CSF Leak After Diastematomyelia Operation

I’ll be frank, I don’t have all the details on this but the findings are clear on this animated gif.  If you watch carefully, you can see the pulsation artifact at the site of leak.  There is a rent in the dura and pseudomeningocele in the dorsal soft tissues.

 

ezgif.com-gif-maker.gif

I’m guessing this was a laminectomy for a bony septum producing symptoms.  I have seen these on myelography where the dye pours out as soon as it’s injected.

Portal Vein Thrombosis on Noncontrast CT

I have seen PVT enough to know that it is:

  • Frequently missed
  • Can have bad consequences of portal venous hypertension
  • Management is a bit of a conundrum for clincians and rads.
    • Who to consult?
      • Vascular surgery
      • Heme/onc
      • GI
    • When to follow-up if at all?
      • Additional studies
        • Is an abdominal doppler needed?
    • Treatment
      • Anticoagulation
        • Fraught with difficulty because of the commonly associated cirrhosis and bleeding potential due to PVH/Varices.

 


One of my former colleagues and fellowship trained body imager missed this diagnosis leading to bad sequela of PVH a year later in a young patient.

In the images below, I have windowed the CT narrowly to show the contrast between the normal attenuation arterial system and the thrombosed portal venous system.  This makes it hard to see the fat and some of the secondary findings of PVH.  The coronal images below show a more normal window, but are harder to make sense of.

axial nc pvt

I’m presuming this patient has some hypercoagulable state since the patient already has an IVC filter.

 

cor nc pvt (2)

Primary Bone Tumor

I have heard that if you see one primary bone tumor in your career, then you’re done. That is a myth. Maybe it’s because I do MSK or more likely, that’s just plain wrong.

Anyway, a great case demonstrating classic features of an unfriendly neoplasm.  I’m not saying it isn’t a met or lymphoma but I’d bet Ewing’s sarcoma or chondrosarcoma over osteosarcoma (although I really like it for chondrosarcoma).

My beef with chondrosarcoma is that it’s not “ring and arc”-y enough compared to others but it’s definitely in the considerations.

The fine reticular calcification in the soft tissue mass rather than bone forming periosteal reaction tips the scales for me.  That said, there is substantial overlap in the imaging appearances of sarcomas and it primarily depends on the ability to mount a reparative response to the destruction.