Imaging Of Facial Trauma Part 3 (2)

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Imaging Of Facial Trauma Part 3 (2) 2

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Hangman's Fracture

Fig. 1: Lateral view of a cervical spine radiograph of an 18-year-old woman who sustained a motor vehicle accident shows anterolisthesis of C2 over C3 (arrowhead) and fracture lines involving the C2 pars interarticulares. The anterior and posterior spinal lines are disrupted.
Fig. 2: Axial CT image of the cervical spine at C2 level shows fractures of bilateral C2 pars interarticulares. The fracture on the right extends to the transverse foramen where the right vertebral artery is located. The examination also demonstrates an abrupt narrowing of the right vertebral artery, consistent with dissection.

Hangman's Fracture

• Traumatic spondylolisthesis of C2
• Fractures of the lamina, articular facets, pedicles or pars interarticulares of C2 with disruption of C2-C3 junction
• Common etiology: fall, diving, motor vehicle collision
• Treatment options depend on the stability of the fracture. Stable injuries without neurological deficit and signs of later instability - usually require only immobilization for a period of time.

Look for:

• If there is anterior translation of C2 over C3, if translation >3 mm with >10 degree angulation -- likely unstable
• If there is dislocation of facet joints -- likely unstable
• Other associated C-spine pathology (found in up to 1/3 of cases)

Reference:

Li XF, Dai LY, Lu H, Chen XD. A systematic review of the management of hangman's fractures. Eur Spine J 2006;15:257-269.

Fulminant Candida Esophagitis

Fig: Double contrast barium esophagography shows innumerable pseudomembranes and plaques (arrows) "shaggy esophagus" in a patient with AIDS.

Candida Esophagitis

• Most common cause of infectious esophagitis
• Usually opportunistic infection in immunocompromised hosts, particularly AIDS
• Can be seen in patients with esophageal stasis i.e. achalasia, scleroderma
• Absence of oral thrush does not exclude this condition! (50% of patients with Candida esophagitis do not have thrush)

Radiographic Findings

• Better with double-contrast barium esophagography (over single contrast)
• Plaque (95% of cases) > abnormal motility = thickened folds = ulcers > "shaggy" contour
• "When patients with esophageal symptoms are clinically immunosuppressed or have underlying obstructive disease of the esophagus, discrete plaque-like lesions should strongly suggest candidiasis on the double-contrast study"

Our case - fulminant Candida esophagitis.

References:

1. Levine MS, Macones AJ, Laufer I. Candida esophagitis: accuracy of radiographic diagnosis. Radiology 1985;154:581-587.

2. Levine MS, Rubesin SE. Diseases of the esophagus: diagnosis with esophagography. Radiology 2005;237:414-427.

Pelvic Congestion Syndrome

Fig. 1: Axial CT image of a 42-year-old woman with chronic pelvic pain shows dilatation of bilateral ovarian veins (arrows).
Fig. 2: Axial CT image of the same patient at the level of the uterus shows multiple dilated veins in the pelvic cavity, indicating pelvic varices.

Pelvic Congestion Syndrome

• Multifactorial disease that may be from anatomical obstruction of ovarian veins, or secondary to other diseases such as valvular incompetence, portal hypertension.
• Dilated, tortuous and congested veins with retrograde flow through ovarian veins
  
• Signs and symptoms: deep, dull chronic pelvic pain, dyspareunia, dysmenorrhea, postcoital pain, varicose veins, tenderness on palpation
  

Imaging Findings

• Not all pelvic varices represent pelvic congestion syndrome!
  
• Dilated ovarian veins (normal 3-4 mm, borderline 4-8 mm, abnormal > 8 mm)
  
• Reflux of contrast into ovarian vein(s)
• Slow (3 cm/s) or reverse flow in ovarian veins
• Polycystic changes of ovary
  

References:
1. Kuligowska E, et al. Pelvic pain: overlooked and underdiagnosed gynecologic conditions. Radiographics 2005;25:3-20.
2. Karaosmanoglu D, et al. MDCT of the ovarian vein: normal anatomy and pathology. AJR 2009;192:295-299.

FDG-PET: False Positive for Cancer

Fig. 1: Scout CT image shows a right hilar mass with right upper lobe opacity and volume loss. Findings are concerning for obstructive pneumonia due to carcinoma in the right hilum.
Fig. 2: Axial CT image shows right hilar lymphadenopathy (arrow) with consolidation, air bronchograms and cavities in the posterior segment of the right upper lobe (star)
Fig. 3: FDG-PET image shows markedly increased uptake of the right upper lobe consolidation, however the right hilar lymph node is not FDG avid.

False Positives FDG-PET in Lung Lesions

• Infection: Pneumonia, mycobacterium avium complex infection, TB, fungal infection
• Inflammation: Sarcoidosis, lipoid pneumonia, aspiration pneumonia, organizing pneumonia, amyloidosis, radiation pneumonitis

Why False Positive?

• 18F-FDG is not specific for tumor.
• Tissues with glucose uptake also takes FDG, especially tissues with metabolically active macrophages
• High expression of gene such as GLUT-1 may also be a reason for high FDG uptake in inflammatory lesions

Our case - surgical resection shows organizing pneumonia in the right upper lobe.

Reference:
Gilman MD, Aquino SL. State-of-the-art FDG-PET imaging of lung cancer. Semin Roentgenol 2005;40:144.