Emergency #16 – Long case

21-year-old male:

* Collapse twice
* Loss of strength of right arm
* Trouble finding words
* Headache

What findings do you see on the CT?

CT Findings

* No abnormalities were seen
* No bleeding
* No signs of recent ischemia

Patient develops fever. Cannot bend his neck properly. When asked, he has been traveling recently to Thailand.

What further imaging could help us?

An MRI is performed.

What findings do you see on the MRI?

MRI Findings

* Two areas left frontal and left parietal with T2/FLAIR hyperintense swelling/edema of cortex and subcortical white matter, with diffusion restriction and patchy, gyriform cortical enhancement

* Diffusely leptomeningeal enhancement

* No ring-enhancing lesions. No white matter vasogenic or cytotoxic edema

What is the most likely diagnosis?

Cerebritis (precursor of abscess) and meningitis. Not yet an abscess

Note: Encephalitis means inflammation of PARENCHYMA

Differential diagnosis of meningitis:
> Leptomeningeal carcinomatosis
> Sarcoidosis and other granulomatous diseases
> Vasculitis
> Connective tissue diseases

Viral inflammatory cause for symptoms was confirmed with lumbar puncture and patient was treated with IV anti-viral treatment

Abdominal #5 – Long case

88-years-old female:
* Presents with acute abdominal pain and pain the right groin
* On clinical examination mass in the right groin
* Slightly elevated inflammatory parameters. Continue on next slide for coronal views.

What do you see?

Right-sided obstructed inguinal herniation with small bowel trapped. Mechanic small bowel ileus. As a coincidence Meckel’s diverticulum (not herniated). Engorgement mesentery but still normal enhancing bowel walls, no direct signs of bowel ischemia yet.


Emergency #15 – Flashcard

62-year-old female.

* Sudden collapse
* Headache
* Paresis of mouth left-sided
* Pupil difference L>R

What is the most likely diagnosis? What should be the next diagnostic step?

Diagnosis: PCOM aneurysm subarachnoid bleed (with subdural hematoma, intraventricular bleed, midline shift, hydrocephalus)
Next step:CTA (you already see aneurysm on NECT)

Neuroradiology #15 – Long case

42-year-old male:
* Presenting with dizziness, vertigo and loss of coordination

What is it?

A focal expansile single lesion.

How is it like?

* Nodular
* Solid
* Hyperdense
* With moderate perilesional edema and mass effect deforming the 4th ventricle without signs of active hydrocephalus (not shown)
* With avid enhancement

Where is it?

Left posterior fossa.

Is the lesion intraaxial (cerebral hemisphere) or extraaxial (cerebellopontine angle)?

TIPS

Suggestive of extraaxial location:
1) Peripheral location and wide dural contact
2) Changes in the adjacent skull vault bone
3) Dural Tail

Definitive for extraaxial location:
1) CSF cleft.
2) Interposed vessels, cortex or dura.

The lesion is intraaxial, located in the left cerebellar hemisphere.

Which are the differentials for intra- and extraaxial posterior fossa tumours?

DIFFERENTIAL DIAGNOSTIC FOR INTRAAXIAL POSTERIOR FOSSA TUMOUR

* HEMANGIOBLASTOMA: Most frequent posterior fossa primary tumour in adults. Strong association with von Hippel Lindau disease. Cystic tumour with mural peripheral solid avidly enhancing nodule. Perilesional pathologic vessels.

* METASTASES: Most frequent posterior fossa tumour in adults. Expanisve focal lesion, single or multiple, well defined, solid-necrotic, great edema, and mass effect.

* GLIOMA: Pilocytic astrocitomas (cystic tumour with solid mural nodule) and diffuse brainstem gliomas (often low-grade, infiltrative, ill-defined lesions without enhancement) much more common in peadiatric population. High-grade gliomas (infiltrative ill-defined lesions with heterogeneous enhancement and necrosis) are uncommon in the posterior fossa.

* MEDULLOBLASTOMA: Paediatric population (more common): Intraventricular, midline; young adults; parenchymal, paramedial, focal solid enhancing lesion. Different subtypes that share hypercellularity as main feature: CT hyperdense, T2 Hypointense and difussion restriction. High propensity for CSF dissemination.

* LYMPHOMA: Focal solid enhancing single lesion or multiple cloud-like enhancing lesions. Hypercellularity as main feature: CT hyperdense, T2 hypointense and diffusion restriction.

* SUBEPENDYMOMA: Adults, intraventricular 4th ventricle. Plastic. None or little enhancement.

* EPENDYMOMA:Paediatric population: intraventricular posterior fossa; young adults: supratentorial periventricular. Plastic, heterogeneous, solid-necrotic, enhancing tumour.

DIFFERENTIAL DIAGNOSTIC FOR EXTRAAXIAL POSTERIOR FOSSA TUMOUR

* MENINGIOMA: Calcifications and bone hyperostosis

* SCHWANNOMA: Intralesional cyst and bone remodelling

* EPIDERMOID: No enhancement, restricted diffusion

* ARACHNOID CYST: CSF behaviour

MAIN CAUSES OF CT HYPERDENSITY

* Mineralization
* Hemorrhage
* Hypercellularity
* Melanin

The images, now supported by diffusion and ADC map, highly suggest and hypercellular tumour

There are two most reasonable diagnostics.

Which are the two most reasonable diagnostics?

MEDULLOBLASTOMA AND LYMPHOMA : Could be appropiate diagnositc options for a lesion with this semiology.
The final histologic diagnosis was: Primary CNS lymphoma

MAIN BRAIN LESIONS WITH CHARACTERISTIC DIFFUSION RESTRICTION

* Abscess
* Lymphoma
* Acute infarct
* Epidermoid

Special tip


In the DSC Perfusion sequence:

* Low relative cerebral blood volume (rCBV) assessed in the colour maps
* T1 Leakage effect assessed in the curve could have helped in the preoperative diagnostic of lymphoma against medulloblastoma.

Abdominal #4 – Long case

27-year-old female:
* No previous history
* Presents with acute kidney insufficiency
* DD glomerulonephritis
* Nephrotic syndrome
* US to exclide post-renal obstruction

US: Bilateral hydronephrosis and hydro-ureter. No obstructing mass or stone visible. Bilateral loss of parenchyma, indicating chronic problem.Mobile bladder stone.

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Patient receives bilateral nephrostomy. On antegrade pyelography no calibre changes or strictures, not proximal or distal. No cause for hydrnephrosis and hydro-ureter bilateral.

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Non-enhanced abdominal CT to evaluate nephrolithiasis. Traction on sigmoid, coecum and small bowel, andalso traction on bladder roof. Consider endometriosis in the differential diagnosis and perform MRI pelvis.

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MRI pelvis. Medialised adnexes. T2 hypo-intense fibrotic plaque centered on uterus very suggestive for deep invasive endometriosis (DIE). Fibrotic changes between uterus and rectum, uterus and bladder and uterus and bowels. No endometrioma cysts. Central in fibrotic area small aircollection with fistula towards anterior fornix (not completely shown here), with small abscess on major labia.

What is the most likely diagnosis?

Diagnosis: Endometriosis