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Isolated spinal artery aneurysm is a rare lesion which could be accountable for spontaneous spinal subarachnoid haemorrhage. We describe the case of a 74-year-old man presenting with sudden onset of chest pain radiating to the neck and back, with subsequent headache and confusion. Initial computed tomography aortogram revealed incidental finding of subtle acute spinal subarachnoid haemorrhage. A set of computed tomography scans of the brain showed further acute intracranial subarachnoid haemorrhage with posterior predominance, small amount of intraventricular haemorrhage, and absence of intracranial vascular lesions. Subsequent magnetic resonance imaging demonstrated a thrombosed intradural spinal aneurysm with surrounding sentinel clot, which was trapped and excised during surgical exploration. High level of clinical alertness is required in order not to miss this rare but detrimental entity. Its relevant aetiopathological features and implications for clinical management are discussed.

Background/Purpose Preoperative templating is essential for the planning of total hip replacement. Digital templating has gained popularity due to the availability of digital images. Scaling is the critical step that calibrates magnified digital images to the actual dimension, for subsequent digital templating. We compared the accuracy of two scaling methods: (1) radiological marker; and (2) fixed magnification factor. Methods Forty-five postoperative radiographs in 21 patients who had undergone either total hip replacement or hip hemiarthroplasty were evaluated. The sizes of femoral head components in the digital radiographs were estimated using the two scaling methods. The estimated values were then compared to the true values stated in operation records. The absolute error (AE) and relative error (RE) of both scaling methods were calculated and compared. Results Both the mean AE and RE were smaller in Method 2 (fixed magnification factor), and were statistically significant (p < 0.05). Conclusion We recommend fixed magnification factor as the scaling method for digital templating.

OBJECTIVE To identify specific angiographic factors associated with haemorrhagic presentation of brain arteriovenous malformation in Chinese paediatric patients. DESIGN Retrospective cross-sectional observational study. SETTING Four locoregional tertiary neurosurgical centres in Hong Kong: Queen Elizabeth Hospital, Tuen Mun Hospital, Kwong Wah Hospital, and Pamela Youde Nethersole Eastern Hospital. PATIENTS Patients aged 18 years or younger who underwent pretreatment digital subtraction angiography for brain arteriovenous malformation between 1 January 2005 and 31 July 2013 were included. Patients were divided into haemorrhagic and non-haemorrhagic groups based on the initial presentation. Pretreatment digital subtraction angiographies were independently reviewed by two experienced neuroradiologists. MAIN OUTCOME MEASURES The following parameters were evaluated for their association with haemorrhagic presentation by univariate and multivariate analyses: nidus location, nidus size, nidus morphology (diffuse or compact); origin and number of arterial feeders; venous drainage; number of draining veins; presence of aneurysms, venous varices, and venous stenosis. RESULTS A total of 67 children and adolescents (28 male, 39 female) with a mean age of 12 years were included. Of them, 52 (78%) presented with haemorrhage. Arteriovenous malformation size (P=0.004) and morphology (P=0.05) were found to be associated with haemorrhagic presentation by univariate analysis. Small arteriovenous malformation nidus size and diffuse nidal morphology were identified as independent risk factors for haemorrhage by multivariate analysis. CONCLUSION Smaller arteriovenous malformation size and diffuse nidal morphology are angiographic factors independently associated with haemorrhagic presentation. Bleeding risk is important in determining the therapeutic approach (aggressive vs conservative) and timeframe, particularly in paediatric patients.

Vascular leiomyoma is a benign soft tissue tumour with a predilection for middle-aged women. It is most often seen in the extremities, particularly in the lower leg. The typical lesion is a small, slow-growing subcutaneous nodule. These tumours are often unexpected or preoperatively confused with other soft tissue tumours including low-grade sarcomas, leading to wide surgical excision. This may partly be due to the relatively few studies delineating the characteristic imaging features of this entity. Here, the imaging findings of a case of vascular leiomyoma in the ankle are presented. Literature review of the magnetic resonance imaging findings of published reports and series of vascular leiomyomas of the extremities is also performed.

OBJECTIVES To describe the thickness of mesorectal fat in local Chinese population and its impact on rectal cancer staging. DESIGN Case series. SETTING Two local regional hospitals in Hong Kong. PATIENTS Consecutive patients referred for multidisciplinary board meetings from January to October 2012 were selected. MAIN OUTCOME MEASURES Reports of cases that had undergone staging magnetic resonance imaging for histologically proven rectal cancer were retrospectively retrieved and reviewed by two radiologists. All magnetic resonance imaging examinations were acquired with 1.5T magnetic resonance imaging. Measurements were made by agreement between the two radiologists. The distance in mm was obtained in the axial plane at levels of 5 cm, 7.5 cm, and 10 cm from the anal verge. Four readings were obtained at each level, namely, anterior, left lateral, posterior, and right lateral positions. RESULTS A total of 25 patients (16 males, 9 females) with a median age of 69 (range, 38-84) years were included in the study. Mean thickness of the mesorectal fat at 5 cm, 7.5 cm, and 10 cm from the anal verge was 3.1 mm (standard deviation, 3.0 mm), 9.8 mm (5.3 mm), and 11.8 mm (4.2 mm), respectively. The proportions of patients with mean mesorectal fat thickness of

FIG 1. (a) Longitudinal and (b) transverse sonography of the right scrotum showing a solid extra-testicular mass separated from the normal-looking right testis. (c) Increased vascularity was evident on Doppler study. (d) Axial and (e) coronal computed tomographic images of the scrotum revealing bilateral scrotal soft-tissue thickening (arrows). (f) The oesophagogastroduodenoscopy reveals an irregular ulcerative tumour (*) over the lower part of gastric body A B S T R A C T Metastases to the scrotal wall are very rare, and being the initial manifestation of occult primary tumours is even rarer. We report on a patient presenting with painless scrotal swelling, attributed to a solid extra-testicular mass found on ultrasonography. Subsequent investigations and surgical exploration revealed it to be a scrotal wall metastasis from an occult gastric primary. To our knowledge, this is the first report of a scrotal wall metastasis from gastric adenocarcinoma. The ensuing discussion and literature review highlight the diagnostic challenges posed by an extra-testicular scrotal metastasis from an occult primary tumour.