Findings and interpretation:

CT brain:

·       There is generalized hypodensity of the subcortical and deep white matter at the anterior temporal lobes, frontal lobes, peri-ventricular white matter and centrum semi-ovale.

·       There are multiple small hypodense lesions in the internal and external capsules and periventricular white matter bilaterally. 

MRI:

·       There is confluent white matter FLAIR hyperintensity in the regions described above.

·       There are scattered small lesions with FLAIR CSF signal in the peri-ventricular white matter.

·       The diffusion weighted sequence shows two hyperintense lesions in the right centrum semi-ovale anteriorly and subcortical white matter at the right frontal lobe anteriorly, with corresponding low ADC values indicating diffusion restriction.

Pertinent negative findings:

·       Unremarkable intracranial arteries on the time of flight sequence.

The findings represent multiple old lacunar infarcts on a background of leuko-encephalopathy, with two acute lacunar infarcts.

Principal diagnosis:

Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL)

Differential diagnosis:

·       Atherosclerosis and arteriolosclerosis causing ischaemic disease of the white matter and lacunar infarcts (this is typically seen in older patients; also, it typically follows a different distribution with no involvement of the subcortical white matter).

·       Mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes (MELAS); this disease has a younger age of onset, and the cortex is typically involved as well.

·       CNS vasculitis (this is extremely unlikely as the intracranial arteries were normal on the TOF sequence).

Management:

Alert referring physician of findings.

Recommend discussion at neurology MDM (multi-disciplinary meeting).  

Pulmonary sequestration

Findings and interpretation:

• There is a lobulated, well defined and homogeneous soft tissue mass in the right lower lobe posteriorly.
• The arterial supply to the mass originates from the infra-diaphragmatic abdominal aorta.
• Venous drainage from the mass flows via pulmonary veins to the left atrium.

Pertinent negative findings:

• The mass does not communicate with the tracheo-bronchial tree.

The findings represent a congenital lesion in the lung, which derives its blood supply from the systemic circulation.

Principal diagnosis:

Intralobar pulmonary sequestration.

Differential diagnosis:

None.

Management:

Alert referring physician of findings.

Recommend referral to cardiothoracic surgeon for surgical excision.

Ileal carcinoid tumour

Findings and interpretation:

• There is a well-defined soft tissue mass in the ileal mesentery, with surrounding mesenteric fibrotic strands connecting the mass to the surrounding ileal loops, giving a spoke-wheel appearance. This is consistent with a mesenteric desmoplastic reaction.
• The surrounding ileal loops show mildly thickened walls; they are distorted with sharp angulations, appearing tethered to the central mass.
• The mass shows avid, heterogeneous post-contrast enhancement.

Pertinent negative findings:

• No lesion identified within the involved small bowel loops. No evidence of bowel obstruction.
• No focal liver lesions / suspicious bony lesions to suggest metastases.

Incidental:

• Tunnelled dialysis line with tip in adequate position within right atrium.
• Minimal bilateral pleural effusions with minimal subpleural atelectasis.
• Thyroid multi-nodular goitre.

The findings represent an aggressive mesenteric mass. This is most likely neuro-endocrine based on the imaging characteristics.

Principal diagnosis:

Carcinoid tumour of the terminal ileum with spread to the mesentery, forming a mesenteric metastatic mass.

Differential diagnosis:

• Sclerosing mesenteritis

Management:

Alert referring physician of findings.

Recommend In-111 octreotide scan / I-123 labelled MIBG scan.

Correlate with chromogranin A and 5HIAA levels

Recommend discussion at surgical MDT to discuss possibility of resection.

Author’s note: The primary small bowel carcinoid tumours are often not identified on CT scans due to their small size.

Progressive massive fibrosis with lung adenocarcinoma and metastasis

Findings and interpretation:

Chest radiograph:

• There are nodules and masses in the lungs bilaterally, with a predominantly upper and mid-zone distribution.
• There is bilateral volume loss with upper zone fibrosis.

Pelvis radiograph:

• There is a lucent lesion in the left iliac bone, centred on the anterior inferior iliac spine, with a wide zone of transition implying an aggressive nature.

CT:

• There are bilateral apical and perihilar masses with coarse peripheral calcifications, with surrounding lung fibrosis.
• There are perilymphatic nodules throughout both lungs.
• There is a large mass in the right lower lobe peripherally; this mass has irregular borders and no calcifications, unlike the other masses. It also shows a higher soft tissue density than the other masses, which are relatively low in density.
• There are calcified mediastinal and hilar lymph nodes.
• Apical and basal emphysematous bullae are noted.

Negative findings:

• No obvious malignant lymphadenopathy/ suspicious lesions in the bony thorax / obvious metastases in the upper abdomen.

Incidental findings:

• Degenerative changes in both hip joints.
• Pancreatic parenchymal calcifications indicate chronic pancreatitis.

The findings represent a chronic, likely occupational fibrotic interstitial lung disease, complicated by development of lung carcinoma, which has metastasized to the left iliac bone.

Principal diagnosis:

Progressive massive fibrosis (which may be caused by silicosis, coal worker’s pneumoconiosis, or sarcoidosis) complicated by lung adenocarcinoma with bone metastasis.

Differential diagnosis:

• Pulmonary amyloidosis

Management:

Review any previous imaging if available.

Recommend CT guided lung biopsy for histological diagnosis.

Refer for pulmonary MDT discussion with regards to further management (chemotherapy / radiotherapy).

Focal nodular hyperplasia

Findings and interpretation:

• There is a well defined, small hepatic parenchymal lesion in segment IVA of the liver, which appears slightly hyperintense on T2 and inconspicuous on T1 compared to normal liver, with a small T2 hyperintense centre.
• It is avidly and homogeneously enhancing on the arterial phase, with retention of contrast in the portal venous and delayed phases; the centre is non-enhancing.
• There is a second, smaller lesion also seen in segment IVA of the liver; this lesion shows an identical contrast enhancement pattern to the larger lesion.
• Both lesions show greater retention of the contrast agent on the hepato-biliary phase.

The findings reflect two non-aggressive lesions in the liver with functioning hepatocytes. One of the lesions contains a central scar.  

Principal diagnosis:

Focal nodular hyperplasia

Differential diagnosis:

None

Management:

Specify in the report that this lesion requires no further follow-up or management.  

Vertebral artery dissection with cerebellar infarct

Findings and interpretation:

CT brain:

• There is a well demarcated, wedge shaped area of parenchymal hypoattenuation within the left cerebellar hemisphere, corresponding to the vascular territory of the left posterior inferior cerebellar artery (PICA).
• There is associated mass effect within the posterior fossa with effacement of the fourth ventricle.
• There is dilatation of the third and lateral ventricles, with effacement of the extra-axial CSF spaces and sulci.

MRI:

• T1 fat saturated images show a hyperintense crescent surrounding the lumen of the V3 segment of the left vertebral artery; the lumen is narrowed at this level. This indicates intramural haematoma in the false lumen of the artery.

Pertinent negative findings:

• No hyperdensity within the cerebellar infarct to suggest haemorrhagic transformation.

There is a PICA territory cerebellar infarct with cytotoxic oedema causing mass effect, leading to obstruction of the fourth ventricle with resultant obstructive hydrocephalus.

This is caused by dissection of the V2 segment of the left vertebral artery.

Principal Diagnosis:

PICA territory cerebellar infarction caused by left vertebral artery dissection. 

Differential diagnosis:

None.

Management:

Urgent neurological consult.

Neurosurgical assessment and referral to a tertiary neurology/neurosurgical centre.