DX: Chronic Sinusitis complicated to Meningitis

With those symptoms, the neurologist performed a spinal tap and revealed Meningitis.So, the main objective of this CT scan was to look for a hidden skull base fracture. As told, patient had history of recurrent sinus symptoms. His dad told us that he had had those problems since he was a kid and was treated as rinitis.  At examination patient had halitosis and a close examination revealed purulent discharge in nasal cavity. So, we searched in paranasal sinus for a fracture and signs of infection.

Here are the relevant images:

There was opacification of ethmoidal and frontal sinuses but a fair irregularity and asymmetry is seen in the right anterior skull base and roof of the orbit. We see a discontinuation in the outter table and a permeative desctrutive bone lesion in the inner table of the skull, almost a cavity. Borders of this cavity are sclerotic thus leading to a chronic inflammatory settting such as osteomyelitis. This is NOT a fracture, but in mild traumas can easlily lead to microleaks from frontal sinus that in fact, show also signs of infection. This confirms the origin of the Meninitis.

Volumetric 3D reconstruction algorithm gives us more spatial resolution and understanding of this problem:

This skull base cavity exposed meninges and eventualy provoked Meningitis. Patient was admited in the ICU but unfortunately died. CT scan control at 2 days (not shown) revealed severe Brain Edema and at 4 days revealed areas of Cerebritis.


Hope this case contributed to you as much as it did to me.

Thank you for your participation Dr. Chris Muñoz and Dr. Pedro Juarez.

CASE 39: 18y/o male patient with head trauma

Patient had head trauma 3 weeks ago but was reffered to us with acute altered mental status. He suffered a Grade I head trauma directly in the forehead with no loss of consciousness but with the course of days he proggresively developed neurological symptoms. At admision he had a GCS of 9. Previous CT scans (not shown) only reported mild brain edema due to effaced gyri. He didn't had history of drug abuse or any disease, only chronic sinusitis.

With a diagnosis in mind, we conduced a CT scan of the base of the skull. (Only relevant images are shown)

Findings?..later the conclusion.

BOOK RECOMENDATION

The AJNR's blog recently published a book review that I will like to spread the news of it.

Even though I haven't read it, I still would highly recommended because of its meaningful clinical issues that us future interventional radiologists will have to manage on a regular basis.

Hope to get it soon.

http://www.ajnrblog.org/2013/10/02/patient-care-vascular-interventional-radiology/


Greetings!

CASE 38: 52 y/o female patient with neck pain

This case was provided by Tecniscan Diagnostic Center. Let me warn you that we have no final diagnosis but the differentials are very useful to decide an invasive or conservatory approach. Patient referred chronic progressive neck pain associated with headache. She was treated with pain killers with little or no effect whatsoever. She had no other symptoms, no previous history of trauma, infection, medication or disease. Brain CT scan (not shown) was normal so the next step was the evaluation of a cervical MR. Here are the images:

 

With these findings, we conducted a CT, here are the images:

 

 

 

 

 

 Findings?...differentials?...later on the conclusion.

DX: Fetus-in-fetu

This is a rare case and one of the most bizarre I've seen. Findings in CT scan revealed a pelvic heterogeneous mass with free, soft borders, with fat and bone content that creates mass effect. It has a rudimentary spine and femur. Here are images from MIP and VR.

Fetus in fetu (or foetus in foetu) is a developmental abnormality in which a mass of tissue resembling a fetus forms inside the body. There are two theories of origin concerning "fetus in fetu". One theory is that the mass begins as a normal fetus but becomes enveloped inside its twin. The other theory is that the mass is a highly developed teratoma. "Fetus in fetu" is estimated to occur in 1 in 500,000 live births.

If patient were a female, the possibility of a Teratoma is more likely to consider.

Few reports describe antenatal diagnosis of Fetus-in-fetu (FIF). Preoperative diagnosis can be made on plain radiographs and CT scan/MRI. The presence of vertebrae, long bones, bones of hands and feet etc are the common radiological findings. Visualization of a non-homogenous mass with bones especially vertebrae is considered pathognomonic of FIF. Failure to visualize vertebrae however does not rule out possibility of FIF.

Most of the reported cases describe FIF suspended with an umbilical cord like stalk in an amnion like membrane containing fluid- equivalent to amniotic cavity. In few cases, the exact blood supply could be identified; in most of cases the blood supply was thought to come from the abdominal wall where amnion like membrane was in close approximation to it. The FIF are usually anencephalic, with the vertebrae and limb-buds (long bones and bones of hands/feet can also present), and acardiac (rarely heart was found). In few cases vertebral column was not found however presence of mature enteric nervous plexi and melanocytes in the skin depicted the fetus would have passed the primitive streak stage of notochord development.


Sorry for the delay in the conslusion. Thank you Dr. Imran Jindani, Sarath Chand Velamala, Sreedhar Settipalli and Amutha Csp for your comments on FB page.




http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3418045/pdf/ajcr-3-9.pdf

CASE 37: 16 m/o male patient with a palpable mass

Here is a case in which Radiology plays an important role in management. This case was provided by Tecniscan Diagnostic Center.

This was a 16 month male patient with intermitent constipation with a palpable pelvic mass that initially was thought to be a dilated sigmoid but later pediatrician noticed that the mass had smooth edges and had a circular configuration. An ultrasound was made (not shown) that reported distended bowel loops hence difficulted the correct visualization, although a pelvic heterogeneous mass was seen mostly echoic with acoustic shadowing but barely depicted. Padiatrician recommended a CT scan, here are the images:

Findings and differentials??...later on I'll post the conclusion of this case.

DX: Cystic brain metastases from lung cancer

Cystic lesions in brain have a broad spectrum. In order of frecuency, NCC is a parasitic infection common in  this lattitude so, we recommended pharmacological treatment and a new MR control when over. Patient did not resolve symptoms and control (not shown) was without change.  In efforts to a definitive diagnosis, we called the neurologist to review patient history. We found that this patient was treated years ago from lung small cell carcinoma!. He underwent chemotherapy and was in remission. He was complaining from cough and chest pain since neurological symptoms. Surprisingly, he skipped the yearly CT control in the past year. We asked for a thorax CT control. 

Here is the control wich clearly shows a left perihiliar lung mass with inflitration to thoracic wall:

With this in mind the possibility of a metastases was clear, even though cystic metastases are uncommon. Brain glioma and abscess were good differentials as well although DWI was completely normal, so abscess can be almost ruled out. We recommended a Magnetic Resonance Spectroscopy (in other institution), shown above:

Single-Voxel MRS showed increased lactate peak and reduction in NAA/Cr and Cho/Cr. Elevation in lactate are found in high-grade gliomas and metastases. Due to medical background metastases was  considered. Almost all high grade gliomas are found with elevation in NAA or Cho metabolites. In summary, although MRS can give information of the celularity of the tumor and in consecuence narrow the differentials, clinical data are mandatory in confirming the diagnosis. Patient is programmed to have a biopsy but oncologic therapy was initiated.

Detection of an intracranial mass on imaging in patients with a known primary raises the possibility of metastasis. Often the diagnosis of an intracranial metastasis is made radiologically without histological confirmation. However, radiological evaluation has its own limitation. Though the MRI has increased the specificity of diagnosis, routine MRI sequences may still not be able to differentiate between different intracranial lesions. The classical appearance of a metastasis is a solid enhancing mass with well-defined margins and extensive edema. Occasionally, central necrosis produces a ring enhancing mass. Such a lesion is difficult to differentiate from an abscess. Recently, diffusion and spectroscopy sequences have proven useful to differentiate between the two entities.

Brain metastases occur in 25%-35% of all cancer patients. The majority of brain metastases are solid tumors; cystic brain metastases are unusual. Several reports of cystic brain metastases associated with non-small cell lung carcinoma have been described, but small cell lung carcinoma presenting with cystic brain metastases is previously recognized in only one study.

This was a difficult case and I appreciate your comments. As some might have seen I'm no expert in MRS yet  :) . All comments are welcome. 

Here are some useful links, 

http://journals.lww.com/clinpulm/Abstract/2005/11000/Cystic_and_Solid_Brain_Metastases_in_a_Patient.11.aspx

http://www.bioline.org.br/request?cr10086

http://www.ajnr.org/content/32/9/1646.full.pdf+html

http://radiology.rsna.org/content/222/3/715.full.pdf+html

http://www.medscape.com/viewarticle/582031_6

http://www.cancerjournal.net/article.asp?issn=0973-1482;year=2010;volume=6;issue=3;spage=356;epage=358;aulast=Shetty

CASE 36: Mid 50's patient with aphasia

This case had a great interdisciplinary approach result from a good communication with the Neurology Department and other Departments also.

Patient reffered problems with understanding the meaning of words associated with progressive headache that started 2 months ago. He did not suffered from any other neurological symptoms. He was directly reffered to us to undergo an MR with suspicion of a mass or a stroke onset.

Here are the relevant images:

FLAIR

 T1

POST GAD

T2

With this medical history given, make some differential diagnosis. Later on, I'll post further information and conclusion.