Head and Neck #11

43-year-old female:
– Known with M. Ollier (multiple enchondromas)
– Long-standing headache
– Recent ophthalmoplegia right side
– MRI was made

What is the most likely diagnosis?

Large, lobulated T2 hyperintese mass centered in the petrous apex, off-midline.
More specific: on the petroclival synchondrosis (bonus point!).
Extension in clivus, sphenoid bone, and cavernous sinus and extracranial to the neck trhough hypoglossal canal and jugular foramen. Not extending to or from the internal acoustic canal.
Very high T2 signal with some T2 hypointense serpiginous lines, possible flow voids or calcifications.
Isointense on T1, intense enhancing after contrast.

Do you need additional CT?

CT shows central arc and ring calcifications in the lesion, suggesting chondromatous origin. Bony margins are lytic, not well-defined margins. Non-sclerotic margins. No hyperostosis.

Differential Diagnosis

– Intraosseous extension and pattern atypical for most common CPA lesions meningioma and schwannoma (of 12th hypoglossal nerve considering mass in this canal also)
– Does not fit with cholesterol granuloma (sclerotic margins)
– High T2 signal does not fit lymphoma or plasmacytoma
– Growth into foramina does not fit metastasis and unknown with primary tumor
– No mucosal space origin (so no nasophayryngeal carcinoma)
– Could be a jugular paraganglioma but, however, not centred at jugular foramen, and no flow voids on additional MRA TOF
– Age and location and also history of M. Ollier, could fit well with chondrosarcoma

Bonus points for those who see the mass multicystic lesion low in the neck on the left with trachea deviation. Unfortunately, no further imaging was done in this hospital. This could be a lot of things, including extensive multinodular struma, lymphangioma, neurofibroma, or paraganglioma.

Emergency #38

51-year-old female:

– Known with hypertension.
– Presents with hemiballism right.

What do you see?

Infarct? Other pathology?

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– Unilateral hyperdense caudate nucleus, globus pallidus, and putamen
– Dx: Non-ketotic hyperglycemic hemichorea
– Key message: Basal Ganglia are a known site for metabolic- and toxic-related pathology, as is the diffuse cortical grey matter
– Key message: Usually bilateral changes in BG indicate toxic or metabolic pathology, but do not forget this in your differential diagnosis if you only see unilateral pathology!
– This woman was not known with diabetes, but the radiologist suggested it

Emergency #36

47-year-old female:

– Found EMV 3 after assault

What do you see?

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– Diagnosis: Diffuse subdural hematomas of multiple ages (convexities, parafalcine, tentorium) But more important:

Diffuse swelling of gyri and edema with effacement of the CSF-containing spaces
– Diffuse loss of normal grey-white differentiation
– Decreased bilateral basal ganglia attenuation

– = Sequelae of traumatic brain injury (TBI) indicating hypoxic-ischemic injury, with poor prognostic outcome. Patient died several hours later

– Note: We do not see here the reversal sign (reversal of the normal CT attenuation of grey and white matter) or white cerebellum sign (diffuse oedema and hypoattenuation of the cerebral hemispheres with sparing of the cerebellum and brainstem, resulting in apparent high attenuation of the cerebellum and brainstem relative to the cerebral hemispheres)

Emergency #35

61-year-old female:
– Trauma
– Fracture? What do you see?

Showing the supine AP and lateral view, due to the inability to stand on the right leg.

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Diagnosis: Lipohemarthrosis (fat-blood level) indicating intra-articular #
Comminutive though non-displaced tibia plateau fracture Avulsion fracture proximal fibula (Segond fracture – 100% association with ACL injury)
CT: Schatzker type VI

Schatzker tibia plateau classification

Schatzker I: wedge-shaped pure cleavage fracture of the lateral tibial plateau, having less than 4 mm of depression or displacement
Schatzker II: splitting and depression of the lateral tibial plateau; namely, type I fracture with a depressed component
Schatzker III: pure depression of the lateral tibial plateau; divided into two subtypes:
Schatzker IIIa: with lateral depression
Schatzker IIIb: with central depression
Schatzker IV:  medial tibial plateau fracture with a split or depressed component
Schatzker V: wedge fracture of both lateral and medial tibial plateau
Schatzker VI: transverse tibial metadiaphyseal fracture, along with any type of tibial plateau fracture (metaphyseal-diaphyseal discontinuity)

Emergency #34

A 73-year-old female:
– Pain LLQ
– CRP 68, leucocytes 19000.

What is the pathology?

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Diagnosis: Sigmoid diverticulitis, no signs of complications/perforation such as air bubbles outside bowel lumen or paracolic abscess. Reactive bowel wall thickening (always be aware of underlying carcinoma!)

Name the three coincidental findings:

1. Gall stones
2. Right adrenal mass, DD metastasis from 3. or adenoma
3. Right interpolar solid mass, suspect for renal cell carcinoma

Emergency #33

83-year-old female:
– Acute loss of function right arm and leg
– Bleeding? Ischemia?

What is the most likely diagnosis?

Dense left medial cerebral artery with subtle obscuring of grey-white matter interface temporal operculum of insula; early ischemia.

CTA: Occlusion M1 Patient received IV thrombolysis and her symptoms improved

Emergency #32

53-year-old male:
– Hemodialysis patient
– Presents with a very large scrotum, size of a football
– Patient is not sick, no fever
– Laboratory results are normal
– US: Incarcerated inguinal hernia? Hydrocele? Malignancy?

What is the most likely diagnosis?

Diagnosis: Extensive scrotal lymphoedema

– Extensive scrotal wall thickening associated with diffuse lymphoedema extending to the base of penis not involving the penile corpora
– No extension into the deep subcutaneous tissue planes, inguinal canal, or muscles
– No extension to the groin or lower abdomen
– No inguinal adenopathy
– Both testicles are morphologically normal with no associated hydroceles
– There is no associated soft-tissue mass