0:01

This next patient is a 58-year-old female who presents with

0:03

microscopic hematuria for which a CT scan was performed.

0:07

As we look at our CT images, we do them in multiple

0:10

phases as per a routine hematuria protocol.

0:15

Now we can see that in the lateral left hepatic

0:17

lobe, There is an indeterminate liver lesion.

0:19

On the non-contrast portion of the

0:21

study, the lesion is hard to see.

0:22

If you window it, you'll probably see that there's

0:24

a faintly hypodense lesion in this location.

0:28

On the nephrographic phase, we can see that

0:30

the lesion enhances pretty homogeneously.

0:33

And finally, in our delayed phases, the lesion is very,

0:36

very difficult to see, very tough to know where it is.

0:38

So this was deemed to be indeterminate, and

0:41

an MRI was suggested for further evaluation.

0:44

We'll start off our MR evaluation

0:46

looking at the T2-weighted sequence.

0:48

We'll scroll down to see if we can find the lesion.

0:50

We can see the lesion over here.

0:52

And on this T2-weighted sequence, we can see

0:55

that the lesion has hyperintense signal.

0:58

Again, the signal is similar, but perhaps a

1:01

little bit less bright than the CSF down here.

1:03

But it's bright nonetheless, and it generally demonstrates

1:06

a signal that, by and large, I would not be worried about.

1:09

However, need to look at the remaining

1:11

sequences to further evaluate this.

1:14

The next set of sequences are going to be

1:16

the T1 performed in phase and out of phase.

1:19

And we'll scroll down to see what this lesion looks like.

1:21

In the out-of-phase sequence over here, you can see the

1:23

lesion in the left hepatic lobe on the in-phase sequence.

1:27

Again, we see this lesion in the left hepatic lobe.

1:28

The overall T1 signal is hypointense, pretty low signal.

1:32

There's no loss of signal in the out-of-

1:34

phase imaging to suggest hepatic steatosis.

1:37

And no areas of, uh, loss of signal in the

1:39

in-phase images to suggest that it contains

1:42

anything that causes increased susceptibility.

1:47

On this, we can see the lesion again in the left

1:50

hepatic lobe over here, and we can see that,

1:57

once again, it has this hypointense T1 signal.

2:00

We'll have to see how it enhances after giving contrast

2:02

to make a final assessment of what we think this is.

2:06

So finally, we now have our dynamic

2:08

post-contrast imaging sequences.

2:10

We'll have a look and see if and how this lesion enhances.

2:14

Once again, we can see it in the lateral left hepatic lobe.

2:18

On the arterial phase images, we notice

2:20

that the lesion homogeneously enhances.

2:23

I'll draw a schematic of this lesion, and it enhances

2:26

very homogeneously on the arterial phase images.

2:30

On the portal venous phase image

2:31

over here, the lesion stays enhanced.

2:34

However, the brightness of it is not as

2:36

bright as it was in the arterial phase image.

2:39

Finally, on the equilibrium phase image,

2:41

once again, this lesion stays enhanced.

2:44

So overall, we have a T2 hyperintense mass,

2:46

homogeneously enhances.

2:50

and remains enhanced or hyperintense on

2:52

the remaining contrast-enhanced phases.

2:56

If you notice, on the arterial phase images,

3:00

the lesion is as bright as the predominant.

3:04

These imaging features are characteristic

3:06

of a flash-filling hemangioma.

3:10

Now, these are a subset of hemangiomas where you have

3:14

homogeneous enhancement with the lesion remaining hyper

3:18

intense on the remaining post-contrast images, and the

3:21

enhancement pattern generally follows the blood pool.

3:24

We tend to see it in hemangiomas that

3:25

are less than two centimeters in size.

3:27

This is, uh, a little bit probably at the cutoff

3:30

for that border, but generally when they're

3:32

less than two centimeters in size, they can

3:33

have this sort of flash-filling appearance.

3:36

Sometimes with these lesions, you may also

3:39

see areas of perilesional enhancement.

3:43

phase, you may sometimes see areas

3:45

of, uh, non-mass-like arterial hyperenhancement

3:49

that subsequently become isointense to the

3:52

remaining liver parenchyma on the remaining phases.

3:55

So these findings are characteristic

3:57

of a flash-filling hemangioma.