Michael J. Opatowsky

Emergency Imaging Assessment of Acute, Nontraumatic Conditions of the Head and Neck

Patients often present to the emergency department with a wide variety of nontraumatic infectious, inflammatory, and neoplastic conditions of the head and neck. Because the use of cervical and neck computed tomography (CT) has become routine in the emergency setting, knowledge of the imaging findings of common acute conditions of the head and neck is essential to ensure an accurate diagnosis of these potentially life-threatening conditions, which include oral cavity infections, tonsillitis and peritonsillar abscess, sialadenitis, parotiditis, diskitis, thrombophlebitis, periorbital and orbital cellulitis, infectious cervical lymphadenopathy, and various neoplasms. Less common conditions that require rapid diagnosis and treatment include epiglottitis, invasive fungal sinusitis, angioedema, and deep neck abscess. Familiarity with these conditions enables the radiologist to make a prompt diagnosis, assess the extent of disease, and evaluate for potential complications. CT is the first-line imaging modality in the emergency setting; however, magnetic resonance imaging plays an important secondary role.

Basilar artery thrombosis in the setting of antiphospholipid syndrome.

Antiphospholipid syndrome is an autoimmune disorder characterized by arterial or venous thrombosis, recurrent first-trimester pregnancy loss, and multiple additional clinical manifestations. We describe a man with severe atherosclerotic basilar artery stenosis and superimposed in situ thrombus who was found to have antiphospholipid syndrome.

Creutzfeldt-Jakob disease: case discussion and imaging review

A 65-year-old man initially experienced difficulty forming his tie and felt unsteady while driving. Days later, these symptoms were followed by periods of dizziness and vague episodes of confusion that he felt were “out of character.” The patient was extremely concerned, especially given a strong family history of strokes. With an unremarkable physical examination, laboratory tests, and brain imaging, the patients symptoms were attributed to his inadvertent ingestion of codeine-containing medication and to multiple increasing life stressors, including recent prostatectomy for prostate cancer. One week later, the patient returned complaining of significant confusion, problems opening doors, and progressive difficulty performing activities of daily living. Physical examination at this time revealed the patient to be confused with notable psychomotor retardation. Decreased left arm swing was noted on gait exam. An electroencephalogram (EEG) showed findings of right temporal slowing. Because of this finding and the patients deteriorating mental status, he was admitted for further evaluation. Repeat EEG demonstrated bihemispheric triphasic wave complexes. Cerebrospinal fluid cytology and cultures were normal, but cerebrospinal fluid protein 14-3-3 was abnormally elevated. Magnetic resonance imaging (MRI) of the brain revealed areas of diffusion restriction in the right cerebral cortex and right basal ganglia (Figure ​(Figure11). No abnormalities were found after extensive laboratory tests, including a metabolic panel and tests for syphilis, HIV, herpes simplex virus, human herpesvirus-6, C-reactive protein, antinuclear antibodies, folate, erythrocyte sedimentation rate, and homocysteine levels. Figure 1 (a, b, c) Multiple axial images from the patients brain MRI demonstrate abnormal signal hyperintensity (arrows) at several cortical locations and in the caudate head on the diffusion-weighted sequence. (d, e, f) Less conspicuous signal hyperintensity ... His neurologic condition continued to deteriorate rapidly. Without effective treatment options, he was referred to hospice and succumbed to his disease process approximately 2 months from the time of initial presentation. A limited autopsy of the brain was performed at the National Prion Disease Pathology Surveillance Center at Case Western Reserve University in Cleveland, Ohio. An abnormal prion protein was detected and characterized by Western blot, histopathological studies, and immunohistochemical examinations. DIAGNOSIS: Sporadic Creutzfeldt-Jakob disease (sCJD). Genetic sequencing of the proteinase-resistant protein (PrP) ruled out the presence of a pathologic genetic mutation in the coding region of the PrP gene. Therefore, the prion disease in this case was not familial.

Solitary supratentorial Listeria monocytogenes brain abscess in an immunocompromised patient.

We describe an 81-year-old man receiving azacitidine monotherapy for myelodysplastic syndrome who was improving from Listeria monocytogenes bacteremia after receiving antibiotic therapy during an earlier hospital admission. Shortly after discharge he developed new-onset seizure activity, with brain imaging on subsequent admissions demonstrating a posterior right frontal lobe mass. Specimen cultures after resection of the mass revealed this to be a cerebral abscess related to L. monocytogenes. Brain abscesses related to this organism are rare.

Bilateral lymphadenopathy in a young woman.

A 20-year-old woman presented to the emergency department with bilateral tender neck masses that had been increasing in size for 2 months. Associated symptoms included weakness, headaches, neck pain, dysphagia, and left-sided earache. In the previous week, she had developed a cough productive of white sputum, chest pain, and shortness of breath. She denied fevers, night sweats, and myalgias but did have occasional chills. She had developed a rash on her arms and lower extremities 3 weeks prior, which was now resolving, and tingling in her feet. She had minimal weight loss secondary to decreased appetite over the previous few months. Several weeks prior to admission, she had been diagnosed with mumps. She was also given a 5-day course of azithromycin that did not alleviate her symptoms. She reported that 6 months earlier, her boyfriend and another good friend had been treated for tuberculosis, but she had not been tested. She received standard vaccinations as a child. She denied alcohol, tobacco, and intravenous drug use. Her family history was significant for lung cancer and thyroid disease. She had not recently traveled outside of the United States, and she had been exposed to dogs but not to cats. Physical examination revealed a healthy appearing young woman with significant bilateral cervical lymphadenopathy that was tender to palpation. The skin over the masses was not discolored and did not have draining sinus tracts. Her oropharynx was clear and nonerythematous. Her lungs were clear. She had a resolving rash on her extremities. The remainder of her examination was normal. A posteroanterior and lateral chest radiograph revealed no abnormalities in her lungs. A computed tomography (CT) scan of the neck demonstrated large, bilateral, necrotic lymph nodes extending from the high to low internal jugular lymph node chains (Figure). Figure Contrast-enhanced CT images of the neck. (a) Coronal image demonstrating multiple large necrotic lymph nodes. (b) Coronal image at a more posterior level, showing involvement of nodes in levels 2 to 4. Nodes are centrally hypodense, representing necrosis, ... What are the differential diagnostic considerations? What is the most likely diagnosis? What tests can confirm the diagnosis? DIAGNOSIS: Infectious cervical lymphadenitis, or scrofula, likely caused by M. tuberculosis. The most likely etiology, considering exposures, age, and symptoms, was cervical tuberculous lymphadenitis, or scrofula. However, the broad differential diagnosis of enhancing cervical lymphadenopathy in an adult includes metastatic squamous cell carcinoma, metastatic papillary thyroid carcinoma, lymphoma, tuberculous and nontuberculous mycobacterial lymphadenitis, cat-scratch disease, Kaposis sarcoma, AIDS-related lymphadenopathy, Kimuras disease, Castlemans disease, and Kikuchis disease. Fungal and viral infections, such as Epstein-Barr virus, cytomegalovirus, and rubella, also may present with bilateral diffuse lymphadenopathy. Imaging of the chest, abdomen, and pelvis revealed no systemic lymphadenopathy or other abnormalities. A tuberculin skin test (purified protein derivative [PPD]) was positive. Acid-fast bacilli (AFB) and fungal blood cultures were negative. An HIV antibody test, monospot, and cytomegalovirus polymerase chain reaction (PCR) test were negative. Her angiotensin-con-verting enzyme level was within normal limits, an antinuclear antibody screen was minimally positive at 1:80, her sedimentation rate was elevated at 40 mm/h (reference range, 0–20), and her lactic acid dehydrogenase level was elevated at 248 U/L (reference range, 135–214). Lymph node sampling by fine-needle aspiration showed caseating granulomatous inflammation, but AFB and fungal smears and Mycobacterium tuberculosis (MTB) PCR results were negative. This sample eventually grew pansensitive MTB, also identifiable by MTB probe. A QuantiFERON-TB Gold test was sent and returned with a positive result.

Endovascular Therapy Using Flow Diversion for Giant Internal Carotid Artery Pseudoaneurysm Arising in the Setting of an Invasive Pituitary Macroadenoma

This report illustrates the unusual occurrence of a pseudoaneurysm arising in the setting of a skull base mass and describes the first reported use of endovascular flow diversion therapy in such a setting. A 63-year-old man with occasional headaches during the preceding month presented with the acute onset of severe left retroorbital headache and oculomotor nerve palsy. Computed tomography (CT) and CT angiogram revealed a destructive skull base mass with an associated giant probable pseudoaneurysm of the cavernous segment of the left internal carotid artery. The patient underwent endoscopic transsphenoidal biopsy with a subsequent diagnosis of prolactinoma. Endovascular therapy utilizing two Pipeline™ flow diversion embolization devices was performed with subsequent resolution of the patients headache and improvement in his cranial nerve deficits/cavernous sinus syndrome.

Endolymphatic sac tumor and otalgia

Otalgia is a common complaint seen by general practitioners, but its etiology is vast. Rarely, otalgia could be secondary to a neoplasm. We describe a case of otalgia and ear discharge in which the imaging revealed a rare neoplasm, an endolymphatic sac tumor, which contributed to the patients symptoms. The primary diagnosis was made via characteristic imaging features that were later confirmed by histology.

Just another headache

A 55-year-old woman with a 35-year history of migraine headaches had a follow-up visit with her neurologist. Her headaches had been preceded by scintillating scotomas, but she noted increasing visual scotomas, especially in the right field of vision. She was not very concerned, as she stated that it was “just another headache.” Neurologic examination including visual field testing by confrontation was normal. However, magnetic resonance imaging of the brain showed a large pituitary macroadenoma (Figure). She underwent successful transsphenoidal excision with no residual complications. Figure (a) Sagittal and (b) axial postcontrast T1-weighted magnetic resonance images of the brain showing a large elliptical avidly enhancing mass measuring 3.5 × 2.9 cm filling the sella turcica and the suprasellar cistern and compressing the optic ... A history of rapidly increasing headache frequency, lack of coordination, localized neurologic signs, or subjective numbness or tingling has been found to be associated with significantly increased odds of finding an abnormality on neuroimaging (1). Physicians should keep in mind that almost one quarter of patients with pituitary adenomas have a normal neuroophthalmological examination (2). This case stresses the importance of neuroimaging in patients with chronic headaches who present with increased headache frequency or a change in the character of their symptoms.