A Unique Technique for Precise Targeting in Treatment of Rare Bifocal Intraosseous Ganglion Cysts of the Talus: A Case Report and Review of the Literature.

BACKGROUND This article presents a rare case of 2 separate intraosseous ganglion cysts of the talus in a 51-year-old man, treated with a unique technique of precise lesion targeting to avoid extensive bone loss and minimize articular chondral injury of the talus. CASE REPORT Two separate intraosseous ganglion cysts of the talus were diagnosed in a 51-year-old man with chronic ankle pain. A single straight-line incision with an entry point through the talonavicular joint was created to spare the precarious blood supply of the talus network. The 2 distinct subchondral lesions were approached under fluoroscopic control for curettage and autologous bone grafting using the anterior cruciate ligament tibial guide in a pair-of-compasses fashion. In almost 5 years of follow-up the patient has been asymptomatic. Magnetic resonance imaging has revealed no signs of degenerative changes in the ankle or the talonavicular joint, and the intraosseous edema has almost disappeared. CONCLUSIONS To the best of our knowledge, this case is the first report of 2 distinct intraosseous ganglion cysts of the talus. We recommend the precise targeting technique used in our case for treating intraosseous talar lesions with intact articular cartilage.

Internal carotid artery origin of the anterior cerebral artery: A rare anatomic intracranial arterial variation in a child with morning glory disc anomaly and moyamoya vascular pattern; case report and review of literature.

Morning glory disc anomaly (MGDA) characterizes a congenital dysgenetic disorder of the optic disc, coexisting with arterial intracranial abnormalities, including Moyamoya vascular disease, a significantly rare disease in the European populations. We report a 2.5-year-old female child from Greece previously diagnosed with MGDA, who presented with right-hand paresis, accompanied by focal epileptic spasms, followed by an episode of brief absence seizure, as well as some arm clonic spasms. Magnetic resonance angiography scan revealed the presence of an anomalous origin of the anterior cerebral artery (ACA) from the internal carotid artery (ICA) along with vascular abnormalities, compatible with Moyamoya pattern. To the very best of our knowledge, this is the first reported case of anomalous origin of ACA from the supraclinoid ICA accompanied by severe occlusive intracranial disease (moyamoya-like pattern) in a patient with known MGDA, highlighting the embryonic character of the vascular manifestations in MGDA. It also verifies the association of Moyamoya pattern with MGDA, thus linking vascular dysgenesis as a possible cause of MGDA.

Arthroscopic Treatment of Luxatio Erecta Humeri Associated with Greater Tuberosity Fracture, Bankart Lesion, and Partial Rotator Cuff Tear: A Case Report.

BACKGROUND Luxatio erecta humeri (LEH) is a rare injury present in only 0.5% of shoulder dislocations. Much of the relevant literature is focused on the initial management and proper reduction techniques, although the prevalence of associated injuries can reach 80%. A case of LEH associated with greater tuberosity (GT) fracture and rotator cuff (RC) tear in a young laborer managed with closed reduction and arthroscopic repair of the labrum and rotator cuff is presented. CASE REPORT A 28-year-old man presented to our hospital with severe pain in his right shoulder after a high-impact motor vehicle accident. Standard anteroposterior radiographs revealed an inferior dislocation (LEH) of the right shoulder and a fracture of the GT. The patient was initially managed with closed reduction under mild intravenous sedation, using a 2-step maneuver followed by arthroscopic evaluation of the joint the next day. During arthroscopic evaluation, an anterior-inferior Bankart lesion, impaction of the humeral head with a minimal displaced GT fracture, and a partial RC tear were identified and successfully treated arthroscopically. The patient had immobilization in a simple sling for 6 weeks and he followed a standard 3-month physiotherapy protocol for rotator cuff, finally regaining almost normal range of shoulder motion at 1 year. CONCLUSIONS Although very good results of non-operative treatment of LEH have been reported in the literature, the co-existence of intra-articular lesions such as labral and rotator cuff tears makes arthroscopic repair an attractive alternative in individual cases.

An MRI study of immune checkpoint inhibitor-induced musculoskeletal manifestations myofasciitis is the prominent imaging finding.

OBJECTIVE: To assess: (i) the prevalence, and clinical and imaging characteristics of immune checkpoint inhibitor (ICI)-induced musculoskeletal immune-related adverse events (ir-AEs) in a prospective manner and (ii) whether serum levels of cytokines associated with the Th1/Th2/Th17 response are differentially expressed in patients with and without musculoskeletal Ir-AEs. METHODS: All patients treated with ICI who developed musculoskeletal manifestations were referred to the Rheumatology Department, and an MRI of the involved area(s) was performed. RESULTS: During the study period, a total of 130 patients were treated with ICIs. Of these, 10 (7.7%) developed ICI-induced Ir-AEs. The median time from ICI treatment since development of symptoms was 2.5 months. Three different patterns of musculoskeletal manifestations were found: (i) prominent joint involvement (n = 3); (ii) prominent 'periarticular' involvement (n = 4). These patients had diffuse swelling of the hands, feet or knees. MRI depicted mild synovitis with more prominent myositis and/or fasciitis in the surrounding tissues in all cases; (iii) myofasciitis (n = 3). Clinically, these patients presented with pain in the knee(s)/thigh(s), whereas MRI depicted myofasciitis of the surrounding muscles. Patients with musculoskeletal ir-AEs had significantly higher oncologic response rates compared with patients not exhibiting musculoskeletal ir-AEs (50% vs 12.5%, respectively, P = 0.0016). Cytokine levels associated with a Th1/Th2/Th17 response were similar between patients with and without musculoskeletal ir-AEs. Overall, symptoms were mild/moderate and responded well to treatment, with no need for ICI discontinuation. CONCLUSION: In our cohort, ICI-induced musculoskeletal manifestations developed in 7.7% of patients. Imaging evidence of myofasciitis was found in most patients, indicating that the muscle/fascia is more frequently involved than the synovium.

An ischemic stroke as the presenting manifestation of rapidly progressive primary angiitis of central nervous system in a 17-year-old boy.

BACKGROUND: Childhood primary angiitis of the central nervous system (cPACNS) is an increasingly recognized inflammatory brain disease in children. CASE PRESENTATION: We present a case of a 17-year-old boy with recurrent ischemic events over a short time period. Diagnosis of angiography positive cPACNS was made based on neuroimaging findings while secondary causes or mimics of CNS vasculitis were meticulously excluded. The patient exhibited rapid deterioration of his condition with poor initial response to immunosuppressive treatment. CONCLUSIONS: Recognition of cPACNS remains a challenge because of rarity of disease, unexplained etiopathogenesis, protean clinical presentation, as well as lack of specific laboratory and neuroimaging markers.

Bilateral Supratentorial Subdural Hematomas after Craniotomy for Posterior Fossa Tumor Removal.

A 69-year-old man was admitted to the emergency department with headache and dizziness. He was submitted to brain computed tomography (CT) which showed a tumor in the right cerebellar hemisphere, findings which were subsequently confirmed with magnetic resonance imaging (MRI). He underwent a paramedian suboccipital craniotomy for removal of the mass. Histology confirmed the presence of a hemangiopericytoma. The patient was discharged 5 days postoperatively with improvement in his symptoms. Fifteen days later, he presented with gait difficulties. Clinical examination revealed positive Mingazzini sign on his left side. He was submitted to brain MRI which revealed bilateral subdural hematomas on late subacute stage with mass effect and midline shift caused by the largest on the right. The patient underwent burr hole evacuation of the right subdural hematoma. The postoperative CT showed evacuation of the right chronic subdural hematoma. Two days postoperatively, the patient's symptoms improved.

Frequent Benign, Nontraumatic, Noninflammatory Causes of Low Back Pain in Adolescents: MRI Findings.

INTRODUCTION: Low back pain (LBP) is common in children and adolescents. There are many factors that cause LBP, including structural disorders, degenerative changes, Scheuermann's disease, fractures, inflammation, and tumors. Magnetic Resonance Imaging is the gold standard for diagnosing spinal abnormalities and is mandatory when neurological symptoms exist. The study focuses on common MRI findings in adolescents with persistent LBP, without history of acute trauma or evidence of either inflammatory or rheumatic disease. MATERIALS AND METHODS: Eleven adolescents were submitted to thoracic and/or lumbar spine MRI due to persistent LBP. The protocol consisted of T1 WI, T2 WI, and T2 WI with FS, in the axial, sagittal, and coronal plane. RESULTS: MRI revealed structural abnormalities (scoliosis and kyphosis) in 4/11 (36.36%); disc abnormalities and endplate changes were found on 11/11 (100%). Typical Scheuermann's disease was found in 3/11 (27.27%). Endplate changes were severe in Scheuermann's patients and mild to moderate in the remaining 8/11 (72.72%). Kyphosis was in all cases secondary to Scheuermann's disease. Disk bulges and hernias were found in 8/11 (72.72%), all located in the lumbar spine. CONCLUSION: In adolescents with LBP, structural spinal disorders, degenerative changes, and Scheuermann's disease are commonly found on MRI; however, degenerative changes prevail.

Giant cell tumor of the tendon seath of the tendinous insertion in pes anserinus.

A 56-year-old woman with a palpable lump in the medial surface of her left knee was referred for diagnostic workup with magnetic resonance imaging. The lesion was pathogically confirmed to be a giant cell tumor of the tendon seath. The MR features of the lesion are presented.

Massive bilocular spinal cord intramedullary lipoma of the thoracic spine.

Spinal cord intramedullary lipomas are rare, comprising 2% of intramedullary tumours. They are more often associated with spinal dysraphism, while lipomas not associated with spinal dysraphism are even less frequent, accounting for 1% of cases. The pathogenesis of spinal cord intramedullary lipomas remains unclear. MRI is the gold standard for the evaluation of these lesions. We hereby present a case of a 37-year-old male, who underwent MRI due to spastic paraparesis. MRI revealed a bilocular, spinal cord intramedullary lesion at the level of T 2-T 5, with dilatation of the spinal canal and signal characteristics compatible with lipoma. There was no clear imaging evidence of spinal dysraphism. The patient underwent surgery and diagnosis was confirmed histopathologically.

OPTIMISATION OF PATIENT DOSE AND IMAGE QUALITY IN ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY: A PHANTOM-BASED EVALUATION.

A phantom-based study is presented aiming to optimise patient dose and image quality (IQ) in endoscopic retrograde cholangiopancreatography procedures, utilising a fluoroscopy system equipped with a flat panel detector. The patient thickness was simulated with various polymethyl methacrylate slabs, whilst IQ was evaluated using the Leeds test object. The main factors evaluated were phantom thickness, distance between phantom and detector, field of view and pulse rate. For all these factors, the dosemetric indices, entrance surface air kerma (ESAK) rate and ESAK per pulse, as well as the IQ parameters, signal-to-noise ratio and high contrast spatial resolution, were measured. Based on these measurements, the figure of merit (FOM) was estimated. The FOM and ESAK rate values indicated the optimum combination of the factors evaluated which could provide adequate clinical information, assuring minimum patient dose.