Various Clinical Cases: Aspergilloma, Broncholith, Aortic Rupture, Nutcracker Syndrome, Angiomyolipoma, Urethral Diverti

1. SPOTS Aarti Sardana 3rd Yr Resident Dept of Radiodiagnosis SSG Hospital Date: 17-07-08

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3. Pulmonary Aspergilloma

4. Aspergillus produces several different clinical illnesses in humans: acute bronchopulmonary aspergillosis and aspergilloma or a fungus ball, which may present as hemoptysis. • Aspergillus is important in immunosuppressed individuals due to the possibility of invasive pulmonary aspergillosis. • Fungus balls usually form within pre-existing pulmonary cavities from TB, old infarcts or abscesses, and bronchiectasis. • Early in the formation of an aspergilloma, an irregular spongelike network filling the cavity may be evident on CT. Other findings include a pulmonary mass surrounded by a zone of lower attenuation due to edema (the halo sign) and associated pleural thickening.

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6. Broncholith with Complete collapse of right lower lobe

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8. Aortic arch traumatic rupture , Acute mediastinal hematoma • Bilateral small pleural effusions without pneumothoraces

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10. Pulmonary thromboembolism

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12. Nutcracker syndrome • Stenosis of the left renal vein between the superior mesenteric artery and the aorta. • Venous phase left renal angiogram shows massive reflux in the left gonadal vein. • Nutcracker syndrome is asso. With secondary varicocele due to compression of left renal vein by SMA

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14. Rt renal Angiomyolipoma with Associated perinephric and retroperitoneal hemorrhage

15. 7. Recurrent lower respiratory infection and occasional hemoptysis

16. Intralobar Bronchopulmonary sequestration • Findings:  There is a focus of mass-like pulmonary consolidation in the left lower lobe, most likely in the medial basal segment, abutting the pleura. There is cavitation, suggesting infection and communication with the tracheobronchial tree. Some coarse calcification is seen. A feeding arterial vessel can be seen arising from the aorta. No anomalous draining veins are seen.

17. 8. Woman undergoing GU workup

18. Diagnosis:  Urethral diverticulum

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20. Findings • Extensive patchy lytic process in the skull vault. This is more confluent in parietal and occipital regions, where the random confluent areas have a geographical appearance. The inner and outer tables are affected differently. The bevelled edges of the lesions are best shown in the lateral view. • Lungs : nodular and coarse linear shadowing with mid and lower zone predominance. There is a superficial honeycomb appearance, but no loss of lung volume that might accompany pulmonary fibrosis.

21. Langerhans Cell Histiocytosis • The characteristic appearance of histiocytosis X in the skull is geographical, like colouring-in the countries on a map. Differential (bevel appearance) involvement of the inner and outer table helps distinguish it. • Eosinophil granuloma presents in skeleton, lymph nodes or skin at any age, mostly children and young adults. In the skeleton, the lesion comprises a lytic area, fairly well-defined, that may be associated with a cortical reaction, often lamellar. • In the spine the flattened vertebra is a pattern recognition image, vertebra plana, but isn't a common presentation. The focal lesion responds to curettage.

22. Histiocytosis X in the chest can be divided into rapidly progressive cases, usually infants with systemic disease and a more chronic group progressing to pulmonary fibrosis. • The evolving pattern can be predicted from nodular, reticulonodular to linear and cystic spaces.

23. 70 year old anaemic male with blood in the faeces. 10.

25. Cecal angiodysplasia

26. Angiodysplasia is a degenerative lesion of previously healthy blood vessels found most commonly in the cecum and proximal ascending colon • Angiodysplasia is the most common vascular abnormality of the GI tract. After diverticulosis, it is the second leading cause of lower GI bleeding in patients older than 60 years. • Angiodysplasia may present as an isolated lesion or as multiple vascular lesions. Unlike congenital or neoplastic vascular lesions of the GI tract, this lesion is not associated with angiomatous lesions of the skin or other viscera. • Clinical presentation is usually characterized by maroon-colored stool, melena, or hematochezia. Bleeding is usually low grade but can be massive in approximately 15% of patients.

27. Selective mesenteric angiography in Cecal angiodysplasia • Useful diagnostic technique, especially in patients with massive bleeding in whom a colonoscopic diagnosis is difficult • Signs: • The most frequent and earliest sign : a densely opacified, dilated, and slowly emptying draining vein within the intestinal wall. This vein is detected during the venous phase of the study and is present in more than 90% of lesions. • As the lesion progresses, a vascular tuft may become apparent during the arterial phase of the study. This is observed in as many as 70-80% of patients. It represents an extension of the dilation process to the mucosal venules. • The latest sign, an early-filling vein, may be observed in the arterial phase, indicating a more developed arteriovenous communication through the angiodysplastic lesion. It is observed in only 60-70% of cases of angiodysplasia.

28. Young adult male with hypertension. 11.

29. Para-aortic Pheochromocytoma • A right femoral artery catheter has permitted an injection of contrast into the abdominal aorta. The aorta and major branches are outlined by contrast. There is filling of a left para-aortic mass of roughly two thirds the size of a kidney. There is filling of numerous coiled, tortuous arteries with contrast enhancement, 'blush', of the soft-tissue of the tumour

30. 12. 3 year old child with proximal limb shortening

31. Achondroplasia

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33. Heterotopic pregnancy : Coexistent intrauterine and cervical pregnancies

34. 14. Teenager hit by car.

35. Left lung atelectasis secondary to right mainstem intubation

36. FOLLOW UP FILM: The ETT tip was pulled back from the R mainstem bronchus and the L lung is now recovering from its iatrogenic atelectasis.

37. Radiographic findings of endobronchial intubation include endotracheal tube tip in the bronchus (usually right), atelectasis, ipsilateral pneumothorax, and mediastinal shift from aerated to non-aerated side. • Complications of attempted intubation include the following: • Right mainstem intubation. • Esophageal intubation. • Pneumothorax. • Post-intubation pneumonia. • Dental trauma. • Vocal cord avulsion. • Hypotension. • Pneumomediastinum. • Atelectasis. • Aspiration

38. 15. Young female with lower abdominal pain

39. Hematometra. • Sagittal T2-weighted MR image shows dilatation of the vagina (straight arrows) and resultant cranial displacement of the uterus

40. Sag T1 Sag T1 & Gd enhanced T1 16. A 28-year-old woman with no known medical history presented with a history of progressive gait imbalance and left upper limb incoordination over a period of 2 years

41. Epidermoid tumor • Sagittal T1-weighted , axial T2-weighted , axial gadolinium-enhanced T1-weightedimages. A fourth ventricle mass is seen expanding, distorting, and compressing the brainstem without any evidence of obstructive hydrocephalus, as demonstrated by the normal size of the lateral ventricles superiorly . • The mass insinuates through the foramen of Magendie and the foramina of Luschka and extends into the cisterna magna and caudally to the level of the foramen magnum . On T1-weighted images its signal is only slightly hyperintense relative to cerebrospinal fluid (CSF). On T2-weighted images the mass has a hyperintense but heterogeneous signal, unlike the homogeneously high signal intensity of CSF. • No significant enhancement is seen.

42. Most intracranial epidermoid tumors are intra-dural tumors. • Site: cerebellopontine angle cistern-most common ( third most common cerebellopontine angle internal auditory canal mass after vestibular schwannoma and meningioma) . • Second most common for an epidermoid tumor in the posterior fossa -4th ventricle

43. Imaging: • classic appearance of an epidermoid tumor is that of a CSF-like mass insinuating into the cisterns and encasing adjacent vessels and neural structures • CT: nonenhancing and hypoattenuating extra-axial mass. • MR : best modality for evaluating these tumors. Characteristically, they are either isointense or slightly hyperintense relative to CSF on T1- and T2-weighted images. • DD: arachnoid cyst. • The distinction is usually made with FLAIR and DW imaging. Arachnoid cysts follow the signal intensity patterns of CSF with all MR pulse sequences, whereas epidermoids are not hypointense on FLAIR images and display areas of hyperintense signal relative to CSF. • On DW images, epidermoids typically show restricted diffusion, unlike arachnoid cysts. Finally, although most epidermoids do not enhance, up to 25% may show minimal rim enhancement

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45. Epicardial fat pad

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47. CYSTIC HYGROMA

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49. Omental infarction

50. It usually occurs in the right lower or right upper quadrant, clinically mimicking appendicitis or cholecystitis. • The right-sided predilection may be related to variant embryologic vascular development, which predisposes to right-sided venous thrombosis. • CT demonstrates a large, cake-like mass centered in the omentum. • The inflammatory mass may or may not lie immediately adjacent to the colon, depending on the precise site of the infarcted omentum. • Reactive colonic wall thickening may occur but is usually mild relative to the degree of Omental abnormality.