Findings and interpretation:

• The T1 images show circumferential mural hyperintensity of the left internal carotid artery, with narrowing of the lumen. Angiographic images also show narrowed lumen of the entire internal carotid artery.
• There is high T2 signal intensity in the left internal capsule, extending to the subcortical white matter and cortex of parts of the frontal and parietal lobe superiorly.
• Those parts of the cortex show low ADC signal. This indicates restricted diffusion.

The internal carotid mural hyperintensity is caused by methaemoglobin in the arterial wall, which indicates dissection. This also explains the narrowed lumen.

The cortical and white matter changes are caused by infarction, the location of which corresponds to the confluence of anterior cerebral, middle cerebral and posterior cerebral vascular territories. These are watershed infarcts caused by left internal carotid artery dissection.   

Principal Diagnosis:

Left internal carotid artery dissection complicated by watershed cerebral infarction

Differential diagnosis:

None

Management:

Urgently inform referring physician of findings and recommend urgent neurological consult.

Findings and interpretation:

• There is diverticulosis in the descending colon.
• At the descending/sigmoid junction there is extensive peri-colic fat stranding, with a complex fistulous tract and tethering of a loop of small bowel.
• The fistulous tract communicates with a large, mostly gas containing abscess in the anterior abdominal wall at the left iliac fossa, as well as the subcutaneous tissues and skin.
• There are adjacent, reactive left iliac fossa lymph nodes.

Incidental findings:

• There are multiple calcified gallstones in the gallbladder lumen.

The findings represent focal inflammation of the colon, complicated by abscess and entero-cutaneous fistula formation.

Principal diagnosis:

Complicated diverticulitis

Differential diagnosis:

None

Management:

Urgent surgical referral and discussion with interventional radiology regarding possibility of drain insertion.

Findings and interpretation:

MRI:

• There is a small area of hypo-enhancement in the right, posterior aspect of the pituitary gland. This is iso-intense to the gland on the non-contrast images.

Sestamibi scan:

• There is a small area of nodular uptake below the left lobe of the thyroid gland at 60 minutes.

SPECT-CT:

• The nodule showing uptake lies within the superior mediastinum.

There is a pituitary micro-adenoma demonstrated on pituitary MRI.

There is an ectopic parathyroid nodule detected on the sestamibi scan and SPECT-CT.    

Principal diagnosis:

Multiple endocrine neoplasia type 1

Differential diagnosis:

None

Management:

Refer for neuro-endocrine / endocrine / neurosurgery MDT to discuss surgical management options.

Recommend abdominal CT / ultrasound surveillance to search for pancreatic neuro-endocrine tumour. 

Findings and interpretation:

CT:

• There is mass-like, fusiform enlargement of the right intra-orbital optic nerve. It is isodense to the contralateral optic nerve, which is normal.
• There is right sided proptosis.

MRI:

• The optic nerve mass is well defined, isointense to brain parenchyma, and is avidly enhancing on the post-contrast images.

Pertinent negative findings:

• There is no calcification in the optic nerve mass.
• There is no increased density / hyperostosis of the bony optic nerve canal.
• There is no intracranial extension of the mass. There are no other masses in the optic chiasma / along the anterior optic nerve pathways.
• The brain parenchyma is normal / no features of neuro-fibromatosis type I.

The findings represent a non-aggressive neoplasm arising from the right optic nerve. This is an isolated finding, with no other features to suggest a syndromic association (neurofibromatosis type I is associated with optic nerve gliomas).

Principal diagnosis:

Right optic nerve glioma

Differential diagnosis:

• Optic nerve sheath meningioma (unlikely as this entity usually features tram-track calcifications and increased bony density of the optic nerve canal)

Management:

Alert referring physician of diagnosis.

Refer for discussion at neurosurgery MDT to discuss possibility of debulking surgery.

Ovarian serous/mucinous carcinoma

Findings and interpretation:

• There is a large right ovarian complex cystic lesion with a thickened, enhancing wall and an eccentric solid component which shows enhancement on the post-contrast images.
• The uterus is enlarged with asymmetric thickening of the posterior wall, with punctate T2 sub-endometrial hyperintense foci representing small myometrial cysts. The junctional zone is widened and indistinct posteriorly.

Pertinent negative findings:

• The left ovary contains a small, simple cyst with no suspicious features.
• There is no evidence of peritoneal metastatic deposits.

Incidental findings:

• There is a well-defined, thinly septated cystic lesion arising from the upper third of the anterior wall of the vagina representing a Gartner duct cyst.
• Small cysts in the cervical stroma represent Nabothian cysts.

The findings represent a right ovarian cystic neoplasm, as well as incidental uterine adenomyosis.

Principal diagnosis:

Right ovarian serous/mucinous carcinoma

Differential diagnosis:

• Ovarian serous/mucinous cystadenoma (this is extremely unlikely as there is a significant solid tissue element).

Management:

Alert referring physician of the diagnosis.

Refer for gynaecology MDT discussion regarding excisional biopsy of the right ovary.

Further imaging by staging CT of the thorax, abdomen and pelvis.

Findings and interpretation:

• There is a heterogeneous mass-like lesion in the lumbar spine, extending over multiple consecutive vertebral body levels (L1 – L5). It is located in the epidural space.
• The lesion shows heterogeneously hyperintense signal on T2, with fluid-fluid levels in some areas. It is iso-intense on T1 (higher signal intensity than normal CSF fluid).
• The lesion is effacing the thecal CSF space, and displacing the terminal cord and filum ventrally.
• The post-contrast images show a linear enhancing structure, likely representing an epidural vessel, as well as focal contrast hyper-intensity within the lesion.

The findings represent an epidural haematoma, which is compressing the terminal spinal cord and filum terminale. The contrast enhanced images show active bleeding into the haematoma.

Principal diagnosis:

Spinal epidural haematoma

Differential diagnosis:

None

Management:

Urgently contact referring physician and inform of findings.

Urgent neuro-surgical consultation is required.