Findings and interpretation:

• The non-contrast images show a serpiginous structure in the left orbit; this represents the superior ophthalmic vein. It drains into an enlarged left cavernous sinus.
• The post-contrast images show normal enhancement of the vein, as well as the enlarged left cavernous sinus.

Pertinent negative findings:

• There is no thrombosis of the superior ophthalmic vein or cavernous sinus.
• There is no proptosis; no enlargement of the extra-ocular muscles.
• There are no left internal carotid aneurysms.

The findings represent high volume arterial flow into the left cavernous sinus, with reversal of flow into the superior ophthalmic vein causing dilatation and engorgement of the vein. This is evidence of an abnormal communication between the left internal carotid artery and the left cavernous sinus.  

Principal diagnosis:

Left carotico-cavernous fistula

Differential diagnosis:

• Ruptured cavernous internal carotid artery aneurysm
• Arterial flow into cavernous sinus from dural arterio-venous fistula

Management:

Alert referring physician of diagnosis.

Obtain early arterial phase CT angiography sequences.

Refer for discussion at neurosurgery MDT to discuss further investigation / referral to interventional neuroradiology for conventional angiography with possible endovascular embolisation.

Findings and interpretation:

Radiographs:

• There is epiphyseal widening of the femur, tibia and fibula, with periarticular osteoporosis.
• The intercondylar notch is widened, with bulbous change of the medial femoral condyle.
• There is loss of joint space, indicating thinning of the articular hyaline cartilage and menisci.

MRI:

• There is thinning of the articular hyaline cartilage overlying the femoral condyles and tibial plateaus. Diminished thickness of the menisci, particularly the frontal horns.

Pertinent negative findings:

• There is no erosion of the bony articular surfaces.
• No active inflammatory synovitis.

The findings represent overgrowth of the epiphyses, indicating longstanding or recurrent hyperaemia. Peri-articular osteoporosis indicates relative disuse of the joint. Cartilage and meniscal erosions indicate a chronic inflammatory process in the joint.  

Principal diagnosis:

Haemophiliac arthropathy

Differential diagnosis:

• Juvenile idiopathic arthritis

Management:

Obtain gradient echo images to search for susceptibility artefact caused by haemosiderin deposition.

Review clinical data to ascertain if the patient is a known haemophiliac.

Refer for orthopaedic MDT to discuss further management / imaging follow up.

Duodenal carcinoma with incidental liver haemangiomatosis

Findings and interpretation:

• The stomach is grossly distended, along with distension of the first, second and third parts of the duodenum. There is abrupt cut-off at the fourth part of the duodenum, which shows irregular concentric mural thickening and luminal constriction.
• Adjacent to the fourth part of the duodenum there are two irregular, ill defined lesions which show marginal enhancement with a hypo-enhancing centre.
• There are two large lesions within the hepatic parenchyma which are hypodense to the liver parenchyma in the non-contrast phase. In the arterial phase, the lesions show nodular, peripheral enhancement. This is seen to progressively fill in on the portal venous phase.

Incidental findings:

• There are two large, simple cysts in the left kidney.

The findings represent a malignant process in the fourth part of the duodenum which is causing obstruction of the GI tract proximal to that level. There is local spread to adjacent lymph nodes.

The findings within the liver represent benign vascular lesions.

Principal diagnosis:

Duodenal adenocarcinoma with incidental liver haemangiomatosis

Differential diagnosis:

• Duodenal lymphoma.
• Duodenal GIST.
• Hypervascular metastases in the liver (This is almost implausible as the contrast pattern is diagnostic for haemangiomas)

Management:

Alert referring physician of findings and advise immediate placement of a nasogastric tube.

Recommend gastro-intestinal referral and gastroduodenoscopy with biopsy of the duodenal lesion.  

Findings and interpretation:

Mammograms:

• There is a small, irregular, spiculated nodule in the upper central portion of the right breast. No associated microcalcifications.
• There is an asymmetric density in the lower inner quadrant of the left breast.

US:

• There is a hypodense lesion in the same area as the previously mentioned mammographic nodule, that is taller than it is wide. It is relatively well defined, and shows a small degree of posterior acoustic shadowing.
• Core biopsy of the lesion has been performed, with a needle seen through the lesion on one of the ultrasound images.

Pertinent negative findings:

• Ultrasound imaging of the axillary region shows axillary lymph nodes of normal reniform shape and fatty hilum.
• The asymmetric density is not seen on ultrasound.

The lesion that was biopsied is an M4 lesion, with radiographic features that designate it as likely to be malignant.

The asymmetric density is an M3 lesion. It is likely benign, yet warrants short term follow up.   

Principal diagnosis:

M4 breast lesion (likely breast carcinoma)

Differential diagnosis:

• Benign lesion such as fibroadenoma

Management:

Refer for breast MDT after obtaining biopsy result to discuss further management.

Findings and interpretation:

• There are multiple small bowel loops that show markedly thickened walls and thickened, hyper-enhancing mucosal folds.
• There are multiple, enlarged mesenteric lymph nodes with low density centres. There is mesenteric hyperaemia and free fluid.
• There are a few hypodense lesions in the liver, spleen, and left kidney.
• Surgical clips are seen at both hila, indicating post- double lung transplant surgical changes. There is an enlarged right hilar lymph node.
• There is left basal consolidation, and a minimal left pleural effusion.

Pertinent negative findings:

• There is no significant mediastinal lymphadenopathy.

In correlation with the surgical history provided, the findings represent a lympho-proliferative disorder involving the small bowel and solid visceral organs, as well as lymph nodes at multiple sites. The left basal consolidation may be part of this process, or be infectious in etiology.

Principal diagnosis:

Post-transplant lymphoproliferative disorder

Differential diagnosis:

None

Management:

Alert referring physician of findings.

Refer for oncology MDT to discuss further management / treatment options.   

Findings and interpretation:

• There is marked central saccular bronchiectasis in a generalised distribution, but which predominantly involves the upper lobes bilaterally and right middle lobe.
• Thickening of the bronchial walls is variably seen.
• Some of the bronchi contain branching soft tissue attenuating material within, representing mucoid impaction. This shows a ‘finger in glove’ appearance on the coronal images.
• A number of thick walled cavities are present, most prominent in the left upper lobe. One of the cavities in the right upper lobe adjacent to the hilum contains low density material within.
• There are a few enlarged mediastinal and bilateral hilar lymph nodes, giving the appearance of reactive nodes.

Pertinent negative findings:

• There is no lung fibrosis.
• No consolidations/ ground glass opacities.

The findings represent damaged and dilated bronchial walls which are filled with mucoid material, resulting in bronchoceles. This is most likely the result of an infectious process centred within the lumen of the bronchi, with resultant hypersensitivity of the bronchial wall and subsequent damage.

Principal diagnosis:

Allergic broncho-pulmonary aspergillosis

Differential diagnosis:

• Cystic fibrosis (the element of fibrosis is more marked in this disease with greater interstitial thickening)
• Recurrent pulmonary infections
• Mounier Kuhn syndrome

Management:

Alert referring physician of findings.

Correlate with clinical data and lab results such as presence of asthma, peripheral eosinophilia and fungal elements in sputum.