1. Interesting Cases Dr. WALEED AL HAJJI

2. History Thirty years old male patient who is experiencing left extensive femoro-popliteal DVT. Hospitalized One day later he developed chest pain and shortness of breath Chest X-ray was obtained

4. CT angiography of the pulmonary arteries was done

6. Case was diagnosed as pulmonary embolism; IVC filter was inserted to guard against further PE

7. The patient survived that attack of PE, with follow up CT angiography of the pulmonary artery revealing complete resolution of the embolization of the right pulmonary artery. Two days later, the patient experienced similar attack of chest pain, that found to be due to another attack of PE. That was inspite of the IVC filter inserted in place!!!

8. CT of the chest and abdomen was performed

10. A B

11. Diagnosis Double IVC

12. Duplication of the IVC results from persistence of both supracardinal veins. The prevalence is 0.2%–3%

14. A double IVC can be associated with other conditions, such as a horseshoe kidney, a circumaortic renal vein, a retroaortic left renal vein, and a retroaortic right renal vein with hemiazygos continuation of the IVC A double IVC can be associated with other conditions, such as a horseshoe kidney, a circumaortic renal vein, a retroaortic left renal vein, and a retroaortic right renal vein with hemiazygos continuation of the IVC

16. Case 2

18. Diagnosis Fenestration of the septum pellucidum.  This is one of the findings in chronic obstructive hydrocephalus.  Also known as non-communicating hydrocephalus is simply hydrocephalus due to obstruction of CSF flow out of the ventricles.  Frequent causes of obstructive hydrocephalus include: -aqueduct stenosis -meningitis

19.  Features of long standing obstructive hydrocephalus are: -Marked dilatation of the lateral and third ventricles. -Thinned and elevated corpus callosum. -Depression of the fornices. -Rounding of the infundibular, optic and pineal recesses. -Ballooning of the suprapineal recess. -Fenestration of the septum pellucidum.

20. Case 3 This is an incidental finding during an angiography procedure

23. Case 4 History: Upper chest discomfort.

30.  Diagnosis:  Carcinoma of the gastric fundus (pseudoachalasia presentation) with direct invasion of the GEJ.

31.  Differential Diagnosis for Pseudoachalasia:  Carcinoma of the gastric cardia or fundus with direct invasion of the GEJ or distal esophagus.  Hematogenous metastases from breast, lung, or pancreatic cancer.  Lymphoma.  Chagas.

32.  Malignancy-induced secondary achalasia is an uncommon condition, accounting for only 2 to 4% of patient with findings of achalasia at manometry.  Most patients with primary achalasia are between 20 and 50 years of age and have symptoms of dysphagia for an average of 4 to 6 years. Whereas, most patients with secondary achalasia are older than 50 years and have symptoms, on average, less than 6 months.

34. Case 5

35. 28 years old male patient Admitted to the casualty with a stab injury to the left popliteal fossa No much bleeding was noted on admission!!

37. Traumatic (stab) pseudoaneurysm Pop. A

39. Case 6

40. A 76-year-old woman presented with: – Vague abdominal pain (persistent for over two years) – Recent (over the previous three months), unwanted 8 kg weight loss

43. Differential Diagnosis Gallbladder carcinoma Adenomyomatosis Chronic inflammation Metastastic disease (metastatic melanoma) And less likely, multiple polyps

44. Diagnosis Adenocarcinoma of the gallbladder

45. Discussion

46. Pathology Discussion Cholecystectomy Cholecystectomy Diffuse thickening of the wall but no obvious focal lesion Diffuse thickening of the wall but no obvious focal lesion.

47. Diffuse papillary projections of epithelium Diffuse, adenomatous epithelial change In some areas, dysplastic changes consistent with adenocarcinoma in situ The tumor focally invades into muscularis propria only superficially

48. Radiology Discussion: GB carcinoma, a highly lethal condition Sixth most common gastrointestinal malignancy (after colon, pancreas, stomach, liver, and esophagus) Because symptoms are often vague, this carcinoma is frequently detected late; in fact, detection is typically related to invasion of adjacent organs

49. Risk factors

50. Post-menopausal status Cigarette smoking Gallstones (seen in 85% of cases of gallbladder carcinoma)

51. choledochal cyst anomalous junction of the pancreaticobiliary ductslow insertion of the cystic duct chronic biliary reflux of pancreatic secretions The presence of a choledochal cyst, anomalous junction of the pancreaticobiliary ducts, and low insertion of the cystic duct are also associated with higher incidence. It is thought, in these cases, that gallbladder carcinoma may develop in response to chronic biliary reflux of pancreatic secretions

52. Imaging appearances Mass replacing the gallbladder Mass replacing the gallbladder (55%) most common (DD hepatocellular carcinoma, cholangiocarcinoma, and metastatic disease of the gallbladder fossa) Focal or diffuse wall thickening Focal or diffuse wall thickening (25%) (DD congestive heart disease, hypoalbuminemia, cirrhosis, hepatitis, cholecystitis, and adenomyomatosis) Polypoid mass Polypoid mass (DD polyps (adenomatous, hyperplastic, or cholesterol), carcinoid tumor, melanoma metastasis, and hematoma)

53. References Levy AD, Murakata LA, Rohrmann CA. AFIP Archives. Gallbladder Carcinoma: Radiologic- Pathologic Correlation. Radiographics 2001; 21: 295-314. Bang Huu Huynh, MD - Case Coordinator Amy Ho Huang, MD - Radiology Discussion Jian Shen, MD, PhD - Pathology Discussion Steven E Seltzer, MD - Attending Radiologist May 12, 2003

55. Thank You