Let’s start with the pinky, and see where it takes us

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This 20-year-old male fell while skiing. Two weeks after the fall, the patient presented with pain, numbness, and tingling in the left pinky finger.

Can you identify the anatomic correlate of the patient’s symptoms? Have a look at images 1 and 2, and see if you can put the story together.

Axial T1

Axial T2

 

In images 3 and 4, the green arrows point to a mass that is hyperintense on T1 and on T2. This is compatible with a chronic hematoma and consistent with the patient’s history of a fall. The red arrows on image 3 also demonstrate a posteromedial superficial hematoma with T1 hyperintense blood related methemoglobin staining.

The anatomic correlate of the patient’s symptoms is the ulnar nerve. A pink arrow identifies the ulnar nerve as a slightly hyperintense structure on the T2 fat-suppressed image. While the signal of a nerve can be hyperintense to muscle on proton density fat-suppression (PD SPIR or PD STIR), it should be isointense or only slightly hyperintense to muscle on T2 imaging. This nerve is swollen and edematous. In addition, the blue arrow (image 4) identifies an area of cystic injury to the nerve which may be seen with blunt trauma, and is a common sequela in the peroneal nerve after a patient is struck by a car bumper, laterally. This is an analogous type of injury in the ulnar nerve as there was a direct impact. There should be no cystic high signal within a nerve.

Axial T1

Axial T2

 

Diagnosis:
Ulnar nerve contusion and interstitial injury without transection or total failure accompanied by a compressive hematoma.

 

For more case review, check out MRI Online.

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His ankle went one way, and he went another

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This 24-year-old male performance athlete presents with inversion injury. The following axial images are in plantar flexion, 30 degrees.

Q1 – What is the pink arrow pointing to in images 2 and 3?

Q2 – To what is the blue arrow pointing in images 1 through 3?

Q3 – Given the findings highlighted with the pink and blue arrows, what is your imaging checklist?

Axial T1

Axial PD-SPIR

Axial T2

Axial FSE

Axial T1

 

A1 – Torn anterior talofibular ligament.

A2 – Torn calcaneofibular ligament.

A3 – The fact that the patient has a two-part ankle rupture involving the anterior talofibular ligament and calcaneofibular ligament, you should consider evaluating the following structures:

(a) The anterolateral soft tissues for hematoma (image 4, yellow arrow).

(b) The high ankle was normal. High ankle assessment should include the anterior tibiofibular ligament, interosseous ligament, and posterior tibiofibular ligament.

(c) The superior peroneal retinaculum is torn (image 5, green arrow), and peroneus brevis tendon demonstrates a split tear (image 5, red arrow).

(d) The talar dome, which was normal.

(e) Occult fractures; none of which were present.

(f) The subtalar space, and ligaments including the talocalcaneal interosseous ligament, cervical ligament, and lateral extensor retinacular / stem / frondiform ligament were all normal.

 

Check out MRI Online for more case review.

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filed under: MSK, Foot

There is pain and swelling, but where is the source?

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This 27-year-old male presents with pain and swelling in the anterior left knee. The symptoms began eight months prior. There was no known injury or previous surgery.

Have a look at images 1 through 3, and see if anything stands out. Do not be distracted by the obvious finding.

Sagittal PD FSE Fat Sat

Sagittal T2

Axial T2 FSE

 

The images show normal menisci, ligaments, and tendons. There is a large joint effusion. A normal plica is visible, which is not thickened.

If you look closely in the posterior aspect of the suprapatellar joint capsule, there is frond-like synovitis or pannus (images 4 through 6, green arrows). Therefore, the most likely diagnosis is rheumatoid arthritis or seronegative arthropathy. In certain continents, Lyme disease would be a differential. Gout is more common in older patients.

It is important to correlate the findings, and not be distracted by prominent plica, which would not cause the degree of joint effusion.

Sagittal PD FSE Fat Sat

Sagittal T2

Axial T2 FSE

 

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filed under: MSK, Knee

After reading her palm, what do you believe her fortune to be?

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This 33-year-old female presents with a mass in the palmar area associated with index finger stiffness.

Q1 – Based on the short-axis T1 fat-weighted images 1 and 2, what is your diagnosis?

Q2 – What are the small dots highlighted by pink arrows in image 1?

Q3 (Advanced) – The blue arrow in image 2 is pointing to what structure in the index finger?

Q4 – What is the signal characteristic, and proper description, of the tissue indicated by the orange arrow on image 2?

Axial T1 FSE

Axial T1 FSE

Coronal PD FSE Fat Sat

Axial T1 FSE

 

A1 – Lipofibromatous hamartoma of the median nerve.

A2 – Bundles of the median nerve.

A3 – Digital nerve surrounded by perineural fat and fibrosis.

A4 – Fat and fatty hypertrophy. Lipofibromatous hamartoma is a rare tumor of peripheral nerves which is characterized by excessive infiltration of the epineurium and perineurium by fiber adipose tissue. Since it is considered a hamartoma, some categorize it as a dysplasia. The median nerve is the most common nerve affected in the body, and often, the abnormality arises in the carpal tunnel. Average age of presentation is often the mid-20s. Lipofibromatous hamartoma of the median nerve has been described rarely in the sciatic, ulnar, and radial nerves.

Because the architecture of the tumor is so infiltrative and intertwined with the nerves, excision is almost never possible. On magnetic resonance imaging, long-axis views have described a spaghetti or cable-like appearance. This is displayed on image 3 (purple arrow).

The disorder is congenital in origin, and is commonly associated with macrodactyly and other conditions at birth.

Several cases of lipofibromatous hamartoma have been associated with exostoses and ectopic calcification. This patient demonstrates an ectopic calcification or ossification (image 4, red arrow). Several references have suggested an association with dysgenetic disorder such as neurofibromatosis. This author and observer has collected over 20 cases of lipofibromatous hamartoma of the median nerve, and none have been associated with neurofibromatosis.

Finally, lipomas and vascular tumors have been associated with this entity. A lipoma or lipomatous hypertrophy is present and was highlighted on image 2 (orange arrow).

Dysplasia’s with macrodactyly and / or extremity enlargement, may be seen in neurofibromatosis type I, Beckwith-Wiedemann syndrome, Proteus syndrome, Klippel-Trenaunay-Weber syndrome, and macrodystrophia lipomatosa.

 

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filed under: MSK, Hand

He didn’t like what was on his plate, but couldn’t return it

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This 55-year-old male presents with right knee pain, and his history indicates no known knee injury, surgery, or cancer.

Q1 – You are shown a sagittal T1 (image 1) and axial T2 (image 2) of the patella. What is wrong with the plate?

Q2 – What is the name of the plate indicated in question 1? The axial is key!

Sagittal T1

Axial T2

 

A1 – The plate is delaminating or separating anteriorly from a deformed patella (image 4, pink arrow).

A2 – The prepatellar plate. The prepatellar plate is analogous to the prepubic plate in the pelvis. The quadriceps descends composed of its four layers namely (a) the anterior rectus femoris, (b) the vastus medialis, (c) the vastus lateralis, and (d) the deep vastus intermedius.

The superficial rectus component continues along the anterior surface of the patella where it rejoins the patellar tendon, inferiorly. This is analogous to the rectus abdominis coursing over the prepubic surface, and joining the adductors below it.

When this separation of plate from pubis occurs in the pelvis, it leads to athletic pubalgia syndrome with, potentially, a sports hernia. In other words, pubic plate detachment is one of the causes of sports hernia syndrome.

In the knee, the prepatellar plate is overlooked. This patient has a patellar deformity that includes the following:

  • Post-traumatic, post-fracture scar and remodeling (image 3, purple arrow)
  • Separated inferior patellar tubercle buried within the patellar tendon (image 3, yellow arrow)
  • Innumerable spurs (image 3, orange arrows)

Yet, despite all of this, it is the delamination or “peel” of the prepatellar plate from the undulating irregular anterior surface of the patella (image 4, blue arrows) that are causing the patient’s symptoms. Focal high signal deep to the plate is a helpful sign (image 4, pink arrow) of plate delamination.

Sagittal T1

Axial FSE T2

 

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filed under: MSK, Knee

It’s as if her shoulder was “frozen”

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This 40-year-old female presents with right shoulder pain that started two weeks prior. There is no known source of injury. Movement has limited range, and there have been no injections or physical therapy.

Q1 – What are the primary abnormal features of this case?

Q2 – Which common diagnosis could be easily misdiagnosed in this case?

Q3 – What is the significance of an os acromiale?

Coronal PD FSE Fat Sat

Coronal T1 FSE

Axial

Coronal T1 FSE

Coronal PD FSE Fat Sat

Coronal PD FSE Fat Sat

Coronal PD FSE Fat Sat

Sagittal T2 FSE Fat Sat

Axial

 

A1 – Thickening of the inferior glenohumeral ligament and anterior rotator interval.

A2 – Primary rotator cuff abnormality / tendinopathy.

A3 – It predisposes to microinstability.

This is a case of adhesive capsulitis masquerading as rotator cuff tear. On initial inspection, it appears as though the supraspinatus tendon demonstrates abnormal signal due to tendinopathy (images 1 and 5, blue arrows). This would be a commonly “overcalled” diagnosis, but on closer inspection, there is capsular thickening and infiltration / inflammation at the inferior glenohumeral ligament (IGHL) (images 1 and 2, green arrows).

There is also capsular thickening and diffuse intermediate signal on the T1-weighted sequences at the anterior rotator interval (images 3 and 4, yellow arrows) between the subscapularis and the supraspinatus. This abnormal signal at the anterior rotator interval does extend to involve and infiltrate the supraspinatus, and to a lesser extent, the subscapularis, which is a common feature of moderate to marked adhesive capsulitis.

The other features of adhesive capsulitis in this case are thickening of the coracohumeral ligament (CHL) (image 8, pink arrow), and eccentrically displaced joint fluid (images 6 and 7, red arrows) with the fluid tracking along the long head of the biceps tendon and the subscapularis tendon.

Therefore, the diagnosis of fibroinflammatory “dry” capsulitis, which is consistent with the clinical entity of adhesive capsulitis, is made rather than primary rotator cuff / supraspinatus tendinopathy. In other words, the cuff is infiltrated secondarily rather than torn.

Unrelated, but an interesting feature of this case is the presence of an os acromiale (image 9, orange arrow).

 

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While observing the mass, we noticed she had a tail

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This 44-year-old female presents with right wrist pain. You are shown five images. A coronal proton density (image 1), a coronal proton density fat suppression (image 2), two sagittal proton density fat suppression (images 3 and 4), and an axial or short-axis proton density (image 5). A hyperintense mass around the ulna is obvious.

Q1 – With regard to the pink arrows in images 1 and 2, what do you think the significance is?

Q2 – What is your differential diagnosis for a septated cystic mass of the wrist?

Q3 – What are masses that are associated with a “tail sign”?

Q4 – What is the most common location for ganglion pseudocyst in the wrist? How about the second most common?

Coronal PD

Coronal STIR

Sagittal STIR

Sagittal STIR

Axial PD

 

A1 – The pink arrows (images 1 and 2; 6 and 7) demonstrate a tail extending back to the joint capsule and subsheath portion of the extensor carpi ulnaris.

A2 – (a) ganglion pseudocyst, (b) epidermoid, (c) myxoma, (d) capsular cyst, (e) pisotriquetral bursal cyst, or (f) capsulosynovial cyst associated with inflammatory arthritis (such as rheumatoid).

A3 – (a) ganglion with a tail to either the capsule or sheath of a tendon, (b) neural tumor with a tail to a nerve, (c) aneurysm or pseudoaneurysm with a tail to a vessel, or (d) capsular or synovial cyst with a tail to a joint.

A4 – The most common is along the dorsal scapholunate interval near the dorsal limb of the scapholunate ligament (SL) and the radial limb of the intercarpal ligament. Sometimes these project at the junction of the scaphoid and base of the capitate dorsally.

The second most common location is along the palmar aspect of the wrist near the volar SL ligament and capsule near the base of the radioscaphocapitate extrinsic or the base of the radial lunatotriquetral ligament extrinsic.

In other words, a ganglion in this location is extremely atypical. Its intimacy with the extensor carpi ulnaris is problematic as it relates to dynamic motion (i.e. can restrict).

The blue arrow on image 8 also corroborates the dorsal tail of a ganglion pseudocyst, and the yellow arrow on image 9 shows the septated mass, sagittally.

In image 10, the green arrow shows the mass’s close proximity to the extensor carpi ulnaris (image 10, purple arrow), displacing it medially.

Coronal PD

Coronal STIR

Sagittal STIR

Sagittal STIR

Axial PD

 

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A close look at a transspatial thoracic spine abscess

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This 55-year-old male patient has history of quadriplegia due to transsection of the upper cervical spinal cord (image 1, orange arrow). Within the last six months, the patient noticed an absence of muscle spasms from the lower lumbar and lower extremities.

At the level of the T11-T12 intervertebral disc space, large loculated fluid collection / abscess obliterates the central spinal canal and portions of the T11 and T12 vertebral bodies as well as extends to the posterior elements and soft tissues. Images 2 and 3 (red arrows) show the extent of the abscess extending from the prevertebral soft tissues through the intervertebral disc space, through the spinal canal, and into the posterior elements.

Fluid collection partially surrounds the descending aorta with edematous changes including the bodies of T11 and T12, and extends approximately two-thirds of the way of the L1 vertebral body. Abscess extends approximately from the level of T10 to L1 measuring 7.25cm in craniocaudal dimension (image 2, yellow line) and 2.00cm in anteroposterior dimension (image 2, blue line). The fluid component measures 7.09cm in the trans-sagittal dimension (image 2, pink line). Given the upper cervical spinal cord transsection, findings are consistent with an abscess likely related to underlying Charcot disease.

Image 4 shows the extent of the abscess (green arrow) obliterating the spinal canal, vertebral body, and posterior elements.

Sagittal T2 FSE

Sagittal T2 FSE

Sagittal T1

Axial T2 FSE

 

Diagnosis:
Large transspatial thoracic spine abscess related to underlying Charcot disease from prior cervical spinal cord transsection.

 

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What can happen when you combine a 33-year-old shoulder with weight lifting?

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This 33-year-old weight lifter presents with anterior shoulder pain and popping.

Q1 – Using images 1 through 4, what are the imaging findings?

Q2 – What intraarticular AC joint pathology is most likely?

T2 TSE Sagittal SPAIR

T2

T2

T2 TSE Sagittal SPAIR

 

A1 – The diagnosis is clavicular osteolysis. Osteolysis of the clavicle more commonly affects younger adult males (mid 30s). MRI imaging characteristics include bone marrow edema of the distal clavicle, cysts or erosions of the distal clavicle, and a subchondral line within the distal clavicle (images 5 and 6, arrows). Additional imaging findings include resorption of the distal clavicle as well as periarticular swelling. Etiologies include fracture, AC joint dislocation as well as microtrauma related to sporting activities and weight lifting; especially bench and military pressing. Treatment is conservative (avoidance of overload activity, stretching, and steroid injection in particular) with resection of the distal clavicle reserved for refractory cases.

A2 – The most common intraarticular abnormality associated with osteolysis clavicle is labral pathology (approximately one-third). This patient has a posterior labral tear with a paralabral cyst (images 7 and 8, arrows). Less commonly, partial-thickness rotator cuff tears are also present. This is a sub-type of “peel-back” labral pathology seen in weightlifters.

Diagnosis: “Weightlifters Shoulder” with clavicular osteolysis and posterior labral “peel-back”.

T2 TSE Sagittal SPAIR

T2

T2

T2 TSE Sagittal SPAIR

 

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Watch out for other diagnoses that look similar in this pediatric brain case

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This 10-year-old male has a history of encephalitis.

Q1 – The most likely diagnosis is:

(a) Herpes encephalitis
(b) Adrenoleukodystrophy
(c) Acute disseminated encephalomyelitis
(d) Acyl-CoA oxidase deficiency
(e) Metachromatic leukodystrophy

Axial T2 FLAIR

TSE

T1 SE

T1W

 

A1 – (b) Adrenoleukodystrophy

Adrenoleukodystrophy (ALD) is an X-linked disorder affecting young males due to the accumulation of very long chain fatty acids from a genetic deficiency in perioxisomal oxidation related to ALDP gene mutation. Carrier females can be symptomatic. MRI appearance includes relative sparing of subcortical U fibers, posterior distribution, central areas of scarring, and an active leading edge of demyelination. There are childhood, adolescent and adult forms as well as spinal (adrenomyeloneuropathy) manifestations and forms limited to Addison’s disease.

Herpes encephalitis is more temporal and hemorrhagic. It also has a more acute, rather than chronic, progressive presentation. Meningeal enhancement is common.

Acyl-CoA oxidase deficiency (pseudo ALD) can have a similar appearance, but is rare and seen in neonates. The disease is progressive unlike acute disseminated encephalomyelitis, which is monophasic.

Arylsulfatase A is decreased in metachromatic leukodystrophy (MLD). It does not have a parieto-occipito-callosal predilection on MRI.

Besides X-linked ALD (symmetric), not very many diseases affect the splenium of the corpus callosum, especially symmetrically. Some include:

  • Lymphoma (mass effect)
  • Glioblastoma (mass effect)
  • Posterior reversible encephalopathy syndrome (PRES)
  • Marchiafava-Bignami disease (alcohol-related non-masslike)
  • Multiple sclerosis (patchy)
  • Infective [e.g. Influenza (reversible), rotavirus, mumps, adnovirus, and E. coli]
  • Hyperosmolar hyperglycemia (reversible)
  • Legionnaires’ disease (reversible)
  • Glufosinate Ammonium Poisoning (non-masslike)
  • Krabbes disease (non-masslike, symmetric)
  • Dai-Diffuse axonal injury (trauma, hemorrhage, siderosis)
  • Infarct (usually hypoxic type)
  • Post-shunt decompression
  • Venous thrombosis (internal cerebral veins and straight sinus)
  • Others: AIDs dementia complex; antiepileptic drugs; mild encephalopathy with reversible splenial lesion (MERS); hemolytic uremic syndrome (HUS)

*For a proposed scoring method on adrenoleukodystrophy (ALD), see the referenced article by Daniel J. Loes.

 

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Reference:

1. Loes DJ, et. al., Adrenoleukodystrophy: A Scoring Method for Brain MR Observations, American Journal of Neuroradiology, (1994) 15:1761-1766.

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