Infected third branchial cleft cyst: retropharyngeal extension to the superior mediastinum.

The presentation of an infected branchial cleft cyst extending into the retropharyngeal space is extremely rare. However, differentiation of this lesion from a simple retropharyngeal abscess is important for surgical planning. The authors describe a 44-year-old woman in whom an infected third branchial cleft cyst was initially misdiagnosed as an abscess and drained surgically. Repeat surgery was necessary when the patient's symptoms recurred several weeks later.

Postcontrast MRI of cranial meninges: leptomeningitis versus pachymeningitis.

OBJECTIVE: Our goal was to characterize the patterns of meningeal enhancement in postcontrast MR images and correlate these patterns with the clinical disorders. MATERIALS AND METHODS: The MR scans, medical records, and laboratory findings of 83 patients, whose postcontrast MR studies of the head demonstrated meningeal enhancement, were reviewed retrospectively. The patterns of enhancement of the different layers of the meninges were divided into two types: leptomeningeal (pia and arachnoid), when enhancement of the meninges followed the convolutions of the gyri and/or involved the meninges around the basal cisterns; and pachymeningeal (dura), when the enhancement was thick and linear or nodular along the inner surface of the calvarium, falx, or tentorium without extension into the cortical gyri or basal cistern involvement. Enhancement around the basal cistern was considered leptomeningeal, since the dura-arachnoid is widely separated from the pia-arachnoid in this region. Further, the meningeal enhancement was divided into five etiologic subgroups, i.e., carcinomatous, infectious, inflammatory, reactive, and chemical. The medical history, clinical presentation, and findings on CSF analysis were used to distinguish infectious from carcinomatous meningitis. Meningeal enhancement due to surgery, shunt, or trauma was considered reactive, while ruptured cysts (dermoid or cysticercoid) or intrathecal chemotherapy were classified as chemical meningitis. Meningitis secondary to involvement by collagen vascular disease or sarcoidosis was considered to be inflammatory. RESULTS: Thirty of the 83 subjects had carcinomatous, 28 infectious, 14 reactive, 8 chemical, and 3 inflammatory etiology for meningitis. Twenty-five cases (83%) of the carcinomatous, 14 (100%) of the reactive, 3 (100%) of the inflammatory, and 1 (12%) of the chemical meningitis subgroups demonstrated pachymeningeal enhancement, while 28 cases (100%) of the infectious meningitis and 7 (78%) of the chemical meningitis subgroups had leptomeningeal enhancement. Only five cases (17%) of the carcinomatous meningitis subgroup showed leptomeningeal enhancement. Four of these five cases were as a result of direct spread of intraparenchymal tumors or through perineural extension, rather than hematogenous involvement. Only one patient with carcinomatous meningitis demonstrated leptomeningeal enhancement without clear intraparenchymal lesion. CONCLUSION: The recognition of various patterns of meningeal enhancement (leptomeningitis versus pachymeningitis) may help in differentiating between infectious and carcinomatous meningitis. This study demonstrated that infectious meningitis presents mostly as leptomeningitis, while carcinomatous meningitis presents as pachymeningitis.

Idiopathic hypertrophic cranial pachymeningitis: a case report.

Hypertrophic pachymeningitis is a rare fibrosing inflammatory process involving dura mater and tentorium. In this report we are presenting contrast enhanced MRI findings of an unusual case of pachymeningitis which presented with a periorbital mass due to dural sinuses occlusion and retrograde filling of periorbital veins through superior sagittal sinus.

Central nervous system tuberculosis: MRI.

The MRI findings of 18 proven cases of central nervous system (CNS) tuberculosis were reviewed; 10 patients were seropositive for HIV. All had medical, laboratory, or surgical proof of CNS tuberculosis. Eleven patients had meningitis, of whom two also had arachnoiditis. Five patients had focal intra-axial tuberculomas: four brain masses and one an intramedullary spinal lesion. Two patients had focal extra-axial tuberculomas: one in the pontine cistern, and one in the spine. In all 11 patients with meningitis MRI showed diffuse, thick, meningeal enhancement. All intraparenchymal tuberculomas showed low signal intensity on T2-weighted images and ring or nodular enhancement. The extra-axial tuberculomas had areas isointense or hypointense relative to normal brain and spinal cord on T2-weighted images. Although tuberculous meningitis cannot be differentiated from other meningitides on the basis of MR findings, intraparenchymal tuberculomas show characteristic T2 shortening, not found in most other space-occupying lesions. In the appropriate clinical setting, tuberculoma should be considered.

Imaging of pregnancy-related complications.

Thirty-six cases of pregnancy-related complications were studied with plain radiography, ultrasonography (US), computed tomography (CT), and magnetic resonance (MR) imaging alone or in combination. Among the complications diagnosed with these various techniques were venous thromboembolic disorders, deep vein thrombosis, ovarian vein thrombosis, endometritis and pyometra, HELLP syndrome (hemolysis, elevated liver enzyme levels, and low platelet counts), hepatic hematoma and rupture, fatty liver, uterine rupture, various hematomas and a foreign body, tubo-ovarian abscess, cerebral venous thrombosis, cerebral ischemia, and cerebral edema. Prompt detection and appropriate management of many of these complications could result in decreased maternal and fetal mortality and morbidity. Although US should be considered first because it can be performed bedside, does not require use of ionizing radiation, and is cost-effective, CT is superior in demonstrating the extent of the abnormality and MR imaging is best for detection of neurologic complications of pregnancy. The radiologist should select the best available method and tailor the examination according to the presumptive clinical diagnosis and the individual problem to be solved.

Computed tomography versus standard radiography in the assessment of fractures of the mandible.

Twenty-nine fractures of the mandible were studied by standard radiographs and axial computed tomographic scans (hard copy). Independent reviewers analyzed each study in a blinded, non-paired fashion. When radiographic diagnostic sensitivities were compared on the basis of known surgical findings, the plain films were found to have a higher diagnostic sensitivity (89%) than the hard copy computed tomograms (64%). This difference occurred primarily with images of nondisplaced fractures in posterior portions of the mandible, and is likely the result of tomographic orientation and volume averaging. Though computed tomography has emerged as the standard diagnostic test in evaluating intracranial and maxillofacial trauma, this study demonstrates that computed tomographic scanning alone is inadequate in excluding nondisplaced fractures of the posterior mandible.

Giant-cell tumor of the sphenoid bone: case report and review of the literature.

We report the case of a 23-year-old man with a giant-cell tumor of the sphenoid bone. The radiologic manifestations consisted of an expansile mass arising from the sphenoid bone with extension into the cranial cavity and the nasopharynx. The findings with computed tomography and magnetic resonance imaging best reflected respectively the osseous and soft-tissue extent of the disease.

Delayed common femoral artery stenosis due to blunt trauma.

Arterial occlusion or stenosis due to blunt trauma is rare. Only isolated examples have been reported. The majority result from sport-related trauma or are iatrogenic in nature. The clinical importance of blunt trauma is that it can create delayed vascular stenosis but few symptoms at the time of the incident. This is even more important in children and adolescents as any delay in diagnosis can lead to severe sequelae such as limb shortening and other growth disturbances. We here report a patient with common femoral artery stenosis after a bicycle injury in whom, apparently uniquely, delayed symptoms developed after eight months.

Wilms tumor (nephroblastoma) in the adult patient: clinical and radiologic manifestations.

Wilms tumor (nephroblastoma), a primary renal neoplasm containing primitive blastema and embryonic glomerulotubular structures, is seen rarely in adults. To identify clinical and radiologic criteria for preoperative diagnosis of adult Wilms tumor, we studied 29 cases reported in the literature from 1975 to 1987 (all patients were 15 years old or older) and four newly diagnosed cases. The mean age of patients was 30 years; 80% were less than 35 years old. Each patient presented with a large, rapidly growing, abdominal mass (average duration of symptoms, less than 2 months), had no constitutional symptoms (e.g., weight loss, fever), and otherwise were healthy (80%). Twenty-six patients had IV or retrograde pyelograms. Twenty-three showed a nonspecific mass effect. In seven (78%) of nine patients, abdominal CT scans showed a large, inhomogeneous mass with large areas of low density and increased enhancement of the compressed remaining normal renal parenchyma, which resembled a pseudocapsule. In five (63%) of eight patients, sonograms showed a complex mass with large cystic components. In 18 (82%) of 22 patients, arteriograms showed a hypovascular mass with fine wavy or zigzag (creeping-vine) neovascularity. We conclude that a rapidly growing renal mass in a young patient (less than 35 years old) that is shown to be complex and cystic by CT or sonography and that is hypovascular with fine, wavy neovascularity on arteriography is suggestive of adult Wilms tumor (75-80%). An awareness of this constellation of findings may be helpful in diagnosing this unusual tumor before surgery.

The Tecumseh Study of Respiratory Illness. IX. Occurence of influenza in the community, 1966--1971.

The occurrence of types A and B influenza infections was determined by isolation and serology over six years among residents of Tecumseh, Michigan. By isolation, there was evidence of type A infection for a limited period during each year of the study; most rises in titer were detected during the periods of viral isolation, but some also occurred out of season. Outbreaks of type B infection were encountered three times during the six-year period and out of season infections were less frequently seen than with type A. Infection rates with type A were relatively flat over the age range, with high rates seen in infants and small children; in contrast, highest infection rates with type B were observed in the 5--14-year-olds. On examination of illness rates, it was found that some of the outbreaks wound have gone undetected if surveillance techniques for infection had not been in operation. Frequency of respiratory illness with activity restriction was taken as a guide to influenza virus activity during outbreaks; it was found that highest rates of such illnesses occurred among the 1--4-year-olds for type A outbreaks, and among the 5--9-year-olds during mixed or type B outbreaks.