A RARE CASE OF ACUTE QUADRIPARESIS IN YOUNG ADULT - ROLE OF DIFFUSION-WEIGHTED MR IMAGING We present a case of a young adult without any comorbidities who presented with acute quadriparesis. There was a diagnostic dilemma of the case whereby the primary team had difficulties to come up with a diagnosis due to lack of supportive information from the clinical history and limited laboratory investigation results prior to neuroimaging. Purely based on the clinical signs and symptoms, the patient was initially treated for transverse myelitis. Initial imaging performed includes computed tomography (CT) of the brain which did not show any abnormalities. Subsequent magnetic resonance imaging (MRI) of the brain showed no supratentorial abnormalities however there was restricted diffusion at medulla noted in the diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) map. MRI of the cervical spine showed high signal intensity on T2-weighted images in the anterior part of the spinal cord on standard MRI spine sequences. The restricted diffusion detected on DWI and ADC map aids in the diagnosis of spinal cord infarction (SCI) in this patient. However, it is to be noted that the DWI sequence of the MRI spine study is not routinely performed. This case report illustrates the role of DWI in diagnosing SCI in a young adult with quadriparesis.

A RARE PRESENTATION OF EWING SACROMA AS A PRIMARY INTRADURAL EXTRAMEDULLARY MASS IN PAEDIATRIC PATIENT Ewing sarcoma (ES) is a highly malignant bone tumor that accounts for 25% of all bone tumors in childhood. Primary spinal ES is very uncommon. Primary intradural extramedullary Ewing sarcoma (IEES) is even rarer, and high clinical suspicion is vital to guide accurate management and tissue diagnosis. A 10-year-old boy presented with a 3-week history of non-specific back pain, which worsened and impaired his regular activities. Urgent magnetic resonance imaging (MRI) revealed a thoracic intradural extramedullary mass causing regional compression. Tumor debulking surgery was performed, and histopathological examination of the excised mass was consistent with ES. Early recognition and management of highly aggressive tumors are essential, more so in critical regions such as the spine. Our case emphasises the need to consider ES as a differential diagnosis for spinal tumors in intradural extramedullary locations in the pediatric age group, as the aim of treatment should be curative and not palliative due to high 5-year survivability.

Biliary atresia is one of the commonest causes of prolonged jaundice in neonate, whereas cystic biliary atresia is a rare form of biliary atresia with similar presentation, but a slightly different sonographic finding. Being able to differentiate them radiologically is important as the surgical management is different for these two diagnoses. An ultrasound examination was done for a 2-month-old baby girl with prolonged jaundice with the finding of a cyst along the portal triad, which raised the suspicion for cystic biliary atresia. The diagnosis was confirmed with intraoperative cholangiography (IOC) and Kasai procedure was done. The patient was well after the surgery with resolution of jaundice.

Hepatobiliary iminodiacetic acid (HIDA) scintigraphy is a non-invasive, functional imaging of the hepatobiliary system that serves as an adjunct imaging modality for neonatal cholestasis work-up. In view of the urgency to diagnose biliary atresia and restore bile flow through surgery, HIDA scintigraphy could help to distinguish between neonatal cholestasis due to biliary atresia and neonatal hepatitis of various causes. We describe a full-term male infant with jaundice beyond the physiological period in which HIDA scintigraphy showed absent tracer excretion from the biliary system into the intestines up to 5 hours on follow-up imaging. The intraoperative diagnosis confirmed the diagnosis of biliary atresia. The prognosis of the patient with biliary atresia depends on early surgical planning and intervention. Therefore, non-invasive diagnostic tools play an important role in the evaluation of a child with neonatal cholestasis.

Internal abdominal herniation can be a cause for bowel obstruction and still being under diagnosed. Transmesenteric internal herniation is increasing in occurrence as more surgical intervention being performed. Clinical diagnosis of internal herniation can be very challenging. Computed tomography could be the first imaging modality to discover a clinically unsuspected internal herniation especially in patient with previous surgical intervention. Radiologist should be aware of computed tomography features like reversal of the normal anatomical arrangement of the bowels as well as the mesenteric vessel changes, which raise the suspicion of internal hernia in patient presenting with bowel obstructive symptoms.

A 7-year-old well and healthy boy was hospitalized for the first time for severe respiratory distress. He was diagnosed with congenital cystic adenomatoid malformation (CCAM) and bronchopulmonary sequestration (BPS). CCAM and BPS are rare congenital pulmonary diseases and their presentation concurrently as a hybrid lesion is even rarer. CCAM is usually diagnosed prenatally however it may regress postnatally and the patient may be asymptomatic. BPS usually presents after birth or later in childhood with recurrent lung infections. We highlight this case of hybrid lesion of CCAM and BPS with an atypical clinical presentation which was lifesaving surgically with diagnosis made via radiographic imaging.
Bronchopulmonary Sequestration

Omohyoid muscle syndrome (OMS) is one of the rare causes of lateral neck swelling during swallowing and it is often a worrisome observation due to the concern of malignancy and cosmetic deformity. Anatomical variation, congenital weakness, or trauma may cause incompetence of the fascial-retaining mechanism and subsequently OMS. Its prevalence is unknown as only a few cases were reported in the past and none in Malaysia. Diagnosing OMS is very challenging. Hence, imaging techniques like real time ultrasound or dynamic computed tomography can be useful in assessing the affected muscles.
Malaysia

Ectasia or abnormal dilatation of a vessel may affect any vein within the body including the neck region. Internal jugular vein (IJV) ectasia commonly presents as a painless, soft swelling on the neck which appears to be prominent with increased intrapleural pressure such as during Valsalva manoeuvre. To the best of our knowledge, the occurrence of venous ectasia is infrequent with limited number of reports on this anomaly available. However with the advancement of technology especially in imaging modalities, there is improvement in detecting this condition. We describe here an incidental finding of focal IJV ectasia in an elderly lady following a cervical spine magnetic resonance imaging (MRI) for bilateral hand numbness, and discuss the management of this rare presentation.
Cervical spine MRI

Malignant intrathoracic disease is the commonest cause of superior vena cava (SVC) obstruction. Life threatening SVC obstruction with intense dyspnoea requires urgent treatment. SVC stenting has been developed in recent years which results in rapid relief of the obstruction. The Yconfiguration technique has been reported to provide support for all three limbs of the bifurcation to prevent restenosis. At present, there are limited reports on the use of Y-configuration stent in stent techniques for endovascular stenting in malignant SVC obstruction. We share our clinical experience of two patients who received balloon-mounted stents using this technique

Primary osteosarcoma of the spine is indeed rare and onlyseveral sporadic cases have been reported. It tends to occurin a slightly older age group than those with appendicularskeleton tumours. We present here an unusual case ofaggressive lumbosacral osteosarcoma in a young teenagercomplicated by extensive dural spread, skip lesions andintravascular extension. Although a histopathologicalexamination is mandatory to establish the diagnosis, thiscase emphasises the need of imaging to ascertain the fullextent of disease spread especially in deciding the type oftreatment to be instituted and to evaluate the response tothe treatment.