Abdominal #7 – Long case

70-year-old female:

* Presents with acute abdominal pain
* Previous history adnex extirpation and appendectomy
* No raised inflammatory parameters
* No peristalsis
* CT abdomen with IV contrast

What do you see?

Click here to see the answer:

Dilated small bowel loops, radiating distribution (“Bunch of grapes”) with impressive mesenterial venous engorgement and edema in the centre. Ascites perihepatic and in Douglas. Loss of bowel enhancement.

What is the most likely diagnosis?

Closed loop obstruction with bowel ischemia.

Teaching point

Seek for 2 (!) calibre changes next to each other to confirm SBO on basis of Closed loop obstruction.

Peroperative 1 meter of necrotic small bowel was resected.


Musculoskeletal #7 – Long case

10-year-old male:

Axial CT brain bone windows

Non-enhanced axial CT brain soft tissue window

Where is the lesion?

Occipital bone within the medullary cavity

What is it like?

Moth-eaten destructive permeative lytic lesion with wide zone of transition.  There is cortical disruption of both the inner and outer table of the skull and a large soft tissue component.

An MRI is performed.
Axial T1Weighted

Axial T2Weighted
Axial Gadolinium enhanced T1Weighted
What does the MRI show?

Destructive bone lesion with a large soft tissue component which is low signal intensity on T1, heterogenous intermediate signal on T2, and heterogeneous intense enhancement in the post contrast image. It causes mass effect on the adjacent brain parenchyma with no gross invasion.

What is the differential diagnosis?

Given the age of the patient the differential diagnosis includes:

* Osteosarcoma: most common primary bone tumor in young adults. Usually involves the metaphyseal regions of long bones but can occur at other sites. Aggressive lesion with sunburst periosteal reaction and calcified osteoid matrix. 

* Ewing's sarcoma: second most common childhood bone tumor. Typically an aggressive permeative tumor which arises within the medullary cavity of the bone and has a large soft tissue component. 

* Metastasis.

What is the most likely diagnosis?

Ewing’s sarcoma

Emergency #17 – Flashcard

40-year-old male:
* Fell off bike at 40 km/h
* Pain left shoulder

> What views of the shoulder in trauma setting should be done?
> Is this in endo- or exorotation?
> Do you need right shoulder to compare with?

Click here to see the images

Right shoulder for comparison

Additional trauma chest X-ray was done.

Differential diagnosis includes:

* AC-luxation
* CC-luxation
* Left pneumothorax
* No rib #

Neuroradiology #17 – Long case

Regarding the following images:

Where is the abnormality?

Bilateral asymmetrical temporal and inferomedial frontal lobes and insular cortices

What is it like?

Abnormal CT hypodensity and high FLAIR signal intensity of the affected white matter and cortex

What is the differential diagnosis?

Herpes encephalitis: affects the limbic system bilaterally, temporal lobes, insular cortices and inferolateral frontal lobes. May progress to hemorrhage. Basal ganglia is typically spared

Paraneoplastic tumor-related limbic encephalitis and autoimmune limbic encephalitis: tumour-related limbic encephalitis and autoimmune limbic encephalitis: autoimmune encephalitis. Same distribution as herpes encephalitis but the basal ganglia is frequently involved. Hemorrhage is uncommon

What is the final diagnosis?

Herpes encephalitis

Abdominal #6 – Long case

56-year-old male:

* Presents with diffuse chronic pain in the abdomen
* Decreased kidney function

A CT is performed:

CT abdomen with IV contrast

What do you see?

Diffuse hypodense solid tissue around the pancreas, compression splenic vein with inhomogeneous attenuation of the splenic parenchyma. Soft tissue manchet around the infrarenal abdominal aorta, compressing the aorta to the spine and continuing around the iliac vessels. No separate lymph nodes can be seen. Right hydronephrosis and hydro-ureter, right kidney shows edematous swelling . Both kidneys show heterogeneous cortical enhancement.

What is the most likely diagnosis?

Right hydronephrosis and hydro-urter, pancreatitis and nephritis.

Differential diagnosis includes:
Retroperitoneal fibrosis (Ormond disease) or auto-immune mediated IgG-4 disease

CT-guided retroperitoneal biopsy was performed.

Pathology report: Fibrous tissue with chronic inflammation. Not enough signs of IgG-4 mediated disease.


Musculoskeletal #6 – Flashcard

28 year-old male with a history of shoulder dislocation.

Regarding this image:

What do you see?

Hill-Sachs lesion
* Edema on posterolateral humeral head secondary to compression fracture, well-demonstrated on axial fat suppressed proton density Weighted image
* Secondary to anterior dislocation of shoulder

Regarding this image:

What do you see?

Bankart lesion
* Tear/injury of anteroinferior labrum, well-demonstrated on axial fat suppressed proton density Weighted image
* Secondary to anterior dislocation of shoulder
* May have associated bony component

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.