Hi, everyone. My name is Sophie Washer. I'm a Musculoskeletal Radiology Fellow at NYU. It is my pleasure to introduce our first speaker, Dr. Nix Kumaravel, who is the Musculoskeletal Deputy Editor and Assistant Professor of Radiology and Orthopedics at UT Houston. He's going to show us some great MSK cases. Thank you very much, Sophie. Thanks again. Welcome to the case collection to everybody. We're going to start off with a couple of cases on the musculoskeletal side. The intention is to get you to think about these cases as we go through. Imagine that you're going through this case in your reporting file, what would be interesting to you, and how do we go about this? Let's go to the next slide. Here's the first case. Here's a patient presenting with left anterior lateral ankle pain after an aversion injury. Think about what could be the possibility, what are the diagnostic choices that could happen in this case, and that's basically what you're showing you here. Then go to the next slide again. Here are some more projections, a slightly more ankle mortis view and a lateral view of the ankle as well. Give you a few seconds to think about what could be a patient presenting with an ankle pain, and more of an aversion mechanism in this case, and what are the possibility? You can go to the next image again, please. Here are some axial images from selected MRI slices across here. You've got a T2 image and another non-fat saturated T2 image. My suggestion to you would be to think about what level do you think these images are taken at, one is at the tibial level, the other one further down a little bit further down at the tail or margin as such, and think about what could be the cause why this patient's having pain. Let's go to the next image again. And again, a couple more images again, just this time again, highlighting at the level where you think would be the reason for the pathology. Please do pay some attention to its ligamentous components often and think about what could be the cause for this patient's pain. Again, T2 with a non-fat saturated images is what we got here. Next one again, please. And here is the more fat saturated image drawing your attention to what could be the potential reason why this patient's got pain. And then the next image, please. And so what is the potential diagnosis for this particular patient? Do you think it's an occult fracture? Do you think it's a syndesmotic ligament injury? Do you think it's a low ankle sprain or a soft tissue contusion? Let's trigger the pause, go to the next slide, please. And again, I hope you have your little devices to go along with it. And we have these pollev.com forward slash RCC. And then if you go back to the last slide for a second so that we can get a choice of what are we looking at? We do have some radiographs across here and then we do have some MRI axial images highlighting the pathology. All right, go to the next. And let's see what we have as choices now. A bit of smattering around there. Most people going in for syndesmotic ligament injury and some thinking about maybe it could be low ankle sprain that we're dealing with. And a small number thinking about occult fractures. We'll give it another couple of seconds for you to think about what are the potential. And again, there are no wrong answers. This is muscular skeletal imaging, it's easy and fun. All right, a little bit of toss up there between occult and low ankle sprain. All right, thanks for playing and let's go to the next image again. And so this is definitely a syndesmotic ligament injury. Kudos to everybody, you got it right. Majority of the people got it right over there. So what are we looking for? Just to again, go to the next slide again, please. And the components we're looking for is obviously marrying up the clinical findings first. You really wanna think about where the pain's coming from, taking as much of the information as available to you. And if you're in my kind of practice, all you get is pain, but in this case, we give you more information than that. The images that are most pertinent are at the distal tibial fibula level. You can see T2 bright signal highlighted by the arrows. It tells you that that's where the action is happening. You have a disruption of the anterior inferior tibial fibula ligament. And obviously with the squeeze state, it also tells you it's gonna be painful. A widened tibial fibular space is also another component that you can actually look at this. MRI demonstrates there's also a full thickness tear of these ligaments across there. And the tear is extending partially through the interosseous membrane region and almost all the way down to the posterior inferior tibial fibular ligament. So this is something that would need a surgical fixation. Thank you for playing with that case. Go to the next one, please. Yes, case two. And here's the first image again, 58-year-old male patient. We got a history of chronic arthritic pain, but unfortunately had a recent fall. And you were thinking about the patient present to the ED and you're wondering what could be the cause for this patient's pain? Is this something that has actually changed in presentation? A couple of axial images. One is a bone window. Another one is a soft tissue window. Just to give you an orientation, we are all the way at the C1, C2 level. Next image, please. Here's a surgical projection demonstrating the inbony windows. Give you a few seconds to look at. And the next slide, please. We got a soft tissue window and a kernel multiplanar reformatted image as well, just to highlight the features that could be potentially causing pain in this patient. The next one again, please. And we also found that the patient had other things going on. And here is in the patient jacket, we find there's a couple of x-rays on the hand that's coming through. And here's a focused view on the right side and a larger view of the hand on the left side of the image. And pay attention to what you think could be the soft tissue and the bony changes that's going on there. And the next image, please. So what could be the diagnosis? And if you want to trigger the poll, go to the next slide and we'll come back to this again. Come back again. So what could be the potential diagnosis? Do you think you're dealing with amyloid arthropathy? Is it just spondyloregular degenerative joint disease? Is that what you're gonna go say on your report? Or would you say this is cervical spine gout? Or do you think this could be rheumatoid arthritis? Again, we've got a smattering of all the images out here, although a little bit smaller size, but now think about what you can correlate between the radiographic features of the hand and also what is available in the cervical spine as such. All right, let's go to the next slide and see what the results are. So we got a pretty dominant number of people still well getting close by, 50% so far think it's cervical spine gout. There's some thinking maybe this is rheumatoid arthritis. No one's gone for the question about degenerative joint disease, which is great because there's a little bit more than that, correct? And so what else could be the choice now? So make up your mind if you want to change your results, go for it. We'll give you another few more seconds. Sorry, I don't have music playing in the background. Maybe we need to work on that. All right, another couple of seconds. Anybody wants to change your mind or add any more information? All right, okay. So dominant number of people going 58% of you going for cervical spine gout. Let's go to the next slide, 60% now. All right, the answer is absolutely correct. It is a cervical spine gout. And when you look at these different features, go to the next slide, please. So what are you trying to do is to understand that we certainly showed you some marginal erosions in the hand that gives away a big portion of the diagnosis is juxtarticular, you know, erosions along with TOFI. Now, if you come back to the cervical spine itself, you're going to see that the erosive changes, criss-line deposits, and which are most likely TOFI. We did not do any, I mean, like here's, in this particular case, the authors did not show you anything with dual energy scan. And that's another thing we can think about the juxtarticular well-defined erosive changes that's happening along here. And with the hand, it was a good idea to look at the soft tissue changes and also TOFI. So this is a case of cervical spine gout. Thank you very much for listening to these cases and looking at these cases. I hope it fets your appetite and think about dwelling a little bit more in the RCC. And thank you again for being an audience here. Next slide, please. Thank you. Thank you so much for those great cases. Our next speaker is Dr. Kush Desai. He'll be showing us some wonderful interventional radiology cases. He is a professor at Northwestern University Medical Center. Thanks. Okay, we'll go to the next slide. Keep moving. Here's the first case. This is a 64-year-old male with history of epiglottic carcinoma two years prior. Presents with a new right lower lobe pulmonary nodule. CT guided biopsies requested to evaluate metastatic disease of primary lung cancer. And with these kinds of things with IR, we're thinking about how we want to position the patient, potential things we need to talk to the patient about in terms of informed consent. So while we're doing this biopsy with adequate sampling, we noticed that there's a small post-procedural pneumothorax. Certainly nothing surprising there. Probably a little bit of a COPD emphysema here. Patient remains asymptomatic. So we pulled the needle out as the patient's transferred off the table and becomes unresponsive. Rapid response team comes in, diagnoses the patient with an acute stroke and they get a head CT. Let's go to the next slide. And before they get a head CT, we're looking a little bit closer at the CT images of the chest. Take a close look, not just at the lung, but at the heart vascular structures. Can we go to the next slide, please? And this is what the head CT shows. I'm no neuroradiologist, but even I can see this. And let's go to the next slide. So what's the diagnosis? Is this a systemic air embolism? And while we're thinking about the diagnostic possibilities, we need to think about also how we would manage it. Is this a systemic air embolism? Is this thromboembolic phenomena resulting from withholding anticoagulants prior to the biopsy, something we deal with every day? Is this a venous air embolism? And as you guys are making the choices, you have to take a look. You have both the head CT images and you have the chest images, although I believe one of the chest images we need is not quite on this picture, but you did see the head CT image should certainly tell you what's going on. Let's go to the next slide to see what our responses are. And as you're answering, think about how something like this could happen and whether it could go to the right heart or the left heart. Think about the flow of blood that should really inform your choice. Another second or two. And also think about how you want to manage this. Okay, go to the next slide, please. We seem to have guided people in the right direction. So the diagnosis indeed is systemic air embolism. And this, even with the best technique, it can happen. It's a peripheral nodule and it's just reality. You sometimes just don't see the pulmonary vasculature that you introduce a little bit of air during your needle exchanges and that can go into the pulmonary vein. Then, of course, become a systemic air embolism. Let's go to the next slide. So time is of the essence. Administer 100% oxygen. That's sort of the obvious choice, but you need to place these patients in left lateral decubitus to prevent an airlock in the right ventricular outflow tract. If you get an airlock, then you will have complete circulatory collapse. So it's very important to move very quickly here and administer 100% oxygen so that the air dissipates out by re-equilibration of the gases within the patient. Next slide. Moving on to the next case. 43-year-old male, colorectal cancer, metastatic to liver, peritoneum, status post-hypec surgery, which is a hyperthermic intraperitoneal chemotherapy administration, completed, complicated by multiple bowel fistulas, clodocutaneous and clovicicular fistulas, and presents following a syncopal episode with severe abdominal pain, melanotic stool, and has colostomy and hematochezia, which you have are a couple of images right here of a CT angiogram, and you can see contrast that's accumulating in bone windows, or bone or vascular windows in the middle image, and then probably a little bit delayed in the rightmost axial image. We'll go to the next slide. And here's an angiogram, and you can see here that there's some collection of, this is a digital subtraction angiogram, the iliac artery, you can see there's a collection of contrast. We'll go to one more slide. Forward. And you can see on the right is the pre, and the left is the post here, and an intervention took place in the midst of it. And let's go to the next slide. So also, again, thinking about what you would do based on what you think the diagnosis is. Is this a variceal hemorrhage? Is this a diverticular bleed? Is this an iliac enteric fistula? Or is this an angio-dysplasia? And again, think about what this patient had, as well as what the most likely diagnosis is based on what they had. Give me a few seconds. Now, how you would want to manage this, this is very challenging. I actually managed this very case about a few hours ago, slightly different structures, but same idea and same therapeutic consideration. Next slide. Excellent. All right, great. Let's go to the next slide. Indeed, this is an iliac enteric fistula. It's not an angio-dysplasia. This patient's had high-pec surgery. They have risk of multiple fistulas, colobacicular, colocutaneous, colovaginal. I mean, it could be anywhere. And this is an iliac enteric fistula. I actually just managed an iliac ureteral fistula about two hours ago. Next slide. This can be rapidly fatal just because of the laws of physics. You're going from a high pressure to a low pressure system and blood accumulates very fast in the capacious GI tract. Embolization, usually the first step, I believe stent graft is used in the case that's shown here. You do need to be careful with stent grafts because if the stent graft is in close proximity to the fecal stream, say it's a blowout, you run a very high risk of that stent becoming infected, which is a surgical nightmare. It's not outright fatal. So there is a risk of septicemia with that. So there are a couple of ways to manage this, embolization, exclusion with stent graft. It's going to depend on what the lesion is. Hope you found these interesting and we'll go on to the next set of cases. Good afternoon, everyone. I'm Dr. Vicini from Sapienza, University of Rome. I am pleased to introduce Dr. Yiming Gao, Assistant Professor of Radiology at New York University, who is about to present some great breast imaging cases. Please, Dr. Gao. Thank you so much for that introduction. And I just want to say thank you for all these wonderful cases. It's always sobering. Look at other sub-specialties and see how urgent other potential clinical situations can be and our breast cases in general are not as urgent. So I'm very grateful. So let's move on to case number one. So case number one is a 67 year old woman with no significant medical history who presents with a palpable mass in the left breast as indicated by the BB marker in the superior aspect of her left breast. And we're showing here bilateral MLO views of mammography. And we can move on to the next slide. I think this is not quite an eye test. As you can see, there are multiple bilateral findings that are both palpable as well as clinically not palpable. Next slide. So bilateral breast ultrasounds are performed and representative findings are demonstrated here. Next slide. Additional representative findings. I think ultrasound does offer a lot of morphologic details in addition to mammography. As you look at findings in terms of their marginal characteristics and internal echoes and associated vascularity. Next slide, please. So we can trigger the poll and come back to the slide. So what is the diagnosis? Is this metastatic melanoma to the breast? Is that bilateral fibroadenomas? Is this primary breast lymphoma? Or is this bilateral cysts? I think we can see the poll potentially. Very interesting. So just thinking back to the patient, right? She is in her 60s. Her mass was enlarging, if you recall. And looking at the ultrasound does give you some sense of whether those actually resembled more benign appearing masses versus more malignant masses. And I like the trend of the poll. Hopefully my information is helpful. So yes, we can move on. So yeah, so the final diagnosis is metastatic melanoma to the breast. And we can move on to the next slide. So metastatic disease to the breast typically manifest as round circumscribed masses. And they can be unilateral, but they can also be multiple bilateral, in which case it's a rare malignant mimicker of the typically benign multiple bilateral circumscribed masses that we talk about on mammography, typically. Typically cysts or fibroadenomas, but as you can see on ultrasound, these indeed are more irregular appearing masses. And most commonly extramammary primaries that metastasize to the breast include melanomas, secondary lymphomas, as opposed to primary lymphomas, which typically is unifocal, lung, ovarian, sarcoma. And interestingly in men, the most common primary to go to the breast is prostate cancer. And in this particular patient, usually we would already have a known history of other primary, but in this case, metastatic disease was biopsied in order to clinch the primary diagnosis. So that's this case. We can go ahead and move on to the next case. So case number two is a 30-year-old woman who presents with bilateral, slow-growing palpable masses in her subareola regions and pertinent negatives. She has no history of trauma. She has no indication of infection. And here you're seeing mammography and MLO and CC views. And you can go ahead to the next slide. So targeted ultrasound is performed in the regions of concern as per clinical standards. And you can see bilaterally, we are showing sonographic findings that appear somewhat similar. And this corresponds exactly to what she is feeling in her breast. And we can go on to the next slide and trigger the poll. Thank you. So what is the diagnosis? Number one is invasive cancer. Number two is diabetic mastopathy. Number three is breast abscess, remembering the pertinent negatives. And finally, fat necrosis, again, pertinent negatives. And we can move on. Excellent. So again, thinking invasive cancer is probably the most common thing we think about, but this individual is very young. This is bilateral symmetric findings. She's never had trauma, no infection. So I think most people are really on the right track. So let's move on to the final diagnosis. So yes, this is a case of diabetic mastopathy. And next slide. So diabetic mastopathy is also known as inflammatory lymphocytic mastitis characterized by lymphocytic infiltrates in periductal, perilobular, and perivascular distribution. And because of a mass-like fibrotic proliferation in the breast on ultrasound, you typically would see shadowing masses. And this could be mammographically occult. And again, this is another entity that could be unilateral but can be bilateral and can also be seen in many other inflammatory arthropathies, including systemic lupus erythematosus. And that concludes the breast cases. I hope you enjoyed it. Moving on. Thank you very much, Dr. Gao. Our next speaker is Dr. Christopher Walker, professor of radiology at the University of Kansas, who will be presenting some interesting chest radiology cases. Please, Dr. Walker. Thank you for that introduction. Let's go to the first case. So this is case one. This is a 41-year-old man who presents with chest pain and palpitations. So we have three images from a cardiac CTA, the level of the pulmonary trunk, and a little bit lower going down to the aortic root. Next slide. So what is the most likely diagnosis? We can trigger the poll. Is this an anomalous origin of the left coronary artery from the pulmonary artery, also known as alkappa, the coronary artery fistula, vasculitis, or a case of Kawasaki disease. I'll give you guys a few seconds to kind of think about that and look at the images. Let's go to the poll. So most people are between L-kappa and a coronary artery fistula. And let's go to the next slide. So this is a case of L-kappa, or anomalous origin of the left coronary artery from the pulmonary artery. And let's go to the next slide. And this is really important to differentiate this disease from a coronary fistula to the pulmonary artery. So with L-kappa, the most important distinction is gonna have the fact that you do not have a normal left coronary artery arising from the left sinus of the valsalva. And so in this case, you can see the left coronary artery arises from the left aspect of the pulmonary trunk, and you're gonna get retrograde flow. This disease is also known as bland white garland syndrome. And most of the time, it's gonna manifest in infancy, unless people have enough collaterals forming between the right and left coronary arteries, at which point you may actually see these people first presenting in adulthood. Let's go to case number two. So this is a 93-year-old woman who presents with worsening dyspnea. We have two images, an axial contrast enhanced chest CT and a coronal contrast enhanced chest CT, kind of centered at the level of the heart. Next slide. So what is the diagnosis? Is this a sinus of valsalva aneurysm, a membranous ventricular septal aneurysm, a muscular intraventricular septal aneurysm, or a mitral aortic intravalvular fibrosis pseudoaneurysm? And so take a close look at the three different images. This is something unusual, probably see it maybe once every couple of years. And so if it's the first time you see it, you probably aren't sure what this is, but let's go to the next slide. So it looks like we're between a membranous ventricular septal aneurysm and a mitral aortic intravalvular fibrosis pseudoaneurysm. Let's go to the next slide. And so this is a case of a membranous ventricular septal aneurysm. So if you remember the anatomy of the intraventricular septum, the membranous portion is the thin portion that's closest to the valve, and the muscular portion is the thin portion and the muscular portion is where the muscle is kind of more distally towards the apex. Let's go to the next slide. And so in this case, you can see this aneurysm bulging in the region of the membranous intraventricular septum. And these are usually incidental findings. Most of the time, the patients are asymptomatic. About 20% of patients will have a VSD that's associated with this condition. And if these become very, very large, they can actually result in right ventricular obstruction or an arrhythmia. But usually you're just gonna find these incidentally on scans performed for another reason. Thank you. Hi, everyone. My name is Richa Patel. I'm a body imaging fellow at Stanford University. And I have the great pleasure of introducing Dr. Douglas Katz. He's vice chair of research and professor of radiology at NYU. And he's gonna be presenting some interesting gastrointestinal cases for us. Hi, thanks, Richa. I actually did my fellowship at Stanford a long time ago. So it's great to be introduced by you. I don't have a camera. I'm actually at work doing a late shift. So I can have the next slide, please. And before I forget, let me thank Mary Moshiri for all her work over the years on the case collection and Valerie, and then more recently, Drew. It's been a pleasure to be part of the team. So our first case is a 52-year-old woman who presented with occasional epigastric pain. And we have two ultrasound images. You can see there is some flow, at least the periphery of this on the Doppler image. And then the next slide, please, shows CT. And non-contrast on the left, we see a pyramidosteatosis of the liver. We have a ovoid mass that's abutting. But as you can note, there's mass effect on the left adrenal. So this is not of adrenal origin, but it's sort of paradrenal. And it's quite vascular on the subsequent IV contrast enhanced image. Next slide, please. And then the coronal and sagittal representative images showing a little bit of heterogeneity, a little bit of lobulation of this ovoid interesting mass. Next slide, please. And so is this unicentric retroperitoneal Castleman's disease that's been also referred to as angiofollicular lymph node hyperplasia? Is this retroperitoneal lymphoma? Is this a retroperitoneal liposarcoma or a retroperitoneal schwannoma? And we see the representative images here. So we can go to the Poll Everywhere slide. Give people a minute to go ahead and vote. And we did not get copyright approval for the Jeopardy music. Sorry about that, as Nix alluded to. We're seeing a preference for Castleman's disease here with a substantial minority thinking this could be a retroperitoneal schwannoma, which is certainly a reasonable thought. Nobody going for lymphoma or liposarcoma. All right, so let's go ahead to the next slide with the diagnosis. And this is, in fact, biopsy-proven unicentric retroperitoneal Castleman's disease. We can go to the Brief Discussion slide, or there's the image slide with the diagnosis, and the next slide. So this can be incidental, occasionally symptomatic, and Castleman's disease is a very, very interesting condition. The vast majority of this is benign. A small subset, at least based on the older literature, can be more aggressive. And it can occur in a variety of locations in the body. So at least in the retroperitoneum, the differential considerations for a vascular focal mass can include a neuroendocrine tumor, paraganglioma, a vascular metastasis in the right clinical setting, neural tumors, and sarcomas, amongst other possibilities. Lymphoma, nobody liked that, and I agree, it's not usually this vascular. Okay, let's go on to case number two. This is really a crazy, crazy case. I had never seen this before in my career, sort of blown away when this came through a few months ago. This is a 72-year-old. Now, you know, sometimes history is not particularly specific. And this is a flavor, a variant of something we see every once in a while, fairly rare. This is really an unbelievable case, but you can actually kind of make the diagnosis, believe it or not, from the history, forgetting the imaging. 72-year-old man presented with four days of increasingly severe left lower quadrant pain rating to the inguinal region in the lower back. Associated symptoms including nausea, vomiting, decreased appetite without bowel movements for three days, and substantial scrotal enlargement for one day. Importantly, he had had intermittent right upper quadrant pain for many years, and a minor swelling with a lump in his left inguinal region for over 10 years. So you put that all together, look at these representative images through the upper and mid abdomen on this IV-enhanced CT. There are several findings. And if we can go now to the next image, which shows the lower abdomen and pelvis. Ignore his spondylolisis, by the way. And you can see some interesting things here as well. Now if we can go on, I think there's one more set of images. Yeah, one image with a coronal image showing the anatomy. Okay, and let's go on to the differential diagnosis slide. So is this perforated diverticulitis? Is this gallstone ileus? Or is this something the authors have labeled as perforated gallstone coleus? Now, I thought coleus was a plant, and I thought this was a mistake. But they said, no, we wanna include in the differential something they're calling gallstone coleus. So let's go on to the Poll Everywhere slide. Okay. So again, we want the most specific answer here. Wait another minute. Okay. All right, let's go on to the answer slide. Next slide, please. And in fact, this is something, again, the authors are coining this term for the first time ever to my knowledge. Perforated gallstone coleus. Let's go on to the discussion slide, or there's the diagnosis. So this unique contribution from Dr. Mindy Haro at Einstein in Philadelphia and our colleagues to my knowledge has never been reported before up until this case. So there are a variety of pathologic points at which a gallstone or enterolith, if it's an enterolith ileus, can lodge, which when freed into the bowel, such as a tumor restrictor, can then present with gallstone ileus. In this case, it's a colon as the site of obstruction of the sclera hernia. And this is, again, a variant of this, but it makes perfect sense. And in fact, you can actually figure it out from the history, and then the images just prove it. So this is what makes this specialty of ours so special. Even for someone experienced at this point, like myself, makes this so incredible a field, and I hope you feel this way as well. So again, it's been a great honor to be involved in this project for several years. Thanks to everybody. Hope you're enjoying this presentation. Let's go on to our next presenter. Thank you so much, Dr. Katz. Our next presenter is Dr. Kianush Hossainzadeh. He's Chair of Education at the VA in Durham, North Carolina, and the Deputy Editor for our GU section in our CNA Case Collection. He'll be showing some interesting GU cases. Thank you, Risha, for the introduction. Let's move on to the first case. So the history here is preoperative assessment prior to liver transplantation. We have a grayscale image of the right kidney and the corresponding color Doppler image. Spend a few seconds here. And then based on this ultrasound, decision was made to order a renal mass protocol CT. So let's move on to the next slide. So here we have a series of axial images at the same level, different time periods. The first, the top one is corticomodulary. The middle one is the middle in between corticomodulary and nephrographic. And then the last one at the bottom is the nephrographic slash excretory phase. And then we have an NPR image, coronal NPR image on the right. So let's spend a few seconds here. Let's move on to the next slide. So what is the diagnosis? Solid renal tumor, dromedary hump, hypertrophy column of birtan, or focal area renal cortical hypertrophy next to a scar. So look at these images, start with the ultrasound and then move on to the CT. Okay, let's move on to the poll. Let's trigger the poll. All right. Looks like the majority have gone and voted for hypertrophy column of birtan. 6% feel that it could be a solid renal mass. Certainly could be on the ultrasound. All right, let's go on to the next slide. Yes, the majority is correct. This is hypertrophy column of birtan. So let's move on to the next slide. So what is hypertrophy column of birtan? So hypertrophy column of birtan was first described by a French anatomist, Monsieur Birtan, otherwise known as a junctional parenchyma. It's a renal pseudo lesion. So it's not a true tumor or neoplasm. It's mass-like. What is the column of birtan? So a typical adult kidney is formed by the fusion of around 14 sub-kidneys. And the sub-kidneys, when they fuse, they usually fuse on an end-to-end fashion. And the intervening parenchyma, which is called polar parenchyma, that resolves. Now, if that fusion doesn't occur in an end-to-end fashion, that intervening polar parenchyma remains, okay? And that then forms a hypertrophy column of birtan or a junctional parenchyma. So it's a variant of normal. It's not true hypertrophy. So that's a misnomer. It's just a variant of normal. But this term is being used to describe this anatomical variant. So what do we see on imaging? On ultrasound, these masses are typically hypoechoic. And why is that? Because of the anisotropic effects of the beam on the tissue interaction itself. It can be isochoic as well, but typically hypoechoic. So you're forced to order a CT or an MR to clarify this. And what do we see on CT in this case? And depending on the plane, you might see, you will see this best in one plane or another. You'll see extension of cortical tissue into the renal sinus. And it should contain the pyramids as well. Now, this can involve either kidney equally. And it's important not to confuse this with a rheumatoid hump, which is a prominent focal bulge, supralateral border of the left kidney. And it's caused by splenic compression, chronic splenic compression. So this is hypertrophy column of glotam. Let's move on to the next case. Case two, 53-year-old woman presented with abdominal pain and glotam. We have an axial image. Let's have a look. Let's move on to the next slide. So here we have a coronal NPR on the left, and we have a single shot Fascineco slash haste image or T2 weighted acquisition on the right. Ignore the right renal lesion. This was just a hemorrhagic cyst. All right, so what's the diagnosis? So the diagnosis, possible considerations ectopic adrenal tissue, horseshoe adrenal gland, discoid adrenal gland, and polysplenia. Have a look again at these images. Let's go to the poll. Okay. Looks like the overwhelming majority looks like the overwhelming majority is selecting horseshoe adrenal gland. And the answer is, next slide. Yes, horseshoe adrenal gland. So what is a horseshoe adrenal gland? Let's move to the next slide. So a horseshoe adrenal gland is also known as a butterfly adrenal gland, depending on which plane you're looking at the adrenal gland. So this is a midline fusion of normally paired adrenal glands. They typically occur anterior to the abdominal aorta. It's important not to confuse this with a discoid or a pancake adrenal gland that you usually see in association with renal agenesis. It's extremely rare, congenital anomaly, and it's usually discovered incidentally, but is associated with vascular, vertebral, and solid organ anomalies. So here I've shown you two anatomical variants. So there's no true pathology here, but there are also important diagnostic considerations to make when reviewing GEU anatomy or pathology. Okay, thank you very much for your attention, and let's move on to the next speaker. Thank you so much, Dr. Jose-Andrade, that was great. Our next speaker is Dr. Cynthia Wu, who's Associate Professor of Neuroradiology at UCSF, and she'll be introducing, or reviewing some interesting neuroradiology cases. Thanks, Dr. Wu. Thank you so much, and thanks again for attending our session, and let's move on to some neuro cases. So this is our first case. Here's a two-year-old pediatric patient who presented with three weeks of neck swelling. You can see here we have a sagittal midline MRI image in T2 weighted image, as well as an axial T1 fat suppressed post-contrast image through the level of the floor of mouth. And you can see the pertinent finding here. Let's go on to the next slide. Here we have, again, axial images through the floor of mouth. The first one on the left is T1 pre-contrast, and the one on the right is T2 with fat suppression. And next slide, please. Here we have diffusion-weighted image and ADC map correspondingly, again, in that floor of mouth level. Let's go on to the next slide. So our choices are thyroglossoduct cyst, lipoma, lymphatic malformation, and sublingual dermoid cyst. Which one do we think this is? Let's go on to the poll. All right, we're getting some answers already. Great, and give it another second here. We're seeing a little bit of extra answers. The vast majority of folks seem to go for a sublingual dermoid cyst. And, oh, and we have someone chatting in as well. All right, well, let's go on to the next slide. And indeed, the answer here is a sublingual dermoid cyst. Next slide, please. And what we see here is the sublingual dermoid cyst, like dermoid cyst anywhere else, arises from a ectodermal rest that is in essentially the wrong place. And being a dermoid cyst, it contains structures from all layers of the dermis, and it usually has some lipid or fatty components that comes from the sebum that you have in your dermis normally. So this is not true adipose tissue, this is sebum coming from those sweat glands that are in the dermis. And in the floor of mouth, what we generally see are these classic sack of marbles appearance that you can see highlighted here with these yellow arrows. And traditionally, this was actually described by an ultrasound. And what it is, is all those pieces of essentially lipid intermixed with liquids and creating that heterogeneous appearance. All right, great. Let's go on to the next case. So case two is a little different. This is an older patient, 68-year-old woman with a history of rheumatoid arthritis, hypertension, osteoporosis, and comes in with recurrent bilateral parotid enlargement over years, and it started eight years ago. So she also complains of some joint pain and swelling and morning stiffness with bilateral autalgia and hearing loss. And here we have an axial contrast enhanced CT image at the level of the parotid glands, and you can take a look at them. Let's go on to the next set of images. Here are some ultrasound images of both of the parotids, well, representative images in longitudinal and axial. You can see some cystic changes. Next slide, please. Here we have MR images in coronal plane, the first one being T1 weighted without contrast. The second one is T2 with fat suppression, and the third one is T1 post-contrast with fat suppression as well. All right, let's go on to the next slide. So what is the diagnosis? Is this cystic lymphadenopathy? Is this Sjogren's syndrome, Wharton's tumor, or is it benign lymphoepithelial cysts of HIV? Let's go to the poll. All right, 100%, things are changing. We're getting some other votes, excellent. All right, we're seeing things go back and forth a little bit, go back and forth a little bit. Okay, all right, let's go on to the next slide. And the vast majority, again, wins, excellent job. This is Sjogren's syndrome. Next slide, please. So Sjogren's syndrome is also known as sicka syndrome, and it's characterized by dry eye and dry mouth symptoms, and it's because of this chronic autoimmune inflammatory process that generally attacks the lacrimal glands and the salivary glands. Sjogren's syndrome may also present with arthritis, pneumonitis, vasculitis, as well as nephritis. You notice the itis in all these names, right, because it's a systemic inflammatory disorder. In the parotid glands, early on, you will see symmetric bilateral parotid enlargement and enhancement that's compatible with early inflammatory changes, but in the later phase, this is what you see. It becomes this multi-cystic appearance with punctate calcifications, and this can actually overlap in imaging features with benign lymphoepithelial cystic changes in HIV, but this is where that history and other symptoms of the patient really comes in to help you make the diagnosis. Thank you so much. All right. All right. Thank you, Dr. Wu. Can we have the next slide, please? Okay. So, hi, everyone. My name is... Dr. Syed, hello, Jamie. I hope I pronounced it correctly. He's an associate professor of radiology and nuclear medicine at the Medical University of South Carolina, and he will be taking us through a couple of interesting cases in nuclear medicine. Thank you, Dr. Syed. Thank you for this introduction. So, let's go ahead and do the nukes cases. So, case number one, this is a 35-year-a-day-old female infant presenting with dark urine, pale stools, and jaundice. Here we have dynamic 60-minute HIDA images, next, along with 4 and 24-hours-delayed static images, next. So, what is the likely diagnosis? Is it biliria atresia, colloidal cysts, or neonatal hepatitis? You can start, Paul. Okay, looks majority had biliary atresia and some of you have neonatal hepatitis. So let's go to the next slide. So the correct answer is biliary atresia. So what we see in this case is delayed clearance of hepatic activity, which is marked with a black arrow with absence of bowel visualization at 24 hours, which would be most concerning in the setting for biliary atresia. Note that in cases of hepatic dysfunction, you might see renal and urinary bladder excretion, which should not be confused with bowel activity. For example, you can see in this case, which some of you may have thought it's bowel, some urinary bladder activity, which we are marking with the blue circle. Next. So in patients with neonatal jaundice, HIDA is going to be super helpful to stratify which patients would need biopsy and which would not. If you see radiotracer excretion into the bowel, as we are showing you here in this companion case, then this essentially would exclude biliary atresia and would favor hepatitis. But if you don't see bowel excretion, then this would be most concerning for biliary atresia, but it's not 100% specific. So other less common condition may cause this, including severe hepatitis, they may have this appearance on HIDA. So biopsy is needed to confirm. Pre-treating the patient with phenobarbital and extending the imaging to 24 hours are important to avoid false positive scans. Next. Case number two. This is a 29 year old male presenting with seizures, despite being on anti-epileptic medication. Here we have axial T2 and coronal T2 and flare images of the brain. Next. We're also showing you axial and coronal FTG PET images of the brain. Next. So based on these images, what do you guys think is likely diagnosis? Is it hyperglycemia, mesial temporal sclerosis, amyloid angiopathy, or artifacts due to motion of the patient during the scan? Go ahead and enter your answers. So it looks like we have a strong Nukes audience today, so that's an excellent job, that's the correct answer. So the correct answer is mesial temporal sclerosis, next. So mesial temporal sclerosis, which is also known as hippocampal sclerosis, is the most common cause of temporal epilepsy. The imaging findings, which are nicely demonstrated in this case, include volume loss on anatomic imaging and increased T2 flare MRI signal in the affected temporal lobe on MRI. On ictal spectrum, in which the patient is injected while they are having the seizure, you expect to see increased activity in the affected temporal lobe as the seizure emanates from this area, while if you're doing interictal spectrum PET, as in this case, which are obtained In between seizure, you would expect to see decreased activity, which is marked with the yellow arrow in this image. Note that you may also see contralateral decreased activity in the cerebellar lobe, which we are marking with a blue arrow, and this is a reactive phenomenon related to cross cerebellar diascesis. Thank you everyone, hope you enjoy the rest of the session. Thank you very much, Dr. Syed, for those cases. So moving on, we're going to have Dr. Kathy Phillips, who is an assistant professor at Vanderbilt University Medical Center, also a medical director of ultrasound, and she will be taking us through some interesting OB-GYN cases. Dr. Kathy, thank you. Thank you. And thank you for that warm introduction. I also want to thank Maryam Moshiri for her unbelievable guidance and creation of the case collection, as well as her mentorship to so many of us. It's part of the deputy editor crew. So next slide, please. Let's get started with case one. This is a 42-year-old woman who's presenting with five-year history of chronic left-sided abdominal pain, which has been worsening over the last month. What you'll see are two axial contrast enhanced CT images. The first is at the level of the left renal vein, and the second is at the level of the left gonadal vein. Next slide, please. We have some additional images from that study, lower in the pelvis in the axial plane, as well as in coronal, through the retroperitoneum, particularly on the left, continue to demonstrate some interesting findings. Next slide, please. The patient went on to have a left renal venogram, which we're seeing some subtraction angiography images of on the left, as well as a frontal image through the pelvis from that venogram as well. Next slide, please. So what's your diagnosis here? Is this pelvic venous congestion due to ovarian vein reflux? Is it ovarian vein reflux because the left renal vein has been compressed, aka nutcracker syndrome? Is there an arteriovenous malformation, or is it pelvic lymphadenopathy? Next slide. Wow. Lots of change here. Wonderful. I see some people changing their answers, perhaps. Great. I think we've reached a steady state. Next slide, please. You guys are correct. This is pelvic venous congestion due to ovarian vein reflux. Next slide. So this commonly affects multiparous women, particularly of the reproductive age, and it's thought to be due to incompetent venous valves leading to reflux of renal vein drainage or ovarian vein drainage into the ovarian vein, and then subsequently into the pelvic veins, which become engorged. Note that these findings can be seen in patients even without symptoms. So what are you looking for? You're looking for greater than or equal to four ipsilateral periuterine veins that are dilated, or you're looking for an ovarian vein, which measures more than eight millimeters in diameter. Frequently, these patients, because of the congestion, will have bridging arcuate vessels that traverse the myometrium, and can be seen particularly well with sonography. Okay. Next case. All right. This is a 21-year-old woman presenting with oligomenorrhea as well as infertility. In here, we have a coronal T2-weighted MRI image to the level of the pelvis. Next slide. As well as a T2-weighted axial image to the level of the cervix. Next slide. And then now a coronal contrast-enhanced image, the abdomen and pelvis, and the level of the kidneys. All right. Next slide. So what's the diagnosis? Is this a unicornuate uterus? Is this a uterus didelphys, a bicornuate uterus, or a septate uterus? All right. Next slide. Oh, 100%. Very strong OBGYN. Very good, guys. No takers for bicornuate uterus? All right. So next slide. Exactly right. This is a unicornuate uterus. Next slide, please. So this is a class II malaria duct anomaly, which is marked by unilateral uterine canal as well as a single cervix. The MRI, as we see here, shows a small hemiuterus, which usually deviated to the side of the original malaria duct off midline. And there's varying classifications of the contralateral horn, from present to completely absent. These are frequently associated with renal anomalies due to the shared embryologic origin from the malaria ducts, and these anomalies are present in up to 40% of cases and can range anywhere from renal agenesis to cross-fusectopia. So always make sure you get additional imaging with the kidneys when you do identify a malaria duct anomaly. Thanks for playing. Thank you so much, Dr. Cathy. So we're going to have Dr. Peshka Chaturvedi, who is from the University of Rochester Medical Center. She's also the assistant editor for pediatrics. And I mean, I have a bias with pediatrics, so it gives me great joy to welcome her to show us a couple of interesting cases. Dr. Peshka, thank you. Thank you for the great introduction. Let's move on to the pediatric cases. So here's case one. This eight-year-old female had a past medical history of chronic constipation, reflux, and emesis, and presents with acute piteous emesis and severe abdominal pain after upper endoscopy with biopsy. So we have two images from an upper GI, contrast upper GI, and then we have a single transverse ultrasound image of the upper abdomen. I would ask you to pay attention to this finding here and this finding here. Next slide, please. So here we have three contrast-enhanced CT images in the axial, coronal, and sagittal plane. So this is the finding that we need to pay attention to. Moving on to the next slide, please. So what is the diagnosis? Is this an intramural duodenal hematoma, midgut volvulus, enteric duplication cyst, or a duodenal web? Let's activate the poll. We can go back to the question slide. All right. Poll slide, please. Okay. So there's quite a spread here. Majority of people think this is an intramural duodenal hematoma, but there are quite a few. Actually, there are... Okay. So that changed very quickly. Enteric duplication cyst, 31%, and duodenal web, 13%. No takers for midgut volvulus. So that's great. Next slide, please. So this is an intramural duodenal hematoma, which is very nicely documented on all these images. Next slide, please. So this usually presents with bilious vomiting and severe abdominal pain, post-endoscopic biopsy, and there is an increased incidence if underlying coagulopathy is there, and usually these are managed conservatively, unlike penetrating duodenal trauma, which needs to go to surgery. Next slide, please. So moving on to case two. This male patient was born at 39 weeks via cesarean section to a 22-year-old G3P2 mother. There was a history of maternal marijuana use and group B streptococcus colonization. No familial genetic syndromes, no maternal diabetes. So here's two radiographs of the patient's torso. So I would ask you to pay attention to the vertebrae here and make sure that you are identifying normal vertebral morphology and a normal complement of vertebral bodies. Next slide, please. So here we have a sagittal ultrasound image of the spine, and again, this is what I would like you to look at. Pay attention to the conus medullaris and look at its configuration and also pay attention to the vertebral bodies and make sure that, you know, whether or not you have a normal complement of vertebrae. Moving on to the next slide, please. So here we have two sagittal MR images of fat-suppressed T2-weighted image and a non-fat-suppressed T1-weighted image, and again, these are the findings, the same findings that I would like you to pay attention to. The sacral spine, please pay attention to the terminus of the spinal cord and move on to the next slide, please. So what do we think is the correct diagnosis? Do these findings represent a myelomeningocele, a tethered cord, diastematomilia, or caudal regression syndrome? Let's activate the poll. All right. Let's go to the poll slide and see how everyone's answering. So the grand majority thinks it's caudal regression syndrome, and there's a small percentage of people who think this is a tethered cord or diastematomilia, and no one's checked myelomeningocele so far. All right, next slide. So excellent work. Yes, this is caudal regression syndrome. As you can very nicely see, the inferior most sacral vertebrae are missing, and there is a blunted sort of club-like terminus of the spinal cord or the conus medullaris is blunted and club-like. Moving on to the next slide. So here, this caudal regression syndrome, there is an increased incidence with maternal diabetes. This particular patient did not have a mother with diabetes. There is a range of severity. It can range from minimal agenesis of the inferior most sacral vertebrae to very profound lumbar sacral agenesis. And there can be associated GI, GU, cardiac, and skeletal abnormalities. And there are syndromic associations, including the bacterial associations, Garadeno's syndrome, as well as the OEIS complex. So with this, we conclude the pediatric section. And thank you for playing, and thank you for being here this evening. And thank you very much to RSNA and to Dr. Moshiri.

radiology education

case presentations

musculoskeletal

interventional radiology

breast imaging

diagnostic dilemmas

differential diagnoses

neuroradiology

pediatrics

imaging interpretation