Images in radiology

Case 1 A 29-year-old male presented with a 2-month history of holocranial headache and intermittent blurring of vision. The patient denied any symptoms of vomiting, loss of consciousness, seizures, motor weakness, sensory changes, or gait abnormalities. He had no previous history of comorbidities or other significant medical conditions. Ophthalmologic examination was normal, with no focal neurological deficits. Imaging findings Magnetic resonance imaging (MRI) revealed 5–6 ring-enhancing lesions in the subcortical areas of the right parietal and left frontoparietal lobes, demonstrating: Characteristic central dot sign (scolex), surrounding perilesional edema, and normal signal intensity in remaining brain parenchyma [Figure 1].Figure 1: (a) Axial T1-weighted image (WI) shows a well-defined hypointense rounded lesion in left frontal lobe with central hyperintense dot (white thick arrow). (b) Axial T2WI shows a well-defined peripheral hypointense rim with central hypointense dot along with surrounding mild edema (red thick arrow). (c) Axial and (d) Coronal postcontrast T1FS images show ring enhancement(green arrow) with central enhancing dot (central dot sign)Discussion Neurocysticercosis (NCC), the most common parasitic central nervous system infection globally, is typically caused by Taenia solium larvae.[1] Its imaging manifestations vary according to the cyst stage². In this case, MRI revealed classic features consistent with the colloidal vesicular stage, which is characterized by ring-enhancing lesions with perilesional edema and a central dot sign (representing the scolex).[2] This stage is frequently identified on MRI due to the strong inflammatory response around the cysts, producing the characteristic ring enhancement on contrast-enhanced studies. The colloidal vesicular stage, as observed in this patient, typically presents as hypointense on T1-weighted images and hyperintense on T2-weighted and fluid-attenuated inversion recovery sequences, with prominent ring enhancement following contrast administration.[1] Diffusion-weighted imaging may vary, but cysts often display restricted diffusion, especially when associated with intense perilesional edema. These features help differentiate NCC from other ring-enhancing lesions such as tuberculomas, metastases, and pyogenic abscesses. Final diagnosis NCC in the colloidal vesicular stage. Case 2 A 38-year-old male presented with three episodes of coffee ground vomitus. On admission, his hemoglobin (Hb) was recorded at 10.7 g/dL. During hospitalization, a further drop in Hb was noted, leading to the transfusion of two units of packed red blood cells. Imaging findings On contrast-enhanced computed tomography abdomen, a well-defined, rounded, homogeneously enhancing endophytic mass measuring 2.6 cm × 2.1 cm (anteroposterior × transverse) was identified in the gastric cardia [Figure 2A]. The lesion bulged into the stomach lumen. The upstream esophagus was not dilated.Figure 2A: Endoscopy image revealing a lesion below gastroesphageal junction, suspected to be GISTEndoscopic ultrasound (EUS) showed a hypoechoic lesion measuring 2 cm × 1.5 cm in the gastric fundus, originating from the second EUS layer (muscularis mucosa). Endoscopy revealed a lesion approximately 1.5 cm × 2 cm in size just below the gastroesophageal junction [Figure 2B]. The lesion was noted to have normal overlying mucosa, with an adjacent clot and a central depression. The possibility of a gastrointestinal stromal tumor (GIST) was raised and on histopathology, it was confirmed to be low-grade GIST.Figure 2B: (a) Axial computed tomography (CT) abdomen plain image shows an isodense soft tissue lesion arising from cardia of stomach and bulging into lumen (thick white arrow). (b) Axial (c) sagittal and (d) coronal post contrast CT abdomen images show the mild homogenous enhancement of the lesion (blue arrow)Discussion GISTs are the most common mesenchymal tumor of the gastrointestinal tract,[3] often originating from the interstitial cells of Cajal. In this case, the imaging findings, including the well-defined, enhancing nature of the lesion and its submucosal origin, strongly suggest a diagnosis of GIST in the gastric cardia. EUS findings further supported this diagnosis, confirming the lesion’s origin from the muscularis mucosa. Differential diagnoses for submucosal gastric lesions include leiomyoma, schwannomas, and gastric adenocarcinomas, but the characteristic imaging and endoscopic findings favor GIST in this patient.[1] Final diagnosis GIST. Case 3 A 13-year-old female presented with a 4-month history of on-and-off abdominal pain localized to the central and lower abdomen. On abdominal examination, the uterus was palpated and found to be consistent with a 20–22-week gestation size. A cystic, nontender mass was also palpated. The upper margin of the mass was clearly delineated, while the lower border could not be distinctly identified. Imaging findings MRI of the abdomen and pelvis with contrast revealed gross distension of the endometrial and endocervical cavities. These cavities contained T1 hyperintense and T2 hypointense contents measuring 9.1 cm × 8.1 cm × 2.1 cm, with an estimated volume of 700–800 cc [Figure 3]. These findings were consistent with hematometra and hematocolpos in the setting of an imperforate hymen. The hematocolpos was noted to be mildly compressing the left distal ureter, resulting in mild hydroureteronephrosis of the left kidney. The myometrium and ovaries were unremarkable.Figure 3: (a) Axial T1 (b) Axial T2 (c) Sagittal T2-weighted images showed T1 hyperintense (white arrow) and T2 hypointense collection (yellow arrow) endometrium and vaginal canal with imperforate hymen (red arrow). (d) T1 FS postcontrast axial image showing hyperintense collection (white arrow) in endometrium and vaginal canal with imperforate hymen (red arrow)Discussion The presence of blood in the vagina (hematocolpos) or in both the vagina and uterus (hematometrocolpos) can lead to acute pain, particularly in adolescent girls.[4] Causes include imperforate hymen, vaginal, and cervical atresia. This case demonstrates classic imaging findings: distended endometrial and endocervical cavities with characteristic T1 hyperintense (indicative of blood) and T2 hypointense signals, confirming hematometra. The associated hydroureteronephrosis highlights the potential for secondary complications due to the mass effect on adjacent structures, such as the ureters. The differential diagnosis includes transverse vaginal septum and vaginal atresia, but the MRI findings and clinical presentation favor imperforate hymen. Early diagnosis is crucial to avoid complications such as pyometra, infection, or infertility. Final diagnosis Hematometra with hematocolpos secondary to imperforate hymen. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.