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What's the most likely diagnosis?
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A. Smith fracture B. Colles fracture C. Pisiform fracture D. Triquetral fracture
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Case of the Week
22 "Must-See" Diagnoses for Medical Students A limited list of

diagnoses and their respective imaging modalities that all students should be able to recognize, regardless of their planned specialty derived from the National Curriculum for Medical Students developed by the Alliance of Medical Student Educators in Radiology (AMSER).
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Welcome to LearningRadiology.com
handouts, images, Cases of the Week, archives of case quizzes, flashcards of differential diagnoses and most commons lists, primarily in the areas of chest, GI, cardiac, and bone radiology.
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LearningRadiology - Quizzes
Quizzes are short, image-centered and focused on a particular topic (see table below). You will get immediate feedback as to the correct answers, how you answered each question and how you did in comparison to others. LearningRadiology.com does not collect any private information from anyone using this site or these quizzes (Privacy Statement). = New quiz
Quiz Subject Area

General Quiz 001 General Quiz 002 General Quiz 003 General Quiz 004 General Quiz 005 Chest Quiz 101 Chest Quiz 102 Abdomen Quiz 201 Abdomen Quiz 202 Abdomen Quiz 203 Abdomen Quiz 204 Abdomen Quiz 205 MSK* Quiz 301 MSK Quiz 302 MSK Quiz 303 MSK Quiz 304
Title
Emergency, Emergency! Whats Next? Charge! Where in the World Were They? What Am I Missing? Whiteout! Tough Starts Belly Aches Ill Drink to That
Skill Level* # Questions B M A

B
Comment
Some important emergency diagnoses
5
5
B B A A B A B B B B B B M B-M A A
10 5 5 5 5 5 5 5
What would be most appropriate to do next? How much do certain, selected imaging studies cost? Identify the country or part of this country these diseases are endemic What body part is missing and whats the most likely diagnosis Differentiating the major causes of an opacified hemithorax Some important chest diseases seen in an infant Abdominal CT fundamental findings
Some common diagnoses found on oral barium studies Some common diagnoses found on rectal barium studies Common calcifications in the abdomen Causes of abnormal gas inside and outside of bowel Some of the more common fractures and dislocations Eponyms of some of the more common fractures and dislocations Some of the more common arthridities Some fundamental bone diseases Some causes of back pain
When the Bowel Breaks Abdominal Calcifications

Air, Air Everywhere Snap, Crackle, Pop-1
5
5 5 5 5 5 5
Name That Fracture-1 Hot Joints! Bone Up on These

My Aching Back
MSK Quiz 305
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LearningRadiology - Quizzes
*MSK=musculoskeletal *Skill Levels B=Beginner M=Moderate A=Advanced
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LearningRadiology.com Miscellaneous Material Index
Flashcards - drop-down lists of differential diagnoses Cardiac ImageCards - 40 cardiac cases presented in flashcard format Most Commons - drop-down lists of most common causes of various findings Pictorial Differential Diagnoses - side-by-side images of similar appearing diseases Case of the Week Randomizer - presents Cases of the Week as unknowns according to
the category you select
Differential Diagnoses
Differential Diagnoses in Cardiac Disease Differential Diagnoses in Chest Disease Differential Diagnoses in GI Disease Differential Diagnoses in MSK Disease Pictorial Differential Diagnoses Differential Diagnoses in Cardiac Disease Differential Diagnoses in Chest Disease Differential Diagnoses in GI Disease Differential Diagnoses in MSK Disease
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Copyright 2003-2005 LearningRadiology.com About Us
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LearningRadiology.com Miscellaneous Material Index
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LearningRadiology.com Medical Students' Table of Contents
Recognizing . . . A series of short modules designed for beginners
Module
1. Recognizing a Technically Adequate Chest X-ray 2. Recognizing Cardiomegaly 3. Recognizing the Causes of an Opacified Hemithorax 4. Recognizing a Pleural Effusion 5. Recognizing Congestive Heart Failure 6. Recognizing Airspace Versus Interstitial Disease 7. Recognizing a Pneumothorax 8. Recognizing the Placement of ICU Tubes and Lines 9. Recognizing Small/Large Bowel Obstruction and Ileus 10. Recognizing Free Air 11. Recognizing Abdominal Calcifications 12. Recognizing Soft Tissue Masses in the Abdomen 13. Recognizing Fractures and Dislocations
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Quizzes
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Quizzes for students
Medical Student Lectures

Lecture
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=Flash
Available in formats below (click on link)

PowerPoint Flash Flash Flash PowerPoint PowerPoint PowerPoint 30-minutes with audio PDF Flash Flash Flash PowerPoint PowerPoint PowerPoint
22 "Must-See" Diagnoses for Medical Students NEW Fundamentals of Chest Roentgenology The ABCs of Heart Disease Test Yourself on the ABCs ABCs of Heart Disease with Audio ABCs Schema-Handout version Approach to Arthritis Plain Films of the Abdomen Soft Tissue Calcifications and Ossification
Pictorial Differential Diagnoses - side-by-side images of similar appearing diseases
Medical Student Modules
Short multiple-choice quizzes (answers not posted)
Medical Student Module 1-Chest Medical Student Module 2-Chest Medical Student Module 3-Abdomen Medical Student Module 4-Abdomen Medical Student Module 5-GU Medical Student Module 6- Musculoskeletal
Medical Student Packets
More extensive case modules (answers not posted)
Packet 1 Packet 2
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Copyright 2004 LearningRadiology.com About Us
Case of the Week Archive- 2006
Click on the date for original Case of Week Quiz Click on the image to enlarge it Click on the diagnosis for more information
2002 2003 20042005 Archives Click here for Index of all Cases of the Week
Case of Week 183 Jan. 1-7, 2006 Case of Week 184 Jan. 8-14, 2006 Case of Week 185 Jan. 15-21, 2006 Case of Week 186 Jan. 22-28, 2006
Back to 2005 Archives
Pneumococcal Pneumonia Case of Week 187 Jan. 29-Feb. 4, 2006 Case of Week 188 Feb. 5-11, 2006
Benign Gastric Ulcer Case of Week 189 Feb. 12-18, 2006
Calcified Left Atrium Case of Week 190 Feb. 19-25, 2006
Uterine Rupture Case of Week 191 Feb. 26-March 4, 2006
Intraperitoneal Bladder Rupture Case of Week 192 March 5-11, 2006
Jefferson Fracture Case of Week 193 March 12-18, 2006
Retroperitoneal Fibrosis Case of Week 194 March 19-25, 2006
Stein-Leventhal Ovaries Case of Week 195 March 26-April 1, 2006
Midesophageal Diverticulum Case of Week 196 April 2-8, 2006
Epiphrenic Diverticulum Case of Week 197 April 9-15, 2006
Ascites Case of Week 198 April 16-22, 2006
Burst Fracture Case of Week 199 April 23-29, 2006
Posterior Hip Dislocation Case of Week 200 April 30-May 6, 2006
Pericardial Cyst Case of Week 201 May 7-13, 2006
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Esophageal Leiomyoma Case of Week 202 May 14-20, 2006
Osteoma Case of Week 203 May 21-27, 2006
Asbestos-Related Pleural Disease Case of Week 204 May 28-June 3, 2006
Luxatio erecta Case of Week 205 June 4-10, 2006
Leriche Syndrome Case of Week 206 June 11-17, 2006
Dislocated Clavicle Case of Week 207 June 18-24, 2006
Pulmonary Laceration Case of Week 208 June 25-July 1, 2006
Spondylitic Spondylolisthesis Case of Week 209 July 2-8, 2006
Avulsion FractureIschial Tuberosity Case of Week 210 July 9-15, 2006
Bullous Disease of the Lungs Case of Week 211 July 16-22, 2006
Dermatomyositis Case of Week 212 July 23-29, 2006
Hiatal Hernia Case of Week 213 July 30-August 5, 2006
Synovial Osteochondromatosis Case of Week 214 August 6-12, 2006
Histoplasmosis Case of Week 215 August 13-19, 2006
Aspiration Case of Week 216 August 20-26, 2006
Mirror-Image Right Arch Case of Week 217 Aug. 27-Sept. 2, 2006
Intertrochanteric Hip Fracture Case of Week 218 September 3-9, 2006
Atlantoaxial Dislocation Case of Week 219 September 10-16, 2006
Chance Fracture Case of Week 220 September 17-23, 2006
Small Bowel Obstruction Case of Week 221 September 24-30, 2006
Lisfranc Fracture Dislocation
Triquetral Fracture
Case of Week 222 October 1-7, 2006
Case of Week 226 Oct. 29-Nov. 4, 2006
Case of Week 227 November 5-11, 2006
Case of Week 230 Nov. 26-Dec. 2, 2006
Case of Week 231 December 3-9 2006
Case of Week 232 December 10-16, 2006
Index of all Cases of the Week
Click on date for original Quiz Click on image to enlarge it Click on diagnosis for more information
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2002 2003 20042005Archives Index of all Cases of the Week
LearningRadiology .com Table of Contents- Images
Bone
Cardiac
Chest
GI
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LearningRadiology .com Table of Contents- Images
Cases of the Week
Pictorial Differential Diagnoses
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LearningRadiology.com Handout Notes
Cardiac Notes
Abdominal Aortic Aneurysm Aortic Dissection Cardiac Radiology Curriculum CHF-chronologic sequence in childhood Constrictive Pericarditis Double aortic arch DDXs of Congenital Heart Disease Ebstein's Anomaly Malpositions, Heterotaxy Chart Mitral Stenosis Nine Lesions that Produce 75% of all CHD Partial Anomalous Pulmonary Venous Return Penetrating Aortic Ulcer Pericardial Effusion Pulmonary Sling Pulmonic Stenosis Right Aortic Arches Surgical Corrective Procedures for CHD Syndromes with Associated CHD The ABCs of Heart Disease Total Anomalous Pulmonary Venous Return Ventricular Aneurysms
MSK Notes
Barton's Fracture Battered Child Syndrome Bennett's Fracture Calcinosis universalis Chance Fracture Charcot arthropathy Charcot foot Child Abuse Chondrosarcoma Colle's Fracture Congenital syphilis Congenital Hip Dysplasia CREST Syndrome Lunate Dislocation Marfucci's Syndrome Multiple hereditary exostoses Multiple myeloma Nonossifying fibroma Ochronosis Osteochondritis dissecans Osteomyelitis-acute Osteomyelitis-skull Osteopetrosis Paget's Disease Perilunate Dislocation Pigmented Villonodular Synovitis
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DISH Enchondroma Fibrous dysplasia Frieberg's infraction Gamekeeper's Thumb Giant Cell Tumor Gouty Arthritis Hand-shoulder Syndrome Hand-foot Syndrome Hemangiopericytoma Hemophilia Hip Diseases in Children-table Hyperparathyroidism Lead Poisoning Legg-Calve-Perthe's Disease
Ping-pong Fracture Pelvic avulsion fractures (graphic) Protrusio acetabuli Psoriatic arthritis Pyle's disease Radiation Induced Osteosarcoma Renal Osteodystrophy Rolando Fracture Round cell lesions by age (table) Sacroiliitis Slipped Capital Femoral Epiphysis Synovioma Tuberous sclerosis Tumoral calcinosis Volar Plate Fracture
Chest Notes
Alpha-1 Antitrypsin Deficiency Actinomycosis Adenomas (Cylindromas) Alveolar Cell Carcinoma Aortic Dissection ARDS Aspiration pneumonia Aspergilloma Bronchiectasis Bronchogenic cysts Coccidioidomycosis Congenital Lobar Emphysema COPD Crack Cocaine Abuse Cryptococcosis Cystic Adenomatoid Malformation Cystic Fibrosis Embolic Disease to the Lung Goodpasture's Syndrome Mycoplasma Pneumonia Neurogenic Tumors Neurofibromatosis Pancoast Tumor Pneumoconiosis Pneumocystis Carinii Pneumonia Pneumonia-gram positive Pneumonia-gram-negative Pneumomediastinum Polyarteritis nodosa Pseudolymphoma Pulmonary Laceration Radiation pneumonitis Re-expansion pulmonary edema Rheumatoid Lung Disease Rounded Atelectasis Round Pneumonia Sarcoidosis Silicosis
Hamartomas Histiocytosis X Histoplasmosis Hyaline Membrane Disease Lipoid Pneumonia Lupus Lymphangiomyomatosis Lymphomas Metastases to the Lung
Scleroderma Sequestration Solitary Pulmonary Nodule Teratomas Thyroid Masses Tuberculosis UIP Varicella Pneumonia Wegener's Granulomatosis
GI Notes
Achalasia Antral Web Ascariasis Boerhavve's Syndrome Candidiasis Carcinoma of the Colon Carcinoma of the Esophagus Carcinoma of the Stomach Cathartic Colon Colonic polyps Crohn's Disease Diffuse Small Bowel Disease Diffuse Small Bowel Disease-Pictorial DDx Diverticular Disease Duodenal Ulcer Endometriosis Esophageal diverticula Esophagitis-caustic Esophageal varices Esophageal Webs Familial Polyposis Syndromes Free Intraperitonal Air Gastric emphysema Gastric Polyps Gastric Ulcer Gastric Volvulus Hiatal Hernia Hypertrophic Pyloric Stenosis Hypertrophic Gastritis Intussusception Leiomyoma of the Esophagus Lipoma of the Colon Liver Laceration Lymphoma of Small Bowel Lymphoma of the Stomach Mesenteric Vascular Ischemia Midgut Volvulous Mucocoele of the Appendix Porcelain Gallbladder Postgastrectomy Complications Sigmoid Volvulous Small Bowel Lymphoma Thorotrast Ulcerative Colitis
GU Notes
Acute Pyelonephritis Adrenal adenoma Adult Polycystic Disease Angiomyolipoma Bladder Rupture Emphysematous pyelonephritis
Ovarian Carcinoma Placenta-grading (pictorial chart) NEW Renal Infarct Retrocaval Ureter Transitional Cell Carcinoma Ureter-causes of displacement
LearningRadiology.com Index of Lectures
= PowerPoint
=Flash
Bone Lectures
Lecture
Approach to Arthritis Bone Tumors-Cues and Clues Cervical Spine Fractures and Dislocations Pelvic Fractures and Dislocations Soft Tissue Calcifications and Ossification Flash

Flash PowerPoint PowerPoint PowerPoint PowerPoint PowerPoint PDF PDF PDF
Cardiac Lectures
Lecture
Module 1: The ABCs of Heart Disease Sub-module A: Test Yourself on the ABCs Sub-module B: ABCs (algorithm only) Sub-module C: ABCs of Heart Disease-audio Module 2: Differentials in Congenital Heart Disease Module 3: Left-to-Right Shunts Module 4: Cyanotic Heart Disease Module 5: Obstructive Lesions Module 6: Valvular Lesions-Congenital and Acquired

Flash Flash PowerPoint PowerPoint PDF Audio version of ABCs of Heart Disease Flash Flash Flash Flash Flash PowerPoint PowerPoint PowerPoint PowerPoint PowerPoint PDF PDF PDF PDF PDF PDF
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Module 7: Diseases of the Great Vessels Module 8: The Heart Inside Out Module 9: Miscellaneous Cardiac Diseases Module 10: Differential Diagnoses in Cardiac Disease Module 11: Review CHF
Flash Flash Flash Flash Flash Flash
PowerPoint PowerPoint PowerPoint PowerPoint PowerPoint PowerPoint
PDF PDF PDF PDF PDF PDF
Chest Lectures
All are in PowerPoint
Alpha-1 Antitrypsin Deficiency Allergic Bronchopulmonary Aspergillosis Actinomycosis Adenomas (cylindromas) AIDS and Lung Disease Allergic Pneumonitis Alveolar Cell Carcinoma Aortic Dissection ARDS Asbestosis Aspiration Pneumonia Atelectasis AVMs BOOP Bronchogenic Cysts Bullous Disease of the Lung Coal Worker's Pneumoconiosis Coccidioidomycosis Collagen Vascular Diseases Congenital Lobar Emphysema COPD Cystic Adenomatoid Malformation Cystic Fibrosis
Histoplasmosis Hypogenetic Lung Syndrome ICU Radiology Lipoid Pneumonia Lung Masses Lupus Lymphomas Metastases to the Lung Mycoplasma Pneumonia Neurogenic Tumors Pancoast Tumor Pleural Effusion Pneumoconiosis Pneumonias Polyarteritis Nodosa Rheumatoid Lung Disease Rounded Atelectasis Round Pneumonia Sarcoidosis Scleroderma Sequestration Silicosis Solitary Pulmonary Nodule
Diaphragmatic Diseases Differential Diagnoses in Chest Radiology Dressler's Syndrome Drug-induced Lung Disease Embolic Disease of the Lung Eosinophilic Lung Disease Goodpasture's Syndrome Hamartomas Histiocytosis X
Swyer-James Syndrome TB Teratoma Thromboembolic Disease Thymoma Thyroid Masses Trauma Wegener's Granulomatosis
GI Lectures
Lecture
Approach to Diffuse Small Bowel Disease Plain Films of the Abdomen Differential Diagnoses in GI Disease

Flash Flash Flash PowerPoint PowerPoint PowerPoint
Differential Diagnoses
Lecture
Differential Diagnoses in Cardiac Disease Differential Diagnoses in Chest Disease Differential Diagnoses in GI Disease Differential Diagnoses in MSK Disease Pictorial Differential Diagnoses Flash Flash

Flash PowerPoint PowerPoint PowerPoint PowerPoint Click here PDF PDF PDF
Faculty Lectures
Lecture Available in formats below (click on link)
Faculty Lecture Table of Contents Page
PowerPoint
General Lectures
Lecture
Lateral Neck - Soft Tissue

Flash
Medical Student Lectures

Lecture 22 "Must-See" Diagnoses for Medical Students Fundamentals of Chest Roentgenology
Flash
PowerPoint PowerPoint
More for Medical Students
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http://www.learningradiology.com/toc/tocorgansystems/toccardiac.htm
Cardiac Lectures
= PowerPoint
=Flash
Lecture
Module 1: The ABCs of Heart Disease Sub-module A: Test Yourself on the ABCs Sub-module B: ABCs (algorithm only) Sub-module C: ABCs of Heart Disease-audio Module 2: Differentials in Congenital Heart Disease Module 3: Left-to-Right Shunts Module 4: Cyanotic Heart Disease Module 5: Obstructive Lesions Module 6: Valvular Lesions-Congenital and Acquired Module 7: Diseases of the Great Vessels Module 8: The Heart Inside Out Module 9: Miscellaneous Cardiac Diseases Module 10: Differential Diagnoses in Cardiac Disease Module 11: Review CHF

Flash Flash PowerPoint PowerPoint PDF Audio version of ABCs of Heart Disease Flash Flash Flash Flash Flash Flash Flash Flash Flash Flash Flash PowerPoint PowerPoint PowerPoint PowerPoint PowerPoint PowerPoint PowerPoint PowerPoint PowerPoint PowerPoint PowerPoint PDF PDF PDF PDF PDF PDF PDF PDF PDF PDF PDF PDF
Cardiac Notes
Abdominal Aortic Aneurysm Aortic Dissection Cardiac Radiology Curriculum CHF-chronologic sequence in childhood Constrictive Pericarditis Double aortic arch DDXs of Congenital Heart Disease Ebstein's Anomaly Malpositions, Heterotaxy Chart Partial Anomalous Pulmonary Venous Return Penetrating Aortic Ulcer Pericardial Effusion Pulmonary Sling Pulmonic Stenosis Right Aortic Arches Surgical Corrective Procedures for CHD Syndromes with Associated CHD The ABCs of Heart Disease
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http://www.learningradiology.com/toc/tocorgansystems/toccardiac.htm
Mitral Stenosis Nine Lesions that Produce 75% of all CHD
Total Anomalous Pulmonary Venous Return Ventricular Aneurysms
Cardiac Images
Cardiac Images-thumbnails
Cardiac Flashcards
Cardiac ImageCards - 40 cardiac images presented in flashcard format Differential Diagnoses in Cardiac Disease
Cardiac Case Archives

Previous Cases of the Week

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http://www.learningradiology.com/toc/tocorgansystems/tocchest.htm
Chest Lectures
Alpha-1 Antitrypsin Deficiency Allergic Bronchopulmonary Aspergillosis Actinomycosis Adenomas (cylindromas) AIDS and Lung Disease Allergic Pneumonitis Alveolar Cell Carcinoma Aortic Dissection ARDS Asbestosis Aspiration Pneumonia Atelectasis AVMs BOOP Bronchogenic Cysts Bullous Disease of the Lung Coal Worker's Pneumoconiosis Coccidioidomycosis Collagen Vascular Diseases Congenital Lobar Emphysema COPD Cystic Adenomatoid Malformation Cystic Fibrosis Diaphragmatic Diseases Differential Diagnoses in Chest Disease Histoplasmosis Hypogenetic Lung Syndrome ICU Radiology Lipoid Pneumonia Lung Masses Lupus Lymphomas Metastases to the Lung Mycoplasma Pneumonia Neurogenic Tumors Pancoast Tumor Pleural Effusion Pneumoconiosis Pneumonias Polyarteritis Nodosa Rheumatoid Lung Disease Rounded Atelectasis Round Pneumonia Sarcoidosis Scleroderma Sequestration Silicosis Solitary Pulmonary Nodule Swyer-James Syndrome TB
http://www.learningradiology.com/toc/tocorgansystems/tocchest.htm (1 de 3)04/09/2006 1:05:57
Dressler's Syndrome Drug-induced Lung Disease Embolic Disease of the Lung Eosinophilic Lung Disease Goodpasture's Syndrome Hamartomas Histiocytosis X
Teratoma Thromboembolic Disease Thymoma Thyroid Masses Trauma Wegener's Granulomatosis
Chest Notes
Alpha-1 Antitrypsin Deficiency Actinomycosis Adenomas (Cylindromas) Alveolar Cell Carcinoma Aortic Dissection ARDS Aspiration pneumonia Aspergilloma Bronchiectasis Bronchogenic cysts Coccidioidomycosis Congenital Lobar Emphysema COPD Crack Cocaine Abuse Cryptococcosis Cystic Adenomatoid Malformation Cystic Fibrosis Embolic Disease to the Lung Goodpasture's Syndrome Hamartomas Histiocytosis X Histoplasmosis Hyaline Membrane Disease Lipoid Pneumonia Mycoplasma Pneumonia Neurogenic Tumors Neurofibromatosis Pancoast Tumor Pneumoconiosis Pneumocystis Carinii Pneumonia Pneumonia-gram positive Pneumonia-gram-negative Pneumomediastinum Polyarteritis nodosa Pseudolymphoma Pulmonary Laceration Radiation pneumonitis Re-expansion pulmonary edema Rheumatoid Lung Disease Rounded Atelectasis Round Pneumonia Sarcoidosis Silicosis Scleroderma Sequestration Solitary Pulmonary Nodule Teratomas Thyroid Masses
Lupus Lymphangiomyomatosis Lymphomas Metastases to the Lung
Tuberculosis UIP Varicella Pneumonia Wegener's Granulomatosis
Chest Images
Chest Images-thumbnails Common Pulmonary Cavities-Pictorial DDx Opacified Hemithorax-Pictorial DDx
Chest Flashcards
Differential Diagnoses in Chest Disease
Chest Archives
http://www.learningradiology.com/toc/tocorgansystems/tocgi.htm
GI Lectures
= PowerPoint
=Flash
Approach to Diffuse Small Bowel Disease Plain Films of the Abdomen GI Differential Diagnoses
Approach to Diffuse Small Bowel Disease Plain Films of the Abdomen GI Differential Diagnoses
GI Notes
Achalasia Antral Web Ascariasis Boerhavve's Syndrome Candidiasis Carcinoma of the Colon Carcinoma of the Esophagus Carcinoma of the Stomach Cathartic Colon Colonic polyps Crohn's Disease Diffuse Small Bowel Disease Diffuse Small Bowel Disease-Pictorial DDx Diverticular Disease Duodenal Ulcer Endometriosis Esophageal diverticula Esophagitis-caustic Esophageal varices Esophageal Webs Familial Polyposis Syndromes Free Intraperitonal Air Gastric emphysema Gastric Polyps Gastric Ulcer Gastric Volvulus Hiatal Hernia Hypertrophic Pyloric Stenosis Hypertrophic Gastritis Intussusception Leiomyoma of the Esophagus Lipoma of the Colon Liver Laceration Lymphoma of Small Bowel Lymphoma of the Stomach Mesenteric Vascular Ischemia Midgut Volvulous Mucocoele of the Appendix Porcelain Gallbladder Postgastrectomy Complications Sigmoid Volvulous Small Bowel Lymphoma Thorotrast Ulcerative Colitis
http://www.learningradiology.com/toc/tocorgansystems/tocgi.htm (1 de 2)04/09/2006 1:06:00
http://www.learningradiology.com/toc/tocorgansystems/tocgi.htm
GI Images
GI Images-thumbnails Diffuse Small Bowel Disease-Pictorial DDx Abnormal Bowel Gas Patterns-Pictorial DDx
GI Flashcards
Differential Diagnoses in GI Disease
GI Archives

Flash files are smaller than PowerPoint, load faster, and appear uniform across all browsers *Allow 30 seconds to load on high-speed connection
http://www.learningradiology.com/toc/tocorgansystems/tocgi.htm (2 de 2)04/09/2006 1:06:00
http://www.learningradiology.com/toc/tocorgansystems/tocbone.htm
MSK Lectures
= PowerPoint
=Flash
Lecture
Approach to Arthritis Bone Tumors-Cues and Clues Cervical Spine Fractures and Dislocations Pelvic Fractures and Dislocations Soft Tissue Calcifications and Ossification

Flash PowerPoint PowerPoint PowerPoint PowerPoint Flash PowerPoint PDF PDF PDF
MSK Notes
Barton's Fracture Battered Child Syndrome Bennett's Fracture Calcinosis universalis Chance Fracture Charcot arthropathy Charcot foot Child Abuse Chondrosarcoma Colle's Fracture Congenital syphilis Congenital Hip Dysplasia CREST Syndrome DISH Enchondroma Fibrous dysplasia Lunate Dislocation Marfucci's Syndrome Multiple hereditary exostoses Multiple myeloma Nonossifying fibroma Ochronosis Osteochondritis dissecans Osteomyelitis-acute Osteomyelitis-skull Osteopetrosis Paget's Disease Perilunate Dislocation Pigmented Villonodular Synovitis Ping-pong Fracture Pelvic avulsion fractures (graphic) Protrusio acetabuli
http://www.learningradiology.com/toc/tocorgansystems/tocbone.htm (1 de 3)04/09/2006 1:06:03
Frieberg's infraction Gamekeeper's Thumb Giant Cell Tumor Gouty Arthritis Hand-shoulder Syndrome Hand-foot Syndrome Hemangiopericytoma Hemophilia Hip Diseases in Children-table Hyperparathyroidism Lead Poisoning Legg-Calve-Perthe's Disease
Psoriatic arthritis Pyle's disease Radiation Induced Osteosarcoma Renal Osteodystrophy Rolando Fracture Round cell lesions by age (table) Sacroiliitis Slipped Capital Femoral Epiphysis Synovioma Tuberous sclerosis Tumoral calcinosis Volar Plate Fracture
MSK Images
MSK Images-thumbnails Common Hip Abnormalities - Pictorial DDx
MSK Flashcards
Differential Diagnoses in MSK Disease
MSK Case Archives


Flash files are smaller than PowerPoint, load faster, and appear uniform across all browsers *Allow 30 seconds to load on high-speed connection
LearningRadiology- Contents GU
GU Lectures
GU Notes
Acute Pyelonephritis Adrenal adenoma Adult Polycystic Disease Angiomyolipoma Bladder Rupture Emphysematous pyelonephritis Ovarian Carcinoma Placenta-grading (pictorial chart) NEW Renal Infarct Retrocaval Ureter Transitional Cell Carcinoma Ureter-causes of displacement
GU Images
GU Images-thumbnails
GU Flashcards
Differential Diagnoses in GU Disease
GU Archives
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LearningRadiology- Contents GU
http://www.learningradiology.com/toc/tocorgansystems/tocgu.htm (2 de 2)04/09/2006 1:06:04
LearningRadiology - Contents Neuroradiology
Neuro Lectures
http://www.neuroradiologyportal.com/
Neuro Notes
Hemangioblastoma
Neuro Images
Neuro Flashcards
Neuro Archives
http://www.learningradiology.com/toc/tocorgansystems/tocneuro.htm04/09/2006 1:06:07
LearningRadiology.com-Faculty Lectures
Prepared by Adam Guttentag, MD

Imaging Arthritis Basic Brain Imaging Basic Chest Radiology CT Angiography Evaluation of the Solitary Pulmonary Nodule Imaging of Back Pain Large Joint MRI Evaluation of the Mediastinum Evaluation of Pulmonary Thromboembolism Radiology of the Pleura
Prepared by Mindy Horrow, MD

CT Diagnosis of Appendicitis CT in Blunt Abdominal Trauma in Adults CT of Acute, Non-traumatic Aortic Disease Imaging in Pelvic Inflammatory Disease - US and CT Appendicitis: Diagnosis by CT CT in Acute Abdominal Pain Carotid Sonography The Retroperitoneal Spaces: Anatomy and Pathology Related to the Urinary Tract Multislice CT: Principles and Perspectives Ectopic Pregnancy US of Renal Transplantation Unenhanced Helical CT in the Patient with Acute Flank Pain: The Stone Search
http://www.learningradiology.com/toc/tocsubsection/tocfacultylectures.htm (1 de 2)04/09/2006 1:06:09
LearningRadiology.com-Faculty Lectures
Prepared by Susan Summerton, MD

Abdominal Pain: A site-Specific Approach Women's Imaging CT Evaluation of the GI Tract MRI of the Abdomen Radiologic Evaluation of Jaundice Skeletal Trauma Radiology of Pelvic/GU Tract Trauma Evaluation of Flank Pain with CT Scan Radiology of Acute Abdominal Emergencies Hernias Basic Intravenous Urography
http://www.learningradiology.com/toc/tocsubsection/tocfacultylectures.htm (2 de 2)04/09/2006 1:06:09
LearningRadiology - Pictorial Differential Diagnosis
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LearningRadiology - Pictorial Differential Diagnosis
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A. Jones fracture B. Chopart fracture C. Lisfranc fracturedislocation D. Rolando fracture

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A. Smith fracture B. Colles fracture C. Pisiform fracture D. Triquetral fracture
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LearningRadiology.com - Lisfranc fracture dislocation, lis franc, fracture, dislocation, foot, tra...eaching cases, file, teaching file, resident, case, interesting, medical, student, medical student
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Triquetral Fracture
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Fractures of the triquetrum usually occur from forced hyperflexion or as an avulsion injury Next to fractures of the scaphoid, triquetral fractures are the second most common carpal bone to fracture They are frequently seen as dorsal chip fractures only on the lateral projection since the pisiform usually overlies the triquetrum on the frontal projection of the wrist r The body of the triquetrum may also be fractured, usually transversely. Triquetral fractures may be associated with transcaphoid perilunate dislocations of the wrist r The dislocation may have been reduced so a triquetral fracture from the proximal radial aspect of the bone may indicate the presence of a former dislocation Patients will complain of point tenderness on the dorsum of the wrist
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Triquetral fracture. There is a small avulsion from the dorsum of the triquetrum seen only on the lateral projection (red arrow). The pisiform overlies the triquetrum in the AP and oblique views and tends to obscure the fracture (white arrows). For the same photo without the arrows, click here.
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Boerhaave's Syndrome
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Calcinosis universalis
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LearningRadiology- Site Index
Lectures - Most lectures are available in either PowerPoint or Adobe PDF format . High speed internet access is best and PowerPoint's slide show feature works at its best in Internet Explorer 6.0 or later.
Notes - Handout notes from the lectures plus many more sets of notes on various diseases, mostly in chest, cardiac, bone and GI. Images - JPEG images suitable for downloading shown first in thumbnail size. All of the Case of the Week images are eventually available here.
Archives - All previous files are included in their original multiple-choice quiz format. The organ system each represents is indicated so you have the opportunity to choose only those in the area you wish to review.
Flashcards - Pull down lists of differential diagnoses presented in a way that you can quiz yourself.
Most Commons Lists - Drop-down lists of some of the most common causes of various findings, signs and symptoms mostly in the areas of GI, chest, bone and cardiac radiology.
Pictorial Differential Diagnoses - Groups of images categorized by lesions that appear in a similar way or affect the same body part shown side-side-side for comparison.
Quizzes - A series of image-centered, short (5 question) quizzes with immediate feedback on assorted topics for beginning and more advanced learning. A "Best Scores" table is shown and you have the ability to e-mail the quiz and the correct answers back to yourself.
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LearningRadiology- Site Index
"Recognizing Series" - Designed for medical students or those just starting out and intended to introduce fundamental concepts in chest, bone, cardiac and GI radiology, especially. They are intentionally short in duration. All are available in both PowerPoint and Adobe Acrobat formats. Many of the modules contain short quizzes at the end of the exercise for self-testing.
Packets - contain a set of unknown images suitable for medical students. They are used as unknowns in our program so the answers are not posted.
Contact - Contact information, authorship of this website and legal Information are contained here.
General Conventions - site-wide
Clicking on the LearningRadiology.com banner at the top of each page always returns you to the Home Page.
Almost all photos are hyperlinked to a larger image. Click once on the photo to enlarge the image.
The owl graphic indicates additional information related to the same subject is available by clicking on the hyperlink.
"Take Home Point" - the moving-men graphic means there is a "Take Home Point" (an important point) attached to the graphic.
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Most Commons
Bone - the most common:

Bone in the wrist to fracture Bone in the wrist to dislocate Skeletal manifestation of multiple myeloma Bones involved by fibrous dysplasia Cause of protrusio acetabuli Bone involved by chondrosarcoma Site of osteochondritis dissecans Benign bone tumor Solitary, malignant, primary bone tumor Malignant tumor of bone Dislocation of the shoulder Dislocation of the hip Bone tumor to complicate Paget's Disease Parathyroid abnormality leading to 1* Hyperparathyroidism Parathyroid abnormality leading to 2* Hyperparathyroidism Bone involved by osteochondritis dissecans Solitary, benign tumor of the ribs Humeral fracture in a child Metatarsal to undergo stress fracture
Cardiac - the most common:

Cong. Heart Dz in Down's Syndrome Vascular ring Cause of CHF in first 24hrs Cause of CHF in First Week Cause of CHF between 2-6 weeks Cause of CHF from 1-4 months Cause of pericardial effusion Site of aortic rupture Cause of Cyanosis from Heart Dz in Newborn Cause of cyanosis from heart dz in older child Cyanotic heart disease Associated with Right Aortic Arch Congenital cardiac anomaly L-R Shunt Associated with Other Lesions Left-to-right shunt Left-to-right shunt diagnosed in an adult Type of right aortic arch Cause of calcification of LA wall Cause of calcifications of the pulmonary artery Type of ASD Type of VSD Type of TAPVR
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Most Commons
Cardiac tumor Primary cardiac tumor Cardiac malignancy Primary benign heart tumor Tumor of the heart in a child Right Arch Associated with CHD Type of Truncus Arteriosus
Cause of a calcified mitral valve Cause of a calcified mitral annulus Cause of a calcified aortic valve Site of true LV aneurysm Cause of false LV aneurysm Type of Coarctation of Aorta CHD in Down Syndrome
Cause of a pericardial effusion
CHD with highest association of pericardial abnormalities
Site of pulmonic stenosis
Site of rupture of aorta
Chest - the most common:

Type of Carcinoma to cavitate Benign extrapleural mass Histology of mediastinal Hodgkin's Location of bullae in Alpha-1 Antitrypsin Deficiency Location of cysts in Eosinophilic Granuloma Segment of lower lobe most often affected by bronchiectasis
GI - the most common:

Benign Esophageal tumor Malignant Tumor of Esophagus Benign Tumor of Stomach Malignant Tumor of Stomach Tumor of the Small Intestine Benign Tumor of the Small Intestine Malignant Tumor of Small Intestine Tumor of Large Bowel Benign Tumor of the Large Bowel Malignant Tumor of Large Bowel
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Sources of Metastatic Lesions to Stomach Cause of Small Bowel Obstruction Cause of Large Bowel Obstruction Cause of free air Type of intussusception Congenital anomaly of the esophagus
Most Commons
LearningRadiology.com - Case of the Week Index
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22.
Aortic Stenosis Atrial Septal Defect Ebsteins Anomaly Coarctation of the Aorta Constrictive Pericarditis Dissecting Aortic Aneurysm Left Atrial Calcification-Mitral Stenosis Left Ventricular Aneurysm Leriche Syndrome Mitral Stenosis Mirror-image Right Aortic Arch Penetrating Aortic Ulcer Pericardial Effusion Persistent Left Superior Vena Cava Pulmonary Arterial Hypertension Pulmonary Sling Pulmonic Stenosis Right Aortic Arch Ruptured Abdominal Aortic Aneurysm Ruptured Left Ventricular Aneurysm Total Anomalous Pulmonary Venous Return Twiddler's Syndrome
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24.
Acute Pyelonephritis Adrenal Adenoma Adult Polycystic Kidney Disease Angiomyolipoma Bladder Carcinoma Bladder Rupture-Extraperitoneal Bladder Rupture-Intraperitoneal Dermoid Cyst of Ovary Emphysematous pyelonephritis Fibromuscular Dysplasia of Renal Artery Hamartoma of the Breast Nephrocalcinosis, medullary Ovarian Cancer metastases Papillary Necrosis Pelvic Congestion Syndrome Polyarteritis Nodosa Polycystic Ovarian Syndrome Renal infarct Renal Laceration Retrocaval ureter Retroperitoneal Fibrosis Serous Cystadenoma ovary Transitional Cell Carcinoma Uterine Rupture
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1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44.
Asbestos-Related Pleural Disease Aspergilloma Aspiration Bronchopleural fistula Bullous Disease of the Lungs Chilaiditi's Syndrome Congenital Lobar Emphysema Croup Cystic Adenomatoid Malformation Cystic Fibrosis Diaphragmatic Hernia Dressler's Syndrome Epiglottitis Epiphrenic Diverticulum Eventration of diaphragm Hamartoma Lung Histoplasmosis Hyaline Membrane Disease Kartageners syndrome Lipoid Pneumonia Lymphoma Lymphangiomyomatosis Malignant mesothelioma Maltoma lungs Meconium Aspiration Syndrome Misplaced Endotracheal Tube Pericardial Cyst, calcified Pneumococcal Pneumonia Pneumocystis Carinii Pneumonia Pneumomediastinum Pneumothorax (Deep Sulcus Sign) Ping-Pong Ball Plombage Pseudotumor Pulmonary Contusion Pulmonary Laceration Pulmonary Thromboembolism Radiation Pneumonitis Re-expansion Pulmonary Edema Respiratory Distress Syndrome of the Newborn Rounded Atelectasis Round Pneumonia Sarcoid Septic Emboli Sequestration
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43.
Acromioclavicular Separation Ankylosing Spondylitis Anterior Dislocation of the Shoulder Atlanto-axial Subluxation from Rheumatoid Arthritis Atlantoaxial Dislocation - Traumatic Avulsion Fracture-Ischial Tuberosity Burst Fracture of cervical spine Calcinosis Universalis Chance Fracture Charcot Knees Child Abuse CPPD Dermatomyositis Dislocated Clavicle Fibrous Dysplasia Galeazzi Fracture Gamekeepers Thumb Giant Cell Tumor Gouty Arthritis Hemophilia Hereditary Exostoses Hip Fracture-Intertrochanteric Housemaid's Knee (Prepatellar bursitis) Hypertrophic osteoarthropathy Jefferson's Fracture Kienbock's Disease Lead Poisoning Legg-Calve-Perthe's Disease Lipohemarthrosis of the Knee Lisfranc Fracture Dislocation Luxatio Erecta Metastatic Bone Disease Neurofibromatosis, spine Non-ossifying fibroma Ochronosis Osteochondritis dissecans Osteomyelitis Osteosarcoma in Paget's Disease Osteopetrosis Pagets disease Perilunate dislocation Posterior dislocation of the shoulder Posterior dislocation of the hip
45. 46. 47. 48. 49. 50. 51. 52.
Silicosis Subcutaneous Emphysema Tuberculosis of the lungs Teratoma, mediastinal Thyroid Goiter Traction Diverticulum Vanishing tumor Varicella Pneumonia
44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59.
Psoriatic arthritis Pigmented villonodular synovitis (PVNS) Rheumatoid arthritis Rickets-wrists Rickets-knees Rolandos fracture Rugger-Jersey Spine Sickle Cell Disease Slipped Capital Femoral Epiphysis Spondylolytic Spondylolisthesis Stress Fracture of the Tibia Synovial Osteochondromatosis Synovial Sarcoma (synovioma) Triquetral Fracture Tumoral Calcinosis Volar Plate Fracture
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24.
Achalasia Acute Appendicitis Ascariasis Ascites Bezoar Bochdalek hernia Boerhaaves syndrome Budd-chiari syndrome Candida Esophagitis Carcinoma of the Colon Caustic Esophagitis Cecal lipoma Cecal volvulus Crohns disease Diverticulitis Emphysematous Cholecystitis Emphysematous Pancreatitis Esophageal Atresia with/without TEF Esophageal Foreign Body Impaction Esophageal Leiomyoma Esophageal Varices Esophageal Web Gallstones, gas in Gallstone Ileus
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.
Arteriovenous Malformation Choroid Plexus Cysts Discitis Fahrs disease Hemangioblastoma Leptomeningeal Cyst Locked Facets Osteoma-Frontal Sinus Ranula Sialolithiasis in Wharton's Duct Subdural Hematoma Thyroid Ophthalmopathy Toxoplasmosis
25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51.
Gastric Emphysema Gastric Volvulus Hemangioma, Giant Cavernous of Liver Hiatal Hernia with Schatzki's Ring Intussusception Leiomyoma of Esophagus Liver Laceration Lipoma - cecum Lymphoma, Small Bowel Mesenteric Vascular Ischemia Midgut Volvulus Mucocele of appendix Necrotizing enterocolitis Perforated Pharynx Pneumoperitoneum Porcelain Gallbladder Puckered Panniculus Sign Retropharyngeal Air Scleroderma, small bowel Sigmoid Volvulus Small Bowel Obstruction Splenic Laceration Sprue Superior Mesenteric Artery Syndrome Thorotrast Ulcer-Gastric, benign Ulcerative Colitis
Case of the Week Randomizer presents previous Cases of the Week categorized by organ system or modality Home | Lectures | Notes | Images | Flashcards | Case of the Week Archives | | Bone | Cardiac | Chest | GI | Miscellaneous | Med Students | Most Common Lists | Quizzes | Copyright 2006 LearningRadiology.com About Us
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Bone
Causes of Secondary DJD Localized thickening of perisoteum Wormian Bones Permeative pattern Expansile Lesions of Bone For Pelvic Lesions, Think of... For Spine Lesions, Think of... Malignant Lesions-Multiple Sites Causes of Avascular Necrosis Round Cell Lesions Expansile Rib Lesions Lytic Lesions in Children Blastic Lesions in Children Lytic Lesions in Adults Blastic Lesions in Adults Benign Lesions, No Sclerotic Margin
Cardiac
Cardiac Flashcards - 40 cardiac images, flashcard style
Cyanosis with Decreased Vascularity Cyanosis with Increased Vascularity Left to Right Shunts
CHF in Newborn Cardiomegaly with Normal Vasculature
Chest
Acute Alveolar infiltrate Anterior Mediastinal Masses Opacified Hemithorax Chronic Alveolar Disease Bibasilar Interstitial Disease Micronodular Lung Disease Chronic Interstitial Disease Large Cavitary lesions
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Masses with Air Bronchograms Small Cavitary Lung Nodules Lymphangitic Spread to the Lungs Small Calcifications in the Lung Middle Mediastinal Masses Posterior Mediastinal Masses Infiltrates with Effusions Cavities containing Masses
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Multiple Lung Nodules
Masses that Cavitate
GI
Colon Cut-Off Sign Air in the Biliary System Causes of Small Bowel Obstruction Causes of Large Bowel Obstruction
GU
Nephrocalcinosis Unilateral small kidney Unilateral large kidney Bilateral small kidneys Bilateral large kidneys
Miscellaneous
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LearningRadiology.com- About us
About us
LearningRadiology.com was conceived, designed, developed, produced and is maintained in its entirety by William Herring, MD. Dr. Herring is the Vice-Chairman and Radiology Residency Program Director at Albert Einstein Medical Center in Philadelphia, PA, where he has been the residency Program Director for over 20 years. All material on the site was produced by Dr. Herring. Started in June of 2002, the site was originally intended to replace the handout notes that accompanied lectures for the residents and medical students at Albert Einstein. It now contains over 10,000 pages, and it has grown in popularity so that, this year alone, about 20 million pages will be accessed during over 700,000 visits. Despite the dot-com suffix, LearningRadiology.com is non-commercial and non-profit. It is maintained on an outside web host and is produced by Dr. Herring using Microsoft FrontPage. The quiz program, but not the content of the quizzes, is a commercial product called QuickQuiz. All graphics were done by Dr. Herring using Microsoft PhotoDraw and Adobe Photoshop. If you have any comments about the site, please feel free to send them by clicking on the following link: contactus at learningradiology.com
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General Quiz 001 Emergency, Emergency!
You may enter a fictitious name and e-mail address or, if you wish, your own name and e-mail address. The name you choose will be shown in a best scores table. You would include your own email address if you wanted the quiz and its results e-mailed to you. Answer the questions below by selecting the one best answer. Each answer is worth 20 points. Before you do the quiz, why not Check out the latest Quiz Statistics and the Top Scores?
See above Email: See above
Name:
1. Look at the following case. Why is this an emergency? The patient has:
a. b. c.
A tension pneumothorax. An acute pneumonia of the right lung. Had a pulmonary embolism.
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d. e.
A simple pneumothorax. Been shot.
2. This patient came in complaining of severe abdominal pain. Why is this an emergency? The patient has:
a. b. c. d. e.
A ruptured gastric ulcer. A ruptured abdominal aortic aneurysm. Acute appendicitis. Acute renal failure. An abscess in the psoas muscle.
3. This patient had acute abdominal pain after a year-long bout of chronic abdominal pain. Why is this an emergency? The patient has:
a. b. c. d. e.
A ruptured abdominal aortic aneurysm. An enlarged spleen. A pericardial effusion. A ruptured gastric ulcer. Acute appendicitis.
4. This patient became acutely short of breath following surgery. Why is this an emergency? The patient has:
a. b. c. d.
Left lower lobe pneumonia. Acute pulmonary edema. A large pneumothorax. A large pericardial effusion.
e.
A ruptured gastric ulcer.
5. This patient began vomiting after eating pumpkin pie and developed severe chest pain. Why is this an emergency? The patient has:
a. b. c. d. e.
Developed SARS. A ruptured aortic aneurysm. Signs of an acute myocardial infarction. Aspirated the pumpkin pie. The patient has a ruptured esophagus
Score
Chest Quiz 101 Whiteout!
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Name:
1. The patient shown below most likely has:
a. b. c. d. e.
Atelectasis of the left lung A large left pleural effusion A large right pneumothorax Pneumonia in the left lung Unilateral pulmonary edema
a. b. c. d. e.
A large right pleural effusion A large left pneumothorax Atelectasis of the right lung Pneumonia in the right lung Unilateral pulmonary edema
a. b. c. d. e.
A large left pleural effusion A large right pneumothorax Atelectasis of the left lung Pneumonia in the left lung Unilateral pulmonary edema
a. b. c. d. e.
A large left pleural effusion A large right pneumothorax Atelectasis of the left lung because of a mucus plug Pneumonia in the left lung Atelectasis of the left lung because the ETT is too low
5. Why is this hemithorax opaque?
a. b. c. d. e.
There is a large left pleural effusion There is a large right pneumothorax Atelectasis of the left lung because of a mucus plug Pneumonia in the left lung The left lung has been surgically removed
Score
To learn more about normal and abnormal bowel gas patterns, go to Recognizing the Causes of an Opacified Hemithorax
Chest Quiz 102 Tough Starts
You may enter a fictitious name and e-mail address or your own name and e-mail address, if you wish. The name you choose will be shown in a best scores table. You would include your own email address if you wanted the quiz and its results e-mailed to you. Answer the questions below by selecting the one best answer. Before you do the quiz, why not Check out the latest Quiz Statistics and the Top Scores?
(see above) Email: (see above
Name:
1. The patient shown below is a premature newborn. The most likely diagnosis is:
a. b. c. d.
Transient tachypnea of the newborn Congenital lobar emphysema Hyaline membrane disease Cystic adenomatoid malformation
e.
Meconium aspiration syndrome
2. The patient is a 3 month old. What is the most likely diagnosis?
a. b. c. d. e.
Transient tachypnea of the newborn Congenital lobar emphysema Hyaline membrane disease Cystic adenomatoid malformation Meconium aspiration syndrome
3. The patient is a post-mature newborn. What is the most likely diagnosis?
a. b. c.
Transient tachypnea of the newborn Congenital lobar emphysema Hyaline membrane disease
d. e.
Cystic adenomatoid malformation Meconium aspiration syndrome
a. b. c. d. e.
Transient tachypnea of the newborn Congenital lobar emphysema Hyaline membrane disease Cystic adenomatoid malformation Meconium aspiration syndrome
5. The patient is a premature infant with respiratory distress. A film done the next day is normal. What is the most likely diagnosis?
a. b.
Transient tachypnea of the newborn Congenital lobar emphysema
c. d. e.
Hyaline membrane disease Cystic adenomatoid malformation Meconium aspiration syndrome
Score
Abdomen Quiz 202 I'll Drink to That
You may enter a fictitious name and e-mail address or your own name and e-mail address, if you wish. The name you choose will be shown in a "best scores" table. You would include your own email address if you wanted the quiz and its results e-mailed to you. Answer the questions below by selecting the one best answer. Before you do the quiz, why not Check out the latest Quiz Statistics and the Top Scores.
(see above) Email: above) (see
Name:
1. What is the most likely diagnosis in the patient shown below?
a. b. c.
Esophageal varices Esophageal carcinoma Reflux esophagitis
d. e.
Lye stricture Fibrovascular polyp
a. b. c. d. e.
Sprue Scleroderma Crohn's disease Carcinoma of the colon Duodenal hematoma
a. b. c. d. e.
Esophageal varices Esophageal carcinoma Reflux esophagitis Lye stricture Fibrovascular polyp
a. b. c. d. e.
Gastric carcinoma Gastric ulcer Gastric polyp Gastrinoma Gastric emphysema
a. b. c. d. e.
Esophageal varices Esophageal carcinoma Reflux esophagitis Lye stricture Fibrovascular polyp
Score
Abdomen Quiz 203 When the Bowel Breaks
(see above) Email: above) (see
Name:
a. b. c.
Colonic volvulus Colonic polyps Ulcerative colitis
d. e.
Diverticulitis Colonic carcinoma
a. b. c. d. e.
Colonic volvulus Colonic polyps Ulcerative colitis Diverticulitis Colonic carcinoma
a. b. c. d. e.
a. b. c. d.
Colonic volvulus Colonic polyps Ulcerative colitis Diverticulitis
e.
Colonic carcinoma
a. b. c. d. e.
Score
Abdomen Quiz 204 Abdominal Calcifications
Name:
1. What do these calcifications represent?
a. b. c.
Gallstones Pancreatic calcifications Calcified hematoma of the liver
d. e.
Hepatic artery aneurysms Hemangioma
2. This is a 57 year-old female. What is the most likely diagnosis?
a. b. c. d. e.
Iliac artery aneurysms Aortic aneurysm Uterine fibroids Bladder calculi Dermoid cyst of the ovary
3. The patient shown below most likely has?
a. b. c.
Renal artery aneurysms Staghorn calculi of the kidneys Calcifications in the pancreas
d. e.
Renal cell carcinoma Gallstones
a. b. c. d. e.
Gallstones Hepatic artery aneurysm Calcification in the pancreas Renal cell carcinoma Calcification of the gallbladder wall
5. This patient shown below has right lower quadrant pain. What does this calcification most likely represent?
a. b. c. d. e.
Gallstones Appendicolith Uterine fibroids Dermoid cyst of the ovary Peach pit in the colon
Score
To learn more about abdominal calcifications, go to Recognizing Abdominal Calcifications

Abdomen Quiz 205 Air, Air Everywhere!
Name:
a.
Large bowel obstruction
b. c. d. e.
Small bowel obstruction Generalized ileus Localized ileus Normal bowel gas pattern
2. The patient shown below has had abdominal pain for a week. What is the most likely diagnosis?
a. b. c. d. e.
Large bowel obstruction Small bowel obstruction Generalized ileus Localized ileus Normal bowel gas pattern
a. b. c. d. e.
Large bowel obstruction Small bowel obstruction Generalized ileus Localized ileus Normal bowel gas pattern
a.
Large bowel obstruction
b. c. d. e.
Small bowel obstruction Generalized ileus Localized ileus Normal bowel gas pattern
a. b. c. d. e.
Large bowel obstruction Small bowel obstruction Generalized ileus Localized ileus Free intraperitoneal air
Score
To learn more about normal and abnormal bowel gas patterns, go to Recognizing Free Air or Recognizing Obstruction
MSK Quiz 302 Name That Fracture-1
Name: (Optional) Email: (Optional)
1. What person's name is associated with the fracture shown below?
a. b.
Monteggia Bennett
c. d. e.
Jones Colle Smith
a. b. c. d. e.
Monteggia Bennett Jones Colle Smith
a. b. c. d. e.
a. b. c. d. e.
a. b. c. d. e.
Score
MSK Quiz 303 Hot Joints!
You may enter a fictitious name and e-mail address or, if you wish, your own name and e-mail address. The name you choose will be shown in a "best scores" table. You would include your own email address if you wanted the quiz and its results e-mailed to you. Answer the questions below by selecting the one best answer. Each correct answer is worth 20 points. Before you do the quiz, why not Check out the latest Quiz Statistics and the Top Scores?
Name:
a. b.
Osteoarthritis Rheumatoid arthritis
c. d. e.
Septic arthritis Avascular necrosis Gout
2. What is the most likely diagnosis?
a. b. c. d. e.
Osteoarthritis Rheumatoid arthritis Septic arthritis Avascular necrosis Gout
a. b. c. d. e.
a. b. c. d. e.
5. What is the most likely diagnosis?
a. b. c. d. e.
Score
To learn more about the radiologic diagnosis of arthritis, go to An Approach to Arthritis (For Netscape, use this link)
MSK Quiz 305 My Aching Back
You may enter a fictitious name and e-mail address or, if you wish, your own name and e-mail address. The name you choose will be shown in a "best scores" table. You would include your own email address if you wanted the quiz and its results e-mailed to you. Answer the questions below by selecting the one best answer. Before you do the quiz, why not Check out the latest Quiz Statistics and the Top Scores.
(see above) Email: (see above)
Name:
1. The patient shown below most likely has which of the following?
a. b. c. d. e.
Paget's disease Sickle cell disease Ankylosing spondylitis Renal osteodystrophy Metastatic prostate carcinoma
a. b. c. d. e.
a. b. c. d. e.
a. b. c. d. e.
a. b. c. d. e.
Score
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LearningRadiology- Differential Diagnoses in Cardiac Disease
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William Herring, M.D. 2003
Differential Diagnoses In Heart Disease

An Incomplete List
In Slide Show mode, to advance slides, press spacebar or click left mouse button
How to Use This File

And How Not to Use It
Use the bookmarks on the left as cues for the differentials Try to recite the differential without looking Then click on the bookmark for the answers The file can be used like flashcards These lists are not meant to be all-inclusive so please do not consider them as such. If you wish all-inclusive lists of differentials, consult the appropriate textbooks
Nine Lesions Which Produce 75% of All Severe Congenital Heart Lesions In the Neonate
Decreased flow
1. Tetralogy of Fallot 2. Tricuspid Atresia 3. Severe Pulmonic Stenosis 4. Ebsteins
Increased Flow
5. Transposition 6. VSD
Pulmonary venous hypertension

7. Hypoplastic left heart 8. Coarctation of the aorta 9. TAPVR with infradiaphragmatic obstruction
Whats left
Left-to-right shunts ASD PDA Truncus arteriosus
Cyanosis With Decreased Vascularity
Tetralogy Truncus-type IV Tricuspid atresia* Transposition* Ebstein's

* Also appears on DDx of Cyanosis with Vascularity
Cyanosis With Increased Vascularity
Truncus types I, II, III TAPVR Tricuspid atresia* Transposition* Single ventricle
Cardiomegaly with Normal Vasculature
Viral myocarditis Endocardial fibroelastosis Aberrant left coronary artery Cystic medial necrosis Diabetic mother
Impede Return of Flow to Left Heart
CHF In Newborn
Infantile coarctation Congenital aortic stenosis Hypoplastic left heart syndrome Congenital mitral stenosis Cor triatriatum Obstruction to venous return from lungs
TAPVR from below diaphragm
CHF In CHF In Chronologic Sequence Chronologic Sequence
CHF In Newborn
Infantile coarctation Congenital aortic stenosis Hypoplastic Left Heart Syndrome Congenital mitral stenosis Cor triatriatum Obstruction to venous return from lungs
CHF In 2nd-3rd Week
Coarctation of the aorta Interruption of the aortic arch
CHF-later
Coarctation of the aorta adult type
Other Differential Diagnoses
Causes of Left Atrium 6

1. CHF 2. Mitral stenosis 3. Mitral regurgitation 4. Prolapsed mitral valve 5. Papillary muscle dysfunction 6. Left atrial myxoma
Causes of Main Pulmonary Artery 4

1. L R shunt 2. Pulmonary arterial hypertension 3. Pulmonic stenosis 4. Idiopathic dilatation of pulmonary artery
Causes of Prominence of the Thoracic Aorta 7

1. Hypertension (entire) 2. Atherosclerosis (entire) 3. Aortic insufficiency (entire) 4. Aortic stenosis (ascending) 5. Aneurysm (ascending or entire) 6. Coarctation of the aorta (ascending) 7. Aortitis (ascending or entire)
Types of Left-to-Right Shunts 6

Atrial Septal defect Ventricular Septal Defect Patent ductus arteriosus Anomalous pulmonary venous return AV communis Anomalous origin of left coronary artery from pulmonary artery
Causes of Increased Flow Vascularity 6

1. Left-to-right shunts
1. Atrial septal defect 2. Ventricular septal defect 3. Patent ductus arteriosus 4. Total anomalous pulmonary venous return 5. AV communis
2. High-output states
Causes of Pulmonary Arterial Hypertension 4

1. Primary or idiopathic 2. Secondary to
1. Lung disease COPD, fibrosis 2. Pulm. arterial dz arteritis, multiple emboli 3. Chronic hypoxia hi altitude
Causes of Pulmonary Venous Hypertension 8

1. Coarctation of aorta 2. Aortic stenosis 3. Hypoplastic Left Heart syndrome 4. Mitral stenosis-acquired or congenital 5. Left atrial myxoma 6. Cor triatriatum 7. TAPVR from below diaphragm 8. CHF
Causes of Congestive Heart Failure 6

1. Coronary artery disease 2. Hypertension 3. Cardiomyopathy 4. Valvular lesions AS, MS 5. Left-to-right shunts 6. Fluid overload
Causes of Marked of Cardiac Silhouette 3

1. Cardiomyopathy 2. Pericardial Effusion 3. Multiple valve disease
Causes of Cardiomyopathy 6
1. Alcoholism 2. Coronary artery disease 3. Collagen-vascular disease 4. Myocarditis e.g. rheumatic 5. Amyloidosis 6. Nutritional e.g. Beriberi
Causes of Pericardial Effusion 7

1. Viral pericarditis 2. Collagen-vascular disease, e.g. lupus 3. Uremia 4. TB 5. Trauma 6. Post myocardial infarction 7. Mets
Most Commons
Most common cause of CHF in newborn
Hypoplastic left heart syndrome
Most common cause of CHF > 2 weeks

Coarctation of the aorta (infantile form)
Most common cyanotic heart disease

Tetralogy of Fallot
Most common dz associated c R arch

Tetralogy of Fallot
Most Commons
Most common L Most common L
Atrial Septal Defect
R shunt R shunt dxd in adult
Ventricular Septal Defect
Dz most commonly associated c R arch

Truncus arteriosus
Most common congenital cardiac lesion

Bicuspid aortic valve
Most Commons
Most common type of ASD
Ostium secundum
Most common type of VSD

Membranous VSD
Most common type of TAPVR

Supracardiac
Most Commons
Most common cardiac tumor
Metastatic disease, e.g. melanoma
Most common 1 benign heart tumor

Myxoma
Most common 1 tumor of heart in child

Rhabdomyoma
Most Commons
Most common CHD in Downs Syndrome
Atrioventricular canal defects
Most common cause of pericardial effusion

Myocardial infarction with LV failure
CHD most commonly assoc. with pericardial abnormalities

ASD
Uncommon Most Commons

Most common site of coronary stenosis
Right coronary artery
Most common site of true LV aneurysm

Anterolateral and apical walls
Most common cause of false LV aneurysm

Post-myocardial infarction rupture of LV into pericardium
The End
LearningRadiology - Differential Diagnoses in Pulmonary Disease
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Differential Diagnoses In Chest Disease

An Incomplete List
How to Use This File

And How Not to Use It
Use the bookmarks on the left as cues for the differentials Try to recite the differential without looking Then click on the bookmark for the answers The file can be used like flashcards These lists are not meant to be all-inclusive so please do not consider them as such. If you wish all-inclusive lists of differentials, consult the appropriate textbooks
Acute Alveolar infiltrate
1. 2. 3. 4.
Pulmonary edema Pneumonia Aspiration Hemorrhage
Anterior Mediastinal Masses
1. 2. 3. 4.
Thymoma Teratoma Substernal thyroid Lymphoma
Opacified Hemithorax
1. 2. 3. 4.
Atelectasis Pleural effusion Pneumonia Post-pneumonectomy
Pneumomediastinum
1. Ruptured esophagus 2. Ruptured trachea/bronchus 3. Iatrogenic 4. Asthma 5. Pneumoperitoneum
Chronic Alveolar Disease
1. 2. 3. 4.
Alveolar cell ca Alveolar sarcoid Lymphoma Alveolar proteinosis
Large Cavitary Lung Lesions
1. 2. 3.
Abscess Carcinoma TB
Bibasilar Interstitial Disease

1. 2. 3. 4. 5. 6. Bronchiectasis Aspiration DIP Asbestosis Sickle Cell Disease Scleroderma
Upper Lobe Disease
1. TB (2 TB) 2. Silicosis 3. Eosinophilic granuloma 4. Ankylosing spondylitis
Micronodular Lung Disease
1. 2. 3. 4.
Mets Sarcoid Pneumoconiosis Miliary TB
Chronic Interstitial Disease

Pulmonary Fibrosis
1. 2. 3. 4. 5. 6.
Pneumoconiosis Interstitial Pneumonia Granulomatous disease Neoplastic disease Idiopathic fibrosis Collagen vascular disease
Small Cavitary Lung Lesions
1. 2. 3. 4.
Septic emboli Rheumatoid nodules Squamous or transitional cell mets Wegeners Granulomatosis
Lymphangitic Spread to the Lungs

1. 2. 3. 4. 5. 6. Lung ca Breast ca Stomach ca Pancreas ca Laryngeal ca Cervical ca
Multiple Lung Nodules

1. 2. 3. 4. 5. Mets Wegeners granulomatosis Rheumatoid nodules AVMs Septic emboli
Pulmonary Interstitial Edema
1. 2. 3.
CHF Lymphangitic spread Allergic reaction
Shifting Infiltrates
1. 2. 3. 4. 5. Loefflers syndrome ABPA Asthma Polyarteritis Viral pneumonia
Unilateral Hyperlucent Lung
1. 2. 3. 4.
Swyer-James syndrome Pulmonary embolism Pneumothorax Obstructive emphysema
Rapidly Clearing Alveolar Infiltrate
1. Hemorrhage 2. Pulmonary edema 3. Aspiration 4. Pneumococcal pneumonia
Cavitating Pneumonia
1. 2. 3. 4.
Staph Strep TB Gram negative (Klebsiella)
Middle Mediastinal Masses
1. 2. 3. 4.
Lymphadenopathy Aneurysms Esophageal duplication Bronchogenic cysts
Masses with Air Bronchograms
1. 2. 3.
Lymphoma Alveolar cell ca Pseudolymphoma (Maltoma)
Hilar Adenopathy
1. Sarcoid 2. TB 3. Lymphoma 4. Bronchogenic ca 5. Mets
Cavities Containing Masses
1. Aspergillosis 2. Cavitating bronchogenic ca 3. Tuberculosis 4. Hydatid cyst
Infiltrates with Effusion
1. 2. 3. 4.
Staph pneumonia Strep pneumonia TB Pulmonary infarct
Mass+ ipsilateral adenopathy
1. 2. 3.
Bronchogenic ca Lymphoma TB
Solitary Pulmonary Nodule

1. Bronchogenic ca 2. Hamartoma 3. Histoplasmoma 4. TB granuloma 5. Bronchial adenoma 6. Solitary met 7. Round pneumonia 8. Rounded atelectasis
Pleural Effusion
1. 2. 3. 4. 5. 6. 7. 8. 9. CHF Mets Pancreatitis Pulmonary embolism Trauma Empyema Collagen vascular Ovarian tumor (Meigs Syndrome) Chylothorax
Left-sided Pleural Effusion
1. Boerhaaves Syndrome 2. Dissecting aortic aneurysm 3. Pancreatitis 4. Distal thoracic duct rupture
Multiple Small Calcifications
1. 2. 3. 4. 5.
Histoplasmosis Silicosis Chicken pox pneumonia Pulmonary ossification 2 MS Alveolar microlithiasis
Posterior Mediastinal Masses
1. 2. 3.
Neurogenic tumors Lymphadenopathy Extramedullary hematopoesis
Mediastinal Adenopathy
1. 2. 3. 4. 5.
Bronchogenic ca Lymphoma TB Mets Sarcoid
Lung Disease & Rib Destruction
1. 2. 3. 4.
Bronchogenic ca, i.e Pancoast tumor Actinomycosis Blastomycosis Multiple myeloma
Pleural Calcification
1. 2. 3.
Old TB empyema Asbestos exposure Hemothorax
Masses in Cardiophrenic Angle
1. 2. 3.
Sequestration Diaphragmatic hernia Pericardial cyst
Unilateral Pulmonary Edema
1. 2. 3. 4.
Aspiration Disease in other lung, e.g. COPD Postural Rapid expansion of PTX
Reverse Pulmonary Edema
1. 2. 3.
Eosinophilic lung disease, e.g. Loefflers Sarcoid Pulmonary contusions
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LearningRadiology - Differential Diagnoses in Musculoskeletal Disease, MSK, DDX
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Differential Diagnoses in Musculoskeletal Disease

DDX In MSK
I see a disclaimer in your future*
*These differentials are not intended to be all inclusive. Consult a textbook for allinclusive differentials. They are designed as an aid to remembering a few of the most important causes for each of the findings shown.
Diffuse Increase in Bone Density

1. 1 malignancy none 2. 2 malignancy - metastases 3. Non-malignant disease - Pagets Disease 4. Myelosclerosis, e.g. Sickle Cell Anemia 5. Fluorosis 6. Mastocytosis 7. Osteopetrosis 8. Hypervitaminosis D
Diffuse Decrease in Bone Density

1. Osteoporosis
a. Multiple myeloma b. Steroid administration
2. Osteomalacia 3. Hyperparathyroidism 4. Immobilization 5. Osteogenesis imperfecta
Focal Sclerotic Lesion(s)

A. Primary malignancy
1. Osteosarcoma
B. Secondary malignancy
1. Metastases 2. Lymphoma
C. Non-malignant
1. Pagets Disease 2. Bone island(s) 3. Healed fracture(s) 4. Bone infarct(s) 5. Osteoid osteoma
Focal lytic lesion

A. 1 malignancy
1. Myeloma
B. 2 malignancy
1. Metastases
C. Non-malignant
1. Eosinophilic granuloma 2. Brown tumors
Round Cell Lesions

1. Lymphoma and leukemia 2. Ewings sarcoma 3. Multiple myeloma 4. Osteomyelitis 5. Neuroblastoma
Expansile Lesion
1. 1 malignancy Plasmacytoma 2. 2 malignancy - Mets 3. Non-malignant Aneurysmal bone cyst 4. GCT 5. Fibrous dysplasia 6. Brown tumor 7. Enchondroma
Expansile Lesion of Rib

1. 1 malignancy Plasmacytoma 2. 2 malignancy Mets 3. Non-malignant Fibrous dysplasia 4. Chondrosarcoma 5. Enchondroma 6. Eosinophilic granuloma 7. Neurofibromatosis
Blowout Lesion
1. Metastases, esp. kidney, thyroid, lung 2. Giant Cell Tumor 3. Plasmacytoma 4. Chondrosarcoma
Soap-bubbly Lesion
1. 1 Malignancy - Plasmacytoma
1. Chondrosarcoma
2. 3. 4. 5. 6. 7. 8.
2 Malignancy - Mets Non-malignant - Fibrous dysplasia GCT ABC Chondromyxoid fibroma Enchondroma EG
Lesions with Associated Soft Tissue Masses

1. Multiple myeloma 2. Metastases 3. Osteomyelitis 4. Primary malignancies of bone
1. Osteosarcoma 2. Chondrosarcoma 3. Fibrosarcoma 4. Ewings sarcoma
Sclerotic Cortical lesions
1. Osteoid osteoma 2. Brodies abscess 3. Healing stress fracture
Short Thumb
1. Myositis ossificans progressiva 2. Fanconis syndrome 3. Holt-Oram Syndrome
Short 4th Metacarpal
1. Turners syndrome 2. Pseudohypoparathyroidism*
3. Pseudopseudohypoparathyroidism
*Short, obese, retarded, abnormal dentition, corneal opacities, hypocalcemia, hypophosphatemia
Clinodactyly
Inward curvature of 5th finger
1. Downs syndrome 2. Cornelia de Lange syndrome* 3. Carpenters syndrome**
*Retarded, hirsutism, feeble cry, arched palate, small nose, brachycepalic skull ** Acrocephalopolysyndactyly = retardation, hypogonadism, PDA, polysyndactyly
Polydactyly
1. Isolated anomaly 2. Ellis-Van Creveld syndrome* 3. Carpenters syndrome**

*Chondroectodermal dysplasia = pointy teeth, brittle nails, scant hair, accelerated maturation, Wormian bones, shortening of all bones ** Acrocephalopolysyndactyly = retardation, hypogonadism, PDA, polysyndactyly
Syndactyly
Osseous c or s soft tissue fusion
1. Aperts syndrome* 2. Carpenters syndrome 3. Downs syndrome
*Hypertelorism, exopthalmus, underdeveloped sinuses, pseudarthroses, high palate
Erosion - Distal Clavicle
1. Rheumatoid Arthritis 2. Hyperparathyroidism 3. Scleroderma 4. Cleidocranial dysplasia
Protrusio Acetabuli
1. Pagets disease 2. RA 3. Osteomalacia 4. Osteoporosis 5. Mucopolysaccharidosis
Acro-osteolysis
1. Thermal injury, burns, frostbite 2. Scleroderma 3. Hyperparathyroidism 4. Psoriasis 5. Raynauds disease 6. PVC worker
Avascular Necrosis
1. 2. 3. 4. 5. 6. 7. 8. Idiopathic (Legg-Calve-Perthes Disease) Steroid administration Sickle cell anemia Arteritis - collagen-vascular disease Trauma Gauchers Pancreatitis Fat embolism
Hypertrophic Osteoarthropathy
1. Carcinoma of the lung 2. Mesothelioma 3. Chronic lung infection (TB) 4. Chronic liver disease, e.g. cirrhosis 5. Ulcerative colitis
Lesions That Affect The Spine
1. Osteoblastoma 2. Chordoma 3. Aneurysmal bone cysts 4. Metastases
Lesions That Affect The Pelvis
1. Chondrosarcoma 2. Plasmacytoma 3. Chordoma
Posterior Scalloping
1. Neurofibromatosis 2. Achondroplasia 3. Spinal cord tumor (ependymoma)
Anterior Scalloping
1. Aortic aneurysm 2. TB 3. Neurofibroma
Lucent Metaphyseal Bands
1. Normal 2. Leukemia 3. Neuroblastoma 4. TORCH infection
Dense Metaphyseal Bands
1. Normal 2. Lead poisoning 3. Treated leukemia 4. Healing rickets
Bone Within a Bone
1. Osteopetrosis 2. Pagets disease 3. Thorotrast
Chondrocalcinosis
1. Pseudogout 2. Gout 3. DJD 4. Hyperparathyroidism 5. Hemochromatosis 6. Wilsons Disease
Ankylosis of SI Joints
1. Ankylosing spondylitis 2. Psoriasis 3. Reiters syndrome 4. Inflammatory bowel disease 5. TB
Intramedullary Calcification
1. Enchondroma 2. Bone infarct 3. Chondrosarcoma
Thinned Ribs (Ribbon-Ribs)
1. Neurofibromatosis 2. Osteogenesis imperfecta 3. Trisomy 18 4. Gorhams Disease
Wide Ribs
1. Achondroplasia 2. Fibrous dysplasia 3. Rickets (rosary) 4. Marrow packing disorders
1. Thalassemia 2. Mucopolysaccharidosis, esp. Hunters and Hurlers 3. Gauchers disease
Lytic Lesion - Finger

1. Enchondroma 2. Epidermoid inclusion cyst 3. Glomus tumor 4. ABC 5. GCT 6. Met from lung, hepatoma
Wormian Bones
1. Normal 2. Hypothyroidism 3. Downs Syndrome 4. Cleidocranial dysostosis 5. Osteogenesis imperfecta
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LearningRadiology - Recognizing Cardiomegaly
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LearningRadiology-Recognizing an Opacified Hemithorax
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Normal
Mitral regurg Mitral Stenosis L Myxoma
A Is the Left Atrium Enlarged?
If yes, then
Look at the Pulmonary Vasculature
If no, then
Increased
VSD, PDA
B Is the Main Pulmonary Artery Big or Bulbous?
If yes, then Look at the Pulmonary Vasculature
Normal
Pulm. stenosis ASD (VSD)
Increased
If no, then
Pulmonary hypertension Normal Don't Look at Pulmonary Vasculature. Look at Aorta Ascending dilated Whole Ao Dilated
Idiopathic (1)
Cardiomyopathy
C Is the Main Pulmonary Artery Segment Concave?
If yes, then
Ao Stenosis Ao regurg HBP
If no, then
D Is the Heart Dilated or DeltaShaped?
If yes, then
Cardiomyopathy Pericardial Effusion Mult. valve dz
Copyright 2000 William Herring, MD
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Case of the Week Archive - 2002
2002 2003 20042005 2006 Archives Click here for Index of all Cases of the Week
Click here for Case of the Week Randomizer which presents previous Cases of the Week categorized by organ system or modality
Case of Week 001 July 7-14, 2002 Case of Week 002 July 15-21, 2002 Case of Week 003 July 22-28, 2002 Case of Week 004 July 29-Aug. 4, 2002 Case of Week 005 August 5-11, 2002
Right Aortic Arch Case of Week 006 August 12-17, 2002
Aspergilloma Case of Week 007 August 18-24, 2002
Neurofibromatosis Case of Week 008 August 25-31, 2002
Sickle Cell Disease Case of Week 009 September 1-7, 2002
Subdural Hematoma Case of Week 010 September 8-14, 2002
Lipoid Pneumonia Case of Week 011 September 15-21, 2002
Caustic Esophagitis Case of Week 012 September 22-28, 2002
Gouty Arthritis Case of Week 013 Sept. 29-Oct. 5, 2002
Thyroid Goiter Case of Week 014 October 6-12, 2002
Atrial Septal Defect Case of Week 015 October 13-19, 2002
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Case of the Week Archive - 2002
Dermoid Cyst of Ovary Case of Week 016 October 20-26, 2002
Ascariasis Case of Week 017 Oct. 27-Nov. 2, 2002
Dermatomyositis Case of Week 018 November 3-9, 2002
Fibrous Dysplasia Case of the Week 019 November 10-16, 2003
Thorotrast Case of the Week 020 November 17-23, 2003
TAPVR Case of Week 021 November 24-30, 2002
Maltoma Case of Week 022 December 1-7, 2002
Fahr's Disease Case of Week 023 December 8-14, 2002
Re-expansion Pulmonary Edema Case of Week 024 December 15-21, 2002
Adult Polycystic Disease Case of Week 025 December 22-28, 2003
Cystic Adenomatoid Malformation Case of Week 026 Dec. 29, 2002-Jan. 4, 2003
Tumoral Calcinosis
Varicella Pneumonia
Diverticulitis
Ochronosis
Jump to 2003 Archives
Jump to 2004 Archives
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2002 2003 20042005 2006 Archives Index of all Cases of the Week
LearningRadiology.com Case of the Week Archive- 2003
Case of Week 026 Dec. 29, 02-Jan. 4, 2003 Case of Week 027 Jan. 5-11, 2003 Case of Week 028 Jan. 12-18, 2003 Case of Week 029 Jan. 19-25, 2003 Case of Week 030 Jan. 26-Feb. 1, 2003
Congenital Lobar Emphysema Case of Week 031 Feb. 2-8, 2003
Crohn's Disease Case of Week 032 Feb. 9-15, 2003
Osteopetrosis Case of Week 033 Feb. 16-22, 2003
Ebstein's Anomaly Case of Week 034 Feb. 23-March 1, 2003
Polyarteritis Nodosa Case of Week 035 March 2-8, 2003
Non-ossifying Fibroma Case of Week 036 March 9-15, 2003
Radiation Pneumonitis Case of Week 037 March 16-22, 2003
Charcot Knees Case of Week 038 March 23-29, 2003
Gastric Emphysema Case of Week 039 March 30-Apr. 5, 2003
Ruptured AAA Case of Week 040 April 6-12, 2003
Hereditary Exostoses Case of Week 041 April 13-19, 2003
Pulmonic Stenosis Case of Week 042 April 20-26, 2003
Round Pneumonia Case of Week 043 April 27-May 3, 2003
Boerhavve's Syndrome Case of Week 044 May 4-10, 2003
Giant Cell Tumor Case of Week 045 May 11-17, 2003
Sprue Case of Week 046 May 18-24, 2003
Pulmonary Sling Case of Week 047 May 25-31, 2003
PCP Case of Week 048 June 1-7, 2003
Osteomyelitis Case of Week 049 June 8-14, 2003
Budd-Chiari Syndrome Case of Week 050 June 15-21, 2003
PVNS Case of Week 051 June 22-28, 2003
Ovarian ca mets Case of Week 052 June 29-Jul. 5, 2003
Dissecting Aneurysm Case of Week 053 July 6-12, 2003
Ping-pong Ball Plombage Case of Week 054 July 13-19, 2003
Rugger-Jersey Spine Case of Week 055 July 20-26, 2003
Hamartoma Case of Week 056 July 27-Aug. 2, 2003
Scleroderma Case of Week 057 August 3-9, 2003
Tuberculosis Case of Week 058 August 10-16, 2003
Midgut Volvulus Case of Week 059 August 17-23, 2003
Hemophilia Case of Week 060 August 24-30, 2003
Diaphragmatic Hernia Case of Week 061 Aug, 31-Sept. 6, 2003
Ruptured Aneurysm Case of Week 062 September 7-13, 2003
Cystic Fibrosis Case of Week 063 September 14-18, 2003
Angiomyolipoma Case of Week 064 September 19-28, 2003
Psoriatic Arthritis Case of Week 065 Sept. 28-Oct. 4, 2003
Persistent Left SVC
Acute Pyelonephritis
Acute Appendicitis
Malignant Mesothelioma
Paget's Disease
Case of Week 069 Oct. 24-Oct. 31, 2003
Case of Week 070 Oct. 31-Nov. 8, 2003
Adrenal Adenoma Case of Week 071 November 9-15, 2003
Kartagener's Syndrome Case of Week 072 November 16-22, 2003
Splenic Laceration Case of Week 073 November 23-29, 2003
Serous Cystadenoma Case of Week 074 Nov. 30-Dec. 6, 2003
Rolando Fracture Case of Week 075 December 7-13, 2003
Bronchopleural Fistula Case of Week 076 December 14-20, 2003
Mitral Stenosis Case of Week 077 December 21-27, 2003
Mucocele of Appendix Case of Week 078 Dec. 28, 2003-Jan. 3, 2004
Perilunate Dislocation
Small Bowel Lymphoma
Jump to 2002 Archives Jump to 2004 Archives Index of all Cases of the Week
Eventration Gamekeeper's Thumb Sarcoidosis
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Case of Week 079 Jan. 4-10, 2004 Case of Week 080 Jan. 11-17, 2004 Case of Week 081 Jan. 18-24, 2004 Case of Week 082 Jan. 25-31, 2004 Case of Week 083 Feb. 1-7, 2004
Liver Laceration Case of Week 084 Feb. 8-14, 2004
Teratoma Case of Week 085 Feb. 15-21, 2004
Hodgkin's Disease Case of Week 086 Feb. 22-28, 2004
Lead poisoning Case of Week 087 Feb. 29-March 6, 2004
Silicosis Case of Week 088 March 7-13, 2004
Candida Esophagitis Case of Week 089 March 14-20, 2004
Porcelain Gallbladder Case of Week 090 March 21-27, 2004
Renal Laceration Case of Week 091 March 28-April 3, 2004
Sigmoid Volvulus Case of Week 092 April 4-10, 2004
Rickets Case of Week 093 April 11-17, 2004
Meconium Aspiration Case of Week 094 April 18-24, 2004
Constrictive Pericarditis Case of Week 095 April 25-May 1, 2004
Esophageal Varices Case of Week 096 May 2-8, 2004
Hyaline Membrane Disease Case of Week 097 May 9-15, 2004
Intussusception Case of Week 098 May 16-22, 2004
Penetrating Aortic Ulcer Case of Week 099 May 23-29, 2004
Emphysematous Pyelonephritis Case of Week 100 May 30-June 5, 2004
Sialolithiasis Case of Week 101 June 6-12, 2004
Transitional Cell Ca Case of Week 102 June 13-19, 2004
Lymphangiomyomatosis Case of Week 103 June 20-26, 2004
Pulmonary Arterial Hypertension Case of Week 104 June 27-July 3, 2004
Achalasia Case of Week 105 July 4-10, 2004
Extraperitoneal Bladder Rupture Case of Week 106 July 11-17, 2004
CPPD Case of Week 107 July 18-24, 2004
Slipped Capital Femoral Epiphysis Case of Week 108 July 25-31, 2004
Legg-Calve-Perthe's Disease Case of Week 109 August 1-7, 2004
Posterior Dislocation Case of Week 110 August 8-14, 2004
Free air Case of Week 111 August 15-21, 2004
Bochdalek Hernia Case of Week 112 August 22-28, 2004
Epiglottitis Case of Week 113 August 29-Sept. 4, 2004
Child Abuse Case of Week 114 September 5-11, 2004
Hemangioblastoma Case of Week 115 September 12-18, 2004
Volar Plate Fracture Case of Week 116 September 19-25, 2004
Pericardial Effusion Case of Week 117 Sept 26-Oct 2, 2004
Mesenteric Ischemia Case of Week 118 October 3-9, 2004
Synovial sarcoma Case of Week 119 October 10-16, 2004
LV Aneurysm Case of Week 120 October 17-23, 2004
Housemaid's Knee Case of Week 121 October 24-30, 2004
Emphysematous Pancreatitis Case of Week 122 Oct. 31-Nov. 6, 2004
Aortic Stenosis Case of Week 123 November 7-13, 2004
Arteriovenous Malformation Case of Week 124 November 14-20, 2004
Osteochondritis Dissecans Case of Week 125 November 21-27, 2004
Hypertrophic Osteoarthropathy Case of Week 126 Nov. 28-Dec. 4, 2004
Deep Sulcus Sign Case of Week 127 December 5-11, 2004
Bilateral Locked Facets Case of Week 128 December 12-18, 2004
Gas in Gallstones Case of Week 129 December 19-25, 2004
Gastric Volvulus Case of Week 130 Dec. 26, 2004-Jan. 1, 2005
Perforated Pharynx
Lipohemarthrosis
Coarctation of the Aorta
Jump to 2003 Archives Jump to 2005 Archives

Misplaced Endotracheal Tube Retrocaval Ureter
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Case of Week 131 Jan. 2-8, 2005 Case of Week 132 Jan. 9-15, 2005 Case of Week 133 Jan. 16-22, 2005 Case of Week 134 Jan. 23-29, 2005 Case of Week 135 Jan. 30-Feb. 5, 2005
Emphysematous Cholecystitis Case of Week 136 Feb. 6-12, 2005
Pneumomediastinum Case of Week 137 Feb. 13-19, 2005
Right Aortic Arch Case of Week 138 Feb. 20-26, 2005
Ankylosing Spondylitis Case of Week 139 Feb. 27-March 5, 2005
Renal Infarct Case of Week 140 March 6-12, 2005
Septic Emboli Case of Week 141 March 13-19, 2005
Esophageal Atresia Case of Week 142 March 20-26, 2005
AC Separation Case of Week 143 March 27-April 2, 2005
Esophageal Web Case of Week 144 April 3-9, 2005
Discitis Case of Week 145 April 10-16, 2005
Twiddler's Syndrome Case of Week 146 April 17-23, 2005
Osteoblastic Metastases Case of Week 147 April 24-30, 2005
Dressler's Syndrome Case of Week 148 May 1-7, 2005
Chilaiditi's Syndrome Case of Week 149 May 8-14, 2005
Choroid Plexus Cysts Case of Week 150 May 15-21, 2005
Ranula Case of Week 151 May 22-28, 2005
Superior Mesenteric Artery Syndrome Case of Week 152 May 29-June 4, 2005
Puckered Panniculus Sign Case of Week 153 June 5-11, 2005
Paget's with Osteosarcoma Case of Week 154 June 12-18, 2005
Gallstone Ileus Case of Week 155 June 19-25, 2005
Hamartoma of the Breast Case of Week 156 June 26-July 2, 2005
Cecal volvulus Case of Week 157 July 3-9, 2005
Impacted Chicken Bone Case of Week 158 July 10-16, 2005
Thyroid Ophthalmopathy Case of Week 159 July 17-23, 2005
Croup Case of Week 160 July 24-30, 2005
Necrotizing Enterocolitis Case of Week 161 July 31-August 6, 2005
Galeazzi Fracture Case of Week 162 August 7-13, 2005
Bezoar Case of Week 163 August 14-20, 2005
Pseudotumor Case of Week 164 August 21-27, 2005
Rounded Atelectasis Case of Week 165 August 28-Sept. 3, 2005
Rheumatoid Arthritis Case of Week 166 September 4-10, 2005
Cecal Lipoma Case of Week 167 September 11-17, 2005
Medullary Nephrocalcinosis Case of Week 168 September 18-24, 2005
Pulmonary Embolism Case of Week 169 Sept. 25-Oct. 1, 2005
Papillary Necrosis Case of Week 170 October 2-8, 2005
Leptomeningeal Cyst Case of Week 171 October 9-15, 2005
Pulmonary Contusion Case of Week 172 October 16-22, 2005
Toxoplasmosis Case of Week 173 October 23-29, 2005
Cavernous Hemangioma of Liver Case of Week 174 Oct. 30-Nov. 5, 2005
Anterior Dislocation Case of Week 175 November 6-12, 2005
Ulcerative Colitis Case of Week 176 November 13-19, 2005
Stress Fracture Case of Week 177 November 20-26, 2005
Sequestration Case of Week 178 Nov. 27-Dec. 3, 2005
Fibromuscular Dysplasia Case of Week 179 December 4-10, 2005
Kienbock's Disease Case of Week 180 December 11-17 2005
Carcinoma of the Colon Case of Week 181 December 18-24, 2005
Atlanto-axial Subluxation Case of Week 182 December 25-31, 2005
Bladder Carcinoma
Pelvic Congestion Syndrome
Subcutaneous Emphysema
Back to 2004 Archives Ahead to 2006 Archives

Rickets-knees Rickets-wrists
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183
A. Tuberculosis B. Klebsiella pneumonia C. Pneumocystis pneumonia D. Pneumococcal pneumonia
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A. Malignant gastric ulcer B. Gastric diverticulum C. Benign gastric Ulcer D. Zollinger-Ellison Syndrome
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A. Calcific pericarditis B. Calcified ventricular aneurysm C. Calcified myocardial infarct D. Calcified left atrium

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186
A. Fibroids B. Intussusception C. Uterine rupture D. Intraperitoneal bladder rupture

24 year-old post-partum female with vaginal bleeding
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LearningRadiology.com - Pneumoccocal,pneumonia,streptococcus,pneumoniae,gram,positive,negative,staph,strep,aerobacter,bacteroides
Return to Case
Pneumococcal Pneumonia
Gram Positive Pneumonias

Pneumococcal Pneumonia
q
Most common gram positive pneumonia 90% community acquired Organism: streptococcus pneumoniae Usually found in compromised hosts, elderly, debilitated Most often types 8, 4, 5 and 12 Type 3 is especially fatal to elderly Sicklers are particularly prone to pneumococcal pneumonia Produces inflammatory edema in the alveoli which spreads via pores of Kohn to more lateral alveoli
X-ray
Extensive infiltrate usually abutting pleural surface Prominent air bronchograms (DDX: Staph has no air bronchogram) Organism is aspirated into the lungs from the upper airways so it shows a predilection for lower lobes
Does not respect segmental boundaries Resolution begins promptly with antibiotics frequently within 24 hours
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Pneumococcal pneumonia produces consolidation in the right upper lobe with multiple air bronchograms (black branching structures) present since the spaces surrounding the air-filled bronchi normally contain air but now are filled with inflammatory exudate. There is no cavitation, the disease is in the lower lobe and it contains air bronchograms, all characteristics of pneumonia caused by Streptococcus Pneumoniae (formerly known as Diplococcus Pneumoniae) Click here for this photo enlarged
q
DDX for alveolar infiltrates with clearing in 24 hours includes r Hemorrhage into lungs, r Pulmonary edema r Pneumococcal pneumonia r Aspiration
Staph Aureus Pneumonia

q
Most common bronchopneumonia Overwhelming majority hospital-acquired Most common cause of death during influenza epidemics Rarely develops in healthy adults Hemolyzes blood agar
r
Coagulase positive
Its ability to produce pathology in humans is due to its production of coagulase Produces its pathologic reaction in the conducting airways
X-ray
Rapid spread through the lungs Empyema, especially in children No air bronchogram Pneumothorax
r
Pyopneumothorax
Abscess formation Bronchopleural fistula In children

Rapidly developing lobar/multilobar consolidation Pleural effusion (90%) Pneumatocoele In adults Patchy bronchopneumonia of segmental distribution, frequency bilateral May be associated with atelectasis since airways are filled (not so with pneumococcal) Pleural effusion (50%)
Streptococcus Pyrogenes Pneumonia

q
Most common in winter

r
Only 5% of bacterial pneumonias
Group A Beta hemolytic strep Predisposed: Newborns and following measles
X-ray
Looks like staph pneumonia but with less of a tendency to produce pneumatocoeles Almost always in the lower lobes Patchy bronchopneumonia Empyemas do form Complications:
Bronchiectasis Lung abscess Glomerulonephritis
Associated with delayed onset of diaphragmatic hernias in newborns
Gram Negative Pneumonias

Pseudomonas Aeruginosa
q
Gram negative rod Frequently hospital acquired Affects patients with COPD, CHF alcoholism, kidney disease, those with trachs Frequently related to use of inhalators or nebulizers Many patients are on multiple antibiotics and/or steroids
X-ray
Resembles staph pneumonia Predilection for the lower lobes Usually affects both lungs Has multiple small lucencies within it Lung abscess greater than 2 cm may also occur Widespread nodular shadows is another manifestation
Klebsiella, Enterobacter, Serratia

q
Encapsulated, gram negative rods Most are hospital acquired Most are chronic alcoholics
Aspirated into lungs so most are unilateral and right sided
X-ray
q
Produces excessive amounts of inflammatory exudate which cause the affected lung to gain volume and the fissures to bulge
Abscess and cavity formation are common Pleural effusion and empyema are common May result in gangrene of the lung where massive pieces of lung tissue fall into an abscess cavity Serratia marcescens may cause bronchopneumonia
Anaerobic Organisms
Frequently from aspiration of gastric contents Organisms include Bacteroides melaninogenicus, B. fragilis
X-ray
q
Almost always lower lobes Frequently right sided Homogeneous consolidation About 70% will have pleural involvementeffusion, empyemawhich may progress very rapidly Half develop abscesses
LearningRadiology.com - Gastric ulcer,stomach,benign,lesser,curve,curvature,Hampton's,line,UGI,upper GI,barium,upper gastrointestinal,exam
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Gastric Ulcers
Causes
Stress Burns=Curling ulcer Cerebral disease=Cushing ulcer Uremia Steroid therapy Hyperparathyroidism (25% have ulcer disease)
Other facts
Multiple in 2-8% Coexistent duodenal ulcer disease in 5-42%; duodenal:gastric ratio=3:1 Multiple postbulbar duodenal ulcers should suggest Zollinger-Ellison
Location
Lesser curvature aspect of body and antrum usually for benign ulcers Benign ulcers also occur on posterior wall; not usually anterior wall May be found in proximal half of stomach in geriatric patient Almost all lesser curvature gastric ulcers <1cm are benign Greater curvature benign ulcers are associated with considerable mass effect which erroneously leads to conclusion of malignancy
Two prerequisites for diagnosis of an ulcer

Collection Persistent
Radiographic Signs of a benign gastric ulcer
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Ulcer crater-collection of barium on dependent surface which usually projects beyond anticipated wall of stomach in profile (penetration) Hamptons line-1 mm thin straight line at neck of ulcer in profile view which represents the thin rim of undermined gastric mucosa
Benign. lesser curvature gastric ulcer. Red arrows point to Hampton's Line, a thin, straight line at neck of ulcer in profile view which represents the thin rim of undermined gastric mucosa. The blue arrows point to the ulcer mound, a smooth, sharply delineated soft-tissue mass surrounding a benign ulcer. Note how the ulcer projects beyond the confines of the expected wall of the stomach. Click here for this photo without the arrows Ulcer collar-smooth, thick, lucent band at neck of ulcer in profile view representing thicker rim of edematous gastric wall Ulcer mound-smooth, sharply delineated tissue mass surrounding a benign ulcer Ring shadow-thin rim of contrast which represents an ulcer on the non-dependent surface of an aircontrast study Thickened folds radiating directly to the base of the ulcer en face
Healing
Most gastric ulcers clear completely in 6-8 weeks. With healing, ulcer decreases in size and is more likely to appear linear Radiating folds become more prominent and extend to crater Between 50-90% of healed gastric ulcers produce visible scars on Double Contrast study
Radiographic signs of malignant ulcers

Ulcer projects within the anticipated wall of the stomach Ulcer is eccentrically located within the ulcer mound Irregularly shaped ulcer crater Nodular ulcer mound Abrupt transition between normal and abnormal mucosa several cms away from the ulcer crater Rigidity, lack of distensibility and lack of changeability Associated large mass Carmen meniscus sign-a relatively shallow gastric ulcerating malignancy projecting as an ulcer which is always convex inwards to the lumen and which does not project beyond the wall=Kirklin meniscus complex
Complications of ulcer disease

Bleeding is slightly more common in the duodenum than the stomach o About 17% of all ulcers are complicated by bleeding o A filling defect in the ulcer crater may represent a blood clot Gastric outlet obstruction is less common than bleeding (5%) o Stomach may have to be suctioned to get good study o Benign ulcer disease at the pylorus is a more likely to cause gastric outlet obstruction than ca Perforation in 5-11% is more common in duodenal than gastric ulcers o Most gastric perforations are from lesser curve ulcers o Free air is not detected by x-ray in 25-35% of perforated duodenal ulcers Penetration is the extension of the ulcer beyond the serosa in to adjacent structures o Pancreas is most common site, but also biliary tree, colon
LearningRadiology.com - Mitral Stenosis,calcified,left,atrial,atrium,wall,hypertension,chronic,valve,stenosis,mitral
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Calcification of Left Atrium
General considerations o Calcification of left atrium relatively common finding in patients with long-lasting rheumatic valve disease o Massive calcification of the left atrial walls (porcelain atrium) is rare condition with implications for mitral valve surgery (see below) o Massive calcification of the left atrium predominantly affects women (3/4 of cases) o Almost always associated with rheumatic mitral stenosis o Most patients have experienced long-term symptoms (more than 15 years) o Most patients have previously undergone mitral valve operations Almost all have atrial fibrillation o With an average duration of 10 years Location o Usually spares the interatrial septum
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Calcification of left atrial wall in long-standing mitral stenosis. Upper photo: The left atrium (black arrows) is located in the center of the heart posteriorly. The anterior wall of the left atrium is calcified in this photo (see inset in lower photo), a finding usually found in patients with chronic mitral stenosis who have already had atrial fibrillation and a mitral valve replacement. There is a prosthetic mitral valve present (blue arrows). The patient had mitral stenosis for 23 years. Click here for this photo without the arrows
Patterns of calcification o Type A Calcification in the left atrial appendage only Underlying lesion is most commonly mitral stenosis Almost always associated with thrombus in the appendage o Type B Free wall of the left atrium and mitral valve are calcified Indicates advanced mitral stenosis o Type C Small area of calcification is confined to the posterior wall of the LA Results from a jet lesion because of mitral regurgitation Called a McCollum patch Treatment o Surgical technique during interventions for valvular substitution are difficult with calcification of the wall o Dislodgement of thrombus from the left atrium during surgery can result in cerebral embolism and uncontrollable hemorrhage if the left atrium is entered through the calcified region This is because of wall rigidity o Endoatriectomy with mitral valve replacement is the currently accepted corrective procedure For more on Mitral Stenosis, click here
References Coconut Atrium: Transmural Calcification of the Entire Left Atrium Carlos Del Campo, MD, Paul Weinstein, MD, Constantine Kunnelis, MD, Peter DiStefano, RDCS, RVT,* and Gloria M. Ebers, RT, CVT* Texas Heart Institute J. 2000; 27(1): 4951. Copyright 2000 by the Texas Heart Institute, Houston eMedicine Cardiac Calcifications Sohail G Contractor, MD with Pierre D Maldjian, MD, Mysore Seetharaman, MD, Hani H Abu-Judeh, MD, Farid Thanawala, MD
LearningRadiology.com - Uterine rupture,uterus,perforation,birth,trauma,delivery,labor,induction
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Uterine Rupture
General o Most common in patients with previous cesarean delivery scars Rupture in the absence of a previous scar is uncommon o Uterine trauma may occur following very prolonged or vigorous labor Especially if patient has relative or absolute cephalopelvic disproportion, and Uterus has been stimulated with oxytocin or prostaglandins o Trauma may result secondary to attempts to remove a retained placenta manually or with instrumentation o Location Corpus with rupture before onset of labor Lower uterine segment during labor Risk factors o Patients with prior classic hysterotomy have higher rate of uterine rupture in subsequent pregnancies Those who have had 2 or more hysterotomies o Those who are treated with prostaglandin agents and have undergone a previous caesarian have highest risk o Those who undergo induction of labor have small increased risk Clinical findings o Acute abdominal pain o Popping sensation o Palpation of fetal parts outside of the confines of the uterus o Repetitive or prolonged fetal heart rate deceleration o Vaginal bleeding early post-partum hemorrhage Diagnosis is clinical o Ultrasound may be useful if immediately available
http://www.learningradiology.com/archives06/COW%20186-Uterine%20Rupture/uterinerupcorrect.htm (1 de 4)04/09/2006 1:19:33
Uterine rupture. Contrast-enhanced CT scan through the pelvis demonstrates the non-involuted uterus with a large discontinuity representing the rupture in the right posterolateral wall (blue arrow). There is a considerable amount of blood (red arrow) in the pelvis. The pelvic veins are dilated from the recent pregnancy. Click here for this photo without the arrows
Treatment o Presence of uterine rupture dictates laparotomy be performed o Treatment consists of immediate cesarean delivery with probable hysterectomy. o Repair of uterus may be possible in some cases Prognosis o 2-20% maternal mortality o 10-25% fetal mortality
eMedicine
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A. Aortic aneurysm B. Extraperitoneal bladder rupture C. Uterine rupture D. Intraperitoneal bladder rupture
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A. Hangman's fracture B. Teardrop fracture C. Jefferson fracture D. Clay shoveler's fracture

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A. Pregnancy B. Serous cystadenomas C. Stein-Leventhal Ovaries D. Endometriosis

Submitted by Ryan Smith, MD
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A. Ulcer B. Leiomyoma C. Diverticulum D. Barrett's esophagus

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LearningRadiology.com - Bladder rupture,intraperitoneal,urinary,trauma,perforation,extraperitoneal
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Intraperitoneal Bladder Rupture
q q
Can be secondary to traumatic or iatrogenic injury Five types of rupture r Type I: Bladder contusion s Most common form s Results from incomplete tear of bladder mucosa s Cystography is normal
r
Type II: Intraperitoneal rupture s Results from trauma to lower abdomen when bladder is distended s Because bladder dome is weakest portion, it ruptures most easily s Contrast is then seen in the paracolic gutters and between loops of small bowel Type III: Interstitial injury-rare s Caused by a tear of the serosal surface s Mural defect without extravasation will be seen Type IV: Extraperitoneal s Almost always associated with pelvic fractures s Usually close to base of bladder anterolaterally s Subdivided into q Simple, with extravasation limited to perivesical space q Complex, with extravasation extending to thigh, scrotum or perineum Type V: Combined extra- and intraperitoneal rupture
Extraperitoneal bladder rupture is the most common type r Occurs in 80% of bladder rupture cases r Extraperitoneal bladder rupture generally secondary to adjacent pelvic fracture or an avulsion tear at fixation points of puboprostatic ligaments Intraperitoneal bladder rupture
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r r
Usually iatrogenic or secondary to penetrating injury Blunt trauma more likely to result in intraperitoneal rupture in children than in adults s Because the pediatric bladder is more intraperitoneal in location. s The adult bladder dome remains mostly extraperitoneal q Blunt trauma in an adult can result in intraperitoneal rupture only if the bladder is fully distended Imaging findings s Contrast flows into paracolic gutters s Contrast outlining small bowel loops
Intraperitoneal bladder rupture. Note the extraluminal contrast (red arrows) outside the confines of the normal bladder and spreading into the peritoneal cavity. There is contrast in the left paracolic gutter (yellow arrow), not within the bowel. The intrarenal collecting systems and ureters are visualized because the patient had a contrast enhanced CT done moments earlier. Click here for this photo without the arrows
q
While extraperitoneal bladder rupture can be treated conservatively, intraperitoneal bladder rupture requires surgical repair Highest morbidity and rupture mortality is associated with intraperitoneal rupture because of potential for development of chemical peritonitis Imaging findings r Diagnostic evaluation of bladder rupture includes voiding cystourethrography (VCUG) or CT scan s VCUG q Voiding cystourethrography historically been preferred contrast enhanced
study for diagnosis of bladder rupture q Bladder needs to be fully distended and evaluation of a post-voiding film essential Plain film: q "Pear-shaped" bladder q Paralytic ileus q Upward displacement of ileal loops q Flame-shaped contrast extravasation into perivesical fat r Best seen on postvoid films r May extend into thigh / anterior abdominal wall q US r "Bladder within a bladder" = bladder surrounded by fluid collection
For a photo of an extraperitoneal bladder rupture click here
Amersham Health Encyclopedia
LearningRadiology.com - Jefferson's Fracture,C2,spine,trauma,fracture,burst,ring,broken,neck,atlas,axis,traumatic
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Jefferson Fracture
Burst fracture of the ring of C1 Typically caused by an axial-loading force on the occiput of the head Classically, it involves fractures of the anterior arch of C1 on both the right and left sides and the posterior arch of C1 on both the right and left sides (4 fractures) o But fracture variants may include two or three-part fractures There is usually no associated neurologic deficit as the ring of C1 widens when it fractures limiting cord compression Mechanism o Original description in 1920 by Sir Geoffrey Jefferson, an English neurologist and neurosurgeon, in Fracture of the atlas vertebra: report of four cases, and a review of those previously recorded that appeared in the British Journal of Surgery o He described the role of axial compression Today, this most frequently occurs when diving into shallow water, the head strikes an obstacle (or the bottom of the pool) and the force is transmitted to the cervical spine It may also occur from motor vehicle accidents in which the head is thrown forcefully against the windshield, frequently producing both hyperextension and compression Another mechanism is falling onto the head from a height Associated injuries o Approx 1/3 of Jefferson fractures are associated with a fracture of C2 Clinical findings o Patients usually complain of upper neck pain following trauma o Neurological examination is usually normal Imaging findings o Conventional radiography Open-mouth (odontoid) view is the most revealing Classically there is bilateral, lateral offset of C1 on C2 Lateral view: May show prevertebral soft tissue swelling anterior to C1 Pre-dentate space (distance between the anterior tubercle of C1 and the dens) may be widened to greater than 3 mm if there is damage to the transverse ligament
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CT Scan Demonstrates the number of fractures, their locations and degree of displacement of fragments Treatment o Depends in part on whether there is damage to the transverse ligament and the degree of offset of C1 on C2 Treatments include collar or brace for 3 months all the way through cranial traction o
Jefferson Fracture. There is bilateral offset of both the right and left lateral masses of C1 relative to the lateral masses of C2 on the open-mouth cervical spine view (above-white arrows). This indicates a bursthttp://www.learningradiology.com/archives06/COW%20188-Jeffersons%20Fx/jeffersonfxcorrect.htm (2 de 5)04/09/2006 1:20:08
type injury to the ring of C1. A single axial CT scan through the level of C1 shows fractures involving the right and left anterior ring of C1 and the right posterior ring (yellow arrows). Click here for this photo without the arrows
Wheeless textbook of Orthopaedics http://www.wheelessonline.com/ortho/atlas_frx_jefferson_fracture Mark R Foster, MD, PhD eMedicine.com
LearningRadiology.com - Retroperitoneal Fibrosis,medial,deviation,ureter,Sansert,ergotomine,methylsergicide,auto-immune,
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Retroperitoneal Fibrosis
General o Relatively uncommon o More common in males than in females o Predominantly patients aged 40-60 years o In almost 70% of patients, no cause is found
Primary or Idiopathic Retroperitoneal Fibrosis (RPF) o May be an autoimmune response to ceroid, an insoluble lipid that can leak through a thinned arterial wall from atherosclerotic plaques Leads to a vasculitis o Also found in association with other fibrosing diseases suggesting auto-immune mechanism Primary biliary cirrhosis Fibrosing mediastinitis Glomerulonephritis Panhypopituitarism Rheumatoid arthritis Ankylosing spondylitis Polyarteritis nodosa Systemic lupus erythematosus (SLE) Hashimoto thyroiditis Secondary Retroperitoneal Fibrosis o Has been found associated with certain drugs, such as Methysergide Beta-adrenergic blockers Lysergic acid diethylamide (LSD) Methyldopa Amphetamines Phenacetin Hydralazine Cocaine o Desmoplastic response to malignancy
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Lymphoma Carcinoid Retroperitoneal metastases (breast, lung, thyroid, GI tract, GU organs) o Retroperitoneal fluid collection as in trauma, surgery or infection o Aneurysm of the aorta or iliac arteries (desmoplastic response) o Radiation therapy Pathology o Mass of whitish, dense, fibrous tissue covering the aorta, vena cava, ureters, and psoas muscles o Center of disease is usually located at the level of the 4th or 5th lumbar vertebra just at the aortic bifurcation Clinical findings o Most common presentation is flank, back, scrotal or lower abdominal pain o Fever o Weight loss o Nausea and vomiting o Symptoms relating to renal impairment and hypertension are common clinical features Imaging Findings o On excretory or CT urography Medial deviation of the ureter beginning at the level of the L3 or L4 (DDx: aortic aneurysm, bladder diverticulum, abdominoperineal resection) Not a constant feature Most retroperitoneal masses displace ureters laterally Proximal ureterectasis and pyelocaliectasis Tapering of ureters distal to mass o On CT scans Rind of soft tissue around aorta and inferior vena cava between level of kidney and sacrum Spreads to involve the ureters, causing varying degrees of obstruction. Fat plane between the mass and the psoas muscle may be obliterated Unlike adenopathy, RPF tends not to displace aorta anteriorly Mass may show varying degrees of enhancement depending on the stage of the disease
Retroperitoneal Fibrosis. There is a thick rind of soft tissue surrounding the aorta from the level of the kidneys (top photo-yellow arrow) to and including the bifurcation (bottom photo-red arrow). The soft tissue enhances slightly. Notice the aorta is not displaced forward as it would more likely be in lymphoma. The left ureter (green arrow) is dilated. Click here for this photo without the arrows
CT features-benign vs. malignant masses Mass in RPF is less bulky than most neoplastic lesions Malignancy produces enlarged mesenteric nodes and displacement of the aorta from the spine Most retroperitoneal neoplasms displace the ureters laterally o US Hypoechoic homogeneous mass o MRI Low to medium homogeneous signal intensity on T1 Heterogeneous high signal intensity on T2 (inflammatory stage) Low signal intensity on T2 (dense fibrotic stage) Treatment o Use of steroids in RPF is controversial o Surgical ureterolysis o Immunosuppressive drugs o Prognosis o Satisfactory if renal impairment is not too severe
Ali Nawaz Khan, Muthusamy Chandramohan and Sumaira Macdonald eMedicine.com Dahnert 4th Edition
LearningRadiology.com - Polycystic Ovarian Syndrome, PCOS, Stein-Leventhal,infertility,hirsutism
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Polycystic Ovarian Syndrome

Stein-Leventhal Ovaries
Submitted by Ryan Smith, MD
Polycystic ovarian syndrome (PCOS), also known as, Stein-Leventhal syndrome, includes o Polycystic ovaries o Obesity o Hirsutism o Infertility
Women with PCOS have abnormalities in the metabolism of androgens and estrogen and in the control of androgen production Elevated androgen levels can be of ovarian (eg, testosterone, androstenedione) or adrenal (dehydroepiandrosterone sulfate) origin The luteinizing hormone level is elevated, with reversal of the LH/FSH ratio as LH becomes higher than FSH throughout the menstrual cycle PCOS is also associated with peripheral insulin resistance o Approximately 10% of women who are obese and have PCOS also have type 2 diabetes mellitus by age 40 years Imaging o Ultrasound is the imaging modality of choice o Polycystic ovaries are enlarged and rounder than normal with increased stromal echogenicity o There are numerous small cysts, less than 5mm, that line up on the periphery, in a string-of-pearls appearance o Ultrasonographic criteria for establishing the diagnosis of PCOS are 10 or more cysts that are 2-8 mm in diameter and are peripherally arranged around an echodense stroma
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Polycystic Ovarian Syndrome (Stein-Leventhal Ovaries). Both the right and left ovaries show numerous cysts arranged around the periphery of the ovaries producing the "string-of-pearls" sign.. Click here for a larger view of this photo
The minimal criteria proposed for the diagnosis of PCOS include o Menstrual dysfunction o Evidence of hyperandrogenism, whether clinical (eg, hirsutism, acne, male pattern balding) or biochemical (elevated androgen level and other causes of hyperandrogenism must be excluded)
LearningRadiology.com - Esophageal Diverticulum,Esophagus,tics,diverticula,zenker's,epiphrenic
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Midesophageal Diverticulum
Esophageal Diverticula
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Zenkers Diverticulum Pharyngoesophageal diverticulum Occurs in older women
Midesophageal Diverticulum May be formed in response to pull from fibrous adhesions following lymph node infection (usually TB) True diverticulum = contains all 3 esophageal layers Or, may form from increased intraluminal pressure and be pulsion diverticula
Epiphrenic Diverticulum Location is usually in distal esophagus on lateral esophageal wall, right > left Often associated with hiatal hernia Pulsion diverticulum False diverticulum
Posteriorly at site of Killian's dehiscence = superior boundary is thyropharyngeal muscle and inferior boundary is cricopharyngeal muscle Pulsion diverticulum False diverticulum = herniation of mucosa and submucosa through muscular layer
192
A. Ulcer B. Lymphoma C. Amebiasis D. Epiphrenic diverticulum

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A. Small bowel obstruction B. Ascites C. Mesenteric ischemia D. Fibroids

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A. Hangman's fracture B. Jefferson fracture C. Locked facets D. Burst fracture

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A. Avulsion fracture B. Posterior fracturedislocation C. Anterior fracturedislocation D. Bladder rupture

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Epiphrenic Diverticulum
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Zenkers Diverticulum Pharyngoesophageal diverticulum Occurs in older women
Midesophageal Diverticulum May be formed in response to pull from fibrous adhesions following lymph node infection (usually TB) True diverticulum = contains all 3 esophageal layers Or, may form from increased intraluminal pressure and be pulsion diverticula
Epiphrenic Diverticulum Location is usually in distal esophagus on lateral esophageal wall, right > left Often associated with hiatal hernia Pulsion diverticulum False diverticulum
Posteriorly at site of Killian's dehiscence = superior boundary is thyropharyngeal muscle and inferior boundary is cricopharyngeal muscle Pulsion diverticulum False diverticulum = herniation of mucosa and submucosa through muscular layer
LearningRadiology.com - Ascites,ascitic,fluid,peritoneum,peritoneal,sign,cause,bladder-ears
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Ascites
Causes o Cirrhosis o Hypoproteinemia o Chronic renal failure o Carcinomatosis o Polyserositis o Pancreatitis o TB peritonitis o Meigs syndrome o Constrictive pericarditis o Budd-Chiari syndrome Imaging Findings o Conventional radiographs Uniform grayness to abdomen Central placement of bowel loops Separation of adjacent loops Loss of definition of the liver and/or spleen edge Bladder-ears fluid collects in pelvis on either side of bladder in peritoneal space Thickening of peritoneal flank stripe Medial displacement of ascending and descending colon Bulging flanks
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Ascites, supine abdomen. Supine view of the abdomen shows central displacement of the loops of bowel, a uniform grayness to the abdomen, loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis, all suggestive of ascites. For a larger photo of the same image, click here o On CT Sparing of the bare area of the posterior aspect of the right lobe of the liver which is not covered by peritoneum Fluid that lies posterior to the liver at this point is pleural effusion, not ascites Ascitic fluid lies anterior to the diaphragm on axial sections, pleural fluid is posterior
LearningRadiology.com - Burst Fracture,burst,fracture,cervical,spine,trauma
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Burst Fracture

Burst fractures result from axial loading most often secondary to motor vehicle accidents and falls The axial load drives the intervertebral disk into vertebral body below Usually produces a comminuted, vertical fracture through the vertebral body Fragments may be retropulsed into the spinal canal injuring the cord Burst fractures may resemble flexion-teardrop fractures o In a classical flexion-teardrop fracture, there is an avulsed anterior, inferior triangular bony fragment that is separated from the body and displaced anteriorly o Both the anterior and posterior ligamentous structures are injured, which may not be the case in a burst fracture Burst fractures, however, can have associated injury to the posterior ligamentous structures, especially if there is a combination of axial loading and flexion at the time of injury Clinically o Neck pain o Numbness or parasthesia o Weakness Imaging on conventional radiography o Lateral view of the cervical spine on conventional radiograph should show a comminuted fracture of the vertebral body o Soft tissue swelling can be recognized by an increase in the prevertebral soft tissue of greater than the AP diameter of the C3 vertebral body at C3 or greater than the full AP diameter of the cervical vertebral body at C6 o The anterior portion of the body will be wedged o Retropulsion can be inferred if the posterior surface of the vertebral body is convex towards the spinal canal, as the normal cervical vertebral body has a concave posterior surface o Injury to the posterior ligamentous structures can be inferred by widening of the interspinous distance and forward subluxation of the vertebral body above the fracture o CT will show the comminuted fracture and the retropulsed fragment
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Burst fracture, C7. Lateral view of the cervical spine demonstrates a comminuted vertical fracture through the body of C7. The posterior surface of C7 is displaced posteriorly toward the spinal canal (red arrow) while there is slight soft tissue swelling anteriorly (white arrow). For a larger photo of the same image without the arrows, click here Treatment o Burst fractures may be treated initially with cervical tongs o The fracture is considered stable if there is no neurologic deficit or if there are no retropulsed fragments
LearningRadiology.com - Posterior Hip Dislocation,Dislocated,hip,pelvis,pelvic,fracture,acetabulum,trauma,accident,car,auto
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Hip Dislocation
Posterior Hip Dislocation
Hip dislocation accounts for only 5% of all dislocations o Posterior hip dislocations are much more common than anterior hip dislocations (90% to about 10%)
About 20% of pelvic fractures involve the acetabulum and about 33% of acetabular fractures involve the posterior rim Mechanism in posterior dislocation classically is unrestrained occupant of a motor vehicle accident, especially collisions which are head-on, in which the flexed knee strikes dash with hip flexed and adducted o Force is transmitted along femoral shaft to the hip o Associated with fractures of the posterior rim of the acetabulum o Posterior dislocations can also result from falls from a height o Anterior dislocations are more apt to occur if the hip is abducted at the time of injury Imaging findings o Conventional radiography In posterior dislocations, the head of the femur is usually situated superior and lateral to its normal position in the acetabulum In anterior dislocations, the head usually rests inferior and medial to its normal acetabular position May be subtle if head lies in AP plane appears as if it still resides in the acetabulum There may be associated fractures of the head of the femur and/or posterior rim of the acetabulum The posterior rim of the acetabulum normally is the more lateral of the two edges (anterior rim and posterior rim) seen on the anteroposterior (AP) view of the pelvis Since the posteriorly dislocated head lies closer to the cassette, the posteriorly dislocated head may appear smaller than the head on the opposite side which lies farther from the cassette and is magnified more o Computed tomography (CT) Provides an accurate means of evaluating not only the dislocation but the associated fractures as well
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Posterior fracture-dislocation, hip. Anteroposterior conventional radiograph of the pelvis (above) shows that right femoral head (blue arrow) lies more superior than the superior rim of the acetabulum (white arrow). The normal left femoral head appears slightly larger than the posteriorly dislocated right because it is farther from the imaging surface and more magnified. The contrast in the bladder was injected intravenously for a CT scan. The CT scan of the pelvis (below) demonstrates the femoral head (red arrow) well posterior to the acetabulum. There are associated fractures of the posterior rim of the acetabulum (yellow arrow). For a larger photo of the same image without the arrows, click here Treatment o Reduction of dislocation Avascular necrosis of the femoral head is more likely to occur if the reduction does not occur before 6 hours
LearningRadiology.com - Pericardial cyst,pericardium,cyst,pericardial,cardiophrenic,angle,sulcus
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Pericardial Cyst

Fluid-filled cysts of the parietal pericardium consisting of a single layer of mesothelial cells Usually discover at age 30-40 years, predominantly in males (3:2) Most are asymptomatic and incidental findings Atypical chest pain can occur They are usually (75%) located at the cardiophrenic angle almost always on the right (3:1) o DDX of a right cardiophrenic angle mass Pericardial cyst Sequestration Foramen of Morgagni hernia They can occur higher and may extend into major fissure o Classically they are soft and can be flattened on the edge that faces the fissure They rarely occur in the mediastinum Imaging findings
Pericardial Cyst. Frontal and lateral views of the chest demonstrate a mass at the right cardiophrenic angle with rim-like calcification that indicates the calcification has formed in the wall of a hollow viscus. This is a characteristic location for a pericardial cyst, which is calcified in this case. For a larger photo of the same image, click here
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o o o o o
Sharply marginated Round or oval mass From 3-8 cm in size usually They can change in size and shape with respiration or body position Rarely calcify
On CT, their attenuation values of 20-40 HU, occasionally higher
197
A. Reflux esophagitis B. Leiomyoma C. Fibrovascular polyp D. Esophageal varices
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A. Sinusitus B. Osteoblastic metastasis C. Osteoma D. Depressed skull fracture

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199
A. Septic emboli B. Metastatic osteosarcoma C. Old tuberculosis D. Asbestos exposure
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A. Anterior dislocation B. Posterior Dislocation C. Inferior dislocation D. Superior dislocation

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201
A. Pelvic fracture B. Leriche Syndrome C. Absent right kidney D. Aortic aneurysm
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LearningRadiology.com - Leiomyoma,esophagus,leiomyoma of the esophag...ophageal,tumor,mass,benign,wall,lesion,intramural,ulcer,most common
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Leiomyoma of Esophagus
Most common benign tumor of esophagus o Leiomyomas are also the most common benign tumor of the small bowel but are not common in the colon Usually asymptomatic May produce dysphagia or hematemesis if large Typically occurs in young males Found most often in distal third of esophagus Usually solitary, but may be multiple (3%) Imaging findings o Smooth, sharply-marginated mass o Well-defined, intramural (wall) mass lesion that typically intersects wall at 90 degree angle when viewed in profile o As a wall lesion, it may narrow the lumen in one plane and widen it in the orthogonal view (a plane at 90 degrees to the original) o May have coarse calcifications (only calcifying esophageal tumor) o Rarely ulcerates
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Leiomyoma of the esophagus. Large filling defect with sharply-marginated border is seen in distal esophagus. Contrast seen within the lesion did represent an irregular ulcer in the mass. Leiomyomas are the most common benign esophageal tumors. For a larger photo of the same image, click here
May demonstrate diffuse contrast-enhancement on CT DDx: Neurofibromas, hemangiomas and lipomas, all uncommon
LearningRadiology.com - Osteoma,frontal,sinus,mandible,polyposis,gardner's,gardener's,syndrome,osteomas
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Osteoma
q q q q q q q q
Most common tumor of the paranasal sinuses Most frequently seen in the frontal and ethmoid sinuses Benign tumor of membranous bone consisting of dense, compact bone Majority of paranasal osteomas are discovered serendipitously In the skull, they usually arise from the outer table Rarely, large osteoma in the frontal or ethmoid region may displace globe forward and cause proptosis Obstruction of a sinus ostium may lead to infection or formation of a mucocele Very rarely, an osteoma may erode through the dura leading to cerebrospinal fluid rhinorrhea or intracranial infection Imaging findings q Well-circumscribed, sharply-marginated round and very dense lesions usually less than 2 cm in size
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Osteoma, frontal sinus. Red arrows point to round density in the right frontal sinus with the characteristic appearance of an osteoma. For a larger photo of the same image without arrows, click here
Multiple paranasal osteomas are found in Gardners syndrome q Multiple osteoma of the mandible and maxilla, along with the frontal, sphenoid and ethmoid sinuses, rarely the long bones or phalanges q Cutaneous and soft tissue tumors q Association between colonic polyps with a predilection to malignant degeneration
LearningRadiology.com - Asbestos,pleural,asbestosis,plaque,calcified,asbestos related pleural disease,rolled edge,holly leaf,parietal
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Asbestos-Related Pleural Disease

Salts of salicic acid 90% of asbestos in the USA is white asbestos (chrysotile) occurs in automotive workers, shipfitters,
construction workers Asbestos particles invoke a hemorrhagic response in the lung o o Fibers are then coated with a ferritin-like material resulting in ferruginous bodies Produces its damage in respiratory bronchioles and alveoli
Affects lower lobes first The presence of pulmonary parenchymal changes differentiates asbestosis from asbestos-related pleural
disease o o Opacities are small and irregularly shaped Cardiac silhouette may become shaggy
Imaging findings o All patients with asbestos-related pleural disease have, by definition, some pleural involvement Pleural involvement without parenchymal disease is common Pleural plaque Parietal pleural plaques in the mid lung are the most common asbestos-related disorder and are
usually bilateral They occur most often in the 6th-9th interspaces usually sparing the apices and lung bases and
involve the parietal pleura Diffuse pleural thickening
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Less common than pleural plaques Diffuse pleural thickening involves diaphragmatic pleura, blunting of costophrenic sulci and
lateral pleural thickening Pleural calcification Pleural calcification occurs in about 50% with asbestos-related disease, especially along the
diaphragmatic pleura Calcified pleural plaques seen en face have a characteristic rolled edge along their margins,
denser than in the central portion of the plaque o The appearance of the entire plaque has been likened to a holly leaf
Later manifestation of pleural disease, calcification may occur in plaque or diffuse pleural
thickening (less often)
Pleural calcification, asbestos exposure. White arrow points to a calcified pleural plaque of asbestos-related pleural disease seen en face. The overall appearance of the plaque has been likened to a holly leaf and the dense white edge of the plaque is called a rolled edge. The black arrows point to many of the calcified pleural plaques seen in profile. For a larger photo of the same image without arrows, click here
Pleural effusion Effusion alone may occur early in the disease (first 20 years) in about 3% of cases Exudative, occasionally bloody, one-sided or bilateral
In contrast to silicosis, hilar lymph nodes are rarely affected
Associations with lung cancer and mesothelioma o o o Estimated to occur in 20-25% of those heavily exposed to asbestos Asbestos-related lung cancer is usually either squamous cell or adenocarcinoma Bronchogenic carcinoma is almost always associated with cigarette smoking Increases risk of bronchogenic carcinoma up to 100x over that in non-smoking, non-asbestos
exposed population o Mesotheliomas are not related to cigarette smoking Mesotheliomas most often due to crocidolite particles
LearningRadiology.com - Luxatio erecta,dislocation,shoulder,humerus,humer...erior,anterior,luxatio,erecta,posterior,hill-sachs,bankart,trauma,injury
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Luxatio Erecta (Inferior Dislocation of the Shoulder)
Types of dislocations about the shoulder o Glenohumeral dislocation (the most common by far) o Acromioclavicular dislocation (12%) o Sternoclavicular dislocation (uncommon) Types of glenohumeral dislocations o Inferior shoulder dislocation (1-2%) Luxatio erecta uncommon form of shoulder dislocation Extremity held over head in fixed position with elbow flexed Mechanism Severe hyperabduction of arm resulting in impingement of humeral head against acromion Humeral articular surface faces inferiorly
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Luxatio Erecta. Humeral head (blue arrows) faces inferiorly and is located below the rim of the glenoid (red arrow) in this uncommon inferior dislocation of the shoulder in which the arm is fixed in an upright position usually with the elbow flexed. For a larger photo of the same image without arrows, click here Complications Rotator cuff tear Fracture of acromion with or without inferior glenoid fossa and with or without fracture of the greater tuberosity Neurovascular injury o Anterior or subcoracoid shoulder dislocation (most common) (96%) Mechanism External rotation and abduction 40% recurrent Age Younger individuals May be associated with: Fracture of greater tuberosity (15%) Bankart lesion o Fracture of anterior glenoid rim Hill-Sachs defect (50%) o Impaction fracture of posterolateral surface of humeral head due to impaction of humeral
head against anterior rim of glenoid during dislocation o Posterior shoulder dislocation (2nd most common) (2-4%) Causes Traumatic o Convulsive disorders or electroshock therapy Nontraumatic o Congenital or developmental o May be done voluntarily, especially in children
Usually due to axial loading of an adducted and internally rotated arm In >50% unrecognized initially and subsequently misdiagnosed as frozen shoulder May be difficult to see on AP radiograph Typically, a scapular Y view or transthoracic lateral of the humeral head demonstrate a posterior dislocation better Imaging signs of posterior dislocation Rim sign (66%) = distance between medial border of humeral head and anterior glenoid rim <6 mm Humeral head is fixed in internal rotation no matter how forearm is turned lightbulb sign May be associated with: o Trough sign (75%) = "reverse Hill-Sachs" = compression fracture of anteromedial humeral head o Fracture of posterior glenoid rim o Avulsion fracture of lesser tuberosity Isolated fractures of the lesser tuberosity should raise suspicion of an associated posterior dislocation o Superior shoulder dislocation (least common) (<1%) Humeral head driven upward through rotator cuff May be associated with fracture of humerus, clavicle or acromion
Dahnert 5th Edition
LearningRadiology.com - Leriche's Syndrome,leriche,aortic,aorta,occlusion,...s,iliac,artery,arterial,claudication,erectile,impotent,femoral,pulse,weak
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Leriche Syndrome

Atheromatous occlusion of the distal abdominal aorta at the bifurcation into the common iliac arteries Triad of symptoms includes o Claudication in the legs or buttocks o o Absent or diminished femoral pulses Erectile dysfunction
Usually affects younger males ages 30-40 Risk factors include o Cigarette smoking o o Hypercholesterolemia Less likely to have associated diabetes
Because development of the disease is slow and collaterals develop, limb-threatening ischemic disease does not tend to occur Imaging can be done with non-invasive methods such as MRI and CT angiography or through arterial duplex scanning Treatment is aortoiliac bypass
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Leriche Syndrome. Coronal reconstruction from a contrast-enhanced abdominal CT scan shows complete occlusion of the infrarenal aorta (red arrow) by thrombus that extends into both common iliac arteries (yellow arrows). The white arrow points to calcification in the wall of the vessel. For a photo of the same image without arrows, click here
202
A. Hemo-pericardium B. Pneumothorax C. Dislocated clavicle D. Aortic dissection

35 year-old in motor vehicle accident Click to Enlarge
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203
A. Ruptured diaphragm B. Pneumothorax C. Sternal fracture D. Pulmonary laceration
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A. Degenerative disc disease B. Spondylitic spondylolisthesis C. Metastatic malignancy D. Laminectomy defect

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A. Osteosarcoma B. Ewing's Sarcoma C. Avulsion fracture D. Chordoma
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206
A. Bullous disease B. Cystic fibrosis C. Eosinophilic granuloma D. TB

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LearningRadiology.com - Sternoclavicular dislocation,posterior,medial,cla...,head,anterior,serendipity,CT,plain,conventional,radiograph,chest,trauma
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Sternoclavicular Dislocation

Normally, about 50% of the medial end of the clavicle articulates with the manubrium of the sternum Joint is freely movable synovial joint Sternoclavicular dislocations are one of the rarest dislocations to occur o Strength of the sternoclavicular ligaments Requires considerable force o Usually a direct or indirect blow to the shoulder or shoulder region
Most commonly occurs from motor vehicle collisions, followed by athletic injuries and falls Sprains are more common than subluxations or dislocations Of dislocations, anterior dislocation of the clavicular head is 9 times more common than posterior dislocations o Usually caused by a force that drives shoulder backwards and clavicular head forward o Posterior blows to the shoulder region may drive the shoulder forward and the clavicular head posteriorly Or direct impact on the head of the clavicle may drive it backward Co-morbidity is unusual in anterior dislocations but occurs in about 25% of posterior dislocations o Complications can include Pneumothorax Superior vena caval laceration Subclavian artery or vein occlusion Tracheal rupture Death Imaging o Conventional radiography Chest x-rays may be normal, even with a dislocation Special views of the clavicles may help Serendipity view is an AP view of the clavicles with the tube angled upward by 40 in the supine position Normally, the medial ends of the clavicles are at the same level Since this is in essence an apical lordotic view, an anteriorly dislocated clavicular head will
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appear higher than the normal side whereas a posteriorly dislocated clavicular head will appear lower than the normal side CT is the study of choice
Posterior sternoclavicular dislocation. Chest radiograph demonstrates an unequal position of the heads of the clavicles with the right side (yellow arrow) being higher than the left (green arrow). In a patient with significant trauma, this is an alert to the presence of a dislocation of the medial end of the clavicle. The CT scan (bottom) shows the normally articulating right clavicular head (yellow arrow) and the posteriorly dislocated left clavicular head (green arrow). The light blue arrow points to the manubrium of the sternum. For a photo of the same image without arrows, click here Treatment o Anteriorly dislocated clavicular heads can be treated without surgery o Reduction of a posterior dislocation frequently requires general anesthesia but closed reduction may fail and require open reduction and internal fixation
eMedicine Sternoclavicular Joint Injury
John P Rudzinski, MD, and John C Burelbach, MD
LearningRadiology.com - Pulmonary Laceration,Hematoma,Traumatic Lung...Traumatic Pneumatocoele,traumatic,chest,CT,blunt,penetrating,trauma
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Pulmonary Laceration
Traumatic hematoma, Traumatic Lung Cyst, Traumatic Pneumatocoele
Most thoracic trauma is due to motor vehicle accidents Most thoracic trauma is blunt, rather than penetrating Lacerations usually result from blunt chest trauma Lacerations are tears in the lung parenchyma They tend to occur more often in children and young adults Imaging Findings o Usually not apparent at first because of surrounding pulmonary contusion Contusions characteristically clear rapidly, sometimes within 48 hours o On CT, they will present as cystic lucencies, frequently beneath a rib fracture CT is more sensitive than conventional radiographs for detecting a pulmonary laceration
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Pulmonary laceration. CT of the chest demonstrates a partially-cystic, partially fluid-filled structure in the left lower lobe (red arrow) near a rib fracture (black arrow) in this patient who was an unrestrained passenger in a motor vehicle collision. The blue arrow points to an area of subpleural hemorrhage representing a pulmonary contusion For a photo of the same image without arrows, click here o Half are solid, mass-like lesions (pulmonary hematoma) o Half are thin-walled cystic structures (traumatic lung cyst) with or without air-fluid level depends on how much bleeding into laceration o Usually subpleural location under point of maximum impact o May be single or multiple Characteristically, they take a long time to heal weeks to months o Gradually decrease in size. No symptoms from laceration itself unless it becomes infected, which is rare
LearningRadiology.com - spondylolisthesis,spondylolesthesis,spondylolysis,...image, jpg file,resident,case,interesting,medical,student,medical student
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Spondylolisthesis
Normally the inferior articulating fact of each lumbar vertebral body lies posterior to the superior articulating facet of the body below it If the bony connection between the inferior and superior articulating facets (pars interarticularis) is defective, the weight of the body may cause the upper vertebra, including all of the vertebral bodies above it, to slip forward for varying amounts on the body below (spondylolisthesis) The defect in the pars interarticularis is called spondylolysis Spondylolysis is not present at birth but increases in frequency with increasing age When symptomatic, pain is the most frequent symptom of either spondylolysis or spondylolisthesis There are several different etiologies for spondylolisthesis o Spondylolytic spondylolisthesis Is the most common type and results from bilateral defects in the pars interarticularis Has a 2:1 male to female predominance and is more common in Caucasians than AfricanAmericans With bilateral spondylolysis, the posterior aspect of vertebral body separates from the anterior body Posterior body remains fixed in position while the anterior part is free to slip forward Cause of spondylolysis appears to be a combination of a dysplastic pars at birth coupled with the long-term stresses of upright posture Certain athletic endeavors (e.g., football, weight-lifting, tennis and wrestling) appear to increase these stresses Fractures of the pars may heal with a pseudarthrosis or fibrous ankylosis o Degenerative spondylolisthesis More common in African American women than in Caucasian women Most frequent at the L4-L5 level Is not the result of a pars defect but a complex interaction between the disk, facets joints and the ligamentous structures There is usually narrowing, sclerosis of the facet joints from osteoarthritis There is less forward slippage (spondylolisthesis) in this group than in spondylolytic group Retrolisthesis (backward slippage of a vertebral body on the body below it) may occur with osteoarthritis of the facets joints
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Dysplastic spondylolisthesis
Results from congenital abnormalities of the body and/or facets in the lumbar region such that the alignment of the facets allows spondylolisthesis to occur The pars may or may not be intact Females are more apt to have this type than males (2:1) Symptoms usually develop during the adolescent growth period o Traumatic spondylolisthesis Trauma can lead to an acute fracture through a normal pars interarticularis Results in a diastatic defect that may lead to a spondylolisthesis Imaging findings o Conventional radiography in the anteroposterior, lateral and both oblique projections is usually adequate to demonstrate both spondylolysis and spondylolisthesis o Spondylolysis appears as a break in the neck of the Scottie Dog on the oblique view o o o Bilateral spondylolysis is visible on the lateral view Forward slippage of one vertebral body on the other is observed and graded on the lateral view Spondylolisthesis is graded in this manner Grade 1-vertebral body above subtends of the AP diameter of the vertebral body below Grade 2- vertebral body above subtends 1/2 of the AP diameter of the vertebral body below Grade 3- vertebral body above subtends 3/4 of the AP diameter of the vertebral body below Grade 4- vertebral body above subtends the full AP diameter of the vertebral body below
Spondylolytic Spondylolisthesis. Lateral view of the lumbar spine demonstrates a bilateral break in the pars interarticularis or spondylolysis (lucency shown by black arrow) that allows the L5 vertebral body (red arrow) to slip forward on the S1 vertebral body (blue arrow). The forward slippage is called spondylolisthesis. The normal pars interarticularis is shown by the white arrow. the degree of forward slippage is equal to about 1/4 to 1/2 of the AP diameter of S1 so this is a Grade1-Grade 2 spondylolisthesis. For a photo of the same image without arrows, click here
eMedicine Spondylolisthesis Zubin Irani, MD, MBBS and Jehangir J Patel, MD
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Avulsion Fractures of the Pelvis

Avulsion fractures result when the fracture fragment is pulled from its parent bone by forceful contraction of a tendon or ligament Avulsion fractures are most common in younger individuals engaging in athletic endeavors In the pelvis, the newly formed secondary centers of ossification, the apophyses, are the most likely portions of the bone to avulse Since the apophyses tend to form at the time of puberty, most of these pelvic avulsions occur at the time of puberty In general, they are uncommon injuries, seen almost exclusively in adolescent athletes with a 2:1 male to female preponderance They occur most often in track events like hurdling and sprinting, or games like soccer or tennis Most common to avulse is the ischial tuberosity followed by anterior inferior iliac spine (AIIS) and the anterior superior iliac spine (ASIS) about equally
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Clinical findings o Acutely, the athlete experiences sudden, shooting pain referred to the involved tuberosity o They may lose muscular function o Swelling and local tenderness may occur o The clinical findings of the fracture are similar to those of soft tissue injuries to the muscles, tendons and ligaments and so may be initially missed Most common site of a missed fracture is the ischial tuberosity Cause is usually forcible contraction of the hamstrings, as in sports such as sprinting and hurdling Imaging findings o Since the apophyses occur in anatomically predictable locations, the findings are those of an avulsed bony fragment usually immediately adjacent to the parent bone Characteristic of these lesions is fracture healing with exuberant bony callus formation Can be confused with a bone tumor but must not be as an osteosarcoma and a healing fracture may appear similar pathologically o Conventional radiography is the study of first choice If negative, magnetic resonance imaging may be helpful in demonstrating soft tissue injury, such as a tear of the tendon of the hamstring muscles Prompt diagnosis will prevent development of chronic pain
Healing avulsion fracture of ischial tuberosity. There is exuberant callus formation around the site of an avulsed ischial tuberosity in this 16 year-old young man who was a school hurdler. The location and appearance are typical for this type of fracture and must not be confused for a bone tumor. For a larger photo of the same image, click here
Avulsion fracture of the ischial tuberosity in adolescentsan easily missed diagnosis; Gidwani, Jagiello, and Bircher; BMJ 2004;329:99-100 (10 July), doi:10.1136/bmj.329.7457.99
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Bullous Disease of the Lungs
Definition o Thin-walledless than 1 mm o Air-filled space o Contained within the lung o 1 cm in size when distended o Walls may be formed by pleura, septa, or compressed lung tissue
What a bulla isnt: other air-containing structures o Pneumatocoele Thin-walled (< 1mm), gas-filled space in the lung developing in association with acute pneumonia, such as staph, and frequently transient o Cavity Gas-containing space in the lung having a wall > 1 mm thick o Cyst Thin-walled, air- or fluid-filled, with a wall that contains respiratory epithelium, cartilage, smooth muscle and glands o Bleb Intrapleural cystic space Bulla terminology o One of them is a bulla o Two or more of them are bullae (pronounced bully) o Diseases which contain bullae are bullous diseases General considerations o Enlarge progressively over a period of months to years o Most are associated with emphysema o May become infected or lead to pneumothorax Primary Bullous Disease o Familial occurrence o Increased incidence in Marfan's and Ehlers-Danlos o Unlike the bullae associated with emphysema, there is usually no airway obstruction and there is
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normal parenchyma between bullae Types of Bullae o Type 1 Originate in a subpleural location usually in upper part of lung Narrow neck Produce passive atelectasis of adjacent lung tissue Paraseptal emphysema o Type 2 Superficial in location Very broad neck Anterior edge of upper and middle lobes and along diaphragm Contain blood vessels and strands of partially destroyed lung Spontaneous pneumothorax o Type 3 Lie deep within lung substance Like type 2, contain residual strands of lung tissue Affect upper and lower lobes with same frequency Imaging findings o Seen more in upper lobes o Thin-walled, sharply demarcated areas containing no visible blood vessels on conventional radiography o Only portion of wall is usually seen on conventional radiography o They tend to trap air May become larger on expiration o Bullae may become so large as to render the remaining normal lung almost invisible, pancaked atop the hemidiaphragm = vanishing lung syndrome
Bullous disease of the lungs-conventional radiograph and CT. Frontal and lateral views of the chest demonstrate numerous thin-walled, air-containing structures that represent the walls of numerous bullae. These lineal densities are characteristic for bullae on conventional radiography. The CT scan on the same patient (below) shows the same thin-walled bullae. For larger photos of the same images, click on the photos above Signs of an infected bulla o Air-fluid level o Differentiation from lung abscess Bulla contains less fluid Much thinner wall No surrounding pneumonitis Patients less sick with infected bulla o Clearing may take weeks to months Bullous disease and spontaneous pneumothorax o Commonly occurs with small bulla affecting lung apices o May be difficult to differentiate large bulla from pneumothorax o Edge of a pneumothorax will usually parallel the chest wall curvature whereas edge of a bulla frequently curves inwards away from the chest wall o CT may help Clinical findings o 1 bullous disease usually has no symptoms o When large, surgical removal may be performed o Patients with chronic obstructive pulmonary disease tend to show little difference clinically or functionally with or without bullae
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A. Myositis ossificans B. Venous insufficiency C. Dermatomyositis D. Sarcoid

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A. CPPD B. Gout C. 2 Synovial osteochondromatosis D. Pigmented villonodular synovitis

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A. Ascariasis B. Thorotrast C. Sickle cell disease D. Histoplasmosis

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A. Dissecting hematoma B. Aspiration C. Pulmonary edema D. Pseudomonas pneumonia

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Dermatomyositis
q q q
Along with polymyositis, part of a group of idiopathic inflammatory myopathies with both cutaneous and visceral manifestations r Affects the esophagus, lungs and heart Damaged chondroitin sulfate, atrophy of muscles, followed by calcification of muscle and subcutaneous tissue Most believe dermatomyositis is closely related to polymyositis although the pathogenesis of the two remain controversial Occur at age 5-10 and again in 50s, dermatomyositis being the only one of the two diseases seen in children More common in females r Linear and confluent calcifications in soft tissues of extremities r Acro-osteolysis r Chest-may have infiltrates associated, especially from aspiration Clinically r Dysphagia r Erythematous purple-red rash of eyelids, trunk and hands (seen in dermatomyositis) s May be sole manifestation in up to 40% of patients with disease r Painless, symmetric, proximal muscle weakness Associated with a higher incidence of malignancies of GI tract, lung, ovary , breast, kidney in adults, not usually children Imaging MRI may show an inflammatory myopathy Calcinosis universalis in dermatomyositis r Diffuse cutaneous, subcutaneous and sometimes muscular calcification r Usually affects children and young adults r Not actual bone formation r More linear than calcifications in scleroderma, which tend to be punctate (calcinosis circumscripta) r Calcium-channel blockers have been reported to help in some cases of calcinosis
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Dermatomyositis. Sheet-like calcifications seen in patients with dermatomyositis is called calcinosis universalis because of its wide-spread distribution. This is more likely to occur in younger patients with dermatomyositis. For a larger photo of the same image, click on the photo above

q
May resemble myositis ossificans progressiva r Myositis ossificans progressive (fibrodyplasia ossificans progressiva) s Begins with subcutaneous, painful masses in neck q Progresses down back over shoulders, chest, abdomen s Rounded or linear calcification starting in neck s More clumplike in places than calcinosis universalis s Ossification of voluntary muscles Treatment r Prednisone r Cytotoxic agents like methotrexate Prognosis depends on age, and cardiac, pulmonary or esophageal involvement r Spontaneous remission has been reported in up to 1/5 of cases
eMedicine Jeffrey P Callen, MD,
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Hiatal Hernia
Two main types: sliding and paraesophageal Most are acquired Incidence increases with age About 1/5 of patients with a hiatal hernia, usually the sliding type, have associated gastro-esophageal reflux (GERD) Sliding Hiatal Hernia (99%) Most hiatal hernias are asymptomatic There is an association between the presence of some hiatal hernias and clinically significant gastroesophageal reflux (GERD) o Gastro-esophageal reflux also occurs in patients without any visible hiatal hernia Usually due to dysfunction of lower esophageal sphincter which normally acts to prevent gastric acid from repeatedly refluxing into esophagus Radiologic findings of hiatal hernia o Bulbous area of distal esophagus containing contrast at level of diaphragm with failure of esophagus to narrow on multiple images as it passes through esophageal hiatus Distalmost esophagus should not measure more than 50% of diameter of the tubular esophagus o Extension of multiple gastric mucosal folds above the diaphragm o Sometimes, a thin, circumferential filling-defect in the distal esophagus called a Schatzkis Ring may be visible Schatzkis ring marks position of esophagogastric junction so that its visualization above diaphragm defines the presence of a sliding hiatal hernia Some limit use of the term Schatzkis ring to only those esophageal rings associated with dysphagia
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Hiatal Hernia with Schatzki's Ring. The red arrows point to a slit-like indentation which marks the position of the esophago-gastric junction and, since it is seen above the diaphragm, therefore defines the presence of a hiatal hernia of the so-called sliding type. This indentation is called a Schatzki's ring (or "B ring") although that term is reserved by some only for such rings that produce dysphagia. The white arrow points to the herniated stomach while the green arrow points to disordered tertiary waves of contraction. For a photo of the same image without arrows, click on this link
Complications Large incarcerated hiatal hernias may slowly weep blood so that patients present with iron deficiency anemia, rather than reflux symptoms Peptic esophagitis from reflux Discrete marginal ulcers Strictures o The terminology can be confusing Hiatal hernias, like any other hernias, may be reducible or incarcerated Sliding refers to a hiatal hernia in which the EG junction is above the diaphragm, not to its reducibility A sliding hiatal hernia can be reducible or incarcerated o
Paraesophageal Hiatal Hernia Portion of stomach herniates through esophageal hiatus and comes to lie above diaphragm but EG junction continues to be subdiaphragmatic Usually incarcerated Not associated with GE reflux Intrathoracic stomach Cardia may still be subdiaphragmatic Greater curvature may be on left or right side Congenitally short esophagus (rare) Gastric ectopy by reason of lack of lengthening of esophagus Short, straight esophagus Stomach in thorax Frequently associated with ulcer at EG junction GE reflux Antireflux mechanisms o Normally, the EG junction, the A or contractile ring above it and, lastly, the cricopharyngeous muscle o Abnormally Large, incarcerated hiatal hernias tend not to be associated with reflux Paraesophageal hiatal hernias are usually not associated with reflux Relationship between hiatal hernia and Barretts esophagus o Barretts esophagus consists of columnar epithelium lining the esophagus o Acquired condition related to chronic gastroesophageal reflux An associated hiatal hernia is common o Patients with a Barretts esophagus can develop Ulcer Stricture Malignancy Patients with Barretts esophagus have a 30-40 times higher risk of esophageal adenocarcinoma than the general population
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Synovial (Osteo)chondromatosis
Occurs in two forms: primary and secondary Primary synovial chondromatosis is an uncommon disease in which there is metaplasia of the synovial lining of joints, bursae or tendons into cartilaginous nodules o The nodules may detach and become loose bodies in the joint o As the loose bodies receive their nourishment from the synovial fluid, they may continue to grow even though floating in the joint Usually monarticular Much more common in men than women Usually in 3rd-5th decade Knee is most frequent site of involvement, followed by o Elbow o o o o Hip Shoulder Ankle Wrist
Clinical findings o Pain Usually chronic and progressive o Swelling o o Limitation of movement (lock knee) Joint effusion
May be hemorrhagic o Occasionally it can present as a slow-growing soft tissue mass Imaging findings o Depend in large part on the degree of calcification of the cartilaginous bodies 1/3 of chondromas show no radio-opacity o An important negative fining in primary form is that the adjacent joint is usually normal o The nodules are usually uniform in size ranging from a few mm to several cm
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o o o o o
Small Multiple There may be pressure erosion of adjacent bone in joints Rarely, widening of joint space from accumulation of loose bodies Usually no osteoporosis
Secondary form of Synovial Osteochondromatosis. There are several osteocartilaginous nodules seen around the knee joint space. They are relatively few in number and associated with osteoarthritis of the knee. This is the appearance of secondary synovial osteochondromatosis. For a large photo of the same image, click on this link
Primary form of Synovial Osteochondromatosis. There are numerous osteocartilaginous nodules seen around the knee joint space. They are relatively uniform in size and are not associated with osteoarthritis of the knee. This is the appearance of primary synovial osteochondromatosis.
CT findings o Intra-articular soft-tissue mass of near water attenuation containing multiple small calcifications
MRI findings o Lobulated intra-articular mass isointense to muscle on T1WI and hyperintense to muscle on T2WI containing multiple foci of low signal intensity Rarely, they may degenerate into a chondrosarcoma o Frequently marked by the onset of pain and an associated soft tissue mass Treatment o Removal of loose bodies o May recur Secondary osteochondromatosis o Caused by and associated with osteoarthritis o o Most common in knee and hip Loose bodies are fewer in number and less uniform in size than in primary form
Synovial chondrosarcoma o May resemble synovial osteochondromatosis o Clues may include destruction of bone and an associated soft tissue mass
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Histoplasmosis
Caused by Histoplasma Capsulatum, a soil fungus found especially in the Ohio River Valley (Ohio, Mississippi) o Infected soil can be carried by birds, although birds themselves are not infected Similar in course and imaging appearance to tuberculosis Histoplasmosis is the most common cause of fibrosing mediastinitis Common cause of diffuse punctate splenic calcifications o Spleen is more frequent site of calcifications than liver o DDX: Brucellosis, TB, Candidiasis in immunocompromised patients
Number of calcifications: more than 6, more likely histoplasmosis Size of calcifications: larger the size, the more likely histoplasmosis Appearance of calcifications: in Brucellosis, calcifications may be 1-3 cm in size (larger than in Histo or TB), and have a calcified rim surrounding a lucent center There also may be suppurative lesions of the spleen present at the same time as the calcifications, unusual for Histo or TB Diffuse uniform calcification of the spleen is most often seen in sickle cell disease o Thorotrast may mimic diffuse calcification but is of a higher density and is usually present in abdominal lymph nodes as well
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Histoplasmosis. There are numerous, punctate calcifications in the spleen and calcification in
two mesenteric lymph nodes. TB usually produces fewer splenic calcified granulomas than histoplasmosis. For a photo of the same image without arrows, click on this link
Clinical findings o Portal of entry is the respiratory tract o o High male to female ratio (4:1) Most infections are asymptomatic
Fewer than 5% of those infected will develop symptoms Primary risk factors for development of symptoms are age and immunosuppression o Tissues react to infection by forming caseating and/or non-caseating granulomas which may calcify
Primary histoplasmosis
Most infections are subclinical o Most acute symptomatic cases are mistaken for a flu-like illness The lungs are the most common organ affected Chest radiographs are most often normal but may show adenopathy with a focal area of consolidation Healing can occur with formation of a histoplasmoma o Histoplasmoma=target calcification=bulls-eye calcification in center of nodule (Pathognomonic)
Chronic histoplasmosis
Chronic pulmonary histoplasmosis is more likely to occur in those with underlying lung disease like COPD Imaging findings o Migratory bronchopneumonia o o Hilar and mediastinal adenopathy Multiple nodules which heal with numerous calcified granulomas
TB granulomas are usually 1 or 2 in number o Upper lobe cavitation, healing with fibrosis (very similar to TB)
Progressive Disseminated Histoplasmosis

Affects multiple organs Infants, elderly and immunosuppressed are predisposed o CD4 count is usually below 150-200/mm Most cases believed to arise from re-activation Can be rapidly fatal Imaging o Consolidation Diffuse and/or miliary pattern o Cavitation Upper lobe, most often in men with COPD o Adenopathy Mediastinal or hilar o Hepatosplenomegaly
o o o o o
Lytic lesions in the bones Broncholithiasis (most common cause) Fibrosing mediastinitis Multiple splenic calcifications (unusual for TB) Epididymitis and prostatitis
Non-pulmonary histoplasmosis
Pericarditis Arthralgias Sarcoid-like syndrome in which the histopathologic findings are similar to sarcoid and, like sarcoid, ACE levels are high
Topin, Jeremy and Mutlu, Gokhan, NEJM 354(2), 12 Jan 2006, P. 179. Splenic and Mediastinal Calcifications in Histoplasmosis
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Aspiration

Defined as the passage of material from the oropharynx into the tracheobronchial tree Predisposing conditions include: CNS disorders Intoxication or drug overdose Seizure disorders Recent anesthesia Swallowing disorders Poor oral care Gastroesophageal reflux Esophageal diverticula, such as Zenkers The likelihood of symptomatic aspiration depends in part on the type of material aspirated, the volume aspirated, both of which may be related to the state of consciousness of the individual Pattern of disease depends on what is aspirated into lungs o Un-neutralized gastric acid produces a chemical pneumonitis Known as Mendelsons Syndrome Can produce near-instantaneous development of airspace disease If massive, the pattern will resemble pulmonary edema Mortality is relatively high (30-60%) o Aspiration of water or neutralized gastric acid may produce fleeting disease that can resolve in hours Although frequently referred to as a pneumonia, it does not typically produce an infectious response and is not a true pneumonia o Aspiration of bacteria can produce pneumonia Frequently anaerobic organisms Communityacquired infections tend to be caused by Strep pneumoniae, Staph aureus, Haemophilus flu and Enterobacteriaceae Hospital-acquired infections tend to be caused by Pseudomonas and other gram-negative organisms Anaerobic infections commonly necrotize, so cavities may be present Broncho-pleural fistulae and para-pneumonic effusions or empyema may develop
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time o o o o o o
Anaerobic organisms typically produce a longer lasting pneumonia Aspiration, no matter what the type, usually occurs in the gravity dependent portions of the lung Lower lobes, especially right-sided, including and especially the superior segments of the lower lobes Because of the larger caliber and straighter course of the right main bronchus Posterior segments of the upper lobes Aspiration which occurs while the person is prone may be seen in the right upper lobe and middle lobe or the lingula Chronic aspiration pneumonia results from repeated aspiration of foreign material over a prolonged Zenkers diverticulum Achalasia TE fistula Neuromuscular diseases Chronic reflux Lipoid pneumonia
Mineral oil (used as a laxative) Oily nose drops (not used anymore) Clinical findings o Choking on swallowing o o Acute onset of respiratory distress, if gastric acid Slow onset if bacterial pneumonia ensues
Low grade fever Productive cough Imaging findings o Conventional chest radiography is usually all that is needed to make the diagnosis o Fleeting infiltrate (lasts less than one or two days) if bland and non-infected Chemical pneumonitis may appear almost instantly while aspiration of bland material may take hours to manifest Pneumonia may not develop fro several days following the incident o Consolidation of lobe if infected with anaerobic organisms or if aspiration of un-neutralized HCl o When chronic, the disease usually starts as airspace disease and becomes interstitial as the macrophages incorporate the aspirated material o May mimic a lung mass when chronic
Aspiration. The patient was thought to have aspirated and a chest radiograph was obtained immediately (upper radiograph). The lungs are clear. Another chest radiograph was obtained two hours later (lower radiograph) and now shows airspace disease in the right lower lobe. The disease disappeared a day later indicating the aspirated material was most was likely neutralized gastric contents or water. For a larger photo of the same image, click on this link
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A. Aortic rupture B. Right arch with aberrant LSCA C. Mirror-image right aortic arch D. Penetrating aortic ulcer
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A. Normal B. Slipped epiphysis C. Hip fracturesubcapital D. Hip fractureintertrochanteric
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A. Hangman's fracture B. Atlantoaxial dislocation C. Jefferson fracture D. Clay-shoveler's fracture

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A. Jefferson fracture B. Teardrop fracture C. Chance fracture D. Schmorl's node
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Mirror-Image Right Aortic Arch
Aortic Anomalies Right Aortic Arch

q
General r Most are asymptomatic s Unless they cause encircling vascular ring like pulmonary sling r Can be complex lesions requiring multiple projections s MRI or CT
Left Aortic Arch With Anomalous Right Subclavian Artery (RSCA)

r r r r r
Occurs in less than 1% of people RSCA passes posterior to esophagus Pushes trachea and esophagus forward Produces oblique shadow above aortic arch on frontal film Origin of RSCA may be dilated s Diverticulum of Kommerell technically was defined with a right aortic arch and anomalous left subclavian artery (LSCA)
Right Aortic Arch
Types At least five different types s Only two of importance q Mirror Image Type Type I q Aberrant left subclavian Type II General considerations s Recognized by leftward displacement of barium-filled esophagus s Of air-filled trachea
s
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s s s s
Aortic knob is absent from left side Aorta descends on right Para-aortic stripe returns to left side of spine just above diaphragm Mirror-image type almost always has associated congenital heart disease (CHD) q Usually Tetralogy of Fallot Aberrant Left Subclavian type rarely has associated CHD q Most common variety of right arch
Type 1Mirror Image Type
s s s
Secondary to interruption of left arch just distal to ductus arteriosis Associated with congenital heart disease 98% of time Imaging Findings q No posterior impression on trachea or barium-filled esophagus q Heart is usually abnormal in size or shape q Aorta descends on right
Mirror-image right aortic arch. This contrast-enhanced axial CT scan at the level of the aortic arch demonstrates a right sided-aortic arch. There is no retrotracheal, retroesophageal aberrant left subclavian artery. This is the mirror-image variety with a high association with congenital heart disease.. For a larger photo of the same image, click on this link
Type llAberrant Left Subclavian
s s
Secondary to interruption of left aortic arch between LCC and LSC arteries Associated with cardiac defects 5-10% of the time Tetralogy of Fallot most often (71%) ASD or VSD next most often (21%) q Coarctation of aorta rarely (7%) Anomalous left subclavian artery (retroesophageal and retrotracheal) Aorta descends on right Imaging Findings -- Right Aortic Arch with Aberrant LSCA
q q
s s s
Posterior impression on trachea and barium-filled esophagus q Heart is usually normal in size and shape q Aorta descends on right Origin of RSCA may be dilated s Diverticulum of Kommerell technically was defined with a right aortic arch and anomalous left subclavian artery (LSCA)
q
If there is a mirror-image right aortic arch, then

r r r
90% will have Tetralogy of Fallot 6% with Truncus Arteriosis 5% with Tricuspid Atresia
If the person has the following lesions, then the association with a mirror-image arch is
r r r r r
Truncus arteriosis Tetralogy of Fallot Transposition Tricuspid atresia VSD
33% 25% 10% 5% 2%
Double Aortic Arch
General considerations
s s
Most common vascular ring Rarely associated with congenital heart disease Vascular ring produces tracheal and/or esophageal compression Caused by persistence of R and L IV branchial arches Passes on both sides of trachea Joins posteriorly behind esophagus Right arch is larger and higher Left arch is smaller and lower Barium swallow shows bilateral impressions on frontal view
q
s s s s s s
s s
Posterior impression on lateral view Angiogram is characteristic Clinical

q q
Symptoms may begin at birth and include

r r
Tracheal compression, or Difficulty swallowing
Anatomy Right arch supplies RSCA and RCC q Left arch supplies LCC and LSCA Imaging Findings -- Double Aortic Arch
q q q q q
Right arch is higher and larger Left arch is lower and smaller Produces reverse S on esophagram on AP On lateral, arches are posterior to esophagus and anterior to trachea
Cervical Aortic Arch
General Rare s Usually asymptomatic s May present as pulsating supraclavicular mass s May produce vascular ring and compress airway s Embryogenesis uncertain s Over 80% are right-sided Imaging FindingsRight-sided lesions
s
Right-sided cervical aortic arches s Right apical mass-like density s Absence of aortic knob on left s Aorta descends on the left s Displace the trachea and esophagus forward s Branching may be normal or mirror-image Imaging FindingsLeft-sided lesions
s s s s s
Left-sided cervical aortic arches Aortic knob at apex of lung Descend on the left Do not displace the trachea or esophagus forward
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Fractures of the Proximal Femur

Hip fractures are associated with a substantial mortality, as many as 15-20% dying within one year of the fracture Conditions that predispose to hip fractures include aging, osteoporosis and osteomalacia o Most hip fractures in the elderly (90%) occur as a result of a fall, frequently a minor fall such as from the standing position In younger individuals, hip fractures are often the result of high velocity, high impact trauma Most hip fractures occur in Caucasian women Imaging o Conventional radiography is the study of first choice o o When further imaging is required, MRI or nuclear medicine scans are used most often utilized The femoral neck will be seen in profile when the leg is held in internal rotation
Hip fractures can be classified as to their geographic position as: subcapital, transcervical, basicervical, intertrochanteric and subtrochanteric o Subcapital, transcervical and basicervical are intracapsular o Intertrochanteric and subtrochanteric are extracapsular Intracapsular fractures have a higher incidence of nonunion and avascular necrosis of the femoral head (up to 35%) than extracapsular fractures o The more displaced the fragments are, the higher the rate of complications Subcapital fractures o Most common intracapsular fracture of the hip o o Subtle, frequently impacted White line of increased density of impacted bone may be seen at base of femoral head
o There may be a discontinuity in the normal smooth curve of the superior aspect of the femoral neck as it joins the head o Pitfall: a rim of osteophytes may form around the femoral head and project over the neck mimicking the sclerotic line of a subcapital fracture Look for cortical discontinuity May require additional imaging such as MRI for confirmation of fracture
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Transcervical fractures o Occur across the neck of the femur o o Usually easy to see on views of the hip obtained in internal rotation Frequently associated with varus deformity
Basicervical fractures o Base of the femoral neck
o May be difficult to differentiate a basicervical fracture from a non-displaced and non-comminuted intertrochanteric fracture Intertrochanteric fractures o Most common of the extracapsular hip fractures o Comminuted fractures may also manifest separate fragments of either or both of the lesser and greater trochanters o Intertrochanteric fractures associated with a separate fragment of lesser trochanter may also include a portion of the posterior cortex of femoral neck and are considered unstable o Many intertrochanteric fracture are associated with a varus deformity
Comminuted intertrochanteric fracture. There is a fracture from the greater to the lesser trochanter (blue arrow). There are separate fragments of the greater trochanter (white arrow) and lesser trochanter (red arrow). There is varus deformity (white line) of the femoral shaft. For a larger photo of the same image without arrows, click on this link
Isolated fractures of the greater trochanter o Occur in osteoporotic females and are the result of a fall on the greater trochanter or may occur as an avulsion-type fracture from pull of the gluteus medius insertion o These fractures may be difficult to see as the greater trochanter may be overexposed on routine views of the hip o Important to exclude an intertrochanteric fracture which requires operative reduction and internal fixation, while the isolated fracture of the greater trochanter does not o MRI may be needed to exclude intertrochanteric extension Classification - Garden Classification o The most commonly used classification system for femoral neck fractures is some variation of the Garden classification o As its basis, the classification separates non-displaced fractures from displaced fractures because of the better healing rate of the former
Stage Stage I Stage II Stage III Stage IV
Description Incomplete fracture of the neck Complete without displacement Complete with partial displacement Complete femoral neck fracture with full displacement
Remarks May be impacted and in valgus Fragments are still connected by posterior retinacular attachment Allows the femoral head to rotate back into anatomical position
Treatment o Intracapsular fractures of the femoral neck are most often treated with a prosthetic or replacement device for the femoral head and/or neck o Intertrochanteric fractures are frequently treated using a compression-type screw, pin or nail and laterally-placed side-plate Intramedullary nails are also used for fixation
Harris and Harris, The Radiology of Emergency Medicine eMedicine, Hieu T Truong and Amilcare Gentili
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Atlantoaxial Subluxation/Dislocation
Distance between the anterior surface of the dens and the posterior surface of the tubercle of C1 is usually 3 mm or less in adults and 5 mm or less in children r This space is called by many names: predentate space, predental space, atlantodental distance The distance may increase slightly on flexion in children but is usually unchanged between flexion and extension in adults Forward movement of the atlas on the axis is normally restricted by the transverse ligament r The transverse ligament is the primary restraint against atlantoaxial, anteroposterior movement Atlantoaxial instability is defined by an increase in the predentate space of greater then 3 mm in adults and 5 mm in children Symptoms will be present when the atlas moves far enough forward on the atlas to narrow the spinal canal and impinge on the spinal cord The spinal canal is typically widest at the level of C2 and should not be less than 18 mm in ins widest AP dimension Non-traumatic conditions associated with increase in the atlantoaxial distance r Down syndrome s Due to laxity of the transverse ligament r Grisel syndrome s Atlantoaxial subluxation associated with inflammation of adjacent soft tissues of the neck r Rheumatoid arthritis s From laxity of the ligaments and destruction of the articular cartilage r Osteogenesis imperfecta r Neurofibromatosis r Morquio syndrome s Secondary to odontoid hypoplasia or aplasia r Other arthridities s Psoriasis s Lupus While chronic atlantoaxial dislocations which occur in the above diseases may be severe yet asymptomatic, acute atlantoaxial dislocations are more often symptomatic and can be life-threatening Traumatic atlantoaxial subluxation/dislocation usually results from a motor vehicle collision in which an unrestrained occupants head strikes the windshield or dashboard r The pathologic mechanism involves hyperflexion of the neck Almost all atlantoaxial dislocations involve forward movement of C1 on C2; posterior dislocation is extremely rare
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q q q q
Anterior atlantoaxial dislocations may be, but are not necessarily, associated with a fracture of the dens (~50% at autopsy) Associated fractures of the skull and/or facial bones are common This injury is unstable Neurologic injury occurs from cord compression between the odontoid and posterior arch of C1 Imaging findings r Widening of the predentate space r Disruption in the smooth curve of the imaginary line connecting the spinolaminar white lines of the vertebral bodies r Soft tissue swelling s C2 retropharyngeal space should be < 7 mm s C3 and C4 retropharyngeal space should be < 5 mm, or s Less than half the AP diameter of C3 or C4 s C6 retrotracheal space should be < 22 mm in adults and < 14 mm in children (under15 years) Treatment r These injuries are usually treated with some form of surgical fusion of C1 and C2
Atlantoaxial dislocation. Lateral view of the cervical spine done as a cross-table lateral shows a marked increase in the distance between the anterior surface of the dens and the posterior surface of the C1 tubercle (blue arrow) that measured 14 mm (black line), well in excess of the 3 mm maximum in adults. The imaginary line connecting the spinolaminar white lines (white line) shows that the body of C1 (red arrow) is displaced anteriorly relative to the remainder of the spine. The patient died shortly after this study was obtained.
For a photo of the same image without the arrows, click here
Neck Injuries: II. Atlantoaxial DislocationA Pathologic Study of 14 Traffic Fatalities Adams, VI Journal of Forensic Sciences 37:2, 1992
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Chance Fracture
Originally most often caused by seat belts as hyperflexion injuries in automobile accidents o With lap belts, it is now seen more often with falls
Seat belt injuries usually involve the lower thoracic and upper to mid lumbar spine (L1 and L2 most commonly) Chance fractures are hyperflexion injuries in which there is distraction of the posterior elements and impaction of the anterior components of the spine o Compression component from hyperflexion is usually minor compared to distraction component Clinical findings o Back pain is the most common symptom
o o
Ecchymosis of anterior abdominal wall should raise suspicion for the presence of this kind of fracture Up to 50% of individuals with Chance fractures may also have serious blunt injury to internal organs
Injuries involve primarily the pancreas, duodenum and mesentery The same mechanism of injury may not produce a fracture in children but may still be associated with intestinal and urinary bladder injuries o Since the spinal cord ends at T12-L1, injuries to cord are infrequent but the spinal nerves may be injured resulting in bowel and bladder signs Those with a kyphosis of less than 15 have a better neurologic prognosis o Mortality is the result of associated internal injuries
Imaging findings o CT is the most sensitive study although conventional radiographs are usually obtained first Vertebral body component may be less prominent than the distraction fractures of the posterior elements which are always present Vertebral body component may not be visible
o o
Horizontal fracture through the spinous process, laminae, pedicles and vertebral body
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Chance Fracture. Reformatted sagittal CT of the lower thoracic spine demonstrates a horizontal fracture through the spinous process and pedicles (yellow arrow) and a compression fracture of the vertebral body (red arrow) characteristic of the hyperflexion distraction-impaction injury associated with lap seat belt injuries and falls. For a photo of the same image without the arrows, click here
o o o
There may be associated soft tissue swelling Open pedicle sign lucency on the medial aspects of the pedicles Posterior ligamentous complex tears
Up to 50% have injuries to Interspinous ligament Ligamentum flavum Facet capsule Posterior annulus Thoracodorsal fascia
Treatment o Most Chance fractures are managed with immobilization Instability is frequently associated with a kyphosis of 20 or more and a kyphosis of 30 or more usually requires internal stabilization o Main treatment for unstable fractures is surgical fixation with spinal canal decompression
Harris and Harris The Radiology of Emergency Medicine Nadalo and Van Meter eMedicine
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Small Bowel Obstruction
General considerations o Small bowel obstruction, as the term is used here, is due to physical and organic changes which produce mechanical obstruction to the passage of the bowel contents somewhere in the small bowel o The bowel proximal to the point of obstruction dilates with swallowed air and secreted fluid, Vomiting may release some of the proximal bowel contents and reduce the amount of proximal dilation o The bowel hyperperistalses o Bowel distal to the point of obstruction (i.e. colon and sometimes distal small bowel) empties over time
o Strangulation of the bowel may result from vascular compromise of the affected loops and is a cause of increased mortality Causes o Overwhelmingly, the most common cause of a mechanical small bowel obstruction are adhesions related to prior surgery (60%) The most common prior surgeries associated with a subsequent SBO include appendectomy, colorectal surgery and gynecologic surgery Bowel may become kinked under an adhesion The obstruction is frequently partial or intermittent o Hernias Most often femoral or inguinal o Intussusception o o o o o o Volvulus Tumor, either primary or metastatic Wall lesions such as leiomyomas or strictures Crohns disease Foreign bodies Gallstones
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Such as in gallstone ileus (which is actually a mechanical obstruction, usually at the ileocecal valve) Clinical findings o Abdominal pain and distension Most marked in patients with distal SBO although its onset in distal obstructions is later in the course of the disease than in proximal obstruction Typically colicky in nature and progressively worsening over time o Nausea o Vomiting An earlier sign of a proximal than a distal obstruction Fluid and electrolyte imbalances from vomiting increase mortality o Constipation o o History of prior abdominal or pelvic surgery Bowel sounds are hyperactive and high-pitched
Absence of bowel sounds may indicate bowel ischemia or peritonitis Imaging findings o Conventional radiography is the study of first choice Loops proximal to the point of obstruction will become dilated and fluid-filled Usually greater than 2.5-3 cm in size Differential height of air-fluid levels in the same loop of small bowel no longer considered reliable sign of mechanical SBO Absence of, or disproportionately smaller amount of, gas in the colon, especially the rectosigmoid Loops of small bowel may arrange themselves in a step-ladder configuration from the left upper to the right lower quadrant in a distal SBO Mostly fluid-filled loops of bowel may demonstrate a string-of-beads sign caused by the small amount of visible air in those loops
Small Bowel Obstruction. Supine view of the abdomen (left) shows several dilated loops of small bowel in the upper abdomen. The small bowel is disproportionately dilated compared the the large bowel which is collapsed. The upright view (right) demonstrates multiple air-fluid levels in the dilated loops in a typical configuration of a small bowel obstruction. The patient had previous bowel surgery. For a larger photo of the same image, click here
CT may demonstrate the site and cause of the obstruction Dilated and fluid-filled loops of small bowel proximal to the obstruction and collapsed loops of small bowel and/or colon distal to the obstruction Small bowel feces sign is seen in SBO because of the intermixing of air with material that is static in obstructed small bowel, resembling the appearance of feces While adhesions are not imaged per se, their presence can be inferred by a rapid change in bowel caliber without any other causes of obstruction (e.g. tumor) suggested Signs of strangulation include thickening of the bowel wall, increased attenuation of the bowel wall, stranding of the adjacent small bowel mesentery or pneumatosis intestinalis CT may demonstrate tumors, Crohns disease, gallstone ileus, hernias, closed loop obstructions which are usually not diagnosable on conventional radiographs
CT of Small Bowel Obstruction. Axial CT scan through the lower abdomen shows multiple fluid-filled and dilated loops of small bowel (white arrows) and collapsed right colon (red arrow) consistent with a mechanical small bowel obstruction.
Closed-loop obstructions o Most (75%) are caused by adhesions o In a closed-loop obstruction, the twisted loop itself remains dilated with gas and fluid thus producing a dilated, U-shaped loop of small bowel Does not change in position or size over time Coffee bean sign or pseudotumor may be seen o Closed-loop obstructions are not usually diagnosable by conventional radiography and require CT
CT findings may include a U- or C-shaped loop of small bowel A spoke-like configuration of the mesentery demonstrating stretched vessels converging on the site of the twist may be seen The appearance of the tightly twisted mesentery has been called the whirl sign The beak sign may be seen as a fusiform tapering at the site of the obstruction Treatment of small bowel obstruction o Many patients are treated conservatively with small bowel decompression and intravenous fluids o Surgical intervention may be necessary if there are signs and symptoms of strangulation, peritonitis or lack of response to conservative treatment
Differentiating SBO from Paralytic Ileus

SBO
Etiology Pain Abdominal distension Bowel sounds Small bowel dilatation Large bowel dilatation
Ileus
Patient with prior surgery weeks to Recent (hours) post-operative patient years prior Colicky Frequently prominent Usually increased Present Absent Not a prominent feature Sometimes not apparent Usually absent Present Present
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61
A. Aortic Nipple B. Persistent left SVC C. AVM D. Cervical aortic arch
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A. Pancreatitis B. Ischemic colitis C. Appendicitis D. Hepatitis
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A. Splenic cyst B. CHF C. Mesothelioma D. Cirrhosis
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A. Depressed fracture B. Meningioma C. Osteoporosis circumscripta D. Prostate metastases
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Lisfranc Fracture-Dislocation
q q
q q
Named after Jacques Lisfranc, a field surgeon in Napoleons army, who described a new technique for an amputation used to treat frostbite of the forefoot in soldiers on the Russian front Used today to describe fractures and dislocations that occur at the junction between the tarsal bones of the midfoot and the metatarsals of the forefoot Causes r Mechanism involves severe plantar flexion of the foot r May occur from sports-related injuries r Motor vehicle accidents r Falling from a height, down stairs or off a curb Ligamentous injuries alone, even without fracture or dislocation, may result in instability on weightbearing Lisfranc ligament diagonally connects the 1st (medial) cuneiform with the base of the 2nd metatarsal st cuneiform or an avulsion of the base or medial border of the 2nd metatarsal r If it remains intact, either an avulsion of the lateral border of the 1 occurs r If it tears, these fractures may not occur Clinical findings r Pain at tarsal-metatarsal joints r Ecchymosis r Instability Types
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Two basic types s Homolateral s All of the metatarsals are dislocated to the same side s More common than divergent nd through 5th dislocated laterally s Usually involves the 2 s May involve all 5 metatarsals s Divergent s Usually more severe than homolateral st cuneiform s May be associated with a fracture of the 1 st metatarsal and lateral displacement of 2nd-5th metatarsals s Usually involves medial displacement of the 1 st metatarsal s Occasionally may involve only medial displacement of only the 1 Fractures associated with Lisfranc dislocations nd metatarsal r Base of 2 r Cuboid r Fractures of shafts of metatarsals st (medial) and 2nd (middle) and cuneonavicular joints r Dislocations of the 1 r Fractures of the tarsal navicular Imaging r Conventional radiographs are usually sufficient to demonstrate the injury r Normal alignment of the cuneiforms and the bases of the metatarsals (see chart below) st metatarsal is aligned with lateral border of 1st (medial) cuneiform on AP view s Lateral border of 1 nd metatarsal is aligned with medial border of 2nd (intermediate or middle) cuneiform on AP view s Medial border of 2 rd (lateral) cuneiform should align with medial and lateral borders of 3rd metatarsal on oblique view s Medial and lateral borders of the 3 th metatarsal aligned with medial border of cuboid on oblique s Medial border of 4 th metatarsal may project lateral to cuboid by as many as 3mm on oblique s Lateral margin of the 5 th metatarsal s On lateral, a line drawn along long axis of talus should intersect long axis of 5
r
Normal Alignment of Tarsal-Metatarsal Joints

Metatarsal AP Projection Oblique Projection
1st
Lateral border of 1st metatarsal is aligned with lateral border of 1st (medial) cuneiform
2nd
Lisfranc with arrows-2
Medial border of 2nd metatarsal is aligned with medial border of 2nd (intermediate) cuneiform
3rd
Medial and lateral borders of the 3rd (lateral) cuneiform should align with medial and lateral borders of 3rd metatarsal
4th
Medial border of 4th metatarsal aligned with medial border of cuboid
5th
Lateral margin of the 5th metatarsal can project lateral to cuboid by up to 3mm on oblique
On lateral view
Line drawn along long axis of talus should intersect long axis of 5th metatarsal
r r r
Stress views of the foot with the patient sedated will usually demonstrate any instability Lisfranc dislocations may be missed in up to 20% of cases Suspect it is present if there is a gap of more than 5 mm between bases of 1st and 2nd metatarsals or 1st (medial) and 2nd (middle or intermediate) cuneiforms On lateral view, bones of the midfoot will be subluxed or dislocated in a plantar direction
Lisfranc Fracture-Dislocation. The bases of all of the metatarsals are dislocated laterally in this homolateral Lisfranc dislocation. There was a fracture of the base of the 2nd metatarsal.
Lateral view of Lisfranc dislocation. Notice how the bones of the midfoot are dislocated towards the plantar aspect of the foot.
Treatment r Sprains with an otherwise stable tarsal-metatarsal joint can be managed with immobilization r Nonanatomic alignment requires open reduction and internal fixation
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A. Adrenal ca B. Adrenal met C. Adrenal hemorrhage D. Adrenal adenoma
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A. Tuberous sclerosis B. Eosinophilic granuloma C. Kartagener's syndrome D. Situs inversus
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Cong Absence Diaphragm

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Crohns disease
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Duodenal atresia
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Jackstone calculous
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Perforated rectum
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GI Thumbnails
Perforated rectum
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Rectal ca
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SBO
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Sprue
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Amyloidosis
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LearningRadiology - Abdominal Aortic Aneurysm (AAA)
| Home | Lectures | Notes | Images | Flashcards | Case of the Week Archives | | Bone | Cardiac | Chest | GI | Miscellaneous | Med Students | Most Common Lists |
Abdominal Aortic Aneurysm

q q
Focal widening >3 cm Normal size of abdominal aorta >50 years of age: r About 2 cm Prevalence: r Increases with age r Greater with atherosclerotic disease r Male predominance r Whites: Blacks = 3:1 Risk factors: r male r age >75 years r white race r prior vascular disease r hypertension r cigarette smoking r family history r hypercholesterolemia Associated with: r visceral + renal artery aneurysm (2%) r isolated iliac + femoral artery aneurysm (16%) s common iliac (89%), internal iliac (10%), external iliac (1%) r stenosis / occlusion of celiac trunk / SMA (22%) r stenosis of renal artery (22-30%) r occlusion of inferior mesenteric artery (80%) r occlusion of lumbar arteries (78%) Growth rate of aneurysm of 3-6 cm in diameter: r 0.39 cm / year Clinical r asymptomatic (30%) r abdominal mass (26%) r abdominal pain (37%) Location r infrarenal (91-95%) with extension into iliac arteries (66-70%) Imaging findings r Plain film s mural calcification (75-86%) r US:>98% accuracy in size measurement
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r
CT-non-contrast enhanced s perianeurysmal fibrosis (10%), may cause ureteral obstruction s "crescent sign" = peripheral high-attenuating crescent in aneurysm wall (= acute intramural hematoma) = sign of impending rupture CT-contrast-enhanced s ruptured aneurysm q anterior displacement of kidney q extravasation of contrast material q fluid collection / hematoma within posterior pararenal + perirenal spaces (see below)
free intraperitoneal fluid contained leak q laminated mural calcification q periaortic mass of mixed / soft-tissue density q lateral "draping" of aneurysm around vertebral body
q
Angio focally widened aortic lumen >3 cm r apparent normal size of lumen secondary to mural thrombus (11%) r mural clot (80%) r slow antegrade flow of contrast medium Contained rupture = extraluminal hematoma / cavity r absent parenchymal stain = avascular halo r displacement + stretching of aortic branches Complications: r Rupture (25%) s into retroperitoneum: commonly on left s into GI tract: massive GI hemorrhage s into IVC: rapid cardiac decompensation q Incidence: aneurysm <4 cm in 10%, 4-5 cm in 23%, 5-7 cm in 25%, 7-10 cm in 46%, >10 cm in 60% q Symptoms of rupture r sudden severe abdominal pain radiating into back r faintness, syncope, hypotension r Prognosis:64-94% die before reaching hospital r Increased risk: size >6 cm, growth >5 mm / 6 months, pain + tenderness
r
Peripheral embolization r Infection r Spontaneous occlusion of aorta Prognosis:17% 5-year survival without surgery r 50-60% 5-year survival with surgery Treatment r surgery recommended if >5 cm in diameter; r 4-5% surgical mortality for nonruptured s 30-80% for ruptured aneurysm Postoperative Complications r Left colonic ischemia (1.6%) with 10% mortality r Renal failure (14%) r 0-8% mortality rate for elective surgery
r
From Dahnert Radiology Review Manual 2002
http://www.learningradiology.com/notes/cardiacnotes/tapvrpage.htm
Total Anomalous Pulmonary Venous Return
TAPVR and PAPVR

Must have ASD for survival All have anatomical L to R shunt at atrial level
r
q q
All have functional R to L shunt of oxygenated blood to right side of heart
Two Types
l
Partial (PAPVR)
l
Mild physiologic abnormality Usually asymptomatic
Total (TAPVR)
l
Serious physiologic abnormalities
Partial Anomalous Pulmonary Venous Drainage (PAPVR) General

l
One of the four pulmonary veins may drain into right atrium Mild or no physiologic consequence Associated with ASD
l
Sinus venosus or ostium secundum types
Total Anomalous Pulmonary Venous Drainage (TAPVR)

l
All have shunt through lungs to R side of heart
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l
All must also have R to L shunt for survival

l
Obligatory ASD to return blood to the systemic side
All are cyanotic Identical oxygenation in all four chambers Types

l
Supracardiac Cardiac Infracardiac Mixed
Supracardiac TypeType I
l
Most common (52%)
Pulmonary veins drain into vertical vein (behind left pulmonary artery) to left brachiocephalic vein to SVC
DDx: VSD with large thymus Supracardiac Type 1X-ray Findings

l
Snowman heart = dilated SVC+ left vertical vein Shunt vasculature 2 increased return to right heart Enlargement of right heart 2 volume overload
Cardiac TypeType II
l
Second most common: 30% Drains into coronary sinus or RA

l
Coronary sinus more common
Increased pulmonary vasculature Overload of RV leads to CHF after birth 20% of Is and IIs survive to adulthood
l
Remainder expire in first year
Infracardiac TypeType III

l
Percent of total: 12% Long pulmonary veins course down along esophagus Empty into IVC or portal vein (more common) Vein constricted by diaphragm as it passes through esophageal hiatus Severe CHF (90%) 2 obstruction to venous return Cyanotic 2 right to left shunt through ASD Associated with asplenia (80%), or polysplenia Prognosis = death within a few days
Mixed TypeType IV
l
Percent of total: 6% Mixtures of types I III
WH/rev2002
Aortic Dissection
Aortic Dissection
q q q
3:1 male to female predominance Over the age of 40 Hemorrhage in the media (at vasa vasorum) leading to either r Tear in the weakened intima which breaks into the lumen, or r Hemorrhage in the wall (less common) r Hemorrhage separate media from adventitia
Predisposing factors o o o o o o o o Hypertension (most commonly) Atherosclerosis Cystic medial necrosis Marfans syndrome Coarctation of the aorta Aortic stenosis S/P prosthetic aortic valve Trauma (rare) Pregnancy (rare)
Aneurysm defined by size criteria o o In general, ascending aorta > 5 cm Descending aorta > 4 cm
Vessels involved with dissection o o o Any artery can be occluded Usually the right coronary and three arch vessels are involved with arch aneurysms Right pulmonary artery and left-sided pulmonary veins may be occluded
Types o o DeBakey Type I Involves entire aorta DeBakey Type II Least common Ascending aorta only DeBakey Type III Most common Descending aorta only Stanford Type A Ascending aorta involved Over half develop aortic regurgitation
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Aortic Dissection
Stanford Type B Ascending aorta NOT involved
Most dissections arise either just distal to the aortic valve or just distal to aortic isthmus True versus false channel o False channel usually arises anterior in the ascending aorta and spirals to posterior and left lateral in descending aorta o True channel is usually larger o Slower flow in false channel on MR
DeBakey Classification DeBakey Type I Stanford Classification Stanford Type A (ascending aorta involved) Stanford Type A (ascending aorta involved) Stanford Type B Portion of Aorta Involved Involves entire aorta Common causes Hypertension Atherosclerosis Cystic medial necrosis e.g.Marfans Ehlers-Danlos Hypertension Atherosclerosis RX Usually surgically*
DeBakey Type II (least common) DeBakey Type III (most common)
Ascending aorta only Descending aorta only
Usually surgically* Usually medically
*Goal is to prevent backward involvement of the aortic valve or rupture into pericardium
Clinical o o o o o Sharp, tearing, intractable chest pain Murmur or bruit of aortic regurgitation Previously hypertensive, now possible shock Asymmetric peripheral pulses Pulmonary edema
Imaging Findings o Chest films o MRI o CT Intimal flap Displacement of intimal calcification Differential contrast enhancement of true versus false lumen Intimal flap Slow flow or clot in false lumen Mediastinal widening Left paraspinal stripe Displacement of intimal calcifications Apical pleural cap Left pleural effusion Displacement of endotracheal tube or nasogastric tube
Aortic Dissection
CT of abdominal aorta show intimal flap (dark line) with true lumen anteriorly and false lumen posteriorly
Angiography Intimal flap Double lumen Compression of true lumen by false channel Increase in aortic wall thickness > 10 mm Obstruction of branch vessels
Diagnosis o o o o MRI if available is usually best for imaging ascending aorta Contrast-enhanced CT can image arch and descending aorta Transesophageal ultrasound, if available, especially for root and ascending aorta Angiography
Prognosis
Timing Immediate Within 24 hours By end of 1st week By 3 weeks By 3 months Alive at 1 year Death 3% 20-30% 50% 60% 80% 10-20%
WH/03
Aortic Dissection
LearningRadiology.com - Penetrating ulcer,aorta,rupture,aneurysm
Penetrating Aortic Ulcer

Submitted by Anthony Chang, MD
Ulceration of an atherosclerotic plaque which penetrates into the internal elastic lamina Hematoma then forms within the media of the aortic wall
Occurs in the elderly who usually have a history of severe atherosclerosis, hypertension, and hyperlipidemia Similar presentation to those with a descending thoracic aortic dissection i.e. acute chest or back pain Plaque ulceration usually in the middle to distal third of the descending aorta Intramural hematoma accompanies the penetrating ulcer 80% of the time Associated with abdominal aortic aneurysm Disease progresses from intimal plaque ulceration to media hematoma formation to adventitial saccular pseudoaneurysm formation and finally rupture if there is transmural penetration Speculated as the cause of descending or thrombosed type dissections with all three Radiographic findings Focal contrast collection projecting beyond the aortic lumen on CT o Intramural hematoma is indistinguishable from intraluminal thrombus Intimal flap is uncommon Intramural wall thickening or thrombus is frequently found On angiography, there is aortic wall thickening and the ulcerated plaque seen On MRI o High signal intensity on both T1 and T2 with subacute hematoma Can be demonstrated by computed tomography, magnetic resonance, angiography and transesophageal echocardiography Differential diagnosis: o Aortic dissection (has an intimal flap) o Atheroma has a low signal on both T1 and T2
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LearningRadiology.com - Penetrating ulcer,aorta,rupture,aneurysm
Treatment Surgical cases are those demonstrating hematoma expansion, impending rupture, inability to control blood pressure Patients routinely have co-morbid conditions that make them poor surgical candidates and are treated with transluminal placement of endovascular stent grafts
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LearningRadiology - Cardiac Radiology Curriculum
Course Outline Cardiac Radiology Conferences July, 2004 - June, 2005 Approximate Chronology of Conferences

ABCs of Heart Disease Introduction
Introduction to Congenital Heart Disease
Left-to-Right Shunts
Cyanotic Heart Disease
Obstructive Lesions
Valvular Lesions
Diseases of the Great Vessels
The Heart Inside Out
Miscellaneous Diseases
Differential Diagnoses in Cardiac Radiology
Review
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Scope of Cardiac Curriculum

1. Fundamental roentgenologic observations in the diagnosis of cardiovascular disease: The ABCs of Heart Disease 2. Left-to-right shunts
q q q q q
ASD VSD PDA TAPVR Endocardial cushion defects
3. Stenotic and insufficient valvular lesions

q q q q
Aortic stenosis and regurgitation Mitral stenosis and regurgitation Pulmonic stenosis Tricuspid insufficiency
4. 4. Primary pulmonary arterial hypertension and Idiopathic dilatation of the pulmonary artery 5. Abnormalities of cardiac position 6. Common congenital lesions
q q q q q q
Transposition Tetralogy of Fallot Truncus arteriosus Tricuspid atresia Ebsteins anomaly Hypoplastic left heart syndrome
7. CHF, cyanosis and cardiomegaly in the newborn 8. Vascular rings and slings 9. CHF 11. Coronary cineangiography-video available 12. Cardiac MRI-overview and selected lesions 13. Cardiac surgerytypes, sequelae
STR Cardiac Curriculum
Thoracic Aorta and Great Vessels 1. State the normal dimensions of the thoracic aorta 2. Describe the classifications of aortic dissection (DeBakey I,II, III; Stanford A, B), and implications
for classification on medical versus surgical management 3. State and recognize the findings of, and distinguish between each of the following on CT and MR: aortic aneurysm aortic dissection aortic intramural hematoma penetrating atherosclerotic ulcer ulcerated plaque ruptured aortic aneurysm sinus of valsalva aneurysm subclavian or brachiocephalic artery aneurysm aortic coarctation aortic pseudocoarctation 4. Recognize a right aortic arch and a double aortic arch on a radiograph, chest CT and chest MR 5. State the significance of a right aortic arch with mirror image branching versus with an aberrant subclavian artery 6. Recognize a cervical aortic arch on a radiograph and chest CT 7. Recognize an aberrant subclavian artery on chest CT 8. Recognize normal variants of aortic arch branching, including common origin of brachiocephalic and left common carotid arteries (bovine arch), separate origin of vertebral artery from arch 9. Define the terms aneurysm and pseudoaneurysm 10. State the common cardiac anomalies associated with aortic coarctation 11. State and identify the findings seen in Takayasus arteritis on chest CT and chest MR 12. State the advantages and disadvantages of CT, MRI/MRA and transesophageal echocardiography in the evaluation of the thoracic aorta Ischemic Heart Disease 1. Describe the anatomy of the coronary arteries and identify the following on a coronary arteriogram and CT scan right coronary artery left main coronary artery left anterior descending coronary artery left circumflex coronary artery 2. State the clinical significance of coronary arterial calcification on a chest radiograph 3. Recognize coronary arterial calcification on CT and state the current role of coronary artery calcium scoring with helical or electron beam CT 4. State which coronary artery is usually diseased when there is papillary muscle dysfunction 5. Describe the common acute complications of myocardial infarction, including left ventricular failure, myocardial rupture and papillary muscle rupture, and recognize radiologic findings that may indicate these 6. Describe the common late complications of myocardial infarction, including ischemic cardiomyopathy, left ventricular aneurysm, left ventricular pseudoaneurysm, coronary-cameral fistula, dyskinesis and akinesis and recognize radiologic findings that may indicate these 7. Identify left heart failure on a radiograph and chest CT 8. Recognize acute myocardial infarction on MR imaging 9. Define ejection fraction and state the normal left ventricular ejection fraction 10. Identify myocardial calcification on CT and state the etiology and significance of this finding 11. State the difference between a left ventricular aneurysm and pseudoaneurysm 12. Define and identify myocardial bridging on MR 13. Define the role of angiography, echocardiography, stress perfusion scintigraphy, chest CT, and chest MRI in the evaluation of a patient with suspected ischemic heart disease, including the advantages and limitations of each modality
Myocardial Disease 1. Define the types of cardiomyopathy (dilated, hypertrophic, restrictive) and list the common causes of each 2. Define right ventricular dysplasia and identify on MRI 3. State the most common benign primary cardiac tumors, including myxoma, lipoma, fibroma and rhabdomyoma 4. State the most common malignant primary cardiac tumors, including angiosarcoma, rhabdomyosarcoma, lymphoma 5. Distinguish cardiac tumor from thrombus on CT and MRI 6. State the most common malignancies to metastasize to the heart, and the appearance on a radiograph, chest CT and chest MR 7. State the advantages and disadvantages of echocardiography, CT, and MRI for evaluation of cardiomyopathy and cardiac tumors Cardiac Valvular Disease 1. State the findings that indicate each of the following and identify each on chest radiographs: enlarged right atrium enlarged left atrium enlarged right ventricle enlarged left ventricle 2. Recognize an enlarged left atrium, vascular redistribution, and mitral valve calcification on a chest radiograph and suggest the diagnosis of mitral stenosis 3. Recognize an enlarged ascending aorta and aortic valve calcification on a chest radiograph and suggest the diagnosis of aortic stenosis 4. State the most common etiologies of the following: aortic stenosis aortic regurgitation mitral stenosis mitral regurgitation tricuspid regurgitation pulmonary stenosis 5. State the cardiac diseases associated with mitral annulus calcification 6. Identify endocarditis and/or complications of endocarditis on radiographs, chest CT and chest MR 7. State the advantages and disadvantages of echocardiography and MRI for evaluation of valvular heart disease Pericardial disease 1. Recognize pericardial calcification on a radiograph and chest CT and list the most common causes 2. Describe and identify two chest radiographic signs of a pericardial effusion 3. State five causes of a pericardial effusion 4. State and recognize the findings of a each of the following on radiography, CT and MR: pericardial cyst constrictive pericarditis pericardial hematoma pericardial metastases partial absence of the pericardium pneumopericardium Congenital Heart Disease in the Adult
1. Recognize increased vascularity, decreased vascularity and shunt vascularity on a chest radiograph and state the common causes of each 2. Recognize the following on imaging examinations of the chest, including radiographs, CT and/or MRI: Heart disease presenting during adulthood Left-to-right shunts and Eisenmenger physiology Atrial septal defect Ventricular septal defect Partial anomalous pulmonary venous connection Patent ductus arteriosus Coarctation of aorta Tetralogy of Fallot and pulmonary atresia with ventricular septal defect Congenitally corrected transposition of the great arteries Persistent left superior vena cava Truncus arteriosus Ebstein anomaly Cardiac malposition, including abnormal situs Heart disease originally treated in childhood Coarctation of the aorta Tetralogy of Fallot and Pulmonary atresia with ventricular septal defect Complete transposition of the great arteries Congenitally corrected transposition of the great arteries Truncus arteriosus Commonly performed surgical corrections for congenital heart disease 3. Define the role of angiography, echocardiography, chest CT, and chest MRI in the evaluation of an adult patient with congenital heart disease, including the advantages and limitations of each modality depending on patient presentation. Monitoring and support devices tubes and lines 1. Be able to identify, state the preferred placement of, complications associated with malposition and identify the location on chest radiography for each of the following : endotracheal tube central venous catheter Swan-Ganz catheter feeding tube nasogastric tube chest tube intra-aortic balloon pump pacemaker and pacemaker leads automatic implantable cardiac defibrillator left ventricular assist device atrial septal defect closure device (clamshell device) pericardial drain extracorporeal life support cannulae intraesophageal manometer, temperature probe or pH probe tracheal or bronchial stent 2. Explain how an intra-aortic balloon pump works
LearningRadiology.com - Pericardial effusion,dilated,cardiomyopathy,enlarged,heart
Pericardial Effusion
Normal anatomy r Inner serous layer is the epicardium r Outer fibrous layer is pericardium r Space between the two is pericardial space r Normally contains about 20-50cc of fluid r Fat covers outside of heart and outside of pericardium sandwiching pericardial space between the two layers s Normal thickness of pericardium (parietal pericardium and fluid in space) is 2-4 mm Requires about 150-250cc before cardiac tamponade occurs r Tamponade compresses heart and causes low cardiac output r Most effusions do not lead to cardiac tamponade r Size of cardiac silhouette is frequently increased r Tamponade is rarely seen in association with pulmonary edema in the lungs
Causes of Pericardial Effusions Cause Remarks Myocardial infarction Most common Collagen vascular disease Especially Lupus Trauma Surgical or accidental Metastatic disease Serosanguinous effusion Tuberculosis Uncommon except in AIDS Viral infection Coxsackie B virus Uremia 18% in acute uremia
q
Other causes r Serous fluid = transudate s Congestive heart failure s Hypoalbuminemia s Irradiation r Blood = hemopericardium s Rupture of ascending aorta or pulmonary trunk s Coagulopathy r Fibrin = exudate s Pyogenic infection, e.g. staph s Uremia: 18% in acute uremia; 51% in chronic uremia; dialysis patient
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q
Imaging findings r "Water bottle configuration" is symmetrically enlarged cardiac silhouette s Major DDX is cardiomegaly r Loss of retrosternal clear space s Non-specific and frequently not valid r "Fat-pad sign" from separation of retrosternal from epicardial fat line >2 mm (15%)
Pericardial effusion on both frontal chest radiograph and axial CT. Red arrow points to fat outside of pericardium. Green arrow points to pericardial space which is 8 mm in this patient (<4 mm is
normal.) The yellow arrow points to fat outside of heart and the blue arrow to the myocardium.
r r
r q
Rapidly appearing cardiomegaly with normal pulmonary vascularity "Differential density sign" is increase in lucency at heart margin secondary to slight difference in contrast between pericardial fluid and heart muscle Diminished cardiac pulsations Echo r Separation of epi- and pericardial echoes extending into diastole (rarely behind LA)
LearningRadiology - CHF Sequence in Childhood
CHF IN CHRONOLOGIC SEQUENCE

CHF IN NEWBORN 1. 2. 3. 4. Hypoplastic Left Heart TAPVR Premature closure of foramen ovale Pulmonary atresia Acyanotic Cyanotic Acyanotic Cyanotic
CHF AFTER 1 WEEK OF AGE 1. 2. 3. 4. 5. Interrupted aortic arch (infantile coarct) Coarctation of the aorta-adult c VSD or PDA MS, MR, AI Cor triatriatum Cardiomyopathy
CHF IN 2nd-3rd WEEK 1. 2. Coarctation of the aorta Interruption of the aortic arch
CHF IN 1st-2nd MONTH

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LearningRadiology - CHF Sequence in Childhood
1. 2. 3.
Aortic stenosis Endocardial fibroelastosis Anomalous origin L coronary artery
CHF IN LATE CHILDHOOD

1. Aortic stenosis
CHF-LATE
1. Coarctation of the aorta adult type
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LearningRadiology - Pulmonary Sling and Double Aortic Arch
Pulmonary Sling & Double Aortic Arch
Pulmonary Sling
q
Pulmonary sling occurs because of failure of formation of Left 6th aortic arch so there is absence of Left pulmonary artery The blood to the Left lung comes from an aberrant Left pulmonary artery which arises from Right pulmonary artery and crosses between esophagus and trachea Bronchial cyst may produce same finding on esophagus/trachea
Pulmonary sling: The key view is the lateral where red arrow points to aberrant right pulmonary artery interposed between the esophagus and trachea.
Double Aortic Arch

q q q q q
Double aortic arch is most common vascular ring Caused by persistence of Right and Left IV branchial arches Rarely associated with Congenital Heart Disease Symptoms (of tracheal compression or difficulty swallowing) may begin at birth Right arch is higher, left arch is lower producing reverse S on esophagram in AP
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q q q
Right arch supplies Right common carotid and Right subclavian arteries Left arch supplies Left common carotid and Left subclavian arteries On lateral, arches are posterior to esophagus and anterior to trachea
Double Aortic Arch. Frontal chest shows impression on right-side of barium-filled esophagus from higher rightsided arch and below it an impression on the left-side of the esophagus from left-sided arch. Lateral film shows anterior displacement of both trachea and esophagus.
q
Anterior impression on the trachea alone may be caused by isolated anomalous innominate artery (arises from arch more distal than normal) or anomalous Left common carotid (originates more proximal than normal)
wh
WH
LearningRadiology.com - Constrictive Pericarditis,restrictive,pericardial,calcification,calcify
Pericardial Calcifications Constrictive Pericarditis

q
Calcification in the pericardium is most likely inflammatory in nature r Can be seen with a variety of infections, trauma, and neoplasms Calcification most commonly occurs along the inferior diaphragmatic surface of the pericardium surrounding the ventricles r Thin, egg-shell like calcification is more often associated with viral infection or uremia r Calcification from old TB is often thick, confluent, and irregular in appearance, especially when compared with myocardial calcification
PA and lateral close-ups show thick pericardial calcification around apex of heart from patient with history of tuberculous pericarditis
q
Calcification is seen in 1/3-1/2 of patients with constrictive pericarditis r Its presence does not imply constriction r Pericardial calcification must be differentiated from coronary artery calcification, valvular calcification, calcified myocardial infarct or ventricular aneurysm, left atrial calcification, or calcification outside the heart r This can usually be accomplished by the locations of these calcifications on multiple views, or the radiographic appearance of the calcium Constrictive Pericarditis
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LearningRadiology.com - Constrictive Pericarditis,restrictive,pericardial,calcification,calcify
Present when a fibrotic, thickened, and adherent pericardium restricts diastolic filling of the heart. r Usually begins with an initial episode of acute pericarditis s May not be detected clinically r This slowly progresses to a chronic stage consisting of fibrous scarring and thickening of the pericardium with obliteration of the pericardial space r This produces uniform restriction of the filling of all heart chambers Signs and Symptoms r Reduced cardiac output ( fatigue, hypotension, reflex tachycardia ) r Elevated systemic venous pressure ( jugular venous distension, hepatomegaly with marked ascites and peripheral edema ) r Pulmonary venous congestion ( exertional dyspnea, cough and orthopnea ) r Chest pain typical of angina may be related to underperfusion of the coronary arteries or compression of an epicardial coronary artery by the thickned pericardium. r Most impressive physical findings are often the insidious development of ascites of hepatomegaly and ascites, such patients are often mistakenly thought to suffer from hepatic cirrhosis or an intra-abdominal tumor.
r
Calcification of the pericardium is detected in up to 50 % of patients This finding is not specific for constrictive pericarditis o A calcified pericardium is not necessarily a constricted one o Lateral chest film is useful for its detection in the atrioventricular groove or along the anterior and diaphragmatic surfaces of the right ventricle. o Pleural effusions are present in about 60 % of patients Persistent unexplained pleural effusions can be the presenting manifestation CT or MRI are superior in the assessment of pericardial anatomy and thickness The diagnosis is confirmed by cardiac catheterization Treatment for constrictive pericarditis is complete resection of the pericardium
Acknowledgement to Eduardo Benchimol Saad, MD
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LearningRadiology - Pulmonic Stenosis
Pulmonic Stenosis
Pulmonic stenosis without VSD= 8% of all CHD Mostly asymptomatic When symptomatic, cyanosis and heart failure Loud systolic ejection murmur Cor pulmonale Rare calcification of pulmonary valve in older adults X-ray Enlarged main pulmonary artery Enlarged left pulmonary artery (jet stream effect) Normal to decreased peripheral pulmonary vasculature
Subvalvular pulmonic stenosis
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Infundibular pulmonic stenosis Typically in Tetralogy of Fallot Subinfundibular pulmonic stenosis Associated with VSD (85%) Valvular Pulmonic Stenosis Classic pulmonic stenosis (95%) Fusion of pulmonary cusps Presents in childhood Pulmonic click Dome-shaped pulmonic valve RX: Balloon valvulo-plasty Trilogy of Fallot Severe pulmonic valvular stenosis RV hypertrophy ASD with RL shunt Supravalvular pulmonic stenosis May be either tubular hypoplasia or localized with poststenotic dilatation May be associated with: Valvular pulmonary stenosis, supravalvular aortic stenosis, VSD, PDA, systemic arterial stenoses Williams-Beuren Syndrome: PS, supravalvular AS, peculiar facies Ehlers-Danlos syndrome Postrubella Syndrome: peripheral pulmonary stenoses, PDA, low birth weight, deafness, cataracts, mental retardation
WH/91
LearningRadiology - Right Aortic Arches

q
General
r
Most are asymptomatic

s Unless they cause encircling vascular ring like pulmonary sling Can be complex lesions requiring multiple projections
MRI or CT Left Aortic Arch With Anomalous RSCA

s r r r r r
Occurs in less than 1% of people RSCA passes posterior to esophagus Pushes trachea and esophagus forward Produces oblique shadow above aortic arch on frontal film Origin of RSCA may be dilated
s Diverticulum of Kommerell Right Aortic Arch
Types
s s
At least five different types Only two of importance

q q
Mirror Image Type Type I Aberrant left subclavian Type II
General
s s s s s s
Recognized by leftward displacement of barium-filled esophagus Of air-filled trachea Aortic knob is absent from left side Aorta descends on right Para-aortic stripe returns to left side of spine just above diaphragm Mirror-image type almost always has associated CHD Usually Tetralogy of Fallot Aberrant Left Subclavian type rarely has associated CHD
q
q Most common variety of right arch Type 1Mirror Image Type
s s s
Secondary to interruption of left arch just distal to ductus arteriosis Associated with congenital heart disease 98% of time X-ray Findings
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No posterior impression on trachea or barium-filled esophagus Heart is usually abnormal in size or shape q Aorta descends on right Type llAberrant Left Subclavian
q q s s
Secondary to interruption of left aortic arch between LCC and LSC arteries Associated with cardiac defects 5-10% of the time Tetralogy of Fallot most often (71%) ASD or VSD next most often (21%) q Coarctation of aorta rarely (7%) Anomalous left subclavian artery (retroesophageal and retrotracheal) Aorta descends on right X-ray Findings
q q q q q
s s s
Posterior impression on trachea and barium-filled esophagus Heart is usually normal in size and shape Aorta descends on right
Right aortic arch with aberrant left subclavian artery-Note aortic knob is on the right and the trachea is displaced toward the left instead of the right, as in normals. On the lateral film, note the trachea is bowed toward by the aberrant left subclavian artery which passes behind it
q
If there is a mirror-image right aortic arch, then 90% will have Tetralogy of Fallot r 6% with Truncus Arteriosis r 5% with Tricuspid Atresia If the person has the following lesions, then the association with a mirror-image arch is
r
Truncus arteriosis Tetralogy of Fallot r Transposition r Tricuspid atresia r VSD Double Aortic Arch
r r
33% 25% 10% 5% 2%
General
s s
Most common vascular ring Rarely associated with congenital heart disease
q Vascular ring produces tracheal and/or esophageal compression Caused by persistence of R and L IV branchial arches Passes on both sides of trachea Joins posteriorly behind esophagus Right arch is larger and higher Left arch is smaller and lower Barium swallow shows bilateral impressions on frontal view
s s s s s s
s s
Posterior impression on lateral view Angiogram is characteristic Clinical

q q
Symptoms may begin at birth and include

r r
Tracheal compression, or Difficulty swallowing
Anatomy Right arch supplies RSCA and RCC Left arch supplies LCC and LSCA X-ray Findings
q q q q
Right arch is higher and larger Left arch is lower and smaller q Produces reverse S on esophagram on AP q On lateral, arches are posterior to esophagus and anterior to trachea Cervical Aortic Arch
r
General Rare s Usually asymptomatic s May present as pulsating supraclavicular mass s May produce vascular ring and compress airway s Embryogenesis uncertain s Over 80% are right-sided Imaging FindingsRight-sided lesions
s
Right-sided cervical aortic arches Right apical mass-like density s Absence of aortic knob on left s Aorta descends on the left s Displace the trachea and esophagus forward s Branching may be normal or mirror-image Imaging FindingsLeft-sided lesions
s s s s s s
Left-sided cervical aortic arches Aortic knob at apex of lung Descend on the left Do not displace the trachea or esophagus forward
LearningRadiology - DDX of CHD
Differential Diagnosis of CHD
CYANOSIS WITH DECREASED VASCULARITY

1. 2. 3. 4. 5. Tetralogy Truncus-type IV Tricuspid atresia Transposition Ebsteins
L L L L L or or
J J
CHF IN NEWBORN
1. 2. 3. 4. 5. 6. Hypoplastic L Heart Syndrome Coarctation of the aorta Cong. aortic stenosis Mitral stenosis Cor triatriatum Pulmonary venous obstruction as in: Stenosis of the pulmonary veins
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CARDIOMEGALY WITH NORMAL VASCULATURE

1. 2. 3. 4. 5. Viral myocarditis Endocardial fibroelastosis Aberrant coronary artery (from PA LR shunt) Cystic medial necrosis of coronary arteries Diabetic mother
CYANOSIS WITH INCREASED VASCULARITY

1. 2. 3. 4. 5. Transposition Truncus types I,II,III TAPVR Tricuspid atresia Single ventricle
L L L L L
or
or
L J
=Cyanotic =Acyanotic =Cardiomegaly
WH/00
LearningRadiology - Cardiac Surgical Corrective Procedures
Congenital Heart Disease Surgical Corrective Procedures
AORTICOPULMONARY WINDOW SHUNT = side-to-side anastamosis between ascending aorta and left pulmonary artery (reversible procedure) used in Tetralogy of Fallot
BLALOCK-HANLON PROCEDURE = surgical creation of ASD: Complete transposition
BLALOCK-TAUSSIG SHUNT = end-to-side anastomosis of subclavian artery to pulmonary artery, performed ipsilateral to innominate artery/opposite to aortic arch: Tetralogy of Fallot, tricuspid atresia c pulmonic stenosis
FONTAN PROCEDURE = (1) external conduit from R atrium to pulmonary trunk (= venous return enters pulmonary artery directly) (2) closure of ASD: floor constructed from flap of atrial wall and roof from piece of prosthetic material: Tricuspid atresia
GLENN SHUNT = end-to-side shunt between distal end of right pulmonary artery and IVC; reserved for patients with cardiac defects in which total correction is not anticipated: Tricuspid atresia
POTT SHUNT = side-to-side anastomosis between descending aorta + left pulmonary artery: Tetralogy of Fallot
MUSTARD PROCEDURE = (1) removal of atrial septum (b) pericardial baffle placed into common atrium such that systemic venous blood is rerouted into left ventricle and pulmonary venous return into right ventricle and aorta: Complete Transposition
RASHKIND PROCEDURE
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LearningRadiology - Cardiac Surgical Corrective Procedures
= balloon atrial septostomy: Complete transposition
RASTELLI PROCEDURE = external conduit (Dacron) with porcine valve connecting RV to pulmonary trunk: Transposition
WATERSON-COOLEY SHUNT = side-to-side anastomosis between ascending aorta and right pulmonary artery (a) extrapericardial (WATERSON) and (b) intrapericaridial (COOLEY): Tetralogy of Fallot
WH/91
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LearningRadiology - Ebstein's Anomaly
Ebsteins Anomaly
Rare
POSTERIOR and SEPTAL cusps of tricuspid valve are displaced into the Right ventricle which makes Right ventricle smaller Combined with tricuspid insufficiency or sometime tricuspid stenosis, the Right Atrial pressure is elevated producing a R to L shunt through the foramen ovale Pulmonary vasculature is usually diminished In those with large atrial septal defects, the pulmonary vasculature may appear prominent There is an atrialized portion of the right ventricle between the AV groove and the tricuspid valve The right ventricle and right atrium dilate
The right heart border becomes prominent
Think of Ebsteins anomaly if:
o Pulmonary flow is decreased o Cyanosis is present in the neonate o One of the few conditions to produce cardiomegaly in the first few days of life
http://www.learningradiology.com/notes/cardiacnotes/ebsteinspage.htm04/09/2006 1:26:00
http://www.learningradiology.com/notes/cardiacnotes/syndromeswithchdpage.htm
Syndromes Associated With Congenital Heart Disease
DiGeorge Syndrome
Interrupted aortic arch
Downs syndrome (Trisomy 21)
Endocardial cushion defect (25%) Membranous VSD ASDostium primum AV communis Cleft mitral valve PDA 11 pairs of ribs Hypersegmented manubrium Single atrium Polydactyly
Ellis-Van-Creveld (50% CHD)
Holt-Oram syndrome (50% CHD)
ASD VSD Pulmonic stenosis Radial dysplasia Cardiomyopathy
Hurler syndrome
Ivemark syndrome
Asplenia Complex cardiac abnormalities Aortic sinus dilatation
Marfans syndrome
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Aortic aneurysm Aortic insufficiency Pulmonary aneurysm Pulmonic stenosis ASD Hypertrophic cardiomyopathy Peripheral pulmonic stenoses Valvular pulmonic stenosis Supravalvular aortic stenosis PDA Deafness Cataracts Coarctation of the aorta (in 15%) Bicuspid aortic valve VSD PDA Double outlet right ventricle VSD Tetralogy of Fallot Double outlet right ventricle Supravalvular aortic stenosis (33%) ASD VSD Valvular and peripheral pulmonary artery stenosis Aortic hypoplasia Stenoses of more peripheral arteries
WH
Noonan syndrome
Postrubella syndrome
Turner syndrome
Trisomy 16-18
Trisomy 13-15
William syndrome (Idiopathic hypercalcemia)
ABCs Page
The ABCs of Heart Disease

William Herring, MD, Bernard J. Ostrum, MD*
The ABCs of Heart Disease is a system for diagnosing cardiac disease in adults by asking certain questions in a set fashion, the answers to which are certain fundamental observations made from the frontal chest x-ray alone. The observations start with one that is widely used: The cardiothoracic ratio.
Heart size
The Cardiothoracic ratio is the maximum transverse diameter of the heart divided by the greatest internal diameter of the thoracic cage (from inside of rib to inside of rib). In normal people, the cardiothoracic ratio is usually less than 50%. Therefore, the cardiothoracic ratio is a handy way of separating most normal hearts from most abnormal hearts. But it is not infallible. A heart may be greater than 50% of the cardiothoracic ratio and still be a normal heart. This can occur if there is an extracardiac cause of cardiac enlargement. Extracardiac causes of cardiac enlargement include: Inability to take a deep breath because of Obesity Pregnancy, or
Ascites Or abnormalities of the chest that compress the heart such as Pectus excavatum deformity, or Straight Back Syndrome
Sometimes the heart can be smaller than 50% of the cardiothoracic ratio but still be an abnormal heart. This occurs when there is something obstructing the flow of blood from the ventricles since the ventricles respond at first by undergoing hypertrophy, which does not produce cardiomegaly. Since not all abnormal hearts are enlarged, definition of cardiac disease in those individuals depends on an assessment of the contours of the heart on the frontal film. There are 7 bumps in all on the frontal film, only 5 of which will have major importance in this system.
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ABCs Page
Cardiac Contours
1. On the right side of the heart, the first contour is that of the ascending aorta. This is a low density, almost-straight edge visible just to the right of the trachea anatomically representing the superior vena cava and the brachiocephalic vein but in practice reflecting the size of the ascending aorta. So we shall call this contour the ascending aorta. The ascending aorta can be small as in ASD or it can be convex outward as in aortic stenosis, aortic regurgitation, and hypertensive cardiovascular disease. The ascending aorta should never project farther to the right than the right heart border in a normal person. 2. Just below the ascending aorta is an indentation where the so-called double density of left atrial enlargement will appear when the left atrium enlarges toward the right side of the heart. Normally, the left atrium forms no border of the heart in the frontal projection. When the left atrium enlarges, it may produce two abnormal contours of the heart. One is on the left side of the heart which well learn about in a moment. The other is the double density of left atrial enlargement and is the less commonly seen of the two. Where the ascending aorta meets the right atrium, there is usually an indentation. In patients with an enlarged left atrium which projects to the right, there will be two overlapping densities seen where this indentation normally is. One of the densities is the normal right atrium. The other overlapping density is the enlarged left atrium. The double density may occasionally be seen in normal individuals; always check left heart border for straightening. 3. The last contour on the right side of the heart is the right atrium. In an adult, every disease that causes enlargement of the right atrium also produces enlargement of the right ventricle. So we can consider the right atrium and ventricle together as a single functional unit in adults and we will estimate right-sided cardiac enlargement by observing another cardiac contour, but not the right atrium. Therefore, for this system the right atrium is not an important contour. Now we move to the left heart border and start at the top. 4. On the left side of the heart, the first contour is the aortic knob. The aortic knob is a radiographic structure that is formed by the foreshortened aortic arch and a portion of the descending aorta. In normal people the aortic knob measures less than 35mm when measured from the lateral border of the trachea to the lateral border of the aortic knob. The knob will be greater than 35 mm due to increased pressure, flow, or changes in the elasticity of the wall e.g. cystic medial necrosis, ASCVD, dissection of the aorta. 5. Just below the aortic knob is the main or undivided segment of the pulmonary artery. The main pulmonary is very important in this system and forms the cornerstone for two of the main categories of disease to follow. First, you must be able to find the main pulmonary artery segment. Then, you can measure it. You can find the main pulmonary artery by either locating the first contour below the aortic knob or by finding the adjacent squiggly vessels that are the left pulmonary artery. The main and left pulmonary arteries are always
ABCs Page
adjacent to each other. We can measure the main pulmonary artery by drawing a tangent line from the apex of the left ventricle to the aortic knob and then measuring along a perpendicular to that tangent line, the distance between the tangent and the main pulmonary artery. In normal people, the distance between the tangent and the main pulmonary artery lies within a range of values between 0mm (the main pulmonary is touching the tangent line) to as far away from the tangent line (medially) as 15mm. Therefore, this sets up two major categories of abnormality. First, the main pulmonary artery may project beyond the tangent line (greater than 0 mm). This can occur if there is increased pressure or increased flow in the pulmonary circuit. Second, the main pulmonary artery may project more than 15 mm away from the tangent line. This can occur either because there is something intrinsically wrong with the pulmonary artery such as absence or hypoplasia of the pulmonary artery, e.g. Tetralogy of Fallot, truncus. But, these diseases are uncommon in adults. The other reason the main pulmonary artery may be more than 15 mm from the tangent line is the left ventricle and/ or aortic knob may enlarge and push the tangent line away from pulmonary artery, e.g. atherosclerosis, HCVD. These are very common diseases. Young females may normally have prominence of the MPA but rarely does the main pulmonary artery project beyond the tangent. 6. Just below the main pulmonary artery segment (area between the main pulmonary artery and the left ventricle) is a little concavity where the left atrium, when it enlarges on the left side of the heart, will appear. Filling in at this concavity by an enlarged left atrium produces straightening of the left heart border. It may be seen in mitral disease or shunt (VSD, PDA) and rarely left atrial myxoma, papillary muscle dysfunction and chronic CHF. Sometimes, the left atrial appendage may enlarge as well. A convexity at this contour means the left atrial appendage is enlarged and is seen in mitral valvular disease, usually mitral stenosis. 7. The last cardiac contour is the left ventricle. Like the right atrium, the left ventricle is not an important contour in this system. The best way to evaluate which ventricle is enlarged (i.e. right or left) is to look at the corresponding outflow tracts for each ventricle. If the heart is enlarged and the main pulmonary artery is large (sticks out beyond the tangent line), then the cardiomegaly is made up of at least right ventricular enlargement. If the heart is enlarged and the aorta is prominent (ascending, knob, descending), then the cardiomegaly is made up of at least left ventricular enlargement
ABCs Page
Once one ventricle is determined to be enlarged, then the other ventricle may also be enlarged but there is no way to identify this with a chest x-ray. Just a few words about the descending aorta. It is a contour seen through the heart to the left of the thoracic spine. It parallels the spine most of the time and is almost invisible. It may become tortuous or enlarged as in ASCVD or aortic regurgitation. So the five important cardiac contours are: The ascending aorta Indentation where double density of left atrial enlargement will appear Aortic knob Main pulmonary artery segment Indentation where the left atrium, when it enlarges, will appear on the left side of the heart
The right atrium and left ventricle are less important because we evaluate ventricular enlargement by looking at the outflow tracts for each ventricle.
Pulmonary Vasculature
Using just the cardiac contours we can come up with a set of differential diagnoses for cardiac disease, but to make the actual diagnosis we unfortunately have to look at the pulmonary vasculature. It is unfortunate because everyone has difficulty evaluating the pulmonary vasculature. In order to evaluate the pulmonary vasculature, we will examine three parameters. Before we do that, it is important to know that the pulmonary vasculature will fall into one of the following four categories: 1. 2. 3. 4. Normal Pulmonary venous hypertension Pulmonary arterial hypertension Increased flow
Decreased flow to the lungs is another category but is very difficult to assess accurately, so well not concern ourselves with it. To evaluate the pulmonary vasculature, we shall look at these three parameters: 1. Measure the right descending pulmonary artery (RDPA).
ABCs Page
The RDPA is visible on almost all chest films as a large vessel just to the right of the right heart border. Its diameter can be measured at about the level of the indentation between the ascending aorta and the right atrium. In normal people, the right descending pulmonary artery is less the 17mm in diameter. 2. Evaluate the distribution of flow from apex to base
In normal people, in the erect position, the blood flow to the bases is greater than the blood flow to the apices. This is due to the effect of gravity. In normal people, the size of the vessels at the base will therefore be greater than the size of the vessels at the apex. We can evaluate the size (not the number) of vessels in two imaginary circles about the size of a silver dollar, one drawn at the apex and another at the base of the lung. You have to use the right base because you cant see the vessels at the left base due to overlap by the heart. So look at the size of the vessels at the right base and compare them to the size of the vessels at either apex. In normal people, the size of the vessels at the base will be greater than the size of the vessels at the apex, so long as the film is done erect. In people with pulmonary venous hypertension, the blood flow to the apex becomes equal to or greater than the blood flow to the base. Therefore the size of the vessels at the apex becomes equal to or greater than the size of the vessels at the bases a reversal of the normal distribution pattern. This is known as cephalization. 3. Evaluate the distribution of flow from central to peripheral
Normally, the pulmonary vessels taper gradually from central to peripheral. It doesn't matter whether they are arteries or veins and it doesnt matter whether it is the lung or any other organ, blood vessels taper gradually from central to peripheral. In pulmonary arterial hypertension, there is a re-distribution of flow in the lungs from central to peripheral such that the peripheral vessels appear too small for the size of the central vessels from which they come. This discrepancy in the size of the central pulmonary vessels (which are large) compared to the peripheral pulmonary vasculature (which even though it is small is still indistinguishable from normal) is called pruning. Using the size of the RDPA and the distribution of flow in the lungsapex to base and central to peripheral, we can define the four states of the pulmonary vasculature. In NORMAL PULMONARY VASCULATURE The right descending pulmonary artery is less than 17mm The lower lobe vessels are larger than the upper lobe vessels There is a gradual tapering of the blood vessels from central to peripheral In PULMONARY VENOUS HYPERTENSION The right descending pulmonary artery is usually greater than 17 mm The upper lobe vessels are equal to or greater than the size of the lower lobe vessels (cephalization) There is a gradual tapering of the blood vessels from central to peripheral
ABCs Page
In PULMONARY ARTERIAL HYPERTENSION The right descending pulmonary artery is greater than 17mm The lower lobe vessels are larger than the upper lobe vessels There is a rapid decrease in the size of the peripheral vessels relative to the central vessels from which they come (pruning) In INCREASED FLOW The right descending pulmonary artery is greater than 17 mm The lower lobe vessels are larger than the upper lobe vessels There is a gradual tapering of the blood vessels from central to peripheral All of the blood vessels, everywhere in the lung, are larger than they should beupper and lower lobe, central and peripheral. But there is more blood flowing through all of the vessels so there appear to be more blood vessel in the lungs than there are in a normal person. That completes all of the observations you need to answer the set of questions that actually constitute The ABCs of Heart Disease. You have just learned the answers. Now, here are the questions.

The system depends for its success on the questions being asked in this order. Question A is: Is the left atrium enlarged? To answer that question, you look at the two places on the frontal chest x-ray where you may see left atrial enlargement - i.e., is there straightening of the left heart border and is there a double-density on the right heart border. If the answer to question A Is the left atrium enlarged is yes, then look at the pulmonary vasculature.
A Heart
Normal Vasculature Mitral Regurgitation Pulmonary venous hypertension Mitral stenosis Left atrial myxoma Papillary muscle dysfunction Look for pulmonary edema, effusions Normal or slightly enlarged heart Remarks Enlarged heart
ABCs Page
Left heart failure Increased flow VSD PDA Pulmonary arterial hypertension Mitral stenosis VSD, PDA Will also have pulmonary venous hyper. Will also have increased flow Enlarged aorta
If the answer to questions A Is the left atrium enlarged is no, then ask question B. Question B is Is the main pulmonary artery segment big or bulbous? To answer question B, you should draw the tangent line from the apex of the left ventricle to the aortic knob to see if the main pulmonary artery protrudes beyond the tangent line. If the main pulmonary artery projects beyond the tangent line, the answer to question B Is the main pulmonary artery enlarged is yes. If the answer to question B is yes, then look at the pulmonary vasculature.
B Heart
Normal Vasculature Pulmonic stenosis Left pulmonary artery sometimes enlarged
Idiopathic pulmonary artery dilatation Hyperdynamic states (e.g. anemia, hyperthyroid) Pulmonary venous hypertension None Increased flow (Left to right shunts) ASD VSD PDA Left atrium not always enlarged Left atrium not always enlarged Presupposes left atrial enlargement
Anomalous pulmonary venous return Pulmonary arterial hypertension Primary (idiopathic) Normal lungs
ABCs Page
Secondary (e.g. multiple pulmonary emboli, arteritis, COPD, Schistosomiasis-Lungs will be abnormal) If the answer to question B is no, then ask question C. Question C is Is the main pulmonary artery segment concave? To answer question C, use the same tangent from the apex of the left ventricle to the aortic knob, measure along the same perpendicular to the tangent, but this time look to see if the main pulmonary artery is more than 15 mm away from the tangent line. If the main pulmonary artery is more than 15 mm away from the tangent line, then the answer to question C Is the main pulmonary artery segment concave? is yes. If the answer to question C is yes, then were not going to look at the pulmonary vasculature; were going to look at the configuration of the aorta. The reason for this is that almost all C hearts have normal pulmonary vasculature so the vasculature wont help to differentiate one C heart from another. Instead, well look at the configuration of the aorta.
C Heart
Normal vasculature Hypertension ASCVD Aortic regurgitation Aortic stenosis Coarctation Cardiomyopathy Remarks Entire aorta prominent Entire aorta prominent Entire aorta prominent Ascending aorta prominent Notch in descending aorta Normal aorta
Pulmonary venous hypertension Cant be Increased flow None Except in rare truncus, pulmonary artery should be big Presupposes left atrial enlargement
Pulmonary arterial hypertension Cant be Presupposes big, not concave, main pulmonary artery
If the answer to question C is no, then the last question is D, Is the heart dilated or delta shaped? A dilated or a delta-shaped heart is usually one that is greater than 65% of the cardiothoracic ratio (a really large heart) and one with smooth contours such that almost as the same amount of heart projects to both the right and the left of the spine..
ABCs Page
The two main entities in the differential diagnosis for a dilated or delta-shaped heart are cardiomyopathy and pericardial effusion.
D Heart
Normal vasculature Pericardial effusion Cardiomyopathy Multiple valve disease Coronary artery disease Ebstein's Corrected transposition * With grateful acknowledgement to Bernard J. Ostrum, MD, who along with his father Joseph Ostrum, MD, both radiologists and both teachers, developed this approach to the diagnosis of heart disease by chest x-ray. Cardiomyopathy Big right heart Remarks Uremia, viral, mets, TB, trauma, post-MI Alcoholism, beri beri
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LearningRadiology.com- Mitral Stenosis, Rheumatic,Heart,Disease,MS,Mitral regurgitation,stenotic
Mitral Stenosis

Rheumatic disease causes mitral stenosis in 99.8% of cases Acute rheumatic fever (ARF) pancarditis o Mitral valve most commonly involved valve o Followed by mitral and aortic together o Then by aortic alone Acute phase cardiomegaly o Mitral regurgitation is valvular lesion of ARF o As acute phase subsides, fibrosis alters leaflet or cusp structure o Results in cuspal or leaflet thickening along valvular margins of closure Mitral Valve Calcification o Calcium usually deposited in clumps on valve leaflets o Heavier calcific deposits in men than women o Calcification of mitral annulus does not signify presence of mitral valve disease Occurs in older women Mitral orifice becomes smaller two circulatory changes o To maintain LV filling across narrowed valve, left atrial pressure goes up o Blood flow across mitral valve is decreased which m cardiac output Mitral Valve Areas o Normal mitral valve orifice 4-6 sq cm in adults o When reduced to <2 sq cm, LA pressure increases o Gradient across mitral valve is hallmark of mitral stenosis About 20 mm Hg in mitral stenosis MS and MR o Rheumatic mitral stenosis occurs with varying degrees of mitral regurgitation o When MS is severe, MR is relatively unimportant Effect of MS on Heart o Left atrium hypertrophies and dilates 2 pressure and volume load o Atrial fibrillation and mural thrombosis follow o Left ventricle is protected by stenotic valve Usually normal in size and contour Effect of MS on Lungs o Increased pulmonary venous and capillary pressure
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o o o
Chronic edema of alveolar walls fibrosis Pulmonary hemosiderin is deposited in lungs Pulmonary ossification may occur
Effect of MS on Lungs o Pulmonary arterial hypertension develops o First passively o Then 2 muscular hypertrophy and hyperplasia increased pulmonary vascular resistance Effect of MS on Right Ventricle o RV hypertrophies in response to increased afterload o Eventually RV fails and dilates o Causes dilation of tricuspid annulus tricuspid regurgitation Mitral Stenosis-Other Causes o Congenital Mitral Stenosis Exists as isolated abnormality 25% of time Coexists with VSD 30% of time Coexists with another form of left ventricular outflow obstruction 40% of time SHONES Syndrome Shones Syndrome o Parachute mitral valve o Supravalvular mitral ring o Subaortic stenosis o Coarctation of aorta o Infective Endocarditis Large vegetations occurring on previously normal mitral valve may produce MS o Carcinoid Syndrome Carcinoid of lung allows for prolonged exposure of mitral valve to serotonin May result in stiff, stenotic mitral valve o Fabrys Disease Deposition of aramide trihexoside thickens and decreases mobility of mitral leaflets o Hurlers Syndrome Deposition of mucopolysaccharide thickens and decreases mobility of mitral leaflets o Whipples Disease Same as gut lesions in mitral leaflets o LA Myxoma Most common form of primary cardiac tumor 86% of myxomas are found in left atrium 90% of myxomas are solitary Usually occur around fossa ovalis X-Ray Findings of MS o Cardiac Findings Usually normal or slightly enlarged cardio-thoracic ratio Straightening of left heart border
Convexity of left heart border 2 to enlarged atrial appendage--only in rheumatic heart disease X-Ray Findings of MS Cardiac Findings Small aortic knob from decreased cardiac output Double density of left atrial enlargement Rarely, right atrial enlargement from tricuspid insufficiency
Frontal radiograph of the chest shows a convexity in the region of the left atrium indicating left atrial enlargement from mitral stenosis. The patient was swallowing barium at the time of the exposure.
X-Ray Findings of MS-Calcifications o Calcification of mitral valve--not annulus--seen best on lateral film at fluoroscopy o Rarely, calcification of the left atrial wall 2 fibrosis from long-standing disease o Rarely, calcification of pulmonary arteries from PAH X-Ray Findings of MS-Pulmonary Findings o Cephalization o Elevation of left mainstem bronchus (especially if 90 to trachea) o With severe, chronic disease enlargement of the main pulmonary artery from pulmonary
arterial hypertension Mitral Stenosis-Echocardiographic Findings o In 90%, M-mode study will demonstrate flattening of E-F slope o Decreased diastolic excursions of mitral leaflets o Concordant anterior movement of anterior and posterior leaflets during systole Mitral Stenosis-Echocardiographic Findings o If left atrium > 5cm, increased incidence of o Atrial fibrillation o Left atrial thrombus o Systemic embolization Mitral Stenosis-Angiographic Findings o Ventriculography in 30 to 40 RAO projection usually used o Severity of lesion determined hemodynamically by simultaneously measuring o Pulmonary capillary wedge pressure o Left ventricular inflow tract pressure and o Cardiac output Mitral Stenosis-Angiographic Findings o Calcified, hypokinetic and domed mitral leaflets o Enlargement of left atrium o Left ventricle is small with a reduced ejection fraction Mitral Stenosis-Angiographic Findings o Mitral valve leaflets appear thickened and nodular and may appear to attach directly to the papillary muscle o Scarring and retraction of the chorda tendina
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LearningRadiology - Nine Most Common Congenital Cardiac Lesions
Decreased flow
Severe PS
Tetralogy of Fallot Tricuspid Atresia Ebsteins
Increased Flow
Transposition VSD

Hypoplastic left heart Coarctation of the aorta TAPVR with infradiaphragmatic obstruction
Whats left
Left-to-right shunts ASD
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LearningRadiology - Nine Most Common Congenital Cardiac Lesions
PDA Truncus arteriosus
WH
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LearningRadiology-Ventricular Aneurysm
Ventricular Aneurysms
Congenital left ventricular aneurysms o Rare o Young black adults o Produce abnormal bulge in region of left atrium or o Cardiac enlargement from aortic insufficiency o Acquired left ventricular aneurysms Usually complication of myocardial infarction May be associated with Persistent congestive heart failure Arrythmias Peripheral embolization Usually are either true or false aneurysms True ventricular aneurysms o Localized outpouching of ventricular cavity Associated with dyskinesia Wide-mouthed in connection with the LV o Anterolateral or apical wall o Frequently not visible on chest x-ray but may produce localized bulge of left heart border o Paradoxical expansion during systole o May have rim of calcium in fibrotic wall o Ventriculography is diagnostic Complications Thrombus with embolization Rarely rupture
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LearningRadiology-Ventricular Aneurysm
Enhanced CT scan at level of heart shows large left ventricular aneurysm partially filled with clot False or pseudoaneurysms o False aneurysm occurs when left ventricle ruptures into pericardial sac Pericardial adhesions contain rupture o Usually occurs on posterolateral wall o Diameter of mouth is smaller o Causes Myocardial infarction Trauma o Increase in size over serial films suggests false aneurysm This finding indicates the patient requires immediate attention o High risk of delayed rupture Calcification of left ventricular wall takes several years after myocardial infarction
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LearningRadiology.com - Rolando, Colle's, Bennett's, Barton's Fractures
Four Fractures of the Wrist
Rolando Fracture
q q q q
Bennett's Fracture
q
Comminuted Intra-articular Fracture through base of thumb Prognosis: worse than Bennett's fracture (difficult to reduce)
Intra-articular fracture/dislocation of base of 1st metacarpal Small fragment of 1st metacarpal continues to articulate with trapezium Lateral retraction of 1st metacarpal shaft by abductor pollicis longus
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LearningRadiology.com - Rolando, Colle's, Bennett's, Barton's Fractures
Barton's Fracture
q
Colles' Fracture
q q q
Intra-articular fracture of the dorsal margin of the distal radius Extends into radio-carpal joint
Extra-articular fracture of the distal radius Does not extend into joint space Dorsal angulation with radial and dorsal displacement of distal fragment Frequently associated with fracture of ulnar styloid
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LearningRadiology.com - Lunate, Perilunate Dislocation
Carpal Instabilities
Lunate Dislocation
q q q q
Most severe of carpal instabilities Most commonly associated with a trans-scaphoid fracture Involves all the intercarpal joints and disruption of most of the major carpal ligaments Produces volar dislocation and forward rotation of lunate Concave distal surface of lunate comes to face anteriorly Capitate drops into space vacated by lunate Capitate and all other carpal bones lie posterior to lunate on lateral radiograph Triangular appearance of lunate on frontal projection
r
q q q
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q q q
Result of a fall on an outstretched, hyperextended hand Relatively rare Occurs when the lunate maintains normal position with respect to the distal radius while all other carpal bones are dislocated posteriorly Very commonly associated with a scaphoid waist fracture Sometimes ulnar styloid as well Lunate appears triangular in shape on frontal view Lunate rotates forward slightly on lateral view In lateral view, all other carpal bones are dislocated posterior with respect to lunate
r
q q q
Lunate and Perilunate Dislocation
Carpal dislocations described by extent of ligamentous injury (Mayfield) r Stage I s Isolated rotatory subluxation of scaphoid q Mechanism: acute dorsiflexion of wrist q May be associated with rheumatoid arthritis q Characterized by increased distance between scaphoid and lunate > than 2 mm (Terry Thomas sign) q Scaphoid ring sign ring-shaped shadow of cortex of distal pole of scaphoid seen on end q Associated more than 50% of the time with distal radial fractures r Stage II
Dislocation or subluxation of capitate q Exceedingly rare Stage III s Perilunate dislocation q Triquetrial and scaphoid malrotation q Result of a fall on an outstretched, hyperextended hand q Relatively rare q Occurs when the lunate maintains normal position with respect to the distal radius while all other carpal bones are dislocated posteriorly q Very commonly associated with a scaphoid waist fracture r Sometimes ulnar styloid as well q Lunate appears triangular in shape on frontal view q Lunate rotates forward slightly on lateral view q In lateral view, all other carpal bones are dislocated posterior with respect to lunate Stage IV s Lunate Dislocation q Most severe of carpal instabilities q Most commonly associated with a trans-scaphoid fracture q Involves all the intercarpal joints and disruption of most of the major carpal ligaments q Produces volar dislocation and forward rotation of lunate r Concave distal surface of lunate comes to face anteriorly q Capitate drops into space vacated by lunate q Capitate and all other carpal bones lie posterior to lunate on lateral radiograph q Triangular appearance of lunate on frontal projection
s
Harris and Harris
LearningRadiology.com - Child Abuse,radiology,battered child syndrome
Battered Child Syndrome Child Abuse
q q q
q q
Most common cause of serious intracranial injuries in children less than 1 year of age 3rd most common cause of death in children after sudden infant death syndrome and true accidents Prevalence r 1.7 million cases reported, 833,000 of which were substantiated in United States in 1990 r Results in 2,500-5,000 deaths/year r 5-10% of children seen in emergency rooms suffer from child abuse Radiologist has legal obligation to report suspected child abuse, usually to the referring physician Age r Usually <2 years In children <2 years of age, a skeletal survey may be best to demonstrate other fractures r In children >2 years of age, a bone scan may be best Clinical findings r Skin burns r Bruises r Lacerations r Hematomas Skeletal trauma is seen in 50-80%
Skeletal Trauma Suspicious for Child Abuse

Site(s) Distal Femur, distal humerus, wrist, ankle Multiple Femur, humerus, tibia Posterior ribs, avulsed spinous processes Multiple skull fractures Fractures with abundant callous formation Metacarpal and metatarsal fractures Sternal and scapular fractures Vertebral body fractures and subluxations Remarks Metaphyseal corner fractures Fractures in different stages of healing Spiral fractures < 1 year of age Unusual naturally-occurring fractures <5years of age Multiple fractures of occipital bone should suggest child abuse Implies repeated trauma and no immobilization Unusual naturally-occurring fractures <5years of age
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Sites of skeletal trauma r Multiple ribs r Transverse fracture of sternum r Costochondral / costovertebral separation r Lateral end of clavicles r Scapula r Acromion r Skull r Vertebral bodies s Anterior-superior wedging of vertebral bodies s Vertebral compression s Vertebral fracture dislocation s Disk space narrowing s Spinous processes
Frontal radiograph of the chest demonstrates multiple rib fractures with callous formation, including a fracture of the left 2nd and 6th ribs posteriorly. Posterior rib fractures are highly suggestive of child abuse (from forceful squeezing)
q
Appearances of skeletal trauma r Hallmark of the syndrome are multiple, asymmetric fractures in different stages of healing r Separation of distal epiphysis r Marked irregularity and fragmentation of metaphyses s "Corner" fracture (11%) or "Bucket-handle" fracture = avulsion of a metaphyseal fragment overlying the lucent epiphyseal cartilage secondary to a sudden twisting motion of extremity r Isolated spiral fracture (15%) of diaphysis secondary to external rotatory force applied to femur / humerus r Extensive periosteal reaction from large subperiosteal hematoma r Exuberant callus formation at fracture sites
Cortical hyperostosis extending to epiphyseal plate r Avulsion fracture at site of ligamentous insertion s Frequently seen without periosteal reaction Head trauma (13-25%) r Most common cause of death and/or physical disability s Skull fracture (flexible calvaria + meninges decrease likelihood of skull fractures) s Subdural hematoma s Brain contusion s Cerebral hemorrhage s Infarction s Generalized edema s Shearing injuries with associated subarachnoid hemorrhage s Skull film (associated fracture in 1%): q Linear fracture > comminuted fracture r CT findings in head trauma s Subdural hemorrhage (most common) q Interhemispheric location most common s Subarachnoid hemorrhage s Epidural hemorrhage (uncommon) s Cerebral edema (focal, multifocal, diffuse) s Acute cerebral contusion appears as ovoid collection of intraparenchymal blood with surrounding edema r MR findings of head trauma s More sensitive in identifying hematomas of differing ages s White matter shearing injuries as areas of prolonged T1 + T2 at corticomedullary junction, centrum semiovale, corpus callosum Viscera (3%) r Second leading cause of death in child abuse r Cause s Crushing blow to abdomen (punch, kick) r Age s Often >2 years r Small bowel and/or gastric rupture r Hematoma of duodenum and/or jejunum r Contusion and/or laceration of lung, pancreas, liver, spleen, kidney r Traumatic pancreatic pseudocyst Differential diagnosis of child abuse r Normal periostitis of infancy r Osteogenesis imperfecta r Congenital insensitivity to pain r Infantile cortical hyperostosis r Menkes kinky hair syndrome r Schmid-type chondrometaphyseal dysplasia r Scurvy r Congenital syphilitic metaphysitis
r
Dahnert 5th edition Requisites-Pediatric Radiology Requisites-Musculoskeletal Radiology
LearningRadiology-Enchondroma
Enchondroma
q
Benign cartilaginous tumor Develops in the medullary cavity Composed of hyaline cartilage Occurs in 2nd to 3rd decade Most common site is small bones of the hand
r
Most common tumor of the hand
Also foot, humerus, femur, tibia and ribs Hand lesions are usually asymptomatic or associated with pain and swelling X-ray appearance
r
Well-defined lytic and slightly expansile lesion (in small bones) Usually have some internal calcification and endosteal thinning There may be cortical expansion or thickening
May fracture or, rarely, undergo malignant transformation r Growth of lesion or pain should suggest malignant transformation Multiple enchondromas is called Ollier's disease r Nonhereditary r May have limb shortening of affected limb r Madelungs deformity of the wrist r Enchondromas point toward the joint s Exostoses point away from joint r Greater incidence of malignant transformation because there are more lesions present (25%) With cavernous hemangiomas of soft tissues called Marfucci's Syndrome r Nonhereditary r Multiple hemangiomas usually on extremities (digits)
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LearningRadiology-Enchondroma
r r r r
Look for phleboliths in hemangioma Large enchondroma Growth disturbance of affected bones Malignant transformation s Greater than solitary enchondroma, less than Olliers s Hemangioma may become sarcoma in 5% of cases
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LearningRadiology - Multiple Hereditary Exostoses
Multiple Hereditary Exostoses

Diaphyseal Aclasis
q q
Inheritance r Autosomal dominant Age of onset r Discovered between 2 and 10 years Male predominance = 2:1 Pathology r Ectopic cartilaginous rest in metaphysis and a defect in periosteum produces exostoses r Cap of hyaline cartilage over bony protuberance r Cortex and cancellous bone of exostosis is contiguous to host bone Clinical r Usually painless mass near joints r Tendons, blood vessels, nerves may be impaired r Mechanical limitation of joint movement may occur Location r Multiple r Usually bilateral r Common sites are knee, elbow, scapula, pelvis, ribs
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Site Metaphyses of long bones near epiphyseal plate (distance to epiphyseal line increases with growth) r Always point away from joint and toward center of shaft r Occasionally small punctate calcifications are seen in cartilaginous cap Other skeletal abnormalities may occur r Shortening of 4th and 5th metacarpals r Supernumerary fingers and/or toes r Madelung / reversed Madelung deformity r Dislocation of radial head Prognosis r Exostosis begins in childhood r Stops growing when nearest epiphyseal center fuses Complications r Malignant transformation to chondrosarcoma in <5% s Iliac bone commonest site s Look for growth with irregularity of contour and fuzziness of margin s Sudden painful growth spurt r Cord compression secondary to involvement of posterior spinal elements
r
From Dahnert
LearningRadiology - Calcinosis Universalis
Calcinosis Universalis
q q q q q
Diffuse cutaneous, subcutaneous and sometimes muscular calcification Usually affects children and young adults Not actual bone formation More linear than calcifications in scleroderma (calcinosis circumscripta) Seen with dermatomyositis (polymyositis)
r
Dermatomyositis
s
Damaged chondroitin sulfate, atrophy of muscles, followed by calcification of muscle and subcu tissue Ages 5-10 and again in 50s
q
More common in females s Linear and confluent calcifications in soft tissues of extremities s Acro-osteolysis s Chest-may have infiltrates associated Clinically
s
Weakness of respiratory muscles s Erythematous rash of eyelids s Proximal muscle weakness s Associated with a high incidence of malignancies of GI tract, lung, ovary , breast, kidney May resemble myositis ossificans progressiva
r
Myositis ossificans progressive (fibrodyplasia ossificans progressiva)

s
Begins with subcutaneous, painful masses in neck Progresses down back over shoulders, chest, abdomen Rounded or linear calcification starting in neck More clumplike in places than calcinosis universalis Ossification of voluntary muscles
q
s s s
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LearningRadiology-Multiple Myeloma
Multiple Myeloma
q
Clinical r Average age is 60-70 r Men much more common than women r Most have an elevated serum protein with 80-90% in the globulin fraction, especially IgG r Bence-Jones protein in 40-60% of patients (light chains) X-ray findings r Osteoporosis is most common skeletal abnormality in this disease r Lesions are usually multiple and found in vertebrae, ribs, skull, pelvis, and femur r Over 50% of solitary lesions are found in vertebrae r Mandible involved in 1/3 of patients with diffuse involvement r Widespread lucencies in bone s Discrete, punched-out lesions s Uniform in size r Distinctive to MM are the lucent, elliptical, subcortical shadows, especially in long bones=endosteal scalloping s Due to buttressing since MM is usually a slower process than mets r In spine, MM destroys body and spares pedicle DDX: mets and disuse osteoporosis r MM is more widespread r More discrete holes in MM r Large foci of coalescence more often due to mets r Severe disuse osteoporosis may simulate bone changes of MM Sclerosis is usually seen only with treatment or fracture r Bone scans may typically be negative and many hot areas on scan may be healing fractures Most believe that almost all patients with a solitary plasmacytoma will develop multiple myeloma r Solitary plasmacytoma produces soap-bubbly expansile, septated lesion, when characteristic
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LearningRadiology-Multiple Myeloma
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LearningRadiology-Chance Fracture
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Chance Fracture
Originally most often caused by seat belts as hyperflexion injuries in automobile accidents o With lap belts, it is now seen more often with falls
Seat belt injuries usually involve the lower thoracic and upper to mid lumbar spine (L1 and L2 most commonly) Chance fractures are hyperflexion injuries in which there is distraction of the posterior elements and impaction of the anterior components of the spine o Compression component from hyperflexion is usually minor compared to distraction component Clinical findings o Back pain is the most common symptom o Ecchymosis of anterior abdominal wall should raise suspicion for the presence of this kind of fracture o Up to 50% of individuals with Chance fractures may also have serious blunt injury to internal organs Injuries involve primarily the pancreas, duodenum and mesentery The same mechanism of injury may not produce a fracture in children but may still be associated with intestinal and urinary bladder injuries o Since the spinal cord ends at T12-L1, injuries to cord are infrequent but the spinal nerves may be injured resulting in bowel and bladder signs Those with a kyphosis of less than 15 have a better neurologic prognosis o Mortality is the result of associated internal injuries Imaging findings o CT is the most sensitive study although conventional radiographs are usually obtained first o Horizontal fracture through the spinous process, laminae, pedicles and vertebral body o Vertebral body component may be less prominent than the distraction fractures of the posterior elements which are always present Vertebral body component may not be visible
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Chance Fracture. Reformatted sagittal CT of the lower thoracic spine demonstrates a horizontal fracture through the spinous process and pedicles (yellow arrow) and a compression fracture of the vertebral body (red arrow) characteristic of the hyperflexion distraction-impaction injury associated with lap seat belt injuries and falls. For a photo of the same image without the arrows, click here
o o o
There may be associated soft tissue swelling Open pedicle sign lucency on the medial aspects of the pedicles Posterior ligamentous complex tears
Up to 50% have injuries to Interspinous ligament Ligamentum flavum Facet capsule Posterior annulus Thoracodorsal fascia Treatment o Most Chance fractures are managed with immobilization o Instability is frequently associated with a kyphosis of 20 or more and a kyphosis of 30 or more usually requires internal stabilization o Main treatment for unstable fractures is surgical fixation with spinal canal decompression
LearningRadiology - Non-ossifying Fibroma
Nonossifying Fibroma
AKA: Nonosteogenic fibroma, fibroxanthoma, xanthogranuloma of bone
q q q
30 to 40% children over two years have one or more lesions Most common between 8-20 years of age Usually occur in metaphysis of one (75%) or more (25%) of the tubular bones
Most often occur in lower extremities around knee r Fewer than 10% occur in upper extremities Characteristics r Geographic r Lytic r Multilobulated r Metaphyseal r Usually intramedullary r Eccentric r Well-marginated r Sclerotic rim r Endosteal scalloping Most lesions heal spontaneously by being replaced with normal bone r Migrate away from epiphysis May undergo pathologic fracture or rarely cause rickets r Do not undergo malignant transformation
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LearningRadiology - Non-ossifying Fibroma
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LearningRadiology - Charcot's Arthropathy
Neuropathic (Charcot) Arthropathy

q
Disturbance in sensation leads to multiple microfractures r Pain sensation is intact from muscles and soft tissue Distribution and causes r Shoulders syrinx, spinal tumor r Hips tertiary syphilis, diabetes r Knees tertiary syphilis (more bone production), diabetes (less bone production) r Feet diabetes r Other causes s Amyloidosis s Congenital indifference to pain s Polio s Alcoholism X-ray findings r Sclerosis r Destruction of joint r Fragmentation r Soft tissue swelling from synovitis r Joint effusions r Osteophytosis r Disorganized and disrupted joint r No osteoporosis
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LearningRadiology - Charcot's Arthropathy
Marked sclerosis, fragmentation and joint destruction are the hallmarks of a neuropathic joint here cause by tabes
q
DDX
r
Degenerative joint disease s Eventually neuropathic joint shows more sclerosis s More fragmentation in neuropathic s More destruction of bone in neuropathic CPPD s Associated with chondrocalcinosis which a neuropathic joint is not
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LearningRadiology-Ochronosis
Ochronosis
Alkaptonuria
q
Rare hereditary disorder More common in males 2:1 Insufficiency of homogentisic acid oxidase Results in excessive homogentisic acid excreted in urine and deposited in soft tissue Urine may be black Sclera may be grey-brown or yellow Cartilage of nose and ears may be bluish in color Clinical findings are combination of spondylitis and arthritis of major joints
r r r
q q q q q q
When deposited in cartilage, synovial thickening develops This results in:

s
Subchondral cysts s Sclerosis s Osteophyte production, all secondary to DJD s Bony ankylosis may occur in joints or spine r Usually affects large joints-knees, shoulders, hips r Chondrocalcinosis of appendicular joints may develop In the spine: Changes of degenerative disc disease r Ligamentous structures mat be involved r Resembles ankylosis spondylitis r Universal disc space calcification is common Universal disc calcification and DJD of root joints (hips and shoulders) in younger patient are pathognomonic
r
Murray and Jacobson, 2nd ed, vol.2
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LearningRadiology-Ochronosis
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LearningRadiology - Charcot's Neuropathy of the Foot
Charcot Foot
Differential diagnosis r TB r Osteomyelitis r Gout More than 1/2 have presenting complaint of foot pain despite neurologic impairment Most common secondary to diabetes r Rarely syphilis Sclerosis or lysis near or away from ulceration Foot frequently shows ulceration Most difficult differential is from osteomyelitis r Osteomyelitis usually first involves metaphysis of MT joint Charcot usually involves MTP joint with astonishing joint destruction on initial radiograph.
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LearningRadiology-Osteochondritis Dissecans
Osteochondritis Dissecans
q q
q q
q q q
Sub-articular, post-traumatic necrosis Occurs only on convex surfaces of bone r Medial condyle of femur r Capitellum r Proximal surface of talus st metatarsal r Head of 1 Most patients are athletic Direct blow is more common cause than a rotational injury r Knee lesions are more common amongst high jumpers Most common cause of an intra-articular loose body In adults, loose body contains larger fragment of cartilage than bone Possible outcomes r Death of bony, but not cartilaginous, portion of loose body s Loose body is invisible except to MRI r Complete resorption of loose body r Reincorporation or regrowth s Usually not in adults s In children, fragment is less likely to separate from bone and therefore more likely to reincorporate Cause of a locking knee
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LearningRadiology - Osteomyeltis
Acute Osteomyelitis
Age
r
Usually affects children s Septic arthritis more common in adults; osteomyelitis in children
Hallmark characteristics r Destruction of bone r Periosteal new bone formation Organisms r Newborns s S. aureus s Group B streptococcus s E. coli r Children s S. aureus r Adults s S. aureus (most common) s Enteric species s Streptococcus r Drug addicts s Pseudomonas (most common) s Klebsiella r Sickle cell disease s Salmonella Pathogenesis r Hematogenous spread r Direct implantation from a traumatic / iatrogenic source r Extension from adjacent soft-tissue infection Location r Lower extremity (most common) s Over pressure points in diabetic foot r Vertebrae s Lumbar > thoracic > cervical r Radial styloid r Sacroiliac joint
ACUTE NEONATAL OSTEOMYELITIS

q
Age
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q q
Onset <30 days of age Little or no systemic disturbance Multicentric involvement more common r Often joint involvement Bone scan falsely negative / equivocal in 70% ACUTE OSTEOMYELITIS IN INFANCY
r
Age <18 months of age Pathomechanism r Spread to epiphysis through blood vessels Marked soft-tissue component Subperiosteal abscess with extensive periosteal new bone formation Complications r Frequent joint involvement Prognosis r Rapid healing
r
q q q
ACUTE OSTEOMYELITIS IN CHILDHOOD

q
Age 2-16 years of age Pathomechanism r Trans-physeal vessels closed r Primary focus of infection is in metaphysis Findings r Sequestration frequent r Periosteal elevation r Small single / multiple osteolytic areas in metaphysis r Extensive periosteal reaction parallel to shaft (after 3-6 weeks) r Shortening of bone with destruction of epiphyseal cartilage r Growth stimulation by hyperemia and premature maturation of adjacent epiphysis ACUTE OSTEOMYELITIS IN ADULTHOOD Delicate periosteal new bone Joint involvement common r Septic arthritis X-ray findings r Initial radiographs often normal for as long as 7-10 days r Localized soft-tissue swelling adjacent to metaphysis with obliteration of usual fat planes (after 3-10 days) r Area of bone destruction (lags 7-14 days behind pathologic changes)
r
q q
Bone destruction of head of 2nd metatarsal with periosteal new bone formation characteristic of osteomyelitis
q q q
Involucrum = cloak of laminated /spiculated periosteal reaction (develops after 20 days) Sequestrum = detached necrotic cortical bone (develops after 30 days) Cloaca formation = space in which dead bone resides MR findings r Bone marrow hypointense on T1WI + hyperintense on T2WI (= water-rich inflammatory tissue) DDx r Neuropathic osteoarthropathy r Aseptic arthritis r Acute fracture r Recent surgery r Ewings sarcoma Findings r Focal / linear cortical involvement hyperintense on T2WI r Hyperintense halo surrounding cortex on T2WI = subperiosteal infection r Hyperintense line on T2WI extending from bone to skin surface and enhancement of borders (= sinus tract) Nuclear Medicine (accuracy approx. 90%): r Ga-67 scans s 100% sensitivity s Increased uptake 1 day earlier than for Tc-99m MDP r Gallium helpful for chronic osteomyelitis Static Tc-99m diphosphonate r 83% sensitivity r 5-60% false-negative rate in neonates and children Complications of osteomyelitis r Abscess in soft-tissue r Fistula or sinus formation r Pathologic fracture
r r r
Extension into joint producing septic arthritis Growth disturbance due to epiphyseal involvement Severe deformity with delayed treatment
Dahnert 4th Edition
LearningRadiology-Chondrosarcoma
Chondrosarcoma
q q
q q q q q
Most often occurs in 5th or 6th decades Pelvis most frequent bone involved r Also femur, tibia, humerus Most often geographic bone lesion r Sometimes permeative r Destruction of bone occurs late in disease Large soft tissue mass is common Frequently calcifies with punctate or circular opacities May produce thickening of the cortex May have periosteal reaction Secondary chondrosarcoma r From pre-exiting skeletal lesion s Osteochondroma s Enchondroma s Parosteal chondroma
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LearningRadiology-Osteomyelitis of Skull
Osteomyelitis of Skull
q q
Two modes of spread r Direct extension from paranasal sinuses r Retrograde septic thrombophlebitis Epidural extension separates the dura from the inner table of skull r Removes major blood supply to the inner table of skull r Predisposes bone to widespread infection r Sutures tend to arrest progress for some time Dura is resistant to infection at first r Then yields to meningitis and abscess X-ray- findings become evident 7-10 days after infection starts r Early s Islands of normal bone s Increased or diminished density r Advanced s Lytic process Frontal sinus is most commonly involved Brain abscess is most common complication
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LearningRadiology - Osteopetrosis
Osteopetrosis
AKA: Albers-Schnberg Disease = Marble Bone Disease

q q q
Rare hereditary disorder Defective osteoclast function with failure of proper reabsorption produces sclerotic bone Structurally weak
Types
q
Infantile autosomal recessive type r Failure to thrive r Premature senility in facies r Dental caries r Anemia, leukocytopenia, thrombocytopenia r Cranial nerve compression (optic atrophy, deafness) r Hepatosplenomegaly (extramedullary hematopoiesis) r Lymphadenopathy r Subarachnoid hemorrhage may occur (due to thrombocytopenia) r May be associated with: s Renal tubular acidosis s Cerebral calcification r Prognosis: survival beyond middle age is uncommon (death due to recurrent infection, massive hemorrhage, terminal leukemia) Benign adult autosomal dominant type r 50% asymptomatic r Recurrent fractures r Mild anemia r Cranial nerve palsy (rarely) r Prognosis: normal r X-ray findings s Diffuse osteosclerosis s Cortical thickening with medullary encroachment s Erlenmeyer flask deformity = clublike long bones due to lack of tubulization + flaring of ends s Bone-within-bone appearance s "Sandwich" vertebrae=alternating sclerotic + radiolucent transverse metaphyseal lines
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LearningRadiology - Osteopetrosis
(phalanges, iliac bones) indicate fluctuating course of disease

s s
Longitudinal metaphyseal striations Mandible least involved
Complications: r Fractures (common because of brittle bones) with abundant callus + normal healing r Crowding of marrow (myelophthisic anemia + extramedullary hematopoiesis) r Frequently terminates in acute leukemia r Rx: bone marrow transplant DDx: r Heavy metal poisoning r Melorheostosis (limited to one extremity) r Hypervitaminosis D r Pyknodysostosis r Fibrous dysplasia of skull / face
From Dahnert
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LearningRadiology-Congenital Syphilis
Congenital Syphilis
q q q
q q
Passes placenta after the third month of gestation Osteoblasts eventually contain spirochetes Skeletal lesions early in disease are r Osteochondritis r Osteomyelitis (diaphyseal) r Periostitis r These all occur early in the course of disease Osteochondritis r Occurs at metaphysis r Widens the zone of provisional calcification until there is epiphyseal separation (usually before age 3 moths) r Dislocation is not pronounced r X-ray shows lucent metaphyseal band r Heals after 6 months of age Osteomyelitis r In skull, may get geographic areas of destruction Periostitis r Less common than osteomyelitis Course r Even if lesions at this stage are not treated, they regress r Remains latent for years and appears again around age 4 or later r In later life, lesion is gummatous or non-gummatous osteomyelitis r Usually affects skull, radius, tibia, ulna-especially skull and tibia r Saber tibia results from growth stimulation of the tibia with forward bowing (in rickets the bowing is lateral and not forward) r Also may get dactylitis, especially of proximal phalanx of index finger DDX: Birth trauma, rickets, severe malnutrition Other changes r Nose-saddle nose r Notched and narrowed incisors-Hutchinsons teeth r Periosteal reaction and new bone formation s Especially proximal 2/3 of tibia shaft common late manifestation Saber shin r Bilateral forward bowing of tibia is conclusive evidence for acquired, tertiary syphilis although similar changes can occur with congenital form r Acquired syphilis affects skull (mixed sclerosis and lysis) s Clavicle and tibia
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LearningRadiology-Congenital Syphilis
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LearningRadiology.com - Paget's Disease,Paget Disease,osteoporosis circumscripta
Osteoporosis Circumscripta
Pagets Disease
q q
Multifocal chronic skeletal disease due to chronic paramyxoviral infection Prevalence r 3% of individuals >40 years r 10% of persons >80 years r Unusual <40 years r M:F = 2:1 Histology r Increased resorption and increased bone formation r Newly formed bone is abnormally soft with disorganized trabecular pattern Active or Osteolytic phase r Aggressive bone resorption with lytic lesions r Replacement of hematopoietic bone marrow by fibrous connective tissue with numerous large vascular channels Inactive or Quiescent phase r Decreased bone turnover with skeletal sclerosis and thickening of the cortex Mixed pattern r Lytic and sclerotic phases frequently coexist Clinical findings r Asymptomatic (1/5) r When symptomatic, symptoms may include s Fatigue s Enlarged hat size s Peripheral nerve compression s Neurologic disorders from compression of brainstem (basilar invagination) s Hearing loss, blindness s Facial palsy (narrowing of neural foramina) - rare s Pain from(a)primary disease process is rare so think of q Pathologic fracture q Malignant transformation q Secondary degenerative joint disease aggravated by skeletal deformity s High-output congestive heart failure from markedly increased perfusion (rare) s Increased alkaline phosphatase (increased bone formation) s Hydroxyproline increased (increased bone resorption) s Normal serum calcium + phosphorus Sites of involvement r Usually polyostotic and asymmetric
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Pelvis (75%) most common, followed by q Lumbar spine q Thoracic spine q Proximal femur q Calvarium q Scapula q Distal femur q Proximal tibia q Proximal humerus Imaging Findings r Classical triad s Thickening of the cortex s Accentuation of the trabecular pattern s Increased size of bone r Cyst-like areas r Skull (involvement in 29-65%) s Inner and outer table involved q Leads to diploic widening s Osteoporosis circumscripta is well-defined lysis, most commonly in frontal bone producing well-defined geographic lytic lesion in skull q Represents early destructive phase of disease active stage
s
Osteoporosis circumscripta of frontal bone is lytic phase of Paget's disease

s
s s s r
"Cotton wool" appearance represents mixed lytic and blastic pattern of thickened calvarium (later stage) Basilar invagination with encroachment on foramen magnum Deossification and sclerosis in maxilla Sclerosis of skull base Long bones (almost invariably starts at end of bone) s "Candle flame" or "blade of grass" pattern of lysis is the advancing tip of V-shaped lytic defect in diaphysis of long bone originating in subarticular site s Lateral curvature of femur

s r
Anterior curvature of tibia (commonly resulting in fracture)
Pelvis Thickened trabeculae in sacrum, ilium s Rarefaction in central portion of ilium (looks like a large lytic lesion) s Thickening of iliopectineal line s Acetabular protrusio with secondary degenerative joint disease Spine (upper cervical, low dorsal, midlumbar most common sites) s Coarse trabeculations at periphery of bone s "Picture-frame vertebra" mimics bone-within-bone appearance q Enlarged vertebral body with reinforced peripheral trabeculae and more lucent center, typically in lumbar spine s "Ivory vertebra" is a blastic vertebra with increased density s Ossification of spinal ligaments, paravertebral soft tissue, disk spaces can occur Bone scan r Sensitivity s Scintigraphy and radiography (60%) q Scintigraphy only (27%) q Radiography only (13%) r Usually markedly increased uptake (symptomatic lesions strikingly positive) r Normal scan may occur in some burned-out lesions r Marginal uptake can be seen in lytic lesions Bone marrow scan r Sulfur colloid bone marrow uptake is decreased (marrow replacement by cellular fibrovascular tissue) MR r Hypointense area / area of signal void on T1WI + T2WI (cortical thickening, coarse trabeculation) r Widening of bone r Reduction in size and signal intensity of medullary cavity due to replacement of high-signalintensity fatty marrow by medullary bone formation r Focal areas of higher signal intensity than fatty marrow (from cyst-like fat-filled marrow spaces) r Areas of decreased signal intensity within marrow on T1WI and increased intensity on T2WI (= fibrovascular tissue resembling granulation tissue) Complications r Associated neoplasia (0.7-20%) r Sarcomatous transformation into osteosarcoma (22-90%) r Fibrosarcoma /malignant fibrous histiocytoma (29-51%) r Chondrosarcoma (1-15%) r Sarcomas are usually osteolytic in pelvis, femur, humerus r Giant cell tumor occurs in 3-10% s Lytic expansile lesion in skull, facial bones r Lymphoma or plasma cell myeloma are reported r Fracture s "Banana fracture" = tiny horizontal cortical infractions (Looser lines) on convex surfaces of lower extremity long bones (lateral bowing of femur, anterior bowing of tibia) s Compression fractures of vertebrae r Early-onset osteoarthritis
s

q
Treatment r Calcitonin, diphosphonate, mithramycin r Detection of recurrence: s In 1/3 detected by bone scan s In 1/3 detected by biomarkers (alkaline phosphatase, urine hydroxyproline) s In 1/3 by scan and biomarkers simultaneously DDx r Depends on the bone in which it occurs r Skull s Osteolytic or osteoblastic metastases r Long bones s Metastases s Chronic osteomyelitis (thickened cortex) s Old trauma (thickened cortex) s Hodgkins disease r Spine s Hemangioma s Metastases
Dahnert 4th Edition
LearningRadiology - Congenital Hip Dysplasia
Congenital Hip Dislocation

5-9 times more common in females 10 times more frequent in breech presentations Present at birth Bilateral in one-third of cases Almost never in blacks Ortlolani click r Dislocated by adducting; then relocated by abduction r Click is heard or felt on relocation Others who get dislocated hips Neurological disorders Hypothyroidism
q q q q q q
See also Table of Hip Diseases in Children
http://www.learningradiology.com/notes/bonenotes/conghipdysplasiapage.htm04/09/2006 1:27:00
LearningRadiology - CRST
CREST Syndrome
q q
More benign variant of scleroderma Consists of r Calcinosis s Calcinosis circumscripta q Usually of hands r Reynauds phenomenon r Sclerodactyly r Telangiectasias s Telangiectasias arise only on skin or mucous membranes of upper extremities or mouth s Telangiectasia is uncommon in scleroderma Internal organ involvement, except for GI, is less common in CRST
http://www.learningradiology.com/notes/bonenotes/crstpage.htm04/09/2006 1:27:01
LearningRadiology - PVNS, Pigmented Villonodular Synovitis
Pigmented Villonodular Synovitis PVNS
Benign synovial proliferation primarily affecting knees with erosions, cysts, soft tissue swelling but with preservation of the joint space, no osteoporosis or calcification. Pigment is hemosiderin. Clinical r Frequent history of antecedent trauma r Hemorrhagic "chocolate" effusion r Insidious onset of swelling r Pain of long duration r Decreased range of motion r Joint locking Age r Mainly 2nd-4th decade; 50% <40 years r F>M Location r Knee (most common) r Ankle r Hip r Elbow r Shoulder r Tarsal or carpal joints r Predominantly monarticular Radiographic findings r Soft-tissue swelling around joint s From effusion and synovial proliferation r Dense soft-tissues from hemosiderin deposits r Subchondral pressure erosions at margins of joint from hypertrophied synovium r Multiple sites of deossification appearing as cysts r No calcifications r No osteoporosis r No joint space narrowing (until late)
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AP and lateral views of the knee demonstrate marked soft tissue swelling, cystic changes in both the femur and tibia without significant joint space narrowing
q
MRI findings r Masses of synovial tissue in a joint with effusion r Scalloping / truncation of prefemoral fat pad r Predominantly low signal intensity on all sequences (due to presence of iron) (characteristic of this lesion) r Often heterogeneous low + high signal intensity on T2WI (hemosiderin deposits in masses + para-articular fat) r DDx s Hemosiderin deposits in other diseases (eg, rheumatoid arthritis) Treatment r Synovectomy r Arthrodesis r Arthroplasty r Radiation DDx r Synovial sarcoma s Mass around, but outside of, joint s Frequently calcify r Degenerative arthritis s Joint space narrowing s Subchondral sclerosis
Dahnert 4th edition
LearningRadiology-DISH
Diffuse Idiopathic Skeletal Hyperostosis (DISH)

q q q q
Laminated, flowing osteophyte formation Must involve four contiguous vertebral bodies Osteophytes are usually quite thick Involves lower cervical and lower thoracic spine most frequently r Disc space height tends to be maintained Whiskering at the sites of tendinous insertion r Pelvic involvement s Crests s Ischial tuberosities s Iliolumbar ligaments s Lesser trochanter r Deltoid tuberosities of humerus r Olecranon spurs DDX: r Ankylosing spondylitis r Acromegaly s May produce osteophytes but they are not flowing r Fluorosis may produce osteophytes, whiskering and ligamentous ossification s But all bones are uniformly increased in density
http://www.learningradiology.com/notes/bonenotes/dishpage.htm04/09/2006 1:27:04
LearningRadiology-Ping-Pong Fracture
Ping-Pong Fracture
q
Occurs in infants and small children r Bones of skull must be relatively soft, thin and resilient r Depressed skull fracture in which no fracture line is seen s In children under the age of 2, the sutures should be less than 3 mm s Over the age of three the sutures should be less than 2 mm
http://www.learningradiology.com/notes/bonenotes/pingpongfxpage.htm04/09/2006 1:27:06
LearningRadiology.com - pelvic avulsion fractures,pelvic,athletic,sports injuries
Pelvic Avulsion Fractures
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About Us
LearningRadiology-Fibrous Dysplasia
Fibrous Dysplasia
q q q q
q q q
q q q
Etiology unknown Most common 3-15 years Fundamental abnormality is replacement of medullary bone by fibrous tissue Clinically r Deformities s Shepherds crook deformity of femur r Bone pain Most commonly involved bones are pelvis, femora In widespread disease, the skull and jaw are almost always involved X-ray r Endosteal scalloping r Cortical thinning r Ground-glass appearance r May have matrix calcification Prone to fracture Growth of lesions usually stops when epiphyses close DDX: r Brown tumor r Unicameral bone cyst Albrights Syndrome r Polyostotic r Sexual precocity r Skin pigmentation r Almost always in a female Polyostotic form is usually bilateral
http://www.learningradiology.com/notes/bonenotes/fibrousdysplasiapage.htm04/09/2006 1:27:11
LearningRadiology-Protusio Acetabuli
Protrusio Acetabuli
q
q q q
Occurs most often with rheumatoid arthritis r Also occurs with osteoporosis r Osteomalacia r Pagets r Idiopathic Defined as 3mm or more between acetabular line and ilioischial line in men and 6 mm or more in women Erosion of cartilage in RA usually results in axial migration of head with uniform loss of joint space Protrusio acetabuli is usually bilateral Occurs more often in patients with RA who are on steroids r About 14% of patients with RA will demonstrate this abnormality
http://www.learningradiology.com/notes/bonenotes/protusioacetabulipage.htm04/09/2006 1:27:12
LearningRadiology-Friebergs Infraction
Friebergs Infraction
Usually head of 2nd metatarsal r But may affect other metatarsal heads as well Women to men by 4:1 r Possibly because of shoes r Usually adolescents Clinical r Local pain and tenderness Typical changes of avascular necrosis occur r End result is flattening of head r May produce loose body Other named avascular necroses: r Keinbocks-carpal lunate r Kohlers- tarsal navicular
http://www.learningradiology.com/notes/bonenotes/friebergspage.htm04/09/2006 1:27:13
LearningRadiology- Psoriatic arthritis, Psoriasis
Psoriatic Arthritis
Major points
q q q
Almost always accompanies skin disease, especially nail changes Mostly involves DIP joints of hands > feet Classical deformity is called cup-and-pencil deformity r Erosion of one end of bone with expansion of the base of the contiguous metacarpal
Radiograph of both hands demonstrates cup-and-pencil deformities of both thumbs and erosion of DIP joint of left middle finger
q q
There is often resorption of terminal phalanges There is usually no osteoporosis Most are HLA-B27 positive, RA factor negative Characteristic findings r Tends to involve smaller joints of hand and foot more than larger joints r Asymmetrical joint involvement r Affects both the juxta-articular and articular margins of joint
Seronegative Spondyloarthropathies Ankylosing spondylitis
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Psoriatic arthritis Reiters syndrome
q q q q
As with ankylosing spondylitis and Reiters syndrome, bone proliferation is a major feature. Manifests itself with: r Bony excrescences r Periosteal new bone formation (common) r Entire phalanx may become cloaked in new bone s Ivory phalanx q Most frequent in terminal phalanges of toes, especially first r Ankylosis is common s Especially in PIP and DIP joints of hands and feet q Feature common to seronegative spondyloarthropathies r Whiskering at sites of tendinous insertion (enthesopathy) occurs Soft tissue swelling of an entire digit (sausage digit) Destruction of IP joint of great toes with exuberant callous formation is characteristic Resorption of tufts of terminal phalanges is characteristic Spine r Asymmetric paravertebral ossification s Usually thicker and larger than syndesmophytes of ankylosing spondylitis or inflammatory bowel disease r Occasionally, there are incomplete non-marginal syndesmophytes similar to AS Bilateral sacroiliitis is most common r May produce erosions and sclerosis r May produce widening of the SI joints r SI joint involvement occurs in about 10-25% of patients with moderate to severe psoriasis
Patterns of Psoriatic Arthritic Changes Arthritis involving multiple joints with DIP joint involvement Arthritis resembling Rheumatoid Arthritis Sacroiliitis and spondylitis Arthritis mutilans
Resnick, 4th Edition
LearningRadiology.com - Gamekeeper's Thumb, Skier's Thumb, Break-dancer's thumb, radiology, injury, thumb, x-ray, photo, image
Gamekeepers Thumb
AKA: Skiers Thumb, Break-dancers Thumb
q q
Chronic injury to ulnar collateral ligament (UCL) of thumb first seen in gamekeepers in Scotland r Because of the method they used to kill rabbits Acute injury now more common amongst skiers r Called "Skier's thumb s Due to fall on fall on outstretched hand with abducted thumb caught in pole strap s May comprise up to 50% of injuries to hand in skiers May also be seen in rheumatoid arthritis Injury results in disruption of the ulnar collateral ligament at its site of insertion on the metacarpalphalangeal joint of thumb r UCL is short ligament that originates from the metacarpal head and inserts into medial aspect and base of proximal phalanx of thumb Often associated with a fracture of the base of the proximal phalanx
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Gamekeeper's or Skier's Thumb: fracture of base of proximal phalanx of thumb from tear of ulnar collateral ligament
q
Torn end of ulnar collateral ligament can be displaced to the abductor pollicis aponeurosis r Called Stener lesion s Distal portion of ligament retracts and points superficially and proximally s Rupture of both the proper and accessory collateral ligaments must occur for this to happen s Produces a lump over medial aspect of the MCP joint of thumb Full evaluation requires abduction stress views st metacarpal and proximal phalanx r Increase of more than 30 in angle between 1 s Indicates subluxation Treatment r Complete ruptures of the UCL require surgical intervention for repair within the first 3 weeks of the injury s Best done in 1st week while the anatomy is maintained s Complete tears repaired after 3 weeks have increased incidence of weakness and pain on pinch grasp. r Increased incidence of MCP joint arthritis has been noted in the long term
LearningRadiology-Pyle's
Craniometaphyseal Dysplasia Pyles Disease

q q
Unknown mode of inheritance Clinical r Large, broad head r Frontal bossing r Mental retardation r Cranial nerve abnormalities s Optic atrophy s Deafness s Facial nerve paralysis X-ray r Progressive, diffuse hyperostosis of cranial vault, skull base and facial bones r Accentuated bands of ossification along suture lines in skull r Obliteration of paranasal sinuses and mastoids r Flaring and widening of the metaphyses s Erlenmeyer flask deformity of the distal femur DDX r Undertubulation s Common in q Anemia q Fibrous dysplasia q Gauchers q Healing fractures s Uncommon q Caffeys Disease q Lead poisoning q Pyknodysostosis
http://www.learningradiology.com/notes/bonenotes/pylespage.htm04/09/2006 1:27:17
LearningRadiology - Giant Cell Tumor
Giant Cell Tumor

Osteoclastoma
q q
q q
Probably arise from zone of osteoclastic activity in skeletally immature patients Incidence r ~ 4% of all primary bone tumors r ~ 20% of benign skeletal tumors Histology r Multinucleated osteoclastic giant cells intermixed throughout a spindle cell stroma Age r > 98% after epiphyseal plate fusion s Most between 20 and 40 years M:F = 1:1 Clinical r Tenderness r Pain at affected site r Weakness r Sensory deficits (if in spine) Location: r 85% in long bones s Lower extremity (50-60% about knee) q Distal femur > proximal tibia s Upper extremity (away from elbow): q Distal radius > proximal humerus r 15% in flat bones s Pelvis s Sacrum near SI joints s Skull Site in bone r Eccentric r Metaphyseal s Adjacent to epiphyseal line q Subarticular if epiphyseal plate is fused
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Giant cell tumor of distal radius is eccentric and extend to the end of the bone
q
Appearance r Expansile r Solitary lytic bone lesion r May be quite large at diagnosis r No reactive sclerosis r No periosteal reaction in absence of fracture r May break through cortex with cortical thinning r Soft-tissue invasion (25%) r Pathologic fracture (5%) r Destruction of vertebral body with secondary invasion of posterior elements (DDx: ABC, osteoblastoma) s Frequently demonstrate vertebral collapse s Can involve adjacent vertebrae and disk (like discitis) and can cross sacroiliac joint r May cross joint space in long bones (exceedingly rare) Nuclear medicine findings r Diffusely increased uptake r May have "doughnut" sign of central photopenia Angiographic findings r Hypervascular lesion CT findings r Tumor has soft-tissue attenuation s May contain foci of low attenuation (hemorrhage/necrosis) r Well-defined margins r May have thin rim of sclerosis MR findings r Heterogeneous signal intensity with low to intermediate intensity on T1WI + T2WI (63-96%) due to collagen + hemosiderin content r Focal cystic areas r Low-signal-intensity pseudocapsule Complications and associations r 15% malignant within first 5 years
Much more often in males (M:F = 3:1) r Metastases to lung r May be associated with s Paget disease (in 50-60% located in skull + facial bones) Prognosis r Locally aggressive r 40-60% recurrence rate Treatment r Complete resection + radiation therapy DDx: r Aneurysmal bone cyst r Brown tumor (lab values) r Cartilaginous tumor s Chondroblastoma (open epiphyses) s Enchondroma (not epiphyseal) s Chondromyxoid fibroma (rare) s Chondrosarcoma r Fibrous dysplasia
s r
Dahnert 6th Edition
LearningRadiology - Radioosteonecrosis
Radiation-Induced Osteosarcoma
Radiation changes in bone occur above 3000 rads Growth disturbances Scoliosis or retarded growth of long bones Radiation osteonecrosis Especially mandible Tumor induction Radiation-induced tumors Benign tumors Benign exostoses have been reported in the treatment field of growing bones Malignant tumors Osteosarcoma is most common but undifferentiated fibrosarcoma is nearly as frequent Head and neck are most common sites for induced osteosarcoma Mandible in adults Orbits in children (retinoblastoma) Chondrosarcoma may also occur
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LearningRadiology - Radioosteonecrosis
Suspect clinically when pain and swelling occur in irradiated area many years after treatment Stage I carcinoma of the cervix can be treated with a combination of external and intracavitary radiation External dose was 4000 rads through four opposed fields Intracavitary dose was 3000 to 6000 rads to cervix but bones of pelvis receive little radiation normally
WH/
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LearningRadiology.com - Gout, Gouty arthritis, acute gout, photo, image, radiology, arthritis, foot, pain, x-ray
Gout
Deposition of sodium urate monohydrate crystals in synovial membranes, articular cartilage, ligaments, bursae leading to destruction of cartilage Age of onset is usually greater than 40 years; males much more often than females Causes: o Idiopathic Gout M:F = 20:1 Overproduction of uric acid Abnormality of renal urate excretion Secondary Gout
Rarely cause for radiographically apparent disease Myeloproliferative disorders, e.g. polycythemia vera, leukemia, lymphoma, multiple myeloma Blood dyscrasias Myxedema, hyperparathyroidism Chronic renal failure Glycogen storage disease Myocardial infarction Lead poisoning Stages: o Asymptomatic hyperuricemia o Acute monarticular gout o Polyarticular gout o Chronic tophaceous gout = multiple large urate deposits
Location: o Joints: hands + feet (1st MTP joint most commonly affected = podagra), elbow, wrist Carpometacarpal compartment especially common), knee, shoulder, hip, sacroiliac joint (15%, unilateral) Ear pinna > bones, tendon, bursa
Radiologic features usually not seen until 6-12 years after initial attack Radiologic features present in 50% of inflicted patients Soft tissue findings o Calcific deposits in gouty tophi in 50% (only calcium urate crystals are opaque) o Eccentric juxta-articular lobulated soft-tissue masses (hand, foot, ankle, elbow, knee)
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o o
Bilateral olecranon bursitis Aural calcification
Joint findings o Preservation of joint space initially o Absence of periarticular demineralization o Erosion of joint margins with sclerosis o Cartilage destruction late in course of disease o Periarticular swelling (in acute monarticular gout) o Chondrocalcinosis (menisci, articular cartilage of knee) resulting in secondary osteoarthritis
The great toe demonstrates extensive juxta-articular erosions with soft tissue swelling and little osteoporosis
Bone findings o "Punched-out" lytic bone lesion sclerosis of margin o "Mouse / rat bite" from erosion of long-standing soft-tissue tophus o "Overhanging margin" (40%) o Ischemic necrosis of femoral / humeral heads o Bone infarction
Coexisting disorders: o Psoriasis o Glycogen storage disease Type I o Hypo- and hyperparathyroidism o Downs syndrome o Lesch-Nyhan syndrome (choreoathetosis, spasticity, mental retardation, self-mutilation of lips + fingertips) Rx:colchicine, allopurinol (effective treatment usually does not change x-ray findings)
Dahnert, 4th Edition

LearningRadiology- Renal Osteodystrophy, Hyperparathyroid
Renal Osteodystrophy
Constellation of musculoskeletal abnormalities occurring with chronic renal failure featuring some combination of o o o o o o Osteomalacia (adults) Rickets (children) 2 hyperparathyroidism Soft-tissue calcifications Osteosclerosis Soft-tissue + vascular calcifications
Low calcium levels lead to osteomalacia o Additional factors responsible for osteomalacia are Inhibitors to calcification produced in the uremic state Aluminum toxicity Dysfunction of hepatic enzyme system A Renal insufficiency with diminished filtration results in phosphate retention Maintenance of Ca x P product lowers serum calcium directly, which in turn increases parathyroid hormone production (2hyperprathyroidsim)
Osteopenia o Combined effect of
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Osteomalacia (reduced bone mineralization due to acquired insensitivity to vitamin D / antivitamin D factor) o Osteitis fibrosa cystica (bone resorption) Osteoporosis (decrease in bone quantity)
Complications Fracture predisposition (lessened structural strength) with minor trauma Spontaneously
Fracture prevalence increases with duration of hemodialysis + remains unchanged after renal transplantation Sites of fractures o o o o o Prognosis Osteopenia may remain unchanged / worsen after renal transplantation + during hemodialysis Secondary hyperparathyroidism o Cause Inability of kidneys to adequately excrete phosphate leads to hyperplasia of parathyroid chief cells (2 hyperparathyroidism) o o o o Excess parathyroid hormone affects the development of osteoclasts, osteoblasts, osteocytes Vertebral body (3-25%) Pubic ramus, rib (5-25%) Milkman fracture / Looser zones (in 1%) Metaphyseal fractures
Hyperphosphatemia Hypocalcemia Increased PTH levels Subperiosteal, cortical, subchondral, trabecular, endosteal, subligamentous bone resorption
o Osteoclastoma = brown tumor = osteitis fibrosa cystica (due to parathyroid hormone -stimulated osteoclastic activity o o More common in 1 hyperparathyroidism
Periosteal new-bone formation (8-25%) Chondrocalcinosis More common in 1 hyperparathyroidism)
Osteosclerosis (9-34%) o One of the most common radiologic manifestations o o Most common with chronic glomerulonephritis
May be the sole manifestation of renal osteodystrophy Diffuse chalky density
o Thoracolumbar spine in 60% with dense end-plates produce appearance of rugger-jersey (rugger jersey spine)
Rugger-jersey spine in Renal osteodystrophy o Also in pelvis, ribs, long bones, facial bones, base of skull (children)
Prognosis May increase/regress after renal transplantation
Soft-tissue calcifications o Metastatic secondary to hyperphosphatemia (solubility product for calcium + phosphate exceeds 60-75 mg/dL in extracellular fluid) o Hypercalcemia Alkalosis with precipitation of calcium salts
Dystrophic secondary to local tissue injury Location Arterial (27-83%) o In medial + intimal elastic tissue o Dorsalis pedis a., forearm, hand, wrist, leg
Pipestem appearance without prominent luminal involvement
Periarticular (0-52%) o o o Multifocal Frequently symmetric May extend into adjacent joint
o o o
Chalky fluid / pastelike material Inflammatory response in surrounding tenosynovial tissue Discrete cloudlike dense areas Fluid-fluid level in tumoral calcinosis
Prognosis Often regresses with treatment
Treatment
o o o
Decrease of phosphorus absorption in bowel Vitamin D3 administration (if vitamin D resistance predominates) Parathyroidectomy for 3 hyperparathyroidism (= autonomous hyperparathyroidism)
Dahnert 5th edition
LearningRadiology-Hand-Shoulder Syndrome
Hand-Shoulder Syndrome
q
q q q
Pain, swelling and osteoporosis r Atrophy of the skin of the hand Etiology not known Reflex circulatory disturbance Seen secondary to r Myocardial infraction r Stroke r Trauma X-ray r Shoulder x-rays are usually negative r Hand shows osteoporosis, sometimes severe
http://www.learningradiology.com/notes/bonenotes/handshoulderpage.htm04/09/2006 1:27:25
LearningRadiology-Hand-Foot Syndrome
Hand-Foot Syndrome
q
One of earliest changes of sickle-cell disease Occurs in small bones of hands and feet resulting from infarction Patients are usually less than two years of age First starts with painful swelling Usually in proximal phalanx or metacarpal Periosteal reaction and bone destruction are present Heals in a few months Indistinguishable by x-ray from osteomyelitis
wh
http://www.learningradiology.com/notes/bonenotes/handfootsyndrome.htm04/09/2006 1:27:26
LearningRadiology - Round Cell Lesions By Age
Round Cell Lesions by Age
Lesion Neuroblastoma Histiocytosis Leukemia Ewings Sarcoma Reticulum Cell Sarcoma Multiple Myeloma
Usual Age Usually infants Usually infant or child About 5-15 years Teenager-early 20s Average age 30 Average age 56
http://www.learningradiology.com/notes/bonenotes/roundcellbyagepage.htm04/09/2006 1:27:27
LearningRadiology - Hemangiopericytoma of Bone
Hemangiopericytoma
q
Glomus tumor
r
May occur anywhere in bone, soft tissues, liver, etc.
Skeletal lesions are rare Most commonly have local pain Usually in young adults Solitary Most common in terminal phalanx of finger Lytic, expansile, hypervascular on angiography.
http://www.learningradiology.com/notes/bonenotes/hemagiopericytomapage.htm04/09/2006 1:27:28
LearningRadiology- Sacroiliitis
Sacroiliitis
q
Normal SI joint is uniform in size throughout Only lower 2/3 of SI joint are true joint Earliest sign of sacroiliitis is widening of the joint
r
Sclerosis and narrowing represent healing Unilateral Sacroiliitis

r
TB Bilateral and symmetric

r r
Ankylosing spondylitis Narrowing and sclerosis s Fusion eventually s Almost always bilateral Inflammatory bowel disease
s s
Ulcerative colitis more often then Crohns

q
Enteropathic arthritis more common in Crohns-usually knee s Inflammatory bowel disease usually does not affect the spine as often as ankylosing spondylitis Bilateral and asymmetric
r
Rheumatoid arthritis, psoriasis and Reiters may affect one SI joint but usually affect both Usually asymmetric Gout is a rare cause of sacroiliitis
s s
May see erosions in spine SI Disease in Crohns

r r r r
About 3-16% of patient with Crohns Occurs independent of activity of bowel disease HLA B27 antigen is usually elevated Bilateral SI joint narrowing and erosions with sclerosis
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LearningRadiology- Sacroiliitis
Identical appearance to AS SI Disease in Ulcerative Colitis

s r r r r r r
About 1-22% of patients with UC Not correlated with activity of bowel disease Spondylitis usually precedes onset of bowel findings Appears identical to AS More common in males Peripheral joint involvement in 50-70% Especially shoulders and hips Higher incidence of elevated HLA B27 in patients with spondylitis or iritis
s
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LearningRadiology-Hemophilia
Hemophiliac arthritis
q
Christmas disease is indistinguishable except milder Females can develop hemophilia if hemophiliac male marries female carrier Hemarthrosis most common in hinge joints, e.g. knee, elbow, ankle
r r r
Chronic synovitis develops from repeated intra-articular hemorrhages Thickened synovium produces marginal erosions Multiple subchondral cysts may develop secondary to intraosseous hemorrhage
X-ray
r r r
X-ray changes due to synovial proliferation and hyperemia Widening of the intercondylar notch of the femur Chronic hyperemia produces enlargement of epiphyses Especially medical condyle Secondary trabeculae are resorbed leaving linear striations in the bone Sometimes hemosiderin in soft tissues may make them appear dense
s
r r
From the increased blood to the epiphyses, the epiphyses may appear too early, grow too large, and fuse early Juvenile rheumatoid arthritis may simulate hemophilia changes in bone
r
JRA occurs more often in females
http://www.learningradiology.com/notes/bonenotes/hemophiliapage.htm04/09/2006 1:27:31
LearningRadiology - Slipped Capital Femoral Epiphysis
Slipped Capital Femoral Epiphysis

Rare less than nine years of age Boys more than girls Plain of cartilage changes during adolescence to more a more oblique one predisposing to easier slipping Higher incidence of slip from June through September Usually boys
r r r
q q
Blacks more often Ages 10 through 15 Usually heavier and or taller than others for their age
Younger in girls 8 to 15 years of age About 20 to 25 percent are bilateral, an occurrence more frequent in girls. X-ray Findings r Osteoporosis of head and neck on AP view early r Indistinct epiphysis-widened r Line along lateral edge of superior femoral neck on AP doesn't intersect epiphysis r Metaphysis displaced laterally so that it does not overlap posterior lip of acetabulum as normal r Late buttressing medial and posterior on neck Sequelae q Degenerative arthritis
q
Varus deformity Avascular necrosis 6 to 15%
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LearningRadiology - Slipped Capital Femoral Epiphysis
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LearningRadiology - Congenital Hip Dysplasia
Hip Diseases in Children

Disease Age Male/Female Bilaterality Race Best Film Other ORTALANI CLICK with leg flexed, dislocate by adduction, click on relocation with abduction
Congenital Hip Dysplasia
Birth
5-9x more common in females 10x more common if breech
Almost never in Blacks
APnot frog
1/3
Slipped Capital Femoral Epiphysis
Teenagers 1215 Heavy or tall Younger in girls (8-15)
Boys>girls June-September most often
1/4
Blacks more often
AP
Avascular necrosis in 6-15%
Legg- CalvePerthes Disease
5 years
Male> females
1/10
Bilateral in females is rare None
Frog lateral-for subarticular lucency
Arthrography usually neg Better prognosis under 5 Synovitis may be 1st sign
http://www.learningradiology.com/notes/bonenotes/hipstablepage.htm04/09/2006 1:27:34
LearningRadiology-Synovioma
Synovioma
Synovial Sarcoma
q q
q q
q q
Middle-aged and older adults Most frequent presentation: painful swelling of the knee r Predisposition for lower extremity It is a malignancy Can occur at any age r Usually third and fourth decades Usually are extra-articular X-ray r Soft tissue mass near articular surface r Frequently, spherical and lobulated in shape r 20-30% calcify r About 1/3 have adjacent erosion of bone s Look for erosions on both sides of a joint r Osteoporosis is common secondary to disuse s DDX from pigmented villonodular synovitis where there is rarely osteoporosis
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LearningRadiology-Synovioma
Frontal radiograph of the foot demonstrates a heavily calcified lesion which is arising from the dorsum of the foot between the 2nd and 3rd metatarsals.
q
q q q q
Can metastasize to lungs r Mets to lungs almost never calcify Mets to bone itself very rare Prognosis is poor Benign variety occurs in the joint capsule around knee DDX: r Tumoral calcinosis
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LearningRadiology-Hyperparathyroidism
Hyperparathyroidism
Calcium Phosphorous Alkaline Phosphatase Calcium Phosphorous Primary - or Secondary or - or Tertiary - or
Serum Urine
Primary Hyperparathyroidism Due mostly to adenoma of one or more glands with increase in chief or oxyphil cells Rarely hyperplasia Even rarer with carcinoma Skeletal lesions have been called osteitis fibrosa cystica or Von Recklinghausens 15-20% who have hyperparathyroidism have x-ray findings Absence of subperiosteal resorption strongly mitigates against the diagnosis Brown tumors-benign, well-defined, radiolucent lesion s Cystic lesion s May be multiple and look like mets s Pathologic fractures are common Soft tissue calcification is more common in secondary, except for knee medial meniscus calcification which is more common in primary
r r r r r r r
Secondary hyperparathyroidism r Hyperplasia r Rarely adenoma r Mostly chief or clear cell r Brown tumors less common r Soft tissue calcification more common r Calcified deposits around joints may mimic tumoral calcinosis
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LearningRadiology-Hyperparathyroidism
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LearningRadiology - Tuberculosis of bone
Tuberous Sclerosis
q q q q q
Autosomal dominant characterized by adenoma sebaceum, seizures and mental retardation Hamartomas in various organ systems 50 percent mentally retarded 80 percent have angiomyolipomas of kidneys Two-thirds have intracranial calcifications Calcifications in brain and dentate nucleus and basil ganglia r Calcification usually multiple 75% r Usually central - periventricular r Rarely in the cerebellum Also may have calvarial calcification in 40 to 50 percent of cases
r
q q
Involvement in the form of small areas of fairly well circumscribed hyperostosis r Usually unilateral in frontal-parietal bone 75 percent are dead by age 20 of CNS involvement CNS almost always involved by hamartomas
r
q q q q
Mostly periventricular. r X-rays may show periventricular, intracerebral and cranial vault calcifications r Usually multiple, increase with age r Produce candle guttering on CT Differential diagnosis from toxoplasmosis and CMD Adenoma sebaceum pink nodules on face in 90% are actually angiofibromas Also subungual fibromas and Shagreen patches About 65 percent have angiomyolipomas of kidney
r r r r r
About one half of patients with angiomyolipoma have tuberous sclerosis Usually asymptomatic, grow very slowly May be lucent on plain film Angiography may not be able to differentiate from hypernephromas
Bone
r r r
Most common are local areas of osteosclerosis Ovoid with poorly defined margins, Tendency for the lesions to cluster on the iliac side of the SI joints
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LearningRadiology - Tuberculosis of bone
Lung
r r
Very uncommon Diffuse interstitial disease
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LearningRadiology.com - Lead Poisoning, Lead, Intoxication, Plumbism, Poison, radiology, image, photo, x-ray
Lead Poisoning Plumbism
Pica Defined as persistent eating of non-nutritive material for 1 month or more Always search for lead lines in any child with an ingested foreign body Main source of lead intoxication is lead paint used in houses painted before 1980 Absorption is greater in children than adults r Lead may be inhaled as well as ingested s Symptoms develop more quickly through GI tract s Toxicity more severe with co-existing iron, zinc, or calcium deficiency Pathology r Lead concentrates in metaphyses of growing bones s Distal femur s Both ends of tibia s Distal radius leading to q Failure of removal of calcified cartilaginous trabeculae in provisional zone Clinical findings r Neurological s Learning disability s Decreased IQ s Mental retardation s Encephalopathy s Motor deficits s Seizures s Cerebral edema s Hearing loss r Gastrointestinal s Abdominal pain s Nausea s Vomiting s Diarrhea s Constipation s Anorexia s Metallic taste in mouth s Ileus r Renal s Tubular damage
r r
q q
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q s
Azotemia
Gout r Hematologic s Affects blood synthesis s Hemolysis s RBC stippling s Iron deficiency r Musculoskeletal s Muscle and joint pain r Soft tissue s Blue-black line in gum margins r Endocrine s Decreased stature q Decreased growth hormone s Decreased vitamin D levels Laboratory findings r Predate bone changes on x-ray r Serum Lead Level >1.2 umol/L r Urine lead level elevated r Peripheral Smear s Stippled erythrocytes r Complete Blood Count s Microcytic Anemia s Leukocytosis r Urine microscopy of sediment or renal biopsy s Acid-fast inclusion bodies in tubular nuclei q Pathognomonic for lead poisoning r Free Erythrocyte Protoporphyrin (FEP) > 0.6 umol/L Imaging findings r Cerebral edema in acute lead intoxication r Particles of lead in GI tract r Bands of increased density at metaphyses of tubular bones (growing bone) s Metaphyses of growing bones may be dense normally q Lead lines more apt to be seen in proximal fibula and distal ulna where growth is not as great as other long bones s Lead lines may persist
Frontal radiograph of both knees of a child with lead poisoning show dense metaphyseal bands involving not only distal femurs and proximal tibias but proximal fibulas as well
r r
Bone-in-bone appearance Abnormalities in bone modeling s Erlenmeyer flask appearance to distal femur DDx (see tables below) Treatment r Surgical removal of lead foreign bodies in the gut (e.g. dice containing lead) if not eliminated within 2 weeks r Chelation is indicated if the level is greater than 45 mcg/dL even if asymptomatic s First correct iron deficiency r Chelating agents include EDTA, BAL, D-Penicillamine, and Succimer
q q
Lucent Metaphyseal Bands Normal Leukemia Neuroblastoma TORCH infection
Dense Metaphyseal Bands Normal Lead poisoning Treated leukemia Healing rickets
LearningRadiology-Tumoral Calcinosis
Tumoral Calcinosis
q q q
Progressively enlarging, juxta-articular, calcified, nodular soft-tissue masses Mostly occurs in 1st or 2nd decade Equal M:F Predominantly African-Americans Normal calcium and phosphorous
r
q q
No renal, metabolic or collagen-vascular disease Autosomal dominant with variable expressivity Pathology: multilocular cystic lesions containing creamy white fluid
r
Hydroxyapatite crystals in suspension Clinical

r
Painful/painless soft tissue mass r Hips>elbows>shoulders>feet r Not knees Imaging

r r r r
Large, nodular, smoothly-marginated juxta-articular masses of calcium density Fluid-fluid levels on erect films due to Milk of Calcium in lesion Underlying bone normal
WH
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LearningRadiology-Tumoral Calcinosis
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LearningRadiology - Legg-Calve-Perthe's Disease
Legg-Calve-Perthe's Disease
q
Peak incidence is five years with a range of 2-14 years Bilateral in 10% Males greater than females r Bilateral involvement in females is very rare The first sign is subarticular translucency seen best on frog lateral Then epiphysis becomes flattened, fragment and dense With revascularization there is gradual reformation of femoral head. Since there is less bone to reform, prognosis is better for those under five years of age than in older children. Arthrography will, except in severe cases, be normal because cartilage derives its nutrition from synovial fluid. First sign may be joint effusion as shown by lateral displacement of femoral head Poor prognosis if there is severe and lateral displacement of metaphysis, by involvement of lateral aspect of head, and by flattening of cartilage seen on arthrography.
http://www.learningradiology.com/notes/bonenotes/leggperthespage.htm04/09/2006 1:27:43
LearningRadiology.com - Volar Plate Fracture,fracture,mallet finger,impacted
Volar Plate Fracture

q
q q q q
Volar plate forms floor of PIP joint and separates the joint space from the flexor tendons r Volar plate is ligamentous at its origin on the proximal phalanx r Cartilaginous in its insertion onto the middle phalanx Hyperextension injury Involves PIP joint of fingers Primarily a ligamentous injury that can result in fracture Injury to the PIP joint is relatively common in athletics, especially sports involving ball-handling r Jammed finger If force of injury is great enough, dorsal dislocation can occur r Rupture of volar plate may occur with longitudinal splitting of the collateral ligament structures s Allows for complete dorsal displacement of middle phalanx s Simple dislocations easily reduced by player coach, or trainer on the field s Following reduction, most dorsal dislocations are stable Fractures of base of middle phalanx also occur in association with dorsal dislocations r If fracture involves more than 40-50% of articular surface s Collateral ligament support is lost s Combined with coexistent volar plate disruption q Represents major loss of joint stability q These injuries are often unstable, exhibiting persistent subluxation of the middle phalanx Imaging findings r Small fragment of bone is avulsed from palmar (volar) aspect of base of middle phalanx
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There is a small avulsed fragment of the base of the middle phalanx from a volar plate injury

q
Complications r Joint instability r Associated collateral ligament tear may heal with abundant fibrous tissue producing bump on one side of joint
Michael E. Robinson, MD eMedicine
http://www.learningradiology.com/notes/chestnotes/alpha1anti.htm
a-1 Antitrypsin Deficiency
Rare autosomal recessive a-1 antitrypsin is synthesized in the liver and released into the blood It acts as a proteolytic inhibitor of trypsin, chymotrypsin, elastase, plasmin, thrombin, kallikrein, proteases, and it neutralizes circulating proteolytic enzymes
With a deficiency of a-1 antitrypsin, then PMNs and alveolar macrophages sequester in lungs and release elastase which digests basement membrane
Early onset (20-30 years) Male: female ratio of 1:1 Rapid and progressive deterioration of lung function Severe panacinar emphysema
X-ray
q
Basilar predominance Bullae at both lung bases Marked flattening of the diaphragm Redistribution of blood to the upper lung zones Associated with cirrhosis in homozygous individuals
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LearningRadiology - Mycoplasma pneumonia
Mycoplasma Pneumonia (Primary atypical pneumonia)

q
Commonest cause of nonbacterial pneumonia Mild course; lasts 2-3 weeks Peak in autumn and winter Common (1/3 of all pneumonias) in service personnel Organism: Eaton agent=pleuropneumonia-like organism (PPLO) probably a bacterium
Clinical
One group has acute onset of fever, cough, chest pain associated with segmental pneumonia Other group has 1-4 week history of lethargy and SOB and is usually associated with interstitial disease May have bullous myringitis Cultures take 3 months so 4X rise in cold agglutinins is used in diagnosis
X-ray
Acute interstitial infiltrate in lower lobes radiating from hila (early) Then alveolar infiltrates, usually unilateral and almost always segmental Usually lower lobes Small pleural effusion in 20% Rare hilar adenopathy
Complications
q
Meningitis Encephalitis
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LearningRadiology - Mycoplasma pneumonia

q
Stevens-Johnson syndrome (erythema multiforme, high fever, stomatitis and pneumonia) Erythema nodosum
WH/91, 93
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LearningRadiology - Actinomycocis
Actinomycosis
Caused by actinomyces israeli, a gram+ pleomorphic anaerobic bacterium related to the morphology of a fungus and Mycobacteriumnot acid fast
At one time, it was the most common pulmonary fungal disease White or yellow sulfur granules in exudate are really mycelial clumps Rod shaped form is found normally in dental caries, gingival margins, tonsillar crypts and GI tract People with very poor dental hygiene and those that are immunosuppressed are predisposed Affects mandibulofacial area, intestinal tract and lung, in that order
Mandibulofacial
q
Osteomyelitis of the mandible with soft tissue mass lumpy jaw
Intestinal
q
Resembles Crohns disease May produce rupture of a hollow viscous, especially appendix May produce fistula formation
Pulmonary
Consolidation which extends across fissure peripheral and lower lobe

s
DDX for lung consolidation which extends through chest wall:

q
Blastomycosis TB Crytococcosis
Abscess Empyema
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LearningRadiology - Actinomycocis
Osteomyelitis of the rib wavy periosteal reaction, rarely rib destruction Draining chest wall sinuses If chronic, it results in severe fibrosis
WH/91
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LearningRadiology - Neurogenic Tumors
Posterior Mediastinal Masses

Neurogenic Tumors
Peripheral nerve origin Neurofibromas Neurilemomas (Schwannomas) Sympathetic nerve origin Ganglioneuromasusually benign Neuroblastomasusually malignant Sympathicoblastomasusually malignant Paraganglionic cells Pheochromocytoma Chemodactomas (paragangliomas)benign or malignant
q
Posterior mediastinum is bordered anteriorly by the pericardium and posteriorly by the anterior border of the spine, so that the paravertebral gutters are technically excluded from the posterior mediastinum but for practical purposes are considered part of it Contains the descending aorta, esophagus, thoracic duct, vagus nerves and nodes About 30% of posterior mediastinal masses are malignant Nerve sheath tumors are the most common and are usually benign; neoplasms which arise from nerve elements other than the sheath are usually malignant In adults, neurofibroma and neurilemomas (Schwannomas) are most common Neurofibroma contains Schwann cells plus nerve cells; occur in 3rd or 4th decade Schwannoma derived from sheath of Schwann without nerve cell
q q q
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q
In children, ganglioneuroma and neuroblastoma are most common Ganglioneuroma benign tumor Neuroblastomavery malignant undifferentiated round cell lesion from sympathetic ganglion usually under age 10 o Produces iron-filings appearance to sutures in the skull infiltrated with tumor
Calcification in a posterior mediastinal mass points to a neural tumor in a kid rather than a met from somewhere else Posterior mediastinal neurofibromas are only rarely associated with neurofibromatosis Most have no symptoms
X-ray
q
Both benign and malignant tumors may erode ribs They may enlarge the neural foramina (dumbbell shaped lesion) Scalloping of posterior vertebral bodies may occur They may produce a scoliosis Pleural effusion may occur with benign as well as malignant neural tumor
Other posterior mediastinal masses

q
Paraspinal abscess from TB look for destruction of two contiguous endplates plus narrowing of the intervening disc space Neurenteric cysts may have associated hemivertebra Extramedullary hematopoiesis should be associated with splenomegaly and sometimes widening of the ribs
WH
LearningRadiology - Broncial adenomas
Bronchial Adenomas
Low grade malignancies about 10% metastasize Most patients are under 50 Most common 1 lung tumor under age 16 Male to female ratio of 1:1 White to Black ratio of 25:1 Pathologically, they fall into two groups: Carcinoid85%-95% of all adenomas Kulchitsky cells=argentaffine cells Part of APUD system (amine precursor uptake and decarboxylation) Neurosecretory production of serotonin, ACTH and bradykinin Salivary gland types Cylindromastwice as common as mucoepidermoids Resembles salivary gland tumor More malignant potential than carcinoid (25%) Mucoepidermoid Mixed
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(CAMP=incidence of bronchial adenomas, where: C=carcinoid A=adenoid cystic carcinoma=cylindroma M=mucoepidermoid P=pleiomorphic=mixed) About 80% are situated centrally Peripheral adenomas show a predilection for the RUL,RML and lingula Cylindromas are always central Clinically Hemoptysis (40-50%) Atypical asthma Persistent cough Recurrent pneumonia Asymptomatic (10%)
X-Ray
Atelectasis 2 bronchial obstruction, or Pneumoniaare most common Rarely may have obstructive emphysema May be seen as a discrete mass, either centrally 80%(carcinoid or cylindroma) or peripherally 20% (carcinoid or mucoepidermoid)
May get bony metastases usually blastic Very few carcinoids of the lung give rise to the Carcinoid Syndrome and those that do always have widespread metastases to the liver May be associated with Cushings Disease Overall prognosis: 75% fifteen-year survival
Think of bronchial adenoma when you see a smooth, well-marginated mass around the carina in a younger woman (DDX bronchial cystget CT)
WH/92 rev
Home
Bone
Chest
Cardiac
GI
Misc
LearningRadiology - Neurofibromatosis
Not Quite 1001 Manifestations of Neurofibromatosis
Lateral meningocoeles Diverticula of the thecal sac caused by dysplasia of the meninges Leads to erosion of adjacent bone
Posterior scalloping of the vertebral bodies (as above) Particularly in the thoracic and lumbar vertebral areas
Cafe au lait spots Multiple skin neurofibromas or schwannomas Diffuse enlargement of an extremity Mental retardation Optic nerve gliomas, meningiomas, acoustic neuromas, astrocytomas, ependymomas, hamartomas and glioblastomas
Syringomyelia Defect in the posterosuperior wall of the orbit Enlargement of the orbit
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Hypoplasia of the greater wing of the sphenoid Enlargement of the middle cranial fossa Holes in the head Cranium bifidum Dural ectasia Posterior scalloping of the vertebral bodies Dumbbell neurofibromas Enlargement of a neural foramen Erosion of a pedicle Intrathoracic meningocele Kyphoscoliosis Ribbon ribs Neurofibromas of the vagus nerve Pulmonary interstitial fibrosis Congenital heart disease (PS most common, VSD, coarct) Renal artery stenosis Other arterial stenoses Neurofibromas of the GI tract Pheochromocytoma Medullary carcinoma of the thyroid Pseudarthrosis of long bones, especially tibia Bowing of the extremities, especially tibia Marginal cortical defects Massive subperiosteal hematoma
WH/
LearningRadiology - Alveolar Cell Carcinoma
Alveolar Cell Carcinoma Bronchoalveolar cell carcinoma
Associated with scleroderma and or local scarring or fibrosis Growth may be very slow (7-12 years) Histologically, they may appear identical to a metastatic adenoca from elsewhere They all probably begin from a single abnormal cell Lymphatic involvement is common
X-ray
Local (more common) Mass containing air bronchogram DDx: Lymphoma, pseudolymphoma, inflammatory pseudotumor Commonly have participating tail of atelectasis to pleura Diffuse May be discrete or represent an area of consolidation Effusion in 10% Symptoms About 50% are asymptomaticsymptoms include cough especially , sometimes very productive (up to 4 liters a day=bronchorhea)
http://www.learningradiology.com/notes/chestnotes/alveolarcellca.htm04/09/2006 1:27:56
LearningRadiology - Pancoast Tumor
Pancoast Tumor
Arises in the superior sulcus of the lung which is a groove formed by the subclavian artery Unique among parenchymal processes for its propensity to violate the pleural barrier and involve chest wall Bone destruction is common first rib most often affected Squamous cell is most common cell type
Complications
q
Brachial plexus involvement on affected side Horners syndrome on affected side r Ptosis r Myosis r Anhydrosis And rarely, enopthalmus Superior vena caval obstruction when tumor occurs on right
X-ray
q
Apical cap on affected side; flat, uniform density DDX: apical pleural thickening
r
Other side is usually normal in Pancoast, thickened with apical pleural thickening
Key to diagnosis is demonstration of bone involvement

r
MR demonstrates blood vessel, brachial plexus and vertebral canal involvement Bone scan may be needed to demonstrate bone involvement if clinical suspicion is high
WH/92
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LearningRadiology - Common Pneumonconioses
The Common Pneumoconioses

Silicosis
q
Exposure to silica from mining of coal, graphite, iron, tin, uranium, gold, silver, copper
r
Also iron and steel foundry workers, sand blasters
After silica particles are ingested by alveolar macrophages, breakdown of macrophage releases enzymes which produce fibrogenic response
Silicosis has a progressive nature despite cessation of dust exposure X-ray picture is of multiple small rounded opacities
r
Usually in the upper lobes May occasionally calcify (20%) Lymph node enlargement is common Large opacities are conglomerations of small opacities
Progressive Massive Fibrosis (PMF)

r
Cavitate from tuberculosis or ischemic necrosis
Eggshell calcification of hilar nodes in 5% Caplans syndrome consists of large necrobiotic nodules superimposed on silicosis Silicosis predisposes to TB
Coal Workers Pneumoconiosis (CWP)

q
Originally silica was erroneously thought to be the cause of CWP Actually mostly due to the inhalation of pure carbon Still referred to as anthrasilicosis or anthracosis although most coal in USA is bituminous Coal dust is deposited in the alveolar macrophages which migrate to, and leave, coal dust deposits around the respiratory bronchiole
r
Here a very small fibrous reaction occurs
Complicated CWP occurs as large masses in either the upper lobes or the superior segments of the lower lobes
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Unlike silicosis, the large upper lobe lesions of CWP are single (rather than conglomerate) black masses with a liquid core, not a fibrous tissue core
The masses may undergo cavitation either from TB or ischemia The rounded opacities of CWP, found predominantly in the upper lobes Do not progress in the absence of more coal dust
Classification is by the International Labor Organizations 1980 classification (p,q,r, etc.) There is a direct correlation between the amount of coal dust contained in the lungs and the profusion category
Asbestosis
q
Salts of salicic acid 90% of asbestos in the USA is white asbestos (chrysotile) occurs in automotive workers, shipfitters, construction workers
Asbestos particles invoke a hemorrhagic response in the lung

r
Fibers are then coated with a ferritin-like material resulting in ferruginous bodies Does its damage in respiratory bronchioles and alveoli
Affects lower lobes first Opacities are small and irregularly shaped Cardiac silhouette may become shaggy Almost all patients have some pleural involvement-pleural plaque, diffuse pleural thickening, calcification or effusion
Pleural involvement without parenchymal disease is common Parietal pleural plaques in the mid lung are the most common asbestos-related disorder and are usually bilateral
Pleural calcification occurs in about 50% with asbestos-related disease, especially diaphragmatic pleura Diffuse pleural thickening involves diaphragmatic pleura, blunting of costophrenic sulci and lateral chest wall thickening
Effusion alone may occur early in the disease (first 20 years) in about 3% of cases Asbestos-related lung cancer is either squamous cell or adenocarcinoma Bronchogenic ca is almost always associated with cigarette smoking Mesotheliomas most often due to crocidolite particles Mesotheliomas are not related to cigarette smoking In contrast to silicosis, hilar lymph nodes are rarely affected
WH/91
LearningRadiology - ARDS
Adult Respiratory Distress Syndrome ARDS
Rapidly developing respiratory insufficiency resulting from leakage of protein-rich edema fluid into the alveoli 2 damage to the capillary endothelium Synonyms: Shock lung, non-cardiogenic pulmonary edema, post-traumatic pulmonary insufficiency, pump lung, stiff lung syndrome, respirator lung, hemorrhagic lung
Constellation of Signs and Symptoms

Tachypnea, dyspnea, cough Diffuse air-space disease on chest x-ray Severe arterial desaturation resistant to high concentrations of inhaled 02 Pulmonary function tests showing increased pulmonary vascular pressures and resistances and decreased compliance
Predisposing conditions:
Shock Hypovolemic, hemorrhagic Septic-especially gram negative Burns Massive aspiration of gastric contents (Mendelssohns Syndrome) Acute pancreatitis Heroin/methadone/crack cocaine overdose
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Disseminated intravascular coagulation Smoke, chlorine gas, nitrogen dioxide inhalation Massive viral pneumonia Fat embolism Near-drowning
Pathology
Diffuse alveolar damage Damage to type I pneumocytes produces flooding of alveoli with edema fluid Hyaline membranes form and line distal airways and alveoli Type II pneumocytes proliferate to reline denuded alveolar surfaces Fibroblastic tissue is generated in and around airspaces
X-ray Findings
No cardiomegaly No pleural effusions No Kerley B lines Delay in onset of any x-ray findings for at least 12 hours post-insult Between 12 and 24 hours Patchy alveolar infiltrates in both lungs Between 24 and 48 hours Coalesce to produce massive air-space consolidation of both lungs From 5 to 7 days Clearing is frequently 2 effects of CPP ventilation rather than true healing Pneumonia may superimpose Difficult to recognize but look for new focal infiltrates and pleural effusion
More than one week Coarse reticular interstitial disease which may lead to fibrosis
Complications of CPP ventilation

Pneumothorax Pneumomediastinum Pulmonary interstitial emphysema
Differential Diagnosis
Severe bacterial pneumonia--impossible to differentiate except clinically Other forms of pulmonary edema (see below)
Cardiogenic
Renal
ARDS
Distribution of Pulmonary edema Kerley B lines/ peribronchial cuffing Pleural effusions Air bronchograms
90% even
70% central
45% Peripheral 35% Even None 10% 70%
30% 40% 20%
30% 30% 20%
WH/94
LearningRadiology - PCP, Pneumocystis Carinii Pneumonia
Pneumocystis Carinii Pneumonia PCP
q q
Most common cause of interstitial pneumonia in immunocompromised patients Organism r Protozoan / fungus Pneumocystis carinii Predisposed r AIDS r Debilitated r Premature infants r Children with hypogammaglobulinemia r Other immunocompromised patients s Congenital immunodeficiency syndromes s Lymphoproliferative disorders s Organ transplant recipients s Patients on long-term corticosteroid therapy s Patients on chemotherapy for cancer Associated infections r CMV r Mycobacterium avium-intracellulare (MAI) r Herpes simplex Clinical r Severe dyspnea and cyanosis r Subacute insidious onset of malaise and slight cough (frequent in AIDS patients) r Respiratory failure r WBC slightly elevated (polys) r Lymphopenia (50%) indicates poor prognosis Imaging findings r Normal CXR in 10-40% r Bilateral diffuse symmetric finely granular / reticular interstitial / airspace infiltrates in 80% s Characteristic central location s Rapid progression to diffuse airspace disease q Resembles non-cardiogenic pulmonary edema
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PCP pneumonia
Pleural effusion and hilar lymphadenopathy are uncommon r Atypical pattern in 5% s Isolated lobar disease / focal parenchymal opacities s Lung nodules cavitation s Hilar / mediastinal lymphadenopathy s Thin- / thick-walled cysts s Cavities with predilection for upper lobes Course r Usually responds to therapy in 5-7 days r Effect of prophylactic use of aerosolized pentamidine s Redistribution of infection to upper lobes Complications r Cystic lung disease s Central location to cysts r Spontaneous pneumothorax, frequently bilateral (6-7%) r Disseminated extrapulmonary disease (1%) r Punctate / rimlike calcifications within enlarged lymph nodes and abdominal viscera CT findings r Patchwork pattern (56%) s Bilateral, asymmetric patchy mosaic appearance r Ground-glass pattern (26%) s Bilateral, diffuse air-space disease in symmetric distribution r Interstitial pattern (18%) s Bilateral, symmetric / asymmetric, reticular markings (thickening of lobular septa) r Abnormal air-filled spaces (38%) s Pneumatocoeles q Thin-walled spaces without lobar predilection resolving within 6 months s Subpleural bullae due to emphysema s Thin-walled cysts s Necrosis of pneumocystis granuloma s Pneumothorax (13%)
r
Lymphadenopathy (18%) r Pleural effusion (18%) Pulmonary nodules and cavities r Usually due to malignancy s Leukemia, lymphoma s Kaposi sarcoma s Metastasis s Or septic emboli r Pulmonary cavities usually due to superimposed fungal / mycobacterial infection
r
Nuclear medicine r Bilateral and diffuse Ga-67 uptake without mediastinal involvement prior to roentgenographic changes DDx r Non-cardiogenic pulmonary edema r TB r MAI infection Diagnosis r Sputum collection r Bronchoscopy with lavage r Transbronchial or transthoracic or open lung Bx
Dahnert 4th edition
LearningRadiology - Aspiration pneumonia
Aspiration Pneumonia
Occurs in gravity dependent portions of the lung Posterior segments of the upper lobes Lower lobes, especially right-sided Predisposing conditions include: CNS disorders, intoxication, mental retardation, seizure disorders, recent anesthesia, swallowing disorders Acute aspiration may lead to a fleeting infiltrate when it is non-infected Anaerobic organisms from GI tract can produce longer lasting pneumonia Chronic aspiration pneumonia results from repeated aspiration of foreign material over a prolonged time Zenkers diverticulum Achalasia TE fistula Neuromuscular diseases Chronic reflux Lipoid pneumonia Mineral oil (used as a laxative) Oily nose drops (not used anymore) Clinically Symptoms include low grade fever, productive cough and choking on swallowing X-Ray
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LearningRadiology - Aspiration pneumonia
Fleeting infiltrate (lasts one or two days) if bland and non-infected Consolidation of lobe if infected with anaerobic organisms or if aspiration of un-neutralized HCl When chronic, the disease usually starts alveolar and becomes interstitial as the macrophages incorporate the aspirated material May present as a mass when chronic
WH/91,93
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LearningRadiology - Gram Positive Pneumonias
Gram Positive Pneumonias

Pneumococcal pneumonia
q
Most common gram positive pneumonia 90% community acquired Organism: strep pneumoniae Usually found in compromised hosts, elderly, debilitated Most often types 8, 4, 5 and 12 Type 3 is especially fatal to elderly Sicklers are particularly prone to pneumococcal pneumonia Produces inflammatory edema in the alveoli which spreads via pores of Kohn to more lateral alveoli
X-ray Extensive infiltrate usually abutting pleural surface Prominent air bronchograms (DDX: Staph has no air bronchogram) Organism is aspirated into the lungs from the upper airways so it shows a predilection for lower lobes Does not respect segmental boundaries Resolution begins promptly with antibiotics frequently within 24 hours DDX for alveolar infiltrates with clearing in 24 hours includes r Hemorrhage into lungs, r Pulmonary edema r Pneumococcal pneumonia r Aspiration
q q
Staph aureus pneumonia

q
Most common bronchopneumonia Overwhelming majority hospital-acquired Most common cause of death during influenza epidemics
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Rarely develops in healthy adults Hemolyzes blood agar

r
Coagulase positive
Its ability to produce pathology in humans is due to its production of coagulase Produces its pathologic reaction in the conducting airways
X-ray
Rapid spread through the lungs Empyema, especially in children No air bronchogram Pneumothorax
r
Pyopneumothorax
Abscess formation Bronchopleural fistula In children

q
Rapidly developing lobar/multilobar consolidation Pleural effusion (90%) Pneumatocoele
In adults Patchy bronchopneumonia of segmental distribution, frequency bilateral May be associated with atelectasis since airways are filled (not so with pneumococcal) Pleural effusion (50%)
Streptococcus pyrogenes pneumonia

q
Most common in winter

r
Only 5% of bacterial pneumonias
Group A Beta hemolytic strep Predisposed: Newborns and following measles
X-ray
Looks like staph pneumonia but with less of a tendency to produce pneumatocoeles Almost always in the lower lobes Patchy bronchopneumonia Empyemas do form Complications:
r
Bronchiectasis Lung abscess Glomerulonephritis
Associated with delayed onset of diaphragmatic hernias in newborns
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LearningRadiology - Aspergilloma
Aspergilloma
Caused by Aspergillus fumigatus-soil fungus Non-invasive Aspergillosis Colonization of pre-existing cavity Most frequently TB cavity of Sarcoid Also can occur with cavitary ca, and bronchiectasis Most common symptom is hemoptysis Histologically, these are intertwined hyphae of the aspergillus forming a mycetoma Findings:
o o o o o
Solid, round mass in thin-walled cavity Usually in upper lobes Moves with changes in positioning Crescent-shaped airspace separates the fungus ball from the wall of cavity Fungus ball may calcify
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LearningRadiology - Aspergilloma
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LearningRadiology - Gram Negative Pneumonias
Gram Negative Pneumonias

Pseudomonas aeruginosa
q
Gram negative rod Frequently hospital acquired Affects patients with COPD, CHF alcoholism, kidney disease, those with trachs Frequently related to use of inhalators or nebulizers Many patients are on multiple antibiotics and/or steroids
X-ray Resembles staph pneumonia Predilection for the lower lobes Usually affects both lungs Has multiple small lucencies within it Lung abscess greater than 2 cm may also occur Widespread nodular shadows is another manifestation
Klebsiella, Enterobacter, Serratia

q
Encapsulated, gram negative rods Most are hospital acquired Most are chronic alcoholics Aspirated into lungs so most are unilateral and right sided
X-ray
q
Produces excessive amounts of inflammatory exudate which cause the affected lung to gain volume and the fissures to bulge
Abscess and cavity formation are common
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Pleural effusion and empyema are common May result in gangrene of the lung where massive pieces of lung tissue fall into an abscess cavity Serratia marcescens may cause bronchopneumonia
Anaerobic organisms
Frequently from aspiration of gastric contents Organisms include Bacteroides melaninogenicus, B. fragilis
X-ray
Almost always lower lobes Frequently right sided Homogeneous consolidation About 70% will have pleural involvementeffusion, empyemawhich may progress very rapidly Half develop abscesses
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LearningRadiology - Bronchiectasis
Bronchiectasis
Pathologic dilation of the medium sized airways Proximal bronchiectasis is characteristic of allergic bronchopulmonary aspergillosis (ABPA) Classical clinical triad: chronic cough, excess sputum production and repeated infection Pathogenesis Three major causes are: obstruction, infection and traction Bronchiectasis is common when there is prolonged partial obstruction, e.g. slow-growing neoplasms, foreign bodies Infection is most important cause of bronchiectasis Bronchial wall destruction occurs in infection Traction comes from a force, usually due to increased elastic recoil in the surrounding lung, which pulls the bronchus and dilates it Location Bronchiectasis from viral or pyogenic infections is usually at the bases Tuberculous bronchiectasis is usually at the apices Diffuse bronchiectasis Impaired mucus clearing e.g. cystic fibrosis and Kartegeners ABPA Chronic diffuse airways disease (chronic bronchitis, asthma, bronchiolitis obliterans Immune deficiency states X-ray Tramlines or honeycombing represents dilated, thickened bronchial walls
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Volume loss due to destruction of lung tissue Multiple small nodular densities from plugged alveoli Signet ring appearance on CT: normally, the vessel is larger than the corresponding bronchus. In bronchiectasis, the bronchus is larger than the corresponding vessel Lack of bronchial tapering Non uniform bronchial dilation Bronchial wall thickening
WH/92
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LearningRadiology - Pneumomediastinum
Pneumomediastinum (Mediastinal Emphysema)

q
Rare in adults (except in ICU patients) and most common in newborns ETIOLOGIES
r
Spontaneous most common mechanism in kids and adults s Pathophysiology involves increased intralveolar pressure such as from cough or vomiting which ruptures alveolus, air tracks back along blood vessels to mediastinum
q
Accompanying pneumothorax common in neonates
When air builds up in mediastinum and cant pass into the neck (especially in kids) this produces mediastinal air block which can reduce flow of blood in great vessels In adults, the air in mediastinum usually progresses into the neck and the subcutaneous tissue
Traumatic 2 closed chest trauma o Same mechanism as spontaneous
Rupture of the esophagus Boerhavve's Syndrome o May occur with vomiting, labor, severe asthmatic attacks and strenuous exercise (each of these can produce pneumomediastinum without rupturing the esophagus) o LEFT, POSTEROLATERAL WALL, DISTAL 8 CM
s
X-ray combination of pneumomediastinum and left pleural effusion is very suggestive; continuous diaphragm sign Symptoms infants none. Adults chest pain (retrosternal) radiating down both arms aggravated by respiration and swallowing; Hammans sign crunching sound heard over the apex of the heart with cardiac cycle
s s
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LearningRadiology - Bronchogenic Cysts
Congenital Bronchial Cysts
Primitive foregut gives rise to both the esophagus (dorsal segment) and the tracheobronchial tree (ventral segment). Bronchial cysts result from abnormal budding of the ventral segment of the foregut [Failure of the solid core of the esophagus to cannulate produces esophageal duplications and abnormalities of the dorsal segment produce neurenteric cysts]. More common in males and Yemenite Jews Bronchial cysts form in the first trimester of pregnancy They may be either mediastinal, parenchymal or, sometimes, infradiaphragmatic Mediastinal More common Occur around carina May be associated with spinal abnormalities Are usually asymptomatic Parenchymal Much less common Usually occur in the lower lobes Become infected and thus contain air May present with hemoptysis Most common type of mediastinal cyst in an infant They do not communicate with the tracheobronchial tree unless infected
X-r ay
Most are mediastinal and occur around the carina, upper trachea or along bronchi.
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Occur in middle mediastinum Almost all are fluid-filled and appear as solid, well-defined, sharply-marginated mass Rarely, they may contain milk of calcium
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LearningRadiology - Polyarteritis Nodosa
Polyarteritis Nodosa
q
Systemic necrotizing inflammation of medium-sized and small muscular arteries r More common in adult males Spares the arterioles, capillaries, venules and glomeruli Associated with hepatitis B antigenemia Signs and symptoms r Abdominal pain r Systemic hypertension r Anorexia and weight loss r Abdominal distention r Hematemesis, melena r Jaundice r Painless hematuria r Peripheral neuropathy r Tender subcutaneous nodules r Gangrene of fingers and toes Kidney (most frequently affected): 85% r Multiple intrarenal aneurysms
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Multiple aneurysms of renal vessels in Polyarteritis

r
r r
Aneurysms may thrombose and disappear s Appear in new locations Multiple small cortical infarcts Angiographic findings s 1-5 mm saccular aneurysms of small and medium-sized arteries in 60-75% of cases s Secondary to necrosis of internal elastic lamina s Luminal irregularities and stenoses s Arterial occlusions and small tissue infarcts Lung (70% of cases) r Findings are variable and rarely characteristic enough to allow diagnosis r Most characteristic pattern is fleeting, patchy consolidation identical to Loeffler's r Pericardial effusion r Pleural effusion r Discoid atelectasis r Nodules which may cavitate r Patchy consolidation Liver: affected 66% of cases Treatment

r
Corticosteroids s 50% 5 year survival
1. Bockus, Henry L. Gastroenterology, 3rd ed., Vol. 4 Pages 538-541. W. B. Saunders Company, Philadelphia, London, Toronto, 1976. 2. Dahnert, Wolfgang Radiology Review Manual, 4th ed. Page 533, Lippincott, Williams and Wilkins, Philadelphia, Baltimore, etc., 2000.
LearningRadiology - Coccidioidomycosis
Coccidioidomycosis
Caused by Coccidioides imitus, a soil fungus endemic to the Southwest (San Joaquin Valley) Primary coccidioidomycosis Most are asymptomatic Clinically, may have arthralgias, skin rash X-ray Patchy infiltrates mainly in lower lobes (80%) Hilar adenopathy (20%) Pleural effusion (10%) Disseminated coccidioidomycosis Meningeal spread Micronodular lung pattern Chronic coccidioidomycosis One or more well-defined nodules (5%) Grape-skin thin-walled upper lobe cavities, mostly solitary
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Resembles TB Mediastinal adenopathy (10%)
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LearningRadiology - Maltoma (Pseudolymphoma)
Pseudolymphoma Maltoma
Collections of apparently benign lymphocytes which lack the usual invasive characteristics of true lymphoma
Lack of invasion of extrapulmonary tissues in this disease Mixed cellular infiltration (as opposed to uniform cellular infiltration of true lymphoma) with mature lymphocytes predominating
Other lesions characterized by the presence of mature lymphocytes

r
LIP Castlemans diseaselymph node hyperplasia Lymphomatoid granulomatosis Well-differentiated lymphocytic lymphoma
Classically, there is no involvement of the lymph nodes in the hilum or mediastinum May be associated with Dilantin administration (as is true lymphoma and benign lymph node hyperplasia) Asymptomatic
X-ray
q
Dense infiltrate Invariably has air bronchogram May also have nodules, segmental consolidation or diffuse interstitial infiltration
WH/92
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LearningRadiology - Congenital Lobar Emphysema
Congenital Lobar Emphysema
Severe overinflation of a lobe, usually causing respiratory distress Male predominance Only 1/3 are manifest at birth; most are some weeks later Associated with congenital heart disease 15% of time (PDA, VSD) Predilection for the left upper lobe and less so for RML X-ray Hazy, mass-like density immediately following birth Overinflation and air-trapping after several days Contralateral mediastinal shift Vascular markings are widely separated DDx aspiration of foreign body with air-trapping, space occupying endobronchial lesion, adenomatoid malformation at birth Clinically About 90% suffer respiratory distress during first few days of life Cyanosis Course is rapid and may be fatal unless emphysematous lobe is resected
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LearningRadiology - Congenital Lobar Emphysema
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LearningRadiology - Pulmonary Laceration
Pulmonary Laceration
Traumatic Lung Cyst Pulmonary Hematoma
q
Usually from blunt chest trauma Occurs more often in children and young adults
X-ray
q q
q q q q
Usually not apparent at first because of surrounding pulmonary contusion Half are solid mass-like lesions (pulmonary hematoma), half are thin-walled cystic structures (traumatic lung cyst) with or without air- fluid level depends on how much bleeding into laceration Usually subpleural location under point of maximum impact May be single or multiple Characteristically, they take a long time to heal many months. They gradually decrease in size. No symptoms from laceration per se unless they become infected, which is rare.
WH
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LearningRadiology - COPD
COPD Emphysema
Proteolytic enzymes secreted by polys and alveolar macrophages are normally inhibited by serum a-1 antitrypsin but not in emphysema Centrilobular (centriacinar) Emphysema (CLE) Involves upper lobes Major pathology is in respiratory bronchioles which become dilated Alveolar ducts and sacs are spared Slightly more common than PLE Characteristically found in heavy smokers Panlobular Emphysema (PLE) Usually affects lower lobes Involves overinflation and destruction of the alveolar sacs More common in aged patients than CLE More common in women than CLE (although both more common in men) Type associated with a-1 antitrypsin deficiency Roentgenographic Patterns Arterial Deficiency pattern (AD) Overinflation Flattened diaphragm Increased Marking pattern (IM) Less or no overinflation
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LearningRadiology - COPD
Prominent pulmonary vasculature Almost always has pulmonary artery hypertension Centrilobular emphysema usually associated with Increased Marking pattern CLEIM Panlobular emphysema usually associated with Arterial Deficiency pattern PLEAD IM are Blue Bloaters; AD are Pink Puffers
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LearningRadiology - Radiation Pneumonitis
Radiation Pneumonitis
q q
q q
Damage to lungs after radiation therapy Usually requires at least 4500 rads r Especially common if >6000 R given in 5-6 weeks Occurs more often if there is concurrent or later chemotherapy Pathologic phases r Exudative phase = edema fluid + hyaline membranes r Organizing phase r Fibrotic phase = interstitial fibrosis Time of onset r Usually at least 6 weeks up to 6 months after treatment Location r Confined to radiation portal
Radiation portal (left) with subsequent radiation pneumonitis
Acute Radiation Pneumonitis

o o Occurs within 1-8 weeks after radiation therapy Pathology Depletion of surfactant (1 week to 1 month later), plasma exudation, desquamation of alveolar + bronchial cells Usually asymptomatic When symptomatic Nonproductive cough, shortness of breath, weakness, fever (insidious onset) Acute respiratory failure (rare) Changes usually confined to radiation portal Patchy / confluent consolidation, may persist up to 1 month (exudative reaction)
o o
o o
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Atelectasis + air bronchogram Spontaneous pneumothorax (rare)
CT findings of acute radiation pneumonitis r Homogeneous slight increase in attenuation (2-4 months after therapy) r Patchy consolidation (1-12 months after therapy) r Non-uniform discrete consolidation (most common; 3 months to 10 years after therapy)
Sequential transverse images through lung showing radiation pneumonitis in right lung
q
Prognosis r Recovery or progression to death from fibrosis Rx r Steroids
Chronic Radiation Damage

o o o 9-12 months after radiation therapy Histology Permanent damage of endothelial + type I alveolar cells May be associated with: Thymic cyst Calcified lymph nodes (in Hodgkin disease) Pericarditis + effusion (within 3 years) Severe loss of volume Dense fibrous strands from hilum to periphery Thickening of pleura CT findings Solid consolidation (radiation fibrosis) + bronchiectasis (stabilized by 1 year after therapy)
Text from Dahnert, 4th Edition
LearningRadiology - Crack Cocaine Abuse
Crack Cocaine Abuse
Crack or rock is prepared by mixing cocaine hydrochloride, which is the preparation usually available on the street, with an alkaline solution such as baking soda. The mixture may be heated directly until it vaporizes, but this form contains impurities. Freebase cocaine can be prepared by adding a solvent, such as ether, to the mixture. The mixture separates into two layers with the top layer containing freebase cocaine dissolved in the solvent. The solvent layer is then separated either by filter or, less commonly today, by evaporating it at low temperatures to leave pure alkaloid cocaine crystals. The product is then smoked. Clinical
q q q q q
Shortness of breath Cough Production of black sputum (2 carbonaceous materials in smoke) Hemoptysis Chest pain
X-ray
q
Non-cardiogenic pulmonary edema (increased permeability) Most likely 2 to damage to capillary membrane, either by
r
Direct toxic effect on capillary endothelium Intense vasoconstrictor effect leads to anoxic cell damage
Bronchiolitis obliterans with organizing pneumonia (BOOP) Pulmonary infiltrates with eosinophilia
r
Adulterants have been implicated in producing hypersensitivity rx

s
Lidocaine, lactose, sucrose, starch and talc
Pulmonary hemorrhage
r
Either from anoxic cell damage 2 vasoconstriction or direct toxic effect
Diffuse Interstitial Pneumonia Pneumothorax Pneumoperitoneum
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Both 2 extended Valsalva maneuver to enhance drugs effect
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LearningRadiology - Re-expansion Pulmonary Edema
Re-expansion Pulmonary Edema
Pulmonary edema of cardiac or renal origin usually affects both lungs Re-expansion pulmonary edema results from the too rapid expansion of a pneumothorax or the rapid removal of pleural fluid Unilateral pulmonary edema can occur either because of an abnormality on the same side as the pulmonary edema or an abnormality on the opposite side Examples of abnormalities on the same side as the pulmonary edema include:
r r r
Venous obstruction confined to the ipsilateral side Prolonged positioning with the affected side dependent Bronchial obstruction (so-called Drowned Lung)
Examples of abnormalities in one lung which spare it and lead to pulmonary edema on the opposite side:
r
Pulmonary artery obstruction Congenital absence or hypoplasia of the pulmonary artery s Thromboembolism occluding one pulmonary artery s Unilateral arterial obstruction Abnormalities of the opposite lung itself
s s s s
Unilateral emphysema Pneumonectomy Swyer-James syndrome
WH
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LearningRadiology - Re-expansion Pulmonary Edema
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LearningRadiology - Cryptococcosis
Cryptococcosis Torulosis
Caused by Cryptococcus neoformans, a single-budding yeast cell with a thick capsule, stains with India ink, found in soil contaminated with pigeon excrement
It is a granulomatous disease Diabetics and immunocompromised are predisposed Frequently produces meningitis Well circumscribed mass (40%), usually peripheral in location Lobar/segmental consolidation (35%) Cavitation (15%) Hilar/ mediastinal adenopathy
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LearningRadiology - Rheumatoid Lung
Rheumatoid Lung
Although rheumatoid arthritis is more common in females, extra-articular manifestations of the disease are more common in males Almost all patients with pulmonary evidence of RA have: r Clinical evidence of the disease r Severe disease Circulating antibody is largely IgM in patients with RA and the changes in the lung are probably immune in origin
Pleural Effusion
q
The most common manifestation of RA in the chest Pleural fluid is an exudate with a high protein and a very low sugar content (below 30 mg per 100 ml) which does not rise with the IV administration of glucose which the low sugar effusion in TB will do. Pleural fluid in RA is also high in LDH, rich in lymphocytes, positive for Rheumatoid Factor, and contains low complement levels. The effusion may remain unchanged for months or years Most are unilateral but they can occur on either side The effusion is almost never associated with parenchymal disease
Pulmonary Fibrosis
q
Begins as micronodular and progresses to coarse reticulation, often more prominent at the bases and indistinguishable from scleroderma r Has a honeycomb appearance Clinically, shortness of breath is most common symptom Subcutaneous rheumatoid nodules are often present PFTs show restrictive disease
q q q
Necrobiotic Nodules
q
Relatively rare
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Almost always associated with subcutaneous nodules and identical pathologically to them
r
Usually well circumscribed masses Typically multiple Subpleural in location With cavitation Frequently at bases
Caplans Syndrome
q
Necrobiotic nodules with silicosis Pathologically, the only difference is a ring of dust in the nodule which produces a darkened ring around the central core Roentgenographically identical to rheumatoid nodules with RA
Rheumatoid Disease with Pulmonary Arterial Hypertension

q
Due to an arteritis which produces PAH and eventual cor pulmonale
Obliterative Bronchiolitis
q
Same as BOOP except the patients have RA
WH
LearningRadiology - Cystic Adenomatoid Malformation

Form of pulmonary hamartoma occurring in utero between 4-10th week Most often found in infants, sometimes adults No lobar preference Solid in infants, more cystic in children Do communicate with the tracheobronchial tree (DDx from intralobar sequestration which usually dont)) Supplied by pulmonary circulation
Types
q q q
Type 1 (50%) single or multiple large cysts excellent prognosis following resection Type 2 (40%) Multiple cysts < 12 mm poor prognosis 2 associated congenital anomalies Type 3 (10%) solitary mass with microscopic cysts poor prognosis 2 hypoplasia of lung
X-ray
Unilateral mass with well-defined margins and numerous air-containing cysts Space occupying so expect shift of heart and mediastinum away from lesion May occasionally present as solid mass which evolves into cystic mass DDX Sequestration, diaphragmatic hernia or rupture, congenital lobar emphysema On fetal US, look for fetal ascites and polyhydramnios
Clinically
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May be cyanotic; usually symptomatic during first days of life
WH
LearningRadiology - Rounded Atelectasis
Rounded Atelectasis
q
Occurs as a consequence of diseases with chronic pleural scarring, especially asbestos-related pleural disease and TB
Most often at the lung bases, posteromedially Must be subpleural in position
Pathophysiology
q
A rapidly forming pleural effusion produces an adjacent area of passive atelectasis A groove of visceral pleura may infold into the area of atelectasis and come to surround a part of it If the effusion recedes at once, the lung will probably re-expand If fibrinous adhesions form or if there is preexistent chronic pleural disease, then the atelectatic area of lung remains trapped by the enfolded visceral pleura
Asymptomatic: important because it resembles a bronchogenic ca
X-ray
q
Rounded density at lung base Contiguous to area of pleural disease or superimposed on apparent asbestos-related pleural disease or TB Comet tail on CT: vessels and bronchi converge upon and appear to swirl around mass Crows feet linear bands radiating from mass into lung parenchyma Linear densities radiate back toward hilum May have air bronchogram
WH/92
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LearningRadiology - Rounded Atelectasis
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LearningRadiology - Cystic Fibrosis
Cystic Fibrosis
q
Autosomal recessive almost always in caucasians Dysfunction of the exocrine glands Elevated concentration of Na and Cl in sweat
X-ray
q
Atelectasis Discoid, segmental, lobar with RUL predominance Mucoid impaction Cylindrical or cystic bronchiectasis Peribronchial cuffing Hilar adenopathy Pulmonary arterial hypertension Recurrent pneumonias, particularly staph and Pseudomonas Hypertrophic osteoarthropathy Pneumothorax
Other findings
q
Rectal prolapse Meconium ileus earliest finding Meconium ileus equivalent due to obstruction from stool in older children Fatty infiltration of the liver Focal biliary cirrhosis with portal hypertension Gallstones Pancreatic fibrosis due to recurrent pancreatitis Sinusitis
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Hypoplastic frontal sinuses
Clinically
q
Chronic cough, recurrent pulmonary infections
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LearningRadiology - Round Pneumonia
Round Pneumonia
q
q q
Spherical pneumonia caused by r Haemophilus influenzae r Streptococcus r Pneumococcus Children are affected much more than adults Location r Usually lower lobe r Most often posterior Clinical r Cough r Fever r Chest pain May change size rapidly May have slightly irregular border and contain air bronchogram
Not to be confused with mass in children
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LearningRadiology - Embolic Disease
Embolic Disease
Thromboembolic Disease
X-ray
q q q q q q
Normal chest x-ray Westermark's sign Abrupt cutoff and increased caliber of descending branch of PA Elevation of the hemidiaphragm Discoid atelectasis Infiltrate r Usually basal and abutting pleural surface
Septic Emboli
q q
From two major sources tricuspid endocarditis or septic thrombophlebitis Predisposing condition almost always present r Drug addiction r Alcoholism r Immunologic deficiencies r Congenital heart disease (shunts)
X-ray
q q q
Multiple solid nodules or thin-walled cavities Rapid resolution with treatment Hilar and mediastinal adenopathy may be present
Fat Embolism
q q q
Nearly all result from trauma, usually leg fractures Pathologically, fat embolism is very common (as high as 97% after injury) Carried via bloodstream as neutral triglycerides and converted by pulmonary lipase to unsaturated fatty acids Most common in young people with leg fractures in MVAs and older people with hip fractures or postarthroplasty Clinical r Dyspnea, cough hemoptysis r Confusion, restlessness, delirium, stupor r Petechiae or rash r Hypocalcemia (calcium bound by free fatty acids)
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r
Fat in the urine (lipiduria)
X-ray
q q q
Full picture takes 1 3 days following trauma (DDX from lung contusion) Chest x-ray is usually normal Typical appearance is a pulmonary edema-like picture sometimes affecting the periphery or the bases more than CHF does
Amniotic Fluid Embolism

q q q
q q
Develops only if fetal products (skin and meconium) enter maternal blood stream Onset is immediate Filtered out in the pulmonary vascular bed, the particles produce pulmonary arterial hypertension, shock, pulmonary edema, hypoxemia May produce rapidly fatal anaphylactic reaction or DIC Predisposing conditions include: r Multiparity r Intrauterine fetal death r Older age of the mother r Difficult or prolonged labor
X-ray Pulmonary edema indistinguishable from CHF (DDX: massive pulmonary hemorrhage and Mendelsohns syndrome)
Oil Embolism
Occurs 100% of the time following lymphangiography Most who demonstrate it on x-ray have lymphatic obstruction Manifests as very fine granular, then reticular interstitial pattern Rarely produces symptoms
Metallic Mercury Embolism

q q q q q
May be introduce by drug abusers, those attempting suicide, or for muscle quickness Characteristic appearance in lungs of diffuse metal density Goes to the dependent portion of the lung at the time of injection Produces mild inflammatory reaction Excretion is via kidneys
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LearningRadiology - Sarcoid
Sarcoid
General

Widespread formation of non-caseating granulomas 3:1 female:male and 14:1 black:white predominance ACE (angiotensin converting enzyme) elevated in 70% Kveim skin test Positive in (70%) but rarely used today Lofgren Syndrome:
Acute bilateral hilar adenopathy, fever, erythema nodosum and arthralgia
Intrathoracic disease (90%)
Stage I
Adenopathy alone (43%)-Stage 1

Intrathoracic adenopathy in 80%
Location
Bilateral hilar and (R) paratracheal
Most common (75-90%) 1-2-3 sign, Pawn-brokers sign, Garland sign

Unilateral hilar nodes rare (3-8%)
Egg-shell calcification hilar nodes in long-standing sarcoid Rare
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DDX: Silicosis
Stage II
Adenopathy and parenchymal disease (41%)-Stage 2 Adenopathy usually decreases as parenchymal disease increases About 1/3 of patients with adenopathy develop parenchymal disease
Stage III

Parenchymal disease alone (30%) Adenopathy does not develop subsequent to parenchymal disease
If adenopathy develops, think of lymphoma or TB
Patterns of lung disease

Reticulonodular (46%) Acinar pattern (20%)

Larger nodules
Alveolar sarcoid (2%)

Coalescence of numerous interstitial granulomas Air bronchograms present
DDX: Alveolar cell ca, alveolar proteinosis, lymphoma
Stage IV
End-stage lung disease-Stage 4 Diffuse fibrosis Bronchiectasis-honeycomb lung Multiple cysts
Uncommon manifestations

Associated with TB (13%) Pleural effusion (2%)

Usually exudate with lymphocytic predominance
Cavitation of nodules (<1%) Fungus ball formation in chronic sarcoid cavities (usually TB) Focal pleural thickening
Bronchostenosis with lobar atelectasis Pulmonary arterial hypertension Cor pulmonale Pneumothorax 2 chronic lung disease
Extrathoracic disease

Peripheral adenopathy (30%) Liver

Hepatomegaly
Spleen
Splenomegaly
Bone-especially hands Skin

Erythema nodosum Lupus pernio (raised purplish nodules)
Muscle
Myopathy
Eyes
Uveitis Uveoparotid fever
CNS
Granulomatous meningitis Facial nerve palsy
Myocardium
Arrhythmias Heart block Cardiomyopathy
Salivary gland
Parotid enlargement
Prognosis
3/4 show complete resolution of hilar adenopathy 1/3 show complete resolution of parenchymal disease 20% have irreversible pulmonary fibrosis
LearningRadiology - Goodpastures Syndrome
Idiopathic Pulmonary Hemorrhage (IPH) and Goodpastures Syndrome

Both are characterized by repeated episodes of pulmonary hemorrhage Both produce iron-deficiency anemia and both can produce pulmonary insufficiency Pathology Hemorrhage is typically confined to peripheral airspaces Diffuse interstitial fibrosis, hemosiderosis are common Vasculitis doesn't always occur even though these are autoimmune diseases Hemoptysis more copious in IPH Prognosis for both diseases is grave both are treated with steroids and cytotoxic agents
Idiopathic pulmonary hemorrhage

Occurs most commonly in children under the age of ten When it occurs in adults, it is twice as common in men Anti-glomerular basement membrane antibody should be absent (unlike Goodpastures)
Goodpastures syndrome
Goodpastures includes renal disease
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Renal lesion is glomerulonephritis It is a disease of young adults Most are men Autoimmune etiology Both lung and renal pathology believed 2 to anti-glomerular basement membrane antibody cross reacting with lung basement membrane
X-ray
Identical changes in both diseases Early in the disease, it is alveolar in nature, more prominent at the bases and perihilar regions simulates pulmonary edema Within 2-3 days, the blood is absorbed in to the interstitium and the pattern changes to interstitial reticular By about 10 days, the reticular disease disappears With repeated bleeds, there is hemosiderin deposit in the lungs and progressive pulmonary fibrosis occurs Once this occurs, the new hemorrhage is superimposed on the old interstitial disease, so the reticular pattern remains rather than disappears when the blood is absorbed May have pulmonary hypertension May have hilar adenopathy
WH/91
LearningRadiology.com - Silicosis,pneumoconiosis,sand blaster,coal miner,silica dust,
Silicosis
Occupational Exposure o Free crystalline silica (quartz) or silicon dioxide from
Mining of coal, graphite, iron

Tin, Uranium, Gold
Silver, Copper
Also, sand blasters Iron and steel foundry workers Ceramic workers Tunneling Silicosis pathophysiology o Silica particles ingested by alveolar macrophages o Breakdown of macrophage releases enzymes which produce fibrogenic response Silicosis natural history o Requires 10-20 years exposure before x-ray appearance o Radiographs frequently overestimate degree of symptoms early o Silicosis has a progressive nature despite cessation of dust exposure Imaging findings o Multiple small rounded opacities 1-10 mm in size
Usually in upper lobes Mostly in apical and posterior regions of upper lobes and apical portion of lower lobes
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Silicosis features a diffuse micronodular lung disease with an upper lobe predominance o o o May have ground-glass appearance May occasionally calcify centrally (20%) Lymph node enlargement common Eggshell calcification of hilar nodes (5%)
DDx: Sarcoidosis
Large opacities are conglomerations of small opacities
Complicated Silicosis (Progressive Massive FibrosisPMF) o Massive fibrosis and conglomerate nodule formation in upper lobes with scarring and retraction of hila upwards o Conglomerate nodules are >1 cm in size Usually in mid-zone or periphery of upper lobes Compensatory emphysema occurs in lower lung fields Nodules tend to disappear from rest of lung when PMF develops o Progressive Massive Fibrosis (PMF) may cavitate from tuberculosis or ischemic necrosis Acute silicosis (silicoproteinosis) o From exposure to high concentrations of silica dust o Alveoli are filled with lipid-rich, PAS-positive material o Bilateral air-space disease with perihilar distribution Imaging findings are similar to alveolar proteinosis Caplans Syndrome o Consists of large necrobiotic nodules (rheumatoid nodules) superimposed on silicosis or coal workers pneumoconiosis (CWP) More common with CWP o Other connective tissue diseases associated with silicosis Scleroderma, RA, SLE
Silicosis Complications o Predisposes to TB o Exhibits limited evidence for carcinogenesis in humans
LearningRadiology - Hamartoma
Hamartomas of the Lung

Hamartoma is composed of tissues normally found at this location but in abnormal quantity, mixture or arrangement INCIDENCE 0.25% in population
8% of all solitary pulmonary nodules
Most common benign lung tumor
5th and 6th decade peak
Male to female ratio of 3:1
CLINICAL Mostly asymptomatic
Cough
Fever (with postobstructive pneumonia)
Hemoptysis (rare)
LOCATION 2/3 are peripheral
Endobronchial in 10%
Rarely multiple
X-ray
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Round, smooth mass increase in size slowly
Calcification in 15% pathognomonic if popcorn type
Fat in 50% detected by CT
Cavitation extremely rare
DDX Other causes of a solitary pulmonary nodule
Bronchial adenoma
Bronchogenic ca
Granuloma
Lipoid pneumonia (both contain fat)
WH/92
LearningRadiology - Scleroderma
Scleroderma
90% of patients with disease have lung disease but only about 25% have abnormal chest x-rays 3:1 female to male ratio Rheumatoid factor found in 35% Increased incidence of lung cancer: alveolar cell Pulmonary fibrosis is uncommon in CREST but pulmonary arterial hypertension can occur
X-ray Diffuse reticular interstitial disease, primarily at bases Proceeds from fine to coarse reticulation Alveolar infiltrates 2 aspiration from disturbed esophageal motility may occur Honeycombing can be found Progressive volume loss (unlike other causes of diffuse fibrosis except Hamman-Rich) Pleural disease is rare (unlike RA and lupus)
WH/91
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LearningRadiology - Histiocytosis X
Histiocytosis X
Letterer-Siwe Disease
10% of histiocytosis X Acute disseminated, fulminant form Age at onset o Several weeks after birth to 2 years Pathology o May be confused with leukemia Symptoms o Hemorrhage, purpura o Severe anemia o Fever o Hepatosplenomegaly and lymphadenopathy Bone involvement in 50% o Widespread lytic lesions Prognosis: 70% mortality rate
Hand-Schuller-Christian
15-40% of Histiocytosis X Triad of: o Exopthalmus (33%)
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o Diabetes insipidus (30-50%) o Lytic skull lesions Pathology o May simulate Ewing's sarcoma Age at onset o 5-10 years Target organs o Bone Lytic skull lesions with overlying soft tissue nodules Large geographic skull lesions "Floating teeth" with mandibular involvement
o Soft tissue Hepatosplenomegaly is rare Lymphadenopathy which may be massive o Lung Cyst and bleb formation with spontaneous PTX Ill-defined diffuse nodular disease often leading to fibrosis and honeycombing Prognosis: spontaneous remissions and exacerbations
Eosinophilic granuloma
60-80% of Histiocytosis X Usually confined to bone Age at onset o 5-10 years highest frequency o Male predominance 3:2 Location o Calvarium>mandible>spine>ribs>long bones o Most are monostotic (50-75%)
Target organs o Skull (50%) Diploic space of parietal bone most often Round or ovoid punched out lesions with beveled edge Sclerotic margin during healing phase Beveled edge=hole-within-a-hole Button sequestrum- bony sequestrum within lytic lesion Axial skeleton (25%)
o "Vertebra plana"-"coin-on-edge" (Calve disease)=collapse of vertebral body, mostly thoracic o o Most common cause of vertebra plana in children
Proximal long bones (15%) Expansile, lytic lesions, mostly diaphyseal Soft tissue mass Laminated periosteal reaction Lung (20%) Age peak between 20-40 years Multiple small nodules Predilection for apices Prototype for honeycomb lung Recurrent pneumothoraces (25%) Rib lesions with fractures common
Nuclear Medicine o Negative bone scans in 35% o Bone lesions usually not Ga-67 avid o Ga-67 may be helpful in detecting non-osseous lesions
Prognosis: excellent
LearningRadiology - Sequestration
Bronchopulmonary Sequestration
Congenital malformation of the primitive foregut in which a part of the lung is not attached to the rest and gets its blood supply from a systemic artery
Intralobar sequestration
q q
q q q
q q
Lies within the same visceral pleura as the lobe in which it occurs Non-functioning intralobar sequestrations are closed systems not communicating with the tracheobronchial tree unless infected Gets its arterial supply from the aorta, most commonly descending thoracic aorta Venous drainage is almost always to the pulmonary venous system (left-to-right shunt) In about 2/3 of cases, the sequestration is in the left lower lobe, posterior segment; in the remainder it is in the right lower lobe, posterior segment Not usually associated with other anomalies Frequently recognized in adulthood because of pneumonia
X-ray
q q q q
When not infected, they appear as solid masses in the left lower lobe usually touching the diaphragm If infected and communicating with the bronchial tree, they may be cystic, air-containing with fluid levels May be obscured by surrounding pneumonia in normal lung Classically, a bronchogram shows the bronchi draped around the mass, a distinctive finding
Extralobar sequestration
q q q q q
Develops as an accessory lung contained within its own pleura Related to the left hemidiaphragm in 90% of cases It usually drains via the systemic venous system the IVC, azygous or hemiazygous The systemic arterial supply is commonly from the abdominal aorta Associated with other anomalies (congenital diaphragmatic hernias are common)
X-ray Since it is enveloped in its own pleural sac, it rarely gets infected so it almost always presents as a homogeneous soft tissue mass
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WH/91
LearningRadiology - Histoplasmosis
Histoplasmosis
q
Caused by Histoplasma Capsulatum, a soil fungus found especially in the Ohio River Valley (Ohio, Mississippi)
Similar in course and x-ray appearance to tuberculosis Histoplasmosis is the most common cause of fibrosing mediastinitis
Primary histoplasmosis
q
Most infections are subclinical X-ray

r
Migratory bronchopneumonia Hilar and mediastinal adenopathy Multiple nodules which heal with numerous calcified granulomas
s
TB granulomas are usually 1 or 2 in number
Histoplasmoma=target calcification=bulls-eye calcification in center of nodule (Pathognomonic)
Chronic histoplasmosis
q
Upper lobe cavitation, healing with fibrosis (very similar to TB)
Disseminated histoplasmosis
q
Infants and elderly are predisposed Can be rapidly fatal X-ray

r
Consolidation Adenopathy Hepatosplenomegaly Multiple splenic calcifications (unusual for TB)
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WH/93
LearningRadiology - Solitary Pulmonary Nodule
The Solitary Pulmonary Nodule

An Approach
Although a large part of the evaluation of a solitary pulmonary nodule (SPN) relies on radiology, the important decisions are made by the patients physician and by the patient himself. It is often the patient who decides between follow-up or surgery. Dividing patients in to five groups 1. The patients clinical course clearly shows the nodule is benign Relatively rare Nodule forms during resolution of a pneumonia, pulmonary infarct or pulmonary hematoma No further management necessary 2. The nodule is benign by virtue of calcification demonstrated by Plain films CT scan Conventional tomography Manage with a few follow-up chest x-rays at 6-12 months for stability 3. The nodule is uncalcified but stable for two years on serial films Almost always benign Manage with a few follow-up chest x-rays at 6-12 months for stability 4. The nodule is uncalcified and growing, or There are no previous radiographs for comparison Large group of patients Further divided into Non-operable patients for other reasons
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No further management necessary Patients at low risk for malignancyunder 30 with no smoking history Manage with serial radiographs or biopsy Patients at risk for cancer Includes middle-aged or older smokers Manage with biopsy, not with serial radiographs 5. The lesion is uncalcified and there is an extrapulmonary malignancy Such a nodule could be a solitary metastasis, a new primary or a benign nodule Manage with biopsy; resection may be considered if no other lesions are demonstrated
WH/93
LearningRadiology.com - Hyaline Membrane disease,respiratory distress syndrome,newborn,tachynea,RSD,HMD
Hyaline Membrane Disease

Respiratory Distress Syndrome (of the Newborn)
Acute pulmonary disorder of the newborn characterized by r Generalized atelectasis r Intrapulmonary shunting r Ventilation-perfusion abnormalities r Reduced lung compliance M:F =1.8:1 Cause r Immature surfactant production (usually begins at 18-20 weeks of gestational age) s Causes acinar atelectasis Predispositions r Premature infants r Cesarean section r Infants of diabetic mothers r Perinatal asphyxia Clinical findings r Onset s Usually less than 2-5 hours after birth s Increases in severity from 24 to 48 hours s Then, gradual improvement after 48-72 hours r Abnormal retraction of chest wall r Cyanosis r Expiratory grunting r Increased respiratory rate Imaging findings r Typically, diffuse ground-glass opacification of both lungs with air bronchograms and hypoaeration r Hypoaeration from loss of lung volume (may be counteracted by respiratory therapy) r Fine granular pattern r Prominent air bronchograms r Bilateral and symmetrical distribution Prognosis r Spontaneous clearing within 7-10 days (mild course in untreated survivors) r Death in 18% Acute complications r Barotrauma may produce s Parenchymal pseudocyst
q q
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s
s s
Pulmonary interstitial emphysema q Pseudoclearing r Lungs appear less because of innumerable small pockets of air in the peribronchial interstitial spaces Pneumomediastinum Pneumothorax
Diffuse ground-glass appearance to both lungs with a left-sided tension pneumothorax and pneumomediastinum (orogastric tube is in distal esophagus)
s s s s r
r r q
Pneumopericardium Pneumoperitoneum Air in the retroperitoneum Subcutaneous emphysema Diffuse opacity s Worsening RDS s Superimposed pneumonia s Massive aspiration s Pulmonary hemorrhage s Congestive heart failure (from PDA or fluid overload) q Persistent patency of ductus arteriosus r Oxygen stimulus is missing to close duct Hemorrhage s Pulmonary hemorrhage s Intracranial hemorrhage Necrotizing enterocolitis Acute renal failure Chronic complications r Lobar emphysema r Localized interstitial emphysema
Recurrent inspiratory tract infections r Retrolental fibroplasia r Subglottic stenosis from intubation Treatment r Supportive r Exogenous surfactant via trachea
r
Dahnert 4th edition
LearningRadiology - Teratoma
Mediastinal Teratoma
Other Germ Cell Neoplasms
q q
q q
Mediastinum is a rare site for occurrence of teratomas, most being ovarian in origin Arise from primitive germ cell rests r Supposed to migrate along urogenital ridge to primitive gonad r Journey is interrupted in the mediastinum May be solid or cystic r Most are cystic Three major categories r Mature teratomas s Well-delineated from surrounding tissues s Contain ectodermal elements along with cartilage, fat and smooth muscle r Immature teratomas s Same elements as above with primitive tissues found in fetus r Teratomas with malignant transformation s Overall about 30% are malignant s Usually adenocarcinoma in mature teratomas s Angiosarcoma or rhabdomyosarcoma in immature teratomas Most of the cystic lesions are benign and most of the solid lesions are malignant Both occur early in lifeyoung adults most commonly r DDX from thymomas which usually occur in 5th or 6th decade Symptoms r Usually asymptomatic r Large lesions can cause shortness of breath, cough or retrosternal pain or fullness r Rare rupture of dermoid into trachea which leads to trichoptysisexpectoration of hair Associations r Non-lymphocytic leukemia and malignant histiocytosis with immature teratomas Imaging findings r Most occur in the anterior mediastinum, near junction of great vessels and heart r Benign lesions are usually smooth in contour whereas malignant masses tend to be lobulated r Usually larger than thymomas r Calcification may rarely occur but is of no help since thymomas also calcify s Exception would be the very rare occurrence of a tooth or bone in a dermoid r CT shows fatty mass with globular calcifications and rarely a tooth or bone s Fat-fluid level may be seen on CT
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Enhanced CT scan of the chest shows large, septated anterior mediastinal mass containing fat and bony elements
r q
Rapid increase in size may mean hemorrhage into a cyst rather than enlarging malignancy Treatment and prognosis r Mature teratomas s For benign cystic teratomas, surgical resection s Excellent prognosis r Immature teratomas s In childhood, surgical excision is often successful s In adults, tend to have a more malignant course r Teratomas with malignancy s Usually highly aggressive s Poor prognosis Teratoma versus dermoid r Dermoid contain only epidermis r Teratomas contain all 3 germ layers, but are mostly endodermal when malignant Other germ cell neoplasms r Benign dermoid cysts r Benign and malignant teratomas r Seminomas r Choriocarcinomas r Embryonal cell carcinomas Mediastinal seminomas r Rare r Almost always in young men r Identical to testicular seminoma and ovarian dysgerminoma r May be well-encapsulated or invasive r Tends to be lobulated r Cannot be differentiated from teratoma Primary choriocarcinoma r Even rarer than seminoma in the mediastinum r Only 23 reported in the literature, almost all in men r Occur between 20-30 years r May be lobulated
r r r r
May have elevated beta sub unit of HCG Growth is very rapid leading to dyspnea, hemoptysis, stridor Gynecomastia and a + Aschheim-Zondek test can occur Rapidly fatal
Fraser and Pare
LearningRadiology - Lipoid Pneumonia
Lipoid Pneumonia
Exogenous accumulation of fat in the lung most often from mineral oil: Older people who are constipated, have a swallowing disorder 2 neurologic disease In infants with feeding difficulties In the past, could be from oily nose drops Accumulation of fat in the lung may also occur from endogenous sources such as fat embolism, alveolar proteinosis lipid storage diseases
Animal fatty acids (like fat embolus) produces hemorrhagic bronchopneumonia Mineral oil produces a giant cell foreign body reaction Starts as an alveolar infiltrate Moves to thicken interstitial septa, then Into macrophages enlarging lymphatics Finally produces a fibrosing reaction
X-ray
Usually lower lobes with predilection for the right Alveolar consolidation, may be well-circumscribed May present as a peripheral mass with fuzzy or distinct margins simulating BrCa Fat attenuation on CT
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Low-attention mass in right lower lobe demonstrates fat density
Clinical
Usually asymptomatic
Diagnosis
Best method of DX is direct Bx Fat-laden macrophages are non-specific since they can be found in sputum of normals as well
WH/91,93
LearningRadiology - Substernal Thyroid Mass
Thyroid Masses
Extension of a thyroid goiter arising in the neck down into the thorax is rare Most (75-80%) arise from lower pole or isthmus of the thyroid and extend into anterior mediastinum Some arise from posterior aspect of the thyroid and extend into posterior mediastinum, almost always on the right Usually nodular, colloid goiters Thyrotoxicosis and carcinoma are rare Thyroid mass is typically well-encapsulated and may show degeneration (calcification) On CT, they usually contrast enhance and many times are found to contain calcification. The contrast enhancement is prolonged. Most patients are asymptomatic
X-ray
Sharply defined, smooth or lobulated soft tissue mass which characteristically displaces the trachea They do not usually project below the arch of the aorta differentiating them from thymomas and teratomas Those in the posterior mediastinum characteristically interpose between the trachea in front and the esophagus in back Curvilinear calcifications are highly suggestive of a degenerated thyroid adenoma Radioisotope scan is diagnostic
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LearningRadiology - Substernal Thyroid Mass
WH
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LearningRadiology - Lupus erythematosus
Systemic Lupus Erythematosus
Lungs and pleura are involved more often in lupus than any other collagen vascular disease (type III immune complex phenomenon)
Findings include:
r
Anti-nuclear antibody present in 87% LE cells in 78% Hypergammaglobulinemia in 77% Rheumatoid factor in 21%
Skin changes include

r
Butterfly rash Alopecia Photosensitivity Raynaud's
Can be induced by drugs

r
Four drugs account for 90% of cases

s
Hydralazine Pronestyl (procainamide) Dilantin INH
Pleuroparenchymal changes more common than SLE This form does not involve kidney and will disappear if drug is stopped
X-ray
q
Patchy areas of consolidation at the lung bases, especially peripherally These may be 2 to infection (common) or lupus infiltrates (uncommon)
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q
Pleural effusion is probably most common lung manifestation 2 pleuritis Usually bilateral and small but may become very large If unilateral, more often on the left Discoid atelectasis is common Massive pulmonary hemorrhage may occur Cavitary nodules may occur (but are more common in RA) Cardiomegaly may be 2 to effusion or cardiomyopathy Diffuse interstitial fibrosis does not occur in SLE
Think of SLE with combination of:

q
Pleural effusion, discoid atelectasis and patchy infiltrates at the bases (DDx: thromboembolic disease)
WH/91
LearningRadiology - TB
Tuberculosis
Primary Pulmonary Tuberculosis
q
Parenchyma Upper lobes affected slightly more than lower Alveolar infiltrate Cavitation is rare
Lobar pneumonia is almost always associated with lymphadenopathytherefore, lobar pneumonia associated with hilar or mediastinal adenopathy at any age should strongly suggest TB
q
Lymph node Mostly unilateral hilar and/or paratracheal, usually right sided, rarely bilateral Differentiates primary from postprimary TBit does not occur in postprimary TB Much more common in children
Airway Atelectasis classically affects the anterior segments of the upper lobes or the medial segment of the RML
Pleura Pleural effusion as a manifestation of primary TB occurs more often in adults than children
With appropriate treatment, it carries the best prognosis of all patterns of TB and is the least likely to develop complications The fluid accumulates slowly and painlesslytherefore, patients with TB are seldom seen with a small amount of pleural fluid Parenchymal disease will almost never be present with a pleural effusion although lymphadenopathy may Apical pleural scarring is rarely tuberculous in origin
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q q
Calcification in the primary complex is relatively rare. Very few patients with primary TB have clinical manifestations
Postprimary Tuberculosis (Reactivation TB)

q
Most cases in adults occur as reactivation of a primary focus of infection acquired in childhood Limited mainly to the apical and posterior segments of the upper lobes and the superior segments of the lower lobe Caseous necrosis and the tubercle (accumulations of mononuclear macrophages, Langerhan's giant cells surrounded by lymphocytes and fibroblasts) are the pathologic hallmarks of postprimary TB Healing occurs with fibrosis and contraction; calcification is rarer than in primary
Patterns of distribution Almost always affect the apical or posterior segments of the upper lobes or the superior segments of the lower lobesbilateral upper lobe disease is very common May present as pneumonia
Cavitation may result: the cavity is usually thin-walled, smooth on the inner margin with no airfluid level Transbronchial spread may occurfrom one upper lobe to opposite lower or to another lobe Miliary spread (below) Bronchiectasisusually asymptomatic
Bronchostenosis due to fibrosis and stricture: fibrosis may cause distortion of a bronchus and atelectasis many years after the initial infectionmiddle lobe syndrome Solitary pulmonary nodulethe tuberculomamay occur in either primary or postprimary disease; round or oval lesions with small, discrete shadows in the immediate vicinity of the lesion the satellite lesion
q
Formation of a pleural effusion in postprimary TB almost always means direct spread of the disease into the pleural cavity and should be regarded as an empyemathis carries a graver prognosis than the pleural effusion of the primary form Direct extension into the ribs or sternoclavicular joints is uncommon
Miliary Tuberculosis
q q q q q
Older men, Blacks and pregnant women are susceptible Onset is insidious Fever, chills, night sweats are common Takes weeks between the time of dissemination and the radiographic appearance of disease Considered to be a manifestation of primary TBalthough clinical appearance of miliary TB may not occur
q q
for many years after initial infection When first visible, they measure about 1 mm in size; they can grow to 2-3mm if left untreated When treated, clearing is rapidmiliary TB seldom, if ever, produces calcification
TB and Other Diseases

q q q
There is an association between TB and silicosis, TB and HIV There may be an association between TB and sarcoid There is no association between TB and bronchogenic carcinoma
HIV and TB
q q q q q
No matter what form of TB the patient has, it tends to look like 1 TB Hilar and mediastinal adenopathy are common Cavitation is less common There is no predilection for the apices MAI (mycobacterium avium-intracellulare) is more common in HIV than TB
WH/91, rev 93
LearningRadiology - Lymphangiomyomatosis
Lymphangiomyomatosis and Tuberous Sclerosis

q q
q q q
Similar in pathology and x-ray appearance Widespread proliferation of smooth muscle in pleura, alveolar septa, bronchi, pulmonary vessels and lymphatics as well as lymph nodes, especially in posterior mediastinum and retroperitoneum Focal emphysema develops as result of narrowing of airways Thoracic duct may be obliterated Produce multiple small cysts with a hamartomatous proliferation of smooth muscle in their walls
Characteristic x-ray triad of:

q q q
Progressive, diffuse interstitial disease Recurrent chylous effusions and sometimes chylous ascites Recurrent pneumothorax Tuberous sclerosis is inherited as a dominant with variable penetrance: Mental defects Epilepsy Retinal phacoma Angiomyolipomas of the kidneys Rhabdomyomas of the heart Intracranial calcifications Sclerotic skull lesions Adenoma sebaceum Subungual fibromas Pulmonary lymphangiomyomatosis (syn: pulmonary myomatosis) Exclusively in females ages 17-47 years Rare
X-ray
q
q q
Identical in both tuberous sclerosis and lymphangiomyomatosis and indistinguishable from pulmonary fibrosis except for decreased lung volume in fibrosis and increased lung volume in the others Generalized, coarse reticulonodular changes Unilateral or bilateral pleural effusions which are usually large and recurrent
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LearningRadiology - Lymphangiomyomatosis
q q q q
Spontaneous pneumothorax is common Clinically Shortness of breath Hemoptysis
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LearningRadiology - UIP
Usual Interstitial Pneumonia

q
The most common of the diffuse interstitial pneumonias Begins with diffuse damage to alveolar walls Necrosis of alveolar lining cells is followed by regeneration There is an abundance of polys in bronchial washings in contrast to lymphocytes found in sarcoid or hypersensitivity pneumonias
X-Ray
q
Earliest manifestation consists of fine reticular pattern, particularly at the lung bases Becomes coarser as disease progresses and ends with honeycomb lung Progressive loss of volume is characteristic of either UIP or scleroderma
Clinically
q
Symptoms include SOB, non-productive cough and fatigue Clubbing of the fingers is very common (85%) Cyanosis and pulmonary hypertension usually occur late in the disease Velcro rales on auscultation About 1/3 have +ANA titers and 1/3 have + Rheumatoid factors
Other chronic interstitial pneumonias

q
BIP (Bronchiolitis obliterans and diffuse interstitial pneumonia)favors upper lobes DIP (desquamative interstitial pneumonia)second most common chronic interstitial pneumonia Heavy concentration of mononuclear cells rather than polys as in UIP Loss of type I alveolar epithelial cells and proliferation of type II cells Ground glass pattern in both lower lung fields LIP (lymphoid interstitial pneumonia) like lymphoma
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LearningRadiology - UIP
No characteristic x-ray picture GIP (giant cell interstitial pneumonia) characterized by multinucleated giant cells in the alveoli No characteristic x-ray picture
WH/91
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LearningRadiology - Hodgkins Disease
Hodgkins Disease
Half of patients with Hodgkins have mediastinal lymph node enlargement visible on chest x-ray. l About 5-10% of patients may have mediastinal adenopathy without any other nodes involved l Clinically, over 90% of patients with Hodgkins have enlarged nodes, the disease behaving most benignly when restricted to the neck l Most have nodular sclerosing type
l
Imaging Findings
l
l l l
Parenchymal involvement occurs in 1/3 of patients with Hodgkins o Almost all have associated hilar or mediastinal adenopathy o Bronchovascular form (most common type of involvement) Coarse reticulonodular pattern contiguous with mediastinum = direct extension from mediastinal nodes along lymphatics Nodular parenchymal lesions Miliary nodules Endobronchial involvement Lobar atelectasis secondary to endobronchial obstruction (rare) Cavitation secondary to necrosis (rare) o Subpleural form Circumscribed subpleural masses Pleural effusion from lymphatic obstruction (20-50%) o Pneumonic form Diffuse nonsegmental infiltrate (pneumonic type) Massive lobar infiltrates (30%) Homogeneous confluent infiltrates with shaggy borders Contain air bronchogram o Nodular form Multiple nodules <1 cm in diameter Extraparenchymal manifestations in the chest Hilar adenopathy is usually bilateral but asymmetric Anterior mediastinal nodes commonly involved o They may calcify after radiation therapy Mediastinal and hilar lymphadenopathy o Most common manifestation Present in 90-99% Commonly multiple lymph node groups involved
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Location Anterior mediastinal and retrosternal nodes commonly involved (DDx: sarcoidosis) Confined to anterior mediastinum in 40% 20% with mediastinal nodes have hilar lymphadenopathy also Hilar lymph nodes involved bilaterally in 50%
Frontal and lateral radiograph of the chest shows mediastinal adenopathy (red arrows) producing lobulated soft tissue masses
Spread from anterior mediastinum to Pleura Pericardium Chest wall o On initial chest film adenopathy identified in 50% Lymph nodes may calcify following radiation / chemotherapy l About 1/3 have pleural effusions o Effusion usually does not contain malignant cells l Atelectasis is very uncommon and almost always due to an endobronchial lesion l Prognostically, mediastinal node enlargement worsens prognosis but only minimally. o Diffuse lung involvement, on the other hand, carries a grave prognosis l Thoracic XRT portal is called a mantel because of its T shape to cover supraclavicular and mediastinal nodes o Lymphoma is radiosensitive tumors frequently beginning to show reduction in size almost at once o Staging Stage I is adenopathy limited to one lymph node bearing group l Stage II is adenopathy involving two or more non-contiguous groups on the same side of the diaphragm l Stage III is adenopathy involving lymph node groups on both sides of the diaphragm l Stage IV is extranodal involvement-such as lung or brain
l

l l
A signifies absence of symptoms B signifies presence of fever, night sweats or pruritis
LearningRadiology - Varicella Pneumonia
Varicella Pneumonia
Occurs most often over the age of 19 rather than in childhood Patchy, diffuse air space consolidation Tendency to coalesce near hila Widespread nodules can occur (30%) Tiny calcifications remain in 2% (DDX is histoplasmosis, alveolar microlithiasis) 11% mortality rate
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LearningRadiology - Metastases to the Lung
Metastatic Lung Disease
SOLITARY METASTASES
MULTIPLE NODULES
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Colon (30-40%) Sarcomas, particularly from bone Kidney Testicle Breast Malignant melanoma
Kidney Thyroid
Sarcoma of bone
LYMPHANGITIC SPREAD
CAVITARY METS
Lesions arise around chest Simulate CHF
Usually thick walled with nodular inner margin
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Lung Breast Thyroid Larynx Stomach Pancreas Cervix
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Squamous cell primaries such as Head and neck tumors Ca of the cervix Transitional cell ca Melanoma Adenocarcinoma
Mets to the lung occurs in about 30% of all malignant disease Routes of spread include hematogenous, lymphangitic and direct extension Lesions which spread by direct extension include carcinoma of the breast, liver or pancreas
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Commonest pathway to the lungs is via systemic veins Lymphangitic spread is actually first hematogenous; then, the cells invade lymphatics and travel antegrade back to the hila Abscopal effect metastatic lesion disappears spontaneously as the primary is removed especially, kidney and trophoblastic malignancies Cavitation occurs more often in the upper than the lower lung fields and most frequently in tumors of epithelial originsuch as squamous cell ca or transitional cell ca Snowstorm appearance of miliary metsthink of thyroid ca Mets with long survivals think of salivary gland tumors and alveolar cell ca Mets with fuzzy borders think of lesions that grow very quickly and bleed, such as metastatic choriocarcinoma Mets that contain calcificationthink of osteosarcoma, chondrosarcoma Things that look like mets but arentother causes of multiple nodules
r
AVMs Wegeners granulomatosis Rheumatoid nodules Septic emboli Hamartomas
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LearningRadiology - Wegener's Granulomatosis
Wegeners Granulomatosis
General
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Male:female ratio of 2:1 Peak in 40s Autoimmune disease characterized by necrotizing granulomas and angiitis Diagnosis is made by lung or kidney biopsy Death comes from renal failure or respiratory failure Treated with steroids and cytotoxic drugs
Respiratory Tract (100% involved)

Upper respiratory tract Mucosal thickening in paranasal sinuses Bone and cartilage destruction
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Lungs Multiple nodules of varying sizes, especially at bases Cavitate frequently (50%) Masses wax and wane Pleural effusion (25%) Alveolar infiltrate occasionally
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Other Organs
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Urinary tract:focal glomerulonephritis (50%) Joints:migratory polyarthropathy (56%) Skin:inflammatory skin lesions (44%) Eyes and ears:proptosis and otitis media (29%) Heart and pericardium: myocardial infarction (28%) CNS: neuritis (22%)
Symptoms
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LearningRadiology - Wegener's Granulomatosis

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Rhinorrhea Sinusitis Epistaxis Cough with hemoptysis
Midline Lethal Granuloma

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Variant of Wegeners consisting of mutilating granulomatosis and neoplastic lesions limited to nose and paranasal sinuses
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LearningRadiology - Achalasia
Achalasia
Cause is generally considered a defect in the cholinergic receptors of Auerbachs plexus (between the inner circular and the outer longitudinal muscle layers of the muscularis). Characteristically, primary peristaltic stripping waves are absent in either the upper (early) or the whole (late) esophagus. Tertiary waves may be present but in the late stages the esophagus is atonic. The lower esophageal sphincter fails to relax. There is a positive response (forceful contraction) following an injection of methacholine but this is not pathognomonic. This contraction may be associated with severe substernal pain. The stomach bubble is usually present in early stages, absent in the later stages of the disease. Hurst phenomenon=transit of food through EG junction 2 increased hydrostatic pressure of barium column In the late stages, the distal esophagus tends to make a right angle bend before entering the stomach due to the extreme tortuosity of the esophagus. This is called birds beak or rat-tail sign. Chagas disease (trypanasoma cruzi) is indistinguishable from achalasia and is the result of destruction of the ganglion cells. Carcinoma of the esophagus can complicate achalasia in 7% of cases, usually in mid-esophagus. DDX: Reflux esophagitis and stricture narrowing is higher than EG junction peristalsis may be preserved Carcinoma usually less dilated peristalsis preserved
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LearningRadiology - Achalasia
Scleroderma empties on standing Chagas disease indistinguishable by x-ray

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LearningRadiology- Gastric Emphysema
Gastric Emphysema
Air in the stomach wall with an appearance similar to emphysematous gastritis with a much more benign clinical course Caused by disruption in mucosa leading to air dissecting into wall from: r Gastric outlet obstruction with increased intraluminal pressure r Severe vomiting r Instrumentation-like endoscopy r Dissection of air from mediastinum from ruptured bleb or pneumothorax r Pneumatosis cystoids - submucosal air collections
Air in stomach wall outlines greater curvature of stomach
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Rare and severe gastritis secondary to mucosal disruption and gas-forming bacterial invasion Characterized by air in the wall of the stomach
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Causes: r Ingestion of toxic material such as corrosives r Alcohol ingestion r Trauma r Gastric infarction r Ulcer disease Submucosa is invaded by gas-forming organisms which include: r Hemolytic strep r Clostridia Welchi r E. Coli r Staph aureus Clinical: r Sudden and violent onset of bloody emesis r Fever r Nausea r Chills r Leukocytosis X-ray: r Linear small gas bubbles in gastric wall s Gastric emphysema is more linear, streak-like r Gas in portal vein Prognosis: r 60-80% fatal Best way to differentiate emphysematous gastritis from gastric emphysema: r Look at patient s Patients with gastric emphysema are a asymptomatic from the bowel gas air s Patients with emphysematous gastritis are usually deathly ill
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LearningRadiology - Antral Web
Antral Diaphragm or Web
A membrane with a variably-sized opening in the antrum of the stomach May occur from 3 months to 80 years Histologically Mucosa around a central core of submucosa and muscularis mucosae
Usually no inflammation of the web itself Usually located from 1 to 1.5 cm proximal to pyloric canal
X-ray
Persistent, thin, band-like deformity perpendicular to the long axis of the antrum Usually 2-3 mm thick Associated ulcers are found in 30-50% of patients Rx: May be intentionally ruptured with an endoscope
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LearningRadiology - Antral Web
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http://www.learningradiology.com/notes/ginotes/polypsgastricpage.htm
Gastric Polyps
Most common benign gastric tumor Associated with: Hyperacidity+ulcers Chronic atrophic gastritis Gastric carcinoma Low incidence of malignant transformation
Hyperplastic polyp=inflammatory polyp (75-90%)

Proliferated gastric mucosa+inflammatory cells Associated with pernicious anemia Random distribution in stomach Usually multiple polyps Usually <1cm with no progression
Adenomatous polyp (10-20%)

True neoplasm with very low malignant potential Associated with Gardners syndrome, coexistent gastric ca Occurs more commonly in antrum Often single Usually>1.5cm in size
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Occur in patients over 50 years old
Hamartomatous polyp (rare)

Densely packed gastric glands Associated with Peutz-Jeghers syndrome Usually <2cm in diameter
Retention polyp (rare)

Dilated cystic glands Associated with Cronkhite-Canada syndrome
Villous polyp (rare)

Can undergo malignant transformation
DDX: Menetrier disease (antrum is spared) Eosinophilic polyps Lymphoma Carcinoma Pancreatic rest (antrum)
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LearningRadiology - Ascariasis
Ascariasis
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Most common parasitic infestation in the world Most common in children ages 1 to 10 years Most often found in distal small bowel Life cycle
r r
Infection is through contaminated soil Involves GI tract of host twice First time as egg Migrates through lungs Adult travels up trachea
s s
r r
Returns to GI tract for maturation (2 months)
Signs and Symptoms

r r r
Colicky pain Hematemesis Eosinophilia
X-ray findings
r r
Long, tubular filling defects, especially in distal small bowel The worm ingests barium and the barium may be seen as a thin line of contrast in the center of the worm
s
Especially after the remainder of the barium exits the small bowel. See below (streak of barium in LUQ):
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Ball of worms
Complications
r r r r r
Appendicitis Jaundice (if bile ducts are involved) Pneumonia Bowel perforation Mechanical obstruction
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http://www.learningradiology.com/notes/ginotes/ulcergastricpage.htm
Gastric Ulcers
Causes
Stress
Burns=Curling ulcer Cerebral disease=Cushing ulcer Uremia Steroid therapy Hyperparathyroidism (25% have ulcer disease)
Other facts
Multiple in 2-8% Coexistent duodenal ulcer disease in 5-42%; duodenal:gastric ratio=3:1 Multiple postbulbar duodenal ulcers should suggest Zollinger-Ellison
Location
Lesser curvature aspect of body and antrum usually for benign ulcers Benign ulcers also occur on posterior wall; not usually anterior wall May be found in proximal half of stomach in geriatric patient Almost all lesser curvature gastric ulcers <1cm are benign Greater curvature benign ulcers are associated with considerable mass effect which erroneously leads to conclusion of malignancy
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Two prerequisites for diagnosis of an ulcer:

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Collection Persistent
X-Ray Signs of a benign gastric ulcer

Ulcer crater-collection of barium on dependent surface which usually projects beyond anticipated wall of stomach in profile (penetration) Hamptons line-1 mm thin straight line at neck of ulcer in profile view which represents the thin rim of undermined gastric mucosa Ulcer collar-smooth, thick, lucent band at neck of ulcer in profile view representing thicker rim of edematous gastric wall Ulcer mound-smooth, sharply delineated tissue mass surrounding a benign ulcer Ring shadow-thin rim of contrast which represents an ulcer on the non-dependent surface of an air-contrast study Thickened folds radiating directly to the base of the ulcer en face
Healing
Most gastric ulcers clear completely in 6-8 weeks. With healing, ulcer decreases in size and is more likely to appear linear Radiating folds become more prominent and extend to crater Between 50-90% of healed gastric ulcers produce visible scars on Double Contrast study
X-ray signs of malignant ulcers

Ulcer projects within the anticipated wall of the stomach
Ulcer is eccentrically located within the ulcer mound Irregularly shaped ulcer crater Nodular ulcer mound Abrupt transition between normal and abnormal mucosa several cms away from the ulcer crater
Rigidity, lack of distensibility and lack of changeability Associated large mass Carmen meniscus sign-a relatively shallow gastric ulcerating malignancy projecting as an ulcer which is always convex inwards to the lumen and which does not project beyond the wall=Kirklin meniscus complex
Complications of ulcer disease

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Bleeding is slightly more common in the duodenum than the stomach
About 17% of all ulcers are complicated by bleeding A filling defect in the ulcer crater may represent a blood clot
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Gastric outlet obstruction is less common than bleeding (5%) Stomach may have to be suctioned to get good study Benign ulcer disease at pylorus is a more likely to cause gastric outlet obstruction than
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Perforation in 5-11% is more common in duodenal than gastric ulcers Most gastric perforations are from lesser curve ulcers Free air is not detected by x-ray in 25-35% of perforated duodenal ulcers
Penetration is the extension of the ulcer beyond the serosa in to adjacent structures
Pancreas is most common site, but also biliary tree, colon
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LearningRadiology - Boerhaave's Syndrome
Ruptured Esophagus
Nearly all esophageal perforations are caused by trauma
Causes include: > Iatrogenicendoscopy (about 75% of the perforations in adults), dilatation procedures > Stab wounds > Occasionally, blunt compression of the chest > Severe vomiting or straining Non-traumatic causes include neoplasm or caustic ingestion In infants, the most frequent site of rupture is the cervical esophagus 2 passage of tubes
Usually in men, although neonatal esophageal rupture occurs primarily in girls Associated with the clinical triad of vomiting, chest pain and subcutaneous/mediastinal emphysema In neonates, there is cyanosis and dyspnea associated with a right tension pneumothorax immediately after birth In Boerhaaves, the inciting cause may be vomiting, straining, childbirth or a blunt blow to the abdomen or thorax Tears are vertically oriented, 1-4 cm in length Almost all (90%) occur along the left posterolateral wall of the distal esophagus
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Photo shows extraluminal contrast arising from left, posterolateral tear of esophagus
X-Ray
Mediastinal emphysema
Left pleural effusion
Photo shows mediastinal emphysema and extraluminal contrast in pleural space on left Mediastinal widening Subcutaneous emphysema Nacleiro sign-a V-shaped radiolucency seen through the heart representing air in the left lower mediastinum that dissects under the left diaphragmatic pleura In neonatal rupture, pneumomediastinum is uncommon Method of study:
First use a water-soluble contrast agent (Gastrografin, oral Hypaque) If no perforation is found, then barium may be used
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http://www.learningradiology.com/notes/ginotes/gastricvolvuluspage.htm
Gastric Volvulus
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Uncommon r May occur in children due to congenital diaphragmatic defects r In adults, rarely occurs before age 50 s Most common cause of gastric volvulus in adults are diaphragmatic defects Stomach twists on itself Etiologies r Abnormality of the suspensory ligaments of the stomach s Gastrohepatic s Gastrosplenic s Gastrocolic s Gastrophrenic r Unusually long gastrocolic and gastrohepatic mesentery Classified as one of two types--organoaxial or mesenteroaxial
Type
Appearance
Description
Remarks
Most common type. Twist occurs along a Usually associated line connecting the with diaphragmatic cardia and the pylorus-defects. the luminal (long) axis of the stomach Vascular compromise more common.
Organoaxial
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Mesenteroaxial
Twist occurs around a plane perpendicular to the luminal (long) axis of the stomach from lesser to greater curvature
Chronic symptoms more common. Diaphragmatic defects less common.
Almost always occur with large diaphragmatic hernia like hiatal hernia r Especially, paraesophageal hiatal hernias s In paraesophageal hernias, gastroesophageal junction remains in abdomen while stomach ascends adjacent to the esophagus s Produces upside-down-stomach s Gastric volvulus is most common complication of paraesophageal hernias r Also occurs with eventration of the diaphragm r Paralysis of diaphragm Despite abnormal placement of stomach, it usually does not become obstructed r Sometimes called partial volvulus or torsion or chronic volvulus r Twisting up to 180 degrees may cause no obstruction r Twisting beyond 180 degrees almost always produces obstruction Clinical findings r Unless acute, patients are frequently asymptomatic r When acute and obstructing s Abdominal pain s Attempts to vomit without results s Inability to pass an NG tube s Together, these three findings comprise the Borchardt triad which is diagnostic of acute volvulus q Reportedly occurs in 70% of cases Imaging findings r Massively dilated stomach in LUQ possibly extending into chest r Inability of barium to pass into stomach (when obstructed)
Frontal radiograph from an upper GI examination shows the stomach located in the lower chest in a large hiatal hernia. The greater curvature of the stomach lies superior to the lesser curvature in an organoaxial twist. Note that the stomach is not obstructed.
Treatment r Surgery in acute gastric volvulus r In patients with chronic gastric volvulus, surgery is performed to prevent complications s Nonoperative mortality rate = as high as 80% s Mortality rate from acute gastric volvulus = 15-20% s Mortality rate from chronic gastric volvulus ranges up to 13% Complications r Gastric emphysema r Twisting of stomach may tear spleen from its normal attachments r Perforation is rare
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Margulis and Burhenne-Alimentary Tract Roentgenology 2nd Ed, Vol. 1 Dahnert 4th edition eMedicine Gastric Volvulus by Mohamed Akoad, MD and Richard Golub, MD
LearningRadiology.com - Candidiasis,candida,moniliasis,esophagitis,candida albicans,image,radiology
Candida Esophagitis (Moniliasis)
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Most common cause of infectious esophagitis Organism r C. albicans r Found in diseased skin, GI tract, female genital tract, urine in patients with an with an indwelling Foley catheter Usually occurs as an opportunistic infection in those with r Depressed immunity s AIDS s Hematologic disease s Renal transplant s Leukemia s Chronic debilitating disease r Diabetes mellitus r Steroids r Chemotherapy r Radiotherapy r Diseases which cause delayed esophageal emptying s Scleroderma s Strictures s Achalasia s S/P fundoplication r Rarely may occur in otherwise healthy individuals Produces whitish slightly raised plaques Symptoms r Dysphagia r Odynophagia r Intense substernal pain r Associated with oral thrush (oropharyngeal moniliasis) in 20-80% Location r Predilection for upper 1/2 of esophagus s Involvement of long esophageal segments Imaging Findings r Discrete plaque-like lesions r Plaques line-up longitudinally = grouping of tiny 1-2 mm nodular filling defects with linear orientation
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r r
Larger plaques may coalesce to produce "cobblestone" appearance Further coalescence produces shaggy contour (from coalescent plaques, pseudomembranes, erosions, ulcerations, intramural hemorrhage) in fulminant candidiasis s More fulminant form is more often associated with AIDS
Double-contrast esophagram shows markedly nodular mucosa with multiple discrete ulcers covering all of esophagus
r
r q
Ulcers invariably appear only on a background of diffuse plaque formation, not as isolated findings Long, smoothly-tapering strictures may develop but are rare s More likely to develop in patients with cutaneous manifestations of Candidiasis Mycetoma resembling large intraluminal tumor is rare Diagnosis r Endoscopy most sensitive method of making diagnosis for mild cases r Double-contrast esophagography should pick up 90% of cases Treatment r Mycostatin r Findings usually regress quickly Differential Diagnosis r Glycogenic esophagitis asymptomatic nodularity r Reflux esophagitis distal esophagus, nodules poorly defined r Superficial spreading carcinoma- nodular and irregular folds r Artifacts (undissolved effervescent crystals, air bubbles, retained food particles) r Herpes esophagitis discrete ulcers surrounded by halo of edema r Acute caustic ingestion long strictures are common r Intramural pseudodiverticulosis unlike ulcers, pseudodiverticula dont appear to connect to lumen r Varices distal esophagus usually; serpiginous elongated filling defects
http://www.learningradiology.com/notes/ginotes/hhpage.htm
Hiatal Hernia
Two main types: sliding and paraesophageal Sliding Hiatal Hernia (99%) EG junction lies above the diaphragm, or Distal most esophagus measures more than 50% of the diameter of the tubular esophagus=patulous cardia=predisposed to GE reflux, or Prominent gastric folds extend into distal esophagus from stomach May be reducible or incarcerated; sliding refers to EG junction, not to reducibility Complications Large incarcerated hiatal hernias may slowly weep blood so that patients with them present with iron deficiency anemia, not reflux symptoms Peptic esophagitis from reflux Discrete marginal ulcers Strictures Paraesophageal Hiatal Hernia Portion of stomach herniates through esophageal hiatus above diaphragm but EG junction continues to be subdiaphragmatic Usually non-reducible Not associated with GE reflux Intrathoracic stomach Cardia may still be subdiaphragmatic
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http://www.learningradiology.com/notes/ginotes/hhpage.htm
Greater curvature may be on left or right side Congenitally short esophagus (rare) Gastric ectopy by reason of lack of lengthening of esophagus Short, straight esophagus Frequently ulcer at EG junction GE reflux Antireflux mechanisms Large, incarcerated hiatal hernias Paraesophageal hiatal hernias A dynamic or contractile ring Cricopharyngeous muscle
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LearningRadiology - Carcinoma of the Colon
Colon Carcinoma
Risk Factors
Adenomatous polyp Family history of benign or malignant colon tumors Chronic ulcerative colitis Crohns disease Prior pelvic radiation In women who have carcinoma of breast or uterus Retinitis pigmentosa Familial polyposis Gardeners syndrome For synchronous lesions=1% (two or more colon cas at same time) For metachronous lesions=4-5% (likelihood of a person with colon ca developing 2nd)
Pathology
Adenocarcinomas make up the vast majority Squamous cell carcinoma can start at the anal verge Cloacogenic carcinoma spreads most by direct invasion
Clinical
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Peak age 50-70 years Weight loss Blood in stool Loss of appetite Change in bowel habits
Location
Rectum (15%), sigmoid (20%), descending colon (10%), transverse colon (12%), ascending colon (8%), cecum (8%) Location seems to be changing and moving back to cecum More common in right colon with advancing years More common in left colon with chronic ulcerative colitis
X-Ray Manifestations
90-95% rate of detection by BE Polypoid filling defect Annular constricting=apple-core lesion Scirrhous ca-rare infiltrating type which gives lead-pipe appearance seen especially in ulcerative colitis Calcifications-rare May have retrograde without antegrade obstruction
Mets to colon
Stomach, breast, pancreas, and GU pelvic malignancies via blood May also spread via intraperitoneal seeding, especially from ovary
Complications
Obstruction-antegrade/retrograde or both Perforation is relatively common
Carcinomas of the transverse colon can spread via direct extension to stomach Intussusception of lesions in TI or cecum Ischemic colitis may occur if chronic obstruction
Metastases
Liver (25%) Retroperitoneal and mesenteric nodes (15%) Hydronephrosis (13%) Adrenal (10%) Ovarian mets Ascites
Complications
Obstruction-may be retrograde but not antegrade More likely to be left-sided than right-sided Perforation Intussusception Pneumatosis intestinalis
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LearningRadiology - Hypertrophic pyloric stenosis
Hypertrophic Pyloric Stenosis

q
Age Usually manifests at 2-8 weeks of life Clinical r Nonbilious projectile vomiting with progression over a period of several weeks after birth (1520%) r Palpable olive-shaped mass (80% sensitive in experienced hands) Positive family history Nasogastric aspirate >10 ml UGI findings r Pyloric wall thickness >10 mm r Elongation and narrowing of pyloric canal (2-4 cm in length) r "Double / triple track sign" s Crowding of mucosal folds in pyloric channel r "String sign" s Passing of small barium streak through pyloric channel r Twining recess = "diamond sign" s Transient triangular tentlike cleft / niche in midportion of pyloric canal with apex pointing inferiorly secondary to mucosal bulging between two separated hypertrophied muscle bundles on the greater curvature side within pyloric channel r "Pyloric teat" s Outpouching along lesser curvature due to disruption of antral peristalsis r "Antral beaking" s Mass impression upon antrum with streak of barium pointing toward pyloric channel
r
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Stomach shows double tracking in region of pyloric canal, indentation on base of bulb and delayed gastric emptying
r r
Kirklin sign = "mushroom sign" s Indentation of base of bulb (in 50%) Gastric distension with fluid Active gastric hyperperistalsis s "Caterpillar sign" q Gastric hyperperistaltic waves US findings r "Target sign" s Hypoechoic ring of hypertrophied pyloric muscle around echogenic mucosa centrally on cross-section r "Cervix sign" s Indentation of muscle mass on fluid-filled antrum on longitudinal section r "Antral nipple sign" s Redundant pyloric channel mucosa protruding into gastric antrum r Pyloric volume >1.4 cm3 (= 1/4 x [maximum pyloric diameter]2 x pyloric length) s Most criteria independent of contracted or relaxed state r Pyloric length (mm) + 3.64 x muscle thickness (mm) > 25 r Pyloric muscle wall thickness >3 mm r Pyloric transverse diameter >13 mm with pyloric channel closed r Elongated pyloric canal >17 mm in length r Exaggerated peristaltic waves r Delayed gastric emptying of fluid into duodenum Complications r Hypochloremic metabolic alkalosis DDx r Infantile pylorospasm s Muscle thickness between 1.5 and 3 mm s Variable caliber of antral narrowing s Antral peristalsis
r r
Delayed gastric emptying s Elongation of pylorus s Prognosis q Resolves in several days / ? early stage of evolving pyloric stenosis s Treatment q Effective with metoclopramide hydrochloride Milk allergy Eosinophilic gastroenteritis
s
Dahnert 4th edition
LearningRadiology- Ca of Esophagus
Carcinoma of the Esophagus
Predisposing factors Men>women Achalasia (polypoid mass in middle or distal third) Asbestosis Plummer-Vinson syndrome (iron deficiency anemia, webs) Barrett esophagus (columnar metaplasia of the distal esophagus 2 chronic GE reflux) Celiac disease Lye stricture Alcoholism Smoking Prior radiation Oral/pharyngeal cancer Tylosis palmaris-hyperkeratosi of the palms and the soles
Histology
Squamous cell ca (95%) Adenocarcinoma arising from heterotopic gastric mucosa or columnar-lined epithelium (Barretts) Carcinosarcoma=spindle-cell carcinoma Location usually middle third of esophagus
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Large, bulky, polypoid intraluminal mass which may be pedunculated Mucoepidermoid carcinoma Spread is facilitated by the esophagus lack of a serosa
Symptoms
Dysphagia Weight loss Retrosternal pain Regurgitation
Location
Upper 1/3 Middle 1/3 Lower 1/3 20% 50% 30%
Radiologic types
Polypoid/fungating form (most common) Sessile, polyp Apple-core lesion Ulcerating form Large ulcer within mass Infiltrating form Gradual narrowing resembling benign stricture Varicoid form=superficial spreading carcinoma Thickened nodular folds looks like varices Squamous cell carcinomas of the distal esophagus almost never invade the stomach whereas adenocarcinomas arising from a Barretts does
Metastases
To lymphatics-especially supraclavicular nodes Hematogenous: lung, liver, adrenal About 5-10% of patients with esophageal ca will develop esophageal-airway fistulae, frequently following XRT
Prognosis
3-20% 5 year survival
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Hypertrophic Gastritis
Hypertrophic Gastropathies
All have hyperrugosity or enlarged folds, usually in the body and fundus of stomach Coarse duodenal folds are usually associated with large folds in the stomach Most often, enlarged gastric folds are normal
Factors which suggest large folds are pathologic
Nodularity or induration of the fold Asymmetry or segmental distribution Wall rigidity Ulceration
Types of Hypertrophic Gastropathies

Zollinger-Ellison Syndrome
Hypersecretion of gastric acid 2 gastrinoma non-b islet cell tumor Pancreas (87%), medial wall of duodenum (13%) Most are malignant (60%) Clinical tetrad of 1) Gastric Hypersecretion 2) Diarrhea or steatorrhea 3) Hyperacidity-elevated serum gastrin levels 4) Recurrent peptic ulcer disease X-ray suggested by
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Hypertrophic Gastritis
1) Multiple ulcers (10%), most in bulb, but also post-bulbar, jejunum 2) Recurrent ulcers 3) Marginal ulcers in post-gastrectomy patients a) On gastric side b) Mesenteric border of efferent loop
Hypertrophic hypersecretory gastropathy Hypersecretion of gastric acid
Hypertrophic hypersecretory gastropathy with protein loss Hypersecretion of gastric acid
Menetriers Disease-fundus and body, esp. greater curvature

Low acid output-hypochlorhydria Hypoproteinemia 2 GI protein loss Peripheral edema Mostly middle-aged men Associated with benign gastric ulcer (13-72%) GI bleeding Carcinoma occurs in 10%, the same number as those patients who have atrophic gastritis and carcinoma DDx: Lymphoma (involves antrum which Menetriers does not), gastric carcinoma, gastritis, gastric varices
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LearningRadiology - Carcinoma of the Stomach
Carcinoma of the Stomach
Precancerous states Pernicious anemia18X normal population Adenomas of the stomachespecially those over 2cm Atrophic Gastritisdisputable Hiatal herniadisputable Gastric stumps for ulcer disease (Bilroth II>Bilroth I) Achlorhydria Histology Adenocarcinoma (95%) Rarely, squamous cell Morphology Polypoid/fungating carcinoma Ulcerating/penetrating carcinoma (70%) Infiltrating/scirrhous type=linitis plastica Superficial spreading type-confined to mucosa/submucosa-NOT linitis plastica Metastases Along peritoneal ligaments Gastrocolic ligament to transverse colon
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Gastrohepatic and hepatoduodenal to liver To lymph nodes Locally Lymphangitic to lungs Hematogenous Liver (most common)/adrenals/ovaries/bones Peritoneal seeding Rectal wall=Blumer shelf Left supraclavicular node=Virchows node Overall 5 year survival 5-18% Malignant ulceris a carcinoma which presents with the radiographic appearance of an ulcer niche; these have the radiographic appearance of a benign ulcer but demonstrate microscopic foci of malignancy, usually at the edge of the ulcer Ulcerating malignancyis a carcinoma having sufficient bulk to present as a mass which also contains a persistent collection representing an ulcer; the mucosa is frequently nodular and the folds do not radiate to the base of the ulcer Linitis plastica (scirrhous carcinoma)is a diffuse involvement of the wall of the stomach, frequently with flattening of the mucosa, and poor distensibility and contraction of the wall; usually associated with significant fibrosis and muscular hypertrophy; very frequently a signet ring cell type
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LearningRadiology.com - Intussusception
Intussusception
Submitted by Megan Werner, MSIV (Temple)
Definition Telescoping of a segment of bowel (the intussusceptum) into another, usually more distal, segment of bowel (the intussuscipiens) Etiology/Pathophysiology Intussusceptum is pulled further into the distal segment by peristalsis, pulling the mesentery along with it and trapping the vessels If not reduced, edema, ischemia and bowel obstruction (usually partial) ensue with necrosis of bowel Three etiologies o Intraluminal Intraluminal mass (e.g., pedunculated tumor) is pulled forward by peristalsis and brings attached bowel wall with it Intramural Abnormality of bowel wall (e.g., sessile malignancy) causes it not to contract properly, allowing a kink which serves as a lead point Extraluminal Extraluminal factor (e.g., inflamed appendix) causes area of abnormal peristalsis, allowing a kink which serves as a lead point In children o Over 90% have no pathologic lead point o Most thought due to lymphoid hypertrophy following viral infection Less than 10% due to Meckels diverticulum, polyp, lymphoma, etc.
In adults o Over 90% have a demonstrable cause 60% due to neoplasm (60% malignant, 40% benign) 30% due to non-neoplastic abnormalities, such as inflammation, trauma or suture lines 10% are idiopathic
Epidemiology In developed nations

r
Majority are in children s Peak incidence 5-9 months of age Approximately 10% occur in adults s Seen in all age groups s Approximately equal in males and females Incidence is higher in adults than it is in developed nations
In developing nations
r
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r
Fewer are associated with malignancy, and fewer have pathologic lead points
Clinical Findings Children o Cyclical, colicky abdominal pain o Vomiting o Currant jelly stools (diarrhea with mucus and blood) or other blood in stool Classic triad occurs in about 1/3 of patients; most have 2 of the 3 o Palpable abdominal mass, often in right upper quadrant o Dances sign: RUQ mass (intussusception) with RLQ empty space (movement of cecum out of normal position) Adults o Usually indolent, with intermittent crampy abdominal pain over days to months o Can be acute obstruction with hours to days of abdominal distention, pain, and constipation o Nausea and vomiting o Tenderness to palpation o Less than 20% have associated blood in stool o Rarely have a palpable abdominal mass o Can be incidental findings if intussusception is transient and asymptomatic Imaging Findings Plain radiographs are not sensitive or specific o Children
s s s s s
Soft tissue mass surrounded by a crescent of gas Evidence of distal small bowel obstruction Absence of or decreased gas in the colon Pneumoperitoneum May be normal
Adults usually normal bowel gas pattern
Barium enema (diagnostic and therapeutic) Coiled spring appearance o Barium in lumen of the intussusceptum and in the intraluminal space Ultrasound (not pathognomonic) o Transverse: Target or doughnut sign, with hypoechoic rim (edematous bowel wall) surrounding hyperechoic central area (intussusceptum and associated mesenteric fat) o Longitudinal: Sandwich, trident or hayfork sign, with layering of hypoechoic bowel wall and hyperechoic mesentery o Oblique: pseudokidney sign, with hypoechoic bowel wall mimicking the renal cortex and hyperechoic mesentery mimicking the renal fat o Doppler may help determine viability of the tissue o Adults: may be less useful, as often cannot identify the pathologic lead point and is most useful when an abdominal mass is palpated CT (virtually pathognomonic, most commonly done in adults) o Transverse Target sign, with layers of fat and bowel wall visible
If enhanced may see mesenteric vessels in the layers and oral contrast in the intraluminal spaces o Longitudinal Elongated, sausage-shaped mass with visible layers o May be helpful in judging the degree of vascular compromise if fluid or gas collections seen in between the walls of the intussusceptum o May or may not see any pathologic lead point Treatment NPO, IV fluids, NG tube if gastric distention Children o Surgical consultation o Then either reduction with barium, hydrostatic (lactated Ringers) or air enema, or surgery Adults (best approach debated) o Colonic: surgical resection without reduction because of risk of venous embolization of tumor or seeding from a malignant tumor o Enteroenteric: depends on cause and symptoms; may require resection or manual reduction during surgery, may be treated with enema reduction, or may require no intervention
LearningRadiology - Cathartic Colon
Cathartic Colon
Prolonged use of irritating stimulant-type laxatives results in neuromuscular incoordination from chronically increased muscle activity Usually requires 15 years or more of laxative use Agents
Cascara Castor oil Senna Phenolphthalein Podophyllum Aloin Location
Usually involves colon proximal to splenic flexure-i.e...... predominantly right colon
X-ray
Effaced mucosa with smooth, flattened surface
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LearningRadiology - Cathartic Colon
Absent haustrations Pseudostrictures-smoothly tapered areas of spasm Poor evacuation of barium Patulous ileocecal valve May have shortening of right colon DDx
Ulcerative colitis-except that rectum is spared in cathartic colon and there are no pseudopolyps or ulcerations
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http://www.learningradiology.com/notes/ginotes/leiomyomaesopahguspage.htm
Leiomyoma of the Esophagus
Most common benign tumor of esophagus
May produce dysphagia or hematemesis if large
Occurs in young males
Found most often in distal third of esophagus
X-Ray
Intramural
May have coarse calcifications (only calcifying esophageal tumor)
Smooth, well-defined mass
Narrowing of lumen in one plane and widening in 90 plane
Rarely ulcerates
May enhance on CT
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LearningRadiology - Colonic Polyps
Colonic Polyps
The majority of colorectal polyps are inflammatory or metaplastic and usually 5mm or less in diameter and have no malignant potential; the majority of larger lesions are adenomatous polyps Predisposing conditions: Prior detection of colonic polyp Cancer of the colon Family history of polyps or colon cancer Inflammatory bowel disease (ulcerative colitis, Crohns) Familial polyposis Peutz-Jeghers Syndrome Gardeners syndrome Incidence rises with age About 3% in 3rd decade 10% in 7th decade 26% in 9th decade About 11% overall in all ages Most (60%) occur in rectum or sigmoid Types
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Type
Incidence
Description
Malignant Potential
Tubular adenoma 75%
Cylindrical glandular structure lined by columnar epithelium
<10mm=1%; 1-2cm=10%; >2cm=35% Least malignant
Tubulovillous adenoma 15%
Mixture between tubular and villous adenoma
<1cm=4%; 1-2cm=7%; >2cm=46%
Infolding of papillary projections of glands Villous adenoma 10%
<1cm=10%; 1-2cm=10%; >2cm=53% Most malignant
Overall size versus malignancy: <1cm=1%; 1-2 cm=10%; >2cm= 46% Symptoms Most are asymptomatic Some may have diarrhea, especially villous tumors in rectum May also produce hypokalemia Abdominal pain (may be 2 to intussusception in a few) Rectal bleeding correlates with size and may be seen in as many as 67% X-ray Rate of detection of polyps less than 1 cm is higher with air contrast Rate of detection of polyps 1cm or greater is about equal with single vs. double contrast From 1/4 to 1/2 of patients with one polyp have a synchronous lesion May be sessile or on a stalk
Bowler hat sign (sessile polyp viewed in profile on A/C exam) Target sign (polyp with stalk viewed en face) Stalk >2cm is almost always benign Differentiating Benign from Malignant polyps Size (see above) Presence of a stalk Lesions on a stalk have less of a chance of being malignant than a sessile lesion of the exact same size Even when malignant polyps have a stalk, the chance of spread to regional nodes is low Surface contour Not really reliable An ulceration is more consistent with ca Dimpling at the base suggests ca If greater than 3cm in size, barium trapped within interstices suggests villous tumor Location Does not help Growth Any polyp which undergoes an interval increase in size should be removed Juvenile Polyps Classified as cystic hamatomas by some and inflammatory retention cysts by others No malignant potential Most occur as isolated colonic lesions in children less than 10 years Most are solitary Rectal bleeding is the most common symptom Most occur in the rectum or sigmoid
Since they have a tendency to autoamputation, they are usually not removed Hyperplastic Polyps No malignant potential Mucous glands lined by a single layer of columnar epithelium Usually located in rectum Usually less than 5mm in diameter
WH
http://www.learningradiology.com/notes/ginotes/lipomacolonpage.htm
Lipoma of Colon
Lipomas are second in prevalence to adenomas Usually asymptomatic When symptomatic: Pain Diarrhea Rectal bleeding Constipation Most are submucosal Most are located on the right side (40%), but about 20% are in the sigmoid Smooth, sharply defined hemispheric mass Squeeze-sign=deformity on post evacuation film Ulceration is rare Contour may be altered by peristalsis May intussuscept CT may demonstrate fatty nature of lesion
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LearningRadiology - Crohn Disease
Crohns Disease
Regional Enteritis
Pathology
Non-caseating granulomas involved with transmural inflammation of the entire GI tract Usual age at onset is 15-30, equal male:female ratio
Clinical
Recurrent episodes of diarrhea Occult blood loss and anemia Abdominal pain Low grade fever Anorexia, weight loss Perirectal abscess and fistulae Malabsorption Erythema nodosum and pyoderma gangrenosum
Location
The maximum length of the involved segment(s) is determined at the time of initial study; i.e. longitudinal
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spread is uncommon-except after surgery Esophagus (very rare) Stomach (2-20%) Usually involves antrum producing granulomatous gastritis Almost always associated with terminal ileal disease Rams horn sign=poorly distensible, smooth tubular antrum, widened pylorus and narrowed bulb Apthous ulcers Antral-duodenal fistula Duodenum (rare) (4-10%) Thickened folds Almost never occurs without antral involvement Small Bowel (80%) = regional enteritis=terminal ileitis Thickening and nodularity of folds Apthous ulcers Cobblestone mucosa Colon (22-55%) = granulomatous colitis Frequently right sided with sparing of rectum and sigmoid Apthous ulcers with target or bulls-eye appearance Long, longitudinal fistulous tracts parallel to bowel lumen Colon may be involved without small bowel, along with small bowel or become involved after surgery for Crohns Rectum (35-50%) Sinus tracts Deep, collar-button ulcers
Squaring of the folds-early manifestation from obstructive lymphedema Apthous ulcers-small nodular filling defects (mound of edema) with central ulceration Skip lesions-discontinuous involvement of the bowel with intervening normal areas Proud loops-separation of the loops caused by infiltration of the mesentery, increase in mesenteric fat and enlarged lymph nodes; simulates a mass Cobblestoning-irregular, blanket-like appearance to bowel wall caused by criss-crossing longitudinal and transverse ulcers separated by areas of edema Pseudopolyps-islands of hyperplastic mucosa between denuded areas of mucosa Filiform post-inflammatory polyps Pseudodiverticula-from bulging area of normal wall opposite side of scarring from disease, usually on anti-mesenteric side String-sign-marked narrowing of terminal ileum (usually) from a combination of edema, spasm and (sometimes, but not always) fibrosis; frequently associated with proximal dilatation
Ulcerative colitiscontinuous involvement L colon and rectum;TI normal Diverticulitistics; intact mucosa; TI normal Tuberculosisbut TB has more involvement of cecum, less of TI Radiation ileitisshould have other loops involved and appropriate hx Lymphomashould have tumor masses, less spasm Carcinoidshould have mass; marked fibrosis with angulation of loops Yersinia may affect TI but clears in 3-4 months Infarctionrare for this location Potassium stricturelacks full clinical picture Amebiasiscone-shaped cecum
Extra-intestinal Manifestations
Fatty infiltration of the liver
Gallstones (28-34%) Sclerosing cholangitis Bile duct carcinoma Amyloidosis Urolithiasis:oxalate/uric acid stones Migratory arthritis Sacroiliitis and ankylosing spondylitis Erythema nodosum and uveitis
Complications
Fistula (33%) Fistulae occur more often with regional enteritis than with granulomatous colitis Enterocolic fistulae are mostly between ileum and cecum Enterocutaneous fistulae mostly from rectum to skin, but also to vagina and bladder Perineal fistula [Other common causes of fistula are iatrogenic and diverticulitis] Intramural sinus tracts Abscess formation [common] Rarely, perforation Toxic megacolon (dilated transverse colon with pseudopolyps in toxic person=no BE) Small bowel obstruction Adenocarcinoma (rare)
Prognosis
Recurrence rate up to 40% after resection, commonly at the site of the new terminal ileum and usually within the first two years post-op X-ray demonstration of improvement in regional enteritis is rare Mortality rate of 7% at 5 years and 12% at 10 years after the first resection
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LearningRadiology.com - Liver laceration,hepatic trauma,rupture,tear
Hepatic Trauma
Liver Laceration
q q
Most frequently injured abdominal organ after spleen Most often due to deceleration injuries r Often seen in association with s Right-sided rib fractures s Right-sided pneumothorax s Right lung contusion s Injuries to the right kidney or adrenal gland Injuries include r Subcapsular hematoma r Laceration r Intrahepatic hematoma r Contusion Right lobe more often injured than left r Injury to left lobe associated with injury to duodenum, pancreas, transverse colon s More often due to direct blows to the epigastrium High association with injuries to other organs r 45% with liver injuries have splenic injury Subcapsular hematomas r Lenticular configuration r Flattens adjacent liver r Often adjacent to rib fracture r Most occur in antero-lateral aspect of right lobe Liver Laceration r Non-enhancing region, linear or branching r Frequently parallel hepatic vein r Hypodense wedge extending to liver surface s Focal hepatic devascularization r Periportal tracking of blood s Frequent finding s Sometimes only evidence of injury q Due to dissecting hemorrhage q Bile q Dilated periportal lymphatics
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Contrast-enhanced CT of abdomen shows linear low-attenuation defect crossing the posterior aspect of the left lobe of the liver representing a laceration
q
q q
Hematoma r Higher attenuation than surrounding liver on unenhanced CT scan r Lower attenuation than surrounding liver on enhanced CT scan r Central high attenuation region containing clot r Hepatic vein laceration usually involves right hepatic vein near vena cava Contusion r Rare lesions r Low attenuation area compared to normally enhanced liver r Do not disrupt major portal or hepatic venous structures Hemoperitoneum Complications r Delayed rupture (rare) r Hemobilia r Arteriovenous fistula r Pseudoaneurysm r Biloma r Superinfection of hematoma Pitfalls r Adjacent rib artifacts-beam-hardening s Mimics laceration q Adjacent to ribs q Fade as they become farther from rib r Linear artifact from air-contrast level in stomach r Fatty liver with laceration or hematoma can be missed s Clue- look at intrahepatic ducts and vessels Treatment r Conservative treatment in up to 80% in adults and almost all children s Monitor hemodynamic state of patient r Transcatheter embolization possible for bleeders r Healing

s s s
Contusions may clear in 5-7 days Subcapsular hematomas may increase in size initially before clearing Lacerations can heal within weeks but small, residual bilomas are common
LearningRadiology - Diffuse Small Bowel Disease
Diffuse Small Bowel Disease
Sprue
3 diseases: Celiac Disease of Children, Nontropical sprue and Tropical Sprue Celiac disease and Nontropical sprue improve on gluten-free diet Tropical sprue improves with antibiotics and folic acid X-ray The hallmark features are: dilatation and dilution, especially in jejunum Segmentation of the barium column occurs because it moves more slowly through areas of excessive fluid and separates from the rest of the column-not commonly seen with newer barium mixtures Fragmentation is an exaggerated example of the irregular stippling of residual barium in the proximal bowel (which is normal) Intussusception is not uncommon but is usually not obstructive; sprue has increased risk of ca and lymphoma Moulage sign is caused by dilated loop with effaced folds looking like tube into which wax has been poured
Scleroderma
Affects esophagus, small bowel and colon, sparing the stomach Atrophy of the muscular layers and replacement with fibrous tissue Associated with malabsorption X-ray Whole small bowel is usually dilated with close approximation of the valvulae (hide-bound appearance) (stackof-coins)
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Does not have increased secretions as does sprue May be associated with pneumatosis intestinales
Whipples Disease
Glycoprotein in the lamina propia of the small bowel is Sudan-negative, PAS-positive Clinically: arthralgia, abdominal pain, diarrhea and weight loss Treated with long term antibiotics-penicillin Very rare X-ray The hallmarks of the disease are nodules and a markedly thickened bowel wall (picket-fence) Small bowel may or may not be dilated Affects jejunum mostly
Amyloidosis
GI involvement is common Associated with malabsorption X-ray Marked thickening of the valvulae (picket-fence) No dilatation or dilution Affects entire small bowel
Hypoproteinemia
Hypoalbuminemia resulting from liver or kidney disease lower than 1.5 grams per cent Usually asymptomatic from intestinal edema itself X-ray Changes are present throughout small bowel Loops are separated due to edema of walls
Folds are quite thick (picket-fence)
Giardiasis
Giardia lamblia is a flagellated protozoan, a normal parasite of the small bowel Clinically: diarrhea and malabsorption Treated with metronidazole (Flagyl) Some patients have hypogammaglobulinemia and nodular lymphoid hyperplasia associated with giardiasis X-ray Usually limited to duodenum and jejunum Thickening of the folds Marked spasm and irritability of the bowel Increased secretions is common
Ischemic Bowel Disease

Thickening of the wall due to edema and hemorrhage Localized perforations can produce air in the bowel wall or in portal venous system X-ray Spasm and irritability early is replaced by an atonic bowel later Lumen is narrowed Folds are thickened, sometimes producing thumb-printing Healing may result in stricture formation
Intramural Bleeding
Suggested if there is duodenal obstruction following trauma Localized lesions occur with trauma Diffuse lesions are seen with anticoagulants X-ray
Uniform, regular, thickening of the folds Separation of the loops Mass effect No spasm
Radiation Enteritis
Changes are identical to ischemia since radiation changes are actually secondary to an arteritis with occlusion of small vessels Localized to area of radiation portal, especially pelvis in female 2 endometrial carcinoma treatment Previous adhesions from surgery may anchor small bowel in pelvic portal and predispose to XRT changes Mucosa is most sensitive to radiation X-ray Localized thickening of the folds 2 edema and hemorrhage May result in strictures later in course
Lymphoma
Most commonly involves terminal ileum Bowel wall becomes markedly thickened and submucosa infiltrated (picket-fence) Thumb-printing may be seen Loops are widely separated and there may be mass effect Another form may have a large ulceration which is confined and produces so called aneurysmal dilatation of the bowel
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LearningRadiology.com - lymphoma of Small Bowel,Hodgkin's,Hodgkin,lymphosarcoma,non-Hodgkin's

Submitted by Tony Chang, MD Small bowel is second most frequent site of GI tract involvement by lymphoma. o Ileum is most common site of occurrence Ileum has most lymphoid tissue o Duodenum is least frequent Most cases of small bowel lymphoma are due to non-Hodgkins lymphoma Mesenteric involvement by lymphoma may occur by o Direct extension from bowel o Indirectly by displacement due to mass effect Risk factors include o Immunocompromised or immunosuppressed state o Long-term celiac sprue o Chronic lymphocytic leukemia Mediterranean abdominal lymphoma o Associated with immuno-proliferative small intestinal disease o Presents with malabsorption syndrome o Consists of diffuse lymphomatous infiltration of mucosa and submucosa in long segments of small intestine o Infection may be important in the development of this type of lymphoma Some are reversible if treated by antibiotics in the very early stages Definitive diagnosis is based on histopathological examination from biopsy of the lesion Staging: o 1E: single bowel tumor without nodal involvement o 2E: GI tumor focus with nodal disease below the diaphragm; nodal disease divided into regional and extraregional o 3E: GI tumor focus with nodal disease above and below the diaphragm and or serosal involvement +/- other organs involved o 3ES: Splenic involvement o 4E: Extralymphatic i.e. bone, liver Prognosis o Poor prognosis is associated with: Stage greater than 2E (nodal disease above and below the diaphragm) Tumor size greater than 10 cm T cell type
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Immunoblastic histology Presence of aneuploidy Presentation as an acute abdomen Primary lymphoma criteria include o Confinement of disease to a small bowel segment o Only regional lymphadenopathy o No hepatic or splenic involvement except by direct tumor extension o No palpable or mediastinal lymphadenopathy o Normal peripheral blood smear and bone marrow biopsy Patterns of small bowel lymphoma o Circumferential infiltration of a small bowel segment Results in a variable length of thickening and effacement of folds Widening of the lumen rather than narrowing From infiltration of muscularis layer with destruction of the myenteric plexus leading to aneurysmal dilatation, often at the antimesentric segment o Nodular lesions can be variable in size and irregularly distributed o Polypoidal lesions are sometimes reported to cause intussusception o Endoexoenteric lesions can cause fistulas Imaging findings o CT appearance of lymphoma is variable Typical appearances can be classified as aneurysmal, constrictive, nodular, or ulcerative o Small bowel series can show luminal narrowing of the involved segment with loss of mucosal pattern and thickening of the plica circulares and intraluminal filling defects possibly with dilatation of the involved segment.
o Ultrasound may demonstrate a hypoechoic lesion of the affected bowel and presence of abdominal lymphadenopathy. o CT scan shows a sausage shaped loop of bowel that is of relatively homogenous tissue density Also asymmetric wall thickening of usually greater than 2cm Aneurysmal dilatation Polypoidal mass Abdominal lymphadenopathy
CT scan of the abdomen shows a loop of small bowel in the mid-abdomen with a markedly thickened wall; lower image shows a large, intraluminal collection of barium representing aneurysmal dilatation of the involved loop
Differential diagnoses include o Tuberculosis o Inflammatory small bowel disease and carcinoma.
Treatment
o Malignant lymphoma of the small bowel is treated with surgical resection, usually followed by chemotherapy to prevent perforation o Radiation therapy may also be used
LearningRadiology-Sprue, Whipples, Lymphoma, Ischemia, Giardiasis
Pictorial Differential Diagnosis

Click on image to enlarge; click on text for more information
Sprue
Amyloid
Lymphoma
Giardiasis
Hypoproteinemia
Scleroderma
Hemorrhage
Radiation Enteritis
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http://www.learningradiology.com/notes/ginotes/lymphomastomachpage.htm
Lymphoma of the Stomach
Comprises 3-5% of all gastric neoplasms Non-Hodgkins accounts for 80% of all gastric lymphomas Begins in the submucosa Most occur in distal body and antrum of stomach Almost all gastric lymphoma presents with some degree of ulceration
Frequency of GI occurrence by site (of all lymphomas)

Stomach Small intestine Rectum Rest of colon
Lymphosarcoma of the Stomach

Suggested by the relatively younger age at presentation than ca Suggested by the extent of the lesions radiographicallymultiple ulcers, irregular masses, widespread infiltration May be associated with involvement of the bowel elsewheree.g. duodenum, cecum or rectosigmoid and mesenteric masses
Forms
Nodularsingle or multiple intragastric masses, easily confused with ca, protrude into the lumen, often with multiple ulcerations
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Polypoidbarium in interstices, frequently with ulceration; sometimes resembles metastatic disease such as melanoma Ulcerativeshallow, saucer-like ulcer indistinguishable from ca Infiltrativethickened, irregular folds, simulating the appearance of hypertrophic gastritis; about 10% present this way
CT Staging Stage I Stage II Stage III Stage IV DDX-Linitis plastica Carcinoma Lymphoma Gastritis, e.g. phlegmonous, eosinophilic, postradiation Granulomatous, e.g. Crohns, sarcoid, TB Syphilis Amyloidosis tumor confined to bowel wall limited to local nodes widespread nodal disease bone marrow, liver, other organs
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LearningRadiology - Diverticular Disease
Diverticulosis/Diverticulitis of the Colon

Herniation of mucosa and submucosa through muscular layers pseudodiverticulum=false diverticulum=pulsion type Diverticula are reducible; they may be seen on one but not another BE Only proven association is with Marfans syndrome (20% get diverticulitis) Location Almost always involves sigmoid; never rectum; more common on left In about 17%, the tics cover the entire colon In another 12%, they are isolated to right colon
Prediverticular Disease
Saw-tooth appearance to the colon, usually sigmoid, with shortening of bowel, crowding of haustra and picket-fencing of folds Muscle spasm is present-may be relieved with glucagon Controversial as to whether this form can be symptomatic, i.e. pain
Diverticulosis
May be due to low roughage, high refined-fiber diet More common in industrialized nations Arise between the mesenteric and anti-mesenteric teniae of the colon and project between circular muscle ringsnot through them May vary in size from tiny projections to several cm in size Have variable filling Associated spasm and numerous tics in sigmoid may make it impossible to see polyp in this regioneven
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difficult with colonoscopy On AC BE tics have sharp outer and fuzzy inner margins viewed en-face Giant sigmoid diverticulumhuge gas-containing cyst-like structure arising in left iliac fossa
Diverticulitis
Perforation of diverticulum with pericolic abscess of varying size; not simply inflammation of a tic Clinical Pain and tenderness, mass in LLQ Fever, leukocytosis Plain Film X-ray Sentinel loop or, less likely, LBO Air bubbles in abscess Pneumoperitoneum (rare) BE Extraluminal contrast Pericolonic abscess produces mass effect Double-tracking=barium in longitudinal sinus tract in wall Spasm is an indirect sign of diverticulitis Fistula to bladder (diverticulitis is most common cause of non-traumatic fistula here) or small bowel or vagina (diverticulitis causes 1/3 of fistulae to vagina) CT Infiltration of pericolonic fat Bowel wall thickening >1cm Abscess Fluid or free air in peritoneal cavity Colovesicle or colovaginal fistula
Intramural sinus tracts DDX Colon ca-but mucosa is left intact in diverticulitis Crohns disease-may be indistinguishable if TI not involved in Crohns Ischemic colitisonly if sigmoid is involved Radiation colitis Complications Peritonitisusually the perforation is walled off but it may spread throughout the peritoneal cavity or the retroperitoneum If a ruptured diverticulum is a strong clinical consideration prior to contrast study, water soluble contrast should be used rather than barium Obstructionis rare Bleedingsee below Hemorrhage from Diverticulosis Doesnt involve Diverticulitis 75% of those that bleed are in right colon Clinically, massive rectal hemorrhage without pain May be diagnosed with nuclear med bleeding scan or angiography
WH
LearningRadiology.com - Mesenteric Ischemia,acute,small bowel,death,infarction,ischemia
Acute Mesenteric Ischemia

Submitted by Jonathon Dorff, MD
q q
Acute interruption of blood flow to small or large intestine Causes: r Arterial embolism s Superior mesenteric artery most commonly involved r Arterial thrombosis r Nonocclusive mesenteric ischemia s Low cardiac output state with diffuse mesenteric vasoconstriction r Mesenteric venous thrombosis Risk Factors r Atrial fibrillation/flutter r Recent acute MI s Ventricular aneurysm s Cardiomyopathies s Valvular disease r Hypovolemia or hypotension (sepsis) r Coagulation disorders or malignancy r Pancreatitis r Portal hypertension/cirrhosis r Medications s Vasopressor medications s Beta-blockers s Digoxin s Diuretics Clinical signs and symptoms r Severe abdominal pain out of proportion to physical exam r Pain initially of a visceral nature and poorly localized r Nausea r Vomiting r Diarrhea r GI bleeding may be present Imaging
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r
Plain abdominal radiographs (abnormal in 20-60% of cases) s Thumbprinting s Non-specific finding indicating intestinal wall edema with hemorrhage in the setting of acute mesenteric ischemia s Pneumatosis s Portal venous gas s Pneumoperitoneum s All are indicative of infarcted bowel CT s Bowel wall thickening from edema or hemorrhage s Lack of enhancement indicates infarction s Pneumatosis, portal venous gas, pneumoperitoneum s Intraluminal thrombus in involved vessel
Top CT image shows gas in portal venous system (blue circle); center image shows absence of contrast in superior mesenteric artery due to thrombosis of this vessel (blue arrow) [The patient also has a markedly dilated common duct, not related to mesenteric ischemia]; lower image shows extensive pneumatosis intestinalis (red arrows)
r
Mesenteric angiogram s Can distinguish between arterial embolic and thrombotic causes of acute mesenteric ischemia Treatment r Mesenteric angiogram s Vasodilator therapy s Thrombectomy/Embolectomy r Surgery s Thrombectomy/Embolectomy s Arterial bypass s Resection of necrotic bowel Complications r Sepsis/septic shock r Multiple system organ failure r Death Mortality r 70-90% overall r From arterial embolism: 60-80% r From arterial thrombosis: 70-100% r From nonocclusive mesenteric ischemia: 40% r From mesenteric venous thrombosis: 25-30%
LearningRadiology - Duodenla Ulcer
Duodenal Ulcer Disease
2-3 times more frequent than gastric ulcers 3:1 male:female ratio
Pathophysiology Excessive acidity in duodenum from Abnormally high gastric secretion Inadequate neutralization Predisposing factors Steroids Severe head injury Post-surgical COPD
Location Bulbar (95%) Anterior wall Posterior wall Inferior fornix Superior fornix Postbulbar (3-5%)
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50% 23% 22% 5%
LearningRadiology - Duodenla Ulcer
Majority on medial wall just proximal to ampulla Tendency for hemorrhage in 66% Male:female ration 7:1 X-ray Small round, ovoid or linear crater Kissing ulcersulcers opposite from each other on the anterior and posterior walls Giant duodenal ulcer>3cm (rare) with higher morbidity and mortality May be mistaken for the duodenal bulb itself and missed Clover-leaf deformityhealed central ulcer of the bulb with four-leaf clover-like deformity remaining
Complications Hemorrhage Perforation Obstruction Penetration 15% <10% 5% <5% walled-off perforation melena>hematemesis anterior>posterior /may fistulize to GB
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LearningRadiology.com - Malrotation,midgut,volvulous,volvulus,obtruction,newborn
Malrotation with a Midgut Volvulus

Torsion of entire gut around superior mesenteric artery (SMA) due to a short mesenteric attachment of small intestine in malrotation Age o Usually neonate or young infant o Occasionally older child and adult Associated with (in 20%) o Duodenal atresia o Duodenal diaphragm o Duodenal stenosis o Annular pancreas Pathophysiology: o Degree of twisting is variable and determines symptomatology o Severe volvulus (= twist of 3 1/2 turns) Can result in bowel necrosis Acute symptoms in newborn (medical emergency) o Bile-stained vomiting Intermittent Postprandial Projectile o Abdominal distension o Shock Intermittent obstructive symptoms in older child o Recurring attacks of nausea o Vomiting o Abdominal pain o Failure to thrive (hypoproteinemic gastroenteropathy as a result of lymphatic + venous obstruction) Plain film findings o Dilated, air-filled duodenal bulb and paucity of gas distally "Double bubble sign" = air-fluid levels in stomach and duodenum o Isolated collection of gas-containing bowel loops distal to obstructed duodenum = gasfilled volvulus = closed-loop obstruction From nonresorption of intestinal gas secondary to obstruction of mesenteric veins
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Barium studies o Duodenojejunal junction (ligament of Treitz) located lower than duodenal bulb and to the right of expected position o Spiral course of midgut loops = "apple-peel / twisted ribbon / corkscrew" appearance (in 81%)
"Corkscrew" duodenum in malrotation with a midgut volvulus o Duodenal-fold thickening and thumbprinting (mucosal edema + hemorrhage) o Abnormally high position of cecum CT findings Whirl-like pattern of small bowel loops and adjacent mesenteric fat converging to the point of torsion (during volvulus) SMV to the left of SMA (NO volvulus) Chylous mesenteric cyst (from interference with lymphatic drainage) US findings o Clockwise whirlpool sign = color Doppler depiction of mesenteric vessels moving clockwise with caudal movement of transducer o Distended proximal duodenum with arrowhead-type compression over spine o Superior mesenteric vein to the left of SMA o Thick-walled bowel loops below duodenum and to the right of spine associated with peritoneal fluid Angio fIndings o "Barber pole sign" = spiraling of SMA o Tapering / abrupt termination of mesenteric vessels o Marked vasoconstriction and prolonged contrast transit time
o Absent venous opacification / dilated tortuous superior mesenteric vein Complications Intestinal ischemia and necrosis in distribution of SMA (bloody diarrhea, ileus, abdominal distension) DDx: Pyloric stenosis (same age group, no bilious vomiting)
Dahnert 5th edition
http://www.learningradiology.com/notes/ginotes/endometriosispage.htm
Endometriosis of GI Tract
Endometriosis develops in 15% of females during active menstrual life Location (in decreasing order of frequency): 1) Ovary 2) Uterine ligaments 3) Rectovaginal septum, including sigmoid colon 4) Pelvic peritoneum 5) Umbilicus 6) Laparotomy and hernia scars 7) Appendix More common in nulliparous women More common in women who become pregnant later in life Symptoms Dysmenorrhea Menorrhagia Metrorrahgia Chronic pelvic pain worsened by menstruation Absolute or relative sterility Signs
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Most have no physical findings High association between uterine fibroids and endometriosis GI involvement in 12-25% of cases of endometriosis 85% in rectosigmoid 7% small bowel 3% rectum 3% appendix Actual mucosal involvement is rare so cyclic GI bleeding is unusual Pathophysiology Repeated bleeding to fibrosis, adhesions and muscular hyperplasia of the bowel Most of the polypoid lesion we see is actually smooth muscle hyperplasia X-Ray
Findings
Four patterns, three of which simulate other diseases
Characteristic lesion is scalloping along the anti-mesenteric side of
the colon
Anterior scalloping of the rectum seen best on a lateral BE film is very suggestive of endometriosis of the rectovaginal septum
Polypoid lesion Long, narrowed segment like inflammatory bowel disease Short, narrow segment like carcinoma except the mucosa is intact
Rupture of an endometrioma can adhesions and SBO as can any endometrial implant About 1% of patients with GI endometriosis also have GU endometriosisinvolving bladder, ureters and kidneys, in that order About 20 cases of catamenial pneumothorax, all involving the right side, most between the ages of 30-45 have been reported. Most implants were on the right hemidiaphragm, most patients had had a previous C-section, D&C, childbirth or hysterectomy.
WH/89
http://www.learningradiology.com/notes/ginotes/mucocoeleappendixpage.htm
Mucocoele of the Appendix
Overdistension of the appendix with mucous 2 to luminal obstruction by fecalith or foreign body, carcinoid or endometriosis Very rare Globular, smooth-walled mass protruding into cecum Peripheral, rim-like calcification may occur Low attenuation content on CT May rupture and produce pseudomyxoma peritonei Myxoglobulosis is a rare variant of mucocoele in which there are pearly white balls of mucous mixed with other mucous in a mucocoele Usually asymptomatic May present as appendicitis Mass contains multiple small, rounded, nonlaminated calcified spheres
WH/93
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http://www.learningradiology.com/notes/ginotes/esophagealticspage.htm
Almost all esophageal diverticula are associated with esophageal motor disorders
Pulsion diverticula contain no muscle in their wall so they tend to stay filled with barium after the rest of the esophagus empties Traction diverticula contain muscle in their walls so they tend to empty with the rest of esophagus
Zenkers diverticulum (pharyngoesophageal tic) Pulsion diverticulum with herniation of mucosa and submucosa through oblique and transverse muscle bundles of the cricopharyngeal muscle (pseudodiverticulum) Cricopharyngeal dysfunction results in increased intraluminal pressures and tic formation in midline of Killian dehiscence at level of C5-C6 Symptoms Dysphagia Regurgitation of food When large enough, may compress lumen and cause obstruction
X-ray
Barium-filled sac arising posterior and usually to the left of esophagus Reflux from tic into hypopharynx
Traction diverticulum (interbronchial diverticulum) Response to pull from fibrous adhesions following lymph node infection (almost always TB) Contains all three esophageal layers Usually located on right anterior wall
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http://www.learningradiology.com/notes/ginotes/esophagealticspage.htm
Epiphrenic diverticulum Usually on lateral distal esophageal wall; right greater than left Often associated with hiatal hernia Pulsion diverticulum
Interaortico-bronchial diverticulum Pulsion diverticulum
Occurs on left anterolateral wall between the inferior border of the aortic arch and upper margin of left mainstem bronchus
wh/94
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LearningRadiology- Porcelain Gallbladder, GB, calcified gb wall, carcinoma of gallbladder, gallbladder calcification
Porcelain Gallbladder
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Calcification of gallbladder wall So named because of its gross appearance and its similarity to porcelain Incidence: r Less than 1% of cholecystectomy patients r F:M 5:1 Histology r Flakes of dystrophic calcium within chronically inflamed and fibrotic muscular wall r Wall is thickened and gallbladder is contracted Associated with gallstones in 90% r Cystic duct is always obstructed r 80% of patients with carcinoma of gallbladder have stones Minimal symptoms Imaging findings r Curvilinear calcifications in segment of the wall or entire wall
Plain film of abdomen shows a curvilear calcification in the left upper quadrant which corresponds to the location of the gallbladder
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Highly echogenic shadowing curvilinear structure in GB fossa s DDx: stone-filled contracted GB
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LearningRadiology- Porcelain Gallbladder, GB, calcified gb wall, carcinoma of gallbladder, gallbladder calcification
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Echogenic GB wall with little acoustic shadowing s DDx: emphysematous cholecystitis Scattered irregular clumps of echoes with posterior acoustic shadowing Imaging pitfall r Contracted gallbladder with calcified wall can be mistaken for a gallstone Complication r 20-30% develop carcinoma of gallbladder
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http://www.learningradiology.com/notes/ginotes/esophagitiscausticpage.htm
Caustic Esophagitis
Starting in 1967, lye (concentrated sodium hydroxide) became available as a liquid in drain cleaners and caustic esophagitis became a serious medical problem
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Other household agents which can produce caustic esophagitis are acids, ammonium chloride, phenols and silver nitrate
Lye produces tissue damage through liquefaction necrosis as opposed to acids which produce coagulative necrosis. Both acidic and alkaline agents can damage esophagus. There are 3 phases to caustic esophagitis: The acute necrotic phase (1-4 days) The ulceration-granulation phase (3-5 days)* Fibrosis and stricture formation (3-4 weeks after ingestion) * Esophagus most prone to perforate during this phase As little as 1cc of lye can produce full-thickness necrosis of the esophagus within 30 minutes of ingestion. Early changes are better evaluated with endoscopy than contrast studies Early treatment may include steroids, antibiotics and, some suggest, prophylactic dilatation. Still as many as 40% will develop strictures. There is a significantly higher risk of developing esophageal carcinoma 20-40 years after ingestion.
X-ray
Mediastinal emphysema Left pleural effusion Long, smooth strictures About 20% have associated gastric abnormality, usually antral narrowing and ulceration In the acute phase, a water-soluble esophagram should be performed, followed by barium if no leak is seen.
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WH/92
http://www.learningradiology.com/notes/ginotes/postgastcomppage.htm
Post-Gastrectomy Complications
Rupture of the Duodenal Stump Incidence <5% Grave complicationdeath in half the cases Occurs without warning from post-op day 1-21 Probably related to ischemia at anastomotic line Usually results in subdiaphragmatic collections Use of iodinated contrast (Gastrografin) preferred Hemorrhage From 3-12% incidence Obstruction Stomal obstructions are caused by edema or hemorrhage usually May be the result of vagotomy without pyloroplasty Gastric bezoars may form in post-op stomach and obstruct Intussusception may be either antegrade or retrograde If retrograde, the jejunum invaginates into the gastric pouch A striated filling defect is seen in stomach which is pathognomonic If antegrade, almost always into efferent loop Marginal Ulcer Disease
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http://www.learningradiology.com/notes/ginotes/postgastcomppage.htm
New ulcerations which occur in the jejunum no more than 2cm distal to anastomosis Usually in efferent loop Radiographic diagnosis of ulcer itself is possible in only about 50% of cases but some sign may be seen in as many as 80% Double-contrast exams are the study of choice X-ray includes 1) Dilatation of the jejunum 2) Thickened folds in jejunum 3) Ulcer crater Ulcerogenic tumors (i.e. gastrinomas) Multiple recurrent ulcers, ulcers in unusual places should alert to retained antrum or ulcerogenic tumor Carcinoma of the gastric stump Post-gastrectomy for gastric ulcer has a lower incidence of ca than does post-gastrectomy for duodenal ulcer disease
WH/93
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LearningRadiology- Esophageal varices, esophagus, GI bleed
Esophageal Varices
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Dilated submucosal veins due to increased collateral blood flow from portal venous system to azygos system Uphill varices r Collateral blood flow from portal vein via azygos vein into SVC (usually lower esophagus drains via left gastric vein into portal vein) r Most common cause is portal hypertension secondary to cirrhosis r Varices in lower half of esophagus to the level of the carina (azygous vein) r More common than downhill varices Causes r Intrahepatic obstruction from cirrhosis r Splenic vein thrombosis (usually gastric varices only) r Obstruction of hepatic veins r Portal vein thrombosis r IVC obstruction below hepatic veins r Marked splenomegaly / splenic hemangiomatosis (rare) Downhill varices r Collateral blood flow from SVC via azygos vein into IVC / portal venous system (upper esophagus usually drains via azygos vein into SVC) r Varices in upper 1/3 of esophagus s Usually extend down to the level of the carina (azygous vein) r Less common than uphill varices Causes r Obstruction of superior vena cava distal to entry of azygos vein due to s Lung cancer (most common) s Lymphoma s Retrosternal goiter s Thymoma s Mediastinal fibrosis Examination Technique r Small amount of barium (not to obscure varices) r Relaxation of esophagus (not to compress varices) s Refrain from swallowing because each succeeding swallow initiates a primary peristaltic wave that lasts for 10-30 seconds r Sustained Valsalva maneuver precludes swallowing r In LAO projection with patient recumbent or in Trendelenburg position Plain film r Lobulated masses in posterior mediastinum (visible in a small percentage of patients with
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LearningRadiology- Esophageal varices, esophagus, GI bleed
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varices) Silhouetting of descending aorta Abnormal convex contour of azygoesophageal recess Thickened and interrupted mucosal folds (earliest sign) Tortuous radiolucencies of variable size and location "Worm-eaten" smooth lobulated filling defects Findings may be accentuated after sclerotherapy
UGI
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CT Thickened esophageal wall and lobulated outer contour r Scalloped esophageal luminal masses r Right- / left-sided soft-tissue masses = paraesophageal varices r Marked enhancement following dynamic CT Complications r Bleeding in 28% within 3 years r Exsanguination in 10-15% DDx r Early s Other forms of chronic esophagitis r Late s Varicoid carcinoma of esophagus q Wall more rigid and less likely to change in varicoid carcinoma q Nodular filling defects in varicoid ca
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Dahnert 4th edition Practical Alimentary Tract Radiology 1993
About Us
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LearningRadiology.com - Sigmoid Volvulous,volvulus,sigmoid colon,twist,obstruction,large bowel
Sigmoid Volvulus
Submitted by Raymond Ropiak
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Twisting of loop of intestine around its mesenteric attachment site may occur at various sites in the GI tract r Most commonly: sigmoid & cecum r Rarely: stomach, small intestine, transverse colon r Results in partial or complete obstruction r May also compromise bowel circulation resulting in ischemia Sigmoid volvulus most common form of GI tract volvulus r Accounts for up to 8% of all intestinal obstructions Most common in elderly persons (often neurologically impaired) Patients almost always have a history of chronic constipation
Pathophysiology
Redundant sigmoid colon that has a narrow mesenteric attachment to posterior abdominal wall allows close approximation of 2 limbs of sigmoid colon twisting of sigmoid colon around mesenteric axis r Other predisposing factors s Chronic constipation s High-roughage diet (may cause a long, redundant sigmoid colon) s Roundworm infestation s Megacolon (often due to Chagas dz) 20-25% mortality rate Peak age > 50 yrs. r Second largest group children Torsion usually counterclockwise ranging from 180 540 degrees Luminal obstruction generally @ 180 degrees Venous occlusion generally @ 360 degrees gangrene & perforation Signs and symptoms r May present as abdominal emergency s Acute distension s Colicky pain (often LLQ) s Failure to pass flatus or stool (constipation is prevailing feature) s Vomiting is late sign r Distention may compromise respiratory & cardiac function r May also present with surprisingly few signs and symptoms in bedridden and debilitated Physical examination
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Tympanitic abdomen Abdominal distention +/- palpable mass
Diagnosis
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Abdominal plain films usually diagnostic s Inverted U-shaped appearance of distended sigmoid loop q Largest and most dilated loops of bowel are seen with volvulus s Loss of haustra s Coffee-bean sign midline crease corresponding to mesenteric root in a greatly distended sigmoid q Sigmoid volvulus bowel loop points to RUQ q Cecal volvulus bowel loop points to LUQ r Dilated cecum comes to rest in left upper quadrant s Birds-beak or bird-of-prey sign seen on barium enema as it encounters the volvulated loop CT scan useful in assessing mural wall ischemia
Photo on left shows large, dilated loop of large bowel with an inverted U-shape with walls between two volvulated loops pointing from LLQ toward RUQ; Photo on right shows same patient with decompressed sigmoid volvulus following insertion of rectal tube
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Large bowel obstruction due to other causes sigmoid colon CA Giant sigmoid diverticulum Pseudoobstruction
Complications
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Colonic ischemia Perforation Sepsis
Treatment o Derotation & decompression by barium enema or with rectal tube, colonoscope, or sigmoidoscope if no signs of bowel ischemia or perforation
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Laparoscopic derotation or laparotomy +/- bowel resection Cecopexy suture fixation of bowel to parietal peritoneum may prevent recurrence Recurrence rate after decompression alone 50%
http://www.learningradiology.com/notes/ginotes/esophagealwebpage.htm
Esophageal Web
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Ringlike constriction of upper esophagus covered on superior and inferior surfaces by squamous epithelium Three types have been described: r A non-specific or idiopathic web (most common) r Webs associated with Plummer-Vinson Syndrome r Webs associated with epidermolysis bullosa dystrophica or graft-versus-host disease Usually found in middle-aged females Plummer-Vinson Syndrome=Patterson-Kelly syndrome r Iron deficiency anemia r Stomatitis r Glossitis r Dysphagia r Spoon-shaped nails r Esophageal webs r Some question as to whether such a syndrome exists Location r Cervical esophagus anteriorly at level of the cricopharyngeous (C5-C6) r Best visualized with maximal distension r Distal esophageal webs may arise from gastroesophageal reflux Imaging Findings r Thin, transverse filling defects r Perpendicular to anterior esophageal wall r Usually less than 3mm in thickness r Frequently they are not circumferential Increased risk of upper esophageal carcinoma DDx r Prominent cricopharyngeous muscle s Arises posteriorly at C5-C6 and produces a much broader defect r Stricture Treatment r Balloon dilatation r Bougienage during esophagoscopy
Halpert, R and Feczko, P: Requisites of Gastrointestinal Radiology, 2nd edition, 1999
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http://www.learningradiology.com/notes/ginotes/familialpolyposispage.htm
Familial Polyposis Syndromes
Autosomal dominant with high penetrance (80%) About 2/3 of affected people have a positive family hx of colonic polyps or ca and about 1/3 are sporadic cases Colonic polyps are numerous and of all different sizes They may be sessile or pedunculated Rectum and left colon are more commonly affected than right side of colon Often, however, the entire colon is carpeted with polyps Extracolonic polyps are uncommon in American patients but more common in the Japanese Generally the polyps arise during the first or second decade of life Colon cancer usually develops between 20-40 years of age Colon cancer will develop in nearly 100% of untreated patients Multiple carcinomas are common Treatment is total prophylactic colectomy Colectomy with maintenance of the rectum is possible in patients who will undergo routine proctoscopy
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http://www.learningradiology.com/notes/ginotes/familialpolyposispage.htm
Syndrome
Malignant Heredity Distribution (mainly) Histology potential
Familial Polyposis
Auto dominant Auto dominant
Colon
Adenomas
100% colon ca
Gardeners
Colon
Adenomas
100% colon ca
Peutz-Jeghers
Auto dominant
Small bowel 30% colon
Hamartomas in small bowel; adenomas in colon
2-3% overall ca
WH/93
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http://www.learningradiology.com/notes/ginotes/thoratrastpage.htm
Thorotrast
Alpha-emitter Previously used for cerebral angiography and liver/spleen imaging Use started in early 30s and continued to early 50s Excellent opacifying agent well-tolerated by patients Could produce intense fibrosis in muscle if it extravasated on injection and it was this side-affect which caused its use to be questioned first Colloidal thorium dioxide deposited in liver (70%), spleen (30%), bone marrow, lymph nodes Produces increased opacity of metal density in liver, spleen and celiac nodes May be visualized in soft tissues of neck if extravasated there Biologic half life of 400 years; physical half-life of 1010 years Hepatic dose in 20 years about 1000-3000 rads Produces angiosarcomas (hemangioendotheliomas) of liver (50%), cholangiocarcinoma, hepatoma One of the causes of bone-within-a-bone in spine Long latency period (25 years)
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LearningRadiology.com - Free Air,free,air,intraperitoneal,extraluminal,perforated,perforation,ulcer
Free Intraperitoneal Air Pneumoperitoneum
Etiology r Disruption of wall of hollow viscus s Blunt or penetrating trauma s Perforating foreign body (eg, thermometer injury to rectum) s Iatrogenic perforation q Laparoscopy / laparotomy (58%) q Absorbed in 1-24 days depending on initial amount of air introduced and body habitus (80% in asthenic, 25% in obese patients) q Leaking surgical anastomosis q Endoscopic perforation q Enema tip injury q Diagnostic pneumoperitoneum s Diseases of GI tract q Perforated gastric / duodenal ulcer q Perforated appendix q Ingested foreign-body perforation q Diverticulitis (ruptured Meckel diverticulum / sigmoid diverticulum, jejunal diverticulosis) q Necrotizing enterocolitis with perforation q Inflammatory bowel disease (eg, toxic megacolon) q Obstruction* (gas traversing intact mucosa): neoplasm, imperforate anus, Hirschsprung disease, meconium ileus q Ruptured pneumatosis cystoides intestinalis q Idiopathic gastric perforation = spontaneous perforation in premature infants (congenital gastric muscular wall defect) r Through peritoneal surface s Transperitoneal manipulation s Abdominal needle biopsy / catheter placement s Mistaken thoracentesis / chest tube placement s Endoscopic biopsy r Extension from chest s Dissection from pneumomediastinum (positive pressure breathing, rupture of bulla / bleb, chest surgery) s Bronchopleural fistula s Rupture of urinary bladder
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Penetrating abdominal injury r Through female genital tract s Iatrogenic s Perforation of uterus / vagina s Culdocentesis s Rubin test = tubal patency test s Pelvic examination s Spontaneous s Intercourse, orogenital insufflation q Douching s Knee-chest exercise, water skiing, horseback riding r Intraperitoneal s Gas forming peritonitis s Rupture of abscess s Air in lesser peritoneal sac gas in scrotum (through open processus vaginalis) Imaging findings r Large collection of gas r Abdominal distension, no gastric air-fluid level r "Football sign" = large pneumoperitoneum outlining entire abdominal cavity r "Double wall sign" = "Rigler sign" = air on both sides of bowel as intraluminal gas and free air outside (usually requires >1,000 mL of free intraperitoneal gas + intraperitoneal fluid) r "Telltale triangle sign" = triangular air pocket between 3 loops of bowel r Depiction of diaphragmatic muscle slips = two or three 6-13 cm long and 8-10 mm wide arcuate soft-tissue bands directed vertically inferiorly + arching parallel to diaphragmatic dome superiorly outline of ligaments of anterior inferior abdominal wall: r "Inverted V sign" = outline of both lateral umbilical ligaments (containing inferior epigastric vessels) r Outline of medial umbilical ligaments (obliterated umbilical arteries) r "Urachus sign" = outline of middle umbilical ligament
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Blue arrows point to falciform ligament, made visible by a large amount of free air in the peritoneal cavity. The red arrows demonstrate both sides of the wall of the stomach (Rigler's sign), a sign of free air. The yellow arrow points to a skin fold.
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RUQ gas (best place to look for small collections)

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Single large area of hyperlucency over the liver Oblique linear area of hyperlucency outlining the posteroinferior margin of liver Doge's cap sign = triangular collection of gas in Morison pouch (posterior hepatorenal space) Outline of falciform ligament = long vertical line to the right of midline extending from ligamentum teres notch to umbilicus; most common structure outlined Lligamentum teres notch = inverted V-shaped area of hyperlucency along undersurface of liver Ligamentum teres sign = air outlining fissure of ligamentum teres hepatis (= posterior free edge of falciform ligament) seen as vertically oriented sharply defined slitlike / oval area of hyperlucency between 10th and 12th rib within 2.5-4.0 cm of right vertebral border 2-7 mm wide and 6-20 mm long "Saddlebag / mustache / cupola sign" = gas trapped below central tendon of diaphragm Parahepatic air = gas bubble lateral to right edge of liver
Dahnert 5th edition
http://www.learningradiology.com/notes/ginotes/ulcerativecolitispage.htm
Ulcerative Colitis
Pathology
Predominantly mucosal disease, possible auto-immune producing crypt abscesses
Usual age at onset is 20-40; another peak at 60-70; equal male:female ratio
Clinical
Recurrent episodes of bloody diarrhea Electrolyte depletion Abdominal pain Fever Periods of exacerbation and remission Iritis, erythema nodosum, pyoderma gangrenosum Pericholangitis, chronic active hepatitis, sclerosing cholangitis, fatty liver Spondylitis, peripheral arthritis, RA (10-20%) Thrombotic complications
Location
Begins in rectum with retrograde progression Rectosigmoid involved 95%; continuous involvement of L colon Terminal ileum in 5-10% with backwash ileitis
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Acute inflammatory stage
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Spasm and irritability
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Fine mucosal granularity=earliest finding on air-contrast BE Spiculated, serrated bowel margins from tiny, multiple ulcerations Collar button ulcers-from undermining (not specific for UC) Double-tracking=long, longitudinal ulcers in submucosa Thumbprinting=from edema of wall Pseudopolyps=scattered islands of edematous mucosa in a sea of ulcerated mucosa
Widening of the presacral space Subacute stage Coarser, more granular mucosa Inflammatory polyps= frondlike lesions of inflamed mucosa Chronic stage Shortening of the colon=may be from spasm of longitudinal muscles or from irreversible fibrosis (lead-pipe colon) Loss of haustrations on left side of colon Postinflammatory polyps=filiform polyps=long worm-like lesions Backwash ileitis (5-10%)=wide open ileocecal valve and dilated terminal ileum
Crohns diseaseskip lesions: R colon; TI abnormal
Cathartic colon-loss of haustrations on Right side of colon; rectum spared

Familial polyposismultiple polyps but no inflammatory changes
Radiation ileitisshould have other loops involved and appropriate hx Lymphomashould have tumor masses, less spasm
Amebiasiscone-shaped cecum
Fatty infiltration of the liver
Gallstones (28-34%) Sclerosing cholangitis Bile duct carcinoma Amyloidosis Urolithiasis:oxalate/uric acid stones Migratory arthritis Sacroiliitis and ankylosing spondylitis Erythema nodosum and uveitis
Complications
Toxic megacolon Adenocarcinoma of the colon (1-16%) Increased risk of developing ca of colon with long-standing (usually more than 25 years) ulcerative colitis Higher incidence of multiple carcinomas Usually involve distal transverse colon, descending colon and rectum May present with smooth, tapering edges and resemble a benign stricture or may be annular constricting lesions Colonic strictures (10%) Smoothly tapering edges, usually single, commonly in sigmoid; must be differentiated from ca
wh
LearningRadiology.com - Acute pyelonephritis
Submitted by Matthew Krasner, M.D.
Etiology o Inflammation of the renal parenchyma and renal pelvis due to an infectious source o Most often secondary to an ascending lower urinary tract infection from gram-negative bacteria E. coli Klebsiella Proteus Pseudomonas. o Exception is S. aureus, which is spread hematogenously Pathologic Causes o Vesicoureteral reflux o Obstruction in the collecting system usually due to a calculus Signs and symptoms o Fever o Chills o Flank pain o Dysuria o Increased frequency of urination. o On exam, costovertebral angle tenderness may be present. Clinical Findings o CBC Elevated white blood cell count. o Urinalysis Bacteriuria Pyuria White blood cell casts o Acute pyelonephritis is clinical diagnosis, Radiographic imaging is used to evaluate underlying pathology Rule out any complications. Complications
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LearningRadiology.com - Acute pyelonephritis
o o
Abscess Emphysematous pyelonephritis Most often occurs in diabetics Can produce gas in the collecting system and renal parenchyma.
Radiographic Imaging Findings o Enlarged kidneys (U/S and CT) o Hydronephrosis (U/S and CT) o Wedge shaped areas of low attenuation secondary to decreased perfusion (CT) o Loss of the ability to distinguish the corticomedullary border (CT) o Perinephric stranding (CT)
Right kidney is markedly enlarged and has a wedge-shaped area of low attenuation Treatment o Antibiotics for non-complicated pyelonephritis. o Radical nephrectomy for emphysematous pyelonephritis. o Percutaneous drainage of abscesses
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LearningRadiology - Calcified Liver Metastases, Ovarian Neoplasms
Calcified Liver Masses Ovarian Neoplasms

Calcified Liver Masses - Causes
q
Inflammatory hepatic lesions

r
Most common cause of calcified hepatic lesions q Inflammatory conditions q For example, granulomatous diseases (tuberculosis). q Calcification involves entire lesion q Appears as a dense mass q May produce artifacts on CT scans Echinococcus cysts have curvilinear or ring calcification q Central water density in cyst
Benign neoplasms
r
Hemangiomas, especially large ones, may contain large, coarse calcifications; may be seen at CT in 20% of cases or radiography in 10%
Malignant liver neoplasms

r
Hepatocellular adenoma q Calcifications may be solitary or multiple q Usually located eccentrically within complex heterogeneous mass. Fibrolamellar carcinoma q Calcifications reported in 15%-25% of cases at CT q Occurs in many patterns Intrahepatic cholangiocarcinoma q Calcifications are typically accompanied by a desmoplastic reaction q Visible at CT in about 18% of cases. Calcified hepatic metastases q Most frequently associated with mucin-producing neoplasms such as colon, or less likely ovarian, carcinoma
Calcified Liver Masses - DDX

Granulomas, as in TB
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Hydatid cysts Hemangiomas Hepatocellular adenoma Fibrolamellar carcinoma Intrahepatic cholangiocarcinoma Mucin-producing metastases
Calcified liver and peritoneal metastases from ovarian carcinoma
Ovarian Neoplasms
q q
Tumors of Surface Epithelium form 90% of ovarian tumors Mucinous Tumors - Incidence 30% of ovarian neoplasms Mucinous cyst adenoma Commonest tumor Age group: 30-50 yrs Bilateral in 10% Mucinous cystadenocarcinoma Age group: 40-60 yrs Bilateral in 10 % - Features Large multilocular pedunculated cyst Rare complication may occur with involvement of the peritoneum Psedomyxoma peritonei (jelly belly) May produce coarse calcifications in primary or metastases

q
Serous Tumors - Incidence 50% of ovarian neoplasms Serous cystadenoma: Age group: 20 30 yrs Bilateral in 15% Malignant transformation in 20 30 % Serous cystadenocarcinoma: Age group: 40 60 yrs Bilateral in 30% 5 year survival rate: 30 50 % - Features: Contain fibrous walled cysts with papillary excrescences Locules contain straw-colored fluid Psammoma bodies=concentric calcification in papillary process Usually fine sand-like calcification frequently difficult to see on plain radiographs Endometrial tumors - Incidence 20% of ovarian tumors - Morphology: Tumors containing solid and cystic areas Filled with hemorrhagic fluid Lined by glandular epithelium Clear Cell (mesonephroid tumor) - Incidence: uncommon - Age group: 50 60 yrs - Morphology: Unilocular cysts with small cystic spaces Brenner tumor: Incidence: 1- 2% Occur commonly in perimenopausal women Germ Cell Tumors - Origin : cells derived form oocytes - Incidence: 15- 20% of all ovarian tumors, 5% malignant Age: young age Dysgerminoma - Incidence : very common Age : 20 20 yrs - Bilateral : 10 15 % - Macroscopic features : Solid tumors, elastic rubbery consistency having smooth, firm capsule Teratoma - Derived from cells of all three germ layers - Types: Mature or benign type (e.g. Dermoid cysts) Immature or malignant type (e.g. Solid Teratoma) Monodermal or highly specialized (e.g. Struma ovarii) Choriocarcinoma and Embryonal Cell Carcinoma - Choriocarcinoma mostly of placental origin occurs in prepubertal girls. Highly malignant
Contains syncytiotrophoblasts and cytotrophoblasts Secretes large quantities of the tumor marker - HCG - Embryonal cell carcinoma Incidence : rare - Highly malignant Ovarian Fibroma: - Meigs syndrome Ascites Right sided effusion Krukenberg tumor - Primary : 15% - small & large bowel , 20% - stomach, 6% - breast - Bilateral smooth surface - Histologically cellular or myxomatous stroma with scattered large signet ring cells
o o o
Routes of Peritoneal Spread

Right subphrenic space The greater omentum The Pouch of Douglas
LearningRadiology- Adrenal Adenoma
Adrenal Adenoma
Contributed by Shuchi Rodgers, MD
q q q q
Incidence in the population is 2-8% Diagnosis is often made as an incidental finding on CT examination. In patient with no known primary, an adrenal mass is almost always a benign adenoma In a patient with a known neoplasm, especially lung cancer, an adrenal mass is problematic and diagnosing a metastasis versus an adenoma is critical for prognosis
Imaging findings
q
CT
r
r r
Size greater than 4 cm tend to be metastases or adrenal carcinoma s Heterogeneous appearance and irregular shape are malignant characteristics Homogeneous and smooth are benign characteristics. s Intracellular lipid in adenoma results in low attenuation on CT Little intracytoplasmic fat in metastases results in high attenuation on non-enhanced CT Non-enhanced CT (NECT) s Threshold 10 HU s Sensitivity 79%, specificity 96% Contrast-enhanced CT (CECT) s Because majority of CT examinations in oncology use IV contrast, the % washout is useful after 10 minutes. s Adenomas have greater than 50% washout after 10 minutes s Washout can also be used on adrenal masses that measure > 10 HU on NECT s Alternative is to do MR or PET Chemical Shift s Most sensitive method for differentiating adenomas from metastases s Sensitivity 81-100%. Specificity 94-100%. s The difference in resonance rate of protons in fat and water is exploited in chemical shift. q Intracellular lipid and water in same voxel result in summation of signal on "inphase" and canceling out of signal on "out of phase" Spleen or muscle is used as an internal standard to visually quantify signal drop-off s Liver is not a reliable standard because of steatosis
MR
r
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LearningRadiology- Adrenal Adenoma
CT shows left adrenal mass. In-phase T1 shows adrenal mass is hyperintense relative to the spleen. T1 out-of-phase shows adrenal mass is hypointense to the spleen and compared to the in-phase, there is a drop in signal intensity
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LearningRadiology.com- Placenta,ultrasound,US,grade,grading,grade 0,grade 1,grade 2,grade 3
Placenta-Grading
Submitted by Tara Herzberg, MD
q
Vascularity r Very vascular has 2 blood supplies s Blood from fetus through 2 (sometimes 1) umbilical arteries through umbilical cord from fetal hypogastric arteries to placenta s 1 umbilical vein carries blood back to fetal left portal vein s Blood from mom through branches of uterine arteries through the myometrium (arcuate arteries) through the basilar plate (spiral arteries) into the placenta The two circulations intertwine in the placenta but do not mix r Exchange of oxygen and nutrients occurs over the large vascular surface area r Maternal venous channels in the placenta are hypoechoic or anechoic spaces called venous lakes (usually small, but can be large) Anatomy on US r Inner border of placenta against the uterine wall has the combined hypoechoic myometrium and interposed basilar layer = hypoechoic band called the decidua basalis (contains maternal blood vessels) r Outer surface abutting the amniotic fluid = chorionic plate (chorioamniotic membrane) = bright specular reflector Placental thickness judged subjectively r But if measure at midposition or cord insertion 2-4 cm = normal
Grade 0 st trimester-early q Late 1 2nd trimester q Uniform moderate echogenicity

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q
Smooth chorionic plate without indentations
Grade 1 nd trimester early q Mid 2 3rd trimester (~18-29 wks) q Subtle indentations of chorionic plate q Small, diffuse calcifications (hyperechoic) randomly dispersed in placenta
Grade 2 rd trimester (~30 q Late 3 wks to delivery)

q
Larger indentations along chorionic plate Larger calcifications in a dot-dash configuration along the basilar plate
Grade 3 q 39 wks post dates q Complete indentations of chorionic plate through to the basilar plate creating cotyledons (portions of placenta separated by the indentations) q More irregular calcifications with significant shadowing q May signify placental dysmaturity which can cause IUGR q Associated with smoking, chronic hypertension, SLE, diabetes
Rumack The Requisites-GU Radiology
http://www.learningradiology.com/notes/gunotes/apkdpage.htm
Polycystic Kidney Disease

Two major types: Autosomal Dominant Polycystic Kidney Disease (Adult Polycystic Kidney Disease [APKD]
and Autosomal Recessive Polycystic Kidney Disease (Infantile Polycystic Kidney Disease)
Autosomal Dominant Polycystic Kidney Disease

q q q
Is a slowly progressive disease with nearly 100% penetrance Potter Type III Cause: gene located on short arm of chromosome 16 (in 90% Spontaneous mutation in 10% Incidence:1:1,000 people carry the mutant gene
r
q q q
3rd most prevalent cause of chronic renal failure Histo: abnormal rate of tubule divisions (Potter Type III) with hypoplasia of portions of tubules left behind as the ureteral bud advances; cystic dilatation of Bowman capsule, loop of Henle, proximal convoluted tubule, coexisting with normal tissue Mean age at diagnosis: 43 years (neonatal / infantile onset has been reported) M:F = 1:1 Onset of cyst formation:
r r r r
54% in 1st decade 72% in 2nd decade 86% in 3rd decade
Associated with:
Cysts in: liver (25-50%), pancreas (9%) Aneurysm: saccular "berry" aneurysm of cerebral arteries (3-13%) Mitral valve prolapse Hypertension (50-70%) Azotemia Hematuria, proteinuria Lumbar / abdominal pain Bilaterally large kidneys with multifocal round lesions; unilateral enlargement may be the first
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manifestation of the disease
Cysts may calcify in curvilinear rim- / ringlike irregular amorphous fashion elongated + distorted + attenuated collecting system nodular puddling of contrast material on delayed images "Swiss cheese" nephrogram = multiple lesions of varying size with smooth margins Polycystic kidneys shrink after beginning of renal failure, after renal transplantation, or on chronic hemodialysis NUC: poor renal function on Tc-99m DTPA scan
US OB-US Large echogenic kidneys similar to infantile PCKD (usually in 3rd trimester, earliest sonographic diagnosis at 14 weeks), can be unilateral Macroscopic cysts (rare) Normal amount of amniotic fluid / oligohydramnios (renal function usually not impaired) Complications
Death from uremia (59%) / cerebral hemorrhage (secondary to hypertension or ruptured aneurysm [13%]) / cardiac complications (mean age 50 years) Renal calculi Urinary tract infection Cyst rupture Hemorrhage Renal cell carcinoma (increased risk) Multiple cysts in cortical region (usually not seen prior to teens) Diffusely echogenic when cysts small (children) Renal contour poorly demarcated
Multiple simple cysts (less diffuse, no family history)
von Hippel-Lindau disease (cerebellar hemangioblastoma, retinal hemangiomas, occasionally pheochromocytomas) Acquired uremic cystic disease (kidneys small, no renal function, transplant) Infantile PCKD (usually microscopic cysts)
Autosomal Recessive Polycystic Kidney Disease = Polycystic Disease of Childhood

Pathology
Kidney: abnormal proliferation + dilatation of collecting tubules resulting in multiple 1- to 2-mm cysts Liver: periportal fibrosis often with abnormal proliferation + dilatation of bile ducts Pancreas: pancreatic fibrosis Potter Type I Incidence:1: 6,000 to 1:50,000 livebirths F > M; carrier frequency of 1:112
ANTENATAL FORM (most common)

90% of tubules show cystic changes Onset of renal failure in utero Potter sequence Oligohydramnios and dystocia (large abdominal mass) Prognosis: death from renal failure / respiratory insufficiency (pulmonary hypoplasia) within 24 hours in 75%, within 1 year in 93%; uniformly fatal
NEONATAL FORM
60% of tubules show ectasia + minimal hepatic fibrosis + bile duct proliferation Onset of renal failure within 1st month of life Prognosis: death from renal failure / hypertension / left ventricular failure within 1st year of life
INFANTILE FORM
20% of renal tubules involved + mild / moderate periportal fibrosis Disease appears by 3-6 months of age Prognosis: death from chronic renal failure / systemic arterial hypertension / portal hypertension
JUVENILE FORM Lung

10% of tubules involved + gross hepatic fibrosis + bile duct proliferation Disease appears at 1-5 years of age Prognosis: death from portal hypertension The less severe the renal findings, the more severe the hepatic findings!
Severe pulmonary hypoplasia Pneumothorax / pneumomediastinum Liver Portal venous hypertension Tubular cystic dilatation of small intrahepatic bile ducts Increase in liver echogenicity (from congenital hepatic fibrosis) Kidneys Bilateral gross renal enlargement Faint nephrogram + blotchy opacification on initial images Increasingly dense nephrogram Poor visualization of collecting system "Sunburst nephrogram" = striated nephrogram with persistent radiating opaque streaks (collecting
ducts) on Delayed images Prominent fetal lobulation
CT US
Hyperechoic enlarged kidneys (unresolved 1- to 2-mm cystic / ectatic dilatation of renal tubules increase number of acoustic interfaces) Increased renal through-transmission (high fluid content of cysts) Loss of corticomedullary differentiation, poor visualization of renal sinus + renal borders Occasionally discrete macroscopic cysts <1 cm Compressed / minimally dilated collecting system Prolonged corticomedullary phase
OB-US (diagnostic as early as 17 weeks GA):

Progressive renal enlargement with renal circumference : abdominal circumference ratio >0.30 Hyperechoic renal parenchyma Nonvisualization of urine in fetal bladder (in severe cases) Oligohydramnios (33%) Small fetal thorax
OB management
Chromosome studies to determine if other malformations present (e.g., trisomy 13 / 18) Option of pregnancy termination <24 weeks Nonintervention for fetal distress >24 weeks if severe oligohydramnios present Risk of recurrence:25% DDx: Meckel-Gruber syndrome, adult polycystic kidney disease
From Dahnert, 4th Edition
LearningRadiology.com- Renal Infarction,kidney,thrombosis,emboli,embolus,rim,sign,wedge
Renal Infarction
Thrombotic disease usually affects larger vessels r Includes main renal artery r Patients with thrombotic disease usually present with hypertension or renal insufficiency r Usually results from atherosclerosis s But, blunt abdominal trauma may cause intimal tears with subsequent dissection and thrombosis Emboli can affect vessels of various sizes depending on the size of the emboli r Renal artery emboli usually come from cardiac source r Embolic disease usually produces acute symptoms s Sudden onset of flank pain s Hematuria s Proteinuria s Fever s Leukocytosis Causes r Trauma s Blunt abdominal trauma s Traumatic avulsion of renal artery s Surgery r Embolism s Cardiac origin q Rheumatic heart disease with arrhythmia r Atrial fibrillation q Myocardial infarction q Prosthetic valves q Myocardial trauma q Left atrial or mural thrombus q Myocardial tumors q Subacute bacterial endocarditis s Catheters q Angiographic catheter manipulation q Umbilical artery catheter above level of renal arteries r Arterial thrombosis s Arteriosclerosis s Thrombangitis obliterans
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Polyarteritis nodosa s Syphilitic cardiovascular disease s Aneurysms of the aorta or renal artery s Sickle cell disease r Sudden complete renal vein thrombosis Lobar Renal Infarction r Early signs s Focal attenuation of collecting system q Tissue swelling s Focally absent nephrogram q Triangular with base at cortex r Late signs s Normal or small kidney(s) s Focally atrophied parenchyma with normal interpapillary line s Cortical atrophy and irregular scarring are seen as late sequelae r CT s Subtle renal infarcts are best demonstrated on CT s Appear as wedge-shaped, cortically based, hypodense areas q Triangular in shape with widest part at the cortex (base of infarct) s Non-perfused area corresponding to vascular division s Renal swelling may also be seen s Cortical rim sign q Entire kidney is nonenhancing except for the outer 24 mm of cortex, which are perfused by capsular branches
s
Two contrast-enhanced axial CT images demonstrate a wedge-shaped non-enhancing lesion in the right kidney with no perinephric inflammatory stranding
r
US Focally increased echogenicity s Color flow Doppler aids in diagnosis of renal artery thrombosis q There is absence of an intrarenal arterial signal q Tardus parvus waveform is seen if incomplete occlusion or collateral supply s Nuclear medicine q Nuclear imaging shows a photopenic area corresponding to the region of ischemia or infarction Chronic Renal Infarction r Pathology s All elements of kidney atrophied with replacement by interstitial fibrosis s Normal or small kidney with smooth contour
s

s s r
Globally atrophied parenchyma Diminished or absent contrast material density
US
s
Increased echogenicity (by 17 days) r Angiography s Normal intrarenal venous architecture s Late visualization of renal arteries on abdominal aortogram s Provides the definitive diagnosis q Abrupt termination of vessels or filling defects q With end-stage renal artery thrombosis r Small kidney with smooth contour, unless multiple small infarcts have occurred independently Treatment r Anticoagulation r Intra-arterial thrombolytic therapy r Surgical revascularization
Dahnert 5th ed Amersham
LearningRadiology - Angiomyolipoma, AML, Tuberous Sclerosis
Angiomyolipoma
q q q
Benign mesenchymal tumor of kidney Rare Histopathology r No true capsule r Commonly bleed r Tumor composed of fat, smooth muscle, aggregates of thick-walled blood vessels Types r Isolated angiomyolipoma is most common (80%) s Usually solitary s Unilateral (80% on right side) s Not associated with tuberous sclerosis s Mean age of incidence: 40s s Much more common in females r Angiomyolipoma associated with tuberous sclerosis (in 20%) s Angiomyolipoma occurs in 80% of patients with tuberous sclerosis q Commonly large q Usually bilateral q Usually multiple s May be only evidence of tuberous sclerosis s Mean age of incidence: teens s Equal incidence in males and females Signs and symptoms r Small lesions are asymptomatic (60%) r Acute flank / abdominal pain (due to hemorrhage) most common presenting symptom r Hematuria (40%) r Palpable mass (47%) r Shock (due to massive retroperitoneal hemorrhage) Imaging findings r Mostly small lesions <5 cm in diameter r Many have a large exophytic component (25%) r Calcifications not common (6%) r Plain film findings s Mass of fat lucency is lesion is large enough r CT findings s Well-marginated, cortical-based, heterogeneous tumor predominantly of fat density (<-
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20 HU) Variable enhancement (smooth muscle, vessels)
Angiomyolipomas of both kidneys are seen to contain fat

r
US findings s Highly echogenic tumor due to high fat content s Less echogenic areas due to hemorrhage, necrosis, dilated calyces MRI findings s Intra-tumoral fat seen with fat-suppression technique s Variable areas of high signal intensity on T1WI Angiographic findings s Hypervascular mass (95%) q Enlarged interlobar + interlobular feeding arteries r Tortuous, irregular, aneurysmal, venous pooling, "sunburst" / "whorled" / "onion peel" appearance, no AV shunting Complications r Angiomyolipomas >4 cm bleed spontaneously in 50-60% s Hemorrhagic shock from bleeding into angiomyolipoma or into retroperitoneum Treatment r Annual follow-up of lesions <4 cm r Emergency laparotomy is required in some including nephrectomy, tumor resection r Selective arterial embolization can be done DDx r Renal / perirenal lipoma or liposarcoma r Wilms tumor r Renal cell carcinoma which will occasionally contain fat
Dahnert 4th edition
LearningRadiology.com- Retrocaval,Circumcaval,Ureter,deviation,displacement,medial,causes,hydronephrosis,radiology,image,x-ray,findings
Retrocaval Ureter
q q
Also known as circumcaval ureter Abnormality in embryogenesis of IVC r Results from abnormal persistence of right subcardinal vein positioned ventral to ureter in the definitive IVC r Developing right ureter courses behind and medial to the IVC Incidence r 0.07% r Male to female ratio of 3:1 Clinical findings r Symptoms of right ureteral obstruction Imaging findings r Normal course of ureters s About the width of your thumb lateral to the lumbar vertebral pedicles s About the width of two fingers medial to pelvic brim in true pelvis r With retrocaval ureter s Right ureters course swings medially over pedicle of L3/4 q Passes behind IVC s Then exits anteriorly between IVC and aorta returning to its normal position s Produces varying degrees of proximal hydroureteronephrosis
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Retrograde pyelogram of right ureter demonstrates displacement of the ureter which passes medial to the pedicle ft the level of L4. The ureter is slightly dilated proximal to this point and returns to a normal position distal to its retrocaval placement.
CT scan below the level of the kidneys demonstrates a more medial
retrocaval placement of the right ureter.

q
Retrocaval ureter can be associated with Turners syndrome
Causes of Ureteral Deviation or Displacement

Medial Displacement or Deviation Upper ureter Retrocaval ureter Retroperitoneal fibrosis Lower ureter Lymphadenopathy Iliac artery aneurysm Bladder diverticulum Post-surgical (esp. AP resection) Pelvic lipomatosis Lateral Displacement or Deviation Upper ureter Lower ureter Lymphadenopathy Pelvic mass, e.g. uterine fibroids Aortic aneurysm Retroperitoneal hematoma
Herman, T and McAlister, W: Radiologic Clinics of North America. Vol. 29:2, March, 1991
LearningRadiology.com- Bladder rupture,perforation,urinary bladder,pelvic,trauma
Bladder Rupture
q q
r
Extraperitoneal bladder rupture is the most common type r Occurs in 80% of bladder rupture cases r Extraperitoneal bladder rupture generally secondary to adjacent pelvic fracture or an avulsion tear at fixation points of puboprostatic ligaments Intraperitoneal bladder rupture r Usually iatrogenic or secondary to penetrating injury r Blunt trauma more likely to result in intraperitoneal rupture in children than in adults s Because the pediatric bladder is more intraperitoneal in location. s The adult bladder dome remains mostly extraperitoneal q Blunt trauma in an adult can result in intraperitoneal rupture only if the bladder is fully distended
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Imaging findings s Contrast extravasation into paracolic gutters s Contrast outlining small bowel loops While extraperitoneal bladder rupture can be treated conservatively, intraperitoneal bladder rupture requires surgical repair Highest morbidity and rupture mortality is associated with intraperitoneal rupture because of potential for development of chemical peritonitis Imaging findings r Diagnostic evaluation of bladder rupture includes voiding cystourethrography (VCUG) or CT scan s VCUG q Voiding cystourethrography historically been preferred contrast enhanced study for diagnosis of bladder rupture q Bladder needs to be fully distended and evaluation of a post-voiding film essential s Plain film: q "Pear-shaped" bladder q Paralytic ileus q Upward displacement of ileal loops q Flame-shaped contrast extravasation into perivesical fat r Best seen on postvoid films r May extend into thigh / anterior abdominal wall
r
One image from an IVU shows a flame-shaped density adjacent to right lateral wall of bladder representing extra-peritoneal contrast from a bladder rupture
q
US

r
"Bladder within a bladder" = bladder surrounded by fluid collection
LearningRadiology.com- Transitional Cell Carcinoma, TCC, Urothelial Carcinoma
Urothelial Carcinoma Transitional Cell Carcinoma

Submitted by Daniel Kowal, MD
q q
q q
q q q
Accounts for 85-90% of all uroepithelial tumors Exophytic, polypoid papillary growth pattern most common r Attached to the mucosa by stalk r Non-papillary tumors less common Most are solid with no characteristic gross findings Location r Bladder is 30-50x more often the site of the tumor than ureter or renal pelvis (most common tumor of GU tract) rd r When it occurs in the ureter, it most commonly occurs in the lower 3 Synchronous (simultaneous) transitional cell carcinomas are common r Bladder involvement with s 24% of primary renal pelvis involvement s 30% of primary ureteral involvement s In 2% with primary bladder tumor r Both ureters involved in 2-9% r Both renal pelves in 1-2% Metachronous (sequential) transitional cell carcinomas in upper tracts r With pelvic and ureteral primaries-12% in 25 months r With bladder primaries-4% (2/3 in 2 years but can reoccur decades later) Most commonly in men age 60 and older Classically present with painless hematuria Risk factors r Exposure to cyclophosphamide r Phenacetin r Chronic urinary stasis r Smoking Metastasizes to r Regional lymph nodes r Liver r Lung r Bone Imaging findings
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r
IVU Enlarged and hydronephrotic kidney q Invasive, poorly differentiated tumors are more likely to obstruct q Dilated calyx with filling defect q Caliceal amputation q Partial or complete obstruction of the infundibulum Retrograde studies s Papillary tumors q Goblet or Champagne glass sign of ureteral dilatation distal to a filling defect allows for differentiation from a calculus impacted in the ureter, which causes distal spasm and narrowing
s
Upper and lower half of right retrograde pyelogram shows hydronephrosis (yellow arrow), filling defect at head of contrast column in ureter (red arrow) and "goblet" shaped dilatation distal to filling defect
s
Non-papillary tumors q Nodular or flat q Cause strictures rather than filling defects CT s Can identify dilated collecting system and demonstrate level of obstruction s Intraluminal mass (30-60 HU) representing ureteral tumor can be differentiated from obstructing calculus (> 190 HU)

s r
May demonstrate extra-ureteral extension
US Discrete hypoechoic mass within the renal sinus s Absence of acoustic shadowing allows for differentiation from calculi Angiography s Hypovascular mass s Vessel encasement and stain s Not usually necessary Treatment r Controversy s Nephroureterectomy with resection of a cuff of bladder versus wide excision of the tumor alone s Adding chemotherapy (cisplatin) in patients with advanced tumors is of unclear utility
s
LearningRadiology.com - Emphysematous Pyelonephritis
Emphysematous Pyelonephritis
q
Acute, fulminant, necrotizing infection of kidney and perirenal tissues associated with gas formation which may be life-threatening Organism r E. coli (vast majority of cases) r Klebsiella pneumoniae (9%) r Proteus mirabilis r Pseudomonas r Enterobacter r Candida r Clostridia (exceptionally rare) Predisposed r Especially diabetics in almost all cases r Immunocompromised patients r Ureteral obstruction Average age r Mid-fifties r Twice as common in females as males Clinical findings r Features of acute severe pyelonephritis (chills, fever, flank pain, lethargy, confusion) not responding to treatment r Positive blood and urine cultures (in majority) r Urosepsis r Shock r Fever of unknown origin and no localizing signs in almost 20% Frequently have multiple associated medical problems r Uncontrolled hyperglycemia r Acidosis r Dehydration r Electrolyte imbalance Location r Most are unilateral r 5-7% bilateral Types r Type I (33%) s Streaky or mottled gas in interstitium of renal parenchyma radiating from medulla to
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cortex s Crescent of subcapsular or perinephric gas s No fluid collection (= no effective immune response) s Prognosis in this type is poor (69% mortality) Type II (66%) s Bubbly and/or loculated intrarenal gas (infers presence of abscess) s Renal and/or perirenal fluid collection s Gas within collecting system in almost all
Two axial CT scans of abdomen and pelvis show air within collecting system of kidney in top image with air and debris in bladder lumen and wall in bottom image
s s s q
Prognosis in this type is much better (18% mortality) Parenchymal destruction absent Decreased contrast excretion (due to compromised renal function) CT findings r Most reliable and sensitive modality r Mottled areas of low attenuation extending radially along the pyramids r Extensive involvement of kidney and perinephric space r Air extending through Gerotas fascia into retroperitoneal space r Occasionally gas in renal veins Ultrasound findings r High-amplitude echoes within renal sinus and/or renal parenchyma associated with "dirty" shadowing
"Comet tail" reverberations r Kidney may be completely obscured by large amount of gas in perinephric space (DDx: surrounding bowel gas) r Gas may be confused with renal calculi MR findings r Signal void on T1WI and T2WI (DDx: renal calculi, rapidly flowing blood) DDx r Emphysematous pyelitis (gas in collecting system but not in parenchyma, diabetes in 50%, less grave prognosis) Treatment r Antibiotic therapy and nephrectomy r Drainage procedure with coexisting obstruction Mortality r 60-75% under antibiotic treatment r 21-29% after antibiotic treatment and nephrectomy r 80% with extension into perirenal space
s
Dahnert 4th edition
LearningRadiology.com- Retrocaval,Circumcaval,Ureter,deviation,displacement,medial,causes,ureteral,hydronephrosis,radiology,image,x-ray,findings
Causes of Ureteral Deviation Displacement

Medial Displacement or Deviation Upper ureter Retrocaval ureter Retroperitoneal fibrosis Lower ureter Lymphadenopathy Iliac artery aneurysm Bladder diverticulum Post-surgical (esp. AP resection) Pelvic lipomatosis Lateral Displacement or Deviation Upper ureter Lower ureter Lymphadenopathy Pelvic mass, e.g. uterine fibroids Aortic aneurysm Retroperitoneal hematoma
http://www.learningradiology.com/notes/gunotes/ureteraldeviationapgepage.htm04/09/2006 1:31:03
LearningRadiology-Bone Tumors
http://www.learningradiology.com/lectures/bonelectures/bonetumorsnetscape_files/frame.htm04/09/2006 1:31:13
Bone Tumors Clues and Cues

In Slide Show mode, advance the slides by pressing the spacebar
All Photos Retain the Copyright of their Authors
Clues by Appearance of Lesion
Patterns of Bone Destruction
Geographic Moth-eaten Permeative
Geographic Bone Destruction

Destructive lesion with sharply defined border Implies a less-aggressive, more slow-growing, benign process Narrow transition zone
R3, 2000
Non-ossifying fibroma
Geographic Lesions
Examples
Non-ossifying fibroma Chondromyxoid fibroma Eosinophilic granuloma
Moth-eaten Appearance
Areas of destruction with ragged borders Implies more rapid growth

Probably a malignancy
R3, 2000
Multiple Myeloma
Moth-eaten Appearance
Examples
Myeloma Metastases Lymphoma Ewings sarcoma
Permeative Pattern
Ill-defined lesion with multiple wormholes Spreads through marrow space Wide transition zone Implies an aggressive malignancy Round-cell lesions
Leukemia
Permeative Pattern
Round cell lesions
Lymphoma, leukemia Ewings Sarcoma Myeloma Osteomyelitis Neuroblastoma
Patterns of Destruction
Geographic
Less malignant
Moth-eaten
Permeative
More malignant
Periosteal Reactions
Benign
None Solid
More aggressive or malignant

Lamellated or onion-skinning Sunburst Codmans triangle
Benign
None Solid
Aggressive/malignant
Onion-skinning Sunburst Codmans triangle
R3, 2000
Benign
None Solid
R3, 2000
Chronic osteomyelitis
Benign
None Solid
Greenspan, 2000
Ewings sarcoma
Benign
None Solid
Greenspan, 2000
Osteosarcoma
Benign
None Solid
R3, 2000
Ewings-Codmans triangle
Solid
Less malignant
Lamellated
Sunburst
Codmans
More malignant
Tumor Matrix
Osteoblastic
Fluffy, cotton-like or cloud-like densities
Osteosarcoma
Cartilaginous
Comma-shaped, punctate, annular, popcornlike
Enchondroma, chondrosarcoma, chondromyxoid fibroma
Tumor matrix
Osteoblastic Cartilaginous
R3, 2000
Osteosarcoma
Tumor matrix
Osteoblastic Cartilaginous
R3, 2000
Chondrosarcoma
Expansile Lesions of Bone
Multiple myeloma Mets Aneurysmal bone cyst Fibrous dysplasia
Brown tumor Enchondroma Lymphoma
Expansile lesions
Multiple myeloma Mets Aneurysmal bone cyst Fibrous dysplasia Brown tumor Enchondroma Lymphoma
Multiple Myeloma
Expansile lesions
Renal Cell Carcinoma
Expansile lesions
Aneurysmal Bone Cyst
Expansile lesions
Fibrous Dysplasia
Expansile lesions
R3, 2000
Brown Tumor
Expansile lesions
R3, 2000
Enchondroma
Expansile lesions
Lymphoma
R3, 2000
Clues by Location of Lesion
In the Transverse Plane

Central
Enchondroma
Eccentric
GCT, osteosarcoma, chondromyxoid fibroma
Cortical
Non-ossifying fibroma, osteoid osteoma
Parosteal
Parosteal osteosarcoma, osteochondroma
Osteosarcoma
Parosteal sarcoma Osteochondroma

Greenspan, Lippincott, 2000
In The Transverse Plane
In the Longitudinal Plane

Epiphyseal
GCT, chondroblastoma
Metaphyseal
Osteomyelitis, osteo- and chondrosarcoma
Diaphyseal
Round cell lesions, ABC, enchondroma
Tumor Types
Characteristic Locations
Simple bone cyst

Proximal humerus
Chondroblastoma
Epiphyses
Giant Cell tumor

Epiphyses
Characteristic locations
Simple bone cyst
Proximal humerus
Chondroblastoma
Epiphyses
Giant Cell tumor

Epiphyses
R3, 2000
Simple bone cyst
Proximal humerus
Chondroblastoma
Epiphyses
Giant Cell tumor

Epiphyses
R3, 2000
Chondroblastoma
Simple bone cyst
Proximal humerus
Chondroblastoma
Epiphyses
Giant Cell tumor

Epiphyses
R3, 2000
Giant Cell Tumor
Tumor Types
Adamantinoma
Tibia
Chordoma
Sacrum, clivus
Osteoblastoma
Spine, posterior
Adamantinoma
Tibia
Chordoma
Sacrum, clivus
Osteoblastoma
Spine, posterior
R3, 2000
Adamantinoma
Adamantinoma
Tibia
Chordoma
Sacrum, clivus
Osteoblastoma
Spine, posterior
R3, 2000
Chordoma
Adamantinoma
Tibia
Chordoma
Sacrum, clivus
Osteoblastoma
Spine, posterior
R3, 2000
Osteoblastoma
Tumor Types
Parosteal sarcoma
Distal femur
Periosteal sarcoma
Tibia
Parosteal sarcoma
Distal femur
Periosteal sarcoma
Tibia
Parosteal sarcoma
Parosteal sarcoma
Distal femur
Periosteal sarcoma
Tibia
R3, 2000
Characteristic Tumors By Body Site
Pelvic Lesions
Chondrosarcoma Solitary plasmacytoma Chordoma
Pelvic lesions
Pelvic lesions
Plasmacytoma
Pelvic lesions
R3, 2000
Chordoma
Expansile Rib Lesions

Plasmacytoma Metastases Chondrosarcoma Eosinophilic granuloma Neurofibromatosis Fibrous dysplasia
Expansile rib lesions


Thyroid Carcinoma

R3, 2000

R3, 2000

R3, 2000

R3, 2000
Lesions of the Spine

Osteoblastoma
Expansile, with punctate densities within
Chordoma ABC Metastatic disease
Spine lesions
Osteoblastoma Chordoma ABC Metastatic disease

R3, 2000
Osteoblastoma
Spine lesions

R3, 2000
Chordoma
Spine lesions

Aneurysmal bone cyst
Spine lesions

Metastatic Breast Carcinoma
R3, 2000
Clues by Density Of Lesion
Sclerotic Cortical Lesions
Osteoid osteoma Brodies abscess Stress fracture
Sclerotic cortical lesions Osteoid osteoma Brodies abscess Stress fracture
Osteoid Osteoma
R3, 2000
Brodies abscess
Healing Stress Fracture
Sclerotic Cortical Lesions
Osteoid Osteoma
Brodies abscess
Healing Stress Fracture
Lytic Lesions in Children
Eosinophilic granuloma Neuroblastoma Leukemia

R3, 2000
Eosinophilic granuloma

R3, 2000
Neuroblastoma

R3, 2000
Leukemia
Lytic Lesions in Adults

Metastatic lesions
Lung Renal Thyroid
Multiple myeloma Primary bone tumor

Mets Myeloma Primary bone tumor
Met from Thyroid Carcinoma

Multiple myeloma

Chondrosarcoma
Blastic Lesions in Children
Medulloblastoma Lymphoma

R3, 2000
Medulloblastoma

Lymphoma
Blastic Lesions in Adults

Metastatic disease
Breast female Prostate male
Lymphoma Pagets disease Etcetera-mastocytosis, fluorosis

Mets Lymphoma Pagets
Prostate Mets

Breast Mets

Lymphoma

Pagets of Spine
Other Clues
Benign Lesions
Without Sclerotic Boarders
Giant Cell tumor Brown tumor Osteolytic phase of Pagets Disease
Benign Lesions without Sclerotic Borders

Giant cell tumor Brown tumor Osteolytic Pagets
R3, 2000
Giant Cell Tumor

R3, 2000
Brown Tumor

R3, 2000
Osteolytic Pagets
Soft Tissue Extension

Usually implies malignancy
More likely to form discrete soft tissue mass
Benign conditions with soft tissue extension

Osteomyelitis
Usually infiltration of fat
R3, 2000
Osteosarcoma
Multiple Lesions
More often benign Malignancies with multiple lesions
Metastatic disease Multiple myeloma Lymphoma Ewings sarcoma (rarely) Osteosarcoma (rarely)
Multiple lesions
Metastatic Multiple myeloma Lymphoma
R3, 2000
Mets from Ca of Prostate
Multiple lesions
R3, 2000
Multiple Myeloma
Multiple lesions
R3, 2000
Lymphoma
Multiple lesions
Metastatic Multiple myeloma Lymphoma Osteosarcomatosis
R3, 2000
Osteosarcomatosis
Benign vs. Malignant
Greenspan, Lippincott, 2000
The End
Fractures and Dislocations of the Cervical Spine
http://www.learningradiology.com/lectures/bonelectures/cpinefxsnetscape_files/frame.htm04/09/2006 1:31:50
Fractures and Dislocations Fractures and Dislocations of the Cervical Spine of the Cervical Spine

3 rules of 3
The predentate space should be < 3mm The prevertebral soft tissue at C3 is usually 3 mm Anterior wedging of 3mm or more suggests a fx
Atlanto-axial Dislocation
Hyperextension injury Children>adults Head slips forward on C1 Usually fatal
Neural Arch Fracture of C1
Most common fracture of C1 Hyperextension injury Not associated with neurologic deficit Confused with congenital anomaly
Jefferson Fracture of C1
Burst fracture Caused by compressive force Bilateral breaks in anterior and posterior arches Open mouth view shows bilateral offset of C1 on C2 Not associated with neurologic deficit
Hangmans Fracture of C2
Most common fracture of C2
Most common cervical spine fracture
Hyperextension/compression fracture Fractures through the pedicles of C2 with anterior slip of C2 on C3 Not associated with neurologic deficit Teardrop fracture of inferior aspect of C2 or C3 is clue to dx of Hangmans fx
Dens Fractures
Hyperextension injuries Most associated with forward subluxation of C1 on C2 High incidence of non-union (60%) Stable
Dens Fractures
Types
Tip of dens Base of dens Sub-dentate
Rare (5%) Common (65%) Uncommon (30%)
Dens Fractures
Pitfalls in Diagnosis
Mach line Congenital non-union Non-union of previous fracture
Flexion-Teardrop Fracture
Combination of flexion and compression, e.g. MVA Teardrop fragment comes from anteroinferior aspect of body Remainder of body displaced backward into spinal canal
Flexion-Teardrop Fracture
Facet joint and interspinous distances usually widened Disk space may be narrowed 70% have associated neurologic deficit
Simple Compression Fracture
Flexion injury Anterior wedging of 3mm or more suggests fracture Usually involves superior endplate of vertebral body
Clay-Shovelers Fracture
Avulsion fracture of spinous process of C6 or C7 Occurs as result of rotation of trunk relative to neck No neurologic deficit
Ligamentous Injuries
Mechanism is flexion/distraction Disk space narrower anteriorly than posteriorly Widening of the interspinpous distance Widening of the facet joint
Usually the posterior aspect
Subluxation of vertebral body Perched facet Locked facets

At least 50% subluxation
85% neurologic deficits with locked facets
Unilateral Locked Facets

Mechanism is flexion/distraction and rotation Only 30% associated with neurologic defect On lateral, some bodies appear lateral, some oblique Spinous processes do not line up on frontal film
Unstable Fractures
Jefferson fracture Hangmans fracture Flexion teardrop fracture Extension teardrop fracture Bilateral locked facets
LearningRadiology-Pelvic Fractures
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Pelvic Trauma
Pelvic Fractures
Stable Fractures (2/3)
Solitary ischial ramus fracture Unilateral fractures both rami Iliac wing fracture (Duverny Fracture) Isolated sacral fracture
Pelvic Fractures
Stable and Unstable
Stable fracturessingle breaks in ring or peripheral fxs (66%)

Result of moderate trauma, e.g. falls
Unstable fracturesfxs of both anterior and posterior arches (33%)

Result of severe trauma, e.g. MVAs
Stable Pelvic Fractures

Solitary Fractures of Ischial Ramus
Most common pelvic fracture (40% of all pelvic fxs) Most common stable fracture Usually seen in osteoporotic females

Unilateral Fractures of Both Rami
If distracted, look for other pelvic ring fractures
Stable Pelvic Fractures Iliac Wing Fracture-Duverny Fracture

Due to direct lateral compression Often associated with paralytic ileus Can perforate bowel and be open fracture

Isolated Sacral Fractures
Usually transversely oriented Difficult to detect Lateral view may show angulation
Pelvic Fractures
Unstable Fractures (1/3)
Malgaigne Fracture Straddle Fracture Pelvic Dislocation Bucket Handle Fracture
Unstable Fractures
Malgaigne Fracture
Most common unstable pelvic fracture (14% of all pelvic fxs) Vertical shearing involves both anterior & posterior arches Results in double vertical fractures Most commonly through pubic rami and sacrum
Sacral Fractures
Associated with Other Fxs
Usually vertically oriented Check symmetry of sacral lines
Unstable Fractures
Straddle Fracture
Bilateral fractures of all pubic rami Fracture fragments are usually elevated Associated with urethral and bladder injuries in 20%
Unstable Fractures
Pelvic Dislocation
Severe trauma Sprung Pelvis usually associated with GU injury Normal SI=1-4mm Normal symphysis=5mm
Unstable Fractures
Bucket Handle Fracture
Fracture of anterior arch and contralateral posterior arch Rare
Pelvic Trauma
Urethral Injury
Usually involves membranous or prostatic urethra Should be suspected in straddle fracture or pelvic dislocation Retrograde urethrogram should be performed prior to insertion of Foley
Pelvic Trauma
Ruptured Bladder
Should be suspected with straddle fractures and sprung pelvis Most common rupture is extraperitoneal (80%) Use retrograde cystogram to demonstrate rupture
Pelvic Trauma
Ruptured Bladder
Extraperitoneal rupture
Contrast will remain adjacent to bladder
Intraperitoneal rupture
Dome is torn and contrast flows freely
Pelvic Trauma
Soft Tissue Clues
Displacement or obliteration of obturator internus fat plane Similar findings with iliopsoas and gluteal fat planes Pelvic hematomas may displace bladder or ureters
Iliopubic Line
Anterior Column Anterior aspect of acetabulum runs from ilium to pubis
Ilioischial Line
Posterior Column Posterior aspect of acetabulum runs from ilium to ischium
Roentgenographic U
The Teardrop
Teardrop should not be located medial to ilioischial line Displacement of teardrop may be sign of occult acetabular fx
Pelvic Trauma
Acetabular Fractures
20% of pelvic fractures involve acetabulum CT best way of evaluating acetabular fxs
Classification
Posterior rim fracture Transverse acetabular fracture Anterior column fracture Posterior column fracture
Posterior Rim Fractures
Most common acetabular fx (33%) Occurs with posterior dislocation of hip Typically in MVAs with forces through femoral shaft
Transverse Acetabular Fractures
Separates innominate bone into two halves Look for break in both iliopubic and ilioischial lines May be associated with central dislocation of femoral head
Anterior Column Fracture
Fracture through iliopubic line May be associated with central dislocation of femoral head
Acetabular Fractures Posterior Column Fracture-Walther Fx
Fracture through ilioischial line May be associated with central dislocation of femoral head
Pelvic Trauma
Avulsion Fractures
Usually occur in athletic individuals

Ischial tuberosity (hamstrings) Anterior inferior iliac spine (rectus femoris) Anterior superior iliac spine (sartorious) Iliac crest (abdominal muscles)
Avulsion Fractures
Ischial Tuberosity
Occurs at insertion of hamstrings Usually seen in sprinters, hurdlers, gymnasts, long jumpers Looks enlarged when healed
Avulsion Fractures
Anterior Inferior Iliac Spine
Occurs at insertion of rectus femoris
Avulsion Fractures
Anterior Superior Iliac Spine
Occurs at insertion of sartorious
Avulsion Fractures
Iliac Crest Avulsion Fracture
Occurs at insertion of abdominal muscles
Pelvic Trauma
Complications
Hemorrhage
Usually from laceration of hypogastric artery
Urinary tract injury

Ruptured urethra or bladder
Pelvic Trauma
Complications
Sacral plexus/sciatic nerve injuries

Especially with fxs of posterior arch
Infection
Retroperitoneal abscess may form in open fxs
Ruptured Urethra
Classical Triad
Blood on external meatus Distended bladder Inability to void

William Herring, M.D. Albert Einstein Medical Center Philadelphia, PA
2000
With Acknowledgement For Its Creation to Bernard J. Ostrum, M.D.
2000
What It Is
An approach For congenital or acquired heart disease in adults Asking systematic set of questions Answers based on certain fundamental observations Visible on frontal chest x-ray alone
Cardio-thoracic Ratio
One of the easiest observations to make is something you already know: the cardio-thoracic ratio which is the widest diameter of the heart compared to the widest internal diameter of the rib cage
<50%
Sometimes, CTR is more than 50%

But Heart is Normal
Extracardiac causes of cardiac enlargement

Portable AP films Obesity Pregnant Ascites Straight back syndrome Pectus excavatum
>50%
Here is a heart that is larger than 50% of the cardiothoracic ratio, but it is still a normal heart. This is because there is an extracardiac cause for the apparent cardiomegaly. On the lateral film, the arrows point to the inward displacement of the lower sternum in a pectus excavatum deformity.
Sometimes, CTR is less than 50%

But Heart is Abnormal
Obstruction to outflow of the ventricles

Ventricular hypertrophy
Must look at cardiac contours
<50%
Here is an example of a heart which is less than 50% of the CTR in which the heart is still abnormal. This is recognizable because there is an abnormal contour to the heart (yellow arrows).
The Cardiac Contours

Aortic knob Ascending Aorta Main pulmonary artery Indentation for LA Left ventricle
Double density of LA enlargement Right atrium
There are 7 contours to the heart in the frontal projection in this system.

But only the top five are really important in making a diagnosis.
Ascending Aorta
Low density, almost straight edge represents size of ascending aorta
Ascending Aorta
Small
Prominent
Double density of left atrial enlargement

Indentation where double density of left atrial enlargement will appear
Even though we are on the right side of the heart, we can see left atrial enlargement. Normally the left atrium sits right in the middle of the heart posteriorly and does not form a normal border on the frontal film.
Left atrium forms no border of normal heart in PA view
Left atrium sits in middle of heart posteriorly
LV RA LA
This inset from a CT scan of the chest shows how RA and LV obscure LA from forming a heart border on the frontal film.
When the LA enlarges, it will do something on the left side of the heart well talk about in a minute. And it may produce a double-density on the right side of the heart.
Double Density of left atrial enlargement
Two shadows, the yellow arrow pointing to the LA and the red arrow to the RA overlap each other where the indentation between the ascending aorta and right heart border meet
RA LA
The last bump on the right side is the right atrium. Since there is no disease in an adult that causes isolated enlargement of the RA, well consider the RA together with the RV later.
Right atrium not important contour in adults
Aortic Knob
The first bump on the left-side is the aortic arch. We can measure the knob from the lateral border of air in the trachea to the edge of the aortic knob.
Aortic knob should measure < 35mm
Aortic Knob
42mm
Enlarged with:
Increased pressure Increased flow Changes in aortic wall
Main Pulmonary Artery

Important
The next bump down is the main pulmonary artery and is the keystone of this system.
Finding the Main Pulmonary Artery
Finding the Main Pulmonary Artery
Adjacent to left pulmonary artery
We can measure the main pulmonary artery . . .
If we draw a tangent line from the apex of the left ventricle to the aortic knob (red line) and measure along a perpendicular to that tangent line (yellow line)
The distance between the tangent and the main pulmonary artery (between two small green arrows) falls in a range between 0 mm (touching the tangent line) to as much as 15 mm away from the tangent line
0 mm
Ao Ao
15 mm
LV LV
Main pulmonary artery ranges from 0 mm15mm from tangent line
Two Major Classifications

The main pulmonary artery (MPA) projects beyond the tangent line The main pulmonary artery is more than 15 mm away from the tangent line
Because the MPA is small or absent Because the tangent line is being pushed away from the MPA
Main pulmonary artery projects beyond tangent

Increased pressure Increased flow
Main pulmonary artery is more than 15 mm from tangent

Small pulmonary artery Truncus arteriosus Tetralogy of Fallot
27
Main pulmonary artery is more than 15 mm from tangent

Left ventricle and/or aortic knob push the tangent away Common
29
To recapitulate:
0 - 15 mm
Left atrial enlargement
Concavity where L atrium will appear on left side when enlarged
Left atrial enlargement
Straightening of the left heart border Left atrium may enlarge without producing double density
In the example on the right, not only is the left atrium enlarged, but the left atrial appendage is too. So there is a convexity outward where there is normally a concavity inward.
Main Pulmonary Artery Left Atrial Appendage
Left ventricle
Left Ventricle
Which Ventricle is Enlarged?
The best way to determine which ventricle is enlarged is to look at the corresponding outflow tract for each ventricle
If Heart Is Enlarged, And Main Pulmonary Artery is Big

>50%
Then Right Ventricle is Enlarged
If Heart Is Enlarged, And Aorta is Big Then Left Ventricle is Enlarged
>50%
Which ventricle is enlarged?

The best way to determine which ventricle is enlarged is to look at the corresponding outflow tract for each ventricle
Aorta for the LV MPA for the RV
Once one ventricle is enlarged, its impossible to tell if other ventricle is also enlarged


The Pulmonary Vasculature
Five States of the Pulmonary Vasculature

Normal Pulmonary venous hypertension Pulmonary arterial hypertension Increased flow Decreased flow
What Were Going to Evaluate
Right Descending Pulmonary Artery Distribution of flow in the lungs

Upper versus lower lobes Central versus peripheral
What to Evaluate
2 1 2 3
1. Right Descending Pulmonary Artery
Right Descending Pulmonary Artery
Serves right middle and lower lobes
1. Right Descending Pulmonary Artery

Diameter can be measured (before bifurcation)
RDPA < 17 mm
Normally, the right descending pulmonary artery should not be more than 17mm in diameter
2. Normal Distribution of Flow

Upper Versus Lower Lobes
In erect position, blood flow to bases > than flow to apices
Size of vessels at bases is normally > than size of vessels at apex
You cant measure size of vessels at the left base because the heart obscures them
3. Normal Distribution of Flow

Central versus peripheral
Central vessels give rise to progressively smaller peripheral branches
Normal tapering of vessels from central to peripheral
Normal Vasculature - review

2
Gradual tapering of vessels from central to peripheral
RDPA < 17 mm in diameter
3 2
Lower lobe vessels larger than upper lobe vessels
Venous Hypertension
RDPA usually > 17 mm
Upper lobe vessels equal to or larger than size of than size lower lobe vessels = Cephalization
Pulmonary Arterial Hypertension

Main Pulmonary Artery projects beyond tangent line
23
Pulmonary Arterial Hypertension

Rapid cutoff in size of peripheral vessels relative to size of central vessels Central vessels appear too large for size of peripheral vessels which come from them = Pruning
31
Increased Flow
All of blood vessels everywhere in lung are bigger than normal
Increased Flow
Distribution of flow is maintained as in normal Gradual tapering from central to peripheral Lower lobe vessels bigger than upper lobe
Normal
Increased Flow
Increased Flow
PAH
Decreased Flow
Unrecognizable most of the time
Small hila
Fewer than normal blood vessels
The Pulmonary Vasculature

Normal Pulmonary venous hypertension Pulmonary arterial hypertension Increased flow Decreased flow - mostly unrecognizable even when it is present
Normal
Mitral regurg Mitral Stenosis L Myxoma
If yes, then
If no, then
Increased
VSD, PDA
If yes, then Look at the Pulmonary Vasculature
Normal
Plum. stenosis ASD (VSD)
Increased
The ABCs
If no, then Pulmonary hypertension Normal If yes, then Don't Look at Pulmonary Vasculature. Look at Aorta Ascending dilated Whole Ao Dilated If no, then If yes, then
Idiopathic (1)
Cardiomyopathy
C Is the Main Pulmonary Artery Segment Concave?
Ao Stenosis Ao regurg HBP
Cardiomyopathy Pericardial Effusion Molt. valve dz
The System
Those were all of the answers Now here are the questions The system is successful only if you ask the questions in this order The answers are the fundamental observations you make on the frontal film alone
Is The Left Atrium Enlarged ?
To answer that question
Double density at site of normal indentation
Straight or convex at site of normal concavity
If Answer To Question A Is
YES
Look At Pulmonary Vasculature
If Answer To Question A Is Then...
NO
Is The Main Pulmonary Artery Big ?
To answer that question Main pulmonary artery projects beyond tangent line
If Answer To Question B Is
YES
Look At Pulmonary Vasculature
If Answer To Question B Is Then...
NO
Is The Main Pulmonary Artery Concave ?
To answer that question
25
Main pulmonary artery is > 15mm away from tangent line
If Answer To Question C Is
YES
Look At Configuration of Aorta
If Answer To Question C Is Then...
NO
Is The Heart a Dilated Or Delta-Shaped Heart ?
1. Pericardial effusion 2. Cardiomyopathy
Cardio-thoracic ratio > 65%
Normal
Mitral regurgitation Mitral Stenosis L Myxoma
If yes, then
If no, then
Increased
VSD, PDA
If yes, then Look at the Pulmonary Vasculature If no, then
Normal
Pulmonic stenosis ASD (VSD)
Increased
Idiopathic 2 to lung dz
Normal C Is the Main Pulmonary Artery Segment Concave? If yes, then Don't Look at Pulmonary Vasculature. Look at Aorta Ascending dilated Whole Aorta Dilated
Cardiomyopathy
Aortic Stenosis Aortic regurgitation HBP
If no, then
If yes, then
Cardiomyopathy Pericardial Effusion Multiple valve dz
Choose the link Test Yourself on the ABCs to see how the system works
For printed notes, choose the link under Cardiac Notes for The ABCs of Heart Disease
The End
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Congenital Heart Disease-Overview
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Differential Diagnosis Differential Diagnosis of CHD of CHD

In Slide Show mode, to advance slides, press spacebar
Decreased flow
Increased Flow

Whats left
Cyanotic
Ebsteins Anomaly
Cyanotic
Total anomalous venous return (TAPVR)
Acyanotic
Endocardial Cushion Defect
Acyanotic
CHF In Newborn
CHF In Newborn
Infantile coarctation Congenital aortic stenosis Hypoplastic Left Heart Syndrome Congenital mitral stenosis Cor triatriatum Obstruction to venous return from lungs
CHF In 2nd-3rd Week
Coarctation of the aorta Interruption of the aortic arch
CHF-later
Coarctation of the aorta adult type
Unknowns
31
Increased flow
1 Pulmonary Hypertension
Mitral Stenosis
26
PAH
17
Normal
Aortic Stenosis
Mitral Stenosis With Severe PAH

33
MS
Tetralogy of Fallot
Cyanotic
Tetralogy of Fallot
Components of
Ventricular septal defect Pulmonic stenosis Overriding aorta Right ventricular hypertrophy
ASD
Acyanotic
LA ASD PDA VSD
Ao
CHF

X-ray Findings
Thickening of the interlobular septa

Kerley B lines
Peribronchial cuffing
Wall is normally hairline thin
Thickening of the fissures

Fluid in the subpleural space in continuity with interlobular septa
Pleural effusions
Ventricular Septal Defect (VSD)
Atrial Septal Defect (ostium primum type) with PAH
35
MS with PAH
Pulmonic Stenosis
Most Commons
Most common cause of CHF in newborn
Hypoplastic left heart syndrome
Most common cause of CHF > 2 weeks

Coarctation of the aorta (infantile form)
Most common cyanotic heart disease

Tetralogy of Fallot
Most common dz associated c R arch

Tetralogy of Fallot
Most Commons
Most common L Most common L
R shunt R shunt dxd in adult
Dz most commonly associated c R arch

Truncus arteriosus
The End
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Learningradiology - Left-to-Right Shunts, ASD, VSD, PDA, TAPVR
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Left to Right Shunts

7 yo acyanotic female

Four Major Types
Ostium secundum Ostium primum Sinus venosus Posteroinferior

General
4:1 ratio of females to males Most frequent congenital heart lesion initially diagnosed in adult Frequently associated with Ellis-van Creveld and Holt-Oram syndromes Associated with prolapsing mitral valve

Ostium Secundum Type
Most common is ostium secundum (60%) located at fossa ovalis High association with prolapse of mitral valve
Normal
Right atrium open looking into left atrium through ASD
Frank Netter, MD Novartis

Ostium Primum Type
Ostium primum type usually part of endocardial cushion defect Frequently associated with cleft mitral and tricuspid valves Tends to act like VSD physiologically
Looking through ostium primum defect at cleft mitral valve
Proximity of ostium primum defect to tricuspid valve

Sinus Venosus Type
Sinus venosus type located high in inter-atrial septum 90% association of anomalous drainage of R upper pulmonary vein with SVC or right atrium
Partial anomalous pulmonary venous return
Right atrium open looking into left atrium through ASD

Posteroinferior Type
Most rare type Associated with absence of coronary sinus and left SVC emptying into LA

Pulmonary Hypertension
Rare in ostium secundum variety (<6%)

Low pressure shunt from LA RA
More common in ostium primum variety

Behaves physiologically like VSD
37 yo female with severe PAH 2 ostium primum type of ASD

X-Ray Findings
Enlarged pulmonary vessels Normal-sized left atrium Normal to small aorta

Complications
Large shunts associated with

Pulmonary infections and cardiac arrythmias
Higher incidence of pericardial disease with ASD than any other CHD Bacterial endocarditis is rare
Differentiating ASD, PDA and VSD
LA ASD PDA VSD
Ao

Why the Left Atrium Isnt Enlarged
RA
LA
RV
LV

General
Most common L
R shunt
Shunt is actually from left ventricle into pulmonary artery more than into right ventricle

Types
Membranous Supracristal Muscular AV canal

Membranous
Membranous = perimembranous VSD (75-80%most common) Location: Posterior and inferior to crista supraventricularis near right and posterior (=non-coronary) aortic valve cusps Associated with: small aneurysms of membranous septum
Right ventricle opened
Crista supraventrularis
Normal
Membranous VSD
Aneurysm of membranous septum
Normal

Supracristal
Supracristal = conal VSD (5%least common) Crista supraventricularis= inverted Ushaped muscular ridge posterior and inferior to the pulmonic valve high in interventricular septum On CXR: right aortic valve cusp may herniate aortic insufficiency
LV open
RV open

Muscular
Muscular VSD (510%) Low and anterior within trabeculations of muscular septum May consist of multiple VSDs = swisscheese septum
Swiss cheese

AV Canal
Atrioventricular canal = endocardial cushion type = posterior VSD (510%) Location: adjacent to septal and anterior leaflet of mitral valve Large VSD pulmonary hypertension, eventually shunt reversal
Eisenmengers physiology
Very large VSD
CHF soon after birth
Large posterior VSD (AV canal)

Natural History
Natural history of VSD is affected by two factors:
Location of defect Muscular and perimembranous have high incidence of spontaneous closure Endocardial cushion defects have low rate of closure

Natural History
Size of the defect

Larger the defect, more likely to CHF Smaller the defect, more likely to be asymptomatic

Eisenmenger Physiology
Progressive increase in pulmonary vascular resistance

Intimal and medial hyperplasia Reversal of L Cyanosis R shunt to R L shunt

Clinical Course
Neonates usually asymptomatic because of high pulmonary vascular resistance from birth to 6 weeks Common cause of CHF in infancy Bacterial endocarditis may develop Severe pulmonary hypertension Eisenmengers physiology/cyanosis

X-ray Findings
Prominent main pulmonary artery
Adult
Shunt vasculature (increased flow to the lungs) LA enlargement (80%) Aorta normal in size
5 yo acyanotic male

Why Left Atrium Is Enlarged
RA
LA
RV
LV
4 mos old acyanotic female

Prognosis
Spontaneous closure occurs in 40% during first 2 years of life 60% by 5 years

Indications For Surgery
Greater than 2:1 shunt, surgery required before pulmonary arterial hypertension develops CHF unresponsive to medical management Failure to grow Supracristal defects because of their high incidence of AI
Patent Ductus Arteriosus

General
Higher incidence in
Trisomy 21 Trisomy 18 Rubella Preemies
Predominance in females 4:1

Anatomy
Ductus connects pulmonary artery to descending aorta just distal to left subclavian artery
Ductus Arteriosus
Ductus Arteriosus
Physiology
In fetal life, shunts blood from pulmonary artery to aorta At birth, increase in arterial oxygen concentration constriction of ductus
Ductus Arteriosus
Normal Closure
Functional closure
By 24 hrs of life
Normal anatomic closure

Complete by 2 months in 90%
Closure at 1 year in 99%

Pathophysiology
Ductus may persist
Because of defect in muscular wall of ductus, or Chemical defect in response to oxygen
Anatomic persistence of ductus beyond 4 months is abnormal Blood is shunted from aorta to pulmonary arteries

Clinical
Common cause of CHF in premature infants

Usually at age 1 week (after HMD subsides and pulmonary arterial pressure falls)
Wide pulse pressure Continuous murmur

X-ray Findings
Cardiomegaly Enlarged left atrium Prominent main pulmonary artery (adult) Prominent peripheral pulmonary vasculature Prominence of ascending aorta

Why Left Atrium Is Enlarged
RA
LA
RV
LV

Calcifications
Punctate calcification at site of closed ductus is normal finding Linear or railroad track calcification at site of ductus may be seen in adults with PDA

Prognosis
Spontaneous closure may occur

Complications
CHF Failure to grow Pulmonary infections Bacterial endocarditis Eisenmengers physiology with advanced lesions
2 yo old cyanotic female
Partial or Total Anomalous Pulmonary Venous Return

* Also appears on DDx of Cyanosis with Inc Vascularity
Two Types
Partial (PAPVR)
Total (TAPVR)
Return of blood from lungs is by four pulmonary veins to LA RA LA
RV
LV
PA
Ao
Normal heart
PAPVR
General
Return of blood from lungs is mostly to LA One vein abnormally connected to right heart
RA
LA
RV
LV
PA
Ao
Frequently associated with sinus venosus or secundum ASD
Partial Anomalous Pulmonary Return
TAPVR
General
All have shunt through lungs to R side of heart All must also have R survival L shunt for
All are cyanotic Identical oxygenation in all four chambers
TAPVR
Types
TAPVR
Most common (52%) Pulmonary veins drain into vertical vein (behind left pulmonary artery) left brachiocephalic vein SVC DDx: VSD with large thymus
Left Brachiocephalic vein Left superior vena cava
Right superior vena cava
Vertical vein Right atrium Pulmonary veins

TAPVR-Supracardiac Type 1
TAPVRSupracardiac Type 1
TAPVR
Supracardiac Type 1X-ray Findings
TAPVR-Supracardiac Type 1
Blood moves through L brachiocephalic v to R SVC RA LA
Blood from lungs drains into left vertical vein to L SVC
RV ASD provides R L shunt to allow oxygenated blood to reach body (moderate cyanosis)
LV
Increased
PA
Ao
return to right heart overloads lungs shunt vessels
TAPVRType ISupracardiac type
Snowman Heart
TAPVRType ISupracardiac type
TAPVR
Cardiac TypeType II
Increased pulmonary vasculature Overload of RV CHF after birth
20% of Is and IIs survive to adulthood

Coronary sinus
TAPVR-Coronary Sinus-Type II
Blood returns from lung to RA or coronary sinus
RA
LA
RV ASD provides R L shunt to allow oxygenated blood to reach body (moderate cyanosis)
LV
Increased
PA
Ao
return to right heart overloads lungs shunt vessels
TAPVRType IICardiac Type
TAPVR
Percent of total: 12% Long pulmonary veins course down along esophagus Empty into IVC or portal vein (more common) Vein constricted by diaphragm as it passes through esophageal hiatus
Portal vein
Pulmonary veins
TAPVR-Type IIIInfradiaphragmatic
TAPVR
Infracardiac TypeContinued
Severe CHF (90%) 2 obstruction to venous return Cyanotic 2 right left shunt through ASD Associated with asplenia (80%), or polysplenia Prognosis=death within a few days
CHF vasculature
RA
LA
Blood returning from lungs pulmonary veins which are constricted by diaphragm CHF
RV ASD provides R L shunt to allow oxygenated blood to reach body (cyanotic)
LV
PA
Ao
To portal v
IVC
RA
TAPVRType IIIInfracardiac type
TAPVR
Mixed TypeType IV
Unknowns
ASD (primum) with PAH
VSD
ASD
The End
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LearningRadiology- Cyanotic Heart Disease
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Cyanotic Heart Disease

Tetralogy of Fallot Tetralogy of Fallot
Tetralogy of Fallot
General
About 10% of all congenital heart lesions Most common cause of cyanotic heart disease beyond neonatal period
Tetralogy of Fallot
Components
High VSD Pulmonic stenosis, i.e. right ventricular outflow obstruction
Usually infundibular, sometimes valvular
Overriding of the aorta Right ventricular hypertrophy
1 2 3 4
Tetralogy of Fallot
Tetralogy of Fallot
Other anomalies
Right aortic arch in 25%
Mirror image type
Left superior vena cava ASD Tricuspid valve abnormalities Anomalies of coronary arteries
Aberrant left anterior descending coronary artery arising from right coronary artery
Tetralogy of Fallot
Other anomalies
Abnormalities of the pulmonary artery and its branches

Peripheral PA coarctations, unilateral Absence or hypoplasia of pulmonary artery
Usually left
Absence of pulmonic valve Bicuspid pulmonic valve
Tetralogy of Fallot
Critical Component
Degree of pulmonic stenosis

Regulates degree of R L shunt Regulates overriding of aorta
Greater the stenosis, the greater the aortic overriding
Tetralogy of Fallot
Clinical findings
Squatting Dyspnea Failure to thrive Cyanosis-usually Severe cases at birth severe PS Mild cases much later mild PS Pink tets (acyanotic) and Blue tets (cyanotic)
Tetralogy of Fallot
Imaging Findings
Heart size normal
Rarely enlarged
Cardiac apex displaced upward coer en sabot PA segment concave Decreased vasculature R aortic arch in 25%
Tetralogy of Fallot
Tetralogy of Fallot
Tetralogy of Fallot
Trilogy of Fallot
Pulmonic valvular stenosis ASD Right ventricular hypertrophy
Truncus Truncus Arteriosus Arteriosus
Truncus Arteriosus
Embryology
Uncommon anomaly 2 failure of primitive common truncus arteriosus to divide into aorta and pulmonary artery
Truncus Arteriosus
General
The truncal valve is usually tricuspid Main pulmonary artery segment is concave in types II, III, and IV Pulmonary vasculature is shunt type in types I, II and III
Truncus Arteriosus
Right sided aortic arch
Right-sided arch in about 33%

Usually mirror image type
But because truncus is so rare, it accounts for only 6% of all right arches
Truncus Arteriosus
Triad
Right aortic arch
Increased flow
Cyanosis
Truncus Arteriosus
Associations
VSD
Always
Anomalies of the coronary arteries
Truncus Arteriosus
Clinical Findings
Infants and small children demonstrate L R shunt

Minimal cyanosis CHF Respiratory infections Growth disturbances
Majority are dead by 6 mos
Truncus Arteriosus
Clinical Findings
Cyanosis is worse in II and III

Cant tell them apart clinically
Associated anomalies
Bony Renal Lung Cleft palate
Truncus Arteriosus
X-ray Findings
Cardiomegaly Right aortic arch (33%) Concave pulmonary artery segment Enlarged left atrium in 50% Displacement of hilum
Elevated right hilum in 20% Left hilum in 10%
Most common (75%)

Shunt vessels Ao PA arises on left via short common stem
Truncus-Type I
Convex pulmonary artery segment
Ao LPA Truncus
Ao
LV
Right Ao Arch
LPA
Truncus Type 1
Truncus Type 1
Uncommon (25%)
Pulmonary arteries arise posteriorly from aorta
Shunt vessels
Concave main pulmonary artery
Truncus-Type II
Truncus Type II
Right and left pulmonary arteries arise laterally
Rare (5%)
Shunt vessels
Truncus-Type III
Truncus Type III
Rare to non-existent
No pulmonary arteries Bronchial circulation
TOF with pulmonary atresia
Truncus-Type IV
Truncus-Type IV (TOF with pulmonary atresia)
Bronchial Circulation
Increased flow
II
III
IV
Truncus Arteriosus
Pulmonary artery Shunt vessels
Yes
I II III IV
Convex
Concave
Yes
Concave
Yes Bronchial circulation
Concave
Truncus Arteriosus
Angiographic Findings
On angiogram, truncal valve (common valve) may have 2-6 cusps
Most often tricuspid
In lateral projection, plane of truncal valve is distinctive

Tilts anteriorly toward patients toes
Helpful to distinguish truncus from aorticopulmonary window or TOF with pulmonic atresia
Tricuspid Tricuspid Atresia Atresia
Tricuspid Atresia
Fusion of dorsal and ventral endocardial cushions occurs too far to the right obliteration of tricuspid valve, and Hypoplasia of right heart
Tricuspid valve, Right ventricle and pulmonary artery
Tricuspid Atresia
Shunts needed
Complete obstruction to outflow from RA
Need R L shunt: Patent foramen ovale or ASD Small ASD elevated RA pressures and enlarged RA Large ASD lower RA pressures and minimal enlargement of RA
Blood in L heart must get back to lungs

Also have associated VSD or PDA
Tricuspid Atresia
Transposition of Great Vessels
70% have normal relationships of great vessels 30% have transposition of great arteries
Tricuspid Atresia
Two main types
No Transposition of the Great Arteries

Some degree of PS
Majority (70%)
Transposition of the Great Arteries

No pulmonic stenosis
Minority (30%)
Tricuspid atresiano transposition

Systemic blood can not enter RV
Need R L shunt through patent foramen ovale
Blood returns to right heart and then lungs either through VSD or PDA
Some unsaturated blood exits aorta
Tricuspid atresiano transposition
Systemic blood can not enter RV
Need R L shunt through patent foramen ovale
Oxygenated blood returns to LA
Need L R shunt to get blood into body

Ao PA
Unoxygenated blood flows to lung via transposed PA flow
Tricuspid atresiawith transposition
Tricuspid atresia
X-ray Findings - No transposition
Normal-sized heart Decreased pulmonary vessels (60-70%) Flat/concave pulmonary artery Small ASD Large ASD RA enlarged RA normal or slightly enlarged
Tricuspid atresiasome PS, no transposition
Tricuspid atresia
X-ray Findings - Transposition
Mild cardiomegaly Engorged pulmonary vessels No characteristic appearance to heart
Tricuspid atresiano PS, shunt vessels
Transposition of The Great Vessels
Cyanosis with or vasculature

Tricuspid atresia Transposition Truncus arteriosus
Type I, II, III Type IV
The TR Lesions
or or

Tetralogy TAPVR TrEbsteins
The Rules
Since anatomic side (i.e. left or right) in complex lesions is frequently reversed or indeterminate Naming conventions for
Atria AV valves Ventricles Ventricular outflow tracts
The Rules
How the atria are named
Anatomic right atrium is on the side of the trilobed lung and liver
Trilobed lung=upper, middle and lower
The anatomic left atrium is on the side of the bilobed lung and spleen
Bilobed lung=upper and lower
The Rules
Mitral and tricuspid valves
The tricuspid valve belongs to the anatomic right ventricle

Not right atrium
The mitral valve belongs to the anatomic left ventricle

Not left atrium
The Rules
How the ventricles are named
The anatomic right ventricle is the trabeculated ventricle The anatomic left ventricle is the smooth-walled ventricle
The Rules
Aortic and pulmonic valves
The pulmonic valve is part of pulmonary artery
Not anatomic right ventricle
The aortic valve is part of aorta

Not anatomic left ventricle
The pulmonic infundibulum is part of anatomic right ventricle
Anatomic Right ventricle is trabeculated
Anatomic Left ventricle is smooth
Normal heart
Pulmonic infundibulum always stays with the anatomic R ventricle
Normal relationship of aortic to pulmonic valves

Pulmonic valve is Anterior Lateral Superior To the aortic valve
PALS
In Transposition, pulmonic valve is
Posterior Medial Inferior To the aortic valve
Normal
Corrected Transposition
Inversion of the Ventricles With Transposition Physiologically flow is normal Consistent with normal life, except Frequently associated with
VSD Tricuspid insufficiency Subpulmonic stenosis Complete heart block
Normal vasculature; or increased with VSD

PA arises from anatomic left ventricle
Acyanotic
Aorta arises from pulmonic infundibulum
Corrected Transposition (L-Trans) Inversion of the Ventricles with Transposition of the Great Vessels

General
Second most common cause of cyanosis in infancy Pulmonary and systemic circulations form two separate circuits Must be mixing between two circuits for life

Associated abnormalities
About 1/3 have VSD

Larger the shunt, more likely CHF
About to have patent ductus Some have ASD Other major finding is obstruction to blood entering pulmonary artery
Usually subpulmonic stenosis
Obligatory shunt since there are 2 separate circulations
ASD
Cyanotic with increased vasculature
VSD
Aorta arises from pulmonic infundibulum
PA arises from anatomic left ventricle
PDA
Transposition of the Great Vessels (D-Trans)

X-ray findings
Mild cardiomegaly Concave pulmonary artery segment Narrow mediastinum (Egg-on-string) Shunt vessels
Depends on size of shunt and degree of PS
Transposition of the Great Vessels Cyanotic with - vasculature
Transposition of the Great Vessels RVgram
Transposition of the Great Vessels LVgram
Narrow waist in Transposition
LVgram with VSD but normal Ao and PA relationships
Corrected Transposition With VSD
Cyanotic
Inversion of the Ventricles Without Transposition
Ebsteins Anomaly Ebsteins Anomaly
Ebsteins Anomaly
General
Rare Posterior and septal cusps of tricuspid valve displaced in to right ventricle
Right ventricle smaller or atrialized
Tricuspid insufficiency right atrial pressure a R L shunt through foramen ovale (or ASD)
Cyanosis is present in neonate
Ebsteins Anomaly
Normal
Ebsteins Anomaly
Ebsteins Anomaly
X-ray Findings
Cardiomegaly
One of few conditions first few days of life cardiomegaly
Unusual prominence to right heart border Pulmonary flow is decreased
Ebsteins Anomaly
Ebsteins Anomaly
Ebsteins Anomaly
Triad
Marked Cardiomegaly
Decreased flow
Cyanosis
Single Ventricle Single Ventricle
Single Ventricle
Surprise!
There are usually two ventricles in this disease
Single ventricle: one ventricle with two atria Three types of Single Ventricle
Morphologic LV with a rudimentary RV (common) Morphologic RV with a rudimentary LV (rare) Morphologically indeterminate ventricle (rare)
Single Ventricle
Most common
Morphologic LV with rudimentary RV
Also called
Double-inlet left ventricle Common ventricle Univentricular heart
Frequently difficult to determine which anatomic ventricle is present
Single Ventricle
Associated Findings
Pulmonic stenosis
Valvular or subvalvular (66%)
Pulmonary atresia PAPVR PDA
Single Ventricle
Imaging Findings
No characteristic appearance Concave pulmonary artery segment Shunt vessels
Single ventricle
The End
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LearningRadiology-Obstrictive Cardiac Lesions, CHF, Infancy
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Obstructive Lesions
All photos retain the rights of their original owners
Lesions That Cause CHF
CHF In Newborn
Causes of CHF in the Newborn
Coarctation of the Aorta Obstruction to venous return from lungs Cor Triatriatum
Congenital Aortic Stenosis
Congenital Mitral Stenosis
Netter
Hypoplastic Left Heart
Diagnosing CHF in a Newborn

Usually have cardiomegaly Ill-defined bronchovascular bundles Flattening of diaphragm
Air hunger
Rare
Kerley B lines Pleural effusions
Commonest Cause of CHF

In Chronologic Sequence
< 24 hrs..Intrauterine arrythmia First week. Hypoplastic Left Heart Syndrome 2-6 weeks.. Infantile coarctation 1-4 months Large L R shunts
VSD, ASD, PDA, AV Canal
Coarctation Of the Aorta

Netter

General
2X more common in males Common classification

Infantile or preductal form Adult or juxtaductal form
Relationship of ductus to coarct affects clinical picture

Coarctation Proximal to Ductus
Flow is frequently from PA to Ao through Ductus Cyanosis in lower half of body as
Unoxygenated blood from PA feeds lower extremities
Oxygenated blood from LV goes to major vessels of head and neck

Not cyanotic

Coarctation Distal to Ductus
Flow is initially from Ao to PA (L R shunt) If there is Eisenmengers physiology, the flow reverses and goes from PA Ao (R L shunt) Cyanosis More common form

Other Classifications
More complicated classifications take following into account

Location and length of coarct Patency of ductus arteriosis Relationship of coarct to ductus

Adult Form
Adult or juxtaductal (postductal) form is more common than infantile Usually localized Area of coarctation just beyond origin of LSCA at level of ductus
R Brachiocephalic
L CCA
L SCA
Ductus
Netter

Infantile Form
Infantile, preductal form = diffuse type Long, tubular segment of narrowed aorta
From just distal to brachiocephalic artery to level of ductus
Intracardiac defects (VSD, ASD, deformed mitral valve) present in 50% of diffuse type
Also patent ductus arteriosis
BCA
LCCA
LSCA
Ductus
Netter

Associated Defects
Bicuspid aortic valve (most common associated defect seen in 50%) VSD ASD Transposition 25% of patients with Turners Syndrome have coarctation of aorta

Shone Syndrome
Coarctation of aorta Aortic stenosis Parachute mitral valve Supravalvular mitral ring
X-Ray Findings
Rib Notching
Single best sign Older the person, more likely to have rib notching (uncommon <6 yrs) Majority with coarcts display it >20 years of age Rib notching occurs in high pressure circuit

To supply aorta distal to ductus, flow in the 3rd-8th intercostals reverses Blood flows from subclavian internal mammary intercostals aorta
First two intercostals arise from costocervical trunk and do not serve aorta
Netter
X-Ray Findings
Rib Notching
Most often involves 4th-8th rib
Sometimes may involve 3rd and 9th
Does not involve 1st and 2nd ribs

Intercostals come off costocervical trunk and do not supply collateral flow to descending aorta
4th-8th do anastomose with internal mammary to form collaterals for descending aorta
Rib Notching in Coarctation

Regresses after coarct is repaired
Costovertebral junction
X-Ray Findings
Rib NotchingUnilateral
Rib notching occurs in the high pressure circuit
X-Ray Findings
Unilateral Right Rib Notching
LCA LSCA BCA
Notching occurs in the high pressure circuit
High Pressure Circuit Ductus
Isolated right-sided rib notching Coarct originates between the LCCA and the LSCA
Netter
X-Ray Findings
Unilateral Left Rib Notching
Notching occurs in the high pressure circuit
High Pressure Circuit
Isolated left- sided rib notching Anomalous RSCA originates distal to site of coarct
X-Ray Findings
Figure 3 Sign
Caused by (in order)
Dilated LSCA or aortic knob Tuck of coarct itself Poststenotic dilatation
Occurs in 1/31/2 of patients with coarct

Not in children
Matched by reverse 3 or E on barium-filled esophagus
Netter
Reverse 3 sign on barium filled esophagus
Figure 3 sign caused by coarctation
X-Ray Findings
Continued
Convexity of left side of mediastinum just above aortic knob 2 to
Dilated aorta proximal to coarct, or Dilated LSCA
May be congenital or may be 2 to pressure
Convexity of ascending aorta in 1/3

May be normal or small in others
Ascending Ao may be dilated, normal or small
Convexity above aortic knob due to dilated LSCA or Aorta proximal to coarct

Clinical FindingsInfancy
Severe CHF most common from 2nd to 6th week of life Weak or absent leg pulses Lower BP in the legs than in the arms EKG: RV hypertrophy because RV assumes most of the cardiac output during fetal life in these patients

Echocardiographic Findings
In infants, 2D echo can demonstrate coarcts from suprasternal notch Echo helpful in excluding associated hypoplastic left heart syndrome

MRI and Angiography
MRI preferred study in children/adults Aortography offers greatest resolution
Amersham
Contrast enhanced MRA shows long segment coarctation of the aorta
BCA
AO
Coarct
Amersham
Oblique sagittal spin-echo-Coarctation of the Aorta
Amersham
Axial spin-echo MRI-Coarctation of the Aorta

Complications
Heart failure in neonate Subarachnoid bleeds 2 ruptured Berry aneurysms Dissection of aorta Bacterial endocarditis Mycotic aneurysm
Pseudocoarctation
Buckling of aorta resembles true coarctation No pressure gradient (<30mmHg) Figure 3 sign present No rib notching

Netter

Valvular-General
Bicuspid aortic valve is most common congenital cardiac anomaly (2%) Usually not stenotic in infancy Becomes stenotic when fibrosis and calcification occur About half of those with coarctation have bicuspid Ao valve

Angiography
Domed and thickened leaflets in systole Two leaflets and two sinuses of Valsalva
Congenital Aortic Stenosis (10 yo)
Ao
Signal void
Ao valve
LV
Amersham
Aortic Stenosis Coronal cine MRI image demonstrates a systolic signal void originating at the stenotic aortic valve. Ascending aorta is dilated
Hypoplastic Left Heart Syndrome

Aortic Atresia
Netter

General
Most common cause of death from cardiac cause during first week of life Common clinical expression of this lesion is CHF in first week of life
Usually cyanotic
Heart is enlarged in most

General
Small ascending aorta
Common to all forms Sometimes infantile coarctation
Often associated mitral stenosis or atresia or aortic stenosis or atresia In 90%, size of LA and LV small A large PDA is essential
VSD, ASD also present
RA, RV and PA are enlarged Oxygenated and deoxygenated blood enter PA
Passes to RA via ASD (L R shunt)
Oxygenated blood returning from lungs can not enter LV
Blood passes through PA lungs and into large PDA aorta to body
PDA
Obstruction to return of blood from lungs CHF
Cyanotic

Pathophysiology
Since outflow tract from L heart is small, aerated blood always shunted Large PDA needed to get aerated blood to body Blood to head, arms and coronaries flows through PDA, then backwards through arch
Need L R shunt through ASD to get blood out of LA
Some blood passes through large PDA to aorta and out to body Some deoxygenated blood goes to lungs Blood returning from lungs can not exit LA to LV because of atretic mitral valve
Blood returning from body mixes with oxygenated blood from LA; passes into PA

Atretic aorta

Associated Anomalies
Coarctation of the aorta Interruption of the aortic arch AV communis Anomalies of the R subclavian artery Bicuspid aortic valve

X-ray Findings
Increased load on RV cardiomegaly at birth
marked
Obstruction to return of blood from lungs CHF at birth

Most common cause of CHF in first two weeks of life
MPA RA Ao
LA
Amersham
Hypoplastic Left heart Syndrome

Gated spin echo at base of heart shows hypoplastic aorta (arrow) posterior and right of main pulmonary artery

Diagnosis
Diagnosis can be made by echo Catheterization may be hazardous

Spasm of PDA during cath can death

Triad
Cardiomegaly
CHF in 1st week of life
Cyanosis

Netter
Exists as isolated abnormality 25% of time Coexists with VSD 30% of time Coexists with another form of left ventricular outflow obstruction 40% of timeSHONES Syndrome
Shones Syndrome
Parachute mitral valve Supravalvular mitral ring Subaortic stenosis Coarctation of aorta
LV
RA
Signal void
LA
Amersham
Cine MR image in axial plane demonstrates a diastolic signal void emanating from the mitral valve indicative of mitral stenosis
Cor Triatriatum
Netter
Cor Triatriatum
General
Rare congenital anomaly Fibromuscular septum with single, large, opening separates embryonic common pulmonary vein from left atrium
Cor Triatriatum
Anatomy
Proximal, accessory chamber lies posteriorly and receives pulmonic veins Distal, true atrial chamber lies anteriorly, emptying into left ventricle through mitral valve
Cor Triatriatum
Distal, true atrial chamber lies anteriorly and contains mitral valve
Netter
Proximal accessory chamber lies posterior and receives pulmonary veins
Cor Triatriatum
Associations
ASD PDA Anomalous pulmonary venous drainage Left SVC VSD Tetralogy of Fallot
Cor Triatriatum
Clinical
Clinically similar to mitral stenosis Dyspnea Heart failure Failure to thrive
Cor Triatriatum
X-ray Findings
Pulmonary edema Enlarged LA
Cor Triatriatum
Cor Triatriatum - angiography
Netter
Ao RVOT RA Ao LA LA RV LA LA MPA
Amersham
Cor Triatriatum
Cor Triatriatum
Treatment
Surgical excision of obstructing membrane
Cor Triatriatum
Prognosis
Usually fatal in first 2 years of life

Associated abnormalities
Obstruction Of the Venous Return from the Lungs

TAPVR from below Diaphragm
Netter
TAPVR
Percent of total: 12% Long pulmonary veins course down along esophagus Empty into IVC or portal vein (more common) Vein constricted by diaphragm as it passes through esophageal hiatus
Obligatory R L shunt to carry oxygenated blood to body
Blood returning from lungs pulmonary veins which are constricted by diaphragm CHF
Oxygenated blood returns to RA
Pulmonary veins empty into portal vein or IVC
TAPVR-Type III-Infradiaphragmatic
Portal vein
Pulmonary veins
Netter
TAPVR-Type IIIInfradiaphragmatic
Causes of CHF in the Newborn
Coarctation of the Aorta Obstruction to venous return from lungs Cor Triatriatum
Netter
Hypoplastic Left Heart
The End
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LearningRadiolgy.comn- Valvular Lesions of the Heart,pulmonic,tricuspid,mitral,aortic,stenosis,regurgitation,insufficiency
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Valvular Lesions of the Heart

In Slide Show mode, to advance slides, press spacebar
Mitral Stenosis Mitral Stenosis

Left Atrial Left Atrial Outflow Obstruction Outflow Obstruction
Mitral Stenosis
Rheumatic Valvular Heart Disease
Rheumatic heart disease causes mitral stenosis in 99.8% of cases
Acute Rheumatic Valvulitis

Pathophysiology
Multiple episodes of Acute Rheumatic Fever (ARF) first pancarditis
Acute Rheumatic Valvulitis

Pathophysiology
Acute phase subsides
Fibrosis alters leaflet and cusp structure Results in leaflet or cuspal thickening along valvular margins of closure
Valves affected
Most often mitral valve alone Then most often mitral and aortic together Lastly aortic alone
Normal mitral valve
Fusion of chordae
Stenotic mitral valve
Thickening of cusps
Chronic Mitral Stenosis

Pathophysiology
Mitral orifice becomes smaller

Two circulatory changes
To maintain LV filling across narrowed valve, left atrial pressure Blood flow across mitral valve is which cardiac output to
Effects of Mitral Stenosis
On heart On lungs On right ventricle
Effect of Mitral Stenosis

On Heart
Left atrium hypertrophies and dilates 2 pressure

Atrial fibrillation and mural thrombosis follow
Left ventricle is protected by stenotic mitral valve

LV usually normal in size and contour

On Heart
Pulmonary arterial pressure
Intimal and medial hypertrophy of pulmonary arteries pulmonary vascular resistance
Right ventricle dilates from pressure overload

Main pulmonary artery dilates valve regurgitation pulmonary

On Heart
Tricuspid regurgitation develops

2 dilated RV
Right atrium dilates 2 volume overload

Right heart failure
Time course of MS in adult

Mitral stenosis occurs Left atrial pressure Left atrium enlarges Cephalization PIE PAH develops PVR increases RV enlarges Pulmonic regurg develops Tricuspid annulus dilates Tricuspid insufficiency RV failure

On Lungs
Pulmonary arterial hypertension develops

First passively
Then 2 muscular hypertrophy and hyperplasia increased pulmonary vascular resistance

On Lungs
Chronic edema of alveolar walls fibrosis

Pulmonary hemosiderin deposited in lungs Pulmonary ossification may occur
Effect of Mitral Stenosis on Lungs

Normal chamber pressures
M 1-5
RA
LA
M 5-10
D 1-7 S 17-32 M 15
RV
LV
D 5-12 S 90-140

On Lungs
pulmonary venous and capillary pressure
Normal Cephalization Kerley B Lines Pulmonary Interstitial Edema Pulmonary Alveolar Edema 5-10 mm Hg 10-15 mm 15-20 20-25 > 25

On Right Ventricle
RV hypertrophies in response to increased afterload Eventually RV fails and dilates

Causes dilation of tricuspid annulus regurgitation tricuspid
X-Ray Findings of MS
Cardiac Findings
Usually normal or slightly enlarged heart
Enlarged atria do not produce cardiac enlargement; only enlarged ventricles
Straightening of left heart border Or, convexity along left heart border 2 to enlarged atrial appendage
Only in rheumatic heart disease
Straightening of left heart border
Mitral Stenosis
Convexity from enlarged left atrial appendage
Mitral Stenosis
Mitral Stenosis
Cardiac Findings
Small aortic knob from decreased cardiac output Double density of left atrial enlargement Rarely, right atrial enlargement from tricuspid insufficiency
LA
RA
Small aorta from cardiac output
Double density
Enlarged L atrial appendage from mitral stenosis Right atrial enlargement from tricuspid regurgitation
Mitral stenosis/regurgitation with tricuspid regurgitation
Calcifications
Calcification of valve--not annulus-seen best on lateral film and at angio Rarely, calcification of left atrial wall 2 fibrosis from long-standing disease Rarely, calcification of pulmonary arteries from PAH
Ao
Mitral
Calcification of mitral valve
Calcification of pulmonary artery Calcification of left atrial wall
Pulmonary Findings
Cephalization Elevation of left mainstem bronchus (especially if 90 to trachea) Enlargement of main pulmonary artery 2 pulmonary arterial hypertension
Severe, chronic disease
Multiple small hemorrhages in lung

Pulmonary hemosiderosis
Upper lobe vessels equal to or larger than size of lower lobe vessels = Cephalization
Enlarged MPA segment from severe pulmonary arterial hypertension
Straightening of left heart border from LA
Mitral Stenosis with severe PAH
Mitral Valve Calcification
Presence indicates MS Calcium usually deposited in clumps on valve leaflets Heavier calcific deposits in men than women
Mitral Annulus Calcification

Calcification of mitral annulus does not signify presence of mitral valve disease
Occurs in older women Usually asymptomatic Rarely Mitral Stenosis
Mitral Stenosis
Other Causes
MS 2 rheumatic disease 99.8% of cases Congenital mitral stenosis Infective endocarditis Carcinoid syndrome Fabrays Disease Hurlers syndrome Whipples Disease Left atrial myxoma
Exists as isolated abnormality 25% of time Coexists with VSD 30% of time Coexists with another form of left ventricular outflow obstruction 40% of time SHONES Syndrome
Shones Syndrome
Parachute mitral valve Supravalvular mitral ring Subaortic stenosis Coarctation of aorta
LA Myxoma
Most common form of primary cardiac tumor 86% of myxomas found in left atrium 90% of myxomas are solitary Usually occur around fossa ovalis
MS and MR
Rheumatic mitral stenosis occurs with varying degrees of mitral regurgitation When MS is severe, MR is relatively unimportant
Mitral Mitral Regurgitation Regurgitation
Mitral Regurgitation
Causes
Thickening of valve leaflets 2 rheumatic disease Rupture of the chordae
Posterior leaflet more often-Trauma, Marfans
Papillary muscle rupture or dysfunction

Acute myocardial infarction
LV enlargement LV aneurysm
dilatation of mitral annulus valvular dysfunction
Any cause of LV enlargement Acute myocardial infarction
General
The acute lesion of rheumatic fever is mitral regurgitation, not stenosis The largest left atria ever are produced by mitral regurgitation, not mitral stenosis
X-ray Findings
In acute MR
Pulmonary edema Heart is not enlarged
In chronic MR
LA and LV are markedly enlarged
Volume overload
Pulmonary vasculature is usually normal

LA volume but not pressure is elevated
Mitral regurgitation
Difference in heart size MS and MR
Mitral Stenosis
Aortic Stenosis
Aortic Stenosis
Frequency of Causes
Most often as result of degeneration of bicuspid aortic valve Less commonly, 2 to degeneration of tricuspid aortic valve in person > 65 Even less commonly, 2 rheumatic heart disease in tricuspid valve
Aortic Stenosis
Locations
Supravalvular Valvular Subvalvular
Valvular Aortic Stenosis Congenital
Congenital Valvular Aortic Stenosis

General
Bicuspid aortic valve is the most common congenital cardiac anomaly
0.5 2%
Usually not stenotic during infancy More prone to fibrosis and calcification than normal valve

Associations
Many malformations of aorta and/or LV are associated with bicuspid valve

50% with coarctation of aorta Hypoplastic left heart syndrome Interruption of aortic arch

Calcification
Bicuspid valves are most apt to calcify Calcification begins earlier (4th decade) than in degenerated tricuspid Ao valve (>65)
Early calcification can also occur with Rheumatic heart dz
Calcification of Aortic Valve

Angiographic findings
A non-calcified, bicuspid valve reveals thickening and doming of valve leaflets in systole A jet of non-opacified blood is visible through stenotic bicuspid valve
Does not occur with acquired AS
Unopacified jet stream through a bicuspid aortic valve Leaflets are domed on systole
Acquired aortic stenosis would not demonstrate this jet stream because severe deformity of valve turbulent flow

Congenitally bicuspid valves usually have 2 aortic sinuses
3 sinuses in acquired AS
In rheumatic disease, aortic valve commissures usually fuse

Dont fuse in degenerated tricuspid valve
Valvular Aortic Stenosis Acquired
Acquired Valvular Aortic Stenosis

Causes
Fusion, thickening or calcification of a tricuspid valve

Degenerative process Rheumatic heart disease
Valvular Aortic Stenosis

Differentiating Features
Etiology/Findings
Calcification
Other clues
Congenital Bicuspid Valve
30s
Jet effect on aortogram
Degeneration of Tricuspid Valve
> 65
Coronary artery ca++ Commissures dont fuse MS or MR almost always present; commissures fuse
Rheumatic dz in Tricuspid Valve
30s here; teens in 3rd world countries
Aortic Stenosis
X-Ray Findings
Depends on age patient/severity of disease
In infants, AS CHF/pulmonary edema
In adults
Normal heart size
Until cardiac muscle decompensates
Enlarged ascending aorta 2 post-stenotic dilatation 2 turbulent flow Normal pulmonary vasculature
Prominence of ascending aorta from post-stenotic dilatation
Aortic stenosis
Post-stenotic Dilatation of Aorta

From turbulent flow just distal to any hemodynamically significant arterial stenosis
Jet effect also plays role
Occurs mostly with valvular aortic stenosis

May occur at any age
Aortic stenosis
Aortic Stenosis
Calcification of Valve
In females, usually indicates hemodynamically significant AS Calcification of valve usually indicates gradient across valve of > 50mm Hg
Subvalvular Aortic Stenosis
Subvalvular Aortic Stenosis

Subaortic Stenosis
Associated with
Subaortic fibrous membrane Hypoplastic left heart syndrome Idiopathic Hypertrophic Subaortic Stenosis
Aortic valve
Subaortic Fibrous Membrane

About 15% of patients with congenital obstruction to LVOF Membrane just below aortic valve May attach to anterior leaflet of mitral valve
Mitral regurg Aortic regurg
Ao
Supravalvular Aortic Stenosis

General
Uncommon Types
Hourglass Membrane Hypoplasia of entire ascending aorta
Associated lesions in 2/3

Williams syndrome

Williams syndrome Supravalvular aortic stenosis Hypercalcemia Elfin facies Pulmonary stenoses Hypoplasia of aorta Stenoses in
Renals, celiac, SMA
Aortic Stenosis
Clinical Triad
Chest pain
SOB
Syncope
Aortic Regurgitation
(Aortic Insufficiency)
Causes
Rheumatic heart disease Marfans Luetic aortitis Ehlers-Danlos syndrome Endocarditis Aortic dissection
Rheumatic Heart Disease
Thickened cusps May have commissural fusion
In degenerative Ao regurg, no commissural fusion
Regurgitant jet is usually central

In degenerative, usually not discrete jet
Imaging Findings
X-ray hallmarks are
Left ventricular enlargement Enlargement of entire aorta
Cine MRI (gradient refocused MRI)

White blood technique Signal loss coming from Ao valve into LV during diastole
Color Doppler is also diagnostic
Enlargement of entire aorta Enlarged left ventricle
Pulmonic Stenosis
Pulmonic Stenosis
General
Without VSD = 8% of all CHD Mostly asymptomatic When symptomatic

Cyanosis and heart failure Cor pulmonale
Loud systolic ejection murmur
Pulmonic Stenosis
Types
Subvalvular Valvular Supravalvular
Pulmonic Stenosis
Valvular Pulmonic Stenosis
Classic pulmonic stenosis (95%)

Congenital in origin Associated with metastatic carcinoid syndrome
Tricuspid valve dz as well
Associated with Noonan Syndrome

ASD Hypertrophic cardiomyopathy
Pulmonic Stenosis
Valvular Pulmonic Stenosis
Morphology of abnormal valve

Membrane with central opening, or Fusion of pulmonary cusps
Pulmonic Stenosis
Valvular pulmonic stenosis
Presents in childhood Pulmonic click Dome-shaped pulmonic valve in systole RX: Balloon valvulo-plasty
Pulmonic Stenosis
X-ray Findings Enlarged main pulmonary artery Enlarged left pulmonary artery (jet effect) Normal to decreased peripheral pulmonary vasculature Rare calcification of pulmonary valve in older adults
Prominent main pulmonary artery segment
Normalsized heart
Enlargement of left pulmonary artery
Pulmonic Stenosis
Pulmonic Stenosis
Subvalvular pulmonic stenosis Infundibular pulmonic stenosis
Typically in Tetralogy of Fallot
50% of pts with TOF also have bicuspid pulmonic valves 50% of patients with TOF also have valvular pulmonic stenosis
Subinfundibular pulmonic stenosis

Associated with VSD (85%)
Concave pulmonary artery segment
Tetralogy of Fallot with subvalvular pulmonic stenosis
Trilogy of Fallot
Severe pulmonic valvular stenosis RV hypertrophy ASD with R L shunt
Supravalvular Pulmonic Stenosis

General
May be either tubular hypoplasia or localized with poststenotic dilatation

Associated CV abnormalities
Valvular pulmonary stenosis Supravalvular aortic stenosis VSD, PDA Systemic arterial stenoses

Associated Syndromes
Williams Syndrome
Pulmonic Stenosis Supravalvular AS Peculiar facies
Post-rubella syndrome Carcinoid syndrome with liver mets Ehlers-Danlos syndrome
The End
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LearningRadiology - Diseases of the Great Vessels
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WilliamHerring,M.D.2003
Diseasesofthe GreatVessels
InSlideShowmode,toadvanceslides,pressspacebar
Allillustrationsretaintheiroriginalcopyrights
AorticAnomalies
General
l
Mostareasymptomatic
n
Unlesstheycause encirclingvascularring likepulmonarysling
Canbecomplex lesionsrequiring multipleprojections

n
MRIorCT
FrankNetter,MDNovartis
AberrantSubclavianArteries
General
Leftarchwithaberrantrightsubclavian
Usuallypassesposteriortoesophagus n DilatedoriginisDiverticulumofKommerell
n
Rightarchwithaberrantleftsubclavian
Mostareasymptomatic n Passesbehindesophagus n Lowincidenceofcongenitalheartdz
n
LeftAorticArch LeftAorticArch WithAnomalousRSCA WithAnomalousRSCA
LeftArchwithAnomalousRSCA
l l
Occursinlessthan1%ofpeople Passesposteriortoesophagus
n
Pushestracheaandesophagusforward
Producesobliqueshadowabove aorticarchonfrontalfilm OriginofRSCAmaybedilated

n
DiverticulumofKommerell
DahnertLippincottWilliams&Wilkins
LeftAorticArchwithAberrantRSCA
LeftAorticArchwithAberrantRightSCA
L.Elliott,MDJ.B.Lippincott
LeftAorticArchwithAberrantRSCA
RightAorticArches RightAorticArches
RightAorticArch
Types
l l
Atleastfivedifferenttypes Onlytwoofimportance
RightAorticArch
Types
MirrorImageTypeTypeI l AberrantleftsubclavianTypeII
l
MirrorImage
AberrantLSCA
StephenMiller,MDMosbyTheRequisites
RightAorticArches
General
l
Recognizedbyleftwarddisplacement
n n
Ofbariumfilledesophagus Ofairfilledtrachea
l l l
Aorticknobisabsentfromleftside Aortadescendsonright Paraaorticstripereturnstoleftsideof spinejustabovediaphragm
RightAorticArches
General
Mirrorimagetypealmostalwayshas associatedCHD
n
UsuallyTetralogyofFallot
AberrantLeftSubclaviantyperarely hasassociatedCHD
n
Mostcommonvarietyofrightarch
RightAorticArch
Type1MirrorImageType
2interruptionofleftarchjustdistalto ductusarteriosis Associatedwithcongenitalheart disease98%oftime
RightAorticArch
Type1MirrorImageTypeXrayFindings
Noposteriorimpressionontracheaor bariumfilledesophagus Heartisusuallyabnormalinsizeor shape Aortadescendsonright
MirrorImageRightAorticArchwithTOF
MirrorImageRightAorticArch
RightAorticArch
TypellAberrantLeftSubclavian 2interruptionofleftaorticarch betweenLCCandLSCarteries Associatedwithcardiacdefects510% ofthetime
n n n
TetralogyofFallotmostoften(71%) ASDorVSDnextmostoften(21%) Coarctationofaortararely(7%)
RightAorticArch
TypellAberrantLeftSubclavian Anomalousleftsubclavianartery (retroesophagealandretrotracheal) Aortadescendsonright
l
RightArchwithAberrantLSCA
RightAorticArch
AberrantLeftSubclavianXrayFindings
Posteriorimpressionontracheaand bariumfilledesophagus Heartisusuallynormalinsizeand shape Aortadescendsonright
RightAorticArchwithAberrantLeftSubclavian
Ifthepatienthas aMirrorRightarch,
Thenitwillbe associated
l l l
90%withTetralogyofFallot 6%withTruncusArteriosis 5%withTricuspidAtresia
Ifthepatienthas thisdisease,
This%willhavea MirrorRightarch
33% 25% 10% 5% 2%
l l l l l
Truncusarteriosis TetralogyofFallot Transposition Tricuspidatresia VSD
Apparentdiscrepancyduetomuch higher - incidenceofTOFthanTruncus
Identifythesethreeanomaliesand tellwhethertheyareusually associatedwithcongenitalheart diseaseornot
C
LeftAorticArch withAberrantRSCA
L
RightAorticArchwith AberrantLeftSubclavian
MirrorImage RightAorticArch
DoubleAorticArch DoubleAorticArch
DoubleAorticArch
General
l l
Mostcommonvascularring Rarelyassociatedwithcongenitalheart disease

n
Butvascularring trachealand/or esophagealcompression
CausedbypersistenceofRandLIV branchialarches
RIVarchnormally becomesmost proximalsegment ofRSCA
LIVarchispartof normalaorticarch betweenLCCand LSCA
PersistenceofbothIVbranchialarchesformsa vascularringorDoubleAorticArch
DoubleAorticArch
General
l
Passesonbothsidesoftrachea
n
Joinsposteriorlybehindesophagus
l l
Rightarchislargerandhigher Leftarchissmallerandlower
n
Baswallowshowsbilateralimpressionson frontalview
Posteriorimpressiononlateralview
Angiogramischaracteristic
DoubleAorticArch
Clinical
l l
Symptomsmaybeginatbirth Symptomsinclude
n n
Trachealcompression,or Difficultyswallowing
DoubleAorticArch
Anatomy
Rightarchsupplies RSCAandRCC Leftarchsupplies LCCandLSCA

DoubleAorticArch
DoubleAorticArch
XrayFindings
l l
Rightarchishigherandlarger Leftarchislowerandsmaller
n
ProducesreverseSonesophagramonAP
Onlateral,archesareposteriorto esophagusandanteriortotrachea
DoubleAorticArch
DoubleAorticArch
DoubleAorticArch ImpressionsonTracheaandEsophagus
DoubleAorticArch
CervicalAortic Arch Arch
CervicalAorticArch
General
l l
Rare Usuallyasymptomatic
n
Maypresentaspulsatingsupraclavicular mass Mayproducevascularringandcompress airway
l l
Embryogenesisuncertain Over80%arerightsided
CervicalAorticArch
ImagingFindingsRightsidedlesions
Rightsidedcervicalaorticarches
n n n n n
Rightapicalmasslikedensity Absenceofaorticknob Descendontheleft Displacethetracheaandesophagusforward Branchingmaybenormalormirrorimage
CervicalAorticArch
ImagingFindingsLeftsidedlesions
Leftsidedcervicalaorticarches
n n n
Aorticknobatapexoflung Descendontheleft
Donotdisplacethetracheaoresophagus forward
CervicalAorticArch
CervicalAorticArch
Aortitis Aortitis
TakayasusAortitis
PulselessDisease
Chronicinflammatoryarteritis Affectsaorta,itsmainbranchesand pulmonaryarteries 1540years,8:1females,Oriental population LSCA,LCCA,brachiocephalic,renals, celiaccommonlyinvolved
l l
TakayasusAortitis
Type3
l
Mostcommonis Type3(55%)
n
Stenosesof aorticarch, distalthoracic andabdominal aorta
TakayasusAortitis
Type2
l
Nextmost commonisType2 (11%)

n
Segmental stenosesin descending thoracicand abdominalaorta

TakayasusAortitis
Type1
l
Nextmost commonisType1 (8%)

n
Stenosesinarch, brachiocephalic, carotidand subclavian arteries

TakayasusAortitis(Type3)
TakayasusAortitis
ImagingFindings
Onangiography,narrowingofaortic lumen OnMRI,thickenedaorticwall Associatedaneurysmsmaybesaccular orfusiform
l l
OtherFormsofAortitis
l l
Inflammationofintimaandmedia Healingproducesscarringtreebark appearanceofluminalsurface Aortadilates

n n n
Ascendingaortamorethanarch Abdominalaortaspared Oppositeofatherosclerosis
OtherFormsofAortitis
l
Aorticwall becomesthickened onhealing Usuallyresultsin aorticregurgitation

n
Diastolicmurmur
GiantCellArteritis
CausesofAortitis
l l l
Rheumaticfever Reiterssyndrome Syphilis

n
Beginsabovesinotubularridge
l l
Giantcellarteritis Ankylosingspondylitis
n
SinotubularRidge JctofSinusesofValsalva andtubularaorta
Crossessinotubularridgeanddilatesboth rootandascendingaorta
SyphiliticAortitis
PulmonarySling PulmonarySling
PulmonarySling
Embryogenesis
Failureofformationofleft6thaorticarch absenceofleftpulmonaryartery
ProximalLVIarch normallybecomes proximalsegmentofL PAdistalVIpersists asductusuntilbirth

PulmonarySling
General
l
Aberrantoriginofleftpulmonaryartery
n
Fromtherightpulmonaryartery
Leftpulmonaryarterypassesbetween tracheaandesophagus Mosthaveotheranomalies

n
Stenosisofrightmainstembronchus
l
Mayleadtoairtrapping,lobaremphysemaand hyperlucentlung
L.Elliott,MDJ.B.Lippincott
PulmonarySling
PulmonarySling
DDX
Onlyvascularmalformationtopass betweenesophagusandtrachea Bronchialcystmayproducesame findingonesophagus/trachea
PulmonarySling
PulmonarySling
TrachealImpressions
PosteriorEsophagus
AnteriorTrachea
LeftAoArchwithAberrantRSCA RightAoArchwithAberrantLSCA
Isolatedanomalies BCAarisingtoodistal CCAarisingtooproximal CCAandBCAarisingtogether
Anteriortracheaand PosteriorEsophagus
Posteriortracheaand AnteriorEsophagus
DoubleAorticArch RAoArchwithAberrantLSCA+Lductus LAoArchwithAberrantRSCA+Rductus
PulmonarySling
AberrantSCA
DoubleAoArch IsolatedAnomalies
PulmonarySling
VenousAnomalies VenousAnomalies
PersistentLeft SVC SVC
PersistentLeftSVC
l
Occursinlessthan0.5%ofpeople
n
FailureofregressionofLcommonandAnt. Cardinalveins
l l l
Drainsleftjugularandleftsubclavianv MostpatientsalsohaverightsidedSVC Drainsintodilatedcoronarysinus R atrium
Postopday3
Postopday6
PersistentLeftSVC
Diseasesofthe NotSoGreat Vessels Vessels
LeftSuperior LeftSuperior IntercostalVein IntercostalVein

AorticNipple AorticNipple
LeftSuperiorIntercostalVein
TheAorticNipple
Visiblein5%ofpeople l Shouldnotbemistakenformass
l
AorticNippleLeftSuperior IntercostalVein
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LearningRadiology.com - The Heart -Inside Out
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WilliamHerring,M.D.2004
TheHeart: InsideOut
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IntraluminalLesions
Tumorsand Thrombi
CardiacTumors
l l
Rare Metastatictumorsare20xmore commonthanprimary

n
Melanoma,lymphoma,lungandbreast mostfrequent
Mostmetsinvolvethepericardium
CardiacTumors
l
Inchildren,mostcommontumoris rhabdomyoma
n
Tuberoussclerosismultiple,IVseptum
Inadults,mostcommonbenigntumor ismyxoma
n
Angiosarcomamostcommonmalignant
s
Usuallyrightsided
Myxomas
l l l l
Mostcommon1benigncardiactumor Usuallyfoundinleftatrium Arisefrominteratrialseptum About10%calcify
MillerRequisites MillerRequisites
MyxomainLeftAtrium
VentricularThrombi
Inleftventricle
n n
AfterMI Inaventricularaneurysm
Fillingdefectsinopacifiedcardiac chamber Maycalcify
VentricularThrombi
Occuroncardiacwallsthatareakinetic
n
UsuallyatcardiacapexoralongIVseptum
Biggestpitfall
n
Maybeconfusedwithposteriorpapillary muscles Lookforthickenedchordae
ThrombusinRightVentricle
AtrialThrombi
CommonlyassociatedwithLA enlargement Mostfrequentinmitralstenosiswith atrialfibrillation Leftatrialappendageafrequentsite
ElliotCardiacImaging ElliotCardiacImaging
Thrombusinleftatrialappendage
Myocardium
Cardiomyopathy
Classification
l
Dilatedcardiomyopathy Restrictive cardiomyopathy Hypertrophic cardiomyopathy Arrhythmogenicright ventriculardysplasia

Dilated Cardiomyopathy Cardiomyopathy
DilatedCardiomyopathy
l
Dilatationofbothventricularcavities
n
Increasedcardiacmass
Over75%havemuralthrombi
n
MostoftenLV>RV>RA>LA
Morethanhalfofpatientsare alcoholics
OtherCauses
l l l l l
Idiopathic Coronaryarterydisease Myocarditis Lupus Viralinfection
Clinical
Poorsystolicventricularfunction
n
Poolingindiastoleleadstothrombogenesis
Severe,intractableCHFisdominant symptom
n
Usualcauseofdeath
ImagingFindings
Cardiomegaly
n
Usuallyinvolvesleftventricle
l l
CHFcommon Echo:poorglobalwallmotion
n
Wallthicknessusuallythin
Amersham
Endsystole DilatedCardiomyopathy
Enddiastole
CineMRimagesintheshortaxisplaneshowlittlechangeinsize betweenenddiastoleandendsystole
ArrhythmogenicRight VentricularDysplasia
l l
Rarecardiomyopathy Arrythmiasandsuddendeath
n
Youngeragegroup
RVanteriorfreewallreplacedbyfatand fibroustissue
n
Thinningofantwallmorefatthannormal
DilatedRV,aneurysmsandtricuspid regurgitation
ArrhythmogenicRight VentricularDysplasia LeftthickeningandreplacementofRVanteriorwallbyfattytissue. LeftthickeningandreplacementofRVanteriorwallbyfattytissue. Fatsuppression(right)lossofsignalinRVanteriorwall,confirming Fatsuppression(right)lossofsignalinRVanteriorwall,confirming fattynatureofthesechanges fattynatureofthesechanges
Restrictive Cardiomyopathy Cardiomyopathy
RestrictiveCardiomyopathy
General
l l l l
Leastcommon Normalventricularsize Inabilityoftheventriclestofillproperly ThickLVwallanddilatedLA
General
l l l
Muralthrombioccasionally Resemblesconstrictivepericarditis Biopsymaybeneeded
Causes
Associatedwithextracellularinfiltration
n n n n n
Amyloid Sarcoid Glycogenstoragediseases Mets Radiation
ImagingFindings
Littlecardiomegaly
n
Wallsarestiffened
l l
CHFcommon Echo:NormalsizedLV
n n
Dilatedleftatrium Pericardiumnotthickened
Amersham
Restrictivecardiomyopathy ECGgatedspinechoimageenlargement ofbothatriaandnormalsizeof ventricleswiththickenedwalls
Hypertrophic Cardiomyopathy (HCM) (HCM)
HypertrophicCardiomyopathy
IdiopathicHypertrophicSubaorticStenosis
SevereLV,andsometimesRV,hypertrophy
n
ThickenedIVseptum
Noventricularenlargement
n
Atleastinitially
l l
Dividedintoprimaryandsecondary Furtherdividedintothosewith andwithoutLVOTobstruction
Secondary,Nonobstructive
Nonobstructivehypertrophic cardiomyopathy(HCM)iscommon Seenwithhighbloodpressure ConcentricanduniformthickeningofLV wall
Uncoiled Uncoiled aorta aorta
Prominent Prominent LV LV
Hypertensivecardiovasculardisease
Primary
l
AnothercauseofHCMisgenetic
n
Autosomaldominantwithvariablepenetrance
Hypertrophymaybeconcentricorlocalized
n
Asymmetricseptalhypertrophy(ASH)
s
IVseptumis1.5xthickerthanposteriorLVwall
Disproportionateupperseptal thickening(DUST)
Primary
l l
Mayappearfrombirthtooldage Commoncauseofsuddencardiacdeathin patients<40yrsold

n
Mostcommoncauseofdeathamongst competitiveathletes
About1/3haveLVOTobstruction
Primary
UnlikeDCwithhypokinesis,HCMis hyperkinetic
n
LVemptiestoocompletely
Atriaattempttocompensateandenlarge
n
MuchlargeratriathaninDC
Obstructive(HOCM)
Hallmark:dynamicsubvalvularaortic stenosis Anteriorleafletofmitralvalvemovesinto LVOTonsystole

n
SystolicAnteriorMotion(SAM) ofmitralvalve OccludesLVOT
Obstructive(HOCM)
NeitherASHnorSAMisspecificforHOCM
n n
E.g.ASHalsoseeninPulmonicStenosis SAMalsoseeninTranspositionofGreatVessels
ImagingFindings
l
Usuallynormalsizedheart
n
Leftatriummaybeenlarged2MR
l l
CHFnotcommon Echo:LVhypertrophy
n
ASH
DynamicLVOTobstruction
n
SAM
Amersham
HypertrophicCardiomyopathy ECGgatedspinechoimagein coronalplaneseveresymmetricalhypertrophyofLV
Asymmetricseptalhypertrophy Asymmetricseptalhypertrophy
Thickened Thickened apex apex
Amersham
MillerRequisites MillerRequisites
Mitral Mitral Regurgitation Regurgitation FromSAM FromSAM
Marked Marked wall wall thickening thickening
Almost Almost complete complete emptyingof emptyingof LV LV

Dilated LVCavitySize Mitral Regurgitation Wallmotion Muralthrombi SystolicFunction DiastolicFunction EjectionFraction

Increased
Restrictive
Normal
Hypertrophic
Normal HOCM:mildto severe Hyperkinetic
Mild
Variable
Globalhypokinesis
Normal
Frequent
Occasional
None
Decreased
Normal
Increased
Normal
Decreased
Normal
Decreased
Normal
Normal
Endocarditis
Endocarditis
General
l l
Triad:fever,murmur,septicemia Causes
n n n
Rheumaticfever Infection Nonbacterialthromboticendocarditis

s s
LibmanSacksEndocarditis Smallervegetationsthanbacterial
Endocarditis
General
Vegetationsfrequentlyproduce regurgitationofaffectedvalve Canembolizetolungsoraorta

n n
Septicemboliinlungs Mayproducemycoticaneurysmofaorta
RheumaticVegetations RheumaticVegetations
SepticEmbolitoLungs SepticEmbolitoLungs
Pericardium Pericardium
Pericarditis Pericarditis
ConstrictivePericarditis
l
Thickeningofpericardiumimpeding diastolicfilling Thickenedpericardiummaycalcify

n
50%onchestxrays
RightsidedfailureduetoimpededRV filling
Causes
Viralpericarditis(mostcommon) Tuberculouspericarditis Uremicpericarditis Postcardiacsurgery
Calcification
About50%withconstrictivepericarditis calcify
n
Eggshellviralanduremic Shaggy,amorphousinAVgroovesTB
Calcifiedpericardiumdoesntimply constriction
ConstrictivePericarditis Eggshellcalcificationasseeninviraloruremicpericarditis
ConstrictivePericarditis Thickcalcificationasseenintuberculouspericarditis
ConstrictivePericarditisvs. RestrictiveCardiomyopathy
l
Maybeimpossibletodistinguishtwo Bothhaveabnormalfillingoftheheart CTbestforcalcifiedpericardium

n
Ifcalcified,notrestrictivecardiomyopathy
NormalpericardiumonbothCTandMRI
n
Excludesconstrictivepericarditis
ConstrictivePericarditisvs. RestrictiveCardiomyopathy
Heartsize
Normal
Normal
PericardialCalcification
Present
Absent
RightAtrialBorder
Straight
Convex
RightAtrialWallThickness
Increased
Normal
CongenitalDefectin CongenitalDefectin thePericardium thePericardium
CongenitalPericardialDefect
Embryogenesis
PrematureatrophyofleftductofCuvier (cardinalvein)leadsto Failureofnourishmentofleftpleuro pericardialmembranewhichleadsto failureofpericardiumtodevelop
General
Male:femaleratioof3:1 Maybedetectedatanyage
n
Mostcommoninlow20s
Location
l
Foraminaldefectonleftside Completeabsenceofleftside giveslevopositionofheart Diaphragmaticsurface Totalbilateralabsence Rightsided
35% 35% 17% 9% 4%
Associations
l l l l
Bronchogeniccysts VSD,PDA,mitralstenosis Diaphragmatichernia Sequestration
Clinical
l
Mostlyasymptomatic Mayhave:
n
Tachycardia Palpitations Rightbundleblock Positionaldiscomfortlyingonleftside Chestpain
XrayFindings
l
Focalbulgeinareaofmainpulmonary artery Sharplymarginated Lungmayinterposebetweenheartleft hemidiaphragm Increaseddistancebetweensternumand heart2absenceofsternopericardial ligament
l l
XrayFindingsContinued
Levopositionofheart Pneumopericardiumfollowing pneumothorax
CongenitalDefectinthePericardium
Treatment
Sinceherniationandstrangulationof leftatrialappendageorherniationof LA/LVmayoccur Foraminaldefectrequiressurgery
TheEnd
Tostartoverfrombeginning,clickhere
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LearningRadiology - Heterotaxy Syndromes, Cardiac Malpositions, Sinus of Valsalva Aneurysm, Pericardial Defect
http://www.learningradiology.com/lectures/cardiaclectures/mischeartdiseasesweb_files/frame.htm04/09/2006 1:40:07
Miscellaneous Cardiac Diseases

Sinus of Valsalva Sinus of Valsalva Aneurysm Aneurysm
Types
Congenital Inherited Acquired
Sinus of Valsalva Aneurysm

Congenital
Usual type Involves a single cusp Most often arise from R coronary sinus

Inherited
Associated with Marfans Disease All cusps involved Produce aortic regurgitation

Acquired
Usually 2 to endocarditis of aortic valve Other causes

Syphilis Atherosclerosis Dissecting aneurysm Marfan's

X-ray Findings
Since aortic root is intracardiac, usual aneurysm is not visible Rarely, a large aneurysm of L aortic sinus bulge L upper heart border in region of LA appendage

Other X-ray Findings
Rarely, a large aneurysm of the R aortic sinus bulge on R heart border Usually the aneurysm dilates the aortic ring AI
Aneurysm of Sinus of Valsalva and Proximal Ascending Aorta = annuloaortic ectasia
Ruptured Ruptured Sinus of Valsalva Sinus of Valsalva Aneurysm Aneurysm
Ruptured Sinus of Valsalva Aneurysm Congenital vs. Acquired
Congenital forms (usually R sided) always produce an intracardiac fistula

Most congenital aneurysms rupture during third or fourth decade of life
Acquired forms can produce either intra- or extracardiac fistulae
Ruptured Sinus of Valsalva Aneurysm

General May rupture
L
aortic-cardiac fistula
R shunt usually
Most ruptures involve R coronary sinus

Into R ventricle
Posterior (non-coronary) aortic sinus ruptures occasionally

Into R atrium
Ruptured Sinus of Valsalva Aneurysm

General
Rupture of aneurysms of L sinus are very rare

May rupture into the pericardial space
Ruptured Sinus of Valsalva Aneurysm Clinical

Symptoms due to sudden onset of massive aortic regurg or L R shunt
Acute onset of SOB Chest pain Acute onset of murmur CHF Death
Ruptured Sinus of Valsalva Aneurysm X-ray Findings
Acute CHF Followed by L R shunt With rupture of L sinus, LA may suddenly enlarge
Two cases of rupture of right coronary sinus into RV
Congenital Defect in Congenital Defect in the Pericardium the Pericardium
Congenital Pericardial Defect

Embryogenesis
Premature atrophy of left duct of Cuvier (cardinal vein) Failure of nourishment of left pleuropericardial membrane failure of pericardium to develop

General
Male:female ratio of 3:1 May be detected at any age

Most common in low 20s

Location
Foraminal defect on left side Complete absence of left side gives levoposition of heart Diaphragmatic surface Total bilateral absence Right sided
35% 35% 17% 9% 4%

Associations
Bronchogenic cysts VSD, PDA, mitral stenosis Diaphragmatic hernia Sequestration

Clinical
Mostly asymptomatic May have:

Tachycardia Palpitations Right bundle block Positional discomfort lying on left side Chest pain

X-ray Findings
Focal bulge in area of main pulmonary artery Sharply marginated Lung may interpose between heart-left hemidiaphragm Increased distance between sternum and heart 2 absence of sternopericardial ligament

X-ray Findings-Continued
Levoposition of heart Pneumopericardium following pneumothorax
Congenital Defect in the Pericardium

Treatment
Since herniation and strangulation of left atrial appendage or herniation of LA/LV may occur Foraminal defect requires surgery
Cardiac Malpositions Cardiac Malpositions Heterotaxy Heterotaxy Syndromes Syndromes
Trilobed and Bilobed Lungs

Bilobed lung
Trilobed lung
Liver Spleen
Naming Rules
Since anatomic side (i.e. left or right) in complex lesions is frequently reversed or indeterminate Naming conventions for
Atria AV valves Ventricles Ventricular outflow tracts
The Rules
How the atria are named
Anatomic right atrium is on side of trilobed lung and liver
Shape of atrial appendage-broad and pyramidal Same side as IVC
Anatomic left atrium is on side of bilobed lung and spleen

Shape of atrial appendage-thin c narrow neck Same side as aortic arch
The Rules
How the ventricles are named
Anatomic right ventricle is trabeculated ventricle
Coarse in both systole and diastole Has tricuspid AV valve
Anatomic left ventricle is smooth-walled ventricle

In diastole; fine trabeculations in systole Has bicuspid AV valve
Anatomic Ventricles
Trabeculated ventricleAnatomic Right
Smooth ventricleAnatomic Left
The Rules
Mitral and tricuspid valves
Tricuspid valve belongs to anatomic right ventricle

Not right atrium
Mitral valve belongs to anatomic left ventricle

Not left atrium
AV Connections
Concordance
Ventricles are concordant to the atria
When R atrium connects to R ventricle L atrium connects to L ventricle
Ventricles are discordant to the atria

When R atrium connects to L ventricle When L atrium connects to R ventricle
With atrial isomerism, AV connections are ambiguous
The Rules
Aortic and pulmonic valves
Pulmonic valve is part of pulmonary artery
Not anatomic right ventricle
Aortic valve is part of aorta

Not anatomic left ventricle
Pulmonic infundibulum is part of anatomic right ventricle
Anatomic R atrium is on side of trilobed lung-same side as IVC Tricuspid valve belongs to anatomic RV
Anatomic L atrium is on side of bilobed lung-same side as Ao arch
Mitral valve belongs to anatomic LV
Pulmonic infundibulum belongs to anatomic RV Pulmonic valve belongs to pulmonary artery Anatomic R ventricle is trabeculated
Aortic valve belongs to aorta
Anatomic L ventricle is smooth
Situs
Definitions
Describes position of asymmetric organs in body

Lungs Liver Spleen Stomach
Situs Solitus
Normal anatomic relationships
Right side Trilobed lung Eparterial bronchus Anatomic right atrium Liver Left side Bilobed lung Hyparterial bronchus Anatomic left atrium Spleen
Situs Solitus
Situs Solitus
Hyparterial/Eparterial Bronchi
Eparterial bronchusFirst branch of Right mainstem bronchus is above pulmonary artery
Hyparterial bronchusFirst branch of Left mainstem bronchus is below pulmonary artery
Situs Solitus 0.6 - 0.8% CHD
Situs Inversus
Reversed anatomic relationships
Right side Bilobed lung Hyparterial bronchus Anatomic left atrium Spleen Left side Trilobed lung Eparterial bronchus Anatomic right atrium Liver
Situs Inversus
Situs Ambiguous
Lungs and abdomen are symmetric so right and left sides cant be defined
Isomerism-both atria have the same features
Either right or left
Two kinds of situs ambiguous

Bilateral right-sidedness Bilateral left-sidedness
Situs Ambiguous
Heterotaxy Syndrome
Bilateral right-sidedness
Since, spleen is usually on left side No spleen
Asplenia syndrome
Bilateral left-sidedness
Since, spleen is usually on left side Many spleens
Polysplenia syndrome
Situs Ambiguous
Cardiac Positions
Position of cardiac apex
Levocardia Dextrocardia Mesocardia on the left on the right in the midline
Cardiac malposition
Anything other than situs solitus with levocardia
Cardiac Malpositions
Types
Situs solitus with dextrocardia Situs inversus with levocardia Situs inversus with dextrocardia
Situs Solitus with Dextrocardia
t es T rt Ale
95% chance of CHD of which 80% corrected transposition If cyanotic with flow, then tricuspid atresia. If cyanotic with flow, then corrected transposition. If asplenia, then 100% have common ventricle. Interrupted IVC common.
Situs Solitus with Dextrocardia Coarctation of Aorta
Situs Inversus with Levocardia
Rare, but 100% CHD If asplenia, 100% have common ventricle Interruption of IVC common
Situs Inversus with Levocardia
Situs Inversus with Levocardia Transposition
Situs Inversus with Dextrocardia
3-5% CHD Most common is Corrected Transposition Kartgeners
Trilobed lung
Situs Inversus with Dextrocardia
Situs Solitus
Malposition of the Stomach
R/O asplenia Most have CHD (L R shunt) Most with polysplenia have azygous continuation of IVC
Situs Solitus with Malposition of the Stomach
Situs Inversus
Malposition of the Stomach
Situs Inversus with Malposition of the Stomach 95% CHD of which 80% are Corrected Transposition
Situs Ambiguous
Heterotaxy Syndrome
Bilateral right-sidedness
Since, liver is usually on right side No spleen
Asplenia syndrome
Since, spleen is usually on left side Multiple spleens
Polysplenia syndrome
Asplenia
Bilateral Right-sidedness
Male Cyanotic High risk of infection Severe cardiac abnormalities

Transposition TAPVR
Polysplenia
Female Abnormalities are more benign
Azygous continuation of IVC Bilateral superior vena cava PAPVR ASD
Situs Ambiguous-polysplenia
Approach to Cardiac Malpositions

Which side is heart on Which side is trilobed lung on Which side is arch on Which side is stomach bubble on Check for asplenia
Midline liver Minor fissures in both lungs
Another Approach
Situs Inversus with Levocardia Rare, but 100% CHD If asplenia, 100% have common ventricle Interruption of IVC common
Situs ambiguous Asplenia with dextrocardia Complex CHD
Decreased flow
Increased Flow

Whats left
The End
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Cardiac Radiology Boards Review
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2004 William Herring, MD
Cardiac Board-type Case Review

All photos retain the copyrights of their original owners
Whats the DDX?
Cyanotic newborn

* Also appears on DDx of cyanosis with increased vascularity
Whats the diagnosis?
Ebsteins Anomaly
Whats the DDX?
8 year-old cyanotic male
* Also appears on DDx of cyanosis with decreased vascularity
TAPVR-Supracardiac type 1
Whats the DDX?
Acyanotic newborn
Viral myocarditis
Whats the DDX?
Acyanotic newborn
Causes of CHF In Newborn

Atrial septal defect
Another example
ASD (primum) with PAH
Ostium Secundum ASD-MRI
Amersham
SCMR
Discontinuity in the atrial septum with systolic signal void consistent with L to R shunt at atrial level Right atrium is slightly dilated; RV, LV and LA size are normal
Another example-VSD
VSD
Membranous VSD-MRI
Amersham
Patent Ductus Arteriosus-MRI

Jet of signal loss showing continuous flow from the aorta to the MPA consistent with sizeable PDA; MPA is severely dilated at level of PDA
SCVMR
ACR
9 mos old cyanotic female
TAPVR-supracardiac type
ACR
TAPVR Supracardiac Type 1
Angiographic Appearance
TAPVR-cardiac type-MRI
Amersham Frank Netter, MD Novartis
TAPVR-infracardiac type-MRI
10 yo cyanotic male
Tetralogy of Fallot
Other examples
Tetralogy of Fallot
Tetralogy of Fallot-MRI Overriding aorta, VSD
Axial spin-echo MR image shows severe infundibular pulmonic stenosis (arrow).
Korean Journal of Radiology
Tetralogy of Fallot
Radiology Resource and Review
12 yo cyanotic male
Truncus arteriosus-Type 1
Ao
LPA
Ao
Truncus
LV
Truncus Type 1
Elliott, L Cardiac Imaging
Single large artery (T) arising from the heart. Pulmonary artery (arrow) originates from the left side of the truncus There is a right aortic arch Truncus Arteriosus Type 1-MRI
Amersham
Truncus Type II
Truncus Type III
ECG-gated spinecho transaxial image demonstrates a bar of muscle and fat (blue arrow) (tricuspid atresia) separating the right atrium (yellow arrow) from the hypoplastic right ventricle (red arrow)
Amersham
Tricuspid atresia-MRI
Small right ventricle
Enlarged right atrium
Tricuspid atresia-MRI
3 mos old cyanotic male
Transposition of the Great Vessels
In Transposition, pulmonic valve is
Posterior Medial Inferior To the aortic valve
Normal
Anatomic Ventricles
Trabeculated ventricleAnatomic Right
Smooth ventricleAnatomic Left
Transposition of the Great Vessels RVgram
Transposition of the Great Vessels LVgram
Oblique axial spin-echo image shows displaced attachment (thick arrow) of the posterior leaflet (thin arrows)
Ebsteins Anomaly
Korean Journal
Acyanotic adult
Coarctation of the aorta
Coarctation of the aorta
Arrow points to indentation representing area of coarctation with dilated aorta (or LSCA) above and post-stenotic dilatation below coarct
Ascending Ao may be dilated, normal or small
Convexity above aortic knob due to dilated LSCA or Aorta proximal to coarct
Yellow arrows point to ribnotching
Amersham
Contrast enhanced MRA shows long segment coarctation of the aorta
BCA
AO
Coarct
Amersham
Oblique sagittal spin-echo-Coarctation of the Aorta
Amersham
Axial spin-echo MRI-Coarctation of the Aorta
Acyanotic adult
Aortic Stenosis
Aortic stenosis
Ao
Signal void
Ao valve
LV
Amersham
Aortic Stenosis Coronal cine MRI image demonstrates a systolic signal void originating at the stenotic aortic valve. Ascending aorta is dilated

Atretic aorta
Neufeld, HN, Circulation, 1962
MPA RA Ao
LA
Amersham
Hypoplastic Left heart Syndrome

Gated spin echo at base of heart shows hypoplastic aorta (arrow) posterior and right of main pulmonary artery
Cor triatriatum
Frontal radiograph demonstrates CHF
Ao RVOT RA Ao LA LA RV LA LA MPA
Amersham
Cor Triatriatum
Ao
RA LV
Aortic Regurgitation Cine MR image during diastole shows signal void emanating from the aortic valve
Acyanotic adult
Mitral Stenosis
Mitral Stenosis
Mitral Stenosis
Upper lobe vessels equal to or larger than size of lower lobe vessels = Cephalization
RV LV
RA
LA
Mitral Stenosis Cine MR image in axial plane demonstrates a diastolic signal void emanating from the mitral valve
Left Atrial Myxoma Contrast-enhanced CT shows large filling defect in lumen of LA
RA
Ao
LV
LA
Left Atrial Myxoma Cine MRI shows soft tissue mass arising from wall of left atrium and projecting into lumen
Acyanotic adult
LA
LV
Mitral Regurgitation Cine MR image in axial plane during systole depicts a signal void emanating from the mitral valve
Difference in heart size MS and MR
Mitral Stenosis
Amersha,m
Acyanotic adult
Pulmonic stenosis
Amersha,m
Prominent main pulmonary artery segment
Normalsized heart
Enlargement of left pulmonary artery
Pulmonic Stenosis
Acyanotic adult
Right Arch with Aberrant Left SCA
Trachea is bowed forward by aberrant left subclavian artery (arrow)
Right Aortic Arch with Aberrant Left Subclavian (Arrows)
36 yo cyanotic female
Mirror image Right aortic arch with TOF
Trachea is not bowed forward
Mirror Image Right Aortic Arch
Left Aortic Arch with Aberrant R SCA
ReviewName the abnormalities. Are they the good or bad variety?
C
Left Aortic Arch with Aberrant R SCA
B
Right Aortic Arch with Aberrant Left Subclavian
Mirror Image Right Aortic Arch
2 month old with stridor
Double aortic arch
Right arch is larger and higher Left arch is smaller and lower
Miller-requisites
Double Aortic Arch
Miller-requisites
Double Aortic Arch-angiographic appearance
Dahnert
Double Aortic Arch Impressions on Trachea and Esophagus
4 month old with stridor
Pulmonary Sling
Dahnert
Pulmonary Sling
Tracheal/esophageal impressions
Dahnert
Aberrant SCA
Double Ao Arch Isolated Anomalies (Rare)
Pulmonary Sling
If you see cases like these, you passed
Miller-Requisites Miller-Requisites
Myxoma in Left Atrium
Elliot-Cardiac Imaging Elliot-Cardiac Imaging
Thrombus in left atrial appendage
Dilated Cardiomyopathy
Amersham
End systole Dilated Cardiomyopathy
End diastole
Cine MR images in the short axis plane show little change in size between end diastole and end systole
Arrhythmogenic Right Ventricular Dysplasia Left-thickening and replacement of RV anterior wall by fatty tissue. Left-thickening and replacement of RV anterior wall by fatty tissue. Fat suppression (right) - loss of signal in RV anterior wall, Fat suppression (right) - loss of signal in RV anterior wall, confirming fatty nature of these changes confirming fatty nature of these changes
Amersham
Restrictive cardiomyopathy ECG-gated spin-echo image - enlargement of both atria and normal size of ventricles with thickened walls
Amersham
Hypertrophic Cardiomyopathy ECG-gated spin-echo image in coronal plane - severe symmetrical hypertrophy of LV
Asymmetric septal hypertrophy Asymmetric septal hypertrophy
Thickened Thickened apex apex
Amersham
Miller-Requisites Miller-Requisites
Hypertrophic Cardiomyopathy
Mitral Mitral Regurgitation Regurgitation From SAM From SAM
Marked Marked wall wall thickening thickening
Almost Almost complete complete emptying of emptying of LV LV

Elliot-Cardiac Imaging Elliot-Cardiac Imaging
Hypertrophic Cardiomyopathy
Congenital Defect in the Pericardium
Types
Situs solitus with dextrocardia Situs inversus with levocardia Situs inversus with dextrocardia
Rule of Thumb
If aortic arch/apex of heart are on opposite sides from stomach bubble, high incidence of CHD
Asplenia
Bilateral Right-sidedness
Male Cyanotic High risk of infection Severe cardiac abnormalities
Transposition TAPVR
Polysplenia
Female Abnormalities are more benign
Azygous continuation of IVC Bilateral superior vena cava PAPVR ASD
Asplenia/Polysplenia
Asplenia bad boy Polysplenia good girl
Click here for downloadable version of this chart

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LearningRadiology - Congestive Heart Failure, CHF
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Congestive Heart Congestive Heart Failure Failure

Congestive Heart Failure

Causes of
Coronary artery disease Hypertension Cardiomyopathy Valvular lesions

AS, MS
L to R shunts

Clinical
Usually from left heart failure

Shortness of breath Paroxysmal nocturnal dyspnea Orthopnea Cough
Right heart failure

Edema
Left Atrial Pressures

Correlated With Pathologic Findings
Pulmonary Circulation
Physiology
Very low pressure circuit Pulmonary capillary bed only has 70cc blood Yet, it could occupy the space of a tennis court if unfolded Therefore, millions of capillaries are resting, waiting to be recruited
Keeping the Lungs Dry

Pulmonary capillary hydrostatic pressure is low about 7 mm Hg
Plasma colloid oncotic pressure is high about 28 mm Hg
Normal osmotic tendency to dehydrate the interstitium and alveoli
Pressure and Flow
Pressure = Flow x Resistance

Normally, resistance is so low that flow can be increased up to 3x normal without increase in pressure

X-ray Findings
Kerley B lines

Pleural effusions
Kerley B Lines
B=distended interlobular septa Location and appearance
Bases 1-2 cm long Horizontal in direction Perpendicular to pleural surface
Kerley B Lines are short, white lines perpendicular to the pleural surface at the lung base.
Kerley A and C Lines

A=connective tissue near bronchoarterial bundle distends
Location and appearance
Near hilum Run obliquely Longer than B lines
C=reticular network of lines

C Lines probably dont exist
Kerley A and C Lines form a pattern of interlacing lines in the lung
Peribronchial Cuffing
Interstitial fluid accumulates around bronchi Causes thickening of bronchial wall When seen on end, looks like little doughnuts
Peribronchial cuffing results when fluid-thickened bronchial walls become visible producing doughnut-like densities in the lung parenchyma
Fluid in The Fissures

Fluid collects in the subpleural space
Between visceral pleura and lung parenchyma
Normal fissure is thickness of a sharpened pencil line Fluid may collect in any fissure
Major, minor, accessory fissures, azygous fissure
Fluid in the major or minor fissure (shown here) produces thickening of the fissure beyond the pencilpoint thickness it can normally attain
Pleural Effusion
Laminar effusions collect beneath visceral pleura

In loose connective tissue between lung and pleura Same location for pseudotumors
Inner margin of the rib starts here
Aerated lung stops here
Laminar pleural effusions can be difficult to see. Aerated lung should normally extend to the inner margin of the ribs. The white band of fluid seen here (white arrow) is a laminar effusion, separating aerated lung from the inner rib margin.
Cephalization
A Proposed Mechanism
If hydrostatic pressure >10 mm Hg, fluid leaks in to interstitium of lung Compresses lower lobe vessels first
Perhaps because of gravity
Resting upper lobe vessels recruited to carry more blood Upper lobes vessels increase in size relative to lower lobe
Cephalization means pulmonary venous hypertension, so long as the person is erect when the chest x-ray is obtained.

Pulmonary Edema
Types
Cardiogenic Neurogenic Increased capillary permeability

X-ray patterns
Interstitial Alveolar

Pulmonary interstitial edema

Kerley B lines

Pleural effusions

Pulmonary alveolar edema
Acinar shadow Outer third of lung frequently spared

Bat-wing or butterfly configuration
Lower lung zones more affected than upper
Pulmonary Alveolar Edema
In pulmonary alveolar edema, fluid presumably spills over from the interstitium to the air spaces of the lung producing a fluffy, confluent bat-wing like pattern of disease.
Pulmonary Alveolar Edema

Clearing
Generally clears in 3 days or less Resolution usually begins peripherally and moves centrally
Kerley B lines and Peribronchial cuffing
Cardiac Renal ARDS
30% 30% None
Distribution of Pulmonary Edema
Cardiac Renal ARDS
Even 90% Central 70% Peripheral in 45% Even in 35%
Air Bronchograms
Cardiac Renal ARDS
20% 20% 70%
Pleural Effusions
Cardiac Renal ARDS
40% 30% 10%

http://www.learningradiology.com/lectures/chestlectures/histoplasmosisppt_files/frame.htm04/09/2006 1:44:17
Allergic Bronchopulmonary Aspergillosis ABPA
http://www.learningradiology.com/lectures/chestlectures/abpappt_files/frame.htm04/09/2006 1:44:34
LearningRadiology - Hypogenetic Lung Syndrome
http://www.learningradiology.com/lectures/chestlectures/hypogeneticlungsyndromeppt_files/frame.htm04/09/2006 1:44:42
Actinomycosis
http://www.learningradiology.com/lectures/chestlectures/actinomycosisppt_files/frame.htm04/09/2006 1:44:55
LearningRadiology - Radiology in the Intensive Care Unit
http://www.learningradiology.com/lectures/chestlectures/icuradiology_files/frame.htm (1 de 2)04/09/2006 1:45:04
LearningRadiology - Radiology in the Intensive Care Unit
http://www.learningradiology.com/lectures/chestlectures/icuradiology_files/frame.htm (2 de 2)04/09/2006 1:45:04
Bronchial Adenomas
http://www.learningradiology.com/lectures/chestlectures/adenomasppt_files/frame.htm04/09/2006 1:45:15
Lipoid Pneumonia
http://www.learningradiology.com/lectures/chestlectures/lipoidpneumoniappt_files/frame.htm04/09/2006 1:45:28
AIDS and Lung Disease
http://www.learningradiology.com/lectures/chestlectures/aidsandlungdzppt_files/frame.htm04/09/2006 1:45:39
Lung Masses
http://www.learningradiology.com/lectures/chestlectures/lungmassesppt_files/frame.htm04/09/2006 1:45:57
Hypersensitivity Pneumonitis
http://www.learningradiology.com/lectures/chestlectures/hypersenypneuppt_files/frame.htm04/09/2006 1:46:11
LearningRadiology - Collagen Vascular Diseases
http://www.learningradiology.com/lectures/chestlectures/lupusppt_files/frame.htm04/09/2006 1:46:23
LearningRadiology - Alveolar Cell Carcinoma
http://www.learningradiology.com/lectures/chestlectures/alveolarcellcappt_files/frame.htm04/09/2006 1:46:34
LearningRadiology - Hodgkins Disease of the Lungs - Lymphoma
http://www.learningradiology.com/lectures/chestlectures/hodgkinsppt_files/frame.htm04/09/2006 1:46:48
LearningRadiology - Aortic Dissection
http://www.learningradiology.com/lectures/chestlectures/aorticdissectionppt_files/frame.htm04/09/2006 1:47:01
LearningRadiology- Metastases to Lung
http://www.learningradiology.com/lectures/chestlectures/metstolungppt_files/frame.htm04/09/2006 1:47:19
http://www.learningradiology.com/lectures/chestlectures/ardrsppt_files/frame.htm (1 de 2)04/09/2006 1:47:35
http://www.learningradiology.com/lectures/chestlectures/ardrsppt_files/frame.htm (2 de 2)04/09/2006 1:47:35
LearningRadiology - Mycoplasma Pneumonia
http://www.learningradiology.com/lectures/chestlectures/mycoplasmapneumoniappt_files/frame.htm04/09/2006 1:47:46
LearningRadiology - Pneumoconiosis - Silicosis - Asbestosis- Coal Worker's Pneumoconiosis
http://www.learningradiology.com/lectures/chestlectures/pneumoconiosisppt_files/frame.htm (1 de 2)04/09/2006 1:48:01
LearningRadiology - Pneumoconiosis - Silicosis - Asbestosis- Coal Worker's Pneumoconiosis
http://www.learningradiology.com/lectures/chestlectures/pneumoconiosisppt_files/frame.htm (2 de 2)04/09/2006 1:48:01
LearningRadiology- Posterior Mediastinal Masses - Neurogenic Tumors
http://www.learningradiology.com/lectures/chestlectures/neurogenictumorsppt_files/frame.htm04/09/2006 1:48:18
LearningRadiology - Aspiration Pneumonia
http://www.learningradiology.com/lectures/chestlectures/aspirationppt_files/frame.htm04/09/2006 1:48:31
http://www.learningradiology.com/lectures/chestlectures/pancoasttumorppt_files/frame.htm04/09/2006 1:48:45
LearningRadiology- Atelectasis
http://www.learningradiology.com/lectures/chestlectures/atelectasisppt_files/frame.htm04/09/2006 1:48:59
LearningRadiology - Pleural Effusion
http://www.learningradiology.com/lectures/chestlectures/pleuraleffusionppt_files/frame.htm04/09/2006 1:49:13
LearningRadiology - AVMs
http://www.learningradiology.com/lectures/chestlectures/avmsppt_files/frame.htm04/09/2006 1:49:27
LearningRadiology - Bronchiolitis Obliterans Organizing Pneumonia (BOOP)
http://www.learningradiology.com/lectures/chestlectures/boopppt_files/frame.htm04/09/2006 1:49:40
LearningRadiology - Pneumonia
http://www.learningradiology.com/lectures/chestlectures/pneumoniawebppt_files/frame.htm04/09/2006 1:50:02
LearningRadiology - Congenital Bronchial Cysts
http://www.learningradiology.com/lectures/chestlectures/bronchialcystsppt_files/frame.htm04/09/2006 1:50:13
LearningRadiology- Polyarteritis Nodosa
http://www.learningradiology.com/lectures/chestlectures/polyarteritisnodosappt_files/frame.htm04/09/2006 1:50:23
LearningRadiology - Bullous Disease Of the Lungs
http://www.learningradiology.com/lectures/chestlectures/bullousdzppt_files/frame.htm04/09/2006 1:50:34
LearningRadiology- Rheumatoid Lung
http://www.learningradiology.com/lectures/chestlectures/rheumatoidlungppt_files/frame.htm04/09/2006 1:50:46
LearningRadiology- Rounded Atelectasis
http://www.learningradiology.com/lectures/chestlectures/roundedatelectasisppt_files/frame.htm04/09/2006 1:50:56
http://www.learningradiology.com/lectures/chestlectures/coccidioidomycosisppt_files/frame.htm04/09/2006 1:51:19
http://www.learningradiology.com/lectures/chestlectures/roundpneumoniappt_files/frame.htm04/09/2006 1:51:29
LearningRadiology - Collagen Vascular Diseases
http://www.learningradiology.com/lectures/chestlectures/collagenvascdzweb_files/frame.htm04/09/2006 1:51:52
LearningRadiology - Sarcoid of the Lungs
http://www.learningradiology.com/lectures/chestlectures/sarcoidppt_files/frame.htm04/09/2006 1:52:09
LearningRadiology- Congenital Lobar Emphysema
http://www.learningradiology.com/lectures/chestlectures/conglobaremphysemappt_files/frame.htm04/09/2006 1:52:23
http://www.learningradiology.com/lectures/chestlectures/sclerodermappt_files/frame.htm04/09/2006 1:52:33
LearningRadiology - Chronic Obstructive Pulmonary Disease COPD
http://www.learningradiology.com/lectures/chestlectures/copdppt_files/frame.htm04/09/2006 1:52:44
LearningRadiology - Sequestration of the Lung
http://www.learningradiology.com/lectures/chestlectures/sequestrationppt_files/frame.htm04/09/2006 1:52:56
LearningRadiology - Pulmonary Malformations
http://www.learningradiology.com/lectures/chestlectures/cysticadenomatoidppt_files/frame.htm04/09/2006 1:53:12
http://www.learningradiology.com/lectures/chestlectures/cysticibrosisppt_files/frame.htm04/09/2006 1:53:34
LearningRadiology - The Solitary Pulmonary Nodule
http://www.learningradiology.com/lectures/chestlectures/SPNppt_files/frame.htm04/09/2006 1:53:46
LearningRadiology.com - Diseases of The Diaphragm
http://www.learningradiology.com/lectures/chestlectures/diaphragmaticdzs_files/frame.htm04/09/2006 1:54:03
LearningRadiology - Swyer James Syndrome
http://www.learningradiology.com/lectures/chestlectures/swyerjamesppt_files/frame.htm04/09/2006 1:54:15
LearningRadiology - Pulmonary Tuberculosis
http://www.learningradiology.com/lectures/chestlectures/TBppt_files/frame.htm04/09/2006 1:54:30
LearningRadiology - Dresslers Syndrome Postpericardiectomy-Postmyocardial Infarction Syndrome
http://www.learningradiology.com/lectures/chestlectures/dresslersppt_files/frame.htm04/09/2006 1:54:48
LearningRadiology - Teratomas, Seminomas and Choriocarcinomas
http://www.learningradiology.com/lectures/chestlectures/Teratomasppt_files/frame.htm04/09/2006 1:55:00
LearningRadiology - Drug-Induced Lung Disease
http://www.learningradiology.com/lectures/chestlectures/druginducedlungdzppt_files/frame.htm04/09/2006 1:55:12
LearningRadiology - Pulmonary Embolic Disease
http://www.learningradiology.com/lectures/chestlectures/thromboembolicdiseaseppt_files/frame.htm04/09/2006 1:55:27
LearningRadiology - Thymoma
http://www.learningradiology.com/lectures/chestlectures/Thymomasppt_files/frame.htm04/09/2006 1:55:39
LearningRadiology - Pulmonary Infiltrates With Eosinophilia
http://www.learningradiology.com/lectures/chestlectures/eosinophiliclungdisease_files/frame.htm (1 de 2)04/09/2006 1:55:51
LearningRadiology - Pulmonary Infiltrates With Eosinophilia
http://www.learningradiology.com/lectures/chestlectures/eosinophiliclungdisease_files/frame.htm (2 de 2)04/09/2006 1:55:51
LearningRadiology - Anterior Mediastinal Masses- Thyroid mass
http://www.learningradiology.com/lectures/chestlectures/Thyroidmassesppt_files/frame.htm04/09/2006 1:56:08
LearningRadiology - Goodpastures Syndrome Idiopathic Pulmonary Hemorrhage
http://www.learningradiology.com/lectures/chestlectures/goodpasturesppt_files/frame.htm04/09/2006 1:56:22
LearningRadiology- Chest Trauma
http://www.learningradiology.com/lectures/chestlectures/chesttraumappt_files/frame.htm04/09/2006 1:56:39
LearningRadiology - Hamartomas of the Lung
http://www.learningradiology.com/lectures/chestlectures/hamartomasppt_files/frame.htm04/09/2006 1:56:50
Wegeners Granulomatosis
http://www.learningradiology.com/lectures/chestlectures/Wegenersppt_files/frame.htm04/09/2006 1:57:03
Histiocytosis X
http://www.learningradiology.com/lectures/chestlectures/histiocytosis_files/frame.htm04/09/2006 1:57:16
http://www.learningradiology.com/lectures/gilectures/diffusesmallflashpage.htm
http://www.learningradiology.com/lectures/gilectures/diffusesmallflashpage.htm (1 de 2)04/09/2006 1:58:08
http://www.learningradiology.com/lectures/gilectures/diffusesmallflashpage.htm
http://www.learningradiology.com/lectures/gilectures/diffusesmallflashpage.htm (2 de 2)04/09/2006 1:58:08
An Approach to Diffuse Small Bowel Disease
http://www.learningradiology.com/lectures/gilectures/diffusesmallboweldz_files/frame.htm04/09/2006 1:58:22
http://www.learningradiology.com/lectures/bonelectures/ddxsinmskflashpage.htm
http://www.learningradiology.com/lectures/bonelectures/ddxsinmskflashpage.htm (1 de 2)04/09/2006 1:59:00
http://www.learningradiology.com/lectures/bonelectures/ddxsinmskflashpage.htm
http://www.learningradiology.com/lectures/bonelectures/ddxsinmskflashpage.htm (2 de 2)04/09/2006 1:59:00
http://www.learningradiology.com/lectures/generallectures/Lateralneckwebflashpage.htm
http://www.learningradiology.com/lectures/generallectures/Lateralneckwebflashpage.htm (1 de 2)04/09/2006 2:00:03
http://www.learningradiology.com/lectures/generallectures/Lateralneckwebflashpage.htm
http://www.learningradiology.com/lectures/generallectures/Lateralneckwebflashpage.htm (2 de 2)04/09/2006 2:00:03
LearningRadiology - Pulmonary Cavities, Differential Diagnosis, Lung

Click on image to enlarge; click on hypertext for more information
Carcinoma
Abscess
Tuberculosis
Aspergilloma
http://www.learningradiology.com/notes/chestnotes/pictorialcavity.htm04/09/2006 2:00:08
LearningRadiology - Pneumonia, Atelectasis, Effusion, Pneumonectomy

Atelectasis
Effusion
Pneumonia
Pneumonectomy
http://www.learningradiology.com/notes/chestnotes/pictorialopaque.htm04/09/2006 2:00:12
LearningRadiology-Abnormal Bowel Gas Patterns, SBO, LBO, Ileus, Volvulus

Click on image to enlarge; click on text for more information
Small Bowel Obstruction
Large Bowel Obstruction
Localized Ileus
Generalized Adynamic Ileus
Sigmoid Volvulus
Normal
http://www.learningradiology.com/notes/ginotes/pictorialbowelgas.htm04/09/2006 2:00:17
LearningRadiology - Pictorial Hip Differential Diagnosis

Osteoarthritis, DJD
Rheumatoid Arthritis
Avascular Necrosis Left Hip
Charcot Hip
Pigmented Villonodular Synovitis
Intertrochanteric Fracture
Subcapital Fracture
Acetabular Protrusio-Right-Paget's
Slipped Epiphysis-Left Hip
http://www.learningradiology.com/notes/bonenotes/pictorialhipdz.htm (1 de 2)04/09/2006 2:00:33
LearningRadiology - Pictorial Hip Differential Diagnosis
Mets from Prostate Carcinoma
Chondrocalcinosis
Hips-Normal
http://www.learningradiology.com/notes/bonenotes/pictorialhipdz.htm (2 de 2)04/09/2006 2:00:33
LearningRadiology.com - hemangioblastoma,brain,tumor,child,children
Cerebellar Hemangioblastoma
q q
q q
Benign neoplasm 80% found in cerebellum r Remainder are located in spinal cord > medulla > cerebrum Account for 10% of posterior fossa masses (vestibular schwannomas and metastases rule here.) Most often occurs in ages 30 to 40 r M > F Relationship to von Hippel-Lindau disease r 20% occur in patients with von Hippel-Lindau disease (multiple lesions). r 35-60% of von Hippel-Lindau disease patients have hemangioblastomas r von Hippel-Lindau disease consists of s Retinal, spinal, cerebellar and medullary hemangioblastomas s Renal cysts and carcinomas s Pancreatic cysts s Pheochromocytomas s Papillary Cystadenoma of the epididymis Clinical findings r Headache r Ataxia r Nausea r Vomiting r Vertigo r Polycythemia caused by increased erythropoietin found in 40%. r Spinal lesions may present with subarachnoid hemorrhage Findings on CT and MRI: r Cystic lesion in the cerebellum with an avidly enhancing mural nodule (75%) r Purely solid enhancing lesion (10%) r Enhancing lesion with multiple cystic areas (15%)
http://www.learningradiology.com/notes/generalnotes/hemangioblastpage.htm (1 de 3)04/09/2006 2:00:40
MRI of brain shows a cystic lesion in the cerebellum with an enhancing nodule (post-Gadolinium)
q
Findings on angiography: r Vascular nodule within an avascular mass
Serpentine vessels Treated with surgical removal of solid nodule r Cystic component is not neoplastic DDx: o Similar appearance to Juvenile pilocytic astrocytoma But that is typically found in patients 5 to 15 years of age.
r
New Page 1
http://www.learningradiology.com/lectures/facultylectures/arthritisswfpage.htm (1 de 2)04/09/2006 2:02:21
New Page 1
http://www.learningradiology.com/lectures/facultylectures/arthritisswfpage.htm (2 de 2)04/09/2006 2:02:21
Stroke Evaluation
http://www.learningradiology.com/lectures/facultylectures/Stroke%20lecture-mod-Adam_files/frame.htm04/09/2006 2:02:32
Basic Chest X-Ray Interpretation
http://www.learningradiology.com/lectures/facultylectures/BASIC%20CXR-mod-Adam_files/frame.htm04/09/2006 2:02:42
CT Angiography
http://www.learningradiology.com/lectures/facultylectures/CT%20Angiography-mod-Adam_files/frame.htm04/09/2006 2:02:54
Evaluation of Pulmonary Nodules
http://www.learningradiology.com/lectures/facultylectures/Pulm%20nodule-mod-Adam_files/frame.htm04/09/2006 2:03:08
Back Pain Imaging
http://www.learningradiology.com/lectures/facultylectures/Back%20Pain%20Imaging-mod-Adam_files/frame.htm04/09/2006 2:03:20
Large Joint MRI An overview
http://www.learningradiology.com/lectures/facultylectures/Large%20joint%20MRI-mod-Adam_files/frame.htm04/09/2006 2:03:33
Slide 1
http://www.learningradiology.com/lectures/facultylectures/mediastinum-mod-Adam_files/frame.htm04/09/2006 2:03:45
Pulmonary Thromboembolism Imaging
http://www.learningradiology.com/lectures/facultylectures/Pulmonary%20Thromboembolism-mod-Adam_files/frame.htm04/09/2006 2:03:58
Slide 1
http://www.learningradiology.com/lectures/facultylectures/Radofthe%20pleura-mod-Adam_files/frame.htm04/09/2006 2:04:14
LearningRadiology.com-Appendicitis,Diagnosis,CT
http://www.learningradiology.com/lectures/facultylectures/appendicitispptmh_files/frame.htm04/09/2006 2:04:27
LearningRadiology.com-CT of Blunt Abdominal Trauma,renal,hepatic,liver,lacreation,splenic,spleen,rupturebladder,tear
http://www.learningradiology.com/lectures/facultylectures/ctblunttraumapptmh_files/frame.htm04/09/2006 2:04:41
LearningRadiology.com-CT of Acute Aortic Non-traumatic Disease,Dissecting,Aneurysm,Hematoma,Itramural
http://www.learningradiology.com/lectures/facultylectures/ctofnontraumaaorticdzmh_files/frame.htm04/09/2006 2:04:53
LearningRadiology.com-Imaging in PID, US and CT,pelvic,inflammatory,disease,PID,ultrasound
http://www.learningradiology.com/lectures/facultylectures/pidpptmh_files/frame.htm04/09/2006 2:05:10
LearningRadiology.com-Acute Abdominal Pain and CT
http://www.learningradiology.com/lectures/facultylectures/ctacuteabdpainpptmh_files/frame.htm04/09/2006 2:05:22
LearningRadiology.com-Carotid Sonography Avoidable and Unavoidable Errors
http://www.learningradiology.com/lectures/facultylectures/carotidsonographyppt_files/frame.htm04/09/2006 2:05:36
LearningRadiology-Retroperitoneal Spaces Anatomy and Pathology of the Urinary Tract
http://www.learningradiology.com/lectures/facultylectures/retroperitonealpptmh_files/frame.htm04/09/2006 2:05:52
Multi-slice CT: Principles and Perspective
http://www.learningradiology.com/lectures/facultylectures/multislicectmh_files/frame.htm04/09/2006 2:06:08
Ectopic Pregnancy
http://www.learningradiology.com/lectures/facultylectures/Ectopic%20Pregnancy%20MH_files/frame.htm04/09/2006 2:06:19
learningRadiology-Ultrasound of Renal Transplantation,US,kidney,transplant,reject,rejection
http://www.learningradiology.com/lectures/facultylectures/usrenaltransplantppt_files/frame.htm04/09/2006 2:06:33
http://www.learningradiology.com/lectures/facultylectures/Stone%20Search%20Lecture%202004-MH.htm (1 de 2)04/09/2006 2:07:45
http://www.learningradiology.com/lectures/facultylectures/Stone%20Search%20Lecture%202004-MH.htm (2 de 2)04/09/2006 2:07:45
LearningRadiology.com-Abdominal Pain
http://www.learningradiology.com/lectures/facultylectures/abdominalpain_files/frame.htm04/09/2006 2:07:51
LearningRadiology.com-Women's Imaging,mammography
http://www.learningradiology.com/lectures/facultylectures/womensimaging_files/frame.htm04/09/2006 2:07:57
LearningRadiology.com-CT Evaulation of the GI Tract
http://www.learningradiology.com/lectures/facultylectures/gitract_files/frame.htm04/09/2006 2:08:06
LearningRadiology.com-MRI of Abdomen
http://www.learningradiology.com/lectures/facultylectures/mriofabdomen_files/frame.htm04/09/2006 2:08:16
LearningRadiology.com-Evaulation of Jaundice
http://www.learningradiology.com/lectures/facultylectures/evalofjaundice_files/frame.htm04/09/2006 2:08:24
LearningRadiology.com-Skeletal Trauma
http://www.learningradiology.com/lectures/facultylectures/skeletaltrauma_files/frame.htm04/09/2006 2:08:31
LearningRadiology.com-GU,Renal,Kidney,Bladder,trauma
http://www.learningradiology.com/lectures/facultylectures/gutrauma_files/frame.htm04/09/2006 2:08:37
LearningRadiology.com-Flank Pain
http://www.learningradiology.com/lectures/facultylectures/flankpain_files/frame.htm04/09/2006 2:08:43
LearningRadiology.com-Acute Abdominal Emergencies
http://www.learningradiology.com/lectures/facultylectures/acuteabdemergencies_files/frame.htm04/09/2006 2:08:50
http://www.learningradiology.com/lectures/facultylectures/herniaspageswf.htm
http://www.learningradiology.com/lectures/facultylectures/herniaspageswf.htm (1 de 2)04/09/2006 2:09:31
http://www.learningradiology.com/lectures/facultylectures/herniaspageswf.htm
http://www.learningradiology.com/lectures/facultylectures/herniaspageswf.htm (2 de 2)04/09/2006 2:09:31
LearningRadiology.com-Basics of Intravenous Urography,IVP,IVU
http://www.learningradiology.com/lectures/facultylectures/ivpbasics_files/frame.htm04/09/2006 2:09:40
LearningRadiology - Pictorial Hand Arthritis

Osteoarthritis
Gout
Sarcoid
Jacquoud's Arthritis
Lupus
Psoriatic Arthritis
Normal hand
http://www.learningradiology.com/notes/bonenotes/pictorialhands.htm04/09/2006 2:09:44
LearningRadiology - Pictorial Foot Arthritis

Gout
RA
Psoriatic Arthritis
Charcot Arthropathy
Scleroderma
Septic Arthritis
http://www.learningradiology.com/notes/bonenotes/pictorialfeet.htm04/09/2006 2:09:49
http://www.learningradiology.com/caseofweek/caseoftheweekpix2006/cow218arr.jpg
http://www.learningradiology.com/caseofweek/caseoftheweekpix2006/cow218arr.jpg04/09/2006 2:09:54
Case of the Week
Case of the Week
Giant cell tumor

426 X 480 24 KB
Scleroderma
404 X 480 29 KB
Pulmonary sling
380 X 480 20 KB
PCP
744 X 582 33 KB
Dematomyocitis
500 X 480 26 KB
Dermoid
320 X 226 17 KB
Dermoid
320 X 218 17 KB
Diverticulitis
360 X 480 21 KB
Double Aortic Arch

360 X 480 17 KB
Ebsteins anomaly
594 X 480 27 KB
Fahr's disease
352 X 480 29 KB
Fahr's disease
376 X 480 32 KB
Case of the Week
Fahr's disease
360 X 480 27 KB
Fibrous dysplasia
276 X 480 12 KB
Gout
214 X 240 6 KB
Hamartoma
550 X 480 13 KB
Hamartoma
640 X 456 33 KB
Hamartoma
640 X 418 29 KB
Hamartoma
640 X 418 29 KB
Lipoid pneumonia
318 X 240 14 KB
Case of the Week
Case of the Week
Esophageal varices
800 X 585 53 KB
Deep sulcus sign

600 X 640 31 KB
Intussusception
437 X 602 46 KB
Penetrating aortic ulcer

610 X 480 37 KB
Emphysematous pyelonephritis
760 X 501 74 KB
640 X 398 48 KB
310 X 400 27 KB
Salivary gland stone

472 X 640 34 KB
Case of the Week
Transitional cell carcinoma

348 X 800 31 KB
Lymphangiomyomatosis
450 X 338 23 KB
Pulmonary artery hypertension

683 X 640 34 KB
Case of the Week (1 of 131)
AAA-ruptured
http://www.learningradiology.com/images/caseoftheweekimages/cowgallerypages/aneurysmrupture2.html04/09/2006 2:10:03
Ascariasis
http://www.learningradiology.com/images/caseoftheweekimages/cowgallerypages/Ascariasis.html04/09/2006 2:10:05
Ascariasis
http://www.learningradiology.com/images/caseoftheweekimages/cowgallerypages/Ascariasis-Ba in worm.html04/09/2006 2:10:06
ASD
http://www.learningradiology.com/images/caseoftheweekimages/cowgallerypages/ASD.html04/09/2006 2:10:07
AVN
http://www.learningradiology.com/images/caseoftheweekimages/cowgallerypages/AVN-Knees-AP.html04/09/2006 2:10:09
http://www.learningradiology.com/images/caseoftheweekimages/cowgallerypages/boerhaavesbaswallow.html04/09/2006 2:10:11
http://www.learningradiology.com/images/caseoftheweekimages/cowgallerypages/boerhaavesct.html04/09/2006 2:10:13
Calcinosis universalis
http://www.learningradiology.com/images/caseoftheweekimages/cowgallerypages/Calcinosis universalis.html04/09/2006 2:10:14
http://www.learningradiology.com/images/caseoftheweekimages/cowgallerypages/CAM1.html04/09/2006 2:10:16
Charcot joint
http://www.learningradiology.com/images/caseoftheweekimages/cowgallerypages/Charcotknees.html04/09/2006 2:10:18
Chondrocalcinosis
http://www.learningradiology.com/images/caseoftheweekimages/cowgallerypages/Chondrocalcinosisknee.html04/09/2006 2:10:19
Crohn's Disease
http://www.learningradiology.com/images/caseoftheweekimages/cowgallerypages/chrons.html04/09/2006 2:10:21
http://www.learningradiology.com/images/caseoftheweekimages/cowgallerypages/conglobaremphysema.html04/09/2006 2:10:23
Radiation fibrosis
http://www.learningradiology.com/images/caseoftheweekimages/cowgallerypages/cow32pic1.html04/09/2006 2:10:25
Charcot joint
http://www.learningradiology.com/images/caseoftheweekimages/cowgallerypages/cow33pic1.html04/09/2006 2:10:26
http://www.learningradiology.com/images/caseoftheweekimages/cowgallerypages/cow34pic.html04/09/2006 2:10:28
Ruptured AAA
http://www.learningradiology.com/images/caseoftheweekimages/cowgallerypages/cow35.html04/09/2006 2:10:30
Hereditary Exostoses
Pulmonic stenosis
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Renal Papillary Necrosis
Necrosis of the renal medullary pyramids and papillae with many causes, all of which mediate the development of ischemia Infection is frequent finding, contributing to the clinical presentation of with fever and chills in about 2/3 of patients and positive urine cultures in 70% o But papillary necrosis can also develop without infection being present Inflammatory reaction in the interstitium of the kidney compresses and compromises the medullary vasculature and predisposes the patient to ischemia and papillary necrosis Other diseases can also impair this circulation, among them o Diabetes mellitus o Urinary obstruction o Analgesic nephropathy Phenacetin, with its toxic metabolite, p-phenetidin Also occurs with NSAIDS (non-steroidal anti-inflammatory drugs) But usually with another predisposing factor present Any condition associated with ischemia predisposes a person to papillary necrosis, such as o Shock o Dehydration o Hypovolemia o Sickle cell disease o Tuberculosis o Trauma o Cirrhosis = alcoholism o Coagulopathy o Renal vein thrombosis o Hemophilia o Christmas disease o Acute tubular necrosis
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Most patients who develop papillary necrosis have two or more contributing factors Usually bilateral o Can affect a single papilla or entire kidney may be involved Mean age of onset is 53 years o More than 90% of cases occur in individuals older than 40 o Uncommon in patients younger than 40 and in the pediatric population More often in women than in men Types o Focal = involves only the tip of the papilla o Diffuse = involves the whole papilla and parts of the medulla o Pathologically divided into medullary form and papillary form dictated by degree of ischemia
Clinical findings o Fever and chills o Flank and/or abdominal pain o Hematuria o Acute ureteral obstruction from sloughed papillae manifests as flank pain and colic from hydronephrosis or pyonephrosis Hematuria is almost always present Clinical picture in such cases may also include fever, chills and sepsis. Imaging findings o The kidneys are usually normal in size until they contract in the late stages of the disease o Linear streak of contrast may appear inside of calyces representing void left by sloughed papilla (lobster claw sign) o Widening of the fornices from shrinking of the papillae o Larger collection of contrast may fill cavities inside of calyces representing a calyx without a papilla o Ring shadows can develop in the medulla outlining detached papilla within contrast material-filled cavity Often in a triangular shape, referred to as the ring sign o Sloughed papillae can produce filling defects in internal collecting system or ureters o The ring shadow or sloughed papilla can rarely calcify Complications o Infection o Obstruction
Coronal image of the left kidney from a CT Urogram shows numerous irregular collections of contrast arising from the calyces, some streak-like densities and overall distortion of the normal medullary-calyceal anatomy For a larger version of this same photo, click here
References: eMedicine Jeffrey M Donohoe, MD, Pediatric Urology Fellow, Department of Urology, Vanderbilt University Medical Center. Jack H Mydlo, MD, Chief, Department of Urology, Woodhull Hospital; Chair and Professor, Department of Urology, Temple University School of Medicine. Ali Nawaz Khan, MBBS, FRCP, FRCR, Consultant Radiologist, Department of Diagnostic Radiology, North Manchester General Hospital. Muthusamy Chandramohan, MBBS, DMRD, FRCR, Special Registrar, Department of Radiology, Manchester Radiology Sumaira Macdonald, MBChB, MRCP, FRCR, PhD, Lecturer, Sheffield University Medical School; Endovascular Fellow, Sheffield Vascular Institute
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A. Diverticulitis B. Pelvic Congestion Syndrome C. Molar Pregnancy D. Vena caval obstruction

34 year-old female with chronic pelvic pain

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MEMORANDUM To From Medical Records Janet Birkmann Academic Coordinator x. 67378 _______________________ Medical Records Access for Medical Student or Intern
Date Re
Please allow the following medical student access to Medical Records during his or her rotation in the Department of Radiology. Thank you.
Name: School/Hospital: Dates of rotation:
URLs for medical students doing rotations at Einstein (primarily Jefferson medical students):
Internet Access for Medical Students 2004-2005 User ID: Password: .JeffStudent.common (note the period in front of Jeff...) jefferson (note: all lowercase)
PLEASE be sure to use the fully qualified user id ".jeffstudent.common", then it doesn't matter where you log in since the context is included. The generic student logon is restricted to approved URLs on the internet, listed below. URLs for Medical Students Doing Rotations at Einstein E-mail: JeffMail http://jeffmail.jefferson.edu/ Jefferson campus news, calendars (Pulse): http://pulse.jefferson.edu/ Last Word tutorial (CIS/CBT) on AEHN Intranet: http://e-net/cbt Jeffline (not Einstein@Jeffline): http://jeffline.tju.edu/ Includes Jefferson's subscriptions to MD Consult, StatRef, Harrison's Online, Ovid databases, Jefferson's full-text e-journals, AccessLange texts, etc. Micromedex on AEHN Intranet: http://aegrap-mmw/mmx UpToDate: http://www.utdol.com/ PubMed: http://www.pubmed.gov/ ScienceDirect e-journals (AEHN titles): http://www.sciencedirect.com/ Einstein Library Web Site (for list of print journals, AEHN e-journals): http://www.einstein.edu/
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URLs for medical students doing rotations at Einstein (primarily Jefferson medical students):
(then click on Education/Residency, then Einstein Medical Libraries) LearningRadiology.com http://www.learningradiology.com/
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MEMORANDUM TO FROM DATE RE : : : : Radiology Residents Medical Students Janet L. Birkmann Academic Coordinator July 1, 2004 Radiology Library and Learning Center Maintenance
Library and Learning Center materials are for the sole use of members of the Department of Radiology. Any other use of these materials is prohibited without the permission of Dr. Herring. Each resident is given a key to the locked, glass-door book cabinets in the library. The books in these cabinets are not to be removed from the library, and should be re-locked each time you are finished with them. Books that disappear from the locked book cabinet will not be re-purchased. Reshelve books and journals when you are finished using them. Do not remove books from the Reference Section from the library. Other books from the regular library shelves may be signed out for a week. Place the signout card in a yellow plastic folder and leave it in the section you took the book from. Residents are assigned on a weekly basis to replace all unshelved items in the library. The clean-up schedule is posted in the library and distributed to each resident. Keep the doors to the Learning Center and to the Medical Student Classroom closed and locked after hours and on weekends. Please leave chairs, tables, stepstools, etc., in place when you leave the room. If you eat or drink, please clean up after yourselves!
ALBERT EINSTEIN MEDICAL CENTER Department of Radiology MEDICAL STUDENT ABSENCE REPORT FORM
Please use this form to report all absences during your rotation. If you know the dates in advance (interviews, etc.), turn the form in to Janet Birkmann beforehand (you may leave it on her desk or under her door). If you are sick, please leave a phone message with Janet at (215) 456-7378, and then fill out the form when you return to the department. Thank you.
Name:
Date(s) out:
Reason:
There are more copies of this form in top drawer of desk in Medical Student Classroom
Radiology Elective - Albert Einstein Medical Center

Internet Access Internet access is available to medical students through a generic user ID and password assigned by the hospital. Further information about this is included in this packet. Student Webpage A webpage has been established exclusively for the use of our medical students at www.learningradiology.com/studentpage.htm. Most of the information contained in this packet, as well as additional useful links, can be found there. Parking Jefferson students: take attached memo to Security Department to obtain free parking in Employee Garage. Other students: take attached memo to Cashier and then to Security Department to obtain reduced-fee parking in Employee Garage. Absences Please use the Pink Form available in the top desk drawer in the classroom to inform Janet of all absences. Attachments Parking Memo Medical Records Memo Internet Access for Medical Students General Information and Instructions Radiology Department Directory, including Staff and Resident Beeper Numbers Radiology Resident Master Schedule Info re: www.LearningRadiology.com Radiology Resident Conference Schedule (blue) Absence Form (pink)
Albert Einstein Medical Center Philadelphia, Pennsylvania Medical Student Elective Program in Diagnostic Radiology General Information and Instructions Susan L. Summerton, MD, Director of Medical Student Education Janet L. Birkmann, Academic Coordinator Welcome to the Radiology Department. We are very pleased to participate in your education and have planned an experience that we hope you will find both educational and enjoyable. Your Headquarters We have established an audiovisual classroom in our Radiology Learning Center specifically for our medical students and other electives. This room will serve as the site for most of your lectures/conferences and will afford you a comfortable space to use our audiovisual instructional materials. You may also use the nearby computers with Internet access to help in the preparation of your required project. Only those individuals assigned to the Radiology Department on elective may use this room and equipment, which is available between 9:00 am and 5:00 pm weekdays. None of the equipment may be removed from this area. We ask that you keep this room clean and orderly. Schedule You will meet with Dr. Sue Summerton at the beginning of your elective to develop a schedule for the month. The program is designed to give you the broadest introduction to diagnostic radiology through a combination of didactic lectures, digital teaching resources and over-the shoulder film reading. The typical day begins with your attendance at the departmental 8:00 am conference. If there is no 8:00 am conference or if you choose not to attend an optional 8:00 am conference, the starting time is between 8:45 and 9:00 am. The usual finishing time is 5:00 pm. Departmental Conferences Two one-hour conferences are held most days starting promptly at 8:00 am and 12:00 noon in the Isard Amphitheater. A copy of the conference schedule will be given to you when you begin your rotation or can be found posted in your classroom or the consultation room. While these conferences are aimed primarily at a resident level, you will still find them very informative, and we expect you to attend. We ask that you do not eat in the Isard Amphitheater; please eat lunch before or after noon conference.
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Medical Student Elective Program General Information and Instructions
Check the conference schedule carefully. On some Thursdays, the morning conference will be pre-empted by a staff meeting or a pediatric radiology conference at St. Christophers Hospital. Radiology Grand Rounds typically occur on the first Wednesday of each month at 4:00 pm. Attendance at the morning Physics Conferences and the Journal Club is optional. Observing the Diagnostic Process Unlike some of your other rotations where you are given primary responsibility to care for a patient, it is impossible to permit you to officially interpret or perform radiological studies. However, you will learn a great deal of radiology by observing the interpretation and performance of examinations. When "free time" is available to you, we urge you to pull up a chair and observe the reading of films with either a staff radiologist or a resident in the consultation room. You will be an active participant, as our staff will frequently give you an opportunity to find the radiological abnormalities and will teach you about the various diseases. Your confidence and ability will increase as you put the information learned from texts and lectures into practice. You will observe clinical consultations from the perspective of the radiologist, so that you will become a good consultant when ordering studies in the future. Observing patients as they undergo radiological procedures will allow you to see exactly what the patient experiences. In the future when you will be ordering these examinations, you will be able to correctly address your patients questions and concerns about the examination. You will also know what stamina will be required of your patient to permit the radiologist to perform a good quality study. You will have the opportunity to observe the performance of fluoroscopy, ultrasound, vascular ultrasound, CT, MRI, nuclear medicine and angiographic studies. This rotation will expose you to the many ways diagnostic imaging will help you in clinical problems that will arise in your future training and should make you more comfortable in viewing some of the imaging studies you will order. Core Book For Your Elective The Department will provide each medical student with a radiology textbook. The book is to be signed out at the beginning of the rotation with Janet Birkmann and returned promptly at the end of the rotation. Return of the textbook ensures timely filing of your course grade. We have selected this book for its specific interest and educational value for medical students. It is, therefore, required reading. Lockers Lockers in the Medical Student Classroom will be provided for your personal belongings. Please lock up any valuables or books. The department or hospital cannot be responsible for loss of personal items.
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Telephone Communications Janet has four hospital pagers that our student group can share. All beepers have a 4 digit pager number. To page someone internally, enter 52; after the beep, enter 2 and the four digit pager number you want to activate; after some more beeps, enter 6 and the four digit telephone extension where you wish to be called. These pagers can also be activated from outside the hospital by using the long-range pager access number 215-363-5000 and entering the 4 digit pager number as the pin. Another way to receive outside calls is by direct connection through the Einstein operators. Your caller should dial 215-456-7890 and ask to be connected to your pager number. You will then be able to pick up the call from any extension by entering the number sequence that appears on your pager. Contact Information: Susan Summerton, MD Janet Birkmann Radiology main number Cardiac Arrest Hospital Security Fire Dress Code The dress code is simple: We expect you to present a professional appearance on the rotation. Everyone is expected to wear a white lab coat. Males are expected to wear a tie. Please wear a name badge at all times. Please wear scrubs when you are assigned to rotate in Special Studies. Absences If you know in advance that you will be absent from the department, please use the pink forms in the top drawer of the desk in the student classroom to indicate your name and the day(s) you will be absent and give this to Janet for your file. If you need to call in for a same-day absence, please call Janet at 215-456-7378. If she is not available, then contact Dr. Summerton or Dr. Herring at 215-456-3438 or 215-456-6226, respectively. Fill in a pink form when you return. Library The department's library is open from 9:00 am to 5:00 pm weekdays. Books can always be used in the library; some may be signed out with Janet for at-home study. Books in the Reference Section or the locked book cabinets may not be signed out of the library. Use of the library is restricted to those students on rotation in the department at the time of their rotation. Beeper in-house 3781; long range 215-363-5000 (pin 23781) SummertonS@einstein.edu 215-456-7378 birkmanj@einstein.edu 215-456-6200 x. 66161 x. 66918 x. 66911
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Case Presentation Near the conclusion of your rotation, you will be expected to deliver a 10-15 minute PowerPoint presentation of a case to the other students and a staff radiologist. The case should be one you have seen while on the rotation. You can ask for assistance in selecting a case from radiology staff or residents and for help obtaining images from our PACS system for use in your PowerPoint presentation. The presentation should include the patients clinical history and clinical findings, a description of the findings on the films, the classical findings for all patients with this disease, as well as a discussion of the disease itself. You should summarize the role that radiology played in determining the diagnosis and offer your opinion about the utilization of radiologic studies, i.e., were the optimal studies performed, was utilization of radiologic services cost-effective, etc. Your case presentation may be used as a Case of the Week on www.learningradiology.com: Consult the site to see how previous Cases of the Week appear (look under Archives). Use an Einstein case - do not use any other institutions case as this is an infringement of their copyright. It must be a case in which you can make the diagnosis on one image. It can be any modality, any organ system. In Microsoft Word (any version), type a one page, or less, summary that includes the findings on your image, the etiology, incidence, pathology and overall findings of whatever disease it is and the prognosis and treatment. Do not use anyone elses material verbatim change the wording so as not to infringe on copyright. Place the Word Document summary of your case and your PowerPoint presentation on a CD. Clearly label the CD with your name and the diagnosis. You will be credited by name both on the opening splash page and the jump page on which the correct answer and your blurb appear; Cases of the Week are archived so that your contribution and its attribution will always remain on the site.
Grading Grades for the clerkship will be based on your level of attendance/participation in the elements of the teaching program and the quality of your Case of the Week presentation. You will discover that radiology is traditionally taught in a Socratic style, which we feel enhances the learning experience through active participation of the student. You may be asked to make a diagnosis during view-box teaching sessions or conferences; feel free to participate fully without fear that your grade will be diminished if you give a wrong answer. Course Evaluation We shall ask you to complete an evaluation of this rotation at the conclusion of your stay. You are not required to sign it but may do so if you wish. Please feel free to answer the evaluation honestly so that we can make improvements and adjustments for future rotations. The completed evaluation should be placed in Dr. Summertons mailbox at the front of the department.
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MEMORANDUM To Cashier ** Tower Building Lobby Albert Einstein Medical Center Cindy Dowhower Parking and Access Control Coordinator Protective Services Tabor Road From Janet Birkmann Academic Coordinator x. 67378 _______________________ Parking Access for Medical Student or Intern
Date Re
Please allow parking privileges for the medical student or intern listed below. Thank you.
Name: School/Hospital: Dates of rotation:
** Students - Go to cashier first
ALBERT EINSTEIN MEDICAL CENTER DIAGNOSTIC RADIOLOGY RESIDENCY PROGRAM CONFERENCE CALENDAR
AUGUST 23, 2005 SEPTEMBER 23, 2005 MONDAY
August 29
Physics-Nunno Course Content
TUESDAY
30
WEDNESDAY
31
THURSDAY
September 1
[Staff Meeting]
FRIDAY
2
Cardiac Radiology-Herring Cong. Heart Dzs 8 a.m. 9 a.m.
Staff/Resident Conference MSK Conference-Kricun 7 a.m. 9 a.m. Course Content 8 a.m. 9 a.m. Interesting Cases 8 a.m. 9 a.m.
Nuclear Medicine-Eisenberg GI Conference-Summerton MRI Conference-Wable Chest Conference-Guttentag Neuroradiology-Garfinkle Course Content Noon 1 p.m. Course Content Noon 1 p.m. Course Content Noon 1 p.m. Course Content Noon 1 p.m. Course content Noon 1 p.m.
Board Examination Day
Staff/Resident Conference CT Conference-Summerton Pediatric Radiology-Faculty Course Content 8 a.m. 9 a.m. Interesting Cases 7:30 a.m. 8:30 a.m. 8 a.m. 9 a.m. At St. Chris Nuclear Medicine-Tran MRI Conference-Kirby Chest Conference-Guttentag Course Content Noon 1 p.m. Course Content Noon 1 p.m. Course Content Noon 1 p.m.
No Conferences
LABOR DAY 12
13
14
15
16
M&M Conference MSK Conference-Kricun 7 a.m. 9 a.m. Course Content 8 a.m. 9 a.m. Chest
Interesting Case Conference IR Conference-Oleaga 8 a.m. 9 a.m. Herring/Loeffler 8 a.m. 9 a.m. Course Content 8 a.m. 9 a.m.
GI Conference-SS/Shrivastava GU Conference-Horrow MRI Conference-Wable US Conference-Kirby Neuroradiology-Sattenberg Interesting Cases Noon 1 p.m. Course Content Noon 1 p.m. Course Content Noon 1 p.m. Course Content Noon 1 p.m. Course content Noon 1 p.m.
19
20
Institutional Curriculum 7am
21
22
23
Staff/Resident Conference MSK Conference-Kricun Mammography-Copit General Conference-Herring 7 a.m. 9 a.m. Course Content 8 a.m. 9 a.m. Interesting Cases 8 a.m. 9 a.m. Interesting Cases 8 a.m. 9 a.m. 8 a.m. 9 a.m. Course Content No Conference Hospital Outing
All Conferences Are held in the Isard Amphitheater Unless Otherwise Noted
GU Conference-Horrow/Hoang CT/US Conference-Horrow Interesting Cases Noon 1 p.m. Course Content Noon 1 p.m.
Rad/Path Conference Neuroradiology-Garfinkle Noon 1 p.m. Griffith/Wable Noon 1 p.m. Course Content
Radiology Department Directory August 25, 2005 Staff Radiologists Brady, Paul Copit, Debra Eisenberg, Daniel Fuscaldo, Karen Garfinkle, William Guttentag, Adam Haber, Scott Herring, William Horrow, Mindy Kirby, Cheryl Kricun, Morrie Matalon, Terence Oleaga, Juan Rodgers, Shuchi Saragovi, Armand Sattenberg, Ronald Slizofski, Walter Summerton, Susan Tran, Huyen Wable, Sumathi Beeper 4026 3072 3875 2674 3947 4484 4212 24025 2179 4265 2520 215-265-1601 4339 3468 3465 3681 3741 3781 3655 3795 Phone x. 6266 x. 6250 x. 6267 x. 6250 x. 6256 x. 6229 215-827-1415 x. 6226 x. 8229 x. 6230 x. 6225 x. 6258 x. 3439 x. 3446 x. 6231 x. 2318 x. 3438 x. 6265 x. 6228 Chairman
Residents 2005-2006 Allen, David Blumenthal, Beth Brody, Marion Chang, Anthony Chaudhri, Yasmin DeMauro, Christopher Dorff, Jonathan Griffith, Heather Hasan, Seema Herzberg, Tara Hoang, Gil Hoffman, Matthew Jung, Jennifer Kowal, Daniel Krasner, Matthew Lee, David Loeffler, Lisa Polasani, Rajeev Sareen, Priya Shevade, Vikas Shrivastava, Abhishek Smith, Ryan Toshav, Aran
Beeper 3679 5112 3002 3869 3069 3874 4505 3876 4896 4506 4211 3321 3871 4246 5127 4186 3258 5113 2509 5128 4504 2027 3873
Chief Resident
Office x. 65191
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Radiology Department Directory August 25, 2005
Name/Place Administrator: Tina Sawycky Amanullah, Aman (Cardiology) Armstrong, Donna Baird, Cathy Belmont Benson, Bonnie Birkmann, Janet Bond, Denise Bryan, Joanne Buckley, Jill Burke, Donna Cafeteria CCU
Beeper 5401 4210
Phone x. 6205 x. 7266 x. 5830 x. 6250 215-877-2000 x. 6398 x. 7378 x. 6577 x. 2344 215-827-1402 x. 6253 x. 6429 (a) x. 8516 (b) x. 8518 (c) x. 8510 x. 65191 x. 6161 x. 6264 x. 6237 215-827-1400 215-827-1403 215-827-1402 215-827-1416 215-827-1417 x. 3450 x. 6359, 8063, 8064 x. 6358 x. 1741, 1742 x. 1743, 1744 Page Operator: 215-663-6000
215-961-3176
Chief Residents Office Code Blue Colucci, Karen (Radiation Safety) Conference Room CORA Front Desk CORA File Room CORA Manager CORA Physician CORA Physician Cranage, Patty CT CT (voicemail) ED - CT ED - Reading Room Elkins Park Hospital Radiologists: Harvey Koolpe, MD Harry Lessig, MD Murray Levyn, DO Steven Munzer, MD Fax: Janet Birkmann Fax: Kathy Quaterola Fax: MNAP Reading Station File Clerk (messenger) File Room
4013
215-961-3176
4825
215-456-1749 215-456-6227 215-456-7184 3157 x. 2258, 6298, 6299
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Name/Place Fluoroscopy Fluoroscopy (voicemail) General X-ray - Hall Phone Germantown - ED Germantown - File room Germantown - PET Germantown - Tech Hanlin, Joanne Hook, Jeanie Humphrey, Roger ICN ICU 4th floor
Beeper No.
Phone Ext. x. 6279 x. 6278 x. 6277 215-951-8060 215-951-8767 215-842-1100
3675 2629 2541
x. 3323 x. 7306
ICU Reading Room Jeff Tech Leo Hoffman Klein Radiology Language Bank Learning Center Levy Lobby front desk Library Luria HB4 Library Radiology Luu, Tram MacMillan, Robert (Cardiology) Mammo Reading Room Mammo Techs Medical Records Medical Student Beepers Medical Student Classroom MNAP MossRehab MREP (MossRehab at Elkins Park) MREP - CT MREP - File Room MREP - File Room Fax MREP - General MREP - Mammo MREP - Manager MREP - MRI MREP - Nuclear Medicine MREP - Reading Room
MREP - Scheduling MREP - Scheduling Fax
x. 6828 (a) x. 8416 (b) x. 8418 (c) x. 8410 x. 8953 215-308-8611 x. 6128 x. 6247 x. 6055 x. 5101 x. 6411 x. 6345 x. 3310 5446 x. 6433 x. 8991 x. 6245 x. 6254 x. 6800 beepers 4907, 4908, 4909, 4617 x. 5102 215-464-3300 215-456-9900 Inside AEMC: Outside AEMC: 215-663-6441 x. 81-6441 215-663-6082 x. 81-6082 215-663-8378 x. 81-8378 215-663-6080 x. 81-6080 215-663-4011 x. 81-4011 215-663-6076 x. 81-6076 215-663-6054 x. 81-6054 215-663-6073 x. 81-6073 215-663-6507 x. 81-6507 215-663-6508 x. 81-6508 215-663-6509 x. 81-6509 215-663-6200 x. 81-6200 215-663-6230 x. 81-6230
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Name/Place MREP - Special Studies MREP - Transcription MREP - US / Vascular Lab MREP - Vascular Acc MRI Molloy, Joann (Radiation Safety) NICU Reading Room Nuclear Med - General Imaging Nuclear Med - Hall phone Nuclear Med - Hot Lab Nuclear Med - Main number Nuclear Med - On-Call Tech Nuclear Med - Reading Rm - Cardiac Nuclear Med - Reading Rm - General Nuclear Med - Stress Lab Nuclear Med - Vertex Cardiac Scan Nuclear Med - Wet Lab Oliner, Craig, MD (Cardiology) On-Call Radiology Resident OR OR Tech (call) OR X-Ray Ortho X-ray PACS - David Wild PACS - Roger Humphrey PACS - Eric Richardson Pathology PA - Special Studies Portable Techs - ICU/CCU Portables Portable Techs - House Portables QA Technologist Quaterola, Kathleen Radiation Oncology Radiation Safety Reading Room - Body CT Reading Room - CR Reading Room - MRI Reading Room - Neuro Resident On-Call Bedroom Richardson, Eric Sawycky, Tina Security Smith, Kevin (Radiation Safety) Smith, Toni
Beeper No. x. 81-6440 x. 81-6042 x. 81-6371 x. 81-6078 4530
Phone Ext. 215-663-6440 215-663-6042 215-663-6371 215-663-6078 x. 5858, 6535 x. 6752 x. 7709 x. 4617, 8253 x. 2163 x. 2275 x. 6261 x. 6274 x. 6743 x. 8169 x. 7274 x. 2375 x. 7260 x. 6885
4129
3570 2180 4103
x. 5893 x. 7902 5443 2541 5442 5446 3635 3281 x. 6120 x. 6433
4013
x. 6577 x. 6221 x. 6280 x. 6264, 6273, 6752 x. 2567 x. 2577 x. 2580 x. 2566 x. 5192 x. 6205 x. 6918 x. 6273 x. 6298
5442 5401 4833
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jlb
Name/Place Special Studies Tech (on call) Special Studies Special Studies (voicemail) Supervisor - CT Supervisor - File Room - Toni Smith Supervisor - General - Maureen Finn Supervisor - MRI - Diane Buck Supervisor - Nuc Med Supervisor - Specials - MaryAnn Wilson Supervisor - US - Mike Czeredarczuk Tech School Classroom Tech School Office Tower Lobby front desk Transcription Trauma CAT Scan Trauma EU Ultrasound Ultrasound Techs Vascular Lab Walsh, Kathleen Wild, David Willowcrest Willowcrest - Ortho Xray
Beeper No. 4072, 4073
Phone Ext.
3680 3058 4073 5008
x. 6433, 6435 x. 6238 Supervisor Office x. 6359 Supervisor Office x. 2258 Supervisor Office x. 6277 Supervisor Office x. 5858 Supervisor Office x. 6221 Supervisor Office x. 6433 Supervisor Office x. 8284 x. 2659 x. 6234, 6398 x. 6412 x. 2344, 6209
2212 2202 x. 3841, 2585, 3046 4162 4910 5443 x. 8284, 3160, 3161, 8199 x. 6239 x. 8765 x. 7902
-5-
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Case of the Week for www.learningradiology.com

Preparing a case for Case of the Week Consult the site to see how previous Cases of the Week appear (look under Archives) Select one of Einsteins cases do not use any other institutions cases as this is an infringement of their copyright It must be a case in which you can make the diagnosis on one image It can be any modality, any organ system Take a digital picture of the case Use these settings: VGA, black and white if your camera has it. The file size should be at least 50Kb. Larger files will be reduced in size by me so that they load faster when a page is accessed on the web. Smaller files may appear pixilated. Save the image as a JPEG or JPG image In Microsoft Word (any version), type a one page, or less, summary that includes the findings on your image, the etiology, incidence, pathology and overall findings of whatever disease it is and the prognosis and treatment. Do not use anyone elses material verbatim-change the wording so as not to infringe on copyright If you want, you can include a second image which could appear on the answer page Place the files (one or two images and one Word file) on a floppy disc we can provide Clearly label the disk with your name and the diagnosis You will be credited by name both on the opening splash page and the jump page on which the correct answer and your blurb appear; Cases of the Week are archived so that your contribution and its attribution will always remain on the site
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http://www.learningradiology.com/cgi-bin/quickquiz/results.cgi?param1=quiz0004&quizno=0004
General Quiz 001 Emergency, Emergency! General Statistics

Total Participants 10102 Average Score 3.52
Grade Statistics
Grade
Great - A Okay - B Try again - C
Scoring Range Frequency

[5, 4] [3, 2] [1, 0] [, ] [, ] 6012 2856 1234 553 553
Percent
59.5 28.3 12.2 5.5 5.5
Display the Top 8

Name
goli goli KK
Total Score
5 5 5
Percent Date
100 100 100 100 100 100 100 Sunday September 3, 2006 Sunday September 3, 2006 Sunday September 3, 2006 Sunday September 3, 2006 Saturday September 2, 2006 Saturday September 2, 2006 Saturday September 2, 2006
a. alrajab 5 fk miao k 5 5 5
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asdf
100
Saturday September 2, 2006
[Do the Quiz] [Home]
Chest Quiz 101 Whiteout! General Statistics

Grade Statistics
Grade

[5, 4] [3, 2] [1, 0] [, ] [, ] 3142 2759 1477 720 720
Percent
42.6 37.4 20.0 9.8 9.8
Display the Top 8

Name
sammy goli a.alrajab
Total Score
5 5 5
Percent Date
100 100 100 100 100 100 100 100 Sunday September 3, 2006 Sunday September 3, 2006 Sunday September 3, 2006 Saturday September 2, 2006 Friday September 1, 2006 Thursday August 31, 2006 Thursday August 31, 2006 Thursday August 31, 2006
dr amisha 5 bk kong dawo RUEDY 5 5 5 5

Chest Quiz 102 Tough Starts General Statistics

Grade Statistics
Grade

[5, 4] [3, 2] [1, 0] [, ] 2035 1223 679 339
Percent
51.7 31.1 17.2 8.6
Display the Top 8

Name Total Score Percent Date
100 100 100 100 100 100 100 100 Sunday September 3, 2006 Thursday August 31, 2006 Thursday August 31, 2006 Thursday August 31, 2006 Thursday August 31, 2006 Thursday August 31, 2006 Thursday August 31, 2006 Thursday August 31, 2006
a. alrajab 5 rsm sa sa usha kong knottie patima 5 5 5 5 5 5 5

Abdomen Quiz 202 I'll Drink to That General Statistics

Grade Statistics
Grade

[5, 4] [3, 2] [1, 0] [, ] [, ] 2465 1560 629 331 331
Percent
53.0 33.5 13.5 7.1 7.1
Display the Top 8

Name Total Score Percent Date
100 100 100 100 100 100 100 Thursday August 31, 2006 Thursday August 31, 2006 Thursday August 31, 2006 Wednesday August 30, 2006 Wednesday August 30, 2006 Wednesday August 30, 2006 Wednesday August 30, 2006
jeff garcia 5 jeff garcia 5 par k hc jackie run 5 5 5 5 5
cc
100
Tuesday August 29, 2006

Abdomen Quiz 203 When the Bowel Breaks General Statistics

Grade Statistics
Grade

[5, 4] [3, 2] [1, 0] [, ] 1810 1139 728 377
Percent
49.2 31.0 19.8 10.3
Display the Top 8

Name
goli mehmet m jeff garcia par oatta k
Total Score
5 5 5 5 5 5 5
Percent Date
100 100 100 100 100 100 100 100 Sunday September 3, 2006 Saturday September 2, 2006 Friday September 1, 2006 Thursday August 31, 2006 Thursday August 31, 2006 Thursday August 31, 2006 Thursday August 31, 2006 Wednesday August 30, 2006
carlos alberto rgis toscano 5

Abdomen Quiz 204 Abdominal Calcifications General Statistics

Grade Statistics
Grade

[5, 4] [3, 2] [1, 0] [, ] [, ] 3065 623 284 205 205
Percent
77.2 15.7 7.2 5.2 5.2
Display the Top 8

Name
ana karina goli JJ a. alrajab amarnath mehmet
Total Score
5 5 5 5 5 5
Percent Date
100 100 100 100 100 100 100 Sunday September 3, 2006 Sunday September 3, 2006 Sunday September 3, 2006 Sunday September 3, 2006 Friday September 1, 2006 Friday September 1, 2006 Friday September 1, 2006
RadiationGirl 5
100
Thursday August 31, 2006

Abdomen Quiz 205 Air, Air Everywhere! General Statistics

Grade Statistics
Grade

[5, 4] [3, 2] [1, 0] [, ] 2525 1747 605 261
Percent
51.8 35.8 12.4 5.4
Display the Top 8

Name
JKM sajjsd goli KK a. alrajab
Total Score
5 5 5 5 5
Percent Date
100 100 100 100 100 100 100 100 Sunday September 3, 2006 Sunday September 3, 2006 Sunday September 3, 2006 Sunday September 3, 2006 Sunday September 3, 2006 Sunday September 3, 2006 Saturday September 2, 2006 Saturday September 2, 2006
Nowfree.tw 5 miao wasim 5 5

MSK Quiz 302 Name That Fracture-1 General Statistics

Grade Statistics
Grade

[5, 4] [3, 2] [1, 0] [, ] 2245 1424 836 353
Percent
49.8 31.6 18.6 7.8
Display the Top 8

Name
Jon Marti sajjsd goli patrick alex mehmet
Total Score
5 5 5 5 5 5
Percent Date
100 100 100 100 100 100 100 Sunday September 3, 2006 Sunday September 3, 2006 Sunday September 3, 2006 Sunday September 3, 2006 Friday September 1, 2006 Friday September 1, 2006 Friday September 1, 2006
RadiationGirl 5
Tommy
100
Thursday August 31, 2006

MSK Quiz 303 Hot Joints! General Statistics

Grade Statistics
Grade

[5, 4] [3, 2] [1, 0] [, ] [, ] 2328 1215 413 251 249
Percent
58.8 30.7 10.4 6.3 6.3
Display the Top 8

Name
a. alrajab
Total Score
5
Percent Date
100 100 100 100 100 100 100 100 Sunday September 3, 2006 Friday September 1, 2006 Friday September 1, 2006 Thursday August 31, 2006 Thursday August 31, 2006 Thursday August 31, 2006 Wednesday August 30, 2006 Tuesday August 29, 2006
john koutras 5 Ruedeekorn 5 rsm kong kitt sameh n 5 5 5 5 5

MSK Quiz 305 My Aching Back General Statistics

Grade Statistics
Grade

[5, 4] [3, 2] [1, 0] [, ] 1501 1617 1215 460
Percent
34.6 37.3 28.0 10.6
Display the Top 8

Name
goli
Total Score
5
Percent Date
100 100 100 100 100 100 100 100 Sunday September 3, 2006 Sunday September 3, 2006 Friday September 1, 2006 Thursday August 31, 2006 Thursday August 31, 2006 Wednesday August 30, 2006 Wednesday August 30, 2006 Wednesday August 30, 2006
a. alrajab 5 amarnath 5 ruedy patima abhijai shuna hc 5 5 5 5 5

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A. Thymoma B. Oat cell carcinoma C. Right aortic arch D. Enlarged azygous vein
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"Most Commons"
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Right Aortic Arches
Type I Mirror image right archwill have congenital heart disease 98% of time Due to interruption of the left arch just distal to Ductus Arteriosis There will be NO posterior impression on the trachea or the barium-filled esophagus Descending aorta will be on the right Type II Right aortic arch with anomalous left subclavian (retroesophageal and retrotracheal) associated with cardiac defects 5-10% of the time Tetralogy of Fallot most often (71%) ASD or VSD next most often (21%) Coarctation of the Aorta rarely (7%) Due to interruption of the left aortic arch between the LCC and the LSC arteries There will be a posterior impression on the trachea and the barium-filled esophagus Descending aorta will be on right
Statistics on Mirror Image Right Arches: If the person has a right arch, then:
* 90% of the time the congenital heart lesion will be Tetralogy of Fallot 6% of the time the congenital heart lesion will be Truncus Arteriosis
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5% of the time the congenital heart lesion will be Tricuspid atresia
If the person has these heart lesions, they have this chance of also having a Right Aortic Arch:
* Truncus arteriosis 33%
Tetralogy of Fallot 25% Transposition Tricuspid atresia VSD 10% 5% 2%
*apparent discrepancy here due to much higher incidence of TOF than Truncus
WH/
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Aspergilloma
Caused by Aspergillus fumigatus-soil fungus Non-invasive Aspergillosis Colonization of pre-existing cavity Most frequently TB cavity of Sarcoid Also can occur with cavitary ca, and bronchiectasis Most common symptom is hemoptysis Histologically, these are intertwined hyphae of the aspergillus forming a mycetoma Findings:
o o o o o wh
Solid, round mass in thin-walled cavity Usually in upper lobes Moves with changes in positioning Crescent-shaped airspace separates the fungus ball from the wall of cavity Fungus ball may calcify
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Not Quite 1001 Manifestations of Neurofibromatosis

q
Lateral meningocoeles Diverticula of the thecal sac caused by dysplasia of the meninges Leads to erosion of adjacent bone
Posterior scalloping of the vertebral bodies (as above) Particularly in the thoracic and lumbar vertebral areas
Cafe au lait spots Multiple skin neurofibromas or schwannomas Diffuse enlargement of an extremity Mental retardation Optic nerve gliomas, meningiomas, acoustic neuromas, astrocytomas, ependymomas, hamartomas and glioblastomas
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Syringomyelia Defect in the posterosuperior wall of the orbit Enlargement of the orbit Hypoplasia of the greater wing of the sphenoid Enlargement of the middle cranial fossa Holes in the head Cranium bifidum Dural ectasia Posterior scalloping of the vertebral bodies Dumbbell neurofibromas Enlargement of a neural foramen Erosion of a pedicle Intrathoracic meningocele Kyphoscoliosis Ribbon ribs Neurofibromas of the vagus nerve Pulmonary interstitial fibrosis Congenital heart disease (PS most common, VSD, coarct) Renal artery stenosis Other arterial stenoses Neurofibromas of the GI tract Pheochromocytoma Medullary carcinoma of the thyroid Pseudarthrosis of long bones, especially tibia Bowing of the extremities, especially tibia Marginal cortical defects Massive subperiosteal hematoma
WH/
LearningRadiology - Sickle Cell Disease
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Multiple Bone Infarcts from Sickle Cell Disease

q
Avascular necrosis may be caused by:

r
Diseases in the blood vessels (thrombi, emboli, abnormal cells) like:

s
Sickle-cell disease Gaucher's Disease Polycythemia Caisson Disease Pancreatitis
Diseases of the blood vessels (intima or wall) like:

s
Collagen-vascular disease vasculitis Radiation-induced avascular necrosis (mediated by vasculitis)
Diseases outside of the blood vessel like:

s
Trauma
In all, the blood supply is interrupted which leads to necrosis of bone MRI and Nuclear Med bone marrow imaging most sensitive in making diagnosis Plain films are least sensitive
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Sickle-cell thrombosis and infarction

q
Occurs in diaphyses of children (sickle dactylitis) and metaphyses and epiphyses of adults Produces dystrophic medullary calcification (DDx: enchondroma) There may be juxta-cortical sclerosis Lincoln log = H-shaped = codfish vertebrae in spine Femoral head may collapse in time Secondary degenerative arthritis will develop over time in affected joints
LearningRadiology - Subdural Hematoma
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Subacute Subdural Hematoma

Contributed by Weiling Chang, M.D. Findings: Axial CT scan demonstrates that there is a large R parietal subdural hematoma isodense to the brain. There is associated mass effect with effacement of the right lateral ventricle. Enhanced images delineate the exact margins of the hemorrhage. (see below)
Acute hemorrhage on CT scan appears as bright on CT scan. Over a period of time, the blood becomes darker. Attenuation decreases by 1.5 HU per day on average. There is a point when the blood becomes isodense to the brain parenchyma. Contrast enhancement can help separate the clot and brain parenchyma since there is enhancement of displaced cortical vessels. Subdural hematomas are usually crescentic shaped and have the capability of crossing the cranial sutures. The etiology of a subdural hemorrhage occurs from a tearing of the bridging veins in the subdural space.
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Subdural hematomas can be lethal with mortality rates ranging from 50-85%.
Reference: Osborn, Ann, Diagnostic Neuroradiology, pp 159-161.
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Lipoid Pneumonia
Exogenous accumulation of fat in the lung most often from mineral oil: Older people who are constipated, have a swallowing disorder 2 neurologic disease In infants with feeding difficulties In the past, could be from oily nose drops Accumulation of fat in the lung may also occur from endogenous sources such as fat embolism, alveolar proteinosis lipid storage diseases
Animal fatty acids (like fat embolus) produces hemorrhagic bronchopneumonia Mineral oil produces a giant cell foreign body reaction Starts as an alveolar infiltrate Moves to thicken interstitial septa, then Into macrophages enlarging lymphatics Finally produces a fibrosing reaction
X-ray
Usually lower lobes with predilection for the right Alveolar consolidation, may be well-circumscribed May present as a peripheral mass with fuzzy or distinct margins simulating BrCa
Clinical
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Diagnosis
Best method of DX is direct Bx Fat-laden macrophages are non-specific since they can be found in sputum of normals as well
WH/91,93
Caustic Esophagitis
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Caustic Esophagitis
Starting in 1967, lye (concentrated sodium hydroxide) became available as a liquid in drain cleaners and caustic esophagitis became a serious medical problem Other household agents which can produce caustic esophagitis are acids, ammonium chloride, phenols and silver nitrate Lye produces tissue damage through liquefaction necrosis as opposed to acids which produce coagulative necrosis. Both acidic and alkaline agents can damage esophagus. There are 3 phases to caustic esophagitis: The acute necrotic phase (1-4 days) The ulceration-granulation phase (3-5 days)* Fibrosis and stricture formation (3-4 weeks after ingestion) * Esophagus most prone to perforate during this phase As little as 1cc of lye can produce full-thickness necrosis of the esophagus within 30 minutes of ingestion. Early changes are better evaluated with endoscopy than contrast studies Early treatment may include steroids, antibiotics and, some suggest, prophylactic dilatation. Still as many as 40% will develop strictures. There is a significantly higher risk of developing esophageal carcinoma 20-40 years after ingestion.
X-ray
Mediastinal emphysema Left pleural effusion Long, smooth strictures About 20% have associated gastric abnormality, usually antral narrowing and ulceration In the acute phase, a water-soluble esophagram should be performed, followed by barium if no leak is seen.
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Caustic Esophagitis
WH/92
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LearningRadiology - Gout
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Gout
Deposition of sodium urate monohydrate crystals in synovial membranes, articular cartilage, ligaments and bursae leading to destruction of cartilage Age of onset is usually greater than 40 years; males much more often than females Causes: o Idiopathic Gout M:F = 20:1 Overproduction of uric acid Abnormality of renal urate excretion o Secondary Gout Rarely cause for radiographically apparent disease Myeloproliferative disorders, e.g. polycythemia vera, leukemia, lymphoma, multiple myeloma Blood dyscrasias Myxedema, hyperparathyroidism Chronic renal failure Glycogen storage disease Myocardial infarction Lead poisoning Stages: o Asymptomatic hyperuricemia o Acute monarticular gout o Polyarticular gout o Chronic tophaceous gout = multiple large urate deposits Location: o Joints: hands + feet (1st MTP joint most commonly affected = podagra), elbow, wrist Carpometacarpal compartment especially common), knee, shoulder, hip, sacroiliac joint (15%, unilateral) o Ear pinna > bones, tendon, bursa Radiologic features usually not seen until 6-12 years after initial attack Radiologic features present in 50% of inflicted patients Soft tissue findings
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o o o o o o o o o o o o o o o o o o o o
Calcific deposits in gouty tophi in 50% (only calcium urate crystals are opaque) Eccentric juxta-articular lobulated soft-tissue masses (hand, foot, ankle, elbow, knee) Bilateral olecranon bursitis Aural calcification Joint findings Preservation of joint space initially Absence of periarticular demineralization Erosion of joint margins with sclerosis Cartilage destruction late in course of disease Periarticular swelling (in acute monarticular gout) Chondrocalcinosis (menisci, articular cartilage of knee) resulting in secondary osteoarthritis Bone findings "Punched-out" lytic bone lesion sclerosis of margin "Mouse / rat bite" from erosion of long-standing soft-tissue tophus "Overhanging margin" (40%) Ischemic necrosis of femoral / humeral heads Bone infarction Coexisting disorders: Psoriasis Glycogen storage disease Type I Hypo- and hyperparathyroidism Downs syndrome Lesch-Nyhan syndrome (mental retardation, self-mutilation of lips + fingertips) Rx:colchicine, allopurinol (effective treatment usually does not change x-ray findings)
Source: Dahnert, 4th Edition
LearningRadiology- Thyroid Goiter
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Thyroid Masses
Extension of a thyroid goiter arising in the neck inferiorly into the thorax is relatively uncommon Most (75-80%) arise from lower pole or isthmus of the thyroid and extend into anterior mediastinum Some arise from posterior aspect of the thyroid and extend into posterior mediastinum, almost always on the right Usually nodular, colloid goiters Thyrotoxicosis and carcinoma are rare Thyroid mass is typically well-encapsulated and may show degeneration (calcification) Most patients are asymptomatic X-ray Sharply defined, smooth or lobulated soft tissue mass which characteristically displaces the trachea They do not usually project below the arch of the aorta differentiating them from thymomas and teratomas Those in the posterior mediastinum characteristically interpose between the trachea in front and the esophagus in back On CT, they usually contrast enhance and many times are found to contain calcification. Contrast enhancement is usually prolonged.
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Curvilinear calcifications are highly suggestive of a degenerated thyroid adenoma Radioisotope scan is diagnostic
WH
LearningRadiology - Atrial Septal Defect
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Atrial Septal Defect ASD

4:1 ratio of females to males The most frequent congenital heart lesion initially diagnosed as an adult Frequently associated with Ellis-van Creveld and Holt-Oram syndromes Associated with prolapsing mitral valve
Four Major Types

q
Most common is ostium secundum (60%) located at fossa ovalis o High association with prolapse of the mitral valve Ostium primum type is usually part of an endocardial cushion defect o It tends to act like a VSD physiologically Sinus venosis type lies high in the interatrial septum o 90% association of anomalous drainage of R upper pulmonary vein with SVC or Right atrium Most rare type is posteroinferior ASD o Associated with absence of the coronary sinus and a left SVC emptying into LA
* Pulmonary hypertension is rare in ostium secundum variety of ASD

(<6%); u More common in ostium primum variety
X-RAY: o Enlarged pulmonary vessels o Normal-sized left atrium o Normal to small aorta
q q q
With large shunts, pulmonary infections and cardiac arrythmias are common There is a higher incidence of pericardial disease with ASD than other CHD Bacterial endocarditis is rare
http://www.learningradiology.com/archives/COW%20010-ASD/asdcorrectpage.htm (1 de 4)04/09/2006 2:20:40
WH
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LearningRadiology - Dermoid Cyst
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Dermoid Cyst
Contributed by Weiling Chang, MD
Findings: Axial CT scan demonstrates an ovoid mass in the pelvis in close association with the right ovary. This mass contains soft tissue, fat, and calcific densities. Round solid tissue within the cyst may represent retained sebaceous material.
Dermoid cysts or mature cystic teratomas are benign ovarian neoplasms that contain endodermal, mesodermal, and ectodermal components. They are most commonly found in women of reproductive age. They are bilateral in 8-25% of cases. Findings of fat and calcific densities in an ovarian mass are highly specific for a dermoid. Although they are often asymptomatic, women can present with pelvic pressure. Complications include malignant degeneration, torsion, rupture, or hydronephrosis.
http://www.learningradiology.com/archives/COW%20011-Dermoid/dermoidcorrectpage.htm (1 de 4)04/09/2006 2:20:53
Reference: Dahnert, Wolfgang, Radiology Review Manual
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Ascariasis
q q q q
Most common parasitic infestation in the world Most common in children ages 1 to 10 years Most often found in distal small bowel Life cycle
r r
Infection is through contaminated soil Involves GI tract of host twice First time as egg Migrates through lungs Adult travels up trachea
s s
r r
Returns to GI tract for maturation (2 months)
Signs and Symptoms

r r r
Colicky pain Hematemesis Eosinophilia
X-ray findings
r r
Long, tubular filling defects, especially in distal small bowel The worm ingests barium and the barium may be seen as a thin line of contrast in the center of the worm
s
Especially after the remainder of the barium exits the small bowel. See below-linear streak of barium on left side of patient (not the same patient as Case of Week):
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Ball of worms
Complications
r r r r r
Appendicitis Jaundice (if bile ducts are involved) Pneumonia Bowel perforation Mechanical obstruction
Return to Case
Calcinosis Universalis
q q q q q
Diffuse cutaneous, subcutaneous and sometimes muscular calcification Usually affects children and young adults Not actual bone formation More linear than calcifications in scleroderma (calcinosis circumscripta) Seen with dermatomyositis (polymyositis)
r
Dermatomyositis
s
Damaged chondroitin sulfate, atrophy of muscles, followed by calcification of muscle and subcu tissue Ages 5-10 and again in 50s
q
More common in females s Linear and confluent calcifications in soft tissues of extremities s Acro-osteolysis s Chest-may have infiltrates associated Clinically
s
Weakness of respiratory muscles s Erythematous rash of eyelids s Proximal muscle weakness s Associated with a high incidence of malignancies of GI tract, lung, ovary, breast, kidney May resemble myositis ossificans progressiva
r
Myositis ossificans progressive (fibrodyplasia ossificans progressiva)

s
Begins with subcutaneous, painful masses in neck Progresses down back over shoulders, chest, abdomen Rounded or linear calcification starting in neck More clumplike in places than calcinosis universalis
q
s s
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s
Ossification of voluntary muscles
LearningRadiology - Fibrous Dysplasia
Return to Case
Fibrous Dysplasia
q q q q
q q q
q q q
Etiology unknown Most common 3-15 years Fundamental abnormality is replacement of medullary bone by fibrous tissue Clinically r Deformities s Shepherds crook deformity of femur r Bone pain Most commonly involved bones are pelvis, femora In widespread disease, the skull and jaw are almost always involved X-ray r Endosteal scalloping r Cortical thinning r Ground-glass appearance r May have matrix calcification Prone to fracture Growth of lesions usually stops when epiphyses close DDX: r Brown tumor r Unicameral bone cyst Albrights Syndrome r Polyostotic r Sexual precocity r Skin pigmentation r Almost always in a female Polyostotic form is usually bilateral
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LearningRadiology - Thoratrast
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Thorotrast
Alpha-emitter Previously used for cerebral angiography and liver/spleen imaging Use started in early 30s and continued to early 50s Excellent opacifying agent well-tolerated by patients Could produce intense fibrosis in muscle if it extravasated on injection and it was this side-affect which caused its use to be questioned first Colloidal thorium dioxide deposited in liver (70%), spleen (30%), bone marrow, lymph nodes Produces increased opacity of metal density in liver, spleen and celiac nodes May be visualized in soft tissues of neck if extravasated there Biologic half life of 400 years; physical half-life of 1010 years Hepatic dose in 20 years about 1000-3000 rads Produces angiosarcomas (hemangioendotheliomas) of liver (50%), cholangiocarcinoma, hepatoma One of the causes of bone-within-a-bone in spine
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Long latency period (25 years)
WH/93
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LearningRadiology - TAPVR
Return to Case
Total Anomalous Pulmonary Venous Return (TAPVR) Supracardiac Type

Must have ASD for survival All have anatomical L to R shunt at atrial level
r
q q
All have functional R to L shunt of oxygenated blood to right side of heart
Two Types
q
Partial (PAPVR)
q
Total (TAPVR)
q
Partial Anomalous Pulmonary Venous Drainage (PAPVR) General

q
q
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Total Anomalous Pulmonary Venous Drainage (TAPVR)

q
All have shunt through lungs to R side of heart All must also have R to L shunt for survival
q
All are cyanotic Identical oxygenation in all four chambers Types

q
q
Most common (52%) Pulmonary veins drain into vertical vein (behind left pulmonary artery) to left brachiocephalic vein to SVC
DDx: VSD with large thymus Supracardiac Type 1X-ray Findings

q
Cardiac TypeType II
q

q
Increased pulmonary vasculature
q
Overload of RV leads to CHF after birth 20% of Is and IIs survive to adulthood
q

q
Percent of total: 12% Long pulmonary veins course down along esophagus Empty into IVC or portal vein (more common) Vein constricted by diaphragm as it passes through esophageal hiatus Severe CHF (90%) 2 obstruction to venous return
Cyanotic 2 right to left shunt through ASD Associated with asplenia (80%), or polysplenia Prognosis = death within a few days
Mixed TypeType IV
q
WH/rev2002
LearningRadiology - Maltoma
Return to Case
Maltoma Pseudolymphoma
Collections of apparently benign lymphocytes which lack the usual invasive characteristics of true lymphoma
Lack of invasion of extrapulmonary tissues in this disease Mixed cellular infiltration (as opposed to uniform cellular infiltration of true lymphoma) with mature lymphocytes predominating
Other lesions characterized by the presence of mature lymphocytes

r
LIP Castlemans diseaselymph node hyperplasia Lymphomatoid granulomatosis Well-differentiated lymphocytic lymphoma
Classically, there is no involvement of the lymph nodes in the hilum or mediastinum May be associated with Dilantin administration (as is true lymphoma and benign lymph node hyperplasia)
Asymptomatic
X-ray
Dense infiltrate
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Invariably has air bronchogram May also have nodules, segmental consolidation or diffuse interstitial infiltration
"Masses" containing air bronchograms-differential diagnosis

q q q q
Lymphoma Pseudolymphoma (maltoma) Alveolar sarcoid Alveolar cell carcinoma
WH
LearningRadiology - Fahr's Disease
Return to Case
Fahr's Disease
Contributed by Andrew Hwang, MD
Findings: Unenhanced CT reveals dense calcifications within the basal ganglia, subcortical white matter of the posterior parietal lobes, and the dentate nuclei of the cerebellum. See images below:
Part of a spectrum of diseases characterized by extensive deposition of calcium within the basal ganglia.
Prominent calcifications may also occur within the dentate nuclei, centrum semiovale, and subcortical white matter.
Other causes of bilateral basal ganglia calcification included in the differential diagnosis include postinflammatory causes, such as TB, toxoplasmosis, cystercercosis, congenital HIV. Clinical presentation is variable. Patients may present with progressive dementia, neuromuscular impairment, and dysarthria. Parkinsonian symptoms may also occur. The disease can present sporadically,
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but is most often purported to be familial, with variable inheritance patterns. There is no known cure, and therapy is supportive in nature. Osborn A. Diagnostic Neuroradiology. Mosby, St. Louis; 1994:745-746 Haaga JR. Computed Tomography and Magnetic Resonance Imaging of
the Whole Body. Mosby, St. Louis; 1994
LearningRadiology- Reexpansion Pulmonary Edema
Return to Case
Re-expansion Pulmonary Edema
Findings: There is unilateral air-space disease opacifying the entire right hemithorax. In addition a chest tube is
seen on the same side. The chest tube was inserted for a large, right-sided, tension pneumothorax which was rapidly re-expanded. See image below of original right-sided, tension pneumothorax.
q q
Pulmonary edema of cardiac or renal origin usually affects both lungs Re-expansion pulmonary edema results from the too rapid expansion of a pneumothorax or the rapid removal of pleural fluid Unilateral pulmonary edema can occur either because of an abnormality on the same side as the pulmonary edema or an abnormality on the opposite side Examples of abnormalities on the same side as the pulmonary edema include: Venous obstruction confined to the ipsilateral side r Prolonged positioning with the affected side dependent r Bronchial obstruction (so-called Drowned Lung) Examples of abnormalities in one lung which spare it and lead to pulmonary edema on the opposite
r
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side:
r
Pulmonary artery obstruction Congenital absence or hypoplasia of the pulmonary artery s Thromboembolism occluding one pulmonary artery s Unilateral arterial obstruction Abnormalities of the opposite lung itself
s s s s
Unilateral emphysema Pneumonectomy Swyer-James syndrome
WH
LearningRadiology - Adult Polycystic Disease
Return to Case
Polycystic Kidney Disease

Two major types: Autosomal Dominant Polycystic Kidney Disease (Adult Polycystic Kidney Disease [APKD])
and Autosomal Recessive Polycystic Kidney Disease (Infantile Polycystic Kidney Disease)
Autosomal Dominant Polycystic Kidney Disease

q q q
Is a slowly progressive disease with nearly 100% penetrance Potter Type III Cause: gene located on short arm of chromosome 16 (in 90% Spontaneous mutation in 10% Incidence:1:1,000 people carry the mutant gene
r
q q q
3rd most prevalent cause of chronic renal failure Histo: abnormal rate of tubule divisions (Potter Type III) with hypoplasia of portions of tubules left behind as the ureteral bud advances; cystic dilatation of Bowman capsule, loop of Henle, proximal convoluted tubule, coexisting with normal tissue Mean age at diagnosis: 43 years (neonatal / infantile onset has been reported) M:F = 1:1 Onset of cyst formation:
r r r r
54% in 1st decade 72% in 2nd decade 86% in 3rd decade
Associated with:
Cysts in: liver (25-50%), pancreas (9%) Aneurysm: saccular "berry" aneurysm of cerebral arteries (3-13%)
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Mitral valve prolapse Hypertension (50-70%) Azotemia Hematuria, proteinuria Lumbar / abdominal pain
Bilaterally large kidneys with multifocal round lesions; unilateral enlargement may be the first manifestation of the disease Cysts may calcify in curvilinear rim- / ringlike irregular amorphous fashion elongated + distorted + attenuated collecting system nodular puddling of contrast material on delayed images "Swiss cheese" nephrogram = multiple lesions of varying size with smooth margins
Polycystic kidneys shrink after beginning of renal failure, after renal transplantation, or on chronic hemodialysis
NUC: poor renal function on Tc-99m DTPA scan
US: OB-US:
Large echogenic kidneys similar to infantile PCKD (usually in 3rd trimester, earliest sonographic diagnosis at 14 weeks), can be unilateral Multiple cysts in cortical region (usually not seen prior to teens) Diffusely echogenic when cysts small (children) Renal contour poorly demarcated
Cx:
Macroscopic cysts (rare) Normal amount of amniotic fluid / oligohydramnios (renal function usually not impaired)
Death from uremia (59%) / cerebral hemorrhage (secondary to hypertension or ruptured aneurysm [13%])
DDx:
Cardiac complications (mean age 50 years)

Renal calculi Urinary tract infection Cyst rupture Hemorrhage Renal cell carcinoma (increased risk)
Multiple simple cysts (less diffuse, no family history)
von Hippel-Lindau disease (cerebellar hemangioblastoma, retinal hemangiomas, occasionally pheochromocytomas) Acquired uremic cystic disease (kidneys small, no renal function, transplant) Infantile PCKD (usually microscopic cysts)
Autosomal Recessive Polycystic Kidney Disease = Polycystic Disease of Childhood

Pathology
Kidney: abnormal proliferation + dilatation of collecting tubules resulting in multiple 1- to 2-mm cysts Potter Type I Incidence:1: 6,000 to 1:50,000 livebirths F > M; carrier frequency of 1:112
Liver: periportal fibrosis often with abnormal proliferation + dilatation of bile ducts Pancreas: pancreatic fibrosis
ANTENATAL FORM (most common)

90% of tubules show cystic changes Onset of renal failure in utero
Potter sequence Oligohydramnios and dystocia (large abdominal mass)
Prognosis: death from renal failure / respiratory insufficiency (pulmonary hypoplasia) within 24 hours in 75%, within 1 year in 93%; uniformly fatal
NEONATAL FORM
60% of tubules show ectasia + minimal hepatic fibrosis + bile duct proliferation Onset of renal failure within 1st month of life Prognosis: death from renal failure / hypertension / left ventricular failure within 1st year of life
INFANTILE FORM
20% of renal tubules involved + mild / moderate periportal fibrosis Disease appears by 3-6 months of age Prognosis: death from chronic renal failure / systemic arterial hypertension / portal hypertension
JUVENILE FORM Lung

Severe pulmonary hypoplasia Pneumothorax / pneumomediastinum 10% of tubules involved + gross hepatic fibrosis + bile duct proliferation Disease appears at 1-5 years of age Prognosis: death from portal hypertension The less severe the renal findings, the more severe the hepatic findings!
Liver
Portal venous hypertension Tubular cystic dilatation of small intrahepatic bile ducts
Kidneys CT: US:
Increase in liver echogenicity (from congenital hepatic fibrosis)
Bilateral gross renal enlargement Faint nephrogram + blotchy opacification on initial images Increasingly dense nephrogram Poor visualization of collecting system
"Sunburst nephrogram" = striated nephrogram with persistent radiating opaque streaks (collecting ducts) on Delayed images Prominent fetal lobulation
Prolonged corticomedullary phase
Hyperechoic enlarged kidneys (unresolved 1- to 2-mm cystic / ectatic dilatation of renal tubules increase number of acoustic interfaces)
Increased renal through-transmission (high fluid content of cysts) Loss of corticomedullary differentiation, poor visualization of renal sinus + renal borders Occasionally discrete macroscopic cysts <1 cm Compressed / minimally dilated collecting system
OB-US (diagnostic as early as 17 weeks GA):

Progressive renal enlargement with renal circumference : abdominal circumference ratio >0.30 Hyperechoic renal parenchyma Nonvisualization of urine in fetal bladder (in severe cases) Oligohydramnios (33%) Small fetal thorax
OB management:
Chromosome studies to determine if other malformations present (e.g., trisomy 13 / 18) Option of pregnancy termination <24 weeks Nonintervention for fetal distress >24 weeks if severe oligohydramnios present Risk of recurrence:25% DDx: Meckel-Gruber syndrome, adult polycystic kidney disease
From Dahnert, 4th Edition
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Return to Case
Form of pulmonary hamartoma occurring in utero between 4-10th week Most often found in infants, sometimes adults No lobar preference Solid in infants, more cystic in children Do communicate with the tracheobronchial tree (DDx from intralobar sequestration which usually dont)) Supplied by pulmonary circulation
Types
q q q q
Type 1 (50%) single or multiple large cysts excellent prognosis following resection Type 2 (40%) Multiple cysts < 12 mm poor prognosis 2 associated congenital anomalies Type 3 (10%) solitary mass with microscopic cysts poor prognosis 2 hypoplasia of lung
X-ray
Unilateral mass with well-defined margins and numerous air-containing cysts Space occupying so expect shift of heart and mediastinum away from lesion
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May occasionally present as solid mass which evolves into cystic mass DDX Sequestration, diaphragmatic hernia or rupture, congenital lobar emphysema On fetal US, look for fetal ascites and polyhydramnios
Clinically
May be cyanotic; usually symptomatic during first days of life
WH
LearningRadiology - Tumoral Calcinosis
Return to Case
Tumoral Calcinosis
q q q
Progressively enlarging, juxta-articular, calcified, nodular soft-tissue masses Mostly occurs in 1st or 2nd decade Equal M:F Predominantly African-Americans Normal calcium and phosphorous
r
q q
No renal, metabolic or collagen-vascular disease Autosomal dominant with variable expressivity Pathology: multilocular cystic lesions containing creamy white fluid
r
Hydroxyapatite crystals in suspension Clinical

r
Painful/painless soft tissue mass r Hips>elbows>shoulders>feet r Not knees Imaging

r r r r
Large, nodular, smoothly-marginated juxta-articular masses of calcium density Fluid-fluid levels on erect films due to Milk of Calcium in lesion Underlying bone normal
WH
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LearningRadiology - Varicella pneumonia
Return to Case
Varicella Pneumonia
Findings: multiple, small punctate calcifications throughout both lungs. Miliary TB classically does not heal with calcification of the granulomas. The lesions in miliary TB are also usually much smaller than these lesions. Mitral hemosiderosis occurs primarily at the lungs bases and is, of course, associated with mitral valve disease which this patient does not have. Staph pneumonia characteristically gives airspace disease with an effusion.
Occurs most often over the age of 19 rather than in childhood Patchy, diffuse air space consolidation Tendency to coalesce near hila Widespread nodules can occur (30%) Tiny calcifications remain in 2% (DDX is histoplasmosis, alveolar microlithiasis) 11% mortality rate
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LearningRadiology - Diverticulitis
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Diverticulosis/Diverticulitis of the Colon
Findings: There are two extraluminal collections of barium arising from the medial border of the sigmoid colon. There is a mass effect (pad sign) on the superior border of the sigmoid. Herniation of mucosa and submucosa through muscular layers pseudodiverticulum=false diverticulum=pulsion type Diverticula are reducible; they may be seen on one but not another BE Only proven association is with Marfans syndrome (20% get diverticulitis) Location Almost always involves sigmoid; never rectum; more common on left
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In about 17%, the tics cover the entire colon In another 12%, they are isolated to right colon
Prediverticular Disease
Saw-tooth appearance to the colon, usually sigmoid, with shortening of bowel, crowding of haustra and picket-fencing of folds Muscle spasm is present-may be relieved with glucagon Controversial as to whether this form can be symptomatic, i.e. pain
Diverticulosis
May be due to low roughage, high refined-fiber diet More common in industrialized nations Arise between the mesenteric and anti-mesenteric teniae of the colon and project between circular muscle ringsnot through them May vary in size from tiny projections to several cm in size Have variable filling Associated spasm and numerous tics in sigmoid may make it impossible to see polyp in this regioneven difficult with colonoscopy On AC BE tics have sharp outer and fuzzy inner margins viewed en-face Giant sigmoid diverticulumhuge gas-containing cyst-like structure arising in left iliac fossa
Diverticulitis
Perforation of diverticulum with pericolic abscess of varying size; not simply inflammation of a tic Clinical Pain and tenderness, mass in LLQ Fever, leucocytosis Plain Film X-ray Sentinel loop or, less likely, LBO Air bubbles in abscess
Pneumoperitoneum (rare) BE Extraluminal contrast Pericolonic abscess produces mass effect Double-tracking=barium in longitudinal sinus tract in wall Spasm is an indirect sign of diverticulitis Fistula to bladder (diverticulitis is most common cause of non-traumatic fistula here) or small bowel or vagina (diverticulitis causes 1/3 of fistulae to vagina) CT Infiltration of pericolonic fat Bowel wall thickening >1cm Abscess Fluid or free air in peritoneal cavity Colovesicle or colovaginal fistula Intramural sinus tracts DDX Colon ca-but mucosa is left intact in diverticulitis Crohns disease-may be indistinguishable if TI not involved in Crohns Ischemic colitisonly if sigmoid is involved Radiation colitis Complications Peritonitisusually the perforation is walled off but it may spread throughout the peritoneal cavity or the retropertineum If a ruptured diverticulum is a strong clinical consideration prior to contrast study, water soluble contrast should be used rather than barium Obstructionis rare
Bleedingsee below
Hemorrhage from Diverticulosis

Doesnt involve Diverticulitis 75% of those that bleed are in right colon Clinically, massive rectal hemorrhage without pain May be diagnosed with nuclear med bleeding scan or angiography
WH/93
learningRadiology - Ochronosis
Return to Case
Ochronosis
Alkaptonuria
Rare hereditary disorder More common in males 2:1 Insufficiency of homogentisic acid oxidase Results in excessive homogentisic acid excreted in urine and deposited in soft tissue Urine may be black Sclera may be grey-brown or yellow Cartilage of nose and ears may be bluish in color Clinical findings are combination of spondylitis and arthritis of major joints
r r r
q q q q q q
When deposited in cartilage, synovial thickening develops This results in:

s
Subchondral cysts s Sclerosis s Osteophyte production, all secondary to DJD s Bony ankylosis may occur in joints or spine r Usually affects large joints-knees, shoulders, hips r Chondrocalcinosis of appendicular joints may develop In the spine: Changes of degenerative disc disease r Ligamentous structures mat be involved r Resembles ankylosis spondylitis r Universal disc space calcification is common Universal disc calcification and DJD of root joints (hips and shoulders) in younger patient are pathognomonic
r
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Murray and Jacobson, 2nd ed, vol.2
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LearningRadiology-Congenital Lobar Emphysema
Congenital Lobar Emphysema

Return to case Severe overinflation of a lobe, usually causing respiratory distress Male predominance Only 1/3 are manifest at birth; most are some weeks later Associated with congenital heart disease 15% of time (PDA, VSD) Predilection for the left upper lobe and less so for RML X-ray Hazy, mass-like density immediately following birth Overinflation and air-trapping after several days Contralateral mediastinal shift Vascular markings are widely separated DDx aspiration of foreign body with air-trapping, space occupying endobronchial lesion, adenomatoid malformation at birth Clinically About 90% suffer respiratory distress during first few days of life Cyanosis Course is rapid and may be fatal unless emphysematous lobe is resected
WH
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LearningRadiology-Congenital Lobar Emphysema
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LearningRadiology-Chron's Disease
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Crohns Disease
Regional Enteritis Pathology
Non-caseating granulomas involved with transmural inflammation of the entire GI tract Usual age at onset is 15-30, equal male:female ratio
Clinical
Recurrent episodes of diarrhea Occult blood loss and anemia Abdominal pain Low grade fever Anorexia, weight loss Perirectal abscess and fistulae Malabsorption Erythema nodosum and pyoderma gangrenosum
Location
The maximum length of the involved segment(s) is determined at the time of initial study; i.e. longitudinal spread is uncommon-except after surgery
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Esophagus (very rare) Stomach (2-20%) Usually involves antrum producing granulomatous gastritis Almost always associated with terminal ileal disease Rams horn sign=poorly distensible, smooth tubular antrum, widened pylorus and narrowed bulb Apthous ulcers Antral-duodenal fistula Duodenum (rare) (4-10%) Thickened folds Almost never occurs without antral involvement Small Bowel (80%) = regional enteritis=terminal ileitis Thickening and nodularity of folds Apthous ulcers Cobblestone mucosa Colon (22-55%) = granulomatous colitis Frequently right sided with sparing of rectum and sigmoid Apthous ulcers with target or bulls-eye appearance Long, longitudinal fistulous tracts parallel to bowel lumen Colon may be involved without small bowel, along with small bowel or become involved after surgery for Crohns Rectum (35-50%) Sinus tracts Deep, collar-button ulcers
Squaring of the folds-early manifestation from obstructive lymphedema
Apthous ulcers-small nodular filling defects (mound of edema) with central ulceration Skip lesions-discontinuous involvement of the bowel with intervening normal areas Proud loops-separation of the loops caused by infiltration of the mesentery, increase in mesenteric fat and enlarged lymph nodes; simulates a mass Cobblestoning-irregular, blanket-like appearance to bowel wall caused by criss-crossing longitudinal and transverse ulcers separated by areas of edema Pseudopolyps-islands of hyperplastic mucosa between denuded areas of mucosa Filiform post-inflammatory polyps Pseudodiverticula-from bulging area of normal wall opposite side of scarring from disease, usually on anti-mesenteric side String-sign-marked narrowing of terminal ileum (usually) from a combination of edema, spasm and (sometimes, but not always) fibrosis; frequently associated with proximal dilatation
Ulcerative colitiscontinuous involvement L colon and rectum;TI normal Diverticulitistics; intact mucosa; TI normal Tuberculosisbut TB has more involvement of cecum, less of TI Radiation ileitisshould have other loops involved and appropriate hx Lymphomashould have tumor masses, less spasm Carcinoidshould have mass; marked fibrosis with angulation of loops Yersinia may affect TI but clears in 3-4 months Infarctionrare for this location Potassium stricturelacks full clinical picture Amebiasiscone-shaped cecum
Fatty infiltration of the liver Gallstones (28-34%) Sclerosing cholangitis
Bile duct carcinoma Amyloidosis Urolithiasis:oxalate/uric acid stones Migratory arthritis Sacroiliitis and ankylosing spondylitis Erythema nodosum and uveitis
Complications
Fistula (33%) Fistulae occur more often with regional enteritis than with granulomatous colitis Enterocolic fistulae are mostly between ileum and cecum Enterocutaneous fistulae mostly from rectum to skin, but also to vagina and bladder Perineal fistula [Other common causes of fistula are iatrogenic and diverticulitis] Intramural sinus tracts Abscess formation [common] Rarely, perforation Toxic megacolon (dilated transverse colon with pseudopolyps in toxic person=no BE) Small bowel obstruction Adenocarcinoma (rare)
Prognosis
Recurrence rate up to 40% after resection, commonly at the site of the new terminal ileum and usually within the first two years post-op X-ray demonstration of improvement in regional enteritis is rare Mortality rate of 7% at 5 years and 12% at 10 years after the first resection
wh
LearningRadiology- Osteopetrosis
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Osteopetrosis
AKA: Albers-Schnberg Disease = Marble Bone Disease
q q q
Rare hereditary disorder Defective osteoclast function with failure of proper reabsorption produces sclerotic bone Structurally weak
Types
q
Infantile autosomal recessive type r Failure to thrive r Premature senility in facies r Dental caries r Anemia, leukocytopenia, thrombocytopenia r Cranial nerve compression (optic atrophy, deafness) r Hepatosplenomegaly (extramedullary hematopoiesis) r Lymphadenopathy r Subarachnoid hemorrhage may occur (due to thrombocytopenia) r May be associated with: s Renal tubular acidosis s Cerebral calcification r Prognosis: survival beyond middle age is uncommon (death due to recurrent infection, massive hemorrhage, terminal leukemia) Benign adult autosomal dominant type r 50% asymptomatic r Recurrent fractures r Mild anemia r Cranial nerve palsy (rarely) r Prognosis: normal r X-ray findings s Diffuse osteosclerosis s Cortical thickening with medullary encroachment s Erlenmeyer flask deformity = clublike long bones due to lack of tubulization + flaring
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of ends s Bone-within-bone appearance s "Sandwich" vertebrae=alternating sclerotic + radiolucent transverse metaphyseal lines (phalanges, iliac bones) indicate fluctuating course of disease s Longitudinal metaphyseal striations s Mandible least involved Complications: r Fractures (common because of brittle bones) with abundant callus + normal healing r Crowding of marrow (myelophthisic anemia + extramedullary hematopoiesis) r Frequently terminates in acute leukemia r Rx: bone marrow transplant DDx: r Heavy metal poisoning r Melorheostosis (limited to one extremity) r Hypervitaminosis D r Pyknodysostosis r Fibrous dysplasia of skull / face
From Dahnert
LearningRadiology-Ebstein's Anomaly
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Ebsteins Anomaly

Rare
POSTERIOR and SEPTAL cusps of tricuspid valve are displaced into the Right ventricle which makes Right ventricle smaller Combined with tricuspid insufficiency or sometime tricuspid stenosis, the Right Atrial pressure is elevated producing a R to L shunt through the foramen ovale Pulmonary vasculature is usually diminished In those with large atrial septal defects, the pulmonary vasculature may appear prominent There is an atrialized portion of the right ventricle between the AV groove and the tricuspid valve The right ventricle and right atrium dilate
The right heart border becomes prominent
Think of Ebsteins anomaly if:
o Pulmonary flow is decreased o Cyanosis is present in the neonate o One of the few conditions to produce cardiomegaly in the first few days of life
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LearningRadiology-Ebstein's Anomaly
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LearningRadiology-Polyarteritis nodosa
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Polyarteritis Nodosa
Submitted by Alexander Trebelev, MD*
q
q q q
Systemic necrotizing inflammation of medium-sized and small muscular arteries r More common in adult males Spares the arterioles, capillaries, venules and glomeruli Associated with hepatitis B antigenemia Signs and symptoms r Abdominal pain r Systemic hypertension r Anorexia and weight loss r Abdominal distention r Hematemesis, melena r Jaundice r Painless hematuria r Peripheral neuropathy r Tender subcutaneous nodules r Gangrene of fingers and toes Kidney (most frequently affected): 85%
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Injection of right renal artery demonstrates multiple intrarenal aneurysms (with acknowledgement to Juan Oleaga, MD, FACR and Paul Brady, MD)
r r
r r
Multiple intrarenal aneurysms Aneurysms may thrombose and disappear s Appear in new locations Multiple small cortical infarcts Angiographic findings s 1-5 mm saccular aneurysms of small and medium-sized arteries in 60-75% of cases s Secondary to necrosis of internal elastic lamina s Luminal irregularities and stenoses s Arterial occlusions and small tissue infarcts
Lung (70% of cases) r Findings are variable and rarely characteristic enough to allow diagnosis r Most characteristic pattern is fleeting, patchy consolidation identical to Loeffler's r Pericardial effusion r Pleural effusion r Discoid atelectasis r Nodules which may cavitate r Patchy consolidation Liver: affected 66% of cases
Selective injection of the hepatic artery demonstrates multiple intrahepatic aneurysms. There are no aneurysms in the periphery of the liver because of a large subcapsular hematoma as a consequence of the vasculitis (with acknowledgement to Juan Oleaga, MD, FACR and Paul Brady, MD)
q
Treatment r Corticosteroids s 50% 5 year survival
* With grateful acknowledgement to Juan Oleaga, MD, FACR and Paul Brady, MD
1. Bockus, Henry L. Gastroenterology, 3rd ed., Vol. 4 Pages 538-541. W. B. Saunders Company, Philadelphia, London, Toronto, 1976. 2. Dahnert, Wolfgang Radiology Review Manual, 4th ed. Page 533, Lippincott, Williams and Wilkins, Philadelphia, Baltimore, etc., 2000.
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LearningRadiology-Nonossifying fibroma
Nonossifying Fibroma
AKA: Nonosteogenic fibroma, fibroxanthoma, xanthogranuloma of bone
Return to Case
q q q
30 to 40% children over two years have one or more lesions Most common between 8-20 years of age Usually occur in metaphysis of one (75%) or more (25%) of the tubular bones
Most often occur in lower extremities around knee r Fewer than 10% occur in upper extremities Characteristics r Geographic r Lytic r Multilobulated r Metaphyseal r Usually intramedullary r Eccentric r Well-marginated r Sclerotic rim r Endosteal scalloping
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LearningRadiology-Nonossifying fibroma
q
Most lesions heal spontaneously by being replaced with normal bone r Migrate away from epiphysis May undergo pathologic fracture or rarely cause rickets r Do not undergo malignant transformation
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LearningRadiology-Radiation fibrosis
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Radiation Pneumonitis
q q
q q
Damage to lungs after radiation therapy Usually requires at least 4500 rads r Especially common if >6000 R given in 5-6 weeks Occurs more often if there is concurrent or later chemotherapy Pathologic phases r Exudative phase = edema fluid + hyaline membranes r Organizing phase r Fibrotic phase = interstitial fibrosis Time of onset r Usually at least 6 weeks up to 6 months after treatment Location r Confined to radiation portal
Radiation portal (left) with subsequent radiation pneumonitis
Acute Radiation Pneumonitis

o o Occurs within 1-8 weeks after radiation therapy Pathology Depletion of surfactant (1 week to 1 month later), plasma exudation, desquamation of alveolar + bronchial cells
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o o
o o
Usually asymptomatic When symptomatic Nonproductive cough, shortness of breath, weakness, fever (insidious onset) Acute respiratory failure (rare) Changes usually confined to radiation portal Patchy / confluent consolidation, may persist up to 1 month (exudative reaction) Atelectasis + air bronchogram Spontaneous pneumothorax (rare)
CT findings of acute radiation pneumonitis r Homogeneous slight increase in attenuation (2-4 months after therapy) r Patchy consolidation (1-12 months after therapy) r Non-uniform discrete consolidation (most common; 3 months to 10 years after therapy)
Sequential transverse images through lung showing radiation pneumonitis in right lung
q
Prognosis r Recovery or progression to death from fibrosis Rx r Steroids
Chronic Radiation Damage

o o o 9-12 months after radiation therapy Histology Permanent damage of endothelial + type I alveolar cells May be associated with: Thymic cyst Calcified lymph nodes (in Hodgkin disease) Pericarditis + effusion (within 3 years) Severe loss of volume Dense fibrous strands from hilum to periphery Thickening of pleura CT findings Solid consolidation (radiation fibrosis) + bronchiectasis (stabilized by 1 year after therapy)
Text from Dahnert, 4th Edition

LearningRadiology-Charcot's Arthropathy
Neuropathic (Charcot) Arthropathy

Return to case
q
Disturbance in sensation leads to multiple microfractures r Pain sensation is intact from muscles and soft tissue Distribution and causes r Shoulders syrinx, spinal tumor r Hips tertiary syphilis, diabetes r Knees tertiary syphilis (more bone production), diabetes (less bone production) r Feet diabetes r Other causes s Amyloidosis s Congenital indifference to pain s Polio s Alcoholism X-ray findings r Sclerosis r Destruction of joint r Fragmentation r Soft tissue swelling from synovitis r Joint effusions r Osteophytosis r Disorganized and disrupted joint r No osteoporosis DDX
r
Degenerative joint disease s Eventually neuropathic joint shows more sclerosis s More fragmentation in neuropathic s More destruction of bone in neuropathic CPPD s Associated with chondrocalcinosis which a neuropathic joint is not
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LearningRadiology-Charcot's Arthropathy
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Gastric Emphysema
Return to case
q
Air in the stomach wall with an appearance similar to emphysematous gastritis with a much more benign clinical course Caused by disruption in mucosa leading to air dissecting into wall from: r Gastric outlet obstruction with increased intraluminal pressure r Severe vomiting r Instrumentation-like endoscopy r Dissection of air from mediastinum from ruptured bleb or pneumothorax r Pneumatosis cystoids - submucosal air collections
q q q
Rare and severe gastritis secondary to mucosal disruption and gas-forming bacterial invasion Characterized by air in the wall of the stomach Causes: r Ingestion of toxic material such as corrosives r Alcohol ingestion r Trauma r Gastric infarction r Ulcer disease Submucosa is invaded by gas-forming organisms which include: r Hemolytic strep r Clostridia Welchi r E. Coli r Staph aureus Clinical: r Sudden and violent onset of bloody emesis r Fever r Nausea r Chills r Leukocytosis X-ray: r Linear small gas bubbles in gastric wall s Gastric emphysema is more linear, streak-like
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Gas in portal vein Prognosis: r 60-80% fatal Best way to differentiate emphysematous gastritis from gastric emphysema: r Look at patient s Patients with gastric emphysema are a asymptomatic from the bowel gas air s Patients with emphysematous gastritis are usually deathly ill
r
WH/wh 03
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LearningRadiology - Ruptured Aortic Aneurysm
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Abdominal Aortic Aneurysm
q q
Focal widening >3 cm Normal size of abdominal aorta >50 years of age: r About 2 cm Prevalence: r Increases with age r Greater with atherosclerotic disease r Male predominance r Whites: Blacks = 3:1 Risk factors: r male r age >75 years r white race r prior vascular disease r hypertension r cigarette smoking r family history r hypercholesterolemia Associated with: r visceral + renal artery aneurysm (2%) r isolated iliac + femoral artery aneurysm (16%) s common iliac (89%), internal iliac (10%), external iliac (1%) r stenosis / occlusion of celiac trunk / SMA (22%) r stenosis of renal artery (22-30%) r occlusion of inferior mesenteric artery (80%) r occlusion of lumbar arteries (78%) Growth rate of aneurysm of 3-6 cm in diameter: r 0.39 cm / year Clinical r asymptomatic (30%) r abdominal mass (26%)
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abdominal pain (37%) Location r infrarenal (91-95%) with extension into iliac arteries (66-70%) Imaging findings r Plain film s mural calcification (75-86%) r US:>98% accuracy in size measurement r CT-non-contrast enhanced s perianeurysmal fibrosis (10%), may cause ureteral obstruction s "crescent sign" = peripheral high-attenuating crescent in aneurysm wall (= acute intramural hematoma) = sign of impending rupture r CT-contrast-enhanced s ruptured aneurysm q anterior displacement of kidney q extravasation of contrast material q fluid collection / hematoma within posterior pararenal + perirenal spaces (see below)
r
free intraperitoneal fluid contained leak q laminated mural calcification q periaortic mass of mixed / soft-tissue density q lateral "draping" of aneurysm around vertebral body
q
Angio focally widened aortic lumen >3 cm r apparent normal size of lumen secondary to mural thrombus (11%) r mural clot (80%) r slow antegrade flow of contrast medium Contained rupture = extraluminal hematoma / cavity r absent parenchymal stain = avascular halo r displacement + stretching of aortic branches Complications: r Rupture (25%) s into retroperitoneum: commonly on left
r
into GI tract: massive GI hemorrhage s into IVC: rapid cardiac decompensation q Incidence: aneurysm <4 cm in 10%, 4-5 cm in 23%, 5-7 cm in 25%, 7-10 cm in 46%, >10 cm in 60% q Symptoms of rupture r sudden severe abdominal pain radiating into back r faintness, syncope, hypotension r Prognosis:64-94% die before reaching hospital r Increased risk: size >6 cm, growth >5 mm / 6 months, pain + tenderness r Peripheral embolization r Infection r Spontaneous occlusion of aorta Prognosis:17% 5-year survival without surgery r 50-60% 5-year survival with surgery Treatment r surgery recommended if >5 cm in diameter; r 4-5% surgical mortality for nonruptured s 30-80% for ruptured aneurysm Postoperative Complications r Left colonic ischemia (1.6%) with 10% mortality r Renal failure (14%) r 0-8% mortality rate for elective surgery
s
From Dahnert Radiology Review Manual 2002
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Multiple Hereditary Exostoses

Diaphyseal Aclasis
q q
Inheritance r Autosomal dominant Age of onset r Discovered between 2 and 10 years Male predominance = 2:1 Pathology r Ectopic cartilaginous rest in metaphysis and a defect in periosteum produces exostoses r Cap of hyaline cartilage over bony protuberance r Cortex and cancellous bone of exostosis is contiguous to host bone Clinical r Usually painless mass near joints r Tendons, blood vessels, nerves may be impaired r Mechanical limitation of joint movement may occur Location r Multiple r Usually bilateral r Common sites are knee, elbow, scapula, pelvis, ribs
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Site Metaphyses of long bones near epiphyseal plate (distance to epiphyseal line increases with growth) r Always point away from joint and toward center of shaft r Occasionally small punctate calcifications are seen in cartilaginous cap Other skeletal abnormalities may occur r Shortening of 4th and 5th metacarpals r Supernumerary fingers and/or toes r Madelung / reversed Madelung deformity r Dislocation of radial head Prognosis r Exostosis begins in childhood r Stops growing when nearest epiphyseal center fuses Complications r Malignant transformation to chondrosarcoma in <5% s Iliac bone commonest site s Look for growth with irregularity of contour and fuzziness of margin s Sudden painful growth spurt r Cord compression secondary to involvement of posterior spinal elements
r
From Dahnert
Return to Case
Pulmonic Stenosis
Pulmonic stenosis without VSD= 8% of all CHD Mostly asymptomatic When symptomatic, cyanosis and heart failure Loud systolic ejection murmur Cor pulmonale Rare calcification of pulmonary valve in older adults X-ray Enlarged main pulmonary artery Enlarged left pulmonary artery (jet stream effect) Normal to decreased peripheral pulmonary vasculature Subvalvular pulmonic stenosis Infundibular pulmonic stenosis Typically in Tetralogy of Fallot Subinfundibular pulmonic stenosis Associated with VSD (85%)
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Valvular Pulmonic Stenosis Classic pulmonic stenosis (95%) Fusion of pulmonary cusps Presents in childhood Pulmonic click Dome-shaped pulmonic valve RX: Balloon valvulo-plasty Trilogy of Fallot Severe pulmonic valvular stenosis RV hypertrophy ASD with RL shunt Supravalvular pulmonic stenosis May be either tubular hypoplasia or localized with poststenotic dilatation May be associated with: Valvular pulmonary stenosis, supravalvular aortic stenosis, VSD, PDA, systemic arterial stenoses Williams-Beuren Syndrome: PS, supravalvular AS, peculiar facies Ehlers-Danlos syndrome Postrubella Syndrome: peripheral pulmonary stenoses, PDA, low birth weight, deafness, cataracts, mental retardation
WH/91
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Round Pneumonia
q q
Spherical pneumonia caused by r Haemophilus influenzae r Streptococcus r Pneumococcus Children are affected much more than adults Location r Usually lower lobe r Most often posterior Clinical r Cough r Fever r Chest pain May change size rapidly May have slightly irregular border and contain air bronchogram
q q
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q
Not to be confused with mass in children
LearningRadiology- Boerhavve's Syndrome
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Boerhaave's Syndrome Ruptured Esophagus
Nearly all esophageal perforations are caused by trauma
Causes include: > Iatrogenicendoscopy (about 75% of the perforations in adults), dilatation procedures > Stab wounds > Occasionally, blunt compression of the chest > Severe vomiting or straining Non-traumatic causes include neoplasm or caustic ingestion In infants, the most frequent site of rupture is the cervical esophagus 2 passage of tubes
Usually in men, although neonatal esophageal rupture occurs primarily in girls Associated with the clinical triad of vomiting, chest pain and subcutaneous/mediastinal emphysema In neonates, there is cyanosis and dyspnea associated with a right tension pneumothorax immediately after birth In Boerhaaves, the inciting cause may be vomiting, straining, childbirth or a blunt blow to the abdomen or thorax Tears are vertically oriented, 1-4 cm in length
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Almost all (90%) occur along the left posterolateral wall of the distal esophagus
Photo shows extraluminal contrast arising from left, posterolateral tear of esophagus
X-Ray
Mediastinal emphysema
Left pleural effusion
Photo shows mediastinal emphysema and extraluminal contrast in pleural space on left Mediastinal widening Subcutaneous emphysema Nacleiro sign-a V-shaped radiolucency seen through the heart representing air in the left lower mediastinum that dissects under the left diaphragmatic pleura In neonatal rupture, pneumomediastinum is uncommon
Method of study: First use a water-soluble contrast agent (Gastrografin, oral Hypaque) If no perforation is found, then barium may be used
WH/
LearningRadiology- Giant Cell Tumor
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Giant Cell Tumor

Osteoclastoma
q q
q q
Probably arise from zone of osteoclastic activity in skeletally immature patients Incidence r ~ 4% of all primary bone tumors r ~ 20% of benign skeletal tumors Histology r Multinucleated osteoclastic giant cells intermixed throughout a spindle cell stroma Age r > 98% after epiphyseal plate fusion s Most between 20 and 40 years M:F = 1:1 Clinical r Tenderness r Pain at affected site r Weakness r Sensory deficits (if in spine) Location: r 85% in long bones s Lower extremity (50-60% about knee) q Distal femur > proximal tibia s Upper extremity (away from elbow): q Distal radius > proximal humerus r 15% in flat bones s Pelvis s Sacrum near SI joints s Skull Site in bone r Eccentric r Metaphyseal s Adjacent to epiphyseal line q Subarticular if epiphyseal plate is fused
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Appearance r Expansile r Solitary lytic bone lesion r May be quite large at diagnosis r No reactive sclerosis r No periosteal reaction in absence of fracture r May break through cortex with cortical thinning r Soft-tissue invasion (25%) r Pathologic fracture (5%) r Destruction of vertebral body with secondary invasion of posterior elements (DDx: ABC, osteoblastoma) s Frequently demonstrate vertebral collapse s Can involve adjacent vertebrae and disk (like discitis) and can cross sacroiliac joint r May cross joint space in long bones (exceedingly rare) Nuclear medicine findings r Diffusely increased uptake r May have "doughnut" sign of central photopenia Angiographic findings r Hypervascular lesion CT findings r Tumor has soft-tissue attenuation s May contain foci of low attenuation (hemorrhage/necrosis) r Well-defined margins r May have thin rim of sclerosis MR findings r Heterogeneous signal intensity with low to intermediate intensity on T1WI + T2WI (63-96%) due to collagen + hemosiderin content r Focal cystic areas r Low-signal-intensity pseudocapsule Complications and associations r 15% malignant within first 5 years s Much more often in males (M:F = 3:1) r Metastases to lung
May be associated with s Paget disease (in 50-60% located in skull + facial bones) Prognosis r Locally aggressive r 40-60% recurrence rate Treatment r Complete resection + radiation therapy DDx: r Aneurysmal bone cyst r Brown tumor (lab values) r Cartilaginous tumor s Chondroblastoma (open epiphyses) s Enchondroma (not epiphyseal) s Chondromyxoid fibroma (rare) s Chondrosarcoma r Fibrous dysplasia
r r
Dahnert 6th Edition
LearningRadiology - Sprue
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Sprue
3 diseases: Celiac Disease of Children, Nontropical sprue and Tropical Sprue Celiac disease and Nontropical sprue improve on gluten-free diet Tropical sprue improves with antibiotics and folic acid X-ray The hallmark features are: dilatation and dilution, especially in jejunum Segmentation of the barium column occurs because it moves more slowly through areas of excessive fluid and separates from the rest of the column-not commonly seen with newer barium mixtures Fragmentation is an exaggerated example of the irregular stippling of residual barium in the proximal bowel (which is normal) Intussusception is not uncommon but is usually not obstructive; sprue has increased risk of ca and lymphoma Moulage sign is caused by dilated loop with effaced folds looking like tube into which wax has been poured
Learn more about Diffuse Small Bowel Disease here and here
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LearningRadiology - Pulmonary Sling
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Pulmonary Sling
q
Pulmonary sling occurs because of failure of formation of Left 6th aortic arch so there is absence of Left pulmonary artery The blood to the Left lung comes from an aberrant Left pulmonary artery which arises from Right pulmonary artery and crosses between esophagus and trachea Bronchial cyst may produce same finding on esophagus/trachea
Key view is lateral where red arrow points to aberrant vessel interposed between the esophagus and trachea.
Double Aortic Arch

q q q
Double aortic arch is most common vascular ring Caused by persistence of Right and Left IV branchial arches Rarely associated with Congenital Heart Disease
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q q q q q
Symptoms (of tracheal compression or difficulty swallowing) may begin at birth Right arch is higher, left arch is lower producing reverse S on esophagram in AP Right arch supplies Right common carotid and Right subclavian arteries Left arch supplies Left common carotid and Left subclavian arteries On lateral, arches are posterior to esophagus and anterior to trachea
Double Aortic Arch. Frontal chest shows impression on right-side of barium-filled esophagus from higher rightsided arch and below it an impression on the left-side of the esophagus from left-sided arch. Lateral film shows anterior displacement of both trachea and esophagus.
q
Anterior impression on the trachea alone may be caused by isolated anomalous inominate artery (arises from arch more distal than normal) or anomalous Left common carotid (originates more proximal than normal)
wh
LearningRadiology - Pneumocystis Carinii Pneumonia PCP
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Pneumocystis Carinii Pneumonia PCP

q q
Most common cause of interstitial pneumonia in immunocompromised patients Organism r Protozoan / fungus Pneumocystis carinii Predisposed r AIDS r Debilitated r Premature infants r Children with hypogammaglobulinemia r Other immunocompromised patients s Congenital immunodeficiency syndromes s Lymphoproliferative disorders s Organ transplant recipients s Patients on long-term corticosteroid therapy s Patients on chemotherapy for cancer Associated infections r CMV r Mycobacterium avium-intracellulare (MAI) r Herpes simplex Clinical r Severe dyspnea and cyanosis r Subacute insidious onset of malaise and slight cough (frequent in AIDS patients) r Respiratory failure r WBC slightly elevated (polys) r Lymphopenia (50%) indicates poor prognosis Imaging findings r Normal CXR in 10-40% r Bilateral diffuse symmetric finely granular / reticular interstitial / airspace infiltrates in 80% s Characteristic central location s Rapid progression to diffuse airspace disease
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q
Resembles non-cardiogenic pulmonary edema
PCP
Pleural effusion and hilar lymphadenopathy are uncommon r Atypical pattern in 5% s Isolated lobar disease / focal parenchymal opacities s Lung nodules cavitation s Hilar / mediastinal lymphadenopathy s Thin- / thick-walled cysts s Cavities with predilection for upper lobes Course r Usually responds to therapy in 5-7 days r Effect of prophylactic use of aerosolized pentamidine s Redistribution of infection to upper lobes Complications r Cystic lung disease s Central location to cysts r Spontaneous pneumothorax, frequently bilateral (6-7%) r Disseminated extrapulmonary disease (1%) r Punctate / rimlike calcifications within enlarged lymph nodes and abdominal viscera CT findings r Patchwork pattern (56%) s Bilateral, asymmetric patchy mosaic appearance r Ground-glass pattern (26%) s Bilateral, diffuse air-space disease in symmetric distribution r Interstitial pattern (18%) s Bilateral, symmetric / asymmetric, reticular markings (thickening of lobular septa) r Abnormal air-filled spaces (38%) s Pneumatocoeles q Thin-walled spaces without lobar predilection resolving within 6 months s Subpleural bullae due to emphysema s Thin-walled cysts s Necrosis of pneumocystis granuloma s Pneumothorax (13%)
r
Lymphadenopathy (18%) r Pleural effusion (18%) Pulmonary nodules and cavities r Usually due to malignancy s Leukemia, lymphoma s Kaposi sarcoma s Metastasis s Or septic emboli r Pulmonary cavities usually due to superimposed fungal / mycobacterial infection Nuclear medicine r Bilateral and diffuse Ga-67 uptake without mediastinal involvement prior to roentgenographic changes DDx r Non-cardiogenic pulmonary edema r TB r MAI infection
r
Diagnosis r Sputum collection r Bronchoscopy with lavage r Transbronchial or transthoracic or open lung Bx
Dahnert 4th edition
LearningRadiology - Acute Osteomyeltis
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Acute Osteomyelitis
q
Age
r
Usually affects children s Septic arthritis more common in adults; osteomyelitis in children
Hallmark characteristics r Destruction of bone r Periosteal new bone formation Organisms r Newborns s S. aureus s Group B streptococcus s E. coli r Children s S. aureus r Adults s S. aureus (most common) s Enteric species s Streptococcus r Drug addicts s Pseudomonas (most common) s Klebsiella r Sickle cell disease s Salmonella Pathogenesis r Hematogenous spread r Direct implantation from a traumatic / iatrogenic source r Extension from adjacent soft-tissue infection Location r Lower extremity (most common) s Over pressure points in diabetic foot r Vertebrae s Lumbar > thoracic > cervical r Radial styloid
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r
Sacroiliac joint
ACUTE NEONATAL OSTEOMYELITIS

q
Age Onset <30 days of age Little or no systemic disturbance Multicentric involvement more common r Often joint involvement Bone scan falsely negative / equivocal in 70%
r
q q
ACUTE OSTEOMYELITIS IN INFANCY

q
Age
r <18 months of age Pathomechanism r Spread to epiphysis through blood vessels Marked soft-tissue component Subperiosteal abscess with extensive periosteal new bone formation Complications r Frequent joint involvement Prognosis r Rapid healing
q q q
ACUTE OSTEOMYELITIS IN CHILDHOOD

q
Age 2-16 years of age Pathomechanism r Trans-physeal vessels closed r Primary focus of infection is in metaphysis Findings r Sequestration frequent r Periosteal elevation r Small single / multiple osteolytic areas in metaphysis r Extensive periosteal reaction parallel to shaft (after 3-6 weeks) r Shortening of bone with destruction of epiphyseal cartilage r Growth stimulation by hyperemia and premature maturation of adjacent epiphysis
r
ACUTE OSTEOMYELITIS IN ADULTHOOD

q q
Delicate periosteal new bone Joint involvement common r Septic arthritis X-ray findings r Initial radiographs often normal for as long as 7-10 days r Localized soft-tissue swelling adjacent to metaphysis with obliteration of usual fat planes (after 3-10 days) r Area of bone destruction (lags 7-14 days behind pathologic changes)
Bone destruction of head of 2nd metatarsal with periosteal new bone formation characteristic of osteomyelitis
q q q q
Involucrum = cloak of laminated /spiculated periosteal reaction (develops after 20 days) Sequestrum = detached necrotic cortical bone (develops after 30 days) Cloaca formation = space in which dead bone resides MR findings r Bone marrow hypointense on T1WI + hyperintense on T2WI (= water-rich inflammatory tissue) DDx r Neuropathic osteoarthropathy r Aseptic arthritis r Acute fracture r Recent surgery r Ewings sarcoma Findings r Focal / linear cortical involvement hyperintense on T2WI r Hyperintense halo surrounding cortex on T2WI = subperiosteal infection r Hyperintense line on T2WI extending from bone to skin surface and enhancement of borders (= sinus tract) Nuclear Medicine (accuracy approx. 90%): r Ga-67 scans s 100% sensitivity s Increased uptake 1 day earlier than for Tc-99m MDP r Gallium helpful for chronic osteomyelitis Static Tc-99m diphosphonate r 83% sensitivity r 5-60% false-negative rate in neonates and children Complications of osteomyelitis r Abscess in soft-tissue r Fistula or sinus formation r Pathologic fracture

r r r
Extension into joint producing septic arthritis Growth disturbance due to epiphyseal involvement Severe deformity with delayed treatment
Dahnert 4th Edition
LearningRadiology - Budd-Chiari Syndrome
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Budd-Chiari Syndrome Hepatic Venous Occlusive Disease
Obstruction to hepatic venous outflow leads to increased sinusoidal pressure producing reversed or delayed flow in portal veins Many causes r Idiopathic most common r Tumor s Hepatocellular carcinoma s Carcinoma of pancreas s Carcinoma of kidneys s Metastatic disease r Blood dyscrasia s Leukemia s Sickle cell disease s Polycythemia vera r Birth control pills r Pregnancy r Pyrrolizidine alkaloids (senecio) found in Jamaican tea r Membranous diaphragm in suprahepatic IVC Acutely r Hepatomegaly and ascites r Severe symptoms including shock r Abdominal pain r Jaundice r CT s Hepatomegaly and ascites s Non-visualization of occluded hepatic veins q Also seen on MRI s Patchy enhanced appearance with dynamic imaging s Inversion of portal blood flow results in inside-out enhancement of liver
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s s q
Caudate lobe is hyperdense early, decreased later q Periphery is hypodense early, increased later q Then enhancement equilibrates r Due to reversed portal venous flow Enlarged right inferior hepatic vein Enlarged portal vein (>12mm in adults)
q
Chronically r Portal hypertension and variceal bleeding r Enlargement of caudate lobe r Collateral circulation through azygous and hemiazygous s Visualization of paraumbilical vein r Non-visualization of hepatic veins r Inversion of portal blood flow results in inside-out enhancement of liver s Periphery is hypodense early s Then enhancement equilibrates s Due to reversed portal venous flow
Early and delayed phases of liver enhancement in Budd-Chiari Syndrome

r r r q
Nuclear medicine shows hot caudate lobe with diminished activity in peripheral zones of liver Angiography shows large lakes of sinusoidal contrast accumulations Absence of main hepatic veins Diagnosis r Usually can be made on imaging study Treatment r Anticoagulants

r r r r
Surgery Balloon dilatation TIPS Liver transplant
WH/03
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Pigmented Villonodular Synovitis PVNS

q
Benign synovial proliferation primarily affecting knees with erosions, cysts, soft tissue swelling but with preservation of the joint space, no osteoporosis or calcification. Pigment is hemosiderin. Clinical r Frequent history of antecedent trauma r Hemorrhagic "chocolate" effusion r Insidious onset of swelling r Pain of long duration r Decreased range of motion r Joint locking Age r Mainly 2nd-4th decade; 50% <40 years r F>M Location r Knee (most common) r Ankle r Hip r Elbow r Shoulder r Tarsal or carpal joints r Predominantly monarticular Radiographic findings r Soft-tissue swelling around joint s From effusion and synovial proliferation r Dense soft-tissues from hemosiderin deposits r Subchondral pressure erosions at margins of joint from hypertrophied synovium r Multiple sites of deossification appearing as cysts r No calcifications r No osteoporosis r No joint space narrowing (until late)
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AP and lateral views of the knee demonstrate marked soft tissue swelling, cystic changes in both the femur and tibia without significant joint space narrowing
q
MRI findings r Masses of synovial tissue in a joint with effusion r Scalloping / truncation of prefemoral fat pad r Predominantly low signal intensity on all sequences (due to presence of iron) (characteristic of this lesion) r Often heterogeneous low + high signal intensity on T2WI (hemosiderin deposits in masses + para-articular fat) r DDx s Hemosiderin deposits in other diseases (eg, rheumatoid arthritis) Treatment r Synovectomy r Arthrodesis r Arthroplasty r Radiation DDx r Synovial sarcoma s Mass around, but outside of, joint s Frequently calcify r Degenerative arthritis s Joint space narrowing s Subchondral sclerosis
Dahnert 4th edition
LearningRadiology - Ovarian Carcinoma, Calcified Liver Masses, Metastases, Liver
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Calcified Liver Masses Ovarian Neoplasms

Calcified Liver Masses - Causes
q
Inflammatory hepatic lesions r Most common cause of calcified hepatic lesions q Inflammatory conditions q For example, granulomatous diseases (tuberculosis). q Calcification involves entire lesion q Appears as a dense mass q May produce artifacts on CT scans r Echinococcus cysts have curvilinear or ring calcification q Central water density in cyst Benign neoplasms r Hemangiomas, especially large ones, may contain large, coarse calcifications; may be seen at CT in 20% of cases or radiography in 10% Malignant liver neoplasms r Hepatocellular adenoma q Calcifications may be solitary or multiple q Usually located eccentrically within complex heterogeneous mass. r Fibrolamellar carcinoma q Calcifications reported in 15%-25% of cases at CT q Occurs in many patterns r Intrahepatic cholangiocarcinoma q Calcifications are typically accompanied by a desmoplastic reaction q Visible at CT in about 18% of cases. r Calcified hepatic metastases q Most frequently associated with mucin-producing neoplasms such as colon, or less
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likely ovarian, carcinoma
Calcified Liver Masses - DDX

Granulomas, as in TB Hydatid cysts Hemangiomas Hepatocellular adenoma Fibrolamellar carcinoma Intrahepatic cholangiocarcinoma Mucin-producing metastases
Calcified ovarian carcinoma metastases in the peritoneum and liver
Ovarian Neoplasms
q q
Tumors of Surface Epithelium form 90% of ovarian tumors Mucinous Tumors

Incidence 30% of ovarian neoplasms Mucinous cyst adenoma Commonest tumor Age group: 30-50 yrs Bilateral in 10% Mucinous cystadenocarcinoma Features Age group: 40-60 yrs Bilateral in 10 %
Large multilocular pedunculated cyst Rare complication may occur with involvement of the peritoneum Psedomyxoma peritonei (jelly belly) May produce coarse calcifications in primary or metastases
Serous Tumors
Incidence 50% of ovarian neoplasms Serous cystadenoma: Age group: 20 30 yrs Bilateral in 15% Malignant transformation in 20 30 % Serous cystadenocarcinoma: Age group: 40 60 yrs Bilateral in 30% 5 year survival rate: 30 50 % Features: Contain fibrous walled cysts with papillary excrescences Locales contain straw-colored fluid Samoa bodies=concentric calcification in papillary process Usually fine sand-like calcification frequently difficult to see on plain radiographs Incidence 20% of ovarian tumors Morphology: Tumors containing solid and cystic areas Filled with hemorrhagic fluid Lined by glandular epithelium Incidence: uncommon Age group: 50 60 yrs Morphology: Unilocular cysts with small cystic spaces Incidence: 1- 2% Occur commonly in perimenopausal women
Endometrial tumors
-
Clear Cell (mesonephroid tumor)

-
Brenner tumor:
Germ Cell Tumors

Origin : cells derived form oocytes Incidence: 15- 20% of all ovarian tumors, 5% malignant Age: young age Incidence : very common Age : 20 20 yrs Bilateral : 10 15 % Macroscopic features : Solid tumors, elastic rubbery consistency having smooth, firm capsule Derived from cells of all three germ layers Types: Mature or benign type (e.g. Dermoid cysts) Immarure or malignant type (e.g. Solid Teratoma) Monodermal or highly specialised (e.g. Struma ovarii)
Dysgerminoma
-
Teratoma
-

q
Choriocarcinoma and Embryonal Cell Carcinoma

Choriocarcinoma mostly of placental origin occurs in prepubertal girls. Highly malignant Contains syncytiotrophoblasts and cytotrophoblasts Secretes large quantities of the tumor marker - HCG Embryonal cell carcinoma Incidence : rare Highly malignant Meigs syndrome Ascites Right sided effusion Primary : 15% - small & large bowel , 20% - stomach, 6% - breast Bilateral smooth surface Histologically cellular or myxomatous stroma with scattered large signet ring cells
Ovarian Fibroma:
-
Krukenberg tumor
-
o o o
Routes of Peritoneal Spread

Right subphrenic space The greater omentum The Pouch of Douglas
LearningRadiology - Dissecting Aortic Aneurysm, Dissecting Hematoma
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Aortic Dissection
q q q
3:1 male to female predominance Over the age of 40 Hemorrhage in the media (at vasa vasorum) leading to either r Tear in the weakened intima which breaks into the lumen, or r Hemorrhage in the wall (less common) r Hemorrhage separate media from adventitia
Predisposing factors o o o o o o o o Hypertension (most commonly) Atherosclerosis Cystic medial necrosis Marfans syndrome Coarctation of the aorta Aortic stenosis S/P prosthetic aortic valve Trauma (rare) Pregnancy (rare)
Aneurysm defined by size criteria o o In general, ascending aorta > 5 cm Descending aorta > 4 cm
Vessels involved with dissection o o o Any artery can be occluded Usually the right coronary and three arch vessels are involved with arch aneurysms Right pulmonary artery and left-sided pulmonary veins may be occluded
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Types o o DeBakey Type I Involves entire aorta DeBakey Type II Least common Ascending aorta only DeBakey Type III Most common Descending aorta only Stanford Type A Ascending aorta involved Over half develop aortic regurgitation Stanford Type B Ascending aorta NOT involved
Most dissections arise either just distal to the aortic valve or just distal to aortic isthmus True versus false channel o False channel usually arises anterior in the ascending aorta and spirals to posterior and left lateral in descending aorta o True channel is usually larger o Slower flow in false channel on MR
DeBakey Classification DeBakey Type I
Stanford Classification Stanford Type A (ascending aorta involved) Stanford Type A (ascending aorta involved) Stanford Type B
Portion of Aorta Involved Involves entire aorta
Common causes Hypertension Atherosclerosis Cystic medial necrosis e.g.Marfans Ehlers-Danlos Hypertension Atherosclerosis
RX Usually surgically*
DeBakey Type II (least common) DeBakey Type III (most common)
Ascending aorta only Descending aorta only
Usually surgically* Usually medically
*Goal is to prevent backward involvement of the aortic valve or rupture into pericardium
Clinical o o o o o Sharp, tearing, intractable chest pain Murmur or bruit of aortic regurgitation Previously hypertensive, now possible shock Asymmetric peripheral pulses Pulmonary edema
Imaging Findings
Chest films Mediastinal widening Left paraspinal stripe Displacement of intimal calcifications Apical pleural cap Left pleural effusion Displacement of endotracheal tube or nasogastric tube
MRI Intimal flap Slow flow or clot in false lumen
CT Intimal flap Displacement of intimal calcification Differential contrast enhancement of true versus false lumen
CT of abdominal aorta show intimal flap (dark line) with true lumen anteriorly and false lumen posteriorly
Angiography Intimal flap Double lumen Compression of true lumen by false channel Increase in aortic wall thickness > 10 mm Obstruction of branch vessels
Diagnosis o o o MRI if available is usually best for imaging ascending aorta Contrast-enhanced CT can image arch and descending aorta Transesophageal ultrasound, if available, especially for root and ascending aorta
Angiography
Prognosis
Timing Immediate Within 24 hours By end of 1st week By 3 weeks By 3 months Alive at 1 year Death 3% 20-30% 50% 60% 80% 10-20%
WH/03
LearningRadiology - Ping Pong Ball Plumbage, TB
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Older Methods of Treating TB Plombage Therapy Ping-Pong Ball Plombage

Early treatments of TB relied upon rest, proper nutrition and isolation In late 1800s, concept of artificial ptx introduced by Carlo Forlanini of Milan o o o Speculated on the feasibility of collapsing lung by introducing air into the pleural space Intentional production of a lung collapse was thought to allow the lung to rest It usually did nothing except to worsen the condition of the patient
o By early 40s, thousands of refills (reinjections of air) were being done each year to maintain collapsed lung Pneumoperitoneum to rest the lung followed in the late 1940s o These techniques were often combined with phrenicolysis (crushing or surgical division of the phrenic nerve) leading to ipsilateral paralysis of the diaphragm. There were other procedures such as thoracoplasty and plombage o Thoracoplasty was more permanent form of collapse therapy in which several upper ribs were removed o The chest cage was then pushed toward the mediastinum, collapsing the upper lobe
Plombage involved the extrapleural insertion of a plombe to collapse the lung. They included: o Fat
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o o o
Solid paraffin wax Lucite spheres Plastic ping pong balls (1940s)
Multiple round ring-shadows in RUL are plastic balls inserted into the pleural space to collapse lung o o Sponges of inert plastic material Oleothorax Oil in the pleural cavity
Sanatorium movement began slower in US than Europe o o Once started, many opened and became a major way of treating TB In 1953, 839 TB sanatoria in the USA stressing Diet Regimented exercise High altitude Bedrest Sunlight Cold air
Chemotherapy began in mid-1940s
Wh/wh
LearningRadiology - Rugger-Jersey Spine, Hyperparathyroidism
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Renal Osteodystrophy
Constellation of musculoskeletal abnormalities occurring with chronic renal failure featuring some combination of o Osteomalacia (adults) o Rickets (children) o 2 hyperparathyroidism o Soft-tissue calcifications o Osteosclerosis o Soft-tissue + vascular calcifications Low calcium levels lead to osteomalacia o Additional factors responsible for osteomalacia are Inhibitors to calcification produced in the uremic state Aluminum toxicity Dysfunction of hepatic enzyme system A Renal insufficiency with diminished filtration results in phosphate retention Maintenance of Ca x P product lowers serum calcium directly, which in turn increases parathyroid hormone production (2hyperparathyroidism) Osteopenia o Combined effect of Osteomalacia (reduced bone mineralization due to acquired insensitivity to vitamin D / antivitamin D factor) Osteitis fibrosa cystica (bone resorption) Osteoporosis (decrease in bone quantity) o Complications Fracture predisposition (lessened structural strength) with minor trauma Spontaneously Fracture prevalence increases with duration of hemodialysis + remains unchanged after renal transplantation Sites of fractures o Vertebral body (3-25%) o Pubic ramus, rib (5-25%)
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o o o
Milkman fracture / Looser zones (in 1%) Metaphyseal fractures
Prognosis Osteopenia may remain unchanged / worsen after renal transplantation + during hemodialysis Secondary hyperparathyroidism o Cause Inability of kidneys to adequately excrete phosphate leads to hyperplasia of parathyroid chief cells (2 hyperparathyroidism) Excess parathyroid hormone affects the development of osteoclasts, osteoblasts, osteocytes o Hyperphosphatemia o Hypocalcemia o Increased PTH levels o Subperiosteal, cortical, subchondral, trabecular, endosteal, subligamentous bone resorption o Osteoclastoma = brown tumor = osteitis fibrosa cystica (due to parathyroid hormone -stimulated osteoclastic activity More common in 1 hyperparathyroidism o Periosteal new-bone formation (8-25%) o Chondrocalcinosis More common in 1 hyperparathyroidism) Osteosclerosis (9-34%) o One of the most common radiologic manifestations Most common with chronic glomerulonephritis o May be the sole manifestation of renal osteodystrophy o Diffuse chalky density o Thoracolumbar spine in 60% with dense end-plates produce appearance of rugger-jersey (rugger jersey spine)
Rugger-jersey spine in Renal osteodystrophy Also in pelvis, ribs, long bones, facial bones, base of skull (children) Prognosis May increase/regress after renal transplantation Soft-tissue calcifications o Metastatic secondary to hyperphosphatemia (solubility product for calcium + phosphate exceeds 60-75 mg/dL in extracellular fluid) Hypercalcemia Alkalosis with precipitation of calcium salts o Dystrophic secondary to local tissue injury Location Arterial (27-83%) o In medial + intimal elastic tissue Dorsalis pedis a., forearm, hand, wrist, leg o Pipestem appearance without prominent luminal involvement Periarticular (0-52%) o Multifocal o Frequently symmetric o May extend into adjacent joint o Chalky fluid / pastelike material o Inflammatory response in surrounding tenosynovial tissue o Discrete cloudlike dense areas Fluid-fluid level in tumoral calcinosis o Prognosis Often regresses with treatment Treatment o Decrease of phosphorus absorption in bowel o Vitamin D3 administration (if vitamin D resistance predominates) o Parathyroidectomy for 3 hyperparathyroidism (= autonomous hyperparathyroidism) o o
Dahnert 5th edition
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Hamartoma of the Lung
Hamartoma is composed of tissues normally found in the location of origin but in abnormal quantity, mixture or arrangement Incidence 0.25% in population 8% of all solitary pulmonary nodules Most common benign lung tumor 5th and 6th decade peak Male to female ratio of 3:1 Clinical Mostly asymptomatic Cough Fever (with postobstructive pneumonia) Hemoptysis (rare) Location 2/3 are peripheral Endobronchial in 10% Rarely multiple
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Findings Round, smooth mass - increase in size slowly Calcification in 15% - pathognomonic if popcorn type Fat in 50% - detected by CT Calcium and fat in only 20%
Hamartoma of the right lung seen on CT contains both calcification and fat
Cavitation extremely rare DDX Some other causes of a solitary pulmonary nodule Bronchial adenoma Bronchogenic carcinoma Granuloma Lipoid pneumonia (both contain fat but lipid pneumonia is less well-circumscribed and usually does not contain calcification) Solitary metastasis Arteriovenous malformation Necrobiotic nodule
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Diffuse Small Bowel Disease
Scleroderma
Affects esophagus, small bowel and colon, sparing the stomach Atrophy of the muscular layers and replacement with fibrous tissue Associated with malabsorption X-ray Whole small bowel is usually dilated with close approximation of the valvulae (hide-bound appearance) (stack-ofcoins)
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Scleroderma of the bowel - note reflux into slightly dilated distal esophagus and dilatation of small bowel with "stack-of-coins" appearance. On the right, a stack-of-coins. Dilatation of esophagus
q
Upon standing, esophagus empties (DDX from Achalsia which does not empty on standing)
Does not have increased secretions in small bowel as does sprue May be associated with pneumatosis intestinales
Sprue
3 diseases: Celiac Disease of Children, Nontropical sprue and Tropical Sprue Celiac disease and Nontropical sprue improve on gluten-free diet Tropical sprue improves with antibiotics and folic acid X-ray The hallmark features are: dilatation and dilution, especially in jeunum Segmentation of the barium column occurs because it moves more slowly through areas of excessive fluid and separates from the rest of the column-not commonly seen with newer barium mixtures Fragmentation is an exaggerated example of the irregular stippling of residual barium in the proximal bowel (which is normal) Intussusception is not uncommon but is usually not obstructive; sprue has increased risk of ca and lymphoma Moulage sign is caused by dilated loop with effaced folds looking like tube into which wax has been poured
Whipples Disease
Glycoprotein in the lamina propia of the small bowel is Sudan-negative, PAS-positive Clinically: arthralgia, abdominal pain, diarrhea and weight loss Treated with long term antibiotics-penicillin Very rare X-ray The hallmarks of the disease are nodules and a markedly thickened bowel wall (picket-fence)
Small bowel may or may not be dilated Affects jejunum mostly
Amyloidosis
GI involvement is common Associated with malabsorption X-ray Marked thickening of the valvulae (picket-fence) No dilatation or dilution Affects entire small bowel
Hypoproteinemia
Hypoalbuminemia resulting from liver or kidney disease lower than 1.5 grams per cent Usually asymptomatic from intestinal edema itself X-ray Changes are present throughout small bowel Loops are separated due to edema of walls Folds are quite thick (picket-fence)
Giardiasis
Giardia lamblia is a flagellated protozoan, a normal parasite of the small bowel Clinically: diarrhea and malabsorption Treated with metronidazole (Flagyl) Some patients have hypogammaglobulinemia and nodular lymphoid hyperplasia associated with giardiasis X-ray Usually limited to duodenum and jejunum Thickening of the folds
Marked spasm and irritability of the bowel Increased secretions is common
Ischemic Bowel Disease

Thickening of the wall due to edema and hemorrhage Localized perforations can produce air in the bowel wall or in portal venous system X-ray Spasm and irritability early is replaced by an atonic bowel later Lumen is narrowed Folds are thickened, sometimes producing thumb-printing Healing may result in stricture formation
Intramural Bleeding
Suggested if there is duodenal obstruction following trauma Localized lesions occur with trauma Diffuse lesions are seen with anticoagulants X-ray Uniform, regular, thickening of the folds Separation of the loops Mass effect No spasm
Radiation Enteritis
Changes are identical to ischemia since radiation changes are actually secondary to an arteritis with occlusion of small vessels Localized to area of radiation portal, especially pelvis in female 2 endometrial carcinoma treatment Previous adhesions from surgery may anchor small bowel in pelvic portal and predispose to XRT changes Mucosa is most sensitive to radiation
X-ray Localized thickening of the folds 2 edema and hemorrhage May result in strictures later in course
Lymphoma
Most commonly involves terminal ileum Bowel wall becomes markedly thickened and submucosa infiltrated (picket-fence) Thumb-printing may be seen Loops are widely separated and there may be mass effect Another form may have a large ulceration which is confined and produces so called aneurysmal dilatation of the bowel
WH
LearningRadiology - TB, Tuberculosis, Reactivation
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Tuberculosis
Primary Pulmonary Tuberculosis
q
Parenchyma
Upper lobes affected slightly more than lower Alveolar infiltrate Cavitation is rare
Lobar pneumonia is almost always associated with lymphadenopathytherefore, lobar pneumonia associated with hilar or mediastinal adenopathy at any age should strongly suggest TB
q
Lymph node
Mostly unilateral hilar and/or paratracheal, usually right sided, rarely bilateral Differentiates primary from postprimary TBit does not occur in postprimary TB Much more common in children
Airway Atelectasis classically affects the anterior segments of the upper lobes or the medial segment of the RML
Pleura Pleural effusion as a manifestation of primary TB occurs more often in adults than children
With appropriate treatment, it carries the best prognosis of all patterns of TB and is the least likely to develop complications The fluid accumulates slowly and painlesslytherefore, patients with TB are seldom seen with a
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small amount of pleural fluid Parenchymal disease will almost never be present with a pleural effusion although lymphadenopathy may
q q
Apical pleural scarring is rarely tuberculous in origin
Calcification in the primary complex is relatively rare. Very few patients with primary TB have clinical manifestations
Postprimary Tuberculosis (Reactivation TB)

q
Most cases in adults occur as reactivation of a primary focus of infection acquired in childhood Limited mainly to the apical and posterior segments of the upper lobes and the superior segments of the lower lobe Caseous necrosis and the tubercle (accumulations of mononuclear macrophages, Langerhan's giant cells surrounded by lymphocytes and fibroblasts) are the pathologic hallmarks of postprimary TB Healing occurs with fibrosis and contraction; calcification is rarer than in primary
Patterns of distribution Almost always affect the apical or posterior segments of the upper lobes or the superior segments of the lower lobesbilateral upper lobe disease is very common May present as pneumonia
Cavitation may result: the cavity is usually thin-walled, smooth on the inner margin with no airfluid level
Bilateral upper lobe Tuberculous cavitary pneumonia (worse on the left) Transbronchial spread may occurfrom one upper lobe to opposite lower or to another lobe Miliary spread (below) Bronchiectasisusually asymptomatic
Bronchostenosis due to fibrosis and stricture: fibrosis may cause distortion of a bronchus and atelectasis many years after the initial infectionmiddle lobe syndrome Solitary pulmonary nodulethe tuberculomamay occur in either primary or postprimary disease; round or oval lesions with small, discrete shadows in the immediate vicinity of the lesionthe satellite lesion
q
Formation of a pleural effusion in postprimary TB almost always means direct spread of the disease into the pleural cavity and should be regarded as an empyemathis carries a graver prognosis than the pleural effusion of the primary form Direct extension into the ribs or sternoclavicular joints is uncommon
Miliary Tuberculosis
q q q q q
q q
Older men, Blacks and pregnant women are susceptible Onset is insidious Fever, chills, night sweats are common Takes weeks between the time of dissemination and the radiographic appearance of disease Considered to be a manifestation of primary TBalthough clinical appearance of miliary TB may not occur for many years after initial infection When first visible, they measure about 1 mm in size; they can grow to 2-3mm if left untreated When treated, clearing is rapidmiliary TB seldom, if ever, produces calcification
TB and Other Diseases

q q q
There is an association between TB and silicosis, TB and HIV There may be an association between TB and sarcoid There is no association between TB and bronchogenic carcinoma
HIV and TB
q q q q q
No matter what form of TB the patient has, it tends to look like 1 TB Hilar and mediastinal adenopathy are common Cavitation is less common There is no predilection for the apices MAI (mycobacterium avium-intracellulare) is more common in HIV than TB
WH
LearningRadiology -Malrotation, Midgut Volvulus
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Malrotation with a Midgut Volvulus
Torsion of entire gut around superior mesenteric artery (SMA) due to a short mesenteric attachment of small intestine in malrotation Age o o Usually neonate or young infant Occasionally older child and adult
Associated with (in 20%) o o o o Duodenal atresia Duodenal diaphragm Duodenal stenosis Annular pancreas
Pathophysiology: o o Degree of twisting is variable and determines symptomatology Severe volvulus (= twist of 3 1/2 turns) Can result in bowel necrosis
Acute symptoms in newborn (medical emergency)
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Bile-stained vomiting Intermittent Postprandial Projectile
o o
Abdominal distension Shock
Intermittent obstructive symptoms in older child o o o Recurring attacks of nausea Vomiting Abdominal pain
o Failure to thrive (hypoproteinemic gastroenteropathy as a result of lymphatic and venous obstruction) Plain film findings o Dilated, air-filled duodenal bulb and paucity of gas distally "Double bubble sign" = air-fluid levels in stomach and duodenum
o Isolated collection of gas-containing bowel loops distal to obstructed duodenum = gas-filled volvulus = closed-loop obstruction Barium studies o Duodenojejunal junction (ligament of Treitz) located lower than duodenal bulb and to the right of expected position o Spiral course of midgut loops = "apple-peel / twisted ribbon / corkscrew" appearance (in 81%) From nonresorption of intestinal gas secondary to obstruction of mesenteric veins
"Corkscrew" duodenum in malrotation with a midgut volvulus o o Duodenal-fold thickening and thumbprinting (mucosal edema + hemorrhage) Abnormally high position of cecum
CT findings Whirl-like pattern of small bowel loops and adjacent mesenteric fat converging to the point of torsion (during volvulus) SMV to the left of SMA (NO volvulus) Chylous mesenteric cyst (from interference with lymphatic drainage)
US findings o Clockwise whirlpool sign = color Doppler depiction of mesenteric vessels moving clockwise with caudal movement of transducer o o Distended proximal duodenum with arrowhead-type compression over spine Superior mesenteric vein to the left of SMA
o Thick-walled bowel loops below duodenum and to the right of spine associated with peritoneal fluid
Angio fIndings o o o o "Barber pole sign" = spiraling of SMA Tapering / abrupt termination of mesenteric vessels Marked vasoconstriction and prolonged contrast transit time Absent venous opacification / dilated tortuous superior mesenteric vein
Complications Intestinal ischemia and necrosis in distribution of SMA (bloody diarrhea, ileus, abdominal distension)
DDx: Pyloric stenosis (same age group, no bilious vomiting)
Dahnert 5th edition
LearningRadiology -Hemophilia,Hemophilic arthritis,knee,image
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Hemophiliac arthritis
Christmas disease is indistinguishable except milder Females can develop hemophilia if hemophiliac male marries female carrier Hemarthrosis most common in hinge joints, e.g. knee, elbow, ankle r Chronic synovitis develops from repeated intra-articular hemorrhages r Thickened synovium produces marginal erosions r Multiple subchondral cysts may develop secondary to intraosseous hemorrhage X-ray
There is widening of the interconylar notch, accentuation of the trabeculae and enlargement of the medial epicondyle
r
X-ray changes due to synovial proliferation and hyperemia
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r r
r r
Widening of the intercondylar notch of the femur Chronic hyperemia produces enlargement of epiphyses s Especially medical condyle Secondary trabeculae are resorbed leaving linear striations in the bone Sometimes hemosiderin in soft tissues may make them appear dense From the increased blood to the epiphyses, the epiphyses may appear too early, grow too large, and fuse early Juvenile rheumatoid arthritis may simulate hemophilia changes in bone r JRA occurs more often in females
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LearningRadiology -Congenital Diaphragmatic Hernia,Bochdalek,Morgagni
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Congenital Diaphragmatic Hernia
If defective development, diaphragmatic hernia develops r Anterior Morgagni s Anteromedial parasternal defect (Space of Larrey) s Maldevelopment of septum transversum s Tends to occur in overweight, middle-aged, women s Right > left (heart protects) s Usually not large s Usually unilateral s Associated with q Pericardial defects q Omental fat in pericardial space r Posterior Bochdalek s Most common q Occurs through old pleuroperitoneal canals r Just lateral to the spine on either side s More frequent on left side q Possibly due to protection of right-side by liver q Hernia may contain intestine, stomach, spleen, liver or omentum s If hernia occurs on right q Intestine and liver or only liver may herniate s If the defect is large, newborns usually present with q Severe respiratory distress q Cyanosis q Scaphoid abdomen s Entire diaphragm is almost never absent q Some part of diaphragm is usually found at surgery, even if defect is very large s Hypoplasia of ipsilateral lung occurs from mass effect of bowel s Most often these are isolated congenital abnormalities q But they can have r Congenital Heart Disease r 13 ribs
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r q
Malrotation of GI tract frequently present
Imaging findings r Initially, hemithorax may appear opaque because loops are fluid-filled r Paucity of bowel loops beneath the diaphragm r Once air swallowing begins, multiple lucencies contained within bowel are seen in chest s Respiratory distress may increase as intestine occupies more of thorax r Some loops may remain fluid-filled r Mediastinal shift to the opposite side r Relative paucity of gas in abdomen s If stomach remains in abdomen, it is more centrally located than normal
Multiple air-containing loops of bowel occupy the left hemithorax and there is a shift of the heart and mediastinal structures to the right side
r q
q q
Contrast through an NGT is diagnostic but often not needed Differential diagnosis of lucent cysts in infant lung r Cystic adenomatoid malformation r Staphylococcal pneumonia s In both, abdomen contains normal amount of air-filled loops Delayed herniation of bowel may occur in older infants following streptococcal pneumonia Mortality around 50% r Pulmonary hypoplasia r Persistent Fetal Circulation Syndrome Treatment r Surgical repair r Many demonstrate ipsilateral pulmonary hypoplasia for years after repair r Obstructive emphysema can occur in either lower lobe
WH
LearningRadiology - Ventricular aneurysm, pseudoaneurysm
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Congenital left ventricular aneurysms o Rare o Young black adults o Produce abnormal bulge in region of left atrium or o Cardiac enlargement from aortic insufficiency o Acquired left ventricular aneurysms Usually complication of myocardial infarction May be associated with Persistent congestive heart failure Arrythmias Peripheral embolization Usually are either true or false aneurysms True ventricular aneurysms o Localized outpouching of ventricular cavity Associated with dyskinesia Wide-mouthed in connection with the LV o Anterolateral or apical wall o Frequently not visible on chest x-ray but may produce localized bulge of left heart border o Paradoxical expansion during systole o May have rim of calcium in fibrotic wall o Ventriculography is diagnostic Complications Thrombus with embolization Rarely rupture False or pseudoaneurysms o False aneurysm occurs when left ventricle ruptures into pericardial sac Pericardial adhesions contain rupture o Usually occurs on posterolateral wall o Diameter of mouth is smaller
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Enhanced CT scan at level of heart shows large left ventricular aneurysm partially filled with clot Causes Myocardial infarction Trauma o Increase in size over serial films suggests false aneurysm This finding indicates the patient requires immediate attention o High risk of delayed rupture Calcification of left ventricular wall takes several years after myocardial infarction o
LearningRadiology - Cystic Fibrosis, Mucoviscidosis
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Cystic Fibrosis
Mucovicidosis
X-ray
q
Abnormal secretions from exocrine glands Autosomal recessive almost always in Caucasians o Defect in gene which codes for cystic fibrosis transmembrane conductance regulator (CFTR) Major clinical manifestations: COPD and pancreatic insufficiency Elevated concentration of Na and Cl in sweat
Atelectasis
r
Discoid, segmental, lobar with RUL predominance Nodular and fingerlike densities along bronchovascular bundle Peribronchial cuffing
Mucoid impaction
r
Cylindrical or cystic bronchiectasis

r
q q q q q
Hilar adenopathy Pulmonary arterial hypertension and cor pulmonale Recurrent pneumonias, particularly Staph, Pseudomonas and P. cepacia Clubbing and hypertrophic osteoarthropathy can occur Recurrent pneumothorax is common
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Frontal chest x-ray in cystic fibrosis shows diffuse interstitial disease with bronchiectasis and nodular densities of mucoid impaction Other findings
q q q q q q q q
Bulky, fatty stools from lack of pancreatic enzymes Rectal prolapse Meconium ileus earliest finding Meconium ileus equivalent due to obstruction from stool in older children Fatty infiltration of the liver Focal biliary cirrhosis with portal hypertension Gallstones Pancreatic fibrosis due to recurrent Pancreatitis
r
Diabetes mellitus
q q
Sinusitis Hypoplastic frontal sinuses
Clinically
q q
Chronic cough, recurrent pulmonary infections Higher incidence of asthma and allergy
LearningRadiology - Angiomyolipoma, AML
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Angiomyolipoma
q q q
Benign mesenchymal tumor of kidney Rare Histopathology r No true capsule r Commonly bleed r Tumor composed of fat, smooth muscle, aggregates of thick-walled blood vessels Types r Isolated angiomyolipoma is most common (80%) s Usually solitary s Unilateral (80% on right side) s Not associated with tuberous sclerosis s Mean age of incidence: 40s s Much more common in females r Angiomyolipoma associated with tuberous sclerosis (in 20%) s Angiomyolipoma occurs in 80% of patients with tuberous sclerosis q Commonly large q Usually bilateral q Usually multiple s May be only evidence of tuberous sclerosis s Mean age of incidence: teens s Equal incidence in males and females Signs and symptoms r Small lesions are asymptomatic (60%) r Acute flank / abdominal pain (due to hemorrhage) most common presenting symptom r Hematuria (40%) r Palpable mass (47%) r Shock (due to massive retroperitoneal hemorrhage) Imaging findings r Mostly small lesions <5 cm in diameter r Many have a large exophytic component (25%) r Calcifications not common (6%)
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r
Plain film findings s Mass of fat lucency is lesion is large enough CT findings s Well-marginated, cortical-based, heterogeneous tumor predominantly of fat density (<20 HU) s Variable enhancement (smooth muscle, vessels)
Fat containing tumors are seen in both kidneys

r
US findings s Highly echogenic tumor due to high fat content s Less echogenic areas due to hemorrhage, necrosis, dilated calyces MRI findings s Intra-tumoral fat seen with fat-suppression technique s Variable areas of high signal intensity on T1WI Angiographic findings s Hypervascular mass (95%) q Enlarged interlobar + interlobular feeding arteries r Tortuous, irregular, aneurysmal, venous pooling, "sunburst" / "whorled" / "onion peel" appearance, no AV shunting Complications r Angiomyolipomas >4 cm bleed spontaneously in 50-60% s Hemorrhagic shock from bleeding into angiomyolipoma or into retroperitoneum Treatment r Annual follow-up of lesions <4 cm r Emergency laparotomy is required in some including nephrectomy, tumor resection r Selective arterial embolization can be done DDx r Renal / perirenal lipoma or liposarcoma r Wilms tumor r Renal cell carcinoma which will occasionally contain fat
r
Dahnert 4th edition
LearningRadiology - Psoriasis, Psoriatic arthritis
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Psoriatic Arthritis
Major points
q q q
Almost always accompanies skin disease, especially nail changes Mostly involves DIP joints of hands > feet Classical deformity is called cup-in-pencil or cup-and-pencil deformity
Radiograph of both hands demonstrates cup-and-pencil deformities of both thumbs and erosion of DIP joint of left middle finger
r q q
Erosion of one end of bone with expansion of the base of the contiguous metacarpal There is often resorption of terminal phalanges There is usually no osteoporosis Most are HLA-B27 positive, RA factor negative Characteristic findings
q q
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r r r
Tends to involve smaller joints of hand and foot more than larger joints Asymmetrical joint involvement Affects both the juxta-articular and articular margins of joint
Seronegative Spondyloarthropathies Ankylosing spondylitis Psoriatic arthritis Reiters syndrome Inflammatory bowel disease
q q q q
As with ankylosing spondylitis and Reiters syndrome, bone proliferation is a major feature. Manifests itself with: r Bony excrescences r Periosteal new bone formation (common) r Entire phalanx may become cloaked in new bone s Ivory phalanx q Most frequent in terminal phalanges of toes, especially first r Ankylosis is common s Especially in PIP and DIP joints of hands and feet q Feature common to seronegative spondyloarthropathies r Whiskering at sites of tendinous insertion (enthesopathy) occurs Soft tissue swelling of an entire digit (sausage digit) Destruction of IP joint of great toes with exuberant callous formation is characteristic Resorption of tufts of terminal phalanges is characteristic Spine r Asymmetric paravertebral ossification s Usually thicker and larger than syndesmophytes of ankylosing spondylitis or inflammatory bowel disease r Occasionally, there are incomplete non-marginal syndesmophytes similar to AS Bilateral sacroiliitis is most common r May produce erosions and sclerosis r May produce widening of the SI joints r SI joint involvement occurs in about 10-25% of patients with moderate to severe psoriasis
Patterns of Psoriatic Arthritic Changes Arthritis involving multiple joints with DIP joint involvement Arthritis resembling Rheumatoid Arthritis Sacroiliitis and spondylitis Arthritis mutilans
Resnick, 4th Edition
LearningRadiology - Persistent Left Superior Vena Cava, SVC
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Persistent Left Superior Vena Cava
Incidence-uncommon r 0.3% of general population; r 4.3-11% of patients with CHD Two types r Persistent left SVC connecting to right atrium via coronary sinus is only common anomaly of SVC (90% of this anomaly) r In other 10%, persistent SVC connects to left atrium s Most with connection to left atrium have associated ASD or heterotaxy syndromes s This produces a right-to-left shunt of a rather small magnitude Etiology r Failure of regression of left anterior and common cardinal veins and left sinus horn Course of persistent left SVC r Draining into right atrium s Starts at junction of left subclavian vein and left internal jugular s Passes lateral to aortic arch s Receives left superior intercostal vein s Anterior to left hilum s Joined by hemiazygous system s Crosses posterior wall of left atrium s Receives great cardiac vein to become coronary sinus (common)
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Yellow arrows point to left-sided persistent SVC passing lateral to aortic arch and anterior to left hilum
r
q q q
Draining into left atrium s Starts at junction of left subclavian vein and left internal jugular s Passes lateral to aortic arch s Receives left superior intercostal vein s Anterior to left hilum s Joined by hemiazygous system s Passes between the left atrial appendage (anteriorly) and the left superior pulmonary vein posteriorly Absent / small left brachiocephalic vein (65%) Really this abnormality produces bilateral SVCs In small percentage, right SVC is absent (10-18%)
Freedom, Culham and Moes, Angiography of Congenital Heart Disease, 1984
LearningRadiology -Acute Pyelonephritis
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Submitted by Matthew Krasner, M.D.
Etiology o Inflammation of the renal parenchyma and renal pelvis due to an infectious source o Most often secondary to an ascending lower urinary tract infection from gram-negative bacteria E. coli Klebsiella Proteus Pseudomonas. o Exception is S. aureus, which is spread hematogenously Pathologic Causes o Vesicoureteral reflux o Obstruction in the collecting system usually due to a calculus Signs and symptoms o Fever o Chills o Flank pain o Dysuria o Increased frequency of urination. o On exam, costovertebral angle tenderness may be present Clinical Findings o CBC Elevated white blood cell count. o Urinalysis Bacteriuria Pyuria White blood cell casts o Acute pyelonephritis is clinical diagnosis,
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Radiographic imaging is used to evaluate underlying pathology Rule out any complications
Complications o Abscess o Emphysematous pyelonephritis Most often occurs in diabetics Can produce gas in the collecting system and renal parenchyma Radiographic Imaging Findings o Enlarged kidneys (U/S and CT) o Hydronephrosis (U/S and CT) o Wedge shaped areas of low attenuation secondary to decreased perfusion (CT) o Loss of the ability to distinguish the corticomedullary border (CT) o Perinephric stranding (CT)
Right kidney is markedly enlarged and has a wedge-shaped area of low attenuation
Treatment o Antibiotics for non-complicated pyelonephritis. o Radical nephrectomy for emphysematous pyelonephritis. o Percutaneous drainage of abscesses
LearningRadiology - Acute Appendicitis, Appy
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Appendicitis
Incidence r 7-12% in Western world population r Peak age s 2nd-3rd decade Etiology r Obstruction of appendiceal lumen by s Lymphoid hyperplasia s Fecolith s Foreign bodies s Stricture s Tumor s Parasite s Crohns disease Clinical findings r RLQ pain over appendix is a positive McBurney sign r Leukocytosis r Fever r Nausea and vomiting r Relatively higher rate of misdiagnosis in women between ages 20-40 s May have an atypical location Imaging Findings r Abdominal plain film (abnormalities seen in <50%) s Plain-film findings become more distinctive after perforation, while clinical findings subside q May simulate other diseases s Calcified, frequently laminated, appendicolith in RLQ (in 7-15%) q Appendicolith and abdominal pain = 90% probability of acute appendicitis q Appendicolith in acute appendicitis means a high probability for perforation s "Cecal ileus" = local paralysis s Small bowel obstruction pattern s Soft-tissue mass and paucity or absence of intestinal gas in RLQ (more often with
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perforation) s Extraluminal gas bubbles (again more often in perforation) s Large pneumoperitoneum is rare because etiology of appendicitis involves obstruction of a very small lumen s Focal increase in thickness of lateral abdominal wall s Loss of properitoneal fat line on right side BE / UGI (accuracy 50-84%): s Failure to fill appendix with barium (normal finding in up to 35%) s Indentation along medial wall of cecum (from edema at base of appendix / matted omentum / periappendiceal abscess) US (77-94% sensitive, 90% specific, 78-96% accurate) s Useful in ovulating women (false-negative appendectomy rate in males 15%, in females 35%): s Visualization of noncompressible appendix as a blind-ending tubular aperistaltic structure (seen only in 2% of normal adults, but in 50% of normal children) s Target appearance of >6 mm in total diameter on cross section (81%) q Mural wall thickness >2 mm s Diffuse hypoechogenicity (associated with higher frequency of perforation) s Lumen may be distended with anechoic / hyperechoic material s Loss of wall layers s Visualization of appendicolith (6%) s Localized periappendiceal fluid collection s Prominent hyperechoic mesoappendix / pericecal fat Color Doppler US: s Increased conspicuity from increase (in size + number) of vessels in and around the appendix s Decreased resistance of arterial waveforms s Continuous / pulsatile venous flow CT (87-98% sensitive, 83-97% specific, 93% accurate) s Distended lumen s Circumferentially thickened and enhancing wall s Appendicolith = homogeneous / ringlike calcification (25%) s Periappendicular inflammation-linear streaky densities in periappendicular fat s Pericecal soft-tissue mass s Abscess q Poorly encapsulated q Single or multiple fluid collection(s) with air q Extraluminal contrast material s Focal cecal wall thickening (80%) s "Arrowhead" sign = funnel of contrast medium in cecum centering about occluded orifice of appendix
Yellow arrowheads point to appendicolith (upper) and appendix with thickened and enhancing wall and peri-appendiceal stranding (lower)
q
Complications r Perforation (13-30%) Differential diagnosis (DDx) r Colitis r Diverticulitis r Epiploic appendagitis r Infectious enteritis r Intussusception r Crohns disease r Mesenteric lymphadenitis r Ovarian torsion r Pelvic inflammatory disease Treatment r Appendectomy r Finding of appendicolith is sufficient evidence to perform prophylactic appendectomy in asymptomatic patients (50% have perforation / abscess formation at surgery)
Dahnert 4th edition
LearningRadiology - Mesothelioma
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Malignant Mesothelioma
q q
q q q
q q
Most common primary neoplasm of pleura Prevalence r 2,000-3,000 cases/year in US Etiology r Asbestos exposure r Zeolite (nonasbestos mineral fiber) r Chronic inflammation (TB, empyema) r Radiation Peak age r 50-70 years r M:F = 4-6:1 Histology r Epithelioid (60%) r Sarcomatoid (15%) r Biphasic (25%) r Intracellular asbestos fibers in 25% Carcinogenic potential: crocidolite > amosite > chrysotile > actinolite, anthophyllite, tremolite Occupational exposure of asbestos found in only 40-80% of all cases 5-10% of asbestos workers will develop mesothelioma (risk factor of 30X compared with general population) No relation to duration/degree of exposure to asbestos or smoking history Latency period r 20-45 years s Earlier than asbestosis s Later than asbestos-related lung cancer Pathology r Multiple tumor masses involving predominantly the parietal pleura and to a lesser degree the visceral pleura r Progresses to thick sheetlike / confluent masses resulting in lung encasement
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q
Associated with r Peritoneal mesothelioma r Hypertrophic osteoarthropathy (10%) Staging (Boutin modification of Butchart staging) r IA confined to ipsilateral parietal / diaphragmatic pleura r IB+ visceral pleura, lung , pericardium r II invasion of chest wall / mediastinum (esophagus, heart, contralateral pleura) or metastases to thoracic lymph nodes r III penetration of diaphragm with peritoneal involvement or metastases to extrathoracic lymph nodes r IV distant hematogenous metastases Stage at presentation r II in 50% r III in 28% r I in 18% r IV in 4% Clinical signs and symptoms r Nonpleuritic (56%) / pleuritic chest pain (6%) r Dyspnea (53%) r Fever + chills + sweats (30%) r Weakness, fatigue, malaise (30%) r Cough (24%) r Weight loss (22%) r Anorexia (10%) r Expectoration of asbestos bodies (= fusiform segmented rodlike structures = iron-protein deposition on asbestos fibers) Spread r Contiguous: chest wall, mediastinum, contralateral chest, pericardium, diaphragm, peritoneal cavity; lymphatics, blood r Lymphatic s Hilar + mediastinal (40%) s Celiac (8%) s Axillary + supraclavicular (1%) s Cervical nodes r Hematogenous: lung, liver, kidney, adrenal gland Imaging findings r Extensive irregular lobulated bulky pleural-based masses typically >5 cm / pleural thickening (60%) r Exudative / hemorrhagic unilateral pleural effusion (30-60-80%) without mediastinal shift; effusion contains hyaluronic acid in 80-100%; bilateral effusions (in 10%) r Distinct pleural mass without effusion (<25%) r Associated with pleural plaques in 50% = pathologic HALLMARK of asbestos exposure r Pleural calcifications (20%) r Circumferential encasement = involvement of all pleural surfaces (mediastinum, pericardium, fissures) as late manifestation r Extension into interlobar fissures (40-86%) r Rib destruction in 20% (in advanced disease) r Ascites (peritoneum involved in 35%) CT
r r r r r r r r
Pleural thickening (92%) Thickening of interlobar fissure (86%) Pleural effusion (74%) Contraction of affected hemithorax (42%): Ipsilateral mediastinal shift Narrowed intercostal spaces Elevation of ipsilateral hemidiaphragm Calcified pleural plaques (20%)
Circumferentially thickened rind of nodular pleura with large effusion

q
MR (best modality to determine resectability) r Minimally hyperintense relative to muscle on T1WI r Moderately hyperintense relative to muscle on T2WI Metastases to: r Ipsilateral lung (60%) r Hilar and mediastinal nodes r Contralateral lung and pleura (rare) r Extension through chest wall and diaphragm Prognosis r 10% of occupationally exposed individuals die of mesothelioma (in 50% pleural + in 50% peritoneal mesothelioma) r Mean survival time of 5-11 months DDx r Pleural fibrosis from infection (TB, fungal, actinomycosis) r Fibrothorax r Empyema r Metastatic adenocarcinoma Diagnosis r Video-assisted thoracoscopic surgery (postprocedural radiation therapy of all entry ports for tumor seeding of needle track [21%])
Dahnert 4th edition
LearningRadiology - Osteoporosis circumscripta, Paget's Disease, Paget
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Osteoporosis Circumscripta
Pagets Disease
q q
Multifocal chronic skeletal disease due to chronic paramyxoviral infection Prevalence r 3% of individuals >40 years r 10% of persons >80 years r Unusual <40 years r M:F = 2:1 Histology r Increased resorption and increased bone formation r Newly formed bone is abnormally soft with disorganized trabecular pattern Active or Osteolytic phase r Aggressive bone resorption with lytic lesions r Replacement of hematopoietic bone marrow by fibrous connective tissue with numerous large vascular channels Inactive or Quiescent phase r Decreased bone turnover with skeletal sclerosis and thickening of the cortex Mixed pattern r Lytic and sclerotic phases frequently coexist Clinical findings r Asymptomatic (1/5) r When symptomatic, symptoms may include s Fatigue s Enlarged hat size s Peripheral nerve compression s Neurologic disorders from compression of brainstem (basilar invagination) s Hearing loss, blindness s Facial palsy (narrowing of neural foramina) - rare s Pain from(a)primary disease process is rare so think of q Pathologic fracture
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Malignant transformation q Secondary degenerative joint disease aggravated by skeletal deformity s High-output congestive heart failure from markedly increased perfusion (rare) s Increased alkaline phosphatase (increased bone formation) s Hydroxyproline increased (increased bone resorption) s Normal serum calcium + phosphorus Sites of involvement r Usually polyostotic and asymmetric s Pelvis (75%) most common, followed by q Lumbar spine q Thoracic spine q Proximal femur q Calvarium q Scapula q Distal femur q Proximal tibia q Proximal humerus Imaging Findings r Classical triad s Thickening of the cortex s Accentuation of the trabecular pattern s Increased size of bone r Cyst-like areas r Skull (involvement in 29-65%) s Inner and outer table involved q Leads to diploic widening s Osteoporosis circumscripta is well-defined lysis, most commonly in frontal bone producing well-defined geographic lytic lesion in skull q Represents early destructive phase of disease active stage
q
Osteoporosis circumscripta of frontal bone in lytic phase of Paget's disease

s
"Cotton wool" appearance represents mixed lytic and blastic pattern of thickened calvarium (later stage)

s s s r
Basilar invagination with encroachment on foramen magnum Deossification and sclerosis in maxilla Sclerosis of skull base Long bones (almost invariably starts at end of bone) s "Candle flame" or "blade of grass" pattern of lysis is the advancing tip of V-shaped lytic defect in diaphysis of long bone originating in subarticular site s Lateral curvature of femur s Anterior curvature of tibia (commonly resulting in fracture) Pelvis s Thickened trabeculae in sacrum, ilium s Rarefaction in central portion of ilium (looks like a large lytic lesion) s Thickening of iliopectineal line s Acetabular protrusio with secondary degenerative joint disease Spine (upper cervical, low dorsal, midlumbar most common sites) s Coarse trabeculations at periphery of bone s "Picture-frame vertebra" mimics bone-within-bone appearance q Enlarged vertebral body with reinforced peripheral trabeculae and more lucent center, typically in lumbar spine s "Ivory vertebra" is a blastic vertebra with increased density s Ossification of spinal ligaments, paravertebral soft tissue, disk spaces can occur Bone scan r Sensitivity s Scintigraphy and radiography (60%) q Scintigraphy only (27%) q Radiography only (13%) r Usually markedly increased uptake (symptomatic lesions strikingly positive) r Normal scan may occur in some burned-out lesions r Marginal uptake can be seen in lytic lesions Bone marrow scan r Sulfur colloid bone marrow uptake is decreased (marrow replacement by cellular fibrovascular tissue) MR r Hypointense area / area of signal void on T1WI + T2WI (cortical thickening, coarse trabeculation) r Widening of bone r Reduction in size and signal intensity of medullary cavity due to replacement of high-signalintensity fatty marrow by medullary bone formation r Focal areas of higher signal intensity than fatty marrow (from cyst-like fat-filled marrow spaces) r Areas of decreased signal intensity within marrow on T1WI and increased intensity on T2WI (= fibrovascular tissue resembling granulation tissue) Complications r Associated neoplasia (0.7-20%) r Sarcomatous transformation into osteosarcoma (22-90%) r Fibrosarcoma /malignant fibrous histiocytoma (29-51%) r Chondrosarcoma (1-15%) r Sarcomas are usually osteolytic in pelvis, femur, humerus r Giant cell tumor occurs in 3-10% s Lytic expansile lesion in skull, facial bones
Lymphoma or plasma cell myeloma are reported r Fracture s "Banana fracture" = tiny horizontal cortical infractions (Looser lines) on convex surfaces of lower extremity long bones (lateral bowing of femur, anterior bowing of tibia) s Compression fractures of vertebrae r Early-onset osteoarthritis Treatment r Calcitonin, diphosphonate, mithramycin r Detection of recurrence: s In 1/3 detected by bone scan s In 1/3 detected by biomarkers (alkaline phosphatase, urine hydroxyproline) s In 1/3 by scan and biomarkers simultaneously DDx r Depends on the bone in which it occurs r Skull s Osteolytic or osteoblastic metastases r Long bones s Metastases s Chronic osteomyelitis (thickened cortex) s Old trauma (thickened cortex) s Hodgkins disease r Spine s Hemangioma s Metastases
r
Dahnert 4th Edition
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LearningRadiology - Adrenal Adenoma
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Adrenal Adenoma
Contributed by Shuchi Rodgers, MD
q q q q
Incidence in the population is 2-8% Diagnosis is often made as an incidental finding on CT examination In patient with no known primary, an adrenal mass is almost always a benign adenoma In a patient with a known neoplasm, especially lung cancer, an adrenal mass is problematic and diagnosing a metastasis versus an adenoma is critical for prognosis
Imaging findings
q
CT
r
r r
Size greater than 4 cm tend to be metastases or adrenal carcinoma s Heterogeneous appearance and irregular shape are malignant characteristics Homogeneous and smooth are benign characteristics s Intracellular lipid in adenoma results in low attenuation on CT Little intracytoplasmic fat in metastases results in high attenuation on non-enhanced CT Non-enhanced CT (NECT) s Threshold 10 HU s Sensitivity 79%, specificity 96% Contrast-enhanced CT (CECT) s Because majority of CT examinations in oncology use IV contrast, the % washout is useful after 10 minutes s Adenomas have greater than 50% washout after 10 minutes s Washout can also be used on adrenal masses that measure > 10 HU on NECT s Alternative is to do MR or PET
MR
r
Chemical Shift s Most sensitive method for differentiating adenomas from metastases s Sensitivity 81-100%. Specificity 94-100%
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The difference in resonance rate of protons in fat and water is exploited in chemical shift. q Intracellular lipid and water in same voxel result in summation of signal on "inphase" and canceling out of signal on "out of phase" Spleen or muscle is used as an internal standard to visually quantify signal drop-off s Liver is not a reliable standard because of steatosis
s
CT shows left adrenal mass. In-phase T1 shows adrenal mass is hyperintense relative to the spleen. T1 out-of-phase shows adrenal mass is hypointense to the spleen and compared to the in-phase, there is a drop in signal intensity
LearningRadiology - Kartegener's Syndome
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Kartageners Syndrome
Dyskinetic Cilia Syndrome
q q
Classic triad consists of r Situs inversus r Sinusitis r Bronchiectasis Other associations r Transposition of great vessels r Trilocular or bilocular heart r Pyloric stenosis r Postcricoid web r Marfans syndrome r Polysplenia r Hepatic steatosis r Hydrocephalus r Ushers syndrome s Deafness s Vestibular dysfunction s Retinitis pigmentosa All have ciliary dyskinesia in common Incidence r 1:12,500-40,000 r Autosomal recessive inheritance Ciliary dyskinesis can also be acquired r Smokers most commonly Imaging findings r Bronchial wall thickening r Hyperinflation r Segmental atelectasis or bronchiectasis r Situs inversus is present in half of patients with Dyskinetic Cilia Syndrome
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Upper CT shows dextrocardia and bronchiectasis at both bases; lower CT shows situs inversus of abdominal organs
r
Bronchiectasis is indistinguishable from bronchiectasis of many other causes s 50% occurs in lower lobes Clinically r Sinusitis r Recurrent bronchitis r Bronchiectasis r Male sterility r Corneal abnormalities and poor sense of smell Pulmonary function test abnormalities r Small airway dysfunction r Increased bronchial responsiveness to methacholine
Fraser and Pare, 4th Edition
LearningRadiology - Spigelian hernia
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Splenic Laceration
Contributed by David Allen, MD
q q
Most frequently injured solid parenchymal organ in blunt trauma to the abdomen Splenic injury often associated with other organ injuries r 20% with left rib fractures r 25% with left renal injury r 40% with splenic laceration have rib fractures Subcapsular hematoma r Crescentic low-attenuation area r Usually along lateral margin r Flattens normal convex margin of spleen Parenchymal lesion r Indistinct splenic margin r Inhomogeneous enhancement r Fractured spleen s Complete separation of fragments r Intrasplenic hematoma s Rounded mass s Disrupted splenic capsule s Often has associated hemoperitoneum
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CT shows a subcapsular hematoma with a splenic laceration extending from the capsule to the hilum with an intraparenchymal hematoma (blue arrow). Within the intraparenchymal and subcapsular hematomas are areas of hyperdensity that represent active extravasation (red arrow).
q
q q
Pitfalls in diagnosis r Normal lobulation or cleft mimics tear r Adjacent unopacified bowel loop (jejunum) simulates splenic tissue s Looks like laceration r Scans taken too early after bolus s Spleen can be inhomogeneous due to differential enhancement of red and white pulp r Previous infarct can mimic laceration r Perisplenic fluid from ascites or lavage mimics hemoperitoneum Grades of laceration r Grade I: small laceration < 1cm and small subcapsular hematoma r Grade II: moderate laceration 1-3cm and moderate subcapsular hematoma r Grade III: large laceration > 3cm not involving hilum with large subcapsular hematoma r Grade IV: laceration involving the hilum r Grade V: destroyed spleen If part of hematoma is isodense to arterial blood on an enhanced CT there is active extravasation Treatment r Follow clinically r Arterial embolization/coiling r Splenorrhaphy r Splenectomy Treatment options r The higher the grade the more likely the need for an intervention r Grade I and II are usually followed clinically unless they worsen r Grade IV and V usually require surgery 15% of low-grade lacerations develop a delayed hemorrhage after 2 days
, ovary,radiology,CT
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Serous Ovarian Tumors

Submitted By Ron Gefen, MSIV
General
Most common of six types of epithelial tumors which derive from surface mesothelial cells of the ovary 70% are benign (serous cystadenoma) o 10% have low malignant potential o 20% are malignant (serous cystadenocarcinoma) Transabdominal and/or transvaginal ultrasound is the most valuable diagnostic study in determining area of origin, size, and cystic versus solid make-up o Screening finds adnexal cysts in up to 15% of postmenopausal woman Only 3% of ovarian cysts are malignant o Doppler color flow imaging can be helpful in differentiating malignant from benign masses Malignancies are rich in neovascularization and therefore have lower resistive and pulsatile indices o Gray-scale ultrasound for diagnosis of ovarian malignancy is 62 100% sensitive and 77 95% specific Treatment involves surgical removal for all serous tumors
Serous Cystadenoma
q q q
q q
20% of all benign ovarian tumors Women usually between 20 - 60 years Present clinically as cystic adnexal masses r Increasing abdominal girth 15% are bilateral Imaging findings r Average 5-10cm (frequently grow larger) r May be indistinguishable from simple cysts s Or they may have thin septations and occasionally papillary projections r Tend to be unilocular, but may also be multilocular
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CT of lower abdomen demonstrates a large, fluid-filled and septated mass arising from the pelvis
r
Lined by a single layer of non-ciliated cuboidal to tall columnar epithelium Straw-colored fluid within them is usually blood tinged
Serous Cystadenocarcinoma
q
q q q
Most common malignant tumor of the ovary r 40% of ovarian cancers Up to 50% are derived from malignant transformation of serous cystadenomas 30% bilateral at time of diagnosis Occur mostly from age 40 60 years r Rare under age 35 Histological characterization r Cells vary from well-differentiated to poorly differentiated tumors
Ciliated cells common r Psammoma bodies (calcified concretions) present in 33% Imaging findings r Predominantly cystic but with variable solid component r Usually multi-loculated r Solid areas can have areas of necrosis and hemorrhage r Many >10cm at time of diagnosis r May produce ascites and omental caking if metastases Intra-abdominal dissemination at initial time of surgery common r Omental cake on CT Staging for Primary Carcinoma of the Ovary r Stage I. Growth limited to the ovaries s Ia. One ovary involved s Ib. Both ovaries involved s Ic. Ia or Ib and ovarian surface tumor, ruptured capsule, malignant ascites, or malignant peritoneal cytology r Stage II. Disease extension from the ovary to the pelvis s IIa. Extension to the uterus or fallopian tube s IIb. Extension to other pelvic tissues s IIc. IIa or IIb and ovarian surface tumor, ruptured capsule, malignant ascites, or malignant peritoneal cytology r Stage III. Disease extension to the abdominal cavity s IIIa. Abdominal peritoneal surfaces with microscopic metastases s IIIb. Tumor metastases <2 cm s IIIc. Tumor metastases >2 cm, or metastatic disease in the pelvic, para-aortic or inguinal lymph nodes r Stage IV. Distant metastatic disease s Malignant pleural effusion s Pulmonary parenchymal metastases s Liver or splenic parenchymal metastases s Metastases to the supraclavicular lymph nodes or skin Cancer staging dictates treatment and predicts prognosis r Stage 1 s Usually TAH and BSO s With or without chemotherapy r > Stage 1 s Usually TAH and BSO s Surgical debulking of tumor, if needed s Chemotherapy 5-year survival rate for all types is 20 - 35%
r
LearningRadiology - Rolando Fracture
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Rolando's Fracture Four Fractures of the Wrist
Rolando's Fracture
q q q q
Bennett's Fracture
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Comminuted Intra-articular Fracture through base of thumb Prognosis: worse than Bennett's fracture (difficult to reduce)
Intra-articular fracture/dislocation of base of 1st metacarpal Small fragment of 1st metacarpal continues to articulate with trapezium Lateral retraction of 1st metacarpal shaft by abductor pollicis longus
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Barton's Fracture
q
Colles' Fracture
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Intra-articular fracture of the dorsal margin of the distal radius Extends into radio-carpal joint
Extra-articular fracture of the distal radius Does not extend into joint space Dorsal angulation with radial and dorsal displacement of distal fragment Frequently associated with fracture of ulnar styloid
LearningRadiology - Pneumonectomy, Bronchopleural Fistula, BP Fistula, Complications,radiology,x-ray,thoracic,surgery
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The Pneumonectomized Hemithorax Bronchopleural Fistula
First 24 hours, postpneumonectomy side contains only air r Slight shift of the mediastinum toward the pneumonectomized side r Slight elevation of ipsilateral hemidiaphragm Postpneumonectomy space fills with serosanguineous fluid at rate of 2 rib spaces/day r By end of 2 weeks, 80-90% of space obliterated r By 4 months, complete obliteration Mediastinum gradually shifts more toward side of pneumonectomy r Maximum shift at 6-8 months Failure of this ipsilateral shift almost always indicates an abnormality in the postpneumonectomy space, including: r BP fistula r Empyema r Hemorrhage r Chylothorax Pneumonectomized side fills more rapidly on the left than the right and more rapidly when the pneumonectomy is extrapleural (i.e. includes the parietal pleura) Most sensitive indicator of late complications is the return to midline of a previously shifted mediastinum r Causes s Recurrent neoplasm s BP fistula s Hemorrhage s Chylothorax s Empyema Rare complications
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Herniation of the heart through a pericardial defect after radical pneumonectomy with a partial pericardiectomy Post-pneumonectomy syndrome s More on right side s More in children and adolescents s Produces marked rightward and posterior displacement of the mediastinum s This, in turn, produces clockwise rotation of the heart and great vessels q Trachea and left main bronchus are compressed between the aorta and pulmonary artery r Leads to dyspnea and recurrent left-sided pneumonia s Displacement of the overinflated left lung into the anterior right hemithorax
Broncho-pleural fistula
o o o Incidence 2% Mortality 30-70% Causes: Necrosis of bronchial stump Dehiscence of suture line More common on the right Increased risk in association with Residual carcinoma Preoperative radiation Diabetes Clinical Sudden onset of dyspnea Expectoration of bloody fluid Imaging findings Return to midline of a previously shifted mediastinum A drop in the fluid level by more than 2 cm is abnormal
o o
Top image demonstrates an air-fluid level normal for the 5th post-operative day; the lower image taken two weeks later shows a drop in the height of the fluid level highly suggestive of a bronchopleural fistula
Thin-section CT may demonstrate the BP fistula
Fraser and Pare
LearningRadiology - Mitral Stenosis,radiology,chest,valve,cardiac,rheumatic
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Mitral Stenosis
Rheumatic disease causes mitral stenosis in 99.8% of cases Acute rheumatic fever (ARF) pancarditis o Mitral valve most commonly involved valve o Followed by mitral and aortic together o Then by aortic alone Acute phase cardiomegaly o Mitral regurgitation is valvular lesion of ARF o As acute phase subsides, fibrosis alters leaflet or cusp structure o Results in cuspal or leaflet thickening along valvular margins of closure Mitral Valve Calcification o Calcium usually deposited in clumps on valve leaflets o Heavier calcific deposits in men than women o Calcification of mitral annulus does not signify presence of mitral valve disease Occurs in older women Mitral orifice becomes smaller two circulatory changes o To maintain LV filling across narrowed valve, left atrial pressure goes up o Blood flow across mitral valve is decreased which m cardiac output Mitral Valve Areas o Normal mitral valve orifice 4-6 sq cm in adults o When reduced to <2 sq cm, LA pressure increases o Gradient across mitral valve is hallmark of mitral stenosis About 20 mm Hg in mitral stenosis MS and MR o Rheumatic mitral stenosis occurs with varying degrees of mitral regurgitation o When MS is severe, MR is relatively unimportant Effect of MS on Heart o Left atrium hypertrophies and dilates 2 pressure and volume load o Atrial fibrillation and mural thrombosis follow o Left ventricle is protected by stenotic valve
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Usually normal in size and contour Effect of MS on Lungs o Increased pulmonary venous and capillary pressure o Chronic edema of alveolar walls fibrosis o Pulmonary hemosiderin is deposited in lungs o Pulmonary ossification may occur Effect of MS on Lungs o Pulmonary arterial hypertension develops o First passively o Then 2 muscular hypertrophy and hyperplasia increased pulmonary vascular resistance Effect of MS on Right Ventricle o RV hypertrophies in response to increased afterload o Eventually RV fails and dilates o Causes dilation of tricuspid annulus tricuspid regurgitation Mitral Stenosis-Other Causes o Congenital Mitral Stenosis Exists as isolated abnormality 25% of time Coexists with VSD 30% of time Coexists with another form of left ventricular outflow obstruction 40% of time SHONES Syndrome Shones Syndrome o Parachute mitral valve o Supravalvular mitral ring o Subaortic stenosis o Coarctation of aorta o Infective Endocarditis Large vegetations occurring on previously normal mitral valve may produce MS o Carcinoid Syndrome Carcinoid of lung allows for prolonged exposure of mitral valve to serotonin May result in stiff, stenotic mitral valve o Fabrys Disease Deposition of aramide trihexoside thickens and decreases mobility of mitral leaflets o Hurlers Syndrome Deposition of mucopolysaccharide thickens and decreases mobility of mitral leaflets o Whipples Disease Same as gut lesions in mitral leaflets o LA Myxoma Most common form of primary cardiac tumor 86% of myxomas are found in left atrium 90% of myxomas are solitary Usually occur around fossa ovalis X-Ray Findings of MS o Cardiac Findings Usually normal or slightly enlarged cardio-thoracic ratio Straightening of left heart border
Convexity of left heart border 2 to enlarged atrial appendage--only in rheumatic heart disease X-Ray Findings of MS Cardiac Findings Small aortic knob from decreased cardiac output Double density of left atrial enlargement Rarely, right atrial enlargement from tricuspid insufficiency
Frontal chest x-ray shows normal-sized heart with enlarged left atrium
X-Ray Findings of MS-Calcifications o Calcification of mitral valve--not annulus--seen best on lateral film at fluoroscopy o Rarely, calcification of the left atrial wall 2 fibrosis from long-standing disease o Rarely, calcification of pulmonary arteries from PAH X-Ray Findings of MS-Pulmonary Findings o Cephalization o Elevation of left mainstem bronchus (especially if 90 to trachea) o With severe, chronic disease enlargement of the main pulmonary artery from pulmonary arterial hypertension Mitral Stenosis-Echocardiographic Findings o In 90%, M-mode study will demonstrate flattening of E-F slope o Decreased diastolic excursions of mitral leaflets o Concordant anterior movement of anterior and posterior leaflets during systole Mitral Stenosis-Echocardiographic Findings o If left atrium > 5cm, increased incidence of o Atrial fibrillation o Left atrial thrombus o Systemic embolization Mitral Stenosis-Angiographic Findings o Ventriculography in 30 to 40 RAO projection usually used
o Severity of lesion determined hemodynamically by simultaneously measuring o Pulmonary capillary wedge pressure o Left ventricular inflow tract pressure and o Cardiac output Mitral Stenosis-Angiographic Findings o Calcified, hypokinetic and domed mitral leaflets o Enlargement of left atrium o Left ventricle is small with a reduced ejection fraction Mitral Stenosis-Angiographic Findings o Mitral valve leaflets appear thickened and nodular and may appear to attach directly to the papillary muscle o Scarring and retraction of the chorda tendina
wh/03
,mucocoele
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Mucocele of the Appendix
Overdistension of the appendix with mucous 2 to luminal obstruction by fecolith or foreign body, carcinoid or endometriosis
Mean age - 55 years M:F = 1:4 Very rare Associated with

r
Colonic adenocarcinoma Mucin-secreting tumor of ovary
Clinical
r
Asymptomatic (25%) Acute or chronic right lower quadrant pain
Globular, smooth-walled mass protruding into cecum
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,mucocoele
Mucocele of the appendix - CT shows low attenuation smooth-walled mass projecting into cecum in region of appendix
q
Peripheral, rim-like calcification may occur Low attenuation content on CT US

r
Purely cystic Cystic with fine internal echoes Complex cystic mass with high-level echoes Gravity-dependent echoes = layering of protein macroaggregates / inspissated mucoid material
May rupture and produce pseudomyxoma peritonei

r
May produce bowel obstruction
Myxoglobulosis is a rare variant of mucocoele in which there are pearly white balls of mucous mixed with other mucous in a mucocoele
r
Usually asymptomatic May present as appendicitis Mass contains multiple small, rounded, nonlaminated calcified sphere
Dahnert 4th Edition
,mucocoele
,mucocoele
,mucocoele
,transscaphoid,trans-scaphoid,carpal
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Carpal dislocations described by extent of ligamentous injury (Mayfield) r Stage I s Isolated rotatory subluxation of scaphoid q Mechanism: acute dorsiflexion of wrist q May be associated with rheumatoid arthritis q Characterized by increased distance between scaphoid and lunate > than 2 mm (Terry Thomas sign) q Scaphoid ring sign ring-shaped shadow of cortex of distal pole of scaphoid seen on end q Associated more than 50% of the time with distal radial fractures r Stage II s Dislocation or subluxation of capitate q Exceedingly rare r Stage III s Perilunate dislocation q Triquetrial and scaphoid malrotation q Result of a fall on an outstretched, hyperextended hand q Relatively rare q Occurs when the lunate maintains normal position with respect to the distal radius while all other carpal bones are dislocated posteriorly q Very commonly associated with a scaphoid waist fracture r Sometimes ulnar styloid as well q Lunate appears triangular in shape on frontal view q Lunate rotates forward slightly on lateral view q In lateral view, all other carpal bones are dislocated posterior with respect to lunate
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Perilunate dislocation - Lunate maintains normal position while all other carpal bones dislocate posterior to it
r
Stage IV s Lunate Dislocation q Most severe of carpal instabilities q Most commonly associated with a trans-scaphoid fracture q Involves all the intercarpal joints and disruption of most of the major carpal ligaments q Produces volar dislocation and forward rotation of lunate r Concave distal surface of lunate comes to face anteriorly q Capitate drops into space vacated by lunate q Capitate and all other carpal bones lie posterior to lunate on lateral radiograph q Triangular appearance of lunate on frontal projection
Lunate dislocation - volar displacement and forward rotation of lunate on lateral view with triangular shape of lunate on frontal view
Harris and Harris
LearningRadiology - Small Bowel Lymphoma, Aneurysmal Dilatation,Hodgkin, non-Hodgkin
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Submitted by Tony Chang, MD
Small bowel is second most frequent site of GI tract involvement by lymphoma. o Ileum is most common site of occurrence Ileum has most lymphoid tissue o Duodenum is least frequent Most cases of small bowel lymphoma are due to non-Hodgkins lymphoma Mesenteric involvement by lymphoma may occur by o Direct extension from bowel o Indirectly by displacement due to mass effect Risk factors include o Immunocompromised or immunosuppressed state o Long-term celiac sprue o Chronic lymphocytic leukemia Mediterranean abdominal lymphoma o Associated with immuno-proliferative small intestinal disease o Presents with malabsorption syndrome o Consists of diffuse lymphomatous infiltration of mucosa and submucosa in long segments of small intestine o Infection may be important in the development of this type of lymphoma Some are reversible if treated by antibiotics in the very early stages Definitive diagnosis is based on histopathological examination from biopsy of the lesion Staging: o 1E: single bowel tumor without nodal involvement o 2E: GI tumor focus with nodal disease below the diaphragm; nodal disease divided into regional and extraregional o 3E: GI tumor focus with nodal disease above and below the diaphragm and or serosal involvement +/- other organs involved o 3ES: Splenic involvement
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4E: Extralymphatic i.e. bone, liver Prognosis o Poor prognosis is associated with: Stage greater than 2E (nodal disease above and below the diaphragm) Tumor size greater than 10 cm T cell type Immunoblastic histology Presence of aneuploidy Presentation as an acute abdomen Primary lymphoma criteria include o Confinement of disease to a small bowel segment o Only regional lymphadenopathy o No hepatic or splenic involvement except by direct tumor extension o No palpable or mediastinal lymphadenopathy o Normal peripheral blood smear and bone marrow biopsy
o
Patterns of small bowel lymphoma o Circumferential infiltration of a small bowel segment Results in a variable length of thickening and effacement of folds Widening of the lumen rather than narrowing From infiltration of muscularis layer with destruction of the myenteric plexus leading to aneurysmal dilatation, often at the antimesentric segment o Nodular lesions can be variable in size and irregularly distributed o Polypoidal lesions are sometimes reported to cause intussusception o Endoexoenteric lesions can cause fistulas Imaging findings o CT appearance of lymphoma is variable Typical appearances can be classified as aneurysmal, constrictive, nodular, or ulcerative o Small bowel series can show luminal narrowing of the involved segment with loss of mucosal pattern and thickening of the plica circulares and intraluminal filling defects possibly with dilatation of the involved segment. o Ultrasound may demonstrate a hypoechoic lesion of the affected bowel and presence of abdominal lymphadenopathy. o CT scan shows a sausage shaped loop of bowel that is of relatively homogenous tissue density Also asymmetric wall thickening of usually greater than 2cm Aneurysmal dilatation Polypoidal mass Abdominal lymphadenopathy
CT scan of the abdomen shows a loop of small bowel in the mid-abdomen with a markedly thickened wall; lower image shows a large, intraluminal collection of barium representing aneurysmal dilatation of the involved loop
Differential diagnoses include o Tuberculosis o Inflammatory small bowel disease and carcinoma. Treatment o Malignant lymphoma of the small bowel is treated with surgical resection, usually followed by chemotherapy to prevent perforation o Radiation therapy may also be used
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LearningRadiology-Eventration of the Diaphragm
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Eventration of the Diaphragm

Diseases of The Diaphragm
Eventration of the Diaphragm Congenitally thin muscular portion of hemidiaphragm o
o Appearance, however, still seems to increase with age
o
r
Anteromedial on right
R:L 5:1
When on left, usually involves whole hemidiaphragm
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Frontal and lateral chest x-ray shows smooth elevation of right hemidiaphragm medially and anteriorly consistent with an eventration of the hemidiaphragm
Anatomy of the Diaphragm Muscle slips attach to 7-12th ribs o o Innervated by phrenic nerve (C4, C3 and C5) o Central portion is tendinous; outer portion muscular o Right is 1/2 interspace higher than left in 90% o Mean diaphragmatic excursion = 0.8-8.0cm Elevation of the Hemidiaphragm Causes o Subpulmonic effusion
Dome is laterally displaced Straight edge of anterior diaphragm seen on lateral at major fissure
Decreased lung volume

Atelectasis Hypoplastic lung
Small pulmonary artery, dextrocardia, scimitar vein Poor inspiration Phrenic Nerve Paralysis
BrCa Mets Iatrogenic-post CABG Idiopathic
Abdominal Disease
Subphrenic abscess
Right=subhepatic-appendicitis Left 2 ulcer perforation
Liver mass Interposition of the colon Distended stomach
Congenital Diaphragmatic Hernia Traumatic Rupture of the Diaphragm Eventration of the Diaphragm
Congenital Diaphragmatic Hernia o General Absence of closure of pleuroperitoneal fold

9th gestational week
Male to female ratio of 2:1 1:2,000 live births Left > right 9:1 Associated Anomalies CNSneural tube defects GImalrotation, omphalocoeles CV GU IUGR Bochdalek Hernia 90% of congenital hernias Posterolateral defect
Abnormality of cephalic fold of pleuroperitoneal membrane
Left (80%), right (15%), B/L (5%) Babieslarge Adultssmall Organs Involved Bowel Spleen Fat Liver (left lobe) Kidney, pancreas Stomach The Bs Babies Back Big
Morgagni Hernia Anteromedial parasternal defect (Space of Larrey)

Maldevelopment of septum transversum
Overweight, middle-aged, women Right > left (heart protects) Associated with Omental fat in pericardial space Organs Involved Liver Bowel The Ms Middle (anterior and central) Mature (older children) Miniscule
Pericardial defects
Congenital Absence of Diaphragm Delayed onset of hernia may occur following streptococcal infection o o Imaging Findings Initially, hemithorax may appear opaque because loops are fluid-filled Paucity of bowel loops beneath diaphragm Once air swallowing begins, multiple lucencies contained within bowel are seen in chest
Respiratory distress may increase as intestine occupies more of thorax
Some loops may remain fluid-filled Mediastinal shift to the opposite side Relative paucity of gas in abdomen
If stomach remains in abdomen, it is more centrally located than normal
Prognosis Intrathoracic stomach 60% Intra-abdominal stomach 6% Polyhydramnios 89% Operative mortality 40-50% DDX Cystic adenomatoid malformation Staphylococcal pneumonia Mediastinal cyst
Diaphragmatic Rupture o Blunt trauma (550%)

o 2 increased intra-abdominal pressure
o o
MVA Fall from height Penetrating trauma (50%)

Knife, bullet
General 5% of all diaphragmatic hernias
Most (90%) are left-sided

Central and posterior >10cm in length Contain stomach, colon, small bowel, omentum, spleen
Half have no initial abnormal radiographic findings Half are missed clinically Associated with
Fx ribs Pneumoperitoneum Ruptured spleen
Delayed diagnosis = higher mortality MRI most useful in showing site of tear Imaging Findings Air/fluid levels in left hemithorax Contralateral shift of heart and mediastinal structures Absence of bowel in abdomen NGT in left hemithorax Pinch-cock hourglass configuration of bowel through rent in diaphragm MRI shows diaphragm in all planes Complications Strangulation of bowel Hydrothorax/hemothorax 2 strangulation
Hiatal Hernia Most common form of diaphragmatic hernia in adult o o Air/fluid level(s) in mass posterior to heart o May contain entire stomach
o Can lead to volvulus
Usually projects to left of spine
Paralysis of the Hemidiaphragm Most often from phrenic nerve involvement o

Neoplasms, CABG surgery (2 ice)
Idiopathic
Males, right hemidiaphragm
Sniff test s Paradoxical upward motion on affected side Normal excursion of 1-2 ribs
Breathe in, diaphragm down Breathe out, diaphragm up Breathe in, diaphragm up Breath out, diaphragm down
Paralyzed paradoxical motion

Useless with large effusion Paralysis of the hemidiaphragm versus eventration

Diaphragmatic motion is paradoxical in paralysis but not with Eventration
Bilateral Paralysis of the Diaphragm Less common than unilateral o
o Occurs in neurologic disease, syrinx, MS o Most develop respiratory failure and hypercapnea Tumors of the Diaphragm Very rare o o Benign vs. malignant 50:50
o o Lipoma (most common benign) Fibrosarcoma (most common malignant)
Mets occur via direct extension from pleura or lung
, breakdancer's,breakdancers
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Gamekeepers Thumb
AKA: Skiers Thumb, Break-dancers Thumb
q q
Chronic injury to ulnar collateral ligament (UCL) of thumb first seen in gamekeepers in Scotland r Because of the method they used to kill rabbits Acute injury now more common amongst skiers r Called "Skier's thumb s Due to fall on fall on outstretched hand with abducted thumb caught in pole strap s May comprise up to 50% of injuries to hand in skiers May also be seen in rheumatoid arthritis Injury results in disruption of the ulnar collateral ligament at its site of insertion on the metacarpalphalangeal joint of thumb r UCL is short ligament that originates from the metacarpal head and inserts into medial aspect and base of proximal phalanx of thumb Often associated with a fracture of the base of the proximal phalanx
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Gamekeeper's or Skier's Thumb: fracture of base of proximal phalanx of thumb from tear of ulnar collateral ligament
q
Torn end of ulnar collateral ligament can be displaced to the abductor pollicis aponeurosis r Called Stener lesion s Distal portion of ligament retracts and points superficially and proximally s Rupture of both the proper and accessory collateral ligaments must occur for this to happen s Produces a lump over medial aspect of the MCP joint of thumb Full evaluation requires abduction stress views st metacarpal and proximal phalanx r Increase of more than 30 in angle between 1 s Indicates subluxation Treatment r Complete ruptures of the UCL require surgical intervention for repair within the first 3 weeks of the injury s Best done in 1st week while the anatomy is maintained s Complete tears repaired after 3 weeks have increased incidence of weakness and pain on pinch grasp. r Increased incidence of MCP joint arthritis has been noted in the long term
LearningRadiology-Pulmonary sarcoid, sarcoidosis, lung, thoracic
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Sarcoidosis
General
Widespread formation of non-caseating granulomas 3:1 female:male and 14:1 black:white predominance ACE (angiotensin converting enzyme) elevated in 70% Kveim skin test o Positive in (70%) but rarely used today Lofgren Syndrome:
o Acute bilateral hilar adenopathy, fever, erythema nodosum and arthralgia
Intrathoracic disease (90%)
Stage I
Adenopathy alone (43%)-Stage 1

Intrathoracic adenopathy in 80%
Location
o Bilateral hilar and (R) paratracheal
o Most common (75-90%) o 1-2-3 sign, Pawn-brokers sign, Garland sign Lymph nodes which enlarge in sarcoid are broncho-pulmonary nodes which are more peripherally placed in the lung than the nodes which enlarge in lymphoma which are true hilar nodes Therefore, there is frequently a separation between nodes and heart in sarcoid which is not seen
in lymphoma Unilateral hilar nodes rare (3-8%)
Egg-shell calcification hilar nodes in long-standing sarcoid o Rare o DDX: Silicosis
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Frontal view of the chest shows bilateral hilar adenopathy with "separation" of nodes from heart since broncho-pulmonary nodes in sarcoid are more peripherally placed than are true hilar nodes that enlarge in lymphoma
Stage II
Adenopathy and parenchymal disease (41%)-Stage 2 Adenopathy usually decreases as parenchymal disease increases About 1/3 of patients with adenopathy develop parenchymal disease
Stage III
Parenchymal disease alone (30%) Adenopathy does not develop subsequent to parenchymal disease If adenopathy develops, think of lymphoma or TB
Stage IV
End-stage lung disease-Stage 4 o Diffuse fibrosis o Bronchiectasis-honeycomb lung o Multiple cysts Reticulonodular (46%) Acinar pattern (20%)
Larger nodules
Patterns of lung disease

o Alveolar sarcoid (2%)

o Coalescence of numerous interstitial granulomas o Air bronchograms present
DDX o Alveolar cell ca o Alveolar proteinosis o Lymphoma
Associated with TB (13%) Pleural effusion (2%)
o Usually exudate with lymphocytic predominance
Cavitation of nodules (<1%) Fungus ball formation in chronic sarcoid cavities (usually TB) Focal pleural thickening Bronchostenosis with lobar atelectasis Pulmonary arterial hypertension o Cor pulmonale Pneumothorax 2 chronic lung disease
Peripheral adenopathy (30%) Liver
o Hepatomegaly
Spleen
o Splenomegaly
Bone-especially hands Skin

o Erythema nodosum o Lupus pernio (raised purplish nodules)
Muscle o Myopathy Eyes

o Uveitis o Uveoparotid fever
CNS
o Granulomatous meningitis o Facial nerve palsy
Myocardium
o Arrhythmias o Heart block o Cardiomyopathy
Salivary gland
o Parotid enlargement
Prognosis
3/4 show complete resolution of hilar adenopathy 1/3 show complete resolution of parenchymal disease 20% have irreversible pulmonary fibrosis
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LearningRadiology-Liver laceration, hepatic laceration, rupture
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Hepatic Trauma
Liver Laceration
q q
Most frequently injured abdominal organ after spleen Most often due to deceleration injuries r Often seen in association with s Right-sided rib fractures s Right-sided pneumothorax s Right lung contusion s Injuries to the right kidney or adrenal gland Injuries include r Subcapsular hematoma r Laceration r Intrahepatic hematoma r Contusion Right lobe more often injured than left r Injury to left lobe associated with injury to duodenum, pancreas, transverse colon s More often due to direct blows to the epigastrium High association with injuries to other organs r 45% with liver injuries have splenic injury Subcapsular hematomas r Lenticular configuration r Flattens adjacent liver r Often adjacent to rib fracture r Most occur in antero-lateral aspect of right lobe Liver Laceration r Non-enhancing region, linear or branching r Frequently parallel hepatic vein r Hypodense wedge extending to liver surface s Focal hepatic devascularization r Periportal tracking of blood
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s s
Frequent finding Sometimes only evidence of injury q Due to dissecting hemorrhage q Bile q Dilated periportal lymphatics
Contrast-enhanced CT of abdomen shows linear low-attenuation defect crossing the posterior aspect of the left lobe of the liver representing a laceration
q
q q
Hematoma r Higher attenuation than surrounding liver on unenhanced CT scan r Lower attenuation than surrounding liver on enhanced CT scan r Central high attenuation region containing clot r Hepatic vein laceration usually involves right hepatic vein near vena cava Contusion r Rare lesions r Low attenuation area compared to normally enhanced liver r Do not disrupt major portal or hepatic venous structures Hemoperitoneum Complications r Delayed rupture (rare) r Hemobilia r Arteriovenous fistula r Pseudoaneurysm r Biloma r Superinfection of hematoma Pitfalls r Adjacent rib artifacts-beam-hardening s Mimics laceration q Adjacent to ribs q Fade as they become farther from rib r Linear artifact from air-contrast level in stomach r Fatty liver with laceration or hematoma can be missed

s q
Clue- look at intrahepatic ducts and vessels
Treatment r Conservative treatment in up to 80% in adults and almost all children s Monitor hemodynamic state of patient r Transcatheter embolization possible for bleeders r Healing s Contusions may clear in 5-7 days s Subcapsular hematomas may increase in size initially before clearing s Lacerations can heal within weeks but small, residual bilomas are common
LearningRadiology-Teratoma, Mediastinal Teratoma, Germ Cell Neoplasms
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Mediastinal Teratoma
Other Germ Cell Neoplasms
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Mediastinum is a rare site for occurrence of teratomas, most being ovarian in origin Arise from primitive germ cell rests r Supposed to migrate along urogenital ridge to primitive gonad r Journey is interrupted in the mediastinum May be solid or cystic r Most are cystic Three major categories r Mature teratomas s Well-delineated from surrounding tissues s Contain ectodermal elements along with cartilage, fat and smooth muscle r Immature teratomas s Same elements as above with primitive tissues found in fetus r Teratomas with malignant transformation s Overall about 30% are malignant s Usually adenocarcinoma in mature teratomas s Angiosarcoma or rhabdomyosarcoma in immature teratomas Most of the cystic lesions are benign and most of the solid lesions are malignant Both occur early in lifeyoung adults most commonly r DDX from thymomas which usually occur in 5th or 6th decade Symptoms r Usually asymptomatic r Large lesions can cause shortness of breath, cough or retrosternal pain or fullness r Rare rupture of dermoid into trachea which leads to trichoptysisexpectoration of hair Associations r Non-lymphocytic leukemia and malignant histiocytosis with immature teratomas Imaging findings r Most occur in the anterior mediastinum, near junction of great vessels and heart r Benign lesions are usually smooth in contour whereas malignant masses tend to be lobulated
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r r
Usually larger than thymomas Calcification may rarely occur but is of no help since thymomas also calcify s Exception would be the very rare occurrence of a tooth or bone in a dermoid CT shows fatty mass with globular calcifications and rarely a tooth or bone s Fat-fluid level may be seen on CT
Enhanced CT scan of the chest shows large, septated anterior mediastinal mass containing fat and bony elements
r q
Rapid increase in size may mean hemorrhage into a cyst rather than enlarging malignancy Treatment and prognosis r Mature teratomas s For benign cystic teratomas, surgical resection s Excellent prognosis r Immature teratomas s In childhood, surgical excision is often successful s In adults, tend to have a more malignant course r Teratomas with malignancy s Usually highly aggressive s Poor prognosis Teratoma versus dermoid r Dermoid contain only epidermis r Teratomas contain all 3 germ layers, but are mostly endodermal when malignant Other germ cell neoplasms r Benign dermoid cysts r Benign and malignant teratomas r Seminomas r Choriocarcinomas r Embryonal cell carcinomas Mediastinal seminomas r Rare r Almost always in young men r Identical to testicular seminoma and ovarian dysgerminoma r May be well-encapsulated or invasive r Tends to be lobulated
Cannot be differentiated from teratoma Primary choriocarcinoma r Even rarer than seminoma in the mediastinum r Only 23 reported in the literature, almost all in men r Occur between 20-30 years r May be lobulated r May have elevated beta sub unit of HCG r Growth is very rapid leading to dyspnea, hemoptysis, stridor r Gynecomastia and a + Aschheim-Zondek test can occur r Rapidly fatal
r
Fraser and Pare
LearningRadiology-Hodgkin's Disease, Lymphoma
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Hodgkins Disease
Half of patients with Hodgkins have mediastinal lymph node enlargement visible on chest x-ray. About 5-10% of patients may have mediastinal adenopathy without any other nodes involved l Clinically, over 90% of patients with Hodgkins have enlarged nodes, the disease behaving most benignly when restricted to the neck l Most have nodular sclerosing type
l l
Imaging Findings
l
Parenchymal involvement occurs in 1/3 of patients with Hodgkins o Almost all have associated hilar or mediastinal adenopathy o Bronchovascular form (most common type of involvement) Coarse reticulonodular pattern contiguous with mediastinum = direct extension from mediastinal nodes along lymphatics Nodular parenchymal lesions Miliary nodules Endobronchial involvement Lobar atelectasis secondary to endobronchial obstruction (rare) Cavitation secondary to necrosis (rare) o Subpleural form Circumscribed subpleural masses Pleural effusion from lymphatic obstruction (20-50%) o Pneumonic form Diffuse nonsegmental infiltrate (pneumonic type) Massive lobar infiltrates (30%) Homogeneous confluent infiltrates with shaggy borders Contain air bronchogram o Nodular form Multiple nodules <1 cm in diameter Extraparenchymal manifestations in the chest
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l
Hilar adenopathy is usually bilateral but asymmetric
Frontal and lateral radiograph of the chest shows mediastinal adenopathy (red arrows) producing lobulated soft tissue masses
Anterior mediastinal nodes commonly involved o They may calcify after radiation therapy l Mediastinal and hilar lymphadenopathy o Most common manifestation Present in 90-99% Commonly multiple lymph node groups involved o Location Anterior mediastinal and retrosternal nodes commonly involved (DDx: sarcoidosis) Confined to anterior mediastinum in 40% 20% with mediastinal nodes have hilar lymphadenopathy also Hilar lymph nodes involved bilaterally in 50% o Spread from anterior mediastinum to Pleura Pericardium Chest wall o On initial chest film adenopathy identified in 50% Lymph nodes may calcify following radiation / chemotherapy l About 1/3 have pleural effusions o Effusion usually does not contain malignant cells l Atelectasis is very uncommon and almost always due to an endobronchial lesion l Prognostically, mediastinal node enlargement worsens prognosis but only minimally. o Diffuse lung involvement, on the other hand, carries a grave prognosis l Thoracic XRT portal is called a mantel because of its T shape to cover supraclavicular and mediastinal nodes o Lymphoma is radiosensitive tumors frequently beginning to show reduction in size almost at once
l
Staging
l l l l l l
Stage I is adenopathy limited to one lymph node bearing group Stage II is adenopathy involving two or more non-contiguous groups on the same side of the diaphragm Stage III is adenopathy involving lymph node groups on both sides of the diaphragm Stage IV is extranodal involvement-such as lung or brain A signifies absence of symptoms B signifies presence of fever, night sweats or pruritis
Lead poison, Plumbism, lead intoxication
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Lead Poisoning Plumbism
Pica Defined as persistent eating of non-nutritive material for 1 month or more Always search for lead lines in any child with an ingested foreign body Main source of lead intoxication is lead paint used in houses painted before 1980 Absorption is greater in children than adults r Lead may be inhaled as well as ingested s Symptoms develop more quickly through GI tract s Toxicity more severe with co-existing iron, zinc, or calcium deficiency Pathology r Lead concentrates in metaphyses of growing bones s Distal femur s Both ends of tibia s Distal radius leading to q Failure of removal of calcified cartilaginous trabeculae in provisional zone Clinical findings r Neurological s Learning disability s Decreased IQ s Mental retardation s Encephalopathy s Motor deficits s Seizures s Cerebral edema s Hearing loss r Gastrointestinal s Abdominal pain s Nausea s Vomiting s Diarrhea
r r
q q
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s s s s r
Constipation Anorexia Metallic taste in mouth Ileus
Renal
s
Tubular damage q Azotemia s Gout r Hematologic s Affects blood synthesis s Hemolysis s RBC stippling s Iron deficiency r Musculoskeletal s Muscle and joint pain r Soft tissue s Blue-black line in gum margins r Endocrine s Decreased stature q Decreased growth hormone s Decreased vitamin D levels Laboratory findings r Predate bone changes on x-ray r Serum Lead Level >1.2 umol/L r Urine lead level elevated r Peripheral Smear s Stippled erythrocytes r Complete Blood Count s Microcytic Anemia s Leukocytosis r Urine microscopy of sediment or renal biopsy s Acid-fast inclusion bodies in tubular nuclei q Pathognomonic for lead poisoning r Free Erythrocyte Protoporphyrin (FEP) > 0.6 umol/L Imaging findings r Cerebral edema in acute lead intoxication r Particles of lead in GI tract r Bands of increased density at metaphyses of tubular bones (growing bone) s Metaphyses of growing bones may be dense normally q Lead lines more apt to be seen in proximal fibula and distal ulna where growth is not as great as other long bones s Lead lines may persist
Frontal radiograph of both knees of a child with lead poisoning show dense metaphyseal bands involving not only distal femurs and proximal tibias but proximal fibulas as well
r r
Bone-in-bone appearance Abnormalities in bone modeling s Erlenmeyer flask appearance to distal femur DDx (see tables below) Treatment r Surgical removal of lead foreign bodies in the gut (e.g. dice containing lead) if not eliminated within 2 weeks r Chelation is indicated if the level is greater than 45 mcg/dL even if asymptomatic s First correct iron deficiency r Chelating agents include EDTA, BAL, D-Penicillamine, and Succimer
q q
Lucent Metaphyseal Bands Normal Leukemia Neuroblastoma TORCH infection
Dense Metaphyseal Bands Normal Lead poisoning Treated leukemia Healing rickets
LearningRadiology-Silicosis, Pneumoconiosis, Radiology, X-ray, Image
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Silicosis
Occupational Exposure o Free crystalline silica (quartz) or silicon dioxide from
Mining of coal, graphite, iron Tin, Uranium, Gold Silver, Copper
Also, sand blasters Iron and steel foundry workers Ceramic workers Tunneling Silicosis pathophysiology o Silica particles ingested by alveolar macrophages o Breakdown of macrophage releases enzymes which produce fibrogenic response Silicosis natural history o Requires 10-20 years exposure before x-ray appearance o Radiographs frequently overestimate degree of symptoms early o Silicosis has a progressive nature despite cessation of dust exposure Imaging findings o Multiple small rounded opacities 1-10 mm in size
Usually in upper lobes Mostly in apical and posterior regions of upper lobes and apical portion of lower lobes
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Silicosis features a diffuse micronodular lung disease with an upper lobe predominance
o
o
May have ground-glass appearance

May occasionally calcify centrally (20%)
Lymph node enlargement common Eggshell calcification of hilar nodes (5%)

DDx: Sarcoidosis
o Large opacities are conglomerations of small opacities Complicated Silicosis (Progressive Massive FibrosisPMF) o Massive fibrosis and conglomerate nodule formation in upper lobes with scarring and retraction of hila upwards
o Conglomerate nodules are >1 cm in size Usually in mid-zone or periphery of upper lobes Compensatory emphysema occurs in lower lung fields Nodules tend to disappear from rest of lung when PMF develops
Progressive Massive Fibrosis (PMF) may cavitate from tuberculosis or ischemic necrosis
Acute silicosis (silicoproteinosis) o From exposure to high concentrations of silica dust o Alveoli are filled with lipid-rich, PAS-positive material o Bilateral air-space disease with perihilar distribution Imaging findings are similar to alveolar proteinosis
Caplans Syndrome o Consists of large necrobiotic nodules (rheumatoid nodules) superimposed on silicosis or coal workers pneumoconiosis (CWP) More common with CWP o Other connective tissue diseases associated with silicosis Scleroderma, RA, SLE Silicosis Complications
o o
Predisposes to TB Exhibits limited evidence for carcinogenesis in humans
Diffuse Micronodular Lung Disease Silicosis Metastatic Disease, esp. thyroid mets Sarcoidosis Miliary TB
LearningRadiology-Candida Esophagitis, Candida, Candidiasis, Moniliasis, Monilial Esophagitis, AIDS, HIV
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Candida Esophagitis (Moniliasis)
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Most common cause of infectious esophagitis Organism r C. albicans r Found in diseased skin, GI tract, female genital tract, urine in patients with an with an indwelling Foley catheter Usually occurs as an opportunistic infection in those with r Depressed immunity s AIDS s Hematologic disease s Renal transplant s Leukemia s Chronic debilitating disease r Diabetes mellitus r Steroids r Chemotherapy r Radiotherapy r Diseases which cause delayed esophageal emptying s Scleroderma s Strictures s Achalasia s S/P fundoplication r Rarely may occur in otherwise healthy individuals Produces whitish slightly raised plaques Symptoms r Dysphagia r Odynophagia
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Intense substernal pain r Associated with oral thrush (oropharyngeal moniliasis) in 20-80% Location r Predilection for upper 1/2 of esophagus s Involvement of long esophageal segments Imaging Findings r Discrete plaque-like lesions r Plaques line-up longitudinally = grouping of tiny 1-2 mm nodular filling defects with linear orientation r Larger plaques may coalesce to produce "cobblestone" appearance r Further coalescence produces shaggy contour (from coalescent plaques, pseudomembranes, erosions, ulcerations, intramural hemorrhage) in fulminant candidiasis s More fulminant form is more often associated with AIDS
r
Double-contrast esophagram shows markedly nodular mucosa with multiple discrete ulcers covering all of esophagus
r
r q
Ulcers invariably appear only on a background of diffuse plaque formation, not as isolated findings Long, smoothly-tapering strictures may develop but are rare s More likely to develop in patients with cutaneous manifestations of Candidiasis Mycetoma resembling large intraluminal tumor is rare Diagnosis r Endoscopy most sensitive method of making diagnosis for mild cases r Double-contrast esophagography should pick up 90% of cases Treatment r Mycostatin r Findings usually regress quickly Differential Diagnosis r Glycogenic esophagitis asymptomatic nodularity r Reflux esophagitis distal esophagus, nodules poorly defined r Superficial spreading carcinoma- nodular and irregular folds r Artifacts (undissolved effervescent crystals, air bubbles, retained food particles) r Herpes esophagitis discrete ulcers surrounded by halo of edema

r r
Acute caustic ingestion long strictures are common Intramural pseudodiverticulosis unlike ulcers, pseudodiverticula dont appear to connect to lumen Varices distal esophagus usually; serpiginous elongated filling defects
LearningRadiology-Porcelain Gallbladder, GB, Chronic Cholecystitis, Calcified Gallbladder Wall,photo
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Porcelain Gallbladder
q q q
q q
Calcification of gallbladder wall So named because of its gross appearance and its similarity to porcelain Incidence: r Less than 1% of cholecystectomy patients r F:M 5:1 Histology r Flakes of dystrophic calcium within chronically inflamed and fibrotic muscular wall r Wall is thickened and gallbladder is contracted Associated with gallstones in 90% r Cystic duct is always obstructed r 80% of patients with carcinoma of gallbladder have stones Minimal symptoms Imaging findings r Curvilinear calcifications in segment of the wall or entire wall
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Plain film of abdomen shows a curvilear calcification in the left upper quadrant which corresponds to the location of the gallbladder
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Highly echogenic shadowing curvilinear structure in GB fossa s DDx: stone-filled contracted GB Echogenic GB wall with little acoustic shadowing s DDx: emphysematous cholecystitis Scattered irregular clumps of echoes with posterior acoustic shadowing Imaging pitfall r Contracted gallbladder with calcified wall can be mistaken for a gallstone Complication r 20-30% develop carcinoma of gallbladder
LearningRadiology-Renal Laceration,Kidney laceration,rupture,fracture renal,kidney,photo,image,radiology,CT
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Renal Fracture
Renal Laceration
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q q
Incidence r Up to 10% of injuries coming to emergency room with blunt trauma Cause r Motor vehicle accident r Contact sports r Falls and fights r Less often penetrating wounds Mechanism r Direct blow (>80%) frequently compressed and often lacerated by lower ribs r Acceleration-deceleration injuries can produce renal artery tears Associated with other organ injury in 20% of cases Signs and symptoms r >95% hematuria s 25% of patients with gross hematuria have significant injuries s But, 24% of patients with renal pedicle injury have no hematuria s Only 1-2% with microhematuria have a severe renal injury Types of injuries
CT Classification of Renal Trauma

CT Grade Grade I Grade II Grade III Grade IV Injury Superficial cortical laceration, contusion and/or perirenal hematoma Deep corticomedullary laceration involving the collecting system Renal crush injury and/or main vascular pedicle injury Injury of the renal pelvis or the ureteropelvic junction Usual Treatment Observation Observation or surgery Surgery Surgery
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r r r r
Renal contusion Superficial cortical laceration (75-85%) Small cortical laceration without calyceal disruption Complete cortical laceration s Fracture communicating with calyceal system (10%) q Extraluminal contrast material q Separation of renal poles or fracture
Contrast-enhanced CT of the mid-abdomen reveals a linear zone of low attenuation through the left kidney with surrounding perinephric stranding characteristic of a deep renal laceration
Crush injury s Usually involves injury to the renal vascular pedicle (5%) s Multiple separate renal fragments q Lack of enhancement of part or all of kidney s Extraluminal contrast material r Subcapsular hematoma Imaging Findings r Focal patchy areas of decreased enhancement / striated nephrogram = contusion r Irregular linear hypodense parenchymal areas = renal laceration r Laceration connecting two cortical surfaces = fracture r Multiple separated renal fragments perfusion = shattered kidney r Superficial crescentic hypodense area compressing adjacent parenchyma = subcapsular hematoma s Subcapsular / perinephric hematoma usually proportional to extent of injury r Wedge-shaped perfusion defect = segmental arterial injury r Diffuse non-perfusion of kidney = devascularized kidney r Persistent nephrogram on delayed scans = renal vein thrombosis
r
Injury Contusion (75-80%)
How do you recognize it focal patchy areas of decreased enhancement
Laceration Fracture Crush injury Calyceal or pelvic injury Vascular pedicle injury Subcapsular hematoma
irregular linear hypodense parenchymal areas laceration connecting two cortical surfaces multiple separated renal fragments perfusion Extraluminal contrast Wedge-shaped or diffuse non-perfusion of kidney superficial crescentic hypodense area compressing adjacent parenchyma
LearningRadiology-Sigmois volvulus, volvulous, large bowel obstruction, radiology, photo, x-ray
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Sigmoid Volvulus
Submitted by Raymond Ropiak
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Twisting of loop of intestine around its mesenteric attachment site may occur at various sites in the GI tract r Most commonly: sigmoid & cecum r Rarely: stomach, small intestine, transverse colon r Results in partial or complete obstruction r May also compromise bowel circulation resulting in ischemia Sigmoid volvulus most common form of GI tract volvulus r Accounts for up to 8% of all intestinal obstructions Most common in elderly persons (often neurologically impaired) Patients almost always have a history of chronic constipation Redundant sigmoid colon that has a narrow mesenteric attachment to posterior abdominal wall allows close approximation of 2 limbs of sigmoid colon twisting of sigmoid colon around mesenteric axis r Other predisposing factors s Chronic constipation s High-roughage diet (may cause a long, redundant sigmoid colon) s Roundworm infestation s Megacolon (often due to Chagas dz) 20-25% mortality rate Peak age > 50 yrs. r Second largest group children Torsion usually counterclockwise ranging from 180 540 degrees Luminal obstruction generally @ 180 degrees Venous occlusion generally @ 360 degrees gangrene & perforation Signs and symptoms r May present as abdominal emergency s Acute distension s Colicky pain (often LLQ) s Failure to pass flatus or stool (constipation is prevailing feature)
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Pathophysiology
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Vomiting is late sign r Distention may compromise respiratory & cardiac function r May also present with surprisingly few signs and symptoms in bedridden and debilitated Physical examination r Tympanitic abdomen r Abdominal distention r +/- palpable mass
s r
Diagnosis
Abdominal plain films usually diagnostic s Inverted U-shaped appearance of distended sigmoid loop q Largest and most dilated loops of bowel are seen with volvulus s Loss of haustra s Coffee-bean sign midline crease corresponding to mesenteric root in a greatly distended sigmoid q Sigmoid volvulus bowel loop points to RUQ q Cecal volvulus bowel loop points to LUQ r Dilated cecum comes to rest in left upper quadrant s Birds-beak or bird-of-prey sign seen on barium enema as it encounters the volvulated loop CT scan useful in assessing mural wall ischemia
Photo on left shows large, dilated loop of large bowel with an inverted U-shape with walls between two volvulated loops pointing from LLQ toward RUQ; Photo on right shows same patient with decompressed sigmoid volvulus following insertion of rectal tube
r r r
Large bowel obstruction due to other causes sigmoid colon CA Giant sigmoid diverticulum Pseudoobstruction
Complications

r r r
Colonic ischemia Perforation Sepsis

o Derotation & decompression by barium enema or with rectal tube, colonoscope, or sigmoidoscope if no signs of bowel ischemia or perforation
Treatment
Laparoscopic derotation or laparotomy +/- bowel resection Cecopexy suture fixation of bowel to parietal peritoneum may prevent recurrence Recurrence rate after decompression alone 50%
r r r
LearningRadiology-Rickets
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Rickets
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Osteomalacia during enchondral bone growth Age r 4-18 months Histology r Zone of preparatory calcification does not form resulting in build-up of maturing cartilage cells r Also occurs in shafts so that osteoid production elevates periosteum Clinical findings r Irritability r Bone pain r Tenderness r Craniotabes r Rachitic rosary r Bowed legs r Delayed dentition r Swelling of wrists and ankles Location r Metaphyses of long bones subjected to stress are particularly involved s Wrists s Ankles s Knees Imaging findings r Cupping and fraying of metaphysis r Poorly mineralized epiphyseal centers with delayed appearance r Irregular widened epiphyseal plates (increased osteoid) r Increase in distance between end of shaft and epiphyseal center r Cortical spurs projecting at right angles to metaphysis r Coarse trabeculation (not the ground-glass pattern found in scurvy) r Periosteal reaction may be present
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Metaphyseal cupping and fraying in the distal radius and ulna in rickets
r
Deformities common s Bowing of long bones s Molding of epiphysis s Fractures s Frontal bossing Causes Of Rickets r Abnormality In Vitamin D Metabolism s Associated with hyperparathyroidism s Vitamin D deficiency q Dietary lack of vitamin D q Famine osteomalacia s Lack of sunshine exposure s Malabsorption of vitamin D q Pancreatitis and biliary tract disease q Steatorrhea, celiac disease, postgastrectomy q Inflammatory bowel disease r Defective conversion of vitamin D to 25-OH-cholecalciferol in liver s Liver disease s Anticonvulsant drug therapy (= induction of hepatic enzymes that accelerate degradation of biologically active vitamin D metabolites) r Defective conversion of 25-OH-D3 to 1,25-OH-D3 in kidney s Chronic renal failure = renal osteodystrophy s Vitamin D-dependent rickets = autosomal recessive enzyme defect of 1-OHase Abnormality In Phosphate Metabolism r Not associated with hyperparathyroidism secondary to normal serum calcium r Phosphate deficiency s Intestinal malabsorption of phosphates
Ingestion of aluminum salts [Al(OH)2] forming insoluble complexes with phosphate s Low phosphate feeding in prematurely born infants s Severe malabsorption state s Parenteral hyperalimentation s Disorders of renal tubular reabsorption of phosphate q Renal tubular acidosis (renal loss of alkali) q deToni-Debr-Fanconi syndrome = hypophosphatemia, glucosuria, aminoaciduria q Vitamin D-resistant rickets q Cystinosis q Tyrosinosis q Lowe syndrome r Hypophosphatemia with nonendocrine tumors s Oncogenic rickets - elaboration of humeral substance which inhibits tubular reabsorption of phosphates q Sclerosing hemangioma q Hemangiopericytoma q Ossifying mesenchymal tumor q Nonossifying fibroma r Hypophosphatasia Calcium Deficiency r Dietary rickets = milk-free diet (extremely rare) r Malabsorption r Consumption of substances forming chelates with calcium Classification Of Rickets r Primary vitamin D-deficiency rickets r Gastrointestinal malabsorption s Partial gastrectomy s Small intestinal disease: gluten-sensitive enteropathy / regional enteritis s Hepatobiliary disease: chronic biliary obstruction / biliary cirrhosis s Pancreatic disease: chronic pancreatitis r Primary hypophosphatemia; vitamin D-deficiency rickets r Renal disease s Chronic renal failure s Renal tubular disorders: renal tubular acidosis s Multiple renal defects Hypophosphatasia and pseudohypophosphatasia r Fibrogenesis imperfecta osseum r Axial osteomalacia Miscellaneous r Hypoparathyroidism, hyperparathyroidism, thyrotoxicosis, osteoporosis, Paget disease, fluoride ingestion, r ureterosigmoidostomy, neurofibromatosis, osteopetrosis, macroglobulinemia, malignancy
s
Dahnert 4th edition
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LearningRadiology - Meconium aspiration syndrome
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Meconium Aspiration Syndrome
Most common cause of neonatal respiratory distress in full-term/postmature infants r Hyaline membrane disease most common cause in premature infants Etiology r Fetal circulatory accidents/placental insufficiency /postmaturity result in perinatal hypoxia and fetal distress r Meconium defecated in utero triggered by vagal response
r
Pathogenesis r Meconium products produce bronchial obstruction and air-trapping r Chemical pneumonitis Incidence r 10% of all deliveries have meconium-stained amniotic fluid r 1% of all deliveries have respiratory distress Clinical findings r Cyanosis (rare) r Large infant Imaging findings r Bilateral diffuse grossly patchy opacities (atelectasis and consolidation) r Hyperinflation of lungs r Areas of emphysema (air-trapping) r Spontaneous pneumothorax and pneumomediastinum s 25% requiring no therapy r Small pleural effusions (20%) r No air bronchograms r Rapid clearing usually within 48 hours
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Frontal chest shows large, ropey and strand-like densities in a post-mature infant consistent with Meconium Aspiration Syndrome
q
Treatment r Supportive s Antibiotics and oxygen s ECMO can be used Complications r Morbidity from anoxic brain damage is high
LearningRadiology - Constrictive Pericarditis
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Pericardial Calcifications Constrictive Pericarditis
Calcification in the pericardium is most likely inflammatory in nature r Can be seen with a variety of infections, trauma, and neoplasms Calcification most commonly occurs along the inferior diaphragmatic surface of the pericardium surrounding the ventricles r Thin, egg-shell like calcification is more often associated with viral infection or uremia r Calcification from old TB is often thick, confluent, and irregular in appearance, especially when compared with myocardial calcification
PA and lateral close-ups show thick pericardial calcification around apex of heart from patient with history of tuberculous pericarditis
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Calcification is seen in 1/3-1/2 of patients with constrictive pericarditis r Its presence does not imply constriction r Pericardial calcification must be differentiated from coronary artery calcification, valvular calcification, calcified myocardial infarct or ventricular aneurysm, left atrial calcification, or calcification outside the heart r This can usually be accomplished by the locations of these calcifications on multiple views, or the radiographic appearance of the calcium Constrictive Pericarditis r Present when a fibrotic, thickened, and adherent pericardium restricts diastolic filling of the heart. r Usually begins with an initial episode of acute pericarditis s May not be detected clinically r This slowly progresses to a chronic stage consisting of fibrous scarring and thickening of the pericardium with obliteration of the pericardial space r This produces uniform restriction of the filling of all heart chambers Signs and Symptoms r Reduced cardiac output ( fatigue, hypotension, reflex tachycardia ) r Elevated systemic venous pressure ( jugular venous distension, hepatomegaly with marked ascites and peripheral edema ) r Pulmonary venous congestion ( exertional dyspnea, cough and orthopnea ) r Chest pain typical of angina may be related to underperfusion of the coronary arteries or compression of an epicardial coronary artery by the thickened pericardium. r Most impressive physical findings are often the insidious development of ascites of hepatomegaly and ascites, such patients are often mistakenly thought to suffer from hepatic cirrhosis or an intra-abdominal tumor.
Calcification of the pericardium is detected in up to 50 % of patients This finding is not specific for constrictive pericarditis o A calcified pericardium is not necessarily a constricted one o Lateral chest film is useful for its detection in the atrioventricular groove or along the anterior and diaphragmatic surfaces of the right ventricle. o Pleural effusions are present in about 60 % of patients Persistent unexplained pleural effusions can be the presenting manifestation CT or MRI are superior in the assessment of pericardial anatomy and thickness The diagnosis is confirmed by cardiac catheterization Treatment for constrictive pericarditis is complete resection of the pericardium
Acknowledgement to Eduardo Benchimol Saad, MD
LearningRadiology - Esophageal varices
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Esophageal Varices
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Dilated submucosal veins due to increased collateral blood flow from portal venous system to azygous system Uphill varices Collateral blood flow from portal vein via azygous vein into SVC (usually lower esophagus drains via left gastric vein into portal vein) r Most common cause is portal hypertension secondary to cirrhosis r Varices in lower half of esophagus to the level of the carina (azygous vein) r More common than downhill varices Causes
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Intrahepatic obstruction from cirrhosis r Splenic vein thrombosis (usually gastric varices only) r Obstruction of hepatic veins r Portal vein thrombosis r IVC obstruction below hepatic veins r Marked splenomegaly / splenic hemangiomatosis (rare) Downhill varices
r r
Collateral blood flow from SVC via azygous vein into IVC / portal venous system (upper esophagus usually drains via azygous vein into SVC) Varices in upper 1/3 of esophagus
s
Usually extend down to the level of the carina (azygous vein) r Less common than uphill varices Causes
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Obstruction of superior vena cava distal to entry of azygous vein due to
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Lung cancer (most common) s Lymphoma s Retrosternal goiter s Thymoma s Mediastinal fibrosis Examination Technique
s r r
Small amount of barium (not to obscure varices) Relaxation of esophagus (not to compress varices)
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Refrain from swallowing because each succeeding swallow initiates a primary peristaltic wave that lasts for 10-30 seconds r Sustained Valsalva maneuver precludes swallowing r In LAO projection with patient recumbent or in Trendelenburg position Plain film Lobulated masses in posterior mediastinum (visible in a small percentage of patients with varices) r Silhouetting of descending aorta r Abnormal convex contour of azygoesophageal recess Upper GI
r r r r r
Thickened and interrupted mucosal folds (earliest sign) Tortuous radiolucencies of variable size and location "Worm-eaten" smooth lobulated filling defects Findings may be accentuated after sclerotherapy
CT
r r r r
Thickened esophageal wall and lobulated outer contour Scalloped esophageal luminal masses Right and/or left-sided soft-tissue masses = paraesophageal varices Marked enhancement following dynamic CT
Enhanced CT of the lower thorax shows multiple, large, contrast-containing varices surrounding the region of the distal esophagus
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Complications
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Bleeding in 28% within 3 years Exsanguination in 10-15%
DDx
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Early
s
Other forms of chronic esophagitis
Late
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Varicoid carcinoma of esophagus

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Wall more rigid and less likely to change in varicoid carcinoma Nodular filling defects in varicoid ca
Practical Alimentary Tract Radiology, 1993 Dahnert 4th edition
LearningRadiology - Hyaline Membrane Disease, Respiratory Distress Syndrome of the Newborn
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Respiratory Distress Syndrome (of the Newborn)
Acute pulmonary disorder of the newborn characterized by Generalized atelectasis r Intrapulmonary shunting r Ventilation-perfusion abnormalities r Reduced lung compliance M:F =1.8:1 Cause
r r
q q
Immature surfactant production (usually begins at 18-20 weeks of gestational age)

s
Causes acinar atelectasis Predispositions Premature infants Cesarean section r Infants of diabetic mothers r Perinatal asphyxia Clinical findings
r r r
Onset Usually less than 2-5 hours after birth s Increases in severity from 24 to 48 hours s Then, gradual improvement after 48-72 hours Abnormal retraction of chest wall Cyanosis Expiratory grunting Increased respiratory rate
s
r r r r
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Imaging findings Typically, diffuse ground-glass opacification of both lungs with air bronchograms and hypoaeration r Hypoaeration from loss of lung volume (may be counteracted by respiratory therapy) r Fine granular pattern r Prominent air bronchograms r Bilateral and symmetrical distribution Prognosis
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Spontaneous clearing within 7-10 days (mild course in untreated survivors) r Death in 18% Acute complications
r r
Barotrauma may produce

s s
Parenchymal pseudocyst Pulmonary interstitial emphysema

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Pseudoclearing
r
s s
Lungs appear less because of innumerable small pockets of air in the peribronchial interstitial spaces Pneumomediastinum Pneumothorax
Diffuse ground-glass appearance to both lungs with a left-sided tension pneumothorax and pneumomediastinum (orogastric tube is in distal esophagus)
s s s
Pneumopericardium Pneumoperitoneum Air in the retroperitoneum

s r
Subcutaneous emphysema Diffuse opacity

s s s s s
Worsening RDS Superimposed pneumonia Massive aspiration Pulmonary hemorrhage Congestive heart failure (from PDA or fluid overload)
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Persistent patency of ductus arteriosus

r
Oxygen stimulus is missing to close duct
Hemorrhage Pulmonary hemorrhage s Intracranial hemorrhage Necrotizing enterocolitis Acute renal failure Chronic complications
s
r r q
Lobar emphysema r Localized interstitial emphysema r Recurrent inspiratory tract infections r Retrolental fibroplasia r Subglottic stenosis from intubation Treatment
r r r
Supportive Exogenous surfactant via trachea
Dahnert 4th edition
LearningRadiology - Intussusception, Intussuceptum
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Intussusception
Definition Telescoping of a segment of bowel (the intussusceptum) into another, usually more distal, segment of bowel (the intussuscipiens) Etiology/Pathophysiology Intussusceptum is pulled further into the distal segment by peristalsis, pulling the mesentery along with it and trapping the vessels If not reduced, edema, ischemia and bowel obstruction (usually partial) ensue with necrosis of bowel Three etiologies o Intraluminal Intraluminal mass (e.g., pedunculated tumor) is pulled forward by peristalsis and brings attached bowel wall with it Intramural Abnormality of bowel wall (e.g., sessile malignancy) causes it not to contract properly, allowing a kink which serves as a lead point Extraluminal Extraluminal factor (e.g., inflamed appendix) causes area of abnormal peristalsis, allowing a kink which serves as a lead point In children o Over 90% have no pathologic lead point o Most thought due to lymphoid hypertrophy following viral infection Less than 10% due to Meckels diverticulum, polyp, lymphoma, etc.
In adults o Over 90% have a demonstrable cause 60% due to neoplasm (60% malignant, 40% benign) 30% due to non-neoplastic abnormalities, such as inflammation, trauma or suture lines 10% are idiopathic
Epidemiology In developed nations

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r
Majority are in children s Peak incidence 5-9 months of age Approximately 10% occur in adults s Seen in all age groups s Approximately equal in males and females Incidence is higher in adults than it is in developed nations Fewer are associated with malignancy, and fewer have pathologic lead points
In developing nations
r r
Clinical Findings Children o Cyclical, colicky abdominal pain o Vomiting o Currant jelly stools (diarrhea with mucus and blood) or other blood in stool Classic triad occurs in about 1/3 of patients; most have 2 of the 3 o Palpable abdominal mass, often in right upper quadrant o Dances sign: RUQ mass (intussusception) with RLQ empty space (movement of cecum out of normal position) Adults o Usually indolent, with intermittent crampy abdominal pain over days to months o Can be acute obstruction with hours to days of abdominal distention, pain, and constipation o Nausea and vomiting o Tenderness to palpation o Less than 20% have associated blood in stool o Rarely have a palpable abdominal mass o Can be incidental findings if intussusception is transient and asymptomatic Imaging Findings Plain radiographs are not sensitive or specific o Children
s s s s s
Soft tissue mass surrounded by a crescent of gas Evidence of distal small bowel obstruction Absence of or decreased gas in the colon Pneumoperitoneum May be normal
Adults usually normal bowel gas pattern
Barium enema (diagnostic and therapeutic) Coiled spring appearance o Barium in lumen of the intussusceptum and in the intraluminal space Ultrasound (not pathognomonic) o Transverse: Target or doughnut sign, with hypoechoic rim (edematous bowel wall) surrounding hyperechoic central area (intussusceptum and associated mesenteric fat) o Longitudinal: Sandwich, trident or hayfork sign, with layering of hypoechoic bowel wall and hyperechoic mesentery o Oblique: pseudokidney sign, with hypoechoic bowel wall mimicking the renal cortex and
hyperechoic mesentery mimicking the renal fat o Doppler may help determine viability of the tissue o Adults: may be less useful, as often cannot identify the pathologic lead point and is most useful when an abdominal mass is palpated CT (virtually pathognomonic, most commonly done in adults) o Transverse Target sign, with layers of fat and bowel wall visible If enhanced may see mesenteric vessels in the layers and oral contrast in the intraluminal spaces o Longitudinal Elongated, sausage-shaped mass with visible layers
Two images from a CT of the abdomen and pelvis show a lipoma of the ileum (red arrow) which serves as the lead point for the intussusception shown by the target sign (blue arrow)
and a longitudinal view of the intussusception showing the sausage shaped mass (green arrow) o May be helpful in judging the degree of vascular compromise if fluid or gas collections seen in between the walls of the intussusceptum o May or may not see any pathologic lead point Treatment NPO, IV fluids, NG tube if gastric distention Children o Surgical consultation o Then either reduction with barium, hydrostatic (lactated Ringers) or air enema, or surgery Adults (best approach debated) o Colonic: surgical resection without reduction because of risk of venous embolization of tumor or seeding from a malignant tumor o Enteroenteric: depends on cause and symptoms; may require resection or manual reduction during surgery, may be treated with enema reduction, or may require no intervention
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LearningRadiology - Penetrating Aortic Ulcer
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Penetrating Aortic Ulcer

Ulceration of an atherosclerotic plaque which penetrates into the internal elastic lamina Hematoma then forms within the media of the aortic wall
Occurs in the elderly who usually have a history of severe atherosclerosis, hypertension, and hyperlipidemia Similar presentation to those with a descending thoracic aortic dissection i.e. acute chest or back pain Plaque ulceration usually in the middle to distal third of the descending aorta Intramural hematoma accompanies the penetrating ulcer 80% of the time Associated with abdominal aortic aneurysm Disease progresses from intimal plaque ulceration to media hematoma formation to adventitial saccular pseudoaneurysm formation and finally rupture if there is transmural penetration Speculated as the cause of descending or thrombosed type dissections with all three
Imaging findings
Focal contrast collection projecting beyond the aortic lumen on CT o Intramural hematoma is indistinguishable from intraluminal thrombus
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Enhanced CT scan through the lower thoracic aorta demonstrates a focal outpouching of contrast posteriorly representing a penetrating aortic ulcer Intimal flap is uncommon Intramural wall thickening or thrombus is frequently found On angiography, there is aortic wall thickening and the ulcerated plaque seen On MRI o High signal intensity on both T1 and T2 with subacute hematoma
Can be demonstrated by computed tomography, magnetic resonance, angiography and trans-esophageal echocardiography Differential diagnosis: o Aortic dissection (has an intimal flap) o Atheroma has a low signal on both T1 and T2
Treatment
Surgical cases are those demonstrating hematoma expansion, impending rupture, inability to control blood pressure
Patients routinely have co-morbid conditions that make them poor surgical candidates and are treated with transluminal placement of endovascular stent grafts
LearningRadiology - Emphysematous Pyelonephritis
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Emphysematous Pyelonephritis
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Acute, fulminant, necrotizing infection of kidney and perirenal tissues associated with gas formation which may be life-threatening Organism E. coli (vast majority of cases) r Klebsiella pneumoniae (9%) r Proteus mirabilis r Pseudomonas r Enterobacter r Candida r Clostridia (exceptionally rare) Predisposed
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Especially diabetics in almost all cases r Immunocompromised patients r Ureteral obstruction Average age
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Mid-fifties r Twice as common in females as males Clinical findings

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Features of acute severe pyelonephritis (chills, fever, flank pain, lethargy, confusion) not responding to treatment r Positive blood and urine cultures (in majority) r Urosepsis r Shock r Fever of unknown origin and no localizing signs in almost 20% Frequently have multiple associated medical problems
r r
Uncontrolled hyperglycemia
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Acidosis r Dehydration r Electrolyte imbalance Location

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Most are unilateral 5-7% bilateral
Types
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Type I (33%) Streaky or mottled gas in interstitium of renal parenchyma radiating from medulla to cortex s Crescent of subcapsular or perinephric gas s No fluid collection (= no effective immune response) s Prognosis in this type is poor (69% mortality) Type II (66%)
s s s s
Bubbly and/or loculated intrarenal gas (infers presence of abscess) Renal and/or perirenal fluid collection Gas within collecting system in almost all
Two axial CT scans of abdomen and pelvis show air within collecting system of kidney in top image with air and debris in bladder lumen and wall in bottom image
s s s q
Prognosis in this type is much better (18% mortality) Parenchymal destruction absent Decreased contrast excretion (due to compromised renal function) CT findings Most reliable and sensitive modality r Mottled areas of low attenuation extending radially along the pyramids r Extensive involvement of kidney and perinephric space r Air extending through Gerotas fascia into retroperitoneal space r Occasionally gas in renal veins Ultrasound findings
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High-amplitude echoes within renal sinus and/or renal parenchyma associated with "dirty" shadowing
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"Comet tail" reverberations r Kidney may be completely obscured by large amount of gas in perinephric space (DDx: surrounding bowel gas) r Gas may be confused with renal calculi MR findings
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Signal void on T1WI and T2WI (DDx: renal calculi, rapidly flowing blood)
DDx Emphysematous pyelitis (gas in collecting system but not in parenchyma, diabetes in 50%, less grave prognosis) Treatment
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Antibiotic therapy and nephrectomy r Drainage procedure with coexisting obstruction Mortality
r r r r
60-75% under antibiotic treatment 21-29% after antibiotic treatment and nephrectomy 80% with extension into perirenal space
Dahnert 4th edition
LearningRadiology - Sialolithiasis, Salivary Gland Stone, Wharton's Duct
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Sialolithiasis Stone in Whartons Duct
q q q q q
Most common disease of salivary glands Twice as common in males as females 80-95% occur in submandibular gland or duct Stones are most common cause of acute and chronic infection of salivary glands 80% of submandibular stones are opaque; 60% of parotid are opaque
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Consist of mainly calcium phosphate

s
Not associated with systemic calcium abnormalities r Very unusual for patients to have a combination of radio-opaque and non-opaque stones Signs and symptoms
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Pain and swelling of involved gland

s
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Sialolithiasis causes pain and swelling of the involved salivary gland by obstructing the food-related flow of salivary secretions Calculi may cause stasis of saliva facilitating bacterial ascent into the gland and subsequent infection Some may be asymptomatic
Imaging
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Plain radiography
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Opaque stone in course of Whartons (submandibular) or Stensens (parotid) ducts
CT
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Stone in duct Ductal dilatation
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Contrast-enhanced CT of the neck demonstrates a stone (blue arrow) in the submandibular region of a dilated Wharton's Duct (red arrow)
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MR Inflammation of gland Sialography is contraindicated in acute infection or in a patient with a significant contrast allergy Treatment
s r r r
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Conservative Surgical removal Lithotripsy
Transitional Cell Carcinoma, TCC, Urothelial Carcinoma
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Urothelial Carcinoma Transitional Cell Carcinoma

Submitted by Daniel Kowal, MD
q q
q q
q q q
Accounts for 85-90% of all uroepithelial tumors Exophytic, polypoid papillary growth pattern most common r Attached to the mucosa by stalk r Non-papillary tumors less common Most are solid with no characteristic gross findings Location r Bladder is 30-50x more often the site of the tumor than ureter or renal pelvis (most common tumor of GU tract) rd r When it occurs in the ureter, it most commonly occurs in the lower 3 Synchronous (simultaneous) transitional cell carcinomas are common r Bladder involvement with s 24% of primary renal pelvis involvement s 30% of primary ureteral involvement s In 2% with primary bladder tumor r Both ureters involved in 2-9% r Both renal pelves in 1-2% Metachronous (sequential) transitional cell carcinomas in upper tracts r With pelvic and ureteral primaries-12% in 25 months r With bladder primaries-4% (2/3 in 2 years but can reoccur decades later) Most commonly in men age 60 and older Classically present with painless hematuria Risk factors r Exposure to cyclophosphamide r Phenacetin r Chronic urinary stasis r Smoking Metastasizes to
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Regional lymph nodes r Liver r Lung r Bone Imaging findings r IVU s Enlarged and hydronephrotic kidney q Invasive, poorly differentiated tumors are more likely to obstruct q Dilated calyx with filling defect q Caliceal amputation q Partial or complete obstruction of the infundibulum r Retrograde studies s Papillary tumors q Goblet or Champagne glass sign of ureteral dilatation distal to a filling defect allows for differentiation from a calculus impacted in the ureter, which causes distal spasm and narrowing
r
Upper and lower half of right retrograde pyelogram shows hydronephrosis (yellow arrow), filling defect at head of contrast column in ureter (red arrow) and "goblet" shaped dilatation distal to filling defect
s
Non-papillary tumors q Nodular or flat q Cause strictures rather than filling defects CT s Can identify dilated collecting system and demonstrate level of obstruction s Intraluminal mass (30-60 HU) representing ureteral tumor can be differentiated from obstructing calculus (> 190 HU) s May demonstrate extra-ureteral extension US s Discrete hypoechoic mass within the renal sinus s Absence of acoustic shadowing allows for differentiation from calculi Angiography s Hypovascular mass s Vessel encasement and stain s Not usually necessary Treatment r Controversy s Nephroureterectomy with resection of a cuff of bladder versus wide excision of the tumor alone s Adding chemotherapy (cisplatin) in patients with advanced tumors is of unclear utility
Lymphangiomyomatosis. LAM, Tuberous Sclerosis
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Lymphangiomyomatosis and Tuberous Sclerosis

q q
q q q
Similar in pathology and x-ray appearance Widespread proliferation of smooth muscle in pleura, alveolar septa, bronchi, pulmonary vessels and lymphatics as well as lymph nodes, especially in posterior mediastinum and retroperitoneum Focal emphysema develops as result of narrowing of airways Thoracic duct may be obliterated Produce multiple small cysts with a hamartomatous proliferation of smooth muscle in their walls
Characteristic imaging triad of:

q q q q
Progressive, diffuse interstitial disease Recurrent chylous effusions and sometimes chylous ascites Recurrent pneumothorax Tuberous sclerosis is inherited as a dominant with variable penetrance:
o o o o o o o o o o Mental defects Epilepsy Retinal phacoma Angiomyolipomas of the kidneys Rhabdomyomas of the heart Intracranial calcifications Sclerotic skull lesions Adenoma sebaceum Subungual fibromas Pulmonary lymphangiomyomatosis (syn:pulmonary myomatosis) Exclusively in females ages 17-47 years Rare
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Imaging findings
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Identical in both tuberous sclerosis and lymphangiomyomatosis and indistinguishable from pulmonary fibrosis except for decreased lung volume in fibrosis and increased lung volume in the others CT r Coarse, reticular interstitial pattern r Normal/increased lung volume r Numerous thin-walled pulmonary cysts and honeycombing r Various sizes/surrounded by normal lung parenchyma
Note multiple thin-walled cysts throughout both lungs Clinically

q q
Unilateral or bilateral pleural effusions which are usually large and recurrent Spontaneous pneumothorax is common
Progressive exertional dyspnea and cough Hemoptysis
LearningRadiology.com - Pulmonary Arterial Hypertension - PAH, Idiopathic, Primary, artery, pulmonary
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Pulmonary Arterial Hypertension (PAH)
Sustained pulmonary arterial pressure

r r r
In systole >30 mm Hg In diastole >15 mm Hg Mean pressure >20 mm Hg
Pathogenesis: o Primary PAH (rare) = unknown cause Diagnosis of exclusion o Clinically unexplained progressive pulmonary arterial hypertension without evidence for thromboembolic disease and pulmonary venoocclusive disease Clinical o Age 3rd decade; females > males o Dyspnea on exertion o Syncope o Easy fatigability o Hyperventilation o Chest pain Imaging findings o Main pulmonary artery usually prominent o Right and left pulmonary arteries large and taper rapidly o Peripheral pulmonary arteries are narrow and inconspicuous o Diffuse oligemia of the lungs
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Frontal radiograph of the chest shows an enlarged main pulmonary artery and a markedly enlarged right and left pulmonary arteries. The peripheral vasculature is normal o o o No overinflation Nuclear medicine Diffuse patchy defects on perfusion scans (low probability) On CT, main pulmonary artery diameter should be less than 30mm
Secondary PAH (more common) o Primary pleuropulmonic disease o Parenchymal pulmonary disease o COPD o Emphysema o Chronic bronchitis o Asthma o Bronchiectasis o Granulomatous disease o Cystic fibrosis o End-stage fibrotic lung o S/P lung resection o Idiopathic hemosiderosis o Alveolar proteinosis Alveolar hypoventilation = hypoxic pulmonary arterial hyperperfusion o Chronic high altitude o Sleep apnea o Hypoventilation due to neuromuscular disease or obesity Pleural disease and chest deformity o Fibrothorax o Thoracoplasty o Kyphoscoliosis
Primary vascular disease o Congenital heart disease Increased flow: large L-R shunt Decreased flow: Tetralogy of Fallot o Capillary obliteration Chronic pulmonary thromboembolism Persistent fetal circulation Arteritides (eg, Takayasu) o Venous obliteration Pulmonary venoocclusive disease o Pulmonary venous hypertension Prognosis o Majority of patients have a median survival of 2-3 years
LearningRadiology.com -
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Achalasia
Submitted by Susannah E. Berke, MS IV
Definition Form of esophageal dysmotility characterized by loss of distal esophageal peristalsis and failure of lower esophageal sphincter relaxation Etiology & Pathophysiology Usually idiopathic in origin o Degeneration of neurons within the myenteric plexus of the esophageal smooth muscle Neuronal destruction is typically inflammatory in nature o Histologically: lymphocytic infiltrate surrounding the plexus o Predominantly involves the nitric-oxide producing inhibitory neurons Cause smooth muscle relaxation by inhibiting the acetylcholine producing excitatory neurons Loss of inhibitory input results in unopposed contractile stimulation and aperistalsis o Acetylcholine producing neurons (which stimulate smooth muscle contraction) are relatively spared in this degenerative process
Types Primary achalasia (idiopathic) o Unknown cause of inflammatory neuronal degeneration Secondary achalasia (pseudoachalasia) o Recognized pathologic causes of esophageal motility disorders often indistinguishable from primary achalasia Malignancy (especially gastric cancer) MEN, Type 2B Chagas disease Juvenile Sjogrens Amyloidosis Chronic idiopathic intestinal Sarcoidosis
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Pseudo-obstruction Neurofibromatosis Eosinophilic gastroenteritis Fabrys disease Scleroderma
Epidemiology o Annual incidence of 1 case per 100,000 o Men and women affected equally o Occurs at any age o Typically between 25-60 years of age Onset rare before adolescence Clinical Findings Dysphagia for solids and liquids predominate (85-95% of patients) o Dysphagia for liquids especially should prompt evaluation for achalasia Difficulty belching Hiccups Weight loss Chest pain o Usually secondary to failure of LES relaxation o More common in younger patients and tends to regress Regurgitation of retained material in esophagus, especially upon lying down o May lead to recurrent aspiration Heartburn in 40-60% o Tend to have lower LES pressures than those without GERD Increased incidence of esophageal cancer o Usually squamous cell o Surveillance endoscopy not recommended (usually seen 15-20 years after development of achalasia)
Imaging Findings Barium studies o 95% diagnostic accuracy o Early/Stage I Primary peristaltic waves absent with abnormal distal peristalsis Only minimal narrowing of the GE junction Occasionally may see nonpropulsive peristaltic waves in the esophageal body (vigorous achalasia secondary to tertiary waves) o Progressive disease Birds beak appearance of GE junction Distal esophagus makes right angle before entering stomach o Hurst phenomenon With the patient upright, barium builds up to a point where the hydrostatic pressure of the barium overcomes the LES pressure Occasional spurt of barium through the GE junction as it is intermittently forced open
Dilated, aperistaltic esophageal body; may assume a sigmoid shape Severe disease Significant esophageal body dilation with large amounts of fluid/food retention Entire esophagus atonic in late stages
Chest x-ray o With severe disease, may readily see the large, dilated esophagus with air fluid level at the aortic arch or above o Stomach bubble frequently absent CT Scan o Not typically used for diagnosis o Seen as dilated luminal structure with retained debris and narrowing at level where it enters the stomach
CT scan of the chest demonstrates a markedly dilated esophagus containing barium, debris and a fluid level Manometry o Usually required for confirmation of diagnosis Elevated resting LES pressure Incomplete LES relaxation Absence of peristalsis Endoscopy o Must rule out malignancy o Reveals dilated esophagus with normal mucosa o Retained fluid/food o Possible candidal infection secondary to esophageal stasis o Endoscope should pass easily through LES with gentle pressure applied Unlike strictures caused by neoplasms, fibrosis etc
Differential Diagnosis Reflux esophagitis with stricture o Narrowing is usually higher than the EG junction
Normal esophageal peristalsis
Carcinoma o Only minimal dilation with normal peristalsis Scleroderma o Barium should empty when patient is upright o Other associated GI abnormalities Chagas disease o Not distinguishable by x-ray; history needed
Treatment Medical therapy o Nitrates, calcium channel blockers (nifedipine) Cause smooth muscle relaxation but with limited success Pneumatic dilation of the LES o Tears muscle fibers of LES, thus weakening it o Varying protocols regarding type and diameter of dilator, balloon inflation pressure and rate at which it is inflated, duration of inflation, and number of inflations per session o Good short-term results, but many patients require further intervention, with successive dilations adding little benefit Potential complications of esophageal perforation (2-6%) and GERD Surgical myotomy o LES muscle fibers cut o Laparoscopy becoming more popular o Good relief of symptoms in majority of patients with complication rate similar to that of dilation o Superior method for achieving better long term results o Debate as to whether fundoplication is necessary to prevent longstanding GERD Botulinum toxin injection o Inhibits release of excitatory acetylcholine from nerve endings (thus causing lower LES pressures) o Good short--term results, but long term efficacy unknown
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Bladder Rupture
q q
r
Extraperitoneal bladder rupture is the most common type r Occurs in 80% of bladder rupture cases r Extraperitoneal bladder rupture generally secondary to adjacent pelvic fracture or an avulsion tear at fixation points of puboprostatic ligaments Intraperitoneal bladder rupture r Usually iatrogenic or secondary to penetrating injury
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Blunt trauma more likely to result in intraperitoneal rupture in children than in adults s Because the pediatric bladder is more intraperitoneal in location. s The adult bladder dome remains mostly extraperitoneal q Blunt trauma in an adult can result in intraperitoneal rupture only if the bladder is fully distended r Imaging findings s Contrast extravasation into paracolic gutters s Contrast outlining small bowel loops While extraperitoneal bladder rupture can be treated conservatively, intraperitoneal bladder rupture requires surgical repair Highest morbidity and rupture mortality is associated with intraperitoneal rupture because of potential for development of chemical peritonitis Imaging findings r Diagnostic evaluation of bladder rupture includes voiding cystourethrography (VCUG) or CT scan s VCUG q Voiding cystourethrography historically been preferred contrast enhanced study for diagnosis of bladder rupture q Bladder needs to be fully distended and evaluation of a post-voiding film essential s Plain film: q "Pear-shaped" bladder q Paralytic ileus q Upward displacement of ileal loops q Flame-shaped contrast extravasation into perivesical fat r Best seen on postvoid films r May extend into thigh / anterior abdominal wall
r
One image from an IVU shows a flame-shaped density adjacent to right lateral wall of bladder representing extra-peritoneal contrast from a bladder rupture
US
r
"Bladder within a bladder" = bladder surrounded by fluid collection
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Calcium Pyrophosphate Dihydrate Crystal Deposition Disease CPPD

q
q q
Terminology r Chondrocalcinosis calcification of hyaline (articular) cartilage or fibrocartilage (menisci) or ligaments s Usually but not always due to calcium pyrophosphate q May also be seen with oxalosis r Pseudogout is an older clinical term referring to acute pain (similar to gout) but without response to the usual treatment for gout r CPPD Deposition of crystals in the joint with or without chondrocalcinosis Most common crystalline arthropathy Prevalence r Widespread in older population r M:F = 3:2 Clinical findings r Intermittent attacks s May be mono-articular or polyarticular (more often) q Pain q Redness q Swelling Types r Frequently occurs in association with osteoarthritis r Aging process with no known etiology r In association with metabolic diseases s Hyperparathyroidism s Hemochromatosis s Hypothyroidism s Hypomagnesemia s Hypophosphatasia s Ochronosis Calcium pyrophosphate crystals may be recovered from synovial fluid (most often) or within leukocytes
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Characteristic weakly positive birefringent diffraction pattern Location r Knee s Especially meniscus s Cartilage of patellofemoral joint r Wrist s Triangular fibrocartilage in distal radioulnar joint bilaterally r Pelvis s Sacroiliac joint s Symphysis r Spine s Annulus fibrosis of lumbar intervertebral disk q Never in nucleus pulposus as in ochronosis r Shoulder s Glenoid s Hip q Labrum s Elbow s Ankle s Acromioclavicular joint Imaging Findings r Pyrophosphate arthropathy resembles osteoarthritis s Joint space narrowing s Extensive subchondral sclerosis r Polyarticular chondrocalcinosis (in fibro- and hyaline cartilage) r In knee, disproportionate narrowing of patellofemoral joint s Large subchondral cysts are a hallmark s Numerous intra-articular bodies q Fragmentation of subchondral bone r In hand, beaklike projections from 2nd, 3rd metacarpal heads s Subchondral cysts (esp. carpal bones) s Unusual distribution of disease (radiocarpal/ulnar joint, patellofemoral joint) s SLAC - scapholunate advanced collapse q Caused by laxness of the ligaments and malpositioning of the scaphoid and lunate q May develop in 25% with CPPD but also occurs for other reasons q Radio-scaphoid, but not radio-lunate, joint is narrowed q Usually have a deep concave scaphoid fossa in distal radius in CPPD as opposed to SLAC from trauma
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CPPD of hand and wrist - upper photo shows hook-like projections arising from radial aspect of metacarpal heads; lower photo shows SLAC-scapholunate advanced collapse with characteristic indentation in distal radius by scaphoid bone. There is also chondrocalcinosis of the triangular fibrocartilage of the distal ulna.
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Treatment r Oral anti-inflammatory drugs (NSAIDs) and corticosteroid joint injections successful in shortening the length of pain and dysfunction of acute attacks of pseudogout r Treatments to prevent attacks, such as colchicine, may be effective r No treatment is available to dissolve the crystal deposits r Controlling inflammation helps to halt the progression of joint degeneration
Imaging of the Wrist and Hand: Gilula and Yin, W.B. Saunders, 1996
Welcome to LearningRadiology.com - Slipped Capital Femoral Epiphysis, SCFE, Slipped Epiphysis
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Slipped Capital Femoral Epiphysis (SCFE)
Rare less than nine years of age Boys more than girls Plain of cartilage changes during adolescence to more a more oblique one predisposing to easier slipping Higher incidence of slip from June through September Usually boys r Blacks more often r Ages 10 through 15 r Usually heavier and or taller than others for their age Younger in girls 8 to 15 years of age About 20 to 25 percent are bilateral, an occurrence more frequent in girls. X-ray Findings
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Osteoporosis of head and neck on AP view early Indistinct epiphysis-widened Line along lateral edge of superior femoral neck on AP doesn't intersect epiphysis Metaphysis displaced laterally so that it does not overlap posterior lip of acetabulum as normal Late buttressing medial and posterior on neck
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Slipped capital femoral epiphysis on left-epiphysis has slipped medial, inferior and posterior to its original location
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Sequelae Degenerative arthritis Varus deformity Avascular necrosis 6 to 15%
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Peak incidence is five years with a range of 2-14 years Bilateral in 10% Males greater than females
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Bilateral involvement in females is very rare
The first sign is subarticular translucency seen best on frog lateral Then epiphysis becomes flattened, fragment and dense
Frontal radiograph of left hip in a 3 year-old shows flattening, sclerosis and cystic lucencies with preservation of the hip joint space
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With revascularization there is gradual reformation of femoral head. Since there is less bone to reform, prognosis is better for those under five years of age than in older children. Arthrography will, except in severe cases, be normal because cartilage derives its nutrition from synovial fluid.
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First sign may be joint effusion as shown by lateral displacement of femoral head Poor prognosis if there is severe and lateral displacement of metaphysis, by involvement of lateral aspect of head, and by flattening of cartilage seen on arthrography
Hip Diseases in Children

Disease Age Birth Male/Female 5-9x more common in females 10x more common if breech Bilaterality Race Almost never in Blacks Best Film APnot frog Other ORTALANI CLICK with leg flexed, dislocate by adduction, click on relocation with abduction
Congenital Hip Dysplasia
1/3
Boys>girls Slipped Capital Teenagers 1215 June-September Femoral Heavy or tall most often Epiphysis Younger in girls (8-15)
1/4
Blacks more often
AP
Avascular necrosis in 6-15%
Legg-CalvePerthes Disease
5 years
Male> females
1/10
Bilateral in females is rare
None
Frog lateral-for subarticular lucency
Arthrography usually neg Better prognosis under 5 Synovitis may be 1st sign
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Free Intraperitoneal Air Pneumoperitoneum
Etiology r Disruption of wall of hollow viscus s Blunt or penetrating trauma s Perforating foreign body (eg, thermometer injury to rectum) s Iatrogenic perforation q Laparoscopy / laparotomy (58%) q Absorbed in 1-24 days depending on initial amount of air introduced and body habitus (80% in asthenic, 25% in obese patients) q Leaking surgical anastomosis q Endoscopic perforation q Enema tip injury q Diagnostic pneumoperitoneum s Diseases of GI tract q Perforated gastric / duodenal ulcer q Perforated appendix q Ingested foreign-body perforation q Diverticulitis (ruptured Meckel's diverticulum / sigmoid diverticulum, jejunal diverticulosis) q Necrotizing enterocolitis with perforation q Inflammatory bowel disease (eg, toxic megacolon) q Obstruction* (gas traversing intact mucosa): neoplasm, imperforate anus, Hirschsprung disease, meconium ileus q Ruptured pneumatosis cystoides intestinalis q Idiopathic gastric perforation = spontaneous perforation in premature infants (congenital gastric muscular wall defect) r Through peritoneal surface s Transperitoneal manipulation s Abdominal needle biopsy / catheter placement s Mistaken thoracentesis / chest tube placement
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Endoscopic biopsy r Extension from chest s Dissection from pneumomediastinum (positive pressure breathing, rupture of bulla / bleb, chest surgery) s Bronchopleural fistula s Rupture of urinary bladder s Penetrating abdominal injury r Through female genital tract s Iatrogenic s Perforation of uterus / vagina s Culdocentesis s Rubin test = tubal patency test s Pelvic examination s Spontaneous s Intercourse, orogenital insufflation q Douching s Knee-chest exercise, water skiing, horseback riding r Intraperitoneal s Gas forming peritonitis s Rupture of abscess s Air in lesser peritoneal sac gas in scrotum (through open processus vaginalis) Imaging findings r Large collection of gas r Abdominal distension, no gastric air-fluid level r "Football sign" = large pneumoperitoneum outlining entire abdominal cavity r "Double wall sign" = "Rigler's sign" = air on both sides of bowel as intraluminal gas and free air outside (usually requires >1,000 mL of free intraperitoneal gas + intraperitoneal fluid) r "Telltale triangle sign" = triangular air pocket between 3 loops of bowel r Depiction of diaphragmatic muscle slips = two or three 6-13 cm long and 8-10 mm wide arcuate soft-tissue bands directed vertically inferiorly and arching parallel to diaphragmatic dome superiorly outline of ligaments of anterior inferior abdominal wall: r "Inverted V sign" is outline of both lateral umbilical ligaments (containing inferior epigastric vessels) r Outline of medial umbilical ligaments (obliterated umbilical arteries) r "Urachus sign" is outline of middle umbilical ligament
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Blue arrows point to falciform ligament, made visible by a large amount of free air in the peritoneal cavity. The red arrows demonstrate both sides of the wall of the stomach (Rigler's sign), a sign of free air. The yellow arrow points to a skin fold.
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RUQ gas (best place to look for small collections) r Single large area of hyperlucency over the liver r Oblique linear area of hyperlucency outlining the posteroinferior margin of liver r Doge's cap sign = triangular collection of gas in Morison pouch (posterior hepatorenal space) r Outline of falciform ligament = long vertical line to the right of midline extending from ligamentum teres notch to umbilicus; most common structure outlined r Ligamentum teres notch = inverted V-shaped area of hyperlucency along undersurface of liver r Ligamentum teres sign = air outlining fissure of ligamentum teres hepatis (= posterior free edge of falciform ligament) seen as vertically oriented sharply defined slit like / oval area of hyperlucency between 10th and 12th rib within 2.5-4.0 cm of right vertebral border 2-7 mm wide and 6-20 mm long r "Saddlebag / mustache / cupola sign" = gas trapped below central tendon of diaphragm r Parahepatic air = gas bubble lateral to right edge of liver
Dahnert 5th edition
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Congenital Diaphragmatic Hernia (Bochdalek Hernia in this case)
If defective development, diaphragmatic hernia develops r Anterior Morgagni s Anteromedial parasternal defect (Space of Larrey) s Maldevelopment of septum transversum s Tends to occur in overweight, middle-aged, women s Right > left (heart protects) s Usually not large s Usually unilateral s Associated with q Pericardial defects q Omental fat in pericardial space r Posterior Bochdalek s Most common q Occurs through old pleuroperitoneal canals r Just lateral to the spine on either side s More frequent on left side q Possibly due to protection of right-side by liver q Hernia may contain intestine, stomach, spleen, liver or omentum s If hernia occurs on right q Intestine and liver or only liver may herniate s If the defect is large, newborns usually present with q Severe respiratory distress q Cyanosis q Scaphoid abdomen s Entire diaphragm is almost never absent q Some part of diaphragm is usually found at surgery, even if defect is very large s Hypoplasia of ipsilateral lung occurs from mass effect of bowel s Most often these are isolated congenital abnormalities q But they can have r Congenital Heart Disease
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13 ribs Malrotation of GI tract frequently present
Two axial images from a contrast-enhanced CT of the abdomen reveal a fatty density protruding through a rent in the posterior aspect of the right hemidiaphragm. The density represents omental fat which has herniated through a small Bochdalek hernia.
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Imaging findings r Initially, hemithorax may appear opaque because loops are fluid-filled r Paucity of bowel loops beneath the diaphragm r Once air swallowing begins, multiple lucencies contained within bowel are seen in chest s Respiratory distress may increase as intestine occupies more of thorax r Some loops may remain fluid-filled r Mediastinal shift to the opposite side r Relative paucity of gas in abdomen s If stomach remains in abdomen, it is more centrally located than normal r Contrast through an NGT is diagnostic but often not needed Differential diagnosis of lucent cysts in infant lung r Cystic adenomatoid malformation r Staphylococcal pneumonia s In both, abdomen contains normal amount of air-filled loops
LearningRadiology.com q q
Delayed herniation of bowel may occur in older infants following streptococcal pneumonia Mortality around 50% r Pulmonary hypoplasia r Persistent Fetal Circulation Syndrome Treatment r Surgical repair r Many demonstrate ipsilateral pulmonary hypoplasia for years after repair r Obstructive emphysema can occur in either lower lobe
WH
LearningRadiology.com - Epiglottitis
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Epiglottitis
Acute bacterial epiglottitis r Life-threatening, medical emergency due to infection with edema of epiglottis and aryepiglottic folds Organism r Introduction of Haemophilus influenzae type B vaccine in 1985 has led to marked decrease in number of cases of epiglottitis s Still remains the most common cause r Also caused by s Pneumococcus s Streptococcus group A r May also be caused by thermal injury Age r Typically between 3-7 years r Peak incidence has become older over last decade and is now closer to 6-7 years Clinical r Classical triad is: drooling, dysphagia and distress (respiratory) r Abrupt onset of respiratory distress with inspiratory stridor r Sore throat r Severe dysphagia r Older child may have neck extended and appear to be sniffing due to air hunger r Resembles croup clinically, but think of epiglottitis if: s Child can not breathe unless sitting up s Croup appears to be worsening s Child can not swallow saliva and drools (80%) r Cough is unusual Location r Purely supraglottic lesion s Associated subglottic edema in 25% r Associated swelling of aryepiglottic folds causes stridor Imaging findings r Patient needs to be accompanied everywhere by a physician experienced in endotracheal
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r r
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intubation Imaging studies are not always necessary for the diagnosis Lateral radiograph should be taken in the erect position only, as s Supine position may close off airway Enlargement of epiglottis s Larger than your thumb Thickening of aryepiglottic folds s True cause of stridor Circumferential narrowing of subglottic portion of trachea during inspiration Ballooning of hypopharynx and pyriform sinuses
Lateral radiograph of the neck demonstrates and enlarged epiglottis (red arrow) and thickening of the aryepiglottic folds (yellow arrow). There is also reversal of the normal lordotic curve in the cervical spine and slight dilatation of the hypopharynx.
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Reversal of the normal lordotic curve of the cervical spine Fiberoptic-assisted, nasotracheal intubation is procedure of choice Complications r Danger of suffocation secondary to complete airway closure
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LearningRadiology.com - Child Abuse, Battered Child
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Battered Child Syndrome Child Abuse
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Most common cause of serious intracranial injuries in children less than 1 year of age 3rd most common cause of death in children after sudden infant death syndrome and true accidents Prevalence r 1.7 million cases reported, 833,000 of which were substantiated in United States in 1990 r Results in 2,500-5,000 deaths/year r 5-10% of children seen in emergency rooms suffer from child abuse Radiologist has legal obligation to report suspected child abuse, usually to the referring physician Age r Usually <2 years In children <2 years of age, a skeletal survey may be best to demonstrate other fractures r In children >2 years of age, a bone scan may be best Clinical findings r Skin burns r Bruises r Lacerations r Hematomas Skeletal trauma is seen in 50-80%
Skeletal Trauma Suspicious for Child Abuse

Site(s) Distal Femur, distal humerus, wrist, ankle Multiple Femur, humerus, tibia Posterior ribs, avulsed spinous processes Remarks Metaphyseal corner fractures Fractures in different stages of healing Spiral fractures < 1 year of age Unusual naturally-occurring fractures <5years of age
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Multiple skull fractures Fractures with abundant callous formation Metacarpal and metatarsal fractures Sternal and scapular fractures Vertebral body fractures and subluxations
Multiple fractures of occipital bone should suggest child abuse Implies repeated trauma and no immobilization Unusual naturally-occurring fractures <5years of age
Sites of skeletal trauma r Multiple ribs r Transverse fracture of sternum r Costochondral / costovertebral separation r Lateral end of clavicles r Scapula r Acromion r Skull r Vertebral bodies s Anterior-superior wedging of vertebral bodies s Vertebral compression s Vertebral fracture dislocation s Disk space narrowing s Spinous processes
Frontal radiograph of the chest demonstrates multiple rib fractures with callous formation, including a fracture of the left 2nd and 6th ribs posteriorly. Posterior rib fractures are highly suggestive of child abuse (from forceful squeezing)
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Appearances of skeletal trauma r Hallmark of the syndrome are multiple, asymmetric fractures in different stages of healing r Separation of distal epiphysis r Marked irregularity and fragmentation of metaphyses s "Corner" fracture (11%) or "Bucket-handle" fracture = avulsion of a metaphyseal
fragment overlying the lucent epiphyseal cartilage secondary to a sudden twisting motion of extremity r Isolated spiral fracture (15%) of diaphysis secondary to external rotatory force applied to femur / humerus r Extensive periosteal reaction from large subperiosteal hematoma r Exuberant callus formation at fracture sites r Cortical hyperostosis extending to epiphyseal plate r Avulsion fracture at site of ligamentous insertion s Frequently seen without periosteal reaction Head trauma (13-25%) r Most common cause of death and/or physical disability s Skull fracture (flexible calvaria + meninges decrease likelihood of skull fractures) s Subdural hematoma s Brain contusion s Cerebral hemorrhage s Infarction s Generalized edema s Shearing injuries with associated subarachnoid hemorrhage s Skull film (associated fracture in 1%): q Linear fracture > comminuted fracture r CT findings in head trauma s Subdural hemorrhage (most common) q Interhemispheric location most common s Subarachnoid hemorrhage s Epidural hemorrhage (uncommon) s Cerebral edema (focal, multifocal, diffuse) s Acute cerebral contusion appears as ovoid collection of intraparenchymal blood with surrounding edema r MR findings of head trauma s More sensitive in identifying hematomas of differing ages s White matter shearing injuries as areas of prolonged T1 + T2 at corticomedullary junction, centrum semiovale, corpus callosum Viscera (3%) r Second leading cause of death in child abuse r Cause s Crushing blow to abdomen (punch, kick) r Age s Often >2 years r Small bowel and/or gastric rupture r Hematoma of duodenum and/or jejunum r Contusion and/or laceration of lung, pancreas, liver, spleen, kidney r Traumatic pancreatic pseudocyst Differential diagnosis of child abuse r Normal periostitis of infancy r Osteogenesis imperfecta r Congenital insensitivity to pain r Infantile cortical hyperostosis r Menkes kinky hair syndrome r Schmid-type chondrometaphyseal dysplasia

r r
Scurvy Congenital syphilitic metaphysitis
Dahnert 5th edition Requisites-Pediatric Radiology Requisites-Musculoskeletal Radiology
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Cerebellar Hemangioblastoma
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Benign neoplasm 80% found in cerebellum r Remainder are located in spinal cord > medulla > cerebrum Account for 10% of posterior fossa masses (vestibular schwannomas and metastases rule here.) Most often occurs in ages 30 to 40 r M > F Relationship to von Hippel-Lindau disease r 20% occur in patients with von Hippel-Lindau disease (multiple lesions). r 35-60% of von Hippel-Lindau disease patients have hemangioblastomas r von Hippel-Lindau disease consists of s Retinal, spinal, cerebellar and medullary hemangioblastomas s Renal cysts and carcinomas s Pancreatic cysts s Pheochromocytomas s Papillary Cystadenoma of the epididymis Clinical findings r Headache r Ataxia r Nausea r Vomiting r Vertigo r Polycythemia caused by increased erythropoietin found in 40%. r Spinal lesions may present with subarachnoid hemorrhage Findings on CT and MRI: r Cystic lesion in the cerebellum with an avidly enhancing mural nodule (75%) r Purely solid enhancing lesion (10%) r Enhancing lesion with multiple cystic areas (15%)
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MRI of brain shows a cystic lesion in the cerebellum with an enhancing nodule (post-Gadolinium)
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Findings on angiography: r Vascular nodule within an avascular mass r Serpentine vessels

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Treated with surgical removal of solid nodule r Cystic component is not neoplastic DDx:
o Similar appearance to Juvenile pilocytic astrocytoma But that is typically found in patients 5 to 15 years of age.
LearningRadiology.com - Volar Plate Fracture
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Volar Plate Fracture

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q q q q
Volar plate forms floor of PIP joint and separates the joint space from the flexor tendons r Volar plate is ligamentous at its origin on the proximal phalanx r Cartilaginous in its insertion onto the middle phalanx Hyperextension injury Involves PIP joint of fingers Primarily a ligamentous injury that can result in fracture Injury to the PIP joint is relatively common in athletics, especially sports involving ball-handling r Jammed finger If force of injury is great enough, dorsal dislocation can occur r Rupture of volar plate may occur with longitudinal splitting of the collateral ligament structures s Allows for complete dorsal displacement of middle phalanx s Simple dislocations easily reduced by player coach, or trainer on the field s Following reduction, most dorsal dislocations are stable Fractures of base of middle phalanx also occur in association with dorsal dislocations r If fracture involves more than 40-50% of articular surface s Collateral ligament support is lost s Combined with coexistent volar plate disruption q Represents major loss of joint stability q These injuries are often unstable, exhibiting persistent subluxation of the middle phalanx Imaging findings r Small fragment of bone is avulsed from palmar (volar) aspect of base of middle phalanx
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There is a small avulsed fragment of the base of the middle phalanx from a volar plate injury
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Complications r Joint instability r Associated collateral ligament tear may heal with abundant fibrous tissue producing bump on
one side of joint
Michael E. Robinson, MD eMedicine.com
LearningRadiology.com - Pericardial effusion, CT, double-lucency sign,fat
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q
Normal anatomy r Inner serous layer is the epicardium r Outer fibrous layer is pericardium r Space between the two is pericardial space r Normally contains about 20-50cc of fluid r Fat covers outside of heart and outside of pericardium sandwiching pericardial space between the two layers s Normal thickness of pericardium (parietal pericardium and fluid in space) is 2-4 mm Requires about 150-250cc before cardiac tamponade occurs r Tamponade compresses heart and causes low cardiac output r Most effusions do not lead to cardiac tamponade r Size of cardiac silhouette is frequently increased r Tamponade is rarely seen in association with pulmonary edema in the lungs
Causes of Pericardial Effusions Cause Myocardial infarction Collagen vascular disease Trauma Metastatic disease Tuberculosis Viral infection Uremia Remarks Most common Especially Lupus Surgical or accidental Serosanguineous effusion Uncommon except in AIDS Coxsackie B virus 18% in acute uremia
Other causes r Serous fluid = transudate
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Congestive heart failure s Hypoalbuminemia s Irradiation r Blood = hemopericardium s Rupture of ascending aorta or pulmonary trunk s Coagulopathy r Fibrin = exudate s Pyogenic infection, e.g. staph s Uremia: 18% in acute uremia; 51% in chronic uremia; dialysis patient Imaging findings r "Water bottle configuration" is symmetrically enlarged cardiac silhouette s Major DDX is cardiomegaly r Loss of retrosternal clear space s Non-specific and frequently not valid r "Fat-pad sign" from separation of retrosternal from epicardial fat line >2 mm (15%)
s
Pericardial effusion on both frontal chest radiograph and axial CT. Red arrow points to fat outside of pericardium. Green arrow points to pericardial space which is 8 mm in this patient (<4 mm is normal.) The yellow arrow points to fat outside of heart and the blue arrow to the myocardium.
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Rapidly appearing cardiomegaly with normal pulmonary vascularity "Differential density sign" is increase in lucency at heart margin secondary to slight difference in contrast between pericardial fluid and heart muscle Diminished cardiac pulsations Echo r Separation of epi- and pericardial echoes extending into diastole (rarely behind LA)
Requisites-Cardiac Radiology Dahnert-5th Edition
LearningRadiology.com - Mesenteric Vascular Ischemia, Mesenteric Ischemia, Ischemic Bowel, Bowel Infarction, Slow Flow Syndrome
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Acute Mesenteric Ischemia

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Acute interruption of blood flow to small or large intestine Causes r Arterial embolism s Superior mesenteric artery most commonly involved r Arterial thrombosis r Nonocclusive mesenteric ischemia s Low cardiac output state with diffuse mesenteric vasoconstriction r Mesenteric venous thrombosis Risk Factors r Atrial fibrillation/flutter r Recent acute MI s Ventricular aneurysm s Cardiomyopathies s Valvular disease r Hypovolemia or hypotension (sepsis) r Coagulation disorders or malignancy r Pancreatitis r Portal hypertension/cirrhosis r Medications s Vasopressor medications s Beta-blockers s Digoxin s Diuretics Clinical signs and symptoms r Severe abdominal pain out of proportion to physical exam r Pain initially of a visceral nature and poorly localized
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Nausea Vomiting Diarrhea GI bleeding may be present
Imaging r Plain abdominal radiographs (abnormal in 20-60% of cases) s Thumbprinting s Non-specific finding indicating intestinal wall edema with hemorrhage in the setting of acute mesenteric ischemia s Pneumatosis s Portal venous gas s Pneumoperitoneum s All are indicative of infarcted bowel r CT s Bowel wall thickening from edema or hemorrhage s Lack of enhancement indicates infarction s Pneumatosis, portal venous gas, pneumoperitoneum s Intraluminal thrombus in involved vessel
Top CT image shows gas in portal venous system (blue circle); center image shows absence of contrast in superior mesenteric artery due to thrombosis of this vessel (blue arrow) [The patient also has a markedly dilated common duct, not related to mesenteric ischemia]; lower image shows extensive pneumatosis intestinalis (red arrows)
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Mesenteric angiogram s Can distinguish between arterial embolic and thrombotic causes of acute mesenteric ischemia Treatment r Mesenteric angiogram s Vasodilator therapy s Thrombectomy/Embolectomy r Surgery s Thrombectomy/Embolectomy s Arterial bypass s Resection of necrotic bowel Complications r Sepsis/septic shock r Multiple system organ failure r Death Mortality r 70-90% overall r From arterial embolism: 60-80% r From arterial thrombosis: 70-100% r From nonocclusive mesenteric ischemia: 40% r From mesenteric venous thrombosis: 25-30%
LearningRadiology.com - Synovioma, Synovial Sarcoma,malignant,tumor,foot
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Synovioma
Synovial Sarcoma
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Middle-aged and older adults Most frequent presentation: painful swelling of the knee Predisposition for lower extremity It is a malignancy Can occur at any age
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Usually third and fourth decades Usually are extra-articular X-ray

r r r r r
Soft tissue mass near articular surface Frequently, spherical and lobulated in shape 20-30% calcify About 1/3 have adjacent erosion of bone Look for erosions on both sides of a joint Osteoporosis is common secondary to disuse
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DDX from pigmented villonodular synovitis where there is rarely osteoporosis
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Frontal radiograph of the foot demonstrates a heavily calcified lesion which is arising from the dorsum of the foot between the 2nd and 3rd metatarsals.
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Can metastasize to lungs Mets to lungs almost never calcify Mets to bone itself very rare Prognosis is poor Benign variety occurs in the joint capsule around knee DDX:
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Tumoral calcinosis
LearningRadiology.com - Left ventricular aneurysm,ventricle
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q q
Congenital left ventricular aneurysm r Rare r Young, Black adult s Submitral type q Bulge at left middle / upper cardiac border s Subaortic type q Small and not visualized q Heart greatly enlarged (from aortic insufficiency) Acquired left ventricular aneurysm r Overwhelming majority are secondary to ischemic heart disease and myocardial infarction r May be asymptomatic and well tolerated for years True aneurysms r Remnants of myocardium within its walls r Consequence of transmural myocardial infarction r Wide-open neck r Rarely rupture False aneurysms (pseudoaneurysms) r Surrounded by tissue other than myocardium, such as pericardium or pleura r Usually the result of localized rupture of the heart r Most often involve posterolateral wall of LV r They themselves more often rupture than true aneurysms r Neck is narrow r Often contain clot Other causes of ventricular aneurysm r Trauma r Postoperative s Frequently involve the right ventricle r Rheumatic heart disease r Mycotic aneurysms Large majority due to infarction of the left ventricle or ventricular septum r Most are on anterior wall Anterior inferior part of septum most susceptible and most frequent site of rupture Aneurysm frequently contains clot and/or organized thrombus
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Portions may break away and embolize systemically Compatible with a long survival May cause r LV failure r Cardiac arrythmias r Embolus Majority of false aneurysms are from trauma and post-surgical Imaging r Conventional chest films can not exclude the presence of a cardiac aneurysm r Unusual bump on the left side of the heart s Most common manifestation on plain film s Has a short-radius of curvature s Usually in the lower 2/3 of the left ventricular curve
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Localized "bump" along mid-left heart border suggests presence of a left ventricular aneurysm
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DDX Cardiac tumors q Enlarged left atrium q Pericardial cysts r Uncommon on left side q Thymomas Calcium in wall of aneurysm or thrombus q Uncommon q Curvilinear q Almost always several millimeters below the exterior surface of the heart q Infarcts without an aneurysm may calcify Localized paradoxical expansion during systole Almost all are seen with radionuclide ventriculography Left ventriculography is diagnostic
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Cooley and Schreiber-Radiology of the Heart and Great Vessels-3rd Edition Dahnert 4th edition
LearningRadiology.com - Prepatellar bursitis,Housemaid's knee
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Prepatellar Bursitis
"Housemaid's Knee"
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Anatomy r Prepatellar bursa is superficial bursa r Thin synovial lining r Located between skin and patella r Main function is to separate patella from patellar tendon and skin r Normally does not communicate with joint r Contains minimal amount of fluid Inflammation of prepatellar bursa results in marked increase of fluid in bursa Incidence of prepatellar bursitis greater in males than females Causes r Direct trauma (eg, a fall on patella or direct blow to knee) s If acute, frequently due to small blood vessel rupture r Repetitive minor injuries (eg, repeated kneeling) r Septic or pyogenic process s Infection usually from Staphylococcus aureus from break in skin s More prevalent in children s Can be mistaken for pyogenic arthritis r Crystal deposition (eg, gout, pseudogout) r Occupation s Carpet layer s Wrestlers s Coal miner s Roofer s Plumber s Homemaker (housemaid's knee) Clinical findings r Knee pain r Swelling r Redness r Difficulty walking
http://www.learningradiology.com/archives04/COW%20116-Housemaid's%20knee/housemaidscorrect.htm (1 de 5)04/09/2006 2:26:19
Relief of pain with rest r History of repetitive motion r History of occupation requiring excessive kneeling r History of a fall on knee or blunt trauma to knee Physical findings r Patella tender to palpation r Fluctuance over lower pole of patella r Erythema r Crepitation r Decreased ROM Imaging Studies r Plain radiographs s Soft tissue swelling s Calcification q Especially if hemorrhage into bursa
r
Frontal and lateral radiographs of both knees demonstrate multiple, punctate calcifications in the pre- and infrapatellar region
r
Computed tomography (CT) scan and magnetic resonance imaging (MRI) s Complex fluid collection anterior to knee in region of prepatellar bursa
Wall of bursa my be thickened and irregular Treatment r NSAIDs r Cortisone injection r Aspiration of bursa r Surgical removal of bursa r Kneepad r Has high recurrence rate
s
Kelly Allen, MD eMedicine.com
LearningRadiology.com - Emphysematous pancreatitis,pancreatitis
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Emphysematous Pancreatitis
q q
q q q
Severe complication of acute pancreatitis Pathophysiology of pancreatitis is a chain of events that result from blockage of the pancreatic duct with subsequent release of pancreatic enzymes into the interstitium of the gland r Most common etiologies of acute pancreatitis are cholelithiasis and alcoholism If necrosis occurs, it tends to occur early in course of disease Diagnosis depends upon clinical presentation and presence of gas in retroperitoneum Diagnosis of necrosis r Focal or diffuse r Well-marginated r Area of parenchymal non-enhancement r >3cm r Infected pancreatic necrosis recognized at helical CT as s Bubbles of gas within areas of pancreas s Or, collection of gas and tissue within the retroperitoneum
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Axial, enhanced CT scans of the upper abdomen show extensive gas in the region of the body and tail of the pancreas with infiltration of the peripancreatic fat
q
E. Coli can infect necrotic pancreas r Produces gas in body of pancreas and retroperitoneum Emphysematous pancreatitis warrants r Early use of antibiotics r Percutaneous drainage of fluid collections r If no response s Surgical resection of infected necrotic tissue Carries grave prognosis
LearningRadiology.com - Aortic Stenosis, Calcified, congenital, aorta, valve
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Aortic Stenosis
Types
Congenital aortic stenosis (more common) o Most frequent CHD associated with IUGR Subvalvular (30%) Valvular (70%) Degeneration of bicuspid valve Supravalvular Acquired aortic stenosis o Rheumatic valvulitis Almost invariably associated with mitral valve disease o Fibrocalcific senile aortic stenosis Degenerative
Clinical Findings
Asymptomatic for many years Classical triad o Angina o Syncope o Shortness of breath (heart failure) Systolic ejection murmur Carotid pulsus parvus et tardus Diminished aortic component of 2nd heart sound Sudden death in severe stenosis after exercise o Diminished flow in coronary arteries causes ventricular dysrhythmias and fibrillation o Decompensation leads to LV dilatation and pulmonary venous congestion
Imaging Findings
In children / young adults
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Prominent ascending aorta 1. Poststenotic dilatation of ascending aorta Due to turbulent flow o Left ventricular heart configuration 2. Normal-sized or enlarged LV (small LV chamber with thick walls) In adults >30 years o Calcification of aortic valve (best seen on RAO) 3. Indicates gradient >50 mm Hg 4. Enlarged ascending aorta 2 post-stenotic dilatation 2 turbulent flow o Discrete enlargement of ascending aorta (NO correlation with severity of stenosis) o Normal to enlarged left ventricle o
Echocardiographic findings
q
q q q q q q q q q
Thickened and calcified aortic valve with multiple dense cusp echoes throughout cardiac cycle (right > noncoronary > left coronary cusp) Decreased separation of leaflets in systole with reduced opening orifice (13-14 mm = mild AS; 8-12 mm = moderate AS; <8 mm = severe AS) Doming in systole Dilated aortic root Increased thickness of LV wall (= concentric LV hypertrophy) Hyperdynamic contraction of LV (in compensated state) Decreased mitral EF slope (reduced LV compliance) LA enlargement Increased aortic valve gradient (Doppler) Decreased aortic valve area (unreliable) DDx r Calcification of aortic annulus in elderly r Calcified coronary artery ostium (thickened cusp echoes only in diastole) Prognosis r Depends on symptomatology (angina, syncope, CHF)
X-Ray Findings
q q
q q
Normal heart size Prominent ascending aorta r Projects farther to right than right heart border (right atrium) Normal pulmonary vasculature Calcification of the aortic valve
o In females, calcification of valve usually indicates a hemodynamically significant degree of aortic stenosis
o
Calcification of the valve usually indicates a gradient across valve of > 50mm Hg
Frontal radiograph of the chest demonstrates a prominent ascending aorta (red arrow), normal sized heart and normal pulmonary vasculature. The ascending aorta projects farther to the right than the right heart border, which is abnormal. On the lateral view, there is calcification of the aortic valve (blue circle)
q
q q
Simultaneous LV and aortic pressures recordings yield valve gradients from left heart catheterization Angiographic technique uses standard RAO left ventriculogram and an aortogram using a 40 LAO projection A non-calcified, bicuspid valve reveals thickening and doming of the valve leaflets in systole A jet of non-opacified blood is visible through stenotic valve
o Congenitally bicuspid valves still usually have three aortic sinuses with one large noncoronary sinus equal in size to the other two o Calcification begins in the bicuspid and rheumatic valve in the 4th decade but not until >65 in tricuspid o In rheumatic disease, the aortic valve commissures usually fuse whereas they do not in the degenerated tricuspid valve
Differentiating Causes of Valvular Aortic Stenosis
Etiology/Findings Congenital Bicuspid Valve Degeneration of Tricuspid Valve Rheumatic dz in Tricuspid Valve 30s > 65
Calcification
Other clues Jet effect on aortogram Coronary artery ca++ Commissures dont fuse MS or MR almost always present; commissures fuse
30s here; teens in 3rd world countries
Valve areas
Normal
2
Mild 1.3-1.7
Severe 1.0
Critical 0.5
2.6-3.5cm
Dahnert 4th edition
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LearningRadiology.com - Arteriovenous malformation, AVM,areterial,venous
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Cerebral Arteriovenous Malformations

Anthony Chang, MD
q q q q
True AVMs contain at least one enlarged feeding artery and at least one enlarged early draining vein These vessels arise congenitally during fetal life and can be supplied from any cerebral vessel Superficial AVMs may be supplied from the external carotid artery with a dural component. The AVM complex begins with the dilated feeding artery to the core/nidus (vascular cluster of entangled vessels) to enlarged draining veins CT findings r Vascular tangles are serpiginous and hyperdense without contrast from the blood pool effect. r AVMs may contain punctate or curvilinear calcification. r AVMs will enhance
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Unenhanced and enhanced axial CTs of brain shows a large, serpiginous AVM adjacent to the tentorium
MRI findings r Curvilinear flow voids r MRA for mapping Angiogram

r
Should demonstrate the three components of the enlarged feeding artery, core/nidus, and enlarged draining vein. Smaller AVMs may simple demonstrate early venous filling during the arterial phase of enhancement
Associated syndromes r Sturge Weber r Wyburn Mason r Klippel-Trenaunay-Weber r Osler Weber Rendu Complications r Hemorrhage r Steal phenomenon where blood supply is preferentially delivered to AVM at the cost of normal brain parenchyma and can lead to focal neurological symptoms, seizure and focal atrophy. r Aneurysms can form and become a source of hemorrhage Treatment r Endovascular embolization r Surgery r Radiation therapy
The Requisites: Neuroradiology 2nd edition, Grossman and Youssem
LearningRadiology.com - Osteochondritis dissecans,osteochondrosis,osteonecrosis,knee,loose body,joint mice,mouse
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Osteochondritis Dissecans
q q
Sub-articular, post-traumatic necrosis Occurs only on convex surfaces of bone Medial condyle of femur r Capitellum r Proximal surface of talus st metatarsal r Head of 1 Most patients are athletic Direct blow is more common cause than a rotational injury
r
q q
Knee lesions are more common amongst high jumpers Most common cause of an intra-articular loose body
r
Osteochondritis dissecans of medial femoral condyle-ovoid fragment of bone is separated from surface of condyle but does not yet lie freely within the joint
http://www.learningradiology.com/archives04/COW%20120-Osteochondritis/osteochondritiscorrect.htm (1 de 4)04/09/2006 2:26:34

q q
In adults, loose body contains larger fragment of cartilage than bone Possible outcomes
r
Death of bony, but not cartilaginous, portion of loose body Loose body is invisible except to MRI Complete resorption of loose body Reincorporation or regrowth
s s
r r
Usually not in adults s In children, fragment is less likely to separate from bone and therefore more likely to reincorporate Cause of a locking knee
LearningRadiology.com - Hypertrophic Osteoarthropathy,hypertrophic pulmonary osteoarthropathy,pulmonary,osteoarthropathy
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Hypertrophic Osteoarthropathy
Etiology r Unknown
Presents clinically as an arthritis with painful and swollen joints Can occur as a primary and secondary form q Primary form also know as pachydermoperiostitis q May include periostitis, clubbing, thickening of the skin q Involves hands q Familial q More common in males q Onset in adolescence with remission in adulthood
q q
Thoracic Causes r Malignant tumor (0.7-12%) s bronchogenic carcinoma (88%) s mesothelioma s lymphoma s pulmonary metastasis from q osteogenic sarcoma q melanoma q renal cell carcinoma q breast cancer r Benign tumor s benign pleural fibroma s tumor of ribs s thymoma s esophageal leiomyoma s pulmonary hemangioma s pulmonary congenital cyst r Chronic infection / inflammation s pulmonary abscess s bronchiectasis s Blastomycosis
http://www.learningradiology.com/archives04/COW%20121-Hypertrophic%20Osteoarthropathy/hpocorrect.htm (1 de 5)04/09/2006 2:26:35
TB (very rare) s cystic fibrosis s interstitial fibrosis r Congenital heart disease with R-to-L shunt Extrathoracic Causes r GI tract s ulcerative colitis s amebic + bacillary dysentery s intestinal TB s Whipple disease s Crohn's disease s gastric ulcer s bowel lymphoma s gastric carcinoma r Liver disease s biliary and alcoholic cirrhosis s posthepatic cirrhosis s chronic active hepatitis s bile duct carcinoma s benign bile duct stricture s amyloidosis, s liver abscess r Undifferentiated nasopharyngeal carcinoma r Pancreatic carcinoma r Chronic myelogenous leukemia Clinical Findings r Pain and swelling about the joints simulating an arthritis r Joints involved s ankles (88%) s wrists (83%) s knees (75%) s elbows (17%) s shoulders (10%) s fingers (7%) r Peripheral neurovascular disorders s local cyanosis s areas of increased sweating s paresthesia s chronic erythema s flushing + blanching of skin r Clubbing r Hypertrophy of extremities (soft-tissue swelling) Location r tibia + fibula (75%) r radius + ulna (80%) r proximal phalanges (60%), femur (50%) r metacarpus + metatarsus (40%), humerus + distal phalanges (25%) r pelvis (5%) r unilateral (rare)
s

q
Imaging Findings r In diametaphyseal regions s Periosteal proliferation of new bone q Symmetrical q Widespread
Frontal and lateral radiograph of the distal femur shows a thick, wavy periosteal reaction that involves the diaphysis but spares the epiphysis
r
r r r
q
Bone scan reveals changes early with greater sensitivity s Symmetric diffusely increased uptake along cortical margins of diaphysis and metaphysis of tubular bones of the extremities with irregularities Increased periarticular uptake (from synovitis) Scapular involvement in 2/3 Mandible maxilla abnormal in 40%
Thoracotomy can lead to immediate clinical remission; radiolographic remission follows
Dahnert 5th Edition
LearningRadiology.com - Pneumothorax, Deep Sulcus Sign
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Pneumothorax
Presence of air in the pleural space r Anatomy s Visceral pleura is adherent to lung surface s There is no air in the pleural space normally s The introduction of air into the pleural space separates the visceral from the parietal pleura q In contradistinction, the visceral and parietal pleura usually do not separate from each other in obstructive atelectasis Pathophysiology r Either from disruption of visceral pleura r Or, trauma to parietal pleura Clinical findings r Acute onset of s Pleuritic chest pain s Dyspnea (in 80-90%) s Cough s Back or shoulder pain Etiologies r Penetrating trauma r Blunt trauma s May be due to rib fracture s May be caused by increased intrathoracic pressure s May lead to bronchial rupture q Fallen lung sign (ptotic lung sign) -- hilum of lung is below expected level within chest cavity q Persistent pneumothorax with functioning chest tube r Iatrogenic s Tracheostomy s Central venous catheter attempt or insertion s Mechanical ventilation q May occur in up to 25% of patients maintained on PEEP
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May be bilateral or under tension s Thoracic irradiation Spontaneous pneumothorax s Most common etiology s Cause q Rupture of subpleural blebs in apical region of lung s Age q 20-40 years q M:F = 8:1 q Especially in patients who are tall and thin q Smokers s Prognosis q Recurrence in 30% on same side q Recurrence in 10% on contralateral side s Treatment q Simple aspiration (success in >50%) q Tube thoracostomy (effective in 90%) Other causes of a pneumothorax s Neonatal disease q Meconium aspiration q Respirator therapy for hyaline membrane disease s Malignancy q Primary lung cancer q Lung metastases, especially from osteosarcoma r Also pancreas, adrenal, Wilms tumor s Pulmonary infections q Tuberculosis q Necrotizing pneumonia q Coccidioidomycosis q Hydatid disease q Pertussis q Acute bacterial pneumonia q Staphylococcal septicemia q AIDS (Pneumocystis carinii, Mycobacterium tuberculosis, atypical mycobacteria) s Complication of pulmonary fibrosis q Histiocytosis X q Idiopathic q Cystic fibrosis q Sarcoidosis q Scleroderma q Eosinophilic granuloma q Interstitial pneumonitis q Rheumatoid lung q Idiopathic pulmonary hemosiderosis q Pulmonary alveolar proteinosis q Biliary cirrhosis s Asthma or emphysema q Produce a second peak incidence of pneumothorax from 45-65 years of age
q
Due to rupture of peripheral emphysematous areas s Catamenial pneumothorax is a recurrent spontaneous pneumothorax that occurs during menstruation and is associated with endometriosis of the diaphragm q R >> L s Marfans syndrome s Ehlers-Danlos syndrome s Pulmonary infarction s Lymphangiomyomatosis and tuberous sclerosis q Incidence of pneumothorax is particularly high in lymphangiomyomatosis and histiocytosis X Types of pneumothorax r Closed pneumothorax = intact thoracic cage r Open pneumothorax = "sucking" chest wound r Tension pneumothorax s Accumulation of air within pleural space due to free ingress and limited egress of air s Pathophysiology: q Intrapleural pressure exceeds atmospheric pressure in lung during expiration (check-valve mechanism) s Frequency q In 3-5% of patients with spontaneous pneumothorax q Higher in barotrauma (mechanical ventilation) r Simple pneumothorax no shift of the heart or mediastinal structures Imaging findings in pneumothorax r Must see the visceral pleural white line s Very thin white line that differs from a skin fold by its thickness r Absence of lung markings distal or peripheral to the visceral pleural white line s Not evidence enough to say there is a pneumothorax only if there are no lung markings seen q No lung markings will be seen with bullous disease q Bullae have a concave surface facing the chest wall r Pneumothorax almost always has a convex surface facing the chest wall r Displacement of mediastinum and/or anterior junction line r Deep sulcus sign s On frontal view, larger lateral costodiaphragmatic recess than on opposite side s Diaphragm may be inverted on side with deep sulcus
q
Lucency at left costophrenic angle which projects well below the costophrenic angle on the opposite side is the "Deep sulcus sign" indicating the presence of a pneumothorax on a supine radiograph of the chest (Bullet is seen overlying the heart)
r
r r
Total / subtotal lung collapse s This is passive or compressive atelectasis Collapse of SVC or IVC due to decreased systemic venous return and decreased cardiac output Tension hydropneumothorax s Sharp delineation of visceral pleural by dense pleural space s Mediastinal shift to opposite side s Air-fluid level in pleural space on erect chest radiograph Radiographic signs in upright position r White margin of visceral pleura separated from parietal pleura r Usually seen in the apex of the lung r Absence of vascular markings beyond visceral pleural margin r May be accentuated by an expiratory film in which lung volume is reduced while amount of air in pneumothorax remains constant so that relative size of pneumothorax appears to increase Radiographic signs in supine position r Anteromedial pneumothorax (earliest location) r Outline of medial diaphragm under cardiac silhouette r Deep sulcus sign s Decubitus views of the chest may demonstrate a pneumothorax on the side that is nondependent q Left lateral decubitus view for right-sided pneumothorax q Right lateral decubitus view for left-sided pneumothorax Subpulmonic pneumothorax (second most common location) r Hyperlucent upper abdominal quadrant r Deep lateral costophrenic sulcus r Sharply outlined diaphragm in spite of parenchymal disease r Visualization of anterior costophrenic sulcus
Visualization of inferior surface of lung Apicolateral pneumothorax (least common location) r Visualization of visceral pleural line Posteromedial pneumothorax (in presence of lower lobe collapse) r Lucent triangle with vertex at hilum r V-shaped base delineating costovertebral sulcus r Pneumothorax outlines pulmonary ligament Pitfalls in diagnosis r Skin fold s Thicker than the thin visceral pleural white line r Air trapped between chest wall and arm s Will be seen as a lucency rather than a visceral pleural white line r Edge of scapula s Follow contour of scapula to make sure it does not project over chest r Overlying sheets s Usually will extend beyond the confines of the lung r Hair braids Prognosis r Resorption of pneumothorax occurs at a rate of 1.25% per day (accelerated by increasing inspired oxygen concentrations)
r
Thoracic Radiology: The Requisites Dahnert 4th Edition
LearningRadiology.com - Locked facet,facets,cervical spine,injury,dislocation
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Hyperflexion Injuries Locked Facets

q
Normal anatomy r Posterior ligamentous complex s Supraspinous ligament s Interspinous ligament s Posterior longitudinal ligament s Capsule of the facet joint r Normal relationship of facets
Normal relationships of facet joints Inferior articulating facet of body above (blue arrow) lies posterior to superior facet of body below (red arrow)
q
http://www.learningradiology.com/archives04/COW%20123-Locked%20facets/lockedfacetscorrect.htm (1 de 6)04/09/2006 2:26:40

r
Mechanism is flexion/distraction s Injury is to the posterior spinal ligamentous complex s Unstable in flexion; stable in extension s If unrecognized, can lead to progressive neurologic damage Imaging Findings s Widening of the interspinous distance s Slight anterior subluxation of one vertebral body on another s Widening of the facet joint q Usually the posterior aspect s Disk space narrower anteriorly than posteriorly
Posterior ligamentous structures involved in flexion injury are (a) supraspinous ligament (b) interspinous ligament (c) facet joint capsule (d) posterior longitudinal ligament From Seminars in Roentgenology, Jan 1978 John H. Harris, Jr.
Sharp angle kyphosis Degrees of ligamentous injury r Subluxation of vertebral body r Perched facet r Locked facets s At least 50% subluxation Unilateral Locked Facet r Mechanism is flexion/distraction and rotation s Only 30% associated with neurologic defect r Most often occurs at C4-5 and C5-6 r Inferior articular facet of superior vertebral body is locked in front of the superior facet of the more inferior vertebral body but only on one side r Imaging Findings s Subtle s Slight anterior subluxation of one vertebral body on the one below
s
Usually less than 25% of the width s On lateral view of cervical spine, some bodies appear true lateral below level of injury and oblique above level of injury s Bow-tie sign s Spinous processes do not align on frontal film q Spinous processes of inferior vertebrae displaced toward the locked side Bilateral Facet Dislocation r Severe flexion injury r Both anterior and posterior ligamentous structures are disrupted at site of injury r More superior vertebra subluxes forward by 50% or more of the body below r Usually occurs in lower cervical spine
q
Body of C4 is subluxed anteriorly on C5. The inferior facet of C4(blue arrow) lies anterior to the superior facet of C5 (red arrow). See normal relationship above
r r
May have associated fractures of the laminae and vertebral arch Quadriplegia frequently develops s If there is a fracture through posterior elements, less chance of neurologic injury as cord can decompress 85% neurologic deficits with locked facets
Seminars in Roentgenology, Jan 1978 Emergency Medicine Clinics of North America, August 1965
LearningRadiology.com - Gas,gallstone,gallstones,air,Mercedes-Benz,sign
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Gas in Gallstones
q q
q q q
Approximately 20 million Americans have gallstones Gallstones are twice as common in women as in men r Up to 55% of adult women were found to have gallstones at autopsy in some studies Gallstone prevalence increases with age In USA, 80% of gallstones are predominantly cholesterol and 20% are pigment stones Classification of gallstones r Pure cholesterol stones s Contain more than 90% cholesterol r Mixed cholesterol stones s Composed of > 50% cholesterol s Usually smaller than pure cholesterol stones s Often faceted and multiple r Pigmented stones s Unconjugated bilirubin carbonate and phosphate q Black in color s Unconjugated bilirubin monomers as well as cholesterol and calcium salts of fatty acids q Brown pigment stones q Commonly large q Assumed to be caused by primary infection of bile Imaging Findings r Plain films s About 10-20% of gallstones sufficiently calcified to be visible on abdominal films s Gallstones are usually round or oval in shape in right upper quadrant s Multiple stones may show flattened sides called faceted stones s "Mercedes Benz" sign is a triradiate collection of nitrogen gas q Fills crevices created by shrinkage of cholesterol crystals in the stone q Radiolucent fissures usually widest centrally radiating like points of star
http://www.learningradiology.com/archives04/COW%20124-Gas%20in%20gallstones/gallstonegascorrect.htm (1 de 5)04/09/2006 2:26:51
CT of the abdomen demonstrates two radiolucencies in gallbladder (top image) and an additional lucency in the gallbladder on the lower image
Mercedes-Benz Hood Ornament

r
Ultrasound s The procedure of choice for gallstone diagnosis q 95% accuracy of detection r Moveable, discrete, echogenic foci within the dependent portion of the gallbladder r Acoustical shadowing emanating directly below the echogenic foci r Stones usually sink to dependent portions of gallbladder s Cholesterol stones may float CT s CT is superior to ultrasound for demonstration of calcification and of fissures in gallstones. s Noncalcified stones may be difficult to detect s CT is still more sensitive than plain film s Noncalcified stones may be recognized as subtle areas of slightly lower or higher attenuation within the bile
Well-calcified stones are shown easily on CT q Stones that have attenuation equal to bile may remain invisible q Cholesterol stones usually have an attenuation value that is lower than bile r Visible on CT as hypo-attenuating structures Differential diagnosis r Gross collections of gas that may occur in a subhepatic or liver abscess r Emphysematous cholecystitis r Gas in biliary ductal or portal venous system r Gas in an abscess in right kidney
s
Amersham The Encyclopaedia of Medical Imaging Volume IV:1
LearningRadiology.com - Gastric,volvulus,volvulous,stomach,twist,image,volvulus.jpg
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Gastric Volvulus
q q
Uncommon r May occur in children due to congenital diaphragmatic defects r In adults, rarely occurs before age 50 s Most common cause of gastric volvulus in adults are diaphragmatic defects Stomach twists on itself Etiologies r Abnormality of the suspensory ligaments of the stomach s Gastrohepatic s Gastrosplenic s Gastrocolic s Gastrophrenic r Unusually long gastrocolic and gastrohepatic mesentery Classified as one of two types--organoaxial or mesenteroaxial
Type
Appearance
Description
Remarks
Most common type. Twist occurs along a Usually associated line connecting the with diaphragmatic cardia and the pylorus-defects. the luminal (long) axis of the stomach Vascular compromise more common.
Organoaxial
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Mesenteroaxial
Twist occurs around a plane perpendicular to the luminal (long) axis of the stomach from lesser to greater curvature
Chronic symptoms more common. Diaphragmatic defects less common.
Almost always occur with large diaphragmatic hernia like hiatal hernia r Especially, paraesophageal hiatal hernias s In paraesophageal hernias, gastroesophageal junction remains in abdomen while stomach ascends adjacent to the esophagus s Produces upside-down-stomach s Gastric volvulus is most common complication of paraesophageal hernias r Also occurs with eventration of the diaphragm r Paralysis of diaphragm Despite abnormal placement of stomach, it usually does not become obstructed r Sometimes called partial volvulus or torsion or chronic volvulus r Twisting up to 180 degrees may cause no obstruction r Twisting beyond 180 degrees almost always produces obstruction Clinical findings r Unless acute, patients are frequently asymptomatic r When acute and obstructing s Abdominal pain s Attempts to vomit without results s Inability to pass an NG tube s Together, these three findings comprise the Borchardt triad which is diagnostic of acute volvulus q Reportedly occurs in 70% of cases Imaging findings r Massively dilated stomach in LUQ possibly extending into chest r Inability of barium to pass into stomach (when obstructed)
Frontal radiograph from an upper GI examination shows the stomach located in the lower chest in a large hiatal hernia. The greater curvature of the stomach lies superior to the lesser curvature in an organoaxial twist. Note that the stomach is not obstructed.
q
Treatment r Surgery in acute gastric volvulus r In patients with chronic gastric volvulus, surgery is performed to prevent complications s Nonoperative mortality rate = as high as 80% s Mortality rate from acute gastric volvulus = 15-20% s Mortality rate from chronic gastric volvulus ranges up to 13% Complications r Gastric emphysema r Twisting of stomach may tear spleen from its normal attachments r Perforation is rare
q q q
Margulis and Burhenne-Alimentary Tract Roentgenology 2nd Ed, Vol. 1 Dahnert 4th edition eMedicine Gastric Volvulus by Mohamed Akoad, MD and Richard Golub, MD
LearningRadiology.com - Perforated pharynx,pharyngeal,rupture,foreign body,tear,retropharyngeal,air,gas,abscess,hematoma
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Retropharyngeal Air
q
Causes r Trauma to esophagus or trachea s Penetrating injuries from weapons s Perforation from within q Chicken bone r Mediastinal emphysema which tracks up into neck r Retropharyngeal abscess from gas-forming organism Clinical findings r Dysphagia r Odynophagia r Neck tenderness r Crepitus r Hematemesis Imaging findings r Streaks of air in the soft tissues of the neck r Anterior displacement of the pharynx r Associated pneumothorax possible
http://www.learningradiology.com/archives04/COW%20126-Perforated%20pharynx/perfpharynxcorrect.htm (1 de 4)04/09/2006 2:26:53
Streaky lucencies seen behind the airway represents retropharyngeal air which in this case was secondary to perforation of the cervical esophagus by a chicken bone
r q
Cervical or mediastinal air is seen in 60% of cases of ruptured esophagus Treatment r If hemodynamically stable, watch r If hemodynamically unstable, emergent surgery
LearningRadiology.com - Lipohemarthrosis,fat-fluid,hemorrhage,fracture
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Lipohemarthrosis
q q q
Mixture of fat and blood in joint capsule following trauma Lipohemarthroses occur in approximately 40% of all intra-articular fractures of the knee May take up to 3 hours after trauma to appear r Gravity and a period of rest are needed to depict fluid-fluid layer which is characteristic of lipohemarthrosis Fat and blood enter joint from marrow space through an osteochondral defect at articular surface of joint r Fat is less dense than blood so fat floats on the surface with the heavier, denser blood beneath it r Can only be seen with a horizontal x-ray beam (beam is parallel to the floor) CT and MRI have been used to diagnose lipohemarthrosis r Also to identify occult fractures not detected by radiography Lipohemarthrosis is not seen in all cases of intracapsular fracture r Presence of a fat-fluid level is nearly diagnostic of a fracture, even when that fracture is radiographically occult
http://www.learningradiology.com/archives04/COW%20127-Lipohemarthrosis/lipohemarthrosiscorrect.htm (1 de 5)04/09/2006 2:26:59
Upper image shows fat floating atop blood in the knee joint; the lower image demonstrates a markedly comminuted fracture of the proximal tibia (white arrows) from which the marrow entered the joint
q
Knee joint r Most commonly, lipohemarthroses are produced with minimally displaced fractures of the tibial plateau r Since cross-table lateral views of the knee in which the x-ray beam is horizontal are commonly performed in trauma patients, lipohemarthroses are more commonly seen with this joint Three bands can sometimes be distinguished r The top band consists of fatty material r The next band below is composed of serum and serous joint effusion r Cellular parts of blood, i.e., erythrocytes and leukocytes settle to the bottom layer due to
gravity
From "The CT, MRI, and Radiographic Appearance of Lipohemarthrosis" Sorenson SM, Wolfson K, Gentile A, Mash S, Seeker LL UCLA School of Medicine AJR On-Line From "Lipohemarthrosis of the knee: specific imaging findings" Christoph Schick Martin G. Mack Ingo Marzi Thomas J. Vogl European Radiology
LearningRadiology.com - Coarctation of the Aorta,Aorta,coarctation
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Coarctation Of the Aorta

l
General o 2X more common in males Common classification

o o Infantile or preductal form Adult or juxtaductal form
Adult Form o Adult or juxtaductal (postductal) form is more common o Usually localized o Area of coarctation is just beyond the origin of LSCA at level of ductus l Infantile Form o Infantile, preductal form = diffuse type o Long, tubular segment of narrowed aorta
l
From just distal to innominate to level of ductus
o
l
Intracardiac defects (VSD,ASD, deformed mitral valve) present in 50% of diffuse type
Also patent ductus arteriosis
Other Classifications o More complicated classifications take following into account:

Location and length of coarct Patency of ductus arteriosis Relationship of coarct to ductus
Associated Defects o Bicuspid aortic valve (most common associated defect seen in 75-80%) o VSD o ASD o Transposition o Found in 25% of patients with Turners Syndrome l Shone Syndrome o Coarctation o Aortic stenosis
l
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o Parachute mitral valve o Supravalvular mitral ring l Imaging findings
Coarctation of the aorta. See photo below for labeled close-up of upper thorax. Click here or on photo to enlarge.
Rib Notching Single best sign Older the person, more likely to have rib notching Majority have it over 20 years of age Rib notching occurs in the high pressure circuit Most often involves 4th-8th rib
Sometimes may involve 3rd and 9th
Does not involve 1st and 2nd ribs

Intercostals come off costocervical trunk and do not supply collateral flow to descending aorta
4th-8th do anastomose with internal mammary to form collaterals for descending aorta Rib NotchingUnilateral Isolated Right sided notching occurs when LSCA is involved in actual coarctation Isolated Left sided notching can occur if there is an aberrant RSCA which
o o
arises from below coarct Figure 3 Sign Caused by (in order) either a dilated LSCA or aortic knob, tuck of coarct itself, and poststenotic dilatation Occurs in 1/31/2 of patients with coarct Matched by reverse 3 or E on barium-filled esophagus Convexity of left side of mediastinum just above aortic knob 2 to dilated LSCA Convexity of ascending aorta in 1/3
Close up of upper thorax in a patient with Coarctation of the Aorta. The red arrows point to rib notching caused by the dilated intercostal arteries. The yellow arrow points to the aortic knob, the blue arrow to the actual coarctation and the green arrow to the post-stenotic dilation of the descending aorta. Click here for same photo without labels.
Clinical FindingsInfancy o Severe CHF most common from 2nd to 6th week of life o Weak or absent leg pulses o Lower BP in the legs than in the arms o EKG RV hypertrophy because RV assumes most of the cardiac output during fetal life in these patients l Clinical Findings-Children and Adults o Differential pulses in arms (bounding) and legs (weak) o EKG LVH l Echocardiographic Findings
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o 2D echo can demonstrate coarcts from suprasternal notch o Echo is most helpful in excluding associated hypoplastic left heart syndrome l Complications o Heart failure in neonate o Subarachnoid bleeds from ruptured Berry aneurysms o Dissection of aorta o Infective endocarditis o Mycotic aneurysm
LearningRadiology.com - Complications of ETT,endotracheal,tube,atelectasis
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Complications of Endotracheal Tubes
Radiographs are obtained routinely after intubation r Endotracheal tube (ETT) is recognized by thin white opaque line usually running the length of the tube Position of carina r Follow right or left main stem bronchus backwards until it meets opposite main stem bronchus r Projects over T5, T6 or T7 in 95% of cases Movement of tip with flexion and extension r Neck flexion may cause 2 cm of descent of tip of tube r Neck extension from neutral may cause 2 cm of ascent of tip With head in neutral position (i.e., bottom of mandible is over C5-C6), tip of ETT should be 5-7 cm from carina r About half the distance between the medical ends of clavicles and carina Ideally tube should be to 2/3 width of trachea r Cuff should fill, but not bulge, the lumen of the trachea Malpositions of the tube r Occurs about 15% of all intubations with emergency intubation having highest rate r Intubation of the esophagus can be recognized by marked gastric distension r Tip of tube too deep s About 10% of ETT are initially placed in the right main stem bronchus s With time, the left lung becomes atelectatic q If on ventilator, the right lung may be hyperinflated r May lead to pneumothorax or tension pneumothorax s If tip is in bronchus intermedius, RUL will also become atelectatic along with all of left lung
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Tip of endotracheal tube (red arrow) projects below the carina (blue arrow) into the bronchus intermedius on the right. Click here to same image without arrows
r
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Tip of tube too shallow s Tip should be at least 3 cm distal to cords s Edema of the nasal mucosa by an ETT may cause sinusitis s Tube in pharynx may cause gastric dilatation s Aspiration of gastric contents s Cuff inflated between the vocal cords may produce glottic edema which may progress to scarring Perforation of the pharynx or trachea by an ETT are uncommon r Think of it if pneumomediastinum or subcutaneous emphysema develop after a difficult intubation r Usually perforation occurs in the posterior pharyngeal wall or piriform sinuses r Inflation of cuff greater than 2.8cm should make one think of tracheal laceration Teeth, fillings or dentures may be dislodged at the time of intubation Atelectasis is the single most frequent cause of airspace disease in an intubated patient Long-term complications r Tracheal stenosis at tube tip or site of inflated cuff
Goodman, L and Putman, C: Intensive Care Radiology: Imaging of the Critically Ill W.B. Saunders, 1983 McCloud T: Thoracic Radiology: The Requisites Mosby, 1998.
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LearningRadiology.com - Emphysematous cholecystitis,gas,gallbladder,air,emphyematous,cholecystitis,gas-forming
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Emphysematous Cholecystitis
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Caused by gas-forming organism r In about 1/3 = clostridium perfringens r Also E. Coli and Klelbsiella Occurs more often in men r As opposed to gallbladder disease in general which occurs more often in women Mostly elderly patients (>60) with diabetes Vascular compromise of the cystic artery may play a role in the etiology Clinical findings r As with cholecystitis, right upper quadrant (RUQ) pain and tenderness r Leukocytosis r Jaundice is rare Gas may occur in the wall and/or the lumen r May spread to pericholecystic tissue r Rarely, gas may escape into the bile ducts s This is rare since cystic duct is usually occluded in cholecystitis Plain film findings r May show air in the wall or lumen US findings r Indistinct shadowing emanating from wall or lumen of gallbladder CT findings of (non-complicated) cholecystitis r Most common is gallbladder wall thickening >3mm, and r Cholelithiasis r Increased density of bile (>20 H) r Loss of clear definition of gallbladder wall r Pericholecystic fluid such as a halo of edema
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Emphysematous cholecystitis-red arrow points to air in lumen of gallbladder; green arrow points to thickened gallbladder wall; blue arrow points to pericholecystic stranding; yellow arrow points to pericholecystic fluid Click here for same photo without arrows
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Treatment r Preoperative Percutaneous drainage r Emergency cholecystectomy s Surgical mortality of 15-25% Complications r Fivefold increase in perforation than uncomplicated acute cholecystitis Perforation of the gallbladder

r r
Frequency is declining because of earlier diagnosis of acute cholecystitis Diagnosis s Pre-perforation plain film showing stones clustered in gallbladder may subsequently show stones scattered in RUQ after perforation s Pericholecystic fluid collection on CT or US (not-specific) s Scintography may show radiotracer outside of gallbladder in Morrisons pouch or flank Treatment s Preoperative percutaneous drainage of gallbladder and biloma s Emergency surgery
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Gore, R. and Levine, M: textbook of Gastrointestinal; Radiology, W.B. Saunders, 2000. Moss, A., Gamsu, G. and Genant, H.: Computed Tomography of the Body. W.B. Saunders,1992. Bloom, A. and Remy, P.: eMedicine; Emphysematous Cholecystitis
LearningRadiology.com - Pneumomediastinum,mediastinal,gas,air,asthma,complication,pneumomediastinal
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Pneumomediastinum
Air in the mediastinal space r Most common in infants r Rare in adults s Result of trauma q Rupture of esophagus q Rupture of airways Air in mediastinum originates from r Lung s Most common mechanism in neonates and adults q Begins with rupture of alveolus r Usually from increased intraparenchymal pressure q Air dissects back along perivascular sheaths to hilum and mediastinum s Air from ruptured bleb can also extend peripherally into pleural space q Pneumothorax s Most instances can be related to sudden rise in intrapulmonary pressure q Asthma q Vomiting q Valsalva maneuver q Artificial ventilation q Closed chest trauma q Sudden drop in atmospheric pressure r Mediastinal airways s Rupture of trachea or mainstem bronchus q Usually produced by accidental trauma r Esophagus
Rupture of the esophagus Boerhaaves Syndrome Can occur with
Vomiting q Labor q Severe asthmatic attacks q Strenuous exercise (each of these can produce pneumomediastinum without rupturing the esophagus) q Site of perforation r Left, posterolateral wall, distal 8 cm Imaging findings
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Combination of pneumomediastinum and left pleural effusion is very suggestive Continuous diaphragm sign of pneumomediastinum
Blue arrow points to "continuous diaphragm sign." The entire diaphragm is visualized from one side to the other because air in the mediastinum outlines the central portion which is usually obscured by the heart and mediastinal soft tissue structures that are in contact with the diaphragm. The red arrow points to the air beneath and posterior to the heart.
Click here for same photo without arrows.

s
Symptoms q Infants r None q Adults r Chest pain (retrosternal) radiating down both arms aggravated by respiration and swallowing
Neck
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Trauma to the neck s Air can track down onto mediastinum Imaging findings r Linear density parallel to heart border s Separated from heart by air r Also ring lucency around aorta or pulmonary artery s Ring around the artery sign r Dissection of air into neck is much less common in infants than adults r Dissection into chest wall much less common in neonates than older r Air can outline the central portion of the diaphragm r Continuous diaphragm sign Clinical Findings r Abrupt onset of retrosternal pain s Usually preceded by episode of vomiting s Pain is worse on inspiration s Dyspnea could be severe r Hammans sign crunching sound heard over the apex of the heart with cardiac cycle
Fraser and Pare: Diseases of the Chest; W.B. Saunders, 1994.
LearningRadiology.com - Right Aortic Arch,arch,right,aortic,mirror-image,aberrant,subclavian
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General r Most are asymptomatic s Unless they cause encircling vascular ring like pulmonary sling r Can be complex lesions requiring multiple projections s MRI or CT Left Aortic Arch With Anomalous Right Subclavian Artery (RSCA) r Occurs in less than 1% of people r RSCA passes posterior to esophagus r Pushes trachea and esophagus forward r Produces oblique shadow above aortic arch on frontal film r Origin of RSCA may be dilated s Diverticulum of Kommerell Right Aortic Arch r Types s At least five different types s Only two of importance q Mirror Image Type Type I q Aberrant left subclavian Type II r General s Recognized by leftward displacement of barium-filled esophagus s Of air-filled trachea s Aortic knob is absent from left side s Aorta descends on right s Para-aortic stripe returns to left side of spine just above diaphragm s Mirror-image type almost always has associated CHD q Usually Tetralogy of Fallot s Aberrant Left Subclavian type rarely has associated CHD q Most common variety of right arch r Type 1Mirror Image Type s Secondary to interruption of left arch just distal to ductus arteriosis s Associated with congenital heart disease 98% of time s X-ray Findings q No posterior impression on trachea or barium-filled esophagus q Heart is usually abnormal in size or shape q Aorta descends on right r Type llAberrant Left Subclavian s Secondary to interruption of left aortic arch between LCC and LSC arteries s Associated with cardiac defects 5-10% of the time q Tetralogy of Fallot most often (71%)
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s s s
ASD or VSD next most often (21%) Coarctation of aorta rarely (7%) Anomalous left subclavian artery (retroesophageal and retrotracheal) Aorta descends on right X-ray Findings q Posterior impression on trachea and barium-filled esophagus q Heart is usually normal in size and shape q Aorta descends on right
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Right aortic arch with aberrant left subclavian artery-Note aortic knob is on the right and the trachea is displaced toward the left instead of the right, as in normals. On the lateral film, note the trachea is bowed toward by the aberrant left subclavian artery which passes behind it
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If there is a mirror-image right aortic arch, then r 90% will have Tetralogy of Fallot r 6% with Truncus Arteriosis r 5% with Tricuspid Atresia If the person has the following lesions, then the association with a mirror-image arch is r Truncus arteriosis 33% r Tetralogy of Fallot 25% r Transposition 10% r Tricuspid atresia 5% r VSD 2% Double Aortic Arch r General s Most common vascular ring s Rarely associated with congenital heart disease q Vascular ring produces tracheal and/or esophageal compression s Caused by persistence of R and L IV branchial arches s Passes on both sides of trachea s Joins posteriorly behind esophagus s Right arch is larger and higher s Left arch is smaller and lower s Ba swallow shows bilateral impressions on frontal view q Posterior impression on lateral view s Angiogram is characteristic s Clinical
Symptoms may begin at birth and include r Tracheal compression, or r Difficulty swallowing s Anatomy q Right arch supplies RSCA and RCC q Left arch supplies LCC and LSCA s X-ray Findings q Right arch is higher and larger q Left arch is lower and smaller q Produces reverse S on esophagram on AP q On lateral, arches are posterior to esophagus and anterior to trachea Cervical Aortic Arch r General s Rare s Usually asymptomatic s May present as pulsating supraclavicular mass s May produce vascular ring and compress airway s Embryogenesis uncertain s Over 80% are right-sided r Imaging FindingsRight-sided lesions s Right-sided cervical aortic arches s Right apical mass-like density s Absence of aortic knob on left s Aorta descends on the left s Displace the trachea and esophagus forward s Branching may be normal or mirror-image r Imaging FindingsLeft-sided lesions s Left-sided cervical aortic arches s Aortic knob at apex of lung s Descend on the left s Do not displace the trachea or esophagus forward
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LearningRadiology.com - Ankylosing Spondylitis,AS,ankyloing,spondylitis
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Ankylosing Spondylitis
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Chronic inflammatory disease of unknown etiology primarily affecting spine Most common spondyloarthropathy r Age-young adults s 15-35 years r Mostly male s M:F = 4:1 r Mostly Caucasian s Caucasians to Blacks = 3:1 Clinical findings r Insidious onset of low back pain and stiffness r Poor chest expansion r Stiffness r Exaggerated dorsal kyphosis r HLA-B 27 positive in >90% Location r Axial skeleton and large, usually central, appendicular joints Sacroiliac joint involvement r Hallmark of disease r Only synovial portion of SI joint is involved s Inferior and anterior portion of joint q Other enthesopathies like DISH can cause bridging of upper, non-synovial part of joint r Usually site of initial involvement r Bilaterally symmetric r Widened with erosions at first r Then ankylosis Spine r Usually begins at either thoracolumbar or lumbosacral junctions s Extends symmetrically without skip areas q Reiters and psoriasis characteristically are asymmetric and have skip areas r Marginal syndesmophyte formation = thin vertical dense spicules bridging the vertebral
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bodies Ossification of outer fibers of annulus fibrosus q Not anterior longitudinal ligament Trolley-track sign on AP view = central line of ossification (supraspinous and interspinous ligaments) with two lateral lines of ossification (apophyseal joints) Bamboo spine on AP view = undulating contour due to syndesmophytes Prone to fracture resulting in pseudarthrosis Straightening / squaring of anterior vertebral margins s Osteitis of anterior corners Reactive sclerosis of corners of vertebral bodies = shiny-corner sign Symmetric erosions of laminar and spinous process at level of lumbar spine Apophyseal and costovertebral ankylosis Periosteal whiskering s Sites of tendinous insertion q Ischial tuberosity q Iliac crest q Ischiopubic rami q Greater femoral trochanter q External occipital protuberance q Calcaneus q Patella Dorsal arachnoid diverticula in lumbar spine with erosion of posterior elements Atlantoaxial subluxation
s
r r r
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Ankylosing spondylitis-Note fusion of both SI joints and thin, symmetrical syndesmophytes bridging the intervertebral disc spaces
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Peripheral joint involvement r Hip is most frequently involved r Concentric joint narrowing r Few erosions r Protrusio acetabuli Temporomandibular joint r Joint space narrowing r Erosions r Osteophytosis Hand (30%) r Target area s MCP, PIP, DIP r Exuberant osseous proliferation r Osteoporosis r Joint space narrowing r Osseous erosions (deformities less striking than in rheumatoid arthritis) Chest r Bilateral upper lobe pulmonary fibrosis (1%) with upward retraction of hila r Resembles tuberculosis Cardiovascular r Aortitis (5%) of ascending aorta aortic valve insufficiency s Prognosis: 20% progress to significant disability s Occasionally death from cervical spine fracture / aortitis DDx r Reiter syndrome (unilateral asymmetric SI joint involvement, paravertebral ossifications) r Psoriatic arthritis (unilateral asymmetric SI joint involvement, paravertebral ossifications) r Inflammatory bowel disease Associated with: r Ulcerative colitis r Regional enteritis s Clinically the SI joint involvement is identical to q Inflammatory Bowel Disease (IBD) r Iritis in 25% r Aortic insufficiency and atrioventricular conduction defect
The Requisites Dahnert 4th Edition
LearningRadiology.com - Renal,Infarction,Kidney,embolus,thrombus,thrombosis
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Renal Infarction
Thrombotic disease usually affects larger vessels r Includes main renal artery r Patients with thrombotic disease usually present with hypertension or renal insufficiency r Usually results from atherosclerosis s But, blunt abdominal trauma may cause intimal tears with subsequent dissection and thrombosis Emboli can affect vessels of various sizes depending on the size of the emboli r Renal artery emboli usually come from cardiac source r Embolic disease usually produces acute symptoms s Sudden onset of flank pain s Hematuria s Proteinuria s Fever s Leukocytosis Causes r Trauma s Blunt abdominal trauma s Traumatic avulsion of renal artery s Surgery r Embolism s Cardiac origin q Rheumatic heart disease with arrhythmia r Atrial fibrillation q Myocardial infarction q Prosthetic valves q Myocardial trauma q Left atrial or mural thrombus q Myocardial tumors q Subacute bacterial endocarditis s Catheters q Angiographic catheter manipulation
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Umbilical artery catheter above level of renal arteries r Arterial thrombosis s Arteriosclerosis s Thrombangitis obliterans s Polyarteritis nodosa s Syphilitic cardiovascular disease s Aneurysms of the aorta or renal artery s Sickle cell disease r Sudden complete renal vein thrombosis Lobar Renal Infarction r Early signs s Focal attenuation of collecting system q Tissue swelling s Focally absent nephrogram q Triangular with base at cortex r Late signs s Normal or small kidney(s) s Focally atrophied parenchyma with normal interpapillary line s Cortical atrophy and irregular scarring are seen as late sequelae r CT s Subtle renal infarcts are best demonstrated on CT s Appear as wedge-shaped, cortically based, hypodense areas q Triangular in shape with widest part at the cortex (base of infarct) s Non-perfused area corresponding to vascular division s Renal swelling may also be seen s Cortical rim sign q Entire kidney is nonenhancing except for the outer 24 mm of cortex, which are perfused by capsular branches
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Two contrast-enhanced axial CT images demonstrate a wedge-shaped non-enhancing lesion in the right kidney with no perinephric inflammatory stranding
r
US Focally increased echogenicity s Color flow Doppler aids in diagnosis of renal artery thrombosis q There is absence of an intrarenal arterial signal q Tardus parvus waveform is seen if incomplete occlusion or collateral supply s Nuclear medicine q Nuclear imaging shows a photopenic area corresponding to the region of ischemia or infarction Chronic Renal Infarction r Pathology s All elements of kidney atrophied with replacement by interstitial fibrosis s Normal or small kidney with smooth contour
s
s s r
Globally atrophied parenchyma Diminished or absent contrast material density
US
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Increased echogenicity (by 17 days) r Angiography s Normal intrarenal venous architecture s Late visualization of renal arteries on abdominal aortogram s Provides the definitive diagnosis q Abrupt termination of vessels or filling defects q With end-stage renal artery thrombosis r Small kidney with smooth contour, unless multiple small infarcts have occurred independently Treatment r Anticoagulation r Intra-arterial thrombolytic therapy r Surgical revascularization
Dahnert 5th ed Amersham
LearningRadiology.com - Septic,emboli,lung,thrombus,infected,cavity,cavitary,embolus
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Septic Emboli to the Lungs
Age Majority <40 years Predisposed r IV drug abusers r Alcoholism r Immunodeficiency r CHD r Dermal infection (cellulitis, carbuncles) Sources r Tricuspid valve endocarditis s Most common cause in IV drug abusers r Pelvic thrombophlebitis r Infected venous catheter or pacemaker wire r Arteriovenous shunts for hemodialysis r Drug abuse producing septic thrombophlebitis (eg, heroin addicts) r Peritonsillar abscess r Osteomyelitis Organism r S. aureus r Streptococcus Clinical Findings r Sepsis r Cough r Dyspnea r Hemoptysis s Sometimes massive r Chest pain r Shaking chills r High fever r Severe sinus tachycardia Location
r
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Predilection for lung bases Imaging Findings r Multiple round or wedge-shaped densities r Cavitation s Frequent s Usually thin-walled r Migratory s Old ones clear and new ones arise r Pleural effusion is rare r Hilar and mediastinal adenopathy can occur
r
Two images from an axial contrast-enhanced CT scan of the chest shows multiple peripheral, thin-walled cavitary lesions consistent with septic emboli
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CT findings r Multiple peripheral parenchymal nodules r Cavitation or air bronchogram in more than 89% s Cavities are thin-walled and may have no fluid level r Wedge-shaped subpleural lesion with apex of lesion directed toward pulmonary hilum (50%) r Feeding vessel sign = pulmonary artery leading to nodule (67%)
Differential Diagnosis of Small Cavitary Lung Lesions Septic emboli Rheumatoid nodules Squamous or transitional cell mets Wegeners Granulomatosis
Complications r Empyema (39%)
Dahnert 5th ed Fraser and Pare Thoracic Radiology Requisites
LearningRadiology.com - acromio-clavicular,clavicular,acromion,clavicle,fracture,dislocation,ac
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Acromioclavicular Separation
Normal anatomy of acromioclavicular (AC) joint r Synovial joint r Acromioclavicular ligament s Weaker r Coracoclavicular ligaments s Medial conoid and lateral trapezoid s Denser, thicker, stronger
From Harris and Harris, Radiology of Emergency Medicine

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Normal measurements r AC joint space is usually <5mm s Right and left differ by no more than 2-3 mm r Coracoclavicular distance usually <11-13 mm s Right and left should differ by < 5 mm
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50% difference in size between the two shoulders is considered significant r Inferior plane of the distal clavicle should be on same plane as inferior border of acromion s Developmental variations reported as high as 19% Fall on shoulder is frequent mechanism of injury r Point tenderness, limitation of motion Abnormal widening of the AC joint due to disruption of the AC ligament r CC separation is the more important soft tissue injury Extent of CC separation has direct effect on degree of AC separation Classification
r
Type I Sprain
Anatomy Stretching of AC ligament AC joint is stable CC ligament intact
Radiographic findings Only seen on stress views of injured and uninjured shoulders=widening of AC joint
Prognosis No instability
Partial or complete rupture of Widening of AC joint but a AC ligament normal coracoclavicular distance II Subluxation Partial, but not complete, disruption of CC ligament Stress films may still be required to demonstrate widening of both AC joint and CC space
May require arthroplasty
III
Disruption of both AC and CC ligaments
Widening of both the AC and CC Internal fixation spaces on routine erect film
IV Posterior
AC and CC ligaments Distal end of clavicle lies inferior disrupted but coracoacromial and posterior to acromion seen ligament remains intact best on axillary view AC and CC ligaments disrupted Coracoacromial ligament remains intact Sternoclavicular separation occurs as well Distal end of clavicle displaced inferiorly and lodges in biceps and coracobrachialis muscles Marked widening of both the AC and CC space Sternoclavicular dislocation
V Inferior
Distal end of clavicle comes to lie inferior to acromion
VI
Two views of right shoulder show elevation of the clavicle and separation of the AC joint in a Type III AC joint separation
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Fracture of distal end of clavicle is frequently associated with CC tears with or without separation of AC ligament Separation may heal with soft tissue calcification or ossification
Harris, J and Harris, W: Radiology of Emergency Medicine, 4th ed, 2000. Manaster, B., Disler, D.,May, D.: The Requisites: Musculoskeletal Imaging, 2002
LearningRadiology.com - Esophageal Web, web,esophagus,esophageal,plummer,vinson,anemia
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Esophageal Web
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Ringlike constriction of upper esophagus covered on superior and inferior surfaces by squamous epithelium Three types have been described: r A non-specific or idiopathic web (most common) r Webs associated with Plummer-Vinson Syndrome r Webs associated with epidermolysis bullosa dystrophica or graft-versus-host disease Usually found in middle-aged females Plummer-Vinson Syndrome=Patterson-Kelly syndrome r Iron deficiency anemia r Stomatitis r Glossitis r Dysphagia r Spoon-shaped nails r Esophageal webs r Some question as to whether such a syndrome exists Location r Cervical esophagus anteriorly at level of the cricopharyngeous (C5-C6) r Best visualized with maximal distension r Distal esophageal webs may arise from gastroesophageal reflux Imaging Findings r Thin, transverse filling defects r Perpendicular to anterior esophageal wall r Usually less than 3mm in thickness r Frequently they are not circumferential
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Barium esophagram demonstrates a thin membrane arising from the anterior wall of the cervical esophagus at the level of C5-C6 without circumferential involvement of the lumen characteristic for an esophageal web For a larger image, double click the photo itself
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Increased risk of upper esophageal carcinoma DDx r Prominent cricopharyngeous muscle s Arises posteriorly at C5-C6 and produces a much broader defect r Stricture Treatment r Balloon dilatation r Bougienage during esophagoscopy
Halpert, R and Feczko, P: Requisites of Gastrointestinal Radiology, 2nd edition, 1999.
LearningRadiology.com - Discitis,infection,spine,disk,disc,staphylococcus
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Discitis and Osteomyelitis

Usually the result of bloodborne agents r Especially from lung and urinary tract r Average age of onset is in children around 6 years r Most common pathogen is staphylococcus r Also Streptococcus r Gram-negative rods in IV drug abusers or immunocompromised patients s E. Coli s Proteus s Non-pyogenic q Tuberculosis q Coccidioidomycosis May occur as a result of invasive procedure r Surgery r Discography r Myelography Pathogenesis r In children, probably begins in still vascularized disc r In adults, in anterior inferior corner of vertebral body with spread across disk to adjacent vertebral endplate Site of involvement r L3/4 r L4/5 r Unusual above T9 r Usually involvement of one disk space (occasionally 2) Bacteria destroy disk and both contiguous end-plates Imaging Findings r Narrowing and destruction of an intervertebral disk s Earliest plain film sign r Indistinctness of adjacent endplates with destruction
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r r r
Often associated with bony sclerosis of the two contiguous vertebral bodies Paravertebral soft tissue mass Endplate sclerosis (during healing phase beginning anywhere from 8 weeks to 8 months after onset) Bone fusion after 6 months to 2 years
Frontal and lateral radiographs of the thoracic spine demonstrate destruction of the endplates of two contiguous vertebral bodies with considerable endplate sclerosis, findings characteristic of discitis
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MRI Decreased marrow intensity on T1-weighted images in two contiguous vertebrae r High signal intensity on T2 s Because of associated edema r Disk space and paravertebral soft tissues enhance on MRI Clinical r Pain is present if disease is acute r Point tenderness r Malaise r Irritability in children r Referred hip pain r Inability to bear weight r Course of discitis is frequently more benign in children than adults s Disk space is narrowed but no destruction of contiguous vertebral bodies
r
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Osteomyelitis of the vertebral body r Usually the result of discitis r But can occur from direct involvement from hematogenous dissemination to body r MRI findings are similar to discitis Bone scan will be positive Gallium scan or Indium-111 scan will be positive Renal spondyloarthropathy r May resemble discitis r Usually involves cervical spine r Destruction of disk space and adjacent vertebral bodies r Signal on T2 is low rather than high r No clinical evidence of infection Complication of disease r Kyphosis Treatment r Bone fusion after 6 months to 2 years
Radiologic Clinics, Imaging of the Spine, 1991 The Requisites, Neuroradiology Dahnert, 4th Ed
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LearningRadiology.com - Twiddler's Syndrome,Twiddler,pacemaker,malfunction,complication
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Twiddler's Syndrome
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Rare occurrence r Due to shape and weight of pacemakers today Subconscious, inadvertent or deliberate rotation of pacemaker in its subcutaneous pocket Older women may be at particular risk r Loose subcutaneous tissue Lead retracts and begins to wrap around the pacemaker itself r Dislodging lead from endocardium and causing r Malfunction of device r Pacemaker may begin to stimulate diaphragm, vagus or phrenic nerve, pectoral muscles or brachial plexus Imaging findings r Chest x-ray shows looping of wires around pacer r Retraction and change in position of tip if wire or catheter May result in sudden cardiac arrest due to conduction disturbances Also occurs with automatic implantable cardiac defibrillators (AICDs)
http://www.learningradiology.com/archives05/COW%20141-Twiddlers%20Syndrome/twiddlerscorrect.htm (1 de 5)04/09/2006 2:27:55
Twiddler's Syndrome-frontal chest radiograph in top photo demonstrates pacemaker lead extending into right ventricle (blue arrows); bottom photo, one year later, shows wire lead is wound around pacer and tip of ventricular lead has retracted into the left subclavian vein (red circle) Click here for same photo without arrows
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LearningRadiology.com - Osteoblastic Metastases, mets, bone,prostate,carcinoma,ca,blastic,sclerotic
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Metastatic Disease to Bone
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Metastases are most common malignant bone tumors Most involve axial skeleton r Skull, spine and pelvis r Rarely do mets occur distal to elbows or knees Spread hematogenously r Most frequently occur where red bone marrow is found r Mets to spine frequently destroy posterior vertebral body including pedicle first=pediclesign 90% of skeletal mets are multiple Primary carcinomas that frequently metastasize to bone r The next four lesions comprise 80% of all metastases to bone s Breast (70% of bone mets in women) s Lung s Prostate (60% of all bone mets in men) s Kidney r Also s Thyroid s Stomach and intestines Clinical r Most lesions are asymptomatic s When symptomatic, pain is major symptom r Fractures of the lesser trochanter in adults should be considered pathologic until proven otherwise Imaging Findings r In general, mets have little or no soft tissue mass associated with them r Usually no periosteal reaction r May appear as moth-eaten, permeative or geographic lesions s Indistinct zones of transition s No sclerotic margins
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May be expansile s Soap-bubbly (septated) s May be sharply circumscribed or have indistinct borders Metastases that are typically purely lytic s Kidney s Thyroid Metastases that are usually mixed lytic and sclerotic s Lung s Breast Metastases that are usually purely blastic s Prostate s Medulloblastoma s Bronchial carcinoid No matter what the primary, skull metastases are usually lytic in appearance
s
Most Common Tumors to Metastasize to Bone (80% of bone mets)

Tumor Prostate Breast Lung Renal Cell Ca Appearance Blastic Mixed Predominantly lytic Predominantly Lytic
Imaging findings suggestive of a particular primary tumor s Lesions distal to elbows and knees q 50% are from lung and breast s Expansile and lytic (soap-bubbly) q Renal cell s Diffuse skeletal sclerosis or multiple round, well-circumscribed sclerotic lesions q Prostate q Breast
Multiple osteoblastic metastases to the pelvis and lumbar vertebral bodies from carcinoma of the prostate Note discrete rounded sclerotic lesions in right ilium and "ivory vertebra" involving L4 and S1.
s
Cookie-bite lesions of the cortices of long bones q Lung r Radioscintographic studies s Bone scans are extremely sensitive but not very specific s 10-40% of lesions will not be visible on plain film but will be positive on bone scans s CT or MRI can be used to show findings in patients with negative conventional radiographs and positive bone scans Complications of metastases to bone r Pathologic fractures s Destruction of 50% or more of bone suggests impending pathologic fracture r Spinal cord compression r Treated lytic mets may become sclerotic with treatment
References: Orthopedic Radiology: A Practical Approach, Greenspan, Adam; Lippincott, 2000 Diagnosis of Bone and Joint Disorders, Resnick, Donald, W. B. Saunders Musculoskeletal Imaging: The Requisites, Manaster, BJ et al; Mosby, 2002
LearningRadiology.com - Dressler's Syndrome,postcardiotomy,postmyocardial,infarction
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Dressler's Syndrome
Postmyocardial Infarction Syndrome/Postcardiotomy Syndrome
General r Incidence s About 4% following transmural infarction s Probably higher in open heart surgery Believed to have immunologic cause r Possibly a latent viral infection may be involved in cause Clinical r Symptoms typically appear 2-3 weeks following infarct/surgerysometimes years r May last for weeks or months s Different from more common post myocardial infarction pericarditis q That entity occurs in 17 to 25 percent of cases of acute myocardial infarction q Occurs between days 2 and 4 after the infarction r Pleuritic chest pain (91%) r Fever r Pericardial and pleural effusion s Pericardial friction rub s Effusions can be bloody and cause tamponade r Also rales r SOB r Leukocytosis Imaging Findings r Pleural effusions (83%) r Parenchymal opacities (74%) r Enlarged cardiac silhouette from pericardial effusion (49%)
http://www.learningradiology.com/archives05/COW%20143-Dresslers%20syndrome/dresslerscorrect.htm (1 de 5)04/09/2006 2:28:00
Three sequential images of the chest show a pre-op chest in which the left lung base is clear (green arrow); on the third day post-op coronary artery jump bypass surgery, there is subsegmental atelectasis at the left base (yellow arrow); Four weeks later, there is a left pleural effusion and subsegmental atelectasis visible (red arrow) Click here for the same image without the arrows
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Treatment r High dose aspirin r Steroids
LearningRadiology.com - Chilaiditi's Syndrome, Chilaiditi's Sign, Interposition, Colon, Pneumoperitoneum, Free Air, pitfall, simulate, miss
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Chilaiditis Sign/Syndrome
Hepatodiaphragmatic Interposition of the Intestine
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Pronounced Ky-La-Ditty Refers to the usually asymptomatic interposition of the bowel (usually hepatic flexure of the colon) between the liver and the (right) hemidiaphragm Seen in 0.1-0.25% of chest x-rays Most frequently an incidental finding r More often in males r Almost always in adults r May be present intermittently Factors contributing to its occurrence include r Absence of normal suspensory ligaments of the transverse colon r Abnormality or absence of the falciform ligament r Redundant colon, as might be seen with chronic constipation or in bedridden individuals r Aerophagia r Paralysis or eventration of the right hemidiaphragm r Patients with chronic lung disease, cirrhosis and ascites The sign refers to the usually asymptomatic presence of the interposed bowel The syndrome may involve r Abdominal pain r Constipation r Vomiting r Respiratory distress r Anorexia Chilaiditis Syndrome is important because it can simulate pneumoperitoneum r Look for the presence of haustral folds which can establish the air beneath the diaphragm is contained within large bowel s Left lateral decubitus abdominal films may help in this distinction r Concomitant pneumoperitoneum may be more difficult to diagnose s May require abdominal CT
http://www.learningradiology.com/archives05/COW%20144-Chilaiditi's%20syndrome/chiliaiditiscorrect.htm (1 de 4)04/09/2006 2:28:02
Abdominal CT scan through the level of the diaphragm shows the transverse colon (note the haustral folds) anterior to the liver in a patient with Chilaiditi's Sign
LearningRadiology.com - Choroid Plexus Cyst,image,jpg,choroid,plexus,cyst
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Choroid Plexus Cysts

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Cyst-like spaces that occur in the choroid in approximately 1-6% of fetuses between 13 and 24 weeks gestation Majority are small and incidental, disappearing by 26 weeks gestation Thought to represent entrapment of cerebrospinal fluid within an in-folding of neuroepithelium May be associated with chromosomal abnormalities, especially trisomy 18 r Likelihood ratio of trisomy 18 with isolated choroid plexus cyst ranges from 0.03 to 13.8 times the mothers background risk r Trisomy 18 is almost always associated with other structural abnormalities r When a choroid plexus cyst is identified s In addition to the routine anatomic survey, a targeted search for structural abnormalities should be performed r Amniocentesis should be offered when a fetus has both a choroid plexus cyst and additional structural abnormalities
Rare cases of symptomatic choroid plexus cysts causing obstructive hydrocephalus have been reported
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Two images form an unenhanced axial CT of the brain show ring-like calcifications in the region of the choroid plexus representing choroid plexus cysts
Middleton, William D., etc: Ultrasound: The Requisites, 2nd edition, 2004. Rumack, Carol, etc: Diagnostic Ultrasound, 3rd edition, 2005.
LearningRadiology.com - Ranula, sublingual, gland, cyst, mucus, mucous, retention, plunging, simple
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Ranula
Submitted by Tony Chang, MD
Mucus retention cyst that occurs in the sublingual gland

Ranulas do not communicate with the duct Etiologies include r Prior trauma, usually iatrogenic from prior surgery r Obstruction of the sublingual gland or its duct Two types of ranulas r Simple r Plunging Simple ranulas are true cysts
r
o Occur in floor of the mouth above the level of the mylohyoid with a lining formed by the
sublingual gland capsule
Plunging/deep/diving ranulas o Occur when the simple ranula ruptures and is walled off by an inflammatory response
o Plunging ranulas are pseudocysts partially contained by the remaining epithelium and
inflammatory cells that react to irritative saliva o Plunging ranulas usually extend below the level of the mylohyoid
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Clinical findings r Both types present as a painless mass in the sublingual space r Plunging ranulas extending inferiorly into the submental or submandibular space Imaging findings r Typical CT findings include s Smooth, well delineated, cystic lesion s Splaying the genioglossus and mylohyoid with a uniformly thin, non-enhancing wall r Ranulas can be slightly increased in attenuation especially the higher the protein content within the fluid
http://www.learningradiology.com/archives05/COW%20146-Ranula/ranulacorrect.htm (1 de 4)04/09/2006 2:28:10
r
Infected ranulas may have thickened enhancing walls and cannot be distinguished from an abscess MRI findings s Low signal intensity on T1 weighted imaging s High signal intensity on T2 weighted imaging but varies with protein content
CT scan shows a large mucous retention cyst arising from the sublingual gland (ranula)
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Treatment r Simple ranulas usually treated with transoral drainage and excision of ipsilateral sublingual gland r Plunging ranulas may require more extensive surgical neck dissection
Reference: Som and Curtin, Head and Neck Imaging
LearningRadiology.com - Superior Mesenteric Artery Syndrome,SMA,syndrome,obstruction,duodenum,body,cast
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Superior Mesenteric Artery Syndrome

Compression of 3rd portion of duodenum between the aorta and superior mesenteric artery (SMA) Females more affected than males r Most often in older children, adolescents Some doubt the true existence of the syndrome Pathophysiology r Narrowing of angle between SMA and aorta s SMA usually forms an angle of 45 degrees with the aorta Etiologies r Prolonged bed rest in supine position (body cast, whole-body burns, surgery) r Substantial and, frequently, rapid weight loss r Anorexia nervosa or malnutrition r Loss of abdominal muscle tone (as in pregnancy) r May be congenital r Seen in those with asthenic build r Exaggerated lumbar lordosis Clinical findings r Epigastric pain r Nausea r Repetitive vomiting r Abdominal cramping r Typically findings are worst in supine position and may be relived by changing to the prone or left lateral decubitus positions r Associated with a higher than normal incidence of peptic ulcer disease and hyperchlorhydria Imaging findings r Usually requires upper GI or CT of abdomen for diagnosis r Megaduodenum st and 2nd portion of duodenum and frequently stomach s Pronounced dilatation of 1 s Best seen in supine position s Compression of duodenum between aorta and SMA
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http://www.learningradiology.com/archives05/COW%20147-SMA%20Syndrome/smasyndromecorrect.htm (1 de 5)04/09/2006 2:28:18
Axial CT scans of the upper abdomen show a dilated 2nd portion of the duodenum (D) just proximal to a narrowed segment of the 3rd portion of the duodenum (green arrow) compressed between the superior mesenteric artery (red arrow) and the aorta (black arrow) For the same image without arrows, click here
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Vertical linear compression defect in transverse portion of duodenum overlying spine Abrupt change in caliber distal to compression defect Treatment r Relief of compression by postural change into prone knee-elbow position r Weight gain r Surgery is indicated only when conservative treatment is not successful s Duodenojejunostomy is the most frequently used procedure
References: Dahnert, 5th Edition Avinash Shetty, MD and Ivor D Hill, MB, ChB, DCH, FCP, MD: eMedicine
LearningRadiology.com - Puckered Panniculous
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Puckered Panniculus Sign
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Plain film abdomen finding On abdominal radiographs, the fatty panniculus, if present, has two configurations Smooth, uniformly convex bow which is the normal appearance (yellow arrows below) Or, a bow with a central indentation (broken bow) (blue arrows below) Latter is a useful radiographic sign of previous lower abdominal surgery Central indentation is created by tissue tethering around the laparotomy scar
http://www.learningradiology.com/archives05/COW%20148-Puckered%20Panniculus/puckeredpancorrect.htm (1 de 5)04/09/2006 2:28:21
See above description For the same image without arrows, click here
References: Bray JF. J Can Assoc Radiol. 1983 Mar; 34(1):75-6.
LearningRadiology.com - Osteosarcoma in Paget's Disease
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Osteosarcoma in Paget's Disease
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Occurs in < 1% of all Paget's patients Pagets: 30 X increase in incidence of bone sarcoma Sarcomatous change usually occurs in diffuse, long standing, polyostotic Paget's disease Sarcomatous change most common in pelvis, humerus, femur 50% are osteosarcoma r Usually osteolytic r Also - fibrosarcoma, chondrosarcoma, giant cell tumor
Frontal radiograph of pelvis demonstrates Paget's Disease of right hemipelvis as evidenced by thickened cortex and prominent trabeculae with large,
http://www.learningradiology.com/archives05/COW%20149-Osteosarcoma%20in%20Pagets/pagetssarcomacorrect.htm (1 de 4)04/09/2006 2:28:22
lytic, geographic lesion in iliac crest representing an osteolytic osteosarcoma

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Treatment r Palliative resection r Chemotherapy Prognosis r Grave, with survival > 2 years rare
LearningRadiology.com - Gallstone Ileus,Pneumobilia,Biliary,Tract,Gas,Fistula,Small bowel,gallsone,complication,obstruction
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Gallstone Ileus
Unusual complication of chronic cholecystitis Impaction of gallstone in ileum after passing through a biliary-enteric fistula 60% are cholecystoduodenal fistulae; others are cholecystocolonic and cholecystogastric fistulae Average age of patient is 70 years old Delay in diagnosis o Mortality of 15-20% o o o Riglers Triad Pneumobilia SBO Impacted gallstone-usually in the terminal ileum at ileocecal valve
http://www.learningradiology.com/archives05/COW%20150-Gallstone%20Ileus/gallstoneileuscorrect.htm (1 de 5)04/09/2006 2:28:26
Two axial images from a contrast-enhanced CT of the abdomen show air in the gall bladder (red arrow) and air in the common bile duct (blue arrow) representing pneumobilia, the gallstone in the small bowel lumen (yellow arrow) and dilated and fluid-filled loops of small bowel from small bowel obstruction (green arrow) -- all of the components of a gallstone ileus For a photo of the same case without the arrows click here
Thanks to Julie Gubenick, MD who submitted the case material
LearningRadiology.com - Hamartoma of the Breast
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Hamartoma of the Breast
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Rare, benign, well-circumscribed mass Mixed density 2 to fat and water Mean age 45 Mass is usually soft and often non-palpable Mammography r Surrounded by a thin capsule under which, there may be r Peripheral radiolucent zone of fat r Mass may contain calcifications
http://www.learningradiology.com/archives05/COW%20151-Hamartoma%20of%20Breast/breasthamarcorrect.htm (1 de 5)04/09/2006 2:28:34
Two images of the left breast demonstrate a well-circumscribed mass of mixed density with a thin white line surrounding the mass underneath which is a zone of radiolucent fat consistent with a hamartoma of the breast
Thanks to Debra Copit, MD who submitted the case material
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Cecal Volvulus
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Volvulus is 3rd most common cause of colonic obstruction r Following obstructing carcinoma and inflammatory stricture Two most common forms are r Cecal r Sigmoid Cecal volvulus can be associated with r Malrotation of the colon r Abnormally long mesentery of cecum and ascending colon s Leads to mobility of right colon predisposing to volvulus s Other factors must be at play, though, since 10% of population has such a long mesentery yet few develop cecal volvulus s Cecal volvulus has been associated with obstructing lesions of the left colon from carcinoma or diverticulitis Ascending colon twists on its longitudinal axis from 180 to 360 and rotates cecum upward and to left of midline Age peak r 20-40 years M>F Imaging findings r Markedly dilated cecum s "Kidney-shaped" distended cecum s Usually positioned in LUQ or to the left of the midline r Most obstructions are complete so there is little gas in the rest of the colon r Tapered end of barium column points toward torsion s Beak configuration to end of barium column
http://www.learningradiology.com/archives05/COW%20152-Cecal%20Volvulus/cecalvolvuluscorrect.htm (1 de 5)04/09/2006 2:28:37
Two radiographs of the abdomen, the upper supine and the lower erect, show a markedly dilated loop of large bowel (blue arrow) with a smooth, tapered end that appears to be the cecum. There is no gas in the large bowel distal to the dilated cecum. To see the same photo without the arrows click here
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About 10-33% of cecal volvuli are cecal bascules r Cecum does not rotate around its luminal axis r Consistent feature of cecal bascule is presence of a constricting band across the ascending
colon, the origin of which is not certain r Cecum folds anteromedial to the ascending colon s Produces a flap-valve occlusion at the site of flexion s Occurs in a transverse plane and is associated with marked distension of the cecum q Often displaced into the center of the abdomen r Findings s Distended air-filled cecum is located more centrally Diagnosis and treatment r Patients present most often with an acute abdomen s Colicky abdominal pain of sudden onset r Most cases of cecal volvulus reportedly occur in patients while they are asleep with normal side to side movement during sleep possibly resulting in displacement of the right colon to an abnormal location r Diagnosis is usually by plain film appearance r Reduction using barium in an enema may be tried r Treatment is usually surgical Prognosis and complications r Mortality between 20-40% in elderly r Closed-loop obstruction that can lead to s Gangrene of bowel s Perforation
Two images of
Ali Nawaz Khan and John Howat; eMedicine, Cecal Volvulus Halpert and Feczko: The Requisites, 2nd ED, Gastrointestinal Radiology
LearningRadiology.com - Chicken bone impacted in cervical esophagus,foreign body
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The Lateral Neck Impacted Chicken Bone

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Soft tissue measurements on the lateral neck image r At C3: <3 mm (less than 1/3 AP diameter) r At C6: < the AP width of C6 vertebral body Retropharyngeal Space r Contains lymphatics that drain s Nasopharynx s Adenoids s Posterior nasal sinuses r These chains atrophy after age 4 Retropharyngeal abscess r Almost all occur before age 6 r 50% between 6-12 months r Most common pathogens are s Staph aureus s Group A Beta hemolytic Strep s Haemophilus r Clinically s Prodromal nasopharyngitis s Severe throat pain with drooling s Dysphagia s Hyperextension of the head s Hot potato muffled voice r In adults, usually 2 trauma to oropharynx s Iatrogenic s Perforated FB Retropharyngeal perforation r Causes
http://www.learningradiology.com/archives05/COW%20153-FB%20in%20esophagus/esophagealfbcorrect.htm (1 de 6)04/09/2006 2:28:43
Trauma to esophagus or trachea s Penetrating injuries from weapons s Perforation from within q Chicken bone q Mediastinal emphysema tracking into neck s Retropharyngeal abscess 2 gas-forming organism Imaging findings of retropharyngeal perforation r Streaks of air in soft tissues of neck r Anterior displacement of pharynx r Associated pneumothorax possible r Cervical or mediastinal air seen in 60% of cases of ruptured esophagus Upper airway infections-The Big Two r Croup r Epiglottitis Croup r Laryngotracheobronchitis r Usually viral r May be difficult to distinguish from early retropharyngeal abscess r Occurs at age 6 months to 2 years s Younger than epiglottitis r The three major findings of croup s Distension of the hypopharynx s Distension of the laryngeal ventricle s Haziness or narrowing of subglottic space Epiglottitis r Most commonly H. flu type B r Peak incidence now closer to 6-7 years s Croup occurs from 6 months to 2 years r Lateral radiograph -- erect position only s Supine position may close off airway r Imaging findings s Epiglottis is enlarged s Appears thumb-like s Aryepiglottic folds are thickened s Pre-epiglottic space (vallecula) is smaller than normal q In many cases, its obliterated
s
Impacted esophageal foreign bodies r Food or true foreign bodies s Chicken bones (opaque), fish bones (non-opaque) s Coins, toy trucks r Most often they impact just below cricopharyngeous (70%) s Another 20% impact at the level of the aortic arch s Another 10% at EG junction s Once past the esophagus, most foreign bodies will pass through the GI tract r Clinical findings of an impacted esophageal foreign body s Dysphagia and odynophagia most commonly s Even if FB passes, many complain of pain referable to cervical esophagus r Always check for lead lines in children
Pica Chicken bones are usually opaque s Fish bones contain less calcium and usually are not Plain films usually do not demonstrate the FB but are still obtained first s If negative, then either contrast esophagram or CT if high index of suspicion
s
Lateral radiograph of the neck demonstrates a linear density in the region of the proximal esophagus (red arrow) consistent with an impacted foreign body--in this case, a chicken bone. There is no air in the soft tissues and no soft tissue swelling is identified to indicate the presence of a retropharyngeal abscess. To see the same photo without the arrows click here
r
Treatment s Removal is most often performed using endoscopy s Temporization and surgery are other options s An ingested button battery lodged in esophagus must be removed immediately Complications of an impacted foreign body s Perforation q Longer the FB remains impacted (>24hrs), higher incidence of perforation

s s
Stricture Diverticulum formation
For more on these diseases click here
eMedicine: Esophageal Foreign Bodies. Veronica Rooks, MD and Ellen Chung, MD, Walter Reed Army Medical Center
LearningRadiology.com -Thyroid Ophthalmopathy, Grave's Disease, eye, findings, proptosis
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Thyroid Ophthalmopathy
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Most common cause of proptosis in adults Typically occurs from 20-50 years old Patients are usually hyperthyroid, but may be euthyroid Neuroimaging usually reveals thick muscles with tendon sparing r Inferior rectus and medial rectus muscles are most commonly involved r Usually bilateral, but may be asymmetric Graves Disease = Diffuse Toxic Goiter r Autoimmune disorder with thyroid stimulating antibodies (LATS) producing hyperplasia and hypertrophy of thyroid gland Age of incidence r 3rd-4th decade r Female predominance 7:1 Laboratory findings r Elevated T3 and T4 r Depressed TSH production Clinical findings r Pretibial myxedema r Ophthalmopathy s Periorbital edema s Lid retraction s Opthalmoplegia s Proptosis s Malignant exophthalmos r Diffuse thyroid enlargement US r Identical to diffuse goiter r Global enlargement of 2-3 times normal size r Normal and/or diffusely hypoechoic pattern r Hyperemia on color Doppler Treatment
http://www.learningradiology.com/archives05/COW%20154-Thyroid%20Ophthalmopathy/thyroidophcorrect.htm (1 de 5)04/09/2006 2:28:44

r r
I-131 treatments (for adults) Complications s 10-30% develop hypothyroidism within 1st year and about 3%/year rate thereafter
Axial and coronal CT scans of the orbits show marked enlargement of the extraocular muscles with sparing of the tendons consistent with the ophthalmopathy seen with Grave's disease
Dahnert 5th Edition
About Us
LearningRadiology.com - Croup
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The Lateral Neck - Croup

Soft tissue measurements on the lateral neck image r At C3: <3 mm (less than 1/3 AP diameter) r At C6: < the AP width of C6 vertebral body Retropharyngeal Space r Contains lymphatics that drain s Nasopharynx s Adenoids s Posterior nasal sinuses r These chains atrophy after age 4 Retropharyngeal abscess r Almost all occur before age 6 r 50% between 6-12 months r Most common pathogens are s Staph aureus s Group A Beta hemolytic Strep s Hemophilus r Clinically s Prodromal nasopharyngitis s Severe throat pain with drooling s Dysphagia s Hyperextension of the head s Hot potato muffled voice r In adults, usually 2 trauma to oropharynx s Iatrogenic s Perforated FB Retropharyngeal perforation r Causes s Trauma to esophagus or trachea s Penetrating injuries from weapons s Perforation from within
http://www.learningradiology.com/archives05/COW%20155-Croup/croupcorrect.htm (1 de 6)04/09/2006 2:28:49
Chicken bone q Mediastinal emphysema tracking into neck s Retropharyngeal abscess 2 gas-forming organism Imaging findings of retropharyngeal perforation r Streaks of air in soft tissues of neck r Anterior displacement of pharynx r Associated pneumothorax possible r Cervical or mediastinal air seen in 60% of cases of ruptured esophagus Upper airway infections-The Big Two r Croup r Epiglottitis
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Croup r Laryngotracheobronchitis r Usually viral r May be difficult to distinguish from early retropharyngeal abscess r Occurs at age 6 months to 2 years s Younger than epiglottitis r The three major findings of croup s Distension of the hypopharynx s Distension of the laryngeal ventricle s Haziness or narrowing of subglottic space
Soft tissue lateral neck (edge enhanced) shows a slightly dilated hypopharynx (red arrow), dilatation of the laryngeal ventricle (white arrow) and narrowing of the sub-glottic trachea (blue arrow)
For the same image without the arrows, click here

q
Epiglottitis r Most commonly H. flu type B r Peak incidence now closer to 6-7 years s Croup occurs from 6 months to 2 years r Lateral radiograph -- erect position only s Supine position may close off airway r Imaging findings s Epiglottis is enlarged s Appears thumb-like s Aryepiglottic folds are thickened s Pre-epiglottic space (vallecula) is smaller than normal q In many cases, its obliterated Impacted esophageal foreign bodies r Food or true foreign bodies s Chicken bones (opaque), fish bones (non-opaque) s Coins, toy trucks r Most often they impact just below cricopharyngeous (70%) s Another 20% impact at the level of the aortic arch s Another 10% at EG junction s Once past the esophagus, most foreign bodies will pass through the GI tract r Clinical findings of an impacted esophageal foreign body s Dysphagia and odynophagia most commonly s Even if FB passes, many complain of pain referable to cervical esophagus r Always check for lead lines in children s Pica r Chicken bones are usually opaque s Fish bones contain less calcium and usually are not r Plain films usually do not demonstrate the FB but are still obtained first s If negative, then either contrast esophagram or CT if high index of suspicion r Treatment s Removal is most often performed using endoscopy s Temporization and surgery are other options s An ingested button battery lodged in esophagus must be removed immediately r Complications of an impacted foreign body s Perforation q Longer the FB remains impacted (>24hrs), higher incidence of perforation s Stricture s Diverticulum formation
eMedicine: Esophageal Foreign Bodies. Veronica Rooks, MD and Ellen Chung, MD, Walter Reed Army Medical Center
LearningRadiology.com - necrotizing enterocolitis, NEC
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Necrotizing Enterocolitis (NEC)
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Most common gastrointestinal medical and/or surgical emergency occurring in neonates Etiology r Remains unknown r Ischemia and/or reperfusion injury may play a role r Cluster cases and outbreaks in nurseries imply an infectious etiology s A single causative organism has not been found r Translocation of intestinal flora across compromised mucosa may play a role Incidence and age at onset r More common in premature infants s But can also be seen in term babies r Inversely related to birth weight and gestational age r Term infants develop NEC earlier after birth than preemies s Average age of onset occurs within first week of life s Affected term neonates are usually systemically ill with other conditions such as birth asphyxia, respiratory distress or congenital heart disease r Premature babies are at risk for several weeks after birth r Babies who are breastfed have a lower incidence of NEC than formula-fed babies Clinical findings r Initial symptoms may be subtle and can include the following s Feeding intolerance s Delayed gastric emptying s Abdominal distention and/or tenderness s Ileus/decreased bowel sounds Imaging findings r Acute disease most commonly affects the terminal ileum r Plain film of the abdomen remains method in which disease is diagnosed most often r Findings include s Dilated loops of bowel s Thickened bowel walls q Fixed and dilated loop that persists is especially worrisome
http://www.learningradiology.com/archives05/COW%20156-NEC/neccorrect.htm (1 de 5)04/09/2006 2:29:01

s s
Absence of bowel gas Pneumatosis intestinalis q Pathognomonic of NEC in newborn r Linear radiolucency parallels bowel lumen within bowel wall r Represents air that has entered from the lumen
Red arrows point to linear bands of radiolucency which parallel the wall of the bowel indicating the presence of pneumatosis intestinalis in necrotizing enterocolitis For a the same photo without the arrows, click here
s
Abdominal free air q Ominous r Usually requires emergency surgical intervention q May require a left lateral decubitus view to be seen Portal venous gas q Originally thought to be ominous but is now considered less so q Appears as linear branching areas of decreased density over periphery of the liver r Represents air in portal venous system Ascites q Late finding q Develops after perforation when peritonitis is present Complications r Occur in about 75% of all patients survive s Of those who survive, 50% develop a long-term complication
Two most common complications are intestinal stricture and short-gut syndrome r Intestinal strictures s Can develop in infants with or without a preceding perforation s Incidence is 25-33% s Strictures most commonly involve the left side of the colon s Diagnosed with barium enema r Short-gut syndrome s Malabsorption syndrome resulting from removal of excessive or critical portions of small s Neonatal gut will grow this growth may take as long as 2 years to occur Mortality r Mortality rate ranges from 10-44% in infants weighing less than 1500 g
r
eMedicine.com: Necrotizing Enterolcolitis; Shelley C Springer, MD, MBA, MSc, and David J Annibale, MD
LearningRadiology.com - Galeazzi Fracture, Monteggia fracture
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Galeazzi and Monteggia Fracture-Dislocations

The correct answer is: Galeazzi fracture
Whenever one of the two bones of the forearm fractures with considerable shortening (usually through angulation), then something has to happen to shorten the other bone o The other bone can also fracture o The other bone can dislocate o Ligaments are torn Galeazzi and Monteggia fractures are both fractures in which there is a fracture with shortening of one of the two bones of the forearm with dislocation of the other bone Galeazzi Fracture o Mechanism: Fall on outstretched hand with elbow flexed o Fracture of the radius with shortening and dislocation of the distal ulna o Dorsal angulation
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Galeazzi fracture consists of a fracture of the radius with angulation and associated dislocation of the distal ulna
Ulnar plus variance (= radial shortening) of >10 mm implies complete disruption of interosseous membrane means complete instability of radioulnar joint Complications of Galeazzi fracture o High incidence of Nonunion Delayed union Malunion (unstable fracture) o Limitation of pronation or supination Monteggia Fracture o Mechanism: direct blow to the forearm o Anterior dislocation of the radial head with a fracture of the ulna, usually angulated dorsally o May have associated wrist injury
Monteggia fracture consists of a fracture of the ulna (red arrow) with angulation and associated dislocation of the radial head. A line drawn through the shaft of the radius (blue line) should always intersect the capitellum, no matter what the position of the arm Complications o Nonunion o Limitation of motion at elbow o Nerve abnormalities Reverse Monteggia Fracture o Dorsally angulated proximal ulnar fracture and posterior dislocation of radial head
With apologies to mnemonic lovers everywhere: Monteggia fracture =Monfurd the Magician=Monteggia=Fracture Ulna, Radial Dislocation
Dahnert 4th Edition
LearningRadiology.com - Bezoar, Trichobezoar, Hairball, Fiber, Indigestible, Foreign body, Stomach
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Bezoar
Collections of indigestible material found in the gastrointestinal tract, usually the stomach o From the Persian word padzahr which means antidote since they were once used for this purpose Incidence is very low Risk of trichobezoar (eating of hair) is greater among mentally retarded or emotionally disturbed children o Also occurs as an occupational disease in brushmakers, blanket weavers and wool workers Much more common in females (90%) aged 10 to 19 Etiology o Chewing on or eating hair or fuzzy materials or indigestible vegetable fiber o Material unable to exit stomach because of large size o Gastric outlet obstruction may play a roll o Poor gastric motility such as might occur in diabetics Predisposition o Previous gastric surgery such as vagotomy, pyloroplasty, antrectomy or partial gastrectomy o Inadequate chewing of food Missing teeth, dentures o Massive overindulgence of food with high fiber contents such as dates or persimmons Clinical symptoms o Anorexia o Bloating o Early satiety o History of trichophagy eating hair o Trichoptysis hair may be coughed up o May be asymptomatic Phytobezoar (55% of all bezoars): o Poorly digested vegetable fibers such as Skin and seeds of fruits and vegetables
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Oranges Persimmons o Most common o Unripe persimmons contain a chemical shibuol that forms a glue-like coagulum after contact with dilute acid in the stomach May become impacted in small bowel after forming in stomach
Trichobezoar (hair) o 80% are < age 30, almost exclusively in females o Associated with gastric ulcer in 24-70% Radiographic findings o Upper part of a large bezoar may be visible as a mass with a convex upper border projecting into the gastric air bubble o An erect abdominal radiograph and a supine radiograph may show a prominent gastric outline with an intragastric mottled mass, outlined by gas in the distended stomach, mimicking a food-filled stomach o On barium studies, they produce an intraluminal filling defect without attachment to bowel wall o Interstices of bezoar are filled with barium
A trichobezoar in a mentally disturbed 14 year-old girl who was eating her own hair. Note the large filling defect occupying most of the stomach with barium mixed in within the interstices of the mass. A delayed film would show the barium remaining in the bezoar while exiting the rest of the stomach
Barium remains in bezoar for hours after exiting remainder of bowel Get delayed film if bezoar is suspected o Partial or complete bowel obstruction o CT Mobile intragastric mass consisting of "compressed concentric rings" A mixed density pattern due to the presence of entrapped air and food debris
Complications o Pressure necrosis of bowel wall may lead to perforation, peritonitis o Distal extension of the bezoar can lead to Obstructive jaundice Acute pancreatitis Protein-losing enteropathy Steatorrhea Mechanical small bowel obstruction alone or with perforation DDx o Lobulated, villous adenoma o Leiomyosarcoma
For a photo of a trichobezoar (not the one in the patient on this page), go to the following link at the National Museum of Health and Medicine: http://nmhm.washingtondc.museum/explore/anatifacts/4_trich.html
Gastric Trichobezoar - Narinder K Kaushik, Yash P Sharma, Asha Negi, Amal Jaswal: Ind J Radiol Imag 1999; 9 : 3 : 137139
LearningRadiology.com - Pseudotumor, Vanishing Tumor, Effusion, Minor fissue, fluid, loculated
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Pseudotumor / Vanishing Tumor of the Lung
Sharply marginated collection of pleural fluid contained either within an interlobar pulmonary fissure or in a subpleural location adjacent to a fissure Result from transudation from the pulmonary vascular space Commonly manifest as incidental radiographic findings in patients with congestive heart failure o Other causes of transudates include Hypoalbuminemia Renal insufficiency Imaging findings o Lenticular or biconvex contour o Located along the course of interlobar fissures Most occur in the minor (horizontal) fissure (more than 75%) and are seen on both the frontal and lateral radiograph Those that occur in the oblique or major fissure may only be seen on the lateral view well Infrequently, they occur in the horizontal and oblique fissures simultaneously o Most are less than 4 cm in size
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Frontal and lateral views of an 89 year-old female with an oval soft tissue density superimposed on the minor fissure on both the frontal and lateral views. The lesion has slight "points" where it abuts the minor fissure, a sign of a "pseudotumor" or "vanishing tumor" in the minor fissure. There are usually more signs associated with congestive heart failure than are seen in this patient. For a larger version of this photo, click here
Management o The underlying condition is managed o Typically an incidental finding that has minimal impact on patient management
Patients who develop pseudotumors tend to develop time repeatedly when the underlying condition causing the transudate (like CHF) returns Pseudotumors may be erroneously diagnosed as parenchymal lung nodules or masses Presence of an interlobar pleural effusion does not always correspond to the severity of the left heart failure o Occasionally, it may be the only sign of cardiac decompensation
Massive Pulmonary Pseudotumor: Brian M. Haus, BA; Paul Stark, MD; Scott L. Shofer, MD and Ware G. Kuschner, MD, FCCP Chest. 2003;124:758-760
LearningRadiology.com - Rounded Atelectasis,round,atelectasis,comet's,tail,asbestos
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Rounded Atelectasis
Occurs as a consequence of diseases with chronic pleural scarring, especially asbestos-related pleural disease and TB
Most often at the lung bases, posteromedially Must be subpleural in position
Pathophysiology
q
A rapidly forming pleural effusion produces an adjacent area of passive atelectasis A groove of visceral pleura may infold into the area of atelectasis and come to surround a part of it If the effusion recedes at once, the lung will probably re-expand If fibrinous adhesions form or if there is preexistent chronic pleural disease, then the atelectatic area of lung remains trapped by the enfolded visceral pleura
Asymptomatic: important because it resembles a bronchogenic ca
Imaging Findings
q
Rounded density at lung base Contiguous to area of pleural disease or superimposed on apparent asbestos-related pleural disease or TB
Comet tail on CT: vessels and bronchi converge upon and appear to swirl around mass Crows feet linear bands radiating from mass into lung parenchyma Linear densities radiate back toward hilum
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May have air bronchogram
Axial enhanced CT scan of the chest shows a nodular-area of increased density (blue arrow), associated with pleural thickening and pleural plaques (yellow arrows) consistent with asbestosrelated pleural disease. Red arrow point to "comet tail" density that surrounds rounded atelectasis. For a version of this photo without the arrows, click here
165
A. Renal cell carcinoma B. Medullary sponge kidney C. Polyarteritis nodosa D. Papillary necrosis
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LearningRadiology.com - Rheumatoid Arthritis,RA,Rheumatoid,Arthritis,Wrists,Erosions,Carpals
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Cause unknown o Possible genetic predisposition o Questionable reaction to antigen from Epstein-Barr virus Age o Highest incidence 40-50 years Female preponderance 3:1 under the age of 40 o M:F = 1:1 if >40 years
Pathogenesis o Injury to synovial endothelial cells leads to o Synovitis with synovial hypertrophy which leads to o Impaired nutrition with necrosis of cartilage and resultant o Joint narrowing Subluxation Ankylosis Clinical findings o Diagnostic criteria of American Rheumatism Association (at least 4 criteria should be present): Morning stiffness for >1 hour Swelling of >3 joints, particularly of wrist, metatarsophalangeal or proximal interphalangeal joints for >6 weeks Symmetric swelling Typical radiographic changes Rheumatoid nodules Biochemical tests o Positive rheumatoid factor Rheumatoid factor Positive in 85-94%) IgM-antibody
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Antinuclear antibodies Positive in many o LE cells Positive in some o Positive latex flocculation test o Location o Usually symmetric involvement of true, diarthrodial joints
Target areas o Proximal joints of hands and wrists All five MCP, PIP joints and interphalangeal joint of thumb All wrist compartments Especially radiocarpal, inferior radioulnar, pisiform-triquetral joints Early signs o Fusiform periarticular soft-tissue swelling (result of effusion) o Regional osteoporosis (disuse and local hyperthermia) o Widened joint space (rare to see) o Marginal and central bone erosions in small joints of hands and wrists Less common in large joints Site of first erosion is classically base of proximal phalanx of 4th finger o Erosion of the ulnar styloid and narrowing of the distal radioulnar joint o Atlantoaxial subluxation >2.5 mm (in >6%) o Giant synovial cysts Late signs o Diffuse loss of interosseous space o Flexion and extension contractures with ulnar subluxation and dislocation o Marked destruction of joint spaces o Extensive destruction of bone ends o Bony fusion o Elevation of humeral heads (from rotator cuff tears) o Resorption of distal clavicle o Erosion of superior margins of posterior portions of ribs 3-5 o Destruction and narrowing of disk spaces Irregular vertebral body outlines Absence of osteophytosis o Destruction of zygapophyseal joints without osteophyte formation o Resorption of spinous processes o "Stepladder appearance" of cervical spine due to subluxations o Protrusio acetabuli (from osteoporosis) o Synovial herniation and cysts (eg, popliteal cyst) o Calcaneal plantar spur
Frontal images of both the right (above) and left wrists (below) show advanced changes of rheumatoid arthritis with soft tissue swelling (yellow arrows), narrowing of the radiocarpal joint space (blue arrow). erosions (red arrows), and destruction of the ulnar styloid (green arrow). The intercarpal joints are destroyed as re all of the carpal-metacarpal joints of both hands. Note the symmetric appearance of the disease. For a version of this photo without the arrows, click here
Extra-articular manifestations (76%) o Feltys syndrome (<1%) Rheumatoid arthritis (present for >10 years) Splenomegaly Neutropenia Age o 40-70 years F>M o Rare in African-Americans Sjgrens syndrome (15%) Keratoconjunctivitis Xerostomia Rheumatoid arthritis Pulmonary manifestations Pleural effusion, mostly unilateral, without change for months Usually not associated with parenchymal disease Interstitial fibrosis with lower lobe predominance Rheumatoid nodules (30%) Well-circumscribed Peripheral Frequent cavitation Caplans syndrome Hyperimmune reactivity to silica inhalation with rapidly developing multiple pulmonary nodules Pulmonary hypertension secondary to arteritis
o o
Subcutaneous nodules o In 5-35% with active arthritis over extensor surfaces of forearm o Other pressure points (eg, olecranon) without calcifications (DDx to gout) Cardiovascular involvement o Pericarditis (20-50%) o Myocarditis (arrhythmia, heart block) o Aortitis (5%) of ascending aorta aortic valve insufficiency Rheumatoid vasculitis Neurologic sequelae o Distal neuropathy (related to vasculitis) o Nerve entrapment (atlantoaxial subluxation, carpal tunnel syndrome, Baker cyst) Lymphadenopathy (up to 25%) o Splenomegaly (1-5%)
Dahnert, 4th Edition
LearningRadiology.com - Cecal lipoma,cecum,lipoma,CT,mass,tumor,colon
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Colonic Lipoma
Uncommon tumors, but second in prevalence to adenomas for colonic tumors Tend to occur more frequently in older females Usually asymptomatic When symptomatic, can produce: o o o o Pain Diarrhea Rectal bleeding-if surface ulcerates Constipation
Almost all are submucosal Most are located on the right side (40%), but about 20% are in the sigmoid o In the small bowel, lipomas are more common proximally (duodenum)
Imaging findings o o o o o Usually less than 4 cm in size Smooth, sharply defined hemispheric mass Typically produces either right-angle or slightly obtuse angle as the lesion meets lumen of bowel Rarely pedunculated Squeeze-sign = deformity due to softness and compressibility of these lesions Contour may be altered by peristalsis
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o o
Ulceration is rare CT may demonstrate fatty nature of lesion, especially if they are large enough for accurate density
measurements
Axial CT image of right lower quadrant shows a large, lobulated filling defect in the cecum with well-circumscribed margins. The lower image demonstrates a negative Hounsfield values (-85HU) consistent with fat. The lesion represents a lipoma of the cecum.
May intussuscept Do not undergo malignant transformation
LearningRadiology.com - Nephrocalcinosis,medullary,sponge,kidney,calculi,stone,calculus,hyperparathyroid
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Medullary Nephrocalcinosis
Increased calcium content of kidneys o Usually applies to a generalized, rather than localized, increase in renal calcium content
Macroscopic nephrocalcinosis is nephrocalcinosis visible without magnification discovered by radiography, ultrasonography, or at autopsy Macroscopic nephrocalcinosis can affect either cortex or medulla o Medulla more common o Diffuse calcification rarely observed in chronic glomerulonephritis or long-standing chronic renal disease Cortical nephrocalcinosis is rare and usually occurs secondary to diffuse cortical disease o Calcification can be patchy or confluent Medullary nephrocalcinosis o Small nodules of calcification clustered in each pyramid
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Axial CT images through the region of the kidneys demonstrates bilateral calcifications clustered in the region of the renal medulla. Some are coarse in appearance. There is hydronephrosis of the right collecting system. The patient had an obstructing calculus in the right ureter. Click here for a larger photo
o Diagnosing underlying renal disease based on the appearance of calcification is difficult, except in the cases of Papillary necrosis due to analgesic abuse because the entire papilla may be calcified, and
Medullary sponge kidney where the sharp areas of calcification and uneven distribution may be seen Clinical findings o Calcium nodules commonly rupture through the papillary epithelium into the calyceal system to become urinary stones and, therefore, the presentation may be that of Renal colic Hematuria Urinary tract infection Passage of urinary stones o Macroscopic nephrocalcinosis should not be considered synonymous with urinary stones because it signifies a metabolic derangement and has broader implications o Episodes of urinary tract infections may occur o Polyuria and polydipsia may be prominent o Hypertension less common o Microscopic pyuria invariably found Represents chronic inflammatory response to medullary calcification o Distal tubular dysfunction is common with a mild salt-losing defect Causes o Primary hyperparathyroidism is single most common cause of nephrocalcinosis in adults Nephrocalcinosis related more to the duration than the intensity of hypercalcemia Nephrocalcinosis occurs in 5% of the cases of hyperparathyroidism o Distal Renal Tubular Acidosis is second most common cause of medullary nephrocalcinosis Both familial and secondary forms have high incidence Contributing mechanisms are hypercalcemia, acidosis, and reduced excretion of citrate in the presence of increased urinary pH Renal function is fairly well maintained o Other causes of nephrocalcinosis are Hhypervitaminosis D due to treatment of hypoparathyroidism or self-administration of vitamins Milk-alkali syndrome due to ingestion of milk or alkali for ulcer dyspepsia Sarcoidosis due to increased conversion of 25-hydroxycholecalciferol to 1,25dihydroxycholecalciferol within the sarcoid granuloma o In children with hypophosphatemic rickets, nephrocalcinosis increasingly being recognized as most common complication o Idiopathic hypercalciuria, one of the common metabolic diseases, also is known cause of nephrocalcinosis o Medullary sponge kidney is a common cause of medullary calcification in which calcium lies in ectatic collecting ducts rather than renal substance Calcium deposits are larger and more sharply defined than in metabolic disease They are uneven in distribution Associated hemihypertrophy of the body may exist Nephrocalcinosis associated with distal RTA and medullary sponge kidney usually is gross and renal function is relatively well preserved o Renal papillary necrosis associated with phenacetin-induced analgesic nephropathy is identified as calcified papillae rather than speckled pattern. o Rapidly progressive osteoporosis due to immobilization, menopause, senility, or steroids also may cause nephrocalcinosis o Hyperoxaluria, primary (familial) or secondary to increased intake of oxalates, enhanced absorption
due to intestinal disease, or ingestion of ethylene glycol or methoxyflurane can induce medullary calcification Prognosis o Depends mainly on the etiology of nephrocalcinosis o Major long-term complication in patients with medullary nephrocalcinosis is renal failure Early treatment of reversible causes of renal failure, such as treatment of urinary infections, calculous obstruction, and hypertension, is essential Once renal failure is established, it must be treated accordingly Patients with idiopathic hypercalciuria and medullary sponge kidney have the least risk of renal failure and the best prognosis, whereas patients with primary type 1 hyperoxaluria have the worst prognosis
Author: Mahendra Agraharkar, MD, FACP, President, Space City Associates of Nephrology; Medical Director, Acute Dialysis Unit and Chronic Home Dialysis Unit, Gambro Healthcare Reliant Dialysis Center; Coauthor(s): Rajiv Gupta, MD, Fellow, Department of Medicine, Division of Cardiology, John Sealy Hospital, University of Texas Medical Branch at Galveston. eMedicine Nephrocalcinosis
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Pulmonary Thromboembolic Disease

Age o Usually occurs after 60 years of age Cause o Most common cause is deep vein thrombosis (DVT) of lower extremity in >90% Predisposing factors o Immobilization (56%) o Surgery (54%)
Pathophysiology o Clot from deep veins of leg breaks off o Travels via venous system to right side of heart o Fragments in right side of heart o Showers lung with emboli varying in size On average > 6-8 vessels are embolized Clinical findings o Hemoptysis (25-34%) o Pleural friction rub o Thrombophlebitis But only about 10-33% of patients with fatal pulmonary embolism (PE) are symptomatic for DVT o Acute dyspnea (81-86%) o Pleuritic chest pain (58-72%) o Apprehension (59%) o Cough (54-70%) o Tachycardia o Tachypnea o Accentuated 2nd heart sound o EKG changes (83%) Mostly nonspecific
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o o
Elevated levels of fibrinopeptide-a (fpa) = small peptide split off of fibrinogen during fibrin generation Positive d-dimer assay (generated during clot lysis)
Location of pulmonary emboli o Bilateral emboli in 45% o Right lung only in 36% o Left lung only in 18% o Multiple emboli [3-6 on average] in 2/3 Distribution by lobe o Lower lobes more often than upper lobes o RUL (16%) o RML (9%) o RLL (25%) o LUL (14%) o LLL (26%) Site central versus peripheral o Central = segmental or larger veins in 58% o Peripheral = subsegmental or smaller veins in 42% o In subsegmental branches exclusively in 30% o Emboli are occlusive in 40%
Resolution of pulmonary embolism o Through fibrinolysis and fragmentation o By time interval In 8% by 24 hours 56% by 14 days 77% by 7 months o By completeness Complete in 65% Partial in 23% No resolution in 12% Resolution less favorable with increasing age and cardiac disease Embolism without infarction (90%) o Dual blood supply of lungs pulmonary and bronchial Imaging findings in embolic disease without infarction o Normal chest film common o Normal chest x-ray has a negative predictive value of only 74% o Plate-like (subsegmental, discoid) atelectasis o Lobar consolidation in lower lung zones and pleural effusion (most common findings with the lowest positive predictive value) o Westermark sign represents an area of oligemia (due to vasoconstriction distal to embolus) Uncommonly seen
Axial CT image just below level of tracheal bifurcation demonstrates large intraluminal filling defects in both right and left pulmonary arteries representing a "saddle embolus" straddling the pulmonary arteries.
o Fleischner sign refers to local widening of artery by impaction of embolus (due to distension by clot / pulmonary hypertension developing secondary to peripheral embolization) o "Knuckle sign" is term used for abrupt tapering of an occluded vessel distally Imaging findings in embolism with infarction o Segmentally distributed wedge-shaped consolidation (54%) With or without cavitation o Hampton hump is a pleural-based area of consolidation in the form of a truncated cone with base against pleural surface o Pleural effusion in slightly over 50% Thoracentesis Bloody (65%) Predominantly PMNs (61%) Exudate (65%) o Usually no air-bronchogram because of hemorrhage into alveoli o "Melting sign" is the sign that refers to disappearance of the opacification within few days to weeks from periphery toward center
o o o o o
Fleischner lines = long-line shadows (fibrotic scar) Plate-like (subsegmental, discoid) atelectasis (27%) Cardiomegaly or CHF (17%) Elevated hemidiaphragm (17%) Subsequent nodular or linear scar more often than pneumonia leads to scarring
CT findings (can be equal to angio in detection of emboli within proximal arteries): o Subsegmental intraluminal filling defects may not be detectable o Detection is poorer in middle lobe and lingular branches o Peripheral wedge-shaped lung densities with the triangle base adjacent to pleural surface o Peripheral rimlike contrast enhancement in a pulmonary artery o Intraluminal filling defect in pulmonary artery
NUC (VQ scan = guide for angiographic evaluation) Interpreted in reference to Biello or PIOPED criteria o Low- / intermediate-probability scans (73%) Additional studies recommended o High-probability scan In 12% normal angiogram Angiographic findings o Intraluminal defect (94%) o Abrupt termination of pulmonary arterial branch o Pruning and attenuation of branches o Wedge-shaped parenchymal hypovascularity o Absence of draining vein in affected segment o Tortuous arterial collaterals o Complications of pulmonary angiography Arrhythmia, endocardial injury, cardiac perforation, cardiac arrest, contrast reaction
Dahnert 4th Edition
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LearningRadiology.com - Leptomeningeal cyst,growing fracture,leptomeninges,dura,tear,skull,fracture,complication
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Leptomeningeal Cyst
Sometimes called a growing fracture Age o Usually <3 years Incidence o Rare - <1% of pediatric skull fractures Clinical findings o Usually detected by parents who note a soft, cystic mass developing on skull of child
Pathogenesis o Skull fracture with dural tear leads to herniation of pia and arachnoid layers (leptomeninges) through the dural tear o Cerebrospinal fluid pulsations lead to progressive erosion of skull around the fracture site o Margins of the fracture will still be apparent months after injury and there will be greater diastasis of the fracture as time goes on than when first injured Imaging findings o Angular, linear lytic lesion in the skull with scalloped margins
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Left lateral radiograph of the skull reveals a sharply marginated, angular, linear lucency in the posterior parietal-occipital region at the site of a previous linear skull fracture. This is the characteristic appearance of a leptomeningeal cyst. For a version of this photo without the arrows, click here
o Brain extrusion may occur shortly after the fracture in neonates and young infants leading to focal dilatation of the lateral ventricle near the growing fracture o MRI Cyst isointense with CSF and communicating with subarachnoid space Area of encephalomalacia underlying fracture (frequent) Intracranial tissue extending between edges of bone Treatment o Surgical repair of the dura and resection of the cyst
LearningRadiology.com - Pulmonary contusion,trauma,lung,blunt,pulmonary,contusion,motor,car,accident,unrestrained,driver
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Pulmonary Contusion
Most common manifestation of blunt chest trauma o Found especially in unrestrained drivers in motor vehicle collisions (deceleration injuries) Pathology o Hemorrhage into the lung parenchyma produces airspace disease Almost always radiographically apparent within 6 hours after trauma o May be clinically inapparent o Hemoptysis is most frequent symptom (50%) Located posteriorly in lungs in most cases (60%) o Usually at the site of direct impact o But may occur on side opposite impact (contrecoup injury) May mask an underlying pulmonary laceration which may become more apparent after contusion clears Imaging findings o Patchy or diffuse areas of airspace disease indistinguishable from any other cause of airspace disease except for the role of trauma and absence of air bronchograms Bronchi are filled with blood o Hallmark is rapid resolution May be complete within 24-48 hours but more often takes about 3 days to clear o Overlying rib fractures (frequent)
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Frontal chest radiograph demonstrates airspace disease in the region of the superior segment of the left lower lobe (blue arrow). The red arrows point to multiple, acute rib fractures. The patient was an unrestrained occupant in a motor vehicle collision and struck the dashboard with his chest. For a version of this photo without the arrows, click here CT findings Nonsegmental coarse ill-defined crescentic (50%) / amorphous (45%) opacification of lung parenchyma without cavitation "Subpleural sparing" outer 1-2 mm rim of uniformly non-opacified subpleural portion of lung Differential diagnosis o If the consolidation lasts longer than 72 hours, consider Aspiration Pneumonia ARDS
Dahnert 4th Edition The Requisites: Thoracic Radiology, Theresa McCloud, editor
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LearningRadiology.com - Toxoplasmosis,HIV,Aids,immunocomromise
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Toxoplasmosis
Ring Enhancing Lesions in a patient with AIDS

Submitted by Marion Brody, MD Diagnoses to consider in anyone with multiple ring-enhancing lesions: o Metastatic disease o Demyelinating disease o Infection Leading diagnoses in patients with advanced AIDS who have CNS abnormality: o Toxoplasma encephalitis (T. Gondii) o Primary CNS Lymphoma (EBV) o PML (JC) o HIV Encephalopathy (HIV) o CMV Encephalitis (CMV)
Other diagnoses to consider in patients with advanced AIDS who have CNS abnormality: o TB (in developing countries) o Staphylococcus, Streptococcus, Salmonella, Nocardia,, Rhodococcus, Listeria; o Cryptococcus; Histoplasmosis; Candidiasis; Coccidioidomycosis; Aspergillosis; Trypanosomiasis; Herpetic meningoencephalitis; Neurocysticercosis; Meningovascular syphilis; Amebic abscesses How does the physician avoid a brain biopsy? Leading diagnoses in patients with advanced AIDS who have Mass Lesions: o Toxoplasma encephalitis (T. Gondii) 50% of all brain lesions in AIDS patients. o Primary CNS Lymphoma (EBV) 30% of all brain lesions in AIDS patients o (PML, HIV-associated encephalopathy, and CMV encephalitis usually do not cause mass lesions) History o Toxo
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Headache, confusion, +/- fever; focal weakness, seizures; if advanced, dull affect o Lymphoma All of above and constitutional symptoms (night sweats, weight loss) o PML Rapid neurologic decline (hemiplegia, visual field defects, ataxia, aphasia) o HIV Encephalopathy Progressive memory loss, depression, movement disorders o CMV encephalitis Confusion, focal deficits Laboratory tests o Blood: Anti-toxoplasma IgG antibodies are almost always positive if patient has toxo encephalitis Toxo IgM Abs generally are not detectable in acute infxn; Toxo IgG quantitative levels do not reflect disease activity. Patients with toxo usually have CD4 < 100 Patients with CMV encephalitis usually have CD4< 50 o A lumbar puncture is contraindicated if patient has lesions producing mass-effect and has focal signs o CSF: Toxo, PCNSL, and PML shows <500 lymphs/uL, increased protein, normal glucose. Lymphoma may or may not show abnormal lymphocytes o Toxo PCR is 50% sensitive, up to 100% specific. o EBV PCR sensitivity/specificity varies with testing center o JC virus PCR is up to 93% sensitive and specific o CMV PCR is 80% sensitive, 90% specific Imaging on CT and MRI o Toxoplasma Encephalitis Thin-walled ring-enhancing lesions, surrounding edema; rarely diffuse encephalitis Multiple lesions 80% Usually hyperintense with hypointense rim on T2 (can have decreased signal in central areas from calcium and hemorrhage) Basal Ganglia, G/W junction; parietal, frontal, thalamus More likely to appear in posterior fossa than PCNSL < 4 cm
T1 weighted, gadolinium-enhanced sagittal MRI images of the brain demonstrate two ring-enhancing lesions, one (red arrows) in the thalamus and the other (yellow arrow) in the cerebellum. For a version of this photo without the arrows, click here
Primary CNS Lymphoma Ring-enhancing lesions, surrounding edema Multiple lesions 50% Variable signal on T2; isointense or hypointense on T1
Basal Ganglia, deep white matter More likely to cross corpus callosum or occur in periependymal areas than TE Can be > 4cm o PML: Multiple areas of demyelination, without contrast-enhancement or edema Bilateral, asymmetric; hypointense on T1, hyperintense on T2 Can see atypical enhancing lesions with immune reconstitution syndrome Periventricular and subcortical white matter (rarely grey matter) o HIV Encephalitis: Indistinct lesions in subcortical white matter Symmetric; hyperintense on T2 o CMV Encephalitis: Scattered micronodules in the cortex, BG, brain stem, and cerebellum; or Large ventricles with periventricular enhancement/hyperintensity on T2; or Ring-enhancing lesions with edema Other imaging modalities: o SPECT lymphoma greater thallium uptake than Toxo o PET lymphoma greater glucose + methionine uptake than Toxo o Perfusion MRI Increased flow in lymphoma, decreased in Toxo o MR Spectroscopy TBA Take home points o 90% likelihood its Toxo if all of the following criteria are met: Toxo IgG (+) in serum. Patient with a CD4 < 100 is not receiving prophylaxis for Toxo Multiple ring enhancing lesions on CT or MRI o In these cases, often patient is treated presumptively for Toxo o If its Toxo, should see clinical improvement in 1 week (caveat: steroids can improve immediate symptoms by reducing brain edema without any true reduction in severity of infection) o If its Toxo, should see radiographic improvement within 2 weeks
Chepuri, NB. Ring Enhancing Cerebral Lesions. In Magnetic Resonance Imaging of CNS Disease, York DH (Ed.), 2002. Mosby, Philadelphia, PA. Heller, HM. Toxoplasmosis in HIV-infected patients. In: Up To Date, April 23, 2005, Aronson, MD, Fletcher, RH, Fletcher, HW, Rind, DM (Eds.) Waltham, MA. Koralnik, IJ. Approach to HIV-infected patients with central nervous system lesions. In: Up To Date, March 30, 2005, Aronson, MD, Fletcher, RH, Fletcher, HW, Rind, DM (Eds.) Waltham, MA.
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LearningRadiology.com - Giant Hemangioma of Liver,Giant,MRI,enhancement,contrast,imaging,liver
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Giant Cavernous Hemangioma of the Liver
Submitted by Matt Hoffman, MD Hemangiomas are the most common benign hepatic neoplasm Incidence of approximately 20% Occur more commonly in women These lesions tend to be stable, though may enlarge during pregnancy or with estrogen administration Clinical findings o Usually asymptomatic and discovered incidentally o Large lesions may cause pain, nausea, or vomiting secondary to extrinsic compression of adjacent bowel, rupture, hemorrhage, or thrombosis o Large hemangiomas may sequester platelets and produce thrombocytopenia and DIC, a condition know as Kasabach-Merritt syndrome Histopathology o Hemangiomas are composed of large vascular channels filled with slowly moving blood and are lined by a single layer of endothelial cells o Giant hemangiomas (measuring greater than 6 cm) can contain hemorrhage, thrombus, calcification, or fibrosis o Larger lesions are less common, comprising less than 10% of all hemangiomas Imaging o Since hemangiomas are often detected incidentally, the importance of imaging lies in the fact that they must be differentiated from more clinically significant lesions, such as primary and secondary hepatic malignancies Ultrasound o Usually homogeneous o Well-defined hyperechoic masses (though few can appear relatively hypoechoic when imaged within a fatty liver) o Giant lesions can appear heterogeneous secondary to internal complex composition o Posterior acoustic enhancement is commonly seen
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Nuclear Imaging o On 99mTc-sulfur colloid scintigraphy, hemangiomas appear as focal photopenic areas o 99mTc-pertechnetate-labeled RBC SPECT is a more specific examination Early dynamic images yield focal photopenic areas that gradually increase in activity over time Limited utility for lesions smaller than 2-3cm due to poor spatial resolution CT o Focal, well-circumscribed, low attenuation lesions on pre-contrast images o Nodular, peripheral centripetal enhancement on dynamic contrast enhanced imaging MRI o Has a sensitivity and specificity of greater than 90% and is the imaging modality of choice o Typically hemangiomas are homogeneously hypointense relative to the liver on T1-weighted and markedly hyperintense (lightbulb sign) on T2-weighted images relative to the liver o On dynamic, contrast-enhanced MR imaging, hemangiomas can demonstrate immediate homogeneous enhancement (lesions < 1.5cm) o Peripheral, nodular centripetal enhancement pattern progressing to homogeneity (lesions 1.5-5cm) o Peripheral nodular centripetal enhancement with persistent central hypointense region (lesions> 5cm)
Giant cavernous hemangioma of the liver: Axial T1-weighted pre-contrast image
shows a hypointense mass within the right hepatic lobe. Sequential enhanced delayed images show peripheral nodular centripetal enhancement with persistent central hypointensity For a static Image of this Case, Click Here
o Giant hemangiomas often do not achieve complete isointensity on delayed images due to their complex internal composition These larger lesions still should demonstrate the characteristic peripheral nodular enhancement MRI appearance is that of a well-defined, heterogeneous mass with areas of bright signal on T2weighted images, cleft-like areas of low intensity on T1, and low intensity internal septae on all pulse sequences
Reference: Semelka RC, Sofka CM: Hepatic Hemangiomas. MRI Clinics of North America. Volume 5 Number 2:241-252. May 1997.
LearningRadiology.com - Anterior Dislocation, shoulder,Hill-Sach,Hill-Sack,trauma,fracture,Bankart
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Anterior Dislocation of the Shoulder
Glenohumeral dislocation most common shoulder dislocation (85%) Glenohumeral joint dislocations make up >50% of all dislocations in the body Anterior / subcoracoid shoulder dislocation (96%) Mechanism o External rotation and abduction and external rotation Age o Younger individuals May be associated with o Hill-Sachs defect (50%) is a depression fracture of posterolateral surface of humeral head from impaction of the head against glenoid rim in subglenoid type Best demonstrated on the AP projection with the arm internally rotated o Bankart lesion is a fracture of anterior aspect of inferior glenoid rim Only cartilaginous portion of glenoid labrum may be fractured which may only be visible on MRI o Fracture of greater tuberosity (15%) Complications o Recurrent dislocations (40%) o Post-traumatic arthritis o Injury to axillary nerve or artery
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Anterior Dislocation of the Humeral Head: Top image shows humeral head displaced from glenoid and lying inferior to the coracoid process (red arrow); the middle image demonstrates a defect along the posterolateral aspect of the head, which is the Hill-Sach's deformity (green arrow). The lower image is the scapular Y view (blue line outlines scapula). The head lies in a subcoracoid (i.e. anterior location). The white arrows point to the acromion. For the same photo with out the arrows, click here
Dahnert 4th edition Orthopedic Radiology, Adam Greenspan
LearningRadiology.com - Ulcerative Colitis,ulcerative,colitis,lead-pipe,colon,barium,enema,air contrast,double contrast
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Ulcerative Colitis
Pathology
o o o Predominantly mucosal disease, possible auto-immune producing crypt abscesses Usual age at onset is 20-40; another peak at 60-70 Equal male:female ratio
Clinical
o o o o o o o o o Recurrent episodes of bloody diarrhea Electrolyte depletion Abdominal pain Fever Periods of exacerbation and remission Iritis, erythema nodosum, pyoderma gangrenosum Pericholangitis, chronic active hepatitis, sclerosing cholangitis, fatty liver Spondylitis, peripheral arthritis, RA (10-20%) Thrombotic complications
Location
o o o Begins in rectum with retrograde progression Rectosigmoid involved 95%; continuous involvement of left colon Terminal ileum in 5-10% with backwash ileitis
o o Acute inflammatory stage Spasm and irritability Fine mucosal granularity=earliest finding on air-contrast BE
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o o o o o o o o
Spiculated, serrated bowel margins from tiny, multiple ulcerations Collar button ulcers-from undermining (not specific for ulcerative colitis) Double-tracking=long, longitudinal ulcers in submucosa Thumbprinting=from edema of wall Pseudopolyps=scattered islands of edematous mucosa in a sea of ulcerated mucosa Widening of the pre-sacral space Subacute stage Coarser, more granular mucosa Inflammatory polyps= frond-like lesions of inflamed mucosa
Chronic stage o Shortening of the colon-may be from spasm of longitudinal muscles or from irreversible fibrosis (leadpipe colon) o Loss of haustrations on left side of colon
Barium enema examination demonstrates loss of haustral folds in the entire descending colon with small ulcerations suggested. The colon has a "lead-pipe" appearance. The distribution and appearance are suggestive of ulcerative colitis. Click here for a larger version of the same photo
o o
Post-inflammatory polyps=filiform polyps=long worm-like lesions Backwash ileitis (5-10%)=wide open ileocecal valve and dilated terminal ileum
o o o o o o Crohns diseaseskip lesions: R colon; TI abnormal Cathartic colon-loss of haustrations on Right side of colon; rectum spared Familial polyposismultiple polyps but no inflammatory changes Radiation ileitisshould have other loops involved and appropriate hx Lymphomashould have tumor masses, less spasm Amebiasiscone-shaped cecum
o o o o o o o o o Fatty infiltration of the liver Gallstones (28-34%) Sclerosing cholangitis Bile duct carcinoma Amyloidosis Urolithiasis: oxalate/uric acid stones Migratory arthritis Sacroiliitis and ankylosing spondylitis Erythema nodosum and uveitis
Complications
o o Toxic megacolon Adenocarcinoma of the colon (1-16%) Increased risk of developing ca of colon with long-standing (usually more than 25 years) ulcerative colitis o Higher incidence of multiple carcinomas Usually involve distal transverse colon, descending colon and rectum o May present with smooth, tapering edges and resemble a benign stricture or may be annular o constricting lesions o Colonic strictures (10%) Smoothly tapering edges, usually single, commonly in sigmoid; must be differentiated from ca o
LearningRadiology.com - Stress Fracture,tibia,fatigue,fracture,stress,insufficiency,Brodie's,abscess
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Stress Fracture
Fractures produced as a result of repetitive stress on bone Most common locations o Lower extremity (calcaneus, tibia, fibula) o Thoracic vertebra o Sacrum o Ilium o Pubic bone General risk factors o New / different / rigorous repetitive activity o Female sex o Increased age o Caucasian race o Low bone mineral density o Low calcium intake Specific risk factors and bones involved o Clay shovelers fracture Spinous process of lower cervical / upper thoracic spine o Clavicle Postoperative (radical neck dissection) o Coracoid process of scapula Trap shooting o Ribs Carrying heavy pack, golf, coughing o Distal shaft of humerus Throwing ball o Coronoid process of ulna Pitching ball, throwing javelin, pitchfork work, propelling wheelchairs o Hook of hamate
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Swinging golf club / tennis racquet / baseball bat o Spondylolysis Ballet, lifting heavy objects, scrubbing floors o Femoral neck Ballet, long-distance running o Femoral shaft Ballet, marching, long-distance running, gymnastics o Obturator ring of pelvis Sooping, bowling, gymnastics o Patella Hurdling o Tibial shaft Ballet, jogging o Fibula Long-distance running, jumping, parachuting o Calcaneus Jumping, parachuting, prolonged standing, recent immobilization o Navicular Stomping on ground, marching, prolonged standing, ballet o Metatarsal (commonly 2nd MT) Marching, stomping on ground, prolonged standing, ballet, postoperative bunionectomy o Sesamoids of metatarsal Prolonged standing X-ray o 15% sensitive in early fractures, increasing to 50% on follow-up o Sclerotic band (due to trabecular compression and callus formation) usually perpendicular to cortex o Intracortical radiolucent striations (early) o Solid thick lamellar periosteal new bone formation o Endosteal thickening (later) o Follow-up radiography after 2-3 weeks of conservative therapy may reveal fracture not seen earlier
two views of the tibia and fibula in a younger woman show a transverse lucency in the cortex surrounded by cortical thickening. There is no periosteal reaction. The patient was a dancer. The tibia is a relatively common site for stress fractures. Click here for a larger version of the same photo
Nuclear medicine o Gold standard" = almost 100% sensitive o Abnormal uptake within 6-72 hours of injury (prior to radiographic abnormality) o "Stress reaction" is a focus of subtly increased uptake o Focal fusiform area of intense cortical uptake o Abnormal uptake persists for months MRI o Very sensitive modality o Fat saturation technique most sensitive to detect increase in water content of medullary edema / hemorrhage o Diminished marrow signal intensity on T1WI o Increased marrow signal intensity on T2WI CT is the least sensitive modality Differential diagnosis o Osteoid osteoma (eccentric, nidus, solid periosteal reaction, night pain) o Chronic sclerosing osteomyelitis Brodies abscess (dense, sclerotic, involving entire circumference, little change on serial radiographs) o Osteomalacia (bowed long bones, looser zones, gross fractures, demineralization)
Dahnert 4th Edition
LearningRadiology.com - Bronchopulmonary sequestration,pulmonary,sequestration,intralobar,extralobar
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Submitted by Samir Jethwa, MS14
q q
Bronchopulmonary sequestration (BPS) is a rare congenital malformation of the lower respiratory tract. It consists of a nonfunctioning mass of normal lung tissue that lacks normal communication with the tracheobronchial tree, and that receives its arterial blood supply from the systemic circulation. BPS is estimated to comprise 0.15 to 6.4 percent of all congenital pulmonary malformations, making it an extremely rare disorder.
Sequestrations are classified anatomically. r Intralobar sequestration (ILS) in which the lesion is located within a normal lobe and lacks its own visceral pleura. r Extralobar sequestration (ELS) in which the mass is located outside the normal lung and has its own visceral pleura q The blood supply of 75% of pulmonary sequestrations is derived from the thoracic or abdominal aorta. r The remaining 25% of sequestrations receive their blood flow from the subclavian, intercostal, pulmonary, pericardiophrenic, innominate, internal mammary, celiac, splenic, or renal arteries. Intralobar sequestration The intralobar variety accounts for 75 percent of all sequestrations. Usually presents in adolescence or adulthood as recurrent pneumonias. Lies within the same visceral pleura as the lobe in which it occurs. Males and females are equally affected with ILS. In ILS, the arterial supply usually is derived from the lower thoracic or upper abdominal aorta. Venous drainage is usually to the left atrium via pulmonary veins establishing a left to right shunt. o Abnormal connections to the vena cava, azygous vein, or right atrium may occur.
q Two thirds of the time, the sequestration is located in the paravertebral gutter in the posterior segment of the left lower lobe. Unlike extralobar sequestration, it is rarely associated with other developmental abnormalities. Patients present with signs and symptoms of pulmonary infection of a lower lobe mass. o It is believed that sequestrations become infected when bacteria migrate through the pores of Kohn or if the sequestration is incomplete. Extralobar sequestration The extralobar variety accounts for 25 percent of all sequestrations. ELS usually presents in infancy with respiratory compromise.
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Develops as an accessory lung contained within its own pleura. ELS has a male predominance (80%). Related to the left hemidiaphragm in 90% of cases. o ELS may present as a subdiaphragmatic or retroperitoneal mass.
In general, the arterial supply of ELS comes from an aberrant vessel arising from the thoracic aorta. It usually drains via the systemic venous system to the right atrium, vena cava, or azygous systems. Congenital anomalies occur more frequently in patients with ELS than ILS. o Associated anomalies include Congenital cystic adenomatoid malformation (CCAM), congenital diaphragmatic hernia, vertebral anomalies, congenital heart disease, pulmonary hypoplasia, and colonic duplication Since it is enveloped in its own pleural sac, it rarely gets infected so almost always presents as a homogeneous soft tissue mass. The mass may be closely associated with the esophagus, and fistulae may develop.

Imaging
An arteriogram has been considered vital in documenting the systemic blood supply, allowing definitive diagnosis as well as preoperative planning. The advent of new noninvasive imaging techniques has changed this thinking. Chest radiograph Sequestrations typically appear as a uniformly dense mass within the thoracic cavity or pulmonary parenchyma. Recurrent infection can lead to the development of cystic areas within the mass. Air-fluid levels due to bronchial communication can be seen. Ultrasound The typical sonographic appearance of BPS is an echogenic homogeneous mass that may be well defined or irregular. Some lesions have a cystic or more complex appearance. Doppler studies are helpful to identify the characteristic aberrant systemic artery that arises from the aorta and to delineate venous drainage. CT CT scans have 90% accuracy in the diagnosis of pulmonary sequestration. The most common appearance is a solid mass that may be homogeneous or heterogeneous, sometimes with cystic changes. Less frequent findings include a large cavitary lesion with an air-fluid level, a collection of many small cystic lesions containing air or fluid, or a well-defined cystic mass. Emphysematous changes at the margin of the lesion are characteristic and may not be visible on the chest radiograph. CT technique for optimal depiction of lesions by using state-of-the-art volumetric scanning requires a fast intravenous (IV) contrast injection rate and appropriate volume and delay based upon size. Multiplanar and 3D reconstructions are helpful. MRI Contrast-enhanced MRA or even conventional T1-weighted spin-echo (SE) images may help in the diagnosis of pulmonary sequestration by demonstrating a systemic blood supply, particularly from the aorta, to a basal lung mass. In addition, MRA may demonstrate venous drainage of the mass and may obviate more invasive investigations. However, CT allows sharper delineation of thin-walled cysts and emphysematous changes than MRI.
CT with IV contrast of the thorax showing an Intralobar Bronchopulmonary Sequestration. The yellow arrow in frames A and B point to a hyperdense region in the left lower lobe of the lung with small cystic lesions containing air within it. The red arrows in frames C and D show a contrast enhanced vessel arising from the aorta and supplying the area of hyperdensity in the lung. Click here for a larger version of the same photo
REFERENCES
Grainger & Allison's Diagnostic Radiology: A Textbook of Medical Imaging, 4th ed., 2001 Churchill Livingstone, Inc. pp 654655. Khan, Ali Nawaz, Bronchopulmonary Sequestriation, e-Medicine, http://www.emedicine.com/radio/topic585.htm. Oermann, Christopher M, Bronchopulmonary Sequestration, Up to Date, http://www.utdol.com/application/topic.asp? file=pedipulm/10425&type=P&selectedTitle=4~6.
LearningRadiology.com - Fibromuscular Dysplasia, Fibromuscular Hyperplasia, String of beads, Renal Artery, CT, Hypertension
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Fibromuscular Dysplasia (Hyperplasia)

Submitted by Ab Shrivastava, MD
Demographics o Incidence 0.6% via angiography 1.1% via autopsy o Female to male ratio 3:1 o Presenting age 25-50 Pathology o Developmental lesion of unknown etiology which can affect multiple vessels. o Consists of areas of heaped-up intima, adventia, and media alternating with areas of medial destruction resulting in small focal aneurysms. o 3 histologic types Intimal fibroplasia Medial fibroplasia, and Subadventitial (perimedial) fibroplasia of the arterial wall 3 subtypes not always apparent on imaging. Classic string of beads appearance on angiography for medial fibroplasias o Some authors describe 5 total subtypes. Medial fibroplasias divided into medial fibroplasia with aneurysm and medial fibromuscular dysplasia. Perimedial fibroplasias subdivided into subadventitial and adventitial fibroplasias o Medial fibroplasias most common Symptoms o Renovascular hypertension (if bilateral renal arteries involved). o Transient ischemic attack o Intracranial aneurysm/thromboembolic stroke o Often asymptomatic Location o Renal arteries 85%
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Only 40% have bilateral renal artery involvement o Most often middle and distal 1/3 of renal arteries involved o Less commonly affected: Internal carotid (often bilateral), vertebral, mesenteric, celiac, hepatic, iliac arteries o If fibromuscular dysplasia (FMD) is found at any location, one must evaluate carotid arteries for lesions Diagnosis o Angiography considered gold standard. CTA and MRA becoming more sensitive. o FMD is characterized by Narrowing of the affected vessel with a string of beads or nodular appearance, due to focal annular repetitive intimal and medial proliferative changes
CT of the abdomen with IV contrast demonstrates nodularity (string-of-beads sign) of the right renal artery (arrows) characteristic of fibromuscular dysplasia (hyperplasia) Click here for the same photo without arrows
Differential o Really a classic appearance o Only entity on differential is atherosclerosis Treatment o If symptomatic (intractable hypertension), improvement to renal blood flow can be me made via surgery or angioplasty o Angioplasty is less invasive and cure rate is approximately 50% and improvement in 30% of patients
Angioplasty suitable for noncalcified short segments Surgery reported to have lower re-stenosis rate and greater improvement in GFR
REFERENCES
http://www.uhrad.com/ctarc/ct015.htm http://www.emedicine.com/radio/topic280.htm http://chorus.rad.mcw.edu/doc/00719.html
LearningRadiology.com - Kienbock's Disease,Osteomalacia,avascular necrosis,avn,wrist
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Kienbock's Disease (Lunatomalacia)

Submitted by Seema Hasan, MD
Avascular necrosis of lunate bone Predisposed o Individuals engaged in manual labor with repeated or single episode of trauma Frequency o Usually affects men aged 20-40 yrs. o Mostly unilateral o More often in right wrist
Pathophysiology o Vascular impairment due to acute or chronic injury Exact cause is unknown o Lunate develops osteonecrosis due to loss of blood supply, causing pain and stiffness in the wrist o In late stages, the bone collapses eventually leading to degenerative changes and osteoarthritis in the radiocarpal joint Clinical findings o Progressive pain o Soft-tissue swelling of wrist Imaging findings o The disease can be staged based on radiographic findings Lichtman's Radiographic Classification of Kienbock's Disease Stage I - Normal radiograph Stage II - Sclerosis of lunate with possible decrease of lunate height on radial side only Stage IIIa - Lunate collapse, no scaphoid rotation Stage IIIb - Lunate collapse, fixed scaphoid rotation Stage IV - Degenerative changes around the lunate The disease may also be associated with negative ulnar variance
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Frontal view of the hand and wrist demonstrates sclerosis, irregularity and collapse of the lunate (blue arrows) in Kienbock's Disease (Kienbock's Osteomalacia) Click here for the same photo without arrows
o Bone scan and MRI may be helpful early in the course of the disease when there are minimal radiographic findings Treatment o Initial therapy is conservative management o Anti-inflammatory medications and splinting or casting o Operative treatment is based on the stage of the disease and may involve Revascularization procedures Ulnar lengthening or radial shortening Fusion or excision of carpal bones
REFERENCES
eMedicine,"Kienbck Disease" : Article by Brian J Divelbiss, MD Wheelessonline.com, "Kienbock's disease: Lunatomalacia"
LearningRadiology.com - Carcinoma of the Colon, Colon cancer,apple-core,annular,constricting,cancer,colon,colonic,large bowel
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Carcinoma of the Colon
Risk Factors
o o o o o o o o o o
o
Adenomatous polyp Family history of benign or malignant colon tumors Chronic ulcerative colitis Crohns disease Prior pelvic radiation In women who have carcinoma of breast or uterus Retinitis pigmentosa Familial polyposis Gardeners syndrome For synchronous lesions=1% (two or more colon cas at same time) For metachronus lesions=4-5% (likelihood of a person with colon ca developing 2nd)
Pathology
o o o Adenocarcinomas make up the vast majority Squamous cell carcinoma can start at the anal verge Cloacogenic carcinoma spreads mostly by direct invasion
Clinical
o o o o o Peak age 50-70 years Weight loss Blood in stool Loss of appetite Change in bowel habits
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Location
o Rectum (15%), sigmoid (20%), descending colon (10%), transverse colon (12%), ascending colon (8%), cecum (8%) Location seems to be changing and moving back to cecum o o o More common in right colon with advancing years More common in left colon with chronic ulcerative colitis
Imaging findings
o o o 90-95% rate of detection by BE Polypoid filling defect Annular constricting=apple-core lesion
Spot film from a double contrast barium enema of the rectum and distal sigmoid colon demonstrates a typical annular constricting carcinoma of the colon with overhanging edges on both the proximal and distal margins forming a so called "apple-core" lesion. Click here for enlarged photo
o o
Scirrhous ca-rare infiltrating type which gives lead-pipe appearance seen especially in o ulcerative colitis Calcifications-rare May have retrograde without antegrade obstruction
Mets to colon
o o
Stomach, breast, pancreas, and GU pelvic malignancies via blood May also spread via intraperitoneal seeding, especially from ovary
Complications
o o o o o Obstruction-antegrade/retrograde or both Perforation is relatively common Carcinomas of the transverse colon can spread via direct extension to stomach Intussusception of lesions in TI or cecum Ischemic colitis may occur if chronic obstruction
Metastases
o o o o o Liver (25%) Retroperitoneal and mesenteric nodes (15%) Hydronephrosis (13%) Adrenal (10%) Ovarian mets Ascites
Complications
o o o o Obstruction-may be retrograde but not antegrade More likely to be left-sided than right-sided Perforation Intussusception Pneumatosis intestinalis
LearningRadiology.com - rheumatoid arthritis,laxity, ligament,subluxation, C1,C2,arthritis,rheumatoid,late,complication
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Cause unknown o Possible genetic predisposition o Questionable reaction to antigen from Epstein-Barr virus Age o Highest incidence 40-50 years Female preponderance 3:1 under the age of 40 o M:F = 1:1 if >40 years
Pathogenesis o Injury to synovial endothelial cells leads to o Synovitis with synovial hypertrophy which leads to o Impaired nutrition with necrosis of cartilage and resultant o Joint narrowing Subluxation Ankylosis Clinical findings o Diagnostic criteria of American Rheumatism Association (at least 4 criteria should be present): Morning stiffness for >1 hour Swelling of >3 joints, particularly of wrist, metatarsophalangeal or proximal interphalangeal joints for >6 weeks Symmetric swelling Typical radiographic changes Rheumatoid nodules Biochemical tests o Positive rheumatoid factor Rheumatoid factor Positive in 85-94%) IgM-antibody o Antinuclear antibodies
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Positive in many o LE cells Positive in some o Positive latex flocculation test Location o Usually symmetric involvement of true, diarthrodial joints
Target areas o Proximal joints of hands and wrists All five MCP, PIP joints and interphalangeal joint of thumb All wrist compartments Especially radiocarpal, inferior radioulnar, pisiform-triquetral joints Early signs o Fusiform periarticular soft-tissue swelling (result of effusion) o Regional osteoporosis (disuse and local hyperthermia) o Widened joint space (rare to see) o Marginal and central bone erosions in small joints of hands and wrists Less common in large joints Site of first erosion is classically base of proximal phalanx of 4th finger o Erosion of the ulnar styloid and narrowing of the distal radioulnar joint o Atlantoaxial subluxation >2.5 mm (in >6%)
Lateral radiograph of the neck with the head in flexion shows an increased distance between
the anterior border of the dens and the posterior border of the anterior tubercle of C1 (blue line) from ligamentous laxity caused by rheumatoid arthritis. The "pre-dentate space," as this is called, should be less than 3 mm in the adult. The red line above should smoothly connect all of the spinolaminar white lines of each vertebral body but clearly is directed posterior to the spinolaminar white line of C1 (green arrow) since C1 is subluxed forward on C2. Click here for this photo without annotations
Giant synovial cysts
Late signs o Diffuse loss of interosseous space o Flexion and extension contractures with ulnar subluxation and dislocation o Marked destruction of joint spaces o Extensive destruction of bone ends o Bony fusion o Elevation of humeral heads (from rotator cuff tears) o Resorption of distal clavicle o Erosion of superior margins of posterior portions of ribs 3-5 o Destruction and narrowing of disk spaces Irregular vertebral body outlines Absence of osteophytosis o Destruction of zygapophyseal joints without osteophyte formation o Resorption of spinous processes o "Stepladder appearance" of cervical spine due to subluxations o Protrusio acetabuli (from osteoporosis) o Synovial herniation and cysts (eg, popliteal cyst) o Calcaneal plantar spur Extra-articular manifestations (76%) o Feltys syndrome (<1%) Rheumatoid arthritis (present for >10 years) Splenomegaly Neutropenia Age o 40-70 years F>M o Rare in African-Americans o Sjgrens syndrome (15%) Keratoconjunctivitis Xerostomia Rheumatoid arthritis o Pulmonary manifestations Pleural effusion, mostly unilateral, without change for months Usually not associated with parenchymal disease Interstitial fibrosis with lower lobe predominance Rheumatoid nodules (30%)
Well-circumscribed Peripheral Frequent cavitation o Caplans syndrome Hyperimmune reactivity to silica inhalation with rapidly developing multiple pulmonary nodules o Pulmonary hypertension secondary to arteritis Subcutaneous nodules o In 5-35% with active arthritis over extensor surfaces of forearm o Other pressure points (eg, olecranon) without calcifications (DDx to gout) Cardiovascular involvement o Pericarditis (20-50%) o Myocarditis (arrhythmia, heart block) o Aortitis (5%) of ascending aorta aortic valve insufficiency Rheumatoid vasculitis Neurologic sequelae o Distal neuropathy (related to vasculitis) o Nerve entrapment (atlantoaxial subluxation, carpal tunnel syndrome, Baker cyst) Lymphadenopathy (up to 25%) o Splenomegaly (1-5%)
LearningRadiology.com - Bladder cancer, carcinoma,transitional cell, urotheial, CT urogram,urinary
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Bladder Cancer
Incidence o In the US, bladder cancer is the 4th most common cancer in men Prostate Lung Colorectal cancer Bladder cancer o It is the 10th most common cancer in women o More common in whites than in blacks 3:1 male to female predominance Classic clinical presentation is painless, gross hematuria Risk factors o Smoking o Pelvic irradiation o Exposure to aniline dyes o Chemotherapy with cyclophosphamide Most common is urothelial carcinoma, formerly known as transitional cell carcinoma (90%) o Multicentric May involve the urothelium in the entire GU tract from kidney to ureter to bladder o Tumors may be classified by growth patterns Papillary (70%) Sessile or mixed (20%) Nodular (10%)
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CT urogram. CT of the abdomen with contrast reformatted in the coronal projection shows a filling defect in the left lateral wall of the urinary bladder (red arrow) representing a papillary urothelial tumor of the bladder. Click here for this photo without annotations
Squamous cell carcinoma (4%) o Worst prognosis Associated with chronic infection and irritation o Worldwide (not in the USA), squamous cell carcinoma of the bladder is the most common cell type In underdeveloped nations, associated with bladder infection by Schistosoma haematobium Adenocarcinoma (1%) o Most common in bladder exstrophy o Respond poorly to radiation therapy Stage of disease o More than 70% of all newly diagnosed bladder cancers are superficial o About 5% present with metastatic disease Most often lymph nodes Lung Liver Bone
Central nervous system Prognosis o Superficial bladder cancer has good prognosis with 5-year survival rates of 82-100% o Prognosis for metastatic transitional cell cancer is much poorer with only 5% of patients living 2 years after diagnosis
eMedicine- Bladder Cancer - Gary David Steinberg, MD with Hyung L Kim, MD, Kush Sachdeva, MD, and Brendan Curti, MD
LearningRadiology.com - Pelvic Congestion Syndrome,pelvic,congestion,sy...ale,chronic,pelvic,pain,dilated,veins,venous,uterus,ovaries,ultrasound
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Pelvic Congestion Syndrome
Submitted by Yasmin Chaudhri, MD
Common cause of chronic pelvic pain
Frequency o Approximately 10% of the general female population may have pelvic varices, and 60% of those women may develop this syndrome Clinical Symptoms o Chronic dull pelvic pain, pressure, and heaviness o Often associated with movement, posture, and activities that increase abdominal pressure o Unilateral or bilateral o Often asymmetric o Physical examination findings Varicose veins and ovarian point tenderness Pathophysiology o Probably multifactorial and may include: o Dilated and tortuous ovarian veins secondary to retrograde flow through incompetent valves o Obstructing anatomic anomalies Retroaortic left renal vein Left ovarian vein congestion due to compression of the left renal vein by the superior mesenteric artery (nutcracker phenomenon) Right common iliac vein compression Secondary congestion can be seen in various disorders including: Valvular incompetence Portal hypertension Acquired inferior vena cava syndrome Risk Factors o Hereditary factors
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o o o o o
Hormonal influence Pelvic surgery Retroverted uterus History of varicose veins Multiple pregnancies
Imaging Findings o Venography Direct visualization of dilated pelvic veins o Transvaginal Ultrasound: Identification of multiple dilated structures around the uterus and ovaries with venous blood Doppler signal Dilated pelvic vein with a diameter greater than 4 mm Slow blood flow (about 3 cm/sec) Dilated arcuate vein in the myometrium communicating between bilateral pelvic varicose veins More than 50% of women have associated cystic ovaries
CT (top) and Color Doppler Ultrasound (bottom) of pelvis. CT of the pelvis with intravenous contrast shows multiple, dilated and tortuous pelvic veins (red arrows) near the patient's uterus on the patient's left side. Color Doppler ultrasound of the same area demonstrates extensive venous blood Doppler signal Click here for this photo without annotations
MR Imaging: Dilated, tortuous, enhancing tubular structures near the uterus and ovary; may see extension to the broad ligament and pelvic sidewall T1-weighted images: varices appear as flow voids Gradient-echo MR: varices have high signal intensity T2-weighted images: usually varices appear low in signal intensity 3D T1 gradient-echo sequences with gadolinium: varices have high signal intensity Treatment o Medical Treatment May be used for underlying disorders o Procedural Treatments: Laparoscopic transperitoneal ligation of ovarian veins Percutaneous coil embolization of the gonadal vein Interventional stent placement for anatomic anomalies o
LearningRadiology.com - Subcutaneous Emphysema,Subcu,air,gas,chest,wall,pectoralis,streaky,pmeumothorax,pneumomediastinum,Hamman
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Subcutaneous Emphysema
Subcutaneous emphysema refers to the presence of air in the loose subcutaneous areolar tissue and muscle Uncommon finding Can occur secondary to o Pneumomediastinum Pneumomediastinum occurs due to intrapulmonary rupture of alveoli and spread of air along the vascular sheath to the mediastinum Air spreads through loose areolar tissue and can enter the neck and subcutaneous tissues leading to subcutaneous emphysema o Necrosis of subcutaneous tissue by gas-forming organisms (gas gangrene) o An air leak in which a chest tube connected to suction inadvertently directs air into the subcutaneous tissue Air in subcutaneous tissue can spread in all directions Commonly upper parts of the body are involved more than lower body parts Rarely subcutaneous emphysema can occur in absence of pneumomediastinum or pneumothorax Subcutaneous emphysema can often produce what appears to be smooth swelling of the skin which is associated with a crunchy sensation on palpation Palpation produces crepitus, an unusual crackling sensation as the gas is pushed through the tissue On imaging studies, subcutaneous emphysema produces a striking picture of air beneath the skin surface, usually covering a large area of the body
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Close-up view of Right Upper Lobe of Lung and Right Shoulder demonstrates streaky lucencies overlying the shoulder and upper chest (blue circle) characteristic of subcutaneous emphysema with muscle bundles of pectoralis muscle becoming visible. The red arrow points to subcutaneous emphysema in the supraclavicular area. The white arrow points to streaky air visible in the mediastinum (pneumomediastinum) Click here for this photo without annotations
The air may interdigitate with the muscle bundles to produce a characteristic linear streaky pattern, especially in the pectoralis muscles over the chest When the streaky linear densities become widespread over the anterior and posterior chest walls, subcutaneous emphysema can obscure underlying lung pathology o It may be impossible to detect the pleural white line of a pneumothorax Treatment is to remove the cause, such as removing or repositioning the chest tube o Air can resolve in a matter of days
182
A. Child abuse B. Rickets C. Scurvy D. Ochronosis
22 "Must-See" Diagnoses for Medical Students A limited list
of diagnoses and their respective imaging modalities that all students should be able to recognize, regardless of their planned specialty derived from the National Curriculum for Medical Students developed by the Alliance of Medical Student Educators in Radiology (AMSER).
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LearningRadiology.com - Rickets,osteomalacia,bowing,rachitic,vitamin D,metaphysis,metaphyseal,cupping,fraying
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Rickets
q q
Osteomalacia during enchondral bone growth Age r 4-18 months Histology r Zone of preparatory calcification does not form resulting in build-up of maturing cartilage cells r Also occurs in shafts so that osteoid production elevates periosteum Clinical findings r Irritability r Bone pain r Tenderness r Craniotabes r Rachitic rosary r Bowed legs r Delayed dentition r Swelling of wrists and ankles Location r Metaphyses of long bones subjected to stress are particularly involved s Wrists s Ankles s Knees Imaging findings r Cupping and fraying of metaphysis r Poorly mineralized epiphyseal centers with delayed appearance r Irregular widened epiphyseal plates (increased osteoid) r Increase in distance between end of shaft and epiphyseal center r Cortical spurs projecting at right angles to metaphysis r Coarse trabeculation (not the ground-glass pattern found in scurvy) r Periosteal reaction may be present r Deformities common
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s s s s
Bowing of long bones Molding of epiphysis Fractures Frontal bossing
Rickets of the knees demonstrates bowing of the femurs, metaphyseal cupping and fraying, coarsening of the trabecular pattern, increase in distance between end of shaft and epiphyseal center, poorly ossified epiphyseal centers Click here for this photo enlarged
Causes Of Rickets
Abnormality In Vitamin D Metabolism s Associated with hyperparathyroidism s Vitamin D deficiency q Dietary lack of vitamin D q Famine osteomalacia s Lack of sunshine exposure s Malabsorption of vitamin D q Pancreatitis and biliary tract disease q Steatorrhea, celiac disease, postgastrectomy q Inflammatory bowel disease r Defective conversion of vitamin D to 25-OH-cholecalciferol in liver s Liver disease s Anticonvulsant drug therapy (= induction of hepatic enzymes that accelerate degradation of biologically active vitamin D metabolites) r Defective conversion of 25-OH-D3 to 1,25-OH-D3 in kidney s Chronic renal failure = renal osteodystrophy s Vitamin D-dependent rickets = autosomal recessive enzyme defect of 1-OHase Abnormality In Phosphate Metabolism r Not associated with hyperparathyroidism secondary to normal serum calcium r Phosphate deficiency s Intestinal malabsorption of phosphates s Ingestion of aluminum salts [Al(OH)2] forming insoluble complexes with phosphate s Low phosphate feeding in prematurely born infants s Severe malabsorption state s Parenteral hyperalimentation s Disorders of renal tubular reabsorption of phosphate q Renal tubular acidosis (renal loss of alkali) q deToni-Debr-Fanconi syndrome = hypophosphatemia, glucosuria, aminoaciduria q Vitamin D-resistant rickets q Cystinosis q Tyrosinosis q Lowe syndrome r Hypophosphatemia with nonendocrine tumors s Oncogenic rickets - elaboration of humeral substance which inhibits tubular reabsorption of phosphates q Sclerosing hemangioma q Hemangiopericytoma q Ossifying mesenchymal tumor q Nonossifying fibroma r Hypophosphatasia Calcium Deficiency r Dietary rickets = milk-free diet (extremely rare) r Malabsorption r Consumption of substances forming chelates with calcium Classification Of Rickets r Primary vitamin D-deficiency rickets r Gastrointestinal malabsorption s Partial gastrectomy
r
Small intestinal disease: gluten-sensitive enteropathy / regional enteritis s Hepatobiliary disease: chronic biliary obstruction / biliary cirrhosis s Pancreatic disease: chronic pancreatitis r Primary hypophosphatemia; vitamin D-deficiency rickets r Renal disease s Chronic renal failure s Renal tubular disorders: renal tubular acidosis s Multiple renal defects Hypophosphatasia and pseudohypophosphatasia r Fibrogenesis imperfecta osseum r Axial osteomalacia Miscellaneous r Hypoparathyroidism, hyperparathyroidism, thyrotoxicosis, osteoporosis, Paget disease, fluoride ingestion, r ureterosigmoidostomy, neurofibromatosis, osteopetrosis, macroglobulinemia, malignancy
s
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LearningRadiology - Bronchogenic Carcinoma
Lung Masses
Incidence
o On routine survey, <5% are malignant nodules o At surgery, 40% of nodules are ca, 40% granulomas Causes of lung nodules-by frequency o Granulomas o Bronchogenic ca o Hamartoma o Metastases Calcification of lung nodules o Laminated: TB granuloma o Central or target: histoplasmoma o Popcorn: hamartoma Doubling time o If a lesion doubles in volume >6 weeks and <16 months, usually malignant Cavitating nodules o Squamous cell most common o Adenocarcinoma o Bronchoalveolar cell ca (rare) o Hodgkin's Disease (rare) Mass with air bronchogram o Alveolar cell ca o Lymphoma o Pseudolymphoma o Inflammatory pseudotumor Pulmonary nodules with pneumothorax
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o Osteosarcoma o Wilm's tumor o Eosinophilic granuloma Types of bronchogenic carcinoma o Squamous cell ca (30-35%) o Adenocarcinoma (25-35%) o Small cell or oat cell (25%) o Large cell undifferentiated (10%) Squamous cell ca o Central Location (2/3) o Atelectasis o "Reverse S sign of Golden" o Post-obstructive pneumonia o Mass o Peripheral location (1/3) o May cavitate o Most closely associated with smoking Adenocarcinoma o Usually peripheral nodule o Found in scars o Solitary pulmonary nodule (52%) o Upper lobe distribution (69%) Small cell undifferentiated=Oat Cell Carcinoma o Appearances
Mediastinal adenopathy Hilar mass Small or invisible lung nodule
o High metastatic potential o Rapid growth o May be associated with Hypoglycemia Cushing's syndrome Inappropriate secretion of ADH Excessive gonadotropin secretion
Large cell undifferentiated (10%) o Large peripheral mass o Pleural involvement
Cell type by location o Central Squamous cell
o Peripheral Adenocarcinoma Large cell Most common site: anterior segment RUL
o Pancoast tumor=superior sulcus tumor (4%) o Squamous cell most often o SVC obstruction (5%) Most often small cell
Associated clinical findings o Horner's syndrome Pancoast tumor
o Elevated hemidiaphragm Phrenic nerve paralysis
o Hoarseness Recurrent laryngeal nerve (left>right)
o SVC obstruction Small cell ca
o Pleural effusion (10%) o Dysphagia o Enlarged nodes o Esophageal invasion Roentgenographic findings o Airway obstruction Atelectasis most common sign No air bronchogram Also postobstructive pneumonia
o Hilar enlargement From either the carcinoma itself or nodes Particularly common in oat cell, uncommon in adenoca
o Mediastinal node enlargement Particularly anaplastic ca
o Cavitation
Common (2-16%) Especially in squamous cell, mostly in upper lobes Cavity is usually thick-walled with nodular inner margin
o Pleural involvement Metastases o Bone Marrow: in 40% at time of presentation Gross lesions in 10-35% Most often in vertebra (70%), next in pelvis (40%), next femurs (25%) Osteolytic mets (3/4) Osteoblastic mets (1/4) o Adrenals o Brain In 30% at autopsy Multiple in 2/3 In 37% pathologically at time of presentation Especially in small cell and alveolar cell Common: 10% Hemorrhagic effusion denotes direct tumor invasion Effusion carries a poor prognosis even if no malignant cells are found
o Kidney, GI tract, liver, contralateral lung Prognosis o Mean survival time < 6 months
o <10% overall 5 year survival o Survival by cell type at 40 months Squamous cell (30%) Large cell (16%) Adenocarcinoma (15%) Oat cell (1%)
WH/96
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Dislocations of the Shoulder

Posterior Dislocation of the Shoulder
Types of dislocations about the shoulder r Glenohumeral dislocation (the most common by far) r Acromioclavicular dislocation (12%) r Sternoclavicular dislocation (uncommon) Types of glenohumeral dislocations r Anterior or subcoracoid shoulder dislocation (96%) s Mechanism q External rotation and abduction q 40% recurrent s Age q Younger individuals s May be associated with: q Fracture of greater tuberosity (15%) q Bankart lesion r Fracture of anterior glenoid rim q Hill-Sachs defect (50%) r Impaction fracture of posterolateral surface of humeral head due to impaction of humeral head against anterior rim of glenoid during dislocation r Posterior shoulder dislocation (2-4%) s Causes q Traumatic r Convulsive disorders or electroshock therapy q Nontraumatic r Congenital or developmental r May be done voluntarily, especially in children q Usually due to axial loading of an adducted and internally rotated arm s In >50% unrecognized initially and subsequently misdiagnosed as frozen shoulder
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May be difficult to see on AP radiograph q Typically, a scapular Y view or transthoracic lateral of the humeral head demonstrate a posterior dislocation better Imaging signs of posterior dislocation q Rim sign (66%) = distance between medial border of humeral head and anterior glenoid rim <6 mm q Humeral head is fixed in internal rotation no matter how forearm is turned lightbulb sign q May be associated with: r Trough sign (75%) = "reverse Hill-Sachs" = compression fracture of anteromedial humeral head r Fracture of posterior glenoid rim r Avulsion fracture of lesser tuberosity s Isolated fractures of the lesser tuberosity should raise suspicion of an associated posterior dislocation
q
Frontal radiograph of shoulder shows a humeral head in internal rotation (lightbulb sign), decreased distance between humeral head and glenoid (red arrow) and a 'trough fracture" or "reverse Hill-Sachs deformity of the medial humeral head (blue arrow). The scapular Y view, shown below, demonstrates the humeral head (yellow arrow) lies posterior to the glenoid and beneath the acromion (green arrow).
r
Inferior shoulder dislocation (1-2%) s Luxatio erecta q Extremity held over head in fixed position with elbow flexed s Mechanism q Severe hyperabduction of arm resulting in impingement of humeral head against acromion q Humeral articular surface faces inferiorly s Complications q Rotator cuff tear q Fracture of acromion with or without inferior glenoid fossa and with or without fracture of the greater tuberosity q Neurovascular injury Superior shoulder dislocation (<1%) s Humeral head driven upward through rotator cuff s May be associated with fracture of humerus, clavicle or acromion
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A. Transitional cell carcinoma B. Retrocaval ureter C. Retroperitoneal fibrosis D. Pelvic hematoma

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LearningRadiology.com - Esophageal,atresia,TEF,tracheoesophageal fistula,fistula,tracheo-esophageal
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Esophageal Atresia and Tracheoesophageal Fistula
q q q
Etiology not completely understood Faulty separation of primitive trachea and esophagus most widely accepted Esophageal atresia with fistulous connection to the distal pouch is more common than esophageal atresia alone or tracheoesophageal fistula without esophageal atresia ( H-type fistula)
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Types of esophageal atresia (EA) with/without tracheoesophageal fistula

From The Requisites-Pediatric Radiology
q q q
Increased incidence of TEF with Down Syndrome About 30% of infants with esophageal atresia/tracheoesophageal fistula are born prematurely Esophageal atresia commonly associated with other abnormalities of the GI tract including r Imperforate anus r Duodenal atresia or stenosis r In 25% of cases, there are 13 or more pairs of ribs or 6 or more lumbar vertebral bodies r VACTERL=vertebral, anal atresia, cardiac abnormalities, TEF and/or esophageal atresia, Renal agenesis and dysplasia and limb defects Clinical findings r Presentation for all types is typically early, except for H-type which may go undiagnosed until late childhood r Symptoms include s Choking s Drooling s Difficulty handling secretions s Regurgitation s Aspiration s Respiratory distress Imaging findings r Depends on the type r Prenatal ultrasound can suggest diagnosis as early as 24 because of polyhydramnios r Aspiration pneumonia often involves the RUL when there is esophageal atresia

r
Radiolucent, blind-end dilated pouch of upper esophagus may be seen on chest x-ray s Confirmed on lateral view q Anterior displacement of trachea q Rarely, air-fluid level in pouch With esophageal atresia and no fistula, no air enters GI tract s Abdomen is airless q Stomach should have air in it 15 minutes after birth normally
Red arrow points to end of orogastric tube which is blocked from entering the distal esophagus by the patient's esophageal atresia. Note the lack of gas in the abdomen indicating a fistulous tract does not connect the trachea to the distal esophagus Click here for the same photo without the arrow
r r
With a distal communication between esophagus and trachea, there is gas in abdomen Further imaging studies are usually not necessary but introduction of a soft catheter into the pouch will prove the diagnosis With H-type, pneumonia may be more widespread s Only clue on lateral film my be close proximity of trachea and esophagus s If barium is introduced through a tube for H-type fistula, it must start high in the esophagus as many fistulae are in the upper esophagus s When seen, the H-type fistula characteristically slopes upward from the esophagus to the trachea Treatment r Primary anastamosis of proximal and distal esophagus usually when infant is a few months old r Colonic interposition if primary anastamosis is impossible

q
Complications r May have hypoplasia and stenosis of the distal esophagus r Motility of distal esophagus may be impaired postoperatively (occurs in more than 90%) r Also s Fistulae and sinus tracts around surgical site r Shortening of esophagus following repair may lead to hiatal hernia and reflux r Focal tracheomalacia may occur from the distended upper esophageal pouch in utero
Swischuk, L. 14th ed: Imaging of the Newborn, Infant and Young Child Blickman, H. The Requisites: Pediatric Radiology, 2nd ed, 1998
146
A. Lymphoma B. Laryngeal cyst C. Ranula D. Thyroid cyst


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Retrocaval Ureter
q q
Also known as circumcaval ureter Abnormality in embryogenesis of IVC r Results from abnormal persistence of right subcardinal vein positioned ventral to ureter in the definitive IVC r Developing right ureter courses behind and medial to the IVC Incidence r 0.07% r Male to female ratio of 3:1 Clinical findings r Symptoms of right ureteral obstruction Imaging findings r Normal course of ureters s About the width of your thumb lateral to the lumbar vertebral pedicles s About the width of two fingers medial to pelvic brim in true pelvis r With retrocaval ureter s Right ureters course swings medially over pedicle of L3/4 q Passes behind IVC s Then exits anteriorly between IVC and aorta returning to its normal position s Produces varying degrees of proximal hydroureteronephrosis
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Retrograde pyelogram of right ureter demonstrates displacement of the ureter which passes medial to the pedicle ft the level of L4. The ureter is slightly dilated proximal to this point and returns to a normal position distal to its retrocaval placement.
CT scan below the level of the kidneys demonstrates a more medial retrocaval placement of the right ureter.
Retrocaval ureter can be associated with Turners syndrome

Medial Displacement or Deviation Upper ureter Retrocaval ureter Retroperitoneal fibrosis Lymphadenopathy Iliac artery aneurysm Bladder diverticulum Post-surgical (esp. AP resection) Pelvic lipomatosis Lateral Displacement or Deviation Upper ureter Lymphadenopathy Aortic aneurysm Retroperitoneal hematoma Herman, T and McAlister, W: Radiologic Clinics of North America. Vol. 29:2, March, 1991 Lower ureter Pelvic mass, e.g. uterine fibroids Lower ureter
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Osteochondritis dissecans
Osteochandritis dissecans-lg
http://www.learningradiology.com/images/caseoftheweekimages/cowgallerypages/cow120xtralg.html04/09/2006 2:46:13
Hypertrophic osteoarthropathy
Deep sulcus sign
Bilateral locked facets
Gas in gallstone
Gastric volvulus
Retropharyngeal air

Learning Radiology

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Learning Radiology

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Welcome to LearningRadiology.

What's the most likely diagnosis?

A. Smith fracture B. Colles fracture C. Pisiform fracture D. Triquetral fracture

33 Lectures in PowerPoint and Flash Look for this icon

Case of the Week

22 "Must-See" Diagnoses for Medical Students A limited list of

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When the Bowel Breaks Abdominal Calcifications

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LearningRadiology.com Miscellaneous Material Index

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LearningRadiology.com Medical Students' Table of Contents

Recognizing . . . A series of short modules designed for beginners

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Case of the Week Archive- 2006

Back to 2005 Archives

Benign Gastric Ulcer Case of Week 189 Feb. 12-18, 2006

Calcified Left Atrium Case of Week 190 Feb. 19-25, 2006

Uterine Rupture Case of Week 191 Feb. 26-March 4, 2006

Intraperitoneal Bladder Rupture Case of Week 192 March 5-11, 2006

Jefferson Fracture Case of Week 193 March 12-18, 2006

Retroperitoneal Fibrosis Case of Week 194 March 19-25, 2006

Stein-Leventhal Ovaries Case of Week 195 March 26-April 1, 2006

Midesophageal Diverticulum Case of Week 196 April 2-8, 2006

Epiphrenic Diverticulum Case of Week 197 April 9-15, 2006

Ascites Case of Week 198 April 16-22, 2006

Burst Fracture Case of Week 199 April 23-29, 2006

Posterior Hip Dislocation Case of Week 200 April 30-May 6, 2006

Pericardial Cyst Case of Week 201 May 7-13, 2006

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Case of the Week Archive- 2006

Esophageal Leiomyoma Case of Week 202 May 14-20, 2006

MSK=musculoskeletal Skill Levels B=Beginner M=Moderate A=Advanced