Emergency #19 – Flash card

34-year-old female with acute onset pelvic pain for the past 3 days.

Pelvic ultrasound revealed the following findings:

What is the diagnosis?

Ovarian torsion

Differential diagnosis includes:

– Polycystic ovarian syndrome
– Massive ovarian edema
– Pelvic inflammatory syndrome

More information

The findings of unilateral enlarged ovary without (or little) arterial and venous flow are said to be diagnostic of torsion. The finding of little or no venous flow is more common than no arterial flow, so persistent flow does not exclude the diagnosis. Ancillary findings include free pelvic fluid, unusual midline location of the ovary or a twisted vascular pedicle (giving the whirlpool sign). Most cases of ovarian torsion are caused by an adnexal mass (including dermoid or other cysts), with some occurring due to ovarian hypermobility. Treatment is based on early recognition and surgery, which aims to prevent necrosis and infection. Its findings should be reported urgently to the surgeons for further care, and the radiologist has an important role in this scenario.

Cáceres’ Corner Case 222 – SOLVED

Dear Friends,

Showing today preoperative radiographs of 57-year-old man with a torn knee cartilage. Sorry about the poor quality of the lateral view.
What do you see?

Come back on Friday to see the answer!

Click here to see the answer

Findings: PA radiograph show widening of the right superior mediastinum (A, arrow), imprinting the tracheal wall (A, red arrow).
In the lateral view there is increased opacity of Raider triangle (B, circle) with slight bowing of the posterior tracheal wall (B, red arrow).

The main causes of occupation of Raider triangle are two: either esophageal disease or congenital malformation of the aortic arch. The last one is the most likely, given the findings in the PA view.
 
Enhanced CT confirms a right aortic arch (C-D, arrows), crossing behind the trachea (C-E, red arrows) and causing the opacity in Raider triangle.

Findings are better seen in the 3-D reconstruction (F).

Final diagnosis: right aortic arch
 
Congratulations to Jolanta who made the correct diagnosis (my initial impression in the plain film was double aortic arch, so I will award another prize to Faelivrin for being wrong with me).
 
Teaching point: this case does not look very exciting, but right aortic arch is very common, and it is important to avoid confusing it with a mediastinal mass.
 
If you want to know more about malformations of the aortic arch, look up the article by Hanneman, Newman and Chan: Congenital variants and anomalies of the aortic arch, RadioGraphics 2017; 37:32–51

Abdominal #8 – Long case

76-year-old male.
* Presents with acute abdominal pain, enlarged abdomen and no defaecation since a few days.

What do you see?

Abdominal CT scan shows dilated colon loops with a calibre change in the sigmoid. Whirl of mesenterial vessels.

Differential diagnosis is Sigmoid volvulus. This was confirmed on OR.

Sigmoid volvulus is differentiated from a cecal volvulus by its ahaustral wall and the lower end pointing to the pelvis.

Abdominal radiographs will show a large, dilated loop of the colon, often with a few gas-fluid levels. Specific signs include coffee bean sign and absent rectal gas.

CT scan will show large gas-filled loop lacking haustra, forming a closed-loop obstruction. Specific signs include:
– whirl sign: twisting of the mesentery and mesenteric vessels
– bird’s beak sign: if rectal contrast has been administered
– X-marks-the-spot sign: crossing loops of bowel at the site of the transition
– split wall sign: mesenteric fat seen indenting or invaginating the wall of the bowel

Rectal tube insertion for treatment is successful in treating 90% of cases. Occasionally patients suffer from recurrent sigmoid volvulus, for which a surgeon may consider sigmoid colopexy (surgical fixation of the sigmoid colon), or in the surgically unfit, a percutaneous endoscopic colostomy (PEC) might be performed. The mortality rate of sigmoid volvulus is 20-25%. The most serious complication is bowel ischemia, not blow-out perforation as you might expect.

Cáceres’ Corner Case 221 – SOLVED

Dear Friends,

Today´s images belong to a 76-year-old man with pain in the back. Antecedents of urothelial carcinoma.

PA chest radiograph was normal and radiographs of the dorsal spine were taken.

What do you see?

Come back on Friday to see the solution!

Click here to see the answer

Findings: AP view of dorsal spine shows fixation screws in the lower spine and partial vertebroplasty of D12. The most important finding is that the left pedicle of D8 is absent (A, circle). In the lateral view, the posterior wall of the same vertebra is not seen (B, circle).

The findings are more evident in the cone down views (C-D, circles). In this particular case I was lucky because the superimposed air of the left main bronchus allows an unimpeded view of the missing pedicle.

Review of a recent chest CT demonstrated a lytic lesion in the body and pedicle of D8 (E-G, circles) that were no reported.

Final diagnosis: metastasis to D8 discovered in the plain film of the spine and overlooked in a previous CT.
 
Congratulations to BujarB, who was the only one to discover the missing pedicle (my hero!)
 
You may think that this case is difficult (only one of seven found the lesion). In the old times our routine included looking at the pedicles in the AP view of dorsal and lumbar spine. To familiarize you with the appearance of the normal spine, an AP view is shown below.

Teaching point: remember to look at the pedicles in the AP view. A missing pedicle in a patient with a known primary tumor is highly suspicious of metastasis.

Musculoskeletal #8 – Flash card

What do you see on the following images?

CT scout view

CT soft tissue window

CT bone window

Click here to see the answer

Skull eosinophilic granuloma
Well defined lytic lesion with scalloped edges. It involves both the inner and outer table. Narrow zone of transition, no cortical breakthrough and no soft tissue component.

Dr. Pepe’s Diploma Casebook 153 – All you need to know to interpret a chest radiograph – Seventh Session

Dear Friends,

Today I am presenting the leading images of the seventh webinar. They belong to a 66-year-old man with vague chest complaints. Chest was read as normal, but there is a visible abnormality, difficult to see.
Can you see it?

Remember, you can see the previous sessions of the webinar in our youtube channel. We will published the answer to this question (and the webinar) on Friday.

Click here to see the answer

Findings: PA radiograph (A) is unremarkable. In the lateral view there is a nodule projected over the mid-thoracic spine (B, arrow). The nodule was overlooked, and the examination was read as normal.

One year later the nodule has increased in size (C, arrow) and has become visible behind the heart in the PA view (D, arrow). It was diagnosed as adenocarcinoma and liver metastases were found.

Two years later, CT and PET-CT show marked progression of the liver metastases.

Final diagnosis: lung adenocarcinoma missed in the first chest radiographs, with widespread metastases two years later
 
Congratulations to Spat, who discovered the initial nodule.
 
Teaching point: remember to look at the dorsal spine in the lateral view. By doing so, you may discover early disease, with great benefit for the patient.