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

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)

Emergency #14 – Flashcard

18-years-old male:
* Rigid abdomen and generalised tenderness
* Pain lower abdomen
* CRP 250

What do you see? Perforated appendicitis? What is your diagnosis?

Diagnosis Perforated sigmoid diverticulitis (Hinchey 3 or 4, peritonitis)

> Mesenterial fatty infiltration, free air bubbled outside bowel lumen.
> Also subdiaphragmal free air and free fluid.
> Notice enlarged reactive lymph nodes and peritoneal thickening and enhancement, indicative of peritonitis.
> Patient was operated, free faeces was found in the abdomen.

Hinchey classification of acute diverticulitis:
* Stage 1a: phlegmon
* Stage 1b: diverticulitis with pericolic or mesenteric abscess
* Stage 2: diverticulitis with walled off pelvic abscess
* Stage 3: diverticulitis with generalised purulent peritonitis
* Stage 4: diverticulitis with generalised faecal peritonitis

Emergency #12 – Flashcard

31-year-old male:
* With flank pain
* Increased inflammatory parameters
* Decreased kidney function

Why is the right kidney less dense than the left?

Click here to see the answer

Obstructive kidney stone in the right proximal ureter (arrow) with secondary hydronephrosis

The increased pressure in the collecting system slows the ultrafiltration of urine and causes a slower enhancement of the right kidney in comparison with the left kidney, reflecting the impaired kidney function

Emergency #11 – Long case

23-year-old male:
* HET
* Macroscopic hematuria and blood at urine meatus

What is the most likely diagnosis? What should we do next?

Click here to see the answer

 X-ray: Bilateral pelvis fractures discontinuity iliopectineal line most clearly left-sided

CT: Bilateral ramus superior/anterior iliac bone and ramus inferior pubic bone
Avulsion fracture symphysis pubis
Fracture sacrum on the right

Look also in soft-tissue setting!

Large hematoma posterior of symphysis pubis around urethra and perineum, lateral around the pelvic floor obturator internus muscles and cranially in the retroperitoneal Retzius space anterior of the bladder

Do a RUG: Retrograde Urethrogram. If intact, followed by CT Cystography

RUG shows contrast extravasation and complete rupture of anterior bulbous part of urethra, grade V isolated anterior injury. However, the rupture might be at the anatomic weak point, the bulbomembranous junction, meaning avulsion of the puboprostatic ligament and stretching of the membranous urethra. There is no contrast above the urogenital diaphragm (level of symphysis pubis). Contrast in the bladder is a residue from the IV contrast given for earlier total body CT.

Goldman classification urethral injury

Anterior urethra = Penile and bulbous part
Posterior urethra = Membranous and prostatic part

  • Type I: stretching the posterior urethra due to disruption of puboprostatic ligaments and hematoma, but urethra is intact
  • Type II: posterior urethral injury above urogenital diaphragm (between ischiopubic rami)
  • Type III: injury to membranous urethra, extending into the proximal bulbous urethra (i.e. with laceration of the urogenital diaphragm), thus contrast extravasation below diaphragm
  • Type IV: bladder base injury involving bladder neck and proximal urethrainternal sphincter is injured, hence the potential for incontinence
  • Type IVa: bladder base injury, not involving bladder neck (cannot be differentiated from type IV radiologically)
  • Type V: anterior urethral injury (isolated)

* In this case, no CT cystography was performed
* Patient was treated conservatively

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