Duodenal Diverticulum - CT sections

Duodenal Diverticulum

Fenestrations and Duplications

A duplication is defined as two distinct arteries with separate origins and no distal arterial
convergence .

Fenestration, by contrast, is defined as a division of the arterial lumen into distinctly separate
channels, each with its own endothelial and muscularis layers, while the adventitia may be shared.

Multiple Cavernomas in Brain

Young male patient with recurrent brain hemorrhages, due to multiple Cavernomas.

Cavum Septum Pellucidum

Cavum Vergae

The main lesion - which is heterogenously hyperdense. Lesion also showed CSF density areas - possibly sequelae to old hemorrhages. Characteristic MRI appearance is described in T2WI as 'Popcorn Appearance'.

Tiny lesion in right high frontal lobe.

This patient had previously undergone MRI Brain, which showed multiple cavernomas (SWI blooming) - much more than that in present CT.

'Popcorn Appearance' of Cavernoma in T2 WI MRI.

Bilateral thalamic and cerebellar hypodensity

These are the CT Brain images of a young male patient, who had h/o fever & Status Epilepticus 

(? for 1 hour),became unresponsive and was intubated.

Left Centrum Semi Ovale showed two calcific foci.

Left frontal lobe showed a round, relatively well defined hypodensity - ? Focal Infarct. Smaller scattered hypodensities were also present bilaterally.

Bilateral symmetrical parieto-occipital, basal ganglia and thalamic hypodensities were noted. See following images.

Thalami are sort of expanded ? Edematous.

Temporal horns and sulci show effeacement -( brain edema)

The patient unfortunately expired after 2 days of the CT.

Hypodensities due to severe Ischemia or Hypoxia usually spares the Cerebellum and the Central structures - which is called as the White Cerebellum Sign or the Dense Cerebellum Sign or Reversal Sign.

See Radiopaedia Article  http://radiopaedia.org/articles/white-cerebellum-sign

But in this case there is Symmetrical involvement of bilateral thalami and cerebellar white matter ! - point against Hypoxic etiology.

Symmetrical cerebellar involvement also !

So this case would be Atypical for Hypoxia/Ischemia alone. One thing here to be noted is, majority of the cerebral parenchyma is not showing much decreased attenuation and the grey-white differentiation is preserved.

These findings 1. Diffuse brain edema +/- Thalamic +/- Cerebellar hypodensities , infarcts has been described in Cerebral Malaria !!

For further data on Imaging in Cerebral Malaria : 

1. Adult Cerebral Malaria: Prognostic Importance of Imaging Findings and Correlation with Postmortem Findings - Radiology 2002, September by Patankar et al.
Cerebral Malaria Imaging @ Radiology RSNA, Patankar et al.

2. http://radiopaedia.org/articles/cerebral-malarial-infection

Patankar et al describes 4 patterns in cases of Cerebral Malaria
1. Normal Imaging 2. Diffuse brain edema 3. Diffuse brain edema with bilateral thalamic hypoattenuation and 4. Diffuse cerebral edema with thalamic and cerebellar hypoattenuation.

"These areas of hypoattenuation represent infarction in the territories supplied by the thalamoperforating and cerebellar vessels as a result of microvascular occlusion.  "

4th pattern is the most severe and survival is rare, as in our case. 

Normal imaging is the most common pattern. (2nd pattern was the MC in Patankar et al Study). 


"Focal hemorrhagic or nonhemorrhagic infarcts in the cortex, basal ganglia, thalamus, pons, and cerebellum in patients with cerebral malaria occasionally have been described in isolated case reports." The left frontal lesion may represent a focal infarct.


"Bilateral, symmetric infarction of the thalami has been seen in internal cerebral vein thrombosis, Japanese encephalitis, and occlusion of both paramedian thalamic and mesencephalic arteries caused by atherosclerosis or tuberculous meningitis."

"Hypoglycemia, which occurs in 8%–32% of patients with cerebral malaria , may also cause serious cerebral damage. The cortex, hippocampus, basal ganglia, and the substantia nigra (but not the thalamus or cerebellum) are particularly vulnerable to this."


So our possible diagnosis for this case would be CEREBRAL MALARIA.


Whats your opinion on this case?

Case Of Ca Lung

A Case of Carcinoma Lung

50year old male patient, smoker, admitted with fever & sepsis.

CT Chest lung window shows a spiculated mass lesion
 in right upper lobe with multiple pleural tails/tags.

Lesion shows heterogenous, peripheral enhancement, indicating a necrotic lesion. 

Enlarged rim enhancing (necrotic) 3cm mediastinal lymph node is also seen.

In same patient liver showed a well-defined, but irregularly marginated hypodense (20-30HU) lesion with minimal peripheral enhancement. ?Liver Abscess !.

Again, the left adrenal showed a macroscopic fat containing lesion. (Adrenal Adenoma)

TSTCs - Too Small To Characterize

TSTCs or ' Too Small To Characterize' Lesions

• Hepatic lesions 1.5 cm in diameter or smaller are frequently difficult to characterize at CT and are often reported as being “too small to characterize” (TSTC) by the interpreting radiologist.
• Most of the TSTCs are hypodense.
• In a patient without a known malignancy, TSTCs should be considered benign.
• Single TSTC in patient with malignancy are considered benign.
• If >1 TSTCs in a Oncology patient, they are mostly benign, especially if they are homogenous and sharply defined.
• Of cancers Ca. Breast TSTCs are more likely to be a metastatic lesion, than others (Ca Breast > Colorectal > Lymphoma).
• TSTCs are followed up, to look for change in size.

References
1. Hepatic lesions deemed too small to characterize at CT: prevalence and importance in women with breast cancer. Radiology 2005.
2. Liver Incidentalomas http://www.radiologyassistant.nl/en/p45a5e818c709d


 

Incidental CP Angle Meningioma

Patient here is a middle aged female, with headache. CT Brain was asked to r/o SAH.

Small hyperdense non-calcified lesion was noted in the left Porus Acousticus of IAC, with minimal intracanalicular extension.

Lesion shows minimal intracanalicular extension. No widening of IAC was noted. No bone sclerosis or lysis was present.

Tentorial Hemorrhage !

And Bilateral SDH !!  ??