Abdominal #7 – Long case

70-year-old female:

* Presents with acute abdominal pain
* Previous history adnex extirpation and appendectomy
* No raised inflammatory parameters
* No peristalsis
* CT abdomen with IV contrast

What do you see?

Click here to see the answer:

Dilated small bowel loops, radiating distribution (“Bunch of grapes”) with impressive mesenterial venous engorgement and edema in the centre. Ascites perihepatic and in Douglas. Loss of bowel enhancement.

What is the most likely diagnosis?

Closed loop obstruction with bowel ischemia.

Teaching point

Seek for 2 (!) calibre changes next to each other to confirm SBO on basis of Closed loop obstruction.

Peroperative 1 meter of necrotic small bowel was resected.


Cáceres’ Corner Case 217 – SOLVED

Dear Friends,

I am showing today PA chest radiographs in two asymptomatic patients They have subtle findings that can be discovered if you paid attention to the previous webinars.

What do you see?

Prof. Cáceres will take some well-deserved holidays and will come back on January 6th with new cases!

Click here to see the answer

Case 1 findings: PA radiograph shows a well-defined opacity behind the cardiac shadow (A, arrow), better seen in the cone-down view (B, arrow). It has an extrapulmonary appearance and the best option is diaphragmatic hernia.

Coronal and sagittal CT demonstrate herniated abdominal fat through a rent in the posterior diaphragm (C-D, arrows).
 
Final diagnosis:Bochdaleck hernia

Case 1 has been diagnosed by most of you. Congratulations to Archanareddyt,
who was the first. Hope my recommendations in Webinar 4 were helpful!


REMEMBER

In the cardiac area look for:

* Opacities behind the left heart
* Double contour on the right

Case 2 findings: This patient has a faint but visible right infraclavicular nodule (A-B, arrows).

The nodule was overlooked and one year later had grown markedly (D, arrow). At surgery, a melanoma was found.
 
Final diagnosis: melanoma of the lung, missed in the initial examination

Teaching point: This is a difficult case, but easily diagnosed if you remember my oft-repeated mantra: “Search for pulmonary nodules in the pulmonary apices” (Webinar 1). Nobody saw the nodule and I feel useless (sniff).

Emergency #17 – Flashcard

40-year-old male:
* Fell off bike at 40 km/h
* Pain left shoulder

> What views of the shoulder in trauma setting should be done?
> Is this in endo- or exorotation?
> Do you need right shoulder to compare with?

Click here to see the images

Right shoulder for comparison

Additional trauma chest X-ray was done.

Differential diagnosis includes:

* AC-luxation
* CC-luxation
* Left pneumothorax
* No rib #

Neuroradiology #17 – Long case

Regarding the following images:

Where is the abnormality?

Bilateral asymmetrical temporal and inferomedial frontal lobes and insular cortices

What is it like?

Abnormal CT hypodensity and high FLAIR signal intensity of the affected white matter and cortex

What is the differential diagnosis?

Herpes encephalitis: affects the limbic system bilaterally, temporal lobes, insular cortices and inferolateral frontal lobes. May progress to hemorrhage. Basal ganglia is typically spared

Paraneoplastic tumor-related limbic encephalitis and autoimmune limbic encephalitis: tumour-related limbic encephalitis and autoimmune limbic encephalitis: autoimmune encephalitis. Same distribution as herpes encephalitis but the basal ganglia is frequently involved. Hemorrhage is uncommon

What is the final diagnosis?

Herpes encephalitis

Abdominal #6 – Long case

56-year-old male:

* Presents with diffuse chronic pain in the abdomen
* Decreased kidney function

A CT is performed:

CT abdomen with IV contrast

What do you see?

Diffuse hypodense solid tissue around the pancreas, compression splenic vein with inhomogeneous attenuation of the splenic parenchyma. Soft tissue manchet around the infrarenal abdominal aorta, compressing the aorta to the spine and continuing around the iliac vessels. No separate lymph nodes can be seen. Right hydronephrosis and hydro-ureter, right kidney shows edematous swelling . Both kidneys show heterogeneous cortical enhancement.

What is the most likely diagnosis?

Right hydronephrosis and hydro-urter, pancreatitis and nephritis.

Differential diagnosis includes:
Retroperitoneal fibrosis (Ormond disease) or auto-immune mediated IgG-4 disease

CT-guided retroperitoneal biopsy was performed.

Pathology report: Fibrous tissue with chronic inflammation. Not enough signs of IgG-4 mediated disease.


Musculoskeletal #6 – Flashcard

28 year-old male with a history of shoulder dislocation.

Regarding this image:

What do you see?

Hill-Sachs lesion
* Edema on posterolateral humeral head secondary to compression fracture, well-demonstrated on axial fat suppressed proton density Weighted image
* Secondary to anterior dislocation of shoulder

Regarding this image:

What do you see?

Bankart lesion
* Tear/injury of anteroinferior labrum, well-demonstrated on axial fat suppressed proton density Weighted image
* Secondary to anterior dislocation of shoulder
* May have associated bony component

Emergency #16 – Long case

21-year-old male:

* Collapse twice
* Loss of strength of right arm
* Trouble finding words
* Headache

What findings do you see on the CT?

CT Findings

* No abnormalities were seen
* No bleeding
* No signs of recent ischemia

Patient develops fever. Cannot bend his neck properly. When asked, he has been traveling recently to Thailand.

What further imaging could help us?

An MRI is performed.

What findings do you see on the MRI?

MRI Findings

* Two areas left frontal and left parietal with T2/FLAIR hyperintense swelling/edema of cortex and subcortical white matter, with diffusion restriction and patchy, gyriform cortical enhancement

* Diffusely leptomeningeal enhancement

* No ring-enhancing lesions. No white matter vasogenic or cytotoxic edema

What is the most likely diagnosis?

Cerebritis (precursor of abscess) and meningitis. Not yet an abscess

Note: Encephalitis means inflammation of PARENCHYMA

Differential diagnosis of meningitis:
> Leptomeningeal carcinomatosis
> Sarcoidosis and other granulomatous diseases
> Vasculitis
> Connective tissue diseases

Viral inflammatory cause for symptoms was confirmed with lumbar puncture and patient was treated with IV anti-viral treatment