Musculoskeletal #35

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52-year-old patient:
·With chronic right hip pain

MRI findings:

T1W
T1W
T2W Fat Sat
T2W Fat Sat
T2W Fat Sat
What is the underlying reason for the alterations observed in the bone marrow?

What is the underlying reason for the alterations observed in the bone marrow?

– A subchondral insufficiency fracture accompanied by bone marrow edema is noted
– The presence of additional bone marrow edema in the right femoral neck, particularly in the anterolateral region, is likely indicative of an insufficiency response
– Complete cartilage damage is observed

Pelvic insufficiency fractures

-Pelvic insufficiency fractures typically manifest in the lateral aspect of the femoral neck, while stress fractures tend to occur on the medial aspect

-Additionally, damage to the articular surface can result from cartilage loss, a condition distinct from osteonecrosis

Reference: Peh WC et al: Imaging of pelvic insufficiency fractures. Radiographics. 16(2):335-48, 1996

Musculoskeletal #34

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51-year-old patient:
* Present with a painful lump in right thigh
* No history of trauma
* MRI requested

T2W Fat Sat
T2W Fat Sat

What should be the subsequent action to be taken?

What should be the subsequent action to be taken?

– Perform an X-ray to exclude the presence of calcifications
– Confirm that there is no prior history of trauma

The patient had been involved in a car accident five months before the lump was detected

What further actions can we taken to assure an accurate diagnosis?

What further actions can we taken to assure an accurate diagnosis?

Perform a follow-up X-ray in three months

What is the most likely diagnosis?

What is the most likely diagnosis?

Myositis ossificans

It should be distinguished from parosteal osteosarcoma and soft tissue sarcoma

Key imaging characteristics to consider include:

-The zonal phenomenon: Mineralization typically initiates and progresses from the periphery towards the center. The absence of this phenomenon should raise concerns.
-Soft tissue edema is more common around myositis ossificans than around sarcomas. It may show marrow edema, periosteal reaction, and peripheral edema at any stage better expressed

Reference: McCarthy EF et al: Heterotopic ossification: a review. Skeletal Radiol. 34(10):609-19, 2005

Emergency #42

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66-year-old male:
– Presented with cough and dyspnea
– Known metastatic prostate cancer, under radiological surveillance

What do you see?

What do you see?

Progressive course with veiling basal lung opacities and right pleural effusion.
Widespread metastatic sclerosis of the examined chest wall and upper humeri, scapulae and clavicle.

Abdominal #25

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57-year-old patient:
With recently diagnosed poorly differentiated vaginal carcinoma underwent FDG PET CT for staging

What do you see?

What do you see?

FDG PET/CT study showing:
-A hypermetabolic lower vaginal lesion representing the known vaginal neoplasm associated with a larger hypermetabolic uterine body neoplastic lesion suggesting synchronous malignant process
-Multiple hypermetabolic enumerable bilateral lung deposits associated with a single right lower para-tracheal nodal deposit representing metastatic disease

Emergency #41

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38-year-old-male:
– Presented with cough
– Previous history of asthma
– The patient was noted to have elevated IgE levels and a mildly raised eosinophil count
– Expectorated sputum demonstrated fungal hyphae on microscopy

What do you see?

What do you see?

Allergic Bronchopulmonary Aspergillosis (ABPA)

Finger in glove sign can be seen.

Cardiac #4

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Clinical Data: A 53-year-old patient with myocardial infarction (STEMI) and cardiac decompensation (Pulmonary-to-systemic flow ratio Qp:Qs of 3.9)

What is the most likely diagnosis?

What is the most diagnosis?

Post-myocardial infarction ventricular septal defect/rupture (VSD/VSR).

Explanation

Ventricular septal defect/rupture is a rare but life-threatening complication after myocardial infarction. Generally, patients with VSR present with a transmural infarction. The defect results in left-to-right shunting and right ventricular pressure and volume overload. The rupture site can expand abruptly, resulting in sudden hemodynamic collapse in previously stable patients. Surgical closure is the definitive treatment for post-infarction VSD; however, the optimal timing of surgery remains controversial. Percutaneous closure devices have also been applied with success.

References

– Crenshaw BS, Granger CB, Birnbaum Y, et al. Risk factors, angiographic patterns, and outcomes in patients with ventricular septal defect complicating acute myocardial infarction. GUSTO-I (Global Utilization of Streptokinase and TPA for Occluded Coronary Arteries) Trial Investigators. Circulation 2000;101:27-32.
– Menon V, Webb JG, Hillis LD, et al. Outcome and profile of ventricular septal rupture with cardiogenic shock after myocardial infarction: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries in cardiogenic shocK? J Am Coll Cardiol 2000;36:1110-6.
– O’Gara PT, Kushner FG, Ascheim DD, Casey DE Jr, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA,
Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013 Jan 29;61(4):e78-e140. doi: 10.1016/j.jacc.2012.11.019. Epub 2012 Dec 17. PMID: 23256914.

Cardiac #3

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Clinical Data: 70-year-old male, asymptomatic, incidental finding on chest X-ray

What are the findings:

What are the findings:

Enlargement of the left coronary artery (LAD) and right coronary artery (RCA) with peripheral thrombus
within both vessels diagnostic of coronary artery aneurysms.

What is the most likely diagnosis:

What is the most likely diagnosis?

Coronary artery aneurysm:

Definition: coronary dilatation which exceeds the diameter of normal adjacent segments or the diameter of the patient’s largest coronary vessel by 1.5 times
Etiology: Atherosclerosis, genetic, autoimmune/inflammatory, infectious
Clinical Presentation: mostly clinically silent
Complications: local thrombosis > distal embolization and myocardial infarction; aneurysm rupture > cardiac tamponade; myocardial stenosis
Treatment: percutaneous or surgical