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Bone epithelioid hemangiomas are classified within benign vascular tumours but are commonly misdiagnosed as low-grade angiosarcomas or epithelioid hemangioendotheliomas. Current therapeutic interventions include various treatment options but local recurrence or distal lymph node involvement has been reported. We report a rare case of scapular epithelioid hemangioma that was initially treated using a combination of chemoembolization and microwave ablation. This combination has not been previously reported in the literature regarding the management of this tumour. A year after the first course of treatment, the tumour size has been reduced more than 70% and the patient has remarkable clinical improvement. Results reported in this case study demonstrated that combination of chemoembolization and microwave ablation is a feasible, safe and effective technique in the treatment of bone epithelioid hemangiomas. Even if the tumour is still present afterwards, a substantially smaller surgical excision will be needed. Keywords: Epithelioid hemangioma, Chemoembolization, Microwave ablation, Scapula

We illustrate the intravascular ultrasound (US) findings in the evaluation of left gonadal vein anatomic variations. During a 2-year period, 4 consecutive patients (mean age, 37 years; range, 28-45 years) with left-sided varicocele underwent embolization. Intravascular US examinations and retrograde venography were performed to assess varicocele anatomy. Anatomic variants were recorded and categorized. A comparison between intravascular US and fluoroscopic findings was performed. The Fisher exact test was used for statistical analysis (P < .05). Technical success was achieved in all cases. There was a statistically significant difference in the maximum gonadal vein diameter between venography and intravascular US (P = .0087). Intravascular US showed left gonadal vein anatomic variations and better ability in the evaluation of the vein diameter.

Background Several tumour-like conditions of the soft tissues may be encountered in clinical practice, or when patients undergo radiologic examinations. Al-though advances in cross sectional imaging (ultra-sound, MDCT and MRI) play a pivotal role in the correct evaluation of tumour-like lesions, a systematic approach is needed to achieve a definitive diagnosis or limit the differential diagnosis. Clinical history, physical examination and anatomic location are of paramount importance. Methods In this pictorial essay we review some of the most frequent benign soft tissue conditions which may be mistaken for malignancy and thus lead to need-less referrals, unnecessary biopsies and great anxiety to the patients and their carers. Level of evidence IV.

Several developmental anomalies have been described with respect to the odontoid process. The purpose of the study was to describe the MR appearance of the odontoid process and to calculate the prevalence of its morphological variants. We retrospectively reviewed 133 patients (85 males and 48 females, age range of 19–81 years, mean 39.5), examined within a 7-year period. Patients were divided into two age groups: ≤30 and >30-year-old. The morphology of the odontoid process was classified into type I: pyramidal tip and type II: ovoid or convex tip. The incidence of os odontoideum and os terminale and the presence of longitudinal cleft were also recorded. Fischer’s exact test was used for statistical analysis (p

Musculoskeletal injuries in the non-elite athletes are a clinical entity that is being seen more frequently nowadays. The term “weekend warriors” applies to amateur participants in sports activities and is related to an increasing number of musculoskeletal injuries mainly due to overuse. Concomitant skeletal variations may as well predispose to trauma. We add to the literature two cases of multipartite patella in which locally injected ropivacaine (ropivacaine hydrochloride) and steroid (betamethasone acetate-betamethasone sodium phosphate) relieved the symptoms completely. Here, we describe the clinical, imaging features and the course of treatment.

Anterior knee pathology is a frequent cause of joint pain and limitation of function and mobility among patients presenting to an orthopaedic department. Proper recognition and treatment of pathologic conditions depend on the knowledge of normal anatomy and of the various abnormalities, which affect this area of the knee and may present with anterior knee pain. A broad array of benign and malignant processes may be manifested as anterior knee discomfort, and this common clinical entity is among the most frequent indications for MR imaging of the lower extremities. Clinical history and physical examination are also of paramount importance. The disorders can be categorized and differentiated primarily according to their location. Traumatic or non-traumatic disorders of the patella, patellar retinacula, quadriceps and patellar tendons and supra or infrapatellar fat pad can be the source of symptoms. This article includes a comprehensive pictorial essay of the characteristic MR features of common and uncommon disorders causing anterior knee pain. For accurate assessment of the aforementioned clinical problem, a radiologist should be able to identify typical MR imaging patterns that contribute in establishing the correct diagnosis and thus tailoring the appropriate therapy. Level of evidence IV.

Primary malignant vascular bone tumors are unusual and include hemangioendothelioma, epitheloid hemangioendothelioma and angiosarcoma. Although few cases of primary bone angiosarcomas have been reported, those of femoral origin are even more infrequent. Such tumors diagnosis may be challenging due to their radiographic and histologic variety. We present a case of a 24-yearold woman with a subperiosteal diaphyseal angiosarcoma originating from the femoral bone and metastatic to the lung at the time of diagnosis. The clinical, histological and radiological features of this extremely rare lesion are presented.

Choledochal cyst is a relatively uncommon disease which is characterized by congenital dilatation of the intra and/or extrahepatic part of the biliary tree. Type IVa choledochal cysts are managed surgically through total excision of the entire extrahepatic part of the abnormal bile ducts and a simultaneous hepaticoenterostomy. Postoperative anastomotic stricture after excision of choledochal cysts and hepaticojejunostomy is a well-known late complication. We report a case of a 17-year-old female in whom gadoxetic acid-enhanced magnetic resonance cholangiography assisted in the evaluation of a biliary stricture following bile duct procedures after choledochal cyst correction surgery.

To describe the multi-ossicle appearance of the os naviculare on MRI and CT examinations and to correlate this appearance with the published classification of this well-known skeletal variant. We retrospectively reviewed 148 patients, examined within a 2-year period (170 CT and MRI studies of the foot-ankle), for the presence of os naviculare. This variant was classified according to a widely used system (type I, II, III). In addition, each navicular variant was further reclassified according to the presence of one or more ossicles. The presence of bone marrow edema was also recorded. Accessory navicular bone was identified in 34 cases (20%) of the 170 exams. It was detected in 14 male and 14 female patients with the following incidence: 11.15% type I (19 cases), 4.11% type II (7 cases) and 4.74% type III (8 cases). In six cases the location was bilateral. Among patients with os naviculare, a multi-ossicle appearance with a total incidence of 14.7% (8.8% two ossicle configuration and 5.9% three ossicle configuration) was observed. In two type II cases studied with MRI, there was bone marrow edema suggesting a painful pseudarthrosis. The presence of multiple accessory navicular bone ossicles, not previously described with cross-sectional imaging, is reported herein. The pathogenesis and clinical relevance of this uncommon variant needs to be elucidated with further studies.

Lipoma arborescens, a diffuse articular lipomatosis, is a rare disorder characterized by marked villiform synovial proliferation and diffuse replacement of the subsynovial tissue by mature adipocytes. Unilateral joint involvement is the usual presentation while bilateral joint involvement is more uncommon. We reported a case of bilateral lipoma arborescens in a male patient with associated marked patellofemoral osteoarthritis and described the MR imaging findings.

Posterior ankle impingement syndrome represents an important cause of chronic ankle pain and has been extensively described in the orthopaedic and radiology literature. A rare case of this painful hindfoot disorder that resulted from two concurrent developmental anomalies is presented herein.

We sought to prospectively evaluate patients' pain perception and technical success of four different arthrographic techniques for shoulder MR arthrography.A total of 125 consecutive patients were referred for shoulder MR arthrography. The patients were randomly injected under fluoroscopic guidance (n(1) = 37), with CT guidance using an anterior (n(2) = 29) or a posterior approach (n(3) = 32) and with ultrasound guidance (n(4) = 27). For each patient, absolute periprocedural pain on a numerical rating pain scale (0 = "no pain", 10 = "intolerable pain"), technical success of the method used, and reason for referral were recorded.The technical success rate was 100% for all injection methods. The results regarding absolute periprocedural pain were as follows: fluoroscopic guidance showed a mean pain of 4.05 ± 1.24, CT anterior guidance demonstrated a mean pain of 3.87 ± 0.95, CT posterior guidance showed a mean pain of 1.59 ± 0.81, and ultrasound guidance a mean pain of 3.63 ± 1.12. A significant difference (p .05) was observed for the posterior route under CT guidance. The mean pain level was significantly higher for older (51 year) female patients.No differences were found for the technical success rate of the aforementioned techniques. A CT-guided posterior approach seems to be a more comfortable method for the patient.

Popliteal or otherwise called Baker’s cyst represents a fluid distension of the gastrocnemiosemimembranosus bursa and is usually incidentally found on imaging studies. However, the clinical manifestation of symptomatic Baker’s cyst is similar to thrombophlebitis hence the term pseudothrombophlebitis syndrome. We add to the literature a case of a partially ruptured popliteal cyst in which locally injected ropivacaine (ropivacaine hydrochloride) and steroid (betamethasone acetate-betamethasone sodium phosphate) injection relieved the symptoms completely. We describe the clinical and imaging features and the treatment applied.

PURPOSE The purpose of this study is to present the characteristic radiologic features of common and uncommon complications in totally implantable central venous ports. MATERIAL AND METHODS The authors reviewed 138 implantations of central venous ports in oncologic patients during an 18-month period and present the characteristic imaging features of the complications detected. RESULTS All chest ports were placed via the internal jugular vein using both fluoroscopic and ultrasound guidance. The technical success rate was 99.3% (137/138). All catheter or port-related complications were retrospectively assessed. Sixteen complications were detected during the follow-up period, and catheter removal was required in 10 patients. CONCLUSIONS Image-guided central venous port catheter implantation is a very safe procedure with a low rate of complications. The typical imaging features of common and uncommon complications are very helpful in establishing the correct diagnosis and thus tailoring the appropriate therapy.

To compare the diagnostic ability of MR arthrography (MRa) and MDCT arthrography (CTa) in depicting surgically proven hip labral tears and articular cartilage degradation.Labral pathology and articular cartilage were prospectively evaluated with MRa and CTa in 14 hips of 10 patients. The findings were evaluated by two independent observers (a musculoskeletal fellow and one senior musculoskeletal radiologist). Sensitivity, specificity, accuracy, and positive predictive value were determined using arthroscopic and open surgery findings as the standard of reference. Interobserver agreement was recorded. All images were assessed for the presence of a labral tear (according to Czerny classification) and for cartilage erosion using a 3 point scale for both methods: 1 = complete visualization-sharp edges, 2 = blurred edges fissuring-partial defects, 3 = exposed bone. The same classification was applied surgically.Disagreement between the senior observer and the fellow observer was recorded in three cases of labral tearing with MRa and six with CTa. Disagreement was also found in four cases of cartilage erosion with both MRa and CTa. The percent sensitivity, specificity, accuracy, and positive predictive value for correctly assessing the labral tear were as follows for MRa/CTa, respectively: 100/15, 50/13, 90/14, and 90/13 (P0.05). The same values for cartilage assessment were 63/66, 33/40, 50/57 and 55/66 (P0.05).Interobserver reproducibility with MRa is very good for labral tearing assessment. MRa is better for assessing labral tears. CTa shows better, but not statistically significant, demonstration of the articular cartilage.

Scapulothoracic stabilization and motion is mainly carried out by the synergic and antagonistic action of three muscles: the serratus anterior, the trapezius, and the rhomboid [1, 2]. The serratus anterior is innervated by the long thoracic nerve (LTN), the trapezius by the spinal accessory nerve, and the rhomboid muscles by the dorsal scapular nerve [1–3]. Direct or indirect trauma, iatrogenic injuries, or idiopathic processes such as the Parsonage– Turner syndrome may result in nerve injury and eventually paresis of the affected muscle [1–3]. The LTN is formed from the anterior rami of the 5th, 6th, and 7th cervical nerves. It passes between the clavicle and the first rib and then enters a fascial sheath and descends along the lateral aspect of the thoracic wall innervating the muscle fibers of serratus anterior [4]. Due to its lengthy course (24 cm in average), its delicate and thin nature (2–3 mm) and the fact that it traverses the middle scalene muscle and descends between the clavicle and the first rib, the nerve is easily susceptible to injuries [4]. In the vast majority of cases, the mechanism of traumatic nerve injury is either overstretchingtraction or compression and constriction of nerve fascicles and the clinical result is serratus anterior muscle denervation, which is demonstrated as medial scapular winging [1–4]. Clinical examination provides valuable information for a correct diagnosis. Serratus anterior paresis results in medial scapular winging whereas lateral winging is the consequence of trapezius and rhomboid paresis [1–5]. In our case, the physical examination revealed medial winging of the right scapula, which became more pronounced when the patient was asked to perform active forward or upward elevation and abduction of his arms (Fig. 1). Since the diagnosis is easily made during clinical examination and visual inspection of the scapula, the need for MR imaging evaluation is limited [6–9]. MR imaging was requested in order to exclude a disk disease-radiculopathy and rule out a possible mass lesion either in the spinal canal or more peripherally. The anatomical distribution of the signal changes on MR aided in the correct diagnosis. The MR imaging findings of uniform muscle edema and the absence of fatty infiltration correlated well with the onset of symptoms and suggested a subacute phase of aponeurositis. This finding is considered essential in treatment planning. Due to imaging findings, electromyographic testing and nerve conduction studies were not performed. The electromyographic testing could have provided the degree of denervation, but according to the literature, the initial degree of denervation cannot be used to predict the extent of nerve recovery [10]. The isolated serratus anterior paresis and the associated medial scapular winging has been shown to respond well to The case presentation can be found at doi:10.1007/s00256-011-1231-2. E. Perdikakis : L. Palladas :A. Karantanas Department of Radiology, University of Crete, Stavrakia, Heraklion, Crete, Greece

A 33-year-old male with a strenuous occupation, presented with a 6-week history of mild pain and right-sided arm weakness. His complaints had progressed slowly over the last few weeks and the patient revealed a gradual inability to lift, pull, and push heavy weights while working. The patient was initially on oral analgesics and lately on steroids (per os methylprednisolone, 4-mg tablets) for a period of 6 days prior to referral, but with only moderate improvement. The patient did not recall any recent or remote traumatic incidence. MR imaging of the cervical spine was normal and MR imaging study of the thoracic wall was performed subsequently upon request (Figs. 1–3).