62-year-old female.
* Sudden collapse
* Headache
* Paresis of mouth left-sided
* Pupil difference L>R
Diagnosis: PCOM aneurysm subarachnoid bleed (with subdural hematoma, intraventricular bleed, midline shift, hydrocephalus)
Next step:CTA (you already see aneurysm on NECT)
There are some things which cannot be learned quickly, and time, which is all we have, must be paid heavily for their acquiring. They are the simplest things; and, because it takes a man’s life to know them, the little new that each man gets from life is very costly and the only heritage he has to leave
Dear friends, this quote from Ernest Hemingway serves as introduction to the next series of webinars. From October to March I intend to give a webinar every two weeks describing my basic approach to interpreting the chest radiograph. The subject is ample, and will continue with a second series in 2021.
To start, I am showing a preoperative PA chest radiograph for varices in a 60-year-old woman. The chest was read as normal, but there is an abnormality, difficult to detect.
Do you see it?
The answer was given during a webinar. You can watch the webinar here
Findings: PA radiograph shows a small nodule overlapping the left cardiac border (A-B, arrows). The nodule was overlooked, and the chest was read as normal.
A chest radiograph taken four years later shows a marked increase in size of the nodule (C, arrow). Enhanced axial CT shows a non-enhancing low-density nodule (-30 H.U.)
(D, arrow). Needle biopsy confirmed the diagnosis of hamartoma.
Final diagnosis: Pulmonary hamartoma, overlooked in the initial film
Congratulations to Uve, who discovered the nodule with a little help.
Teaching point: Remember that overlooking visible findings accounts for 50% of our errors. Using checklists is an excellent way to change an error into a discovery.
42-year-old male:
* Presenting with dizziness, vertigo and loss of coordination
A focal expansile single lesion.
* Nodular
* Solid
* Hyperdense
* With moderate perilesional edema and mass effect deforming the 4th ventricle without signs of active hydrocephalus (not shown)
* With avid enhancement
Left posterior fossa.
Suggestive of extraaxial location:
1) Peripheral location and wide dural contact
2) Changes in the adjacent skull vault bone
3) Dural Tail
Definitive for extraaxial location:
1) CSF cleft.
2) Interposed vessels, cortex or dura.
The lesion is intraaxial, located in the left cerebellar hemisphere.
* HEMANGIOBLASTOMA: Most frequent posterior fossa primary tumour in adults. Strong association with von Hippel Lindau disease. Cystic tumour with mural peripheral solid avidly enhancing nodule. Perilesional pathologic vessels.
* METASTASES: Most frequent posterior fossa tumour in adults. Expanisve focal lesion, single or multiple, well defined, solid-necrotic, great edema, and mass effect.
* GLIOMA: Pilocytic astrocitomas (cystic tumour with solid mural nodule) and diffuse brainstem gliomas (often low-grade, infiltrative, ill-defined lesions without enhancement) much more common in peadiatric population. High-grade gliomas (infiltrative ill-defined lesions with heterogeneous enhancement and necrosis) are uncommon in the posterior fossa.
* MEDULLOBLASTOMA: Paediatric population (more common): Intraventricular, midline; young adults; parenchymal, paramedial, focal solid enhancing lesion. Different subtypes that share hypercellularity as main feature: CT hyperdense, T2 Hypointense and difussion restriction. High propensity for CSF dissemination.
* LYMPHOMA: Focal solid enhancing single lesion or multiple cloud-like enhancing lesions. Hypercellularity as main feature: CT hyperdense, T2 hypointense and diffusion restriction.
* SUBEPENDYMOMA: Adults, intraventricular 4th ventricle. Plastic. None or little enhancement.
* EPENDYMOMA:Paediatric population: intraventricular posterior fossa; young adults: supratentorial periventricular. Plastic, heterogeneous, solid-necrotic, enhancing tumour.
* MENINGIOMA: Calcifications and bone hyperostosis
* SCHWANNOMA: Intralesional cyst and bone remodelling
* EPIDERMOID: No enhancement, restricted diffusion
* ARACHNOID CYST: CSF behaviour
* Mineralization
* Hemorrhage
* Hypercellularity
* Melanin
There are two most reasonable diagnostics.
MEDULLOBLASTOMA AND LYMPHOMA : Could be appropiate diagnositc options for a lesion with this semiology.
The final histologic diagnosis was: Primary CNS lymphoma
* Abscess
* Lymphoma
* Acute infarct
* Epidermoid
Special tip
In the DSC Perfusion sequence:
* Low relative cerebral blood volume (rCBV) assessed in the colour maps
* T1 Leakage effect assessed in the curve could have helped in the preoperative diagnostic of lymphoma against medulloblastoma.
Dear Friends,
Today’s radiographs belong to a 53-year-old man with dysphagia.
What do you see?
Come back on Friday to see the answer!
Findings: PA radiograph (A) is unremarkable. The lateral view shows a slight anterior bowing of the trachea (B, arrow) with an apparently dilated upper esophagus with an air/solid interface (B, red arrow).
These findings are well seen in the cone down view, which better shows a thickened retrotracheal stripe (C, red arrows), a sign that suggests esophageal pathology, among others.
For all of you who diagnosed achalasia there is a negative finding: the lack of occupation of the retrocardiac space (D, circle) which practically rules out dilatation of the lower esophagus.
Sorry to say that I do not have additional images. After receiving the possible diagnosis of esophageal tumor, the patient went to another hospital, where esophagoscopy and biopsy confirmed upper esophageal dilatation by a carcinoma of the middle third.
Final diagnosis: Carcinoma of the middle third of the esophagus with proximal dilatation and food retention.
Congratulations to Dr Ahmad who was the first to describe the findings.
Teaching point: this case emphasizes the value of clinical information in selected cases. I suspect that some of you would not have discovered the dilated esophagus in the lateral view if I had withheld the history of dysphagia :).
27-year-old female:
* No previous history
* Presents with acute kidney insufficiency
* DD glomerulonephritis
* Nephrotic syndrome
* US to exclide post-renal obstruction
US: Bilateral hydronephrosis and hydro-ureter. No obstructing mass or stone visible. Bilateral loss of parenchyma, indicating chronic problem.Mobile bladder stone.
Patient receives bilateral nephrostomy. On antegrade pyelography no calibre changes or strictures, not proximal or distal. No cause for hydrnephrosis and hydro-ureter bilateral.
Non-enhanced abdominal CT to evaluate nephrolithiasis. Traction on sigmoid, coecum and small bowel, andalso traction on bladder roof. Consider endometriosis in the differential diagnosis and perform MRI pelvis.
MRI pelvis. Medialised adnexes. T2 hypo-intense fibrotic plaque centered on uterus very suggestive for deep invasive endometriosis (DIE). Fibrotic changes between uterus and rectum, uterus and bladder and uterus and bowels. No endometrioma cysts. Central in fibrotic area small aircollection with fistula towards anterior fornix (not completely shown here), with small abscess on major labia.
Diagnosis: Endometriosis
Dear Friends,
Today I’m showing chest radiographs of a 50-year-old woman with cough and sputum production.
What do you see?
You will have more images on Wednesday.
Dear Friends,
showing today CT images of the patient. What do you see?
Findings: PA chest shows a small right lung, with a triangular opacity occupying the lower lung (A, arrow). The right heart border is not seen. The trachea and mediastinum are displaced to the right. In the lateral view the lower opacity occupies the lower lung from front to back (B, arrows).
This appearance is typical of combined RLL and RML collapse (obliteration of right heart border) and the most likely diagnosis is an obstructing lesion in the intermediary bronchus.
Enhanced axial CT shows marked narrowing of the intermediary bronchus (C, arrow). A caudal image shows marked dilatation of mucous-filled bronchi (D, arrows). This appearance indicates a long-standing obstruction and goes against a malignant process
Comparison with a previous radiograph (F) shows that the chest has not changed in comparison with the recent one (E). Bronchoscopy performed three years earlier demonstrated chronic stenosis of intermediate bronchus secondary to previous TB
Final diagnosis: Chronic TB changes of intermediary bronchus causing collapse of RML and RLL.
Congratulations to Maged Shaban and Yelgha who made the correct diagnosis of RLL and RML collapse
Teaching point: remember that central lobar collapse with bronchiectasis is rarely caused by malignancy.
Regarding the following X-Ray:
Metaphysis of the base of the fourth middle phalanx.
Expansile lytic lesion (bubbly appearance) with narrow zone of transition, no cortical break through, and no soft-tissue component.
Enchondroma: Enchondromas have variable imaging appearances but are typically lytic lesions with non-aggressive features. They could show chondroid calcifications (rings and arcs calcification). But in the hands and feet they are typically purely lytic with no matrix.
Eosinophilic granuloma: It mainly involves the diaphysis and does not cross the growth plates. It appears as punched out lytic lesions without sclerotic rim. Imaging appearance in the long bones depends on the phase of the disease which is imaged. It can look aggressive in the initial phase. In the healing phase it can show solid benign periosteal reaction.
Fibrous dysplasia.Usually shows ground-glass matrix but may be completely lucent or sclerotic. Well-circumscribed lesions with no periosteal reaction may lead to premature fusion of growth plates leading to short stature in the lower limbs and bowing deformities (Shepherd’s Crook deformity of the femoral neck)
Diagnosis: Enchondroma
What are the associated syndromes with multiple enchondromas?
Ollier disease: multiple enchondromas are usually confined to one side of the body and limited to the limbs. There is increased risk of chondrosarcoma
Maffucci syndrome: multiple enchondromas with soft-tissue haemangiomas
Dear Friends,
Today I am presenting another “Art of interpretation case”, from last August.
Radiographs belong to a 22-year-old Spanish national with fever and dry cough for the last seven days. He had visited South Korea during the month of July. Chest radiographs read as normal by the Emergency Room physician.
What do you see?
More images will be shown on Wednesday.
Dear Friends,
showing several images of the enhanced CT.
What do you see?
Findings: PA radiograph shows convexity of the aortopulmonary window (A, white arrow) and increased opacity of the left hilum (A, red arrow). The lateral view shows a faint opacity projected over the middle third of the thoracic spine (B, circle) that was overlooked in the initial reading.
The convexity of the APW suggested mediastinal lymphadenopathy, and CT was performed.
Coronal enhanced CT shows an enlarged lymph node in the APW (A, arrow). Axial CT depicts enlarged lymph nodes in the left hilum (B, circle). Lung window demonstrates air-space disease in the apical segment of the LLL (C, arrow), which explains the posterior faint opacity in the lateral view.
Summary of CT findings:
– Unilateral enlarged hilar lymph nodes
– Lymph node in APW
– Air-space disease in the apical segment of LLL
The most significant finding is the presence of unilateral hilar lymph nodes which have a limited differential diagnosis: in the great majority of patients they are due either to lung carcinoma or active tuberculosis. As this particular patient is 27 y.o., carcinoma is unlikely. Therefore, our tentative diagnosis should be active TB, which is also supported by disease in the apical segment of the LLL, a common location for TB.
The patient was placed in isolation, bronchoscopy was performed, and Mycobacterium tuberculosis was found in the aspirate.
Final diagnosis: active tuberculosis
YOUNG PERSON + UNILATERAL ENLARGED HILAR LYMPH NODES + PULMONARY INFILTRATE IN APICAL SEGMENT OF LLL = ACTIVE TUBERCULOSIS
Active pulmonary tuberculosis is not uncommon, and the chest radiograph plays an important role in its detection. Findings that help to suspect TB in the plain film are:
Location of the parenchymal disease. Involvement of the apices or the apical segment of either lower lobe should raise the possibility of a tuberculous infiltrate, although TB can affect any area of the lung.
Cavitation. The presence of cavities within a pulmonary infiltrate suggest tuberculosis or necrotic pneumonia.
Visible lymphadenopathies. Tuberculous lymph nodes are usually unilateral and located in the hilum and homolateral mediastinum. In about one third of patients they are bilateral. In such cases, lymphoma and sarcoidosis, among others, should also be considered.
CT refines these parameters by discovering cavitation or lymphadenopathy that is not evident in the plain film. The presence of low-attenuation lymph nodes due to caseous necrosis is highly suggestive of TB, although it is not pathognomonic. Other conditions can also show these features. However, normal-density lymph nodes do not exclude TB, as was seen in the present case.
Below, I show a few nice images of active TB in which low-attenuation lymph nodes
suggested the correct diagnosis.
23-year-old woman with cough and low-grade fever. Chest radiographs shows air-space disease in the RLL (A and B, white arrows). There is obvious widening of the right paratracheal line (A, red arrow), indicating mediastinal lymphadenopathy.
Enhanced axial CT confirms the RLL disease which is non-specific (C, arrow). No cavitations are visible. The mediastinal window shows numerous enlarged lymph nodes, some with a hypodense center (D and E, arrows) and others with peripheral enhancement (ring sign) (F, arrows).
Abdominal CT also shows enlarged mesenteric lymph nodes with the ring sign (G and H, circles).
It is interesting to note that lower lobe TB occurs in only 5% of patients. In this particular case the diagnosis of TB was suggested by the CT appearance of the affected lymph nodes. Mycobacterium tuberculosis was recovered from sputum.
Final diagnosis: active TB
Dr. Pepe’s teaching points:
1. Think of TB in unilateral hilar adenopathy in a young person.
2. Low-density lymph nodes on CT are highly suggestive of active TB, although normal-density nodes do not exclude it.
18-years-old male:
* Rigid abdomen and generalised tenderness
* Pain lower abdomen
* CRP 250
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
Dear Friends,
showing another case seen during this summer. Preoperative chest radiography for knee surgery in a 57-year-old man. More images will be shown on Wednesday.
What do you see?
New images are shown:
Findings: PA radiographs shows a right mediastinal mass at the level of the tracheal bifurcation (A, arrow), which has not changed significantly in comparison with a chest film taken for pneumonia one year earlier (B, arrow).
Several of you have mentioned a triangular shadow at the right cardiophrenic angle
(A-B, red arrows). This appearance should suggest paracardial fat pad as the first choice.
The differential diagnosis of a right mediastinal mass at the level of the tracheal bifurcation is simple: most of the times it is either an enlarged azygos vein or lymphadenopathy.
CT shows a dilated azygos vein with a prominent azygos arch (C-D, arrows), suggesting a impeded blood flood either in the inferior or superior vena cava. Considering that the patient is asymptomatic, the most likely diagnosis is congenital interruption of the inferior vena cava, with azygos continuation. The diagnosis is confirmed noting the absence of the suprarenal portion of the IVC (C, circle) and the association of other congenital anomalies, such as polisplenia (C, red arrows) and abnormal bifurcation of the bronchial tree (E, arrows).
Coronal CT confirms that the triangular paracardial shadow represents paracardiac fat.
Final diagnosis: Congenital absence of IVC with azygos continuation
Congratulations to MK, who made a late (and accurate) diagnosis of prominent azygos vein
Teaching point: remember that the most common right lower paratracheal masses are either an enlarged azygos vein or mediastinal lymph nodes.
