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Sudden Onset Right Side Weakness • Xray of the Week This 76 year old female presented with sudden onset of right side weakness. What is the diagnosis? Figure 1. Non-contrast axial CT scan of the brain. Figure 2. A. Non-contrast axial CT scan of the brain demonstrates high attenuation within the left middle cerebral artery (MCA), appearing as a high attenuation dot (red arrow) as the MCA is in the short axis. Figure 2. B. The high attenuation MCA is visualized as a line (red arrow) as the artery is in the long axis. Figure 2. C. There is also an old infarct in the left basal ganglia. (yellow arrow) Note that the gray and white matter differentiation is normal indicating that the high attenuation MCA is the only sign of infarct. Figure 3. A. Axial T2-weighted image demonstrating the old lacunar infarct in the left basal ganglia (blue arrows). High signal intensity is present throughout the left MCA distribution due to the acute infarct. Figure 3. B. The axial diffusion weighted image (DWI) demonstrates high signal intensity due to restricted diffusion in the left MCA distribution. Figure 3. C. Axial apparent diffusion coefficient (ADC) map demonstrates the left MCA infarct with low signal, confirming this is an acute infarct rather than "T2 shine through". Discussion: The hyperdense artery sign (HAS) has a 90-100% specificity (1-5) for acute infarct and was first reported in 1983(6). Other causes of HAS include high hematocrit(5), viral infection(3), dissection(7), and retained contrast (4). However, sensitivity is only 30%. In order to have objective criteria for HAS, Koo et al (3) set a ratio of 1.2 when compared to the non-affected contralateral vessel or an absolute value of > 43 HU. In patients with the hyperdense artery sign, the outcome is often poor with a large infarct and significant neurological deficit. This is likely due to the high volume of thrombus required to produce the high attenuation within the artery. References: 1. Unnikrishnan D, Yada S, Gilson N A case of large right MCA stroke with hyperdense MCA sign in CT imaging Case Reports 2017;2017:bcr-2017-222529. http://dx.doi.org/10.1136/bcr-2017-222529 2. Abd Elkhalek YI, Elia RZ. Qualitative and quantitative value of hyperdense MCA sign as a prognostic marker for infarction. The Egyptian Journal of Radiology and Nuclear Medicine (2016)47, 1043-1048. https://doi.org/10.1016/j.ejrnm.2016.06.005 3. Koo CK, Teasdale E, Muir KW. What constitutes a true hyperdense middle cerebral artery sign? Cerebrovasc Dis. 2000 Nov-Dec;10(6):419-23. https://doi.org/10.1159/000016101 4. Jensen-kondering U, Riedel C, Jansen O. Hyperdense artery sign on computed tomography in acute ischemic stroke. World J Radiol. 2010;2 (9): 354-7. 5. Rauch RA, Bazan C 3rd, Larsson EM, Jinkins JR. Hyperdense middle cerebral arteries identified on CT as a false sign of vascular occlusion. AJNR Am J Neuroradiol. 1993;14:669–673. https://www.ncbi.nlm.nih.gov/pubmed/8517357 6. Gács G, Fox AJ, Barnett HJ, Vinuela F. CT visualization of intracranial arterial thromboembolism. Stroke.1983;14:756–762. 7. Yakushiji Y, Haraguchi Y, Soejima S, Takase Y, Uchino A, Koizumi S, Kuroda Y. A hyperdense artery sign and middle cerebral artery dissection. Intern Med. 2006;45:1319–1322. https://www.ncbi.nlm.nih.gov/pubmed/17170508 Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice serves as the Chair of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice along with Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. All Posts by Kevin M Rice, MD

Hemoptysis and Lung Nodule • Xray of the Week This 40 year old female presented with hemoptysis. What is the diagnosis? Left image: CXR with mass in RUL Right image: Coronal CT showing RUL mass with feeding artery and draining vein diagnostic of pulmonary AVM. Video of pulmonary AVM in this patient, and a surprising second finding. Discussion Pulmonary arteriovenous malformations (AVM) are caused by an abnormal connection between the pulmonary arterial system and pulmonary venous system due to a direct fistula between a branch of the pulmonary artery and a branch of the pulmonary vein. This is a rare anomaly with an incidence of approximately 2/100,000. The patients may be seen with an incidental lung nodule. However, due to the right to left shunt, patients may present with shortness of breath, hemoptysis, or paradoxical emboli to the brain or elsewhere in the systemic circulation. Pulmonary AVM's are associated with hereditary hemorrhagic telangiectasia (HHT), also known as Osler-Weber-Rendu syndrome. Approximately a third of patients with a single AVM and up to half of patients with multiple AVM's have HHT. On plain radiographs, the AVM's usually have the appearance of a nodule or multiple nodules. On CT scan, the nodule has a feeding artery and draining vein. Treatment options include percutaneous catheter directed embolization and surgical excision. References: 1. Gossage JR, Kanj G. Pulmonary arteriovenous malformations. A state of the art review. Am J Respir Crit Care Med. 1998; 158(2): 643-61. 2. Remy-Jardin M, Dumont P, Brillet PY, Dupuis P, et. al. Pulmonary arteriovenous malformations treated with embolotherapy: helical CT evaluation of long-term effectiveness after 2-21-year follow-up. Radiology. 2006;239(2): 576-85. 3. Pulmonary Arteriovenous Malformations: Safety and Efficacy of Microvascular Plugs. AJR: 1135-1143. 10.2214/AJR.17.19200 4. Guttmacher AE, Marchuk DA, White RI Jr. Hereditary hemorrhagic telangiectasia. N Engl J Med. 1995; 333(14): 918-24. 5. Remy J, Remy-Jardin M, Wattinne L, Deffontaines C. Pulmonary arteriovenous malformations: evaluation with CT of the chest before and after treatment. Radiology. 1992; 182(3): 809-16. Kevin M. Rice, MD is the president of Global Radiology CME and serves as the Chair of the Radiology Department of Valley Presbyterian Hospital in Van Nuys, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice co-founded Global Radiology CME with Natalie Rice to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

LLQ Pain in 44 F • Xray of the Week This 44 year old female presented to the Emergency Department with sudden onset left lower quadrant pain. There was no fever or vomiting. What is the diagnosis? Fig. 1 Axial (left) and coronal (right) CT with contrast. There is a well defined region of fat attenuation with surrounding mesenteric edema with a central dot representing a thrombosed vein, diagnostic of epiploic appendagitis. Fig. 2 Axial (left) and coronal (right) CT. Central thrombosed vein in epiploic appendage (blue arrow) with surrounding mesenteric edema diagnostic of epiploic appendagitis. Fig. 3 A Second patient with epiploic appendagitis in RLQ mimicking appendicitis clinically and on CT: Central thrombosed vein in a fatty lesion with a thin high attenuation rim (blue arrows on coronal images and red arrow on axial image). Findings consistent with epiploic appendagitis. Case courtesy of Geoffrey Sigmund, MD. Fig. 4 A third patient with subtle epiploic appendagitis in LLQ mimicking diverticulitis clinically. CT demonstrates the central thrombosed vein in a fatty lesion with a thin high attenuation rim (yellow arrows). Findings consistent with epiploic appendagitis. Fig. 5 A different patient with ascites outlining normal epiploic appendages (blue arrows) Discussion: Epiploic appendagitis is an uncommon inflammatory process of the epiploic appendices of the colon which can mimic diverticulitis clinically. The etiology is probably due to torsion of a large epiploic appendage or spontaneous thrombosis of a vein in the appendage. The hallmark appearance of epiploic appendagitis on CT scan is a well defined 2-4 cm region of fat attenuation, a thin surrounding high attenuation rim, surrounding mesenteric edema, and a central dot representing a thrombosed mesenteric vein. (Fig. 1-2) If present in the right lower quadrant, it may also be confused clinically with appendicitis. (Fig. 3) The findings on CT may be subtle as seen in Figure 4. The normal epiploic appendages are usually not visualized on CT unless outlined by free fluid. (Fig. 5) The radiologist plays an important role in the management as a correctly interpreted CT scan alerts the clinician to the diagnosis and the fact that it is self-limiting. This often prevents unnecessary surgery. Treatment is anti-inflammatory drugs and symptoms usually resolve within a week. References: 1. Singh AK, Gervais DA, Hahn PF et-al. Acute epiploic appendagitis and its mimics. Radiographics. 25 (6): 1521-34. 2. Purysko AS, Remer EM, Filho HM et-al. Beyond appendicitis: common and uncommon gastrointestinal causes of right lower quadrant abdominal pain at multidetector CT. Radiographics. 2011;31 (4): 927-47. Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice serves as the Chair of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances and given as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. Due to his online teaching activities, Dr. Rice was nominated and became a semifinalist for a "Minnie" award for the Most Effective Radiology Educator in 2016. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

Headache, Altered, Pancreas Cancer • Xray of the Week This 61 year old female with a history of pancreatic cancer presented with altered mental status, and had a CT scan and MRI brain. A subsequent lumbar puncture revealed the diagnosis. What is the abnormality and what is the diagnosis? Upper row: CT brain without contrast. Note the high attenuation overlying the right cerebral convexity. There is no abnormality in the basal cisterns. Bottom left and right: T1 weighted images with contrast demonstrate abnormal leptomeningeal enhancement along the right cerebral hemisphere, over the right frontal lobe, parietal lobe, operculum, Sylvian fissure, and temporal lobe. Bottom middle: T2* GRE image shows no blood products, with no region of low signal. The history of pancreatic carcinoma and the lack of high attenuation material in the basal cisterns on the CT scan may give the reader a clue that the findings are not due to subarachnoid hemorrhage (SAH). The leptomeningeal enhancement on the MRI may be due to leptomeningeal carcinomatosis, meningitis, or other inflammatory processes. A subsequent lumbar puncture revealed pancreatic carcinoma on cytology. Therefore, the findings are due to leptomeningeal carcinomatosis. Differential diagnosis of pseudo-subarachnoid hemorrhage on CT: •Meningitis •Leptomeningeal carcinomatosis •Artifacts on CT: anoxic encephalopathy, spontaneous intracranial hypotension •Iatrogenic causes: recently administered intrathecal or IV contrast material; and following endovascular procedures such as aneurysm coiling and stroke intervention. Highly proteinaceous material in the subarachnoid space causes increased attenuation which may be due to purulent fluid seen with meningitis or leptomeningeal carcinomatosis, mimicking SAH. Anoxic encephalopathy and spontaneous intracranial hypotension both cause a perceptual error due to relatively higher attenuation of the basal cisterns related to the low attenuation seen with these conditions. Iodinated contrast in the subarachnoid space either due to IV or intrathecal administration causes high attenuation in the subarachnoid space which should be easily differentiated from SAH if the history is known. Likewise, endovascular procedures may result in leakage of iodinated contrast which could be confused with SAH, especially given that the procedures are often done for patients with SAH or aneurysms. Follow up CT scan within 3-4 hours after the procedure will show clearing of the contrast, whereas SAH will persist. References: 1. Carrie P. Marder, et al. Subarachnoid Hemorrhage: Beyond Aneurysms. American Journal of Roentgenology. 2014;202: 25-37. 10.2214/AJR.12.9749 2. Mendelsohn DB, Moss ML, Chason DP, Muphree S, Casey S. Acute purulent leptomeningitis mimicking subarachnoid hemorrhage on CT. J Comput Assist Tomogr 1994; 18:126–128 3. Tsuchiya K, Katase S, Yoshino A, Hachiya J. FLAIR MR imaging for diagnosing intracranial meningeal carcinomatosis. AJR 2001; 176:1585–1588 4. al-Yamany M, Deck J, Bernstein M. Pseudo-subarachnoid hemorrhage: a rare neuroimaging pitfall. Can J Neurol Sci 1999; 26:57–59 Case courtesy of my friend and colleague Gregory P. Lekovic, M.D., Ph.D. Kevin Rice, MD serves as the Medical Director of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. Due to his online teaching activities, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator in 2016. Follow Dr. Rice on Twitter @KevinRiceMD All Posts by Kevin M Rice, MD

Abdominal Pain and Vomiting in 76 M with Melanoma • Xray of the Week A 76 yo male with a history of malignant melanoma presented with blood in the stool. Twenty days later he returned with vomiting. CT scan of abdomen and pelvis was performed. Day 1: Axial and coronal images showing masses in the small bowel due to melanoma metastases. 20 days later: Axial and coronal images showing dilated small bowel indicating obstruction. There is also also a target sign due to intussusception. The lead point is a metastatic focus of melanoma. Note also the enhancing metastatic masses in the gallbladder. Day 1: Larger coronal image showing mass in the small bowel due to melanoma metastases (blue arrow). Note also the enhancing metastatic masses in the gallbladder. (red arrow) 20 days later: Coronal image showing dilated small bowel indicating obstruction. There is also a target sign due to intussusception. (green arrow) The lead point is a metastatic focus of melanoma. Discussion In children intussusception is usually idiopathic; whereas, with adult intussusception a lead point is present in greater than 90% of cases. Melanoma metastases to the small bowel is seen in approximately 60% of patients with malignant melanoma. However, these only become symptomatic in less than 5% of patients. Symptoms may include abdominal pain, intestinal obstruction with vomiting, weight loss or anemia. Rarely, masses from metastatic melanoma within the small bowel can cause intussusception. Treatment is surgical, usually requiring resection of the mass and the adjacent segment of bowel. Related Global Rad CME case: Ileo-colic intussusception in a 6 month old References: 1. Frederico Ferreira de SouzaI; Felipe Ferreira de SouzaII, et al. Metastatic melanoma causing small bowel intussusception: diagnosis by 18F-FDG PET/CT. Radiol Bras vol.42 no.5 São Paulo Sept./Oct. 2009 2. P Floros, B Rai; Small Bowel Intussusception Due To Malignant Melanoma of Unknown Primary With Adrenal Metastasis At Presentation. The Internet Journal of Surgery. Volume 26. Number 2. http://ispub.com/IJS/26/2/11652 3. Ahmed Guirata, Gadiel Lisciaa; Acute ileo-ileal intussusception due to intestinal metastatic melanoma. Polish Annals of Medicine. Volume 22, Issue 1, June 2015, Pages 41–44 4. Fernando A. Alvarez, Matías Nicolás; Ileocolic intussusception due to intestinal metastatic melanoma. Case report and review of the literature. Int J Surg Case Rep. 2011; 2(6): 118–121 Kevin Rice, MD is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All Posts by Kevin M Rice, MD

Sacral Dimple in a Neonate • Xray of the Week 2016 • Week #23 This neonate had an ultrasound of the lumbar spine to evaluate a sacral dimple. What is the abnormality? What is the significance of this finding? Above image: Sagittal ultrasound image of the lumbar spine in 1 day old female showing a well-defined, fusiform shaped cystic lesion in the midline within filum, just inferior to the conus medullaris. This is typical for a benign filar cyst. Filar cyst, also known as ventriculus terminalis, is seen in up to 12% of children aged less than 8 months. As in this case, ultrasound shows a well-defined, fusiform shaped cystic lesion in the midline within filum, just inferior to the conus medullaris. It is a normal variant that has no known clinical significance and does not require additional imaging. In fact, follow-up MRI usually fails to demonstrate the cyst. References: 1. Irani N, et al. Isolated filar cyst on lumbar spine sonography in infants: a case-control study. Pediatr Radiol. 2006 Dec;36(12):1283-8. 2. Lowe L, et al. Sonography of the Neonatal Spine: Part 1, Normal Anatomy, Imaging Pitfalls, and Variations That May Simulate Disorders. AJR Am J Roentgenol 2007; 188:733–738 Kevin Rice, MD serves as the Medical Director of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a Member of Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice launched Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. Follow Dr. Rice on Twitter @KevinRiceMD All Posts by Kevin M Rice, MD

SOB in HIV Positive 29M • Xray of the Week This HIV positive 29 year old male presented with SOB, which worsened 3 weeks later. What is the diagnosis? Left images: CT with diffuse ground glass opacification. Note the small pneumatocele on the left side anterior medially. Right image: Three weeks later, CT with diffuse ground glass opacification and new bilateral pneumatoceles. The patient had rapid onset of shortness of breath the following day. A chest x-ray demonstrated a large left pneumothorax with shift of the mediastinum to the right indicating tension pneumothorax. A left chest tube was emergently inserted. Discussion Pneumocystis pneumonia is only seen in immunocompromised patients. Chest radiographic findings and CT scan findings usually demonstrate ground-glass opacification in the perihilar and lower zone distribution. However, the distribution may be diffuse as seen in this case. Treatment is trimethoprim-sulfamethoxazole, and corticosteroids. Pneumatoceles occur in up to 30% of cases. Pneumatocele rupture may lead to pneumothorax or even tension pneumothorax which is a medical emergency, treated with chest tube placement. References: 1. Boiselle PM, Crans CA, Kaplan MA. The changing face of Pneumocystis carinii pneumonia in AIDS patients. AJR Am J Roentgenol. 1999;172 (5): 1301-9. 2. Müller NL, Franquet T, Lee KS et-al. Imaging of pulmonary infections. Lippincott Williams & Wilkins. (2007) ISBN:078177232X. Read it at Google Books 3. Hartman TE, Primack SL, Müller NL et-al. Diagnosis of thoracic complications in AIDS: accuracy of CT. AJR Am J Roentgenol. 1994;162 (3): 547-53. https://www.ajronline.org/doi/abs/10.2214/ajr.162.3.8109494 4. Hidalgo A, Falcó V, Mauleón S et-al. Accuracy of high-resolution CT in distinguishing between Pneumocystis carinii pneumonia and non- Pneumocystis carinii pneumonia in AIDS patients. Eur Radiol. 2003;13 (5): 1179-84. doi:10.1007/s00330-002-1641-6 5. Suster B, Akerman M, Orenstein M et-al. Pulmonary manifestations of AIDS: review of 106 episodes. Radiology. 1986;161 (1): 87-93. 6. Kanne JP, Yandow DR, Meyer CA. Pneumocystis jiroveci Pneumonia: High-Resolution CT Findings in Patients With and Without HIV Infection. American Journal of Roentgenology. 2012;198: W555-W561 7. Kuhlman JE, Kavuru M, Fishman EK, Siegelman SS. Pneumocystis carinii pneumonia: spectrum of parenchymal CT findings. Radiology. 1990 Jun;175(3):711-4. Kevin M. Rice, MD is president of Global Radiology CME and serves as the Chief of Staff of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice co-founded Global Radiology CME with Natalie Rice to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

Masses in the Spine and Abdomen • Xray of the Week This 42 year old female with a history of prior craniotomy has abnormalities in the spine and abdomen. What is the diagnosis? Figure 1. A and B: Cervical Spine MRI shows cystic lesions (red arrow) with an enhancing mural nodule (yellow arrow) in the upper cervical spine. Figure 1. C and D: Thoracic Spine MRI shows an intermediate intensity intramedullary nodule in the mid thoracic on T2 weighted images (blue arrow), with enhancement on T1 weighted fat saturation images (green arrow). Figure 2. A: Contrast-enhanced CT scan axial image shows a right renal cyst (red arrow) and innumerable small pancreatic cysts (yellow arrows). Figure 2. B: T2 weighted axial image with fat sat MRI shows a right renal cyst and innumerable small pancreatic cysts. There is a defect in the left kidney due to prior Renal Cell Carcinoma resection (green arrow). Discussion Von Hippel–Lindau disease is inherited in an autosomal dominant pattern and is caused by mutations of the von Hippel–Lindau tumor suppressor (vHL) gene on the short arm of chromosome 3 (3p25-26). The condition is rare with a prevalence of 1:39,000–53,000. Manifestations of vHL disease include: • Cerebellar hemangioblastoma 44-72% • Spinal hemangioblastoma 13-59% • Retinal hemangioblastoma 45-59% • Pheochromocytoma 0-60% • Renal cell carcinoma (usually clear cell type) 24-45% • Renal cysts 59-63% • Pancreatic cysts 50-91% • Pancreatic serous cystadenoma 12% • Pancreatic neuroendocrine tumor 5-17% • Papillary cystadenoma of the epididymis 10-60% To make the diagnosis of vHL: • Positive family history of vHL disease: one hemangioblastoma, pheochromocytoma or renal cell carcinoma. • No family history of vHL disease: at least two of the above tumors. Spinal hemangioblastomas are present in 13-59% of vHL patients and 80% of people with spinal hemangioblastomas have vHL disease. When associated with vHL disease, they occur at a younger age and have a worse prognosis. On imaging studies, hemangioblastomas may be solid, cystic, hemorrhagic, or mixed. The classic appearance is a cystic lesion with a solid enhancing mural nodule. Spinal cord lesions may be associated with a syrinx. Pancreatic cysts are extremely rare in the general population; therefore, the presence of a single cyst in an individual undergoing vHL disease screening because of a family history makes it highly likely that the person has vHL disease. CNS hemangioblastomas are usually surgically removed if they are symptomatic. Radiosurgery has also been shown to be effective in some cases. Renal tumors may be treated with partial nephrectomy or radiofrequency ablation. References: 1. Nordstrom-O'Brien M, van der Luijt RB, van Rooijen E, et al. (May 2010). "Genetic analysis of von Hippel-Lindau disease". Hum. Mutat. 31 (5): 521–37. doi:10.1002/humu.21219. 2. Leung RS, Biswas SV, Duncan M et-al. Imaging features of von Hippel-Lindau disease. Radiographics. 28 (1): 65-79. http://dx.doi.org/10.1148/rg.281075052 3. Hough DM, Stephens DH, Johnson CD et-al. Pancreatic lesions in von Hippel-Lindau disease: prevalence, clinical significance, and CT findings. AJR Am J Roentgenol. 1994;162. https://www.ajronline.org/doi/pdf/10.2214/ajr.162.5.8165988 4. Bachir Taouli, Mehdi Ghouadni, et al. Spectrum of Abdominal Imaging Findings in von Hippel-Lindau Disease. AJR:181, October 2003 149-1054. https://www.ajronline.org/doi/pdf/10.2214/ajr.162.5.8165988 Kevin Rice, MD has been the Medical Director of the Radiology Department as well as Chief of Staff of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice co-founded Global Radiology CME with Natalie Rice to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All Posts by Kevin M Rice, MD

Testicular mass in 40M • Xray of the Week This 40 year old male presented with a large tender right testicular mass and a left neck supraclavicular mass. What is the diagnosis? A: Ultrasound demonstrating a large right testicular heterogeneous mass. B: Ultrasound demonstrating testicular microlithiasis in the otherwise normal left testis. C: CT demonstrating left para-aortic lymphadenopathy. D: Ultrasound demonstrating a large biopsy-proven metastatic node in the left side of neck. Testicular seminoma, a type of germ cell tumor, is the most common testicular neoplasm, accounting for nearly half of all cases. Undescended testis has a 10-40 fold increase in the risk for seminoma, and there is also increased risk in the contralateral testis, even if it is within the scrotum. Presentation with distant disease is rare as most cases present with a painless mass confined to the testis (stage 1). Ultrasound findings are a hypoechoic intratesticular mass, usually confined within the tunica albuginea. Retroperitoneal lymphadenopathy (stage 2) is seen in 15% at presentation, while distant metastatic disease (stage 3) is only present in about 5% of patients. Treatment is orchiectomy, radiation therapy of the nodal disease, and chemotherapy. Prognosis is excellent with a greater than 90% five year survival. Testicular microlithiasis is present in about 50% of men with a germ cell tumor. (1,2) However, the association with testicular microlithiasis is very controversial. Some authorities recommend screening ultrasound on all patients with the condition (1). However, recent articles concluded that screening is necessary in only a select high risk population with the following characteristics: a personal history of germ cell tumor, first degree relative with testicular cancer, undescended or maldescended testis, infertility, or testicular atrophy. They state that patients with testicular microlithiasis and no risk factors should be screened the as the rest of the population, with monthly testicular self exam (2,3). References: 1. Richenberg J, Belfield J, Ramchandani P, et al. Testicular microlithiasis imaging and follow-up: guidelines of the ESUR scrotal imaging subcommittee. Eur Radiol. 2015;25(2):323-330. doi:10.1007/s00330-014-3437-x 2. Shanmugasundaram R, Singh JC, Kekre NS. Testicular microlithiasis: Is there an agreed protocol?. Indian J Urol. 2007;23(3):234-239. doi:10.4103/0970-1591.33442 3. Winter TC, Kim B, Lowrance WT, Middleton WD. Testicular Microlithiasis: What Should You Recommend?. AJR Am J Roentgenol. 2016;206(6):1164-1169. doi:10.2214/AJR.15.15226 Kevin Rice, MD is a radiologist with Renaissance Imaging Medical Associates. He has held many leadership positions including Radiology Department Chair and Chief of Staff. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. Follow Dr. Rice on Twitter @KevinRiceMD All Posts by Kevin M Rice, MD

RUQ Pain in 89F • Xray of the Week This 89 year old female presented to the Emergency Department with right upper quadrant abdominal pain. What is the differential diagnosis? Fig. 1 CT: Diffuse gallbladder wall thickening with surrounding mesenteric infiltration and lymphadenopathy. The patient underwent a cholecystectomy and the pathology was gallbladder carcinoma. Fig. 2 CT: Diffuse gallbladder wall thickening with surrounding mesenteric infiltration (red arrow) and lymphadenopathy (blue arrow). The patient underwent a cholecystectomy and the pathology was gallbladder carcinoma. Gallbladder carcinoma is an uncommon malignancy, which usually presents at an advanced stage. Greater than 90% of the histologic type is adenocarcinoma with squamous comprising most of the remainder. Most cases occur in the elderly population with F:M ratio of 4:1. At least 75% are associated with gallstones. Fig. 3 Porcelain gallbladder. CT scan with dense calcification throughout the wall of the gallbladder. Porcelain gallbladder (Fig. 3) is also highly correlated with gallbladder cancer as up to 25% of patients with diffuse calcification of the gallbladder wall go on to develop gallbladder cancer. Symptoms occur late in the disease and are usually related to local invasion resulting in biliary obstruction, gastric outlet obstruction or adjacent bowel obstruction. Prognosis is extremely poor with 5 year survival less than 5%. Fig. 4 Left: Ultrasound with polypoid masses in the gallbladder. Right: Axial CT and MRI with contrast. Polypoid masses in the gallbladder. Fig. 5 Axial CT with contrast. Large mass in the gallbladder fossa with direct extension and invasion of the adjacent liver. Case courtesy of Radswiki, a href=httpradiopaedia.orgRadiopaedia.orga. From the case a href=httpradiopaedia.orgcases11438rID 11438a Imaging features on CT, MRI, and US include focal or diffuse gallbladder wall thickening or a polypoid mass in the gallbladder lumen (Fig. 4). Due to late presentation, the majority of cases have a large mass replacing the gallbladder with direct extension to the liver and adjacent organs (Fig.5). Biliary dilatation is present in close to half of cases. This case presented with diffuse gallbladder wall thickening (Fig.1), a nonspecific finding. Differential diagnosis of diffuse gallbladder wall thickening includes acute and chronic cholecystitis, hepatic disease, hypoalbuminaemia, congestive heart failure, and adjacent inflammatory processes such as perforated duodenal ulcer or pancreatitis, diffuse adenomyomatosis of the gallbladder, and gallbladder carcinoma. In this case, the adjacent lymphadenopathy and mesenteric infiltration (Fig.2) are a clue to the diagnosis of gallbladder carcinoma. References: 1. Levy A, Murakata L, et-al. Gallbladder Carcinoma: Radiologic-Pathologic Correlation RadioGraphics 2001; 21:295–314 2. Furlan A, Ferris J, et-al. Gallbladder Carcinoma Update: Multimodality Imaging Evaluation, Staging, and Treatment Options. American Journal of Roentgenology. 2008;191: 1440-1447 3. Ralls PW, Quinn MF, Juttner HU et-al. Gallbladder wall thickening: patients without intrinsic gallbladder disease. AJR Am J Roentgenol. 1981;137 (1): 65-8. 4. Van breda vriesman AC, Engelbrecht MR, Smithuis RH et-al. Diffuse gallbladder wall thickening: differential diagnosis. AJR Am J Roentgenol. 2007;188 (2): 495-501. Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice serves as the Chair of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances and given as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice to launched Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. All posts by Kevin M. Rice, MD

New Right Breast Nodule in 62F • Xray of the Week 2016 • Week #29 This 62 year old female presented with a new right breast nodule. Mammogram and ultrasound were done. The patient had an ultrasound guided biopsy of the nodule, and subsequent excision. What rare type of breast cancer could this be? Figure 1. Left 2 images: CC Mammogram, shows a nodule with indistinct margins in the right breast medially. Figure 1. Right 2 images: MLO Mammogram, shows a nodule with indistinct margins in the right breast inferiorly. Figure 2. Left image: Mammogram spot compression view, shows the nodule with indistinct margins in the right breast medially(red arrow). Figure 2. Middle and right images: Ultrasound images show a hypoechoic right breast nodule with angular margin (red arrow), which is also taller than wide. Ultrasound biopsy was performed, followed by excision of the nodule and pathology was medullary breast cancer [Figs.3-4.] Figure 3. Low power view of medullary carcinoma with well circumscribed, "pushing" border. Histology images courtesy of Dennis Kasimian, MD. Chair of Pathology at Valley Presbyterian Hospital - Los Angeles, CA, USA. Figure 4. High power views. A: Syncytial growth of large pleomorphic cells with indistinct cell borders, large vesicular nuclei containing prominent nucleoli and numerous mitoses. B: Characteristic prominent lymphoplasmacytic inflammatory infiltrate at the periphery of the tumor. Histology images courtesy of Dennis Kasimian, MD. Chair of Pathology at Valley Presbyterian Hospital - Los Angeles, CA, USA. Medullary breast cancer is a rare form of breast cancer, comprising less than 2% of all breast tumors (1-3). The cancer tends to occur in younger patients, with a mean age at presentation of 46-54. The masses may be well circumscribed or have ill-defined margins (1-3). MRI is nonspecific usually with an oval or lobular shaped mass and rim enhancement with or without enhancing internal septations (4). Of note, ultrasound with a taller than wide appearance has a positive predictive value (PPV) for malignancy of 81% and angular margin on ultrasound has a PPV of 68% (5). Pathologically, the World Health Organization criteria for diagnosis is “a well circumscribed carcinoma composed of poorly differentiated cells with scant stroma and prominent lymphoid infiltration” (6,7). The classic presentation of medullary carcinoma involves a syncytial growth pattern of poorly-differentiated tumor cells with a high mitotic rate (6,7) [Figs.3-4.]. Syncytial pattern indicates a multinucleated mass of cytoplasm that is not separated into individual cells. (7) Although medullary breast cancer has a better prognosis than invasive ductal carcinoma, the nodules may rapidly enlarge (1-4). Related cases: Invasive Ductal Carcinoma of the Breast in 27 Year Old Phyllodes Tumor References: 1. Harvey JA. Unusual breast cancers: useful clues to expanding the differential diagnosis. Radiology. 2007;242 (3): 683-94. 2. Meyer JE, Amin E, Lindfors KK et-al. Medullary carcinoma of the breast: mammographic and US appearance. Radiology. 1989;170 (1): 79-82. 3. Yoo JL, Woo OH, Kim YK et-al. Can MR Imaging contribute in characterizing well-circumscribed breast carcinomas? Radiographics. 2010;30 (6): 1689-702 4. Jeong SJ, et al. Medullary Carcinoma of the Breast: MRI Findings American Journal of Roentgenology. 2012;198: http://www.ajronline.org/doi/pdf/10.2214/AJR.11.6944 5. Stavros AT, Thickman D, Rapp CL et-al. Solid breast nodules: use of sonography to distinguish between benign and malignant lesions. Radiology. 1995;196 (1): 123-34. 6. Rosen PP. Medullary carcinoma. In: Rosen's breast pathology. Philadelphia, Pa: Lippincott-Raven, 1997; 355–374. 7. Pedersen L, Schiødt T, Holck S, Zedeler K. The prognostic importance of syncytial growth pattern in medullary carcinoma of the breast. APMIS. 1990 Oct;98(10):921-6. Kevin M. Rice, MD is the President of Global Radiology CME Dr. Rice serves as the Chair of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances and as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. Follow Dr. Rice on Twitter @KevinRiceMD All Posts by Kevin M. Rice, MD

Headache and Dizziness • Xray of the Week 51 year old male with a left cerebellar mass. What is the diagnosis? Figure1. Left cerebellar Mass. Diagnosis? Figure1.A: MRI- T2 weighted axial image shows cystic lesion in left cerebellar hemisphere with mass effect (green arrow). There is hydrocephalus (not shown). B: MRI- T1 weighted axial image shows cystic lesion in left cerebellar hemisphere with mass effect. There is an enhancing mural nodule with small serpentine flow voids (green arrow). C: MRI- T1 sagittal image shows cystic lesion in left cerebellar hemisphere with mass effect. There is an enhancing mural nodule (green arrow). Approximately 20-25% of people with cerebellar hemangioblastomas have von Hippel–Lindau disease, and as in this case, the majority (75-80%) are sporadic. 44-72% of patients with von Hippel–Lindau (vHL disease have at least one cerebellar hemangioblastoma, and 13-59% have at least one spinal hemangioblastoma. 80% of people with spinal hemangioblastomas have vHL disease. When associated with vHL disease, they occur at a younger age and have a worse prognosis. The vast majority (95%) of intracranial hemangioblastomas occur in posterior fossa with 85% in the cerebellar hemisphere, 10% in the cerebellar vermis, and 5% in the medulla. On imaging studies, hemangioblastomas may be solid, cystic, hemorrhagic, or mixed. Seen in about 60% of cases, the classic appearance is a cystic lesion with a solid enhancing mural nodule. About 40% of cases consist only of the enhancing nodule. Often there are serpentine flow voids within the nodule due to the highly vascular nature of the tumor. Surgical resection is usually curative, however, up to 25% of cases have subsequent local recurrence. References: 1. Ho VB, Smirniotopoulos JG, Murphy FM et-al. Radiologic-pathologic correlation: hemangioblastoma. AJNR Am J Neuroradiol. 13 (5): 1343-52. 2. Leung RS, Biswas SV, Duncan M et-al. Imaging features of von Hippel-Lindau disease. Radiographics. 28 (1): 65-79. Kevin M. Rice, MD is the president of Global Radiology CME. He has served in many leadership roles including Chair of the Radiology Department and Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. He has been a radiologist with Renaissance Imaging Medical Associates since 2000. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All Posts by Kevin M Rice, MD