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Hepatic pseudolesion secondary to superior vena cava stenosis

Case contributed by Hoe Han Guan
Diagnosis almost certain

Presentation

Swelling of the face, neck, upper body, and arms with prolonged history of central venous dialysis catheter.

Patient Data

Age: 70 years
Gender: Male

CT contrast administered via the left upper limb.
Hypervascular liver pseudolesion in the segment IV with enhancing vein of Sappey (best visualized in axial view).
Dilated and abnormally opacified left internal mammary vein, left inferior phrenic vein and hepatic capsule veins.
Stenotic right and left brachiocephalic vein.
Presence of right central venous catheter with the tip located at the atrio-caval junction. No opacification of superior vena cava in keeping with stenosis. No abnormal mediastinal mass especially at the region of superior vena cava.

Bilateral pleural effusion with multiple lung granulomas.
Multiple tortuous venous collaterals over the anterior chest wall and anterior abdomen.

Bilateral atrophied kidneys.

Annotated images show the hepatic pseudolesion and the dilated vein of Sappey.

Case Discussion

This case shows the hepatic pseudolesion at the liver segment IV secondary due to central venous stenosis. The central venous stenosis is likely due to prolonged history of central venous dialysis catheter.

The cranial portion of the falciform ligament and the medial aspect of the diaphragm are drained by the superior vein of Sappey, which then enters the peripheral portal branches of the left hepatic lobe. Additionally, it connects with branches of the superior epigastric or internal thoracic veins.

The inferior vein of Sappey drains the caudal section of the falciform ligament and enters the peripheral portal branches of the left hepatic lobe. It also travels along the round ligament and communicates with the inferior epigastric veins surrounding the umbilicus.

Meanwhile, the vein of Burow communicates with the inferior epigastric veins around the umbilicus, but it doesn't directly enter the liver. Instead, it ends in the middle section of the collapsed umbilical vein. However, some small intercalary veins are present between it and the inferior vein of Sappey.

In cases of SVC obstruction, the cavo-mammary-phrenic-hepatic-capsule-portal pathway is utilized, allowing venous blood to flow into the internal mammary vein, inferior phrenic vein, hepatic capsule veins, and the intrahepatic portal system. As a result, a hypervascular pseudolesion occurs in segment IV A of the liver.

The nuclear-medicine equivalent of this physiological process is the focal hepatic hotspot sign, which is visible on technetium-99m sulfur colloid scans of the liver and spleen. This sign represents the localized increase in uptake of the radiopharmaceutical material in segment IV A of the liver.

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