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Severe extracranial carotid stenosis (SECS) patients may present with nonspecific neurological symptoms that require intracranial magnetic resonance imaging (MRI) and time-of-flight (TOF)-MR angiography (MRA) to exclude intracranial pathology. Recognition of SECS on intracranial TOF-MRA findings is beneficial to provide a prompt carotid imaging study and aggressive stroke prevention. Patients with SECS (January 2016 to May 2019) undergoing percutaneous transluminal angioplasty and stenting (PTAS) were included. Differences in normalized signal intensities (SRICA) and diameters (DICA) between bilateral petrous internal carotid arteries (ICAs) were calculated 1 cm from the orifice. A hypothesized criterion describing the opacification grades (GOPH) of bilateral ophthalmic arteries was proposed. We correlated SRICA (p = 0.041), DICA (p = 0.001) and GOPH (p = 0.012), with the severity of extracranial carotid stenosis on digital subtractive angiography (DSA) in the examined group (n = 113), and all showed statistical significance in predicting percentages of ICA stenosis. The results were further validated in another patient group with SECS after radiation therapy (n = 20; p = 0.704 between the actual and predicted stenosis grades). Our findings support the evaluation of the signal ratio and diameter of intracranial ICA on TOF-MRA to achieve early diagnosis and provide appropriate management of SECS.

OBJECTIVE The aim of the study was to evaluate cerebral hemorrhage (CH) and contrast media leakage (CML or commonly synonymous with "contrast staining") differentiation on flat-panel volume computed tomography (FPVCT) after intra-arterial mechanical thrombectomy. METHODS We evaluated patients with hyperattenuation on FPVCT after intra-arterial mechanical thrombectomy between 2018 and 2021 by multiple parameters on CT angiography, FPVCT, CT, and/or magnetic resonance imaging. RESULTS The CH (n = 43) versus CML (n = 24) groups revealed: (1) regional anatomical characteristics (preserved and distorted): 7 of 43 (9.6%) and 36 of 43 (83.7%) versus 22 of 24 (91.7%) and 2 of 24 (8.3%, P < 0.001); (2) thrombus in proximal two-thirds versus distal one-thirds M1 segment of middle cerebral artery (preserved and distorted): 17 of 21 (81.0%) and 4 of 21 (19.0%) versus 5 of 11 (45.5%) and 6 of 11 (54.5%, P = 0.040); and (3) average density ratio: 1.83 ± 0.65 versus 1.35 ± 0.13 (P = 0.004). CONCLUSIONS Contrast media leakage can be differentiated from CH by preserved regional anatomical characteristics and relatively low average density ratio on FPVCT. Patients with CML who have embolism in proximal two thirds of M1 segment are more likely to develop hyperattenuation with preserved regional anatomy.

Background: Benign immunoglobulin G4 (IgG4)-related orbital disease (IgG4-ROD)&mdash, characterized as tumors mimicking malignant orbital lymphoma (OL)&mdash, responds well to steroids, instead of chemotherapy, radiotherapy and/or surgery of OL. The objective of this study was to report the differences in computed tomography (CT) features and- serum IgG4 levels of IgG4-ROD and OL. Methods: This study retrieved records for patients with OL and IgG4-ROD from a pathology database during an eight-year-and-five-month period. We assessed the differences between 16 OL patients with 27 lesions and nine IgG4-ROD patients with 20 lesions according to prebiopsy CT features of lesions and prebiopsy serum IgG4 levels and immunoglobulin G (IgG) levels This study also established the receiver-operating curves (ROC) of precontrast and postcontrast CT Hounsfield unit scales (CTHU), serum IgG4 levels, serum IgG levels and their ratios. Results: Significantly related to IgG4-ROD (all p &lt, 0.05) were the presence of lesions with regular borders, presence of multiple lesions&mdash, involving both lacrimal glands on CT scans&mdash, higher median values of postcontrast CTHU, postcontrast CTHU/precontrast CTHU ratios, serum IgG4 levels and serum IgG4/IgG level ratios. Compared to postcontrast CTHU, serum IgG4 levels had a larger area under the ROC curve (0.847 [95% confidence interval (CI): 0.674&ndash, 1.000, p = 0.005] vs. 0.766 [95% CI: 0.615&ndash, 0.917, p = 0.002]), higher sensitivity (0.889 [95% CI: 0.518&ndash, 0.997] vs. 0.75 [95% CI: 0.509&ndash, 0.913]), higher specificity (0.813 [95% CI: 0.544&ndash, 0.960] vs. 0.778 [95% CI: 0.578&ndash, 0.914]) and a higher cutoff value (&ge, 132.5 mg/dL [milligrams per deciliter] vs. &ge, 89.5). Conclusions: IgG4-ROD showed distinct CT features and elevated serum IgG4 (&ge, 132.5 mg/dL), which could help distinguish IgG4-ROD from OL.

Background: Due to the potential consequences of post-traumatic epilepsy (PTE) exacerbating secondary injury following traumatic brain injury (TBI), the use of antiepileptic drugs (AEDs) is an accepted option for seizure prophylaxis. However, there is only a paucity of data that can be found regarding outcomes surrounding the use of AEDs. The purpose of this retrospective study is to evaluate whether the prophylactic administration of AEDs significantly decreased the incidence of PTE, when considering the severity of TBI. Methods: All trauma patients who had been newly diagnosed with TBI from January 1, 2010 to December 31, 2017 were retrospectively analyzed. Statistical comparisons were made using the chi-square test, Mann-Whitney U test, and Cox regression modeling. After excluding any exposed subjects with no appropriate match, patients who had received AED prophylaxis were matched by propensity score with those who did not receive AEDs. All of the TBI populations were followed up until June 30, 2018. Results: We identified 1316 patients who met the inclusion and exclusion criteria in our matched cohort through their propensity scores, where 138 patients had been receiving prophylactic AEDs and 138 patients had not. Baseline characteristics were similar in gender, age, Glasgow Coma Scale (GCS) scores, and risk factors of PTE including skull fracture, chronic alcoholism, subdural hematoma, epidural hematoma, and intracerebral hematoma. After adjusting for those risk factors, the relative incidence of seizure was not statistically significant in either of the groups (p = 0.566). Conclusion: In our cohort analysis, AED prophylaxis was ineffective in preventing seizures, as the rate of seizures was similar whether patients had been receiving the drugs or not. We therefore concluded that the benefits of routine prophylactic anticonvulsant therapy in patients with TBI need to be re-evaluated.

Objective Primary hepatic angiosarcoma (PHA) is extremely rare and most patients die within 12 months of diagnosis. The object of the study is to determine the association of initial clinical-radiological features and staging with outcomes in patients with PHA. Methods The medical records of adult patients with PHA were retrieved from an electronic medical record database and a pathology database and retrospectively reviewed. During 10 years, 22 eligible patients were included. Data extracted focused on the information before the first formal treatment with a pathological proof, including demographic characteristics, medical history, laboratory data, preliminary images, histopathological records, treatment, and follow-up survival period. Two radiologists blindly re-analyzed preliminary images of all 22 patients together and recorded tumor features and imaging stage based on the American Joint Committee on Cancer (AJCC) 8th edition tumor-node-metastasis (TNM) Staging System for hepatocellular carcinoma. A radiologist compiled the initial clinical data and preliminary image stage to analyze the association with patients’ survival outcome. Results Higher aspartate aminotransferase (AST), higher total bilirubin (TB), lower albumin (ALB), longer prothrombin time (PT) and lower platelet count of serum relative to the normal reference range were more common in patients who survived ≤ 90 days (all P < 0.05). Overall survival was much better in patients with single PHA than in those with other tumor patterns of multiple PHA (all P < 0.05). Overall survival determined by preliminary imaging showed significant differences between stage I and stage III (P = 0.044), stage I and stage IV (P = 0.011), and stage III and IV (P = 0.047). No patients were at stage II. Conclusions Initial serum levels of ALT, TB, ALB, and PT, platelet count, single mass in liver, and preliminary imaging staging could help predict survival outcomes of patients with PHA.

Objective: Although the majority of available evidence suggests that vertebroplasty and kyphoplasty can relieve pain associated with vertebral compression fractures (VCFs) and improve function, some studies have suggested results are similar to those of placebo. The purpose of this meta-analysis was to compare the outcomes of vertebroplasty and kyphoplasty with conservative treatment in patients with osteoporotic VCFs. Methods: Medline, Cochrane, and Embase databases were searched until January 31, 2015 using the keywords: vertebroplasty, kyphoplasty, compression fracture, osteoporotic, and osteoporosis. Inclusion criteria were randomized controlled trials (RCTs) in which patients with osteoporosis, and VCFs were treated with vertebroplasty/kyphoplasty or conservative management. Outcome measures were pain, function, and quality of life. Standardized differences in means were calculated as a measure of effect size. Main results: Ten RCTs were included. The total number of patients in the treatment and control groups was 626 and 628, respectively, the mean patient age ranged from 64 to 80 years, and the majority was female. Vertebroplasty/kyphoplasty was associated with greater pain relief (pooled standardized difference in means = 0.82, 95% confidence interval [CI]: 0.374–1.266, P

We reviewed the follow-up findings of patients who received percutaneous vertebroplasty, in order to understand the effects of vertebroplasty on following issues: pain relief, height restoration, wedge deformity correction, kyphosis correction, and other radiological findings found in follow up studies, such as new fractures. Generally, the pain relieving effect after vertebroplasty is long lasting except when new fracture occurred, or presence of other problems that caused the back pain. Height restoration and wedge deformity correction last for more than one year. The effect of kyphosis angle correction may vanish one year after procedure due to occurrence of new fracture in adjacent vertebral bodies.

Introduction We report a case of a 54-year-old male patient with a hard, painful nodule within his right breast which was misdiagnosed preoperatively as breast cancer. Case description Preoperative work-up included physical examination, non-contrast chest computed tomography (CT), sonography, and sono-guided breast biopsy. Isolated breast panniculitis with vasculitis (BPWV), a rare disease, was diagnosed by histopathologic examination of tissue obtained from excisional biopsy. Discussion and Evaluation Subcutaneous panniculitis with or without vasculitis, a condition of nonsuppurative inflammatory process involving the subcutaneous fat layer of skin, is related to different causes. A palpable benign male breast lesion resembling a malignancy includes gynecomastia, panniculitis with or without vasculitis, fat necrosis, ruptured epidermal cyst, pseudoangiomatous stromal hyperplasia, subareolar abscess, intraductal papilloma, hematoma, and atypical fibroadenoma. To make an accurate preoperative diagnosis of a male breast mass, a physician has to carefully analyze various imaging findings. The cases of BPWV may present as an isolated breast lesion or as a component of a systemic disease. The diagnosis of the reported patient was compatible with an isolated BPWV because panniculitis and/or vasculitis were not present at other sites or organs at the time of diagnosis or during follow-up. Conclusions Excisional biopsy and clinical data can provide the correct diagnosis and determined the appropriate treatment strategy of a male BPWV.

The objective of our study was to evaluate the CT characteristics of globe rupture.The medical records of patients seen in the emergency department with blunt, penetrating, or explosive orbit injury were retrospectively reviewed. A total of 75 patients (76 injured globes) were included (56 males and 19 females; average age, 45.1 years; age range, 5-95 years). CT examinations were reviewed by two experienced radiologists without knowledge of ophthalmologic findings, original orbital CT images, or surgical outcomes.Of the 76 globe injuries, 33 (43%) were ruptured and 43 (57%) were nonruptured. There were significant differences between the ruptured and nonruptured globes with respect to intraocular hemorrhage, lens dislocation and destruction, an intraocular foreign body, intraocular gas, anterior chamber depth (ACD), and globe deformity and wall irregularity (p0.05). There was good interrater agreement between the two radiologists (kappa value range, 0.63-0.96). The average sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of CT for the detection of globe rupture based on readings by two radiologists were 76%, 85%, 80%, 82%, and 81%, respectively.Although CT is extremely useful in the evaluation of ocular trauma, it should not be solely relied on for the diagnosis of globe rupture because of the potentially catastrophic consequences of an undiagnosed injury. A difference in ACD can be diagnostic of globe rupture.

Background Computed tomography (CT) is known to be the first-line imaging method for patients with or suspect to have intraocular foreign bodies (IOFBs). The purpose of this study is to evaluate clinical outcomes in the management of IOFBs with the aid of CT. Methods Retrospective chart review of patients who received orbital CT prior to the removal of an IOFB between January 2000 and December 2010 was carried out. Patients with an IOFB who did not receive an operation or those without a preoperation CT examination were excluded. Twenty patients with a mean age of 37 years were selected. The duration between injury and surgery ranged from hours to 4 months. Detailed information and ophthalmologic examination results including patient history, visual acuity (VA), slit-lamp examination, fundoscopic examination, operation notes and bacterial culture results were recorded for all patients. The orbital CT images were performed with multidetector CT scanners with a 2–3.75 mm slice thickness. Results This study found 18 patients (90%) with only one IOFB on CT image, in which only nine IOFBs were discovered on clinical assessment. The CT image failed to discover the IOFB in two patients who had tiny iron dust fragments located in the cornea stroma or embedded in the lens. Preoperative determination of the IOFB size and location was helpful in the decision-making of the route of extraction. Further, there was a correlation between clinical presentation about vitreous hemorrhage and the development of postoperative retinal detachment (Fisher's exact test, p = 0.029). The presence of positive bacterial cultures was also found to be associated with decreased VA (Fisher's exact test, p = 0.047). The injured eyes were anatomically preserved in all patients. However, two patients had loss of light perception. Eleven patients (55%) had improved VA of more than two lines on Snellen's chart, seven patients worsened, and two patients retained the same initial VA. Conclusion Multidetector CT plays an important role in the detection, localization, size measurement, and surgical approach towards the extraction of the IOFB. The presence of vitreous hemorrhage is a predictive factor for postoperative retinal detachment, and positive bacterial cultures result in poorer visual outcomes.

BACKGROUND: Multiple sclerosis (MS) is less common in Asia, including Taiwan, and some characteristics of MS in Asians differ from those of Caucasians. Tumefactive brain lesion is even rarer in MS patients. OBJECTIVE: To review patients with tumefactive MS and compare them with those in other studies investigating tumefactive demyelinating lesions and our Taiwanese typical MS patients. METHODS: Twelve patients (6.3%) from the 190 MS patients visiting Taipei Veterans General Hospital from 1985 to 2010 were enrolled. They all fulfilled the McDonald or Poser criteria for MS and had at least one brain lesion larger than 2 centimeters with or without a mass effect. RESULTS: Eleven patients (91.7%) were female and presented tumefactive brain lesions during the first attack. The clinical course of all patients was relapsing-remitting with a second attack within 2 years. Their initial extended disability status score was higher, but the prognosis was better after more than 2 years of follow-up, than in other studies. Moreover, our patients did not have optic or spinal involvement as well as positive neuromyelitis optica immunoglobulin or aquaporin-4 antibody, which is very common in Taiwanese MS patients. CONCLUSION: Tumefactive MS is not common in Taiwan. Although the tumefactive demyelinating lesions seem to be terrible initially, their prognosis is relatively more favorable than expected.

This study aimed to report the differences in sonographic features of ruptured and unruptured epidermal cysts.We reviewed and analyzed the sonographic features of superficial epidermal cysts of in 2 subgroups of 46 patients: 20 with ruptured cysts and 26 with unruptured cysts. All lesions were diagnosed either by excisional biopsy or by debridement biopsy. Sonographic features used in the analysis included tumor size, location, echo texture, pericystic changes, boundary, and shape on gray scale sonography and lesion vascularity on color Doppler sonography. Pathologic examinations were reviewed with emphasis on differences between ruptured and unruptured epidermal cysts.Unruptured epidermal cysts showed significantly higher frequencies of an oval shape, presence of a halo, well-circumscribed boundaries, and lack of blood flow signals (P.05). In contrast, ruptured cysts usually had a lobulated shape, a slightly poorly defined or poorly defined boundary, the absence of a halo, and intermediate grades of lesion vascularity. The lesion sizes and sonographic features, including dermal attachment, a hypoechoic echo texture, posterior acoustic enhancement, and the presence of intralesional hyperechoic strips and hypoechoic debris, showed no significant differences between the groups (P.05). In pathologic studies, acute and chronic inflammatory reactions, more prominent microvessels, and abscess formation in the adjacent stromal tissue, the lesions, or both could be detected in the 20 ruptured epidermal cysts but not in the unruptured cysts.This research shows that recognition of different sonographic features is helpful for differentiating ruptured and unruptured epidermal cysts.

We evaluated the detectability of painful vertebral compression fractures (VCFs) on different MRI protocols in 40 osteoporotic patients with thoraco-lumbar osteoporotic vertebral fractures. Five hundred and ten thoracic and lumbar vertebrae in 40 patients were evaluated. All patients underwent percutaneous vertebroplasty. Vertebral fractures were found in 126 (24.7%) of 510 vertebrae. Healed vertebral fractures were found in 33 (26.2%) of 126 vertebral fractures. Painful osteoporotic VCFs was found in 93 (73.8%) of 126 fractures. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of contrast-enhanced MR images, and the non-contrasted combined protocol (including T1-weighted, T2-weighted and STIR images) for the detection of painful osteoporotic VCFs were all more than 90%. Therefore, the non-contrasted combined protocol can be used for detection of painful osteoporotic VCFs prior to percutaneous vertebroplasty, unless there are conditions where contrast-enhanced MR is needed to rule out other causes of VCFs.

Our aim was to assess the specific ultrasonic characteristics of pleomorphic adenoma and Warthin's tumor in major salivary glands.We retrospectively reviewed and analyzed the ultrasonographic (US) features of 19 pleomorphic adenomas in 16 patients and 29 Warthin's tumors in 20 patients. The features included tumor size, echotexture, boundary, and shape on gray-scale US imaging and grading and distribution of tumor vascularity on color Doppler ultrasound (CDU).All lesions were hypoechoic, and only 22.9% had a homogeneous echotexture. Most of the tumors (87.5%) wereor=10 mm, and 93.8% were well defined. On CDU, 91.7% had intermediate (+ and ++) grades of vascularity. Only two of 29 Warthin's tumors had the highest grade of vascularity (+++). Predominantly central blood flow was present in 58.6% of Warthin's tumors and 42.1% of pleomorphic adenomas. Lobulated margin (shape) was noted in 84.2% of pleomorphic adenomas and 51.7% of Warthin's tumors (P.05). Anechoic cystic components were present in 13 (44.8%) of 29 Warthin's tumors and in only one pleomorphic adenoma (1/19, 5.3%) (P.01).Most pleomorphic adenomas were lobulated. Internal anechoic cystic components were absent from pleomorphic adenomas but present in some Warthin's tumors. The grading and distribution of blood flow signals on CDU provided only limited additional diagnostic information for distinguishing pleomorphic adenomas from Warthin's tumors. Gray-scale ultrasonography is a useful method for evaluating and distinguishing pleomorphic adenomas from Warthin's tumors.

The aim of this study was to investigate the clinical relevance of thoracic high-resolution computed tomography (HRCT) in evaluating the severity and outcome of Pneumocystis jirovecii pneumonia (PJP) in non-AIDS immunocompromised patients. We measured mean lung attenuation (MLA) and extent of increased attenuation (EIA) of PJP lesions on thoracic HRCT in 40 non-AIDS immunocompromised patients with PJP diagnosed by demonstration of the pathogens in cytological smears of bronchoalveolar lavage fluid. The MLA and EIA of PJP lesions on thoracic HRCT were used to investigate the severity of PJP. Clinically, the severity of PJP was determined by arterial oxygen tension/fraction of inspired oxygen concentration (PaO2/FiO2) ratio, acute physiology and chronic health evaluation (APACHE) II scores, the need of mechanical ventilation, and death. MLA highly correlated with EIA of PJP lesions (ρ = 0.906, P

Torticollis due to atlantoaxial rotatory fixation (AARF) is rare. Most cases are idiopathic or occur after infection or minor trauma. AARF can cause neurologic deficits, and patients often present with torticollis that fails to resolve. AARF should be excluded before idiopathic spasmodic torticollis is diagnosed. Computed tomography helps in confirming AARF, and early diagnosis can improve outcomes, although treatment is debatable. We present three children and one adult with AARF and review the literature.

The purpose of this study is to assess the specific ultrasonic characteristics of papillary thyroid carcinoma and to determine the relative frequency of various patterns of papillary carcinoma on gray-scale ultrasonography (US) and color Doppler ultrasonography (CDU).We retrospectively reviewed US features in 51 patients with confirmed papillary thyroid carcinoma. The features were analyzed based on tumor size, echogenicity, echotexture, boundary, margin, shape, and calcification pattern on gray-scale US imaging, and on patterns of vascularity on CDU. We obtained the relative frequency of features and classified these features into three categories: common (or =50% of lesions), less common (10% but50%), and uncommon (or =10%). Individual differences and combinations of features were also analyzed.In total, 67 nodules were enrolled in our study. The sizes of 76% of nodular lesions were20.0 mm. Common US features of papillary carcinoma included: a homogeneous hypoechoic solid picture; a poorly defined boundary; an irregular margin; the absence of halo; the absence of calcifications or microcalcifications; and mixed perinodular and intranodular blood flow patterns. Less common features included: a heterogeneous hypoechoic or very hypoechoic picture; microcalcifications; a well-defined boundary; a regular margin; a halo with uneven thickness or an incomplete halo; and a taller-than-wide shape. Uncommon features included: an isoechoic picture; solid with cystic components; coarse calcifications; mixed coarse calcifications and microcalcifications; "inferno"-type blood flow; and absence of blood flow. On average, each nodule had 4.9 US features considered common, 1.8 US features considered less common, and 0.4 US feature considered uncommon. Features such as predominantly cystic composition, hyperechoic texture, and hypoechoic halo with even thickness were never found in our study. The top two common manifestations of papillary carcinoma were solid architecture and mixed perinodular and intranodular blood flow signals.All lesions in our series had a predominantly solid characteristic on gray-scale US.

An aortoesophageal fistula is a rare but fatal disease, most commonly associated with thoracic aortic aneurysm. Early diagnosis and emergency surgical intervention are mandatory for survival. We reported a case of mycotic aneurysm of thoracic aorta with aortoesophageal fistula, presenting with intermittent hematemesis, tarry stool and sepsis. Initially, misdiagnosis of esophageal submucosal tumor with bleeding was made clinically and endoscopically. With contrast-enhanced spiral computed tomography (CT) scan the diagnosis was confirmed. The pathogenesis, clinical presentation, endoscopic feature and imaging findings were reviewed.

Background Granular cell tumors are rare neoplasms which can occur in any part of the body. Granular cell tumors of the orbit account for only 3 % of all granular cell tumor cases. Computed tomography and magnetic resonance imaging of the orbit have proven useful for diagnosing orbital tumors. However, the rarity of intraorbital granular cell tumors poses a significant diagnostic challenge for both clinicians and radiologists. Case presentation We report a case of a 37-year-old Chinese woman with a rare intraocular granular cell tumor of her right eye presenting with diplopia, proptosis, and restriction of ocular movement. Preoperative orbital computed tomography and magnetic resonance imaging with contrast enhancement revealed an enhancing solid, ovoid, well-demarcated, retrobulbar nodule. In addition, magnetic resonance imaging features included an intraorbital tumor which was isointense relative to gray matter on T1-weighted imaging and hypointense on T2-weighted imaging. No diffusion restriction of water was noted on either axial diffusion-weighted images or apparent diffusion coefficient maps. Both computed tomography and magnetic resonance imaging features suggested an intraorbital hemangioma. However, postoperative pathology (together with immunohistochemistry) identified an intraorbital granular cell tumor. Conclusions When intraorbital T2 hypointensity and free diffusion of water are observed on magnetic resonance imaging, a granular cell tumor should be included in the differential diagnosis of an intraocular tumor.