Abdominal #1 – Long case

A 47-year-old female presented to the Emergency Room with bilateral upper extremity paresthesia, redness and edema. Her symptoms were not position-dependent. The patient was otherwise healthy, and did not take any medication. There is no pertinent surgical history.

An MR angiogram was ordered. The following images were obtained during bolus tracking:

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Coronal MRV

MRA

T1-weighted images with fat saturation, following contrast administration


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Diagnosis:

Superior vena cava (SVC) syndrome from right apical lung mass

Discussion:

In this patient with bilateral neurological deficits and edema, the suspicion of SVC syndrome must be addressed. This can be done using either an MRI or a CT protocol. In this case, the MRI scout bolus images (Image 1 & 2) revealed a pathognomonic sign for SVC occlusion:

Please note the marked collateral circulation following contrast administration to the right upper extremity with dilation of multiple intercostal and lateral thoracic veins. These collateral vessels then pool into the liver’s quadrate (segment 4 of the liver), giving the characteristic “hot spot sign”. This name originates from terminology in nuclear medicine, where it was occasionally seen in the case of SVC syndrome. Nowadays, it is more likely to be noticed on a CT or MR. This image also reveals the complete occlusion of the SVC.

Following fat-saturated T1-weighted axial image acquisition with contrast, the cause of the obstruction is evident. There is an infiltrative right apical mass which obstructs the SVC, as well as bilateral pleural effusions. Additionally, there is tumor thrombus noted in the left innominate vein, likely secondary to stasis.

Please review the following video and identify all these pertinent findings:

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?

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 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

Neuroradiology #11 – Long case

47-year-old male:
* Presented with epistaxis

Axial & coronal CT+C

Where is the lesion?

The bulk of the tumour is within the ethmoid sinuses extending inferiorly into the nasal cavity and superiorly into the intracranial cavity through the cribriform plates

What is the lesion like?

Enhancing soft-tissue tumor expanding the ethmoid sinuses and nasal cavity

T2, T1 and T1+C

What are the MRI signal characteristics?

Mixed signal intensity on T2, low signal on T1, and intense enhancement on post-contrast images

What is the differential diagnosis of paranasal sinus tumour?

* Olfactory neuroblastoma:  involves the ethmoid sinuses  and extends through the cribriform plate into the anterior cranial fossa. Usually, shows intense enhancement and may show calcifications. They are slow growing with sinus expansion

* Juvenile angiofibroma: benign locally aggressive vascular  tumor that affects adolescents. It is usually lobulated and expands the sphenopalatine foramen. Intense enhancement on post-contrast images

* Sinonasal carcinoma: heterogeneously enhancing mass that erodes the bone and may extend into the orbits or intracranially

* Lymphoma: low T2 signal with intense contrast enhancement and usually expands the bone

Diagnosis:Olfactory neuroblastoma

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

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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

Neuroradiology #10 – Flashcard

What do you see in the following images?

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Cerebellopontine angle meningioma

* Extra-axial CP angle mass.
* Heterogenous low signal intensity on T2.
* Intense enhancement on post-contrast images with thickening and enhancement of the tentorium cerebelli.
* No intracanalicular extension.
Differential diagnosis: Schwannoma, ependymoma, metastasis

Emergency #9 – Long case

60-year-old female:
* Known with hypertension
* Acute pain on the chest
* X-ray
* Abnormal?
* Differential Diagnosis: No.

What should we think of and do next?

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Clinically suspect for aortic dissection

What protocol?
Non-enhanced chest CT, followed by CT angiography chest-abdomen

No NECT was made:

Imaging findings and key messages

* Soft tissue surrounding ascending aorta from the root, continuing around the aortic arch and descending aorta
* Between the soft-tissue band and the intraluminal contrast, we see intimal calcifications, these are NOT displaced outwards
* At some spots, there is contrast extravasation in the soft tissue
* No intimal tear or dissection flap is seen
* Slight pericardial effusion

What is the diagnosis?

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Aortic intramural hematoma.

Treatment is like an aortic dissection with anti-hypertensive medication. In this case, it is a type A since the mural hematoma is seen proximal to the left subclavian artery, involving the ascending aorta.

Differential Diagnosis

* Thrombosed false lumen in classic aortic dissection: Typically spirals longitudinally around the aorta, whereas an intramural haematoma usually maintains a constant circumferential relationship with the aortic wall

* Aortitis: Typically shows concentric uniform thickening of the aortic wall with or without peri-aortic inflammatory stranding, whereas an intramural haematoma is often eccentric in configuration

Treatment/Prognosis

* If an intramural haematoma involves the ascending aorta (Stanford A), treatment is surgical to prevent rupture and progression to a classic aortic dissection

* Conservative management is indicated for an intramural haematoma of the descending aorta (Stanford B)
* 77% of intramural haematomas regress at 3 years
* Survival of >90% at 5 years

* Untreated, an intramural haematoma can be life-threatening as it can lead to: aortic rupture, aortic dissection, aortic aneurysm.