Spinal cord compression is a neurosurgical emergency. Symptoms of this disorder are highlighted as back pain, ambulatory difficulties, and bladder/bowel incontinence. Diagnostic imaging is not indicated in many circumstances of nonspecific back pain; however, the addition of neurologic deficits in the setting of back pain justifies radiologic imaging. Various pathologies can cause constriction of the spinal cord due to the delicate nature of spinal cord anatomy. Etiologies may include trauma, neoplasms, and infections. In this report, we present an unusual case of a 31-year-old male who presented to the emergency department with a history of chronic back pain accompanied by neurological deficits, ataxia, and bladder dysfunction. Contrast-enhanced MRI imaging heightened the suspicion of a neoplastic etiology; however, neuropathology revealed a non-neoplastic nature with abnormal lymphohistiocytic infiltrate suspicious for Langerhans cell histiocytosis or infectious etiology. A second opinion was provided by Mayo Clinic Laboratories, resulting in the definitive conclusion that the mass was non-neoplastic and tested negative for SD1a and Langerhin, biomarkers used to diagnose Langerhans cell histiocytosis. This unusual non-neoplastic lesion exemplifies one of many diverse and multifaceted pathologies that can precipitate spinal cord compression. Additionally, these findings underscore the importance of considering both neoplastic and non-neoplastic causes in the differential diagnosis of spinal cord compression, thereby enhancing clinical vigilance and improving patient outcomes for underlying spinal conditions.

Introduction The purpose of this study was to determine whether multi-voxel magnetic resonance spectroscopic imaging (MRSI) can differentiate between intracranial neoplastic and non-neoplastic and between neoplastic ring-enhancing lesions (RELs) based on differences in major metabolite ratios in their enhancing and peri-enhancing regions. Methods In a prospective observational study involving patients with an intracerebral RELs, MRSI using the two-dimensional multi-voxel point-resolved spectroscopy (PRESS) chemical-shift imaging (CSI) sequence at an echo time (TE) of 135 milliseconds (ms) was performed on a total of 38 patients. Of 38 lesions, 23 (60.5%) were neoplastic and 15 (39.5%) were non-neoplastic. Of the 23 neoplastic lesions, 12 were high-grade gliomas (HGGs), seven were metastases, and four were low-grade gliomas (LGGs). Major metabolite ratios, i.e., choline-to-N-acetylaspartate (Cho/NAA), choline-to-creatine (Cho/Cr), and N-acetylaspartate-to-creatine (NAA/Cr), were calculated in the enhancing and peri-enhancing regions of the RELs. A Mann-Whitney U test was run to determine differences in metabolite ratios at different voxel locations between neoplastic versus non-neoplastic lesions, HGGs versus metastatic lesions, and HGGs versus LGGs. A receiver operating characteristic (ROC) curve analysis was performed to derive cut-off values for Cho/NAA and NAA/Cr ratios in the enhancing and peri-enhancing portions of the lesions. Results The sensitivity, specificity, positive predictive value, and negative predictive value for categorizing an REL in either neoplastic or non-neoplastic lesions using MRSI with magnetic resonance imaging (MRI) were 91.3%, 73.3%, 84%, and 84.6%, respectively. There was a statistically significant difference between Cho/NAA (p = 0.006) and NAA/Cr (p = 0.021) ratios in the enhancing region of 23 neoplastic and 15 non-neoplastic lesions. In the voxel placed in the peri-enhancing portions, the differences between Cho/Cr ratios were just significant (p = 0.047). A cut-off score of Cho/NAA >1.67 in the enhancing regions gave a sensitivity of 82.6% and specificity of 60%. The cut-off score for NAA/Cr of <0.80 in the enhancing regions showed a sensitivity and specificity of 60.9% and 86.7%, respectively. Of the 23 neoplastic lesions, 12 HGGs and seven metastases were differentiated using the Cho/NAA ratio in the peri-enhancing region with a cut-off value of 1.21, sensitivity of 100%, and specificity of 85%. A cut-off value of Cho/Cr ≥1.45 in the peri-enhancing regions showed a sensitivity of 83% and a specificity of 71.4%. For discriminating between 12 HGGs and four LGGs both from the 23 neoplastic REL group, using the cut-off score for Cho/NAA in the enhancing portions ≥4.16 showed a sensitivity of 0.75 and specificity of 100%. In the peri-enhancing regions, a cut-off score of ≥2.07 provided a sensitivity and specificity of 83% and 100%, respectively. Conclusion Conventional MRI sometimes poses a diagnostic challenge in distinguishing between neoplastic and non-neoplastic lesions and other neoplastic RELs. Interpreting MRSI findings by comparing the major metabolite ratios in the enhancing and peri-enhancing regions of these lesions may enable distinction between the two.

Cardiac calcified amorphous tumor (CAT) is a rare, non-neoplastic, intra-cavity cardiac mass. Only a few cases have been described in the literature. A 46-year-old Indian female presented with decompensated heart failure. On echocardiography, 1.9 x 1.7 cm pedunculated mobile mass in the left ventricle attached to the intraventricular septum was seen. On cardiac magnetic resonance imaging (MRI), the lesion was isointense. Histopathology of the excised mass revealed fibrin deposition with eosinophilic amorphous material in the center with the periphery of the lesion showing calcification without any myxomatous tissue. A final diagnosis of CAT of the heart was established. CAT is composed of calcium deposits in the background of amorphous degenerating fibrinous material. It presents as a pedunculated mass in any chamber of the heart with a very high preponderance of distal embolization. Differentiation from calcified atrial myxoma, calcified thrombi, or other cardiac neoplasms is very difficult. Histopathological examination is the mainstay of diagnosis. Treatment is emergency excision to prevent distal embolization. CAT is a rare non-neoplastic tumor, which is mainly a tissue diagnosis after its resection.

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