Sunday 17 October 2021

Rice bodies in subdeltoid bursa MRI

This MRI shoulder joint shows fluid distended sub deltoid bursa with numerous typical rice bodies.
Differentials given are rheumatoid arthritis and tuberculosis.
Suggested CBC, ESR, C-reactive protein, RA, anti-CCP in view of RA and joint fluid aspiration for culture and sensitivity in view of Tubercular Arthritis.

Rice body effusion or rice bodies in joint effusion or bursa represents an uncommon, nonspecific, inflammatory process, where multiple small loose intra-articular bodies resembling polished grains of white rice. 
They are typically seen with Rheumatoid arthritis, Tuberculosis. However it is also known to occur with juvenile arthritis, seronegative arthritis, osteoarthritis, septic joint, trauma and chronic bursitis.

They are almost of same size, hypointense on T1 as well as T2 weighted images without enhancement on post contrast, the shape is very typical with tapering ends resembling rice grains.
They should be differentiated from synovial chondromatosis where loose bodies are relatively larger in size, round to ovoid in shape and impart slightly high signal on T2-weighted images.

Elbow Neuropathic Arthropathy MRI

A middle aged male with unilateral left elbow pain, deformity, progressive swelling, restricted movement.

This MRI elbow joint shows:

Joint effusion, osteolysis involving proximal end of radius as well as ulna, articulating surface of capitulum as well as trochlea. Marked synovial thickening with frond like projections. 

Considering unilateral involvement possibility of infectious aetiology like Tubercular arthritis was one possibility would have been dealt with joint fluid aspiration for culture and sensitivity.
However, MRI CERVICAL SPINE screening was done with suspicion of neuropathic arthropathy which surprisingly revealed cervical cord syrinx.

Here is MRI CERVICAL SPINE of same patient which shows moderate cervical cord syrinx supporting neuropathic arthropathy.

So take home note is it is worthy to suspect and rule out conditions like this whenever applicable and possible as it considerably changes the line of management.

Friday 8 October 2021

Steinstrasse CT KUB

This non-contrast CT study of abdomen for KUB of patient with left abdominal pain shows a dense large calculus in Urinary bladder which is in continuity with ribbon like column of multiple calculi in left ureter. 
Retrograde history taking unfurled that the patient had undergone ESWL one month ago.

Imaging diagnosis: Steinstrasse.

Steinstrasse is the German term which means "stone street", used to describe a possible complication of extracorporeal shock wave lithotripsy (ESWL) for urinary tract calculi, wherein a column of stone fragments forms that blocks the ureter.
Steinstrasse usually develops couple of months after ESWL and the most common site is the distal ureter.
The refined extracorporeal shock wave lithotripsy technique has reduced the incidence of steinstrasse from 20% to 6% 2.
Usually, the stone fragments pass spontaneously, but in about 25% of patients, retrograde stenting may be required. SOS more complex interventions such as stone flushing, ureteral dilatation, or long-term ureteral stenting may be required.

Sunday 3 October 2021

Vitamin C deficiency mimicking inflammatory bone disease MRI hip

A 15 years old school goer presented with on and off bilateral hip pain, restricted hip joint movement, associated backache. 
MRI bilateral hip joint shows abnormal bone marrow edema involving bilateral acetabulum and subchondral portion of right sacral ala. Associated mild left hip joint effusion.
Imaging finding were suggestive of either inflammatory bone disease or multifocal osteitis. However the possibility of nutritional cause like Vit C or D deficiency was kept during discussion with the referring physician. Accordingly, getting the lab investigation done, was assured by refereeing doctor.

Patient's CBC, ESR, C-reactive protein was normal, RA factor was negative. Vitamin and mineral status showed normal zinc, folate and vitamin B6 levels. The vitamin C turned out strikingly low at 5 μmol/L (normal range 23–114 μmol/L) and vitamin D 25-OH at 12.2 ng/mL (normal > 30 ng/mL).
Treatment was already initiated by refereeing doctor with ascorbic acid, cholecalciferol, and liquid meal supplements keeping the diagnosis of scurvy on the basis of severely low vitamin C levels. 

The crucial message from this case is considering the nutritional cause for nonspecific bone marrow edema in MSK imaging is mandatory rather than confining our diagnosis between infective, inflammatory and neoplastic etiology all the time as in our case the treatable cause like Vitamin C deficiency was mimicking the inflammatory bone disease. 

Morel-Lavallée lesion MRI

Clinically RTA, run over by tractor.

This MRI study shows a focal well defined lentiform shaped subcutaneous collection on medial aspect of knee joint superficial to the superficial fascia. Collection is clear, hypo intense on T1-weighted images without any septations or loculations. No obvious high signal intensity methaemoglobin staining on T1-weighted images to suggest any frank haematoma.

Morel-Lavallée lesion

These are focal well defined lentiform shaped subcutaneous serous collections commonly encountered during MRI knee joint in the setting of severe trauma. However these lesions are typically described in thigh as a well defined collection overlying the greater trochanter of the femur and the tensor facia lata. 

These are actually localized haemolymphatic collections secondary to closed degloving injuries, where the skin and subcutaneous fatty tissue abruptly separate from the underlying fascia owing to trauma. The potential space thus created superficial to the superficial fascia is filled by serous fluid, some times frank blood. Similar collection secondary to similar biomechanical forces are described in lumbar region and over the scapula as well. 

The accumulated collection usually needs nothing to be done, resolves spontaneously. However may persist longer if it gets organized and encapsulated. The conservative management is with compression bandage. Surgical drainage may be sufficient for larger collection. However, the capsule may need to be resected to prevent recurrence if it is long standing and encapsulated collection with thick organized wall. 

Osteochondrosis of Superior Pole of Patella

Clinically young male patient with athletic background complaining of typical unilateral anterior knee pain. Marked tenderness at the superior pole of patella.

This MRI study of knee joint shows abnormal irregularity, fragmentation with sclerosis involving superior pole of patella. An associated thickening of quadriceps tendon. 
Knee joint effusion.
Imaging findings consistent with osteochondrosis of patella at superior pole.

Osteochondrosis of the superior pole of the patella

Osteochondroses are the heterogeneous group of injuries to the epiphyses and apophyses of children or adolescents, are actually osteonecrosis owing to repetitive microtrauma and avulsion injuries at tendinous insertions. Imaging wise characterized by bone fragmentation and sclerosis.

There are two well-known such syndromes associated with knee joint, one is Osgood-Schlatter disease, an avulsion of the tibial tuberosity and another is Sinding-Larsen-Johansson disease, a chronic avulsion injury involving lower pole of the patella at the insertion of patellar tendon.
The less well described osteochondrosis at the superior pole of patella appears secondary to similar mechanism associated with quadriceps tendon insertion, a rare cause of anterior knee pain in children between 5 and 10 years of age, usually single knee is affected but bilateral cases have also been reported.

Excessive lateral pressure syndrome MRI

This MRI Axial STIR sections of knee show clinical marker on skin on anteromedial aspect of knee joint. There is patellar tilt, articulating surface of patella facing medially, abnormal thickening of lateral patellar retinaculum and patellofemoral ligament. Associated bone marrow oedema involving lateral margin of lateral articulating facet of patella.

Imaging findings consistent with clinical diagnosis of Excessive lateral pressure syndrome.

Lateral Patellar Compression Syndrome

Synonym : Excessive lateral pressure syndrome, ELPS

This is another common cause of anterior knee pain.

The improper tracking of the patella in the trochlear groove generally caused by imbalance between medial and lateral dynamic stabilizers of knee, the tight lateral retinaculum restricting the patellar mobility with excessive lateral tilt of patella causing friction between lateral articulating facet of patella with lateral trochlea of femur.
Typically affects adults, patient presents with pain on compression of the patella, lateral facet tenderness. Condition is aggravated physical activity.

This is mainly a clinical diagnosis. However, lateral tilt of patella on axial sections of MRI or sunrise knee radiographs, patella facing medially without lateral translation should be depicted meticulously which is very commonly overlooked during MRI interpretation. Furthermore, abnormal thickening and shortening of lateral patellar retinaculum and lateral patellofemoral ligament could be appreciated on MRI. Nonetheless, the important ancillary findings on MRI are subchondral bone marrow oedema, cystic geodes involving lateral articulating facet of patella and adjacent lateral femoral trochlea facing the patella. The patellofemoral angle is calculated on axial sections, the medial opening of the angle, that is demonstration of angle more than 8° can support the diagnosis of ELPS.

Treatment is mainly conservative with physiotherapy focusing on quadriceps stretching and strengthening. Operative lateral retinaculum release is reserved for refractory cases. 

Discoid Meniscus

This MRI study of knee joint depicts discoid lateral meniscus.
No obvious associated meniscal tear or para meniscal cyst.

Discoid meniscus

This is a congenital condition and is bilateral in about 50% of the cases. Usually encountered as an incidental finding on MRI examination in about 5% of the cases, typically affecting lateral meniscus. Discoid medial meniscus is very rare.

The pathology behind  this discoid shape is loss of normal orientation of collagen fibres of meniscus.
Frequently this is an asymptomatic condition however the discoid meniscus has propensity for pressure, wear and tear leading early cystic degeneration, meniscal tear and para meniscal cyst formation. In such cases patient may present with knee pain with or without locking. 
MRI is the investigation of choice. 
The width of the body of meniscus, if 15 mm or more on coronal section is diagnostic of discoid meniscus. The body of the lateral meniscus is normally has bowtie configuration on sagittal section and seen only on two consecutive slices. If the meniscal body is seen on three or more consecutive slices while scrolling the sagittal sections, instead of normal bowtie tie should alarm of discoid morphology. 

The observation is usually managed conservatively if patient is not symptomatic. 
Partial or total resection is the option kept in front of patient if accompanied with complications like tear.

Supraspinatous Ganglion Cyst MRI

Clinically severe painful restricted shoulder movement, especially the abduction. Patient complaining that symptoms got aggravated over the period of time with shoulder exercise and physiotherapy. No obvious history of arthroscopy or intra articular injection.

This MRI shoulder joint shows a well-defined tear drop shaped cystic lesion along supraspinatus tendon tapering laterally towards its insertion suggestive of intra tendinous ganglion cyst. Associated changes of tendinosis involving supraspinatus tendon as there is mild tendon thickening. 
There was no sub acromial spur or para labral cyst.
Acromioclavicular joint normal.

The observation managed conservatively with intra-articular steroid. Clinical follow-up mentioned that patient improved clinically with range of movement improved by approximately 75%.
Suggested follow-up imaging

Imaging diagnosis: intra tendinous ganglion cyst of supraspinatus tendon causing shoulder impingement.

Trevor disease MRI

Clinical details, discharge summary mentions corrective osteotomy done for congenital progressive uni lateral knee deformity. Previous imaging details not available.
This MRI of knee joint shows post-operative status with corrective osteotomy for femur and tibia.
Well defined bone signal intensity outgrowth with cortex and medulla involving medial epiphysis of distal end of femur, epiphysis of tibial tuberosity with distinct cortex, medulla and fatty marrow in continuity with parent bone. Marked enlargement of patella with fragmentation.

Trevor’s disease

Synonym: Dysplasia epiphysealis hemimelica.

An extremely rare, approximately 1:1,000,000, congenital, non-hereditary condition consist of multiple osteochondromas arising from the epiphyses. Age of presentation is young children with slight male predilection.

There are three different types of involvement. The classic form has characteristic hemimelic distribution involving more than one bone or epiphysis within a single lower extremity. The localised form encompasses single bone involvement, either unilateral or bilateral. The generalised form incorporates the whole limb from pelvis to foot.
The abnormalities comprising the lower extremity is more common than upper, distal ends are more frequently encountered than upper ends of bone, medial aspects predilection is twice more common than lateral. The most common site of involvement is distal end of femur.

The condition typically demonstrates an irregular bone density mass on x-ray/CT arising from the epiphysis. The bony growth delineates areas of fatty marrow as well as foci sclerosis secondary to ossification on MRI. The illustration of continuity of cortex and medulla with the parent bone is must to end the search.

The bony growth can result in widening of joint space, deformity, bursa formation with soft tissue oedema, bursitis, tendinitis secondary to chronic irritation. The bony overgrowth can land up with fragmentation, detachment forming intra-articular bony loose body and changes of secondary osteoarthritis in advanced case.

Medial patellar plica syndrome

Clinically young patient presented with anteromedial knee pain.

MRI sagittal T2 and axial T2 images delineates a linear well-defined low signal intensity band running across medial patellofemoral recess. However, there is no obvious associated bone marrow oedema involving medial articulating facet of patella or medial femoral trochlea. Mild associated joint effusion.
Medial plica mentioned in the report with joint effusion.

Medial plica syndrome

Synonym: synovial plicae of the knee.

The another common cause of anterior knee pain typically present with pain on anteromedial aspect of the knee, just cranial to the joint line with or without associated with crepitation, catching and locking sensations. Typically involves young with athletic background. 

There are actually synovial invaginations as a part of remnants of embryological development. They are encountered in MRI over 70% of individuals and are mostly asymptomatic. However these tags can get inflamed secondary to repetitive friction and stretching, making patient symptomatic. They can undergo fibrosis after long standing inflammation imparting them non-stretchable restricting the joint movement and painful.
In symptomatic patients, medial plica seen as low signal intensity band on T1 as well as T2-weighted images with an associated chondral defect involving medial articulating facet of patella.
Treatment is mainly conservative, physiotherapy and intra articular steroid injections.

Sunday 29 August 2021

Leukoencephalopathy, Calcifications and Cysts MRI

Clinically middle age male with history of progressive headache for last 5months.
CT brain shows multiple dense bilateral basal ganglia calcification. 
DDs thought were like Fahrs disease, hypo thyroidism, hypo, pseudo hypo para thyroidism.
However patients thyroid and para thyroid profile was normal and the posterior cranial fossa cyst could not be explained even by Fahrs. With a possibility of a concurrent posterior fossa tumor, patient was referred for MRI brain with contrast.
MRI brain with contrast showed dense calcification in bilateral basal ganglia. The posterior fossa cyst with debris level. No abnormal enhancement along wall of cyst or enhancing eccentric solid nodule depicted on post contrast MRI which ruled out tumor nodule. 
The bilateral symmetric confluent T2 white matter hyper intensity which represents an associated leukoencephalopathy.

Imaging wise primary diagnosis given was LCC. 

Due to mass effect, fourth ventricle compression by the posterior fossa cyst leading to obstructive hydrocephalus, patient underwent posterior fossa craniotomy and excision of posterior fossa cyst was done. Histopathology revealed nonspecific cyst without any tumor cells keeping with MRI diagnosis of LCC. 

LCC or  Labrune syndrome syndrome MRI

Leukoencephalopathy, brain calcifications, and cysts (LCC) also known as Labrune syndrome, an extremely rare with only near  10 cases reported so far in the medical literature.

The condition is caused by homozygous or compound heterozygous mutations in the SNORD118 gene on chromosome 17p13. Clinical presentation varies from spasticity, dystonia, seizures, and cognitive decline.

Etiopathogenesis of LCC is still a matter of debate. Obliterative microangiopathy has been found on histopathological examination as the basic abnormality, the cyst formation is due to necrotic process secondary to obliterative microangiopathy and calcifications is dystrophic in nature. White matter changes result from changes in water content rather than abnormality of myelination.

Another entity which deserves a special mention is cerebro retinal microangiopathy with calcifications and cysts is a distinct genetic disorder due to CTC1 gene problem. Similar leukoencephalopathy, cysts, and calcification have been reported in few cases in association with Coat's disease, described as “Coat's plus. Coat's disease is unilateral retinal telangiectasia with exudation commonly occurring in boys sporadically without systemic features. However, in Coat's plus, there is bilateral retinal telangiectasia with exudation along with systemic features in the form of LCC. 

In my case patient did not have any visual issues so that rules out retinal abnormality and the possibility of cerebro retinal microangiopathy. 

Ears of the lynx sign MRI Brain

Ears of the lynx sign

The ears of the lynx sign refers to an abnormal bilateral symmetric cone-shaped hyperintensity on FLAIR and T2w images at the tip of the frontal horns of lateral ventricles. The abnormality corresponds to the region of forceps minor which resembles the tufts of hair crowning the ears of a lynx. Sagittal T1w images show an associated thin stripe of corpus callosum. 

The sign is typically seen in hereditary spastic paraplegia with thin corpus callosum (HSP-TCC), a form of hereditary spastic paraplegia associated with mutations of the spastic paraparesis gene 11 (SPG11) on chromosome 15. The spatacsin vesicle trafficking associated (SPG11) gene, codes spatacsin. 

The sign may also be seen in SPG15, another of the hereditary spastic paraplegias, which is caused by a mutation in the zinc finger fyve domain-containing protein 26 (ZFYVE26) gene, encoding spastizin. 

This sign has also been described in chronic cases of Marchiafava-Bignami disease.

Isolated Superficial Sylvian Vein Thrombosis MRI

Clinical Details: middle-aged female, altered sensorium after convulsions.

MRI study of brain shows:
Abnormal T2 hyperintensity with marked focal parenchymal swelling due to vasogenic oedema involving left temporal, insular cortex and adjacent opercular parietal white matter. 
Diffusion restriction in corresponding region confined to cortical grey matter of left temporal lobe and adjacent insular cortex on diffusion weighted images. Sub cortical white matter is spared.
 An abnormal leptomeningeal enhancement depicted along left sylvian fissure and in left medial temporal region near cavernous sinus on post contrast MRI. 
Multifocal low signal intensity clustered nodularity demonstrated along left sylvian fissure extending towards cavernous sinus on GRE, which is hyper dense on CT. No abnormal calcification on CT. Normal MR angiography of brain. No obvious aneurysm or high flow vascular malformation on MR angio.
Mass effect, mid brain compression.

Left side Decompressive hemicraniectomy done.
Intraoperative findings revealed thrombosed superficial cortical veins in left sylvian fissure region and at the floor of left middle cranial fossa. 

Final diagnosis: Isolated superficial middle cerebral or Sylvian vein thrombosis.

Superficial middle cerebral vein also known as the Sylvian vein, is one of the superficial cerebral veins. It usually courses along the Sylvian fissure posteroanteriorly and drains numerous small tributaries from the opercular areas around the lateral sulcus. It curves anteriorly around the tip of the temporal lobe and drains into the sphenoparietal sinus or directly into the cavernous sinus. 

Suzuki classification of the superficial Sylvian venous drainage pathways:
1. sphenoparietal type: (54%) drains into the sphenoparietal sinus.
2. emissary type: (12%) courses along the lesser wing of sphenoid, turns inferiorly to reach the floor of the middle cranial fossa, joins the sphenoidal emissary veins, and passes through the floor to reach the pterygoid plexus.
3. cavernous type: (7%) directly drains into the anterior end of the cavernous sinus.
4. superior petrosal type: (2%) runs along the lesser wing and just before reaching the cavernous sinus, turns downward along the anterior inner wall of the middle cranial fossa, then runs along its floor medially to the foramen ovale to join the superior petrosal sinus.
5. basal type: (2%) runs along the lesser wing, turns downward along the anterior wall of the middle cranial fossa, then runs along its floor laterally to the foramen ovale over the petrous pyramid, presumably to join the transverse sinus through the lateral tentorial sinus or superior petrosal sinus.
6. squamosal type: (2%) turns directly backward along the inner aspect of the temporal squama and runs posteriorly to join the transverse sinus or lateral tentorial sinus.