2018 RSNA Image Interpretation Session Neuro
Transcript of 2018 RSNA Image Interpretation Session Neuro
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2018 RSNA
Image Interpretation Session
Neuro
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10 y.o. old boy with fevers and fatigue x 5 days,
admitted due to altered mental status
HR 123, BP 140/90 Lumbar puncture
• Opening pressure 35 cm H20• 194 nucleated cells/mL, 99% lymphocytes• protein 234 mg/dL• glucose 45 mg/dL
Started acyclovir & broad spectrum antibiotics
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Initial Evaluation
• History – viral prodrome
• Exam - Fever, HTN, tachycardia
• LP – lymphocytic pleocytosis, high opening pressure
• RX – acyclovir, antibiotics
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2 days later…
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1 day later… CSF cultures and PCR come back negative;
continued tachycardia and hypertension• Subtle central perivascular enhancement
• Leptomeningitis
T1+ FLAIR T1+ FLAIR
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T2 DWI T2 T1+
3 days later… coma, flaccid paralysis
• Periventricular T2 worse, reduced DWI
• Longitudinally extensive myelitis
• Subtle spinal leptomeningeal enhancement
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T2 DWI T2 T1+
3 days later… coma, flaccid paralysis
• Periventricular T2 worse, reduced DWI
• Longitudinally extensive myelitis
• Subtle spinal leptomeningeal enhancement
Diagnostic Considerations: Meningoencephalomyelitis
Viral, Inflammatory, Vasculitis, Autoimmune
What would you do next to treat this patient?
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Steroids, IVIG, Plasmapheresis… dramatic improvement !
• Walking with assistance 2 weeks later
• Maintained on IV steroids – deficits resolve (mild difficulty concentrating)
• Brain MRI normal on 6 month follow-up
• Normal CAP CT, scrotal US
T1+ T2
Differential Diagnosis
Viral
Inflammatory
Vasculitis
Autoimmune
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2018 RSNA
Image Interpretation Session
Breast
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History
• 37 yo woman with no contributing history
• Presents with painless enlarging left breast over last 12 months. Left now 2 bra sizes asymmetric c/w right
• Physical exam: • right breast normal exam
• left breast diffusely firm, no skin changes, no axillary or supra-clavicular adenopathy; prominent veins visible throughout the left breast
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simple cyst (ignore)
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Large painless mass in a young woman without adenopathy/skin changes growing over a year
• Lipofibroadenoma (hamartoma)
• Giant Fibroadenoma / Phyllodes Tumor
• Cancer / Angiosarcoma
• Lymphangiomatosis
• Giant Pseudoangiomatous Stromal Hyperplasia (PASH)
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Biopsy performed at this point
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multiple slices from superior to inferior2nd pass T1 +C
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multiple slices from superior to inferior2nd pass T1 +C, subtraction
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T1 fat-sat, pre-contrast T1 non fat-sat T2WI
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2018 RSNA
Image Interpretation Session
Thoracic
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Middle age man; former smoker, hemoptysis
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Imaging Findings
CXR: Ill-defined mass in the LLL extending from the left
hilum.
Contrast enhanced CT: Homogeneous non-cavitary soft-
tissue mass with left hilar adenopathy, displacement of
broncho-vascular structures and areas of peripheral
collapse
PET-CT: Intense homogenous increased glucose uptake of
the mass and increased abnormal glucose uptake in left
lower paratracheal, subcarinal nodal station and left hilum (>
than reactive uptake)
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Differential Diagnosis
1. Neoplastic: Lung cancer (invasive ADK,
undifferentiated neuroendocrine tumor
(carcinoid), Maltoma,…
2. Inflammatory / Granulomatous:Sarcoidosis, IgG4 disease, GPA,
Bronchocentric granulomatosis…
3. Infectious: Mycobacteria, Fungi
Solitary lung mass with lymphadenopathies: many possibilities
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A diagnostic procedure is performed and treatment is
started
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Increasing dyspnea after 4 months of treatment
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Baseline
Increasing dyspnea after 4 months of treatment
4 months later
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Baseline 4 months later
Increasing dyspnea after 4 months of treatment
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Baseline 4 months later
Increasing dyspnea after 4 months of treatment
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Baseline 4 months later
Increasing dyspnea after 4 months of treatment
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Baseline 4 months later
Increasing dyspnea after 4 months of treatment
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Baseline 4 months later
Increasing dyspnea after 4 months of treatment
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CT: Multiple small nodules in peri-lymphatic distribution,
subpleural, along the bronchovascular bundles, interlobular
septum and in a symmetric and upper zone predominant
distribution
Imaging Findings
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Increasing dyspnea after 4 months of treatment
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Increasing dyspnea after 4 months of treatment
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Differential DiagnosisNeoplastic:
1. Lymphangitis carcinomatosa: ADK (breast, lung, stomach)
2. Lymphoproliferative disease
3. Pulmonary tumor thrombotic microangiopathy (PTTM): Gastric cancer is the most commonly associated malignancy
Infection:
1. Mycobacteria / Fungi
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Differential Diagnosis
Inflammatory / Granulomatous:
1. IgG4 related lung disease: features are often excellent
mimickers of malignancies, infections, and other immune-mediated
disorders (vasculitis)
2. Sarcoidosis / Sarcoid reaction
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2018 RSNA
Image Interpretation Session
Cardiovascular
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History
57 year-old female presenting with:
• 3-month history of daily exertional shortness of breath
• fatigue, and
• non-localized lower back pain
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Aortitis – diffuse inflammation of the aorta
• giant cell arteritis (GCA)• Takayasu arteritis • Cogan's syndrome• systemic lupus erythematosus/rheumatoid arthritis• HLA-B27 associated spondyloarthropathies (Reiter’s and ankylosing spondylosis)• ANCA-associated vasculitides (Wegener’s, microscopic polyangiitis (MPA), and eosinophilic
granulomatosis with polyangiitis (EGPA), previously known as Churg-Strauss)• Behçet's disease• sarcoidosis• infectious (tuberculosis, syphilis, salmonella and other bacteria)• idiopathic retroperitoneal fibrosis (Ormond’s disease)/inflamed abdominal aortic aneurysm• Erdheim-Chester.• idiopathic isolated
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Exertional SOB
• Lung – SLE, RA, sarcoid, HLA-B27 associated, ANCA-associated vasculitides, Behçet's, infectious, giant cell arteritis
• Cardiac – giant cell, Takaysu, Cogan’s, SLE, sarcoid, HLA-B27 associated, ANCA-associated, Behçet's, infectious
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Back pain? Sacroiliac joint, other bone involvement?
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“Coated aorta”
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2018 RSNA
Image Interpretation Session
Abdomen: GI
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• 66 year-old male with chronic abdominal pain
• Acute exacerbation
• Chronic medical history, includes– Gout
– Hypertension
– “Congenital emphysema”: Rx inhalers and prn steroids• Recurrent pneumothoraces
• Recurrent infections
• Chronically short of breath
History
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• Relevant Surgical history
– Bilateral carpal tunnel releases; right side 1970’s
– Bilateral finger amputations: etiology?
– Hx of intussusception: small bowel resection
History
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• Relevant Surgical history• Bilateral carpal tunnel releases; right side 1970’s
• Bilateral finger amputations: etiology?
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Findings: X-ray
• Third finger amputation
• Macrodactyly (disproportionate overgrowth)
• Course trabeculation of enlarged phalanxes
• Soft tissue hypertrophy (metacarpus and around second digit)
• Abnormally calcified connective tissue
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Findings: MR
• Soft-tissue fibrotic lesion (low signal on T1/T2), i.e. fibrous hamartoma
• Bone cystic lesions
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•Overgrowth of connective tissues (bone, fat)
•Progressive disease
•Onset at young age
Findings
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T1+C PV
• “Congenital emphysema”: Rx inhalers and prn steroids• Recurrent pneumothoraces
• Recurrent infections
• Chronically short of breath
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Findings
• Chest X-ray
• Asymmetric hemithoraces; hyperinflation of left lung
• Redistribution of blood flow to the upper lung zones with abnormal enlargement of the upper lobe vessels
• Prominent hila with reticular and streaky densities in both perihilar areas
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• Lung CT
• Hyperinflation of the left lung
• Emphysematous changes
• Areas of scarring and cystic changes in the left lower lobe
Findings
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• Hx of intussusception: small bowel resection
History
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Findings
• Multiple encapsulated lipomas in the stomach, duodenum and jejunum
• Fatty overgrowth in the omentum• Lipohypoplasia of subcutaneous fat• Dysregulated adipose tissue• Splenomegaly• ?Thick wall of the right ventricle
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• Macrodystrophia lipomatosa
• Multiple symmetric lipomatosis (Madelung disease)
• CLOVE (Congenital Lipomatous Overgrowth, Vascular malformations, and Epidermal nevi, Skeletal) syndrome
• Proteus syndrome
DIFFERENTIAL DIAGNOSIS
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2018 RSNA
Image Interpretation Session
Abdomen: GU
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63 year-old female with:• right abdomen/flank pain• long standing history of seizures • 5.0 kg unintentional weight loss
History
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Ultrasound Found:
A thing.
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CT shows: Large bilateral solid perinephric masses
Iso, no fat attenuation Extrarenal
Just bowel Just bowel
No nodes
Solid
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Volume averaging?
Normal adrenals
Fat plane
Nothing perineural
Normal skin
Normal skin
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Thought Process1. Ultrasound was very helpful, thanks for that
2. Renal vs. perirenal have very different DDx
3. Seizures imply a neuro-oncologic syndrome
4. Multi-year = probably not mets
5. “Guess that mass” always seemed odd to me
Why bother thinking?
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Perirenal Differential DiagnosisPerirenal
Lymphoma or mets
Histiocytosis conditions
Plasmacytomas
Paragangliomas
ExtramedullaryHematopoesis
Erdheim Chester
Mass-forming IgG4
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Neuro-Oncologic Differential Diagnosis
Perirenal
NF-1
vHL
Many others
Tuberous Sclerosis
Some AMLs nasty:Epithelioid AMLs
(aggressive)
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Final Differential and PlanReasonable possibilities
--Fat-poor epithelioid AMLs in setting of TS
--Histiocytosis (Rosai-Dorfman [non-Langerhans cell])
--Lymphoma
--Paragangliomas
--Mass-forming IgG4
Plan:Look at chart (do they have TS?)
Comparisons (esp. CNS)Metanephrines – if above (-)
Set up for biopsy
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2018 RSNA
Image Interpretation Session
MSK
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• Male in his 60’s
• Several years of generalized pain, fatigue, and muscle weakness with abnormal gait
• History of pubic ramus fractures and rib fractures
• Recent diagnosis of prostate cancer– Watchful waiting
• 2-3 year history of pain and discomfort in right thigh
History
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T1 STIR
T1 with contrast
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T1 STIR
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Additional Data
• Bone density evaluation → osteopenia
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Clinical History
Chronic pain, fatigue muscle weakness
abnormal gait
OSTEOMALACIA
FRACTURES
• Vitamin D
deficiency/liver dz
• X-linked hypophosphatemia
• Drug toxicity
• Tumor-induced
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Laboratory
Chronic pain, fatigue muscle weakness
abnormal gait
OSTEOMALACIA
FRACTURES
• Vitamin D
deficiency/liver dz
• X-linked hypophosphatemia
• Drug toxicity
• Tumor-induced
Ca PO4 25D 1,25D
+ N N
NN
N+N N
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Z-score -3.4
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T1
STIR T1+GdT1
MRI
• Heterogeneous
• Primarily
–T1 hyperintense
–STIR isointense
• *Foci of low signal
• *Markedly enhancing
Imaging
– Size
– Location
– Density
– Enhancement
– *Tumor matrix
•Amorphous
•Punctate
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Octreoscan(Octreotide, 111In-pentetreotide)
• Tumors - high expression somatostatin receptors
–Neuroendocrine tumors
–Adrenal medullary tumors
–Merkel cell tumor of skin
–Pituitary adenoma
–Small-cell lung carcinoma
–Phosphaturic mesenchymal tumors
–Neuroendocrine tumors
–Adrenal medullary tumors
–Merkel cell tumor of skin
–Pituitary adenoma
–Small-cell lung carcinoma
–Phosphaturic mesenchymal tumors
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2018 RSNA
Image Interpretation Session
Peds
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• 2 year old girl who originally presented at an outside practice• “renal abnormalities”
• abdominal distension
• Followed by renal ultrasound
History
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Renal Ultrasound at 2 Years of Age
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• 2 year old girl who originally presented at an outside practice• “renal abnormalities”
• abdominal distension
• Followed by renal ultrasound
• At 26 months of age:• enlarged right kidney; mass suspected
• MRI performed
History
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MRI at 26 Months of Age
T1+C Arterial Phase T1+C PV Phase
T2-FST2-FS
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Subsequently, US-Guided Right Renal Biopsies:eventual path diagnosis was “Wilms”
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Findings
• Young child with asymmetric nephromegaly and multiple solid masses replacing normal renal parenchyma with loss of cortico-medullary distinction
↓
• Nephroblastomatosis +/- Wilms tumor >>>>>>>>>> lymphoma, metastases
• Very difficult to distinguish hyperplastic nephrogenic rests from Wilms tumor on biopsy
• It can’t be that straightforward, can it?
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Additional Findings
• Fluid-filled locules within left abdominal wall, para-aortic/para-renal retroperitoneum, and right pelvis; ? thoracic and right hip lipomatosis; otherwise, decreased adipose tissue
↓
• Overgrowth syndrome with veno-lymphatic vascular malformations
• Isolated hemihypertrophy, Beckwith-Wiedemann, Perlman, Soto, and Simpson-Golabi-Behmel syndromes are associated with overgrowth, nephrogenic rests and Wilms tumor
• So, what could be the diagnosis in this case?
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Abd GI: Rendon Nelson, MD
MSK:Lee Cothran, MD
Breast:Jay Baker, MD
Neuro:Michael Malinzak, MD
Peds:Gary Schooler, MD
Thoracic:Page McAdams MD
CVI & Abd GU: Daniele Marin, MD
Deepest Gratitude
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Thank You