Aortic Transection

Findings and interpretation:

• There is an ill-defined rim of soft tissue density surrounding the aortic arch and descending aorta, also extending cranially to the roots of the left common carotid and subclavian arteries, as well as mediastinal fat stranding.
• There is irregularity of the wall of the aortic arch distal to the origin of the left subclavian, with an intimal flap visualised at this level, as well as a pseudoaneurysm extending into the mediastinum.
• There is subsegmental atelectasis in the posterior aspects of both lungs.
• There are contiguous fractures of ribs 1 – 7 on the right side with resultant surgical emphysema of the right chest wall and a minor, anteriorly placed pneumothorax.
• There is a displaced fracture of the manubrium sterni.

The findings represent a traumatic aortic transection with a resultant mediastinal pseudo-aneurysm, as well as a surrounding mediastinal haematoma, along with the other traumatic pathology as described.  

Principal diagnosis:

Traumatic aortic transection.

Differential diagnosis:

• Aortic intramural perforated ulcer: this is far less likely given the morphology of the lesion and the provided history.

Management:

Urgently contact referring physician / vascular surgeon and inform of findings.

Open vascular repair vs. TEVAR (thoracic endovascular aortic repair) should be carried out urgently.

Autoimmune Pancreatitis

Findings and interpretation:

• There is diffuse enlargement of the pancreas with loss of the normal lobular contour of the pancreas. There is a thin rim of hypo-attenuating soft tissue surrounding the pancreas, giving a ‘halo’ appearance.
• The pancreatic duct appears diffusely narrowed.
• There is diffuse dilatation of the intra-hepatic and extra-hepatic bile ducts, down to the level of the mid-CBD. There is abrupt cut-off of the bile duct at the mid-CBD level.
• The proximal extra-hepatic bile ducts (particularly at the CHD level) show slight thickening and enhancement of the wall.
• There are multiple cystic lesions at the pancreatic head.

Pertinent negative findings:

• There is very little peri-pancreatic fat stranding.
• There is no retroperitoneal fibrosis or abdominal lymphadenopathy.

Incidental findings:

• There are bilateral, simple renal cysts.

The findings represent inflammation of the pancreas, with features typical of auto-immune pancreatitis. Obstruction of the biliary system is caused by a CBD stricture, due to extra-pancreatic disease involvement of the extra-hepatic bile ducts. Cystic lesions in the pancreatic head likely represent pancreatic pseudo-cysts.

Principal diagnosis:

Auto-immune pancreatitis.

Differential diagnosis:

• Pancreatic lymphoma: this is unlikely as there are no enlarged local lymph nodes.
• Acute pancreatitis: This is unlikely as the imaging features do not fit this diagnosis.

Management:

Alert referring physician of findings.

Recommend MRCP to further assess biliary ductal involvement.

Recommend ERCP with retrograde biliary stenting to facilitate biliary drainage.

Correlate with serology (IgG’s and antinuclear antibody levels may be raised).

Steroid administration is the mainstay of treatment.

Spinal Chondrosarcoma

Findings and interpretation:

CT:

• There is an ill-defined mass arising from the posterior elements of the T12 vertebra and extending into the posterior spinal muscles and surrounding soft tissues.
• The mass shows mixed soft tissue and calcified densities, with punctate and ‘ring and arc’ calcification consistent with a chondroid matrix.
• Destruction of the posterior elements of T12 are noted.
• There is an ossified pulmonary lesion in the left lung base.

MRI:

• There is a large multi-lobulated mass corresponding to that described above, showing marked heterogeneous T2 hyperintensity and low signal on T1.
• Punctate areas of low signal are demonstrated on T2 representing the calcifications in the matrix.
• The mass extends into the posterior spinal epidural space.

Pertinent negative findings:

• The mass is not causing spinal canal stenosis, and is not compressing the spinal cord/ cauda equina.

The findings represent an aggressive musculoskeletal neoplasm, most likely of chondroid origin. The lung nodule represents a secondary calcified metastasis.

Principal diagnosis:

Chondrosarcoma.

Differential diagnosis:

• Osteosarcoma: unlikely as there is no osteoid matrix and the location does not favour this diagnosis.
• Other type of sarcoma such as malignant fibrous histiocytoma / fibrosarcoma.

Management:

• Alert referring physician.
• Recommend staging CT thorax abdomen and pelvis.
• Recommend discussion at sarcoma MDT regarding biopsy for tissue diagnosis.

Oto-mastoiditis with brain abscess

Findings and interpretation:

CT:

• There is right mastoid bone hypo-pneumatization, as well as complete opacification of the mastoid air cells. There is partial opacification of the middle ear cavity.
• Partial opacification of the left mastoid air cells and middle ear cavity is also present.

MRI:

• There is a T2 hyperintense lesion in the right temporal lobe, with surrounding T2 hyperintensity indicating vasogenic oedema.
• The lesion shows marked restricted diffusion, appearing bright on DWI with corresponding low ADC values.
• A thin, regular peripheral rim of enhancement is demonstrated on post-contrast images.

Negative findings:

• Normal enhancement of the subdural venous sinuses on MR venography.
• No destruction of the bony mastoid walls.

The findings represent severe right sided oto-mastoiditis, which has spread intracranially to give rise to a brain abscess. Left sided oto-mastoiditis is also present.

Principal diagnosis:

Bilateral oto-mastoiditis causing right temporal brain abscess.

Differential diagnosis:

None in this case.

Management:

Urgently contact referring physician with findings.

Perform CT / MR venography to rule out concurrent dural venous sinus thrombosis.

Urgent ENT / neurosurgical consult should be obtained.

Boerhaave’s syndrome

Findings and interpretation:

Contrast swallow:

• There is a large amount of extraluminal contrast in the mediastinum adjacent to the lower third of the esophagus.

CT:

• There are bilateral pleural effusions, the left far larger than the right. There is also a pneumothorax on the left side, creating an air-fluid level of a hydropneumothorax.
• There is near total collapse of the left lung, with the exception of a small part of the left upper lobe. There is basal atelectasis on the right.
• There is air density within the mediastinum and extending into the pericardial sac and cranially into the soft tissues of the neck, signifying a pneumomediastinum and pneumopericardium.

Negative findings:

• No oesophageal mass creating a fistula is detected.

The findings represent oesophageal rupture, causing air and fluid from the oesophageal lumen to escape into the mediastinum and left pleural space.  

Principal diagnosis:

Boerhaave’s syndrome.

Differential diagnosis:

• Iatrogenic oesophageal rupture.
• Other causes of oesophageal rupture, such as trauma or corrosive material ingestion.

Management:

Urgently contact the referring physician and inform of findings.

Urgent surgery/ endoscopic management will be required.

Insertion of a left chest drain by radiology may be required.

Metastatic Wilm’s Tumour

Findings and interpretation:

• There is a large, solid, lobulated, ill-defined, exophytic mass arising from the anterior aspect of the right kidney.
• It appears heterogeneously hyperintense on T2 and hypointense on T1 with punctate areas of hyperintensity signifying haemorrhagic foci.
• The mass shows heterogeneous enhancement on the post-contrast images.
• The mass directly invades the inferior surface of the liver; there are multiple liver T2 hyperintense parenchymal lesions in segment VI of the liver.
• There are large local lymph nodes at the right renal hilum which displace the adjacent IVC and encase the renal artery and vein.
• There are scattered nodules throughout both lungs.

Pertinent negative findings:

• There is no invasion of the right renal vein or IVC.
• The mass does not cross the midline.
• The contralateral kidney is normal.

The findings represent a malignant tumour arising from the right kidney. This has spread to the liver by direct invasion, as well as to local draining lymph nodes and via haematogeneous spread to the lungs.

Principal diagnosis:

Metastatic Wilm’s Tumour

Differential diagnosis:

• Renal cell carcinoma- extremely unlikely as this is encountered far less than Wilm’s tumour in children, especially at this age. It is usually significantly smaller than Wilm’s tumour at presentation.

Management:

Alert referring physician of findings.

Ultrasound guided biopsy may be performed for histological diagnosis.

Discussion at paediatric oncology MDT.

Chemotherapy should be commenced to attempt to downstage the tumour prior to surgery.