Peter Kalina

Lyme disease of the brainstem

Lyme disease is a multisystem infectious disease caused by the tick-borne spirochete, Borrelia burgdorferi. Central nervous system (CNS) involvement typically causes local inflammation, most commonly meningitis, but rarely parenchymal brain involvement. We describe a patient who presented with clinical findings suggesting a brainstem process. Magnetic resonance imaging (MRI) and positron emission tomography (PET) suggested a brainstem neoplasm. Prior to biopsy, laboratory evaluation led to the diagnosis of Lyme disease. Clinical and imaging abnormalities improved markedly following antimicrobial therapy. We describe Lyme disease involvement of the cerebellar peduncles with hypermetabolism on PET. Although MRI is the primary imaging modality for most suspected CNS pathology, the practical applications of PET continue to expand.

Intrathecal injection of epidural blood patch: a case report and review of the literature

Epidural blood patch (EBP) is a commonly performed procedure for the treatment of persistent severe post- dural-puncture headache (PDPH). It has a high success rate with a low incidence of complications. We report the case of a 27-year-old woman who developed progressive back pain and radicular symptoms after an EBP was performed for PDPH. An emergency MRI showed a subarachnoid hematoma. Gradual recovery occurred without the need for intervention. To our knowledge, this is the only case demonstrating the MRI findings of a rare complication of a common procedure. Radiologists may benefit from familiarity with epidural blood patching, including the technique, risks, benefits, and potential complications

Spinal epidural hematoma in an infant as the initial presentation of severe hemophilia

We describe the clinical manifestations, radiographic features, and management options of an extensive spontaneous spinal epidural hematoma in a 7-month boy who had severe hemophilia that had not been previously diagnosed, despite a baseline factor VIII level less than 1% of normal. We believe this to be the youngest reported case of a symptomatic spontaneous spinal epidural hemorrhage in an infant subsequently initially establishing a diagnosis of hemophilia.

Perineural extension of facial melanoma

A 64-year-old man presented with a pigmented cutaneous lesion on the right side of his face along with right facial numbness. Histological examination revealed malignant melanoma. Magnetic resonance imaging (MRI) revealed perineural extension along the entire course of the maxillary division of the right trigeminal nerve. This is a rare but important manifestation of the spread of head and neck malignancy.

Multiple Myeloma of the Thyroid Cartilage

A 60-year-old male presented with hoarseness. His past medical history was remarkable for a plasmacytoma of the left maxillary sinus having been resected without systemic evidence of plasma cell myeloma (PCM), also known as multiple myeloma (MM), at the time. This maxillary sinus disease recurred and was treated with radiation. Workup for PCM was conducted. Treatment included melphalan and autologous stem cell transplant. Because of the therapeutic and prognostic implications, a Plasma cell neoplasm (PCN) in a neck mass must be carefully evaluated by clinical and pathological criteria in order to distinguish plasmacytoma from PCM. PCN involvement of the thyroid cartilage is very rare, with only 5 previously reported cases.

Pediatric Cerebellar Hemorrhagic Glioblastoma Multiforme

We report the case of an 11 year old boy who presented with nausea, vomiting and ataxia. He was evaluated with computed tomography (CT) and magnetic resonance imaging (MRI). Imaging demonstrated minimal enhancement and hemorrhage of a cerebellar mass. Cerebellar glioblastoma multiforme (GBM) is extremely rare in the cerebellum at any age but especially in children. The atypical findings of minimal enhancement, cerebellar location and hemorrhagic presentation combine to make the prospective diagnosis of GBM a difficult one. This rare combination of findings has not been previously reported.

Brooke-Spiegler Syndrome with Multiple Scalp Cylindromas and Bilateral Parotid Gland Adenomas

A 62-year-old female presented with numerous soft tissue lesions of her scalp and bilateral preauricular region. Several of these have been biopsied or removed with a diagnosis of cylindromas. Cylindromas are benign tumors with a differentiation towards apocrine sweat glands that increase in number and size throughout life. Multiple scalp cylindromas may coalesce and cover the entire scalp, resulting in the “turban tumor.” These are often associated with the autosomal dominant Brooke-Spiegler syndrome with coexistent facial trichoepitheliomas and spiradenomas. There is a very rare association between cylindromas and basal cell adenoma and adenocarcinoma of the parotid gland, with only 17 reported cases. Ours is the first CT demonstration of both the scalp and parotid gland findings in this uncommon situation.

Pediatric sphenoidal Rathke's cleft cyst

We report the case of a 13-year-old boy who underwent a head computed tomography for seizures revealing an incidental very large intrasphenoidal Rathke cleft cyst (RCC). The initial pre-operative differential diagnosis included meningocele and muco- cele. It is important to consider a benign entity such as RCC to avoid potential unnecessary aggressive intervention. This is only the second reportedcaseof an intrasphenoidal RCC and it is the first reported case of an intrasphenoidal RCC in the pediatric population.

Pediatric facial arteriovenous malformations: case report and overview of the basics.

Aims: Describe the multimodality imaging of a large facial AVM in a child and discuss the treatment options of pediatric facial AVMs Case Presentation: An 11 year old girl developed spontaneous (no prior trauma) enlargement of her left cheek with bleeding from her mouth when eating hard foods. The bleeding was described as pulsatile red bleeding that stopped spontaneously. On physical exam, she had a palpable pulsatile left buccal AVM; auscultation revealing high-flow through it. MRI demonstrated a 2.7 cm heterogeneous vascular mass arising in the soft tissues of the left cheek with involvement of the anterior wall of the left maxillary sinus with a large tortuous ectatic draining vein. CTA demonstrated a large AVM involving the left face with the nidus along the posterior wall of the left maxillary sinus, markedly enlarged draining veins throughout the left face/cheek and prominence of the pterygoid venous plexus. Left common carotid artery angiogram demonstrated an extensive AVM centered in the left maxilla. Left external carotid artery angiogram demonstrates the AVM receiving supply from the distal left internal maxillary, left facial, and left internal maxillary arteries. Angiography of the left internal maxillary demonstrated a high flow AVM with drainage to the left facial vein. The left internal maxillary artery was embolized using Onyx. The left facial, transverse facial, and internal

A complication of an epidural blood patch

Epidural blood patch (EBP) is generally accepted as an effective and relatively low risk therapeutic option for post dural puncture headache, as well spontaneous spinal cerebrospinal fluid (CSF) leak in patients not responding to conservative management [1]. Subdural hematoma (SDH) after EBP is a very rare complication. As in the case described by Verduzco et al., our patients also demonstrated an eight segment spread of the hematoma [2]. There are generally three predominant theories for development of SDH after EBP [3,4]. One is that the initial dural puncture with the Tuohy needle created a means of communication between the epidural and subdural spaces. The other is that the Tuohy needle