From 55716a16c508919699be7ed71fc2e89abe95911c Mon Sep 17 00:00:00 2001
From: Ross <xkjq@ymail.com>
Date: Fri, 17 Oct 2025 22:27:59 +0100
Subject: [PATCH] Add comprehensive documentation for adrenal conditions

- Created detailed articles for Adrenal Adenoma, Adrenal Cyst, Adrenal Myelolipoma, and general Adrenal anatomy.
- Included key facts, imaging findings, differential diagnoses, pathology, clinical issues, and diagnostic checklists for each condition.
- Enhanced understanding of adrenal tumors and their characteristics through structured documentation.
---
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 scrapers/capture_passive_playwright_async.py  | 169 ++++++++-
 38 files changed, 1232 insertions(+), 291 deletions(-)
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+---
+title: "Adrenal Adenoma"
+docid: "e2916d86-5f9f-4dd3-9576-1a7b89d8dda0"
+breadcrumbs:
+  - "Genitourinary"
+  - "Diagnosis"
+  - "Adrenal"
+  - "Benign Neoplasms"
+  - "Adrenal Adenoma"
+---
+# KEY FACTS
+
+- ## Imaging
+  
+  
+    - Well-circumscribed, uniform, low-attenuation, small adrenal mass 
+          - Low attenuation due to abundant intracytoplasmic lipid
+          - Imaging features of typical lipid-rich adenomas 
+                  - NECT: < 10 HU (71% sensitivity, 98% specificity)
+                  - MR: Significant decrease in signal on out-of-phase T1WI due to intravoxel lipid and water
+                  - May show focal areas of heterogeneous attenuation or absence of signal loss due to degeneration, hemorrhage, and fibrin deposition
+                            - Clinical context key to differentiate from collision tumor: Unlikely in absence of extraadrenal malignancy
+          - Lipid-poor adenomas (10-40% cases): Utilize relative or absolute CT contrast washout kinetics for diagnosis
+    - Accounts for vast majority of adrenal "incidentalomas"
+          - Imaging intensive algorithm suggested for incidental adrenal lesions, though overwhelming majority are benign and hormonally inactive
+          - Primary hyperaldosteronism (Conn syndrome): 80% due to unilateral, typically small (< 2 cm) adenoma
+          - Cushing syndrome: 80-85% due to adrenal hyperplasia
+    - Typically shows FDG uptake < that of liver on PET/CT
+- ## Top Differential Diagnoses
+  
+  
+    - Adrenal metastases and lymphoma
+    - Adrenal (macronodular) hyperplasia
+    - Pheochromocytoma
+    - Adrenal carcinoma
+    - Adrenal myelolipoma
+    - Gastric diverticulum
+    - Adrenal cyst
+- ## Diagnostic Checklist
+  
+  
+    - Asymptomatic mass: Usually nonfunctioning adenoma, even in patients with known cancer
+    - NECT and MR are equally accurate for diagnosis of lipid-rich adenoma
+    - Utilize dedicated CECT adrenal protocol with 15-minute delayed imaging for diagnosis of potential lipid-poor adenomas
+
+# TERMINOLOGY
+
+- ## Definitions
+  
+  
+    - Benign adrenal cortical tumor
+
+# IMAGING
+
+- ## General Features
+  
+  
+    - ### Best diagnostic clue
+      
+      
+          - Imaging strategies target typical adenoma histology: Abundant intracytoplasmic lipid
+                  - Low attenuation (< 10 HU) on NECT
+                  - Significant loss of signal on out-of-phase T1WI MR (intravoxel fat and water)
+    - ### Size
+      
+      
+          - Cushing syndrome adenoma: 2-5 cm
+          - Conn syndrome adenoma: Classically < 2 cm (20% < 1 cm)
+          - Vast majority of incidental, hormonally inactive adrenal adenomas are small (< 2 cm)
+    - ### Morphology
+      
+      
+          - Usually round to oval suprarenal mass
+    - Key concepts
+          - Most common adrenal cortex tumor (10% bilateral)
+                  - Accounts for > 90% of all "incidentalomas"
+          - May occur in up to 9% of general population, diagnosed on 5% of CT exams with various indications
+          - Lipid-rich adrenal adenoma: 60-90% of adenomas
+          - Lipid-poor adrenal adenoma: 10-40% of adenomas
+          - Increased incidence in patients with diabetes and hypertension
+          - NECT (or chemical shift MR): Study of choice to diagnose incidental adrenal masses
+          - Classified into 2 types based on function
+                  - Nonhyperfunctioning: Normal hormone levels
+                  - Hyperfunctioning: Primary hyperaldosteronism, Cushing syndrome, hyperandrogenism
+          - **Cushing syndrome**
+                  - 15-25% of cases are due to autonomous adrenal adenoma
+                  - 80-85% of cases are due to**adrenal hyperplasia**
+                  - Adenomas usually > 2 cm
+          - **Primary hyperaldosteronism (Conn syndrome)**
+                  - 80% of cases are due to****adrenal adenoma
+                  - 20% of cases are due to adrenal hyperplasia
+                  - Adenomas are often small (< 2 cm)
+- ## CT Findings
+  
+  
+    - ### NECT
+      
+      
+          - Smooth, well defined, round or oval in shape
+          - Homogeneous soft tissue mass of 0-20 HU
+          - **Lipid-rich adrenal adenoma** (60-90% of cases)
+                  - Uniform low attenuation
+                            - Metaanalysis of < 10 HU threshold: 71% sensitivity, 98% specificity
+                            - Sensitivity may increase to almost 90% with histogram analysis (identify negative pixels), though variable results and scanner dependent
+          - **Lipid-poor adrenal adenoma** (10-40% of cases)
+                  - Attenuation varies from 10-30 HU
+                  - Difficult to differentiate from metastases on NECT
+          - Cushing syndrome due to adrenal adenoma
+                  - Remainder of ipsilateral gland and contralateral adrenal gland may be atrophic due to ↓ ACTH levels
+                  - ↑ cortisol: Feedback inhibition on pituitary ACTH
+          - ACTH-independent macronodular hyperplasia: Multiple, bilateral, functioning adrenal adenomas
+          - Conn syndrome due to adrenal adenoma
+                  - Remainder of ipsilateral gland and contralateral adrenal gland appear normal
+          - Large adenomas
+                  - More heterogeneous than small adenomas
+                  - ± hemorrhage, cystic degeneration, calcification
+                            - Growth should raise suspicion for malignancy
+    - ### CECT
+      
+      
+          - Enhancing adrenal mass that deenhances rapidly
+                  - Dedicated adrenal CT exam incorporates initial dynamic enhanced phase (~ 70-second delay) and 15-minute delay
+                  - Relative percentage washout = dynamic enhanced (HU) - delayed (HU) / dynamic enhanced HU
+                            - Relative percentage washout > 40%: 96% sensitivity, 100% specificity
+                  - Absolute percentage washout (if NECT available) = dynamic enhanced (HU) - delayed (HU) / dynamic enhanced (HU) - unenhanced (HU)
+                            - Absolute percentage washout > 60%: 86-88% sensitivity, 92-96% specificity
+                  - 10-minute delay utilized by some centers, but shorter delay may decrease sensitivity
+                  - Adrenal washout calculators readily available online
+                  - Utilize technique for indeterminate, potentially lipid-poor adenomas
+                  - Clinical context critical: Rapid washout can be seen with pheochromocytomas, renal cell, hepatocellular carcinoma, and hypervascular metastases
+          - Dual-energy CT and iodine subtraction techniques can generate virtual noncontrast (VNC) images
+                  - May identify lipid-rich adenomas and obviate need for additional imaging
+                  - Iodine:VNC ratio ≥ 6.7 has sensitivity and specificity of 95% for adenoma (higher ratios in adenoma compared to metastasis)
+- ## MR Findings
+  
+  
+    - T1WI and T2WI
+          - Low to intermediate signal
+    - Chemical shift (in- and out-of-phase) imaging
+          - Mainstay of MR diagnosis
+          - Sensitivity and specificity equivalent to NECT
+          - Signal loss on out-of-phase T1WI due to intravoxel water and fat protons
+          - Inverse relationship between percentage of lipid-rich cells and relative ↓ signal on out-of-phase imaging
+                  - May not identify lipid-poor adenomas
+          - Visual inspection of signal in phase (SIP) and out of phase (SOP), though quantitative analysis may be helpful
+                  - Adrenal to spleen chemical shift imaging (CSI) ratio: Lesion:spleen SOP/adrenal/spleen SIP
+                            - < .71 = adenoma
+                  - Adrenal signal intensity index: 100 x (SIP - SOP) / SIP
+                            - > 16.5% = adenoma
+          - Beware technical pitfalls
+                  - Sampling of 1st echo pair at 3T is challenging
+                  - India ink artifact mimics signal loss, particularly in small adrenal lesions
+                  - Other primary or secondary adrenal lesions may contain lipid
+                  - Adenomas and metastases may coexist in same gland (collision tumor)
+    - T1 C+ MR
+          - Rapid, uniform enhancement and deenhancement
+    - Ancillary MR techniques
+          - Diffusion MR: Not specific (ADC overlap between adenomas and metastases)
+          - MR spectroscopy: Choline:creatinine and choline:lipid ratio discriminatory threshold ratios may aid in adrenal lesion characterization, though larger studies needed
+- ## Ultrasonographic Findings
+  
+  
+    - ### Grayscale ultrasound
+      
+      
+          - Nonspecific, solid suprarenal mass
+                  - Right suprarenal mass seen more clearly left due to acoustic window provided by liver
+- ## Angiographic Findings
+  
+  
+    - Conventional
+          - Adrenal arteriography
+                  - Catheterization of renal or inferior adrenal arteries shows vascular supply of adrenal tumors
+                  - Adenomas are usually hypo- to moderately vascular
+                  - No arterial encasement or venous laking or puddling, which are malignant vascular features
+          - Adrenal venography
+                  - Most commonly to obtain adrenal vein samples
+                            - Advocated for patients with primary hyperaldosteronism triaged to adrenalectomy
+                            - Technically difficult study but may confirm laterality of small, aldosterone-secreting adenoma
+                            - Technical approach and criteria for positive study varies; ACTH stimulation may increase accuracy
+                  - Adrenal adenoma is seen as filling defect within adrenal gland displacing adjacent vessels
+                  - Circumferential vein frequently seen around adrenal adenoma
+- ## Nuclear Medicine Findings
+  
+  
+    - PET/CT
+          - Utilized as part of malignancy staging
+          - Markedly increased F-18 FDG uptake characteristic of metastases
+          - Adenomas may also accumulate F-18 FDG, typically less intense than liver
+                  - Potential false-negatives: Metastases from primary carcinomas that are non-FDG avid (e.g., neuroendocrine tumors)
+          - SUV thresholds published but adenomas typically less intense than liver
+    - Adrenocortical scintigraphy by using NP-59
+          - NP-59 is cholesterol analog that binds to low-density lipoprotein receptors of adrenal cortex
+          - NP-59 used and dexamethasone: Accentuate uptake in non-ACTH-dependent adrenal tissues (adenoma)
+          - Normal NP-59: When both adrenal glands are seen 5 days after injection or thereafter
+          - Adrenal adenoma: Unilateral early adrenal visualization before day 5 after NP-59 injection
+          - Adrenal hyperplasia: Bilateral early adrenal visualization before day 5 after NP-59 injection
+- ## Imaging Recommendations
+  
+  
+    - NECT is initial study of choice to confirm diagnosis of lipid-rich adrenal adenoma
+          - ROI should encompass lesion: Attenuation < 10 HU is diagnostic
+    - In- and out-of-phase MR equivalent to NECT for lipid-rich lesions
+          - Signal dropout on out-of-phase T1WI MR: Qualitative assessment typically suffices
+    - CECT, including 15-minute delayed phase, used for potential lipid-poor adenomas: Calculate either relative or absolute washout
+
+# DIFFERENTIAL DIAGNOSIS
+
+- [Adrenal Metastases and Lymphoma](/document/adrenal-lymphoma/44639c90-bd04-4e2a-a470-2c28a0e2ff78)
+    - Adrenal metastases
+          - Unilateral or bilateral masses ± central necrosis, hemorrhage
+          - Usually known to have malignancy elsewhere
+          - NECT: Metastases mimic lipid-poor adenoma
+          - CECT: Hypo- or hypervascular and prolonged washout pattern
+    - Adrenal lymphoma
+          - Usually spread to adrenal gland from retroperitoneal tumor
+                  - Unilateral or bilateral masses
+          - Unilateral primary lymphoma (non-Hodgkin) can mimic adenoma
+          - Hypovascular; moderate enhancement with contrast
+- [Adrenal Myelolipoma](/document/adrenal-myelolipoma/5813a554-06a4-4696-af71-7ce50693039d)
+    - Small or large, asymptomatic adrenal mass
+    - Intramural macroscopic fatty elements on imaging
+- [Adrenal Hyperplasia](/document/adrenal-hyperplasia/90d09395-41d4-49b4-bb1d-4cb00b8bc272)
+    - Adrenal glands are often symmetrically enlarged
+    - Width of adrenal gland limbs > 10 mm (diagnostic)
+    - No discrete mass or nodule seen as rule
+    - Dominant macronodule of macronodular hyperplasia mimics small adrenal adenomas
+          - Cortisol-secreting adenoma: Remainder of ipsilateral and contralateral glands, atrophic (↓ ACTH)
+          - Macronodular hyperplasia: Both glands are enlarged (due to elevated ACTH levels)
+    - No obvious enhancement and washout pattern seen
+- [Pheochromocytoma](/document/pheochromocytoma/7d3c4062-643c-4030-8783-f85184ad8132)
+    - Tumor > 3 cm in most cases; classically T2 hyperintense
+    - Highly vascular tumor prone to hemorrhage, necrosis
+    - Bilateral adrenal tumors in multiple endocrine neoplasia (MEN) syndromes
+- [Unilateral Adrenal Hemorrhage](/document/adrenal-hemorrhage/5812e5c4-ca8a-4af5-884b-f75795bcde0f)
+    - Chronic hematoma: Well-defined, round, low-density, mass-like lesion simulating adenoma
+- [Adrenal Carcinoma](/document/adrenal-cortical-carcinoma/bdc7a08b-a64f-4bd2-9dfc-24331728e85e)
+    - Rare, unilateral, invasive and enhancing mass
+    - > 6 cm when initially diagnosed
+- [Gastric Diverticulum](/document/gastric-diverticulum/eeb101f0-8bdf-4771-b44a-fe6e73b3a463)
+    - Abnormal, rounded soft tissue lesion in left suprarenal area; mimics adrenal mass
+    - Diverticular contents do not enhance, whereas adenomas do
+    - Distend stomach with gas and fluid; scan in prone position to distend diverticulum
+- [Ganglioneuroma](/document/pheochromocytoma/7d3c4062-643c-4030-8783-f85184ad8132)
+    - Younger patients; mean age: 27 years
+    - Larger mass; average tumor size: 8 cm
+- ## Adrenal Cyst
+  
+  
+    - Attenuation similar to lipid-rich adenoma
+    - Lack of enhancement, rim calcification may suggest diagnosis
+
+# PATHOLOGY
+
+- ## General Features
+  
+  
+    - ### Etiology
+      
+      
+          - Unknown
+    - ### Associated abnormalities
+      
+      
+          - MEN syndromes
+          - Most adrenals with adenoma have normal function
+                  - Occasionally adenoma causes adrenal hyperfunction
+          - Normal adrenocortical secretory hormones
+                  - Cortisol, aldosterone, androgens
+- ## Gross Pathologic & Surgical Features
+  
+  
+    - Well-delineated, tan-yellow, ovoid mass
+    - 3 microscopic patterns
+          - Pure (fasciculata- or reticularis-type cells), mixed, or hybrid
+    - May have focal areas of degeneration, hemorrhage, and fibrin deposition
+- ## Microscopic Features
+  
+  
+    - 70% of adenomas: High % of intracytoplasmic lipid
+    - 30% of adenomas: Low % of intracytoplasmic lipid
+
+# CLINICAL ISSUES
+
+- ## Presentation
+  
+  
+    - ### Most common signs/symptoms
+      
+      
+          - Asymptomatic incidental CT finding
+          - Conn syndrome: Hypertension and weakness
+          - Cushing syndrome: Moon facies, truncal obesity, purple striae, and buffalo hump
+          - Virilization in women
+          - Lab data: ↑ aldosterone, cortisol, &/or androgens
+          - Diagnosis: Clinical, biochemical, imaging, histology
+- ## Demographics
+  
+  
+    - ### Age
+      
+      
+          - Prevalence of adenoma increases with age
+                  - Peak at 60-69 years, decreasing thereafter
+    - ### Epidemiology
+      
+      
+          - Most common adrenal tumor of all incidentalomas
+          - ↑ incidence in patients with diabetes or hypertension
+          - Occurs in up to 9% of population (postmortem data)
+- ## Natural History & Prognosis
+  
+  
+    - Prognosis: Excellent when incidental and nonhyperfunctioning
+- ## Treatment
+  
+  
+    - No treatment when asymptomatic incidental finding
+    - Laparoscopic removal of gland if hyperfunctioning
+
+# DIAGNOSTIC CHECKLIST
+
+- ## Consider
+  
+  
+    - Asymptomatic mass: Usually nonhyperfunctioning adenoma, even in patient with known cancer
+- ## Image Interpretation Pearls
+  
+  
+    - Well-defined, low-density (< 10 HU) suprarenal mass
+    - Enhances with washout pattern > 50% within 15 minutes
+    - Out-of-phase T1WI MR: Signal dropout, lipid-rich mass
+
+ adc00b93-b4c7-4e75-91bd-72023f4cd548
\ No newline at end of file
diff --git a/docs_md/articles/adrenal-cyst_c5d717a3-3d6e-4e86-9efe-1ad0ec14740f.md b/docs_md/articles/adrenal-cyst_c5d717a3-3d6e-4e86-9efe-1ad0ec14740f.md
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+---
+title: "Adrenal Cyst"
+docid: "c5d717a3-3d6e-4e86-9efe-1ad0ec14740f"
+breadcrumbs:
+  - "Genitourinary"
+  - "Diagnosis"
+  - "Adrenal"
+  - "Benign Neoplasms"
+  - "Adrenal Cyst"
+---
+# KEY FACTS
+
+- ## Imaging
+  
+  
+    - "Adrenal cyst" is descriptive term, not pathological diagnosis
+    - True adrenal cysts 
+          - Majority are endothelial cysts (lymphangiomas)
+          - Epithelial cysts exceedingly rare
+          - Simple, or minimally complex, adrenal cyst, thin rim calcification, no enhancement
+    - Pseudocysts
+          - Prior hemorrhage inferred
+          - Nonenhancing but complex contents and wall calcification
+          - Relevant history (extraadrenal malignancy, rapid growth), biochemical evaluation (cortisol, metanephrines): Consider underlying adrenal neoplasm
+                  - Enhancing soft tissue components may suggest adrenal mass hemorrhage and pseudocyst formation
+    - Parasitic (echinococcal) cyst
+          - Rare outside endemic areas
+          - Typically in setting of generalized echinococcus
+- ## Top Differential Diagnoses
+  
+  
+    - Adrenal adenoma
+          - CECT: Enhancing mass without visible wall or peripheral calcifications
+    - Gastric diverticulum
+          - Air-, fluid-, or contrast-filled mass with no enhancement of contents
+    - Adrenal myelolipoma
+          - Macroscopic fat
+    - Necrotic adrenal tumor
+          - Complex wall with heterogeneous contents
+    - Retroperitoneal bronchogenic cyst
+- ## Clinical Issues
+  
+  
+    - No treatment required usually
+    - Imaging surveillance performed, although intensity and length of follow-up not defined
+    - Biochemical evaluation (cortisol, metanephrines) routinely performed to exclude underlying adrenal neoplasm
+    - Surgical resection for complex cyst with enhancing components, or symptomatic cyst
+- ## Diagnostic Checklist
+  
+  
+    - Complicated cyst has high attenuation, thick enhancing wall, &/or septations
+
+# TERMINOLOGY
+
+- ## Definitions
+  
+  
+    - "Adrenal cyst" is descriptive term, not pathological diagnosis
+          - Can mean true cyst, pseudocyst, or cystic mass
+
+# IMAGING
+
+- ## General Features
+  
+  
+    - ### Best diagnostic clue
+      
+      
+          - Well-defined, nonenhancing, water-density adrenal mass ± calcifications
+    - ### Location
+      
+      
+          - Suprarenal
+          - Unilateral > bilateral (8-10% of cases)
+    - ### Size
+      
+      
+          - < 5 cm (50%), up to 20 cm
+- ## CT Findings
+  
+  
+    - ### NECT
+      
+      
+          - Unilocular or multilocular mass
+          - Well-defined, round to oval, homogeneous mass usually with water (0 HU) or near-water density
+                  - Higher- or mixed-attenuation mass (hemorrhage, intracystic debris, crystals)
+          - Wall usually very thin
+                  - ↑ wall thickness, up to 3 mm for complex cysts
+          - Calcifications
+                  - Rim-like or nodular (51-69%)
+                  - Centrally in intracystic septation (19%)
+                  - Punctate within intracystic hemorrhage (5%)
+    - ### CECT
+      
+      
+          - No central enhancement ± wall enhancement
+          - Coronal reformats helpful to determine organ of origin if large cyst
+- ## MR Findings
+  
+  
+    - ### T1WI
+      
+      
+          - Homogeneous, hypointense mass
+          - Hyperintense mass (hemorrhage)
+    - ### T2WI
+      
+      
+          - Hyperintense mass
+- ## Ultrasonographic Findings
+  
+  
+    - Simple or septated suprarenal cyst
+    - Shadowing from calcification
+    - Real-time examination helpful to differentiate adrenal cyst from adjacent (renal, pancreatic) cyst
+- ## Imaging Recommendations
+  
+  
+    - ### Best imaging tool
+      
+      
+          - CECT or MR; US for confirmation
+
+# DIFFERENTIAL DIAGNOSIS
+
+- [Adrenal Adenoma](/document/adrenal-adenoma/e2916d86-5f9f-4dd3-9576-1a7b89d8dda0)
+    - NECT: Lipid-rich adenoma (< 10 HU) mimics adrenal cyst
+          - Peripheral or septal calcification favors adrenal cyst
+    - CECT: **Enhancing mass** without visible wall or peripheral calcifications
+          - Assess washout kinetics to diagnose lipid-poor adenoma
+    - MR: Signal suppression at out-of-phase, chemical-shift imaging
+    - US: Solid adrenal lesion
+- [Gastric Diverticulum](/document/gastric-diverticulum/eeb101f0-8bdf-4771-b44a-fe6e73b3a463)
+    - May simulate left adrenal cyst
+    - Air-, fluid-, or contrast-filled suprarenal mass
+    - No enhancement
+    - Normal adjacent adrenal gland
+- [Adrenal Myelolipoma](/document/adrenal-myelolipoma/5813a554-06a4-4696-af71-7ce50693039d)
+    - Fat (not fluid) attenuation mass
+- ## Necrotic Adrenal Tumor
+  
+  
+    - Primary (pheochromocytoma or carcinoma) or metastatic
+          - Clinical history, biochemical evaluation, lesion complexity suggest correct diagnosis
+          - Enhancing soft tissue components
+- ## Retroperitoneal Bronchogenic Cyst
+  
+  
+    - Rare, benign, suprarenal fluid or soft tissue attenuation lesion
+    - Adjacent to but separate from adrenal gland
+- ## Renal Cyst
+  
+  
+    - Coronal MR/CT or US useful to determine organ of origin of large, retroperitoneal cystic lesions
+
+# PATHOLOGY
+
+- ## General Features
+  
+  
+    - ### Etiology
+      
+      
+          - Congenital (endothelial, epithelial) cysts
+          - Acquired (post hemorrhagic, inflammatory) pseudocysts
+          - Cystic, hemorrhagic degeneration of underlying adrenal neoplasm
+- ## Staging, Grading, & Classification
+  
+  
+    - Accepted classification scheme
+          - Pseudocyst
+                  - Most common type of cystic adrenal lesion in surgical series
+                  - No epithelial or endothelial lining: Fibrous cyst wall
+                  - Potentially as complication of prior trauma or hemorrhage though history of such often not elicited
+                  - May be associated with underlying adrenal neoplasm (pheochromocytoma, adrenal carcinoma, myelolipoma)
+                  - Attenuation and complexity at imaging varies depending upon hemorrhagic component
+                  - Wall and septal calcification common
+          - Endothelial cyst
+                  - Subtypes: Lymphangiomatous and hemangiomatous
+                  - True cyst: Endothelial lining
+                  - Originate from preexisting vascular malformation or obstructed, ectatic lymphatic channels
+                  - Thin rim calcification typical
+          - Epithelial cyst
+                  - Extremely rare: No acinar structures within normal adrenal gland
+                  - Mesothelial origin suggested (mesothelial cells potentially incorporated within adrenal gland during embryogenesis)
+          - Parasitic (hydatid) cyst
+
+# CLINICAL ISSUES
+
+- ## Presentation
+  
+  
+    - ### Most common signs/symptoms
+      
+      
+          - Typically asymptomatic
+          - Larger cysts may be symptomatic
+                  - Abdominal pain
+                  - Hemorrhage
+          - Clinical history (malignancy, hypertension) elicited
+                  - May indicate cystic degeneration of underlying adrenal neoplasm (e.g., metastasis, pheochromocytoma)
+    - Diagnosis
+          - Usually incidental finding at imaging
+          - Endocrine-biochemical evaluation performed to exclude underlying functional adrenal tumor
+- ## Demographics
+  
+  
+    - ### Age
+      
+      
+          - Any, though patients 20-50 years of age most common
+    - ### Sex
+      
+      
+          - M:F = 1:3
+    - ### Epidemiology
+      
+      
+          - Uncommon entity: Autopsy incidence 0.064-0.18%
+          - Accounts for 1% of incidental adrenal lesions in large imaging series
+- ## Natural History & Prognosis
+  
+  
+    - Complications
+          - Hypertension, infection, rupture, hemorrhage
+    - Excellent prognosis for vast majority of incidental, benign adrenal cysts
+    - Prognosis for pseudocysts secondary to adrenal neoplasm depends upon tumor histology
+- ## Treatment
+  
+  
+    - No treatment required usually
+          - Imaging follow-up typically performed
+                  - Intensity and length of surveillance not defined
+          - Cysts may enlarge over time
+          - Endocrine evaluation (cortisol, metanephrine, etc.) performed
+    - Surgical resection if symptomatic, underlying adrenal neoplasm
+          - Laparoscopic resection preferred
+
+# DIAGNOSTIC CHECKLIST
+
+- ## Consider
+  
+  
+    - Complicated cyst may suggest underlying adrenal neoplasm
+    - Clinical history, biochemical evaluation, and prior imaging helpful
+- ## Image Interpretation Pearls
+  
+  
+    - Simple adrenal cyst: Scant septation, no enhancement, thin rim calcification
+          - Likely benign endothelial cyst or pseudocyst
+    - Coronal imaging helpful to determine organ of origin (and exclude exophytic renal or pancreatic cyst)
+    - Complicated cyst: High attenuation, thick enhancing wall, &/or septations
+          - Complexity may suggest underlying adrenal neoplasm and secondary pseudocyst
+
+ 35fa0290-3451-422f-8726-c69b68aadbb5
\ No newline at end of file
diff --git a/docs_md/articles/adrenal-myelolipoma_5813a554-06a4-4696-af71-7ce50693039d.md b/docs_md/articles/adrenal-myelolipoma_5813a554-06a4-4696-af71-7ce50693039d.md
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+---
+title: "Adrenal Myelolipoma"
+docid: "5813a554-06a4-4696-af71-7ce50693039d"
+breadcrumbs:
+  - "Genitourinary"
+  - "Diagnosis"
+  - "Adrenal"
+  - "Benign Neoplasms"
+  - "Adrenal Myelolipoma"
+---
+# KEY FACTS
+
+- ## Terminology
+  
+  
+    - Uncommon benign tumor composed of mature fat tissue and hematopoietic elements (myeloid and erythroid cells)
+- ## Imaging
+  
+  
+    - Benign, nonfunctioning adrenal tumor
+    - Accounts for 7-15% of incidental adrenal masses, usually in older population
+    - Typically unilateral and very rarely bilateral
+    - Large tumors can mimic retroperitoneal lipomas, liposarcomas
+    - Asymptomatic, though larger tumors may hemorrhage
+    - CT
+          - Lesion containing fat attenuation (-30 to -90 HU)
+          - Usually well-defined mass with recognizable pseudocapsule (remaining adrenal)
+          - Punctate calcifications seen in 24% of cases
+          - Coronal reconstruction helpful to differentiate from exophytic renal angiomyolipoma
+    - MR
+          - Tumor with major fat component
+          - T1WI in phase: Typically hyperintense
+          - FS sequences: Loss of signal
+- ## Top Differential Diagnoses
+  
+  
+    - Adrenal adenoma
+          - Intracellular lipid vs. macroscopic fat
+    - Adrenal metastases and lymphoma
+    - Retroperitoneal liposarcoma
+          - Involving perirenal space, may simulate adrenal (or renal) fatty tumor
+    - Pheochromocytoma
+          - Highly vascular, prone to hemorrhage and necrosis
+    - Adrenal carcinoma
+    - Renal angiomyelolipoma
+          - Coronal CT reconstruction or MR useful to determine organ of origin
+
+# TERMINOLOGY
+
+- ## Definitions
+  
+  
+    - Uncommon benign tumor composed of mature adipose tissue and hematopoietic elements
+
+# IMAGING
+
+- ## General Features
+  
+  
+    - ### Best diagnostic clue
+      
+      
+          - Suprarenal mass containing fat
+    - ### Location
+      
+      
+          - Suprarenal
+                  - Rare extraadrenal myelolipomas (presacral, retroperitoneal)
+    - ### Size
+      
+      
+          - Usually 2-10 cm, rarely 10-20 cm
+    - Key concepts
+          - Benign neoplasm of adrenal gland
+          - Autopsy prevalence rate of 0.2-0.4%
+          - Accounts for 7-15% of adrenal "incidentalomas"
+          - Usually unilateral incidental finding in older patient
+          - Larger tumors can bleed spontaneously
+          - Most are nonfunctioning (do not secrete hormones)
+          - Large myelolipomas can mimic retroperitoneal lipoma or liposarcoma
+- ## CT Findings
+  
+  
+    - CT appearance depends on histologic composition
+          - Most tumors are heterogeneous adrenal masses composed of varying percentages of fat
+                  - Low-attenuation suprarenal lesion containing fat density (-30 to -90 HU)
+                            - Average NECT attenuation value of tumor: -74 HU in one series
+                            - Interspersed soft tissue attenuation components: Myeloid elements, hemorrhage
+                  - Presence of macroscopic fat within tumor is diagnostic
+          - Punctate calcifications seen in 24% of cases
+          - Usually well-defined mass with recognizable pseudocapsule (remnant adrenal)
+          - Coronal reconstructions may help determine organ of origin: Adrenal myelolipoma vs. exophytic renal angiomyelolipoma
+- ## MR Findings
+  
+  
+    - MR appearance depends on histologic composition
+          - Tumor with major fat component
+                  - T1WI in phase: Typically hyperintense
+                  - T1WI out phase: Persistent hyperintensity of macroscopic fat
+                  - T1WI FS: Confirmatory suppression of signal
+          - Bone marrow elements (myeloid and erythroid cells)
+                  - Low signal on T1WI, moderate signal on T2WI
+          - Hemorrhage: Varying T1, T2 signal depending on age of blood
+- ## Ultrasonographic Findings
+  
+  
+    - ### Grayscale ultrasound
+      
+      
+          - Well-defined, echogenic mass (↑ fat tissue)
+                  - Often overlooked: Lack of mass effect and isoechogenicity relative to retroperitoneal fat
+          - Heterogeneous mass (↑ myeloid cells)
+- ## Angiographic Findings
+  
+  
+    - Conventional
+          - Differentiate myelolipoma from retroperitoneal liposarcoma by determining origin of blood supply and vascularity of tumors
+- ## Nuclear Medicine Findings
+  
+  
+    - Typically not metabolically active, though uptake reported at FDG PET
+- ## Imaging Recommendations
+  
+  
+    - Helical NECT or MR with FS sequence
+
+# DIFFERENTIAL DIAGNOSIS
+
+- [Adrenal Adenoma](/document/adrenal-adenoma/e2916d86-5f9f-4dd3-9576-1a7b89d8dda0)
+    - Lipid-rich adenoma: ↓ attenuation (< 10 HU) at NECT
+    - Can contain small amounts of macroscopic fat due to lipomatous metaplasia
+    - CECT: Washout 15 minutes post injection: > 50%
+          - Relative washout: > 40%
+          - Absolute washout: > 60%
+- [Metastases and Lymphoma, Adrenal](/document/adrenal-lymphoma/44639c90-bd04-4e2a-a470-2c28a0e2ff78)
+    - Bilateral lesions: Clinical history paramount
+          - Metastases: Soft tissue attenuation (signal)
+          - Lymphoma: May maintain adreniform shape, adjacent retroperitoneal adenopathy
+- [Liposarcoma, Retroperitoneal](/document/retroperitoneal-sarcoma/c1466b30-b730-41c4-a065-2c2de018a5f7)
+    - Retroperitoneal primary sarcoma involving perirenal space may simulate adrenal (or renal) fatty tumor
+- [Pheochromocytoma](/document/pheochromocytoma/7d3c4062-643c-4030-8783-f85184ad8132)
+    - Highly vascular, prone to hemorrhage and necrosis
+    - Hyperintense on T2WI, bilateral in multiple endocrine neoplasia syndromes (MEN) syndromes
+    - Clinical history (labile hypertension) and urinary catecholamines
+- [Adrenal Carcinoma](/document/adrenal-cortical-carcinoma/bdc7a08b-a64f-4bd2-9dfc-24331728e85e)
+    - Rare, unilateral, invasive, enhancing mass
+    - Venous invasion, distant metastases
+    - May contain fat: Engulfed retroperitoneal fat vs. lipomatous metaplasia
+- ## Renal Angiomyelolipoma
+  
+  
+    - Exophytic upper pole angiomyolipoma may mimic
+    - Coronal reconstruction/MR helpful to determine organ of origin
+
+# PATHOLOGY
+
+- ## General Features
+  
+  
+    - ### Etiology
+      
+      
+          - Unknown
+          - Best hypothesis: Reticuloendothelial cell metaplasia of capillaries in adrenal (stress/infection/necrosis)
+          - Secondary hypothesis: Myelolipoma represents site of extramedullary hematopoiesis
+    - ### Associated abnormalities
+      
+      
+          - Adrenal collision tumors (coexistent myelolipoma and adenoma typical)
+          - Large, bilateral myelolipomas reported with longstanding, poorly treated congenital adrenal hyperplasia
+- ## Gross Pathologic & Surgical Features
+  
+  
+    - Cut section: Fat, soft tissue components
+- ## Microscopic Features
+  
+  
+    - Mature fat cells and megakaryocytes; no malignant cells
+    - Calcification
+    - Hemorrhage within larger lesions
+
+# CLINICAL ISSUES
+
+- ## Presentation
+  
+  
+    - ### Most common signs/symptoms
+      
+      
+          - Asymptomatic
+                  - Usually incidental finding on CT, MR
+                  - Typically biochemically nonfunctioning
+          - Symptomatic
+                  - Acute abdomen: Flank pain due to rupture and hemorrhage
+                  - Case reports of hormonally active tumors: Cushing, Conn syndromes, virilization
+    - Diagnosis: Pathognomonic MR/CT features
+          - Biopsy reserved for larger, atypical lesions, though prone to sampling error
+- ## Demographics
+  
+  
+    - ### Age
+      
+      
+          - Usually older patients (50-70 years old)
+    - ### Epidemiology
+      
+      
+          - Autopsy incidence: 0.2-0.4%
+- ## Natural History & Prognosis
+  
+  
+    - Complication: Rupture with hemorrhage (rare)
+    - Prognosis: Excellent
+- ## Treatment
+  
+  
+    - When diagnosis is certain, surgery not needed for lesions < 5-7 cm
+    - Surgery reserved for larger, symptomatic, or atypical lesions
+          - Surgical series have confirmed utility of laparoscopic resection
+
+# DIAGNOSTIC CHECKLIST
+
+- ## Consider
+  
+  
+    - Differentiate from other tumors (lipid-rich adenoma)
+    - Key is presence of imaging-apparent adipose tissue; avoid further work-up for incidental mass
+- ## Image Interpretation Pearls
+  
+  
+    - Well-defined, heterogeneous, fat-attenuation tumor on CT
+    - T1 hyperintense, signal loss with fat suppression
+
+ 81ce3ad3-c446-4b08-8b87-df9511f95360
\ No newline at end of file
diff --git a/docs_md/articles/adrenal_082ca43c-db5c-4770-aeed-0c6ea317e8fc.md b/docs_md/articles/adrenal_082ca43c-db5c-4770-aeed-0c6ea317e8fc.md
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@@ -0,0 +1,113 @@
+---
+title: "Adrenal"
+docid: "082ca43c-db5c-4770-aeed-0c6ea317e8fc"
+breadcrumbs:
+  - "Genitourinary"
+  - "Anatomy"
+  - "Adrenal"
+---
+# TERMINOLOGY
+
+- ## Abbreviations
+  
+  
+    - Adrenal corticotrophic hormone (ACTH)
+
+# GROSS ANATOMY
+
+- ## Overview
+  
+  
+    - Adrenal (**suprarenal**) glands are part of endocrine and neurological systems
+          - Essentially different organs within same structure, composed of thick outer cortex and thin inner medulla
+          - Lie within**perirenal space**bilaterally, bounded by**renal** (**perirenal**)**fascia**, above/medial to kidneys
+          - Composed of "body" and 2 limbs (medial and lateral)
+- ## Anatomic Relationships
+  
+  
+    - Right adrenal is usually more apical in location
+          - Lies anterolateral to right crus of diaphragm, medial to liver, and posterior to inferior vena cava (IVC)
+          - Often pyramidal in shape with inverted V shape on transverse section
+    - Left adrenal is usually more caudal and lies medial to upper pole of left kidney, lateral to left crus of diaphragm, and posterior to splenic vein and pancreas
+          - Often crescentic in shape with λ or triangular shape on transverse section
+- ## Divisions
+  
+  
+    - **Adrenal cortex**
+          - Embryologically derived from mesoderm
+          - Divided into 3 distinct zones (zona glomerulosa, zona fasciculata, and zona reticularis)
+          - Secretes **mineralocorticoids**(aldosterone) from zona glomerulosa, **glucocorticoids**(cortisol) from zona fasciculata, and **androgens**from zona reticularis
+    - **Adrenal medulla**
+          - Embryologically derived from neural crest
+          - Part of sympathetic nervous system
+          - **Chromaffin cells** secrete **catecholamines** (mostly epinephrine) into bloodstream
+    - **Vessels**,**nerves**, and **lymphatics**
+          - Arteries
+                  - **Superior adrenal arteries**: Typically 6-8; from inferior phrenic arteries
+                  - **Middle adrenal artery**: 1; from abdominal aorta
+                  - **Inferior adrenal artery**: 1; from renal arteries
+          - Veins
+                  - **Right adrenal vein** drains into IVC
+                  - **Left adrenal vein** drains into left renal vein (usually after joining left inferior phrenic vein)
+          - Nerves
+                  - Extensive sympathetic connection to adrenal medulla
+                  - Presynaptic sympathetic fibers from paravertebral ganglia end directly on secretory cells of medulla
+          - Lymphatics
+                  - Drain to **lumbar** (**aortic** and **caval**) **nodes**
+
+# ANATOMY IMAGING ISSUES
+
+- ## Multimodality Imaging Appearance
+  
+  
+    - No consensus on "normal" size or thickness of adrenals but average thickness of ~ 3 mm for medial/lateral limbs
+          - While not based on any strong evidence, > 10-mm thickness can be used as threshold for hyperplasia
+    - MR: Generally isointense to liver on T1 MR and isointense to slightly hyperintense to liver on T2 MR
+    - Ultrasound: Easiest to visualize in newborns (as result of physiologic enlargement) and become progressively more difficult to visualize with age
+          - Right adrenal gland easier to visualize than left (due to lack of liver as acoustic window and overlying bowel gas)
+          - Adrenal glands in adults usually hypoechoic (juxtaposed against hyperechoic periadrenal fat), although medulla can rarely be discretely seen and appears hyperechoic
+- ## Key Concepts
+  
+  
+    - **Adrenal** (**cortical**) **adenomas**
+          - Very common (at least 2% of general population) but usually cause no symptoms
+                  - Mostly "nonfunctioning" but identical to "functional" adenomas that cause Cushing/Conn syndrome
+          - Most adenomas contain abundant lipid (precursor to steroid hormones), allowing definitive diagnosis using CT/MR sequences that highlight lipid
+                  - Lipid is intracellular/intercellular (not macroscopic deposits of fat)
+          - Best CT technique: Nonenhanced CT with nodule measuring < 10 HU; or multiphase-enhanced CT with nodule demonstrating "washout" kinetics
+          - Best MR technique: Chemical-shift MR with signal dropout within nodule on opposed-phase images
+          - Standard imaging features for diagnosis of adenoma should be used for nodules measuring < 4 cm, while lesions > 4 cm should raise concern for malignancy
+    - **Pheochromocytoma** (tumor of adrenal medulla)
+          - Signs: Headache, palpitations, excessive perspiration
+          - 90% arise in adrenal, 90% unilateral, 90% benign
+                  - Similar tumor arising in other chromaffin cells of sympathetic ganglia is called **paraganglioma**
+          - More common with multiple endocrine neoplasia, neurofibromatosis, and von Hippel-Lindau
+          - Often markedly hypervascular in arterial phase
+    - **Adrenal myelolipoma**
+          - Uncommon benign tumor (usually incidental finding) composed of mature adipose and hematopoietic tissue
+          - Characterized by presence of **macroscopic fat**
+          - May have internal soft tissue component or calcification
+    - **Adrenocortical carcinoma**
+          - Highly aggressive malignancy with poor prognosis
+          - Large, heterogeneous mass (often with necrosis, hemorrhage, or calcification) with frequent local invasion, vascular invasion, and distant metastases
+    - **Cushing syndrome** (excess cortisol)
+          - Signs: Truncal obesity, hirsutism, hypertension
+          - Causes: Pituitary tumors (→ adrenal corticotrophic hormone), exogenous (medications) > adrenal adenoma > carcinoma
+    - **Conn syndrome** (excess aldosterone)
+          - Signs: Hypertension, hypokalemic alkalosis
+          - Causes: Adrenal adenomas > hyperplasia > carcinoma
+    - **Addison syndrome**(adrenal insufficiency)
+          - Signs: Hypotension, weight loss, altered pigmentation
+          - Causes: Autoimmune disease > adrenal metastases > adrenal hemorrhage > adrenal infection
+
+# CLINICAL IMPLICATIONS
+
+- ## Clinical Importance
+  
+  
+    - Rich adrenal blood supply due to endocrine function
+          - Results in adrenal glands being common site for hematologic **metastases** (lung, breast, melanoma, etc.)
+    - Adrenal glands respond to stress (trauma, sepsis, surgery, etc.) by secreting ↑ cortisol and epinephrine
+          - Overwhelming stress may result in **adrenal hemorrhage**or acute adrenal insufficiency (addisonian crisis)
+
+ d7703d36-250d-428e-bf99-6439a7cdc980
\ No newline at end of file
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----
-title: "https://app.statdx.com/document/49510d0e-acf7-45cb-9eb1-53f8193b0b6d/tables"
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-[
-  "
-# Imaging Features for Various Clinical Subtypes of Frontotemporal Dementia
-
-| Clinical Subtypes | Imaging Features |
-| --- | --- |
-| bvFTD | MR: Atrophy of frontal & temporal lobes; asymmetric right frontal &/or temporal lobe atrophy may occur NM: Decreased perfusion & metabolism in frontal &/or te |
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--- a/docs_md/external/https-appstatdxcom-document-content-24559f7a-ed5a-4ab6-90ba-769f0b5c1197_app.statdx.com_document_content_24559f7a-ed5a-4ab6-90ba-769f0b5c1197_40ec4a22_20251014T200033Z.meta.md
+++ /dev/null
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----
-title: "https://app.statdx.com/document/content/24559f7a-ed5a-4ab6-90ba-769f0b5c1197"
----
-# ESSENTIAL INFORMATION
-
-- ## Key Differential Diagnosis Issues
-  
-  
-    - Key imaging questions
-          - Does lesion follow CSF on all modalities/sequences?
-          - Is there any associated mass effect?
-          - Does lesion enhance?
-      
-      </l
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----
-title: "https://app.statdx.com/document/content/24559f7a-ed5a-4ab6-90ba-769f0b5c1197"
----
-# ESSENTIAL INFORMATION
-
-- ## Key Differential Diagnosis Issues
-  
-  
-    - Key imaging questions
-          - Does lesion follow CSF on all modalities/sequences?
-          - Is there any associated mass effect?
-          - Does lesion enhance?
-      
-      </l
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----
-title: "https://app.statdx.com/document/content/834ccc3e-2116-4295-8408-0ac9a06bd2ff"
----
-# KEY FACTS
-
-- ## Terminology
-  
-  
-    - Normal-pressure hydrocephalus (NPH): Ventriculomegaly out of proportion to sulcal enlargement in setting of normal cerebrospinal fluid (CSF) pressure
-- ## Imaging</h
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--- a/docs_md/external/https-appstatdxcom-document-content-9f9eda8c-7e3c-4292-9861-4b8abc2c6474_app.statdx.com_document_content_9f9eda8c-7e3c-4292-9861-4b8abc2c6474_623c493f_20251014T193351Z.meta.md
+++ /dev/null
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----
-title: "https://app.statdx.com/document/content/9f9eda8c-7e3c-4292-9861-4b8abc2c6474"
----
-# KEY FACTS
-
-- ## Terminology
-  
-  
-    - Frontotemporal dementia (FTD): Progressive neurodegenerative disorder of frontal/anterior temporal lobes
-- ## Imaging
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--- a/docs_md/external/https-appstatdxcom-document-content-a1bedda5-6478-40b2-98e7-6c5f5363b06f_app.statdx.com_document_content_a1bedda5-6478-40b2-98e7-6c5f5363b06f_2536cd31_20251014T184836Z.meta.md
+++ /dev/null
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----
-title: "https://app.statdx.com/document/content/a1bedda5-6478-40b2-98e7-6c5f5363b06f"
----
-# IMAGING ANATOMY
-
-- ## Overview
-  
-  
-    - Attention control network is a constellation of distributed brain networks processing attention to external stimuli and symbols
-          - Many aliases: Task-positive network, frontoparietal network, executive control network, and central executiv
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+++ /dev/null
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----
-title: "https://app.statdx.com/document/content/a1bedda5-6478-40b2-98e7-6c5f5363b06f"
----
-# IMAGING ANATOMY
-
-- ## Overview
-  
-  
-    - Attention control network is a constellation of distributed brain networks processing attention to external stimuli and symbols
-          - Many aliases: Task-positive network, frontoparietal network, executive control network, and central executiv
\ No newline at end of file
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--- a/docs_md/external/https-appstatdxcom-document-content-e1b27954-6591-4bb0-a659-b13790492620_app.statdx.com_document_content_e1b27954-6591-4bb0-a659-b13790492620_46d03a76_20251014T193441Z.meta.md
+++ /dev/null
@@ -1,10 +0,0 @@
----
-title: "https://app.statdx.com/document/content/e1b27954-6591-4bb0-a659-b13790492620"
----
-# KEY FACTS
-
-- ## Terminology
-  
-  
-    - Creutzfeldt-Jakob disease (CJD): Rapidly progressing, fatal, potentially transmissible dementia caused by prion
-- ## Imaging
\ No newline at end of file
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--- a/docs_md/external/https-appstatdxcom-document-content-e8e46d1d-46d2-4e5a-880f-f025a84c5871_app.statdx.com_document_content_e8e46d1d-46d2-4e5a-880f-f025a84c5871_3e5608ea_20251014T190919Z.meta.md
+++ /dev/null
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----
-title: "https://app.statdx.com/document/content/e8e46d1d-46d2-4e5a-880f-f025a84c5871"
----
-# KEY FACTS
-
-- ## Terminology
-  
-  
-    - Progressive neurodegenerative dementia
-          - Parkinsonism, visual hallucinations prominent
-          - Caused by abnormal accumulation of α-synuclein protein
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deleted file mode 100644
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-        "caption": "A 53-year-old man with rapidly progressing cognitive decline due to sporadic Creutzfeldt-Jakob disease (sCJD) is shown. Axial DWI MR demonstrates symmetric bilateral basal ganglia (BG) diffusion restriction ![](/img/arrows/CS.png) and asymmetric cortical restricted diffusion (cortical ribbon sign) in bilateral (right > > left) hemispheres ![](/img/arrows/CO.png).",
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deleted file mode 100644
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+++ /dev/null
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----
-title: "https://app.statdx.com/document/e8e46d1d-46d2-4e5a-880f-f025a84c5871/media"
----
-[
-  {
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-    "name": "Selected Images",
-    "images": [
-      {
-        "imageId": "d2ff700c-f618-401b-94df-595198c45827",
-        "caption": "Right & left medial sagittal FDG PET source & 3DSSP images of a 74-year-old man with dementia with Lewy bodies (DLB) presenting with visual hallucinations show severe ↓ metabolic activity in left visual cortex ![](/img/arrows/CO.png) & precuneus ![](/img/arrows/WS.png). Note moderate ↓ metabolic activity in right occipital lobe ![](/img/arrows/CS.png) & precuneus ![](/img/arrows/WC.png) & relative sparing of bilateral posterior cingulate gyri ![](/img/arrows/CC.png).",
-        "title": "",
-        "enhancedTitle": "",
-        "annotated":
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index 1708ee5..0000000
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----
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-  {
-    "groupId": "bce2eb1d-5b42-493d-b6f2-86c7fb747dcb",
-    "name": "Selected Images",
-    "images": [
-      {
-        "imageId": "add7af59-3e22-4ebd-bda3-585280f734e0",
-        "caption": "Axial graphic of vascular dementia (VaD) shows diffuse cerebral atrophy, focal volume loss due to multiple chronic infarcts ![](/img/arrows/CS.png), an acute left occipital lobe infarct ![](/img/arrows/CO.png), and small lacunar infarcts in the basal ganglia/thalami ![](/img/arrows/CC.png).",
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deleted file mode 100644
index 076a4f8..0000000
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deleted file mode 100644
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deleted file mode 100644
index 076a4f8..0000000
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deleted file mode 100644
index 076a4f8..0000000
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diff --git a/docs_md/external/https-appstatdxcom-tree-brain-6d8829f1-14d7-45af-8675-255189aa526a_app.statdx.com_tree_brain_6d8829f1-14d7-45af-8675-255189aa526a_412e5db0_20251014T195824Z.meta.md b/docs_md/external/https-appstatdxcom-tree-brain-6d8829f1-14d7-45af-8675-255189aa526a_app.statdx.com_tree_brain_6d8829f1-14d7-45af-8675-255189aa526a_412e5db0_20251014T195824Z.meta.md
deleted file mode 100644
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diff --git a/docs_md/external/https-appstatdxcom-tree-brain-6d8829f1-14d7-45af-8675-255189aa526a_app.statdx.com_tree_brain_6d8829f1-14d7-45af-8675-255189aa526a_7b8e7696_20251014T184448Z.meta.md b/docs_md/external/https-appstatdxcom-tree-brain-6d8829f1-14d7-45af-8675-255189aa526a_app.statdx.com_tree_brain_6d8829f1-14d7-45af-8675-255189aa526a_7b8e7696_20251014T184448Z.meta.md
deleted file mode 100644
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-html
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diff --git a/docs_md/external/https-appstatdxcom-tree-brain-6d8829f1-14d7-45af-8675-255189aa526a_app.statdx.com_tree_brain_6d8829f1-14d7-45af-8675-255189aa526a_cb2b2388_20251014T195923Z.meta.md b/docs_md/external/https-appstatdxcom-tree-brain-6d8829f1-14d7-45af-8675-255189aa526a_app.statdx.com_tree_brain_6d8829f1-14d7-45af-8675-255189aa526a_cb2b2388_20251014T195923Z.meta.md
deleted file mode 100644
index daeab2b..0000000
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diff --git a/docs_md/external/https-appstatdxcom-tree-brain-6d8829f1-14d7-45af-8675-255189aa526a_app.statdx.com_tree_brain_6d8829f1-14d7-45af-8675-255189aa526a_d25e5ec0_20251014T184833Z.meta.md b/docs_md/external/https-appstatdxcom-tree-brain-6d8829f1-14d7-45af-8675-255189aa526a_app.statdx.com_tree_brain_6d8829f1-14d7-45af-8675-255189aa526a_d25e5ec0_20251014T184833Z.meta.md
deleted file mode 100644
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diff --git a/docs_md/external/https-appstatdxcom-tree-brain-6d8829f1-14d7-45af-8675-255189aa526a_app.statdx.com_tree_brain_6d8829f1-14d7-45af-8675-255189aa526a_eb4d72f7_20251014T190912Z.meta.md b/docs_md/external/https-appstatdxcom-tree-brain-6d8829f1-14d7-45af-8675-255189aa526a_app.statdx.com_tree_brain_6d8829f1-14d7-45af-8675-255189aa526a_eb4d72f7_20251014T190912Z.meta.md
deleted file mode 100644
index daeab2b..0000000
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diff --git a/scrapers/capture_passive_playwright_async.py b/scrapers/capture_passive_playwright_async.py
index 7f46767..5da879a 100644
--- a/scrapers/capture_passive_playwright_async.py
+++ b/scrapers/capture_passive_playwright_async.py
@@ -87,6 +87,30 @@ async def run(args):
             await asyncio.sleep(5)
             async with capture_count_lock:
                 print(f"[heartbeat] captured={capture_count}")
+        
+    # Build an in-memory index of content_hash -> list of index entries for quick dedupe lookups.
+    # If older index lines lack a content_hash but reference a body file, hash that file once at startup.
+    in_memory_index = {}
+    try:
+        if index_path.exists():
+            with open(index_path, 'r', encoding='utf-8') as idxf:
+                for line in idxf:
+                    try:
+                        j = json.loads(line)
+                    except Exception:
+                        continue
+                    ch = j.get('content_hash')
+                    body = j.get('body_file')
+                    if not ch and body and os.path.exists(body):
+                        try:
+                            with open(body, 'rb') as bf:
+                                ch = hashlib.sha256(bf.read()).hexdigest()
+                        except Exception:
+                            ch = None
+                    if ch:
+                        in_memory_index.setdefault(ch, []).append(j)
+    except Exception:
+        in_memory_index = {}
 
     async with async_playwright() as p:
         browser_type = p.chromium
@@ -102,6 +126,82 @@ async def run(args):
 
         page = await context.new_page()
 
+        async def attempt_autologin(page, username: str, password: str, post_login_selector: str, wait_after: float = 1.0):
+            """Async form-based autologin similar to save_page_snapshots.attempt_autologin."""
+            if not username or not password:
+                return False
+            # selectors
+            user_selectors = ['input[name="username"]', 'input.usernameSelector', 'input[type="email"]', 'input[name*="email" i]', 'input[name*="user" i]', 'input[type="text"]']
+            pass_selectors = ['input[type="password"]', 'input[name="password"]', 'input.passwordSelector']
+
+            user_sel = None
+            for sel in user_selectors:
+                try:
+                    el = await page.query_selector(sel)
+                    if el:
+                        user_sel = sel
+                        break
+                except Exception:
+                    continue
+
+            pass_sel = None
+            for sel in pass_selectors:
+                try:
+                    el = await page.query_selector(sel)
+                    if el:
+                        pass_sel = sel
+                        break
+                except Exception:
+                    continue
+
+            if not user_sel or not pass_sel:
+                try:
+                    with open(output / '_debug_events.log', 'a', encoding='utf-8') as dbg:
+                        dbg.write(f"{now_ts()}\tAUTOLOGIN\tselectors_missing\n")
+                except Exception:
+                    pass
+                return False
+
+            try:
+                await page.fill(user_sel, username)
+                await asyncio.sleep(0.1)
+                await page.fill(pass_sel, password)
+                await asyncio.sleep(0.1)
+                # try submit
+                submit_selectors = ['button[type=submit]', 'input[type=submit]', 'button:has-text("Sign in")', 'button:has-text("Sign In")', 'button:has-text("Log in")']
+                clicked = False
+                for s in submit_selectors:
+                    try:
+                        btn = await page.query_selector(s)
+                        if btn:
+                            await btn.click()
+                            clicked = True
+                            break
+                    except Exception:
+                        continue
+                if not clicked:
+                    try:
+                        await page.press(pass_sel, 'Enter')
+                    except Exception:
+                        pass
+
+                # wait for post-login selector
+                try:
+                    if post_login_selector:
+                        await page.wait_for_selector(post_login_selector, timeout=10000)
+                except Exception:
+                    pass
+                await asyncio.sleep(wait_after)
+                return True
+            except Exception:
+                try:
+                    with open(output / '_debug_events.log', 'a', encoding='utf-8') as dbg:
+                        dbg.write(f"{now_ts()}\tAUTOLOGIN\tfailed_exception\n")
+                except Exception:
+                    pass
+                return False
+
+
         async def on_response(resp):
             nonlocal capture_count
             try:
@@ -237,6 +337,51 @@ async def run(args):
                         # skip if still failing
                         return
 
+                # compute content hash for dedupe
+                content_hash = None
+                try:
+                    if 'txt' in locals() and isinstance(txt, str):
+                        content_hash = hashlib.sha256(txt.encode('utf-8')).hexdigest()
+                    elif 'pretty' in locals() and isinstance(pretty, str):
+                        content_hash = hashlib.sha256(pretty.encode('utf-8')).hexdigest()
+                    elif 'data' in locals() and isinstance(data, (bytes, bytearray)):
+                        content_hash = hashlib.sha256(data).hexdigest()
+                except Exception:
+                    content_hash = None
+
+                # prepare the meta filename we'll write for this response
+                new_meta_name = f"{safe}_{h}_{ts}.meta.json"
+                new_meta_abs = os.path.abspath(str(output / new_meta_name))
+
+                # If older responses exist with the same content, delete them (fast in-memory lookup)
+                try:
+                    matches = in_memory_index.get(content_hash, []) if content_hash else []
+                    for j in matches:
+                        body = j.get('body_file')
+                        metaf = j.get('meta_file')
+                        try:
+                            if body and os.path.exists(body) and os.path.abspath(body) != os.path.abspath(body_path):
+                                os.remove(body)
+                                try:
+                                    with open(output / '_debug_events.log', 'a', encoding='utf-8') as dbg:
+                                        dbg.write(f"{now_ts()}\tDELETED_OLD_BODY\t{body}\n")
+                                except Exception:
+                                    pass
+                        except Exception:
+                            pass
+                        try:
+                            if metaf and os.path.exists(metaf) and os.path.abspath(metaf) != new_meta_abs:
+                                os.remove(metaf)
+                                try:
+                                    with open(output / '_debug_events.log', 'a', encoding='utf-8') as dbg:
+                                        dbg.write(f"{now_ts()}\tDELETED_OLD_META\t{metaf}\n")
+                                except Exception:
+                                    pass
+                        except Exception:
+                            pass
+                except Exception:
+                    pass
+
                 meta = {
                     'url': url,
                     'resource_type': rtype,
@@ -245,12 +390,17 @@ async def run(args):
                     'response_headers': resp_headers,
                     'response_body_file': body_path,
                     'response_excerpt': excerpt,
+                    'content_hash': content_hash,
                 }
                 meta_name = f"{safe}_{h}_{ts}.meta.json"
                 save_text(output / meta_name, json.dumps(meta, ensure_ascii=False, indent=2))
                 try:
+                    entry = {'url': url, 'resource_type': rtype, 'timestamp': ts, 'body_file': body_path, 'meta_file': str(output / meta_name), 'excerpt': excerpt, 'content_hash': content_hash}
                     with open(index_path, 'a', encoding='utf-8') as idx:
-                        idx.write(json.dumps({'url': url, 'resource_type': rtype, 'timestamp': ts, 'body_file': body_path, 'meta_file': str(output / meta_name), 'excerpt': excerpt}, ensure_ascii=False) + '\n')
+                        idx.write(json.dumps(entry, ensure_ascii=False) + '\n')
+                    # update in-memory index
+                    if content_hash:
+                        in_memory_index.setdefault(content_hash, []).append(entry)
                 except Exception:
                     pass
 
@@ -290,6 +440,20 @@ async def run(args):
         except Exception:
             pass
 
+        # attempt autologin (form-based) if credentials provided
+        uname = args.username or os.getenv('STATDX_USERNAME')
+        pwd = args.password or os.getenv('STATDX_PASSWORD')
+        if uname and pwd:
+            try:
+                ok = await attempt_autologin(page, uname, pwd, args.post_login_selector)
+                try:
+                    with open(output / '_debug_events.log', 'a', encoding='utf-8') as dbg:
+                        dbg.write(f"{now_ts()}\tAUTOLOGIN_RESULT\t{ok}\n")
+                except Exception:
+                    pass
+            except Exception:
+                pass
+
         # If interactive, let user log in; otherwise start capture immediately
         if not args.no_prompt:
             print('When you have logged in in the opened browser, press Enter here to continue and capture...')
@@ -325,6 +489,9 @@ def parse_args():
     parser.add_argument('--headless', action='store_true')
     parser.add_argument('--continuous', action='store_true')
     parser.add_argument('--no-prompt', action='store_true')
+    parser.add_argument('--username', help='STATdx username (or use STATDX_USERNAME env var)')
+    parser.add_argument('--password', help='STATdx password (or use STATDX_PASSWORD env var)')
+    parser.add_argument('--post-login-selector', default='#ds-app', help='Selector that indicates a successful login')
     parser.add_argument('--channel', default=os.getenv('PLAYWRIGHT_CHROME_CHANNEL', 'chrome'))
     parser.add_argument('--capture-types', default='xhr,fetch,document,other')
     return parser.parse_args()