Musculoskeletal #42

~ EDiR Holders ~ Leave a comment

Clinical Data

55-year-old female:

  • With trauma

  • Painful elbow after a fall from height

  • Supination and pronation painful



What’s the radiological sign visible on the radiograph?

Capitellum fracture

The case represents a classic capitellum fracture, with a mildly displaced fragment on the lateral projection, which can easily be missed if one is not familiar with the double-arc sign.

Head and Neck #18

~ EDiR Holders ~ Leave a comment

Clinical Data

73-year-old male:

  • With worsening paresis of cranial nerves CN3-7







What do you see?


Axial T2 image on the left shows partial obliteration of the right Meckel’s cave and an ill-defined T2 hypointense lesion on the right temporal fossa.

Axial T2 image on the right shows atrophy of the right-sided masticatory muscles.



Post-contrast 3D T1 FSE fat-saturated images showing an enhancing lesion overlying the right temporal fossa, with perineural spread along CN7, the auriculotemporal nerve and continuing intracranially via the right foramen ovale (note the asymmetry in enhancement).



3D bSSFP images (CISS) before (left) and after (right) contrast administration. bSSFP images contain both T1 and T2 information, therefore showing enhancement after contrast administration.

While pre-contrast image doesn’t depict any obvious pathology, the post-contrast image on the right clearly highlights tumor deposits (red arrows) along the lateral aspect of the right cavernous sinus. The tumor has encased the cranial nerves, leading to the patient’s symptoms. For comparison, the normal anatomy of the cranial nerves is shown on the left (green arrows).

  • This case shows a histologically verified squamous cell carcinoma of the temporal fossa spreading along the CN7, auriculotemporal nerve, mandibular nerve and into the right cavernous sinus.

  • Teaching points:

    • Multiple CN palsies of CN3-6 should raise a suspicion of cavernous sinus pathology.

    • Auriculotemporal nerve is an important connection between the facial and mandibular nerves.

    • bSSFP sequences like CISS contain both T1 and T2 information and therefore show post-contrast enhancement which can be diagnostically useful in conjunction to their excellent spatial resolution.

Chest and Thorax #2

~ EDiR Holders ~ 1 Comment

69-year-old male patient with:

  • Dysphagia
  • Chronic food regurgitation
  • Barium swallow (oesophagogram) was performed
Lateral projection, early
Lateral projection, early
AP projection
AP projection
Lateral projection, late
Lateral projection, late
What do you see?

Findings:

Retroesophageal outpouching located along the midline at the C5-C7 level, with barium retention.

What is the most likely diagnosis?

Zenker diverticulum

Neuroradiology #39

~ EDiR Holders ~ 3 Comments

Clinical Data

40-year-old female presents with:

  • Fever

  • Progressive headache

  • Confusion in the last two days

  • Previous medical history was unremarkable

  • CT brain without contrast was performed in the emergency department

CT images:

Unenhanced CT
Unenhanced CT
What are the most important findings on CT?

  • Subtle hypodensity in the medial temporal lobe on the right side.

  • Sparing of the basal nuclei on the right side.

What are your next steps?

  • Immediately call the ordering physician to communicate that the imaging (and clinical) findings are suggestive of Herpes Simplex Encephalitis.

    • This will prompt the clinician to directly start with an antiretroviral agent (acyclovir) if not started already and to perform a lumbar puncture to confirm HSV in CSF.

MRI was performed:

T2
Coronal T2 FLAIR
T1 + C
What are the findings on MRI?

  • T2 hyperintense regions with swelling/oedema and involvement of both white matter and cortex centered around the right sylvian fissure with involvement of the right temporal, frontal and insular region. Subtle patchy and leptomeningeal enhancement in the right temporal lobe can be seen.

What is the most likely diagnosis?

Herpes Simplex Encephalitis

  • The clinical picture is already highly suggestive of this diagnosis with supporting imaging findings. The diagnosis was confirmed with positive PCR for HSV-1 in CSF.

  • Typical imaging findings of herpes encephalitis are T2(/FLAIR) hyperintense swollen areas of cortex and white matter with bilateral but asymmetrical involvement of the fronto-temporo-insular regions. Characteristic is sparing of the lentiform nuclei, which distinguishes it from ischemia due to vessel occlusion. Diffusion restriction and hemorrhage can be present.

  • This is a radiological emergency and the phone must be picked up directly to alert the clinician and to prevent significant mortality and morbidity.

Reference:

Neuroradiology #38

~ EDiR Holders ~ 2 Comments

Clinical Data

35-year-old male presents with:
  • Progressive headache and ataxia
  • Previous medical history was unremarkable
  • MRI brain was performed
T1 + C
T1 + C
T1 C+
T1 C+
T2
T2
T2
T2
T2 FLAIR
T2 FLAIR
What do you see?
  • Cystic lesion with an enhancing lesion in the posterior fossa on the left side. No enhancement of the cystic wall. Discrete flow voids in the solid nodule.
  • Relevant mass effect with compression on the 4th ventricle and obstructing supratentorial hydrocephalus.
What is your differential diagnosis?
  • The differential diagnosis of a cyst with an enhancing mural nodule in the posterior fossa includes hemangioblastoma, pilocytic astrocytoma, ganglioglioma and cystic metastasis.
What are the most likely diagnoses?
  • When a cystic lesion with a mural nodule is encountered in the posterior fossa, the most likely diagnosis is hemangioblastoma in an adult in the absence of a primary tumor elsewhere. The imaging findings support hemangioblastoma, since the mural nodule shows flow voids on T2 and no enhancing cystic wall. Typically, the cystic wall of hemangioblastoma does not enhance, while a subtle enhancing wall can be discerned in pilocytic astrocytomas.
  • The majority of hemangioblastomas occur spontaneously. In case of multiple hemangioblastomas, think about Von Hippel-Lindau syndrome.

    • Reference:

  • Raz et al. Cyst with a mural nodule tumor of the brain. Cancer Imaging. 2012 Aug 10;12(1):237–244. doi: 10.1102/1470-7330.2012.0028

Chest and Thorax #1

~ EDiR Holders ~ 2 Comments

56-year-old male patient:
After kidney transplantion presented with cough

Findings:

Multiple intrapulmonary consolidations with peripheral ground-glass opacities . No bronchial obstruction. No pathologically enlarged lymph nodes

What is the most likely diagnosis?

Fungal infection (Rhizopus infection)

Fungal infections in immunocompromised patients may manifest as intrapulmonary nodules or consolidations with peripheral ground glass opacities. May lead to cavitation, pseudoaneurysm formation and bleeding.

Treatment in this case: Anti-fungal systemic therapy

Patient died 5 months thereafter from pulmonary artery aneurysmal bleeding.

Urogenital #3

~ EDiR Holders ~ 2 Comments

87-year-old woman:
* Presented with lower abdominal discomfort and weight loss.
* Pelvic MRI is performed.


What can be seen in the uterine cavity?

Blood, hematometra

In this case what is the cause?

Cervical cancer

What are some congenital causes of hematometra?

Imperforate hymen, vaginal septum, vaginal hypoplasia

Explanation:

In non-adolescent women, hematometra can often be caused by malignancy, so a search for cervical/endometrial cancer must be done.

Cardiac #6

~ EDiR Holders ~ Leave a comment

75-year-old patient:
Medical history:
* Previous left anterior descending artery (LAD) stenosis and iatrogenic left coronary artery (LCA) dissection.
* Underwent coronary artery bypass grafting (CABG) complicated by subsequent graft thrombosis.
* Stress myocardial perfusion imaging performed to assess myocardial ischemia/viability (first row stress perfusion imaging, second row dark blood late gadolinium enhancement imaging).

What is the diagnosis?

Subendocardial scar in LAD territory basal/midventricular with perfusion defect/inducible ischemia in LAD territory surpassing the area of infarction.

Explanation:

Stress myocardial perfusion depicts reversible ischemia in the LAD coronary artery territory anteroseptal/anterior (perfusion at rest not shown). Dark blood-LGE imaging depicts subendocardial scar in LAD territory especially basal, but smaller in extension than the inducible ischemia, indicating potential suitability of revascularization.
Standard dose of adenosine is 140 mcg/kg/min for at least 3 min.

References:

– Patel, A, Salerno, M, Kwong, R. et al. Stress Cardiac Magnetic Resonance Myocardial Perfusion Imaging: JACC Review Topic of the Week. JACC. 2021 Oct, 78 (16) 1655–1668. https://doi.org/10.1016/j.jacc.2021.08.022.
– Shehata ML, Basha TA, Hayeri MR, Hartung D, Teytelboym OM, Vogel-Claussen J. MR myocardial perfusion imaging: insights on techniques, analysis, interpretation, and findings. Radiographics. 2014 Oct;34(6):1636-57. doi: 10.1148/rg.346140074. PMID: 25310421.

Musculoskeletal #41

~ EDiR Holders ~ 2 Comments

45-year-old female with forefoot pain:

What is the pathology located?

Where is the pathology located?

D3/D4 intermetatarsal space

Describe the pathology. Can you name it?

T1- and T2-hypointense soft tissue mass located in D3/D4 intermetatarsal space – Morton neuroma.

References:

Morton neuroma is a result of a compressive neuropathy of the forefoot interdigital nerve. The most common location for interdigital neuromas are between the 3rd and 4th metatarsal heads. Most patients with Morton neuroma have a good recovery with non-surgical treatment. 

Munir U, Tafti D, Morgan S. Morton Neuroma. [Updated 2023 May 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470249/

Urogenital #2

~ EDiR Holders ~ 1 Comment

25-year-old female:
* On ultrasound, a large pelvic mass was found.
* CA-125: 24 U/ml
* Risk of ovarian malignancy algorithm (ROMA): 6.6%
* CT imaging was acquired.

What is the most likely diagnosis?

Dermoid cyst/mature cystic teratoma

Which component is diagnostic of this lesion?

Fat content

What sign can be seen on the 2nd image?

Floating ball sign/pokemon ball sign

References:

A fat-fluid level is present with a ball of debris in the center. Calcification can also be seen