Today’s cases: October 31st, 2015

Hi. These are some of the cases from today in Tokyo. As always, remember, I am a student, so there may be information that is incorrect!

  1. 80 y.o., (F) rectal cancer, recurrent tumor, invaded into small bowel, small bowel obstruction, large bowel expanded – diameter L.36.5mm (normal about 20mm), pt had no free air (result of perforation of gastro-intestinal tract) in abdominal cavity, no ascites (accumulation of fluid in the peritoneal cavity), pneumonia, hydronephrosis

Hydronephrosis: Hydronephrosis is defined as dilatation of the urinary collecting system of the kidney (the calices, the infundibula, and the pelvis) 1. The term hydroureteronephrosis is used when the dilatation also involves the ureter. 

Case courtesy of Dr Jeremy Jones,, rID: 6222

Below shows Bilateral Hydronephrosis LINK


Below: Specimen of a kidney that has undergone extensive dilation due to hydronephrosis. Note the extensive atrophy and thinning of the renal cortex. LINK


Below: Hydronephrosis due to a kidney stone at the ureteral vesicular junction seen on CT

2. 91 y.o., (F), A subarachnoid hemorrhage (SAH), hematoma from previous study compared in today’s study, shows shrinking, (another one noticed which could be sub-dural, or a hygroma) – Subdural hygromas refer to a cerebrospinal fluid (CSF) accumulation in the subdural space, remember layers P.A.D. “The meninges PAD the brain.” — Pia; Arachnoid; Dura. 


3. 83 y.o., (F), RLQ pain, ruled out appendicitis, no ovarian mass, noticed uterine myoma: A uterine myoma is a benign growth of smooth muscle in the wall of the uterus. Description of Uterine Myomas. A uterine myoma (myoma uteri) is a solid tumor made of fibrous tissue, hence it is often called a ‘fibroid’ tumor. Myomas vary in size and number, are most often slow-growing and usually cause no symptoms – BUT sometimes hemorrhage CAN CAUSE ABDOMINAL PAIN

Rt. kidney was atrophied, left kidney comparatively large to compensate, phlebitis (inflammation of the walls of a vein – due to stone?)

Image below shows atrophied LEFT kidney (remember, I cannot show actual images of our patients, these are Google images)

4. Recommended radiology book:

Pocket Atlas of Sectional Anatomy, Vol. 1: Head and Neck, Computed Tomography and Magnetic Resonance Imaging, 4th Edition (Basic Sciences (Thieme)) 4th Edition

CLICK IMAGES for links to English and Japanese translations


5. 57 y.o., (M), Cervical spondylosis, also known as cervical osteoarthritis or neck arthritis, age-related condition that affects the joints and discs in your neck. It develops from wear and tear of the cartilage and bones found in your cervical spine, which is in your neck. While it’s largely due to age, it can be caused by other factors as well.

Spur noticed, causes shoulder pain, neck pain, spur pushes on dural sac, in this case it was mild – spinal cord not involved, ‘dural sac indentation’, involving C4,/5,5/6,6/7

We also looked at CSF -weighted image, a.ka., heavy T2 image of spinal cord.

First, some anatomy:

Heavy T2 image:

6. Brain infarction after one day (shortage of blood supply). A cerebral infarction is a type of ischemic stroke resulting from a blockage in the blood vessels supplying blood to the brain. It can be atherothrombotic or embolic. Stroke caused by cerebral infarction should be distinguished from two other kinds of stroke: cerebral hemorrhage and subarachnoid hemorrhage.


This patient had presented with bilateral parietal cerebral infarction 20 days prior. The axial non-enhanced CT (click image for arrows) shows bilateral frontoparietal areas of hypodensity (large arrows) involving both grey and white matter, consistent with infarcts.


7. Let’s try to find the thalamus in the brain:

8. MRA examination

I have looked at many MRAs, but often, I am not able to name the structures when the attending radiologist asks me to name vessels from other angles – it is relatively easy when you are looking straight on:

Can you name them?

9. Now let’s look at a 2D image of the brain, looking at major arteries:

2D time-of-flight MRA of the internal carotid arteries

2D MR angiography demonstrating the severely narrowed lumen shown by the small focus of flow-related signal of the left internal carotid artery (short arrow) is compared to the normal right internal carotid artery (long arrow) and to the vertebral arteries (thin arrows).

10. 62 y.o., (M), Gliosis of white matter due to aging, small infarctions (shortage of blood flow) may naturally progress to dementia – not hemiparesis

Hemiparesis is weakness of the entire left or right side of the body. Hemiplegia is its most severe form, complete paralysis of half of the body. Hemiparesis and hemiplegia can be caused by different medical conditions, including congenital causes, trauma, tumors, or stroke

We looked for aneurysms – What is the most common are for an aneurysm? It is the ACA – anterior communicating artery.
The anterior communicating artery is a blood vessel of the brain that connects the left and right anterior cerebral arteries.

Gliosis, Cerebral hemispheres, CT

11. 90 y.o., (M),  ileus (a painful obstruction of the ileum or other part of the intestine), improving  (改善傾向), peritoneum had free air, which is not good, drainage tube present, atelectasis of lungs (partial collapse or incomplete inflation of the lung from fluid/mass), inguinal herniation, increase in Pleural effusion (condition in which excess fluid builds around the lung)


“Ileus2” by THWZ – Own work. Licensed under CC BY-SA 3.0 via Commons –

-This CT demonstrates the classic Rigler’s Triad of gallstone ileus: Pneumobilia (air in the biliary tract), low small bowel obstruction with distended small bowel loops, and an impacted gallstone in the terminal ileum. LINK

Below: 68-year-old woman with perforation of posterior wall of gastric body and this complicates endoscopic submucosal dissection.Transverse CT image shows free air (arrow) in lesser sac. Large quantity of free air (arrowheads) anterior to stomach is also seen.

Inguinal hernia

12. 23 y.o., (F), headache, her brain looked typical – small CSF space, small ventricles, barin is big (puffy and full), older brain is exact opposite (narrow arteries, often gliosis, infarctions). the most important thing for the brain is clear artery walls

Normal brain

13. Let’s look at the superior saggital sinus:

Below: 1, Inferior sagittal sinus. 2, Anterior end of superior sagittal sinus. 2, Posterior end of superior sagittal sinus. LINK

14. Let’s look at the pituitary gland in the saggital view

The major endocrine gland, a pea-sized body attached to the base of the brain that is important in controlling growth and development and the functioning of the other endocrine glands.

15. Let’s look at the clivis LINK

The clivus (Latin for “slope”) is a part of the cranium at the skull base, a shallow depression behind the dorsum sellæ that slopes obliquely backward. It forms a gradual sloping process at the anterior most portion of the basilar occipital bone at its junction with the sphenoid bone. On axial planes, it sits just posterior to the sphenoid sinuses. Just lateral to the clivus bilaterally is the foramen lacerum (the internal carotid artery reaches the middle cranial fossa above the foramen lacerum), proximal to its anastomosis with the Circle of Willis. Posterior to the clivus is the basilar artery.

The pons sits on the clivus.

Clinical Importance:Clivus is also the site for chordoma (a rare malignant tumour.)

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