Head and Neck #21

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Clinical Data

62-year-old female:

    • With subacute-onset visual disturbances

What is the differential diagnosis?

1. AQP4‑NMOSD optic neuritis (most likely)
2. MOGAD optic neuritis (usually more anterior, optic sheath oedema)
3. Multiple sclerosis optic neuritis (short segment, unilateral)
4. Granulomatous/infective optic neuritis (sarcoid, TB, syphilis)

What is the differential diagnosis?
  • AQP4-NMOSD
Teaching Points
  • NMOSD ON shows longitudinally extensive, often bilateral nerve involvement with predilection for the posterior nerve and chiasm
  • Imaging pattern plus seropositivity establishes diagnosis; spinal MRI is recommended to look for LETM
  • Early treatment improves visual prognosis, so pattern recognition is key. Bilateral posterior optic nerve + chiasm = think NMOSD
  • Always check the chiasm when evaluating optic neuritis
  • Correlate imaging with AQP4/MOG antibody testing—imaging guides the right test

Abdominal #34

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35-year-old patient:

    • Presenting with right flank pain and elevated CRP
    • CT in portal venous phase was performed

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What is your diagnosis and what patient information will lead you to the correct pathogenesis?
    • Subphrenic abscess with focal calcification, history of prior appendectomy

 

Explanation:
Lost appendicoliths (as well as gall stones) can cause delayed abscesses years after the surgical procedure. Due to a tilted position of the patient during surgery, the lost stones may “travel” towards the upper abdomen and can cause abscesses in the Morison pouch.
Therapy consists of surgical or interventional removal of the stone and drainage of the abscess.

References:

– Singh AK, Hahn PF, Gervais D, Vijayraghavan G, Mueller PR. Dropped appendicolith: CT findings and implications for management. AJR Am J Roentgenol. 2008 Mar;190(3):707-11. doi: 10.2214/AJR.07.2917. PMID: 18287442.

Musculoskeletal #50

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32-year-old male:

    • With chronic back pain lasting for 6 months, worsening at night, with a feeling of morning stiffness lasting about 2-3 hours, slight anaemia in laboratory tests, history of Crohn’s disease

MRI of the sacroiliac joints was performed (STIR, T1):

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Taking into account clinical data and MR images, what is the correct diagnosis?
      • B) Axial spondyloarthritis (axSPA)
Referring to the ASAS criteria, what MR imaging features typical of axSPA do you recognise in the images?
      • A) Bone marrow oedema
      • B) Joint space fluid
      • D) Erosions
      • E) Sclerosis

Explanation:
There are areas of bone marrow oedema in the left SI joint, with a small amount of joint space fluid in the upper segments, along with increased subchondral sclerosis and erosions. No features of capsulitis, no evident backfill or ankylosis visible. Joint space enhancement cannot be confirmed—this was a non-contrast study.

What are the initial eligibility requirements for assessing a patient according to the ASAS criteria?
      • Chronic back pain lasting more than three months
      • Onset of pain before age 45

Explanation:
To be eligible for the ASAS criteria, patients must have chronic back pain (lasting more than three months) with onset before age 45.
They can then be classified into one of two groups: the “imaging arm” if they have evidence of sacroiliitis (on X-ray or MRI) and at least one other feature of spondyloarthritis, or the “clinical arm” if they are HLA-B27 positive and have two or more other features of spondyloarthritis (e.g. uveitis, enthesitis, dactylitis, positive family history for axSPA, psoriasis, increased C-reactive protein level, etc).

Musculoskeletal #49

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43-year-old patient:

        • Evaluation of right foot pain and swelling

T1, T2 and t1 POST-CONTRAST SEQUENCES

What are the findings?

Dumbbell-shaped lesion in third web space near the metatarsophalangeal joint with isointensity on T1 and hypo to isointensity and T2 sequences and inhomogeneous contrast enhancement

What is the most appropriate diagnosis?

Morton’s neuroma in third web space

Musculoskeletal #48

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29-year-old female:

      • Left knee pain for three months
      • Body mass index: 35
      • X-rays are unremarkable

Showing images from an MRI

Coronal PDFS
Coronal PDFS
Coronal T1
What is wrong in the bone marrow?
    • Bone marrow reconversion: Signal intensity is that of normal red marrow being low T1 signal but still higher than skeletal muscle. Marrow reconversion occurs in the reverse order of normal red to yellow marrow conversion.
What could be the cause in general?
    • Physiological (e.g. cigarette smoking, obesity, high altitude), iatrogenic (e.g. post erythropoietin treatment), pathological (e.g. diabetes mellitus, severe chronic anaemia).
What could be the cause in this specific case?
    • Obesity (BMI 35)
Reference:

Musculoskeletal #47

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54-year-old male:

      • Chronic shoulder pain and limited ROM
What is causing the symptoms? Describe all abnormalities you see.

Adhesive capsulitis


There is a thickening and edema of the inferior joint capsule in the axillary recess which is characteristic of adhesive capsulitis.

Additionally, there is an interstitial tear of supraspinatus tendon.

Explanation:

Adhesive capsulitis, also known as frozen shoulder, is an inflammatory condition characterized by shoulder stiffness, pain, and significant loss of passive range of motion.
The joint capsule exhibits inflammation, thickening and fibrosis, leading to pain and loss of ROM.
In most cases, adhesive capsulitis is a self-limited disease with high spontaneous recovery rates within 18 to 30 months.

Abdominal #33

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33-year-old-male-patient:

    • Presented with jaundice
    • laboratory tests revealed elevated levels of serum alkaline phosphatase (ALP), gamma-glutamyl transferase (GGT), total bilirubin, and direct bilirubin

What do you see?
    • A lobulated mass within the bile ducts (shown in red areas)
    • Dilatation of intrahepatic bile ducts
    • A 3.5-cm-lobulated mass within the bile ducts (red arrows) with
      upstream and downstream dilatation of bile ducts
What is your diagnosis?
    • Intraductal papillary neoplasm of the bile duct (IPNB) with invasive carcinoma
    • In our case, the patient underwent surgery and the diagnosis was histopathologically confirmed
Teaching points
    • IPNBs are premalignant biliary epithelial tumors.
    • IPNBs originate from and communicate with the biliary tree and can occur anywhere along the biliary tree.
    • 30-40% of IPNBs exhibit mucin hypersecretion.
    • When symptomatic, patients present with recurrent abdominal pain, cholangitis, and jaundice.
    • Risk factors for IPNBs include hepatolithiasis, clonorchiasis, primary sclerosing cholangitis, biliary tree malformations, choledochal cysts, and familial adenomatous polyposis.
    • IPNB is analogous to the intraductal papillary mucinous neoplasm of the pancreas (IPMN).
    • Imaging findings of IPNB include:
        • Intraductal mass with upstream and downstream dilatation
        • Complex cystic mass with biliary ductal dilatation
        • Ductal dilatation without a mass, with associated parenchymal atrophy
        • Thread sign at MRCP (linear and curved filling defects due to mucin)
    • IPNBs may be associated with invasive carcinoma (27-94%)
    • Imaging findings that suggest invasive carcinoma at MRI include
        • A visible intraductal mass
        • Tumor size greater than 2.5 cm
        • Tumor multiplicity
        • Ductal wall thickening
        • Adjacent hepatic invasion
    • Early surgical intervention is the key management for IPNB.
    • All patients with IPNB should be considered for treatment, given the high potential for malignancy and for recurrent cholangitis and obstructive jaundice in nonmalignant cases

Musculoskeletal #46

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17-year-old-female:

    • Jumped off a horse
    • Pain in the lateral and medial side of the right knee
    • X-ray requested

1. What is the most likely diagnosis and the next step?

Images from an MRI
    • Coronal PDFS
      Sagittal PDFS

 

What is the most likely diagnosis and the next step?
      • Segond fracture: A curvilinear bone fragment projected parallel to the lateral aspect of the tibial plateau. This has been referred to as the lateral capsular sign. MRI is needed for the evaluation of the anterior cruciate ligament.
What are the findings?
    • Segond fracture
    • Partial tear of the medial collateral ligament (deep branch femoral part)
    • Complete tear of anterior cruciate ligament
    • Moderate hemarthrosis
    • Soft tissue oedema around the knee joint

 

Abdominal #32

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60-year-old male patient:

  • Diarrhea, postprandial dizziness and weakness

  • Weight loss of 20 kgs in the last 2 years

  • CT imaging was acquired

What do you see?

  • Mesenteric mass with calcifications surrounded by tethered small bowel loops

  • Retroperitoneal lymphadenopathy

  • Hypodense hepatic lesion, most likely metastasis

What is the most likely diagnosis?

Mesenteric, retroperitoneal lymph node and hepatic metastasis of small bowel neuroendocrine tumor (NET)
Most commonly, this tumor originates in the terminal ileum, but in many cases, the submucosal primary lesion can’t be identified on CT
The mesenteric mass shows both calcifications and tethering of the surrounding bowels due to the characteristic desmoplastic reaction of the mesentery
For further work-up, the radiotracer Ga-68 DOTATATE is shown to be the most accurate at identifying NET

Musculoskeletal #45

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Clinical Data

40-year-old female:
with chronic medial side knee pain.

What abnormality is present?

Pellegrini-Stieda lesion


There is an ossified lesion adjacent to medial femoral condyle, at the insertion of medial collateral ligament (MCL).

MCL fibers are intact.

No signs of osteoarthritis.

Slight degenerative changes within the body of medial meniscus.

Explanation:

Pellegrini-Stieda lesions are defined as post-traumatic ossifications of the medial collateral ligament (MCL) at or near its proximal insertion on the medial femoral condyle.
Pellegrini-Stieda disease (or syndrome) is defined as the combination of the radiographic findings and concomitant medial knee joint pain or restricted range of motion.