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Opening Round Cases Fair Game Cases Case 051 History: middle-aged man with left eye blurred vision and respiratory symptoms. Legend: Axial T2WI shows a hypointense heterogeneous lesion in the medial aspect of the left orbit (arrows) and slightly displacing the globe laterally. The anterior portion of the medial rectus muscle cannot be well identified and all of the retrobulbar fat is edematous. Differential diagnosis: lymphoma, sarcoidosis, meningioma, Wegener’s granulomatosis of the orbit, orbital pseudotumor. Case 052 History: strange voice after total thyroidectomy in a young woman. Legends: A) Enhanced CT scan shows medial deviation of the right aryepiglottic fold (arrow) and enlargement of ipsilateral piriform sinus. B) Enhanced CT scan shows adduction of the right true vocal cord (arrow) and medialization of the arytenoid. Differential diagnosis of causes of vocal cord paralysis: above the hyoid- metastases to the jugular foramen, glomus tumors, schwannomas, nasopharyngeal carcinomas, chordomas; below the hyoid- squamous cell carcinoma, thyroid masses, glomus vagale tumors, schwannomas, posttraumatic dissections, pseudoaneurysm, intraoperative injury, lymphadenopathy, also lesions in the parathyroid tissue and esophagus; in the mediastinum- lymphoma, bronchogenic carcinoma, lymphadenopathy, patent ductus arteriosus, mitral stenosis, aneurysms, arterial dissections. Case 053 History: woman presenting with left-sided neck pain and shocks. Legends: A) Coronal post gad fat suppressed T1WI shows enhancement of the V cranial nerve branches on its path (arrows) and the pterygoid muscle (p). B) On this coronal post gad fat suppressed T1WI one can also see the V cranial nerve’s branch enhancement and thickening in the Meckel’s cave region (arrow). Differential diagnosis: schwannoma, neuroma, perineural spread of neoplasm, neuritis, meningioma. Case 054 History: smoker, drinker middle-aged man presenting with otalgia. Legend: Enhanced CT scans (A, B) demonstrate anterolateral extension of a poorly defined hyperdense mass to the base of the tongue (arrows), approaching the left retromolar trigone. Bilateral adenopathy (N) can be seen. Differential diagnosis: nasopharyngeal carcinoma, tonsil carcinoma, lymphoma, rhabdomyosarcoma of the tongue, synovial sarcoma. Case 055 History: middle-aged man with seizures. Legend: A) Coronal T2WI demonstrates a right temporal lesion (arrows) herniating into the sphenoid sinus. Note the presence of cerebro-spinal fluid in the lesion (C). Differential diagnosis: meningocele, meningoencephalocele, arachnoid cyst of Meckel’s cave, mucocele, lytic skull mass, temporal lobe encephalocele. Case 056 History: young woman presenting with left-sided hearing loss after car accident. Legends: A, B) CT scans show a left horizontal fracture (short arrows) of the temporal bone extending to the middle ear cavity. Note the widened space (separation) between the neck of the malleus and the incus short process (large arrow). Dislocation of the fragments can be also seen in figure B. C) CT scan shows tracking of air around the carotid canal (large arrow) and along the Eustachian tube (short arrow). Diagnosis: temporal bone fracture. Case 057 History: elderly man presenting with slowly progressive periorbital swelling, fronto- temporal soft tissue increase and bilateral vision disturbance. Legends: A) Coronal T2WI shows a hypointense diffuse infiltrative mass (arrows) affecting both orbits and extra orbital tissues. B) Enhanced CT scan shows a hyperdense lesion along the medial wall of the right orbit probably infiltrating the medial rectus muscle and causing periorbital swelling. (arrows) Differential diagnosis: orbital pseudotumor, Wegener’s disease, sarcoidosis, multifocal orbital lymphoma, schwannoma/neurogenic tumor, leiomyoma, metastasis. Case 058 History: young man with a long-term history of atopy and sinonasal obstruction. Legend: B) Non- enhanced CT scan shows a slightly hyperdense lesion bilaterally occupying, expanding and thinning (large arrows) the ethmoid and sphenoid sinuses. Erosions of the posterior wall of the sphenoid sinus and clivus can be seen (short arrows). Differential diagnosis: allergic fungal sinusitis, polyps, mucoceles, cystic fibrosis, inverted papilloma. Case 059 History: middle-aged left-handed smoker housewife presenting with ataxia and vertigo when cleaning the house. Legends: A) Axial 2DTOF MRA raw data shows both carotid arteries and right vertebral artery. Left vertebral artery is not seen (arrow). B) Contrast enhanced MRA of the great vessels of the neck and head shows stenosis of the proximal left subclavian artey (large arrow) and both vertebral arteries (left vertebral artery demonstrated with arrows). It’s presence on the CEMRA but not on the NC 2D TOF implies retrograde flow. A superior sat pulse is placed on the latter. C) Coronal CTA image of the great vessels of the neck shows an intraluminal thrombus (arrow) in the left proximal subclavian artery before the origin of the vertebral artery. Marked calcified plaque is seen distally. Diagnosis: subclavian steal. Clinical symptoms: early arm fatigue, ataxia, vertigo, dizziness; worse with arm exercise. Focal sensory or motor loss, dysphasia, and unilateral visual disturbances rarely may occur. Case 060 History: young woman presenting with right-sided lower neck mass after previous thyroidectomy. Legends: A) Enhanced CT scan shows a hyperdense mass in the right thyroid gland (large arrow), involving and posterior displacing the right carotid artery. A lymph node with tiny calcifications can be seen (short arrow). B) Enhanced CT scan through the upper thorax shows the extension of the hyperdense thyroid mass to the anterior mediastinum, encasing the inominate artery. (arrow) Differential diagnosis: adenoma, follicular carcinoma, papillary carcinoma, medullary carcinoma of the thyroid gland, lymphoma, parathyroid carcinoma. Case 061 History: middle-aged woman presenting with left-handed weakness after radiotherapy for breast cancer axillary nodes. Legends: A, B) Coronal fat suppressed T2WI shows a hyperintense left brachial plexus (arrows). Upper trunks and divisions are bright. Small arrows in B depict the posterior division. Differential diagnosis of causes of brachial plexopathy: viral, injury secondary to birth trauma and shoulder dystocia, Pancoast tumor, breast cancer radiation, lymphadenopathy from neoplasms, cervical rib, chronic inflammatory demyelinating polyneuropathy. Case 062 NO IMAGES AVAILABLE. History: middle-aged woman presenting with headache, galactorrhea and bitemporal hemianopsia. Differential diagnosis: craniopharyngioma, meningioma, metastases, granulomatous disease, lymphocytic hypophysitis, pituitary adenoma, chordoma, nasopharyngeal carcinoma, plasmacytoma. Case 063 NO IMAGES AVAILABLE. History: toddler presenting with an asymmetric face due to a left-sided violaceous mass. Differential diagnosis: venous vascular malformation, capillary hemangioma, schwannoma, neurofibroma, fibromatosis, Sturge-Weber syndrome, Klippel-Trénaunay syndrome. Case 064 History: middle-aged man with dental caries and pain in the right mandible. Legend: B) Non-enhanced CT scan shows erosion in the right ramus of the mandible and periosteal reaction (arrows). Differential diagnosis: radicular cyst, brown tumor, osteomyelitis, dentigerous cyst, keratocyst, osteosarcoma, Ewing’s sarcoma, fracture, SAPHO syndrome. Case 065 History: asymptomatic man undergoing routine scan for dentist appointment. Legend: Non- enhanced CT scan shows a lucent slightly expansile lesion (arrow) in the midline incisive canal. Differential diagnosis: nasopalatine cyst, radicular cyst, globulomaxillary cyst. Case 066 History: toddler with bilateral leukokoria, decreased vision and right ocular pain. Legend: Coronal T2WI shows a hypointense mass occupying the majority of the right globe and just a small spot in the left globe (arrows). Unfortunately, MRI cannot discern evidence of calcification. Differential diagnosis: persistent hyperplastic primary vitreous (PHPV), Coats’ disease, toxocara canis infection, bilateral retinoblastoma, retrolental fibroplasias, Von Hippel Lindau disease, multiple hemangioblastomas, melanoma. Case 067 History: woman presenting with pain referred to the left-sided skull base. Legends: A) Axial T2WI demonstrates an isointense skull base mass (arrow) posterior to the carotid artery within the jugular foramen and growing in the jugular vein. B) Axial post gad fat suppressed T1WI shows enhancement of the lesion (arrow) with flow voids within it (salt and pepper pattern). Differential diagnosis: meningiomas, metastases from thyroid, renal cell carcinoma, and melanoma, schwannomas, glomus jugulare, chondroid lesions. Case 068 History: child presenting with sensorineural hearing loss especially for low- frequency sounds. Legends: Axial (A) and coronal (B) CT scans show absence of well-formed cochlear turns creating a cystic- inner ear structure (arrows) where the cochlea should be located. The modiolus is insufficient. Differential diagnosis: Cock’s deformity, Mondini malformation, cochlear aplasia or hypoplasia, large vestibular aqueduct syndrome. Case 069 NO IMAGES AVAILABLE. History: one-year-old girl presenting with skin spots, menstruation and right-sided lesion on the head. Differential diagnosis: Paget’s disease, neurofibromatosis, nonossifying fibroma, giant cell tumor, osteoblastoma, enchondromatosis, fibrous dysplasia, osteopetrosis. Case 070 History: middle-aged woman presenting with left-sided decreased visual acuity and pain. Legends:
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