Intracranial
Bone

Jaw

Ovarian

Neck

Srotal

Mesiastinal

Cysts

Retro-rectal

Pulmonary

Dr/ Hytham Nafady
Retroperiton...
Intracranial cysts
Intracranial cysts
Non neoplastic
cysts

Normal
variants

Developmental
cysts

Postinfectious

Neoplastic

cysts

Posttrau...
Normal variant cysts
Normal variants

Cavum
septum
pellucidum

Cavum
vergae

Cavum
villum
interpositum

Mega
cisterna
magn...
Developmental cysts
Intra-axial
Extra-axial cyst
Intra-ventricular
Posterior fossa

• Neuro-glial cysts
• Arachnoid cyst.
...
Post-infectious

Neurocysticercosis

Hydatid cyst
Post-traumatic

Porencephalic
cysts

Leptomeningeal
cysts
Neoplastic cysts

Extra-axial cyst

• Glioblastoma multiforme.
• Ganglioglioma.
• Pleomorphic xanthoastrocytoma.
• DNET.
•...
Cystic schwannoma

• Extra-axial (CP angle)

Cystic meningioma

• Extra-axial (convexity, paraflacine or CP angle)

Cystic...
Cavum septum pellucidum

• Lack of fusion of the 2 leaflets of the septum pellucidum.

Cavum vergae

• Lack of fusion of t...
Intracranial cysts of
endodermal origin

Colloid cyst

Rathke’s cleft
cyst

Neuroenteric
cyst
Intracranial cysts of
endodermal origin

Colloid cyst

Rathke’s cleft
cyst

Neuroenteric
cyst
Cavum septum pellucidum
Cavum vergae
Cavum vellum interpositum
Dilated VR spaces
Mega cisterna magna

Dandy Walker spectru...
Cavum septum pellucidum

• No

Cavum vergae

• No

Cavum vellum interpositum

• No

Dilated VR spaces

• No

Mega cisterna...
Cavum septum pellucidum

• CSF like

Cavum vergae

• CSF like

Cavum vellum interpositum

• CSF like

Dilated VR spaces

•...
Dandy Walker
spectrum
Dandy
Walker
malformation

Dandy
Walker
variant

Persistent
Balke’s pouch

Mega
cisterna
magna
DWM

DWV

Anterior membranous area anomaly

Persistent Blake’s
pouch

Mega cisterna
magna

Posteriror membranous area
anom...
Vellum interpositum cistern
• Vellum interpositum is the double layered tela choroidea.
Location:
• Superior to the roof o...
Cavum vili
interpositi
Vellum interpositum cistern
Embryologic Basis for the Development and
Anatomy of the Cavum Veli Interpositi
Choroid plexus cyst
Ependymal cyst
Colloid cyst
Pineal cyst
Arachnoid cyst
Hydatid cyst
Neurocysticercosis
Leptomeningeal cyst
(growing skull fracture)
Leptomeningeal cyst
(growing skull fracture)
Leptomeningeal cyst
(growing skull fracture)
Pathology:
• It is not cyst (misnomer).
• Calvarial fracture, with dural tear...
Porencephalic cyst
Pathology:
• Cystic encephalomalacia that communicates with the
subarachnoid space or ventricular syste...
Porencephalic cyst

Internal

External

Communicates with the
ventricular system

Communicates with the
subarachnoid space
Porencephalic cyst
DD of porencephalic cyst
Arachnoid cyst
lined by grey matter

Neuroglial cyst
no communication with the
SAC or ventricular...
Cystic meningioma
Cystic schwannoma
Pilocytic astrocytoma
Glioblastoma multiforme
Ganglioglioma
Ganglioglioma
Pleomorphic xanthoastrocytoma
DNET
Suprasellar cysts
Arachnoid
cyst

CSF

Epidermoid
cyst

CSF
Diffusion
restriction

Dermoid
cyst

Fat signal

Rathke’s clef...
Jaw cysts
Jaw cysts
Non neoplastic

Epithelial

Developmental

Odontogenic

Dentigerous
cyst
Odontogenic
keratocyst

Non
odontogenic...
Residual radicular cyst
Globulo-maxillary cyst
Stafne cyst
remodelling of the mandibular cortex around salivary tissue
Dentigerous cyst
Simple bone cyst
Fibrous dysplasia
Dentigerous cyst
Incisive canal cyst
Incisive canal cyst
• Heart shaped (superimposed anterior nasal spine).
Ameloblastoma
Ameloblastoma
Cystic neck masses
Neck spaces
Supra-hyoid neck

Infra-hyoid neck

Pharyngeal mucosal space

Visceral space

Retropharyngeal space

Retrophar...
Suprahyoid neck
Supra-hyoid neck spaces
1.
2.
3.
4.
5.
6.
7.

Parapharyngeal space.
Masticator space.
Carotid space.
Parotid space.
Pharyn...
Pharyngeal mucosal space cyst
• Torn Waldt cyst.
• Retention cyst.
Torn Waldt cyst
Pathology:
• Developmental cyst.
Location:
• Midline nasopharyngeal cyst.
Radiology:
• Midline nasopharyng...
Torn Waldt cyst
Mucus retention cyst
Pathology:
• Obstruction of the duct of mucus gland.
Location:
• Vallecula (vallecular cyst).
• Aryep...
Vallecular retension cyst
Vallecular retension cyst
Retro-pharyngeal cyst
• Foregut cyst.
Retro-pharyngeal foregut cyst
Perivertebral space cysts
Para-pharyngeal space
• 2nd branchial cleft cyst.
• Cystic lymphangioma.
2nd branchial cyst
Cystic lymphangioma
Carotid space
• Branchial cleft cyst.
Parotid cyst
Parotid cysts
Non neoplastic

Developmental

Inflammatory

1st branchial
cleft cyst

Sarcoidosis

Dermoid cyst

Sjogern’
s...
Benign lympho-epithelial cysts
Pathology:
• HIV +ve patients.
• Obstruction of intra-glandular ducts due to
lymphoid hyper...
Benigh lymphoepithelial cyst
Masticator space
• Mandibular cysts
Mandibular cysts
Non neoplastic

Epithelial

Developlmental
(Odontogenic)

Neoplastic

Non epithelial

inflammatory

Stafn...
Infra-hyoid neck
Deep spaces of infra-hyoid neck
Infra-hydoid deep space

Cyst

Visceral space

Thyroglossal cyst.
4th branchial cleft cyst.
Laryngocele.

Retropharyngeal ...
Nasopharyngeal cysts
• Thorn Waldt cyst.
• Retension cyst
Cyst

Age

Thyroglossal
duct cyst
<10 y
Branchial
cleft cyst
Middle
1st
age

Sex

Location

Equal

Hyoid level or below (8...
Thyroglossal cyst
• The most common congenital neck cyst.
• C.P:
• Midline cyst mass moves with tongue
protrusion
• Compli...
Thyroglossal cyst
1.
2.
3.
4.

Infra-hyoid.
Juxta-hyoid.
Supra-hyoid.
Intra-lingual.

4

3
2
1
Branchial cysts
• Branchial = gills
• Responsible for the development of gills in
fish.
Branchial cleft cyst
Branchial cyst
1st branchial cleft cyst

Location
Parotid space.

2nd branchial cleft cyst 1.
2.
3.
4...
3rd branchial cleft cyst
4th branchial cleft cyst
4th branchial cleft cyst
Laryngocele
Pathology:
• Dilated laryngeal ventricle.
Types:
• Internal or external.
• Primary or secondary.
Radiology:
• ...
Laryngocele
External Internal
Laryngocele

Secondary

Primary

neoplastic

Idiopathic
Sub-mandibular cyst
Submandibular cysts
Non neoplastic

Developmental

Inflammatory

2nd branchial
cleft cyst

Sarcoidosis

Dermoid cyst

Sjog...
Floor of the mouth cysts
• Dermoid / epidermoid.
• Ranula.
Dermoid / epidermoid
Dermoid cyst
• Sac of marbles appearance.
Epidermoid cyst
Ranula
Pathology:
• Mucous retension cyst of the sublingual salivary
gland.
• It is a pseudocyst (not lined by epithelium)...
Ranula
Radiology:
• Sublingual space cystic lesion.
Ranula
C.P:
• Mass at the floor of the
mouth with bluish
discoloration.
• Neck mass.
Cystic mediastinal masses
Mediastinal cystic masses
Anterior
mediastinal

Thymic cyst.

Middle
mediastinal

Bronchogenic cyst

Posterior
mediastinal...
Thymic cyst

• Congenital (unilocular).
• Acquired (multilocular): post-chemotherapy, post-thoracotomy, post-inflammtory.
...
Foregut
cysts
Bronchogenic cyst

Esophageal
duplication cyst

Neuro-enteric cyst

Abnormal ventral
budding of the
primitiv...
Cyst

Location

Thymic cyst

Prevascular

Cystic thymoma

Prevascular

cystic teratoma

Prevascular

Cystic hygroma (lymph...
Anterior mediastinal cysts
Thymic cyst
Cystic thymoma
Lymphangioma
Dermoid cyst
Pericardial cyst
Middle mediastinal cysts
Bronchogenic cyst
Posterior mediastinal cysts
Duplication cyst
Cystic schwannoma
Meningocele
Pseudopancreatic cyst
Cystic lung disease
DD of
air filled spaces
Thick walled
> 1 mm
Cavity

Thin walled
< 1 mm
Bulla

Bleb

Sub-pleural

Sub-pleural

> 1cm

< 1cm...
Cystic lung diseases
Pediatrics

Adults
Multifocal

Focal

(1 lobe or multiple lobes
in 1lung)

Pneumatocele

Congenital l...
Diffuse cystic lung disease & its mimics
Findings

C.P

Distribution

Associated findings

Subpleural & basilar
predominan...
Lymphoid interstitial
pneumonia
• Diffuse ground glass
opacification.
• Perivascular cysts.
UIP
• Honeycombing.
• Reticular opacities.
Congenital cysts
Intrapulmonary bronchogenic cyst
Infected bronchogenic cyst
Renal cysts
Simple cysts

ARPKD
ADPKD

TS

MCDK

Medullary
sponge kidney

Medullary
uremic

Dialysis
cysts
Cysts versus hydronephrosis
Etiology
Developmental

Genetic
Cysts associated with
systemic disease

• MCDK
• ADPKD
• ARPKD
• Medullary cystic disease ...
Renal cysts
Large cysts
> 2 cm

Small cysts
< 1cm

MCDK

ARPKD

ADPKD

Medullary
cystic disease

Simple cysts

Medullary
s...
Large renal cysts

Simple
cysts

ADPKD

MCDK

Cystic
neoplasms
Renal cysts
Children

Adult

MCDK

ADPKD

ARPKD

Medullary
cystic disease

TS / VHL

Medullary
sponge kidney

Cystic neopl...
Large renal cysts

MCDK

ARPK

TS

Medullary
cystic disease
MCDK

• Atresia of the proximal ureter during intrauterine
development, with replacement of the kidney by multiple
cysts &...
MCDK

• Neonate, with abdominal mass.

ARPKD

• Infant, with bilateral flank masses, renal failure,
hypertension or portal...
MCDK

• Multiple non communicating cysts with
dysplastic echogenic renal tissue.

ARPKD

• Nephromegaly, with echogenic pa...
MCDK
ARPKD

ADPKD
Medullary cystic disease
(nephronophthisis)

• Bilateral MCDK is incompatible with life.
• Renal falilur...
MCDK

• Contralateral PUJ obstruction or VUR

ARPKD

• Hepatic periportal fibrosis

ADPKD

• Liver cysts & cerebral aneury...
Multicystic dysplastic kidney
Bilateral ureteric atresia with bilateral
MCDK
ARPKD with hepatic fibrosis
Acquired uremic cystic disease
Medullary sponge kidney
Tuberous sclerosis
VHL

RCC
Multilocular cystic nephroma
Bosniak
classification:

Grade I
Simple cyst

Grade II
Minimally
complicated cyst

Grade III
Grade IV
Moderately
Malignant...
Management of renal cysts

Simple cysts

Cystic masses

(Bosniak I)

(Bosniak II, III or IV)

Ignore

Ignore

Follow

Exci...
• A fluid-filled lesion is considered a cystic mass (ie not a
simple cyst) when it has any of the following features:
1 - ...
Management Consequences in calcification

Ignore

Follow

Excise

Small amounts
Smooth, septal
Milk of Ca
No enhancement

...
Management Consequences in hyperdense
cysts

Ignore
Sharp margins
< 3 cm
Not completely intrarenal
Homogenous
Cystic on US...
Management Consequences in septations

Ignore

Follow

Excise

Thin
Smooth
No enhancement

Slightly > hairline

Thick ,
Ir...
Management Consequences in
enhancement

Ignore

Follow

Excise

< 10 HU

10 – 15 HU

15 HU
*unless Infection
• NECT : 16 HU
• Cortical phase 17 HU
• Nephrographic phase 19 HU

Ignore
• NECT : 44 HU

• Enhanced scan:61 HU

------ Excise
Management Consequences in
multiloculated lesions

Ignore
---------

Follow
----------

Excise
All

*unless Infection
Management Consequences in nodular
cysts

Ignore
---------

Follow

Excise

Very small
Non enhancing

All others
Renal sinus cysts
Renal sinus cysts
Renal sinus cysts
Parapelvic cyst

Peripelvic cysts

Renal cortical cyst

Lymphatic cyst (lymphangiectasia)

Single

Multi...
Hepatic cysts
Etiology
Developmental
Traumatic
Inflammatory

Neoplastic

• Simple cysts.
• Bile duct hamartomas.
• Caroli disease.

• Bi...
C.P

Associations

Simple cysts

Asymptomatic

Homogeneous, rounded, regular,
no wall, no enhancment.

Bile duct
hamartoma...
Hepatic cyst
Biloma
Multiple biliary hamartomas
Multiple biliary hamartomas
Double target sign with transient
segmental enhancement
Inner enhancing rim

• Abscess capsule.

Outer hypodense rim

• Ed...
Retroperitoneal cysts
Retroperitoneal cysts
Non neoplastic

Neoplastic

Hematoma

Cystic lymphangioma

Urinoma

Mucinous cystadenoma

Lymphocele...
Cyst

History

Radiology

Non neoplastic
Hematoma

Trauma

Urinoma

Trauma

Lymphocele

Lymphadenectomy

Pseudopancreatic
...
Lymphocele
Retroperitoneal urinoma
Retroperitoneal hematoma
Pseudopancreatic cyst
Retroperitoneal serous cystadenoma
Retroperitoneal mucinous cystadenoma
Retroperitoneal cystic teratoma
Retro-rectal cysts
Epidermoid cyst

• Unilocular.
• Thin wall.
• Clear contents.

Dermoid cyst

• Fat contents.
• Sacral d...
Epidermoid cyst
Anterior sacral meningocele
Rectal duplication cyst
Tailgut cyst
Pancreatic cysts
Pancreatic cysts
Serous cystadenoma
Mucinous cystadenoma
IPMN
Intraductal papillary & mucinous neoplasm

Main duct

Segmental

Side branch

Diffuse

Microcystic

Macrocystic
IPMN
main duct diffuse
IPMN
main duct segmental
Side branch
IPMN
Ovarian cysts
Ovarian cysts
Functional cysts

Non functional

(can produce hormones)
Follicular cyst

Corpus luteum cyst

Non neoplastic...
Functional cysts
Follicular cyst
Epidemiology
• Reproductive age.
C.P:
• asymptomatic
Pathology
• Un-ruptured Graafian follicle.
Natural co...
Corpus luteum cyst
Epidemiology
• 1st trimester of pregnancy.
• Post-menopasual female.
C.P:
• asymptomatic
Pathology
• Fa...
PCO
Ovarain cysts
Simple

Hemorrhagic

Functional cyst

Hemorrhagic
functional cyst

Cystic neoplasm

Chocolate cyst

Cystic n...
Management of ovarian cysts
Ultrasound pattern recognition
Criteria of malignancy
Size

• Large size.

Wall

• Thick irregular wall.
• Mural vascularity.
• Mural vegetations.
• Mura...
MR signal of ovarian cysts
Breast cysts

Breast cyst

Simple

Complicated

Complex

cyst

cyst

cyst
Breast cyst

Breast cyst

Micro-cyst

Marco-cyst

< 3 mm

> 3 mm
Simple cyst

Complicated cyst

Complex cyst

BIRADS 2

BIRADS 3

BIRADS 4

U/S

An-echoic
Smooth wall.
Circumscribed in
sh...
Complex breast cyst

Type 1

Thick wall or
thick septa

Type 2

Solid mural
nodule

Type 3

Type 4

Solid & cystic
compone...
Simple cyst
Simple cyst
Simple cyst
Complicated cyst
Complicated cyst
Breast cysts
Simple

Fibrocystic disease

Complicated

Galactocele

Complex

Benign

Malignant

Oil cyst

Galactocele

Nec...
Galactocele
• Pathology: retension cyst due to obstruction of
lactiferous duct.
• C.P: lactating female.
• Mamography: rad...
Galactocele
Oil cyst
• Pathology: traumatic fat necrosis.
• C.P: history of trauma or operation.
• Mamography: well circumscribed radi...
Oil cyst
Oil cyst
Breast abscess
• Pathology: staph aureus
• C.P: constitutional symptoms, local hotness,
redness and tenderness.
• Lactatin...
Breast abscess
Scrotal cysts
Intra-testicular
cysts

Paratesticular
cysts

Simple cyst

Epididymal cyst

Tunica albuginea cyst

Spermatoc...
Simple testicular cysts
•
•
•
•

C.P:
not palpable & not firm (even if large).
U/S:
Anechoic, thin imperceptible wall, thr...
Simple testicular cyst
Tunica albuginea cyst
C.P:
• small palpable mass.
Radiology (U/S):
• Similar to simple cyst (anechoic cyst with thin
imper...
Tunica albuginea cyst
Epidermoid cyst
•
•
•
•

C.P:
painless palpable testicular mass.
Radiology (U/S):
onion peel appearance.
Epidermoid cyst
Cystic transformation of the rete testis
Pathology:
• partial or complete obliteration of the efferent
ducts.
Radiology (U...
Cystic transformation of the rete testis
Cystadenoma of the rete testis
Epididymal cyst
Cystic transformation of the rete testis
associated with spermatocele
Epididymal cyst

Spermatocele

Any where in the epididymis Epididymal head
Anechoic

Low level internal echos.

Unilocular...
Choledochal cysts
Definition
• Congenital cystic dilatation of the biliary tree.
PATHOPHYSIOLOGY
Anomalous junction of the CBD, with
pancreatic duct (90%).
Reflux of the pancreatic secretions &
enzymes i...
Demographics
Age:
• it can be discovered at any age.
• 60 % below 10 ys.

Sex:
• F > M, 4 : 1
C.P

Choledochal cyst
Abdominal
pain

Jaundice

Abdominal
mass
Complications
Pancreatitis.
Cholangitis.
Cholangiocarcinoma.
Cholangiocarcinoma within a
choledochal cyst
Types
Todani classification
Type I: dilatation of the CBD.
Type II: true diverticulum.
Type III: Choledochocele.
Type IV: ...
Type I
• Fusiform dilatation of a segment or the entire
CBD.
• True choledochal cyst.
• Most common type 80%.
Portal vein
Splenic vein
Type II
• True diverticulum.
• Saccular outpouching of the supra-pancreatic
portion of the CBD.
• 3%.
Type III
• Choledochocele (dilatation of the ampullary portion
of the CBD).
• 5 %.
Type IV
• 2nd most common type 10%
Type V
• Caroli disease
Central dot sign
Caroli disease
• Autosomal recessive disorder 2ry to ductal
plate malformation.
Normal development of ductal plate
Patterns of Caroli disease
• Segmental 83 %.
• Diffuse 17 %.
Central dot sign
Associations of Caroli disease
Liver:
• Congenital hepatic fibrosis (due to involvement of
small ducts).
• Caroli syndrome...
Caroli disease &
medullary sponge kidney
Complications of Caroli disease
•
•
•
•

Intraductal stones.
Ascending cholangitis & abscess formation.
Cholangiocarcinoma...
Intraductal stones
Liver cirrhosis

Central dot sign

abscess
Cholangiocarcinoma
Abscess formation
Bone cysts
Cysts
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Cysts

  1. 1. Intracranial Bone Jaw Ovarian Neck Srotal Mesiastinal Cysts Retro-rectal Pulmonary Dr/ Hytham Nafady Retroperitoneal Hepatic Renal Biliary
  2. 2. Intracranial cysts
  3. 3. Intracranial cysts Non neoplastic cysts Normal variants Developmental cysts Postinfectious Neoplastic cysts Posttraumatic
  4. 4. Normal variant cysts Normal variants Cavum septum pellucidum Cavum vergae Cavum villum interpositum Mega cisterna magna Dilated PVR spaces
  5. 5. Developmental cysts Intra-axial Extra-axial cyst Intra-ventricular Posterior fossa • Neuro-glial cysts • Arachnoid cyst. • Epidermoid cyst. • Dermoid. • Choroid plexus cyst. • Ependymal cyst • Colloid cyst •Dandy Walker spectrum Pineal region • Pineal cyst Sellar region • Rathke’s cleft cyst Premedullary • Neuroenteric cyst.
  6. 6. Post-infectious Neurocysticercosis Hydatid cyst
  7. 7. Post-traumatic Porencephalic cysts Leptomeningeal cysts
  8. 8. Neoplastic cysts Extra-axial cyst • Glioblastoma multiforme. • Ganglioglioma. • Pleomorphic xanthoastrocytoma. • DNET. • Cystic metastasis. • Cystic meningoma. • Cystic schwannoma. Posterior fossa •Pilocytic astrocytoma. Hemangioblastoma. Pineal region • Cystic pineocytoma. Sellar region • Craniopharyngioma. • Cystic pituitary macroadenoma. Intra-axial
  9. 9. Cystic schwannoma • Extra-axial (CP angle) Cystic meningioma • Extra-axial (convexity, paraflacine or CP angle) Cystic macroadenoma • Sellar & supra-sellar Craniopharyngioma • Sellar & supra-sellar Pineocytoma • Pineal gland Hemangioblastoma • Intra-axial, Posterior fossa Pilocytic astrocytoma • Intra-axial, Posterior fossa Glioblastoma multiforme • Intra-axial, Supra-tentorial Cystic oligodendroglioma • Intra-axial, Supra-tentorial (frontal lobe) Pleomorphic xanthoastrocytoma • Intra-axial, Supra-tentorial (cortical) Ganglioglioma Cystic metastases • Intra-axial, Temporal lobe • Intra-axial, Cortical / white matter interface
  10. 10. Cavum septum pellucidum • Lack of fusion of the 2 leaflets of the septum pellucidum. Cavum vergae • Lack of fusion of the 2 leaflets of the septum pellucidum Cavum vellum interpositum Dilated VR spaces • Cystic dilatation of the vellum interpositum cistern. • Atrophy, or CSF trapping. Mega cisterna magna Dandy Walker spectrum Arachnoid cyst Epidermoid cyst Choroid plexus cyst Ependymal cyst Colloid cyst • Congenital splitting of the arachnoid layer, with entrapment of CSF. •Congenital inclusion of ectodermal epithelial elements. • Entrapment of CSF within an in-folding of neuroepithelium. • Sequestration of developing neuroectoderm during embryogenesis. • Cyst of endodermal origion (similar to Rathke’s cleft cyst) Neuroglial cyst Pineal cyst Rathke’s cleft cyst •Cyst of endodermal origin (due to peristent Rathke’s cleft). Neuroenteric cyst • Cyst of endodermal origin (due to persistent neuroenteric canal). Hydatid cyst Cysticercosis Porencephalic cyst Leptomeningeal cyst • Cystic encephalomalacia communicating with CSF. • Calvarial fracture, with dural tear.
  11. 11. Intracranial cysts of endodermal origin Colloid cyst Rathke’s cleft cyst Neuroenteric cyst
  12. 12. Intracranial cysts of endodermal origin Colloid cyst Rathke’s cleft cyst Neuroenteric cyst
  13. 13. Cavum septum pellucidum Cavum vergae Cavum vellum interpositum Dilated VR spaces Mega cisterna magna Dandy Walker spectrum Arachnoid cyst Epidermoid cyst Choroid plexus cyst Ependymal cyst Colloid cyst Neuroglial cyst Pineal cyst • Between the frontal horns anterior to the foramen of Monro • Between the lateral ventricles posterior to the foramen of Monro • Superior to the roof of the 3rd ventricle & inferior to the fornix. • Centrum semi-ovale, basal ganglia & midbrain, • Midline (posterior fossa) •Posterior fossa • Middle cranial fossa •CP angle • Choroid plexus • Periventricular or intraventricular. • Thrid ventricle • Intra-axial • Pineal gland Rathke’s cleft cyst •Sellar & suprasellar Neuroenteric cyst • Premedullary cistern. Hydatid cyst • Intra-axial, usually hemispheric (middle cerebral territory). Cysticercosis • CSF cisterns > parenchyma > ventricular system. Porencephalic cyst Leptomeningeal cyst • Intra-axial • Intra-axial, below clavrial fracture.
  14. 14. Cavum septum pellucidum • No Cavum vergae • No Cavum vellum interpositum • No Dilated VR spaces • No Mega cisterna magna • No Dandy Walker spectrum Arachnoid cyst Epidermoid cyst Choroid plexus cyst Ependymal cyst Colloid cyst •Hydrocephalus. • Subdural hemorrhage •CP angle • May be associated with trisomy 18. • Obstructive hydrocephalus (large cysts in vulnerable locations). • hydrocephalus Neuroglial cyst • No Pineal cyst • No Rathke’s cleft cyst Hydatid cyst Cysticercosis Porencephalic cyst Leptomeningeal cyst •Compression of the optic chiasm if large • Compression.
  15. 15. Cavum septum pellucidum • CSF like Cavum vergae • CSF like Cavum vellum interpositum • CSF like Dilated VR spaces • CSF like Mega cisterna magna Dandy Walker spectrum Arachnoid cyst Epidermoid cyst • CSF like (septations) •CSF like (+ vermian hypoplasia & elevated torcular herophilli) • CSF like signal on all pulse sequences • CSF like( lobulated margin, bright on FLAIR, restricted diffusion) Choroid plexus cyst • CSF like, with marginal calcification & restricted diffusion. Ependymal cyst • CSF like, with well defined wall & no surrounding gliosis. Colloid cyst Neuroglial cyst Pineal cyst • Hyperdense on CT, may be bright on T1 & low signal on T2 • CSF like • CSF like with thick enhancing margin Rathke’s cleft cyst •, Variable signal, may be bright on T1, with intracystic non enhancing nodule. Neuroenteric cyst • Variable signal, may be bright on T1. Hydatid cyst • CSF like, no enhancement, rarely calcification. Cysticercosis • According to stage (vesicular, colloidal, granular or involution). Porencephalic cyst Leptomeningeal cyst • CSF like (communicating with the subarachnoid space or ventricular system) • CSF like protruding through the scalloped calvarial defect.
  16. 16. Dandy Walker spectrum Dandy Walker malformation Dandy Walker variant Persistent Balke’s pouch Mega cisterna magna
  17. 17. DWM DWV Anterior membranous area anomaly Persistent Blake’s pouch Mega cisterna magna Posteriror membranous area anomaly Retro-cerebellar cyst Vermis Hypoplastic Rotated upwards hypoplastic No or mild hypoplasia No or mild hypoplasia 4th ventricle Markedly dilated Dilated Dilated Normal Posterior fossa Expanded Normal size Normal size Normal size hydrocephalus 80 % of cases No Present No
  18. 18. Vellum interpositum cistern • Vellum interpositum is the double layered tela choroidea. Location: • Superior to the roof of the third ventricle. • Inferior to the body of fornix. • The anterior end of the vellum interpositum is closed posterior to the interventricular foramen. • The posterior end of the vellum interpositum is open & continuous with the quadrigeminal cistern. Contents: • Internal cerebral veins .
  19. 19. Cavum vili interpositi
  20. 20. Vellum interpositum cistern
  21. 21. Embryologic Basis for the Development and Anatomy of the Cavum Veli Interpositi
  22. 22. Choroid plexus cyst
  23. 23. Ependymal cyst
  24. 24. Colloid cyst
  25. 25. Pineal cyst
  26. 26. Arachnoid cyst
  27. 27. Hydatid cyst
  28. 28. Neurocysticercosis
  29. 29. Leptomeningeal cyst (growing skull fracture)
  30. 30. Leptomeningeal cyst (growing skull fracture)
  31. 31. Leptomeningeal cyst (growing skull fracture) Pathology: • It is not cyst (misnomer). • Calvarial fracture, with dural tear. Radiology: • Lytic calvarial lesion, with scallped edges, in which encephalomalacia invaginates.
  32. 32. Porencephalic cyst Pathology: • Cystic encephalomalacia that communicates with the subarachnoid space or ventricular system. Types: • Developmental (simple porencephaly). • Congenital encephaloclastic porencephaly (acquired porencephaly). • Radiology: • CSF like signal on all pulse sequence. • Usually no mass effect. • Occasionally, associated with mass effect, if large. • Communication with SAC or ventricular system. • Lined by gliotic white matter.
  33. 33. Porencephalic cyst Internal External Communicates with the ventricular system Communicates with the subarachnoid space
  34. 34. Porencephalic cyst
  35. 35. DD of porencephalic cyst Arachnoid cyst lined by grey matter Neuroglial cyst no communication with the SAC or ventricular system
  36. 36. Cystic meningioma
  37. 37. Cystic schwannoma
  38. 38. Pilocytic astrocytoma
  39. 39. Glioblastoma multiforme
  40. 40. Ganglioglioma
  41. 41. Ganglioglioma
  42. 42. Pleomorphic xanthoastrocytoma
  43. 43. DNET
  44. 44. Suprasellar cysts Arachnoid cyst CSF Epidermoid cyst CSF Diffusion restriction Dermoid cyst Fat signal Rathke’s cleft cyst Variable signal Non enhancing intracystic nodule (pathogonomonic) Craniopharyngioma Multilocular Calcification Cystic macroadenoma Enhancing solid component
  45. 45. Jaw cysts
  46. 46. Jaw cysts Non neoplastic Epithelial Developmental Odontogenic Dentigerous cyst Odontogenic keratocyst Non odontogenic Cyst of the incisive papilla Neoplastic Non epithelial inflammatory Stafne cyst Radicular (periapical) Simple bone cyst Residual cyst Aneurysmal bone cyst Ameloblastoma
  47. 47. Residual radicular cyst
  48. 48. Globulo-maxillary cyst
  49. 49. Stafne cyst remodelling of the mandibular cortex around salivary tissue
  50. 50. Dentigerous cyst
  51. 51. Simple bone cyst
  52. 52. Fibrous dysplasia
  53. 53. Dentigerous cyst
  54. 54. Incisive canal cyst
  55. 55. Incisive canal cyst • Heart shaped (superimposed anterior nasal spine).
  56. 56. Ameloblastoma
  57. 57. Ameloblastoma
  58. 58. Cystic neck masses
  59. 59. Neck spaces Supra-hyoid neck Infra-hyoid neck Pharyngeal mucosal space Visceral space Retropharyngeal space Retropharyngeal space Perivertebral space Perivertebral space Carotid space Carotid space Paraphrayngeal space Posterior cervical space Masticator space Parotid space
  60. 60. Suprahyoid neck
  61. 61. Supra-hyoid neck spaces 1. 2. 3. 4. 5. 6. 7. Parapharyngeal space. Masticator space. Carotid space. Parotid space. Pharyngeal mucosal space. Perivertebral space. Retropharyngeal space.
  62. 62. Pharyngeal mucosal space cyst • Torn Waldt cyst. • Retention cyst.
  63. 63. Torn Waldt cyst Pathology: • Developmental cyst. Location: • Midline nasopharyngeal cyst. Radiology: • Midline nasopharyngeal unilocular cyst with thin wall & no enhancement.
  64. 64. Torn Waldt cyst
  65. 65. Mucus retention cyst Pathology: • Obstruction of the duct of mucus gland. Location: • Vallecula (vallecular cyst). • Aryepiglottic folds. • Piriform sinuses. • Tonsils (tonsillar cyst). Radiology: • Off midline unilocular cyst with thin wall & no enhancement.
  66. 66. Vallecular retension cyst
  67. 67. Vallecular retension cyst
  68. 68. Retro-pharyngeal cyst • Foregut cyst.
  69. 69. Retro-pharyngeal foregut cyst
  70. 70. Perivertebral space cysts
  71. 71. Para-pharyngeal space • 2nd branchial cleft cyst. • Cystic lymphangioma.
  72. 72. 2nd branchial cyst
  73. 73. Cystic lymphangioma
  74. 74. Carotid space • Branchial cleft cyst.
  75. 75. Parotid cyst
  76. 76. Parotid cysts Non neoplastic Developmental Inflammatory 1st branchial cleft cyst Sarcoidosis Dermoid cyst Sjogern’ syndrome Neoplastic Obstructive Sialocele Benign Wartin’s tumor Lymphoepithelal cyst (HIV) Neoplastic Necrotic neoplasm or LN
  77. 77. Benign lympho-epithelial cysts Pathology: • HIV +ve patients. • Obstruction of intra-glandular ducts due to lymphoid hypertrophy. C.P: • Painless parotid swelling. • Bilateral in 20% of cases. Radiology:
  78. 78. Benigh lymphoepithelial cyst
  79. 79. Masticator space • Mandibular cysts
  80. 80. Mandibular cysts Non neoplastic Epithelial Developlmental (Odontogenic) Neoplastic Non epithelial inflammatory Stafne cyst Dentigerous cyst Radicular (periapical) Simple bone cyst Odontogenic keratocyst Residual cyst Aneurysmal bone cyst Ameloblastoma
  81. 81. Infra-hyoid neck
  82. 82. Deep spaces of infra-hyoid neck
  83. 83. Infra-hydoid deep space Cyst Visceral space Thyroglossal cyst. 4th branchial cleft cyst. Laryngocele. Retropharyngeal space Retension cyst Posterior cervical space 3rd branchial celft cyst.
  84. 84. Nasopharyngeal cysts • Thorn Waldt cyst. • Retension cyst
  85. 85. Cyst Age Thyroglossal duct cyst <10 y Branchial cleft cyst Middle 1st age Sex Location Equal Hyoid level or below (80%), within 2 cm of midline F > M Parotid, external auditory canal Submandibular space, lateral to carotid vessels 2nd 10–40 y Equal 3rd 10–30 y … 4th Cystic hygroma Any age … <2 y Equal Left posterior cervical space Sinus tract arising from left pyriform sinus Posterior cervical triangle, oral cavity Dermoid cyst 10–30 y Epidermoid cyst Infancy Equal Floor of mouth Equal Floor of mouth Thymic cyst M > F Low anterolateral neck (L > R) 2–13 y Ranula Floor of the mouth Laryngocele Visceral space.
  86. 86. Thyroglossal cyst • The most common congenital neck cyst. • C.P: • Midline cyst mass moves with tongue protrusion • Complications: • Infection • Malignancy (very rare).
  87. 87. Thyroglossal cyst 1. 2. 3. 4. Infra-hyoid. Juxta-hyoid. Supra-hyoid. Intra-lingual. 4 3 2 1
  88. 88. Branchial cysts • Branchial = gills • Responsible for the development of gills in fish.
  89. 89. Branchial cleft cyst Branchial cyst 1st branchial cleft cyst Location Parotid space. 2nd branchial cleft cyst 1. 2. 3. 4. 5. 6. Anterior to the sternomastoid & deep to the paltysma muscle. Anterior to the sternomastoid & superficial to the carotid sheath. Carotid bifurcation. Submandibular space. Parapharyngeal space. Pharyngeal mucosal space medial to the carotid sheath. 3rd branchial cleft cyst Posterior cervical space, posterior to the sternomastoid muscle. 4th branchial cleft cyst Visceral space, adjacent to the left thyroid lobe.
  90. 90. 3rd branchial cleft cyst
  91. 91. 4th branchial cleft cyst
  92. 92. 4th branchial cleft cyst
  93. 93. Laryngocele Pathology: • Dilated laryngeal ventricle. Types: • Internal or external. • Primary or secondary. Radiology: • May be air filled or fluid filled.
  94. 94. Laryngocele External Internal
  95. 95. Laryngocele Secondary Primary neoplastic Idiopathic
  96. 96. Sub-mandibular cyst
  97. 97. Submandibular cysts Non neoplastic Developmental Inflammatory 2nd branchial cleft cyst Sarcoidosis Dermoid cyst Sjogern’ syndrome Neoplastic Obstructive Sialocele Benign Wartin’s tumor Neoplastic Necrotic neoplasm
  98. 98. Floor of the mouth cysts • Dermoid / epidermoid. • Ranula.
  99. 99. Dermoid / epidermoid
  100. 100. Dermoid cyst • Sac of marbles appearance.
  101. 101. Epidermoid cyst
  102. 102. Ranula Pathology: • Mucous retension cyst of the sublingual salivary gland. • It is a pseudocyst (not lined by epithelium). Ranula Simple Plunging Confined to the sublingual space Extend to the submandibular space (through or around the myelohyoid muscle)
  103. 103. Ranula Radiology: • Sublingual space cystic lesion.
  104. 104. Ranula C.P: • Mass at the floor of the mouth with bluish discoloration. • Neck mass.
  105. 105. Cystic mediastinal masses
  106. 106. Mediastinal cystic masses Anterior mediastinal Thymic cyst. Middle mediastinal Bronchogenic cyst Posterior mediastinal Meningocele Cystic thymoma Cystic schwannoma Cystic teratoma Esophageal duplication cyst Cystic hygroma Neuroenteric cyst Pericardial cyst Pseudopancreatic cyst
  107. 107. Thymic cyst • Congenital (unilocular). • Acquired (multilocular): post-chemotherapy, post-thoracotomy, post-inflammtory. Cystic thymoma Cystic teratoma Cystic hygroma Pericardial cyst • Aberration in the formation of the coelomic cavities. Bronchogenic cyst • Abnormal ventral budding of the primitive foregut Esophageal duplication cyst • Abnormal dorsal budding of the primitive foregut. Neuroenteric cyst • Persistent neuroenteric canal. Cystic schwannoma Meningocele Pseudo-pancreatic cyst • Neural tube defect (NF, Marfan) • Pancreatitis.
  108. 108. Foregut cysts Bronchogenic cyst Esophageal duplication cyst Neuro-enteric cyst Abnormal ventral budding of the primitive foregut Abnormal dorsal budding of the primitive foregut Persistent neuroenteric canal
  109. 109. Cyst Location Thymic cyst Prevascular Cystic thymoma Prevascular cystic teratoma Prevascular Cystic hygroma (lymphangioma) Prevascular Pericardial cyst Right cardiophrenic angle Bronchogenic cyst Subcarinal or right paratracheal. Meningocele Paraspinal Cystic schwnnoma Paraspinal Foregut cyst Paraesophageal Pseudopancreatic cyst Tracking up into the posterior mediastinum.
  110. 110. Anterior mediastinal cysts
  111. 111. Thymic cyst
  112. 112. Cystic thymoma
  113. 113. Lymphangioma
  114. 114. Dermoid cyst
  115. 115. Pericardial cyst
  116. 116. Middle mediastinal cysts
  117. 117. Bronchogenic cyst
  118. 118. Posterior mediastinal cysts
  119. 119. Duplication cyst
  120. 120. Cystic schwannoma
  121. 121. Meningocele
  122. 122. Pseudopancreatic cyst
  123. 123. Cystic lung disease
  124. 124. DD of air filled spaces Thick walled > 1 mm Cavity Thin walled < 1 mm Bulla Bleb Sub-pleural Sub-pleural > 1cm < 1cm Cyst Intrapulmonary with epithelialized wall Pneumatocele Intrapulmonary without epithelialized wall
  125. 125. Cystic lung diseases Pediatrics Adults Multifocal Focal (1 lobe or multiple lobes in 1lung) Pneumatocele Congenital lobar emphysema (staph, PCC) Uni-locular Intrapulmonary bronchogenic cyst Pulmonary sequestation Type I CCAM Pneumatocele Diffuse (all lobes of both lungs) Cystic bronchiectasis Emphysema Cysts associated with PA hypoplasia Multi-locular Large Focal or multifocal Small Type II CCAM Intrapulmonary bronchogenic cyst PLCH Cysts associated with PV hypoplasia Cystic metastases LAM Lymphoid interstitial pneumonia Honeycombing IPF
  126. 126. Diffuse cystic lung disease & its mimics Findings C.P Distribution Associated findings Subpleural & basilar predominance Reticular opacities. GGO IPF Honeycombing LIP Thin walled cysts AIDs Sjogren syndrome Basilar predominance Peri-vascular GGO PLCH Bizzare shaped cysts Male smoker Random Spares the bases. Nodules LAM Thin walled cysts Female TS Random Diffuse Chylous effusion. TS Cystic bronchiectasis Cysts communicating with the bronchial tree Focal Diffuse (central, upper, middle & lower) Air fluid levels. Emphysema Cystic air spaces without discernable wall Upper (cetrilobular) Hyperinflation Lower (panlobular) Subpleural (paraseptal)
  127. 127. Lymphoid interstitial pneumonia • Diffuse ground glass opacification. • Perivascular cysts.
  128. 128. UIP • Honeycombing. • Reticular opacities.
  129. 129. Congenital cysts
  130. 130. Intrapulmonary bronchogenic cyst
  131. 131. Infected bronchogenic cyst
  132. 132. Renal cysts
  133. 133. Simple cysts ARPKD ADPKD TS MCDK Medullary sponge kidney Medullary uremic Dialysis cysts
  134. 134. Cysts versus hydronephrosis
  135. 135. Etiology Developmental Genetic Cysts associated with systemic disease • MCDK • ADPKD • ARPKD • Medullary cystic disease (nephronophthisis). • TS • VHL Acquired cysts • Simple cyst. • Medullary sponge kidney. • Acquired cystic disease of uremia. Malignant cysts • Multilocular cystic nephroma. • Cystic renal cell carcinoma
  136. 136. Renal cysts Large cysts > 2 cm Small cysts < 1cm MCDK ARPKD ADPKD Medullary cystic disease Simple cysts Medullary sponge kidney Cystic neoplasms Acquired cystic disease of uremia
  137. 137. Large renal cysts Simple cysts ADPKD MCDK Cystic neoplasms
  138. 138. Renal cysts Children Adult MCDK ADPKD ARPKD Medullary cystic disease TS / VHL Medullary sponge kidney Cystic neoplasms Acquired cystic disease of uremia TS / VHL Cystic neoplasm
  139. 139. Large renal cysts MCDK ARPK TS Medullary cystic disease
  140. 140. MCDK • Atresia of the proximal ureter during intrauterine development, with replacement of the kidney by multiple cysts & un-differentiated mesenchymal tissue. ARPKD • Cystic dilatation of distal convoluted tubules & collecting ducts. ADPKD • Cystic dilatation of Bowman's capsule, loop of Henle & proximal convoluted tubules Medullary cystic disease (nephronophthisis) • Ciliary dysfunction of renal tubules. TS • Mutation of tuberin & hamartin suppressor gene  proliferation of renal tubular epithelium. VHL • Mutation of VHL suppressor gene  proliferation of renal tubular epithelium. Medullary sponge kidney Simple cortical cysts Acquired cystic disease of uremia • Renal tubular duct ectasia. • Unknown. • Hypertrophy of functioning nephrons, hyperplasia of tubular epithelium  obstruction & expansion of renal tubules.
  141. 141. MCDK • Neonate, with abdominal mass. ARPKD • Infant, with bilateral flank masses, renal failure, hypertension or portal hypertension. ADPKD • Adult, with bilateral flank pain, hematuria, renal failure, hypertension, SAH or family history. Medullary cystic disease (nephronophthisis) TS VHL Medullary sponge kidney Simple cortical cysts Acquired cystic disease of uremia • Renal failure • Triad: Adenoma sebaceum, Fits & Mental retardation. • Renal, pancreatic or epididymal cysts. • Cerebellar, spinal or retinal hemanigoblastoma. • Asymptomatic • Complications (stones or sepsis) • Asymptomatic. • Complications (rupture or infection) • Chronic renal dialysis.
  142. 142. MCDK • Multiple non communicating cysts with dysplastic echogenic renal tissue. ARPKD • Nephromegaly, with echogenic parenchyma & striated nephrogram. ADPKD • Multiple non communicating cysts with spider leg deformity of the pelvicalyceal system. Medullary cystic disease (nephronophthisis) TS VHL • Medullary multiple cysts. • • • • • Cysts. AML Oncocytoma. Renal, pancreatic or epididymal cysts. Cerebellar, spinal or retinal hemanigoblastoma. Medullary sponge kidney • Medullary nephrocalcinosis, paint brush appearance or bouquet of flowers appearance. Simple cortical cysts • Clear contents, thin regular wall, with no mural vegetations, internal septations or calcification. Acquired cystic disease of uremia • Small atrophic kidney, with multiple cysts.
  143. 143. MCDK ARPKD ADPKD Medullary cystic disease (nephronophthisis) • Bilateral MCDK is incompatible with life. • Renal falilure, • hypertension or • portal hypertension. • Hemorrhage, rupture, infection. • Subarachnoid hemorrhage. • Aortic dissection. • Renal failure TS • The incidence of RCC in TS is similar to the general population. VHL • Cystic renal cell carcinoma. Medullary sponge kidney Simple cortical cysts Acquired cystic disease of uremia • Stones or • Sepsis. • Hemorrhage, • Rupture, • Infection. • Hemorrhage. • Infection. • Malignancy.
  144. 144. MCDK • Contralateral PUJ obstruction or VUR ARPKD • Hepatic periportal fibrosis ADPKD • Liver cysts & cerebral aneurysms. Medullary cystic disease (nephronophthisis) TS VHL Medullary sponge kidney Simple cortical cysts Acquired cystic disease of uremia • Cortical tubers, subependymal calcified nodules, white matter lesions, subependymal giant cell astrocytoma, LAM, renal angiomyolipoma, cardiac rhabdomyoma. • CNS hemangioblastoma, pancreatic cysts • Caroli disease.
  145. 145. Multicystic dysplastic kidney
  146. 146. Bilateral ureteric atresia with bilateral MCDK
  147. 147. ARPKD with hepatic fibrosis
  148. 148. Acquired uremic cystic disease
  149. 149. Medullary sponge kidney
  150. 150. Tuberous sclerosis
  151. 151. VHL RCC
  152. 152. Multilocular cystic nephroma
  153. 153. Bosniak classification: Grade I Simple cyst Grade II Minimally complicated cyst Grade III Grade IV Moderately Malignant cyst complicated cyst Wall: Thin walled. Thin walled. Thick walled. Contents: Clear contents: Turbid contents U/S: U/S: -anechoic. Internal echoes. -back enhancement. U/S: Internal echoes. Septations: CT: < 20 HU. No CT: > 20HU. Thick septations. Calcification: No CT: < 20 HU. Paper thin septations. Minimal calcification. Has solid and cystic components. Heavy calcification. Enhancement: No Wall enhancement. Wall enhancement. Workup: Follow up by U/S or CT. No further workup. -biopsy. Nephrectomy. -aspiration of cyst.
  154. 154. Management of renal cysts Simple cysts Cystic masses (Bosniak I) (Bosniak II, III or IV) Ignore Ignore Follow Excise
  155. 155. • A fluid-filled lesion is considered a cystic mass (ie not a simple cyst) when it has any of the following features: 1 - Calcification 2 - High attenuation ( > 20 HU ) at NECT 3 - Septation 4 - Multiple locules 5 - Enhancement 6 - Wall thickening 7 - Nodularity
  156. 156. Management Consequences in calcification Ignore Follow Excise Small amounts Smooth, septal Milk of Ca No enhancement Thick or nodular Nodularity or thickening of the wall No enhancement enhamncement
  157. 157. Management Consequences in hyperdense cysts Ignore Sharp margins < 3 cm Not completely intrarenal Homogenous Cystic on US No enhancement Follow Excise Poorly defined > 3 cm Totally intrarenal Cystic on US No enhancement Heterogenous Solid on US Enhamncement
  158. 158. Management Consequences in septations Ignore Follow Excise Thin Smooth No enhancement Slightly > hairline Thick , Irregular or nodular Enhancement No enhancement
  159. 159. Management Consequences in enhancement Ignore Follow Excise < 10 HU 10 – 15 HU 15 HU *unless Infection
  160. 160. • NECT : 16 HU • Cortical phase 17 HU • Nephrographic phase 19 HU Ignore
  161. 161. • NECT : 44 HU • Enhanced scan:61 HU ------ Excise
  162. 162. Management Consequences in multiloculated lesions Ignore --------- Follow ---------- Excise All *unless Infection
  163. 163. Management Consequences in nodular cysts Ignore --------- Follow Excise Very small Non enhancing All others
  164. 164. Renal sinus cysts
  165. 165. Renal sinus cysts
  166. 166. Renal sinus cysts Parapelvic cyst Peripelvic cysts Renal cortical cyst Lymphatic cyst (lymphangiectasia) Single Multiple Unilateral Bilateral
  167. 167. Hepatic cysts
  168. 168. Etiology Developmental Traumatic Inflammatory Neoplastic • Simple cysts. • Bile duct hamartomas. • Caroli disease. • Biloma. • Hematoma. • Hydatid cyst. • Hepatic abscess. • Extrapancreatic pseudocyst • • • • Biliary cystadenoma & cystadenocarcinoma. Embryonal sarcoma. Cystic HCC. Cystic metastasis.
  169. 169. C.P Associations Simple cysts Asymptomatic Homogeneous, rounded, regular, no wall, no enhancment. Bile duct hamartoma Asymptomatic Homogeneous, rounded, regular, mural enhancment, all lesions are < 1.5 cm in diameter Caroli diease Asymptomatic, Cummunicating with the biliary unless complicated. tree. Central dot sign. Embyronal sarcoma Young adults Complex cyst with enhancing solid component Cystadenoma & cystadenocarcinoma Asymptomatic Middle aged females Multilocular, mural nodules. Cystic metastasis Abscess Multiplicity. Mural enhancement. Not equal to fluid on heavy T2 Constitutional symptoms Double target sign History of trauma Surrounding pseudocapsule Hydatid cyst biloma ADPKD VHL Medullary sponge kidney
  170. 170. Hepatic cyst
  171. 171. Biloma
  172. 172. Multiple biliary hamartomas
  173. 173. Multiple biliary hamartomas
  174. 174. Double target sign with transient segmental enhancement Inner enhancing rim • Abscess capsule. Outer hypodense rim • Edematous liver parenchyma. Transient segemental enhancement • Hyperemia.
  175. 175. Retroperitoneal cysts
  176. 176. Retroperitoneal cysts Non neoplastic Neoplastic Hematoma Cystic lymphangioma Urinoma Mucinous cystadenoma Lymphocele Cystic teratoma Pseudopancreatic cyst
  177. 177. Cyst History Radiology Non neoplastic Hematoma Trauma Urinoma Trauma Lymphocele Lymphadenectomy Pseudopancreatic cyst Retroperitoneal fluid collection. Pancreatitis Neoplastic: Cystic Lymphangioma Mucinous cystadenoma Multilocular Cystic teratoma Calcification. Fat density.
  178. 178. Lymphocele
  179. 179. Retroperitoneal urinoma
  180. 180. Retroperitoneal hematoma
  181. 181. Pseudopancreatic cyst
  182. 182. Retroperitoneal serous cystadenoma
  183. 183. Retroperitoneal mucinous cystadenoma
  184. 184. Retroperitoneal cystic teratoma
  185. 185. Retro-rectal cysts Epidermoid cyst • Unilocular. • Thin wall. • Clear contents. Dermoid cyst • Fat contents. • Sacral defects Tail gut cyst Sacro-coccygeal teratoma Anterior sacral meningocele • Multilocular cyst (thin internal septations). • Mucinous content (may be bright on T1). • Mural calcification • Pediatrics. • Solid & cystic components. • Sacral defect. • Communicating with the thecal sac.
  186. 186. Epidermoid cyst
  187. 187. Anterior sacral meningocele
  188. 188. Rectal duplication cyst
  189. 189. Tailgut cyst
  190. 190. Pancreatic cysts
  191. 191. Pancreatic cysts
  192. 192. Serous cystadenoma
  193. 193. Mucinous cystadenoma
  194. 194. IPMN Intraductal papillary & mucinous neoplasm Main duct Segmental Side branch Diffuse Microcystic Macrocystic
  195. 195. IPMN main duct diffuse
  196. 196. IPMN main duct segmental
  197. 197. Side branch IPMN
  198. 198. Ovarian cysts
  199. 199. Ovarian cysts Functional cysts Non functional (can produce hormones) Follicular cyst Corpus luteum cyst Non neoplastic Single Endometrioid cyst Serous inclusion cyst Neoplastic multiple PCO Theca lutein cysts (ovarian hyperstimulation syndrome) Benign malignant Mature cystic teratoma Immature cystic teratoma Serous cystadenoma Serous cystadenocarcinoma Mucinous cyst adenoma Mucinous cystadenocarcinoma Endometerioid carcinoma Cystic metastases
  200. 200. Functional cysts
  201. 201. Follicular cyst Epidemiology • Reproductive age. C.P: • asymptomatic Pathology • Un-ruptured Graafian follicle. Natural course • Spontaneous resolution in 2 or 3 cycles Radiographic features Ultrasound • Simple cyst • Unilocular. • Thin wall, with no mural vegetations, internal septations or solid components. • Clear contents, with acoustic enhancement & no internal echoes. Duplex: • No color flow.
  202. 202. Corpus luteum cyst Epidemiology • 1st trimester of pregnancy. • Post-menopasual female. C.P: • asymptomatic Pathology • Failure of regression of corpus luteum. Natural course • Spontaneous regression by the end of 2nd trimester. Radiographic features • Ultrasound • Simple cyst • Hemorrhagic cyst • Duplex: • Ring of fire (DD with tubal pregnancy).
  203. 203. PCO
  204. 204. Ovarain cysts Simple Hemorrhagic Functional cyst Hemorrhagic functional cyst Cystic neoplasm Chocolate cyst Cystic neoplasm Complex Cystic neoplasm
  205. 205. Management of ovarian cysts
  206. 206. Ultrasound pattern recognition
  207. 207. Criteria of malignancy Size • Large size. Wall • Thick irregular wall. • Mural vascularity. • Mural vegetations. • Mural papillary projections. • Mural solid components. Septations Secondary signs •Thick septations (> 3 mm). •Vascularized septations • Ascites. • Peritoneal deposits. • lymphadenopathy
  208. 208. MR signal of ovarian cysts
  209. 209. Breast cysts Breast cyst Simple Complicated Complex cyst cyst cyst
  210. 210. Breast cyst Breast cyst Micro-cyst Marco-cyst < 3 mm > 3 mm
  211. 211. Simple cyst Complicated cyst Complex cyst BIRADS 2 BIRADS 3 BIRADS 4 U/S An-echoic Smooth wall. Circumscribed in shaped. Posterior acoustic enhancement. Reverberation artefact. Internal echo or layering debris Thick wall. Thick septations (> 5 mm). Solid mural nodules. Solid & cystic compnents MRI Hypointense on T1. Hyperintense on T2. Variable signal depending on cyst contents Thick wall Thick septations Solid mural nodule Enhancement No enhancement Thin marginal enhancement.
  212. 212. Complex breast cyst Type 1 Thick wall or thick septa Type 2 Solid mural nodule Type 3 Type 4 Solid & cystic component Solid & cystic component (> 50 % cystic) (> 50% solid)
  213. 213. Simple cyst
  214. 214. Simple cyst
  215. 215. Simple cyst
  216. 216. Complicated cyst
  217. 217. Complicated cyst
  218. 218. Breast cysts Simple Fibrocystic disease Complicated Galactocele Complex Benign Malignant Oil cyst Galactocele Necrotic breast mass Hematoma Oil cyst Intracystic breast carcinoma Abscess Hematoma Abscess
  219. 219. Galactocele • Pathology: retension cyst due to obstruction of lactiferous duct. • C.P: lactating female. • Mamography: radiolucent lesion, with eggshell calcification. • U/S: complicated cyst or complex cyst. • Colour doppler: no flow. • Complications: 2ry infection  breast abscess.
  220. 220. Galactocele
  221. 221. Oil cyst • Pathology: traumatic fat necrosis. • C.P: history of trauma or operation. • Mamography: well circumscribed radiolucent mass with or without eggshell calcification. • U/S: complicated cyst or complex cyst, with no acoustic shadowing or enhancement. • Fat fluid level. • Color doppler: no flow.
  222. 222. Oil cyst
  223. 223. Oil cyst
  224. 224. Breast abscess • Pathology: staph aureus • C.P: constitutional symptoms, local hotness, redness and tenderness. • Lactating female. • Mamography: non specific. • U/S: complicated or complex cyst. • Hypoechoic rim. • Adjacent interstitial fluid.
  225. 225. Breast abscess
  226. 226. Scrotal cysts Intra-testicular cysts Paratesticular cysts Simple cyst Epididymal cyst Tunica albuginea cyst Spermatocele Cystic transformation of the rete testis Cystadenoma of the rete testis Testicular epidermoid cyst Testicular neoplasm with cystic component
  227. 227. Simple testicular cysts • • • • C.P: not palpable & not firm (even if large). U/S: Anechoic, thin imperceptible wall, through transmission.
  228. 228. Simple testicular cyst
  229. 229. Tunica albuginea cyst C.P: • small palpable mass. Radiology (U/S): • Similar to simple cyst (anechoic cyst with thin imperceptible wall). • But small in size and located at the upper anterior or lateral aspect to the testis.
  230. 230. Tunica albuginea cyst
  231. 231. Epidermoid cyst • • • • C.P: painless palpable testicular mass. Radiology (U/S): onion peel appearance.
  232. 232. Epidermoid cyst
  233. 233. Cystic transformation of the rete testis Pathology: • partial or complete obliteration of the efferent ducts. Radiology (U/S): • Multiple cyst or tubular anechoic structures that replace the mediastinum testis. • No mass effect. • No internal flow.
  234. 234. Cystic transformation of the rete testis
  235. 235. Cystadenoma of the rete testis
  236. 236. Epididymal cyst
  237. 237. Cystic transformation of the rete testis associated with spermatocele
  238. 238. Epididymal cyst Spermatocele Any where in the epididymis Epididymal head Anechoic Low level internal echos. Unilocular Unilocular or multilocuar
  239. 239. Choledochal cysts
  240. 240. Definition • Congenital cystic dilatation of the biliary tree.
  241. 241. PATHOPHYSIOLOGY Anomalous junction of the CBD, with pancreatic duct (90%). Reflux of the pancreatic secretions & enzymes into the CBD. Inflammation & weakening of the bile duct wall. Formation of choledochal cyst.
  242. 242. Demographics Age: • it can be discovered at any age. • 60 % below 10 ys. Sex: • F > M, 4 : 1
  243. 243. C.P Choledochal cyst Abdominal pain Jaundice Abdominal mass
  244. 244. Complications Pancreatitis. Cholangitis. Cholangiocarcinoma.
  245. 245. Cholangiocarcinoma within a choledochal cyst
  246. 246. Types Todani classification Type I: dilatation of the CBD. Type II: true diverticulum. Type III: Choledochocele. Type IV: dilatation of the extrahepatic & intrhepatic biliary system. Type V: Caroli disease.
  247. 247. Type I • Fusiform dilatation of a segment or the entire CBD. • True choledochal cyst. • Most common type 80%.
  248. 248. Portal vein Splenic vein
  249. 249. Type II • True diverticulum. • Saccular outpouching of the supra-pancreatic portion of the CBD. • 3%.
  250. 250. Type III • Choledochocele (dilatation of the ampullary portion of the CBD). • 5 %.
  251. 251. Type IV • 2nd most common type 10%
  252. 252. Type V • Caroli disease
  253. 253. Central dot sign
  254. 254. Caroli disease • Autosomal recessive disorder 2ry to ductal plate malformation.
  255. 255. Normal development of ductal plate
  256. 256. Patterns of Caroli disease • Segmental 83 %. • Diffuse 17 %.
  257. 257. Central dot sign
  258. 258. Associations of Caroli disease Liver: • Congenital hepatic fibrosis (due to involvement of small ducts). • Caroli syndrome (caroli disease associated with congenital hepatic fibrosis) due to involvement of large & small ducts. Kidney: • Medullary sponge kidney. • Polycystic kidney. • Medullary cystic disease
  259. 259. Caroli disease & medullary sponge kidney
  260. 260. Complications of Caroli disease • • • • Intraductal stones. Ascending cholangitis & abscess formation. Cholangiocarcinoma. Liver cirrhiosis.
  261. 261. Intraductal stones
  262. 262. Liver cirrhosis Central dot sign abscess
  263. 263. Cholangiocarcinoma
  264. 264. Abscess formation
  265. 265. Bone cysts
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