Wunderlich Syndrome: Wonder What It Is.

Wunderlich syndrome (WS) refers to spontaneous renal or perinephric hemorrhage occurring in the absence of known trauma. WS is much less common than hemorrhage occurring after iatrogenic or traumatic conditions. Lenk's triad of acute onset flank pain, flank mass, and hypovolemic shock is a classic presentation of WS but seen in less than a quarter of patients. The majority of patients present only with isolated flank pain and often imaged with an unenhanced CT in the emergency department. The underlying etiology is varied with most cases attributed to neoplasms, vascular disease, cystic renal disease and anticoagulation induced; the etiology is often occult on the initial exam and further evaluation is necessary. Urologists are familiar with this unique entity but radiologists, who are more likely to be the first to diagnose WS, may not be familiar with the imaging work up and management options. In the last decade or so, there has been a conspicuous shift in the approach to WS and thus it will be worthwhile to revisit WS in detail. In our review, we will review the multimodality imaging approach to WS, describe optimal follow up and elaborate on management.

Effect of Stereotactic Body Radiotherapy on the Growth Kinetics and Enhancement Pattern of Primary Renal Tumors.

OBJECTIVE: The objective of our study was to assess the growth rate and enhancement of renal masses before and after treatment with stereotactic body radiotherapy (SBRT). MATERIALS AND METHODS: This retrospective study included all patients with renal masses who underwent SBRT during a 5-year period. Orthogonal measurements of renal masses were obtained on pre- and posttreatment CT or MRI. Pre- and posttreatment growth rates were compared for renal mass diameter and volume using the t test. Pre- and posttreatment tumor enhancement values were compared for tumors that underwent multiphasic contrast-enhanced MRI. RESULTS: Forty patients underwent SBRT for the treatment of 41 renal tumors: clear cell renal cell carcinomas (RCCs) (n = 16), papillary RCCs (n = 6), oncocytic neoplasms (n = 8), unclassified RCCs (n = 2), urothelial carcinoma (n = 1), and no pathologic diagnosis (n = 8). The mean maximum tumor diameter before treatment was 3.9 cm (range, 1.6-8.3 cm). Three hundred thirty-eight pre- and posttreatment imaging studies were analyzed: 214 MRI studies and 124 CT studies. The mean pre- and posttreatment lengths of observation were 416 days (range, 2-1800 days) and 561 days (83-1366 days), respectively. The mean pretreatment tumor growth rate of 0.68 cm/y decreased to -0.37 cm/y post treatment (p < 0.0001), and the mean tumor volume growth rate of 21.2 cm(3)/y before treatment decreased to -5.35 cm(3)/y after treatment (p = 0.002). Local control-defined as less than 5 mm of growth-was achieved in 38 of 41 (92.7%) tumors. The Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 showed progression in one tumor (2.4%), stability in 31 tumors (75.6%), partial response in eight tumors (19.5%), and complete response in one tumor (2.4%). No statistically significant change in tumor enhancement was shown (mean follow-up, 142 days; range, 7-581 days). CONCLUSION: Renal tumors treated with SBRT show statistically significant reductions in growth rate and tumor size after treatment but do not show statistically significant differences in enhancement in the initial (mean, 142 days) posttreatment period.

Gallbladder splenosis: a hereto unreported mimicker of a gallbladder neoplasm.

Splenosis is a completely benign entity that can mimic a primary mass or metastasis. Herein we report the first known case of gallbladder splenosis in a 49-year-old woman with an extensive surgical and medical history. Cross-sectional computed tomography and MRI demonstrated a single mass arising from the gallbladder fundus. Revelation of splenectomy, confirmed to be traumatic from medical records, raised the suspicion for splenosis. The diagnosis was confirmed with a Technecium-99m-labeled heat-damaged blood cell scan, considered the gold-standard for detection of ectopic splenic tissue.

Whole-brain proton MR spectroscopic imaging of mild-to-moderate traumatic brain injury and correlation with neuropsychological deficits.

Changes in the distribution of the magnetic resonance (MR)-observable brain metabolites N-acetyl aspartate (NAA), total choline (Cho), and total creatine (Cre), following mild-to-moderate closed-head traumatic brain injury (mTBI) were evaluated using volumetric proton MR spectroscopic imaging (MRSI). Studies were carried out during the subacute time period following injury, and associations of metabolite indices with neuropsychological test (NPT) results were evaluated. Twenty-nine subjects with mTBI and Glasgow Coma Scale (GCS) scores of 10-15 were included. Differences in individual metabolite and metabolite ratio distributions relative to those of age-matched control subjects were evaluated, as well as analyses by hemispheric lobes and tissue types. Primary findings included a widespread decrease of NAA and NAA/Cre, and increases of Cho and Cho/NAA, within all lobes of the TBI subject group, and with the largest differences seen in white matter. Examination of the association between all of the metabolite measures and the NPT scores found the strongest negative correlations to occur in the frontal lobe and for Cho/NAA. No significant correlations were found between any of the MRSI or NPT measures and the GCS. These results demonstrate that significant and widespread alterations of brain metabolites occur as a result of mild-to-moderate TBI, and that these measures correlate with measures of cognitive performance.