Break through Cases

Case 3 - Gastric outlet obstruction with Superior Mesenteric Artery Syndrome & Nutcracker syndrome.

A 32-year-old man presents to the emergency department with epigastric pain multiple episodes of episodes of vomiting which was non bilious in nature. History of weight loss. Mildly altered sensorium. Similar complaints in the past 3 to 4 months.

Grossly dilated stomach with mild circumferential thickening at pyloric region as described – Suggestive of gastric outlet obstruction

Coronal reformatted images showing Stomach which appears grossly dilated with mild circumferential wall thickening (~ 10 mm) noted in the pyloric antrum. There is abrupt narrowing of lumen at the junction of pylorus and first part of duodenum.

CECT coronal and axial sections showing Stomach which appears grossly dilated with mild circumferential wall thickening (~ 10 mm) noted in the pyloric antrum. There is abrupt narrowing of lumen at the junction of pylorus and first part of duodenum.
Few small mucosal ulcers in distal pylorus (likely chronic peptic ulcer).

CECT sagittal reformatted images showing a reduction of aortomesenteric angle (~ 100). between the abdominal aorta and SMA. There is reduction of aortomesenteric distance (~ 4 mm).
Reduced aorto-mesenteric angle and distance as described – Suggestive of Possible SMA syndrome.

There is evidence of abrupt narrowing of the left renal vein between the superior mesenteric artery and abdominal aorta with dilated proximal left renal vein measuring 13mm. However, there is no evidence of thrombosis.
Abrupt narrowing of left renal vein between the superior mesenteric artery and abdominal aorta with peri renal collaterals and retroperitoneal prominent collaterals – Suggestive of Nutcracker syndrome.

Case 4 - Browns tumor

A 32 year old man presented with complaints of low back pain since 1 yr.
Pain over left thigh , which was insidious in onset, severe in nature, gradually progressive, aggravates on day to day activities, relieves on medications. No h/o recent fall/ trauma.
S. Calcium : 13.0 mg/dl
PTH - 3103 ug/dl

USG images showing a fairly defined heterogenous lesion posterio-inferiorly to the right lobe of thyroid, demonstrating increased vascularity on color Doppler imaging - Suggestive of parathyroid origin – (Parathyroid adenoma was confirmed on FNAC).

USG grey scale image shows multiple calcific foci in bilateral renal medulla - Suggestive of medullary nephrocalcinosis.

X-ray abdomen & pelvis - AP & Lateral views showing nephrocalcinosis of kidney

Skull radiograph lateral view showing cortical thickening with multiple tiny osteolytic lesions in skull giving classical appearance of salt and pepper.

Frontal radiograph of bilateral hands with wrist joint showing (sub periosteal erosions) acro osteolysis of distal phalanx with sclerotic changes involving the carpal bones.

The pelvis x-ray AP view shows lytic lesions in bilateral ilium & proximal femur with cortical thinning noted involving the left femur.

Well defined expansile lytic lesions noted in proximal diaphysis of left femur with cortical thinning.

The above features are suggestive of browns tumor secondary to hyperparathyroidism (Parathyroid adenoma).

Case 5 - Osteoid osteoma

A 20 year old patient complaining of nocturnal pain in right hip joint since 3 months. No history of trauma / prior surgeries.

CT axial images

CT coronal reformatted images

Shows an expansile cortical based lytic lesion with thick sclerotic rim and central nidus noted in the anteromedial cortex of the right femoral neck.

T1 axial

T2 axial & coronal

STIR

Showing T1 isointense and T2/STIR hyperintense lesion in the anteromedial cortex of right femoral neck with sclerotic rim & central nidus. Cortical thickening and surrounding marrow edema seen- likely Osteoid osteoma.

T1 Fat-sat Coronal

T2 coronal

STIR coronal

Showing T1 fat sat isointense and T2/STIR hyperintense lesion in the anteromedial cortex of right femoral neck with sclerotic rim & central nidus. Cortical thickening and surrounding marrow edema seen- likely Osteoid osteoma.

Case 6 - Fetal anomaly - Myeloschisis with Corpus callosum agenesis.

A 29 year old G3P1L1A1 with 5 months of amenorrhea came for anomaly scan

Lemon shaped skull with obliteration of cisterna magna (Normal value – 3 to 8 mm)

Crowding of cerebellum (Banana shaped)

Absence of overlying skin resulting in exposure of neural placode to surrounding amniotic fluid

MRI– T2 Haste coronal

Showing Absence of overlying skin at lumbar region, spinal cord and surrounding nervous tissue are also exposed to amniotic fluid, no dilatation of subarachnoid space – likely open spina bifida (Myelocele/Myeloschisis)
No evidence of chiari malformation

MRI T2 - Coronal section - showing dilated bilateral lateral ventricles.

MRI sequence – T2 Haste Axial – showing defect with nerve roots