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BACKGROUND: Spontaneous pneumomediastinum (SPM) is a rare and often unrecognized condition of which vomiting is one of the reported triggering factors. Differentiating SPM from Boerhaave's syndrome (pneumomediastinum secondary to esophageal breach) is the first step in management and prognosis. OBSERVATION: A 27-year-old woman with systemic lupus erythematous presented to the emergency department with epigastralgia, incoercible vomiting and diarrhoea. Abdominal CT showed circumferential thickening of the duodenum and bilateral ureteritis. Chest sections showed pneumomediastinum extending to the cervical region. Therapeutic management was based on prophylactic antibiotic therapy and an absolute diet (fasting). A CT scan with upper gastrointestinal opacification was performed to prevent esophageal rupture and showed quasi-obstructive thickening of the antral mucosa. The diagnosis was lupus enteritis and pneumomediastinum was secondary to the vomiting efforts. The patient was placed on corticosteroids and a favorable outcome ensued. CONCLUSION: Strenuous vomiting is one of the precipitating factors of SPM. Boerhaave's syndrome is the main differential diagnosis with a poor prognosis, unlike SPM, which has a good prognosis with conservative treatment.

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INTRODUCTION: Alagille syndrome is a multisystem autosomal disorder. The main clinical features are chronic cholestasis due to paucity of intrahepatic bile ducts, which can progress to cirrhosis and liver failure. PRESENTATION OF CASE: A 15 year-old girl with Alagille syndrome was referred for liver transplantation. She developed severe cirrhosis with refractory ascites. In the pre-transplant evaluation, imaging studies disclosed liver atrophy with a high density pseudotumor in the segment 4, raising the possibility of a hepatocellular carcinoma. However, behavior of the lesion was highly suggestive of focal compensatory hyperplasia surrounded by an atrophic liver. The patient was registered on the waiting list. DISCUSSION: Hepatic lesions have been described in Alagille syndrome in isolated case reports, and most of these have been reported to be hepatocellular carcinoma. However, they can be related to an area of focal compensatory hyperplasia in severe cirrhosis. These findings may also explain why progression of liver disease occurs only in 15% of patients. CONCLUSION: The presence of a large hepatic nodule Alagille syndrome can be benign in these patients also predisposed to hepatocellular carcinoma. Therefore, cautious evaluation with magnetic resonance imaging study before liver transplantation is mandatory.

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Takayasu's arteritis is the most frequent inflammatory arteritis in young patients. It is characterized by the presence of giant cells and typically involves specific vascular sites: aorta and its main branches and pulmonary arteries. Inflammatory arterial involvements leads to stenosis, aneurysm, occlusion and arterial wall thickening. Diagnosis relies mainly on imaging, namely Doppler US, CT, and MRI. The imaging features of this disease are reviewed based on a retrospective review of 36 patients imaged over a 13 year period.

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Hepatic epithelioid hemangioendothelioma (EHE) is a rare neoplasm of vascular origin. EHE is an intermediate-grade malignancy, between benign hemangioma and angiosarcoma, with variable aggressiveness. Involvement often is multinodular simulating metastases from a primatry extra-hepatic malignancy leading to delays in diagnosis. We report the imaging features in three cases of histologically proven hepatic EHE. The imaging features suggestive of EHE will be emphasized, especially for multinodular lesions suggesting liver metastases in patients with no known primary.

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OBJECTIVE: This study aims to assess the diagnostic capability of CT to preoperatively detect evidence of locoregional spread of gallbladder cancer. PATIENTS AND METHODS: Two radiologists independently performed retrospective review of CT scans on 20 patients who had undergone surgical resection for carcinoma of the gallbladder. Local spread was categorized by the TNM system and the results were correlated with surgical and pathologic findings. RESULTS: All cases of hepatic spread (14 cases), common bile duct extension (four cases), pancreatic spread (three cases) and duodenal spread (three cases) were correctly diagnosed by helical CT. One of three cases of peritoneal spread and two of three cases of gastric spread were misdiagnosed. CT evaluation of T stage (T1: one case [5%]; T2: four cases [20%]; T3: four cases [20%], and T4: 11 cases [55%]) was accurate in 85%. The sensitivity and positive predictive value (PPV) of T1-T2 lesions were 80%. The specificity and negative predictive value (NPV) were 93%. For T4 lesions sensitivity, specificity, PPV and NPV were 100%. CONCLUSION: Helical CT provided 85% accuracy in the diagnosis of the locoregional extent of gallbladder cancer. It allows an acceptable classification according to the TNM staging system and predicts prognosis.

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Percutaneous extraction of intravascular foreign bodies is becoming an increasingly common technique. It is an effective and low aggressive way to avoid surgery. We report four new cases of percutaneous retrieval.

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Pseudotumoral xanthogranulomatous pyelonephritis is a rare chronic renal infection. Preoperative diagnosis is difficult because of its non-specific presentation. The purpose of this retrospective review of 8 cases is to assess the value of different imaging techniques in the evaluation of this pathology. Six males and 2 females, aged 29 to 75 years were included. The right kidney was involved in 5 cases and the left kidney was involved in 3 cases. Involvement was upper polar in 2 cases and lower polar in 6 cases. A kidney stone was present in 3 cases. US showed a heterogeneous hypoechoic lesion in 3 cases, a homogeneous hypoechoic lesion in 3 cases, and isoechoic lesion in 1 case and a cystic lesion in 1 case. CT showed a focal solid lesion with peripheral enhancement in 4 cases and a cystic mass with peripheral enhancement in 3 cases. US features are non-specific. CT shows a non-specific renal mass, the presence of obstruction and demonstrates perirenal involvement. Preoperative MRI, not performed in our patient population, demonstrates specific changes in the perirenal fat that suggests the diagnosis. The diagnosis of pseudotumoral xanthogranulomatous pyelonephritis can be suspected on a constellation of clinical and laboratory findings combined with non-specific features on CT and US and specific MRI features of perirenal fat changes. Percutaneous biopsy may be needed in selected cases to confirm diagnosis.

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BACKGROUND: Schistosomia haematobium infection has been eradicated from Tunisia since 1980. Only some imported cases are noted each year. AIM: The authors report nine cases of Schistosomia haematobium infection diagnosed. METHODS: The diagnosis was carried out within the framework of a survey carried out by the service of Pediatry of the hospital Mongi Slim of Tunis concerning 20 students of African extraction. RESULTS: Hematuria was found in all cases. Schistosomia haematobium infection is diagnosed in all patients by urinary parasitologic examination. Radiological evaluation had revealed mild uroradiologic abnormalities in five patients. All patients were treated by praziquantel. Remission was confirmed by urinary sterilization. Radiologic abnormilities persisted in 3 patients. CONCLUSION: Radiological evaluation and regular follow-up after treatment of students with Schistosomia haematobium infection is required.

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The aim of this study was to evaluate the altered flow dynamics of liver perfusion that can be observed during superior vena cava obstruction. Through the description of three case reports of patients with SVC obstruction, the authors discuss the different collateral pathways used that result in systemic portal venous shunting creating this altered flow dynamics and their appearance in computed tomography.

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OBJECTIVES: Elongated styloid process also known as Eagle's syndrome is an entity that may be the source of craniofacial and cervical pain. It is frequently reported but is probably more common than generally considered. The symptoms related to Eagle's syndrome can be confused with those attributed to a wide variety of oropharyngeal and maxillofacial diseases. From four observations of Eagle's syndrome, we recall the clinical and radiological findings of this affection. MATERIAL AND METHODS: Retrospective analysis of four patients examined during a 2-year period. These patients presented cervical pain associated with headache, vertigo, otalgia and dysphagia. All patients were explored by conventional radiographs and three-dimensional computer tomography reconstruction. RESULTS: Digital palpation of the fossa reproduced and exacerbated the pain. Neck radiographic examination showed a bilateral elongation of the styloid process in both cases. The cervical scanner showed a bilateral elongation of the styloid process in all cases. CONCLUSION: Eagle's syndrome is a frequent entity that remains vaguely known by physicians. Three-dimensional computer tomography is useful for the diagnosis of this entity.

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The authors report the case of a vertebromedullary hydatidosis revealed by medullar compression in a 40-year-old male patient. Magnetic resonance imaging showed lesions of the seventh and eighth dorsal vertebras, cystic lesions in the epidural space and in the perivertebral soft tissues. Surgical excision lead to clinical cure. Vertebromedullary hydatidosis is rare and severe. Modern techniques of imaging are very helpful for the diagnosis and the follow-up of patients after treatment.

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Osler-Weber-Rendu disease is a hereditary vascular disease with multiple manifestations. The liver is involved rarely. Vascular abnormalities include telangiectasis and arteriovenous fistulas, sometimes associated with fibrosis and cirrhosis. Hepatic arteriovenous shunting may include secondary portal hypertension, reduced liver function and high cardiac output. Two cases of Osler-Weber-Rendu disease with extensive hepatic arteriovenous fistulation were described in detail and we report on their clinical features. In the first patient, treatment was symptomatic since liver transplantation is not indicated because the patient was asymptomatic. Embolization treatment of hepatic arteries was indicated in the second patient because he had biliary disease and recurrent cholangitis secondary to vasculo-biliary shunts. Therapy with arterial embolization, banding, or ligature of hepatic arteries is still limited and provides unsatisfactory long-term results. Liver transplantation offers now another therapeutic option for patients with intrahepatic high shunting and secondary pulmonary hypertension.

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