Transcript Long Island Radiological Society Interesting Case Panel

Long Island Radiological Society
Interesting Case Panel
March 11, 2014
Case 1
30yo obese female, restrained driver rollover MVC.
Positive “seat-belt sign.” Tenderness over multiple areas
of the abdomen.
Presented by Brian Goodman, MD PGY-3
Presented by Brian Goodman, MD PGY-3
STOP. Proceed to Diagnosis.
Traumatic Abdominal Wall Hernia
 Rare, associated with high-impact blunt trauma (eg,
high-velocity motor vehicle accidents), which produces
increased intra-abdominal pressure sufficient to
disrupt the abdominal wall musculature.
 Seat belt use increases the risk for traumatic hernias.
 The most common locations are areas of relative
anatomic weakness, such as the lower abdomen and
the lumbar region.
 Easily overlooked at physical examination performed
at initial presentation.
Traumatic Abdominal Wall Hernia

Incarceration and strangulation of hernia contents is common, and
up to 60% of cases are associated with additional intra-abdominal
injuries.

For these reasons, traumatic abdominal wall hernias usually require
emergent laparotomy (not in our case).

Multi–detector row CT permits reliable diagnosis and assessment of
traumatic hernias, including characterization of hernia contents,
visualization of disrupted abdominal muscle layers, and identification
of associated intra-abdominal injuries.
References
RSNA Radiographics. November-Decemeber 2005, Volume 25, Issue 6.
“Abdominal Wall Hernias: Imaging Features, Complications, and Diagnostic
Pitfalls at Multi-Detector Row CT.” Aguirre D, Santosa A, Casola G, Sirlin C
Hernia. Aug 2011; 15(4): 443-445 :”Acute Traumatic Abdominal Wall Hernia.”
Hartog D, Tuinebreijer WE, Oprell PP, Patka P
Case 2
28yo female with generalized weakness. No PMHx.
Submitted by HyukJun Yoon, MD PGY 2
STOP. Proceed to Diagnosis.
Hydatid Cysts
- Infestation with Echinococcus granulosus or Echinococcus
multilocularis tapeworm.
- Endemic in central and northern Europe, Mediterranean,
northern Asia and some parts of North America
- Most commonly found in Liver (95%). Lung is second most
frequent location.
- Single or Multiple cystic masses with well defined walls that
commonly calcify (50%).
- Enhancing cyst wall with septations.
- Daughter cysts can be identified within the parent cyst in 75%.
- Tx: Mebendazole or surgical excision.
Hydatid Cysts
• Type 1: Simple cyst without internal architecture.
• Type 2a : Peripherally located round daughter cysts.
• Type 2b: Large, irregular coutour daughter cysts
occupying the mother cyst.
• Type 2c: Oval shaped masses with scattered
calcifications and some daughter cysts.
• Type 3: Calcified cyst.
• Type 4: Complicated cyst.
References
• William E. Brant and Clyde A. Helms ,2012,Fundamentals of
Diagnostic Radiology, Lippincott Williams & Wilkins,
Philadelphia, PA, p. 709
• Jourdan JL, Morris DL. Hydatid liver disease. In: Holzheimer
RG, Mannick JA, editors. Surgical Treatment: Evidence-Based
and Problem-Oriented. Munich: Zuckschwerdt; 2001.
• Pedrosa I, Saíz A, Arrazola J et-al. Hydatid disease: radiologic
and pathologic features and complications. Radiographics. 20
(3): 795-817.
Case 3
34yo female with syncopal episode. No PMHx.
Submitted by Jonathan Holstad, MD PGY 3
STOP. Proceed to Diagnosis.
Arterovenous Malformation
Most common type of brain vascular malformation.
98% Sporadic: Hox D3/B3 malfunction->dysregulated
angiogenesis
Abnormal tangle of enlarged feeding artieries and central
tightly packed nidus directly communicating with veins, no
intervening brain parenchyma or capillary network.
Typically young adult with non-traumatic
hemorrhage/headache, seizures, or focal neurological
deficit.
Approximately 1/3 have a dual supply with dura/pia.
2-4% risk of hemorrhage per year, 2x-3x if previous
hemorrhage
Arterovenous Malformation
Treatment involves embolization, microneurosurgical
resection, and stereotactic radiosurgery.
Spetzler-Martin scale estimates surgical risk (1-5)
small <3cm – 1pt
medium 3-6cm – 2 pts
large >6cm – 3pts
Involves “eloquent” brain? – 1pt
Deep draining vein? - 1pt
References
William E. Brant and Clyde A. Helms, 2012,
Fundamentals of Diagnostic Radiology, Lippincott
Williams & Wilkins, Philadelphia, PA, p. 102.
Santos ML et al: Angioarchitechture and clinical
presentation of brain arteriorvenous malformations.
Arg Neuropsiquiatr. 67(2A):316-21, 2009.
Case 4
62yo male, fell on ice.
Submitted by Asim Maher, MD PGY2
STOP. Proceed to Diagnosis.
Ossification of the Posterior Longitudinal
Ligament (OPLL)
• Begins in the cervical spine (75%) but may extend
into the thoracic spine (15%) or lumbar spine (10%).
• Most common location C4-C6.
• 95% of ossification is located in C spine.
• Associated with DISH.
Ossification of the Posterior Longitudinal
Ligament (OPLL)
• Cause is unclear, Oriental races especially Japanese,
men, obesity, poor calcium absorption, ankylosing
spondylitis and diabetics have an increase incidence.
• Most people are asymptomatic, However it can
cause spinal stenosis and compression of the
anterior part of the cord.
• Treatment is NSAIDs. If conservative treatment is
unsuccessful, spine surgery may be recommended to
relieve pressure on the spinal cord.
Ossification of the Posterior Longitudinal
Ligament (OPLL)
• Stages of spinal cord damage by OPLL
• stage 0 - normal or mild compression of
anterior horn without neuronal loss.
• stage 1 - mild compression of ant. horn with
partial neuronal loss.
• stage 2 - marked deformity of anterior horn;
severe neuronal loss.
• stage 3 - severe spinal cord damage
References
• http://www.emoryhealthcare.org/spine/medical-conditions/ossificationposterior-longitudinal-ligament.html
• http://www.orthobullets.com/spine/2046/ossification-posteriorlongitudinal-ligament
• http://radiopaedia.org/articles/ossification-of-the-posterior-longitudinalligament
Case 5
40yo female with hemoptysis.
Submitted by HyukJun Yoon MD PGY2
STOP. Proceed to Diagnosis.
Aspergilloma(Fungus Ball)
• Mass-like fungus balls, which are collections of
fungal hypahe, mucus, and cellular debris
including inflammatory cells in preexisting
structural lung disease (i.e. bulla or cavitary
lesions)
• Usually solitary and located in the upper
lungs,similar to post primary pulmonary TB:
posterior segments of the upper lobes or
superior segments of the lower lobes.
• Typically infection with Aspergillus fumigatus.
• Commonly occurs in immunocompetent patients.
Aspergilloma(Fungus Ball)
• Rounded, ovoid soft tissue density well
formed focal intracavitary mass outlined by air
(Monod sign), mobile with altered position of
the patient.
• May calcify, adjacent pleural thickening
common
• Tx: Antifugal (Amphotericin) agent
administration into the cavitary lesion.
• Surgical resection for repeated hemoptysis
References
• William E. Brant and Clyde A. Helms, 2012,
Fundamentals of Diagnostic Radiology,
Lippincott Williams & Wilkins, Philadelphia,
PA, p. 445-446
• Franquet T, Müller NL, Giménez A et-al.
Spectrum of pulmonary aspergillosis:
histologic, clinical, and radiologic findings.
Radiographics. 21 (4): 825-37.