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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

33 Lectures in PowerPoint and Flash Look for this icon

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Case of the Week

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

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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).

Cases of the Week ...now, over 130 downloadable Case of the Week images

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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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| Home | Lectures | Notes | Images | Flashcards | Case of the Week Archives | | Bone | Cardiac | Chest | GI | Miscellaneous | Med Students | Most Common Lists | Quizzes |

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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

Title

General Quiz 001

Emergency, Emergency!

General Quiz 002

Skill Level* # Questions B M A

Comment

B

5

Some important emergency diagnoses

What’s Next?

B

5

General Quiz 003

Charge!

B

10

General Quiz 004

Where in the World Were They?

A

5

General Quiz 005

What Am I Missing?

A

5

Chest Quiz 101

Whiteout!

B

5

Chest Quiz 102

Tough Starts

A

5

Abdomen Quiz 201

Belly Aches

B

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 what’s the most likely diagnosis Differentiating the major causes of an opacified hemithorax Some important chest diseases seen in an infant Abdominal CT fundamental findings

Abdomen Quiz 202

I’ll Drink to That

B

5

Abdomen Quiz 203

When the Bowel Breaks

B

5

Abdomen Quiz 204

Abdominal Calcifications

B

5

Abdomen Quiz 205

Air, Air Everywhere

B

5

MSK* Quiz 301

Snap, Crackle, Pop-1

B

5

MSK Quiz 302

Name That Fracture-1

M

5

MSK Quiz 303

Hot Joints!

B-M

5

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

MSK Quiz 304

Bone Up on These

A

5

Some fundamental bone diseases

•MSK Quiz 305

My Aching Back

A

5

Some causes of back pain

http://www.learningradiology.com/quizzes/tocquiz.htm (1 de 2)04/09/2006 1:05:16

Some common diagnoses found on oral barium studies Some common diagnoses found on rectal barium studies Common calcifications in the abdomen

LearningRadiology - Quizzes

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

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| Home | Lectures | Notes | Images | Flashcards | Case of the Week Archives | | Bone | Cardiac | Chest | GI | Miscellaneous | Med Students | Most Common Lists | Quizzes | Copyright © 2002-2003 LearningRadiology.com

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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 Cardiac Disease

Differential Diagnoses in Chest Disease


Differential Diagnoses in GI Disease


Differential Diagnoses in MSK Disease


Pictorial Differential Diagnoses

*Allow 30 seconds to load on high-speed connection

| Home | Lectures | Notes | Images | Flashcards | Case of the Week Archives | | Bone | Cardiac | Chest | GI | Miscellaneous | Med Students | Most Common Lists | Quizzes | 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

Available in (click on link)

1. Recognizing a Technically Adequate Chest X-ray

Flash

PowerPoint

2. Recognizing Cardiomegaly

Flash

PowerPoint

3. Recognizing the Causes of an Opacified Hemithorax

Flash

PowerPoint

4. Recognizing a Pleural Effusion

Flash

PowerPoint

5. Recognizing Congestive Heart Failure

Flash

PowerPoint

6. Recognizing Airspace Versus Interstitial Disease

Flash

PowerPoint

7. Recognizing a Pneumothorax

Flash

PowerPoint

8. Recognizing the Placement of ICU Tubes and Lines

Flash

PowerPoint

9. Recognizing Small/Large Bowel Obstruction and Ileus

Flash

PowerPoint

10. Recognizing Free Air

Flash

PowerPoint

11. Recognizing Abdominal Calcifications

Flash

PowerPoint

12. Recognizing Soft Tissue Masses in the Abdomen

Flash

PowerPoint

13. Recognizing Fractures and Dislocations

Flash

PowerPoint

Quizzes

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Quizzes for students

Medical Student Lectures

= PowerPoint

Lecture

= Acrobat PDF format

=Flash

Available in formats below (click on link) PowerPoint

22 "Must-See" Diagnoses for Medical Students NEW Fundamentals of Chest Roentgenology

Flash

PowerPoint

The ABCs of Heart Disease

Flash

PowerPoint

Test Yourself on the ABCs

Flash

PowerPoint

ABCs of Heart Disease with Audio

30-minutes with audio

ABCs Schema-Handout version

PDF

Approach to Arthritis

Flash

PowerPoint

Plain Films of the Abdomen

Flash

PowerPoint

Soft Tissue Calcifications and Ossification

Flash

PowerPoint

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

* Requires hi-speed internet connection, Windows operating system, IE 5.0 or greater and Windows Media Player 6.4 or greater

**Install Macromedia Flash Player Flash files are smaller than PowerPoint, load faster, and appear uniform across all browsers

| Home | Lectures | Notes | Images | Flashcards | Case of the Week Archives | | Bone | Cardiac | Chest | GI | Miscellaneous | Med Students | Most Common Lists | Quizzes | 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 │2004│2005│ 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

Pneumococcal Pneumonia

Benign Gastric Ulcer

Calcified Left Atrium

Uterine Rupture

Case of Week 187 Jan. 29-Feb. 4, 2006

Case of Week 188 Feb. 5-11, 2006

Case of Week 189 Feb. 12-18, 2006

Case of Week 190 Feb. 19-25, 2006

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

Intraperitoneal Bladder Rupture

Jefferson Fracture

Retroperitoneal Fibrosis

Stein-Leventhal Ovaries

Midesophageal Diverticulum

Case of Week 192 March 5-11, 2006



Case of Week 195 March 26-April 1, 2006

Case of Week 196 April 2-8, 2006

Epiphrenic Diverticulum

Ascites

Burst Fracture

Posterior Hip Dislocation

Pericardial Cyst




Case of Week 200 April 30-May 6, 2006

Case of Week 201 May 7-13, 2006

Back to 2005 Archives

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Esophageal Leiomyoma

Osteoma

Asbestos-Related Pleural Disease

Luxatio erecta

Leriche Syndrome



Case of Week 204 May 28-June 3, 2006

Case of Week 205 June 4-10, 2006


Dislocated Clavicle

Pulmonary Laceration

Spondylitic Spondylolisthesis

Avulsion FractureIschial Tuberosity

Bullous Disease of the Lungs


Case of Week 208 June 25-July 1, 2006

Case of Week 209 July 2-8, 2006



Dermatomyositis

Hiatal Hernia

Synovial Osteochondromatosis

Histoplasmosis

Aspiration


Case of Week 213 July 30-August 5, 2006

Case of Week 214 August 6-12, 2006



Mirror-Image Right Arch

Intertrochanteric Hip Fracture

Atlantoaxial Dislocation

Chance Fracture

Small Bowel Obstruction

Case of Week 217 Aug. 27-Sept. 2, 2006

Case of Week 218 September 3-9, 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

Top ▲

2002 │2003 │2004│2005│Archives 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



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LearningRadiology.com Handout Notes

Cardiac Notes Abdominal Aortic Aneurysm

Partial Anomalous Pulmonary Venous Return

Aortic Dissection

Penetrating Aortic Ulcer

Cardiac Radiology Curriculum

Pericardial Effusion

CHF-chronologic sequence in childhood

Pulmonary Sling

Constrictive Pericarditis

Pulmonic Stenosis

Double aortic arch

Right Aortic Arches

DDXs of Congenital Heart Disease

Surgical Corrective Procedures for CHD

Ebstein's Anomaly

Syndromes with Associated CHD

Malpositions, Heterotaxy Chart


Mitral Stenosis

Total Anomalous Pulmonary Venous Return

Nine Lesions that Produce 75% of all CHD

Ventricular Aneurysms

MSK Notes Barton's Fracture

Lunate Dislocation

Battered Child Syndrome

Marfucci's Syndrome

Bennett's Fracture

Multiple hereditary exostoses

Calcinosis universalis

Multiple myeloma

Chance Fracture

Nonossifying fibroma

Charcot arthropathy

Ochronosis

Charcot foot

Osteochondritis dissecans

Child Abuse

Osteomyelitis-acute

Chondrosarcoma

Osteomyelitis-skull

Colle's Fracture

Osteopetrosis

Congenital syphilis

Paget's Disease

Congenital Hip Dysplasia

Perilunate Dislocation

CREST Syndrome

Pigmented Villonodular Synovitis

http://www.learningradiology.com/toc/tocsubsection/tocnotes.htm (1 de 4)04/09/2006 1:05:46


DISH

Ping-pong Fracture

Enchondroma

Pelvic avulsion fractures (graphic)

Fibrous dysplasia

Protrusio acetabuli

Frieberg's infraction

Psoriatic arthritis

Gamekeeper's Thumb

Pyle's disease

Giant Cell Tumor

Radiation Induced Osteosarcoma

Gouty Arthritis

Renal Osteodystrophy

Hand-shoulder Syndrome

Rolando Fracture

Hand-foot Syndrome

Round cell lesions by age (table)

Hemangiopericytoma

Sacroiliitis

Hemophilia

Slipped Capital Femoral Epiphysis

Hip Diseases in Children-table

Synovioma

Hyperparathyroidism

Tuberous sclerosis

Lead Poisoning

Tumoral calcinosis

Legg-Calve-Perthe's Disease

Volar Plate Fracture

Chest Notes Alpha-1 Antitrypsin Deficiency

Mycoplasma Pneumonia

Actinomycosis

Neurogenic Tumors

Adenomas (Cylindromas)

Neurofibromatosis

Alveolar Cell Carcinoma

Pancoast Tumor

Aortic Dissection

Pneumoconiosis

ARDS

Pneumocystis Carinii Pneumonia

Aspiration pneumonia

Pneumonia-gram positive

Aspergilloma

Pneumonia-gram-negative

Bronchiectasis

Pneumomediastinum

Bronchogenic cysts

Polyarteritis nodosa

Coccidioidomycosis

Pseudolymphoma

Congenital Lobar Emphysema


COPD

Radiation pneumonitis

Crack Cocaine Abuse

Re-expansion pulmonary edema

Cryptococcosis

Rheumatoid Lung Disease

Cystic Adenomatoid Malformation

Rounded Atelectasis

Cystic Fibrosis

Round Pneumonia

Embolic Disease to the Lung

Sarcoidosis

Goodpasture's Syndrome

Silicosis



Hamartomas

Scleroderma

Histiocytosis X

Sequestration

Histoplasmosis

Solitary Pulmonary Nodule

Hyaline Membrane Disease

Teratomas

Lipoid Pneumonia

Thyroid Masses

Lupus

Tuberculosis

Lymphangiomyomatosis

UIP

Lymphomas

Varicella Pneumonia

Metastases to the Lung

Wegener's Granulomatosis

GI Notes Achalasia

Gastric emphysema

Antral Web

Gastric Polyps

Ascariasis

Gastric Ulcer

Boerhavve's Syndrome

Gastric Volvulus

Candidiasis

Hiatal Hernia

Carcinoma of the Colon

Hypertrophic Pyloric Stenosis

Carcinoma of the Esophagus

Hypertrophic Gastritis

Carcinoma of the Stomach

Intussusception

Cathartic Colon

Leiomyoma of the Esophagus

Colonic polyps

Lipoma of the Colon

Crohn's Disease

Liver Laceration

Diffuse Small Bowel Disease

Lymphoma of Small Bowel

Diffuse Small Bowel Disease-Pictorial DDx

Lymphoma of the Stomach

Diverticular Disease

Mesenteric Vascular Ischemia

Duodenal Ulcer

Midgut Volvulous

Endometriosis

Mucocoele of the Appendix

Esophageal diverticula

Porcelain Gallbladder

Esophagitis-caustic

Postgastrectomy Complications

Esophageal varices

Sigmoid Volvulous

Esophageal Webs

Small Bowel Lymphoma

Familial Polyposis Syndromes

Thorotrast

Free Intraperitonal Air

Ulcerative Colitis

GU Notes



Acute Pyelonephritis

Ovarian Carcinoma

Adrenal adenoma

Placenta-grading (pictorial chart) NEW

Adult Polycystic Disease

Renal Infarct

Angiomyolipoma

Retrocaval Ureter

Bladder Rupture

Transitional Cell Carcinoma

Emphysematous pyelonephritis

Ureter-causes of displacement




LearningRadiology.com Index of Lectures

= PowerPoint


=Flash

Bone Lectures Lecture Approach to Arthritis

Available in formats below (click on link) Flash

PowerPoint

Bone Tumors-Cues and Clues

PowerPoint

PDF

Cervical Spine Fractures and Dislocations

PowerPoint

PDF

Pelvic Fractures and Dislocations

PowerPoint

PDF


Flash

PowerPoint

Cardiac Lectures

Lecture Module 1: The ABCs of Heart Disease Sub-module A: Test Yourself on the ABCs


PowerPoint

Flash

PowerPoint

Sub-module B: ABCs (algorithm only) Sub-module C: ABCs of Heart Disease-audio

PDF

PDF Audio version of ABCs of Heart Disease

Module 2: Differentials in Congenital Heart Disease

Flash

PowerPoint

PDF

Module 3: Left-to-Right Shunts

Flash

PowerPoint

PDF

Module 4: Cyanotic Heart Disease

Flash

PowerPoint

PDF

Module 5: Obstructive Lesions

Flash

PowerPoint

PDF

Module 6: Valvular Lesions-Congenital and Acquired

Flash

PowerPoint

PDF

http://www.learningradiology.com/toc/tocsubsection/toclectures.htm (1 de 4)04/09/2006 1:05:50


Module 7: Diseases of the Great Vessels

Flash

PowerPoint

PDF

Module 8: The Heart Inside Out

Flash

PowerPoint

PDF

Module 9: Miscellaneous Cardiac Diseases

Flash

PowerPoint

PDF

Module 10: Differential Diagnoses in Cardiac Disease

Flash

PowerPoint

PDF

Module 11: Review

Flash

PowerPoint

PDF

CHF

Flash

PowerPoint

PDF

Chest Lectures

All are in PowerPoint

Alpha-1 Antitrypsin Deficiency

Histoplasmosis

Allergic Bronchopulmonary Aspergillosis

Hypogenetic Lung Syndrome

Actinomycosis

ICU Radiology

Adenomas (cylindromas)

Lipoid Pneumonia

AIDS and Lung Disease

Lung Masses

Allergic Pneumonitis

Lupus


Lymphomas

Aortic Dissection


ARDS


Asbestosis

Neurogenic Tumors

Aspiration Pneumonia

Pancoast Tumor

Atelectasis

Pleural Effusion

AVMs

Pneumoconiosis

BOOP

Pneumonias

Bronchogenic Cysts

Polyarteritis Nodosa

Bullous Disease of the Lung


Coal Worker's Pneumoconiosis

Rounded Atelectasis

Coccidioidomycosis

Round Pneumonia

Collagen Vascular Diseases

Sarcoidosis


Scleroderma

COPD

Sequestration


Silicosis

Cystic Fibrosis




Diaphragmatic Diseases

Swyer-James Syndrome

Differential Diagnoses in Chest Radiology

TB

Dressler's Syndrome

Teratoma

Drug-induced Lung Disease

Thromboembolic Disease

Embolic Disease of the Lung

Thymoma

Eosinophilic Lung Disease

Thyroid Masses


Trauma

Hamartomas


Histiocytosis X

GI Lectures

Lecture

Available in formats below (click on link)

Approach to Diffuse Small Bowel Disease

Flash

PowerPoint


Flash

PowerPoint


Flash

PowerPoint

Differential Diagnoses Lecture Differential Diagnoses in Cardiac Disease



PowerPoint

PDF

PowerPoint

PDF


Flash

PowerPoint


Flash

PowerPoint


PDF

Click here

Faculty Lectures Lecture




PowerPoint

Faculty Lecture Table of Contents Page

General Lectures Lecture


Lateral Neck - Soft Tissue

Medical Student Lectures Lecture


22 "Must-See" Diagnoses for Medical Students

PowerPoint

Fundamentals of Chest Roentgenology

Flash

PowerPoint

More for Medical Students

*** Requires hi-speed internet connection, Windows operating system, IE 5.0 or greater and Windows Media Player 6.4 or greater

* Allow 30 seconds to load on high-speed connection




http://www.learningradiology.com/toc/tocorgansystems/toccardiac.htm

Cardiac Lectures

= PowerPoint


Lecture

=Flash


Module 1: The ABCs of Heart Disease Sub-module A: Test Yourself on the ABCs

Flash

PowerPoint

Flash

PowerPoint

PDF

PDF

Sub-module B: ABCs (algorithm only)

Audio version of ABCs of Heart Disease

Sub-module C: ABCs of Heart Disease-audio Module 2: Differentials in Congenital Heart Disease

Flash

PowerPoint

PDF

Module 3: Left-to-Right Shunts

Flash

PowerPoint

PDF

Module 4: Cyanotic Heart Disease

Flash

PowerPoint

PDF

Module 5: Obstructive Lesions

Flash

PowerPoint

PDF

Module 6: Valvular Lesions-Congenital and Acquired

Flash

PowerPoint

PDF

Module 7: Diseases of the Great Vessels

Flash

PowerPoint

PDF

Module 8: The Heart Inside Out

Flash

PowerPoint

PDF

Module 9: Miscellaneous Cardiac Diseases

Flash

PowerPoint

PDF

Module 10: Differential Diagnoses in Cardiac Disease

Flash

PowerPoint

PDF

Module 11: Review

Flash

PowerPoint

PDF

CHF

Flash

PowerPoint

PDF

Cardiac Notes Abdominal Aortic Aneurysm

Partial Anomalous Pulmonary Venous Return

Aortic Dissection


Cardiac Radiology Curriculum


CHF-chronologic sequence in childhood

Pulmonary Sling


Pulmonic Stenosis

Double aortic arch

Right Aortic Arches

DDXs of Congenital Heart Disease

Surgical Corrective Procedures for CHD

Ebstein's Anomaly

Syndromes with Associated CHD

Malpositions, Heterotaxy Chart


http://www.learningradiology.com/toc/tocorgansystems/toccardiac.htm (1 de 2)04/09/2006 1:05:55

http://www.learningradiology.com/toc/tocorgansystems/toccardiac.htm

Mitral Stenosis


Nine Lesions that Produce 75% of all CHD


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



*** Requires hi-speed internet connection, Windows operating system, IE 5.0 or greater and Windows Media Player 6.4 or greater


http://www.learningradiology.com/toc/tocorgansystems/toccardiac.htm (2 de 2)04/09/2006 1:05:55

http://www.learningradiology.com/toc/tocorgansystems/tocchest.htm

Chest Lectures Alpha-1 Antitrypsin Deficiency

Histoplasmosis

Allergic Bronchopulmonary Aspergillosis

Hypogenetic Lung Syndrome

Actinomycosis

ICU Radiology

Adenomas (cylindromas)

Lipoid Pneumonia


Lung Masses

Allergic Pneumonitis

Lupus


Lymphomas

Aortic Dissection


ARDS


Asbestosis

Neurogenic Tumors


Pancoast Tumor

Atelectasis

Pleural Effusion

AVMs

Pneumoconiosis

BOOP

Pneumonias

Bronchogenic Cysts


Bullous Disease of the Lung


Coal Worker's Pneumoconiosis

Rounded Atelectasis

Coccidioidomycosis

Round Pneumonia

Collagen Vascular Diseases

Sarcoidosis


Scleroderma

COPD

Sequestration


Silicosis

Cystic Fibrosis


Diaphragmatic Diseases

Swyer-James Syndrome


TB

http://www.learningradiology.com/toc/tocorgansystems/tocchest.htm (1 de 3)04/09/2006 1:05:57


Dressler's Syndrome

Teratoma

Drug-induced Lung Disease

Thromboembolic Disease

Embolic Disease of the Lung

Thymoma

Eosinophilic Lung Disease

Thyroid Masses


Trauma

Hamartomas


Histiocytosis X

Chest Notes Alpha-1 Antitrypsin Deficiency


Actinomycosis

Neurogenic Tumors

Adenomas (Cylindromas)

Neurofibromatosis


Pancoast Tumor

Aortic Dissection

Pneumoconiosis

ARDS

Pneumocystis Carinii Pneumonia

Aspiration pneumonia

Pneumonia-gram positive

Aspergilloma

Pneumonia-gram-negative

Bronchiectasis

Pneumomediastinum

Bronchogenic cysts

Polyarteritis nodosa

Coccidioidomycosis

Pseudolymphoma



COPD

Radiation pneumonitis

Crack Cocaine Abuse

Re-expansion pulmonary edema

Cryptococcosis



Rounded Atelectasis

Cystic Fibrosis

Round Pneumonia

Embolic Disease to the Lung

Sarcoidosis


Silicosis

Hamartomas

Scleroderma

Histiocytosis X

Sequestration

Histoplasmosis



Teratomas

Lipoid Pneumonia

Thyroid Masses



Lupus

Tuberculosis


UIP

Lymphomas

Varicella Pneumonia



Chest Images Chest Images-thumbnails

Common Pulmonary Cavities-Pictorial DDx Opacified Hemithorax-Pictorial DDx

Chest Flashcards Differential Diagnoses in Chest Disease

Chest Archives Previous Cases of the Week




http://www.learningradiology.com/toc/tocorgansystems/tocgi.htm

GI Lectures

= PowerPoint


=Flash





GI Differential Diagnoses

GI Differential Diagnoses

GI Notes Achalasia

Gastric emphysema

Antral Web

Gastric Polyps

Ascariasis

Gastric Ulcer


Gastric Volvulus

Candidiasis

Hiatal Hernia


Hypertrophic Pyloric Stenosis




Intussusception

Cathartic Colon


Colonic polyps

Lipoma of the Colon

Crohn's Disease

Liver Laceration


Lymphoma of Small Bowel

Diffuse Small Bowel Disease-Pictorial DDx


Diverticular Disease

Mesenteric Vascular Ischemia

Duodenal Ulcer

Midgut Volvulous

Endometriosis


Esophageal diverticula


Esophagitis-caustic

Postgastrectomy Complications

Esophageal varices

Sigmoid Volvulous

Esophageal Webs



Thorotrast

Free Intraperitonal Air

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 Previous Cases of the Week

**Install Macromedia Flash Player 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


Lecture

=Flash



Flash

PowerPoint

Bone Tumors-Cues and Clues

PowerPoint

PDF

Cervical Spine Fractures and Dislocations

PowerPoint

PDF

Pelvic Fractures and Dislocations

PowerPoint

PDF

Flash


PowerPoint

MSK Notes Barton's Fracture

Lunate Dislocation

Battered Child Syndrome

Marfucci's Syndrome

Bennett's Fracture



Multiple myeloma

Chance Fracture

Nonossifying fibroma

Charcot arthropathy

Ochronosis

Charcot foot


Child Abuse

Osteomyelitis-acute

Chondrosarcoma

Osteomyelitis-skull

Colle's Fracture

Osteopetrosis

Congenital syphilis

Paget's Disease



CREST Syndrome


DISH

Ping-pong Fracture

Enchondroma

Pelvic avulsion fractures (graphic)

Fibrous dysplasia

Protrusio acetabuli

http://www.learningradiology.com/toc/tocorgansystems/tocbone.htm (1 de 3)04/09/2006 1:06:03


Frieberg's infraction

Psoriatic arthritis

Gamekeeper's Thumb

Pyle's disease

Giant Cell Tumor

Radiation Induced Osteosarcoma

Gouty Arthritis


Hand-shoulder Syndrome

Rolando Fracture

Hand-foot Syndrome

Round cell lesions by age (table)

Hemangiopericytoma

Sacroiliitis

Hemophilia


Hip Diseases in Children-table

Synovioma

Hyperparathyroidism

Tuberous sclerosis

Lead Poisoning

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Ovarian Carcinoma

Adrenal adenoma

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Renal Infarct

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LearningRadiology - Contents Neuroradiology

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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



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LearningRadiology - Pictorial Differential Diagnosis

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LearningRadiology - Pictorial Differential Diagnosis


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217

A. Jones fracture B. Chopart fracture C. Lisfranc fracturedislocation D. Rolando fracture


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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218

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 ❍ The body of the triquetrum may also be fractured, usually transversely. Triquetral fractures may be associated with transcaphoid perilunate dislocations of the wrist ❍ 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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AAA-ruptured

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ASD

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AVN

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Cong. Lobar Emphysema

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Radiation fibrosis

Charcot joint

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Ruptured AAA

Hereditary Exostoses

Pulmonic stenosis


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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

Dislocation of the shoulder

Bone in the wrist to dislocate

Dislocation of the hip

Skeletal manifestation of multiple myeloma

Bone tumor to complicate Paget's Disease

Bones involved by fibrous dysplasia

Parathyroid abnormality leading to 1* Hyperparathyroidism

Cause of protrusio acetabuli

Parathyroid abnormality leading to 2* Hyperparathyroidism

Bone involved by chondrosarcoma

Bone involved by osteochondritis dissecans

Site of osteochondritis dissecans

Solitary, benign tumor of the ribs

Benign bone tumor

Humeral fracture in a child

Solitary, malignant, primary bone tumor

Metatarsal to undergo stress fracture

Malignant tumor of bone

Cardiac - the most common: Cong. Heart Dz in Down's Syndrome

Associated with Right Aortic Arch

Vascular ring

Congenital cardiac anomaly

Cause of CHF in first 24hrs

L-R Shunt Associated with Other Lesions

Cause of CHF in First Week

Left-to-right shunt

Cause of CHF between 2-6 weeks

Left-to-right shunt diagnosed in an adult

Cause of CHF from 1-4 months

Type of right aortic arch

Cause of pericardial effusion

Cause of calcification of LA wall

Site of aortic rupture

Cause of calcifications of the pulmonary artery

Cause of Cyanosis from Heart Dz in Newborn

Type of ASD

Cause of cyanosis from heart dz in older child

Type of VSD

Cyanotic heart disease

Type of TAPVR

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Cardiac tumor

Cause of a calcified mitral valve

Primary cardiac tumor

Cause of a calcified mitral annulus

Cardiac malignancy

Cause of a calcified aortic valve

Primary benign heart tumor

Site of true LV aneurysm

Tumor of the heart in a child

Cause of false LV aneurysm

Right Arch Associated with CHD

Type of Coarctation of Aorta

Type of Truncus Arteriosus

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

Location of bullae in Alpha-1 Antitrypsin Deficiency

Benign extrapleural mass

Location of cysts in Eosinophilic Granuloma

Histology of mediastinal Hodgkin's

Segment of lower lobe most often affected by bronchiectasis

GI - the most common: Benign Esophageal tumor

Sources of Metastatic Lesions to Stomach

Malignant Tumor of Esophagus

Cause of Small Bowel Obstruction

Benign Tumor of Stomach

Cause of Large Bowel Obstruction

Malignant Tumor of Stomach

Cause of free air

Tumor of the Small Intestine

Type of intussusception

Benign Tumor of the Small Intestine

Congenital anomaly of the esophagus

Malignant Tumor of Small Intestine Tumor of Large Bowel Benign Tumor of the Large Bowel Malignant Tumor of Large Bowel

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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 Ebstein’s 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

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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.

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


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 Kartagener’s 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 Gamekeeper’s 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 Paget’s 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 Rolando’s 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 Boerhaave’s syndrome Budd-chiari syndrome Candida Esophagitis Carcinoma of the Colon Caustic Esophagitis Cecal lipoma Cecal volvulus Crohn’s 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 Fahr’s 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


http://www.learningradiology.com/flashcards/tocflashcards.htm

Bone Causes of Secondary DJD Localized thickening of perisoteum

Causes of Avascular Necrosis Round Cell Lesions

Wormian Bones

Expansile Rib Lesions

Permeative pattern Expansile Lesions of Bone

Lytic Lesions in Children Blastic Lesions in Children

For Pelvic Lesions, Think of...

Lytic Lesions in Adults

For Spine Lesions, Think of...

Blastic Lesions in Adults

Malignant Lesions-Multiple Sites

Benign Lesions, No Sclerotic Margin

Cardiac Cardiac Flashcards - 40 cardiac images, flashcard style

Cyanosis with Decreased Vascularity

CHF in Newborn

Cyanosis with Increased Vascularity

Cardiomegaly with Normal Vasculature

Left to Right Shunts

Chest Acute Alveolar infiltrate Anterior Mediastinal Masses

Masses with Air Bronchograms Small Cavitary Lung Nodules

Opacified Hemithorax

Lymphangitic Spread to the Lungs

Chronic Alveolar Disease

Small Calcifications in the Lung

Bibasilar Interstitial Disease Micronodular Lung Disease

Middle Mediastinal Masses Posterior Mediastinal Masses

Chronic Interstitial Disease

Infiltrates with Effusions

Large Cavitary lesions

Cavities containing Masses

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Multiple Lung Nodules

Masses that Cavitate

GI Colon Cut-Off Sign

Causes of Small Bowel Obstruction

Air in the Biliary System

Causes of Large Bowel Obstruction

GU Nephrocalcinosis

Bilateral small kidneys

Unilateral small kidney

Bilateral large kidneys

Unilateral large kidney

Miscellaneous

| Home | Lectures | Notes | Images | Flashcards | Case of the Week Archives | | Bone | Cardiac | Chest | GI | Miscellaneous | Med Students | Most Common Lists | Quizzes | Copyright © 2002 LearningRadiology.com

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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

Name: above Email:

See above

1. Look at the following case. Why is this an emergency? The patient has:

a.

A tension pneumothorax.

b.

An acute pneumonia of the right lung.

c.

Had a pulmonary embolism.

http://www.learningradiology.com/quizzes/quiz0004/index0004.htm (1 de 4)04/09/2006 1:07:08


d.

A simple pneumothorax.

e.

Been shot.

2. This patient came in complaining of severe abdominal pain. Why is this an emergency? The patient has:

a.

A ruptured gastric ulcer.

b.

A ruptured abdominal aortic aneurysm.

c.

Acute appendicitis.

d.

Acute renal failure.

e.

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.

A ruptured abdominal aortic aneurysm.

b.

An enlarged spleen.

c.

A pericardial effusion.

d.


e.

Acute appendicitis.

4. This patient became acutely short of breath following surgery. Why is this an emergency? The patient has:

a.

Left lower lobe pneumonia.

b.

Acute pulmonary edema.

c.

A large pneumothorax.

d.

A large pericardial effusion.



e.


5. This patient began vomiting after eating pumpkin pie and developed severe chest pain. Why is this an emergency? The patient has:

a.

Developed SARS.

b.

A ruptured aortic aneurysm.

c.

Signs of an acute myocardial infarction.

d.

Aspirated the pumpkin pie.

e.

The patient has a ruptured esophagus

Score | Home | Lectures | Notes | Images | Flashcards | Case of the Week Archives | | Bone | Cardiac | Chest | GI | Miscellaneous | Med Students | Most Common Lists | Quizzes | Copyright © 2003 LearningRadiology.com


Chest Quiz 101 Whiteout!


Name: above Email: above

1. The patient shown below most likely has:


See

a.

Atelectasis of the left lung

b.

A large left pleural effusion

c.

A large right pneumothorax

d.

Pneumonia in the left lung

e.

Unilateral pulmonary edema


a.

A large right pleural effusion

b.

A large left pneumothorax

c.

Atelectasis of the right lung

d.

Pneumonia in the right lung

e.




a.


b.


c.

Atelectasis of the left lung

d.


e.




a.


b.


c.

Atelectasis of the left lung because of a mucus plug

d.


e.

Atelectasis of the left lung because the ETT is too low

5. Why is this hemithorax opaque?


a.

There is a large left pleural effusion

b.

There is a large right pneumothorax

c.

Atelectasis of the left lung because of a mucus plug

d.


e.

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 | Home | Lectures | Notes | Images | Flashcards | Case of the Week Archives | | Bone | Cardiac | Chest | GI | Miscellaneous | Med Students | Most Common Lists | Quizzes | Copyright © 2003 LearningRadiology.com



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

Name: above) Email:

(see above

1. The patient shown below is a premature newborn. The most likely diagnosis is:

a.

Transient tachypnea of the newborn

b.

Congenital lobar emphysema

c.

Hyaline membrane disease

d.

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.


3. The patient is a post-mature newborn. What is the most likely diagnosis?

a.


b.


c.




d.


e.



a.


b.


c.


d.


e.


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.




c.


d.


e.





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

Name: above) Email: above)

1. What is the most likely diagnosis in the patient shown below?

a.

Esophageal varices

b.

Esophageal carcinoma

c.

Reflux esophagitis


(see


d.

Lye stricture

e.

Fibrovascular polyp


a.

Sprue

b.

Scleroderma

c.

Crohn's disease

d.

Carcinoma of the colon

e.

Duodenal hematoma




a.

Esophageal varices

b.


c.

Reflux esophagitis

d.

Lye stricture

e.

Fibrovascular polyp


a.

Gastric carcinoma

b.

Gastric ulcer

c.

Gastric polyp

d.

Gastrinoma

e.

Gastric emphysema




a.

Esophageal varices

b.


c.

Reflux esophagitis

d.

Lye stricture

e.

Fibrovascular polyp




Abdomen Quiz 203 When the Bowel Breaks

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

Name: above) Email: above)


a.

Colonic volvulus

b.

Colonic polyps

c.

Ulcerative colitis


(see


d.

Diverticulitis

e.

Colonic carcinoma


a.

Colonic volvulus

b.

Colonic polyps

c.

Ulcerative colitis

d.

Diverticulitis

e.

Colonic carcinoma




a.

Colonic volvulus

b.

Colonic polyps

c.

Ulcerative colitis

d.

Diverticulitis

e.

Colonic carcinoma


a.

Colonic volvulus

b.

Colonic polyps

c.

Ulcerative colitis

d.

Diverticulitis



e.

Colonic carcinoma


a.

Colonic volvulus

b.

Colonic polyps

c.

Ulcerative colitis

d.

Diverticulitis

e.

Colonic carcinoma




Abdomen Quiz 204 Abdominal Calcifications



1. What do these calcifications represent?

a.

Gallstones

b.

Pancreatic calcifications

c.

Calcified hematoma of the liver


See


d.

Hepatic artery aneurysms

e.

Hemangioma

2. This is a 57 year-old female. What is the most likely diagnosis?

a.

Iliac artery aneurysms

b.

Aortic aneurysm

c.

Uterine fibroids

d.

Bladder calculi

e.

Dermoid cyst of the ovary

3. The patient shown below most likely has?

a.

Renal artery aneurysms

b.

Staghorn calculi of the kidneys

c.

Calcifications in the pancreas



d.

Renal cell carcinoma

e.

Gallstones


a.

Gallstones

b.

Hepatic artery aneurysm

c.

Calcification in the pancreas

d.

Renal cell carcinoma

e.

Calcification of the gallbladder wall

5. This patient shown below has right lower quadrant pain. What does this calcification most likely represent?



a.

Gallstones

b.

Appendicolith

c.

Uterine fibroids

d.

Dermoid cyst of the ovary

e.

Peach pit in the colon

Score

To learn more about abdominal calcifications, go to Recognizing Abdominal Calcifications | Home | Lectures | Notes | Images | Flashcards | Case of the Week Archives | | Bone | Cardiac | Chest | GI | Miscellaneous | Med Students | Most Common Lists | Quizzes | Copyright © 2003 LearningRadiology.com



Abdomen Quiz 205 Air, Air Everywhere!




a.

Large bowel obstruction


See


b.

Small bowel obstruction

c.

Generalized ileus

d.

Localized ileus

e.

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.

Generalized ileus

d.

Localized ileus

e.





a.


b.


c.

Generalized ileus

d.

Localized ileus

e.



a.




b.


c.

Generalized ileus

d.

Localized ileus

e.



a.


b.


c.

Generalized ileus

d.

Localized ileus

e.

Free intraperitoneal air

Score

To learn more about normal and abnormal bowel gas patterns, go to Recognizing Free Air or Recognizing Obstruction | Home | Lectures | Notes | Images | Flashcards | Case of the Week Archives | | Bone | Cardiac | Chest | GI | Miscellaneous | Med Students | Most Common Lists | Quizzes | Copyright © 2003 LearningRadiology.com



MSK Quiz 302 Name That Fracture-1

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.

Name: (Optional) Email: (Optional)

1. What person's name is associated with the fracture shown below?

a.

Monteggia

b.

Bennett



c.

Jones

d.

Colle

e.

Smith


a.

Monteggia

b.

Bennett

c.

Jones

d.

Colle

e.

Smith




a.

Monteggia

b.

Bennett

c.

Jones

d.

Colle

e.

Smith


a.

Monteggia

b.

Bennett

c.

Jones

d.

Colle

e.

Smith




a.

Monteggia

b.

Bennett

c.

Jones

d.

Colle

e.

Smith



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? See



a.

Osteoarthritis

b.

Rheumatoid arthritis


See

c.

Septic arthritis

d.

Avascular necrosis

e.

Gout

2. What is the most likely diagnosis?

a.

Osteoarthritis

b.


c.

Septic arthritis

d.

Avascular necrosis

e.

Gout



a.

Osteoarthritis

b.


c.

Septic arthritis

d.

Avascular necrosis

e.

Gout


a.

Osteoarthritis

b.


c.

Septic arthritis

d.

Avascular necrosis

e.

Gout

5. What is the most likely diagnosis?


a.

Osteoarthritis

b.


c.

Septic arthritis

d.

Avascular necrosis

e.

Gout

Score

To learn more about the radiologic diagnosis of arthritis, go to An Approach to Arthritis (For Netscape, use this link) | Home | Lectures | Notes | Images | Flashcards | Case of the Week Archives | | Bone | Cardiac | Chest | GI | Miscellaneous | Med Students | Most Common Lists | Quizzes | Copyright © 2003 LearningRadiology.com



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

Name: above) Email:

1. The patient shown below most likely has which of the following?


(see above)


a.

Paget's disease

b.

Sickle cell disease

c.

Ankylosing spondylitis

d.

Renal osteodystrophy

e.

Metastatic prostate carcinoma




a.

Paget's disease

b.

Sickle cell disease

c.


d.


e.





a.

Paget's disease

b.

Sickle cell disease

c.


d.


e.





a.

Paget's disease

b.

Sickle cell disease

c.


d.


e.





a.

Paget's disease

b.

Sickle cell disease

c.


d.


e.




Cardiac Flashcards


Cardiac Flashcards Next Card Flip Card Remove Card Reverse Restart Timer On Timer Off

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Random Radiology Cases

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Misc

Click on any of the buttons above to select a random Case of the Week of the desired organ system or modality

With thanks to Behrang Amini, an MD/Ph.D student at The University of Texas Health Science Center at Houston, for writing the script for the Case of the Week Randomizer.

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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 O

Decreased flow 1. Tetralogy of Fallot 2. Tricuspid Atresia 3. Severe Pulmonic Stenosis 4. Ebstein’s

O

Increased Flow 5. Transposition 6. VSD


Pulmonary venous hypertension 7. Hypoplastic left heart 8. Coarctation of the aorta 9. TAPVR with infradiaphragmatic obstruction

O

What’s left Q

Q

Left-to-right shunts O

ASD

O

PDA

Truncus arteriosus

Cyanosis With Decreased Vascularity

O

Tetralogy

O

Truncus-type IV

O

Tricuspid atresia*

O

Transposition*

O

Ebstein's

* Also appears on DDx of Cyanosis with ↑ Vascularity

Cyanosis With Increased Vascularity

O

Truncus types I, II, III

O

TAPVR

O

Tricuspid atresia*

O

Transposition*

O

Single ventricle

* Also appears on DDx of Cyanosis with ↓ Vascularity


O

Viral myocarditis

O

Endocardial fibroelastosis

O

Aberrant left coronary artery

O

Cystic medial necrosis

O

Diabetic mother

CHF In Newborn

Impede Return of Flow to Left Heart O O O O O O

Infantile coarctation Congenital aortic stenosis Hypoplastic left heart syndrome Congenital mitral stenosis Cor triatriatum Obstruction to venous return from lungs O

TAPVR from below diaphragm

CHF CHF In In Chronologic Chronologic Sequence Sequence

CHF In Newborn

Impede Return of Flow to Left Heart O O O O O O

Infantile coarctation Congenital aortic stenosis Hypoplastic Left Heart Syndrome Congenital mitral stenosis Cor triatriatum Obstruction to venous return from lungs O


CHF In 2nd-3rd Week

Coarctation of the aorta O Interruption of the aortic arch O

CHF-later

O

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 O

Most common cause of CHF in newborn Q

O

Most common cause of CHF > 2 weeks Q

O

Coarctation of the aorta (infantile form)

Most common cyanotic heart disease Q

O

Hypoplastic left heart syndrome

Tetralogy of Fallot

Most common dz associated c R arch Q

Tetralogy of Fallot

Most Commons O

Most common L Î R shunt Q

O

Most common L Î R shunt dx’d in adult Q

O

Atrial Septal Defect

Dz most commonly associated c R arch Q

O

Ventricular Septal Defect

Truncus arteriosus

Most common congenital cardiac lesion Q

Bicuspid aortic valve

Most Commons

O

Most common type of ASD Q

O

Most common type of VSD Q

O

Ostium secundum

Membranous VSD

Most common type of TAPVR Q

Supracardiac

Most Commons O

Most common cardiac tumor Q

O

Most common 1° benign heart tumor Q

O

Metastatic disease, e.g. melanoma

Myxoma

Most common 1° tumor of heart in child Q

Rhabdomyoma

Most Commons O

Most common CHD in Down’s Syndrome Q

O

Most common cause of pericardial effusion Q

O

Atrioventricular canal defects

Myocardial infarction with LV failure

CHD most commonly assoc. with pericardial abnormalities Q

ASD

Uncommon Most Commons O

Most common site of coronary stenosis Q

O

Most common site of true LV aneurysm Q

O

Right coronary artery

Anterolateral and apical walls

Most common cause of false LV aneurysm Q

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

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

Acute Alveolar infiltrate

1.

Pulmonary edema

2.

Pneumonia

3.

Aspiration

4.

Hemorrhage

Anterior Mediastinal Masses

1.

Thymoma

2.

Teratoma

3.

Substernal thyroid

4.

Lymphoma

Opacified Hemithorax

1.

Atelectasis

2.

Pleural effusion

3.

Pneumonia

4.

Post-pneumonectomy

Pneumomediastinum 1. Ruptured esophagus 2. Ruptured trachea/bronchus 3. Iatrogenic 4. Asthma 5. Pneumoperitoneum

Chronic Alveolar Disease

1.

Alveolar cell ca

2.

Alveolar sarcoid

3.

Lymphoma

4.

Alveolar proteinosis

Large Cavitary Lung Lesions

1.

Abscess

2.

Carcinoma

3.

TB

Bibasilar Interstitial Disease 1.

Bronchiectasis

2.

Aspiration

3.

DIP

4.

Asbestosis

5.

Sickle Cell Disease

6.

Scleroderma

Upper Lobe Disease

1. TB (2° TB) 2. Silicosis 3. Eosinophilic granuloma 4. Ankylosing spondylitis

Micronodular Lung Disease

1.

Mets

2.

Sarcoid

3.

Pneumoconiosis

4.

Miliary TB

Chronic Interstitial Disease Pulmonary Fibrosis

1.

Pneumoconiosis

2.

Interstitial Pneumonia

3.

Granulomatous disease

4.

Neoplastic disease

5.

Idiopathic fibrosis

6.

Collagen vascular disease

Small Cavitary Lung Lesions

1.

Septic emboli

2.

Rheumatoid nodules

3.

Squamous or transitional cell mets

4.

Wegener’s Granulomatosis

Lymphangitic Spread to the Lungs 1.

Lung ca

2.

Breast ca

3.

Stomach ca

4.

Pancreas ca

5.

Laryngeal ca

6.

Cervical ca

Multiple Lung Nodules 1.

Mets

2.

Wegener’s granulomatosis

3.

Rheumatoid nodules

4.

AVMs

5.

Septic emboli

Pulmonary Interstitial Edema

1.

CHF

2.

Lymphangitic spread

3.

Allergic reaction

Shifting Infiltrates 1.

Loeffler’s syndrome

2.

ABPA

3.

Asthma

4.

Polyarteritis

5.

Viral pneumonia

Unilateral Hyperlucent Lung

1.

Swyer-James syndrome

2.

Pulmonary embolism

3.

Pneumothorax

4.

Obstructive emphysema

Rapidly Clearing Alveolar Infiltrate

1. Hemorrhage 2. Pulmonary edema 3. Aspiration 4. Pneumococcal pneumonia

Cavitating Pneumonia

1.

Staph

2.

Strep

3.

TB

4.

Gram negative (Klebsiella)

Middle Mediastinal Masses

1.

Lymphadenopathy

2.

Aneurysms

3.

Esophageal duplication

4.

Bronchogenic cysts

Masses with Air Bronchograms

1.

Lymphoma

2.

Alveolar cell ca

3.

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.

Staph pneumonia

2.

Strep pneumonia

3.

TB

4.

Pulmonary infarct

“Mass”+ ipsilateral adenopathy

1.

Bronchogenic ca

2.

Lymphoma

3.

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 (Meig’s Syndrome) Chylothorax

Left-sided Pleural Effusion

1. Boerhaave’s Syndrome 2. Dissecting aortic aneurysm 3. Pancreatitis 4. Distal thoracic duct rupture

Multiple Small Calcifications

1.

Histoplasmosis

2.

Silicosis

3.

Chicken pox pneumonia

4.

Pulmonary ossification 2° MS

5.

Alveolar microlithiasis

Posterior Mediastinal Masses

1.

Neurogenic tumors

2.

Lymphadenopathy

3.

Extramedullary hematopoesis

Mediastinal Adenopathy

1.

Bronchogenic ca

2.

Lymphoma

3.

TB

4.

Mets

5.

Sarcoid

Lung Disease & Rib Destruction

1.

Bronchogenic ca, i.e Pancoast tumor

2.

Actinomycosis

3.

Blastomycosis

4.

Multiple myeloma

Pleural Calcification

1.

Old TB empyema

2.

Asbestos exposure

3.

Hemothorax

“Masses” in Cardiophrenic Angle

1.

Sequestration

2.

Diaphragmatic hernia

3.

Pericardial cyst

Unilateral Pulmonary Edema

1.

Aspiration

2.

Disease in other lung, e.g. COPD

3.

Postural

4.

Rapid expansion of PTX

Reverse “Pulmonary Edema”

1.

Eosinophilic lung disease, e.g. Loeffler’s

2.

Sarcoid

3.

Pulmonary contusions

LearningRadiology.com - DDXs in GI Radiology

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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 - Paget’s 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. Paget’s 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. Ewing’s 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. Ewing’s sarcoma

Sclerotic Cortical lesions

1. Osteoid osteoma 2. Brodie’s abscess 3. Healing stress fracture

Short Thumb

1. Myositis ossificans progressiva 2. Fanconi’s syndrome 3. Holt-Oram Syndrome

Short 4th Metacarpal

1. Turner’s syndrome 2. Pseudohypoparathyroidism*

3. Pseudopseudohypoparathyroidism *Short, obese, retarded, abnormal dentition, corneal opacities, hypocalcemia, hypophosphatemia

Clinodactyly Inward curvature of 5th finger

1. Down’s syndrome 2. Cornelia de Lange syndrome* 3. Carpenter’s 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. Carpenter’s 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. Apert’s syndrome* 2. Carpenter’s syndrome 3. Down’s syndrome

*Hypertelorism, exopthalmus, underdeveloped sinuses, pseudarthroses, high palate

Erosion - Distal Clavicle

1. Rheumatoid Arthritis 2. Hyperparathyroidism 3. Scleroderma 4. Cleidocranial dysplasia

Protrusio Acetabuli 1. Paget’s disease 2. RA 3. Osteomalacia 4. Osteoporosis 5. Mucopolysaccharidosis

Acro-osteolysis 1. Thermal injury, burns, frostbite 2. Scleroderma 3. Hyperparathyroidism 4. Psoriasis 5. Raynaud’s disease 6. PVC worker

Avascular Necrosis 1. 2. 3. 4. 5. 6. 7. 8.

Idiopathic (Legg-Calve-Perthe’s Disease) Steroid administration Sickle cell anemia Arteritis - collagen-vascular disease Trauma Gaucher’s 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. Paget’s disease 3. Thorotrast

Chondrocalcinosis 1. Pseudogout 2. Gout 3. DJD 4. Hyperparathyroidism 5. Hemochromatosis 6. Wilson’s Disease

Ankylosis of SI Joints 1. Ankylosing spondylitis 2. Psoriasis 3. Reiter’s 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. Gorham’s Disease

Wide Ribs 1. Achondroplasia 2. Fibrous dysplasia 3. Rickets (rosary) 4. Marrow packing disorders 1. Thalassemia 2. Mucopolysaccharidosis, esp. Hunter’s and Hurler’s 3. Gaucher’s 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. Down’s Syndrome 4. Cleidocranial dysostosis 5. Osteogenesis imperfecta

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LearningRadiology-Recognizing a Technically Adequate Chest X-Ray

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LearningRadiology - Recognizing Cardiomegaly

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LearningRadiology-Recognizing an Opacified Hemithorax

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LearningRadiology-Recognizing Pleural Effusions

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LearningRadiology-Recognizing CHF

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LearningRadiology-recognizing Airspve versus Interstitail Lung Disease

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LearningRadiology-Recognizing a Pneumothorax

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LearningRadiology-ICU Tubes and Lines

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LearningRadiology-Recognizing Obstruction

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LearningRadiology-Recognizing Free Air

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LearningRadiology-Recognizing Abdominal Calcifications

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LearningRadiology-Recognizing Abdominal Soft Tissue Masses

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LearningRadiology- Recognizing Fractures and Dislocations

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LearningRadiology-The Fundamentals of Chest Roentgenology

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LearningRadiology - ABCs of Heart Disease

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LearningRadiology - Test Yourself on the ABCs

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A Is the Left Atrium Enlarged?

If yes, then

Look at the Pulmonary Vasculature

If no, then

B Is the Main Pulmonary Artery Big or Bulbous?

C Is the Main Pulmonary Artery Segment Concave?

D Is the Heart Dilated or DeltaShaped?

If yes, then

If no, then

If yes, then

Mitral regurg

Pulmonary venous hypertension

Mitral Stenosis L Myxoma

Increased

If yes, then

If no, then

Normal


VSD, PDA

Normal

Pulm. stenosis

Increased

ASD (VSD)

Pulmonary hypertension

Don't Look at Pulmonary Vasculature. Look at Aorta

Idiopathic (1°)

Normal

Cardiomyopathy

Ascending dilated

Ao Stenosis

Whole Ao Dilated

Ao regurg HBP

Cardiomyopathy Pericardial Effusion Mult. valve dz

© Copyright 2000 William Herring, MD

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LearningRadiology.com - Soft Tissue Calcification and Ossification

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Case of the Week Archive - 2002


2002 │ 2003 │2004│2005 │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 004 July 29-Aug. 4, 2002


Right Aortic Arch

Aspergilloma

Neurofibromatosis

Sickle Cell Disease

Subdural Hematoma






Lipoid Pneumonia

Caustic Esophagitis

Gouty Arthritis

Thyroid Goiter




Case of Week 013 Sept. 29-Oct. 5, 2002



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Case of the Week Archive - 2002

Dermoid Cyst of Ovary

Ascariasis

Dermatomyositis

Fibrous Dysplasia

Thorotrast




Case of the Week 019 November 10-16, 2003

Case of the Week 020 November 17-23, 2003

TAPVR

Maltoma

Fahr's Disease

Re-expansion Pulmonary Edema








Tumoral Calcinosis

Varicella Pneumonia

Diverticulitis

Ochronosis

Jump to 2003 Archives

Jump to 2004 Archives


Case of Week 026 Dec. 29, 2002-Jan. 4, 2003


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2002 │ 2003 │2004│2005 │2006 Archives Index of all Cases of the Week | Home | Lectures | Notes | Images | Flashcards | Case of the Week Archives | | Bone | Cardiac | Chest | GI | Miscellaneous | Med Students | Most Common Lists | Quizzes | Copyright © 2002-2006 LearningRadiology.com About Us


LearningRadiology.com Case of the Week Archive- 2003


2002 │ 2003 │2004│2005 │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 026 Dec. 29, 02-Jan. 4, 2003


Case of Week 028 Jan. 12-18, 2003

Case of Week 029 Jan. 19-25, 2003



Crohn's Disease

Osteopetrosis

Ebstein's Anomaly




Case of Week 033 Feb. 16-22, 2003



Non-ossifying Fibroma

Radiation Pneumonitis

Charcot Knees

Gastric Emphysema

Ruptured AAA




Case of Week 039 March 30-Apr. 5, 2003





Pulmonic Stenosis

Round Pneumonia


Giant Cell Tumor






Sprue

Pulmonary Sling

PCP

Osteomyelitis

Budd-Chiari Syndrome






PVNS

Ovarian ca mets

Dissecting Aneurysm

Ping-pong Ball Plombage

Rugger-Jersey Spine


Case of Week 052 June 29-Jul. 5, 2003




Hamartoma

Scleroderma

Tuberculosis

Midgut Volvulus

Hemophilia

Case of Week 056 July 27-Aug. 2, 2003





Diaphragmatic Hernia

Ruptured Aneurysm

Cystic Fibrosis

Angiomyolipoma

Psoriatic Arthritis

Case of Week 061 Aug, 31-Sept. 6, 2003





Persistent Left SVC

Acute Pyelonephritis

Acute Appendicitis

Malignant Mesothelioma

Paget's Disease






Case of Week 069 Oct. 24-Oct. 31, 2003


Adrenal Adenoma

Kartagener's Syndrome

Splenic Laceration

Serous Cystadenoma

Rolando Fracture






Bronchopleural Fistula

Mitral Stenosis

Mucocele of Appendix






Jump to 2002 Archives Jump to 2004 Archives Index of all Cases of the Week Eventration

Gamekeeper's Thumb


Sarcoidosis

Top ▲

2002 │ 2003 │2004│2005 │2006 Archives Index of all Cases of the Week







2002 │ 2003 │2004│2005 │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 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


Liver Laceration

Teratoma

Hodgkin's Disease

Lead poisoning

Silicosis


Case of Week 085 Feb. 15-21, 2004

Case of Week 086 Feb. 22-28, 2004



Candida Esophagitis


Renal Laceration

Sigmoid Volvulus

Rickets






Meconium Aspiration


Esophageal Varices


Intussusception









Emphysematous Pyelonephritis

Sialolithiasis

Transitional Cell Ca







Pulmonary Arterial Hypertension

Achalasia

Extraperitoneal Bladder Rupture

CPPD








Posterior Dislocation

Free air

Bochdalek Hernia

Epiglottitis





Case of Week 113 August 29-Sept. 4, 2004

Child Abuse

Hemangioblastoma



Mesenteric Ischemia




Case of Week 117 Sept 26-Oct 2, 2004


Synovial sarcoma

LV Aneurysm

Housemaid's Knee

Emphysematous Pancreatitis

Aortic Stenosis








Arteriovenous Malformation

Osteochondritis Dissecans


Deep Sulcus Sign

Bilateral Locked Facets






Gas in Gallstones

Gastric Volvulus

Perforated Pharynx

Lipohemarthrosis

Coarctation of the Aorta





Jump to 2003 Archives Jump to 2005 Archives Misplaced Endotracheal Tube

Retrocaval Ureter

Top ▲








2002 │ 2003 │2004│2005 │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 131 Jan. 2-8, 2005


Case of Week 133 Jan. 16-22, 2005

Case of Week 134 Jan. 23-29, 2005


Emphysematous Cholecystitis

Pneumomediastinum

Right Aortic Arch

Ankylosing Spondylitis

Renal Infarct


Case of Week 137 Feb. 13-19, 2005

Case of Week 138 Feb. 20-26, 2005



Septic Emboli

Esophageal Atresia

AC Separation

Esophageal Web

Discitis






Twiddler's Syndrome

Osteoblastic Metastases

Dressler's Syndrome

Chilaiditi's Syndrome

Choroid Plexus Cysts








Ranula

Superior Mesenteric Artery Syndrome

Puckered Panniculus Sign

Paget's with Osteosarcoma

Gallstone Ileus






Hamartoma of the Breast

Cecal volvulus

Impacted Chicken Bone

Thyroid Ophthalmopathy

Croup






Necrotizing Enterocolitis

Galeazzi Fracture

Bezoar

Pseudotumor

Rounded Atelectasis

Case of Week 161 July 31-August 6, 2005




Case of Week 165 August 28-Sept. 3, 2005

Rheumatoid Arthritis

Cecal Lipoma

Medullary Nephrocalcinosis

Pulmonary Embolism

Papillary Necrosis






Leptomeningeal Cyst

Pulmonary Contusion

Toxoplasmosis

Cavernous Hemangioma of Liver

Anterior Dislocation








Ulcerative Colitis

Stress Fracture

Sequestration

Fibromuscular Dysplasia

Kienbock's Disease





Case of Week 180 December 11-17 2005


Atlanto-axial Subluxation

Bladder Carcinoma

Pelvic Congestion Syndrome

Subcutaneous Emphysema





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183

A. Tuberculosis B. Klebsiella pneumonia C. Pneumocystis pneumonia D. Pneumococcal pneumonia

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184

A. Malignant gastric ulcer B. Gastric diverticulum C. Benign gastric Ulcer D. Zollinger-Ellison Syndrome



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185

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

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LearningRadiology.com - Pneumoccocal,pneumonia,streptococcus,pneumoniae,gram,positive,negative,staph,strep,aerobacter,bacteroides


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Pneumococcal Pneumonia

Gram Positive Pneumonias Pneumococcal Pneumonia ●

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 ●

DDX for alveolar infiltrates with clearing in 24 hours includes ❍ Hemorrhage into lungs, ❍ Pulmonary edema ❍ Pneumococcal pneumonia ❍ Aspiration

Staph Aureus Pneumonia ●

Most common bronchopneumonia

●

Overwhelming majority hospital-acquired

●

Most common cause of death during influenza epidemics

●

Rarely develops in healthy adults

●

Hemolyzes blood agar ❍

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 ❍

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)

•


Streptococcus Pyrogenes Pneumonia ●

Most common in winter ❍

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 ●

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 ●

Encapsulated, gram negative rods

●

Most are hospital acquired

●

Most are chronic alcoholics • Aspirated into lungs so most are unilateral and right sided

X-ray ●

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 ●

Almost always lower lobes

●

Frequently right sided

●

Homogeneous consolidation

●

About 70% will have pleural involvement–effusion, empyema–which 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) • Hampton’s 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): 49–51. 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









187

A. Aortic aneurysm B. Extraperitoneal bladder rupture C. Uterine rupture D. Intraperitoneal bladder rupture



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188

A. Hangman's fracture B. Teardrop fracture C. Jefferson fracture D. Clay shoveler's fracture




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189

A. Aortic dissection B. Lymphoma C. Retroperitoneal lipoma D. Retroperitoneal fibrosis




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190

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



Submitted by Ryan Smith, MD

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191

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

● ●

Can be secondary to traumatic or iatrogenic injury Five types of rupture ❍ Type I: Bladder contusion ■ Most common form ■ Results from incomplete tear of bladder mucosa ■ Cystography is normal ❍

❍

❍

❍

●

●

Type II: Intraperitoneal rupture ■ Results from trauma to lower abdomen when bladder is distended ■ Because bladder dome is weakest portion, it ruptures most easily ■ Contrast is then seen in the paracolic gutters and between loops of small bowel Type III: Interstitial injury-rare ■ Caused by a tear of the serosal surface ■ Mural defect without extravasation will be seen Type IV: Extraperitoneal ■ Almost always associated with pelvic fractures ■ Usually close to base of bladder anterolaterally ■ Subdivided into ● Simple, with extravasation limited to perivesical space ● Complex, with extravasation extending to thigh, scrotum or perineum Type V: Combined extra- and intraperitoneal rupture

Extraperitoneal bladder rupture is the most common type ❍ Occurs in 80% of bladder rupture cases ❍ 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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LearningRadiology.com - Bladder rupture,intraperitoneal,urinary,trauma,perforation,extraperitoneal ❍ ❍

❍

Usually iatrogenic or secondary to penetrating injury Blunt trauma more likely to result in intraperitoneal rupture in children than in adults ■ Because the pediatric bladder is more intraperitoneal in location. ■ The adult bladder dome remains mostly extraperitoneal ● Blunt trauma in an adult can result in intraperitoneal rupture only if the bladder is fully distended Imaging findings ■ Contrast flows into paracolic gutters ■ 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 ●

●

●

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 ❍ Diagnostic evaluation of bladder rupture includes voiding cystourethrography (VCUG) or CT scan ■ VCUG ● Voiding cystourethrography historically been preferred contrast enhanced



■

study for diagnosis of bladder rupture ● Bladder needs to be fully distended and evaluation of a post-voiding film essential Plain film: ● "Pear-shaped" bladder ● Paralytic ileus ● Upward displacement of ileal loops ● Flame-shaped contrast extravasation into perivesical fat ❍ Best seen on postvoid films ❍ May extend into thigh / anterior abdominal wall ● US ❍ "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 http://www.learningradiology.com/archives06/COW%20189-Retroperitoneal%20fibrosis/retrofibrosiscorrect.htm (1 de 6)04/09/2006 1:20:15


§ 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

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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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Zenker’s Diverticulum •

Pharyngoesophageal diverticulum

•

Occurs in older women

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

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

•


•

False diverticulum












192

A. Ulcer B. Lymphoma C. Amebiasis D. Epiphrenic diverticulum




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193

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



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194

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



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195

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



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196

A. Round pneumonia B. Thyroid goiter C. Pericardial cyst D. Left ventricular aneurysm


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Epiphrenic Diverticulum


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Zenker’s Diverticulum •

Pharyngoesophageal diverticulum

•


Posteriorly at site of Killian's dehiscence = superior • boundary is thyropharyngeal muscle and inferior boundary is cricopharyngeal muscle •


False diverticulum = herniation of mucosa and • submucosa through muscular layer

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 •


•


•

False diverticulum










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 Meig’s 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 ½ 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 http://www.learningradiology.com/archives06/COW%20196-Pericardial%20cyst/pericardialcystcorrect.htm (1 de 4)04/09/2006 1:21:16


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


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197

A. Reflux esophagitis B. Leiomyoma C. Fibrovascular polyp D. Esophageal varices



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198

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


Click to Enlarge 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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200

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



42 year-old male Click to Enlarge


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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

● ● ● ● ● ● ● ●

●

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 ● 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 Gardner’s syndrome ● Multiple osteoma of the mandible and maxilla, along with the frontal, sphenoid and ethmoid sinuses, rarely the long bones or phalanges ● Cutaneous and soft tissue tumors ● 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

Fibers are then coated with a ferritin-like material resulting in ferruginous bodies

o

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

Opacities are small and irregularly shaped

o

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



o •

In contrast to silicosis, hilar lymph nodes are rarely affected

Associations with lung cancer and mesothelioma o

Estimated to occur in 20-25% of those heavily exposed to asbestos

o

Asbestos-related lung cancer is usually either squamous cell or adenocarcinoma

o

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

Absent or diminished femoral pulses

o

Erectile dysfunction

Usually affects younger males ages 30-40 Risk factors include o Cigarette smoking o

Hypercholesterolemia

o

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

http://www.learningradiology.com/archives06/COW%20201-Leriche%20Syndrome/lerichecorrect.htm (1 de 4)04/09/2006 1:22:12


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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204

A. Degenerative disc disease B. Spondylitic spondylolisthesis C. Metastatic malignancy D. Laminectomy defect



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205

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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o

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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o

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

Bilateral spondylolysis is visible on the lateral view

o

Forward slippage of one vertebral body on the other is observed and graded on the lateral view

o

Spondylolisthesis is graded in this manner § § § §

Grade 1-vertebral body above subtends ¼ 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







LearningRadiology.com - avulsion fracture of ischial tuberosity,avulsion,pe... image, jpg file,resident,case,interesting,medical,student,medical student


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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 adolescents—an easily missed diagnosis; Gidwani, Jagiello, and Bircher; BMJ 2004;329:99-100 (10 July), doi:10.1136/bmj.329.7457.99







LearningRadiology.com - bullous disease,bulla,bullae,emphysema,COPD,chro...age, jpg file,resident,case,interesting,medical,student,medical student


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Bullous Disease of the Lungs •

Definition o Thin-walled–less 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 isn’t: 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









207

A. Myositis ossificans B. Venous insufficiency C. Dermatomyositis D. Sarcoid




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A. Achalasia B. Esophageal Carcinoma C. Caustic ingestion D. Hiatal hernia



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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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211

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




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LearningRadiology.com - dermatomyositis,calcinosis universalis,calcinosis,...image, jpg file,resident,case,interesting,medical,student,medical student


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Dermatomyositis

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●

●

●

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●

● ● ●

Along with polymyositis, part of a group of idiopathic inflammatory myopathies with both cutaneous and visceral manifestations ❍ 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 50’s, dermatomyositis being the only one of the two diseases seen in children More common in females ❍ Linear and confluent calcifications in soft tissues of extremities ❍ Acro-osteolysis ❍ Chest-may have infiltrates associated, especially from aspiration Clinically ❍ Dysphagia ❍ Erythematous purple-red rash of eyelids, trunk and hands (seen in dermatomyositis) ■ May be sole manifestation in up to 40% of patients with disease ❍ 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 ❍ Diffuse cutaneous, subcutaneous and sometimes muscular calcification ❍ Usually affects children and young adults ❍ Not actual bone formation ❍ More linear than calcifications in scleroderma, which tend to be punctate (calcinosis circumscripta) ❍ 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


LearningRadiology.com - dermatomyositis,calcinosis universalis,calcinosis,...image, jpg file,resident,case,interesting,medical,student,medical student ●

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May resemble myositis ossificans progressiva ❍ Myositis ossificans progressive (fibrodyplasia ossificans progressiva) ■ 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 Treatment ❍ Prednisone ❍ Cytotoxic agents like methotrexate Prognosis depends on age, and cardiac, pulmonary or esophageal involvement ❍ Spontaneous remission has been reported in up to 1/5 of cases

eMedicine Jeffrey P Callen, MD,







LearningRadiology.com - hiatal hernia,hiatal,hernia,Schatzki,ring,Schatzki'... image, jpg file,resident,case,interesting,medical,student,medical student


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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 Schatzki’s Ring may be visible § Schatzki’s 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 Schatzki’s 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 Barrett’s esophagus o Barrett’s 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 Barrett’s esophagus can develop § Ulcer § Stricture § Malignancy • Patients with Barrett’s esophagus have a 30-40 times higher risk of esophageal adenocarcinoma than the general population









LearningRadiology.com - synovial chondromatosis,synovial osteochondromat...age, jpg file,resident,case,interesting,medical,student,medical student


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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

Hip

o

Shoulder

o

Ankle

o

Wrist

Clinical findings o Pain § Usually chronic and progressive o Swelling o

Limitation of movement (lock knee)

o

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

Small

o

Multiple

o

There may be pressure erosion of adjacent bone in joints

o

Rarely, widening of joint space from accumulation of loose bodies

o

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

Most common in knee and hip

o

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 http://www.learningradiology.com/archives06/COW%20210-Histoplasmosis/histoplasmosiscorrect.htm (2 de 6)04/09/2006 1:23:37


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

High male to female ratio (4:1)

o

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=bull’s-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

Hilar and mediastinal adenopathy

o

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

Lytic lesions in the bones

o

Broncholithiasis (most common cause)

o

Fibrosing mediastinitis

o

Multiple splenic calcifications (unusual for TB)

o

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 Zenker’s • 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 Mendelson’s 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 • Community–acquired 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 http://www.learningradiology.com/archives06/COW%20211-Aspiration%20pneumonia/aspirationcorrect.htm (1 de 6)04/09/2006 1:23:39


•

§ 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

• time o

Zenker’s diverticulum

o

Achalasia

o

TE fistula

o

Neuromuscular diseases

o

Chronic reflux

o

Lipoid pneumonia

§ Mineral oil (used as a laxative) § Oily nose drops (not used anymore) • Clinical findings o Choking on swallowing o

Acute onset of respiratory distress, if gastric acid

o

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

http://www.learningradiology.com/archives06/COW%20211-Aspiration%20pneumonia/aspirationcorrect.htm (2 de 6)04/09/2006 1:23:39


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











212

A. Aortic rupture B. Right arch with aberrant LSCA C. Mirror-image right aortic arch D. Penetrating aortic ulcer

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Mirror-Image Right Aortic Arch

Aortic Anomalies Right Aortic Arch ●

General ❍ Most are asymptomatic ■ Unless they cause encircling vascular ring like pulmonary sling ❍ Can be complex lesions requiring multiple projections ■ MRI or CT

Left Aortic Arch With Anomalous Right Subclavian Artery (RSCA) ❍ ❍ ❍ ❍ ❍

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 ■ 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 ■ Only two of importance ● Mirror Image Type — Type I ● Aberrant left subclavian — Type II General considerations ■ Recognized by leftward displacement of barium-filled esophagus ■ Of air-filled trachea ■

❍

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■

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) ● Usually Tetralogy of Fallot Aberrant Left Subclavian type rarely has associated CHD ● Most common variety of right arch

Type 1—Mirror Image Type

■ ■ ■

Secondary to interruption of left arch just distal to ductus arteriosis Associated with congenital heart disease 98% of time Imaging Findings ● No posterior impression on trachea or barium-filled esophagus ● Heart is usually abnormal in size or shape ● 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 ll—Aberrant Left Subclavian

■ ■

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%) ● Coarctation of aorta rarely (7%) Anomalous left subclavian artery (retroesophageal and retrotracheal) Aorta descends on right Imaging Findings -- Right Aortic Arch with Aberrant LSCA ● ●

■ ■ ■

Posterior impression on trachea and barium-filled esophagus ● Heart is usually normal in size and shape ● Aorta descends on right Origin of RSCA may be dilated ■ Diverticulum of Kommerell technically was defined with a right aortic arch and anomalous left subclavian artery (LSCA) ●

●

■

If there is a mirror-image right aortic arch, then ❍ ❍ ❍

■

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 ❍ ❍ ❍ ❍ ❍

Truncus arteriosis Tetralogy of Fallot Transposition Tricuspid atresia VSD

33% 25% 10% 5% 2%

Double Aortic Arch

❍

General considerations ■ ■

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 ●

■ ■ ■ ■ ■ ■



Posterior impression on lateral view Angiogram is characteristic Clinical ●

■ ■

●

Symptoms may begin at birth and include ❍ ❍

Tracheal compression, or Difficulty swallowing

■

Anatomy

■

Right arch supplies RSCA and RCC ● Left arch supplies LCC and LSCA Imaging Findings -- Double Aortic Arch ●

● ● ● ●

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 ■ Usually asymptomatic ■ May present as pulsating supraclavicular mass ■ May produce vascular ring and compress airway ■ Embryogenesis uncertain ■ Over 80% are right-sided Imaging Findings–Right-sided lesions

❍

Right-sided cervical aortic arches ■ Right apical mass-like density ■ Absence of aortic knob on left ■ Aorta descends on the left ■ Displace the trachea and esophagus forward ■ Branching may be normal or mirror-image Imaging Findings–Left-sided lesions

■

■

■ ■ ■ ■

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

When further imaging is required, MRI or nuclear medicine scans are used most often utilized

o

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

Subtle, frequently impacted

o

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

Usually easy to see on views of the hip obtained in internal rotation

o

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

Description

Remarks

Stage I Stage II

Incomplete fracture of the neck Complete without displacement

May be impacted and in valgus

Stage III

Complete with partial displacement

Stage IV

Complete femoral neck fracture with full displacement

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 ❍ 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 ❍ 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 ❍ Down syndrome ■ Due to laxity of the transverse ligament ❍ Grisel syndrome ■ Atlantoaxial subluxation associated with inflammation of adjacent soft tissues of the neck ❍ Rheumatoid arthritis ■ From laxity of the ligaments and destruction of the articular cartilage ❍ Osteogenesis imperfecta ❍ Neurofibromatosis ❍ Morquio syndrome ■ Secondary to odontoid hypoplasia or aplasia ❍ Other arthridities ■ Psoriasis ■ 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 occupant’s head strikes the windshield or dashboard ❍ 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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●

● ● ● ●

●

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 ❍ Widening of the predentate space ❍ Disruption in the smooth curve of the imaginary line connecting the spinolaminar white lines of the vertebral bodies ❍ Soft tissue swelling ■ C2 ─ retropharyngeal space should be < 7 mm ■ C3 and C4 ─ retropharyngeal space should be < 5 mm, or ■ Less than half the AP diameter of C3 or C4 ■ C6 ─ retrotracheal space should be < 22 mm in adults and < 14 mm in children (under15 years) Treatment ❍ 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. http://www.learningradiology.com/archives06/COW%20214-Atlantoaxial%20subluxation/atlantoaxialcorrect.htm (2 de 5)04/09/2006 1:24:16


For a photo of the same image without the arrows, click here

Neck Injuries: II. Atlantoaxial Dislocation—A 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

o o

Horizontal fracture through the spinous process, laminae, pedicles and vertebral body

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

http://www.learningradiology.com/archives06/COW%20215-Chance%20Fx/chancefxcorrect.htm (1 de 5)04/09/2006 1:24:18


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

o



Harris and Harris The Radiology of Emergency Medicine Nadalo and Van Meter eMedicine







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•

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

Volvulus

o

Tumor, either primary or metastatic

o

Wall lesions such as leiomyomas or strictures

o

Crohn’s disease

o

Foreign bodies

o

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

History of prior abdominal or pelvic surgery

o

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

o

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, Crohn’s 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. http://www.learningradiology.com/archives06/COW%20216-SBO/sbocorrect.htm (3 de 7)04/09/2006 1:24:22


•

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

Ileus

Patient with prior surgery weeks to Recent (hours) post-operative patient years prior

Pain

Colicky

Not a prominent feature

Abdominal distension

Frequently prominent

Sometimes not apparent

Bowel sounds

Usually increased

Usually absent

Small bowel dilatation

Present

Present

Large bowel dilatation

Absent

Present




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LearningRadiology - Case of the Week 61


61

A. Aortic Nipple B. Persistent left SVC C. AVM D. Cervical aortic arch

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63

A. Pancreatitis B. Ischemic colitis C. Appendicitis D. Hepatitis

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64

A. Splenic cyst B. CHF C. Mesothelioma D. Cirrhosis


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65

A. Depressed fracture B. Meningioma C. Osteoporosis circumscripta D. Prostate metastases


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Lisfranc Fracture-Dislocation

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● ●

● ●

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Named after Jacques Lisfranc, a field surgeon in Napoleon’s 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 ❍ Mechanism involves severe plantar flexion of the foot ❍ May occur from sports-related injuries ❍ Motor vehicle accidents ❍ 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 ❍ If it remains intact, either an avulsion of the lateral border of the 1 occurs ❍ If it tears, these fractures may not occur Clinical findings ❍ Pain at tarsal-metatarsal joints ❍ Ecchymosis ❍ Instability Types

http://www.learningradiology.com/archives06/COW 217-Lisfranc fx/lisfranccorrect.htm (1 de 9)04/09/2006 1:24:53


Two basic types ■ Homolateral ■ All of the metatarsals are dislocated to the same side ■ More common than divergent nd through 5th dislocated laterally ■ Usually involves the 2 ■ May involve all 5 metatarsals ■ Divergent ■ Usually more severe than homolateral st cuneiform ■ May be associated with a fracture of the 1 st metatarsal and lateral displacement of 2nd-5th metatarsals ■ Usually involves medial displacement of the 1 st metatarsal ■ Occasionally may involve only medial displacement of only the 1 Fractures associated with Lisfranc dislocations nd metatarsal ❍ Base of 2 ❍ Cuboid ❍ Fractures of shafts of metatarsals st (medial) and 2nd (middle) and cuneonavicular joints ❍ Dislocations of the 1 ❍ Fractures of the tarsal navicular Imaging ❍ Conventional radiographs are usually sufficient to demonstrate the injury ❍ 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 ■ Lateral border of 1 nd metatarsal is aligned with medial border of 2nd (intermediate or middle) cuneiform on AP view ■ Medial border of 2 rd (lateral) cuneiform should align with medial and lateral borders of 3rd metatarsal on oblique view ■ Medial and lateral borders of the 3 th ■ Medial border of 4 metatarsal aligned with medial border of cuboid on oblique th metatarsal may project lateral to cuboid by as many as 3mm on oblique ■ Lateral margin of the 5 th metatarsal ■ On lateral, a line drawn along long axis of talus should intersect long axis of 5 ❍

●

●

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

Medial border of 2nd metatarsal is aligned with medial border of 2nd (intermediate) cuneiform ←

3rd

Lisfranc with arrows-2

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

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 ❍ Sprains with an otherwise stable tarsal-metatarsal joint can be managed with immobilization ❍ Nonanatomic alignment requires open reduction and internal fixation











66

A. Adrenal ca B. Adrenal met C. Adrenal hemorrhage D. Adrenal adenoma


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LearningRadiology.com - Case of the Week 67


67

A. Tuberous sclerosis B. Eosinophilic granuloma C. Kartagener's syndrome D. Situs inversus

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68

A. Gastric lymphoma B. Splenic laceration C. Hepatic laceration D. Mets to spleen

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LearningRadiology - Abdominal Aortic Aneurysm (AAA)

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Abdominal Aortic Aneurysm ● ●

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Focal widening >3 cm Normal size of abdominal aorta >50 years of age: ❍ About 2 cm Prevalence: ❍ Increases with age ❍ Greater with atherosclerotic disease ❍ Male predominance ❍ Whites: Blacks = 3:1 Risk factors: ❍ male ❍ age >75 years ❍ white race ❍ prior vascular disease ❍ hypertension ❍ cigarette smoking ❍ family history ❍ hypercholesterolemia Associated with: ❍ visceral + renal artery aneurysm (2%) ❍ isolated iliac + femoral artery aneurysm (16%) ■ common iliac (89%), internal iliac (10%), external iliac (1%) ❍ stenosis / occlusion of celiac trunk / SMA (22%) ❍ stenosis of renal artery (22-30%) ❍ occlusion of inferior mesenteric artery (80%) ❍ occlusion of lumbar arteries (78%) Growth rate of aneurysm of 3-6 cm in diameter: ❍ 0.39 cm / year Clinical ❍ asymptomatic (30%) ❍ abdominal mass (26%) ❍ abdominal pain (37%) Location ❍ infrarenal (91-95%) with extension into iliac arteries (66-70%) Imaging findings ❍ Plain film ■ mural calcification (75-86%) ❍ US:>98% accuracy in size measurement

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LearningRadiology - Abdominal Aortic Aneurysm (AAA) ❍

❍

CT-non-contrast enhanced ■ perianeurysmal fibrosis (10%), may cause ureteral obstruction ■ "crescent sign" = peripheral high-attenuating crescent in aneurysm wall (= acute intramural hematoma) = sign of impending rupture CT-contrast-enhanced ■ ruptured aneurysm ● anterior displacement of kidney ● extravasation of contrast material ● fluid collection / hematoma within posterior pararenal + perirenal spaces (see below)

free intraperitoneal fluid contained leak ● laminated mural calcification ● periaortic mass of mixed / soft-tissue density ● lateral "draping" of aneurysm around vertebral body ●

■

●

Angio focally widened aortic lumen >3 cm ❍ apparent normal size of lumen secondary to mural thrombus (11%) ❍ mural clot (80%) ❍ slow antegrade flow of contrast medium Contained rupture = extraluminal hematoma / cavity ❍ absent parenchymal stain = avascular halo ❍ displacement + stretching of aortic branches Complications: ❍ Rupture (25%) ■ into retroperitoneum: commonly on left ■ into GI tract: massive GI hemorrhage ■ into IVC: rapid cardiac decompensation ● 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% ● Symptoms of rupture ❍ sudden severe abdominal pain ± radiating into back ❍ faintness, syncope, hypotension ❍ Prognosis:64-94% die before reaching hospital ❍ Increased risk: size >6 cm, growth >5 mm / 6 months, pain + tenderness ❍

●

●


LearningRadiology - Abdominal Aortic Aneurysm (AAA)

Peripheral embolization ❍ Infection ❍ Spontaneous occlusion of aorta Prognosis:17% 5-year survival without surgery ❍ 50-60% 5-year survival with surgery Treatment ❍ surgery recommended if >5 cm in diameter; ❍ 4-5% surgical mortality for nonruptured ■ 30-80% for ruptured aneurysm Postoperative Complications ❍ Left colonic ischemia (1.6%) with 10% mortality ❍ Renal failure (14%) ❍ 0-8% mortality rate for elective surgery ❍

●

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From Dahnert Radiology Review Manual 2002

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TAPVR and PAPVR

● ●

Must have ASD for survival All have anatomical L to R shunt at atrial level ❍

All have functional R to L shunt of oxygenated blood to right side of heart

Two Types l

l

Partial (PAPVR) l

Mild physiologic abnormality

l

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

l

Mild or no physiologic consequence

l

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

http://www.learningradiology.com/notes/cardiacnotes/tapvrpage.htm (1 de 3)04/09/2006 1:25:30

http://www.learningradiology.com/notes/cardiacnotes/tapvrpage.htm l

All must also have R to L shunt for survival l

Obligatory ASD to return blood to the systemic side

l

All are cyanotic

l

Identical oxygenation in all four chambers

l

Types

l

l

Supracardiac

l

Cardiac

l

Infracardiac

l

Mixed

Supracardiac Type—Type I l

Most common (52%)

Pulmonary veins drain into vertical vein (behind left pulmonary artery) to •left brachiocephalic vein to SVC

l

l

DDx: VSD with large thymus

l

Supracardiac Type 1—X-ray Findings

l

l

Snowman heart = dilated SVC+ left vertical vein

l

Shunt vasculature 2° increased return to right heart

l

Enlargement of right heart 2° volume overload

Cardiac Type—Type II l

Second most common: 30%

l

Drains into coronary sinus or RA l

Coronary sinus more common

l

Increased pulmonary vasculature

l

Overload of RV leads to •CHF after birth

l

20% of I’s and II’s survive to adulthood


http://www.learningradiology.com/notes/cardiacnotes/tapvrpage.htm l

l

l

Remainder expire in first year

Infracardiac Type—Type III l

Percent of total: 12%

l

Long pulmonary veins course down along esophagus

l

Empty into IVC or portal vein (more common)

l

Vein constricted by diaphragm as it passes through esophageal hiatus

l

Severe CHF (90%) 2° obstruction to venous return

l

Cyanotic 2° right to left shunt through ASD

l

Associated with asplenia (80%), or polysplenia

l

Prognosis = death within a few days

Mixed Type—Type IV l


l

Mixtures of types I – III

WH/rev2002



Aortic Dissection


Aortic Dissection

● ● ●

•

3:1 male to female predominance Over the age of 40 Hemorrhage in the media (at vasa vasorum) leading to either ❍ Tear in the weakened intima which breaks into the lumen, or ❍ Hemorrhage in the wall (less common) ❍ Hemorrhage separate media from adventitia Predisposing factors o o o o o o o o

Hypertension (most commonly) Atherosclerosis Cystic medial necrosis § Marfan’s 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

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

Types

o

o

o

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Aortic Dissection

o

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

Stanford Classification

Portion of Aorta Involved

DeBakey Type I

Stanford Type A (ascending aorta involved)

Involves entire aorta

DeBakey Type II (least common)


Ascending aorta only

DeBakey Type III (most common)

Stanford Type B

Descending aorta only

Common causes Hypertension Atherosclerosis Cystic medial necrosis e.g.Marfan’s Ehlers-Danlos Hypertension Atherosclerosis

*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

Mediastinal widening Left paraspinal stripe Displacement of intimal calcifications Apical pleural cap Left pleural effusion Displacement of endotracheal tube or nasogastric tube

Intimal flap Slow flow or clot in false lumen

CT § § §

Intimal flap Displacement of intimal calcification Differential contrast enhancement of true versus false lumen


RX Usually surgically*

Usually surgically* Usually medically

Aortic Dissection

CT of abdominal aorta show intimal flap (dark line) with true lumen anteriorly and false lumen posteriorly

o

Angiography § § § § §

•

Diagnosis o o o o

•

Intimal flap Double lumen Compression of true lumen by false channel Increase in aortic wall thickness > 10 mm Obstruction of branch vessels

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

http://www.learningradiology.com/notes/cardiacnotes/penetratingulcerpage.htm (1 de 2)04/09/2006 1:25:39

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


http://www.learningradiology.com/notes/cardiacnotes/penetratingulcerpage.htm (2 de 2)04/09/2006 1:25:39

LearningRadiology - Cardiac Radiology Curriculum


Course Outline Cardiac Radiology Conferences July, 2004 - June, 2005 Approximate Chronology of Conferences •

ABC’s 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

http://www.learningradiology.com/notes/cardiacnotes/heartcurriculumpage.htm (1 de 8)04/09/2006 1:25:41


Scope of Cardiac Curriculum 1. Fundamental roentgenologic observations in the diagnosis of cardiovascular disease: The ABC’s of Heart Disease 2. Left-to-right shunts ● ● ● ● ●

ASD VSD PDA TAPVR Endocardial cushion defects

3. Stenotic and insufficient valvular lesions ● ● ● ●

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 ● ● ● ● ● ●

Transposition Tetralogy of Fallot Truncus arteriosus Tricuspid atresia Ebstein’s 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 surgery–types, 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 Takayasu’s 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 http://www.learningradiology.com/notes/cardiacnotes/heartcurriculumpage.htm (3 de 8)04/09/2006 1:25:41


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 http://www.learningradiology.com/notes/cardiacnotes/heartcurriculumpage.htm (4 de 8)04/09/2006 1:25:41


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



●

●

Normal anatomy ❍ Inner serous layer is the epicardium ❍ Outer fibrous layer is pericardium ❍ Space between the two is pericardial space ❍ Normally contains about 20-50cc of fluid ❍ Fat covers outside of heart and outside of pericardium sandwiching pericardial space between the two layers ■ Normal thickness of pericardium (parietal pericardium and fluid in space) is 2-4 mm Requires about 150-250cc before cardiac tamponade occurs ❍ Tamponade compresses heart and causes low cardiac output ❍ Most effusions do not lead to cardiac tamponade ❍ Size of cardiac silhouette is frequently increased ❍ 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 ●

Other causes ❍ Serous fluid = transudate ■ Congestive heart failure ■ Hypoalbuminemia ■ Irradiation ❍ Blood = hemopericardium ■ Rupture of ascending aorta or pulmonary trunk ■ Coagulopathy ❍ Fibrin = exudate ■ Pyogenic infection, e.g. staph ■ Uremia: 18% in acute uremia; 51% in chronic uremia; dialysis patient

http://www.learningradiology.com/notes/cardiacnotes/pericardialeffpage.htm (1 de 3)04/09/2006 1:25:44

LearningRadiology.com - Pericardial effusion,dilated,cardiomyopathy,enlarged,heart ●

Imaging findings ❍ "Water bottle configuration" is symmetrically enlarged cardiac silhouette ■ Major DDX is cardiomegaly ❍ Loss of retrosternal clear space ■ Non-specific and frequently not valid ❍ "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 http://www.learningradiology.com/notes/cardiacnotes/pericardialeffpage.htm (2 de 3)04/09/2006 1:25:44

LearningRadiology.com - Pericardial effusion,dilated,cardiomyopathy,enlarged,heart

normal.) The yellow arrow points to fat outside of heart and the blue arrow to the myocardium. ❍ ❍

❍ ●

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 ❍ Separation of epi- and pericardial echoes extending into diastole (rarely behind LA)


http://www.learningradiology.com/notes/cardiacnotes/pericardialeffpage.htm (3 de 3)04/09/2006 1:25:44

LearningRadiology - CHF Sequence in Childhood


CHF IN CHRONOLOGIC SEQUENCE CHF IN NEWBORN 1.

Hypoplastic Left Heart

2.

TAPVR

3.

Premature closure of foramen ovale

4.

Pulmonary atresia

Acyanotic Cyanotic Acyanotic

CHF AFTER 1 WEEK OF AGE 1.

Interrupted aortic arch (infantile coarct)

2.

Coarctation of the aorta-adult c VSD or PDA

3.

MS, MR, AI

4.

Cor triatriatum

5.

Cardiomyopathy

CHF IN 2nd-3rd WEEK 1.

Coarctation of the aorta

2.

Interruption of the aortic arch

CHF IN 1st-2nd MONTH http://www.learningradiology.com/notes/cardiacnotes/chfsequencepage.htm (1 de 2)04/09/2006 1:25:46

Cyanotic

LearningRadiology - CHF Sequence in Childhood

1.

Aortic stenosis

2.


3.

Anomalous origin L coronary artery

CHF IN LATE CHILDHOOD 1.

Aortic stenosis

CHF-LATE 1.



http://www.learningradiology.com/notes/cardiacnotes/chfsequencepage.htm (2 de 2)04/09/2006 1:25:46

LearningRadiology - Pulmonary Sling and Double Aortic Arch


Pulmonary Sling & Double Aortic Arch

Pulmonary Sling ●

●

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 ●

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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●

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. ●

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 ●

●

Calcification in the pericardium is most likely inflammatory in nature ❍ 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 ❍ Thin, egg-shell like calcification is more often associated with viral infection or uremia ❍ 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 ●

●

Calcification is seen in 1/3-1/2 of patients with constrictive pericarditis ❍ Its presence does not imply constriction ❍ 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 ❍ This can usually be accomplished by the locations of these calcifications on multiple views, or the radiographic appearance of the calcium Constrictive Pericarditis

http://www.learningradiology.com/notes/cardiacnotes/constrictpericardpage.htm (1 de 2)04/09/2006 1:25:53

LearningRadiology.com - Constrictive Pericarditis,restrictive,pericardial,calcification,calcify

Present when a fibrotic, thickened, and adherent pericardium restricts diastolic filling of the heart. ❍ Usually begins with an initial episode of acute pericarditis ■ May not be detected clinically ❍ This slowly progresses to a chronic stage consisting of fibrous scarring and thickening of the pericardium with obliteration of the pericardial space ❍ This produces uniform restriction of the filling of all heart chambers Signs and Symptoms ❍ Reduced cardiac output ( fatigue, hypotension, reflex tachycardia ) ❍ Elevated systemic venous pressure ( jugular venous distension, hepatomegaly with marked ascites and peripheral edema ) ❍ Pulmonary venous congestion ( exertional dyspnea, cough and orthopnea ) ❍ 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. ❍ 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


http://www.learningradiology.com/notes/cardiacnotes/constrictpericardpage.htm (2 de 2)04/09/2006 1:25:53

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

http://www.learningradiology.com/notes/cardiacnotes/pulmonicstenosispage.htm (1 de 3)04/09/2006 1:25:54


•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 R—L 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



General ❍

Most are asymptomatic

❍

■ 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 ■

●

❍ ❍ ❍ ❍ ❍

●

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

■ Diverticulum of Kommerell Right Aortic Arch

❍

Types ■ ■

At least five different types Only two of importance ● ●

❍

Mirror Image Type — Type I Aberrant left subclavian — Type II

General

■

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

■ ■ ■ ■ ■

●

❍

● Most common variety of right arch Type 1—Mirror Image Type

■ ■ ■

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 ● Aorta descends on right Type ll—Aberrant Left Subclavian ● ●

❍

■ ■

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%) ● Coarctation of aorta rarely (7%) Anomalous left subclavian artery (retroesophageal and retrotracheal) Aorta descends on right X-ray Findings ● ●

■ ■ ■

● ● ●

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 ●

If there is a mirror-image right aortic arch, then

●

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

●

Truncus arteriosis Tetralogy of Fallot ❍ Transposition ❍ Tricuspid atresia ❍ VSD Double Aortic Arch

❍

❍ ❍

33% 25% 10% 5% 2%



❍

General ■ ■

■ ■ ■ ■ ■ ■

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

Posterior impression on lateral view Angiogram is characteristic Clinical ●

■ ■

●

Symptoms may begin at birth and include ❍ ❍

Tracheal compression, or Difficulty swallowing

■

Anatomy

■

Right arch supplies RSCA and RCC Left arch supplies LCC and LSCA X-ray Findings ● ●

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 ■ Usually asymptomatic ■ May present as pulsating supraclavicular mass ■ May produce vascular ring and compress airway ■ Embryogenesis uncertain ■ Over 80% are right-sided Imaging Findings–Right-sided lesions

❍

Right-sided cervical aortic arches Right apical mass-like density ■ Absence of aortic knob on left ■ Aorta descends on the left ■ Displace the trachea and esophagus forward ■ Branching may be normal or mirror-image Imaging Findings–Left-sided lesions

■

■ ■

■ ■ ■ ■

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.

Tetralogy

L

2.

Truncus-type IV

L

3.

Tricuspid atresia

L

or

J

4.

Transposition

L

or

J

5.

Ebsteins

L

¤

¤

CHF IN NEWBORN 1.

Hypoplastic L Heart Syndrome

2.


3.

Cong. aortic stenosis

4.

Mitral stenosis

5.

Cor triatriatum

6.

Pulmonary venous obstruction as in: • Stenosis of the pulmonary veins

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• TAPVR from below diaphragm

¤

CARDIOMEGALY WITH NORMAL VASCULATURE 1.

Viral myocarditis

¤

2.


¤

3.

Aberrant coronary artery (from PA LÜR shunt)

¤

4.

Cystic medial necrosis of coronary arteries

¤

5.

Diabetic mother

¤

CYANOSIS WITH INCREASED VASCULARITY

L

1.

Transposition

2.

Truncus types I,II,III

3.

TAPVR

L

4.

Tricuspid atresia

L

5.

Single ventricle

L

=Cyanotic

J

=Acyanotic

¤

or

J

or

J

L

L

=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


Ebstein’s 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

o •

Think of Ebstein’s 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 | Home | Lectures | Notes | Images | Flashcards | Case of the Week Archives | | Bone | Cardiac | Chest | GI | Miscellaneous | Med Students | Most Common Lists | Copyright © 2003 LearningRadiology.com

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

Down’s syndrome

Endocardial cushion defect (25%)

(Trisomy 21)

Membranous VSD ASD–ostium primum AV communis Cleft mitral valve PDA 11 pairs of ribs

Ellis-Van-Creveld (50% CHD)

Holt-Oram syndrome (50% CHD)

Hypersegmented manubrium Single atrium Polydactyly

ASD VSD Pulmonic stenosis

Hurler syndrome

Radial dysplasia Cardiomyopathy

Ivemark syndrome

Asplenia

Marfan’s syndrome

Complex cardiac abnormalities Aortic sinus dilatation

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Aortic aneurysm Aortic insufficiency

Noonan syndrome

Pulmonary aneurysm Pulmonic stenosis ASD

Postrubella syndrome

Hypertrophic cardiomyopathy Peripheral pulmonic stenoses Valvular pulmonic stenosis Supravalvular aortic stenosis PDA Deafness

Turner syndrome

Cataracts Coarctation of the aorta (in 15%)

Trisomy 16-18

Bicuspid aortic valve VSD PDA

Trisomy 13-15

Double outlet right ventricle VSD Tetralogy of Fallot

William syndrome (Idiopathic hypercalcemia)

Double outlet right ventricle Supravalvular aortic stenosis (33%) ASD VSD Valvular and peripheral pulmonary artery stenosis Aortic hypoplasia Stenoses of more peripheral arteries

WH







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 we’ll 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 http://www.learningradiology.com/notes/cardiacnotes/abcsnotespage.htm (2 de 24)04/09/2006 1:26:13

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.

Normal

2.


3.

Pulmonary arterial hypertension 4.

Increased flow

Decreased flow to the lungs is another category but is very difficult to assess accurately, so we’ll 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 can’t 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 doesn’t 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 lungs—apex 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 http://www.learningradiology.com/notes/cardiacnotes/abcsnotespage.htm (5 de 24)04/09/2006 1:26:13

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 be—upper 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 ABCs of Heart Disease 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

Remarks Enlarged heart

Pulmonary venous hypertension Mitral stenosis

Normal or slightly enlarged heart

Left atrial myxoma Papillary muscle dysfunction

Look for pulmonary edema, effusions


ABCs Page

Left heart failure Increased flow VSD PDA

Enlarged aorta

Pulmonary arterial hypertension Mitral stenosis

Will also have pulmonary venous hyper.

VSD, PDA

Will also have increased flow

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

Presupposes left atrial enlargement

Increased flow (Left to right shunts) ASD VSD

Left atrium not always enlarged

PDA

Left atrium not always enlarged

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 we’re not going to look at the pulmonary vasculature; we’re 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 won’t help to differentiate one C heart from another. Instead, we’ll look at the configuration of the aorta.

C Heart Normal vasculature

Remarks

Hypertension

Entire aorta prominent

ASCVD


Aortic regurgitation


Aortic stenosis

Ascending aorta prominent

Coarctation

Notch in descending aorta

Cardiomyopathy

Normal aorta

Pulmonary venous hypertension Can’t be

Presupposes left atrial enlargement

Increased flow None

Except in rare truncus, pulmonary artery should be big

Pulmonary arterial hypertension Can’t 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.. http://www.learningradiology.com/notes/cardiacnotes/abcsnotespage.htm (8 de 24)04/09/2006 1:26:13

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

Remarks


Uremia, viral, mets, TB, trauma, post-MI

Cardiomyopathy

Alcoholism, beri beri

Multiple valve disease Coronary artery disease

Cardiomyopathy

Ebstein's

Big right heart

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.



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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 •

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

•

Chronic edema of alveolar walls → fibrosis Pulmonary hemosiderin is deposited in lungs Pulmonary ossification may occur

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— SHONE’S Syndrome • Shone’s 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 Fabry’s Disease § Deposition of aramide trihexoside thickens and decreases mobility of mitral leaflets o Hurler’s Syndrome § Deposition of mucopolysaccharide thickens and decreases mobility of mitral leaflets o Whipple’s 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



o

§ 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


Nine Lesions Which Produce 75% of All Severe Congenital Heart Lesions In the Neonate Decreased flow • Severe PS • Tetralogy of Fallot • Tricuspid Atresia • Ebstein’s

Increased Flow • Transposition • VSD

Pulmonary venous hypertension • Hypoplastic left heart • Coarctation of the aorta • TAPVR with infradiaphragmatic obstruction

What’s left • Left-to-right shunts •ASD http://www.learningradiology.com/notes/cardiacnotes/ninelesionspage.htm (1 de 2)04/09/2006 1:26:18

LearningRadiology - Nine Most Common Congenital Cardiac Lesions

•PDA • Truncus arteriosus

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LearningRadiology-Ventricular Aneurysm



•

•

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 ● ● ● ●

Comminuted Intra-articular Fracture through base of thumb Prognosis: worse than Bennett's fracture (difficult to reduce)

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Bennett's Fracture ●

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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

LearningRadiology.com - Rolando, Colle's, Bennett's, Barton's Fractures

Barton's Fracture ●

●

Colles' Fracture

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


Copyright © 2003 LearningRadiology.com

http://www.learningradiology.com/notes/bonenotes/wristfxs.htm (2 de 2)04/09/2006 1:26:26

LearningRadiology.com - Lunate, Perilunate Dislocation


Carpal Instabilities

Lunate Dislocation ● ● ● ●

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 ❍

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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 ❍

● ● ●

Lunate and Perilunate Dislocation

●

Carpal dislocations described by extent of ligamentous injury (Mayfield) ❍ Stage I ■ Isolated rotatory subluxation of scaphoid ● Mechanism: acute dorsiflexion of wrist ● May be associated with rheumatoid arthritis ● Characterized by increased distance between scaphoid and lunate > than 2 mm (Terry Thomas sign) ● Scaphoid ring sign – ring-shaped shadow of cortex of distal pole of scaphoid seen on end ● Associated more than 50% of the time with distal radial fractures ❍ Stage II



Dislocation or subluxation of capitate ● Exceedingly rare Stage III ■ Perilunate dislocation ● Triquetrial and scaphoid malrotation ● 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 Stage IV ■ Lunate Dislocation ● 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 ■

❍

❍

Harris and Harris




LearningRadiology.com - Child Abuse,radiology,battered child syndrome


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 ❍ 1.7 million cases reported, 833,000 of which were substantiated in United States in 1990 ❍ Results in 2,500-5,000 deaths/year ❍ 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 ❍ Usually <2 years In children <2 years of age, a skeletal survey may be best to demonstrate other fractures ❍ In children >2 years of age, a bone scan may be best Clinical findings ❍ Skin burns ❍ Bruises ❍ Lacerations ❍ 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 ❍ Multiple ribs ❍ Transverse fracture of sternum ❍ Costochondral / costovertebral separation ❍ Lateral end of clavicles ❍ Scapula ❍ Acromion ❍ Skull ❍ Vertebral bodies ■ Anterior-superior wedging of vertebral bodies ■ Vertebral compression ■ Vertebral fracture dislocation ■ Disk space narrowing ■ 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) ●

Appearances of skeletal trauma ❍ Hallmark of the syndrome are multiple, asymmetric fractures in different stages of healing ❍ Separation of distal epiphysis ❍ Marked irregularity and fragmentation of metaphyses ■ "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 ❍ Isolated spiral fracture (15%) of diaphysis secondary to external rotatory force applied to femur / humerus ❍ Extensive periosteal reaction from large subperiosteal hematoma ❍ Exuberant callus formation at fracture sites



Cortical hyperostosis extending to epiphyseal plate ❍ Avulsion fracture at site of ligamentous insertion ■ Frequently seen without periosteal reaction Head trauma (13-25%) ❍ Most common cause of death and/or physical disability ■ Skull fracture (flexible calvaria + meninges decrease likelihood of skull fractures) ■ Subdural hematoma ■ Brain contusion ■ Cerebral hemorrhage ■ Infarction ■ Generalized edema ■ Shearing injuries with associated subarachnoid hemorrhage ■ Skull film (associated fracture in 1%): ● Linear fracture > comminuted fracture ❍ CT findings in head trauma ■ Subdural hemorrhage (most common) ● Interhemispheric location most common ■ Subarachnoid hemorrhage ■ Epidural hemorrhage (uncommon) ■ Cerebral edema (focal, multifocal, diffuse) ■ Acute cerebral contusion appears as ovoid collection of intraparenchymal blood with surrounding edema ❍ MR findings of head trauma ■ More sensitive in identifying hematomas of differing ages ■ White matter shearing injuries as areas of prolonged T1 + T2 at corticomedullary junction, centrum semiovale, corpus callosum Viscera (3%) ❍ Second leading cause of death in child abuse ❍ Cause ■ Crushing blow to abdomen (punch, kick) ❍ Age ■ Often >2 years ❍ Small bowel and/or gastric rupture ❍ Hematoma of duodenum and/or jejunum ❍ Contusion and/or laceration of lung, pancreas, liver, spleen, kidney ❍ Traumatic pancreatic pseudocyst Differential diagnosis of child abuse ❍ Normal periostitis of infancy ❍ Osteogenesis imperfecta ❍ Congenital insensitivity to pain ❍ Infantile cortical hyperostosis ❍ Menkes kinky hair syndrome ❍ Schmid-type chondrometaphyseal dysplasia ❍ Scurvy ❍ Congenital syphilitic metaphysitis ❍

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Dahnert 5th edition Requisites-Pediatric Radiology Requisites-Musculoskeletal Radiology





LearningRadiology-Enchondroma


Enchondroma ●

Benign cartilaginous tumor

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Develops in the medullary cavity

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Composed of hyaline cartilage

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Occurs in 2nd to 3rd decade

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Most common site is small bones of the hand ❍

Most common tumor of the hand

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Also foot, humerus, femur, tibia and ribs

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Hand lesions are usually asymptomatic or associated with pain and swelling

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X-ray appearance

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Well-defined lytic and slightly expansile lesion (in small bones)

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Usually have some internal calcification and endosteal thinning

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There may be cortical expansion or thickening

May fracture or, rarely, undergo malignant transformation ❍ Growth of lesion or pain should suggest malignant transformation Multiple enchondromas is called Ollier's disease ❍ Nonhereditary ❍ May have limb shortening of affected limb ❍ Madelung’s deformity of the wrist ❍ Enchondromas point toward the joint ■ Exostoses point away from joint ❍ Greater incidence of malignant transformation because there are more lesions present (25%) With cavernous hemangiomas of soft tissues called Marfucci's Syndrome ❍ Nonhereditary ❍ Multiple hemangiomas usually on extremities (digits)

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LearningRadiology-Enchondroma ❍ ❍ ❍ ❍

Look for phleboliths in hemangioma Large enchondroma Growth disturbance of affected bones Malignant transformation ■ Greater than solitary enchondroma, less than Ollier’s ■ Hemangioma may become sarcoma in 5% of cases


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LearningRadiology - Multiple Hereditary Exostoses


Multiple Hereditary Exostoses Diaphyseal Aclasis

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Inheritance ❍ Autosomal dominant Age of onset ❍ Discovered between 2 and 10 years Male predominance = 2:1 Pathology ❍ Ectopic cartilaginous rest in metaphysis and a defect in periosteum produces exostoses ❍ Cap of hyaline cartilage over bony protuberance ❍ Cortex and cancellous bone of exostosis is contiguous to host bone Clinical ❍ Usually painless mass near joints ❍ Tendons, blood vessels, nerves may be impaired ❍ Mechanical limitation of joint movement may occur Location ❍ Multiple ❍ Usually bilateral ❍ 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) ❍ Always point away from joint and toward center of shaft ❍ Occasionally small punctate calcifications are seen in cartilaginous cap Other skeletal abnormalities may occur ❍ Shortening of 4th and 5th metacarpals ❍ Supernumerary fingers and/or toes ❍ Madelung / reversed Madelung deformity ❍ Dislocation of radial head Prognosis ❍ Exostosis begins in childhood ❍ Stops growing when nearest epiphyseal center fuses Complications ❍ Malignant transformation to chondrosarcoma in <5% ■ Iliac bone commonest site ■ Look for growth with irregularity of contour and fuzziness of margin ■ Sudden painful growth spurt ❍ Cord compression secondary to involvement of posterior spinal elements ❍

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From Dahnert





LearningRadiology - Calcinosis Universalis


Calcinosis Universalis

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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) ❍

Dermatomyositis ■

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Damaged chondroitin sulfate, atrophy of muscles, followed by calcification of muscle and subcu tissue Ages 5-10 and again in 50s

More common in females ■ Linear and confluent calcifications in soft tissues of extremities ■ Acro-osteolysis ■ Chest-may have infiltrates associated Clinically ●

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Weakness of respiratory muscles ■ Erythematous rash of eyelids ■ Proximal muscle weakness ■ Associated with a high incidence of malignancies of GI tract, lung, ovary , breast, kidney May resemble myositis ossificans progressiva ■

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Myositis ossificans progressive (fibrodyplasia ossificans progressiva) ■

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 ●

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LearningRadiology-Multiple Myeloma


Multiple Myeloma ●

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Clinical ❍ Average age is 60-70 ❍ Men much more common than women ❍ Most have an elevated serum protein with 80-90% in the globulin fraction, especially IgG ❍ Bence-Jones protein in 40-60% of patients (light chains) X-ray findings ❍ Osteoporosis is most common skeletal abnormality in this disease ❍ Lesions are usually multiple and found in vertebrae, ribs, skull, pelvis, and femur ❍ Over 50% of solitary lesions are found in vertebrae ❍ Mandible involved in 1/3 of patients with diffuse involvement ❍ Widespread lucencies in bone ■ Discrete, “punched-out” lesions ■ Uniform in size ❍ Distinctive to MM are the lucent, elliptical, subcortical shadows, especially in long bones=endosteal scalloping ■ Due to buttressing since MM is usually a slower process than mets ❍ In spine, MM destroys body and spares pedicle DDX: mets and disuse osteoporosis ❍ MM is more widespread ❍ More discrete holes in MM ❍ Large foci of coalescence more often due to mets ❍ Severe disuse osteoporosis may simulate bone changes of MM Sclerosis is usually seen only with treatment or fracture ❍ 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 ❍ Solitary plasmacytoma produces “soap-bubbly” expansile, septated lesion, when characteristic


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LearningRadiology-Multiple Myeloma

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LearningRadiology-Chance Fracture

| Home | Letures | Notes | Images | Flashcards | Case of the Week Archives | | Bone | Cardiac | Chest | GI | Miscellaneous | Med Students | Most Common Lists |

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

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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

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There may be associated soft tissue swelling

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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 http://www.learningradiology.com/notes/bonenotes/chancefxpage.htm (2 de 3)04/09/2006 1:26:41



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LearningRadiology - Non-ossifying Fibroma


Nonossifying Fibroma AKA: Nonosteogenic fibroma, fibroxanthoma, xanthogranuloma of bone ● ● ●

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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 ❍ Fewer than 10% occur in upper extremities Characteristics ❍ Geographic ❍ Lytic ❍ Multilobulated ❍ Metaphyseal ❍ Usually intramedullary ❍ Eccentric ❍ Well-marginated ❍ Sclerotic rim ❍ Endosteal scalloping Most lesions heal spontaneously by being replaced with normal bone ❍ Migrate away from epiphysis May undergo pathologic fracture or rarely cause rickets ❍ Do not undergo malignant transformation

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LearningRadiology - Non-ossifying Fibroma


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LearningRadiology - Charcot's Arthropathy


Neuropathic (Charcot) Arthropathy ●

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Disturbance in sensation leads to multiple microfractures ❍ Pain sensation is intact from muscles and soft tissue Distribution and causes ❍ Shoulders – syrinx, spinal tumor ❍ Hips – tertiary syphilis, diabetes ❍ Knees – tertiary syphilis (more bone production), diabetes (less bone production) ❍ Feet – diabetes ❍ Other causes ■ Amyloidosis ■ Congenital indifference to pain ■ Polio ■ Alcoholism X-ray findings ❍ Sclerosis ❍ Destruction of joint ❍ Fragmentation ❍ Soft tissue swelling from synovitis ❍ Joint effusions ❍ Osteophytosis ❍ Disorganized and disrupted joint ❍ 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 ●

DDX ❍

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Degenerative joint disease ■ Eventually neuropathic joint shows more sclerosis ■ More fragmentation in neuropathic ■ More destruction of bone in neuropathic CPPD ■ Associated with chondrocalcinosis which a neuropathic joint is not


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LearningRadiology-Ochronosis


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 ❍

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When deposited in cartilage, synovial thickening develops This results in:

Subchondral cysts ■ Sclerosis ■ Osteophyte production, all secondary to DJD ■ Bony ankylosis may occur in joints or spine ❍ Usually affects large joints-knees, shoulders, hips ❍ Chondrocalcinosis of appendicular joints may develop In the spine: ■

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Changes of degenerative disc disease ❍ Ligamentous structures mat be involved ❍ Resembles ankylosis spondylitis ❍ Universal disc space calcification is common Universal disc calcification and DJD of root joints (hips and shoulders) in younger patient are pathognomonic ❍

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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

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Differential diagnosis ❍ TB ❍ Osteomyelitis ❍ Gout More than 1/2 have presenting complaint of foot pain despite neurologic impairment Most common secondary to diabetes ❍ Rarely syphilis

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Sclerosis or lysis near or away from ulceration

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Foot frequently shows ulceration

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Most difficult differential is from osteomyelitis ❍ 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 ● ●

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Sub-articular, post-traumatic necrosis Occurs only on convex surfaces of bone ❍ Medial condyle of femur ❍ Capitellum ❍ Proximal surface of talus st metatarsal ❍ Head of 1 Most patients are athletic Direct blow is more common cause than a rotational injury ❍ 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 ❍ 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 ■ Usually not in adults ■ 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

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Usually affects children ■ Septic arthritis more common in adults; osteomyelitis in children

Hallmark characteristics ❍ Destruction of bone ❍ Periosteal new bone formation Organisms ❍ Newborns ■ S. aureus ■ Group B streptococcus ■ E. coli ❍ Children ■ S. aureus ❍ Adults ■ S. aureus (most common) ■ Enteric species ■ Streptococcus ❍ Drug addicts ■ Pseudomonas (most common) ■ Klebsiella ❍ Sickle cell disease ■ Salmonella Pathogenesis ❍ Hematogenous spread ❍ Direct implantation from a traumatic / iatrogenic source ❍ Extension from adjacent soft-tissue infection Location ❍ Lower extremity (most common) ■ Over pressure points in diabetic foot ❍ Vertebrae ■ Lumbar > thoracic > cervical ❍ Radial styloid ❍ Sacroiliac joint

ACUTE NEONATAL OSTEOMYELITIS ●

Age

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

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

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ACUTE OSTEOMYELITIS IN CHILDHOOD ●

Age 2-16 years of age Pathomechanism ❍ Trans-physeal vessels closed ❍ Primary focus of infection is in metaphysis Findings ❍ Sequestration frequent ❍ Periosteal elevation ❍ Small single / multiple osteolytic areas in metaphysis ❍ Extensive periosteal reaction parallel to shaft (after 3-6 weeks) ❍ Shortening of bone with destruction of epiphyseal cartilage ❍ Growth stimulation by hyperemia and premature maturation of adjacent epiphysis ACUTE OSTEOMYELITIS IN ADULTHOOD Delicate periosteal new bone Joint involvement common ❍ Septic arthritis X-ray findings ❍ Initial radiographs often normal for as long as 7-10 days ❍ Localized soft-tissue swelling adjacent to metaphysis with obliteration of usual fat planes (after 3-10 days) ❍ Area of bone destruction (lags 7-14 days behind pathologic changes) ❍

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Bone destruction of head of 2nd metatarsal with periosteal new bone formation characteristic of osteomyelitis ● ● ●

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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 ❍ Bone marrow hypointense on T1WI + hyperintense on T2WI (= water-rich inflammatory tissue) DDx ❍ Neuropathic osteoarthropathy ❍ Aseptic arthritis ❍ Acute fracture ❍ Recent surgery ❍ Ewing’s sarcoma Findings ❍ Focal / linear cortical involvement hyperintense on T2WI ❍ Hyperintense halo surrounding cortex on T2WI = subperiosteal infection ❍ Hyperintense line on T2WI extending from bone to skin surface and enhancement of borders (= sinus tract) Nuclear Medicine (accuracy approx. 90%): ❍ Ga-67 scans ■ 100% sensitivity ■ Increased uptake 1 day earlier than for Tc-99m MDP ❍ Gallium helpful for chronic osteomyelitis Static Tc-99m diphosphonate ❍ 83% sensitivity ❍ 5-60% false-negative rate in neonates and children Complications of osteomyelitis ❍ Abscess in soft-tissue ❍ Fistula or sinus formation ❍ Pathologic fracture


LearningRadiology - Osteomyeltis ❍ ❍ ❍

Extension into joint producing septic arthritis Growth disturbance due to epiphyseal involvement Severe deformity with delayed treatment

Dahnert 4th Edition



LearningRadiology-Chondrosarcoma


Chondrosarcoma

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Most often occurs in 5th or 6th decades Pelvis most frequent bone involved ❍ Also femur, tibia, humerus Most often geographic bone lesion ❍ Sometimes permeative ❍ 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 ❍ From pre-exiting skeletal lesion ■ Osteochondroma ■ Enchondroma ■ Parosteal chondroma


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LearningRadiology-Osteomyelitis of Skull


Osteomyelitis of Skull

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Two modes of spread ❍ Direct extension from paranasal sinuses ❍ Retrograde septic thrombophlebitis Epidural extension separates the dura from the inner table of skull ❍ Removes major blood supply to the inner table of skull ❍ Predisposes bone to widespread infection ❍ Sutures tend to arrest progress for some time Dura is resistant to infection at first ❍ Then yields to meningitis and abscess X-ray- findings become evident 7-10 days after infection starts ❍ Early ■ Islands of normal bone ■ Increased or diminished density ❍ Advanced ■ Lytic process Frontal sinus is most commonly involved Brain abscess is most common complication


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LearningRadiology - Osteopetrosis


Osteopetrosis

AKA: Albers-Schönberg Disease = Marble Bone Disease ● ● ●

Rare hereditary disorder Defective osteoclast function with failure of proper reabsorption produces sclerotic bone Structurally weak

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

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LearningRadiology - Osteopetrosis

(phalanges, iliac bones) indicate fluctuating course of disease ■ ■

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Longitudinal metaphyseal striations Mandible least involved

Complications: ❍ Fractures (common because of brittle bones) with abundant callus + normal healing ❍ Crowding of marrow (myelophthisic anemia + extramedullary hematopoiesis) ❍ Frequently terminates in acute leukemia ❍ Rx: bone marrow transplant DDx: ❍ Heavy metal poisoning ❍ Melorheostosis (limited to one extremity) ❍ Hypervitaminosis D ❍ Pyknodysostosis ❍ Fibrous dysplasia of skull / face

From Dahnert


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LearningRadiology-Congenital Syphilis


Congenital Syphilis ● ● ●

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Passes placenta after the third month of gestation Osteoblasts eventually contain spirochetes Skeletal lesions early in disease are ❍ Osteochondritis ❍ Osteomyelitis (diaphyseal) ❍ Periostitis ❍ These all occur early in the course of disease Osteochondritis ❍ Occurs at metaphysis ❍ Widens the zone of provisional calcification until there is epiphyseal separation (usually before age 3 moths) ❍ Dislocation is not pronounced ❍ X-ray shows lucent metaphyseal band ❍ Heals after 6 months of age Osteomyelitis ❍ In skull, may get geographic areas of destruction Periostitis ❍ Less common than osteomyelitis Course ❍ Even if lesions at this stage are not treated, they regress ❍ Remains latent for years and appears again around age 4 or later ❍ In later life, lesion is gummatous or non-gummatous osteomyelitis ❍ Usually affects skull, radius, tibia, ulna-especially skull and tibia ❍ Saber tibia results from growth stimulation of the tibia with forward bowing (in rickets the bowing is lateral and not forward) ❍ Also may get dactylitis, especially of proximal phalanx of index finger DDX: Birth trauma, rickets, severe malnutrition Other changes ❍ Nose-saddle nose ❍ Notched and narrowed incisors-Hutchinson’s teeth ❍ Periosteal reaction and new bone formation ■ Especially proximal 2/3 of tibia shaft common late manifestation Saber shin ❍ Bilateral forward bowing of tibia is conclusive evidence for acquired, tertiary syphilis although similar changes can occur with congenital form ❍ Acquired syphilis affects skull (mixed sclerosis and lysis) ■ 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

Paget’s Disease ● ●

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Multifocal chronic skeletal disease due to chronic paramyxoviral infection Prevalence ❍ 3% of individuals >40 years ❍ 10% of persons >80 years ❍ Unusual <40 years ❍ M:F = 2:1 Histology ❍ Increased resorption and increased bone formation ❍ Newly formed bone is abnormally soft with disorganized trabecular pattern Active or Osteolytic phase ❍ Aggressive bone resorption with lytic lesions ❍ Replacement of hematopoietic bone marrow by fibrous connective tissue with numerous large vascular channels Inactive or Quiescent phase ❍ Decreased bone turnover with skeletal sclerosis and thickening of the cortex Mixed pattern ❍ Lytic and sclerotic phases frequently coexist Clinical findings ❍ Asymptomatic (1/5) ❍ When symptomatic, symptoms may include ■ Fatigue ■ Enlarged hat size ■ Peripheral nerve compression ■ Neurologic disorders from compression of brainstem (basilar invagination) ■ Hearing loss, blindness ■ Facial palsy (narrowing of neural foramina) - rare ■ Pain from(a)primary disease process is rare so think of ● Pathologic fracture ● Malignant transformation ● Secondary degenerative joint disease aggravated by skeletal deformity ■ High-output congestive heart failure from markedly increased perfusion (rare) ■ Increased alkaline phosphatase (increased bone formation) ■ Hydroxyproline increased (increased bone resorption) ■ Normal serum calcium + phosphorus Sites of involvement ❍ Usually polyostotic and asymmetric

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LearningRadiology.com - Paget's Disease,Paget Disease,osteoporosis circumscripta

Pelvis (75%) most common, followed by ● Lumbar spine ● Thoracic spine ● Proximal femur ● Calvarium ● Scapula ● Distal femur ● Proximal tibia ● Proximal humerus Imaging Findings ❍ Classical triad ■ Thickening of the cortex ■ Accentuation of the trabecular pattern ■ Increased size of bone ❍ Cyst-like areas ❍ Skull (involvement in 29-65%) ■ Inner and outer table involved ● Leads to diploic widening ■ Osteoporosis circumscripta is well-defined lysis, most commonly in frontal bone producing well-defined geographic lytic lesion in skull ● Represents early destructive phase of disease active stage ■

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Osteoporosis circumscripta of frontal bone is lytic phase of Paget's disease ■

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"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) ■ "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 ■ Lateral curvature of femur


LearningRadiology.com - Paget's Disease,Paget Disease,osteoporosis circumscripta ■ ❍

Anterior curvature of tibia (commonly resulting in fracture)

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

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LearningRadiology.com - Paget's Disease,Paget Disease,osteoporosis circumscripta ●

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Treatment ❍ Calcitonin, diphosphonate, mithramycin ❍ Detection of recurrence: ■ In 1/3 detected by bone scan ■ In 1/3 detected by biomarkers (alkaline phosphatase, urine hydroxyproline) ■ In 1/3 by scan and biomarkers simultaneously DDx ❍ Depends on the bone in which it occurs ❍ Skull ■ Osteolytic or osteoblastic metastases ❍ Long bones ■ Metastases ■ Chronic osteomyelitis (thickened cortex) ■ Old trauma (thickened cortex) ■ Hodgkin’s disease ❍ Spine ■ Hemangioma ■ Metastases

Dahnert 4th Edition



LearningRadiology - Congenital Hip Dysplasia


Congenital Hip Dislocation

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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 ❍ Dislocated by adducting; then relocated by abduction ❍ Click is heard or felt on relocation Others who get dislocated hips

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Neurological disorders

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Hypothyroidism

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

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More benign variant of scleroderma Consists of ❍ Calcinosis ■ Calcinosis circumscripta ● Usually of hands ❍ Reynaud’s phenomenon ❍ Sclerodactyly ❍ Telangiectasias ■ Telangiectasias arise only on skin or mucous membranes of upper extremities or mouth ■ 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

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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 ❍ Frequent history of antecedent trauma ❍ Hemorrhagic "chocolate" effusion ❍ Insidious onset of swelling ❍ Pain of long duration ❍ Decreased range of motion ❍ Joint locking Age ❍ Mainly 2nd-4th decade; 50% <40 years ❍ F>M Location ❍ Knee (most common) ❍ Ankle ❍ Hip ❍ Elbow ❍ Shoulder ❍ Tarsal or carpal joints ❍ Predominantly monarticular Radiographic findings ❍ Soft-tissue swelling around joint ■ From effusion and synovial proliferation ❍ Dense soft-tissues from hemosiderin deposits ❍ Subchondral pressure erosions at margins of joint from hypertrophied synovium ❍ Multiple sites of deossification appearing as cysts ❍ No calcifications ❍ No osteoporosis ❍ No joint space narrowing (until late)

http://www.learningradiology.com/notes/bonenotes/pvnspage.htm (1 de 3)04/09/2006 1:27:03


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 ●

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MRI findings ❍ Masses of synovial tissue in a joint with effusion ❍ Scalloping / truncation of prefemoral fat pad ❍ Predominantly low signal intensity on all sequences (due to presence of iron) (characteristic of this lesion) ❍ Often heterogeneous low + high signal intensity on T2WI (hemosiderin deposits in masses + para-articular fat) ❍ DDx ■ Hemosiderin deposits in other diseases (eg, rheumatoid arthritis) Treatment ❍ Synovectomy ❍ Arthrodesis ❍ Arthroplasty ❍ Radiation DDx ❍ Synovial sarcoma ■ Mass around, but outside of, joint ■ Frequently calcify ❍ Degenerative arthritis ■ Joint space narrowing ■ Subchondral sclerosis

Dahnert 4th edition





LearningRadiology-DISH


Diffuse Idiopathic Skeletal Hyperostosis (DISH) ● ● ● ●

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Laminated, flowing osteophyte formation Must involve four contiguous vertebral bodies Osteophytes are usually quite thick Involves lower cervical and lower thoracic spine most frequently ❍ Disc space height tends to be maintained “Whiskering” at the sites of tendinous insertion ❍ Pelvic involvement ■ Crests ■ Ischial tuberosities ■ Iliolumbar ligaments ■ Lesser trochanter ❍ Deltoid tuberosities of humerus ❍ Olecranon spurs DDX: ❍ Ankylosing spondylitis ❍ Acromegaly ■ May produce osteophytes but they are not flowing ❍ Fluorosis may produce osteophytes, whiskering and ligamentous ossification ■ 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 ●

Occurs in infants and small children ❍ Bones of skull must be relatively “soft,” thin and resilient ❍ Depressed skull fracture in which no fracture line is seen ■ In children under the age of 2, the sutures should be less than 3 mm ■ 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


http://www.learningradiology.com/notes/bonenotes/pelvicavulsionfxspage.htm (1 de 4)04/09/2006 1:27:10


About Us






LearningRadiology-Fibrous Dysplasia


Fibrous Dysplasia ● ● ● ●

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Etiology unknown Most common 3-15 years Fundamental abnormality is replacement of medullary bone by fibrous tissue Clinically ❍ Deformities ■ Shepherd’s crook deformity of femur ❍ Bone pain Most commonly involved bones are pelvis, femora In widespread disease, the skull and jaw are almost always involved X-ray ❍ Endosteal scalloping ❍ Cortical thinning ❍ Ground-glass appearance ❍ May have matrix calcification Prone to fracture Growth of lesions usually stops when epiphyses close DDX: ❍ Brown tumor ❍ Unicameral bone cyst Albright’s Syndrome ❍ Polyostotic ❍ Sexual precocity ❍ Skin pigmentation ❍ 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 ●

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Occurs most often with rheumatoid arthritis ❍ Also occurs with osteoporosis ❍ Osteomalacia ❍ Paget’s ❍ 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 ❍ About 14% of patients with RA will demonstrate this abnormality


http://www.learningradiology.com/notes/bonenotes/protusioacetabulipage.htm04/09/2006 1:27:12

LearningRadiology-Frieberg’s Infraction


Frieberg’s Infraction

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Usually head of 2nd metatarsal ❍ But may affect other metatarsal heads as well Women to men by 4:1 ❍ Possibly because of shoes ❍ Usually adolescents Clinical ❍ Local pain and tenderness Typical changes of avascular necrosis occur ❍ End result is flattening of head ❍ May produce “loose body” Other named avascular necroses: ❍ Keinbocks-carpal lunate ❍ Kohlers- tarsal navicular


http://www.learningradiology.com/notes/bonenotes/friebergspage.htm04/09/2006 1:27:13

LearningRadiology- Psoriatic arthritis, Psoriasis


Psoriatic Arthritis Major points ● ● ●

Almost always accompanies skin disease, especially nail changes Mostly involves DIP joints of hands > feet Classical deformity is called “cup-and-pencil deformity” ❍ 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 ● ●

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There is often resorption of terminal phalanges There is usually no osteoporosis Most are HLA-B27 positive, RA factor negative Characteristic findings ❍ 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

http://www.learningradiology.com/notes/bonenotes/psoriaticarthritispage.htm (1 de 3)04/09/2006 1:27:14


Psoriatic arthritis Reiter’s syndrome

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As with ankylosing spondylitis and Reiter’s syndrome, bone proliferation is a major feature. Manifests itself with: ❍ Bony excrescences ❍ Periosteal new bone formation (common) ❍ Entire phalanx may become “cloaked” in new bone ■ “Ivory phalanx” ● Most frequent in terminal phalanges of toes, especially first ❍ Ankylosis is common ■ Especially in PIP and DIP joints of hands and feet ● Feature common to seronegative spondyloarthropathies ❍ 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 ❍ Asymmetric paravertebral ossification ■ Usually thicker and larger than syndesmophytes of ankylosing spondylitis or inflammatory bowel disease ❍ Occasionally, there are incomplete non-marginal syndesmophytes similar to AS Bilateral sacroiliitis is most common ❍ May produce erosions and sclerosis ❍ May produce widening of the SI joints ❍ 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


Gamekeeper’s Thumb AKA: Skier’s Thumb, Break-dancer’s Thumb

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Chronic injury to ulnar collateral ligament (UCL) of thumb first seen in gamekeepers in Scotland ❍ Because of the method they used to kill rabbits Acute injury now more common amongst skiers ❍ Called "Skier's thumb” ■ Due to fall on fall on outstretched hand with abducted thumb caught in pole strap ■ 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 ❍ 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

http://www.learningradiology.com/notes/bonenotes/gamekeeperspage.htm (1 de 3)04/09/2006 1:27:16


Gamekeeper's or Skier's Thumb: fracture of base of proximal phalanx of thumb from tear of ulnar collateral ligament ●

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Torn end of ulnar collateral ligament can be displaced to the abductor pollicis aponeurosis ❍ Called Stener lesion ■ Distal portion of ligament retracts and points superficially and proximally ■ Rupture of both the proper and accessory collateral ligaments must occur for this to happen ■ Produces a lump over medial aspect of the MCP joint of thumb Full evaluation requires abduction stress views st metacarpal and proximal phalanx ❍ Increase of more than 30° in angle between 1 ■ Indicates subluxation Treatment ❍ Complete ruptures of the UCL require surgical intervention for repair within the first 3 weeks of the injury ■ Best done in 1st week while the anatomy is maintained ■ Complete tears repaired after 3 weeks have increased incidence of weakness and pain on pinch grasp. ❍ Increased incidence of MCP joint arthritis has been noted in the long term




Copyright © 2004 LearningRadiology.com About Us


LearningRadiology-Pyle's


Craniometaphyseal Dysplasia Pyle’s Disease ● ●

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Unknown mode of inheritance Clinical ❍ Large, broad head ❍ Frontal bossing ❍ Mental retardation ❍ Cranial nerve abnormalities ■ Optic atrophy ■ Deafness ■ Facial nerve paralysis X-ray ❍ Progressive, diffuse hyperostosis of cranial vault, skull base and facial bones ❍ Accentuated bands of ossification along suture lines in skull ❍ Obliteration of paranasal sinuses and mastoids ❍ Flaring and widening of the metaphyses ■ Erlenmeyer flask deformity of the distal femur DDX ❍ Undertubulation ■ Common in ● Anemia ● Fibrous dysplasia ● Gaucher’s ● Healing fractures ■ Uncommon ● Caffey’s Disease ● Lead poisoning ● Pyknodysostosis


http://www.learningradiology.com/notes/bonenotes/pylespage.htm04/09/2006 1:27:17

LearningRadiology - Giant Cell Tumor


Giant Cell Tumor Osteoclastoma

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Probably arise from zone of osteoclastic activity in skeletally immature patients Incidence ❍ ~ 4% of all primary bone tumors ❍ ~ 20% of benign skeletal tumors Histology ❍ Multinucleated osteoclastic giant cells intermixed throughout a spindle cell stroma Age ❍ > 98% after epiphyseal plate fusion ■ Most between 20 and 40 years M:F = 1:1 Clinical ❍ Tenderness ❍ Pain at affected site ❍ Weakness ❍ Sensory deficits (if in spine) Location: ❍ 85% in long bones ■ Lower extremity (50-60% about knee) ● Distal femur > proximal tibia ■ Upper extremity (away from elbow): ● Distal radius > proximal humerus ❍ 15% in flat bones ■ Pelvis ■ Sacrum near SI joints ■ Skull Site in bone ❍ Eccentric ❍ Metaphyseal ■ Adjacent to epiphyseal line ● Subarticular if epiphyseal plate is fused

http://www.learningradiology.com/notes/bonenotes/gctpage.htm (1 de 3)04/09/2006 1:27:18


Giant cell tumor of distal radius is eccentric and extend to the end of the bone ●

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Appearance ❍ Expansile ❍ Solitary lytic bone lesion ❍ May be quite large at diagnosis ❍ No reactive sclerosis ❍ No periosteal reaction in absence of fracture ❍ May break through cortex with cortical thinning ❍ Soft-tissue invasion (25%) ❍ Pathologic fracture (5%) ❍ Destruction of vertebral body with secondary invasion of posterior elements (DDx: ABC, osteoblastoma) ■ Frequently demonstrate vertebral collapse ■ Can involve adjacent vertebrae and disk (like discitis) and can cross sacroiliac joint ❍ May cross joint space in long bones (exceedingly rare) Nuclear medicine findings ❍ Diffusely increased uptake ❍ May have "doughnut" sign of central photopenia Angiographic findings ❍ Hypervascular lesion CT findings ❍ Tumor has soft-tissue attenuation ■ May contain foci of low attenuation (hemorrhage/necrosis) ❍ Well-defined margins ❍ May have thin rim of sclerosis MR findings ❍ Heterogeneous signal intensity with low to intermediate intensity on T1WI + T2WI (63-96%) due to collagen + hemosiderin content ❍ Focal cystic areas ❍ Low-signal-intensity pseudocapsule Complications and associations ❍ 15% malignant within first 5 years



Much more often in males (M:F = 3:1) ❍ Metastases to lung ❍ May be associated with ■ Paget disease (in 50-60% located in skull + facial bones) Prognosis ❍ Locally aggressive ❍ 40-60% recurrence rate Treatment ❍ Complete resection + radiation therapy DDx: ❍ Aneurysmal bone cyst ❍ Brown tumor (lab values) ❍ Cartilaginous tumor ■ Chondroblastoma (open epiphyses) ■ Enchondroma (not epiphyseal) ■ Chondromyxoid fibroma (rare) ■ Chondrosarcoma ❍ Fibrous dysplasia ■

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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 http://www.learningradiology.com/notes/bonenotes/radioosteonecrosipage.htm (1 de 2)04/09/2006 1:27:20

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/


http://www.learningradiology.com/notes/bonenotes/radioosteonecrosipage.htm (2 de 2)04/09/2006 1:27:20

LearningRadiology.com - Gout, Gouty arthritis, acute gout, photo, image, radiology, arthritis, foot, pain, x-ray


Gout

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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

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M:F = 20:1 Overproduction of uric acid Abnormality of renal urate excretion Secondary Gout

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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

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Location: o Joints: hands + feet (1st MTP joint most commonly affected = podagra), elbow, wrist

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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)

http://www.learningradiology.com/notes/bonenotes/goutpage.htm (1 de 3)04/09/2006 1:27:22


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

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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

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Coexisting disorders: o Psoriasis o Glycogen storage disease Type I o Hypo- and hyperparathyroidism o Down’s 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 http://www.learningradiology.com/notes/bonenotes/goutpage.htm (2 de 3)04/09/2006 1:27:22




http://www.learningradiology.com/notes/bonenotes/goutpage.htm (3 de 3)04/09/2006 1:27:22

LearningRadiology- Renal Osteodystrophy, Hyperparathyroid



• Constellation of musculoskeletal abnormalities occurring with chronic renal failure featuring some combination of

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Osteomalacia (adults)

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Rickets (children)

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2° hyperparathyroidism

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Soft-tissue calcifications

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Osteosclerosis

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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

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Aluminum toxicity

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Dysfunction of hepatic enzyme system A

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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 (2°hyperprathyroidsim)

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Osteopenia o

Combined effect of

http://www.learningradiology.com/notes/bonenotes/renalosteodyspage.htm (1 de 5)04/09/2006 1:27:24


§ Osteomalacia (reduced bone mineralization due to acquired insensitivity to vitamin D / antivitamin D factor)

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Osteitis fibrosa cystica (bone resorption)

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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 •

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Sites of fractures o

Vertebral body (3-25%)

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Pubic ramus, rib (5-25%)

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Milkman fracture / Looser zones (in 1%)

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Metaphyseal fractures

Prognosis § Osteopenia may remain unchanged / worsen after renal transplantation + during hemodialysis

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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

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Hyperphosphatemia

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Hypocalcemia

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Increased PTH levels

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Subperiosteal, cortical, subchondral, trabecular, endosteal, subligamentous bone resorption



o Osteoclastoma = brown tumor = osteitis fibrosa cystica (due to parathyroid hormone -stimulated osteoclastic activity § o

Periosteal new-bone formation (8-25%)

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Chondrocalcinosis §

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More common in 1° hyperparathyroidism

More common in 1° hyperparathyroidism)

Osteosclerosis (9-34%) o

One of the most common radiologic manifestations §

Most common with chronic glomerulonephritis

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May be the sole manifestation of renal osteodystrophy

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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)



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Prognosis §

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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)

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Hypercalcemia

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Alkalosis with precipitation of calcium salts

Dystrophic secondary to local tissue injury §

Location •

Arterial (27-83%) o

In medial + intimal elastic tissue §

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Pipestem appearance without prominent luminal involvement

Periarticular (0-52%) o

Multifocal

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Frequently symmetric

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May extend into adjacent joint

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Chalky fluid / pastelike material

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Inflammatory response in surrounding tenosynovial tissue

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Discrete cloudlike dense areas §

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Fluid-fluid level in tumoral calcinosis

Prognosis §

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Dorsalis pedis a., forearm, hand, wrist, leg

Often regresses with treatment

Treatment http://www.learningradiology.com/notes/bonenotes/renalosteodyspage.htm (4 de 5)04/09/2006 1:27:24


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Decrease of phosphorus absorption in bowel

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Vitamin D3 administration (if vitamin D resistance predominates)

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Parathyroidectomy for 3° hyperparathyroidism (= autonomous hyperparathyroidism)

Dahnert 5th edition



LearningRadiology-Hand-Shoulder Syndrome


Hand-Shoulder Syndrome ●

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Pain, swelling and osteoporosis ❍ Atrophy of the skin of the hand Etiology not known Reflex circulatory disturbance Seen secondary to ❍ Myocardial infraction ❍ Stroke ❍ Trauma X-ray ❍ Shoulder x-rays are usually negative ❍ 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 ●

One of earliest changes of sickle-cell disease

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Occurs in small bones of hands and feet resulting from infarction

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Patients are usually less than two years of age

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First starts with painful swelling

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Usually in proximal phalanx or metacarpal

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Periosteal reaction and bone destruction are present

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Heals in a few months

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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

Usual Age

Neuroblastoma

Usually infants

Histiocytosis

Usually infant or child

Leukemia

About 5-15 years

Ewing’s Sarcoma

Teenager-early 20’s

Reticulum Cell Sarcoma

Average age 30

Multiple Myeloma

Average age 56


http://www.learningradiology.com/notes/bonenotes/roundcellbyagepage.htm04/09/2006 1:27:27

LearningRadiology - Hemangiopericytoma of Bone


Hemangiopericytoma ●

Glomus tumor ❍

May occur anywhere in bone, soft tissues, liver, etc.

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Skeletal lesions are rare

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Most commonly have local pain

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Usually in young adults

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Solitary

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Most common in terminal phalanx of finger

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Lytic, expansile, hypervascular on angiography.


http://www.learningradiology.com/notes/bonenotes/hemagiopericytomapage.htm04/09/2006 1:27:28

LearningRadiology- Sacroiliitis


Sacroiliitis ●

Normal SI joint is uniform in size throughout

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Only lower 2/3 of SI joint are true joint Earliest sign of sacroiliitis is widening of the joint

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Sclerosis and narrowing represent healing Unilateral Sacroiliitis

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TB Bilateral and symmetric

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Narrowing and sclerosis ■ Fusion eventually ■ Almost always bilateral Inflammatory bowel disease ■

■

Ulcerative colitis more often then Crohn’s

Enteropathic arthritis more common in Crohn’s-usually knee ■ Inflammatory bowel disease usually does not affect the spine as often as ankylosing spondylitis Bilateral and asymmetric ●

●

❍

Rheumatoid arthritis, psoriasis and Reiter’s may affect one SI joint but usually affect both

❍

Usually asymmetric Gout is a rare cause of sacroiliitis ■

May see erosions in spine SI Disease in Crohn’s ■

●

❍ ❍ ❍ ❍

About 3-16% of patient with Crohn’s 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 ■

●

❍

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

❍ ❍ ❍ ❍ ❍

■


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LearningRadiology-Hemophilia


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 ❍ ❍ ❍

●

Chronic synovitis develops from repeated intra-articular hemorrhages Thickened synovium produces marginal erosions Multiple subchondral cysts may develop secondary to intraosseous hemorrhage

X-ray ❍ ❍ ❍

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 ■

❍ ❍

●

●

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 ❍

JRA occurs more often in females


http://www.learningradiology.com/notes/bonenotes/hemophiliapage.htm04/09/2006 1:27:31

LearningRadiology - 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 ❍ ❍ ❍

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 ❍ 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 Sequelae ● Degenerative arthritis ●

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



Legg- CalvePerthe’s Disease

Age

Birth

Teenagers 1215 Heavy or tall Younger in girls (8-15)

∼5 years

Male/Female

5-9x more common in females 10x more common if breech

Boys>girls June-September most often

Male> females

Bilaterality

Race

Best Film

Almost never in Blacks

AP—not frog

Blacks more often

AP

None

Frog lateral-for subarticular lucency

1/3

1/4

1/10 Bilateral in females is rare


http://www.learningradiology.com/notes/bonenotes/hipstablepage.htm04/09/2006 1:27:34

Other ORTALANI CLICK— with leg flexed, dislocate by adduction, click on relocation with abduction

Avascular necrosis in 6-15%

Arthrography usually neg Better prognosis under 5 Synovitis may be 1st sign

LearningRadiology-Synovioma


Synovioma Synovial Sarcoma

● ●

● ●

● ●

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 ❍ Usually third and fourth decades Usually are extra-articular X-ray ❍ 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 ■ 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. ●

● ● ● ●

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: ❍ Tumoral calcinosis


http://www.learningradiology.com/notes/bonenotes/synoviomapage.htm (2 de 2)04/09/2006 1:27:35

LearningRadiology-Hyperparathyroidism


Hyperparathyroidism

Serum Urine

●

Secondary « or ¯ - or « ¯ ¯

Tertiary - or «

Primary Hyperparathyroidism

❍ ❍ ❍ ❍ ❍ ❍ ❍

❍

●

Calcium Phosphorous Alkaline Phosphatase Calcium Phosphorous

Primary ¯ - or « -

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 Recklinghausen’s 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 ■ Cystic lesion ■ May be multiple and look like mets ■ Pathologic fractures are common Soft tissue calcification is more common in secondary, except for knee medial meniscus calcification which is more common in primary

Secondary hyperparathyroidism ❍ Hyperplasia ❍ Rarely adenoma ❍ Mostly chief or clear cell ❍ Brown tumors less common ❍ Soft tissue calcification more common ❍ Calcified deposits around joints may mimic tumoral calcinosis


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LearningRadiology-Hyperparathyroidism

http://www.learningradiology.com/notes/bonenotes/hyperparathyroidismpage.htm (2 de 2)04/09/2006 1:27:37

LearningRadiology - Tuberculosis of bone


Tuberous Sclerosis

●

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 ❍ Calcification usually multiple 75% ❍ Usually central - periventricular ❍ Rarely in the cerebellum Also may have calvarial calcification in 40 to 50 percent of cases

● ● ● ●

❍

Involvement in the form of small areas of fairly well circumscribed hyperostosis ❍ Usually unilateral in frontal-parietal bone 75 percent are dead by age 20 of CNS involvement CNS almost always involved by hamartomas ❍

● ●

Mostly periventricular. ❍ X-rays may show periventricular, intracerebral and cranial vault calcifications ❍ Usually multiple, increase with age ❍ 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 ❍

● ● ● ●

❍ ❍ ❍ ❍ ●

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 ❍ ❍ ❍

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 ❍ ❍

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 ❍ Lead may be inhaled as well as ingested ■ Symptoms develop more quickly through GI tract ■ Toxicity more severe with co-existing iron, zinc, or calcium deficiency Pathology ❍ Lead concentrates in metaphyses of growing bones ■ Distal femur ■ Both ends of tibia ■ Distal radius leading to ● Failure of removal of calcified cartilaginous trabeculae in provisional zone Clinical findings ❍ Neurological ■ Learning disability ■ Decreased IQ ■ Mental retardation ■ Encephalopathy ■ Motor deficits ■ Seizures ■ Cerebral edema ■ Hearing loss ❍ Gastrointestinal ■ Abdominal pain ■ Nausea ■ Vomiting ■ Diarrhea ■ Constipation ■ Anorexia ■ Metallic taste in mouth ■ Ileus ❍ Renal ■ Tubular damage ❍ ❍

● ●

●

●

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LearningRadiology.com - Lead Poisoning, Lead, Intoxication, Plumbism, Poison, radiology, image, photo, x-ray ●

Azotemia

Gout ❍ Hematologic ■ Affects blood synthesis ■ Hemolysis ■ RBC stippling ■ Iron deficiency ❍ Musculoskeletal ■ Muscle and joint pain ❍ Soft tissue ■ Blue-black line in gum margins ❍ Endocrine ■ Decreased stature ● Decreased growth hormone ■ Decreased vitamin D levels Laboratory findings ❍ Predate bone changes on x-ray ❍ Serum Lead Level >1.2 umol/L ❍ Urine lead level elevated ❍ Peripheral Smear ■ Stippled erythrocytes ❍ Complete Blood Count ■ Microcytic Anemia ■ Leukocytosis ❍ Urine microscopy of sediment or renal biopsy ■ Acid-fast inclusion bodies in tubular nuclei ● Pathognomonic for lead poisoning ❍ Free Erythrocyte Protoporphyrin (FEP) > 0.6 umol/L Imaging findings ❍ Cerebral edema in acute lead intoxication ❍ Particles of lead in GI tract ❍ Bands of increased density at metaphyses of tubular bones (growing bone) ■ Metaphyses of growing bones may be dense normally ● Lead lines more apt to be seen in proximal fibula and distal ulna where growth is not as great as other long bones ■ Lead lines may persist ■

●

●


LearningRadiology.com - Lead Poisoning, Lead, Intoxication, Plumbism, Poison, radiology, image, photo, x-ray

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 ❍ ❍

● ●

Bone-in-bone appearance Abnormalities in bone modeling ■ Erlenmeyer flask appearance to distal femur DDx (see tables below) Treatment ❍ Surgical removal of lead foreign bodies in the gut (e.g. dice containing lead) if not eliminated within 2 weeks ❍ Chelation is indicated if the level is greater than 45 mcg/dL even if asymptomatic ■ First correct iron deficiency ❍ Chelating agents include EDTA, BAL, D-Penicillamine, and Succimer

Lucent Metaphyseal Bands Normal Leukemia Neuroblastoma TORCH infection

Dense Metaphyseal Bands Normal Lead poisoning Treated leukemia Healing rickets




LearningRadiology-Tumoral Calcinosis


Tumoral Calcinosis

●

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

● ●

❍

●

No renal, metabolic or collagen-vascular disease Autosomal dominant with variable expressivity Pathology: multilocular cystic lesions containing creamy white fluid

●

Hydroxyapatite crystals in suspension Clinical

●

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

❍

●

❍

❍

❍ ❍ ❍

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 ●

Peak incidence is five years with a range of 2-14 years

●

Bilateral in 10%

●

Males greater than females ❍ 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 ●

● ● ● ●

●

●

●

Volar plate forms floor of PIP joint and separates the joint space from the flexor tendons ❍ Volar plate is ligamentous at its origin on the proximal phalanx ❍ 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 ❍ “Jammed finger” If force of injury is great enough, dorsal dislocation can occur ❍ Rupture of volar plate may occur with longitudinal splitting of the collateral ligament structures ■ Allows for complete dorsal displacement of middle phalanx ■ Simple dislocations easily reduced by player coach, or trainer on the field ■ Following reduction, most dorsal dislocations are stable Fractures of base of middle phalanx also occur in association with dorsal dislocations ❍ If fracture involves more than 40-50% of articular surface ■ Collateral ligament support is lost ■ Combined with coexistent volar plate disruption ● Represents major loss of joint stability ● These injuries are often unstable, exhibiting persistent subluxation of the middle phalanx Imaging findings ❍ Small fragment of bone is avulsed from palmar (volar) aspect of base of middle phalanx

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LearningRadiology.com - Volar Plate Fracture,fracture,mallet finger,impacted

There is a small avulsed fragment of the base of the middle phalanx from a volar plate injury


LearningRadiology.com - Volar Plate Fracture,fracture,mallet finger,impacted ●

Complications ❍ Joint instability ❍ 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 ●

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


http://www.learningradiology.com/notes/chestnotes/alpha1anti.htm04/09/2006 1:27:47

LearningRadiology - Mycoplasma pneumonia


Mycoplasma Pneumonia (Primary atypical pneumonia) ●

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 ●

Meningitis

●

Encephalitis

http://www.learningradiology.com/notes/chestnotes/mycomplasmapage.htm (1 de 2)04/09/2006 1:27:48

LearningRadiology - Mycoplasma pneumonia ●

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 Mycobacterium—not 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 ●

Osteomyelitis of the mandible — with soft tissue mass – “lumpy jaw”

Intestinal ●

Resembles Crohn’s disease

●

May produce rupture of a hollow viscous, especially appendix

●

May produce fistula formation

Pulmonary

●

Consolidation which extends across fissure — peripheral and lower lobe ■

●

Abscess

●

Empyema

DDX for lung consolidation which extends through chest wall: ●

Blastomycosis

●

TB

●

Crytococcosis

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LearningRadiology - Actinomycocis

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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 • Ganglioneuromas—usually benign • Neuroblastomas—usually malignant • Sympathicoblastomas—usually malignant Paraganglionic cells • Pheochromocytoma • Chemodactomas (paragangliomas)—benign or malignant ●

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

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LearningRadiology - Neurogenic Tumors ●

In children, ganglioneuroma and neuroblastoma are most common

●

Ganglioneuroma– benign tumor

●

Neuroblastoma–very 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 ●

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 ●

●

●

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 - Neurogenic Tumors


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: • Carcinoid—85%-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 • Cylindromas—twice as common as mucoepidermoids • Resembles salivary gland tumor • More malignant potential than carcinoid (25%) • Mucoepidermoid •Mixed http://www.learningradiology.com/notes/chestnotes/adenomaspage.htm (1 de 5)04/09/2006 1:27:52


(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 •Pneumonia—are 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)

http://www.learningradiology.com/notes/chestnotes/adenomaspage.htm (2 de 5)04/09/2006 1:27:52


•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 Cushing’s 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 cyst—get 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

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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

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Defect in the posterosuperior wall of the orbit

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Enlargement of the orbit

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Hypoplasia of the greater wing of the sphenoid

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Enlargement of the middle cranial fossa

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Holes in the head

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Cranium bifidum

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Dural ectasia

●

Posterior scalloping of the vertebral bodies

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Dumbbell neurofibromas

●

Enlargement of a neural foramen

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Erosion of a pedicle

●

Intrathoracic meningocele

●

Kyphoscoliosis

●

Ribbon ribs

●

Neurofibromas of the vagus nerve

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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 asymptomatic—symptoms 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 ●

Brachial plexus involvement on affected side

●

Horner’s syndrome on affected side ❍ Ptosis ❍ Myosis ❍ Anhydrosis And rarely, enopthalmus

●

Superior vena caval obstruction when tumor occurs on right

●

X-ray ●

Apical cap on affected side; flat, uniform density

●

DDX: apical pleural thickening ❍

●

Other side is usually normal in Pancoast, thickened with apical pleural thickening

Key to diagnosis is demonstration of bone involvement ❍

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 ●

Exposure to silica from mining of coal, graphite, iron, tin, uranium, gold, silver, copper ❍

●

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

●

❍

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) ❍

Cavitate from tuberculosis or ischemic necrosis

●

Eggshell calcification of hilar nodes in 5%

●

Caplan’s syndrome consists of large necrobiotic nodules superimposed on silicosis

●

Silicosis predisposes to TB

Coal Workers’ Pneumoconiosis (CWP) ●

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 ❍

●

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 Organization’s 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 ●

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 ❍

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 (Mendelssohn’s Syndrome) • Acute pancreatitis • Heroin/methadone/crack cocaine overdose

http://www.learningradiology.com/notes/chestnotes/ards.htm (1 de 3)04/09/2006 1:28:00


• 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

90% even

70% central

45% Peripheral 35% Even

Kerley B lines/ peribronchial cuffing

30%

30%

None

Pleural effusions

40%

30%

10%

Air bronchograms

20%

20%

70%

Distribution of Pulmonary edema

WH/94



LearningRadiology - PCP, Pneumocystis Carinii Pneumonia


Pneumocystis Carinii Pneumonia PCP

● ●

●

●

●

●

Most common cause of interstitial pneumonia in immunocompromised patients Organism ❍ Protozoan / fungus Pneumocystis carinii Predisposed ❍ AIDS ❍ Debilitated ❍ Premature infants ❍ Children with hypogammaglobulinemia ❍ Other immunocompromised patients ■ Congenital immunodeficiency syndromes ■ Lymphoproliferative disorders ■ Organ transplant recipients ■ Patients on long-term corticosteroid therapy ■ Patients on chemotherapy for cancer Associated infections ❍ CMV ❍ Mycobacterium avium-intracellulare (MAI) ❍ Herpes simplex Clinical ❍ Severe dyspnea and cyanosis ❍ Subacute insidious onset of malaise and slight cough (frequent in AIDS patients) ❍ Respiratory failure ❍ WBC slightly elevated (polys) ❍ Lymphopenia (50%) indicates poor prognosis Imaging findings ❍ Normal CXR in 10-40% ❍ Bilateral diffuse symmetric finely granular / reticular interstitial / airspace infiltrates in 80% ■ Characteristic central location ■ Rapid progression to diffuse airspace disease ● Resembles non-cardiogenic pulmonary edema

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PCP pneumonia

Pleural effusion and hilar lymphadenopathy are uncommon ❍ Atypical pattern in 5% ■ Isolated lobar disease / focal parenchymal opacities ■ Lung nodules ± cavitation ■ Hilar / mediastinal lymphadenopathy ■ Thin- / thick-walled cysts ■ Cavities with predilection for upper lobes Course ❍ Usually responds to therapy in 5-7 days ❍ Effect of prophylactic use of aerosolized pentamidine ■ Redistribution of infection to upper lobes Complications ❍ Cystic lung disease ■ Central location to cysts ❍ Spontaneous pneumothorax, frequently bilateral (6-7%) ❍ Disseminated extrapulmonary disease (1%) ❍ Punctate / rimlike calcifications within enlarged lymph nodes and abdominal viscera CT findings ❍ Patchwork pattern (56%) ■ Bilateral, asymmetric patchy mosaic appearance ❍ Ground-glass pattern (26%) ■ Bilateral, diffuse air-space disease in symmetric distribution ❍ Interstitial pattern (18%) ■ Bilateral, symmetric / asymmetric, reticular markings (thickening of lobular septa) ❍ Abnormal air-filled spaces (38%) ■ Pneumatocoeles ● Thin-walled spaces without lobar predilection resolving within 6 months ■ Subpleural bullae due to emphysema ■ Thin-walled cysts ■ Necrosis of pneumocystis granuloma ■ Pneumothorax (13%) ❍

●

●

●



Lymphadenopathy (18%) ❍ Pleural effusion (18%) Pulmonary nodules and cavities ❍ Usually due to malignancy ■ Leukemia, lymphoma ■ Kaposi sarcoma ■ Metastasis ■ Or septic emboli ❍ Pulmonary cavities usually due to superimposed fungal / mycobacterial infection ❍

●

●

●

●

Nuclear medicine ❍ Bilateral and diffuse Ga-67 uptake without mediastinal involvement prior to roentgenographic changes DDx ❍ Non-cardiogenic pulmonary edema ❍ TB ❍ MAI infection Diagnosis ❍ Sputum collection ❍ Bronchoscopy with lavage ❍ Transbronchial or transthoracic or open lung Bx

Dahnert 4th edition



LearningRadiology - 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 • Zenker’s 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 http://www.learningradiology.com/notes/chestnotes/aspiration.htm (1 de 2)04/09/2006 1:28:03

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 ●

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 ❍ Hemorrhage into lungs, ❍ Pulmonary edema ❍ Pneumococcal pneumonia ❍ Aspiration

Staph aureus pneumonia ●

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 ❍

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 ❍

Pyopneumothorax

●

Abscess formation

●

Bronchopleural fistula

●

In children ●

Rapidly developing lobar/multilobar consolidation

●


●

Pneumatocoele

•

In adults

•

Patchy bronchopneumonia of segmental distribution, frequency bilateral

•

May be associated with atelectasis since airways are filled (not so with pneumococcal)

•


Streptococcus pyrogenes pneumonia ●

Most common in winter ❍

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

WH/‘91,‘93



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

Solid, round mass in thin-walled cavity

o

Usually in upper lobes

o

Moves with changes in positioning

o

Crescent-shaped airspace separates the fungus ball from the wall of cavity

o

Fungus ball may calcify

wh

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LearningRadiology - Aspergilloma


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LearningRadiology - Gram Negative Pneumonias


Gram Negative Pneumonias Pseudomonas aeruginosa ●

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 ●

Encapsulated, gram negative rods

●

Most are hospital acquired

●

Most are chronic alcoholics

●

Aspirated into lungs so most are unilateral and right sided

X-ray ●

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 involvement–effusion, empyema–which may progress very rapidly

●

Half develop abscesses

WH/‘91,‘93







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 http://www.learningradiology.com/notes/chestnotes/bronchiectasis.htm (1 de 3)04/09/2006 1:28:08


• 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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Home

Bone

Chest

Cardiac

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GI

Misc

LearningRadiology - Pneumomediastinum


Pneumomediastinum (Mediastinal Emphysema) ●

Rare in adults (except in ICU patients) and most common in newborns

●

ETIOLOGIES ❍

Spontaneous – most common mechanism in kids and adults ■ Pathophysiology involves increased intralveolar pressure such as from cough or vomiting which ruptures alveolus, air tracks back along blood vessels to mediastinum ●

■

■

•

Accompanying pneumothorax common in neonates

When air builds up in mediastinum and can’t 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 ■

■ ■

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; Hamman’s sign – crunching sound heard over the apex of the heart with cardiac cycle

WH/91

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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

WH/’91





LearningRadiology - Polyarteritis Nodosa


Polyarteritis Nodosa ●

Systemic necrotizing inflammation of medium-sized and small muscular arteries ❍ More common in adult males

●

Spares the arterioles, capillaries, venules and glomeruli

●

Associated with hepatitis B antigenemia

●

●

Signs and symptoms ❍ Abdominal pain ❍ Systemic hypertension ❍ Anorexia and weight loss ❍ Abdominal distention ❍ Hematemesis, melena ❍ Jaundice ❍ Painless hematuria ❍ Peripheral neuropathy ❍ Tender subcutaneous nodules ❍ Gangrene of fingers and toes Kidney (most frequently affected): 85% ❍ Multiple intrarenal aneurysms

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LearningRadiology - Polyarteritis Nodosa

Multiple aneurysms of renal vessels in Polyarteritis ❍

❍ ❍

●

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

●

Liver: affected 66% of cases

●

Treatment


LearningRadiology - Polyarteritis Nodosa ❍

Corticosteroids ■ 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%)

WH/‘93





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 ❍

LIP

❍

Castleman’s disease–lymph 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

●

Invariably has air bronchogram

●

May also have nodules, segmental consolidation or diffuse interstitial infiltration

WH/92

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LearningRadiology - 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 WH/’91

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LearningRadiology - Congenital Lobar Emphysema


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LearningRadiology - Pulmonary Laceration


Pulmonary Laceration Traumatic Lung Cyst Pulmonary Hematoma ●

Usually from blunt chest trauma

●

Occurs more often in children and young adults

X-ray ● ●

● ● ● ●

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


http://www.learningradiology.com/notes/chestnotes/pulmonarylacerationpage.htm04/09/2006 1:28:20

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 http://www.learningradiology.com/notes/chestnotes/copdpage.htm (1 de 2)04/09/2006 1:28:21

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


http://www.learningradiology.com/notes/chestnotes/copdpage.htm (2 de 2)04/09/2006 1:28:21

LearningRadiology - Radiation Pneumonitis


Radiation Pneumonitis ● ●

● ●

●

●

Damage to lungs after radiation therapy Usually requires at least 4500 rads ❍ Especially common if >6000 R given in 5-6 weeks Occurs more often if there is concurrent or later chemotherapy Pathologic phases ❍ Exudative phase = edema fluid + hyaline membranes ❍ Organizing phase ❍ Fibrotic phase = interstitial fibrosis Time of onset ❍ Usually at least 6 weeks up to 6 months after treatment Location ❍ Confined to radiation portal

Radiation portal (left) with subsequent radiation pneumonitis

• Acute Radiation Pneumonitis o o

o o

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)

http://www.learningradiology.com/notes/chestnotes/radiationpneumonitispage.htm (1 de 3)04/09/2006 1:28:25


§ § ●

Atelectasis + air bronchogram Spontaneous pneumothorax (rare)

CT findings of acute radiation pneumonitis ❍ Homogeneous slight increase in attenuation (2-4 months after therapy) ❍ Patchy consolidation (1-12 months after therapy) ❍ Non-uniform discrete consolidation (most common; 3 months to 10 years after therapy)

Sequential transverse images through lung showing radiation pneumonitis in right lung ●

●

Prognosis ❍ Recovery or progression to death from fibrosis Rx ❍ Steroids

• Chronic Radiation Damage o 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 ● ● ● ● ●

Shortness of breath Cough Production of black sputum (2° carbonaceous materials in smoke) Hemoptysis Chest pain

X-ray ●

Non-cardiogenic pulmonary edema (“increased permeability”)

●

Most likely 2° to damage to capillary membrane, either by ❍

Direct toxic effect on capillary endothelium

❍

Intense vasoconstrictor effect leads to anoxic cell damage

●

Bronchiolitis obliterans with organizing pneumonia (BOOP)

●

Pulmonary infiltrates with eosinophilia ❍

Adulterants have been implicated in producing hypersensitivity rx ■

●

Lidocaine, lactose, sucrose, starch and talc

Pulmonary hemorrhage ❍

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 drug’s effect

WH/92





LearningRadiology - 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: ❍ ❍ ❍

●

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: ❍

Pulmonary artery obstruction

❍

Congenital absence or hypoplasia of the pulmonary artery ■ Thromboembolism occluding one pulmonary artery ■ Unilateral arterial obstruction Abnormalities of the opposite lung itself ■

■ ■ ■

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


http://www.learningradiology.com/notes/chestnotes/cryptococcosispage.htm04/09/2006 1:28:28

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: ❍ Clinical evidence of the disease ❍ Severe disease Circulating antibody is largely IgM in patients with RA and the changes in the lung are probably immune in origin

Pleural Effusion ●

●

●

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 ●

● ● ●

Begins as micronodular and progresses to coarse reticulation, often more prominent at the bases and indistinguishable from scleroderma ❍ Has a honeycomb appearance Clinically, shortness of breath is most common symptom Subcutaneous rheumatoid nodules are often present PFTs show restrictive disease

Necrobiotic Nodules ●

Relatively rare

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●

Almost always associated with subcutaneous nodules and identical pathologically to them ❍

Usually well circumscribed masses

❍

Typically multiple

❍

Subpleural in location

❍

With cavitation

❍

Frequently at bases

Caplan’s Syndrome ●

●

●

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 ●

Due to an arteritis which produces PAH and eventual cor pulmonale

Obliterative Bronchiolitis ●

Same as BOOP except the patients have RA

WH







LearningRadiology - Cystic Adenomatoid Malformation


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 don’t)) • Supplied by pulmonary circulation

Types ● ● ●

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 ●

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 ●

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 ●

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

●

Crow’s 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 ●

Autosomal recessive almost always in caucasians

●

Dysfunction of the exocrine glands

●

Elevated concentration of Na and Cl in sweat

X-ray ●

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 ●

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 ●

Chronic cough, recurrent pulmonary infections

WH/’91





LearningRadiology - Round Pneumonia


Round Pneumonia ●

● ●

Spherical pneumonia caused by ❍ Haemophilus influenzae ❍ Streptococcus ❍ Pneumococcus Children are affected much more than adults Location ❍ Usually lower lobe ❍ Most often posterior

●

Clinical ❍ Cough ❍ Fever ❍ 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 ● ● ● ● ● ●

Normal chest x-ray Westermark's sign Abrupt cutoff and increased caliber of descending branch of PA Elevation of the hemidiaphragm Discoid atelectasis Infiltrate ❍ Usually basal and abutting pleural surface

Septic Emboli ● ●

From two major sources – tricuspid endocarditis or septic thrombophlebitis Predisposing condition almost always present ❍ Drug addiction ❍ Alcoholism ❍ Immunologic deficiencies ❍ Congenital heart disease (shunts)

X-ray ● ● ●

Multiple solid nodules or thin-walled cavities Rapid resolution with treatment Hilar and mediastinal adenopathy may be present

Fat Embolism ● ● ●

●

●

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 ❍ Dyspnea, cough hemoptysis ❍ Confusion, restlessness, delirium, stupor ❍ Petechiae or rash ❍ Hypocalcemia (calcium bound by free fatty acids)

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Fat in the urine (lipiduria)

❍

X-ray ● ● ●

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 ● ● ●

● ●

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: ❍ Multiparity ❍ Intrauterine fetal death ❍ Older age of the mother ❍ Difficult or prolonged labor

X-ray • Pulmonary edema indistinguishable from CHF (DDX: massive pulmonary hemorrhage and Mendelsohn’s 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 ● ● ● ● ●

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

WH/’91





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-broker’s 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%)

·


·

Usually exudate with lymphocytic predominance

·

Cavitation of nodules (<1%)

·

Fungus ball formation in chronic sarcoid cavities (usually TB)

·

Focal pleural thickening

Uncommon manifestations ·

Bronchostenosis with lobar atelectasis

·


·

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 Goodpasture’s 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 Goodpasture’s)

Goodpasture’s syndrome • Goodpasture’s includes renal disease http://www.learningradiology.com/notes/chestnotes/goodpasturepage.htm (1 de 3)04/09/2006 1:28:44


• 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

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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

o

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%)

• o

DDx: Sarcoidosis

Large opacities are conglomerations of small opacities

•

Complicated Silicosis (Progressive Massive Fibrosis—PMF) 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 Caplan’s Syndrome o Consists of large necrobiotic nodules (rheumatoid nodules) superimposed on silicosis or coal worker’s 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 http://www.learningradiology.com/notes/chestnotes/hamartomaspage.htm (1 de 4)04/09/2006 1:28:48


• 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


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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 §

•

Most common cause of vertebra plana in children

o § § §

Proximal long bones (15%) Expansile, lytic lesions, mostly diaphyseal Soft tissue mass Laminated periosteal reaction

o § § § § § §

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 ● ●

● ● ●

● ●

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 ● ● ● ●

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 ● ● ● ● ●

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 ●

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 ●

Most infections are subclinical

●

X-ray ❍

Migratory bronchopneumonia

❍

Hilar and mediastinal adenopathy

❍

Multiple nodules which heal with numerous calcified granulomas ■

❍

TB granulomas are usually 1 or 2 in number

Histoplasmoma=target calcification=bull’s-eye calcification in center of nodule (Pathognomonic)

Chronic histoplasmosis ●

Upper lobe cavitation, healing with fibrosis (very similar to TB)

Disseminated histoplasmosis ●

Infants and elderly are predisposed

●

Can be rapidly fatal

●

X-ray ❍

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 patient’s 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 patient’s 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 http://www.learningradiology.com/notes/chestnotes/spnpage.htm (1 de 4)04/09/2006 1:28:55


No further management necessary • Patients at low risk for malignancy–under 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


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LearningRadiology.com - Hyaline Membrane disease,respiratory distress syndrome,newborn,tachynea,RSD,HMD


Hyaline Membrane Disease Respiratory Distress Syndrome (of the Newborn)

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Acute pulmonary disorder of the newborn characterized by ❍ Generalized atelectasis ❍ Intrapulmonary shunting ❍ Ventilation-perfusion abnormalities ❍ Reduced lung compliance M:F =1.8:1 Cause ❍ Immature surfactant production (usually begins at 18-20 weeks of gestational age) ■ Causes acinar atelectasis Predispositions ❍ Premature infants ❍ Cesarean section ❍ Infants of diabetic mothers ❍ Perinatal asphyxia Clinical findings ❍ Onset ■ Usually less than 2-5 hours after birth ■ Increases in severity from 24 to 48 hours ■ Then, gradual improvement after 48-72 hours ❍ Abnormal retraction of chest wall ❍ Cyanosis ❍ Expiratory grunting ❍ Increased respiratory rate Imaging findings ❍ Typically, diffuse “ground-glass” opacification of both lungs with air bronchograms and hypoaeration ❍ Hypoaeration from loss of lung volume (may be counteracted by respiratory therapy) ❍ Fine granular pattern ❍ Prominent air bronchograms ❍ Bilateral and symmetrical distribution Prognosis ❍ Spontaneous clearing within 7-10 days (mild course in untreated survivors) ❍ Death in 18% Acute complications ❍ Barotrauma may produce ■ Parenchymal pseudocyst

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LearningRadiology.com - Hyaline Membrane disease,respiratory distress syndrome,newborn,tachynea,RSD,HMD ■

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Pulmonary interstitial emphysema ● Pseudoclearing ❍ 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)

■ ■ ■ ■ ❍

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Pneumopericardium Pneumoperitoneum Air in the retroperitoneum Subcutaneous emphysema Diffuse opacity ■ Worsening RDS ■ Superimposed pneumonia ■ Massive aspiration ■ Pulmonary hemorrhage ■ Congestive heart failure (from PDA or fluid overload) ● Persistent patency of ductus arteriosus ❍ Oxygen stimulus is missing to close duct Hemorrhage ■ Pulmonary hemorrhage ■ Intracranial hemorrhage Necrotizing enterocolitis Acute renal failure Chronic complications ❍ Lobar emphysema ❍ Localized interstitial emphysema


LearningRadiology.com - Hyaline Membrane disease,respiratory distress syndrome,newborn,tachynea,RSD,HMD

Recurrent inspiratory tract infections ❍ Retrolental fibroplasia ❍ Subglottic stenosis from intubation Treatment ❍ Supportive ❍ Exogenous surfactant via trachea ❍

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Dahnert 4th edition



LearningRadiology - Teratoma


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 ❍ Supposed to migrate along urogenital ridge to primitive gonad ❍ Journey is interrupted in the mediastinum May be solid or cystic ❍ Most are cystic Three major categories ❍ Mature teratomas ■ Well-delineated from surrounding tissues ■ Contain ectodermal elements along with cartilage, fat and smooth muscle ❍ Immature teratomas ■ Same elements as above with primitive tissues found in fetus ❍ Teratomas with malignant transformation ■ Overall about 30% are malignant ■ Usually adenocarcinoma in mature teratomas ■ 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 life—young adults most commonly ❍ DDX from thymomas which usually occur in 5th or 6th decade Symptoms ❍ Usually asymptomatic ❍ Large lesions can cause shortness of breath, cough or retrosternal pain or fullness ❍ Rare rupture of dermoid into trachea which leads to trichoptysis—expectoration of hair Associations ❍ Non-lymphocytic leukemia and malignant histiocytosis with immature teratomas Imaging findings ❍ Most occur in the anterior mediastinum, near junction of great vessels and heart ❍ Benign lesions are usually smooth in contour whereas malignant masses tend to be lobulated ❍ Usually larger than thymomas ❍ Calcification may rarely occur but is of no help since thymomas also calcify ■ 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 ■ Fat-fluid level may be seen on CT

http://www.learningradiology.com/notes/chestnotes/teratomapage.htm (1 de 6)04/09/2006 1:29:00


Enhanced CT scan of the chest shows large, septated anterior mediastinal mass containing fat and bony elements ❍ ●

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Rapid increase in size may mean hemorrhage into a cyst rather than enlarging malignancy Treatment and prognosis ❍ Mature teratomas ■ For benign cystic teratomas, surgical resection ■ Excellent prognosis ❍ Immature teratomas ■ In childhood, surgical excision is often successful ■ In adults, tend to have a more malignant course ❍ Teratomas with malignancy ■ Usually highly aggressive ■ Poor prognosis Teratoma versus dermoid ❍ Dermoid contain only epidermis ❍ Teratomas contain all 3 germ layers, but are mostly endodermal when malignant Other germ cell neoplasms ❍ Benign dermoid cysts ❍ Benign and malignant teratomas ❍ Seminomas ❍ Choriocarcinomas ❍ Embryonal cell carcinomas Mediastinal seminomas ❍ Rare ❍ Almost always in young men ❍ Identical to testicular seminoma and ovarian dysgerminoma ❍ May be well-encapsulated or invasive ❍ Tends to be lobulated ❍ Cannot be differentiated from teratoma Primary choriocarcinoma ❍ Even rarer than seminoma in the mediastinum ❍ Only 23 reported in the literature, almost all in men ❍ Occur between 20-30 years ❍ May be lobulated


LearningRadiology - Teratoma ❍ ❍ ❍ ❍

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

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Exogenous accumulation of fat in the lung most often from mineral oil:

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Older people who are constipated, have a swallowing disorder 2° neurologic disease

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In infants with feeding difficulties

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In the past, could be from oily nose drops

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Accumulation of fat in the lung may also occur from endogenous sources such as fat embolism, alveolar proteinosis lipid storage diseases

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Animal fatty acids (like fat embolus) produces hemorrhagic bronchopneumonia

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Mineral oil produces a giant cell foreign body reaction

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Starts as an alveolar infiltrate

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Moves to thicken interstitial septa, then

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Into macrophages enlarging lymphatics

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Finally produces a fibrosing reaction

X-ray

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Usually lower lobes with predilection for the right

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Alveolar consolidation, may be well-circumscribed

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May present as a peripheral mass with fuzzy or distinct margins simulating BrCa

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Fat attenuation on CT

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Low-attention mass in right lower lobe demonstrates fat density

Clinical

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Diagnosis

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Best method of DX is direct Bx

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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 http://www.learningradiology.com/notes/chestnotes/thyroidmasspage.htm (1 de 2)04/09/2006 1:29:02

LearningRadiology - Substernal Thyroid Mass

WH


http://www.learningradiology.com/notes/chestnotes/thyroidmasspage.htm (2 de 2)04/09/2006 1:29:02

LearningRadiology - Lupus erythematosus


Systemic Lupus Erythematosus

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Lungs and pleura are involved more often in lupus than any other collagen vascular disease (type III immune complex phenomenon)

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Findings include: ❍

Anti-nuclear antibody present in 87%

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LE cells in 78%

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Hypergammaglobulinemia in 77%

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Rheumatoid factor in 21%

Skin changes include ❍

Butterfly rash

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Alopecia

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Photosensitivity

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Raynaud's

Can be induced by drugs ❍

Four drugs account for 90% of cases ■

Hydralazine

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Pronestyl (procainamide)

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Dilantin

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INH

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Pleuroparenchymal changes more common than SLE

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This form does not involve kidney and will disappear if drug is stopped

X-ray ●

Patchy areas of consolidation at the lung bases, especially peripherally

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These may be 2° to infection (common) or lupus infiltrates (uncommon)

http://www.learningradiology.com/notes/chestnotes/lupuspage.htm (1 de 4)04/09/2006 1:29:04

LearningRadiology - Lupus erythematosus ●

Pleural effusion is probably most common lung manifestation 2° pleuritis

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Usually bilateral and small but may become very large

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If unilateral, more often on the left

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Discoid atelectasis is common

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Massive pulmonary hemorrhage may occur

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Cavitary nodules may occur (but are more common in RA)

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Cardiomegaly may be 2° to effusion or cardiomyopathy

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Diffuse interstitial fibrosis does not occur in SLE

Think of SLE with combination of: ●

Pleural effusion, discoid atelectasis and patchy infiltrates at the bases (DDx: thromboembolic disease)

WH/’91







LearningRadiology - TB


Tuberculosis Primary Pulmonary Tuberculosis ●

Parenchyma § § §

Upper lobes affected slightly more than lower Alveolar infiltrate Cavitation is rare

§ Lobar pneumonia is almost always associated with lymphadenopathy—therefore, lobar pneumonia associated with hilar or mediastinal adenopathy at any age should strongly suggest TB ●

Lymph node

•

§

Mostly unilateral hilar and/or paratracheal, usually right sided, rarely bilateral

§

Differentiates primary from postprimary TB—it 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 painlessly—therefore, 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

http://www.learningradiology.com/notes/chestnotes/tbpage.htm (1 de 3)04/09/2006 1:29:05

LearningRadiology - TB ● ●

Calcification in the primary complex is relatively rare. Very few patients with primary TB have clinical manifestations

Postprimary Tuberculosis (“Reactivation TB”) ●

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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 lobes—bilateral 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 occur—from one upper lobe to opposite lower or to another lobe

§ §

Miliary spread (below) Bronchiectasis—usually asymptomatic

§ Bronchostenosis due to fibrosis and stricture: fibrosis may cause distortion of a bronchus and atelectasis many years after the initial infection—“middle lobe syndrome” § Solitary pulmonary nodule—the tuberculoma—may 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 ●

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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 empyema—this carries a graver prognosis than the pleural effusion of the primary form Direct extension into the ribs or sternoclavicular joints is uncommon

Miliary Tuberculosis ● ● ● ● ●

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 TB–although clinical appearance of miliary TB may not occur


LearningRadiology - TB

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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 rapid—miliary TB seldom, if ever, produces calcification

TB and Other Diseases ● ● ●

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 ● ● ● ● ●

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 ● ●

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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:

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Progressive, diffuse interstitial disease Recurrent chylous effusions and sometimes chylous ascites Recurrent pneumothorax

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Tuberous sclerosis is inherited as a dominant with variable penetrance:

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• • • • • • • • •

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 ●

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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 Generalized, coarse reticulonodular changes Unilateral or bilateral pleural effusions which are usually large and recurrent

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LearningRadiology - Lymphangiomyomatosis ● ● ● ●

Spontaneous pneumothorax is common Clinically Shortness of breath Hemoptysis


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LearningRadiology - UIP


Usual Interstitial Pneumonia ●

The most common of the diffuse interstitial pneumonias

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Begins with diffuse damage to alveolar walls

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Necrosis of alveolar lining cells is followed by regeneration

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There is an abundance of polys in bronchial washings in contrast to lymphocytes found in sarcoid or hypersensitivity pneumonias

X-Ray ●

Earliest manifestation consists of fine reticular pattern, particularly at the lung bases

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Becomes coarser as disease progresses and ends with honeycomb lung

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Progressive loss of volume is characteristic of either UIP or scleroderma

Clinically ●

Symptoms include SOB, non-productive cough and fatigue

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Clubbing of the fingers is very common (85%)

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Cyanosis and pulmonary hypertension usually occur late in the disease

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“Velcro” rales on auscultation

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About 1/3 have +ANA titers and 1/3 have + Rheumatoid factors

Other chronic interstitial pneumonias ●

BIP (Bronchiolitis obliterans and diffuse interstitial pneumonia)–favors upper lobes

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DIP (desquamative interstitial pneumonia)–second most common chronic interstitial pneumonia

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Heavy concentration of mononuclear cells rather than polys as in UIP

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Loss of type I alveolar epithelial cells and proliferation of type II cells

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Ground glass pattern in both lower lung fields

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LIP (lymphoid interstitial pneumonia) — like lymphoma

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LearningRadiology - UIP

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No characteristic x-ray picture

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GIP (giant cell interstitial pneumonia) — characterized by multinucleated giant cells in the alveoli

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No characteristic x-ray picture

WH/’91


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LearningRadiology - Hodgkins Disease


Hodgkin’s Disease

Half of patients with Hodgkin’s 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 Hodgkin’s 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

l

Parenchymal involvement occurs in 1/3 of patients with Hodgkin’s 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

http://www.learningradiology.com/notes/chestnotes/hodgkinspage.htm (1 de 3)04/09/2006 1:29:10

LearningRadiology - Hodgkins Disease

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%

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


LearningRadiology - Hodgkins Disease l l

“A” signifies absence of symptoms “B” signifies presence of fever, night sweats or pruritis


Copyright © 2002-2004 LearningRadiology.com About Us


LearningRadiology - Varicella Pneumonia


Varicella Pneumonia

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Occurs most often over the age of 19 rather than in childhood

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Patchy, diffuse air space consolidation

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Tendency to coalesce near hila

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Widespread nodules can occur (30%)

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Tiny calcifications remain in 2% (DDX is histoplasmosis, alveolar microlithiasis)

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11% mortality rate


http://www.learningradiology.com/notes/chestnotes/varicellapage.htm04/09/2006 1:29:11

LearningRadiology - Metastases to the Lung


Metastatic Lung Disease

SOLITARY METASTASES

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Colon (30-40%) Sarcomas, particularly from bone Kidney Testicle Breast Malignant melanoma

MULTIPLE NODULES

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Kidney •

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Thyroid

Sarcoma of bone

LYMPHANGITIC SPREAD

CAVITARY METS

Lesions arise around chest

Usually thick walled with nodular inner margin

Simulate CHF

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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 origin–such as squamous cell ca or transitional cell ca

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“Snowstorm” appearance of miliary mets–think of thyroid ca

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Mets with long survivals– think of salivary gland tumors and alveolar cell ca

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Mets with fuzzy borders —think of lesions that grow very quickly and bleed, such as metastatic choriocarcinoma

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Mets that contain calcification—think of osteosarcoma, chondrosarcoma

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Things that look like mets but aren’t—other causes of multiple nodules ❍

AVMs

❍

Wegener’s granulomatosis

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Rheumatoid nodules

❍

Septic emboli

❍

Hamartomas

WH/’91







LearningRadiology - Wegener's Granulomatosis


Wegener’s Granulomatosis General ● ● ● ● ● ●

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

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Mucosal thickening in paranasal sinuses

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Bone and cartilage destruction

Lungs

● ● ● ● ●

Multiple nodules of varying sizes, especially at bases Cavitate frequently (50%) Masses wax and wane Pleural effusion (25%) Alveolar infiltrate occasionally

Other Organs ● ● ● ● ● ●

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

http://www.learningradiology.com/notes/chestnotes/wegenerspage.htm (1 de 2)04/09/2006 1:29:13

LearningRadiology - Wegener's Granulomatosis ● ● ● ●

Rhinorrhea Sinusitis Epistaxis Cough with hemoptysis

Midline Lethal Granuloma ●

Variant of Wegener’s consisting of mutilating granulomatosis and neoplastic lesions limited to nose and paranasal sinuses

WH/ ‘93


http://www.learningradiology.com/notes/chestnotes/wegenerspage.htm (2 de 2)04/09/2006 1:29:13

LearningRadiology - Achalasia


Achalasia • Cause is generally considered a defect in the cholinergic receptors of Auerbach’s 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 “bird’s 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

http://www.learningradiology.com/notes/ginotes/achalasiapage.htm (1 de 2)04/09/2006 1:29:16

LearningRadiology - Achalasia

• Scleroderma —empties on standing • Chagas disease —indistinguishable by x-ray WH/92


http://www.learningradiology.com/notes/ginotes/achalasiapage.htm (2 de 2)04/09/2006 1:29:16

LearningRadiology- Gastric Emphysema


Gastric Emphysema

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●

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: ❍ Gastric outlet obstruction with increased intraluminal pressure ❍ Severe vomiting ❍ Instrumentation-like endoscopy ❍ Dissection of air from mediastinum from ruptured bleb or pneumothorax ❍ Pneumatosis cystoids - submucosal air collections

Air in stomach wall outlines greater curvature of stomach

Emphysematous gastritis ● ●

Rare and severe gastritis secondary to mucosal disruption and gas-forming bacterial invasion Characterized by air in the wall of the stomach

http://www.learningradiology.com/notes/ginotes/gastricemphysemapage.htm (1 de 2)04/09/2006 1:29:17

LearningRadiology- Gastric Emphysema ●

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Causes: ❍ Ingestion of toxic material such as corrosives ❍ Alcohol ingestion ❍ Trauma ❍ Gastric infarction ❍ Ulcer disease Submucosa is invaded by gas-forming organisms which include: ❍ Hemolytic strep ❍ Clostridia Welchi ❍ E. Coli ❍ Staph aureus Clinical: ❍ Sudden and violent onset of bloody emesis ❍ Fever ❍ Nausea ❍ Chills ❍ Leukocytosis X-ray: ❍ Linear small gas bubbles in gastric wall ■ Gastric emphysema is more linear, streak-like ❍ Gas in portal vein Prognosis: ❍ 60-80% fatal Best way to differentiate emphysematous gastritis from gastric emphysema: ❍ Look at patient ■ Patients with gastric emphysema are a asymptomatic from the bowel gas air ■ Patients with emphysematous gastritis are usually deathly ill

WH/wh 03


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LearningRadiology - Antral Web


Antral Diaphragm or Web

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A membrane with a variably-sized opening in the antrum of the stomach

•

May occur from 3 months to 80 years

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Histologically • Mucosa around a central core of submucosa and muscularis mucosae

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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

wh/94


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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 Gardner’s syndrome, coexistent gastric ca • Occurs more commonly in antrum • Often single • Usually>1.5cm in size http://www.learningradiology.com/notes/ginotes/polypsgastricpage.htm (1 de 3)04/09/2006 1:29:19


• 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)

WH/92


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LearningRadiology - Ascariasis


Ascariasis ● ● ● ●

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 ❍ ❍

Infection is through contaminated soil Involves GI tract of host twice First time as egg Migrates through lungs Adult travels up trachea ■

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Signs and Symptoms ❍ ❍ ❍

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Returns to GI tract for maturation (2 months)

Colicky pain Hematemesis Eosinophilia

X-ray findings ❍ ❍

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 ■

Especially after the remainder of the barium exits the small bowel. See below (streak of barium in LUQ):

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❍

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Ball of worms

Complications ❍ ❍ ❍ ❍ ❍

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: l

Collection

l

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) • Hampton’s 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 http://www.learningradiology.com/notes/ginotes/ulcergastricpage.htm (2 de 3)04/09/2006 1:29:22


• 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 l

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 l

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

ca l

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

l

Penetration is the extension of the ulcer beyond the serosa in to adjacent structures

• Pancreas is most common site, but also biliary tree, colon

WH


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LearningRadiology - Boerhaave's Syndrome


Ruptured Esophagus

•

Nearly all esophageal perforations are caused by trauma

• Causes include: > Iatrogenic–endoscopy (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

Boerhaave's Syndrome • 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 Boerhaave’s, 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 WH/93



http://www.learningradiology.com/notes/ginotes/gastricvolvuluspage.htm


Gastric Volvulus

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Uncommon ❍ May occur in children due to congenital diaphragmatic defects ❍ In adults, rarely occurs before age 50 ■ Most common cause of gastric volvulus in adults are diaphragmatic defects Stomach twists on itself Etiologies ❍ Abnormality of the suspensory ligaments of the stomach ■ Gastrohepatic ■ Gastrosplenic ■ Gastrocolic ■ Gastrophrenic ❍ Unusually long gastrocolic and gastrohepatic mesentery Classified as one of two types--organoaxial or mesenteroaxial

Type

Appearance

Description

Remarks

• Most common type.

Organoaxial

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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.


Mesenteroaxial

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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 ❍ Especially, paraesophageal hiatal hernias ■ In paraesophageal hernias, gastroesophageal junction remains in abdomen while stomach ascends adjacent to the esophagus ■ Produces “upside-down-stomach” ■ Gastric volvulus is most common complication of paraesophageal hernias ❍ Also occurs with eventration of the diaphragm ❍ Paralysis of diaphragm Despite abnormal placement of stomach, it usually does not become obstructed ❍ Sometimes called “partial volvulus” or “torsion” or “chronic volvulus” ❍ Twisting up to 180 degrees may cause no obstruction ❍ Twisting beyond 180 degrees almost always produces obstruction Clinical findings ❍ Unless acute, patients are frequently asymptomatic ❍ When acute and obstructing ■ Abdominal pain ■ Attempts to vomit without results ■ Inability to pass an NG tube ■ Together, these three findings comprise the Borchardt triad which is diagnostic of acute volvulus ● Reportedly occurs in 70% of cases Imaging findings ❍ Massively dilated stomach in LUQ possibly extending into chest ❍ 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.

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Treatment ❍ Surgery in acute gastric volvulus ❍ In patients with chronic gastric volvulus, surgery is performed to prevent complications ■ Nonoperative mortality rate = as high as 80% ■ Mortality rate from acute gastric volvulus = 15-20% ■ Mortality rate from chronic gastric volvulus ranges up to 13% Complications ❍ Gastric emphysema ❍ Twisting of stomach may tear spleen from its normal attachments ❍ Perforation is rare

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 ❍ C. albicans ❍ 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 ❍ Depressed immunity ■ AIDS ■ Hematologic disease ■ Renal transplant ■ Leukemia ■ Chronic debilitating disease ❍ Diabetes mellitus ❍ Steroids ❍ Chemotherapy ❍ Radiotherapy ❍ Diseases which cause delayed esophageal emptying ■ Scleroderma ■ Strictures ■ Achalasia ■ S/P fundoplication ❍ Rarely may occur in otherwise healthy individuals Produces whitish slightly raised plaques Symptoms ❍ Dysphagia ❍ Odynophagia ❍ Intense substernal pain ❍ Associated with oral thrush (oropharyngeal moniliasis) in 20-80% Location ❍ Predilection for upper 1/2 of esophagus ■ Involvement of long esophageal segments Imaging Findings ❍ Discrete plaque-like lesions ❍ Plaques line-up longitudinally = grouping of tiny 1-2 mm nodular filling defects with linear orientation

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LearningRadiology.com - Candidiasis,candida,moniliasis,esophagitis,candida albicans,image,radiology ❍ ❍

Larger plaques may coalesce to produce "cobblestone" appearance Further coalescence produces “shaggy” contour (from coalescent plaques, pseudomembranes, erosions, ulcerations, intramural hemorrhage) in fulminant candidiasis ■ More fulminant form is more often associated with AIDS

Double-contrast esophagram shows markedly nodular mucosa with multiple discrete ulcers covering all of esophagus ❍

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Ulcers invariably appear only on a background of diffuse plaque formation, not as isolated findings Long, smoothly-tapering strictures may develop but are rare ■ More likely to develop in patients with cutaneous manifestations of Candidiasis Mycetoma resembling large intraluminal tumor is rare Diagnosis ❍ Endoscopy most sensitive method of making diagnosis for mild cases ❍ Double-contrast esophagography should pick up 90% of cases Treatment ❍ Mycostatin® ❍ Findings usually regress quickly Differential Diagnosis ❍ Glycogenic esophagitis – asymptomatic nodularity ❍ Reflux esophagitis – distal esophagus, nodules poorly defined ❍ Superficial spreading carcinoma- nodular and irregular folds ❍ Artifacts (undissolved effervescent crystals, air bubbles, retained food particles) ❍ Herpes esophagitis – discrete ulcers surrounded by halo of edema ❍ Acute caustic ingestion – long strictures are common ❍ Intramural pseudodiverticulosis – unlike ulcers, pseudodiverticula don’t appear to connect to lumen ❍ Varices – distal esophagus usually; serpiginous elongated filling defects


LearningRadiology.com - Candidiasis,candida,moniliasis,esophagitis,candida albicans,image,radiology



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 WH/93


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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 • Crohn’s disease • Prior pelvic radiation • In women who have carcinoma of breast or uterus • Retinitis pigmentosa • Familial polyposis • Gardener’s syndrome • For synchronous lesions=1% (two or more colon ca’s 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 http://www.learningradiology.com/notes/ginotes/cacolonpage.htm (2 de 7)04/09/2006 1:29:34


• 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

WH/93











LearningRadiology - Hypertrophic pyloric stenosis


Hypertrophic Pyloric Stenosis ●

Age Usually manifests at 2-8 weeks of life Clinical ❍ Nonbilious projectile vomiting with progression over a period of several weeks after birth (1520%) ❍ Palpable olive-shaped mass (80% sensitive in experienced hands) Positive family history Nasogastric aspirate >10 ml UGI findings ❍ Pyloric wall thickness >10 mm ❍ Elongation and narrowing of pyloric canal (2-4 cm in length) ❍ "Double / triple track sign" ■ Crowding of mucosal folds in pyloric channel ❍ "String sign" ■ Passing of small barium streak through pyloric channel ❍ Twining recess = "diamond sign" ■ 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 ❍ "Pyloric teat" ■ Outpouching along lesser curvature due to disruption of antral peristalsis ❍ "Antral beaking" ■ Mass impression upon antrum with streak of barium pointing toward pyloric channel ❍

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Stomach shows double tracking in region of pyloric canal, indentation on base of bulb and delayed gastric emptying

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Kirklin sign = "mushroom sign" ■ Indentation of base of bulb (in 50%) Gastric distension with fluid Active gastric hyperperistalsis ■ "Caterpillar sign" ● Gastric hyperperistaltic waves US findings ❍ "Target sign" ■ Hypoechoic ring of hypertrophied pyloric muscle around echogenic mucosa centrally on cross-section ❍ "Cervix sign" ■ Indentation of muscle mass on fluid-filled antrum on longitudinal section ❍ "Antral nipple sign" ■ Redundant pyloric channel mucosa protruding into gastric antrum ❍ Pyloric volume >1.4 cm3 (= 1/4 ÷ x [maximum pyloric diameter]2 x pyloric length) ■ Most criteria independent of contracted or relaxed state ❍ Pyloric length (mm) + 3.64 x muscle thickness (mm) > 25 ❍ Pyloric muscle wall thickness >3 mm ❍ Pyloric transverse diameter >13 mm with pyloric channel closed ❍ Elongated pyloric canal >17 mm in length ❍ Exaggerated peristaltic waves ❍ Delayed gastric emptying of fluid into duodenum Complications ❍ Hypochloremic metabolic alkalosis DDx ❍ Infantile pylorospasm ■ Muscle thickness between 1.5 and 3 mm ■ Variable caliber of antral narrowing ■ Antral peristalsis



Delayed gastric emptying ■ Elongation of pylorus ■ Prognosis ● Resolves in several days / ? early stage of evolving pyloric stenosis ■ Treatment ● Effective with metoclopramide hydrochloride Milk allergy Eosinophilic gastroenteritis ■

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Dahnert 4th edition




LearningRadiology- Ca of 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 (Barrett’s) • 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

20%

Middle 1/3

50%

Lower 1/3

30%

Radiologic types •

Polypoid/fungating form (most common) Sessile, polyp Apple-core lesion

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Ulcerating form Large ulcer within mass

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Infiltrating form Gradual narrowing resembling benign stricture

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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 Barrett’s 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

wh/93





Hypertrophic Gastropathies

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All have hyperrugosity or enlarged folds, usually in the body and fundus of stomach

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Coarse duodenal folds are usually associated with large folds in the stomach

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Most often, enlarged gastric folds are normal

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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 http://www.learningradiology.com/notes/ginotes/hypertrophicgastritispage.htm (1 de 2)04/09/2006 1:29:40


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

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Hypertrophic hypersecretory gastropathy • Hypersecretion of gastric acid

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Hypertrophic hypersecretory gastropathy with protein loss • Hypersecretion of gastric acid

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Menetrier’s 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 Menetrier’s does not), gastric carcinoma, gastritis, gastric varices

WH/93


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LearningRadiology - Carcinoma of the Stomach



Precancerous states •Pernicious anemia—18X normal population •Adenomas of the stomach—especially those over 2cm •Atrophic Gastritis—disputable •Hiatal hernia—disputable •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=Virchow’s node • Overall 5 year survival 5-18% Malignant ulcer—is 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 malignancy—is 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

WH/92







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

o

• Intraluminal mass (e.g., pedunculated tumor) is pulled forward by peristalsis and brings attached bowel wall with it Intramural

o

• 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

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In children o Over 90% have no pathologic lead point o

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• Most thought due to lymphoid hypertrophy following viral infection Less than 10% due to Meckel’s 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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Majority are in children ■ Peak incidence 5-9 months of age Approximately 10% occur in adults ■ Seen in all age groups ■ Approximately equal in males and females

In developing nations ❍

Incidence is higher in adults than it is in developed nations

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LearningRadiology.com - Intussusception ❍

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 Dance’s 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 ■ ■ ■ ■ ■

o •

•

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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 Ringer’s) 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



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Most common benign tumor of esophagus

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•May produce dysphagia or hematemesis if large

•

Occurs in young males

•

Found most often in distal third of esophagus

X-Ray •

Intramural

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May have coarse calcifications (only calcifying esophageal tumor)

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Smooth, well-defined mass

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Narrowing of lumen in one plane and widening in 90° plane

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Rarely ulcerates

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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, Crohn’s) • Familial polyposis • Peutz-Jegher’s Syndrome • Gardener’s 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

Tubular adenoma

Description

Malignant Potential

Cylindrical glandular structure lined by columnar epithelium

<10mm=1%;

75%

Least malignant Mixture between tubular and villous adenoma

Tubulovillous adenoma 15%

<1cm=4%; 1-2cm=7%; >2cm=46%

Infolding of papillary projections of glands Villous adenoma

1-2cm=10%; >2cm=35%

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 http://www.learningradiology.com/notes/ginotes/colonicpolypspage.htm (2 de 9)04/09/2006 1:29:47


• 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 http://www.learningradiology.com/notes/ginotes/colonicpolypspage.htm (3 de 9)04/09/2006 1:29:47


• 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


Crohn’s 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 http://www.learningradiology.com/notes/ginotes/crohnsdiseasepage.htm (1 de 5)04/09/2006 1:29:50


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 bull’s-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 Crohn’s • Rectum (35-50%) • Sinus tracts • Deep, collar-button ulcers

X-Ray Manifestations

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• 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

Differential Diagnosis • Ulcerative colitis–continuous involvement L colon and rectum;TI normal • Diverticulitis–tics; intact mucosa; TI normal • Tuberculosis–but TB has more involvement of cecum, less of TI • Radiation ileitis–should have other loops involved and appropriate hx • Lymphoma–should have tumor masses, less spasm • Carcinoid–should have mass; marked fibrosis with angulation of loops • Yersinia– may affect TI but clears in 3-4 months • Infarction–rare for this location • Potassium stricture–lacks full clinical picture • Amebiasis–cone-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 http://www.learningradiology.com/notes/ginotes/crohnsdiseasepage.htm (4 de 5)04/09/2006 1:29:50


WH



LearningRadiology.com - Liver laceration,hepatic trauma,rupture,tear


Hepatic Trauma Liver Laceration ● ●

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Most frequently injured abdominal organ after spleen Most often due to deceleration injuries ❍ Often seen in association with ■ Right-sided rib fractures ■ Right-sided pneumothorax ■ Right lung contusion ■ Injuries to the right kidney or adrenal gland Injuries include ❍ Subcapsular hematoma ❍ Laceration ❍ Intrahepatic hematoma ❍ Contusion Right lobe more often injured than left ❍ Injury to left lobe associated with injury to duodenum, pancreas, transverse colon ■ More often due to direct blows to the epigastrium High association with injuries to other organs ❍ 45% with liver injuries have splenic injury Subcapsular hematomas ❍ Lenticular configuration ❍ Flattens adjacent liver ❍ Often adjacent to rib fracture ❍ Most occur in antero-lateral aspect of right lobe Liver Laceration ❍ Non-enhancing region, linear or branching ❍ Frequently parallel hepatic vein ❍ Hypodense wedge extending to liver surface ■ Focal hepatic devascularization ❍ Periportal tracking of blood ■ Frequent finding ■ Sometimes only evidence of injury ● Due to dissecting hemorrhage ● Bile ● Dilated periportal lymphatics

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LearningRadiology.com - Liver laceration,hepatic trauma,rupture,tear

Contrast-enhanced CT of abdomen shows linear low-attenuation defect crossing the posterior aspect of the left lobe of the liver representing a laceration ●

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Hematoma ❍ Higher attenuation than surrounding liver on unenhanced CT scan ❍ Lower attenuation than surrounding liver on enhanced CT scan ❍ Central high attenuation region containing clot ❍ Hepatic vein laceration usually involves right hepatic vein near vena cava Contusion ❍ Rare lesions ❍ Low attenuation area compared to normally enhanced liver ❍ Do not disrupt major portal or hepatic venous structures Hemoperitoneum Complications ❍ Delayed rupture (rare) ❍ Hemobilia ❍ Arteriovenous fistula ❍ Pseudoaneurysm ❍ Biloma ❍ Superinfection of hematoma Pitfalls ❍ Adjacent rib artifacts-beam-hardening ■ Mimics laceration ● Adjacent to ribs ● Fade as they become farther from rib ❍ Linear artifact from air-contrast level in stomach ❍ Fatty liver with laceration or hematoma can be missed ■ Clue- look at intrahepatic ducts and vessels Treatment ❍ Conservative treatment in up to 80% in adults and almost all children ■ Monitor hemodynamic state of patient ❍ Transcatheter embolization possible for bleeders ❍ Healing


LearningRadiology.com - Liver laceration,hepatic trauma,rupture,tear ■ ■ ■

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



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

Whipple’s 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/93





LearningRadiology.com - lymphoma of Small Bowel,Hodgkin's,Hodgkin,lymphosarcoma,non-Hodgkin's


Small Bowel Lymphoma 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-Hodgkin’s 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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§ §

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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

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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

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Differential diagnoses include o Tuberculosis o Inflammatory small bowel disease and carcinoma.

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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


http://www.learningradiology.com/notes/ginotes/pictorialsbdz.htm04/09/2006 1:30:01

http://www.learningradiology.com/notes/ginotes/lymphomastomachpage.htm



• Comprises 3-5% of all gastric neoplasms • Non-Hodgkin’s 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 radiographically—multiple ulcers, irregular masses, widespread infiltration • May be associated with involvement of the bowel elsewhere—e.g. duodenum, cecum or rectosigmoid and mesenteric masses

Forms • Nodular—single or multiple intragastric masses, easily confused with ca, protrude into the lumen, often with multiple ulcerations

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http://www.learningradiology.com/notes/ginotes/lymphomastomachpage.htm

• Polypoid—barium in interstices, frequently with ulceration; sometimes resembles metastatic disease such as melanoma • Ulcerative—shallow, saucer-like ulcer indistinguishable from ca • Infiltrative—thickened, irregular folds, simulating the appearance of hypertrophic gastritis; about 10% present this way

CT Staging • Stage I

tumor confined to bowel wall

• Stage II

limited to local nodes

• Stage III

widespread nodal disease

• Stage IV

bone marrow, liver, other organs

DDX-Linitis plastica •Carcinoma •Lymphoma •Gastritis, e.g. phlegmonous, eosinophilic, postradiation •Granulomatous, e.g. Crohn’s, sarcoid, TB •Syphilis •Amyloidosis

WH/95


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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 Marfan’s 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 rings–not 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 region–even http://www.learningradiology.com/notes/ginotes/diverticulardiseasepage.htm (1 de 3)04/09/2006 1:30:04


difficult with colonoscopy • On AC BE tics have sharp outer and fuzzy inner margins viewed en-face • Giant sigmoid diverticulum–huge 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

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• Intramural sinus tracts DDX • Colon ca-but mucosa is left intact in diverticulitis • Crohn’s disease-may be indistinguishable if TI not involved in Crohn’s • Ischemic colitis–only if sigmoid is involved • Radiation colitis Complications • Peritonitis–usually 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 • Obstruction–is rare • Bleeding–see below Hemorrhage from Diverticulosis • Doesn’t 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


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LearningRadiology.com - Mesenteric Ischemia,acute,small bowel,death,infarction,ischemia


Acute Mesenteric Ischemia Submitted by Jonathon Dorff, MD

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Acute interruption of blood flow to small or large intestine Causes: ❍ Arterial embolism ■ Superior mesenteric artery most commonly involved ❍ Arterial thrombosis ❍ Nonocclusive mesenteric ischemia ■ Low cardiac output state with diffuse mesenteric vasoconstriction ❍ Mesenteric venous thrombosis Risk Factors ❍ Atrial fibrillation/flutter ❍ Recent acute MI ■ Ventricular aneurysm ■ Cardiomyopathies ■ Valvular disease ❍ Hypovolemia or hypotension (sepsis) ❍ Coagulation disorders or malignancy ❍ Pancreatitis ❍ Portal hypertension/cirrhosis ❍ Medications ■ Vasopressor medications ■ Beta-blockers ■ Digoxin ■ Diuretics Clinical signs and symptoms ❍ Severe abdominal pain out of proportion to physical exam ❍ Pain initially of a visceral nature and poorly localized ❍ Nausea ❍ Vomiting ❍ Diarrhea ❍ GI bleeding may be present Imaging

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LearningRadiology.com - Mesenteric Ischemia,acute,small bowel,death,infarction,ischemia ❍

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Plain abdominal radiographs (abnormal in 20-60% of cases) ■ Thumbprinting ■ Non-specific finding indicating intestinal wall edema with hemorrhage in the setting of acute mesenteric ischemia ■ Pneumatosis ■ Portal venous gas ■ Pneumoperitoneum ■ All are indicative of infarcted bowel CT ■ Bowel wall thickening from edema or hemorrhage ■ Lack of enhancement indicates infarction ■ Pneumatosis, portal venous gas, pneumoperitoneum ■ Intraluminal thrombus in involved vessel


LearningRadiology.com - Mesenteric Ischemia,acute,small bowel,death,infarction,ischemia

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 ■ Can distinguish between arterial embolic and thrombotic causes of acute mesenteric ischemia Treatment ❍ Mesenteric angiogram ■ Vasodilator therapy ■ Thrombectomy/Embolectomy ❍ Surgery ■ Thrombectomy/Embolectomy ■ Arterial bypass ■ Resection of necrotic bowel Complications ❍ Sepsis/septic shock ❍ Multiple system organ failure ❍ Death Mortality ❍ 70-90% overall ❍ From arterial embolism: 60-80% ❍ From arterial thrombosis: 70-100% ❍ From nonocclusive mesenteric ischemia: 40% ❍ From mesenteric venous thrombosis: 25-30%



LearningRadiology - Duodenla Ulcer


Duodenal Ulcer Disease

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2-3 times more frequent than gastric ulcers

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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–

50%

• Posterior wall–

23%

• Inferior fornix–

22%

• Superior fornix–

5%

Postbulbar (3-5%) http://www.learningradiology.com/notes/ginotes/duodenalulcerpage.htm (1 de 2)04/09/2006 1:30:08

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 ulcers–ulcers 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 deformity–healed central ulcer of the bulb with four-leaf clover-like deformity remaining

Complications •

Hemorrhage

15%

melena>hematemesis

•

Perforation

<10%

anterior>posterior /may fistulize to GB

•

Obstruction

5%

•

Penetration

<5%

walled-off perforation


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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 http://www.learningradiology.com/notes/ginotes/midgutvoluluspage.htm (1 de 3)04/09/2006 1:30:11


•

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

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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


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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 endometriosis—involving 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



• 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

Zenker’s 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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Epiphrenic diverticulum •

Usually on lateral distal esophageal wall; right greater than left

•


•


Interaortico-bronchial 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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●

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Calcification of gallbladder wall So named because of its gross appearance and its similarity to porcelain Incidence: ❍ Less than 1% of cholecystectomy patients ❍ F:M 5:1 Histology ❍ Flakes of dystrophic calcium within chronically inflamed and fibrotic muscular wall ❍ Wall is thickened and gallbladder is contracted Associated with gallstones in 90% ❍ Cystic duct is always obstructed ❍ 80% of patients with carcinoma of gallbladder have stones Minimal symptoms Imaging findings ❍ 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 ❍

Highly echogenic shadowing curvilinear structure in GB fossa ■ DDx: stone-filled contracted GB

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LearningRadiology- Porcelain Gallbladder, GB, calcified gb wall, carcinoma of gallbladder, gallbladder calcification ❍

❍ ●

●

Echogenic GB wall with little acoustic shadowing ■ DDx: emphysematous cholecystitis Scattered irregular clumps of echoes with posterior acoustic shadowing Imaging pitfall ❍ Contracted gallbladder with calcified wall can be mistaken for a gallstone Complication ❍ 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 ●

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 complication–death 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 http://www.learningradiology.com/notes/ginotes/postgastcomppage.htm (1 de 2)04/09/2006 1:30:19

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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●

●

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Dilated submucosal veins due to increased collateral blood flow from portal venous system to azygos system Uphill varices ❍ Collateral blood flow from portal vein via azygos vein into SVC (usually lower esophagus drains via left gastric vein into portal vein) ❍ Most common cause is portal hypertension secondary to cirrhosis ❍ Varices in lower half of esophagus to the level of the carina (azygous vein) ❍ More common than downhill varices Causes ❍ Intrahepatic obstruction from cirrhosis ❍ Splenic vein thrombosis (usually gastric varices only) ❍ Obstruction of hepatic veins ❍ Portal vein thrombosis ❍ IVC obstruction below hepatic veins ❍ Marked splenomegaly / splenic hemangiomatosis (rare) Downhill varices ❍ Collateral blood flow from SVC via azygos vein into IVC / portal venous system (upper esophagus usually drains via azygos vein into SVC) ❍ Varices in upper 1/3 of esophagus ■ Usually extend down to the level of the carina (azygous vein) ❍ Less common than uphill varices Causes ❍ Obstruction of superior vena cava distal to entry of azygos vein due to ■ Lung cancer (most common) ■ Lymphoma ■ Retrosternal goiter ■ Thymoma ■ Mediastinal fibrosis Examination Technique ❍ Small amount of barium (not to obscure varices) ❍ Relaxation of esophagus (not to compress varices) ■ Refrain from swallowing because each succeeding swallow initiates a primary peristaltic wave that lasts for 10-30 seconds ❍ Sustained Valsalva maneuver precludes swallowing ❍ 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

http://www.learningradiology.com/notes/ginotes/esophagusvarixpage.htm (1 de 2)04/09/2006 1:30:20

LearningRadiology- Esophageal varices, esophagus, GI bleed

❍ ❍ ●

UGI ❍ ❍ ❍ ❍

●

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

CT Thickened esophageal wall and lobulated outer contour ❍ Scalloped esophageal luminal masses ❍ Right- / left-sided soft-tissue masses = paraesophageal varices ❍ Marked enhancement following dynamic CT Complications ❍ Bleeding in 28% within 3 years ❍ Exsanguination in 10-15% DDx ❍ Early ■ Other forms of chronic esophagitis ❍ Late ■ Varicoid carcinoma of esophagus ● Wall more rigid and less likely to change in varicoid carcinoma ● 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 ❍ Most commonly: sigmoid & cecum ❍ Rarely: stomach, small intestine, transverse colon ❍ Results in partial or complete obstruction ❍ May also compromise bowel circulation resulting in ischemia Sigmoid volvulus most common form of GI tract volvulus ❍ 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 à twisting of sigmoid colon around mesenteric axis ❍ Other predisposing factors ■ Chronic constipation ■ High-roughage diet (may cause a long, redundant sigmoid colon) ■ Roundworm infestation ■ Megacolon (often due to Chagas dz) 20-25% mortality rate Peak age > 50 yrs. ❍ Second largest group à children Torsion usually counterclockwise ranging from 180 – 540 degrees Luminal obstruction generally @ 180 degrees Venous occlusion generally @ 360 degrees à gangrene & perforation Signs and symptoms ❍ May present as abdominal emergency ■ Acute distension ■ Colicky pain (often LLQ) ■ Failure to pass flatus or stool (constipation is prevailing feature) ■ Vomiting is late sign ❍ Distention may compromise respiratory & cardiac function ❍ May also present with surprisingly few signs and symptoms in bedridden and debilitated Physical examination ❍

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LearningRadiology.com - Sigmoid Volvulous,volvulus,sigmoid colon,twist,obstruction,large bowel ❍ ❍ ❍

·

Tympanitic abdomen Abdominal distention +/- palpable mass

Diagnosis ❍

❍

Abdominal plain films usually diagnostic ■ Inverted U-shaped appearance of distended sigmoid loop ● Largest and most dilated loops of bowel are seen with volvulus ■ Loss of haustra ■ Coffee-bean sign à midline crease corresponding to mesenteric root in a greatly distended sigmoid ● Sigmoid volvulus – bowel loop points to RUQ ● Cecal volvulus – bowel loop points to LUQ ❍ Dilated cecum comes to rest in left upper quadrant ■ Bird’s-beak or bird-of-prey sign à 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

·

Differential Diagnosis ❍ ❍ ❍

Large bowel obstruction due to other causes à sigmoid colon CA Giant sigmoid diverticulum Pseudoobstruction


LearningRadiology.com - Sigmoid Volvulous,volvulus,sigmoid colon,twist,obstruction,large bowel

·

Complications ❍ ❍ ❍

•

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 ❍ ❍ ❍

Laparoscopic derotation or laparotomy +/- bowel resection Cecopexy à suture fixation of bowel to parietal peritoneum may prevent recurrence Recurrence rate after decompression alone à 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: ❍ A non-specific or idiopathic web (most common) ❍ Webs associated with Plummer-Vinson Syndrome ❍ Webs associated with epidermolysis bullosa dystrophica or graft-versus-host disease Usually found in middle-aged females Plummer-Vinson Syndrome=Patterson-Kelly syndrome ❍ Iron deficiency anemia ❍ Stomatitis ❍ Glossitis ❍ Dysphagia ❍ Spoon-shaped nails ❍ Esophageal webs ❍ Some question as to whether such a syndrome exists Location ❍ Cervical esophagus anteriorly at level of the cricopharyngeous (C5-C6) ❍ Best visualized with maximal distension ❍ Distal esophageal webs may arise from gastroesophageal reflux Imaging Findings ❍ Thin, transverse filling defects ❍ Perpendicular to anterior esophageal wall ❍ Usually less than 3mm in thickness ❍ Frequently they are not circumferential Increased risk of upper esophageal carcinoma DDx ❍ Prominent cricopharyngeous muscle ■ Arises posteriorly at C5-C6 and produces a much broader defect ❍ Stricture Treatment ❍ Balloon dilatation ❍ 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



• 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

Malignant

Syndrome

Heredity

Distribution (mainly)

Histology

potential

Familial Polyposis

Auto dominant

Colon

Adenomas

100% colon ca

Gardener’s

Auto dominant

Colon

Adenomas

100% colon ca

Peutz-Jegher’s

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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WH/93


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LearningRadiology.com - Free Air,free,air,intraperitoneal,extraluminal,perforated,perforation,ulcer


Free Intraperitoneal Air Pneumoperitoneum

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Etiology ❍ Disruption of wall of hollow viscus ■ Blunt or penetrating trauma ■ Perforating foreign body (eg, thermometer injury to rectum) ■ Iatrogenic perforation ● Laparoscopy / laparotomy (58%) ● Absorbed in 1-24 days depending on initial amount of air introduced and body habitus (80% in asthenic, 25% in obese patients) ● Leaking surgical anastomosis ● Endoscopic perforation ● Enema tip injury ● Diagnostic pneumoperitoneum ■ Diseases of GI tract ● Perforated gastric / duodenal ulcer ● Perforated appendix ● Ingested foreign-body perforation ● Diverticulitis (ruptured Meckel diverticulum / sigmoid diverticulum, jejunal diverticulosis) ● Necrotizing enterocolitis with perforation ● Inflammatory bowel disease (eg, toxic megacolon) ● Obstruction* (gas traversing intact mucosa): neoplasm, imperforate anus, Hirschsprung disease, meconium ileus ● Ruptured pneumatosis cystoides intestinalis ● Idiopathic gastric perforation = spontaneous perforation in premature infants (congenital gastric muscular wall defect) ❍ Through peritoneal surface ■ Transperitoneal manipulation ■ Abdominal needle biopsy / catheter placement ■ Mistaken thoracentesis / chest tube placement ■ Endoscopic biopsy ❍ Extension from chest ■ Dissection from pneumomediastinum (positive pressure breathing, rupture of bulla / bleb, chest surgery) ■ Bronchopleural fistula ■ Rupture of urinary bladder

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LearningRadiology.com - Free Air,free,air,intraperitoneal,extraluminal,perforated,perforation,ulcer

Penetrating abdominal injury ❍ Through female genital tract ■ Iatrogenic ■ Perforation of uterus / vagina ■ Culdocentesis ■ Rubin test = tubal patency test ■ Pelvic examination ■ Spontaneous ■ Intercourse, orogenital insufflation ● Douching ■ Knee-chest exercise, water skiing, horseback riding ❍ Intraperitoneal ■ Gas forming peritonitis ■ Rupture of abscess ■ Air in lesser peritoneal sac gas in scrotum (through open processus vaginalis) Imaging findings ❍ Large collection of gas ❍ Abdominal distension, no gastric air-fluid level ❍ "Football sign" = large pneumoperitoneum outlining entire abdominal cavity ❍ "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) ❍ "Telltale triangle sign" = triangular air pocket between 3 loops of bowel ❍ 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: ❍ "Inverted V sign" = outline of both lateral umbilical ligaments (containing inferior epigastric vessels) ❍ Outline of medial umbilical ligaments (obliterated umbilical arteries) ❍ "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. ●

RUQ gas (best place to look for small collections)


LearningRadiology.com - Free Air,free,air,intraperitoneal,extraluminal,perforated,perforation,ulcer ❍ ❍ ❍ ❍

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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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X-Ray Manifestations • Acute inflammatory stage ●

Spasm and irritability

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Fine mucosal granularity=earliest finding on air-contrast BE

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Spiculated, serrated bowel margins from tiny, multiple ulcerations

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Collar button ulcers-from undermining (not specific for UC)

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Double-tracking=long, longitudinal ulcers in submucosa

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Thumbprinting=from edema of wall

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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

Differential Diagnosis • Crohn’s disease–skip lesions: R colon; TI abnormal

• Cathartic colon-loss of haustrations on Right side of colon; rectum spared • Familial polyposis–multiple polyps but no inflammatory changes



• Radiation ileitis–should have other loops involved and appropriate hx • Lymphoma–should have tumor masses, less spasm • Amebiasis–cone-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 • 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


Acute Pyelonephritis Submitted by Matthew Krasner, M.D.

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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

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Pathologic Causes o Vesicoureteral reflux o Obstruction in the collecting system usually due to a calculus

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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.

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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.

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Complications

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LearningRadiology.com - Acute pyelonephritis

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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


http://www.learningradiology.com/notes/gunotes/acutepyelopage.htm (2 de 2)04/09/2006 1:30:33

LearningRadiology - Calcified Liver Metastases, Ovarian Neoplasms


Calcified Liver Masses Ovarian Neoplasms Calcified Liver Masses - Causes ●

Inflammatory hepatic lesions ❍

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Benign neoplasms ❍

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Most common cause of calcified hepatic lesions ● Inflammatory conditions ● For example, granulomatous diseases (tuberculosis). ● Calcification involves entire lesion ● Appears as a dense mass ● May produce artifacts on CT scans Echinococcus cysts have curvilinear or ring calcification ● Central water density in cyst

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 ❍

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Hepatocellular adenoma ● Calcifications may be solitary or multiple ● Usually located eccentrically within complex heterogeneous mass. Fibrolamellar carcinoma ● Calcifications reported in 15%-25% of cases at CT ● Occurs in many patterns Intrahepatic cholangiocarcinoma ● Calcifications are typically accompanied by a desmoplastic reaction ● Visible at CT in about 18% of cases. Calcified hepatic metastases ● 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 ● ●

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


LearningRadiology - Calcified Liver Metastases, Ovarian Neoplasms ●

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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



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§ Contains syncytiotrophoblasts and cytotrophoblasts § Secretes large quantities of the tumor marker - HCG - Embryonal cell carcinoma § Incidence : rare - Highly malignant Ovarian Fibroma: - Meig’s 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

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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 ●

CT ❍

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Size greater than 4 cm tend to be metastases or adrenal carcinoma ■ Heterogeneous appearance and irregular shape are malignant characteristics Homogeneous and smooth are benign characteristics. ■ 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) ■ Threshold 10 HU ■ Sensitivity 79%, specificity 96% Contrast-enhanced CT (CECT) ■ Because majority of CT examinations in oncology use IV contrast, the % washout is useful after 10 minutes. ■ Adenomas have greater than 50% washout after 10 minutes ■ Washout can also be used on adrenal masses that measure > 10 HU on NECT ■ Alternative is to do MR or PET

MR ❍

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Chemical Shift ■ Most sensitive method for differentiating adenomas from metastases ■ Sensitivity 81-100%. Specificity 94-100%. ■ The difference in resonance rate of protons in fat and water is exploited in chemical shift. ● 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 ■ Liver is not a reliable standard because of steatosis

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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 ●

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Vascularity ❍ Very vascular – has 2 blood supplies ■ Blood from fetus through 2 (sometimes 1) umbilical arteries through umbilical cord from fetal hypogastric arteries to placenta ■ 1 umbilical vein carries blood back to fetal left portal vein ■ 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 ❍ Exchange of oxygen and nutrients occurs over the large vascular surface area ❍ Maternal venous channels in the placenta are hypoechoic or anechoic spaces called venous lakes (usually small, but can be large) Anatomy on US ❍ 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) ❍ Outer surface abutting the amniotic fluid = chorionic plate (chorioamniotic membrane) = bright specular reflector Placental thickness judged subjectively ❍ But if measure at midposition or cord insertion 2-4 cm = normal

Grade 0 st trimester-early ● Late 1 2nd trimester ● Uniform moderate echogenicity http://www.learningradiology.com/notes/gunotes/placentapage.htm (1 de 3)04/09/2006 1:30:41

LearningRadiology.com- Placenta,ultrasound,US,grade,grading,grade 0,grade 1,grade 2,grade 3 ●

Smooth chorionic plate without indentations

Grade 1 nd trimester –early ● Mid 2 3rd trimester (~18-29 wks) ● Subtle indentations of chorionic plate ● Small, diffuse calcifications (hyperechoic) randomly dispersed in placenta

Grade 2 rd trimester (~30 ● Late 3 wks to delivery)

http://www.learningradiology.com/notes/gunotes/placentapage.htm (2 de 3)04/09/2006 1:30:41

LearningRadiology.com- Placenta,ultrasound,US,grade,grading,grade 0,grade 1,grade 2,grade 3 ●

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Larger indentations along chorionic plate Larger calcifications in a “dot-dash” configuration along the basilar plate

Grade 3 ● 39 wks – post dates ● Complete indentations of chorionic plate through to the basilar plate creating “cotyledons” (portions of placenta separated by the indentations) ● More irregular calcifications with significant shadowing ● May signify placental dysmaturity which can cause IUGR ● Associated with smoking, chronic hypertension, SLE, diabetes

Rumack The Requisites-GU Radiology


http://www.learningradiology.com/notes/gunotes/placentapage.htm (3 de 3)04/09/2006 1:30:41

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

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Is a slowly progressive disease with nearly 100% penetrance Potter Type III Cause: gene located on short arm of chromosome 16 (in 90%

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Spontaneous mutation in 10% Incidence:1:1,000 people carry the mutant gene

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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: ❍

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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

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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 • • •

Multiple cysts in cortical region (usually not seen prior to teens) Diffusely echogenic when cysts small (children) Renal contour poorly demarcated

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)

Differential Diagnosis •

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 • • •

Potter Type I Incidence:1: 6,000 to 1:50,000 livebirths F > M; carrier frequency of 1:112

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

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 • • • •

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!

Lung http://www.learningradiology.com/notes/gunotes/apkdpage.htm (3 de 5)04/09/2006 1:30:44


• 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 •

Prolonged corticomedullary phase

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

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

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Thrombotic disease usually affects larger vessels ❍ Includes main renal artery ❍ Patients with thrombotic disease usually present with hypertension or renal insufficiency ❍ Usually results from atherosclerosis ■ 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 ❍ Renal artery emboli usually come from cardiac source ❍ Embolic disease usually produces acute symptoms ■ Sudden onset of flank pain ■ Hematuria ■ Proteinuria ■ Fever ■ Leukocytosis Causes ❍ Trauma ■ Blunt abdominal trauma ■ Traumatic avulsion of renal artery ■ Surgery ❍ Embolism ■ Cardiac origin ● Rheumatic heart disease with arrhythmia ❍ Atrial fibrillation ● Myocardial infarction ● Prosthetic valves ● Myocardial trauma ● Left atrial or mural thrombus ● Myocardial tumors ● Subacute bacterial endocarditis ■ Catheters ● Angiographic catheter manipulation ● Umbilical artery catheter above level of renal arteries ❍ Arterial thrombosis ■ Arteriosclerosis ■ Thrombangitis obliterans

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Polyarteritis nodosa ■ Syphilitic cardiovascular disease ■ Aneurysms of the aorta or renal artery ■ Sickle cell disease ❍ Sudden complete renal vein thrombosis Lobar Renal Infarction ❍ Early signs ■ Focal attenuation of collecting system ● Tissue swelling ■ Focally absent nephrogram ● Triangular with base at cortex ❍ Late signs ■ Normal or small kidney(s) ■ Focally atrophied parenchyma with normal interpapillary line ■ Cortical atrophy and irregular scarring are seen as late sequelae ❍ CT ■ Subtle renal infarcts are best demonstrated on CT ■ Appear as wedge-shaped, cortically based, hypodense areas ● Triangular in shape with widest part at the cortex (base of infarct) ■ Non-perfused area corresponding to vascular division ■ Renal swelling may also be seen ■ Cortical rim sign ● 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 ❍

US Focally increased echogenicity ■ Color flow Doppler aids in diagnosis of renal artery thrombosis ● There is absence of an intrarenal arterial signal ● Tardus parvus waveform is seen if incomplete occlusion or collateral supply ■ Nuclear medicine ● Nuclear imaging shows a photopenic area corresponding to the region of ischemia or infarction Chronic Renal Infarction ❍ Pathology ■ All elements of kidney atrophied with replacement by interstitial fibrosis ■ Normal or small kidney with smooth contour ■

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LearningRadiology.com- Renal Infarction,kidney,thrombosis,emboli,embolus,rim,sign,wedge ■ ■ ❍

Globally atrophied parenchyma Diminished or absent contrast material density

US

Increased echogenicity (by 17 days) ❍ Angiography ■ Normal intrarenal venous architecture ■ Late visualization of renal arteries on abdominal aortogram ■ Provides the definitive diagnosis ● Abrupt termination of vessels or filling defects ● With end-stage renal artery thrombosis ❍ Small kidney with smooth contour, unless multiple small infarcts have occurred independently Treatment ❍ Anticoagulation ❍ Intra-arterial thrombolytic therapy ❍ Surgical revascularization ■

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Dahnert 5th ed Amersham




LearningRadiology - Angiomyolipoma, AML, Tuberous Sclerosis


Angiomyolipoma ● ● ●

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Benign mesenchymal tumor of kidney Rare Histopathology ❍ No true capsule ❍ Commonly bleed ❍ Tumor composed of fat, smooth muscle, aggregates of thick-walled blood vessels Types ❍ Isolated angiomyolipoma is most common (80%) ■ Usually solitary ■ Unilateral (80% on right side) ■ Not associated with tuberous sclerosis ■ Mean age of incidence: 40s ■ Much more common in females ❍ Angiomyolipoma associated with tuberous sclerosis (in 20%) ■ Angiomyolipoma occurs in 80% of patients with tuberous sclerosis ● Commonly large ● Usually bilateral ● Usually multiple ■ May be only evidence of tuberous sclerosis ■ Mean age of incidence: teens ■ Equal incidence in males and females Signs and symptoms ❍ Small lesions are asymptomatic (60%) ❍ Acute flank / abdominal pain (due to hemorrhage) most common presenting symptom ❍ Hematuria (40%) ❍ Palpable mass (47%) ❍ Shock (due to massive retroperitoneal hemorrhage) Imaging findings ❍ Mostly small lesions <5 cm in diameter ❍ Many have a large exophytic component (25%) ❍ Calcifications not common (6%) ❍ Plain film findings ■ Mass of fat lucency is lesion is large enough ❍ CT findings ■ Well-marginated, cortical-based, heterogeneous tumor predominantly of fat density (<-

http://www.learningradiology.com/notes/gunotes/amlpage.htm (1 de 3)04/09/2006 1:30:48


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20 HU) Variable enhancement (smooth muscle, vessels)

Angiomyolipomas of both kidneys are seen to contain fat ❍

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US findings ■ Highly echogenic tumor due to high fat content ■ Less echogenic areas due to hemorrhage, necrosis, dilated calyces MRI findings ■ Intra-tumoral fat seen with fat-suppression technique ■ Variable areas of high signal intensity on T1WI Angiographic findings ■ Hypervascular mass (95%) ● Enlarged interlobar + interlobular feeding arteries ❍ Tortuous, irregular, aneurysmal, venous pooling, "sunburst" / "whorled" / "onion peel" appearance, no AV shunting Complications ❍ Angiomyolipomas >4 cm bleed spontaneously in 50-60% ■ Hemorrhagic shock from bleeding into angiomyolipoma or into retroperitoneum Treatment ❍ Annual follow-up of lesions <4 cm ❍ Emergency laparotomy is required in some including nephrectomy, tumor resection ❍ Selective arterial embolization can be done DDx ❍ Renal / perirenal lipoma or liposarcoma ❍ Wilms tumor ❍ 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 ● ●

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Also known as “circumcaval ureter” Abnormality in embryogenesis of IVC ❍ Results from abnormal persistence of right subcardinal vein positioned ventral to ureter in the definitive IVC ❍ Developing right ureter courses behind and medial to the IVC Incidence ❍ 0.07% ❍ Male to female ratio of 3:1 Clinical findings ❍ Symptoms of right ureteral obstruction Imaging findings ❍ Normal course of ureters ■ About the width of your thumb lateral to the lumbar vertebral pedicles ■ About the width of two fingers medial to pelvic brim in true pelvis ❍ With retrocaval ureter ■ Right ureter’s course swings medially over pedicle of L3/4 ● Passes behind IVC ■ Then exits anteriorly between IVC and aorta returning to its normal position ■ Produces varying degrees of proximal hydroureteronephrosis

http://www.learningradiology.com/notes/gunotes/retrocavalpage.htm (1 de 3)04/09/2006 1:30:51


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 Turner’s syndrome

Causes of Ureteral Deviation or Displacement Medial Displacement or Deviation Upper ureter

Lower ureter

Retrocaval ureter Retroperitoneal fibrosis

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 ● ●


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Extraperitoneal bladder rupture is the most common type ❍ Occurs in 80% of bladder rupture cases ❍ Extraperitoneal bladder rupture generally secondary to adjacent pelvic fracture or an avulsion tear at fixation points of puboprostatic ligaments Intraperitoneal bladder rupture ❍ Usually iatrogenic or secondary to penetrating injury ❍ Blunt trauma more likely to result in intraperitoneal rupture in children than in adults ■ Because the pediatric bladder is more intraperitoneal in location. ■ The adult bladder dome remains mostly extraperitoneal ● Blunt trauma in an adult can result in intraperitoneal rupture only if the bladder is fully distended

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LearningRadiology.com- Bladder rupture,perforation,urinary bladder,pelvic,trauma

Imaging findings ■ Contrast extravasation into paracolic gutters ■ 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 ❍ Diagnostic evaluation of bladder rupture includes voiding cystourethrography (VCUG) or CT scan ■ VCUG ● Voiding cystourethrography historically been preferred contrast enhanced study for diagnosis of bladder rupture ● Bladder needs to be fully distended and evaluation of a post-voiding film essential ■ Plain film: ● "Pear-shaped" bladder ● Paralytic ileus ● Upward displacement of ileal loops ● Flame-shaped contrast extravasation into perivesical fat ❍ Best seen on postvoid films ❍ May extend into thigh / anterior abdominal wall ❍

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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


LearningRadiology.com- Bladder rupture,perforation,urinary bladder,pelvic,trauma ❍

"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

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Accounts for 85-90% of all uroepithelial tumors Exophytic, polypoid papillary growth pattern most common ❍ Attached to the mucosa by stalk ❍ Non-papillary tumors less common Most are solid with no characteristic gross findings Location ❍ Bladder is 30-50x more often the site of the tumor than ureter or renal pelvis (most common tumor of GU tract) rd ❍ When it occurs in the ureter, it most commonly occurs in the lower 3 Synchronous (simultaneous) transitional cell carcinomas are common ❍ Bladder involvement with ■ 24% of primary renal pelvis involvement ■ 30% of primary ureteral involvement ■ In 2% with primary bladder tumor ❍ Both ureters involved in 2-9% ❍ Both renal pelves in 1-2% Metachronous (sequential) transitional cell carcinomas in upper tracts ❍ With pelvic and ureteral primaries-12% in 25 months ❍ 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 ❍ Exposure to cyclophosphamide ❍ Phenacetin ❍ Chronic urinary stasis ❍ Smoking Metastasizes to ❍ Regional lymph nodes ❍ Liver ❍ Lung ❍ Bone Imaging findings

http://www.learningradiology.com/notes/gunotes/trancellcapage.htm (1 de 4)04/09/2006 1:30:58

LearningRadiology.com- Transitional Cell Carcinoma, TCC, Urothelial Carcinoma ❍

IVU Enlarged and hydronephrotic kidney ● Invasive, poorly differentiated tumors are more likely to obstruct ● Dilated calyx with filling defect ● Caliceal amputation ● Partial or complete obstruction of the infundibulum Retrograde studies ■ Papillary tumors ● “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 ■

❍


LearningRadiology.com- Transitional Cell Carcinoma, TCC, Urothelial Carcinoma

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 ■

❍

Non-papillary tumors ● Nodular or flat ● Cause strictures rather than filling defects CT ■ Can identify dilated collecting system and demonstrate level of obstruction ■ Intraluminal mass (30-60 HU) representing ureteral tumor can be differentiated from obstructing calculus (> 190 HU)


LearningRadiology.com- Transitional Cell Carcinoma, TCC, Urothelial Carcinoma ■ ❍

May demonstrate extra-ureteral extension

US Discrete hypoechoic mass within the renal sinus ■ Absence of acoustic shadowing allows for differentiation from calculi Angiography ■ Hypovascular mass ■ Vessel encasement and stain ■ Not usually necessary Treatment ❍ Controversy ■ Nephroureterectomy with resection of a cuff of bladder versus wide excision of the tumor alone ■ Adding chemotherapy (cisplatin) in patients with advanced tumors is of unclear utility ■

❍

●




LearningRadiology.com - Emphysematous Pyelonephritis


Emphysematous Pyelonephritis ●

●

●

●

●

●

●

●

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) ❍ Klebsiella pneumoniae (9%) ❍ Proteus mirabilis ❍ Pseudomonas ❍ Enterobacter ❍ Candida ❍ Clostridia (exceptionally rare) Predisposed ❍ Especially diabetics in almost all cases ❍ Immunocompromised patients ❍ Ureteral obstruction Average age ❍ Mid-fifties ❍ Twice as common in females as males Clinical findings ❍ Features of acute severe pyelonephritis (chills, fever, flank pain, lethargy, confusion) not responding to treatment ❍ Positive blood and urine cultures (in majority) ❍ Urosepsis ❍ Shock ❍ Fever of unknown origin and no localizing signs in almost 20% Frequently have multiple associated medical problems ❍ Uncontrolled hyperglycemia ❍ Acidosis ❍ Dehydration ❍ Electrolyte imbalance Location ❍ Most are unilateral ❍ 5-7% bilateral Types ❍ Type I (33%) ■ Streaky or mottled gas in interstitium of renal parenchyma radiating from medulla to

http://www.learningradiology.com/notes/gunotes/emphysemapyelopage.htm (1 de 3)04/09/2006 1:31:01


❍

cortex ■ Crescent of subcapsular or perinephric gas ■ No fluid collection (= no effective immune response) ■ Prognosis in this type is poor (69% mortality) Type II (66%) ■ 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 ■ ■ ■ ●

●

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 ❍ Mottled areas of low attenuation extending radially along the pyramids ❍ Extensive involvement of kidney and perinephric space ❍ Air extending through Gerota’s fascia into retroperitoneal space ❍ Occasionally gas in renal veins Ultrasound findings ❍ High-amplitude echoes within renal sinus and/or renal parenchyma associated with "dirty" shadowing



"Comet tail" reverberations ❍ Kidney may be completely obscured by large amount of gas in perinephric space (DDx: surrounding bowel gas) ❍ Gas may be confused with renal calculi MR findings ❍ 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 ❍ Antibiotic therapy and nephrectomy ❍ Drainage procedure with coexisting obstruction Mortality ❍ 60-75% under antibiotic treatment ❍ 21-29% after antibiotic treatment and nephrectomy ❍ 80% with extension into perirenal space ■

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Dahnert 4th edition




LearningRadiology.com- Retrocaval,Circumcaval,Ureter,deviation,displacement,medial,causes,ureteral,hydronephrosis,radiology,image,x-ray,findings


Causes of Ureteral Deviation Displacement


Lower ureter

Retrocaval ureter Retroperitoneal fibrosis

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

O

Geographic

O

Moth-eaten

O

Permeative

Geographic Bone Destruction

O

O

O

Destructive lesion with sharply defined border Implies a less-aggressive, more slow-growing, benign process Narrow transition zone


O

Geographic

O

Moth-eaten

O

Permeative

© R3, 2000

Non-ossifying fibroma

Geographic Lesions Examples

O


O

Chondromyxoid fibroma

O

Eosinophilic granuloma

Moth-eaten Appearance

O

O

Areas of destruction with ragged borders Implies more rapid growth Q

Probably a malignancy


O

Geographic

O

Moth-eaten

O

Permeative

© R3, 2000

Multiple Myeloma

Moth-eaten Appearance Examples

O

Myeloma

O

Metastases

O

Lymphoma

O

Ewing’s sarcoma

Permeative Pattern

O

Ill-defined lesion with multiple “wormholes”

O

Spreads through marrow space

O

Wide transition zone

O

Implies an aggressive malignancy Q

Round-cell lesions


O

Geographic

O

Moth-eaten

O

Permeative

Leukemia

Permeative Pattern Round cell lesions

O Lymphoma, leukemia O Ewing’s Sarcoma O Myeloma O Osteomyelitis O Neuroblastoma

Patterns of Destruction

Geographic Less malignant

Moth-eaten

Permeative More malignant

Periosteal Reactions O

O

Benign Q

None

Q

Solid

More aggressive or malignant Q

Lamellated or onion-skinning

Q

Sunburst

Q

Codman’s triangle


O

Benign Q

None

Q

Solid

Aggressive/malignant Q

Onion-skinning

Q

Sunburst

Q

Codman’s triangle © R3, 2000



O

Benign Q

None

Q

Solid


Onion-skinning

Q

Sunburst

Q


Chronic osteomyelitis


O

Benign Q

None

Q

Solid


Onion-skinning

Q

Sunburst

Q

Codman’s triangle © Greenspan, 2000

Ewing’s sarcoma


O

Benign Q

None

Q

Solid


Onion-skinning

Q

Sunburst

Q

Codman’s triangle © Greenspan, 2000

Osteosarcoma


O

Benign Q

None

Q

Solid


Onion-skinning

Q

Sunburst

Q


Ewing’s-Codman’s triangle

Periosteal Reactions

Solid Less malignant

Lamellated

Sunburst

Codman’s More malignant

Tumor Matrix O

Osteoblastic Q

Fluffy, cotton-like or cloud-like densities V Osteosarcoma

O

Cartilaginous Q

Comma-shaped, punctate, annular, popcornlike V

Enchondroma, chondrosarcoma, chondromyxoid fibroma

Tumor matrix

O

Osteoblastic

O

Cartilaginous

© R3, 2000

Osteosarcoma

Tumor matrix

O

Osteoblastic

O

Cartilaginous

© R3, 2000

Chondrosarcoma

Expansile Lesions of Bone

O

Multiple myeloma

O

Brown tumor

O

Mets

O

Enchondroma

O

Aneurysmal bone cyst

O

Lymphoma

O

Fibrous dysplasia

Expansile lesions O

Multiple myeloma

O

Mets

O


O

Fibrous dysplasia

O

Brown tumor

O

Enchondroma

O

Lymphoma Multiple Myeloma

Expansile lesions O

Multiple myeloma

O

Mets

O


O

Fibrous dysplasia

O

Brown tumor

O

Enchondroma

O

Lymphoma Renal Cell Carcinoma

Expansile lesions O

Multiple myeloma

O

Mets

O


O

Fibrous dysplasia

O

Brown tumor

O

Enchondroma

O

Lymphoma Aneurysmal Bone Cyst

Expansile lesions O

Multiple myeloma

O

Mets

O


O

Fibrous dysplasia

O

Brown tumor

O

Enchondroma

O

Lymphoma Fibrous Dysplasia

Expansile lesions O

Multiple myeloma

O

Mets

O


O

Fibrous dysplasia

O

Brown tumor

O

Enchondroma

O

Lymphoma

© R3, 2000

Brown Tumor

Expansile lesions O

Multiple myeloma

O

Mets

O


O

Fibrous dysplasia

O

Brown tumor

O

Enchondroma

O

Lymphoma © R3, 2000

Enchondroma

Expansile lesions O

Multiple myeloma

O

Mets

O


O

Fibrous dysplasia

O

Brown tumor

O

Enchondroma

O

© R3, 2000

Lymphoma Lymphoma

Clues by Location of Lesion

In the Transverse Plane O

Central Q

O

Eccentric Q

O

GCT, osteosarcoma, chondromyxoid fibroma

Cortical Q

O

Enchondroma

Non-ossifying fibroma, osteoid osteoma

Parosteal Q

Parosteal osteosarcoma, osteochondroma

Osteosarcoma

Parosteal sarcoma Osteochondroma © Greenspan, Lippincott, 2000

In The Transverse Plane

In the Longitudinal Plane

O

Epiphyseal Q

O

Metaphyseal Q

O

GCT, chondroblastoma

Osteomyelitis, osteo- and chondrosarcoma

Diaphyseal Q

Round cell lesions, ABC, enchondroma

Tumor Types Characteristic Locations

O

Simple bone cyst Q

O

Chondroblastoma Q

O

Proximal humerus

Epiphyses

Giant Cell tumor Q

Epiphyses

Characteristic locations O

Simple bone cyst Q

O

Chondroblastoma Q

O

Proximal humerus

Epiphyses

Giant Cell tumor Q

Epiphyses © R3, 2000


Simple bone cyst Q

O

Chondroblastoma Q

O

Proximal humerus

Epiphyses

Giant Cell tumor Q


Chondroblastoma


Simple bone cyst Q

O

Chondroblastoma Q

O

Proximal humerus

Epiphyses

Giant Cell tumor Q


Giant Cell Tumor


O

Adamantinoma Q

O

Chordoma Q

O

Tibia

Sacrum, clivus

Osteoblastoma Q

Spine, posterior


Adamantinoma Q

O

Chordoma Q

O

Tibia

Sacrum, clivus

Osteoblastoma Q

Spine, posterior © R3, 2000

Adamantinoma


Adamantinoma Q

O

Chordoma Q

O

Tibia

Sacrum, clivus

Osteoblastoma Q


Chordoma


Adamantinoma Q

O

Chordoma Q

O

Tibia

Sacrum, clivus

Osteoblastoma Q


Osteoblastoma


O

Parosteal sarcoma Q

O

Distal femur

Periosteal sarcoma Q

Tibia

Characteristic locations

O

Parosteal sarcoma Q

O

Distal femur


Tibia

Parosteal sarcoma

Characteristic locations

O

Parosteal sarcoma Q

O

Distal femur


Tibia

© R3, 2000

Characteristic Tumors By Body Site

Pelvic Lesions

O

Chondrosarcoma

O

Solitary plasmacytoma

O

Chordoma

Pelvic lesions

O O

O

Chondrosarcoma Solitary plasmacytoma Chordoma

Pelvic lesions

O O

O


Plasmacytoma

Pelvic lesions

O O

O


© R3, 2000

Chordoma

Expansile Rib Lesions O

Plasmacytoma

O

Metastases

O

Chondrosarcoma

O


O

Neurofibromatosis

O

Fibrous dysplasia

Expansile rib lesions O

Plasmacytoma

O

Metastases

O

Chondrosarcoma

O


O

Neurofibromatosis

O

Fibrous dysplasia


Plasmacytoma

O

Metastases

O

Chondrosarcoma

O


O

Neurofibromatosis

O

Fibrous dysplasia

Thyroid Carcinoma


Plasmacytoma

O

Metastases

O

Chondrosarcoma

O


O

Neurofibromatosis

O

Fibrous dysplasia

© R3, 2000


Plasmacytoma

O

Metastases

O

Chondrosarcoma

O

O O

Eosinophilic granuloma Neurofibromatosis Fibrous dysplasia

© R3, 2000


Plasmacytoma

O

Metastases

O

Chondrosarcoma

O


O

Neurofibromatosis

O

Fibrous dysplasia

© R3, 2000


Plasmacytoma

O

Metastases

O

Chondrosarcoma

O


O

Neurofibromatosis

O

Fibrous dysplasia

© R3, 2000

Lesions of the Spine

O

Osteoblastoma Q

Expansile, with punctate densities within

O

Chordoma

O

ABC

O

Metastatic disease

Spine lesions

O

Osteoblastoma

O

Chordoma

O

ABC

O

Metastatic disease © R3, 2000

Osteoblastoma

Spine lesions

O

Osteoblastoma

O

Chordoma

O

ABC

O

Metastatic disease © R3, 2000

Chordoma

Spine lesions

O

Osteoblastoma

O

Chordoma

O

ABC

O

Metastatic disease Aneurysmal bone cyst

Spine lesions

O

Osteoblastoma

O

Chordoma

O

ABC

O

Metastatic disease

© R3, 2000

Metastatic Breast Carcinoma

Clues by Density Of Lesion

Sclerotic Cortical Lesions

O

Osteoid osteoma

O

Brodie’s abscess

O

Stress fracture

Sclerotic cortical lesions

O

Osteoid osteoma

O

Brodie’s abscess

O

Stress fracture

Osteoid Osteoma


O

Osteoid osteoma

O

Brodie’s abscess

O

Stress fracture

© R3, 2000

Brodie’s abscess


O

Osteoid osteoma

O

Brodie’s abscess

O

Stress fracture

Healing Stress Fracture

Sclerotic Cortical Lesions

Osteoid Osteoma

Brodie’s abscess

Healing Stress Fracture

Lytic Lesions in Children

O


O

Neuroblastoma

O

Leukemia


O


O

Neuroblastoma

O

Leukemia

© R3, 2000



O


O

Neuroblastoma

O

Leukemia

© R3, 2000

Neuroblastoma


O


O

Neuroblastoma

O

Leukemia

© R3, 2000

Leukemia

Lytic Lesions in Adults O

Metastatic lesions Q

Lung

Q

Renal

Q

Thyroid

O

Multiple myeloma

O

Primary bone tumor


O

Mets

O

Myeloma

O

Primary bone tumor

Met from Thyroid Carcinoma


O

Mets

O

Myeloma

O

Primary bone tumor

Multiple myeloma


O

Mets

O

Myeloma

O

Primary bone tumor

Chondrosarcoma

Blastic Lesions in Children

O

Medulloblastoma

O

Lymphoma


O

Medulloblastoma

O

Lymphoma

© R3, 2000

Medulloblastoma


O

Medulloblastoma

O

Lymphoma

Lymphoma

Blastic Lesions in Adults O

Metastatic disease Q

Breast – female

Q

Prostate – male

O

Lymphoma

O

Paget’s disease

O

Etcetera-mastocytosis, fluorosis


O

Mets

O

Lymphoma

O

Paget’s

Prostate Mets


O

Mets

O

Lymphoma

O

Paget’s

Breast Mets


O

Mets

O

Lymphoma

O

Paget’s

Lymphoma


O

Mets

O

Lymphoma

O

Paget’s

Paget’s of Spine

Other Clues

Benign Lesions Without Sclerotic Boarders

O

Giant Cell tumor

O

Brown tumor

O

Osteolytic phase of Paget’s Disease

Benign Lesions without Sclerotic Borders

O

Giant cell tumor

O

Brown tumor

O

Osteolytic Paget’s

© R3, 2000

Giant Cell Tumor


O

Giant cell tumor

O

Brown tumor

O


© R3, 2000

Brown Tumor


O

Giant cell tumor

O

Brown tumor

O


© R3, 2000


Soft Tissue Extension O

Usually implies malignancy Q

O

More likely to form discrete soft tissue mass

Benign conditions with soft tissue extension Q

Osteomyelitis V

Usually infiltration of fat

© R3, 2000

Osteosarcoma

Multiple Lesions O

More often benign

O

Malignancies with multiple lesions Q

Metastatic disease

Q

Multiple myeloma

Q

Lymphoma

Q

Ewing’s sarcoma (rarely)

Q

Osteosarcoma (rarely)

Multiple lesions

O

Metastatic

O

Multiple myeloma

O

Lymphoma

© R3, 2000

Mets from Ca of Prostate

Multiple lesions

O

Metastatic

O

Multiple myeloma

O

Lymphoma

© R3, 2000

Multiple Myeloma

Multiple lesions

O

Metastatic

O

Multiple myeloma

O

Lymphoma

© R3, 2000

Lymphoma

Multiple lesions

O

Metastatic

O

Multiple myeloma

O

Lymphoma

O

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 Fractures and and Dislocations Dislocations of of the the Cervical Cervical Spine Spine

In Slide Show mode, advance the slides by pressing the spacebar All Photos Retain the Copyright of their Authors

3 rules of 3

O O

O

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

O

Hyperextension injury

O

Children>adults

O

Head slips forward on C1

O

Usually fatal

Neural Arch Fracture of C1

O

Most common fracture of C1

O

Hyperextension injury

O

Not associated with neurologic deficit

O

Confused with congenital anomaly

Jefferson Fracture of C1 O

Burst fracture

O

Caused by compressive force

O

O

O

Bilateral breaks in anterior and posterior arches Open mouth view shows bilateral offset of C1 on C2 Not associated with neurologic deficit

Hangman’s Fracture of C2 O

Most common fracture of C2 Q

O O

O O

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 Hangman’s fx

Dens Fractures

O O

Hyperextension injuries Most associated with forward subluxation of C1 on C2

O

High incidence of non-union (60%)

O

Stable

Dens Fractures Types

O

Tip of dens

Rare (5%)

O

Base of dens

Common (65%)

O

Sub-dentate

Uncommon (30%)

Dens Fractures Pitfalls in Diagnosis

O

Mach line

O

Congenital non-union

O

Non-union of previous fracture

Flexion-Teardrop Fracture

O

O

O

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

O

Facet joint and interspinous distances usually widened

O

Disk space may be narrowed

O

70% have associated neurologic deficit

Simple Compression Fracture

O O

O

Flexion injury Anterior wedging of 3mm or more suggests fracture Usually involves superior endplate of vertebral body

Clay-Shoveler’s Fracture

O

O

O

Avulsion fracture of spinous process of C6 or C7 Occurs as result of rotation of trunk relative to neck No neurologic deficit

Ligamentous Injuries

O O

Mechanism is flexion/distraction Disk space narrower anteriorly than posteriorly

O

Widening of the interspinpous distance

O

Widening of the facet joint Q

Usually the posterior aspect


O

Subluxation of vertebral body

O

Perched facet

O

Locked facets Q

O

At least 50% subluxation

85% neurologic deficits with locked facets

Unilateral Locked Facets O

O

O

O

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

O

Jefferson fracture

O

Hangman’s fracture

O

Flexion teardrop fracture

O

Extension teardrop fracture

O

Bilateral locked facets

LearningRadiology-Pelvic Fractures

http://www.learningradiology.com/lectures/bonelectures/pelvicfxsnetscape_files/frame.htm04/09/2006 1:31:57


Pelvic Trauma In Slide Show mode, advance the slides by pressing the spacebar All Photos Retain the Copyright of their Authors

Pelvic Fractures Stable Fractures (2/3)

z

Solitary ischial ramus fracture

z

Unilateral fractures —both rami

z

Iliac wing fracture (Duverny Fracture)

z

Isolated sacral fracture

Pelvic Fractures Stable and Unstable

z

Stable fractures—single breaks in ring or peripheral fxs (66%)

z

Result of moderate trauma, e.g. falls

Unstable fractures—fxs of both anterior and posterior arches (33%)

Result of severe trauma, e.g. MVAs

Stable Pelvic Fractures Solitary Fractures of Ischial Ramus

z

Most common pelvic fracture (40% of all pelvic fxs)

z

Most common stable fracture

z

Usually seen in osteoporotic females

Stable Pelvic Fractures Unilateral Fractures of Both Rami

z

If distracted, look for other pelvic ring fractures

Stable Pelvic Fractures Iliac Wing Fracture-Duverny Fracture

z

Due to direct lateral compression

z

Often associated with paralytic ileus

z

Can perforate bowel and be open fracture

Stable Pelvic Fractures Isolated Sacral Fractures

z

Usually transversely oriented

z

Difficult to detect

z

Lateral view may show angulation

Pelvic Fractures Unstable Fractures (1/3)

z

Malgaigne Fracture

z

Straddle Fracture

z

Pelvic Dislocation

z

Bucket Handle Fracture

Unstable Fractures Malgaigne Fracture

z

z

z z

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

z

Usually vertically oriented

z

Check symmetry of sacral lines

Unstable Fractures Straddle Fracture

z

Bilateral fractures of all pubic rami

z

Fracture fragments are usually elevated

z

Associated with urethral and bladder injuries in 20%

Unstable Fractures Pelvic Dislocation

z z

Severe trauma “Sprung Pelvis” usually associated with GU injury

z

Normal SI=1-4mm

z

Normal symphysis=5mm

Unstable Fractures Bucket Handle Fracture

z

z

Fracture of anterior arch and contralateral posterior arch Rare

Pelvic Trauma Urethral Injury

z

z

z

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

z

z

z

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

z

Extraperitoneal rupture

z

Contrast will remain adjacent to bladder

Intraperitoneal rupture

Dome is torn and contrast flows freely

Pelvic Trauma Soft Tissue Clues

z

z

z

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

z z

Anterior Column Anterior aspect of acetabulum runs from ilium to pubis

Ilioischial Line

z z

Posterior Column Posterior aspect of acetabulum runs from ilium to ischium

Roentgenographic “U” The Teardrop

z

z

“Teardrop” should not be located medial to ilioischial line Displacement of “teardrop” may be sign of occult acetabular fx

Pelvic Trauma Acetabular Fractures

z

z

20% of pelvic fractures involve acetabulum CT best way of evaluating acetabular fxs

Acetabular Fractures Classification

z

Posterior rim fracture

z

Transverse acetabular fracture

z

Anterior column fracture

z

Posterior column fracture

Acetabular Fractures Posterior Rim Fractures

z

Most common acetabular fx (33%)

z

Occurs with posterior dislocation of hip

z

Typically in MVAs with forces through femoral shaft

Acetabular Fractures Transverse Acetabular Fractures

z

z

z

Separates innominate bone into two halves Look for break in both iliopubic and ilioischial lines May be associated with central dislocation of femoral head

Acetabular Fractures Anterior Column Fracture

z z

Fracture through iliopubic line May be associated with central dislocation of femoral head

Acetabular Fractures Posterior Column Fracture-Walther Fx

z z

Fracture through ilioischial line May be associated with central dislocation of femoral head

Pelvic Trauma Avulsion Fractures

z

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

z z

z

Occurs at insertion of hamstrings Usually seen in sprinters, hurdlers, gymnasts, long jumpers Looks enlarged when healed

Avulsion Fractures Anterior Inferior Iliac Spine

z

Occurs at insertion of rectus femoris

Avulsion Fractures Anterior Superior Iliac Spine

z

Occurs at insertion of sartorious

Avulsion Fractures Iliac Crest Avulsion Fracture

z

Occurs at insertion of abdominal muscles

Pelvic Trauma Complications

z

Hemorrhage

z

Usually from laceration of hypogastric artery

Urinary tract injury

Ruptured urethra or bladder

Pelvic Trauma Complications

z

Sacral plexus/sciatic nerve injuries

z

Especially with fxs of posterior arch

Infection

Retroperitoneal abscess may form in open fxs

Ruptured Urethra Classical Triad

z

Blood on external meatus

z

Distended bladder

z

Inability to void


The ABC’s of Heart Disease In Slide Show mode, to advance slides, press spacebar or click left mouse button

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 O O

O O

O

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

O

Extracardiac causes of cardiac enlargement Q

Portable AP films

Q

Obesity

Q

Pregnant

Q

Ascites

Q

Straight back syndrome

Q

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

O

Obstruction to outflow of the ventricles Q

O

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

“Double density” of LA enlargement Right atrium

Main pulmonary artery Indentation for LA Left ventricle

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 sits in middle of heart posteriorly

Left atrium forms no border of normal heart in PA view

LV RA

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.

LA

When the LA enlarges, it will do something on the left side of the heart we’ll 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, we’ll 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: O

Increased pressure

O

Increased flow

O

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

15 mm

Ao Ao

Main Pulmonary Artery

Main Pulmonary Artery

LV LV

Main pulmonary artery ranges from 0 mm–15mm from tangent line

Two Major Classifications O

O

The main pulmonary artery (MPA) projects beyond the tangent line The main pulmonary artery is more than 15 mm away from the tangent line Q Q

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

>50%

Then Left Ventricle is Enlarged

Which ventricle is enlarged? O

The best way to determine which ventricle is enlarged is to look at the corresponding outflow tract for each ventricle Q

Aorta for the LV

Q

MPA for the RV


Once one ventricle is enlarged, it’s impossible to tell if other ventricle is also enlarged







The Pulmonary Vasculature

Five States of the Pulmonary Vasculature O

Normal

O


O


O

Increased flow

O

Decreased flow

What We’re Going to Evaluate

O

Right Descending Pulmonary Artery

O

Distribution of flow in the lungs Q

Upper versus lower lobes

Q

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 can’t measure size of vessels at the left base because the heart obscures them

3. Normal Distribution of Flow Central versus peripheral

Normal tapering of vessels from central to peripheral

Central vessels give rise to progressively smaller peripheral branches

Normal Vasculature - review 2

RDPA < 17 mm in diameter

Gradual tapering of vessels from central to peripheral

1

3 2

Lower lobe vessels larger than upper lobe vessels

Venous Hypertension RDPA usually > 17 mm

Upper lobe vessels equal to or larger than than size size of lower lobe vessels = Cephalization

Pulmonary Arterial Hypertension Main Pulmonary Artery projects beyond tangent line

RDPA usually > 17 mm 23

Pulmonary Arterial Hypertension Rapid cutoff in size of peripheral vessels relative to size of central vessels

31

Central vessels appear too large for size of peripheral vessels which come from them = Pruning

Increased Flow RDPA usually > 17 mm

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 O O O O O

Normal Pulmonary venous hypertension Pulmonary arterial hypertension Increased flow Decreased flow - mostly unrecognizable even when it is present


If yes, then


If no, then


Normal

Mitral regurg



Increased

If yes, then Look at the Pulmonary Vasculature

VSD, PDA

Normal

Plum. stenosis

Increased

ASD (VSD)

The ABC’s If no, then


C Is the Main Pulmonary Artery Segment Concave?


If yes, then

If no, then

If yes, then


Idiopathic (1°)

Normal

Cardiomyopathy

Ascending dilated

Ao Stenosis

Whole Ao Dilated

Ao regurg HBP

Cardiomyopathy Pericardial Effusion Molt. valve dz

The System O

Those were all of the answers

O

Now here are the questions

O

O

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%


If yes, then


If no, then


Normal

Mitral regurgitation



Increased

VSD, PDA

Pulmonic stenosis

Normal

If yes, then Look at the Pulmonary Vasculature

ASD (VSD)

Increased

If no, then Pulmonary hypertension

Normal C Is the Main Pulmonary Artery Segment Concave?


If yes, then

If no, then

If yes, then


Idiopathic 2° to lung dz

Cardiomyopathy

Ascending dilated

Aortic Stenosis

Whole Aorta Dilated

Aortic regurgitation HBP

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

http://www.learningradiology.com/lectures/cardiaclectures/chdppt_files/frame.htm04/09/2006 1:32:44


Differential Differential Diagnosis Diagnosis of of CHD CHD In Slide Show mode, to advance slides, press spacebar



O




O

What’s left Q

Q

Left-to-right shunts O ASD O PDA Truncus arteriosus

Cyanotic


O O O O O

Tetralogy Truncus-type IV Tricuspid atresia* Transposition* Ebstein's


Ebstein’s Anomaly

Cyanotic


O O O O O

Truncus types I, II, III TAPVR Tricuspid atresia* Transposition* Single ventricle


Total anomalous venous return (TAPVR)

Acyanotic


O O O O O

Viral myocarditis Endocardial fibroelastosis Aberrant left coronary artery Cystic medial necrosis Diabetic mother

Endocardial Cushion Defect

Acyanotic

CHF In Newborn Impede Return of Flow to Left Heart

O O O O O O





O O O O O O

Infantile coarctation Congenital aortic stenosis Hypoplastic Left Heart Syndrome Congenital mitral stenosis Cor triatriatum Obstruction to venous return from lungs O


CHF In 2nd-3rd Week

Coarctation of the aorta O Interruption of the aortic arch O

CHF-later

O


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

O O O O

Ventricular septal defect Pulmonic stenosis Overriding aorta Right ventricular hypertrophy

ASD

Acyanotic

LA

Ao

ASD

Ù

Ø

PDA

×

×

VSD

×

Ù

CHF

Pulmonary Interstitial Edema X-ray Findings

O

Thickening of the interlobular septa Q

O

Peribronchial cuffing Q

O

Wall is normally hairline thin

Thickening of the fissures Q

O

Kerley B lines

Fluid in the subpleural space in continuity with interlobular septa

Pleural effusions

Ventricular Septal Defect (VSD)

Atrial Septal Defect (ostium primum type) with PAH

MS with PAH

35

Pulmonic Stenosis

Most Commons O

Most common cause of CHF in newborn Q

O

Most common cause of CHF > 2 weeks Q

O

Coarctation of the aorta (infantile form)

Most common cyanotic heart disease Q

O


Tetralogy of Fallot

Most common dz associated c R arch Q

Tetralogy of Fallot

Most Commons O

Most common L Î R shunt Q

O

Most common L Î R shunt dx’d in adult Q

O



Dz most commonly associated c R arch Q

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 In Slide Show mode, to advance slides, press spacebar or click left mouse button

7 yo acyanotic female


Atrial Septal Defect Four Major Types

Ostium secundum Ostium primum Sinus venosus Posteroinferior

Atrial Septal Defect 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

Atrial Septal Defect 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®

Atrial Septal Defect 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


Atrial Septal Defect 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

Atrial Septal Defect Posteroinferior Type

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

Atrial Septal Defect 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

Atrial Septal Defect X-Ray Findings

Enlarged pulmonary vessels Normal-sized left atrium Normal to small aorta

Atrial Septal Defect 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

Ø

LA

Ao

ASD

Ù

Ø

PDA

×

×

VSD

×

Ù

Atrial Septal Defect Why the Left Atrium Isn’t Enlarged

RA

LA

RV

LV



Ventricular Septal Defect General

Most common L

R shunt

Shunt is actually from left ventricle into pulmonary artery more than into right ventricle

Ventricular Septal Defect Types

Membranous Supracristal Muscular AV canal

Ventricular Septal Defect 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



Ventricular Septal Defect 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


Ventricular Septal Defect Muscular

Muscular VSD (5–10%) Low and anterior within trabeculations of muscular septum May consist of multiple VSDs = “swisscheese septum”

Swiss cheese


Ventricular Septal Defect AV Canal Atrioventricular canal = endocardial cushion type = posterior VSD (5–10%) Location: adjacent to septal and anterior leaflet of mitral valve Large VSD pulmonary hypertension, eventually shunt reversal Eisenmenger’s physiology

Very large VSD

CHF soon after birth


Large posterior VSD (AV canal)


Ventricular Septal Defect 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

Ventricular Septal Defect Natural History

Size of the defect Larger the defect, more likely to

CHF

Smaller the defect, more likely to be asymptomatic

Ventricular Septal Defect Eisenmenger Physiology

Progressive increase in pulmonary vascular resistance Intimal and medial hyperplasia Reversal of L Cyanosis

R shunt to R

L shunt

Ventricular Septal Defect 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 Eisenmenger’s physiology/cyanosis

Ventricular Septal Defect 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

Ventricular Septal Defect Why Left Atrium Is Enlarged

RA

LA

RV

LV

4 mos old acyanotic female

Ventricular Septal Defect Prognosis

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

Ventricular Septal Defect 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

Patent Ductus Arteriosus General

Higher incidence in Trisomy 21 Trisomy 18 Rubella Preemies

Predominance in females 4:1

Patent Ductus Arteriosus 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 Ç 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%

Patent Ductus Arteriosus 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

Patent Ductus Arteriosus 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

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

Patent Ductus Arteriosus Why Left Atrium Is Enlarged

RA

LA

RV

LV

Patent Ductus Arteriosus 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

Patent Ductus Arteriosus Prognosis

Spontaneous closure may occur

Patent Ductus Arteriosus Complications CHF Failure to grow Pulmonary infections Bacterial endocarditis Eisenmenger’s physiology with advanced lesions

2 yo old cyanotic female

Partial or Total Anomalous Pulmonary Venous Return

Cyanosis With Increased Vascularity Truncus types I, II, III TAPVR Tricuspid atresia* Transposition* Single ventricle * Also appears on DDx of Cyanosis with Inc Vascularity

Two Types

Partial (PAPVR) Mild physiologic abnormality Usually asymptomatic

Total (TAPVR) Serious physiologic abnormalities

Return of blood from lungs is by four pulmonary veins to LA RA

LA

RV

LV

PA

Normal heart

Ao

PAPVR General

One of the four pulmonary veins may drain into right atrium Mild or no physiologic consequence Associated with ASD Sinus venosus or ostium secundum types

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 Ü R side of heart All must also have R survival

L shunt for


All are cyanotic Identical oxygenation in all four chambers

TAPVR Types

Supracardiac Cardiac Infracardiac Mixed

TAPVR Supracardiac Type—Type I

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 © Frank Netter, MD Novartis®

TAPVR-Supracardiac Type 1

TAPVRSupracardiac Type 1

TAPVR Supracardiac Type 1—X-ray Findings

Snowman heart = dilated SVC+ left vertical vein Shunt vasculature 2° increased return to right heart Enlargement of right heart 2° volume overload

TAPVR-Supracardiac Type 1

Blood from lungs drains into left vertical vein to L SVC

Blood moves through L brachiocephalic v to R SVC

ASD provides R L shunt to allow oxygenated blood to reach body (moderate cyanosis)

RA

LA

RV

LV Increased

PA

Ao

return to right heart overloads lungs shunt vessels

TAPVR–Type I–Supracardiac type

“Snowman Heart”

TAPVR–Type I–Supracardiac type

TAPVR Cardiac Type—Type II Second most common: 30% Drains into coronary sinus or RA Coronary sinus more common

Increased pulmonary vasculature Overload of RV

CHF after birth

20% of I’s and II’s survive to adulthood Remainder expire in first year

Coronary sinus © Frank Netter, MD Novartis®

TAPVR-Coronary Sinus-Type II

Blood returns from lung to RA or coronary sinus

ASD provides R L shunt to allow oxygenated blood to reach body (moderate cyanosis)

RA

LA

RV

LV

PA

Ao

Increased

return to right heart overloads lungs shunt vessels

TAPVR–Type II–Cardiac Type

TAPVR Infracardiac Type—Type III 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

Pulmonary veins

Portal vein


TAPVR-Type IIIInfradiaphragmatic

TAPVR Infracardiac Type—Continued Severe CHF (90%) 2° obstruction to venous return Cyanotic 2° right Ü left shunt through ASD Associated with asplenia (80%), or polysplenia Prognosis=death within a few days

Blood returning from lungs pulmonary veins which are constricted by diaphragm CHF

CHF vasculature

ASD provides R L shunt to allow oxygenated blood to reach body (cyanotic)

RA

LA

RV

LV

PA

Ao

To portal v

TAPVR–Type III–Infracardiac type

IVC

RA

TAPVR Mixed Type—Type IV

Percent of total: 6% Mixtures of types I – III

Unknowns

ASD (primum) with PAH


VSD

ASD

The End


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LearningRadiology- Cyanotic Heart Disease

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Cyanotic Heart Disease In Slide Show mode, to advance slides, press spacebar or click left mouse button


O O O O O

Tetralogy Truncus-type IV Tricuspid atresia* Transposition* Ebstein's



O O O O O

Truncus types I, II, III TAPVR Tricuspid atresia* Transposition* Single ventricle


Tetralogy Tetralogy of of Fallot 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 © Frank Netter, MD Novartis®

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) © Frank Netter, MD Novartis®

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

z

Cyanosis is worse in II and III z

z

Can’t tell them apart clinically

Associated anomalies Bony z Renal z Lung z Cleft palate z

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%) PA arises on left via short common stem

Shunt vessels Ao

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

TOF with pulmonary atresia

Truncus-Type IV

Bronchial circulation


Truncus-Type IV (TOF with pulmonary atresia)

Bronchial Circulation

Increased flow

I

III

II

IV

Truncus Arteriosus Pulmonary artery

Shunt vessels

I

Convex

Yes

II

Concave

Yes

III

Concave

Yes

IV

Concave

Bronchial circulation

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 patient’s 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 atresia—no transposition © Frank Netter, MD Novartis®

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

Tricuspid atresia—no transposition

Some unsaturated blood exits aorta

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

Tricuspid atresia—with transposition

Unoxygenated blood flows to lung via transposed PA « ↑ flow

Tricuspid atresia X-ray Findings - No transposition • Normal-sized heart • Decreased pulmonary vessels (60-70%) • Flat/concave pulmonary artery • Small ASD « enlarged RA • Large ASD « normal or slightly enlarged RA

Tricuspid atresia—some PS, no transposition

Tricuspid atresia X-ray Findings - Transposition

• Mild cardiomegaly • Engorged pulmonary vessels • No characteristic appearance to heart

Tricuspid atresia—no PS, shunt vessels

Transposition of The Great Vessels

The “TR” Lesions

Cyanosis with ↑ or ↑ vasculature • Tricuspid atresia • Transposition • Truncus arteriosus

↑ or ↓ ↑ or ↓

• Type I, II, III • Type IV

↑ ↓

• Tetralogy • TAPVR • TrEbstein’s

↓ ↑ ↓

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

Normal heart

Anatomic Left ventricle is smooth

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

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





Transposition of the Great Arteries 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

Transposition of the Great Arteries Associated abnormalities

• About 1/3 have VSD • Larger the shunt, more likely CHF

• About ¼ to ½ 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

PA arises from anatomic left ventricle

Aorta arises from pulmonic infundibulum

PDA

Transposition of the Great Vessels (D-Trans)

Transposition of the Great Arteries 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

Ebstein’s Ebstein’s Anomaly Anomaly

Ebstein’s 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


Ebstein’s Anomaly

Normal


Ebstein’s Anomaly

Ebstein’s Anomaly X-ray Findings

• Cardiomegaly • One of few conditions « cardiomegaly first few days of life

• Unusual prominence to right heart border • Pulmonary flow is decreased

Ebstein’s Anomaly

Ebstein’s Anomaly

Ebstein’s Anomaly Triad

Marked Cardiomegaly

Decreased flow

Cyanosis

Single Single Ventricle 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

In Slide Show mode, to advance slides, press spacebar or click left mouse button All photos retain the rights of their original owners

Lesions That Cause CHF


O O O O O O



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


Diagnosing CHF in a Newborn O O O

Usually have cardiomegaly Ill-defined bronchovascular bundles Flattening of diaphragm Q

O

Air hunger

Rare Q Q

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

Coarctation of the Aorta General

O

2X more common in males

O

Common classification

O

Q

Infantile or preductal form

Q

Adult or juxtaductal form

Relationship of ductus to coarct affects clinical picture

Coarctation of the Aorta Coarctation Proximal to Ductus

O

O

Flow is frequently from PA to Ao through Ductus Cyanosis in lower half of body as Q

O

Unoxygenated blood from PA feeds lower extremities

Oxygenated blood from LV goes to major vessels of head and neck Q

Not cyanotic

Coarctation of the Aorta Coarctation Distal to Ductus

O

O

Flow is initially from Ao to PA (L « R shunt) If there is Eisenmenger’s physiology, the flow reverses and goes from PA « Ao (R « L shunt)

O

Cyanosis

O

More common form

Coarctation of the Aorta Other Classifications

O

More complicated classifications take following into account Q

Location and length of coarct

Q

Patency of ductus arteriosis

Q

Relationship of coarct to ductus

Coarctation of the Aorta Adult Form

O

O O

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


Coarctation of the Aorta Infantile Form O

Infantile, preductal form = diffuse type

O

Long, tubular segment of narrowed aorta Q

O

From just distal to brachiocephalic artery to level of ductus

Intracardiac defects (VSD, ASD, deformed mitral valve) present in 50% of diffuse type Q

Also patent ductus arteriosis

BCA

LCCA

LSCA

Ductus

© Netter

Coarctation of the Aorta Associated Defects O

Bicuspid aortic valve (most common associated defect seen in 50%)

O

VSD

O

ASD

O

Transposition

O

25% of patients with Turner’s Syndrome have coarctation of aorta

Coarctation of the Aorta Shone Syndrome

O

Coarctation of aorta

O

Aortic stenosis

O

Parachute mitral valve

O

Supravalvular mitral ring

X-Ray Findings Rib Notching

O O

O

O

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

Coarctation of the Aorta 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 O

Most often involves 4th-8th rib Q

O

Sometimes may involve 3rd and 9th

Does not involve 1st and 2nd ribs Q

Intercostals come off costocervical trunk and do not supply collateral flow to descending aorta V

4th-8th do anastomose with internal mammary to form collaterals for descending aorta

Rib Notching in Coarctation

4

5

Regresses after coarct is repaired

6

Costovertebral junction

7

X-Ray Findings Rib Notching–Unilateral

Rib notching occurs in the high pressure circuit

X-Ray Findings Unilateral Right Rib Notching Notching occurs in the high pressure circuit

LCA LSCA BCA

High Pressure Circuit

Isolated right-sided rib notching

Ductus

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 O

O

Caused by (in order) Q

Dilated LSCA or aortic knob

Q

“Tuck” of coarct itself

Q

Poststenotic dilatation

Occurs in 1/3–1/2 of patients with coarct Q

O

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 O

Convexity of left side of mediastinum just above aortic knob 2° to Q

Dilated aorta proximal to coarct, or

Q

Dilated LSCA V

O

May be congenital or may be 2° to ↑ pressure

Convexity of ascending aorta in 1/3 Q

May be normal or small in others

Convexity above aortic knob due to dilated LSCA or Aorta proximal to coarct

Ascending Ao may be dilated, normal or small


Coarctation of the Aorta Clinical Findings–Infancy 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

Coarctation of the Aorta Echocardiographic Findings

O

O

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

Coarctation of the Aorta MRI and Angiography O

MRI preferred study in children/adults

O

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

Coarctation of the Aorta Complications

O O

Heart failure in neonate Subarachnoid bleeds 2° ruptured Berry aneurysms

O

Dissection of aorta

O

Bacterial endocarditis

O

Mycotic aneurysm

Pseudocoarctation

O

Buckling of aorta resembles true coarctation

O

No pressure gradient (<30mmHg)

O

Figure 3 sign present

O

No rib notching

Congenital Aortic Stenosis © Netter

Congenital Aortic Stenosis Valvular-General O

O O

O

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

Congenital Aortic Stenosis Angiography O

Domed and thickened leaflets in systole

O

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

Hypoplastic Left Heart Syndrome General

O

O

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 Q

O

Usually cyanotic

Heart is enlarged in most

Hypoplastic Left Heart Syndrome General O

O

Small ascending aorta Q

Common to all forms

Q

Sometimes infantile coarctation

Often associated mitral stenosis or atresia or aortic stenosis or atresia

O

In 90%, size of LA and LV small

O

A large PDA is essential Q

VSD, ASD also present

RA, RV and PA are enlarged

Passes to RA via ASD (L « R shunt)

Oxygenated and deoxygenated blood enter PA

Blood passes through PA « lungs and into large PDA « aorta « to body

PDA

Hypoplastic Left Heart Syndrome

Oxygenated blood returning from lungs can not enter LV

Obstruction to return of blood from lungs « CHF

Cyanotic

Hypoplastic Left Heart Syndrome Pathophysiology

O

O

O

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


Hypoplastic Left Heart Syndrome Atretic aorta

Hypoplastic Left Heart Syndrome Associated Anomalies

O


O

Interruption of the aortic arch

O

AV communis

O

Anomalies of the R subclavian artery

O

Bicuspid aortic valve

Hypoplastic Left Heart Syndrome X-ray Findings

O

O

Increased load on RV « marked cardiomegaly at birth Obstruction to return of blood from lungs « CHF at birth Q

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

Hypoplastic Left Heart Syndrome Diagnosis

O

Diagnosis can be made by echo

O

Catheterization may be hazardous Q

Spasm of PDA during cath can « death

Hypoplastic Left Heart Syndrome Triad

Cardiomegaly

CHF in 1st week of life

Cyanosis

Congenital Mitral Stenosis © Netter


O

Exists as isolated abnormality 25% of time

O

Coexists with VSD 30% of time

O

Coexists with another form of left ventricular outflow obstruction 40% of time—SHONE’S Syndrome

Shone’s Syndrome

O


O


O

Subaortic stenosis

O



LV

Signal void

RA

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

O O

Rare congenital anomaly Fibromuscular septum with single, large, opening separates embryonic common pulmonary vein from left atrium

Cor Triatriatum Anatomy O

O

Proximal, accessory chamber lies posteriorly and receives pulmonic veins Distal, true atrial chamber lies anteriorly, emptying into left ventricle through mitral valve

Cor Triatriatum

Proximal accessory chamber lies posterior and receives pulmonary veins

Distal, true atrial chamber lies anteriorly and contains mitral valve © Netter

Cor Triatriatum Associations

O

ASD

O

PDA

O

Anomalous pulmonary venous drainage

O

Left SVC

O

VSD

O

Tetralogy of Fallot

Cor Triatriatum Clinical

O

Clinically similar to mitral stenosis

O

Dyspnea

O

Heart failure

O

Failure to thrive

Cor Triatriatum X-ray Findings

O

Pulmonary edema

O

Enlarged LA

Cor Triatriatum

Cor Triatriatum - angiography

© Netter

Ao RVOT RA

Ao

MPA LA LA

LA

LA

RV

Amersham

Cor Triatriatum

Cor Triatriatum Treatment

O

Surgical excision of obstructing membrane

Cor Triatriatum Prognosis

O

Usually fatal in first 2 years of life Q

Associated abnormalities

Obstruction Of the Venous Return from the Lungs TAPVR from below Diaphragm © Netter

TAPVR Infracardiac Type—Type III

O O

O

O

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

Pulmonary veins

Portal vein

© Netter

TAPVR-Type IIIInfradiaphragmatic

Causes of CHF in the Newborn

Coarctation of the Aorta Obstruction to venous return from lungs Cor Triatriatum

Congenital Aortic Stenosis


© Netter


The End


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LearningRadiolgy.comn- Valvular Lesions of the Heart,pulmonic,tricuspid,mitral,aortic,stenosis,regurgitation,insufficiency

http://www.learningradiology.com/lectures/cardiaclectures/valvularlesionsweb_files/frame.htm04/09/2006 1:36:17


Valvular Lesions of the Heart In Slide Show mode, to advance slides, press spacebar

Mitral Mitral Stenosis Stenosis Left Left Atrial Atrial Outflow Outflow Obstruction Obstruction

Mitral Stenosis Rheumatic Valvular Heart Disease

z

Rheumatic heart disease causes mitral stenosis in 99.8% of cases

Acute Rheumatic Valvulitis Pathophysiology Multiple episodes of Acute Rheumatic Fever (ARF) first « pancarditis © Frank Netter, MD Novartis®

Acute Rheumatic Valvulitis Pathophysiology z

Acute phase subsides

z

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

z

Mitral orifice becomes smaller «

Two circulatory changes O

O

To maintain LV filling across narrowed valve, left atrial pressure ↑ Blood flow across mitral valve is ↓ which « to ↓ cardiac output

Effects of Mitral Stenosis

z

On heart

z

On lungs

z

On right ventricle

Effect of Mitral Stenosis On Heart

z

Left atrium hypertrophies and dilates 2° ↑ pressure

z

Atrial fibrillation and mural thrombosis follow

Left ventricle is “protected” by stenotic mitral valve

LV usually normal in size and contour


z

Pulmonary arterial pressure ↑

z

Intimal and medial hypertrophy of pulmonary arteries « ↑ pulmonary vascular resistance

Right ventricle dilates from pressure overload

Main pulmonary artery dilates « pulmonary valve regurgitation


z

Tricuspid regurgitation develops

z

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 © Frank Netter, MD Novartis®

Effect of Mitral Stenosis On Lungs

z

Pulmonary arterial hypertension develops

z

First passively

Then 2° muscular hypertrophy and hyperplasia « increased pulmonary vascular resistance

Effect of Mitral Stenosis On Lungs

z

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

Effect of Mitral Stenosis On Lungs z

↑ pulmonary venous and capillary pressure Normal

5-10 mm Hg

Cephalization

10-15 mm

Kerley B Lines

15-20


20-25

Pulmonary Alveolar Edema

> 25

Effect of Mitral Stenosis On Right Ventricle

z

z

RV hypertrophies in response to increased afterload Eventually RV fails and dilates

Causes dilation of tricuspid annulus « tricuspid regurgitation

X-Ray Findings of MS Cardiac Findings z

Usually normal or slightly enlarged heart

z z

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

X-Ray Findings of MS Cardiac Findings

z

z

z

Small aortic knob from decreased cardiac output Double density of left atrial enlargement Rarely, right atrial enlargement from tricuspid insufficiency

RA

LA

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

X-Ray Findings of MS Calcifications

z

z

z

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

X-Ray Findings of MS Pulmonary Findings z z

z

Cephalization Elevation of left mainstem bronchus (especially if 90° to trachea) Enlargement of main pulmonary artery 2° pulmonary arterial hypertension

z

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

z z

z

Presence indicates MS Calcium usually deposited in clumps on valve leaflets Heavier calcific deposits in men than women © Frank Netter, MD Novartis®

Mitral Annulus Calcification z

Calcification of mitral annulus does not signify presence of mitral valve disease



Rarely « Mitral Stenosis

Mitral Stenosis Other Causes O

MS 2° rheumatic disease 99.8% of cases z z z z z z z

Congenital mitral stenosis Infective endocarditis Carcinoid syndrome Fabray’s Disease Hurler’s syndrome Whipple’s Disease Left atrial myxoma


z

Exists as isolated abnormality 25% of time

z

Coexists with VSD 30% of time

z

Coexists with another form of left ventricular outflow obstruction 40% of time — SHONE’S Syndrome

Shone’s Syndrome

z


z


z

Subaortic stenosis

z


LA Myxoma

z

Most common form of primary cardiac tumor

z

86% of myxomas found in left atrium

z

90% of myxomas are solitary

z

Usually occur around fossa ovalis

MS and MR

z

z

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 z

Thickening of valve leaflets 2° rheumatic disease

z

Rupture of the chordae

z

Papillary muscle rupture or dysfunction

z

Acute myocardial infarction

LV enlargement « dilatation of mitral annulus

z

Posterior leaflet more often-Trauma, Marfan’s

Any cause of LV enlargement

LV aneurysm « valvular dysfunction

Acute myocardial infarction

Mitral Regurgitation General

z

z

The acute lesion of rheumatic fever is mitral regurgitation, not stenosis The largest left atria ever are produced by mitral regurgitation, not mitral stenosis

Mitral Regurgitation X-ray Findings z

In acute MR

z

Pulmonary edema Heart is not enlarged

In chronic MR

LA and LV are markedly enlarged O

Volume overload

Pulmonary vasculature is usually normal O

LA volume but not pressure is elevated



Difference in heart size – MS and MR

Mitral Stenosis

Mitral Regurgitation

Aortic Stenosis

Aortic Stenosis Frequency of Causes

z

z

z

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

z

Supravalvular

z

Valvular

z

Subvalvular

Valvular Aortic Stenosis Congenital

Congenital Valvular Aortic Stenosis General z

Bicuspid aortic valve is the most common congenital cardiac anomaly

z z

0.5 –2%

Usually not stenotic during infancy More prone to fibrosis and calcification than normal valve

Congenital Valvular Aortic Stenosis Associations

z

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

50% with coarctation of aorta


Interruption of aortic arch

Congenital Valvular Aortic Stenosis Calcification

z z

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

Congenital Valvular Aortic Stenosis Angiographic findings

z

z

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

Congenital Valvular Aortic Stenosis Angiographic findings

z

Congenitally bicuspid valves usually have 2 aortic sinuses

z

3 sinuses in acquired AS

In rheumatic disease, aortic valve commissures usually fuse

Don’t fuse in degenerated tricuspid valve

Valvular Aortic Stenosis Acquired

Acquired Valvular Aortic Stenosis Causes

z

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

30’s

Jet effect on aortogram

Degeneration of Tricuspid Valve

> 65

Coronary artery ca++ Commissures don’t fuse

Rheumatic dz in Tricuspid Valve

30’s here; teens in 3rd world countries

MS or MR almost always present; commissures fuse

Aortic Stenosis X-Ray Findings z

Depends on age patient/severity of disease

z

In infants, AS «CHF/pulmonary edema

In adults

Normal heart size O

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

z

From turbulent flow just distal to any hemodynamically significant arterial stenosis

z

Jet effect also plays role

Occurs mostly with valvular aortic stenosis

May occur at any age


Aortic stenosis

Aortic Stenosis Calcification of Valve

z

z

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

z

Associated with

Subaortic fibrous membrane


Idiopathic Hypertrophic Subaortic Stenosis

Subaortic Fibrous Membrane

Aortic valve

About 15% of patients with congenital obstruction to LVOF z Membrane just below aortic valve z May attach to anterior leaflet of mitral valve z


Ao

Mitral regurg Aortic regurg

Supravalvular Aortic Stenosis

Supravalvular Aortic Stenosis General z

Uncommon

z

Types

z

Hourglass

Membrane

Hypoplasia of entire ascending aorta

Associated lesions in 2/3

William’s syndrome

Supravalvular Aortic Stenosis • William’s syndrome • Supravalvular aortic stenosis • Hypercalcemia • Elfin facies • Pulmonary stenoses • Hypoplasia of aorta • Stenoses in • Renals, celiac, SMA

Aortic Stenosis Clinical Triad

Chest pain

Syncope

SOB

Aortic Regurgitation (Aortic Insufficiency)

Aortic Regurgitation Causes

z z z z z z

Rheumatic heart disease Marfan’s Luetic aortitis Ehlers-Danlos syndrome Endocarditis Aortic dissection

Aortic Regurgitation Rheumatic Heart Disease z

Thickened cusps

z

May have commissural fusion

z

In degenerative Ao regurg, no commissural fusion

Regurgitant jet is usually central

In degenerative, usually not discrete jet © Frank Netter, MD Novartis®

Aortic Regurgitation Imaging Findings z

z

X-ray hallmarks are

Left ventricular enlargement

Enlargement of entire aorta

Cine MRI (gradient refocused MRI)

z

“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

Aortic Regurgitation

Pulmonic Stenosis

Pulmonic Stenosis General

z z z

Without VSD = 8% of all CHD Mostly asymptomatic When symptomatic

z

Cyanosis and heart failure Cor pulmonale

Loud systolic ejection murmur

Pulmonic Stenosis Types

z

Subvalvular

z

Valvular

z

Supravalvular

Pulmonic Stenosis Valvular Pulmonic Stenosis

z

Classic pulmonic stenosis (95%)

Congenital in origin Associated with metastatic carcinoid syndrome O

Tricuspid valve dz as well

Associated with Noonan Syndrome O

ASD

O

Hypertrophic cardiomyopathy

Pulmonic Stenosis Valvular Pulmonic Stenosis

z

Morphology of abnormal valve

Membrane with central opening, or

Fusion of pulmonary cusps


Pulmonic Stenosis Valvular pulmonic stenosis

z

Presents in childhood

z

Pulmonic click

z

z

Dome-shaped pulmonic valve in systole RX: Balloon valvulo-plasty

Pulmonic Stenosis X-ray Findings

z z

z

z

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

z

Infundibular pulmonic stenosis

Typically in Tetralogy of Fallot O

O

z

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

z

Severe pulmonic valvular stenosis

z

RV hypertrophy

z

ASD with R « L shunt

Supravalvular Pulmonic Stenosis General

z

May be either tubular hypoplasia or localized with poststenotic dilatation

Supravalvular Pulmonic Stenosis Associated CV abnormalities

z

Valvular pulmonary stenosis

z

Supravalvular aortic stenosis

z

VSD, PDA

z

Systemic arterial stenoses

Supravalvular Pulmonic Stenosis Associated Syndromes z

Williams Syndrome

z z

z

Pulmonic Stenosis Supravalvular AS Peculiar facies

Post-rubella syndrome Carcinoid syndrome with liver mets Ehlers-Danlos syndrome

9

2

The End

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LearningRadiology - Diseases of the Great Vessels

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Diseases of the Great Vessels In Slide Show mode, to advance slides, press spacebar All illustrations retain their original copyrights

Aortic Anomalies General l

Most are asymptomatic Unless they cause encircling vascular ring like pulmonary sling

n

l

Can be complex lesions requiring multiple projections n

MRI or CT © Frank Netter, MD Novartis®

Aberrant Subclavian Arteries General

l

Left arch with aberrant right subclavian Usually passes posterior to esophagus n Dilated origin is “Diverticulum of Kommerell” n

l

Right arch with aberrant left subclavian Most are asymptomatic n Passes behind esophagus n Low incidence of congenital heart dz n

Left Aortic Arch Left Aortic Arch With Anomalous RSCA With Anomalous RSCA

Left Arch with Anomalous RSCA l

Occurs in less than 1% of people

l

Passes posterior to esophagus n

l

l

Pushes trachea and esophagus forward

Produces oblique shadow above aortic arch on frontal film Origin of RSCA may be dilated n

Diverticulum of Kommerell


© Dahnert Lippincott Williams & Wilkins

Left Aortic Arch with Aberrant R SCA

Left Aortic Arch with Aberrant Right SCA

© L. Elliott, MD J.B. Lippincott ®


Right Aortic Arches Right Aortic Arches

Right Aortic Arch Types

l

At least five different types

l

Only two of importance

Right Aortic Arch Types Mirror Image Type — Type I l Aberrant left subclavian — Type II l

Mirror Image

Aberrant LSCA © Stephen Miller, MD Mosby The Requisites

Right Aortic Arches General l

Recognized by leftward displacement n

Of bariumfilled esophagus

n

Of airfilled trachea

l

Aortic knob is absent from left side

l

Aorta descends on right

l

Paraaortic stripe returns to left side of spine just above diaphragm

Right Aortic Arches General

l

Mirrorimage type almost always has associated CHD n

l

Usually Tetralogy of Fallot

Aberrant Left Subclavian type rarely has associated CHD n

Most common variety of right arch

Right Aortic Arch Type 1—Mirror Image Type

l

l

2° interruption of left arch just distal to ductus arteriosis Associated with congenital heart disease 98% of time

Right Aortic Arch Type 1—Mirror Image Type–Xray Findings

l

l

l

No posterior impression on trachea or bariumfilled esophagus Heart is usually abnormal in size or shape Aorta descends on right

Mirror Image Right Aortic Arch with TOF

Mirror Image Right Aortic Arch

Right Aortic Arch Type ll—Aberrant Left Subclavian

l

l

2° interruption of left aortic arch between LCC and LSC arteries Associated with cardiac defects 510% of the time n

Tetralogy of Fallot most often (71%)

n

ASD or VSD next most often (21%)

n

Coarctation of aorta rarely (7%)

Right Aortic Arch Type ll—Aberrant Left Subclavian

l

l

Anomalous left subclavian artery (retroesophageal and retrotracheal) Aorta descends on right



© Stephen Miller, MD Mosby The Requisites

Right Arch with Aberrant LSCA

Right Aortic Arch Aberrant Left Subclavian—Xray Findings

l

l

l

Posterior impression on trachea and bariumfilled esophagus Heart is usually normal in size and shape Aorta descends on right


Right Aortic Arch with Aberrant Left Subclavian



If the patient has a Mirror Right arch,

Then it will be associated

l

90% with Tetralogy of Fallot

l

6% with Truncus Arteriosis

l

5% with Tricuspid Atresia

If the patient has this disease,

This % will have a Mirror Right arch

l

Truncus arteriosis

33%

l

Tetralogy of Fallot

25%

l

Transposition

10%

l

Tricuspid atresia

5%

l

VSD

2%

Apparent discrepancy due to much higher - incidence of TOF than Truncus

A

J

Identify these three anomalies and tell whether they are usually associated with congenital heart disease or not

C Left Aortic Arch with Aberrant R SCA

B

J

L Right Aortic Arch with Aberrant Left Subclavian


Double Aortic Arch Double Aortic Arch

Double Aortic Arch General

l l

Most common vascular ring Rarely associated with congenital heart disease n

l

But vascular ring Ü tracheal and/or esophageal compression

Caused by persistence of R and L IV branchial arches

L IV arch is part of normal aortic arch between LCC and LSCA

R IV arch normally becomes most proximal segment of RSCA


Persistence of both IV branchial arches forms a vascular ring or Double Aortic Arch

Double Aortic Arch General l

Passes on both sides of trachea n

Joins posteriorly behind esophagus

l

Right arch is larger and higher

l

Left arch is smaller and lower n

Ba swallow shows bilateral impressions on frontal view

Posterior impression on lateral view

n

l

Angiogram is characteristic

Double Aortic Arch Clinical

l

Symptoms may begin at birth

l

Symptoms include n

Tracheal compression, or

n

Difficulty swallowing

Double Aortic Arch Anatomy

l

l

Right arch supplies RSCA and RCC Left arch supplies LCC and LSCA © Stephen Miller, MD Mosby The Requisites



Double Aortic Arch

Double Aortic Arch Xray Findings

l

Right arch is higher and larger

l

Left arch is lower and smaller n

l

Produces reverse S on esophagram on AP


Double Aortic Arch


Double Aortic Arch


Double Aortic Arch Impressions on Trachea and Esophagus

Double Aortic Arch

Cervical Aortic Arch Arch

Cervical Aortic Arch General l

Rare

l

Usually asymptomatic May present as pulsating supraclavicular mass

n

May produce vascular ring and compress airway

n

l

Embryogenesis uncertain

l

Over 80% are rightsided

Cervical Aortic Arch Imaging Findings–Rightsided lesions

l

Rightsided cervical aortic arches n

Right apical masslike density

n

Absence of aortic knob

n

Descend on the left

n

Displace the trachea and esophagus forward

n

Branching may be normal or mirrorimage

Cervical Aortic Arch Imaging Findings–Leftsided lesions

l

Leftsided cervical aortic arches n

Aortic knob at apex of lung

n

Descend on the left

Do not displace the trachea or esophagus forward

n



Aortitis Aortitis

Takayasu’s Aortitis Pulseless Disease

l l

l

l

Chronic inflammatory arteritis Affects aorta, its main branches and pulmonary arteries 1540 years, 8:1 females, Oriental population LSCA, LCCA, brachiocephalic, renals, celiac commonly involved

Takayasu’s Aortitis Type 3 l

Most common is Type 3 (55%) n

Stenoses of aortic arch, distal thoracic and abdominal aorta



Next most common is Type 2 (11%) n

Segmental stenoses in descending thoracic and abdominal aorta © Stephen Miller, MD Mosby The Requisites


Next most common is Type 1 (8%) n

Stenoses in arch, brachiocephalic, carotid and subclavian arteries © Stephen Miller, MD Mosby The Requisites


Takayasu’s Aortitis (Type 3)

Takayasu’s Aortitis Imaging Findings

l

l l

On angiography, narrowing of aortic lumen On MRI, thickened aortic wall Associated aneurysms may be saccular or fusiform

Other Forms of Aortitis l l

l

Inflammation of intima and media Healing produces scarring “treebark” appearance of luminal surface Aorta dilates n

Ascending aorta more than arch

n

Abdominal aorta spared

n

Opposite of atherosclerosis

Other Forms of Aortitis l

l

Aortic wall becomes thickened on healing Usually results in aortic regurgitation n

Diastolic murmur

Giant Cell Arteritis © Stephen Miller, MD Mosby The Requisites

Causes of Aortitis l

Rheumatic fever

l

Reiter’s syndrome

l

Syphilis n

Begins above sinotubular ridge

l

Giant cell arteritis

l

Ankylosing spondylitis n

Sinotubular Ridge Jct of Sinuses of Valsalva and tubular aorta

Crosses sinotubular ridge and dilates both root and ascending aorta © Stephen Miller, MD Mosby The Requisites

Syphilitic Aortitis

Pulmonary Sling Pulmonary Sling

Pulmonary Sling Embryogenesis

l

Failure of formation of left 6th aortic arch Ü absence of left pulmonary artery

Proximal L VI arch normally becomes proximal segment of L PA; distal VI persists as ductus until birth © Frank Netter, MD Novartis®

Pulmonary Sling General l

Aberrant origin of left pulmonary artery n

l

l

From the right pulmonary artery

Left pulmonary artery passes between trachea and esophagus Most have other anomalies n

Stenosis of right mainstem bronchus l

May lead to airtrapping, lobar emphysema and hyperlucent lung


© L. Elliott, MD J.B. Lippincott ®

Pulmonary Sling

Pulmonary Sling DDX

l

l

Only vascular malformation to pass between esophagus and trachea Bronchial cyst may produce same finding on esophagus/trachea

Pulmonary Sling

Pulmonary Sling

Tracheal Impressions

Posterior Esophagus


Left Ao Arch with Aberrant R SCA Right Ao Arch with Aberrant L SCA

Anterior Trachea


Isolated anomalies BCA arising too distal CCA arising too proximal CCA and BCA arising together

Anterior trachea and Posterior Esophagus


Double Aortic Arch R Ao Arch with Aberrant LSCA + L ductus L Ao Arch with Aberrant RSCA + R ductus

Posterior trachea and Anterior Esophagus


Pulmonary Sling


Aberrant SCA

Double Ao Arch Isolated Anomalies

Pulmonary Sling

Venous Anomalies Venous Anomalies

Persistent Left SVC SVC

Persistent Left SVC l

Occurs in less than 0.5% of people n

Failure of regression of L common and Ant. Cardinal veins

l

Drains left jugular and left subclavian v

l

Most patients also have rightsided SVC

l

Drains into dilated coronary sinus Ü R atrium

Postop day 3

Postop day 6

Persistent Left SVC


Diseases of the NotSoGreat Vessels Vessels

Left Superior Left Superior Intercostal Vein Intercostal Vein Aortic Nipple Aortic Nipple

Left Superior Intercostal Vein The Aortic Nipple

Visible in 5% of people l Should not be mistaken for mass l

Aortic NippleLeft Superior Intercostal Vein



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LearningRadiology.com - The Heart -Inside Out

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The Heart: Inside Out To exit program, use back button on your browser To exit program, use back button on your browser

Intraluminal Lesions

Tumors and Thrombi

Cardiac Tumors l l

Rare Metastatic tumors are 20x more common than primary n

l

Melanoma, lymphoma, lung and breast most frequent

Most mets involve the pericardium

Cardiac Tumors l

In children, most common tumor is rhabdomyoma n

l

Tuberous sclerosis; multiple, IV septum

In adults, most common benign tumor is myxoma n

Angiosarcoma most common malignant s

Usually rightsided

Myxomas

l

Most common 1° benign cardiac tumor

l

Usually found in left atrium

l

Arise from interatrial septum

l

About 10% calcify

©MillerRequisites ©MillerRequisites

Myxoma in Left Atrium

Ventricular Thrombi

l

l

l

In left ventricle n

After MI

n

In a ventricular aneurysm

Filling defects in opacified cardiac chamber May calcify

Ventricular Thrombi

l

Occur on cardiac walls that are akinetic n

l

Usually at cardiac apex or along IV septum

Biggest pitfall n

n

May be confused with posterior papillary muscles Look for thickened chordae

Thrombus in Right Ventricle

Atrial Thrombi

l

l

l

Commonly associated with LA enlargement Most frequent in mitral stenosis with atrial fibrillation Left atrial appendage a frequent site

©ElliotCardiac Imaging ©ElliotCardiac Imaging

Thrombus in left atrial appendage

Myocardium

Cardiomyopathy

Classification l

l

l

l

Dilated cardiomyopathy Restrictive cardiomyopathy Hypertrophic cardiomyopathy Arrhythmogenic right ventricular dysplasia ©ElliotCardiac Imaging ©ElliotCardiac Imaging

Dilated Cardiomyopathy Cardiomyopathy

Dilated Cardiomyopathy l

Dilatation of both ventricular cavities n

l

Over 75% have mural thrombi n

l

Increased cardiac mass

Most often LV>RV>RA>LA

More than half of patients are alcoholics

Dilated Cardiomyopathy Other Causes

l

Idiopathic

l

Coronary artery disease

l

Myocarditis

l

Lupus

l

Viral infection

Dilated Cardiomyopathy Clinical

l

Poor systolic ventricular function n

l

Pooling in diastole leads to thrombogenesis

Severe, intractable CHF is dominant symptom n

Usual cause of death

Dilated Cardiomyopathy Imaging Findings

l

Cardiomegaly n

Usually involves left ventricle

l

CHF common

l

Echo: poor global wall motion n

Wall thickness usually thin

Dilated Cardiomyopathy

Amersham

End systole

End diastole Dilated Cardiomyopathy

Cine MR images in the short axis plane show little change in size between end diastole and end systole

Arrhythmogenic Right Ventricular Dysplasia l

Rare cardiomyopathy

l

Arrythmias and sudden death n

l

RV anterior free wall replaced by fat and fibrous tissue n

l

Younger age group

Thinning of ant wall; more fat than normal

Dilated RV, aneurysms and tricuspid regurgitation

Arrhythmogenic Right Ventricular Dysplasia Leftthickening and replacement of RV anterior wall by fatty tissue. Leftthickening and replacement of RV anterior wall by fatty tissue. Fat suppression (right) loss of signal in RV anterior wall, confirming Fat suppression (right) loss of signal in RV anterior wall, confirming fatty nature of these changes fatty nature of these changes

Restrictive Cardiomyopathy Cardiomyopathy

Restrictive Cardiomyopathy General

l

Least common

l

Normal ventricular size

l

Inability of the ventricles to fill properly

l

Thick LV wall and dilated LA

Restrictive Cardiomyopathy General

l

Mural thrombi occasionally

l

Resembles constrictive pericarditis

l

Biopsy may be needed

Restrictive Cardiomyopathy Causes

l

Associated with extracellular infiltration n

Amyloid

n

Sarcoid

n

Glycogen storage diseases

n

Mets

n

Radiation

Restrictive Cardiomyopathy Imaging Findings

l

Little cardiomegaly n

Walls are stiffened

l

CHF common

l

Echo: Normalsized LV n

Dilated left atrium

n

Pericardium not thickened

Amersham

Restrictive cardiomyopathy ECGgated spinecho image enlargement of both atria and normal size of ventricles with thickened walls

Hypertrophic Cardiomyopathy (HCM) (HCM)

Hypertrophic Cardiomyopathy Idiopathic Hypertrophic Subaortic Stenosis

l

Severe LV, and sometimes RV, hypertrophy n

l

No ventricular enlargement n

l l

Thickened IV septum

At least initially

Divided into primary and secondary Further divided into those with and without LVOT obstruction

Hypertrophic Cardiomyopathy Secondary, Nonobstructive

l

l

l

Nonobstructive hypertrophic cardiomyopathy (HCM) is common Seen with high blood pressure Concentric and uniform thickening of LV wall

Uncoiled Uncoiled aorta aorta

Prominent Prominent LV LV

Hypertensive cardiovascular disease

Hypertrophic Cardiomyopathy Primary l

Another cause of HCM is genetic n

l

Autosomal dominant with variable penetrance

Hypertrophy may be concentric or localized n

Asymmetric septal hypertrophy (ASH) s

n

IV septum is 1.5x thicker than posterior LV wall

Disproportionate upper septal thickening (DUST)

Hypertrophic Cardiomyopathy Primary

l l

May appear from birth to old age Common cause of sudden cardiac death in patients < 40 yrs old n

l

Most common cause of death amongst competitive athletes

About 1/3 have LVOT obstruction

Hypertrophic Cardiomyopathy Primary

l

Unlike DC with hypokinesis, HCM is hyperkinetic n

l

LV empties too completely

Atria attempt to compensate and enlarge n

Much larger atria than in DC

Hypertrophic Cardiomyopathy Obstructive (HOCM)

l

l

Hallmark: dynamic subvalvular aortic stenosis Anterior leaflet of mitral valve moves into LVOT on systole n

n

Systolic Anterior Motion (SAM) of mitral valve Occludes LVOT

Hypertrophic Cardiomyopathy Obstructive (HOCM)

l

Neither ASH nor SAM is specific for HOCM n

E.g. ASH also seen in Pulmonic Stenosis

n

SAM also seen in Transposition of Great Vessels

Hypertrophic Cardiomyopathy Imaging Findings l

Usually normalsized heart n

Left atrium may be enlarged 2° MR

l

CHF not common

l

Echo: LV hypertrophy n

l

ASH

Dynamic LVOT obstruction n

SAM

Amersham

Hypertrophic Cardiomyopathy ECGgated spinecho image in coronal plane severe symmetrical hypertrophy of LV

Asymmetric septal hypertrophy Asymmetric septal hypertrophy

Thickened Thickened apex apex

Amersham

©MillerRequisites ©MillerRequisites

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 ©ElliotCardiac Imaging ©ElliotCardiac Imaging


Dilated

Restrictive

Hypertrophic

LV Cavity Size

Increased

Normal

Normal


Mild

Variable

HOCM: mild to severe

Wall motion

Global hypokinesis

Normal

Hyperkinetic

Mural thrombi

Frequent

Occasional

None

Systolic Function

Decreased

Normal

Increased

Diastolic Function

Normal

Decreased

Normal

Ejection Fraction

Decreased

Normal

Normal

Endocarditis

Endocarditis General l

Triad: fever, murmur, septicemia

l

Causes n

Rheumatic fever

n

Infection

n

Nonbacterial thrombotic endocarditis s

LibmanSacks Endocarditis

s

Smaller vegetations than bacterial

Endocarditis General

l

l

Vegetations frequently produce regurgitation of affected valve Can embolize to lungs or aorta n

Septic emboli in lungs

n

May produce mycotic aneurysm of aorta


Rheumatic Vegetations Rheumatic Vegetations

Septic Emboli to Lungs Septic Emboli to Lungs

Pericardium Pericardium

Pericarditis Pericarditis

Constrictive Pericarditis l

l

Thickening of pericardium impeding diastolic filling Thickened pericardium may calcify n

l

50% on chest xrays

Rightsided failure due to impeded RV filling

Constrictive Pericarditis Causes

l

Viral pericarditis (most common)

l

Tuberculous pericarditis

l

Uremic pericarditis

l

Postcardiac surgery

Constrictive Pericarditis Calcification

l

l

About 50% with constrictive pericarditis calcify n

Eggshell – viral and uremic

n

Shaggy, amorphous in AV grooves – TB

Calcified pericardium doesn’t imply constriction

Constrictive Pericarditis Eggshell calcification as seen in viral or uremic pericarditis

Constrictive Pericarditis Thick calcification as seen in tuberculous pericarditis

Constrictive Pericarditis vs. Restrictive Cardiomyopathy l

May be impossible to distinguish two

l

Both have abnormal filling of the heart

l

CT best for calcified pericardium n

l

If calcified, not restrictive cardiomyopathy

Normal pericardium on both CT and MRI n

Excludes constrictive pericarditis

Constrictive Pericarditis vs. Restrictive Cardiomyopathy


Restrictive Cardiomyopathy

Heart size

Normal

Normal

Pericardial Calcification

Present

Absent

Right Atrial Border

Straight

Convex

Right Atrial Wall Thickness

Increased

Normal

Congenital Defect in Congenital Defect in the Pericardium the Pericardium

Congenital Pericardial Defect Embryogenesis

l

l

Premature atrophy of left duct of Cuvier (cardinal vein) leads to Failure of nourishment of left pleuro pericardial membrane which leads to failure of pericardium to develop

Congenital Pericardial Defect General

l

Male:female ratio of 3:1

l

May be detected at any age n

Most common in low 20’s

Congenital Pericardial Defect Location Foraminal defect on left side

35%

Complete absence of left side gives levoposition of heart

35%

l

Diaphragmatic surface

17%

l

Total bilateral absence

9%

l

Right sided

4%

l

l

Congenital Pericardial Defect Associations

l

Bronchogenic cysts

l

VSD, PDA, mitral stenosis

l


l

Sequestration

Congenital Pericardial Defect Clinical l

Mostly asymptomatic

l

May have: n

Tachycardia

n

Palpitations

n

Right bundle block

n

Positional discomfort lying on left side

n

Chest pain

Congenital Pericardial Defect Xray Findings l

l l

l

Focal bulge in area of main pulmonary artery Sharply marginated Lung may interpose between heartleft hemidiaphragm Increased distance between sternum and heart 2° absence of sternopericardial ligament

Congenital Pericardial Defect Xray FindingsContinued

l

l

Levoposition of heart Pneumopericardium following pneumothorax

Congenital Defect in the Pericardium

Congenital Pericardial Defect Treatment

l

l

Since herniation and strangulation of left atrial appendage or herniation of LA/LV may occur Foraminal defect requires surgery

The End To start over from beginning, click here

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LearningRadiology - Heterotaxy Syndromes, Cardiac Malpositions, Sinus of Valsalva Aneurysm, Pericardial Defect

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Miscellaneous Cardiac Diseases In Slide Show mode, to advance slides, press spacebar or click left mouse button

Sinus Sinus of of Valsalva Valsalva Aneurysm Aneurysm


Types

z

Congenital

z

Inherited

z

Acquired

Sinus of Valsalva Aneurysm Congenital

z

Usual type

z

Involves a single cusp

z

Most often arise from R coronary sinus

Sinus of Valsalva Aneurysm Inherited

z

Associated with Marfan’s Disease

z

All cusps involved

z

Produce aortic regurgitation

Sinus of Valsalva Aneurysm Acquired

z

Usually 2˚ to endocarditis of aortic valve

z

Other causes Syphilis Atherosclerosis Dissecting Marfan's

aneurysm

Sinus of Valsalva Aneurysm X-ray Findings

z

Since aortic root is intracardiac, usual aneurysm is not visible

z

Rarely, a large aneurysm of L aortic sinus « bulge L upper heart border in region of LA appendage

Sinus of Valsalva Aneurysm

Sinus of Valsalva Aneurysm Other X-ray Findings

z

Rarely, a large aneurysm of the R aortic sinus « bulge on R heart border

z

Usually the aneurysm dilates the aortic ring « AI

Aneurysm of Sinus of Valsalva and Proximal Ascending Aorta = annuloaortic ectasia

Ruptured Ruptured Sinus Sinus of of Valsalva Valsalva Aneurysm Aneurysm

Ruptured Sinus of Valsalva Aneurysm Congenital vs. Acquired

z

Congenital forms (usually R sided) always produce an intracardiac fistula Most

congenital aneurysms rupture during third or fourth decade of life

z

Acquired forms can produce either intra- or extracardiac fistulae

Ruptured Sinus of Valsalva Aneurysm General z

May rupture « aortic-cardiac fistula L

z

« R shunt usually

Most ruptures involve R coronary sinus Into

z

R ventricle

Posterior (non-coronary) aortic sinus ruptures occasionally Into

R atrium

Ruptured Sinus of Valsalva Aneurysm General

z

Rupture of aneurysms of L sinus are very rare May

rupture into the pericardial space

Ruptured Sinus of Valsalva Aneurysm Clinical

z

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

z

Acute CHF

z

Followed by L « R shunt

z

With rupture of L sinus, LA may suddenly enlarge

Two cases of rupture of right coronary sinus into RV

Congenital Congenital Defect Defect in in the the Pericardium Pericardium

Congenital Pericardial Defect Embryogenesis

z

Premature atrophy of left duct of Cuvier (cardinal vein)

z

Failure of nourishment of left pleuropericardial membrane « failure of pericardium to develop

Congenital Pericardial Defect General

z

Male:female ratio of 3:1

z

May be detected at any age Most

common in low 20’s

Congenital Pericardial Defect Location

Foraminal defect on left side z Complete absence of left side gives levoposition of heart z Diaphragmatic surface z Total bilateral absence z Right sided z

35% 35% 17% 9% 4%

Congenital Pericardial Defect Associations

z

Bronchogenic cysts

z

VSD, PDA, mitral stenosis

z


z

Sequestration

Congenital Pericardial Defect Clinical

Mostly asymptomatic z May have: z

Tachycardia Palpitations Right

bundle block Positional discomfort lying on left side Chest pain

Congenital Pericardial Defect X-ray Findings z

Focal bulge in area of main pulmonary artery

z

Sharply marginated

z

Lung may interpose between heart-left hemidiaphragm

z

Increased distance between sternum and heart 2° absence of sternopericardial ligament

Congenital Pericardial Defect X-ray Findings-Continued

z

Levoposition of heart

z

Pneumopericardium following pneumothorax


Congenital Pericardial Defect Treatment

z

Since herniation and strangulation of left atrial appendage or herniation of LA/LV may occur

z

Foraminal defect requires surgery

Cardiac Cardiac Malpositions Malpositions Heterotaxy Heterotaxy Syndromes Syndromes

Trilobed and Bilobed Lungs

Trilobed lung

Bilobed lung

Liver Spleen

Naming Rules Since anatomic side (i.e. “left” or “right”) in complex lesions is frequently reversed or indeterminate z Naming conventions for z

Atria AV

valves Ventricles Ventricular outflow tracts

The Rules How the atria are named z

Anatomic right atrium is on side of trilobed lung and liver Shape Same

z

of atrial appendage-broad and pyramidal

side as IVC

Anatomic left atrium is on side of bilobed lung and spleen Shape Same

of atrial appendage-thin c narrow neck

side as aortic arch

The Rules How the ventricles are named z

Anatomic right ventricle is trabeculated ventricle Coarse Has

z

in both systole and diastole

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

z

Tricuspid valve belongs to anatomic right ventricle Not

z

right atrium

Mitral valve belongs to anatomic left ventricle Not

left atrium

AV Connections Concordance z

Ventricles are concordant to the atria When

R atrium connects to R ventricle L atrium connects to L ventricle z

Ventricles are discordant to the atria When

R atrium connects to L ventricle When L atrium connects to R ventricle z

With atrial isomerism, AV connections are ambiguous

The Rules Aortic and pulmonic valves z

Pulmonic valve is part of pulmonary artery Not

z

Aortic valve is part of aorta Not

z

anatomic right ventricle 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

Pulmonic infundibulum belongs to anatomic RV

Anatomic L atrium is on side of bilobed lung-same side as Ao arch

Mitral valve belongs to anatomic LV

Aortic valve belongs to aorta

Pulmonic valve belongs to pulmonary artery Anatomic R ventricle is trabeculated

Anatomic L ventricle is smooth

Situs Definitions

z

Describes position of asymmetric organs in body

Lungs

Liver

Spleen

Stomach

Situs Solitus z 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 z

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 z

Lungs and abdomen are symmetric so right and left sides can’t 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 z


Since, spleen is usually on left side

No spleen

z

Asplenia syndrome



Many spleens

Polysplenia syndrome

Situs Ambiguous

Cardiac Positions z Position

z

of cardiac apex

Levocardia

on the left

Dextrocardia

on the right

Mesocardia

in the midline

Cardiac malposition Anything other than situs solitus with levocardia

Cardiac Malpositions Types

Situs solitus with dextrocardia z Situs inversus with levocardia z Situs inversus with dextrocardia z

Situs Solitus with Dextrocardia

st e 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 Kartgener’s

Trilobed lung

S

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 z


Since, liver is usually on right side

No spleen

z

Asplenia syndrome



Multiple spleens

Polysplenia syndrome

Asplenia Bilateral Right-sidedness

z

Male

z

Cyanotic

z

High risk of infection

z

Severe cardiac abnormalities

Transposition

TAPVR

Polysplenia Bilateral left-sidedness

z

Female

z

Abnormalities are more benign

Azygous continuation of IVC

Bilateral superior vena cava

PAPVR

ASD

Situs Ambiguous-polysplenia


Approach to Cardiac Malpositions z

Which side is heart on

z

Which side is trilobed lung on

z

Which side is arch on

z

Which side is stomach bubble on

z

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



O




O

What’s left Q

Q

Left-to-right shunts O ASD O PDA Truncus arteriosus

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

What’s the DDX?

Cyanotic newborn


O

Tetralogy

O

Truncus-type IV

O

Tricuspid atresia*

O

Transposition*

O

Ebstein's

* Also appears on DDx of cyanosis with increased vascularity

What’s the diagnosis?

Ebstein’s Anomaly

What’s the DDX?

8 year-old cyanotic male


O

Truncus types I, II, III

O

TAPVR

O

Tricuspid atresia*

O

Transposition*

O

Single ventricle

* Also appears on DDx of cyanosis with decreased vascularity


TAPVR-Supracardiac type 1

What’s the DDX?

Acyanotic newborn


O

Viral myocarditis

O


O

Aberrant left coronary artery

O

Cystic medial necrosis

O

Diabetic mother


Viral myocarditis

What’s the DDX?

Acyanotic newborn

Causes of CHF In Newborn Impede Return of Flow to Left Heart O O O O O O







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

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

Ao

LPA

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)

Ebstein’s Anomaly

Korean Journal


Acyanotic adult



Arrow points to indentation representing area of coarctation with dilated aorta (or LSCA) above and post-stenotic dilatation below coarct

Convexity above aortic knob due to dilated LSCA or Aorta proximal to coarct

Ascending Ao may be dilated, normal or small

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


Hypoplastic Left Heart Syndrome 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

MPA LA LA

LA

LA

RV

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

LV

Ao

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



A

C

B

ReviewName the abnormalities. Are they the “good” or “bad” variety?

A

C Left Aortic Arch with Aberrant R SCA

B Right Aortic Arch with Aberrant Left Subclavian



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 ©Elliot-Cardiac Imaging Imaging

Thrombus in left atrial appendage

Dilated Cardiomyopathy

Amersham

End systole

End diastole Dilated Cardiomyopathy

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 Left-thickening and and replacement replacement of of RV RV anterior anterior wall wall by by fatty fatty tissue. tissue. Fat Fat suppression suppression (right) (right) -- loss loss of of signal signal in in RV RV anterior anterior wall, wall, confirming confirming fatty fatty nature nature of of these these changes 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 Asymmetric septal septal hypertrophy hypertrophy

Thickened Thickened apex apex

Amersham

©Miller-Requisites ©Miller-Requisites


Mitral Mitral Regurgitation Regurgitation From From SAM SAM

Marked Marked wall wall thickening thickening

Almost Almost complete complete emptying emptying of of LV LV ©Elliot-Cardiac ©Elliot-Cardiac Imaging Imaging



Cardiac Malpositions

Cardiac Malpositions Types

O

Situs solitus with dextrocardia

O

Situs inversus with levocardia

O

Situs inversus with dextrocardia

Rule of Thumb

O

If aortic arch/apex of heart are on opposite sides from stomach bubble, high incidence of CHD

Asplenia Bilateral Right-sidedness O

Male

O

Cyanotic

O

High risk of infection

O

Severe cardiac abnormalities Q

Transposition

Q

TAPVR

Polysplenia Bilateral left-sidedness

O

Female

O

Abnormalities are more benign Q

Azygous continuation of IVC

Q

Bilateral superior vena cava

Q

PAPVR

Q

ASD

Asplenia/Polysplenia

O

Asplenia – bad boy

O

Polysplenia – good girl


Click here for downloadable version of this chart http://www.learningradiology.com/notes/cardiacnotes/cardiacmalpositionspdf.pdf

Good Luck

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LearningRadiology - Congestive Heart Failure, CHF

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Congestive Congestive Heart Heart Failure Failure In Slide Show mode, to advance slides, press spacebar or click left mouse button

Congestive Heart Failure Causes of

O

Coronary artery disease

O

Hypertension

O

Cardiomyopathy

O

Valvular lesions Q

O

AS, MS

L to R shunts

Congestive Heart Failure Clinical

O

O

Usually from left heart failure Q

Shortness of breath

Q

Paroxysmal nocturnal dyspnea

Q

Orthopnea

Q

Cough

Right heart failure Q

Edema

Left Atrial Pressures Correlated With Pathologic Findings

Normal

5-10 mm Hg

Cephalization

10-15 mm

Kerley B Lines

15-20


20-25


> 25

Pulmonary Circulation Physiology

O O

O

O

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

Pulmonary Interstitial Edema X-ray Findings

O


O


O



O

Kerley B lines


Pleural effusions


Kerley B Lines O

B=distended interlobular septa

O

Location and appearance Q

Bases

Q

1-2 cm long

Q

Horizontal in direction

Q

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 O

A=connective tissue near bronchoarterial bundle distends Q

O

Location and appearance O

Near hilum

O

Run obliquely

O

Longer than B lines

C=reticular network of lines Q

C Lines probably don’t exist

Kerley A and C Lines form a pattern of interlacing lines in the lung

Peribronchial Cuffing

O

O O

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 O

Fluid collects in the subpleural space Q

O

O

Between visceral pleura and lung parenchyma

Normal fissure is thickness of a sharpened pencil line Fluid may collect in any fissure Q

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

O

Laminar effusions collect beneath visceral pleura Q

Q

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

O

O

If hydrostatic pressure >10 mm Hg, fluid leaks in to interstitium of lung Compresses lower lobe vessels first Q

O

O

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.


Normal

5-10 mm Hg

Cephalization

10-15 mm

Kerley B Lines

15-20


20-25


> 25

Pulmonary Edema Types

O

Cardiogenic

O

Neurogenic

O

Increased capillary permeability

Congestive Heart Failure X-ray patterns

O

Interstitial

O

Alveolar

Congestive Heart Failure Pulmonary interstitial edema

O


O


O



O

Kerley B lines


Pleural effusions

Congestive Heart Failure Pulmonary alveolar edema

O

Acinar shadow

O

Outer third of lung frequently spared Q

O

Bat-wing or butterfly configuration

Lower lung zones more affected than upper



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

O O

Generally clears in 3 days or less Resolution usually begins peripherally and moves centrally

Differential Diagnosis Kerley B lines and Peribronchial cuffing

O

Cardiac

30%

O

Renal

30%

O

ARDS

None

Differential Diagnosis Distribution of Pulmonary Edema

O

Cardiac

Even 90%

O

Renal

Central 70%

O

ARDS

Peripheral in 45% Even in 35%

Differential Diagnosis Air Bronchograms

O

Cardiac

20%

O

Renal

20%

O

ARDS

70%

Differential Diagnosis Pleural Effusions

O

Cardiac

40%

O

Renal

30%

O

ARDS

10%


Normal

5-10 mm Hg

Cephalization

10-15 mm

Kerley B Lines

15-20


20-25


> 25


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Allergic Bronchopulmonary Aspergillosis ABPA

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LearningRadiology - Hypogenetic Lung Syndrome

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Actinomycosis

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LearningRadiology - Radiology in the Intensive Care Unit

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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


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 - Hodgkin’s Disease of the Lungs - Lymphoma

http://www.learningradiology.com/lectures/chestlectures/hodgkinsppt_files/frame.htm04/09/2006 1:46:48

LearningRadiology - Aortic Dissection

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LearningRadiology- Metastases to Lung

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http://www.learningradiology.com/lectures/chestlectures/ardrsppt_files/frame.htm (1 de 2)04/09/2006 1:47:35


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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

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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

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LearningRadiology - Collagen Vascular Diseases

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LearningRadiology - Sarcoid of the Lungs

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LearningRadiology- Congenital Lobar Emphysema

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LearningRadiology - Chronic Obstructive Pulmonary Disease COPD

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LearningRadiology - Sequestration of the Lung

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LearningRadiology - Pulmonary Malformations

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LearningRadiology - The Solitary Pulmonary Nodule

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LearningRadiology.com - Diseases of The Diaphragm

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LearningRadiology - Swyer James Syndrome

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LearningRadiology - Pulmonary Tuberculosis

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LearningRadiology - Dressler’s Syndrome Postpericardiectomy-Postmyocardial Infarction Syndrome

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LearningRadiology - Teratomas, Seminomas and Choriocarcinomas

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LearningRadiology - Drug-Induced Lung Disease

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LearningRadiology - Pulmonary Embolic Disease

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LearningRadiology - Thymoma

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LearningRadiology - Pulmonary Infiltrates With Eosinophilia

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LearningRadiology - Pulmonary Infiltrates With Eosinophilia

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LearningRadiology - Anterior Mediastinal Masses- Thyroid mass

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LearningRadiology - Goodpasture’s Syndrome Idiopathic Pulmonary Hemorrhage

http://www.learningradiology.com/lectures/chestlectures/goodpasturesppt_files/frame.htm04/09/2006 1:56:22

LearningRadiology- Chest Trauma

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LearningRadiology - Hamartomas of the Lung

http://www.learningradiology.com/lectures/chestlectures/hamartomasppt_files/frame.htm04/09/2006 1:56:50

Wegener’s Granulomatosis

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Histiocytosis X

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An Approach to Diffuse Small Bowel Disease

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LearningRadiology - Pulmonary Cavities, Differential Diagnosis, Lung

Pictorial Differential Diagnosis 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

Pictorial Differential Diagnosis Click on image to enlarge; click on text for more information


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


Avascular Necrosis Left Hip

Charcot Hip


Intertrochanteric Fracture

Subcapital Fracture

Acetabular Protrusio-Right-Paget's

Slipped Epiphysis-Left Hip

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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

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Benign neoplasm 80% found in cerebellum ❍ 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 ❍ M > F Relationship to von Hippel-Lindau disease ❍ 20% occur in patients with von Hippel-Lindau disease (multiple lesions). ❍ 35-60% of von Hippel-Lindau disease patients have hemangioblastomas ❍ von Hippel-Lindau disease consists of ■ Retinal, spinal, cerebellar and medullary hemangioblastomas ■ Renal cysts and carcinomas ■ Pancreatic cysts ■ Pheochromocytomas ■ Papillary Cystadenoma of the epididymis Clinical findings ❍ Headache ❍ Ataxia ❍ Nausea ❍ Vomiting ❍ Vertigo ❍ Polycythemia caused by increased erythropoietin found in 40%. ❍ Spinal lesions may present with subarachnoid hemorrhage Findings on CT and MRI: ❍ Cystic lesion in the cerebellum with an avidly enhancing mural nodule (75%) ❍ Purely solid enhancing lesion (10%) ❍ 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) ●

Findings on angiography: ❍ Vascular nodule within an avascular mass



Serpentine vessels Treated with surgical removal of solid nodule ❍ 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. ❍

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New Page 1

http://www.learningradiology.com/lectures/facultylectures/arthritisswfpage.htm (1 de 2)04/09/2006 2:02:21

New Page 1

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Stroke Evaluation

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Basic Chest X-Ray Interpretation

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CT Angiography

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Evaluation of Pulmonary Nodules

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Back Pain Imaging

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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

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Pulmonary Thromboembolism Imaging

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Slide 1

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LearningRadiology.com-Appendicitis,Diagnosis,CT

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LearningRadiology.com-CT of Blunt Abdominal Trauma,renal,hepatic,liver,lacreation,splenic,spleen,rupturebladder,tear

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LearningRadiology.com-CT of Acute Aortic Non-traumatic Disease,Dissecting,Aneurysm,Hematoma,Itramural

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LearningRadiology.com-Imaging in PID, US and CT,pelvic,inflammatory,disease,PID,ultrasound

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LearningRadiology.com-Acute Abdominal Pain and CT

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LearningRadiology.com-Carotid Sonography Avoidable and Unavoidable Errors

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LearningRadiology-Retroperitoneal Spaces Anatomy and Pathology of the Urinary Tract

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Multi-slice CT: Principles and Perspective

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Ectopic Pregnancy

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learningRadiology-Ultrasound of Renal Transplantation,US,kidney,transplant,reject,rejection

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http://www.learningradiology.com/lectures/facultylectures/Stone%20Search%20Lecture%202004-MH.htm (1 de 2)04/09/2006 2:07:45


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LearningRadiology.com-Abdominal Pain

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LearningRadiology.com-Women's Imaging,mammography

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LearningRadiology.com-CT Evaulation of the GI Tract

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LearningRadiology.com-MRI of Abdomen

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LearningRadiology.com-Evaulation of Jaundice

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LearningRadiology.com-Skeletal Trauma

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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

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LearningRadiology.com-Acute Abdominal Emergencies

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http://www.learningradiology.com/lectures/facultylectures/herniaspageswf.htm

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LearningRadiology.com-Basics of Intravenous Urography,IVP,IVU

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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


Giant cell tumor

Scleroderma

Pulmonary sling

PCP

426 X 480 24 KB

404 X 480 29 KB

380 X 480 20 KB

744 X 582 33 KB

Dematomyocitis

Dermoid

Dermoid

Diverticulitis

500 X 480 26 KB

320 X 226 17 KB

320 X 218 17 KB

360 X 480 21 KB

Double Aortic Arch

Ebsteins anomaly

Fahr's disease

Fahr's disease

360 X 480 17 KB

594 X 480 27 KB

352 X 480 29 KB

376 X 480 32 KB


Case of the Week

Fahr's disease

Fibrous dysplasia

Gout

Hamartoma

360 X 480 27 KB

276 X 480 12 KB

214 X 240 6 KB

550 X 480 13 KB

Hamartoma

Hamartoma

Hamartoma

Lipoid pneumonia

640 X 456 33 KB

640 X 418 29 KB

640 X 418 29 KB

318 X 240 14 KB


Case of the Week


Esophageal varices

Deep sulcus sign

Intussusception

800 X 585 53 KB

600 X 640 31 KB

437 X 602 46 KB




760 X 501 74 KB

640 X 398 48 KB

310 X 400 27 KB


Penetrating aortic ulcer 610 X 480 37 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

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Ascariasis

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Ascariasis

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ASD

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AVN

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Chondrocalcinosis

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Crohn's Disease

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Radiation fibrosis

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Charcot joint

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Emphysematous gastritis

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Ruptured AAA

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Pulmonic stenosis






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A. Lymphoma B. Multiple mets C. Infantile polycystic disease D. Adult polycystic disease


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A. Lipoma B. Dermoid cyst C. Follicular ovarian cyst D. Pelvic lipomatosis


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LearningRadiology.com - Renal Papillary Necrosis,renal,papillary,necrosis,CT urogram


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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. Atrial myxoma B. Dissection of pulmonary arteries C. Pulmonary embolism D. Lymphoma


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A. Pneumonia B. Foreign body ingestion C. Radiation pneumonitis D. Loeffler's syndrome


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A. CHF B. Re-expansion pulmonary edema C. Near-drowning D. Pulmonary contusion


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A. Bronchogenic carcinoma B. Round pneumonia C. Rounded atelectasis D. Mesothelioma




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A. Lymphoma B. Cryptococossis C. AVM D. Round Pneumonia


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A. Lymphoma B. Sarcoid C. TB D. Bronchogenic carcinoma



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A. Metastatic pancreatic ca B. Infected bulla C. Septic emboli D. Silicosis




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173

A. Pneumonia B. Aspiration C. Sequestration D. Atelectasis




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A. Posterior dislocation B. Anterior dislocation C. AC separation D. Clavicular fracture



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A. DISH B. DDD C. Ankylosing spondylitis D. Reiter's syndrome




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A. Clay Shoveler's Fracture B. Psoriasis C. Rheumatoid arthritis D. Hangman's fracture



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A. Osteo-sarcoma B. Myositis ossificans progressiva C. Calcinosis universalis D. Hyperparathyroidism



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A. Rheumatoid arthritis B. Charcot arthropathy C. Gout D. Tuberculosis


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A. Rheumatoid arthritis B. Reiter's syndrome C. CPPD D. Gout



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A. Renal cell carcinoma B. Multiple myeloma C. Unicameral bone cyst D. Fibrous dysplasia



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A. Monteggia fracture B. Nightstick fracture C. Galeazzi fracture D. Spimoni fracture




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A. Barton's fx B. Bennett's fx C. Gamekeeper's Thumb D. Rolando's fx


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A. Aneurysmal bone cyst B. Giant Cell Tumor C. Chondroblastoma D. Unicameral bone cyst



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A. Rheumatoid arthritis B. Tuberculous arthritis C. Sarcoid D. Gout


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A. Gout B. Osteoarthritis C. Septic arthritis D. Hemophilia


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A. Gout B. Pyle's disease C. Multiple hereditary exostoses D. Prior trauma


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A. Bilateral synoviomas B. Pigmented villonodular synovitis C. Housemaid's knee D. Accessory ossicles




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121

A. Osteomyelitis B. Chronic venous insufficiency C. Hypertrophic osteoarthropathy D. Fluorosis


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175

A. Frieberg's Infraction B. Kohler's Disease C. Severs Disease D. Kienbock's Disease



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A. Rickets B. Lead poisoning C. Leukemia D. Normal



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A. Salter III fracture B. Congenital hip dysplasia C. Legg-CalvePerthe's Disease D. Rheumatoid arthritis


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A. Lipoma B. Absent patella C. Lipohemarthrosis D. Rheumatoid arthritis




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A. Renal Cell Carcinoma B. Multiple Myeloma C. Degenerative Disc Disease D. Osteoblastic Metastases


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A. Sturge Weber syndrome B. Neurofibromatosis C. Ehlers-Danlos Syndrome D. Joubert Syndrome


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A. Aneurysmal bone cyst B. Chondrosarcoma C. Nonossifying fibroma D. Solitary plasmacytoma


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A. Diffuse Idiopathic Skeletal Hyperostosis B. Ochronosis C. Degenerative disc disease D. Ankylosing spondylitis



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A. Osteoarthritis B. Osteochondritis dissecans C. Osteomyelitis D. Osteoporosis


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A. Rheumatoid arthritis B. Fracture C. Osteomyelitis D. Pseudogout


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A. Mets to right pelvis B. Paget's with sarcoma of bone C. Lymphoma D. Osteoporosis circumscripta


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A. Multiple myeloma B. Osteopetrosis C. Paget's Disease D. Cushing's syndrome


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A. Lunate dislocation B. Perilunate dislocation C. Triquetrial fx D. Scapho-lunate disassociation



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105

A. Acromioclavicular separation B. Posterior dislocation C. Anterior dislocation D. Winged scapula



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83

A. Alveolar proteinosis B. Colon metastases C. Loeffler's syndrome D. Silicosis



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180

A. Pulmonary Edema B. Anterior Dislocation C. Subcutaneous Emphysema D. Pneumonia



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53

A. a-1 Antitrysin deficiency B. Scleroderma C. TB D. Asbestosis


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80

A. Thymoma B. Substernal thyroid C. Lymphoma D. Teratoma


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9

A. Thymoma B. Substernal thyroid C. Lymphoma D. Bronchogenic carcinoma


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23

A. Healed milary TB B. Mitral hemosiderosis C. Varicella pneumonia D. Staph pneumonia

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60

A. Gout B. TB C. Psoriasis D. Rheumatoid arthritis


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46

A. Osteoarthritis B. Hemophilia C. Pigmented villonodular synovitis D. Avascular necrosis



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161

A. Psoriatic arthritis B. TB C. Gout D. Rheumatoid arthritis




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88

A. Child abuse B. Rickets C. Scurvy D. Ochronosis




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181

A. Child abuse B. Rickets C. Scurvy D. Sickle cell anemia




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A. Bennett's fx B. Barton's fx C. Rolando's fx D. Colles' fx




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50

A. Paget's Disease B. Mets to spine C. Renal osteodystrophy D. Degenerative disc disease



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4

A. Osteopathia striata B. Ollier's syndrome C. Sickle cell disease D. Giant cell tumors


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103

A. Sprung pelvis B. Avascular necrosis of Right femoral head C. Congenital hip dysplasia D. Slipped capital femoral epiphysis

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172

A. Multiple myeloma B. Chronic osteomyelitis C. Stress fracture D. Osteosarcoma

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114

A. Pigmented villonodular synovitis B. Synovial chondromatosis C. Gout D. Synovioma





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22

A. Loculated pleural effusion B. Tumoral calcinosis C. Pillow artifact D. Cystic hygroma


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111

A. Mallet finger B. Foreign body C. Volar plate fracture D. Salter II fracture



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100

A. Teratoma B. Achalasia C. Tuberculosis D. Carcinoma of esophagus


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12

A. Sprue B. Whipple's disease C. Malrotation D. Nematode infestation



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158

A. Menetrier's disease B. Carcinoma of the stomach C. Amebic infestation D. Bezoar


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107

A. Lipoma of diaphragm B. Bochdalek hernia C. Lipoid pneumonia D. Renal angiomyolipoma


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39

A. Ruptured aorta B. TB C. Ruptured Esophagus D. Asthma


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45

A. Hepatoma B. Budd-Chiari Syndrome C. Laceration D. Hemangioma

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84

A. Herpes esophagitis B. Varices C. Caustic esophagitis D. Candida esophagitis



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176

A. Diverticulitis B. Carcinoma of the colon C. Crohn's Disease D. Ischemic colitis



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7

A. Ca of the esophagus B. Caustic esophagitis C. Reflux esophagitis D. Esophageal varices


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162

A. Meckel's diverticulum B. Hamartoma C. Carcinoma D. Lipoma




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152

A. Sentinel loop B. Small bowel obstruction C. Sigmoid volvulus D. Cecal volvulus




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27

A. Sprue B. Scleroderma C. TB D. Crohn's disease



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A. Appendicitis B. Crohn's Disease C. Carcinoid tumor D. Diverticulitis



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131

A. Hepatic abscess B. Renal cyst C. Emphysematous cholecystitis D. Teratoma




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117

A. Cholecystitis B. Diverticulitis C. Appendicitis D. Emphysematous pancreatitis




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137

A. Pelvic rib B. Esophageal atresia C. Duodenal atresia D. Meconium aspiration syndrome




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153

A. Epiglottitis B. Impacted chicken bone C. Laryngeal carcinoma D. Tonsillitis



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91

A. Hiatal hernia B. Varicoid carcinoma C. Varices D. Chronic esophagitis


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139

A. Esophageal polyp B. Esophageal web C. Cricopharyngeal achalasia D. Carcinoma of esophagus



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124

A. Pancreatitis B. Gallstones C. Adrenal adenoma D. Renal vein thrombosis




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150

A. Appendicitis B. Pancreatitis C. Renal cell carcinoma D. Gallstone ileus




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119

A. Glioma B. AVM C. Infarct D. Meningioma




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145

A. Choroid plexus cysts B. Pinealomas C. Meningiomas D. Neurofibromas




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140

A. Degenerative disc disease B. Compression fracture C. Metastatic disease D. Discitis


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18

A. Wilson's Disease B. Hemophilia C. Fahr's Disease D. Addison's Disease

LearningRadiology.com is a noncommercial site aimed primarily at medical students and radiology residents-in-training, containing PowerPoint lectures, 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. Case submitted by Andrew Hwang, M.D.

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110

A. Glioblastoma B. Hemangioblastoma C. Juvenile pilocytic astrocytoma D. Epidermoid



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166

A. Pituitary adenoma B. Leptomeningeal cyst C. Metastatic disease D. Paget's Disease


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123

A. Hangman's fracture B. Unilateral locked facet C. Bilateral locked facets D. Perched facet



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LearningRadiology.com - Sialolithiasis, salivary gland, stone, Wharton's duct


96

A. Stone in Stensen's Duct B. Stone in Santorini's Duct C. Lymphoma D. Stone in Wharton's Duct


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5

A. Right parietal mass B. Acute subdural hematoma C. Chronic intraparenchymal hemorrhage D. Subacute subdural hematoma


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154

A. Cataracts B. Optic glioma C. Thyroid ophthalmopathy D. Rhabdomyoma




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168

A. Multiple meningiomas B. Cysticercosis C. Toxoplasmosis D. Sarcoid




37 yo male HIV positive Submitted by Marion Brody, MD



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34

A. Pneumatosis cystoides B. Bezoar C. Ascariasis D. Gastric emphysema



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125

A. Pancreatitis B. Pancreatic carcinoma C. Gastric volvulus D. Gastric atony



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169

A. Hepatoma B. Adenoma C. Giant Hemangioma D. Fatty infiltration



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93

A. Acute appendicitis B. Ovarian cyst C. Intussusception D. Ruptured bladder


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79

A. Subcapsular hematoma B. Hepatic Contusion C. Liver laceration D. Hepatocellular carcinoma


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75

A. Renal cell ca B. Crohn's Disease C. Lymphoma D. Jejunal diverticulum


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113

A. Pancreatitis B. Constipation C. Mesenteric Ischemia D. Gallstone ileus




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LearningRadiology.com- Cse of the Week 54


54

A. Pyloric stenosis B. SMA syndrome C. Midgut volvulus D. Esophageal reflux


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73

A. Ca of cecum B. Mucocele C. Appendicitis D. Crohn's disease


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156

A. Duodenal atresia B. Necrotizing enterocolitis C. Pyloric stenosis D. Ascites



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126

A. Hangman's fracture B. Perforated pharynx C. Retropharyngeal hematoma D. Epiglottitis



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106

A. Spina bifida B. Sigmoid volvulus C. Gastric outlet obstruction D. Free air



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85

A. TB of kidney B. Psoas abscess C. Porcelain gallbladder D. Adrenal hemorrhage


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148

A. Prior laparotomy B. Botox injections C. Prior laminectomy D. Hernia



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52

A. Sprue B. Scleroderma C. Stomach ca D. Amyloid



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87

A. Cecal volvulus B. Toxic megacolon C. Cathartic colon D. Sigmoid volvulus




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41

A. Whipple's Disease B. Radiation enteritis C. Lymphoma D. Sprue


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147

A. Acute cholecystitis B. SMA Syndrome C. Midgut volvulus D. Hepatic TB




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15

A. HemoChromatosis B. Amiodarone toxicity C. Thorotrast D. Sickle cell disease


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171

A. Cathartic colon B. Ulcerative colitis C. Lymphoma D. Ischemic bowel disease





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MEMORANDUM To

Medical Records

From

Janet Birkmann Academic Coordinator x. 67378

Date

_______________________

Re

Medical Records Access for Medical Student or Intern

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:

.JeffStudent.common (note the period in front of Jeff...)

Password:

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/ http://www.learningradiology.com/studentpage/internetaccess.htm (1 de 2)04/09/2006 2:19:44

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/

http://www.learningradiology.com/studentpage/internetaccess.htm (2 de 2)04/09/2006 2:19:44

MEMORANDUM TO

:

Radiology Residents Medical Students

FROM

:

Janet L. Birkmann Academic Coordinator

DATE

:

July 1, 2004

RE

:

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. Christopher’s 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

Beeper in-house 3781; long range 215-363-5000 (pin 23781) [email protected] 215-456-7378 [email protected] 215-456-6200 x. 66161 x. 66918 x. 66911

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.

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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 patient’s 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 institution’s 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 else’s 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. Summerton’s mailbox at the front of the department.

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jlb 08/28/05

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

Date

_______________________

Re

Parking Access for Medical Student or Intern

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

TUESDAY

August 29 Physics-Nunno Course Content

WEDNESDAY

THURSDAY 31

30

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.

FRIDAY

September 1

2 Cardiac Radiology-Herring Cong. Heart Dzs 8 a.m. – 9 a.m.

[Staff Meeting]

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.

5

6

7

8

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

Board Examination Day

9

No Conferences

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.

LABOR DAY 12 Physics-Nunno Course Content

13

14

M&M Conference MSK Conference-Kricun 7 a.m. – 9 a.m. Course Content 8 a.m. – 9 a.m. Chest

15

16

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 Physics-Nunno Course Content

20

Institutional Curriculum 7am

22

21

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

GU Conference-Horrow/Hoang CT/US Conference-Horrow Interesting Cases Noon – 1 p.m. Course Content Noon – 1 p.m.

No Conference

Rad/Path Conference Neuroradiology-Garfinkle Noon – 1 p.m. Griffith/Wable Noon – 1 p.m. Course Content

Hospital Outing All Conferences Are held in the Isard Amphitheater Unless Otherwise Noted

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

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 4026 3072 3875 2674 3947 4484 4212 24025 2179 4265 2520 215-265-1601 4339 3468 3465 3681 3741 3781 3655 3795

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

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

Office x. 65191

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Radiology Department Directory August 25, 2005

Name/Place

Beeper

Phone

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

5401 4210

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

Chief Resident’s 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

215-961-3176

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

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

Beeper No.

Phone Ext. x. 6279 x. 6278 x. 6277 215-951-8060 215-951-8767 215-842-1100

3675 2629

x. 3323 x. 7306

2541 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

Beeper No.

Phone Ext.

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

x. 81-6440 x. 81-6042 x. 81-6371 x. 81-6078

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

4530

4129

3570 2180

x. 6274 x. 6743 x. 8169 x. 7274 x. 2375 x. 7260 x. 6885

4103 x. 5893 x. 7902 5443 2541 5442 5446 3635 3281

4013

5442 5401 4833

-4-

x. 6120 x. 6433

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

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Name/Place

Beeper No.

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

4072, 4073

3680 3058 4073 5008

Phone Ext.

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

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Guidelines

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 Einstein’s 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 else’s 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

http://www.learningradiology.com/studentpage/cowguidelines.htm04/09/2006 2:19:57

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

Scoring Range Frequency

Percent

Great - A

[5, 4]

6012

59.5

Okay - B

[3, 2]

2856

28.3

Try again - C

[1, 0]

1234

12.2

[, ]

553

5.5

[, ]

553

5.5

Display the Top 8 Name

Total Score

Percent Date

goli

5

100

Sunday September 3, 2006

goli

5

100


KK

5

100


a. alrajab 5

100


fk

5

100

Saturday September 2, 2006

miao

5

100


k

5

100


http://www.learningradiology.com/cgi-bin/quickquiz/results.cgi?param1=quiz0004&quizno=0004 (1 de 2)04/09/2006 2:19:58


asdf

5

100


[Do the Quiz] [Home]




Chest Quiz 101 Whiteout! General Statistics Total Participants 7378 Average Score 2.97



Percent

Great - A

[5, 4]

3142

42.6

Okay - B

[3, 2]

2759

37.4

Try again - C

[1, 0]

1477

20.0

[, ]

720

9.8

[, ]

720

9.8


Total Score

Percent Date

sammy

5

100


goli

5

100


a.alrajab

5

100


dr amisha 5

100


bk

5

100

Friday September 1, 2006

kong

5

100

Thursday August 31, 2006

dawo

5

100


RUEDY

5

100




[Do the Quiz] [Home] | Home | Lectures | Notes | Images | Flashcards | Case of the Week Archives | | Bone | Cardiac | Chest | GI | Miscellaneous | Med Students | Most Common Lists | Quizzes | Copyright © 2003 LearningRadiology.com



Chest Quiz 102 Tough Starts General Statistics Total Participants 3937 Average Score 3.39



Percent

Great - A

[5, 4]

2035

51.7

Okay - B

[3, 2]

1223

31.1

Try again - C

[1, 0]

679

17.2

[, ]

339

8.6


Total Score

Percent Date

a. alrajab 5

100


rsm

5

100


sa

5

100


sa

5

100


usha

5

100


kong

5

100


knottie

5

100


patima

5

100







Abdomen Quiz 202 I'll Drink to That General Statistics Total Participants 4654 Average Score 3.32



Percent

Great - A

[5, 4]

2465

53.0

Okay - B

[3, 2]

1560

33.5

Try again - C

[1, 0]

629

13.5

[, ]

331

7.1

[, ]

331

7.1


Total Score

Percent Date

jeff garcia 5

100


jeff garcia 5

100


par

5

100


k

5

100

Wednesday August 30, 2006

hc

5

100


jackie

5

100


run

5

100




cc

5

100

Tuesday August 29, 2006




Abdomen Quiz 203 When the Bowel Breaks General Statistics Total Participants 3677 Average Score 3.21



Percent

Great - A

[5, 4]

1810

49.2

Okay - B

[3, 2]

1139

31.0

Try again - C

[1, 0]

728

19.8

[, ]

377

10.3


Total Score

Percent Date

goli

5

100


carlos alberto régis toscano 5

100


mehmet

5

100


m

5

100


jeff garcia

5

100


par

5

100


oatta

5

100


k

5

100







Abdomen Quiz 204 Abdominal Calcifications General Statistics Total Participants 3972 Average Score 4.01



Percent

Great - A

[5, 4]

3065

77.2

Okay - B

[3, 2]

623

15.7

Try again - C

[1, 0]

284

7.2

[, ]

205

5.2

[, ]

205

5.2


Total Score

Percent Date

ana karina

5

100


goli

5

100


JJ

5

100


a. alrajab

5

100


amarnath

5

100


mehmet

5

100


RadiationGirl 5

100




m

5

100





Abdomen Quiz 205 Air, Air Everywhere! General Statistics Total Participants 4877 Average Score 3.35



Percent

Great - A

[5, 4]

2525

51.8

Okay - B

[3, 2]

1747

35.8

Try again - C

[1, 0]

605

12.4

[, ]

261

5.4


Total Score

Percent Date

JKM

5

100


sajjsd

5

100


goli

5

100


KK

5

100


a. alrajab

5

100


Nowfree.tw 5

100


miao

5

100


wasim

5

100







MSK Quiz 302 Name That Fracture-1 General Statistics Total Participants 4505 Average Score 3.37



Percent

Great - A

[5, 4]

2245

49.8

Okay - B

[3, 2]

1424

31.6

Try again - C

[1, 0]

836

18.6

[, ]

353

7.8


Total Score

Percent Date

Jon Marti

5

100


sajjsd

5

100


goli

5

100


patrick

5

100


alex

5

100


mehmet

5

100


RadiationGirl 5

100




Tommy

5

100





MSK Quiz 303 Hot Joints! General Statistics Total Participants 3956 Average Score 3.40



Percent

Great - A

[5, 4]

2328

58.8

Okay - B

[3, 2]

1215

30.7

Try again - C

[1, 0]

413

10.4

[, ]

251

6.3

[, ]

249

6.3


Total Score

Percent Date

a. alrajab

5

100


john koutras 5

100


Ruedeekorn 5

100


rsm

5

100


kong

5

100


kitt

5

100


sameh

5

100


n

5

100

Tuesday August 29, 2006






MSK Quiz 305 My Aching Back General Statistics Total Participants 4333 Average Score 2.79



Percent

Great - A

[5, 4]

1501

34.6

Okay - B

[3, 2]

1617

37.3

Try again - C

[1, 0]

1215

28.0

[, ]

460

10.6


Total Score

Percent Date

goli

5

100


a. alrajab 5

100


amarnath 5

100


ruedy

5

100


patima

5

100


abhijai

5

100


shuna

5

100


hc

5

100







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Most Commons


1

A. Thymoma B. Oat cell carcinoma C. Right aortic arch D. Enlarged azygous vein

Click to enlarge LearningRadiology.com is a noncommercial site aimed primarily at medical students and radiology residents-in-training, containing PowerPoint lectures, 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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"Most Commons"







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http://www.learningradiology.com/archives/COW%20001-Right%20Arch/rightarchcorrectpage.htm


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Right Aortic Arches

Type I Mirror image right arch—will 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

http://www.learningradiology.com/archives/COW%20001-Right%20Arch/rightarchcorrectpage.htm (1 de 4)04/09/2006 2:20:22


• 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

10%

•Tricuspid atresia

5%

•VSD

2%

*apparent discrepancy here due to much higher incidence of TOF than Truncus

WH/







http://www.learningradiology.com/archives/COW%20002-Aspergilloma/aspergillomacorrectpage.htm


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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

Solid, round mass in thin-walled cavity

o

Usually in upper lobes

o

Moves with changes in positioning

o

Crescent-shaped airspace separates the fungus ball from the wall of cavity

o

Fungus ball may calcify

wh

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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

http://www.learningradiology.com/archives/COW%20003-N...omatosis%20myelogram/neurofibromatosispagecorrect.htm (1 de 5)04/09/2006 2:20:24


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Syringomyelia

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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

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Dural ectasia

●

Posterior scalloping of the vertebral bodies

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Dumbbell neurofibromas

●

Enlargement of a neural foramen

●

Erosion of a pedicle

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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 ●

Avascular necrosis may be caused by: ❍

❍

❍

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

Sickle-cell disease

■

Gaucher's Disease

■

Polycythemia

■

Caisson Disease

■

Pancreatitis

Diseases of the blood vessels (intima or wall) like: ■

Collagen-vascular disease vasculitis

■

Radiation-induced avascular necrosis (mediated by vasculitis)

Diseases outside of the blood vessel like: ■

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 ●

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.

http://www.learningradiology.com/archives/COW%20005-Subdural%20Hematoma/subduralcorrectpage.htm (1 de 4)04/09/2006 2:20:27


●

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.

http://www.learningradiology.com/archives/COW%20007-Lye%20stricture/causticesophagitiscorrectpage.htm (1 de 2)04/09/2006 2:20:37

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

http://www.learningradiology.com/archives/COW%20008-Gout%20toe/goutcorrectpage.htm (1 de 4)04/09/2006 2:20:38


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 Down’s 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.

http://www.learningradiology.com/archives/COW%20009-Thyroid%20goiter/thyroidgoitercorrectpage.htm (1 de 4)04/09/2006 2:20:39


• 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 ●

●

●

●

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 ● ● ●

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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http://www.learningradiology.com/caseofweek/caseoftheweekpix/Thorotrasweb.jpg04/09/2006 2:20:47

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 ● ● ● ●

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 ❍ ❍

Infection is through contaminated soil Involves GI tract of host twice First time as egg Migrates through lungs Adult travels up trachea ■

❍ ❍

■

●

Signs and Symptoms ❍ ❍ ❍

●

Returns to GI tract for maturation (2 months)

Colicky pain Hematemesis Eosinophilia

X-ray findings ❍ ❍

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 ■

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):

http://www.learningradiology.com/archives/COW%20012-Ascariasis/ascariscorrectpage.htm (1 de 4)04/09/2006 2:20:54


❍

●

Ball of worms

Complications ❍ ❍ ❍ ❍ ❍

Appendicitis Jaundice (if bile ducts are involved) Pneumonia Bowel perforation Mechanical obstruction









Return to Case

Calcinosis Universalis ● ● ● ● ●

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) ❍

Dermatomyositis ■

■

Damaged chondroitin sulfate, atrophy of muscles, followed by calcification of muscle and subcu tissue Ages 5-10 and again in 50s

More common in females ■ Linear and confluent calcifications in soft tissues of extremities ■ Acro-osteolysis ■ Chest-may have infiltrates associated Clinically ●

❍

Weakness of respiratory muscles ■ Erythematous rash of eyelids ■ Proximal muscle weakness ■ Associated with a high incidence of malignancies of GI tract, lung, ovary, breast, kidney May resemble myositis ossificans progressiva ■

●

❍

Myositis ossificans progressive (fibrodyplasia ossificans progressiva) ■

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 ●

■

http://www.learningradiology.com/archives/COW%20013-Calcinosis%20universalis/calcinosiscorrectpage.htm (1 de 4)04/09/2006 2:20:55

LearningRadiology - Calcinosis Universalis ■

Ossification of voluntary muscles







LearningRadiology - Fibrous Dysplasia


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Fibrous Dysplasia

● ● ● ●

● ● ●

● ● ●

●

●

Etiology unknown Most common 3-15 years Fundamental abnormality is replacement of medullary bone by fibrous tissue Clinically ❍ Deformities ■ Shepherd’s crook deformity of femur ❍ Bone pain Most commonly involved bones are pelvis, femora In widespread disease, the skull and jaw are almost always involved X-ray ❍ Endosteal scalloping ❍ Cortical thinning ❍ Ground-glass appearance ❍ May have matrix calcification Prone to fracture Growth of lesions usually stops when epiphyses close DDX: ❍ Brown tumor ❍ Unicameral bone cyst Albright’s Syndrome ❍ Polyostotic ❍ Sexual precocity ❍ Skin pigmentation ❍ Almost always in a female Polyostotic form is usually bilateral

http://www.learningradiology.com/archives/COW%20014-Fibrous%20dysplasia/fibrousdysplasiacorrect.htm (1 de 4)04/09/2006 2:20:56








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

http://www.learningradiology.com/archives/COW%20015-Thorotrast/thoratrastcorrect.htm (1 de 4)04/09/2006 2:20:57


• Long latency period (25 years)

WH/93







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LearningRadiology - TAPVR


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Total Anomalous Pulmonary Venous Return (TAPVR) Supracardiac Type

● ●

Must have ASD for survival All have anatomical L to R shunt at atrial level ❍

All have functional R to L shunt of oxygenated blood to right side of heart

Two Types ●

●

Partial (PAPVR) ●

Mild physiologic abnormality

●


Total (TAPVR) ●

Serious physiologic abnormalities

Partial Anomalous Pulmonary Venous Drainage (PAPVR) General ●

One of the four pulmonary veins may drain into right atrium

●

Mild or no physiologic consequence

●

Associated with ASD ●

Sinus venosus or ostium secundum types

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Total Anomalous Pulmonary Venous Drainage (TAPVR) ●

All have shunt through lungs to R side of heart

●

All must also have R to L shunt for survival ●


●

All are cyanotic

●

Identical oxygenation in all four chambers

●

Types

●

●

Supracardiac

●

Cardiac

●

Infracardiac

●

Mixed

Supracardiac Type—Type I ●

●

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 1—X-ray Findings

●

●

Snowman heart = dilated SVC+ left vertical vein

●

Shunt vasculature 2° increased return to right heart

●

Enlargement of right heart 2° volume overload

Cardiac Type—Type II ●

Second most common: 30%

●

Drains into coronary sinus or RA ●

●

Coronary sinus more common

Increased pulmonary vasculature


LearningRadiology - TAPVR ●

Overload of RV leads to •CHF after birth

●

20% of I’s and II’s survive to adulthood ●

●

●

Remainder expire in first year

Infracardiac Type—Type III ●


●

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

●

Cyanotic 2° right to left shunt through ASD

●

Associated with asplenia (80%), or polysplenia

●

Prognosis = death within a few days

to venous return

Mixed Type—Type IV ●


●

Mixtures of types I – III

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 ❍

LIP

❍

Castleman’s disease–lymph 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 ● ● ● ●

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


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.

●

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 ❍ 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

● ●

●

❍

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side: ❍

Pulmonary artery obstruction

❍

Congenital absence or hypoplasia of the pulmonary artery ■ Thromboembolism occluding one pulmonary artery ■ Unilateral arterial obstruction Abnormalities of the opposite lung itself ■

■ ■ ■

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

●

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

● ●

❍

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: ❍

●

● ● ●

❍ ❍ ❍

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

•

Multiple cysts in cortical region (usually not seen prior to teens)

•

Diffusely echogenic when cysts small (children)

•

Renal contour poorly demarcated

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)

Cx: •

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)

DDx: •

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 •

Potter Type I

•

Incidence:1: 6,000 to 1:50,000 livebirths

•

F > M; carrier frequency of 1:112

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

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 •

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

Lung

Liver •

Portal venous hypertension

•

Tubular cystic dilatation of small intrahepatic bile ducts



•

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

Kidneys

•

"Sunburst nephrogram" = striated nephrogram with persistent radiating opaque streaks (collecting ducts) on

•

Delayed images

•

Prominent fetal lobulation

•

Prolonged corticomedullary phase

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

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 don’t)) • Supplied by pulmonary circulation

Types ● ● ●

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 http://www.learningradiology.com/archives/COW%20021-CAM/camcorrect.htm (1 de 4)04/09/2006 2:21:24


• 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


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LearningRadiology - Tumoral Calcinosis


Return to Case

Tumoral Calcinosis

●

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

● ●

❍

●

No renal, metabolic or collagen-vascular disease Autosomal dominant with variable expressivity Pathology: multilocular cystic lesions containing creamy white fluid

●

Hydroxyapatite crystals in suspension Clinical

●

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

❍

●

❍

❍

❍ ❍ ❍

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


Return to Case

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 Marfan’s 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 rings–not 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 region–even difficult with colonoscopy • On AC BE tics have sharp outer and fuzzy inner margins viewed en-face • Giant sigmoid diverticulum–huge 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 • Crohn’s disease-may be indistinguishable if TI not involved in Crohn’s • Ischemic colitis–only if sigmoid is involved • Radiation colitis Complications • Peritonitis–usually 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 • Obstruction–is rare



• Bleeding–see below

Hemorrhage from Diverticulosis • Doesn’t 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 ❍

● ● ● ● ● ●

❍ ❍

When deposited in cartilage, synovial thickening develops This results in:

Subchondral cysts ■ Sclerosis ■ Osteophyte production, all secondary to DJD ■ Bony ankylosis may occur in joints or spine ❍ Usually affects large joints-knees, shoulders, hips ❍ Chondrocalcinosis of appendicular joints may develop In the spine: ■

●

Changes of degenerative disc disease ❍ Ligamentous structures mat be involved ❍ Resembles ankylosis spondylitis ❍ Universal disc space calcification is common Universal disc calcification and DJD of root joints (hips and shoulders) in younger patient are pathognomonic ❍

●

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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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Crohn’s 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 bull’s-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 Crohn’s • Rectum (35-50%) • Sinus tracts • Deep, collar-button ulcers

X-Ray Manifestations • 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

Differential Diagnosis • Ulcerative colitis–continuous involvement L colon and rectum;TI normal • Diverticulitis–tics; intact mucosa; TI normal • Tuberculosis–but TB has more involvement of cecum, less of TI • Radiation ileitis–should have other loops involved and appropriate hx • Lymphoma–should have tumor masses, less spasm • Carcinoid–should have mass; marked fibrosis with angulation of loops • Yersinia– may affect TI but clears in 3-4 months • Infarction–rare for this location • Potassium stricture–lacks full clinical picture • Amebiasis–cone-shaped cecum

Extra-intestinal Manifestations • Fatty infiltration of the liver • Gallstones (28-34%) • Sclerosing cholangitis http://www.learningradiology.com/archives03/COW%20027-Crohn'sileum/chronscorrect.htm (3 de 5)04/09/2006 2:21:41


• 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-Schönberg Disease = Marble Bone Disease ● ● ●

Rare hereditary disorder Defective osteoclast function with failure of proper reabsorption produces sclerotic bone Structurally weak

Types ●

●

Infantile autosomal recessive type ❍ Failure to thrive ❍ Premature senility in facies ❍ Dental caries ❍ Anemia, leukocytopenia, thrombocytopenia ❍ Cranial nerve compression (optic atrophy, deafness) ❍ Hepatosplenomegaly (extramedullary hematopoiesis) ❍ Lymphadenopathy ❍ Subarachnoid hemorrhage may occur (due to thrombocytopenia) ❍ May be associated with: ■ Renal tubular acidosis ■ Cerebral calcification ❍ Prognosis: survival beyond middle age is uncommon (death due to recurrent infection, massive hemorrhage, terminal leukemia) Benign adult autosomal dominant type ❍ 50% asymptomatic ❍ Recurrent fractures ❍ Mild anemia ❍ Cranial nerve palsy (rarely) ❍ Prognosis: normal ❍ X-ray findings ■ Diffuse osteosclerosis ■ Cortical thickening with medullary encroachment ■ Erlenmeyer flask deformity = clublike long bones due to lack of tubulization + flaring

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●

●

of ends ■ Bone-within-bone appearance ■ "Sandwich" vertebrae=alternating sclerotic + radiolucent transverse metaphyseal lines (phalanges, iliac bones) indicate fluctuating course of disease ■ Longitudinal metaphyseal striations ■ Mandible least involved Complications: ❍ Fractures (common because of brittle bones) with abundant callus + normal healing ❍ Crowding of marrow (myelophthisic anemia + extramedullary hematopoiesis) ❍ Frequently terminates in acute leukemia ❍ Rx: bone marrow transplant DDx: ❍ Heavy metal poisoning ❍ Melorheostosis (limited to one extremity) ❍ Hypervitaminosis D ❍ Pyknodysostosis ❍ Fibrous dysplasia of skull / face

From Dahnert







LearningRadiology-Ebstein's Anomaly


Return to case

Ebstein’s 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

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There is an atrialized portion of the right ventricle between the AV groove and the tricuspid valve

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The right ventricle and right atrium dilate

o •

The right heart border becomes prominent

Think of Ebstein’s 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


Return to case

Polyarteritis Nodosa Submitted by Alexander Trebelev, MD* ●

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Systemic necrotizing inflammation of medium-sized and small muscular arteries ❍ More common in adult males Spares the arterioles, capillaries, venules and glomeruli Associated with hepatitis B antigenemia Signs and symptoms ❍ Abdominal pain ❍ Systemic hypertension ❍ Anorexia and weight loss ❍ Abdominal distention ❍ Hematemesis, melena ❍ Jaundice ❍ Painless hematuria ❍ Peripheral neuropathy ❍ Tender subcutaneous nodules ❍ 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)

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Multiple intrarenal aneurysms Aneurysms may thrombose and disappear ■ Appear in new locations Multiple small cortical infarcts Angiographic findings ■ 1-5 mm saccular aneurysms of small and medium-sized arteries in 60-75% of cases ■ Secondary to necrosis of internal elastic lamina ■ Luminal irregularities and stenoses ■ Arterial occlusions and small tissue infarcts

Lung (70% of cases) ❍ Findings are variable and rarely characteristic enough to allow diagnosis ❍ Most characteristic pattern is fleeting, patchy consolidation identical to Loeffler's ❍ Pericardial effusion ❍ Pleural effusion ❍ Discoid atelectasis ❍ Nodules which may cavitate ❍ 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) ●

Treatment ❍ Corticosteroids ■ 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 ● ● ●

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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 ❍ Fewer than 10% occur in upper extremities Characteristics ❍ Geographic ❍ Lytic ❍ Multilobulated ❍ Metaphyseal ❍ Usually intramedullary ❍ Eccentric ❍ Well-marginated ❍ Sclerotic rim ❍ Endosteal scalloping

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LearningRadiology-Nonossifying fibroma ●

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Most lesions heal spontaneously by being replaced with normal bone ❍ Migrate away from epiphysis May undergo pathologic fracture or rarely cause rickets ❍ Do not undergo malignant transformation


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LearningRadiology-Radiation fibrosis


Return to case

Radiation Pneumonitis ● ●

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Damage to lungs after radiation therapy Usually requires at least 4500 rads ❍ Especially common if >6000 R given in 5-6 weeks Occurs more often if there is concurrent or later chemotherapy Pathologic phases ❍ Exudative phase = edema fluid + hyaline membranes ❍ Organizing phase ❍ Fibrotic phase = interstitial fibrosis Time of onset ❍ Usually at least 6 weeks up to 6 months after treatment Location ❍ 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

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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 ❍ Homogeneous slight increase in attenuation (2-4 months after therapy) ❍ Patchy consolidation (1-12 months after therapy) ❍ Non-uniform discrete consolidation (most common; 3 months to 10 years after therapy)

Sequential transverse images through lung showing radiation pneumonitis in right lung ●

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Prognosis ❍ Recovery or progression to death from fibrosis Rx ❍ Steroids

• Chronic Radiation Damage o 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)

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LearningRadiology-Charcot's Arthropathy


Neuropathic (Charcot) Arthropathy Return to case ●

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Disturbance in sensation leads to multiple microfractures ❍ Pain sensation is intact from muscles and soft tissue Distribution and causes ❍ Shoulders – syrinx, spinal tumor ❍ Hips – tertiary syphilis, diabetes ❍ Knees – tertiary syphilis (more bone production), diabetes (less bone production) ❍ Feet – diabetes ❍ Other causes ■ Amyloidosis ■ Congenital indifference to pain ■ Polio ■ Alcoholism X-ray findings ❍ Sclerosis ❍ Destruction of joint ❍ Fragmentation ❍ Soft tissue swelling from synovitis ❍ Joint effusions ❍ Osteophytosis ❍ Disorganized and disrupted joint ❍ No osteoporosis DDX ❍

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Degenerative joint disease ■ Eventually neuropathic joint shows more sclerosis ■ More fragmentation in neuropathic ■ More destruction of bone in neuropathic CPPD ■ 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 ●

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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: ❍ Gastric outlet obstruction with increased intraluminal pressure ❍ Severe vomiting ❍ Instrumentation-like endoscopy ❍ Dissection of air from mediastinum from ruptured bleb or pneumothorax ❍ Pneumatosis cystoids - submucosal air collections

Emphysematous gastritis ● ● ●

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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 Causes: ❍ Ingestion of toxic material such as corrosives ❍ Alcohol ingestion ❍ Trauma ❍ Gastric infarction ❍ Ulcer disease Submucosa is invaded by gas-forming organisms which include: ❍ Hemolytic strep ❍ Clostridia Welchi ❍ E. Coli ❍ Staph aureus Clinical: ❍ Sudden and violent onset of bloody emesis ❍ Fever ❍ Nausea ❍ Chills ❍ Leukocytosis X-ray: ❍ Linear small gas bubbles in gastric wall ■ Gastric emphysema is more linear, streak-like

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Gas in portal vein Prognosis: ❍ 60-80% fatal Best way to differentiate emphysematous gastritis from gastric emphysema: ❍ Look at patient ■ Patients with gastric emphysema are a asymptomatic from the bowel gas air ■ Patients with emphysematous gastritis are usually deathly ill ❍

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WH/wh 03


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LearningRadiology - Ruptured Aortic Aneurysm


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Abdominal Aortic Aneurysm

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Focal widening >3 cm Normal size of abdominal aorta >50 years of age: ❍ About 2 cm Prevalence: ❍ Increases with age ❍ Greater with atherosclerotic disease ❍ Male predominance ❍ Whites: Blacks = 3:1 Risk factors: ❍ male ❍ age >75 years ❍ white race ❍ prior vascular disease ❍ hypertension ❍ cigarette smoking ❍ family history ❍ hypercholesterolemia Associated with: ❍ visceral + renal artery aneurysm (2%) ❍ isolated iliac + femoral artery aneurysm (16%) ■ common iliac (89%), internal iliac (10%), external iliac (1%) ❍ stenosis / occlusion of celiac trunk / SMA (22%) ❍ stenosis of renal artery (22-30%) ❍ occlusion of inferior mesenteric artery (80%) ❍ occlusion of lumbar arteries (78%) Growth rate of aneurysm of 3-6 cm in diameter: ❍ 0.39 cm / year Clinical ❍ asymptomatic (30%) ❍ abdominal mass (26%)

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abdominal pain (37%) Location ❍ infrarenal (91-95%) with extension into iliac arteries (66-70%) Imaging findings ❍ Plain film ■ mural calcification (75-86%) ❍ US:>98% accuracy in size measurement ❍ CT-non-contrast enhanced ■ perianeurysmal fibrosis (10%), may cause ureteral obstruction ■ "crescent sign" = peripheral high-attenuating crescent in aneurysm wall (= acute intramural hematoma) = sign of impending rupture ❍ CT-contrast-enhanced ■ ruptured aneurysm ● anterior displacement of kidney ● extravasation of contrast material ● fluid collection / hematoma within posterior pararenal + perirenal spaces (see below) ❍

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free intraperitoneal fluid contained leak ● laminated mural calcification ● periaortic mass of mixed / soft-tissue density ● lateral "draping" of aneurysm around vertebral body ●

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Angio focally widened aortic lumen >3 cm ❍ apparent normal size of lumen secondary to mural thrombus (11%) ❍ mural clot (80%) ❍ slow antegrade flow of contrast medium Contained rupture = extraluminal hematoma / cavity ❍ absent parenchymal stain = avascular halo ❍ displacement + stretching of aortic branches Complications: ❍ Rupture (25%) ■ into retroperitoneum: commonly on left ❍

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into GI tract: massive GI hemorrhage ■ into IVC: rapid cardiac decompensation ● 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% ● Symptoms of rupture ❍ sudden severe abdominal pain ± radiating into back ❍ faintness, syncope, hypotension ❍ Prognosis:64-94% die before reaching hospital ❍ Increased risk: size >6 cm, growth >5 mm / 6 months, pain + tenderness ❍ Peripheral embolization ❍ Infection ❍ Spontaneous occlusion of aorta Prognosis:17% 5-year survival without surgery ❍ 50-60% 5-year survival with surgery Treatment ❍ surgery recommended if >5 cm in diameter; ❍ 4-5% surgical mortality for nonruptured ■ 30-80% for ruptured aneurysm Postoperative Complications ❍ Left colonic ischemia (1.6%) with 10% mortality ❍ Renal failure (14%) ❍ 0-8% mortality rate for elective surgery ■

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From Dahnert Radiology Review Manual 2002









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Return to Case

Multiple Hereditary Exostoses Diaphyseal Aclasis

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Inheritance ❍ Autosomal dominant Age of onset ❍ Discovered between 2 and 10 years Male predominance = 2:1 Pathology ❍ Ectopic cartilaginous rest in metaphysis and a defect in periosteum produces exostoses ❍ Cap of hyaline cartilage over bony protuberance ❍ Cortex and cancellous bone of exostosis is contiguous to host bone Clinical ❍ Usually painless mass near joints ❍ Tendons, blood vessels, nerves may be impaired ❍ Mechanical limitation of joint movement may occur Location ❍ Multiple ❍ Usually bilateral ❍ 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) ❍ Always point away from joint and toward center of shaft ❍ Occasionally small punctate calcifications are seen in cartilaginous cap Other skeletal abnormalities may occur ❍ Shortening of 4th and 5th metacarpals ❍ Supernumerary fingers and/or toes ❍ Madelung / reversed Madelung deformity ❍ Dislocation of radial head Prognosis ❍ Exostosis begins in childhood ❍ Stops growing when nearest epiphyseal center fuses Complications ❍ Malignant transformation to chondrosarcoma in <5% ■ Iliac bone commonest site ■ Look for growth with irregularity of contour and fuzziness of margin ■ Sudden painful growth spurt ❍ Cord compression secondary to involvement of posterior spinal elements ❍

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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 R—L 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









Return to Case

Round Pneumonia

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Spherical pneumonia caused by ❍ Haemophilus influenzae ❍ Streptococcus ❍ Pneumococcus Children are affected much more than adults Location ❍ Usually lower lobe ❍ Most often posterior Clinical ❍ Cough ❍ Fever ❍ Chest pain May change size rapidly May have slightly irregular border and contain air bronchogram

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LearningRadiology - Round Pneumonia ●

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: > Iatrogenic–endoscopy (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

Boerhaave's Syndrome • 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 Boerhaave’s, 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 http://www.learningradiology.com/archives03/COW%20039-Boerhaaves/boerhaavescorrectpage.htm (1 de 5)04/09/2006 2:22:16


• 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

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• Method of study: • First use a water-soluble contrast agent (Gastrografin, oral Hypaque) • If no perforation is found, then barium may be used WH/

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LearningRadiology- Giant Cell Tumor


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Giant Cell Tumor Osteoclastoma ● ●

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Probably arise from zone of osteoclastic activity in skeletally immature patients Incidence ❍ ~ 4% of all primary bone tumors ❍ ~ 20% of benign skeletal tumors Histology ❍ Multinucleated osteoclastic giant cells intermixed throughout a spindle cell stroma Age ❍ > 98% after epiphyseal plate fusion ■ Most between 20 and 40 years M:F = 1:1 Clinical ❍ Tenderness ❍ Pain at affected site ❍ Weakness ❍ Sensory deficits (if in spine) Location: ❍ 85% in long bones ■ Lower extremity (50-60% about knee) ● Distal femur > proximal tibia ■ Upper extremity (away from elbow): ● Distal radius > proximal humerus ❍ 15% in flat bones ■ Pelvis ■ Sacrum near SI joints ■ Skull Site in bone ❍ Eccentric ❍ Metaphyseal ■ Adjacent to epiphyseal line ● Subarticular if epiphyseal plate is fused

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Appearance ❍ Expansile ❍ Solitary lytic bone lesion ❍ May be quite large at diagnosis ❍ No reactive sclerosis ❍ No periosteal reaction in absence of fracture ❍ May break through cortex with cortical thinning ❍ Soft-tissue invasion (25%) ❍ Pathologic fracture (5%) ❍ Destruction of vertebral body with secondary invasion of posterior elements (DDx: ABC, osteoblastoma) ■ Frequently demonstrate vertebral collapse ■ Can involve adjacent vertebrae and disk (like discitis) and can cross sacroiliac joint ❍ May cross joint space in long bones (exceedingly rare) Nuclear medicine findings ❍ Diffusely increased uptake ❍ May have "doughnut" sign of central photopenia Angiographic findings ❍ Hypervascular lesion CT findings ❍ Tumor has soft-tissue attenuation ■ May contain foci of low attenuation (hemorrhage/necrosis) ❍ Well-defined margins ❍ May have thin rim of sclerosis MR findings ❍ Heterogeneous signal intensity with low to intermediate intensity on T1WI + T2WI (63-96%) due to collagen + hemosiderin content ❍ Focal cystic areas ❍ Low-signal-intensity pseudocapsule Complications and associations ❍ 15% malignant within first 5 years ■ Much more often in males (M:F = 3:1) ❍ Metastases to lung



May be associated with ■ Paget disease (in 50-60% located in skull + facial bones) Prognosis ❍ Locally aggressive ❍ 40-60% recurrence rate Treatment ❍ Complete resection + radiation therapy DDx: ❍ Aneurysmal bone cyst ❍ Brown tumor (lab values) ❍ Cartilaginous tumor ■ Chondroblastoma (open epiphyses) ■ Enchondroma (not epiphyseal) ■ Chondromyxoid fibroma (rare) ■ Chondrosarcoma ❍ Fibrous dysplasia ❍

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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

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LearningRadiology - Pulmonary Sling


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Pulmonary Sling ●

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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

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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 ●

Double aortic arch is most common vascular ring

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Caused by persistence of Right and Left IV branchial arches

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Rarely associated with Congenital Heart Disease

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Symptoms (of tracheal compression or difficulty swallowing) may begin at birth

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Right arch is higher, left arch is lower producing reverse S on esophagram in AP

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Right arch supplies Right common carotid and Right subclavian arteries

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Left arch supplies Left common carotid and Left subclavian arteries

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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. ●

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)

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LearningRadiology - Pneumocystis Carinii Pneumonia PCP


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Pneumocystis Carinii Pneumonia PCP ● ●

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Most common cause of interstitial pneumonia in immunocompromised patients Organism ❍ Protozoan / fungus Pneumocystis carinii Predisposed ❍ AIDS ❍ Debilitated ❍ Premature infants ❍ Children with hypogammaglobulinemia ❍ Other immunocompromised patients ■ Congenital immunodeficiency syndromes ■ Lymphoproliferative disorders ■ Organ transplant recipients ■ Patients on long-term corticosteroid therapy ■ Patients on chemotherapy for cancer Associated infections ❍ CMV ❍ Mycobacterium avium-intracellulare (MAI) ❍ Herpes simplex Clinical ❍ Severe dyspnea and cyanosis ❍ Subacute insidious onset of malaise and slight cough (frequent in AIDS patients) ❍ Respiratory failure ❍ WBC slightly elevated (polys) ❍ Lymphopenia (50%) indicates poor prognosis Imaging findings ❍ Normal CXR in 10-40% ❍ Bilateral diffuse symmetric finely granular / reticular interstitial / airspace infiltrates in 80% ■ Characteristic central location ■ Rapid progression to diffuse airspace disease

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LearningRadiology - Pneumocystis Carinii Pneumonia PCP ●

Resembles non-cardiogenic pulmonary edema

PCP

Pleural effusion and hilar lymphadenopathy are uncommon ❍ Atypical pattern in 5% ■ Isolated lobar disease / focal parenchymal opacities ■ Lung nodules ± cavitation ■ Hilar / mediastinal lymphadenopathy ■ Thin- / thick-walled cysts ■ Cavities with predilection for upper lobes Course ❍ Usually responds to therapy in 5-7 days ❍ Effect of prophylactic use of aerosolized pentamidine ■ Redistribution of infection to upper lobes Complications ❍ Cystic lung disease ■ Central location to cysts ❍ Spontaneous pneumothorax, frequently bilateral (6-7%) ❍ Disseminated extrapulmonary disease (1%) ❍ Punctate / rimlike calcifications within enlarged lymph nodes and abdominal viscera CT findings ❍ Patchwork pattern (56%) ■ Bilateral, asymmetric patchy mosaic appearance ❍ Ground-glass pattern (26%) ■ Bilateral, diffuse air-space disease in symmetric distribution ❍ Interstitial pattern (18%) ■ Bilateral, symmetric / asymmetric, reticular markings (thickening of lobular septa) ❍ Abnormal air-filled spaces (38%) ■ Pneumatocoeles ● Thin-walled spaces without lobar predilection resolving within 6 months ■ Subpleural bullae due to emphysema ■ Thin-walled cysts ■ Necrosis of pneumocystis granuloma ■ Pneumothorax (13%) ❍

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Lymphadenopathy (18%) ❍ Pleural effusion (18%) Pulmonary nodules and cavities ❍ Usually due to malignancy ■ Leukemia, lymphoma ■ Kaposi sarcoma ■ Metastasis ■ Or septic emboli ❍ Pulmonary cavities usually due to superimposed fungal / mycobacterial infection Nuclear medicine ❍ Bilateral and diffuse Ga-67 uptake without mediastinal involvement prior to roentgenographic changes DDx ❍ Non-cardiogenic pulmonary edema ❍ TB ❍ MAI infection ❍

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Diagnosis ❍ Sputum collection ❍ Bronchoscopy with lavage ❍ Transbronchial or transthoracic or open lung Bx

Dahnert 4th edition







LearningRadiology - Acute Osteomyeltis


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Acute Osteomyelitis ●

Age ❍

Usually affects children ■ Septic arthritis more common in adults; osteomyelitis in children

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Hallmark characteristics ❍ Destruction of bone ❍ Periosteal new bone formation Organisms ❍ Newborns ■ S. aureus ■ Group B streptococcus ■ E. coli ❍ Children ■ S. aureus ❍ Adults ■ S. aureus (most common) ■ Enteric species ■ Streptococcus ❍ Drug addicts ■ Pseudomonas (most common) ■ Klebsiella ❍ Sickle cell disease ■ Salmonella Pathogenesis ❍ Hematogenous spread ❍ Direct implantation from a traumatic / iatrogenic source ❍ Extension from adjacent soft-tissue infection Location ❍ Lower extremity (most common) ■ Over pressure points in diabetic foot ❍ Vertebrae ■ Lumbar > thoracic > cervical ❍ Radial styloid

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LearningRadiology - Acute Osteomyeltis ❍

Sacroiliac joint

ACUTE NEONATAL OSTEOMYELITIS ●

Age Onset <30 days of age Little or no systemic disturbance Multicentric involvement more common ❍ Often joint involvement Bone scan falsely negative / equivocal in 70% ❍

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ACUTE OSTEOMYELITIS IN INFANCY ●

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

ACUTE OSTEOMYELITIS IN CHILDHOOD ●

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

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ACUTE OSTEOMYELITIS IN ADULTHOOD ● ●

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Delicate periosteal new bone Joint involvement common ❍ Septic arthritis X-ray findings ❍ Initial radiographs often normal for as long as 7-10 days ❍ Localized soft-tissue swelling adjacent to metaphysis with obliteration of usual fat planes (after 3-10 days) ❍ 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 ● ● ● ●

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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 ❍ Bone marrow hypointense on T1WI + hyperintense on T2WI (= water-rich inflammatory tissue) DDx ❍ Neuropathic osteoarthropathy ❍ Aseptic arthritis ❍ Acute fracture ❍ Recent surgery ❍ Ewing’s sarcoma Findings ❍ Focal / linear cortical involvement hyperintense on T2WI ❍ Hyperintense halo surrounding cortex on T2WI = subperiosteal infection ❍ Hyperintense line on T2WI extending from bone to skin surface and enhancement of borders (= sinus tract) Nuclear Medicine (accuracy approx. 90%): ❍ Ga-67 scans ■ 100% sensitivity ■ Increased uptake 1 day earlier than for Tc-99m MDP ❍ Gallium helpful for chronic osteomyelitis Static Tc-99m diphosphonate ❍ 83% sensitivity ❍ 5-60% false-negative rate in neonates and children Complications of osteomyelitis ❍ Abscess in soft-tissue ❍ Fistula or sinus formation ❍ Pathologic fracture


LearningRadiology - Acute Osteomyeltis ❍ ❍ ❍

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

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Obstruction to hepatic venous outflow leads to increased sinusoidal pressure producing reversed or delayed flow in portal veins Many causes ❍ Idiopathic most common ❍ Tumor ■ Hepatocellular carcinoma ■ Carcinoma of pancreas ■ Carcinoma of kidneys ■ Metastatic disease ❍ Blood dyscrasia ■ Leukemia ■ Sickle cell disease ■ Polycythemia vera ❍ Birth control pills ❍ Pregnancy ❍ Pyrrolizidine alkaloids (senecio) found in Jamaican tea ❍ Membranous diaphragm in suprahepatic IVC Acutely ❍ Hepatomegaly and ascites ❍ Severe symptoms including shock ❍ Abdominal pain ❍ Jaundice ❍ CT ■ Hepatomegaly and ascites ■ Non-visualization of occluded hepatic veins ● Also seen on MRI ■ Patchy enhanced appearance with dynamic imaging ■ Inversion of portal blood flow results in inside-out enhancement of liver

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Caudate lobe is hyperdense early, decreased later ● Periphery is hypodense early, increased later ● Then enhancement equilibrates ❍ Due to reversed portal venous flow Enlarged right inferior hepatic vein Enlarged portal vein (>12mm in adults) ●

■ ■ ●

Chronically ❍ Portal hypertension and variceal bleeding ❍ Enlargement of caudate lobe ❍ Collateral circulation through azygous and hemiazygous ■ Visualization of paraumbilical vein ❍ Non-visualization of hepatic veins ❍ Inversion of portal blood flow results in inside-out enhancement of liver ■ Periphery is hypodense early ■ Then enhancement equilibrates ■ Due to reversed portal venous flow

Early and delayed phases of liver enhancement in Budd-Chiari Syndrome ❍ ❍ ❍ ●

●

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 ❍ Usually can be made on imaging study Treatment ❍ Anticoagulants


LearningRadiology - Budd-Chiari Syndrome ❍ ❍ ❍ ❍

Surgery Balloon dilatation TIPS Liver transplant

WH/03







http://www.learningradiology.com/caseofweek/caseoftheweekpix/cow46ap.JPG

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http://www.learningradiology.com/caseofweek/caseoftheweekpix/ruggerjerseyspine.jpg

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Pigmented Villonodular Synovitis PVNS ●

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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 ❍ Frequent history of antecedent trauma ❍ Hemorrhagic "chocolate" effusion ❍ Insidious onset of swelling ❍ Pain of long duration ❍ Decreased range of motion ❍ Joint locking Age ❍ Mainly 2nd-4th decade; 50% <40 years ❍ F>M Location ❍ Knee (most common) ❍ Ankle ❍ Hip ❍ Elbow ❍ Shoulder ❍ Tarsal or carpal joints ❍ Predominantly monarticular Radiographic findings ❍ Soft-tissue swelling around joint ■ From effusion and synovial proliferation ❍ Dense soft-tissues from hemosiderin deposits ❍ Subchondral pressure erosions at margins of joint from hypertrophied synovium ❍ Multiple sites of deossification appearing as cysts ❍ No calcifications ❍ No osteoporosis ❍ 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 ●

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MRI findings ❍ Masses of synovial tissue in a joint with effusion ❍ Scalloping / truncation of prefemoral fat pad ❍ Predominantly low signal intensity on all sequences (due to presence of iron) (characteristic of this lesion) ❍ Often heterogeneous low + high signal intensity on T2WI (hemosiderin deposits in masses + para-articular fat) ❍ DDx ■ Hemosiderin deposits in other diseases (eg, rheumatoid arthritis) Treatment ❍ Synovectomy ❍ Arthrodesis ❍ Arthroplasty ❍ Radiation DDx ❍ Synovial sarcoma ■ Mass around, but outside of, joint ■ Frequently calcify ❍ Degenerative arthritis ■ Joint space narrowing ■ 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 ●

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Inflammatory hepatic lesions ❍ Most common cause of calcified hepatic lesions ● Inflammatory conditions ● For example, granulomatous diseases (tuberculosis). ● Calcification involves entire lesion ● Appears as a dense mass ● May produce artifacts on CT scans ❍ Echinococcus cysts have curvilinear or ring calcification ● Central water density in cyst Benign neoplasms ❍ 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 ❍ Hepatocellular adenoma ● Calcifications may be solitary or multiple ● Usually located eccentrically within complex heterogeneous mass. ❍ Fibrolamellar carcinoma ● Calcifications reported in 15%-25% of cases at CT ● Occurs in many patterns ❍ Intrahepatic cholangiocarcinoma ● Calcifications are typically accompanied by a desmoplastic reaction ● Visible at CT in about 18% of cases. ❍ Calcified hepatic metastases ● 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 ● ●

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 • •

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Age group: 40-60 yrs Bilateral in 10 %

Features



§ § § ●

Serous Tumors -

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Incidence – 20% of ovarian tumors Morphology: § Tumors containing solid and cystic areas § Filled with hemorrhagic fluid § Lined by glandular epithelium

Clear Cell (mesonephroid tumor) -

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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

Endometrial tumors -

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Incidence: uncommon Age group: 50 – 60 yrs Morphology: § Unilocular cysts with small cystic spaces

Brenner tumor: § §

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Origin : cells derived form oocytes Incidence: 15- 20% of all ovarian tumors, 5% malignant § Age: young age

Dysgerminoma -

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Incidence: 1- 2% Occur commonly in perimenopausal women

Germ Cell Tumors -

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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

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) § Immarure or malignant type (e.g. Solid Teratoma) § Monodermal or highly specialised (e.g. Struma ovarii)


LearningRadiology - Ovarian Carcinoma, Calcified Liver Masses, Metastases, Liver ●

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

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Ovarian Fibroma: -

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Meig’s 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

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Routes of Peritoneal Spread

o

Right subphrenic space

o

The greater omentum

o

The Pouch of Douglas







LearningRadiology - Dissecting Aortic Aneurysm, Dissecting Hematoma


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Aortic Dissection

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•

3:1 male to female predominance Over the age of 40 Hemorrhage in the media (at vasa vasorum) leading to either ❍ Tear in the weakened intima which breaks into the lumen, or ❍ Hemorrhage in the wall (less common) ❍ Hemorrhage separate media from adventitia Predisposing factors o o o o o o o o

Hypertension (most commonly) Atherosclerosis Cystic medial necrosis § Marfan’s 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

o

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

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Most dissections arise either just distal to the aortic valve or just distal to aortic isthmus

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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

Stanford Classification

Portion of Aorta Involved

DeBakey Type I


Involves entire aorta

DeBakey Type II (least common)


Ascending aorta only

DeBakey Type III (most common)

Stanford Type B

Descending aorta only

Common causes Hypertension Atherosclerosis Cystic medial necrosis e.g.Marfan’s Ehlers-Danlos Hypertension Atherosclerosis

*Goal is to prevent backward involvement of the aortic valve or rupture into pericardium

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Clinical o o o o o

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Sharp, tearing, intractable chest pain Murmur or bruit of aortic regurgitation Previously hypertensive, now possible shock Asymmetric peripheral pulses Pulmonary edema

Imaging Findings


RX Usually surgically*

Usually surgically* Usually medically


o

Chest films § § § § § §

o

MRI § §

o

Mediastinal widening Left paraspinal stripe Displacement of intimal calcifications Apical pleural cap Left pleural effusion Displacement of endotracheal tube or nasogastric tube

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

o

Angiography § § § § §

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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



o •

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 1800’s, concept of artificial ptx introduced by Carlo Forlanini of Milan o

Speculated on the feasibility of collapsing lung by introducing air into the pleural space

o

Intentional production of a lung collapse was thought to allow the lung to rest

o

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

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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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Solid paraffin wax

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Lucite spheres

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Plastic ping pong balls (1940s)

Multiple round ring-shadows in RUL are plastic balls inserted into the pleural space to collapse lung o

Sponges of inert plastic material

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Oleothorax §

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Oil in the pleural cavity

Sanatorium movement began slower in US than Europe o

Once started, many opened and became a major way of treating TB

o

In 1953, 839 TB sanatoria in the USA stressing §

Diet

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Regimented exercise

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High altitude

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Bedrest

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Sunlight

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Cold air



•

Chemotherapy began in mid-1940s

Wh/wh








LearningRadiology - Rugger-Jersey Spine, Hyperparathyroidism


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• 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 (2°hyperparathyroidism) • 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%) http://www.learningradiology.com/archives03/COW%20050-Rugger-jersey%20spine/ruggerjerseycorrect.htm (1 de 5)04/09/2006 2:22:40


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) o

•

•

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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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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 ●

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

Whipple’s 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 ●

Parenchyma § § §

Upper lobes affected slightly more than lower Alveolar infiltrate Cavitation is rare

§ Lobar pneumonia is almost always associated with lymphadenopathy—therefore, lobar pneumonia associated with hilar or mediastinal adenopathy at any age should strongly suggest TB ●

Lymph node

•

§

Mostly unilateral hilar and/or paratracheal, usually right sided, rarely bilateral

§

Differentiates primary from postprimary TB—it 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 painlessly—therefore, 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 § ● ●

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”) ●

●

●

●

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 lobes—bilateral 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 occur—from one upper lobe to opposite lower or to another lobe

§ §

Miliary spread (below) Bronchiectasis—usually asymptomatic

§ Bronchostenosis due to fibrosis and stricture: fibrosis may cause distortion of a bronchus and atelectasis many years after the initial infection—“middle lobe syndrome” § Solitary pulmonary nodule—the tuberculoma—may 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 ●

●

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 empyema—this carries a graver prognosis than the pleural effusion of the primary form Direct extension into the ribs or sternoclavicular joints is uncommon

Miliary Tuberculosis ● ● ● ● ●

● ●

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 TB–although 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 rapid—miliary TB seldom, if ever, produces calcification

TB and Other Diseases ● ● ●

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 ● ● ● ● ●

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

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)

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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 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 § •

From nonresorption of intestinal gas secondary to obstruction of mesenteric veins

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 "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 •

•

o

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

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Christmas disease is indistinguishable except milder

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Females can develop hemophilia if hemophiliac male marries female carrier

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●

Hemarthrosis most common in hinge joints, e.g. knee, elbow, ankle ❍ Chronic synovitis develops from repeated intra-articular hemorrhages ❍ Thickened synovium produces marginal erosions ❍ 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 ❍

X-ray changes due to synovial proliferation and hyperemia

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LearningRadiology -Hemophilia,Hemophilic arthritis,knee,image ❍ ❍

❍ ❍

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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 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 ❍ JRA occurs more often in females

















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LearningRadiology -Congenital Diaphragmatic Hernia,Bochdalek,Morgagni


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Congenital Diaphragmatic Hernia

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If defective development, diaphragmatic hernia develops ❍ Anterior – Morgagni ■ Anteromedial parasternal defect (Space of Larrey) ■ Maldevelopment of septum transversum ■ Tends to occur in overweight, middle-aged, women ■ Right > left (heart protects) ■ Usually not large ■ Usually unilateral ■ Associated with ● Pericardial defects ● Omental fat in pericardial space ❍ Posterior – Bochdalek ■ Most common ● Occurs through old pleuroperitoneal canals ❍ Just lateral to the spine on either side ■ More frequent on left side ● Possibly due to “protection” of right-side by liver ● Hernia may contain intestine, stomach, spleen, liver or omentum ■ If hernia occurs on right ● Intestine and liver or only liver may herniate ■ If the defect is large, newborns usually present with ● Severe respiratory distress ● Cyanosis ● Scaphoid abdomen ■ Entire diaphragm is almost never absent ● Some part of diaphragm is usually found at surgery, even if defect is very large ■ Hypoplasia of ipsilateral lung occurs from mass effect of bowel ■ Most often these are isolated congenital abnormalities ● But they can have ❍ Congenital Heart Disease ❍ 13 ribs

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LearningRadiology -Congenital Diaphragmatic Hernia,Bochdalek,Morgagni ❍ ●

Malrotation of GI tract frequently present

Imaging findings ❍ Initially, hemithorax may appear opaque because loops are fluid-filled ❍ Paucity of bowel loops beneath the 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

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 ❍ ●

● ●

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Contrast through an NGT is diagnostic but often not needed Differential diagnosis of lucent cysts in infant lung ❍ Cystic adenomatoid malformation ❍ Staphylococcal pneumonia ■ 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% ❍ Pulmonary hypoplasia ❍ Persistent Fetal Circulation Syndrome Treatment ❍ Surgical repair ❍ Many demonstrate ipsilateral pulmonary hypoplasia for years after repair ❍ 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 •

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

X-ray ●

Atelectasis ❍

●

Mucoid impaction ❍

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Discoid, segmental, lobar with RUL predominance Nodular and fingerlike densities along bronchovascular bundle

Cylindrical or cystic bronchiectasis ❍

Peribronchial cuffing

●

Hilar adenopathy

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Pulmonary arterial hypertension and cor pulmonale

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Recurrent pneumonias, particularly Staph, Pseudomonas and P. cepacia

●

Clubbing and hypertrophic osteoarthropathy can occur

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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 ●

Bulky, fatty stools from lack of pancreatic enzymes

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Rectal prolapse

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Meconium ileus — earliest finding

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Meconium ileus equivalent — due to obstruction from stool in older children

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Fatty infiltration of the liver

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Focal biliary cirrhosis with portal hypertension

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Gallstones

●

Pancreatic fibrosis due to recurrent Pancreatitis ❍

Diabetes mellitus

●

Sinusitis

●

Hypoplastic frontal sinuses

Clinically ●

Chronic cough, recurrent pulmonary infections

●

Higher incidence of asthma and allergy









LearningRadiology - Angiomyolipoma, AML


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Angiomyolipoma

● ● ●

●

●

●

Benign mesenchymal tumor of kidney Rare Histopathology ❍ No true capsule ❍ Commonly bleed ❍ Tumor composed of fat, smooth muscle, aggregates of thick-walled blood vessels Types ❍ Isolated angiomyolipoma is most common (80%) ■ Usually solitary ■ Unilateral (80% on right side) ■ Not associated with tuberous sclerosis ■ Mean age of incidence: 40s ■ Much more common in females ❍ Angiomyolipoma associated with tuberous sclerosis (in 20%) ■ Angiomyolipoma occurs in 80% of patients with tuberous sclerosis ● Commonly large ● Usually bilateral ● Usually multiple ■ May be only evidence of tuberous sclerosis ■ Mean age of incidence: teens ■ Equal incidence in males and females Signs and symptoms ❍ Small lesions are asymptomatic (60%) ❍ Acute flank / abdominal pain (due to hemorrhage) most common presenting symptom ❍ Hematuria (40%) ❍ Palpable mass (47%) ❍ Shock (due to massive retroperitoneal hemorrhage) Imaging findings ❍ Mostly small lesions <5 cm in diameter ❍ Many have a large exophytic component (25%) ❍ Calcifications not common (6%)

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LearningRadiology - Angiomyolipoma, AML ❍

❍

Plain film findings ■ Mass of fat lucency is lesion is large enough CT findings ■ Well-marginated, cortical-based, heterogeneous tumor predominantly of fat density (<20 HU) ■ Variable enhancement (smooth muscle, vessels)

Fat containing tumors are seen in both kidneys ❍

❍

❍

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●

US findings ■ Highly echogenic tumor due to high fat content ■ Less echogenic areas due to hemorrhage, necrosis, dilated calyces MRI findings ■ Intra-tumoral fat seen with fat-suppression technique ■ Variable areas of high signal intensity on T1WI Angiographic findings ■ Hypervascular mass (95%) ● Enlarged interlobar + interlobular feeding arteries ❍ Tortuous, irregular, aneurysmal, venous pooling, "sunburst" / "whorled" / "onion peel" appearance, no AV shunting Complications ❍ Angiomyolipomas >4 cm bleed spontaneously in 50-60% ■ Hemorrhagic shock from bleeding into angiomyolipoma or into retroperitoneum Treatment ❍ Annual follow-up of lesions <4 cm ❍ Emergency laparotomy is required in some including nephrectomy, tumor resection ❍ Selective arterial embolization can be done DDx ❍ Renal / perirenal lipoma or liposarcoma ❍ Wilms tumor ❍ Renal cell carcinoma which will occasionally contain fat ❍

Dahnert 4th edition









LearningRadiology - Psoriasis, Psoriatic arthritis


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Psoriatic Arthritis

Major points ● ● ●

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 ❍ ● ●

● ●

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

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LearningRadiology - Psoriasis, Psoriatic arthritis ❍ ❍ ❍

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 Reiter’s syndrome Inflammatory bowel disease

●

● ● ● ●

●

As with ankylosing spondylitis and Reiter’s syndrome, bone proliferation is a major feature. Manifests itself with: ❍ Bony excrescences ❍ Periosteal new bone formation (common) ❍ Entire phalanx may become “cloaked” in new bone ■ “Ivory phalanx” ● Most frequent in terminal phalanges of toes, especially first ❍ Ankylosis is common ■ Especially in PIP and DIP joints of hands and feet ● Feature common to seronegative spondyloarthropathies ❍ 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 ❍ Asymmetric paravertebral ossification ■ Usually thicker and larger than syndesmophytes of ankylosing spondylitis or inflammatory bowel disease ❍ Occasionally, there are incomplete non-marginal syndesmophytes similar to AS Bilateral sacroiliitis is most common ❍ May produce erosions and sclerosis ❍ May produce widening of the SI joints ❍ 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

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●

●

●

Incidence-uncommon ❍ 0.3% of general population; ❍ 4.3-11% of patients with CHD Two types ❍ Persistent left SVC connecting to right atrium via coronary sinus is only common anomaly of SVC (90% of this anomaly) ❍ In other 10%, persistent SVC connects to left atrium ■ Most with connection to left atrium have associated ASD or heterotaxy syndromes ■ This produces a right-to-left shunt of a rather small magnitude Etiology ❍ Failure of regression of left anterior and common cardinal veins and left sinus horn Course of persistent left SVC ❍ Draining into right atrium ■ Starts at junction of left subclavian vein and left internal jugular ■ Passes lateral to aortic arch ■ Receives left superior intercostal vein ■ Anterior to left hilum ■ Joined by hemiazygous system ■ Crosses posterior wall of left atrium ■ 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 ❍

● ● ●

Draining into left atrium ■ Starts at junction of left subclavian vein and left internal jugular ■ Passes lateral to aortic arch ■ Receives left superior intercostal vein ■ Anterior to left hilum ■ Joined by hemiazygous system ■ 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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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,

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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

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Incidence ❍ 7-12% in Western world population ❍ Peak age ■ 2nd-3rd decade Etiology ❍ Obstruction of appendiceal lumen by ■ Lymphoid hyperplasia ■ Fecolith ■ Foreign bodies ■ Stricture ■ Tumor ■ Parasite ■ Crohn’s disease Clinical findings ❍ RLQ pain over appendix is a positive McBurney sign ❍ Leukocytosis ❍ Fever ❍ Nausea and vomiting ❍ Relatively higher rate of misdiagnosis in women between ages 20-40 ■ May have an atypical location Imaging Findings ❍ Abdominal plain film (abnormalities seen in <50%) ■ Plain-film findings become more distinctive after perforation, while clinical findings subside ● May simulate other diseases ■ Calcified, frequently laminated, appendicolith in RLQ (in 7-15%) ● Appendicolith and abdominal pain = 90% probability of acute appendicitis ● Appendicolith in acute appendicitis means a high probability for perforation ■ "Cecal ileus" = local paralysis ■ Small bowel obstruction pattern ■ Soft-tissue mass and paucity or absence of intestinal gas in RLQ (more often with

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❍

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perforation) ■ Extraluminal gas bubbles (again more often in perforation) ■ Large pneumoperitoneum is rare because etiology of appendicitis involves obstruction of a very small lumen ■ Focal increase in thickness of lateral abdominal wall ■ Loss of properitoneal fat line on right side BE / UGI (accuracy 50-84%): ■ Failure to fill appendix with barium (normal finding in up to 35%) ■ 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) ■ Useful in ovulating women (false-negative appendectomy rate in males 15%, in females 35%): ■ Visualization of noncompressible appendix as a blind-ending tubular aperistaltic structure (seen only in 2% of normal adults, but in 50% of normal children) ■ Target appearance of >6 mm in total diameter on cross section (81%) ● Mural wall thickness >2 mm ■ Diffuse hypoechogenicity (associated with higher frequency of perforation) ■ Lumen may be distended with anechoic / hyperechoic material ■ Loss of wall layers ■ Visualization of appendicolith (6%) ■ Localized periappendiceal fluid collection ■ Prominent hyperechoic mesoappendix / pericecal fat Color Doppler US: ■ Increased conspicuity from increase (in size + number) of vessels in and around the appendix ■ Decreased resistance of arterial waveforms ■ Continuous / pulsatile venous flow CT (87-98% sensitive, 83-97% specific, 93% accurate) ■ Distended lumen ■ Circumferentially thickened and enhancing wall ■ Appendicolith = homogeneous / ringlike calcification (25%) ■ Periappendicular inflammation-linear streaky densities in periappendicular fat ■ Pericecal soft-tissue mass ■ Abscess ● Poorly encapsulated ● Single or multiple fluid collection(s) with air ● Extraluminal contrast material ■ Focal cecal wall thickening (80%) ■ "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) ●

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●

Complications ❍ Perforation (13-30%) Differential diagnosis (DDx) ❍ Colitis ❍ Diverticulitis ❍ Epiploic appendagitis ❍ Infectious enteritis ❍ Intussusception ❍ Crohn’s disease ❍ Mesenteric lymphadenitis ❍ Ovarian torsion ❍ Pelvic inflammatory disease Treatment ❍ Appendectomy ❍ 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

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Most common primary neoplasm of pleura Prevalence ❍ 2,000-3,000 cases/year in US Etiology ❍ Asbestos exposure ❍ Zeolite (nonasbestos mineral fiber) ❍ Chronic inflammation (TB, empyema) ❍ Radiation Peak age ❍ 50-70 years ❍ M:F = 4-6:1 Histology ❍ Epithelioid (60%) ❍ Sarcomatoid (15%) ❍ Biphasic (25%) ❍ 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 ❍ 20-45 years ■ Earlier than asbestosis ■ Later than asbestos-related lung cancer Pathology ❍ Multiple tumor masses involving predominantly the parietal pleura and to a lesser degree the visceral pleura ❍ Progresses to thick sheetlike / confluent masses resulting in lung encasement

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LearningRadiology - Mesothelioma ●

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Associated with ❍ Peritoneal mesothelioma ❍ Hypertrophic osteoarthropathy (10%) Staging (Boutin modification of Butchart staging) ❍ IA confined to ipsilateral parietal / diaphragmatic pleura ❍ IB+ visceral pleura, lung , pericardium ❍ II invasion of chest wall / mediastinum (esophagus, heart, contralateral pleura) or metastases to thoracic lymph nodes ❍ III penetration of diaphragm with peritoneal involvement or metastases to extrathoracic lymph nodes ❍ IV distant hematogenous metastases Stage at presentation ❍ II in 50% ❍ III in 28% ❍ I in 18% ❍ IV in 4% Clinical signs and symptoms ❍ Nonpleuritic (56%) / pleuritic chest pain (6%) ❍ Dyspnea (53%) ❍ Fever + chills + sweats (30%) ❍ Weakness, fatigue, malaise (30%) ❍ Cough (24%) ❍ Weight loss (22%) ❍ Anorexia (10%) ❍ Expectoration of asbestos bodies (= fusiform segmented rodlike structures = iron-protein deposition on asbestos fibers) Spread ❍ Contiguous: chest wall, mediastinum, contralateral chest, pericardium, diaphragm, peritoneal cavity; lymphatics, blood ❍ Lymphatic ■ Hilar + mediastinal (40%) ■ Celiac (8%) ■ Axillary + supraclavicular (1%) ■ Cervical nodes ❍ Hematogenous: lung, liver, kidney, adrenal gland Imaging findings ❍ Extensive irregular lobulated bulky pleural-based masses typically >5 cm / pleural thickening (60%) ❍ Exudative / hemorrhagic unilateral pleural effusion (30-60-80%) without mediastinal shift; effusion contains hyaluronic acid in 80-100%; bilateral effusions (in 10%) ❍ Distinct pleural mass without effusion (<25%) ❍ Associated with pleural plaques in 50% = pathologic HALLMARK of asbestos exposure ❍ Pleural calcifications (20%) ❍ Circumferential encasement = involvement of all pleural surfaces (mediastinum, pericardium, fissures) as late manifestation ❍ Extension into interlobar fissures (40-86%) ❍ Rib destruction in 20% (in advanced disease) ❍ Ascites (peritoneum involved in 35%) CT


LearningRadiology - Mesothelioma ❍ ❍ ❍ ❍ ❍ ❍ ❍ ❍

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 ●

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MR (best modality to determine resectability) ❍ Minimally hyperintense relative to muscle on T1WI ❍ Moderately hyperintense relative to muscle on T2WI Metastases to: ❍ Ipsilateral lung (60%) ❍ Hilar and mediastinal nodes ❍ Contralateral lung and pleura (rare) ❍ Extension through chest wall and diaphragm Prognosis ❍ 10% of occupationally exposed individuals die of mesothelioma (in 50% pleural + in 50% peritoneal mesothelioma) ❍ Mean survival time of 5-11 months DDx ❍ Pleural fibrosis from infection (TB, fungal, actinomycosis) ❍ Fibrothorax ❍ Empyema ❍ Metastatic adenocarcinoma Diagnosis ❍ 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

Paget’s Disease

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Multifocal chronic skeletal disease due to chronic paramyxoviral infection Prevalence ❍ 3% of individuals >40 years ❍ 10% of persons >80 years ❍ Unusual <40 years ❍ M:F = 2:1 Histology ❍ Increased resorption and increased bone formation ❍ Newly formed bone is abnormally soft with disorganized trabecular pattern Active or Osteolytic phase ❍ Aggressive bone resorption with lytic lesions ❍ Replacement of hematopoietic bone marrow by fibrous connective tissue with numerous large vascular channels Inactive or Quiescent phase ❍ Decreased bone turnover with skeletal sclerosis and thickening of the cortex Mixed pattern ❍ Lytic and sclerotic phases frequently coexist Clinical findings ❍ Asymptomatic (1/5) ❍ When symptomatic, symptoms may include ■ Fatigue ■ Enlarged hat size ■ Peripheral nerve compression ■ Neurologic disorders from compression of brainstem (basilar invagination) ■ Hearing loss, blindness ■ Facial palsy (narrowing of neural foramina) - rare ■ Pain from(a)primary disease process is rare so think of ● Pathologic fracture

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Malignant transformation ● Secondary degenerative joint disease aggravated by skeletal deformity ■ High-output congestive heart failure from markedly increased perfusion (rare) ■ Increased alkaline phosphatase (increased bone formation) ■ Hydroxyproline increased (increased bone resorption) ■ Normal serum calcium + phosphorus Sites of involvement ❍ Usually polyostotic and asymmetric ■ Pelvis (75%) most common, followed by ● Lumbar spine ● Thoracic spine ● Proximal femur ● Calvarium ● Scapula ● Distal femur ● Proximal tibia ● Proximal humerus Imaging Findings ❍ Classical triad ■ Thickening of the cortex ■ Accentuation of the trabecular pattern ■ Increased size of bone ❍ Cyst-like areas ❍ Skull (involvement in 29-65%) ■ Inner and outer table involved ● Leads to diploic widening ■ Osteoporosis circumscripta is well-defined lysis, most commonly in frontal bone producing well-defined geographic lytic lesion in skull ● Represents early destructive phase of disease active stage ●

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Osteoporosis circumscripta of frontal bone in lytic phase of Paget's disease ■

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


LearningRadiology - Osteoporosis circumscripta, Paget's Disease, Paget ■ ■ ■ ❍

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



Lymphoma or plasma cell myeloma are reported ❍ Fracture ■ "Banana fracture" = tiny horizontal cortical infractions (“Looser lines”) on convex surfaces of lower extremity long bones (lateral bowing of femur, anterior bowing of tibia) ■ Compression fractures of vertebrae ❍ Early-onset osteoarthritis Treatment ❍ Calcitonin, diphosphonate, mithramycin ❍ Detection of recurrence: ■ In 1/3 detected by bone scan ■ In 1/3 detected by biomarkers (alkaline phosphatase, urine hydroxyproline) ■ In 1/3 by scan and biomarkers simultaneously DDx ❍ Depends on the bone in which it occurs ❍ Skull ■ Osteolytic or osteoblastic metastases ❍ Long bones ■ Metastases ■ Chronic osteomyelitis (thickened cortex) ■ Old trauma (thickened cortex) ■ Hodgkin’s disease ❍ Spine ■ Hemangioma ■ Metastases ❍

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Dahnert 4th Edition














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LearningRadiology - Adrenal Adenoma


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Adrenal Adenoma Contributed by Shuchi Rodgers, MD

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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


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Size greater than 4 cm tend to be metastases or adrenal carcinoma ■ Heterogeneous appearance and irregular shape are malignant characteristics Homogeneous and smooth are benign characteristics ■ 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) ■ Threshold 10 HU ■ Sensitivity 79%, specificity 96% Contrast-enhanced CT (CECT) ■ Because majority of CT examinations in oncology use IV contrast, the % washout is useful after 10 minutes ■ Adenomas have greater than 50% washout after 10 minutes ■ Washout can also be used on adrenal masses that measure > 10 HU on NECT ■ Alternative is to do MR or PET

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Chemical Shift ■ Most sensitive method for differentiating adenomas from metastases ■ 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. ● 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 ■ Liver is not a reliable standard because of steatosis ■

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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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Kartagener’s Syndrome Dyskinetic Cilia Syndrome

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Classic triad consists of ❍ Situs inversus ❍ Sinusitis ❍ Bronchiectasis Other associations ❍ Transposition of great vessels ❍ Trilocular or bilocular heart ❍ Pyloric stenosis ❍ Postcricoid web ❍ Marfan’s syndrome ❍ Polysplenia ❍ Hepatic steatosis ❍ Hydrocephalus ❍ Usher’s syndrome ■ Deafness ■ Vestibular dysfunction ■ Retinitis pigmentosa All have ciliary dyskinesia in common Incidence ❍ 1:12,500-40,000 ❍ Autosomal recessive inheritance Ciliary dyskinesis can also be acquired ❍ Smokers most commonly Imaging findings ❍ Bronchial wall thickening ❍ Hyperinflation ❍ Segmental atelectasis or bronchiectasis ❍ Situs inversus is present in half of patients with Dyskinetic Cilia Syndrome

http://www.learningradiology.com/archives03/COW%20067-Kartegeners/kartegenerscorrect.htm (1 de 4)04/09/2006 2:23:47


Upper CT shows dextrocardia and bronchiectasis at both bases; lower CT shows situs inversus of abdominal organs ❍

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Bronchiectasis is indistinguishable from bronchiectasis of many other causes ■ 50% occurs in lower lobes Clinically ❍ Sinusitis ❍ Recurrent bronchitis ❍ Bronchiectasis ❍ Male sterility ❍ Corneal abnormalities and poor sense of smell Pulmonary function test abnormalities ❍ Small airway dysfunction ❍ Increased bronchial responsiveness to methacholine

Fraser and Pare, 4th Edition







LearningRadiology - Spigelian hernia


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Splenic Laceration Contributed by David Allen, MD

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Most frequently injured solid parenchymal organ in blunt trauma to the abdomen Splenic injury often associated with other organ injuries ❍ 20% with left rib fractures ❍ 25% with left renal injury ❍ 40% with splenic laceration have rib fractures Subcapsular hematoma ❍ Crescentic low-attenuation area ❍ Usually along lateral margin ❍ Flattens normal convex margin of spleen Parenchymal lesion ❍ Indistinct splenic margin ❍ Inhomogeneous enhancement ❍ Fractured spleen ■ Complete separation of fragments ❍ Intrasplenic hematoma ■ Rounded mass ■ Disrupted splenic capsule ■ Often has associated hemoperitoneum

http://www.learningradiology.com/archives03/COW%20068-Splenic%20laceration/spleniclaccorrect.htm (1 de 5)04/09/2006 2:23:50


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). ●

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Pitfalls in diagnosis ❍ Normal lobulation or cleft mimics tear ❍ Adjacent unopacified bowel loop (jejunum) simulates splenic tissue ■ Looks like laceration ❍ Scans taken too early after bolus ■ Spleen can be inhomogeneous due to differential enhancement of red and white pulp ❍ Previous infarct can mimic laceration ❍ Perisplenic fluid from ascites or lavage mimics hemoperitoneum Grades of laceration ❍ Grade I: small laceration < 1cm and small subcapsular hematoma ❍ Grade II: moderate laceration 1-3cm and moderate subcapsular hematoma ❍ Grade III: large laceration > 3cm not involving hilum with large subcapsular hematoma ❍ Grade IV: laceration involving the hilum ❍ Grade V: destroyed spleen If part of hematoma is isodense to arterial blood on an enhanced CT there is active extravasation Treatment ❍ Follow clinically ❍ Arterial embolization/coiling ❍ Splenorrhaphy ❍ Splenectomy Treatment options ❍ The higher the grade the more likely the need for an intervention ❍ Grade I and II are usually followed clinically unless they worsen ❍ 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 ● ● ●

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20% of all benign ovarian tumors Women usually between 20 - 60 years Present clinically as cystic adnexal masses ❍ Increasing abdominal girth 15% are bilateral Imaging findings ❍ Average 5-10cm (frequently grow larger) ❍ May be indistinguishable from simple cysts ■ Or they may have thin septations and occasionally papillary projections ❍ 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 ❍

Lined by a single layer of non-ciliated cuboidal to tall columnar epithelium

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Straw-colored fluid within them is usually blood tinged

Serous Cystadenocarcinoma ●

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Most common malignant tumor of the ovary ❍ 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 ❍ Rare under age 35 Histological characterization ❍ Cells vary from well-differentiated to poorly differentiated tumors



Ciliated cells common ❍ Psammoma bodies (calcified concretions) present in 33% Imaging findings ❍ Predominantly cystic but with variable solid component ❍ Usually multi-loculated ❍ Solid areas can have areas of necrosis and hemorrhage ❍ Many >10cm at time of diagnosis ❍ May produce ascites and omental caking if metastases Intra-abdominal dissemination at initial time of surgery common ❍ “Omental cake” on CT Staging for Primary Carcinoma of the Ovary ❍ Stage I. Growth limited to the ovaries ■ Ia. One ovary involved ■ Ib. Both ovaries involved ■ Ic. Ia or Ib and ovarian surface tumor, ruptured capsule, malignant ascites, or malignant peritoneal cytology ❍ Stage II. Disease extension from the ovary to the pelvis ■ IIa. Extension to the uterus or fallopian tube ■ IIb. Extension to other pelvic tissues ■ IIc. IIa or IIb and ovarian surface tumor, ruptured capsule, malignant ascites, or malignant peritoneal cytology ❍ Stage III. Disease extension to the abdominal cavity ■ IIIa. Abdominal peritoneal surfaces with microscopic metastases ■ IIIb. Tumor metastases <2 cm ■ IIIc. Tumor metastases >2 cm, or metastatic disease in the pelvic, para-aortic or inguinal lymph nodes ❍ Stage IV. Distant metastatic disease ■ Malignant pleural effusion ■ Pulmonary parenchymal metastases ■ Liver or splenic parenchymal metastases ■ Metastases to the supraclavicular lymph nodes or skin Cancer staging dictates treatment and predicts prognosis ❍ Stage 1 ■ Usually TAH and BSO ■ With or without chemotherapy ❍ > Stage 1 ■ Usually TAH and BSO ■ Surgical debulking of tumor, if needed ■ Chemotherapy 5-year survival rate for all types is 20 - 35% ❍

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LearningRadiology - Rolando Fracture


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Rolando's Fracture Four Fractures of the Wrist

Rolando's Fracture ● ● ● ●

Comminuted Intra-articular Fracture through base of thumb Prognosis: worse than Bennett's fracture (difficult to reduce)

Bennett's Fracture ●

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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 ●

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Colles' Fracture

Intra-articular fracture of the dorsal margin of the distal radius Extends into radio-carpal joint

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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

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First 24 hours, postpneumonectomy side contains only air ❍ Slight shift of the mediastinum toward the pneumonectomized side ❍ Slight elevation of ipsilateral hemidiaphragm Postpneumonectomy space fills with serosanguineous fluid at rate of 2 rib spaces/day ❍ By end of 2 weeks, 80-90% of space obliterated ❍ By 4 months, complete obliteration Mediastinum gradually shifts more toward side of pneumonectomy ❍ Maximum shift at 6-8 months Failure of this ipsilateral shift almost always indicates an abnormality in the postpneumonectomy space, including: ❍ BP fistula ❍ Empyema ❍ Hemorrhage ❍ 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 ❍ Causes ■ Recurrent neoplasm ■ BP fistula ■ Hemorrhage ■ Chylothorax ■ Empyema Rare complications

http://www.learningradiology.com/archives03/COW%20071-BP%20fistula/bpfistulacorrect.htm (1 de 5)04/09/2006 2:23:57


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Herniation of the heart through a pericardial defect after radical pneumonectomy with a partial pericardiectomy Post-pneumonectomy syndrome ■ More on right side ■ More in children and adolescents ■ Produces marked rightward and posterior displacement of the mediastinum ■ This, in turn, produces clockwise rotation of the heart and great vessels ● Trachea and left main bronchus are compressed between the aorta and pulmonary artery ❍ Leads to dyspnea and recurrent left-sided pneumonia ■ Displacement of the overinflated left lung into the anterior right hemithorax

• Broncho-pleural fistula o o o

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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



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

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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 • •

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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— SHONE’S Syndrome • Shone’s 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 Fabry’s Disease § Deposition of aramide trihexoside thickens and decreases mobility of mitral leaflets o Hurler’s Syndrome § Deposition of mucopolysaccharide thickens and decreases mobility of mitral leaflets o Whipple’s 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



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§ 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

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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



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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

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Overdistension of the appendix with mucous 2° to luminal obstruction by fecolith or foreign body, carcinoid or endometriosis

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Mean age - 55 years

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M:F = 1:4

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Very rare

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Associated with

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Colonic adenocarcinoma

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Mucin-secreting tumor of ovary

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Asymptomatic (25%)

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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 ●

Peripheral, rim-like calcification may occur

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Low attenuation content on CT

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Purely cystic

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Cystic with fine internal echoes

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Complex cystic mass with high-level echoes

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Gravity-dependent echoes = layering of protein macroaggregates / inspissated mucoid material

May rupture and produce pseudomyxoma peritonei ❍

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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 ❍


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May present as appendicitis

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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) ❍ Stage I ■ Isolated rotatory subluxation of scaphoid ● Mechanism: acute dorsiflexion of wrist ● May be associated with rheumatoid arthritis ● Characterized by increased distance between scaphoid and lunate > than 2 mm (Terry Thomas sign) ● Scaphoid ring sign – ring-shaped shadow of cortex of distal pole of scaphoid seen on end ● Associated more than 50% of the time with distal radial fractures ❍ Stage II ■ Dislocation or subluxation of capitate ● Exceedingly rare ❍ Stage III ■ Perilunate dislocation ● Triquetrial and scaphoid malrotation ● 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

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Perilunate dislocation - Lunate maintains normal position while all other carpal bones dislocate posterior to it ❍

Stage IV ■ Lunate Dislocation ● 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

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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Small Bowel Lymphoma Submitted by Tony Chang, MD

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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

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Most cases of small bowel lymphoma are due to non-Hodgkin’s lymphoma Mesenteric involvement by lymphoma may occur by o Direct extension from bowel o Indirectly by displacement due to mass effect

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Risk factors include o Immunocompromised or immunosuppressed state o Long-term celiac sprue o Chronic lymphocytic leukemia

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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

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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

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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

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Differential diagnoses include o Tuberculosis o Inflammatory small bowel disease and carcinoma.

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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

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Anteromedial on right §

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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

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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

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Elevation of the Hemidiaphragm Causes o Subpulmonic effusion § • •

Dome is laterally displaced Straight edge of anterior “diaphragm” seen on lateral at major fissure

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Decreased lung volume

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• Atelectasis Hypoplastic lung

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• Small pulmonary artery, dextrocardia, scimitar vein Poor inspiration Phrenic Nerve Paralysis



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• BrCa • Mets • Iatrogenic-post CABG Idiopathic

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Abdominal Disease

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Subphrenic abscess

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Right=subhepatic-appendicitis Left 2° ulcer perforation

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Liver mass Interposition of the colon Distended stomach

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Congenital Diaphragmatic Hernia Traumatic Rupture of the Diaphragm Eventration of the Diaphragm

Congenital Diaphragmatic Hernia o General Absence of closure of pleuroperitoneal fold § §

o

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9th gestational week

§ Male to female ratio of 2:1 1:2,000 live births § Left > right 9:1 § Associated Anomalies CNS–neural tube defects § GI–malrotation, omphalocoeles § CV § GU § IUGR § Bochdalek Hernia 90% of congenital hernias § Posterolateral defect § §

§ § § §

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Abnormality of cephalic fold of pleuroperitoneal membrane

Left (80%), right (15%), B/L (5%) Babies–large Adults–small Organs Involved Bowel • Spleen • Fat • Liver (left lobe) • Kidney, pancreas • • Stomach The “B’s” • Babies • Back • Big



o

Morgagni Hernia Anteromedial parasternal defect (Space of Larrey) § §

Maldevelopment of septum transversum

§ § §

Overweight, middle-aged, women Right > left (heart protects) Associated with •

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§

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• Omental fat in pericardial space Organs Involved Liver • Bowel • The “M’s” Middle (anterior and central) • Mature (older children) • Miniscule •

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 •

o

o

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Pericardial defects

Respiratory distress may increase as intestine occupies more of thorax

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Some loops may remain fluid-filled Mediastinal shift to the opposite side Relative paucity of gas in abdomen

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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 (5–50%) o

2° increased intra-abdominal pressure

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§ MVA Fall from height § Penetrating trauma (50%) §

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Knife, bullet

General 5% of all diaphragmatic hernias §



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Most (90%) are left-sided

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Central and posterior >10cm in length Contain stomach, colon, small bowel, omentum, spleen

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Half have no initial abnormal radiographic findings Half are missed clinically Associated with

§

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o

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§ 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

o

Usually projects to left of spine

Paralysis of the Hemidiaphragm Most often from phrenic nerve involvement o §

Neoplasms, CABG surgery (2° ice)

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Idiopathic

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Males, right hemidiaphragm

o

Sniff test ■ Paradoxical upward motion on affected side Normal excursion of 1-2 ribs § • •

§

o

Breathe in, diaphragm down Breathe out, diaphragm up

Paralyzed – paradoxical motion • •

Breathe in, diaphragm up Breath out, diaphragm down

§ Useless with large effusion Paralysis of the hemidiaphragm versus eventration §

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Fx ribs Pneumoperitoneum Ruptured spleen

Diaphragmatic motion is paradoxical in paralysis but not with Eventration

Bilateral Paralysis of the Diaphragm Less common than unilateral o



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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)

o

Mets occur via direct extension from pleura or lung







, breakdancer's,breakdancers


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Gamekeeper’s Thumb AKA: Skier’s Thumb, Break-dancer’s Thumb

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Chronic injury to ulnar collateral ligament (UCL) of thumb first seen in gamekeepers in Scotland ❍ Because of the method they used to kill rabbits Acute injury now more common amongst skiers ❍ Called "Skier's thumb” ■ Due to fall on fall on outstretched hand with abducted thumb caught in pole strap ■ 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 ❍ 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 ●

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Torn end of ulnar collateral ligament can be displaced to the abductor pollicis aponeurosis ❍ Called Stener lesion ■ Distal portion of ligament retracts and points superficially and proximally ■ Rupture of both the proper and accessory collateral ligaments must occur for this to happen ■ Produces a lump over medial aspect of the MCP joint of thumb Full evaluation requires abduction stress views st metacarpal and proximal phalanx ❍ Increase of more than 30° in angle between 1 ■ Indicates subluxation Treatment ❍ Complete ruptures of the UCL require surgical intervention for repair within the first 3 weeks of the injury ■ Best done in 1st week while the anatomy is maintained ■ Complete tears repaired after 3 weeks have increased incidence of weakness and pain on pinch grasp. ❍ 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

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Intrathoracic disease (90%)

Stage I • •

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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-broker’s 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

Patterns of lung disease • • •

Reticulonodular (46%) Acinar pattern (20%) Larger nodules

o “Alveolar sarcoid” (2%) o Coalescence of numerous interstitial granulomas o Air bronchograms present http://www.learningradiology.com/archives03/COW%20078-Sarcoid%20lung/sarcoidcorrect.htm (2 de 6)04/09/2006 2:24:21


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DDX o Alveolar cell ca o Alveolar proteinosis o Lymphoma

Uncommon manifestations • •

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

Extrathoracic disease • •

Peripheral adenopathy (30%) Liver o Hepatomegaly

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Spleen o Splenomegaly

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Bone-especially hands Skin o Erythema nodosum o Lupus pernio (raised purplish nodules)

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Muscle o Myopathy Eyes o Uveitis o Uveoparotid fever

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CNS o Granulomatous meningitis o Facial nerve palsy

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Myocardium o Arrhythmias o Heart block o Cardiomyopathy

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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

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Most frequently injured abdominal organ after spleen Most often due to deceleration injuries ❍ Often seen in association with ■ Right-sided rib fractures ■ Right-sided pneumothorax ■ Right lung contusion ■ Injuries to the right kidney or adrenal gland Injuries include ❍ Subcapsular hematoma ❍ Laceration ❍ Intrahepatic hematoma ❍ Contusion Right lobe more often injured than left ❍ Injury to left lobe associated with injury to duodenum, pancreas, transverse colon ■ More often due to direct blows to the epigastrium High association with injuries to other organs ❍ 45% with liver injuries have splenic injury Subcapsular hematomas ❍ Lenticular configuration ❍ Flattens adjacent liver ❍ Often adjacent to rib fracture ❍ Most occur in antero-lateral aspect of right lobe Liver Laceration ❍ Non-enhancing region, linear or branching ❍ Frequently parallel hepatic vein ❍ Hypodense wedge extending to liver surface ■ Focal hepatic devascularization ❍ Periportal tracking of blood

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LearningRadiology-Liver laceration, hepatic laceration, rupture ■ ■

Frequent finding Sometimes only evidence of injury ● Due to dissecting hemorrhage ● Bile ● 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 ●

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Hematoma ❍ Higher attenuation than surrounding liver on unenhanced CT scan ❍ Lower attenuation than surrounding liver on enhanced CT scan ❍ Central high attenuation region containing clot ❍ Hepatic vein laceration usually involves right hepatic vein near vena cava Contusion ❍ Rare lesions ❍ Low attenuation area compared to normally enhanced liver ❍ Do not disrupt major portal or hepatic venous structures Hemoperitoneum Complications ❍ Delayed rupture (rare) ❍ Hemobilia ❍ Arteriovenous fistula ❍ Pseudoaneurysm ❍ Biloma ❍ Superinfection of hematoma Pitfalls ❍ Adjacent rib artifacts-beam-hardening ■ Mimics laceration ● Adjacent to ribs ● Fade as they become farther from rib ❍ Linear artifact from air-contrast level in stomach ❍ Fatty liver with laceration or hematoma can be missed


LearningRadiology-Liver laceration, hepatic laceration, rupture ■ ●

Clue- look at intrahepatic ducts and vessels

Treatment ❍ Conservative treatment in up to 80% in adults and almost all children ■ Monitor hemodynamic state of patient ❍ Transcatheter embolization possible for bleeders ❍ Healing ■ 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-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 ❍ Supposed to migrate along urogenital ridge to primitive gonad ❍ Journey is interrupted in the mediastinum May be solid or cystic ❍ Most are cystic Three major categories ❍ Mature teratomas ■ Well-delineated from surrounding tissues ■ Contain ectodermal elements along with cartilage, fat and smooth muscle ❍ Immature teratomas ■ Same elements as above with primitive tissues found in fetus ❍ Teratomas with malignant transformation ■ Overall about 30% are malignant ■ Usually adenocarcinoma in mature teratomas ■ 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 life—young adults most commonly ❍ DDX from thymomas which usually occur in 5th or 6th decade Symptoms ❍ Usually asymptomatic ❍ Large lesions can cause shortness of breath, cough or retrosternal pain or fullness ❍ Rare rupture of dermoid into trachea which leads to trichoptysis—expectoration of hair Associations ❍ Non-lymphocytic leukemia and malignant histiocytosis with immature teratomas Imaging findings ❍ Most occur in the anterior mediastinum, near junction of great vessels and heart ❍ Benign lesions are usually smooth in contour whereas malignant masses tend to be lobulated

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LearningRadiology-Teratoma, Mediastinal Teratoma, Germ Cell Neoplasms ❍ ❍

❍

Usually larger than thymomas Calcification may rarely occur but is of no help since thymomas also calcify ■ 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 ■ 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 ❍ ●

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Rapid increase in size may mean hemorrhage into a cyst rather than enlarging malignancy Treatment and prognosis ❍ Mature teratomas ■ For benign cystic teratomas, surgical resection ■ Excellent prognosis ❍ Immature teratomas ■ In childhood, surgical excision is often successful ■ In adults, tend to have a more malignant course ❍ Teratomas with malignancy ■ Usually highly aggressive ■ Poor prognosis Teratoma versus dermoid ❍ Dermoid contain only epidermis ❍ Teratomas contain all 3 germ layers, but are mostly endodermal when malignant Other germ cell neoplasms ❍ Benign dermoid cysts ❍ Benign and malignant teratomas ❍ Seminomas ❍ Choriocarcinomas ❍ Embryonal cell carcinomas Mediastinal seminomas ❍ Rare ❍ Almost always in young men ❍ Identical to testicular seminoma and ovarian dysgerminoma ❍ May be well-encapsulated or invasive ❍ Tends to be lobulated



Cannot be differentiated from teratoma Primary choriocarcinoma ❍ Even rarer than seminoma in the mediastinum ❍ Only 23 reported in the literature, almost all in men ❍ Occur between 20-30 years ❍ May be lobulated ❍ 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 ❍

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Fraser and Pare







LearningRadiology-Hodgkin's Disease, Lymphoma


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Hodgkin’s Disease

Half of patients with Hodgkin’s 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 Hodgkin’s have enlarged nodes, the disease behaving most benignly when restricted to the neck l Most have nodular sclerosing type l l

Imaging Findings l

l

Parenchymal involvement occurs in 1/3 of patients with Hodgkin’s 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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LearningRadiology-Hodgkin's Disease, Lymphoma 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 http://www.learningradiology.com/archives04/COW%20081-Hodgkins/hodgkinscorrect.htm (2 de 5)04/09/2006 2:24:35


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

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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 ❍ Lead may be inhaled as well as ingested ■ Symptoms develop more quickly through GI tract ■ Toxicity more severe with co-existing iron, zinc, or calcium deficiency Pathology ❍ Lead concentrates in metaphyses of growing bones ■ Distal femur ■ Both ends of tibia ■ Distal radius leading to ● Failure of removal of calcified cartilaginous trabeculae in provisional zone Clinical findings ❍ Neurological ■ Learning disability ■ Decreased IQ ■ Mental retardation ■ Encephalopathy ■ Motor deficits ■ Seizures ■ Cerebral edema ■ Hearing loss ❍ Gastrointestinal ■ Abdominal pain ■ Nausea ■ Vomiting ■ Diarrhea ❍ ❍

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Lead poison, Plumbism, lead intoxication ■ ■ ■ ■ ❍

Constipation Anorexia Metallic taste in mouth Ileus

Renal

Tubular damage ● Azotemia ■ Gout ❍ Hematologic ■ Affects blood synthesis ■ Hemolysis ■ RBC stippling ■ Iron deficiency ❍ Musculoskeletal ■ Muscle and joint pain ❍ Soft tissue ■ Blue-black line in gum margins ❍ Endocrine ■ Decreased stature ● Decreased growth hormone ■ Decreased vitamin D levels Laboratory findings ❍ Predate bone changes on x-ray ❍ Serum Lead Level >1.2 umol/L ❍ Urine lead level elevated ❍ Peripheral Smear ■ Stippled erythrocytes ❍ Complete Blood Count ■ Microcytic Anemia ■ Leukocytosis ❍ Urine microscopy of sediment or renal biopsy ■ Acid-fast inclusion bodies in tubular nuclei ● Pathognomonic for lead poisoning ❍ Free Erythrocyte Protoporphyrin (FEP) > 0.6 umol/L Imaging findings ❍ Cerebral edema in acute lead intoxication ❍ Particles of lead in GI tract ❍ Bands of increased density at metaphyses of tubular bones (growing bone) ■ Metaphyses of growing bones may be dense normally ● Lead lines more apt to be seen in proximal fibula and distal ulna where growth is not as great as other long bones ■ Lead lines may persist ■

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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 ❍ ❍

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Bone-in-bone appearance Abnormalities in bone modeling ■ Erlenmeyer flask appearance to distal femur DDx (see tables below) Treatment ❍ Surgical removal of lead foreign bodies in the gut (e.g. dice containing lead) if not eliminated within 2 weeks ❍ Chelation is indicated if the level is greater than 45 mcg/dL even if asymptomatic ■ First correct iron deficiency ❍ Chelating agents include EDTA, BAL, D-Penicillamine, and Succimer

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

o

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

May have ground-glass appearance

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May occasionally calcify centrally (20%)

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Lymph node enlargement common § Eggshell calcification of hilar nodes (5%) •

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DDx: Sarcoidosis

o Large opacities are conglomerations of small opacities Complicated Silicosis (Progressive Massive Fibrosis—PMF) 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

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Progressive Massive Fibrosis (PMF) may cavitate from tuberculosis or ischemic necrosis

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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

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Caplan’s Syndrome o Consists of large necrobiotic nodules (rheumatoid nodules) superimposed on silicosis or coal worker’s 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

Differential Diagnosis 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 ❍ C. albicans ❍ 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 ❍ Depressed immunity ■ AIDS ■ Hematologic disease ■ Renal transplant ■ Leukemia ■ Chronic debilitating disease ❍ Diabetes mellitus ❍ Steroids ❍ Chemotherapy ❍ Radiotherapy ❍ Diseases which cause delayed esophageal emptying ■ Scleroderma ■ Strictures ■ Achalasia ■ S/P fundoplication ❍ Rarely may occur in otherwise healthy individuals Produces whitish slightly raised plaques Symptoms ❍ Dysphagia ❍ Odynophagia

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Intense substernal pain ❍ Associated with oral thrush (oropharyngeal moniliasis) in 20-80% Location ❍ Predilection for upper 1/2 of esophagus ■ Involvement of long esophageal segments Imaging Findings ❍ Discrete plaque-like lesions ❍ Plaques line-up longitudinally = grouping of tiny 1-2 mm nodular filling defects with linear orientation ❍ Larger plaques may coalesce to produce "cobblestone" appearance ❍ Further coalescence produces “shaggy” contour (from coalescent plaques, pseudomembranes, erosions, ulcerations, intramural hemorrhage) in fulminant candidiasis ■ More fulminant form is more often associated with AIDS ❍

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Double-contrast esophagram shows markedly nodular mucosa with multiple discrete ulcers covering all of esophagus ❍

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Ulcers invariably appear only on a background of diffuse plaque formation, not as isolated findings Long, smoothly-tapering strictures may develop but are rare ■ More likely to develop in patients with cutaneous manifestations of Candidiasis Mycetoma resembling large intraluminal tumor is rare Diagnosis ❍ Endoscopy most sensitive method of making diagnosis for mild cases ❍ Double-contrast esophagography should pick up 90% of cases Treatment ❍ Mycostatin® ❍ Findings usually regress quickly Differential Diagnosis ❍ Glycogenic esophagitis – asymptomatic nodularity ❍ Reflux esophagitis – distal esophagus, nodules poorly defined ❍ Superficial spreading carcinoma- nodular and irregular folds ❍ Artifacts (undissolved effervescent crystals, air bubbles, retained food particles) ❍ Herpes esophagitis – discrete ulcers surrounded by halo of edema


LearningRadiology-Candida Esophagitis, Candida, Candidiasis, Moniliasis, Monilial Esophagitis, AIDS, HIV ❍ ❍

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Acute caustic ingestion – long strictures are common Intramural pseudodiverticulosis – unlike ulcers, pseudodiverticula don’t 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 ● ● ●

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Calcification of gallbladder wall So named because of its gross appearance and its similarity to porcelain Incidence: ❍ Less than 1% of cholecystectomy patients ❍ F:M 5:1 Histology ❍ Flakes of dystrophic calcium within chronically inflamed and fibrotic muscular wall ❍ Wall is thickened and gallbladder is contracted Associated with gallstones in 90% ❍ Cystic duct is always obstructed ❍ 80% of patients with carcinoma of gallbladder have stones Minimal symptoms Imaging findings ❍ 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 ■ DDx: stone-filled contracted GB Echogenic GB wall with little acoustic shadowing ■ DDx: emphysematous cholecystitis Scattered irregular clumps of echoes with posterior acoustic shadowing Imaging pitfall ❍ Contracted gallbladder with calcified wall can be mistaken for a gallstone Complication ❍ 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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Incidence ❍ Up to 10% of injuries coming to emergency room with blunt trauma Cause ❍ Motor vehicle accident ❍ Contact sports ❍ Falls and fights ❍ Less often penetrating wounds Mechanism ❍ Direct blow (>80%) frequently compressed and often lacerated by lower ribs ❍ Acceleration-deceleration injuries can produce renal artery tears Associated with other organ injury in 20% of cases Signs and symptoms ❍ >95% hematuria ■ 25% of patients with gross hematuria have significant injuries ■ But, 24% of patients with renal pedicle injury have no hematuria ■ Only 1-2% with microhematuria have a severe renal injury Types of injuries

CT Classification of Renal Trauma CT Grade

Injury

Usual Treatment

Grade I

Superficial cortical laceration, contusion and/or perirenal hematoma

Observation

Grade II

Deep corticomedullary laceration involving the collecting system

Grade III

Renal crush injury and/or main vascular pedicle injury

Surgery

Grade IV

Injury of the renal pelvis or the ureteropelvic junction

Surgery

Observation or surgery

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Renal contusion Superficial cortical laceration (75-85%) Small cortical laceration without calyceal disruption Complete cortical laceration ■ Fracture communicating with calyceal system (10%) ● Extraluminal contrast material ● 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 ■ Usually involves injury to the renal vascular pedicle (5%) ■ Multiple separate renal fragments ● Lack of enhancement of part or all of kidney ■ Extraluminal contrast material ❍ Subcapsular hematoma Imaging Findings ❍ Focal patchy areas of decreased enhancement / striated nephrogram = contusion ❍ Irregular linear hypodense parenchymal areas = renal laceration ❍ Laceration connecting two cortical surfaces = fracture ❍ Multiple separated renal fragments ± perfusion = shattered kidney ❍ Superficial crescentic hypodense area compressing adjacent parenchyma = subcapsular hematoma ■ Subcapsular / perinephric hematoma usually proportional to extent of injury ❍ Wedge-shaped perfusion defect = segmental arterial injury ❍ Diffuse non-perfusion of kidney = devascularized kidney ❍ Persistent nephrogram on delayed scans = renal vein thrombosis ❍

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Injury Contusion (75-80%)

How do you recognize it focal patchy areas of decreased enhancement



Laceration

irregular linear hypodense parenchymal areas

Fracture

laceration connecting two cortical surfaces

Crush injury

multiple separated renal fragments ± perfusion

Calyceal or pelvic injury

Extraluminal contrast

Vascular pedicle injury

Wedge-shaped or diffuse non-perfusion of kidney

Subcapsular hematoma

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 ❍ Most commonly: sigmoid & cecum ❍ Rarely: stomach, small intestine, transverse colon ❍ Results in partial or complete obstruction ❍ May also compromise bowel circulation resulting in ischemia Sigmoid volvulus most common form of GI tract volvulus ❍ 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 à twisting of sigmoid colon around mesenteric axis ❍ Other predisposing factors ■ Chronic constipation ■ High-roughage diet (may cause a long, redundant sigmoid colon) ■ Roundworm infestation ■ Megacolon (often due to Chagas dz) 20-25% mortality rate Peak age > 50 yrs. ❍ Second largest group à children Torsion usually counterclockwise ranging from 180 – 540 degrees Luminal obstruction generally @ 180 degrees Venous occlusion generally @ 360 degrees à gangrene & perforation Signs and symptoms ❍ May present as abdominal emergency ■ Acute distension ■ Colicky pain (often LLQ) ■ Failure to pass flatus or stool (constipation is prevailing feature) ❍

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Vomiting is late sign ❍ Distention may compromise respiratory & cardiac function ❍ May also present with surprisingly few signs and symptoms in bedridden and debilitated Physical examination ❍ Tympanitic abdomen ❍ Abdominal distention ❍ +/- palpable mass ■

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Diagnosis ❍

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Abdominal plain films usually diagnostic ■ Inverted U-shaped appearance of distended sigmoid loop ● Largest and most dilated loops of bowel are seen with volvulus ■ Loss of haustra ■ Coffee-bean sign à midline crease corresponding to mesenteric root in a greatly distended sigmoid ● Sigmoid volvulus – bowel loop points to RUQ ● Cecal volvulus – bowel loop points to LUQ ❍ Dilated cecum comes to rest in left upper quadrant ■ Bird’s-beak or bird-of-prey sign à 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 ·

Differential Diagnosis ❍ ❍ ❍

·

Large bowel obstruction due to other causes à sigmoid colon CA Giant sigmoid diverticulum Pseudoobstruction

Complications


LearningRadiology-Sigmois volvulus, volvulous, large bowel obstruction, radiology, photo, x-ray ❍ ❍ ❍

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 ❍ ❍ ❍

Laparoscopic derotation or laparotomy +/- bowel resection Cecopexy à suture fixation of bowel to parietal peritoneum may prevent recurrence Recurrence rate after decompression alone à 50%







LearningRadiology-Rickets


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Rickets

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Osteomalacia during enchondral bone growth Age ❍ 4-18 months Histology ❍ Zone of preparatory calcification does not form resulting in build-up of maturing cartilage cells ❍ Also occurs in shafts so that osteoid production elevates periosteum Clinical findings ❍ Irritability ❍ Bone pain ❍ Tenderness ❍ Craniotabes ❍ Rachitic rosary ❍ Bowed legs ❍ Delayed dentition ❍ Swelling of wrists and ankles Location ❍ Metaphyses of long bones subjected to stress are particularly involved ■ Wrists ■ Ankles ■ Knees Imaging findings ❍ Cupping and fraying of metaphysis ❍ Poorly mineralized epiphyseal centers with delayed appearance ❍ Irregular widened epiphyseal plates (increased osteoid) ❍ Increase in distance between end of shaft and epiphyseal center ❍ Cortical spurs projecting at right angles to metaphysis ❍ Coarse trabeculation (not the ground-glass pattern found in scurvy) ❍ Periosteal reaction may be present

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Metaphyseal cupping and fraying in the distal radius and ulna in rickets ❍

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Deformities common ■ Bowing of long bones ■ Molding of epiphysis ■ Fractures ■ Frontal bossing Causes Of Rickets ❍ Abnormality In Vitamin D Metabolism ■ Associated with hyperparathyroidism ■ Vitamin D deficiency ● Dietary lack of vitamin D ● Famine osteomalacia ■ Lack of sunshine exposure ■ Malabsorption of vitamin D ● Pancreatitis and biliary tract disease ● Steatorrhea, celiac disease, postgastrectomy ● Inflammatory bowel disease ❍ Defective conversion of vitamin D to 25-OH-cholecalciferol in liver ■ Liver disease ■ Anticonvulsant drug therapy (= induction of hepatic enzymes that accelerate degradation of biologically active vitamin D metabolites) ❍ Defective conversion of 25-OH-D3 to 1,25-OH-D3 in kidney ■ Chronic renal failure = renal osteodystrophy ■ Vitamin D-dependent rickets = autosomal recessive enzyme defect of 1-OHase Abnormality In Phosphate Metabolism ❍ Not associated with hyperparathyroidism secondary to normal serum calcium ❍ Phosphate deficiency ■ Intestinal malabsorption of phosphates



Ingestion of aluminum salts [Al(OH)2] forming insoluble complexes with phosphate ■ Low phosphate feeding in prematurely born infants ■ Severe malabsorption state ■ Parenteral hyperalimentation ■ Disorders of renal tubular reabsorption of phosphate ● Renal tubular acidosis (renal loss of alkali) ● deToni-Debré-Fanconi syndrome = hypophosphatemia, glucosuria, aminoaciduria ● Vitamin D-resistant rickets ● Cystinosis ● Tyrosinosis ● Lowe syndrome ❍ Hypophosphatemia with nonendocrine tumors ■ Oncogenic rickets - elaboration of humeral substance which inhibits tubular reabsorption of phosphates ● Sclerosing hemangioma ● Hemangiopericytoma ● Ossifying mesenchymal tumor ● Nonossifying fibroma ❍ Hypophosphatasia Calcium Deficiency ❍ Dietary rickets = milk-free diet (extremely rare) ❍ Malabsorption ❍ Consumption of substances forming chelates with calcium Classification Of Rickets ❍ Primary vitamin D-deficiency rickets ❍ Gastrointestinal malabsorption ■ Partial gastrectomy ■ Small intestinal disease: gluten-sensitive enteropathy / regional enteritis ■ Hepatobiliary disease: chronic biliary obstruction / biliary cirrhosis ■ Pancreatic disease: chronic pancreatitis ❍ Primary hypophosphatemia; vitamin D-deficiency rickets ❍ Renal disease ■ Chronic renal failure ■ Renal tubular disorders: renal tubular acidosis ■ Multiple renal defects Hypophosphatasia and pseudohypophosphatasia ❍ Fibrogenesis imperfecta osseum ❍ Axial osteomalacia Miscellaneous ❍ Hypoparathyroidism, hyperparathyroidism, thyrotoxicosis, osteoporosis, Paget disease, fluoride ingestion, ❍ ureterosigmoidostomy, neurofibromatosis, osteopetrosis, macroglobulinemia, malignancy ■

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Dahnert 4th edition











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LearningRadiology - Meconium aspiration syndrome


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Meconium Aspiration Syndrome

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Most common cause of neonatal respiratory distress in full-term/postmature infants ❍ Hyaline membrane disease most common cause in premature infants Etiology ❍ Fetal circulatory accidents/placental insufficiency /postmaturity result in perinatal hypoxia and fetal distress ❍ Meconium defecated in utero triggered by vagal response ❍

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Pathogenesis ❍ Meconium products produce bronchial obstruction and air-trapping ❍ Chemical pneumonitis Incidence ❍ 10% of all deliveries have meconium-stained amniotic fluid ❍ 1% of all deliveries have respiratory distress Clinical findings ❍ Cyanosis (rare) ❍ Large infant Imaging findings ❍ Bilateral diffuse grossly patchy opacities (atelectasis and consolidation) ❍ Hyperinflation of lungs ❍ Areas of emphysema (air-trapping) ❍ Spontaneous pneumothorax and pneumomediastinum ■ 25% requiring no therapy ❍ Small pleural effusions (20%) ❍ No air bronchograms ❍ 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 ●

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Treatment ❍ Supportive ■ Antibiotics and oxygen ■ ECMO can be used Complications ❍ Morbidity from anoxic brain damage is high







LearningRadiology - Constrictive Pericarditis


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Pericardial Calcifications Constrictive Pericarditis

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Calcification in the pericardium is most likely inflammatory in nature ❍ 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 ❍ Thin, egg-shell like calcification is more often associated with viral infection or uremia ❍ 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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LearningRadiology - Constrictive Pericarditis ●

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Calcification is seen in 1/3-1/2 of patients with constrictive pericarditis ❍ Its presence does not imply constriction ❍ 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 ❍ This can usually be accomplished by the locations of these calcifications on multiple views, or the radiographic appearance of the calcium Constrictive Pericarditis ❍ Present when a fibrotic, thickened, and adherent pericardium restricts diastolic filling of the heart. ❍ Usually begins with an initial episode of acute pericarditis ■ May not be detected clinically ❍ This slowly progresses to a chronic stage consisting of fibrous scarring and thickening of the pericardium with obliteration of the pericardial space ❍ This produces uniform restriction of the filling of all heart chambers Signs and Symptoms ❍ Reduced cardiac output ( fatigue, hypotension, reflex tachycardia ) ❍ Elevated systemic venous pressure ( jugular venous distension, hepatomegaly with marked ascites and peripheral edema ) ❍ Pulmonary venous congestion ( exertional dyspnea, cough and orthopnea ) ❍ 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. ❍ 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. • •

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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

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Collateral blood flow from portal vein via azygous vein into SVC (usually lower esophagus drains via left gastric vein into portal vein) ❍ Most common cause is portal hypertension secondary to cirrhosis ❍ Varices in lower half of esophagus to the level of the carina (azygous vein) ❍ More common than downhill varices Causes

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Intrahepatic obstruction from cirrhosis ❍ Splenic vein thrombosis (usually gastric varices only) ❍ Obstruction of hepatic veins ❍ Portal vein thrombosis ❍ IVC obstruction below hepatic veins ❍ Marked splenomegaly / splenic hemangiomatosis (rare) Downhill varices

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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

Usually extend down to the level of the carina (azygous vein) ❍ 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) ■ Lymphoma ■ Retrosternal goiter ■ Thymoma ■ Mediastinal fibrosis Examination Technique ■

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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 ❍ Sustained Valsalva maneuver precludes swallowing ❍ In LAO projection with patient recumbent or in Trendelenburg position Plain film

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Lobulated masses in posterior mediastinum (visible in a small percentage of patients with varices) ❍ Silhouetting of descending aorta ❍ Abnormal convex contour of azygoesophageal recess Upper GI

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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 ❍ ❍ ❍ ❍

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 ●

Complications ❍ ❍

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Bleeding in 28% within 3 years Exsanguination in 10-15%

DDx ❍

Early ■

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Other forms of chronic esophagitis

Late ■

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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Hyaline Membrane Disease Respiratory Distress Syndrome (of the Newborn)

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Acute pulmonary disorder of the newborn characterized by Generalized atelectasis ❍ Intrapulmonary shunting ❍ Ventilation-perfusion abnormalities ❍ Reduced lung compliance M:F =1.8:1 Cause ❍

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Immature surfactant production (usually begins at 18-20 weeks of gestational age)

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Causes acinar atelectasis Predispositions

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Premature infants Cesarean section ❍ Infants of diabetic mothers ❍ Perinatal asphyxia Clinical findings

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Onset

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Usually less than 2-5 hours after birth ■ Increases in severity from 24 to 48 hours ■ Then, gradual improvement after 48-72 hours Abnormal retraction of chest wall Cyanosis Expiratory grunting Increased respiratory rate ■

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LearningRadiology - Hyaline Membrane Disease, Respiratory Distress Syndrome of the Newborn ●

Imaging findings

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Typically, diffuse “ground-glass” opacification of both lungs with air bronchograms and hypoaeration ❍ Hypoaeration from loss of lung volume (may be counteracted by respiratory therapy) ❍ Fine granular pattern ❍ Prominent air bronchograms ❍ Bilateral and symmetrical distribution Prognosis

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Spontaneous clearing within 7-10 days (mild course in untreated survivors) ❍ Death in 18% Acute complications

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Barotrauma may produce ■ ■

Parenchymal pseudocyst Pulmonary interstitial emphysema ●

Pseudoclearing

Lungs appear less because of innumerable small pockets of air in the peribronchial interstitial spaces Pneumomediastinum Pneumothorax ❍

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Diffuse ground-glass appearance to both lungs with a left-sided tension pneumothorax and pneumomediastinum (orogastric tube is in distal esophagus) ■ ■ ■

Pneumopericardium Pneumoperitoneum Air in the retroperitoneum


LearningRadiology - Hyaline Membrane Disease, Respiratory Distress Syndrome of the Newborn ■ ❍

Subcutaneous emphysema Diffuse opacity ■ ■ ■ ■ ■

Worsening RDS Superimposed pneumonia Massive aspiration Pulmonary hemorrhage Congestive heart failure (from PDA or fluid overload) ●

Persistent patency of ductus arteriosus ❍

Oxygen stimulus is missing to close duct

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Hemorrhage

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Pulmonary hemorrhage ■ Intracranial hemorrhage Necrotizing enterocolitis Acute renal failure Chronic complications

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Lobar emphysema ❍ Localized interstitial emphysema ❍ Recurrent inspiratory tract infections ❍ Retrolental fibroplasia ❍ Subglottic stenosis from intubation Treatment

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Supportive Exogenous surfactant via trachea

Dahnert 4th edition









LearningRadiology - Intussusception, Intussuceptum


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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

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• Intraluminal mass (e.g., pedunculated tumor) is pulled forward by peristalsis and brings attached bowel wall with it Intramural

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• 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

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In children o Over 90% have no pathologic lead point o

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• Most thought due to lymphoid hypertrophy following viral infection Less than 10% due to Meckel’s 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 http://www.learningradiology.com/archives04/COW%20093-intussusception/intussusceptcorrect.htm (1 de 6)04/09/2006 2:25:07

LearningRadiology - Intussusception, Intussuceptum ❍

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Majority are in children ■ Peak incidence 5-9 months of age Approximately 10% occur in adults ■ Seen in all age groups ■ Approximately equal in males and females

In developing nations ❍ ❍

Incidence is higher in adults than it is in developed nations 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 Dance’s 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 ■ ■ ■ ■ ■

o •

•

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

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•

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) http://www.learningradiology.com/archives04/COW%20093-intussusception/intussusceptcorrect.htm (3 de 6)04/09/2006 2:25:07


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 Ringer’s) 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 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

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

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E. coli (vast majority of cases) ❍ Klebsiella pneumoniae (9%) ❍ Proteus mirabilis ❍ Pseudomonas ❍ Enterobacter ❍ Candida ❍ Clostridia (exceptionally rare) Predisposed

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Especially diabetics in almost all cases ❍ Immunocompromised patients ❍ Ureteral obstruction Average age

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Mid-fifties ❍ 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 ❍ Positive blood and urine cultures (in majority) ❍ Urosepsis ❍ Shock ❍ Fever of unknown origin and no localizing signs in almost 20% Frequently have multiple associated medical problems

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Uncontrolled hyperglycemia

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Acidosis ❍ Dehydration ❍ Electrolyte imbalance Location ❍

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Most are unilateral 5-7% bilateral

Types ❍

Type I (33%)

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Streaky or mottled gas in interstitium of renal parenchyma radiating from medulla to cortex ■ Crescent of subcapsular or perinephric gas ■ No fluid collection (= no effective immune response) ■ Prognosis in this type is poor (69% mortality) Type II (66%) ■

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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



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Prognosis in this type is much better (18% mortality) Parenchymal destruction absent Decreased contrast excretion (due to compromised renal function) CT findings

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Most reliable and sensitive modality ❍ Mottled areas of low attenuation extending radially along the pyramids ❍ Extensive involvement of kidney and perinephric space ❍ Air extending through Gerota’s fascia into retroperitoneal space ❍ 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

"Comet tail" reverberations ❍ Kidney may be completely obscured by large amount of gas in perinephric space (DDx: surrounding bowel gas) ❍ 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)

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DDx

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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 ❍ Drainage procedure with coexisting obstruction Mortality

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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 Wharton’s Duct

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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 ❍

Consist of mainly calcium phosphate

Not associated with systemic calcium abnormalities ❍ 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 ■

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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 ❍

Plain radiography ■

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Opaque stone in course of Wharton’s (submandibular) or Stensen’s (parotid) ducts

CT ■ ■

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) ❍

MR

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Inflammation of gland Sialography is contraindicated in acute infection or in a patient with a significant contrast allergy Treatment ■

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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

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Accounts for 85-90% of all uroepithelial tumors Exophytic, polypoid papillary growth pattern most common ❍ Attached to the mucosa by stalk ❍ Non-papillary tumors less common Most are solid with no characteristic gross findings Location ❍ Bladder is 30-50x more often the site of the tumor than ureter or renal pelvis (most common tumor of GU tract) rd ❍ When it occurs in the ureter, it most commonly occurs in the lower 3 Synchronous (simultaneous) transitional cell carcinomas are common ❍ Bladder involvement with ■ 24% of primary renal pelvis involvement ■ 30% of primary ureteral involvement ■ In 2% with primary bladder tumor ❍ Both ureters involved in 2-9% ❍ Both renal pelves in 1-2% Metachronous (sequential) transitional cell carcinomas in upper tracts ❍ With pelvic and ureteral primaries-12% in 25 months ❍ 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 ❍ Exposure to cyclophosphamide ❍ Phenacetin ❍ Chronic urinary stasis ❍ Smoking Metastasizes to

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Regional lymph nodes ❍ Liver ❍ Lung ❍ Bone Imaging findings ❍ IVU ■ Enlarged and hydronephrotic kidney ● Invasive, poorly differentiated tumors are more likely to obstruct ● Dilated calyx with filling defect ● Caliceal amputation ● Partial or complete obstruction of the infundibulum ❍ Retrograde studies ■ Papillary tumors ● “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 ❍

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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 ■

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Non-papillary tumors ● Nodular or flat ● Cause strictures rather than filling defects CT ■ Can identify dilated collecting system and demonstrate level of obstruction ■ Intraluminal mass (30-60 HU) representing ureteral tumor can be differentiated from obstructing calculus (> 190 HU) ■ May demonstrate extra-ureteral extension US ■ Discrete hypoechoic mass within the renal sinus ■ Absence of acoustic shadowing allows for differentiation from calculi Angiography ■ Hypovascular mass ■ Vessel encasement and stain ■ Not usually necessary Treatment ❍ Controversy ■ Nephroureterectomy with resection of a cuff of bladder versus wide excision of the tumor alone ■ Adding chemotherapy (cisplatin) in patients with advanced tumors is of unclear utility









Lymphangiomyomatosis. LAM, Tuberous Sclerosis


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Lymphangiomyomatosis and Tuberous Sclerosis ● ●

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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: ● ● ● ●

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

Mental defects Epilepsy Retinal phacoma Angiomyolipomas of the kidneys Rhabdomyomas of the heart Intracranial calcifications Sclerotic skull lesions Adenoma sebaceum Subungual fibromas

o

Pulmonary lymphangiomyomatosis (syn:pulmonary myomatosis) § §

Exclusively in females ages 17-47 years Rare

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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 ❍ Coarse, reticular interstitial pattern ❍ Normal/increased lung volume ❍ Numerous thin-walled pulmonary cysts and honeycombing ❍ Various sizes/surrounded by normal lung parenchyma

Note multiple thin-walled cysts throughout both lungs • •

Unilateral or bilateral pleural effusions which are usually large and recurrent Spontaneous pneumothorax is common

Clinically ● ●

Progressive exertional dyspnea and cough Hemoptysis



















LearningRadiology.com - Pulmonary Arterial Hypertension - PAH, Idiopathic, Primary, artery, pulmonary


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Pulmonary Arterial Hypertension (PAH)

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Sustained pulmonary arterial pressure ❍ ❍ ❍

In systole >30 mm Hg In diastole >15 mm Hg Mean pressure >20 mm Hg

•

Pathogenesis: o Primary PAH (rare) = unknown cause

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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

•

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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

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Alveolar hypoventilation = hypoxic pulmonary arterial hyperperfusion o Chronic high altitude o Sleep apnea o Hypoventilation due to neuromuscular disease or obesity

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Pleural disease and chest deformity o Fibrothorax o Thoracoplasty o Kyphoscoliosis



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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







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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 Sjogren’s § Amyloidosis § Chronic idiopathic intestinal § Sarcoidosis

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§ § § § §

Pseudo-obstruction Neurofibromatosis Eosinophilic gastroenteritis Fabry’s 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

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Heartburn in 40-60% o Tend to have lower LES pressures than those without GERD

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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 § “Bird’s 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 http://www.learningradiology.com/archives04/COW%20100-Achalasia/achalasiacorrect.htm (2 de 6)04/09/2006 2:25:35


o

§ 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

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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 http://www.learningradiology.com/archives04/COW%20100-Achalasia/achalasiacorrect.htm (3 de 6)04/09/2006 2:25:35


o

Normal esophageal peristalsis

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Carcinoma o Only minimal dilation with normal peristalsis

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Scleroderma o Barium should empty when patient is upright o Other associated GI abnormalities

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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

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Extraperitoneal bladder rupture is the most common type ❍ Occurs in 80% of bladder rupture cases ❍ Extraperitoneal bladder rupture generally secondary to adjacent pelvic fracture or an avulsion tear at fixation points of puboprostatic ligaments Intraperitoneal bladder rupture ❍ 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 ■ Because the pediatric bladder is more intraperitoneal in location. ■ The adult bladder dome remains mostly extraperitoneal ● Blunt trauma in an adult can result in intraperitoneal rupture only if the bladder is fully distended ❍ Imaging findings ■ Contrast extravasation into paracolic gutters ■ 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 ❍ Diagnostic evaluation of bladder rupture includes voiding cystourethrography (VCUG) or CT scan ■ VCUG ● Voiding cystourethrography historically been preferred contrast enhanced study for diagnosis of bladder rupture ● Bladder needs to be fully distended and evaluation of a post-voiding film essential ■ Plain film: ● "Pear-shaped" bladder ● Paralytic ileus ● Upward displacement of ileal loops ● Flame-shaped contrast extravasation into perivesical fat ❍ Best seen on postvoid films ❍ May extend into thigh / anterior abdominal wall ❍

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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

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US ❍

"Bladder within a bladder" = bladder surrounded by fluid collection










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Calcium Pyrophosphate Dihydrate Crystal Deposition Disease CPPD ●

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Terminology ❍ Chondrocalcinosis – calcification of hyaline (articular) cartilage or fibrocartilage (menisci) or ligaments ■ Usually but not always due to calcium pyrophosphate ● May also be seen with oxalosis ❍ Pseudogout is an older clinical term referring to acute pain (similar to gout) but without response to the usual treatment for gout ❍ CPPD – Deposition of crystals in the joint with or without chondrocalcinosis Most common crystalline arthropathy Prevalence ❍ Widespread in older population ❍ M:F = 3:2 Clinical findings ❍ Intermittent attacks ■ May be mono-articular or polyarticular (more often) ● Pain ● Redness ● Swelling Types ❍ Frequently occurs in association with osteoarthritis ❍ Aging process with no known etiology ❍ In association with metabolic diseases ■ Hyperparathyroidism ■ Hemochromatosis ■ Hypothyroidism ■ Hypomagnesemia ■ Hypophosphatasia ■ 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 ❍ Knee ■ Especially meniscus ■ Cartilage of patellofemoral joint ❍ Wrist ■ Triangular fibrocartilage in distal radioulnar joint bilaterally ❍ Pelvis ■ Sacroiliac joint ■ Symphysis ❍ Spine ■ Annulus fibrosis of lumbar intervertebral disk ● Never in nucleus pulposus as in ochronosis ❍ Shoulder ■ Glenoid ■ Hip ● Labrum ■ Elbow ■ Ankle ■ Acromioclavicular joint Imaging Findings ❍ Pyrophosphate arthropathy resembles osteoarthritis ■ Joint space narrowing ■ Extensive subchondral sclerosis ❍ Polyarticular chondrocalcinosis (in fibro- and hyaline cartilage) ❍ In knee, disproportionate narrowing of patellofemoral joint ■ Large subchondral cysts are a hallmark ■ Numerous intra-articular bodies ● Fragmentation of subchondral bone ❍ In hand, beaklike projections from 2nd, 3rd metacarpal heads ■ Subchondral cysts (esp. carpal bones) ■ Unusual distribution of disease (radiocarpal/ulnar joint, patellofemoral joint) ■ SLAC - scapholunate advanced collapse ● Caused by laxness of the ligaments and malpositioning of the scaphoid and lunate ● May develop in 25% with CPPD but also occurs for other reasons ● Radio-scaphoid, but not radio-lunate, joint is narrowed ● 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. ●

Treatment ❍ Oral anti-inflammatory drugs (NSAIDs) and corticosteroid joint injections successful in shortening the length of pain and dysfunction of acute attacks of pseudogout ❍ Treatments to prevent attacks, such as colchicine, may be effective ❍ No treatment is available to dissolve the crystal deposits ❍ 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)

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Rare less than nine years of age

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Boys more than girls

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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 ❍ Blacks more often ❍ Ages 10 through 15 ❍ Usually heavier and or taller than others for their age

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Younger in girls 8 to 15 years of age

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About 20 to 25 percent are bilateral, an occurrence more frequent in girls.

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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 ●

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

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Bilateral in 10%

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Males greater than females ❍

Bilateral involvement in females is very rare

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The first sign is subarticular translucency seen best on frog lateral

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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 ●

With revascularization there is gradual reformation of femoral head.

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Since there is less bone to reform, prognosis is better for those under five years of age than in older children.

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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

Bilaterality

Race

Best Film

Other

5-9x more common in females 10x more common if breech

1/3

Almost never in Blacks

AP—not frog

ORTALANI CLICK— with leg flexed, dislocate by adduction, click on relocation with abduction

1/4

Blacks more often

AP

Avascular necrosis in 6-15%

None

Frog lateral-for subarticular lucency

Arthrography usually neg Better prognosis under 5 Synovitis may be 1st sign

Boys>girls Slipped Capital Teenagers 1215 June-September Femoral Heavy or tall most often Epiphysis Younger in girls (8-15)

Legg-CalvePerthe’s Disease

∼5 years

Male> females

1/10 Bilateral in females is rare









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Free Intraperitoneal Air Pneumoperitoneum

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Etiology ❍ Disruption of wall of hollow viscus ■ Blunt or penetrating trauma ■ Perforating foreign body (eg, thermometer injury to rectum) ■ Iatrogenic perforation ● Laparoscopy / laparotomy (58%) ● Absorbed in 1-24 days depending on initial amount of air introduced and body habitus (80% in asthenic, 25% in obese patients) ● Leaking surgical anastomosis ● Endoscopic perforation ● Enema tip injury ● Diagnostic pneumoperitoneum ■ Diseases of GI tract ● Perforated gastric / duodenal ulcer ● Perforated appendix ● Ingested foreign-body perforation ● Diverticulitis (ruptured Meckel's diverticulum / sigmoid diverticulum, jejunal diverticulosis) ● Necrotizing enterocolitis with perforation ● Inflammatory bowel disease (eg, toxic megacolon) ● Obstruction* (gas traversing intact mucosa): neoplasm, imperforate anus, Hirschsprung disease, meconium ileus ● Ruptured pneumatosis cystoides intestinalis ● Idiopathic gastric perforation = spontaneous perforation in premature infants (congenital gastric muscular wall defect) ❍ Through peritoneal surface ■ Transperitoneal manipulation ■ Abdominal needle biopsy / catheter placement ■ Mistaken thoracentesis / chest tube placement

http://www.learningradiology.com/archives04/COW%20106-Falciform%20ligament%20sign/falciformcorrect.htm (1 de 6)04/09/2006 2:25:49


Endoscopic biopsy ❍ Extension from chest ■ Dissection from pneumomediastinum (positive pressure breathing, rupture of bulla / bleb, chest surgery) ■ Bronchopleural fistula ■ Rupture of urinary bladder ■ Penetrating abdominal injury ❍ Through female genital tract ■ Iatrogenic ■ Perforation of uterus / vagina ■ Culdocentesis ■ Rubin test = tubal patency test ■ Pelvic examination ■ Spontaneous ■ Intercourse, orogenital insufflation ● Douching ■ Knee-chest exercise, water skiing, horseback riding ❍ Intraperitoneal ■ Gas forming peritonitis ■ Rupture of abscess ■ Air in lesser peritoneal sac gas in scrotum (through open processus vaginalis) Imaging findings ❍ Large collection of gas ❍ Abdominal distension, no gastric air-fluid level ❍ "Football sign" = large pneumoperitoneum outlining entire abdominal cavity ❍ "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) ❍ "Telltale triangle sign" = triangular air pocket between 3 loops of bowel ❍ 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: ❍ "Inverted V sign" is outline of both lateral umbilical ligaments (containing inferior epigastric vessels) ❍ Outline of medial umbilical ligaments (obliterated umbilical arteries) ❍ "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. ●

RUQ gas (best place to look for small collections) ❍ 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 ❍ Ligamentum 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 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 ❍ "Saddlebag / mustache / cupola sign" = gas trapped below central tendon of diaphragm ❍ 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)

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If defective development, diaphragmatic hernia develops ❍ Anterior – Morgagni ■ Anteromedial parasternal defect (Space of Larrey) ■ Maldevelopment of septum transversum ■ Tends to occur in overweight, middle-aged, women ■ Right > left (heart protects) ■ Usually not large ■ Usually unilateral ■ Associated with ● Pericardial defects ● Omental fat in pericardial space ❍ Posterior – Bochdalek ■ Most common ● Occurs through old pleuroperitoneal canals ❍ Just lateral to the spine on either side ■ More frequent on left side ● Possibly due to “protection” of right-side by liver ● Hernia may contain intestine, stomach, spleen, liver or omentum ■ If hernia occurs on right ● Intestine and liver or only liver may herniate ■ If the defect is large, newborns usually present with ● Severe respiratory distress ● Cyanosis ● Scaphoid abdomen ■ Entire diaphragm is almost never absent ● Some part of diaphragm is usually found at surgery, even if defect is very large ■ Hypoplasia of ipsilateral lung occurs from mass effect of bowel ■ Most often these are isolated congenital abnormalities ● But they can have ❍ 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 ❍ Initially, hemithorax may appear opaque because loops are fluid-filled ❍ Paucity of bowel loops beneath the 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 ❍ Contrast through an NGT is diagnostic but often not needed Differential diagnosis of lucent cysts in infant lung ❍ Cystic adenomatoid malformation ❍ Staphylococcal pneumonia ■ In both, abdomen contains normal amount of air-filled loops


LearningRadiology.com ● ●

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Delayed herniation of bowel may occur in older infants following streptococcal pneumonia Mortality around 50% ❍ Pulmonary hypoplasia ❍ Persistent Fetal Circulation Syndrome Treatment ❍ Surgical repair ❍ Many demonstrate ipsilateral pulmonary hypoplasia for years after repair ❍ Obstructive emphysema can occur in either lower lobe

WH







LearningRadiology.com - Epiglottitis


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Epiglottitis

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Acute bacterial epiglottitis ❍ Life-threatening, medical emergency due to infection with edema of epiglottis and aryepiglottic folds Organism ❍ Introduction of Haemophilus influenzae type B vaccine in 1985 has led to marked decrease in number of cases of epiglottitis ■ Still remains the most common cause ❍ Also caused by ■ Pneumococcus ■ Streptococcus group A ❍ May also be caused by thermal injury Age ❍ Typically between 3-7 years ❍ Peak incidence has become older over last decade and is now closer to 6-7 years Clinical ❍ Classical triad is: drooling, dysphagia and distress (respiratory) ❍ Abrupt onset of respiratory distress with inspiratory stridor ❍ Sore throat ❍ Severe dysphagia ❍ Older child may have neck extended and appear to be sniffing due to air hunger ❍ Resembles croup clinically, but think of epiglottitis if: ■ Child can not breathe unless sitting up ■ “Croup” appears to be worsening ■ Child can not swallow saliva and drools (80%) ❍ Cough is unusual Location ❍ Purely supraglottic lesion ■ Associated subglottic edema in 25% ❍ Associated swelling of aryepiglottic folds causes stridor Imaging findings ❍ Patient needs to be accompanied everywhere by a physician experienced in endotracheal

http://www.learningradiology.com/archives04/COW%20108-Epiglottitis/epiglottitiscorrect.htm (1 de 5)04/09/2006 2:25:55


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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 ■ Supine position may close off airway Enlargement of epiglottis ■ “Larger than your thumb” Thickening of aryepiglottic folds ■ 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. ❍ ● ●

Reversal of the normal lordotic curve of the cervical spine Fiberoptic-assisted, nasotracheal intubation is procedure of choice Complications ❍ 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 ❍ 1.7 million cases reported, 833,000 of which were substantiated in United States in 1990 ❍ Results in 2,500-5,000 deaths/year ❍ 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 ❍ Usually <2 years In children <2 years of age, a skeletal survey may be best to demonstrate other fractures ❍ In children >2 years of age, a bone scan may be best Clinical findings ❍ Skin burns ❍ Bruises ❍ Lacerations ❍ 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

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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 ❍ Multiple ribs ❍ Transverse fracture of sternum ❍ Costochondral / costovertebral separation ❍ Lateral end of clavicles ❍ Scapula ❍ Acromion ❍ Skull ❍ Vertebral bodies ■ Anterior-superior wedging of vertebral bodies ■ Vertebral compression ■ Vertebral fracture dislocation ■ Disk space narrowing ■ 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) ●

Appearances of skeletal trauma ❍ Hallmark of the syndrome are multiple, asymmetric fractures in different stages of healing ❍ Separation of distal epiphysis ❍ Marked irregularity and fragmentation of metaphyses ■ "Corner" fracture (11%) or "Bucket-handle" fracture = avulsion of a metaphyseal



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fragment overlying the lucent epiphyseal cartilage secondary to a sudden twisting motion of extremity ❍ Isolated spiral fracture (15%) of diaphysis secondary to external rotatory force applied to femur / humerus ❍ Extensive periosteal reaction from large subperiosteal hematoma ❍ Exuberant callus formation at fracture sites ❍ Cortical hyperostosis extending to epiphyseal plate ❍ Avulsion fracture at site of ligamentous insertion ■ Frequently seen without periosteal reaction Head trauma (13-25%) ❍ Most common cause of death and/or physical disability ■ Skull fracture (flexible calvaria + meninges decrease likelihood of skull fractures) ■ Subdural hematoma ■ Brain contusion ■ Cerebral hemorrhage ■ Infarction ■ Generalized edema ■ Shearing injuries with associated subarachnoid hemorrhage ■ Skull film (associated fracture in 1%): ● Linear fracture > comminuted fracture ❍ CT findings in head trauma ■ Subdural hemorrhage (most common) ● Interhemispheric location most common ■ Subarachnoid hemorrhage ■ Epidural hemorrhage (uncommon) ■ Cerebral edema (focal, multifocal, diffuse) ■ Acute cerebral contusion appears as ovoid collection of intraparenchymal blood with surrounding edema ❍ MR findings of head trauma ■ More sensitive in identifying hematomas of differing ages ■ White matter shearing injuries as areas of prolonged T1 + T2 at corticomedullary junction, centrum semiovale, corpus callosum Viscera (3%) ❍ Second leading cause of death in child abuse ❍ Cause ■ Crushing blow to abdomen (punch, kick) ❍ Age ■ Often >2 years ❍ Small bowel and/or gastric rupture ❍ Hematoma of duodenum and/or jejunum ❍ Contusion and/or laceration of lung, pancreas, liver, spleen, kidney ❍ Traumatic pancreatic pseudocyst Differential diagnosis of child abuse ❍ Normal periostitis of infancy ❍ Osteogenesis imperfecta ❍ Congenital insensitivity to pain ❍ Infantile cortical hyperostosis ❍ Menkes kinky hair syndrome ❍ Schmid-type chondrometaphyseal dysplasia


LearningRadiology.com - Child Abuse, Battered Child ❍ ❍

Scurvy Congenital syphilitic metaphysitis

Dahnert 5th edition Requisites-Pediatric Radiology Requisites-Musculoskeletal Radiology









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Cerebellar Hemangioblastoma Submitted by Matt Hoffman, MD ● ●

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Benign neoplasm 80% found in cerebellum ❍ 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 ❍ M > F Relationship to von Hippel-Lindau disease ❍ 20% occur in patients with von Hippel-Lindau disease (multiple lesions). ❍ 35-60% of von Hippel-Lindau disease patients have hemangioblastomas ❍ von Hippel-Lindau disease consists of ■ Retinal, spinal, cerebellar and medullary hemangioblastomas ■ Renal cysts and carcinomas ■ Pancreatic cysts ■ Pheochromocytomas ■ Papillary Cystadenoma of the epididymis Clinical findings ❍ Headache ❍ Ataxia ❍ Nausea ❍ Vomiting ❍ Vertigo ❍ Polycythemia caused by increased erythropoietin found in 40%. ❍ Spinal lesions may present with subarachnoid hemorrhage Findings on CT and MRI: ❍ Cystic lesion in the cerebellum with an avidly enhancing mural nodule (75%) ❍ Purely solid enhancing lesion (10%) ❍ Enhancing lesion with multiple cystic areas (15%)

http://www.learningradiology.com/archives04/COW%20110-Hemangioblastoma/hemangiocorrect.htm (1 de 5)04/09/2006 2:26:08


MRI of brain shows a cystic lesion in the cerebellum with an enhancing nodule (post-Gadolinium) ●

Findings on angiography: ❍ Vascular nodule within an avascular mass ❍ Serpentine vessels


LearningRadiology.com - Child Abuse, Battered Child ●

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Treated with surgical removal of solid nodule ❍ 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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Volar plate forms floor of PIP joint and separates the joint space from the flexor tendons ❍ Volar plate is ligamentous at its origin on the proximal phalanx ❍ 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 ❍ “Jammed finger” If force of injury is great enough, dorsal dislocation can occur ❍ Rupture of volar plate may occur with longitudinal splitting of the collateral ligament structures ■ Allows for complete dorsal displacement of middle phalanx ■ Simple dislocations easily reduced by player coach, or trainer on the field ■ Following reduction, most dorsal dislocations are stable Fractures of base of middle phalanx also occur in association with dorsal dislocations ❍ If fracture involves more than 40-50% of articular surface ■ Collateral ligament support is lost ■ Combined with coexistent volar plate disruption ● Represents major loss of joint stability ● These injuries are often unstable, exhibiting persistent subluxation of the middle phalanx Imaging findings ❍ 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 ●

Complications ❍ Joint instability ❍ 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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Pericardial Effusion ●

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Normal anatomy ❍ Inner serous layer is the epicardium ❍ Outer fibrous layer is pericardium ❍ Space between the two is pericardial space ❍ Normally contains about 20-50cc of fluid ❍ Fat covers outside of heart and outside of pericardium sandwiching pericardial space between the two layers ■ Normal thickness of pericardium (parietal pericardium and fluid in space) is 2-4 mm Requires about 150-250cc before cardiac tamponade occurs ❍ Tamponade compresses heart and causes low cardiac output ❍ Most effusions do not lead to cardiac tamponade ❍ Size of cardiac silhouette is frequently increased ❍ 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

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Remarks Most common Especially Lupus Surgical or accidental Serosanguineous effusion Uncommon except in AIDS Coxsackie B virus 18% in acute uremia

Other causes ❍ Serous fluid = transudate

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Congestive heart failure ■ Hypoalbuminemia ■ Irradiation ❍ Blood = hemopericardium ■ Rupture of ascending aorta or pulmonary trunk ■ Coagulopathy ❍ Fibrin = exudate ■ Pyogenic infection, e.g. staph ■ Uremia: 18% in acute uremia; 51% in chronic uremia; dialysis patient Imaging findings ❍ "Water bottle configuration" is symmetrically enlarged cardiac silhouette ■ Major DDX is cardiomegaly ❍ Loss of retrosternal clear space ■ Non-specific and frequently not valid ❍ "Fat-pad sign" from separation of retrosternal from epicardial fat line >2 mm (15%) ■

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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 ❍ 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 Submitted by Jonathon Dorff, MD

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Acute interruption of blood flow to small or large intestine Causes ❍ Arterial embolism ■ Superior mesenteric artery most commonly involved ❍ Arterial thrombosis ❍ Nonocclusive mesenteric ischemia ■ Low cardiac output state with diffuse mesenteric vasoconstriction ❍ Mesenteric venous thrombosis Risk Factors ❍ Atrial fibrillation/flutter ❍ Recent acute MI ■ Ventricular aneurysm ■ Cardiomyopathies ■ Valvular disease ❍ Hypovolemia or hypotension (sepsis) ❍ Coagulation disorders or malignancy ❍ Pancreatitis ❍ Portal hypertension/cirrhosis ❍ Medications ■ Vasopressor medications ■ Beta-blockers ■ Digoxin ■ Diuretics Clinical signs and symptoms ❍ Severe abdominal pain out of proportion to physical exam ❍ Pain initially of a visceral nature and poorly localized

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LearningRadiology.com - Mesenteric Vascular Ischemia, Mesenteric Ischemia, Ischemic Bowel, Bowel Infarction, Slow Flow Syndrome ❍ ❍ ❍ ❍

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Nausea Vomiting Diarrhea GI bleeding may be present

Imaging ❍ Plain abdominal radiographs (abnormal in 20-60% of cases) ■ Thumbprinting ■ Non-specific finding indicating intestinal wall edema with hemorrhage in the setting of acute mesenteric ischemia ■ Pneumatosis ■ Portal venous gas ■ Pneumoperitoneum ■ All are indicative of infarcted bowel ❍ CT ■ Bowel wall thickening from edema or hemorrhage ■ Lack of enhancement indicates infarction ■ Pneumatosis, portal venous gas, pneumoperitoneum ■ 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 ■ Can distinguish between arterial embolic and thrombotic causes of acute mesenteric ischemia Treatment ❍ Mesenteric angiogram ■ Vasodilator therapy ■ Thrombectomy/Embolectomy ❍ Surgery ■ Thrombectomy/Embolectomy ■ Arterial bypass ■ Resection of necrotic bowel Complications ❍ Sepsis/septic shock ❍ Multiple system organ failure ❍ Death Mortality ❍ 70-90% overall ❍ From arterial embolism: 60-80% ❍ From arterial thrombosis: 70-100% ❍ From nonocclusive mesenteric ischemia: 40% ❍ 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 ❍

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Soft tissue mass near articular surface Frequently, spherical and lobulated in shape 20-30% calcify About 1/3 have adjacent erosion of bone

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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

http://www.learningradiology.com/archives04/COW%20114-Synovioma/synoviomacorrect.htm (1 de 5)04/09/2006 2:26:17


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. ●

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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Ventricular Aneurysms ●

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Congenital left ventricular aneurysm ❍ Rare ❍ Young, Black adult ■ Submitral type ● Bulge at left middle / upper cardiac border ■ Subaortic type ● Small and not visualized ● Heart greatly enlarged (from aortic insufficiency) Acquired left ventricular aneurysm ❍ Overwhelming majority are secondary to ischemic heart disease and myocardial infarction ❍ May be asymptomatic and well tolerated for years True aneurysms ❍ Remnants of myocardium within its walls ❍ Consequence of transmural myocardial infarction ❍ Wide-open neck ❍ Rarely rupture False aneurysms (pseudoaneurysms) ❍ Surrounded by tissue other than myocardium, such as pericardium or pleura ❍ Usually the result of localized rupture of the heart ❍ Most often involve posterolateral wall of LV ❍ They themselves more often rupture than true aneurysms ❍ Neck is narrow ❍ Often contain clot Other causes of ventricular aneurysm ❍ Trauma ❍ Postoperative ■ Frequently involve the right ventricle ❍ Rheumatic heart disease ❍ Mycotic aneurysms Large majority due to infarction of the left ventricle or ventricular septum ❍ 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 ❍ LV failure ❍ Cardiac arrythmias ❍ Embolus Majority of false aneurysms are from trauma and post-surgical Imaging ❍ Conventional chest films can not exclude the presence of a cardiac aneurysm ❍ Unusual “bump” on the left side of the heart ■ Most common manifestation on plain film ■ Has a short-radius of curvature ■ 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 ■

DDX Cardiac tumors ● Enlarged left atrium ● Pericardial cysts ❍ Uncommon on left side ● Thymomas Calcium in wall of aneurysm or thrombus ● Uncommon ● Curvilinear ● Almost always several millimeters below the exterior surface of the heart ● 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 ❍ Prepatellar bursa is superficial bursa ❍ Thin synovial lining ❍ Located between skin and patella ❍ Main function is to separate patella from patellar tendon and skin ❍ Normally does not communicate with joint ❍ 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 ❍ Direct trauma (eg, a fall on patella or direct blow to knee) ■ If acute, frequently due to small blood vessel rupture ❍ Repetitive minor injuries (eg, repeated kneeling) ❍ Septic or pyogenic process ■ Infection usually from Staphylococcus aureus from break in skin ■ More prevalent in children ■ Can be mistaken for pyogenic arthritis ❍ Crystal deposition (eg, gout, pseudogout) ❍ Occupation ■ Carpet layer ■ Wrestlers ■ Coal miner ■ Roofer ■ Plumber ■ Homemaker (housemaid's knee) Clinical findings ❍ Knee pain ❍ Swelling ❍ Redness ❍ 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 ❍ History of repetitive motion ❍ History of occupation requiring excessive kneeling ❍ History of a fall on knee or blunt trauma to knee Physical findings ❍ Patella tender to palpation ❍ Fluctuance over lower pole of patella ❍ Erythema ❍ Crepitation ❍ Decreased ROM Imaging Studies ❍ Plain radiographs ■ Soft tissue swelling ■ Calcification ● Especially if hemorrhage into bursa ❍

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Frontal and lateral radiographs of both knees demonstrate multiple, punctate calcifications in the pre- and infrapatellar region ❍

Computed tomography (CT) scan and magnetic resonance imaging (MRI) ■ Complex fluid collection anterior to knee in region of prepatellar bursa



Wall of bursa my be thickened and irregular Treatment ❍ NSAIDs ❍ Cortisone injection ❍ Aspiration of bursa ❍ Surgical removal of bursa ❍ Kneepad ❍ Has high recurrence rate ■

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Kelly Allen, MD eMedicine.com







LearningRadiology.com - Emphysematous pancreatitis,pancreatitis


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Emphysematous Pancreatitis

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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 ❍ 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 ❍ Focal or diffuse ❍ Well-marginated ❍ Area of parenchymal non-enhancement ❍ >3cm ❍ Infected pancreatic necrosis recognized at helical CT as ■ Bubbles of gas within areas of pancreas ■ Or, collection of gas and tissue within the retroperitoneum

http://www.learningradiology.com/archives04/COW%20117-Emphysematous%20pancreatitis/emphypanccorrect.htm (1 de 5)04/09/2006 2:26:21


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 ●

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E. Coli can infect necrotic pancreas ❍ Produces gas in body of pancreas and retroperitoneum Emphysematous pancreatitis warrants ❍ Early use of antibiotics ❍ Percutaneous drainage of fluid collections ❍ If no response ■ 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

http://www.learningradiology.com/archives04/COW%20118-Aortic%20Stenosis/ascorrect.htm (1 de 7)04/09/2006 2:26:26


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 ●

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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 ❍ Calcification of aortic annulus in elderly ❍ Calcified coronary artery ostium (thickened cusp echoes only in diastole) Prognosis ❍ Depends on symptomatology (angina, syncope, CHF)

X-Ray Findings ● ●

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Normal heart size Prominent ascending aorta ❍ 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)



Angiographic findings ●

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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

Calcification

Other clues

Congenital Bicuspid Valve

30’s

Jet effect on aortogram

Degeneration of Tricuspid Valve

> 65

Rheumatic dz in Tricuspid Valve

30’s here; teens in 3rd world countries

Coronary artery ca++ Commissures don’t fuse MS or MR almost always present; commissures fuse

Valve areas

Normal 2

2.6-3.5cm

Mild

Severe

Critical

1.3-1.7

1.0

0.5

Dahnert 4th edition




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LearningRadiology.com - Arteriovenous malformation, AVM,areterial,venous


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Cerebral Arteriovenous Malformations Anthony Chang, MD

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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 ❍ Vascular tangles are serpiginous and hyperdense without contrast from the blood pool effect. ❍ AVMs may contain punctate or curvilinear calcification. ❍ AVMs will enhance

http://www.learningradiology.com/archives04/COW%20119-AVM%20of%20Brain/avmcorrect.htm (1 de 5)04/09/2006 2:26:33


Unenhanced and enhanced axial CTs of brain shows a large, serpiginous AVM adjacent to the tentorium

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MRI findings ❍ Curvilinear flow voids ❍ MRA for mapping Angiogram


LearningRadiology.com - Arteriovenous malformation, AVM,areterial,venous ❍

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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 ❍ Sturge Weber ❍ Wyburn Mason ❍ Klippel-Trenaunay-Weber ❍ Osler Weber Rendu Complications ❍ Hemorrhage ❍ 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. ❍ Aneurysms can form and become a source of hemorrhage Treatment ❍ Endovascular embolization ❍ Surgery ❍ 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

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Sub-articular, post-traumatic necrosis Occurs only on convex surfaces of bone

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Medial condyle of femur ❍ Capitellum ❍ Proximal surface of talus st metatarsal ❍ Head of 1 Most patients are athletic Direct blow is more common cause than a rotational injury

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Knee lesions are more common amongst high jumpers Most common cause of an intra-articular loose body

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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

LearningRadiology.com - Osteochondritis dissecans,osteochondrosis,osteonecrosis,knee,loose body,joint mice,mouse ● ●

In adults, loose body contains larger fragment of cartilage than bone Possible outcomes ❍

Death of bony, but not cartilaginous, portion of loose body

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Loose body is invisible except to MRI Complete resorption of loose body Reincorporation or regrowth ■

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Usually not in adults ■ 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.com - Hypertrophic Osteoarthropathy,hypertrophic pulmonary osteoarthropathy,pulmonary,osteoarthropathy


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Etiology ❍ Unknown Presents clinically as an arthritis with painful and swollen joints Can occur as a primary and secondary form ● Primary form also know as pachydermoperiostitis ● May include periostitis, clubbing, thickening of the skin ● Involves hands ● Familial ● More common in males ● Onset in adolescence with remission in adulthood

Thoracic Causes ❍ Malignant tumor (0.7-12%) ■ bronchogenic carcinoma (88%) ■ mesothelioma ■ lymphoma ■ pulmonary metastasis from ● osteogenic sarcoma ● melanoma ● renal cell carcinoma ● breast cancer ❍ Benign tumor ■ benign pleural fibroma ■ tumor of ribs ■ thymoma ■ esophageal leiomyoma ■ pulmonary hemangioma ■ pulmonary congenital cyst ❍ Chronic infection / inflammation ■ pulmonary abscess ■ bronchiectasis ■ Blastomycosis

http://www.learningradiology.com/archives04/COW%20121-Hypertrophic%20Osteoarthropathy/hpocorrect.htm (1 de 5)04/09/2006 2:26:35


TB (very rare) ■ cystic fibrosis ■ interstitial fibrosis ❍ Congenital heart disease with R-to-L shunt Extrathoracic Causes ❍ GI tract ■ ulcerative colitis ■ amebic + bacillary dysentery ■ intestinal TB ■ Whipple disease ■ Crohn's disease ■ gastric ulcer ■ bowel lymphoma ■ gastric carcinoma ❍ Liver disease ■ biliary and alcoholic cirrhosis ■ posthepatic cirrhosis ■ chronic active hepatitis ■ bile duct carcinoma ■ benign bile duct stricture ■ amyloidosis, ■ liver abscess ❍ Undifferentiated nasopharyngeal carcinoma ❍ Pancreatic carcinoma ❍ Chronic myelogenous leukemia Clinical Findings ❍ Pain and swelling about the joints simulating an arthritis ❍ Joints involved ■ ankles (88%) ■ wrists (83%) ■ knees (75%) ■ elbows (17%) ■ shoulders (10%) ■ fingers (7%) ❍ Peripheral neurovascular disorders ■ local cyanosis ■ areas of increased sweating ■ paresthesia ■ chronic erythema ■ flushing + blanching of skin ❍ Clubbing ❍ Hypertrophy of extremities (soft-tissue swelling) Location ❍ tibia + fibula (75%) ❍ radius + ulna (80%) ❍ proximal phalanges (60%), femur (50%) ❍ metacarpus + metatarsus (40%), humerus + distal phalanges (25%) ❍ pelvis (5%) ❍ unilateral (rare) ■

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LearningRadiology.com - Hypertrophic Osteoarthropathy,hypertrophic pulmonary osteoarthropathy,pulmonary,osteoarthropathy ●

Imaging Findings ❍ In diametaphyseal regions ■ Periosteal proliferation of new bone ● Symmetrical ● Widespread

Frontal and lateral radiograph of the distal femur shows a thick, wavy periosteal reaction that involves the diaphysis but spares the epiphysis

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Bone scan reveals changes early with greater sensitivity ■ 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%

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Thoracotomy can lead to immediate clinical remission; radiolographic remission follows

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Dahnert 5th Edition







LearningRadiology.com - Pneumothorax, Deep Sulcus Sign


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Pneumothorax

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Presence of air in the pleural space ❍ Anatomy ■ Visceral pleura is adherent to lung surface ■ There is no air in the pleural space normally ■ The introduction of air into the pleural space separates the visceral from the parietal pleura ● In contradistinction, the visceral and parietal pleura usually do not separate from each other in obstructive atelectasis Pathophysiology ❍ Either from disruption of visceral pleura ❍ Or, trauma to parietal pleura Clinical findings ❍ Acute onset of ■ Pleuritic chest pain ■ Dyspnea (in 80-90%) ■ Cough ■ Back or shoulder pain Etiologies ❍ Penetrating trauma ❍ Blunt trauma ■ May be due to rib fracture ■ May be caused by increased intrathoracic pressure ■ May lead to bronchial rupture ● “Fallen lung sign” (ptotic lung sign) -- hilum of lung is below expected level within chest cavity ● Persistent pneumothorax with functioning chest tube ❍ Iatrogenic ■ Tracheostomy ■ Central venous catheter attempt or insertion ■ Mechanical ventilation ● May occur in up to 25% of patients maintained on PEEP

http://www.learningradiology.com/archives04/COW%20122-PTX-Deep%20Sulcus/deepsulcuscorrect.htm (1 de 7)04/09/2006 2:26:37


May be bilateral or under tension ■ Thoracic irradiation Spontaneous pneumothorax ■ Most common etiology ■ Cause ● Rupture of subpleural blebs in apical region of lung ■ Age ● 20-40 years ● M:F = 8:1 ● Especially in patients who are tall and thin ● Smokers ■ Prognosis ● Recurrence in 30% on same side ● Recurrence in 10% on contralateral side ■ Treatment ● Simple aspiration (success in >50%) ● Tube thoracostomy (effective in 90%) Other causes of a pneumothorax ■ Neonatal disease ● Meconium aspiration ● Respirator therapy for hyaline membrane disease ■ Malignancy ● Primary lung cancer ● Lung metastases, especially from osteosarcoma ❍ Also pancreas, adrenal, Wilms tumor ■ Pulmonary infections ● Tuberculosis ● Necrotizing pneumonia ● Coccidioidomycosis ● Hydatid disease ● Pertussis ● Acute bacterial pneumonia ● Staphylococcal septicemia ● AIDS (Pneumocystis carinii, Mycobacterium tuberculosis, atypical mycobacteria) ■ Complication of pulmonary fibrosis ● Histiocytosis X ● Idiopathic ● Cystic fibrosis ● Sarcoidosis ● Scleroderma ● Eosinophilic granuloma ● Interstitial pneumonitis ● Rheumatoid lung ● Idiopathic pulmonary hemosiderosis ● Pulmonary alveolar proteinosis ● Biliary cirrhosis ■ Asthma or emphysema ● Produce a second peak incidence of pneumothorax from 45-65 years of age ●

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Due to rupture of peripheral emphysematous areas ■ “Catamenial pneumothorax” is a recurrent spontaneous pneumothorax that occurs during menstruation and is associated with endometriosis of the diaphragm ● R >> L ■ Marfan’s syndrome ■ Ehlers-Danlos syndrome ■ Pulmonary infarction ■ Lymphangiomyomatosis and tuberous sclerosis ● Incidence of pneumothorax is particularly high in lymphangiomyomatosis and histiocytosis X Types of pneumothorax ❍ Closed pneumothorax = intact thoracic cage ❍ Open pneumothorax = "sucking" chest wound ❍ Tension pneumothorax ■ Accumulation of air within pleural space due to free ingress and limited egress of air ■ Pathophysiology: ● Intrapleural pressure exceeds atmospheric pressure in lung during expiration (check-valve mechanism) ■ Frequency ● In 3-5% of patients with spontaneous pneumothorax ● Higher in barotrauma (mechanical ventilation) ❍ Simple pneumothorax –no shift of the heart or mediastinal structures Imaging findings in pneumothorax ❍ Must see the visceral pleural white line ■ Very thin white line that differs from a skin fold by its thickness ❍ Absence of lung markings distal or peripheral to the visceral pleural white line ■ Not evidence enough to say there is a pneumothorax only if there are no lung markings seen ● No lung markings will be seen with bullous disease ● Bullae have a concave surface facing the chest wall ❍ Pneumothorax almost always has a convex surface facing the chest wall ❍ Displacement of mediastinum and/or anterior junction line ❍ Deep sulcus sign ■ On frontal view, larger lateral costodiaphragmatic recess than on opposite side ■ Diaphragm may be inverted on side with deep sulcus ●

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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) ❍

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Total / subtotal lung collapse ■ This is passive or compressive atelectasis Collapse of SVC or IVC due to decreased systemic venous return and decreased cardiac output Tension hydropneumothorax ■ Sharp delineation of visceral pleural by dense pleural space ■ Mediastinal shift to opposite side ■ Air-fluid level in pleural space on erect chest radiograph Radiographic signs in upright position ❍ White margin of visceral pleura separated from parietal pleura ❍ Usually seen in the apex of the lung ❍ Absence of vascular markings beyond visceral pleural margin ❍ 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 ❍ Anteromedial pneumothorax (earliest location) ❍ Outline of medial diaphragm under cardiac silhouette ❍ Deep sulcus sign ■ Decubitus views of the chest may demonstrate a pneumothorax on the side that is nondependent ● Left lateral decubitus view for right-sided pneumothorax ● Right lateral decubitus view for left-sided pneumothorax Subpulmonic pneumothorax (second most common location) ❍ Hyperlucent upper abdominal quadrant ❍ Deep lateral costophrenic sulcus ❍ Sharply outlined diaphragm in spite of parenchymal disease ❍ Visualization of anterior costophrenic sulcus



Visualization of inferior surface of lung Apicolateral pneumothorax (least common location) ❍ Visualization of visceral pleural line Posteromedial pneumothorax (in presence of lower lobe collapse) ❍ Lucent triangle with vertex at hilum ❍ V-shaped base delineating costovertebral sulcus ❍ Pneumothorax outlines pulmonary ligament Pitfalls in diagnosis ❍ Skin fold ■ Thicker than the thin visceral pleural white line ❍ Air trapped between chest wall and arm ■ Will be seen as a lucency rather than a visceral pleural white line ❍ Edge of scapula ■ Follow contour of scapula to make sure it does not project over chest ❍ Overlying sheets ■ Usually will extend beyond the confines of the lung ❍ Hair braids Prognosis ❍ Resorption of pneumothorax occurs at a rate of 1.25% per day (accelerated by increasing inspired oxygen concentrations) ❍

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Thoracic Radiology: The Requisites Dahnert 4th Edition







LearningRadiology.com - Locked facet,facets,cervical spine,injury,dislocation


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Hyperflexion Injuries Locked Facets ●

Normal anatomy ❍ Posterior ligamentous complex ■ Supraspinous ligament ■ Interspinous ligament ■ Posterior longitudinal ligament ■ Capsule of the facet joint ❍ 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) ●


http://www.learningradiology.com/archives04/COW%20123-Locked%20facets/lockedfacetscorrect.htm (1 de 6)04/09/2006 2:26:40

LearningRadiology.com - Locked facet,facets,cervical spine,injury,dislocation ❍

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Mechanism is flexion/distraction ■ Injury is to the posterior spinal ligamentous complex ■ Unstable in flexion; stable in extension ■ If unrecognized, can lead to progressive neurologic damage Imaging Findings ■ Widening of the interspinous distance ■ Slight anterior subluxation of one vertebral body on another ■ Widening of the facet joint ● Usually the posterior aspect ■ 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 ❍ Subluxation of vertebral body ❍ Perched facet ❍ Locked facets ■ At least 50% subluxation Unilateral Locked Facet ❍ Mechanism is flexion/distraction and rotation ■ Only 30% associated with neurologic defect ❍ Most often occurs at C4-5 and C5-6 ❍ 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 ❍ Imaging Findings ■ Subtle ■ Slight anterior subluxation of one vertebral body on the one below ■

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Usually less than 25% of the width ■ On lateral view of cervical spine, some bodies appear true lateral below level of injury and oblique above level of injury ■ “Bow-tie sign” ■ Spinous processes do not align on frontal film ● Spinous processes of inferior vertebrae displaced toward the locked side Bilateral Facet Dislocation ❍ Severe flexion injury ❍ Both anterior and posterior ligamentous structures are disrupted at site of injury ❍ More superior vertebra subluxes forward by 50% or more of the body below ❍ Usually occurs in lower cervical spine ●

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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 ❍ ❍

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May have associated fractures of the laminae and vertebral arch Quadriplegia frequently develops ■ 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

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Approximately 20 million Americans have gallstones Gallstones are twice as common in women as in men ❍ 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 ❍ Pure cholesterol stones ■ Contain more than 90% cholesterol ❍ Mixed cholesterol stones ■ Composed of > 50% cholesterol ■ Usually smaller than pure cholesterol stones ■ Often faceted and multiple ❍ Pigmented stones ■ Unconjugated bilirubin carbonate and phosphate ● Black in color ■ Unconjugated bilirubin monomers as well as cholesterol and calcium salts of fatty acids ● Brown pigment stones ● Commonly large ● Assumed to be caused by primary infection of bile Imaging Findings ❍ Plain films ■ About 10-20% of gallstones sufficiently calcified to be visible on abdominal films ■ Gallstones are usually round or oval in shape in right upper quadrant ■ Multiple stones may show flattened sides called “faceted stones” ■ "Mercedes Benz" sign is a triradiate collection of nitrogen gas ● Fills crevices created by shrinkage of cholesterol crystals in the stone ● 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 ❍

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Ultrasound ■ The procedure of choice for gallstone diagnosis ● 95% accuracy of detection ❍ Moveable, discrete, echogenic foci within the dependent portion of the gallbladder ❍ Acoustical shadowing emanating directly below the echogenic foci ❍ Stones usually sink to dependent portions of gallbladder ■ Cholesterol stones may float CT ■ CT is superior to ultrasound for demonstration of calcification and of fissures in gallstones. ■ Noncalcified stones may be difficult to detect ■ CT is still more sensitive than plain film ■ 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 ● Stones that have attenuation equal to bile may remain invisible ● Cholesterol stones usually have an attenuation value that is lower than bile ❍ Visible on CT as hypo-attenuating structures Differential diagnosis ❍ Gross collections of gas that may occur in a subhepatic or liver abscess ❍ Emphysematous cholecystitis ❍ Gas in biliary ductal or portal venous system ❍ Gas in an abscess in right kidney ■

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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

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Uncommon ❍ May occur in children due to congenital diaphragmatic defects ❍ In adults, rarely occurs before age 50 ■ Most common cause of gastric volvulus in adults are diaphragmatic defects Stomach twists on itself Etiologies ❍ Abnormality of the suspensory ligaments of the stomach ■ Gastrohepatic ■ Gastrosplenic ■ Gastrocolic ■ Gastrophrenic ❍ Unusually long gastrocolic and gastrohepatic mesentery Classified as one of two types--organoaxial or mesenteroaxial

Type

Appearance

Description

Remarks

• Most common type.

Organoaxial

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.

http://www.learningradiology.com/archives04/COW%20125-Gastric%20volvulus/gastricvlvuluscorrect.htm (1 de 5)04/09/2006 2:26:52


Mesenteroaxial

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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 ❍ Especially, paraesophageal hiatal hernias ■ In paraesophageal hernias, gastroesophageal junction remains in abdomen while stomach ascends adjacent to the esophagus ■ Produces “upside-down-stomach” ■ Gastric volvulus is most common complication of paraesophageal hernias ❍ Also occurs with eventration of the diaphragm ❍ Paralysis of diaphragm Despite abnormal placement of stomach, it usually does not become obstructed ❍ Sometimes called “partial volvulus” or “torsion” or “chronic volvulus” ❍ Twisting up to 180 degrees may cause no obstruction ❍ Twisting beyond 180 degrees almost always produces obstruction Clinical findings ❍ Unless acute, patients are frequently asymptomatic ❍ When acute and obstructing ■ Abdominal pain ■ Attempts to vomit without results ■ Inability to pass an NG tube ■ Together, these three findings comprise the Borchardt triad which is diagnostic of acute volvulus ● Reportedly occurs in 70% of cases Imaging findings ❍ Massively dilated stomach in LUQ possibly extending into chest ❍ 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. ●

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Treatment ❍ Surgery in acute gastric volvulus ❍ In patients with chronic gastric volvulus, surgery is performed to prevent complications ■ Nonoperative mortality rate = as high as 80% ■ Mortality rate from acute gastric volvulus = 15-20% ■ Mortality rate from chronic gastric volvulus ranges up to 13% Complications ❍ Gastric emphysema ❍ Twisting of stomach may tear spleen from its normal attachments ❍ Perforation is rare

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 ●

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Causes ❍ Trauma to esophagus or trachea ■ Penetrating injuries from weapons ■ Perforation from within ● Chicken bone ❍ Mediastinal emphysema which tracks up into neck ❍ Retropharyngeal abscess from gas-forming organism Clinical findings ❍ Dysphagia ❍ Odynophagia ❍ Neck tenderness ❍ Crepitus ❍ Hematemesis Imaging findings ❍ Streaks of air in the soft tissues of the neck ❍ Anterior displacement of the pharynx ❍ 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 ❍ ●

Cervical or mediastinal air is seen in 60% of cases of ruptured esophagus Treatment ❍ If hemodynamically stable, watch ❍ If hemodynamically unstable, emergent surgery







LearningRadiology.com - Lipohemarthrosis,fat-fluid,hemorrhage,fracture


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Lipohemarthrosis

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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 ❍ 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 ❍ Fat is less dense than blood so fat floats on the surface with the heavier, denser blood beneath it ❍ 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 ❍ Also to identify occult fractures not detected by radiography Lipohemarthrosis is not seen in all cases of intracapsular fracture ❍ Presence of a fat-fluid level is nearly diagnostic of a fracture, even when that fracture is radiographically occult

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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 ●

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Knee joint ❍ Most commonly, lipohemarthroses are produced with minimally displaced fractures of the tibial plateau ❍ 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 ❍ The top band consists of fatty material ❍ The next band below is composed of serum and serous joint effusion ❍ 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

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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

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Intracardiac defects (VSD,ASD, deformed mitral valve) present in 50% of diffuse type § Also patent ductus arteriosis

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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 Turner’s 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.

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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 Notching–Unilateral • 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 http://www.learningradiology.com/archives04/COW%20128-Coarctation/coarctcorrect.htm (2 de 6)04/09/2006 2:27:02


o

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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 1/3–1/2 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 Findings–Infancy 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 l



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

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Radiographs are obtained routinely after intubation ❍ Endotracheal tube (ETT) is recognized by thin white opaque line usually running the length of the tube Position of carina ❍ Follow right or left main stem bronchus backwards until it meets opposite main stem bronchus ❍ Projects over T5, T6 or T7 in 95% of cases Movement of tip with flexion and extension ❍ Neck flexion may cause 2 cm of descent of tip of tube ❍ 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 ❍ About half the distance between the medical ends of clavicles and carina Ideally tube should be ½ to 2/3 width of trachea ❍ Cuff should fill, but not bulge, the lumen of the trachea Malpositions of the tube ❍ Occurs about 15% of all intubations with emergency intubation having highest rate ❍ Intubation of the esophagus can be recognized by marked gastric distension ❍ Tip of tube too deep ■ About 10% of ETT are initially placed in the right main stem bronchus ■ With time, the left lung becomes atelectatic ● If on ventilator, the right lung may be hyperinflated ❍ May lead to pneumothorax or tension pneumothorax ■ 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 ❍

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Tip of tube too shallow ■ Tip should be at least 3 cm distal to cords ■ Edema of the nasal mucosa by an ETT may cause sinusitis ■ Tube in pharynx may cause gastric dilatation ■ Aspiration of gastric contents ■ 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 ❍ Think of it if pneumomediastinum or subcutaneous emphysema develop after a difficult intubation ❍ Usually perforation occurs in the posterior pharyngeal wall or piriform sinuses ❍ 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 ❍ 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 ❍ In about 1/3 = clostridium perfringens ❍ Also E. Coli and Klelbsiella Occurs more often in men ❍ 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 ❍ As with cholecystitis, right upper quadrant (RUQ) pain and tenderness ❍ Leukocytosis ❍ Jaundice is rare Gas may occur in the wall and/or the lumen ❍ May spread to pericholecystic tissue ❍ Rarely, gas may escape into the bile ducts ■ This is rare since cystic duct is usually occluded in cholecystitis Plain film findings ❍ May show air in the wall or lumen US findings ❍ Indistinct shadowing emanating from wall or lumen of gallbladder CT findings of (non-complicated) cholecystitis ❍ Most common is gallbladder wall thickening >3mm, and ❍ Cholelithiasis ❍ Increased density of bile (>20 H) ❍ Loss of clear definition of gallbladder wall ❍ 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 ❍ Preoperative Percutaneous drainage ❍ Emergency cholecystectomy ■ Surgical mortality of 15-25% Complications ❍ Fivefold increase in perforation than uncomplicated acute cholecystitis Perforation of the gallbladder


LearningRadiology.com - Emphysematous cholecystitis,gas,gallbladder,air,emphyematous,cholecystitis,gas-forming ❍ ❍

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Frequency is declining because of earlier diagnosis of acute cholecystitis Diagnosis ■ Pre-perforation plain film showing stones clustered in gallbladder may subsequently show stones scattered in RUQ after perforation ■ Pericholecystic fluid collection on CT or US (not-specific) ■ Scintography may show radiotracer outside of gallbladder in Morrison’s pouch or flank Treatment ■ Preoperative percutaneous drainage of gallbladder and biloma ■ Emergency surgery

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

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Air in the mediastinal space ❍ Most common in infants ❍ Rare in adults ■ Result of trauma ● Rupture of esophagus ● Rupture of airways Air in mediastinum originates from ❍ Lung ■ Most common mechanism in neonates and adults ● Begins with rupture of alveolus ❍ Usually from increased intraparenchymal pressure ● Air dissects back along perivascular sheaths to hilum and mediastinum ■ Air from ruptured bleb can also extend peripherally into pleural space ● Pneumothorax ■ Most instances can be related to sudden rise in intrapulmonary pressure ● Asthma ● Vomiting ● Valsalva maneuver ● Artificial ventilation ● Closed chest trauma ● Sudden drop in atmospheric pressure ❍ Mediastinal airways ■ Rupture of trachea or mainstem bronchus ● Usually produced by accidental trauma ❍ Esophagus § §

Rupture of the esophagus – Boerhaave’s Syndrome Can occur with

Vomiting ● Labor ● Severe asthmatic attacks ● Strenuous exercise (each of these can produce pneumomediastinum without rupturing the esophagus) ● Site of perforation ❍ 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. ■

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Symptoms ● Infants ❍ None ● Adults ❍ Chest pain (retrosternal) radiating down both arms aggravated by respiration and swallowing

Neck

Trauma to the neck ■ Air can track down onto mediastinum Imaging findings ❍ Linear density parallel to heart border ■ Separated from heart by air ❍ Also ring lucency around aorta or pulmonary artery ■ “Ring around the artery” sign ❍ Dissection of air into neck is much less common in infants than adults ❍ Dissection into chest wall much less common in neonates than older ❍ Air can outline the central portion of the diaphragm ❍ “Continuous diaphragm sign” Clinical Findings ❍ Abrupt onset of retrosternal pain ■ Usually preceded by episode of vomiting ■ Pain is worse on inspiration ■ Dyspnea could be severe ❍ Hamman’s sign – crunching sound heard over the apex of the heart with cardiac cycle ■

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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 ❍ Most are asymptomatic ■ Unless they cause encircling vascular ring like pulmonary sling ❍ Can be complex lesions requiring multiple projections ■ MRI or CT Left Aortic Arch With Anomalous Right Subclavian Artery (RSCA) ❍ 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 ■ Diverticulum of Kommerell Right Aortic Arch ❍ Types ■ At least five different types ■ Only two of importance ● Mirror Image Type — Type I ● Aberrant left subclavian — Type II ❍ General ■ 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 ● Most common variety of right arch ❍ Type 1—Mirror Image Type ■ Secondary to interruption of left arch just distal to ductus arteriosis ■ Associated with congenital heart disease 98% of time ■ X-ray Findings ● No posterior impression on trachea or barium-filled esophagus ● Heart is usually abnormal in size or shape ● Aorta descends on right ❍ Type ll—Aberrant Left Subclavian ■ 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%)

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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 ● Posterior impression on trachea and barium-filled esophagus ● Heart is usually normal in size and shape ● 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 ❍ 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 ❍ Truncus arteriosis 33% ❍ Tetralogy of Fallot 25% ❍ Transposition 10% ❍ Tricuspid atresia 5% ❍ VSD 2% Double Aortic Arch ❍ General ■ 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 ■ Ba swallow shows bilateral impressions on frontal view ● Posterior impression on lateral view ■ Angiogram is characteristic ■ Clinical



Symptoms may begin at birth and include ❍ Tracheal compression, or ❍ Difficulty swallowing ■ Anatomy ● Right arch supplies RSCA and RCC ● Left arch supplies LCC and LSCA ■ X-ray Findings ● 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 ■ Usually asymptomatic ■ May present as pulsating supraclavicular mass ■ May produce vascular ring and compress airway ■ Embryogenesis uncertain ■ Over 80% are right-sided ❍ Imaging Findings–Right-sided lesions ■ Right-sided cervical aortic arches ■ Right apical mass-like density ■ Absence of aortic knob on left ■ Aorta descends on the left ■ Displace the trachea and esophagus forward ■ Branching may be normal or mirror-image ❍ Imaging Findings–Left-sided lesions ■ 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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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 ❍ Age-young adults ■ 15-35 years ❍ Mostly male ■ M:F = 4:1 ❍ Mostly Caucasian ■ Caucasians to Blacks = 3:1 Clinical findings ❍ Insidious onset of low back pain and stiffness ❍ Poor chest expansion ❍ Stiffness ❍ Exaggerated dorsal kyphosis ❍ HLA-B 27 positive in >90% Location ❍ Axial skeleton and large, usually central, appendicular joints Sacroiliac joint involvement ❍ Hallmark of disease ❍ Only synovial portion of SI joint is involved ■ Inferior and anterior portion of joint ● Other enthesopathies like DISH can cause bridging of upper, non-synovial part of joint ❍ Usually site of initial involvement ❍ Bilaterally symmetric ❍ Widened with erosions at first ❍ Then ankylosis Spine ❍ Usually begins at either thoracolumbar or lumbosacral junctions ■ Extends symmetrically without skip areas ● Reiter’s and psoriasis characteristically are asymmetric and have skip areas ❍ Marginal syndesmophyte formation = thin vertical dense spicules bridging the vertebral

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bodies Ossification of outer fibers of annulus fibrosus ● 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 ■ 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 ■ Sites of tendinous insertion ● Ischial tuberosity ● Iliac crest ● Ischiopubic rami ● Greater femoral trochanter ● External occipital protuberance ● Calcaneus ● Patella Dorsal arachnoid diverticula in lumbar spine with erosion of posterior elements Atlantoaxial subluxation ■

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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 ❍ Hip is most frequently involved ❍ Concentric joint narrowing ❍ Few erosions ❍ Protrusio acetabuli Temporomandibular joint ❍ Joint space narrowing ❍ Erosions ❍ Osteophytosis Hand (30%) ❍ Target area ■ MCP, PIP, DIP ❍ Exuberant osseous proliferation ❍ Osteoporosis ❍ Joint space narrowing ❍ Osseous erosions (deformities less striking than in rheumatoid arthritis) Chest ❍ Bilateral upper lobe pulmonary fibrosis (1%) with upward retraction of hila ❍ Resembles tuberculosis Cardiovascular ❍ Aortitis (5%) of ascending aorta ± aortic valve insufficiency ■ Prognosis: 20% progress to significant disability ■ Occasionally death from cervical spine fracture / aortitis DDx ❍ Reiter syndrome (unilateral asymmetric SI joint involvement, paravertebral ossifications) ❍ Psoriatic arthritis (unilateral asymmetric SI joint involvement, paravertebral ossifications) ❍ Inflammatory bowel disease Associated with: ❍ Ulcerative colitis ❍ Regional enteritis ■ Clinically the SI joint involvement is identical to ● Inflammatory Bowel Disease (IBD) ❍ Iritis in 25% ❍ 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

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Thrombotic disease usually affects larger vessels ❍ Includes main renal artery ❍ Patients with thrombotic disease usually present with hypertension or renal insufficiency ❍ Usually results from atherosclerosis ■ 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 ❍ Renal artery emboli usually come from cardiac source ❍ Embolic disease usually produces acute symptoms ■ Sudden onset of flank pain ■ Hematuria ■ Proteinuria ■ Fever ■ Leukocytosis Causes ❍ Trauma ■ Blunt abdominal trauma ■ Traumatic avulsion of renal artery ■ Surgery ❍ Embolism ■ Cardiac origin ● Rheumatic heart disease with arrhythmia ❍ Atrial fibrillation ● Myocardial infarction ● Prosthetic valves ● Myocardial trauma ● Left atrial or mural thrombus ● Myocardial tumors ● Subacute bacterial endocarditis ■ Catheters ● Angiographic catheter manipulation

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Umbilical artery catheter above level of renal arteries ❍ Arterial thrombosis ■ Arteriosclerosis ■ Thrombangitis obliterans ■ Polyarteritis nodosa ■ Syphilitic cardiovascular disease ■ Aneurysms of the aorta or renal artery ■ Sickle cell disease ❍ Sudden complete renal vein thrombosis Lobar Renal Infarction ❍ Early signs ■ Focal attenuation of collecting system ● Tissue swelling ■ Focally absent nephrogram ● Triangular with base at cortex ❍ Late signs ■ Normal or small kidney(s) ■ Focally atrophied parenchyma with normal interpapillary line ■ Cortical atrophy and irregular scarring are seen as late sequelae ❍ CT ■ Subtle renal infarcts are best demonstrated on CT ■ Appear as wedge-shaped, cortically based, hypodense areas ● Triangular in shape with widest part at the cortex (base of infarct) ■ Non-perfused area corresponding to vascular division ■ Renal swelling may also be seen ■ Cortical rim sign ● 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 ❍

US Focally increased echogenicity ■ Color flow Doppler aids in diagnosis of renal artery thrombosis ● There is absence of an intrarenal arterial signal ● Tardus parvus waveform is seen if incomplete occlusion or collateral supply ■ Nuclear medicine ● Nuclear imaging shows a photopenic area corresponding to the region of ischemia or infarction Chronic Renal Infarction ❍ Pathology ■ All elements of kidney atrophied with replacement by interstitial fibrosis ■ Normal or small kidney with smooth contour ■

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LearningRadiology.com - Renal,Infarction,Kidney,embolus,thrombus,thrombosis ■ ■ ❍

Globally atrophied parenchyma Diminished or absent contrast material density

US

Increased echogenicity (by 17 days) ❍ Angiography ■ Normal intrarenal venous architecture ■ Late visualization of renal arteries on abdominal aortogram ■ Provides the definitive diagnosis ● Abrupt termination of vessels or filling defects ● With end-stage renal artery thrombosis ❍ Small kidney with smooth contour, unless multiple small infarcts have occurred independently Treatment ❍ Anticoagulation ❍ Intra-arterial thrombolytic therapy ❍ Surgical revascularization ■

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Dahnert 5th ed Amersham























LearningRadiology.com - Septic,emboli,lung,thrombus,infected,cavity,cavitary,embolus


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Septic Emboli to the Lungs

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Age Majority <40 years Predisposed ❍ IV drug abusers ❍ Alcoholism ❍ Immunodeficiency ❍ CHD ❍ Dermal infection (cellulitis, carbuncles) Sources ❍ Tricuspid valve endocarditis ■ Most common cause in IV drug abusers ❍ Pelvic thrombophlebitis ❍ Infected venous catheter or pacemaker wire ❍ Arteriovenous shunts for hemodialysis ❍ Drug abuse producing septic thrombophlebitis (eg, heroin addicts) ❍ Peritonsillar abscess ❍ Osteomyelitis Organism ❍ S. aureus ❍ Streptococcus Clinical Findings ❍ Sepsis ❍ Cough ❍ Dyspnea ❍ Hemoptysis ■ Sometimes massive ❍ Chest pain ❍ Shaking chills ❍ High fever ❍ Severe sinus tachycardia Location ❍

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Predilection for lung bases Imaging Findings ❍ Multiple round or wedge-shaped densities ❍ Cavitation ■ Frequent ■ Usually thin-walled ❍ Migratory ■ Old ones clear and new ones arise ❍ Pleural effusion is rare ❍ Hilar and mediastinal adenopathy can occur ❍

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Two images from an axial contrast-enhanced CT scan of the chest shows multiple peripheral, thin-walled cavitary lesions consistent with septic emboli ●

CT findings ❍ Multiple peripheral parenchymal nodules ❍ Cavitation or air bronchogram in more than 89% ■ Cavities are thin-walled and may have no fluid level ❍ Wedge-shaped subpleural lesion with apex of lesion directed toward pulmonary hilum (50%) ❍ 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 Wegener’s Granulomatosis

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Complications ❍ 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

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Normal anatomy of acromioclavicular (AC) joint ❍ Synovial joint ❍ Acromioclavicular ligament ■ Weaker ❍ Coracoclavicular ligaments ■ Medial conoid and lateral trapezoid ■ Denser, thicker, stronger

From Harris and Harris, Radiology of Emergency Medicine ●

Normal measurements ❍ AC joint space is usually <5mm ■ Right and left differ by no more than 2-3 mm ❍ Coracoclavicular distance usually <11-13 mm ■ Right and left should differ by < 5 mm

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50% difference in size between the two shoulders is considered significant ❍ Inferior plane of the distal clavicle should be on same plane as inferior border of acromion ■ Developmental variations reported as high as 19% Fall on shoulder is frequent mechanism of injury ❍ Point tenderness, limitation of motion Abnormal widening of the AC joint due to disruption of the AC ligament ❍ CC separation is the more important soft tissue injury Extent of CC separation has direct effect on degree of AC separation Classification ❍

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Type I Sprain

Anatomy Stretching of AC ligament AC joint is stable

Radiographic findings Only seen on stress views of injured and uninjured shoulders=widening of AC joint

CC ligament intact Partial or complete rupture of Widening of AC joint but a AC ligament normal coracoclavicular distance

II Subluxation

III

IV Posterior

V Inferior

VI

Prognosis No instability

May require arthroplasty

Partial, but not complete, disruption of CC ligament

Stress films may still be required to demonstrate widening of both AC joint and CC space

Disruption of both AC and CC ligaments

Widening of both the AC and CC Internal fixation spaces on routine erect film

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

Marked widening of both the AC and CC space

Distal end of clavicle displaced inferiorly and lodges in biceps and coracobrachialis muscles

Distal end of clavicle comes to lie inferior to acromion

Sternoclavicular dislocation



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: ❍ A non-specific or idiopathic web (most common) ❍ Webs associated with Plummer-Vinson Syndrome ❍ Webs associated with epidermolysis bullosa dystrophica or graft-versus-host disease Usually found in middle-aged females Plummer-Vinson Syndrome=Patterson-Kelly syndrome ❍ Iron deficiency anemia ❍ Stomatitis ❍ Glossitis ❍ Dysphagia ❍ Spoon-shaped nails ❍ Esophageal webs ❍ Some question as to whether such a syndrome exists Location ❍ Cervical esophagus anteriorly at level of the cricopharyngeous (C5-C6) ❍ Best visualized with maximal distension ❍ Distal esophageal webs may arise from gastroesophageal reflux Imaging Findings ❍ Thin, transverse filling defects ❍ Perpendicular to anterior esophageal wall ❍ Usually less than 3mm in thickness ❍ Frequently they are not circumferential

http://www.learningradiology.com/archives05/COW%20139-Esophageal%20web/esophagealwebcorrect.htm (1 de 4)04/09/2006 2:27:44


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 ❍ Prominent cricopharyngeous muscle ■ Arises posteriorly at C5-C6 and produces a much broader defect ❍ Stricture Treatment ❍ Balloon dilatation ❍ 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

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Usually the result of blood–borne agents ❍ Especially from lung and urinary tract ❍ Average age of onset is in children around 6 years ❍ Most common pathogen is staphylococcus ❍ Also Streptococcus ❍ Gram-negative rods in IV drug abusers or immunocompromised patients ■ E. Coli ■ Proteus ■ Non-pyogenic ● Tuberculosis ● Coccidioidomycosis May occur as a result of invasive procedure ❍ Surgery ❍ Discography ❍ Myelography Pathogenesis ❍ In children, probably begins in still vascularized disc ❍ In adults, in anterior inferior corner of vertebral body with spread across disk to adjacent vertebral endplate Site of involvement ❍ L3/4 ❍ L4/5 ❍ Unusual above T9 ❍ Usually involvement of one disk space (occasionally 2) Bacteria destroy disk and both contiguous end-plates Imaging Findings ❍ Narrowing and destruction of an intervertebral disk ■ Earliest plain film sign ❍ Indistinctness of adjacent endplates with destruction

http://www.learningradiology.com/archives05/COW%20140-Discitis/discitiscorrect.htm (1 de 5)04/09/2006 2:27:45

LearningRadiology.com - Discitis,infection,spine,disk,disc,staphylococcus ❍ ❍ ❍

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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 ●

MRI Decreased marrow intensity on T1-weighted images in two contiguous vertebrae ❍ High signal intensity on T2 ■ Because of associated edema ❍ Disk space and paravertebral soft tissues enhance on MRI Clinical ❍ Pain is present if disease is acute ❍ Point tenderness ❍ Malaise ❍ Irritability in children ❍ Referred hip pain ❍ Inability to bear weight ❍ Course of discitis is frequently more benign in children than adults ■ Disk space is narrowed but no destruction of contiguous vertebral bodies ❍

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LearningRadiology.com - Discitis,infection,spine,disk,disc,staphylococcus ●

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Osteomyelitis of the vertebral body ❍ Usually the result of discitis ❍ But can occur from direct involvement from hematogenous dissemination to body ❍ MRI findings are similar to discitis Bone scan will be positive Gallium scan or Indium-111 scan will be positive Renal spondyloarthropathy ❍ May resemble discitis ❍ Usually involves cervical spine ❍ Destruction of disk space and adjacent vertebral bodies ❍ Signal on T2 is low rather than high ❍ No clinical evidence of infection Complication of disease ❍ Kyphosis Treatment ❍ 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 ❍ 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 ❍ Loose subcutaneous tissue Lead retracts and begins to wrap around the pacemaker itself ❍ Dislodging lead from endocardium and causing ❍ Malfunction of device ❍ Pacemaker may begin to stimulate diaphragm, vagus or phrenic nerve, pectoral muscles or brachial plexus Imaging findings ❍ Chest x-ray shows looping of wires around pacer ❍ 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 ❍ Skull, spine and pelvis ❍ Rarely do mets occur distal to elbows or knees Spread hematogenously ❍ Most frequently occur where red bone marrow is found ❍ 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 ❍ The next four lesions comprise 80% of all metastases to bone ■ Breast (70% of bone mets in women) ■ Lung ■ Prostate (60% of all bone mets in men) ■ Kidney ❍ Also ■ Thyroid ■ Stomach and intestines Clinical ❍ Most lesions are asymptomatic ■ When symptomatic, pain is major symptom ❍ Fractures of the lesser trochanter in adults should be considered pathologic until proven otherwise Imaging Findings ❍ In general, mets have little or no soft tissue mass associated with them ❍ Usually no periosteal reaction ❍ May appear as moth-eaten, permeative or geographic lesions ■ Indistinct zones of transition ■ No sclerotic margins

http://www.learningradiology.com/archives05/COW%20142-Osteoblastic%20mets/blasticmetscorrect.htm (1 de 6)04/09/2006 2:27:57


May be expansile ■ Soap-bubbly (septated) ■ May be sharply circumscribed or have indistinct borders Metastases that are typically purely lytic ■ Kidney ■ Thyroid Metastases that are usually mixed lytic and sclerotic ■ Lung ■ Breast Metastases that are usually purely blastic ■ Prostate ■ Medulloblastoma ■ Bronchial carcinoid No matter what the primary, skull metastases are usually lytic in appearance ■

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Most Common Tumors to Metastasize to Bone (80% of bone mets) Tumor Prostate Breast Lung Renal Cell Ca

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Appearance Blastic Mixed Predominantly lytic Predominantly Lytic

Imaging findings suggestive of a particular primary tumor ■ Lesions distal to elbows and knees ● 50% are from lung and breast ■ Expansile and lytic (soap-bubbly) ● Renal cell ■ Diffuse skeletal sclerosis or multiple round, well-circumscribed sclerotic lesions ● Prostate ● 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. ■

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Cookie-bite lesions of the cortices of long bones ● Lung ❍ Radioscintographic studies ■ Bone scans are extremely sensitive but not very specific ■ 10-40% of lesions will not be visible on plain film but will be positive on bone scans ■ CT or MRI can be used to show findings in patients with negative conventional radiographs and positive bone scans Complications of metastases to bone ❍ Pathologic fractures ■ Destruction of 50% or more of bone suggests impending pathologic fracture ❍ Spinal cord compression ❍ 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

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General ❍ Incidence ■ About 4% following transmural infarction ■ Probably higher in open heart surgery Believed to have immunologic cause ❍ Possibly a latent viral infection may be involved in cause Clinical ❍ Symptoms typically appear 2-3 weeks following infarct/surgery–sometimes years ❍ May last for weeks or months ■ Different from more common post myocardial infarction pericarditis ● That entity occurs in 17 to 25 percent of cases of acute myocardial infarction ● Occurs between days 2 and 4 after the infarction ❍ Pleuritic chest pain (91%) ❍ Fever ❍ Pericardial and pleural effusion ■ Pericardial friction rub ■ Effusions can be bloody and cause tamponade ❍ Also rales ❍ SOB ❍ Leukocytosis Imaging Findings ❍ Pleural effusions (83%) ❍ Parenchymal opacities (74%) ❍ 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 ●

Treatment ❍ High dose aspirin ❍ Steroids







LearningRadiology.com - Chilaiditi's Syndrome, Chilaiditi's Sign, Interposition, Colon, Pneumoperitoneum, Free Air, pitfall, simulate, miss


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Chilaiditi’s 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 ❍ More often in males ❍ Almost always in adults ❍ May be present intermittently Factors contributing to its occurrence include ❍ Absence of normal suspensory ligaments of the transverse colon ❍ Abnormality or absence of the falciform ligament ❍ Redundant colon, as might be seen with chronic constipation or in bedridden individuals ❍ Aerophagia ❍ Paralysis or eventration of the right hemidiaphragm ❍ Patients with chronic lung disease, cirrhosis and ascites The “sign” refers to the usually asymptomatic presence of the interposed bowel The “syndrome” may involve ❍ Abdominal pain ❍ Constipation ❍ Vomiting ❍ Respiratory distress ❍ Anorexia Chilaiditi’s Syndrome is important because it can simulate pneumoperitoneum ❍ Look for the presence of haustral folds which can establish the air beneath the diaphragm is contained within large bowel ■ Left lateral decubitus abdominal films may help in this distinction ❍ Concomitant pneumoperitoneum may be more difficult to diagnose ■ 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 Submitted by Jonathon Dorff, MD

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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 ❍ Likelihood ratio of trisomy 18 with isolated choroid plexus cyst ranges from 0.03 to 13.8 times the mother’s background risk ❍ Trisomy 18 is almost always associated with other structural abnormalities ❍ When a choroid plexus cyst is identified ■ In addition to the routine anatomic survey, a targeted search for structural abnormalities should be performed ❍ Amniocentesis should be offered when a fetus has both a choroid plexus cyst and additional structural abnormalities

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Rare cases of symptomatic choroid plexus cysts causing obstructive hydrocephalus have been reported

http://www.learningradiology.com/archives05/COW%20145-Choroid%20Plexus%20Cyst/choroidcystcorrect.htm (1 de 5)04/09/2006 2:28:03


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

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Mucus retention cyst that occurs in the sublingual gland Ranulas do not communicate with the duct Etiologies include ❍ Prior trauma, usually iatrogenic from prior surgery ❍ Obstruction of the sublingual gland or its duct Two types of ranulas ❍ Simple ❍ Plunging Simple ranulas are true cysts ❍

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o Occur in floor of the mouth above the level of the mylohyoid with a lining formed by the sublingual gland capsule

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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 ❍ Both types present as a painless mass in the sublingual space ❍ Plunging ranulas extending inferiorly into the submental or submandibular space Imaging findings ❍ Typical CT findings include ■ Smooth, well delineated, cystic lesion ■ Splaying the genioglossus and mylohyoid with a uniformly thin, non-enhancing wall ❍ 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

LearningRadiology.com - Ranula, sublingual, gland, cyst, mucus, mucous, retention, plunging, simple ❍

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Infected ranulas may have thickened enhancing walls and cannot be distinguished from an abscess MRI findings ■ Low signal intensity on T1 weighted imaging ■ 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) ●

Treatment ❍ Simple ranulas usually treated with transoral drainage and excision of ipsilateral sublingual gland ❍ 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

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Compression of 3rd portion of duodenum between the aorta and superior mesenteric artery (SMA) Females more affected than males ❍ Most often in older children, adolescents Some doubt the true existence of the syndrome Pathophysiology ❍ Narrowing of angle between SMA and aorta ■ SMA usually forms an angle of 45 degrees with the aorta Etiologies ❍ Prolonged bed rest in supine position (body cast, whole-body burns, surgery) ❍ Substantial and, frequently, rapid weight loss ❍ Anorexia nervosa or malnutrition ❍ Loss of abdominal muscle tone (as in pregnancy) ❍ May be congenital ❍ Seen in those with asthenic build ❍ Exaggerated lumbar lordosis Clinical findings ❍ Epigastric pain ❍ Nausea ❍ Repetitive vomiting ❍ Abdominal cramping ❍ Typically findings are worst in supine position and may be relived by changing to the prone or left lateral decubitus positions ❍ Associated with a higher than normal incidence of peptic ulcer disease and hyperchlorhydria Imaging findings ❍ Usually requires upper GI or CT of abdomen for diagnosis ❍ Megaduodenum st and 2nd portion of duodenum and frequently stomach ■ Pronounced dilatation of 1 ■ Best seen in supine position ■ Compression of duodenum between aorta and SMA

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 ❍ ❍ ●

Vertical linear compression defect in transverse portion of duodenum overlying spine Abrupt change in caliber distal to compression defect Treatment ❍ Relief of compression by postural change into prone knee-elbow position ❍ Weight gain ❍ Surgery is indicated only when conservative treatment is not successful ■ 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 Paget’s: 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 ❍ Usually osteolytic ❍ 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 ❍ Palliative resection ❍ Chemotherapy Prognosis ❍ Grave, with survival > 2 years rare


http://www.learningradiology.com/archives05/COW%20149-Osteosarcoma%20in%20Pagets/pagetssarcomacorrect.htm (2 de 4)04/09/2006 2:28:22





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

Rigler’s 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 ❍ Surrounded by a thin capsule under which, there may be ❍ Peripheral radiolucent zone of fat ❍ 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 ❍ Following obstructing carcinoma and inflammatory stricture Two most common forms are ❍ Cecal ❍ Sigmoid Cecal volvulus can be associated with ❍ Malrotation of the colon ❍ Abnormally long mesentery of cecum and ascending colon ■ Leads to mobility of right colon predisposing to volvulus ■ Other factors must be at play, though, since 10% of population has such a long mesentery yet few develop cecal volvulus ■ 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 ❍ 20-40 years M>F Imaging findings ❍ Markedly dilated cecum ■ "Kidney-shaped" distended cecum ■ Usually positioned in LUQ or to the left of the midline ❍ Most obstructions are complete so there is little gas in the rest of the colon ❍ Tapered end of barium column points toward torsion ■ 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 ●

About 10-33% of cecal volvuli are cecal bascules ❍ Cecum does not rotate around its luminal axis ❍ Consistent feature of cecal bascule is presence of a constricting band across the ascending



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colon, the origin of which is not certain ❍ Cecum folds anteromedial to the ascending colon ■ Produces a flap-valve occlusion at the site of flexion ■ Occurs in a transverse plane and is associated with marked distension of the cecum ● Often displaced into the center of the abdomen ❍ Findings ■ Distended air-filled cecum is located more centrally Diagnosis and treatment ❍ Patients present most often with an acute abdomen ■ Colicky abdominal pain of sudden onset ❍ 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 ❍ Diagnosis is usually by plain film appearance ❍ Reduction using barium in an enema may be tried ❍ Treatment is usually surgical Prognosis and complications ❍ Mortality between 20-40% in elderly ❍ Closed-loop obstruction that can lead to ■ Gangrene of bowel ■ 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 ❍ At C3: <3 mm (less than 1/3 AP diameter) ❍ At C6: < the AP width of C6 vertebral body Retropharyngeal Space ❍ Contains lymphatics that drain ■ Nasopharynx ■ Adenoids ■ Posterior nasal sinuses ❍ These chains atrophy after age 4 Retropharyngeal abscess ❍ Almost all occur before age 6 ❍ 50% between 6-12 months ❍ Most common pathogens are ■ Staph aureus ■ Group A Beta hemolytic Strep ■ Haemophilus ❍ Clinically ■ Prodromal nasopharyngitis ■ Severe throat pain with drooling ■ Dysphagia ■ Hyperextension of the head ■ “Hot potato” muffled voice ❍ In adults, usually 2° trauma to oropharynx ■ Iatrogenic ■ Perforated FB Retropharyngeal perforation ❍ 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 ■ Penetrating injuries from weapons ■ Perforation from within ● Chicken bone ● Mediastinal emphysema tracking into neck ■ Retropharyngeal abscess 2° gas-forming organism Imaging findings of retropharyngeal perforation ❍ Streaks of air in soft tissues of neck ❍ Anterior displacement of pharynx ❍ Associated pneumothorax possible ❍ Cervical or mediastinal air seen in 60% of cases of ruptured esophagus Upper airway infections-The Big Two ❍ Croup ❍ Epiglottitis Croup ❍ Laryngotracheobronchitis ❍ Usually viral ❍ May be difficult to distinguish from early retropharyngeal abscess ❍ Occurs at age 6 months to 2 years ■ Younger than epiglottitis ❍ The three major findings of croup ■ Distension of the hypopharynx ■ Distension of the laryngeal ventricle ■ Haziness or narrowing of subglottic space Epiglottitis ❍ Most commonly H. flu type B ❍ Peak incidence now closer to 6-7 years ■ Croup occurs from 6 months to 2 years ❍ Lateral radiograph -- erect position only ■ Supine position may close off airway ❍ Imaging findings ■ Epiglottis is enlarged ■ Appears thumb-like ■ Aryepiglottic folds are thickened ■ Pre-epiglottic space (vallecula) is smaller than normal ● In many cases, it’s obliterated ■

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Impacted esophageal foreign bodies ❍ Food or true foreign bodies ■ Chicken bones (opaque), fish bones (non-opaque) ■ Coins, toy trucks ❍ Most often they impact just below cricopharyngeous (70%) ■ Another 20% impact at the level of the aortic arch ■ Another 10% at EG junction ■ Once past the esophagus, most foreign bodies will pass through the GI tract ❍ Clinical findings of an impacted esophageal foreign body ■ Dysphagia and odynophagia most commonly ■ Even if FB passes, many complain of pain referable to cervical esophagus ❍ Always check for lead lines in children



Pica Chicken bones are usually opaque ■ Fish bones contain less calcium and usually are not Plain films usually do not demonstrate the FB but are still obtained first ■ If negative, then either contrast esophagram or CT if high index of suspicion ■

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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 ❍

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Treatment ■ Removal is most often performed using endoscopy ■ Temporization and surgery are other options ■ An ingested button battery lodged in esophagus must be removed immediately Complications of an impacted foreign body ■ Perforation ● Longer the FB remains impacted (>24hrs), higher incidence of perforation


LearningRadiology.com - Chicken bone impacted in cervical esophagus,foreign body ■ ■

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 ❍ Inferior rectus and medial rectus muscles are most commonly involved ❍ Usually bilateral, but may be asymmetric Grave’s Disease = Diffuse Toxic Goiter ❍ Autoimmune disorder with thyroid stimulating antibodies (LATS) producing hyperplasia and hypertrophy of thyroid gland Age of incidence ❍ 3rd-4th decade ❍ Female predominance 7:1 Laboratory findings ❍ Elevated T3 and T4 ❍ Depressed TSH production Clinical findings ❍ Pretibial myxedema ❍ Ophthalmopathy ■ Periorbital edema ■ Lid retraction ■ Opthalmoplegia ■ Proptosis ■ Malignant exophthalmos ❍ Diffuse thyroid enlargement US ❍ Identical to diffuse goiter ❍ Global enlargement of 2-3 times normal size ❍ Normal and/or diffusely hypoechoic pattern ❍ 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

LearningRadiology.com -Thyroid Ophthalmopathy, Grave's Disease, eye, findings, proptosis ❍ ❍

I-131 treatments (for adults) Complications ■ 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




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LearningRadiology.com - Croup


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The Lateral Neck - Croup

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Soft tissue measurements on the lateral neck image ❍ At C3: <3 mm (less than 1/3 AP diameter) ❍ At C6: < the AP width of C6 vertebral body Retropharyngeal Space ❍ Contains lymphatics that drain ■ Nasopharynx ■ Adenoids ■ Posterior nasal sinuses ❍ These chains atrophy after age 4 Retropharyngeal abscess ❍ Almost all occur before age 6 ❍ 50% between 6-12 months ❍ Most common pathogens are ■ Staph aureus ■ Group A Beta hemolytic Strep ■ Hemophilus ❍ Clinically ■ Prodromal nasopharyngitis ■ Severe throat pain with drooling ■ Dysphagia ■ Hyperextension of the head ■ “Hot potato” muffled voice ❍ In adults, usually 2° trauma to oropharynx ■ Iatrogenic ■ Perforated FB Retropharyngeal perforation ❍ Causes ■ Trauma to esophagus or trachea ■ Penetrating injuries from weapons ■ Perforation from within

http://www.learningradiology.com/archives05/COW%20155-Croup/croupcorrect.htm (1 de 6)04/09/2006 2:28:49


Chicken bone ● Mediastinal emphysema tracking into neck ■ Retropharyngeal abscess 2° gas-forming organism Imaging findings of retropharyngeal perforation ❍ Streaks of air in soft tissues of neck ❍ Anterior displacement of pharynx ❍ Associated pneumothorax possible ❍ Cervical or mediastinal air seen in 60% of cases of ruptured esophagus Upper airway infections-The Big Two ❍ Croup ❍ Epiglottitis ●

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Croup ❍ Laryngotracheobronchitis ❍ Usually viral ❍ May be difficult to distinguish from early retropharyngeal abscess ❍ Occurs at age 6 months to 2 years ■ Younger than epiglottitis ❍ The three major findings of croup ■ Distension of the hypopharynx ■ Distension of the laryngeal ventricle ■ 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 ●

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

LearningRadiology.com - necrotizing enterocolitis, NEC ■ ■

Absence of bowel gas Pneumatosis intestinalis ● Pathognomonic of NEC in newborn ❍ Linear radiolucency parallels bowel lumen within bowel wall ❍ 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 ■

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Abdominal free air ● Ominous ❍ Usually requires emergency surgical intervention ● May require a left lateral decubitus view to be seen Portal venous gas ● Originally thought to be ominous but is now considered less so ● Appears as linear branching areas of decreased density over periphery of the liver ❍ Represents air in portal venous system Ascites ● Late finding ● Develops after perforation when peritonitis is present Complications ❍ Occur in about 75% of all patients survive ■ Of those who survive, 50% develop a long-term complication



Two most common complications are intestinal stricture and short-gut syndrome ❍ Intestinal strictures ■ Can develop in infants with or without a preceding perforation ■ Incidence is 25-33% ■ Strictures most commonly involve the left side of the colon ■ Diagnosed with barium enema ❍ Short-gut syndrome ■ Malabsorption syndrome resulting from removal of excessive or critical portions of small ■ Neonatal gut will grow this growth may take as long as 2 years to occur Mortality ❍ Mortality rate ranges from 10-44% in infants weighing less than 1500 g ❍

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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

http://www.learningradiology.com/archives05/COW%20157-Galeazzi%20Fx/galeazzicorrect.htm (1 de 6)04/09/2006 2:29:09


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 http://www.learningradiology.com/archives05/COW%20157-Galeazzi%20Fx/galeazzicorrect.htm (3 de 6)04/09/2006 2:29:09


• 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

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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

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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

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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

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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

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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

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Phytobezoar (55% of all bezoars): o Poorly digested vegetable fibers such as § Skin and seeds of fruits and vegetables

http://www.learningradiology.com/archives05/COW%20158-Bezoar/bezoarcorrect.htm (1 de 5)04/09/2006 2:29:11


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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

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Trichobezoar (hair) o 80% are < age 30, almost exclusively in females o Associated with gastric ulcer in 24-70%

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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

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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

http://www.learningradiology.com/archives05/COW%20159-Pseudotumor/pseudotumorcorrect.htm (1 de 5)04/09/2006 2:29:15


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

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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

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Occurs as a consequence of diseases with chronic pleural scarring, especially asbestos-related pleural disease and TB

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Most often at the lung bases, posteromedially

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Must be subpleural in position

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A rapidly forming pleural effusion produces an adjacent area of passive atelectasis

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A groove of visceral pleura may infold into the area of atelectasis and come to surround a part of it

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If the effusion recedes at once, the lung will probably re-expand

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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

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Asymptomatic: important because it resembles a bronchogenic ca

Imaging Findings ●

Rounded density at lung base

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Contiguous to area of pleural disease or superimposed on apparent asbestos-related pleural disease or TB

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Comet tail on CT: vessels and bronchi converge upon and appear to swirl around mass

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Crow’s feet — linear bands radiating from mass into lung parenchyma

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Linear densities radiate back toward hilum

http://www.learningradiology.com/archives05/COW%20160-Rounded%20atlectasis/roundatelectasiscorrect.htm (1 de 5)04/09/2006 2:29:20


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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

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Age o Highest incidence 40-50 years

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Female preponderance 3:1 under the age of 40 o M:F = 1:1 if >40 years

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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

http://www.learningradiology.com/archives05/COW%20161-Rheumatoid%20Arthritis-Hands/racorrect.htm (1 de 7)04/09/2006 2:29:38


Antinuclear antibodies § Positive in many o LE cells § Positive in some o Positive latex flocculation test o

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Location o Usually symmetric involvement of true, diarthrodial joints

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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



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Extra-articular manifestations (76%) o Felty’s syndrome (<1%) § Rheumatoid arthritis (present for >10 years) § Splenomegaly § Neutropenia • Age o 40-70 years •

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F>M o Rare in African-Americans Sjögren’s 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 Caplan’s syndrome § Hyperimmune reactivity to silica inhalation with rapidly developing multiple pulmonary nodules Pulmonary hypertension secondary to arteritis

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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)

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Cardiovascular involvement o Pericarditis (20-50%) o Myocarditis (arrhythmia, heart block) o Aortitis (5%) of ascending aorta ± aortic valve insufficiency

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Rheumatoid vasculitis Neurologic sequelae o Distal neuropathy (related to vasculitis) o Nerve entrapment (atlantoaxial subluxation, carpal tunnel syndrome, Baker cyst)

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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

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Uncommon tumors, but second in prevalence to adenomas for colonic tumors

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Tend to occur more frequently in older females

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When symptomatic, can produce: o

Pain

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Diarrhea

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Rectal bleeding-if surface ulcerates

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Constipation

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Almost all are submucosal

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Most are located on the right side (40%), but about 20% are in the sigmoid o

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In the small bowel, lipomas are more common proximally (duodenum)

Imaging findings o

Usually less than 4 cm in size

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Smooth, sharply defined hemispheric mass

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Typically produces either right-angle or slightly obtuse angle as the lesion meets lumen of bowel

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Rarely pedunculated

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Squeeze-sign = deformity due to softness and compressibility of these lesions §

Contour may be altered by peristalsis

http://www.learningradiology.com/archives05/cow162-Cecal%20lipoma/cecallipomacorrect.htm (1 de 5)04/09/2006 2:29:40


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Ulceration is rare

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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.



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May intussuscept

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Do not undergo malignant transformation







LearningRadiology.com - Nephrocalcinosis,medullary,sponge,kidney,calculi,stone,calculus,hyperparathyroid


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Medullary Nephrocalcinosis

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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

http://www.learningradiology.com/archives05/COW%20163-Nephrocalcinosis/nephrocalcinosiscorrect.htm (1 de 6)04/09/2006 2:29:42


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 http://www.learningradiology.com/archives05/COW%20163-Nephrocalcinosis/nephrocalcinosiscorrect.htm (2 de 6)04/09/2006 2:29:42


§ 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

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Cause o Most common cause is deep vein thrombosis (DVT) of lower extremity in >90%

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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 http://www.learningradiology.com/archives05/COW%20164-Westermarks%20sign/westermarkcorrect.htm (1 de 6)04/09/2006 2:29:44


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

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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

•

Located posteriorly in lungs in most cases (60%) o Usually at the site of direct impact o

• •

Hemoptysis is most frequent symptom (50%)

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

o

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 it’s 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 it’s 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 it’s 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 http://www.learningradiology.com/archives05/COW%20169-Hemangioma%20of%20Liver/hemangiomacorrect.htm (1 de 5)04/09/2006 2:30:06


•

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

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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 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

o o o

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

X-Ray Manifestations • 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

Differential Diagnosis o o o o o o

Crohn’s disease–skip lesions: R colon; TI abnormal Cathartic colon-loss of haustrations on Right side of colon; rectum spared Familial polyposis–multiple polyps but no inflammatory changes Radiation ileitis–should have other loops involved and appropriate hx Lymphoma–should have tumor masses, less spasm Amebiasis–cone-shaped cecum

Extra-intestinal Manifestations 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 shoveler’s 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─ Brodie’s abscess ─ (dense, sclerotic, involving entire circumference, little change on serial radiographs) o Osteomalacia (bowed long bones, looser zones, gross fractures, demineralization)



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LearningRadiology.com - Bronchopulmonary sequestration,pulmonary,sequestration,intralobar,extralobar


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Bronchopulmonary Sequestration Submitted by Samir Jethwa, MS14

Bronchopulmonary Sequestration ● ●

●

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. ❍ Intralobar sequestration (ILS) in which the lesion is located within a normal lobe and lacks its own visceral pleura. ❍ Extralobar sequestration (ELS) in which the mass is located outside the normal lung and has its own visceral pleura ● The blood supply of 75% of pulmonary sequestrations is derived from the thoracic or abdominal aorta. ❍ 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. ●

• 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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LearningRadiology.com - Bronchopulmonary sequestration,pulmonary,sequestration,intralobar,extralobar • • •

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%

http://www.learningradiology.com/archives05/COW%20174-Fibromuscular%20Dysplasia/fmhcorrect.htm (1 de 5)04/09/2006 2:30:31


§ 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

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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



o

o

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

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Frequency o Usually affects men aged 20-40 yrs. o Mostly unilateral o More often in right wrist

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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

http://www.learningradiology.com/archives05/COW%20175-Kienbocks%20Disease/kienbockscorrect.htm (1 de 5)04/09/2006 2:30:34


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,"Kienböck 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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• Risk Factors

•

•

o

Adenomatous polyp

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Family history of benign or malignant colon tumors

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Chronic ulcerative colitis

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Crohn’s disease

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Prior pelvic radiation

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In women who have carcinoma of breast or uterus

o

Retinitis pigmentosa

o

Familial polyposis

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Gardener’s syndrome

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For synchronous lesions=1% (two or more colon ca’s at same time)

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For metachronus lesions=4-5% (likelihood of a person with colon ca developing 2nd)

Pathology o

Adenocarcinomas make up the vast majority

o

Squamous cell carcinoma can start at the anal verge

o

Cloacogenic carcinoma spreads mostly by direct invasion

Clinical o

Peak age 50-70 years

o

Weight loss

o

Blood in stool

o

Loss of appetite

o

Change in bowel habits

http://www.learningradiology.com/archives05/COW%20176-Colon%20cancer/coloncacorrect.htm (1 de 5)04/09/2006 2:30:43


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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

More common in right colon with advancing years

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More common in left colon with chronic ulcerative colitis

Imaging findings o

90-95% rate of detection by BE

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Polypoid filling defect

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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

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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



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Stomach, breast, pancreas, and GU pelvic malignancies via blood

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May also spread via intraperitoneal seeding, especially from ovary

• Complications

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•

o

Obstruction-antegrade/retrograde or both

o

Perforation is relatively common

o

Carcinomas of the transverse colon can spread via direct extension to stomach

o

Intussusception of lesions in TI or cecum

o

Ischemic colitis may occur if chronic obstruction

Metastases o

Liver (25%)

o

Retroperitoneal and mesenteric nodes (15%)

o

Hydronephrosis (13%)

o

Adrenal (10%)

o

Ovarian mets

o

Ascites

Complications Obstruction-may be retrograde but not antegrade

o • o

More likely to be left-sided than right-sided Perforation

o

Intussusception

o

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

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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

http://www.learningradiology.com/archives05/COW%20177-RA-CSpine/racspinecorrect.htm (1 de 6)04/09/2006 2:30:47


§ 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

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

•

Extra-articular manifestations (76%) o Felty’s syndrome (<1%) § Rheumatoid arthritis (present for >10 years) § Splenomegaly § Neutropenia • Age o 40-70 years •

F>M o Rare in African-Americans o Sjögren’s 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 Caplan’s 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%)

http://www.learningradiology.com/archives05/COW%20178-Bladder%20cancer/bladdercacorrect.htm (1 de 5)04/09/2006 2:30:49


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 http://www.learningradiology.com/archives05/COW%20179-Pelvic%20Congestion%20Syndrome/pelcongsyncorrect.htm (1 de 5)04/09/2006 2:30:58


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

http://www.learningradiology.com/archives05/COW%20179-Pelvic%20Congestion%20Syndrome/pelcongsyncorrect.htm (2 de 5)04/09/2006 2:30:58


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

http://www.learningradiology.com/archives05/COW%20180-Subcu%20Emphysema/subcuemphysemacorrect.htm (1 de 5)04/09/2006 2:31:01


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




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LearningRadiology.com - Rickets,osteomalacia,bowing,rachitic,vitamin D,metaphysis,metaphyseal,cupping,fraying


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Rickets

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Osteomalacia during enchondral bone growth Age ❍ 4-18 months Histology ❍ Zone of preparatory calcification does not form resulting in build-up of maturing cartilage cells ❍ Also occurs in shafts so that osteoid production elevates periosteum Clinical findings ❍ Irritability ❍ Bone pain ❍ Tenderness ❍ Craniotabes ❍ Rachitic rosary ❍ Bowed legs ❍ Delayed dentition ❍ Swelling of wrists and ankles Location ❍ Metaphyses of long bones subjected to stress are particularly involved ■ Wrists ■ Ankles ■ Knees Imaging findings ❍ Cupping and fraying of metaphysis ❍ Poorly mineralized epiphyseal centers with delayed appearance ❍ Irregular widened epiphyseal plates (increased osteoid) ❍ Increase in distance between end of shaft and epiphyseal center ❍ Cortical spurs projecting at right angles to metaphysis ❍ Coarse trabeculation (not the ground-glass pattern found in scurvy) ❍ Periosteal reaction may be present ❍ Deformities common

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LearningRadiology.com - Rickets,osteomalacia,bowing,rachitic,vitamin D,metaphysis,metaphyseal,cupping,fraying ■ ■ ■ ■

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

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Causes Of Rickets



Abnormality In Vitamin D Metabolism ■ Associated with hyperparathyroidism ■ Vitamin D deficiency ● Dietary lack of vitamin D ● Famine osteomalacia ■ Lack of sunshine exposure ■ Malabsorption of vitamin D ● Pancreatitis and biliary tract disease ● Steatorrhea, celiac disease, postgastrectomy ● Inflammatory bowel disease ❍ Defective conversion of vitamin D to 25-OH-cholecalciferol in liver ■ Liver disease ■ Anticonvulsant drug therapy (= induction of hepatic enzymes that accelerate degradation of biologically active vitamin D metabolites) ❍ Defective conversion of 25-OH-D3 to 1,25-OH-D3 in kidney ■ Chronic renal failure = renal osteodystrophy ■ Vitamin D-dependent rickets = autosomal recessive enzyme defect of 1-OHase Abnormality In Phosphate Metabolism ❍ Not associated with hyperparathyroidism secondary to normal serum calcium ❍ Phosphate deficiency ■ Intestinal malabsorption of phosphates ■ Ingestion of aluminum salts [Al(OH)2] forming insoluble complexes with phosphate ■ Low phosphate feeding in prematurely born infants ■ Severe malabsorption state ■ Parenteral hyperalimentation ■ Disorders of renal tubular reabsorption of phosphate ● Renal tubular acidosis (renal loss of alkali) ● deToni-Debré-Fanconi syndrome = hypophosphatemia, glucosuria, aminoaciduria ● Vitamin D-resistant rickets ● Cystinosis ● Tyrosinosis ● Lowe syndrome ❍ Hypophosphatemia with nonendocrine tumors ■ Oncogenic rickets - elaboration of humeral substance which inhibits tubular reabsorption of phosphates ● Sclerosing hemangioma ● Hemangiopericytoma ● Ossifying mesenchymal tumor ● Nonossifying fibroma ❍ Hypophosphatasia Calcium Deficiency ❍ Dietary rickets = milk-free diet (extremely rare) ❍ Malabsorption ❍ Consumption of substances forming chelates with calcium Classification Of Rickets ❍ Primary vitamin D-deficiency rickets ❍ Gastrointestinal malabsorption ■ Partial gastrectomy ❍

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Small intestinal disease: gluten-sensitive enteropathy / regional enteritis ■ Hepatobiliary disease: chronic biliary obstruction / biliary cirrhosis ■ Pancreatic disease: chronic pancreatitis ❍ Primary hypophosphatemia; vitamin D-deficiency rickets ❍ Renal disease ■ Chronic renal failure ■ Renal tubular disorders: renal tubular acidosis ■ Multiple renal defects Hypophosphatasia and pseudohypophosphatasia ❍ Fibrogenesis imperfecta osseum ❍ Axial osteomalacia Miscellaneous ❍ Hypoparathyroidism, hyperparathyroidism, thyrotoxicosis, osteoporosis, Paget disease, fluoride ingestion, ❍ ureterosigmoidostomy, neurofibromatosis, osteopetrosis, macroglobulinemia, malignancy ■

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Hangmans fx

http://www.learningradiology.com/images/boneimages1/bonegallerypages/Hangmans fx.html04/09/2006 2:32:47



Hemophilac arthropathy

http://www.learningradiology.com/images/boneimages1/bonegallerypages/Hemophilac arthropathy.html04/09/2006 2:32:48



DJD

http://www.learningradiology.com/images/boneimages1/bonegallerypages/Hip-DJD.html04/09/2006 2:32:50



Lipohemarthrosis

http://www.learningradiology.com/images/boneimages1/bonegallerypages/Lipohemarthrosis.html04/09/2006 2:32:51



Ochronosis

http://www.learningradiology.com/images/boneimages1/bonegallerypages/Ochronosis-AP.html04/09/2006 2:32:52



Ochronosis

http://www.learningradiology.com/images/boneimages1/bonegallerypages/Ochronosis-lat.html04/09/2006 2:32:53




http://www.learningradiology.com/images/boneimages1/bonegallerypages/Ossification in scar.html04/09/2006 2:32:55

Cardiac Images

LearningRadiology.com Cardiac Images

Tetralogy of Fallot

VSD

Ruptured AAA

Holt-Oram Syndrome

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Cardiac Images (1 of 24)


ASD with PAH

http://www.learningradiology.com/images/cardiacimages1/cardiacgallerypages/ASD with PAH.html04/09/2006 2:32:58



ASD

http://www.learningradiology.com/images/cardiacimages1/cardiacgallerypages/ASD.html04/09/2006 2:33:00



Coarctation-figure3 sign

http://www.learningradiology.com/images/cardiacimages1/cardiacgallerypages/Coarct figure3.html04/09/2006 2:33:01



Double aortic arch

http://www.learningradiology.com/images/cardiacimages1/cardiacgallerypages/Double aortic arch-esoph.html04/09/2006 2:33:03



Ebsteins anomaly

http://www.learningradiology.com/images/cardiacimages1/cardiacgallerypages/Ebsteins anomaly.html04/09/2006 2:33:04



Hypolastic L Heart Syndrome

http://www.learningradiology.com/images/cardiacimages1/cardiacgallerypages/Hypolastic L Heart Syndrome.html04/09/2006 2:33:11



L Ao Arch-Aberant RSCA

http://www.learningradiology.com/images/cardiacimages1/cardiacgallerypages/L Ao Arch-Aberant R SCA.html04/09/2006 2:33:13



Mitral Stenosis

http://www.learningradiology.com/images/cardiacimages1/cardiacgallerypages/Mitral Stenosis.html04/09/2006 2:33:16



Multiple valve dz

http://www.learningradiology.com/images/cardiacimages1/cardiacgallerypages/MR, AS, TR-multi-valve dz.html04/09/2006 2:33:17




http://www.learningradiology.com/images/cardiacimages1/cardiacgallerypages/Pericardial effusion.html04/09/2006 2:33:21



Persistent L SVC

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http://www.learningradiology.com/images/cardiacimages1/cardiacgallerypages/Pulmonary hypertension.html04/09/2006 2:33:25



Pulmonary sling-lat

http://www.learningradiology.com/images/cardiacimages1/cardiacgallerypages/Pulmonary sling-lat with Ba.html04/09/2006 2:33:27



R Ao Arch-Mirror image

http://www.learningradiology.com/images/cardiacimages1/cardiacgallerypages/R Ao Arch Mirror Lat.html04/09/2006 2:33:28



R Ao Arch Mirror image

http://www.learningradiology.com/images/cardiacimages1/cardiacgallerypages/R Ao Arch Mirror PA.html04/09/2006 2:33:31



R Ao Arch-Aberrant LSCA

http://www.learningradiology.com/images/cardiacimages1/cardiacgallerypages/R Ao Arch-Aberrant LSCA.html04/09/2006 2:33:32



R Ao Arch-mirror image

http://www.learningradiology.com/images/cardiacimages1/cardiacgallerypages/R Ao Arch-mirror image.html04/09/2006 2:33:34



Scimitar syndrome

http://www.learningradiology.com/images/cardiacimages1/cardiacgallerypages/Scimitar syndrome-lat.html04/09/2006 2:33:35



Scimitar syndrome

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TAPVR

http://www.learningradiology.com/images/cardiacimages1/cardiacgallerypages/TAPVR-snowman.html04/09/2006 2:33:40

Chest Images


TB

TB

Atelectasis 2 ETT

Atelectasis-LLL

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701 X 557 35 KB

661 X 800 32 KB

Aatelectasis-LLL

Atelectasis from Br Ca

Atelectasis-RLL

Atelectasis-RLL

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800 X 672 41 KB

Atelectasis-RML

Atelectasis-RML

Atelectasis-RML

Atelectasis-RML

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Chest Images


Bronchogenic carcinoma

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Large R Effusion

Free Air

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Abscess-staph

TB

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Hydropneumothorax

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Chest Images


Meconium aspiration syndrome 272 X 240 9 KB

Pneumonia-lingula

Pneumonia-lingula

Tension pneumothorax

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http://www.learningradiology.com/images/chestimages1/chestgallerypages/index2.html04/09/2006 2:33:45

Chest Images (1 of 44)


Aspergilloma

http://www.learningradiology.com/images/chestimages1/chestgallerypages/Aspergilloma-PA.html04/09/2006 2:33:47



Atelectasis

http://www.learningradiology.com/images/chestimages1/chestgallerypages/Atelectasis L lung-asthma.html04/09/2006 2:33:55



Atelectasis

http://www.learningradiology.com/images/chestimages1/chestgallerypages/Atelectasis LUL lat.html04/09/2006 2:33:56



Atelectasis

http://www.learningradiology.com/images/chestimages1/chestgallerypages/Atelectasis LUL PA.html04/09/2006 2:33:58



Br Ca cavitary

http://www.learningradiology.com/images/chestimages1/chestgallerypages/Br Ca cavitary.html04/09/2006 2:34:00



Hamartoma

http://www.learningradiology.com/images/chestimages1/chestgallerypages/Hamartoma-CT.html04/09/2006 2:34:02



Hamartoma

http://www.learningradiology.com/images/chestimages1/chestgallerypages/Hamartoma-cu.html04/09/2006 2:34:04



Hydatid cyst

http://www.learningradiology.com/images/chestimages1/chestgallerypages/Hydatid cyst.html04/09/2006 2:34:05



Neurofibromatosis

http://www.learningradiology.com/images/chestimages1/chestgallerypages/Neurofibromatosis PA.html04/09/2006 2:34:07



Neurofibromatosis

http://www.learningradiology.com/images/chestimages1/chestgallerypages/Neurofibromatosis.html04/09/2006 2:34:08



Noncardiac pulmonary edema

http://www.learningradiology.com/images/chestimages1/chestgallerypages/Noncardiogenic pulmonary edema.html04/09/2006 2:34:10



Osteochondroma

http://www.learningradiology.com/images/chestimages1/chestgallerypages/Osteochondroma rib.html04/09/2006 2:34:12



Pancoast

http://www.learningradiology.com/images/chestimages1/chestgallerypages/Pancoast.html04/09/2006 2:34:14



PTX-tension

http://www.learningradiology.com/images/chestimages1/chestgallerypages/PTX-tension-lat.html04/09/2006 2:34:15



PTX-tension

http://www.learningradiology.com/images/chestimages1/chestgallerypages/PTX-tension-PA.html04/09/2006 2:34:17



Pulmonary infarct

http://www.learningradiology.com/images/chestimages1/chestgallerypages/Pulmonary infarct.html04/09/2006 2:34:18



Radiation fibrosis

http://www.learningradiology.com/images/chestimages1/chestgallerypages/Radiation fibrosis.html04/09/2006 2:34:20



SPN-hamartoma

http://www.learningradiology.com/images/chestimages1/chestgallerypages/SPN-hamartoma-CU.html04/09/2006 2:34:21



SPN-hamartoma

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SPN-hamartoma

http://www.learningradiology.com/images/chestimages1/chestgallerypages/SPN-hamartoma-PA.html04/09/2006 2:34:24

GI Thumbnails

LearningRadiology.com GI Thumbnails

Diverticulitis

Giardiasis

Hypoalbuminemia

Localized ileus-LUQ

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378 X 480 20 KB

322 X 480 16 KB

Lymphoma

Ovarian ca mets

Porcelain GB


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http://www.learningradiology.com/images/giimages1/gigallerypages/index1.html04/09/2006 2:34:33

GI Thumbnails (1 of 28)


Adynamic ileus

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Ca of cecum

http://www.learningradiology.com/images/giimages1/gigallerypages/Ca of cecum.html04/09/2006 2:34:37



Ca of esophagus

http://www.learningradiology.com/images/giimages1/gigallerypages/Ca of esophagus.html04/09/2006 2:34:39



Carmens meniscus

http://www.learningradiology.com/images/giimages1/gigallerypages/Carmens meniscus.html04/09/2006 2:34:40



Carmens meniscus

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http://www.learningradiology.com/images/giimages1/gigallerypages/Cong Absence Diaphragm1.html04/09/2006 2:34:43




http://www.learningradiology.com/images/giimages1/gigallerypages/Cong Absence Diaphragm2.html04/09/2006 2:34:45



Crohns disease

http://www.learningradiology.com/images/giimages1/gigallerypages/Crohns.html04/09/2006 2:34:47



Duodenal atresia

http://www.learningradiology.com/images/giimages1/gigallerypages/Duodenal atresia.html04/09/2006 2:34:51



Hamptons line-ulcer

http://www.learningradiology.com/images/giimages1/gigallerypages/Hamptons line-ulcer.html04/09/2006 2:34:52



Jackstone calculous

http://www.learningradiology.com/images/giimages1/gigallerypages/Jackstone calculous.html04/09/2006 2:34:54



Perforated rectum

http://www.learningradiology.com/images/giimages1/gigallerypages/Perforated rectum-BE.html04/09/2006 2:34:55



Perforated rectum

http://www.learningradiology.com/images/giimages1/gigallerypages/Perforated rectum-post.html04/09/2006 2:34:57



Rectal ca

http://www.learningradiology.com/images/giimages1/gigallerypages/Rectal ca.html04/09/2006 2:34:59



SBO

http://www.learningradiology.com/images/giimages1/gigallerypages/SBO.html04/09/2006 2:35:00



Sprue

http://www.learningradiology.com/images/giimages1/gigallerypages/Sprue.html04/09/2006 2:35:02



Amyloidosis

http://www.learningradiology.com/images/giimages1/gigallerypages/amyloidosis.html04/09/2006 2:35:09



Appendicolith

http://www.learningradiology.com/images/giimages1/gigallerypages/appendicolith.html04/09/2006 2:35:10



Colonic polyps

http://www.learningradiology.com/images/giimages1/gigallerypages/colonicpolyps.html04/09/2006 2:35:11



Scleroderma

http://www.learningradiology.com/images/giimages1/gigallerypages/cow52_small1.html04/09/2006 2:35:12

http://www.learningradiology.com/lectures/cardiaclectures/cardiacbdsreviewflashpage.htm

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http://www.learningradiology.com/images/giimages1/Sprue.jpg

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http://www.learningradiology.com/images/giimages1/lymphoma.JPG

http://www.learningradiology.com/images/giimages1/lymphoma.JPG04/09/2006 2:35:43

http://www.learningradiology.com/images/giimages1/giardiasis.JPG

http://www.learningradiology.com/images/giimages1/giardiasis.JPG04/09/2006 2:35:43

http://www.learningradiology.com/images/giimages1/hypoalbuminemia.jpg

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http://www.learningradiology.com/images/giimages1/purpura.jpg

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http://www.learningradiology.com/images/chestimages1/CavityAspergilloma.JPG04/09/2006 2:36:02

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

http://www.learningradiology.com/notes/chestnotes/bronchogeniccarcinoma.htm (1 de 12)04/09/2006 2:36:07


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 http://www.learningradiology.com/notes/chestnotes/bronchogeniccarcinoma.htm (4 de 12)04/09/2006 2:36:07


§

Common (2-16%)

§

Especially in squamous cell, mostly in upper lobes

§

Cavity is usually thick-walled with nodular inner margin

o Pleural involvement

·

§

Common: 10%

§

Hemorrhagic effusion denotes direct tumor invasion

§

Effusion carries a poor prognosis even if no malignant cells are found

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) ·

Especially in small cell and alveolar cell

o Adrenals §

In 37% pathologically at time of presentation

o Brain §

In 30% at autopsy

§

Multiple in 2/3

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

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Types of dislocations about the shoulder ❍ Glenohumeral dislocation (the most common by far) ❍ Acromioclavicular dislocation (12%) ❍ Sternoclavicular dislocation (uncommon) Types of glenohumeral dislocations ❍ Anterior or subcoracoid shoulder dislocation (96%) ■ Mechanism ● External rotation and abduction ● 40% recurrent ■ Age ● Younger individuals ■ May be associated with: ● Fracture of greater tuberosity (15%) ● Bankart lesion ❍ Fracture of anterior glenoid rim ● Hill-Sachs defect (50%) ❍ Impaction fracture of posterolateral surface of humeral head due to impaction of humeral head against anterior rim of glenoid during dislocation ❍ Posterior shoulder dislocation (2-4%) ■ Causes ● Traumatic ❍ Convulsive disorders or electroshock therapy ● Nontraumatic ❍ Congenital or developmental ❍ 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

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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: ❍ Trough sign (75%) = "reverse Hill-Sachs" = compression fracture of anteromedial humeral head ❍ Fracture of posterior glenoid rim ❍ Avulsion fracture of lesser tuberosity ■ Isolated fractures of the lesser tuberosity should raise suspicion of an associated posterior dislocation ●

■



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). ❍

❍

Inferior shoulder dislocation (1-2%) ■ Luxatio erecta ● 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 ■ Complications ● Rotator cuff tear ● Fracture of acromion with or without inferior glenoid fossa and with or without fracture of the greater tuberosity ● Neurovascular injury Superior shoulder dislocation (<1%) ■ Humeral head driven upward through rotator cuff ■ May be associated with fracture of humerus, clavicle or acromion







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130

A. Transitional cell carcinoma B. Retrocaval ureter C. Retroperitoneal fibrosis D. Pelvic hematoma




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Esophageal Atresia and Tracheoesophageal Fistula

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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 ● ● ●

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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 ❍ Imperforate anus ❍ Duodenal atresia or stenosis ❍ In 25% of cases, there are 13 or more pairs of ribs or 6 or more lumbar vertebral bodies ❍ VACTERL=vertebral, anal atresia, cardiac abnormalities, TEF and/or esophageal atresia, Renal agenesis and dysplasia and limb defects Clinical findings ❍ Presentation for all types is typically early, except for H-type which may go undiagnosed until late childhood ❍ Symptoms include ■ Choking ■ Drooling ■ Difficulty handling secretions ■ Regurgitation ■ Aspiration ■ Respiratory distress Imaging findings ❍ Depends on the type ❍ Prenatal ultrasound can suggest diagnosis as early as 24 because of polyhydramnios ❍ Aspiration pneumonia often involves the RUL when there is esophageal atresia


LearningRadiology.com - Esophageal,atresia,TEF,tracheoesophageal fistula,fistula,tracheo-esophageal ❍

❍

Radiolucent, blind-end dilated pouch of upper esophagus may be seen on chest x-ray ■ Confirmed on lateral view ● Anterior displacement of trachea ● Rarely, air-fluid level in pouch With esophageal atresia and no fistula, no air enters GI tract ■ Abdomen is airless ● 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 ❍ ❍

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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 ■ Only clue on lateral film my be close proximity of trachea and esophagus ■ 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 ■ When seen, the H-type fistula characteristically slopes upward from the esophagus to the trachea Treatment ❍ Primary anastamosis of proximal and distal esophagus usually when infant is a few months old ❍ Colonic interposition if primary anastamosis is impossible


LearningRadiology.com - Esophageal,atresia,TEF,tracheoesophageal fistula,fistula,tracheo-esophageal ●

Complications ❍ May have hypoplasia and stenosis of the distal esophagus ❍ Motility of distal esophagus may be impaired postoperatively (occurs in more than 90%) ❍ Also ■ Fistulae and sinus tracts around surgical site ❍ Shortening of esophagus following repair may lead to hiatal hernia and reflux ❍ 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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Case of the Week 5

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Notes

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What is the most likely diagnosis? A. Right Parietal Mass B. Acute Subdural Hemorrhage C. Chronic Intraparenchymal Hemorrhage D. Subacute Subdural Hemorrhage

Case of the Week Contributed by Weiling Chang, M.D. About Us

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Atelectasis-RML

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http://www.learningradiology.com/images/chestimages1/chestgallerypages/CAM1.html04/09/2006 2:42:15



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Bronchogenic carcinoma

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Abscess-staph

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TB

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Large R Effusion

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Free Air

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Hydropneumothorax

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Pneumonia-lingula

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Pneumonia-lingula

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Tension pneumothorax

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Diverticulitis

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Giardiasis

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Hypoalbuminemia

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Localized ileus-LUQ

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Lymphoma

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Ovarian ca mets

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Porcelain GB

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Rickets




Meconium aspiration






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LearningRadiology.com - Retrocaval Ureter


Return to Case

Retrocaval Ureter ● ●

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Also known as “circumcaval ureter” Abnormality in embryogenesis of IVC ❍ Results from abnormal persistence of right subcardinal vein positioned ventral to ureter in the definitive IVC ❍ Developing right ureter courses behind and medial to the IVC Incidence ❍ 0.07% ❍ Male to female ratio of 3:1 Clinical findings ❍ Symptoms of right ureteral obstruction Imaging findings ❍ Normal course of ureters ■ About the width of your thumb lateral to the lumbar vertebral pedicles ■ About the width of two fingers medial to pelvic brim in true pelvis ❍ With retrocaval ureter ■ Right ureter’s course swings medially over pedicle of L3/4 ● Passes behind IVC ■ Then exits anteriorly between IVC and aorta returning to its normal position ■ Produces varying degrees of proximal hydroureteronephrosis

http://www.learningradiology.com/archives04/COW%20130-Retrocaval%20ureter/retrocavcorrect.htm (1 de 5)04/09/2006 2:44:56


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. http://www.learningradiology.com/archives04/COW%20130-Retrocaval%20ureter/retrocavcorrect.htm (2 de 5)04/09/2006 2:44:56


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Retrocaval ureter can be associated with Turner’s syndrome


Lower ureter

Retrocaval ureter

Lymphadenopathy

Retroperitoneal fibrosis

Iliac artery aneurysm Bladder diverticulum Post-surgical (esp. AP resection) Pelvic lipomatosis Lateral Displacement or Deviation Upper ureter

Lymphadenopathy

Lower ureter 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











Rugger-jersey spine

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Scleroderma

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Tension Ptx

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Achalasia






Extraperitoneal bladder rupture




CPPD




Slipped epiphysis














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Child abuse






Hemangioblastoma






Volar plate fracture










Pericardial effusion-CT

http://www.learningradiology.com/images/caseoftheweekimages/cowgallerypages/cow112ct.html04/09/2006 2:45:57





Mesenteric ischemia






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Arteriovenous malformation








Osteochandritis dissecans-lg

http://www.learningradiology.com/images/caseoftheweekimages/cowgallerypages/cow120xtralg.html04/09/2006 2:46:13







Deep sulcus sign










Gas in gallstone






Gastric volvulus




Retropharyngeal air




Learning Radiology

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