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@@ -0,0 +1,253 @@
+---
+title: "Abdominal Wall Mass"
+docid: "d51e2268-67b6-4a60-9222-f5a86f61ddec"
+authors:
+ - key: "c1df94ab-4a9f-44c4-add7-1f174fb9ac45"
+ value: "Siva P. Raman, MD"
+breadcrumbs:
+ -
+ name: "Gastrointestinal"
+ slug: "gastrointestinal"
+ treeNodeId: "b52263f7-5978-4a22-a17d-7260e0033943"
+ -
+ name: "Differential Diagnosis"
+ slug: "differential-diagnosis"
+ treeNodeId: "a0fd80ff-6231-49d3-94b8-ea083449979d"
+ -
+ name: "Abdominal Wall"
+ slug: "abdominal-wall"
+ treeNodeId: "08db01f7-2961-47f7-954d-2a5fca7e707d"
+ -
+ name: "Anatomically Based Differentials"
+ slug: "anatomically-based-differentials"
+ treeNodeId: "1525b44f-9d47-4ff4-8330-693211bd5eb5"
+ -
+ name: "Abdominal Wall Mass"
+ slug: "abdominal-wall-mass"
+ treeNodeId: null
+category: "Gastrointestinal"
+documentVersionId: "258ccc6a-0370-4b08-adc4-dfc3ef9a1ce6"
+imageCount: 18
+lastUpdated: "07/15/22"
+pageDescription: "Abdominal Wall Mass"
+pageKeywords: "Gastrointestinal, Differential Diagnosis, Abdominal Wall, Anatomically Based Differentials, Abdominal Wall Mass"
+pageTitle: "Abdominal Wall Mass | STATdx"
+enhancedTitle: "Abdominal Wall Mass"
+type: "DDX"
+references: true
+breadcrumbs:
+ - "Gastrointestinal"
+ - "Differential Diagnosis"
+ - "Abdominal Wall"
+ - "Anatomically Based Differentials"
+ - "Abdominal Wall Mass"
+---
+# ESSENTIAL INFORMATION
+
+- ## Key Differential Diagnosis Issues
+
+
+ - Given limitations of clinical examination, imaging plays important role in differentiating true soft tissue masses from hernias, vascular abnormalities, and normal variants
+ - Most soft tissue masses have nonspecific appearance and may require biopsy or excision for diagnosis
+- ## Helpful Clues for Common Diagnoses
+
+
+ - **Abdominal Wall Hernias**
+ - **Inguinal hernia**
+ - Most common external hernia, which extends into groin anterior to horizontal plane of pubic tubercle
+ - Divided into direct (arises anteromedial to inferior epigastric vessels) and indirect (arises superolateral to inferior epigastric vessels) subtypes
+ - **Ventral hernia**
+ - Broad term describing acquired or congenital hernias through anterior and lateral abdominal wall
+ - Midline hernias include epigastric (above umbilicus) and hypogastric (below umbilicus) hernias
+ - Incisional hernias occur at prior surgical incision sites
+ - **Umbilical hernia**
+ - Hernias arising at midline in upper 1/2 of umbilical ring, which can be congenital or acquired
+ - Very common incidental finding on imaging, although usually small and asymptomatic
+ - **Spigelian hernia**
+ - Hernia through defect lateral to rectus sheath (inferior and lateral to umbilicus) often covered by external oblique muscle and aponeurosis
+ - **Femoral hernia**
+ - Groin hernia extending medial to femoral vessels with frequent compression of femoral vein
+ - Most common in older female patients with very high risk of strangulation and incarceration
+ - **Lumbar hernia**
+ - Hernia through defect in lumbar muscle or thoracolumbar fascia
+ - Can be congenital or acquired with many acquired due to incisions in flank region for renal surgery
+ - **Abdominal Wall Abscess**
+ - Loculated fluid collection (± internal gas) with peripheral enhancement and surrounding edema/fat stranding
+ - Differentiate drainable abscess from diffuse, nondrainable edema/fluid (cellulitis/phlegmon)
+ - Presence of gas-containing abdominal wall abscess in close contiguity with bowel tethered to abdominal wall raises possibility of enterocutaneous fistula
+ - **Sebaceous Cyst**
+ - Common incidental finding, appearing as small, round/oval, well-encapsulated cyst near skin surface
+ - Should be low density and nonenhancing without surrounding subcutaneous edema/fat stranding
+ - **Lipoma**
+ - Common incidental mass in subcutaneous tissues and between muscle planes, demonstrating uniform fat density with no internal soft tissue component
+ - Differentiate from liposarcoma, which demonstrates internal complexity and soft tissue component
+ - Confident diagnosis may be difficult on US, but mass should have similar echogenicity to subcutaneous fat
+ - **Keloid**
+ - Benign fibrotic scar tissue or tissue overgrowth at site of soft tissue injury (i.e., surgical incision or trauma)
+ - Usually asymptomatic but can be painful or pruritic
+ - No clear imaging features to allow differentiation of large keloid from other soft tissue masses
+ - **Hematoma**
+ - Heterogeneous, high-density blood products, which gradually evolve and become lower in density over time
+ - More diffuse subcutaneous blood products may reflect subcutaneous ecchymosis
+ - **Paraumbilical Varices**
+ - Common portosystemic collaterals in patients with severe cirrhosis and portal hypertension
+ - Serpiginous enhancing structures that connect to recanalized paraumbilical vein near falciform ligament
+ - May be visible/palpable at skin (i.e., caput medusae)
+ - **Injection Site**
+ - Common incidental finding usually secondary to injection of heparin, insulin, or other medications
+ - Small nodular foci with ectopic gas, blood, or fluid
+ - May chronically evolve into injection granulomas, appearing as rounded or linear foci of soft tissue or calcification (most common in buttocks)
+ - **Calcified Scar**
+ - Heterotopic ossification (myositis ossificans traumatica) can occur at abdominal incision sites and is most common in linear alba after midline abdominal incision
+ - Ossified scar in incision can resemble rib (with both cortex and medulla)
+ - **Muscle Asymmetry (Mimic)**
+ - May be mistaken for mass and are common secondary to prior surgery, paralysis, myopathy, etc.
+ - **Melanoma**
+ - 5th most common new cancer in US, but imaging typically not utilized for diagnosis of primary tumor
+ - Most commonly multiple small subcutaneous nodules, although rarely presents as solitary abdominal wall mass
+ - Homogeneous enhancement ± hyperintense on T1 MR
+- ## Helpful Clues for Less Common Diagnoses
+
+
+ - **Endometriosis**
+ - Endometriosis implants may be seen within incision sites after prior C-section or hysterectomy
+ - Typically appears as solid, spiculated subcutaneous mass with variable enhancement (usually hypointense on T1 and hyperintense on T2 MR)
+ - May be associated with clinical history of cyclical pain (corresponding with menstruation) at incision site
+ - **Calcinosis Syndromes**
+ - Dystrophic: Calcifications may be due to tissue injury response, such as implanted medical device, connective tissue diseases (scleroderma, dermatomyositis, CREST), severe pancreatitis, or fat necrosis
+ - Metastatic: Most often in patients with calcium-phosphate imbalance (renal failure, milk-alkali syndrome)
+ - Tumoral calcification: Large globular deposits of calcification near joints
+ - **Soft Tissue Metastases**
+ - Most common malignancies to metastasize to soft tissues are melanoma and renal cell carcinoma
+ - Soft tissue nodule or mass(es) in subcutaneous fat or muscle with enhancement similar to primary tumor
+ - Easily overlooked on CT if careful survey of soft tissues not undertaken, but often more apparent on PET
+ - Tumor may also be implanted at site of surgery (probably more common with laparoscopic surgery) or biopsy
+ - Surgical seeding can also occur with benign lesions, including uterine fibroids and ectopic splenic tissue
+ - **Lymphoma and Leukemia**
+ - Cutaneous T-cell lymphoma (a.k.a. mycosis fungoides or Sézary syndrome)
+ - Skin 2nd most common site of extranodal lymphoma (after GI tract)
+ - Skin involvement may be difficult to appreciate on imaging unless unusually nodular or mass-like
+ - Subcutaneous panniculitis-like T-cell lymphoma
+ - Manifests as site of soft tissue induration/infiltration or as discrete nodules
+ - Leukemia cutis (i.e., chloroma or granulocytic sarcoma)
+ - Primary B-cell cutaneous lymphomas more likely to present as solitary isolated skin lesion
+ - Posttransplant lymphoproliferative disorders (PTLD) can rarely manifest in subcutaneous soft tissues
+ - **Desmoid**
+ - Benign locally aggressive neoplasm, which can be intraabdominal or extraabdominal (e.g., abdominal wall)
+ - Abdominal wall lesions most frequently arise from rectus or oblique muscles, especially at incision sites
+ - Major risk factors include prior surgery, trauma, Gardner syndrome, and familial adenomatous polyposis
+ - Variable appearance but typically solid, well-defined, hypoenhancing, heterogeneously high signal on T2 and low signal on T1 MR
+ - **Sarcoma**
+ - Malignant mesenchymal soft tissue tumors, which encompass wide range of different histologic subtypes
+ - May be difficult to differentiate from other soft tissue masses based on imaging alone, although most sarcomas tend to be larger and more heterogeneous with frequent necrosis (± distant metastatic disease)
+ - Different subtypes of sarcomas cannot be differentiated on imaging with any accuracy
+ - **Rhabdomyolysis**
+ - Muscle necrosis in response to wide variety of causes, including crush injury, seizures, statin medications, etc.
+ - Involved muscles on CT generally appear either normal or abnormally hypodense (due to edema)
+ - MR more sensitive, with muscles demonstrating T2 hyperintensity and enlargement, as well as hyperenhancement (can appear ring-like or mass-like)
+ - Commonly leads to severe renal damage due to release of myoglobin into bloodstream
+ - **Pancreatic Panniculitis**
+ - Subcutaneous fat necrosis seen with pancreatitis and pancreatic adenocarcinoma (due to ↑ serum lipase)
+ - Manifest as small nodular foci of predominantly fat density on CT and hyperechoic on US
+ - **Kaposi Sarcoma**
+ - Most common AID-related vascular neoplasm in Western world, presenting as either diffuse infiltration of skin or discrete subcutaneous nodules
+
+## References
+
+# Selected References
+
+1. [Ballard DH et al: Imaging of abdominal wall masses, masslike lesions, and diffuse processes. Radiographics. 40(3):684-706, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32330085%5Bpmid%5D)
+1. [Draghi F et al: Abdominal wall sonography: a pictorial review. J Ultrasound. 23(3):265-78, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32125676%5Bpmid%5D)
+1. [Kania LM et al: Interpreting body MRI cases: classic findings in pelvic MRI. Abdom Radiol (NY). 45(9):2916-30, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32607649%5Bpmid%5D)
+1. [Mao A et al: Post-cesarean section abdominal wall endometrioma. Cureus. 12(8):e10088, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=33005511%5Bpmid%5D)
+1. [Youssef AT: The ultrasound of subcutaneous extrapelvic endometriosis. J Ultrason. 20(82):e176-80, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=33365153%5Bpmid%5D)
+1. [Hensen JH et al: Abdominal wall endometriosis: clinical presentation and imaging features with emphasis on sonography. AJR Am J Roentgenol. 186(3):616-20, 2006](http://www.ncbi.nlm.nih.gov/pubmed/?term=16498086%5Bpmid%5D)
+1. [Zafar HM et al: Anterior abdominal wall hernias: findings in barium studies. Radiographics. 26(3):691-9, 2006](http://www.ncbi.nlm.nih.gov/pubmed/?term=16702448%5Bpmid%5D)
+1. [Aguirre DA et al: Abdominal wall hernias: imaging features, complications, and diagnostic pitfalls at multi-detector row CT. Radiographics. 25(6):1501-20, 2005](http://www.ncbi.nlm.nih.gov/pubmed/?term=16284131%5Bpmid%5D)
+1. [Shadbolt CL et al: Imaging of groin masses: inguinal anatomy and pathologic conditions revisited. Radiographics. 21 Spec No:S261-71, 2001](http://www.ncbi.nlm.nih.gov/pubmed/?term=11598262%5Bpmid%5D)
+
+
+## Images
+
+
+### Selected Images
+
+
containing loops of nonobstructed small bowel.](images/app.statdx.com_image_thumbnail_dcf3e531-1181-43fa-8a2a-588ef14eb1de_annotated_true_size_900_quality_90_7a3efacf7c9ea3cb8a17271f24a81f1ac6d54288.jpg)
+**Abdominal Wall Hernias**
+*Axial CECT shows a right inguinal hernia containing loops of nonobstructed small bowel.*
+
+
+**Abdominal Wall Hernias**
+*Axial CECT shows a right inguinal hernia containing loops of nonobstructed small bowel.*
+
+
+**Sebaceous Cyst**
+*Axial CECT shows an encapsulated, near water density mass in the left buttock. Sebaceous cysts are a common incidental finding and, when demonstrating a classic appearance, do not require further follow-up or evaluation.*
+
+
+**Lipoma**
+*Coronal CECT shows a large, fat-containing mass within the right lateral abdominal wall, compatible with a simple lipoma. Note the absence of any complexity or soft tissue component within the mass.*
+
+
+**Hematoma**
+*Axial CECT shows an acute, high-density subcutaneous hematoma in a patient with recent trauma.*
+
+
+**Hematoma**
+*Axial CECT in a patient with cirrhosis and portal hypertension shows subcutaneous varices overlying the anterior abdominal wall, representing a caput medusae.*
+
+
+**Paraumbilical Varices**
+*Axial T1 C+ MR shows an enhancing mass in the left anterior pelvic wall, found to represent a scar endometrioma in this patient status post prior laparoscopic pelvic surgery.*
+
+
+**Endometriosis**
+*Sagittal CECT shows a soft tissue mass intimately associated with the umbilicus, ultimately found at biopsy to represent endometriosis.*
+
+
+**Soft Tissue Metastases**
+*Axial CECT shows a hypodense mass in the midline anterior abdominal wall, proven to represent a metastasis from the patient's known primary colon cancer.*
+
+
+**Soft Tissue Metastases**
+*Axial CECT shows a hypodense mass in the abdominal wall musculature, representing a metastasis from the patient's known colon cancer.*
+
+
+**Lymphoma and Leukemia**
+*Axial CECT shows a biopsy-proven chloroma in the right anterior abdominal wall in a patient with known leukemia.*
+
+
+**Desmoid**
+*Axial CECT shows multiple large, hypodense masses in the pelvic subcutaneous soft tissues in a patient with known familial polyposis, representing desmoid tumors.*
+
+
+**Desmoid**
+*Axial CECT shows a hypodense mass in the right anterior abdominal wall, ultimately found to represent a desmoid tumor.*
+
+
+**Sarcoma**
+*Axial CECT shows a large, rapidly growing mass in the left anterior abdominal wall, representing a primary soft tissue sarcoma (malignant fibrous histiocytoma).*
+
+
+**Sarcoma**
+*Axial T1 C+ FS MR shows a highly invasive, large tumor in the buttock , which enhances significantly. This lesion proved on biopsy to be a high-grade epithelioid sarcoma.*
+
+
+### Additional Images
+
+
with extensive varices 
in the parastomal region. These develop in patients with portal hypertension (e.g., following colectomy for primary sclerosing cholangitis with cirrhosis).](images/app.statdx.com_image_thumbnail_b593a259-7880-4bc0-893a-3cede1985b33_annotated_true_size_900_quality_90_d23259d664dcbe385fadc731b06bfaabbe8cb8ed.jpg)
+**Paraumbilical Varices**
+*Axial CECT shows a colostomy with extensive varices in the parastomal region. These develop in patients with portal hypertension (e.g., following colectomy for primary sclerosing cholangitis with cirrhosis).*
+
+
+**Paraumbilical Varices**
+*Axial CECT shows prominent parastomal varices .*
+
+
+**Paraumbilical Varices**
+*Axial CECT shows a cirrhotic liver and a large parumbilical varix .*
+
+
+**Paraumbilical Varices**
+*Axial CECT shows continuation of the parumbilical varix with collaterals in the rectus muscles and subcutaneous fat (caput medusae).*
+
diff --git a/docs_md/articles/cnvii-facial-nerve_98cb2d45-e64c-4295-9662-3470cd46513a.md b/docs_md/articles/cnvii-facial-nerve_98cb2d45-e64c-4295-9662-3470cd46513a.md
new file mode 100644
index 0000000..0731666
--- /dev/null
+++ b/docs_md/articles/cnvii-facial-nerve_98cb2d45-e64c-4295-9662-3470cd46513a.md
@@ -0,0 +1,298 @@
+---
+title: "CNVII (Facial Nerve)"
+docid: "98cb2d45-e64c-4295-9662-3470cd46513a"
+authors:
+ - key: "1fa14dfd-71ea-4960-908e-e720313bc63a"
+ value: "Santhosh Gaddikeri, MD"
+ - key: "94f835c8-fa13-4e8a-995b-53048e6b0605"
+ value: "Philip R. Chapman, MD"
+breadcrumbs:
+ -
+ name: "Head and Neck"
+ slug: "head-and-neck"
+ treeNodeId: "ed24ed8c-5d57-4629-879b-447b82d2973d"
+ -
+ name: "Anatomy"
+ slug: "anatomy"
+ treeNodeId: "678bc99d-d43e-45e6-9c8d-9fa5a7648616"
+ -
+ name: "Cranial Nerves"
+ slug: "cranial-nerves"
+ treeNodeId: "5cb153f5-b8a6-4321-a37d-ac4e2a31be47"
+ -
+ name: "CNVII (Facial Nerve)"
+ slug: "cnvii-facial-nerve"
+ treeNodeId: null
+category: "Head and Neck"
+cmeTopicId: "0baca093-e8fa-4711-9ecc-05167315d50b"
+documentVersionId: "1e66f9a4-6069-4b31-b464-8a6b37d40f11"
+imageCount: 39
+lastUpdated: "12/06/23"
+pageDescription: "CNVII (Facial Nerve)"
+pageKeywords: "Head and Neck, Anatomy, Cranial Nerves, CNVII (Facial Nerve)"
+pageTitle: "CNVII (Facial Nerve) | STATdx"
+enhancedTitle: "CNVII (Facial Nerve)"
+type: "ANATOMY"
+breadcrumbs:
+ - "Head and Neck"
+ - "Anatomy"
+ - "Cranial Nerves"
+ - "CNVII (Facial Nerve)"
+---
+# TERMINOLOGY
+
+- ## Abbreviations
+
+
+ - Facial nerve (CNVII)
+- ## Synonyms
+
+
+ - 7th cranial nerve
+- ## Definitions
+
+
+ - CNVII: Cranial nerve carrying motor nerves to muscles of facial expression; parasympathetics to lacrimal, submandibular, & sublingual glands; and taste from anterior 2/3 of tongue
+
+# IMAGING ANATOMY
+
+- ## Overview
+
+
+ - Mixed nerve: Motor, parasympathetic, and special sensory (taste)
+ - 2 roots: Motor and sensory (nervus intermedius) roots
+ - Nervus intermedius exits lateral brainstem between motor root of CNVII and CNVIII, hence its name
+ - 3 nuclei and 4 segments: Intraaxial, cisternal, intratemporal, and extracranial (parotid)
+ - Blood supply from petrosal branch of **middle meningeal artery** & stylomastoid branch of **posterior auricular artery**
+- ## Nuclei and Intraaxial Segment
+
+
+ - 3 nuclei (1 motor, 2 sensory)
+ - **Motor nucleus of facial nerve**
+ - Located in ventrolateral pontine tegmentum
+ - Efferent fibers loop dorsally around CNVI nucleus in floor of 4th ventricle, forming facial colliculus
+ - Fibers then course anterolaterally to exit lateral brainstem at pontomedullary junction
+ - **Superior salivatory nucleus**
+ - Located lateral to CNVII motor nucleus in pons
+ - Efferent **parasympathetic fibers** exit brainstem posterior to CNVII as nervus intermedius
+ - To submandibular, sublingual, and lacrimal glands
+ - **Solitarius tract nucleus**
+ - Taste sensation fibers from anterior 2/3 of tongue
+ - **Cell bodies** of these fibers in **geniculate ganglion**
+ - Fibers travel within nervus intermedius
+- ## Cisternal Segment
+
+
+ - 2 roots in cisternal CNVII
+ - Larger motor root anteriorly
+ - Smaller sensory nervus intermedius posteriorly
+ - Emerge from lateral brainstem at **root exit zone** in pontomedullary junction to enter cerebellopontine angle (CPA) cistern
+ - CNVIII exits brainstem posterior to CNVII
+ - 2 roots join together and pass anterolaterally through CPA cistern with CNVIII to internal auditory canal (IAC)
+- ## Intratemporal Segment
+
+
+ - Further divided in temporal bone into 4 segments: IAC, labyrinthine, tympanic, & mastoid
+ - **IAC segment**: Porus acusticus to IAC fundus; anterosuperior position above crista falciformis
+ - **Labyrinthine segment**: Connects fundal CNVII to geniculate ganglion (anterior genu)
+ - **Tympanic segment**: Connects anterior to posterior genu, passing under lateral semicircular canal
+ - **Mastoid segment**: Inferiorly directed from posterior genu to stylomastoid foramen
+- ## Extracranial Segment
+
+
+ - Main CNVII exits skull base through **stylomastoid foramen** to enter parotid space
+ - Parotid CNVII passes lateral to retromandibular vein
+ - Ramifies within parotid, passes anteriorly to innervate muscles of facial expression
+- ## CNVII Branches
+
+
+ - **Greater (superficial) petrosal nerve**
+ - Arises at geniculate ganglion, passes anteromedially, exits temporal bone via facial hiatus
+ - Carries **parasympathetic** fibers to **lacrimal gland**
+ - Joined by deep petrosal nerve (sympathetic fibers) in foramen lacerum to form **vidian nerve**
+ - **Nerve to stapedius**
+ - Arises from high mastoid segment of CNVII behind pyramidal eminence
+ - Provides **motor** innervation to **stapedius muscle**
+ - **Chorda tympani**
+ - Arises from lower mastoid segment
+ - Courses across middle ear to exit anterior temporal bone
+ - Carries **taste** fibers from **anterior 2/3 of tongue**
+ - Fibers travel with lingual branch of mandibular division of trigeminal nerve
+ - Carries **parasympathetic** fibers to **submandibular & sublingual glands** via submandibular ganglion
+ - **Terminal motor branches** to muscles of facial expression
+ - Superior to inferior: Temporal, zygomatic, buccal, mandibular, cervical
+
+# ANATOMY IMAGING ISSUES
+
+- ## Imaging Recommendations
+
+
+ - High-resolution bone CT best for intratemporal CNVII
+ - MR for intraaxial, cisternal, IAC, and extracranial segments
+ - 3D heavily T2 sequence, thin-section axial and coronal T2, precontrast and postcontrast fat-saturated T1
+ - Include brainstem, CPA cistern, IAC, temporal bone, and **parotid**when MR completed for CNVII palsy
+ - Do not image typical Bell palsy
+- ## Imaging Pitfalls
+
+
+ - Enhancement of geniculate ganglion, tympanic & mastoid segments of CNVII normal on postcontrast T1 MR; can be asymmetric intensity of enhancement on right & left
+ - Secondary to circumneural arteriovenous plexus
+ - Cisternal, IAC, labyrinthine, and parotid segments do not normally enhance on MR
+ - Faint enhancement may be seen depending on MR scanner, sequence, & type of contrast used
+ - Be familiar with normal images in different institutions
+ - Always check parotid in peripheral CNVII paralysis
+- ## Clinical Issues
+
+
+ - Facial nerve paralysis can be central or peripheral
+ - **Central**: Supranuclear injury; paralysis of contralateral muscles of facial expression with **forehead sparing**
+ - **Peripheral**: Injury to CNVII from brainstem nucleus peripherally, resulting in paralysis of all ipsilateral muscles of facial expression
+ - Lesion proximal to geniculate ganglion; lacrimation, sound dampening and taste are affected
+ - CNVI involved; check pons for lesion
+ - CNVIII involved; check CPA-IAC for lesion
+ - Lacrimation, sound dampening, and taste are variably affected; temporal bone lesion possible
+ - Lacrimation, sound dampening, and taste are spared; extracranial CNVII implicated
+
+ 965f30b5-41e0-4767-82e6-813a492e4281
+
+
+## Images
+
+
+### Graphics
+
+
+*Axial graphic shows CNVII nuclei. The motor nucleus sends out its fibers to circle the CNVI nucleus before reaching the root exit zone at the pontomedullary junction. The superior salivatory nucleus sends parasympathetic secretomotor fibers to the lacrimal, submandibular, and sublingual glands. The solitary tract nucleus receives taste information from the anterior 2/3 of the tongue.*
+
+
+*Axial graphic shows CNVII nuclei. The motor nucleus sends out its fibers to circle the CNVI nucleus before reaching the root exit zone at the pontomedullary junction. The superior salivatory nucleus sends parasympathetic secretomotor fibers to the lacrimal, submandibular, and sublingual glands. The solitary tract nucleus receives taste information from the anterior 2/3 of the tongue.*
+
+
+*Sagittal graphic depicts CNVII within the temporal bone. Motor fibers pass through the temporal bone, dropping stapedius nerve to stapedius muscle, then exits via the stylomastoid foramen to the extracranial CNVII (entirely motor). Parasympathetic fibers from the superior salivatory nucleus reach the lacrimal gland via the greater superficial petrosal nerve and the submandibular-sublingual glands via the chorda tympanic nerve. The anterior 2/3 of tongue taste fibers come via the chorda tympani nerve.*
+
+
+*Sagittal graphic depicts the extracranial motor branches of CNVII.*
+
+
+### Axial Bone CT
+
+
+*First of 5 high-resolution NECT bone window images of the right temporal bone from superior to inferior demonstrates the CNVII canal for the labyrinthine segment coursing anterolaterally from the fundus of the internal auditory canal (IAC) to the geniculate fossa. The labyrinthine segment is the shortest and narrowest segment.*
+
+
+*This image demonstrates the geniculate fossa, which lodges the geniculate ganglion. The greater (superficial) petrosal nerve (not shown) arises here and travels anteromedially toward the foramen lacerum.*
+
+
+*This image demonstrates the tympanic segment of CNVII arising from the geniculate ganglion and traversing posteriorly and laterally to take a 2nd turn downward, forming the posterior genu (not shown).*
+
+
+*This image demonstrates the high mastoid segment of CNVII canal posteriorly, which then descends toward the stylomastoid foramen. Nerve to stapedius arises at this level.*
+
+
+*This image demonstrates the midmastoid segment of CNVII with adjacent chorda tympani.*
+
+
+*Axial soft tissue window NECT through the skull base demonstrates bilateral fat-containing stylomastoid foramen. CNVII exits from bone canal into the parotid space through this foramen.*
+
+
+### Coronal Bone CT
+
+
+*First of 6 coronal reformatted high-resolution NECT bone window images show the labyrinthine segment of CNVII canal arising from the superior aspect of the fundus of the IAC.*
+
+
+*This image shows the snake eye appearance of labyrinthine and tympanic segments coursing adjacent to each other. The labyrinthine segment courses posteriorly toward the geniculate fossa, and the tympanic segment courses anteriorly away from the geniculate fossa.*
+
+
+*This image shows the geniculate fossa, which lodges the geniculate ganglion.*
+
+
+*This image shows the lateral semicircular canal, the tympanic segment of CNVII canal, and oval window from superior to inferior along the medial wall of the middle ear cavity.*
+
+
+*This image shows the descending mastoid segment of the CNVII canal. The chorda tympani leaves the CNVII canal 6 mm above the stylomastoid foramen and enters the middle ear cavity through the posterior canaliculus (not shown).*
+
+
+*This image shows the distal part of the CNVII mastoid segment exiting through the stylomastoid foramen into the parotid space.*
+
+
+### Axial T2 MR
+
+
+*First of 2 axial 3D T2 SPACE MR images through the left IAC shows CNVII arising from the lateral pontomedullary junction at the root exit zone. It then traverses the cerebellopontine angle cistern and enters the IAC through the porus acusticus. Note that posterior to it is the superior vestibular nerve.*
+
+
+*This image shows the IAC and labyrinthine segments of CNVII in the anterosuperior quadrant.*
+
+
+*Axial 3D T2 SPACE MR through the skull base at the level of stylomastoid foramina shows bilateral facial nerve mastoid segment exiting the bony canal and entering the parotid space. Note the fat surrounding the facial nerves bilaterally at this level.*
+
+
+### Oblique Sagittal T2 MR
+
+
+*First of 3 sagittal oblique MR images of the IAC from medial to lateral is shown. This image through the porus acusticus shows the anteriorly traversing facial nerve trunk, and immediately posterior to it is the vestibulocochlear nerve, both entering the IAC.*
+
+
+*This image through the middle of the IAC shows the appearance of a ball in the catcher's mitt where the ball is CNVII and the catcher's mitt is formed by the vestibulocochlear nerve complex.*
+
+
+*This image through the fundus of the IAC shows CNVII in the anterosuperior quadrant above the crista falciformis. Note the anteroinferiorly located cochlear nerve, posterosuperiorly located superior vestibular nerve, and posteroinferiorly located inferior vestibular nerve.*
+
+
+### Additional Images
+
+
+*First of 6 axial bone CT images of the left temporal bone presented from superior to inferior shows the labyrinthine segment of the facial nerve canal as a C-shaped structure arching anterolaterally over the top of the cochlea.*
+
+
+*In this image, the labyrinthine segment of CNVII canal terminates in the geniculate fossa. The facial nerve canal turns abruptly at the geniculate fossa (anterior genu). The tympanic segment arises from the geniculate fossa, coursing posterolaterally in axial plane, running under the lateral semicircular canal before turning 90 degrees inferiorly at the posterior genu to become the mastoid segment.*
+
+
+*At the level of the oval window, the mastoid segment is visible deep to the facial nerve recess. Notice the more medial pyramidal eminence and sinus tympani.*
+
+
+*Mastoid segment extends ~ 13 mm from the posterior genu to the stylomastoid foramen, coursing inferiorly within the posterior wall of the middle ear cavity. Mastoid segment is related anteriorly to the facial nerve recess and medially to the stapedius muscle within the pyramidal eminence on the posterior wall of the middle ear cavity.*
+
+
+*At the level of the basal turn of the cochlea, the mastoid segment of the facial nerve is still visible. Both the nerve to stapedius muscle proximally and chorda tympani distally branch off the mastoid segment of CNVII.*
+
+
+*Image at the level of the stylomastoid foramen is shown. Notice the "bell" of the stylomastoid foramen is just anteromedial to the mastoid tip. The mastoid tip protects the facial nerve from traumatic injury as it exits the skull base.*
+
+
+*First of 6 coronal bone CT images of the left temporal bone presented from posterior to anterior shows the lower mastoid segment of CNVII and stylomastoid foramen.*
+
+
+*At the level of the round window, the posterior genu of the facial nerve can be seen just lateral to the pyramidal eminence. Notice the sinus tympani is medial to the pyramidal eminence.*
+
+
+*At the level of the oval window, the tympanic segment of the facial nerve can be seen coursing under the lateral semicircular canal. Notice the fine bony covering (thin white line) surrounding the facial nerve. Also note the location relative to the upper margin of the oval window. In patients with oval window atresia, the facial nerve is found near or within the oval window niche.*
+
+
+*At the level of the anterior margin of the oval window, the tympanic segment of CVII can be seen under the lateral semicircular canal. Notice the fine bony covering (thin white line) surrounding the facial nerve is now not seen. The facial nerve canal bony covering in this area is normally incomplete.*
+
+
+*In the anterior middle ear cavity, the labyrinthine segment of CNVII can be seen exiting the internal auditory canal over the top of the cochlea. The anterior tympanic segment of the facial nerve is also visible. Do not confuse the muscle-tendon of the tensor tympani in the cochleariform process with the facial nerve.*
+
+
+*In the most anterior portion of middle ear cavity (where both the carotid and the cochlea are visible), the geniculate ganglion is seen within the geniculate fossa as an ovoid structure just above the cochlea.*
+
+
+*First of 2 axial high-resolution T2 MR images through the cerebellopontine angle cistern and internal auditory canal is shown. The facial nerve root exit zone is seen anterior to the vestibulocochlear nerve in the pontomedullary junction bilaterally. Notice the facial nerve maintains an anterior relationship with the vestibulocochlear nerve as it crosses through the cerebellopontine angle cistern.*
+
+
+*Image through cephalad internal auditory canal on the patient's left shows the facial nerve anterior to the superior vestibular nerve throughout its internal auditory canal course.*
+
+
+*Axial T1 MR at the level of the stylomastoid foramen shows the exiting low-signal facial nerve surrounded by high-signal fat in the "bell" of the stylomastoid foramen. If perineural parotid malignancy is present, the fat in this area is obscured.*
+
+
+*First of 3 oblique sagittal T2 MR images presented from lateral to medial shows normal fundal anatomy. The horizontal crista falciformis separates the fundus into upper and lower portions. Facial nerve is anterosuperior, separated from superior vestibular nerve by a vertical bony septum called "Bill bar," which is not resolved. Below the falciform crest are the larger anterior cochlear nerve and posterior inferior vestibular nerve.*
+
+
+*In the mid internal auditory canal, 4 nerves are clearly identified. The facial nerve is anterosuperior.*
+
+
+*This image through the porus acusticus reveals the characteristic ball in catcher's mitt appearance of the facial and vestibulocochlear nerves. The facial nerve is the "ball" and the vestibulocochlear nerve is the "catcher's mitt."*
+
diff --git a/docs_md/articles/colloid-cyst_1dd74fcf-b879-406b-a848-3ac31c95ae5f.md b/docs_md/articles/colloid-cyst_1dd74fcf-b879-406b-a848-3ac31c95ae5f.md
new file mode 100644
index 0000000..8a48c96
--- /dev/null
+++ b/docs_md/articles/colloid-cyst_1dd74fcf-b879-406b-a848-3ac31c95ae5f.md
@@ -0,0 +1,498 @@
+---
+title: "Colloid Cyst"
+docid: "1dd74fcf-b879-406b-a848-3ac31c95ae5f"
+authors:
+ - key: "5cff4116-3654-4b3a-bb75-5ebe0b8c9850"
+ value: "Anne G. Osborn, MD, FACR"
+breadcrumbs:
+ -
+ name: "Brain"
+ slug: "brain"
+ treeNodeId: "6d8829f1-14d7-45af-8675-255189aa526a"
+ -
+ name: "Diagnosis"
+ slug: "diagnosis"
+ treeNodeId: "51c00394-446e-4a38-94af-d3b1d14d34e8"
+ -
+ name: "Pathology-Based Diagnoses"
+ slug: "pathology-based-diagnoses"
+ treeNodeId: "d9d3a8ed-f21b-4831-8c77-591a3500ef77"
+ -
+ name: "Primary Nonneoplastic Cysts"
+ slug: "primary-nonneoplastic-cysts"
+ treeNodeId: "8037bffe-f61e-4433-b841-a263bcfbe056"
+ -
+ name: "Colloid Cyst"
+ slug: "colloid-cyst"
+ treeNodeId: null
+category: "Brain"
+cmeTopicId: "0ca08ad4-8341-48e8-98b5-7d2147b19d88"
+documentVersionId: "410074b6-d62c-4859-85f9-acadaccffcfe"
+imageCount: 26
+lastUpdated: "07/16/20"
+pageDescription: "Colloid Cyst"
+pageKeywords: "Brain, Diagnosis, Pathology-Based Diagnoses, Primary Nonneoplastic Cysts, Colloid Cyst"
+pageTitle: "Colloid Cyst | STATdx"
+enhancedTitle: "Colloid Cyst"
+type: "DX"
+references: true
+cases: 2
+breadcrumbs:
+ - "Brain"
+ - "Diagnosis"
+ - "Pathology-Based Diagnoses"
+ - "Primary Nonneoplastic Cysts"
+ - "Colloid Cyst"
+---
+# KEY FACTS
+
+- ## Terminology
+
+
+ - Unilocular, mucin-containing 3rd ventricular cyst
+- ## Imaging
+
+
+ - > 99% are wedged into foramen of Monro
+ - Pillars of fornix straddle, drape around cyst
+ - Majority are hyperdense on NECT
+ - Density correlates inversely with hydration state
+ - MR signal more variable
+ - Generally reflects water content
+ - Majority isointense to brain on T2WI (small cysts may be difficult to see)
+ - 25% mixed hypo/hyper ("black hole" effect)
+ - May show mild rim enhancement (rare)
+ - Rare: Fluid-fluid or blood-fluid level (cyst "apoplexy")
+- ## Top Differential Diagnoses
+
+
+ - Neurocysticercosis
+ - Cerebrospinal fluid flow artifact (MR "pseudocyst")
+ - Vertebrobasilar dolichoectasia (VBD)/aneurysm
+ - Subependymoma
+ - Craniopharyngioma
+- ## Pathology
+
+
+ - From embryonic endoderm, not neuroectoderm
+ - Similar to other foregut-derived cysts (neurenteric, Rathke)
+- ## Clinical Issues
+
+
+ - 40-50% asymptomatic, discovered incidentally
+ - Headache (50-60%)
+ - Acute foramen of Monro obstruction may lead to rapid-onset hydrocephalus, herniation, death
+ - Peak age = 3rd to 4th decades (rare in children)
+ - 90% stable or stop enlarging
+ - 10% enlarge
+- ## Diagnostic Checklist
+
+
+ - Beware of flow artifact in 3rd ventricle mimicking colloid cyst
+
+# TERMINOLOGY
+
+- ## Abbreviations
+
+
+ - Colloid cyst (CC)
+- ## Synonyms
+
+
+ - Paraphyseal cyst, endodermal cyst
+- ## Definitions
+
+
+ - Unilocular, mucin-containing 3rd ventricular cyst
+
+# IMAGING
+
+- ## General Features
+
+
+ - ### Best diagnostic clue
+
+
+ - Hyperdense foramen of Monro mass on NECT
+ - ### Location
+
+
+ - > 99% are wedged into foramen of Monro
+ - Attached to anterosuperior 3rd ventricular roof
+ - Pillars of fornix straddle, drape around cyst
+ - Posterior part of frontal horns splayed laterally around cyst
+ - < 1% found at other sites
+ - Lateral, 4th ventricles
+ - Extraventricular CCs (very rare)
+ - Parenchyma (cerebellum)
+ - Extraaxial (prepontine, meninges, olfactory groove)
+ - ### Size
+
+
+ - Variable (few mm to 3 cm)
+ - Mean: 15 mm
+ - ### Morphology
+
+
+ - Well-demarcated round > ovoid/lobulated mass
+- ## CT Findings
+
+
+ - ### NECT
+
+
+ - Density correlates inversely with hydration state
+ - 2/3 hyperdense
+ - 1/3 iso-/hypodense
+ - ± hydrocephalus
+ - Rare
+ - Hypodense
+ - Change in density/size
+ - ### CECT
+
+
+ - Usually does not enhance
+ - Rim enhancement (rare)
+- ## MR Findings
+
+
+ - ### T1WI
+
+
+ - Signal correlates with cholesterol concentration
+ - 2/3 hyperintense on T1WI
+ - 1/3 isointense
+ - Small CCs may be difficult to see
+ - May have associated ventriculomegaly
+ - ### T2WI
+
+
+ - Signal more variable
+ - Generally reflects water content
+ - Majority isointense to brain on T2WI
+ - Small CCs may be difficult to see
+ - Less common findings
+ - 25% mixed hypo/hyper ("black hole" effect)
+ - Rare
+ - Fluid-fluid or blood-fluid level (cyst "apoplexy"), Ca⁺⁺ rare
+ - ### FLAIR
+
+
+ - Does not suppress
+ - ### DWI
+
+
+ - Does not restrict
+ - ### T1WI C+
+
+
+ - Usually no enhancement
+ - Rare: May show peripheral (rim) enhancement
+ - ### MRS
+
+
+ - Normal brain metabolites absent
+- ## Imaging Recommendations
+
+
+ - ### Protocol advice
+
+
+ - NECT + contrast-enhanced MR
+ - ± serial imaging for asymptomatic cysts < 1 cm, no hydrocephalus
+
+# DIFFERENTIAL DIAGNOSIS
+
+- [Neurocysticercosis](/document/neurocysticercosis/6a45835f-6d7c-443e-874a-f33131d3def1)
+ - Multiple lesions within parenchyma and cisterns
+ - Associated ependymitis or basilar meningitis common
+ - Ca⁺⁺ common
+ - Look for scolex
+- ## Cerebrospinal Fluid Flow Artifact (MR "Pseudocyst")
+
+
+ - Multiplanar technique confirms artifact
+ - Look for phase artifact
+- [Vertebrobasilar Dolichoectasia/Aneurysm](/document/asvd-fusiform-aneurysm/883c9117-6fdb-4030-8765-aedd9711432a)
+ - Extreme vertebrobasilar dolichoectasia (VBD) can cause hyperdense foramen of Monro mass
+ - Look for flow void, phase artifact on MR
+- ## Neoplasm
+
+
+ - [Subependymoma](/document/subependymoma/b899ded1-d2f2-4dc4-9812-48d3fb194117)
+ - Frontal horn of lateral ventricle
+ - Attached to septum pellucidum
+ - Patchy/solid enhancement
+ - [Craniopharyngioma](/document/craniopharyngioma/00e66680-6731-4287-b5a1-3f0b3f09053b)
+ - 3rd ventricle rare location
+ - Usually not wedged into foramen of Monro, fornix
+ - Ca⁺⁺, rim/nodular enhancement common
+ - [Pituitary adenoma](/document/pituitary-microadenoma/283f3068-d369-4f79-bf01-0f2b82c6e49b)
+ - Rare in 3rd ventricle
+ - Enhances (usually strongly, uniformly)
+- ## Choroid Plexus Mass
+
+
+ - [Choroid plexus papilloma](/document/choroid-plexus-papilloma/18e712f5-8553-487d-a939-044336cbf0ad)
+ - Rare in 3rd ventricle
+ - Tumor of early childhood
+ - [Xanthogranuloma](/document/choroid-plexus-cyst/1f3fc9e9-9243-4d74-8261-7db846eeac05)
+ - Rare in 3rd ventricle
+ - Ovoid > round
+ - Can be hyper- or hypodense ± Ca⁺⁺
+ - Can obstruct foramen of Monro
+ - Can be indistinguishable on imaging studies
+ - [Choroid plexus cyst](/document/choroid-plexus-cyst/1f3fc9e9-9243-4d74-8261-7db846eeac05)
+ - Usually found in infants
+ - Anechoic at ultrasound
+
+# PATHOLOGY
+
+- ## General Features
+
+
+ - ### Etiology
+
+
+ - From embryonic endoderm, not neuroectoderm
+ - Similar to other foregut-derived cysts (neurenteric, Rathke)
+ - Ectopic endodermal elements migrate into embryonic diencephalic roof
+ - Contents accumulate from mucinous secretions, desquamated epithelial cells
+ - ### Genetics
+
+
+ - None known, but familial CCs represent 5-25% of cases
+ - Patients often younger, more symptomatic
+ - ### Associated abnormalities
+
+
+ - Variable hydrocephalus
+- ## Gross Pathologic & Surgical Features
+
+
+ - Gross appearance, location virtually pathognomonic
+ - Smooth, spherical/ovoid well-delineated cyst
+ - Thick gelatinous center, variable viscosity (mucinous or desiccated)
+ - Rare = evidence for recent/remote hemorrhage
+- ## Microscopic Features
+
+
+ - Outer wall = thin fibrous capsule
+ - Inner lining
+ - Simple or pseudostratified epithelium
+ - Interspersed goblet cells, scattered ciliated cells
+ - Rests on thin connective tissue layer
+ - Cyst contents
+ - PAS + gelatinous ("colloid") material
+ - Variable viscosity
+ - ± necrotic leukocytes, cholesterol clefts
+ - Immunohistochemistry
+ - ± epithelial antigen reactivity (cytokeratins, EMA)
+ - Neuroepithelial markers negative
+ - Electron microscopy
+ - Resembles mature respiratory epithelium
+ - Nonciliated or tall columnar cells
+ - Basal cells contain dense core vesicles
+
+# CLINICAL ISSUES
+
+- ## Presentation
+
+
+ - ### Most common signs/symptoms
+
+
+ - Headache (50-60%)
+ - Less common = nausea, vomiting, memory loss, altered personality, gait disturbance, visual changes
+ - Acute foramen of Monro obstruction may lead to rapid onset hydrocephalus, herniation, death
+ - 40-50% asymptomatic, discovered incidentally
+ - 5-15% 5-year risk of future progression necessitating operative intervention
+ - ### Clinical profile
+
+
+ - Adult with headache
+- ## Demographics
+
+
+ - ### Age
+
+
+ - 3rd to 4th decades
+ - Peak: 40
+ - Rare in children (only 8% < 15 at diagnosis), but may have precipitous symptoms, rapid deterioration
+ - ### Sex
+
+
+ - M = F
+ - ### Epidemiology
+
+
+ - 0.5-1.0% primary brain tumors
+ - 15-20% intraventricular masses
+ - Few familial cases reported
+- ## Natural History & Prognosis
+
+
+ - Varies with presence/rate of growth, development of cerebrospinal fluid (CSF) obstruction
+ - Colloid Cyst Risk Score (CCRS)
+ - 5-point measure to predict symptomatic clinical status, stratify risk for hydrocephalus
+ - Age < 65 years; headache, cyst ≥ 7 mm, FLAIR hyperintense, anatomic risk zone (I-III from front to back of 3rd ventricle)
+ - CCRSs 2 to 5 = 13% → 100% symptomatic, 8% → 83% develop hydrocephalus
+ - Prognosis excellent when CCs diagnosed early and excised
+ - 90% stable or stop enlarging
+ - Older age
+ - Small cyst
+ - No hydrocephalus
+ - Hyperdense on NECT, hypointense on T2-weighted MR
+ - 10% enlarge
+ - Younger patients
+ - Larger cyst, hydrocephalus
+ - Iso-/hypodense on NECT, often hyperintense on T2WI
+ - May enlarge rapidly, cause coma/death
+ - Rare: Hemorrhage with cyst "apoplexy"
+ - Rare: Regression
+- ## Treatment
+
+
+ - Most common = complete surgical resection
+ - Neuronavigation-guided endoscopic removal + capsule coagulation
+ - 50% experience short-term memory disturbance (usually resolves)
+ - Recurrence rare if resection complete
+ - Options
+ - Stereotactic aspiration (difficult with extremely viscous/solid cysts)
+ - Imaging features that may predict difficulty with percutaneous therapy
+ - Hyperdensity on CT/hypointensity on T2WI suggest high viscosity
+ - Ventricular shunting
+ - Observation (rare; not recommended, as sudden obstruction can occur with even small CCs)
+
+# DIAGNOSTIC CHECKLIST
+
+- ## Consider
+
+
+ - Consider CT or MR in patient with longstanding history of intermittent headaches
+ - Notify referring MD immediately if CC identified (especially if hydrocephalus is present)
+- ## Image Interpretation Pearls
+
+
+ - Beware of flow artifact in 3rd ventricle mimicking CC
+
+ 9c1df1e2-4144-4a0c-a69c-edfe7c96a862
+
+## References
+
+# Selected References
+
+1. [Alford EN et al: Interrater and intrarater reliability of the Colloid Cyst Risk Score. Neurosurgery. 86(1):E47-53, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=31552408%5Bpmid%5D)
+1. [Alford EN et al: Independent validation of the colloid cyst risk score to predict symptoms and hydrocephalus in patients with colloid cysts of the third ventricle. World Neurosurg. 134:e747-53, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=31706971%5Bpmid%5D)
+1. [Heller RS et al: Colloid cysts: evolution of surgical approach preference and management of recurrent cysts. Oper Neurosurg (Hagerstown). 18(1):19-25, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=31220314%5Bpmid%5D)
+1. [Isaacs AM et al: Long-term outcomes of endoscopic third ventricle colloid cyst resection: case series with a proposed grading system. Oper Neurosurg (Hagerstown). 19(2):134-42, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=31960056%5Bpmid%5D)
+1. [Kutty RK et al: Flying with colloid cyst: a cautionary note. World Neurosurg. 138:84-8, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32001391%5Bpmid%5D)
+1. [Magalhães-Ribeiro C et al: Spontaneous asymptomatic resolution of a third ventricle colloid cyst. Neurochirurgie. 66(2):137-8, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32067974%5Bpmid%5D)
+1. [Mulcahy MJ et al: The case of the disappearing colloid cyst. World Neurosurg. 135:100-2, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=31837498%5Bpmid%5D)
+1. [Muscas G et al: Are familial colloid cysts of the third ventricle associated with a worse clinical course than sporadic forms? Case illustration and systematic literature review. J Neurosurg Sci. ePub, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32043846%5Bpmid%5D)
+1. [Ciappetta P et al: Schwalbe's triangular fossa: normal and pathologic anatomy on frozen cadavers. anatomo-magnetic resonance imaging comparison and surgical implications in colloid cyst surgery. World Neurosurg. 128:e116-28, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=30981795%5Bpmid%5D)
+1. [Cuoco JA et al: Postexercise death due to hemorrhagic colloid cyst of third ventricle: case report and literature review. World Neurosurg. 123:351-6, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=30590211%5Bpmid%5D)
+1. [Al Abdulsalam HK et al: Hemorrhagic colloid cyst. Neurosciences (Riyadh). 23(4):326-33, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=30351291%5Bpmid%5D)
+1. [O'Neill AH et al: Natural history of incidental colloid cysts of the third ventricle: a systematic review. J Clin Neurosci. 53:122-6, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=29731276%5Bpmid%5D)
+1. [Vazhayil V et al: Surgical management of colloid cysts in children: experience at a tertiary care center. Childs Nerv Syst. 34(6):1215-20, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=29488075%5Bpmid%5D)
+1. [Barbagallo GM et al: Out-of-third ventricle colloid cysts: review of the literature on pathophysiology, diagnosis and treatment of an uncommon condition, with a focus on headache. J Neurosurg Sci. 63(3):330-6, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=27603409%5Bpmid%5D)
+1. [Margetis K et al: Endoscopic resection of incidental colloid cysts. J Neurosurg. 120(6):1259-67, 2014](http://www.ncbi.nlm.nih.gov/pubmed/?term=24745712%5Bpmid%5D)
+1. [Sheikh AB et al: Endoscopic versus microsurgical resection of colloid cysts: a systematic review and meta-analysis of 1,278 patients. World Neurosurg. 82(6):1187-97, 2014](http://www.ncbi.nlm.nih.gov/pubmed/?term=24952223%5Bpmid%5D)
+1. [Woodley-Cook J et al: Neurosurgical management of a giant colloid cyst with atypical clinical and radiological presentation. J Neurosurg. 121(5):1185-8, 2014](http://www.ncbi.nlm.nih.gov/pubmed/?term=25148004%5Bpmid%5D)
+
+## Cases
+
+- {'cases': [{'authors': [{'key': 'c313fa7b-5bff-4b39-a8cd-dcf06aa6a69d', 'value': 'A. Carlson Merrow, Jr., MD, FAAP'}], 'caseVersionId': '0409292b-c233-4dfc-a50c-5b0de33b09ea', 'description': 'Axial NECT (#1), axial T1WI MR (#2), and sagittal T2* GRE MR (#3) show a small round mass (arrows) at the midline between the lateral ventricles near the foramina of Monro. The mass is hyperdense on CT (#1), bright on T1WI MR (#2), and isointense to white matter on T2* GRE MR (#3).', 'history': 'Headaches.', 'imagePoolId': '493e74df-8b88-47b5-bee3-cb786777b12c', 'name': 'Small hyperdense cyst', 'teachingPoint': 'This mass has typical signal characteristics and location for a colloid cyst.', 'demographics': '17 Years old male'}, {'authors': [{'key': '5cff4116-3654-4b3a-bb75-5ebe0b8c9850', 'value': 'Anne G. Osborn, MD, FACR'}], 'caseVersionId': '60b6667a-1c5a-45c6-8437-5a8e1a9ead33', 'description': "Axial NECT scan (#1) shows a small round hyperdense mass at the foramen of Monro (arrow). The lateral ventricles are moderately enlarged for the patient's age.\n\nThe lesion (arrows) appears hyperintense on sagittal (#2) and axial (#3) T1WIs. The mass is hypointense on T2WI (arrow, #4) and FLAIR (arrow, #5). While the ventricles appear moderately enlarged, there is no evidence for transependymal migration of CSF that would indicate acute obstructive hydrocephalus. T1 C+ FS scan (#6) shows the internal cerebral veins (arrows) and fornices (open arrows) are splayed around the mass.", 'history': 'Intermittent headache, ataxia.', 'imagePoolId': '96bb1dbd-0c3a-4afa-8bdb-d449ed8c934c', 'name': 'Small; hypointense on T2WI', 'teachingPoint': 'This is a classic colloid cyst in the classic location (99% are wedged into the foramen of Monro). The patient probably had intermittent obstruction of the foramen of Monro, accounting for the waxing and waning symptoms. The "black hole" effect (hypointensity on T2WI) correlates with desiccation and high viscosity, making cysts with this imaging finding difficult to aspirate. A colloid cyst was removed at surgery via transcallosal approach.', 'demographics': '43 Years old male'}, {'authors': [{'key': 'c313fa7b-5bff-4b39-a8cd-dcf06aa6a69d', 'value': 'A. Carlson Merrow, Jr., MD, FAAP'}], 'caseVersionId': '96b87d1b-d3ec-46eb-b2c3-438d5e9d8c02', 'description': 'Axial NECT (#1) shows a round hyperdense mass (open arrow) in the midline covering the foramina of Monro. The lateral ventricles (curved arrow) are enlarged. Axial T2WI MR (#2), T1WI MR (#3), T1 WI C+ MR (#4), and DWI MR (#5) show that the mass (open arrows) is of intermediate T2 (#2) and slightly high T1 (#3) signal intensity with no significant enhancement (#4). No restricted diffusion is seen in the mass (#5). Mild increased T2 signal intensity surrounds the frontal horns of the lateral ventricles (straight arrow, #2), typical of interstitial edema in the setting of obstructive hydrocephalus.', 'history': 'Headaches.', 'imagePoolId': '6440685f-5830-4007-ac86-a5a57beff7af', 'name': 'T1 bright, hydrocephalus', 'teachingPoint': 'This mass is a typical appearance for a colloid cyst with mild hydrocephalus.', 'demographics': '14 Years old male'}, {'authors': [{'key': '5cff4116-3654-4b3a-bb75-5ebe0b8c9850', 'value': 'Anne G. Osborn, MD, FACR'}], 'caseVersionId': 'e0c3703a-3371-4f49-b7ec-0453197536f7', 'description': 'Classic colloid cyst shown on CT.\n\nAxial NECT shows a round hyperdense foramen of Monro mass (open arrow) causing mild hydrocephalus. Note fornices (arrows) are draped and splayed around the mass.', 'history': 'Sudden onset of headache, papilledema.', 'imagePoolId': '0dff071c-507f-434f-94ca-fec4547efa13', 'name': 'Hyperdense mass', 'teachingPoint': None}, {'authors': [{'key': '5cff4116-3654-4b3a-bb75-5ebe0b8c9850', 'value': 'Anne G. Osborn, MD, FACR'}], 'caseVersionId': 'c11df014-01dd-479f-8ae4-f1e3d084fdb7', 'description': 'Tiny colloid cysts can sometimes be detected on MR when they are viscous and therefore hyperintense on T1 weighted sequences.\n\nSagittal (#1) and coronal (#2) show a very small mildly hyperintense mass at the foramen of Monro (arrow). The lesion is isointense with gray matter on T2WI (#3, arrow). Sagittal (#4) and coronal (#5) post-contrast T1WIs demonstrate slight displacement of the choroid plexus and internal cerebral veins (arrows) by the mass.', 'history': 'Incidental finding.', 'imagePoolId': '268267df-ebfc-4701-ab3b-556aa596698f', 'name': 'Viscous', 'teachingPoint': None}, {'authors': [{'key': '5cff4116-3654-4b3a-bb75-5ebe0b8c9850', 'value': 'Anne G. Osborn, MD, FACR'}], 'caseVersionId': 'fbaeb781-1e71-40e2-a236-ee41ca33a472', 'description': 'Colloid cysts vary in signal intensity and can sometimes be mostly isointense with brain on MR.\n\nAxial T2WI MR (#1), shows a colloid cyst (arrow) at the foramen of Monro. The cyst is isointense with brain and is causing moderate but compensated hydrocephalus. The cyst remains isointense with brain on T2WI (#2, arrow). Axial FLAIR MR (#3), shows the cyst (arrow) does not suppress and is hyperintense to brain. Note absence of transependymal CSF flow around atria of lateral ventricle. The contrast-enhanced fat-suppressed T1WI (#4) shows the cyst does not enhance. Note deviation of the internal cerebral veins around the cyst (open arrows).', 'history': 'Middle-aged female with headaches.', 'imagePoolId': 'd088e38b-f110-43ba-8ec5-393853851476', 'name': 'Classic', 'teachingPoint': None, 'demographics': '42 Years old female'}, {'authors': [{'key': '5cff4116-3654-4b3a-bb75-5ebe0b8c9850', 'value': 'Anne G. Osborn, MD, FACR'}], 'caseVersionId': '4384758a-9ba0-4853-b927-4922454e7123', 'description': 'Close-up view of an NECT scan obtained in this case shows a focal hyperdense area at the foramen of Monro (arrow). This represents a hemorrhagic axonal stretch injury to the fornix, a compact white matter fiber tract that occasionally is involved by the sudden deceleration/rotational forces seen in closed head injury. In this case the DAI is right at the foramen of Monro. Without the history it might be mistaken for a colloid cyst with the fornices straddling the cyst.', 'history': 'Closed head injury.', 'imagePoolId': 'a28629e4-6e8d-4d36-a8a1-3b8e8383f668', 'name': 'Axonal injury to fornix mimics colloid cyst', 'teachingPoint': None, 'demographics': '16 Years old female'}, {'authors': [{'key': '5cff4116-3654-4b3a-bb75-5ebe0b8c9850', 'value': 'Anne G. Osborn, MD, FACR'}], 'caseVersionId': 'ab653321-4742-4948-8880-be53cd110639', 'description': 'NECT scan shows a 3-mm nonobstructive hyperdense mass at the foramen of Monro (arrow, #1). Series of MR scans (#2-5) show the mass (arrows) is essentially isointense with brain on all sequences, rendering it essentially invisible on MR.', 'history': 'Young adult with headaches.', 'imagePoolId': '8bbfaea2-5a8c-4c4c-874a-074d51ad75b8', 'name': 'Invisible on MR', 'teachingPoint': "This may have been an incidental finding on this patient's NECT scan, given the size of the mass. However, occasionally colloid cysts, even small ones, can cause intermittent or acute obstruction at the foramen of Monro. They may be life-threatening in some cases. Had only an MR scan been obtained, this small colloid cyst could easily have been overlooked."}], 'caseType': 'typical', 'name': 'TYPICAL'}
+- {'cases': [{'authors': [{'key': '5cff4116-3654-4b3a-bb75-5ebe0b8c9850', 'value': 'Anne G. Osborn, MD, FACR'}], 'caseVersionId': '14f4945b-54ff-4137-9543-460eb1a9114f', 'description': 'NECT scan (#1) shows well-delineated hyperdense mass at the foramen of Monro (arrow). No enhancement could be identified on CECT scan (#2). MR was obtained. Axial T1WI (#3) shows slightly hyperintense mass within the foramen of Monro (arrow). The lesion was very hypointense on sagittal and axial T2WIs (arrows, #4,5). The ventricles are moderately enlarged. Axial and coronal FLAIR scans (#6,7) show a mostly hypointense lesion with a distinct hyperintense rim (arrows). T1C+ scan (#8) shows rim enhancement around the lesion (arrow).\n\nThe lesion was removed. Histopathologic examination of the surgical specimen (#9) showed classic colloid cyst. Flattened cuboidal to low columnar epithelium with interspersed goblet cells and some flattened basal cells surrounded amorphous material that comprised the cyst contents. Scattered foci of chronic inflammatory infiltrates were identified.', 'history': 'Patient in ER with sudden-onset severe ("thunderclap\') headache, nausea, vomiting. NECT scan was obtained to look for subarachnoid hemorrhage.', 'imagePoolId': '5f81d46e-69d1-4d27-b356-c14b406ac01f', 'name': 'Hypointense on T2; ring-enhancing', 'teachingPoint': 'A colloid cyst with densely inspissated cyst contents was found at surgery. Mild reactive inflammatory changes around the cyst periphery probably account for the rim enhancement seen on MR.', 'demographics': '65 Years old male'}, {'authors': [{'key': '5cff4116-3654-4b3a-bb75-5ebe0b8c9850', 'value': 'Anne G. Osborn, MD, FACR'}], 'caseVersionId': 'f0954471-c873-4868-bc64-00a3952b3520', 'description': 'Axial T1Ws (#1, 2), show a classic hyperintense lesion at the foramen of Monro. The lesion is isointense with gray matter on T2WIs (#3, 4). Sagittal (#4) and axial (#5) T1WI MR images, were obtained when the patient developed a sudden increase in headaches. They show marked interval enlargement of the mass and worsening hydrocephalus. The mass appears rather inhomogeneous on T2WI (#6).', 'history': 'The patient initially presented with only mild headaches. Observation rather than surgical intervention was the chosen treatment. The patient subsequently, however, developed a sudden increase in headaches, correlating with the enlarging cyst.', 'imagePoolId': '4a886534-855f-4218-868e-f16a9872b809', 'name': 'Enlarging', 'teachingPoint': 'It is unusual for colloid cysts to show rapid change in size but it does occur.'}, {'authors': [{'key': '5cff4116-3654-4b3a-bb75-5ebe0b8c9850', 'value': 'Anne G. Osborn, MD, FACR'}], 'caseVersionId': '342415d2-2b04-45d3-bf98-6eb243f733b6', 'description': 'NECT scan (#1) shows moderate enlargement of the lateral ventricles, with "blurring" of the ventricular margins. The posterior aspects of the frontal horns appear splayed laterally (arrows). Sagittal (#2) and axial (#3) T1WIs show the fornix draped superiorly and anteriorly around a mass at the foramen of Monro (arrows). The mass is approximately isointense with gray matter. Axial PD (#4), as well as axial (#5) and coronal (#6) T2WI show the mass is hyperintense. Note: focus of relative hypointensity (arrow, #6). Sagittal (#7) and axial (#8) FLAIR scans show the lesion does not suppress and remains hyperintense. Note transependymal CSF flow (arrows, #8). The lesion shows minimal rim enhancement on axial (#9) and coronal (#10) T1C+ scans (arrows).', 'history': 'Teenaged male presented in the ER with severe headaches. Papilledema was found on physical examination.', 'imagePoolId': '5f378739-c667-4774-b605-bbd0ffda3c67', 'name': 'Isodense', 'teachingPoint': 'The appearance is typical for a colloid cyst on MR. What is atypical about this case is its isodensity with brain on NECT scan as well as the relatively young age of the patient. Colloid cysts are less common in children and adolescents compared with adults.', 'demographics': '16 Years old male'}, {'authors': [{'key': '5cff4116-3654-4b3a-bb75-5ebe0b8c9850', 'value': 'Anne G. Osborn, MD, FACR'}], 'caseVersionId': '6e6df753-a53e-44ee-b833-81aede500ba1', 'description': 'Colloid cysts may be isodense with surrounding brain and difficult to detect on CT scans.\n\nAxial NECT scan (#1) shows focal deformity of the frontal horns, which appear splayed posteriorly at the foramen of Monro (arrows). No definite mass is identified.\n\nA series of MR images (#2-8) clearly show a mass at the foramen of Monro. Sagittal (#2) and axial (#3) T1 weighted scans show the mass is mostly iso- to slightly hyperintense with brain (arrows). Note the forniceal splaying (#4, arrows) and central hypointensity (#5, arrow) on T2 weighted scans. The cyst does not suppress on FLAIR and the central hypointense focus is clearly seen (#6-7). Slight rim-enhancement is identified on the post-contrast T1WI (#8, arrow). This may represent displaced choroid and internal cerebral and/or septal veins around the mass.', 'history': None, 'imagePoolId': '95a7ec82-d0ba-41c2-a393-2e172c99ced9', 'name': 'Isodense', 'teachingPoint': None}, {'authors': [{'key': '5cff4116-3654-4b3a-bb75-5ebe0b8c9850', 'value': 'Anne G. Osborn, MD, FACR'}], 'caseVersionId': '53c375b9-8d72-4224-ad18-694faa4a84fe', 'description': 'Occasionally colloid cysts show rim-enhancement.\n\nAxial NECT scan shows moderately severe hydrocephalus with blurring of the ventricular margins caused by transependymal extravasation of CSF. There is some splaying of the posterior aspects of the frontal horns (#1, arrows) but if a mass is present (it is), its attenuation is identical to surrounding brain which renders it invisible. CECT scan (#2) shows faint rim-enhancement (arrows). Colloid cyst was removed at surgery.', 'history': 'Lethargic with decreased mental status.', 'imagePoolId': 'dc8e669e-abef-48e6-b49c-1bf34e73621a', 'name': 'Rim-enhancing', 'teachingPoint': None, 'demographics': '24 Years old female'}, {'authors': [{'key': '5cff4116-3654-4b3a-bb75-5ebe0b8c9850', 'value': 'Anne G. Osborn, MD, FACR'}], 'caseVersionId': '3cc37fe5-4346-462a-b9e9-c75f8644caad', 'description': 'Sagittal (#1) and axial (#2) pre-contrast T1-weighted scans show a well-delineated mass at the foramen of Monro (arrow). The mass is isointense with brain on both T1 and T2 weighted (arrows, #3, 4) sequences. The lesion is hyperintense on FLAIR (arrow, #5). Note: presence of striking subependymal CSF flow on this image (open arrows). T1C+ scans (#6-8) show the lesion enhances (arrows).\n\nColloid cysts do not show solid enhancement, as this case does. A few ring-enhancing colloid cysts have been described but are unusual.', 'history': 'Known renal carcinoma, severe headaches.', 'imagePoolId': 'bd38c230-2389-4569-bdac-b1fa9df3f52a', 'name': 'Met mimics colloid cyst', 'teachingPoint': None}, {'authors': [{'key': '5cff4116-3654-4b3a-bb75-5ebe0b8c9850', 'value': 'Anne G. Osborn, MD, FACR'}], 'caseVersionId': 'd5c2031b-f1de-49ac-b0bd-587fff55834a', 'description': 'The first slice in the coronal T1-weighted scan shows striking flow artifact within the third and lateral ventricles (arrows). If you look at the adjacent brain parenchyma, you see propagation of phase artifact (open arrows) across the scan indicating this is flow-related.', 'history': 'Headaches.', 'imagePoolId': '365f2a97-0918-4bcd-944c-9a72bb93b31d', 'name': 'CSF flow mimics colloid cyst', 'teachingPoint': None, 'demographics': '56 Years old female'}, {'authors': [{'key': '5cff4116-3654-4b3a-bb75-5ebe0b8c9850', 'value': 'Anne G. Osborn, MD, FACR'}], 'caseVersionId': 'db053f71-cf48-44e4-b6a7-5446af5e4bf0', 'description': 'Axial NECT scan (#1) obtained at an outside hospital shows a hyperdense mass near the foramen of Monro (arrow). Note markedly enlarged ventricles with "blurry" margins indicating transependymal CSF flow (open arrows). CECT scan (#2) shows the mass enhances strongly and uniformly (arrow). Initial diagnosis was colloid cyst. A shunt was placed in the lateral ventricles and the patient transferred for emergent "removal of colloid cyst."\n\nReview of the imaging study led to the revised diagnosis of extremely ectatic basilar artery that protruded into the third ventricle and caused obstructive hydrocephalus.\n\nColloid cysts do not enhance strongly and uniformly. In older patients, vertebrobasilar ectasia (VBD) can present as a mass indenting the third ventricle and even the foramen of Monro.', 'history': 'Older patient with severe headaches, papilledema on physical examination.', 'imagePoolId': '60ef074e-b74e-4018-8c8c-32f25ce28eab', 'name': 'VBD mimics colloid cyst', 'teachingPoint': None, 'demographics': '61 Years old male'}, {'authors': [{'key': '5cff4116-3654-4b3a-bb75-5ebe0b8c9850', 'value': 'Anne G. Osborn, MD, FACR'}], 'caseVersionId': 'dbaeb2a6-3112-477b-8c76-88de5f51769c', 'description': 'Flow artifacts in and around the third ventricle and foramen of Monro can mimic colloid cyst. \n\nAxial FLAIR scans (#1, 2) show inhomogeneous signal within the third ventricle and foramen of Monro (arrows). Coronal T1C+ scans (#3, 4) show hyperintensity in the anterior third ventricle (arrows).\n\nNote that the intraventricular signal is in the inferior third ventricle, below the foramen of Monro, seen especially well on image 4. Colloid cysts are typically in the upper aspect of the third ventricle, wedged between the fornices (#4, curved arrow).', 'history': 'Headaches, no neurologic findings.', 'imagePoolId': '11afc5aa-126f-4b75-b839-eee61bbd9c61', 'name': 'Flow mimics colloid cyst', 'teachingPoint': None}, {'authors': [{'key': '5cff4116-3654-4b3a-bb75-5ebe0b8c9850', 'value': 'Anne G. Osborn, MD, FACR'}], 'caseVersionId': 'e04b071c-ee82-4768-b79b-cc8e39c3dc9b', 'description': 'Sagittal (#1) and axial (#2) T1WIs show an isointense 3rd ventricular mass (arrows). It appears hyperintense on PD (#3) and T2WI (#4). Note transependymal CSF flow (arrows,#3, 4). On T1C+ scan the mass showed striking rim enhancement (arrow, #5).', 'history': 'Headaches.', 'imagePoolId': '0c8825e0-a803-48fd-8d88-9fc54e86f776', 'name': 'Rim enhancement', 'teachingPoint': 'Rim enhancement around the margin of a colloid cyst is unusual. It may represent inflammatory reaction to the cyst or, in some cases, displacement of veins and choroid plexus around the cyst. In this case, some inflammatory changes were found surrounding the cyst that was surgically removed.'}, {'authors': [{'key': '5cff4116-3654-4b3a-bb75-5ebe0b8c9850', 'value': 'Anne G. Osborn, MD, FACR'}], 'caseVersionId': 'fbb1c89e-1071-4b58-a5f4-902c5f7eed30', 'description': 'Close-up views of the axial NECT (#1) and CECT scans (#2) show a hyperdense mass in the 3rd ventricle (arrows). The mass is somewhat oblong and seems to fill the third ventricle. This would be unusual for a colloid cyst and may represent a xanthogranuloma of the 3rd ventricular choroid plexus.', 'history': 'Patient presented at an outside emergency room with severe headache. Papilledema was found on physical examination. CT scan was obtained emergently but the patient collapsed and died. Autopsy was refused.', 'imagePoolId': 'aad4004a-ea21-4c77-b4ee-b68a15cca8ff', 'name': 'Xanthogranuloma mimics colloid cyst', 'teachingPoint': None}, {'authors': [{'key': '5cff4116-3654-4b3a-bb75-5ebe0b8c9850', 'value': 'Anne G. Osborn, MD, FACR'}], 'caseVersionId': '0ad4295d-eb86-4a4e-8701-a7d9091e9c80', 'description': 'Single coronal T1WI shows a hyperintense mass within the inferior third ventricle. The mass is too low for a colloid cyst, which are typically wedged into the roof of the third ventricle just below the fornices. Intraventricular pituitary adenoma was found at surgery. Ectopic pituitary adenomas may occur in many locations, including the sphenoid sinus and third ventricle.', 'history': None, 'imagePoolId': '795a57d3-76f5-42bb-a75f-c5574664410b', 'name': 'Ectopic pituitary adenoma mimics colloid cyst', 'teachingPoint': None}, {'authors': [{'key': '5cff4116-3654-4b3a-bb75-5ebe0b8c9850', 'value': 'Anne G. Osborn, MD, FACR'}], 'caseVersionId': '0fe2ba0f-4902-4e98-859d-a21a034c7554', 'description': 'Axial NECT scan (#1) shows a slightly hyperdense mass at the foramen of Monro (arrow). The mass enhances very strongly on CECT (arrow, #2). Initial diagnosis was colloid cyst.\n\nAfter transfer to the University Hospital, an MR scan was obtained. The axial T1WI (#1) shows the "colloid cyst" is vascular with high flow (arrow) causing phase artifact to propagate across the image (open arrows). This was caused by extreme fusiform ectasia of the basilar artery.', 'history': 'Elderly patient with headaches had a CT scan performed at an outside clinic.', 'imagePoolId': 'dd5fccfc-bcf8-45ad-977d-28af4a53a7f2', 'name': 'VBD mimics colloid cyst', 'teachingPoint': None, 'demographics': '73 Years old male'}, {'authors': [{'key': '5cff4116-3654-4b3a-bb75-5ebe0b8c9850', 'value': 'Anne G. Osborn, MD, FACR'}], 'caseVersionId': '70c8836e-137d-4411-a718-b1e9af2ba0ef', 'description': 'Axial T1WI MRs (#1-2), show a large, lobulated foramen of Monro mass. Axial T2WI MRs (#3-4), show a mixed signal mass with a focus of profound hypointensity ("black hole" effect), indicated by the arrow.', 'history': 'Middle-aged patient with headache and obstructive hydrocephalus. An unusually large, very viscous colloid cyst was found at surgery.', 'imagePoolId': '6ca864d5-f385-42e7-9567-195c94b07fb0', 'name': '"Black hole" effect', 'teachingPoint': 'The signal intensity of colloid cysts varies widely. If the proteinaceous contents become very desiccated and inspissated, the cyst can appear rather unusual, as is illustrated by this case.'}], 'caseType': 'variant', 'name': 'VARIANT'}
+
+
+## Images
+
+
+### Selected Images
+
+
.](images/app.statdx.com_image_thumbnail_2f62b7d5-328b-4884-ab8c-10826e13b41a_annotated_true_size_900_quality_90_92e3af1339cb029e5426cfb14273d3c54e9d71b4.jpg)
+*Axial graphic shows a classic colloid cyst (CC) at the foramen of Monro causing mild/moderate obstructive hydrocephalus. Note that the fornices and choroid plexus are elevated and stretched over the cyst .*
+
+
+*Axial graphic shows a classic colloid cyst (CC) at the foramen of Monro causing mild/moderate obstructive hydrocephalus. Note that the fornices and choroid plexus are elevated and stretched over the cyst .*
+
+
are draped over the cyst. (Courtesy R. Hewlett, MD.)](images/app.statdx.com_image_thumbnail_c8e5f2bd-38a9-491b-a512-951c39df96ee_annotated_true_size_900_quality_90_d0c29da7a32d30514e892824412410dda75cbaa9.jpg)
+*Axial gross pathology in a patient who suddenly and inexplicably died shows a large CC causing moderate obstructive hydrocephalus. A small cavum septi pellucidi is present. Fornices are draped over the cyst. (Courtesy R. Hewlett, MD.)*
+
+
+*Axial NECT obtained to look for a subarachnoid hemorrhage in a 65-year-old man with a thunderclap headache shows a classic CC, seen here as a hyperdense mass wedged into the foramen of Monro and upper 3rd ventricle.*
+
+
+*Sagittal T2WI MR in the same patient shows the mass to be very hypointense, indicating inspissated proteinaceous contents. Note the markedly enlarged lateral ventricle with a normal-sized 3rd ventricle. The CC was removed emergently.*
+
+
+*Axial T1WI MR in a 52-year-old man with headache, amnesia, and TIA-like symptoms shows a large, mildly hyperintense, well-delineated mass in the 3rd ventricle and foramen of Monro. Note the blood-fluid level in the dependent part of the mass.*
+
+
+*Axial T2WI MR in the same patient shows the mass is cystic and even more hyperintense than cerebrospinal fluid (CSF) in the adjacent ventricles. Note the blood-fluid level and splaying of the fornices around the mass.*
+
+
draped around the mass.](images/app.statdx.com_image_thumbnail_57303289-678c-4c0a-a4a7-607205deb9cf_annotated_true_size_900_quality_90_0d7d235d1755eebb0eed3503289cc42076317bdb.jpg)
+*Axial thin-section T2-space MR shows the fornices draped around the mass.*
+
+
+*Axial FLAIR MR shows the cyst is extremely hyperintense and does not suppress. Note hyperintensity in the fornices and adjacent corpus callosum genu , suggesting edema from acute inflammation.*
+
+
+*Axial T1 C+FS MR shows rim enhancement around the cyst wall.*
+
+
+*Coronal T1 C+ MR in the same patient shows the rim enhancement surrounds the entire cyst wall. Diagnosis of a CC with apoplexy, intracystic hemorrhage, and inflammatory changes was documented at surgery.*
+
+
+### Additional Images
+
+
+*Axial NECT in a 16-year-old boy who presented in the ER with severe headaches and papilledema shows severe obstructive hydrocephalus with dilated lateral ventricles and complete effacement of all superficial sulci. An isodense mass is present at the foramen of Monro.*
+
+
+*Axial FLAIR MR in the same patient shows the lesion to be very hyperintense and straddled by the fornix . Ventricles are dilated and transependymal CSF flow is present. The CC was removed at surgery.*
+
+
+*Axial T1WI MR shows a slightly hypointense CC . Note the pillars of fornix elevated and draped over cyst.*
+
+
+*Axial NECT shows a round, hyperdense foramen of Monro mass causing mild hydrocephalus. Note the fornices draped and splayed around the mass. This is a classic CC.*
+
+
+*Axial T2WI MR shows a CC at the foramen of Monro. The cyst is isointense with the brain and is causing moderate, but compensated, hydrocephalus.*
+
+
+*Axial FLAIR MR in the same patient shows that the cyst does not suppress and is hyperintense to brain. Note the absence of transependymal CSF flow around the atria of the lateral ventricle.*
+
+
+*Axial T1WI MR shows a large, lobulated foramen of Monro mass in a middle-aged patient with headache and obstructive hydrocephalus.*
+
+
+*Axial T2WI MR in the same case shows a mixed signal mass with a focus of profound hypointensity ("black hole" effect) . An unusually large, inspissated viscous colloid cyst was found at surgery.*
+
+
+*Axial T1WI MR shows a classic CC at the foramen of Monro. This patient had only mild headaches. Observation rather than surgical intervention was the chosen treatment.*
+
+
+*Axial T1WI MR in the same patient, obtained after the patient developed a sudden increase in headaches, shows marked interval enlargement of the mass. The CC now appears less hyperintense and hydrocephalus is present. The CC was removed at surgery.*
+
+
+*Sagittal T1WI MR shows a tiny CC discovered incidentally in this asymptomatic patient.*
+
+
+*Axial NECT in a 24-year-old man with severe headaches shows a hyperdense mass at the foramen of Monro. The superficial sulci are effaced and the brain appears "tight", suggesting moderate cerebral edema.*
+
+
+*Axial T1WI MR in the same patient shows the mass is slightly hyperintense compared to the brain.*
+
+
+*Axial T2WI MR in the same patient shows most of the cyst appears relatively isointense with gray matter, but exhibits a central hypointense focus that suggests inspissated colloid within the cyst.*
+
+
+*Coronal T2WI MR shows the central inspissated cyst as very hypointense. Note elevation and splaying of the fornices around the cyst.*
+
+
+*Axial T1 C+ SPGR MR for stereotaxic surgery shows enhancement around the lateral margins of the cyst. This represents displaced internal cerebral and septal veins, not rim enhancement. An inspissated CC was removed at surgery.*
+
diff --git a/docs_md/articles/cpa-iac-facial-nerve-schwannoma_9db01630-23a4-4f42-ad83-0ec399503495.md b/docs_md/articles/cpa-iac-facial-nerve-schwannoma_9db01630-23a4-4f42-ad83-0ec399503495.md
new file mode 100644
index 0000000..925b5ae
--- /dev/null
+++ b/docs_md/articles/cpa-iac-facial-nerve-schwannoma_9db01630-23a4-4f42-ad83-0ec399503495.md
@@ -0,0 +1,333 @@
+---
+title: "CPA-IAC Facial Nerve Schwannoma"
+docid: "9db01630-23a4-4f42-ad83-0ec399503495"
+authors:
+ - key: "07a2c087-6202-49e7-870b-7aa162d18f06"
+ value: "Bronwyn E. Hamilton, MD"
+ - key: "33151213-01b2-4542-9105-342e006b3915"
+ value: "H. Ric Harnsberger, MD"
+breadcrumbs:
+ -
+ name: "Head and Neck"
+ slug: "head-and-neck"
+ treeNodeId: "ed24ed8c-5d57-4629-879b-447b82d2973d"
+ -
+ name: "Diagnosis"
+ slug: "diagnosis"
+ treeNodeId: "19b6b986-97d0-40e7-b317-00f0c5cd8fa2"
+ -
+ name: "CPA-IAC"
+ slug: "cpa-iac"
+ treeNodeId: "6cacc6c2-d862-48ae-ac30-6a31c7b4b599"
+ -
+ name: "Benign and Malignant Tumors"
+ slug: "benign-and-malignant-tumors"
+ treeNodeId: "3b8b8a40-f05b-4a1b-b6af-962b3e856d1e"
+ -
+ name: "CPA-IAC Facial Nerve Schwannoma"
+ slug: "cpa-iac-facial-nerve-schwannoma"
+ treeNodeId: null
+category: "Head and Neck"
+cmeTopicId: "9edc9b6c-c92f-4baa-867f-4dd7db1bdc0a"
+documentVersionId: "7a17d454-a5ec-4929-9f7f-88b88a1b255d"
+imageCount: 11
+lastUpdated: "08/03/21"
+pageDescription: "CPA-IAC Facial Nerve Schwannoma"
+pageKeywords: "Head and Neck, Diagnosis, CPA-IAC, Benign and Malignant Tumors, CPA-IAC Facial Nerve Schwannoma"
+pageTitle: "CPA-IAC Facial Nerve Schwannoma | STATdx"
+enhancedTitle: "CPA-IAC Facial Nerve Schwannoma"
+type: "DX"
+references: true
+cases: 2
+breadcrumbs:
+ - "Head and Neck"
+ - "Diagnosis"
+ - "CPA-IAC"
+ - "Benign and Malignant Tumors"
+ - "CPA-IAC Facial Nerve Schwannoma"
+---
+# KEY FACTS
+
+- ## Terminology
+
+
+ - Facial nerve schwannoma (FNS): Rare, benign tumor of Schwann cells that surround CNVII in CPA-IAC ± labyrinthine CNVII
+- ## Imaging
+
+
+ - Temporal bone CT findings
+ - Smoothly widened facial canal without destruction
+ - MR findings
+ - T1 C+ MR: CPA-IAC-facial canal enhancing mass
+- ## Top Differential Diagnoses
+
+
+ - Bell palsy (herpetic facial paralysis)
+ - Vestibular schwannoma
+ - CPA-IAC meningioma
+- ## Pathology
+
+
+ - Tumor of Schwann cells lining CNVII, usually sporadic
+ - Neurofibromatosis type 2
+ - **Bilateral** CPA-IAC schwannomas
+ - May be of **vestibular** or **facial** nerve origin
+- ## Clinical Issues
+
+
+ - Clinical presentation
+ - Sensorineural hearing loss (SNHL) if CPA-IAC
+ - Facial nerve paralysis &/or conductive hearing loss if tympanic segment involved
+ - SNHL & facial nerve paralysis similar in frequency
+ - Treatment options
+ - Conservative management: Do nothing until CNVII paralysis present
+ - Surgical management: Used when CNVII paralysis + other symptoms evolving
+ - Debulking also effective
+ - Stereotactic radiosurgery
+ - Used for poor surgical candidates
+ - Recent use in small- to medium-sized FNS with CNVII function & hearing relatively preserved
+
+# TERMINOLOGY
+
+- ## Abbreviations
+
+
+ - Facial nerve schwannoma (FNS)
+- ## Synonyms
+
+
+ - Facial neuroma, facial neurilemmoma
+- ## Definitions
+
+
+ - FNS: Rare, benign tumor of Schwann cells that surround facial nerve in cerebellopontine angle (CPA)-internal auditory canal (IAC)
+
+# IMAGING
+
+- ## General Features
+
+
+ - ### Best diagnostic clue
+
+
+ - CPA-IAC mass + **tail in labyrinthine CNVII canal**
+ - ### Location
+
+
+ - CPA-IAC & labyrinthine segment of CNVII canal
+ - Geniculate ganglion & tympanic segments most commonly involved in temporal bone
+ - ### Size
+
+
+ - Wide range from millimeters to centimeters
+ - ### Morphology
+
+
+ - Large: CPA-IAC ice cream on cone shape with comma-shaped tail in labyrinthine segment CNVII
+ - Small: IAC mass curves into labyrinthine tail (may be in IAC CNVII only mimicking vestibular schwannoma)
+- ## CT Findings
+
+
+ - ### Bone CT
+
+
+ - ↑ size labyrinthine CNVII canal ± geniculate fossa
+ - Requires high-resolution temporal bone CT technique
+- ## MR Findings
+
+
+ - ### T1WI C+
+
+
+ - CPA-IAC-labyrinthine canal enhancing mass
+ - ± **intramural cystic change**
+ - CISS, FIESTA, T2 SPACE
+ - FNS CPA-IAC = low-signal mass displaces CSF signal
+- ## Imaging Recommendations
+
+
+ - ### Best imaging tool
+
+
+ - CNVII or CNVIII symptoms 1st study with T1 C+ FS MR
+ - Axial ≤ 3-mm T1 C+ MR; axial & coronal of CPA-IAC
+ - Bone CT: Smooth, scalloped widening of facial canal without destructive changes
+ - Coregistering 3D T1 C+ MR and temporal bone CT may improve diagnosis & surgical planning
+
+# DIFFERENTIAL DIAGNOSIS
+
+- [Bell Palsy (Herpetic Facial Paralysis)](/document/bell-palsy/0958e575-8f76-4d70-b806-0dbed9c62a67)
+ - T1 C+ MR: Prominent enhancement of intratemporal CNVII with IAC fundal tuft of enhancement
+- [Vestibular Schwannoma](/document/vestibular-schwannoma/48772166-59dc-4909-bc75-538de7dd9ddf)
+ - T1 C+ MR: CPA-IAC enhancing mass without labyrinthine canal tail or other facial canal involvement
+- [CPA-IAC Meningioma](/document/cpa-iac-meningioma/88301b77-f1c8-4efc-acf7-405999b42c3d)
+ - T1 C+ MR: Dural-based, eccentric CPA enhancing mass with dural tail projecting into IAC
+
+# PATHOLOGY
+
+- ## General Features
+
+
+ - ### Etiology
+
+
+ - Tumor of Schwann cells investing CNVII
+ - Most often sporadic
+ - ### Genetics
+
+
+ - Multiple schwannomas = neurofibromatosis 2 (NF2)
+ - ### Associated abnormalities
+
+
+ - **NF2:**Bilateral vestibular schwannoma; other CN schwannoma, meningiomas also seen
+- ## Gross Pathologic & Surgical Features
+
+
+ - Tan, ovoid-tubular, encapsulated mass
+ - From outer nerve sheath layer
+- ## Microscopic Features
+
+
+ - Encapsulated; bundles of spindle-shaped Schwann cells forming whorled pattern
+ - Cellular architecture: Densely cellular (**Antoni A**) areas ± loose, myxomatous (**Antoni B**) areas
+
+# CLINICAL ISSUES
+
+- ## Presentation
+
+
+ - ### Most common signs/symptoms
+
+
+ - Transient or persistent facial palsy is most common symptom, followed by hearing loss
+ - IAC or CPA FNS cause sensorineural hearing loss
+ - Tympanic segment FNS tend to cause facial palsy &/or conductive hearing loss
+ - Other symptoms: Vertigo, hemifacial spasm
+- ## Demographics
+
+
+ - ### Age
+
+
+ - Average age at presentation: ~ **50 years**
+ - Unless neurofibromatosis type 2 present; younger group
+ - ### Epidemiology
+
+
+ - Rare tumor (CPA-IAC > temporal bone > parotid)
+- ## Natural History & Prognosis
+
+
+ - CNVII paralysis takes years to develop
+ - Surgical cure can be worse than disease
+- ## Treatment
+
+
+ - Conservative: Do nothing until CNVII paralysis present
+ - Some do not grow; some never become symptomatic
+ - Surgery when CNVII paralysis + other symptoms evolving
+ - Goal: Complete tumor removal + preservation of hearing & restoration of CNVII function
+ - Debulking procedure is alternative approach
+ - Early indications: ↓ CNVII loss of function without significant recurrence rates
+ - Stereotactic radiosurgery
+ - Primary treatment for small- to medium-sized FNS when CNVII function & hearing relatively preserved
+
+# DIAGNOSTIC CHECKLIST
+
+- ## Consider
+
+
+ - Thin-section imaging shows labyrinthine tail
+- ## Image Interpretation Pearls
+
+
+ - CPA-IAC FNS exactly mimics vestibular schwannoma if no labyrinthine tail or temporal bone component present
+
+ dbd95a5f-de27-43f0-9e3c-646adfc859be
+
+## References
+
+# Selected References
+
+1. [Bartindale M et al: Facial schwannoma management outcomes: a systematic review of the literature. Otolaryngol Head Neck Surg. 163(2):293-301, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32228141%5Bpmid%5D)
+1. [Furukawa T et al: Facial nerve and chorda tympani schwannomas: case series, and advantages of using non-rigid registration of post-enhanced 3D-T1 Turbo Field Echo and CT images (TURFECT) in their diagnosis and surgical treatment. Auris Nasus Larynx. 47(3):383-90, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=31948824%5Bpmid%5D)
+1. [Gao W et al: Facial nerve meningioma: a case mimicking facial nerve schwannoma. Ear Nose Throat J. 145561320962582, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=33023341%5Bpmid%5D)
+1. [Lahlou G et al: Evolution of the management of sporadic facial nerve schwannomas: a series of 83 cases over three decades. Clin Otolaryngol. 45(4):595-9, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32198836%5Bpmid%5D)
+1. [Loos E et al: Intratemporal facial nerve schwannomas: multicenter experience of 80 cases. Eur Arch Otorhinolaryngol. 277(8):2209-17, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32279104%5Bpmid%5D)
+1. [Mehta GU et al: Effect of anatomic segment involvement on stereotactic radiosurgery for facial nerve schwannomas: an international multicenter cohort study. Neurosurgery. 88(1):E91-8, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32687577%5Bpmid%5D)
+1. [Rotter J et al: Surgery versus radiosurgery for facial nerve schwannoma: a systematic review and meta-analysis of facial nerve function, postoperative complications, and progression. J Neurosurg. 1-12, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=33126214%5Bpmid%5D)
+1. [Goel A et al: Subtemporal "interdural" surgical approach for "giant" facial nerve neurinomas. World Neurosurg. 110:e835-41, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=29191541%5Bpmid%5D)
+1. [Sah SK et al: Facial nerve schwannomas: a case series with an analysis of imaging findings. Neurol India. 66(1):139-43, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=29322973%5Bpmid%5D)
+1. [Li Y et al: A retrospective study on facial nerve schwannomas: a disease with a high risk of misdiagnosis and hearing loss. Eur Arch Otorhinolaryngol. 274(9):3359-66, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28687918%5Bpmid%5D)
+1. [Carlson ML et al: Facial nerve schwannomas: review of 80 cases over 25 years at Mayo Clinic. Mayo Clin Proc. 91(11):1563-76, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=27720200%5Bpmid%5D)
+1. [Mundada P et al: Imaging of facial nerve schwannomas: diagnostic pearls and potential pitfalls. Diagn Interv Radiol. 22(1):40-6, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=26712680%5Bpmid%5D)
+1. [Moon JH et al: Gamma Knife surgery for facial nerve schwannomas. J Neurosurg. 121 Suppl:116-22, 2014](http://www.ncbi.nlm.nih.gov/pubmed/?term=25434945%5Bpmid%5D)
+1. [McRackan TR et al: Facial nerve outcomes in facial nerve schwannomas. Otol Neurotol. 2012 Jan;33(1):78-82. Erratum in: Otol Neurotol. 33(3):472, 2012](http://www.ncbi.nlm.nih.gov/pubmed/?term=22143290%5Bpmid%5D)
+1. [Mowry S et al: Surgical management of internal auditory canal and cerebellopontine angle facial nerve schwannoma. Otol Neurotol. 33(6):1071-6, 2012](http://www.ncbi.nlm.nih.gov/pubmed/?term=22772011%5Bpmid%5D)
+1. [Chao WC et al: Facial nerve schwannoma. Otolaryngol Head Neck Surg. 141(1):146-7, 2009](http://www.ncbi.nlm.nih.gov/pubmed/?term=19559977%5Bpmid%5D)
+1. [Madhok R et al: Gamma knife radiosurgery for facial schwannomas. Neurosurgery. 64(6):1102-5; discussion 1105, 2009](http://www.ncbi.nlm.nih.gov/pubmed/?term=19487889%5Bpmid%5D)
+1. [Presutti L et al: Facial nerve schwannoma. Otol Neurotol. 30(5):683-5, 2009](http://www.ncbi.nlm.nih.gov/pubmed/?term=19628999%5Bpmid%5D)
+1. [Thompson AL et al: Magnetic resonance imaging of facial nerve schwannoma. Laryngoscope. 119(12):2428-36, 2009](http://www.ncbi.nlm.nih.gov/pubmed/?term=19780031%5Bpmid%5D)
+1. [Litré CF et al: Gamma knife surgery for facial nerve schwannomas. Prog Neurol Surg. 21:131-5, 2008](http://www.ncbi.nlm.nih.gov/pubmed/?term=18810210%5Bpmid%5D)
+1. [McMonagle B et al: Facial schwannoma: results of a large case series and review. J Laryngol Otol. 122(11):1139-50, 2008](http://www.ncbi.nlm.nih.gov/pubmed/?term=18177538%5Bpmid%5D)
+1. [Prasai A et al: A facial nerve schwannoma masquerading as a vestibular schwannoma. Ear Nose Throat J. 87(9):E4-6, 2008](http://www.ncbi.nlm.nih.gov/pubmed/?term=18800315%5Bpmid%5D)
+1. [Lee JD et al: Management of facial nerve schwannoma in patients with favorable facial function. Laryngoscope. 117(6):1063-8, 2007](http://www.ncbi.nlm.nih.gov/pubmed/?term=17464236%5Bpmid%5D)
+1. [Park HY et al: Intracanalicular facial nerve schwannoma. Otol Neurotol. 28(3):376-80, 2007](http://www.ncbi.nlm.nih.gov/pubmed/?term=17414044%5Bpmid%5D)
+1. [Wiggins RH 3rd et al: The many faces of facial nerve schwannoma. AJNR Am J Neuroradiol. 27(3):694-9, 2006](http://www.ncbi.nlm.nih.gov/pubmed/?term=16552018%5Bpmid%5D)
+1. [Kim JC et al: Facial nerve schwannoma. Ann Otol Rhinol Laryngol. 112(2):185-7, 2003](http://www.ncbi.nlm.nih.gov/pubmed/?term=12597294%5Bpmid%5D)
+1. [Liu R et al: Facial nerve schwannoma: surgical excision versus conservative management. Ann Otol Rhinol Laryngol. 110(11):1025-9, 2001](http://www.ncbi.nlm.nih.gov/pubmed/?term=11713912%5Bpmid%5D)
+1. [Salzman KL et al: Dumbbell schwannomas of the internal auditory canal. AJNR Am J Neuroradiol. 22(7):1368-76, 2001](http://www.ncbi.nlm.nih.gov/pubmed/?term=11498429%5Bpmid%5D)
+1. [Yokota N et al: Facial nerve schwannoma in the cerebellopontine cistern. Findings on high resolution CT and MR cisternography. Br J Neurosurg. 13(5):512-5, 1999](http://www.ncbi.nlm.nih.gov/pubmed/?term=10627787%5Bpmid%5D)
+1. [McMenomey SO et al: Facial nerve neuromas presenting as acoustic tumors. Am J Otol. 15(3):307-12, 1994](http://www.ncbi.nlm.nih.gov/pubmed/?term=8579133%5Bpmid%5D)
+
+## Cases
+
+- {'cases': [{'authors': [{'key': '6651ae1c-5f55-4d2e-9f68-46223037c90a', 'value': ' , '}], 'caseVersionId': 'f99106f0-6076-48ae-a670-6435e6de529e', 'description': 'Facial nerve schwannoma in fundus of IAC with subtle labyrinthine segment "tail" on high-resolution thin-section T2 MR images.\n\nAxial T2 images (#1-3) show a tissue-intensity ovoid mass in the fundus of the IAC (arrow). First impression is that of a fundal acoustic schwannoma. However, on images 2 & 3, the labyrinthine segment facial nerve "tail" (open arrow) suggests the correct diagnosis of facial nerve schwannoma. \n\nSagittal T2 MR images from medial to lateral (#4-7) show the tumor above the crista falciformis (curved arrow, #5 image), then extending out along the labyrinthine segment of the facial nerve (open arrows, images 6 & 7). \n\nComment: It is imperative that the radiologist look for a "labyrinthine tail" on all fundal acoustic schwannomas. A small percentage (< 1%) will be IAC facial nerve schwannomas and must be recognized in the pre-operative period.', 'history': 'Patient with 5 year history of mild right facial nerve paresis and moderate sensorineural hearing loss.', 'imagePoolId': '8ef26e9d-8d7f-4e7f-8cea-8a038945e9ab', 'name': 'Small, fundal', 'teachingPoint': None, 'demographics': '42 Years old female'}, {'authors': [{'key': '6651ae1c-5f55-4d2e-9f68-46223037c90a', 'value': ' , '}], 'caseVersionId': '1a7a64dc-b87e-4dd2-8874-860e979bb625', 'description': 'CPA-IAC facial nerve schwannoma extending to involve labyrinthine segment and geniculate ganglion of intratemporal facial nerve.\n\nAxial CECT (#1) shows a CPA enhancing mass (arrow) at first thought to represent acoustic schwannoma. After this exam a temporal bone CT was ordered because of history of mild facial nerve paresis. T-bone CT (#2) shows enlargement of labyrinthine segment of facial nerve and the geniculate fossa on the right (open arrow). In addition, the normal left labyrinthine segment of CN7 is seen (curved arrow). Coronal right T-bone CT (#3) reveals enlarged geniculate fossa (open arrow). Image #4 is included to show the size of the normal left labyrinthine segment (curved arrow).\n\nTwo unenhanced T1 axial MR images of the right CPA demonstrate the CPA component of the facial nerve schwannoma (arrow) with a labyrinthine "tail" (open arrow) arising from the medial IAC.\n\nComment: Acoustic schwannoma rarely causes facial nerve injury even when very large. For a lesion this size to cause facial nerve symptoms would be exceedingly rare. It is therefore recommended that if the history is that of combined sensorineural hearing loss and facial nerve symptoms, temporal bone CT be done to look for enlargement of the labyrinthine segment of the facial nerve canal. If enlarged, facial nerve schwannoma is present.', 'history': 'Patient with right sensorineural hearing loss with mild right facial nerve paresis.', 'imagePoolId': '4e830916-6460-4146-b578-32db31941850', 'name': 'Medium sized', 'teachingPoint': None, 'demographics': '46 Years old female'}, {'authors': [{'key': '33151213-01b2-4542-9105-342e006b3915', 'value': 'H. Ric Harnsberger, MD'}], 'caseVersionId': '5ac20a6d-9ea8-4bc9-b512-1247aa2a745f', 'description': 'CPA-IAC facial nerve schwannoma extending to involve the labyrinthine segment of the facial nerve.\n\nAxial and coronal temporal bone CT images (#1-3) show enlargement of the labyrinthine segment of the facial nerve canal (open arrow). Axial T2 MR image (#4) shows both the IAC component (arrow) and the labyrinthine "tail" (open arrow). Enhanced MR images (#5-10) show an enhancing CPA (curved arrow, #5-8) and IAC (arrow, #5-7,9) and labyrinthine (open arrow, #5-6) components of facial nerve schwannoma. At first glance, the diagnosis of acoustic schwannoma might be suggested. However, the enhancing labyrinthine "tail" (open arrow, #10) in combination with the temporal bone CT findings confirm this lesion is a facial nerve schwannoma.', 'history': 'Patient with right sensorineural hearing loss. No history of facial nerve symptoms.', 'imagePoolId': '6671db4c-ab72-41e1-8a3e-16661f34f757', 'name': 'Subtle labyrinthine "tail"', 'teachingPoint': None, 'demographics': '68 Years old female'}, {'authors': [{'key': '6651ae1c-5f55-4d2e-9f68-46223037c90a', 'value': ' , '}], 'caseVersionId': '767afd14-f12f-4ede-82db-2b50d0e38f3d', 'description': 'Small facial nerve schwannoma of the lateral IAC, labrynthine segment and geniculate ganglion portions of CN7.\n\nAxial & coronal T-bone CT images (#1-2) show enlargement of the labyrinthine segment of the facial nerve (open arrow) and the geniculate fossa (curved arrow). \n\nHigh-resolution thin-section T2 images (#3-6) reveal an obvious tissue intensity mass in the fundal IAC (arrow) with subtle involvement of the geniculate ganglion area (curved arrow). Enhanced T1 MR images (#7-9) demonstrate the fundal IAC (arrow), labyrinthine segment (open arrow) and geniculate gangion (curved arrow) involvement as enhancing tumor in these locations.', 'history': None, 'imagePoolId': '1021d087-adeb-4a52-8882-db9cca0ab4e0', 'name': 'Small', 'teachingPoint': None}, {'authors': [{'key': '6651ae1c-5f55-4d2e-9f68-46223037c90a', 'value': ' , '}], 'caseVersionId': 'bffa4469-28c4-4088-aca2-35f950bb189b', 'description': 'Intracanalicular facial nerve schwannoma with characteristic labyrinthine "tail".\n\nAxial and coronal temporal bone CT images (#1-2) shows a normal appearing IAC with enlargement of the labyrinthine segment of the facial nerve canal (open arrow). On the coronal CT image the anterior tympanic segment of the facial nerve canal is normal (curved arrow). \n\nAxial enhanced T1 MR images (#3-5) reveal enhancing tumor in the IAC with a classic enhancing labyrinthine "tail" of the facial nerve schwannoma. The nonenhancing tympanic segment of the facial nerve is evident laterally (curved arrow).', 'history': 'Patient with 3 year history of mild right facial nerve paresis and moderate sensorineural hearing loss.', 'imagePoolId': '65d1433d-e5da-4a0e-9122-cb72ef8e168b', 'name': 'Classic labyrinthine "tail"', 'teachingPoint': None, 'demographics': '52 Years old female'}, {'authors': [{'key': '6651ae1c-5f55-4d2e-9f68-46223037c90a', 'value': ' , '}], 'caseVersionId': '005c61f5-8dc1-43c0-8c48-091f2b8e24a3', 'description': 'IAC facial nerve schwannoma with subtle labyrinthine segment and geniculate ganglion extension.\n\nAxial & coronal T1 C+ MR images show an avidly enhancing right IAC mass (arrow). Careful evaluation of the right geniculate ganglion area (open arrow) shows asymmetric enlargement and enhancement. Putting the two findings together allows the radiologist to come to the correct diagnosis of facial nerve schwannoma, not acoustic schwannoma. Normal left tympanic segment facial nerve enhancement (curved arrow, image #2).', 'history': 'Patient with right sensorineural hearing loss with normal facial nerve function.', 'imagePoolId': '3b051617-5d16-4b98-bab8-0c5e957a57fd', 'name': 'Subtle labyrinthine "tail"', 'teachingPoint': None, 'demographics': '75 Years old male'}], 'caseType': 'typical', 'name': 'TYPICAL'}
+- {'cases': [{'authors': [{'key': '564b28bd-4dbe-4066-9201-d10d689688fb', 'value': 'Christine M. Glastonbury, MBBS'}], 'caseVersionId': '179a054d-1bdc-4d4e-8e7d-ebeb9c8204fb', 'description': 'Variant case of a facial nerve schwannoma with a large cisternal component.\n\nAxial T1 WI MR (#1) shows a large right CPA mass (arrows) which is slightly hypointense to adjacent deformed cerebellum and pons. Axial thin-slice T2 WI (#2-4) shows the predominantly solid mass (arrow) to be hyperintense to brain parenchyma. A subtle rim of T2 hyperintense CSF is evident on some slices (curved arrow) delineating this as an extra-axial mass, which can also be seen to fill the right IAC (open arrow, #3). Post-contrast T1 C+ FS (#5-9) shows heterogeneous enhancement of the mass (arrow, #5-8) and no evidence of a dural attachment. Note that the mass fills the right IAC (curved arrow, #6,8) but a second component is found in the right middle cranial fossa (open arrow, #7-9). Perfusion MR (#10) with curve #2 indicating the mass (arrow) and showing very little return to baseline in keeping with this extra-axial tumor.\n\nPearls: While the most common CPA mass is a vestibular schwannoma, it is very important to follow the entire course of the mass into the IAC and in this case along the labyrinthine segment of the facial nerve to the geniculate ganglion, confirming that it arises from the facial nerve and not the vestibular nerve.', 'history': 'This patient was being screened for dementia and a posterior fossa mass was incidentally discovered. Facial nerve function is normal, but there is mild SNHL on direct testing.', 'imagePoolId': '7f14b2ee-ba6b-4c14-a945-b2491210e9a8', 'name': 'Large cisternal component', 'teachingPoint': None, 'demographics': '53 Years old female'}, {'authors': [{'key': '6651ae1c-5f55-4d2e-9f68-46223037c90a', 'value': ' , '}], 'caseVersionId': 'd17cd720-6840-4992-a021-6c72679512f9', 'description': 'Variant case of very small facial nerve schwannoma arising from the anterosuperior fundal IAC and extending along the labyrinthine segment of the facial nerve.\n\nAxial temporal bone CT (#1) shows subtle enlargement of the labyrinthine segment of the facial nerve canal (open arrow). \n\nHigh-resolution thin-section T2 MR images (#2-5) show the body of the schwannoma (arrow) nestled above the crista falciformis (black horizontal line) in the fundus of the IAC. Axial & coronal T1 C+ MR images (#5-8) reveal the expected enhancement of the body of the tumor (arrow) and the labyrinthine segment of the facial nerve extension (open arrow).', 'history': None, 'imagePoolId': '802b8f78-cbf9-4489-8db6-8037ec7b551e', 'name': 'Very small', 'teachingPoint': None}, {'authors': [{'key': '6651ae1c-5f55-4d2e-9f68-46223037c90a', 'value': ' , '}], 'caseVersionId': '7dcbb102-c355-45e2-b4b0-fdddd14ba6e9', 'description': 'Variant case of extensive facial nerve schwannoma that extends from the CPA cistern, through the IAC to involve the geniculate ganglion.\n\nInitial screening high-resolution thin-section T2 MR images (#1-3) show tissue intensity mass extending from the CPA through the IAC (arrow) with a large component present in the geniculate fossa (open arrow). Coronal image 3 reveals multiple intramural cysts within the geniculate ganglion component of the tumor (curved arrows).\n\nAxial & coronal enhanced T1 MR images (#4-8) demonstrate the IAC (arrow) and geniculate ganglion (open arrow) involvement again. On coronal image 8 a prominent intramural cyst (curved arrow) is readily visible. \n\nComment: All schwannomas, no matter where they are found, have a tendency to form intramural cysts, especially when they become large. This case is unusual in that the lesion is quite large. CPA-IAC facial nerve schwannoma tend to be diagnosed earlier in their natural history when they are smaller because of the early associated symptom, sensorineural hearing loss.', 'history': 'Patient with left sensorineural hearing loss.', 'imagePoolId': 'bfe4a316-709a-40ba-8222-382778587730', 'name': 'Large geniculate ganglion component', 'teachingPoint': None, 'demographics': '55 Years old female'}, {'authors': [{'key': '6651ae1c-5f55-4d2e-9f68-46223037c90a', 'value': ' , '}], 'caseVersionId': 'f0332a14-c716-4406-9b48-a56542bf8776', 'description': 'CPA-IAC facial nerve schwannoma with extension to geniculate ganglion and an associated large arachnoid cyst.\n\nAxial and coronal temporal bone CT images show an enlarged labyrinthine segment and geniculate fossa (open arrow) with erosion into the roof of the cochlea (arrow). These CT images signal the presence of a facial nerve schwannoma that has dehisced into the inner ear but they do not fully define the tumors full extent.\n\nAxial T2 (#7) and FLAIR (#8) images show a CPA-IAC tumor with a large associated arachnoid cyst (curved arrow). Both images show abnormal signal in the cochlear aspect of the membranous labyrinth (arrow). Enhanced axial & coronal T1 MR images (#9-14) show the extension of the tumor to involve the geniculate ganglion (open arrow, images 9 & 14) as well as the dehisced tumor inside the cochlea itself (arrow, image 10). \n\nComment: CPA arachnoid cyst, so called "herald cyst" is seen associated with acoustic schwannoma in < 1% of cases. This case is a rare CPA-IAC facial nerve schwannoma with an associated arachnoid cyst. It is possible to make the diagnosis of facial nerve schwannoma based on the labyrinthine facial nerve segment and geniculate ganglion involvement. The dehiscence into the cochlear membranous labyrinth complicates the radiologic appearance.', 'history': 'Patient with long history of progressive right facial nerve paralysis with recent development of profound right sensorineural hearing loss. ', 'imagePoolId': 'c85cef6f-2d98-4cdb-b5e2-1edc24828796', 'name': 'Large, with arachnoid cyst', 'teachingPoint': None, 'demographics': '56 Years old male'}, {'authors': [{'key': '624acd80-0502-4325-be71-e68fec740eb3', 'value': 'Richard H. Wiggins, III, MD, CIIP, FSIIM, FAHSE, FACR'}], 'caseVersionId': '7448f119-03e6-4d5b-8d2b-24f8f38d50a3', 'description': 'This is a rare variant case of facial nerve schwannoma found in the CPA cistern only without significant IAC or labyrinthine segment CNVII involvement.\n\nThe axial precontrasted T1 images (#1-2) show the lesion within the right CPA (arrow) as an extraaxial lesion with homogeneous signal intensity higher than CSF, and lower than adjacent cerebellar tissue.\n\nThe axial T2-weighted image (#3) show the heterogeneous T2 signal intensity of the lesion (arrow), and the axial FLAIR image (#4) shows signal intensity slightly higher than that of the adjacent cerebellar tissue. Both the T2 and FLAIR images show no significant abnormal signal intensity within the brain parenchyma.\n\nThe coronal T2-weighted images (#5-6) show the heterogeneous nature of this extraaxial lesion (arrow) with internal signal intensity similar to that of CSF.\n\nThe axial T1 postcontrasted images (#7-8) show the avid peripheral enhancement of the lesion (arrow) and the small bulbous portion of enhancing tissue extending into the right porous acusticus (open arrow).\n\nThe coronal T1 postcontrasted images (#9-10) confirm the avid peripheral enhancement of the mass (arrow) and the small bulbous portion extending into the opening of the internal auditory canal (IAC) (open arrow). There is no enhancement seen along the segments of the facial nerve within the temporal bone.', 'history': 'Patient presented with longstanding tinnitus and progressive hearing loss in the right ear. ', 'imagePoolId': '7e2f01f0-c80e-4873-86cf-c10df6b0d29a', 'name': 'CPA only', 'teachingPoint': 'At the time of surgery, the tumor was found to arise from the facial nerve in the CPA cistern.', 'demographics': '53 Years old male'}, {'authors': [{'key': '6651ae1c-5f55-4d2e-9f68-46223037c90a', 'value': ' , '}], 'caseVersionId': '7659adca-53a4-40af-b48b-a49da8a2cb2a', 'description': 'Variant case of facial nerve schwannoma with a large CPA component combined with a very thin labyrinthine segment isthmus and re-emergence of the tumor in the geniculate fossa.\n\nAxial temporal bone CT images (#1-2) show a normal proximal labyrinthine segment of the facial nerve canal (open arrow) with an obvious enlarged geniculate fossa (curved arrow). Flaring of the porus acusticus is evident.\n\nT1 C+ MR (#3-4) and enhanced SPGR (#4-6) axial images show a remarkably large CPA component of the tumor (arrow) as well as obvious IAC involvement. The labyrinthine segment of the facial nerve enhances but is not enlarged (open arrow). Tumor in the enlarged geniculate fossa is easily seen (curved arrow). \n\nComment: This case is considered variant both for the disproportionate size of the CPA component and the very thin isthmus of tumor between the fundal IAC tumor and the geniculate fossa component.', 'history': 'Patient with mild left facial palsy along with mild sensorineural hearing loss.', 'imagePoolId': 'e626bc08-ffc2-4096-9d2e-2f38c1706ae1', 'name': 'Large CPA component', 'teachingPoint': None, 'demographics': '40 Years old female'}], 'caseType': 'variant', 'name': 'VARIANT'}
+
+
+## Images
+
+
+### Selected Images
+
+
+*Axial graphic of a larger facial nerve schwannoma (FNS) shows cerebellopontine angle (CPA) ("ice cream") & internal auditory canal (IAC) ("cone") components that mimic a vestibular schwannoma. The labyrinthine segment of facial nerve involvement makes the diagnosis.*
+
+
+*Axial graphic of a larger facial nerve schwannoma (FNS) shows cerebellopontine angle (CPA) ("ice cream") & internal auditory canal (IAC) ("cone") components that mimic a vestibular schwannoma. The labyrinthine segment of facial nerve involvement makes the diagnosis.*
+
+
+*Axial T1 C+ FS MR in a patient with unilateral sensorineural hearing loss shows FNS with CPA & IAC components. Note the labyrinthine segment facial nerve tail , which differentiates FNS from vestibular schwannoma.*
+
+
+*Axial T1 C+ FS MR shows enhancement of a large schwannoma expanding the geniculate fossa . The geniculate ganglion is the most common area involved. Correlating with smooth, bony expansile changes on CT is helpful to confirm diagnosis.*
+
+
+*Axial T1 C+ FS MR shows an enhancing schwannoma involving the CPA-IAC & anterior genu of the facial nerve . This patient with NF2 has a large trigeminal schwannoma partly seen. A contralateral IAC schwannoma was also present (not shown).*
+
+
+### Additional Images
+
+
+*Axial bone CT reveals smooth scalloped enlargement of the labyrinthine segment of the facial nerve canal and geniculate fossa in a patient with facial nerve schwannoma of CPA-IAC. Notice there is erosion into subjacent cochlea.*
+
+
+*Axial T1WI C+ MR in the same patient shows facial nerve schwannoma with associated large arachnoid cyst . Notice the labyrinthine facial nerve schwannoma tail .*
+
+
+*Axial C+ T1 FS MR in a patient with neurofibromatosis type 2 reveals bilateral enhancing vestibular schwannomas in the IACs. Careful inspection shows the left IAC has a smaller, anterior facial nerve schwannoma in addition. Notice also the left Meckel cave trigeminal schwannoma .*
+
+
+*Magnified axial C+ FS T1 MR in a patient with neurofibromatosis type 2 demonstrates both an anterior facial nerve schwannoma and a posterior superior vestibular schwannoma in the left IAC fundus. Notice also the left Meckel cave trigeminal schwannoma .*
+
+
+*Low-powered H&N micrograph shows the hypocellular appearance of spindled cells associated with a myxoid and edematous Antoni B area , adjacent to an Antoni A cellular area that is more hypercellular with a whorled pattern .*
+
+
+*Axial T1 C+ FS MR in a patient with left facial nerve paralysis shows expansile enhancement of the tympanic segment of facial nerve , consistent with schwannoma.*
+
+
+*Axial bone CT in the same patient shows localized expansion of the tympanic segment of facial nerve due to schwannoma , where tumor appears to erode the short process of incus. Tympanic segment schwannomas more often cause facial nerve paralysis &/or conductive hearing loss.*
+
diff --git a/docs_md/articles/defect-in-abdominal-wall-hernia_5af046fa-59ef-45b5-952b-acbcdee36196.md b/docs_md/articles/defect-in-abdominal-wall-hernia_5af046fa-59ef-45b5-952b-acbcdee36196.md
new file mode 100644
index 0000000..8162324
--- /dev/null
+++ b/docs_md/articles/defect-in-abdominal-wall-hernia_5af046fa-59ef-45b5-952b-acbcdee36196.md
@@ -0,0 +1,228 @@
+---
+title: "Defect in Abdominal Wall (Hernia)"
+docid: "5af046fa-59ef-45b5-952b-acbcdee36196"
+authors:
+ - key: "c1df94ab-4a9f-44c4-add7-1f174fb9ac45"
+ value: "Siva P. Raman, MD"
+breadcrumbs:
+ -
+ name: "Gastrointestinal"
+ slug: "gastrointestinal"
+ treeNodeId: "b52263f7-5978-4a22-a17d-7260e0033943"
+ -
+ name: "Differential Diagnosis"
+ slug: "differential-diagnosis"
+ treeNodeId: "a0fd80ff-6231-49d3-94b8-ea083449979d"
+ -
+ name: "Abdominal Wall"
+ slug: "abdominal-wall"
+ treeNodeId: "08db01f7-2961-47f7-954d-2a5fca7e707d"
+ -
+ name: "Anatomically Based Differentials"
+ slug: "anatomically-based-differentials"
+ treeNodeId: "1525b44f-9d47-4ff4-8330-693211bd5eb5"
+ -
+ name: "Defect in Abdominal Wall (Hernia)"
+ slug: "defect-in-abdominal-wall-hernia"
+ treeNodeId: null
+category: "Gastrointestinal"
+documentVersionId: "284df942-e3e0-4957-8c3b-8b7855e23af9"
+imageCount: 16
+lastUpdated: "07/01/22"
+pageDescription: "Defect in Abdominal Wall (Hernia)"
+pageKeywords: "Gastrointestinal, Differential Diagnosis, Abdominal Wall, Anatomically Based Differentials, Defect in Abdominal Wall (Hernia)"
+pageTitle: "Defect in Abdominal Wall (Hernia) | STATdx"
+enhancedTitle: "Defect in Abdominal Wall (Hernia)"
+type: "DDX"
+references: true
+breadcrumbs:
+ - "Gastrointestinal"
+ - "Differential Diagnosis"
+ - "Abdominal Wall"
+ - "Anatomically Based Differentials"
+ - "Defect in Abdominal Wall (Hernia)"
+---
+# ESSENTIAL INFORMATION
+
+- ## Key Differential Diagnosis Issues
+
+
+ - CT is most accurate imaging modality for diagnosis of hernias and associated complications
+ - US can be helpful for determining reducibility of hernias, as well as diagnosis of hernias, which are transiently reducible
+ - Offers advantage of scanning patient in upright position or with Valsalva maneuver to elicit hernia
+ - Efficacy of US for hernias is debatable in literature, and CT should certainly be 1st-line modality in patients with acute presentation or concerns for hernia-related complications
+ - US should be reserved for nonurgent presentation in outpatient setting
+ - Evaluate any hernia for presence of complications, including bowel involvement, obstruction, and ischemia
+ - Different types of hernias are associated with very different risks of complications
+ - Descriptive terms used to describe abdominal wall hernias
+ - **Interparietal** (i.e., interstitial) hernia: Hernia sac is located in fascial planes between abdominal wall muscles without entering subcutaneous soft tissues
+ - **Richter** hernia: Entirety of bowel circumference does not herniate (just antimesenteric border of bowel)
+- ## Helpful Clues for Common Diagnoses
+
+
+ - **Inguinal Hernia**
+ - Most common type of external hernia (~ 80%) with indirect hernias typically congenital (due to weakness of processus vaginalis), and direct hernias usually acquired due to abdominal wall weakness
+ - Hernia seen in groin region anterior to horizontal plane of pubic tubercle
+ - Do not result in compression of femoral vessels (unlike femoral hernia)
+ - **Direct** hernias: Hernia sac arises anteromedial to inferior epigastric vessels
+ - **Indirect** hernia: Hernia sac arises superomedial to inferior epigastric vessels
+ - 5x more common than direct hernias
+ - Complications more common with indirect hernias
+ - **Femoral Hernia**
+ - Most commonly seen in older female patients (especially > 80 years) but much less common than inguinal hernias
+ - Hernia extends into femoral canal medial to femoral vein and inferior to inferior epigastric vessels with frequent compression of femoral vein
+ - Hernia sac located posterior and lateral to pubic tubercle
+ - Very high risk of complications (incarceration, strangulation) and mortality compared to inguinal hernias
+ - **Ventral Hernia**
+ - General term encompassing hernias extending through anterior and lateral abdominal wall
+ - Can be acquired or congenital
+ - **Epigastric** hernias occur at midline through linea alba above umbilicus, while **hypogastric** hernias occur at midline below umbilicus
+ - **Incisional** hernias occur through any prior surgical incision site
+ - Most often occur within a few months (usually first 4 months) of surgery but can occur at later time points as well
+ - **Parastomal hernias**(considered type of incisional hernia) are quite common adjacent to ileostomy or colostomy
+ - Parastomal hernias tend to slowly develop and enlarge over time and are very common with end-colostomies (48%) and end-ileostomies (28%) but much less common with loop ileostomies (6%)
+ - Even if asymptomatic, most ventral hernias get larger over time with increasing risk of complications, making surgical treatment advisable
+ - **Spigelian Hernia**
+ - Hernia extending through defect in aponeurosis of internal oblique and transverse abdominal muscles
+ - Arise along lateral margin of rectus abdominis muscles, at level of arcuate line, inferior and lateral to umbilicus
+ - Usually congenital in children and acquired in adults (prior surgery, obesity, pregnancies, etc. are risk factors)
+ - High risk of strangulation and incarceration
+ - **Lumbar Hernia**
+ - Hernia extends through defect in lumbar muscle or thoracolumbar fascia (usually below 12th rib and above iliac crest)
+ - Can herniate through superior (Grynfeltt-Lesshaft) or inferior (petit) lumbar triangles
+ - Most (80%) are acquired, usually due to surgical incisions (especially renal surgery)
+ - Complications uncommon due to typically large neck, which makes incarceration/strangulation uncommon
+ - **Umbilical Hernia**
+ - Hernia at midline extends through umbilical ring (usually upper 1/2 of umbilicus)
+ - Can be congenital (diagnosed in infancy) or acquired (usually in middle age)
+ - Congenital type 8x more common in Black patients but most resolve spontaneously by 4-6 years of age
+ - Acquired hernias associated with obesity, multiparity, and ascites
+ - Very common and usually small/asymptomatic, but larger or symptomatic hernias may require repair
+ - **Subcutaneous Abdominal Wall Mass (Mimic)**
+ - Any subcutaneous or intramuscular mass may be superficially mistaken for hernia on clinical examination, although distinction should be obvious on imaging
+ - Consider inguinal lymphadenopathy, abdominal wall tumors, cryptorchidism (especially in children), abscess, hydrocele, varicocele, or hematoma as entities that may be mistaken for hernia on physical examination
+ - **Enterocutaneous Fistula (Mimic)**
+ - Gas- or contrast-filled tract from intraabdominal bowel loop into anterior abdominal wall may be confused for hernia
+ - Bowel loops often tethered to anterior abdominal wall at site of fistula
+ - Careful examination illustrates lack of true abdominal wall defect
+- ## Helpful Clues for Less Common Diagnoses
+
+
+ - **Obturator Hernia**
+ - Rare type of hernia extending through obturator foramen into superolateral obturator canal
+ - Usually involves loop of ileum but can involve any pelvic viscera
+ - Typically seen in older female patients (especially older or multiparous females) secondary to either pelvic floor defect or pelvic floor laxity
+ - High risk of complications (incarceration, strangulation) and mortality
+ - **Traumatic Abdominal Wall Hernia**
+ - Hernia in anterior abdominal wall developing at site of focal trauma
+ - Majority occur in lower abdomen with iliac crest region very common due to seat belt injuries
+ - Most commonly seen in young children < 10 years due to bicycle injury (e.g., handlebar hernia) but can also be seen in adults after high-energy trauma (e.g., motor vehicle collisions)
+ - **Sciatic Hernia**
+ - Very uncommon hernia involving herniation of bowel loop through greater sciatic foramen laterally into subgluteal region
+ - Occurs most often in female patients, likely as result of piriformis muscle atrophy
+ - Can result in symptoms of sciatica as result of compression of sciatic nerve
+ - **Perineal Hernia**
+ - Uncommon hernia with hernia sac extending anteriorly through urogenital diaphragm (most common) or posteriorly between levator ani and coccygeus muscles
+ - Usually diagnosed in older women (> 50 years of age) with history of prior surgery in deep pelvis/perineum, prior pregnancies, obesity, or ascites
+ - **Spermatic Cord Lipoma or Liposarcoma (Mimic)**
+ - Uncommon fat-containing mass arising in spermatic cord, which can extend into scrotum inferiorly or inguinal canal/retroperitoneum superiorly
+ - When extending into inguinal canal, can mimic inguinal hernia, but lesion typically appears expansile and mass-like
+ - Liposarcomas will often demonstrate internal complexity (or even soft tissue component) depending on degree of dedifferentiation
+ - Well-differentiated liposarcomas may appear largely fat attenuation and are more apt to be confused for inguinal hernia containing omental fat
+ - Usually appear hyperechoic on US (particularly when well differentiated) with similar echogenicity to subcutaneous fat
+
+## References
+
+# Selected References
+
+1. [Aly M et al: Should surgeons repair symptomatic, clinically occult, radiologically evident, inguinal hernias? A case-control study of patient-reported outcomes. Hernia. 25(5):1209-13, 2021](http://www.ncbi.nlm.nih.gov/pubmed/?term=33428011%5Bpmid%5D)
+1. [Fezoulidi G et al: Amyand's hernia: presumptive diagnosis by CT and literature review. Radiol Case Rep. 16(4):911-5, 2021](http://www.ncbi.nlm.nih.gov/pubmed/?term=33613803%5Bpmid%5D)
+1. [Ng M et al: Paratesticular liposarcoma: a rare cause of scrotal lump. BMJ Case Rep. 14(2):e240008, 2021](http://www.ncbi.nlm.nih.gov/pubmed/?term=33568414%5Bpmid%5D)
+1. [Steenburg SD et al: Traumatic abdominal wall injuries-a primer for radiologists. Emerg Radiol. 28(2):361-71, 2021](http://www.ncbi.nlm.nih.gov/pubmed/?term=32827286%5Bpmid%5D)
+1. [Kim AG et al: Inguinal and other hernias. Adv Pediatr. 67:131-43, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32591057%5Bpmid%5D)
+1. [Park J: Obturator hernia: clinical analysis of 11 patients and review of the literature. Medicine (Baltimore). 99(34):e21701, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32846788%5Bpmid%5D)
+1. [Keenan RA et al: Paratesticular sarcomas: a case series and literature review. Ther Adv Urol. 11:1756287218818029, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=30671140%5Bpmid%5D)
+1. [Mnari W et al: Strangulated obturator hernia: a case report with literature review. Pan Afr Med J. 32:144, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=31303916%5Bpmid%5D)
+1. [Tonolini M: A closer look at the stoma: multimodal imaging of patients with ileostomies and colostomies. Insights Imaging. 10(1):41, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=30927144%5Bpmid%5D)
+1. [Park HR et al: Sonographic evaluation of inguinal lesions. Clin Imaging. 40(5):949-55, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=27209238%5Bpmid%5D)
+1. [Stensby JD et al: Athletic injuries of the lateral abdominal wall: review of anatomy and MR imaging appearance. Skeletal Radiol. 45(2):155-62, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=26450606%5Bpmid%5D)
+1. [Valeshabad AK et al: An important mimic of inguinal hernia. Urology. 97:e11, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=27502033%5Bpmid%5D)
+1. [Burkhardt JH et al: Diagnosis of inguinal region hernias with axial CT: the lateral crescent sign and other key findings. Radiographics. 31(2):E1-12, 2011](http://www.ncbi.nlm.nih.gov/pubmed/?term=21415178%5Bpmid%5D)
+
+
+## Images
+
+
+### Selected Images
+
+
+**Inguinal Hernia**
+*Axial CECT shows a large right inguinal hernia containing multiple loops of small bowel without evidence of obstruction. Inguinal hernias account for the vast majority of external hernias.*
+
+
+**Inguinal Hernia**
+*Axial CECT shows a large right inguinal hernia containing multiple loops of small bowel without evidence of obstruction. Inguinal hernias account for the vast majority of external hernias.*
+
+
+**Inguinal Hernia**
+*Coronal NECT shows a classic right inguinal hernia containing loops of small bowel without evidence of obstruction.*
+
+
+**Femoral Hernia**
+*Axial CECT shows a herniated bowel loop in the left groin. Note the close relationship of the hernia to the femoral vessels at the level of the symphysis pubis, characteristic of a femoral hernia.*
+
+
+**Ventral Hernia**
+*Sagittal volume-rendered CECT shows a ventral hernia containing loops of small bowel . The small bowel proximal to the hernia sac is dilated , compatible with small bowel obstruction.*
+
+
+**Ventral Hernia**
+*Axial CECT in a patient with a history of prior thoracic surgery shows a fat-containing ventral hernia arising in the upper abdomen. Ventral hernias occurring above the umbilicus, as in this case, are termed epigastric hernias.*
+
+
+**Spigelian Hernia**
+*Axial CECT shows a left abdominal spigelian hernia with multiple dilated loops of small bowel , compatible with small bowel obstruction.*
+
+
+**Lumbar Hernia**
+*Axial NECT shows a large lumbar hernia in the right flank containing a portion of the right kidney .*
+
+
+**Lumbar Hernia**
+*Coronal CECT shows a large lumbar hernia containing colon , small bowel , as well as a portion of the right hepatic lobe . Lumbar hernias are often secondary to prior surgical incisions and are particularly common after renal surgeries.*
+
+
+**Umbilical Hernia**
+*Sagittal CECT shows an umbilical hernia containing ascites in a patient with cirrhosis and portal hypertension.*
+
+
+**Enterocutaneous Fistula (Mimic)**
+*Axial CECT shows an enterocutaneous fistula with enteric contrast directly extending from the small bowel into the anterior abdominal wall .*
+
+
+**Obturator Hernia**
+*Axial CECT shows a loop of small bowel lying between the obturator externus and pectineus muscles, compatible with an obturator hernia.*
+
+
+**Traumatic Abdominal Wall Hernia**
+*Axial CECT in a trauma patient shows disruption of the musculofascial plane near the insertion into the iliac crest and thoracolumbar fascia. Note the presence of adjacent subcutaneous hematoma. The spleen was also lacerated (not shown). These findings are compatible with a traumatic hernia.*
+
+
+**Spermatic Cord Lipoma or Liposarcoma (Mimic)**
+*Axial T1 MR shows a large mass with fat signal extending through the inguinal canal into the left scrotum. This was found to be a spermatic cord liposarcoma at resection.*
+
+
+**Spermatic Cord Lipoma or Liposarcoma (Mimic)**
+*Sagittal US in the same patient shows that the mass is very echogenic as a result of its fatty component, a fairly common appearance for these lesions, and extends down to just above the testicle .*
+
+
+### Additional Images
+
+
+**Subcutaneous Abscess (Mimic)**
+*Axial CECT shows a loculated fluid collection in the subcutaneous tissue adjacent to the site of incisional hernia repair (abdominal wall abscess).*
+
+
+**Soft Tissue Neoplasm (Mimic)**
+*Axial CECT shows a partly calcified mass in the abdominal wall adjacent to a descending colostomy (metastatic colonic carcinoma).*
+
diff --git a/docs_md/articles/desmoid_f0ca3968-a2f3-4f1d-8825-44819a047224.md b/docs_md/articles/desmoid_f0ca3968-a2f3-4f1d-8825-44819a047224.md
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@@ -0,0 +1,451 @@
+---
+title: "Desmoid"
+docid: "f0ca3968-a2f3-4f1d-8825-44819a047224"
+authors:
+ - key: "c1df94ab-4a9f-44c4-add7-1f174fb9ac45"
+ value: "Siva P. Raman, MD"
+breadcrumbs:
+ -
+ name: "Gastrointestinal"
+ slug: "gastrointestinal"
+ treeNodeId: "b52263f7-5978-4a22-a17d-7260e0033943"
+ -
+ name: "Diagnosis"
+ slug: "diagnosis"
+ treeNodeId: "5a7c51af-b1c6-4629-8f0e-d99e6fe57a98"
+ -
+ name: "Peritoneum, Mesentery, and Abdominal Wall"
+ slug: "peritoneum-mesentery-and-abdominal-"
+ treeNodeId: "a3fb9f00-f894-4b38-9e01-2f78406cf547"
+ -
+ name: "Benign Neoplasms"
+ slug: "benign-neoplasms"
+ treeNodeId: "6e8371e6-baeb-49ad-b087-cf827ae9f3a0"
+ -
+ name: "Desmoid"
+ slug: "desmoid"
+ treeNodeId: null
+category: "Gastrointestinal"
+documentVersionId: "816f437b-64d7-47e7-b5de-186fedf4daf6"
+imageCount: 32
+lastUpdated: "06/11/25"
+pageDescription: "Desmoid"
+pageKeywords: "Gastrointestinal, Diagnosis, Peritoneum, Mesentery, and Abdominal Wall, Benign Neoplasms, Desmoid"
+pageTitle: "Desmoid | STATdx"
+enhancedTitle: "Desmoid"
+type: "DX"
+references: true
+breadcrumbs:
+ - "Gastrointestinal"
+ - "Diagnosis"
+ - "Peritoneum, Mesentery, and Abdominal Wall"
+ - "Benign Neoplasms"
+ - "Desmoid"
+---
+# KEY FACTS
+
+- ## Terminology
+
+
+ - Rare, benign, locally aggressive, nonencapsulated mesenchymal neoplasms of connective or fibrous tissue
+- ## Imaging
+
+
+ - Can be intraabdominal (particularly small bowel mesentery) or extraabdominal (including abdominal wall)
+ - When involving abdominal wall, often involve rectus or oblique muscles, frequently at incision sites
+ - Usually solid with well-defined margins, but can also be infiltrative in appearance
+ - Classically thought to be low signal on all MR pulse sequences due to fibrous content, but this is unreliable
+ - Usually hyperdense to muscle on NECT and hypoenhancing on CECT (but rarely avidly enhancing)
+- ## Pathology
+
+
+ - Strong associations with Gardner syndrome and familial adenomatous polyposis (FAP)
+ - Other major risk factors include previous abdominal surgery (75% of cases), trauma, pregnancy, or oral contraceptives
+- ## Clinical Issues
+
+
+ - Complications arise from locally aggressive growth with involvement of adjacent structures, such as small bowel obstruction, ureteral obstruction, bladder outlet obstruction, hydrosalpinx, etc.
+ - Surgical resection was once mainstay of treatment, but this has now become increasingly controversial due to morbidity and mortality of resection, as well as high risk of recurrence (even in setting of R0 resection)
+ - Active surveillance now mainstay of treatment whenever possible (particularly when lesions are small and asymptomatic), as many lesions remain stable or even spontaneously regress
+ - Conservative management with variety of pharmacologic agents and radiation treatment increasingly utilized even for symptomatic lesions
+
+# TERMINOLOGY
+
+- ## Synonyms
+
+
+ - Deep or aggressive fibromatosis
+- ## Definitions
+
+
+ - Rare, benign, locally aggressive, nonencapsulated mesenchymal neoplasms of connective or fibrous tissue
+
+# IMAGING
+
+- ## General Features
+
+
+ - ### Best diagnostic clue
+
+
+ - Small bowel mesentery or abdominal wall mass arising at site of scarring from prior surgery
+ - ### Location
+
+
+ - Can be intraabdominal or extraabdominal (including abdominal wall)
+ - **Abdominal desmoids**
+ - Account for 2/3 of all desmoid tumors
+ - Tumors associated with Gardner syndrome or familial adenomatous polyposis (FAP) are usually intraabdominal
+ - Most commonly occur in small bowel mesentery but can occur nearly anywhere
+ - **Extraabdominal**
+ - Pregnancy-related desmoid tumors tend to occur within abdominal wall
+ - 1/3 occur in shoulder and upper extremity
+ - ~ 20% in chest wall, ~ 10% in head and neck
+ - Musculature most often involved: Rectus, internal/external oblique, psoas, pelvic (rare)
+ - ### Morphology
+
+
+ - Most often demonstrate clear, lobulated margins on imaging (75%), but minority of cases can appear ill defined and infiltrative (25%)
+ - **Key concepts**
+ - Locally aggressive primary mesenchymal tumor
+ - Sometimes classified as low-grade fibrosarcoma or subgroup of fibromatosis
+ - Tend to arise in musculoaponeurotic planes
+ - Tend to invade locally, recur after treatment, and grow very rapidly, especially in Gardner syndrome
+ - May involve bowel loops, bladder, ribs, pelvic bones, and virtually any other structure
+ - Lesions are locally aggressive and cause morbidity/mortality primarily due to local invasion, but **do not metastasize**
+ - Desmoids can be solitary or multiple (15% of cases)
+ - Etiology
+ - Most cases are sporadic
+ - 75% of patients with desmoid tumors have had prior abdominal surgery
+ - May be associated with Gardner syndrome and FAP, which can be characterized by a number of abnormalities
+ - Familial polyposis coli, osteomas, dental defects, congenital pigmented lesions of retina
+ - Epidermoid (sebaceous) cyst and fibromas of skin
+ - Periampullary, adrenal, thyroid, and liver malignancies
+ - 18-20% of patients with Gardner syndrome develop desmoids and desmoids account for 45% of fibrous lesions in Gardner syndrome
+- ## CT Findings
+
+
+ - **Abdominal wall desmoids**
+ - Usually solid with well-defined margins (but can be infiltrative in appearance)
+ - Usually hyperdense compared to surrounding muscle on NECT
+ - Usually hypoenhancing on CECT, but can in some cases be quite avidly enhancing
+ - Often involve rectus or oblique muscles and occur frequently at incision sites
+ - **Mesenteric desmoids**
+ - Soft tissue mass with well-defined or ill-defined margins
+ - Hyperdense relative to muscle on NECT with variable, heterogeneous enhancement on CECT
+ - Whorled appearance: Radiating fibrotic strands into adjacent mesenteric fat
+ - May displace, retract, or compress adjacent bowel loops and potentially cause small bowel obstruction
+ - Can infiltrate into adjacent organs and musculature
+ - Calcification very uncommon
+- ## MR Findings
+
+
+ - Can be poorly marginated or very well circumscribed
+ - Often will cross fascial boundaries (1/3 of cases) and may be lobulated or infiltrative
+ - Classically thought to be low signal on all pulse sequences due to fibrous content
+ - Not consistent or common feature, and may be seen with other entities (including malignancies, such as fibrosarcoma and malignant fibrous histiocytoma)
+ - Usually homogeneously isointense or mildly hypointense on T1WI
+ - Can demonstrate T2 hypointensity due to fibrotic component, but in practice more often heterogeneously high signal on T2WI
+ - Higher T2 signal more common with actively growing or aggressive desmoids
+ - Internal bands of low signal on all pulse sequences (corresponding to fibrosis and collagen) in 2/3 of cases
+ - Variable enhancement on post gadolinium sequences, but usually heterogeneous
+ - No specific MR features to differentiate desmoids from malignancy or to make specific imaging diagnosis
+- ## Ultrasonographic Findings
+
+
+ - Well-defined mesenteric mass with variable echogenicity
+- ## Radiographic Findings
+
+
+ - Fluoroscopic double-contrast studies
+ - FAP: Innumerable, variably sized radiolucent filling defects in colon
+- ## Imaging Recommendations
+
+
+ - ### Best imaging tool
+
+
+ - Multiplanar CT or MR
+
+# DIFFERENTIAL DIAGNOSIS
+
+- ## Soft Tissue Sarcoma
+
+
+ - Imaging cannot differentiate desmoid tumor in abdominal wall or musculature from sarcoma and biopsy ultimately required to make this distinction
+ - History of prior surgical incision at site of mass raises possibility of desmoid rather than malignancy
+- [Leukemia and Lymphoma](/document/leukemia-and-lymphoma-abdominal-si-/b763f036-e025-4f6d-8ae3-8af4257c5617)
+ - Retroperitoneal and mesenteric lymphadenopathy, which is typically much softer than desmoid (envelops, but rarely obstructs, bowel or vessels)
+- [Omental or Mesenteric Metastases](/document/peritoneal-metastases/77ce2f66-499b-4e2e-b361-4a9919313970)
+ - Usually multiple less well-defined lesions that are often associated with stranding and induration in mesentery and omentum
+- [Carcinoid Tumor](/document/carcinoid-tumor/ae665f80-1b75-4726-9396-18c06259bb78)
+ - Usually occurs in right lower quadrant ileocolic mesentery
+ - Desmoplastic reaction and calcification very common, features which are not typically found in desmoids
+- ## Small Bowel Tumors Extending Into Mesentery
+
+
+ - Gastrointestinal stromal tumors (GISTs) or small bowel adenocarcinoma can extend into mesentery and appear similar to desmoid tumor
+- [Abdominal Mesothelioma](/document/abdominal-mesothelioma/a2c0e285-e04b-4889-8cdf-ace038613aa6)
+ - Arises from serosal lining of pleural and peritoneal cavity
+ - Mostly affects males exposed to asbestos
+ - Peritoneal cavity is involved alone or in association with pleural disease
+ - Usually diffusely thickens omentum and mesentery ± peritoneal and omental nodular masses, ascites
+- [Sclerosing Mesenteritis](/document/sclerosing-mesenteritis/39256300-bb6c-4dad-ba7e-3a6ccf5c38c2)
+ - Usually less mass-like than desmoid, although retractile mesenteritis can produce discrete mesenteric mass with desmoplastic reaction and calcification
+
+# PATHOLOGY
+
+- ## General Features
+
+
+ - ### Etiology
+
+
+ - Exact cause is unknown
+ - Majority of cases are sporadic
+ - Strong associations with Gardner syndrome and FAP
+ - Due to mutation in *APC* gene (5q22)
+ - Autosomal dominant disorder characterized by innumerable colonic polyps and multiple extracolonic tumors (including desmoids in 18-20% of cases)
+ - Other risk factors include previous abdominal surgery (75% of cases), trauma, pregnancy, or oral contraceptives
+ - Most often in women of childbearing age
+- ## Staging, Grading, & Classification
+
+
+ - Church et al staging system for desmoid tumors (primarily intended for FAP-related desmoids)
+ - Stage I: Asymptomatic patients with tumors < 10 cm that are not growing
+ - Stage II: Mildly symptomatic patients with tumors < 10 cm that are not growing
+ - Stage III: Moderately symptomatic, bowel/ureter obstruction, tumors 10-20 cm, or tumor slowly growing
+ - Stage IV: Severely symptomatic, septic complications (such as abscess/fistula), tumor > 20 cm, or tumor rapidly growing
+ - Staging system can be used to guide treatment, with stage I and II desmoids potentially treated with active surveillance (along with low toxicity drugs), while stage III and IV desmoids often treated with surgical resection and more aggressive pharmacologic treatment
+- ## Gross Pathologic & Surgical Features
+
+
+ - Desmoid tumors may be intermediate step between reparative process and true malignancy
+ - Tan/white, firm, well- or poorly defined mass
+ - May be "rock hard" and resistant to percutaneous biopsy
+- ## Microscopic Features
+
+
+ - Well-differentiated fibroblasts invading surrounding tissues
+ - Elongated spindle-shaped cells of uniform appearance with dense bands of collagen
+
+# CLINICAL ISSUES
+
+- ## Presentation
+
+
+ - ### Most common signs/symptoms
+
+
+ - Patients may be asymptomatic or may present with abdominal pain and palpable mass
+ - Acute abdominal findings
+ - Due to ischemia/ulceration of mass
+ - Encasement of mesentery and bowel → ischemia and obstruction → progressive resection of bowel → short gut syndrome
+ - Hydronephrosis due to ureteral encasement
+- ## Demographics
+
+
+ - ### Age
+
+
+ - 70% of cases between 20-40 years old
+ - Tends to be more aggressive in younger patients
+ - ### Sex
+
+
+ - M:F = 1:3
+ - Increased incidence in women of childbearing age
+ - ### Epidemiology
+
+
+ - Rare: 2-4 cases per million per year
+ - 18-20% of patients with Gardner syndrome develop desmoid tumor
+ - Mesenteric location more common than abdominal wall desmoid
+ - 8-18% of desmoids are related to pregnancy, typically develop in 3rd trimester or post partum, and are most often located in abdominal wall
+- ## Natural History & Prognosis
+
+
+ - Complications
+ - Locally aggressive growth pattern with compression and invasion of adjacent structures
+ - Intraabdominal desmoids tend to be most aggressive and infiltrative (particularly when associated with FAP or Gardner syndrome)
+ - Can cause bowel obstruction, ureteral obstruction, and bowel ischemia due to vasculature encasement
+ - In pelvis, can cause bladder outlet obstruction or involve fallopian tubes and cause hydrosalpinx
+ - Extraabdominal desmoids can involve nerves and cause pain
+ - Chest wall desmoids can invade pleura
+ - Short gut syndrome can be major issue after multiple small bowel resections
+ - High recurrence rate (up to 2/3 of cases)
+ - Imaging and pathology not predictive of recurrence
+ - Poor prognostic features
+ - Large size of tumor ( > 10 cm) and multiplicity
+ - Extensive involvement of bowel loops, encasement of mesenteric vessels, and involvement of ureters
+- ## Treatment
+
+
+ - Active surveillance now considered 1st-line treatment whenever possible, and National Comprehensive Cancer Network (NCCN) now recommends that most patients should be initially placed on active surveillance in absence of progressive or symptomatic disease
+ - Bonvalot et al found that of those tumors assigned to active surveillance 1/3 remained stable and 1/3 actually spontaneously regressed
+ - While surgical treatment was once mainstay of desmoid treatment, this has now increasingly become controversial as result of morbidity and mortality associated with resection (although surgery may still be necessary in some cases)
+ - May be difficult due to involvement of adjacent critical structures
+ - Particularly when small bowel mesentery involved, surgery can result in significant morbidity (bowel ischemia, short gut syndrome, obstruction, etc.)
+ - Small bowel transplantation may be option in patients who require resection for intraabdominal desmoid and undergo significant bowel resection
+ - Recurrence after surgery is very common, particularly with extraabdominal desmoids, even if surgical margins are negative
+ - Exact relationship between negative margins and local recurrence is unclear based on several studies, which is why performing resections that prioritize maintaining local function may be more important than simply trying to achieve R0 resection
+ - Recurrence rates for desmoids is roughly 50% and may be higher for intraabdominal desmoids (57-88%)
+ - FAP and larger tumor size (> 10 cm) increases risk of recurrence
+ - Conservative management now increasingly utilized for even symptomatic desmoids (in lieu of surgery)
+ - Systemic therapy: Cytotoxic agents (including anthracyclines), antiestrogen agents (e.g., tamoxifen), interferon, molecular-targeted agents (e.g., imatinib), steroids, NSAIDs (e.g., sulindac)
+ - Radiation therapy: Can be effective for establishing local control of tumor, but usually utilized after other options exhausted due to toxicity
+
+# DIAGNOSTIC CHECKLIST
+
+- ## Consider
+
+
+ - Consider desmoid tumors in patients with history of prior abdominal surgery
+ - Look for other features of Gardner syndrome
+ - Rule out other more common causes of solid mesenteric mass
+- ## Image Interpretation Pearls
+
+
+ - Soft tissue density mesenteric mass ± invasion, displacement, or encasement of bowel loops and vessels
+
+ a8bf5d57-3c71-41da-988e-48a7b21fbd0f
+
+## References
+
+# Selected References
+
+1. [Mangla A et al: Desmoid tumors: current perspective and treatment. Curr Treat Options Oncol. 25(2):161-75, 2024](http://www.ncbi.nlm.nih.gov/pubmed/?term=38270798%5Bpmid%5D)
+1. [Moore D et al: Surgical management of abdominal desmoids: a systematic review and meta-analysis. Ir J Med Sci. 192(2):549-60, 2023](http://www.ncbi.nlm.nih.gov/pubmed/?term=35445926%5Bpmid%5D)
+1. [Yang W et al: Update on familial adenomatous polyposis-associated desmoid tumors. Clin Colon Rectal Surg. 36(6):400-5, 2023](http://www.ncbi.nlm.nih.gov/pubmed/?term=37795470%5Bpmid%5D)
+1. [Marsh-Armstrong B et al: Pregnancy-associated large pelvic desmoid tumor: a case report of fetal-protective strategies and fertility preservation. Gynecol Oncol Rep. 39:100901, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=35531359%5Bpmid%5D)
+1. [Ballard DH et al: Imaging of abdominal wall masses, masslike lesions, and diffuse processes. Radiographics. 40(3):684-706, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32330085%5Bpmid%5D)
+1. [Garcia-Ortega DY et al: Desmoid-type fibromatosis. Cancers (Basel). 12(7), 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32660036%5Bpmid%5D)
+1. [Hartung MP et al: Mimics of malignancy in abdominal imaging: multisystem radiology. Radiographics. 37(7):2202-3, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=29131766%5Bpmid%5D)
+1. [Howard JH et al: Intra-abdominal and abdominal wall desmoid fibromatosis. Oncol Ther. 4(1):57-72, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=28261640%5Bpmid%5D)
+1. [Bonvalot S et al: Spontaneous regression of primary abdominal wall desmoid tumors: more common than previously thought. Ann Surg Oncol. 20(13):4096-102, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=24052312%5Bpmid%5D)
+1. [Lamboley JL et al: Desmoid tumour of the chest wall. Diagn Interv Imaging. 93(7-8):635-8, 2012](http://www.ncbi.nlm.nih.gov/pubmed/?term=22721603%5Bpmid%5D)
+1. [Roy AG: Desmoid tumors. Am Surg. 78(2):79-80, 2012](http://www.ncbi.nlm.nih.gov/pubmed/?term=22369803%5Bpmid%5D)
+1. [Shinagare AB et al: A to Z of desmoid tumors. AJR Am J Roentgenol. 197(6):W1008-14, 2011](http://www.ncbi.nlm.nih.gov/pubmed/?term=22109314%5Bpmid%5D)
+1. [McDonald ES et al: Best cases from the AFIP: extraabdominal desmoid-type fibromatosis. Radiographics. 28(3):901-6, 2008](http://www.ncbi.nlm.nih.gov/pubmed/?term=18480491%5Bpmid%5D)
+1. [Dinauer PA et al: Pathologic and MR imaging features of benign fibrous soft-tissue tumors in adults. Radiographics. 27(1):173-87, 2007](http://www.ncbi.nlm.nih.gov/pubmed/?term=17235006%5Bpmid%5D)
+1. [McCarville MB et al: MRI and biologic behavior of desmoid tumors in children. AJR Am J Roentgenol. 189(3):633-40, 2007](http://www.ncbi.nlm.nih.gov/pubmed/?term=17715111%5Bpmid%5D)
+1. [Lee JC et al: Aggressive fibromatosis: MRI features with pathologic correlation. AJR Am J Roentgenol. 186(1):247-54, 2006](http://www.ncbi.nlm.nih.gov/pubmed/?term=16357411%5Bpmid%5D)
+1. [Levy AD et al: From the archives of the AFIP: benign fibrous tumors and tumorlike lesions of the mesentery: radiologic-pathologic correlation. Radiographics. 26(1):245-64, 2006](http://www.ncbi.nlm.nih.gov/pubmed/?term=16418255%5Bpmid%5D)
+1. [Azizi L et al: MRI features of mesenteric desmoid tumors in familial adenomatous polyposis. AJR Am J Roentgenol. 184(4):1128-35, 2005](http://www.ncbi.nlm.nih.gov/pubmed/?term=15788583%5Bpmid%5D)
+1. [Sheth S et al: Mesenteric neoplasms: CT appearances of primary and secondary tumors and differential diagnosis. Radiographics. 23(2):457-73; quiz 535-6, 2003](http://www.ncbi.nlm.nih.gov/pubmed/?term=12640160%5Bpmid%5D)
+1. [Healy JC et al: MR appearances of desmoid tumors in familial adenomatous polyposis. AJR Am J Roentgenol. 169(2):465-72, 1997](http://www.ncbi.nlm.nih.gov/pubmed/?term=9242755%5Bpmid%5D)
+1. [Mindelzun RE et al: The misty mesentery on CT: differential diagnosis. AJR Am J Roentgenol. 167(1):61-5, 1996](http://www.ncbi.nlm.nih.gov/pubmed/?term=8659422%5Bpmid%5D)
+1. [Ichikawa T et al: Abdominal wall desmoid mimicking intra-abdominal mass: MR features. Magn Reson Imaging. 12(3):541-4, 1994](http://www.ncbi.nlm.nih.gov/pubmed/?term=8007785%5Bpmid%5D)
+1. [Kawashima A et al: CT of intraabdominal desmoid tumors: is the tumor different in patients with Gardner's disease? AJR Am J Roentgenol. 162(2):339-42, 1994](http://www.ncbi.nlm.nih.gov/pubmed/?term=8310922%5Bpmid%5D)
+1. [Casillas J et al: Imaging of intra- and extraabdominal desmoid tumors. Radiographics. 11(6):959-68, 1991](http://www.ncbi.nlm.nih.gov/pubmed/?term=1749859%5Bpmid%5D)
+1. [Einstein DM et al: Abdominal desmoids: CT findings in 25 patients. AJR Am J Roentgenol. 157(2):275-9, 1991](http://www.ncbi.nlm.nih.gov/pubmed/?term=1853806%5Bpmid%5D)
+1. [Baron RL et al: Mesenteric desmoid tumors: sonographic and computed-tomographic appearance. Radiology. 140(3):777-9, 1981](http://www.ncbi.nlm.nih.gov/pubmed/?term=7280249%5Bpmid%5D)
+
+
+## Images
+
+
+### Selected Images
+
+
+*Axial CECT demonstrates a large, homogeneous mass in the deep pelvis involving the rectosigmoid colon and portions of the small bowel. While this was prospectively thought to perhaps be a gastrointestinal stromal tumor on imaging, it turned out to be a desmoid tumor at resection.*
+
+
+*Axial CECT demonstrates a large, homogeneous mass in the deep pelvis involving the rectosigmoid colon and portions of the small bowel. While this was prospectively thought to perhaps be a gastrointestinal stromal tumor on imaging, it turned out to be a desmoid tumor at resection.*
+
+
+*Axial CECT demonstrates a homogeneous mass in the right psoas muscle that was incidentally discovered on imaging done for other reasons. This was shown to be a desmoid tumor on biopsy.*
+
+
+*Sagittal T2 MR demonstrates a relatively T2-hypointense mass in the subcutaneous soft tissues of the posterior pelvic wall in a patient who had felt this mass growing over time.*
+
+
+*Axial T1 C+ FS MR in the same patient demonstrates that the mass exhibits substantial enhancement with mildly irregular margins . This was found to be a desmoid tumor at resection.*
+
+
+*Axial CECT demonstrates a homogeneously enhancing mass in the right hemipelvis.*
+
+
+*Axial CECT in the same patient demonstrates a large avidly enhancing mass in the right lower quadrant. This was a patient with familial adenomatous polyposis (FAP), and both of these lesions were found to represent desmoid tumors.*
+
+
+*Axial CECT shows a large mesenteric desmoid with involvement of multiple bowel loops that had been slowly growing on serial examinations. The patient underwent surgical resection, but desmoids with extensive bowel involvement can often be very difficult to resect.*
+
+
+*Axial CECT demonstrates a well- circumscribed, homogenous mass in the pelvis involving the colon and small bowel, found to be a desmoid tumor at resection.*
+
+
+*Coronal T2 HASTE MR in a patient who had undergone bowel resection roughly 6 months earlier demonstrates a well-circumscribed, T2-hypointense mass in very close proximity to the surgical site.*
+
+
+*Axial T1 C+ MR in the same patient demonstrates that the mass demonstrates homogeneous enhancement, which increases on this delayed phase image. Because of their fibrotic component, desmoids can demonstrate relative T2 hypointensity and increasing delayed enhancement, as in this case.*
+
+
+### Additional Images
+
+
+*Axial CECT in a 36-year-old man 12 months following a colectomy for Gardner syndrome shows a solid mesenteric desmoid .*
+
+
+*Axial CECT 20 months following a colectomy for Gardner syndrome shows rapid growth of a mesenteric mass (desmoid tumor).*
+
+
+*Axial CECT shows desmoid in the subcutaneous tissue adjacent to a scar from a prior paramedian incision.*
+
+
+*Axial CECT shows multiple omental masses near the site of prior colon surgery, representing desmoid tumors. Note the surgical clip .*
+
+
+*Axial CECT in a patient with Gardner syndrome shows a large, bilobed, mesenteric desmoid tumor.*
+
+
+*Axial NECT in a patient with Gardner syndrome shows desmoid tumors filling the abdomen, obstructing kidneys and deforming the abdominal wall.*
+
+
+*Axial CECT in a 79-year-old woman shows a homogeneous omental mass . This was a sporadic form of desmoid.*
+
+
+*Axial NECT in a 79-year-old woman shows a homogeneous, enhancing mass in the left pelvis. CT-guided biopsy showed a "rock hard" mass but enough tissue to confirm desmoid tumor.*
+
+
+*Axial CECT demonstrates a very well-circumscribed, relatively hypoenhancing mass in the right anterior abdominal wall musculature in a patient with a prior history of a surgical incision in this location, representing a desmoid tumor.*
+
+
+*Axial CECT demonstrates a hypodense soft tissue mass in the left mesentery in close proximity to the jejunum, stomach, and pancreas. There is a some surrounding fat stranding and inflammatory change.*
+
+
+*Axial T2 FS MR in the same patient demonstrates that the mass has both cystic and solid components. This was originally thought to possibly represent a jejunal gastrointestinal stromal tumor, but was found to be a sporadic desmoid in a patient without risk factors.*
+
+
+*Axial CT reveals a solid mass that involves the lower rectus muscle. This is a surgically proven desmoid tumor. In Gardner syndrome, desmoids may involve the mesentery or abdominal wall. As with other types of fibrous masses, such as keloids, sites of prior surgery or trauma are commonly involved.*
+
+
+*Axial CT in the same patient again reveals a solid mass that involves the lower rectus muscle. This was a surgically proven desmoid tumor. In Gardner syndrome, desmoids may involve the mesentery or abdominal wall. As with other types of fibrous masses, such as keloids, sites of prior surgery or trauma are commonly involved.*
+
+
+*Axial CECT shows an isolated mesenteric desmoid in a 24-year-old woman with no personal evidence of colonic polyps but a family history of familial polyposis. Note the infiltrative mesenteric mass .*
+
+
+*Axial CECT in a 75-year-old Black woman shows an isolated mesenteric desmoid as a nonspecific soft tissue density mass adjacent to the bladder , uterus, and colon. A core needle biopsy was requested. The mass was extremely hard and bent each of the biopsy needles.*
+
+
+*Axial CECT demonstrates a soft tissue mass in the left upper quadrant with surrounding soft tissue edema and induration, found to represent a desmoid at resection.*
+
+
+*Axial CECT demonstrates a very homogeneous, hypoenhancing mass in the pelvis encasing loops of adjacent bowel. This was found to be a desmoid tumor. Desmoids with extensive involvement of the bowel can be very difficult to surgically resect.*
+
+
+*Axial CECT demonstrates a relatively homogeneous, enhancing, well-circumscribed mass in the right anterior pelvis.*
+
+
+*Axial CECT in the same patient demonstrates a very similar-appearing smaller mass in the more inferior pelvis. This was a patient with Gardner syndrome, and both of these lesions were found to represent desmoid tumors.*
+
+
+*Axial T1WI C+ FS MR in the same patient demonstrates relatively avid enhancement of the mass , which is once again noted to be quite infiltrative and poorly marginated. In cases like this, only histologic confirmation can differentiate a desmoid from a soft tissue malignancy.*
+
+
+*Axial CECT demonstrates an infiltrative, hypoenhancing mass in the right anterior abdominal wall musculature at the site of a prior surgical incision.*
+
+
+*Axial CECT in a young woman with Gardner syndrome 2 years after total colectomy shows mesenteric fibromatosis (desmoids) encasing the entire small bowel mesentery, filling the abdominal cavity.*
+
diff --git a/docs_md/articles/elevated-or-deformed-hemidiaphragm_208baaa2-8772-4560-af34-46ce757edcb9.md b/docs_md/articles/elevated-or-deformed-hemidiaphragm_208baaa2-8772-4560-af34-46ce757edcb9.md
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+++ b/docs_md/articles/elevated-or-deformed-hemidiaphragm_208baaa2-8772-4560-af34-46ce757edcb9.md
@@ -0,0 +1,185 @@
+---
+title: "Elevated or Deformed Hemidiaphragm"
+docid: "208baaa2-8772-4560-af34-46ce757edcb9"
+authors:
+ - key: "c1df94ab-4a9f-44c4-add7-1f174fb9ac45"
+ value: "Siva P. Raman, MD"
+breadcrumbs:
+ -
+ name: "Gastrointestinal"
+ slug: "gastrointestinal"
+ treeNodeId: "b52263f7-5978-4a22-a17d-7260e0033943"
+ -
+ name: "Differential Diagnosis"
+ slug: "differential-diagnosis"
+ treeNodeId: "a0fd80ff-6231-49d3-94b8-ea083449979d"
+ -
+ name: "Abdominal Wall"
+ slug: "abdominal-wall"
+ treeNodeId: "08db01f7-2961-47f7-954d-2a5fca7e707d"
+ -
+ name: "Anatomically Based Differentials"
+ slug: "anatomically-based-differentials"
+ treeNodeId: "1525b44f-9d47-4ff4-8330-693211bd5eb5"
+ -
+ name: "Elevated or Deformed Hemidiaphragm"
+ slug: "elevated-or-deformed-hemidiaphragm"
+ treeNodeId: null
+category: "Gastrointestinal"
+documentVersionId: "c5d9083d-d7a6-430b-9be6-4a6013d67387"
+imageCount: 18
+lastUpdated: "07/01/22"
+pageDescription: "Elevated or Deformed Hemidiaphragm"
+pageKeywords: "Gastrointestinal, Differential Diagnosis, Abdominal Wall, Anatomically Based Differentials, Elevated or Deformed Hemidiaphragm"
+pageTitle: "Elevated or Deformed Hemidiaphragm | STATdx"
+enhancedTitle: "Elevated or Deformed Hemidiaphragm"
+type: "DDX"
+references: true
+breadcrumbs:
+ - "Gastrointestinal"
+ - "Differential Diagnosis"
+ - "Abdominal Wall"
+ - "Anatomically Based Differentials"
+ - "Elevated or Deformed Hemidiaphragm"
+---
+# ESSENTIAL INFORMATION
+
+- ## Key Differential Diagnosis Issues
+
+
+ - Axial CT suboptimal for distinguishing diaphragm from spleen, liver, and muscle and identifying many diaphragmatic abnormalities
+ - Multiplanar reformations critical for accurate diagnosis
+ - Diaphragm easier to visualize discretely on MR compared to CT and can demonstrate diaphragm in multiple planes
+ - Fluoroscopy and US useful for providing functional information, particularly for paralysis
+ - Dynamic MR (not widely utilized) can provide functional information similar to US or fluoroscopy
+ - US in sagittal plane easily identifies diaphragm and location of peridiaphragmatic fluid collection
+ - Ascites and abdominal contents lie medial to and within confines of diaphragm
+ - Pleural fluid and thoracic contents lie outside confines of diaphragm
+- ## Helpful Clues for Common Diagnoses
+
+
+ - **Paralyzed Diaphragm**
+ - Normal diaphragm that fails to contract secondary to abnormalities of brain, spinal cord, neuromuscular junction, phrenic nerve, or muscle
+ - US or fluoroscopy demonstrate no motion or paradoxical (upward) motion during inspiration or sniff test
+ - **Eventration of Diaphragm**
+ - Congenital thinning/weakness of portion of diaphragm, which normally attaches to costal margin
+ - Eccentric diaphragmatic contour (usually anteromedial right hemidiaphragm) ± paradoxical motion with large eventrations
+ - **Hiatal Hernia**
+ - Herniation of abdominal contents into thoracic cavity through esophageal hiatus
+ - Divided into sliding type (GE junction displaced upward through hiatus) and paraesophageal type (GE junction in normal location with stomach herniating above diaphragm)
+ - **Bochdalek Hernia**
+ - Type of congenital diaphragmatic hernia due to defect in posterolateral diaphragm (usually on left side)
+ - Hernia may contain retroperitoneal fat, bowel, kidney, stomach, spleen, or liver
+ - **Morgagni Hernia**
+ - Type of congenital diaphragmatic hernia due to defect in retrosternal diaphragm (usually on right side)
+ - Usually located in right cardiophrenic angle and most often contains just omental fat (but can contain colon, liver, small bowel, or stomach)
+ - **Traumatic Diaphragmatic Hernia**
+ - Traumatic injury may be due to blunt or penetrating trauma
+ - Multiple imaging signs of injury include dependent viscus sign, collar sign, and dangling diaphragm sign
+ - Injuries both above and below diaphragm should raise concern for diaphragmatic injury
+ - **Subdiaphragmatic Mass**
+ - Tumor, hepatomegaly, or splenomegaly can exert mass effect and raise ipsilateral diaphragm
+ - **Abdominal****Abscess**
+ - Subphrenic abscess can cause upward displacement of diaphragm due to mass effect or splinting (decreased motion of diaphragm due to pain)
+ - **Unilateral Lung Volume Loss**
+ - Diminished unilateral lung volume (lung resection, atelectasis) will cause elevation of ipsilateral diaphragm
+ - **Subpulmonic Pleural Effusion (Mimic)**
+ - Pleural fluid loculated in subpulmonic pleural space will displace lung upward and may simulate elevated diaphragm on radiographs (but not on cross-sectional imaging)
+
+## References
+
+# Selected References
+
+1. [Abdellatif W et al: Unravelling the mysteries of traumatic diaphragmatic injury: an up-to-date review. Can Assoc Radiol J. 71(3):313-21, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32157897%5Bpmid%5D)
+1. [Kharma N: Dysfunction of the diaphragm: imaging as a diagnostic tool. Curr Opin Pulm Med. 19(4):394-8, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=23715292%5Bpmid%5D)
+1. [Nason LK et al: Imaging of the diaphragm: anatomy and function. Radiographics. 32(2):E51-70, 2012](http://www.ncbi.nlm.nih.gov/pubmed/?term=22411950%5Bpmid%5D)
+1. [Roberts HC: Imaging the diaphragm. Thorac Surg Clin. 19(4):431-50, v, 2009](http://www.ncbi.nlm.nih.gov/pubmed/?term=20112626%5Bpmid%5D)
+1. [Verhey PT et al: Differentiating diaphragmatic paralysis and eventration. Acad Radiol. 2007 Apr;14(4):420-5](http://www.ncbi.nlm.nih.gov/pubmed/?term=17368210%5Bpmid%5D)
+1. [Eren S et al: Imaging of diaphragmatic rupture after trauma. Clin Radiol. 61(6):467-77, 2006](http://www.ncbi.nlm.nih.gov/pubmed/?term=16713417%5Bpmid%5D)
+1. [Eren S et al: Diaphragmatic hernia: diagnostic approaches with review of the literature. Eur J Radiol. 54(3):448-59, 2005](http://www.ncbi.nlm.nih.gov/pubmed/?term=15899350%5Bpmid%5D)
+
+
+## Images
+
+
+### Selected Images
+
+
+**Paralyzed Diaphragm**
+*Coronal CECT shows marked asymmetric elevation of the left hemidiaphragm. In this case, the left diaphragm is paralyzed due to phrenic nerve involvement by the patient's mediastinal lymphoma (not shown).*
+
+
+**Paralyzed Diaphragm**
+*Coronal CECT shows marked asymmetric elevation of the left hemidiaphragm. In this case, the left diaphragm is paralyzed due to phrenic nerve involvement by the patient's mediastinal lymphoma (not shown).*
+
+
+**Eventration of Diaphragm**
+*Coronal CECT shows the characteristic appearance of diaphragmatic eventration with focal scalloping of the right anterior hemidiaphragm and superior protrusion of the liver at the site of eventration .*
+
+
+**Hiatal Hernia**
+*Coronal CECT shows a large hiatal hernia with the entirety of the stomach located within the thoracic cavity.*
+
+
+**Bochdalek Hernia**
+*Sagittal CECT shows a large Bochdalek hernia containing bowel and kidney. There is focal interruption of the hemidiaphragm with herniation of the kidney into the thorax.*
+
+
+**Morgagni Hernia**
+*Coronal NECT shows a characteristic Morgagni hernia with omental fat herniating into the chest through a defect in the right anteromedial diaphragm.*
+
+
+**Traumatic Diaphragmatic Hernia**
+*Sagittal T2 MR shows a posttraumatic defect in the left hemidiaphragm with the stomach herniating into the chest. Note that the diaphragm is identified as a low-signal curvilinear structure. The stomach is pinched as it traverses the defect in the diaphragm.*
+
+
+**Traumatic Diaphragmatic Hernia**
+*Axial CECT shows the fallen viscus sign associated with traumatic diaphragmatic injury. Note that the stomach lies in the chest and has fallen medially and posteriorly to lie against the lung and the posteromedial chest wall.*
+
+
+**Subpulmonic Pleural Effusion (Mimic)**
+*Axial CECT shows a pleural effusion below the lung and lateral to the diaphragm . Ascites lies medial to the diaphragm and adjacent to the cirrhotic liver.*
+
+
+### Additional Images
+
+
+**Paralyzed Diaphragm**
+*Axial NECT shows elevation of the left hemidiaphragm without focal bulge or eventration. The abdominal contents do not fall dependently but are suspended by the intact diaphragm.*
+
+
+**Eventration of Diaphragm**
+*Sagittal CECT shows a focal bulge of the liver through a weakened eventration of the right hemidiaphragm.*
+
+
+**Hiatal Hernia**
+*Axial NECT shows herniation of most of the stomach as well as the splenic flexure of colon through a massive hiatal hernia.*
+
+
+**Bochdalek Hernia**
+*Axial CECT shows bilateral defects in the posteromedial portions of the diaphragm with herniation of omental fat.*
+
+
+**Morgagni Hernia**
+*Axial NECT shows a large hiatal hernia that contains much of the stomach. There is also a large Morgagni hernia , lateral to and displacing the heart, containing omental fat and colon.*
+
+
+**Traumatic Diaphragmatic Hernia**
+*Coronal T2 MR shows herniation of the stomach and omental fat through a defect in the left hemidiaphragm . The stomach is pinched as it traverses the defect in the diaphragm.*
+
+
+**Traumatic Diaphragmatic Hernia**
+*Axial CECT shows herniation of the stomach through a defect in the left hemidiaphragm. The stomach has fallen to lie against the posteromedial chest wall and is pinched .*
+
+
+**Hiatal Hernia**
+*Coronal CECT shows a large hiatal hernia with the entirety of the stomach located within the thoracic cavity.*
+
+
+**Paralyzed Diaphragm**
+*Coronal CECT shows marked asymmetric elevation of the left hemidiaphragm. In this case, the left diaphragm is paralyzed as a result of phrenic nerve involvement by a mediastinal soft tissue mass in this patient with metastatic lung cancer.*
+
+
+**Bochdalek Hernia**
+*Sagittal CECT shows a large Bochdalek hernia containing bowel and kidney. There is focal interruption of the hemidiaphragm with herniation of the kidney into the thorax.*
+
diff --git a/docs_md/articles/facial-nerve-cnvii_2f4818dd-6438-405b-8561-5cbbb9c91562.md b/docs_md/articles/facial-nerve-cnvii_2f4818dd-6438-405b-8561-5cbbb9c91562.md
new file mode 100644
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--- /dev/null
+++ b/docs_md/articles/facial-nerve-cnvii_2f4818dd-6438-405b-8561-5cbbb9c91562.md
@@ -0,0 +1,258 @@
+---
+title: "Facial Nerve (CNVII)"
+docid: "2f4818dd-6438-405b-8561-5cbbb9c91562"
+authors:
+ - key: "94f835c8-fa13-4e8a-995b-53048e6b0605"
+ value: "Philip R. Chapman, MD"
+ - key: "b0a6efa4-ad68-430c-b5da-f5c904adf809"
+ value: "Ryan P. Cabeen, PhD"
+breadcrumbs:
+ -
+ name: "Brain"
+ slug: "brain"
+ treeNodeId: "6d8829f1-14d7-45af-8675-255189aa526a"
+ -
+ name: "Anatomy"
+ slug: "anatomy"
+ treeNodeId: "45a4cfd4-910b-4f11-8eba-c887895fdbf8"
+ -
+ name: "Skull Base and Cranial Nerves"
+ slug: "skull-base-and-cranial-nerves"
+ treeNodeId: "95ed8b31-2615-40e8-befe-a6a742a0872a"
+ -
+ name: "Facial Nerve (CNVII)"
+ slug: "facial-nerve-cnvii"
+ treeNodeId: null
+category: "Brain"
+cmeTopicId: "e4cb8b15-b95c-4309-b9d9-c9719f291581"
+documentVersionId: "b4c5e191-d167-409d-9300-1c0a03b77e1a"
+imageCount: 27
+lastUpdated: "10/20/20"
+pageDescription: "Facial Nerve (CNVII)"
+pageKeywords: "Brain, Anatomy, Skull Base and Cranial Nerves, Facial Nerve (CNVII)"
+pageTitle: "Facial Nerve (CNVII) | STATdx"
+enhancedTitle: "Facial Nerve (CNVII)"
+type: "ANATOMY"
+breadcrumbs:
+ - "Brain"
+ - "Anatomy"
+ - "Skull Base and Cranial Nerves"
+ - "Facial Nerve (CNVII)"
+---
+# TERMINOLOGY
+
+- ## Abbreviations
+
+
+ - Facial nerve (CNVII)
+- ## Synonyms
+
+
+ - 7th cranial nerve
+- ## Definitions
+
+
+ - CNVII: Cranial nerve that carries motor nerves to muscles of facial expression; parasympathetics to lacrimal, submandibular, and sublingual glands; and taste from anterior 2/3 of tongue
+
+# IMAGING ANATOMY
+
+- ## Overview
+
+
+ - Mixed nerve: Motor, parasympathetic, and special sensory (taste)
+ - 2 roots: Motor and sensory (nervus intermedius) roots
+ - Nervus intermedius exits lateral brainstem between motor root of facial and vestibulocochlear nerves, hence its name
+ - 3 nuclei and 4 segments: Intraaxial, cisternal, intratemporal, and extracranial (parotid)
+- ## Nuclei and Intraaxial Segment
+
+
+ - 3 nuclei (1 motor, 2 sensory)
+ - **Motor nucleus of facial nerve**
+ - Located in ventrolateral pontine tegmentum
+ - Efferent fibers loop dorsally around CNVI nucleus in floor of 4th ventricle, forming facial colliculus
+ - Fibers then course anterolaterally to exit lateral brainstem at pontomedullary junction
+ - **Superior salivatory nucleus**
+ - Located lateral to CNVII motor nucleus in pons
+ - Efferent **parasympathetic fibers** exit brainstem posterior to CNVII as nervus intermedius
+ - To submandibular, sublingual, and lacrimal glands
+ - **Solitarius tract nucleus**
+ - Termination of taste sensation fibers from anterior 2/3 of tongue
+ - **Cell bodies** of these fibers in **geniculate ganglion**
+ - Fibers travel within nervus intermedius
+- ## Cisternal Segment
+
+
+ - 2 roots in cisternal CNVII
+ - Larger motor root anteriorly
+ - Smaller sensory nervus intermedius posteriorly
+ - Emerge from lateral brainstem at **root exit zone** in pontomedullary junction to enter cerebellopontine angle (CPA) cistern
+ - CNVIII exits brainstem posterior to CNVII
+ - 2 roots join together and pass anterolaterally through CPA cistern with CNVIII to internal auditory canal (IAC)
+- ## Intratemporal Segment
+
+
+ - CNVII further divided in T-bone into 4 segments: IAC, labyrinthine, tympanic, and mastoid
+ - **IAC segment**: Porus acusticus to IAC fundus; anterosuperior position above crista falciformis
+ - **Labyrinthine segment**: Connects fundal CNVII to geniculate ganglion (anterior genu)
+ - **Tympanic segment**: Connects anterior to posterior genu, passing under lateral semicircular canal
+ - **Mastoid segment**: Inferiorly directed from posterior genu to stylomastoid foramen
+- ## Extracranial Segment
+
+
+ - Main CNVII exits skull base through **stylomastoid foramen** to enter parotid space
+ - Parotid CNVII passes lateral to retromandibular vein
+ - Ramifies within parotid, passes anteriorly to innervate muscles of facial expression
+- ## CNVII Branches
+
+
+ - **Greater superficial petrosal nerve**
+ - Arises at geniculate ganglion, passes anteromedially, exits temporal bone via facial hiatus
+ - Carries **parasympathetic** fibers to **lacrimal gland**
+ - **Stapedius nerve**
+ - Arises from high mastoid segment of CNVII
+ - Provides **motor** innervation to **stapedius muscle**
+ - **Chorda tympani nerve**
+ - Arises from lower mastoid segment
+ - Courses across middle ear to exit anterior T-bone
+ - Carries **taste** fibers from **anterior 2/3 of tongue**
+ - These fibers travel with lingual branch of mandibular division of trigeminal nerve
+ - **Terminal motor branches** to muscles of facial expression
+ - Superior to inferior: Temporal, zygomatic, buccal, mandibular, cervical
+
+# ANATOMY IMAGING ISSUES
+
+- ## Imaging Recommendations
+
+
+ - Bone CT best for intratemporal segment of CNVII
+ - MR for intraaxial, cisternal, IAC, and extracranial segments
+ - Do not image routine Bell palsy!
+- ## Imaging Sweet Spots
+
+
+ - Include brainstem, CPA cistern, IAC, T-bone, and **parotid** when MR completed for CNVII palsy
+- ## Imaging Pitfalls
+
+
+ - Mild enhancement of labyrinthine segment, geniculate ganglion, and proximal tympanic segments of CNVII can be normal on postcontrast T1 MR
+ - Secondary to circumneural arteriovenous plexus
+ - Always check parotid in peripheral CNVII paralysis
+- ## Clinical Issues
+
+
+ - Facial nerve paralysis can be central or peripheral
+ - **Central**: Supranuclear injury resulting in paralysis of contralateral muscles of facial expression with forehead sparing
+ - **Peripheral**: Injury to CNVII from brainstem nucleus peripherally, resulting in paralysis of all ipsilateral muscles of facial expression
+ - If lesion proximal to geniculate ganglion, lacrimation, sound dampening, and taste affected
+ - If CNVI involved, check pons for lesion
+ - If CNVIII involved, check CPA-IAC for lesion
+ - If lacrimation, sound dampening, and taste are variably affected, T-bone lesion possible
+ - If lacrimation, sound dampening and taste are spared, extracranial CNVII implicated
+
+ ca024fe5-308b-4a45-965f-f5040eddf104
+
+
+## Images
+
+
+### Graphics
+
+
+*Axial graphic shows CNVII nuclei. Motor nucleus sends out its fibers to circle CNVI nucleus before reaching root exit zone at the pontomedullary junction. The superior salivatory nucleus sends parasympathetic secretomotor fibers to the lacrimal, submandibular, and sublingual glands. Solitary tract nucleus receives anterior 2/3 of tongue taste information.*
+
+
+*Sagittal graphic depicts CNVII within the temporal bone. Motor fibers pass through the temporal bone, dropping the stapedius nerve to the stapedius muscle, then exit via the stylomastoid foramen to extracranial CNVII (entirely motor). Parasympathetic fibers from superior salivatory nucleus reach the lacrimal gland via the greater superficial petrosal nerve and submandibular-sublingual glands via the chorda tympanic nerve. The anterior 2/3 of tongue taste fibers come via the chorda tympani nerve.*
+
+
+*Sagittal graphic depicts extracranial motor branches of the facial nerve.*
+
+
+### Axial Bone CT
+
+
+*First of 6 axial bone CT of the left temporal bone presented from superior to inferior shows the labyrinthine segment of the facial nerve canal as a C-shaped structure arching anterolaterally over the top of the cochlea.*
+
+
+*In this image, the labyrinthine segment of CNVII canal terminates in the geniculate fossa. The facial nerve canal turns abruptly at the geniculate fossa (anterior genu). The tympanic segment arises from the geniculate fossa, coursing posterolaterally in the axial plane, running under the lateral semicircular canal before turning 90° inferiorly at the posterior genu to become the mastoid segment.*
+
+
+*At the level of the oval window, the mastoid segment is visible deep to the facial nerve recess. Notice the more medial pyramidal eminence and sinus tympani.*
+
+
+*Mastoid segment extends ~ 13 mm from the posterior genu to the stylomastoid foramen, coursing inferiorly within the posterior wall of the middle ear cavity. The mastoid segment is related anteriorly to the facial nerve recess and medially to the stapedius muscle within the pyramidal eminence on the posterior wall of the middle ear cavity.*
+
+
+*At the level of the basal turn of the cochlea, the mastoid segment of the facial nerve is still visible. Both the nerve to the stapedius muscle proximally and the chorda tympani distally branch off the mastoid segment (CNVII).*
+
+
+*Image at the level of the stylomastoid foramen is shown. Notice the "bell" of the stylomastoid foramen is just anteromedial to the mastoid tip. The mastoid tip protects the facial nerve from traumatic injury as it exits the skull base.*
+
+
+### Coronal Bone CT
+
+
+*First of 6 coronal bone CT of the left temporal bone presented from posterior to anterior shows the lower mastoid segment of the facial nerve (CNVII) and stylomastoid foramen.*
+
+
+*At the level of the round window, the posterior genu of the facial nerve can be seen just lateral to the pyramidal eminence. Notice the sinus tympani is medial to the pyramidal eminence.*
+
+
+*At the level of the oval window, the tympanic segment of the facial nerve can be seen coursing under the lateral semicircular canal. Notice the fine bony covering (thin white line) surrounding the facial nerve. Also note the location relative to the upper margin of the oval window. In patients with oval window atresia, the facial nerve is found near or within the oval window niche.*
+
+
+*At the level of the anterior margin of the oval window, the tympanic segment of the facial nerve can be seen under the lateral semicircular canal. Notice the fine bony covering (thin white line) surrounding the facial nerve is now not seen. The facial nerve canal bony covering in this area is normally incomplete.*
+
+
+*In the anterior middle ear cavity, the labyrinthine segment of the facial nerve can be seen exiting the internal auditory canal over the top of the cochlea. The anterior tympanic segment of the facial nerve is also visible. Do not confuse the muscle-tendon of the tensor tympani in the cochleariform process with the facial nerve.*
+
+
+*In the most anterior portion of middle ear cavity (where both the carotid and the cochlea are visible), the geniculate ganglion is seen within the geniculate fossa as an ovoid structure just above the cochlea.*
+
+
+### 3T Axial T2 & T1 MR
+
+
+*First of 2 axial high-resolution T2 MR through the cerebellopontine angle cistern and internal auditory canal is shown. The facial nerve root exit zone is seen anterior to the vestibulocochlear nerve in the pontomedullary junction bilaterally. Notice the facial nerve maintains an anterior relationship with the vestibulocochlear nerve as it crosses through the cerebellopontine angle cistern.*
+
+
+*Image through the cephalad internal auditory canal on the patient's left shows the facial nerve anterior to the superior vestibular nerve throughout its internal auditory canal course.*
+
+
+*Axial T1 MR at the level of the stylomastoid foramen shows the exiting low-signal facial nerve surrounded by high-signal fat in the "bell" of the stylomastoid foramen. If perineural parotid malignancy is present, the fat in this area is obscured.*
+
+
+### 3T Oblique Sagittal T2 MR
+
+
+*First of 3 oblique sagittal T2 MR presented from lateral to medial shows normal fundal anatomy. The horizontal crista falciformis separates the fundus into the upper and lower portions. The facial nerve is anterosuperior, separated from the superior vestibular nerve by a vertical bony septum called the "Bill bar," which is not resolved. Below the falciform crest are the larger anterior cochlear nerve and posterior inferior vestibular nerve.*
+
+
+*In the midinternal auditory canal, 4 nerves are clearly identified. The facial nerve is anterosuperior.*
+
+
+*This image through the porus acusticus reveals the characteristic ball in a catcher's mitt appearance of the facial and vestibulocochlear nerves. The facial nerve is the "ball" and the vestibulocochlear nerve is the "catcher's mitt."*
+
+
+### 3T T2-SPACE MR
+
+
+*First of a series of 3 axial slices of a T2 sampling perfection with application-optimized contrasts by using flip angle evolution (T2-SPACE) MR showing the facial nerve.*
+
+
+*Second in the series shows a more superior axial T2-SPACE MR slice through the facial nerve.*
+
+
+*Third in the series shows a detailed view of an axial T2-SPACE MR slice through the facial nerve. The facial nerve was manually segmented and rendered in 3D in pink. The cochlear and vestibular nerves are also partially visible in green and orange, respectively.*
+
+
+### 3T MR
+
+
+*A 3D surface rendering from T2-SPACE MR of the facial (CNVII) and vestibulocochlear nerve (CNVIII) is shown. The facial nerve was manually segmented and rendered in 3D in pink. The cochlear and vestibular nerves are also partially visible in green and orange, respectively.*
+
+
+*First of 2 axial sections of a diffusion tensor imaging (DTI) dataset shows the facial nerve along with white matter pathways. The image is colored to indicate orientation, where left-right fibers are colored in red, anterior-posterior fibers are colored in green, and inferior-superior fibers are colored in blue. Note: The facial nerve (CNVII) cannot be visibly discerned from the vestibulocochlear nerve (CNVIII) at this resolution.*
+
+
+*Second of 2 axial sections of a DTI dataset showing the facial nerve along with white matter pathways is shown. The facial nerve (CNVII) was modeled using diffusion tractography (orange). Note: The facial nerve (CNVII) cannot be visibly discerned from the vestibulocochlear nerve (CNVIII) at this resolution.*
+
diff --git a/docs_md/articles/facial-nerve-in-temporal-bone_21dccac8-d73d-4ef3-859b-73e013ec15cc.md b/docs_md/articles/facial-nerve-in-temporal-bone_21dccac8-d73d-4ef3-859b-73e013ec15cc.md
new file mode 100644
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+++ b/docs_md/articles/facial-nerve-in-temporal-bone_21dccac8-d73d-4ef3-859b-73e013ec15cc.md
@@ -0,0 +1,214 @@
+---
+title: "Facial Nerve in Temporal Bone"
+docid: "21dccac8-d73d-4ef3-859b-73e013ec15cc"
+authors:
+ - key: "b2e6dabb-ee1c-42a4-a332-9f0814c1c607"
+ value: "Surjith Vattoth, MD, FRCR"
+breadcrumbs:
+ -
+ name: "Head and Neck"
+ slug: "head-and-neck"
+ treeNodeId: "ed24ed8c-5d57-4629-879b-447b82d2973d"
+ -
+ name: "Anatomy"
+ slug: "anatomy"
+ treeNodeId: "678bc99d-d43e-45e6-9c8d-9fa5a7648616"
+ -
+ name: "Temporal Bone"
+ slug: "temporal-bone"
+ treeNodeId: "0a35733d-482c-412f-acbc-19b34e7ba61d"
+ -
+ name: "Facial Nerve in Temporal Bone"
+ slug: "facial-nerve-in-temporal-bone"
+ treeNodeId: null
+category: "Head and Neck"
+cmeTopicId: "16b49f7c-b13a-4957-a456-28bff373fe31"
+documentVersionId: "0b11b8a3-7805-4dd7-b7ac-f1db6ef4f9d3"
+imageCount: 21
+lastUpdated: "11/28/23"
+pageDescription: "Facial Nerve in Temporal Bone"
+pageKeywords: "Head and Neck, Anatomy, Temporal Bone, Facial Nerve in Temporal Bone"
+pageTitle: "Facial Nerve in Temporal Bone | STATdx"
+enhancedTitle: "Facial Nerve in Temporal Bone"
+type: "ANATOMY"
+breadcrumbs:
+ - "Head and Neck"
+ - "Anatomy"
+ - "Temporal Bone"
+ - "Facial Nerve in Temporal Bone"
+---
+# TERMINOLOGY
+
+- ## Abbreviations
+
+
+ - Facial nerve (FN); greater superficial petrosal nerve (GSPN)
+- ## Definitions
+
+
+ - FN in temporal bone: Internal auditory canal, labyrinthine, anterior genu, tympanic, posterior genu, & mastoid segments
+
+# IMAGING ANATOMY
+
+- ## Overview
+
+
+ - **Internal auditory canal (IAC) segment**: Porus acusticus to IAC fundus; anterosuperior position above crista falciformis
+ - **Labyrinthine segment**: Connects fundal CNVII to geniculate ganglion (anterior genu)
+ - **Anterior genu**: Geniculate ganglion of FN resides here
+ - **GSPN**originates at geniculate ganglion, where **nervus intermedius of Wrisberg (NIW)** joins FN
+ - **Tympanic segment**: Connects anterior to posterior genu
+ - On coronal CT/MR, seen under lateral semicircular canal & above oval window in **medial wall of middle ear**
+ - On more anterior coronal CT/MR, look for snake eyes (snail eyes) appearance of FN labyrinthine segment medially & tympanic segment laterally
+ - **Posterior genu**: Beyond this, FN dips down inferiorly as descending mastoid segment
+ - **Mastoid segment**: Inferiorly directed from posterior genu to exit mastoid temporal bone at **stylomastoid foramen**
+ - Extracranial FN enters parotid gland
+ - Gives off **nerve to stapedius** & **chorda tympani nerve (CTN)**
+ - Runs in posterior wall of ME cavity with air-filled **facial recess** just anterior to FN upper mastoid segment
+ - Bony **pyramidal eminence (PE)** with stapedius muscle at it base located just medial to FN upper mastoid segment
+ - Do not confuse stapedius muscle for FN
+ - Air-filled **sinus tympani**lies further medially in retrotympanum (RT) & connects to air underneath bony round window niche
+ - Mnemonic for this mediolateral orientation of RT: Sinus ty**m**pani has "**m**"; hence **m**edial; & facia**l** recess has an "**l**"; hence**l**ateral
+ - Sinus tympani can be blindspot at mastoidectomy where cholesteatoma may hide
+- ## Branches of Facial Nerve in Temporal Bone
+
+
+ - **GSPN**: Origin from geniculate ganglion (anterior genu)
+ - Travels anteromedially through small hiatus in petrous temporal bone, then in middle cranial fossa floor between layers of dura mater underneath temporal lobe → **foramen lacerum**; at foramen lacerum, GSPN (parasympathetic via NIW) joined by **deep petrosal nerve (DPN)** (sympathetic fibers from internal carotid plexus) to form **vidian nerve**
+ - Evaluate for GSPN schwannoma or perineural tumor spread in these locations
+ - **Nerve to stapedius**: Origin from upper aspect of descending mastoid segment of FN near PE
+ - Motor innervation to stapedius muscle
+ - **CTN**: Origin from mastoid FN
+ - From proximal, mid, or distal mastoid segment, or, rarely, even after exiting stylomastoid foramen
+ - Ascends through **posterior canaliculus of CTN**in posterior wall of middle ear
+ - Courses in middle ear cavity from posterior to anterior in substance of **tympanic membrane** between mucous & fibrous layers
+ - Then between upper aspect of handle (manubrium) of malleus & long process of incus, on **medial**side of **upper**part of **handle of malleus**
+ - Then travels through **anterior canaliculus of CTN** & exits temporal bone into masticator space (MS) through **petrotympanic fissure (Glaserian fissure)** posteromedial to TMJ; in MS, CTN joins lingual nerve (LN) 2 cm below skull base
+ - **Chordal eminence**: Bony prominence on posterior wall of tympanic cavity formed by CTN posterior canaliculus
+ - **Lateral RT** divided by chordal eminence into **facial recess** medially & **lateral tympanic sinus** laterally
+ - **Styloid eminence** separates lateral RT superiorly from hypotympanum inferiorly
+ - **Chordiculus**: Bony crest between chordal eminence inferolaterally & PE superomedially; origin of tympanic segment of CTN at lateral end of chordiculus
+- ## Anatomy Relationships
+
+
+ - **NIW** exits brainstem at pontomedullary junction between pons & inferior cerebellar peduncle lateral to motor root of FN & medial to CNVIII
+ - NIW then courses along with motor root of FN through cerebellopontine angle into anterosuperior IAC quadrant
+ - NIW **joins motor root of FN** near geniculate ganglion
+ - NIW: Somatic sensory, special sensory, & visceral motor (secretomotor) fibers from various brainstem nuclei
+ - **Superior salivatory nucleus (SSN)** in pons: **Parasympathetic** root through NIW → FN → **GSPN** (+ **DPN**, sympathetic) → **vidian nerve** → **pterygopalatine ganglion** in pterygopalatine fossa → **lacrimal gland** & **nasal** glands
+ - SSN in pons: **Parasympathetic** root through NIW → FN → **CTN** → **LN** (CNV3 branch) → **submandibular ganglion** suspended by roots from LN in sublingual space → **submandibular & sublingual salivary glands**
+ - **CTN**also carries afferent **taste** sensation from anterior 2/3rd of tongue via **LN**
+ - LN: Branch of mandibular nerve [V3, trigeminal (CNV) branch]
+ - **Nucleus of tractus solitarius (NTS)** in medulla/lower pons: **Geniculate ganglion** at anterior genu of CNVII in temporal bone contains pseudounipolar cell bodies
+ - Central processes of cell bodies enter gustatory part of NTS, forming special visceral afferent root
+ - Peripheral processes receive **taste** sensation from anterior 2/3rd of **tongue**(**CTN**) & palate (**GSPN**)
+ - **Main sensory nucleus of CNV** in pons: General somatic afferents **sensation** from lateral pinna, posterior external auditory auditory canal & mastoid via **geniculate ganglion**
+ - **Mastoid canaliculus**with**Arnold nerve** [auricular branch of vagus (CNX)] extending laterally from lateral aspect of pars vascularis of jugular foramen toward **tympanomastoid fissure** first **connects** **to descending mastoid segment FN canal** several millimeters above stylomastoid foramen
+ - Then dips inferolaterally toward tympanomastoid fissure (suture) at posterior aspect of external auditory canal
+ - Arnold nerve supplies part of tympanic membrane & external auditory canal
+ - Arnold nerve **cough reflex** on ear stimulation
+ - When mechanically stimulating ear with finger or ear bud
+
+# CLINICAL IMPLICATIONS
+
+- ## Clinical Importance
+
+
+ - Enhancement of geniculate ganglion, tympanic & mastoid segments of CNVII normal on postcontrast T1W MR; can be asymmetric intensity of enhancement on right & left
+ - Secondary to circumneural arteriovenous plexus
+ - **Cisternal**, **IAC**, **labyrinthine**& **parotid** segments **do not**normally **enhance** on MR
+ - Faint enhancement may be seen depending on MR scanner, sequence, & type of contrast used
+ - Be familiar with normal images in different institutions
+ - Always check parotid in peripheral CNVII paralysis
+ - Focal dehiscence of undersurface of tympanic segment FN canal normal variant occurring in as much as 20- 25% of adults, most commonly just above oval window
+ - Important to mention in presurgical temporal bone CT reports to avoid nerve injury during middle ear surgery
+
+ 73481e07-60c3-4a54-b1aa-e4adc388db30
+
+
+## Images
+
+
+### Graphics: Sagittal, Coronal, & Axial
+
+![Sagittal graphic shows the medial wall of the middle ear. Note craniocaudal orientation of the lateral semicircular canal (LSCC), facial nerve (tympanic segment), oval window (stapes footplate attaches to oval window), and cochlear promontory (bony bulge covering the basal turn of cochlea). Greater superficial petrosal nerve (GSPN) originates at geniculate ganglion in the anterior genu of the facial nerve, where the nervus intermedius of Wrisberg [(NIW) not shown] joins the facial nerve. Posteroinferiorly, the descending mastoid segment of the facial nerve exits the temporal bone at the stylomastoid foramen on its way to the parotid gland.](images/app.statdx.com_image_thumbnail_71edd785-03d7-4904-8a71-ee56654bcccd_annotated_false_size_900_quality_90_70534c1f125b63d083db4f7bbb4fb72ec4acfcc0.jpg)
+*Sagittal graphic shows the medial wall of the middle ear. Note craniocaudal orientation of the lateral semicircular canal (LSCC), facial nerve (tympanic segment), oval window (stapes footplate attaches to oval window), and cochlear promontory (bony bulge covering the basal turn of cochlea). Greater superficial petrosal nerve (GSPN) originates at geniculate ganglion in the anterior genu of the facial nerve, where the nervus intermedius of Wrisberg [(NIW) not shown] joins the facial nerve. Posteroinferiorly, the descending mastoid segment of the facial nerve exits the temporal bone at the stylomastoid foramen on its way to the parotid gland.*
+
+![Sagittal graphic shows the medial wall of the middle ear. Note craniocaudal orientation of the lateral semicircular canal (LSCC), facial nerve (tympanic segment), oval window (stapes footplate attaches to oval window), and cochlear promontory (bony bulge covering the basal turn of cochlea). Greater superficial petrosal nerve (GSPN) originates at geniculate ganglion in the anterior genu of the facial nerve, where the nervus intermedius of Wrisberg [(NIW) not shown] joins the facial nerve. Posteroinferiorly, the descending mastoid segment of the facial nerve exits the temporal bone at the stylomastoid foramen on its way to the parotid gland.](images/app.statdx.com_image_thumbnail_71edd785-03d7-4904-8a71-ee56654bcccd_size_174_quality_85_83550ad83c9d3279852bebae9429c8b9077a9e52.jpg)
+*Sagittal graphic shows the medial wall of the middle ear. Note craniocaudal orientation of the lateral semicircular canal (LSCC), facial nerve (tympanic segment), oval window (stapes footplate attaches to oval window), and cochlear promontory (bony bulge covering the basal turn of cochlea). Greater superficial petrosal nerve (GSPN) originates at geniculate ganglion in the anterior genu of the facial nerve, where the nervus intermedius of Wrisberg [(NIW) not shown] joins the facial nerve. Posteroinferiorly, the descending mastoid segment of the facial nerve exits the temporal bone at the stylomastoid foramen on its way to the parotid gland.*
+
+
+*Coronal graphic shows craniocaudal orientation of LSCC, facial nerve canal (tympanic segment), oval window, & cochlear promontory, a very useful anatomic landmark for evaluating a coronal temporal bone CT. Superior & LSCCs, vestibule, & basal turn of cochlea together form a goose/duck-like appearance on coronal images.*
+
+
+*Axial graphic shows the posterior wall of the mesotympanum with small, air-filled areas (called sinus tympani) medially & facial (CNVII) recess laterally with the bony pyramidal eminence in between.*
+
+
+### Coronal Bone CT
+
+
+*First of 3 coronal reformatted bone CT images from anterior to posterior shows snake eyes (snail eyes) appearance of right facial nerve labyrinthine segment medially lying next to tympanic segment laterally. In the anterior aspect of the internal auditory canal (IAC)/petrous temporal bone, facial nerve (CNVII) lies above with cochlear nerve (CNVIII) lying below (mnemonic: "7-up"/"Coke-down"). The posterior aspect of IAC coronally will have the superior vestibular nerve above with inferior vestibular nerve lying below (both CNVIII); not shown.*
+
+
+*CT shows characteristic craniocaudal orientation of the LSCC, facial nerve canal (tympanic segment), oval window, & cochlear promontory. Superior & LSCCs, vestibule, & basal turn of cochlea together form a goose/duck-like appearance. Focal dehiscence of undersurface of tympanic segment facial nerve canal is a normal variant occurring in as many as 20-25% of adults, most commonly just above oval window, but is important to mention in presurgical temporal bone CT reports to avoid nerve injury during middle ear surgery.*
+
+
+*CT shows the posterior genu & descending mastoid segment of the facial nerve with branches.*
+
+
+### Axial Bone CT
+
+
+*First of 7 axial temporal bone CT images from top to bottom shows the right facial nerve IAC fundal segment continuing as the labyrinthine segment towards the anterior genu. GSPN originates at the geniculate ganglion in the anterior genu, where NIW joins the facial nerve. GSPN carries preganglionic parasympathetic fibers from superior salivatory nucleus (SSN) in lower dorsal pons (via NIW coming from cerebellopontine angle/IAC; then facial nerve geniculate ganglion in anterior genu; and then the vidian nerve) to supply lacrimal gland and nasal glands through the pterygopalatine ganglion in the pterygopalatine fossa. GSPN also carries sensory afferent taste fibers from the soft palate to nucleus of tractus solitarius (NTS) in medulla/lower pons. GSPN passes through a small hiatus in the petrous temporal bone & then in the middle cranial fossa floor between the 2 layers of dura mater underneath the temporal lobe. Also note the superior vestibular nerve.*
+
+
+*Second bone CT shows the tympanic segment of the right facial nerve. Note the inferior vestibular nerve & singular nerve.*
+
+
+*Third bone CT shows the posterior genu of the right facial nerve.*
+
+
+*Fourth bone CT shows the right facial nerve descending the mastoid segment, posteroinferior to posterior genu. Note the stapedius muscle; the tiny nerve to the stapedius arises from the proximal upper descending mastoid segment. Posterior mesotympanum (retrotympanum) has small, air-filled areas (called sinus tympani) medially & facial (CNVII) recess laterally with bony pyramidal eminence in between. Mnemonic for this mediolateral orientation is that sinus tympani has an "m," hence medial; & facial recess has an "l," hence lateral. Sinus tympani can be a blindspot at mastoidectomy where cholesteatoma may hide. Do not mistake the tensor tympani muscle for facial nerve tympanic segment. Chorda tympani nerve enters the anterior wall of the middle ear cavity at the anterior canaliculus of chorda tympani & continues into petrotympanic fissure (Glaserian fissure), which is medial to the TMJ.*
+
+
+*Image shows descending mastoid segment & posterior canaliculus of the chorda tympani nerve. Note GSPN forming the vidian nerve at the foramen lacerum.*
+
+
+*Chorda tympani nerve origin from the descending mastoid segment of the right facial nerve is shown.*
+
+
+### Axial Bone CT, Photon-Counting Detector CT, & Graphic
+
+
+*Last of 7 axial bone CT images shows the right facial nerve exiting the mastoid temporal bone at the stylomastoid foramen on its way to ramify within the parotid gland. Facial nerve perineural tumor spread from parotid malignancy should always be carefully evaluated.*
+
+![Axial photon-counting detector CT shows the mastoid canaliculus with the Arnold nerve (auricular branch of vagus [CNX]) originating from the lateral aspect of pars vascularis of the right jugular foramen. Mastoid canaliculus first connects laterally to the descending mastoid segment facial nerve canal a few millimeters above the stylomastoid foramen, then dips inferolaterally toward the tympanomastoid fissure (suture) at the posterior aspect of the external auditory canal (EAC). The Arnold nerve supplies part of the tympanic membrane & EAC & causes Arnold nerve cough reflex when mechanically stimulating the ear with a finger or ear bud.](f539764e-d057-4439-a65e-92b24fe2c03d)
+*Axial photon-counting detector CT shows the mastoid canaliculus with the Arnold nerve (auricular branch of vagus [CNX]) originating from the lateral aspect of pars vascularis of the right jugular foramen. Mastoid canaliculus first connects laterally to the descending mastoid segment facial nerve canal a few millimeters above the stylomastoid foramen, then dips inferolaterally toward the tympanomastoid fissure (suture) at the posterior aspect of the external auditory canal (EAC). The Arnold nerve supplies part of the tympanic membrane & EAC & causes Arnold nerve cough reflex when mechanically stimulating the ear with a finger or ear bud.*
+
+![Axial graphic shows the right mastoid canaliculus with the Arnold nerve [auricular branch of vagus (CNX)] on its way from the lateral aspect of pars vascularis of the jugular foramen toward the descending mastoid segment facial nerve canal.](10f0b222-3ef7-4d59-92e5-6f57eeacbc12)
+*Axial graphic shows the right mastoid canaliculus with the Arnold nerve [auricular branch of vagus (CNX)] on its way from the lateral aspect of pars vascularis of the jugular foramen toward the descending mastoid segment facial nerve canal.*
+
+
+### Chorda Tympani Nerve: Sagittal Graphic, Sagittal Bone CT, & Longitudinal Oblique (Stenver) Bone CT Reformation
+
+
+*Sagittal graphic shows an internal view of the lateral wall of the middle ear cavity. The chorda tympani nerve originates from the descending mastoid segment of the facial nerve, ascends through the posterior canaliculus of chorda tympani at the posterior wall of the middle ear, courses in the middle ear cavity from posterior to anterior in the substance of the tympanic membrane between mucous & fibrous layers, & then between the upper aspect of the handle (manubrium) of malleus & long process of incus, on the medial side of the upper part of the handle of malleus. It then travels through the anterior canaliculus of chorda tympani & exits the temporal bone into the masticator space through the petrotympanic fissure (Glaserian fissure), which is posteromedial to the TMJ, & joins the lingual nerve 2 cm below the skull base.*
+
+
+*Straight parasagittal bone CT reconstruction perpendicular to the axial CT without any obliquity shows the course of the chorda tympani nerve.*
+
+
+*Longitudinal oblique (Stenver) bone CT of the right ear near the anterior margin of the petrous temporal bony pyramid shows the chorda tympani nerve canal & the nerve itself in the middle ear cavity.*
+
+
+### Longitudinal Oblique (Stenver) & Transverse Oblique (Pöschl) Bone CT Reformations
+
+
+*Another longitudinal oblique (Stenver) bone CT more posteriorly shows the entire tympanic segment of the facial nerve. Note the anterior genu, tympanic segment, posterior genu, mastoid segment, & stylomastoid foramen, all seen on this single view. The tympanic segment passes beneath the LSCC.*
+
+
+*Further posterior longitudinal oblique (Stenver view) bone CT shows the labyrinthine & tympanic segments of the right facial nerve canal. Note the "2-dot" view of crura of the stapes just before they meet the footplate of the stapes at the oval window.*
+
+
+*Transverse oblique (Pöschl) bone CT reformation of the right ear parallel to the long axis of the superior SCC is shown. The image toward the medial aspect of the petrous temporal bone shows the axis of the labyrinthine segment of the facial nerve. When CNVII pathology is present, it is very helpful to have multiple different views of its canal. Transverse oblique (Pöschl) view image set is made in a plane parallel to the axis created by a line through superior SCC, whereas the longitudinal oblique (Stenver) view image set is made in a plane perpendicular to the superior SCC axis.*
+
diff --git a/docs_md/articles/facial-nerve-lesion-temporal-bone_1428754b-a8ee-48a0-98f8-4faeebf8dbab.md b/docs_md/articles/facial-nerve-lesion-temporal-bone_1428754b-a8ee-48a0-98f8-4faeebf8dbab.md
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+++ b/docs_md/articles/facial-nerve-lesion-temporal-bone_1428754b-a8ee-48a0-98f8-4faeebf8dbab.md
@@ -0,0 +1,307 @@
+---
+title: "Facial Nerve Lesion, Temporal Bone"
+docid: "1428754b-a8ee-48a0-98f8-4faeebf8dbab"
+authors:
+ - key: "eef2f839-5706-47b9-89c3-60d8315b2b3a"
+ value: "Nicholas A. Koontz, MD"
+breadcrumbs:
+ -
+ name: "Head and Neck"
+ slug: "head-and-neck"
+ treeNodeId: "ed24ed8c-5d57-4629-879b-447b82d2973d"
+ -
+ name: "Differential Diagnosis"
+ slug: "differential-diagnosis"
+ treeNodeId: "40d68862-8975-4dde-ac2b-ebc43ab0fb5c"
+ -
+ name: "Temporal Bone"
+ slug: "temporal-bone"
+ treeNodeId: "2f7dc690-4970-486f-abb6-ed24d99b7a04"
+ -
+ name: "Anatomically Based Differentials"
+ slug: "anatomically-based-differentials"
+ treeNodeId: "115faedf-cc6e-41cd-a155-665ce5b062ee"
+ -
+ name: "Facial Nerve Lesion, Temporal Bone"
+ slug: "facial-nerve-lesion-temporal-bone"
+ treeNodeId: null
+category: "Head and Neck"
+cmeTopicId: "5d11bc10-dd61-4bcd-8c3b-ac0d32054bb1"
+documentVersionId: "61084d95-357b-49d1-8ce1-5fc8c8732500"
+imageCount: 23
+lastUpdated: "08/13/18"
+pageDescription: "Facial Nerve Lesion, Temporal Bone"
+pageKeywords: "Head and Neck, Differential Diagnosis, Temporal Bone, Anatomically Based Differentials, Facial Nerve Lesion, Temporal Bone"
+pageTitle: "Facial Nerve Lesion, Temporal Bone | STATdx"
+enhancedTitle: "Facial Nerve Lesion, Temporal Bone"
+type: "DDX"
+references: true
+breadcrumbs:
+ - "Head and Neck"
+ - "Differential Diagnosis"
+ - "Temporal Bone"
+ - "Anatomically Based Differentials"
+ - "Facial Nerve Lesion, Temporal Bone"
+---
+# ESSENTIAL INFORMATION
+
+- ## Key Differential Diagnosis Issues
+
+
+ - Differential diagnosis considerations
+ - Differential diagnosis built on lesions primary to intratemporal facial nerve
+ - Other lesions included because part of lesion complex is abnormal facial nerve canal
+ - Imaging recommendations for Bell palsy
+ - Routine acute-onset Bell palsy **not** imaged
+ - Image only "atypical" Bell palsy
+ - Imaging recommendations for facial nerve lesion group
+ - Temporal bone (T-bone) CT & high-resolution MR are often complementary
+ - Particularly true when larger lesions are discovered with either modality
+- ## Helpful Clues for Common Diagnoses
+
+
+ - **Normal Facial Nerve Enhancement**
+ - Key facts
+ - Asymptomatic patient
+ - Normal imaging finding
+ - More prominent on 3T MR
+ - Imaging findings
+ - Bone CT: Normal facial nerve canal
+ - T1 C+ MR: Area of geniculate ganglion, anterior tympanic segment, & posterior genu of facial nerve may normally enhance
+ - Symmetric enhancement typical of normal variation
+ - **Bell Palsy**
+ - Key facts
+ - Acute onset of unilateral peripheral facial nerve paralysis
+ - > 90% recover & do not need imaging
+ - MR imaging for "atypical Bell palsy"
+ - Imaging findings
+ - T-bone CT: Normal facial nerve (CNVII) canal
+ - T1 C+ MR: Intratemporal facial nerve enhances along entire course
+ - T1 C+ MR other: Internal auditory canal (IAC) fundal "tuft" enhancement
+ - Increasing role of 3D-FLAIR
+ - 3D-FLAIR C-: Bright signal along canalicular CNVII
+ - 3D-FLAIR C+: Avid enhancement of canalicular CNVII, particularly fundal "tuft"
+ - High-resolution steady-state free precession T2 should **not** show mass-like nodular enlargement of CNVII
+ - **Temporal Bone Fracture Involving Facial Nerve Canal**
+ - Key facts
+ - Fracture line crosses facial nerve canal
+ - Fracture line may be difficult to see
+ - Multiplanar reconstructions are essential
+ - High-resolution T-bone CT is criterion standard for imaging but is imperfect tool
+ - Posterior genu & mastoid segment fractures are challenging to identify on CT; easily overlooked
+ - Imaging findings
+ - T-bone CT: Fracture may affect geniculate ganglion, tympanic, or mastoid segment of facial nerve
+ - Transverse fractures affect facial nerve more commonly than longitudinal fractures
+ - **Intratemporal Facial Nerve Perineural Malignancy**
+ - Key facts
+ - If invasive parotid malignancy found on CT or MR, imaging of stylomastoid foramen & mastoid segment facial nerve is critical
+ - Always look for perineural malignancy on intratemporal facial nerve
+ - Imaging findings
+ - T-bone CT: Normal to enlarged mastoid facial nerve canal ± opacification of adjacent mastoid air cells
+ - T1 C+ MR: Enlarged & asymmetrically enhancing facial nerve segment(s)
+ - Regardless of modality, scrutinize stylomastoid foramen & evaluate for loss of normal fat plane
+ - On CT, look for soft tissue replacing normal fat density at stylomastoid foramen
+ - On MR, look for loss of bright precontrast T1 signal at stylomastoid foramen
+ - **Caution: Do not fat saturate precontrast T1 MR**
+ - **Facial Nerve Venous Malformation ("Hemangioma")**
+ - Key facts
+ - May present with acute onset of peripheral facial nerve paralysis
+ - May be subtle imaging finding early in disease course
+ - Any focal facial nerve enhancement on MR should be investigated with T-bone CT
+ - Imaging findings
+ - Most common location: Geniculate fossa
+ - T-bone CT: "Honeycomb" matrix (50%)
+ - T1 C+ MR: Geniculate ganglion enhancing mass
+ - Other MR findings: When large, spreads anteromedially along greater superficial petrosal nerve course
+ - **Facial Nerve Schwannoma**
+ - Key facts
+ - 50% present with hearing loss
+ - Facial nerve symptoms may be delayed
+ - Imaging findings
+ - Most common location: Geniculate fossa
+ - Often affects multiple contiguous segments of intratemporal facial nerve
+ - T-bone CT: Expanded, tubular facial nerve canal
+ - T1 C+ MR: Enhancing mass along facial nerve
+ - Intramural cystic change possible when large
+- ## Helpful Clues for Less Common Diagnoses
+
+
+ - **Oval Window Atresia W****ith Ectopic Facial Nerve**
+ - Key facts
+ - May be seen with external auditory canal (EAC) atresia or as isolated lesion
+ - Presents with conductive hearing loss with normal otoscopic exam
+ - Key diagnosis to make, as facial nerve ectopia may preclude surgery
+ - If ectopic CNVII not recognized on preoperative imaging, may result in iatrogenic facial nerve injury
+ - Imaging findings
+ - T-bone CT: Oval window narrowed with bony atresia plate covering window itself
+ - Tympanic segment facial nerve moves medially from normal location under lateral semicircular canal
+ - Tympanic segment may be found on superior margin, within, or on inferior margin of atresia plate
+ - **External Auditory Canal Atresia W****ith Ectopic Facial Nerve**
+ - Key facts
+ - Severity of external ear microtia directly related to degree of EAC-middle ear malformation
+ - Mastoid segment is most commonly ectopic
+ - Imaging findings
+ - T-bone CT: EAC is dysplastic with mastoid segment facial nerve anterior to normal location
+ - Other CT findings: EAC is stenotic or absent
+ - Small middle ear with ossicle fusion mass ± oval window atresia
+- ## Helpful Clues for Rare Diagnoses
+
+
+ - **Prolapsing Facial Nerve I****nto Middle Ear**
+ - Key facts
+ - Intratemporal facial nerve bordering middle ear cavity may have variable bone covering
+ - If dehiscence of facial nerve is accompanied by protrusion of nerve into middle ear, there is high risk of injury during surgery
+ - Imaging findings
+ - T-bone CT: Tympanic segment facial nerve dehiscent ± nerve hanging into middle ear cavity
+ - Other T-bone CT findings: Facial nerve may appear slightly enlarged when not in bony canal
+ - **Ramsay Hunt Syndrome**
+ - Key facts
+ - Herpes zoster oticus affects facial nerve ± vestibulocochlear nerve ± inner ear
+ - EAC vesicles usually precede facial nerve symptoms
+ - When vesicular rash is delayed or mild, clinical confusion about diagnosis may be present
+ - Imaging findings
+ - T-bone CT: Facial nerve canal normal
+ - T1 C+ MR: Enhancing facial nerve in IAC & T-bone
+ - Increasing role of 3D-FLAIR
+ - Bright 3D-FLAIR C- inner ear signal & 3D-FLAIR C+ cochlear nerve enhancement more commonly seen in Ramsay Hunt than Bell Palsy
+ - Enhancement of inner ear structures & cochlear nerve is more variable on T1 C+ MR
+ - **Lyme Borreliosis****of Intratemporal****Facial Nerve**
+ - Key facts
+ - Bacteria *Borrelia* is tick-borne systemic infection
+ - May cause acute facial nerve paralysis
+ - Imaging findings
+ - T-bone CT: Normal facial nerve canal
+ - T1 C+ MR: Entire intratemporal CNVII enhances
+ - IAC-CPA CNVII enhancement may also be present
+
+## References
+
+# Selected References
+
+1. [Chen Y et al: Reliability of temporal bone high-resolution CT in patients with facial paralysis in temporal bone fracture. Am J Otolaryngol. 39(2):150-152, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=29258690%5Bpmid%5D)
+1. [Kirsch CFE et al: Practical tips for MR imaging of perineural tumor spread. Magn Reson Imaging Clin N Am. 26(1):85-100, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=29128008%5Bpmid%5D)
+1. [Kuya J et al: Usefulness of high-resolution 3D multi-sequences for peripheral facial palsy: differentiation between Bell's palsy and Ramsay Hunt syndrome. Otol Neurotol. 38(10):1523-1527, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=29135869%5Bpmid%5D)
+1. [Benoit MM et al: Facial nerve hemangiomas: vascular tumors or malformations? Otolaryngol Head Neck Surg. 142(1):108-14, 2010](http://www.ncbi.nlm.nih.gov/pubmed/?term=20096233%5Bpmid%5D)
+1. [Saraiya PV et al: Temporal bone fractures. Emerg Radiol. 16(4):255-65, 2009](http://www.ncbi.nlm.nih.gov/pubmed/?term=18982367%5Bpmid%5D)
+1. [Okada K et al: Benign mass lesions deep inside the temporal bone: imaging diagnosis for proper management. Acta Otolaryngol Suppl. (559):71-7, 2007](http://www.ncbi.nlm.nih.gov/pubmed/?term=18340574%5Bpmid%5D)
+1. [Chan EH et al: Facial palsy from temporal bone lesions. Ann Acad Med Singapore. 34(4):322-9, 2005](http://www.ncbi.nlm.nih.gov/pubmed/?term=15937573%5Bpmid%5D)
+1. [Kress B et al: Bell palsy: quantitative analysis of MR imaging data as a method of predicting outcome. Radiology. 230(2):504-9, 2004](http://www.ncbi.nlm.nih.gov/pubmed/?term=14699179%5Bpmid%5D)
+1. [Salzman KL et al: Dumbbell schwannomas of the internal auditory canal. AJNR Am J Neuroradiol. 22(7):1368-76, 2001](http://www.ncbi.nlm.nih.gov/pubmed/?term=11498429%5Bpmid%5D)
+1. [Caldemeyer KS et al: Imaging features and clinical significance of perineural spread or extension of head and neck tumors. Radiographics. 18(1):97-110; quiz 147, 1998](http://www.ncbi.nlm.nih.gov/pubmed/?term=9460111%5Bpmid%5D)
+1. [Gebarski SS et al: Enhancement along the normal facial nerve in the facial canal: MR imaging and anatomic correlation. Radiology. 183(2):391-4, 1992](http://www.ncbi.nlm.nih.gov/pubmed/?term=1561339%5Bpmid%5D)
+1. [Parker GD et al: Clinical-radiologic issues in perineural tumor spread of malignant diseases of the extracranial head and neck. Radiographics. 11(3):383-99, 1991](http://www.ncbi.nlm.nih.gov/pubmed/?term=1852933%5Bpmid%5D)
+1. [Curtin HD et al: "Ossifying" hemangiomas of the temporal bone: evaluation with CT. Radiology. 164(3):831-5, 1987](http://www.ncbi.nlm.nih.gov/pubmed/?term=3112865%5Bpmid%5D)
+
+
+## Images
+
+
+### Selected Images
+
+
+**Normal Facial Nerve Enhancement**
+*Axial T1 C+ FS MR shows the normal enhancement pattern of the facial nerves. Note mild symmetric enhancement of the geniculate ganglia and anterior tympanic segments but absent enhancement of the intracanalicular segments bilaterally.*
+
+
+**Normal Facial Nerve Enhancement**
+*Axial T1 C+ FS MR shows the normal enhancement pattern of the facial nerves. Note mild symmetric enhancement of the geniculate ganglia and anterior tympanic segments but absent enhancement of the intracanalicular segments bilaterally.*
+
+
+**Normal Facial Nerve Enhancement**
+*Axial T1 C+ MR reveals prominent but normal enhancement of the geniculate ganglion and anterior tympanic segment of facial nerve .*
+
+
+**Normal Facial Nerve Enhancement**
+*Axial T1 C+ MR reveals prominent but normal enhancement of the geniculate ganglion and anterior tympanic segment of facial nerve .*
+
+
+**Bell Palsy**
+*Axial T1 C+ FS MR in a patient with Bell palsy shows a "tuft" of enhancement at the fundus of the internal auditory canal as well as abnormal enhancement along the labyrinthine segment and anterior genu of facial nerve.*
+
+
+**Bell Palsy**
+*Axial T1 C+ FS MR in a patient with Bell palsy shows a "tuft" of enhancement at the fundus of the internal auditory canal as well as abnormal enhancement along the labyrinthine segment and anterior genu of facial nerve.*
+
+
+**Bell Palsy**
+*Coronal T1 C+ FS MR in a patient with Bell palsy shows a classic "tuft" of enhancement at the fundus of the internal auditory canal above the crista falciformis . Note additional enhancement of the tympanic segment of facial nerve, which courses below the lateral semicircular canal.*
+
+
+**Temporal Bone Fracture Involving Facial Nerve Canal**
+*Axial bone CT shows a complex, longitudinally oriented fracture of the right temporal bone, which traverses the anterior genu of the facial nerve canal , resulting in ipsilateral facial paralysis. Note avulsion of the petrous ridge .*
+
+
+**Intratemporal Facial Nerve Perineural Malignancy**
+*Coronal T1 C+ FS MR shows a small, high, intraparotid adenoid cystic carcinoma centered just below the stylomastoid foramen . Note avid enhancement of the mastoid segment of the facial nerve from perineural tumor spread.*
+
+
+**Facial Nerve Venous Malformation ("Hemangioma")**
+*Axial bone CT shows a permeative expansile lesion with a "honeycomb" matrix centered at the anterior genu of the facial nerve canal. Note extension into the widened labyrinthine and anterior tympanic segments of the facial nerve canal.*
+
+
+**Facial Nerve Schwannoma**
+*Axial bone CT demonstrates smooth enlargement of the geniculate fossa and the anterior tympanic segment of the facial nerve canal , which is typical of facial nerve schwannoma. Note that unlike a venous malformation, no internal matrix is seen.*
+
+
+**Oval Window Atresia With Ectopic Facial Nerve**
+*Axial NECT shows a medialized course of the facial nerve tympanic segment overlying the oval window, which has a prominent bony atresia plate abutting the facial nerve.*
+
+
+**Oval Window Atresia With Ectopic Facial Nerve**
+*Coronal bone CT in a child with a complex ear malformation shows an atresia plate at the oval window with associated ectopic course of the facial nerve , which is positioned more medial than usual along the atresia plate. Note additional hypoplastic lateral semicircular canal as well as EAC atresia with microtia.*
+
+
+**External Auditory Canal Atresia With Ectopic Facial Nerve**
+*Coronal bone CT in a child with EAC atresia shows an aberrant course of the facial nerve canal that is positioned inferolateral to its expected course immediately beneath the lateral semicircular canal . A BB marks the expected location of the absent auricle.*
+
+
+**Prolapsing Facial Nerve Into Middle Ear**
+*Axial bone CT shows a typical case of midtympanic segment facial nerve prolapse into the middle ear cavity . The facial nerve is sagging into the oval window niche.*
+
+
+**Ramsay Hunt Syndrome**
+*Axial T1 C+ FS MR reveals linear internal auditory canal and intracochlear enhancement, in addition to prominent enhancement of the tympanic segment of the facial nerve. The patient had external ear vesicles at the time of imaging.*
+
+
+**Lyme Borreliosis of Intratemporal Facial Nerve**
+*Axial T1WI C+ FS MR in a patient with Lyme borreliosis of facial nerve demonstrates intense enhancement of labyrinthine , geniculate , and anterior tympanic segments of the left intratemporal facial nerve. Note that the IAC-CPA segment also enhances faintly.*
+
+
+### Additional Images
+
+
+**Normal Facial Nerve Enhancement**
+*Axial T1 C+ FS MR shows normal enhancement of anterior tympanic segment and geniculate ganglion portions of intratemporal facial nerve in this asymptomatic patient.*
+
+
+**Bell Palsy**
+*Axial T1 C+ FS MR reveals an internal auditory canal fundal "tuft" of facial nerve enhancement along with enhancement of the labyrinthine segment and geniculate ganglion in this patient with Bell palsy.*
+
+
+**Bell Palsy**
+*Axial T1 C+ FS MR shows the midmastoid segment of the facial nerve enhancing avidly . A normal mastoid segment never enhances to this degree.*
+
+
+**Temporal Bone Fracture Involving Facial Nerve Canal**
+*Axial bone CT demonstrates a transverse fracture through the inner ear. The fracture line passes anteriorly through the labyrinthine segment of the facial nerve canal .*
+
+
+**Facial Nerve Venous Malformation ("Hemangioma")**
+*Axial bone CT shows a C-shaped venous malformation of the labyrinthine segment and geniculate ganglion segments of the facial nerve. The anterior surface of the petrous apex is also involved.*
+
+
+**Oval Window Atresia With Ectopic Facial Nerve**
+*Coronal bone CT shows a typical case of oval window atresia with aberrant facial nerve overlying the site of the oval window. Any attempt to repair this atresia will result in injury to CNVII.*
+
+
+**Oval Window Atresia With Ectopic Facial Nerve**
+*Axial bone CT demonstrates the tympanic segment of the facial nerve overlying the oval window, which has an atresia plate visible .*
+
+
+**External Auditory Canal Atresia With Ectopic Facial Nerve**
+*Axial bone CT demonstrates that the mastoid segment of the facial nerve is anterior to its normal location as a result of atresia of the EAC.*
+
+
+**Lyme Borreliosis of Intratemporal Facial Nerve**
+*Axial T1 C+ FS MR shows intense enhancement of the tympanic segment of the facial nerve in this patient with Lyme borreliosis of intratemporal facial nerve.*
+
diff --git a/docs_md/articles/femoral-hernia_45d54e6d-97bd-4dd4-beed-b31f572d7b95.md b/docs_md/articles/femoral-hernia_45d54e6d-97bd-4dd4-beed-b31f572d7b95.md
new file mode 100644
index 0000000..3747a87
--- /dev/null
+++ b/docs_md/articles/femoral-hernia_45d54e6d-97bd-4dd4-beed-b31f572d7b95.md
@@ -0,0 +1,344 @@
+---
+title: "Femoral Hernia"
+docid: "45d54e6d-97bd-4dd4-beed-b31f572d7b95"
+authors:
+ - key: "c1df94ab-4a9f-44c4-add7-1f174fb9ac45"
+ value: "Siva P. Raman, MD"
+breadcrumbs:
+ -
+ name: "Gastrointestinal"
+ slug: "gastrointestinal"
+ treeNodeId: "b52263f7-5978-4a22-a17d-7260e0033943"
+ -
+ name: "Diagnosis"
+ slug: "diagnosis"
+ treeNodeId: "5a7c51af-b1c6-4629-8f0e-d99e6fe57a98"
+ -
+ name: "Peritoneum, Mesentery, and Abdominal Wall"
+ slug: "peritoneum-mesentery-and-abdominal-"
+ treeNodeId: "a3fb9f00-f894-4b38-9e01-2f78406cf547"
+ -
+ name: "External Hernias"
+ slug: "external-hernias"
+ treeNodeId: "71ab3f79-4332-463c-9f60-d3dd2902d974"
+ -
+ name: "Femoral Hernia"
+ slug: "femoral-hernia"
+ treeNodeId: null
+category: "Gastrointestinal"
+documentVersionId: "3147d7c8-677b-41f1-b7e8-0cd8cd5a0489"
+imageCount: 16
+lastUpdated: "03/13/25"
+pageDescription: "Femoral Hernia"
+pageKeywords: "Gastrointestinal, Diagnosis, Peritoneum, Mesentery, and Abdominal Wall, External Hernias, Femoral Hernia"
+pageTitle: "Femoral Hernia | STATdx"
+enhancedTitle: "Femoral Hernia"
+type: "DX"
+references: true
+ddx: true
+cases: 1
+breadcrumbs:
+ - "Gastrointestinal"
+ - "Diagnosis"
+ - "Peritoneum, Mesentery, and Abdominal Wall"
+ - "External Hernias"
+ - "Femoral Hernia"
+---
+# KEY FACTS
+
+- ## Terminology
+
+
+ - Protrusion of abdominal contents through femoral ring into femoral canal
+- ## Imaging
+
+
+ - Omental fat or bowel herniating into femoral canal **medial to femoral vein**and **inferior to inferior epigastric vessels**
+ - Femoral vein often indented or compressed by hernia sac
+ - Hernia sac located posterior and lateral to pubic tubercle
+ - Narrow, funnel-shaped neck
+ - 2x as common on right side compared to left
+- ## Top Differential Diagnoses
+
+
+ - Inguinal hernia
+ - Inguinal hernias seen **anterior**to horizontal plane of pubic tubercle
+ - Abdominal contents within inguinal canal **anteromedial**to femoral vessels with extension into scrotum
+ - Obturator hernia
+ - Hernia into superolateral aspect of obturator canal
+ - Lymphadenopathy
+- ## Clinical Issues
+
+
+ - Primarily occur in older women with 36% occurring in patients > 80 years old
+ - Relatively uncommon, representing only 2-4% of groin hernias in adults
+ - ~ 1/10 as common as inguinal hernias
+ - ~ 1/3 of groin hernias occur in women
+ - Highest risk of incarceration/strangulation (25-40%) among all groin hernias
+ - 8-12x more prone to incarceration/strangulation than inguinal hernias
+ - Significant risk of mortality, primarily related to incarceration and intestinal obstruction
+ - Mortality: 1% in 70-79 age group; 5% in 80-90 age group
+ - Symptomatic hernia (or newly discovered asymptomatic hernia) should undergo immediate surgical repair
+
+# TERMINOLOGY
+
+- ## Abbreviations
+
+
+ - Femoral hernia (FH)
+- ## Synonyms
+
+
+ - Crural hernia, enteromerocele, femorocele
+- ## Definitions
+
+
+ - Groin hernia with protrusion of abdominal contents through femoral ring into femoral canal
+
+# IMAGING
+
+- ## General Features
+
+
+ - ### Location
+
+
+ - Protrusion of hernia sac contents at right angle to inguinal canal through femoral ring into femoral canal
+ - Posterior to inguinal ligament, anterior to pubic ramus periosteum (Cooper ligament), and medial to femoral vessels
+ - Inguinal ligament not visible on CT as discrete structure, but horizontal plane connecting pubic tubercles defines plane of inguinal ligament
+ - FH located posterior to plane of pubic tubercle
+ - 2x as common on right side compared to left
+ - ### Morphology
+
+
+ - Narrow neck with characteristic pear shape
+- ## CT Findings
+
+
+ - Omental fat or bowel herniating into femoral canal **medial to femoral vein**and **inferior to inferior epigastric vessels**
+ - Femoral vein often indented or compressed by hernia sac
+ - Hernia sac located **posterior**and **lateral**to pubic tubercle
+ - Narrow funnel-shaped or pear-shaped neck, often best appreciated on coronal or sagittal images
+- ## Ultrasonographic Findings
+
+
+ - Hernia sac visualized extending medial to femoral vein
+ - Hernia sac may be easier to define with Valsalva maneuver
+- ## Radiographic Findings
+
+
+ - Herniography: Hernia curves smoothly over superior pubic ramus on all projections
+ - Pear-shaped hernia sac with narrow neck
+- ## Imaging Recommendations
+
+
+ - ### Best imaging tool
+
+
+ - CECT
+
+# DIFFERENTIAL DIAGNOSIS
+
+- [Inguinal Hernia](/document/inguinal-hernia/cf4d4a15-6a85-4aeb-9563-7be7e8131bc7)
+ - Abdominal contents within inguinal canal **anteromedial**to femoral vessels with extension into scrotum
+ - Seen **anterior**to horizontal plane of pubic tubercle
+ - Does not involve femoral canal or compress femoral vessels
+- [Obturator Hernia](/document/obturator-hernia/3da35b45-a34c-4c05-9183-33b77dbc439d)
+ - Hernia into superolateral obturator canal
+ - Typically occurs in older women (80-90%) with high risk of incarceration
+- ## Lymphadenopathy
+
+
+ - When medial to femoral vessels, can theoretically mimic FH on clinical exam but distinction easily made with CT
+
+# PATHOLOGY
+
+- ## General Features
+
+
+ - ### Etiology
+
+
+ - May be partially attributable to congenital defect in insertion of transversalis fascia to ileopubic tract
+ - Right-sided predominance thought to be secondary to delay during development in closure of processus vaginalis, as right testicle normally descends slower during development
+ - Sigmoid colon may exert pressure on left femoral canal during development and make left-sided FHs less likely
+ - Femoral ring connective tissues may dilate during pregnancy, placing women at increased risk for FH
+ - Associated with increased intraabdominal pressure
+
+# CLINICAL ISSUES
+
+- ## Presentation
+
+
+ - ### Most common signs/symptoms
+
+
+ - Swelling, groin discomfort, vague pelvic discomfort
+ - Lump usually felt at top of thigh, below groin crease
+ - Pain is uncommon in absence of strangulation
+ - 1/3 of patients asymptomatic at time of diagnosis
+ - ### Other signs/symptoms
+
+
+ - Nausea, vomiting, severe pain with strangulated hernia
+ - Difficult to diagnose clinically, especially in obese patients, due to deep location of femoral canal
+- ## Demographics
+
+
+ - ### Age
+
+
+ - 36% occur in patients > 80 years old
+ - 16% occur in 7th decade
+ - < 1% of all groin hernias in children
+ - ### Sex
+
+
+ - Predominantly women (M:F = 1:10)
+ - ### Epidemiology
+
+
+ - ~ 2-4% of groin hernias in adults
+ - ~ 1/10 as common as inguinal hernias
+ - ~ 1/3 of groin hernias in women
+ - 10% of women and 50% of men with FHs also have coexisting inguinal hernias at diagnosis
+- ## Natural History & Prognosis
+
+
+ - Complications
+ - High risk of incarceration &/or strangulation (25-40%), primarily due to narrow neck and unyielding margins of femoral ring
+ - Highest rate of incarceration of all groin hernias
+ - 8-12x more prone to incarceration/strangulation than inguinal hernias
+ - Rarely, inflamed appendix extends into hernia sac (**De Garengeot hernia**)
+ - Morbidity and mortality
+ - Primarily related to incarceration/bowel obstruction
+ - Mortality: 1% in 70-79 age group; 5% in 80-90 age group
+- ## Treatment
+
+
+ - Symptomatic hernia (or newly discovered asymptomatic hernia) should undergo immediate surgical repair
+ - Longstanding, asymptomatic hernias may theoretically be treated conservatively with watchful waiting
+ - Can be repaired either with laparoscopic or open surgery (without any consensus in literature)
+
+# DIAGNOSTIC CHECKLIST
+
+- ## Image Interpretation Pearls
+
+
+ - FHs lie medial to femoral vein and inferior to inferior epigastric vessels, often compressing femoral vein
+
+ 75526537-4844-4ee0-b8ce-a4b2d77fd2bf
+
+## References
+
+# Selected References
+
+1. [Goethals A et al: Femoral hernia. StatPearls, 2024](http://www.ncbi.nlm.nih.gov/pubmed/?term=30571070%5Bpmid%5D)
+1. [Kumar N et al: The use of CECT in the diagnosis of intestinal obstruction: a case of difficult diagnosis in a strangulated left femoral hernia. Niger J Clin Pract. 27(4):534-6, 2024](http://www.ncbi.nlm.nih.gov/pubmed/?term=38679778%5Bpmid%5D)
+1. [Pelly T et al: Inguinal and femoral hernias. BMJ. 386:e079531, 2024](http://www.ncbi.nlm.nih.gov/pubmed/?term=39009372%5Bpmid%5D)
+1. [Guenther TM et al: De Garengeot hernia: a systematic review. Surg Endosc. 35(2):503-13, 2021](http://www.ncbi.nlm.nih.gov/pubmed/?term=32880011%5Bpmid%5D)
+1. [McArthur D et al: Epiploic appendagitis in a femoral hernia. J Radiol Case Rep. 13(5):10-4, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=31558954%5Bpmid%5D)
+1. [Dahlstrand U et al: Limited potential for prevention of emergency surgery for femoral hernia. World J Surg. 38(8):1931-16, 2014](http://www.ncbi.nlm.nih.gov/pubmed/?term=24682315%5Bpmid%5D)
+1. [Alhambra-Rodriguez de Guzmán C et al: Improved outcomes of incarcerated femoral hernia: a multivariate analysis of predictive factors of bowel ischemia and potential impact on postoperative complications. Am J Surg. 205(2):188-93, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=23021195%5Bpmid%5D)
+1. [Burkhardt JH et al: Diagnosis of inguinal region hernias with axial CT: the lateral crescent sign and other key findings. Radiographics. 31(2):E1-12, 2011](http://www.ncbi.nlm.nih.gov/pubmed/?term=21415178%5Bpmid%5D)
+1. [Cherian PT et al: The diagnosis and classification of inguinal and femoral hernia on multisection spiral CT. Clin Radiol. 63(2):184-92, 2008](http://www.ncbi.nlm.nih.gov/pubmed/?term=18194695%5Bpmid%5D)
+1. [Cherian PT et al: Radiologic anatomy of the inguinofemoral region: insights from MDCT. AJR Am J Roentgenol. 189(4):W177-83, 2007](http://www.ncbi.nlm.nih.gov/pubmed/?term=17885029%5Bpmid%5D)
+1. [Suzuki S et al: Differentiation of femoral versus inguinal hernia: CT findings. AJR Am J Roentgenol. 189(2):W78-83, 2007](http://www.ncbi.nlm.nih.gov/pubmed/?term=17646443%5Bpmid%5D)
+1. [Akopian G et al: De Garengeot hernia: appendicitis within a femoral hernia. Am Surg. 71(6):526-7, 2005](http://www.ncbi.nlm.nih.gov/pubmed/?term=16044937%5Bpmid%5D)
+1. [Bringman S et al: Intestinal obstruction after inguinal and femoral hernia repair: a study of 33,275 operations during 1992-2000 in Sweden. Hernia. 9(2):178-83, 2005](http://www.ncbi.nlm.nih.gov/pubmed/?term=15568160%5Bpmid%5D)
+1. [Holzheimer RG: Inguinal Hernia: classification, diagnosis and treatment--classic, traumatic and Sportsman's hernia. Eur J Med Res. 10(3):121-34, 2005](http://www.ncbi.nlm.nih.gov/pubmed/?term=15851379%5Bpmid%5D)
+1. [Ikossi DG et al: Laparoscopic femoral hernia repair using umbilical ligament as plug. J Laparoendosc Adv Surg Tech A. 15(2):197-200, 2005](http://www.ncbi.nlm.nih.gov/pubmed/?term=15898918%5Bpmid%5D)
+1. [Alvarez JA et al: Incarcerated groin hernias in adults: presentation and outcome. Hernia. 8(2):121-6, 2004](http://www.ncbi.nlm.nih.gov/pubmed/?term=14625699%5Bpmid%5D)
+1. [Malek S et al: Emergency repair of groin herniae: outcome and implications for elective surgery waiting times. Int J Clin Pract. 58(2):207-9, 2004](http://www.ncbi.nlm.nih.gov/pubmed/?term=15055870%5Bpmid%5D)
+1. [Hachisuka T: Femoral hernia repair. Surg Clin North Am. 83(5):1189-205, 2003](http://www.ncbi.nlm.nih.gov/pubmed/?term=14533910%5Bpmid%5D)
+1. [Swarnkar K et al: Sutureless mesh-plug femoral hernioplasty. Am J Surg. 186(2):201-2, 2003](http://www.ncbi.nlm.nih.gov/pubmed/?term=12885618%5Bpmid%5D)
+1. [Zollinger RM Jr: Classification systems for groin hernias. Surg Clin North Am. 83(5):1053-63, 2003](http://www.ncbi.nlm.nih.gov/pubmed/?term=14533903%5Bpmid%5D)
+1. [Lau WY: History of treatment of groin hernia. World J Surg. 26(6):748-59, 2002](http://www.ncbi.nlm.nih.gov/pubmed/?term=12053232%5Bpmid%5D)
+1. [Dieudonne G: Plug repair of groin hernias: a 10-year experience. Hernia. 5(4):189-91, 2001](http://www.ncbi.nlm.nih.gov/pubmed/?term=12003046%5Bpmid%5D)
+1. [Zhang GQ et al: Groin hernias in adults: value of color Doppler sonography in their classification. J Clin Ultrasound. 29(8):429-34, 2001](http://www.ncbi.nlm.nih.gov/pubmed/?term=11745848%5Bpmid%5D)
+1. [Ianora AA et al: Abdominal wall hernias: imaging with spiral CT. Eur Radiol. 10(6):914-9, 2000](http://www.ncbi.nlm.nih.gov/pubmed/?term=10879702%5Bpmid%5D)
+1. [Toms AP et al: Illustrated review of new imaging techniques in the diagnosis of abdominal wall hernias. Br J Surg. 86(10): 1243-9, 1999](http://www.ncbi.nlm.nih.gov/pubmed/?term=10540124%5Bpmid%5D)
+1. [Loftus WK et al: Case report: femoral hernia causing small bowel obstruction--ultrasound diagnosis. Clin Radiol. 53(8):618-9, 1998](http://www.ncbi.nlm.nih.gov/pubmed/?term=9744593%5Bpmid%5D)
+1. [Radcliffe G et al: Reappraisal of femoral hernia in children. Br J Surg. 84(1): 58-60, 1997](http://www.ncbi.nlm.nih.gov/pubmed/?term=9043453%5Bpmid%5D)
+1. [Harrison LA et al: Abdominal wall hernias: review of herniography and correlation with cross-sectional imaging. Radiographics. 15(2):315-32, 1995](http://www.ncbi.nlm.nih.gov/pubmed/?term=7761638%5Bpmid%5D)
+1. [Chamary VL: Femoral hernia: intestinal obstruction is an unrecognized source of morbidity and mortality. Br J Surg. 80(2): 230-2, 1993](http://www.ncbi.nlm.nih.gov/pubmed/?term=8443665%5Bpmid%5D)
+1. [Lewin JR: Femoral hernia with upward extension into abdominal wall: CT diagnosis. AJR Am J Roentgenol. 136(1):206-7, 1981](http://www.ncbi.nlm.nih.gov/pubmed/?term=6450522%5Bpmid%5D)
+
+## Differential diagnosis
+
+### Abdominal Wall Mass
+DDX:d51e2268-67b6-4a60-9222-f5a86f61ddec
+
+### Defect in Abdominal Wall (Hernia)
+DDX:5af046fa-59ef-45b5-952b-acbcdee36196
+
+### Groin Mass
+DDX:160e727f-dabe-4187-aa46-c29625076cc5
+
+### Small Bowel Obstruction
+DDX:ad8209f0-71e5-4496-860f-d2724ca22892
+
+### Cluster of Dilated Small Bowel
+DDX:6a20ee48-b80a-4d67-9011-7a3c7176ef79
+
+## Cases
+
+- {'cases': [{'authors': [{'key': 'b61b8522-59ff-48f3-aaeb-65cc6d64aab2', 'value': 'Tracy A Jaffe, MD'}], 'caseVersionId': '2549544c-ebb1-4b6c-aaa2-c619e125e620', 'description': 'This is a classic illustration of a patient with small bowel obstruction from an incarcerated femoral hernia. \n\nThe axial images of the upper abdomen demonstrate dilated small bowel (arrow, #1, 2). Distal small bowel is decompressed (curved arrow, #3). Despite the streak artifact caused by the patients total hip arthroplasty, one can easily identify a knuckle of small bowel within the femoral canal, the source of the patients small bowel obstruction (open arrow, #4, 5). \n\nComment: Femoral hernias are more prone to incarceration than inguinal hernias, and mortality is closely associated with intestinal obstruction. This patient went on to exploratory laparotomy, excision of necrotic small bowel, and repair of the femoral hernia.', 'history': 'Elderly women with vomiting and abdominal pain.', 'imagePoolId': '2c01b04f-cdee-47c1-8e03-1f25f22a1694', 'name': 'Strangulated small bowel', 'teachingPoint': None, 'demographics': '74 Years old female'}, {'authors': [{'key': 'b61b8522-59ff-48f3-aaeb-65cc6d64aab2', 'value': 'Tracy A Jaffe, MD'}], 'caseVersionId': '26c94b87-a3cc-4ab3-96d8-e3631e5cdc1d', 'description': 'This case illustrates a femoral hernia which has become incarcerated in the femoral canal. \n\nThe images of the upper abdomen demonstrate dilated small bowel (arrows, #1, 2). More inferior images demonstrate decompressed distal small bowel suggesting a small bowel obstruction (open arrow, #3). Even more inferiorly we identify the source of obstruction, small bowel trapped in the femoral canal (curved arrow, #4). \n\nCoronal reformation (#5) confirms the location of the hernia (arrow). The neck of a femoral hernia is below the inguinal ligament and lateral to the pubic tubercle. The hernia is medial to the femoral vessels. Femoral hernias occur more frequently in women and may become incarcerated, as in this case (8-12 times more likely to become trapped than inguinal hernia).', 'history': 'Middle-aged patient with right groin pain and nausea.', 'imagePoolId': '09327dee-e765-494a-ab29-ed7c86d02bcf', 'name': 'Incarcerated', 'teachingPoint': None, 'demographics': '57 Years old female'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '2702a000-04be-4be1-89c1-4586d0a4e415', 'description': 'CECT shows massive distension of small bowel segments. Some distal small bowel (open arrow, #3) and the colon are collapsed, indicating a distal mechanical small bowel obstruction. The cause of the obstruction is seen as a femoral hernia (arrow, #4). Note that the herniated bowel lies just medial to the femoral vessels.', 'history': 'Young woman with abdominal pain and distention.', 'imagePoolId': '2cce5cc7-6d4d-4106-bacf-876353db273d', 'name': 'With small bowel obstruction', 'teachingPoint': None, 'demographics': '40 Years old female'}, {'authors': [{'key': 'b61b8522-59ff-48f3-aaeb-65cc6d64aab2', 'value': 'Tracy A Jaffe, MD'}], 'caseVersionId': 'a32e13a0-dfd7-4b77-9bbd-f7862d44ee94', 'description': 'This is a typical presentation of small bowel obstruction caused by a femoral hernia. \n\nAxial CECT images of the upper abdomen demonstrate multiple dilated, fluid-filled small bowel loops (arrow, #1). Image of the pelvis illustrates the source of obstruction, a knuckle of small bowel incarcerated in the femoral canal (arrow, #2). The hernia is protruding posterior to the inguinal ligament, medial to the femoral vessels (open arrow, #2). This is confirmed on the coronal reformation (arrow, #3). As expected, this femoral hernia has a narrow neck and "pear" shape.', 'history': 'Elderly patient with abdominal pain and obstructive symptoms.', 'imagePoolId': '174be9c1-80e6-4d13-9e6d-70a1749addec', 'name': 'Small bowel obstruction', 'teachingPoint': None, 'demographics': '80 Years old female'}, {'authors': [{'key': '49dc75da-ca12-45cb-97fc-2fe88198512c', 'value': 'Erik K Paulson, MD'}], 'caseVersionId': 'a7464dd1-c572-40a7-ad52-eca02e8f08f4', 'description': 'This case illustrates typical findings of a small bowel obstruction, due to a femoral hernia. \n\nImage #1 shows dilated small bowel (arrow) and decompressed distal small bowel (curved arrows).\n\nImages #2 and #3 show a loop of bowel (arrow) coursing into the femoral ring, medial to the femoral vessels, which represents the transition point from dilated to decompressed bowel and is the cause of the small bowel obstruction. Note the decompressed sigmoid colon (curved arrow, #2) with diverticula.\n\nCoronal reformation (#4) nicely demonstrates the incarcerated loop of small bowel (arrow) within the femoral ring.', 'history': 'Elderly woman with abdominal pain, nausea and vomiting. ', 'imagePoolId': '8bda08be-775a-4b9a-85cb-a9265e0afef8', 'name': 'Femoral hernia', 'teachingPoint': None, 'demographics': '80 Years old female'}, {'authors': [{'key': 'b61b8522-59ff-48f3-aaeb-65cc6d64aab2', 'value': 'Tracy A Jaffe, MD'}], 'caseVersionId': 'c566f2ee-e12d-4d71-947f-0fea65361014', 'description': 'This patient was referred for imaging of a palpable abnormality in the right groin. \n\nCECT images of the pelvis demonstrate nondilated, contrast-filled loops of small and large bowel (#1, 2). Axial image inferior to the pubic symphysis (#3) demonstrate a fluid-filled structure with a "pear" shape seen medial to the femoral vessels (arrow). This structure is also identified on the coronal image (arrow, #4). This is a femoral hernia without incarceration. The hernia is low within the femoral canal and the neck is below the inguinal ligament. \n\nComment: This femoral hernia was identified prior to bowel strangulation and the patient went on to surgical repair without small bowel resection.', 'history': 'Elderly female with pain in right groin.', 'imagePoolId': 'd5c2829f-f972-4a8c-a04b-c75a93e2b33d', 'name': 'Nondilated small bowel', 'teachingPoint': None, 'demographics': '78 Years old female'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'cdf131d2-9f11-448e-b3be-3953c29a91c5', 'description': 'A supine radiograph (#1) shows distended small bowel and minimal colonic gas.\n\nCT shows fluid distended small bowel segments in the pelvis. The distended bowel could be followed into a femoral hernia (arrow, #3, 4). Note the close relationship of the hernia to the femoral vessels at the level of the symphysis pubis.', 'history': 'Elderly woman with abdominal pain.', 'imagePoolId': 'e8a7cd5a-90fd-49a9-83df-4e285cc98b10', 'name': 'With bowel obstruction', 'teachingPoint': None, 'demographics': '76 Years old female'}], 'caseType': 'typical', 'name': 'TYPICAL'}
+
+
+## Images
+
+
+### Selected Images
+
+
+*Graphic of a femoral hernia demonstrates a characteristic "knuckle" of small bowel closely associated with the femoral vein . Femoral hernias are usually found medial to the femoral vessels with frequent compression of the femoral vein.*
+
+
+*Axial CECT demonstrates the typical position of a femoral hernia . Note that the herniated loop of small bowel lies just medial to the femoral vessels .*
+
+
+*Axial CECT shows a loop of thickened, hyperemic bowel herniating into the right groin medial to the femoral vessels.*
+
+
+*Coronal CECT in the same patient demonstrates multiple dilated loops of small bowel with abrupt narrowing at the level of a segment of bowel coursing into the femoral ring, medial to the femoral vessels , compatible with small bowel obstruction secondary to a femoral hernia.*
+
+
+### Additional Images
+
+
+*Axial CECT shows a femoral hernia with a small bowel obstruction. Note the loop of bowel entrapped in the right femoral canal .*
+
+
+*Axial CECT at higher level in the same patient reveals a small bowel obstruction .*
+
+
+*Axial CECT shows an incarcerated femoral hernia in the femoral canal. Note the decompressed distal small bowel, suggesting a small bowel obstruction .*
+
+
+*Axial CECT in the same patient at a lower level identifies the source of the obstruction: Small bowel trapped in the femoral canal .*
+
+
+*Coronal CECT reformation of a femoral hernia causing small bowel obstruction shows that the neck of the hernia is medial to the femoral artery . Note the proximal dilation of the small bowel due to obstruction .*
+
+
+*Coronal reformation in the same patient clearly demonstrates a herniated loop of small bowel .*
+
+
+*Axial CECT at a lower level demonstrates herniated bowel medial to the femoral vein .*
+
+
+*Axial CECT shows a left femoral hernia containing a "knuckle" of strangulated bowel.*
+
+
+*Axial CECT in an older woman shows a right femoral hernia and pessary .*
+
+
+*Axial CECT shows a right femoral hernia containing small bowel that caused obstruction.*
+
+
+*Axial CECT in an 80-year-old woman with abdominal pain, fever, and nausea shows a loop of bowel coursing into the femoral ring medial to the femoral vessels; the transition point from the dilated to the decompressed bowel, causing a small bowel obstruction. Note the presence of diverticula within the decompressed sigmoid colon.*
+
+
+*Coronal CECT reformation in the same patient demonstrates an incarcerated loop of small bowel within the femoral ring.*
+
diff --git a/docs_md/articles/groin-mass_160e727f-dabe-4187-aa46-c29625076cc5.md b/docs_md/articles/groin-mass_160e727f-dabe-4187-aa46-c29625076cc5.md
new file mode 100644
index 0000000..9e0159a
--- /dev/null
+++ b/docs_md/articles/groin-mass_160e727f-dabe-4187-aa46-c29625076cc5.md
@@ -0,0 +1,257 @@
+---
+title: "Groin Mass"
+docid: "160e727f-dabe-4187-aa46-c29625076cc5"
+authors:
+ - key: "c1df94ab-4a9f-44c4-add7-1f174fb9ac45"
+ value: "Siva P. Raman, MD"
+breadcrumbs:
+ -
+ name: "Gastrointestinal"
+ slug: "gastrointestinal"
+ treeNodeId: "b52263f7-5978-4a22-a17d-7260e0033943"
+ -
+ name: "Differential Diagnosis"
+ slug: "differential-diagnosis"
+ treeNodeId: "a0fd80ff-6231-49d3-94b8-ea083449979d"
+ -
+ name: "Abdominal Wall"
+ slug: "abdominal-wall"
+ treeNodeId: "08db01f7-2961-47f7-954d-2a5fca7e707d"
+ -
+ name: "Anatomically Based Differentials"
+ slug: "anatomically-based-differentials"
+ treeNodeId: "1525b44f-9d47-4ff4-8330-693211bd5eb5"
+ -
+ name: "Groin Mass"
+ slug: "groin-mass"
+ treeNodeId: null
+category: "Gastrointestinal"
+documentVersionId: "be3d839b-85cb-40bb-9883-4885388531ef"
+imageCount: 25
+lastUpdated: "09/13/22"
+pageDescription: "Groin Mass"
+pageKeywords: "Gastrointestinal, Differential Diagnosis, Abdominal Wall, Anatomically Based Differentials, Groin Mass"
+pageTitle: "Groin Mass | STATdx"
+enhancedTitle: "Groin Mass"
+type: "DDX"
+references: true
+breadcrumbs:
+ - "Gastrointestinal"
+ - "Differential Diagnosis"
+ - "Abdominal Wall"
+ - "Anatomically Based Differentials"
+ - "Groin Mass"
+---
+# ESSENTIAL INFORMATION
+
+- ## Key Differential Diagnosis Issues
+
+
+ - Although clinical exam may diagnose many common groin masses (particularly hernias), imaging often necessary for accurate diagnosis, particularly with atypical masses
+ - US 1st-line modality for vascular and male reproductive (e.g., cryptorchidism, varicocele) abnormalities
+ - CT and US are best options for diagnosis of groin hernias
+ - US offers advantage of being able to image patients in different positions (such as standing) or during Valsalva to increase chance of visualizing hernias
+ - CT or MR appropriate for suspected musculoskeletal lesions, such as bursitis or bone tumor
+- ## Helpful Clues for Common Diagnoses
+
+
+ - **Inguinal Hernia**
+ - Divided into **direct** or **indirect** subtypes based on relationship to inferior epigastric vessels
+ - Direct hernias arising anteromedial to inferior epigastric vessels
+ - Indirect hernias arising superolateral to inferior epigastric vessels
+ - Typically located anterior to horizontal plane of pubic tubercle with no significant mass effect on femoral vein
+ - Hernia sac can contain omental fat, bowel, bladder, appendix, and other pelvic structures
+ - Usually diagnosed on clinical exam, but diagnosis easily confirmed on both CT and US
+ - **Femoral Hernia**
+ - Almost always diagnosed in older women
+ - Extends medial to femoral vein and inferior to inferior epigastric vessels with mass effect on femoral vessels
+ - Hernia sac located posterior and lateral to pubic tubercle
+ - Highest strangulation rate among groin hernias (25-40%)
+ - **Groin Hematoma**
+ - Most often encountered after groin catheterization and should prompt search for underlying pseudoaneurysm or active extravasation, though also commonly seen in setting of inguinal or scrotal surgery and anticoagulation
+ - May demonstrate active extravasation on CECT in setting of active bleeding
+ - **Groin****Pseudoaneurysm**
+ - Most often encountered after groin catheterization (3% of cases following cardiac catheterization)
+ - US demonstrates cystic structure connecting to femoral artery with internal yin-yang biphasic flow
+ - Often treated with compression or thrombin injection
+ - **Groin Arteriovenous Fistula**
+ - Abnormal communication between artery and vein, which is most often iatrogenic and related to groin catheterization
+ - Direct communication between femoral artery and vein may not be readily visible on US, but secondary findings can help make diagnosis (increased diastolic flow in artery, arterialized flow in vein, turbulent flow with soft tissue color bruit artifact)
+ - **Inguinal Lymphadenopathy**
+ - Inguinal regions are common site of lymphadenopathy in many malignancies and systemic disease
+ - Lymph nodes are usually mobile and easily distinguished from hernia based on clinical exam alone, although imaging can easily make distinction in difficult cases
+ - **Varicocele**
+ - Can extend into inguinal canal (as can hydrocele) and may be thought to represent mass on clinical exam
+ - US demonstrates tangle of mildly dilated vessels (≥ 3 mm) with slow flow and enlargement during Valsalva
+ - May be seen on CT with tangle of dilated vessels, which communicate with dilated ipsilateral gonadal vein
+ - Most often found on left side, as isolated right-sided varicocele should raise concern for obstructing mass in abdominal or pelvic cavity
+ - **Spermatic Cord Lipoma**
+ - Can clinically mimic hernia without true hernia being present and frequently mistaken for inguinal hernia on CT/MR
+ - Extremely common incidental finding at surgery (seen in 20-70% of all inguinal hernia repairs)
+ - Fat-containing lesion in inguinal canal **without** any true connection to intraperitoneal fat, though differentiating spermatic cord lipoma from small inguinal hernia on any imaging modality can be extremely difficult to do with accuracy
+ - **Mesh Hernia Repair (Mimic)**
+ - Mesh plugs used during inguinal hernia repair can appear focal and mass-like and potentially mimic lymph node or other mass
+ - Ipsilateral spermatic cord often thickened as well due to surgical manipulation
+- ## Helpful Clues for Less Common Diagnoses
+
+
+ - **Cryptorchidism**
+ - Common congenital anomaly found in up to 4% of term male babies, which can be associated with increased risk of infertility and malignancy later in life
+ - Undescended testicle (usually are found in vicinity of groin/inguinal canal) can be palpated on physical exam in vast majority of cases
+ - US or MR are 1st-line imaging modalities with MR offering ability to identify intraabdominal testicle
+ - **Groin Aneurysm**
+ - True atherosclerotic aneurysms of common femoral artery are rare and often associated with aneurysms elsewhere (especially aorta and popliteal arteries)
+ - **Iliopsoas Bursitis**
+ - Focal, teardrop-shaped collection of fluid immediately anterior to hip joint typically associated with hip joint pathology (such as degeneration, infection, etc.)
+ - **Bone Tumor**
+ - Any benign or malignant primary bone tumor arising from pubic rami or hip can present as groin mass with CT and MR best initial modalities for evaluation
+ - **Inguinal Abscess**
+ - Focal, rim-enhancing fluid collection with surrounding stranding and edema in patient with clinical signs and symptoms of infection
+- ## Helpful Clues for Rare Diagnoses
+
+
+ - **Canal of Nuck Hydrocele**
+ - Extremely rare condition caused by congenital incomplete obliteration of canal of Nuck (fold of parietal peritoneum that extends into inguinal canal and toward labia majora)
+ - Typically diagnosed in female children (and extremely rarely in female adults) as painless, fluctuant swelling in groin
+ - Unilocular cystic mass in groin extending along inguinal canal toward labia (without any solid or soft tissue component and usually simple in appearance)
+ - **Inguinal Canal Endometriosis**
+ - Endometriosis can rarely extend into inguinal canal (usually on right)
+ - Imaging appearance akin to endometriosis elsewhere with pain groin mass varying with menstrual cycle
+ - Incomplete closure of canal of Nuck may provide pathway for endometriosis to extend into groin
+ - **Liposarcoma**
+ - Fat-containing mass typically with solid, soft tissue components, septations, and other complexity (and with variable amounts of internal fat depending of degree of differentiation)
+ - Primary spermatic cord liposarcomas arise below superficial ring without extension superiorly into peritoneum
+ - Other primary sarcomas of spermatic cord (leiomyosarcoma, rhabdomyosarcoma, etc.) are also possible but far less common
+ - Retroperitoneal liposarcomas with secondary extension downward into inguinal canal are much less common but can clinically mimic groin hernia
+ - **Metastases to Inguinal Canal**
+ - Metastases to inguinal canal are extraordinary rare, but most common with prostate cancer, pancreatic cancer, melanoma, rhabdomyosarcoma, and pseudomyxoma peritonei
+
+## References
+
+# Selected References
+
+1. [Piga E et al: Imaging modalities for inguinal hernia diagnosis: a systematic review. Hernia. 24(5):917-26, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32328842%5Bpmid%5D)
+1. [Thomas AK et al: Canal of Nuck abnormalities. J Ultrasound Med. 39(2):385-95, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=31378959%5Bpmid%5D)
+1. [Yang DM et al: Groin abnormalities: ultrasonographic and clinical findings. Ultrasonography. 39(2):166-77, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=31786905%5Bpmid%5D)
+1. [Lechner M et al: Retroperitoneal liposarcoma: a concern in inguinal hernia repair. JSLS. 23(1), 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=30700965%5Bpmid%5D)
+1. [Chun EJ: Ultrasonographic evaluation of complications related to transfemoral arterial procedures. Ultrasonography. 37(2):164-73, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=29145350%5Bpmid%5D)
+1. [Cabarrus MC et al: From inguinal hernias to spermatic cord lipomas: pearls, pitfalls, and mimics of abdominal and pelvic hernias. Radiographics. 37(7):2063-82, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=29131768%5Bpmid%5D)
+1. [Rhu J et al: Comparison of retroperitoneal liposarcoma extending into the inguinal canal and inguinoscrotal liposarcoma. Can J Surg. 60(6):399-407, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28930047%5Bpmid%5D)
+1. [Park HR et al: Sonographic evaluation of inguinal lesions. Clin Imaging. 40(5):949-55, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=27209238%5Bpmid%5D)
+1. [Vagnoni V et al: Inguinal canal tumors of adulthood. Anticancer Res. 33(6):2361-8, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=23749883%5Bpmid%5D)
+1. [Siegelman ES et al: MR imaging of endometriosis: ten imaging pearls. Radiographics. 32(6):1675-91, 2012](http://www.ncbi.nlm.nih.gov/pubmed/?term=23065164%5Bpmid%5D)
+1. [Shadbolt CL et al: Imaging of groin masses: inguinal anatomy and pathologic conditions revisited. Radiographics. 21 Spec No: S261-71, 2001](http://www.ncbi.nlm.nih.gov/pubmed/?term=11598262%5Bpmid%5D)
+
+
+## Images
+
+
+### Selected Images
+
+
+**Inguinal Hernia**
+*Coronal NECT shows a large right inguinal hernia containing loops of small bowel without evidence of obstruction. In most cases, inguinal hernias can be palpated and diagnosed clinically.*
+
+
+**Inguinal Hernia**
+*Coronal NECT shows a large right inguinal hernia containing loops of small bowel without evidence of obstruction. In most cases, inguinal hernias can be palpated and diagnosed clinically.*
+
+
+**Femoral Hernia**
+*Axial CECT shows the characteristic position of a femoral hernia with a knuckle of bowel identified medial to the femoral vessels. Note the characteristic compression of the adjacent femoral vein .*
+
+
+**Groin Hematoma**
+*Coronal CECT shows a large right groin hematoma with massive active extravasation of contrast . This patient had recently undergone a complicated right groin catheterization with subsequent severe blood loss.*
+
+
+**Groin Hematoma**
+*Longitudinal US in a patient with groin swelling after catheterization shows a large, complex hematoma with internal echoes and mixed echogenicity.*
+
+
+**Groin Pseudoaneurysm**
+*Color Doppler US in a patient who had undergone recent groin catheterization shows the characteristic features of a pseudoaneurysm with a yin-yang pattern of internal color flow. Note that the pseudoaneurysm does appear to connect with the adjacent femoral artery .*
+
+
+**Groin Pseudoaneurysm**
+*Axial CECT in a patient with a history of IV drug abuse shows a large, mycotic pseudoaneurysm of the right common femoral artery with surrounding fat stranding and edema.*
+
+
+**Groin Arteriovenous Fistula**
+*Axial CECT in a patient with swelling of the right groin after groin catheterization shows asymmetric enlargement and enhancement of the right common femoral vein , while the contralateral left femoral vein is not yet opacified. This constellation of findings should rise strong concern for an AV fistula.*
+
+
+**Inguinal Lymphadenopathy**
+*Axial CECT shows an enlarged left inguinal lymph node , found to represent posttransplant lymphoproliferative disorder in this patient with a history of renal transplant.*
+
+
+**Varicocele**
+*Sagittal color Doppler US shows a classic tangle of tortuous vessels within the upper part of the scrotum. Flow and vessel dilation are accentuated by Valsalva maneuver, characteristic of a varicocele.*
+
+
+**Mesh Hernia Repair (Mimic)**
+*Axial CECT shows the characteristic appearance of a mesh plug related to prior inguinal hernia repair. This is a classic appearance, which should not be confused for pathology.*
+
+
+**Cryptorchidism**
+*Axial T2 FS MR in a patient with an undescended left testicle shows the T2-bright testicle in the left pelvis. MR is the best modality for identifying an undescended testicle with an advantage over US for identifying testicles in the abdominal/pelvic cavities.*
+
+
+**Iliopsoas Bursitis**
+*Axial CECT shows the classic appearance of iliopsoas bursitis with a fluid collection anterior to the right hip displacing the neurovascular bundle anteriorly.*
+
+
+**Liposarcoma**
+*Axial NECT shows a complex, fat-containing mass in the left inguinal canal, found at resection to represent a primary spermatic cord liposarcoma.*
+
+
+**Liposarcoma**
+*Coronal CECT shows a fat-containing mass with minimal internal complexity extending from the right lower quadrant into the right inguinal canal. This represents a primary retroperitoneal liposarcoma with secondary extension into the inguinal canal.*
+
+
+### Additional Images
+
+
+**Inguinal Lymphadenopathy**
+*Axial CECT shows bilateral pelvic and inguinal nodal masses that were part of generalized disease from non-Hodgkin lymphoma.*
+
+
+**Inguinal Abscess**
+*Axial CECT shows a loculated fluid collection that extended along the iliopsoas.*
+
+
+**Groin Hematoma**
+*Axial NECT shows a heterogeneous, high-attenuation mass deep to the femoral vessels and superficial to the femur. This was found to be groin hematoma.*
+
+
+**Iliopsoas Bursitis**
+*Sagittal CECT shows a cylindrical fluid collection along the right iliopsoas muscle near its insertion on the femur.*
+
+
+**Inguinal Hernia**
+*Axial CECT shows an inguinal hernia containing only fat. Hernia is anterior to pubic tubercle, and there is no compression of femoral vessels .*
+
+
+**Groin Pseudoaneurysm**
+*Sagittal color Doppler US shows a yin-yang or to-and-fro flow of blood within a spherical common femoral artery pseudoaneurysm, resulting from cardiac catheterization.*
+
+
+**Groin Hematoma**
+*Axial CECT shows a groin hematoma that resulted from surgical revision of an AV fistula for dialysis. Unlike a pseudoaneurysm, there is no enhancement of the mass.*
+
+
+**Femoral Hernia**
+*Coronal CECT shows a knuckle of small bowel that is incarcerated within a femoral hernia, resulting in small bowel obstruction.*
+
+
+**Cryptorchidism**
+*Axial CECT shows a small soft tissue mass within the right inguinal ring. The right hemiscrotum was small and empty. Normal left spermatic cord is noted.*
+
+
+**Femoral Hernia**
+*Axial CECT shows a left-sided femoral hernia , with the herniated bowel just medial to the femoral vessels.*
+
+
+**Iliopsoas Bursitis**
+*Axial CECT shows a cylindrical fluid collection along the right iliopsoas muscle, near its insertion on the femur.*
+
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+anatomy:
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+ - "{'authors': 'Eric Turner, MD; Mark E. Lockhart, MD, MPH; Daniel Childers, MD', 'bookmarked': False, 'bookmarkUrl': '/document/bookmark/79a4117f-773a-40b3-bdb5-b0195f84e087', 'category': 'Ultrasound', 'compareUrl': '/compare/document/79a4117f-773a-40b3-bdb5-b0195f84e087/related-anatomy/treeNode?subContext=Mesenteric Vessels', 'documentId': '79a4117f-773a-40b3-bdb5-b0195f84e087', 'documentType': 'ANATOMY', 'documentUrl': '/document/mesenteric-vessels/79a4117f-773a-40b3-bdb5-b0195f84e087', 'enhancedTitle': 'Mesenteric Vessels', 'entryDate': '05/13/24', 'imageCount': 22, 'imageUrl': '/image/thumbnail/102e0a5e-f97c-46b9-9dc0-6193e796506d?size=174&quality=85', 'inCompareCart': False, 'rank': 2, 'referenceCount': 0, 'showCompareButton': False, 'title': 'Mesenteric Vessels'}"
+cases: 2
+breadcrumbs:
+ - "Gastrointestinal"
+ - "Diagnosis"
+ - "Peritoneum, Mesentery, and Abdominal Wall"
+ - "External Hernias"
+ - "Inguinal Hernia"
+---
+# KEY FACTS
+
+- ## Imaging
+
+
+ - **Direct inguinal hernia**: Hernia passes through Hesselbach triangle (bounded by inguinal ligament, lateral margin of rectus abdominis, and inferior epigastric artery)
+ - CT: Arises **anteromedial**to origin of inferior epigastric artery and extends through anterior abdominal wall lateral to rectus muscle
+ - Contents of inguinal canal (testicular vessels, vas deferens) can be seen as crescent of density along lateral aspect of hernia (**lateral crescent sign**)
+ - No compression of femoral artery/vein
+ - **Indirect inguinal hernia**: Hernia passes through internal inguinal ring, down inguinal canal, and emerges at external ring
+ - CT: Arises **superolateral** to inferior epigastric vessels and extends lateral to medial within inguinal canal
+ - Lateral crescent sign not present with indirect hernias
+ - **US**: Can scan patient either with Valsalva maneuver or in upright position to precipitate hernia
+ - US can determine reducibility of hernia (unlike CT) and identify reducible hernias that may not be seen on CT
+- ## Pathology
+
+
+ - 75-80% of all hernias occur in inguinal region with indirect hernias 5x more common than direct
+ - Indirect inguinal hernia usually congenital defect due to patency of processus vaginalis, whereas direct hernias are acquired due to abdominal wall weakness
+- ## Clinical Issues
+
+
+ - Much more common in men than women
+ - Symptoms often worse when standing, lifting, or straining
+ - Complications: Incarceration and strangulation (much more common with indirect than direct inguinal hernia)
+ - Emergent surgical repair (laparoscopic or open) in patients with strangulated inguinal hernia
+ - Symptomatic hernias usually surgically repaired on elective basis, although conservative management possible in some asymptomatic or minimally symptomatic patients
+ - Conservative management possible in patients who are asymptomatic or have minimal symptoms
+
+# TERMINOLOGY
+
+- ## Abbreviations
+
+
+ - Inguinal hernia (IH)
+- ## Synonyms
+
+
+ - Pelvic hernia, groin hernia
+- ## Definitions
+
+
+ - IH: External hernia with orifice in inguinal location
+ - External hernia: Abnormal protrusion of intraabdominal tissue through defect in abdominal/pelvic wall with extension outside abdominal cavity
+
+# IMAGING
+
+- ## General Features
+
+
+ - ### Location
+
+
+ - Inguinal canal is opening in anterior abdominal wall connecting deep and superficial inguinal rings
+ - Contains spermatic cord, ductus deferens, testicular artery and veins, genital branch of genitofemoral nerve, and ilioinguinal nerve in males
+ - Contains round ligament, ilioinguinal nerve, and genital branch of genitofemoral nerve in females
+ - Bounded by external and internal oblique aponeurosis anteriorly, conjoint tendon and fascia transversalis posteriorly, internal oblique and transversus abdominis muscles superiorly, and inguinal/lacunar ligaments inferiorly
+ - **Indirect IH**: Hernia passes through internal inguinal ring, down inguinal canal, and emerges at external ring
+ - Lateral IH: Arises superior and lateral to epigastric vessels (lateral umbilical fold)
+ - Can extend along spermatic cord into scrotum (i.e., complete hernia) in male patients
+ - Can follow course of round ligament of uterus into labium majus in female patients
+ - Juxtafunicular hernia: Indirect hernia that passes outside spermatic cord into surrounding soft tissues
+ - Occurs most often on right in both men and women
+ - **Direct IH**: Hernia passes through Hesselbach triangle (in floor of inguinal canal bounded by inguinal ligament, lateral margin of rectus abdominis, and inferior epigastric artery)
+ - Arises medial to course of inferior epigastric vessels
+ - Not contained in spermatic cord and generally does not pass into scrotum
+ - Medial umbilical fold divides Hesselbach triangle into medial and lateral parts and directs IH into medial and lateral types
+ - ### Morphology
+
+
+ - Indirect IH within spermatic cord has smooth contour with elongated, oblique course
+ - Juxtafunicular hernia has more irregular contour without protrusion into preformed sac
+ - Dissect through subcutaneous fat and fibrous tissue
+ - Direct IH appears broad and dome-shaped
+- ## CT Findings
+
+
+ - Some IHs, particularly when small, have tendency to reduce when patient is supine and may be missed on CT
+ - Primary landmark is inferior epigastric artery, which arises opposite to origin of deep circumflex iliac artery from external iliac artery
+ - **Direct IH**: Arises **anteromedial**to origin of inferior epigastric artery, extends through anterior abdominal wall lateral to rectus muscle, and courses below inferior epigastric artery
+ - Contents of inguinal canal (testicular vessels, vas deferens) can be seen as crescent of density along lateral aspect of hernia as it protrudes (**lateral crescent sign**)
+ - No compression of nearby femoral artery and vein (unlike femoral hernias)
+ - Relationship of hernia sac relative to pubic tubercle may help differentiate inguinal and femoral hernias
+ - IH seen anterior to horizontal plane connecting pubic tubercles (femoral hernias seen posterior)
+ - **Indirect IH**: Arises **superolateral** to epigastric vessels and extends lateral to medial within inguinal canal
+ - Lateral crescent sign seen with direct hernias not present with indirect hernias, as normal contents of inguinal canal are not compressed
+ - Direct and indirect hernias can very rarely be visualized in same groin: **Saddlebag**or**pantaloon** hernia (combined-type hernia)
+ - CT very helpful for identifying contents of hernia sac (omental fat, bowel, bladder) and identifying complications (bowel obstruction, ischemia, perforation, etc.)
+ - IH described as **sliding**hernias when partially retroperitoneal structures (bladder, distal ureters, ascending/descending colon) are within hernia sac
+ - Key to identify, as blood vessels supplying herniated segments may be injured during surgery or trauma
+ - Appendix within hernia sac: Amyand hernia
+ - Meckel diverticulum within hernia sac: Littre hernia
+ - Other uncommon contents in IH can be ureter, ovaries, uterus, and undescended testis
+ - CT should be 1st-line modality in patients presenting with acute symptoms from hernia
+ - **Normal postoperative imaging findings**
+ - Polypropylene mesh patch appears as thin, linear structures of soft tissue density (often difficult to distinguish from fascia and muscle)
+ - Polytetrafluoroethylene mesh patch appears hyperdense and more easily visualized
+ - Polypropylene mesh plugs appear as soft tissue density nodules at internal inguinal ring (usually 2-3 cm in size) and should not be confused with enlarged lymph node or mass
+ - Can rarely demonstrate central fat density with higher density rim (perhaps in up to 40% of cases)
+ - Spermatic cord may appear thickened after surgery (and may remain thickened for years) due to surgical manipulation and should not be confused for pathology
+ - Surgical staples for fascial fixation not common with modern surgical techniques
+- ## Ultrasonographic Findings
+
+
+ - Some debate in literature regarding efficacy of US in diagnosing hernias: Various studies have shown sensitivities ranging from 29-100%
+ - Most useful if patient presents nonurgently with history suggesting reducible IH
+ - Typically high-frequency transducer (> 10 MHz) best, since IHs are superficial, but lower frequencies may be utilized in more obese patients
+ - US probe placed longitudinal to inguinal canal and anterior to inferior epigastric artery (at site of origin from external iliac artery)
+ - Advantage of US is ability to scan patient either with Valsalva maneuver or in upright position to precipitate hernia (if hernia not seen initially at rest in supine position)
+ - Bowel loops may peristalsis within hernia sac and may aid in identification of hernia
+ - US can determine reducibility of hernia (unlike CT) and identify reducible hernias that may not be seen on CT due to supine scan position
+ - Primary sonographic landmarks are pubic tubercle and inferior epigastric artery (along lateral border of rectus abdominis and can be traced back to external iliac artery)
+ - **Indirect IH:** Hernia seen to originate **lateral** to inferior epigastric artery and extend medially toward pubic tubercle
+ - Valsalva maneuver: Impaired swelling of pampiniform plexus
+ - **Direct IH:**Hernia seen to originate **medial**to inferior epigastric artery and extend anteriorly toward probe
+ - Valsalva maneuver: Distended pampiniform plexus is displaced by hernia sac
+- ## Radiographic Findings
+
+
+ - ### Radiography
+
+
+ - Soft tissue density or gas-containing mass overlying obturator foramen on affected side suggests hernia
+ - Presence of dilated bowel loops with convergence of distended intestinal loops toward inguinal region suggests bowel obstruction due to IH
+ - Fluoroscopy: Tapered narrowing or obstruction of intestinal segments entering hernia orifice
+ - Visualize afferent and efferent loops of protruding intestine
+- ## Imaging Recommendations
+
+
+ - ### Best imaging tool
+
+
+ - US is appropriate 1st-line modality in patients with nonurgent presentation
+ - CECT in patients with acute symptoms or suspicion of complications related to hernia
+
+# DIFFERENTIAL DIAGNOSIS
+
+- [Femoral Hernia](/document/femoral-hernia/45d54e6d-97bd-4dd4-beed-b31f572d7b95)
+ - Protrusion of abdominal contents through femoral ring and into femoral canal
+ - Omental fat or bowel herniating into femoral canal medial to femoral vein and inferior to inferior epigastric vessels
+ - Femoral vein often indented/compressed by hernia sac
+ - Hernia sac located posterior to horizontal plane of pubic tubercle, whereas IH located anterior
+ - More common in women
+- ## Lymphadenopathy
+
+
+ - Soft tissue nodule near inguinal ligament might mimic IH clinically, but distinction easily made with imaging
+ - CT and US can help differentiate hernia contents from other groin and scrotal masses, such as hydrocele, varix, lipoma of spermatic cord, undescended testicle, abscess, tumor, etc.
+- ## Iatrogenic Hematoma
+
+
+ - Arterial puncture following arteriography, needle biopsy, aspiration
+ - Hematoma may extend into rectus muscle, lateral abdominal wall muscles
+ - Blood can track directly from groin along transversalis fascia and transversus abdominis muscle
+ - CT, US, MR: Appearance of blood; extent of lesion changes over time
+ - Pseudoaneurysm: Perivascular, rounded mass; neck and track connecting with injured artery
+- ## Spermatic Cord Lipoma or Liposarcoma
+
+
+ - Rare, fat-containing masses that typically grow into scrotum but can involve inguinal canal and mimic IH containing omental fat
+ - Well-differentiated liposarcomas or lipomas may be difficult to differentiate from omental fat in hernia, but lesions usually appear more mass-like, and liposarcomas often demonstrate some internal complexity
+
+# PATHOLOGY
+
+- ## General Features
+
+
+ - ### Etiology
+
+
+ - 75-80% of all hernias occur in inguinal region with**indirect hernias 5x more common than direct**
+ - Indirect IH considered most often congenital defect due to patency of processus vaginalis and weakness of crus lateralis at lateral aspect of inguinal canal
+ - Although congenital, may not become clinically apparent until later in life
+ - Direct IH considered acquired lesion arising due to weakness in transversalis fascia of posterior wall of inguinal canal in Hesselbach triangle
+ - Related to a number of factors, including old age, chronic cough, pregnancy, connective tissue abnormalities, constipation, etc.
+
+# CLINICAL ISSUES
+
+- ## Presentation
+
+
+ - ### Most common signs/symptoms
+
+
+ - Highly variable depending on hernia size
+ - May be asymptomatic (especially when small), palpable lump in groin, heavy sensation in groin, or cause groin pain
+ - Symptoms often increase when standing, lifting, or straining
+ - Incarcerated or strangulated hernias may have severe fulminant presentations
+ - Most hernias diagnosed on clinical examination (without imaging) with hernia best palpated with patient standing, coughing, or performing Valsalva maneuver
+ - Diagnosis can be made with history and physical examination, although physical exam fails to properly make distinction between direct and indirect IHs in as many as 30% of cases
+- ## Demographics
+
+
+ - ### Age
+
+
+ - Indirect IH may occur from infancy to old age but generally present by 5th decade
+ - Occurs in 1-3% of all children with 1.5-2x greater incidence in premature infants
+ - Pediatric IH almost always indirect with increased incarceration risk
+ - Usually right (60-75%) but often bilateral (10-15%)
+ - Direct IH increases in incidence with age
+ - ### Sex
+
+
+ - Indirect IH 5-10x more common in men
+ - Direct IH occurs mostly in men
+ - Overall lifetime risk is 27% in men and 3% in women
+- ## Natural History & Prognosis
+
+
+ - Complications: Incarceration, strangulation, and bowel obstruction
+ - Direct IH rarely incarcerated and has lower association with strangulation
+ - Indirect IH accounts for 15% of intestinal obstructions
+ - Diverticulitis, appendicitis, or primary/metastatic tumor may occur within hernia sac
+ - IH may recur after herniorrhaphy in ~ 20%
+ - Direct IH may develop after indirect IH repair
+- ## Treatment
+
+
+ - Emergent surgical repair (laparoscopic or open) in patients with strangulated IH
+ - Symptomatic hernias repaired electively using open or laparoscopic surgical technique
+ - Conservative management possible in patients who are asymptomatic or have minimal symptoms
+
+# DIAGNOSTIC CHECKLIST
+
+- ## Consider
+
+
+ - Indirect IH protrude from lateral inguinal fossa
+ - Direct IH are from medial and supravesical fossae
+
+ 1600ad5b-4439-49c2-8ba2-966c88beb385
+
+## References
+
+# Selected References
+
+1. [Hammoud M et al: Inguinal hernia. StatPearls, 2024](http://www.ncbi.nlm.nih.gov/pubmed/?term=30020704%5Bpmid%5D)
+1. [Morrison Z et al: Adult inguinal hernia. 2024](http://www.ncbi.nlm.nih.gov/pubmed/?term=30725926%5Bpmid%5D)
+1. [Ganesan G et al: A radiological review of the unusual contents of inguinal region. Indian J Radiol Imaging. 33(3):373-81, 2023](http://www.ncbi.nlm.nih.gov/pubmed/?term=37362368%5Bpmid%5D)
+1. [Kopscik M et al: Sports hernias: a comprehensive review for clinicians. Cureus. 15(8):e43283, 2023](http://www.ncbi.nlm.nih.gov/pubmed/?term=37692688%5Bpmid%5D)
+1. [Plumb AA et al: Contemporary imaging of inguinal hernia and pain. Br J Radiol. 95(1134):20220163, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=35348361%5Bpmid%5D)
+1. [Wu WT et al: Ultrasound imaging for inguinal hernia: a pictorial review. Ultrasonography. 41(3):610-23, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=35569836%5Bpmid%5D)
+1. [Liu N et al: Unnecessary use of radiology studies in the diagnosis of inguinal hernias: a retrospective cohort study. Surg Endosc. 35(8):4444-51, 2021](http://www.ncbi.nlm.nih.gov/pubmed/?term=32909205%5Bpmid%5D)
+1. [Chaudhary SR et al: Thinking beyond hernia: a review of non-hernia groin lumps. Abdom Radiol (NY). 45(6):1929-49, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=31786622%5Bpmid%5D)
+1. [Kohga A et al: Does preoperative enhanced CT predict requirement of intestinal resection in the patients with incarcerated myopectineal hernias containing small bowel? Hernia. 25(5):1279-17, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=33128678%5Bpmid%5D)
+1. [Piga E et al: Imaging modalities for inguinal hernia diagnosis: a systematic review. Hernia. 24(5):917-26, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32328842%5Bpmid%5D)
+1. [Sim WY et al: Sonographic appearance of a large lipoma of the spermatic cord presenting clinically as an inguinoscrotal hernia. J Clin Ultrasound. 49(4):395-7, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32914871%5Bpmid%5D)
+1. [Itani KMF et al: Approach to groin hernias. JAMA Surg. 154(6):551-2, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=30865244%5Bpmid%5D)
+1. [Cabarrus MC et al: From inguinal hernias to spermatic cord lipomas: pearls, pitfalls, and mimics of abdominal and pelvic hernias. Radiographics. 37(7):2063-82, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=29131768%5Bpmid%5D)
+1. [Revzin MV et al: US of the inguinal canal: comprehensive review of pathologic processes with CT and MR imaging correlation. Radiographics. 36(7):2028-48, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=27715712%5Bpmid%5D)
+1. [Tonolini M: Multidetector CT of expected findings and complications after contemporary inguinal hernia repair surgery. Diagn Interv Radiol. 22(5):422-9, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=27460285%5Bpmid%5D)
+1. [Burkhardt JH et al: Diagnosis of inguinal region hernias with axial CT: the lateral crescent sign and other key findings. Radiographics. 31(2):E1-12, 2011](http://www.ncbi.nlm.nih.gov/pubmed/?term=21415178%5Bpmid%5D)
+1. [Lassandro F et al: Abdominal hernias: radiological features. World J Gastrointest Endosc. 3(6):110-7, 2011](http://www.ncbi.nlm.nih.gov/pubmed/?term=21860678%5Bpmid%5D)
+1. [Light D et al: The role of ultrasound scan in the diagnosis of occult inguinal hernias. Int J Surg. 9(2):169-72, 2011](http://www.ncbi.nlm.nih.gov/pubmed/?term=21059415%5Bpmid%5D)
+1. [Narci A et al: O. Preoperative sonography of nonreducible inguinal masses in girls. J Clin Ultrasound. 36(7):409-12, 2008](http://www.ncbi.nlm.nih.gov/pubmed/?term=18506746%5Bpmid%5D)
+1. [Cherian PT et al: Radiologic anatomy of the inguinofemoral region: insights from MDCT. AJR Am J Roentgenol. 189(4):W177-83, 2007](http://www.ncbi.nlm.nih.gov/pubmed/?term=17885029%5Bpmid%5D)
+1. [Suzuki S et al: Differentiation of femoral versus inguinal hernia: CT findings. AJR Am J Roentgenol. 189(2):W78-83, 2007](http://www.ncbi.nlm.nih.gov/pubmed/?term=17646443%5Bpmid%5D)
+1. [Robinson P et al: Inguinofemoral hernia: accuracy of sonography in patients with indeterminate clinical features. AJR Am J Roentgenol. 187(5):1168-78, 2006](http://www.ncbi.nlm.nih.gov/pubmed/?term=17056901%5Bpmid%5D)
+1. [Alam A et al: The accuracy of ultrasound in the diagnosis of clinically occult groin hernias in adults. Eur Radiol. 15(12):2457-61, 2005](http://www.ncbi.nlm.nih.gov/pubmed/?term=15986204%5Bpmid%5D)
+1. [van den Berg JC: Inguinal hernias: MRI and ultrasound. Semin Ultrasound CT MR. 23(2): 156-73, 2002](http://www.ncbi.nlm.nih.gov/pubmed/?term=11996229%5Bpmid%5D)
+1. [Shadbolt CL et al: Imaging of groin masses: inguinal anatomy and pathologic conditions revisited. Radiographics. 21 Spec No: S261-71, 2001](http://www.ncbi.nlm.nih.gov/pubmed/?term=11598262%5Bpmid%5D)
+1. [Zhang GQ et al: Groin hernias in adults: value of color Doppler sonography in their classification. J Clin Ultrasound. 29(8): 429-34, 2001](http://www.ncbi.nlm.nih.gov/pubmed/?term=11745848%5Bpmid%5D)
+1. [Toms AP et al: Illustrated review of new imaging techniques in the diagnosis of abdominal wall hernias. Br J Surg. 86(10): 1243-9, 1999](http://www.ncbi.nlm.nih.gov/pubmed/?term=10540124%5Bpmid%5D)
+
+## Differential diagnosis
+
+### Abdominal Wall Mass
+DDX:d51e2268-67b6-4a60-9222-f5a86f61ddec
+
+### Acute Abdomen in Infants and Children
+DDX:88dc4860-4e13-441f-815c-45180d11fa50
+
+### Acute Left Abdominal Pain
+DDX:65c32297-ce9e-41dd-80b5-60fd7160f2a6
+
+### Defect in Abdominal Wall (Hernia)
+DDX:5af046fa-59ef-45b5-952b-acbcdee36196
+
+### Extratesticular Solid Mass
+DDX:43677c94-f36b-46ff-adde-e0e0134d78c6
+
+### Groin Mass
+DDX:160e727f-dabe-4187-aa46-c29625076cc5
+
+### Scrotal Pain
+DDX:24bdc87e-2601-4ba9-b559-e12ff3a20dce
+
+### Small Bowel Obstruction
+DDX:ad8209f0-71e5-4496-860f-d2724ca22892
+
+## Anatomy
+
+### Peritoneal Cavity
+Gastrointestinal/ANATOMY:6691f48d-ac34-477b-8ec1-b9dd731a14a8
+
+### Mesenteric Vessels
+Ultrasound/ANATOMY:79a4117f-773a-40b3-bdb5-b0195f84e087
+
+## Cases
+
+- {'cases': [{'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'd02ca38c-fb31-48ee-b26b-70f2b4063699', 'description': 'CT and barium studies show small bowel herniated into the hernia.\n\nAxial CECT images (#1-4) show the hernia sac, lying anterior to the right femoral vessels. Contrast-opacified small bowel is present within the hernia (arrows, #2, 3), but there is no sign of bowel obstruction.\n\nA barium small bowel follow through study (#5, 6) shows the herniated small bowel (open arrow). Note the constriction of the bowel (curved arrows, #6) as it passes through the inguinal ring.', 'history': 'Elderly woman with painful swelling in groin and abdominal pain.', 'imagePoolId': '663fc803-015b-415e-a026-ad2084ca6857', 'name': 'Classic, with bowel herniated', 'teachingPoint': None, 'demographics': '82 Years old female'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '8e4a2dd7-63ec-46f0-ae98-81f1dd218de9', 'description': 'CT (#1-4) shows herniation of small bowel loops (curved arrows, #2,5) and fat through an inguinal hernia, causing low grade obstruction of more proximal SB. SBFT (#5) confirms the hernia (open arrows)and the dilation of more proximal small bowel.', 'history': 'Elderly woman with intermittent crampy abdominal pain and a palpable groin mass.', 'imagePoolId': '8bc4bbae-1a3b-4613-9687-9eeb6f972f7b', 'name': 'shown on SBFT + CT; partial SBO', 'teachingPoint': None}], 'caseType': 'typical', 'name': 'TYPICAL'}
+- {'cases': [{'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '83ad66eb-24a3-427b-9f42-e7fac6c63041', 'description': 'CT shows ascites fluid within bilateral inguinal hernias.\n\nCT shows extensive ascites. Some of the ascites distends the inguinal canals bilaterally (arrows, #2), a common finding in patients with tense ascites and patent funicular process (processus vaginalis).', 'history': 'Young man with ascites due to chronic renal failure.', 'imagePoolId': 'abe3f4f3-350a-4a81-91e2-d1d5a2e21e3e', 'name': 'With ascites', 'teachingPoint': None, 'demographics': '37 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '8c480ba2-235d-4b75-95da-0c22bad9034b', 'description': 'CT confirms a pelvic bleed and an incidental inguinal hernia.\n\nCT shows a small hemorrhage in the right obturator region (open arrow, #2). Also noted is a large left inguinal hernia (arrow, #3) that contains a segment of sigmoid colon. The hernia sac has a wide opening with little apparent constriction of the colon. There is no sign of bowel obstruction.', 'history': 'Elderly man being evaluated for a bleed on anticoagulant therapy.', 'imagePoolId': 'ee799b3b-145d-4596-9adf-778ffc99e68a', 'name': 'Containing colon', 'teachingPoint': None}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'a76f7550-35f4-4535-bc19-c24a95f9c800', 'description': 'Radiographs show huge inguinal hernia.\n\nAn abdominal radiograph (#1) shows a "gasless" abdomen. Most of her bowel lies in the pelvis, and much of the small bowel has protruded into a large left inguinal hernia (arrow).', 'history': 'Elderly woman with abdominal discomfort.', 'imagePoolId': '73f63393-f3e1-4ae4-8e34-3bfabdca9b38', 'name': 'Huge', 'teachingPoint': None, 'demographics': '85 Years old female'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'b761a521-8c46-44e0-8451-e6cb55e46e3a', 'description': 'A supine film of the abdomen (#1) shows distention of the colon (but not the rectum). Both the inner and outer walls of the transverse colon are sharply defined (arrow) and there is a triangular collection of gas density between the colon and the liver shadow (curved arrow).\nAxial NECT sections confirm massive free intraperitoneal gas (arrows, # 2-6). The colon is massively dilated (curved arrows, #3-7). A few bubbles of extraluminal gas (arrows, #7) are seen immediately adjacent to a markedly dilated cecum and ascending colon. The dilated colon can be followed into a large left inguinal hernia (open arrow, #8-9) that contains a portion of sigmoid colon. The rectum is collapsed. Axial NECT images viewed at "lung windows" (#10-13) demonstrate the free intraperitoneal gas outlining the falciform ligament (arrow, #10) and the outer wall of the transverse colon (arrow, #11). Some of the smaller gas bubbles are seen (black arrow, #12) adjacent to the wall of the ascending colon. Sagittal reconstruction (#13) optimally demonstrates the free air sharply outlining the ventral surface of the transverse colon and liver (arrows). Coronal reformatted images (#14-15) optimally demonstrate the sigmoid colon that is incarcerated and obstructed within the left inguinal hernia (open arrow, #14-15).\n\nComment: It is uncommon though not rare for the colon to become incarcerated and obstructed within a hernia. Any cause of marked colonic distention (obstruction or ileus) may lead to ischemia and perforation of the colon, usually of the cecum or ascending colon. At surgery, a small perforation of the posterior wall of the ascending colon was confirmed and treated with partial colectomy, along with repair of the inguinal hernia.', 'history': 'Patient with abdominal distention and severe pain.', 'imagePoolId': '553e48b4-c170-4caf-a551-202efca183ac', 'name': 'Hernia causing colonic perforation', 'teachingPoint': None, 'demographics': '64 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '61054b2d-9307-4e72-9b3b-d0595d69754d', 'description': 'CTs (#1-10) show an inguinal hernia (arrows, #6-10). The herniated fat within the inguinal hernia is infiltrated, and there is a tubular structure (curved arrows, #2-9) within the hernia that represents an inflamed appendix. \n\nComment: The position of the appendix can be quite variable, although the base of the appendix almost always arises from the tip of the cecum. Depending on the location of the tip of the appendix, focal symptoms of pain and tenderness may be encountered in almost any part of the abdomen. When the appendix is located within a hernia (inguinal, Spigelian, etc.), symptoms are especially likely to be misinterpreted as a complication of the hernia, such as strangulation of herniated bowel or omental fat.', 'history': 'Right lower abdominal and groin pain.', 'imagePoolId': '2efeca50-1f68-4b5d-9cc1-ee0d196efabc', 'name': 'Appendix within hernia', 'teachingPoint': None, 'demographics': '44 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'd79f8e7b-2a58-4cab-94e4-5a3e90460766', 'description': 'CT shows a right inguinal hernia (arrow, #1, 2) that contains herniated fat. The fat is somewhat "dirty", or infiltrated, in appearance, suggesting incarceration or ischemia of the herniated fat.', 'history': 'Young man with painful swelling in groin.', 'imagePoolId': '2a2b52ef-4c45-4633-adf3-8656028d4c76', 'name': 'Containing only fat', 'teachingPoint': None, 'demographics': '21 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '6f8f0a5c-c3b5-46ba-9edf-5e1805cbbd09', 'description': 'The radiograph (#1) shows gross dilation of the small bowel. Following placement of an NG tube, the bowel became less dilated, as shown on the CT scan (#2-4). However, CT showed persistent dilated, fluid-filled segments of bowel (arrows, #2,3), extraluminal gas bubbles (curved arrow, #3), and small bowel incarcerated within an inguinal hernia (open arrow, #4). At surgery, a segment of obstructed small bowel (arrow, #5) was necrotic from ischemia and was resected.', 'history': 'Patient with abdominal pain and hypotension.', 'imagePoolId': 'bd9f3993-d089-4463-b105-cb7bb91656f9', 'name': 'SBO with infarct; inguinal hernia', 'teachingPoint': None, 'demographics': '77 Years old female'}], 'caseType': 'variant', 'name': 'VARIANT'}
+
+
+## Images
+
+
+### Selected Images
+
+
+*Graphic demonstrates a direct inguinal hernia with the hernia neck located medial to the inferior epigastric artery and vein .*
+
+
+*Graphic demonstrates an indirect inguinal hernia with the hernia neck located lateral to the inferior epigastric artery and vein . The inferior epigastric vessels serve as the key landmark in distinguishing direct and indirect inguinal hernias.*
+
+
+*Axial CECT in a patient with a palpable groin mass demonstrates a right inguinal hernia containing loops of small bowel .*
+
+
+*Coronal NECT demonstrates the typical appearance of an inguinal hernia in the coronal plane with involvement of small bowel loops .*
+
+
+*Coronal CECT demonstrates small bowel extending into an inguinal hernia with a transition point and dilatation of the proximal small bowel , compatible with bowel obstruction.*
+
+
+*Coronal NECT demonstrates a sliding inguinal hernia containing a portion of the bladder . Sliding inguinal hernias contain portions of partially retroperitoneal structures, such as the bladder, and care must be taken at surgery to avoid damage to these structures or their supplying vessels.*
+
+
+*Axial NECT demonstrates a right lower quadrant transplant kidney with marked hydronephrosis .*
+
+
+*Axial NECT in the same patient demonstrates the cause of the hydronephrosis with the right ureter trapped and dilated within a right inguinal hernia.*
+
+
+*Grayscale ultrasound of the inguinal canal shows bowel loops herniating into the right inguinal canal with echogenic foci of gas in the lumen . Note the relation of the hernia sac to the testis .*
+
+
+*Axial CECT demonstrates the characteristic appearance of a mesh plug utilized for inguinal hernia repair. This is a characteristic appearance and location, which should not be confused for an abnormal lymph node or mass.*
+
+
+### Additional Images
+
+
+*Axial CECT shows a hernia sac lying anterior to the right femoral vessels. A contrast-opacified small bowel is present within the hernia, but no sign of bowel obstruction is seen.*
+
+
+*Axial CECT shows an inguinal hernia causing small bowel obstruction. Note the entrapped and thickened small bowel in the right inguinal hernia sac .*
+
+
+*Axial CECT at a higher level in the same patient demonstrates a dilated small bowel from obstruction.*
+
+
+*Axial CECT of a right inguinal hernia contains herniated fat. The fat is somewhat "dirty" or infiltrated in appearance, suggesting incarceration or ischemia of herniated fat.*
+
+
+*Axial CECT at a higher level in the same patient demonstrates abdominal wall defect .*
+
+
+*CECT shows an incarcerated small bowel with perforation within the inguinal hernia sac. Note the thickened small bowel within the large hernia sac .*
+
+
+*Axial CECT shows a dilated small bowel entering the inguinal canal and the leaving collapsed bowel .*
+
+
+*Axial CECT shows a "knuckle" of fluid-filled small intestine strangulated within the right inguinal hernia .*
+
+
+*Axial CECT shows a left inguinal hernia containing only fat and spermatic cord.*
+
+
+*Small bowel follow-through shows a large portion of the small intestine within the scrotum due to a right inguinal hernia.*
+
+
+*Axial CECT shows a left inguinal hernia at the upper end of the inguinal canal. There is a mass effect due to the herniated fat and bowel.*
+
+
+*Axial CECT shows a left inguinal hernia containing a sigmoid colon. Also note the right thigh hematoma.*
+
+
+*Axial CECT shows a right inguinal hernia with the colon in the upper scrotum.*
+
+
+*Axial CECT in an older woman shows a left inguinal hernia, right obturator hernia , and pessary .*
+
+
+*Coronal CECT demonstrates a large right inguinal hernia in a patient who reported a long history of a growing bulge in the groin. The hernia contains multiple small bowel loops, portions of the colon, and small ascites .*
+
+
+*Axial CECT in an older man who presented with sepsis and a large right scrotal mass demonstrates a large scrotal abscess from perforated incarcerated bowel within an inguinal hernia.*
+
+
+*Axial CECT in the same patient illustrates a collection of bowel and omental fat within the hernia sac.*
+
+
+*Coronal CECT demonstrates multiple dilated loops of small bowel in the pelvis, compatible with small bowel obstruction.*
+
+
+*Coronal CECT in the same patient demonstrates that the small bowel extends into a right inguinal hernia with a transition point in the hernia sac. This incarcerated hernia could not be manually reduced, and urgent surgery was performed for repair.*
+
+
+*Axial CECT in an older man who presented with a large groin mass and a small bowel obstruction demonstrates a large right inguinal hernia containing sections of the small bowel , colon , and omentum .*
+
+
+*Barium small bowel follow-through study in a patient with a right inguinal hernia shows the herniated small bowel lying over the right femoral head. Note the constriction of the bowel as it passes through the inguinal ring.*
+
diff --git a/docs_md/articles/inner-ear-lesion-adult_e5bbf757-d77a-4546-a848-d1a1a64cb230.md b/docs_md/articles/inner-ear-lesion-adult_e5bbf757-d77a-4546-a848-d1a1a64cb230.md
new file mode 100644
index 0000000..1027326
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+++ b/docs_md/articles/inner-ear-lesion-adult_e5bbf757-d77a-4546-a848-d1a1a64cb230.md
@@ -0,0 +1,282 @@
+---
+title: "Inner Ear Lesion, Adult"
+docid: "e5bbf757-d77a-4546-a848-d1a1a64cb230"
+authors:
+ - key: "d19354f3-7ff2-495a-ad3f-064122e45602"
+ value: "Bernadette L. Koch, MD"
+breadcrumbs:
+ -
+ name: "Head and Neck"
+ slug: "head-and-neck"
+ treeNodeId: "ed24ed8c-5d57-4629-879b-447b82d2973d"
+ -
+ name: "Differential Diagnosis"
+ slug: "differential-diagnosis"
+ treeNodeId: "40d68862-8975-4dde-ac2b-ebc43ab0fb5c"
+ -
+ name: "Temporal Bone"
+ slug: "temporal-bone"
+ treeNodeId: "2f7dc690-4970-486f-abb6-ed24d99b7a04"
+ -
+ name: "Anatomically Based Differentials"
+ slug: "anatomically-based-differentials"
+ treeNodeId: "115faedf-cc6e-41cd-a155-665ce5b062ee"
+ -
+ name: "Inner Ear Lesion, Adult"
+ slug: "inner-ear-lesion-adult"
+ treeNodeId: null
+category: "Head and Neck"
+documentVersionId: "e47e6e6d-1bca-481c-9123-ff1abb4acc60"
+imageCount: 18
+lastUpdated: "06/24/24"
+pageDescription: "Inner Ear Lesion, Adult"
+pageKeywords: "Head and Neck, Differential Diagnosis, Temporal Bone, Anatomically Based Differentials, Inner Ear Lesion, Adult"
+pageTitle: "Inner Ear Lesion, Adult | STATdx"
+enhancedTitle: "Inner Ear Lesion, Adult"
+type: "DDX"
+references: true
+breadcrumbs:
+ - "Head and Neck"
+ - "Differential Diagnosis"
+ - "Temporal Bone"
+ - "Anatomically Based Differentials"
+ - "Inner Ear Lesion, Adult"
+---
+# ESSENTIAL INFORMATION
+
+- ## Key Differential Diagnosis Issues
+
+
+ - Differential encompasses all lesions, including normal variants, that may be found in inner ear region of adults
+ - Inner ear region in temporal bone includes all structures from medial wall of middle ear to lateral aspect of petrous apex
+- ## Helpful Clues for Common Diagnoses
+
+
+ - **Semicircular Canal Dehiscence**
+ - Clinical clues: Tinnitus, dizziness, vertigo, & conductive hearing loss (CHL)
+ - Tullio phenomenon: Sound-induced vertigo &/or nystagmus
+ - Pathophysiology: Focal superior semicircular canal (SCC) dehiscence causes "3rd" window in inner ear
+ - Bone CT findings
+ - Superior SCC roof dehiscent ≥ 2 mm into middle cranial fossa dura
+ - Transverse oblique CT reformation best shows lesion
+ - Rarely, posterior SCC dehiscence
+ - **Fenestral Otosclerosis**
+ - Clinical clues: Young adult develops gradual increased CHL
+ - Early disease location
+ - Begins at anterior margin of oval window (fissula ante fenestram)
+ - Bone CT findings
+ - Lucent & sclerotic lesions along margins of oval & round windows
+ - MR findings
+ - Enhancing millimeter-sized foci along margins of oval & round windows
+ - **Labyrinthine Ossificans**
+ - Clinical clue: Profound sensorineural hearing loss (SNHL) following episode of meningitis
+ - Pathophysiology: Healing of suppurative labyrinthitis may lead to osteoneogenesis in inner ear fluid spaces
+ - Bone CT findings
+ - Ossific plaques impinge on inner ear fluid spaces
+ - MR findings
+ - High-resolution T2: Loss of fluid signal/encroachment on membranous labyrinthine fluid spaces
+ - **High Jugular Bulb**
+ - Clinical clue: Often asymptomatic normal variant, uncommonly cause of pulsatile tinnitus
+ - Bone CT findings
+ - Cephalad portion of jugular bulb projects to level of internal auditory canal (IAC)
+ - MR findings
+ - May simulate enhancing lesion posterior to IAC
+ - **Jugular Bulb Diverticulum**
+ - Clinical clue: Asymptomatic normal variant
+ - Bone CT findings
+ - Thumb-like projection off jugular bulb
+ - Most commonly projects superiorly behind IAC
+ - May project in any direction
+ - MR findings
+ - May simulate enhancing lesion posterior to IAC
+ - **I****nner Ear****Fracture**
+ - Bone CT findings
+ - Transverse or longitudinal fracture line traverses inner ear structures
+ - Pneumolabyrinth possible
+ - Otic capsule sparing vs. otic capsule violating classification better predicts complications, such as SNHL, CNVII injury, & CSF leak
+ - ± ossicular dislocations &/or fractures
+ - MR findings
+ - High T1 signal (blood) within inner ear fluid spaces
+- ## Helpful Clues for Less Common Diagnoses
+
+
+ - **Cochlear Incomplete Partition Type II (IP-2)**
+ - Clinical clue: Congenital SNHL in child or young adult with cascading hearing loss pattern
+ - Key fact: Most common congenital imaging abnormality in adult SNHL
+ - Bone CT findings
+ - Deficient interscalar septum (ISS) between middle & apical cochlear turns
+ - Flattening of interscalar ridge (anchor point) between upper basal & upper middle cochlear turns
+ - Usually with enlarged bony vestibular aqueduct
+ - MR findings
+ - Deficient ISS between middle & apical cochlear turns
+ - Usually with enlarged endolymphatic sac/duct
+ - Literature suggests dysplastic osseous spiral lamina-basilar membrane neural complex may mimic ISS on high-resolution, 3D cisternographic MR images, resulting in underdiagnosed IP-2 anomalies
+ - Reformat images parallel to lateral SCC to measure distance X = distance between osseous spiral lamina-basilar membrane complex of upper basal turn & 1st linear signal void anterior to basilar membrane
+ - When 1st linear signal void = normal ISS, distance X < 1.2 mm
+ - When 1st linear signal void = dysplastic osseous spiral lamina-basilar membrane neural complex, distance X ≥ 1.2 mm
+ - **Facial Nerve Venous Malformation ("Hemangioma")**
+ - Clinical clues: Mimics Bell palsy
+ - Facial nerve (FN) paralysis; often with rapid onset
+ - Location/morphology: Geniculate fossa most common
+ - Poorly circumscribed; amorphous
+ - Vascular malformation, not hemangioma
+ - Bone CT findings
+ - Enlarged geniculate fossa
+ - As it increases, spreads along anterior surface of petrous apex
+ - ~ 50% show "honeycomb" ossific matrix
+ - MR findings
+ - Amorphous enhancing geniculate ganglion area mass
+ - **Facial Nerve Schwannoma**
+ - Clinical clues: 50% present with hearing loss
+ - FN symptoms often subtle or absent
+ - Location/morphology: Most commonly found in geniculate fossa
+ - Smooth, tubular expanding lesion
+ - Bone CT findings
+ - Focal or tubular enlargement intratemporal FN canal
+ - MR findings
+ - High-resolution T2: Hypointense soft tissue nodule replacing normal fluid signal
+ - C+ MR: Enhancing mass follows intratemporal FN
+ - **Labyrinthitis**
+ - Clinical clue: Acute-onset vertigo, hearing loss ± FN paralysis
+ - Bone CT findings
+ - Acute phase normal
+ - MR findings
+ - Normal or diffuse enhancement of inner ear fluid spaces
+ - **Intralabyrinthine Schwannoma**
+ - Clinical clue: 10-20 year history of gradual increased SNHL
+ - Bone CT findings
+ - Normal unless larger transmodiolar, transmacular, or transotic type present
+ - MR findings
+ - Focal enhancement within inner ear fluid space
+ - T2-hypointense nodule replacing normal fluid signal
+ - Recommended descriptive terms include location: Intracochlear, intravestibular, vestibulocochlear, transmodiolar, transmacular, & transotic options
+- ## Helpful Clues for Rare Diagnoses
+
+
+ - **Cochlear Otosclerosis**
+ - Clinical clue: Bilateral mixed CHL & SNHL
+ - Bone CT findings
+ - Lucent foci in bony labyrinth surrounding cochlea
+ - MR findings
+ - Punctate or linear enhancing foci in otic capsule
+ - **Intralabyrinthine Hemorrhage**
+ - Clinical clue: Idiopathic, anticoagulant therapy, posttraumatic, sickle cell disease
+ - Bone CT findings
+ - Normal unless associated with trauma
+ - MR findings
+ - High T1 signal in inner ear fluid spaces
+ - **Endolymphatic Sac Tumor**
+ - Clinical clues: Associated with von Hippel-Lindau disease > sporadic
+ - Bone CT findings
+ - Permeative lytic destruction of posterior petrous temporal bone at expected location of vestibular aqueduct/endolymphatic sac
+ - Spiculated or coarse calcifications within tumor matrix
+ - Thin calcification seen along posterior margin
+ - MR findings
+ - T1 high signal foci from blood products trapped within tumor matrix
+ - Avidly enhancing tumor; T1 flow voids ("pepper") also common
+
+## References
+
+# Selected References
+
+1. [Razskazovskiy V et al: Prevalence of cochlear-facial and other non-superior semicircular canal third window dehiscence on high-resolution temporal bone CT. AJNR Am J Neuroradiol. 44(11):1309-13, 2023](http://www.ncbi.nlm.nih.gov/pubmed/?term=37884302%5Bpmid%5D)
+1. [Deng F et al: Diagnostic performance of conebeam CT pixel values in active fenestral otosclerosis. AJNR Am J Neuroradiol. 42(9):1667-70, 2021](http://www.ncbi.nlm.nih.gov/pubmed/?term=34140277%5Bpmid%5D)
+1. [Ganeshan D et al: Tumors in von Hippel-Lindau syndrome: from head to toe-comprehensive state-of-the-art review. Radiographics. 38(3):849-66, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=29601266%5Bpmid%5D)
+1. [Conte G et al: MR imaging in sudden sensorineural hearing loss. Time to talk. AJNR Am J Neuroradiol. 38(8):1475-9, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28546251%5Bpmid%5D)
+1. [Reinshagen KL et al: Measurement for detection of incomplete partition type II anomalies on MR imaging. AJNR Am J Neuroradiol. 38(10):2003-7, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28775060%5Bpmid%5D)
+1. [Sparacia G et al: Diagnostic performance of reformatted isotropic thin-section helical CT images in the detection of superior semicircular canal dehiscence. Neuroradiol J. 30(3):216-21, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28627985%5Bpmid%5D)
+1. [Bausch B et al: Characterization of endolymphatic sac tumors and von Hippel-Lindau disease in the international ELST registry. Head Neck. 38 Suppl 1:E673-9, 2015](http://www.ncbi.nlm.nih.gov/pubmed/?term=25867206%5Bpmid%5D)
+1. [Kennedy TA et al: Imaging of temporal bone trauma. Neuroimaging Clin N Am. 24(3):467-86, viii, 2014](http://www.ncbi.nlm.nih.gov/pubmed/?term=25086807%5Bpmid%5D)
+1. [Nevoux J et al: Management of endolymphatic sac tumors: sporadic cases and von Hippel-Lindau disease. Otol Neurotol. 35(5):899-904, 2014](http://www.ncbi.nlm.nih.gov/pubmed/?term=24662627%5Bpmid%5D)
+1. [Young JY et al: Preoperative imaging of sensorineural hearing loss in pediatric candidates for cochlear implantation. Radiographics. 34(5):E133-49, 2014](http://www.ncbi.nlm.nih.gov/pubmed/?term=25208295%5Bpmid%5D)
+1. [Nadgir RN et al: Superior semicircular canal dehiscence: congenital or acquired condition? AJNR Am J Neuroradiol. 32(5):947-9, 2011](http://www.ncbi.nlm.nih.gov/pubmed/?term=21393404%5Bpmid%5D)
+1. [Benoit MM et al: Facial nerve hemangiomas: vascular tumors or malformations? Otolaryngol Head Neck Surg. 142(1):108-14, 2010](http://www.ncbi.nlm.nih.gov/pubmed/?term=20096233%5Bpmid%5D)
+1. [Offiah CE et al: Imaging appearances of unusual conditions of the middle and inner ear. Br J Radiol. 81(966):504-14, 2008](http://www.ncbi.nlm.nih.gov/pubmed/?term=18316346%5Bpmid%5D)
+1. [Salomone R et al: Sudden hearing loss caused by labyrinthine hemorrhage. Braz J Otorhinolaryngol. 74(5):776-9, 2008](http://www.ncbi.nlm.nih.gov/pubmed/?term=19082362%5Bpmid%5D)
+1. [Tieleman A et al: Imaging of intralabyrinthine schwannomas: a retrospective study of 52 cases with emphasis on lesion growth. AJNR Am J Neuroradiol. 29(5):898-905, 2008](http://www.ncbi.nlm.nih.gov/pubmed/?term=18321986%5Bpmid%5D)
+
+
+## Images
+
+
+### Selected Images
+
+
+**Semicircular Canal Dehiscence**
+*Transverse oblique bone CT reformation displays the dehiscent roof of the superior semicircular canal to best advantage by showing the entire extent of the dehiscence in a single image. Symptomatic patients typically present with sound-induced vertigo &/or nystagmus, i.e., Tullio phenomenon.*
+
+
+**Semicircular Canal Dehiscence**
+*Transverse oblique bone CT reformation displays the dehiscent roof of the superior semicircular canal to best advantage by showing the entire extent of the dehiscence in a single image. Symptomatic patients typically present with sound-induced vertigo &/or nystagmus, i.e., Tullio phenomenon.*
+
+
+**Fenestral Otosclerosis**
+*Axial bone CT demonstrates a subtle active otosclerotic plaque along the anterior margin of the oval window . This is the location of the fissula ante fenestram where fenestral otosclerosis begins.*
+
+
+**Labyrinthine Ossificans**
+*Axial bone CT in a patient with prior history of meningitis shows complete ossification of the vestibule and lateral semicircular canal . There was also partial opacification of the cochlea (not shown).*
+
+
+**High Jugular Bulb**
+*Axial bone CT shows a high jugular bulb visible at the level of the internal auditory canal . The high jugular bulb abuts the bony vestibular aqueduct . Note that it does not enter the middle ear cavity as a dehiscent jugular bulb might.*
+
+
+**Jugular Bulb Diverticulum**
+*Coronal bone CT demonstrates a jugular bulb diverticulum as a superomedial projection off the top of the jugular bulb . These lesions are often asymptomatic but can be the cause of pulsatile tinnitus.*
+
+
+**Inner Ear Fracture**
+*Axial bone CT in a patient with multiple skull base fractures secondary to a high-speed collision shows fractures traversing the left temporal bone, crossing the right posterior limb of the lateral semicircular canal with associated pneumolabyrinth in the vestibule and basal turn of the cochlea .*
+
+
+**Cochlear Incomplete Partition Type II (IP-2)**
+*Axial T2 MR shows a large endolymphatic sac along the posterior wall of the temporal bone. Note the associated cochlear dysplasia with modiolar deficiency and bulbous asymmetric scalar chambers . These patients present with a cascading pattern of progressive hearing loss.*
+
+
+**Facial Nerve Venous Malformation ("Hemangioma")**
+*Axial bone CT demonstrates a nonossifying, amorphous, geniculate ganglion lesion protruding into the anterior epitympanic recess. The anterior tympanic segment of CNVII is also shown.*
+
+
+**Facial Nerve Schwannoma**
+*Coronal T1 C+ FS MR reveals an enhancing well-circumscribed lesion of the geniculate ganglion . Notice that this ovoid facial nerve schwannoma sits just superior to the normal-appearing cochlea , the most common location for facial nerve schwannomas to occur.*
+
+
+**Labyrinthitis**
+*Coronal T1 C+ MR shows a diffusely enhancing cochlea along with facial nerve enhancement in the geniculate ganglion area . Clinical presentation included acute-onset vertigo and sensorineural hearing loss.*
+
+
+**Intralabyrinthine Schwannoma**
+*Axial T2 DRIVE image shows a very small intralabyrinthine hypointense schwannoma in the posterior aspect of the vestibule surrounded by otherwise normal hyperintense T2 signal intensity fluid. There was typical corresponding enhancement after contrast (not shown).*
+
+
+**Cochlear Otosclerosis**
+*Axial bone CT in a patient with severe cochlear and fenestral otosclerosis shows multifocal osteolytic foci surrounding the cochlea.*
+
+
+**Intralabyrinthine Hemorrhage**
+*Axial T1 MR reveals high-signal intralabyrinthine hemorrhage involving the cochlea , vestibule , and endolymphatic sac .*
+
+
+**Endolymphatic Sac Tumor**
+*Axial T1 MR shows a very large right endolymphatic sac tumor. The high-signal blood in the tumor matrix and broad involvement of the posterior temporal bone wall suggest this diagnosis. The majority of these lesions are associated with von Hippel-Lindau disease.*
+
+
+### Additional Images
+
+
+**Inner Ear Fracture**
+*Axial bone CT reveals a transverse fracture traversing the inner ear structures , crossing obliquely from just anterior to the vestibular aqueduct to the vestibule and then anterolaterally to cross the cochlea. Notice the pneumolabyrinth in the vestibule indicating a perilymphatic fistula at the oval window level.*
+
+
+**Cochlear Otosclerosis**
+*Axial bone CT shows a patient with severe cochlear and fenestral otosclerosis. The cochlear otospongiosis plaque initially appears to be a "3rd turn of the cochlea."*
+
+
+**Labyrinthine Ossificans**
+*Axial bone CT shows severe labyrinthine ossificans. Notice that the basal turn of the cochlea is partially ossified but still identifiable whereas the 2nd turn is nearly invisible .*
+
+
+**Intralabyrinthine Schwannoma**
+*Axial T1 C+ FS MR shows a mildly enhancing schwannoma involving the posterolateral aspect of the basal turn of the cochlea . The lesion protrudes into the middle ear cavity. These patients typically present with gradual increase in sensorineural hearing loss.*
+
diff --git a/docs_md/articles/intratemporal-facial-nerve-enhancement_a3569ec5-a566-411d-877f-41ad832e3fd2.md b/docs_md/articles/intratemporal-facial-nerve-enhancement_a3569ec5-a566-411d-877f-41ad832e3fd2.md
new file mode 100644
index 0000000..16ffc46
--- /dev/null
+++ b/docs_md/articles/intratemporal-facial-nerve-enhancement_a3569ec5-a566-411d-877f-41ad832e3fd2.md
@@ -0,0 +1,290 @@
+---
+title: "Intratemporal Facial Nerve Enhancement"
+docid: "a3569ec5-a566-411d-877f-41ad832e3fd2"
+authors:
+ - key: "94f835c8-fa13-4e8a-995b-53048e6b0605"
+ value: "Philip R. Chapman, MD"
+breadcrumbs:
+ -
+ name: "Head and Neck"
+ slug: "head-and-neck"
+ treeNodeId: "ed24ed8c-5d57-4629-879b-447b82d2973d"
+ -
+ name: "Diagnosis"
+ slug: "diagnosis"
+ treeNodeId: "19b6b986-97d0-40e7-b317-00f0c5cd8fa2"
+ -
+ name: "Temporal Bone"
+ slug: "temporal-bone"
+ treeNodeId: "9ad7d7b2-b2e4-4de2-be04-55ce607560c9"
+ -
+ name: "Intratemporal Facial Nerve"
+ slug: "intratemporal-facial-nerve"
+ treeNodeId: "35b77f60-796d-460f-8bac-4a187a150171"
+ -
+ name: "Pseudolesions"
+ slug: "pseudolesions"
+ treeNodeId: "eb1df224-339c-469f-857b-200d08f330df"
+ -
+ name: "Intratemporal Facial Nerve Enhancement"
+ slug: "intratemporal-facial-nerve-enhance-"
+ treeNodeId: null
+category: "Head and Neck"
+cmeTopicId: "2388da47-1d41-4309-8db6-b977b488180a"
+documentVersionId: "0fdb4514-1f1b-4100-a7fd-91cff6019fde"
+imageCount: 10
+lastUpdated: "09/24/21"
+pageDescription: "Intratemporal Facial Nerve Enhancement"
+pageKeywords: "Head and Neck, Diagnosis, Temporal Bone, Intratemporal Facial Nerve, Pseudolesions, Intratemporal Facial Nerve Enhancement"
+pageTitle: "Intratemporal Facial Nerve Enhancement | STATdx"
+enhancedTitle: "Intratemporal Facial Nerve Enhancement"
+type: "DX"
+references: true
+ddx: true
+anatomy:
+ - "{'authors': 'Philip R. Chapman, MD; Ryan P. Cabeen, PhD', 'bookmarked': False, 'bookmarkUrl': '/document/bookmark/2f4818dd-6438-405b-8561-5cbbb9c91562', 'category': 'Brain', 'compareUrl': '/compare/document/2f4818dd-6438-405b-8561-5cbbb9c91562/related-anatomy/treeNode?subContext=Facial Nerve (CNVII)', 'documentId': '2f4818dd-6438-405b-8561-5cbbb9c91562', 'documentType': 'ANATOMY', 'documentUrl': '/document/facial-nerve-cnvii/2f4818dd-6438-405b-8561-5cbbb9c91562', 'enhancedTitle': 'Facial Nerve (CNVII)', 'entryDate': '10/20/20', 'imageCount': 27, 'imageUrl': '/image/thumbnail/22d61165-f6cb-4f78-83a6-c5b5d308b29f?size=174&quality=85', 'inCompareCart': False, 'rank': 1, 'referenceCount': 0, 'showCompareButton': False, 'title': 'Facial Nerve (CNVII)'}"
+ - "{'authors': 'Santhosh Gaddikeri, MD; Philip R. Chapman, MD', 'bookmarked': False, 'bookmarkUrl': '/document/bookmark/98cb2d45-e64c-4295-9662-3470cd46513a', 'category': 'Head and Neck', 'compareUrl': '/compare/document/98cb2d45-e64c-4295-9662-3470cd46513a/related-anatomy/treeNode?subContext=CNVII (Facial Nerve)', 'documentId': '98cb2d45-e64c-4295-9662-3470cd46513a', 'documentType': 'ANATOMY', 'documentUrl': '/document/cnvii-facial-nerve/98cb2d45-e64c-4295-9662-3470cd46513a', 'enhancedTitle': 'CNVII (Facial Nerve)', 'entryDate': '12/06/23', 'imageCount': 39, 'imageUrl': '/image/thumbnail/1f7e56c2-da7a-4445-ac01-44eee0776f17?size=174&quality=85', 'inCompareCart': False, 'rank': 2, 'referenceCount': 0, 'showCompareButton': False, 'title': 'CNVII (Facial Nerve)'}"
+cases: 1
+breadcrumbs:
+ - "Head and Neck"
+ - "Diagnosis"
+ - "Temporal Bone"
+ - "Intratemporal Facial Nerve"
+ - "Pseudolesions"
+ - "Intratemporal Facial Nerve Enhancement"
+---
+# KEY FACTS
+
+- ## Terminology
+
+
+ - **Normal** contrast enhancement (CE) along course of intratemporal facial nerve (CNVII); typically subtle, symmetric with contralateral facial nerve and without bone changes or facial nerve symptoms
+ - Prominent perineural arteriovenous plexus responsible for normal enhancement
+- ## Imaging
+
+
+ - T1 C+ MR enhancement along CNVII
+ - Mastoid, tympanic, and geniculate ganglion segments generally show CE
+ - CE variable, dependent on technique and field strength but normally symmetric bilaterally
+ - Facial nerve within internal auditory canal should not enhance normally
+- ## Top Differential Diagnoses
+
+
+ - Bell palsy
+ - Ramsay Hunt syndrome
+ - Perineural parotid tumor of intratemporal CNVII
+ - Facial nerve schwannoma within temporal bone
+ - Facial nerve venous malformation
+- ## Clinical Issues
+
+
+ - Normal nerve enhancement **a****symptomatic** by definition
+- ## Diagnostic Checklist
+
+
+ - **Asymmetric** intratemporal facial nerve CE should be viewed with suspicion
+ - Correlation with facial nerve paralysis or hemifacial spasm important if abnormal CE suspected
+ - Any previous history of H&N cancer should alert to possibility of perineural tumor spread
+ - High-resolution T1 C+ FS MR through temporal bone should cover from brainstem through parotid glands to evaluate for facial nerve pathology
+ - Bone CT complementary in evaluation to exclude underlying bony changes
+
+# TERMINOLOGY
+
+- ## Definitions
+
+
+ - **Normal** contrast enhancement (CE) along course of intratemporal facial nerve (CNVII); typically mild to moderate, **symmetric** with contralateral facial nerve and without bone changes or facial nerve symptoms
+ - Prominent perineural arteriovenous plexus responsible for normal enhancement
+
+# IMAGING
+
+- ## General Features
+
+
+ - ### Best diagnostic clue
+
+
+ - T1 C+ MR CE along CNVII geniculate ganglion, tympanic and mastoid segments without bony CNVII canal changes
+ - CE variable, dependent on technique and field strength but **normally symmetric** bilaterally
+ - Facial nerve within internal auditory canal (IAC) should not enhance normally
+- ## CT Findings
+
+
+ - ### Bone CT
+
+
+ - Normal bony intratemporal CNVII canal
+- ## MR Findings
+
+
+ - ### T1WI
+
+
+ - Normal CNVII can be seen as isointense signal that can appear prominent compared with surrounding low signal of adjacent osseous or pneumatized structures
+ - ### T1WI C+
+
+
+ - Normal CE along portions of CNVII (1.5T spin-echo CE T1)
+ - Mastoid > geniculate ganglion > tympanic segments
+ - Usually symmetrical side-to-side
+ - MR field strength and sequence summary
+ - 1.5T MR: CE of CNVII canalicular and labyrinthine segments not seen
+ - 3T MR: CE of CNVII
+ - Mastoid (100%), geniculate (75%), tympanic (40%)
+ - Subtle enhancement can even be seen****in****canalicular (15%) and labyrinthine (5%) segments
+ - Comparing CE spin-echo to CE inversion recovery-prepared fast spoiled gradient-echo (IR-FSPGR)
+ - IR-FSPGR: Greater CNVII signal intensity in all segments
+- ## Imaging Recommendations
+
+
+ - ### Best imaging tool
+
+
+ - Normal CE seen best on 3-mm axial and coronal spin-echo T1 C+ MR at 3T
+
+# DIFFERENTIAL DIAGNOSIS
+
+- [Bell Palsy](/document/bell-palsy/0958e575-8f76-4d70-b806-0dbed9c62a67)
+ - Clinical: Acute onset of unilateral peripheral CNVII paralysis
+ - T1 C+ MR: Intense enhancement of intratemporal CNVII
+ - "Tuft" of IAC fundal enhancement highly suggestive
+ - Bone CT: CNVII bony canal normal
+- [Ramsay Hunt Syndrome](/document/ramsay-hunt-syndrome/94fd9d75-cbe7-4f01-9d36-7c54d629f5c6)
+ - Reactivation of herpes zoster from geniculate ganglion
+ - Typically robust enhancement of intratemporal facial nerve with typical vesicular rash of ear or soft palate
+- ## Perineural Parotid Tumor of Intratemporal CNVII
+
+
+ - T1 C+ MR: Nodular, asymmetric enhancement of facial nerve usually extending from intraparotid segment into mastoid segment and beyond
+ - May occur from primary parotid neoplasm or local spread of cutaneous malignancy
+- [Facial Nerve Schwannoma of Intratemporal CNVII](/document/temporal-bone-facial-nerve-schwann-/cf2bcc82-4a1b-4989-adeb-f4e82116111b)
+ - Most frequently found in geniculate fossa
+ - T1 C+ MR: Focal, enhancing mass along CNVII course
+ - Bone CT: Enlargement of intratemporal CNVII canal
+- [Facial Nerve Venous Malformation (Hemangioma) Within Temporal Bone](/document/temporal-bone-facial-nerve-venous--/dcd6a44e-cbe6-457c-9b03-598a2b874ece)
+ - Clinical: Early, unilateral CNVII paralysis
+ - Most frequent location = geniculate fossa
+ - T1 C+ MR: Enhancing mass enlarges geniculate fossa
+ - Bone CT: Honeycomb bony changes ~ 50%
+ - Irregular margins common
+
+# PATHOLOGY
+
+- ## General Features
+
+
+ - Embryology/anatomy
+ - CNVII plexus has 3 components
+ - Anterior: From anterior tympanic branch of internal maxillary artery or middle meningeal artery
+ - Middle: Tympanic plexus on medial wall of mesotympanum supplied from ascending pharyngeal artery
+ - Posterior: From stylomastoid artery (from occipital artery)
+ - Lush**arteriovenous plexus** surrounds CNVII within temporal bone
+ - Labyrinthine segment is least well vascularized
+- ## Gross Pathologic & Surgical Features
+
+
+ - Arteriovenous plexus consists of combination of relatively large arteries and veins in capillary plexus
+- ## Microscopic Features
+
+
+ - Dense CNVII circumneutral arteriovenous plexus predominantly located in geniculate ganglion, tympanic and mastoid segments ± greater superficial petrosal nerve
+
+# CLINICAL ISSUES
+
+- ## Presentation
+
+
+ - ### Most common signs/symptoms
+
+
+ - **Asymptomatic** by definition
+ - CNVII normal enhancement seen incidentally during T1 C+ MR work-up for unrelated clinical findings
+
+# DIAGNOSTIC CHECKLIST
+
+- ## Consider
+
+
+ - If facial nerve is normal in size and enhancement is symmetric to corresponding contralateral facial nerve segment, probably normal
+ - **Asymmetric** intratemporal facial nerve CE should be viewed with suspicion
+ - Correlation with facial nerve paralysis or hemifacial spasm important if abnormal CE suspected
+ - Any previous history of H&N cancer should alert to possibility of perineural tumor spread
+ - Higher field strength (3T) and IR-FSPGR MR sequences make normal CNVII CE more conspicuous
+ - If fundal vestibular schwannoma present, labyrinthine segment of CNVII may enhance normally
+ - Arteriovenous plexus congestion is likely cause
+ - Evaluation of tympanic or mastoid segments difficult if opacification, inflammation, or infection of middle ear and mastoid air cells
+ - Significant CE along cisternal, labyrinthine segment or extracranial mastoid CNVII segments **not** normal
+
+ 44fba962-014f-4057-a9c3-52a2c22841ca
+
+## References
+
+# Selected References
+
+1. [George E et al: Facial nerve palsy: clinical practice and cognitive errors. Am J Med. 133(9):1039-44, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32445717%5Bpmid%5D)
+1. [Radhakrishnan R et al: Comparison of normal facial nerve enhancement at 3T MRI using gadobutrol and gadopentetate dimeglumine. Neuroradiol J. 30(6):554-60, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28696161%5Bpmid%5D)
+1. [Dehkharghani S et al: Redefining normal facial nerve enhancement: healthy subject comparison of typical enhancement patterns--unenhanced and contrast-enhanced spin-echo versus 3D inversion recovery-prepared fast spoiled gradient-echo imaging. AJR Am J Roentgenol. 202(5):1108-13, 2014](http://www.ncbi.nlm.nih.gov/pubmed/?term=24758667%5Bpmid%5D)
+1. [Hong HS et al: Enhancement pattern of the normal facial nerve at 3.0 T temporal MRI. Br J Radiol. 83(986):118-21, 2010](http://www.ncbi.nlm.nih.gov/pubmed/?term=19546177%5Bpmid%5D)
+1. [Tabuchi T et al: Vascular permeability to fluorescent substance in human cranial nerves. Ann Otol Rhinol Laryngol. 111(8):736-7, 2002](http://www.ncbi.nlm.nih.gov/pubmed/?term=12184597%5Bpmid%5D)
+1. [Martin-Duverneuil N et al: Contrast enhancement of the facial nerve on MRI: normal or pathological? Neuroradiology. 39(3):207-12, 1997](http://www.ncbi.nlm.nih.gov/pubmed/?term=9106296%5Bpmid%5D)
+1. [Gebarski SS et al: Enhancement along the normal facial nerve in the facial canal: MR imaging and anatomic correlation. Radiology. 183(2):391-4, 1992](http://www.ncbi.nlm.nih.gov/pubmed/?term=1561339%5Bpmid%5D)
+
+## Differential diagnosis
+
+### Facial Nerve Lesion, Temporal Bone
+DDX:1428754b-a8ee-48a0-98f8-4faeebf8dbab
+
+## Anatomy
+
+### Facial Nerve (CNVII)
+Brain/ANATOMY:2f4818dd-6438-405b-8561-5cbbb9c91562
+
+### CNVII (Facial Nerve)
+Head and Neck/ANATOMY:98cb2d45-e64c-4295-9662-3470cd46513a
+
+## Cases
+
+- {'cases': [{'authors': [{'key': '624acd80-0502-4325-be71-e68fec740eb3', 'value': 'Richard H. Wiggins, III, MD, CIIP, FSIIM, FAHSE, FACR'}], 'caseVersionId': '1e34cd15-48c8-4451-b42b-14d967d90b75', 'description': 'This is a classic case of normal enhancement of the intra-temporal bone facial nerve on MR.\n\nThe right axial T1 weighted post-contrasted image (#1) shows normal enhancement at the geniculate ganglion (open arrow) and proximal tympanic segment (arrow). The coronal post-contrasted T1 weighted image (#2) also demonstrates the normal enhancement at the right geniculate ganglion (open arrow), superior to the normal cochlea (curved arrow).', 'history': None, 'imagePoolId': 'ad489f2a-935a-42a8-9c38-0fd41bfbc40a', 'name': 'Classic', 'teachingPoint': None, 'demographics': '35 Years old male'}, {'authors': [{'key': '624acd80-0502-4325-be71-e68fec740eb3', 'value': 'Richard H. Wiggins, III, MD, CIIP, FSIIM, FAHSE, FACR'}], 'caseVersionId': '32a339bf-b7cc-49ec-ae61-8c92fb74a06a', 'description': 'This is a classic case of normal enhancement along the facial nerve on MR.\n\nThe axial post-contrasted T1 weighted MRI with fat-saturation (#1) shows normal enhancement at the right geniculate ganglion (arrow).\n\nThe coronal images (#2-3) show the normal enhancement along the proximal tympanic segment (arrow, #2), superior to the cochlea (curved arrow, #2). A more posterior coronal image also show the normal tympanic segment enhancement (arrow, #3), below the lateral semicircular canal (open arrow, #3).', 'history': None, 'imagePoolId': 'be5d1b24-1eab-41b1-9c48-497b9c4667a8', 'name': 'Classic', 'teachingPoint': None, 'demographics': '44 Years old female'}, {'authors': [{'key': '624acd80-0502-4325-be71-e68fec740eb3', 'value': 'Richard H. Wiggins, III, MD, CIIP, FSIIM, FAHSE, FACR'}], 'caseVersionId': '53a809ba-0d87-4e1c-8e0a-91f32d64b307', 'description': 'This is a typical case of normal enhancement along the intratemporal facial nerve on MR.\n\nThe axial, whole brain, post-contrasted T1 weighted MR fat-saturated images (#1-5) shows normal enhancement at the geniculate ganglion on the left (arrow, #1), and the right (arrow, #2), and the proximal left tympanic segment (open arrow, #2). The magnified axial images confirm this enhancement at the right geniculate ganglion (arrow, #3), and on the left (arrow, #4), and at the left proximal tympanic segment (open arrow, #5).\n\nThe coronal post-contrasted images (#6-7) also show the normal enhancement at the left geniculate ganglion (arrow), and the proximal tympanic segment (open arrow).', 'history': None, 'imagePoolId': '07ca0ec3-ae96-4902-b30e-b3c5de01328b', 'name': 'Classic', 'teachingPoint': None, 'demographics': '68 Years old male'}, {'authors': [{'key': '624acd80-0502-4325-be71-e68fec740eb3', 'value': 'Richard H. Wiggins, III, MD, CIIP, FSIIM, FAHSE, FACR'}], 'caseVersionId': '8346972f-258e-4307-a8e2-c75c98682cbb', 'description': 'This is a classic case of normal facial nerve enhancement on MR.\n\nThis axial post-contrasted T1 weighted MRI with fat-saturation show the normal enhancement along the proximal tympanic segment (arrow). There is no enhancement seen within the internal auditory canal (open arrow).', 'history': None, 'imagePoolId': '6573d494-b008-42da-b7b7-91aa1ebb4142', 'name': 'Classic', 'teachingPoint': None, 'demographics': '74 Years old female'}, {'authors': [{'key': '624acd80-0502-4325-be71-e68fec740eb3', 'value': 'Richard H. Wiggins, III, MD, CIIP, FSIIM, FAHSE, FACR'}], 'caseVersionId': 'b5352292-4ccc-473b-892e-1c190d205953', 'description': 'This is a typical case of normal enhancement of the intratemporal facial nerve.\n\nThese axial T1 weighted post-contrasted images (#1, 2) with fat-saturation show subtle normal enhancement along the proximal tympanic segment of the left facial nerve (arrow) and the geniculate ganglion (open arrow, #1). There is no enhancement seen in the cisternal or canalicular segments of the facial nerve.', 'history': None, 'imagePoolId': '1afc0120-5710-4f04-b641-4ad3ebd006bd', 'name': 'Classic', 'teachingPoint': None, 'demographics': '59 Years old female'}], 'caseType': 'typical', 'name': 'TYPICAL'}
+
+
+## Images
+
+
+### Selected Images
+
+
+*Typical normal enhancement pattern of facial intratemporal facial nerves in a patient with vestibular schwannoma is shown. On this axial MR, the geniculate ganglia (triangular structures superolateral to the IAC) demonstrate moderate symmetric enhancement. Right vestibular schwannoma is noted .*
+
+
+*Typical normal enhancement pattern of facial intratemporal facial nerves in a patient with vestibular schwannoma is shown. On this axial MR, the geniculate ganglia (triangular structures superolateral to the IAC) demonstrate moderate symmetric enhancement. Right vestibular schwannoma is noted .*
+
+
+*Axial MR slightly lower shows mild to moderate symmetric enhancement of the tympanic portions of the facial nerves . Aside from the vestibular schwannoma , no IAC enhancement is identified.*
+
+
+*Axial (slightly oblique) MR in the same patient demonstrates little or no enhancement of the posterior genu of the left facial nerve and subtle normal enhancement of the proximal mastoid segment of the right facial nerve. The lower vestibular schwannoma is noted.*
+
+
+*Axial MR in the same patient shows moderate, normal linear enhancement of the lower mastoid segments of the facial nerves. Contrast enhancement of mastoid segment CNVII is usually more robust distally.*
+
+
+### Additional Images
+
+
+*Axial T1 C+ FS MR through the internal auditory canals reveals a normal geniculate ganglion and anterior tympanic segment CNVII enhancement on the left. On the right, normal anterior tympanic segment enhancement is visible.*
+
+
+*Axial T1 C+ FS MR in a patient with right vestibular schwannoma demonstrates increased enhancement of the labyrinthine CNVII, geniculate ganglion , and anterior tympanic segment CNVII.*
+
+
+*Coronal T1 C+ FS MR at the level of the vestibules reveals normal enhancement of the midtympanic segment of the facial nerves .*
+
+
+*Coronal T1 C+ FS MR in the same patient shows the normal geniculate ganglion enhancement just superior to the cochleas . Note that the tensor tympani muscles both also enhance. With 3T imaging, more normal enhancement of structures within the temporal bone is seen.*
+
+
+*Axial T1 C+ MR at 3T shows prominent but normal enhancement of geniculate ganglion as well as the anterior tympanic segment of intratemporal CNVII.*
+
+
+*Coronal T1 C+ MR at 3T demonstrates conspicuous enhancement of the geniculate ganglion ; compare the degree of enhancement to the nonenhancing cochlea that is seen inferiorly.*
+
diff --git a/docs_md/articles/lumbar-hernia_0fa5904f-36a1-42db-8398-80b5e495f7ae.md b/docs_md/articles/lumbar-hernia_0fa5904f-36a1-42db-8398-80b5e495f7ae.md
new file mode 100644
index 0000000..fd4bfbc
--- /dev/null
+++ b/docs_md/articles/lumbar-hernia_0fa5904f-36a1-42db-8398-80b5e495f7ae.md
@@ -0,0 +1,306 @@
+---
+title: "Lumbar Hernia"
+docid: "0fa5904f-36a1-42db-8398-80b5e495f7ae"
+authors:
+ - key: "c1df94ab-4a9f-44c4-add7-1f174fb9ac45"
+ value: "Siva P. Raman, MD"
+breadcrumbs:
+ -
+ name: "Gastrointestinal"
+ slug: "gastrointestinal"
+ treeNodeId: "b52263f7-5978-4a22-a17d-7260e0033943"
+ -
+ name: "Diagnosis"
+ slug: "diagnosis"
+ treeNodeId: "5a7c51af-b1c6-4629-8f0e-d99e6fe57a98"
+ -
+ name: "Peritoneum, Mesentery, and Abdominal Wall"
+ slug: "peritoneum-mesentery-and-abdominal-"
+ treeNodeId: "a3fb9f00-f894-4b38-9e01-2f78406cf547"
+ -
+ name: "External Hernias"
+ slug: "external-hernias"
+ treeNodeId: "71ab3f79-4332-463c-9f60-d3dd2902d974"
+ -
+ name: "Lumbar Hernia"
+ slug: "lumbar-hernia"
+ treeNodeId: null
+category: "Gastrointestinal"
+documentVersionId: "04dd5f57-9301-4bf0-b6f2-42661575dc41"
+imageCount: 8
+lastUpdated: "03/13/25"
+pageDescription: "Lumbar Hernia"
+pageKeywords: "Gastrointestinal, Diagnosis, Peritoneum, Mesentery, and Abdominal Wall, External Hernias, Lumbar Hernia"
+pageTitle: "Lumbar Hernia | STATdx"
+enhancedTitle: "Lumbar Hernia"
+type: "DX"
+references: true
+ddx: true
+anatomy:
+ - "{'authors': 'Atif Zaheer, MD, FSAR; Siva P. Raman, MD; Michael P. Federle, MD, FACR', 'bookmarked': False, 'bookmarkUrl': '/document/bookmark/6691f48d-ac34-477b-8ec1-b9dd731a14a8', 'category': 'Gastrointestinal', 'compareUrl': '/compare/document/6691f48d-ac34-477b-8ec1-b9dd731a14a8/related-anatomy/treeNode?subContext=Peritoneal Cavity', 'documentId': '6691f48d-ac34-477b-8ec1-b9dd731a14a8', 'documentType': 'ANATOMY', 'documentUrl': '/document/peritoneal-cavity/6691f48d-ac34-477b-8ec1-b9dd731a14a8', 'enhancedTitle': 'Peritoneal Cavity', 'entryDate': '07/06/23', 'imageCount': 53, 'imageUrl': '/image/thumbnail/e305c4ce-1242-49fa-bc19-e0f5461cdafa?size=174&quality=85', 'inCompareCart': False, 'rank': 1, 'referenceCount': 0, 'showCompareButton': False, 'title': 'Peritoneal Cavity'}"
+ - "{'authors': 'Jade Wong-You-Cheong, MBChB, MRCP, FRCR, FSRU, FSAR', 'bookmarked': False, 'bookmarkUrl': '/document/bookmark/9c50ad6a-e96b-44a1-93d1-a4e7de5212c2', 'category': 'Ultrasound', 'compareUrl': '/compare/document/9c50ad6a-e96b-44a1-93d1-a4e7de5212c2/related-anatomy/treeNode?subContext=Peritoneal Spaces and Structures', 'documentId': '9c50ad6a-e96b-44a1-93d1-a4e7de5212c2', 'documentType': 'ANATOMY', 'documentUrl': '/document/peritoneal-spaces-and-structures/9c50ad6a-e96b-44a1-93d1-a4e7de5212c2', 'enhancedTitle': 'Peritoneal Spaces and Structures', 'entryDate': '06/01/21', 'imageCount': 19, 'imageUrl': '/image/thumbnail/2f75e19a-ac4a-4c80-b849-10223abf64f2?size=174&quality=85', 'inCompareCart': False, 'rank': 2, 'referenceCount': 2, 'showCompareButton': False, 'title': 'Peritoneal Spaces and Structures'}"
+ - "{'authors': 'Eric Turner, MD; Mark E. Lockhart, MD, MPH; Daniel Childers, MD', 'bookmarked': False, 'bookmarkUrl': '/document/bookmark/79a4117f-773a-40b3-bdb5-b0195f84e087', 'category': 'Ultrasound', 'compareUrl': '/compare/document/79a4117f-773a-40b3-bdb5-b0195f84e087/related-anatomy/treeNode?subContext=Mesenteric Vessels', 'documentId': '79a4117f-773a-40b3-bdb5-b0195f84e087', 'documentType': 'ANATOMY', 'documentUrl': '/document/mesenteric-vessels/79a4117f-773a-40b3-bdb5-b0195f84e087', 'enhancedTitle': 'Mesenteric Vessels', 'entryDate': '05/13/24', 'imageCount': 22, 'imageUrl': '/image/thumbnail/102e0a5e-f97c-46b9-9dc0-6193e796506d?size=174&quality=85', 'inCompareCart': False, 'rank': 3, 'referenceCount': 0, 'showCompareButton': False, 'title': 'Mesenteric Vessels'}"
+cases: 2
+breadcrumbs:
+ - "Gastrointestinal"
+ - "Diagnosis"
+ - "Peritoneum, Mesentery, and Abdominal Wall"
+ - "External Hernias"
+ - "Lumbar Hernia"
+---
+# KEY FACTS
+
+- ## Terminology
+
+
+ - Lumbar hernia: Protrusion of abdominal contents through defect in lumbar region
+ - Can occur in either superior lumbar triangle of Grynfeltt-Lesshaft or inferior lumbar triangle of Petit
+ - Superior lumbar triangle of Grynfeltt-Lesshaft defined by 12th rib superiorly, superior border of internal oblique inferiorly, and erector spinae medially
+ - Inferior lumbar triangle of Petit defined by latissimus dorsi muscle medially, iliac crest inferiorly, and free border of external oblique muscle laterally
+ - Overall, hernias are more common in superior triangle
+- ## Imaging
+
+
+ - Disruption of thoracolumbar fascia at insertion of aponeurosis of internal oblique and transverse abdominal muscles
+ - Hernia may contain extraperitoneal fat, colon, kidney, or intraperitoneal structures (small bowel, ascites)
+ - Most commonly involved are colon and small bowel
+- ## Top Differential Diagnoses
+
+
+ - Abdominal wall neoplasms
+ - Abdominal wall hematoma
+ - Abdominal wall lipoma
+- ## Pathology
+
+
+ - 80% of lumbar hernias are acquired
+ - Can be spontaneous (especially in older patients and patients with excessive weight loss) or secondary to trauma, infection, or previous surgery in flank
+ - Most commonly occurs following flank incision for renal surgery or iliac crest bone harvesting
+ - < 20% of lumbar hernias are congenital and often associated with other congenital abnormalities
+- ## Clinical Issues
+
+
+ - Very difficult to detect (and often missed) on physical examination and more likely to be diagnosed on CT
+ - Risk of incarceration and strangulation higher than originally believed (approaching 30%)
+ - Incarceration more common with traumatic lumbar hernias
+ - Treatment: Early surgical repair because repair becomes technically more difficult as hernia enlarges
+
+# TERMINOLOGY
+
+- ## Definitions
+
+
+ - Lumbar hernia: Protrusion of abdominal contents through defect in lumbar region
+ - Lumbar region: Area bounded by 12th rib superiorly, iliac crest inferiorly, erector spinae muscles medially, and free border of external oblique muscle laterally
+ - Superior lumbar triangle of Grynfeltt-Lesshaft
+ - Defined by 12th rib superiorly, superior border of internal oblique inferiorly, and erector spinae muscles medially
+ - Transversus abdominis muscle lies deep in floor; latissimus dorsi muscle serves as roof of this space
+ - Inferior lumbar triangle of Petit
+ - Defined by latissimus dorsi muscle medially, iliac crest inferiorly, and free border of external oblique muscle laterally
+ - Thoracolumbar fascia lies in floor of this triangle
+
+# IMAGING
+
+- ## General Features
+
+
+ - ### Best diagnostic clue
+
+
+ - Disruption of fascia and muscles in lumbar region with protrusion of abdominal contents
+ - ### Location
+
+
+ - Superior and inferior lumbar triangles
+ - Primary type more common in superior lumbar triangle, more common on left side
+ - Secondary type more common in inferior lumbar triangle
+ - Traumatic lumbar hernias more common in inferior triangle because of deceleration forces during motor vehicle accidents at junction of lap belt and shoulder belt
+ - Overall, hernias more common in superior triangle because it is larger than inferior triangle
+ - ### Morphology
+
+
+ - Disruption of thoracolumbar fascia at insertion of aponeurosis of internal oblique and transverse abdominal muscles
+ - Hernia may contain extraperitoneal fat, colon, kidney, or intraperitoneal structures (small bowel, ascites)
+ - Most commonly involved structures are colon (41%) and small bowel (32%)
+ - Bowel wall thickening, infiltrated fat, and pain at site of hernia suggest strangulation and ischemia
+- ## Imaging Recommendations
+
+
+ - ### Best imaging tool
+
+
+ - CECT
+ - ### Protocol advice
+
+
+ - Multiplanar reformations can help visualize nature and size of defect as well as aiding in preoperative planning
+
+# DIFFERENTIAL DIAGNOSIS
+
+- ## Abdominal Wall Neoplasms
+
+
+ - Can be primary (e.g., sarcoma) or metastatic (e.g., melanoma)
+ - While mass could theoretically be confused with hernia on physical exam, distinction should be obvious on imaging
+- ## Abdominal Wall Hematoma
+
+
+ - Most often in setting of trauma or coagulopathy
+ - Heterogeneous high-density collection should be easily distinguishable from hernia on cross-sectional imaging
+- ## Abdominal Wall Lipoma
+
+
+ - Discrete fat-containing mass without evidence of fascial defect or protrusion of abdominal contents
+
+# PATHOLOGY
+
+- ## General Features
+
+
+ - ### Etiology
+
+
+ - Congenital (< 20%)
+ - Associated with variety of other congenital abnormalities, including musculoskeletal abnormalities (i.e., absent ribs, spinal dysraphism, hemivertebrae), urinary tract abnormalities (ureteropelvic junction obstruction, cloacal extrophy, etc.), diaphragmatic hernia, myelomeningocele, etc.
+ - Maybe secondary to somatic mutation during embryogenesis, possibly also explaining high rates of concomitant musculoskeletal abnormalities in spine and abdominal wall
+ - Exact incidence is somewhat unclear, but only a few cases actually reported in literature
+ - Acquired (80%)
+ - Primary (55%): Spontaneous, seen in older-age patients and patients with excessive weight loss
+ - Entities that increase intraabdominal pressure may also predispose to development of lumbar hernias, such as pregnancy, obesity, ascites, etc. (similar to other hernias)
+ - Abdominal wall weakness that develops with age, muscle atrophy, etc. can also play role
+ - Secondary (25%): Due to trauma, infection, or previous surgery in flank
+ - Most common prior surgeries to result in lumbar hernia include nephrectomy, abdominal aortic aneurysm repair, latissimus dorsi myocutaneous flap repair, and iliac crest bone harvesting
+ - Acute traumatic lumbar hernias are very rare and usually occur after blunt abdominal trauma (especially with seat belt injury)
+ - Can occur after infections that weaken abdominal wall at this site (hepatic abscess, pelvic bone infections, etc.)
+ - Surgeries with highest risk of development of lumbar hernia
+ - Iliac crest bone harvesting (5-10%)
+ - Open nephrectomy or adrenalectomy
+
+# CLINICAL ISSUES
+
+- ## Presentation
+
+
+ - ### Most common signs/symptoms
+
+
+ - Flank bulge, "dragging" sensation, back pain
+ - Palpable mass in posterolateral abdominal wall that worsens with coughing, activity, or Valsalva maneuver
+ - Very difficult to detect on physical examination (and often missed) and more likely to be diagnosed on CT
+- ## Demographics
+
+
+ - ### Age
+
+
+ - Most diagnosed patients between 60-70 years old
+ - ### Sex
+
+
+ - M > F (2:1)
+ - ### Epidemiology
+
+
+ - Primary type: More common in men and older patients
+ - Secondary type: History of trauma, infection, or surgery in lumbar region
+- ## Natural History & Prognosis
+
+
+ - While incarceration and strangulation have traditionally been thought to be uncommon because of large size of opening into hernia, more recent data suggests risk may be higher than previously thought (perhaps as high as 30%)
+ - Incarceration more common with acute traumatic lumbar hernias
+ - Acute posttraumatic lumbar hernias have strong association with other internal abdominal injuries
+ - Erythema and increased pain may suggest strangulation
+ - Strangulation is secondary to volvulus or constricted neck of hernia
+- ## Treatment
+
+
+ - In absence of acute complications (such as obstruction, incarceration, etc.), elective surgery is advocated as soon as possible
+ - Early surgery is advocated, because as hernia enlarges, repair becomes technically more difficult (and due to risk of incarceration)
+ - While lumbar hernia repair has traditionally been performed with open technique, these repairs are now increasingly being done laparoscopically (without clear data showing advantage of one vs. other) and typically with use of mesh
+ - Laparoscopic repair typically recommended in hernias < 5 cm in size, while approach for larger hernias more variable
+ - Recurrence more likely for large hernias (> 15 cm in size) and in obese patients
+ - In congenital hernias, repair is usually performed before 12 months of age (as surgery may become more technically difficult as hernia enlarges over time)
+
+# DIAGNOSTIC CHECKLIST
+
+- ## Consider
+
+
+ - Look for evidence of prior surgery
+ - Nephrectomy or iliac crest bone harvest site (typically for spinal fusion)
+- ## Image Interpretation Pearls
+
+
+ - Identify muscle and fascial planes to determine specific type of hernia
+
+ 36a0911b-5166-43a2-9324-bce342e97745
+
+## References
+
+# Selected References
+
+1. [Sabbagh ED et al: Management of a primary Grynfeltt's hernia. J Visc Surg. 161(4):273-4, 2024](http://www.ncbi.nlm.nih.gov/pubmed/?term=38604931%5Bpmid%5D)
+1. [van Steensel S et al: Pitfalls and clinical recommendations for the primary lumbar hernia based on a systematic review of the literature. Hernia. 23(1):107-17, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=30315438%5Bpmid%5D)
+1. [Mellnick VM et al: Traumatic lumbar hernias: do patient or hernia characteristics predict bowel or mesenteric injury? Emerg Radiol. 21(3):239-43, 2014](http://www.ncbi.nlm.nih.gov/pubmed/?term=24402010%5Bpmid%5D)
+1. [Saboo SS et al: Traumatic lumbar hernia: can't afford to miss. Emerg Radiol. 21(3):325-7, 2014](http://www.ncbi.nlm.nih.gov/pubmed/?term=24424984%5Bpmid%5D)
+1. [Aguirre DA et al: Abdominal wall hernias: imaging features, complications, and diagnostic pitfalls at multi-detector row CT. Radiographics. 25(6):1501-20, 2005](http://www.ncbi.nlm.nih.gov/pubmed/?term=16284131%5Bpmid%5D)
+1. [Baker ME et al: Lumbar hernia: diagnosis by CT. AJR Am J Roentgenol. 148(3):565-7, 1987](http://www.ncbi.nlm.nih.gov/pubmed/?term=3492886%5Bpmid%5D)
+1. [Touloukian RJ: The lymbocostovertebral syndrome: a single somatic defect. Surgery. 71(2):174-81, 1972](http://www.ncbi.nlm.nih.gov/pubmed/?term=5057828%5Bpmid%5D)
+
+## Differential diagnosis
+
+### Abdominal Wall Mass
+DDX:d51e2268-67b6-4a60-9222-f5a86f61ddec
+
+### Defect in Abdominal Wall (Hernia)
+DDX:5af046fa-59ef-45b5-952b-acbcdee36196
+
+## Anatomy
+
+### Peritoneal Cavity
+Gastrointestinal/ANATOMY:6691f48d-ac34-477b-8ec1-b9dd731a14a8
+
+### Peritoneal Spaces and Structures
+Ultrasound/ANATOMY:9c50ad6a-e96b-44a1-93d1-a4e7de5212c2
+
+### Mesenteric Vessels
+Ultrasound/ANATOMY:79a4117f-773a-40b3-bdb5-b0195f84e087
+
+## Cases
+
+- {'cases': [{'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '58c96b57-63db-4ca0-a349-5a94904cd179', 'description': 'There is a defect in the thoracolumbar fascia on the right side (curved arrows, #2,3) through which retroperitoneal fat herniates (arrow, #1). The site of herniation is just cephalad to the insertion of the fascia on the iliac crest.', 'history': 'Bulge in right flank.', 'imagePoolId': '7eff1f2b-8a13-4c53-9687-4aff5336ee3c', 'name': 'Right lumbar hernia', 'teachingPoint': None, 'demographics': '65 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '9e260cfc-1da3-4653-be86-21e587c2b643', 'description': 'CT shows a defect (arrows, #1,2) in the left thoracolumbar fascia through which the descending colon (open arrow, #1) herniates dorsally. The thoracolumbar fascia should be a strong sheet of tissue that inserts on the iliac crest (curved arrow, #4).', 'history': 'Left flank pain and bulge.', 'imagePoolId': '722090c5-0cb2-4df7-8d2e-ec208c296008', 'name': 'Left hernia with herniated colon', 'teachingPoint': None, 'demographics': '78 Years old female'}], 'caseType': 'typical', 'name': 'TYPICAL'}
+- {'cases': [{'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '11d6423f-b807-4a3a-9507-234d36d68eb7', 'description': 'A series of axial (#1-6) and coronal (#7-15) contrast-enhanced CT sections show avulsion of the muscular and tendinous insertions of the abdominal wall muscles from the left iliac wing and thoracolumbar fascia (arrows, #4-5, 8-13), especially along the more dorsal surfaces. More anteriorly, the musculotendinous insertions are intact (open arrows, #6, 14-15). The herniated abdominal fat is covered only by the latissimus dorsi muscle (curved arrows, #3-4). Also noted is infiltration of the fat adjacent to the descending colon (curved arrows, #1-2). \n\nComment: At surgery, a serosal tear of the descending colon was confirmed.', 'history': 'Patient injured in high-speed motor vehicle crash.', 'imagePoolId': '847c0a5b-0b04-43e1-a1b1-77018adfbc41', 'name': 'Traumatic lumbar hernia', 'teachingPoint': None, 'demographics': '46 Years old female'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '2e3903c4-0c1c-4fe3-acee-5c6c3db7fa74', 'description': 'A series of axial nonenhanced CT sections (#1-5) show surgical absence of the left kidney with protrusion of abdominal fat through the site of the incision. The hernia is covered mostly by the thin latissimus dorsi muscle (arrows, #1-4). The defect, a variant of a lumbar hernia, is through the aponeuroses of the abdominal oblique and transverse muscles.', 'history': 'Bulge in flank some months after open nephrectomy.', 'imagePoolId': 'bf7bec4c-e54a-4371-add2-ed1ff53c85ba', 'name': 'Following nephrectomy for renal cancer', 'teachingPoint': None, 'demographics': '60 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'd07fd737-202f-4c9a-80de-41e588b75a13', 'description': 'A series of axial contrast-enhanced CT sections (#1-11) show 2 separate protrusions of fat. The more cephalic of these (curved arrows, #1-2) is a herniation of abdominal fat into the thorax through a posteromedial defect in the diaphragm, called a Bochdalek hernia. The more caudal of these is a herniation of abdominal fat through a defect in the aponeuroses of the transverse abdominal and oblique muscles at their insertion into the thoracolumbar fascia. This is called a lumbar hernia. The herniated fat is covered by the latissimus dorsi muscle (arrows, #4-9). The fascial defect (open arrows) is seen best on sections #9-10. Caudal to this defect, the aponeuroses are intact but very thin bilaterally (curved arrows, #11), predisposing this patient to a lumbar hernia on the left side as well.\n\nComment: Lumbar hernias may allow herniation of retroperitoneal contests, such as fat, kidneys, or colon, or intraperitoneal contents, such as ascites or small intestine.', 'history': 'Patient with a nontender bulge in right flank.', 'imagePoolId': 'e3b26b1e-effc-450c-ad03-16422f747036', 'name': 'Lumbar and Bochdalek hernia', 'teachingPoint': None, 'demographics': '72 Years old female'}], 'caseType': 'variant', 'name': 'VARIANT'}
+
+
+## Images
+
+
+### Selected Images
+
+
+*Axial CECT demonstrates a classic right-sided lumbar hernia with herniation of retroperitoneal fat and a portion of the right kidney covered only by the thinned latissimus dorsi muscle .*
+
+
+*Axial CECT demonstrates a defect in the thoracolumbar fascia on the right side through which retroperitoneal fat herniates. The site of herniation is just cephalad to the insertion of the fascia on the iliac crest, classic for a lumbar hernia.*
+
+
+*Axial NECT demonstrates a traumatic lumbar hernia in the setting of blunt trauma. The abdominal wall is disrupted in the left flank with herniated abdominal fat covered only by the latissimus dorsi muscle .*
+
+
+*Coronal CECT demonstrates a large right-sided lumbar hernia containing a long segment of the colon and a portion of the liver .*
+
+
+### Additional Images
+
+
+*Axial NECT demonstrates a lumbar hernia with extension of the right kidney into the hernia sac.*
+
+
+*Axial CECT shows avulsion of the muscular and tendinous insertions of the abdominal wall muscles from the left iliac wing and thoracolumbar fascia with creation of a posttraumatic lumbar hernia . Posttraumatic lumbar hernias are rare but much more likely to be associated with strangulation or incarceration.*
+
+
+*Coronal CECT shows avulsion of the muscular and tendinous insertions of the abdominal wall muscles from the left iliac wing and thoracolumbar fascia with creation of a posttraumatic lumbar hernia. Posttraumatic lumbar hernias are rare but much more likely to be associated with strangulation or incarceration.*
+
+
+*Axial NECT shows surgical absence of the left kidney with protrusion of abdominal fat through the site of the incision. The hernia is covered mostly by the thin latissimus dorsi muscle. The defect, a variant of a lumbar hernia, is through the aponeuroses of the abdominal oblique and transverse muscles.*
+
diff --git a/docs_md/articles/lymphangioma-mesenteric-cyst_bb42a128-c819-4368-a085-232b6db3434c.md b/docs_md/articles/lymphangioma-mesenteric-cyst_bb42a128-c819-4368-a085-232b6db3434c.md
new file mode 100644
index 0000000..b6ca586
--- /dev/null
+++ b/docs_md/articles/lymphangioma-mesenteric-cyst_bb42a128-c819-4368-a085-232b6db3434c.md
@@ -0,0 +1,290 @@
+---
+title: "Lymphangioma (Mesenteric Cyst)"
+docid: "bb42a128-c819-4368-a085-232b6db3434c"
+authors:
+ - key: "c1df94ab-4a9f-44c4-add7-1f174fb9ac45"
+ value: "Siva P. Raman, MD"
+breadcrumbs:
+ -
+ name: "Gastrointestinal"
+ slug: "gastrointestinal"
+ treeNodeId: "b52263f7-5978-4a22-a17d-7260e0033943"
+ -
+ name: "Diagnosis"
+ slug: "diagnosis"
+ treeNodeId: "5a7c51af-b1c6-4629-8f0e-d99e6fe57a98"
+ -
+ name: "Peritoneum, Mesentery, and Abdominal Wall"
+ slug: "peritoneum-mesentery-and-abdominal-"
+ treeNodeId: "a3fb9f00-f894-4b38-9e01-2f78406cf547"
+ -
+ name: "Benign Neoplasms"
+ slug: "benign-neoplasms"
+ treeNodeId: "6e8371e6-baeb-49ad-b087-cf827ae9f3a0"
+ -
+ name: "Lymphangioma (Mesenteric Cyst)"
+ slug: "lymphangioma-mesenteric-cyst"
+ treeNodeId: null
+category: "Gastrointestinal"
+documentVersionId: "554a62de-23db-4b78-9d4c-102d1586b91e"
+imageCount: 18
+lastUpdated: "03/23/25"
+pageDescription: "Lymphangioma (Mesenteric Cyst)"
+pageKeywords: "Gastrointestinal, Diagnosis, Peritoneum, Mesentery, and Abdominal Wall, Benign Neoplasms, Lymphangioma (Mesenteric Cyst)"
+pageTitle: "Lymphangioma (Mesenteric Cyst) | STATdx"
+enhancedTitle: "Lymphangioma (Mesenteric Cyst)"
+type: "DX"
+references: true
+breadcrumbs:
+ - "Gastrointestinal"
+ - "Diagnosis"
+ - "Peritoneum, Mesentery, and Abdominal Wall"
+ - "Benign Neoplasms"
+ - "Lymphangioma (Mesenteric Cyst)"
+---
+# KEY FACTS
+
+- ## Terminology
+
+
+ - Generic descriptive term for variety of different benign, congenital, cystic masses that can arise in mesentery or retroperitoneum
+- ## Imaging
+
+
+ - Lymphangiomas of abdomen are rare (7% of all lymphangiomas) and can arise from or involve virtually any structure
+ - Circumscribed, cystic mass that typically demonstrates water density (near 0 HU) or chylous density (< -20 HU)
+ - Can vary in size from very small lesions to massive cysts occupying much of abdomen
+ - No enhancement, mural nodularity, or solid component
+ - Can be multiloculated (± septations) with**feathery**appearance and may demonstrate subtle peripheral or septal calcifications
+ - Soft lesions without mass effect that are easily indented by surrounding structures
+ - Usually hypointense on T1WI MR and hyperintense on T2WI but can demonstrate more complex signal characteristic in setting of prior hemorrhage
+- ## Clinical Issues
+
+
+ - Symptoms are uncommon in adults, but can rarely cause issues as result of mass effect, superinfection, or internal hemorrhage
+ - In vast majority of cases, these are incidental imaging findings that can be followed with serial imaging to establish stability
+ - In those rare cases where lesions are symptomatic, surgery is treatment of choice
+- ## Diagnostic Checklist
+
+
+ - Differentiate from other primary cystic lesions or cystic neoplasms arising from adjacent visceral organs (such as exophytic renal cysts or hepatic cysts), as these are much more common than abdominal lymphangiomas
+
+# TERMINOLOGY
+
+- ## Synonyms
+
+
+ - Lymphoepithelial cyst, cystic lymphangioma, mesenteric cyst, lymphatic malformation
+- ## Definitions
+
+
+ - Generic descriptive term used for benign, congenital, cystic mass arising in mesentery or retroperitoneum that encompasses variety of different histologic entities
+ - Many different cyst types are included under this term, including true cystic lymphangioma, chylolymphatic mesenteric cyst, enteric duplication cyst, peritoneal simple mesothelial cyst, etc.
+ - Exact histologic cyst type can usually not be ascertained on imaging, and accordingly, generic term mesenteric cyst is usually utilized
+
+# IMAGING
+
+- ## General Features
+
+
+ - ### Best diagnostic clue
+
+
+ - Cystic mass (without mass effect on adjacent structures) in mesentery or retroperitoneum that does not clearly arise from any adjacent visceral organ
+ - ### Location
+
+
+ - Majority of lymphangiomas arise in head, neck, or axillae
+ - Lymphangiomas of abdomen are rare (7% of all lymphangiomas)
+ - Can involve multiple compartments of peritoneum or retroperitoneum
+ - Can arise from or involve virtually any structure
+ - Abdominal lymphangiomas most often arise in retroperitoneum in adults (> 50%)
+ - Lymphangiomatosis: Widespread lymphangiomas (usually liver, spleen, mediastinum, lungs, mesentery)
+ - Usually presents in infants and young children
+ - ### Size
+
+
+ - Few mm to 40 cm in diameter
+- ## CT Findings
+
+
+ - Circumscribed, cystic mass with variable density
+ - Typically water density (near 0 HU) or chylous (< -20 HU) with lesions rarely demonstrating hemorrhagic contents
+ - No internal enhancement, solid component, or mural nodularity
+ - Can be multiloculated (± septations) with **feathery** appearance
+ - ± fine calcifications along cyst wall
+ - Soft lesions without mass effect that are indented by surrounding structures (e.g., mesenteric vessels or bowel)
+- ## Ultrasonographic Findings
+
+
+ - Fluid-filled cystic structure with thin internal septa
+ - ± internal echoes due to debris, hemorrhage, or infection
+ - May demonstrate multiloculated appearance with multiple internal septations and cystic spaces
+- ## MR Findings
+
+
+ - Simple or multiloculated cyst, which is usually hypointense on T1WI and hyperintense on T2WI
+ - Can be T1 hyperintense due to internal fat/chyle
+ - Septations and internal complexity may be more apparent on T2 MR compared to CECT
+ - Internal signal characteristics can appear more complex on T1WI and T2WI in setting of prior hemorrhage
+
+# DIFFERENTIAL DIAGNOSIS
+
+- [Loculated Ascites](/document/ascites/75d00057-46d2-4ddb-b7c2-ac79523636a9)
+ - May appear similar to lymphangioma, but there is typically known underlying cause for ascites (e.g., cirrhosis)
+- [Gastrointestinal Duplication Cyst](/document/duplication-cyst/34c9516c-5fcb-4d8c-abba-3a5ef2e9ce00)
+ - Cystic mass with thick wall abutting bowel
+- [Pancreatic Pseudocyst](/document/pancreatic-pseudocyst/c585fc8f-a222-4944-99a2-dc8d34f359bc)
+ - Cyst with visible wall in patient with history of pancreatitis
+ - Cyst often associated with stranding of surrounding fat
+- [Cyst or Cystic Tumor Arising From Visceral Organ](/document/mucinous-cystic-neoplasm-of-pancre-/f0940a63-2a15-48ea-b8b3-2babd34bde4c)
+ - Mesenteric cysts can abut visceral organs and mimic cystic lesion arising from organ (e.g., exophytic renal cyst)
+- [Peritoneal Inclusion Cyst](/document/peritoneal-inclusion-cyst/b071952a-7a0b-41b1-9fff-8ef90bf4cfdf)
+ - Cystic mass in reproductive-age female after surgery
+ - Loculated cystic lesion conforming to shape of pelvis and often surrounding ovary
+
+# PATHOLOGY
+
+- ## General Features
+
+
+ - ### Etiology
+
+
+ - True lymphangiomas result from failure of normal embryologic development with lymphatic tissue not communicating with rest of lymphatic system
+- ## Gross Pathologic & Surgical Features
+
+
+ - Thin walled and multiseptated with serous, serosanguineous, hemorrhagic, or chylous fluid contents
+- ## Microscopic Features
+
+
+ - Cuboidal or columnar cells lining cyst ± smooth muscle, lymphatics, and blood vessels within walls
+
+# CLINICAL ISSUES
+
+- ## Presentation
+
+
+ - ### Most common signs/symptoms
+
+
+ - Usually asymptomatic (particularly in adults) and incidental findings on imaging
+ - Rare symptoms (abdominal distention, pain) due to size (particularly in neonates) or superinfection
+ - Complications due to mass effect (such as bowel obstruction, volvulus, urinary tract obstruction, etc.) are unusual due to "soft" nature of these lesions
+- ## Demographics
+
+
+ - ### Epidemiology
+
+
+ - Can occur at any age but 75% discovered < 5 years of age
+ - 90% continue to grow until 2 years of age
+ - M > F
+ - Rare (1/40,000 persons)
+- ## Treatment
+
+
+ - Asymptomatic lesions do not require any intervention or treatment and can be followed with repeat imaging
+ - Utilization of aspiration and sclerosing agents for symptomatic lesions is controversial as treatments almost always ineffective and relapse rates approach 100%
+ - Open or laparoscopic surgery preferred approach if lesion is symptomatic or there is concern for malignancy
+ - Given that these are benign lesions, attempt is usually made at surgery to spare adjacent organs and structures (such as bowel)
+ - Good prognosis after surgery with low rates of recurrence (0-13.6%)
+ - Recurrence more common with incomplete resections
+
+# DIAGNOSTIC CHECKLIST
+
+- ## Consider
+
+
+ - Differentiate from other primary cystic lesions or tumors of visceral organs (such as exophytic renal or hepatic cysts)
+
+ 00ff7e69-55fe-43ff-94b4-aa6f341e9625
+
+## References
+
+# Selected References
+
+1. [Al-Khafaji RA et al: Mesenteric cystic lymphangioma, an acute presentation in a 9-year-old child. Radiol Case Rep. 19(6):2371-5, 2024](http://www.ncbi.nlm.nih.gov/pubmed/?term=38572275%5Bpmid%5D)
+1. [Hoang VT et al: Review of diagnosis, differential diagnosis, and management of retroperitoneal lymphangioma. Jpn J Radiol. 41(3):283-301, 2023](http://www.ncbi.nlm.nih.gov/pubmed/?term=36327088%5Bpmid%5D)
+1. [Maghrebi H et al: Intra-abdominal cystic lymphangioma in adults: a case series of 32 patients and literature review. Ann Med Surg (Lond). 81:104460, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=36147158%5Bpmid%5D)
+1. [Yacoub JH et al: Approach to cystic lesions in the abdomen and pelvis, with radiologic-pathologic correlation. Radiographics. 41(5):1368-86, 2021](http://www.ncbi.nlm.nih.gov/pubmed/?term=34469214%5Bpmid%5D)
+1. [Raufaste Tistet M et al: Imaging features, complications and differential diagnoses of abdominal cystic lymphangiomas. Abdom Radiol (NY).45(11):3589-607, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32296900%5Bpmid%5D)
+1. [Gümüştaş OG et al: Retroperitoneal cystic lymphangioma: a diagnostic and surgical challenge. Case Rep Pediatr. 2013:292053, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=23533897%5Bpmid%5D)
+1. [Kwag E et al: CT features of generalized lymphangiomatosis in adult patients. Clin Imaging. 37(4):723-7, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=23391872%5Bpmid%5D)
+1. [Rajiah P et al: Imaging of uncommon retroperitoneal masses. Radiographics. 31(4):949-76, 2011](http://www.ncbi.nlm.nih.gov/pubmed/?term=21768233%5Bpmid%5D)
+1. [Hachisuga M et al: Prenatal diagnosis of a retroperitoneal lymphangioma: a case and review. Fetal Diagn Ther. 24(3):177-81, 2008](http://www.ncbi.nlm.nih.gov/pubmed/?term=18753753%5Bpmid%5D)
+1. [Rani DV et al: Unusual presentation of a retroperitoneal lymphangioma. Indian J Pediatr. 73(7):617-8, 2006](http://www.ncbi.nlm.nih.gov/pubmed/?term=16877857%5Bpmid%5D)
+1. Chan IYF et al: Retroperitoneal lymphangioma in an adult. J HK Coll Radiol 6:94-96, 2003
+1. [de Perrot M et al: Mesenteric cysts. Toward less confusion? Dig Surg. 17(4):323-8, 2000](http://www.ncbi.nlm.nih.gov/pubmed/?term=11053936%5Bpmid%5D)
+1. [Stoupis C et al: Bubbles in the belly: imaging of cystic mesenteric or omental masses. Radiographics. 14(4):729-37, 1994](http://www.ncbi.nlm.nih.gov/pubmed/?term=7938764%5Bpmid%5D)
+1. Dyer R et al: Cystic retroperitoneal lymphangioma: CT, ultrasound, and MR findings. Pediatr Radiol 23:305-306, 1993
+1. [Ros PR et al: Mesenteric and omental cysts: histologic classification with imaging correlation. Radiology. 164(2):327-32, 1987](http://www.ncbi.nlm.nih.gov/pubmed/?term=3299483%5Bpmid%5D)
+1. [Vanek VW et al: Retroperitoneal, mesenteric, and omental cysts. Arch Surg. 119(7):838-42, 1984](http://www.ncbi.nlm.nih.gov/pubmed/?term=6732494%5Bpmid%5D)
+
+
+## Images
+
+
+### Selected Images
+
+
+*Axial CECT demonstrates a cystic mass in the left retroperitoneum. The lesion abuts the pancreatic tail and left colon without appreciable mass effect. Note the presence of a coarse calcification along the margin of the lesion.*
+
+
+*Axial CECT demonstrates a cystic mass in the left retroperitoneum. The lesion abuts the pancreatic tail and left colon without appreciable mass effect. Note the presence of a coarse calcification along the margin of the lesion.*
+
+
+*Coronal CECT in the same patient nicely demonstrates the multiloculated, feathery morphology of the lesion . This appearance is quite common with lymphangiomas, which frequently appear to have multiple internal discrete components or locules.*
+
+
+*Axial NECT demonstrates a large, cystic lesion in the right hemiabdomen immediately adjacent to the gallbladder , representing a lymphangioma. Notice the simple appearance of this lesion without any appreciable internal complexity.*
+
+
+*Coronal CECT demonstrates a retroperitoneal lymphangioma abutting the duodenal sweep. This lesion had been stable over many exams and was deemed to be benign.*
+
+
+*Coronal volume-rendered CECT demonstrates a large, simple-appearing lymphangioma in the left hemiabdomen abutting adjacent loops of small bowel without any appreciable internal complexity or enhancement.*
+
+
+*Axial T1 C+ MR in the same patient demonstrates the absence of any significant enhancement, mural nodularity, or solid component within the cystic lesion . The presence of any of these features should argue against the diagnosis of a lymphangioma.*
+
+
+*Coronal CECT demonstrates a large congenital cyst/lymphangioma in the right hemiabdomen in a patient being imaged for a primary pancreatic lesion (not shown). These lesions are frequently incidental findings on exams performed for other reasons.*
+
+
+*Axial CECT shows a thin-walled mass with water density in this patient with cystic lymphangioma. Notice the manner in which this cystic mass confirms to the shape of nearby structures in the left upper quadrant without any appreciable mass effect.*
+
+
+*Coronal CECT demonstrates a cystic lymphangioma wrapped around the margins of the right colon but without any associated mass effect.*
+
+
+*Coronal NECT demonstrates the classic appearance of an incidental lymphangioma . Notice the feathery, multiloculated appearance of the lesion with multiple small internal compartments.*
+
+
+*Coronal volume-rendered CECT demonstrates a multiloculated, cystic lesion in the left retroperitoneum. The lesion envelops multiple arteries and veins , which do not appear deviated or narrowed.*
+
+
+*Axial CECT shows a complex mesenteric cyst/lymphangioma in the mesentery, which surrounds a small bowel segment . The mass is of near water density, and has small foci of calcification in its septations and peripheral walls .*
+
+
+*Axial CECT demonstrates a large mesenteric cystic mass with a thin wall, multiple septations , and no soft tissue mass component. The mass is very soft, as shown by blood vessels extending freely through the mass.*
+
+
+*Axial T2 MR in the same patient nicely demonstrates that the mass has numerous internal septations and conforms to the shape of surrounding structures without any significant mass effect, typical of a lymphangioma.*
+
+
+*Axial CECT demonstrates a cystic mass that fills much of the pelvis and lower abdomen. Note the presence of calcifications both within septations and peripheral walls. The mass was resected and proved to be a lymphangioma.*
+
+
+*Axial CECT demonstrates a water density mass with no discernible wall. This lesion demonstrates multiple small internal compartments and loculations, a typical appearance for a lymphangioma.*
+
+
+### Additional Images
+
+
+*Axial CECT shows cystic lymphangioma as a thin-walled, water-density mesenteric mass with scattered calcifications in septa.*
+
+
+*Coronal T2WI MR shows large, multiloculated cystic lymphangioma with water intensity.*
+
diff --git a/docs_md/articles/mass-in-iliopsoas-compartment_e39c8918-27cb-4dd6-9166-2b265b777a35.md b/docs_md/articles/mass-in-iliopsoas-compartment_e39c8918-27cb-4dd6-9166-2b265b777a35.md
new file mode 100644
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+++ b/docs_md/articles/mass-in-iliopsoas-compartment_e39c8918-27cb-4dd6-9166-2b265b777a35.md
@@ -0,0 +1,215 @@
+---
+title: "Mass in Iliopsoas Compartment"
+docid: "e39c8918-27cb-4dd6-9166-2b265b777a35"
+authors:
+ - key: "c1df94ab-4a9f-44c4-add7-1f174fb9ac45"
+ value: "Siva P. Raman, MD"
+breadcrumbs:
+ -
+ name: "Gastrointestinal"
+ slug: "gastrointestinal"
+ treeNodeId: "b52263f7-5978-4a22-a17d-7260e0033943"
+ -
+ name: "Differential Diagnosis"
+ slug: "differential-diagnosis"
+ treeNodeId: "a0fd80ff-6231-49d3-94b8-ea083449979d"
+ -
+ name: "Abdominal Wall"
+ slug: "abdominal-wall"
+ treeNodeId: "08db01f7-2961-47f7-954d-2a5fca7e707d"
+ -
+ name: "Anatomically Based Differentials"
+ slug: "anatomically-based-differentials"
+ treeNodeId: "1525b44f-9d47-4ff4-8330-693211bd5eb5"
+ -
+ name: "Mass in Iliopsoas Compartment"
+ slug: "mass-in-iliopsoas-compartment"
+ treeNodeId: null
+category: "Gastrointestinal"
+documentVersionId: "b98553dd-1557-4132-99d5-3304036dd914"
+imageCount: 26
+lastUpdated: "07/01/22"
+pageDescription: "Mass in Iliopsoas Compartment"
+pageKeywords: "Gastrointestinal, Differential Diagnosis, Abdominal Wall, Anatomically Based Differentials, Mass in Iliopsoas Compartment"
+pageTitle: "Mass in Iliopsoas Compartment | STATdx"
+enhancedTitle: "Mass in Iliopsoas Compartment"
+type: "DDX"
+references: true
+breadcrumbs:
+ - "Gastrointestinal"
+ - "Differential Diagnosis"
+ - "Abdominal Wall"
+ - "Anatomically Based Differentials"
+ - "Mass in Iliopsoas Compartment"
+---
+# ESSENTIAL INFORMATION
+
+- ## Key Differential Diagnosis Issues
+
+
+ - Iliopsoas compartment masses are much more likely to result from infection or hemorrhage than from tumor
+ - Iliopsoas pathology often due to spread from adjacent infection (such as spine) or adjacent tumor, rather than originating within iliopsoas itself
+- ## Helpful Clues for Common Diagnoses
+
+
+ - **Iliopsoas****Hematoma**
+ - Iliopsoas is most common site for spontaneous retroperitoneal hemorrhage (usually due to bleeding diathesis or anticoagulation)
+ - Presence of multiple hematocrit levels within hematoma suggests coagulopathic hemorrhage
+ - Other causes include surgery, trauma, or extension of bleeding from adjacent structures (e.g., bleeding renal AML, ruptured abdominal aortic aneurysm, etc.)
+ - Appearance variable depending on age of hematoma
+ - Acute bleeding may simply appear as homogeneous enlargement of muscle ± hematocrit levels
+ - Chronic bleeds may appear hypodense and can be difficult to differentiate from abscess
+ - **Asymmetric Musculature (Mimic)**
+ - Iliopsoas muscles can be asymmetric in size, particularly in patients with unilateral leg amputation, paralysis, or lower extremity/spine arthritis
+ - **Secondary Infection/Abscess**
+ - Infection and abscess formation in iliopsoas typically due to spread of infection from contiguous structures
+ - Most commonly infectious spread from bone, kidney, and bowel (including appendix)
+ - Paraspinal psoas abscess should prompt careful search for infectious spondylitis (TB or pyogenic)
+ - Renal sources of iliopsoas infection include renal/perirenal abscess or xanthogranulomatous pyelonephritis
+ - Common bowel sources of iliopsoas infection include appendicitis, diverticulitis, or Crohn disease
+ - Often associated with other features of infection (fat stranding, blurring of fat planes, ectopic gas)
+- ## Helpful Clues for Less Common Diagnoses
+
+
+ - **Retroperitoneal Fibrosis**
+ - Irregular soft tissue mass enveloping aorta, inferior vena cava, and ureters, which can involve adjacent psoas muscles
+ - Variable enhancement depending on stage with hyperenhancement in early stages of disease and hypoenhancement in later stages
+ - **Primary Infection**
+ - Iliopsoas compartment is rarely primary site of infection, except in immunocompromised patients (including HIV) and intravenous drug abusers
+ - Infection usually due to *Staphylococcus aureus*and mixed gram-negative organisms
+ - **Primary Neoplasm**
+ - Primary mesenchymal tumors (liposarcoma, fibrosarcoma, leiomyosarcoma, hemangiopericytoma, etc.) may rarely originate from iliopsoas compartment
+ - **Secondary Neoplasm**
+ - Hematogenous metastasis (e.g., lymphoma, melanoma) to iliopsoas very rare
+ - More commonly directly invaded by adjacent tumors (e.g., retroperitoneal sarcoma, lymphoma, neurogenic tumors, adjacent bone tumor, etc.)
+ - Plexiform neurofibroma (in neurofibromatosis) may involve psoas compartment
+
+## References
+
+# Selected References
+
+1. [Mondie C et al: Retroperitoneal hematoma. StatPearls, 2021](http://www.ncbi.nlm.nih.gov/pubmed/?term=32644354%5Bpmid%5D)
+1. [Improta L et al: Overview of primary adult retroperitoneal tumours. Eur J Surg Oncol. 46(9):1573-9, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32600897%5Bpmid%5D)
+1. [Peisen F et al: Retroperitoneal fibrosis and its differential diagnoses: the role of radiological imaging. Rofo. 192(10):929-36, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32698236%5Bpmid%5D)
+1. [Babic M et al: Infections of the spine. Infect Dis Clin North Am. 31(2):279-97, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28366222%5Bpmid%5D)
+1. [Messiou C et al: Primary retroperitoneal soft tissue sarcoma: imaging appearances, pitfalls and diagnostic algorithm. Eur J Surg Oncol. 43(7):1191-8, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28057392%5Bpmid%5D)
+1. [Sunga KL et al: Spontaneous retroperitoneal hematoma: etiology, characteristics, management, and outcome. J Emerg Med. 43(2):e157-61, 2012](http://www.ncbi.nlm.nih.gov/pubmed/?term=21911282%5Bpmid%5D)
+1. [Singh AK et al: Neoplastic iliopsoas masses in oncology patients: CT findings. Abdom Imaging. 33(4):493-7, 2008](http://www.ncbi.nlm.nih.gov/pubmed/?term=17639377%5Bpmid%5D)
+
+
+## Images
+
+
+### Selected Images
+
+
+**Iliopsoas Hematoma**
+*Axial NECT shows enlargement of both psoas muscles due to coagulopathic hemorrhage. Although the hematoma is partly isodense to the muscle, the presence of hematocrit levels makes the hematomas more apparent. Hematocrit levels suggest coagulopathy as the underlying cause of the bleed.*
+
+
+**Iliopsoas Hematoma**
+*Axial NECT shows enlargement of both psoas muscles due to coagulopathic hemorrhage. Although the hematoma is partly isodense to the muscle, the presence of hematocrit levels makes the hematomas more apparent. Hematocrit levels suggest coagulopathy as the underlying cause of the bleed.*
+
+
+**Asymmetric Musculature (Mimic)**
+*Axial CECT shows marked asymmetry of the psoas muscles. In this case, the left psoas muscle is atrophic due to a prior left leg amputation.*
+
+
+**Secondary Infection/Abscess**
+*Axial CECT shows lytic destruction of a vertebral body with an abscess extending into the right psoas muscle. Note the presence of a large mycotic aneurysm immediately anteriorly arising from the abdominal aorta.*
+
+
+**Secondary Infection/Abscess**
+*Axial T1 C+ MR shows an abscess in the iliopsoas muscle directly contiguous with phlegmonous change in the right lower quadrant due to the patient's fistulizing Crohn disease.*
+
+
+**Retroperitoneal Fibrosis**
+*Axial CECT shows a rind of mass-like soft tissue encasing the aorta and inferior vena cava. While more mass-like than is typical, this was found to represent retroperitoneal fibrosis.*
+
+
+**Primary Neoplasm**
+*Axial T1 MR shows a large, fat-containing mass occupying much of the right hemipelvis, with the right left psoas muscle appearing stretched and distorted as a result of the retroperitoneal tumor. This was found to be a well-differentiated liposarcoma at resection.*
+
+
+**Secondary Neoplasm**
+*Axial CECT shows a large, homogeneous soft tissue mass involving the right psoas and iliopsoas musculature. There were multiple enlarged lymph nodes elsewhere (not shown), and this was found to represent non-Hodgkin lymphoma.*
+
+
+**Secondary Neoplasm**
+*Coronal CECT shows an avidly enhancing mass with central necrosis arising in the left iliopsoas muscle, representing a metastasis related to the patient's known renal cell carcinoma.*
+
+
+### Additional Images
+
+
+**Primary Neoplasm**
+*Axial CECT shows a huge retroperitoneal mass abutting the psoas compartment. Some portions of the mass have well-differentiated fatty components, characteristic of liposarcoma.*
+
+
+**Primary Neoplasm**
+*Axial CECT shows a large, heterogeneous retroperitoneal mass , which displaces the right kidney anteriorly. Note medial displacement of the inferior vena cava (IVC) . Malignant fibrous histiocytoma.*
+
+
+**Iliopsoas Hematoma**
+*Axial CECT shows hemorrhage into multiple sites, including iliopsoas, with active bleeding and hematocrit sign , indicating coagulopathic bleeding.*
+
+
+**Iliopsoas Hematoma**
+*Axial CECT shows a large abdominal aortic aneurysm with extensive free hematoma tracking laterally in the retroperitoneum, including immediately adjacent to the psoas muscle, compatible with aneurysm rupture.*
+
+
+**Iliopsoas Hematoma**
+*Axial CECT shows a large abdominal aortic aneurysm that has ruptured into the psoas compartment and retroperitoneum. Blood dissects along the left psoas and throughout the retroperitoneal planes.*
+
+
+**Iliopsoas Hematoma**
+*Axial CECT shows a large retroperitoneal mass arising from the iliopsoas compartment. A focus of active bleeding and hematocrit levels confirm coagulopathic hemorrhage.*
+
+
+**Retroperitoneal Fibrosis**
+*Axial CECT shows mantle of soft tissue encasing aorta, IVC, and ureter (with stent ).*
+
+
+**Secondary Infection/Abscess**
+*Axial CECT shows a small collection of gas and fluid within the psoas muscle due to Crohn disease with a sinus tract from the terminal ileum.*
+
+
+**Primary Neoplasm**
+*Axial CECT shows a large, heterogeneous tumor , which displaces the bladder and external iliac artery . This is a leiomyosarcoma arising from the psoas muscle.*
+
+
+**Secondary Neoplasm**
+*Axial CECT shows a soft tissue mass that extends along the aorta, IVC, and right psoas. Biopsy showed ganglioneuroma arising from the sympathetic neural chain.*
+
+
+**Secondary Neoplasm**
+*Axial CECT shows retroperitoneal , psoas compartment, and mesenteric lymphadenopathy in non-Hodgkin lymphoma.*
+
+
+**Iliopsoas Hematoma**
+*Coronal NECT shows a large hematoma extending from the right psoas muscle into the adjacent right iliopsoas muscle .*
+
+
+**Primary Neoplasm**
+*Axial CECT shows a large, fat-containing mass occupying much of the left abdomen with the left psoas muscle appearing stretched and distorted as a result of the retroperitoneal tumor. This was found to be a well-differentiated liposarcoma at resection.*
+
+
+**Iliopsoas Hematoma**
+*Axial CECT shows a large hematoma extending from the psoas muscle into the adjacent right abdomen. Note the presence of a tiny focus of active extravasation within the hematoma.*
+
+
+**Secondary Infection/Abscess**
+*Axial T1 C+ FS MR at the level of the renal hilum shows predominantly right-sided enhancing paraspinal and epidural phlegmon , associated with discitis and vertebral osteomyelitis. The presence of psoas infection should always prompt careful appraisal of the spine.*
+
+
+**Iliopsoas Hematoma**
+*Axial NECT shows enlargement of the right psoas muscle due to coagulopathic hemorrhage. Although the hematoma is partly isodense to the muscle, the presence of a hematocrit level makes the bleed more apparent. Hematocrit levels suggest coagulopathy as the underlying cause of the bleed.*
+
+
+**Secondary Neoplasm**
+*Axial T1 C+ FS MR shows a heterogeneously enhancing mass expanding the right psoas muscle, found to be a neurogenic tumor (ganglioneuroma) at resection.*
+
+
+**Primary Neoplasm**
+*Axial CECT shows a large mixed cystic and solid mass involving the left psoas muscle , representing a primary retroperitoneal leiomyosarcoma.*
+
diff --git a/docs_md/articles/mesenteric-vessels_79a4117f-773a-40b3-bdb5-b0195f84e087.md b/docs_md/articles/mesenteric-vessels_79a4117f-773a-40b3-bdb5-b0195f84e087.md
new file mode 100644
index 0000000..ebdf89b
--- /dev/null
+++ b/docs_md/articles/mesenteric-vessels_79a4117f-773a-40b3-bdb5-b0195f84e087.md
@@ -0,0 +1,219 @@
+---
+title: "Mesenteric Vessels"
+docid: "79a4117f-773a-40b3-bdb5-b0195f84e087"
+authors:
+ - key: "738b847a-9cda-4cbd-ad90-2d1fdaecd4ca"
+ value: "Eric Turner, MD"
+ - key: "3c685430-58b7-4676-a18e-dd1c1de70f1a"
+ value: "Mark E. Lockhart, MD, MPH"
+ - key: "0817f9c9-9bce-42a9-aacc-5d18a3cd66be"
+ value: "Daniel Childers, MD"
+breadcrumbs:
+ -
+ name: "Ultrasound"
+ slug: "ultrasound"
+ treeNodeId: "e7cdfeb1-bb55-4cca-9854-46cadee515d2"
+ -
+ name: "Anatomy"
+ slug: "anatomy"
+ treeNodeId: "d4765014-54f9-4477-8c9c-4b2ae0b82f24"
+ -
+ name: "Abdomen"
+ slug: "abdomen"
+ treeNodeId: "1e981810-ddca-4af9-82b9-38d5fdecad76"
+ -
+ name: "Mesenteric Vessels"
+ slug: "mesenteric-vessels"
+ treeNodeId: null
+category: "Ultrasound"
+documentVersionId: "c7579afe-f64d-44b5-9ef0-902d777084f6"
+imageCount: 22
+lastUpdated: "05/13/24"
+pageDescription: "Mesenteric Vessels"
+pageKeywords: "Ultrasound, Anatomy, Abdomen, Mesenteric Vessels"
+pageTitle: "Mesenteric Vessels | STATdx"
+enhancedTitle: "Mesenteric Vessels"
+type: "ANATOMY"
+breadcrumbs:
+ - "Ultrasound"
+ - "Anatomy"
+ - "Abdomen"
+ - "Mesenteric Vessels"
+---
+# IMAGING ANATOMY
+
+- ## Internal Contents
+
+
+ - **Abdominal aorta**
+ - Anatomy
+ - Continuation of thoracic aorta beginning at diaphragmatic hiatus posterior to diaphragm at approximately level of T12 and coursing slightly left of midline, ultimately terminating in right and left common iliac arteries
+ - Ultimately supplies all anatomic structures below level of diaphragm
+ - Normal caliber: 15-25 mm
+ - Upper (above renal arteries): 22 mm
+ - Middle (below renal arteries): 18 mm
+ - Lower (immediately above bifurcation): 15 mm
+ - Imaging characteristics
+ - Best visualized with 5-MHz curved transducer after patient fasting at least 6 hours
+ - Best US imaging plane
+ - Both transverse and longitudinal
+ - Normal peak systolic velocity (PSV)
+ - 60-110 cm/s
+ - Spectral Doppler waveform
+ - Upper: Narrow, well-defined systolic complex with forward flow during diastole
+ - Mid: Reduced diastolic flow
+ - Distal: Absent diastolic flow, similar to lower limb arteries
+ - **Celiac axis**
+ - Anatomy
+ - Typically arises from abdominal aorta at T12-L1 and courses inferior to median arcuate ligament of diaphragmatic crura, which can compress celiac and cause median arcuate ligament syndrome
+ - Normal caliber
+ - 7-8 mm
+ - ~ 1.25 cm length before bifurcating into left gastric artery and hepatosplenic common origin
+ - Extensive variant anatomy can arise from celiac axis
+ - Conventional anatomy is 3 branches: Proper hepatic artery, left gastric artery, and splenic artery
+ - Supplies foregut
+ - Imaging characteristics
+ - Best visualized with 5-MHz curved transducer after patient fasting at least 6 hours
+ - Best US imaging plane
+ - Longitudinal midline: Best for evaluation of celiac axis blood flow
+ - Transverse: Best for evaluation of anatomy and detecting branch vessels
+ - Normal PSV
+ - 92-176 cm/s
+ - Spectral Doppler demonstrates low-resistance flow with relatively high diastolic velocities due to constant metabolic activity of liver
+ - **Superior mesenteric artery (SMA)**
+ - Anatomy
+ - Typically arises from abdominal aorta at L1 immediately below origin of celiac axis and courses to left of superior mesenteric vein
+ - Left renal vein and 3rd portion of duodenum course posterior to superior mesenteric artery, which can compress and cause Nutcracker syndrome and SMA syndrome, respectively
+ - Normal caliber
+ - 5-8 mm
+ - Main SMA branches
+ - Superior pancreaticoduodenal, right colic, middle colic, and ileocolic arteries
+ - Hepatic arteries can also arise from SMA, known as either replaced right or replaced left hepatic artery
+ - Left-sided ileal and jejunal branches typically present
+ - Supplies midgut
+ - Imaging characteristics
+ - Best visualized with 5-MHz curved transducer after patient fasting at least 6 hours
+ - Best US imaging plane
+ - Longitudinal midline: Best for evaluation of SMA blood flow
+ - Transverse: Useful for identifying short anteriorly directed stump; SMA shows dot-like appearance surrounded by distinctive triangular mantle of fat
+ - Normal PSV
+ - 97-142 cm/s
+ - End-diastolic velocity increases ~ 30-90 min after meal due to vasodilation of mesenteric branches
+ - High-resistance flow with low diastolic velocities during fasting due to vasoconstriction
+ - Low-resistance flow in postprandial period due to vasodilation from midgut becoming metabolically active
+ - If replaced hepatic artery arises from SMA rather than celiac axis, spectral Doppler will demonstrate persistent low-resistance waveform due to constant metabolic activity of liver
+ - **Inferior mesenteric artery**
+ - Anatomy
+ - Typically arises from abdominal aorta at L3 level below renal arteries and courses to left of midline
+ - Normal caliber
+ - 1-5 mm
+ - Main branches
+ - Left colic artery, sigmoid arteries, and superior rectal artery
+ - Supplies hindgut
+ - Imaging characteristics
+ - Best visualized with 5-MHz curved transducer after patient fasting at least 6 hours
+ - Best imaging plane
+ - Transverse following line of aorta; may be difficult to visualize given proximity of surrounding bowel gas
+ - Normal PSV
+ - 93-189 cm/s
+ - End-diastolic velocity increases after meal due to vasodilation of mesenteric branches
+ - High-resistance flow with low diastolic velocities during fasting due to vasoconstriction
+
+ a2d778bc-07c9-491b-84ee-954c508bf31d
+
+
+## Images
+
+
+### Small Intestine, Colon, Rectum, and Anus
+
+
+*Graphic shows the vascular supply of the entire small intestine from the superior mesenteric artery (SMA). The small bowel segments are displaced inferiorly. The SMA arises from the anterior abdominal aorta and gives off the inferior pancreaticoduodenal branch that supplies the duodenum and pancreas. Arising from the left side of the SMA are numerous branches to the jejunum and ileum. Jejunal arteries are generally larger and longer than those of the ileum. After a straight course, the arteries form multiple intercommunicating, curvilinear arcades.*
+
+
+*Graphic shows the vascular supply of the entire small intestine from the superior mesenteric artery (SMA). The small bowel segments are displaced inferiorly. The SMA arises from the anterior abdominal aorta and gives off the inferior pancreaticoduodenal branch that supplies the duodenum and pancreas. Arising from the left side of the SMA are numerous branches to the jejunum and ileum. Jejunal arteries are generally larger and longer than those of the ileum. After a straight course, the arteries form multiple intercommunicating, curvilinear arcades.*
+
+
+*Graphic shows the colon in situ. The transverse colon has been retracted upward to demonstrate the arterial supply of the colon from the superior and inferior mesenteric arteries. The SMA supplies the colon from the appendix through the splenic flexure, and the inferior mesenteric artery (IMA) supplies the descending colon through the rectum. Note the band of smooth muscle (taenia coli) running along the length of the intestine, which terminates in the vermiform appendix; these result in sacculations/haustrations along the colon, giving it a segmented appearance.*
+
+
+### Aorta
+
+
+*Graphic shows the major mesenteric vessels labeled with overlying bowel and many organs removed for better anatomic visualization. The origins of the major arterial branches from the aorta are well depicted. Many of the arterial origins in this region are in close approximation.*
+
+
+*Longitudinal US shows the abdominal aorta. Note the close proximity of the SMA and left renal vein.*
+
+
+*Longitudinal spectral Doppler US of the aorta shows a normal aortic triphasic waveform. Rapid systolic acceleration is followed by transient reversal of flow and subsequent anterior diastolic flow.*
+
+
+*Transverse US at the level of the aortic bifurcation shows the right and left common iliac arteries, which are usually symmetric in size. Asymmetric size should prompt measurement to detect aneurysmal dilatation.*
+
+
+### Peritoneal Cavity
+
+
+*Graphic shows the relationship of many of the major intraabdominal organs relative to the vasculature. The deep location of the aortic branches and presence of overlying bowel loops depicts why fasting is important for mesenteric vascular Doppler imaging.*
+
+
+### Celiac Axis
+
+
+*Transverse US shows the celiac axis. This view depicts the most common appearance of the celiac artery branching pattern to form the common hepatic artery and splenic artery. The lateral hepatic segment can serve as a sonographic window to allow better visualization of the midline vascular structures.*
+
+
+*Transverse color Doppler US shows the celiac axis and branch vessels. Normal arterial flow should have nonturbulent laminar flow without aliasing.*
+
+
+*Midline sagittal spectral Doppler US shows a normal, low-resistance waveform of the celiac axis due to the liver's constant metabolic activity. In sagittal plane, the celiac artery may have a mildly curved course but should not demonstrate severe angulation, which may be seen in median arcuate ligament syndrome. Occasionally, the celiac axis and SMA may share a common trunk. Note the origin of the left gastric artery from the cranial aspect of the celiac axis.*
+
+
+### SMA
+
+
+*Transverse US shows the SMA surrounded by a cuff of echogenic fat and lying immediately posterior to the splenic vein, coursing to the portal venous confluence.*
+
+
+*Midline sagittal color Doppler US shows the celiac axis and SMA arising from the aorta. Note the homogeneous flow pattern without turbulence or aliasing. The splenic artery courses leftward from the celiac axis but may be partly seen in the sagittal plane, showing the celiac origin due to the severe tortuosity of the splenic artery.*
+
+
+*Midline sagittal spectral Doppler US of the SMA depicts high-resistance waveform in a patient who is fasting. Note the transient cessation of flow at end systole.*
+
+
+### IMA
+
+
+*Midline sagittal US shows the IMA arising from the aorta. The IMA may be difficult to visualize due to overlying bowel gas and its small caliber.*
+
+
+*Midline sagittal color Doppler US shows the IMA arising from the aorta. The Doppler flow is initially red toward the transducer, but as the artery dives deeper, the flow turns away from the transducer and is represented by blue color encoding. This finding is common and should not be mistaken for stenosis.*
+
+
+*Midline sagittal spectral Doppler US of the IMA shows a normal, high-resistance waveform in a patient who is fasting. Note the relative lack of diastolic flow in the spectral waveform.*
+
+
+### Replaced Right Hepatic Artery from SMA
+
+
+*Transverse US shows the right hepatic artery arising from the SMA. This is the most common variant hepatic artery supply.*
+
+
+*Midline sagittal color Doppler US shows the right hepatic artery arising from the SMA. In this variant, the celiac artery branching usually has a normal pattern at the bifurcation.*
+
+
+*Midline sagittal spectral Doppler US shows the persistent diastolic flow in the SMA. This is resulting from the SMA supplying the right hepatic artery, which supplies liver parenchyma. The liver is continuously metabolically active, so there is a lower resistance waveform and persistent diastolic flow.*
+
+
+### Postprandial
+
+
+*Midline sagittal spectral Doppler postprandial US shows the persistent low-resistance waveform in the celiac axis due to constant metabolic activity from the liver.*
+
+
+*Midline sagittal spectral Doppler postprandial US of the SMA shows a low-resistance waveform as the foregut becomes metabolically active. Compare this appearance to the high-resistance fasting SMA waveform seen previously.*
+
+
+*Transverse spectral Doppler postprandial US shows the persistent high-resistance waveform in the IMA. The IMA supplies the colon, so early postprandial images remain high resistance.*
+
diff --git a/docs_md/articles/middle-ear-prolapsing-facial-nerve_61f6bcaa-f073-4385-b895-dc420ddc8a1e.md b/docs_md/articles/middle-ear-prolapsing-facial-nerve_61f6bcaa-f073-4385-b895-dc420ddc8a1e.md
new file mode 100644
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--- /dev/null
+++ b/docs_md/articles/middle-ear-prolapsing-facial-nerve_61f6bcaa-f073-4385-b895-dc420ddc8a1e.md
@@ -0,0 +1,294 @@
+---
+title: "Middle Ear Prolapsing Facial Nerve"
+docid: "61f6bcaa-f073-4385-b895-dc420ddc8a1e"
+authors:
+ - key: "94f835c8-fa13-4e8a-995b-53048e6b0605"
+ value: "Philip R. Chapman, MD"
+ - key: "33151213-01b2-4542-9105-342e006b3915"
+ value: "H. Ric Harnsberger, MD"
+breadcrumbs:
+ -
+ name: "Head and Neck"
+ slug: "head-and-neck"
+ treeNodeId: "ed24ed8c-5d57-4629-879b-447b82d2973d"
+ -
+ name: "Diagnosis"
+ slug: "diagnosis"
+ treeNodeId: "19b6b986-97d0-40e7-b317-00f0c5cd8fa2"
+ -
+ name: "Temporal Bone"
+ slug: "temporal-bone"
+ treeNodeId: "9ad7d7b2-b2e4-4de2-be04-55ce607560c9"
+ -
+ name: "Intratemporal Facial Nerve"
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+ name: "Middle Ear Prolapsing Facial Nerve"
+ slug: "middle-ear-prolapsing-facial-nerve"
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+pageDescription: "Middle Ear Prolapsing Facial Nerve"
+pageKeywords: "Head and Neck, Diagnosis, Temporal Bone, Intratemporal Facial Nerve, Pseudolesions, Middle Ear Prolapsing Facial Nerve"
+pageTitle: "Middle Ear Prolapsing Facial Nerve | STATdx"
+enhancedTitle: "Middle Ear Prolapsing Facial Nerve"
+type: "DX"
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+breadcrumbs:
+ - "Head and Neck"
+ - "Diagnosis"
+ - "Temporal Bone"
+ - "Intratemporal Facial Nerve"
+ - "Pseudolesions"
+ - "Middle Ear Prolapsing Facial Nerve"
+---
+# KEY FACTS
+
+- ## Terminology
+
+
+ - Definition: Midtympanic facial nerve (CNVII) segment protrudes through bony dehiscence
+ - **CNVII dehiscence**refers only to segmental absence of bony covering of CNVII
+ - **Prolapsing CNVII**: CNVII protrudes through dehiscence in tympanic CNVII canal
+- ## Imaging
+
+
+ - **Incidental finding** on temporal bone CT
+ - Tubular soft tissue extends from midtympanic CNVII into oval window niche
+ - Coronal bone CT
+ - Soft tissue mass in oval widow niche
+ - Along undersurface of lateral semicircular canal
+ - Contiguous with midtympanic segment of CNVII
+ - Axial bone CT
+ - Hammock-like CNVII spanning middle ear cavity under lateral semicircular canal
+- ## Top Differential Diagnoses
+
+
+ - Intratemporal facial nerve schwannoma
+ - Oval window atresia
+ - Persistent stapedial artery
+ - Congenital cholesteatoma in facial nerve canal
+- ## Clinical Issues
+
+
+ - Clinical presentation
+ - Most commonly **asymptomatic**
+ - Rarely conductive hearing loss present from impingement on stapes
+ - Prolapsed facial nerve can be injured during surgical exposure of stapes or oval window
+- ## Diagnostic Checklist
+
+
+ - Warning to radiologist
+ - Prolapsed CNVII in peril during stapedectomy
+ - Report & call this finding to ear surgeon
+
+# TERMINOLOGY
+
+- ## Definitions
+
+
+ - Midtympanic facial nerve (CNVII) segment protrudes through bony dehiscence
+ - **CNVII dehiscence**refers only to segmental absence of bony covering of CNVII
+ - **Prolapsing CNVII**: CNVII protrudes through dehiscence
+
+# IMAGING
+
+- ## General Features
+
+
+ - ### Best diagnostic clue
+
+
+ - Tubular soft tissue extends from midtympanic CNVII into oval window niche (CT)
+ - ### Location
+
+
+ - Undersurface of lateral semicircular canal (LSCC) → oval window niche
+ - ### Size
+
+
+ - Variable; may be subtle or appear mass-like (2-3 mm) within oval window niche
+ - ### Morphology
+
+
+ - Smooth, tubular appearance
+- ## CT Findings
+
+
+ - ### Bone CT
+
+
+ - Coronal: Soft tissue mass in oval widow niche
+ - Along undersurface of LSCC
+ - Contiguous with midtympanic segment of CNVII
+ - Axial: Hammock-like CNVII spanning middle ear cavity under LSCC
+ - Simple dehiscence (uncovered CNVII) poorly seen unless CNVII prolapsed through dehiscence
+- ## MR Findings
+
+
+ - No abnormality identified
+ - T1 C+ is normal, excluding facial nerve schwannoma
+- ## Imaging Recommendations
+
+
+ - ### Best imaging tool
+
+
+ - Axial & coronal thin-section temporal bone CT
+ - Best seen on **coronal** at level of oval window
+ - Contrast not necessary or recommended
+ - ### Protocol advice
+
+
+ - When protruding CNVII is mass-like, use contrast-enhanced MR to exclude CNVII schwannoma
+ - Facial nerve schwannoma enhances
+
+# DIFFERENTIAL DIAGNOSIS
+
+- [Intratemporal Facial Nerve Schwannoma](/document/temporal-bone-facial-nerve-schwann-/cf2bcc82-4a1b-4989-adeb-f4e82116111b)
+ - Clinical: Hearing loss > > facial nerve palsy
+ - CT: Tubular enlargement of CNVII canal
+ - Geniculate fossa > tympanic > mastoid segments
+ - MR: Enhancing tubular mass enlarges CNVII canal
+- [Oval Window Atresia](/document/oval-window-atresia/35bcc265-c33a-4acf-8e1b-ea5029ae0a74)
+ - Clinical: Conductive hearing loss
+ - ± external auditory canal (EAC) atresia
+ - CT: Facial nerve tympanic segment ectopic
+ - Tympanic CNVII in oval window niche
+- [Persistent Stapedial Artery](/document/persistent-stapedial-artery/ca36e22e-2bbc-41c9-a381-ddcf47ed27ca)
+ - Asymptomatic vascular variant
+ - CT: Absent foramen spinosum
+ - Tubular lesion on cochlear promontory
+ - Large anterior tympanic segment CNVII
+- ## Congenital Cholesteatoma in Facial Nerve Canal
+
+
+ - Rare congenital cholesteatoma type
+ - CT: Enlargement of CNVII bony canal
+ - Most commonly geniculate ganglion area
+
+# PATHOLOGY
+
+- ## General Features
+
+
+ - ### Etiology
+
+
+ - Congenital/developmental; can be acquired from cholesteatoma
+- ## Gross Pathologic & Surgical Features
+
+
+ - Protrusion: Identified in oval window niche during middle ear surgery
+ - Dehiscence: Tympanic > > mastoid segment CNVII
+
+# CLINICAL ISSUES
+
+- ## Presentation
+
+
+ - ### Most common signs/symptoms
+
+
+ - **Asymptomatic** most commonly
+ - Rarely, conductive hearing loss: Impingement on stapes
+ - ### Clinical profile
+
+
+ - **Incidental finding** on temporal bone CT
+ - Critical to communicate its presence to surgeon prior to middle ear exploration
+ - Easy to injure facial nerve during stapedectomy if CNVII prolapse is present
+- ## Demographics
+
+
+ - ### Age
+
+
+ - All ages; congenital lesion
+ - ### Epidemiology
+
+
+ - Simple dehiscence without protrusion ~ 50% of cases
+ - Prolapsing facial nerve is rare (~ 1% of cases)
+- ## Natural History & Prognosis
+
+
+ - Excellent if left alone
+- ## Treatment
+
+
+ - Careful avoidance at time of middle ear surgery
+
+# DIAGNOSTIC CHECKLIST
+
+- ## Image Interpretation Pearls
+
+
+ - Prolapse often associated with absence of notch defect along undersurface of LSCC
+ - If notch is seen, consider alternative explanation
+- ## Reporting Tips
+
+
+ - Caveat: Prolapsed CNVII in peril during stapedectomy
+ - Report & call this finding to ear surgeon
+
+ 69aa896c-0d3e-431e-9f74-ded28b2244b6
+
+## References
+
+# Selected References
+
+1. [Hernandez-Trejo AF et al: Prevalence of facial canal dehiscence and other bone defects by computed tomography. Eur Arch Otorhinolaryngol. 277(10):2681-6, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32383094%5Bpmid%5D)
+1. [Amadei EM et al: Revision stapes surgery after stapedotomy: a retrospective evaluation of 75 cases. Ear Nose Throat J. 97(6):E1-4, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=30036415%5Bpmid%5D)
+1. [Gosselin E et al: Predictable prosthesis length on a high-resolution CT scan before a stapedotomy. Eur Arch Otorhinolaryngol. 275(9):2219-26, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=30054728%5Bpmid%5D)
+1. [Kim SH et al: A case of a prolapsed facial nerve into the middle ear cavity. Br J Hosp Med (Lond). 76(1):50-1, 2015](http://www.ncbi.nlm.nih.gov/pubmed/?term=25585185%5Bpmid%5D)
+1. [Yetiser S: The dehiscent facial nerve canal. Int J Otolaryngol. 679708, 2012](http://www.ncbi.nlm.nih.gov/pubmed/?term=22518159%5Bpmid%5D)
+1. [Yu Z et al: The value of preoperative CT scan of tympanic facial nerve canal in tympanomastoid surgery. Acta Otolaryngol. 131(7):774-8, 2011](http://www.ncbi.nlm.nih.gov/pubmed/?term=21453222%5Bpmid%5D)
+1. [Ozbek C et al: Incidence of fallopian canal dehiscence at surgery for chronic otitis media. Eur Arch Otorhinolaryngol. 266(3):357-62, 2009](http://www.ncbi.nlm.nih.gov/pubmed/?term=18566822%5Bpmid%5D)
+1. [Di Martino E et al: Fallopian canal dehiscences: a survey of clinical and anatomical findings. Eur Arch Otorhinolaryngol. 262(2):120-6, 2005](http://www.ncbi.nlm.nih.gov/pubmed/?term=15592859%5Bpmid%5D)
+1. [Daniels RL et al: The other ear: findings and results in 1,800 bilateral stapedectomies. Otol Neurotol. 22(5):603-7, 2001](http://www.ncbi.nlm.nih.gov/pubmed/?term=11568665%5Bpmid%5D)
+1. [Park GC et al: Dehiscence of the tympanic segment of the facial nerve. Otolaryngol Head Neck Surg. 123(4):522, 2000](http://www.ncbi.nlm.nih.gov/pubmed/?term=11020202%5Bpmid%5D)
+1. [Tange RA et al: Dehiscences of the horizontal segment of the facial canal in otosclerosis. ORL J Otorhinolaryngol Relat Spec. 59(5):277-9, 1997](http://www.ncbi.nlm.nih.gov/pubmed/?term=9279867%5Bpmid%5D)
+1. [Swartz JD: The facial nerve canal: CT analysis of the protruding tympanic segment. Radiology. 153(2):443-7, 1984](http://www.ncbi.nlm.nih.gov/pubmed/?term=6484176%5Bpmid%5D)
+
+
+## Images
+
+
+### Selected Images
+
+
+*Graphic of medial wall of the right ear (anterior is to the right) demonstrates loss of bone covering midtympanic segment of the facial nerve canal with associated mild enlargement and prolapse of tympanic facial nerve into oval window niche.*
+
+
+*Graphic of medial wall of the right ear (anterior is to the right) demonstrates loss of bone covering midtympanic segment of the facial nerve canal with associated mild enlargement and prolapse of tympanic facial nerve into oval window niche.*
+
+
+*Coronal bone CT of the right ear in a patient with sensorineural hearing loss (SNHL) shows incidental prolapse of the tympanic portion of the facial nerve . The nerve is slightly larger than normal and devoid of a bony canal. A tiny density just below the facial nerve is a portion of the stapes crus .*
+
+
+*Axial CT in a patient with conductive hearing loss shows the protruding tympanic segment of CNVII is strung across the middle ear cavity. Notice that CNVII is prominent in size and touches the crura of the stapes, explaining conductive hearing loss presentation.*
+
+
+*Coronal left ear temporal bone CT shows the enlarged, prolapsed tympanic segment of CNVII in cross section . Enhanced MR can differentiate protrusion of CNVII (no enhancement) vs. facial nerve schwannoma (enhancement).*
+
+
+### Additional Images
+
+
+*Coronal left ear temporal bone CT shows the normal tympanic segment of the facial nerve in cross section along the undersurface of the lateral semicircular canal. Note subtle bone covering and relationship to the oval window niche .*
+
+
+*Coronal left ear temporal bone CT reveals a focal mass projecting from the midtympanic facial nerve . The lesion is prolapsed facial nerve, not a facial nerve schwannoma. Facial nerve prolapse can create significant surgical difficulties during stapedectomy.*
+
+
+*Coronal temporal bone CT of the right ear shows a soft tissue mass in the oval window niche along the undersurface of the lateral semicircular canal in the location of a normal tympanic facial nerve segment. A prolapsing facial nerve was diagnosed at surgery.*
+
diff --git a/docs_md/articles/parotid-schwannoma_039d782c-2e1e-455f-9cdc-dc00dc65c750.md b/docs_md/articles/parotid-schwannoma_039d782c-2e1e-455f-9cdc-dc00dc65c750.md
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index 0000000..b484da7
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+++ b/docs_md/articles/parotid-schwannoma_039d782c-2e1e-455f-9cdc-dc00dc65c750.md
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+---
+title: "Parotid Schwannoma"
+docid: "039d782c-2e1e-455f-9cdc-dc00dc65c750"
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+ - key: "639a3888-2423-42a0-ba09-67dd25a0b4f3"
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+ - "{'authors': 'Surjith Vattoth, MD, FRCR; H. Ric Harnsberger, MD', 'bookmarked': False, 'bookmarkUrl': '/document/bookmark/1ac3369a-afb8-4c59-a628-7014069b13bc', 'category': 'Head and Neck', 'compareUrl': '/compare/document/1ac3369a-afb8-4c59-a628-7014069b13bc/related-anatomy/treeNode?subContext=Parotid Space', 'documentId': '1ac3369a-afb8-4c59-a628-7014069b13bc', 'documentType': 'ANATOMY', 'documentUrl': '/document/parotid-space/1ac3369a-afb8-4c59-a628-7014069b13bc', 'enhancedTitle': 'Parotid Space', 'entryDate': '12/20/23', 'imageCount': 31, 'imageUrl': '/image/thumbnail/1d5c376d-a040-4065-8f1f-d0cf5d5ea18e?size=174&quality=85', 'inCompareCart': False, 'rank': 3, 'referenceCount': 0, 'showCompareButton': False, 'title': 'Parotid Space'}"
+ - "{'authors': 'Santhosh Gaddikeri, MD; Philip R. Chapman, MD', 'bookmarked': False, 'bookmarkUrl': '/document/bookmark/98cb2d45-e64c-4295-9662-3470cd46513a', 'category': 'Head and Neck', 'compareUrl': '/compare/document/98cb2d45-e64c-4295-9662-3470cd46513a/related-anatomy/treeNode?subContext=CNVII (Facial Nerve)', 'documentId': '98cb2d45-e64c-4295-9662-3470cd46513a', 'documentType': 'ANATOMY', 'documentUrl': '/document/cnvii-facial-nerve/98cb2d45-e64c-4295-9662-3470cd46513a', 'enhancedTitle': 'CNVII (Facial Nerve)', 'entryDate': '12/06/23', 'imageCount': 39, 'imageUrl': '/image/thumbnail/1f7e56c2-da7a-4445-ac01-44eee0776f17?size=174&quality=85', 'inCompareCart': False, 'rank': 4, 'referenceCount': 0, 'showCompareButton': False, 'title': 'CNVII (Facial Nerve)'}"
+cases: 2
+breadcrumbs:
+ - "Head and Neck"
+ - "Diagnosis"
+ - "Parotid Space"
+ - "Benign Tumors"
+ - "Parotid Schwannoma"
+---
+# KEY FACTS
+
+- ## Terminology
+
+
+ - Benign nerve sheath neoplasm from Schwann cells of intraparotid facial nerve (CNVII)
+- ## Imaging
+
+
+ - Heterogeneously enhancing tumor with intramural cystic areas when large
+ - Cystic areas may be small, multifocal, or large
+ - May extend toward or into stylomastoid foramen
+ - Presence of **target sign** suggestive if present
+ - Similar to schwannomas in other anatomic locations
+- ## Top Differential Diagnoses
+
+
+ - Parotid benign mixed tumor
+ - Warthin tumor
+ - Parotid metastatic nodal disease
+ - Parotid mucoepidermoid carcinoma
+ - Perineural tumor spread, CNVII
+- ## Pathology
+
+
+ - < 10% CNVII schwannoma = extratemporal (intraparotid), remaining = intratemporal or intracranial
+ - Type A: Exophytic off CNVII branch; no CNVII resection required
+ - Type B: Intrinsic to facial nerve branch; branch resection required
+ - Type C: Intrinsic to facial nerve trunk; resection & reconstruction required
+ - Type D: Encases main trunk & branches; resection & reconstruction required
+- ## Clinical Issues
+
+
+ - Presents like any parotid mass; difficult to differentiate clinically or radiographically
+ - Facial nerve palsy uncommon
+ - Associated with neurofibromatosis type 2
+ - Treatment goal: Preserve facial nerve function
+ - Controversial: Observation vs. surgery vs. radiation
+
+# TERMINOLOGY
+
+- ## Synonyms
+
+
+ - Facial neurilemmoma, intraparotid neurilemmoma
+- ## Definitions
+
+
+ - Benign nerve sheath neoplasm from Schwann cells of intraparotid facial nerve (CNVII)
+
+# IMAGING
+
+- ## General Features
+
+
+ - ### Best diagnostic clue
+
+
+ - Heterogeneously enhancing + **intramural cysts**
+ - Cystic areas may be small, multifocal, or large
+ - ### Location
+
+
+ - Course of intraparotid CNVII ± stylomastoid foramen
+ - ### Morphology
+
+
+ - Round or elongated along course of CNVII
+- ## Imaging Recommendations
+
+
+ - ### Best imaging tool
+
+
+ - T1WI C+ FS MR best demonstrates cystic areas
+ - FS useful for distinguishing tumor enhancement from intraparotid fat
+- ## CT Findings
+
+
+ - ### CECT
+
+
+ - Well-defined, round or oval intraparotid mass
+ - Intramural cysts within larger (> 2-cm) lesions
+ - Enlarged stylomastoid foramen in proximal lesions
+- ## MR Findings
+
+
+ - ### T1WI
+
+
+ - Tumor isointense to muscle, well defined
+ - ### T2WI
+
+
+ - Slightly hyperintense to brain, muscle
+ - Larger lesions with high-intensity cysts
+ - **Target sign** (hypointense center with hyperintense fluid rim) suggestive if present
+ - ### T1WI C+ FS
+
+
+ - Enhancing & cystic regions + peripheral enhancement
+
+# DIFFERENTIAL DIAGNOSIS
+
+- [Parotid Benign Mixed Tumor](/document/parotid-benign-mixed-tumor/619fefa6-2266-494d-9a80-3fd2b21debcf)
+ - Difficult to distinguish preoperatively
+ - Appears similar to schwannoma on CT & MR
+ - Benign mixed tumor classically with bosselated margins
+ - Parotid schwannoma usually mistaken for benign mixed tumor
+- [Warthin Tumor](/document/warthin-tumor/1fd4b7da-113d-4bee-b431-4111d65055ce)
+ - Cystic areas present as in schwannoma
+ - Can be multiple, bilateral, & favor parotid tail
+- [Parotid Metastatic Nodal Disease](/document/metastatic-disease-of-parotid-node-/df446621-cdbb-4654-bee4-8bad10e81bdf)
+ - Often multiple; have primary lesion (e.g., skin, lymphoma)
+- [Parotid Mucoepidermoid Carcinoma](/document/parotid-mucoepidermoid-carcinoma/74ed7ee4-5869-49f5-a28e-638a04849ce8)
+ - Low-grade form of mucoepidermoid carcinoma
+ - Well defined
+- ## Perineural Tumor Spread, CNVII
+
+
+ - Parotid or skin primary lesion
+
+# PATHOLOGY
+
+- ## General Features
+
+
+ - ### Etiology
+
+
+ - Arises from differentiated neoplastic Schwann cells of CNVII nerve sheath
+ - < 10% CNVII schwannoma = extratemporal (intraparotid), remaining = intratemporal or intracranial
+ - ### Associated abnormalities
+
+
+ - Multiple schwannomas are associated with neurofibromatosis type 2
+- ## Staging, Grading, & Classification
+
+
+ - Type A: Exophytic off CNVII branch; no CNVII resection required
+ - Type B: Intrinsic to CNVII branch; branch resection required
+ - Type C: Intrinsic to CNVII trunk; resection & reconstruction required
+ - Type D: Encases main CNVII trunk & branches; resection & reconstruction required
+- ## Gross Pathologic & Surgical Features
+
+
+ - Smooth, rubbery, yellow, encapsulated fusiform mass
+ - May arise eccentrically from CNVII
+- ## Microscopic Features
+
+
+ - Same as schwannomas in other anatomic locations
+ - Spindle cells with elongated nuclei
+ - Divided into regions of Antoni A (compact cells) & Antoni B (loose clusters)
+ - Predicts regional enhancement
+ - No necrosis; intramural cysts
+ - Immunochemistry: Strong, diffuse immunostaining for S100 protein = neural crest marker antigen present in supporting cells of nervous system
+
+# CLINICAL ISSUES
+
+- ## Presentation
+
+
+ - ### Most common signs/symptoms
+
+
+ - Painless, slowly enlarging cheek mass
+ - Often asymptomatic for > 10 years
+ - ### Other signs/symptoms
+
+
+ - Presents like any parotid mass; difficult to differentiate clinically or radiographically
+ - Rarely diagnosed preoperatively unless biopsied
+ - CNVII palsy uncommon: ↑ risk if intratemporal extension
+ - Associated with neurofibromatosis type 2
+- ## Demographics
+
+
+ - Age: Can affect any age group
+ - Most frequent in 4th & 5th decades
+ - Earlier in patients with neurofibromatosis
+- ## Natural History & Prognosis
+
+
+ - Slow growth; typically 0.5-2.0 mm/year
+ - May eventually cause mass effect or cosmetic issues
+- ## Treatment
+
+
+ - Controversial: Observation vs. surgery vs. radiation
+ - Depends on CNVII function & location of tumor
+ - Goal: CNVII function preservation & facial cosmesis
+ - Can dissect tumor off nerve but may cause CNVII palsy
+ - Types C & D lesions at ↑ risk of postoperative CNVII palsy
+ - Stereotactic radiosurgery may be used if CNVII intact
+
+# DIAGNOSTIC CHECKLIST
+
+- ## Consider
+
+
+ - Which branch of facial nerve involved
+ - Main trunk most common
+ - Relationship of mass to stylomastoid foramen
+ - Extent into mastoid segment of bony facial nerve canal
+- ## Image Interpretation Pearls
+
+
+ - Difficult to make radiographic diagnosis
+ - Tissue sampling required but excisional biopsy risky
+ - Image-guided biopsy (CT or US) very useful
+ - Core needle biopsy required (fine-needle aspiration inadequate)
+
+ 788f9901-75ea-42a0-91d6-4b9e114708fb
+
+## References
+
+# Selected References
+
+1. [Behera P et al: Aspiration cytology of facial nerve schwannoma of parotid gland: a rare diagnosis. Cytopathology. 33(5):618-21, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=35385173%5Bpmid%5D)
+1. [Jiang JY et al: A giant schwannoma extending from medial portion of middle cranial fossa to parapharyngeal space and deep parotid space. Ear Nose Throat J. ePub, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=35349782%5Bpmid%5D)
+1. [Malić M et al: Multicentric intra/extracranial cystic facial nerve schwannoma: case report and review of literature. Indian J Otolaryngol Head Neck Surg. 74(Suppl 3):3872-6, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=36742915%5Bpmid%5D)
+1. [Shamim M et al: Giant facial nerve schwannoma with extra-temporal involvement: a series of two cases. Indian J Otolaryngol Head Neck Surg. 74(Suppl 3):4399-404, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=36742768%5Bpmid%5D)
+1. [Singh AK et al: Systematic review of intra parotid facial nerve schwannoma and a case report. Indian J Otolaryngol Head Neck Surg. 74(Suppl 3):6268-84, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=36742919%5Bpmid%5D)
+1. [Bartindale M et al: Facial schwannoma management outcomes: a systematic review of the literature. Otolaryngol Head Neck Surg. 163(2):293-301, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32228141%5Bpmid%5D)
+1. [Seo BF et al: Intraparotid facial nerve schwannomas. Arch Craniofac Surg. 20(1):71-4, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=30703867%5Bpmid%5D)
+1. [Carlson ML et al: Facial nerve schwannomas: review of 80 cases over 25 years at Mayo Clinic. Mayo Clin Proc. 91(11):1563-76, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=27720200%5Bpmid%5D)
+1. [Zhang GZ et al: Clinical retrospective analysis of 9 cases of intraparotid facial nerve schwannoma. J Oral Maxillofac Surg. pii: S0278-2391(16)00165-8, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=26973226%5Bpmid%5D)
+1. [Bartindale M et al: The natural history of facial schwannomas: a meta-analysis of case series. J Neurol Surg B Skull Base. 80(5):458-68, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=31534886%5Bpmid%5D)
+1. [McCarthy WA et al: Intraparotid schwannoma. Arch Pathol Lab Med. 138(7):982-5, 2014](http://www.ncbi.nlm.nih.gov/pubmed/?term=24978928%5Bpmid%5D)
+1. [Nader ME et al: Facial nerve paralysis due to a pleomorphic adenoma with the imaging characteristics of a facial nerve schwannoma. J Neurol Surg Rep. 75(1):e84-8, 2014](http://www.ncbi.nlm.nih.gov/pubmed/?term=25083397%5Bpmid%5D)
+1. [De Ceulaer J et al: Intraparotid facial nerve schwannoma: case report and literature review. B-ENT. 8(3):225-8, 2012](http://www.ncbi.nlm.nih.gov/pubmed/?term=23113388%5Bpmid%5D)
+1. [Gross BC et al: The intraparotid facial nerve schwannoma: a diagnostic and management conundrum. Am J Otolaryngol. 33(5):497-504, 2012](http://www.ncbi.nlm.nih.gov/pubmed/?term=22185683%5Bpmid%5D)
+1. [Ma Q et al: Diagnosis and management of intraparotid facial nerve schwannoma. J Craniomaxillofac Surg. 38(4):271-3, 2010](http://www.ncbi.nlm.nih.gov/pubmed/?term=19692254%5Bpmid%5D)
+1. [Alicandri-Ciufelli M et al: Critical literature review on the management of intraparotid facial nerve schwannoma and proposed decision-making algorithm. Eur Arch Otorhinolaryngol. 266(4):475-9, 2009](http://www.ncbi.nlm.nih.gov/pubmed/?term=19096863%5Bpmid%5D)
+1. [Guzzo M et al: Schwannoma in the parotid gland. Experience at our institute and review of the literature. Tumori. 95(6):846-51, 2009](http://www.ncbi.nlm.nih.gov/pubmed/?term=20210258%5Bpmid%5D)
+1. [Tanna N et al: Intraparotid facial nerve schwannoma: clinician beware. Ear Nose Throat J. 88(8):E18-20, 2009](http://www.ncbi.nlm.nih.gov/pubmed/?term=19688704%5Bpmid%5D)
+1. [Mehta RP et al: Intraoperative diagnosis of facial nerve schwannoma at parotidectomy. Am J Otolaryngol. 29(2):126-9, 2008](http://www.ncbi.nlm.nih.gov/pubmed/?term=18314025%5Bpmid%5D)
+1. [Salemis NS et al: Large intraparotid facial nerve schwannoma: case report and review of the literature. Int J Oral Maxillofac Surg. 37(7):679-81, 2008](http://www.ncbi.nlm.nih.gov/pubmed/?term=18339519%5Bpmid%5D)
+1. [Marchioni D et al: Intraparotid facial nerve schwannoma: literature review and classification proposal. J Laryngol Otol. 121(8):707-12, 2007](http://www.ncbi.nlm.nih.gov/pubmed/?term=17381883%5Bpmid%5D)
+1. [Ciko Z: [Current treatment of acute leukemias.] Vojnosanit Pregl. 26(11):563-6, 1969](http://www.ncbi.nlm.nih.gov/pubmed/?term=5198300%5Bpmid%5D)
+
+## Anatomy
+
+### Facial Nerve (CNVII)
+Brain/ANATOMY:2f4818dd-6438-405b-8561-5cbbb9c91562
+
+### Suprahyoid and Infrahyoid Neck Overview
+Head and Neck/ANATOMY:50ac1eaf-3866-4ebd-8f5c-437055a64ba4
+
+### Parotid Space
+Head and Neck/ANATOMY:1ac3369a-afb8-4c59-a628-7014069b13bc
+
+### CNVII (Facial Nerve)
+Head and Neck/ANATOMY:98cb2d45-e64c-4295-9662-3470cd46513a
+
+## Cases
+
+- {'cases': [{'authors': [{'key': '564b28bd-4dbe-4066-9201-d10d689688fb', 'value': 'Christine M. Glastonbury, MBBS'}], 'caseVersionId': '19773c63-084f-4e8a-a6ad-4599b73b6f3f', 'description': 'Typical CECT and MR case of a tubular, cystic parotid schwannoma.\r\n\r\nAxial CECT (#1-3) demonstrates a low-density lesion (open arrows) within the superficial lobe of the parotid, which appears slightly denser than the normal parotid tissue. Sagittal reformatted CECT (#4) best shows extension of the lesion (open arrows) to the stylomastoid foramen (arrow), which appears widened. Axial (#5-7) and coronal (#8-10) T2 MR reveal this lesion (arrows) to be markedly hyperintense and very well circumscribed. T1 MR (#11) shows the mass (arrows) to have similarly well-defined margins and to have homogeneous low signal. It is only on T1 C+ FS MR (#12) that heterogeneous enhancement of this lesion (arrows) reveals to have a cystic internal nature.', 'history': 'Patient presented with a longstanding parotid mass without facial nerve weakness.', 'imagePoolId': '862231cf-68b1-4e58-9b8b-be9063f724a2', 'name': 'Cystic, tubular', 'teachingPoint': None, 'demographics': '36 Years old male'}, {'authors': [{'key': '564b28bd-4dbe-4066-9201-d10d689688fb', 'value': 'Christine M. Glastonbury, MBBS'}], 'caseVersionId': '75347872-f89b-4095-b34c-b96fcca92970', 'description': "Typical MR case of a target-like schwannoma of the parotid.\n\nAxial T1 MR (#1) shows a heterogeneous well-defined solid mass (arrow) in the superficial lobe of the left parotid. On T2 MR (#2,3) the lesion shows central hyperintensity (arrow) with a peripheral intermediate signal rim (curved arrow), and this target-like feature is also seen on the post-contrast images (#4,5) where the tumor's periphery shows greater enhancement (curved arrow).", 'history': 'Patient presented with a slowly growing lump and no evidence of facial nerve abnormality. FNA revealed spindle cells without a clear diagnosis.', 'imagePoolId': '1cf4abc6-531a-4b67-89ab-a7759a83593d', 'name': 'Target-like', 'teachingPoint': None, 'demographics': '38 Years old male'}, {'authors': [{'key': '564b28bd-4dbe-4066-9201-d10d689688fb', 'value': 'Christine M. Glastonbury, MBBS'}], 'caseVersionId': 'b0d85e05-a09b-45ac-8e58-9bdb94bde5f0', 'description': 'Typical case of homogeneous facial nerve schwannoma within the parotid space.\n\nAxial T1 MR (#1) and axial and sagittal T2 MR (#2,3) show a well-defined mass (arrow) in the right parotid, immediately anterior to the mastoid tip. Post-contrast T1 MR (#4) shows homogeneous enhancement of the mass. Notice the lesion "points" into the stylomastoid foramen (open arrow, #2,4). The mastoid segment of the facial nerve can also be followed into the mass on the sagittal view (open arrow, #3).\n\nPearls: The contour of this mass makes it unlikely to be a large lymph node. The sharply defined contour suggests either a benign or low-grade malignant parotid neoplasm, however the intermediate T2 signal intensity is uncommon for benign mixed tumors. Features such as these should raise suspicion for a schwannoma so that the surgeon is able to preoperatively plan for the possibility that this arises from the facial nerve.', 'history': 'This young man presented with a mass and FNA suggested pleomorphic adenoma. His facial nerve function was normal both pre and post-resection.', 'imagePoolId': '813c6ffb-93aa-4802-bea8-550c4144f5e4', 'name': 'Homogeneous', 'teachingPoint': None, 'demographics': '16 Years old male'}], 'caseType': 'typical', 'name': 'TYPICAL'}
+- {'cases': [{'authors': [{'key': '564b28bd-4dbe-4066-9201-d10d689688fb', 'value': 'Christine M. Glastonbury, MBBS'}], 'caseVersionId': '3ba5eede-00c5-4b9b-b2db-c0a31f1e10a5', 'description': 'Variant MR case of a tubular parotid schwannoma.\r\n\r\nAxial T1 MR (#1-3) demonstrates a subtle, tubular low-density lesion (arrows) within the superficial lobe of the right parotid gland. The lesion is along the expected course of the intraparotid facial nerve, lateral to the retromandibular vein (curved arrow, #1). On axial T2 FS MR (#4-6) images, the mass is readily evident as a heterogeneous, tubular hyperintense lesion (arrows). The lesion (arrows, #7-9) has minimal contrast enhancement on axial T1 C+ FS MR.\r\n\r\nThe initial FNA was hypocellular, but the second attempt revealed schwannoma. The lesion has not been excised.', 'history': 'Patient presented with a palpable mass and right pain in the nasolabial fold and preauricular to right neck; he had but normal facial nerve function.', 'imagePoolId': 'ddeb10e9-3923-4fae-b3fb-cc436361d66f', 'name': 'Tubular', 'teachingPoint': None, 'demographics': '59 Years old male'}], 'caseType': 'variant', 'name': 'VARIANT'}
+
+
+## Images
+
+
+### Selected Images
+
+
+*Axial T2 FS MR shows a heterogeneous, hyperintense parotid mass wedged into the stylomastoid foramen . The location & characteristic target sign suggest the possibility of facial schwannoma.*
+
+
+*Axial T2 FS MR shows a heterogeneous, hyperintense parotid mass wedged into the stylomastoid foramen . The location & characteristic target sign suggest the possibility of facial schwannoma.*
+
+
+*Coronal T1 C+ FS MR in the same patient shows an enhancing schwannoma along the main trunk of the facial nerve with the target sign & small intratumoral cysts . An additional clue to the diagnosis is contiguous enhancing tumor along the intratemporal facial nerve extending into the IAC .*
+
+
+*Axial CECT in a patient with neurofibromatosis type 2 shows a round, subcentimeter mass in the anterior aspect of the superficial parotid lobe. This schwannoma has heterogeneous enhancement but no cystic areas because of its small size.*
+
+
+*Coronal bone CT shows smooth expansion of the vertical segment of the facial canal . The facial nerve schwannoma extends from the parotid gland up through the stylomastoid foramen.*
+
+
+### Additional Images
+
+
+*Axial T1 FS MR shows a small mass in the superficial lobe of the parotid gland. It has heterogeneous high signal. There are no imaging features that would suggest schwannoma over the far more common benign mixed tumor (BMT).*
+
+
+*Coronal T1 C+ FS MR shows a tubular mass in the inferior superficial parotid lobe. Small schwannomas usually do not have cystic regions. This patient has neurofibromatosis type 2, as evidenced by the schwannoma along CNV3 .*
+
+
+*Coronal T1 C+ FS MR shows an oval, heterogeneously enhancing mass with a large intramural cyst in the superficial parotid lobe. The imaging appearance is similar to schwannomas in other anatomic locations.*
+
+
+*Axial T1 C+ MR shows a mass with enhancement that allows it to blend into the surrounding high-intensity parotid fat. Fat-saturated images are useful to distinguish intraparotid schwannomas after contrast has been administered.*
+
diff --git a/docs_md/articles/peripheral-facial-nerve-paralysis_4da52ac4-c03c-4711-ae7e-bb4f2f7c5ab8.md b/docs_md/articles/peripheral-facial-nerve-paralysis_4da52ac4-c03c-4711-ae7e-bb4f2f7c5ab8.md
new file mode 100644
index 0000000..266e5d1
--- /dev/null
+++ b/docs_md/articles/peripheral-facial-nerve-paralysis_4da52ac4-c03c-4711-ae7e-bb4f2f7c5ab8.md
@@ -0,0 +1,406 @@
+---
+title: "Peripheral Facial Nerve Paralysis"
+docid: "4da52ac4-c03c-4711-ae7e-bb4f2f7c5ab8"
+authors:
+ - key: "eef2f839-5706-47b9-89c3-60d8315b2b3a"
+ value: "Nicholas A. Koontz, MD"
+breadcrumbs:
+ -
+ name: "Head and Neck"
+ slug: "head-and-neck"
+ treeNodeId: "ed24ed8c-5d57-4629-879b-447b82d2973d"
+ -
+ name: "Differential Diagnosis"
+ slug: "differential-diagnosis"
+ treeNodeId: "40d68862-8975-4dde-ac2b-ebc43ab0fb5c"
+ -
+ name: "Temporal Bone"
+ slug: "temporal-bone"
+ treeNodeId: "2f7dc690-4970-486f-abb6-ed24d99b7a04"
+ -
+ name: "Clinically Based Differentials"
+ slug: "clinically-based-differentials"
+ treeNodeId: "a1829ef3-3870-48d4-81d6-2505fc8db7b8"
+ -
+ name: "Peripheral Facial Nerve Paralysis"
+ slug: "peripheral-facial-nerve-paralysis"
+ treeNodeId: null
+category: "Head and Neck"
+cmeTopicId: "e3a8ceca-c2c5-4be5-a423-e134a0965ae9"
+documentVersionId: "2701a4b6-e89a-41e8-a30f-d64d621b420f"
+imageCount: 48
+lastUpdated: "10/09/18"
+pageDescription: "Peripheral Facial Nerve Paralysis"
+pageKeywords: "Head and Neck, Differential Diagnosis, Temporal Bone, Clinically Based Differentials, Peripheral Facial Nerve Paralysis"
+pageTitle: "Peripheral Facial Nerve Paralysis | STATdx"
+enhancedTitle: "Peripheral Facial Nerve Paralysis"
+type: "DDX"
+references: true
+breadcrumbs:
+ - "Head and Neck"
+ - "Differential Diagnosis"
+ - "Temporal Bone"
+ - "Clinically Based Differentials"
+ - "Peripheral Facial Nerve Paralysis"
+---
+# ESSENTIAL INFORMATION
+
+- ## Key Differential Diagnosis Issues
+
+
+ - Peripheral facial nerve paralysis
+ - Definition: Unilateral facial nerve injury between pontine motor nucleus & proximal extracranial facial nerve trunk after it emerges from stylomastoid foramen
+ - Clinical manifestation of peripheral facial nerve injury: All muscles of facial expression, including forehead muscles, are paralyzed
+ - Motor: Facial expression muscles; stapedius muscles
+ - Parasympathetic: Lacrimal, submandibular, & sublingual glands
+ - Special sensory: Anterior 2/3 tongue taste
+ - Imaging hints in searching for causes
+ - **Typical** Bell palsy: Does not need imaged routinely
+ - **Atypical** Bell palsy best examined by thin-section enhanced (C+) MR; increasing role of 3D-FLAIR C+
+ - Subtle MR abnormalities: Imaged with T-bone CT to exclude facial nerve hemangioma
+- ## Helpful Clues for Common Diagnoses
+
+
+ - **Bell Palsy**
+ - Entire intratemporal facial nerve enhances on MR without mass effect
+ - IAC fundal "tuft" often also present on T1 C+ MR
+ - **Temporal Bone****Fractures**
+ - Tympanic segment of facial nerve most vulnerable
+ - **Metastases****in****CPA-IAC**
+ - Poorly marginated enhancing mass in CPA-IAC ± dural enhancement
+ - History of primary cancer usually known
+ - Caveat: CPA-IAC mass with associated facial nerve paralysis is **not** vestibular schwannoma
+ - **Pars Flaccida Acquired Cholesteatoma**
+ - T-bone CT: Nondependent soft tissue in middle ear filling Prussak space with ossicle + bone erosion ± involving facial nerve canal
+ - MR: Nonenhancing mass with reduced diffusivity
+ - Reduced diffusivity better seen on nonecho-planar (e.g., HASTE) DWI than echo-planar DWI
+ - **Acute Cerebral Ischemia-Infarction in Pons**
+ - MR: Reduced diffusivity (~ 30 minutes) + increased T2/FLAIR signal (~ 6 hours)
+- ## Helpful Clues for Less Common Diagnoses
+
+
+ - **Facial Nerve Perineural Tumor**
+ - Parotid space malignancy ascends through stylomastoid foramen to mastoid facial nerve (CNVII)
+ - **Facial Nerve Schwannoma in T-Bone**
+ - Fusiform enhancing mass along CNVII canal with expansile bone margins
+ - Geniculate fossa most common location
+ - **Glomus Jugulare****Paraganglioma**
+ - Bone CT: Permeative destructive bone changes along jugular foramen (JF) margins
+ - T1 C+ MR: Enhancing JF mass with high-velocity flow voids projects superolateral through middle ear floor
+ - Clinical clues: Vascular retrotympanic mass, pulsatile tinnitus
+ - **Meningioma in CPA-IAC**
+ - Bone CT: Underlying bone ± hyperostosis or permeative sclerosis
+ - T1 C+ MR: Lobulated, enhancing CPA mass with dural base ± dural tails
+ - **Congenital Cholesteatoma in Middle Ear**
+ - Otoscopy: White mass behind **intact** tympanic membrane in child
+ - Bone CT: Nondependent soft tissue mass often medial to ossicles
+ - MR: Nonenhancing mass with reduced diffusivity
+ - Reduced diffusivity better seen on nonecho-planar (e.g., HASTE) DWI than echo-planar DWI
+ - **Meningioma****in****T-Bone**
+ - Bone CT: Hyperostosis or permeative sclerosis of tegmen, JF margins
+ - T1 C+ MR: Middle ear enhancing tumor comes from tegmen tympani, JF, or inner ear
+ - **Metastasis in T-Bone**
+ - Destructive T-bone mass in patient with known cancer
+ - **Multiple Sclerosi****s****in Brainstem**
+ - Young adult with predominantly supratentorial white matter disease
+ - Pontine plaques may or may not be visible in setting of facial nerve paralysis
+- ## Helpful Clues for Rare Diagnoses
+
+
+ - **Adenoid Cystic Carcinoma****in****Parotid**
+ - Flame-shaped enhancing parotid space invasive mass
+ - Tumor replaces normal fat in stylomastoid foramen
+ - **Mucoepidermoid Carcinoma in****Parotid**
+ - Ovoid invasive parotid space mass usually with complex matrix
+ - **Facial Nerve Venous Malformation ("Hemangioma")**
+ - Bone CT: Poorly marginated mass in geniculate fossa with “honeycomb” matrix (50%)
+ - T1 C+ MR: Lesion enhances avidly
+ - Geniculate fossa most common location
+ - **Cavernous Malformation in Pons**
+ - CT: Pontine lesion with "popcorn" calcifications
+ - MR: Pontine lesion with complex signal from blood products & calcifications ± nearby DVA
+ - **Ramsay Hunt Syndrome**
+ - Herpes zoster oticus affects facial nerve ± vestibulocochlear nerve ± inner ear
+ - External auditory canal vesicles usually precede facial nerve symptoms
+ - T1 C+ MR: Enhancing facial nerve in IAC & temporal bone
+ - Other MR findings: Enhancement of inner ear structures & vestibulocochlear nerve variable; increasing role of 3D-FLAIR C+ to differentiate from Bell palsy
+ - 3D-FLAIR C+ enhancement of CNVIII, IAC wall, & inner ear more typical of Ramsay Hunt than Bell palsy
+ - **Sarcoidosis****in****CPA-IAC**
+ - MR: Dural-based enhancing "meningioma mimic" that may track along cistern-IAC CNVII
+ - **Langerhans Histiocytosis****in****T-Bone**
+ - Expansile punched-out T-bone lytic lesion in child
+ - **Rhabdomyosarcoma in T-bone**
+ - Destructive lesion of T-bone in child
+ - Often centered in middle ear
+ - **F****acial Nerve****Schwannoma in CPA-IAC**
+ - CPA-IAC enhancing "vestibular schwannoma mimic"
+ - Diagnosis can be made if schwannoma projects into labyrinthine segment of CNVII
+ - Looks like "labyrinthine tail" projecting off IAC fundus
+- ## Alternative Differential Approaches
+
+
+ - Organize by **anatomic segment of CNVII**
+ - Divide facial nerve into its discrete segments
+ - **Intramedullary**: 3 nuclei (1 motor & 2 sensory) tracts; motor fibers circle CNVI nucleus to create facial colliculus in floor of 4th ventricle
+ - **CPA-IAC cistern**: Root exit zone of lateral brainstem to fundus of IAC
+ - **Intratemporal**: Labyrinthine, tympanic, & mastoid intratemporal CNVII
+ - **Extracranial**: Stylomastoid foramen to functional terminal segment of CNVII
+ - By looking at CNVII injury from this vantage point, you create method for designing your imaging protocol
+ - Scanning protocol must include pons, CPA-IAC cistern, T-bone, & parotid space
+ - Segmental anatomic approach to CNVII paralysis DDx
+ - **Intramedullary lesions**
+ - [Cavernous malformation in pons](/document/cavernous-malformation/d6c0dfc6-25d3-4713-941f-373c68ca8f0d)
+ - [Multiple sclerosis in brainstem](/document/multiple-sclerosis/7892b2a2-f52a-4d7f-9858-a326f2b7ab04)
+ - [Acute cerebral ischemia-infarction in pons](/document/acute-cerebral-ischemiainfarction/a405285f-aaea-43ca-8dc4-6f8120eaabc1)
+ - **CPA-IAC lesions**
+ - [Metastases in CPA-IAC](/document/cpa-iac-metastases/451451c8-7b49-4ce9-bf22-7c02b4652f23)
+ - [Meningioma in CPA-IAC](/document/cpa-iac-meningioma/88301b77-f1c8-4efc-acf7-405999b42c3d)
+ - [Sarcoidosis in CPA-IAC](/document/cpa-iac-neurosarcoid/2fdac517-7385-4bfd-92fc-a3445502675b)
+ - [Ramsay Hunt syndrome](/document/ramsay-hunt-syndrome/94fd9d75-cbe7-4f01-9d36-7c54d629f5c6)
+ - [Facial nerve schwannoma in CPA-IAC](/document/cpa-iac-facial-nerve-schwannoma/9db01630-23a4-4f42-ad83-0ec399503495)
+ - **T-bone lesions**
+ - [Bell palsy](/document/bell-palsy/0958e575-8f76-4d70-b806-0dbed9c62a67)
+ - [Temporal bone fractures](/document/temporal-bone-fractures/12b6bafb-6bd8-498b-87b9-f4bb8222da57)
+ - [Pars flaccida acquired cholesteatoma](/document/pars-flaccida-cholesteatoma/cf2c20e7-2417-4373-b771-ed3f65a793b4)
+ - [Facial nerve schwannoma in T-bone](/document/temporal-bone-facial-nerve-schwann-/cf2bcc82-4a1b-4989-adeb-f4e82116111b)
+ - [Facial nerve venous malformation in T-bone](/document/temporal-bone-facial-nerve-venous--/dcd6a44e-cbe6-457c-9b03-598a2b874ece)
+ - Glomus jugulare paraganglioma
+ - [Congenital cholesteatoma in middle ear](/document/congenital-middle-ear-cholesteatoma/5990c663-ca85-4177-9109-aed6949fc115)
+ - [Meningioma in T-bone](/document/temporal-bone-meningioma/959c8ccf-fe4f-405a-97fd-ba9fe822c8c7)
+ - Metastasis in T-bone
+ - [Langerhans histiocytosis in T-bone](/document/temporal-bone-langerhans-cell-hist-/e8ad8ade-9299-471b-9ef1-d381c1ed20c4)
+ - [Rhabdomyosarcoma in T-bone](/document/temporal-bone-rhabdomyosarcoma/f1f41d58-2289-4d55-b398-95fd00f7babe)
+ - **Parotid lesions**
+ - Facial nerve perineural tumor
+ - [Adenoid cystic carcinoma](/document/parotid-adenoid-cystic-carcinoma/8571ae8a-0aae-432d-977c-1bab4f8888e9)
+ - [Mucoepidermoid carcinoma](/document/parotid-mucoepidermoid-carcinoma/74ed7ee4-5869-49f5-a28e-638a04849ce8)
+
+## References
+
+# Selected References
+
+1. [Jindal G et al: Imaging evaluation and treatment of vascular lesions at the skull base. Radiol Clin North Am. 55(1):151-166, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=27890183%5Bpmid%5D)
+1. [Kuya J et al: Usefulness of high-resolution 3D multi-sequences for peripheral facial palsy: differentiation between Bell's palsy and Ramsay Hunt syndrome. Otol Neurotol. 38(10):1523-1527, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=29135869%5Bpmid%5D)
+1. [Lingam RK et al: A meta-analysis on the diagnostic performance of non-echoplanar diffusion-weighted imaging in detecting middle ear cholesteatoma: 10 years on. Otol Neurotol. 38(4):521-528, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28195998%5Bpmid%5D)
+1. [Chevallier KM et al: Differentiating pediatric rhabdomyosarcoma and Langerhans cell histiocytosis of the temporal bone by imaging appearance. AJNR Am J Neuroradiol. 37(6):1185-9, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=26869468%5Bpmid%5D)
+1. [Chung MS et al: The clinical significance of findings obtained on 3D-FLAIR MR imaging in patients with Ramsay-Hunt syndrome. Laryngoscope. 125(4):950-5, 2015](http://www.ncbi.nlm.nih.gov/pubmed/?term=25346250%5Bpmid%5D)
+1. [Gamss C et al: Imaging evaluation of the suprahyoid neck. Radiol Clin North Am. 53(1):133-44, 2015](http://www.ncbi.nlm.nih.gov/pubmed/?term=25476177%5Bpmid%5D)
+1. [Ho ML et al: Anatomy and pathology of the facial nerve. AJR Am J Roentgenol. 204(6):W612-9, 2015](http://www.ncbi.nlm.nih.gov/pubmed/?term=26001250%5Bpmid%5D)
+1. [Singh AK et al: Imaging spectrum of facial nerve lesions. Curr Probl Diagn Radiol. 44(1):60-75, 2015](http://www.ncbi.nlm.nih.gov/pubmed/?term=24975082%5Bpmid%5D)
+1. [McRackan TR et al: Facial nerve outcomes in facial nerve schwannomas. Otol Neurotol. 2012 Jan;33(1):78-82. Erratum in: Otol Neurotol. 33(3):472, 2012](http://www.ncbi.nlm.nih.gov/pubmed/?term=22143290%5Bpmid%5D)
+1. [Magliulo G et al: Facial nerve dehiscence and cholesteatoma. Ann Otol Rhinol Laryngol. 120(4):261-7, 2011](http://www.ncbi.nlm.nih.gov/pubmed/?term=21585157%5Bpmid%5D)
+1. [Benoit MM et al: Facial nerve hemangiomas: vascular tumors or malformations? Otolaryngol Head Neck Surg. 142(1):108-14, 2010](http://www.ncbi.nlm.nih.gov/pubmed/?term=20096233%5Bpmid%5D)
+1. [Nakata S et al: 3D-FLAIR MRI in facial nerve paralysis with and without audio-vestibular disorder. Acta Otolaryngol. 130(5):632-6, 2010](http://www.ncbi.nlm.nih.gov/pubmed/?term=19916898%5Bpmid%5D)
+1. [Finsterer J: Management of peripheral facial nerve palsy. Eur Arch Otorhinolaryngol. 265(7):743-52, 2008](http://www.ncbi.nlm.nih.gov/pubmed/?term=18368417%5Bpmid%5D)
+1. [Moody MW et al: Incidence of dehiscence of the facial nerve in 416 cases of cholesteatoma. Otol Neurotol. 28(3):400-4, 2007](http://www.ncbi.nlm.nih.gov/pubmed/?term=17159491%5Bpmid%5D)
+1. [Quaranta N et al: Facial paralysis associated with cholesteatoma: a review of 13 cases. Otol Neurotol. 28(3):405-7, 2007](http://www.ncbi.nlm.nih.gov/pubmed/?term=17414046%5Bpmid%5D)
+1. [Critchley EP: Multiple sclerosis initially presenting as facial palsy. Aviat Space Environ Med. 75(11):1001-4, 2004](http://www.ncbi.nlm.nih.gov/pubmed/?term=15559004%5Bpmid%5D)
+1. [Park SU et al: The usefulness of MR imaging of the temporal bone in the evaluation of patients with facial and audiovestibular dysfunction. Korean J Radiol. 3(1):16-23, 2002](http://www.ncbi.nlm.nih.gov/pubmed/?term=11919474%5Bpmid%5D)
+1. [Martin N et al: Haemangioma of the petrous bone: MRI. Neuroradiology. 34(5):420-2, 1992](http://www.ncbi.nlm.nih.gov/pubmed/?term=1407526%5Bpmid%5D)
+1. [Curtin HD et al: "Ossifying" hemangiomas of the temporal bone: evaluation with CT. Radiology. 164(3):831-5, 1987](http://www.ncbi.nlm.nih.gov/pubmed/?term=3112865%5Bpmid%5D)
+
+
+## Images
+
+
+### Selected Images
+
+
+**Bell Palsy**
+*Axial T1 C+ FS MR in a patient with Bell palsy shows the classic faint, tuft-like enhancement at the fundus of the IAC , which extends as a linear enhancement along the labyrinthine segment , anterior genu , and anterior tympanic segments of the facial nerve.*
+
+
+**Bell Palsy**
+*Axial T1 C+ FS MR in a patient with Bell palsy shows the classic faint, tuft-like enhancement at the fundus of the IAC , which extends as a linear enhancement along the labyrinthine segment , anterior genu , and anterior tympanic segments of the facial nerve.*
+
+
+**Bell Palsy**
+*Coronal T1 C+ FS MR shows a classic "tuft" of enhancement at the superior fundus of the IAC as well as along the tympanic segment of the facial nerve in a patient with Bell palsy.*
+
+
+**Temporal Bone Fractures**
+*Axial NECT shows a complex temporal bone fracture with a longitudinal component traversing the anterior genu of the facial nerve canal and resulting in facial nerve injury. Note a large distracted fragment of the anterior petrous ridge and temporal squamosal fracture component .*
+
+
+**Temporal Bone Fractures**
+*Axial NECT shows a complex T-bone fracture with transverse component violating the anterior genu and anterior tympanic segments of the CNVII canal.*
+
+
+**Metastases in CPA-IAC**
+*Axial T1 C+ MR in a patient with breast cancer & progressive facial weakness shows enhancement along CNVII & CNVIII within the right IAC due to leptomeningeal metastatic disease. Additional enhancing focus is present at the left IAC fundus .*
+
+
+**Metastases in CPA-IAC**
+*Axial FLAIR C+ MR in a melanoma patient presenting with progressive facial weakness, vestibular symptoms, & hearing loss shows avid enhancement in IAC & cochlea bilaterally at left trigeminal cave due to florid leptomeningeal metastatic disease.*
+
+
+**Pars Flaccida Acquired Cholesteatoma**
+*Axial NECT in a patient with cholesteatoma post mastoidectomy and new facial weakness shows a large soft tissue mass within the mastoidectomy bowl corresponding to recurrent cholesteatoma, which has eroded into the descending mastoid segment of the CNVII canal.*
+
+
+**Pars Flaccida Acquired Cholesteatoma**
+*Coronal nonecho-planar (HASTE) DWI in a patient with pars flaccida cholesteatoma shows a markedly hyperintense mass in the right middle ear. Cholesteatomas characteristically show reduced diffusivity on DWI.*
+
+
+**Acute Cerebral Ischemia-Infarction in Pons**
+*Axial T2 MR demonstrates a subacute lateral pontine infarction on the right. This patient presented with acute onset of right facial nerve paralysis and facial numbness.*
+
+
+**Facial Nerve Perineural Tumor**
+*Axial T1 C+ FS MR demonstrates adenoid cystic carcinoma spreading along a branch of the extracranial facial nerve . In cases where antegrade perineural tumor spreads from the parotid distally along CNVII, peripheral facial nerve paralysis may be only partial.*
+
+
+**Facial Nerve Schwannoma in T-Bone**
+*Axial NECT in a patient with CNVII schwannoma shows a soft tissue middle ear mass extending eccentrically from tympanic segment of CNVII. Widening of the CNVII canal at the posterior genu was a helpful feature in recognizing the CNVII origin of this lesion.*
+
+
+**Glomus Jugulare Paraganglioma**
+*Axial NECT shows a permeative-destructive lesion of the left jugular foramen , typical of a glomus jugulare. Facial weakness was due to invasion of the descending mastoid segment of CNVII . Note normal appearance of right jugular foramen .*
+
+
+**Meningioma in CPA-IAC**
+*Axial T1 C+ FS MR shows an avidly enhancing extraaxial mass centered in the CPA but extending into the IAC . Note the prominent dural tails of enhancement, characteristic of meningioma.*
+
+
+**Congenital Cholesteatoma in Middle Ear**
+*Coronal bone CT shows a large congenital cholesteatoma of the middle ear that has eroded the lateral bony wall of the anterior tympanic segment of the facial nerve canal as well as the ossicles. This child presented with a middle ear mass behind the intact tympanic membrane and CNVII paresis.*
+
+
+**Meningioma in T-Bone**
+*Axial T1 C+ FS MR shows an enhancing extraaxial mass with dural tail , intraosseous extension, and hyperostosis consistent with aggressive meningioma that obliterates the CPA. Note schwannomas of left CNV and right IAC in this NF2 patient.*
+
+
+**Metastasis in T-Bone**
+*Axial T1 C+ MR shows a large left T-bone mass obliterating the middle ear, including the expected course of CNVII . Note a similar-appearing but smaller mass in the right occipital bone . Multiplicity is a helpful clue to metastatic disease, in this case, from neuroblastoma.*
+
+
+**Multiple Sclerosis in Brainstem**
+*Axial FLAIR MR demonstrates a large pontine multiple sclerosis plaque in this patient with florid supratentorial white matter disease (not shown).*
+
+
+**Adenoid Cystic Carcinoma in Parotid**
+*Axial T1 MR in a patient with adenoid cystic carcinoma of the parotid shows an irregular-shaped, infiltrative mass replacing the deep lobe of the parotid and extending through the stylomandibular tunnel into the superficial parotid , obliterating the plane of the facial nerve.*
+
+
+**Mucoepidermoid Carcinoma in Parotid**
+*Axial T2 FS MR shows an infiltrating, ill-defined mass spanning deep & superficial lobes of parotid gland, obliterating plane of CNVII. Note T2-bright mucous cystic regions as well as areas of dark T2 signal intensity from high cellularity portions of the tumor.*
+
+
+**Facial Nerve Venous Malformation (Hemangioma)**
+*Axial NECT in a patient with CNVII venous malformation shows a permeative expansile lesion centered at geniculate fossa that widens labyrinthine segment of CNVII canal. Note the characteristic "honeycomb" matrix within the lesion.*
+
+
+**Cavernous Malformation in Pons**
+*Coronal T2* GRE MR reveals a "blooming" cavernous malformation in the left pons . T1 images (not shown) showed hyperintense foci of methemoglobin, consistent with prior hemorrhage.*
+
+
+**Ramsay Hunt Syndrome**
+*Axial T1 C+ MR in Ramsay Hunt syndrome shows enhancement along the IAC and intratemporal facial nerve . A compelling clinical history is helpful, as distinguishing from Bell palsy on imaging alone is challenging. 3D-FLAIR C+ has shown promise in this regard.*
+
+
+**Sarcoidosis in CPA-IAC**
+*Axial T1 C+ FS MR reveals sarcoid affecting the 7th and 8th CNs in the IAC . Notice that the tympanic segment of the facial nerve is also avidly enhancing .*
+
+
+**Langerhans Histiocytosis in T-Bone**
+*Axial T1 C+ FS MR in a child with Langerhans histiocytosis shows a destructive middle ear/mastoid mass with ossicular encasement and encroachment of the CNVII tympanic segment . Note aggressive periosteal reaction not commonly seen with Langerhans calvarial lesions.*
+
+
+**Rhabdomyosarcoma in T-Bone**
+*Coronal T1 C+ FS MR shows transspatial mass of middle ear , external auditory canal , & infratemporal fossa . Note obliteration of the tympanic segment of CNVII . Histology revealed rhabdomyosarcoma.*
+
+
+**Facial Nerve Schwannoma in CPA-IAC**
+*Axial T2 MR shows a CPA mass extending along posterior IAC into CNVII labyrinthine segment . While CNVII lives anteriorly in IAC, close attention shows a near-CSF signal-associated arachnoid cyst displacing CNVII schwannoma posteriorly. Note CSF is slightly brighter.*
+
+
+### Additional Images
+
+
+**Bell Palsy**
+*Axial T1 C+ FS MR shows a "tuft" sign in this patient with acute onset of left peripheral CNVII paralysis. The enhancing fundal portion of the IAC CNVII often has this diffuse, less linear appearance.*
+
+
+**Bell Palsy**
+*Axial T1 C+ FS MR demonstrates enhancement of the labyrinthine and tympanic segments of the intratemporal facial nerve. Mastoid segment enhancement was also present (not shown).*
+
+
+**Bell Palsy**
+*Coronal T1 C+ FS MR demonstrates avid enhancement of the mastoid segment of the facial nerve and the proximal extracranial segment in the stylomastoid foramen in this patient with typical acute onset Bell palsy.*
+
+
+**Temporal Bone Fractures**
+*Axial bone CT shows healing bone fragments in the lateral geniculate fossa . This patient suffered temporal bone fracture with persistent facial nerve paralysis 6 weeks before this CT.*
+
+
+**Temporal Bone Fractures**
+*Sagittal bone CT demonstrates disrupted ossicles in the attic and healing bone in the lateral roof of the geniculate fossa . Six weeks after temporal bone fracture, persistent conductive hearing loss and facial nerve paralysis were still present.*
+
+
+**Metastases in CPA-IAC**
+*Axial T1 C+ MR shows breast carcinoma metastases in both IACs . This type of linear enhancement is seen when the metastasis is in the pia-arachnoid of CNVII and CNVIII.*
+
+
+**Metastases in CPA-IAC**
+*Axial T2WI MR reveals bilateral IAC breast carcinoma metastases thickening the facial and vestibulocochlear nerve bundles. Pia-arachnoid metastasis has a floating in CSF appearance.*
+
+
+**Pars Flaccida Acquired Cholesteatoma**
+*Axial bone CT demonstrates an epitympanic cholesteatoma that has eroded the anterior superior wall of the attic, shaved off the anterior head of the malleus , and dehisced the lateral bony wall of the anterior tympanic segment of the facial nerve canal .*
+
+
+**Pars Flaccida Acquired Cholesteatoma**
+*Sagittal bone CT shows an anterior middle ear cholesteatoma that has both eroded the tegmen tympani and dehisced the lateral bony wall of the geniculate fossa .*
+
+
+**Facial Nerve Schwannoma in T-Bone**
+*Axial T1 C+ FS MR in a patient with facial nerve schwannoma shows an avidly enhancing middle ear mass growing along the expected course of the tympanic segment of the facial nerve.*
+
+
+**Facial Nerve Schwannoma in T-Bone**
+*Coronal T1 C+ FS MR in a patient with facial nerve schwannoma shows an avidly enhancing middle ear mass growing below the level of the lateral semicircular canal, which is the typical course of the tympanic segment of the facial nerve . Note the eccentric growth pattern relative to the nerve of origin, typical of schwannomas.*
+
+
+**Facial Nerve Schwannoma in T-Bone**
+*Axial bone CT shows smooth enlargement of the geniculate fossa by a facial nerve schwannoma. T1-enhanced MR (not shown) revealed enhancing tissue within the enlarged geniculate fossa.*
+
+
+**Glomus Jugulare Paraganglioma**
+*Coronal T1 C+ FS MR shows a glomus jugulare paraganglioma filling the jugular foramen and spreading superolaterally through the middle ear floor to involve the tympanic segment of CNVII .*
+
+
+**Meningioma in CPA-IAC**
+*Axial T2 FS MR reveals a lobulated dural-based meningioma with a CSF vascular cleft and asymmetric relationship to the porus acusticus .*
+
+
+**Meningioma in T-Bone**
+*Axial bone CT reveals the permeative-sclerotic bone changes of an anterior tegmen tympani meningioma . Notice that the lateral wall of the anterior tympanic segment of the facial nerve canal is affected by the meningioma .*
+
+
+**Metastasis in T-Bone**
+*Axial bone CT shows a large floor of middle cranial fossa destructive metastasis eroding the anterior wall of the middle ear cavity and invading the geniculate fossa . This patient with known colon cancer presented with acute onset of facial nerve paralysis.*
+
+
+**Adenoid Cystic Carcinoma in Parotid**
+*Axial CECT shows a poorly marginated adenoid cystic carcinoma of the parotid gland with deep invasion toward the stylomastoid foramen and proximal extracranial facial nerve .*
+
+
+**Mucoepidermoid Carcinoma in Parotid**
+*Axial T1 C+ FS MR shows an aggressive-appearing enhancing left parotid mucoepidermoid carcinoma that involves both the superficial and the deep lobes. Note the spread into the lower portion of the stylomastoid foramen .*
+
+
+**Facial Nerve Venous Malformation (Hemangioma)**
+*Axial bone CT reveals a venous malformation enlarging the geniculate fossa . Note the central tumor matrix calcifications.*
+
+
+**Langerhans Histiocytosis in T-Bone**
+*Axial bone CT demonstrates a lesion of the right temporal bone eroding the bones of the petrous apex and middle ear . The lateral wall of the middle ear/mastoid is absent with periauricular soft tissue mass visible.*
+
+
+**Rhabdomyosarcoma in T-Bone**
+*Axial T1 C+ FS MR shows a very large skull base and temporal bone rhabdomyosarcoma. The inner ear bony otic capsule appears to be "floating" in the tumor .*
+
+
+**Facial Nerve Schwannoma in CPA-IAC**
+*Axial T1 C+ MR shows an enhancing tumor of the CPA and IAC . This tumor can be correctly identified as a facial nerve schwannoma because of the "labyrinthine tail" of enhancement of the facial nerve .*
+
diff --git a/docs_md/articles/peritoneal-cavity_6691f48d-ac34-477b-8ec1-b9dd731a14a8.md b/docs_md/articles/peritoneal-cavity_6691f48d-ac34-477b-8ec1-b9dd731a14a8.md
new file mode 100644
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--- /dev/null
+++ b/docs_md/articles/peritoneal-cavity_6691f48d-ac34-477b-8ec1-b9dd731a14a8.md
@@ -0,0 +1,342 @@
+---
+title: "Peritoneal Cavity"
+docid: "6691f48d-ac34-477b-8ec1-b9dd731a14a8"
+authors:
+ - key: "6c5a9e0e-9dea-461b-9ad4-c00f5c4c2bbf"
+ value: "Atif Zaheer, MD, FSAR"
+ - key: "c1df94ab-4a9f-44c4-add7-1f174fb9ac45"
+ value: "Siva P. Raman, MD"
+ - key: "e987d3d3-1206-48d6-824b-3347c2968855"
+ value: "Michael P. Federle, MD, FACR"
+breadcrumbs:
+ -
+ name: "Gastrointestinal"
+ slug: "gastrointestinal"
+ treeNodeId: "b52263f7-5978-4a22-a17d-7260e0033943"
+ -
+ name: "Anatomy"
+ slug: "anatomy"
+ treeNodeId: "45ec4b9f-2862-478f-9f5a-0c2f0a315260"
+ -
+ name: "Gastrointestinal Tract and Abdominal Cavity"
+ slug: "gastrointestinal-tract-and-abdomin-"
+ treeNodeId: "5f5bff76-fdba-4fb0-8102-ba9244cb7d22"
+ -
+ name: "Peritoneal Cavity"
+ slug: "peritoneal-cavity"
+ treeNodeId: null
+category: "Gastrointestinal"
+documentVersionId: "33627bb0-2a6c-4165-a20e-5c1741b04b32"
+imageCount: 53
+lastUpdated: "07/06/23"
+pageDescription: "Peritoneal Cavity"
+pageKeywords: "Gastrointestinal, Anatomy, Gastrointestinal Tract and Abdominal Cavity, Peritoneal Cavity"
+pageTitle: "Peritoneal Cavity | STATdx"
+enhancedTitle: "Peritoneal Cavity"
+type: "ANATOMY"
+breadcrumbs:
+ - "Gastrointestinal"
+ - "Anatomy"
+ - "Gastrointestinal Tract and Abdominal Cavity"
+ - "Peritoneal Cavity"
+---
+# TERMINOLOGY
+
+- ## Definitions
+
+
+ - **Peritoneal cavity**: Potential space in abdomen between visceral and parietal peritoneum, containing only small amount of peritoneal fluid (for lubrication)
+ - **Abdominal cavity**: Not synonymous with peritoneal cavity, contains all intraperitoneal and retroperitoneal abdominal viscera
+
+# GROSS ANATOMY
+
+- ## Peritoneum
+
+
+ - Thin serous membrane consisting of single layer of squamous epithelium (**mesothelium**) and 2 discrete continuous layers (parietal and visceral peritoneum)
+ - **Parietal peritoneum** lines inner aspect of abdominal wall
+ - Shares somatic nervous supply with adjacent abdominal wall and is pain sensitive (with sharp localization)
+ - **Visceral peritoneum** (**serosa**) lines and covers abdominal organs
+ - Shares nervous supply with viscera and is therefore sensitive to pain due to stretching of bowel or mesentery (with poor localization)
+ - Pain due to stretching or irritation of visceral peritoneum may be referred to skin dermatomes
+- ## Divisions of Peritoneal Cavity
+
+
+ - **Greater sac**of peritoneal cavity: Largest portion of peritoneal cavity ("proper" peritoneal cavity), which is outside lesser sac
+ - **Lesser****sac** (a.k.a. **omental bursa**)
+ - Communicates with greater sac via **epiploic foramen** (of**Winslow**, site of most common type of lesser sac hernia)
+ - Bounded: Anteriorly: Caudate lobe, stomach, and greater omentum; posteriorly: Pancreas, left adrenal, and kidney; left: **Splenorenal** and **gastrosplenic ligaments**; right: Epiploic foramen and lesser omentum
+- ## Mesentery
+
+
+ - Double layer of visceral peritoneum that encloses organ and connects it to abdominal wall
+ - Covered on both sides by mesothelium and has core of loose connective tissue and fat, which encloses lymph nodes, blood vessels, and nerves passing to and from viscera
+ - Most mobile parts of intestine have mesentery, while ascending and descending colon are considered retroperitoneal (covered only by peritoneum on their anterior surface)
+ - **Root of mesentery** is its attached border with posterior abdominal wall
+ - Root of small bowel mesentery is ~ 15 cm in length and passes from left side of L2 vertebra downward and to right
+ - Contains **superior mesenteric artery and vein**, nerves, and lymphatics
+ - **Transverse mesocolon**crosses almost horizontally in front of pancreas, duodenum, and right kidney
+- ## Omentum
+
+
+ - Multilayered fold of peritoneum that extends from stomach and proximal duodenum to adjacent organs
+ - **Lesser omentum** joins lesser curve of stomach and proximal duodenum to liver
+ - Consists of 2 components: **Hepatogastric** and **hepatoduodenal** **ligaments**
+ - Hepatoduodenal ligament contains **common bile duct**, **hepatic artery**, and**portal vein**
+ - Hepatogastric ligament contains **right and left gastric arteries**
+ - **Greater omentum**is 4-layered fold of peritoneum hanging from greater curve of stomach, similar to apron, covering transverse colon and much of small intestine
+ - Contains variable amounts of fat and abundant lymph nodes
+ - Mobile and can fill gaps between viscera as well as act as barrier to generalized spread of intraperitoneal infection or tumor ("**abdominal policeman**")
+- ## Peritoneal Ligaments
+
+
+ - All double-layered folds of peritoneum other than mesentery and omentum are referred to as peritoneal ligaments
+ - Connect one viscus to another (e.g., **splenorenal ligament**) or viscus to abdominal wall (e.g., **falciform ligament**)
+ - Contain blood vessels or remnants of fetal vessels
+- ## Peritoneal Folds
+
+
+ - Reflections of peritoneum with defined borders, often lifting peritoneum off abdominal wall (e.g., **median umbilical fold**covers **urachus** and extends from dome of urinary bladder to umbilicus)
+- ## Peritoneal Recesses
+
+
+ - Dependent pouches formed by reflections of peritoneum
+ - Because of clinical relevance, often have eponyms [e.g., **Morison pouch** for **posterior subhepatic**(**hepatorenal**)**recess**; **pouch of Douglas** for **rectouterine recess**]
+
+# ANATOMY IMAGING ISSUES
+
+- ## Imaging Pitfalls
+
+
+ - Peritoneal cavity and its various mesenteries and recesses are usually not apparent on imaging studies unless distended or outlined by intraperitoneal fluid or air
+ - Internal herniation of abdominal viscera within confines of peritoneal cavity may be difficult to diagnose
+
+# CLINICAL IMPLICATIONS
+
+- ## Clinical Importance
+
+
+ - Peritoneum that is evident on imaging is **thickened** due to inflammation or tumor
+ - Nodular thickening is usually due to malignancy, whereas smooth, regular thickening of peritoneum can be seen either as result of infectious/inflammatory peritonitis or early tumoral involvement
+ - Peritoneal recesses are common sites for accumulation of peritoneal fluid (ascites), pus, or peritoneal tumor**** implants
+ - Recesses all potentially communicate with each other but become functionally isolated by processes that cause adherence between layers of peritoneum (e.g., abscess)
+ - **Phrenicocolic ligament** limits spread of fluid from left subphrenic space to left paracolic gutter
+
+ 578f37cd-93e6-484d-8549-2b05447b6c1b
+
+
+## Images
+
+
+### Lateral View of Mesenteries and Peritoneal Cavity
+
+
+*Sagittal graphic of the abdomen shows the peritoneal cavity artificially distended with air. Note the margins of the lesser sac in this plane, including the caudate lobe of the liver superiorly, stomach and gastrocolic ligament anteriorly, and pancreas posteriorly. The hepatogastric ligament is part of the lesser omentum and carries the hepatic artery and portal vein to the liver. The mesenteries are multilayered folds of peritoneum that enclose a layer of fat and convey blood vessels, nerves, and lymphatics to the intraperitoneal abdominal viscera. The greater omentum is a 4-layered fold of peritoneum that extends down from the stomach, covering much of the colon and small bowel. The layers are generally fused together caudal to the transverse colon. The gastrocolic ligament is part of the greater omentum.*
+
+
+### Lesser Sac and Peritoneal Recesses
+
+
+*The lesser sac (omental bursa) is bordered anteriorly to the right by the lesser omentum, which conveys the common bile duct, hepatic artery, portal vein, and gastric vessels. The left borders include the gastrosplenic ligament (with short gastric vessels) and the splenorenal ligament (with splenic vessels).*
+
+
+*The paracolic gutters are formed by reflections of peritoneum covering the ascending and descending colon and the lateral abdominal wall. Note the innumerable potential peritoneal recesses lying between the bowel loops and their mesenteric leaves.*
+
+
+### Omentum and Peritoneal Reflections
+
+
+*The liver has been retracted upward in this graphic, revealing the lesser omentum. The lesser omentum, which is composed of the hepatoduodenal and hepatogastric ligaments, forms part of the anterior wall of the lesser sac and conveys the common bile duct, hepatic artery, portal vein, and gastric arteries. The aorta and celiac artery can be seen through the lesser omentum, as they lie just posterior to the lesser sac. The greater omentum is seen on this graphic as a large fatty apron extending from the stomach downward along the anterior abdomen.*
+
+
+*Frontal graphic shows the abdomen with all of the intraperitoneal organs removed. The root of the transverse mesocolon divides the peritoneal cavity into supramesocolic and inframesocolic spaces that communicate only along the paracolic gutters. The coronary and triangular ligaments suspend the liver from the diaphragm. The superior mesenteric vessels traverse the small bowel mesentery whose root crosses obliquely from the upper left to the lower right posterior abdominal wall.*
+
+
+### Peritoneal Spaces and Reflections
+
+
+*First of 4 axial CECT images of a middle-aged man with cirrhosis with delineation of the peritoneal spaces and reflections is shown. Ascites distends the peritoneal cavity in these images, allowing visualization of recesses and peritoneal reflections, which are not normally seen.*
+
+
+*The lesser and greater sacs of the peritoneal cavity are distended with ascites. The gastrosplenic ligament and pancreas border the lesser sac, as does the lesser omentum, whose position is marked by the portal vein and celiac trunk.*
+
+
+*The falciform ligament suspends the liver from the anterior abdominal wall. The greater omentum lies between the bowel and the anterior abdominal wall.*
+
+
+*The intraperitoneal organs, such as the liver, transverse colon, and small bowel, are suspended within the ascites, while the position of the retroperitoneal organs, such as the kidneys and pancreas, is unaffected by the ascites.*
+
+
+### Peritoneal Spaces and Mesenteries
+
+
+*First of 4 axial CECT images shows a middle-aged man with cirrhosis and ascites delineating the peritoneal spaces and mesenteries. The liver is suspended from the anterior abdominal wall by the falciform ligament and from the diaphragm by the coronary ligament, between the leaves of which lies the bare area of the liver. Notice that there is no ascites contacting the liver at this bare area of the liver.*
+
+
+*The lesser omentum and gastrosplenic ligament compose 2 of the walls of the lesser sac. The lesser omentum is marked by the portal vein and hepatic artery in this image.*
+
+
+*The mesenteries are easily identified by their internal fat content and blood vessels. Retroperitoneal organs, such as the pancreas and kidneys, remain in normal position surrounded by retroperitoneal fat that conveys their blood supply.*
+
+
+*Note the retroperitoneal position of the duodenum. The 3rd portion of the duodenum crosses behind the superior mesenteric vessels, which supply the small bowel. The branches of the mesenteric vessels lie within the leaves of the mesentery, surrounded by fat.*
+
+
+### Distended Peritoneal Cavity
+
+
+*First of 6 axial CECT images of an older man with renal failure treated with peritoneal dialysis is shown. Contrast medium was added to the dialysate to identify potential sites of loculated fluid and accounts for the dense appearance of the fluid. Note the intraperitoneal fluid collecting in the subphrenic spaces.*
+
+
+*Note how the diaphragm suspends the liver and spleen away from the chest wall. The bare area of the liver is in direct contact with the diaphragm but not with the peritoneal cavity, and, accordingly, lavage fluid is not in contact with the bare area.*
+
+
+*Fluid invaginates into the fissure for the falciform ligament. Note that there is no fluid within the lesser sac. As a general rule, unless the ascites is tense or of a "local" source (such as a perforated gastric ulcer or pancreatitis), it remains confined to the greater peritoneal cavity and does not pass through the epiploic foramen. The greater omentum "floats" on top of the ascites and is normally of fat density with small internal vessels.*
+
+
+*The peritoneal fluid is mostly confined to the paracolic gutters at this level.*
+
+
+*The peritoneal fluid is somewhat loculated in this patient, typical in the setting of chronic peritoneal dialysis, which results in inflammation and scarring of the peritoneum over time. Note the transplanted kidney in the left iliac fossa, which had stopped functioning due to rejection.*
+
+
+*The most dependent recess of the peritoneal cavity is in the pelvis, which is distended by dialysis fluid in this patient.*
+
+
+### Peritoneal Mesenteries
+
+
+*Axial CECT in a patient with ascites due to cirrhosis nicely demonstrates the small bowel mesentery. The leaves of the small bowel mesentery are separated and accentuated by the ascites. Each leaf of the mesentery carries blood vessels, nerves, and lymphatics to a bowel segment.*
+
+
+*Coronal CECT demonstrates the normal appearance of the mesentery. This image nicely demonstrates the small vessels carried by the mesentery to the small bowel.*
+
+
+*Axial CECT demonstrates the sigmoid colon and its mesentery well defined by the adjacent ascites.*
+
+
+### Peritoneal Recesses (Morison and Douglas)
+
+
+*The most dependent peritoneal recess in the upper abdomen is the hepatorenal recess, also known as the posterior subhepatic space and Morison pouch. It communicates superiorly with the right subphrenic space and inferiorly with the right paracolic gutter.*
+
+
+*The pouch of Douglas, also known as the rectouterine recess, is the most dependent recess of the entire peritoneal cavity in either the upright or supine position and is a common site for inflammatory, neoplastic, or traumatic fluid collections.*
+
+
+### Lesser Sac (Omental Bursa)
+
+
+*First of 3 axial CECT images focusing on the lesser sac is shown. The gastrosplenic ligament connects the stomach to the spleen and carries the short gastric vessels. Abdominal "ligaments" are double-layered folds of peritoneum that connect one viscus to another. They contain fat and transmit vessels, nerves, and lymphatics between the retroperitoneum and the abdominal viscera.*
+
+
+*The gastrosplenic and splenorenal ligaments form the left anterior and posterior walls of the lesser sac, respectively.*
+
+
+*Note the structures abutting the lesser sac, including the stomach anteriorly and the pancreas posteriorly.*
+
+
+### Umbilical Ligaments, Delineated by Ascites
+
+
+*First of 3 axial CECT images focuses on the umbilical ligaments. Ascites outlines the sigmoid mesocolon and small bowel loops in this image.*
+
+
+*The umbilical ligaments are outlined by ascites in this more caudal image. These are the remnants of the fetal umbilical arteries that had connected the internal iliac arteries to the umbilical cord. The peritoneal reflections covering these ligaments are the lateral umbilical folds.*
+
+
+*The ascites is not loculated in this patient, but normal structures, such as the umbilical ligaments and the wall of the urinary bladder, may be mistaken for septations within the fluid collection.*
+
+
+### Umbilical Folds (Ligaments)
+
+
+*Sagittal T1 C+ FS MR of the pelvis shows a linear structure extending from the umbilicus to the dome of the urinary bladder, representing the urachus (median umbilical ligament). This is the fibrous remnant of the allantois and should be completely obliterated after birth. In some individuals, parts of the tract may remain patent leading to a urachal diverticulum or a urachal cyst, as in this patient.*
+
+
+*The median and lateral umbilical ligaments are evident in this patient on this axial T1 C+ FS MR. Recall that these ligaments are covered with peritoneal reflections called the median and lateral umbilical folds, respectively.*
+
+
+*The urachal cyst is evident within the median umbilical fold. The enhancement around the cyst indicates inflammation (infection) of the cyst, which ultimately brought the patient to clinical attention.*
+
+
+### Peritonitis With Loculated Ascites
+
+
+*Axial T1 C+ FS MR in a patient with perforated appendicitis demonstrates findings of peritonitis with extensive thickening and enhancement of the peritoneum with large loculated ascites and fluid collections. The peritoneal lining should not be visible in normal patients and is typically only visible when thickened by infection, inflammation, or tumor.*
+
+
+*Axial CECT in a septic patient after surgery demonstrates prominent peritoneal enhancement and thickening with an associated loculated fluid collection along the margin of the liver.*
+
+
+*Axial CECT in the same patient demonstrates multiple loculated intraperitoneal fluid collections throughout the abdomen and pelvis, including 2 large collections extending down the paracolic gutters. The peritoneum adjacent to the these collections is thickened and enhancing. This constellation of findings is typical for peritonitis with abscess formation.*
+
+
+### Peritoneal Reflections
+
+
+*Sagittal T2 MR shows the peritoneal reflection. In men, the apex of the seminal vesicle serves as a landmark to identify the peritoneal reflection. The identification of rectal cancer in relation to the peritoneal reflection is important, as the tumor is staged as T4a when it involves the peritoneal reflection.*
+
+
+*Sagittal T2 MR shows the peritoneal reflection. In women, the equivalent to the seminal vesicles is the cervix.*
+
+
+### Fibrosing Peritonitis Due to Peritoneal Dialysis
+
+
+*Axial CECT in a patient undergoing chronic peritoneal dialysis demonstrates large ascites with extensive calcification and thickening of the peritoneal lining. The small bowel is clumped together in a "cocoon" of thickened visceral peritoneum (serosa) that compresses the bowel loops together. This is a classic example of fibrosing peritonitis, most often seen in the setting of chronic peritoneal dialysis.*
+
+
+*Axial CECT in the same patient demonstrates more extensive calcification surrounding the small bowel. The small bowel is clustered in the central abdomen, often described as an abdominal "cocoon" in this disorder.*
+
+
+*Abdominal radiograph taken 2 hours after ingestion of barium shows slow transit of the barium and dilated small bowel. The small bowel loops are also crowded together and fixed in position instead of being freely mobile on their mesentery, as is normal. This is an example of severe fibrosing peritonitis, a rare complication of peritoneal dialysis.*
+
+
+### Peritoneal Carcinomatosis
+
+
+*First of 2 axial CECT images of a middle-aged woman with ovarian carcinoma is shown. Subtle soft tissue density nodules are present in the omental fat overlying the colon and small bowel. These are characteristic of peritoneal tumor deposits (i.e., peritoneal carcinomatosis).*
+
+
+*The nodular tumor deposits in the omentum are more evident on this axial CECT. Peritoneal spread of tumor is often, but not always, accompanied by malignant ascites, which is absent in this case.*
+
+
+*Axial CECT in a patient with peritoneal carcinomatosis demonstrates nodular soft tissue density tumor implants present within the lesser sac and along the parietal peritoneum. A mass of tumor is noted in the omentum, a so-called omental cake. Note the presence of loculated fluid within the lesser sac. Loculated ascites is most often caused by adhesions (usually from prior surgery), peritonitis, or peritoneal carcinomatosis.*
+
+
+### Peritoneal Carcinomatosis
+
+
+*Axial CECT in a patient with colon cancer demonstrates the classic findings of peritoneal carcinomatosis, including thickening and enhancement of the peritoneum, a "pleated" thickened mesentery due to tumor infiltration, and frank omental caking with tumor.*
+
+
+*Axial T2 FS MR demonstrates extensive tumor cake throughout the omentum, which in this case is relatively T2 isointense to the bowel. Note the presence of adjacent ascites, which should always prompt a careful search for carcinomatosis in any cancer patient.*
+
+
+*Axial T1 C+ FS MR in the same patient demonstrates enhancing tumor throughout the omentum, as well as thickening of the mesentery, in this patient with extensive carcinomatosis.*
+
+
+### Peritoneal Disease
+
+
+*MR of the left upper quadrant region in this patient with laparoscopic distal pancreatectomy and splenectomy for pancreatic tail ductal adenocarcinoma shows an omental infarct as an area of heterogeneity on T2 with absence of enhancement on T1 C+ imaging. The laparoscopic approach to entering the lesser sac during surgery involves dividing the anterior leaf of the greater omentum to avoid thermal injury to the colon. This approach results in the division of the short gastric arteries and the removal of only the portion of the omentum that loses its blood supply. In contrast, the classic open technique involves dividing the greater omentum along an avascular margin.*
+
+
+*CT example of an omental infarct in a patient with distal pancreatectomy is shown. Note mixed areas of soft tissue and fat attenuation.*
+
+
+*Patient from India with tuberculosis peritonitis is shown. The history and the clinical picture are the key to differentiate from carcinomatosis.*
+
+
+### Pseudomyxoma Peritonei
+
+
+*Axial CECT demonstrates the classic appearance of pseudomyxoma peritonei in which peritoneal metastases from a mucin-secreting appendiceal tumor result in profuse accumulation of gelatinous material within the peritoneal cavity. The loculations and quantity of the material produce the typical mass effect, or indentations, on abdominal viscera and often result in bowel obstruction.*
+
+
+*Axial CECT in the same patient demonstrates the complex, septated appearance of the "ascites," which is actually semisolid gelatinous material. The implants are seen throughout the peritoneal cavity, including implants extending along the surface of the liver, omentum, and paracolic gutters. Note that the kidneys are unaffected due to their retroperitoneal location.*
+
+
+*Coronal CECT with volume-rendered reconstruction demonstrates the classic "scalloping" of the liver surface by mucinous implants along with extensive implants elsewhere in the peritoneal cavity in this patient with pseudomyxoma peritonei.*
+
diff --git a/docs_md/articles/peritoneal-spaces-and-structures_9c50ad6a-e96b-44a1-93d1-a4e7de5212c2.md b/docs_md/articles/peritoneal-spaces-and-structures_9c50ad6a-e96b-44a1-93d1-a4e7de5212c2.md
new file mode 100644
index 0000000..c862431
--- /dev/null
+++ b/docs_md/articles/peritoneal-spaces-and-structures_9c50ad6a-e96b-44a1-93d1-a4e7de5212c2.md
@@ -0,0 +1,213 @@
+---
+title: "Peritoneal Spaces and Structures"
+docid: "9c50ad6a-e96b-44a1-93d1-a4e7de5212c2"
+authors:
+ - key: "07469ec4-05aa-4d65-a788-08b4d64048af"
+ value: "Jade Wong-You-Cheong, MBChB, MRCP, FRCR, FSRU, FSAR"
+breadcrumbs:
+ -
+ name: "Ultrasound"
+ slug: "ultrasound"
+ treeNodeId: "e7cdfeb1-bb55-4cca-9854-46cadee515d2"
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+ name: "Anatomy"
+ slug: "anatomy"
+ treeNodeId: "d4765014-54f9-4477-8c9c-4b2ae0b82f24"
+ -
+ name: "Abdomen"
+ slug: "abdomen"
+ treeNodeId: "1e981810-ddca-4af9-82b9-38d5fdecad76"
+ -
+ name: "Peritoneal Spaces and Structures"
+ slug: "peritoneal-spaces-and-structures"
+ treeNodeId: null
+category: "Ultrasound"
+documentVersionId: "8c87a1a2-008f-4d2b-a0a8-57d919e883c3"
+imageCount: 19
+lastUpdated: "06/01/21"
+pageDescription: "Peritoneal Spaces and Structures"
+pageKeywords: "Ultrasound, Anatomy, Abdomen, Peritoneal Spaces and Structures"
+pageTitle: "Peritoneal Spaces and Structures | STATdx"
+enhancedTitle: "Peritoneal Spaces and Structures"
+type: "ANATOMY"
+references: true
+breadcrumbs:
+ - "Ultrasound"
+ - "Anatomy"
+ - "Abdomen"
+ - "Peritoneal Spaces and Structures"
+---
+# TERMINOLOGY
+
+- ## Definitions
+
+
+ - Peritoneal cavity: Potential space in abdomen between visceral and parietal peritoneum, usually containing only small amount of peritoneal fluid (for lubrication)
+ - Abdominal cavity: Not synonymous with peritoneal cavity
+ - Limited by abdominal wall muscles, diaphragm, and (arbitrarily) by pelvic brim
+ - Peritoneum divides peritoneal cavity from subperitoneal space, which contains all abdominal viscera, ligaments, and mesenteries
+
+# GROSS ANATOMY
+
+- ## Divisions
+
+
+ - Greater sac of peritoneal cavity
+ - Lesser sac (omental bursa)
+ - Communicates with greater sac via epiploic foramen (of Winslow)
+ - Bounded anteriorly by caudate lobe, stomach, and greater omentum; posteriorly by pancreas, left adrenal, and kidney; on left by splenorenal and gastrosplenic ligaments; on right by epiploic foramen and lesser omentum
+- ## Compartments Divided by Transverse Mesocolon
+
+
+ - Supramesocolic space
+ - Divided into right and left supramesocolic spaces, which are separated by falciform ligament
+ - Right supramesocolic space: Includes right subphrenic space, right subhepatic space, and lesser sac
+ - Left supramesocolic space: Includes left perihepatic spaces (anterior and posterior) and left subphrenic (anterior perigastric and posterior perisplenic)
+ - Inframesocolic compartment
+ - Divided into right inframesocolic space, left inframesocolic space, paracolic gutters, and pelvic cavity
+ - Pelvic cavity is most dependent part of peritoneal cavity in erect and supine positions
+- ## Peritoneum
+
+
+ - Thin serous membrane consisting of single layer of squamous epithelium (mesothelium)
+ - Parietal peritoneum lines abdominal wall
+ - Visceral peritoneum (serosa) lines abdominal organs
+- ## Mesentery
+
+
+ - Double layer of peritoneum that encloses organ and connects it to abdominal wall
+ - Covered on both sides by mesothelium and has core of loose connective tissue containing fat, lymph nodes, blood vessels, and nerves passing to and from viscera
+ - Most mobile parts of intestine have mesentery, while ascending and descending colon are considered retroperitoneal (peritoneum covers only anterior surface)
+ - Root of mesentery is its attachment to posterior abdominal wall
+ - Root of small bowel mesentery is ~ 15 cm in diameter and passes from left side of L2 vertebra downward and to right; contains superior mesenteric vessels, nerves, and lymphatics
+ - Transverse mesocolon crosses almost horizontally in front of pancreas, duodenum, and right kidney
+- ## Omentum
+
+
+ - Multilayered fold of peritoneum that extends from stomach to adjacent organs
+ - Lesser omentum joins lesser curve of stomach and proximal duodenum to liver
+ - Hepatogastric and hepatoduodenal ligament components contain common bile duct, hepatic and gastric vessels, and portal vein
+ - Greater omentum
+ - 4-layered fold of peritoneum hanging from greater curve of stomach like apron, covering transverse colon and much of small intestine, containing variable amounts of fat and abundant lymph nodes
+ - Mobile, filling gaps between viscera, acting as barrier to generalized spread of intraperitoneal infection or tumor
+- ## Ligaments
+
+
+ - All double-layered folds of peritoneum, other than mesentery and omentum, are peritoneal ligaments
+ - Connect 1 viscus to another (e.g., splenorenal ligament) or viscus to abdominal wall (e.g., falciform ligament)
+ - Contain blood vessels or remnants of fetal vessels
+- ## Folds
+
+
+ - Reflections of peritoneum with defined borders, often lifting peritoneum off abdominal wall (e.g., median umbilical fold covers urachus and extends from dome of urinary bladder to umbilicus)
+- ## Peritoneal Recesses
+
+
+ - Dependent pouches formed by peritoneal reflections
+ - Many have eponyms [e.g., Morison pouch for posterior subhepatic (hepatorenal) recess; pouch of Douglas for rectouterine recess]
+
+# ANATOMY IMAGING ISSUES
+
+- ## Imaging Recommendations
+
+
+ - Transducer: Typically 2-5 MHz for abdominal survey and deep recesses, up to 9 MHz for thinner patients
+ - High-frequency linear transducer 8-15 MHz may be used to evaluate anterior abdominal wall and parietal peritoneum
+ - Patient examined supine with additional decubitus positions to determine if fluid collection is free or loculated
+ - Peritoneal cavity and its various mesenteries and recesses are usually not apparent on imaging studies unless distended or outlined by intraperitoneal fluid or air
+ - Focused assessment with sonography for trauma (FAST) point-of-care ultrasound is widely used in acute abdominal trauma and undifferentiated hypotension and shock; right and left supramesocolic spaces and pelvis are scanned for free fluid/acute hemorrhage
+- ## Imaging Pitfalls
+
+
+ - Acute intraperitoneal bleeding is typically anechoic and may be confused with ascites
+
+ 03c66bee-31f2-43af-906d-f0e7f2bcb141
+
+## References
+
+# Selected References
+
+1. [Pannu HK et al: The subperitoneal space and peritoneal cavity: basic concepts. Abdom Imaging. 40(7):2710-22, 2015](http://www.ncbi.nlm.nih.gov/pubmed/?term=26006061%5Bpmid%5D)
+1. [Tirkes T et al: Peritoneal and retroperitoneal anatomy and its relevance for cross-sectional imaging. Radiographics. 32(2):437-51, 2012](http://www.ncbi.nlm.nih.gov/pubmed/?term=22411941%5Bpmid%5D)
+
+
+## Images
+
+
+### Peritoneal Cavity, Divisions, and Compartments
+
+
+*Graphic of a sagittal section of the abdomen shows the peritoneal cavity artificially distended with air. Note the margins of the lesser sac, including the caudate lobe of the liver, stomach, and gastrocolic ligament anteriorly and pancreas posteriorly. The mesenteries convey blood vessels, nerves, and lymphatics to the intraperitoneal abdominal viscera. The greater omentum extends down from the stomach, covering much of the colon and small intestine. The layers are generally fused together caudal to the transverse colon. The gastrocolic ligament is part of the greater omentum.*
+
+
+*Graphic of a sagittal section of the abdomen shows the peritoneal cavity artificially distended with air. Note the margins of the lesser sac, including the caudate lobe of the liver, stomach, and gastrocolic ligament anteriorly and pancreas posteriorly. The mesenteries convey blood vessels, nerves, and lymphatics to the intraperitoneal abdominal viscera. The greater omentum extends down from the stomach, covering much of the colon and small intestine. The layers are generally fused together caudal to the transverse colon. The gastrocolic ligament is part of the greater omentum.*
+
+
+*The borders of the lesser sac (omental bursa) include the lesser omentum, which contains the common bile duct and hepatic and gastric vessels. The left border includes the gastrosplenic ligament (with short gastric vessels) and the splenorenal ligament (with splenic vessels).*
+
+
+*The paracolic gutters are formed by reflections of the peritoneum covering the ascending and descending colon and the lateral abdominal wall. Note the innumerable potential peritoneal recesses lying between the bowel loops and their mesenteric leaves.*
+
+
+### Peritoneal Divisions and Compartments
+
+
+*In this graphic, the liver has been retracted upward. The lesser omentum is comprised of the hepatoduodenal and hepatogastric ligaments. It forms part of the anterior wall of the lesser sac and contains the common bile duct, hepatic and gastric vessels, and the portal vein. The aorta and celiac artery can be seen through the lesser omentum, as they lie just posterior to the lesser sac.*
+
+
+*Frontal view of the abdomen, with all of the intraperitoneal organs removed, shows that the root of the transverse mesocolon divides the peritoneal cavity into supramesocolic and inframesocolic spaces that communicate only along the paracolic gutters. The coronary and triangular ligaments suspend the liver from the diaphragm. The superior mesenteric vessels traverse the small bowel mesentery, whose root crosses obliquely from the upper left to the lower right posterior abdominal wall.*
+
+
+### Right and Left Supramesocolic Spaces and Inframesocolic space
+
+
+*Longitudinal transabdominal grayscale ultrasound shows fluid in the right posterior subhepatic space, also known as the Morison pouch, and hepatorenal fossa. This space is continuous with the right anterior subhepatic space and right paracolic gutter.*
+
+
+*Longitudinal grayscale ultrasound of the left upper quadrant shows a small amount of perisplenic fluid extending under the left hemidiaphragm. The left subphrenic space is separated from the right subphrenic space by the falciform ligament.*
+
+
+*Longitudinal grayscale ultrasound of the female pelvis shows a large amount of free fluid. The uterus divides the pelvic cavity into the vesicouterine and rectouterine (pouch of Douglas) spaces. In this case, the bladder is empty.*
+
+
+### Right and Left Inframesocolic Spaces and Pelvic Cavity
+
+
+*Transverse ultrasound of the right lateral mid abdomen shows simple ascites in the paracolic gutter.*
+
+
+*On this transverse ultrasound through the left lower quadrant, ascites surrounds small bowel.*
+
+
+*Transverse ultrasound of a female pelvis above the level of the bladder shows ascitic fluid encircling the uterus.*
+
+
+### Right Supramesocolic Space: Lesser Sac
+
+
+*Subxiphoid transverse grayscale ultrasound shows a fluid collection in the lesser sac, which extends to the left behind the stomach and anterior to the pancreas. The lesser sac is part of the right supramesocolic space and communicates with the rest of the peritoneal cavity through the epiploic foramen (of Winslow).*
+
+
+*Subxiphoid transverse color Doppler ultrasound of the same patient shows moderate fluid in the lesser sac posterior to the stomach. The splenic vein was dilated in this patient with portal hypertension status post liver transplant.*
+
+
+*Axial CECT of the same patient shows fluid in the lesser sac and peritoneal cavity as well as diffuse anasarca.*
+
+
+### Additional Images
+
+
+*Intercostal oblique grayscale ultrasound (in a patient with cirrhosis) shows the dome of the right lobe of the liver and moderate fluid in the right subphrenic region extending anterior to the liver. The fluid is separated from the right-sided pleural effusion by the right diaphragmatic leaf.*
+
+
+*Subcostal oblique transverse ultrasound of the right upper quadrant shows fluid in the right anterior subhepatic space and in the hepatorenal space. The ascites are secondary to hepatic cirrhosis and the gallbladder is physiologically distended.*
+
+
+*Subxiphoid transverse grayscale ultrasound shows fluid anterior to the left lobe of the liver that is localized to the left posterior subhepatic space. Incidental calculi are seen within a dilated intrahepatic biliary duct.*
+
+
+*Longitudinal ultrasound of the midline suprapubic region in a male patient demonstrates intraperitoneal fluid between bowel loops and extending into the dependent rectovesical pouch. There is a distended urinary bladder.*
+
+
+*Transverse transabdominal ultrasound of the central abdomen reveals moderate to large ascites with floating small bowel loops. The left inframesocolic space is larger compared to the right and communicates directly with the pelvic cavity.*
+
diff --git a/docs_md/articles/pheochromocytoma_1bfc887d-4686-445b-a0d2-f3b380a0da3a.md b/docs_md/articles/pheochromocytoma_1bfc887d-4686-445b-a0d2-f3b380a0da3a.md
new file mode 100644
index 0000000..d953df8
--- /dev/null
+++ b/docs_md/articles/pheochromocytoma_1bfc887d-4686-445b-a0d2-f3b380a0da3a.md
@@ -0,0 +1,388 @@
+---
+title: "Pheochromocytoma"
+docid: "1bfc887d-4686-445b-a0d2-f3b380a0da3a"
+authors:
+ - key: "7e25292c-4d6a-4f35-98b2-1877e5989352"
+ value: "Ashish P. Wasnik, MD, FSAR"
+breadcrumbs:
+ -
+ name: "Ultrasound"
+ slug: "ultrasound"
+ treeNodeId: "e7cdfeb1-bb55-4cca-9854-46cadee515d2"
+ -
+ name: "Diagnosis"
+ slug: "diagnosis"
+ treeNodeId: "594506fe-1241-4d01-9b37-a9d64f0c98c4"
+ -
+ name: "Adrenal Gland"
+ slug: "adrenal-gland"
+ treeNodeId: "bdbaa036-5505-43ee-94e1-5a2ece43da0f"
+ -
+ name: "Pheochromocytoma"
+ slug: "pheochromocytoma"
+ treeNodeId: null
+category: "Ultrasound"
+cmeTopicId: "294ea24b-7fbc-4cf4-89d4-e53caacbe2e6"
+documentVersionId: "84b213c9-8864-4424-b1e5-b6a46d8489bc"
+imageCount: 16
+lastUpdated: "07/01/21"
+pageDescription: "Pheochromocytoma"
+pageKeywords: "Ultrasound, Diagnosis, Adrenal Gland, Pheochromocytoma"
+pageTitle: "Pheochromocytoma | STATdx"
+enhancedTitle: "Pheochromocytoma"
+type: "DX"
+references: true
+breadcrumbs:
+ - "Ultrasound"
+ - "Diagnosis"
+ - "Adrenal Gland"
+ - "Pheochromocytoma"
+---
+# KEY FACTS
+
+- ## Terminology
+
+
+ - Rare catecholamine-secreting tumor arising from chromaffin cells of adrenal medulla
+ - Termed **paraganglioma** if extraadrenal
+- ## Imaging
+
+
+ - Best diagnostic clue
+ - Adrenal mass in setting of clinical symptoms or biochemical abnormality
+ - Paroxysmal headache, palpitations, sweating
+ - ↑ levels of 24-hour urine-fractionated metanephrines
+ - "**Imaging chameleon**": Variable US/CT/MR appearance; mimics other lesions
+ - Commonly solid and hypervascular ± cystic change, necrosis, and calcification
+ - Can be purely cystic
+ - **1st line**: CT or MR
+ - **US**: Comparable to CT in detecting adrenal tumors; limited for extraadrenal disease
+ - **I-123 MIBG**: For extraadrenal, metastatic, or recurrent disease
+- ## Top Differential Diagnoses
+
+
+ - Adrenal adenoma
+ - Adrenal metastases or lymphoma
+ - Adrenocortical carcinoma
+ - Adrenal neuroblastoma
+ - Adrenal granulomatous infection
+- ## Diagnostic Checklist
+
+
+ - Remembered as "**r****ule of 10s**"
+ - 10% extraadrenal (paraganglioma)
+ - 10% bilateral (suggest hereditary disease)
+ - 10% pediatric (suggest hereditary disease)
+ - 10% contain calcification
+ - 10% malignant (↑ extraadrenal cases)
+ - 25% familial (previously thought to be 10%)
+
+# TERMINOLOGY
+
+- ## Definitions
+
+
+ - Paraganglioma: Neuroendocrine tumor arising from paraganglia anywhere in sympathetic chain
+ - Pheochromocytoma: Adrenal medullary paraganglioma arising from catecholamine-secreting chromaffin cells of adrenal medulla
+
+# IMAGING
+
+- ## General Features
+
+
+ - ### Best diagnostic clue
+
+
+ - Adrenal mass in setting of clinical symptoms or biochemical abnormality
+ - ### Location
+
+
+ - Paragangliomas can occur along sympathetic chain from neck to urinary bladder
+ - Majority are subdiaphragmatic (98%)
+ - Adrenal (90%)
+ - Extraadrenal (10%)
+ - Organ of Zuckerkandl, 2.5% [from superior mesenteric artery (SMA) to aortic bifurcation, mostly around inferior mesenteric artery]
+ - Urinary bladder sympathetic chain, 1%
+ - Typically unilateral
+ - Bilateral: Commonly with hereditary conditions
+ - ### Size
+
+
+ - Variable: Typically 3-5 cm (can be up to 15 cm)
+ - ### Morphology
+
+
+ - Well-circumscribed, encapsulated tumor
+ - Variable size and appearance on morphology and imaging renders name "chameleon tumors"
+ - Commonly solid and hypervascular ± cystic change, necrosis, and calcification
+ - Can be purely cystic
+ - Pheochromocytomas and paragangliomas demonstrate similar imaging features but vary in location
+- ## Ultrasonographic Findings
+
+
+ - ### Grayscale ultrasound
+
+
+ - Variable appearance: Solid (75%) > solid/cystic or cystic
+ - Iso-/hypoechoic (75%) or hyperechoic (25%) to renal cortex
+ - Small tumors: Solid, well-circumscribed; uniform echoes → can be poorly delineated due to obscuration from overlying bowel gas
+ - Large tumors: Solid, heterogeneous, or homogeneous echotexture
+ - Heterogeneity due to necrosis (hypoechoic) and hemorrhage (hyperechoic)
+ - Can be predominantly cystic due to chronic hemorrhage and necrotic debris (fluid-fluid level)
+ - Always evaluate bladder wall, renal hilum, and organ of Zuckerkandl at origin of inferior mesenteric artery (CT more sensitive)
+ - ### Color Doppler
+
+
+ - Hypervascular ± heterogeneous
+ - Compression/invasion of inferior vena cava (IVC)/renal vein
+ - Seen with both benign and malignant tumors
+- ## CT Findings
+
+
+ - **NECT**: Well-defined mass with low soft tissue attenuation
+ - Generally attenuation > 10 HU; however, rarely intracellular fat may result in lower attenuation → posing challenge to differentiate from adenoma
+ - ± ↑ density (hemorrhage), ↓ density (cystic degeneration; necrosis), calcification (rare; 10%)
+ - **CECT**: Marked enhancement; may be heterogeneous due to hemorrhage/necrosis
+ - Variable washout characteristics: Can show rapid washout that mimics adenoma
+ - No convincing evidence that IV injection of iodinated contrast precipitates hypertensive crisis
+- ## MR Findings
+
+
+ - **T1WI**: **Isointense** to muscle and hypointense to liver
+ - Variable signal intensity if necrosis/hemorrhage present
+ - Rarely, contain microscopic fat on chemical shift imaging, mimicking adenoma
+ - **T2WI**: T2 hyperintense due to ↑ water content (cystic/liquefactive necrosis)
+ - Classic light bulb appearance of marked T2-bright signal intensity (SI), variably (present in up to 2/3)
+ - 35% have low T2 SI (isointense to spleen)
+ - Most common: Heterogeneously enhancing lesion with multiple high-SI pockets
+ - **T1WI C+**: Characteristic **salt and pepper** pattern
+ - **Salt** (enhancing parenchyma); **pepper** (↑ vascular flow voids due to hypervascular tumor)
+- ## Nuclear Medicine Findings
+
+
+ - **1st line**: I-123 metaiodobenzylguanidine (**MIBG**)
+ - Norepinephrine analog
+ - After 24-72 hours: ↑ uptake of I-123 MIBG in tumor
+ - Useful for extraadrenal, metastatic, recurrent disease
+ - Sensitivity (77-90%); specificity (95-100%)
+ - 2nd line: 111In-pentetreotide FDG PET
+ - F-18 fluorodopamine, F-18 dihydroxyphenylalanine (DOPA) analogs
+- ## Imaging Recommendations
+
+
+ - ### Best imaging tool
+
+
+ - **NE + CECT**: Overall 93-100% sensitive; however, up to 40% of extraadrenal lesions may be missed on CT
+ - **I-123 MIBG**: Superior detection of extraadrenal, metastatic, &/or recurrent disease
+ - US limited for smaller adrenal tumors; poor sensitivity for extraadrenal lesions
+ - ### Protocol advice
+
+
+ - Include aortic bifurcation in CT/MR FOV to evaluate for paragangliomas (along sympathetic chain)
+
+# DIFFERENTIAL DIAGNOSIS
+
+- [Adrenal Adenoma](/document/adrenal-adenoma/25bd0538-d37f-4bd1-9eb3-094d625723a5)
+ - Most common benign adrenal lesion
+ - Pheochromocytomas tend to be larger than adenomas
+ - Cystic and rare microscopic fat-containing pheochromocytomas may also be hypodense on NECT
+ - Adenoma: Characteristic CT washout and MR signal dropout (majority)
+- ## Adrenal Metastases
+
+
+ - Most common malignant adrenal neoplasm (up to 25%)
+ - Typically bilateral; delayed contrast washout
+- [Adrenal Lymphoma](/document/adrenal-lymphoma/44639c90-bd04-4e2a-a470-2c28a0e2ff78)
+ - Large infiltrative, bilateral masses; maintain adrenal contour
+ - 25% secondary to non-Hodgkin lymphoma; primary is rare
+- ## Adrenocortical Carcinoma
+
+
+ - Rare; aggressive; large, unilateral, heterogeneous solid mass with necrosis; hemorrhage ± calcification
+ - T2 hyperintense and T1 hypointense to liver (as with "classic" pheochromocytomas)
+ - Aggressive, often with IVC extension
+- ## Adrenal Neuroblastoma
+
+
+ - Large pediatric adrenal mass; calcification (80-90%)
+- ## Adrenal Granulomatous Infection
+
+
+ - TB, histoplasmosis, other fungal diseases; usually bilateral
+ - Acute (hypoechoic masses) or chronic (small and calcified)
+
+# PATHOLOGY
+
+- ## General Features
+
+
+ - ### Associated abnormalities
+
+
+ - Majority are sporadic
+ - 25% have autosomal dominant gene mutation
+ - **Multiple endocrine neoplasia type 2 (MEN2)**
+ - *MEN2*mutation; 50% have pheochromocytoma
+ - Medullary thyroid carcinoma, hyperparathyroidism, neuromas, and marfanoid habitus
+ - **von Hippel-Lindau (VHL) disease**
+ - *VHL*tumor suppressor gene; 10-25% risk
+ - Multiple benign and malignant tumors
+ - **Neurofibromatosis type 1**
+ - Rare cause of pheochromocytomas; 1% risk
+ - Cutaneous/plexiform neurofibromas, optic nerve gliomas, peripheral nerve sheath tumors, gastrointestinal stromal tumors
+ - **Pheochromocytoma-paraganglioma syndromes**
+ - Mutations of succinate dehydrogenase gene family; 50% risk
+ - ↑ incidence of extraadrenal tumors and head/neck paragangliomas
+ - Most are benign; 10% are malignant
+ - Diagnosis of malignancy is based solely on presence of direct local tumor invasion or metastatic disease
+ - Extraadrenal paragangliomas are more likely to be malignant
+- ## Gross Pathologic & Surgical Features
+
+
+ - Small tumor: Well-circumscribed, yellow-tan lesion confined to adrenals
+ - Large tumor: Hemorrhagic, cystic/necrotic masses
+- ## Microscopic Features
+
+
+ - Predominantly chromaffin cells; occasionally spindle cells are dominant feature
+ - Term pheochromocytoma refers to dusky color of cells stained with chromium salts
+ - No single histologic feature of pheochromocytoma consistently predicts malignancy
+ - Definitive pathologic diagnosis of malignancy is based on presence of metastatic disease
+
+# CLINICAL ISSUES
+
+- ## Presentation
+
+
+ - ### Most common signs/symptoms
+
+
+ - Majority are asymptomatic; symptoms may be episodic or paroxysmal
+ - Classic triad (arises from adrenergic excess)
+ - Paroxysmal headache, palpitations, sweating
+ - 90% specific but uncommon (only present in 10.0-36.5% of patients)
+ - ### Other signs/symptoms
+
+
+ - Hypertensive crisis: Palpitations, tremors, arrhythmias, pain, myocardial infarction
+ - Laboratory data
+ - Tumors typically secrete norepinephrine > epinephrine
+ - **↑**levels of 24-hour urine-fractionated metanephrines
+ - 90-97% sensitivity; 69-98% specificity
+- ## Demographics
+
+
+ - ### Age
+
+
+ - Sporadic cases, 3rd and 4th decades
+ - Hereditary cases, 3rd decade
+ - 10% are found in children
+ - ### Sex
+
+
+ - Slight female predilection (M:F = 1:1.4)
+ - ### Epidemiology
+
+
+ - Exact incidence: Unknown
+ - Prevalence in hypertensive adults 0.1-0.6%
+ - Majority of pheochromocytomas are likely asymptomatic (incidentalomas)
+- ## Natural History & Prognosis
+
+
+ - Hypertensive crises and cardiovascular complications ↑ morbidity/mortality
+ - Prognosis: Noninvasive and nonmetastatic: Typically favorable
+- ## Treatment
+
+
+ - Symptomatic therapy: α-adrenergic blockade and calcium channel antagonists
+ - Laparoscopic resection/debulking for both benign and malignant tumors
+ - Adjuvant therapy (malignant tumors): I-131 MIBG therapy ± chemotherapy (cyclophosphamide, vincristine, dacarbazine)
+
+# DIAGNOSTIC CHECKLIST
+
+- ## Consider
+
+
+ - Imaging can mimic other diagnoses; labs essential for diagnosis
+- ## Image Interpretation Pearls
+
+
+ - Extraadrenal tumors arise anywhere along sympathetic ganglia (neck to bladder), attention to these locations
+
+ c0256142-d2c8-452c-ad4f-032d36d44ba0
+
+## References
+
+# Selected References
+
+1. [Nandra G et al: Technical and interpretive pitfalls in adrenal imaging. Radiographics. 40(4):1041-60, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32609593%5Bpmid%5D)
+1. [Chang CA et al: (68)Ga-DOTATATE and (18)F-FDG PET/CT in paraganglioma and pheochromocytoma: utility, patterns and heterogeneity. Cancer Imaging. 16(1):22, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=27535829%5Bpmid%5D)
+1. [Lattin GE Jr et al: From the radiologic pathology archives: adrenal tumors and tumor-like conditions in the adult: radiologic-pathologic correlation. Radiographics. 34(3):805-29, 2014](http://www.ncbi.nlm.nih.gov/pubmed/?term=24819798%5Bpmid%5D)
+1. [Leung K et al: Pheochromocytoma: the range of appearances on ultrasound, CT, MRI, and functional imaging. AJR Am J Roentgenol. 200(2):370-8, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=23345359%5Bpmid%5D)
+1. [Raja A et al: Multimodality imaging findings of pheochromocytoma with associated clinical and biochemical features in 53 patients with histologically confirmed tumors. AJR Am J Roentgenol. 201(4):825-33, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=24059371%5Bpmid%5D)
+1. [Parenti G et al: Updated and new perspectives on diagnosis, prognosis, and therapy of malignant pheochromocytoma/paraganglioma. J Oncol. 2012:872713, 2012](http://www.ncbi.nlm.nih.gov/pubmed/?term=22851969%5Bpmid%5D)
+1. [Blake MA et al: Pheochromocytoma: an imaging chameleon. Radiographics. 24 Suppl 1:S87-99, 2004](http://www.ncbi.nlm.nih.gov/pubmed/?term=15486252%5Bpmid%5D)
+
+
+## Images
+
+
+### Selected Images
+
+
+*Graphic shows a typical pheochromocytoma , moderate in size with a well-circumscribed margin and solid appearance. Note hypervascularity of the mass, which commonly results in necrosis and cystic change.*
+
+
+*Graphic shows a typical pheochromocytoma , moderate in size with a well-circumscribed margin and solid appearance. Note hypervascularity of the mass, which commonly results in necrosis and cystic change.*
+
+
, proven to be a pheochromocytoma.](images/app.statdx.com_image_thumbnail_49dae42d-f58a-4b44-895e-afa709899446_annotated_true_size_900_quality_90_5631abd56094d59dcb19b3758f8159fde1d675f1.jpg)
+*Transverse (left) and longitudinal (right) transabdominal ultrasound show a well-demarcated, heterogenous, solid right adrenal mass hyperechoic to the renal cortex , proven to be a pheochromocytoma.*
+
+
in the right suprarenal region medially, proven to be a paraganglioma.](images/app.statdx.com_image_thumbnail_0319f064-3c59-42e3-9b35-56d895048d9b_annotated_true_size_900_quality_90_9a98eb818bac8c87fdf4bd942b07b110d34ece4f.jpg)
+*Longitudinal transabdominal ultrasound demonstrates well-circumscribed, round, heterogeneous, hypoechoic mass in the right suprarenal region medially, proven to be a paraganglioma.*
+
+
, proven to be a paraganglioma.](images/app.statdx.com_image_thumbnail_320a766e-0e57-4194-88b2-d3fbb58bcea8_annotated_true_size_900_quality_90_299fbc8b184de3906e0d903ade2b46dcffda67db.jpg)
+*Axial CECT in the previous patient shows a well-circumscribed, round, heterogeneous, hypodense mass , anteromedial to the upper pole right kidney , proven to be a paraganglioma.*
+
+
+*Longitudinal transabdominal ultrasound shows a large left adrenal mass , slightly heterogeneous and hypoechoic to the renal cortex .*
+
+
+*Axial CECT in the same patient confirms the left adrenal mass , along with right adrenal mass and a liver lesion , confirmed lung cancer metastases.*
+
+
+*Axial T2WI MR shows 2 well-circumscribed, paraaortic paragangliomas .*
+
+
+*Corresponding axial T1WI C+ FS MR demonstrates the same paragangliomas . Notice the salt and pepper appearance of the right-most paragangliomas, consisting of enhancing parenchyma and internal flow void (hypervascularity).*
+
+
+*Transverse transabdominal color Doppler ultrasound shows heterogenous, hypervascular mass anteromedial to the left kidney, confirmed paraganglioma.*
+
+
+*Axial arterial-phase CECT in the same patient confirms a large heterogeneously enhancing mass in the left retroperitoneum , confirmed paraganglioma.*
+
+
+### Additional Images
+
+
+*Transverse transabdominal color Doppler ultrasound of a right adrenal pheochromocytoma shows a well-defined, heterogenous mass .*
+
+
+*Coronal CECT shows a large, well-defined mass with avidly enhancing solid portions and large, hypodense areas of necrosis , confirmed paraganglioma.*
+
+
+*Axial fused PET/CT demonstrates ↑ radiotracer uptake within the solid portions of the paraganglioma, whereas the necrotic areas appear photopenic . The mass is distinct from the left kidney , but notice abutment/narrowing of the main left renal vein .*
+
+
+*Transverse color Doppler ultrasound shows a right adrenal pheochromocytoma displacing and compressing the inferior vena cava .*
+
+
+*Axial CECT shows a large, well-circumscribed, moderately enhancing right adrenal pheochromocytoma with hypodense area of necrosis .*
+
+
+*DTPA-MIBG scan of the same patient shows uptake within the pheochromocytoma . Note DTPA uptake in kidneys . MIBG is useful to detect extraadrenal tumors.*
+
diff --git a/docs_md/articles/pheochromocytoma_7d3c4062-643c-4030-8783-f85184ad8132.md b/docs_md/articles/pheochromocytoma_7d3c4062-643c-4030-8783-f85184ad8132.md
new file mode 100644
index 0000000..82bb5c9
--- /dev/null
+++ b/docs_md/articles/pheochromocytoma_7d3c4062-643c-4030-8783-f85184ad8132.md
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+---
+title: "Pheochromocytoma"
+docid: "7d3c4062-643c-4030-8783-f85184ad8132"
+authors:
+ - key: "c3463c5c-31d3-4489-bbfe-6b895abdb86d"
+ value: "Mitchell Tublin, MD"
+ - key: "b1738976-d5a8-48bc-a435-ed1434cd451a"
+ value: "Mark D. Sugi, MD"
+breadcrumbs:
+ -
+ name: "Genitourinary"
+ slug: "genitourinary"
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+ name: "Diagnosis"
+ slug: "diagnosis"
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+ name: "Adrenal"
+ slug: "adrenal"
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+ -
+ name: "Benign Neoplasms"
+ slug: "benign-neoplasms"
+ treeNodeId: "eeebc0ba-f71a-4ae6-8daf-525d0d18fa16"
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+ name: "Pheochromocytoma"
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+pageTitle: "Pheochromocytoma | STATdx"
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+type: "DX"
+references: true
+breadcrumbs:
+ - "Genitourinary"
+ - "Diagnosis"
+ - "Adrenal"
+ - "Benign Neoplasms"
+ - "Pheochromocytoma"
+---
+# KEY FACTS
+
+- ## Terminology
+
+
+ - Tumor arising from chromaffin cells of adrenal medulla or extraadrenal paraganglia
+- ## Imaging
+
+
+ - Adrenal medulla (90%)
+ - Extraadrenal (10%)
+ - Along sympathetic chain: Anywhere from neck to urinary bladder
+ - Subdiaphragmatic (98%) or thoracic (1-2%)
+ - Organ of Zuckerkandl and near urinary bladder are relatively common sites
+ - Hereditary pheochromocytomas
+ - Small, bilateral adrenal lesions in younger patient
+ - Sporadic pheochromocytoma
+ - Large (> 3 cm), unilateral adrenal mass in older patients
+ - US: Hypoechoic suprarenal lesion ± cystic change
+ - Cystic components may be identified
+ - NECT: > 10 HU
+ - CECT: Heterogeneous enhancement
+ - Delayed washout kinetics typically similar to adrenal carcinoma and metastases, but rapid washout (like adenoma) possible
+ - Heterogeneous enhancement: Necrosis, cystic degeneration, and hemorrhage
+ - MR
+ - Variable T1/T2 signal due to hemorrhage, cystic degeneration, and necrosis
+ - Traditional classic imaging feature: T2 ("light bulb") hyperintensity
+ - Hypervascular solid components
+ - Ga-68 DOTATATE: Ectopic, recurrent, and metastatic tumors
+- ## Pathology
+
+
+ - Autosomal dominant familial syndromes
+ - von Hippel-Lindau, multiple endocrine neoplasia 2, neurofibromatosis type 1
+- ## Diagnostic Checklist
+
+
+ - Pheochromocytoma is not distinguished from other tumors by imaging appearance alone
+ - Clinical history and lab values are necessary for diagnosis
+ - Urinary and plasma fractionated metanephrines and catecholamines
+
+# TERMINOLOGY
+
+- ## Definitions
+
+
+ - Tumor arising from chromaffin cells of adrenal medulla or sympathetic nervous system
+ - Extraadrenal pheochromocytoma: Paraganglioma, ganglioneuroma
+
+# IMAGING
+
+- ## General Features
+
+
+ - ### Best diagnostic clue
+
+
+ - Adrenal mass with appropriate clinical history and supporting biochemical studies (elevated catecholamines)
+ - Characteristic T2 hyperintensity described in very early literature, though imaging appearance varies at MR (and other modalities)
+ - ### Location
+
+
+ - Adrenal medulla (90%) or extraadrenal (10%)
+ - Extraadrenal, along sympathetic chain: Neck to urinary bladder
+ - Subdiaphragmatic (98%) or thoracic (1-2%)
+ - Organ of Zuckerkandl and near bladder are relatively common sites
+ - ### Size
+
+
+ - Usually larger (> 3 cm) in sporadic (nonsyndromic) or clinically silent cases
+ - ### Morphology
+
+
+ - Well-circumscribed, encapsulated tumor
+ - Solitary (sporadic) or multiple (familial)
+ - Key concepts
+ - Classic teaching: Rule of 10s (or 10% tumor)
+ - 10% extraadrenal (paraganglioma)
+ - 10% bilateral
+ - 10% malignant
+ - 10% extraabdominal
+ - 10% familial
+ - 10% pediatric
+ - 10% silent
+ - 10% autosomal dominant transmission
+ - Demographics evolving
+ - ↑ detection of incidental, clinically silent adrenal lesions (including pheochromocytoma) on CT
+ - Large imaging series: 23-58% of pheochromocytomas clinically occult
+ - Prompts aggressive biochemical evaluation of incidental adrenal lesion
+ - Larger percentage of syndromic tumors likely: More aggressive screening for predisposing hereditary conditions
+ - Multiple endocrine neoplasia 2 (MEN2), von Hippel-Lindau (VHL)
+ - Neuroectodermal disorders: Neurofibromatosis type 1 (NF1), Sturge-Weber syndrome, Carney triad
+ - 25% of patients with apparent sporadic pheochromocytomas are carriers of gene mutations
+ - Extraadrenal tumors arise from sympathetic ganglia
+ - Neck, mediastinum, pelvis, or urinary bladder
+ - Aortic bifurcation (organ of Zuckerkandl): Ganglia at origin of inferior mesenteric artery
+ - Imaging: Difficult to distinguish benign from malignant
+ - Distant metastases indicate malignancy
+- ## CT Findings
+
+
+ - ### NECT
+
+
+ - Attenuation ranges from low density to soft tissue attenuation
+ - Attenuation almost always > 10 HU and usually ≥ 40 HU, though rare intracellular lipid-containing pheochromocytomas reported
+ - ± areas of ↑ density (hemorrhage)
+ - ± areas of ↓ density (cystic degeneration, necrosis)
+ - ± areas of curvilinear or mural calcification
+ - ### CECT
+
+
+ - Heterogeneous enhancement due to tissue necrosis, cystic degeneration, and hemorrhage
+ - Modified criteria: 1 min ≥ 160 HU; 15 min ≥ 70 HU; or intralesional cystic degeneration at both 1 min and 15 min
+ - Solid components briskly enhance
+ - Hyperenhancement (> 110 HU) on late arterial phase may suggest pheochromocytoma
+ - Early, marked enhancement also possible with vascular metastases (hepatocellular carcinoma, renal cell carcinoma)
+ - Initial literature suggested pheochromocytoma washout characteristics similar to adrenal carcinoma and metastases
+ - Recent work suggests large percentage of pheochromocytomas with washout percentages similar to adenomas
+ - Theoretical risk of induction of hyperadrenergic symptoms with iodinated contrast administration discounted by retrospective series utilizing nonionic material
+- ## MR Findings
+
+
+ - ### T1WI
+
+
+ - Isointense to muscle and hypointense to liver
+ - Heterogeneous signal
+ - Due to areas of hemorrhage and necrosis
+ - ± areas of ↑ signal
+ - Due to acute or subacute hemorrhage
+ - ### T2WI
+
+
+ - T2 heterogeneity typical
+ - Due to ↑ water content as result of necrosis, cystic degeneration
+ - Markedly hyperintense ("light bulb") characteristic in early MR series, later discounted
+ - ↓ T2 signal does not exclude pheochromocytoma
+ - ### DWI
+
+
+ - Unlike lesion size, ADC values generally not useful for differentiating benign vs. malignant
+ - ### T1WI C+
+
+
+ - Characteristic salt and pepper pattern (due to ↑ tumor vascularity)
+ - Salt: Represents enhancing parenchyma
+ - Pepper: Represents flow void of vessels
+ - Can show marked early as well as prolonged contrast enhancement
+- ## Ultrasonographic Findings
+
+
+ - ### Grayscale ultrasound
+
+
+ - Variable echogenicity: Majority iso- to hypoechoic
+ - Intralesional hemorrhage may be echogenic
+ - Round and well-circumscribed mass
+ - Cystic components may be identified
+ - Malignant features include large size, irregular shape, poorly defined margins, heterogeneity, and hypervascularity
+ - 75% of malignant pheochromocytomas are hypoechoic; 20% show mixed echogenicity and cystic necrosis
+- ## Angiographic Findings
+
+
+ - Conventional
+ - Hypervascular tumor
+- ## Nuclear Medicine Findings
+
+
+ - I-131 or I-123 MIBG
+ - Most common and available technique
+ - MIBG is norepinephrine analogue: Uptake proportional to number of neurosecretory granules within lesion
+ - I-123 MIBG has largely replaced I-131 MIBG (lower radiation dose, improved image quality)
+ - I-123 MIBG sensitivity: 77-90%; specificity: 95-100%
+ - Hybridized MIBG SPECT/CT improves diagnostic accuracy
+ - Particularly useful for extraadrenal paraganglioma detection, malignant pheochromocytoma staging
+ - In-111 pentetreotide (somatostatin analog): Potentially useful for dedifferentiated pheochromocytoma
+ - PET
+ - Ga-68 DOTATATE: Largely replaced MIBG as primary imaging modality
+ - Neuroendocrine tumors express somatostatin receptors
+ - F-18: Can be utilized in imaging of faster-growing pheochromocytomas
+- ## Imaging Recommendations
+
+
+ - Helical NE + CECT
+ - Hypertensive crises not documented with IV administration of nonionic contrast material
+ - Routine **premedication** (α and β blockade) is**not recommended**
+ - MR ± contrast
+ - Ga-68 DOTATATE PET/CT
+ - For ectopic, recurrent, and metastatic tumors
+
+# DIFFERENTIAL DIAGNOSIS
+
+- [Adrenal Adenoma](/document/adrenal-adenoma/e2916d86-5f9f-4dd3-9576-1a7b89d8dda0)
+ - NECT: Well-defined mass < 10 HU (lipid rich)
+ - CECT: Enhancing mass that washes out rapidly
+ - Early hyperenhancement and marked wash out of pheochromocytomas are reported and may mimic adenomas
+ - Adenoma with hemorrhage or necrosis may resemble pheochromocytoma
+- [Adrenal Carcinoma](/document/adrenal-cortical-carcinoma/bdc7a08b-a64f-4bd2-9dfc-24331728e85e)
+ - Rare; usually unilateral
+ - Large, unilateral adrenal mass with invasive margins
+ - ± calcification (30% of cases); variable enhancement
+ - Metastatic tumor spread: Lungs, liver, nodes, and bone
+ - Inferior vena cava tumor thrombus
+- [Adrenal Metastases and Lymphoma](/document/adrenal-lymphoma/44639c90-bd04-4e2a-a470-2c28a0e2ff78)
+ - Adrenal metastases
+ - e.g., lung, breast, renal cell carcinoma, and melanoma
+ - Unilateral or bilateral; central necrosis ± hemorrhage
+ - History of primary malignancy
+ - Adrenal lymphoma
+ - Usually as part of diffuse disease
+ - Rarely limited to adrenals
+ - Non-Hodgkin most common; usually bilateral
+ - CECT: Mild enhancement (hypovascular)
+- [Adrenal Myelolipoma](/document/adrenal-myelolipoma/5813a554-06a4-4696-af71-7ce50693039d)
+ - Rare benign tumor (fat + hematopoietic elements)
+ - Unilateral fatty adrenal tumor (-100 to -30 HU)
+ - T1WI: Typically hyperintense; size varies (2-10 cm)
+ - Signal loss on T1WI with fat suppression
+- [Adrenal Hemorrhage](/document/adrenal-hemorrhage/5812e5c4-ca8a-4af5-884b-f75795bcde0f)
+ - Etiology: Septicemia, burns, trauma, stress, hypotension, and hematological abnormalities
+ - CT findings
+ - Usually bilateral
+ - Old hemorrhage: Soft tissue attenuation (20-35 HU)
+ - Recent hemorrhage: ↑ attenuation values
+ - MR findings: T1WI and T2WI
+ - Varied signal depending on hematoma age
+ - Subacute phase: Usually ↑ signal (methemoglobin)
+ - Perilesional dark ring (hemosiderin or ferritin)
+- [Adrenal Tuberculosis and Fungal Infection](/document/adrenal-tuberculosis-and-fungal-in-/56a3b7b4-f9bc-4f89-87bb-98b80ddee00a)
+ - e.g., tuberculosis, histoplasmosis, other fungal diseases
+ - Usually bilateral, heterogeneous, poorly enhancing (acute)
+ - Chronic: Small and calcified adrenals
+ - Diagnosis: Clinical history and lab data
+
+# PATHOLOGY
+
+- ## General Features
+
+
+ - ### Etiology
+
+
+ - Chromaffin cells of adrenal medulla or extraadrenal paraganglioma
+ - Adrenal medulla: Pheochromocytoma
+ - Extraadrenal: Paraganglioma
+ - ### Associated abnormalities
+
+
+ - Classic associated syndromes
+ - VHL syndrome
+ - Pheochromocytoma may be only manifestation of VHL or occur along with other tumors
+ - NF1
+ - MEN syndromes types 2A and 2B
+ - Tuberous sclerosis; Sturge-Weber syndrome
+ - Carney triad
+ - Functional extraadrenal paraganglioma, pulmonary chondroma, gastric leiomyosarcoma
+ - Adage that only 10% of pheochromocytomas are hereditary discounted with recent advances in molecular studies
+ - 25% of patients with previously considered sporadic pheochromocytomas are carriers of gene mutations
+ - Embryology/anatomy
+ - Neoplasm of chromaffin cells derived from neural crest or neuroectoderm
+- ## Gross Pathologic & Surgical Features
+
+
+ - Round, tan-pink to violaceous, encapsulated mass
+ - ± cystic, mucoid, serosanguineous hemorrhage
+- ## Microscopic Features
+
+
+ - Large cells: Granular cytoplasm and pleomorphic nuclei
+ - Chromaffin reaction: Cells stained + chromium salt
+
+# CLINICAL ISSUES
+
+- ## Presentation
+
+
+ - ### Most common signs/symptoms
+
+
+ - Symptoms may be episodic or paroxysmal
+ - Crisis: Headaches, hypertension, palpitations, diaphoresis, tremors, arrhythmias, pain
+ - Classic triad: Headache, palpitations, diaphoresis
+ - 90% specific but uncommon presentation (10-36%)
+ - Atypical: Labile hypertension, myocardial infarction, stroke
+ - Often clinically silent
+ - ### Clinical profile
+
+
+ - Young patient with paroxysmal attacks of headache, palpitations, sweating, and tremors
+ - Lab data
+ - 24-hour urine-fractionated metanephrine evaluation often initial biochemical test
+ - Excretion of metanephrine, normetanephrine, and 3-methoxytyramine (dopamine metabolite) measured
+ - Sensitivity: 90-97%; specificity: 69-98%
+ - Plasma-fractionated metanephrines also measured, though low positive predictive value and ↓ specificity results in high false-positive rates
+- ## Demographics
+
+
+ - ### Age
+
+
+ - Sporadic pheochromocytoma: Older patients (mean: 44 years)
+ - Hereditary pheochromocytoma: Younger patients (mean: 25 years)
+ - Pheochromocytomas are exceedingly rare in pediatric patients
+ - Higher genetic predisposition and malignancy incidence
+ - ### Sex
+
+
+ - F > M
+ - ### Epidemiology
+
+
+ - Incidence
+ - 0.13% in autopsy series; accounts for 0.1-0.5% of patients with hypertension
+ - Prevalence likely underestimated
+- ## Natural History & Prognosis
+
+
+ - Complications: During hypertensive crisis
+ - Cerebrovascular accidents
+ - Pregnancy + pheochromocytoma: Mortality (48%)
+ - Malignancy in 2-14% cases
+ - Prognosis
+ - Noninvasive and nonmetastatic: Good prognosis
+ - Malignant and metastatic: Poor prognosis
+ - 5-year survival rate: < 50%
+- ## Treatment
+
+
+ - Medical therapy: Before, during, and after surgery
+ - α-adrenergic blockers
+ - Phenoxybenzamine, phentolamine
+ - β-adrenergic blocker: Propranolol
+ - Surgical resection: Benign and malignant
+ - Laparoscopic resection preferred
+ - Posterior retroperitoneoscopic adrenalectomy associated with ↓ morbidity compared to transabdominal laparoscopic approach
+ - Partial adrenalectomy may be performed with bilateral pheochromocytomas
+ - Cortical-sparing adrenalectomy in patients with hereditary pheochromocytoma shows survival similar to total adrenalectomy but recurrence in 13%
+ - HSA I-131 MIBG and tumor debulking for metastatic, unresectable, or locally advanced malignant pheochromocytomas
+ - Combination chemotherapy: Cyclophosphamide + vincristine + dacarbazine
+
+# DIAGNOSTIC CHECKLIST
+
+- ## Consider
+
+
+ - Clinical history, supporting biochemical data ultimately drive diagnosis
+- ## Reporting Tips
+
+
+ - CT and MR features (vascularity, cystic change, T2 heterogeneity) may suggest pheochromocytoma, but overlap precludes definitive diagnosis solely by imaging
+ - Possibility of pheochromocytoma should be raised, but lab analysis confirms or excludes diagnosis
+
+ 483df3a0-a77f-4ff8-9024-1fa2032a515a
+
+## References
+
+# Selected References
+
+1. [Jain A et al: Pheochromocytoma and paraganglioma-an update on diagnosis, evaluation, and management. Pediatr Nephrol. 35(4):581-94, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=30603807%5Bpmid%5D)
+1. [Kang S et al: Distinguishing pheochromocytoma from adrenal adenoma by using modified computed tomography criteria. Abdom Radiol (NY). 46(3):1082-90, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32951125%5Bpmid%5D)
+1. [Alshahrani MA et al: Bilateral adrenal abnormalities: imaging review of different entities. Abdom Radiol (NY). 44(1):154-79, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=29938331%5Bpmid%5D)
+1. [Canu L et al: CT characteristics of pheochromocytoma: relevance for the evaluation of adrenal incidentaloma. J Clin Endocrinol Metab. 104(2):312-8, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=30383267%5Bpmid%5D)
+1. [Gong X et al: Ultrasonographic findings of 1385 adrenal masses: a retrospective study of 1319 benign and 66 malignant masses. J Ultrasound Med. 38(9):2249-57, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=29194699%5Bpmid%5D)
+1. [Goroshi M et al: Radiological differentiation of phaeochromocytoma from other malignant adrenal masses: importance of wash-in characteristics on multiphase CECT. Endocr Connect. 8(7):898-905, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=31252396%5Bpmid%5D)
+1. [Neumann HPH et al: Comparison of pheochromocytoma-specific morbidity and mortality among adults with bilateral pheochromocytomas undergoing total adrenalectomy vs cortical-sparing adrenalectomy. JAMA Netw Open. 2(8):e198898, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=31397861%5Bpmid%5D)
+1. [Pryma DA et al: Efficacy and safety of high-specific-activity 131I-MIBG therapy in patients with advanced pheochromocytoma or paraganglioma. J Nucl Med. 60(5):623-30, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=30291194%5Bpmid%5D)
+1. [Foti G et al: Characterization of adrenal lesions using MDCT wash-out parameters: diagnostic accuracy of several combinations of intermediate and delayed phases. Radiol Med. 123(11):833-40, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=29923085%5Bpmid%5D)
+1. [Mohammed MF et al: Pheochromocytomas versus adenoma: role of venous phase CT enhancement. AJR Am J Roentgenol. 210(5):1073-8, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=29570377%5Bpmid%5D)
+1. [Woo S et al: Pheochromocytoma as a frequent false-positive in adrenal washout CT: a systematic review and meta-analysis. Eur Radiol. 28(3):1027-36, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=29026974%5Bpmid%5D)
+1. [Kim DW et al: Assessment of clinical and radiologic differences between small and large adrenal pheochromocytomas. Clin Imaging. 43:153-7, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28324715%5Bpmid%5D)
+1. [Mendiratta-Lala M et al: Adrenal imaging. Endocrinol Metab Clin North Am. 46(3):741-59, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28760236%5Bpmid%5D)
+1. [Schieda N et al: Update on CT and MRI of adrenal nodules. AJR Am J Roentgenol. 1-12, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28225653%5Bpmid%5D)
+1. [Zhang GM et al: Differentiating pheochromocytoma from lipid-poor adrenocortical adenoma by CT texture analysis: feasibility study. Abdom Radiol (NY). 42(9):2305-13, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28357529%5Bpmid%5D)
+1. [Northcutt BG et al: Adrenal adenoma and pheochromocytoma: comparison of multidetector CT venous enhancement levels and washout characteristics. J Comput Assist Tomogr. 40(2):194-200, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=26978001%5Bpmid%5D)
+1. [Schieda N et al: Comparison of quantitative MRI and CT washout analysis for differentiation of adrenal pheochromocytoma from adrenal adenoma. AJR Am J Roentgenol. 206(6):1141-8, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=27011100%5Bpmid%5D)
+1. [Borhani AA et al: Quantitative versus qualitative methods in evaluation of T2 signal intensity to improve accuracy in diagnosis of pheochromocytoma. AJR Am J Roentgenol. 205(2):302-10, 2015](http://www.ncbi.nlm.nih.gov/pubmed/?term=26204279%5Bpmid%5D)
+1. [Derlin T et al: Intraindividual comparison of 123I-mIBG SPECT/MRI, 123I-mIBG SPECT/CT, and MRI for the detection of adrenal pheochromocytoma in patients with elevated urine or plasma catecholamines. Clin Nucl Med. 38(1):e1-6, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=22996238%5Bpmid%5D)
+1. [Leung K et al: Pheochromocytoma: the range of appearances on ultrasound, CT, MRI, and functional imaging. AJR Am J Roentgenol. 200(2):370-8, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=23345359%5Bpmid%5D)
+1. [Northcutt BG et al: MDCT of adrenal masses: can dual-phase enhancement patterns be used to differentiate adenoma and pheochromocytoma? AJR Am J Roentgenol. 201(4):834-9, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=24059372%5Bpmid%5D)
+1. [Patel J et al: Can established CT attenuation and washout criteria for adrenal adenoma accurately exclude pheochromocytoma? AJR Am J Roentgenol. 201(1):122-7, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=23789665%5Bpmid%5D)
+1. [Raja A et al: Multimodality imaging findings of pheochromocytoma with associated clinical and biochemical features in 53 patients with histologically confirmed tumors. AJR Am J Roentgenol. 201(4):825-33, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=24059371%5Bpmid%5D)
+1. [Dong Y et al: Differentiation of malignant from benign pheochromocytomas with diffusion-weighted and dynamic contrast-enhanced magnetic resonance at 3.0 T. J Comput Assist Tomogr. 36(4):361-6, 2012](http://www.ncbi.nlm.nih.gov/pubmed/?term=22805661%5Bpmid%5D)
+1. [Timmers HJ et al: Current and future anatomical and functional imaging approaches to pheochromocytoma and paraganglioma. Horm Metab Res. 44(5):367-72, 2012](http://www.ncbi.nlm.nih.gov/pubmed/?term=22399235%5Bpmid%5D)
+1. [Miller FH et al: Utility of diffusion-weighted MRI in characterization of adrenal lesions. AJR Am J Roentgenol. 194(2):W179-85, 2010](http://www.ncbi.nlm.nih.gov/pubmed/?term=20093571%5Bpmid%5D)
+1. [Blake MA et al: Pheochromocytoma: an imaging chameleon. Radiographics. 24 Suppl 1:S87-99, 2004](http://www.ncbi.nlm.nih.gov/pubmed/?term=15486252%5Bpmid%5D)
+
+
+## Images
+
+
+### Selected Images
+
+
+*Coronal CECT in a 74-year-old man with neurofibromatosis type 1 (NF1) shows a 10-cm, cystic and solid right adrenal mass , surgically proven to be a pheochromocytoma. ~ 1-6% of patients with NF1 develop pheochromocytoma. Note IVC filter .*
+
+
+*Coronal CECT in a 74-year-old man with neurofibromatosis type 1 (NF1) shows a 10-cm, cystic and solid right adrenal mass , surgically proven to be a pheochromocytoma. ~ 1-6% of patients with NF1 develop pheochromocytoma. Note IVC filter .*
+
+
+*Axial T2 FS MR in an 80-year-old man with sporadic pheochromocytoma shows a rounded right adrenal mass with heterogeneous signal. Sporadic pheochromocytoma occurs more often in older patients. Note incidental hepatic cyst .*
+
+
+*Axial T2 FS MR in a 40-year-old woman with headaches, palpitations, and chronic diaphoresis shows an intermediate-signal, 5-cm left adrenal mass with internal areas of hyperintensity suggesting cystic degeneration or necrosis.*
+
+
+*Axial T1 C+ FS MR in the same patient shows heterogeneous enhancement of the left adrenal mass with cystic degeneration or necrosis . Surgical pathology showed pheochromocytoma, which was sporadic in this patient with no family history.*
+
+
+*Coronal CECT shows a heterogeneous right adrenal mass in a 51-year-old woman with abdominal pain, headaches, and markedly elevated 24-hour urine metanephrines. The mass was surgically proven to be pheochromocytoma.*
+
+
+*Axial CECT in a 44-year-old man with hypertension shows an incidental right adrenal mass following motor vehicle collision. The mass was resected via right posterior retroperitoneoscopic adrenalectomy and pheochromocytoma was confirmed.*
+
+
+*Axial T2 FS MR in a 66-year-old woman with ↑ 24-hour metanephrines shows a heterogeneous mass in the hepatorenal space . Heterogeneous T2 signal is often seen due to varying degrees of hemorrhage and necrosis.*
+
+
+*Axial T1 FS C+ MR in the same patient shows heterogeneous enhancement of the surgically proven pheochromocytoma . The patient was treated with alpha-blockade (phenoxybenzamine) for 1 month prior to intervention.*
+
+
+*Axial CECT in a 79-year-old man with locally recurrent pheochromocytoma shows an irregular, enhancing mass in the left adrenal fossa abutting the anterior left kidney . Note incidental chronic aortic dissection .*
+
+
+*Axial Ga-68 DOTATATE PET/CT in the same patient shows avid tracer uptake in the left adrenal fossa , corresponding to the enhancing mass on CT and consistent with locally recurrent pheochromocytoma.*
+
+
+*Axial CECT shows bilateral, centrally necrotic adrenal masses in a 10 year old with von Hippel-Lindau (VHL) syndrome and pheochromocytomas. Cortical-sparing adrenalectomy was performed on the left mass. Up to 30% of patients with VHL develop pheochromocytoma.*
+
+
+*Axial Cu-61 DOTATATE PET/CT in the same patient shows minimal peripheral uptake by the bilateral adrenal masses due to extensive necrosis. Note physiologic uptake in the left kidney .*
+
+
+*Axial T2 FS MR in a 21-year-old man with neurofibromatosis type 1 (NF1) shows a heterogeneous right adrenal mass proven to be pheochromocytoma. While classically described as "light bulb bright," the T2 signal of this neoplasm is highly variable.*
+
+
+*Axial CECT shows a heterogeneously enhancing right adrenal mass in a 55-year-old man with elevated 24-hour urine metanephrine and pheochromocytoma shown at surgical pathology.*
+
+
+*Transverse US of the RUQ for pleuritic chest pain in a 20-year-old man shows a round mass posterior to the right hepatic lobe with centrally decreased echogenicity suggesting necrosis.*
+
+
+*Axial CECT in the same patient shows a centrally necrotic right adrenal mass , surgically proven pheochromocytoma. Multiple pancreatic cysts are also noted, and the diagnosis of familial VHL syndrome was subsequently confirmed.*
+
+
+### Additional Images
+
+
+*Axial I-123 MIBG SPECT/CT in a 79-year-old man with locally recurrent pheochromocytoma shows avid tracer uptake in the left adrenal fossa extending to the perisplenic space , consistent with recurrent pheochromocytoma.*
+
+
+*Axial CECT in a 36-year-old woman shows a 7-cm, heterogeneous left adrenal mass . The differential includes adrenal carcinoma, pheochromocytoma, and metastasis. Urinary metanephrines were ↑, and laparoscopic resection (after α and β blockade) confirmed hemorrhagic pheochromocytoma.*
+
+
+*Axial T2 MR in the same patient shows a hyperintense ("light bulb") left adrenal lesion . Although this appearance was historically thought to be characteristic of pheochromocytoma, it is neither sensitive nor specific. Elevated 24-hour urine metanephrines confirmed pheochromocytoma in this case.*
+
+
+*Axial T1 C+ MR in a 52-year-old woman to evaluate an incidental adrenal lesion previously identified on CT shows a 2-cm, vascular left adrenal mass .*
+
+
+*Axial T2 MR in the same patient shows a slightly intense right adrenal lesion and adjacent renal/hepatic cysts . Elevated 24-hour urinary metanephrines indicated (sporadic) unilateral pheochromocytoma, although the imaging appearance is nonspecific.*
+
diff --git a/docs_md/articles/rhabdomyoma_2915b0ba-a2fc-425c-beb7-2566dd945aed.md b/docs_md/articles/rhabdomyoma_2915b0ba-a2fc-425c-beb7-2566dd945aed.md
new file mode 100644
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+++ b/docs_md/articles/rhabdomyoma_2915b0ba-a2fc-425c-beb7-2566dd945aed.md
@@ -0,0 +1,412 @@
+---
+title: "Rhabdomyoma"
+docid: "2915b0ba-a2fc-425c-beb7-2566dd945aed"
+authors:
+ - key: "7e393d6e-f8be-4315-b1cd-b4639ee57a5f"
+ value: "Randy R. Richardson, MD"
+ - key: "db1ca0c5-292f-4acd-847d-c73a4f4ba734"
+ value: "Ryan A. Moore, MD"
+ - key: "961f3a7f-ad62-43bc-98f4-5116b17ab812"
+ value: "Paula J. Woodward, MD, FSRU"
+breadcrumbs:
+ -
+ name: "Pediatrics"
+ slug: "pediatrics"
+ treeNodeId: "a915965c-d436-44cf-ae65-2f22e7246ea4"
+ -
+ name: "Diagnosis"
+ slug: "diagnosis"
+ treeNodeId: "2b5cea64-a083-489e-ac0c-ec14ba059026"
+ -
+ name: "Cardiac"
+ slug: "cardiac"
+ treeNodeId: "7b8bc469-b6b8-4b0c-a552-38a906099111"
+ -
+ name: "Miscellaneous"
+ slug: "miscellaneous"
+ treeNodeId: "f9f94c98-8eb2-46eb-8552-909d84cb1df3"
+ -
+ name: "Rhabdomyoma"
+ slug: "rhabdomyoma"
+ treeNodeId: null
+category: "Pediatrics"
+cmeTopicId: "702657a1-8298-4d26-8b2b-5c7249ecda7f"
+documentVersionId: "97f69fa2-7987-4883-9f4f-4275e92bab38"
+imageCount: 18
+lastUpdated: "10/28/21"
+pageDescription: "Rhabdomyoma"
+pageKeywords: "Pediatrics, Diagnosis, Cardiac, Miscellaneous, Rhabdomyoma"
+pageTitle: "Rhabdomyoma | STATdx"
+enhancedTitle: "Rhabdomyoma"
+type: "DX"
+references: true
+breadcrumbs:
+ - "Pediatrics"
+ - "Diagnosis"
+ - "Cardiac"
+ - "Miscellaneous"
+ - "Rhabdomyoma"
+---
+# KEY FACTS
+
+- ## Terminology
+
+
+ - Congenital cardiac hamartoma composed of abnormal myocytes
+- ## Imaging
+
+
+ - Initial diagnosis is often by fetal &/or postnatal echocardiogram
+ - Homogeneous, hyperechoic mass(es) of myocardium
+ - Intramyocardial: May appear as wall thickening
+ - Intracavitary: Mass attached to myocardium protrudes into lumen
+ - MR is leading diagnostic test to delineate location, extent, & tissue characteristics of cardiac masses in children
+ - T1: Iso- or mildly hyperintense to myocardium
+ - T2: Hyperintense to myocardium
+ - 1st-pass perfusion: Hypointense to myocardium
+ - Late gadolinium enhancement: Isointense to myocardium
+ - Homogeneous appearance on all sequences
+ - Normal chest radiograph in small masses
+ - Cardiomegaly & signs of congestive heart failure in large masses
+ - Image brain (MR) & kidneys (US) for findings of tuberous sclerosis complex (TSC)
+ - ~ 100% of patients with multiple rhabdomyomas & 50% with single rhabdomyoma have TSC
+- ## Top Differential Diagnoses
+
+
+ - Fibroma; pericardial teratoma
+- ## Clinical Issues
+
+
+ - Cardiac tumors are rare in children
+ - Rhabdomyoma is most common pediatric cardiac tumor
+ - 75% are diagnosed before 1 year of age
+ - Natural history: Up to 93% show spontaneous regression; 70% regress by 4 years of age
+ - Surgical excision for minority of cases with refractory arrhythmias or hemodynamic compromise
+
+# TERMINOLOGY
+
+- ## Definitions
+
+
+ - Congenital cardiac hamartoma composed of abnormal myocytes
+
+# IMAGING
+
+- ## General Features
+
+
+ - ### Best diagnostic clue
+
+
+ - Cardiac mass within or contiguous with myocardium
+ - ### Location
+
+
+ - Interventricular septum > left or right ventricular free wall > > atrium
+ - Multiple in up to 90% of cases
+ - ### Size
+
+
+ - < 1 mm to 10 cm; most are 3-4 cm
+ - ### Morphology
+
+
+ - Well-circumscribed, nonencapsulated mass(es)
+ - Intramural or exophytic
+ - May involve entire wall & appear as wall thickening
+- ## Radiographic Findings
+
+
+ - Normal chest radiograph in small masses
+ - Cardiomegaly & signs of heart failure in large masses
+- ## Echocardiographic Findings
+
+
+ - Often superior to MR for detection of small masses
+ - Homogeneous, hyperechoic mass involving myocardium
+ - No blood flow within mass
+ - Most often in interventricular septum but can be anywhere
+ - May appear as simple wall thickening
+ - Intraluminal portion of mass may move across adjacent valve during cardiac cycle
+- ## CT Findings
+
+
+ - ### NECT
+
+
+ - Often hypodense compared with myocardium
+ - ### CECT
+
+
+ - Intraluminal component may be assessed with contrast-enhanced studies
+- ## MR Findings
+
+
+ - ### T1WI
+
+
+ - Iso- or mildly hyperintense to myocardium
+ - ### T2WI
+
+
+ - Hyperintense to myocardium
+ - No change with fat saturation (rules out lipoma)
+ - ### T1WI C+
+
+
+ - Minimal initial enhancement (1st-pass perfusion)
+ - Isointense to myocardium with late gadolinium enhancement (LGE)
+ - ### SSFP cine
+
+
+ - Help to differentiate tumor from contractile myocardium, evaluate hemodynamic effect of mass, & look for valvular leak
+- ## Imaging Recommendations
+
+
+ - ### Best imaging tool
+
+
+ - Dedicated transthoracic echo in all cases
+ - MR is helpful for diagnostic uncertainty, large masses, & surgical planning
+ - ### Protocol advice
+
+
+ - If cardiac mass is identified
+ - Look for additional masses
+ - Assess location & quality of mass
+ - Look for rhythm abnormalities
+ - Premature atrial or ventricular contractions are common
+ - Supraventricular tachycardia
+ - Sinus bradycardia
+ - Look for signs of obstruction
+ - Ventricular inflow or outflow obstruction
+ - May manifest as valve regurgitation or stenosis
+ - ↑ cardiac work to overcome obstruction → wall hypertrophy
+ - Evaluate for other findings of tuberous sclerosis complex (TSC)
+ - In fetus, monitor for signs of hydrops (poor function, effusions)
+
+# DIFFERENTIAL DIAGNOSIS
+
+- [Fibroma](/document/fibroma/8ed96e48-c833-4244-87b3-6c34b6ee34f1)
+ - Benign congenital cardiac neoplasm composed of fibroblasts & collagen
+ - 2nd most common cardiac neoplasm in pediatric population after rhabdomyoma
+ - Often arises from interventricular septum or left ventricular free wall
+ - MR: Isointense on T1, hypointense on T2
+- [Teratoma](/document/pericardial-teratoma/c115823c-1a05-4185-9ce4-774cd0984249)
+ - Pericardial (not myocardial) tumor
+ - Exophytic growth (will not be in cardiac chamber)
+ - Pericardial effusion is often present
+ - Contains all 3 germ cell layers → may be very heterogeneous on imaging with cystic, fatty, & calcified components
+- [Lipoma](/document/cardiac-lipoma/c332f74f-e3cd-47ba-9ff5-5bce83e0e595)
+ - Most arise from endocardial surface & protrude into chamber lumen
+ - Fat density/intensity on imaging studies allows for specific diagnosis
+- [Myxoma](/document/atrial-myxoma/f9b6c595-ff7b-4731-a799-666983e7f4ed)
+ - Majority manifest in adulthood (4th-7th decades)
+ - 90% are solitary & atrial in location
+ - 75% in left atrium, 10-20% in right atrium
+ - Predilection for interatrial septum adjacent to fossa ovalis
+- [Papillary Fibroelastoma](/document/papillary-fibroelastoma/7081571d-9b34-4b8e-9bfa-d08e375a1919)
+ - > 90% involve valves
+ - Typically small (< 15 mm)
+- [Cardiac Malignancies](/document/cardiac-sarcomas/62ce81d0-f7c9-4a17-9ccf-6204aff4f62e)
+ - Extremely uncommon in children
+ - Sarcomas account for most (with angiosarcoma being most common)
+ - Usually large masses with invasive features
+ - Pericardial & pleural effusion are often present
+
+# PATHOLOGY
+
+- ## General Features
+
+
+ - ### Etiology
+
+
+ - Unknown, but data suggests maternal hormones may play role in growth & development of fetal rhabdomyomas
+ - Helps explain regression after delivery
+ - ### Genetics
+
+
+ - Nearly 100% of patients with multiple & 50% with single rhabdomyomas have TSC
+ - TSC: Autosomal dominant with variable expressivity
+ - ~ 30% of cases are inherited
+ - Other cases are due to new mutation
+ - Caused by mutations in *TSC1* or*TSC2* genes
+ - *TSC1* is located on chromosome 9q
+ - Encodes for hamartin protein
+ - Complexes with tuberin to regulate cell cycle
+ - *TSC2* located on chromosome 16p
+ - Encodes for tuberin protein
+ - Participates in normal brain development & cardiomyocyte differentiation
+ - ### Associated abnormalities
+
+
+ - Other findings of TSC
+ - Brain: Subependymal nodules, cortical/subcortical tubers, subependymal giant cell astrocytoma
+ - Lung: Lymphangioleiomyomatosis
+ - Kidney: Angiomyolipomas & cysts
+ - Eye: Retinal hamartomas
+ - Nails: Ungual fibromas
+ - Pathophysiology
+ - Mass may interfere with myocardial contraction
+ - Exophytic masses frequently obstruct blood flow or cause valvular insufficiency
+- ## Gross Pathologic & Surgical Features
+
+
+ - Well-circumscribed, intramyocardial or exophytic mass(es)
+- ## Microscopic Features
+
+
+ - Large, vacuolated myocytes
+ - Glycogen-rich vacuoles stretch perinuclear cytoplasm (spider cells)
+
+# CLINICAL ISSUES
+
+- ## Presentation
+
+
+ - ### Most common signs/symptoms
+
+
+ - Obstruction to blood flow → heart failure
+ - Arrhythmias
+ - Large intracavitary tumors causing turbulent flow → hemolytic anemia & thrombocytopenia
+ - May be seen prenatally
+ - Generally incidental finding
+ - Rarely presents with arrhythmia or hydrops
+ - Can detect as early as 22-weeks gestation
+ - May discover more masses as pregnancy progresses
+ - Tend to ↑ in size prenatally & then regress after birth
+- ## Demographics
+
+
+ - ### Age
+
+
+ - 75% are diagnosed before 1 year of age
+ - ### Epidemiology
+
+
+ - Cardiac tumors rare (1:30,000-1:100,000)
+ - Rhabdomyoma is most common pediatric cardiac tumor
+- ## Natural History & Prognosis
+
+
+ - Generally excellent with spontaneous regression in 70% of children by 4 years of age
+ - Poor prognosis for untreated large masses interfering with cardiac hemodynamics
+ - Most respond well to surgical excision
+ - Case reports of response to mTOR (mammalian target of rapamycin) inhibitor sirolimus
+ - mTOR: Protein kinase that regulates cellular proliferation; used to treat subependymal giant cell tumors & angiomyolipomas
+- ## Treatment
+
+
+ - Surgical excision should be considered only for those with refractory arrhythmias or hemodynamic compromise
+ - Partial resection of intraluminal component of large exophytic masses may be necessary
+ - 3D printing from CT/MR data can build heart model with tumor location & extent for easy visualization; can assist with procedural planning
+ - Attempts at electrophysiology testing & ablation around tumor focus have variable success rates
+ - 3D printed models have been helpful
+ - Small, intramural masses with no hemodynamic effect typically need no treatment or surgical excision
+
+# DIAGNOSTIC CHECKLIST
+
+- ## Consider
+
+
+ - Overall prognosis is excellent
+ - However, rhabdomyomas may cause significant morbidity from obstruction to inflow or outflow, ventricular dysfunction, or arrhythmias
+
+ ac7ab661-20c8-405d-97f4-80c98e82f4a7
+
+## References
+
+# Selected References
+
+1. [Tsoumani Z et al: Magnetic resonance imaging of intramyocardial fat deposition in tuberous sclerosis. Diagnostics (Basel). 10(12), 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=33271987%5Bpmid%5D)
+1. [Victoria T et al: Imaging of fetal tumors and other dysplastic lesions: a review with emphasis on MR imaging. Prenat Diagn. 40(1):84-99, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=31925807%5Bpmid%5D)
+1. [Poterucha TJ et al: Cardiac tumors: clinical presentation, diagnosis, and management. Curr Treat Options Oncol. 20(8):66, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=31250250%5Bpmid%5D)
+1. [Ugurlucan M et al: Giant rhabdomyoma requiring emergency resection early after birth. Ann Thorac Surg. 107(1):e65, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=30009805%5Bpmid%5D)
+1. [Chen J et al: Fetal cardiac tumors: fetal echocardiography, clinical outcome and genetic analysis in 53 cases. Ultrasound Obstet Gynecol. 54(1):103-9, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=29877000%5Bpmid%5D)
+1. [Dragoumi P et al: Diagnosis of tuberous sclerosis complex in the fetus. Eur J Paediatr Neurol. 22(6):1027-34, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=30279084%5Bpmid%5D)
+1. [Palaskas N et al: Evaluation and management of cardiac tumors. Curr Treat Options Cardiovasc Med. 20(4):29, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=29556752%5Bpmid%5D)
+1. [von Ranke FM et al: Imaging of tuberous sclerosis complex: a pictorial review. Radiol Bras. 50(1):48-54, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28298732%5Bpmid%5D)
+1. [Ying L et al: Primary cardiac tumors in children: a center's experience. J Cardiothorac Surg. 11(1):52, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=27067427%5Bpmid%5D)
+1. [Sciacca P et al: Rhabdomyomas and tuberous sclerosis complex: our experience in 33 cases. BMC Cardiovasc Disord. 14:66, 2014](http://www.ncbi.nlm.nih.gov/pubmed/?term=24884933%5Bpmid%5D)
+1. [Tao TY et al: Pediatric cardiac tumors: clinical and imaging features. Radiographics. 34(4):1031-46, 2014](http://www.ncbi.nlm.nih.gov/pubmed/?term=25019440%5Bpmid%5D)
+1. [Beroukhim RS et al: Characterization of cardiac tumors in children by cardiovascular magnetic resonance imaging a multicenter experience. J Am Coll Cardiol. 58(10):1044-54, 2011](http://www.ncbi.nlm.nih.gov/pubmed/?term=21867841%5Bpmid%5D)
+1. [Miyake CY et al: Cardiac tumors and associated arrhythmias in pediatric patients, with observations on surgical therapy for ventricular tachycardia. J Am Coll Cardiol. 58(18):1903-9, 2011](http://www.ncbi.nlm.nih.gov/pubmed/?term=22018302%5Bpmid%5D)
+1. [Tiberio D et al: Regression of a cardiac rhabdomyoma in a patient receiving everolimus. Pediatrics. 127(5):e1335-7, 2011](http://www.ncbi.nlm.nih.gov/pubmed/?term=21464184%5Bpmid%5D)
+1. [Jain D et al: Benign cardiac tumors and tumorlike conditions. Ann Diagn Pathol. 14(3):215-30, 2010](http://www.ncbi.nlm.nih.gov/pubmed/?term=20471569%5Bpmid%5D)
+1. [Yinon Y et al: Fetal cardiac tumors: a single-center experience of 40 cases. Prenat Diagn. 30(10):941-9, 2010](http://www.ncbi.nlm.nih.gov/pubmed/?term=20721876%5Bpmid%5D)
+1. [Burke A et al: Pediatric heart tumors. Cardiovasc Pathol. 17(4):193-8, 2008](http://www.ncbi.nlm.nih.gov/pubmed/?term=18402818%5Bpmid%5D)
+1. [Syed IS et al: MR imaging of cardiac masses. Magn Reson Imaging Clin N Am. 16(2):137-64, vii, 2008](http://www.ncbi.nlm.nih.gov/pubmed/?term=18474324%5Bpmid%5D)
+1. [Kellenberger CJ et al: Cardiovascular MR imaging in neonates and infants with congenital heart disease. Radiographics. 27(1):5-18, 2007](http://www.ncbi.nlm.nih.gov/pubmed/?term=17234995%5Bpmid%5D)
+1. [Sparrow PJ et al: MR imaging of cardiac tumors. Radiographics. 25(5):1255-76, 2005](http://www.ncbi.nlm.nih.gov/pubmed/?term=16160110%5Bpmid%5D)
+1. [Kiaffas MG et al: Magnetic resonance imaging evaluation of cardiac tumor characteristics in infants and children. Am J Cardiol. 89(10):1229-33, 2002](http://www.ncbi.nlm.nih.gov/pubmed/?term=12008185%5Bpmid%5D)
+1. [Grebenc ML et al: Primary cardiac and pericardial neoplasms: radiologic-pathologic correlation. Radiographics. 20(4):1073-103; quiz 1110-1, 1112, 2000](http://www.ncbi.nlm.nih.gov/pubmed/?term=10903697%5Bpmid%5D)
+
+
+## Images
+
+
+### Selected Images
+
+
+*Axial graphic shows a partially exophytic rhabdomyoma in the apex of the left ventricle (LV).*
+
+
+*Axial graphic shows a partially exophytic rhabdomyoma in the apex of the left ventricle (LV).*
+
+
+*Axial T1 MR was performed in an asymptomatic 8-year-old girl with tuberous sclerosis complex (TSC) after a routine screening echocardiogram showed an intracardiac mass. MR shows a round, well-demarcated, intraluminal mass originating from the free wall of the LV. It is slightly hyperintense to myocardium, a characteristic finding of rhabdomyomas.*
+
+
+*Axial US through the fetal chest shows multiple echogenic, intracardiac masses involving both ventricles & the interventricular septum. Multiple rhabdomyomas are virtually diagnostic of TSC.*
+
+
+*Axial CECT of the heart in a 15-year-old patient with a history of multiple rhabdomyomas shows complete involution of masses with only small fatty deposits now seen along the interventricular septum, consistent with known TSC.*
+
+
+*Four-chamber view from a fetal echocardiogram shows an echogenic mass in the apex of the right ventricle (RV), most consistent with a rhabdomyoma. The patient was later diagnosed with TSC. A mass this size will likely have no physiologic effect on the cardiac function.*
+
+
+*Gross pathology of the heart shows a well-defined mass arising from the wall of the ventricle. Histology confirmed a rhabdomyoma.*
+
+
+*SSFP bright blood cine short-axis MR in a neonate demonstrates a large, hypointense rhabdomyoma within the RV wall .*
+
+
+*SSFP cine short-axis MR in same patient at 13 years of age demonstrates near-complete resolution of the rhabdomyoma with minimal residual tumor . The RV appears borderline dilated, & the LV appears normal.*
+
+
+*Postnatal axial US in a patient with tuberous sclerosis shows a large echogenic mass filling the LV. Rhabdomyomas are often large at birth but usually spontaneously regress postnatally.*
+
+
+*Four-chamber view double IR image from a cardiac MR demonstrates an echogenic mass filling the LV, consistent with a rhabdomyoma. Masses of this size may have cardiac obstruction & heart failure. Note the marked enlargement of the heart in this neonate.*
+
+
+### Additional Images
+
+
+*CT-derived 3D-printed heart model demonstrates a rhabdomyoma in the LV free wall of a teenager being considered for mass resection due to refractory ventricular tachycardia.*
+
+
+*Postnatal echocardiogram in the parasternal long axis shows a large mass along the interventricular septum of the LV. Rhabdomyomas may grow during pregnancy but usually spontaneously regress postnatally.*
+
+
+*Gross pathology shows a rhabdomyoma causing dramatic LV wall thickening. Rhabdomyomas can vary widely in size, number, & morphology.*
+
+
+*Echocardiogram in a neonate with TSC shows persistence of multiple echogenic rhabdomyomas in the heart.*
+
+
+*Four-chamber echocardiogram of the fetal heart shows a right atrial rhabdomyoma . This is a far less common location for rhabdomyoma than the ventricles.*
+
+
+*Four-chamber fetal echocardiogram shows a large, echogenic solitary tumor in the ventricular septum, which makes both the left ventricular & RV volumes small.*
+
+
+*Axial T1 MR of a newborn with an in utero diagnosis of a cardiac mass shows dramatic LV wall thickening . The infant was hemodynamically stable. The prognosis for rhabdomyomas is good if there are no complications in utero or in the first 6 months of life (as these lesions regress over time).*
+
+
+*Follow-up axial T1 MR in the same patient at 2 years of age shows marked involution of the mass with residual wall thickening.*
+
diff --git a/docs_md/articles/spigelian-hernia_3bbee7e5-dcd2-423c-a079-ce530cdb08c0.md b/docs_md/articles/spigelian-hernia_3bbee7e5-dcd2-423c-a079-ce530cdb08c0.md
new file mode 100644
index 0000000..04d6a93
--- /dev/null
+++ b/docs_md/articles/spigelian-hernia_3bbee7e5-dcd2-423c-a079-ce530cdb08c0.md
@@ -0,0 +1,334 @@
+---
+title: "Spigelian Hernia"
+docid: "3bbee7e5-dcd2-423c-a079-ce530cdb08c0"
+authors:
+ - key: "c1df94ab-4a9f-44c4-add7-1f174fb9ac45"
+ value: "Siva P. Raman, MD"
+breadcrumbs:
+ -
+ name: "Gastrointestinal"
+ slug: "gastrointestinal"
+ treeNodeId: "b52263f7-5978-4a22-a17d-7260e0033943"
+ -
+ name: "Diagnosis"
+ slug: "diagnosis"
+ treeNodeId: "5a7c51af-b1c6-4629-8f0e-d99e6fe57a98"
+ -
+ name: "Peritoneum, Mesentery, and Abdominal Wall"
+ slug: "peritoneum-mesentery-and-abdominal-"
+ treeNodeId: "a3fb9f00-f894-4b38-9e01-2f78406cf547"
+ -
+ name: "External Hernias"
+ slug: "external-hernias"
+ treeNodeId: "71ab3f79-4332-463c-9f60-d3dd2902d974"
+ -
+ name: "Spigelian Hernia"
+ slug: "spigelian-hernia"
+ treeNodeId: null
+category: "Gastrointestinal"
+documentVersionId: "7720c8c2-19fd-4aa0-a7dc-c23026d61a8a"
+imageCount: 13
+lastUpdated: "03/12/25"
+pageDescription: "Spigelian Hernia"
+pageKeywords: "Gastrointestinal, Diagnosis, Peritoneum, Mesentery, and Abdominal Wall, External Hernias, Spigelian Hernia"
+pageTitle: "Spigelian Hernia | STATdx"
+enhancedTitle: "Spigelian Hernia"
+type: "DX"
+references: true
+ddx: true
+cases: 2
+breadcrumbs:
+ - "Gastrointestinal"
+ - "Diagnosis"
+ - "Peritoneum, Mesentery, and Abdominal Wall"
+ - "External Hernias"
+ - "Spigelian Hernia"
+---
+# KEY FACTS
+
+- ## Terminology
+
+
+ - Hernia through defect in aponeurosis of internal oblique and transverse abdominal muscles
+- ## Imaging
+
+
+ - Hernia occurs along lateral border of rectus abdominis muscles, inferior/lateral to umbilicus, at level of arcuate line
+ - Occurs at or below arcuate line due to lack of posterior rectus sheath at this level
+ - Lies deep to external oblique aponeurosis and muscle
+ - 90% within **Spigelian belt**, 6-cm transverse band above line joining anterior superior iliac spines
+ - Most often contains portions of greater omentum, small bowel, or colon
+ - Rarely can involve appendix, bladder, and other abdominal/pelvic structures
+ - Defect size is usually small (usually < 2 cm), resulting in narrow hernia neck and high risk of strangulation
+- ## Top Differential Diagnoses
+
+
+ - Other abdominal wall hernias
+ - Subcutaneous or intramuscular lipoma
+ - Subcutaneous masses, fluid collections, or hematoma
+- ## Pathology
+
+
+ - Probably multifactorial etiology, including congenital weakness of Spigelian fascia
+ - Usually congenital in children and acquired in adults
+ - Prior history of abdominal surgery and obesity are biggest risk factors in adults
+ - Other risk factors include multiple pregnancies, rapid weight loss, COPD, and trauma
+- ## Clinical Issues
+
+
+ - Rare hernia that accounts for 1-2% of anterior abdominal wall hernias
+ - Difficult to diagnose clinically due to deep anatomic location, especially in obese patients
+ - Most common symptoms are pain and palpable bulge most apparent when standing
+ - Surgical treatment indicated in virtually all patients due to high risk of strangulation and incarceration
+
+# TERMINOLOGY
+
+- ## Abbreviations
+
+
+ - Spigelian hernia (SH)
+- ## Synonyms
+
+
+ - Lateral ventral hernia; anterolateral hernia; hernia through conjoint tendon
+- ## Definitions
+
+
+ - Hernia through defect in aponeurosis of internal oblique and transverse abdominal muscles
+ - Spigelian aponeurosis: Aponeurosis of internal oblique and transverse abdominal muscles
+
+# IMAGING
+
+- ## General Features
+
+
+ - ### Best diagnostic clue
+
+
+ - Hernia located lateral to rectus muscle and caudal/lateral to umbilicus, which is covered by intact external oblique muscle
+ - ### Location
+
+
+ - Hernia sac extends through defect in aponeurosis of transverse abdominal and internal oblique muscles
+ - Typically at or below level of arcuate line = semicircular line
+ - Occur at or below arcuate line due to lack of posterior rectus sheath at this level
+ - Lies deep to external oblique aponeurosis
+ - External oblique aponeurosis usually remains intact (hernial sac is intermuscular)
+ - Occurs along lateral border of rectus abdominis muscles, inferior and lateral to umbilicus, at level of arcuate line
+ - 90% of SHs are within **Spigelian belt of Spangen**, 6-cm transverse band above line joining both anterior superior iliac spines
+ - 2 primary types
+ - **Interstitial or interparietal SH**: Located below major oblique muscle among muscle layers of abdominal wall
+ - By far most common (98% of cases)
+ - **Subcutaneous SH**: Hernia sac crosses major oblique aponeurosis and becomes superficial (crosses beyond muscle layer of wall)
+ - Very rare
+ - May have slight left-sided predominance, although exact reason is unknown
+ - ### Morphology
+
+
+ - Defect size range: 1- to 7.5-cm diameter (most defects small and < 2 cm in size)
+ - Most often contains portions of greater omentum, small bowel, or colon
+ - Rarely can involve appendix, bladder, and other abdominal/pelvic structures
+- ## CT Findings
+
+
+ - Hernia defect in aponeurosis of transverse abdominal and internal oblique muscles
+ - Lateral to rectus sheath, caudal to umbilicus, and deep to external oblique muscle and fascia
+ - Herniation of omentum ± bowel loops
+- ## Imaging Recommendations
+
+
+ - ### Best imaging tool
+
+
+ - CECT
+- ## Ultrasonographic Findings
+
+
+ - Begin at lateral margin of rectus abdominis in transverse plane at umbilicus
+ - As transducer is moved inferiorly, inferior epigastric artery can be identified
+ - SH can be visualized along linea semilunaris
+ - Cough and Valsalva maneuver during exam may help increase conspicuity of hernia
+
+# DIFFERENTIAL DIAGNOSIS
+
+- [Ventral Hernia](/document/ventral-hernia/ab08cd87-4342-4825-948b-d02fc178078f)
+ - Majority occur through midline aponeurosis
+ - Incisional hernia through off-midline incision can mimic SH
+ - No intact external oblique muscle or fascia
+- [Umbilical Hernia](/document/umbilical-hernia/ff51faeb-9832-4e87-a6cc-ca45673d754f)
+ - Bowel, fat, or ascites protruding through umbilical defect in midline
+ - SHs occur inferior and lateral to umbilicus
+- [Hernia Through Laparoscopy Port](/document/ventral-hernia/ab08cd87-4342-4825-948b-d02fc178078f)
+ - Usually smaller defect and tend to be located medial or lateral to spigelian site
+- [Rectus Sheath Hematoma](/document/retroperitoneal-hemorrhage/56d5188d-85d3-49ff-af89-2b9d08608931)
+ - Cylindrical, heterogeneous mass within sheath without true fascial defect or hernia
+ - Easily differentiated from hernia on CT
+- ## Subcutaneous or Intramuscular Lipoma
+
+
+ - Should be easily distinguished from hernia on CT
+
+# PATHOLOGY
+
+- ## General Features
+
+
+ - ### Etiology
+
+
+ - Probably multifactorial etiology, including congenital weakness of Spigelian fascia
+ - Abdominal wall at site of SH intrinsically weak due to lack of posterior sheath behind rectus muscle
+ - Usually congenital defect in children and infants
+ - Usually acquired defects in adults
+ - Prior history of abdominal surgery and obesity are biggest risk factors in adults for development of SH
+ - Other risk factors include multiple pregnancies, rapid weight loss, COPD, and trauma
+ - ### Associated abnormalities
+
+
+ - Undescended testis (17%) in children; ipsilateral
+ - Other anterior wall defects (e.g., omphalocele, bladder extrophy, prune belly)
+ - Coexisting ventral, inguinal, umbilical hernia
+- ## Gross Pathologic & Surgical Features
+
+
+ - Interparietal or interstitial herniation (i.e., hernias cross transversus abdominis and internal oblique muscles but are behind external oblique aponeurosis)
+ - Contents: Omentum ± short segment of small or large bowel
+
+# CLINICAL ISSUES
+
+- ## Presentation
+
+
+ - Can be asymptomatic
+ - Most common symptoms are pain and palpable bulge or mass, usually most apparent when standing
+ - Symptoms of bowel obstruction due to high predisposition for incarceration
+ - Difficult to diagnose clinically due to deep anatomic location, especially in obese patients
+- ## Demographics
+
+
+ - ### Age
+
+
+ - Patients between 40-70 years of age
+ - ### Sex
+
+
+ - Children: M:F = 2:1
+ - Essentially equal among adults, although possibly very minimal female predominance
+ - ### Epidemiology
+
+
+ - Accounts for 1-2% of anterior abdominal hernias
+ - Bilateral hernia: 15% incidence in children
+- ## Natural History & Prognosis
+
+
+ - Omentum within SH may infarct and cause symptoms
+ - Hernia defect tends to be tight with narrow diameter of hernia neck (usually < 2 cm), making strangulation very common (24% of patients at presentation)
+- ## Treatment
+
+
+ - Surgical treatment recommended in virtually all patients due to high risk of strangulation and incarceration
+ - Surgical treatment can be performed using either open or laparoscopic technique, although laparoscopic treatment has now become preferred option
+ - Surgical treatment usually performed with primary mesh repair or mesh reinforcement
+ - Recurrence rates after mesh repair are quite low
+
+# DIAGNOSTIC CHECKLIST
+
+- ## Consider
+
+
+ - Pre-/intraoperative US for accurate localization of SH, especially in obese patients
+ - Extensive intraoperative dissection, distortion of tissue planes, and morbidity risks may be avoided
+- ## Image Interpretation Pearls
+
+
+ - Incisional hernias lateral to rectus muscle can mimic SH
+ - Incisional hernias have no intact external oblique muscle or aponeurosis
+
+ f4a8e939-fd6a-4921-859e-0b6f62cfc0f4
+
+## References
+
+# Selected References
+
+1. [Shrestha P et al: Spigelian hernia: a case report. JNMA J Nepal Med Assoc. 62(270):145-7, 2024](http://www.ncbi.nlm.nih.gov/pubmed/?term=38409978%5Bpmid%5D)
+1. [Hanzalova I et al: Spigelian hernia: current approaches to surgical treatment-a review. Hernia. 26(6):1427-33, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=34665343%5Bpmid%5D)
+1. [Azar SF et al: MDCT imaging in Spigelian hernia, clinical, and surgical implications. Clin Imaging. 74:131-8, 2021](http://www.ncbi.nlm.nih.gov/pubmed/?term=33493970%5Bpmid%5D)
+1. [Lavin A et al: Incarcerated Spigelian hernias: a rare cause of a high-grade small bowel obstruction. Cureus. 12(3):e7397, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32337123%5Bpmid%5D)
+1. [Webber V et al: Contemporary thoughts on the management of Spigelian hernia. Hernia. 21(3):355-61, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28097450%5Bpmid%5D)
+1. [Martin M et al: Spigelian hernia: CT findings and clinical relevance. Abdom Imaging. 38(2):260-4, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=22476335%5Bpmid%5D)
+1. [Mustaffa N et al: Education and imaging. Gastrointestinal: Spigelian hernia; an uncommon cause of longstanding intermittent abdominal pain. J Gastroenterol Hepatol. 28(1):202, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=23278154%5Bpmid%5D)
+1. [Sucandy I et al: Spigelian hernia, diagnosis, and minimally invasive repair: a case series of 11 patients. Am Surg. 79(8):E284-5, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=23896238%5Bpmid%5D)
+1. [Perrakis A et al: Spigel hernia: a single center experience in a rare hernia entity. Hernia. 16(4):439-44, 2012](http://www.ncbi.nlm.nih.gov/pubmed/?term=22644060%5Bpmid%5D)
+1. [Salameh JR: Primary and unusual abdominal wall hernias. Surg Clin North Am. 88(1):45-60, viii, 2008](http://www.ncbi.nlm.nih.gov/pubmed/?term=18267161%5Bpmid%5D)
+1. [Jamadar DA et al: Sonography of inguinal region hernias. AJR Am J Roentgenol. 187(1):185-90, 2006](http://www.ncbi.nlm.nih.gov/pubmed/?term=16794175%5Bpmid%5D)
+1. [Losanoff JE et al: Spigelian hernia in a child: case report and review of the literature. Hernia. 6(4): 191-3, 2002](http://www.ncbi.nlm.nih.gov/pubmed/?term=12424600%5Bpmid%5D)
+1. [Losanoff JE et al: Recurrent Spigelian hernia: a rare cause of colonic obstruction. Hernia. 5(2): 101-4, 2001](http://www.ncbi.nlm.nih.gov/pubmed/?term=11505645%5Bpmid%5D)
+1. [Losanoff JE et al: Incarcerated Spigelian hernia in morbidly obese patients: the role of intraoperative ultrasonography for hernia localization. Obes Surg. 7(3): 211-4, 1997](http://www.ncbi.nlm.nih.gov/pubmed/?term=9730551%5Bpmid%5D)
+1. [Harrison LA et al: Abdominal wall hernias: review of herniography and correlation with cross-sectional imaging. Radiographics. 15(2):315-32, 1995](http://www.ncbi.nlm.nih.gov/pubmed/?term=7761638%5Bpmid%5D)
+
+## Differential diagnosis
+
+### Abdominal Wall Mass
+DDX:d51e2268-67b6-4a60-9222-f5a86f61ddec
+
+### Acute Left Abdominal Pain
+DDX:65c32297-ce9e-41dd-80b5-60fd7160f2a6
+
+### Defect in Abdominal Wall (Hernia)
+DDX:5af046fa-59ef-45b5-952b-acbcdee36196
+
+## Cases
+
+- {'cases': [{'authors': [{'key': '64470aa4-5429-4786-81fa-be44c86ca020', 'value': 'Kristine S Spinelli, MD'}], 'caseVersionId': 'c5463905-e3f8-4cd0-a8de-0aa0b61e8e55', 'description': 'Classic spigelian hernia on CECT.\n\nA loop of large intestine is seen herniated lateral to the rectus abdominus muscle (arrow, #1-3), consistent with a spigelian hernia.', 'history': None, 'imagePoolId': 'af273cd7-9a32-4a1b-b833-5dac98949716', 'name': 'Classic', 'teachingPoint': None, 'demographics': '65 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'cc436c73-ea4f-45ce-bd88-4db6ade70016', 'description': 'Axial CECT shows aortic and iliac aneurysms and an incidental spigelian hernia. The hernia (open arrow, #1) contains a segment of ascending colon, but there is no sign of bowel obstruction.', 'history': 'Elderly man being evaluated for an abdominal aortic aneurysm.', 'imagePoolId': '9571e5a8-af45-4e4b-8cd5-6a171815798c', 'name': 'Incidental finding', 'teachingPoint': None, 'demographics': '76 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'e7340c27-1d19-43a2-917f-e918df5add1c', 'description': 'CT shows a small bowel obstruction and a spigelian hernia.\n\nThe hernia (open arrow, #2) is evident, just lateral to the rectus muscle. A segment of small bowel herniates through the defect, resulting in partial obstruction. The hernia and obstruction were confirmed and corrected at surgery.', 'history': 'Middle-aged woman with distended abdomen and abdominal pain.', 'imagePoolId': 'e81acda9-0fe8-4001-8c86-e483141eeebd', 'name': 'With partial bowel obstruction', 'teachingPoint': None, 'demographics': '62 Years old female'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'ea9291ee-372a-4332-b115-a57f974b92d1', 'description': 'CT shows herniation of descending colon through spigelian aponeurosis.\n\nA frontal radiograph (#1) shows the distorted and displaced descending colon (arrow). Note the defect (open arrow, #4) in the abdominal wall lateral to the rectus muscle, through which a portion of the descending colon herniates. Note that the external oblique muscle (curved arrow, #2) and its aponeurosis remain intact, making the hernia sac an intramuscular process, which is classic for a spigelian hernia.', 'history': None, 'imagePoolId': '54664b68-275e-40eb-90aa-a8a8a0fe1aff', 'name': 'Classic, with colon', 'teachingPoint': None, 'demographics': '52 Years old male'}], 'caseType': 'typical', 'name': 'TYPICAL'}
+- {'cases': [{'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '8fe62ec3-1a09-40ef-b14a-99463fe13e8c', 'description': 'CT shows distended, ischemic bowel, obstructed in a spigelian hernia.\n\nFree air (curved arrow, #1) indicated bowel perforation. The small intestine is dilated and pneumatosis (arrow, #2-4) indicates bowel ischemia. The point of obstruction was a spigelian hernia (open arrow, #4).\n\nComment: Infarcted bowel was resected at surgery, but the patient expired soon after surgery.', 'history': 'Elderly woman with distended abdomen and pain.', 'imagePoolId': '5290ab4d-9f98-4d51-b5b2-1ce3ef0f25ac', 'name': 'With bowel obstruction and ischemia', 'teachingPoint': None, 'demographics': '92 Years old female'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'c4d2db95-3bb0-4f9c-9388-b9d0a3ee2490', 'description': 'Axial CECT shows a spigelian hernia, with herniation of omental fat through a defect in the aponeurosis of the transverse abdominal and internal oblique muscles, covered by an intact aponeurosis of the external oblique muscle. Also present within the hernia is a thick-walled tubular structure (arrows, #1-4) (inflamed appendix), seen arising from the tip of the cecum.', 'history': 'Right lower quadrant pain & fever.', 'imagePoolId': '9333dddf-fbad-4976-ba1b-8d74d01ca29b', 'name': 'Inflamed appendix within spigelian hernia', 'teachingPoint': None, 'demographics': '81 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '0a940857-19ac-4e61-89d0-ca2c275d88ab', 'description': 'A series of axial (#1-7) and coronal reformatted (#8-14) CT sections shows an intact external oblique muscle and its aponeurosis (curved arrows, #2-5,10-13), though these are thin and stretched over a subtle fat density bulge in the left lower abdominal wall, caudal and lateral to the umbilicus (open arrows, #1,8). A defect in the aponeurosis of the internal oblique and transverse abdominal muscles (arrows, #6,12-13) is a Spigelian hernia, and the herniated omental fat accounts for the other signs and symptoms.\n\nComment: The intact external oblique muscle is a distinguishing feature not found in cases of incisional hernias, which may occur in the same location.', 'history': 'Pain sharply localized to the left lower quadrant on straining.', 'imagePoolId': '24dd810d-998e-4ae6-8a53-edbd3aaaa6a1', 'name': 'Small and subtle', 'teachingPoint': None, 'demographics': '37 Years old male'}], 'caseType': 'variant', 'name': 'VARIANT'}
+
+
+## Images
+
+
+### Selected Images
+
+
+*Axial CECT demonstrates a Spigelian hernia arising just lateral to the rectus muscle. A segment of small bowel herniates through the defect, resulting in partial obstruction. The hernia and obstruction were confirmed and corrected at surgery.*
+
+
+*Axial NECT demonstrates a small Spigelian hernia in the left lower quadrant, inferior and lateral to the umbilicus. Note the layer of the external oblique muscle overlying the hernia sac.*
+
+
+*Axial NECT in a patient being imaged for iliac aneurysms demonstrates an incidental spigelian hernia. The hernia contains a segment of ascending colon, but there is no sign of bowel obstruction.*
+
+
+*Axial CECT shows a small bowel obstruction and a Spigelian hernia . A segment of small bowel herniates through the defect, resulting in obstruction and dilatation of the upstream bowel .*
+
+
+### Additional Images
+
+
+*Axial CECT shows a Spigelian hernia just lateral to the rectus muscle with an obstructed, herniated descending colon.*
+
+
+*Axial CECT shows a left Spigelian hernia .*
+
+
+*Axial NECT shows a loop of large intestine herniating lateral to the rectus abdominis muscle, consistent with a Spigelian hernia.*
+
+
+*Axial NECT shows aortic and iliac aneurysms and an incidental Spigelian hernia . The hernia contains a segment of ascending colon, but there is no sign of bowel obstruction.*
+
+
+*Axial CECT shows a Spigelian hernia with herniation of omental fat through a defect in the aponeurosis of the transverse abdominal and internal oblique muscles, covered by an intact aponeurosis of the external oblique muscle. Also present within the hernia is a thick-walled tubular structure (inflamed appendix) seen arising from the tip of the cecum.*
+
+
+*Axial CECT shows a Spigelian hernia with herniation of omental fat through a defect in the aponeurosis of the transverse abdominal and internal oblique muscles, covered by an intact aponeurosis of the external oblique muscle. Also present within the hernia is a thick-walled tubular structure (inflamed appendix) seen arising from the tip of the cecum.*
+
+
+*Axial T2 MR demonstrates a Spigelian hernia in the left lower quadrant, inferior and lateral to the umbilicus. Note the layer of the external oblique muscle overlying the hernia sac.*
+
+
+*Axial CECT in a patient with left lower quadrant pain demonstrates a Spigelian hernia containing a fat-containing lesion , which extends from the surface of the colon with adjacent fat stranding or inflammation. This represents epiploic appendagitis within a Spigelian hernia.*
+
+
+*Axial CECT demonstrates a Spigelian hernia containing a fat-containing lesion , which extends from the surface of the colon with adjacent fat stranding or inflammation. This represents epiploic appendagitis within a Spigelian hernia.*
+
diff --git a/docs_md/articles/subependymoma_b899ded1-d2f2-4dc4-9812-48d3fb194117.md b/docs_md/articles/subependymoma_b899ded1-d2f2-4dc4-9812-48d3fb194117.md
new file mode 100644
index 0000000..a990ffd
--- /dev/null
+++ b/docs_md/articles/subependymoma_b899ded1-d2f2-4dc4-9812-48d3fb194117.md
@@ -0,0 +1,475 @@
+---
+title: "Subependymoma"
+docid: "b899ded1-d2f2-4dc4-9812-48d3fb194117"
+authors:
+ - key: "8d5254e9-8dda-478b-8f08-bdee97a32c79"
+ value: "Karen L. Salzman, MD, FACR"
+breadcrumbs:
+ -
+ name: "Brain"
+ slug: "brain"
+ treeNodeId: "6d8829f1-14d7-45af-8675-255189aa526a"
+ -
+ name: "Diagnosis"
+ slug: "diagnosis"
+ treeNodeId: "51c00394-446e-4a38-94af-d3b1d14d34e8"
+ -
+ name: "Pathology-Based Diagnoses"
+ slug: "pathology-based-diagnoses"
+ treeNodeId: "d9d3a8ed-f21b-4831-8c77-591a3500ef77"
+ -
+ name: "Neoplasms"
+ slug: "neoplasms"
+ treeNodeId: "dca72b7f-4b36-409d-a717-47d0cea8b0d2"
+ -
+ name: "Gliomas, Glioneuronal Tumors, and Neuronal Tumors"
+ slug: "gliomas-glioneuronal-tumors-and-ne-"
+ treeNodeId: "62497e91-93fd-4a5c-8d7e-f7cd31d2aea6"
+ -
+ name: "Ependymal tumors"
+ slug: "ependymal-tumors"
+ treeNodeId: "5c42c2a0-9f62-4aa6-8991-affcac46ef82"
+ -
+ name: "Subependymoma"
+ slug: "subependymoma"
+ treeNodeId: null
+category: "Brain"
+documentVersionId: "5ebccc99-3007-4fb8-8a42-b794e41e26dd"
+imageCount: 19
+lastUpdated: "08/05/20"
+pageDescription: "Subependymoma"
+pageKeywords: "Brain, Diagnosis, Pathology-Based Diagnoses, Neoplasms, Gliomas, Glioneuronal Tumors, and Neuronal Tumors, Ependymal tumors, Subependymoma"
+pageTitle: "Subependymoma | STATdx"
+enhancedTitle: "Subependymoma"
+type: "DX"
+references: true
+breadcrumbs:
+ - "Brain"
+ - "Diagnosis"
+ - "Pathology-Based Diagnoses"
+ - "Neoplasms"
+ - "Gliomas, Glioneuronal Tumors, and Neuronal Tumors"
+ - "Ependymal tumors"
+ - "Subependymoma"
+---
+# KEY FACTS
+
+- ## Terminology
+
+
+ - Rare, benign, well-differentiated, intraventricular ependymal tumor, typically attached to ventricular wall
+- ## Imaging
+
+
+ - Intraventricular, inferior 4th ventricle typical (60%)
+ - Other locations: Lateral > 3rd ventricle > spinal cord
+ - T2-/FLAIR hyperintense intraventricular mass
+ - Heterogeneity related to cystic changes; blood products or Ca⁺⁺ may be seen in larger lesions
+ - Variable enhancement, typically none to mild
+ - T2 and FLAIR are often most sensitive sequences
+- ## Top Differential Diagnoses
+
+
+ - Ependymoma
+ - Central neurocytoma
+ - Subependymal giant cell astrocytoma
+ - Choroid plexus papilloma (CPP)
+ - Hemangioblastoma
+ - Metastases
+- ## Pathology
+
+
+ - WHO grade 1
+- ## Clinical Issues
+
+
+ - 40% become symptomatic, often supratentorial
+ - Related to increased intracranial pressure, hydrocephalus
+ - Present in middle-aged/elderly adults (typically 5th-6th decades)
+ - Treatment: Conservative management with serial imaging if asymptomatic patient
+ - Surgical resection is curative in most cases
+ - Excellent prognosis for supratentorial lesions
+ - Recurrence is extremely rare
+- ## Diagnostic Checklist
+
+
+ - If 4th or lateral ventricular hyperintense mass in older man (50-60 years old), think subependymoma
+
+# TERMINOLOGY
+
+- ## Synonyms
+
+
+ - Older literature: Subependymal glomerulate astrocytoma, subependymal astrocytoma, subependymal mixed glioma
+- ## Definitions
+
+
+ - Rare, benign, well-differentiated, intraventricular ependymal tumor, often attached to ventricular wall
+
+# IMAGING
+
+- ## General Features
+
+
+ - ### Best diagnostic clue
+
+
+ - T2-hyperintense, lobular, nonenhancing, intraventricular mass
+ - ### Location
+
+
+ - Typical: Intraventricular, inferior 4th ventricle (60%)
+ - Often protrudes through foramen of Magendie
+ - Other locations: Lateral > 3rd ventricle > spinal cord (cervical or cervicothoracic)
+ - Lateral ventricle: Attached to septum pellucidum or lateral wall
+ - Rare: Periventricular
+ - ### Size
+
+
+ - Typically small: 1-2 cm
+ - May become large: > 5 cm
+ - More commonly symptomatic when large
+ - ### Morphology
+
+
+ - Well-defined, solid, lobular mass
+ - When large, may see cysts, hemorrhage, Ca⁺⁺
+- ## CT Findings
+
+
+ - ### NECT
+
+
+ - Iso- to hypodense intraventricular mass
+ - Cysts or Ca⁺⁺ may be seen in larger lesions
+ - Rarely hemorrhage
+ - ### CECT
+
+
+ - No or mild enhancement typical
+ - Heterogeneous enhancement may be seen
+- ## MR Findings
+
+
+ - ### T1WI
+
+
+ - Intraventricular mass, hypo- or isointense to white matter
+ - Typically homogeneous solid mass
+ - Heterogeneity may be seen in larger lesions
+ - ### T2WI
+
+
+ - Hyperintense intraventricular mass
+ - Heterogeneity related to cystic changes; blood products or Ca⁺⁺ may be seen in larger lesions
+ - No edema seen in adjacent brain parenchyma
+ - ### FLAIR
+
+
+ - Hyperintense intraventricular mass
+ - No edema seen in adjacent brain parenchyma
+ - ### T2* GRE
+
+
+ - May see Ca⁺⁺ bloom in larger lesions and 4th ventricle location
+ - ### T1WI C+
+
+
+ - Variable enhancement, typically none to mild
+ - Marked enhancement may be seen: More common in 4th than lateral ventricular subependymomas
+ - ### MRS
+
+
+ - Low metabolites reported
+ - Lactate peak present in subependymoma
+ - Elevated Cho peak in central neurocytoma compared with subependymoma
+- ## Nuclear Medicine Findings
+
+
+ - ### PET
+
+
+ - Rare reports show exceedingly low rates of glucose metabolism and kinetic constants
+ - Hypometabolism indicates low cellular density and slow growth
+- ## Imaging Recommendations
+
+
+ - ### Best imaging tool
+
+
+ - MR is most sensitive
+ - CT may be useful for Ca⁺⁺
+ - ### Protocol advice
+
+
+ - Multiplanar contrast-enhanced MR, including T2, FLAIR
+
+# DIFFERENTIAL DIAGNOSIS
+
+- ## Ependymoma
+
+
+ - Younger patients
+ - Heterogeneous enhancing mass with edema
+ - Typically 4th ventricular mass with hydrocephalus
+ - Often parenchymal when supratentorial
+- ## Central Neurocytoma
+
+
+ - Typical "bubbly" appearance, Ca⁺⁺ common
+ - Lateral ventricle, attached to septum pellucidum
+ - Moderate to strong enhancement
+- [Subependymal Giant Cell Astrocytoma](/document/subependymal-giant-cell-astrocytoma/da263200-4b41-4f9d-b4c1-e56c04be46c5)
+ - Enhancing mass at foramen of Monro
+ - Ca⁺⁺ common
+ - Tuberous sclerosis patients: Subependymal nodules, cortical tubers, white matter lesions
+- [Choroid Plexus Papilloma](/document/choroid-plexus-papilloma/18e712f5-8553-487d-a939-044336cbf0ad)
+ - Typically pediatric tumors, lateral ventricle
+ - In adults, 4th ventricle
+ - Enhancing papillary mass, hydrocephalus common
+- [Hemangioblastoma](/document/hemangioblastoma/cd94800c-d577-441b-9ca1-eaa98783dd46)
+ - Cystic mass with enhancing mural nodule
+ - Typically cerebellar hemispheres, often at pial surface
+ - Rarely intraventricular
+- ## Metastases
+
+
+ - Primary tumor often known
+ - Often multiple lesions at gray-white junctions
+ - Typically involve choroid plexus if intraventricular
+- [Cavernous Malformation](/document/cavernous-malformation/d6c0dfc6-25d3-4713-941f-373c68ca8f0d)
+ - Rarely intraventricular, 2.5-11% of cases
+ - Ca⁺⁺ and T2 hypointense hemosiderin rim common
+ - Enhancement variable
+
+# PATHOLOGY
+
+- ## General Features
+
+
+ - ### Etiology
+
+
+ - Proposed cells of origin: Subependymal glia, astrocytes of subependymal plate, ependymal cells
+ - Development from subependymal glial precursors appears likely
+ - ### Genetics
+
+
+ - Most are sporadic
+ - Rare familial cases have been reported
+ - ### Associated abnormalities
+
+
+ - Contains both astrocytes and ependymal elements
+ - Occasionally coexists with cellular ependymomas
+ - Rare: Multiple lesions
+- ## Staging, Grading, & Classification
+
+
+ - WHO grade 1
+- ## Gross Pathologic & Surgical Features
+
+
+ - Solid, well-delineated, white to grayish avascular mass
+ - Firmly attached to site of origin
+ - 4th ventricle: Floor typical
+ - Lateral ventricle: Septum pellucidum or lateral wall
+ - Larger lesions are lobulated, more often Ca⁺⁺; hemorrhage, cyst formation common
+ - 4th ventricular lesions often protrude out of foramen of Magendie
+- ## Microscopic Features
+
+
+ - Highly fibrillar, low cellularity with nuclei clustering
+ - Microcystic change common in tumors near foramen of Monro
+ - Ca⁺⁺ is commonly seen in 4th ventricle tumors
+ - Mitoses are rare or absent, MIB < 1%
+ - Hemorrhage is rare
+ - Immunohistochemistry: Strongly GFAP(+)
+ - Reports of brainstem subependymomas with H3K27M mutations (not more aggressive)
+ - Electron microscopy: Closely packed cell processes filled with glial intermediate filaments
+
+# CLINICAL ISSUES
+
+- ## Presentation
+
+
+ - ### Most common signs/symptoms
+
+
+ - Most asymptomatic
+ - 40% become symptomatic, often supratentorial
+ - Related to increased intracranial pressure, hydrocephalus
+ - Headache, gait ataxia, visual disturbance, cranial neuropathy, nystagmus, vertigo, nausea, vomiting
+ - If spinal location, motor or sensory deficits
+- ## Demographics
+
+
+ - ### Age
+
+
+ - Middle-aged/elderly adult (typically 5th-6th decades)
+ - Asymptomatic patients: Mean age = 60 years
+ - Symptomatic patients: Mean age = 40 years
+ - Rare in children
+ - ### Sex
+
+
+ - Male predominance, M:F = 2.3:1
+ - ### Epidemiology
+
+
+ - Reported in 0.5-1% of autopsies
+ - Account for 0.7% of intracranial neoplasms
+ - Represent ~ 8% of ependymal tumors
+- ## Natural History & Prognosis
+
+
+ - Excellent prognosis for supratentorial lesions
+ - Recurrence is extremely rare
+ - Complications include hydrocephalus and rarely hemorrhage
+ - Rare, benign, slow-growing tumors often found incidentally at imaging or autopsy
+- ## Treatment
+
+
+ - Surgical resection is curative in most cases
+ - Lateral ventricle lesions: Complete resection
+ - 4th ventricle lesions: Subtotal resection more common
+ - Perioperative mortality low but increased by attachment of tumor to adjacent structures
+ - If hydrocephalus, CSF diversion may be required
+ - Adjuvant radiation therapy is controversial
+ - Conservative management with serial imaging if asymptomatic
+
+# DIAGNOSTIC CHECKLIST
+
+- ## Consider
+
+
+ - Other intraventricular tumors tend to enhance more prominently
+ - May be indistinguishable from ependymoma or central neurocytoma
+ - Differential diagnosis varies with age
+ - Adults: Central neurocytoma, choroid plexus papilloma, metastases, hemangioblastoma
+ - Children: Ependymoma, choroid plexus papilloma, subependymal giant cell astrocytoma
+- ## Image Interpretation Pearls
+
+
+ - If 4th or lateral ventricular hyperintense mass in older man, think subependymoma
+ - T2 and FLAIR are often most sensitive
+
+ 411ddf02-7d9e-49d8-ad4f-5ce7fc41fc3f
+
+## References
+
+# Selected References
+
+1. [Pontillo G et al: Is this truly a "leave-me-alone" lesion? An unusual case of multiple ring-shaped lateral ventricular nodules. World Neurosurg. 136:32-6, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=31901494%5Bpmid%5D)
+1. [Wu L et al: Subependymoma of the conus medullaris with cystic formation: case report and a literature review. World Neurosurg. 137:235-8, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32081826%5Bpmid%5D)
+1. [Klotz E et al: Minimizing cortical disturbance to access ventricular subependymoma - a novel approach utilizing spinal minimally invasive tubular retractor system. Surg Neurol Int. 10:95, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=31528433%5Bpmid%5D)
+1. [Mikula AL et al: Subependymoma involving multiple spinal cord levels: A clinicopathological case series with chromosomal microarray analysis. Neuropathology. 39(2):97-105, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=30856298%5Bpmid%5D)
+1. [Yao K et al: Detection of H3K27M mutation in cases of brain stem subependymoma. Hum Pathol. 84:262-9, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=30389438%5Bpmid%5D)
+1. [Moinuddin FM et al: Bilateral lateral ventricular subependymoma with extensive multiplicity presenting with hemorrhage. Neuroradiol J. 31(1):27-31, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=28696174%5Bpmid%5D)
+1. [Muly S et al: MRI of intracranial intraventricular lesions. Clin Imaging. 52:226-39, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=30138862%5Bpmid%5D)
+1. [Varma A et al: Surgical management and long-term outcome of intracranial subependymoma. Acta Neurochir (Wien). 160(9):1793-9, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=29915887%5Bpmid%5D)
+1. [Leeper H et al: Recent advances in the classification and treatment of ependymomas. Curr Treat Options Oncol. 18(9):55, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28795287%5Bpmid%5D)
+1. [Nguyen HS et al: Intracranial subependymoma: a SEER analysis 2004-2013. World Neurosurg. 101:599-605, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28232153%5Bpmid%5D)
+1. [Ueda F et al: MR spectroscopy to distinguish between supratentorial intraventricular subependymoma and central neurocytoma. Magn Reson Med Sci. 16(3):223-30 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=27941295%5Bpmid%5D)
+1. Louis DN et al: WHO Classification of Tumours of the Central Nervous System: Subependymoma. Lyon: IARC Press. 102-3, 2016
+1. [Zhou S et al: Neuroradiological features of cervical and cervicothoracic intraspinal subependymomas: a study of five cases. Clin Radiol. 71(5):499.e9-15, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=26944695%5Bpmid%5D)
+1. [Bi Z et al: Clinical, radiological, and pathological features in 43 cases of intracranial subependymoma. J Neurosurg. 122(1):49-60, 2015](http://www.ncbi.nlm.nih.gov/pubmed/?term=25361493%5Bpmid%5D)
+1. [Arvanitis LD et al: A 40-year-old male with an intraventricular tumor. Combined tanycytic ependymoma and subependymoma. Brain Pathol. 23(3):359-60, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=23587142%5Bpmid%5D)
+1. [Hou Z et al: Clinical features and management of intracranial subependymomas in children. J Clin Neurosci. 20(1):84-8, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=23117139%5Bpmid%5D)
+1. [Iwasaki M et al: Thoracolumbar intramedullary subependymoma with multiple cystic formation: a case report and review. Eur Spine J. 22 Suppl 3:S317-20, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=22562689%5Bpmid%5D)
+1. [Smith AB et al: From the radiologic pathology archives: intraventricular neoplasms: radiologic-pathologic correlation. Radiographics. 33(1):21-43, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=23322825%5Bpmid%5D)
+1. [Cunha AM et al: Cerebellopontine angle subependymoma without fourth ventricle extension: an uncommon tumor in a rare location. Neuropathology. 32(2):164-70, 2012](http://www.ncbi.nlm.nih.gov/pubmed/?term=21692863%5Bpmid%5D)
+1. [Jain A et al: Subependymoma: clinical features and surgical outcomes. Neurol Res. 34(7):677-84, 2012](http://www.ncbi.nlm.nih.gov/pubmed/?term=22747714%5Bpmid%5D)
+1. [Koral K et al: Subependymoma of the cerebellopontine angle and prepontine cistern in a 15-year-old adolescent boy. AJNR Am J Neuroradiol. 29(1):190-1, 2008](http://www.ncbi.nlm.nih.gov/pubmed/?term=17925361%5Bpmid%5D)
+1. [Romoli S et al: Unusual exophytic subependymoma in the bulbo-cerebellar angle. Case report. J Neurosurg Sci. 51(2):81-4, 2007](http://www.ncbi.nlm.nih.gov/pubmed/?term=17571040%5Bpmid%5D)
+1. [Rushing EJ et al: Subependymoma revisited: clinicopathological evaluation of 83 cases. J Neurooncol. 85(3):297-305, 2007](http://www.ncbi.nlm.nih.gov/pubmed/?term=17569000%5Bpmid%5D)
+1. [Ragel BT et al: Subependymomas: an analysis of clinical and imaging features. Neurosurgery. 58(5):881-90; discussion 881-90, 2006](http://www.ncbi.nlm.nih.gov/pubmed/?term=16639322%5Bpmid%5D)
+1. [Rath TJ et al: Massive symptomatic subependymoma of the lateral ventricles: case report and review of the literature. Neuroradiology. 47(3):183-8, 2005](http://www.ncbi.nlm.nih.gov/pubmed/?term=15702322%5Bpmid%5D)
+1. [Shuangshoti S et al: Supratentorial extraventricular ependymal neoplasms: a clinicopathologic study of 32 patients. Cancer. 103(12):2598-605, 2005](http://www.ncbi.nlm.nih.gov/pubmed/?term=15861411%5Bpmid%5D)
+1. [Kim HC et al: Subependymoma in the third ventricle in a child. Clin Imaging. 28(5):381-4, 2004](http://www.ncbi.nlm.nih.gov/pubmed/?term=15471674%5Bpmid%5D)
+1. [Im SH et al: Clinicopathological study of seven cases of symptomatic supratentorial subependymoma. J Neurooncol. 61(1):57-67, 2003](http://www.ncbi.nlm.nih.gov/pubmed/?term=12587796%5Bpmid%5D)
+1. [Seol HJ et al: A case of recurrent subependymoma with subependymal seeding: case report. J Neurooncol. 62(3):315-20, 2003](http://www.ncbi.nlm.nih.gov/pubmed/?term=12777084%5Bpmid%5D)
+1. Burger PC et al: Surgical pathology of the nervous system and its coverings: The Brain: Tumors. 4th ed. Philadelphia: Churchill Livingstone. 250-4, 2002
+1. Ironside JW et al: Diagnostic pathology of nervous system tumours: Ependymal and choroid plexus tumors. 1st ed. Edinburgh: Churchill Livingstone. 145-83, 2002
+1. [Nishio S et al: Tumours around the foramen of Monro: clinical and neuroimaging features and their differential diagnosis. J Clin Neurosci. 9(2):137-41, 2002](http://www.ncbi.nlm.nih.gov/pubmed/?term=11922700%5Bpmid%5D)
+1. [Fontenele GI et al: Symptomatic child case of subependymoma in the fourth ventricle without hydrocephalus. Radiat Med. 19(1):37-42, 2001](http://www.ncbi.nlm.nih.gov/pubmed/?term=11305617%5Bpmid%5D)
+1. Wiestler OD et al: Pathology and genetics of tumours of the nervous system: Subependymoma. Lyon: IARC Press. 80-1, 2000
+1. [Maiuri F et al: Symptomatic subependymomas of the lateral ventricles. Report of eight cases. Clin Neurol Neurosurg. 99(1):17-22, 1997](http://www.ncbi.nlm.nih.gov/pubmed/?term=9107462%5Bpmid%5D)
+1. [Mineura K et al: Subependymoma of the septum pellucidum: characterization by PET. J Neurooncol. 32(2):143-7, 1997](http://www.ncbi.nlm.nih.gov/pubmed/?term=9120543%5Bpmid%5D)
+1. [Jallo GI et al: Intramedullary subependymoma of the spinal cord. Neurosurgery. 38(2):251-7, 1996](http://www.ncbi.nlm.nih.gov/pubmed/?term=8869051%5Bpmid%5D)
+1. [Chiechi MV et al: Intracranial subependymomas: CT and MR imaging features in 24 cases. AJR Am J Roentgenol. 165(5):1245-50, 1995](http://www.ncbi.nlm.nih.gov/pubmed/?term=7572512%5Bpmid%5D)
+1. [Furie DM et al: Supratentorial ependymomas and subependymomas: CT and MR appearance. J Comput Assist Tomogr. 19(4):518-26, 1995](http://www.ncbi.nlm.nih.gov/pubmed/?term=7622676%5Bpmid%5D)
+1. [Hoeffel C et al: MR manifestations of subependymomas. AJNR Am J Neuroradiol. 16(10):2121-9, 1995](http://www.ncbi.nlm.nih.gov/pubmed/?term=8585504%5Bpmid%5D)
+1. [Silverstein JE et al: MRI of intracranial subependymomas. J Comput Assist Tomogr. 19(2):264-7, 1995](http://www.ncbi.nlm.nih.gov/pubmed/?term=7890853%5Bpmid%5D)
+1. [Iqbal Z et al: Subependymoma of the lateral ventricle: case report and literature review. Br J Neurosurg. 8(1):83-5, 1994](http://www.ncbi.nlm.nih.gov/pubmed/?term=8011200%5Bpmid%5D)
+1. [Ryken TC et al: Familial occurrence of subependymoma. Report of two cases. J Neurosurg. 80(6):1108-11, 1994](http://www.ncbi.nlm.nih.gov/pubmed/?term=8189269%5Bpmid%5D)
+1. [Lindboe CF et al: Hemorrhage in a highly vascularized subependymoma of the septum pellucidum: case report. Neurosurgery. 31(4):741-5, 1992](http://www.ncbi.nlm.nih.gov/pubmed/?term=1407461%5Bpmid%5D)
+1. [Spoto GP et al: Intracranial ependymoma and subependymoma: MR manifestations. AJNR Am J Neuroradiol. 11(1):83-91, 1990](http://www.ncbi.nlm.nih.gov/pubmed/?term=2105621%5Bpmid%5D)
+
+
+## Images
+
+
+### Selected Images
+
+
+*Sagittal T2 MR shows a solid, hyperintense mass along the inferior 4th ventricle in a 64-year-old man with headaches. A subependymoma was found at resection. These 4th ventricular tumors are often asymptomatic. T2 and FLAIR are typically the most sensitive sequences to identify this WHO grade 1 tumor.*
+
+
+*Sagittal graphic shows a solid, well-circumscribed mass arising from the floor of the 4th ventricle with mild mass effect . Note the lack of hydrocephalus and edema in the adjacent brain, typical of a subependymoma.*
+
+
+*Axial T2 MR shows a hyperintense mass along the inferior 4th ventricle at the level of the medulla. This case shows classic imaging of a subependymoma.*
+
+
+*Axial FLAIR MR in a 62-year-old man with a headache shows a hyperintense mass filling the 4th ventricle . Note the lack of edema in the surrounding brain. Subependymomas are most commonly found in the inferior 4th ventricle (50-60%). The lateral ventricle is the next most common location (30-40%). Surgical resection is typically curative.*
+
+
+*Axial T1 C+ MR shows an enhancing mass in the 4th ventricular outflow tract . The moderate enhancement is uncommon. Subependymomas classically have no or minimal enhancement. They can protrude through the foramen of Magendie. In this case, tumor is also present anterior to the cerebellar hemisphere through the foramen of Luschka.*
+
+
+*Axial T2 MR shows a heterogeneous right lateral ventricle mass in a 58-year-old man. Subependymoma was found at resection. Imaging mimics a cavernous malformation.*
+
+
+*Coronal graphic shows a solid, well-circumscribed, intraventricular mass attached to the septum pellucidum with neither mass effect nor hydrocephalus. Subependymomas are typically asymptomatic, but they may cause hydrocephalus and increased intracranial pressure.*
+
+
+*Coronal T1 C+ MR in a 35-year-old man shows a lateral ventricle mass with central enhancement and mild mass effect on the septum pellucidum. Note the lack of associated hydrocephalus, typical of a subependymoma.*
+
+
+*Axial FLAIR MR shows a hyperintense lateral ventricle mass at the level of the septum pellucidum. Subependymomas in the lateral ventricle are typically attached to the septum pellucidum or lateral wall.*
+
+
+*Sagittal T1 C+ MR shows a large enhancing mass filling the 4th ventricle. Cysts, blood, and Ca⁺⁺ may be seen in larger subependymomas. Imaging may mimic other ventricular masses, including choroid plexus papilloma, ependymoma, and hemangioblastoma.*
+
+
+### Additional Images
+
+
+*Axial T1 C+ MR in an older man with headaches shows a well-circumscribed, enhancing mass attached to the septum pellucidum; it proved to be a subependymoma. No enhancement or mild enhancement is typical.*
+
+
+*Axial NECT shows a calcified 4th ventricular mass in this 52-year-old woman. Calcification is more commonly seen in 4th ventricular subependymomas than in others.*
+
+
+*Sagittal T1WI C+ MR in a 60-year-old man shows a classic, nonenhancing 4th ventricular subependymoma . The origin in the 4th ventricular floor is typical. The mass may be best seen on T2WI &/or FLAIR.*
+
+
+*Axial T2WI MR shows a circumscribed, hyperintense, subependymal mass. No enhancement was present on contrast images. This 56-year-old man with headaches was diagnosed with subependymoma in an atypical periventricular location.*
+
+
+*Sagittal T2WI MR shows a solid, hyperintense mass along the inferior 4th ventricle in a 43-year-old man with headaches and trigeminal neuralgia. Subependymoma was found at resection. These 4th ventricular tumors are often asymptomatic. T2 and FLAIR are typically the most sensitive sequences for this tumor.*
+
+
+*Axial FLAIR MR shows a hyperintense lateral ventricle mass at the level of the septum pellucidum. When in the lateral ventricle, subependymomas are typically attached to the septum pellucidum or lateral wall.*
+
+
+*Axial T1 C+ MR shows a markedly enhancing 4th ventricular mass . Differential considerations include ependymoma and choroid plexus papilloma. Subependymoma was diagnosed at resection.*
+
+
+*Sagittal T2WI MR shows a heterogeneous mass filling the 4th ventricle with inferior extension. Enhancement was present on contrast images of this WHO grade I subependymoma. Cysts, blood, and Ca⁺⁺ may be seen in larger lesions. Imaging mimics ependymoma and hemangioblastoma.*
+
+
+*Sagittal FLAIR MR shows a solid, hyperintense mass along the inferior 4th ventricle in a 64-year-old man with headaches. Subependymoma was found at resection. These 4th ventricular tumors are often asymptomatic. T2 and FLAIR are typically the most sensitive sequences to identify this WHO grade I tumor.*
+
diff --git a/docs_md/articles/temporal-bone-facial-nerve-schwannoma_cf2bcc82-4a1b-4989-adeb-f4e82116111b.md b/docs_md/articles/temporal-bone-facial-nerve-schwannoma_cf2bcc82-4a1b-4989-adeb-f4e82116111b.md
new file mode 100644
index 0000000..07f3815
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+++ b/docs_md/articles/temporal-bone-facial-nerve-schwannoma_cf2bcc82-4a1b-4989-adeb-f4e82116111b.md
@@ -0,0 +1,437 @@
+---
+title: "Temporal Bone Facial Nerve Schwannoma"
+docid: "cf2bcc82-4a1b-4989-adeb-f4e82116111b"
+authors:
+ - key: "07a2c087-6202-49e7-870b-7aa162d18f06"
+ value: "Bronwyn E. Hamilton, MD"
+ - key: "33151213-01b2-4542-9105-342e006b3915"
+ value: "H. Ric Harnsberger, MD"
+breadcrumbs:
+ -
+ name: "Head and Neck"
+ slug: "head-and-neck"
+ treeNodeId: "ed24ed8c-5d57-4629-879b-447b82d2973d"
+ -
+ name: "Diagnosis"
+ slug: "diagnosis"
+ treeNodeId: "19b6b986-97d0-40e7-b317-00f0c5cd8fa2"
+ -
+ name: "Temporal Bone"
+ slug: "temporal-bone"
+ treeNodeId: "9ad7d7b2-b2e4-4de2-be04-55ce607560c9"
+ -
+ name: "Intratemporal Facial Nerve"
+ slug: "intratemporal-facial-nerve"
+ treeNodeId: "35b77f60-796d-460f-8bac-4a187a150171"
+ -
+ name: "Benign and Malignant Tumors"
+ slug: "benign-and-malignant-tumors"
+ treeNodeId: "353e7622-0bb3-4dce-96d6-f5f889dad7cb"
+ -
+ name: "Temporal Bone Facial Nerve Schwannoma"
+ slug: "temporal-bone-facial-nerve-schwann-"
+ treeNodeId: null
+category: "Head and Neck"
+cmeTopicId: "e4d7bd7c-9fb3-4ba4-a909-8cd12d4f09e5"
+documentVersionId: "925a57f2-14ad-4c18-93d5-9586c1b3d8a0"
+imageCount: 18
+lastUpdated: "08/18/21"
+pageDescription: "Temporal Bone Facial Nerve Schwannoma"
+pageKeywords: "Head and Neck, Diagnosis, Temporal Bone, Intratemporal Facial Nerve, Benign and Malignant Tumors, Temporal Bone Facial Nerve Schwannoma"
+pageTitle: "Temporal Bone Facial Nerve Schwannoma | STATdx"
+enhancedTitle: "Temporal Bone Facial Nerve Schwannoma"
+type: "DX"
+references: true
+ddx: true
+cases: 2
+breadcrumbs:
+ - "Head and Neck"
+ - "Diagnosis"
+ - "Temporal Bone"
+ - "Intratemporal Facial Nerve"
+ - "Benign and Malignant Tumors"
+ - "Temporal Bone Facial Nerve Schwannoma"
+---
+# KEY FACTS
+
+- ## Terminology
+
+
+ - Facial nerve schwannoma (FNS): Rare benign tumor of Schwann cells that invests intratemporal facial nerve (CNVII)
+- ## Imaging
+
+
+ - Temporal bone CT: Tubular mass spanning multiple intratemporal CNVII segments with smooth enlargement of bony CNVII canal
+ - **> 90%** of FNS span ≥ 3 intratemporal CNVII segments
+ - T1 C+ MR: Homogeneously enhancing tubular mass ± intramural cysts
+ - Temporal bone CT appearance dictated by specific location
+ - **Geniculate fossa FNS**: Ovoid, smooth enlargement of geniculate fossa with projections into labyrinthine ± anterior tympanic segments of CNVII
+ - **Tympanic segment FNS**: Pedunculated FNS emanates from tympanic CNVII into middle ear
+ - **Mastoid segment FNS**: Either tubular with sharp margins or globular with irregular margins (breaks into mastoid air cells)
+ - **Greater superficial petrosal nerve (****GSPN) schwannoma**: Enlargement of GSPN canal; middle cranial fossa mass
+- ## Top Differential Diagnoses
+
+
+ - Normal intratemporal facial nerve enhancement
+ - Bell palsy (herpetic facial paralysis)
+ - Intratemporal facial nerve venous malformation
+ - Intratemporal CNVII perineural malignancy
+- ## Clinical Issues
+
+
+ - Symptoms: Hearing loss (70%), CNVII paresis (50%)
+ - Treatment options
+ - Conservative: Observation
+ - Surgical treatment: Complete removal is goal
+ - Radiotherapy: Nerve edema and hearing loss limit utility
+
+# TERMINOLOGY
+
+- ## Abbreviations
+
+
+ - Facial nerve schwannoma (FNS)
+- ## Synonyms
+
+
+ - Facial neuroma, facial neurilemmoma
+- ## Definitions
+
+
+ - FNS: Rare benign tumor of Schwann cells that invests intratemporal facial nerve (CNVII)
+
+# IMAGING
+
+- ## General Features
+
+
+ - ### Best diagnostic clue
+
+
+ - Temporal bone CT: Tubular mass spanning multiple intratemporal CNVII segments with smooth enlargement of bony CNVII canal
+ - T1 C+ MR: Homogeneously enhancing tubular mass ± intramural cysts
+ - ### Location
+
+
+ - Most common location: Geniculate ganglion
+ - **> 90%** of FNS span ≥ **3 intratemporal CNVII segments**
+ - ### Size
+
+
+ - Often long (multiple centimeters)
+ - Cross-sectional measurement usually < 1 cm
+ - ### Morphology
+
+
+ - Location dependent
+ - Geniculate fossa: Ovoid or triangular
+ - Greater superficial petrosal nerve (GSPN): Ovoid, projects into middle cranial fossa
+ - Tympanic CNVII: Lobulates into middle ear
+ - Mastoid CNVII: Irregular margin if breaks into surrounding air cells
+ - Parotid CNVII: Tubular or ovoid mass along CNVII intraparotid course
+ - **Tubular shape** along multiple CNVII segments
+- ## CT Findings
+
+
+ - ### CECT
+
+
+ - No role for CECT in this diagnosis
+ - Use enhanced MR instead
+ - ### Bone CT
+
+
+ - General temporal bone CT appearances
+ - Tubular enlargement of CNVII canal
+ - Bony margins are smooth, benign-appearing
+ - Temporal bone CT appearance is dictated by specific location of FNS along CNVII
+ - **Geniculate fossa FNS**: Ovoid, smooth enlargement of geniculate fossa
+ - Tumor projects into labyrinthine ± anterior tympanic segments of CNVII
+ - **Tympanic segment FNS**: Pedunculated FNS emanates from tympanic segment of CNVII into middle ear cavity
+ - **Mastoid segment FNS**: Either tubular with sharp margins or globular with irregular margins
+ - Shape depends on whether FNS breaks into surrounding mastoid air cells
+ - **GSPN schwannoma**: Ovoid enlargement of GSPN canal anteromedial to geniculate fossa
+- ## MR Findings
+
+
+ - ### T1WI
+
+
+ - Intermediate- to low-signal lesion
+ - ### T2WI
+
+
+ - High-signal lesion
+ - ### T1WI C+
+
+
+ - **Geniculate ganglion FNS**: Ovoid, enhancing mass in enlarged geniculate fossa
+ - Tumor tails project into labyrinthine ± anterior tympanic segments of CNVII
+ - **Tympanic segment FNS**: Pedunculates into middle ear cavity
+ - **Mastoid segment FNS**
+ - Either tubular with sharp margins or globular with irregular margins
+ - Depends on whether it breaks into surrounding mastoid air cells
+ - **GSPN schwannoma**
+ - Diagnosed when enhancing mass is seen in location of GSPN
+ - Just anteromedial to geniculate fossa
+ - Middle cranial fossa enhancing mass with connection to geniculate fossa
+ - May be difficult to establish extraaxial nature of this schwannoma
+- ## Imaging Recommendations
+
+
+ - ### Best imaging tool
+
+
+ - Patient presents with hearing loss ± CNVII paresis
+ - Start with thin-section T1 C+ fat-saturated MR in axial and coronal plane through internal auditory canal (IAC) and temporal bone
+ - If intratemporal, tubular enhancing mass is diagnosed on MR, then temporal bone CT helps delineate nature of lesion based on bone changes
+
+# DIFFERENTIAL DIAGNOSIS
+
+- [Normal Intratemporal Facial Nerve Enhancement](/document/intratemporal-facial-nerve-enhance-/a3569ec5-a566-411d-877f-41ad832e3fd2)
+ - Clinical: Asymptomatic
+ - Temporal bone CT: Intratemporal CNVII canal is normal
+ - T1 C+ MR: Geniculate ganglion, anterior tympanic ± mastoid segments enhance normally
+ - Labyrinthine CNVII does not enhance normally
+- [Bell Palsy (Herpetic Facial Paralysis)](/document/bell-palsy/0958e575-8f76-4d70-b806-0dbed9c62a67)
+ - Clinical: Sudden onset of peripheral CNVII paralysis
+ - Temporal bone CT: Normal intratemporal CNVII canal
+ - T1 C+ MR: Intratemporal + IAC fundal CNVII enhancement
+- [Intratemporal Facial Nerve Venous Malformation](/document/temporal-bone-facial-nerve-venous--/dcd6a44e-cbe6-457c-9b03-598a2b874ece)
+ - Clinical: Sudden unilateral peripheral CNVII paralysis
+ - Temporal bone CT: Intratumoral honeycomb or bone spicules
+ - T1 C+ MR: Poorly circumscribed, geniculate fossa enhancing mass
+- ## Intratemporal CNVII Perineural Malignancy
+
+
+ - Clinical: Known or recurrent parotid malignancy
+ - Temporal bone CT: Mastoid CNVII canal is enlarged but less than in FNS
+ - T1 C+ MR: Infiltrating parotid mass is present
+
+# PATHOLOGY
+
+- ## General Features
+
+
+ - ### Etiology
+
+
+ - Slowly growing, benign tumor from Schwann cells investing intratemporal CNVII
+ - ### Genetics
+
+
+ - If multiple schwannomas ± meningiomas, think neurofibromatosis type 2 (NF2)
+ - ### Associated abnormalities
+
+
+ - NF2: Bilateral vestibular schwannomas; other schwannoma and meningioma possible
+- ## Gross Pathologic & Surgical Features
+
+
+ - Tan, ovoid-tubular, encapsulated mass
+ - Arises from outer nerve sheath layer of CNVII, expanding eccentrically away from nerve
+- ## Microscopic Features
+
+
+ - Benign, encapsulated tumor made up of bundles of spindle-shaped Schwann cells forming whorled pattern
+ - Cellular architecture consists of densely cellular (Antoni A) areas ± loose, myxomatous (Antoni B) areas
+ - S100 protein stain: Strongly and diffusely positive in both nucleus and cytoplasm
+ - May display **intramural cystic changes**
+
+# CLINICAL ISSUES
+
+- ## Presentation
+
+
+ - ### Most common signs/symptoms
+
+
+ - Hearing loss present in ~ 70%
+ - Facial nerve symptoms present in ~ 50%
+ - CNVII weakness or paralysis > involuntary facial movements
+ - Bell palsy-like CNVII paralysis is rare
+ - Ear ± facial pain
+ - ### Other signs/symptoms
+
+
+ - Cerebellopontine angle (CPA)-IAC FNS: Sensorineural hearing loss, vertigo, and tinnitus
+ - Larger tympanic and mastoid segments FNS
+ - Avascular retrotympanic mass
+ - Conductive hearing loss
+- ## Demographics
+
+
+ - ### Age
+
+
+ - Mean age at presentation: 50 years
+ - ### Epidemiology
+
+
+ - FNS is rare tumor (< 1% of intrapetrous tumors)
+ - Within temporal bone > > intraparotid > CPA-IAC
+- ## Natural History & Prognosis
+
+
+ - Slow-growing benign tumor
+ - Eventually enlarges sufficiently to cause hearing loss and other cranial neuropathy
+ - Some tumors (< 10%) do not grow or become symptomatic
+ - Risk of facial weakness ↑ with intratemporal involvement
+ - Risk for facial weakness and hearing loss ↑ with more segments involved
+ - Risk for hearing loss ↑ with more proximal tumor
+- ## Treatment
+
+
+ - **Conservative management**
+ - If CNVII paralysis is absent or mild when diagnosed, surgical cure can be worse than disease
+ - Incomplete recovery of full CNVII function may occur despite surgical restoration of CNVII continuity
+ - Follow until CNVII symptoms begin to develop
+ - Treatment used in older adult patients
+ - **Surgical treatment**
+ - Goal = complete FNS removal with preservation of hearing and CNVII function restoration
+ - Size-specific surgical techniques
+ - Large FNS: Remove tumor + CNVII cable graft
+ - Small FNS (< 1 cm): CNVII transposition with primary anastomosis
+ - Location-specific surgery
+ - Labyrinthine or geniculate FNS: Middle cranial fossa and transmastoid approaches combined
+ - Tympanic-mastoid FNS: Transmastoid alone
+ - **Radiotherapy**
+ - Stereotactic radiotherapy is possible but generally contraindicated for temporal bone location due to
+ - Postradiation edema and nerve swelling
+ - Risk of hearing loss
+
+# DIAGNOSTIC CHECKLIST
+
+- ## Consider
+
+
+ - Older patients with FNS often followed, not operated
+ - Younger patients without CNVII paresis often followed
+- ## Image Interpretation Pearls
+
+
+ - Intratemporal FNS: Segmental, tubular enlargement of CNVII canal
+ - Distinctive imaging findings depending on segment of CNVII involved
+ - CPA-IAC FNS: Exactly mimics vestibular schwannoma if no extension into labyrinthine segment CNVII occurs
+ - If present, labyrinthine segment tail makes imaging diagnosis
+ - Intraparotid FNS: Tubular mass in parotid coursing lateral to retromandibular vein
+ - If present, mastoid segment tail suggests diagnosis
+ - Differentiate from perineural parotid malignancy
+
+ 01b8eeb4-a52d-4271-b49c-199cc46770da
+
+## References
+
+# Selected References
+
+1. [Bartindale M et al: Facial schwannoma management outcomes: a systematic review of the literature. Otolaryngol Head Neck Surg. 163(2):293-301, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32228141%5Bpmid%5D)
+1. [Bartindale M et al: The natural history of facial schwannomas: a meta-analysis of case series. J Neurol Surg B Skull Base. 80(5):458-68, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=31534886%5Bpmid%5D)
+1. [Loos E et al: Cochlear erosion due to a facial nerve schwannoma. J Int Adv Otol. 15(2):330-2, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=31287431%5Bpmid%5D)
+1. [Park JC et al: Large facial nerve schwannoma with extensive temporal bone destruction. Otol Neurotol. 39(3):e220-1, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=29342046%5Bpmid%5D)
+1. [Chen WJ et al: Case analysis of temporal bone lesions with facial paralysis as main manifestation and literature review. Cancer Biomark. 20(2):199-205, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28826175%5Bpmid%5D)
+1. [Nishijima H et al: Facial nerve paralysis associated with temporal bone masses. Auris Nasus Larynx. 44(5):548-53, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28161243%5Bpmid%5D)
+1. [Schulze M et al: Improvement in imaging common temporal bone pathologies at 3 T MRI: small structures benefit from a small field of view. Clin Radiol. 72(3):267.e1-12, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28034444%5Bpmid%5D)
+1. [Yi H et al: Primary tumors of the facial nerve misdiagnosed: a case series and review of the literature. Acta Otolaryngol. 137(6):651-5, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28079432%5Bpmid%5D)
+1. [Bäck L et al: Management of facial nerve schwannoma: a single institution experience. Acta Otolaryngol. 130(10):1193-8, 2010](http://www.ncbi.nlm.nih.gov/pubmed/?term=20441526%5Bpmid%5D)
+1. [Chao WC et al: Facial nerve schwannoma. Otolaryngol Head Neck Surg. 141(1):146-7, 2009](http://www.ncbi.nlm.nih.gov/pubmed/?term=19559977%5Bpmid%5D)
+1. [Madhok R et al: Gamma knife radiosurgery for facial schwannomas. Neurosurgery. 64(6):1102-5; discussion 1105, 2009](http://www.ncbi.nlm.nih.gov/pubmed/?term=19487889%5Bpmid%5D)
+1. [Nishioka K et al: Stereotactic radiotherapy for intracranial nonacoustic schwannomas including facial nerve schwannoma. Int J Radiat Oncol Biol Phys. 75(5):1415-9, 2009](http://www.ncbi.nlm.nih.gov/pubmed/?term=19386429%5Bpmid%5D)
+1. [Thompson AL et al: Magnetic resonance imaging of facial nerve schwannoma. Laryngoscope. 119(12):2428-36, 2009](http://www.ncbi.nlm.nih.gov/pubmed/?term=19780031%5Bpmid%5D)
+1. [McMonagle B et al: Facial schwannoma: results of a large case series and review. J Laryngol Otol. 122(11):1139-50, 2008](http://www.ncbi.nlm.nih.gov/pubmed/?term=18177538%5Bpmid%5D)
+1. [Lee JD et al: Management of facial nerve schwannoma in patients with favorable facial function. Laryngoscope. 117(6):1063-8, 2007](http://www.ncbi.nlm.nih.gov/pubmed/?term=17464236%5Bpmid%5D)
+1. [Stasolla A et al: Dural tail: another face of facial nerve schwannoma? AJNR Am J Neuroradiol. 27(9):1804; author reply 1805, 2006](http://www.ncbi.nlm.nih.gov/pubmed/?term=17032843%5Bpmid%5D)
+1. [Wiggins RH 3rd et al: The many faces of facial nerve schwannoma. AJNR Am J Neuroradiol. 27(3):694-9, 2006](http://www.ncbi.nlm.nih.gov/pubmed/?term=16552018%5Bpmid%5D)
+1. [Kim CS et al: Management of intratemporal facial nerve schwannoma. Otol Neurotol. 24(2):312-6, 2003](http://www.ncbi.nlm.nih.gov/pubmed/?term=12621350%5Bpmid%5D)
+1. [Kertesz TR et al: Intratemporal facial nerve neuroma: anatomical location and radiological features. Laryngoscope. 111(7):1250-6, 2001](http://www.ncbi.nlm.nih.gov/pubmed/?term=11568549%5Bpmid%5D)
+1. [Liu R et al: Facial nerve schwannoma: surgical excision versus conservative management. Ann Otol Rhinol Laryngol. 110(11):1025-9, 2001](http://www.ncbi.nlm.nih.gov/pubmed/?term=11713912%5Bpmid%5D)
+1. [Salzman KL et al: Dumbbell schwannomas of the internal auditory canal. AJNR Am J Neuroradiol. 22(7):1368-76, 2001](http://www.ncbi.nlm.nih.gov/pubmed/?term=11498429%5Bpmid%5D)
+1. [Chung SY et al: Facial nerve schwannomas: CT and MR findings. Yonsei Med J. 39(2):148-53, 1998](http://www.ncbi.nlm.nih.gov/pubmed/?term=9587255%5Bpmid%5D)
+1. [McMenomey SO et al: Facial nerve neuromas presenting as acoustic tumors. Am J Otol. 15(3):307-12, 1994](http://www.ncbi.nlm.nih.gov/pubmed/?term=8579133%5Bpmid%5D)
+1. [Parnes LS et al: Magnetic resonance imaging of facial nerve neuromas. Laryngoscope. 101(1 Pt 1):31-5, 1991](http://www.ncbi.nlm.nih.gov/pubmed/?term=1984548%5Bpmid%5D)
+1. [Inoue Y et al: Facial nerve neuromas: CT findings. J Comput Assist Tomogr. 11(6):942-7, 1987](http://www.ncbi.nlm.nih.gov/pubmed/?term=3500193%5Bpmid%5D)
+
+## Differential diagnosis
+
+### Facial Nerve Lesion, Temporal Bone
+DDX:1428754b-a8ee-48a0-98f8-4faeebf8dbab
+
+### Hemifacial Spasm
+DDX:1b390143-1212-4447-beb3-ed9e85ef34e4
+
+### Inner Ear Lesion, Adult
+DDX:e5bbf757-d77a-4546-a848-d1a1a64cb230
+
+### Peripheral Facial Nerve Paralysis
+DDX:4da52ac4-c03c-4711-ae7e-bb4f2f7c5ab8
+
+## Cases
+
+- {'cases': [{'authors': [{'key': '33151213-01b2-4542-9105-342e006b3915', 'value': 'H. Ric Harnsberger, MD'}], 'caseVersionId': 'a65ace43-fea3-4034-8b6e-43e9d0a29dcd', 'description': 'Typical MR case of intratemporal facial nerve schwannoma (FNS) affecting the geniculate ganglion, labyrinthine segment, and fundal aspects of the facial nerve.\n\nFive MR images are presented, two T2 (#1-2) and three enhanced T1 (#3-5). Axial T2 images (#1-2) show the FNS is centered in the geniculate fossa (arrows) with a medial projection of the tumor (open arrows) along the labyrinthine segment of CN7 into the fundus of the internal auditory canal. On enhanced T1 images (#3-5), the bulk of the FNS is seen as a globoid enhancing mass (arrows) in the enlarged geniculate fossa. The enlarged enhancing labyrinthine segment of CN7 leads to a fundal component (open arrows, #3, 5) of this FNS.\n\nTeaching point: The most common location for an intratemporal FNS to be found is the geniculate ganglion/fossa. Most facial nerve schwannomas involve at least 2 regions of the intratemporal facial nerve. In this case, the fundus, labyrinthine segment, and geniculate ganglion are all affected.', 'history': 'Patient presents with gradually progressive peripheral facial nerve palsy on the right.', 'imagePoolId': 'ac4891ca-b0f3-4f5f-8328-fe0fe27846cc', 'name': 'Geniculate ganglion & labyrinthine segment CN7', 'teachingPoint': None, 'demographics': '37 Years old male'}, {'authors': [{'key': '33151213-01b2-4542-9105-342e006b3915', 'value': 'H. Ric Harnsberger, MD'}], 'caseVersionId': 'd7259f92-4ab3-4e67-8e0d-0947a575f57d', 'description': 'Typical CT-MR case of facial nerve schwannoma involving the mastoid segment of the intratemporal facial nerve.\n\nAxial and coronal bone CT images show an enlarged mastoid segment facial nerve canal (arrows, #1, 2) with dehiscence into the external auditory canal (open arrow, #1). Enhanced axial T1 MR and axial T1 MR with magnification reveal an avidly enhancing facial nerve schwannoma (arrow #3, 4) protruding into the external auditory canal (open arrow, #3, 4). The coronal enhanced T1 MR image shows the tumor (arrow, #5) to be ovoid with irregular margins where it has broken into adjacent mastoid air cells.\n\nPearl: When facial nerve schwannoma affects the mastoid segment, it may have irregular margins when it breaks into adjacent mastoid air cells.', 'history': 'Patient presents with mild hemifacial spasm that progressed to facial nerve paresis over a 3 year period.', 'imagePoolId': '340f4472-5b51-4b73-938d-93f2f5094176', 'name': 'Mastoid segment CN7', 'teachingPoint': None, 'demographics': '37 Years old male'}, {'authors': [{'key': '33151213-01b2-4542-9105-342e006b3915', 'value': 'H. Ric Harnsberger, MD'}, {'key': '365b3b45-cf39-4f87-b238-d2bc74224b16', 'value': 'Lawrence E. Ginsberg, MD'}], 'caseVersionId': '1798b265-c17f-4156-8803-ae6116fb1222', 'description': 'Typical CT-MR case of facial nerve schwannoma centered in the geniculate fossa, extending into the IAC fundus, middle cranial fossa, and middle ear.\n\nAxial bone CT images (#1-2) reveal an enlarged geniculate fossa with the tumor extending anteromedially (open arrows) along the greater superficial petrosal nerve branch, as well as pedunculating into the middle ear cavity (arrows) pushing the ossicles posterolaterally.\n\nAxial enhanced fat-saturated MR images (#3-5) show the CN7 schwannoma enhances with characteristic intramural cysts visible (arrows, #3). At the level of the IAC (#4-5) the tumor extension along the greater superficial petrosal nerve branch (open arrow), into the middle ear (arrow), and fundus of the IAC (curved arrow) can be seen. Coronal enhanced MR images (#6-7) demonstrate, to better advantage, the pedunculation of the tumor into the middle ear cavity (arrows).', 'history': 'Patient presented with a long history of slowly progressive hearing loss and facial nerve palsy.', 'imagePoolId': '1b27228c-058a-496e-9885-3b100422f0a5', 'name': 'Geniculate ganglion location; pedunculates into ME', 'teachingPoint': None, 'demographics': '71 Years old male'}, {'authors': [{'key': 'c727c995-865a-40dd-aa20-eb058ea2bd0a', 'value': 'Patricia A. Hudgins, MD, FACR'}, {'key': '94f835c8-fa13-4e8a-995b-53048e6b0605', 'value': 'Philip R. Chapman, MD'}], 'caseVersionId': 'd6154efb-bb7d-41e9-a6ba-29ff73c86668', 'description': 'Typical CT-MR case of facial nerve schwannoma involving the geniculate ganglion, tympanic and mastoid segments of the intratemporal facial nerve.\n\nAxial (#1) and coronal (#2-4) T-bone CT images show enlargement of the left geniculate ganglion (arrow, #1, 4), tympanic segment (open arrow, #1, 3) and the mastoid segment (curved arrow, #2) of the intratemporal facial nerve canal. Axial (#5-6) and coronal enhanced T1 MR (#7) images reveal the enhancing tubular facial nerve schwannoma in the geniculate ganglion (arrow, #5, 7) and the mastoid segment (curved arrow, #6). On the coronal image the cochlear membranous labyrinth (open arrow, #7) is seen below the facial nerve schwannoma. \n\nComment: The tubular morphology and absence of bony spicules around the geniculate ganglion on the bone CT definitively differentiates this facial nerve schwannoma from ossifying hemangioma.', 'history': 'Child presents with gradual left facial paresis.', 'imagePoolId': 'c5a77987-a771-476b-a7ca-1487a213142d', 'name': 'Classic', 'teachingPoint': None}, {'authors': [{'key': '33151213-01b2-4542-9105-342e006b3915', 'value': 'H. Ric Harnsberger, MD'}], 'caseVersionId': 'f11257d2-e2df-478b-a47f-44db806ffe50', 'description': 'Typical CT-MR case of intratemporal facial nerve schwannoma.\n\nAxial left temporal bone CT presented from superior to inferior (#1-7) show a tubular soft tissue mass enlarging the facial nerve canal from the tympanic segment (arrows, #1-3) through the mastoid segment (open arrows, #5-7). Notice that the mid-mastoid segment is multilobular (open arrows, #4-5).\n\nAxial (#8-15) and coronal (#16-20) enhanced fat-saturated MR images are presented from superior to inferior and posterior to anterior respectively. The tympanic segment enhancing tubular facial nerve schwannoma (arrows, #8-9,17-20) extends from the geniculate fossa anteriorly to the posterior genu posteriorly. The mastoid component of the schwannoma (open arrows, #10-17) loses its tubular shape and becomes more multilobular in the mid-mastoid area (open arrows, #10-11,16). The cochlea fluid is visible (curved arrows, #8-9,19). The schwannoma can be seen exiting into the parotid gland (open arrows, #15,17).\n\nComment: When a facial nerve schwannoma involves the mastoid segment of the facial nerve canal, it may lose its tubular shape as it breaks into adjacent air cells. When it does, its multilobular shape does not suggest schwannoma. The tubular nature of the rest of the mass, however, still allows the diagnosis to be made.', 'history': 'Patient presented with a long history of conductive hearing loss; recently, the patient developed mild facial nerve paralysis.', 'imagePoolId': 'bfdb3aff-4df3-42f1-b0ec-18bd099d1960', 'name': 'Spans geniculate ganglion to stylomastoid foramen', 'teachingPoint': None, 'demographics': '51 Years old male'}, {'authors': [{'key': '33151213-01b2-4542-9105-342e006b3915', 'value': 'H. Ric Harnsberger, MD'}], 'caseVersionId': '865a4c64-6c7e-4bc5-a84d-ebcaae83d00b', 'description': 'Typical CT-MR case of a focal intratemporal facial nerve schwannoma centered in the geniculate fossa.\n\nAxial CT images (#1,2) reveal smooth enlargement of the geniculate fossa (arrow, #1) and anterior tympanic segment facial nerve canal (open arrow). Axial and coronal enhanced fat-saturated T1 MR images (#3,4) show this lesion as an enlarged enhancement of the geniculate ganglion (arrow) and tympanic segment (open arrow, #3) of the facial nerve typical of facial nerve schwannoma.\n\nPearl: The most common location for a facial nerve schwannoma to be found within the temporal bone is the geniculate fossa/ganglion area.', 'history': 'Patient presents with 6 month history of gradual onset of facial nerve paralysis without recovery. Referring clinician ordered temporal bone CT scan for "atypical Bell palsy".', 'imagePoolId': 'c50ac11a-dc08-41aa-ad2e-5807290a39ec', 'name': 'Geniculate ganglion + anterior tympanic segment CN7', 'teachingPoint': None, 'demographics': '35 Years old male'}, {'authors': [{'key': '624acd80-0502-4325-be71-e68fec740eb3', 'value': 'Richard H. Wiggins, III, MD, CIIP, FSIIM, FAHSE, FACR'}], 'caseVersionId': '0b7764cf-f9dd-48b1-947b-627db248cab8', 'description': 'This is a typical case of a facial nerve schwannoma of the mastoid segment of the facial nerve on CT.\n\nThe axial bone algorithm CT images (#1-4) show the homogeneous soft tissue mass centered at the descending (mastoid) segment of the facial nerve on the right. There is soft tissue extending anteriorly from the mastoid segment into the posterior aspect of the middle ear cavity (arrow). The mass is homogeneous in appearance and demonstrates no surrounding aggressive changes. The axial post-contrasted CT image (#5) shows an oval soft tissue mass (open arrow) at the right stylomastoid foramen.\n\nThis case demonstrates the importance of the surrounding anatomic landscape of the facial nerve segments. The schwannoma expands through the osseous canal of the descending (mastoid) segment of the facial nerve and pedunculates into the surrounding air cells of the mastoid process, causing a pedunculated appearance of the mass.', 'history': 'Patient presented with a right middle ear mass.', 'imagePoolId': '0fa782a4-7242-4c30-82b8-5ad874492d52', 'name': 'Classic', 'teachingPoint': None, 'demographics': '52 Years old female'}], 'caseType': 'typical', 'name': 'TYPICAL'}
+- {'cases': [{'authors': [{'key': 'd19354f3-7ff2-495a-ad3f-064122e45602', 'value': 'Bernadette L. Koch, MD'}], 'caseVersionId': 'f4bcc2f0-1796-4365-a5b7-74618b67293d', 'description': 'Variant MR and CT appearance of a large facial nerve schwannoma with a large intracranial component. \n\nAxial post-contrast image shows abnormal contrast enhancement in the distal left IAC (arrow, #1), widening and abnormal enhancement of the labyrinthine segment of the facial nerve canal (open arrow, #1), and large mass in the region of the geniculate ganglion (curved arrow, #1). Coronal post-contrast image shows a small intracanalicular component (arrow, #2), the large geniculate ganglion component (open arrow, #2) and a large component extending through the mastoid segment of the facial nerve canal (curved arrow, #2), into the parotid space. Typical of many schwannomas, there is a small intramural cyst within the intracranial component. Coronal bone CT images demonstrate the enlarged descending facial nerve canal (arrow, #3), the middle ear mass (curved arrow, #4), and an eggshell covering on the massively expanded geniculate ganglion (open arrow, #4).', 'history': '16 year old with an 8 month history of progressive facial nerve paralysis.', 'imagePoolId': '9ac310b0-e605-4e12-b163-dd48b8b53b80', 'name': 'large', 'teachingPoint': None, 'demographics': '16 Years old male'}, {'authors': [{'key': '564b28bd-4dbe-4066-9201-d10d689688fb', 'value': 'Christine M. Glastonbury, MBBS'}], 'caseVersionId': '179a054d-1bdc-4d4e-8e7d-ebeb9c8204fb', 'description': 'Variant case of a facial nerve schwannoma with a large cisternal component.\n\nAxial T1 WI MR (#1) shows a large right CPA mass (arrows) which is slightly hypointense to adjacent deformed cerebellum and pons. Axial thin-slice T2 WI (#2-4) shows the predominantly solid mass (arrow) to be hyperintense to brain parenchyma. A subtle rim of T2 hyperintense CSF is evident on some slices (curved arrow) delineating this as an extra-axial mass, which can also be seen to fill the right IAC (open arrow, #3). Post-contrast T1 C+ FS (#5-9) shows heterogeneous enhancement of the mass (arrow, #5-8) and no evidence of a dural attachment. Note that the mass fills the right IAC (curved arrow, #6,8) but a second component is found in the right middle cranial fossa (open arrow, #7-9). Perfusion MR (#10) with curve #2 indicating the mass (arrow) and showing very little return to baseline in keeping with this extra-axial tumor.\n\nPearls: While the most common CPA mass is a vestibular schwannoma, it is very important to follow the entire course of the mass into the IAC and in this case along the labyrinthine segment of the facial nerve to the geniculate ganglion, confirming that it arises from the facial nerve and not the vestibular nerve.', 'history': 'This patient was being screened for dementia and a posterior fossa mass was incidentally discovered. Facial nerve function is normal, but there is mild SNHL on direct testing.', 'imagePoolId': '7f14b2ee-ba6b-4c14-a945-b2491210e9a8', 'name': 'Large cisternal component', 'teachingPoint': None, 'demographics': '53 Years old female'}, {'authors': [{'key': 'c727c995-865a-40dd-aa20-eb058ea2bd0a', 'value': 'Patricia A. Hudgins, MD, FACR'}, {'key': '6651ae1c-5f55-4d2e-9f68-46223037c90a', 'value': ' , '}], 'caseVersionId': 'e0d99c25-62fe-441a-89e0-42011e19f198', 'description': 'This is an atypical case of facial nerve schwannoma involving predominantly the geniculate ganglion, tympanic, and mastoid segments.\n\nThe four images show a large, extensive, but benign facial nerve schwannoma. The CT images of the left ear (#1-2) show there is expansion of the entire tympanic segments of CN7 (white arrows) from the expected location of the geniculate ganglion to the facial nerve recess (black arrow). There is complete opacification of the mastoid air cells, and on CT it is impossible to differentiate tumor from secretions in the middle ear and mastoids. Notice the facial nerve canal labyrinthine segment (curved arrow) and distal internal auditory canal are normal, suggesting the nerve is spared at these levels.\n\nThe MR images (#3-4) clearly show the enhancing tumor, extending from the geniculate ganglion, through the middle ear, into the mastoid complex (arrows). The proximal mastoid portion of the facial nerve is enlarged and enhances (curved arrow, #4), consistent with a facial nerve schwannoma.', 'history': 'Young adult with left facial nerve twitching, progressing to palsy.', 'imagePoolId': '7c6841c8-7b5d-4708-ae30-5a8378ddbf77', 'name': 'Tympanic and mastoid portions involved', 'teachingPoint': None}, {'authors': [{'key': 'c727c995-865a-40dd-aa20-eb058ea2bd0a', 'value': 'Patricia A. Hudgins, MD, FACR'}, {'key': '6651ae1c-5f55-4d2e-9f68-46223037c90a', 'value': ' , '}], 'caseVersionId': '04598659-00b7-4f46-8a20-963001c5d5a0', 'description': 'Variant CT-MR case of a large facial nerve schwannoma that has eroded into cochlea, causing intra-cochlear enhancement.\n\nAxial (#1) and coronal (#2) T-bone CT images of the left ear show smooth erosion and widening of the facial nerve canal from the labyrinthine segment (arrow, #1), geniculate fossa (curved arrows, #1) to proximal tympanic segment (arrow, #2). Note erosion of superior aspect of cochlea (open arrow, #2) by the schwannoma.\n\nThe MR images (#3-4) show homogeneous enhancement of the tumor, including the labyrinthine segment of the facial nerve (open arrow, #3), geniculate ganglion (arrow, #3) and mid-tympanic portion (open arrow, #4). There is enhancement in the cochlea (curved arrow, #3-4). This is likely due not to intra-cochlear extension of tumor, but to passage of gadolinium-based contrast agent into the perilymph and endolymph. Cochlear enhancement is never a normal finding.\n\nComment: It is unusual for facial nerve schwannoma to dehisce into the membranous labyrinth. Hence the designation as a variant case.', 'history': 'Patient presents with long-standing facial nerve palsy and new sensorineural hearing loss.', 'imagePoolId': '64ff3a67-bdc2-4aca-8376-459fe4f95529', 'name': 'Geniculate fossa tumor, with cochlear erosion', 'teachingPoint': None, 'demographics': '63 Years old female'}, {'authors': [{'key': '33151213-01b2-4542-9105-342e006b3915', 'value': 'H. Ric Harnsberger, MD'}], 'caseVersionId': '6a13fa49-b398-46fa-bf2b-2d5457033989', 'description': 'Variant enhanced MR case of schwannoma of the greater superficial petrosal nerve branch of the intratemporal facial nerve.\n\nSeven axial T1 C+ MR images of the temporal bone presented from superior to inferior show a well-circumscribed enhancing mass (arrow, #1-4, 7) in the left medial middle cranial fossa. At first glance meningioma or trigeminal schwannoma are suspected. Closer examination of images #4-6 reveal tumor tails along the anterior tympanic segment (curved arrow) and labyrinthine-IAC segment (open arrow, #5, 6) of the facial nerve. Schwannoma affecting the greater superficial petrosal nerve branch of the facial nerve was found at surgery.\n\nPearl: Ovoid shape with multiple intramural cysts highly suggestive of schwannoma. The fact that it tracks along the tympanic and labyrinthine segment of the facial nerve suggests its relationship to this cranial nerve. Its anatomic location focuses in on the greater superficial petrosal nerve.', 'history': 'Patient presents with left-sided facial pain. No history of facial nerve paralysis.', 'imagePoolId': 'd8c95122-4561-47c8-82a4-f324b871473a', 'name': 'Greater superficial petrosal nerve origin', 'teachingPoint': None, 'demographics': '37 Years old male'}], 'caseType': 'variant', 'name': 'VARIANT'}
+
+
+## Images
+
+
+### Selected Images
+
+
+*Axial graphic shows a tubular facial nerve schwannoma (FNS) involving the labyrinthine segment, geniculate ganglion , and anterior tympanic segment of the intratemporal facial nerve.*
+
+
+*Axial graphic shows a tubular facial nerve schwannoma (FNS) involving the labyrinthine segment, geniculate ganglion , and anterior tympanic segment of the intratemporal facial nerve.*
+
+
+*Axial bone CT in a patient with CNVII paresis shows tubular enlargement of the distal labyrinthine segment , geniculate fossa , and anterior tympanic segment of the CNVII canal. Involvement of multiple segments of the facial nerve, as in this case, is highly suggestive of FNS.*
+
+
+*Coronal bone CT in the same patient reveals the FNS involving the midtympanic segment of the facial nerve. Notice that the facial nerve bony canal "opens" into the middle ear mass .*
+
+
+*Coronal bone CT in the same patient demonstrates that the FNS also involves the mastoid CNVII , exiting the enlarged stylomastoid foramen inferiorly. The tumor has broken into adjacent air cells on its lateral margin.*
+
+
+*Axial temporal bone CT in a patient with a history of hearing loss and tinnitus shows a lobulated FNS extending along the course of the tympanic segment CNVII . The patient developed subjective right facial weakness not reproducible on clinical exam.*
+
+
+*Axial T1 C+ FS MR in the same patient shows corresponding soft tissue enhancement along the tympanic segment of CNVII. Adjacent intrinsic mastoid hyperintensity was due to T1-hyperintense secretions, not enhancing tumor.*
+
+
+*Axial temporal bone CT in a patient with progressive partial left facial nerve paralysis associated with episodes of ipsilateral otalgia shows localized expansile enlargement of the tympanic segment of the facial nerve . The patient was initially treated with steroids for presumed Bell palsy, but subsequently underwent imaging when he did not respond.*
+
+
+*Axial T1 C+ MR in the same patient shows enhancing schwannoma corresponding to the area of smooth osseous expansion on CT.*
+
+
+*Coronal T1 C+ FS MR in a patient with conductive hearing loss and facial twitching shows a multilobular, enhancing FNS that has broken into mastoid air cells and projects inferiorly along the mastoid CN segment .*
+
+
+*Axial T1 C+ MR shows an enhancing mass projecting into the medial middle cranial fossa from the greater superficial petrosal nerve. FNS diagnosis is suggested if the projections along the tympanic CNVII and along the labyrinthine CNVII into the internal auditory canal are seen.*
+
+
+### Additional Images
+
+
+*Axial left ear temporal bone CT demonstrates FNS enlarging the labyrinthine and anterior tympanic segments of the CNVII canal, the geniculate fossa , and greater superficial petrosal nerve canal .*
+
+
+*Coronal temporal bone CT of the right ear shows benign-appearing, smooth enlargement of the geniculate fossa by an ovoid-shaped FNS. Note that the roof of fossa is dehiscent .*
+
+
+*Coronal T1WI C+ MR in the same patient reveals an avidly enhancing, ovoid FNS enlarging the geniculate ganglion. Notice cochlear signal just below the tumor .*
+
+
+*Axial T1WI C+ MR reveals an enhancing FNS involving the geniculate ganglion and labyrinthine CNVII segment . The tumor has also invaded the subjacent cochlea .*
+
+
+*Paraffin section, hematoxylin & eosin stain shows there is a juxtaposition and blending of cellular Antoni A areas with hypocellular Antoni B areas . The nuclei have palisading.*
+
+
+*Paraffin section, S100 stain shows the neoplastic cells of a schwannoma are strongly and diffusely positive in both the nucleus and cytoplasm with S100 protein.*
+
+
+*Axial bone CT in a patient with an external auditory canal (EAC) polyp shows an irregular mass centered in the area of the mastoid segment of CN that appears contiguous.*
+
+
+*Axial T1WI C+ FS MR in the same patient reveals the enhancing FNS in the CNVII mastoid segment , projecting through a bony dehiscence into the EAC .*
+
diff --git a/docs_md/articles/temporal-bone-facial-nerve-venous-malformation-hemangioma_dcd6a44e-cbe6-457c-9b03-598a2b874ece.md b/docs_md/articles/temporal-bone-facial-nerve-venous-malformation-hemangioma_dcd6a44e-cbe6-457c-9b03-598a2b874ece.md
new file mode 100644
index 0000000..02fb1bf
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+++ b/docs_md/articles/temporal-bone-facial-nerve-venous-malformation-hemangioma_dcd6a44e-cbe6-457c-9b03-598a2b874ece.md
@@ -0,0 +1,458 @@
+---
+title: "Temporal Bone Facial Nerve Venous Malformation (Hemangioma)"
+docid: "dcd6a44e-cbe6-457c-9b03-598a2b874ece"
+authors:
+ - key: "07a2c087-6202-49e7-870b-7aa162d18f06"
+ value: "Bronwyn E. Hamilton, MD"
+ - key: "33151213-01b2-4542-9105-342e006b3915"
+ value: "H. Ric Harnsberger, MD"
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+ name: "Temporal Bone Facial Nerve Venous Malformation (Hemangioma)"
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+pageDescription: "Temporal Bone Facial Nerve Venous Malformation (Hemangioma)"
+pageKeywords: "Head and Neck, Diagnosis, Temporal Bone, Intratemporal Facial Nerve, Benign and Malignant Tumors, Temporal Bone Facial Nerve Venous Malformation (Hemangioma)"
+pageTitle: "Temporal Bone Facial Nerve Venous Malformation (Hemangioma) | STATdx"
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+ddx: true
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+cases: 2
+breadcrumbs:
+ - "Head and Neck"
+ - "Diagnosis"
+ - "Temporal Bone"
+ - "Intratemporal Facial Nerve"
+ - "Benign and Malignant Tumors"
+ - "Temporal Bone Facial Nerve Venous Malformation (Hemangioma)"
+---
+# KEY FACTS
+
+- ## Terminology
+
+
+ - Facial nerve venous malformation (FNVM)
+ - Older terms: Facial nerve hemangioma/ossifying hemangioma
+ - Definition: Benign developmental lesion near intratemporal CNVII in geniculate fossa area
+- ## Imaging
+
+
+ - Bone CT
+ - **Honeycomb high-density matrix** lesion (50%)
+ - Most commonly located in geniculate fossa
+ - T1 C+ FS MR
+ - Enhancing geniculate ganglion area lesion
+ - Usually with irregular margins
+- ## Top Differential Diagnoses
+
+
+ - Normal intratemporal facial nerve enhancement
+ - Intratemporal facial nerve schwannoma
+ - Bell palsy
+ - Perineural parotid malignancy on intratemporal CNVII
+ - Congenital cholesteatoma within intratemporal CNVII canal
+- ## Pathology
+
+
+ - **Immunohistochemical markers** critical to correct venous malformation (hemangioma) diagnosis
+ - Endothelial lining of vascular channels stain negatively for hemangioma-associated markers (**GLUT1 & LeY**)
+ - **Podoplanin** staining utilizing D2-40 antibody **negativity** excludes lymphatic malformation
+- ## Clinical Issues
+
+
+ - Intratemporal FNVM produces **peripheral CNVII paralysis** early in its natural history
+ - Caveat: May be described as "**atypical Bell palsy**"
+ - Treatment: Perform surgery as soon as possible
+ - Final CNVII function depends on duration of preoperative CNVII deficit
+ - Smaller lesion are extraneural, larger lesion invade CNVII
+
+# TERMINOLOGY
+
+- ## Abbreviations
+
+
+ - Facial nerve venous malformation (FNVM)
+- ## Synonyms
+
+
+ - Facial nerve hemangioma/ossifying hemangioma
+ - Historic terms for FNVM
+- ## Definitions
+
+
+ - FNVM: Benign developmental lesion near intratemporal facial nerve in geniculate fossa area
+
+# IMAGING
+
+- ## General Features
+
+
+ - ### Best diagnostic clue
+
+
+ - **Honeycomb high-density matrix** lesion in geniculate fossa area (bone CT)
+ - Enhancing geniculate ganglion area lesion with irregular margins on T1 C+ MR
+ - ### Location
+
+
+ - **Geniculate fossa area** > > internal auditory canal (IAC)
+ - ### Size
+
+
+ - Range: 2 mm to 2 cm
+ - Small at presentation, **often < 1 cm**
+ - ### Morphology
+
+
+ - Irregular, invasive-appearing margins typical
+- ## CT Findings
+
+
+ - ### Bone CT
+
+
+ - Poorly marginated lesion of geniculate fossa
+ - Larger lesions affect adjacent temporal bone
+ - Anteromedial to geniculate fossa
+ - Labyrinthine segment CNVII → IAC
+ - Dumbbell lesion appearance
+ - Amorphous**honeycomb bone changes** are distinctive
+ - Present in 50% of all lesions
+ - Seen in 100% of larger lesions
+ - Punctate high-density foci also possible
+- ## MR Findings
+
+
+ - ### T1WI
+
+
+ - Mixed signal lesion with foci of low signal within lesion matrix (ossific matrix)
+ - ### T2WI
+
+
+ - High-signal lesion with foci of low signal within lesion matrix
+ - ### FLAIR
+
+
+ - Mixed intermediate- & high-signal lesion
+ - ### T1WI C+
+
+
+ - **Avid lesion enhancement** is rule
+ - Perineural spread from geniculate ganglion
+ - Posterolateral along tympanic segment CNVII
+ - Posteromedial along labyrinthine segment CNVII → IAC
+ - **Dumbbell** appearance possible
+ - Fundal IAC FNVM, exactly mimics vestibular schwannoma
+ - Ovoid, well-demarcated, enhancing IAC mass
+ - Low-signal foci may distinguish FNVM from vestibular schwannoma
+- ## Imaging Recommendations
+
+
+ - ### Best imaging tool
+
+
+ - Imaging indicates CNVII (**facial nerve paresis**) or CNVIII (hearing loss) dysfunction
+ - 1st exam: Thin-section **T1 C+ MR** focused to cerebellopontine angle (CPA)-IAC-inner ear
+ - If MR negative or shows equivocal small area of enhancement along intratemporal CNVII, recommend **temporal** **bone CT**
+ - Bone CT may show small FNVM in geniculate fossa
+ - Inspect intratemporal CNVII canal carefully for 1- to 2-mm FNVM
+
+# DIFFERENTIAL DIAGNOSIS
+
+- [Normal Intratemporal Facial Nerve Enhancement](/document/intratemporal-facial-nerve-enhance-/a3569ec5-a566-411d-877f-41ad832e3fd2)
+ - Clinical: Asymptomatic
+ - Imaging: T1 C+ MR shows normal enhancement of geniculate ganglion, anterior tympanic CNVII, &/or mastoid segment CNVII
+ - Comment: Sometimes mistaken for facial nerve pathology
+- [Intratemporal Facial Nerve Schwannoma](/document/temporal-bone-facial-nerve-schwann-/cf2bcc82-4a1b-4989-adeb-f4e82116111b)
+ - Clinical: Hearing loss ± gradual onset of CNVII paralysis
+ - Imaging: T1 C+ MR reveals tubular enhancing mass, smoothly enlarging CNVII canal (bone CT)
+ - Comment: Most commonly centered in geniculate ganglion similar to FNVM
+- [Bell Palsy](/document/bell-palsy/0958e575-8f76-4d70-b806-0dbed9c62a67)
+ - Clinical: Acute onset of peripheral CNVII paralysis
+ - Imaging: T1 C+ MR shows prominent enhancement of all or most of intratemporal CNVII
+ - IAC enhancing tuft often present
+ - Comment: No focal mass; bone CT normal
+- ## Perineural Parotid Malignancy on Intratemporal CNVII
+
+
+ - Clinical: Parotid malignancy in history, palpable or subclinical
+ - Imaging: T1 C+ MR shows invasive parotid mass
+ - Stylomastoid foramen is tissue filled
+ - CNVII enlarged & enhancing from distal to proximal
+ - CNVII may be involved to CPA-IAC
+ - Mastoid air cell invasion also possible
+ - Comment: Continuous linear nature different from focal FNVM
+- ## Congenital Cholesteatoma Within Intratemporal CNVII Canal
+
+
+ - Clinical: Avascular mass behind intact tympanic membrane
+ - Imaging: T1 C+ MR shows nonenhancing middle ear mass tracking along CNVII canal
+ - Comment: Involvement of facial nerve canal rare with this lesion
+
+# PATHOLOGY
+
+- ## General Features
+
+
+ - ### Etiology
+
+
+ - Benign congenital venous malformation arising out of sites of anastomoses between feeding arteries in temporal bone
+- ## Staging, Grading, & Classification
+
+
+ - Classification for vascular lesions based on clinical, histopathologic, & cytologic features was introduced by Mulliken & Glowacki in 1982
+ - **Malformation** term used for errors of vascular morphogenesis that develop in utero & persist postnatally
+ - **Hemangioma** term reserved for benign vascular tumors that arise by cellular hyperplasia
+- ## Gross Pathologic & Surgical Features
+
+
+ - Richly vascular lesion without large feeding vessels
+- ## Microscopic Features
+
+
+ - H&E: Nonencapsulated venous malformation composed of dilated vascular channels of varying sizes
+ - Widely ectatic vascular channels rimmed by thin smooth muscle coats without evident elastic laminae
+ - Flattened & mitotically quiescent endothelial cells
+ - Venous malformations = low-flow lesions
+ - Ossifying type: Lesion has spicules of lamellar bone
+ - When seen, called **ossifying venous malformation**
+ - **Immunohistochemical markers** critical to correct venous malformation diagnosis
+ - Endothelial lining of vascular channels stain negatively for hemangioma-associated markers (**GLUT1 & LeY antigen**)
+ - CD31-positive endothelial lining & smooth muscle component, consistent with venous malformation
+ - Venous vs. lymphatic malformation endothelial differentiation
+ - **Podoplanin** staining utilizing D2-40 antibody **negative** for endothelial cells confirms lack of lymphatic differentiation
+
+# CLINICAL ISSUES
+
+- ## Presentation
+
+
+ - ### Most common signs/symptoms
+
+
+ - Intratemporal FNVM produces **peripheral CNVII paralysis** early in its natural history
+ - Occurs early because of intimate relationship between CNVII & FNVM
+ - Onset of CNVII paralysis usually acute: May be slowly progressive or intermittent
+ - Caveat: May be described as "**atypical Bell palsy**"
+ - IAC FNVM
+ - Sensorineural hearing loss may be more prominent symptom
+ - IAC lesion with CNVII symptoms, consider FNVM
+ - ### Other signs/symptoms
+
+
+ - Hemifacial spasm may progress to CNVII paralysis
+ - ### Clinical profile
+
+
+ - Intratemporal FNVM: Adult with relatively rapid onset of peripheral CNVII paralysis (over weeks)
+ - IAC FNVM: Adult with relatively rapid onset of CNVII paralysis with concomitant Sensorineural hearing loss (SNHL) (over weeks)
+- ## Demographics
+
+
+ - ### Age
+
+
+ - Wide range but usually adults
+ - ### Epidemiology
+
+
+ - Rare lesion
+ - 0.7% of all temporal bone lesions
+ - Slightly less common than CNVII schwannoma
+- ## Natural History & Prognosis
+
+
+ - FNVM = slowly growing lesion
+ - Proportional growth is norm
+ - Disproportionate growth can occur secondary to infection, trauma, hormonal influences, or progressive hemodynamic forces
+ - Prognosis related to size at diagnosis, severity & duration of preoperative CNVII paralysis
+ - After surgery, full CNVII function rarely regained
+- ## Treatment
+
+
+ - Surgery done as soon as possible
+ - Final facial nerve function depends on duration of preoperative CNVII deficit
+ - Surgical alternatives
+ - Middle cranial fossa (MCF) approach for lesions confined to geniculate fossa
+ - MCF-transmastoid approach for lesion of geniculate fossa & tympanic segment CNVII
+ - Small FNVM are extraneural
+ - Resection with preservation of CNVII function = goal
+ - Even with small lesions, rarely achieved
+ - Larger FNVM invades facial nerve
+ - Segmental facial nerve resection completed
+ - Followed by primary or cable graft repair of CNVII
+ - When necessary, yields poorer outcome
+
+# DIAGNOSTIC CHECKLIST
+
+- ## Consider
+
+
+ - FNVM presents with CNVII dysfunction when small
+ - Since early removal is best chance at CNVII preservation, radiologist must make diagnosis of subtle lesions
+ - Caveat: **Small FNVM** may be **subtle** on T1 C+ **MR**
+ - Use CT liberally in negative or equivocal MR
+- ## Image Interpretation Pearls
+
+
+ - Poorly circumscribed, C+ lesion in geniculate fossa in setting of CNVII paralysis is most likely FNVM
+
+ ba26f431-c00d-4d38-b485-6267fa52965a
+
+## References
+
+# Selected References
+
+1. [Rao D et al: A case of a facial nerve venous malformation presenting with crocodile tear syndrome. Surg Neurol Int. 11:3, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=31966922%5Bpmid%5D)
+1. [Bonali M et al: Endoscopic transcanal approach to geniculate ganglion hemangioma and simultaneous facial nerve reinnervation: a case report. J Int Adv Otol. 15(1):165-68, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=30924777%5Bpmid%5D)
+1. [Guerin JB et al: Facial nerve venous malformation: a radiologic and histopathologic review of 11 cases. Laryngoscope Investig Otolaryngol. 4(3):347-52, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=31236470%5Bpmid%5D)
+1. [ISSVA International Society for the Study of Vascular Anomalies. Published May 2018. Accessed 1/30/2021. https://www.issva.org/classification](https://www.issva.org/classification)
+1. [Wick CC et al: Transcanal endoscopic ear surgery for excision of a facial nerve venous malformation with interposition nerve grafting: a case report. Otol Neurotol. 38(6):895-9, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28498268%5Bpmid%5D)
+1. [Lahlou G et al: Geniculate ganglion tumors: clinical presentation and surgical results. Otolaryngol Head Neck Surg. 155(5):850-5, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=27484229%5Bpmid%5D)
+1. [Maiodna E et al: Cavernous malformation of the seventh cranial nerve: case report and review of literature. World Neurosurg. 91:676.e13-21, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=27155386%5Bpmid%5D)
+1. [Omor Y et al: "Honeycomb" sign. Presse Med. 45(5):541-3, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=27062115%5Bpmid%5D)
+1. [Yue Y et al: Retrospective case series of the imaging findings of facial nerve hemangioma. Eur Arch Otorhinolaryngol. 272(9):2497-503, 2015](http://www.ncbi.nlm.nih.gov/pubmed/?term=25108340%5Bpmid%5D)
+1. [Ma X et al: Facial nerve preservation in geniculate ganglion hemangiomas. Acta Otolaryngol. 134(9):974-6, 2014](http://www.ncbi.nlm.nih.gov/pubmed/?term=24930913%5Bpmid%5D)
+1. [Benoit MM et al: Facial nerve hemangiomas: vascular tumors or malformations? Otolaryngol Head Neck Surg. 142(1):108-14, 2010](http://www.ncbi.nlm.nih.gov/pubmed/?term=20096233%5Bpmid%5D)
+1. [Greene AK et al: Intraosseous "hemangiomas" are malformations and not tumors. Plast Reconstr Surg. 119(6):1949-50; author reply 1950, 2007](http://www.ncbi.nlm.nih.gov/pubmed/?term=17440384%5Bpmid%5D)
+1. [Isaacson B et al: Hemangiomas of the geniculate ganglion. Otol Neurotol. 26(4):796-802, 2005](http://www.ncbi.nlm.nih.gov/pubmed/?term=16015187%5Bpmid%5D)
+1. [Bernardeschi D et al: Vascular malformation (so-called hemangioma) of Scarpa's ganglion. Acta Otolaryngol. 124(9):1099-102, 2004](http://www.ncbi.nlm.nih.gov/pubmed/?term=15513557%5Bpmid%5D)
+1. [Piccirillo E et al: Management of temporal bone hemangiomas. Ann Otol Rhinol Laryngol. 113(6):431-7, 2004](http://www.ncbi.nlm.nih.gov/pubmed/?term=15224824%5Bpmid%5D)
+1. [Achilli V et al: Facial nerve hemangioma. Otol Neurotol. 23(6):1003-4, 2002](http://www.ncbi.nlm.nih.gov/pubmed/?term=12438871%5Bpmid%5D)
+1. [Friedman O et al: Temporal bone hemangiomas involving the facial nerve. Otol Neurotol. 23(5):760-6, 2002](http://www.ncbi.nlm.nih.gov/pubmed/?term=12218631%5Bpmid%5D)
+1. [Salib RJ et al: The crucial role of imaging in detection of facial nerve haemangiomas. J Laryngol Otol. 115(6):510-3, 2001](http://www.ncbi.nlm.nih.gov/pubmed/?term=11429083%5Bpmid%5D)
+1. [Dufour JJ et al: Intratemporal vascular malformations (angiomas): particular clinical features. J Otolaryngol. 23(4):250-3, 1994](http://www.ncbi.nlm.nih.gov/pubmed/?term=7996623%5Bpmid%5D)
+1. [Martin N et al: Haemangioma of the petrous bone: MRI. Neuroradiology. 34(5):420-2, 1992](http://www.ncbi.nlm.nih.gov/pubmed/?term=1407526%5Bpmid%5D)
+1. [Shelton C et al: Intratemporal facial nerve hemangiomas. Otolaryngol Head Neck Surg. 104(1):116-21, 1991](http://www.ncbi.nlm.nih.gov/pubmed/?term=1900607%5Bpmid%5D)
+1. [Lo WW et al: Intratemporal vascular tumors: detection with CT and MR imaging. Radiology. 171(2):445-8, 1989](http://www.ncbi.nlm.nih.gov/pubmed/?term=2704809%5Bpmid%5D)
+1. [Curtin HD et al: "Ossifying" hemangiomas of the temporal bone: evaluation with CT. Radiology. 164(3):831-5, 1987](http://www.ncbi.nlm.nih.gov/pubmed/?term=3112865%5Bpmid%5D)
+1. [Mulliken JB et al: Hemangiomas and vascular malformations in infants and children: a classification based on endothelial characteristics. Plast Reconstr Surg. 69(3):412-22, 1982](http://www.ncbi.nlm.nih.gov/pubmed/?term=7063565%5Bpmid%5D)
+
+## Differential diagnosis
+
+### Bony Lesions of Temporal Bone
+DDX:a33cf59d-2d6e-40cb-960e-4e1e37066d09
+
+### Facial Nerve Lesion, Temporal Bone
+DDX:1428754b-a8ee-48a0-98f8-4faeebf8dbab
+
+### Inner Ear Lesion, Adult
+DDX:e5bbf757-d77a-4546-a848-d1a1a64cb230
+
+### Peripheral Facial Nerve Paralysis
+DDX:4da52ac4-c03c-4711-ae7e-bb4f2f7c5ab8
+
+## Anatomy
+
+### Facial Nerve (CNVII)
+Brain/ANATOMY:2f4818dd-6438-405b-8561-5cbbb9c91562
+
+### Vestibulocochlear Nerve (CNVIII)
+Brain/ANATOMY:498e844d-faca-4c6a-bff1-9c6ad4993e62
+
+### Middle Ear-Mastoid Anatomy
+Head and Neck/ANATOMY:99aff289-b689-4693-9b41-2adbbda59179
+
+### Inner Ear Anatomy
+Head and Neck/ANATOMY:48ee77aa-d460-43f3-a3e2-9fd61632ca4a
+
+### CNVII (Facial Nerve)
+Head and Neck/ANATOMY:98cb2d45-e64c-4295-9662-3470cd46513a
+
+### CNVIII (Vestibulocochlear Nerve)
+Head and Neck/ANATOMY:e9917c41-94c9-46aa-b9d8-b196c375d35b
+
+## Cases
+
+- {'cases': [{'authors': [{'key': '33151213-01b2-4542-9105-342e006b3915', 'value': 'H. Ric Harnsberger, MD'}, {'key': '94f835c8-fa13-4e8a-995b-53048e6b0605', 'value': 'Philip R. Chapman, MD'}], 'caseVersionId': '151a88e3-b12d-4b87-8615-71fe3ee561ba', 'description': 'Typical T-bone CT case of ossifying facial nerve hemangioma (FNH) of the geniculate fossa.\n\nThree T-bone CT images of the right ear presented from superior to inferior show an enlarged geniculate fossa (arrow, #1-3) filled by the FNH. Within the tissue of the lesion there is visible punctate areas ossification (open arrow, #1-3) making this an "ossifying hemangioma". On the two coronal T-bone CT images shown (#4,5) the hemangioma in the enlarged geniculate fossa (arrow) is again seen with its areas of ossification (open arrow). Notice the ovoid soft tissue area just inferolateral to the FNH on the upper cochlear promontory (curved arrow). This is the belly of the tensor tympani muscle.\n\nAxial T2 MR image (#6) shows tissue in the enlarged geniculate fossa (arrow) with low signal foci (open arrow) from intratumoral ossifications. Axial (#7,8) and coronal (#9) enhanced T1 MR images show the FNH enhances (arrow, #7,9). Again punctate low signal can be seen in the tumor matrix (open arrow, #8). \n\nPearl: About 50% of FNH are show areas of ossification. When seen in larger lesions the term "honeycomb ossification" may be applied. The geniculate ganglion is the most common location for FNH to be found within the T-bone.', 'history': 'Patient presents with history of acute onset of right facial nerve paralysis that did not resolve over 6 weeks. Initially called "Bell palsy" by referring clinician, MR was then completed looking for other causes of the facial nerve paralysis.', 'imagePoolId': '9f4fe8af-d0a3-4261-808f-af1426bc1118', 'name': 'Ossifying, geniculate fossa', 'teachingPoint': None, 'demographics': '31 Years old female'}, {'authors': [{'key': '624acd80-0502-4325-be71-e68fec740eb3', 'value': 'Richard H. Wiggins, III, MD, CIIP, FSIIM, FAHSE, FACR'}], 'caseVersionId': '61b1875a-9bb5-4f3b-a122-b23321928abe', 'description': 'This is a typical case of a facial nerve hemangioma.\n\nThe axial bone algorithm CT images (#1-3) show the abnormal osseous density in the region of the left geniculate ganglion (arrow). The mass seen arising from the geniculate ganglion is associated with loss of normal bone density at this site, and extends posteriorly, just medial and anterior to the inner ear ossicles (open arrow). The coronal bone algorithm CT images (#4-5) also show the abnormal osseous density at the anterior genu of the facial nerve (arrow), which extends posteriorly, to a location just medial to the ossicles (open arrow).\n\nThe axial T2 weighted image (#6) shows abnormal increased signal intensity at the left geniculate ganglion (arrow). The axial (#7) and the coronal (#8) images show the abnormal enhancement at the left geniculate ganglion (arrow), consistent with a facial nerve hemangioma.', 'history': 'Patient presented with a history of acute onset left facial nerve paralysis that remitted after one week.', 'imagePoolId': '9da9b6eb-b694-4755-8b07-a5a75f7cb034', 'name': 'Lateral geniculate', 'teachingPoint': None, 'demographics': '65 Years old female'}, {'authors': [{'key': '33151213-01b2-4542-9105-342e006b3915', 'value': 'H. Ric Harnsberger, MD'}], 'caseVersionId': '80cc900c-dae5-478d-a7be-2809aa8eb694', 'description': 'Typical CT and MR case of a large geniculate fossa facial nerve hemangioma with subtle ossific matrix.\n\nAxial (#1-4) and coronal (#5-6) T-bone CT images reveal a lesion in the right geniculate ganglion (arrow, #1-3) with extension along the anteromedial surface of the temporal bone (curved arrow). Note the enlarged, tumor filled labyrinthine segment of the facial nerve (open arrow, #1). In the coronal CT images (#5, 6) the geniculate fossa tumor (arrow) is again seen with spread along the cephalad surface of the temporal bone particularly apparent (open arrows). \n\nEnhanced MR images (axial, #7-9 and coronal, #10-12) demonstrate the hemangioma as an enhancing mass (arrow) that is larger than that perceived in the CT images. Coronal image #10 reveals the tumor in the labyrinthine segment of the facial nerve (open arrow).\n\nPearl: The crescentic shape of the lesion seen on axial CT arching around the cochlea medially on anterior surface of the temporal bone is typical of large facial nerve hemangiomas in this location.', 'history': 'Patient presents with right-sided peripheral facial nerve paralysis originally thought to be Bell palsy. When paralysis did not improve over a 2 month period, CT & MR images completed of the temporal bone.', 'imagePoolId': 'e6c0b56d-046d-425e-9c23-9f8694defa20', 'name': 'Large, subtle ossific matrix', 'teachingPoint': None, 'demographics': '52 Years old female'}, {'authors': [{'key': '624acd80-0502-4325-be71-e68fec740eb3', 'value': 'Richard H. Wiggins, III, MD, CIIP, FSIIM, FAHSE, FACR'}, {'key': '94f835c8-fa13-4e8a-995b-53048e6b0605', 'value': 'Philip R. Chapman, MD'}], 'caseVersionId': '85f20b2e-8a1a-425a-badf-a67dc89e7b85', 'description': 'This is a classic CT and MRI facial nerve hemangioma case.\n\nThe axial bone algorithm CT images (#1-2) show the unusual calcifications within the geniculate fossa (arrow).\n\nThe axial post-contrast T1 weighted images (#3-5) show the avid enhancement of the anterior genu of the facial nerve (arrow). The oblique sagittal image (#6) shows enhancement at the geniculate fossa (arrow) as well as the tympanic segment (open arrow), posterior genu, and descending (mastoid) segment (curved arrow) of the facial nerve.', 'history': 'Patient presented with a rapid onset of left facial nerve paralysis.', 'imagePoolId': 'd8915c51-5df7-4779-88fd-4a6fd2057b37', 'name': 'Rapid growth', 'teachingPoint': None, 'demographics': '45 Years old female'}, {'authors': [{'key': '624acd80-0502-4325-be71-e68fec740eb3', 'value': 'Richard H. Wiggins, III, MD, CIIP, FSIIM, FAHSE, FACR'}], 'caseVersionId': 'e6480ed9-39c7-4635-80cb-7d18d2280712', 'description': 'This is a classic case of a facial nerve hemangioma at the geniculate ganglion.\n\nThe axial bone algorithm CT images (#1-2) show the abnormal bony spicules (arrow) at the geniculate ganglion.\n\nThe axial post-contrast T1 weighted images (#3-4) show avid enhancement near the geniculate ganglion (arrow) correlating with the CT region of loss of bone density.', 'history': 'Patient presented with slowly progressive left facial nerve paralysis.', 'imagePoolId': '3488e8b3-51f1-4d3b-822f-c72d03db18b7', 'name': 'Classic', 'teachingPoint': None, 'demographics': '25 Years old female'}, {'authors': [{'key': '624acd80-0502-4325-be71-e68fec740eb3', 'value': 'Richard H. Wiggins, III, MD, CIIP, FSIIM, FAHSE, FACR'}], 'caseVersionId': '1ec6d174-59ca-435f-a04d-0bb7d4fcb74a', 'description': 'This is a classic case of a facial nerve ossifying hemangioma.\n\nThe axial bone algorithm CT images (#1, 2) demonstrate the honeycombing appearance (arrow) of the lesion at the geniculate fossa. There is extension of the ossification along the proximal tympanic segment (open arrow, #2). The coronal CT images (#3-6) also show the ossification at the geniculate fossa (arrow).\n\nThe axial T1 post-contrast images (#7, 8) and the coronal post-contrasted images (#9-10) show the avid enhancement at the geniculate fossa (arrow, #7, 9, 10). Note extension along tympanic segment of facial nerve (open arrow, #7).', 'history': 'Patient presented with chronic facial paralysis.', 'imagePoolId': 'da1af59f-0fc1-4d4b-9ae3-5bb2f772dd92', 'name': 'Ossifying', 'teachingPoint': None, 'demographics': '46 Years old male'}, {'authors': [{'key': '624acd80-0502-4325-be71-e68fec740eb3', 'value': 'Richard H. Wiggins, III, MD, CIIP, FSIIM, FAHSE, FACR'}], 'caseVersionId': '2b2cf5ba-8647-4713-95de-9953103b8708', 'description': 'This is a typical case of facial nerve hemangioma.\n\nThe axial bone algorithm CT images (#1-4) show the abnormal osseous density at the right anterior genu of the facial nerve (arrow). There is also extension of abnormal osseous density along the tympanic segment of the facial nerve (open arrow). The coronal CT images (#5-7) show the abnormal loss of bone density at the right geniculate ganglion (arrow).\n\nThe coronal T2 weighted image (#8) shows the abnormal increased signal intensity at the right anterior genu of the facial nerve (arrow). The axial post-contrast T1 weighted image (#9) and the coronal image (#10) show the abnormal enhancement at the right geniculate ganglion (arrow).', 'history': 'Patient presented with right sided hearing loss.', 'imagePoolId': 'da51d06a-3bbd-44a3-8057-33e6d52a9c48', 'name': 'Classic', 'teachingPoint': None, 'demographics': '40 Years old male'}, {'authors': [{'key': '624acd80-0502-4325-be71-e68fec740eb3', 'value': 'Richard H. Wiggins, III, MD, CIIP, FSIIM, FAHSE, FACR'}], 'caseVersionId': '4c1d64eb-b8c1-4089-990d-5b5801030581', 'description': 'This is a typical facial nerve hemangioma case.\n\nThe axial bone algorithm CT images (#1-2) show the laminated osseous deposition at the left geniculate ganglion (arrow).\n\nThe axial post-contrast T1 weighted images (#3-4) show the abnormal enhancement at the left geniculate ganglion (arrow). The coronal post-contrast images (#5-6) also show the abnormal enhancement at the anterior genu of the left facial nerve (arrow).', 'history': None, 'imagePoolId': '0842164c-2b9f-447d-a984-a8ac7ba3c3da', 'name': 'Classic', 'teachingPoint': None}, {'authors': [{'key': '624acd80-0502-4325-be71-e68fec740eb3', 'value': 'Richard H. Wiggins, III, MD, CIIP, FSIIM, FAHSE, FACR'}], 'caseVersionId': 'f6d47f77-0b7b-42d8-a832-66487719bcd1', 'description': 'This is a classic case of a facial nerve hemangioma at the anterior genu of the facial nerve.\n\nThe axial bone algorithm CT images (#1-4) show the laminated appearance of osseous deposition at the left geniculate ganglion (arrow), compared to the normal appearing osseous anatomic landscape at the right geniculate ganglion (open arrow).\n\nThe axial post-contrast T1 weighted images (#5-8) show the abnormal enhancement at the left geniculate ganglion (arrow), compared to the normal relative lack of enhancement in the region of the right geniculate ganglion (open arrow). The coronal post-contrast T1 weighted images also show the abnormal avid enhancement at the left geniculate ganglion (arrow), compared to the relative lack of enhancement in the region of the right ganglion (open arrow).', 'history': 'Patient presented with a 2 year history of worsening left facial nerve palsy, an "atypical Bell\'s palsy".', 'imagePoolId': '8aa84b20-5b7a-4ab3-a889-e7ebdcae04d1', 'name': 'Classic', 'teachingPoint': None, 'demographics': '42 Years old male'}], 'caseType': 'typical', 'name': 'TYPICAL'}
+- {'cases': [{'authors': [{'key': '33151213-01b2-4542-9105-342e006b3915', 'value': 'H. Ric Harnsberger, MD'}, {'key': 'ab4396df-0647-4f6a-b534-995eda06646c', 'value': 'Nancy J. Fischbein, MD'}], 'caseVersionId': 'a7e74b0c-83f0-4c72-a092-8d063715beba', 'description': 'Variant case of facial nerve hemangioma (FNH)(venous malformation) involving the areas of the geniculate fossa and the internal auditory canal simultaneously.\n\nAxial (#1-3) and coronal (#4-6) temporal bone CT images show an intraosseous venous malformation (FNH) with the bone anteromedial to the geniculate fossa (arrows, #1-3,5-6) and around the geniculate fossa (curved arrows, #2-3,6). Subtle calcification in the internal auditory canal (IAC)(open arrows, #2-3,4-5) is visible. \n\nAxial T1 (#7-9), T2 (#10-11), and FLAIR (#12) MR reveals intraosseous component anteromedial to the geniculate ganglion (arrows, #7-8,10-11) and around the geniculate ganglion (curved arrows, #8-9,11). Signal in the IAC (open arrows, #9,12) indicates that the venous malformation (FNH) involves this area as well.\n\nEnhanced axial (#13-15) and coronal (#16-17) fat-saturated MR images demonstrate that the venous malformation (FNH) enhances in the medial temporal bone (arrows, #13-14,16-17), around the geniculate ganglion (curved arrows, #14-15,17), and in the IAC (open arrows, #15-16).', 'history': 'Patient presents with history of vertigo, left-sided hearing loss, and mild facial weakness. Referred for focused radiation therapy as "left vestibular schwannoma."', 'imagePoolId': '63023f4e-221d-42fb-8157-e7fb9ebbf4fa', 'name': 'Geniculate fossa area, IAC involvement', 'teachingPoint': 'This "ossifying" facial nerve hemangioma is most likely a "calcified venous malformation of the temporal bone." When the tissue is submitted to immunoanalysis, it is found to be GLUT1/LeY antigen and podoplanin negative, indicating that venous malformation is the better term for this lesion. Hemangiomas are GLUT1 and LeY antigen positive, with podoplanin positivity present if the lesion is a lymphatic malformation.', 'demographics': '38 Years old male'}], 'caseType': 'variant', 'name': 'VARIANT'}
+
+
+## Images
+
+
+### Selected Images
+
+
+*Axial graphic illustrates a classic example of a medium-sized facial nerve venous malformation (FNVM) centered in the geniculate fossa of the temporal bone. Notice the honeycomb bone within the lesion matrix.*
+
+
+*Axial graphic illustrates a classic example of a medium-sized facial nerve venous malformation (FNVM) centered in the geniculate fossa of the temporal bone. Notice the honeycomb bone within the lesion matrix.*
+
+
+*Axial T1 C+ MR with fat saturation in a patient with left atypical Bell palsy reveals a classic left geniculate fossa enhancing FNVM . Punctate areas of high density on bone CT (not shown) confirmed this imaging impression.*
+
+
+*Axial bone CT demonstrates the honeycombing appearance of FNVM centered in the geniculate fossa . Note extension of the lesion along the proximal tympanic CNVII segment .*
+
+
+*Axial T1 C+ MR in the same patient shows a poorly marginated, avidly enhancing lesion in the geniculate fossa . Note extension along the tympanic segment of CNVII and into the fundus of the internal auditory canal (IAC) . IAC extension occurred via the labyrinthine segment of CNVII (not shown).*
+
+
+*Axial bone CT in a patient with right facial nerve palsy shows a small FNVM in the geniculate fossa . Notice the punctate ossific foci within the lesion. This finding allows differentiation of FNVM from facial nerve schwannoma, which also occurs most frequently in the geniculate fossa.*
+
+
+*Axial T1 C+ MR with fat saturation in the same patient reveals FNVM enhancing in the geniculate ganglion. The punctate ossific area is seen as an intralesional low-signal focus .*
+
+
+*Axial bone CT through the right temporal bone demonstrates a medium-sized FNVM in the geniculate fossa with extension along the anteromedial surface of the temporal bone . The crescentic shape of this lesion arching around the cochlea medially on the anterior temporal bone surface is typical of FNVM.*
+
+
+*Axial T1 C+ MR in the same patient shows diffuse FNVM enhancement in the geniculate fossa , arching around the cochlea along the anteromedial temporal bone surface .*
+
+
+*Axial bone CT shows an FNVM within the anteromedial temporal bone and in the bone surrounding the geniculate fossa . Subtle foci of increased density are also seen in the IAC.*
+
+
+*Axial T1 C+ FS MR in the same patient shows the venous malformation enhancing in the anteromedial temporal bone , around the geniculate ganglion , and in the IAC . The IAC lobe of FNVM occurs due to extension along the labyrinthine segment of CNVII (not shown).*
+
+
+### Additional Images
+
+
+*Axial left ear temporal bone CT reveals a typical medium-sized FNVM hemangioma) emanating from the geniculate fossa around the anterior cochlear surface. Note relative sparing of the otic capsule.*
+
+
+*Axial T1 C+ MR in the same patient shows diffuse enhancement of a medium-sized FNVM (hemangioma) . MR is not fat saturated, making it difficult to distinguish petrous apex fatty marrow from this developmental lesion.*
+
+
+*Axial temporal bone CT reveals a very small FNVM (hemangioma) as a single dot of high-density matrix within a mildly enlarged geniculate fossa. Note adjacent otic capsule involvement . Radiologists beware, as this would be easily missed.*
+
+
+*Axial T1 C+ MR in the same patient demonstrates a tiny enhancing FNVM (hemangioma) in the location of the geniculate ganglion in this patient with acute-onset peripheral facial nerve paralysis. Also note the lesion involves the adjacent otic capsule .*
+
diff --git a/docs_md/articles/tuberous-sclerosis-complex_60611839-bd46-4b21-a671-d7f62e45b967.md b/docs_md/articles/tuberous-sclerosis-complex_60611839-bd46-4b21-a671-d7f62e45b967.md
new file mode 100644
index 0000000..84ce6dd
--- /dev/null
+++ b/docs_md/articles/tuberous-sclerosis-complex_60611839-bd46-4b21-a671-d7f62e45b967.md
@@ -0,0 +1,528 @@
+---
+title: "Tuberous Sclerosis Complex"
+docid: "60611839-bd46-4b21-a671-d7f62e45b967"
+authors:
+ - key: "47381de4-c9fd-4999-8dd0-1808cd72db6b"
+ value: "Luke L. Linscott, MD"
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+ slug: "diagnosis"
+ treeNodeId: "2b5cea64-a083-489e-ac0c-ec14ba059026"
+ -
+ name: "Pediatric Neuroradiology"
+ slug: "pediatric-neuroradiology"
+ treeNodeId: "d0eb8f4a-e769-43dd-896c-8c9c27ce8759"
+ -
+ name: "Brain"
+ slug: "brain"
+ treeNodeId: "feaaadba-649b-4f0a-9aad-9188a8f9926a"
+ -
+ name: "Pathology-Based Diagnoses"
+ slug: "pathology-based-diagnoses"
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+ -
+ name: "Congenital Malformations"
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+ slug: "familial-tumorneurocutaneous-syndr-"
+ treeNodeId: "0bc21363-6bb4-4742-b039-6e7860801b42"
+ -
+ name: "Tuberous Sclerosis Complex"
+ slug: "tuberous-sclerosis-complex"
+ treeNodeId: null
+category: "Pediatrics"
+cmeTopicId: "a8decdb5-42a4-493f-823d-058ab6803340"
+documentVersionId: "f2af2581-a4fa-479d-9940-13179f8f34b2"
+imageCount: 29
+lastUpdated: "02/13/24"
+pageDescription: "Tuberous Sclerosis Complex"
+pageKeywords: "Pediatrics, Diagnosis, Pediatric Neuroradiology, Brain, Pathology-Based Diagnoses, Congenital Malformations, Familial Tumor/Neurocutaneous Syndromes, Tuberous Sclerosis Complex"
+pageTitle: "Tuberous Sclerosis Complex | STATdx"
+enhancedTitle: "Tuberous Sclerosis Complex"
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+references: true
+breadcrumbs:
+ - "Pediatrics"
+ - "Diagnosis"
+ - "Pediatric Neuroradiology"
+ - "Brain"
+ - "Pathology-Based Diagnoses"
+ - "Congenital Malformations"
+ - "Familial Tumor/Neurocutaneous Syndromes"
+ - "Tuberous Sclerosis Complex"
+---
+# KEY FACTS
+
+- ## Terminology
+
+
+ - Hamartomas of multiple organs → CNS, skin, kidney, bone
+- ## Imaging
+
+
+ - Cerebral tubers
+ - Cortical/subcortical lesion expanding overlying gyri
+ - T2/FLAIR hyperintense, T1 hypointense after myelination
+ - T1 hyperintense prior to myelination
+ - Cerebellar tubers
+ - Wedge-shaped foci of volume loss
+ - Often enhance & calcify
+ - Subependymal nodules (SENs)
+ - Elongated nodules in locations of fetal germinal matrix
+ - Increasing Ca⁺⁺ over time
+ - 30-80% enhance
+ - Subependymal giant cell astrocytoma (SEGA)
+ - Growing nodule at caudothalamic groove
+ - WHO grade 1 neoplasm
+- ## Top Differential Diagnoses
+
+
+ - Focal cortical dysplasia
+ - Dysembryoplastic neuroepithelial tumor
+ - Ganglioglioma
+ - TORCH infections that cause periventricular Ca⁺⁺
+ - X-linked subependymal heterotopia
+- ## Pathology
+
+
+ - 2 distinct gene loci
+ - *TSC1* (9q34) encodes **hamartin**
+ - *TSC2* (16p13) encodes **tuberin** → more severe
+- ## Clinical Issues
+
+
+ - Medical antiseizure therapy, resection of seizure focus
+ - mTOR inhibitors now 1st-line therapy for SEGA
+- ## Diagnostic Checklist
+
+
+ - Tubers + SEN pathognomonic for TSC
+ - Surveillance imaging is performed to detect SEGA
+
+# TERMINOLOGY
+
+- ## Abbreviations
+
+
+ - Tuberous sclerosis complex (TSC)
+- ## Synonyms
+
+
+ - Bourneville syndrome, Pringle disease, epiloia
+- ## Definitions
+
+
+ - Neurocutaneous syndrome: Hamartomatosis
+ - Hamartomas of multiple organs → CNS, skin, kidney, bone
+ - "Original" phakomatosis
+ - "Phakoma" 1st used by Dutch ophthalmologist to describe retinal hamartoma
+
+# IMAGING
+
+- ## General Features
+
+
+ - ### Best diagnostic clue
+
+
+ - Cerebral & cerebellar "tubers"
+ - Tubers = potato-like texture observed at surgery
+ - Dysplastic lesions present from birth
+ - Subependymal nodules (SENs)
+ - Subependymal giant cell astrocytoma (SEGA)
+ - ### Location
+
+
+ - Tubers → cerebrum (90%) > cerebellum (24-36%)
+ - SEN → anatomic distribution is same as fetal germinal matrix with preponderance in caudothalamic grooves
+ - Caudothalamic groove > body/atrium > temp horn
+ - SEGA → enlarging mass at foramen of Monro
+ - ### Morphology
+
+
+ - Tubers
+ - Cerebral
+ - Cortical/subcortical tubers expand overlying gyri
+ - Cystic tuber degeneration → "empty gyri"
+ - Often associated with radial migration lines extending toward lateral ventricles
+ - Cerebellar
+ - Typically wedge-shaped foci with volume loss & folia distortion
+ - SENs
+ - Usually small, nodular foci along ventricle margin
+ - Majority calcify (↑ Ca⁺⁺ with ↑ age)
+ - SEGAs become more spherical with ↑ size
+- ## Radiographic Findings
+
+
+ - ### Radiography
+
+
+ - Sclerotic bone islands (axial skeleton)
+ - Lucent bone "cysts" with undulating periosteal new bone (hands, feet)
+- ## CT Findings
+
+
+ - ### NECT
+
+
+ - SENs → Ca⁺⁺ ↑ with time
+ - Tubers → low-attenuation subcortical lesion expanding overlying gyri
+ - Cerebral tubers usually noncalcified (↑ Ca⁺⁺ with ↑ age)
+ - Cerebellar tubers often calcified (~ 30%)
+ - Hamartomatous lobe → Ca⁺⁺ in dysplasia/hamartoma of entire lobe (frontal) or hemisphere
+ - Giant optic drusen → Ca⁺⁺ in retinal hamartoma
+ - ### CECT
+
+
+ - Most SENs enhance → may be masked by Ca⁺⁺
+ - Some tubers faintly enhance
+ - ### CTA
+
+
+ - Aneurysms occur infrequently (0.74%)
+- ## MR Findings
+
+
+ - ### T1WI
+
+
+ - SENs → typically slightly hyperintense
+ - Best shown on sagittal & coronal images
+ - Tubers & radial migration lines are T1 hyperintense in very young patients prior to myelination
+ - Tubers & radial migration lines become T1 hypointense after myelination
+ - Magnetization transfer ↑ detection of cortical tubers & radial migration lines in children
+ - ### T2WI
+
+
+ - Tubers/radial migration lines typically inconspicuous in very young patients prior to myelination
+ - More apparent (hyperintense) with maturation of normal myelin (hypointense)
+ - ### FLAIR
+
+
+ - Tubers → hyperintense
+ - "Empty gyri" & periventricular cysts suppress completely
+ - Best sequence for detection of tubers & radial migration lines
+ - ### T2* GRE
+
+
+ - Helpful to show Ca⁺⁺ in tubers & SENs
+ - ### DWI
+
+
+ - ↑ ADC values reported in epileptogenic tubers
+ - ↑ diffusivity & ↓ fractional anisotropy (FA) values in normal-appearing white matter (WM)
+ - ### T1WI C+
+
+
+ - Best sequence for showing SEN enhancement
+ - 3-4% of cortical tubers enhance
+ - 33-92% of cerebellar tubers enhance
+ - ### MRA
+
+
+ - Aneurysms (0.74%) & ectasias occasionally encountered
+ - ### MRS
+
+
+ - ↑ myo-inositol (mI) in central & peripheral lesions
+ - ↓ NAA with ↑ mI in SEN at foramen of Monro = SEGA
+- ## Angiographic Findings
+
+
+ - Conventional
+ - Used for diagnosis (beyond CTA/MRA) & treatment of aneurysms
+- ## Nuclear Medicine Findings
+
+
+ - ### PET
+
+
+ - Tubers are hypometabolic
+- ## Other Lesions
+
+
+ - Cerebral aneurysms (0.78%) & dolichoectasia
+ - Retinal hamartoma
+ - Giant optic drusen
+ - Renal angiomyolipoma (RAM)
+ - 40-80% incidence
+ - Amenable to embolization to reduce bleeding risk
+ - Lymphangioleiomyomatosis (LAM)
+ - Cardiac rhabdomyoma
+ - Present at birth, usually resolves spontaneously
+ - May be multifocal
+ - Sclerotic bone islands & cysts
+- ## Imaging Recommendations
+
+
+ - ### Best imaging tool
+
+
+ - MR ± contrast
+ - ### Protocol advice
+
+
+ - Use DWI to assess epileptogenic foci
+ - ↑ MR field strength may improve tuber detection
+
+# DIFFERENTIAL DIAGNOSIS
+
+- ## Infection
+
+
+ - [TORCH infections that cause periventricular Ca⁺⁺](/document/torch-infections-overview/e02da955-3e5b-4079-8863-5832b5338f00)
+ - CMV, toxoplasmosis
+ - May be distinguished by location outside distribution of fetal germinal matrix
+ - Periventricular, not subependymal
+ - Hematogenous spread of infections that cause subcortical lesions
+ - [Fungus](/document/fungal-diseases/e8be0e10-a70b-47a6-9f04-ae81ed4ababc)
+ - [Neurocysticercosis](/document/neurocysticercosis/6a45835f-6d7c-443e-874a-f33131d3def1)
+- ## Neoplasms
+
+
+ - Superficial tumors that can resemble tubers
+ - [Dysembryoplastic neuroepithelial tumor (DNET)](/document/dnet/30baaad9-4835-4cf0-8b95-974d6517511e)
+ - [Ganglioglioma](/document/ganglioglioma/207fb0f4-9899-44b1-bfe5-33c696960d6a)
+ - Angiocentric glioma
+ - Intraventricular tumors
+ - [Choroid plexus tumors](/document/choroid-plexus-papilloma/18e712f5-8553-487d-a939-044336cbf0ad)
+ - [Subependymoma](/document/subependymoma/b899ded1-d2f2-4dc4-9812-48d3fb194117)
+ - Central neurocytoma
+- [Focal Cortical Dysplasia](/document/focal-cortical-dysplasia/046564e0-5bb7-4f23-8a3e-010a68cfbafe)
+ - Especially type II
+- [X-Linked Subependymal Heterotopia](/document/heterotopic-gray-matter/c88b27b7-d352-4231-b296-bd9d93b8c68b)
+ - Gray matter heterotopia along lateral ventricle margins
+ - No Ca⁺⁺ or enhancement
+- [Subcortical Ischemia, Infarction](/document/childhood-stroke/12f14b63-8dd0-4523-afe1-6fda2331e6bf)
+ - Regions of hyperintense subcortical signal on T2WI & FLAIR
+ - Restricted diffusion, gyral swelling
+
+# PATHOLOGY
+
+- ## General Features
+
+
+ - ### Etiology
+
+
+ - Tuberin & hamartin combine to form complex in vivo
+ - Act together to regulate mTOR pathway
+ - **M**ammalian **t**arget **o**f**r**apamycin
+ - Normally inhibit part of mTOR activity
+ - Regulate cell growth & proliferation
+ - Mutations prevent them from downregulating mTOR
+ - Affects germinal matrix → disordered neuronal migration & growth
+ - ### Genetics
+
+
+ - 2 distinct gene loci
+ - *TSC1* (9q34) encodes **hamartin**
+ - *TSC2* (16p13) encodes **tuberin**
+ - *TSC2*most common with severe phenotype
+ - More likely to have complex partial seizures, infantile spasms, SEGAs, & intellectual disability
+ - 1/3 familial
+ - Autosomal dominant, high penetrance
+ - ### Associated abnormalities
+
+
+ - RAM → 40-80% incidence, amenable to embolization
+ - Cardiac rhabdomyomas → majority involute spontaneously
+- ## Staging, Grading, & Classification
+
+
+ - SEGA = WHO grade 1 neoplasm
+ - Diagnostic criteria: 2 major (definite) or 1 major + 1 minor (probable)
+ - Major: Tubers &/or radial migration lines, SEN, SEGA, cardiac rhabdomyoma, RAM, LAM, adenoma sebaceum, sub-/periungual fibroma, hypomelanotic macules, shagreen patch, retinal hamartoma
+ - Minor: WM lesions, dental pits, gingival fibromas, rectal polyps, bone cysts, nonrenal hamartoma, retinal achromic patch, confetti skin lesions, multiple renal cysts
+ - Genetic testing detects mutations in 60-80% of affected individuals
+- ## Gross Pathologic & Surgical Features
+
+
+ - Firm cortical masses with umbilication
+- ## Microscopic Features
+
+
+ - Tubers: Balloon cells, giant cells, ectopic neurons
+ - Tubers share many histopathologic features with focal cortical dysplasia (FCD) type 2B
+ - Myelin loss, vacuolation, & gliosis
+
+# CLINICAL ISSUES
+
+- ## Presentation
+
+
+ - Classic clinical triad: Adenoma sebaceum, seizures, intellectual disability
+ - Seen in only 30-40%
+ - Infantile spasms → poorer outcome
+ - Autism
+- ## Demographics
+
+
+ - ### Age
+
+
+ - Rhabdomyomas present prenatally & in infancy
+ - CNS lesions present in infancy & childhood
+ - Skin lesions present in childhood
+ - Renal, lung, & bone lesions present in adolescence & adulthood
+ - ### Epidemiology
+
+
+ - 1:10,000 incidence
+- ## Natural History & Prognosis
+
+
+ - Prognosis dependent upon severity of symptoms (seizures, arrhythmias, renal insufficiency) & success of treatment
+- ## Treatment
+
+
+ - Medical antiseizure therapy, resection of seizure focus
+ - mTOR inhibitors now 1st-line therapy for SEGA
+ - Have been shown to be highly effective at reducing seizure frequency
+
+# DIAGNOSTIC CHECKLIST
+
+- ## Consider
+
+
+ - ↑ incidence of non-CNS lesions as patients age
+- ## Image Interpretation Pearls
+
+
+ - Do not forget to look for vascular lesions
+
+ 5f44e44e-70b6-4d31-8fc1-0932e468be02
+
+## References
+
+# Selected References
+
+1. [Goergen SK et al: Prenatal MR imaging phenotype of fetuses with tuberous sclerosis: an institutional case series and literature review. AJNR Am J Neuroradiol. 43(4):633-8, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=35332020%5Bpmid%5D)
+1. [Northrup H et al: Updated international tuberous sclerosis complex diagnostic criteria and surveillance and management recommendations. Pediatr Neurol. 123:50-66, 2021](http://www.ncbi.nlm.nih.gov/pubmed/?term=34399110%5Bpmid%5D)
+1. [Wang MX et al: Tuberous sclerosis: current update. Radiographics. 41(7):1992-2010, 2021](http://www.ncbi.nlm.nih.gov/pubmed/?term=34534018%5Bpmid%5D)
+1. [Russo C et al: Neuroimaging in tuberous sclerosis complex. Childs Nerv Syst. 36(10):2497-509, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32519125%5Bpmid%5D)
+1. [Gül Mert G et al: Factors affecting epilepsy prognosis in patients with tuberous sclerosis. Childs Nerv Syst. 35(3):463-8, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=30673834%5Bpmid%5D)
+1. [Curatolo P et al: Management of epilepsy associated with tuberous sclerosis complex: updated clinical recommendations. Eur J Paediatr Neurol. 22(5):738-48, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=29880258%5Bpmid%5D)
+1. [Sun K et al: Magnetic resonance imaging of tuberous sclerosis complex with or without epilepsy at 7 T. Neuroradiology. 60(8):785-94, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=29869697%5Bpmid%5D)
+1. [French JA et al: Adjunctive everolimus therapy for treatment-resistant focal-onset seizures associated with tuberous sclerosis (EXIST-3): a phase 3, randomised, double-blind, placebo-controlled study. Lancet. 388(10056):2153-63, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=27613521%5Bpmid%5D)
+1. [Krishnan A et al: Cross-sectional imaging review of tuberous sclerosis. Radiol Clin North Am. 54(3):423-40, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=27153781%5Bpmid%5D)
+1. [Daghistani R et al: MRI characteristics of cerebellar tubers and their longitudinal changes in children with tuberous sclerosis complex. Childs Nerv Syst. 31(1):109-13, 2015](http://www.ncbi.nlm.nih.gov/pubmed/?term=25200047%5Bpmid%5D)
+1. [Manoukian SB et al: Comprehensive imaging manifestations of tuberous sclerosis. AJR Am J Roentgenol. 204(5):933-43, 2015](http://www.ncbi.nlm.nih.gov/pubmed/?term=25905927%5Bpmid%5D)
+1. [Kothare SV et al: Severity of manifestations in tuberous sclerosis complex in relation to genotype. Epilepsia. 55(7):1025-9, 2014](http://www.ncbi.nlm.nih.gov/pubmed/?term=24917535%5Bpmid%5D)
+1. [Ouyang T et al: Subependymal giant cell astrocytoma: current concepts, management, and future directions. Childs Nerv Syst. 30(4):561-70, 2014](http://www.ncbi.nlm.nih.gov/pubmed/?term=24549759%5Bpmid%5D)
+1. [Boronat S et al: Intracranial arteriopathy in tuberous sclerosis complex. J Child Neurol. 29(7):912-9, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=24056157%5Bpmid%5D)
+1. [Kadom N et al: Utility of magnetization transfer T1 imaging in children with seizures. AJNR Am J Neuroradiol. 34(4):895-8, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=23153867%5Bpmid%5D)
+1. [Krsek P et al: Predictors of seizure-free outcome after epilepsy surgery for pediatric tuberous sclerosis complex. Epilepsia. 54(11):1913-21, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=24117179%5Bpmid%5D)
+1. [Pascual-Castroviejo I et al: Significance of tuber size for complications of tuberous sclerosis complex. Neurologia. 28(9):550-7, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=23274119%5Bpmid%5D)
+1. [Cepeda C et al: Comparative study of cellular and synaptic abnormalities in brain tissue samples from pediatric tuberous sclerosis complex and cortical dysplasia type II. Epilepsia. 51 Suppl 3:160-5, 2010](http://www.ncbi.nlm.nih.gov/pubmed/?term=20618424%5Bpmid%5D)
+1. [Krueger DA et al: Everolimus for subependymal giant-cell astrocytomas in tuberous sclerosis. N Engl J Med. 363(19):1801-11, 2010](http://www.ncbi.nlm.nih.gov/pubmed/?term=21047224%5Bpmid%5D)
+1. [Kalantari BN et al: Neuroimaging of tuberous sclerosis: spectrum of pathologic findings and frontiers in imaging. AJR Am J Roentgenol. 190(5):W304-9, 2008](http://www.ncbi.nlm.nih.gov/pubmed/?term=18430816%5Bpmid%5D)
+1. [Karadag D et al: Diffusion tensor imaging in children and adolescents with tuberous sclerosis. Pediatr Radiol. 2005](http://www.ncbi.nlm.nih.gov/pubmed/?term=16170442%5Bpmid%5D)
+1. [Jansen FE et al: Diffusion-weighted magnetic resonance imaging and identification of the epileptogenic tuber in patients with tuberous sclerosis. Arch Neurol. 60(11):1580-4, 2003](http://www.ncbi.nlm.nih.gov/pubmed/?term=14623730%5Bpmid%5D)
+
+
+## Images
+
+
+### Selected Images
+
+
+*Axial FLAIR MR in a 6-year-old boy with tuberous sclerosis complex (TSC) shows a moderate to severe burden of cerebral tubers and right subependymal giant cell astrocytoma (SEGA) . Cystic change is seen in a left parietal lobe tuber . Tubers are dysplastic lesions that are present in nearly all patients with TSC.*
+
+
+*Axial FLAIR MR in a 6-year-old boy with tuberous sclerosis complex (TSC) shows a moderate to severe burden of cerebral tubers and right subependymal giant cell astrocytoma (SEGA) . Cystic change is seen in a left parietal lobe tuber . Tubers are dysplastic lesions that are present in nearly all patients with TSC.*
+
+
+*Axial T1 C+ MR in a 9-year-old girl with TSC shows a lobular, homogeneously enhancing mass in the left caudothalamic groove, consistent with a SEGA. Note the subependymal nodule .*
+
+
+*Axial T1 C+ MR in a 4-year-old boy shows a wedge-shaped, enhancing left cerebellar tuber . The majority of cerebellar tubers enhance, in contrast to the supratentorial cerebral hemisphere tubers, which rarely enhance.*
+
+
+*Axial NECT in a 23-month-old girl with TSC shows multiple calcified subependymal nodules . Note that the location of the nodules adheres to the distribution of fetal germinal matrix with a preponderance in the caudothalamic grooves.*
+
+
+*Axial T1 MR in a female infant with TSC at 3 months (left) & 10 months (right) of age shows how the cerebral tubers & radial migration lines are relatively hyperintense before myelination (left) & relatively hypointense after myelination (right).*
+
+
+*Axial T2 MR in the same patient at 3 months (left) & 10 months (right) of age shows how the cerebral tubers are inconspicuous prior to myelination (left) but become conspicuous after myelination (right).*
+
+
+*Axial T2 MR SSFSE of a 36-weeks gestation fetus shows a hypointense subependymal nodule . Other non-CNS features confirmed a diagnosis of TSC.*
+
+
+*Axial T1 C+ MR in a 4-year-old girl shows a large SEGA in the left caudothalamic groove (left). Three months after initiation of an mTOR inhibitor (right), the SEGA has substantially decreased in size. mTOR inhibitors are often used as 1st-line therapy for symptomatic SEGAs & have secondary benefits of decreased seizure frequency.*
+
+
+*Axial SWI MR in a 4-year-old boy with TSC shows signal loss within a calcified, wedge-shaped cerebellar tuber . Approximately 1/3 of all cerebellar tubers are calcified. In contrast to cerebral tubers, which show gyral expansion, cerebellar tubers typically show volume loss.*
+
+
+*High-resolution axial T2 TSE MR in a 10-month-old girl with TSC shows small, bilateral retinal contour abnormalities , consistent with retinal hamartomas.*
+
+
+### Additional Images
+
+
+*Axial FLAIR MR in a 3-year-old boy with TSC shows a moderate to severe burden of cerebral tubers. Cystic change is seen in a left parietal lobe tuber . FLAIR is the most sensitive sequence for tuber detection. Tubers are dysplastic lesions that are present in nearly all patients with TSC.*
+
+
+*Axial T1 C+ MR in the same patient shows a wedge-shaped, enhancing right cerebellar tuber . The majority of cerebellar tubers enhance, in contrast to the cerebral tubers, which rarely enhance.*
+
+
+*Axial SWI MR in a 9-year-old boy with TSC shows signal loss within a calcified, wedge-shaped cerebellar tuber . Approximately 1/3 of all cerebellar tubers are calcified. In contrast to cerebral tubers, which show gyral expansion, cerebellar tubers typically show volume loss.*
+
+
+*Axial T1 C+ MR in a 4-year-old girl with TSC shows a lobular, homogeneously enhancing mass in the left caudothalamic groove, consistent with a subependymal giant cell astrocytoma.*
+
+
+*Axial T1 MR in a 3-month-old girl shows hyperintense radial migration lines & cortical/subcortical tubers .*
+
+
+*Axial T2 MR in a 9-year-old boy with TSC shows a wedge-shaped tuber in the right cerebellum. The decreased T2 signal intensity suggests associated mineralization.*
+
+
+*Axial T2 MR shows a mass-like tuber in the left cerebellum in this 11-year-old TSC patient. Infratentorial tubers are much less common than supratentorial ones.*
+
+
+*AP catheter angiography with injection of the vertebral artery shows a large mid-basilar aneurysm in a 19-month-old with TSC. Aneurysms are a known, but uncommon, manifestation of this disorder.*
+
+
+*MRS shows a characteristic short-echo proton spectroscopy profile of a SEGA with depression of NAA , elevation of choline , & elevation of myoinositol .*
+
+
+*Axial T1 C+ MR shows multiple enhancing subependymal nodules in a patient with TSC. Enhancement of these nodules is much easier to discern on MR than CT & does not in itself indicate transformation to a SEGA.*
+
+
+*Axial FLAIR MR shows bilateral SEGAs at the foramina of Monro that had grown over a 1-year period. These tumors become symptomatic when they cause obstructive hydrocephalus.*
+
+
+*Axial FLAIR MR in the same patient 6 months later, after treatment with an mTOR inhibitor, shows a significant decrease in the size of the tumors .*
+
+
+*Axial NECT shows a calcified lesion of the left frontal lobe in a child with TSC. These stable hamartomatous lesions can be excised to treat seizures. Note the subependymal nodules in the temporal horns.*
+
+
+*Axial FLAIR MR in a 3-year-old shows tubers , radial white matter lesions , & a subependymal nodule . Note the "empty gyri" in the left parietal lobe tuber .*
+
+
+*Coronal NECT in a 7-year-old girl shows prominent calcifications in the subcortical & deep white matter in association with cerebral tubers.*
+
+
+*Axial NECT of the left globe shows a calcified retinal lesion in a patient with TSC. These hamartomas, sometimes called giant optic drusen, are one of the major criteria for the diagnosis of TSC.*
+
+
+*Axial FLAIR MR shows multiple tubers & white matter lesions in a teenager with tuberous sclerosis complex. Note the gyral enlargement & distortion of the tubers as well as the radiating, linear white matter abnormalities that track centrally toward the ventricles.*
+
+
+*Axial NECT in this 1-year-old boy with TSC shows a large hamartomatous lesion in the right frontal lobe with overlying cortical malformation, extensive calcification, & volume loss.*
+
+
+*Axial T2 FS MR in this 1-year-old boy with TSC shows a large hamartomatous lesion in the right frontal lobe with overlying cortical malformation, extensive calcification, & volume loss.*
+
diff --git a/docs_md/articles/umbilical-hernia_ff51faeb-9832-4e87-a6cc-ca45673d754f.md b/docs_md/articles/umbilical-hernia_ff51faeb-9832-4e87-a6cc-ca45673d754f.md
new file mode 100644
index 0000000..84edeed
--- /dev/null
+++ b/docs_md/articles/umbilical-hernia_ff51faeb-9832-4e87-a6cc-ca45673d754f.md
@@ -0,0 +1,314 @@
+---
+title: "Umbilical Hernia"
+docid: "ff51faeb-9832-4e87-a6cc-ca45673d754f"
+authors:
+ - key: "c1df94ab-4a9f-44c4-add7-1f174fb9ac45"
+ value: "Siva P. Raman, MD"
+breadcrumbs:
+ -
+ name: "Gastrointestinal"
+ slug: "gastrointestinal"
+ treeNodeId: "b52263f7-5978-4a22-a17d-7260e0033943"
+ -
+ name: "Diagnosis"
+ slug: "diagnosis"
+ treeNodeId: "5a7c51af-b1c6-4629-8f0e-d99e6fe57a98"
+ -
+ name: "Peritoneum, Mesentery, and Abdominal Wall"
+ slug: "peritoneum-mesentery-and-abdominal-"
+ treeNodeId: "a3fb9f00-f894-4b38-9e01-2f78406cf547"
+ -
+ name: "External Hernias"
+ slug: "external-hernias"
+ treeNodeId: "71ab3f79-4332-463c-9f60-d3dd2902d974"
+ -
+ name: "Umbilical Hernia"
+ slug: "umbilical-hernia"
+ treeNodeId: null
+category: "Gastrointestinal"
+documentVersionId: "b7132216-076e-4ae9-9af4-60ff52ce0ef7"
+imageCount: 7
+lastUpdated: "04/21/25"
+pageDescription: "Umbilical Hernia"
+pageKeywords: "Gastrointestinal, Diagnosis, Peritoneum, Mesentery, and Abdominal Wall, External Hernias, Umbilical Hernia"
+pageTitle: "Umbilical Hernia | STATdx"
+enhancedTitle: "Umbilical Hernia"
+type: "DX"
+references: true
+ddx: true
+cases: 1
+breadcrumbs:
+ - "Gastrointestinal"
+ - "Diagnosis"
+ - "Peritoneum, Mesentery, and Abdominal Wall"
+ - "External Hernias"
+ - "Umbilical Hernia"
+---
+# KEY FACTS
+
+- ## Terminology
+
+
+ - Protrusion of abdominal contents (omental fat ± bowel) into or through anterior abdominal wall via umbilical ring
+- ## Imaging
+
+
+ - Hernia sac located at midline (usually upper 1/2 of umbilicus) with protrusion of omental fat ± bowel loops
+ - Fat stranding/fluid within hernia sac (in absence of abnormal bowel) suggests fat necrosis due to incarceration
+ - Can cause patient symptoms but does not necessitate urgent surgery
+ - Findings of bowel ischemia include evidence of bowel obstruction, bowel wall thickening, fat stranding, etc.
+- ## Top Differential Diagnoses
+
+
+ - Omphalocele
+ - Congenital defect in abdominal wall at umbilicus
+ - May allow some or nearly all abdominal contents to herniate
+ - Ventral hernia
+ - Epigastric and hypogastric hernias develop above and below umbilicus, respectively
+ - Incisional hernias develop through prior incision site
+ - Spigelian hernia
+ - Between linea semilunaris and lateral rectus abdominis
+ - Often has intact external oblique muscle or aponeurosis
+- ## Pathology
+
+
+ - Congenital: Due to incomplete closure of umbilical ring
+ - More likely in children with Down syndrome, trisomy 18, mucopolysaccharidoses, Ehlers-Danlos syndrome, and Beckwith-Wiedemann syndrome
+ - Acquired: Results from weakening of cicatricial tissue that normally closes umbilical ring
+ - Usually secondary to ↑ intraabdominal pressure (e.g., obesity, multiple pregnancies, tense ascites, etc.)
+- ## Clinical Issues
+
+
+ - Congenital type: Diagnosed in infancy
+ - 8x more common in Black patients
+ - > 90% close spontaneously by 1 year of age
+ - Surgical repair of congenital hernias (unless symptomatic) not considered until at least 3 years of age
+ - Treatment only if hernia is large, symptomatic, or persistent (present > 5 years)
+ - Acquired type: Develops in later life (usually middle age)
+ - More common in women (M:F = 1:3)
+ - Incarceration is more likely in men and less likely in women (particularly when nonobese)
+ - Small and asymptomatic hernias do not undergo repair
+ - Symptoms, large hernia size, and incarceration all necessitate surgical repair
+
+# TERMINOLOGY
+
+- ## Definitions
+
+
+ - Protrusion of abdominal contents (omental fat ± bowel) into or through anterior abdominal wall via umbilical ring
+ - Congenital: Diagnosed in infancy
+ - Acquired: Develops in later life
+ - Defined by European hernia society as midline hernia located within 3 cm of umbilicus (either above or below)
+ - Hernia bounded by umbilical fascia posteriorly, linea alba anteriorly, and medial margins of rectus sheath bilaterally
+
+# IMAGING
+
+- ## General Features
+
+
+ - ### Best diagnostic clue
+
+
+ - CT demonstrates protrusion of omental fat ± bowel loops through umbilical ring
+ - ### Location
+
+
+ - Midline and usually located in upper 1/2 of umbilicus (through opening in linea alba)
+ - ### Size
+
+
+ - Varies but typically small in most cases
+ - ### Morphology
+
+
+ - Hernia sac containing fat ± bowel
+ - Most commonly contains omental fat and small bowel with colonic involvement less common
+ - Often demonstrates narrow neck, feature that can ↑ risk of strangulation
+- ## CT Findings
+
+
+ - Hernia sac at midline of abdomen (usually superior aspect of umbilicus)
+ - Protrusion of omental fat ± bowel loops
+ - Fat stranding and fluid within hernia sac (in absence of abnormal-appearing bowel) may suggest fat necrosis due to incarceration
+ - Can be cause of patient symptoms but does not necessarily necessitate urgent surgery
+ - Findings in bowel ischemia include wall thickening, abnormal mural enhancement, fat obliteration, vessel engorgement, mesenteric haziness, ascites
+- ## Ultrasonographic Findings
+
+
+ - Offers advantage of acquiring images with patient standing or during Valsalva, as some hernias may not be apparent with patient in supine position
+- ## Imaging Recommendations
+
+
+ - ### Best imaging tool
+
+
+ - CECT
+ - Multiplanar views can offer additional information to help guide treatment/surgery
+ - Useful to evaluate possible bowel obstruction
+ - Many umbilical hernias are diagnosed clinically with imaging utilized in cases with clinical doubt or suspicion for complications
+- ## Fluoroscopic Findings
+
+
+ - ### Contrast enema
+
+
+ - Can theoretically be helpful to show large bowel in hernia sac or demonstrate Richter hernia (only part of bowel wall herniated)
+ - Limited utility in modern era with CECT considered primary modality for diagnosis and assessment of complications
+
+# DIFFERENTIAL DIAGNOSIS
+
+- [Omphalocele](/document/omphalocele/30c2da7f-e14e-4053-90d3-715f7c10c932)
+ - Congenital defect in abdominal wall at umbilicus, evident at birth or in utero
+ - May allow some or nearly all abdominal contents to herniate
+- [Ventral Hernia](/document/ventral-hernia/ab08cd87-4342-4825-948b-d02fc178078f)
+ - Epigastric and hypogastric hernias develop above and below umbilicus, respectively
+ - Incisional hernias develop through prior incision site
+- [Spigelian Hernia](/document/spigelian-hernia/3bbee7e5-dcd2-423c-a079-ce530cdb08c0)
+ - Hernia protruding between linea semilunaris and lateral edge of rectus muscle
+ - Often has intact external oblique muscle or aponeurosis
+
+# PATHOLOGY
+
+- ## General Features
+
+
+ - ### Etiology
+
+
+ - Congenital
+ - Incomplete closure of umbilical ring fascia (which should normally close during development)
+ - Exact etiology is unknown, although thought to be related to umbilical vein portion of ring
+ - Acquired
+ - Weakening of cicatricial tissue that normally closes umbilical ring
+ - Usually secondary to any number of processes, which can result in ↑ intraabdominal pressure, including obesity, multiple pregnancies, chronic bowel distension, ascites, etc.
+ - ### Associated abnormalities
+
+
+ - Cirrhosis with tense ascites very frequently can be associated with umbilical hernia (and also ↑ risk of recurrence after umbilical hernia surgical repair)
+ - More likely in children with Down syndrome, trisomy 13, trisomy 18, mucopolysaccharidoses, Ehlers-Danlos, Marfan syndrome, and Beckwith-Wiedemann syndrome
+ - Peritoneal dialysis
+ - Hypothyroidism
+- ## Gross Pathologic & Surgical Features
+
+
+ - Portions of greater omentum, properitoneal fat, or bowel loop protrude anteriorly through umbilical ring
+
+# CLINICAL ISSUES
+
+- ## Presentation
+
+
+ - ### Most common signs/symptoms
+
+
+ - Mass protruding via umbilicus, which often enlarges when coughing or straining
+ - Pain in region of umbilicus
+ - ### Other signs/symptoms
+
+
+ - Bowel obstruction
+- ## Demographics
+
+
+ - ### Sex
+
+
+ - Acquired type more common in women (M:F = 1:3)
+ - Incarceration is more likely in men and less likely in women (particularly when nonobese)
+ - ### Ethnicity
+
+
+ - Congenital type 8x more common in Black patients
+ - ### Epidemiology
+
+
+ - Most common ventral hernia comprising 4% of all hernias
+ - 175,000 umbilical hernia repairs performed every year in USA
+ - Congenital umbilical hernias seen in up to 23% of all newborns, although many close spontaneously, and incidence drops to 2-10% by 1 year of age
+ - Congenital umbilical hernias more common in premature and low-birth-weight infants
+- ## Natural History & Prognosis
+
+
+ - Congenital type
+ - Vast vast majority of congenital umbilical hernias close spontaneously (> 90% by 1 year of age)
+ - Umbilical hernias > 1.5 cm in size less likely to close spontaneously
+ - Incarceration or strangulation is very rare
+ - Acquired type
+ - Incarceration is unusual
+ - Ischemia of incarcerated bowel occurs quickly due to nonelasticity of ring and because these hernias often demonstrate relatively narrow neck
+ - Rupture of hernia may result from massive ascites
+ - Skin over hernia is often very thinned
+ - Danger of infected fluid (peritonitis)
+ - Erythema and ↑ pain suggest strangulation
+- ## Treatment
+
+
+ - Surgical repair can be performed using either primary suture repair or mesh repair
+ - Suture repair is traditional method and tends to be more commonly utilized for small abdominal wall defects (< 3 cm) but carries higher risk of recurrence
+ - Mesh repair carries lower risk of recurrence and relatively comparable risk of infection and other complications (compared to suture repair)
+ - Surgical mesh repair can be performed either laparoscopically or with open technique with decision often based primarily on surgeon preference (although complication rate for laparoscopic repair may be slightly lower)
+ - Recurrence of hernia after surgery more common in setting of patient obesity, large abdominal wall defects, and ascites
+ - Common indications for surgery
+ - **Congenital**
+ - Hernia persists beyond 5 years, incarceration, defect > 2 cm, ventriculoperitoneal shunt
+ - Surgical repair of congenital hernias (unless symptomatic) not considered until at least 3 years of age as well > 90% of these hernias will close spontaneously
+ - Surgery often performed in asymptomatic patients after 5 years of age in cases where abdominal wall defect is > 1.5 cm (although symptoms may necessitate earlier repair)
+ - **Acquired**
+ - Patient symptoms, large hernia, or incarceration
+ - Small and asymptomatic hernias generally do not undergo repair and should be treated as incidental finding on imaging
+
+ 9ee7579c-287b-49a0-b521-282b515f31c9
+
+## References
+
+# Selected References
+
+1. [Coste AH et al: Umbilical hernia. StatPearls, 2024](http://www.ncbi.nlm.nih.gov/pubmed/?term=29083594%5Bpmid%5D)
+1. [He K et al: Age and probability of spontaneous umbilical hernia closure. JAMA Pediatr. 178(5):497-8, 2024](http://www.ncbi.nlm.nih.gov/pubmed/?term=38466296%5Bpmid%5D)
+1. [Shrestha BB et al: Incarcerated Littre's umbilical hernia: a case report. JNMA J Nepal Med Assoc. 62(270):139-41, 2024](http://www.ncbi.nlm.nih.gov/pubmed/?term=38409995%5Bpmid%5D)
+1. [Hager M et al: Primary uncomplicated ventral hernia repair: guidelines and practice patterns for routine hernia repairs. Surg Clin North Am. 103(5):901-15, 2023](http://www.ncbi.nlm.nih.gov/pubmed/?term=37709395%5Bpmid%5D)
+1. [Henriksen NA et al: Guidelines for treatment of umbilical and epigastric hernias from the European Hernia Society and Americas Hernia Society. Br J Surg. 107(3):171-90, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=31916607%5Bpmid%5D)
+1. [Kulaçoğlu H: Current options in umbilical hernia repair in adult patients. Ulus Cerrahi Derg. 31(3):157-61, 2015](http://www.ncbi.nlm.nih.gov/pubmed/?term=26504420%5Bpmid%5D)
+1. [Konerman M et al: Image of the month: umbilical hernia with ascites and a collateral paraumbilical vein in decompensated cirrhosis. Am J Gastroenterol. 108(8):1237, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=23912403%5Bpmid%5D)
+1. [Aguirre DA et al: Abdominal wall hernias: imaging features, complications, and diagnostic pitfalls at multi-detector row CT. Radiographics. 25(6):1501-20, 2005](http://www.ncbi.nlm.nih.gov/pubmed/?term=16284131%5Bpmid%5D)
+1. [Khati NJ et al: Imaging of the umbilicus and periumbilical region. Radiographics. 18(2):413-31, 1998](http://www.ncbi.nlm.nih.gov/pubmed/?term=9536487%5Bpmid%5D)
+
+## Differential diagnosis
+
+### Abdominal Wall Mass
+DDX:d51e2268-67b6-4a60-9222-f5a86f61ddec
+
+## Cases
+
+- {'cases': [{'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '02021248-bc54-4489-b241-0198dd405ab9', 'description': 'A series of contrast-enhanced axial CT sections (#1-10) show loculated ascites (arrows, #1-2, 9) and a peritoneal dialysis catheter (open arrow, #10). There is a small umbilical hernia (open arrows, #4-6) containing a short segment of bowel. The small bowel segments "upstream" from the herniated bowel are dilated with air-fluid levels (curved arrows, #2-5), while the segments "downstream" from the hernia are collapsed (arrows, #8), indicating that the hernia is the cause of the bowel obstruction.\n\nComment: The presence of ascites with a SBO usually raises concern for ischemic complication of the obstructed bowel; however, in this case it was due to the peritoneal dialysate and chronic renal failure. Umbilical hernias occur more frequently in patients with ascites.', 'history': 'Patient with chronic renal insufficiency treated with peritoneal dialysis; presents with abdominal pain and distention.', 'imagePoolId': '736c54ba-48f2-42bc-a3e0-656b2e3029cf', 'name': 'Causing partial small bowel obstruction', 'teachingPoint': None, 'demographics': '67 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '39d6b7cd-50aa-4837-beb1-13eacf5ff0ac', 'description': 'There is a focal bulge of omental fat (arrow) toward the umbilicus and between the rectus muscles, representing a small umbilical hernia.', 'history': 'Asymptomatic finding.', 'imagePoolId': '86a67b82-565a-4b79-b5b4-cfa444a8ffa6', 'name': 'Small bulge of fat', 'teachingPoint': None, 'demographics': '35 Years old female'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'cec54390-3da4-414b-bcbc-4865210fd557', 'description': 'A series of axial (#1-7) and coronal reformatted (#8-12) CECT images demonstrate protrusion of a portion of the transverse colon and omental fat through a defect in the anterior abdominal wall in the midline, representing an umbilical hernia (arrows). There is no sign of colonic obstruction nor infarction of the herniated fat, which are 2 of the common complications of abdominal wall hernias.', 'history': 'Obese patient with periumbilical discomfort and palpable mass effect.', 'imagePoolId': 'c6e429c1-2af1-406e-99d7-d078acc89eff', 'name': 'Containing transverse colon', 'teachingPoint': None, 'demographics': '82 Years old female'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'f580aa4a-399f-460f-aa85-8c1e37d9f4fd', 'description': 'CECT images (#1-3) shows ascites and dilated proximal small bowel (arrows, #1-3). There is an umbilical hernia (curved arrow, #1,2) containing ascites and bowel. Dilated bowel leads into the hernia and collapsed bowel (open arrow, #2) leaves the hernia, confirming bowel obstruction caused by a strangulated umbilical hernia.', 'history': 'Patient with cirrhosis and tense ascites with bulging umbilicus and crampy abdominal pain.', 'imagePoolId': 'a68928b9-a77e-4259-9f32-86340f4f1487', 'name': 'With bowel obstruction & ascites', 'teachingPoint': None, 'demographics': '48 Years old male'}], 'caseType': 'variant', 'name': 'VARIANT'}
+
+
+## Images
+
+
+### Selected Images
+
+
+*Axial CECT demonstrates protrusion of the transverse colon through a defect in the abdominal wall at the midline, representing an umbilical hernia . There is no sign of obstruction nor infarction of the herniated fat, 2 of the common complications of abdominal wall hernias.*
+
+
+*Axial CECT demonstrates an umbilical hernia filled with ascites fluid in this patient with cirrhosis. Umbilical hernias frequently fill with fluid in cirrhotic patients with tense ascites due to portal hypertension.*
+
+
+*Sagittal CECT demonstrates an umbilical hernia containing a loop of bowel with surrounding ascites. Note the dilated small bowel upstream from the hernia, compatible with bowel obstruction. The strangulated bowel was found to be ischemic at surgery.*
+
+
+*Axial CECT demonstrates an umbilical hernia containing a short segment of bowel. Dilated bowel leads into the hernia, suggesting bowel obstruction caused by a strangulated umbilical hernia.*
+
+
+### Additional Images
+
+
+*Axial CECT demonstrates protrusion of a portion of the transverse colon and omental fat through a defect in the anterior abdominal wall in the midline, representing an umbilical hernia . There is no sign of colonic obstruction nor infarction of the herniated fat, which are 2 of the common complications of abdominal wall hernias.*
+
+
+*Axial CECT in a middle-aged man with cirrhosis shows ascites, a dilated small bowel , and an umbilical hernia containing ascites and small bowel.*
+
+
+*Axial CECT in the same patient again demonstrates the umbilical hernia . Note the collapsed loop of small bowel leaving the hernia sac, confirming the hernia as the cause of the small bowel obstruction. Umbilical hernias are common among patients with cirrhosis and ascites due to thin abdominal wall musculature and chronically increased intraabdominal pressure.*
+
diff --git a/docs_md/articles/ventral-hernia_ab08cd87-4342-4825-948b-d02fc178078f.md b/docs_md/articles/ventral-hernia_ab08cd87-4342-4825-948b-d02fc178078f.md
new file mode 100644
index 0000000..473dfee
--- /dev/null
+++ b/docs_md/articles/ventral-hernia_ab08cd87-4342-4825-948b-d02fc178078f.md
@@ -0,0 +1,322 @@
+---
+title: "Ventral Hernia"
+docid: "ab08cd87-4342-4825-948b-d02fc178078f"
+authors:
+ - key: "c1df94ab-4a9f-44c4-add7-1f174fb9ac45"
+ value: "Siva P. Raman, MD"
+breadcrumbs:
+ -
+ name: "Gastrointestinal"
+ slug: "gastrointestinal"
+ treeNodeId: "b52263f7-5978-4a22-a17d-7260e0033943"
+ -
+ name: "Diagnosis"
+ slug: "diagnosis"
+ treeNodeId: "5a7c51af-b1c6-4629-8f0e-d99e6fe57a98"
+ -
+ name: "Peritoneum, Mesentery, and Abdominal Wall"
+ slug: "peritoneum-mesentery-and-abdominal-"
+ treeNodeId: "a3fb9f00-f894-4b38-9e01-2f78406cf547"
+ -
+ name: "External Hernias"
+ slug: "external-hernias"
+ treeNodeId: "71ab3f79-4332-463c-9f60-d3dd2902d974"
+ -
+ name: "Ventral Hernia"
+ slug: "ventral-hernia"
+ treeNodeId: null
+category: "Gastrointestinal"
+documentVersionId: "b71efcc9-3851-46b2-baed-5a5cd4dfb72f"
+imageCount: 14
+lastUpdated: "03/12/25"
+pageDescription: "Ventral Hernia"
+pageKeywords: "Gastrointestinal, Diagnosis, Peritoneum, Mesentery, and Abdominal Wall, External Hernias, Ventral Hernia"
+pageTitle: "Ventral Hernia | STATdx"
+enhancedTitle: "Ventral Hernia"
+type: "DX"
+references: true
+ddx: true
+cases: 2
+breadcrumbs:
+ - "Gastrointestinal"
+ - "Diagnosis"
+ - "Peritoneum, Mesentery, and Abdominal Wall"
+ - "External Hernias"
+ - "Ventral Hernia"
+---
+# KEY FACTS
+
+- ## Terminology
+
+
+ - Ventral hernia is generic term encompassing variety of hernias through anterior and lateral abdominal wall
+- ## Imaging
+
+
+ - **Epigastric** and **hypogastric** hernias occur at midline through linea alba
+ - Epigastric hernias arise above umbilicus and below xiphoid process
+ - Hypogastric hernias arise below umbilicus
+ - **Incisional** hernias develop at prior abdominal wall incision
+ - CT: Defect in musculofascial layers of abdominal wall through which omentum and bowel protrude
+ - Differentiate true hernias from rectus diastasis (widening of distance between 2 sides of rectus muscles resulting in bulging of anterior abdominal wall)
+ - Diastasis does not result in true musculofascial defect
+ - Narrow hernia opening ("neck") may increase risk of strangulation or obstruction
+- ## Pathology
+
+
+ - Ventral hernias may be either acquired or congenital
+ - Incisional hernias: Acquired hernias at site of prior surgery, incision, or abdominal wall injury
+ - May be related to previous abdominal surgery, laparoscopy, peritoneal dialysis, or stab wound
+ - Epigastric and hypogastric hernias: Possible congenital predisposition due to weakness of linea alba
+ - Acquired risk factors include obesity, increased intraabdominal pressures, and abdominal wall strains
+- ## Clinical Issues
+
+
+ - Incisional hernias usually occur during first 4 months after surgery but can develop many years later
+ - Ventral hernias do not close spontaneously and almost always enlarge over time
+ - Incarceration and strangulation are common
+ - Surgical closure is recommended (even for asymptomatic hernias) due to risk of incarceration and strangulation
+ - Tension-free mesh repair is now gold standard
+ - Mesh material may or may not be visible on CT depending on type of mesh material
+
+# TERMINOLOGY
+
+- ## Definitions
+
+
+ - Ventral hernia (VH): Broad term encompassing variety of different hernias through anterior and lateral aspects of abdominal wall
+ - Incisional hernia (IH): Hernia through site of prior abdominal wall incision
+
+# IMAGING
+
+- ## General Features
+
+
+ - ### Location
+
+
+ - Most occur in midline through aponeuroses
+ - Epigastric hernia: At midline above umbilicus and below xiphoid process
+ - Hypogastric hernia: At midline below umbilicus
+ - IH: Any surgical incision may be potential site for hernia
+ - ### Morphology
+
+
+ - 18-22% of patients have multiple hernias
+- ## Radiographic Findings
+
+
+ - Barium small bowel follow-through
+ - Anterior hernia best recognized on lateral view during Valsalva maneuver
+ - May be indirectly detected on frontal or oblique view by displacement of bowel loops, but finding should be confirmed on lateral view
+ - Findings of bowel obstruction with transition point in hernia sac
+ - Focal narrowing of bowel at exit and entry points
+ - Distended bowel loops proximal to transition point in hernia sac and collapsed bowel distal to hernia
+- ## CT Findings
+
+
+ - Most accurate diagnostic test for detection of VHs
+ - Defect in musculofascial layers of abdominal wall through which omentum and loops of small or large bowel protrude into subcutaneous fat of anterior abdominal wall
+ - Unlike rectus diastasis (which represents anterior bulging of abdominal wall at midline due to widening of rectus abdominis muscles), hernia should demonstrate true defect in abdominal wall
+ - Rectus diastasis often incorrectly described as midline hernia in radiology reports
+ - Increased attenuation or fat stranding within herniated fat raises possibility of internal fat necrosis or inflamed fat
+ - CT can easily differentiate incarcerated hernia from other entities that may be mimics on clinical exam (such as postoperative hematoma, abscess, etc.)
+ - CT can identify signs of resultant obstruction with abrupt narrowing of bowel entering hernia sac, decompression of bowel exiting sac, and proximal bowel dilatation
+ - Narrow opening of hernia sac (i.e., hernia "neck") may increase risk of strangulation/obstruction and should be described in radiology report
+- ## Ultrasonographic Findings
+
+
+ - Usually depicts hernia and fascial defect with detection aided by ability to have patient perform Valsalva maneuver during real-time scanning
+- ## Imaging Recommendations
+
+
+ - ### Best imaging tool
+
+
+ - CECT: Consider having patient perform Valsalva during scan
+
+# DIFFERENTIAL DIAGNOSIS
+
+- [Umbilical Hernia](/document/umbilical-hernia/ff51faeb-9832-4e87-a6cc-ca45673d754f)
+ - May be classified as type of VH
+ - Opening in linea alba at level of umbilicus in midline
+ - Can be present in either children or adults
+ - Usually congenital defect in children due to patent umbilical ring, although defect may close spontaneously at 12-18 months of age
+ - Adult form is acquired due to increased intraabdominal pressure, often in obese patients or multiparous/pregnant women
+- ## Diastasis of Rectus Abdominis Musculature
+
+
+ - "Stretching" and attenuation of anterior abdominal wall fascia at midline causing widening of rectus abdominis muscles (> 2 mm separation)
+ - Results in anterior bulging and protuberance of anterior abdominal wall
+ - Not true hernia, as there is no fascial defect, but can be difficult to differentiate from true hernia on clinical exam
+ - Typically present in obese patients or multiparous women
+- ## Pannus
+
+
+ - Subcutaneous fat and skin protruding over lower abdomen may simulate hernia
+ - No evidence of discrete facial or muscular defect to suggest hernia
+- [Hematoma or Abscess in Abdominal Wall](/document/abdominal-incision-and-injection-s-/1ca34a11-7dd7-4f66-96a3-8b201c64d2c5)
+ - Collection of blood or fluid within subcutaneous fat of anterior abdominal wall
+ - No defect in fascial layer or evidence of protrusion of omental fat or bowel
+
+# PATHOLOGY
+
+- ## General Features
+
+
+ - ### Etiology
+
+
+ - Depending on type of hernia, VHs may be due to either acquired or congenital factors
+ - IHs: Acquired hernias at site of prior surgery, incision, or abdominal wall injury
+ - May be related to previous abdominal surgery, laparoscopy, peritoneal dialysis, or stab wound
+ - Risk factors include older age, ascites, COPD, emergency surgery, and wound infections
+ - Epigastric and hypogastric hernias: Possible congenital predisposition due to congenital weakness of linea alba
+ - Acquired risk factors include obesity, increased intraabdominal pressures, and abdominal wall strains
+ - Factors which increase likelihood of hernia occurrence
+ - Patient-related: Collagen biochemistry, obesity, age > 65 years, pulmonary disease, uremia, diabetes, steroids, malignancy, trauma
+ - Technical factors: Wound infection, suture material, types of incisions and closures
+
+# CLINICAL ISSUES
+
+- ## Presentation
+
+
+ - Bulge or swelling on abdominal wall ± abdominal pain
+ - Can become larger and more painful with exertion
+ - Some patients may have clinically occult VHs with 1st clinical presentation being related to small bowel obstruction
+ - May be difficult to detect in patients with obesity, pain, or scarring
+ - Valsalva maneuver may elicit hernia
+ - IHs: Tend to occur during first 4 months after surgery but can develop many years later
+ - Progressive enlargement is common
+ - 5-10% remain clinically silent for several years
+ - Most IH are incidental findings at imaging
+ - Advanced stage: Persistent bulging mass resulting from herniated fat and bowel
+ - More common with vertical than transverse incisions
+ - Can occur through laparoscopy port (usually small opening with increased chance of strangulation)
+ - Symptoms out of proportion to objective findings if incarceration or strangulation occurs
+- ## Demographics
+
+
+ - ### Epidemiology
+
+
+ - > 80% of VHs result of prior surgery
+ - Occur after 0.2-26% of abdominal procedures
+- ## Natural History & Prognosis
+
+
+ - VHs do not close spontaneously and almost always enlarge over time
+ - Complications: Incarceration and strangulation are frequent with incisional, hypogastric, and epigastric hernias
+- ## Treatment
+
+
+ - Some debate about treatment of asymptomatic VHs, but, in principle, surgical closure of hernias is recommended due to risk of incarceration and strangulation
+ - Repair techniques include open suture, open mesh, and laparoscopic mesh repairs
+ - Repair with simple suture (rather than mesh) has high risk of recurrence but may still be utilized for smaller hernias
+ - Tension-free mesh repair is now gold standard and is most commonly utilized technique
+ - Polypropylene mesh is isodense to surrounding tissues and not well visualized on CT, while polytetrafluoroethylene (PTFE) mesh tends to be visible on CT as linear hyperdense material
+ - Surgical complications in up to 50%, most commonly recurrence of hernia
+ - Laparoscopic and mesh repair have lower recurrence rates (< 5%)
+
+# DIAGNOSTIC CHECKLIST
+
+- ## Consider
+
+
+ - Report size of hernia opening (i.e., hernia "neck") and whether there is any thinning or atrophy of surrounding abdominal wall musculature
+ - These features can be useful in assessing risk of strangulation and likely success of hernia repair
+
+ a0cbf1c6-67dd-4a09-bf68-d01d188c4f65
+
+## References
+
+# Selected References
+
+1. [Morrell DJ et al: Radiographic identification of thoracoabdominal hernias. Hernia. 26(1):287-95, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=34125302%5Bpmid%5D)
+1. [Kushner B et al: Identifying critical computed tomography (CT) imaging findings for the preoperative planning of ventral hernia repairs. Hernia. 25(4):963-69, 2021](http://www.ncbi.nlm.nih.gov/pubmed/?term=33025298%5Bpmid%5D)
+1. [Smith J et al: Ventral hernia. StatPearls, 2021](http://www.ncbi.nlm.nih.gov/pubmed/?term=29763102%5Bpmid%5D)
+1. [Patil AR et al: Mind the gap: imaging spectrum of abdominal ventral hernia repair complications. Insights Imaging. 10(1):40, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=30923952%5Bpmid%5D)
+1. [Halligan S et al: Imaging complex ventral hernias, their surgical repair, and their complications. Eur Radiol. 28(8):3560-9, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=29532239%5Bpmid%5D)
+1. [Jin J et al: Laparoscopic versus open ventral hernia repair. Surg Clin North Am. 88(5):1083-100, viii, 2008](http://www.ncbi.nlm.nih.gov/pubmed/?term=18790156%5Bpmid%5D)
+1. [Jamadar DA et al: Characteristic locations of inguinal region and anterior abdominal wall hernias: sonographic appearances and identification of clinical pitfalls. AJR Am J Roentgenol. 188(5):1356-64, 2007](http://www.ncbi.nlm.nih.gov/pubmed/?term=17449782%5Bpmid%5D)
+1. [Zafar HM et al: Anterior abdominal wall hernias: findings in barium studies. Radiographics. 26(3):691-9, 2006](http://www.ncbi.nlm.nih.gov/pubmed/?term=16702448%5Bpmid%5D)
+1. [Aguirre DA et al: Abdominal wall hernias: imaging features, complications, and diagnostic pitfalls at multi-detector row CT. Radiographics. 25(6):1501-20, 2005](http://www.ncbi.nlm.nih.gov/pubmed/?term=16284131%5Bpmid%5D)
+1. [Aguirre DA et al: Abdominal wall hernias: MDCT findings. AJR Am J Roentgenol. 183(3):681-90, 2004](http://www.ncbi.nlm.nih.gov/pubmed/?term=15333356%5Bpmid%5D)
+1. [Millikan KW: Incisional hernia repair. Surg Clin North Am. 83(5):1223-34, 2003](http://www.ncbi.nlm.nih.gov/pubmed/?term=14533912%5Bpmid%5D)
+1. [Yahchouchy-Chouillard E et al: incisional hernias. I. Related risk factors. Dig Surg. 20(1):3-9, 2003](http://www.ncbi.nlm.nih.gov/pubmed/?term=12637797%5Bpmid%5D)
+1. [Thoman DS et al: Current status of laparoscopic ventral hernia repair. Surg Endosc. 16(6):939-42, 2002](http://www.ncbi.nlm.nih.gov/pubmed/?term=12163959%5Bpmid%5D)
+
+## Differential diagnosis
+
+### Abdominal Wall Mass
+DDX:d51e2268-67b6-4a60-9222-f5a86f61ddec
+
+### Defect in Abdominal Wall (Hernia)
+DDX:5af046fa-59ef-45b5-952b-acbcdee36196
+
+### Epigastric Pain
+DDX:20f944e9-a7b2-4b52-a7bf-8a002cb5b2de
+
+### Left Upper Quadrant Mass
+DDX:fd065ba5-e8b9-47d7-b09f-89f963b58f5c
+
+### Small Bowel Obstruction
+DDX:ad8209f0-71e5-4496-860f-d2724ca22892
+
+## Cases
+
+- {'cases': [{'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'b1a5c325-202a-46ad-9307-174d7bd28dcc', 'description': 'A series of axial NECT sections (#1-8) shows small metallic anchors (curved arrows, #1) and a sheet of tissue density material (curved arrows, #2,4) linking them within or just deep to the anterior abdominal wall musculofascial plane, which appears quite thin. Just lateral and caudal to this is a bulge through the anterolateral abdominal wall (arrows, #4-8) that contains omental fat and portions of the small intestine. The proximal small bowel is dilated and filled with fluid and gas (open arrows, #3,6), while the portion near the hernia has gas and particulate debris within it (open arrow, #5). The small bowel distal to the hernia is collapsed (curved arrows, #5,7).\n\nA series of sagittal (#9-10) and coronal (#11-13) reformations demonstrates the hernia (arrows, #9,11-13) with a dilated small bowel proximal to the hernia (open arrows, #10,12-13) and a collapsed bowel distal to it (curved arrows, #9,13).\n\nComment: This is a typical case of failed ventral hernia repair in an obese, deconditioned woman, resulting in small bowel obstruction. In such patients, the musculofascial tissues are often so weak and attenuated that surgical repair of the hernia, even with mesh and anchor reinforcement, often fails.', 'history': 'Patient presented with crampy abdominal pain and recurrent bulge in abdominal wall.', 'imagePoolId': '3915cf9b-3022-4b75-a223-34030358363e', 'name': 'Recurrent with bowel obstruction', 'teachingPoint': None, 'demographics': '79 Years old female'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '5b93dfda-24ae-461d-a0d7-d1f0fa7838ed', 'description': 'CT shows a ventral incisional hernia with bowel obstruction.\n\nAxial CECT shows a "knuckle" of small bowel herniated through a defect (arrow, #1) in the anterior abdominal wall. The small intestine proximal to the herniated segment is dilated (open arrow, #2), while that which is distal to the hernia is collapsed (curved arrow, #2), indicating that the herniated bowel is obstructed.', 'history': 'Elderly man with abdominal pain and distention.', 'imagePoolId': '20cc95e2-c6b3-4542-915d-4a8916aa9e28', 'name': 'Causing bowel obstruction', 'teachingPoint': None, 'demographics': '77 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'fd858e55-b9f0-458d-a959-190cc77cf7f1', 'description': 'CT shows a large defect in the anterior abdominal wall, containing non-obstructed bowel.\n\nThere is a wide gap (arrow, #1) between the thin rectus muscles, through which a long segment of small bowel has herniated. Due to the atrophy of the rectus muscles and the wide opening, the herniated bowel is not obstructed.\n\nComment: Ventral hernias are most common in obese women following abdominal surgery. The rectus muscles are often atrophic from lack of use, and sometimes from the surgical procedure itself, that may disrupt the nerve and vascular supply of the abdominal wall musculature. Long segments of bowel may herniate, and the diagnosis may often be inapparent to the referring physician, as the abdomen is usually soft to palpation and bowel obstruction in this setting is uncommon.', 'history': 'Elderly woman with abdominal distention, and a palpable "mass"', 'imagePoolId': '4f238777-3ffd-4af0-9c40-f14a606301d1', 'name': 'Large, without bowel obstruction', 'teachingPoint': None}], 'caseType': 'typical', 'name': 'TYPICAL'}
+- {'cases': [{'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'f6c0b08d-d5be-4f70-806b-eb29c5bbab52', 'description': 'CT shows herniation of bowel through a laparoscopy port, with bowel obstruction.\n\nCT shows distended proximal small bowel (open arrow, #1). The dilated bowel could be followed into a hernia (arrow, #2, 3) that represented one of the sites of instrument access for the laparoscopic appendectomy. Bowel distal to the hernia site is collapsed.\n\nComment: This case is very similar to a spigelian hernia, given the location lateral to the rectus muscle. The small size of the opening in the musculo-fascial layer makes it more likely that any bowel that herniated through the opening will become strangulated and obstructed.', 'history': 'Abdominal distension and pain weeks after an uneventful appendectomy.', 'imagePoolId': 'c5bb855f-5bce-4b44-8014-b2033f2c6366', 'name': 'Through a laparoscopy port site', 'teachingPoint': None}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '8897331d-27b7-43df-9727-225ed346a981', 'description': 'CT shows a ventral hernia with strangulated and obstructed small bowel.\n\nAxial CECT images (#1-3) show massively dilated proximal small bowel. Ascites (open arrow, #2) is also noted and suggests bowel ischemia. The site of obstruction is a ventral hernia (arrow, #1). Collapsed distal bowel is noted (curved arrow, #3).', 'history': 'Abdominal pain and distention.\n', 'imagePoolId': 'dab54e30-67fb-4f08-959c-242e1617b166', 'name': 'With strangulated bowel', 'teachingPoint': None}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '6244d3e3-e8b5-4551-a1fb-edd9a5c197b8', 'description': 'CT shows a right flank incisional hernia.\n\nCT shows a portion of the ascending colon herniating through a defect (curved arrow, #1, 2) in the right abdominal wall musculature, at the site of prior incision. There are no signs of strangulation or bowel obstruction.', 'history': 'Flank pain 2 years following partial nephrectomy.', 'imagePoolId': 'd69e67b7-ae25-4d46-beab-40cef59186bf', 'name': 'Through flank incision', 'teachingPoint': None}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '0155a085-5adb-4477-a2f8-0a0a27f23b6c', 'description': 'Axial CECT images (#1, 2) show bowel herniated into the right rectus sheath (curved arrow). The rectus muscle is atrophic and replaced with fat, common in elderly patients who have had a muscle-splitting laparotomy. A surgical clip (arrow, #1) indicated prior surgery in the region.', 'history': 'Elderly woman with right lower abdominal pain.', 'imagePoolId': 'cc6cc37f-57f2-4b8b-8eab-fb8e941ca86b', 'name': 'Within the rectus sheath', 'teachingPoint': None}], 'caseType': 'variant', 'name': 'VARIANT'}
+
+
+## Images
+
+
+### Selected Images
+
+
+*Axial CECT demonstrates a hernia containing omental fat arising in the midline above the umbilicus and below the xiphoid, characteristic of an epigastric hernia.*
+
+
+*Axial CECT demonstrates a ventral hernia containing a loop of small bowel . Notice the mildly dilated upstream small bowel , compatible with obstruction. The patient was taken to surgery to relieve the obstruction.*
+
+
+*Axial CECT demonstrates a ventral hernia in the right lower quadrant containing the patient's transplant kidney , ostensibly representing an incisional hernia related to the patient's prior transplant surgery.*
+
+
+*Axial CECT demonstrates a small bowel containing hernia in the left lower quadrant at a previous laparoscopic port site. Note the presence of some dilated proximal small bowel loops , compatible with obstruction.*
+
+
+### Additional Images
+
+
+*Axial CECT shows herniation of small bowel through a wide ventral hernia at the site of a prior paramedian surgical incision.*
+
+
+*Axial CECT shows ventral hernia containing ascites and varices in a patient with cirrhosis (umbilicus at a lower section).*
+
+
+*Axial CECT shows a lateral ventral hernia.*
+
+
+*Axial CECT shows a lateral incisional hernia containing colon.*
+
+
+*Axial CECT in an older obese woman with a bulge that increases with straining shows a large defect in the anterior abdominal wall containing nonobstructed bowel.*
+
+
+*Axial CECT shows a ventral incisional hernia with bowel obstruction. Axial CECT shows a "knuckle" of small bowel herniated through a defect in the anterior abdominal wall.*
+
+
+*Axial CECT in the same patient shows that the small intestine proximal to the herniated segment is dilated , while that which is distal to the hernia is collapsed , indicating that the herniated bowel is obstructed.*
+
+
+*Axial CECT demonstrates a hernia containing small bowel arising in the midline above the umbilicus and below the xiphoid, characteristic of an epigastric hernia. The bowel within the hernia appears normal, without evidence of obstruction or ischemia.*
+
+
+*Axial CECT in the same patient shows dilated bowel leading up to the hernia and collapsed bowel leaving the hernia. As suggested by the ascites , the obstructed bowel was ischemic but proved viable at surgery.*
+
+
+*Axial CECT in a middle-aged woman with nausea and vomiting shows a ventral hernia with strangulated, obstructed small bowel as well as ascites , suggesting bowel ischemia.*
+
diff --git a/results.json b/results.json
index 2d3a61f..ede7146 100644
--- a/results.json
+++ b/results.json
@@ -1,550 +1,236 @@
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+ "path": "docs_md/articles/facial-nerve-in-temporal-bone_21dccac8-d73d-4ef3-859b-73e013ec15cc.md",
+ "title": "Facial Nerve in Temporal Bone",
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- "Aortic Aneurysm: Rupture"
- ],
- "authors": [
- {
- "key": "b00d2bdb-66e1-41ed-90b4-c52904f4d598",
- "value": "Seth Kligerman, MD, MS"
- },
- {
- "key": "9ad9af12-61a1-44d6-af52-0ee1f38eb298",
- "value": "Davis Vigneault, MD, DPhil"
- },
- {
- "key": "5de0df07-7b3e-4678-8767-1519e1153f29",
- "value": "Dominik Fleischmann, MD"
- }
- ],
- "pageKeywords": "Cardiac, Diagnosis, Aorta, Aortic Aneurysm: Rupture"
- },
- {
- "path": "docs_md/articles/traumatic-aortic-injury_061b04b5-e37e-4f63-a198-1020a984e041.md",
- "title": "Traumatic Aortic Injury",
- "docid": "061b04b5-e37e-4f63-a198-1020a984e041",
- "breadcrumbs": [
- "Cardiac",
- "Diagnosis",
- "Aorta",
- "Traumatic Aortic Injury"
- ],
- "authors": [
- {
- "key": "770e1d77-2287-436e-910b-48232afc7842",
- "value": "Prabhakar Rajiah, MBBS, MD, FACR, FRCR, FACC, FAHA, FSCCT"
- },
- {
- "key": "8b719ccc-d695-4377-9afb-2b399714d382",
- "value": "Terrance Healey, MD"
- }
- ],
- "pageKeywords": "Cardiac, Diagnosis, Aorta, Traumatic Aortic Injury"
- },
- {
- "path": "docs_md/articles/right-aortic-arch_5f186c96-4cc3-453e-840d-12ebfad13115.md",
- "title": "Right Aortic Arch",
- "docid": "5f186c96-4cc3-453e-840d-12ebfad13115",
- "breadcrumbs": [
- "Cardiac",
- "Diagnosis",
- "Aorta",
- "Right Aortic Arch"
- ],
- "authors": [
- {
- "key": "ee6ece9d-ad74-458c-a8df-11628ae7f879",
- "value": "Arzu Canan, MD"
- },
- {
- "key": "10bb95ac-a27a-4ebe-833b-e59fea07734b",
- "value": "Santiago Martínez-Jiménez, MD, FACR"
- }
- ],
- "pageKeywords": "Cardiac, Diagnosis, Aorta, Right Aortic Arch"
- },
- {
- "path": "docs_md/articles/thoracic-aorta-and-great-vessel-anatomy_67498b94-770a-47ee-bd74-622b5e0b6817.md",
- "title": "Thoracic Aorta and Great Vessel Anatomy",
- "docid": "67498b94-770a-47ee-bd74-622b5e0b6817",
- "breadcrumbs": [
- "Cardiac",
+ "Head and Neck",
"Anatomy",
- "Thoracic Aorta and Great Vessel Anatomy"
+ "Temporal Bone",
+ "Facial Nerve in Temporal Bone"
],
"authors": [
{
- "key": "9fea2857-d729-4fe4-b4fd-3b7bf1db23cf",
- "value": "Mortadha Al-Kinani, MD, MBChB"
- },
- {
- "key": "3d1e4c57-c1cf-4c89-b0f0-5d82b29a31e1",
- "value": "Suhny Abbara, MD, FACR, MSCCT, FNASCI"
+ "key": "b2e6dabb-ee1c-42a4-a332-9f0814c1c607",
+ "value": "Surjith Vattoth, MD, FRCR"
}
],
- "pageKeywords": "Cardiac, Anatomy, Thoracic Aorta and Great Vessel Anatomy"
+ "pageKeywords": "Head and Neck, Anatomy, Temporal Bone, Facial Nerve in Temporal Bone"
},
{
- "path": "docs_md/articles/thoracic-aortic-aneurysm_3c637054-d97c-4ae6-bc0c-ceac5f4a4f1f.md",
- "title": "Thoracic Aortic Aneurysm",
- "docid": "3c637054-d97c-4ae6-bc0c-ceac5f4a4f1f",
+ "path": "docs_md/articles/cnvii-facial-nerve_98cb2d45-e64c-4295-9662-3470cd46513a.md",
+ "title": "CNVII (Facial Nerve)",
+ "docid": "98cb2d45-e64c-4295-9662-3470cd46513a",
"breadcrumbs": [
- "Cardiac",
- "Diagnosis",
- "Aorta",
- "Thoracic Aortic Aneurysm"
+ "Head and Neck",
+ "Anatomy",
+ "Cranial Nerves",
+ "CNVII (Facial Nerve)"
],
"authors": [
{
- "key": "b00d2bdb-66e1-41ed-90b4-c52904f4d598",
- "value": "Seth Kligerman, MD, MS"
+ "key": "1fa14dfd-71ea-4960-908e-e720313bc63a",
+ "value": "Santhosh Gaddikeri, MD"
+ },
+ {
+ "key": "94f835c8-fa13-4e8a-995b-53048e6b0605",
+ "value": "Philip R. Chapman, MD"
}
],
- "pageKeywords": "Cardiac, Diagnosis, Aorta, Thoracic Aortic Aneurysm"
+ "pageKeywords": "Head and Neck, Anatomy, Cranial Nerves, CNVII (Facial Nerve)"
},
{
- "path": "docs_md/articles/pseudocoarctation_a5a7c623-d5cb-4bb1-b628-986d9ca1f94a.md",
- "title": "Pseudocoarctation",
- "docid": "a5a7c623-d5cb-4bb1-b628-986d9ca1f94a",
+ "path": "docs_md/articles/facial-nerve-cnvii_2f4818dd-6438-405b-8561-5cbbb9c91562.md",
+ "title": "Facial Nerve (CNVII)",
+ "docid": "2f4818dd-6438-405b-8561-5cbbb9c91562",
"breadcrumbs": [
- "Cardiac",
- "Diagnosis",
- "Aorta",
- "Pseudocoarctation"
+ "Brain",
+ "Anatomy",
+ "Skull Base and Cranial Nerves",
+ "Facial Nerve (CNVII)"
],
"authors": [
{
- "key": "a354e6da-2757-40e8-b7ff-5e6fb6413ff6",
- "value": "Sachin S. Saboo, MD, FRCR, FSCMR"
+ "key": "94f835c8-fa13-4e8a-995b-53048e6b0605",
+ "value": "Philip R. Chapman, MD"
},
{
- "key": "b00d2bdb-66e1-41ed-90b4-c52904f4d598",
- "value": "Seth Kligerman, MD, MS"
- },
- {
- "key": "0e97d53b-518f-493d-bcf9-236f6494f4c2",
- "value": "Carlos A. Rojas, MD"
+ "key": "b0a6efa4-ad68-430c-b5da-f5c904adf809",
+ "value": "Ryan P. Cabeen, PhD"
}
],
- "pageKeywords": "Cardiac, Diagnosis, Aorta, Pseudocoarctation"
+ "pageKeywords": "Brain, Anatomy, Skull Base and Cranial Nerves, Facial Nerve (CNVII)"
},
{
- "path": "docs_md/articles/aortic-intramural-hematoma_128bc4cc-a26d-47d5-90e7-b1a1f608e657.md",
- "title": "Aortic Intramural Hematoma",
- "docid": "128bc4cc-a26d-47d5-90e7-b1a1f608e657",
+ "path": "docs_md/articles/peripheral-facial-nerve-paralysis_4da52ac4-c03c-4711-ae7e-bb4f2f7c5ab8.md",
+ "title": "Peripheral Facial Nerve Paralysis",
+ "docid": "4da52ac4-c03c-4711-ae7e-bb4f2f7c5ab8",
"breadcrumbs": [
- "Cardiac",
- "Diagnosis",
- "Aorta",
- "Aortic Intramural Hematoma"
+ "Head and Neck",
+ "Differential Diagnosis",
+ "Temporal Bone",
+ "Clinically Based Differentials",
+ "Peripheral Facial Nerve Paralysis"
],
"authors": [
{
- "key": "b66f94a2-4335-4ce8-a3ba-8c5527f8774c",
- "value": "Domenico Mastrodicasa, MD"
- },
- {
- "key": "5de0df07-7b3e-4678-8767-1519e1153f29",
- "value": "Dominik Fleischmann, MD"
+ "key": "eef2f839-5706-47b9-89c3-60d8315b2b3a",
+ "value": "Nicholas A. Koontz, MD"
}
],
- "pageKeywords": "Cardiac, Diagnosis, Aorta, Aortic Intramural Hematoma"
+ "pageKeywords": "Head and Neck, Differential Diagnosis, Temporal Bone, Clinically Based Differentials, Peripheral Facial Nerve Paralysis"
},
{
- "path": "docs_md/articles/persistent-fifth-arch_931c64bc-e8a0-4a99-848b-1429f3c1d500.md",
- "title": "Persistent Fifth Arch",
- "docid": "931c64bc-e8a0-4a99-848b-1429f3c1d500",
+ "path": "docs_md/articles/temporal-bone-facial-nerve-venous-malformation-hemangioma_dcd6a44e-cbe6-457c-9b03-598a2b874ece.md",
+ "title": "Temporal Bone Facial Nerve Venous Malformation (Hemangioma)",
+ "docid": "dcd6a44e-cbe6-457c-9b03-598a2b874ece",
"breadcrumbs": [
- "Cardiac",
+ "Head and Neck",
"Diagnosis",
- "Aorta",
- "Persistent Fifth Arch"
+ "Temporal Bone",
+ "Intratemporal Facial Nerve",
+ "Benign and Malignant Tumors",
+ "Temporal Bone Facial Nerve Venous Malformation (Hemangioma)"
],
"authors": [
{
- "key": "9fea2857-d729-4fe4-b4fd-3b7bf1db23cf",
- "value": "Mortadha Al-Kinani, MD, MBChB"
+ "key": "07a2c087-6202-49e7-870b-7aa162d18f06",
+ "value": "Bronwyn E. Hamilton, MD"
},
{
- "key": "3d1e4c57-c1cf-4c89-b0f0-5d82b29a31e1",
- "value": "Suhny Abbara, MD, FACR, MSCCT, FNASCI"
+ "key": "33151213-01b2-4542-9105-342e006b3915",
+ "value": "H. Ric Harnsberger, MD"
}
],
- "pageKeywords": "Cardiac, Diagnosis, Aorta, Persistent Fifth Arch"
+ "pageKeywords": "Head and Neck, Diagnosis, Temporal Bone, Intratemporal Facial Nerve, Benign and Malignant Tumors, Temporal Bone Facial Nerve Venous Malformation (Hemangioma)"
},
{
- "path": "docs_md/articles/takayasu-arteritis_d35eb6f3-bfd3-4121-8781-325a93ccc197.md",
- "title": "Takayasu Arteritis",
- "docid": "d35eb6f3-bfd3-4121-8781-325a93ccc197",
+ "path": "docs_md/articles/middle-ear-prolapsing-facial-nerve_61f6bcaa-f073-4385-b895-dc420ddc8a1e.md",
+ "title": "Middle Ear Prolapsing Facial Nerve",
+ "docid": "61f6bcaa-f073-4385-b895-dc420ddc8a1e",
"breadcrumbs": [
- "Cardiac",
+ "Head and Neck",
"Diagnosis",
- "Aorta",
- "Takayasu Arteritis"
+ "Temporal Bone",
+ "Intratemporal Facial Nerve",
+ "Pseudolesions",
+ "Middle Ear Prolapsing Facial Nerve"
],
"authors": [
{
- "key": "ee6ece9d-ad74-458c-a8df-11628ae7f879",
- "value": "Arzu Canan, MD"
+ "key": "94f835c8-fa13-4e8a-995b-53048e6b0605",
+ "value": "Philip R. Chapman, MD"
},
{
- "key": "3d1e4c57-c1cf-4c89-b0f0-5d82b29a31e1",
- "value": "Suhny Abbara, MD, FACR, MSCCT, FNASCI"
+ "key": "33151213-01b2-4542-9105-342e006b3915",
+ "value": "H. Ric Harnsberger, MD"
}
],
- "pageKeywords": "Cardiac, Diagnosis, Aorta, Takayasu Arteritis"
+ "pageKeywords": "Head and Neck, Diagnosis, Temporal Bone, Intratemporal Facial Nerve, Pseudolesions, Middle Ear Prolapsing Facial Nerve"
},
{
- "path": "docs_md/articles/chronic-posttraumatic-pseudoaneurysm_21837987-efb6-4218-90ff-22362f61a21d.md",
- "title": "Chronic Posttraumatic Pseudoaneurysm",
- "docid": "21837987-efb6-4218-90ff-22362f61a21d",
+ "path": "docs_md/articles/temporal-bone-facial-nerve-schwannoma_cf2bcc82-4a1b-4989-adeb-f4e82116111b.md",
+ "title": "Temporal Bone Facial Nerve Schwannoma",
+ "docid": "cf2bcc82-4a1b-4989-adeb-f4e82116111b",
"breadcrumbs": [
- "Cardiac",
+ "Head and Neck",
"Diagnosis",
- "Aorta",
- "Chronic Posttraumatic Pseudoaneurysm"
+ "Temporal Bone",
+ "Intratemporal Facial Nerve",
+ "Benign and Malignant Tumors",
+ "Temporal Bone Facial Nerve Schwannoma"
],
"authors": [
{
- "key": "10bb95ac-a27a-4ebe-833b-e59fea07734b",
- "value": "Santiago Martínez-Jiménez, MD, FACR"
+ "key": "07a2c087-6202-49e7-870b-7aa162d18f06",
+ "value": "Bronwyn E. Hamilton, MD"
},
{
- "key": "5de0df07-7b3e-4678-8767-1519e1153f29",
- "value": "Dominik Fleischmann, MD"
+ "key": "33151213-01b2-4542-9105-342e006b3915",
+ "value": "H. Ric Harnsberger, MD"
}
],
- "pageKeywords": "Cardiac, Diagnosis, Aorta, Chronic Posttraumatic Pseudoaneurysm"
+ "pageKeywords": "Head and Neck, Diagnosis, Temporal Bone, Intratemporal Facial Nerve, Benign and Malignant Tumors, Temporal Bone Facial Nerve Schwannoma"
},
{
- "path": "docs_md/articles/marfan-syndrome_61d06223-8428-401c-89bc-d12205410726.md",
- "title": "Marfan Syndrome",
- "docid": "61d06223-8428-401c-89bc-d12205410726",
+ "path": "docs_md/articles/intratemporal-facial-nerve-enhancement_a3569ec5-a566-411d-877f-41ad832e3fd2.md",
+ "title": "Intratemporal Facial Nerve Enhancement",
+ "docid": "a3569ec5-a566-411d-877f-41ad832e3fd2",
"breadcrumbs": [
- "Cardiac",
+ "Head and Neck",
"Diagnosis",
- "Aorta",
- "Marfan Syndrome"
+ "Temporal Bone",
+ "Intratemporal Facial Nerve",
+ "Pseudolesions",
+ "Intratemporal Facial Nerve Enhancement"
],
"authors": [
{
- "key": "9fea2857-d729-4fe4-b4fd-3b7bf1db23cf",
- "value": "Mortadha Al-Kinani, MD, MBChB"
- },
- {
- "key": "10bb95ac-a27a-4ebe-833b-e59fea07734b",
- "value": "Santiago Martínez-Jiménez, MD, FACR"
+ "key": "94f835c8-fa13-4e8a-995b-53048e6b0605",
+ "value": "Philip R. Chapman, MD"
}
],
- "pageKeywords": "Cardiac, Diagnosis, Aorta, Marfan Syndrome"
+ "pageKeywords": "Head and Neck, Diagnosis, Temporal Bone, Intratemporal Facial Nerve, Pseudolesions, Intratemporal Facial Nerve Enhancement"
},
{
- "path": "docs_md/articles/limited-intimal-tear_bb253de9-ab48-4740-89bd-0036fb8c12f5.md",
- "title": "Limited Intimal Tear",
- "docid": "bb253de9-ab48-4740-89bd-0036fb8c12f5",
+ "path": "docs_md/articles/hemifacial-spasm_1b390143-1212-4447-beb3-ed9e85ef34e4.md",
+ "title": "Hemifacial Spasm",
+ "docid": "1b390143-1212-4447-beb3-ed9e85ef34e4",
"breadcrumbs": [
- "Cardiac",
- "Diagnosis",
- "Aorta",
- "Limited Intimal Tear"
+ "Head and Neck",
+ "Differential Diagnosis",
+ "CPA-IAC and Posterior Fossa",
+ "Clinically Based Differentials",
+ "Hemifacial Spasm"
],
"authors": [
{
- "key": "5de0df07-7b3e-4678-8767-1519e1153f29",
- "value": "Dominik Fleischmann, MD"
- },
- {
- "key": "5a4d7c03-82a7-4740-947a-9638213aec4a",
- "value": "Mohammad H. Madani, MD"
+ "key": "eef2f839-5706-47b9-89c3-60d8315b2b3a",
+ "value": "Nicholas A. Koontz, MD"
}
],
- "pageKeywords": "Cardiac, Diagnosis, Aorta, Limited Intimal Tear"
+ "pageKeywords": "Head and Neck, Differential Diagnosis, CPA-IAC and Posterior Fossa, Clinically Based Differentials, Hemifacial Spasm"
+ },
+ {
+ "path": "docs_md/articles/cpa-iac-facial-nerve-schwannoma_9db01630-23a4-4f42-ad83-0ec399503495.md",
+ "title": "CPA-IAC Facial Nerve Schwannoma",
+ "docid": "9db01630-23a4-4f42-ad83-0ec399503495",
+ "breadcrumbs": [
+ "Head and Neck",
+ "Diagnosis",
+ "CPA-IAC",
+ "Benign and Malignant Tumors",
+ "CPA-IAC Facial Nerve Schwannoma"
+ ],
+ "authors": [
+ {
+ "key": "07a2c087-6202-49e7-870b-7aa162d18f06",
+ "value": "Bronwyn E. Hamilton, MD"
+ },
+ {
+ "key": "33151213-01b2-4542-9105-342e006b3915",
+ "value": "H. Ric Harnsberger, MD"
+ }
+ ],
+ "pageKeywords": "Head and Neck, Diagnosis, CPA-IAC, Benign and Malignant Tumors, CPA-IAC Facial Nerve Schwannoma"
+ },
+ {
+ "path": "docs_md/articles/facial-nerve-lesion-temporal-bone_1428754b-a8ee-48a0-98f8-4faeebf8dbab.md",
+ "title": "Facial Nerve Lesion, Temporal Bone",
+ "docid": "1428754b-a8ee-48a0-98f8-4faeebf8dbab",
+ "breadcrumbs": [
+ "Head and Neck",
+ "Differential Diagnosis",
+ "Temporal Bone",
+ "Anatomically Based Differentials",
+ "Facial Nerve Lesion, Temporal Bone"
+ ],
+ "authors": [
+ {
+ "key": "eef2f839-5706-47b9-89c3-60d8315b2b3a",
+ "value": "Nicholas A. Koontz, MD"
+ }
+ ],
+ "pageKeywords": "Head and Neck, Differential Diagnosis, Temporal Bone, Anatomically Based Differentials, Facial Nerve Lesion, Temporal Bone"
}
]
\ No newline at end of file
diff --git a/scrapers/document_to_markdown.py b/scrapers/document_to_markdown.py
index 97faf6f..4e0b5a0 100644
--- a/scrapers/document_to_markdown.py
+++ b/scrapers/document_to_markdown.py
@@ -529,7 +529,11 @@ def process_file(path: str, out_dir: str, overwrite: bool = False, verbose: bool
# deterministic doc id (if present in filename)
docid = None
- docid = base.split("_document_content_")[1].split("_")[0]
+ try:
+ docid = base.split("_document_content_")[1].split("_")[0]
+ except Exception as e:
+ logger.error(f"Failed to extract docid from filename {base}: {e}")
+ return False, "invalid-filename"
logger.debug(f"Extracted docid: {docid}")
# logger.debug(f"DOCUMENT_SUMMARYS keys: {DOCUMENT_SUMMARYS.get(docid)}")
diff --git a/scrapers/map_titles_to_ids.py b/scrapers/map_titles_to_ids.py
new file mode 100644
index 0000000..9358ac8
--- /dev/null
+++ b/scrapers/map_titles_to_ids.py
@@ -0,0 +1,131 @@
+#!/usr/bin/env python3
+"""
+Map titles from a content-set JSON to document IDs by scanning captured search-ajax responses.
+
+Usage:
+ python map_titles_to_ids.py \
+ --titles /home/ross/statdx/xhr_captured_async/app.statdx.com_search_content-set_productVersionId_bf09eabd-282b-4f83-b937-88d54b49db83_7e4593f2e47ed5942af45c77b9a7ff08e635ecc0.json \
+ --captures-dir /home/ross/statdx/xhr_captured_async \
+ --out mapping.json
+
+The script produces a JSON mapping of the form:
+ [{
+ "title": "Original Title",
+ "normalized": "original title",
+ "matches": [ {"id": "...", "slug": "...", "source_file": "..."}, ... ]
+ }, ...]
+
+It uses exact normalized-title matching (lowercased, whitespace collapsed). If needed we can add fuzzy matching.
+"""
+
+import argparse
+import json
+import os
+import re
+from pathlib import Path
+from collections import defaultdict
+
+
+def normalize_title(s: str) -> str:
+ if not isinstance(s, str):
+ return ""
+ s = s.strip().lower()
+ # collapse whitespace
+ s = re.sub(r"\s+", " ", s)
+ return s
+
+
+def scan_search_ajax_files(captures_dir: Path):
+ mapping = defaultdict(list)
+ for p in captures_dir.iterdir():
+ name = p.name
+ # look for files that appear to be search-ajax JSON (not meta.json)
+ if "search-ajax" in name and name.endswith('.json') and not name.endswith('.meta.json'):
+ try:
+ with p.open('r') as fh:
+ doc = json.load(fh)
+ except Exception:
+ # skip unreadable files
+ continue
+
+ # pattern: doc['searchResults']['results'] is a list of result objects
+ results = None
+ if isinstance(doc, dict):
+ results = doc.get('searchResults', {}).get('results')
+ if not results:
+ continue
+
+ for r in results:
+ title = r.get('title') or (r.get('metadata') or {}).get('title')
+ _id = r.get('id') or (r.get('metadata') or {}).get('search_id')
+ # metadata.slug can be useful
+ slug = None
+ if isinstance(r.get('metadata'), dict):
+ sl = r['metadata'].get('slug')
+ # sometimes slug is a list inside metadata
+ if isinstance(sl, list) and sl:
+ slug = sl[0]
+ else:
+ slug = sl
+
+ if title and _id:
+ norm = normalize_title(title)
+ mapping[norm].append({
+ 'id': _id,
+ 'title': title,
+ 'slug': slug,
+ 'source_file': name,
+ })
+
+ return mapping
+
+
+def load_titles_file(titles_file: Path):
+ with titles_file.open('r') as fh:
+ data = json.load(fh)
+ # expecting a list of strings
+ titles = []
+ if isinstance(data, list):
+ for item in data:
+ if isinstance(item, str):
+ titles.append(item)
+ else:
+ titles.append(str(item))
+ else:
+ raise SystemExit('titles file does not contain a JSON array')
+ return titles
+
+
+def build_output(titles, mapping):
+ out = []
+ for t in titles:
+ norm = normalize_title(t)
+ matches = mapping.get(norm, [])
+ out.append({
+ 'title': t,
+ 'normalized': norm,
+ 'matches': matches,
+ })
+ return out
+
+
+def main():
+ p = argparse.ArgumentParser()
+ p.add_argument('--titles', required=True, type=Path)
+ p.add_argument('--captures-dir', required=True, type=Path)
+ p.add_argument('--out', required=True, type=Path)
+ args = p.parse_args()
+
+ titles = load_titles_file(args.titles)
+ mapping = scan_search_ajax_files(args.captures_dir)
+ out = build_output(titles, mapping)
+
+ # write output
+ with args.out.open('w') as fh:
+ json.dump(out, fh, indent=2)
+
+ print(f'Wrote {len(out)} title mappings to {args.out}')
+
+
+if __name__ == '__main__':
+ main()