Findings and interpretation:

CT:

• The non-contrast images show an aortic stent-graft in situ, within a large, infrarenal abdominal aortic aneurysm. There is good opposition at the attachment zones between the graft and the native aorta.
• The post-contrast images show contrast extravasation within the aneurysm sac. This is seen at L3 level, at the origin of the inferior mesenteric artery. It does not extend to the superior or inferior ends of the graft.

DSA:

• Angiography performed with the catheter in a branch of the superior mesenteric artery shows anastomosis between the superior and inferior mesenteric circulations, via the marginal artery of Drummond.
• Contrast is seen opacifying the aneurysm sac retrogradely via the inferior mesenteric artery.
• Metallic coils are seen deployed within the aneurysm sac and inferior mesenteric artery.  

The CT study shows a type II aortic endoleak, as evidenced by contrast media entering the sac via collaterals, through the inferior mesenteric artery.

The DSA images show an interventional radiology procedure, with access to the aneurysm sac via the inferior mesenteric artery, by way of collaterals forming an anastomosis between the superior and inferior mesenteric circulation. Coil embolisation of the aneurysm sac was performed.

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Principal Diagnosis:

Type II aortic endoleak with coil embolisation performed

Differential diagnosis:

None

Management:

Perform follow up imaging to ensure that the sac is no longer enlarging. This may be performed using contrast-enhanced ultrasound to avoid metallic streak artefact.

Discuss at vascular surgery MDT.

Findings and interpretation:

CT:

• There is collapse of the left lower lobe. The left lower lobe bronchus is compressed by bulky left hilar lymphadenopathy.
• Nodular left pleural thickening, with a small left pleural effusion.
• Scattered ground-glass nodules bilaterally. There is an area of consolidation in the left apex.
• Bilateral apical bullous disease.
• Heterogeneous, large bilateral adrenal masses.
• Multiple, heterogeneous renal masses bilaterally. Obstructive hydronephrosis of upper pole pelvi-calyceal system on the left.
• There is a lytic lesion involving the left transverse process of one of the lower thoracic vertebrae. There is also a lytic lesion of the left side of L4 vertebral body, with an adjacent soft tissue mass.

MRI:

• There are multiple T1 hypointense and T2 hyperintense bony lesions involving the thoracic vertebrae at multiple levels.
• The T1 post contrast images show a large, enhancing mass originating from the left posterior elements of a lower thoracic vertebra, and causing destruction of the transverse process and adjacent head of the rib.

The findings represent an aggressive multi-system process. Solid soft tissue deposits are seen within multiple systems at multiple sites. The pathology is most prominent in the left lung, with obstruction of the left lower bronchus by bulky lymphadenopathy causing collapse of the left lower lobe.

Principal Diagnosis:

Left lung/bronchial carcinoma with disseminated metastatic disease involving the contralateral lung, kidneys, adrenals and bones

Differential diagnosis:

Multi-system tuberculous infection

Management:

Refer for pulmonary MDT, to discuss image guided biopsy. The kidney masses are amenable to ultrasound guided biopsy.

Findings and interpretation:

• There is a lobulated, ill defined, anterior mediastinal mass, which is heterogeneously high in density on the non-contrast images, and showing moderate post-contrast enhancement.
• The mass is encasing the mediastinal vessels without compression / invasion.
• There is posterior mediastinal and right hilar lymphadenopathy.
• There is moderate splenomegaly.
• Bilateral pleural effusion, more on the left. Lower lung lobe segmental atelectasis bilaterally.

Pertinent negative findings:

• There are no fat densities / calcifications in the anterior mediastinal mass.
• No abdominal / axillary / low cervical lymphadenopathy.
• No hepatic parenchymal lesions.

The findings represent a mediastinal malignancy.

Principal diagnosis:

Lymphoma

Differential diagnosis:

Thymic carcinoma (this is highly unlikely given the age of the patient and imaging characteristics)

Management:

Alert referring physician of findings.

Referral to tertiary centre (oncology/paediatrics) for MDT discussion with regards to image guided biopsy for tissue diagnosis and further management.

Findings and interpretation:

CT:

• There is nodular, marked, circumferential pleural thickening on the right side, with similar marked thickening of the pleural fissures. This appears to be encasing the right lung.
• There is significant volume loss of the right lung.
• There is a moderate right sided pleural effusion.
• There are multiple hypodense splenic lesions.

Pertinent negative findings:

• There is no mediastinal lymphadenopathy.
• There are no calcified pleural plaques.

The findings represent a malignant process originating from the pleural, with probable splenic metastases.

Principal diagnosis:

Pleural mesothelioma

Differential diagnosis:

• Pleural metastases from unknown primary (this is highly unlikely)

Management:

Alert referring physician of diagnosis.

Refer for discussion at pulmonary MDT to discuss further imaging (staging abdomen pelvis CT) and image guided biopsy of the pleura and splenic lesions.

Findings and interpretation:

CT:

• There are multiple, partially calcified, intracranial, extra-axial masses.
• The largest mass is intraventricular, arising from the temporal horn of the right lateral ventricle. This mass is causing mass effect with compression of the adjacent temporal lobe, which demonstrates vasogenic oedema. It is causing effacement of the third and fourth ventricles, with resultant obstructive hydrocephalus.
• A second large mass is seen in a parafalcine location, exerting mass effect on the right frontal lobe with resultant vasogenic oedema.
• There is a small calcified lesion surrounding a segment of the intra-orbital right optic nerve.

MRI:

• The MRI study confirms the CT findings. The lesions seen on CT demonstrate avid, heterogeneous enhancement.
• Multiple peripheral lesions show broad-based attachment to the pachymeninges with dural tails.
• It also shows bilateral, well defined, hyper-enhancing cerebello-pontine angle lesions which extend into the internal acoustic meatus on both sides.

The findings represent multiple dural, parafalcine and intraventricular meningiomas. There are also bilateral acoustic neuromas and a right orbital nerve sheath meningioma. Some of the meningiomas are causing mass effect with obstructive hydrocephalus.  

Principal diagnosis:

Neurofibromatosis type II

Differential diagnosis:

None

Management:

Inform referring physician of findings, particularly with regards to mass effect and obstructive hydrocephalus.

Refer for discussion at neurosurgery MDT to discuss management by ventricular CSF shunting / debulking surgery.

Findings and interpretation:

• The ACL (anterior cruciate ligament) fibres are not visualised; there is heterogeneous high signal (T2 and STIR) in the expected location of the ACL.
• The medial meniscus appears truncated and small on the coronal images; the bowtie appearance of the meniscus is not seen on the sagittal images. There is displacement of a medial fragment of the meniscus into the intercondylar notch; on the sagittal images, a double PCL appearance is noted.
• There is horizontal high STIR signal in the posterior horn of the lateral meniscus, indicating a radial tear.
• There is a focal area of STIR signal hyperintensity in the articular surface of the medial femoral condyle, extending to the overlying hyaline cartilage.
• There is a small supra-patellar knee joint effusion.

Pertinent negative findings:

• The posterior cruciate, as well as medial and lateral collateral ligaments are intact.
• No bony fractures.

There is complete rupture of the ACL, as well as a bucket handle tear of the medial meniscus and a radial tear of the lateral meniscus. There is also an osteochondral lesion involving the medial femoral condyle.

Principal diagnosis:

Traumatic knee injury

Differential diagnosis:

None

Management:

Alert referring physician and recommend orthopaedic referral.