What Goes Around Comes Around

Check out the freehand circle drawing champion Alex Overwijk. He can draw a perfect freehand circle, one meter in diameter, in less than a second. He's a freak of nature!

Housemaid's Knee-MRI

Note the Prepatellar bursitis on MRI knee.

It's All The Same In The End

He's "upsetting" Iran and North Korea by making "insensitive" comments and meddling in their business....

Wait a minute!?!?!?!?!?! AAAAAAAHHHHHHH!!!!! They're the same person!!!!

Lymphangioma of spinal canal

Findings

Homogeneously enhancing T1 isointense / T2 hyper intense well-defined extramedullary extradural lesion posterior to the mid-thoracic thecal sac. The lesion extends from the T8 superior endplate through T9 inferior endplate levels. Minimal posterior deformity the dorsal aspect of the thecal sac. No associated significant spinal canal stenosis or neuroforaminal compromise. No evidence of adjacent osseous invasion.

Differential diagnosis:
- Meningioma
- Metastasis
- Extramedullary hematopoiesis
- Lymphoma
- Lymphangioma


Diagnosis: Lymphangioma of spinal canal


Key points

Lymphatic malformation, benign hamartomatous, proliferation of lymph vessels.
Incidence estimated to be around 1 per 10 000 live births.
Fluid filled sacs that result from blockage of the lymphatic system.
Often associated with karyotype abnormalities such as Turner syndrome.
Usually divided into 2 major groups based on depth and size.
Superficial vesicles are called lymphangioma circumscriptum.
More deep-seated group includes cavernous lymphangioma and cystic hygroma, with many categorizing cystic hygroma as a variant of cavernous lymphangioma.
Most common sites are the head and the neck (75%), followed by the proximal extremities, the buttocks, and the trunk. However, they can be found anywhere, including the intestines, the pancreas, the mesentery, and the spine.
Typically seen in infants, (90%) are either evident at birth or become evident before age 2 years.
Rare in adults, the etiology in the adult population may be traumatic rather than congenital.

MR Findings:
- MRI can define the degree of involvement and the entire anatomy of the lesion.
- MRI can help prevent unnecessary extensive, incomplete surgical resection, because of the association with a high recurrence rate.

CT Findings:
- Low density, often poorly-circumscribed cystic mass, fluid-fluid levels may be seen in multi-loculated lesions.
- No significant enhancement in cystic uni- or multilocular neck mass.
- Wall is imperceptible & does not enhance if no infection.
- US can diagnose lymphangiomas, but MR or CT are usually necessary to map their entire extent.

Treatment:
- Surgical: preferred treatment is complete surgical excision if feasible. Image guided sclerosis with alcohol.
- Nonsurgical: No proven medical care for lymphangiomas exists, not responsive to radiation therapy or steroids.

'Hue' Is It?

Here's another game! The only reason I'm posting it is because I scored so well.

I've been sitting here, for what seems like forever (three minutes), trying to think of a witty title for this post. That's all I was able to come up with. I'm dissapointed.

The game is an online version of the 'Munsell Hue Test', and is used to determine your ability to distinguish subtle differences in color. The object of the game is to drag and drop the colors in each row to arrange them by hue order. The first and last color chips are fixed. To receive your score, click on "Score Test" at the bottom of the page when you're done.

Anyway, I scored an 8! The lower the score the better. They say that the lowest score possible is 0, but when I got my test score, they told me the lowest score for my age range was -4. Also, I tried clicking the "Score Test" button on the bottom of the page without moving any of the tiles, and I scored 968.

Click on the picture of the game to play....

Diastematomyelia-MRI

Note the bony spur and two spinal canals.
Teleradiology Providers

Cryptic Canvas

A while back, I blogged about a dark M&M's game, where the player would have to identify 5o horror movies cryptically displayed in a piece of art.

Now, to celebrate Empire Magazine's 20th Birthday, they've created their own 'Cryptic Canvas'. Can you identify all 50 movies?

Here are a few hints.....

1. The movies are all from the last 20 years...
2. There are no movies titled 'Kung-Fu Cheerleaders' or 'Car Eating Dragon'
3. Sometimes it helps to put the word 'the' in front of the movie title.
4. If you don't want to enter an e-mail address to save your results, copy and paste 'idontwantto@aol.com' into the box.

Click on the 'Cryptic Canvas' below to go to the site....

Blech

I don't care if he stays in hotels, this man is crazy.

Watsonville

I was able to travel to the beautiful city of Watsonville to inspect a property last week. Here are a few photos from my journey. While I was driving, the Martinelli's Apple Cider factory caught my eye. I had no idea that Martinelli's Apple Cider was made in this little town.


It's not a very big factory. I would have thought that the factory would be huge! But it's just a small factory, across the street from a high school.


Did you toast New Year's Eve with Martinelli's Apple Cider when you were a kid? I vaguely remember drinking Martinelli's Apple Cider while the adults all had their libations.


This shocked me.... I tried calling the family center at the park where Sotomayor Field is located, they have no idea who it was named for.


I'm just going to make up a story.... Supreme Court Nominee Sonia Sotomayor was the Pele of the Bronx, so they named the park after her.... There you go, I could think of nothing funny to say about Sonia Sotomayor.


Finally, here's the vicious beast that was out of his cage when we inspected his home.

Sleepover

Alleen, Noah's cousin, is spending the night tonight. We all had a really fun evening. We ate some pizza, watched Strawberry Shortcake and Curious George, went to the park, and had strawberries for dessert.

Now it's midnight, and I'm sleeping in Noah's bunk bed.

It's really an interesting story about how this came to be... Well, it'll be interesting to the people who read this blog.

Noah and Alleen were tucked into Noah's bunk bed, I read them a couple bedtime stories, then we shut everything down (except for the hall light). Colleen and I went to our room and got ready, until we heard Noah and Alleen talking about how Noah was scared....

Colleen was already in bed, so I went and sat on the floor and asked if they wanted to hear a bedtime song. They both enthusiastically agreed to a bedtime song, however, Noah demanded that he get to sing 'Twinkle, Twinkle, Little Star' before I get a chance to sing anything.

After he finished, after starting over three times, we all decided that they'd like to hear the 'Winnie the Pooh' song. Halfway through, Noah wrapped his arms around my neck and said 'I want to sleep in Mommy and Daddy's bed.' Alleen quickly said 'I'm going with him, I don't want to sleep alone.'

Sounds good to me, I'll go ahead and trade, Noah and Alleen would sleep in my bed, and I'll sleep in Noah's bed.

Ten minutes later, my name is called and my bedtime story services are needed yet again.... So I laid at the end of the bed and asked what kind of story they'd like to hear. Alleen asked for a George Washington story. Of course I had a stack of George Washington stories handy.... If you've never heard the story about how George Washington loved trees, you've really been missing out! He loved them so much, that his mother told him that if he loved trees so much, he should eat one. So he went for a walk in the forest, found the perfect tree, and ate it. After he ate it, he noticed his teeth had turned into wood, and that's how they came up with the famous tongue twister:

How much wood could a wood-George george if a wood-George could george wood?

A wood-George could george as much wood, as a wood-George could george, if a Wood-George could george wood.

That story earned me the title of the "funniest person in all the land". After that story, they were right on the edge of slumber, so the question was posed again, "Would you like to hear another story?"

"Why don't you tell us another story about George Washington?" Alleen says. So I go back to my 'infinite' supply of George Washington stories, and tell them about how George Washington helped make the United States what they are today, until they fell asleep.

So now it's midnight, and I'm all alone in Noah's bed. All alone.....

Wonderland

Check these out! They're publicity shots from the live action Walt Disney film 'Alice in Wonderland' directed by Tim Burton. Tim Burton and Johnny Depp are a winning combination! These pictures are beautiful. I'm soooooo excited about this movie. By the way, if you click on the photos, you can see larger versions of them....


Mia Wasikowska as Alice


Johnny Depp as The Mad Hatter


Helena Bonham Carter as The Red Queen


Anne Hathaway as The White Queen


Matt Lucas as Tweedledee and Tweedledum

Ruptured spinal dermoid with chemical meningitis

Findings

Figure 1: Sagittal T1W image of the cervicodorsal spine shows multiple hyperintense foci in the subarachnoid space suggestive of fat deposition from dermoid rupture.
Figure 2 and Figure 3: Sagittal T1W and T2W images reveal a heterogeneous hyperintense mass expanding the lower spinal cord and conus medullaris.
Figure 4 and Figure 4: Axial T1W images demonstrate hyperintense signal within the central canal.
Figure 6 and Figure 7: Axial T1W images of brain show fat droplets, seen as hyperintense foci in the peri-mesencephalic cistern and in the frontal horn of left lateral ventricle.

Differential diagnosis
- Spinal dermoid
- Teratomas
- Lipomas

Differential diagnosis of brain lesions that appear hyperintense on T1W images on brain MRI are as follows:
- Lesions with hemorrhagic components (such as infarct, encephalitis, intraparenchymal hematoma, cortical contusion, diffuse axonal injury, subarachnoid hemorrhage, subdural and epidural hematoma, intraventricular hemorrhage, vascular malformation and aneurysm, and hemorrhagic neoplasm)
- Protein-containing lesions (such as colloid cysts, craniopharyngiomas, Rathke's cleft cysts and atypical epidermoids)
- Lesions with fatty components (such as lipoma, dermoid and lipomatous meningioma)
- Melanin-containing lesions (such as metastasis from melanoma and leptomeningeal melanosis)
- Lesions with calcification or ossification (such as endocrine-metabolic disorder, calcified neoplasm, infection, and dural osteoma)
- Lesions with other mineral accumulation (such as acquired hepatocerebral degeneration and Wilson disease)
- Miscellaneous group (which includes ectopic neurohypophysis, chronic stages of multiple sclerosis and neurofibromatosis type I)


Diagnosis: Ruptured spinal dermoid with chemical meningitis


A spinal dermoid is a rare, benign, slow-growing, dysontogenetic tumor arising from the inclusion of ectopic embryonic rests of the ectoderm and mesoderm within the spinal canal at the time of neural tube closure between the 3rd and the 5th week of fetal life. Several causes including spontaneous, iatrogenic or traumatic rupture have been reported to result in dissemination of lipid material from the dermoid tumours into the subarachnoid space or ventricles. Intra-spinal dermoids account for approximately 1–2% of intra-spinal tumors and tend to extend to the subarchnoid space, however there is no communication between the cyst and the subarchnoid space. They occur predominantly in the lumbosacral region and rarely in the cervicothoracic region. They show a slight male predominance, and most reveal themselves during the second and third decades.

Pathologically, spinal dermoids have a thick wall covered with stratified squamous epithelium containing dermal appendages such as hair, sebaceous glands and sweat glands and less commonly, teeth and nails. Dermoid tumours commonly have areas of calcification. Their rupture and spread is a rare event, which may be asymptomatic or may present acutely as chemical meningitis. The exact incidence of rupture of spinal dermoids is not known. Cholesterol, which is the most irritating element of the dermoid excites an inflammatory/ granulomatous meningeal reaction.

Spinal dermoids appear as variegated, space-occupying lesions showing a heterogeneous signal on T2-weighted MRI due to the different components within the cyst. These have high protein-containing fluid and thereby appear brighter than CSF on T1-weighted images. The high lipid content also gives a characteristic hyperintense signal on T1-weighted spin-echo images.

In conclusion, radiologists need to be aware that whenever a diagnosis of intra-spinal dermoid is suggested, it is essential to screen the entire neural axis to look for possible rupture and CSF spread. MRI is the imaging modality of choice.

Father's Day Card

Ok, so here it is, let me walk you through it.

As you can see, Noah wrote 'HAPPY' really well at the top of the card. 'FATHERS' is a little out of order, but still clear. And 'DAY' is clear in the middle of the card, right above the picture of me.

Here's the back of the card. You can see the picture of Noah, the number 3 (which is how old he is) on the left hand side of the picture, and his signature on the right side of the picture.

Finally, you open the card, and find two large pictures of me. It made me feel pretty important!

Do You Have A Better Idea?

"To those who simply criticize without offering new ideas of their own,

I have to ask,

What's your answer?"

Barack Obama

Father's Day

I hope everyone had a wonderful Father's Day. Noah and I had a wonderful day! We took mommy with us to see "UP"! What a fantastic movie! The 3D glasses we were wearing helped hide the tears....

I got a beautiful card from Noah that I'll try to post pictures of later on Noah's Notables.

By the way, 'Boardwalk Fries'.... I have a bone to pick with you.... Do not send advertisements to my home stating that you will be opening on June 20, only to still have not opened on June 21! You owe me fries! You are a murderer of love!

Ok, to finish this up, I'm going to send you to the site of a game designer that came up with a clever way of notifying his employer and fellow employees that he was leaving his job. Click on the banner below to see how he used Mario let them know!

Spinal metastatic disease-MRI

Primary sources for spinal metastatic disease include the following: Lung (31%), Breast (24%), GI (9%), Prostate (8%), Lymphoma (6%), Melanoma (4%), Unknown (2%), Kidney (1%), Others including multiple myeloma (13%). Time relation between primary and spinal metastases vary according to the site and nature of the primary. Spread from primary tumors is mainly by the arterial route via nutrient artery. Retrograde spread through the Batson plexus during Valsalva maneuver has been postulated. Direct invasion through the intervertebral foramina also can occur.

Multiple Sclerosis-MRI

Multiple discrete variable sized ovoid perpendicularly directed T2W and FLAIR hyperintense lesions (plaques), appearing iso-hypointense on T1W images and hyperintense on T2W images involving bilateral periventricular and subcortical white matter regions, including the calloso-septal interface. 35 year old female, case reported by Teleradiology Providers

Aortic Aneurysm-CT

CT image of a descending aortic aneurysm.

Ooooh..... A Hot Lips Phone!

A couple of weeks ago I posted a blog about the State of California attempting to sell the Orange County Fairgrounds and other large state owned landmarks for a large sum of money to close the budget gap. Maybe, they should do an internal investigation to find out where they're spending money.

Officials in Los Angeles County have found more than 8,000 phone lines, that cost the county approximately $1.5 million annually, that have been abandoned! Auditors, who are only halfway through their search, say the number of abandoned phone lines may top 16,000, totaling approximately $3 million a year in phone bills!

I wonder how many people we pay to sit in an office to do nothing all day..... Ha Ha Ha Colleen! Very funny! I actually do work in my office!

No Fly Zone

Well, we can't say 'Oh, that Barack Obama, he wouldn't hurt a fly!' anymore....

He wrecked that fly!



And since we have a young hip president.... You know what that means! Oh, you don't? Well, I'll tell you! REMIX!!!!!

Lymphocytic hypophysitis

Findings

Figure 1: Thickened pituitary infundibulum.
Figure 2 and Figure 3: Enhancing thickened pituitary infundibulum.


Diagnosis: Lymphocytic hypophysitis


Lymphocytic hypophysitis is an inflammatory lesion of the pituitary gland characterized by lymphocytic infiltration. The disease was first recognized in 1962 by Goudie and Pinkerton. The disease is rare, with a striking female predominance (approximately 9:1). As of 1997, only six cases had been diagnosed in men; however, definitive diagnosis requires pathologic correlation either through surgery or autopsy. There is a predilection for the disease during pregnancy and the postpartum period.

Radiologically, the disease is characterized by homogeneously enhancing pituitary mass with infundibular thickening. This is often difficult to distinguish from an atypically enhancing macroadenoma; however, the finding of dural enhancement or extrapituitary involvement within the subarachnoid space can favor the diagnosis of lymphocytic hypophysitis.

Clinically patients present with either partial/total hypopituitarism or symptoms related to mass effect. Treatment consists of corticosteroids with replacement of any deficient hormones.

Haglund's Syndrome

Haglund syndrome is a common cause of posterior heel pain, characterized clinically by a painful soft-tissue swelling at the level of the Achilles tendon insertion. On the lateral heel radiograph the syndrome is characterized by a prominent calcaneal bursal projection, retrocalcaneal bursitis, thickening of the Achilles tendon, and a convexity of the superficial soft tissues at the level of the Achilles tendon insertion, a “pump-bump.

Reported by- Teleradiology Providers

Can You Guess This TV Theme? #22 - Answer

Who would have thought that twins Brenda and Brandon Walsh, played by Shannen Doherty and Jason Priestly, would have fit in so well when they moved from Minnesota to Beverly Hills, California.

With Dylan McKay, Steve Sanders, and David Silver, played by Luke Perry, Ian Ziering and Brian Austin Green respectively, and Kelly Taylor, Donna Martin and Andrea Zuckerman, played by Jennie Garth, Tori Spelling and Gabrielle Carteris respectively, the show was on the air for ten years.

Do you remember that time that Dylan got married to the daughter of the mob boss that was trying to kill Dylan's father..... And the mob boss wasn't comfortable with their marriage, and was going to kill Dylan..... So he put a hit out on Dylan, but the daughter of the mob boss was mistakenly shot and killed when she was driving Dylan's car with her head covered with the hood of a rain coat? I'm sorry, did I ruin it for you?

Did you know that the show's creator, Darren Starr, is from Potomac, Maryland. The show was originally titled 'Potomac 20854', but was changed later to a more recognizable Beverly Hills?

And that Kelly Taylor, Donna Martin, Steve Sanders and David Silver were the only series regulars through all ten seasons? Nat Bussichio, the owner of the Peach Pit played by Joe E. Tata, was also in every season, but wasn't considered a regular.

Ok, I could go on for hours about this show.... But I'll only give you one more. Dylan McKay, as noted before was played by Luke Perry, was first featured in the show's second episode. Luke Perry was only going to be in one or two episodes, and Fox was initially reluctant to have him included as a regular, but Aaron Spelling (the show's producer) felt differently and paid Perry's salary himself during the first two years, until the network was won over.

Anybody who wants to have a 'Beverly Hills, 90210' marathon.... Just let me know.... I'll make it happen.

Can You Guess This TV Theme? #22

Is anybody else going to be glued to their television this weekend? Anyone else interested in the US Open? Just me? Ok.

Os Odontoideum

Findings

The coronal CT neck image in Figure 1 shows a small, round os odontoideum separated from the body of C2 by a wide radiolucent gap. It has smooth and uniform cortical margins.
The sagittal CT neck image in Figure 2 shows signs of C1 anterior arch hypertrophy. There is no paravertebral swelling. The posterior atlanto-dens interval (PADI) also known as the space available for cord (SAC) is 12mm (less than 13mm has a poor prognosis).


Diagnosis: Os Odontoideum


Os odontoideum describes a rare condition in which the dens is separated from the axis body. Two types of os odontoideum have been identified. An orthotropic os odontoideum is located in the normal position of the odontoid process, whereas a dystrophic os odontoideum is either attached to the anterior arch of C1 or the clivus.

The etiology of os odontoideum is still debated. The leading hypothesis suggests that trauma in early childhood causes injury to the soft tissues between C1 and C2. This is often seen when babies fall from their cribs or toddlers fall from stairs. Radiographic images taken after this injury usually do not show any significant pathology besides retropharyngeal swelling.

Injury results in avascular necrosis of the odontoid process over a period of months or years. Therefore, the cephalad ossification centers do not fuse with the C2 body. With growth, the alar ligaments that attach the tip of the dens to the occiput pull the ossicle upwards giving it its characteristic appearance.

Os odontoideum may also occur in patients with congenital anomalies including Down's syndrome, multiple epiphyseal dysplasia, Klippel-Feil malformation and Morquio syndrome. These patients are born with deficient odontoid processes.

Symptoms are variable with vague pain in the neck and shoulders being the most common. Less commonly reported symptoms include headaches, torticollis, weakness and paresthesias. The most serious complications of an os odontoideum occur when C1-C2 instability causes spinal cord compression or vertebral artery compromise. This may result in brain stem symptoms, quadraparesis, transient bouts of unconsciousness and sudden death.

The best way to evaluate an os odontoideum is by obtaining open-mouth anterior-posterior and flexion-extension lateral plain films. A criteria often used to make the diagnosis is the Posterior AtlantoDens Interval (PADI) also known as the Space Available for Cord (SAC). This is the distance between the posterior border of the dens and the anterior border of the posterior ring of the atlas. A PADI of less than 13mm is associated with neurologic decline. C1-C2 translation of more than 5mm on flexion-extension radiographs also has a poor prognosis.

The most common treatment for a symptomatic os odontoideum is C1-C2 posterior arthrodesis. This is particularly indicated in patients who exhibit signs of cord compression. Medical management is indicated for patients with only mechanical symptoms.

Chiari Malformation with Syringomyelia-MRI

Note the associated CVJ anomaly and syringomyelia.

Teleradiology Providers

MVPuppets 8

The Los Angeles Lakers championship parade is today. So you know what that means.... More of the puppet commercials.

Here's the thing.... I appreciate Kobe and LeBron, their talents and their athleticism. I'm not typically in awe of someone's physical abilities, but a couple of years ago I was listening to a Kobe Bryant interview, and a reporter asked Kobe about a play in the game where he jumped into the air with the ball in one hand, did a 180 degree turn, put the ball in his other hand, and then slam dunked the basketball. Kobe replied with, 'Well, I saw the defender, and I made the decision to switch hands and dunk the ball on the other side so there was no chance it could be blocked.' Of course I paraphrased that, but I just jumped in my office and I was barely able to think about landing on two feet. So, I'm just saying, don't go with him if he tells you that he wants to show you his trophy in his hotel room, but at least get him to sign a coffee cup.

Idiopathic Tumoral Calcinosis

Characteristic imaging findings of idiopathic tumoral calcinosis
Circular or oval, well-demarcated masses of calcium, usually located about joints
Direct involvement of the bones or joints is rare (bony erosion by anadjacent mass of calcification is seen on rare occasions)
radionuclide bone scan may reveal intense uptake in the calcific masses
The calcified deposits appear white on CT and dark on MR -- either study may demonstrate fluid-fluid levels within some of these masses.

Surprises

I have trouble being away from Noah for more than 8 hours.... I can't even imagine what it would be like, for me or Noah, if I was deployed in a war zone for months....

I'm warning you now, I am not able to watch the video of the father surprising his little boy in his classroom without involuntarily bursting into tears.... And I don't care if that makes me a girl!

Barack Obama Is Just Like Us!

Ok Mr. President.... Just wait until you see what these two girls do with that one cup!!!!

More Food Porn

Here's another Food Porn site, however, there's a twist. 'FoodGawker' only posts photos of food that is supported by a recipe. Every time you click on any of the beautiful photos, it takes you to a blog with a detailed recipe. And by creating an account and clicking those tiny hearts near the photos, you can save your favorite recipes and pictures. Don't expect to be directed to the recipes by clicking the photos seen below.... I didn't want to take too much from their site. But here's a few photos that can be seen on their site.

Sparkling Strawberry Lemonade

M & M Chocolate Pretzels

Pumpkin Chocolate Chip Whoopie Pies

Classic Cheeseburger

You can click on their banner below to visit their site.