68-year-old female patient presented with headaches, nausea and vomiting. She also complained of blurry vision affecting her right eye.

Evidence Based Case Study 10239 ( general description about the assignment)

The case study requires the students to distinguish between the application of CT and MR imaging techniques in relation to the patient’s clinical history, patient management and explain the application of the respective imaging modality in relation to the type of abnormality demonstrated. The image appearance using the respective imaging modality will need to be clearly critiqued using the image quality evaluation criteria. Students are required to apply the basic principles to interpret the images systematically. This assessment also tests the critical analysis of the diagnostic limitations of CT and MR imaging.

the information below provided by the lectrurer

Clinical History:

68-year-old female patient presented with headaches, nausea and vomiting. She also complained of blurry vision affecting her right eye.

Examination request:

CT – Head/  ? space occupying lesion (SOL) ??

 

Images with contras medium injection

CT image without contrast medium.

Hint: The final diagnosis of this exam is menangioma with vasogenic oedema in the mid cranial fossa (right temporal lobe). Don’t use this finding from the beginning, I want make the assignment more  interesting.

Start write from down here :

The following areas need to be addressed in this assignment:

Introduction

Discuss the patient’s clinical history, clinical manifestations and imaging request addressing the clinical question in this case.

Hints to be written in paragraphs:

  • Create a scenario (for example patient present in ED with the symptoms above) the physician check vital signs. Patient referred to radiology for CT brain to role out lesion pathology.
  • Discuss briefly the rule of CT in diagnosis brain lesions and tumour.

Imaging Modality/Modalities

Describe the imaging procedure using the respective imaging modality. Discuss the potential examination protocol, patient positioning, exposure factors and dose in the case of CT imaging. If the clinical question remains unanswered, which other alternative imaging modality can be used? This must be clearly supported with current literature.

Hints to be written in paragraph:

  • CT brain protocol: non-contrast brain then post contrast brain. (amount of contras medium 50cc Omnipaque 350, scan delay 3-4 minutes (why?). post processing (axial, saggital, coronal view) bone windowing (window width (ww) and window level (WL) mention the proper levels )/ 3mm slice thickness and 3mm slice interval.
  • Positioning: patient in supine position, the rested in a head rest, the patient head enters the gantry first (known as head first in CT exams), midsagittal plane (MSP) of the head is perpendicular to the table. The patient chin must be tucked until the orbital meatal line is perpendicular to the table. Accordingly,  the base of skul (BOS) and supraorbital margin (SOM) will be aligned and perpendicular to the floor.
  • Exposure factors: helical it is automatic exposure factors using dose modulation (what is dose modulation) 120 KVp and 319mAs . radiation dose: DLP 1650 mGy*cm/ CT dose index (CTDI) 98.46 mGy
  • This CT non-contrast showed the lesion , however when the contrast medium injected, the lesion enhanced more and become brighter (hyper dense) and well-defined.
  • Answer this question : what the role of MRI (other imaging modality) in is showing this kind of lesions? Is it adding further information and diagnosis?  Just brief answer because you will elaborate more in the next part

Imaging Techniques related to patient management

Critically analyse the application of CT and or MR imaging techniques considering the prognosis in relation to patient management in this case. What are the diagnostic limitations of CT & MR imaging? This must be clearly supported with current literature.

Hints to be written in paragraph

  • You can compare and contrast between both MRI and CT in terms of risk and benefits.
  • For example the contrast medium used in CT is non-ionic iodine (omnipaque) which affects the renal function Therfore it is important to check the eGFR level and creatinine. (provide the normal and abnormal readings)

ROI- Anatomy, Image Appearances

The anatomy and the imaging appearance of the clinical findings of this case in relation to the region of interest must be clearly labelled and discussed.

Hints and to be written in paragraph.

  • Location of lesion: This space-occupying lesion is seen in the right temporal lobe, mid cranial fossa, posteriorly to the right orbit, and sphenoid bone at the level of the cranial floor. The size of this lesion is decent, which extends to be seen in the level of Sella Turcica and suprasellar cistern levels. This hyperdense lesion compresses the dark rim filled with CSF fluid and leads to a hypodense appearance surrounding the lesion in the right temporal lobe. This vasogenic oedema can be seen clearly at the level of the basal cistern when the right lateral fissure and frontal horn are compressed.
  • I will label the images, but you provide more information about the anatomical parts that will be affected based on my description to the lesion location.

Mechanism of injury/Pathogenesis

Describe the mechanism of injury/ pathogenesis in relation to the clinical history and clinical findings. The discussion of the mechanism of injury/ pathogenesis must be supported with relevant literature.

Hints and to be re-written in paragraph.

  • As  I mentioned earlier this lesion is meningioma with vasogenic oedema.
  • Please write about this lesion based on the description of this section  above

Image Critique (very important part)

The relevant criteria must be used to evaluate the quality of the diagnostic images in this case. The source of the image evaluation criteria must be clearly referenced.

Image critique

Please write about every single part  of this table below and use the reference I added named “image critique reference”

You can use my friend image critique below as a guidance but be careful don’t plagiarise because he submitted already the assignment.

The image quality of the CT brain with and without contrast medium is adequate. the contrast-enhanced images are adequate in the axial, saggital and coronal views. The borders between grey and white matter can be distinguished, although they do appear slightly grainy. The basal ganglia appear sharp and are well visualised, particularly on the axial slices. The ventricles margins are showing a well-defined contour on their outer margins with no graininess present. The cerebrospinal fluid can be visualised, covering the brain’s entire exterior and within the basal cistern. The intracranial arteries and dural venous sinuses can be seen. The pituitary stalk appears sharp and well defined. The internal and external auditory canals can be adequately visualised on the bone windows. The cortical bone and calvarial diploic bone also appear well defined on bone windows.

The overall noise and spatial resolution of the CT images are optimal. There is an adequate signal ratio due to the representation of fine detail and an optimal contrast resolution due to the small attenuation differences that can be seen. According to research, these are the qualities that make a diagnostic image (Manson et al., 2016, Khoramian et al., 2019, Verdum et al., 2015).

Image Interpretation (extremely important)

Apply the relevant criteria to interpret the images in this ROI. Summarise the findings after applying the systematic approach to interpret the images.

  • Write about the image interpretation of the brain  which is based the reference document I added name “ ABVCP interpretation method”
    • Adequacy of scan
    • Brain/ blood
    • Ventricles
    • Cistern
    • Parenchyma

The following paragraph is my friend image interpretation becarufl don’t plagirise use it as guide .

Adequacy of the Scan:

The scan is adequate. The patient is correctly positioned in the gantry without head tilt or rotation. The correct patient position can be confirmed by the symmetrical appearance of the sphenoid ridges and the appearance of the optic nerves being well visualised on the same slice. There are an adequate number of slices. The correct number of slices can be determined as the foramen magnum is well visualised in the inferior slices, particularly on the axial slices with soft tissue window applied. At the superior most slices the apex of the skull is shown, therefore, the correct slice range has been acquired. There is no indication of the slice thickness or slice interval. Both non-contrast and contrast enhanced images have been obtained. These can be differentiated by the homogeneous appearance of the interhemispheric fissure on the non-contrast enhanced images compared to the hyperdense appearance of the ambient cistern on the contrast-enhanced images.

Brain:

Located in the right mid cranial fossa is a well-define, slow growing, hyperdense, space occupying lesion. The lesion is affecting the brain parenchyma in the right cerebral hemisphere causing a very slight mass effect and is surrounded by a hypodense region when compared to normal brain parenchyma, indicating vasogenic oedema. There is a loss of asymmetry affecting the lateral ventricles. There is no loss of grey-white matter differentiation.

Blood:

There is no evidence of ischemia present or bleeds including subdural and epidural haematomas affecting the brain parenchyma on either the right or left cerebral hemispheres. There is also no evidence of subarachnoid, intraparenchymal or intraventricular haemorrhage.

Ventricles:

The right and left lateral ventricles do not appear symmetrical in relation to their size and shape, although the spatial relationship has been maintained bilaterally. The lack of symmetry is affecting the frontal, occipital and temporal horns. The right lateral ventricle is visualised having a reduction In size compared to the left lateral ventricle with compression of the right frontal horn and almost complete obliteration of the temporal horn. The compression of the right frontal horn may be due to the slight mass effect caused by the space occupying lesion in the right cerebral hemisphere. This same space occupying lesion is causing the obliteration of the temporal horn.

The third ventricle is still situated midllne between the right and left cerebral hemispheres between the thalamus. There is a hyperdense region located in the posterior aspects of the third ventricle, which may indicate the presence of blood.

The fourth ventricle does not appear to be affected, showing no signs of dilation or blood present. There is no sign of the fourth ventricle being affecting by the mass effect pushing midline structures pushing midline structures slightly towards the left cerebral hemisphere. There is no evidence of pathological findings to this region such as atrophy or acute hydrocephalus.

Cistern:

There is no loss of symmetry or evidence of blood or effacement in the circum-mesencephalic, supra-sellar , quadrigeminal or sylvian cisterns. This indicates there has been no large mass effect present.

Bone:

There is no evidence of underlying intracranial pathology or fractures identified by the Information provided on the bone windows. There is no sign of soft tissue swelling or defects such as scar formation or previous ablative procedures. There is no evidence of any depressed fractures or disruptions to the bony cortex. There Is no evidence of intracranial air or infections. On the axial slice at the level of the Maxilla there appears to be an iso-dense area affecting the right maxillary sinus. The iso-dense area has air-fluid levels and is likely to be fluid within the right maxillary sinus.

In summary, there is a space occupying lesion present in the right cerebral hemisphere, located in the right mid cranial fossa. The lesion is in very close proximity to the dura matter on the right and is therefore likely a Meningioma. The lesion is surrounded by a hypodense fluid, likely to be vasogenic oedema. The lesion’s presence is causing slight mass effect, causing structures within the right cerebral hemisphere to deviate slightly towards the left. In doing so, this has caused partial effacement of the right lateral ventricle when compared to the contralateral, unaffected, left side.

Clinical findings and conclusion

Describe the clinical findings (injury/pathology). This must be described thoroughly using current literature. The conclusion must be clear.

Assignment Submission:

The assignment is will be submitted online) as an individual assessment.

The presentation of your assignment must be neat and appear as a formal document consistent with the formatting and APA style of referencing. The assignment must be thoroughly referenced, supporting the discussion with the relevant current literature. (Avoid any unnecessary artwork). If there is any breach of confidentiality found, it may result in a fail grade being awarded in this unit.

The content of this assignment must be categorised under each of the headings/sub-headings based on the criteria outlined above and the marking rubric (ensure Referencing is included ).

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