Osteomyelitis

Osteomyelitis (plural: osteomyelitides) refers to inflammation of bone that is almost always due to infection, typically bacterial. This article primarily deals with pyogenic osteomyelitis, which may be acute or chronic. 

Osteomyelitis

Other non-pyogenic causes of osteomyelitis are discussed separately:

• fungal osteomyelitis
• skeletal syphilis
• tuberculous osteomyelitis

Epidemiology

Osteomyelitis can occur at any age. In those without specific risk factors, it is particularly common between the ages of 2-12 years and is more common in males (M: F of 3:1) 6.

Pathology

In most instances, osteomyelitis results from haematogenous spread, although direct extension from trauma and/or ulcers is relatively common (especially in the feet of diabetic patients).

In the initial stages of infection, bacteria multiply, triggering a localized inflammatory reaction that results in localized cell death. With time, the infection becomes demarcated by a rim of granulation tissue and new bone deposition.

Although no organisms are recovered in up to 50% of cases 1, when one is isolated, Staphylococcus aureus is by far the most common pathogen. Different organisms are more common in specific clinical scenarios 1,4:

• Staphylococcus aureus: 80-90% of all infections
• Escherichia coli: intravenous drug users (IVDU) and genitourinary tract infection
• Pseudomonas spp.: IVDU and genitourinary tract infection
• Klebsiella spp.: IVDU and genitourinary tract infection
• Salmonella spp.: sickle cell disease
• Haemophilus influenzae: neonates
• group B streptococci: neonates

Other uncommon infective agents include

• fungi - fungal osteomyelitis

Location

Frequency by location, in descending order 18:

• lower limb (most common)
• vertebrae: lumbar > thoracic > cervical
• radial styloid
• sacroiliac joint
• The location of osteomyelitis within a bone varies with age, on account of changes in vascularization of different parts of the bone 1,4:

• neonates: metaphysis and/or epiphysis
• children: metaphysis
• adults: epiphyses and subchondral regions

CT

CT is superior to both MRI and plain film in depicting the bony margins and identifying a sequestrum or involucrum. The CT features are otherwise similar to plain films. The overall sensitivity and specificity of CT is low, even in the setting of chronic osteomyelitis, and according to one study are 67% and 50%, respectively 17.

Some limitations CT include 20:

inability to confidently detect marrow edema; therefore, a normal CT does not exclude early osteomyelitis.

image degradation by streak artifact when metallic implants are present

MRI

MRI is the most sensitive and specific and is able to identify soft-tissue/joint complications 5,14.

Bone marrow edema is the earliest feature of acute osteomyelitis seen on MRI and can be detected as early as 1 to 2 days after the onset of infection 20.

T1

intermediate to low signal central component (fluid)

surrounding bone marrow of lower signal than normal due to edema

cortical bone destruction

T2

bone marrow edema

central high signal (fluid)

T1 C+

post contrast enhancement of bone marrow, abscess margins, periosteum and adjacent soft tissue collections

Madelung Deformity    

15 year old male boy come with complaint of shorting of right hand 

There is relative shortening of radius. There is thinning of epiphyseal plate of radius along medial aspect. There is lateral bowing of ulna. Radio-ulnar joint space is increase. 

There is proximal migration of lunate between radius & ulna. Scaphoid is vertical in orientation.

Madelung Deformity.    

                                       

Tentorial meningioma

Tentorial Meningioma

18Yrs Gilr come with complete of ?TBM

There is a well defined extra axial lesion in left temporal region & left cerebello-pontine cistern appearing hyperintense on T2W & FLAIR images while hypointense on T1W images. Restricted diffusion is seen. Mass effect of the lesion is causing compression over left lateral ventricle & midline shift of approx 11 mm towards right side. 

On Contrast Administration: -There is intense enhancement of the lesion.Enhancing dural tail is also seen. 

likely Tentorium Based Meningioma.

Tramp-Stamp oedema

Tram-stamp edema.

Tramp-stamp oedema is a colloquial term used by some radiologists to denote posterior lumbar subcutaneous oedema. The term is used to describ a oedema in the distribution seen with lower back tattoos, usually in young women, which are known as tramp-stamps.



This oedema is thought be related to a recumbent position and is associated with elevated body mass index 1, and is most commonly of little significance. 

Cardiac MRI

Magnetic resonance imaging (MRI) is a safe, noninvasive test that creates detailed pictures of your organs and tissues. "Noninvasive" means that no surgery is done and no instruments are inserted into your body.

MRI uses radio waves, magnets, and a computer to create pictures of your organs and tissues. Unlike other imaging tests, MRI doesn't use ionizing radiation or carry any risk of causing cancer.

Cardiac MRI creates both still and moving pictures of your heart and major blood vessels. Doctors use cardiac MRI to get pictures of the beating heart and to look at its structure and function. These pictures can help them decide the best way to treat people who have heart problems.

Cardiac MRI is a common test. It's used to diagnose and assess many diseases and conditions, including:

• Coronary heart disease
• Damage caused by a heart attack
• Heart failure
• Heart valve problems
• Congenital (kon-JEN-ih-tal) heart defects (heart defects present at birth)
• Pericarditis (a condition in which the membrane, or sac, around your heart is inflamed)
• Cardiac tumors.

Tolosa Hunt syndrome

Tolosa Hunt syndrome (THS) is an idiopathic inflammatory condition that involves the cavernous sinus and orbital apex and is essentially a clinical diagnosis of exclusion.

Clinical presentation

Clinically it refers to the presence of a painful ophthalmoplegia secondary to surrounding cavernous sinus inflammation. The Tolosa Hunt syndrome is essentially a clinical diagnosis of exclusion.

Pathology

The constant pain which characterises the disorder is due to infiltration of lymphocytes and plasma cells, along with thickening of dura mater within the cavernous sinus.

Radiographic features

MRI

A 52 Y/F Patient Present with weakness in vision.

There is an ill defined soft tissue intensity lesion in left para-cavernous region appearing slightly hypointense on T2W images while isointense to brain parenchyma on T1W images.

The lesion is involving orbital apex & superior orbital fissure.

There is intense enhancement of lesion.

T1W Plain

T1W Contrast

Nasal Encephalocoele

A nasal encephalocele refers to a the herniation of cranial content in the nasal area. It is one of the causes of craniospinal dysraphism.

Clinical Presentation

Nasal encephaloceles usually present at birth with symptom of obstruction or other complications. It presents as an external swelling on the nose.Swelling is usually soft and skin over the swelling is normal. The swelling increases in size on coughing and straining. Symptoms usually present with obstruction or rhinorhea.

Nasal encephalocele are typically identified in association with a discernible cranial bone defect.

Pathology

Nasal encephalocoeles are anterior encephalocoeles where meningeal herniation occurs through a midline defect in the floor of the anterior cranial fossa.

Radiographic features

MRI
A 18 Y/F  Patient present with birth swelling on nose.

There is well defined lesion in naso-ethmoid region. The lesion appearing hyperintense on T2W & STIR images while hypointense on T1W images. The lesion is communicating with the brain parenchyma through bony defect in fronto-nasal region.

No fat component is seen within the lesion

There is no enhancement of the lesion in post contrast images.

T1W

     

T2W 

 

T1W Plain 

T1W Contrast

Diastematomyelia

Diastematomyelia (also known as a split cord malformation) refers to a type of spinal dysraphism (Spina bifida occulta) when there is a  longitudinal split in the spinal cord. Although traditionally it has been distinguished from diplomyelia (in which the cord is duplicated rather than split) the term split cord malformation (SCM) is advocated to encompass both conditions 6. For the purposes of this articles the terms diastematomyelia and split cord malformation are used interchangeably.

Epidemiology

Split cord malformations are a congenital abnormality and account for approximately 4% of all congenital spinal defects 6. 

Clinical presentation

The majority of patients with diastematomyelia are symptomatic, presenting with signs and symptoms of tethered cord, although patients wilh mild type II (see below) may be minimally affected or entirely asymptomatic 6. Presenting symptoms include:

leg weakness

low back pain

scoliosis

incontinence

Patients with diastematomyelia also frequently have other associated annomalies including: 

meningocele

neuroenteric cyst

dermoid

club foot

spinal cord lipoma

haemangioma overlying spine

Pathology

Classification

Split cord malformations are divided into two types according to presence of a dividing septum and single vs dual dural sac. 

type I: duplicated dural sac, with common midline spur (osseous or fibrous) and usually symptomatic

type II: single dural sac containing both hemicords; impairment less marked

Type I

Type I is the classic diastematomyelia, characterised by 1-6:

duplicated dural sac

hydromyelia common

midline spur often present (osseous or osteocartilaginous)

vertebral abnormalities: hemivertebrae, butterfly vertebrae, spina bifida, fusion of laminae of adjacent levels

skin pigmentation, haemangioma and hypertrichosis (hair patch) are common

patients are usually symptomatic presenting with scoliosis and tethered cord syndrome

Type II

Type II is milder than type I, and lack many of the features of latter:

single dural sac and no spur/septum

cord divided, sometimes incompletely so

hydromyelia may be present

spina bifida may be present, but other vertebral anomalies are far less common

patients a less symptomatic or may even be asymptomatic 

Radiographic features

Split cord malformations are more common in the lower cord but can sometimes occur at multiple levels.

50% occur between L1 and L3

25% occur between T7 and T12

An associated bony, cartilagenous or fibrous spur projecting through the dura mater forwards from the neural arch is visible in 33% of cases 1. 

Vertebral anomalies (spina bifida, butterfly or hemivertebrae) are common. Laminar fusion associated with a neural arch defect is a good predictor of diastematomyelia and occurs the level of the defect, or at an adjacent level. 

CT

CT is able to better image many of the features seen on plain films and in addition may demonstrate the bony septum. Modern scanners are also able to visualise the cord. 

MRI

MRI is the modality of choice for assessing children with split cord malformations. As well as being able to elegantly demonstrate the cord and presence of hydromyelia (if present), it can also assess for the presence of the numerous associated anomalies (see above).

CT Scan 128 slice machine

In CT highlights, Philips is further diversifying its product portfolio with a 128-slice version of its iCT scanner, and the company is also bringing to North America a line of 16-slice systems currently sold internationally.

Brilliance iCT SP is a 128-detector-row system that gives customers a more value-oriented option to the company's flagship 256-slice iCT model. The scanner can also be upgraded to 256 slices as a facility's needs change, according to Philips.



The system sports a 0.27-sec gantry rotation speed and can be sited in 365 sq ft. It features Philips' Smart Focal Spot x-ray tube technology, which improves sampling density for enhanced spatial resolution in all exams, the company said.

Other features include the company's Nano-Panel detector design, which enables large area coverage for fast exams in clinical applications such as coronary artery imaging, lung scanning, and brain perfusion. Philips has also included its Eclipse DoseWise collimator on the scanner to reduce radiation dose.

The 16-slice product family, MX, is being displayed in North America for the first time, Philips said. The scanner is already sold internationally, and is ideal for customers who want to replace a current scanner or buy a second system but face economic constraints.

MX systems perform routine clinical applications such as CT angiography and are also appropriate for dental planning and virtual colonoscopy. The MX line is pending 510(k) approval from the U.S. Food and Drug Administration (FDA).

On the software side, Philips is highlighting new software applications for its Brilliance Workspace console, as well as Brilliance Everywhere thin-client software. The company is promoting automated features and new clinical applications for liver analysis, cardiac plaque assessment (shown as a work-in-progress), and whole-body bone removal for advanced vessel analysis.

The company is also touting its Perspective Filet View software for virtual colonoscopy studies. The application unfolds colon images, displaying the colon flat like a landscape in a 3D manner, which helps avoid "blind spots" created by folds. Philips claims the software can improve accuracy and reduce reading times for physicians.

Moderate Calcification in Coronary Arteries

Moderate Calcification in Coronary Arteries

About Patient 

a 77 Y Patient 

c/o severe Chest Pain 

• Total Agatston score is more then 400 

• Calcified plaques in arteries as described above with complete blockage of LCXA , significant luminal narrowing of RCA and moderate luminal narrowing in LAD and ramus intermediate