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DOI: 10.1055/s-0045-1809030
Hot Spot Sign: Unique Case and Uncommon Pattern
Funding The authors did not receive support from any organization for the submitted work.
We present here two cases, highlighting “hot spot sign” in a unique case and another showing a heterogeneous presentation.
First case is of a 7-year-old female, presenting with complaints of progressive swelling over the body. She is a known case of spastic cerebral paralysis with intellectual disability, seizure disorder, and microcephaly. Vitals were stable. General examination revealed pallor and anasarca. A symptomatic management was done, and chest X-ray planned. It revealed a calcified right perihilar lesion, which was nonresolving when compared with previous repeated X-rays. For this, tuberculosis testing was conducted, which was negative, and further contrast-enhanced computed tomography (CECT) was planned. Noncontrast scan revealed extensive concentric calcification of the superior vena cava (SVC) in its entire extent, from the confluence of brachiocephalic veins extending into the right atrium, as shown in [Fig. 1A]. CECT revealed a complete SVC obstruction and a wedge-shaped hyperenhancing area in the segment IV (both Iva and Ivb) with early opacifying dilated and tortious vascular collaterals along the anterior thoracic and abdominal wall, arising from the left brachiocephalic vein (left internal thoracic vein, left anterior chest wall, and anterior abdominal wall collaterals), seen draining into a tortuous dilated middle hepatic vein, as shown in [Fig. 1B–D]. In addition, multiple dilated cardiophrenic collaterals were noted arising from the left brachiocephalic vein, joining the left hepatic vein, causing its early enhancement. Dilatated right chest wall and pericardiophrenic collaterals were also noted. No reflux of contrast into the azygos system was noted. The gamut of above findings suggested a type IV SVC obstruction. No past history of SVC catheterization was documented. No intrathoracic or other mass lesion was found on further evaluation.
The second case, given in [Fig. 2 (A-D)], is of a 47-year-old lady, who underwent CECT abdomen for an unrelated indication, which revealed well-defined arterial phase hyperenhancing wedge-shaped areas in the left lobe of the liver (segment II, III, Iva, and Ivb) with few early enhancing dilated tortuous vascular collaterals along the thoracic and abdominal wall, draining into the left and middle hepatic vein, which showed early arterial phase opacification, as shown in [Fig. 2B–D]. These findings raised the possibility of an SVC thrombus. Upon further introspection, history of multiple past central venous catheterizations was given by the attending doctor. To confirm the possibility of thrombosis, a venography was performed, which revealed thrombosis of right internal jugular, brachiocephalic vein, extending into the SVC with a central catheter in situ, as shown in [Fig. 2A]. This was also associated with dilated azygos and hemiazygos veins with tortious right internal mammary vein, which were seen continuing into the anterior abdominal wall collaterals. The conglomerate of these findings suggested a type III SVC obstruction.
Focal hot spot quadrate sign is an indirect tell-tale sign, indicating toward a potential SVC obstruction. It manifests as an inhomogenous, wedge-shaped hyperenhancement in the segment Ivb of the liver, also commonly known as quadrate lobe.[1] Underlying pathophysiology is that of portosystemic venous shunting occurring secondary to SVC obstruction.[1] [2] Although primarily defined for SVC obstruction, this sign can also be seen in IVC obstruction with a similar underlying pathophysiology.[2] An unwary CT interpreters can mistake this for hepatic hemangiomas, focal nodular hyperplasia, hepatocellular carcinomas, and abscess.[3] However, characteristic location, wedge-shaped enhancement, arterial hyperenhancement, and venous washout are the features that helps one to distinguish this sign from other lesions. The role of a radiologist is to identify the sign, differentiate it from mimics, and, if not already known, should look for central vein obstruction. With the advent of therapeutic vascular intervention, prompt and precise reporting leads to early management of the patient. With this article we bring forth two patients, one with a unique clinical presentation and another with an uncommon pattern of a rare sign.
Statement of Ethical Approval
Ethical approval was waived by the local Ethics Committee of ABVIMS and Dr. RML Hospital, New Delhi, in view of the retrospective nature of the study and all the procedures being performed were part of the routine care.
Consent to Participate
Informed consent was obtained from all individual participants included in the study.
Consent to Publish
Patients signed informed consent regarding publishing their data and photographs.
Authors' Contributions
Conceptualization: R.S., R.S., and L.B.
* They are Co-First Author, in view of equal contribution towards the manuscript.
Publikationsverlauf
Artikel online veröffentlicht:
09. Mai 2025
© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)
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Reference
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