Long Island Radiological Society Interesting Case Panel
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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.