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Interesting cases

Here are a number of cases we have recently scanned at The Queen Square Imaging Centre.

We can offer this as an independent examination or as part of our full stroke work-up. Our stroke package consists of a MRI Head (including diffusion weighted imaging), MRA neck and Carotid Doppler Ultrasound.

 

Neurofibromatosis

History
A patient presents with 'café au lait' spots and a subcutaneous mass in the abdomen.

Findings
High-resolution T2FSE images demonstrate multiple neurofibromas throughout the cervical and lumbar spine. There are also plexiform changes in the brachial plexus.

Metastatic Disease

History
A patient with known breast cancer presents with lower back pain.

Findings
There is a large metastatic mass in T12 with extra osseous extension into the paravertebral tissues and intraspinally. The lesion is clearly identified on both the sagittal and axial post contrast sequences.

Facial Angioma

History
A patient presents with marked deformity of the right cheek.

Findings
There is an enormous facial angioma extending through the palate to almost obliterate the oro-pharyngeal airway. A small extension into the middle cranial fossa from the infra temporal fossa is shown. Signal change is present in the immediately overlying brain suggesting a breach in the dura. Bone is partly destroyed in and around the right orbit, especially the right frontal bone.

MR Perfusion Imaging in Stroke

History
A patient presents with an extensive middle cerebral artery territory infarct.

Findings
The MRA demonstrates complete occlusion of the right internal carotid artery (ICA). The perfusion sequence shows prolonged mean transit time in the right frontal area, indicating a delay in the transit time of contrast media as a result of the right ICA stenosis.

Posterior Tibial Neuroma

History
A patient presents with swelling in the right calf above the ankle.

Findings
The sagittal MR images demonstrate a well-defined lobulated mass in the posterior compartment of the right calf. The lesion enhances after contrast and the features are suggestive of a posterior tibial neuroma.

Right Internal Carotid Artery Aneurysm

History
A patient presents with longstanding headaches.

Findings
A contrast enhanced 3DTOF MRA with post processing reformatted images demonstrates a large right supraclinoid aneurysm. The entering and exiting vessels lie at the anterior aspect of the aneurysm.

Right Orbital Mass

History
A patient presents with right-sided ocular pain and parietal headaches.

Findings
A large ovoid intraconal mass is shown in the right orbit. It does not extend intracranially or into the optic canal and it is transversed by the optic nerve. The appearances are most likely to be those of a glioma.

Carotid Dissection and Recanalisation

History
A patient presents with pain the neck, weakness in left foot and clumsiness in the right hand.

Findings
The left internal carotid artery (ICA) is of reduced calibre throughout its extra and intracranial course. In addition there is a marked focal narrowing with a flow gap at its origin. The axial fat saturated images through the petrous portion of the left ICA reveals high signal material surrounding the narrowed lumen. The appearances are suggestive of a partially recanalised dissection of the left ICA.

Arteriovenous Malformation

History
A patient presents with persistent headaches.

Findings
There is a large arteriovenous malformation in the right cerebello-pontine angle extending into the right fossa of Lushka. There is a large varix seen within the lesion.

Popliteal Cyst

History
A patient presents with pain at the back of the knee.

Findings
There is a large posterior popliteal fluid collection. Marked tri-compartmental degenerative change in the medial joint compartment is also seen. These latter changes are in keeping with secondary avascular necrosis. Also present is a large joint effusion with marked synovitis and synovial hypertrophy.

Internal Carotid Artery Stenosis

History
A patient presents with a known left hemisphere infarct, ? degree of internal carotid artery stenosis.

Findings
There is a critical stenosis of the left internal carotid artery (ICA) at its origin. Moderate irregularity and narrowing of the right ICA is noted at its origin. Carotid Doppler ultrasound quantifies the left ICA stenosis to be greater than 70% and the spectral waveform pattern suggests string flow or a near occlusion. The right ICA stenosis was measured at between 50-59%.

Foetal MRI

History
Ultrasound suggests borderline ventriculomegaly.

Findings
There is a cavum of the septum pellucidum. Occipital white matter may be slightly reduced in bulk, but no other significant abnormality is demonstrated. Whilst Ultrasound remains the gold standard in imaging the foetus, MRI is becoming a useful accessory tool for confirming US findings.

fMRI

History
A patient presents with blurring vision and unsteadiness.

Findings
A solitary mixed signal intensity lesion is seen in the anterior left frontal lobe. The lesion is surrounded by a ring of haemosiderin and is likely to represent a cavernoma with a recent haemorrhage. The fMRI demonstrates that the areas of primary right hand, foot and lip activation are very close to the cavernoma as are the supplementary motor areas activated by the right hand and foot.

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