Interactive Transcript
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Hello and welcome to Noon Conference hosted by MRI online.
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3 00:00:06,570 --> 00:00:08,550 In response to the changes happening around the
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world right now and the shutting down of in-person
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events, we have decided to provide free
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Noon Conferences to all radiologists worldwide.
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Today we are joined by Dr. Rony Kampalath.
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Dr. Kampalath is an abdominal imager at the
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University of California, Irvine Medical Center,
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where he has worked for two and a half years.
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His professional interests include oncologic imaging,
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as well as resident and medical student education.
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A reminder that there'll be a Q and A session
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at the end of the lecture, so please use the
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Q and A feature to ask your questions, and we will
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get to as many as we can before our time is up.
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That being said, thank you
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all for joining us today. Dr. Kampalath,
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20 00:00:49,680 --> 00:00:51,269 I will let you take it from here.
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Thank you, Ryan.
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Okay.
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Um, so what I'm gonna talk about today, I'm
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gonna talk about some interesting and challenging
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cases from the ER that we saw at, uh, UC Irvine.
1:01
So I'm gonna talk about some interesting
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and challenging cases from the ER.
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Um, so the, um, basically what I'm gonna do, I'm
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gonna review some interesting, um, emergency and
1:10
inpatient CTs where, uh, significant pathology was
1:13
missed by the radiologist taking overnight call.
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And then we're gonna reflect a little bit on
1:17
the factors that contributed to these errors.
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Uh, most of these are gonna be, uh, CTs,
1:22
but there's some, there's some ultrasound
1:24
and MRI images scattered in there.
1:28
So if you're not familiar with our medical
1:30
center, we're UC Irvine Medical Center,
1:31
located in sunny Orange, California,
1:34
we're about an hour south of Los Angeles.
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Um, uh, let's see here.
1:41
Um, we have overnight call and I wanna explain a
1:45
little bit about how the overnight call is structured.
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We're a 417-bed acute care and teaching hospital.
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Uh, we're a tertiary referral center,
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and we're an NCI-designated Cancer Center.
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Um.
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Let's see.
1:59
We are Orange County's only Level 1 Trauma Center,
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and we're a Level 2 Pediatric Trauma Center.
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In fiscal year 2018, we saw over 51,000 ED
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visits, almost 16,000 surgeries, and about 4,300
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trauma patients were treated at our institution.
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Um, so the way our call is structured, uh,
2:18
an upper-level radiology resident provides
2:20
prelim interpretations for inpatient and ED CTs
2:24
from 4:00 PM to 7:00 AM the next day. Um,
2:27
from midnight to 7:00 AM, the resident is
2:30
accompanied, uh, virtually by a teleradiologist.
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So a second prelim report is generated
2:36
independently by an overnight teleradiologist,
2:38
and then a final report is rendered by a faculty
2:40
radiologist the following morning.
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Um, the call is really busy.
2:47
Our residents are awesome.
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They, uh, read about 140 to 160 total
2:52
cases over an entire overnight shift.
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And, uh, between midnight and seven
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o'clock, uh, they read between five and 15
2:59
CT abdomens and pelvises from the ER there.
3:02
And those are both read by the resident
3:04
and teleradiologist independently.
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So let me get into my, uh, first case.
3:11
Uh, so this is a case of a 31-year-old lady,
3:13
history of uncontrolled type 1 diabetes,
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methamphetamine abuse, and stage II cervical cancer.
3:19
Uh, she lives in a group home and she presents
3:21
with generalized weakness, uh, and she was noted
3:23
to be weak while walking down the stairs.
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Uh, she had a recent fall when her legs
3:28
gave out, and now she's complaining
3:29
of right hip pain radiating to the knee.
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So she got a CT of the abdomen
3:33
and pelvis without contrast.
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And these are her, uh, images.
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So if you take a look at the images, uh, the first
3:43
thing you kind of see is the bladder.
3:45
You can see that it looks like there's
3:46
air, uh, definitely in the bladder lumen,
3:48
and probably in the bladder wall as well.
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Um, and that's what draws your attention first.
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Uh, and if you don't look carefully at the rest
3:56
of the images, you might miss this finding.
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There's a focus of gas, which looks like it's, uh,
4:00
anterior to the right femur in the right hip joint.
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So what we ended up saying, the, uh, the
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overnight resident, um, read this case and
4:10
said the bladder is filled mostly with gas,
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concerning for emphysematous cystitis. Um,
4:16
but didn't comment on the right hip findings.
4:20
Um, the teleradiologist reading, um, in
4:23
parallel said there's diffuse amount of gas
4:26
in the bladder wall, consistent with emphysematous
4:27
cystitis. Again, didn't mention the hip.
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Then the faculty radiologist reading the
4:33
following morning said emphysematous cystitis, but he
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also commented on the right hip joint effusion
4:39
and gas with edema and hypoattenuation of
4:41
the adjacent muscles and fascial planes.
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Please correlate for infection and septic arthritis.
4:48
Um.
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So unfortunately the patient expired
4:53
from septic shock the following day.
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So this was an example of probable missed,
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um, uh, septic arthritis of the right hip.
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And the reason I, I'm discussing this case is to
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talk a little bit about satisfaction of search.
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So this is a sort of familiar concept in radiology,
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and, uh, the idea is that your visual search is
5:11
particularly error-prone if you have multiple targets.
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Uh, and this is called the satisfaction of
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search or subsequent search miss effect.
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And actually this isn't just, uh, unique to radiology,
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although we write about it a lot in radiology.
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Anyone who, um, evaluates images like TSA
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security screeners or people analyzing satellite
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photographs, um, are, uh, prone to this error.
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So both novice and more experienced radiologists
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can, uh, fall victim to satisfaction of search.
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Um, there are several theories as to
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what causes satisfaction of search.
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Um, the first is that, um, one, an observer becomes
5:48
satisfied with the nature of the evaluation after the
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first target, and then prematurely stops their search.
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Another idea is that after finding your
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first target, the radiologist becomes
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biased to look only for similar targets.
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Um, and another idea is that when the first
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target is found, you take your attention
6:05
and your working memory resources and
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allocate it to processing the first target.
6:09
And then you, um, you kind of forget about, uh,
6:12
any additional targets which may be present.
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I had an attending who, um,
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expressed this sort of very elegantly.
6:19
He would always ask me, what's
6:21
the hardest fracture to find?
6:23
And the answer, of course, is, uh, the second one.
6:27
Um, there's a couple ways to, uh, mitigate
6:30
the problem of satisfaction of search.
6:31
One is to keep a verbal checklist, always look at the
6:34
same things on every study the same way every time.
6:37
Uh, and then, uh, the corollary to that is to adopt
6:39
a specific order to report those abnormalities.
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And just being aware of the satisfaction
6:44
of search phenomenon, uh, can help you
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sort of mitigate, uh, this problem.
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Okay, great.
6:50
Moving onward.
6:51
This is the next case.
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In this case, a 37-year-old
6:54
guy was riding his motorcycle.
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He was helmeted.
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He laid his bike down in traffic at 20
6:59
miles an hour and then rolled over once.
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He denies loss of consciousness and
7:02
then came into the ER hemodynamically
7:04
stable with a benign abdominal exam.
7:07
And I'll have you look at these images.
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He got a CT of the abdomen and pelvis with contrast.
7:14
So just to orient you, this is a, a
7:16
coronal image on the left, and you've
7:18
got two axial images on the right.
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And, um, this loop of bowel here is a,
7:23
uh, is the splenic flexure of the colon.
7:27
So this is the finding right here, right?
7:28
The splenic flexure of the colon looks sort of weird.
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It's got a cystic, bubbly appearance.
7:33
There's all these cystic-looking
7:34
things in the, uh, in the colon wall.
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And then on your bottom right, you see an image
7:39
where it looks like there's a little bit of free air.
7:41
Remember, this is a patient who, uh,
7:42
laid his motorcycle down in traffic.
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So how was this read?
7:48
Um, initially we read it.
7:49
Um, the resident on call said, no evidence of
7:52
layering free fluid, no evidence of pneumoperitoneum.
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Um, the teleradiologist, uh, or rather the final
7:58
read, said there are small foci of pneumoperitoneum,
8:01
concerning for subtle bowel injury and perforation.
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There's a subtle cystic appearance of
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the splenic flexure of the colon.
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So because of the pneumoperitoneum,
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this guy actually went to surgery.
8:12
This, uh, we did a repeat CT.
8:14
It showed, uh, persistent pneumoperitoneum.
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The patient underwent an ex-lap.
8:18
Um, on the operative report it said there's no
8:20
evidence of bowel injury, but there were some
8:22
cyst-like structures projecting from the wall of
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the distal transverse colon and splenic flexure.
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Um, so what they, they went ahead and did a
8:30
segmental resection of this splenic flexure,
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and here's the gross path specimen you can see.
8:34
So this is the wall of the colon.
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These are the cystic structures that we saw on the CT.
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This was actually a case of
8:42
Pneumatosis Cystoides Intestinalis.
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And this is—what this is, is this is a rare
8:48
disease, and you get gas-filled cysts in the,
8:51
um, uh, intestinal submucosa and subserosa.
8:54
Um, it can occur in any age group,
8:56
anywhere in the GI tract, and
8:58
the pathogenesis is unclear.
9:00
The thinking is that there's some sort of
9:01
inflammation or physical damage of the intestinal
9:04
mucosa with increase in, um, intraluminal
9:07
pressure, and then formation of gas in the
9:10
wall of the bowel by gas-producing bacteria.
9:13
Um.
9:15
Right.
9:16
Um, it may be, uh, asymptomatic or
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associated with vague, kind of nonspecific
9:21
symptoms like diarrhea, constipation, or gas
9:24
distension. And treatment is really conservative,
9:27
typically, if it's indicated at all.
9:29
Um, and incidentally, there are a number of
9:31
case reports like this one in the literature
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where pneumatosis was mistaken for bowel
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perforation, and the patient underwent, uh,
9:37
surgery, which was ultimately unnecessary.
9:43
Okay, great.
9:44
Next case.
9:48
So you can see there's a big, um, so this is
9:50
presumably the uterus here on these axial images, and
9:53
there's a big sort of collection inside the uterus.
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And, um, it's kind of difficult to figure out
9:59
exactly what the orientation of the uterus is,
10:02
because this collection, this uterus, is so enlarged.
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Um, if you look.
10:06
Uh, here on this axial image, you
10:07
can tell where these arrows are.
10:09
This is actually the endocervical canal.
10:11
So this uterus is, um, uh, profoundly retro-
10:15
positioned, uh, kind of wedged almost,
10:17
um, underneath the, uh, sacral promontory.
10:20
Uh, but if you don't, if you don't make notice
10:23
that, it's unclear where the fundus is. But in
10:25
actuality, the fundus of the uterus is right here.
10:28
So what did we end up saying?
10:30
Um, there's a large, well-circumscribed,
10:33
heterogeneous mass in the midline of
10:35
the pelvis, likely represents the uterus
10:37
containing a large intrauterine hematoma.
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Uh, the teleradiologist reading afterwards
10:43
said there's a large hematoma present
10:44
within the uterus, and the myometrium is
10:46
indistinct with heterogeneous attenuation.
10:51
So she got followed up with an ultrasound.
10:53
Oh, I'm sorry.
10:53
The, uh, final read actually, uh, came back.
10:56
The uterus is enlarged with
10:57
likely intraluminal hematoma.
10:59
There's mass effect compressing the
11:01
bladder and the distal right ureter.
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So she got an ultrasound.
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Um, and I don't know if this adds any information,
11:08
but this is a, um, um, transverse view.
11:11
This is a sagittal view of the same thing.
11:13
You can see that the uterus is enlarged.
11:15
There's a heterogeneous collection.
11:17
You can see that it's kind of wedged
11:18
against the sacral promontory here.
11:20
Um, if you look, this is where we
11:22
were pointing to earlier on the CT.
11:23
This is the endocervical canal.
11:25
So the, um, uh, the uterus kind of
11:27
takes a, is severely retropositioned
11:29
and kind of takes an acute angle.
11:31
The ultrasound read said.
11:33
Uterine incarceration with a retroflexed
11:35
uterus and endometrial cavity containing
11:37
hematoma measuring up to 13 centimeters.
11:41
So this lady was actually taken
11:43
to the OR. Um, uh, on laparoscopy,
11:46
the retro-
11:46
the uterus was retroverted and stuck behind the
11:49
sacral bone, consistent with an incarcerated uterus.
11:52
Um, they reduced the incarcerated uterus.
11:55
About half a liter of blood came
11:57
out, uh, and the uterus shrank.
11:59
Uh, and at the end of the procedure, um, the uterus
12:02
was small and normal in size, about one third of
12:04
the size compared to the start of the procedure.
12:07
So this is a case of uterine incarceration,
12:10
and this often, usually when you read
12:12
about it, it occurs in pregnancy.
12:14
So it's a rare pregnancy complication in
12:16
which the uterus grows, but it's, uh, retro-
12:18
positioned and becomes trapped between the
12:20
sacral promontory and the pubic symphysis.
12:23
It can occur in any trimester, uh, or during
12:26
the postpartum period, like in this patient.
12:28
And, uh, the thinking is that pelvic masses, adhesions,
12:31
or variant anatomy predispose to this condition.
12:37
Okay.
12:37
Moving onward to another pregnancy case.
12:40
This is a 33-year-old lady.
12:41
She was 31 weeks pregnant.
12:43
Prenatal ultrasound a few weeks prior
12:45
showed bilateral adnexal masses concerning for
12:48
germ cell tumors. That was done at an outside hospital.
12:51
The patient was transferred to our institution.
12:54
Uh, she presents with intermittent
12:55
lower abdominal pain since last night.
12:58
The pain is diffuse, crampy, and intermittent.
13:02
For whatever reason, they did a non-contrast CT.
13:04
I'm not really sure why, uh, that was chosen.
13:07
Uh, but this was, uh, this was the CT, and, uh,
13:10
I can give you a second to take a look at it.
13:17
Um, so the resident overnight said, sorry, I. Um,
13:25
there's a complex cystic and solid right adnexal mass.
13:28
There's a left adnexal cystic mass.
13:30
The findings are concerning for ovarian neoplasm, and
13:33
the resident recommended further evaluation with MRI.
13:42
Okay.
13:42
On the final read, we said there's two
13:44
large ovoid, multiloculated, solid and cystic
13:47
structures on either side of the uterus.
13:49
Given the large size of these structures,
13:51
ovarian torsion should be considered.
13:56
So the patient, the images from the
13:59
subsequent ultrasound, you can see
14:00
that the right ovary is enlarged.
14:02
There's this kind of a central
14:04
echogenic stroma with peripherally, um,
14:07
arranged follicles, and there's no flow.
14:09
We didn't see any arterial or, or
14:11
venous flow in the right ovary.
14:13
The left ovary was also enlarged, lots of cysts, but
14:15
we did see arterial and venous flow in that ovary.
14:18
So what we ended up saying was.
14:20
Enlarged right ovary with architectural distortion,
14:23
no arterial or venous flow at the right ovary.
14:25
And we said the findings are compatible
14:27
with right-sided ovarian torsion.
14:29
So she got taken to the OR, and on our next
14:31
lap, they saw a 12-centimeter ovoid, right
14:33
adnexal mass consistent with acute ovarian torsion,
14:36
with infarction and necrosis.
14:38
There were underlying benign
14:40
ovarian cysts in that ovary.
14:42
So then if you look back at this CT, um, and
14:46
you just kind of zoom in on this right ovary, I.
14:51
You think about the classic
14:54
description of ovarian torsion.
14:56
Here's an image of an MRI of ovarian torsion.
14:59
The classic description is you have a
15:00
central sort of echogenic stroma with
15:04
peripheral displacement of the follicles.
15:06
And maybe I'm hallucinating here, but I, I kind
15:08
of see that now, maybe on this non-contrast
15:11
CT, you see this kind of central hyperattenuating
15:14
stroma with peripherally displaced follicles.
15:17
Maybe that could have been a clue that this was
15:19
a torsed ovary rather than a, uh, germ cell tumor.
15:23
So ovarian torsion in pregnancy, the
15:25
classic description, as we just mentioned,
15:27
a unilaterally enlarged ovary with
15:29
peripheral displacement of follicles,
15:31
is the classic sort of description.
15:33
Pelvic free fluid and inflammatory fat
15:35
stranding are generally present on, uh, CT.
15:38
And if you do give contrast, you can see
15:40
hemorrhage and absent, uh, adnexal enhancement.
15:43
The sort of hallmark, super-specific finding
15:46
on CT is a twisted adnexal pedicle.
15:49
So if you see a spirally twisted adnexal
15:51
pedicle, that's considered
15:53
pathognomonic on CT for ovarian torsion.
15:57
Um, it's not all that rare in pregnancy.
15:59
10 to 20% of ovarian torsion does occur in pregnancy.
16:02
Um, it usually occurs in the first or early
16:05
second trimester, and for whatever reason,
16:06
usually on the right, and the thinking is
16:09
that exogenous ovarian stimulation, um,
16:12
uh, increases the incidence of torsion.
16:17
Uh, right.
16:17
So an underlying ovarian lesion is
16:19
typically present, most often a corpus
16:21
luteum cyst in pregnant patients.
16:26
Great, moving onward.
16:29
Uh, this is a 68-year-old gentleman.
16:31
He, uh, was a sick guy.
16:32
He had, uh, erythrodermic psoriasis,
16:35
transferred from an outside hospital, uh,
16:37
and he was, uh, he had a septic picture.
16:39
His blood cultures were positive
16:40
for Pseudomonas, MRSA, and Candida.
16:42
So he is both bacteremic and fungi.
16:45
So let me play a short video here.
16:47
This place.
16:52
So this was his CT, uh, done to evaluate a
16:55
further evaluation in a patient with sepsis.
17:04
Okay.
17:07
So, I don't know if you caught the finding, uh, but
17:09
the finding is actually in the anterior abdomen.
17:12
Um, the person reading, uh, this
17:14
study initially didn't see it.
17:16
Uh, it was, uh, and we read the CT as mild
17:19
gallbladder wall thickening and edema.
17:21
Uh, there's diffuse anasarca and there's
17:23
wall thickening of the urinary bladder.
17:25
So the kind of subtle finding that we didn't
17:26
catch on the initial read was this thing,
17:29
uh, which is actually a branch of the gastro-
17:31
epiploic artery, and it looks kind of dilated.
17:34
It looks like there's some mural thrombus in it.
17:36
Uh, it looks very irregular.
17:39
Four days later, the patient presented
17:40
with worsening abdominal pain and got a CT.
17:42
This was his CT.
17:43
Uh, four days later.
17:45
And you can see this, there's,
17:47
there's new findings on this CT.
17:48
One is he's got a moderate sized hemoperitoneum.
17:51
Now he's still got this irregular-looking,
17:53
um, vascular structure here in the anterior
17:55
abdomen, and he has got a, he's got a
17:57
heterogeneous clot here in his anterior abdomen.
18:00
So what we ended up saying was there's a
18:02
moderate volume hemoperitoneum, large acute
18:05
to subacute hematoma noted along the greater
18:07
curvature of the gastric fundus and body.
18:09
The hemorrhage likely arises from
18:11
the two-centimeter pseudoaneurysm.
18:14
This patient went to the IR suite.
18:15
They, uh, cannulated what looked like a, um,
18:18
pseudoaneurysm off the branch of the, um, uh, left
18:21
gastroepiploic artery, and then they embolized it.
18:26
So this is a case of a gastroepiploic artery aneurysm.
18:29
This is very rare, uh, only a few
18:31
reported cases in the literature.
18:33
Um, and although it's rare, if
18:34
it does happen, it can be bad.
18:36
Uh, the rate of rupture is reported to be 90%, and
18:38
when the rupture does happen, mortality is about 70%.
18:42
Uh, and the most common contributing
18:44
factor is thought to be atherosclerosis.
18:46
Um, but other potential contributing
18:49
factors could be collagen vascular disease,
18:51
fibromuscular dysplasia, infection, or vasculitis.
18:54
In this patient, we think, 'cause he was
18:56
septic, we think that, uh, this was actually
18:58
a mycotic aneurysm of the, uh, gastroepiploic artery.
19:02
Um, so yeah.
19:07
Great.
19:07
Moving on to the next case.
19:10
This is a 54-year-old lady.
19:12
She was at work and she was stabbed multiple times
19:14
to the chest and arms during an attempted robbery.
19:18
She got a CT of the abdomen and
19:19
pelvis, and these are the images.
19:22
I'll give you a second to take a look.
19:27
So the fi, the sort of salient findings
19:29
are pointed to you in the arrows.
19:31
Here.
19:31
You can see that, uh, here on the top left, it
19:34
looks like there's a little bit of herniation
19:36
of fat, which is confirmed on the sagittal.
19:38
Here there's a little bit of herniation of
19:39
fat, and you got some air, uh, which probably
19:42
represents, um, um, where she was stabbed.
19:49
So the resident reading it overnight,
19:51
there was actually no other post-traumatic
19:53
finding in the abdomen or pelvis.
19:54
So the resident reading it overnight said,
19:56
no acute findings in the abdomen or pelvis.
19:59
Uh, the teleradiologist overreading,
20:00
it said there's no acute traumatic
20:02
abnormality in the abdomen or pelvis.
20:06
And on the final read we said there's a focal
20:08
defect in the upper left ventral abdominal
20:10
wall with associated herniation of omental
20:12
fat, likely due to penetrating trauma.
20:15
The defect involves a diaphragmatic slip.
20:18
So because of that, the patient went to the OR.
20:20
Diagnostic laparoscopy was performed and they
20:23
found a three-centimeter left diaphragmatic, um,
20:26
injury with a hernia, uh, with omentum inside.
20:29
Uh, the patient underwent repair
20:31
of her left diaphragmatic injury.
20:33
So, uh, my mantra that I tell all the
20:37
residents in penetrating trauma is, in
20:40
penetrating trauma, trajectory is everything.
20:43
So make sure that you understand the
20:45
trajectory to the best of your ability and, uh, look,
20:48
uh, look carefully for any, uh, organs along that
20:51
trajectory to make sure they are or are not injured.
20:55
Anytime someone has a bullet wound or a stab wound,
20:58
anywhere between their nipples and umbilicus,
21:00
you should think about transdiaphragmatic injury.
21:04
Remember, that trajectory can be difficult to
21:06
trace, especially if, like in this case, there
21:08
are multiple stab wounds or bullet wounds to the
21:11
thoracoabdominal region above and below the diaphragm.
21:15
Um.
21:17
Uh, remember, penetrating diaphragmatic
21:19
injuries are usually small, and they can
21:21
be almost invisible on axial images.
21:24
So, uh, remember to evaluate
21:26
your, uh, multiplanar reformats.
21:28
Um, if you do suspect a diaphragmatic injury,
21:31
one of the specific signs, or rather sensitive
21:33
signs described for diaphragmatic injury in the
21:36
literature is the so-called contiguous injury sign.
21:39
So in a patient with penetrating trauma,
21:41
if you have evidence of injury both above and
21:44
below the diaphragm, and the trajectory appears
21:46
to cross the diaphragm, you should look very
21:48
hard, uh, and suggest diaphragmatic injury.
21:52
Herniation, like we saw in this case, is very specific
21:55
for diaphragmatic injury, but it's insensitive.
21:58
So just as a cautionary tale, I want to
22:00
show you this companion case, which is kind
22:01
of the nightmare scenario of what happens
22:03
if you miss a, uh, diaphragmatic hernia.
22:06
This is a 31-year-old guy who,
22:08
uh, stabbed himself in the chest.
22:11
He got a CT of his, uh, chest and, um,
22:15
you know, there's lots of findings here.
22:19
Um, but the one I wanted to call
22:21
attention to is here on the sagittal view.
22:24
You can see there's a visible defect in the
22:26
diaphragm with herniation of mesenteric fat.
22:31
Um, unfortunately, uh, I guess we
22:33
were focused on the lung findings.
22:35
So we said, we described the pulmonary contusions,
22:37
small left hemo pneumothorax, but we did not,
22:39
uh, describe the, uh, diaphragmatic injury.
22:43
And the patient actually came back one year later,
22:46
uh, with abdominal pain, uh, and nausea with this CT.
22:49
And you can see that through the preexisting
22:51
diaphragmatic injury, the gastric
22:53
fundus has now herniated through it.
22:56
Um.
22:57
So that was his finding.
22:58
A year later he was admitted to the hospital
23:01
and he got this CT the following day.
23:03
You can see now there's worsening gastric, uh,
23:06
herniation, um, with compression of his left lung.
23:09
Uh, he had worsening symptoms, so, um, GI emergently
23:12
scoped him and, uh, the EGD showed a strangulated
23:16
gastric hernia with purple and erythematous mucosa,
23:19
and they weren't able to reduce it endoscopically.
23:22
Unfortunately, the patient was too unstable
23:24
to be taken to the OR, and, uh, he expired from
23:26
septic shock and severe ARDS two days later.
23:29
This was all from a diaphragmatic
23:31
injury one year prior.
23:35
Okay, moving on to the next case.
23:37
Now we're gonna stay on the topic of stabbings.
23:40
This is a 36-year-old gentleman
23:41
who was stabbed during an assault.
23:44
Here was his CT of the abdomen and pelvis.
23:56
Okay, let's move on.
23:58
So these were the kind of
23:59
relevant images from that CT.
24:00
You can see on the top left, it looks like
24:02
there's a little bit of a pneumomediastinum.
24:04
Um, there's some, uh, pericardial thickening, uh, that
24:08
you can see both on the axial and the coronal images.
24:11
So.
24:11
And then you can see this density
24:12
here, which looks like it's similar to
24:14
the blood pool in the left ventricle.
24:17
Um, and, uh, you know, another thing,
24:19
uh, remember, trajectory is everything.
24:21
The fact that there's injury here in the pericardium.
24:24
Uh, on the, the video we saw that there was
24:26
evidence of injury in the left chest wall.
24:29
Think about, think about cardiac injury.
24:32
So these are the, uh, these are the, um, findings.
24:38
The resident said there's anterior pericardial
24:40
thickening concerning for pericardial
24:41
hematoma, no evidence of cardiac tamponade.
24:46
Teleradiologist reading in parallel said
24:48
there's a large left pleural effusion.
24:49
There's hyperdense material worrisome for hemorrhage.
24:53
592 00:24:53,550 --> 00:24:54,990 And on the final read, what we ended up
24:54
saying was there's a trace pericardial
24:56
effusion, query small hemopericardium.
24:59
There's a stab wound injury in the anterior
25:01
lateral lower chest wall with trace gas and
25:03
stranding between the anterolateral left
25:06
hemidiaphragm and chest wall,
25:07
extending close to the pericardium.
25:10
So this guy, uh, went to the OR. He underwent
25:14
thoracotomy and he had a 200 cc hemopericardium
25:17
and a two-centimeter full-thickness cardiac
25:19
laceration, and they did a pericardial window.
25:22
So this is an example of cardiac
25:24
trauma due to penetrating trauma.
25:26
Sorry.
25:28
And the clinical variation presentation can be
25:31
very variable, and we're not really conditioned to
25:33
look for this because CT isn't very often ordered
25:36
specifically to evaluate for cardiac injury.
25:39
Uh, usually in cardiac injury, the right
25:41
ventricle is the most commonly injured location,
25:43
although in penetrating trauma, anything goes,
25:46
and this guy, uh, had a left ventricular injury.
25:49
The patients kind of, uh, patients kind of present
25:51
with, uh, nonspecific symptoms, chest pain, dyspnea,
25:55
arrhythmia, all could be signs of cardiac trauma.
25:58
And, uh, in the literature they describe both
26:00
direct signs and indirect signs of cardiac trauma.
26:03
Direct signs include decreased myocardial attenuation,
26:06
active extravasation, like we probably saw in
26:09
this case, and focal outpouching or a defect
26:11
in the myocardium, are considered direct signs.
26:15
Indirect signs, pulmonary edema, cardiac chamber
26:18
enlargement, pneumopericardium, hemopericardium,
26:21
or a suspicious trajectory should all make you
26:23
raise your antenna for, uh, cardiac trauma.
26:27
Okay, moving onward.
26:29
This is an 18-year-old guy with bright
26:32
red blood per rectum who presented to an
26:34
outside hospital, um, with a hemoglobin of
26:37
seven and syncope requiring rapid transfusion.
26:40
Um, he underwent EGD, colonoscopy, and Meckel scan,
26:44
um, and those were all negative for acute bleeding.
26:47
A capsule endoscopy showed a small
26:49
AVM but no evidence of bleeding.
26:51
So we did a CTA of the, uh, abdomen and pelvis,
26:54
and I want you to focus your attention on
26:56
the right side of the patient's right side.
27:02
And this was a little bit of a heroic call,
27:04
so I wouldn't feel bad if I don't see it.
27:11
Okay, so this was the finding, actually very subtle.
27:18
Right here there's a little, uh, it
27:19
looks like a bright enhancing vessel
27:21
on the right lower quadrant bowel.
27:23
And then here are the multiphase images.
27:25
So your pre-contrast here, arterial
27:27
phase, and then delayed phase.
27:28
Here you see this enhancing sort
27:30
of serpiginous vessel in the bowel.
27:32
Um, there's no real pooling of contrast.
27:35
It's not clear whether it's actively
27:36
bleeding at the time of this scan.
27:37
655 00:27:40,560 --> 00:27:43,110 So what we ended up saying was, uh, well, the resident
27:43
said there's no CT evidence of active gastrointestinal
27:45
bleeding, which is probably technically true.
27:48
Um, on the final read we said there's a small
27:50
enhancing serpiginous-shaped tangle of vessels in the
27:53
wall of a small bowel loop in the right mid abdomen.
27:56
No evidence of active
27:57
contrast extravasation at this site.
27:59
So they ended up scoping him.
28:00
They were able to reach that site using
28:02
an enteroscopy, and this is what they saw.
28:05
Uh, there was a large blood clot in the
28:06
proximal to mid jejunum, uh, no active
28:09
bleeding on initial visualization.
28:11
Uh, and they used straight suction to remove
28:13
the clot, and this revealed what was
28:15
likely a Dieulafoy lesion with active oozing.
28:19
Um, because they weren't able to completely
28:20
stop the bleeding on, um, scope, the patient
28:23
went to the OR and underwent small bowel
28:25
resection with primary reanastomosis.
28:27
On path, they showed a rupture of a
28:30
submucosal malformed artery,
28:32
consistent with a Dieulafoy lesion.
28:34
I. So what is a Dieulafoy lesion?
28:37
Uh, a Dieulafoy lesion is a histologically normal
28:39
GI tract vessel, which is abnormally large and
28:42
runs a tortuous course through the submucosa.
28:46
It's a relatively rare cause of acute, uh, GI
28:48
bleeding, and it can occur in the stomach, although
28:52
one third of lesions are elsewhere, like in this case.
28:58
Um, it was once thought to be acquired
29:01
and aneurysmal, uh, but there have been some case
29:03
reports of Dieulafoy lesions occurring in newborns,
29:05
suggesting a congenital, uh, etiology, and
29:09
the exact pathogenesis, um, is poorly understood.
29:13
The thinking is that there's
29:14
some form of, um, there's a, um.
29:17
Uh, congenitally abnormal vessel, um, which
29:20
undergoes some sort of ischemic
29:23
injury or mucosal erosion, which, uh, weakens
29:26
an intrinsically vulnerable point and then
29:28
unmasks the lesion, resulting in, uh, GI bleeding.
29:33
Um, so treatment can be endoscopic or angiographic.
29:35
Surgery is reserved for cases
29:37
of treatment failure, like in this case.
29:41
Alright, moving onward.
29:44
Uh, here in the, uh, this is the ER patient
29:47
that provided history was abdominal pain.
29:50
These are the images.
29:57
So, um, the findings are here.
30:03
So you see this ill-defined hypodense lesion
30:06
in the pancreas, and in the coronal images,
30:08
it appears that there's actually
30:09
several of them here, here.
30:11
Here, um, there's, uh, there's some indication
30:16
that something else, uh, may be going on with
30:18
this patient other than pancreatic lesions.
30:19
You see all these, um, collaterals
30:22
in the anterior abdominal wall.
30:24
What we ended up saying, the residents
30:26
said, uh, ill-defined low-density
30:28
masses at the neck of the pancreas.
30:30
Intraparenchymal mass vs. focal pancreatitis
30:32
may be considered; correlate with amylase and
30:34
lipase, and consider follow-up dynamic imaging.
30:37
We also commented on multiple
30:39
anterior abdominal varices.
30:41
The teleradiologist reading it said
30:43
there's two nodular structures at
30:44
the neck and body of the pancreas.
30:46
These are incompletely characterized.
30:48
They're also prominent venous collaterals
30:50
throughout the anterior and lateral abdominal wall.
30:54
Um, so, um.
30:56
What, um, we didn't, uh, it would've
30:58
helped if we looked at this chest CT
31:00
that was done four months earlier.
31:02
Uh, and the patient has a history of
31:03
lymphoma, which wasn't provided to us,
31:05
and she has this big mediastinal mass.
31:07
It looks like it probably obstructs
31:08
the SVC and is responsible for those
31:10
abdominal collaterals that we saw earlier.
31:14
So on the final read, we said hypo-
31:16
attenuating structures in the pancreas.
31:18
Given diagnosis of lymphoma, this
31:20
may represent disease involvement.
31:22
So this is a case of non-Hodgkin's lymphoma. The
31:25
pancreas — primary pancreatic lymphoma is rare,
31:28
but secondary and extranodal involvement of the
31:30
pancreas by non-Hodgkin's lymphoma is not uncommon.
31:34
And up to 30% of patients with widespread disease
31:36
may actually have involvement of the pancreas.
31:39
And, uh, this can present as well-
31:41
circumscribed masses or a diffuse form.
31:44
This case we saw, well, sort of
31:46
mild, well-circumscribed masses throughout the
31:48
pancreas, and it can be easily confused with
31:51
pancreatitis, like it was maybe in this case.
31:55
There's some ways you can distinguish pancreatic
31:58
lymphoma from pancreatic adenocarcinoma, uh, one of
32:01
which is dilation of the main pancreatic duct tends
32:04
to be much more severe in pancreatic adenocarcinoma.
32:08
Um, uh, uh.
32:12
Lymphadenopathy below the renal vein is
32:14
more common in pancreatic lymphoma, um, and
32:17
infiltrative disease of the surrounding organs.
32:20
Uh, the retroperitoneum and the GI
32:22
tract is more common in lymphoma than
32:24
it is with pancreatic adenocarcinoma.
32:28
Um, on the other hand, pancreatic lymphoma
32:30
less commonly invades the vasculature.
32:33
And then tumoral calcification is less common in
32:35
pancreatic lymphoma than it is in adenocarcinoma.
32:42
Okay, moving onward to the next case.
32:44
This is a 29-year-old female,
32:48
rule out ectopic pregnancy.
32:50
The patient got this ultrasound.
32:53
You can see immediately.
32:54
So this is a transverse view.
32:55
This is a sagittal view of the uterus.
32:57
You can see immediately that the,
32:59
uh, gestational sac looks kind of
33:01
eccentrically placed, uh, within the uterus.
33:04
Um, uh, you can't tell that
33:06
as well on the sagittal image.
33:08
What we ended up saying was, intrauterine gestational
33:11
sac appears in high-end position in the left uterine
33:14
horn with some margins demonstrating near 0.5
33:18
centimeter thickness of the overlying myometrium.
33:21
The overall appearance is concerning
33:23
for interstitial implantation.
33:24
The.
33:25
So if you guys don't remember, uh, if you need
33:27
a refresher as to what interstitial implantation
33:29
is, here's an image from Radiographics,
33:32
uh, showing interstitial implantation.
33:34
And what it is, is the gestational sac implants in
33:37
the intramyometrial segment of the fallopian tube.
33:40
Um, so, um, right about here.
33:45
Uh, the classic sort of radiologic finding
33:48
is that you see an eccentrically located
33:50
gestational sac surrounded by a thin layer
33:52
of myometrium that measures less than five.
33:57
So we ended up getting an MRI because there
33:59
was a little ambiguity on the, uh, original
34:01
ultrasound images, and this is what we found.
34:07
Unfortunately, there was a lot
34:08
of motion artifact on this MR.
34:12
So these are the axial T2-weighted images,
34:21
and then we did, uh, these are the coronal,
34:23
um, T2-weighted fat-sat images.
34:33
All righty.
34:35
So these are the images, these
34:36
are the sort of screenshots.
34:38
Um, and it's kind of hard to
34:39
figure out what's going on here.
34:41
This is the gestational sac right here, and here.
34:44
It doesn't look as eccentrically located
34:46
in the uterus as it did on the ultrasound.
34:48
In fact, here it looks kind of centrally
34:50
located actually within the endometrium.
34:52
There's this structure here, which is maybe
34:54
a fibroid or an adenomyoma or something, uh,
34:57
which we didn't really see on the ultrasound.
34:59
Um, so, uh, the trainee initially
35:01
reading it said, oh, it doesn't look.
35:04
Like, um, interstitial pregnancy.
35:09
So, uh, we were kind of uncertain.
35:11
It was, it was difficult to
35:12
figure out what was going on.
35:13
So we had the patient come back, um, to
35:15
repeat some T2-weighted images, and
35:17
this is what we saw, uh, a few hours later.
35:27
And then these are the coronal T2s.
35:36
Okay, so, so these are the,
35:38
these are the follow-up images.
35:39
Done.
35:40
A few done a few, um, few hours later.
35:44
And this, you'll notice, looks kind of different.
35:47
It looks like the gestational sac is here.
35:48
It definitely looks eccentrically
35:49
located in the uterus right now.
35:51
And here there's very thin
35:53
myometrial coverage of this gestational sac.
35:55
Probably less than five millimeters.
35:58
So we read this MRI as left
35:59
interstitial pregnancy. Overlying
36:01
myometrium is thin to 1.5 millimeters.
36:05
So what happened between this case, these images?
36:09
The gestational sac looks centrally located,
36:11
and these images done a few hours later where
36:13
the, uh, gestational sac looks eccentrically
36:15
located, and we ended up diagnosing it
36:18
with interstitial, uh, pregnancy.
36:21
This patient incidentally went
36:22
to the OR after this MRI and, uh,
36:24
interstitial pregnancy was confirmed.
36:29
This was a case of myometrial contraction.
36:31
Um, so myometrial contractions are something
36:33
you have to be, uh, kind of careful about.
36:36
They can mimic a benign uterine pathology such
36:38
as fibroids or adenomyosis and endometriosis,
36:41
or they can lead to overstaging in malignancy.
36:44
And if you suspect myometrial contraction,
36:46
like we did in this case, you can do a repeat T2-
36:49
weighted acquisition in the conclusion of the
36:50
study and it may be helpful to differentiate
36:54
myometrial contraction from, um, um.
36:58
Myometrial contraction, uh, from something else.
37:01
And then you can see if we go back to these
37:03
images, so it looks like there was
37:05
a myometrial contraction that was actually
37:06
pushing this eccentrically located gestational
37:09
sac and giving it a more central appearance.
37:12
But after we did the images a few hours
37:13
later, um, it turned out to be an
37:16
interstitial pregnancy.
37:24
Okay, moving onward to the next case.
37:27
So this patient is a 41-year-old male with a
37:30
recurrent pancreatitis history, complicated
37:32
by portal vein thrombosis and pseudocyst.
37:35
The patient presents with diffuse abdominal pain.
37:41
So the patient had, uh, a couple CTs.
37:43
This one is, uh, from September 2019.
37:46
This one was from, uh, October 2019.
37:49
You can see there's a lot of
37:50
collaterals in the upper abdomen.
37:53
This was, uh, one of the CTs I
37:55
believe in, um, October 2019.
37:58
I'll let you see the images.
38:06
Okay, great.
38:08
So here are the arterial phase images on
38:09
your left, portal venous phase images on
38:11
your right, and the finding here is this.
38:18
Here you see 'em on, um, here
38:20
you see 'em on coronal images.
38:24
The initial resident read said, demonstration of a bilobed
38:26
peripancreatic walled-off necrotic collection.
38:29
There's increased hyperattenuating
38:31
material in this collection.
38:32
This could represent debris,
38:34
hematoma, or infectious process.
38:37
On the final read, we said there's a 2.5 by 1.7
38:40
centimeter rounded hyperdense structure in the
38:42
superior aspect of the bilobed collection, and it
38:44
represents a splenic artery pseudoaneurysm.
38:47
The patient went to the IR suite.
38:50
They, um, uh, found a pseudoaneurysm.
38:53
It was a large pseudoaneurysm, which arose from
38:55
the posterior gastric artery, which itself arose
38:57
from the splenic artery, and they embolized it.
39:01
So this was a case of a splenic artery
39:02
pseudoaneurysm, initially not recognized.
39:05
These can be caused by pancreatitis, trauma,
39:07
surgery, or rarely peptic ulcer disease.
39:10
Um, in 41% of cases, there's a coexisting
39:12
pseudocyst, and it can often be asymptomatic.
39:16
I. Um, but, um, um, presenting
39:20
symptoms may include pain, GI bleeding,
39:22
or hemorrhage into the pancreatic duct.
39:24
And these, uh, tend to rupture. The risk of,
39:27
uh, rupture is as high as 37%, and if they
39:29
do rupture, mortality rate is close to 90%.
39:34
So an important thing to look for in a patient
39:36
with severe pancreatitis, especially when
39:38
they have a pseudocyst, look for a splenic
39:41
artery pseudoaneurysm as a complication.
39:43
'Cause these can be potentially lethal.
39:47
Okay.
39:48
Um, moving onward.
39:51
This is a patient, he is a 52-year-old guy.
39:53
He was struck by a vehicle traveling at
39:55
about 50 miles per hour on a surface street.
39:58
He was thrown 25 feet with a
40:00
temporary loss of consciousness.
40:02
These were his CT images.
40:06
And, uh, the finding that I guess
40:08
jumps out at you most is this one here.
40:10
There's a linear laceration in the liver.
40:14
The finding.
40:15
The second finding that's kind of
40:16
more difficult to see is this here.
40:21
There's a focal little blush right
40:23
next to the aorta in the right retroperitoneum.
40:27
What we said on the initial read: there's small
40:29
amounts of free fluid throughout the abdomen.
40:32
Findings are suspicious for bowel contusion.
40:34
There was some free fluid.
40:36
Um, the initial liver laceration was
40:39
not described, but the teleradiologist
40:41
said there's a linear lucency in the right
40:43
hepatic lobe consistent with liver laceration.
40:46
And, um, actually neither of them
40:48
mentioned this little retroperitoneal
40:49
high-density focus that we pointed to.
40:51
I.
40:54
This patient ended up having, uh, an episode of
40:56
hemodynamic instability, tachycardia, and hypotension.
41:00
They did a FAST scan, which was negative,
41:02
and the patient was taken for ex-lap.
41:04
They saw the grade one liver
41:05
laceration, which they cauterized.
41:07
Um, but they also found a right zone two
41:09
retroperitoneal hematoma, which was non-
41:11
pulsatile and non-expanding, which probably
41:14
is what, uh, we saw on this CT here.
41:20
So this is an example of
41:21
retroperitoneal injury in blunt trauma.
41:23
Remember, retroperitoneal
41:25
injuries can be super subtle.
41:26
Um, and one of the things that can help you is
41:28
thinking about the pattern of injury in blunt trauma.
41:31
Um, so think about the part of the body that
41:33
struck first, the patient's body habitus,
41:36
and whether he or she was wearing a seatbelt.
41:38
Um, if you see, um, right rib, right hepatic
41:42
lobe, right lung, and right kidney injuries,
41:44
um, think about other retroperitoneal
41:46
injuries, um, because in blunt trauma, multiple
41:49
organs are often affected simultaneously.
41:52
I. Sometimes it's hard to figure out
41:55
exactly where the retroperitoneal injury is.
41:58
Blunt trauma injuries to the
41:59
abdominal aorta and IVC are rare.
42:02
Uh, but retroperitoneal hemorrhage
42:03
is actually quite common.
42:05
And when you look at your, um, trauma CT,
42:07
um, you may not be able to figure out exactly
42:10
where the retroperitoneal bleed is coming from.
42:12
So instead, focus on the location, the
42:14
source, and the stability of hemorrhage.
42:16
And you can still be very helpful to the surgeons.
42:20
Um, you'll sometimes read in your surgical reports
42:22
the surgeons referring to the zones of the retroperitoneum.
42:26
Zone one is this right here, and it refers
42:29
to the central retroperitoneum, which
42:31
contains the aorta, the IVC,
42:34
and portions of the renal arteries.
42:37
Zone two is considered the lateral retroperitoneum.
42:40
This contains the adrenal glands and the kidneys.
42:43
And then zone three, which I'm not showing
42:44
here, is actually the pelvic retroperitoneum.
42:46
Retroperitoneum.
42:47
Um, so if you think about how, um, surgeons
42:50
classify retroperitoneal bleeds, um, and then rather
42:54
than focusing on the source, just focus on the
42:56
location and stability of retroperitoneal bleeds.
42:58
You can still be helpful to the surgeons if you're
43:01
not able to figure out which exact organ was injured.
43:05
And, uh, that's all I have.
43:07
Thank you very much.
43:09
Let's question, well, it does
43:10
look like, have a few questions in the Q&A feature.
43:15
Okay, so the first question is,
43:17
was pneumatosis related to trauma?
43:20
Um, I think you're referring to the, um,
43:24
the case earlier of, uh, pneumatosis cystoides
43:28
intestinalis, and, um, it's hard to say for sure.
43:30
What we think happened was, um, these,
43:33
this patient had, uh, these, uh, cysts in his.
43:36
Let's see if I can go all the way back.
43:37
It might be hard, but ultimately what we, what we
43:41
thought was the patient had these preexisting cysts
43:43
in the wall of his, uh, splenic flexure of his colon.
43:46
Uh, maybe he had some mild trauma to his abdomen,
43:48
which caused, uh, rupture of one of these
43:50
cysts, which gave him pneumatosis, but there
43:52
wasn't, um, there wasn't frank bowel injury.
43:56
Um, patients from what I understand can
43:58
also present with pneumatosis completely
43:59
unrelated to trauma, uh, with this condition.
44:02
Um, and they tend to present with a benign abdomen.
44:07
Um, great.
44:09
The second question is, is myometrial
44:11
contraction limited only to a gravid uterus?
44:13
No, not necessarily.
44:15
Um, myometrial contraction can occur, um,
44:18
in, um, gravid or non-gravid uterus and, uh,
44:21
it can be a factor in, um, cancer staging.
44:24
You can occasionally see, um, myometrial
44:26
contraction that leads to accidental overstaging
44:29
of, um, of, uh, cancer in non-pregnant patients.
44:35
Okay, the following question.
44:37
In your hospital, would the staff radiologist
44:39
validate and finalize reports for trauma cases
44:41
who are clinically ill, either through telerad
44:44
or are they finalized the next day?
44:47
So the way our call works is that, um, the,
44:50
uh, that critically ill trauma patients that
44:53
their imaging is initially read by a resident.
44:56
Um, and then the, um,
44:58
Uh, the case is also read, uh, at the
45:01
same time by a board-certified tele-
45:03
radiologist who, uh, sends in their report.
45:06
And so the, uh, clinicians have two reports, both
45:09
the resident prelim and the teleradiologist prelim.
45:12
The teleradiologist pre, uh, teleradiologist.
45:14
Although they are board-certified,
45:16
they don't provide final reads.
45:17
So final read is ultimately, uh, get made by the
45:21
faculty radiologist reading the following morning.
45:26
Right.
45:27
So the, the question they only finalize the next day.
45:29
Yeah.
45:29
The, the final reports are, uh,
45:31
provided the following morning.
45:34
Next question.
45:35
Can you explain again that small pseudoaneurysm of
45:37
the small artery in the mesentery on case three or so?
45:42
Why was it hyperdense on native small pseudoaneurysm?
45:51
Which case were we referring to?
45:55
They did, they did reference
45:56
case three in their question.
45:59
Yeah.
45:59
I don't see a pseudoaneurysm in case three, small
46:05
pseudoaneurysm of the small artery in the mesentery.
46:08
See, maybe Dr. Stanek.
46:10
Could you, uh, follow up?
46:12
I, maybe we can, uh, move along to the
46:14
next question and see if we can get
46:16
a little more, uh, clarity on that.
46:18
Okay.
46:18
Okay.
46:18
Sorry.
46:21
So why was CT preferred over MRI in the
46:23
case of ovarian torsion in pregnant patient
46:25
if the ultrasound is not conclusive?
46:27
Yeah.
46:27
I actually don't know why that happened.
46:30
Um, the, the patient got much of her imaging at an
46:32
outside institution and came to our institution with.
46:36
A presumptive diagnosis of ovarian neoplasm.
46:39
And, um, I think that may have
46:41
factored into why a CT was performed.
46:44
Um, at our institution, typically we do, uh, do,
46:47
uh, ultrasound in cases of suspected ovarian torsion.
46:50
We typically don't go to MRI because
46:52
the patients, if there is high suspicion
46:54
for torsion, they go straight to the OR.
46:58
Um, is the telerad service of
47:00
your own or an outside institution?
47:02
We actually contract with an outside
47:03
institution, uh, outside teleradiology service
47:06
to provide, um, prelim reads overnight.
47:10
Um, what is the threshold of myometrial
47:12
thickness referring to interstitial pregnancy?
47:14
So, what's reported in the
47:15
literature is five millimeters.
47:17
So you need to see five millimeters of myometrium
47:20
surrounding the entire gestational sac.
47:22
Um, if you see less than that with an eccentrically
47:25
placed, uh, eccentrically placed gestational
47:28
sac in the region of the interstitial,
47:30
think about interstitial ectopic pregnancy.
47:35
Would you please show us the
47:36
images for pneumatosis intestinalis?
47:39
I think what you're referring to is this, these
47:41
images for pneumatosis cystoides intestinalis.
47:44
And let me, uh, close the images.
47:46
So this was the patient's initial CT.
47:48
You can see that there were these cystic
47:50
structures in the wall of the splenic flexure,
47:52
and then there was a small pneumoperitoneum.
47:56
Um, it, uh, I like this case 'cause it
47:58
correlated very nicely with, uh, let
48:00
me jump ahead to the, uh, gross path.
48:06
So this was the patient's, uh, splenic
48:08
flexure when they finally took it out.
48:09
You can see these cyst-like
48:10
structures, they're air-filled.
48:12
They correlate quite nicely
48:13
with the findings on the CT.
48:17
Do all appendicitis cases go for CT?
48:19
I would say the majority of them, uh, assuming they're
48:23
not, uh, children or pregnant women, go for CT.
48:26
Uh, we encourage the ER to perform, um,
48:28
ultrasound, um, in children as a first option,
48:31
or MRI in pregnant patients as a first option
48:34
in patients with suspected appendicitis.
48:39
Okay.
48:40
Well, we still do have a few minutes, so, uh,
48:42
Dr. Stanek, if you can hear, if you could
48:44
clarify what you were looking for for the,
48:46
uh, pseudoaneurysm, then it does look like
48:49
we just had another, uh, question come in
48:51
as well.
48:52
Okay.
48:52
Yeah.
48:52
Let me jump ahead.
48:56
This one.
48:57
Um, so remember, this patient was, uh,
49:00
stabbed multiple times to the chest and arms
49:02
during, uh, during an attempted robbery.
49:04
These were her images, so she didn't have
49:06
any sort of, um, uh, solid organ injury.
49:09
She didn't have free air.
49:10
This was her only finding.
49:12
And you can see there's a little bit of mesenteric
49:13
fat herniating into the, uh, chest wall.
49:17
Um, right there.
49:18
You can see it, uh, more clearly on the sagittal view.
49:21
Here's, uh, the mesenteric fat.
49:23
You can see that this herniation
49:24
appears to traverse the, um, anterior
49:27
diaphragm, anterior left hemidiaphragm.
49:30
And that is indeed what they
49:31
found on, um, uh, laparoscopy.
49:34
They found a diaphragmatic injury
49:36
with herniation of the fat.
49:41
Okay, there was, let me just
49:43
jump to this Dieulafoy lesion.
49:48
Okay, so this is the, this is the Dieulafoy lesion
49:50
case, and this might be what you're referring to.
49:52
And this is, we did a multiphase CTA of
49:55
the, um, the abdomen and pelvis, which is our
49:57
usual, uh, go-to in patients with acute GI bleeding.
50:01
Um, you can actually see that
50:02
this lesion, uh, this, um.
50:05
Uh, this serpiginous vessel was
50:07
not bright on the pre-contrast, so we
50:10
don't see it on the pre-contrast images.
50:11
We do see it on the arterial phase, and
50:13
there's no pooling on the portal venous phase.
50:15
It just looks like this, uh, um, serpiginous vessel.
50:18
And this was what ended up being a Dieulafoy lesion.
50:23
Great.
50:24
And Doctor, I think, uh, there was one.
50:25
I'm not sure if you, uh, saw it in the chat.
50:27
There was one, uh, attendee asking
50:29
would you please show us again the, uh.
50:31
Pneumatosis intestinalis?
50:34
Well, I did.
50:35
I did.
50:36
Okay.
50:36
That, but I can show it again if you like.
50:38
Alright, just
50:41
so this was the case, pneumatosis
50:43
cystoides intestinalis.
50:47
Great.
50:48
Thanks.
50:48
Sorry, I just wasn't sure if I— Oh, yeah.
50:50
Covered that.
50:51
Yeah.
50:52
Oh, did, did another question pop up?
50:55
Is Dieulafoy lesion from normal or potentially
50:57
abnormal vessels? Second hit need to be there.
51:00
I think that's exactly right.
51:01
So the, the thinking behind a Dieulafoy lesion, um,
51:05
initially they thought it was some sort of acquired,
51:07
um, abnormality, but like I said, there was, um.
51:12
There's some case reports of
51:13
newborns with Dieulafoy lesions.
51:15
So the thinking is it's actually a congenitally
51:17
abnormal vessel, and for whatever reason,
51:19
there's some sort of ischemic injury or
51:21
inflammation of the bowel wall, which unmasks
51:24
the lesion and results in GI bleeding.
51:26
Um, like in this case, how come the
51:30
gastric aneurysm had such thick walls?
51:32
So I think you're referring to
51:34
the, um, the gastroepiploic aneurysm.
51:37
Let me just show that real quick.
51:42
Uh, this one?
51:44
Uh, that's a good question.
51:45
This, uh, this thing was.
51:48
Quite dilated.
51:49
It had thick walls, which I think were
51:51
intraluminal—was intraluminal thrombus.
51:53
I think this vessel had both an aneurysm
51:56
and some intraluminal thrombus, but
51:57
that's just speculation on my part.
52:00
Um, the patient was, if I remember correctly, the
52:03
patient was transferred from an outside hospital
52:05
and there's no telling really how long this, um,
52:08
aneurysm was sitting there before we discovered it.
52:10
After he, uh, presented to our institution.
52:14
Um, the cases of uterine laceration,
52:17
I think you're referring to the
52:18
case of, um, uterine incarceration.
52:22
So this is the case.
52:23
This lady had a recent D&C, uh, she
52:25
presented with, uh, abdominal pain.
52:28
Uh, here's the uterus, and like I said, if you,
52:30
when you first look at this case, it's kind of
52:32
difficult to figure out what's going on with
52:34
the uterus, um, which, uh, how it's positioned.
52:38
Um.
52:39
So, but if you pay attention, if you
52:41
look where these arrows are, these arrows
52:42
point to the, uh, endocervical canal.
52:45
Um, so this, this, uh, uterus
52:47
is severely retropositioned.
52:48
There's an acute angle between the lower
52:50
uterine segment and the uterine fundus,
52:55
and we see kind of just the same findings on, um.
52:59
Uh, on ultrasound, you can see that the
53:01
uterus is, uh, again, retropositioned.
53:04
Here's the endocervical canal, lower uterine
53:06
segment, and it's, uh, wedged between the sacral
53:08
promontory here and the pubic symphysis anteriorly.
53:14
In the case where the patient passed the year after
53:17
with the gastric hernia in the chest, was there
53:19
a suit against the hospital for the misfinding?
53:21
I actually have no idea.
53:22
I'm sorry.
53:26
Okay, well that looks like it
53:28
might be it for the questions.
53:29
Uh, I'll keep an eye on the
53:31
Q and A, uh, window just in case.
53:33
But as we bring this to a close, I want to thank
53:35
Dr. Kampalath for this lecture and thanks all of
53:38
you for participating in our noon conference.
53:40
A reminder that this conference will be
53:42
available on demand on MRIonline.com in
53:45
addition to all previous noon conferences.
53:47
And be sure to join us again on Friday for
53:49
a lecture from Dr. Susan Hobbs on "Don't
53:52
Mess With the Esophagus on Chest Exams."
53:55
You can register for that at MRIonline.com and follow
53:58
us on social media at the MRI Online for updates
54:01
and reminders on upcoming noon conferences.
54:04
Thanks again and have a great day.
54:06
Thank you.
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