Acute back pain with neurological symptoms is a medical emergency. Here we report a case of severe degenerative spine disease with raised inflammatory markers due to an atypical cause.

MR arthrography (MRA) has previously been the radiological gold standard for investigating labral and chondral lesions of the hip joint. In recent years, 3T MRI has demonstrated comparable accuracy, being adopted as the first-line imaging investigation in many institutions. We compare the associated increased cost and radiation dose of the fluoroscopic component of the MRA compared to MRI. In this retrospective review over 2 years, 120 patients (mean age 27.3 years ± 13.2, range 8–67) underwent 3T MRA or non-contrast 3T MRI. Three musculoskeletal radiologists reported the data independently. Primary objectives included cost-comparison between each and radiation dose of the fluoroscopic component of the MRA. Secondary objectives included comparing detection of pathology involving the acetabular labrum, femoral cartilage, and acetabular cartilage. Then, 58 (48

Herniation of the ureters into the inguinal canal is a rare but recognized phenomenon. It may be noted incidentally on cross-sectional imaging, or when it presents with complications such as obstruction or infection. It is important to highlight the finding when present, as surgical intervention will be required in the majority of cases. We present a case of a 91-year-old man who developed obstructive uropathy and pyelonephritis due to inguinal herniation of the ureter.

Objectives To assess if brake response times are altered pre and post CT-guided cervical spine nerve root injections.Methods Brake response times were assessed before and after CT-guided cervical spine nerve root injections in a cohort of patients. The average of 3 brake response times was recorded before and 30 min after injection. Statistical analysis was performed using GraphPad. A paired Student t-test was used to compare the times before and after the injections.Results Forty patients were included in this study. The mean age was 55 years. There were 17 male and 23 female patients. There was no significant difference in the mean pre and post CT-guided cervical spine nerve root injection brake response times; 0.94 s (range 0.4-1.2 s) and 0.93 s (range 0.5-1.25 s), respectively (P = .77).Conclusions Brake response time did not significantly differ pre and 30 min post CT-guided cervical spine nerve root injections.Advances in knowledge To the authors' best knowledge, there are no current studies assessing brake response times post CT-guided cervical spine nerve root injections. While driving safety cannot be proven by a single metric, it is a useful study in demonstrating that this is not inhibited in a cohort of patients.

Objectives To assess the most common lower limb acute muscle injuries on MRI imaging in a national specialist centre for orthopaedics and sports medicine and to explore potential gender differences. Methods Over a 3-year time period, all MRI lower limb studies with acute muscle injury (AMI) were reviewed. A British Athletics muscle injury classification (BAMIC) was given and a statistical analysis was performed. Results A total of 195 AMIs were diagnosed: 177 (91%) male and 18 (9%) female injuries (M to F = 9.8:1). The most common lower limb AMIs were BAMIC grade 1a injuries ( n = 48, 25%). The most commonly injured muscle was biceps femoris ( n = 87, 45%), specifically grade 1b and grade 2b injuries. There was no significant difference in age between men and women with acute lower limb muscle injuries ( p = 0.19). Females were 1.5 times more likely to have a lower grade AMI than males, although this did not reach statistical significance ( p = 0.7) owing to a striking lower number of female patients. There was no significant difference between genders in the likelihood of sustaining a hamstring or quadricep AMI (hamstrings OR = 2.47, p = 0.14 and quadriceps OR = 0.926, p 0.99). Conclusions Grade 1a is the most common lower limb AMI grade in our institution, accounting for 25%. Biceps femoris is the most commonly injured muscle (45%) with grade 1b and grade 2b being the most frequently encountered grades of biceps femoris injuries. Lower-grade injuries are more common in females compared to males, although not significantly so. Further studies are required to explore possible reasons for this gender gap.

A 34-year-old female presented to the emergency department with neck pain, dysphonia and dysphagia ten days after a fall from an electric scooter. Subsequent computed tomography of the neck revealed bilateral vertebral artery and unilateral internal carotid artery non-occlusive dissections, which were managed with antiplatelet therapy. This case describes mechanisms of injury, clinical presentation, imaging appearances, and subsequent management of cervical artery dissection.

We report the case of a 50-year old woman with a known history of lipodystrophy. A pelvic radiograph was taken for the investigation of right hip pain. The image shown demonstrates an indeterminate artefact projected over the right iliac fossa. A previous CT renal study was reviewed, demonstrating the same device in the subcutaneous tissues of the contralateral left lower quadrant which on close inspection was consistent with a continuous glucose monitoring device. Features of lipodystrophy were also noted on review of the CT imaging. Although many devices such as vagal stimulators and prosthetic valves are easily recognized by radiologists on radiographic images, they may be less familiar with devices such as continuous glucose monitors. The aim of this case report is to familiarize radiologists with the appearances of continuous glucose monitors to allow for effective reporting.

Objective: The purpose of this study was to evaluate the technical success and complication rates of image-guided lumbar puncture (IGLP) and to evaluate for differences in approach employed to help establish the optimum technique. Methods: A retrospective search of the hospital picture archiving and communications system was performed to identify all IGLPs that had taken place over a 5-year period. Radiology reports and the electronic medical record were examined to identify technical parameters and complications associated with each procedure. Results: The technical success rate was 96% (219/228). 69.4% (n = 161) had a previously failed bedside attempt. The rate of complications was 0.01% (n = 2). No major complications were observed. There was no difference in the rates of failure (2.4% vs 3.6%, p = 0.68) or complications (0.008% vs 0.012%, p = 1) between interlaminar and interspinous approaches. Conclusion: IGLP is a safe procedure with a high rate of technical success. Where a difficult bedside attempt is anticipated, it is reasonable to forego this and proceed directly to IGLP. Advances in knowledge: : This paper helps to confirm what is already assumed about a common radiological procedure. This is important as there has been a shift from bedside technique to most lumbar punctures being performed via image guidance.

Objective: Acetabular paralabral cysts are common and are almost always associated with labral tears. Uncommonly, they extend into the periacetabular soft tissues or may propagate along peripheral nerves causing pain and hip dysfunction. The aim was to evaluate the clinical and MRI presentations of such cases including perineural propagation. Methods: Retrospective cross-sectional study with a search of electronic health records for cases of acetabular paralabral cysts demonstrating perineural propagation was performed. Clinical and MR imaging features were tabulated after re-review by experienced musculoskeletal radiologists, and available outcomes were recorded. Descriptive statistics were performed. Results: 14 cases were recorded. The mean age was 56.9 years (range = 30–79 years) and female:male ratio was 1:2.6. The commonest presenting complaint was hip pain (10/14, 71.4%). Other complaints included groin pain, perineal pain and hip dysfunction. No symptoms were attributed to the acetabular paralabral cyst in 3/14 patients (21.4%). None had foot drop. The cysts were multilocular in all cases and were homogenously T2 hyperintense in 13/14 (92.9%). Labral tears were identified in 11/14 cases (78.6%). The sciatic nerve was most commonly involved in 5/14 cases (35.7%) with the obturator, medial femoral cutaneous nerve, femoral nerve, superior and inferior gluteal nerves also affected. No intervention was undertaken in 9/14 cases (64.3%). 5/14 (35.7%) underwent image guided aspiration and corticosteroid injection. 4/5 such patients reported reduced pain following the procedure. Conclusion: Paralabral cysts demonstrating perineural propagation are uncommon and exhibit varied presentations. Most patients who underwent image-guided or surgical interventions reported an improvement in symptoms. Advances in knowledge.: This is the first description of a series of patients with acetabular paralabral cysts demonstrating perineural propagation in the literature. A comprehensive description of their clinical and imaging characteristics and interventions/outcomes where relevant is provided.

Aim The purpose of our study was to review a large cohort of athletes of all levels presenting with groin pain who underwent investigation with MRI and to determine what the commonest patterns of injury were. We aimed to explore whether particular findings were commonly found in association and whether measurable gender differences exist in the incidence of specific injuries. Materials and methods Imaging records were reviewed to identify MRI studies of the pelvis performed for the investigation of groin pain in patients who were active in sports/athletic pursuits. Findings were classified and recorded as follows: injury to the common rectus abdominis/adductor longus origin, injury to the short adductor muscles, pubic bone oedema, pubic symphysis degenerative changes, hip joint injury and ‘other’. The prevalence of specific injuries in female athletes compared to males was analysed using relative risk ratios. Results A total of 470 athletes underwent MRI for the investigation of groin pain during the study period. Forty-six were female, and 424 were male. Female athletes were significantly less likely to have rectus abdominis-adductor longus (RR = 0.31, p = .017), short adductor (RR = 0.14, p = .005) or hip (RR = 0.41, p = .003) injuries. Pubic bone degenerative changes were much more common in female athletes (RR = 7.37, p = .002). Conclusion Significant gender differences exist in the frequency with which specific injuries are observed. Female athletes are also significantly underrepresented; this is likely a multifactorial phenomenon; however, the possibility of unconscious referrer bias must be considered.

Neurofibromatosis type 1 is an autosomal dominant genetic disorder with multisystem manifestations including vascular abnormalities. The condition is also associated with an increased risk of both ischemic and hemorrhagic stroke. Here we report a case of a 60-year-old male with known neurofibromatosis who presented with right sided hemiparesis. Neuroimaging work-up revealed left internal carotid artery dissection and tandem occlusion of the left internal carotid artery and left middle cerebral artery. There was associated territorial ischemic infarction. The patient was found to have extensive intra and extra cranial vasculopathy including gross basilar dolichoectasia and a right-sided cervical internal carotid artery pseudoaneurysm. This case highlights the clinical significance of neurofibromatosis associated vasculopathy which can result in stroke.

This paper demonstrates a case of multiple glomangiomas, or glomangiomatosis, including clinical presentation, imaging appearances, and subsequent management. Differentiating features from typical glomus tumors are described. To the best of our knowledge, this is the first reported case of a glomangioma involving the distal tibiofibular syndesmosis.

The rotator cuff is a group of muscles and tendons which support the shoulder joint. Rotator cuff disease is a frequent cause of morbidity in adulthood. The aims of his study are to determine the prevalence and patterns of rotator cuff derangement in symptomatic patients using MRI and to attempt to correlate identified patterns of disease with age and gender Five hundred ninety-seven patients attending for MRI of the shoulder with atraumatic shoulder pain were included for study. Patients’ age and gender was recorded. Record was made of the presence or absence of rotator cuff derangement and of degenerative change in the AC and glenohumeral joints. Correlation was made between age and gender. There were 358 males (60%) and 239 females (40%) with a mean age of 49.4 ± 17.1 years. Subacromial bursitis was identified in 517 patients. A normal supraspinatus tendon was identified in 219 patients and supraspinatus full thickness tearing was identified in 102 patients. A normal AC joint was identified in 267 patients while degenerative AC joint changes were identified in 370 patients. A significant correlation was identified between age and rotator cuff derangement (p < .001) and between age and AC joint derangement (p < .001). No significant difference was identified between gender and patterns of cuff derangement The extent of rotator cuff and AC joint derangement increases with ageing. Impingement appears to trigger a cascade of events in sequence, from isolated subacromial bursitis through to supraspinatus tendon tearing. Patterns of rotator cuff derangement are similar in men and women.

Voriconazole is a broad-spectrum triazole antifungal used to treat invasive fungal infections. It is commonly used prophylactically in immunocompromized patient cohorts, including transplant recipients. Diffuse periostitis is a very rare complication of chronic voriconazole use. It is associated with diffuse bone pain, elevated serum alkaline phosphatase and fluorine levels. Characteristic imaging findings include periosteal thickening with a dense, nodular, irregular and often bilateral pattern. We describe the case of a 71-year-old female who presented with multifocal bone pain six years following double lung transplantation. Her post transplantation course had been complicated by a life threatening episode of sepsis secondary to Scedosporium apiospermum, a rare invasive fungal infection following which lifelong prophylaxis with oral Voriconazole was commenced. We discuss the characteristic clinical and imaging manifestations of this rare condition.

Intra-articular viscoelastic supplements are commonly administered by musculoskeletal radiologists for the treatment of symptomatic osteoarthritis (OA). This article provides an overview of the putative mechanism of action of the agents, a brief review of the evidence base underlying the practice, a commentary on some of the major society guidelines regarding the treatment, and a description of the adverse events that are associated with intra-articular hyaluronic acid administration.

Complications in musculoskeletal interventions are rare and where they do occur tend to be minor, and often short-lived or self-limiting. Nonetheless, the potential for significant complications exists, and a thorough understanding of both the mechanisms which contribute and the manner in which they may clinically present is of critical importance for all musculoskeletal radiologists involved in performing procedures, both to mitigate against the occurrence of complications and to aid rapid recognition. The purpose of this review is to analyse the relevant literature to establish the frequency with which complications occur following musculoskeletal intervention. Furthermore, we highlight some of the more commonly discussed and feared complications in musculoskeletal intervention, such as the risk of infection, potential deleterious articular consequences including accelerated joint destruction and the poorly understood and often underestimated systemic effects of locally injected corticosteroids. We also consider both extremely rare but emergent scenarios such as anaphylactic reactions to medications, and much more common but less significant complications such as post-procedural pain. We suggest that meticulous attention to detail including strict adherence to aseptic technique and precise needle placement may reduce the frequency with which complications occur.

Background and Objectives In pooled analyses of endarterectomy trials for symptomatic carotid stenosis, several subgroups experienced no net benefit from revascularization. The validated symptomatic carotid atheroma inflammation lumen-stenosis (SCAIL) score includes stenosis severity and inflammation measured by PET and improves the identification of patients with recurrent stroke compared with lumen-stenosis alone. We investigated whether the SCAIL score improves the identification of recurrent stroke in subgroups with uncertain benefit from revascularization in endarterectomy trials. Methods We did an individual-participant data pooled analysis of 3 prospective cohort studies (Dublin Carotid Atherosclerosis Study [DUCASS], 2008-2011; Biomarkers and Imaging of Vulnerable Atherosclerosis in Symptomatic Carotid Artery Disease [BIOVASC], 2014-2018; Barcelona Plaque Study, 2015-2018). Eligible patients had a recent nonsevere (modified Rankin Scale score <= 3) anterior circulation ischemic stroke/TIA and ipsilateral mild carotid stenosis (<50%); ipsilateral moderate carotid stenosis (50%-69%) plus at least 1 of female sex, age <65 years, diabetes mellitus, TIA, or delay >14 days to revascularization; or monocular loss of vision. Patients underwent coregistered carotid F-18-fluorodeoxyglucosePET/CT angiography (<= 7 days from inclusion). The primary outcome was 90-day ipsilateral ischemic stroke. Multivariable Cox regression modeling was performed. Results We included 135 patients. All patients started optimal modern-era medical treatment at admission, and 62 (45.9%) underwent carotid revascularization (36 within the first 14 days and 26 beyond). At 90 days, 18 (13.3%) patients had experienced at least 1 stroke recurrence. The risk of recurrence increased progressively according to the SCAIL score (0.0% in patients scoring 0-1, 15.1% scoring 2-3, and 26.7% scoring 4-5; p = 0.04). The adjusted (age, smoking, hypertension, diabetes, carotid revascularization, antiplatelets and statins) hazard ratio for ipsilateral recurrent stroke per 1-point SCAIL increase was 2.16 (95% CI 1.32-3.53; p = 0.002). A score >= 2 had a sensitivity of 100% for recurrence. Discussion The SCAIL score improved the identification of early recurrent stroke in subgroups who did not experience benefit in endarterectomy trials. Randomized trials are needed to test whether a combined stenosis-inflammation strategy will improve selection for carotid revascularization when benefit is currently uncertain. Classification of Evidence This study provides Class II evidence that, in patients with recent anterior circulation ischemic stroke who do not benefit from carotid revascularization, the SCAIL score accurately distinguishes those at risk for recurrent ipsilateral ischemic stroke.

Objectives Patients with TIA and minor stroke commonly undergo CT and CTA in the emergency department with subsequent MRI with MRA for further workup. The purpose of this study was to review outpatient MRIs for TIA/stroke patients to assess the additional benefit, if any, of the MRA sequence in the detection of intracranial atherosclerotic disease in patients for whom CTA had already been performed. Methods The radiology reports of outpatient MRIs of the brain for TIA/minor stroke patients were retrospectively reviewed via the hospital PACS system. Following this, the imaging report from the patient's initial presentation to the emergency department was reviewed. This index imaging and subsequent MRI were compared to assess the incidence of new vascular findings detected on the MRA sequence in patients for whom CTA had already been performed. Where new lesions had been identified at follow-up, the imaging was retroactively reviewed to assess if they were present on the index imaging. Results Two hundred seven consecutive patients were reviewed. Significant (> 50%) intracranial atherosclerotic disease was present on MRA in 18 patients (8.7%). This was a new finding in 11 patients. Five had initial CTA where the atherosclerosis was not detected. All 5 of these cases were located in the posterior cerebral arteries. Incidental aneurysms were seen in 14 (6.7%); 12 were a new finding at time of MRI. Conclusion The MRA sequence provides additional value by increasing the detection of clinically important intracranial atherosclerotic disease which may inform management in patients with minor stroke and TIA.

Background and Objectives To determine whether carotid plaque inflammation identified by 18F-fluorodeoxyglucose (18FDG)-PET is associated with late (5-year) recurrent stroke. Methods We did an individual-participant data pooled analysis of 3 prospective studies with near-identical study methods. Eligible patients had recent nonsevere (modified Rankin Scale score ≤3) ischemic stroke/TIA and ipsilateral carotid stenosis (50%–99%). Participants underwent carotid 18FDG-PET/CT angiography ≤14 days after recruitment. 18FDG uptake was expressed as maximum standardized uptake value (SUVmax) in the axial single hottest slice of symptomatic plaque. We calculated the previously validated Symptomatic Carotid Atheroma Inflammation Lumen-Stenosis (SCAIL) score, which incorporates a measure of stenosis severity and 18FDG uptake. The primary outcome was 5-year recurrent ipsilateral ischemic stroke after PET imaging. Results Of 183 eligible patients, 181 patients completed follow-up (98.9%). The median duration of follow-up was 4.9 years (interquartile range 3.3–6.4 years, cumulative follow-up period 901.8 patient-years). After PET imaging, 17 patients had a recurrent ipsilateral ischemic strokes at 5 years (recurrence rate 9.4%, 95% confidence interval [CI] 5.6%–14.6%). Baseline plaque SUVmax independently predicted 5-year ipsilateral recurrent stroke after adjustment for age, sex, carotid revascularization, stenosis severity, NIH Stroke Scale score, and diabetes mellitus (adjusted hazard ratio [HR] 1.98, 95% CI 1.10–3.56, p = 0.02 per 1–g/mL increase in SUVmax). On multivariable Cox regression, SCAIL score predicted 5-year ipsilateral stroke (adjusted HR 2.73 per 1-point increase, 95% CI 1.52–4.90, p = 0.001). Discussion Plaque inflammation–related 18FDG uptake improved identification of 5-year recurrent ipsilateral ischemic stroke. Addition of plaque inflammation to current selection strategies may target patients most likely to have late and early benefit from carotid revascularization. Classification of Evidence This study provides Class I evidence that in individuals with recent ischemic stroke/TIA and ipsilateral carotid stenosis, carotid plaque inflammation–related 18FDG uptake on PET/CT angiography was associated with 5-year recurrent ipsilateral stroke.

This case raises the potential association between cervical arterial dissection and VZV vasculopathy. We advise angiographic imaging of neck vessels when VZV vasculopathy is suspected.