Is there cause for concern in this 10-year-old with knee pain?

This 10-year-old presents with right knee pain and swelling. There is no known trauma. What’s the most likely diagnosis? What is indicated by the arrows in the back of the knee? Is it concerning?

Sagittal SPAIR

Coronal T1


The diagnosis is Sinding-Larsen-Johansson syndrome or inferior patellar “apophysitis” (yellow arrow). The green arrows indicate lymph nodes, and they are innocuous (since they contain fat in the coronal). It is common to see lymph nodes behind the femur, particularly in children. Of course they are more numerous or larger in patients with inflammatory processes of the knee such as JIA (juvenile idiopathic arthritis).

For more knee case review, visit MRI Online.

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Lumps have returned for this Sjogren’s patient

This 66-year-old woman presents with parotid adenoma and Sjogren’s syndrome. History of fibroid removal surgery. Patient states she was diagnosed with Sjogren’s syndrome 12 years ago, and complains of lumps on the left side of her neck for 7-8 years, that went away and have come back in the last two months, with more lumps than before. Is this consistent with her Sjogren’s history or a sign of something more serious?

Findings are consistent with the patient’s history of Sjogren’s syndrome and likely intraglandular lymphocytic aggregates at the site of clinical concern. Alternative considerations, though unlikely, are small abscesses within the left parotid gland (lack of surrounding inflammation and pristine adjacent subcutaneous fat and skin make this differential unlikely). Overall, findings are consistent with intermediate stage Sjogren’s syndrome. For more case review, visit MRI Online.

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How should you repair this patient’s heel pain?

This 59-year-old presents with heel pain. Diagnosis is obvious on water-weighted sagittal MRI, but how do you repair this?


It’s an obvious plantar fasciitis with a tear. As for how to repair it, that’s a trick question. You put the patient in a boot and manage their pain. The surgical treatment for plantar fasciitis is cutting the fascia, so-called plantar fascial release. But this patient did it themselves “without the surgeon.” “Patient, heal thyself.” For more case review, check out MRI Online.

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What is the cause of this patient’s droopy eye?

This 55-year-old female presents with a droopy eye, which isn’t something to be taken lightly. In this particular case, the droopy eye is symptomatic of a syndrome with a name you might remember.

Axial T1

Axial T2


Remember Horner’s syndrome, i.e. ptosis meiosis anhydrosis? Here is the classic cause, carotid dissection, with a meniscal curvilinear appearance of the vessel wall. If you hear this history, make a beeline for the carotid canal and you will have a great diagnosis. I have even seen neck vascular dissection from a sneeze.

For more neuro case review, check out MRI Online.

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What does the alpha angle suggest in this hip?

You are shown two MRI images. One is a standard orthogonal coronal with a line through it. This shows the angle of acquisition to evaluate the alpha angle. The second image is the axial oblique with the lines used for alpha angle measurement. Questions:

  • What is a normal alpha angle?
  • What does an abnormal alpha angle suggest?
  • Is an abnormal alpha angle pathognomonic of a symptomatic disease process?


  • Normal alpha angle is 55 to 60 degrees or less.
  • Increased alpha angles suggest cam impingement syndrome or impingement syndrome type 1.
  • The yellow line in the second image is placed from the center of the femoral head to the junction of the medial transition of the upper femoral head to the bump. The green line bisects the center of the femoral head, neck, and trochanteric region as demonstrated on the axial oblique image.
  • Athletic, large men often have abnormal alpha angles in the absence of symptoms. Therefore, the alpha angle is not pathognomonic of symptomatic cam impingement, only suggestive.
  • For more orthopaedic case review, head to MRI Online.

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Figuring out T stage with limited imaging

This 87-year-old man presents with two cancers. Note they are unrelated and not the result of one cancer spreading to another organ. What are the two cancers? Advanced questions: Can you posit the T stage of cancer #1 from limited imaging? How valuable is diffusion imaging in the prostate as an example?

Answer: Prostate and rectal cancer. You can posit the T stage of the prostate lesion on the left (arrow) as T3b as there is seminal vesicle invasion. The diffusion image is especially valuable for mass-like lesions over 3 millimeters in size in the prostate peripheral zone. Many “benign’ or nonaggressive central zone masses in the prostate will have mild diffusion restriction. For more prostate staging resources, visit MRI Online.

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What sport has a squeeze play? And where is the squeeze play on this cardiac MRI?


The squeeze play is seen in baseball. It’s used when a batter bunts the ball in an attempt to bring his teammate on third base home to score a run. It is an exciting play, as the team initiating it is often looking for a tying or winning run late in a close game.

Where is the squeeze play here on axial T1 cardiac MRI?

The squeeze play here is a fatty tumor compressing the superior vena cava. The vena cava is normally round. Here, it appears squeezed or slit-like (second image, arrow). This could lead to superior vena cava syndrome. Surveillance recommended every 6 months. The third MR image shows signs of right ventricular dysplasia. The anterior right ventricle is lobulated, irregular and exhibits sparse fat signal.

For more case review resources, head to MRI Online.

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ADEM or MS? How to differentiate between two favored diagnoses

This 15-year-old presents with blurred vision and white-matter lesions on axial FLAIR MRI. Acute disseminated encephalomyelitis (ADEM) and multiple sclerosis (MS) are the two favored diagnoses, so what questions would you ask to differentiate?

You should ask: How long has this symptom been present? Is it clinically monophasic or polyphasic? Was there a recent upper respiratory infection (URI) or vaccination? A longer symptom time favors MS. Monphasic favors ADEM. Polyphasic waxing and waning clinical course favors MS. History of URI, viral infection or recent vaccination favors ADEM. In this case, ADEM is favored due to the patient being an adolescent. Other factors include the extension into the parasagittal genu of the corpus callosum (left greater than right forceps minor). The fact that this is a single monophasic episodic event (blurred vision for two weeks) also favors ADEM.

For more neuro case review, check out MRI Online.

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A meniscus case with some dangerous verbiage

This 12-year-old female presents with left knee pain, and the clinician alleges meniscal tear. The initial read was noncommunicating tear, but is this the proper call? You are shown four gradient echo sagittal water-weighted images and one sagittal T1.





Sagittal T1


No, this was not the proper call! Save the whales and the menisci. It’s a 12-year-old. High signal due to vascularity and overuse is not uncommon in this age group. A meniscectomy in a 12-year-old is a DISASTER in most cases in the long term. This signal fades in meniscus inner third and is most conspicuous in the outer one-third red-red zone. It is also window framed by dark signal, the meniscus has normal size and shape, the signal in the meniscus is ill-defined and not very bright on T1 and finally T2* gradient echoes always tend to overestimate signal in menisci compared to proton density SPIR MRI. Patient has patellofemoral maltracking as cause of pain anyway. There is NO meniscal tear.

For more meniscus content, head to MRI Online.

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What do your grill and this prostate case have in common?

What do your grill and this prostate case have in common? The first image is a prostate axial MRI T2. Can you name the sign? There is also an axial diffusion and ADC parametric map. Gleason score is probably greater than what number?

“Charcoal erasure sign” of malignancy (axial T2 arrow). With erasure sign (on axial T2 the normal anatomy is “smeared away,” by hypointensity), broad capsular contact anteriorly (a worrisome sign for capsular invasion), and pronounced diffusion restriction. The Gleason score is likely greater than 6. You use charcoal in your grill and you have the charcoal erasure sign in the anterior prostate as a sign of malignancy.

For more interesting prostate case review, visit MRI Online.

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