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Never visited RIGHT ISCHIAL ANEURYSMAL BONE CYST (ABC)
Contributed by: patricia burrows, Radiologist, Children's Hospital Boston, Massachusetts, USA.
Patient: 3 year old male
History: RIGHT ISCHIAL LESION, POSSIBLE ANEURYSMAL BONE CYST.  PATIENT COMPLAINS OF PAIN IN RIGHT PELVIS/HIP. 
Images:[small]larger

Fig. 1: Pelvic X-Ray dated 08/31/1993 Pre-Treatment

Fig. 2: Arterial Embolization (Ethanol) 10/7/93 Patient 3 y/o

Fig. 3: Arterial Embolization (Ethanol) 10/7/93 Patient 3 y/o

Fig. 4: Angio/Embo dated 03/22/1994 Patient 4 y.o.

Fig. 5: Angio/Embo dated 06/01/1995 Patient 5 y.o.

Fig. 6: Angio/Embo dated 06/01/1995 Patient 5 y.o.

Fig. 7: MRI dated 06/17/1996 Patient 6 y.o.

Fig. 8: MRI dated 06/17/1996 Patient 6 y.o.

Fig. 9: Pelvic X-Ray dated 06/18/1996 Patient 6 y.o.

Fig. 10: Angio/Embo dated 08/20/1996 Patient 6 y.o.

Fig. 11: Angio/Embo dated 08/20/96 Patient 6 y.o.

Fig. 12: CT dated 08/17/1997 Patient 7 y.o.

Fig. 13: Pelvic X-Ray dated 08/10/1999 Patient 9 y.o.
Findings:

AP PELVIS - 8/31/93:


FINDINGS: THERE IS AN EXPANSILE,WELL-CIRCUMSCRIBED LUCENT LESION INVOLVING THE RIGHT ISCHIUM. THERE IS NO PERIOSTEAL NEW BONE AND THE INFEROLATERAL ASPECT OF THE MASS APPEARS TO BE SCALLOPED. THERE DOES NOT APPEAR TO BE A SOFT TISSUE COMPONENT TO THE MASS. NO OTHER BONY ABNORMALITY IS NOTED.

IMPRESSION:  EXPANSILE LESION OF THE RIGHT ISCHIUM, AS DESCRIBED ABOVE, WHICH IS COMPATIBLE WITH THE DIAGNOSIS OF AN ANEURYSMAL BONE CYST. 




RIGHT ILIAC EMBOLIZATION AND SCLEROTHERAPY OF AN ANEURYSMAL BONE CYST - 10/7/93:

DIAGNOSTIC ANGIOGRAPHY OF THE RIGHT INTERNAL ILIAC ARTERY WAS PERFORMED AND DEMONSTRATED A HYPERVASCULAR LESION OF THE RIGHT ISCHIUM AND PUBIC BONE IN THE ACETABULUM. SELECTIVE INJECTIONS OF THE RIGHT INTERNAL ILIAC, RIGHT OBTURATOR, RIGHT PUDENTAL AND POSTERIOR GLUTEAL ARTERY WERE PERFORMED.  THE SAFEST ROUTE FOR EMBOLIZATION WAS THE RIGHT OBTURATOR ARTERY WHICH HAD NO BLOOD SUPPLY EITHER TO THE FEMORAL HEAD OR TO THE PENIS.  THIS VESSEL WAS EMBOLIZED WITH 100 TO 150 MICRON PARTICLES OF POLYVINYL ALCOHOL (CONTOUR).  THE EMBOLIZATION WAS PARTIALLY COMPLICATED BY SOME SPASM SO APPROXIMATELY 80 MICROGRAMS OF NITROGLYCERIN WERE INJECTED
INTRA-ARTERIALLY WHICH RELIEVED SOME OF THE SPASM AND LET US FURTHER EMBOLIZE THE BRANCHES FEEDING THE ANEURYSMAL BONE CYST. THE FEEDING VESSEL WAS THEN EMBOLIZED WITH TWO PLEDGETS OF GEL FOAM AND THERE WAS NO FLOW DEMONSTRATED.  THEN A CONTROL ANGIOGRAM WAS DONE IN THE RIGHT INTERNAL ILIAC ARTERY WHICH AGAIN DEMONSTRATED LITTLE IF ANY FILLING OF NEOVASCULAR BRANCHES OF THE  ANEURYSMAL BONE CYST. THROUGH THE ORIGINAL NEEDLE PLACED INTO THE BONE CONTRAST WAS INJECTED WHICH DEMONSTRATED CYSTIC SPACES REMINISCENT OF A VENOUS MALFORMATION. 100% ETHYL ALCOHOL MIXED WITH POWDERED METRIZAMIDE WAS INJECTED AT A VOLUME OF 4.5CC INTO THIS ANEURYSMAL BONE CYST. THERE IS NO EXTRAVASATION.  THE TRACT WAS THEN EMBOLIZED WITH AN AVETENE SCLURRY AS THE NEEDLE WAS WITHDRAWN AND THERE WAS NO BLEEDING. 
IMPRESSION: SUCCESSFUL EMBOLIZATION AND SCLEROTHERAPY OF A RIGHT ISCHIAL, ACETABULAR ANEURYSMAL BONE CYST.  
                                                                  
  


PELVIC ANGIOGRAPHY AND EMBOLIZATION - 3/22/94


CLINICAL HISTORY:  3 YEAR OLD BOY WITH ANEURYSMAL BONE CYST OF THE RIGHT ILIAC BONE.  EMBOLIZED IN 10/93 WITH SYMPTOMATIC IMPROVEMENT, BUT INTERVAL ENLARGEMENT OF THE SUPERIOR PORTION OF THE CYST.

ANGIOGRAPHIC FINDINGS:  ANGIOGRAPHY AGAIN SHOWS A HYPERVASCULAR MASS INVOLVING THE RIGHT ISCHIUM AND EXTENDING SUPERIORLY ALONG THE MEDIAL WALL OF THE ACETABULUM.  THIS IS APPLIED PREDOMINANTLY RIGHT OBTURATOR INTERNUS ARTERY BUT ALSO BY THE RIGHT INFERIOR GLUTEAL ARTERY AND A SMALL BRANCH ARISING MEDIALLY FROM THE RIGHT COMMON FEMORAL ARTERY.  POST-EMBOLIZATION INJECTIONS CONFIRM OCCLUSION OF THESE VESSELS. THE IMAGES OF THE INJECTION INTO THE CYST DEMONSTRATE MULTIPLE INTERCONNECTING CYSTS THROUGHOUT THE INFERIOR TWO-THIRDS OF THE LESION.  A CT SCAN PERFORMED SHORTLY AFTER SHOWS ABSENCE OF CONTRAST MEDIUM WITHIN THE SUPERIOR PART OF THE CYST ALONG THE
MEDIAL AND SUPERIOR WALLS OF THE ACETABULUM.

SUMMARY:  TECHNICALLY SUCCESSFUL EMBOLIZATION OF RIGHT PELVIC ANEURYSMAL BONE CYST.  PERCUTANEOUS INJECTION OF MOST OF THE CYST WITH A SCLEROSING AGENT.




 
PERCUTANEOUS ETHANOL AND COIL EMBOLIZATION OF RIGHT ISCHIAL ABC - 6/1/95:


FINDINGS:  INITIAL INJECTION DEMONSTRATED FILLING OF MOST OF THE ANEURYSMAL BONE CYST AS WELL AS SEVERAL INCOMPLETE SEPTI. HOWEVER, TWO AREAS WERE NOT OPACIFIED, ONE SUPERIORLY AND ANOTHER SUPRALATERALLY.  FOLLOWING INJECTION OF PLATINUM FIBER COILS AND ALCOHOL INTO THE LARGEST LOCULATION, THE SMALL SUPERIOR AND SUPRALATERAL LOCULATIONS WITH THEN ACCESSED.  WITH INJECTION OF CONTRAST MEDIUM INTO THE SUPERIOR LOCULATION, SOME FLOW WAS OBTAINED INTO THE LARGER LOCULATION INFERIORLY.  HOWEVER, THE TWO PLATINUM FIBER COILS PLACED WITHIN THE SUPERIOR LOCULATION REMAIN THERE.  THE SAME WAS TRUE OF THE SMALL SUPRALATERAL LOCULATION. NO HEMATOMA WAS PRESENT.  IMPRESSION:  ETHANOL AND PLATINUM FIBER COIL EMBOLIZATION OF THREE LOCULATIONS OF A RIGHT ISCHIAL ANEURYSMAL BONE CYST.  IT APPEARED THAT ALL PORTIONS OF THE ANEURYSMAL BONE CYST WERE TREATED.
                                                               



PELVIC MRI - 6/17/96:


FINDINGS:  THERE IS A 4.4 CM (SUPERIOR TO INFERIOR) X 3.5 CM (ANTERIOR TO POSTERIOR) X 2.3 CM (LEFT TO RIGHT) MASS IN THE RIGHT ISCHIUM.  THIS MASS CROSSES THE TRIRADIATE CARTILAGE AND ACETABULUM.  MULTIPLE FLUID-FLUID LEVELS ARE IDENTIFIED. IN COMPARISON TO THE MRI FROM 7/21/93, WHEN THIS LESION MEASURED 3.6 X 2.2 X 2.2 CM, THIS LESION HAS INCREASED IN SIZE.  IN COMPARISON TO THE MRI FROM 2/3/94, WHEN THE LESION MEASURED 4.5 X 4.0 X 3.0 CM, THIS LESION HAS DECREASED IN SIZE.  IN ADDITION, IN 2/94, THE LESION EXERTED MORE MASS EFFECT ON THE PELVIC ORGANS WITH DISPLACEMENT OF THE BLADDER TOWARDS THE LEFT.  ALTHOUGH DIRECT COMPARISON IS SOMEWHAT DIFFICULT, IN COMPARED TO A CT EXAM  FROM 11/16/95, THERE HAS NOT BEEN A DRAMATIC CHANGE IN THE SIZE OR EXTENT OF THIS LESION. IN COMPARISON TO THE MOST RECENT CT EXAM FROM 11/16/95, THE LESION HAS NOT CHANGED IN SIZE; HOWEVER, IT IS POSSIBLE THAT DURING THIS INTERVAL OF TIME, THERE WAS AN INITIAL DECREASE IN SIZE, POST-EMBOLIZATION, FOLLOWED BY INCREASE IN SIZE.



                                                               

RIGHT ILIAC ANGIOGRAM - 8/20/96:

HISTORY:  THIS IS A 6-YEAR OLD MALE WITH A RIGHT ILIAC ANEURYSMAL BONE CYST, WHICH WAS EMBOLIZED SEVERAL TIMES SINCE 1993 AND WITH INTRALESIONAL PLACEMENT OF COILS AND ETHANOL IN 1995. SERIAL RADIOGRAPHS DEMONSTRATE PROGRESSIVE DECREASE IN SIZE OF THE CYST, WITH FURTHER MARGIN SCLEROSIS SINCE 6/96.  MRI OF 6/96 SUGGESTED PERSISTENT VASCULAR CHANNELS OR CYSTIC SPACES WITHIN THE ANEURYSMAL BONE CYST.  THIS IS FOR PREOPERATIVE EVALUATION AND POSSIBLE EMBOLIZATION OF THE ANEURYSMAL BONE CYST.

ANGIOGRAPHIC FINDINGS:  THE PATIENT HAS NO EVIDENCE OF ABNORMAL ARTERIAL PERFUSION TO THE ANEURYSMAL BONE CYST.  IT APPEARS TO HAVE BEEN WELL EMBOLIZED BY THE PATIENT'S PRIOR PROCEDURE.  THERE IS A VERY SMALL REMAINING OBTURATOR INTERNUS ARTERY.
SUMMARY:  THE PATIENT'S RIGHT ILIAC ANEURYSMAL BONE CYST APPEARS TO BE AVASCULAR. THERE WERE NO ARTERIAL FEEDERS TO EMBOLIZE ON TODAY'S EXAMINATION, WITH INJECTION OF THE RIGHT INTERNAL ILIAC ARTERY AND SUBSELECTION OF THE RIGHT INTERNAL PUDENDAL, RIGHT INFERIOR GLUTEAL, AND RIGHT OBTURATOR INTERNUS ARTERIES. 




AP VIEW OF THE PELVIS - 8/10/99:

FINDINGS: MULTIPLE EMBOLIZATION COILS ARE IN POSITION IN THE RIGHT ISCHIUM AT THE LEVEL OF THE ACETABULUM.  WHEN COMPARED TO THE PRIOR FILM OF 8/4/98, THE COILS HAVE AN UNCHANGED APPEARANCE.  THERE IS POSSIBLE SLIGHTLY INCREASED SCLEROSIS IN THE ISCHIUM SURROUNDING THE COILS.  THERE CONTINUES TO BE A COXA VALGA DEFORMITY WITH LATERAL SUBLUXATION OF THE RIGHT HIP. THE PRESENT EXAMINATION SHOWS THAT THERE HAS BEEN FUSION OF THE TRIRADIATE CARTILAGE. THE ACETABULUM IS SMALLER ON THE RIGHT THAN ON THE LEFT. THERE IS DECREASED ANTERIOR AND LATERAL COVERAGE OF THE FEMUR. THERE ARE COILS IN THE REGION OF
PREVIOUS CYST.

                                                     


Diagnosis: Aneurysmal bone cyst (diagnosed 1993) managed by arterial embolization, sclerotherapy (x3) and direct injection of platinum/fiber coils and ethanol (x2).  Follow-up Angio/MRI (1996) showed healed cyst. Iliac osteotomy later preformed to cover femoral head.  ABC led to leg length discrepancy (LLD).
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Additional Details:

Case Number: 6604325Last Updated: 03-15-2007
Anatomy: Skeletal System   Pathology: Vascular
Modality: CT, Conventional Radiograph, MR, AngiographyAccess Level: Readable by all users
Keywords: coil embolization

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