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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.

0:54

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

1:02

and challenging cases from the ER.

1:04

Um, so the, um, basically what I'm gonna do, I'm

1:07

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.

1:15

And then we're gonna reflect a little bit on

1:17

the factors that contributed to these errors.

1:20

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.

1:36

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.

1:47

We're a 417-bed acute care and teaching hospital.

1:50

Uh, we're a tertiary referral center,

1:53

and we're an NCI-designated Cancer Center.

1:56

Um.

1:58

Let's see.

1:59

We are Orange County's only Level 1 Trauma Center,

2:02

and we're a Level 2 Pediatric Trauma Center.

2:04

In fiscal year 2018, we saw over 51,000 ED

2:08

visits, almost 16,000 surgeries, and about 4,300

2:12

trauma patients were treated at our institution.

2:17

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.

2:34

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.

2:45

Um, the call is really busy.

2:47

Our residents are awesome.

2:48

They, uh, read about 140 to 160 total

2:52

cases over an entire overnight shift.

2:55

And, uh, between midnight and seven

2:57

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.

3:07

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,

3:15

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.

3:26

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.

3:32

So she got a CT of the abdomen

3:33

and pelvis without contrast.

3:35

And these are her, uh, images.

3:40

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.

3:51

Um, and that's what draws your attention first.

3:54

Uh, and if you don't look carefully at the rest

3:56

of the images, you might miss this finding.

3:58

There's a focus of gas, which looks like it's, uh,

4:00

anterior to the right femur in the right hip joint.

4:04

So what we ended up saying, the, uh, the

4:06

overnight resident, um, read this case and

4:10

said the bladder is filled mostly with gas,

4:13

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.

4:31

Then the faculty radiologist reading the

4:33

following morning said emphysematous cystitis, but he

4:36

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.

4:44

Please correlate for infection and septic arthritis.

4:48

Um.

4:50

So unfortunately the patient expired

4:53

from septic shock the following day.

4:55

So this was an example of probable missed,

4:57

um, uh, septic arthritis of the right hip.

5:00

And the reason I, I'm discussing this case is to

5:02

talk a little bit about satisfaction of search.

5:05

So this is a sort of familiar concept in radiology,

5:08

and, uh, the idea is that your visual search is

5:11

particularly error-prone if you have multiple targets.

5:14

Uh, and this is called the satisfaction of

5:16

search or subsequent search miss effect.

5:18

And actually this isn't just, uh, unique to radiology,

5:21

although we write about it a lot in radiology.

5:23

Anyone who, um, evaluates images like TSA

5:27

security screeners or people analyzing satellite

5:30

photographs, um, are, uh, prone to this error.

5:34

So both novice and more experienced radiologists

5:37

can, uh, fall victim to satisfaction of search.

5:41

Um, there are several theories as to

5:43

what causes satisfaction of search.

5:45

Um, the first is that, um, one, an observer becomes

5:48

satisfied with the nature of the evaluation after the

5:51

first target, and then prematurely stops their search.

5:54

Another idea is that after finding your

5:56

first target, the radiologist becomes

5:58

biased to look only for similar targets.

6:01

Um, and another idea is that when the first

6:03

target is found, you take your attention

6:05

and your working memory resources and

6:07

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.

6:15

I had an attending who, um,

6:18

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.

6:42

And just being aware of the satisfaction

6:44

of search phenomenon, uh, can help you

6:46

sort of mitigate, uh, this problem.

6:49

Okay, great.

6:50

Moving onward.

6:51

This is the next case.

6:52

In this case, a 37-year-old

6:54

guy was riding his motorcycle.

6:55

He was helmeted.

6:56

He laid his bike down in traffic at 20

6:59

miles an hour and then rolled over once.

7:01

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.

7:08

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.

7:20

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.

7:31

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.

7:37

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.

7:47

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.

7:56

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.

8:04

There's a subtle cystic appearance of

8:06

the splenic flexure of the colon.

8:09

So because of the pneumoperitoneum,

8:10

this guy actually went to surgery.

8:12

This, uh, we did a repeat CT.

8:14

It showed, uh, persistent pneumoperitoneum.

8:16

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

8:25

the distal transverse colon and splenic flexure.

8:28

Um, so what they, they went ahead and did a

8:30

segmental resection of this splenic flexure,

8:32

and here's the gross path specimen you can see.

8:34

So this is the wall of the colon.

8:36

These are the cystic structures that we saw on the CT.

8:41

This was actually a case of

8:42

Pneumatosis Cystoides Intestinalis.

8:45

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

9:19

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

9:33

where pneumatosis was mistaken for bowel

9:35

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.

9:56

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.

10:04

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.

10:41

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.

11:04

So she got an ultrasound.

11:05

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.