28 year old femal patient. Hypostenia and hypoestesia localized at lower limbs and loss of sphincterial control. Sagittal T2, PD and T1 weighted images pre- and post- paramagnetic contrast medium i.v. administration, and axial T1 and T2 weighted images in the area of the suspected lesion were performed.These Images are given below.
axial T1-weighted post-Gadolinium image

sagittal image T1-weighted post-Gadolinium
sagittal T2-weighted image
sagittal PD-weighted image

Identify what  the lesion is  and where the lesion is?

A 50-year-old man, who was previously healthy, presented with symptoms that included progressive intermittent but severe dysphagia, halitosis, paroxysms of coughing and regurgitation of food and liquids. He also had an unintentional weight loss of 20 kg. These symptoms developed during a 15-month period. He had no history of tobacco or alcohol use. Results of the physical examination done were found to be normal. A radiographic image was obtained.




What Is the diagnosis?

ANSWER

Giant Zenker's diverticulum

Xray showed a large fluid level from the midline at the upper mediastinum above the aortic arch and there was no evidence of a lower mediastinum widening.After swallowing barium, there appeared a large esophageal outpouching arising from the midline of the posterior wall of the pharyngoesophageal junction. The radiological diagnosis suggested that the patient had a pharyngoesophageal diverticulum (Zenker´s diverticulum).

Zenker's diverticulum is a pseudodiverticulum consisting of mucosa and submucosa that arise from the posterior portion of the inferior pharyngeal constrictor muscle. The Zenker diverticulum occurs at an area of potential weakness in the inferior pharyngeal constrictor muscle referred to as the Killian dehiscence.
The most common presenting feature is upper esophageal dysphagia, which occurs in as many as 98% of patients. Other common symptoms include halitosis, regurgitation of undigested food, noisy swallowing, and aspiration. Some patients also report excessive salivation and the sensation of a mass within the throat. Weight loss and recurrent pulmonary infections occur in approximately one-third of the patients.
hysical examination findings are rare, although some extremely large diverticula are occasionally palpable on examination. These are usually present to the left of the midline.
Fluoroscopic barium esophagography is the mainstay of the diagnosis of the Zenker diverticulum.
Patients with minimal symptomatology who do not desire surgical therapy may be followed up on a routine outpatient basis by monitoring their symptoms.
Several surgical options exist; however, the approach most frequently cited is myotomy of the cricopharyngeus muscle with or without diverticulopexy. Endoscopic treatment of Zenker's diverticulum, including endoscopic stapling, holds promise and is currently being investigated in clinical trials.


An 11-year-old boy who lived on a farm presented with a 2-week history of fever, vomiting and pain in the right hip that extended into the right buttock. The patient was non-weight bearing on the right leg, with restricted movement of the right hip. CRP was elevated. The pelvic radiograph at presentation was normal. Clinical examination had revealed tenderness on deep palpation of the right iliac fossa, and an abdominal ultrasound obtained to exclude appendicitis was negative. No hip joint effusion was seen on ultrasound.
MRI image study was requested.Axial T1wFS image post IV gadolinium and coronal STIR images at the level of Sacrum given below.

Axial T1wFS image post IV gadolinium

coronal STIR image

What is the Diagnosis?

ANSWER

Sacral osteomyelitis associated with pyogenic sacroiliitis

Axial and coronal STIR and T2w images showed a focal lesion with surrounding high signal in the right sacral alum and less well-defined high signal in the right iliac bone also. The sacral lesion was associated with cortical loss at the inferior aspect of the right sacroiliac joint and a low signal central bony sequestrum. The adjacent iliacus, pectineus, obturator internus, psoas and gluteus maximus muscles were thickened and of high signal. There was marked enhancement post-gadolinium of the bony sacral lesion and the anterior soft tissue collection.

Sacral osteomyelitis is rare and diagnosis is often delayed due to a variable clinical presentation, low suspicion of examining clinician, lack of awareness of diagnostic procedure, and rare findings on plain radiographs. The rate of complications increases with delay in diagnosis, and includes abscess or sequestrum formation, prolonged period of sepsis, long-term joint deformity, disability or even death .
Presentation is often a triad of fever, low back pain and difficulty weight-bearing, associated with an elevated C-reactive protein. The most common causative agent is Staphlococcus aureus.Brucellosis and other atypical organisms are associated with sacral osteomyelitis.
The plain radiograph is rarely helpful. An ultrasound examination is useful to exclude a hip joint effusion. Tc99-MDP bone scan is a sensitive test, but lacks specificity. CT clearly shows bone and soft tissue involvement, and may have a role in aspiration or biopsy. MRI has emerged as the imaging modality of choice due to its increased sensitivity and specificity.

A 76-year-old man, with a long story of hypertension, arrived at the emergency room with sudden severe tearing thoracic pain, tachycardia and progressive hypotension. Few minutes after his arrival he lost consciousness.

CT images taken.


What is the diagnosis?

ANSWER

Acute aortic dissection
CT imaging reveals a dissection involving the ascending aorta.

Acute aortic dissection is the most common emergency affecting the aorta; its prevalence exceeds that of ruptures of thoracic and abdominal aneurysms combined. Untreated, acute aortic dissection can rapidly be fatal.
Patients with hypertension or connective tissue disorders such as Marfan syndrome, cystic medial necrosis, Ehlers-Danlos syndrome and Turner syndrome are at risk for aortic dissection. Pregnancy, aortic stenosis, and coarctation of the aorta are other risk factors.

Stanford classification is the widely used. Regardless of the site of intimal tear or the distal extent of the dissection, dissections involving the ascending aorta (Stanford type A) usually require emergency surgical repair (because of the risk of acute aortic insufficiency, occlusion of the coronary vessels or rupture of the dissection into the pericardium), whereas dissections that are distal to the left subclavian artery (Stanford type B) usually can be controlled medically, unless there is aortic ropture or renal or visceral vascular compromise.

CT is a rapid, relatively noninvasive, and readily available method for evaluation of acute aortic dissection. It is 93.8% sensitive and 87.1% specific. The classic features of AAD on CT scans are an intimate flap and false lumen, which are found in approximately 70% of cases; demonstration of an intimate flap is usually conclusive.Secondary findings include increased attenuation of the acutely thrombosed false lumen on scans obtained before administration of contrast material, internal displacement of intimal calcification, mediastinal or pericardial haematoma, delayed enhancement of the false lumen, mural thickening with increased attenuation, and irregular compression of the true lumen by an expanding intramural haematoma or thrombus.

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