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This next patient is a 60-year-old female who has a

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history of cirrhosis and presents for surveillance MR

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imaging in order to look for hepatocellular carcinoma.

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So we'll start off with our T2-weighted sequences in order

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to evaluate any potential liver lesions in this patient.

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As you scroll through it, we do see

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a lesion in the left hepatic lobe.

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On the T2-weighted sequence performed without

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FATSAT, you can see the lesion right over here.

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It's mildly T2 or hyperintense.

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And the T2 hyperintensity is certainly not as bright

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as CSF, and it's not as bright as some of the other

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things we've seen so far, other hemangiomas we've

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seen so far, and certainly not as bright as the cyst.

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On the T2-weighted sequence performed with FAT SAT,

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the treble spin echo sequence, this is the one where

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we're really going to scrutinize the T2 signal.

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And once again, it is hyperintense, but not as

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bright as some of the other lesions we've seen.

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Another thing that I want to point out is that which will

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become relevant in this case is, granted the liver has

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a quite nodular contour compatible with cirrhosis.

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But as you start to approach this lesion,

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you can see a very discrete area of capsular

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retraction over here and over here.

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And we'll come back to that later on in this case.

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The next set of images are the T1s in and out of phase.

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We'll see how this lesion looks like on these images.

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And the out-of-phase sequence over here, the lesion's

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a little bit tough to pick up, but there it is.

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Slightly, slightly T1 hypointense on this image.

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On the in-phase sequence, again, a little bit,

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uh, tough to see, but remains T1 hypointense.

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We don't see any fat within it on the out-of-phase sequence.

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We don't see any signal drop on the in-phase sequence.

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This suggests it contains any content that

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can result in increased susceptibility.

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Once again, if we follow the liver border, we can

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note that that, there is that discrete area of

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capsular retraction that's associated with this mass.

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is the T1 FATSAT pre-contrast sequence.

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And on this sequence, the, uh, pre-contrast FATSAT, we

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can see the lesion again, mildly T1 hypointense, capsular

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traction associated with over here, and the key then is

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going to be, what does it look like when we give contrast?

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So we'll move on to our post-contrast dynamic images,

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and we can see the lesion right here in the left hepatic

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lobe, showing some, uh, enhancement with contrast.

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On the arterial phase images, it demonstrates

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pretty much continuous ring enhancement.

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We're seeing enhancement surrounding

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the entire portion of this lesion.

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On the portal venous phase, the lesion becomes a little

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bit tougher to see, but it still sort of has that ring

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enhancement potentially, potentially some of that ring

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enhancement is filling in a little bit as the central

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portion of this lesion becomes less conspicuous.

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And on the equilibrium phase images, again,

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demonstrates pretty much ring enhancement

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and potentially that central portion is less

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conspicuous than seen on the arterial phase images.

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So here we have a mildly T2 hyperintensive lesion with

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sort of continuous ring enhancement that maybe fills in.

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It's associated again with this capsular retraction

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and as such it remains an indeterminate finding.

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But one of the things you have

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to think about in this instance.

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is this entity of a sclerosed hemangioma.

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Now these are uncommon entities, and they result

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when the vascular channels within the hemangioma,

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for whatever reason, undergo thrombosis.

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And so these hemangiomas look a little bit

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more different than your typical hemangiomas,

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the hemangiomas that we've covered so far.

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They are, um, characterized by, um, sort of

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mild T2 hyperintense signal, So, Sometimes

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this sort of ring enhancement that fills in.

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But typically, these, when they're associated, uh, out

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in the periphery of the liver, have capsular retraction.

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capsular retraction, one of which could be a

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malignant entity, such as a cholangiocarcinoma.

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However, cholangiocarcinomas, as you go from the

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arterial to the portal venous to the equilibrium

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phase, their contrast gets a lot brighter.

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It looks brighter on that image.

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In this instance, this contrast doesn't get

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brighter, and if anything, follows the blood pool.

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So that's why we're going to think that

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this could be a sclerosed hemangioma.

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However, the definitive way to make this

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diagnosis is really one of two ways.

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You can either biopsy it, or if you're lucky enough to

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see if the patient had prior imaging, we can hopefully

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look at that to see if the patient had a lesion in this

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location that looked like a more typical hemangioma.

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Now in this instance, we were lucky enough to have imaging

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from a couple of years prior that looked at this lesion.

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And so we'll look at it quickly in our T2-weighted images.

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We can see that it looks a little bit larger on the

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prior MRI study, seen here on the T2 fat-saturated image.

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And I think the T2 signal within

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this is nicely seen on the sequence.

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It's relatively bright on the T2

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weighted fat-saturated sequence.

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We'll do our due diligence and look at the in and out

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of phase sequences to make sure this lesion doesn't

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contain any fat or areas of susceptibility artifact.

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We can see this lesion here, T1 hypointense on the out

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of phase image, T1 hypointense on the in phase image.

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And then we'll move right along to the dynamic

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post-contrast images, where we can see this lesion

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once again in the left hepatic lobe, demonstrating

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imaging features of a more typical hemangioma.

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So in the arterial phase, we can see it once again

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over here, demonstrating this sort of peripheral

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discontinuous puddling of contrast on the portal

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venous phase images, a little bit tougher to see.

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contrast starts to fill in, and even harder

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to see on the equilibrium phase images.

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The fact that it's harder to see on these images tells

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us that it's filling in on the subsequent phases.

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So, we were able to diagnose this as a sclerosed hemangioma,

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a benign entity in this patient with a history of cirrhosis.