0:01

Okay, so, uh,

0:03

our next case is this is a 57-year-old woman.

0:06

Um, she presented with a three year history of knee pain,

0:10

uh, additional history withheld.

0:13

I'll let you know that she, uh,

0:15

was seen in the ER approximately, um, two weeks earlier.

0:20

On physical exam, she had normal range of motion.

0:22

She had some mild crepitus in the knee

0:24

and some, uh, mild medial on lateral joint

0:27

line tenors to palpation.

0:28

And she had a loose knee with a lockman two A.

0:32

So let me go ahead and pull her images

0:35

and of course, let's go ahead

0:37

and start with, um, some radiographs.

0:41

So you can see she indeed,

0:42

she does have some arthritic changes

0:44

in keeping with her age.

0:45

She says some osteophytes in her medial

0:47

and lateral femoral tube compartments.

0:48

If you look closely and if you window this,

0:51

you can see the presence of choral calcinosis within her

0:54

lateral compartment and probably

0:56

also in the medial compartment.

0:57

In the medial meniscus as well.

1:00

We go to the lateral view

1:01

and she can, you can see

1:02

that she has pretty significant patella femoral joint space

1:05

narrowing some bodies in the super patella recess.

1:08

And if we go to the, um, merchant view, we can see indeed

1:12

that she has basically bone on bone, severe lateral, uh,

1:15

excuse me, patella femoral compartment

1:17

joint space narrowing.

1:19

So the constellation

1:20

of findings altogether really suggest CPPD arthropathy.

1:27

And if we go to her, uh, knee MRI, um,

1:31

the quad calcinosis is difficult

1:33

to appreciate in the cartilage and the menisci.

1:36

But sometimes if you see low signal intensity foci,

1:39

particularly in the mid zone

1:40

of the articular cartilage on MRI,

1:42

then you can consider the possibility of CPPD, um,

1:46

deposition, especially if you don't

1:48

have those knee radiographs.

1:50

But you can see that this patient has pretty much full

1:53

thickness chondral loss in her patellofemoral compartment,

1:57

uh, most pronounced laterally.

1:59

So this would be in keeping with a pattern

2:01

of CPPD arthropathy.

2:04

Uh, but I'm not showing you this case just to, uh,

2:06

show a nice example of chondral loss in the setting

2:09

of CPPD arthropathy.

2:11

Um, Dr. Patridge just gave a nice talk on the popliteal, um,

2:15

region of the knee.

2:17

And if you look closely at her popliteal region,

2:20

we can find her neurovascular structures,

2:22

the artery, the vein.

2:24

And if we look at the intramuscular veins

2:27

within the gastrocnemius muscles, you can see

2:30

that the intramuscular vein to the medial head

2:32

of the gastroc muscle looks a little bit dilated.

2:36

Now, as you recall, you can't use signal intensity reliably

2:40

for thrombosis, but notice that there's a peculiar pattern

2:43

of perivascular edema, perivascular intramuscular edema,

2:47

that's pretty much confined to the,

2:49

uh, vicinity of the vessel.

2:52

And if you look on the sagal images too, not only do you see

2:55

that there's this perivascular pattern of edema, you can see

2:58

That there's focal vein dilatation.

3:02

So the history that was withheld in this patient,

3:06

she was seen in the ER for knee swelling

3:08

and was previously, uh, diagnosed, sorry,

3:10

not two weeks earlier, but one week earlier with a uh, DVT.

3:14

And this extended from her gastroc anemia vein

3:18

to her PT vein.

3:20

So she just happened to have an outpatient MRI scheduled

3:24

after her ER visit.

3:27

And this is the paper that, uh, Dr.

3:29

Patria was referring to an investigation

3:31

that we did now about five years ago, of the

3:35

relative diagnostic accuracy of various imaging patterns

3:39

that may indicate the presence

3:41

of intramuscular vein thrombosis.

3:44

So those include perivascular intramuscular edema.

3:46

Again, that's edema confined

3:48

to the area immediately adjacent to the vessel

3:51

or intramuscular edema, which tends to be, uh,

3:54

can be more diffuse focal vein dilation

3:58

and abnormal intraluminal signal.

4:00

And this could be on PD or T two weighted images.

4:03

Unfortunately, this was a little bit of a subjective, um,

4:06

finding because as Dr.

4:08

Pat alluded, um, vessel signal intensity can be dependent,

4:12

uh, particularly, um, the flow rate within the, um, vein

4:17

and also if there's an adjacent venous valve.

4:20

Nevertheless, when, um, all parameters are present, um,

4:24

the diagnostic accuracy, especially for the specificity

4:27

or ruling in of an intravascular vein thrombosis

4:31

is very good.

4:33

So we diagnose this in about 13 patients.

4:36

It's important to know about a quarter of these patients

4:39

actually presented with central extension.

4:41

That means extension into the popal vein.

4:43

And it's important to note

4:45

and put that on your report

4:46

that these patients should get an ultrasound DVT

4:49

to make sure that there is no central extension,

4:52

because treatment

4:53

of isolated intramuscular vein thrombosis still is somewhat

4:57

debatable because of the risk of anticoagulation.