0:00

So let's try and to couple other

0:03

cases. We have 20 more minutes left. So we

0:06

do have time for a few more cases. And this case

0:09

was actually I think one of the most tricky cases

0:12

I've seen this was basically a perceptual problem and

0:15

it can be really really tricky and it reminded

0:18

me of that. There is Waldo gained that

0:21

many of us might have played as kids or even

0:24

now where there is a very popular character very distinctive,

0:27

but depending on how it

0:31

really hides in its surroundings that can be very difficult

0:34

to pick up.

0:35

So this was a 35 year old female has hypertension

0:38

elevated urine metanephrine. So the concern here

0:41

was a paraganglioma and let me

0:44

show you the CT chest contrast enhanced images.

0:47

So we'll start off with the CT chest of this patient. Hopefully

0:50

this will cooperate and it does so as

0:53

we are scrolling down. I want you to pay attention and see if

0:56

you can find the paraganglioma on these

0:59

images.

1:02

And I will go through it a couple more times just to give

1:05

you.

1:08

So if you were reading this case, how would you

1:11

read this case? And the only relevant finding is in the media standal window?

1:14

So that's all that I'm going to really show you for this particular case today.

1:21

So hopefully you've had a good look at this case.

1:25

and

1:27

this is a question is basically if you were to read this question,

1:30

how would you read it? Would you call it a normal scan? No paraganglioma.

1:33

Do you think there is a mass or

1:36

do you think there's some other finding?

1:41

And in the interest of time, let's see if we can find the results of the pole,

1:44

please.

1:45

So some people think it's normal something

1:48

they might be another Finding and

1:51

I don't disagree with you at all. I think

1:54

this is a very very difficult case. Now that I know where the lesion

1:57

is. It's a lot easier for me to point the

2:00

abnormality, but I will I will

2:03

definitely agree that when I saw this case for the first time I thought

2:06

it was a really tricky case. In fact,

2:09

it was reported as a normal case, but actually the

2:12

patient has a mass and let me show that to you.

2:15

So like I said, our original report was a negative CT.

2:19

Patient also had a CT neck and they suggested a nodule in

2:22

the neck and because of that CT neck report

2:25

the patient received an mibg scan and they

2:28

found intense activity in the heart.

2:31

So if you go back again, let me see if I can point out

2:34

defining for you this time.

2:41

This is not really moving. But in any case, let

2:44

me show it to you.

2:45

What where that abnormality was here is the

2:48

abnormality on the T1 weighted images. It was centered right

2:51

in the right AV Groove.

2:53

This is what it looked like on the stir images very very

2:56

bright. And if I play the perfusion images.

3:00

Here it is. You can see this is such an intensely vascular

3:03

lesion that when we have a contrast enhanced

3:06

CT. It's very nicely hid between the right

3:09

atrium and the right ventricle and it was very very difficult to

3:12

pick it up.

3:14

So again, if I showed you the chassis Team images, this is

3:17

kind of where it was if I try and outline it this

3:20

is the lesion now knowing where it is in MRI. It really

3:23

makes it easy to pick this out. But here is the lesion

3:26

this is the contrast enhanced Mr. This is the

3:29

lesion but you can see how this can be extremely challenging

3:32

to pick up if you're reading the scan prospectively.

3:36

So this was the main intention of showing you this case. This was

3:39

a patients known paraganglioma. And this is a

3:42

really big Mass but it's so nicely hit because

3:45

of its intense enhancement. It really made it

3:48

very very difficult to pick up the scam.