Role of Clinical and Multimodality Neuroimaging in the Evaluation of Brain Death/Death by Neurologic Criteria and Recent Highlights from 2023 Updated Guidelines.

Purpose of Review: This review aims to provide a comprehensive overview of the diagnosis of brain death/death by neurologic criteria (BD/DNC) by emphasizing the clinical criteria established by the American Academy of Neurology (AAN) in light of their updated guidelines released in 2023. In this review, we will focus on the current implementation of ancillary tests including the catheter cerebral angiogram, nuclear scintigraphy, and transcranial Doppler, which provide support in diagnoses when clinical examination and apnea tests are inconclusive. Finally, we will also provide examples to discuss the implementation of certain imaging studies in the context of diagnosing BD/DNC. Recent Findings: Recent developments in the field of neurology have emphasized the importance of clinical criteria for diagnosing BD/DNC, with the AAN providing clear updated guidelines that include coma, apnea, and the absence of brainstem reflexes. Current ancillary tests, including the catheter cerebral angiogram, nuclear scintigraphy, and transcranial Doppler play a crucial role in confirming BD/DNC when the clinical assessment is limited. The role of commonly used imaging studies including computed tomography and magnetic resonance angiographies of the brain as well as CT/MR perfusion studies will also be discussed in the context of these new guidelines. Summary: BD/DNC represents the permanent cessation of brain functions, including the brainstem. This review article provides the historical context, clinical criteria, and pathophysiology that goes into making this diagnosis. Additionally, it explores the various ancillary tests and selected imaging studies that are currently used to diagnose BD/DNC under the newly updated AAN guidelines. Understanding the evolution of how to effectively use these diagnostic tools is crucial for healthcare professionals who encounter these BD/DNC cases in their practice.

Sinogram: A Valuable Diagnostic Tool for an Adult Male With Discharging Heel Ulcer and Suspected Calcaneal Osteomyelitis.

This report highlights the clinical significance of a sinogram in diagnosing osteomyelitis in resource-poor areas. We report a case in which a sinogram was used successfully for the diagnosis of calcaneal osteomyelitis. A 25-year-old male patient sought medical attention for persistent pain in the right ankle joint and heel, accompanied by a discharging ulcer over the right heel. He had a history of foot trauma involving vegetative matter sustained during a farming injury one month prior to the onset of symptoms. An ankle radiograph revealed an osteolytic lesion involving the calcaneum, prompting further investigation with a sinogram, which indicated a subcutaneous sinus tract with intramedullary extension into the calcaneum. Despite the clinical necessity for a magnetic resonance imaging (MRI) or computed tomography (CT) evaluation to precisely assess the lesion's extent and aid in formulating an appropriate treatment plan, the patient faced significant financial constraints that hindered him from undergoing the essential imaging procedure.

Artificial Intelligence (AI) in Radiology: A Deep Dive Into ChatGPT 4.0's Accuracy with the American Journal of Neuroradiology's (AJNR) "Case of the Month".

The advent of artificial intelligence (AI), particularly large language models (LLMs) such as ChatGPT 4.0, holds significant potential in healthcare, specifically in radiology. This study examined the accuracy of ChatGPT 4.0 (July 20, 2023, version) in solving diagnostic quizzes from the American Journal of Neuroradiology's (AJNR) "Case of the Month." We evaluated the diagnostic accuracy of ChatGPT 4.0 when provided with a patient's history and imaging findings weekly over four weeks, using 140 cases from the AJNR "Case of the Month" portal (from November 2011 to July 2023). The overall diagnostic accuracy was found to be 57.86% (81 out of 140 cases). The diagnostic performance varied across brain, head and neck, and spine subgroups, with accuracy rates of 54.65%, 67.65%, and 55.0%, respectively. These findings suggest that AI models such as ChatGPT 4.0 could serve as useful adjuncts in radiological diagnostics, thus potentially enhancing patient care and revolutionizing medical education.

Pericardial Cyst at an Unusual Location: The Role of CT Imaging.

The pericardial cyst is a benign, uncommon congenital cystic lesion of pericardial origin located in the anterior and middle mediastinum. Most commonly, pericardial cysts are located in the right anterior cardiophrenic angle. Computed tomography (CT) and magnetic resonance imaging (MRI) of the chest are the non-invasive imaging modalities for the diagnosis of the pericardial cyst. Here we present a case of a 55-year-old male who presented with coughing and chest pain for two weeks. A chest X-ray revealed a soft-tissue opacity mass in the left lower zone. A CT of the chest showed a fluid-density cystic lesion in close proximity to the pericardium, located along the left posterior cardiophrenic angle, an uncommon location for a pericardial cyst.

Merkel Cell Carcinoma of the Left Cheek With Testicular Metastasis: An Uncommon Occurrence.

Merkel cell carcinoma (MCC) is an infrequent and aggressive neuroendocrine tumor of the skin. 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) is an effective imaging technique with good diagnostic accuracy that may be used to help stage MCC and for detecting unexpected recurrences and distant metastatic disease. Other causes of testicular neoplasms, such as primary testicular tumors, lymphomas, or anaplastic small cell melanomas, are difficult to differentiate from MCC testicular metastases on imaging, and tumor markers and histopathology will help confirm it. The current case is a 65-year-old non-immunocompromised male with Merkel cell carcinoma who was incidentally identified with testicular metastases on PET/CT and confirmed on histopathology.

Large Chorioangioma in Triplets: An Uncommon Occurrence.

A 25-year-old primigravida presented at 26 weeks of gestation by dates, the first time for the routine antenatal checkup. No histories were suggestive of pregnancy-induced hypertension (PIH) and edema. On physical examination, pallor was present with microcytic hypochromic anemia. Raised beta-human chorionic gonadotropin (HCG) and alpha-fetoprotein (AFP) levels were present. Ultrasonography revealed triples with two thin echogenic intertwining membranes. Anomaly scan did not reveal any abnormality in fetuses. The placenta showed a large oval hypoechoic mass arising from its edge and bulge into the amniotic fluid. A central feeding vessel with a branching pattern and pulsatile color flow like that of the umbilical artery is noted on the color Doppler. She was spontaneously preterm delivered vaginally at 28 weeks of gestation. All three fetuses were stillborn. Histopathological diagnosis of angiomatous chorioangioma was confirmed. This case classically represents a grave complication of the large chorioangioma.

Rarity in conspicuity-Ultrasound diagnosis of sliding left inguinal hernia through canal of Nuck with uterus, fallopian tubes and ovaries.

We present a case of a one month old female infant who presented with left inguinal swelling. She was prematurely born at 32 weeks of gestational age. Preoperative ultrasound showed features of sliding indirect inguinal hernia with both ovaries, fallopian tubes and uterus; which were also evident per operatively. Patient underwent successful hernia repair and uneventful post-operative period. Patient is on follow up currently. In conclusion, we attempt to highlight the exiguous prevalence of inguinal hernia with uterus, fallopian tubes and ovaries; which has been sparsely reported in the literature and also the importance of preoperative of sonography.