Anatomy Queen or King for a day

Here is your chance to be an anatomy king or queen for a day. We plan on dispersing these anatomic snippets of the brain in small groups so as not to overwhelm you, however, you will find complete descriptions at MRI Online.

You are shown one T1 sagittal image of a 71-year-old male. Focus on the inferior frontal gyrus anteriorly which makes the letter M. Do you see the letter M? It is made up of three components.

Q1 – Can you identify these inferior frontal sulcus structures labeled in pink, blue, and yellow?

Q2 – The staircase descending sulcus labeled with a multitude of orange arrows, behind the pars opercularis, is representative of what sulcus?

Q3 – The purple arrow highlights what sulcus?

Q4 – The unlabeled gyrus in front of the purple arrow represents what?

Q5 – The pars opercularis of the inferior frontal gyrus is known as Brodmann area ___?

Q6 – The pars triangularis of the inferior frontal gyrus surrounds the anterior horizontal limb of the lateral sulcus and is bounded caudally by the anterior ascending limb of the lateral sulcus, white arrow, represents Brodmann area ___?

Q7 – Brodmann areas 44 and 45 are named after what famous French physician?

Sagittal T1 FSE

 

A1 – The pink arrow highlights the pars orbitalis, blue indicates the pars triangularis, and yellow is the pars opercularis.

A2 – Precentral sulcus.

A3 – Central sulcus of Rolando.

A4 – Precentral gyrus, a critical contributor to motor function.

A5 – Brodmann area 44.

A6 – Brodmann area 45.

A7 – Pierre Paul Broca who lived from 1824 to 1880. This French physician, anatomist and anthropologist is best known for the area named after him, namely Broca’s area. He ascertained that patients suffering from aphasia contained abnormalities in the left frontal region in this locus. Broca’s area abnormalities produce expressive aphasia. Expressive aphasia is characterized by partial loss of the ability to produce language (spoken, manual, or written), although comprehension remains intact. Speech is difficult and full of effort. It usually includes important words of content but omits functional words that only have grammatical significance and not real word meaning such as prepositions. Another name given to this is “telegraphic speech”. The person’s intended message can be understood but is usually grammatically incorrect. In severe forms of expressive aphasia a person may only speak with single-word utterances.

 

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ACL contusion patterns: The importance of medial sided contusions

This 52-year-old male presents with knee pain following an injury one week ago.

Q1 – What is the most likely mechanism of injury in this individual with an ACL tear?

Q2 – What are the potential internal derangements associated with this knee contusion pattern?

Coronal PD Fat Sat

Sagittal PD Fat Sat

Sagittal PD Fat Sat

Sagittal PD Fat Sat

Sagittal PD Fat Sat

Axial T2

 

A1 – Image 7 demonstrates an acute ACL tear (blue arrow). In addition, osseous contusions are identified in the posterior aspect of the lateral compartment in both the lateral femoral condyle (red arrow) and lateral tibial plateau (yellow arrow). Image 8 (arrow) also demonstrates an osseous contusion in the anterior medial tibial plateau (anterior medial tibial rim sign). Radiologists are most familiar with pivot-shift contusions in the lateral compartment. However, medial compartment osseous contusions also occur, and are associated with higher-energy injuries. The most commonly reported mechanism with an anterior medial tibial rim sign is axial loading. Axial loading occurred in this 52-year-old male following a fall from a ladder. An anterior medial rim sign is identified in approximately 30% of individuals with acute ACL tears.

A2 – The rim sign is associated with a significant increased risk of contusions and fractures as well as posterolateral corner injuries and tears of the posterior horn lateral meniscus. Image 9 (arrow) indicates a torn popliteofibular ligament. Images 10 and 11 (arrows) indicate a complex tear of the posterior horn / root attachment of the lateral meniscus. Image 12 (arrows) demonstrates an impaction fracture of the posterolateral tibial plateau. The proposed etiology for the anterior medial rim sign is a contusion between the inferior pole of the patella and anterior medial rim. Patellar edema is less common than the edema in the anterior medial tibia, likely related to the relative hardness of the sesamoid bone relative to the tibia. The identification of edema in both the patella and anterior medial rim is uncommon, occurring in approximately 4% of all acute ACL tears.

Coronal PD Fat Sat

Sagittal PD Fat Sat

Sagittal PD Fat Sat

Sagittal PD Fat Sat

Sagittal PD Fat Sat

Axial T2

 

Check out MRI Online for more case review.

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Dr. Stephen Pomeranz

Dr. Robert Wissman

 

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Don’t miss the salient finding in this brain case

A 55-year-old man presents with headache, neck pain and dizziness. See if you can answer the questions below by looking at images 1 through 3 before looking at the duplicate images with arrows (images 4 through 6).

Q1 – What is the salient finding on the presented MRI study?

(a) Cortical atrophy
(b) Dural venous thrombosis
(c) Pachymeningeal thickening
(d) Subdural hematoma
(e) Demyelinating plaques

Q2 – What is the most likely diagnosis?

(a) Sarcoidosis
(b) Bacterial meningitis
(c) Pseudotumor cerebri
(d) Intracranial hypotension
(e) Metastasis

Sagittal T1

Sagittal T1

Axial T2

 

A1 – (c) Pachymeningeal thickening. The salient finding on precontrast images is bilateral and symmetrical subdural fluid collections and pachymeningeal thickening.

Cortical atrophy (a) is false since supporting findings of cerebral atrophy, such as sulcal enlargement and ex vacuo ventricular enlargement, are not present. Dural venous thrombosis (b) is false given that T1-weighted images demonstrate slightly increased signal in the sinuses, but flow void is confirmed on T2-weighted images. No dural thrombosis is evident. Subdural hematoma (d) is false because there is no evidence of signal alterations associated with blood products on T1- or T2-weighted images. Demyelinating plagues (e) is also false. There are scattered T2 and FLAIR hyperintensities in the white matter of bilateral frontal lobes. However, these lesions do not demonstrate typical septocallosal distribution of MS demyelinating plaques.

A2 – (d) Intracranial hypotension. Diffuse, smooth, supra and infratentorial enhancement of the thickened dura mater is a classical finding of intracranial hypotension. Often, veins compensatorily distend (image 4, green arrow). Such compensatory distention includes the dural venous sinus flow void (image 5, green arrow).

Sarcoidosis (a) and pseudotumor cerebri (c) are false. Sarcoidosis and other granulomatous diseases, including tuberculosis, Wegener granulomatous, and fungal disease, may produce dural masses and pachymeningeal enhancement, though granulomatous processes typically affect the basilar leptomeninges rather than hemispheric convexities. They are often “lumpy-bumpy”. Bacterial meningitis (b) is false given that it is associated with leptomeningeal enhancement, not isolated pachymeningeal enhancement. It may be thick and irregular. Patients are usually very sick. Metastasis (e) is also false. Metastases, particularly breast, prostate, melanoma and RCC, can present with pachymeningeal enhancement. However, in the absence of medical history, metastasis is unlikely. Furthermore meningeal carcinomatosis often involves the leptomeninges (pia arachnoid) and may be “lumpy-bumpy”.

As a note, transient pachymeningeal enhancement can also be seen after cranial surgery and uncomplicated lumbar puncture.

Sagittal T1

Sagittal T1

Axial T2

 

Q3 (BONUS) – Which is not a supporting image finding of spontaneous intracranial hypotension in this case?

(a) Decreased dimension of the suprasellar cistern
(b) Empty sella
(c) Venous distension
(d) Effacement of the basal cisterns
(e) Tonsillar ectopia

A3 (BONUS) – (b) Empty sella. Supporting imaging features of spontaneous intracranial hypotension (SIH) include all but empty sella. Empty sella could be seen with idiopathic intracranial hypertension (IIH), previously known as pseudotumor cerebri. In spontaneous intracranial hypotension, venous engorgement at the dura mater across the sella turcica could produce reactive hyperemia and increase in size of the pituitary gland. Other supporting findings of SIH include small slit-like ventricles (image 6, green arrows) bowing of optic chiasm, flattening of the pons against the clivus, dural thickening and intense enhancement with extrathecal cerebrospinal fluid collection. Retroclival venous engorgement (image 4, green arrow) is a useful sign on sagittal T1 MRI supporting spontaneous intracranial hypertension.

 

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References:

1. Saindane Am. Recent Advances in Brain and Spine Imaging. Radiol Clin N Am. Feb 2015.
2. Smirniotopoulos JG, Murphy FM, Rushing EJ, Rees JH, Schroeder JW. Patterns of contrast enhancement in the brain and meninges. Radiographics. 2007 Mar-Apr;27(2):525-51.
3. Park ES, Kim E. Spontaneous intracranial hypotension: clinical presentation, imaging features and treatment. J Korean Neurosurg Soc. 2009 Jan; 45(1):1-4.
4. Medina JH, Abrams K, Falcone S, Bhatia RG. Spinal imaging findings in spontaneous intracranial hypotension. AJR Am J Roentgenol. 2010 Aug;195(2).

 

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Be kind to your AC joint. It can only take so much.

Many of us have experienced pain in the shoulder. It is often attributed to some deep-seated joint abnormality, and we wonder if it is the dreaded rotator cuff tear. However, one of the most common causes of shoulder pain is premature degeneration from overuse of the acromioclavicular (AC) joint, the so-called “joint on top”. If there is pain on top, with grinding or crunching, odds are it is the AC joint that is causing the problem.

Believe it or not, almost no one over age 20 has a normal AC joint. It seems that this joint was not meant to sustain the amount of activity that we humans undertake throughout our lives. In particular, the advent of backpacks, as well as modern sport, has put undue stress on this structure.

Since almost everyone over age 20 has an abnormal AC joint, this post will attempt to address (1) when this joint is the cause of the symptoms, (2) when it needs to be addressed, (3) what exacerbates disease in this joint, and (4) what imaging findings cinch the diagnosis.

You are shown three coronal images of the left shoulder of a 39-year-old male. He presents with pain, limited range of motion, and arm weakness.

Q1 – What symptoms should point you in the direction of the AC joint as the cause of discomfort?

Q2 – What activities in young athletes particularly aggravate this problem?

Q3 – In image 2, see if you can locate the swelling in the joint, edema of bone, and erosions. Since everyone has some of these, how can an imager know that this joint is actually the cause of the patient’s symptoms?

Coronal T1W TSE

Coronal T2W SPAIR

Coronal T2W TSE

 

A1 – Pain on “top”; motion specific pain with the arms over the head; crunching or grinding noises that you can feel and sometimes hear.

A2 – Weightlifting (especially heavier weights), and performing the activities of bench pressing or military pressing. Most young men do this in the gym. A tip-off that this activity is occurring is the size of the shoulder muscles, especially the supraspinatus, trapezius and pectoralis major.

A3 – Check out image 5 for identification of some swelling (pink arrow), erosions and/or edema of bone (blue arrow), and further erosions (yellow arrow). Now look at image 6, the standard T2 sequence. In patients that have symptomatic acromioclavicular joint disease, there are often tip-offs on the less sensitive water weighted sequence:

(a) The swelling or high signal in the joint persists on the T2 weighted image as a sign of active disease (image 6, orange arrow).

(b) In younger patients there is often no other evidence of any other pathology or an alternative explanation.

(c) Finally, the patient’s muscularity suggests that weightlifting activity is occurring and exacerbating this condition, and corroborating your diagnosis.

Coronal T1W TSE

Coronal T2W SPAIR

Coronal T2W TSE

 

Check out MRI Online for more case review.

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Do you know why this patient has resting tremor and diplopia?

Imaging signs on MR can be a helpful tipoff toward the correct diagnosis. Take a look at this textbook example in today’s neurological imaging case.

This 71-year-old male presents with resting tremor and diplopia. Is the most likely diagnosis Parkinson’s disease, Lewy body dementia, Progressive supranuclear palsy, Alzheimer’s disease, or Frontobasal degeneration? Have a look at images 1 and 2, and see if you can generate a diagnosis.

Clue: Do you have a hummingbird feeder in your yard?

FLAIR Axial IR

T1 Sagittal

Image 2 supplement – “Hummingbird Sign”

 

This patient was diagnosed with progressive supranuclear palsy (PSP), also known as Steele-Richardson-Olszewski syndrome or Richardson’s syndrome. The condition is associated with supranuclear ophthalmoplegia, pseudobulbar palsy, nuchal dystonia, dementia, gradual progressive monophasic disease onset at age 40 or older, and prominent posterior instability in the first year of the disease.

PSP is a tauopathy like frontotempolobar dementia (formerly known as Pick’s disease). Tau is a microtubule-associated protein which, in the normal human brain, is distributed by axons. Neurofibrillary tangles and tau protein filaments are found in cases of Alzheimer’s disease.

Sometimes, PSP has early brainstem involvement with a frontal predominance. It is typical for there to be more posterior fossa and brainstem involvement than in classic Parkinson’s disease. Midbrain atrophy, divergence of the red nuclei, dilatation of the third ventricle, atrophy of the superior cerebellar peduncle, and frontocortical atrophy are common. The hummingbird sign is used to describe mid-sagittal imaging appearance of PSP, at the midbrain level (image 2, yellow arrows).

In addition to the midbrain atrophy in PSP, the dentate nucleus (not shown) is markedly involved. This leads to its main efferent pathway, the brachium conjunctivum or superior cerebellar peduncle being affected and atrophic.  Its fibers pass into the brainstem and decussate at the inferior colliculi before synapsing at the red nucleus and ventrolateral nucleus of thalamus.

Q1 – What diseases found in the brain are linked to tau proteins?

(a) Pick’s disease
(b) Alzheimer’s
(c) Progressive supranuclear palsy (PSP)
(d) Wilson’s disease
(e) a, b, and c

Q2 – The “hummingbird sign” is typical of:

(a) Parkinson’s disease
(b) Progressive supranuclear palsy (PSP)
(c) Wilson’s disease
(d) Hurler’s disease
(e) None of the above

Q3 – The “big panda sign” is typical of:

(a) Parkinson’s disease
(b) Progressive supranuclear palsy (PSP)
(c) Wilson’s disease
(d) Hurler’s disease
(e) NF-2

Q4 – The “swallow tail sign” is typical of:

(a) Parkinson’s disease
(b) Progressive supranuclear palsy (PSP)
(c) Wilson’s disease
(d) Multisystem atrophy
(e) None of the above

 

For more advanced nuanced thoughts (“putaminal slit sign” and “the smudging sign”), read on. Differential subtle features of similar diseases:

  • PSP can be differentiated from multisystem atrophy-P (Parkinson type) using a midbrain diameter of less than 14mm on the sagittal scan in the AP dimension.
  • Multisystem atrophy cerebellar-type (MSA-C) may be differentiated from PSP and idiopathic Parkinson’s disease by the “hot-cross bun sign” or “pontine cross sign” seen in MSA-C.
  • Putaminal low signal intensity helps differentiate MSA from idiopathic Parkinson’s disease.
  • The “putaminal slit sign” differentiates a parkinsonian-type or MSA-P type from progressive supranuclear palsy and standard idiopathic Parkinson’s disease.
  • Zona compacta atrophy results in confluence or “the smudging sign” between the substantia nigra and red nucleus hypointensity in classic Parkinson’s disease.
  • Corticobasal degeneration is characterized by global atrophy or asymmetric atrophy which helps differentiate it from the other entities.
  • Classic Parkinson’s or idiopathic Parkinson’s disease should be suspected when there is resting tremor, rigidity, hypokinesia, but not upward gaze palsy as in PSP.
  • Some later stage Parkinson’s patients may have visual hallucinations, but this is more typical of Lewy body dementia.

 

A1 – (e) a, b, and c

A2 – (b) Progressive supranuclear palsy (PSP)

A3 – (c) Wilson’s disease

A4 – (a) Parkinson’s disease

 

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References

1. Kornenko, Aronin.  Neuroradiology

2. Cossotini M et al. MRI of the Substantia Nigra. Radiology 2014.  Jun;271(3): 831-838.

3. Quattrone A et al. MR Imaging Differentiation of PSP from Parkinson’s. Radiology 2008; 246: 214-221.

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Think “pump bump” and you may come up with the correct answer in this adult male with heel pain

You are shown six images of a 58-year-old male athlete with persistent heel pain for two years. The case seems simple, but have a look at the images, and see how many conditions or abnormalities you can find.

Sagittal T1W TSE

Sagittal T2W TSE

Sagittal PD SPIR

Sagittal T1W TSE

Sagittal T2W TSE

Sagittal PD SPIR

 

With arrows now highlighting the key areas (images 7 to 12), see if you can answer the following questions.

Q1 – On images 7, 8 and 9, what does the pink arrow point to? If you think “pump bump”, you might come up with the right answer.

Q2 – The blue arrow on image 9 points to what?

Q3 – The green arrows on images 10, 11 and 12 point to what?

Q4 – The yellow arrow points to an abnormality in the calcaneus itself on images 10, 11 and 12. How would you describe this abnormality?

Q5 – A series of orange arrows are seen on image 12. How would you describe this abnormality?

 

Sagittal T1W TSE

Sagittal T2W TSE

Sagittal PD SPIR

Sagittal T1W TSE

Sagittal T2W TSE

Sagittal PD SPIR

 

A1 – A Haglund deformity, also known as a “pump-bump” in honor of high-heel wearers, is an exacerbating morphologic problem in this patient.

A2 – Delamination and/or separation of the footprint of the Achilles. These deeper fibers tend to have more of a soleal than a gastrocnemius contribution.

A3 – Supracalcaneal bursitis. But, there is more. A focal “spot” of hypointensity is seen on image 11. The findings represent a coalescent area of calcium pyrophosphate deposition disease (CPPD).

A4 – An erosion from traction enthesopathy. Erosions in the heel and plantar fascia may sometimes conjure up visions of seronegative spondyloarthropathies. However, in this case, the abnormality was mechanical due to exercise, overuse, and alteration in bone morphology. Erosion represents the inflammatory sequela of mechanical irritation and CPPD.

A5 – Any of the below would do:

  • Undersurface delamination as a partial thickness tear
  • 50% depth partial thickness undersurface tear (concealed from the superficial surface) associated with a hypertrophied tendon
  • Moderate depth fraying and delamination in a hypertrophic tendon

A cocktail of these adjectives would do just fine.

 

Diagnosis:

1 – Delamination partial thickness tear
2 – Hypertrophic tendinopathy
3 – Bursitis
4 – Calcium Pyrophosphate Deposition (CPPD)
5 – “Pump-bump” or Haglund deformity

 

For more case review, check out MRI Online.

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As a rule of thumb, just remember… the higher the slope, the further the fall

Chloe Kim, Red Gerard, and soon, Mikaela Shiffrin are representing the USA well in Pyeongchang, South Korea. So, let’s have a look at a winter sports case!

This 17-year-old female fell during a winter-related sporting accident, and now presents with right thumb pain. You are shown three finger coil images. Image 1 uses a coronal 3D data set.

Q1 – When falling, the patient attempted to brace herself using the sporting equipment in hand. What do you think the sport was?

Q2 – What is the name of the entity?

Q3 – What is the abnormality?

Q4 (BONUS QUESTION) – Why does a Stener lesion occur more frequently on the medial than the lateral side of the thumb?

Coronal T2 GE 3D

Coronal T1 FSE

Coronal STIR

 

A1 – Skiing.

A2 – Skier’s thumb.

A3 – Avulsion fracture to include the distal insertion of the ulnar collateral ligament (UCL) involving the base of the medial proximal phalanx.

A4 – While this is not a Stener lesion (folded entrapment of the proximal retracted UCL ensconced by the adductor aponeurosis), the reason is simple:

(a) The aponeurosis on the radial side of the thumb is more vertical, or oriented straight and parallel to the collateral ligament. This parallel course does not permit the deeper radial collateral ligament from transgressing the radial aponeurosis.

(b) On the other hand, the adductor aponeurosis has an oblique course allowing the UCL to retract underneath it, flap backwards, and then flip over the top.

The pink and blue arrows on images 4 and 5 highlight the avulsion fracture. On image 6, the oblique course of the adductor aponeurosis is indicated with a red line demarcated by a green arrow. The UCL will get caught in a small notch proximal to this (image 6, yellow arrow). The straighter course of the radial aponeurosis is highlighted with a purple line. You can see how much more oblique the adductor aponeurosis is by tracing the red line.

 

Coronal T2 GE 3D

Coronal T1 FSE

Coronal STIR

 

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What surgical emergency is afflicting this patient?

This 57-year-old female presents with hippocampal atrophy, sudden cognitive decline, and visual disturbances.

Q1 – Using images 1 and 2, what is the most likely diagnosis?

(a) Thrombosed aneurysm
(b) Pituitary apoplexy
(c) Craniopharyngioma
(d) Choristoma

Coronal T2 FSE

Coronal T1 SE

 

A1 – (b) Pituitary apoplexy

 

Q2 – Which statement is false about pituitary apoplexy?

(a) Often requires urgent surgical decompression
(b) Often requires steroid therapy
(c) Occurs with microadenoma
(d) May be present with ophthalmoplegia
(e) May be associated with subarachnoid hemorrhage

Q3 – Which statement is false about prolactin-secreting adenomas?

(a) May be invasive with skull base destruction
(b) May be diagnosed with greater than 95 percent accuracy by prolactin greater than 200 ng/ml
(c) Mild elevations of prolactin (<100 ng/ml) can be related to medications, hypothyroidsm, or “stalk effect”
(d) Microadenomas may demonstrate the “hook effect” on laboratory studies

 

Pituitary apoplexy may often present as ophthalmoplegia, visual loss, and confusion in a patient with known pituitary macroadenoma.

Pituitary apoplexy is a surgical emergency requiring acute decompression. Steroid administration is required for endocrine support as the patient may exhibit acute pituitary insufficiency. Sometimes, intravenous T3 is also required.

Pituitary apoplexy may be associated with subarachnoid hemorrhage as well as vasospasm.

Prolactinomas are known to be invasive and, when large, can produce skull base erosion.

Prolactin is the only pituitary hormone which is regulated by an inhibitory mechanism. Large nonsecreting lesions which compress the pituitary stalk can result in elevations of the prolactin described as “stalk effect.” Elevations on this basis are relatively small as are those secondary to medications or hypothyroidism. A rule of thumb in elevating prolactin elevations is that the percentage of chance of a lesion being a secreting prolactinoma is about half of the level, so a prolactin of greater than 200 has an essentially 100 percent chance of being a prolactinoma.

Falsely low prolactin in the face or a large or invasive prolactinoma may represent the “hook effect” where the binding sites of the RIA antibody become saturated and the antibody curve is no longer proportional to the amount of prolactin. This is resolved by performing serial dilutions. This effect never occurs in microadenomas, but rather in macroadenomas.

 

A2 – (c) Occurs with microadenoma

A3 – (d) Microadenomas may demonstrate the “hook effect” on laboratory studies

 

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For more case review, check out MRI Online.

References:

1. Diagnostic Imaging Brain Osborn et. al. Amirsys.

2. Greenberg MS Handbook of Neurosurgery. Thieme.

3. Liu JK, Couldwell WT Contemporary management of prolactinomas. Neurosurg. Focus 2004: 16 (4)

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When your hip has had enough of all that dancing and snapping

This 20-year-old female presents with hip pain. You are getting two clues for the price of one. First, look at images 1 and 2. Hip pain is quite an amorphous symptom. It can come from the joint, the groin, the sacrum, the pubis, or even the spine. We all have a tendency to gravitate towards the joint.

Q1 – Why are we getting two clues for the price of one?

Q2 – Why does the patient have hip pain?

Axial PDW SPAIR TSE

Coronal PDW SPAIR TSE

Axial PDW SPAIR TSE

 

A1 – Because there are two iliopsoas tendons. In other words, the iliopsoas tendon has a bifid morphology (image 4, pink arrows).

A2 – Swelling is more conspicuous around the lateral of the two heads (images 4 and 5, blue arrows). Such swelling is an indirect sign of irritation of the tendon and its surrounding tissues. The iliopsoas tendon is a primary hip flexor and passes over the iliopectineal eminence of the pelvis. This bony prominence is labeled on image 6 (yellow arrow). As the tendons ride over this area, a snap or a click occurs, otherwise known as coxa saltans. Hip flexion and extension, raising and lowering of the whole leg or rotation, namely twisting of the hip, may exacerbate or reproduce symptoms. The peritendinitis, demonstrated with the blue arrows, is a secondary manifestation of this catching phenomenon on the iliopectineal eminence. In this case, the eminence itself is indeed edematous (high signal deep to the yellow arrow on image 6).

 

Q3 – Names like coxa saltans, or iliopsoas tendonitis perhaps, are given to this condition. Can you think of another name?

 

Axial PDW SPAIR TSE

Coronal PDW SPAIR

Axial PDW SPAIR TSE

 

A3 – Dancer’s hip.

Some have actually broken down snapping hip tendon syndrome into extra- and intraarticular types.

Extraarticular Type:

  • Lateral extraarticular type occurs when the iliotibial band, tensor fascia lata, or gluteus medius slide back and forth across the greater trochanter. This can lead to tearing, especially of the gluteus medius and particularly in large women. Concomitant bursitis is frequently present.
  • The medial extraarticular type addresses the iliopsoas tendon catching on either the anteroinferior iliac spine, the lesser trochanter, or the iliopectineal eminence during hip extension especially. Peritendinitis and eventually bursitis results. Our patient has this type with peritendinitis.

Intraarticular Type:

  • With tight constriction and irregular tracking over the anterior labrum, some patients with snapping hip tendon syndrome may develop intraarticular abnormalities involving the labrum and even signs and symptoms of hip impingement with effusion. In this author’s experience, ligamentum teres rupture is another cause of intraarticular snapping hip syndrome.
  • The condition is more common in athletes and MR identifies the indirect, and sometimes direct, signs. However, the direct signs are best identified with dynamic ultrasound with hip motion.

 

Check out MRI Online for more case review.

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|MRI Online| Master the Shoulder – Rotator Cuff Review

Colleagues,

If you are looking for somewhere to start with our video series, MRI Online, the Shoulder series is a great choice. It’s short, it’s accessible and you’ll be able to put the learnings into practice right away. We will revisit the shoulder in additional series later this year, so stay tuned.

The Shoulder series starts with an adhesive capsulitis case, where I show you my approach to shoulder cases. My hope is that by the end of the series, you’ll have a confident framework for attacking shoulder studies in a way that is both thorough and fast.

Next, we review the Six Components of Rotator Cuff Anatomy leveraging medical illustrations from our early text book — MRI Total Body Atlas. We end with a thorough case review of an adult with impingement, which we will evaluate for a rotator cuff tear.

A detailed video curriculum is below. Note this course is only available to MRI Online Premium Members. If you’d like a 14-day trial, please fill out this form.

Enjoy,
Dr. Stephen J Pomeranz

Shoulder MRI: Rotator Cuff Review

Shoulder “Shark” Week — Review of Rotator Cuff Anatomy

The Six Components of the Rotator Cuff

Identifying The Six Components of Rotator Cuff Tears in Practice