of the spinal cord presenting to a hospital with a tertiary neurosciences service in East London. Results Sensory disturbance in the lower (± upper) limbs was the commonest presenting feature, along with gait abnormalities and sensory ataxia. MRI imaging of the spine showed the characteristic features of dorsal column hyperintensity on T2 weighted sequences. Serum B12 levels may be normal because subacute degeneration of the spinal cord in this situation is triggered by functional rather than absolute B12 deficiency. Discussion A high index of suspicion is required to prompt appropriate investigation, make the diagnosis and commence treatment early. This is the largest reported series of patients with subacute degeneration of the spinal cord induced by recreational use of N2O. However, the number of patients admitted to hospital likely represents the ‘tip of the iceberg’, with many less severe presentations remaining undetected. After raising awareness, attention should focus on measuring the extent of the problem, the groups affected, and devising ways to prevent potentially long-term neurological damage.

Key Clinical Message If superficial siderosis is suspected based on clinical presentation, susceptibility weighted imaging should be undertaken in addition to standard MRI sequences as it is more sensitive than T2 weighted imaging. Once diagnosed, imaging of the entire brain and spine must be undertaken to assess for an underlying cause.

Labyrinthine fistula is a defect of the bony labyrinth of the petrous portion of the temporal bone. This can proceed to involve the membranous labyrinth.[1][1] Causes include surgery, trauma, barotrauma, cholesteatoma and even noise exposure. This results in vertigo, hearing loss and tinnitus.[2][2

Rebound disease following cessation of disease modifying treatment (DMT) has been reported in people with both relapsing and progressive multiple sclerosis (pwRMS, pwPMS) questioning strict separation between these two phenotypes. While licensed DMT is available for pwRMS to counter rebound disease, no such option exists for pwPMS. We report on a pwPMS who developed rebound disease, with 45 Gadolinium‐enhancing lesions on T1 weighted MRI brain, within 6 months after fingolimod 0.5 mg/day was stopped. Treatment with a short course of subcutaneous cladribine 60 mg led to effective suppression of inflammatory activity and partial recovery with no short‐term safety issues or adverse events.

A 57-year-old woman was admitted with a tonic-clonic seizure on a background of systemic sarcoidosis with uveitis and hilar lymphadenopathy. She had previously been well and stopped steroids 1 year before presentation. CT showed a sclerotic lesion with focal lucent areas in the skull base (figure 1, A and B). MRI revealed a frontal fluid-attenuated inversion recovery hyperintense edematous lesion with meningeal enhancement in gadolinium T1 (figure 1C). This appearance on imaging evokes broad differential diagnoses such as sarcoidosis, fungal (although she had increasing lesion size despite 6-month treatment with amphotericin B), craniofacial fibrous dysplasia, atypical lymphoma, nasopharyngeal carcinoma, myeloma, and tuberculosis, therefore necessitating biopsy for definitive evaluation. Transsphenoidal biopsy revealed noncaseating granulomatous inflammation and the patient was started on oral glucocorticoid therapy for sarcoidosis (figure 2). Neurosarcoidosis with skull base bone involvement is uncommonly reported.1,2

Hyperparathyroidism jaw tumour syndrome is a rare autosomal dominant inherited endocrine neoplasia syndrome, which predisposes carriers to develop a triad of multiple ossifying fibromas of the maxilla and mandible, parathyroid adenomas and carcinomas (with consequent hyperparathyroidism) as well as renal and uterine tumours. The prevalence of this condition is unknown. Patients typically present initially with symptoms and signs of a jaw tumour. A high index of suspicion is required for the underlying diagnosis to be recognised, enabling appropriate management of jaw lesions, treatment of hyperparathyroidism, if present, as well as early detection of malignant disease and screening of family members. Teaching points • HPT-JT is a rare autosomal dominant inherited endocrine neoplasia syndrome. • HPT-JT causes facial disfigurement, morbidity secondary to hyperparathyroidism and malignancy. • Patients can present with ossifying fibromas of the jaw, hypercalcaemia or malignancy. • A high index of suspicion is required for the underlying diagnosis to be recognised. • Management involves screening of family members.

Background Whilst there is a broad selection of drugs licensed as disease modifying treatments (DMTs) for people with relapsing multiple sclerosis (pwRMS), access to DMTs remains restricted, particularly for people with progressive MS (pwPMS). Cladribine has shown efficacy at all stages of MS. Following withdrawal from the market of oral cladribine in 2011, partly due to issues associated with lymphopenia, and following a thorough risk assessment, we started using subcutaneously injected cladribine (Litak®) to treat both pwRMS and pwPMS. Here, we report on the real life safety and tolerability of this treatment option. Methods Cladribine was offered to (i) pwRMS as a choice despite fulfilling NHS England (NHSE) criteria for licensed DMTs, and (ii) pwRMS and pwPMS not eligible for NHSE approved DMTs. To avoid lymphocyte depletion lower than 0.5 × 109/l (WHO grade 2) cladribine was administered using a personalised dosing scheme (30–40 mg in week 1; and another 0–30 mg in week 5 pending total lymphocyte count at week 4). Anti-viral prophylaxis was given from day 1 for 60 days. Patients approaching week 48 were given a second treatment cycle. Data collection included side effects, relapses, change in disability and MRI indices. Results Seventy-one pwMS (40 female, 31 male; 36 RMS, 35 PMS,) received at least one treatment cycle. Mean age for starting cladribine was 44 years (range 22–72 years), median EDSS was 5 (range 1–8.5). Maximum follow-up was 28 months. 35/71 pwMS were followed up for at least 20 weeks. These patients had a median EDSS of 5.0 (range 1.0–7.5) at baseline and 5.5 (range 1.0–8.0) after a mean follow-up of 11 months (range 5–28). Cladribine was well tolerated with very few treatment-related adverse events observed. Personalised dosing led to grade 1–2 lymphopenia in 50% of cases. A single patient developed transient grade 3 lymphopenia. No cases of varicella or other infections were observed. Four/17 people with relapsing MS, experienced a total of six relapses during a mean follow-up of 13 months (range 5–28 months). In people with PMS (n = 18) median EDSS was 5.5 (2.0–7.5) at baseline and 6.0 (2.5–7.5) after a median of 10 months (range 5–18). In pwPMS MRI showed that 25% had active scans at baseline, and 0% at follow-up. Conclusion Personalised dosing of cladribine avoided severe lymphopenia in all but one patients and was very well tolerated across a large spectrum of disease severity. Our data suggests cladribine may offer benefit people with relapsing and progressive MS alike. The personalised protocol used appears safe, however warrants controlled studies to more definitively assess efficacy and safety, particularly in groups of pwMS who are not eligible for licensed DMT including oral cladribine (Mavenclad®).

The anterior skull base (ASB) is intimately associated with the unique soft tissue subtypes of the nasal cavity, paranasal sinuses, orbits, and intracranial compartment. Pathology involving the ASB is rare but the causes are manifold and can be broadly subdivided into those intrinsic to the skull base and processes extending from below or above. Sinonasal pathology is the most commonly encountered and poses significant management challenges that rely heavily on accurate interpretation of the radiological findings. We illustrate the normal anatomy of the ASB and present a cross-sectional imaging review of the pathological entities that may be encountered, focusing on the specific features that will impact on clinical and surgical management.

Aneurysmal bone cysts (ABCs) are expansile cystic lesions that can affect any bone of the body. Whilst these lesions are histologically benign, the lesions are locally aggressive and can affect the integrity of the affected bone as well as surrounding structures. ABCs arising in the head and neck region, particularly the paranasal sinuses are rare and they are limited to case reports in the literature. Due to the proximity of critical anatomical structures and the visual apparatus, the potential complications can be devastating. The present article discusses both the clinical and radiological findings of an ABC arising from the ethmoid sinuses in a 6-year-old child and the potentially challenging diagnosis with its complex ensuing surgical management. The identification of an ABC arising in the paranasal sinuses is both a diagnostic and surgical challenge and ideally requires complex management in a joint paediatric ENT and craniofacial unit.

Positron emission tomography - computed tomography (PET-CT) with fluorine-18-fluorodeoxy-d-glucose (

Accurate interpretation of orbital imaging in the presence of either orbital implants requires a sound knowledge of both the surgical approach used and the imaging characteristics of the implanted devices themselves. In this article, the radiological appearance of the various devices used in ophthalmology, and their relationship to other orbital structures, is reviewed. In addition, the intended anatomical location, function of these devices, and clinical indications for their use are provided.

Low back pain is a common medical condition that has significant implications for healthcare providers and the UK economy. Low back pain can be classified as ‘specific’ in which an underlying pathophysiological mechanism is identified (eg, herniated intervertebral disc). Advanced imaging should be performed in this situation and in those patients in whom systemic disease is strongly suspected. In the majority (approximately 90%), low back pain in ‘non specific’ and there is a weak correlation with imaging abnormalities. This is an area of ongoing research and remains controversial in terms of imaging approach and treatment (eg, theory of discogenic pain, interpretation and treatment of endplate changes). With regards Modic endplate changes, current research suggests that an infective component may be involved that may identify novel potential treatments in patients with chronic low back pain refractory to other treatment modalities. MRI is the imaging modality of choice for the assessment of degenerative changes in intervertebral discs. MRI has superior soft tissue contrast resolution when compared to other imaging modalities (eg, plain radiography, CT). An understanding of normal anatomy and MR appearances of intervertebral discs, particularly with regards to how these appearances change with advancing age, is required to aid image interpretation. Knowledge of the spectrum of degenerative processes that may occur in the intervertebral discs is required in order to identify and explain abnormal MRI appearances. As the communication of MRI findings may guide therapeutic decision making and surgical intervention, the terminology used by radiologists must be accurate and consistent. Therefore, description of degenerative disc changes in the current paper is based on the most up-to-date recommendations, the aim being to aid reporting by radiologists and interpretation of reports by referring clinicians.

The craniocervical junction is an area with unique biomechanical properties and injuries conferred often represent high-impact trauma. The vital structures traversing this region are susceptible to injury with frequent, only subtle findings identified on unenhanced CT, with MRI and CT angiography often revealing the full extent of injuries. This article reviews the osseous and ligamentous anatomy of the region and common injury patterns. Endovascular and neurosurgical management will also be discussed.

Vertebral artery dissection is an important cause of stroke in the young and diagnosis is often challenging as symptoms are varied and subtle.\ud Case presentation\ud \ud A 33-year-old, previously healthy, white male office worker was stretching his neck when he developed sudden left-sided visual loss lasting 5 minutes associated with headache. He had no other neurological symptoms or signs. He was investigated with a computed tomography angiogram, which revealed a left vertebral artery dissection with a right posterior cerebral artery vascular occlusion.\ud Conclusions\ud \ud We describe an atypical case of vertebral artery dissection presenting with sudden transient visual disturbance without neurological signs in an otherwise healthy man. This is a rare but potentially fatal condition that can result in thromboembolic infarction. A high index of suspicion is crucial to make an early diagnosis and avoid devastating neurological outcomes.

Background Thoracic injuries are the third most common injuries in trauma patients with cardiac injuries amongst the most lethal. Imaging is essential in diagnosis and triage of patients with pericardial injuries, and this review aims to highlight the spectrum of imaging findings of pericardial trauma. Focussed assessment with sonography for trauma (FAST) is the preferred initial examination, being rapid and accurate. Sensitivity of FAST for pericardial fluid detection is high with reported sensitivities of 97–100%. Plain chest radiography has low sensitivity for pericardial injuries but is useful in the evaluation of associated injuries. Computed tomography (CT) is the modality of choice for stable patients and can accurately diagnose traumatic pathology of the pericardium being especially useful in identification of cardiac herniation. The spectrum of CT findings includes pericardial fluid collections, focal pericardial defects and pneumopericardium. Methods A selection of cases of pericardial trauma encountered at a level one trauma centre is presented. Operative findings were correlated with the FAST scan, plain radiography and computed tomography imaging. Conclusion The imaging findings of pericardial trauma with various imaging modalities (ultrasound, plain radiography and computed tomography) are presented in order to aid interpretation during the acute trauma setting.

Vertebral artery injuries can complicate attempted cannulation of the internal jugular vein including arteriovenous fistula formation. Such a fistula may occlude spontaneously in the acute phase but once established, spontaneous occlusion is extremely unusual. To the best of our knowledge, this has not been reported in the medical literature. We present a case of a patient who developed a right-sided vertebral arteriovenous fistula following instrumentation of the neck vessels but formal angiography/intervention was declined. The reason to report this case is that follow-up magnetic resonance angiography was performed, with spontaneous resolution of the right-sided vertebral arteriovenous fistula occurring postoperatively between days 30 and 135. Endovascular treatment options are available but for those who decline intervention, this report highlights the fact that spontaneous resolution of vertebral arteriovenous fistulae can occur.

The aim of this study was to investigate the ability of aminoguanidine (AG) to prevent diabetes-induced changes in nitric oxide synthase- (nNOS), vasoactive intestinal polypeptide- (VIP) and noradrenaline- (NA) containing nerves of the rat ileum using immunohistochemical and biochemical techniques. Diabetes was induced in adult male Wistar rats by a single intraperitoneal injection of streptozotocin (65 mg/kg). AG was administered in the drinking water to control (1.8 g/l) and diabetic (0.9 g/l) rats over a period of 8 weeks. Diabetes caused a significant increase in the thickness of nNOS-containing nerve fibres (p

PURPOSE: Although in vivo MRS has been extensively applied to gliomas, the relevance of myoinositol (Myo) to malignant phenotype and the cell types that contribute signal are poorly understood. Microglial infiltration is associated with Myo elevation in inflammatory and neurodegenerative diseases, and has been implicated in neoangiogenesis in transforming gliomas. The aim of this study was to examine the relationship between Myo and Cho imaging biomarkers and enzymatic tissue markers of Myo synthesis and microglial cell type in grade II and III astrocytomas. SUBJECTS AND METHODS: 28 patients with diffuse astrocytoma (14 diffuse LGG, WHO grade II; 14 anaplastic, WHO grade III; 13 stereotactic biopsies, 15 surgical specimens) underwent multivoxel spectroscopy at 1.5 T or 3T (TE = 30ms, TR = 1500ms, 8x8 grid; Siemens Avanto/Verio, Erlangen, De). Metabolite ratios were estimated using proprietary software. Tissue immunostains with rabbit polyclonal antibodies directed against human inositol monophosphatase (IMPA1; Sigma – dilution 1:400; 25 cases) and Iba1 (Wako – dilution 1:750; 21 cases), were assessed semi-quantitatively. Myo/Cr and Cho/Cr ratios were compared (Kruskal-Wallis) and compared with Iba-1 and IMPA1 levels (Wilcoxon rank-sum), and metabolite ratios with Iba1 (Spearman's rank test). Co-localisation of highest Myo/Cr and Cho/Cr was also measured (Fisher's exact test). RESULTS: Myo/Cr was significantly lower in grade II compared with grade III tumours (p < 0.01). Highest Myo/Cr co-localised with highest Cho/Cr voxels in 72%. IMPA1 scores were significantly higher in grade III compared to grade II lesions (p < 0.01). There was no correlation between semi-quantitative microglial analysis using Iba1 antibody and Myo/Cr or tumour grade. CONCLUSION: Higher Myo in grade III than grade II astrocytomas suggests that it is not a marker of indolent tumour phenotype, as has been previously suggested, and may reflect increased de novo synthesis relating to p53 mutations. Our data do not suggest that microglia account for raised Myo levels in gliomas.

Aim To unravel the potential idiopathic intracranial hypertension (IIH) endocrine-metabolic comorbidities by studying the natural (and targeted drug-modified) history of disease in children. IIH is a disorder of unclear pathophysiology, characterized by raised intracranial pressure without hydrocephalus or space-occupying lesion coupled with normal cerebrospinal fluid (CSF) composition. Methods Retrospective study (years 2001-2010) of clinical records and images and prospective follow-up (years 2010-2013) in 15 children (11 girls, 4 boys; aged 5-16 years) diagnosed previously as "IIH", according to the criteria for pediatric IIH proposed by Rangwala, at four university pediatric centers in northern, central, and southern Italy. Results We identified six potential endocrine-metabolic comorbidities including, weight gain and obesity (n=5), recombinant growth hormone therapy (n=3), obesity and metabolic syndrome (n=1), secondary hyperaldosteronism (n=1), hypervitaminosis A (n=1), and corticosteroid therapy (n=1). Response to etiologically targeted treatments (e.g., spironolactone, octreotide) was documented. Conclusions IIH is a protean syndrome caused by various potential (risk and) associative factors. Several conditions could influence the pressure regulation of CSF. An endocrine-metabolic altered homeostasis could be suggested in some IIH patients, and in this context, etiologically targeted therapies (spironolactone) should be considered.