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 #37

94-year-old female:
– Lower consciousness. E1M3V2
– CT brain: Ischemia? Bleeding? Malignancy?

What do you see?

Complete hypodense right hemisphere with no grey-white matter differentiation possible indicative of ischemia. Large mass effect with subfalcine herniation (midline shift), uncal, and transtentorial herniation. Obliteration basal cisterns Old infarct left frontal and global cortical atrophy

Dx: Malignant medial artery infarction
Coincidental finding: Bilateral course calcifications in basal ganglia and dentate nuclei
Dx: M. Fahr: striato pallido dentate calcinosis


Head and Neck #9

47-year-old male:
– Headache since 2 months, nausea, and vomiting.
– Papilledema but no loss of vision.
– MRI is made.

What is the most likely diagnosis?

Expansive mass in the midline centered in the clivus (basiocciput and basisphenoid) with high signal on FLAIR (upper left), intermediate to low T1 signal, high T2 signal, and moderate heterogeneous enhancement after contrast administration.

No diffusion restriction.
ADC value is around 1350. No dural tail.
No encasement of basilar artery.
Compression on pons but no invasive growth.
Upward displacement of chaism, anterior displacement of pituitary gland and stalk.

Diagnosis: chordoma.

Does not fit with meningioma, pituitary macroadenoma, chondrosarcoma, lymphoma, or plasmacytoma.This
was histologically proven.

Head and neck #8

Where is the lesion?

Left carotid sheath posterior to the carotid bulb, internal, and external carotid arteries.

How does it look like?

Large oval avidly enhancing lesion displacing the carotid bifurcation anteriorly.

What is the differential diagnosis?

Carotid bulb paraganglioma: avidly enhancing lesion with characteristic splaying of the internal and external carotid arteries (lyre sign).
Glomus vagale: paragangliomas but of the vagus nerve, located posterior to the carotid arteries displacing them anteriorly.
Vagal schwannoma: those that arises within the carotid sheath posteriorly but usually shows moderate enhancement compared with the avid enhancement of the paragangliomas.

What is the most likely diagnosis

Glomus vagale

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)

Musculoskeletal #26

Describe the abnormality

Bilateral sacroiliac joint space narrowing, subchondral erosions, subchondral sclerosis, and subchondral fatty marrow infiltration.

What is the differential diagnosis?

Bilateral symmetrical:
Ankylosing spondylitis
Inflammatory bowel disease. 

Bilateral asymmetrical:
Psoriasis
Reactive arthritis (Reiter syndrome) 

What is the most likely diagnosis?

Ankylosing spondylitis

What are the markers of active inflammation?

Erosions with high signal intensity on STIR or T2- weighted images, subchondral edema, and enhancement within or adjacent to the sacroiliac joint.

What are the markers of chronic disease?

Low signal intensity on T1- and T2- weighted images, subchondral sclerosis, narrowing of the joint spaces, bone bridging, and ankylosis.

Head and neck #7

60-year-old female:
– Since a few weeks eye movement disorder and diplopia of the left eye, tinnitus, and sinusitis.
– Non-enhanced CT of the orbits is performed (due to contrast allergy).

What are your findings?

Widened infraorbital canal left eye with thickening of the infraorbital nerve.

What is your differential diagnosis and do you want more imaging?

Yes, we want MRI to sort things out more.

Findings: Smoothly thickened T2 hyperintense, enhancing infraorbital nerve in its canal. No continuation posteriorly to the vidian canal or anteriorly to the pre-antral region. No pathologic paranasal sinus mass or pharyngeal mucosal mass indicating perineural tumor spread.

Differential diagnosis:
Schwannoma.
Less likely malignant cause like perineural tumour spread.

Biopsy is performed of right lacrimal gland, since clinically this was found to be prominent (radiologically slight asymmetry, slightly higher T2 signal).

Histopathology: IgG4 disease or dacryoadenitis.

After this, whole body scanning showed evidence of IgG4 disease in the pancreas also. Patient was treated with steroids.

Follow-up MRI: Decrease in size of the infraorbital nerve from 11 to 5 mm. Still high T2 signal, however, the decrease in size on steroids suggests other diagnosis than schwannoma, in this case probably involved in orbital IgG4 disease. Rare!

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)