Intracranial aneurysms at higher clinical risk for rupture demonstrate increased wall enhancement and thinning on multicontrast 3D vessel wall MRI.

OBJECTIVE:: Identification of aneurysms at risk for rupture is important and challenging. We sought to evaluate if intracranial vessel wall (IVW) imaging characteristics of unruptured aneurysms correlate with clinical risk factors for rupture. METHODS:: Patients with unruptured intracranial aneurysms were prospectively recruited and underwent a multi contrast 3D IVW protocol between April 6, 2016 and August 29, 2017. Two independent raters, blinded to aneurysm vulnerability, evaluated each aneurysm for wall enhancement, extent of enhancement in terms of the numbers of quadrants enhancing circumferentially, intensity of enhancement, and qualitative wall thinning. PHASES score was calculated for each aneurysm. Univariate logistic regression analysis was used to compare IVW characteristics between aneurysms at higher clinical risk for rupture (PHASES score > 3) and lower clinical risk for rupture (PHASES score ≤ 3). RESULTS:: 45 patients with 65 unruptured aneurysms were analyzed; 38 aneurysms with PHASES score > 3 (58%) and 27 aneurysms with PHASES score ≤ 3 (42%). Aneurysms with PHASES score > 3 were more likely to demonstrate enhancement (42.1% vs 14.8%, p = 0.022), greater extent of enhancement (mean: 2.9 vs 2.2 quadrants, p = 0.063), and wall thinning (9.2% vs 0%, p = 0.044). Inter-reader agreement was moderate-to-good for the presence (κ = 0.64), extent (κ = 0.64), and intensity of enhancement (κ = 0.60) but relatively low for wall thinning (κ = 0.25). CONCLUSION:: Aneurysms at higher risk of rupture by PHASES score are more likely to demonstrate wall enhancement, more diffuse enhancement, and wall thinning on IVW. ADVANCES IN KNOWLEDGE:: This study prospectively compares IVW-detected wall enhancement and thinning between unruptured aneurysms stratified into high and low risk groups by clinical scores (PHASES) of vulnerability.

Nondisseminated histoplasmosis of the trachea.

Histoplasma capsulatum can rarely affect the trachea. We report the case of a 68-year-old woman with rheumatoid arthritis on immunosuppressive therapy who presented with fevers, worsening shortness of breath, nonproductive cough and subjective throat hoarseness and fullness. Chest computed tomography demonstrated no tracheal findings. Bronchoscopy found mucosal irregularity, nodularity and vesicular regions in the proximal trachea extending seven centimeters distal to the vocal cords. Also seen was an edematous, exudative left vocal cord with polyps and an ulcerative lesion. Silver staining and culture and wash of the tracheal biopsy revealed Histoplasma capsulatum. She was treated with oral itraconazole then briefly on intravenous amphotericin for rising Histoplasma urinary antigen levels. She continued treatment 24 months following diagnosis with minimal dyspnea. Histoplasma tracheitis has been proposed as an indicator of disseminated infection. However, our patient did not demonstrate other organ manifestations. Histoplasma tracheitis should be considered in a differential diagnosis of tracheal lesions even in the absence of systemic involvement.

Management of ureteral obstruction in crossed fused renal ectopia: A case report.

Crossed fused renal ectopia is a rare congenital malformation. We describe a case in which a 58-year-old male with left-sided crossed fused renal ectopia presented with urinary bladder outlet obstruction due to metastatic prostate adenocarcinoma. Glomerular filtration rate (GFR) was 13 mL/min, creatinine 4 mg/dL, and blood urea nitrogen (BUN) 58 mg/dL. The patient underwent successful image-guided placement of percutaneous nephrostomy tubes which were later converted to nephroureteral stents. Labs improved to a GFR of 28 mL/min, creatinine of 2.4 mg/dL, and BUN of 41 mg/dL. In this case standard image-guided renal decompression techniques were effective in treating a patient with crossed fused renal ectopia.