Traumatic intracranial aneurysms are rare consequences of blunt or penetrating head injury, carrying significant morbidity and mortality. We report a 33-year-old male who sustained severe head trauma with base of skull fracture and subarachnoid hemorrhage following a motor vehicle accident. He underwent craniotomy with evacuation of an intracerebral hematoma and fixation of depressed fracture segments. During the third week, he deteriorated due to a re-bleed at the operated site. Cerebral digital subtraction angiography revealed a pseudoaneurysm from the proximal A2 segment of the left anterior cerebral artery, prompting re-exploration. This case highlights the importance of considering post-traumatic aneurysm in patients with delayed neurological decline after head injury associated with skull bone fracture and subarachnoid hemorrhage.

The pelvic ring is a closed, ring-shaped skeletal framework composed of the sacrum and paired innominate bones, stabilized by strong ligaments. It plays a critical role in weight transmission and provides protective enclosure for vital internal organs. Injuries of the pelvic ring represent a broad spectrum of injury severity, ranging from stable fractures to life-threatening unstable fracture-dislocations. Disruption of this ring can injure major vascular, neural, and genitourinary structures, with hemorrhage remaining a leading cause of preventable mortality in pelvic trauma. Although advances in resuscitation strategies, surgical techniques, and implant design have improved outcomes in pelvic ring injuries, early and accurate injury characterization remains critical to guiding appropriate management and reducing complications. CT is the cornerstone of pelvic trauma assessment and offers high-resolution visualization of fracture morphology and associated soft-tissue injuries. Radiologic imaging-based classification systems provide a structured framework for assessing fracture stability, guiding treatment decisions, and facilitating multidisciplinary management. Incorporating a systematic, checklist-driven approach to CT interpretation improves diagnostic accuracy, reduces the risk of missed injuries, and enables consistent recognition of unstable fracture patterns. The authors outline a comprehensive, structured approach for CT assessment of pelvic ring trauma, with the goal of enhancing diagnostic confidence, streamlining triage, and improving patient outcomes. ©RSNA, 2025.

BackgroundMagnetic resonance imaging (MRI) is crucial in modern medical diagnostics, providing detailed insights into soft tissue structures and pathological changes. Traditional grayscale images can sometimes obscure critical details, complicating accurate interpretations. Automated color coding of the MRI signal intensities may enhance the visualization of various pathologies, potentially leading to improved diagnostic accuracy and image quality. This paper aims to explore the effectiveness of color-coded MR image reconstruction in enhancing both diagnostic precision and overall image quality in musculoskeletal MRI.MethodsTwo fellowship-trained musculoskeletal radiologists evaluated the images reconstructed with color coding, rating their diagnostic value, image quality, and visual appeal using a five-point Likert scale. To assess interrater reliability, Cohen's Kappa statistical analysis was performed. Additionally, descriptive statistics summarizing the Likert scores for diagnostic value, image quality, and visual appeal of the reconstructed images have been described.ResultsStatistical analysis of the data revealed that the diagnostic value, image value, and visual appeal of the color-coded MR images were excellent in almost two-thirds of the data set. The minimum Likert score recorded was 3, signifying a good quality rating.ConclusionOur study shows positive results, supporting the efficiency of color-coded MR imaging in aiding the conventional gray scale MR imaging to improve its diagnostic efficiency.

Objectives:Ischaemic stroke (IS) is a heterogeneous condition with varied mechanisms. Some patients have more than 1 stroke mechanism coexisting, irrespective of the mechanism of the incident stroke.~This study aimed to examine the association of coexisting dual stroke mechanisms among IS patients with risk factors and clinical outcomes. Methods:This retrospective study included adult patients with IS diagnosed using the TOAST criteria in Sultan Qaboos University Hospital's stroke registry who were admitted and treated from January 2011 to December 2020. The records were reviewed for the presence of dual IS mechanisms (combinations involving small vessel disease [SVD], cardioembolism [CE] or large artery atherosclerosis [LA]). Outcomes were classified as modified Rankin score (mRS) = 0-3 (favourable) or mRS = 4-6 (poor). Univariate and multivariate methods of analysis were used. Results:Among 1,220 patients with IS (age = 64 ± 13 years; male:female = 63:37), 177 (14.5%) had an additional mechanism of stroke. The most common second mechanism was SVD (53.1%), while CE stroke (23.7%) and LA stroke (23.2%) were similar in frequency. Patients with dual stroke mechanisms were significantly older (P <0.001), had a higher frequency of conventional risk factors (P <0.007), abnormal brain magnetic resonance imaging (P = 0.004) and worse outcomes (P = 0.058). Poor outcomes at hospital discharge or 12-month follow-up were independently associated with older age (P = 0.007), female gender (P = 0.017), poor sensorium (P <0.001) and type of primary stroke (P <0.001). Conclusions:Up to 1 in 7 patients with IS may have an additional mechanism of stroke. Such patients are likely older, with poorly controlled risk factors, worse sensorium and possibly worse outcomes. SVD is the most common additional stroke mechanism. Studies to explore the influence of dual stroke mechanisms on outcomes, as well as strategies for secondary prevention, are indicated.

Non-traumatic fat embolism syndrome (FES) affecting brain, lung and hematopoietic system is a rare, but a serious complication of sickle cell disease (SCD), resulting from bone marrow necrosis. SCD-related FES is rare, with the spectrum of clinical, laboratory, radiological manifestations and patient outcome is not fully understood. After medical research & ethics committee approval, retrospectively, SCD-FES patients at our centre, were reviewed between January 2006 to December 2023. 27 patients (17 males, 10 females) with a median age of 24 years and length of hospital stay of 24 (16-38) days were enrolled. They had fever, chest/back pain, cough and crepitation in 100%, 96%, 56% and 100% respectively, with neurological manifestations in 96%. Abnormal chest X-rays and CT scans were observed in 96%, and 100% respectively. Patients had significant anemia, reticulocytopenia, and thrombocytopenia, with raised WBC (p < 0.05). There was a significant rise in LDH, ALP, Ferritin and C-reactive protein levels. All patients received antibiotics, and exchange transfusions, whereas 24%, 76% required non-invasive ventilation (NIV) and mechanical ventilation respectively, with 18.5% mortality. FES is a rapidly progressive respiratory and neurological syndrome, characterized by hypoxia, and cytopenia, with raised inflammatory markers, raised LDH and ALP, with distinctive multiple cerebral microbleeds.

BACKGROUND:Acute hematogenous osteomyelitis (AHO), the most common osteoarticular infection in children, carries a significant risk for chronic complications. Predicting chronic complications early in the course of disease is challenging. The underlying pathogenesis of complications is not fully understood. METHODS:Children who presented to Sultan Qaboos University Hospital, Muscat, Oman between January 2015 and April 2022 for AHO were identified by a search of magnetic resonance imaging (MRI) records. Children between 1 month and 18 years of age who did not meet exclusion criteria, and whose MRI also included gadolinium-enhanced subtraction (GES) sequences were included in the analysis. Outcomes were compared between patients who showed early evidence of bone ischemia and those who did not. RESULTS:The analysis included 11 children who had GES MRI sequences from among 18 AHO cases in total. Median age was 5 years (IQR, 4-9), and 82% were males. Median duration of symptoms at presentation was 5 days (IQR, 3-7). GES sequences showed early bone ischemia in 6 of 11 (55%) patients. Patients with early bone ischemia were treated with significantly longer durations of IV antibiotics (median 23 vs. 10 days, P = 0.017) and oral antibiotics (median 134 vs. 29 days, P = 0.004), and required more surgical debridements (median 3 vs. 0 debridements, P = 0.017). Chronic osteomyelitis only developed among patients with early bone ischemia (5/6 vs. 0/5, P = 0.015). CONCLUSIONS:In pediatric AHO, GES MRI sequences revealed early bone ischemia in a significant proportion of patients. Early bone ischemia was strongly associated with progression to chronic osteomyelitis.

Background/Objectives: Intraneural tumors (INTs) pose a diagnostic challenge, owing to their varied origins within nerve fascicles and their wide spectrum, which includes both benign and malignant forms. Accurate diagnosis and management of these tumors depends upon the skills of the radiologist in identifying key imaging features and correlating them with the patient’s clinical symptoms and examination findings. Methods: This comprehensive review systematically analyzes the various imaging features in the diagnosis of intraneural tumors, ranging from basic MR to advanced MR imaging techniques such as MR neurography (MRN), diffusion tensor imaging (DTI), and dynamic contrast-enhanced (DCE) MRI. Results: The article emphasizes the differentiation of benign from malignant lesions using characteristic MRI features, such as the “target sign” and “split-fat sign” for tumor characterization. The role of advanced multiparametric MRI in improving biopsy planning, guiding surgical mapping, and enhancing post-treatment monitoring is also highlighted. The review also underlines the importance of common diagnostic pitfalls and highlights the need for a multi-disciplinary approach to achieve an accurate diagnosis, appropriate treatment strategy, and post-therapy surveillance planning. Conclusions: In this review, we illustrate the main imaging findings of intraneural tumors, focusing on specific MR imaging features that are crucial for an accurate diagnosis and the differentiation between benign and malignant lesions.

Introduction: Sickle cell disease (SCD) is one of the most common genetic blood disorders in Oman, with an incidence of around 6% of the population. SCD patients are at high risk of getting osteomyelitis (OM). The method of choice for diagnosing OM is by obtaining a positive blood culture and a bone/joint biopsy. However, a negative blood culture does not exclude the diagnosis of OM, and bone biopsy is an invasive procedure that is not routinely performed in all patients. Standard Magnetic Resonance Imaging (MRI) is recognized as the study of choice for confirming OM in normal populations and has been reported to have high sensitivity and specificity. However, in patients with SCD, due to significant bone infarcts, it’s challenging to differentiate from bone infections, with MRI sensitivity and specificity of around 82% and 75%, respectively, as reported. An ambidirectional study was done to evaluate the role of clinical, laboratory, and radiological parameters in establishing the diagnosis of OM in children with SCD. Methodology: Fifty-one SCD patients with a mean age of 9 years were recruited. The inclusion criteria of our study are all patients with SCD aged from 6 months to 18 years, suspected to have OM, and involvement of the limb or joint. Clinical, laboratory, and radiological findings were collected and grouped into two groups: OM vs VOC patients. Results: In our study, the sensitivity of MRI alone was 29.6% in detecting OM. Cortical destruction was found in only 12.5% of patients who had an MRI, which confirms the diagnosis of OM. Combined with Clinical and laboratory data, the likelihood of diagnosing osteomyelitis increases significantly. Conclusion: In SCD patients, it is usually difficult to distinguish between OM and VOC. In many cases, the MRI findings were either inconclusive or led to an incorrect diagnosis. Combining clinical, laboratory, and radiological data might increase the likelihood of diagnosing OM in these patients.

Abnormal development of the posterior pituitary gland can lead to an ectopic location of the neurohypophysis, commonly seen at the median eminence of the hypothalamus or along the infundibular stalk. A partial ectopic posterior pituitary (PEPP) is a very rare variant of the ectopic posterior pituitary, defined as the presence of a double bright spot of neurohypophysis seen in both orthotopic and ectopic locations. We report a two-year-old male toddler with bilateral optic nerve hypoplasia and severe visual impairment who presented to the endocrine outpatient clinic for hypopituitarism evaluation. Magnetic resonance imaging (MRI) of the brain revealed a hypoplastic pituitary gland and infundibulum with a double bright spot of neurohypophysis in the expected normal location and along the median eminence. Severe hypoplasia of both optic nerves and the optic chiasm was also seen. Septum pellucidum was present with no evidence of other brain malformations. The findings are in the septo-optic dysplasia spectrum associated with hypothalamic-pituitary dysfunction and a very rare entity called PEPP. To our knowledge, only a handful of reported cases of this rare entity exist in the literature.

Objective To assess the displacement of the supinator fat pad in radial head and neck fractures and to validate its significance. Material and methods One hundred two adult patients from the Royal Orthopaedic Hospital, Birmingham, United Kingdom and Sultan Qaboos University Hospital, Muscat, Oman with confirmed radial head and/or neck fractures were included. Fractures were classified using the Mason-Johnston classification. The displacement of the supinator fat pad from the radius was measured on anterior-posterior (AP) and lateral radiographs and correlated to fracture classification. Results The supinator fat pad was on average displaced by 10.6 mm and 13.8 mm from the radius on AP and lateral radiographs, respectively. The displacement of the fat pad progressively increased between non-displaced (Mason I) and severely comminuted (Mason III) fractures on both the AP (10.25 to 14.25 mm) and lateral (12.70 to 16.00 mm) projections. The progression of displacement on AP ( p = 0.016) and on lateral ( p = 0.007) projections was statistically significant. Fracture dislocation was not associated with increased fat pad displacement. Conclusion The supinator fat pad sign is a useful adjunct in the assessment of radial head and neck fractures.

A 17-year-old male, with no comorbidities, presented with a mass from the left lateral chest extending to the back. At age seven, he had a small mass in the left lateral chest wall at the mid-axillary line which was excised in a periphery hospital (no official medical report). Six years after the surgery, another mass appeared just above the scar of the previously excised mass. The size of the mass increased dramatically over four years; therefore, the patient came to our center. On examination, the swelling was soft, lobulated, cystic, not attached to the overlying skin, extending from the left lateral chest to the back, measuring 13 × 7 cm anteriorly, 7 × 4 cm on the lateral chest, and 28 × 23 cm posteriorly [Figure 1]. Magnetic resonance imaging (MRI) revealed a large heterogenous mass measuring 17 × 6 × 20 cm, extending from the 4th to the 10th rib involving the left paravertebral muscles [Figure 2].

Several mimics of acute ischemic stroke may complicate the decision to administer intravenous thrombolysis. Developmental venous anomalies (DVA) are fairly common variants of normal cerebral vasculature and may occasionally present with acute focal neurologic symptoms. We report a case of DVA presenting with the acute onset of focal neurologic deficits and focal hypodensities on the CT of the brain, resulting in a dilemma regarding whether to administer intravenous tissue-type plasminogen activator (IV tPA) for stroke thrombolysis. Recognition of subtle brain changes on the CT that were inconsistent with an acute ischemic stroke led to further imaging and a definitive diagnosis. Developmental venous anomalies should be considered in the differential diagnosis of acute ischemic stroke.

Book Citations: Authors, Title, HemaSphere, 2023;7(S3):pages. The individual abstract DOIs can be found at https://journals.lww.com/hemasphere/pages/default.aspx. Disclaimer: Articles published in the journal HemaSphere exclusively reflect the opinions of the authors. The authors are responsible for all content in their abstracts including accuracy of the facts, statements, citing resources, etc. 4780 Definitive OM Erythema & Hotness in the affected limb + Clinical criteria in Possible OM Leukocytosis (>15) with left neutrophilic shift High ESR Positive blood culture Cortical destruction in MRI Possible OM Pain, tenderness & Limited mobility. Fever Leukocytosis (>15) with left neutrophilic shift Subperiosteal fluid in US > 4mm Unlikely OM Only pain in the affected limb with no other local signs of infection Absence of fever Normal WBC count Presence of bone edema, infarction, and subperiosteal edema only without collection Summary/Conclusion: In SCD patients, it is usually difficult to distinguish between OM and VOC. In many cases, the MRI findings were either inconclusive or gave a wrong diagnosis. Combining clinical, laboratory, and radiological data might increase the likelihood of diagnosing OM in these patients. HemaSphere | 2023;7(S3) EHA2023 Hybrid Congress Copyright Information: (Online) ISSN: 2572-9241 © 2023 the Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the European Hematology Association. This is an open access Abstract Book distributed under the Attribution-NonCommercial-NoDerivs (CC BY-NC-ND) which allows third parties to download the articles and share them with others as long as they credit the author and the Abstract Book, but they cannot change the content in any way or use them commercially. Abstract Book Citations: Authors, Title, HemaSphere, 2023;7(S3):pages. The individual abstract DOIs can be found at https://journals.lww.com/hemasphere/pages/default.aspx.Book Citations: Authors, Title, HemaSphere, 2023;7(S3):pages. The individual abstract DOIs can be found at https://journals.lww.com/hemasphere/pages/default.aspx. Disclaimer: Articles published in the journal HemaSphere exclusively reflect the opinions of the authors. The authors are responsible for all content in their abstracts including accuracy of the facts, statements, citing resources, etc. 4781

Abstract Background: Ischemic stroke (IS) is a heterogeneous condition with varied mechanisms. Some patients have more than one stroke mechanism underlying the incident stroke. This study aimed to examine the association of dual stroke mechanisms among ischemic stroke patients with risk factors and clinical outcomes. Methods: Case records of adult patients with IS diagnosed using TOAST criteria in a University Stroke-Registry were reviewed for presence of dual IS mechanisms- viz. combinations involving small vessel disease(SVD), cardio-embolism(CE), or large artery atherosclerosis(LA). Outcomes were classified as good (modified Rankin Score=0-3) or poor (4-6). Univariate and multivariate methods of analysis were used. Results: Among 1220 patients with IS (age: 64+13 years; M:F::63%:37%), 177(14.5%) had an additional mechanism of stroke. SVD(51%) was the most common second mechanism, while CE(23%) and LA stroke(25%) were similar in frequency. On univariate analysis, patients with dual stroke mechanisms were significantly older(p<0.001), had higher frequency of conventional risk factors (p<0.007), abnormal brain MRI(p=0.004) and worse outcomes(p=0.058). On logistic regression analysis, poor outcomes at hospital discharge or 12 month follow-up were independently associated with: older age(p=0.007); female gender(p=0.017); poor sensorium(p<0.001); and type of primary stroke(p<0.001). Conclusions: Up to one in seven patients with ischemic stroke may have an additional mechanism of stroke. Such patients are likely older, with poorly controlled risk factors, worse sensorium and possible worse outcomes. Small vessel disease is the most common additional stroke mechanism. Studies to explore the influence of dual stroke mechanisms on outcomes as well strategies for secondary prevention are indicated.

Abstract Background Current literature cites avascular necrosis as one of the rare and late complications of pediatric acute hematogenous osteomyelitis (AHO). Gadolinium-enhanced subtraction (GES) MRI sequences could potentially detect avascular necrosis more frequently and at an earlier time point in the course of pediatric AHO. Such an advantage could aid in the identification of patients at risk for chronic complications early in the course of disease. GES sequences are produced by subtracting pre-gadolinium images from the corresponding gadolinium-enhanced sequences. Methods Pediatric patients managed at Sultan Qaboos University Hospital between January, 2015 and April, 2022 with a confirmed diagnosis of AHO were reviewed. Patients were included in the analysis if GES MRI sequences were included in the initial diagnostic evaluation. Clinical presentation and outcomes were compared between patients with evidence of avascular necrosis on initial GES MRI and those without. Results Eleven patients were identified with a diagnosis of AHO for whom which GES MRI sequences had been obtained. Median age was 5 years (IQR 4-9), and 10 (91%) patients were males. Evidence of avascular necrosis on initial MRI (Figure 1) was identified in 6 (55%) patients. Patients with avascular necrosis showed a trend towards higher markers of inflammation (median absolute neutrophil count 10.7 vs 5.0, P = 0.052). Patients with avascular necrosis had significantly longer lengths of stay (median 16 days vs 9, P = 0.030), longer IV antibiotic treatment durations (median 14 days vs 7, P = 0.009) and longer oral antibiotic treatment durations (median 206 days vs 26, P = 0.036) (Table 1). Progression to chronic osteomyelitis occurred frequently, and only among patients with evidence of avascular necrosis on initial GES MRI (P = 0.008). Table 1 Comparison of clinical presentation and outcomes between patients whose initial MRI showed evidence of avascular necrosis on gadolinium-enhanced subtraction sequences, and patients whose imaging did not. *Represented as median (interquartile range). **For two patients, follow-up time at the time of writing was insufficient to determine if chronic osteomyelitis had developed. Figure 1Images A, B and C- Coronal MRI of the proximal femur in a child with uncomplicated acute hematogenous osteomyelitis. A- Pre-Gd T1, B- Post-Gd T1 and C- subtraction. Images show bone marrow edema with enhancement without any evidence of ischemia or necrosis (blue parenthesis). Images D, E and F- Sagittal MRI of the distal tibia in a child with complicated acute hematogenous osteomyelitis. D- Pre-Gd FAT SAT T1, E- Post-Gd FAT SAT T1 and F-subtraction. Images show bone marrow edema with a large central non-enhancing region of bone marrow suggestive of ischemia/necrosis (yellow rectangles). Conclusion GES MRI readily detected avascular necrosis in a large percentage of patients during the initial presentation of pediatric AHO, suggesting a much higher prevalence and an earlier presence of this complication than previously thought. The presence of avascular necrosis appeared to correlate highly with later progression to chronic osteomyelitis, providing for a promising early predictor of later complications. The findings of this study need to be validated in a larger, prospective cohort. Disclosures All Authors: No reported disclosures.