1991, The British Journal of Radiology, 64, 751-752
Case reports An unusual cause of a pain in the calf By Arpan K. Banerjee, M B , BS, MRCP(UK) Department of Diagnostic Radiology, Westminster Hospital, Dean Ryle Street, Horseferry Road, London SW1P2AP, UK
(Received September 1990)
Keywords: Calf, Venous, Haemangioma Calf pain is a common cause for a request for a venogram to exclude the possibility of a deep venous thrombosis. An unusual cause of calf pain due to a venous haemangioma is presented and the radiological features are reviewed. Case report A 42-year-old Caucasian woman attended the Accident and Emergency Department with a 2-day history of increasing right-sided calf pain. As a child, she had been told she had an abnormality in her right calf that was inoperable. The venogram and computed tomographic (CT) scan of the calf are shown in Figs 1 and 2. Discussion
The venogram shows normal deep vein anatomy but an abnormal collection of dilated tortuous disorganized
veins in the calf communicating with the deep venous system is seen. No arterio-venous communication was demonstrated. The CT scan of the calf in the same patient performed with vascular enhancement showed the venous haemangioma to be within the calf muscles. Clinical examination of the limb revealed a further small subcutaneous haemangioma over the right buttock with no evidence of limb hypertrophy. Venous haemangioma of the calf is an unusual cause of calf pain. Venous haemangiomas are formed from venular capillaries or large veins. In the former case they form the so-called port-wine stain, which are cutaneous and often multiple. Malformations of the larger veins may affect the upper or lower limbs but are usually solitary (Browse et al, 1988). They may occur in association with other abnormalities, e.g. prominent superficial
Figure 1. (a, b) Venograms of the right calf. Vol. 64, No. 764
751
1991, The British Journal of Radiology, 64, 752-754
Figure 2. Computed tomographic scan of both calves (the right calf performed with contrast medium injected in the right foot).
veins, hemihypertrophy of the limb and deep venous hypoplasia as the Klippel-Trenaunay syndrome (Klippel & Trenaunay, 1900). In our case, the patient's calf pain was due to a solitary deep intramuscular venous haemangioma in the calf. A venous haemangioma is essentially a collection of large dilated disorganized veins that communicate with the normal venous system. They are benign, but may fluctuate in size. Thrombosis and thrombophlebitis are common complications. The arterial system is normal in these patients but there may be associated lymphatic dilatation (Trout et al, 1985). Clinically, deep venous haemangioma usually presents with pain, which is described as a dull ache present all the time, relieved by elevation of the limb.
Case reports
Exacerbation of the pain may be due to episodes of haemorrhage, thrombosis or thrombophlebitis. Useful radiological investigations include a plain radiograph of the calf, which may show soft-tissue swelling, phleboliths and, occasionally, translucent areas in the bone if there are dilated veins within it. A Doppler probe may be useful to exclude arterio-venous malformations (Van Der Molen, 1976). An ascending phlebogram will show dilated tortuous venous channels communicating with a normal deep venous system. Occasionally it may be difficult to demonstrate the haemangioma by venography. A CT scan with injection of contrast medium confirms the haemangioma and shows the relationship between the lesion and the surrounding muscles and joints. This is important to the surgeon as it is easier to remove more superficial haemangiomas and the intermuscular haemangioma whereas the intramuscular lesions are hard to remove without excising all the muscle. Fortunately, symptoms rarely justify this drastic measure (Lofgren & Lofgren, 1985). References BROWSE, N. L., BURNAND, K. G. & LEA THOMAS, M.,
1988.
Disease of the Veins (Edward Arnold, London), pp. 663-671. KLIPPEL, M. & TRENAUNAY, P., 1900. Naevus variquex osteohypertrophique. Arch. Gen. Med. Paris, 3, 641-642. LOFGREN, E. P. & LOFGREN, K. A., 1985. Surgical treatment of
cavernous haemangiomas. Surgery, 97, 474. TROUT, H. H., MCALLISTER, H. A., GIORDANO, J. M. & RUCH,
N. M., 1985. Vascular malformations. Surgery, 97, 36. VAN DER MOLEN, H. R., 1976. Use of Doppler ultrasound in the examination of the extent of venous angiomas. Phlebologie, 29, 9.
Unusual magnetic resonance findings in Wilson's disease By T. Singcharoen, MD, K. Chakkaphak, MD and 0. Udompanich, MD Department of Radiology, Bumrungrad Hospital and Pramongkutklao Hospital Bangkok, Thailand (Received September 1990 and in revised form December 1990) Keywords: Wilson's disease, Magnetic resonance imaging
Wilson's disease or hepatolenticular degeneration is an uncommon genetic disorder of copper metabolism, characterized by abnormal deposition of copper especially in the liver and brain. Computed tomography (CT) and magnetic resonance (MR) findings in Wilson's disease have been described (Kendall et al, 1981; Lawler et al, 1983; Aisen et al, 1985). We report unusual MR findings in two cases of Wilson's disease.
showed Kayser-Fleischer rings, tremor, spasticity, rigidity, dysphasia and dysarthria. Serum caeruloplasmin was low. The patient also had long-standing cirrhosis. Computed tomography of the brain showed symmetrical low-density lesions in the basal ganglia. Magnetic resonance imaging revealed areas of increased signal intensity in the basal ganglia and caudate nuclei in both proton density and ^-weighted images. Foci of low signal intensity were seen within the hyperintense basal ganglia (Fig. 1).
Case reports
Case 2
Case 1
A 19-year-old male presented with tremor and difficulty in writing for several months. Physical examination showed Kayser-Fleischer rings, tremor and signs of liver cirrhosis.
A 28-year-old female presented with tremor and difficulty in speaking and walking for several months. Physical examination
752
The British Journal of Radiology, August 1991
Case reports An unusual cause of a pain in the calf By Arpan K. Banerjee, M B , BS, MRCP(UK) Department of Diagnostic Radiology, Westminster Hospital, Dean Ryle Street, Horseferry Road, London SW1P2AP, UK
(Received September 1990)
Keywords: Calf, Venous, Haemangioma Calf pain is a common cause for a request for a venogram to exclude the possibility of a deep venous thrombosis. An unusual cause of calf pain due to a venous haemangioma is presented and the radiological features are reviewed. Case report A 42-year-old Caucasian woman attended the Accident and Emergency Department with a 2-day history of increasing right-sided calf pain. As a child, she had been told she had an abnormality in her right calf that was inoperable. The venogram and computed tomographic (CT) scan of the calf are shown in Figs 1 and 2. Discussion
The venogram shows normal deep vein anatomy but an abnormal collection of dilated tortuous disorganized
veins in the calf communicating with the deep venous system is seen. No arterio-venous communication was demonstrated. The CT scan of the calf in the same patient performed with vascular enhancement showed the venous haemangioma to be within the calf muscles. Clinical examination of the limb revealed a further small subcutaneous haemangioma over the right buttock with no evidence of limb hypertrophy. Venous haemangioma of the calf is an unusual cause of calf pain. Venous haemangiomas are formed from venular capillaries or large veins. In the former case they form the so-called port-wine stain, which are cutaneous and often multiple. Malformations of the larger veins may affect the upper or lower limbs but are usually solitary (Browse et al, 1988). They may occur in association with other abnormalities, e.g. prominent superficial
Figure 1. (a, b) Venograms of the right calf. Vol. 64, No. 764
751
1991, The British Journal of Radiology, 64, 752-754
Figure 2. Computed tomographic scan of both calves (the right calf performed with contrast medium injected in the right foot).
veins, hemihypertrophy of the limb and deep venous hypoplasia as the Klippel-Trenaunay syndrome (Klippel & Trenaunay, 1900). In our case, the patient's calf pain was due to a solitary deep intramuscular venous haemangioma in the calf. A venous haemangioma is essentially a collection of large dilated disorganized veins that communicate with the normal venous system. They are benign, but may fluctuate in size. Thrombosis and thrombophlebitis are common complications. The arterial system is normal in these patients but there may be associated lymphatic dilatation (Trout et al, 1985). Clinically, deep venous haemangioma usually presents with pain, which is described as a dull ache present all the time, relieved by elevation of the limb.
Case reports
Exacerbation of the pain may be due to episodes of haemorrhage, thrombosis or thrombophlebitis. Useful radiological investigations include a plain radiograph of the calf, which may show soft-tissue swelling, phleboliths and, occasionally, translucent areas in the bone if there are dilated veins within it. A Doppler probe may be useful to exclude arterio-venous malformations (Van Der Molen, 1976). An ascending phlebogram will show dilated tortuous venous channels communicating with a normal deep venous system. Occasionally it may be difficult to demonstrate the haemangioma by venography. A CT scan with injection of contrast medium confirms the haemangioma and shows the relationship between the lesion and the surrounding muscles and joints. This is important to the surgeon as it is easier to remove more superficial haemangiomas and the intermuscular haemangioma whereas the intramuscular lesions are hard to remove without excising all the muscle. Fortunately, symptoms rarely justify this drastic measure (Lofgren & Lofgren, 1985). References BROWSE, N. L., BURNAND, K. G. & LEA THOMAS, M.,
1988.
Disease of the Veins (Edward Arnold, London), pp. 663-671. KLIPPEL, M. & TRENAUNAY, P., 1900. Naevus variquex osteohypertrophique. Arch. Gen. Med. Paris, 3, 641-642. LOFGREN, E. P. & LOFGREN, K. A., 1985. Surgical treatment of
cavernous haemangiomas. Surgery, 97, 474. TROUT, H. H., MCALLISTER, H. A., GIORDANO, J. M. & RUCH,
N. M., 1985. Vascular malformations. Surgery, 97, 36. VAN DER MOLEN, H. R., 1976. Use of Doppler ultrasound in the examination of the extent of venous angiomas. Phlebologie, 29, 9.
Unusual magnetic resonance findings in Wilson's disease By T. Singcharoen, MD, K. Chakkaphak, MD and 0. Udompanich, MD Department of Radiology, Bumrungrad Hospital and Pramongkutklao Hospital Bangkok, Thailand (Received September 1990 and in revised form December 1990) Keywords: Wilson's disease, Magnetic resonance imaging
Wilson's disease or hepatolenticular degeneration is an uncommon genetic disorder of copper metabolism, characterized by abnormal deposition of copper especially in the liver and brain. Computed tomography (CT) and magnetic resonance (MR) findings in Wilson's disease have been described (Kendall et al, 1981; Lawler et al, 1983; Aisen et al, 1985). We report unusual MR findings in two cases of Wilson's disease.
showed Kayser-Fleischer rings, tremor, spasticity, rigidity, dysphasia and dysarthria. Serum caeruloplasmin was low. The patient also had long-standing cirrhosis. Computed tomography of the brain showed symmetrical low-density lesions in the basal ganglia. Magnetic resonance imaging revealed areas of increased signal intensity in the basal ganglia and caudate nuclei in both proton density and ^-weighted images. Foci of low signal intensity were seen within the hyperintense basal ganglia (Fig. 1).
Case reports
Case 2
Case 1
A 19-year-old male presented with tremor and difficulty in writing for several months. Physical examination showed Kayser-Fleischer rings, tremor and signs of liver cirrhosis.
A 28-year-old female presented with tremor and difficulty in speaking and walking for several months. Physical examination
752
The British Journal of Radiology, August 1991
