Neuroradiology #11 – Long case

47-year-old male:
* Presented with epistaxis

Axial & coronal CT+C

Where is the lesion?

The bulk of the tumour is within the ethmoid sinuses extending inferiorly into the nasal cavity and superiorly into the intracranial cavity through the cribriform plates

What is the lesion like?

Enhancing soft-tissue tumor expanding the ethmoid sinuses and nasal cavity

T2, T1 and T1+C

What are the MRI signal characteristics?

Mixed signal intensity on T2, low signal on T1, and intense enhancement on post-contrast images

What is the differential diagnosis of paranasal sinus tumour?

* Olfactory neuroblastoma:  involves the ethmoid sinuses  and extends through the cribriform plate into the anterior cranial fossa. Usually, shows intense enhancement and may show calcifications. They are slow growing with sinus expansion

* Juvenile angiofibroma: benign locally aggressive vascular  tumor that affects adolescents. It is usually lobulated and expands the sphenopalatine foramen. Intense enhancement on post-contrast images

* Sinonasal carcinoma: heterogeneously enhancing mass that erodes the bone and may extend into the orbits or intracranially

* Lymphoma: low T2 signal with intense contrast enhancement and usually expands the bone

Diagnosis:Olfactory neuroblastoma

Dr. Pepe Case 140 – Art of interpretation – SOLVED!

Dear Friends,

I am presenting today a new “Art of interpretation” case.
Radiographs belong to a 51-year-old with chest pain, dyspnea and D-dimer of 750.

Diagnosis:
1. Pulmonary infarct
2. Pneumonia
3. Chronic pulmonary changes
4. None of the above

What do you see? Come back on Friday to see the answer!

Click here to see the images


Click here to see the answer

Findings: the PA radiograph shows an ill-defined opacity in the right mid-lung field (A, white arrows) which looks intrapulmonary. There is blunting of the right costophrenic angle, indicative of pleural disease (A, red arrow).

The main diagnostic findings are seen in the lateral view. There are oblique posterior pulmonary strands (“crow’s feet”) (B, white arrow) which lead our attention to a posterior vertical white line (B, red arrows), which represents calcified pleura.
A negative finding is the absence of pulmonary disease in the lateral view.

These findings are better seen in the cone down views (C and D, arrows) .

Analysis of findings:
1. Apparent pulmonary disease in the PA radiograph
2. No visible pulmonary disease in the lateral view
3. Blunting of costophrenic angle with calcified posterior pleura
4. Crow’s feet

Summing up the findings: The apparent pulmonary disease in the PA view, which was not seen in the lateral view, together with chronic pleural disease (evidenced by blunting of the costophrenic angle and calcified posterior pleura) are highly suggestive of pleural disease simulating a pulmonary infiltrate.

APPARENT PULMONARY DISEASE IN THE PA RADIOGRAPH, NOT SEEN IN THE LATERAL VIEW + CALCIFIED PLEURA IN THE LATERAL VIEW = CALCIFIED PLEURA SIMULATING PULMONARY DISEASE.

Enhanced axial CT confirms the posterior calcified pleura (A, arrow), the lack of pulmonary infiltrate, and the crow’s feet adjacent to the diseased pleura (B, red arrow).
Crow’s feet are better seen in the coronal and sagittal reconstructions (C and D, red arrows), especially the sagittal view, which is practically identical to the lateral chest radiograph.

Final diagnosis: Pleural calcification simulating pulmonary infiltrate

(My heartfelt thanks to Dr. Eva Castañer for providing the CT images)

Pleural calcifications are not uncommon. Bilateral calcifications are almost always related to asbestos exposure. Unilateral calcifications are usually due to a previous infection or hemorrhage. In any case, when located in the anterior or posterior chest wall they are seen en face in the PA radiograph and may be confused with pulmonary infiltrates, as in the present case. Seen in profile in the lateral view they appear as a calcified line, and the diagnosis is then evident.

Sometimes, the calcified pleura are overlooked. In this particular case we have a useful marker that points our attention to the diseased pleura: the radiologic sign known as crow’s feet which represents subsegmental areas of peripheral fibrosis/atelectasis fixed by the fibrotic pleura. They are likely an early stage of rounded atelectasis. (Personally, I prefer the alternative term sun rays rather than crow’s feet. As a frequent visitor to Minorca, I am more familiar with sun rays than with crows, let alone their feet).

To emphasize the deceitful appearance of pleural calcification, I am showing two more cases.

FIRST CASE

Radiographs belong to a 52-year-old asymptomatic woman. The PA radiograph shows what appears to be a poorly-defined pulmonary infiltrate in the left lung (A, arrow). The lateral view shows two calcified pleural plaques: the posterior one is depicted as a calcified line (B, white arrow), whereas the anterior one is more oblique and simulates a rounded opacity (B, red arrow).

Sagittal CT clearly shows the anterior (C, arrow) and posterior plaques (D, arrow). No pulmonary infiltrates were seen in the lung view (not shown).

SECOND CASE

Preoperative PA chest radiograph in a 57-year-old man. There are several opacities in the left hemithorax that may be pulmonary infiltrates (A, white arrows) accompanied by left diaphragmatic and pleural calcifications (A, red arrows).

In the coronal CT (B) there are no lung abnormalities. Enhanced axial and sagittal CTs depict extensive pleural calcification (C and D, arrows). The apparent pulmonary infiltrates were due to pleural calcifications depicted en face. The patient had a history of TB in his youth.


Dr. Pepe’s teaching points:

1. Pleural disease can simulate pulmonary infiltrates.

2. Crow’s feet can direct our attention to overlooked pleural disease

Emergency #10 – Long case

23-year-old male:
* Blunt force trauma of the abdomen
* Patient is hemodynamically stable

What do you see?

Arterial phase

Venous phase

Arterial phase

Venous phase

Click here to see the answer

Findings:

* Linear zone of hypodensity through the pancreatic body on both phases
* Surrounding fluid with relatively high-density retroperitoneal AND intraperitoneal

Note that the pancreas may appear normal in 20%-40% of patients when CT is performed within 12 h after trauma
MRCP may be useful to evaluate the integrity of the pancreatic duct

Pancreatic fracture:

* Complete laceration of the pancreatic body: AAST Grade III
* Require surgery within 24h
* Possible complications: fistula, pseudocyst, pancreatitis, abscesses, hemorrhage, pseudo-aneurysm
* Usually, injuries of other organs as well

Treatment in this case: distal pancreatectomy and closing of main pancreatic duct transsection, discharge to hospital in home country after 2 weeks

Cáceres’ Corner Case 203 – SOLVED!

Dear Friends,

Today I am showing radiographs of a 40-year-old man with chest pain.
What do you see?

More images will be shown on Wednesday.

Click here to see the images

Dear Friends,

showing today enhanced CT images of the case.

Do they help?

Click here to see the images

Click here to see the answer

Findings: PA radiograph shows a mediastinal mass (A, arrow) superimposed to the right hilum. In the lateral view the mass is faintly visible behind the distal trachea (B, circle). This location excludes a right hilar mass, because the right hilum is anterior to the trachea.

Enhanced coronal and sagittal CT confirm a posterior mediastinal mass (C-D, arrows) with necrotic areas and marked contrast enhancement. This is an important finding because it limits the differential diagnosis to four conditions: intrathoracic goiter, Castleman’s disease, paraganglioma and hemangioma.
Some of you have mentioned extramedullary hematopoiesis. In my (limited) experience I don’t recall seeing avid contrast enhancement in it. I have asked some friends and searched the web without finding a clear answer. If any of you have better information I am willing to be corrected. At any rate, this patient does not have any bone abnormalities, which makes the diagnosis of extrapulmonary hematopoiesis very unlikely.
 
Final diagnosis: posterior mediastinal paraganglioma surgically proved. A similar case was presented in case 168 of Caceres’ corner.
 
Congratulations to MK, who was the first to suggest the correct diagnosis.
 
Teaching point: remember the four mediastinal processes with avid contrast enhancement: intrathoracic goiter (frequent), Castleman´s disease and paraganglioma (uncommon) and hemangioma (never saw a case).

Neuroradiology #10 – Flashcard

What do you see in the following images?

Click here to see the answer

Cerebellopontine angle meningioma

* Extra-axial CP angle mass.
* Heterogenous low signal intensity on T2.
* Intense enhancement on post-contrast images with thickening and enhancement of the tentorium cerebelli.
* No intracanalicular extension.
Differential diagnosis: Schwannoma, ependymoma, metastasis

Dr. Pepe Case 139 – Webinar

Dear Friends,

Presenting PA chest radiograph of a 57-year-old woman with dyspnea and  fever.

What would be your diagnosis?
1. Lobar collapse
2. Pneumonia
3. Unilateral pulmonary edema
4. Any of the above

You have one week to post your answers. The correct answer will be given during the webinar of Wednesday 3 at 12:30 P.M.
You can join the webinar here

Click here to see the image

Emergency #9 – Long case

60-year-old female:
* Known with hypertension
* Acute pain on the chest
* X-ray
* Abnormal?
* Differential Diagnosis: No.

What should we think of and do next?

Click here to see the answer

Clinically suspect for aortic dissection

What protocol?
Non-enhanced chest CT, followed by CT angiography chest-abdomen

No NECT was made:

Imaging findings and key messages

* Soft tissue surrounding ascending aorta from the root, continuing around the aortic arch and descending aorta
* Between the soft-tissue band and the intraluminal contrast, we see intimal calcifications, these are NOT displaced outwards
* At some spots, there is contrast extravasation in the soft tissue
* No intimal tear or dissection flap is seen
* Slight pericardial effusion

What is the diagnosis?

Click here to see the diagnosis

Aortic intramural hematoma.

Treatment is like an aortic dissection with anti-hypertensive medication. In this case, it is a type A since the mural hematoma is seen proximal to the left subclavian artery, involving the ascending aorta.

Differential Diagnosis

* Thrombosed false lumen in classic aortic dissection: Typically spirals longitudinally around the aorta, whereas an intramural haematoma usually maintains a constant circumferential relationship with the aortic wall

* Aortitis: Typically shows concentric uniform thickening of the aortic wall with or without peri-aortic inflammatory stranding, whereas an intramural haematoma is often eccentric in configuration

Treatment/Prognosis

* If an intramural haematoma involves the ascending aorta (Stanford A), treatment is surgical to prevent rupture and progression to a classic aortic dissection

* Conservative management is indicated for an intramural haematoma of the descending aorta (Stanford B)
* 77% of intramural haematomas regress at 3 years
* Survival of >90% at 5 years

* Untreated, an intramural haematoma can be life-threatening as it can lead to: aortic rupture, aortic dissection, aortic aneurysm.