Meningiomas, the most common primary intracranial tumours (accounting for 36% of central nervous system neoplasms), typically present as well-circumscribed, extra-axial masses with homogeneous enhancement, dural tails and hyperostosis on imaging. However, 15% show atypical features that can mimic gliomas, metastases or abscesses, posing diagnostic challenges. This case series present seven histologically confirmed meningiomas illustrating atypical imaging appearances, identified retrospectively from the institutional teaching archive. The cases include intraventricular, septated cystic, perineural spread, circumscribed low T2 or FLAIR signal, frond-like low T2 or FLAIR signal, peritumoural cystic and radiation-induced meningiomas. All were WHO grade 1, except one radiation-induced grade 2 tumour. Key atypical imaging findings included heterogeneous enhancement, non-suppressing cystic components on FLAIR, brain invasion, absent dural tail and perilesional oedema. Although these features suggested higher-grade behaviour, they did not correlate with the final histological grade. Atypical imaging features in meningiomas may closely mimic more aggressive pathologies and do not reliably predict histological grade. Recognition of these variants is essential for accurate diagnosis and appropriate management. Contribution: This case series expands the recognised imaging spectrum of meningiomas by demonstrating diverse atypical appearances that closely mimic other intracranial pathologies. Importantly, it highlights the discordance between aggressive imaging features and histological grade, reinforcing that atypical morphology should not be equated with higher-grade disease.
Multiple plum pit impaction at the ileocaecal junction is an under-recognised cause of right lower quadrant pathology in Africa. A 54-year-old man presented with chronic abdominal pain, haematemesis and peritonism. CT confirmed partial luminal impaction with secondary appendiceal region inflammation. Conservative management was successful. Dietary history, careful plain radiograph review and CT with volumetric reconstruction were key diagnostic steps in this unusual presentation. Contribution: This case documents an uncommon occurrence of ileocaecal impaction from multiple plum pits with secondary appendiceal region inflammation, while highlighting volumetric CT reconstruction as a valuable diagnostic adjunct in confirming pit morphology.
Background: Penetrating neck injuries (PNIs) are common, yet imaging protocols for asymptomatic patients remain debated in resource-limited settings. Objectives: Describe the clinical course, imaging findings and outcomes of asymptomatic PNI patients who underwent CT angiography and oesophagography (CTA&O) at a tertiary hospital in the Western Cape, South Africa. Method: A retrospective review of asymptomatic PNI patients who underwent CTA&O at Tygerberg Hospital between 01 January 2021 and 30 June 2022. Demographics, mechanism, imaging findings and outcomes were extracted from electronic hospital systems. Results: Ninety-one patients were included (median age 30 years; 88 [97%] males; 84 [92%] stab wounds). Sixty (66%) had a normal CTA&O; 31 (34%) had 40 abnormalities (aerodigestive tract: n = 28 [70%]; vascular: n = 7 [17.5%]; orthopaedic n = 5 [12.5%]). Of these, 18/31 (58%) had no further investigation and 13/31 (42%) had 14 investigations. Most 17/18 (94%) suspected aerodigestive injury investigations were negative. One (3%) required facial artery embolization. There were no complications or deaths. Conclusion: CTA&O identified PNI-related radiological abnormalities in one-third of the asymptomatic PNI patients. Although most did not represent clinically important injuries requiring intervention, CTA&O is valuable for screening. These findings may improve CTA&O interpretation and reduce downstream investigations while ensuring safety. Contribution: This study provides context-specific evidence on CTA&O findings in asymptomatic PNI patients. Distinguishing common PNI-related radiological abnormalities from clinically important findings may improve CTA&O interpretation and improve resource use.
Background: Radiological imaging is crucial for diagnosing hepatic cystic echinococcosis (HCE) and assessing complications. Case studies suggest HCE with human immunodeficiency virus (HIV) co-infection is associated with larger, more multilocular cysts, increased extrahepatic dissemination, rupture, secondary infection and biliary invasion. Objectives: To compare the radiological presentation of HCE in HIV-positive (HIV+) and HIV-negative (HIV-) patients and determine whether HIV co-infection influences imaging features. Method: Pre-operative imaging (chest X-rays, ultrasound, CT and MRI of HIV+ and HIV- HCE patients at our tertiary facility between 2011 and 2023 was reviewed. Cyst characteristics and disease staging (WHO and Gharbi classifications) were independently assessed by two blinded radiology specialists. Results: Eighty-six patients (45 HIV+, 63 females) were included. Single unilocular cysts predominated (37.8% HIV+ and 36.6% HIV-). Extrahepatic cysts occurred in 40% of HIV+ and 34.1% of HIV- patients. Right hepatic lobe involvement was more common in HIV+ patients (86% vs. 62.5%). Median cyst diameter was 14.2cm in HIV+ vs. 11.3cm in HIV- patients. Rates of biliary communication, bile duct dilatation, intraperitoneal cyst rupture and cyst infection were similar in HIV+ versus HIV- patients (11.1% vs 12.2%, 11.1% vs 17.1%, 20% vs. 26.8% and 8.9% vs. 19.5%, respectively), as was WHO and Gharbi stage distributions. Conclusion: HIV prevalence (52.3%) exceeded the national prevalence (12.7%), supporting hypotheses that HCE may self-limit less frequently in HIV+ patients. However, co-infection was not associated with more advanced or complicated radiological disease. Contribution: Imaging remains central to HCE diagnosis and management, particularly in HIV+ individuals, where serological testing is less reliable.
Concurrent pituitary apoplexy and ruptured intracranial aneurysm are rare, but potentially fatal, if unrecognised. A 53-year-old hypertensive woman presented with acute confusion and transient hemiparesis. Brain CT demonstrated a haemorrhagic sellar-suprasellar mass with atypical subarachnoid and intraventricular haemorrhage. CT angiography (CTA) confirmed a ruptured right middle cerebral artery (MCA) aneurysm and two additional unruptured aneurysms. Subsequent endovascular coil embolisation was successful. The pituitary macroadenoma was managed conservatively. Contribution:Early recognition using haemorrhage pattern analysis and CTA is critical to avoid missed dual pathology in pituitary apoplexy and to guide timely management.
Supra-hepatic gallbladder is an exceptionally rare form of ectopic gallbladder. Its identification can be particularly challenging in patients with cirrhosis, where distortion of hepatic architecture obscures expected anatomical relationships. This report describes a case of supra-hepatic gallbladder in a patient with chronic liver disease, in which surrounding inflammatory oedema mimicked intra-abdominal fat necrosis, creating a significant diagnostic dilemma on imaging. Contribution: This case underscores the importance of recognizing unusual gallbladder locations, understanding their embryological basis, and being aware of potential imaging pitfalls and complications associated with ectopic positioning.
Neuroglial heterotopia is a congenital developmental anomaly characterised by mature glial tissue located outside the cranial cavity or spinal canal, without intracranial communication. A 12-month-old girl presented with an enlarging left cervical mass and worsening respiratory symptoms. MRI demonstrated a trans-spatial, multiseptated cystic lesion in the left parotid and submandibular spaces, extending medially into the parapharyngeal space with upper airway compression. No intracranial communication was identified. The postoperative specimen revealed mature glial tissue interspersed within fibroconnective stroma, confirming neuroglial heterotopia. Contribution: This case highlights the importance of considering neuroglial heterotopia in the differential diagnosis for congenital or progressive cystic neck masses in infants. Although MRI plays a central role in defining the lesion extent, a definitive diagnosis requires histopathological confirmation.
Background: The examination of the Fellowship of the College of Diagnostic Radiologists South Africa (FC Rad Diag [SA]), conducted by the Colleges of Medicine of South Africa (CMSA), is the national exit examination for qualification as a radiology specialist. There is limited published evidence on South African pass rates and factors influencing success in the FC Rad Diag (SA) Part 2 examination. Objectives: This study aimed to determine the pass rate and factors associated with success in the FC Rad Diag (SA) Part 2 examination. Method: A descriptive quantitative study was conducted using CMSA examination data from 2015 to 2023. Descriptive and inferential analyses were used to assess associations between candidate characteristics and examination outcomes. Results: A total of 377 candidates sat in the examination, with an overall pass rate of 85.7% (323/377). Candidates who failed were older (median age 42 years old [37–47 years] vs. 35 years old [33–38 years]; p 0.001). Higher pass rates were observed among candidates in registrar training posts compared with medical officers (80.2% [259/323] vs. 19.8% [64/323]; p 0.001). Successful candidates had more recently completed their Bachelor of Medicine and Bachelor of Surgery (MBBCh /MBChB) (median 11 [9–13] vs. 14.5 [12–17] years; p 0.001) and Part 1 examinations (4 years [3–5 years] vs 5 years [4–6 years]; p 0.001). They also had fewer examination attempts (median 1 [1–2] vs. 3.5 [2–5]; p 0.001). Conclusion: Success in the FC Rad Diag (SA) Part 2 examination is influenced by multiple candidate-related factors. Contribution: Targeted academic support programmes should focus on candidates at higher risk of failure, particularly those outside formal registrar posts and those with multiple examination attempts, to improve equity and overall specialist throughput nationally.
Neuroendocrine neoplasms (NENs) are rare, heterogeneous tumours arising from neuroendocrine cells located throughout the body. The gastrointestinal (GI) tract is the most frequent site of origin, but lesions in unusual locations such as the duodenum, gallbladder and rectum are diagnostically challenging because of their atypical presentation and radiological appearance. This series describes three patients with NENs at uncommon GI sites, highlighting imaging findings, histopathological features and management tailored to the tumour site and grade. Contribution: Although rare, NENs at uncommon GI sites should be included in the differential diagnosis of hypervascular lesions. Accurate diagnosis requires integration of cross-sectional imaging, somatostatin-receptor PET and immunohistochemistry, guiding individualised therapy.
Background: HIV-associated large-vessel vasculopathy (HALVV), previously described as a distinct entity characterised by young patients with atypical aneurysmal sites and few traditional risk factors, is now recognised across a wider age range in the antiretroviral therapy (ART) era. It continues to demonstrate aneurysmal and occlusive patterns distinct from conventional atherosclerotic disease. Despite its clinical importance, systematic correlations between imaging findings, management strategies and outcomes remain limited, particularly in sub-Saharan Africa. Objectives: This study aimed to characterise the multi-detector computed tomography (MDCT) angiographic features of HALVV and assess their association with intervention and clinical outcomes. Method: A retrospective observational study was conducted at Inkosi Albert Luthuli Central Hospital (IALCH) between 2018 and 2023. HIV-positive adults with extracranial large-vessel vasculopathy undergoing MDCT angiography were included. Associations between imaging findings, intervention and outcomes were assessed using the Pearson’s chi-squared test (χ2) and logistic regression to identify predictors of adverse outcomes. Results: A total of 210 patients were included; 90 had aneurysmal disease, and 120 had occlusive disease. Fusiform aneurysms predominated (55.6%), and endovascular intervention was performed in 51.1% of cases. Device-related complications included type I and II endoleaks (13.3%) and stent failure (4.4%). Common iliac artery aneurysm independently predicted adverse device-related outcomes. Occlusive disease was predominantly long segment (85.8%), frequently multivessel (≥ 3 vessels in 70.8%) and associated with a high amputation rate (53.4%). Conclusion: Multi-detector CT angiography demonstrates distinct HALVV phenotypes with direct management implications. Endovascular treatment of aneurysmal HALVV shows favourable short-term outcomes but requires vigilant surveillance, particularly with iliac involvement. Occlusive HALVV is characterised by diffuse disease and poor limb salvage outcomes. Contribution: This study provides ART-era MDCT imaging–outcome correlations for HALVV in a South African tertiary setting.
Communicating bronchopulmonary foregut malformations (CBPFM) are rare developmental tracheo-bronchial anomalies characterised by a patent communication between the respiratory system and upper gastrointestinal tract. Clinical diagnosis is challenging because of non-specific symptoms and overlapping clinical presentation with tracheo-oesophageal fistula. Imaging plays a key role in early diagnosis and management of this rare entity. This case report describes two cases of CBPFM, highlighting the key imaging findings on various modalities along with a brief review of literature. Contribution: This case report underscores the typical imaging features of CBPFM and the role of imaging in differentiating it from the more common tracheo-oesophageal fistula.
Intraductal oncocytic papillary neoplasm of the pancreas (IOPN-P) is a rare cystic epithelial tumour with distinctive imaging, cytological and histological features. This case report describes a 65-year-old female who presented with abdominal pain and vomiting for 6 months and was later diagnosed with IOPN-P. Multimodality imaging, including ultrasound, contrast-enhanced CT, MRI, MRCP and endoscopic ultrasound, played an important role in lesion evaluation. Cytopathological evaluation and immunohistochemistry confirmed the diagnosis. Contribution: The case highlights the importance of recognising radiological features of IOPN-P to differentiate it from more aggressive pancreatic neoplasms.
Bilateral isolated cerebral peduncle infarction is a rare stroke, previously reported only in adults. This report describes a paediatric burns patient with preceding cardiac arrest who developed subtle neurology. Imaging revealed bilateral isolated peduncle infarcts with hypoplasia of the left posterior communicating and vertebral arteries. Despite supportive care, the patient deteriorated and demised. This case highlights the vulnerability of peduncular perforators to haemodynamic instability and emphasises the need for early imaging in the detection of paediatric stroke. Contribution: Isolated bilateral cerebral peduncle infarction is a rare form of stroke, particularly in the paediatric population, and is associated with a poor prognosis. Imaging plays an important role in the early diagnosis of this type of stroke.
Vocal cord palsy (VCP) can be caused by laryngeal and extra-laryngeal pathologies affecting the recurrent laryngeal nerves (RLNs). Many cases of left VCP related to cardiovascular pathologies have been documented. However, right VCP associated with cardiovocal (Ortner) syndrome is an atypical and rare presentation. A case of right VCP caused by a right aortic arch (RAA) and Kommerell diverticulum (KD), diagnosed on CT angiography, and its association with the variant course of the right RLN, is described. Contribution: This case report highlights the rarity of cardiovocal syndrome causing a right VCP and the association of a RAA with the variant course of the right RLN hooking around the RAA in place of the right subclavian artery.
Background: Blunt chest trauma (BCT) is a frequent manifestation of traumatic injury, either as isolated thoracic injury or in the setting of polytrauma. Objectives: Several chest trauma scores (CTSs) exist based on clinical, biochemical and imaging findings to assist in the risk stratification of patients who have sustained blunt chest trauma. These injuries are often not initially clinically evident and a risk stratification tool serves to identify patients at risk for pulmonary compromise and to establish early diagnostic and therapeutic strategies to improve morbidity and mortality. Method: Patient data were obtained from the Greys Hospital Emergency Department’s triage books. The images for patients within the study sample were scored under the categories of age, number of rib fractures, bilaterality of rib fractures, presence and significance of pulmonary contusions, and pleural-based injury. Patients were classified as either critical or non-critical using final disposition as a surrogate. The seminal CTS was initially calculated, following which a novel South African chest trauma score (SA-CTS) was hypothesised and computed based on the chest X-ray alone for ease of applicability and reproducibility in resource-constrained settings. Results: A conventional CTS ≥ 5 was clinically significant for a critical outcome. However, with the SA-CTS, a score ≥ 4 was found to be statistically significant. Age was not found to be a significant contributing factor. Pleural-based injuries were found to be contributory factors to a critical outcome. Conclusion: Clinical prediction models serve in the risk stratification and early identification and pre-emptive management of patients at high risk for clinical decompensation. Based on the results, the incorporation of the SA-CTS into daily practice in the management of BCT patients is proposed. Contribution: This will prove especially useful in triggering early up-referral for both advanced imaging and tertiary level care in a resource limited setting.
Splenic pathologies, often overlooked in abdominal imaging, encompass a broad spectrum of imaging appearances and diagnostic challenges, including congenital anomalies, benign cysts, infarcts, trauma, vascular lesions, infections and neoplasms. Recognising these entities is crucial to distinguish incidental benign findings from potentially life-threatening conditions. This pictorial review illustrates the spectrum through 20 cases, including a rare case of a wandering spleen complicated by torsion and auto-infarction that demonstrates the classical ‘whorled pedicle’ and ‘twisted vascular pedicle’ signs. Ultrasound, CT, MRI and PET-CT images demonstrate typical and atypical features, emphasising key differentiating points and teaching pearls. Although not exhaustive, this overview underscores that closer scrutiny of the spleen is rewarding: a structured approach focusing on lesion location, enhancement patterns and clinical context improves diagnostic accuracy and guides timely management.
This case report highlights the findings and treatment in a patient with a splenic arteriovenous fistula causing non-cirrhotic portal hypertension (NCPH). Splenic arteriovenous malformations (AVMs) are rare, and their management using percutaneous embolisation is an emerging alternative modality as opposed to open surgical intervention. Contribution: Similar cases have been published; however, few highlight the management role of interventional radiology.
Congenital depressed skull fractures (ping-pong fractures) without obstetric trauma are rare. A term male neonate delivered via uncomplicated caesarean section, demonstrated a right parieto-temporal skull depression (5 cm × 5 cm) at birth. Computed tomography revealed a 4 mm parietal depression without intracranial injury. No instrumental delivery or maternal trauma were present. The likely aetiology was intrauterine compression (‘faulty foetal packing’). The patient was managed conservatively with close follow-up. Contribution: This case underscores the importance of perinatal history and neuroimaging in distinguishing spontaneous from traumatic fractures and supports conservative management in neurologically intact infants.
Conductive hearing loss (CHL) results from impaired mechanical transmission of sound through the external or middle ear and is commonly associated with conditions such as otosclerosis, cholesteatoma, ossicular discontinuity, congenital malformations and trauma. Less frequently, it may arise from vascular or neoplastic lesions. Imaging plays a central role in the evaluation of CHL, with high-resolution CT (HRCT) regarded as the gold standard for initial assessment because of its superior spatial resolution in detecting bony pathologies, including fenestral otosclerosis, ossicular chain defects, third-window lesions and trauma-related disruptions. MRI complements HRCT by providing excellent soft tissue contrast, facilitating the detection of postoperative cholesteatoma via non-echo-planar diffusion-weighted imaging and the characterisation of vascular tumours such as glomus tympanicum. CT angiography (CTA), while not routinely indicated, can be valuable for identifying vascular anomalies and aiding surgical planning in selected cases. Technical considerations, such as optimised scan parameters, strategies for radiation dose reduction in paediatric patients and the integration of multiple imaging modalities, are essential for accurate diagnosis and effective treatment planning. Collectively, HRCT, MRI and CTA provide a structured, evidence-based framework for the comprehensive evaluation and management of CHL. Contribution: This review synthesises current evidence on HRCT, MRI and CTA in the assessment of CHL, emphasising their complementary roles, protocol optimisation and multimodal integration to enhance diagnostic accuracy and surgical guidance in both paediatric and adult populations.
Background:Many South African peripheral medical centres lack direct access to CT scans or neurosurgery. The Glasgow Coma Scale (GCS), used with or without other findings, remains widely utilised in traumatic brain injury (TBI) assessments with lack of standardisation between centres. There is limited data from South Africa (SA) correlating GCS scores to CT imaging in TBI. Objectives:This study aimed to assess CT findings at various GCS levels to determine whether GCS was a reliable indicator for imaging and referral. Method:A retrospective review of 385 patients categorised with mild, moderate or severe TBI was performed. The initial non-sedated post-resuscitation GCS score and initial CT brain findings were compared using the chi-square and Fisher's exact tests. Results:Increased intracranial pressure and subdural haemorrhage occurred in 41.7% and 53.7% of patients with GCS 9-12, respectively, and 30.5% and 41.4% of patients with GCS 13-15, respectively. The highest incidence of depressed skull fractures (51.3%; 95% confidence interval [CI], 43.2-59.3%; p < 0.001) and pneumocephalus (25.6%; 95% CI, 42.2-56.4; p < 0.001) were reported in the CGS 13-15 category. Neurosurgical intervention was required in 83.2% and 73.0% of patients with GCS scores of 9-12 and 13-15, respectively. Conclusion:The severe category of GCS predicts imaging and neurosurgery requirements while the mild to moderate categories underpredict the need for patient referral. Contribution:This study provides rationale for the development of a local, standardised assessment tool to guide referral of TBI patients for imaging in resource-limited settings.
