87-year-old woman:
* Presented with lower abdominal discomfort and weight loss.
* Pelvic MRI is performed.
Blood, hematometra
Cervical cancer
Imperforate hymen, vaginal septum, vaginal hypoplasia
In non-adolescent women, hematometra can often be caused by malignancy, so a search for cervical/endometrial cancer must be done.
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).
Subendocardial scar in LAD territory basal/midventricular with perfusion defect/inducible ischemia in LAD territory surpassing the area of infarction.
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.
– 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.
45-year-old female with forefoot pain:
D3/D4 intermetatarsal space
T1- and T2-hypointense soft tissue mass located in D3/D4 intermetatarsal space – Morton neuroma.
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/
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.
Dermoid cyst/mature cystic teratoma
Fat content
Floating ball sign/pokemon ball sign
A fat-fluid level is present with a ball of debris in the center. Calcification can also be seen
80-year-old patient:
* Underwent aortic arch repair two years ago, now experiencing back pain
* Elevated levels of troponinin I (TNI) and D dimers
* Small pericardial effusion
Intramural hematoma type A.
Aortic intramural hematoma (IMH) is an atypical form of aortic dissection. It is considered part of the acute aortic syndrome spectrum, which also includes penetrating atherosclerotic ulcers and classical aortic dissection. The condition involves a contained hemorrhage within the aortic wall, which is best visualized on non-contrast CT scans. On contrast-enhanced imaging, a small ulcer-like projection (ULP) is observed, with an ascending aorta diameter of 53 mm. Risk factors for progression of intramural hematoma and worse prognosis include the presence of ULPs, IMH thickness greater than 10 mm, associated aortic aneurysm, and increase of the thickness of the intramural hematoma at follow-up CTA. Similar to aortic dissections, aortic intramural hematomas are categorized according to the Stanford classification system (type A: involves the ascending aorta, with or without descending aortic involvement, type B: confined to the descending aorta, distal to the origin of the left subclavian artery).The patient underwent emergency supracoronary ascending aortic replacement.
Premature baby (gestation week 33) + 0
Nasogastric tube positioned in the left upper quadrant. The stomach and proximal duodenum are distended and filled with gas (double bubble sign). The remainder of the abdomen shows no gas-filled bowel loops.
Obstruction of the proximal duodenum (duodenal atresia)
Possible causes:
Duodenal web, duodenal atresia, annular pancreas, midgut volvulus, retroperitoneal tumour
Require surgery within 24 h
Treatment in this case: Surgery (duodeno-duodenostomy) the same day
59-year-old female:
– Presented with weight loss (35 kg weight loss in 1 year)
– Diagnosed with celiac disease 2 years ago
– Laboratory findings: low levels of sodium, potassium, chloride, and calcium in the blood
Multiple mesenteric lymphadenopathies that contain fat-fluid levels (red arrows)
Splenic atrophy (red arrows)
Cavitating mesenteric lymph node syndrome
– Cavitating mesenteric lymph node syndrome is associated with celiac disease
– It is characterized by the triad:
(a) low attenuation lymphadenopathies that may contain fat-fluid levels
(b) splenic atrophy
(c) villous atrophy
– Cavitating mesenteric lymph node syndrome is associated with poor prognosis
– Many patients die of complications of cachexia and intestinal hemorrhage. Patients are prone to sepsis, often due to infections commonly associated with clinical hyposplenism, such as pneumococcal infection
– Treatment: Correction of electrolyte abnormalities, strict gluten-free diet, steroid therapy
– In our case, US-guided biopsy of one of the mesenteric lymphadenopathies was performed. Histopathologic examination showed acellular, chylous fluid. It was negative for malignancy or mycobacterial infection. The diagnosis of cavitating mesenteric lymph node syndrome was made in the clinical setting of celiac disease
30-year-old female patient:
– With cervical cancer
– Recent hysterectomy with bilateral adnexectomy and pelvic lymphadenectomy
– Urinary tract infection with pyuria
– Persistent pelvic fluid collection between the vaginal stump and rectum (asterisk)
– Contrast-enhanced CT (portal venous phase) shows the right ureter merging with the collection (arrow)
Scan in the excretory (urographic) phase
*Usually performed 10 minutes after contrast injection, but useful even if done a couple of hours later (such as in this case)
Urinoma – iatrogenic
Urology consultation
Double-J ureteral stent was placed
73-year-old female patient:
* Abdominal pain
* Suspicion for ileus
Small bowel obstruction, with small bowel wall distension and transition point in the pelvis. At the point of transition there is a metal structure visible with the lumen of the bowel
No signs of bowel wall ischemia, no perforation
Acute small bowel obstruction due to migrated stomach tube plate
Requires surgery within 24 h
Possible complications: Perforation, abscess, ischemic changes
Treatment in this case: Laparotomy and surgical removal of the metal plate
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.
