Author: EDiR Holders

Musculoskeletal #44

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Clinical Data

39-year-old male:

  • With wrist trauma

Wrist X-ray AP projection
Wrist X-ray lateral projection
Which is the diagnosis?

  • Undisplaced scaphoid fracture

  • Acute boxer’s fracture

  • Dorsal avulsion fracture of the triquetrum

  • No abnormality

Which is the diagnosis?

  • Undisplaced scaphoid fracture – FALSE

  • Acute boxer’s fracture – FALSE

  • Dorsal avulsion fracture of the triquetrum (Red arrow) – TRUE

  • No abnormality – FALSE

    Explanation:

    • Notice also the dorsal soft tissue swelling with air lucencies (Located inside the orange line).




    Triquetral fractures:

    • Second most common carpal bone fracture (after the scaphoid)

    • Fall onto an outstretched hand in ulnar deviation and carpal extension or direct blow to the dorsum of the hand (latter in this case)

    • Almost always dorsal avulsion type

    • Usually only seen on lateral radiographs with the classic “pooping duck” sign




Neuroradiology #43

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Clinical Data

2-year-old male:

  • Presented with enlarged skull and suspected hydrocephalus



Indicate the abnormality:



Description:

  • Mild symmetrical dilatation of the supra & infratentorial ventricular system. Crowded foramen magnum with an inferior location of the cerebellar tonsils below the margins of the foramen magnum.

Which of the following statements are correct?

  • Chiari I malformation characterized by a caudal descent of the cerebellar tonsils through the foramen magnum

  • Treatment with posterior decompression is usually reserved for symptomatic patients or those with a syrinx

  • Chiari I malformations may be seen in association with cervical cord syrinx or hydrocephalus

  • Becoming symptomatic is proportional to the degree of descent of the tonsils

  • Abnormal skull base , cervical segmentation anomalies, small cranial vault, and posterior fossa could be resembling Chiari I malformation

  • Excessive brain tissue could represent acquired Chiari malformation

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Chest and Thorax #1

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56-year-old male patient:
After kidney transplantion presented with cough

Findings:

Multiple intrapulmonary consolidations with peripheral ground-glass opacities . No bronchial obstruction. No pathologically enlarged lymph nodes

What is the most likely diagnosis?

Fungal infection (Rhizopus infection)

Fungal infections in immunocompromised patients may manifest as intrapulmonary nodules or consolidations with peripheral ground glass opacities. May lead to cavitation, pseudoaneurysm formation and bleeding.

Treatment in this case: Anti-fungal systemic therapy

Patient died 5 months thereafter from pulmonary artery aneurysmal bleeding.

Urogenital #3

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87-year-old woman:
* Presented with lower abdominal discomfort and weight loss.
* Pelvic MRI is performed.


What can be seen in the uterine cavity?

Blood, hematometra

In this case what is the cause?

Cervical cancer

What are some congenital causes of hematometra?

Imperforate hymen, vaginal septum, vaginal hypoplasia

Explanation:

In non-adolescent women, hematometra can often be caused by malignancy, so a search for cervical/endometrial cancer must be done.

Cardiac #6

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75-year-old patient:
Medical history:
* Previous left anterior descending artery (LAD) stenosis and iatrogenic left coronary artery (LCA) dissection.
* Underwent coronary artery bypass grafting (CABG) complicated by subsequent graft thrombosis.
* Stress myocardial perfusion imaging performed to assess myocardial ischemia/viability (first row stress perfusion imaging, second row dark blood late gadolinium enhancement imaging).

What is the diagnosis?

Subendocardial scar in LAD territory basal/midventricular with perfusion defect/inducible ischemia in LAD territory surpassing the area of infarction.

Explanation:

Stress myocardial perfusion depicts reversible ischemia in the LAD coronary artery territory anteroseptal/anterior (perfusion at rest not shown). Dark blood-LGE imaging depicts subendocardial scar in LAD territory especially basal, but smaller in extension than the inducible ischemia, indicating potential suitability of revascularization.
Standard dose of adenosine is 140 mcg/kg/min for at least 3 min.

References:

– Patel, A, Salerno, M, Kwong, R. et al. Stress Cardiac Magnetic Resonance Myocardial Perfusion Imaging: JACC Review Topic of the Week. JACC. 2021 Oct, 78 (16) 1655–1668. https://doi.org/10.1016/j.jacc.2021.08.022.
– Shehata ML, Basha TA, Hayeri MR, Hartung D, Teytelboym OM, Vogel-Claussen J. MR myocardial perfusion imaging: insights on techniques, analysis, interpretation, and findings. Radiographics. 2014 Oct;34(6):1636-57. doi: 10.1148/rg.346140074. PMID: 25310421.

Musculoskeletal #41

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45-year-old female with forefoot pain:

What is the pathology located?

Where is the pathology located?

D3/D4 intermetatarsal space

Describe the pathology. Can you name it?

T1- and T2-hypointense soft tissue mass located in D3/D4 intermetatarsal space – Morton neuroma.

References:

Morton neuroma is a result of a compressive neuropathy of the forefoot interdigital nerve. The most common location for interdigital neuromas are between the 3rd and 4th metatarsal heads. Most patients with Morton neuroma have a good recovery with non-surgical treatment. 

Munir U, Tafti D, Morgan S. Morton Neuroma. [Updated 2023 May 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470249/

Urogenital #2

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25-year-old female:
* On ultrasound, a large pelvic mass was found.
* CA-125: 24 U/ml
* Risk of ovarian malignancy algorithm (ROMA): 6.6%
* CT imaging was acquired.

What is the most likely diagnosis?

Dermoid cyst/mature cystic teratoma

Which component is diagnostic of this lesion?

Fat content

What sign can be seen on the 2nd image?

Floating ball sign/pokemon ball sign

References:

A fat-fluid level is present with a ball of debris in the center. Calcification can also be seen

Cardiac #5

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80-year-old patient:
* Underwent aortic arch repair two years ago, now experiencing back pain
* Elevated levels of troponinin I (TNI) and D dimers
* Small pericardial effusion

What is the diagnosis?

Intramural hematoma type A.

Explanation:

Aortic intramural hematoma (IMH) is an atypical form of aortic dissection. It is considered part of the acute aortic syndrome spectrum, which also includes penetrating atherosclerotic ulcers and classical aortic dissection. The condition involves a contained hemorrhage within the aortic wall, which is best visualized on non-contrast CT scans. On contrast-enhanced imaging, a small ulcer-like projection (ULP) is observed, with an ascending aorta diameter of 53 mm. Risk factors for progression of intramural hematoma and worse prognosis include the presence of ULPs, IMH thickness greater than 10 mm, associated aortic aneurysm, and increase of the thickness of the intramural hematoma at follow-up CTA. Similar to aortic dissections, aortic intramural hematomas are categorized according to the Stanford classification system (type A: involves the ascending aorta, with or without descending aortic involvement, type B: confined to the descending aorta, distal to the origin of the left subclavian artery).The patient underwent emergency supracoronary ascending aortic replacement.