Case 240:   Cirrhosis

Diagnostic Category:

Clinical Presentation:

48 year old man with acute lymphoblastic leukemia with incidental imaging finding. Patient has history of frequent blood transfusions.

MR: Posterior hepatic notch sign and hemosiderosis

Imaging Findings:

Posterior hepatic notch sign in MR, typical for cirrhosis. The posterior notch sign is an indentation of the visceral hepatic surface between the hypertrophic caudate lobe and right lobar segments. T2w also shows signs of portal hypertension including trace of perihepatic ascites over the right hepatic lobe, and mesenteric edema on the left.

The sensitivity, specificity, accuracy, and positive predictive value of the right posterior hepatic notch sign for diagnosis of cirrhosis at MR have been reported to be 72%, 98%, 82%, and 99%, respectively [1]. 

Significant hypointensity of hepatic parenchyma on in-phase GRE T1w sequence due to blood transfusions, representing iron overload. Note that iron overload is also present in the spleen, which is typical for hemosiderosis.

Hepatic parenchymal signal is also slightly decreased on the opposed-phase sequence due to the significant iron overload when compared to normal; however this is not well appreciated given the substantial signal drop on in-phase.

1. Ito K, Mitchell D. Right posterior hepatic notch sign: a simple diagnostic MR finding of cirrhosis. J Magn Reson Imaging 2003;18: 561–566.