Thursday, October 28, 2010

Atypical Sites Of Metastasis-Two Cases

These are two atypical sites of secondaries in recent past in my practise, which we are sharing in our site.

The metastatic lesions of pancreas are extremely rare. Tumors metastasizing to the pancreas include lung carcinoma, gastrointestinal tract carcinoma, breast carcinoma, renal carcinoma, melanoma, lymphoma, and (osteo)sarcoma. This is a 15 year old girl known case of osteosarcoma, with suspected pancreatic secondaries.

Another atypical case, is a 67 year old male with past nephrectomy for hypernephroma and had shoulder pain. MRI done revealed altered marrow signal intensity involving the glenoid process of scapula along with involvement of the coracoid process. There is evidence of associated osseous destruction and soft tissue component. Similar cases of glenoid secondaries has been reported previously in the literature especially with hypernephroma. Reference-Daluga D, Quast M, Bach Bernard, Gilelis S. Shoulder neoplasms mimicking rotator cuff tears. Orthopaedics 1990 July; 13:765-767.

Tuesday, October 26, 2010

Brodie's Abscess-CT

Classical radiological features are oval elliptical or serpiginous radiolucency usually around 1cm surrounded by a reactive sclerosis, granulation tissue, and a Nidus often less than 1cm. The margins often appear scalloped on radiograph. Brodie's abscess is best visualized using CT scan. Tunnelling is a classical sign of brodie's abscess.

Saturday, October 23, 2010

Double stent assisted coiling of a complex basilar top aneurysm-Video

Rupture of brain aneurysm (A balloon like swelling over a blood vessel) results in brain hemorrhage (Subarachnoid Hemorrhage- SAH). Patients present to the emergency with a complaints of "worst headache of their life." Treating the aneurysm in a patient of SAH if of paramount importance, as aneurysms are know to have very high risk of re-bleed leading to death of patients

Please click the link below to see Double stent assisted coiling of a complex basilar top aneurysm with both PCAs and both SCAs coming out of the aneurysm.

Case submitted by- Dr. Sibasankar Dalai, MD, FACP
Fellow, Australasian College of Phlebology,
Member, American College of Phlebology,

Wednesday, October 20, 2010

Pulmonary Fibrosis- CXR

76 yr old compalints of shortness of breath with history of COPD with decreased oxygen saturation with no definite occupational history relating to toxins/pollutants. There is extensive, ill defined reticular hard shadowing  in all zones  with suggestion of Rt CP angle blunting and rt diaphragmatic, possible calcium with no significant Rt ventricular enlargement  on this film.

Best  described as Dirty lung fields.

Teaching points
-Hard reticular shadows with some subpleural nodules  with at places loss of  tissue interfaces
-Rt pleural thickening along with plaque diaphragmatic region
-Questionable mediastinal adenopathy
-Few areas of focal hyper inflation
-Heart not conformity to  COPD with pulmonary conus not full

Xray diagnosis could suggest Pulmonary fibrosis - needs compariosn with old Xrays/ HRCT evaluation

Pulmonary fibrosis
Definition: literally scarring andreplacemnt of lung tisue with fibrous tisue
Classification: at the most confusing and rapidly changing as the etiology and types are broad progresses rapidly after 40s and 50 s, presents with shortness of breath and dry cough, typically misdiagnosed initially in view of clinical mimic to infection/embolism/COPD/ heart failure /Asthma etc. Xray chest could be normal adding to the misdiagnosis
Restrictive lung disease suggested by maintained FEV1/Fvital capacity  , though the latter is decreased  depending on the etiology radiolgical features vary idiopathic may show usual interstitial patern(UIP)  

More on this will be presented with HRCT picture -look out for it.

Tuesday, October 19, 2010

Adenosquamous Carcinoma Lung-CT

50 year male with cough and CT showed a large well defined regular, heterogeneously enhancing , peripheral , broadbased , noncalcifying, nonnecrotised SOL with no defintie bronchus cutoff. The medial and proximal lung of upper lobe displays airbronchogram. Mediastinal lymphadenopathy of moderate size is suggested in paratracheal and precarinal region with possible involvement of ipsilateral hilum. Ribcage, pleuralmargin, soft tissues, rest of the lung fields and adrenal glands are normal along with supraclavicular regions. CT value suggests solid lesion consistent with mass lesion

CT guide FNAC suggested adenosquamous carcinoma

AdenoSquamous carcinoma is unusual and rare pulmonary malignancy with two distinct cell types. Constitutes only 0.4 to 4% of all pulmonary malignancies.

Etiology: can arise from damaged parenchyma posibly from pneumoconiosis, and radiaiton fibrosis

Histology was defined by WHO in 1982 , modified by japanese lung society recently with suggestion of atleast 10% of microscopic appearance from both adeno and squmous components This can arise by collison of two adjacent tumours and yet distinct tumours , or as some consider as high grade mucoepidermoid ca with high squamous content or adenoca with squamous metaplasia

Studies-Mass Gen Hosp reports them to be peripheral in 83%, right lung involv in 63%,size varying from 7 to 65 mm with presence of cavitation in only 14%. It has been recently reported in chest journal presenting as multiple cavitating nodules mimicking infections . Prognosis is generaly considered poor with nagasaka et al reporting 6.2%survival at 5 yrs compared to appx 42% each for adeno and squamous varieties amongst review involving 1400 cases.

Case Submitted by – Dr Sudheer , Dr Krishnamohan and Dr MGK Murthy

Monday, October 18, 2010

Air Mensicus Sign in Hydatid Disease

In chest roentgenograms, the pulmonary meniscus sign is a crescent-shaped inclusion of air surrounded by consolidated lung tissue. The common cause is aspergilloma. A hydatid cyst is, however, the most common cause in endemic areas. Cyst growth produces erosions in the bronchioles that are included in the pericyst, and, as a result, air is introduced between the pericyst and exocyst, producing the crescent or meniscus sign. Air penetrating the interior of the cyst may outline the inner surface of the exocyst, producing parallel arches of air that are referred to as Cumbo's sign with an “onion peel” appearance.

Sunday, October 17, 2010

Carpal Tunnel Syndrome-MRI

62 yr old house wife has clinical symptom of falling objects from the wrist with electrophysiological data of median nerve compression has reported for MRI. MR axial images show degenerative changes in the wrist in general , median nerve appears compromised within the canal with ratio of width to height nearly 2.0 and bowing of retinaculum with height of the canal at upper border of normal(1cm)

Radiological points of interest

Definition: fibroossoeus passage from palmar side connecting distal forearm to midlepalmar region

Contents: Total 9 tendons

Flexor digitorium profoundus 4

Flexor digitorium superficialis 4

Flexor pollicis longus 1

Nerve 1 = median nerve passes between FDP and FDS

FDP and FDS are enclosed in ulnar sheath and FPL is enclosed in radial sheath. From hook of hammate to trapezium tubercle extends the flexor retinaculum and the height of the canal is usually 10mm. Median nerve can show flattening (rep by increased width/ height ratio), ill defintion, more signal intensity on fat suppression (compared to hypothenar muscels ), and enhancement on CEMR, age related quantitative studies showed volume increase with age, anatomical variations and dynamics of flexion/ extension of wrist affect the relative space for median nerve. Newer developments include calculation of age related volume measurements, dynamic study of the joints, and posibly MR neurography.

Case by Dr MGK Murthy, Sr Consultant Radiologist
Prime Telerad Providers (P) Ltd.

Saturday, October 16, 2010

Marjolin Ulcer

Dr. Jean Nicolas Marjolin first described the occurrence of ulcerating lesions within scar tissue in 1828. Marjolin’s ulcer is the term given to these aggressive epidermoid tumors that arise from areas of chronic injury, with burn wounds being a common site.

Friday, October 15, 2010

Hypoxic ischemic encephalopathy-MRI

History : 4 day old neonate was delivered by LSCS after clinical fetal destress on account of meconium staining of the liquor. Apgar at birth reported normal with normal sugar levels presently, with history of seizures.MRI Brain shows two well defined dots of restricted diffusion seen in the parasagittal location of posterior parietal region predominantly involving the white matter, with not reaching upto the cortex, no significant basal ganglia or thalamic involvement, or cortical highlighting or diffuse white matter hyperintensity or gross structural abnormalities.

Hypoxic ischemic encephalopathy is now appropriatly reffered to as neonatal encephalopathy to encompase all the variants:

a) Commonest presentation for an acute hypoxia in term children usually leads to severe basal ganglia thalamic lesions ( BGT), predominantly an initially involving posterolateral lentiform nucleus and ventrolateral thalami. These are usually severe and lead to high mortality. The additional features amongst them diffuse cerebral edema, slit like ventricles and reduced extra-cerebral spaces.

b) The other uncommon variant is reffered to as parasagittal infarction which involves the deep white matter only at border zones of major arterial territories ( water shed ) some of these may present with full blown HIE as well. These occur usually in the presence of severe hypoglycemia and lead to microcephaly all though the neurodevelopmental outcome surprisingly good particularly for motor function because there is minimal or no involvement of BGT. These infants may also show more profound metabolic abnormalities such as prolonged conjugated hyperbilirubinemia, and recurrent hypoglysemia and developed marked cognitive and motor impairement.

c) Multifocal areas of infarction that do not appear to be in parasagittal distribution may be secondary to infections like herpes, varicella, and listeria, in which case contrast study would help. The CMV lesions may persist for years in white matter and not show atrophy, the key lies in the presence of subependymal cysts.

Case by Dr MGK Murthy, Sr Consultant Radiologist
Teleradiology Providers, Unit of Prime Telerad Providers (P) Ltd

Thursday, October 14, 2010

Possible Creutzfeld-Jakob Disease-MRI

This is patient presented with progessive dementia and myoclonic jerks. MRI revealed FLAIR and DWI hyperintensity in the caudate nucleus, putamen. Possibility of CJD was suggested. Diffusion abnormalities were not so  prominent which are probably due to intermediate to late stage of the disease and myoclonic jerks were also present.

Wednesday, October 13, 2010

Parotid Lipoma-CT

Lipoma of the parotid gland is rare finding and seldom considered in the differential of parotid swelling. Lipoma of the superficial lobe of parotid gland is frequently reported, but from the deep, lobe it is extremely rare.  In our case, the lipoma was arising from the deep lobe of parotid gland. 

Wednesday, October 06, 2010

Anterior Spinal Cord Infarction-MRI

Patient is 60 year old diabetic female who presented with 2 day history of quadriparesis. Brain MRI revealed extensive small vessel occlusive white matter changes. MRI of the cervical spine reveals T2-weighted images showed an abnormal long segment increase in signal intensity affecting the anterior two third of the spinal cord. On axial T2-weighted images, ASCI appeared as two rounded intramedullary high-intensity lesions (the so-called “owl’s eye” appearance). Spinal cord ischemia most often occurs in the anterior spinal artery (ASA) territory. ASA is a blood vessel that supplies the anterior portion of the spinal cord.
Hyperintensities on T2-weighted images are nonspecific for ischemia. It can also be seen in

• Demyelinating plaques

• Myelitis

• Non-haemorrhagic contusion

Nevertheless, high T2 signal located in the anterior two-thirds of the spinal cord is suggestive of ASCI.

Friday, October 01, 2010

Parotid Abscess

Right parotid gland is bulky and shows central necrotic area with air loculi within measuring around 3.8cm x 2.3cm. Surrounding fat planes with massetric space are lost.Findings indicate parotid abscess as described.  Patient is 70 year old male, alcoholic.

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