Colloid cyst

Findings

Head CT: A 7 mm diameter homogeneous hyperdense mass is present at the foramen of Monroe. There is no hydrocephalus or areas of hemorrhage.
Brain MRI: An approximately 7 mm in diameter homogeneous mass is identified within the anterior-superior third ventricle near the foramen of Monroe, slightly lateralizing to the right. It posteriorly displaces the anterior aspect of the internal cerebral veins and superiorly displaces the adjacent anterior septal veins, right more so than left. It demonstrates slight T1 shortening and appears isointense to the brain on FLAIR and fast spin-echo T2-weighted sequences. No definite contrast enhancement is identified. There is no suggestion of obstructive hydrocephalus.

Differential diagnosis:
- Colloid cyst
- Meningioma
- Ependymoma
- Choroid plexus papilloma


Diagnosis: Colloid cyst


Discussion

Colloid cysts are rare brain lesions that account for approximately 1-3% of primary intracranial tumors. The typical location is in the anterior superior third ventricle. Rare cases have been reported in the lateral ventricles, fourth ventricle, and even outside the ventricular system. Diagnoses usually occurs incidentally in adult patients. Very rarely diagnosed in children. Colloid cysts originate during the development of the nervous system from ectopic endodermal elements which migrate into the velum interpositum. These lesions are lined by cuboidal or stratified columnar epithelium and contain proteinaceous components. This lining accounts for the enhancement that is sometimes seen as in this case. The proteinaceous material is derived from the breakdown products and secretions of the epithelial cells.

In many patients, colloid cysts remain clinically silent. They enlarge slowly or stop growing, allowing a balance to develop between the production and absorption of CSF. Even with this slow growth some patients experience signs and symptoms of hydrocephalus due to the obstruction of the foramina of Monro. They experience headache, memory deficits, and nausea/vomiting. The headache is often positional because the foramina of Monro may only become obstructed in certain positions as the cyst is often somewhat mobile. Cases of sudden death have been reported. Although these lesions are benign, they are often surgically managed since the complication of obstructive hydrocephalus may be life threatening.

On CT scans, most are hyperdense to the brain although they are not calcified. Occasionally, they may be hypodense or isodense. The appearance on MRI is variable as well. Most lesions have high signal intensity on T1 and low signal intensity on T2, though they may vary from high to low intensity on both T1 and T2. Thin rim enhancement occasionally is seen as in this case.


Key Points

Typically arise at the anterior superior portion of the third ventricle
Hyperdense on CT and generally have high signal intensity on T1 and low intensity on T2
May obstruct the foramina of Mono, causing hydrocephalus
Associated with acute / severe / positional headache, and may result in sudden death.
Headache worsens by tilting patient's head forward, causing Foramen of Monro obstruction. This is called Brun phenomenon.

Multitalented

Did you know that Barack Obama has two Grammy Awards?

He's won Grammy's for 'Best Spoken Word Album' in 2006 and 2008.

Current Edition of Internet Journal of Radiology

Dear friends/readers

You all may be aware of the fact that i have taken over as the editor-in-chief Internet Jounral of Radiology, in 2008. The first edition of the journal with me as the anchor is now online and is open access to all. Link on your websites will be appreciated. Also feel free to forward this table of contents to any of your friends or colleagues whom you feel will enjoy the journal.

Seeking more support for all the readers in form of more and more quality submissions for the journal. We have a world class editorial team with prompt peer review process, a fast publication process We firmly believe in open access to the scientific publications, hence this journal is an open access journal.

The current edition is available here-
Internet Journal of Radiology
Volume 8 Number 1

Table of contents for your persual

Editorial
Radiology in today's flat world - Sumer K. Sethi.
A New Beginning - Sumer K. Sethi.

Original Articles
Role of three-phase contrast-enhanced multislice helical CT in evaluating resectability of pancreatic carcinoma - Emre Ergul, Erdal Ozgur Gozetlik.

Reviews
Radiologic Evaluation of the Stylohyoid Syndromes - Shamir O. Cawich, Peter, Michael Gardner, Eric Williams, Lisa Burnett.
Artefacts In Mammography: A Three year experience in a new teaching hospital. Pictorial Essay - Rachael Akinola, Oluwarotimi Akinola, Faosat Jinadu, Tope Akintomide, Peter Soeze, Omini Asuquo.
Journal Club - Sumer K. Sethi.

Case Reports
Radiology Case Quiz - Sumer K. Sethi.
Pneumosinus Dilatans of the Frontal Sinus - K. Saravanan, N. Saravanappa.
The Practice of Ottawa Ankle Rules in radiographs taken for acute ankle and midfoot injury - O. Nurul Akhmar, A.M. Ezane, N.A.R. Nik Hisamuddin, I.L. Shuaib.

Press Releases

Best Regards

Dr.Sumer K Sethi, MD
Consultant Radiologist ,VIMHANS
CEO-Teleradiology Providers http://teleradproviders.com/
Blog- Sumer's Radiology Site http://sumerdoc.blogspot.com/
Editor-in-chief, The Internet Journal of Radiology
Director, DAMS (Delhi Academy of Medical Sciences) http://www.damsdelhi.com/

Growing Up 1970s Style

It was the 1970s, and I miss those times.

Like most Filipino children growing up during the Martial Law years under the Marcos regime, I grew up a complacent child, learned early proper discipline, and enjoyed afternoons watching Sesame Street, a beloved program which is sometimes cut to give way to an impromptu Marcos speech. Back then, we as children understood what was authority, and we know how to keep quiet whenever someone older than us has something important to say.

Although our family disliked Marcos, we respected his authority, and my father forbade us to say anything against Marcos. My father knew that Marcos was a powerful man and we understood it. It would be inviting trouble to say anything against the dictator. Everyone seemed to be spying on everyone.

Right now I see how many children become so unruly that their parents become so frustrated disciplining them. I should say that I was still fortunate growing up as I did, respecting authority. Perhaps Marcos wasn't really so bad. Certainly he did a lot of bad things, but the discipline that he instilled in the minds of the people is admirable.

Which brings me to today's sad reality.

Nowadays, children are not so afraid o authorities. They have learned the word freedom, which is very dangerous. They hurl threats to authorities, to teachers, to parents. You spank a child and you can end up being sued in the Bantay Bata. These children will eventually grow up and then their own children will do the same to them. That is because they were not as disciplined as we were during our time. And so they just passed what they learned in childhood to their own children.

The new media of the internet and home videos contribute to the current degeneration of today's children. Some parents let their children use the internet not knowing that a lot of hazardous things are in store for their children to learn. Children today kill each other all over the internet, in dangerous games like Ragnarok, Diablo, and the like. In between they can watch porno, which is all over the internet. There is one Filipino 8 year old child discovered by his parents masturbating in front of the computer screen, watching hentai. Apparently, his favorite anime hero, Goku (of Dragonball Z) was featured in the movie having sex with Sailor Moon! Parents should be careful of giving their child gifts of laptops, cellphone, and mp4 as these can easily be downloaded with sex movies.

Back in the 1970s, our family owned a black and whit TV set called Zenith. It had dial knobs to change channels and volumes. On afternoons we watch Speedy Gonzales, Sesame Street, and endless reruns of black and white old tagalog movies. On evenings we watch Wild Wild West, Six Million Dollar Man, Starsky and Hutch, the Incredible Hulk and Charlie's Angels. I later learned that these series were all filmed in color and the reason why they appear black and white was that our TV was black and white...

The closest thing that I can ever come up to watching porno was when Gloria Diaz starred in the movie Pinakamagandang Hayop sa Balat ng Lupa, and it was shown on TV, and even the scene when she didn't have a bra was cut. To my dismay. All our neighbors were flocking to our house because we were one of the few who happened to own a TV set in the entire neighborhood.

I remember curfew. No one was allowed to loiter in the streets from 12 pm to 4 am. From that time on you can secretly look from the window through a small opening of the curtains, and you see a very quiet neighborhood. Every barrio was like a ghost town. Even the stray dogs were herded into the city pound. The vagrants had to stay out of the streets. The result was that the crime was lessened. Everyone was afraid of Marcos.

Now, I still think I'm fortunate growing up in the Martial Law years. It was a relatively peaceful time. And we respect our elders.

It was the 1970s, and I miss those times.

Right MCA thrombus leading to acute infarction

Findings

Figure 1: Noncontrast head CT demonstrates high attenuation within the right MCA corresponding to thrombus.
Figure 2, Figure 4, and Figure 6 : T2, FLAIR, and DWI images demonstrate high signal on all sequences, representing high water content (swelling, cytotoxic edema) and restricted diffusion.
Figure 3, Figure 5, and Figure 7 : T2, FLAIR, and DWI images, respectively, demonstrate hyperintensity in the region of infarct.


Diagnosis: Right MCA thrombus leading to acute infarction


Cerebrovascular accident (CVA), or stroke, is caused by disruption of blood flow to an area of the brain as the result of infarction or hemorrhage. Atherosclerosis as the primary cause, early diagnosis and intervention are critical to limit morbidity and mortality. CT can be unremarkable during the first few hours of acute ischemic stroke.

Early acute subtle findings include loss of gray/white differentiation (e.g. “insular ribbon” sign), effacement of cortical sulci and a hypodense area (secondary to cytotoxic edema) corresponding to a particular vascular distribution, which is the middle cerebral artery approximately 50% of the time. Less frequently, increased attenutation of an arterial segment indicating presence of thrombus may be identified (as in this case). Similar acute changes representing brain swelling are also noted on MR. Acute stroke manifests as areas of DWI hyperintensity within one to two hours. If contrast enhancement is utilized, intravascular enhancement is commonly seen during the first week. Typically noted at 1 to 3 days, enhancement of the involved vessel is thought to be due to slow flow or vasodilation leading to stasis of gadolinium. Thus, MR intravascular enhancement helps identify early strokes and dates them to less than 11 days old.

On the other hand, parenchymal enhancement typically begins after the first week when intravascular enhancement is waning and indicates a more subacute event.

T1 and DWI changes typically precede changes on T2 and FLAIR sequences which develop within hours of the ischemic event. T2 changes develop 6 to 12 hours postictus and result from increased water content in the infarcted tissue (cytotoxic edema). FLAIR allows heavy T2 weighting, suppressing free water signal from CSF, increasing the conspicuity and hyperintesity from ischemia.

In the chronic phase (> 30 days) further decrease in mass effect and eventual resolution of parenchymal enhancement is seen. Encephalomalacia and loss of enhancement are characteristic.

Radiology Grand Rounds-XXI

Here is a case of Spontaneous Spinal Epidural Hematoma for the Radiology Grand Rounds submitted by Dr MGK Murthy, Dr Sumer Sethi of Teleradiology Providers. Concept and Archive of the Radiology Grand Rounds is available at- Radiology Grand Rounds.

A 63 yr old judge by profession has suden pain while brushing teeth. he is a known case of renal failure with hameodialysis about a month back. MR shows large epidural hematoma in dorsolumbar region with cord edema. After excluding other known causes like, bleeding diathesis, tumour, trauma, it is possibly related to use of anticoagulants in haemodialysis. but can it coccur after one month is debatable. He has also renal ostedystrophy signs on MRI.

The etiological mechanism of spinal epidural haematoma still remains controversial. The spinal epidural venous plexus is postulated commonly to be the origin of the hematoma. Usually, a high intracavitary pressure induced by, for example, pregnancy increases the plexus pressure, and it finally brings about rupture. In these situations, the small spinal artery was reported to be responsible for the bleeding. Abnormal coagulability, atherosclerosis or mechanical compression by a spinal tumor further facilitate vessel rupture.

Hope you enjoyed this edition of Radiology Grand Rounds submissions are requested for the next Radiology Grand Rounds posted every month last sunday. If you interested in hosting any of the future issues contact me at sumerdoc-AT-yahoo-DOT-com.


Images Courtesy
Teleradiology Providers

Are we overestimating cancer risk from CT?

An interesting letter in NEJM, according to Maurice Tubiana "an excess of cancers has never been detected in laboratory animals or in humans for doses below 100 mSv. Computed tomographic (CT) scans deliver a radiation dose of about 20 mSv. After repeated x-ray examinations, induction of cancer has been observed only when the cumulative dose was above 500 mSv. In patients treated with radiotherapy, a threshold was reported for irradiation doses of 0.6 Sv delivered in 30 sessions. Overestimation of the risk may deprive patients of beneficial examinations. " and the debate continues...

Reference- Computed Tomography and Radiation ExposureN Engl J Med 2008 358: 850-853
[Full Text]

Radiology and Web 2.0

Do you also prefer to visit my site over places like e-medicine and medcyclopedia. Since regular google searches always sends to e-medicine, etc. Ben of radswiki has made a custom search engine that queries the radiology blogs, wikis, and social networks.

Check this out-

Radiology and web 2.0

Toxoplasmosis

Findings

Figure 1: Foci of vasogenic edema are appreciated in the left fronal lobe
Figure 2, Figure 3, Figure 4, and Figure 5: Diffusion, FLAIR, T2, and T1 weighted MR images respectively show vasogenic edema with an underlying ring lesion suspected.
Figure 6 and Figure 7: Post contrast T1 weighted axial and coronal images demonstrate a ring enhancing lesion with a relatively thin rim centered at the grey white junction with surrounding vasogenic edema.
Figure 8: Pulsed arterial spin labeled sequence that provides quantitative cerebral blood flow values shows decreased perfusion in the lesion.
Figure 9: Single voxel MRI spectroscopy obtained with a TE of 35 shows a dominant lipid peak at 1.3 ppm (yellow arrowhead) with depression of the normally expected metabolites including choline at 3.2 ppm, creatine at 3.0 ppm and N-Acetyl aspartate (NAA) at 2.0 ppm. This spectra is characteristic of toxoplasmosis and shows no characteristic features of a neoplastic process.

The patient was treated for toxoplasmosis and showed significant improvement in her mental status as well as interval decrease in the size and edema associated with the ring enhancing lesion.


Diagnosis: Toxoplasmosis


In the patient with HIV, a frequently encountered diagnostic dilemma is the ring enhancing lesion. On conventional MRI sequences in the immunocompromised patient, lymphoma and toxoplasmosis can have similar appearances. Historically nuclear medicine thallium or PET imaging studies have helped differentiate the two entities.

Toxoplasmosis and primary CNS lymphoma, the two most common etiologies of focally destructive brain lesions in AIDS, can share identical presentations clinically [headache, seizures, focal neurologic deficits] and radiologically [ring-enhancing lesion(s) with surrounding vasogenic edema on CT or MR]. Prognosis and treatment vary greatly; toxoplasmosis patients can respond dramatically to antibiotic therapy while lymphoma patients typically survive <1 year even when treated. Serology, polymerase chain reaction, SPECT and PET, response to treatment, and biopsy have been used to differentiate these entities. However, MR perfusion and spectroscopy are fast noninvasive ways to help differentiate these diseases and direct appropriate initial therapy in AIDS patients with acute focal neurologic deficits.

Perfusion analysis in enhancing areas of lymphoma demonstrates an increase in relative cerebral blood volume (CBV) and maximum perfusion, thought to be secondary to greater vascularity in active areas of tumor growth, while enhancing areas of toxoplasmosis demonstrate a decrease in CBV. Central areas of necrosis and surrounding vasogenic edema in both diseases typically show decreased CBV, secondary to avascularity in areas of necrosis and to vasoconstriction in surrounding edematous brain.

Spectroscopy in lymphoma demonstrates a markedly elevated choline peak in enhancing solid areas of tumor, with less pronounced increases in lactate and lipid. In contrast, spectroscopy in toxoplasmosis demonstrates marked elevation of lactate and lipid peaks with significant depression of normal brain metabolites. As with perfusion, necrotic areas of lymphoma and toxoplasmosis may demonstrate similar spectral patterns.

Historically, SPECT and PET have helped differentiate toxoplasmosis and lymphoma, demonstrating hypometabolic activity in the former and hypermetabolic activity in the latter. However, MR perfusion and spectroscopy have demonstrated congruent results with the capability of evaluating the entire brain at once with higher spatial resolution, avoiding additional contrast and radioactivity, and adding only a few minutes to the MR acquisition time.

Now PACS by Microsoft

According to the website- The Microsoft Amalga family of Enterprise Health Systems is built on Microsoft technology, offering a comprehensive range of solutions to meet the needs of health enterprise. Amalga is a "Unified Intelligence System" for healthcare organisations that includes a HIS (Hospital Information System) "built around an Electronic Medical Record (EMR) that includes complete patient and bed management, laboratory, Medication Management, Radiology Information System/Picture Archiving and Communication System (RIS/PACS), pathology, financial accounting, materials management, and human resource systems. Sounds Interesting...

Hat Tip- Dr Dalai's Blog

Teleradiology Providers

Please Come Back Later..I'm Sick

Just as everyone is having a great time celebrating Valentines in classy restaurants and motels, I was suffering from the ravages of flu and tonsilitis.

It always starts with a sneeze....Actually I really liked to sneeze because it feels so good. But to sneeze three or four times in succession is a different story. I begin to feel irritated. Especially when I start to sneeze and it would not push through. I try to rest for a while, unplugging my pc (which is the easiest way to turn it off), laying my back on the bed, closing my eyes, and sleep.

Then while sleeping, the malevolent army of flu virus begins to invade my body, wreaking havoc on my entire system. A weakening of my body is a usual sign of this, a general feeling of malaise, a sign that war is going on inside my body, my antibodies against the foreign invaders.

My antibodies stage a heroic defense to prevent the flu virus from overcoming my system. This war will go on for days.

While asleep, I dream a lot of strange things. I dream I was being pushed to the ground by some unknown force. And then I dream of going round and round until I get a headache. Strange. I realize that sick people really dream a lot of weird things.

I wake up at three in the morning, feeling weak. I have a fever. My temperature is 40. I am shivering from cold. Tears welled from my eyes because of the pain.

Right now, I have taken some pain relievers to reduce the pain in my throat, and to reduce my fever. I know I will get better in a few days. But not yet now. I am still suffering.

Four days now.

Multiple myeloma with extramedullary plasmacytomas

Findings

Figure 1: Axial section from a non-contrast head CT at the level of the orbits shows an oval-shaped soft tissue mass involving the right lateral rectus muscle consistent with an extramedullary plasmocytoma.
Figure 3, Figure 4, and Figure 5: There are bifrontal lytic bone lesions with soft tissue components consistent with plasmacytomas as well as additional lytic lesions in the calvarium.
Single AP view of the CXR (not showed) shows a Mediport in place. There are multiple old rib fractures as well as an old fracture of the right clavicle.


Diagnosis: Multiple myeloma with extramedullary plasmacytomas


Multiple myeloma is characterized by malignant single clone of plasma cells with a wide spectrum of manifestations. The malignant clone of plasma cells secretes malignant paraprotein (heavy and/or light chain immunoglobulin) which in turn leads to a variety of clinical consequences. The peak incidence of multiple myeloma is between 50-60 years of age. The pathophysiology of myeloma is diverse. Over proliferation of plasma cells may hinder production of normal marrow elements resulting in anemia, thrombocytopenia and leukopenia. There is impaired humoral immunity secondary to an inadequate complement of antibodies. Overproduction of clonal antibodies leads to hyperviscosity, amyloidosis and renal failure. Plasma cell proliferation may result in soft tissue tumors (plasmacytomas) or lytic lesions within bone producing pain, pathologic fractures and hypercalcemia.

The diagnosis of multiple myeloma rests on three clinical criteria: (1) M-protein in the serum and/or urine. Electrophoresis of the serum and/or urine reveals increased monoclonal immunoglobulin in the blood or light chains in the urine. Paraprotein levels directly correlate to tumor burden (2) Clonal bone marrow plasma cells or plasmacytoma (3) Related organ or tissue impairment (hypercalcemia, renal insufficiency, anemia, or lytic bone lesions). Myeloma may have a variety of presentations in the skeleton: a permeative pattern, purely lytic lesions (as seen in this case), or as a bubbly lytic lesion i.e. medullary plasmacytoma. Because the solitary bony lesions of myeloma are purely lytic, they may not be conspicuous on bone scan. Skeletal lesions in myeloma involve the hematopoetic axial skeleton i.e. skull, spine and pelvis.

Plasmacytomas are masses of clonal plasma cells involving the bone (medullary) or soft tissue (extramedullary). These entities can be found independent of myeloma, however, medullary plasmacytomas progress to myeloma in 50-60% of patients while the extramedullary variety progresses to myeloma in 11-30% of patients. Plasmacytomas may precede clinical evidence of myeloma by 3-5 years. Medullary plasmacytomas arise from the bone marrow. The most common presentation of medullary plasmacytomas is pain related to bony destruction. Medullary plasmacytomas may present as solitary lytic lesions with a narrow zone of transition on plain radiographs. Rarely, they present as a lucent lesion of bone resembling aneurysmal bone cyst or giant cell tumor. Sclerotic appearing plasmacytomas are associated with POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy and skin changes). On magnetic resonance imaging, medullary plasmacytomas are low in signal on T1 and high in signal on T2 weighted-images.

Extramedullary plasmacytomas arise from submucosal plasma cells. Eighty percent of extramedullary plasmacytomas occur in the head and neck. Involvement of the nasophayrnx and paranasal sinuses is common with most symptoms related to tumor size and location. Extramedullary plasmacytomas appear as nonspecific soft tissue density on imaging studies. Because of submucosal growth, deep biopsy, open biopsy or excision is necessary for histopathologic examination. Other clinical features of myeloma must be excluded before making the diagnosis of solitary extramedullary plasmacytoma. There are three clinical stages of extramedullary plasmacytoma. Stage I is local disease. Stage II disease is characterized by regional lymph node spread or bony erosion. Stage III represents disseminated disease (including bony metastases) which carries a better prognosis then multiple myeloma. Primary treatment of symptomatic plasmacytomas is radiotherapy. Recurrence is common for which additional treatment with surgery or chemotherapy may be considered.

Baastrup’s disease

Findings

Pseudo-articulation and close approximation of multiple hypertrophic lumbar spinous processes. Associated sclerosis and degenerative spurring. Vertebral compression deformities and vaccuum disks with prior L1 and L4 vertebroplasty.


Diagnosis: Baastrup’s disease


Key points

Baastrup's sign, aka "Kissing Spine", and many other synonyms including: Arthrosis interspinosa, diarthrosis interspinosa, kissing osteophytes, kissing spinous disease, osteoarthrosis processus spinosi vertebrarum lumbalum, osteoarthrosis interspinalis.
Hypertrophy of spinous processes of adjacent vertebral bodies in close approximation or actual contact; i.e., arthritic joints between the spinous processes.
Joints undergo reactive sclerosis/degenerative change, including formation of degenerative cysts as seen in this case.
Etiology uncertain, may be related to excessive lordosis with degeneration of intervening ligaments.
Can cause low back pain; originally described as "pain in the back when standing erect which is relieved by bending forward".
Can be associated with interspinous bursal fluid, which can extend into posterocentral epidural space and cause posterior compression of the thecal sac.
Named for Danish radiologist Christian Baastrup (1885-1950).

Floor of the mouth abscess causing early symptoms of Ludwig angina

Findings

Figure 1: Contrast enhanced axial CT at the level of the hyoid bone demonstrates complex cystic mass with peripheral rim enhancement and adjacent soft tissue reticulation.
Figure 2: Axial CT in bone window demonstrating the left mandibular molar dental extraction site.

Differential diagnosis:
- Branchial cleft cyst
- Neoplasm (squamous cell carcinoma)
- Cystic hygroma
- Dermoid
- Thyroglossal duct cyst
- Laryngocele
- Abscess
- Necrotic node (metastasis)
- Ranula


Diagnosis: Floor of the mouth abscess causing early symptoms of Ludwig angina


In a case of suspected oral cavity infection, the role of imaging is to evaluate the integrity of the airway and to document the presence of gas forming organisms, underlying dental infection, and possibly drainable neck abscess. Reactive or suppurative adenopathy involving the submandibular and submental nodes is commonly seen in association with oral cavity infections. As these nodes receive drainage from the chin, floor of the mouth, and the tongue, foci of infection within these regions should be sought.

Before the antibiotic era, infections at the floor of the mouth dissected inferiorly along the fascial planes into the mediastinum. Ludwig angina is a feared complication of abscess at the floor of the mouth. Ludwig angina is characterized by swelling from a rapidly spreading cellulitis of the sublingual, submental, and submandibular spaces with elevation and edema of the tongue, drooling, potentially leading to airway obstruction. The condition is odontogenic in 90% of cases and arises from the second and third mandibular molars in 75% of cases.

In this case, the patient had undergone left mandibular molar extraction two weeks prior to this presentation. She presented to the ED with mild intermittent airway discomfort and was admitted following the CT. During the incision and drainage in the operating room, the abscess was found to be in direct connection with the mandibular extraction site as the surgeon was able to express pus in the mouth by compressing the neck abscess from outside. Although this case presented early and was treated successfully, airway compromise is the leading cause of death in Ludwig angina.

Supratentorial Glioblatoma Multiforme with spinal secondaries ( a rare case report)

The tendency of the GBM to spread via the CSF is well documented. This patient was operated for supratentorial GBM which was histologically proven. Following which he developed lower limb weakness. Pathological diagnosis was confirmed to be spinal metastasis of GBM. GBM may spread via the white matter tracts or via CSF. Awareness of this condition helps in suspecting this whenever a patient of GBM presents with radiculopathy or myelopathy.

Case By Dr Sumer Sethi, MD

Teleradiology Providers

Nobody Will Care

I know that none of you guys will find this interesting, but there is currently a gap of 11.06 points between the number one and number two golfer in the world, Tiger Woods (20.07 points) and Phil Mickelson (9.01 points).

This means that the largest gap between the number two golfer and all the other golfers in the world is at most 9.01 points.

So at this point in time, there is a bigger gap between the number one and number two golfers in the world, then there is between the number two golfer in the world and all other golfers in the world!

Internet Journal Of Radiology

I would like to thank Internet Scientific Publications and Dr Oliver Wenker for giving me this opportunity to be the "Editor-in-Chief" of the Internet Journal of Radiology. This journal is an Open-access journal, which means Every peer-reviewed research article appearing in this journal is 'open access', or universally and freely accessible via the Internet.

Anybody who would like to be part of the editorial process are requested to send me an email. If reviewers are important, authors are more so. Without articles, there is no journal. We welcome all publications related to Radiology including Case reports, Original papers, Letter to editors regarding previous publications, Review articles and pictorial essay. Papers on non-traditional subjects like computers in radiology, role of internet and web 2.0 are also welcome.

Dr Sumer K Sethi, MD
Editor-in-chief, The Internet Journal of Radiology TM ISSN: 1528-8404
Sr Consultant Radiologist VIMHANS, Delhi
CEO-Teleradiology Providers Author- Sumer's Radiology Site

Orbital cellulitis and abscess secondary to dacryocystitis

Findings

Right sided preseptal soft tissue inflammation with rim enhancing preseptal and extraconal fluid collections. No definitive evidence of intraconal spread of infection, extension to the orbital apex or adjacent bony erosion.

Differential Diagnosis:
- Cellulitis with abscess
- Subperiosteal abscess
- Ethmoid mucocele
- Dacryocystocele
- Congenital/Developmental lesions: lymphangioma, dermoid cyst
- Subperiosteal hematoma
- Orbital pseudotumor
- Orbital rhabdomyosarcoma


Diagnosis: Orbital cellulitis and abscess secondary to dacryocystitis


Key points

Dacryocystitis occurs secondary to stagnation of fluid within the lacrimal sac resulting in bacterial overgrowth.
Acute dacryocystitis commonly presents as tender preseptal cellulitis and is treated with antibiotics while chronic cases usually present as painless purulent reflux from the lacrimal sac and is treated with definitive dacryocystorhinostomy.
Acute dacryocystitis most often results in preseptal cellulitis; however, orbital extension with abscess is also a known complication which can result in severe visual compromise.


Key radiologic features

MRI and CT are imaging modalities of choice, with MRI preferred when evaluating for possible intra-cranial extension.
Edema of the orbital soft tissues.
Low density fluid collection with rim enhancement.
Associated myositis represented by swelling and/or abnormal enhancement of the extra-ocular musculature.

Nasopharyngeal teratoma

Findings

Figure 1 and Figure 2: Centered within the nasopharynx, there is a large heterogeneous, soft tissue mass with associated calcifications. There is no associated bony destruction or intra-cranial extension.
Figure 3, Figure 4, and Figure 5: MRI of the brain reveals a large complex mass with sold and fatty areas centered within the nasopharynx. Areas of low signal within the mass correspond to calcifications visualized on CT images. There in no intracranial extension or visualized intracranial abnormality. A normal pituitary gland and sella turcica can be appreciated on the sagittal image (Figure 3).


Diagnosis: Nasopharyngeal teratoma


Neonatal teratomas are very rare congenital tumors which are formed from cells derived from all three embryonic germ cell layers. The incidence of neonatal teratomas is between 1:20,000 and 1:80,000 live births. Most occur in the sacrococcygeal region and only 5% are found in the head and neck region, specifically the cervical region followed by the nasopharynx. They can be associated with a cleft palate, intracranial abnormalities including hemicrania and anencephaly, other head and neck anomalies, diaphragmatic hernia and renal and vertebral anomalies.

Nasopharyngeal teratomas most commonly present with difficulties in swallowing and obstructive respiratory distress. The size and location serve as the major causes of morbidity and mortality. Rapid airway stabilization, including endotracheal intubation, cricothyrotomy or tracheotomy, is crucial in the management of these patients. After securing the airway, imaging is very useful to help differentiate this tumor from other masses. Ultimately surgical excision is the mode of treatment. These tumors are often encapsulated or pseudoencapsulated which yields excellent surgical prognosis.

The differential diagnosis for neonatal nasopharyngeal lesions is extensive and includes: teratoma, dermoid, craniopharyngioma, encephalocele, cystic hygroma, rhabdomyoscarcoma, hemangioma, lipoma, chordoma, neurofibroma, Rathke’s pouch and sarcoma botryoides.

Prenatal ultrasound can be useful in identifying a nasopharyngeal teratoma when there are signs of polyhydramnios secondary to pharyngeal obstruction. On CT and MR, these tumors are heterogeneous masses with cystic and solid components and in some cases associated calcifications. CT and MR are also important in helping to identify vascularity and intracranial extension. There may be signs of a long-standing lesion with mass effect on adjacent structures, especially distortion of the ipsilateral hemimandible and pterygoid plates.

Routine follow up is necessary for complete management. Patients should be evaluated for recurrence by physical examination and flexible nasopharyngoscopy, CT or MRI when indicated.

Dural metastasis

Additional clinical history: The patient has a history of breast cancer.


Findings

Axial FLAIR, axial T1 W pre- and post-contrast and coronal T1 W post-contrast images through the posterior fossa demonstrate an enhancing primarily extra axial mass which appears dural-based with possible extension into the underlyingcerebellar parenchyma. There was also regional mass effect resulting in acute hydrocephalic changes, inferior tonsillar herniation and effacement of the pontomedullary junction.

Differential Diagnosis:
- Meningioma
- Schwannoma
- Sarcoidosis
- Primary meningeal lymphoma
- Leptomeningeal metastases
- Acute cerebellitis
- Dysplastic cerebellar gangliocytoma


Diagnosis: Metastatic breast cancer


Key points (Posterior fossa extra-axial metastatic disease)

Adult population.
Clinical presentation may include headache, 7th and 8th nerve palsies, polycranial neuropathy, vertigo.
Most common tumors to metastasize to this area include breast, lung and melanoma.
Diagnosed with increasing frequency due to improved cancer survival.
Poor prognosis.


Key radiologic features

Enhancing lesion with meningeal and/or calvarial destruction.
Smooth thickening, nodularity, loculation, lobulation, fungating masses.
May extend into the IAC resembling acoustic tumor.

Optical CT mammography

This is a new imaging technology using laser computed-tomography (CT) to aid in the detection and management of breast cancer. CT laser mammography is designed to be used in conjunction with mammography. It reveals information about blood distribution in the breast and may visualize the process of angiogenesis, which usually accompanies tumor growth.

Reference- Medical Imaging International

Thomas Guide

Did you know that there is an intentional mistake on every page of the Thomas Guide Maps that only the Rand McNally and Thomas Guide company knows about? They place this intentional mistake on each page as a copyright. The fake roads are all reported to be less than a block, and are typically named to resemble the surrounding streets in the area.

ABBA

Another Did You Know! Did you know that musical powerhouse ABBA, the Swedish group that broke up in 1983, turned down an offer of $1 BILLION to reunite in 2003?

If you've never had the opportunity to see an ABBA music video, check these out! The videos are horrible, but their music is the best!

Bananas

Last post of the day..... Mike Seaver (Kirk Cameron) has become a believer in god after being a "long time atheist". This is a clip of Kirk Cameron sitting with his "partner in christ", proving the existence of god with an "atheist's worst nightmare". It's only a minute long, but you'll be able to make about a thousand jokes comparing it to gay porn.



And if you have a lot of time on your hands, you can find a debate on Nightline with Kirk Cameron and his 'partner in christ', and two atheists.

New York Bar

Brady's Bar in New York is changing their name to support their recent Super Bowl MVP.