interesting cases

Interesting CasesInteresting Cases

Dr. WALEED AL HAJJIDr. WALEED AL HAJJI

HistoryHistory

Thirty years old male patient who is experiencing left extensive femoro-popliteal DVT.

HospitalizedOne day later he developed chest pain and

shortness of breathChest X-ray was obtained

CT angiography of the pulmonary arteries was done

Case was diagnosed as pulmonary embolism; IVC filter was inserted to guard against further PE

The patient survived that attack of PE, with follow up CT angiography of the pulmonary artery revealing complete resolution of the embolization of the right pulmonary artery.

Two days later, the patient experienced similar attack of chest pain, that found to be due to another attack of PE.

That was inspite of the IVC filter inserted in place!!!

CT of the chest and abdomen was performed

A

B

Diagnosis Diagnosis

Double IVCDouble IVC

Duplication of the IVC results from persistence of both supracardinal

veins. The prevalence is 0.2%–3%

A double IVC can be associated with A double IVC can be associated with other conditions, such as a horseshoe other conditions, such as a horseshoe kidney, a circumaortic renal vein, a kidney, a circumaortic renal vein, a retroaortic left renal vein, and a retroaortic left renal vein, and a retroaortic right renal vein with retroaortic right renal vein with hemiazygos continuation of the IVChemiazygos continuation of the IVC

Case 2Case 2

Diagnosis

Fenestration of the septum pellucidum.

This is one of the findings in chronic obstructive hydrocephalus. Also known as non-communicating hydrocephalus is simply hydrocephalus due to obstruction of CSF flow out of the ventricles. Frequent causes of obstructive hydrocephalus include:-aqueduct stenosis -meningitis

Features of long standing obstructive hydrocephalus are:

-Marked dilatation of the lateral and third ventricles.

-Thinned and elevated corpus callosum.

-Depression of the fornices.

-Rounding of the infundibular, optic and pineal recesses.

-Ballooning of the suprapineal recess.

-Fenestration of the septum pellucidum.

Case 3Case 3

This is an incidental finding during an angiography procedure

Case 4Case 4

History:  Upper chest discomfort.

Diagnosis: 

 Carcinoma of the gastric fundus (pseudoachalasia presentation) with direct invasion of the GEJ.

Differential Diagnosis for Pseudoachalasia:

Carcinoma of the gastric cardia or fundus with direct invasion of the GEJ or distal esophagus.

Hematogenous metastases from breast, lung, or pancreatic cancer.

Lymphoma.

Chagas.

Malignancy-induced secondary achalasia is an uncommon condition, accounting for only 2 to 4% of patient with findings of achalasia at manometry. 

Most patients with primary achalasia are between 20 and 50 years of age and have symptoms of dysphagia for an average of 4 to 6 years. Whereas, most patients with secondary achalasia are older than 50 years and have symptoms, on average, less than 6 months.

Case 5Case 5

28 years old male patientAdmitted to the casualty with a stab

injury to the left popliteal fossaNo much bleeding was noted on

admission!!

Traumatic (stab) pseudoaneurysm Pop. A

Case 6Case 6

A 76-year-old woman presented with:– Vague abdominal pain (persistent for over

two years)– Recent (over the previous three months),

unwanted 8 kg weight loss

Differential Diagnosis Differential Diagnosis

Gallbladder carcinomaAdenomyomatosisChronic inflammationMetastastic disease (metastatic

melanoma)And less likely, multiple polyps

Diagnosis Diagnosis

Adenocarcinoma of the gallbladder

DiscussionDiscussion

Pathology DiscussionPathology Discussion

CholecystectomyCholecystectomyDDiffuse iffuse

thickening of the thickening of the wall but no wall but no obvious focal obvious focal lesionlesion.

Diffuse papillary projections of epithelium

Diffuse, adenomatous epithelial change

In some areas, dysplastic changes consistent with adenocarcinoma in situ

The tumor focally invades into muscularis propria only superficially

Radiology Discussion:Radiology Discussion: GB carcinoma, a highly lethal condition Sixth most common gastrointestinal

malignancy (after colon, pancreas, stomach, liver, and esophagus)

Because symptoms are often vague, this carcinoma is frequently detected late; in fact, detection is typically related to invasion of adjacent organs

Risk factorsRisk factors

Post-menopausal statusCigarette smokingGallstones (seen in 85% of cases of

gallbladder carcinoma)

The presence of a choledochal cystcholedochal cyst, anomalous junction of the anomalous junction of the pancreaticobiliary ductspancreaticobiliary ducts, and low low insertion of the cystic ductinsertion of the cystic duct are also associated with higher incidence. It is thought, in these cases, that gallbladder carcinoma may develop in response to chronic biliary reflux of pancreatic chronic biliary reflux of pancreatic secretionssecretions

Imaging appearancesImaging appearances MMass replacing the gallbladderass replacing the gallbladder (55%) most

common (DD hepatocellular carcinoma, cholangiocarcinoma, and metastatic disease of the gallbladder fossa)

FFocal or diffuse wall thickeningocal or diffuse wall thickening (25%) (DD congestive heart disease, hypoalbuminemia, cirrhosis, hepatitis, cholecystitis, and adenomyomatosis)

PPolypoid massolypoid mass (DD polyps (adenomatous, hyperplastic, or cholesterol), carcinoid tumor, melanoma metastasis, and hematoma)

References References

Levy AD, Murakata LA, Rohrmann CA. AFIP Archives. Gallbladder Carcinoma: Radiologic-Pathologic Correlation. Radiographics 2001; 21: 295-314.

Bang Huu Huynh, MD - Case Coordinator Amy Ho Huang, MD - Radiology Discussion Jian Shen, MD, PhD - Pathology Discussion Steven E Seltzer, MD - Attending Radiologist

May 12, 2003

Thank YouThank You