Arti Chaturvedi, MD

 A 67-year-old female with a history of long standing goiter presented with a short onset history of cough and breathlessness. She did not have any fever or hemoptysis. The chest X-ray was unremarkable.

 Contrast enhanced CT of the chest (Fig 1) revealed irregular concentric wall thickening and luminal narrowing of the distal left main bronchus till the lobar bifurcation. Multiple, clustered subcentimetric mediastinal nodes were also present.

 The entire left lung was hyperlucent, consistent with air trapping, but no parenchymal infiltrates were seen (Fig 2). There was no associated pleural pathology. An incidental multinodular goiter with early retrosternal extension was also noted.

 Since CT findings were highly suspicious for bronchial malignanacy, bronchocopy and bronchoscopic biopsy was performed. Bronchoscopy (Fig 3) revealed severe narrowing of the distal left main bronchus with associated mucosal nodularity.

 Brochoscopic biopsy (Fig 4) demonstrated presence of granulomas containing multiple epitheloid cells and central caseous necrosis. (Hematoxylin and eosin, 10x magnification.)

 The patient was started on antituberculous treatment with four drugs. A review CT chest performed after 2 months (Fig 5) showed significant resolution of the bronchial wall thickening with normalization of the lumen. The lucency of the left lung had also become normal. The mediastinal nodes were persisting.

 Endobronchial tuberculosis (EBTB) is defined as tuberculous infection of the tracheobronchial tree with microbial and/or histopathological evidence. EBTB may occur through one or more of numerous proposed routes: implantation from an adjacent parenchymal focus; intrabronchial rupture of a node; infected sputum; lymphatic or hematogenous spread. EBTB is a highly infectious and the diagnosis is often missed or delayed due to absent or minimal X-ray findings and a low pick up rate from sputum or bronchial lavage fluid.

CT findings in EBTB are varied. There may be isolated segmental bronchial narrowing with concentric wall thickening as in the above case (41- 43%); complete endobronchial obstruction (32%) and extrinsic obstruction from adjacent adenopathy (23 - 50%). Air trapping in a segment or lobe may draw attention to the bronchial abnormality which could otherwise have been overlooked. The presence of associated linear and branching opacities (tree in bud” appearance) is typical of peripheral endobronchial spread of tuberculosis. The tree in bud appearance is a result of dilation and luminal impaction of the peripheral bronchioles with mucus, pus, or fluid along with wall thickening and peribronchiolar inflammation. In the absence of these tree in bud opacities, isolated bronchial wall thickening with luminal narrowing/occlusion may be mistaken for bronchial carcinoma. Other conditions which may mimic EBTB are non specific inflammation, sarcoidosis, endobronchial actinomycosis. Endobronchial Kaposi's sarcoma is also a possibility in AIDS patients.

The aim of this case study is to highlight an uncommon cause of bronchial wall thickening and emphasise that all cases of bronchial wall thickening are not carcinomas. A high index of suspicion, timely CT scan and bronchoscopic biopsy can result in early diagnosis and treatment of EBTB. CT is the modality of choice for diagnosis, assessment of extent of bronchial involvement, guidance for bronchoscopic biopsies and evaluation of delayed complications like bronchial stenosis, bronchiectasis or broncholiths.


1. Kashyap S, Mohapatra PR and Saini V. Review Article- Endobronchial Tuberculosis. Indian J Chest Dis Allied Sci 2003; 45 : 247-256
2. Gupta PP, Agarwal D, Gupta KB, Sood S. CT evaluation in diagnosis of endobronchial tuberculosis. Lung India 2006; 23:126-12992.
3. Tetikkurt C. Current perspectives on endobronchial tuberculosis. Pneumon 2008; 21(3):239 –245
4. Qingliang X and Jianxin W. Investigation of endobronchial tuberculosis - diagnoses in 22 cases. European Journal of Medical Research 2010; 15:309-313.

Arti Chaturvedi, MD
Senior Consultant, Department of Radiodiagnosis
Fortis International Hospital, Noida, India

Articles

Case history: A 67-year-old female with a history of long standing goiter presented with a short onset history of cough and breathlessness. She did not have any fever or hemoptysis. The chest X-ray was unremarkable.

Endobronchial Tuberculosis 

 An 18-year-old boy presented to the surgery outpatient clinic with a one-week history of a painful swelling at the umbilicus with purulent discharge.

FIGURE 1
Ultrasound revealed a bilobed cystic lesion under the umbilicus with echogenic contents in the umbilical cleft and relatively hypoechoic contents in the deeper component of the collection (Fig1).

FIGURE 2
A contrast CT of the abdomen revealed a lobulated collection under the umbilicus with thick marginal enhancement (Fig 2).

FIGURE 3
The posterior margin of the collection was closely applied to the urachus which showed mild focal thickening and enhancement (Fig 3).[[{"type":"media","view_mode":"media_crop","fid":"17441","attributes":{"alt":"","class":"media-image","id":"media_crop_8956586225","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"973","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","title":" ","typeof":"foaf:Image"}}]]

FIGURE 4
Rest of the urachus was best visualized on sagittal reformatted images as a thin isodense cord extending from the umbilical collection till the bladder vault (arrowed in Fig 4).

An imaging diagnosis of an urachal abscess draining through the umbilicus was made, most likely due to an infected urachal cyst. The patient was treated with surgical drainage under antimicrobial cover followed by complete excision of the cyst. Total removal of the cyst wall is essential to avoid reinfection. Reinfection rates are as high as 30 percent in incompletely treated cases.

The urachus is a fibrous cord extending from the bladder vault till the umbilicus and is the vestigial remnant of the urogenital sinus and allantois. Persistence of all or part of the urachus can result in congenital or acquired urachal remnant diseases. Congenital urachal remnants may present as a patent urachus (50 percent), umbilical-urachal sinus (15 percent), vesicourachal diverticulum (3 percent to 5 percent) or an urachal cyst (30 percent) (Fig-5 - Courtesy reference 3 below)

Acquired remnant disorders are mainly due to infection or neoplasm. Infection within an urachal cyst is uncommon with a peak incidence in infancy and then again in early adulthood. The adult presentation may be a consequence of partial opening of the urachus which may have closed at birth. Direction of drainage of infected urachal fluid depends on the type of urachal patency. Umbilical urachal sinuses and infected cysts close to the abdominal wall will result in umbilical discharge. Infected cysts close to the bladder and vesico-urachal diverticuli may present with urinary symptoms. Uncommonly, a large infected cyst may rupture into the peritoneal cavity and cause peritonitis.

Ultrasound and CT are both reliable modalities for diagnosis of urachal abscess. Demonstration of a midline fluid containing structure within the anterior abdominal wall and extension into the umbilicus with or without umbilical discharge is virtually diagnostic of a urachal abscess. In some complex abscesses, the mixed echoes on USS and heterogeneous enhancement on CT may mimic a urachal carcinoma and an image guided FNAC or biopsy is then indicated for definitive diagnosis and therapeutic planning.

Arti Chaturvedi MD
Senior Consultant, Department of Radiodiagnosis
Fortis International Hospital, Noida, India 


1. Yu JS, Kim KW, Lee HJ, Yoon CS, Kim MJ. Urachal Remnant Diseases: Spectrum of CT and US Findings. Radiographics March 2001; 21: 451-461.
2. Walker C A Case Report of Urachal Abscess: A Rare Differential in Adult Abdominal Pain. Hawaii Med J. 2010 February; 69(2): 35–36.
3. Abscess of urachal remnants presenting with acute abdomen: a case series. Tazi F, Ahsaini M, Khalouk. Journal of Medical Case Reports Journal of Medical Case Reports 2012, 6:226 doi:10.1186/1752-1947-6-226
4. Ash A, Gujral R, Raio C. Infected urachal cyst initially misdiagnosed as an incarcerated umbilical hernia. J Emerg Med. 2012 Feb; 42(2):171-3.

Urachal Remnant Abscess 

 A 27-year-old man had a history of hemiplegia and seizures since childhood. The seizures were partially controlled with medication. The present hospital visit was due to breakthrough seizure activity.
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 Axial T2 and T1 images at level of lateral ventricles demonstrates atrophy of the right cerebral hemisphere with enlarged sulcal spaces and a midline shift to left. The right cerebral cortex is thinned, the basal ganglia are small and there is mild increased T2 signal in the deep white matter.

 T1W image at the same level as in Figure 1 shows calvarial thickening along with the cerebral atrophy. Note the thickened fat density falx. 

 Axial T2 image at level of midbrain reveals atrophy of the cerebral peduncle. Hypertrophy of the frontal sinuses is also evident.

 Coronal T2 image showing atrophy of the left cerebellar hemisphere along with right cerebral atrophy.

Dyke-Davidoff-Masson Syndrome (Cerebral Hemiatrophy)

 MRI of the brain showed atrophy of the right cerebral hemisphere, midline shift to right and associated sulcal widening and prominence of the right lateral ventricle. The grey matter is thinned and there is reduced volume and T2 hyperintensity of the deep white matter. Atrophy of the right thalamus, basal ganglia and cerebral peduncle was present.  The contra lateral cerebellar hemisphere was atrophied – this was best demonstrated on the coronal images. Associated compensatory calvarial hypertrophy and enlarged frontal sinuses were also present.

Cerebral hemiatrophy may be congenital or acquired. The basic underlying etiology is a vascular insult with resultant hypoperfusion and impaired growth or destruction of neuronal tissue. The congenital variety is usually an intrauterine vascular occlusion. Acquired causes are more numerous and may be due to ischemia, vasculitis, trauma, tumors, prolonged infantile seizures, hemorrhagic conditions or infections.

Magnetic resonance imaging is the imaging of choice for evaluation of the extent of parenchymal loss and also for assessment of possible etiology. Calvarial overgrowth and enlargement of paranasal sinuses occurs in congenital and infantile types of hemiatrophy as a compensatory mechanism and can be differentiated from the adult acquired type where bony changes are not a feature. Enlarged sulcal spaces are present when the vascular insult occurs after birth or after sulcation. This is in contrast with congenital type when the insult is in the early intrauterine period before sulcation has completed and therefore sulcal widening is not a feature.

Dr Arti Chaturvedi MD
Senior Consultant, Department of Radiodiagnosis
Fortis International Hospital, Noida, India

1. Singh P, Saggar K, Ahluwalia A. Dyke-Davidoff-Masson syndrome: Classical imaging findings. J Pediatr Neurosci 2010;5:124-5.

2. Shetty DS, Lakhkar BN, John JR. Dyke-Davidoff-Masson syndrome . Neurol India 2003;51:136 

Dyke-Davidoff-Masson Syndrome

A 48-year-old female with a history of thyroidectomy for papillary cancer of thyroid. She presented six months later with a palpable mass in the left thyroid region and with backache radiating to left upper limb.

Contrast MRI of the cervical spine and neck revealed a hyperintense, enhancing extradural soft tissue mass in the left lateral cervical spinal canal extending from C1 to C5 levels and extending into the left C1-2 and C2-3 neural foramina. This mass was compressing the cord from the left lateral aspect and completely filling the left sided lateral recesses with infiltration of the nerve roots. This is consistent with epidural metastases. There was no obvious vertebral destruction or marrow involvement to suggest bony metastases.

Another well defined rounded necrotic mass was present in the left thyroid region showing shaggy marginal enhancement, consistent with a recurrent thyroid mass. The mass was insinuating into the prevertebral space but there did not appear to be an obvious communication of the extradural mass with the left thyroid region mass.

Recurrent thyroid Cancer with epidural metastases

 The incidence of spinal metastases in thyroid malignancy varies from 3 percent to 20 percent and depends on the type of tumor. Hurthle cell cancers have the highest incidence of spinal metastases (20 percent), follicular cancers have an incidence of 7 percent to 10 percent and the least common is papillary carcinoma with an incidence of 1 percent to 7 percent. The thoracic spine is the commonest site of involvement (60 percent to 80 percent) followed by lumbar (15 percent to 30 percent) and cervical (<10 percent) spinal regions.

Extradural lesions are the most common type of spinal metastases and account for up to 95 percent of spinal lesions. Intradural and intramedullary metastases are uncommon with an average incidence of 5 percent to 6 percent and 0.5 percent to 1 percent respectively.

The most common route of epidural spread is the spinal venous plexus and arteries, resulting in multifocal lesions. Other potential routes are direct infiltration from paraspinous disease, or rarely via the lymphatics or CS. In the majority of cases it is the vertebral body which is involved first (85 percent) with secondary spread to the epidural space.

In a small percentage of patients, the paravertebral spaces (10 percent to 15 percent) and the epidural space (<5 percent) may also initial sites of metastatic involvement. Thyroid papillary carcinoma in particular has a propensity to metastasize preferentially to the epidural space.

Spinal cord and cauda equina compression by the epidural tumor will present with neurological deficits of varying degrees. Nerve root compression will cause typical radicular or neuropathic pain. Tumoral soft tissue material impinging upon the epidural venous plexus may result in venous hypertension and vasogenic edema. 

Spinal radiotherapy is effective for palliation of spinal epidural metastases. Studies have also demonstrated good results with a combination of surgical decompression and radiation in some patients with spinal epidural metastases.

The aim of presenting this case is to highlight the uncommon occurrence of isolated epidural metastases in the cervical spine in a patient with recurrent thyroid cancer.

1.Ramadan S, Ugas MA, Berwick RJ, Notay M, Cho H, Jerjes W, Giannoudis PV. Spinal metastasis in thyroid cancer. Head & Neck Oncology 2012, 4:39

2. Brian P. Walcott, MD; Jeffrey R. Jaglowski, MD; William T. Curry, Jr, MD. Spinal Epidural Metastasis. 

2010;67(3):358-359. doi:10.1001/archneurol.2010.7

3. Shah LM, Salzman KL. Imaging of Spinal Metastatic Disease. International Journal of Surgical Oncology. Volume 2011, Article ID 769753, 12 pages doi:10.1155/2011/769753

4. Patchell RA, Tibbs PA, Regine WF et al. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomized trial. Lancet 2005; 366(94-81) 643-648.

Recurrent Thyroid Cancer with Epidural Metastases

This case is a 26-year-old female in whom MRI imaging was done24 hours after an attempted hanging episode.

In a hanging, the probable cause of death or disability is cerebral hypoxia due to compression of the neck vessels, especially the carotid arteries and jugular veins. The vertebral arteries are relatively protected in the transverse foramina and are often spared.

Here, T2W and FLAIR images revealed diffuse, hyperintense signal all along the cerebral cortex and symmetrical hyperintensity in the basal ganglia. Similar signal alteration was also present in the middle cerebral peduncles and adjacent midbrain. All these regions revealed markedly restricted diffusion consistent with acute ischemia. No signal alteration was seen in the cerebellum. T1W images revealed hyperintensity in both basal ganglia.

MRI findings after attempted hanging depend upon the time elapsed, severity and duration of anoxia or hypoxia and variables such as continued cardiac activity and body temperature variations. The acute ischemia results in disruption of the Krebs cycle and resultant cytotoxic cell edema of the brain.

In the acute stages of ischemia due to the edema, there is diffuse hyperintense signal in the cerebral cortex and basal ganglia. There is preferential involvement of the cortex and basal ganglia in hypoxic-ischemic injury. This is attributed to the high metabolic activity in these regions and the earliest areas to be affected are the occipital and peri-rolandic cortices.

Diffusion imaging is far more sensitive than conventional MR sequences for detection of early cortical changes due to its sensitivity in detecting restriction of molecular water motion. There is high signal in the basal ganglia on T1W images - presumably due to micro hemorrhages through the damaged endothelium.

Days to weeks after the hypoxic insult, T1W gyriform cortical hyperintensity may appear. These are due to cortical laminar necrosis of layers 3, 4 and 5 due to hypoxic injury. The T1 hyperintensity of cortical laminar necrosis is attributed to accumulation of denatured proteins in the necrosed layers and not due to blood degradation products.

Neuroimaging can serve an important role for prognostication of patients following hypoxic-ischemic injury and thus guide further management. Diffusion imaging in particular can accurately predict the extent of ischemic involvement in the early stages. The presence of widespread cortical diffusion abnormalities have been reported to be associated with poor outcomes.