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Required Diagnoses Image

Compendium
1. CRITICAL DIAGNOSES

Abdominal Aortic Aneurysm


Aortic Dissection

Pulmonary Embolism
73M with pulsatile abdominal mass on
physical exam and known history of
peripheral vascular disease status post Above
the Knee Amputation (AKA) (and previously
known infrarenal AAA to 6.6 cm).
Findings:
Aneurysmal AAA,
up to 8.0 x 9.0 cm
distally with
extensive mural
thrombus
What imaging
modality would you
order next?
Findings:
CTA I- and I+ images
demonstrating:
Abdominal Aortic Aneurism
measuring up to 10 cm,
enlarged
Extensive mural thrombus
with contrast filled lumen
measuring ~ 2 cm.
No evidence of dissection

Coronal Maximal Intensity


Projection (MIP) Image in
bone windows
Discussion: AAA
General Features:
Abdominal aorta is considered aneurysmal when its outer wall to outer wall diameter reaches 3 cm,
outer wall to outer wall diameter. Common iliac artery is considered aneurysmal when it exceeds 2 cm
in diameter.
AAA can demonstrate fusiform or saccular morphology.
Most common site for aortic aneurysm is in the infrarenal aorta, although aneurysm can occu anywhere
in the aorta.. Extension into the internal iliac artery is not uncommon, however extension into the
external iliac artery is almost never seen.
Surgical or endovascular repair is usually recommended for abdominal aortic aneurysm (AAA) > 5.5
cm in diameter and iliac aneurysm > 3 cm.
Imaging:
Ultrasound is an excellent non invasive tool for aneurysm screening, follow-up and useful for
assessment of endoleak post endovascular repair. And may demonstrate:
Bulbous or fusiform dilatation of the aorta/artery, Concentric layers of mural thrombus
may line the interior of large aneurysms, Membrane or intimal flap as present in
dissection, Retroperitoneal hematoma which is highly suggestive of aortic rupture.
Color Doppler is useful for demonstration of aortic dissection and to confirm patency major
aortic branches, including celiac axis, superior mesenteric artery, renal arteries.
CT remains the gold standard and preferred imaging modality::
For evaluation of possible aortic rupture
For assessment of suitability for endovascular or surgical repair of the aortic aneurysm
For post endovascular repair follow-up, particularly for assessment of endoleak
67-year-old obese female with acute onset
chest pain radiating to the back
What is your imaging study of choice?
Which protocol?
- What is the finding? Is it
a surgical emergency?
Findings:
CTA of the Chest, Abdomen and Pelvis with
dissection protocol, demonstrating an
extensive aortic dissection with an intimal
aortic flap extending from proximal ascending
aorta to the right iliac artery (Type A
dissection).
Discussion: Thoracic Aortic Dissection
Definition:
Aortic dissection: Spontaneous tear between the intima and media layers with

propagation of subintimal hematoma


Staging, Grading, or Classification Criteria:
Stanford classification (preferred classification)
Type A: Originates in ascending thoracic aorta (60-70%), treated surgically

Type B: Originates distal to left subclavian artery (30-40%), conservative treatment

with HTN management


DeBakey classification
Type 1: Ascending and descending thoracic aorta (30-40%)

Type 2: Ascending only (10-20%)

Type 3: Descending only (40-50%) A: Extends to diaphragm, B: Descends below

diaphragm
Radiographic Findings: widened mediastinum, left apical cap
CT findings: hyperdense intramural hematoma on noncontrast images, displaced intimal
calcifications intraluminally, intimal flap (True vs False lumen with false lumen usually
larger and with delayed filling of contrast as seen on bolus images).
55M POD #1 s/p orthopedic procedure, with
sudden onset dyspnea, tachycardia to 130s
and desaturation to 80%
What is your first imaging examination of
choice?
Findings:
Single, portable, semi-upright chest radiograph
demonstrating no acute findings.
Clear lungs; no pneumothorax, pleural effusion,
pneumonia, or lobar atelectasis. The
cardiomediastinal silhouette is within normal limits
given portable technique.

What is your concern at this time? What is your next


imaging study of choice?
Findings:
Contiguous coronal CTPA images
demonstrating large acute saddle embolus
involving the right and left pulmonary arteries
Discussion: Pulmonary Emboli

Definition: Embolization of thrombi to the pulmonary arteries, usually from deep veins
in lower extremities or pelvis
Radiographic findings: usually normal chest; rarely see wedge-shaped pulmonary
infarcts (Hampton hump: Pleural-based, cone-shaped opacity pointing toward the
hilum); focal areas of oligemia (Westermark sign).
CTPA findings:
direct visualization of the thrombus (with central dark filling defects surrounded by
contrast usually indicative of acute PE; eccentric and adherent to the vessel wall clot
and webs indicative of chronic clot burden), evaluation for right heart strain (i.e.
leftward bowing of the interventricular septum as the RV enlarges)
Standard of care
Nuclear Medicine: V/Q scan
Indirect indicator of clot; does not directly visualize the clot, only the disruption of
vascular perfusion.
Combined with clinical Wells Criteria Score to assess propability.
Used for patients with contraindications to CTPA (contrast allergy, renal failure, and
in some institutions in pregnant females)
2. CHEST

Pneumothorax
Lung Collapse / Atelectasis

Congestive Heart Failure

Common Tubes and Lines


Pneumothorax
63M with shortness of breath

Hyperinflation of lungs
pt has emphysema with Pneumothorax (air in
bullae pleural space)
After chest tube placement

chest tube Diaphragmatic flattening & barrel


chest consistent with emphysema
Next Day

Chest tube failure


resulting in subcutaneous And persisting
emphysema pneumothorax
Subcutaneous
emphysema

Residual
pneumothorax

Chest tube

Bulla in the right lower


lobe potential for
rupture and right-sided
pneumothorax
Lung Collapse / Atelectasis
58M with fever and crackles

Plate-like atelectasis in the left lung base


(minimal airway collapse)
68F with shortness of breath s/p bronchoscopy

Minor fissure

Inferior/anterior portion
of major fissure

Right middle lobe collapse


52M with shortness of breath
endotracheal
tube

Right mainstem bronchus intubation with left lung


collapse the endotracheal tube needs to be retracted
so that it ends above the carina
ETT

s/p retraction of the endotracheal tube (ETT) the left


lung should re-aerate with time
Congestive Heart Failure (CHF)
Endotracheal tube
(ETT) terminates
above carina

R subclavian
central line ends
in SVC

batwing appearance in CHF

CHF low cardiac output results in blood backup in


pulmonary vessels and fluid leak from capillaries - wet
lungs
Aortic balloon
pump used in
hemodynamic
instability

Volume overload in CHF in this case results in:


Batwing appearance
Indistinct pulmonary vessels
Fluid in minor fissure on the right
78M found unresponsive BTW: Enteric tube should go into stomach
and not stop in throat advance or pull!

Bilateral pleural effusions on portable film the fluid layers


posteriorly when the patient lies in bed with head raised 30
Common tubes and lines and their
expected locations
29 year-old man

PICC (peripherally-inserted central catheter)


Terminates in superior vena cava
62M: check central line placement

Right-sided central line crosses midline and enters


left subclavian vein, instead of terminating in
the desired location (SVC)
60M
ETT ends above carina

Enteric tube enters nose (NG)


or mouth (OG) and courses
through esophagus into the
stomach (for suction or tube
feeds)

Swan-Ganz catheter entering subclavian vein SVC


right atrium right ventricle pulmonary artery (to
measure pulmonary arterial wedge pressure)
Reason for exam: check Dobhoff tube placement
1st try 2nd try

Dobhoff tube enters right- Dobhoff tube enters left-


sided bronchus sided bronchus

Dobhoff tubes are used for tube feeds you want the liquid
to go in the stomach, not the lungs
83M in ICU s/p VFIB and resuscitation
Endotracheal
Right internal
tube
jugular central
line ends in
SVC
Enteric tube

CHF volume overload: fullness of right hilum, left pleural


effusion, indistinct pulmonary vasculature
3. CHEST

Lung cancer, pulmonary nodules


Pleural effusion

Pneumonia
45 year old female with 15 pound
unintentional weight loss and cough.
How would you describe the abnormality?
Do you need further imaging? If so, what would you
recommend?
Findings:

There is a 2.5 cm pulmonary


nodule in the right upper lobe.
No lymphadenopathy is
identified.

Recommend contrast enhanced


chest CT for further
characterization and to asses for
satellite lesions.
Pulmonary nodule
Lesions upto 3cm are considered pulmonary
nodules, greater than 3cm are considered
masses.
Generally any nodule greater than 4mm is
followed based on the Fleishner criteria
guidelines.
Nodules greater than 8mm require more
rigorous followup.
How would you describe the findings on this image?
Findings:

There is a 2.5 cm nodular


opacity in the right upper lobe
with lobulated borders.

No lymphadenopathy by CT
size criteria.

Path:

Pulmonary adenocarcinoma.
65 year old male with shortness
of breath.
How would you describe the salient findings?
FINDINGS:
There is an opacity in the right lower
lung zone, tracking up the right chest
wall with blunting of the right
costophrenic angle and a meniscus.
Pleural Effusion
Will show blunting of the costophrenic angle in an
upright chest xray.
200cc needed to show blunting of the lateral
costophrenic angle
50cc needed to show blunting of the posterior
costophrenic angle.

Larger effusions can develop a meniscus and track up the


chest wall.
45 year old female, smoker, with fever,
cough, chest pain with inspiration.
How would you describe the salient findings?
FINDINGS:

There is a lobar consolidation in


the left lower lobe.
Pneumonia
On CXR, often seen as a focal parenchymal
abnormality in a patient with fever.
Differential includes atelectasis, edema, and
hemorrhage.
In patients with lobar pneumonia, followup
can be obtained in 6 weeks to ensure
resolution. If not resolved, a CT can be
obtained to rule out obstructing lesion.
4. GASTROINTESTINAL
Small Bowel Obstruction

Colorectal Cancer

GI bleed

Large Bowel Obstruction/Sigmoid volvulus

Cholecystitis and Biliary Obstruction

Diverticulitis

Appendicitis
52M with abdominal distension
Findings
No gas in the left lower quadrant where you
would expect to see the descending colon

Dilated loops of small bowel. The layering


or stair case appearance of the small bowel
loops is from lack of movement.
Small Bowel Obstruction (SBO)
Difficult to distinguish complete versus partial
SBO with imaging
Bowel > 2.5 cm +/- air-fluid level within bowel
Causes
Adhesions 60%
Hernia 15%
Tumor 15%
69F with abdominal distension and
pain
Findings

Best clue to diagnosis: a short segment of colon


wall thickening

Early cancer irregular polyp or sessile plaque


Advanced cancer annular wall thickening
creating an apple core apperance or lumenal
filling defect can cause obstruction
Colon adenocarcinoma
Dukes Stage 5 yr Survival by Stage

A = mucosa & sub-mucosa only A 80 85%

B = serosa & local/direct soft tissue B 64 78%


spread

C = lymph node metastasis


C 27 33%
D = distant metastasis (liver, lung,
bone) D 5 14%
Must aggressively search for metastatic disease
2011 Estimated US Cancer Cases
(excluding basal cell & squamous cell skin carcinoma)
68 year old woman with fatigue,
dark stool.

Fecal occult blood test + but


nothing found on colonoscopy

What do you want to do next?


Evaluation of Lower GI Bleed
Fast active bleed colonoscopy or angiography

Slow intermittent bleed may miss it on colonoscope! Need a


tagged RBC scan

Performed prior to IR procedure (embolization or coiling) so


angiographer can minimize time of procedure and IV contrast
exposure to patient while pinpointing the exact bleeding site.
Nuclear medicine GI Bleeding Scan
Advantages:
Bleeding scan can detect bleeds as slow as 0.1 cc/min

(Angiography detects bleeds only as low as 1cc/min)


Nonivasive compared to angiography
Greater than 90% accuracy for localization of bleeding
sites in the setting of acute bleeding.

Disadvantages:
Accuracy is not high for slow chronic bleeding.
If ordered after all other evaluations are negative and
bleeding has slowed or stopped, accuracy is poorer.
Nuclear Medicine GI Bleeding Scan

Draw patients blood and label w/ radioactive


tracer (at BMC it is Technetium 99m) then
reinject.

Each frame in the scan = 1 minute of recorded


activity

Uses a gamma camera which detects


continuous radiation
Positive GI Bleeding Scans

1. Abnormal hot spot of radiotracer activity appearsout of


nowhere as it enters the bowel lumen.

2. Activity must persist and may increase over time.

3. Activity must move with peristalsis anterograde,


retrograde, or in both directions.
Our patients Tc 99m RBC Bleeding Scan
Aorta Common iliac a
Liver
Time = 0 min

Bladder

47 min
Findings
Right upper quadrant bleed following the
course of the colon, starts to appear at 17-20
minutes.

Notice how many minutes it takes for the


tagged blood to travel in the colon.
84M with abdominal distension and pain
Large Bowel
wall

Haustra
1. Air fluid levels from bowel stasis
2. Dilated haustra & colon (>9 cm)
Findings
Large bowel obstruction at the level of the
sigmoid colon

Haustra further apart 2/2 dilation

Coffee bean appearance of sigmoid colon as


bowel has loopedin a u-shape. Twisting of bowel
sigmoid volvulus
Sigmoid Volvulus
Often elderly men / nursing home population

Pain out of proportion to exam

Emergent colonoscopy or surgery decompresssion

Concern for wall strangulation (like a hernia or


appendicitis) from obstructed venous/arterial flow
45M with nausea & pain
Findings:

Dilated loops,
Stacking. Notice the
stagnant stool in the
small bowel is starting
to fecalize or become
more solid

Stomach
dilated. Place an NG
Tube to decompress.

Q: What is going
on in the liver?
A: There is abnormal
air in the liver.

Q: Where is the air?

a.Hepatic veins
vein
b.Portal veins
vein
c.Biliary tree
d.Liver parenchyma

Portal venous gas in the setting of bowel obstruction is concerning


for bowel ischemia and necrosis.
50F with nausea, right upper quadrant pain
Arrow Key:
Medical
record
number

Technical
Parameters
for image
acquisition

Zone of
optimum
Focus

Depth in cm
From skin

Type of US
probe used

Techs initials
Skin

Anterior
Liver
Head Feet

Posterior

Dark shadow behind


objects reflecting US wave

Gallbladder
Sagittal
Same patient. Diagnosis?
Findings
Stones in the gallbladder on ultrasound
Shadow deep to gallbladder due to lack of
signal from reflected ultrasound waves.
Why does it reflect? Stones are dense!
String of pearl appearance of stones on xray
Note that the laminated appearance of the
stones: peripherally dense and centrally lucent
Cholelithiasis
If unsure on ultrasound, move the patient to
watch the gallstones fall dependently!

Cholelithiasis =/= cholecystitis!


Look for fluid around gallbladder, edema in the
wall, dilated biliary tree, stone within the CBD to
diagnosis cholecystitis
73F with bright red blood per rectum, fever,
and abdominal pain
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Findings
No oral contrast within colon lumen
Pockets of air extending from sigmoid colon
Peri-colonic fat stranding or inflammation (water
density in the fat around the wall)
Colon wall inflammation progressed to a mural
abscess
water density in the wall
thicker size of wall
Arterial contrast enhancement of wall
Diagnosis?
Diverticulitis
Sigmoid colon involved in 95% of cases
Fecal impaction at diverticula mouth with
subsequent ischemia. Similar mechanism to
appendicitis!

Prevent: high fiber diet, less processed foods


Treat amild case: IV fluids, antibiotics, bowel rest
Treat severe case: Surgical resection
23F with midline abdominal pain
Diagnosis?
Appendicitis Findings
Fluid within the appendix
Dilated appendix > 7 mm
Wall thickening or vascular enhancement
Edema or fat stranding around appendix
+/- dense appendicolith at mouth of appendix

For thin pt, ultrasound may be better than CT!


Appendicitis treatment
IV fluids
Antibiotics
Pain management
Bowel rest
Surgery if no appendix perforation
5. GU & GYN

Nephrolithiasis
Intrauterine and ectopic Pregnancy
34 y/o F, R flank pain
Why are the right kidney
findings present?
What are the findings?
US: Right hydronephrosis (large right renal
pelvis w/blunted calyces outlined in
yellow; compare to normal left kidney with
bright echogenic fatty renal hilum but no
enlarged pelvis/calyces, surrounded by the
darker normal renal parenchyma). Also
right hydroureter (lack of color Doppler
flow in large anechoic tubular structure in
green therefore obstructed dilated ureter,
not vessel)
Reason for the right
hydroureter/hydronep
hrosis?
A right 1.7 cm
calculus in the right
mid ureter

Note that renal


pelvises are
approximately at the
L2 level, and course
of ureters project
approximately along
the transverse
processes on XR
(they lie on the
iliopsoas muscles for
much of their course)
Diagnosis?
Dx: Obstructing right ureteral kidney
stone, with proximal
hydroureteronephrosis
Previous CT Abd/Pelv
Previous CT Abd/Pelv

Pt has h/o right hydroureteronephrosis from stone!


Prior CT abd/pelvis showed obstructing distal stone at
ureterovesicular junction (see how the stone in red is at
the end of the dilated ureter outlined in green), as well
as a larger bladder calculus
Previous CT Abd/Pelv

Note that the renal stone CT protocol is performed in PRONE


position (belly on the table; flipped around here for viewing
convenience), in order to use gravity to better discern the
ureterovesicular junction from the bladder, to distinguish UVJ stone
from bladder stone if needed, as in this case. No contrast given, so
as not to obscure the radiodense stones.
Nephrolithiasis
Rate of spontaneous passage indirectly proportional to size (eg, 80% if < 4mm, 50%
if 4-6 mm, 20% > 8mm), often managed accordingly
If obstruction present (hydronephrosis, hydroureter) affects management
Many types of stones: calcium (oxalate or phosphate, 75-80%), struvite (15-20%),
uric acid, cystine, matrix, xanthine, protease inhibitor-induced
Plain film (XR): misses many
Radiopaque (visible if large): calcium, struvite or cystine (these two types can be staghorn
calculus that fill the pelvis/calyces to look like staghorns)
Radiolucent: uric acid, xanthine, protease inhibitor
CT: extremely sensitive
Most stones uniformly dense except matrix and protease inhibitor-induced
If contrast enhanced (I+): could obscure stones. But if urographic phase is done, with
contrast excreted into collecting system, all of the types of stones will be represented by
filling defects in the collecting system
Secondary signs: hydronephrosis, hydroureter; ureteral wall swelling/edema around stone,
perinephric/periureteral stranding of fat (inflammatory changes)
US:
Stones = echogenic bright focus with posterior shadowing (acoustic waves blocked by
stone, unable to travel through to reflect off structures posterior to stone)
Best seen if in kidneys or ureterovesicular junction (UVJ), difficult to see if in ureter
Can see hydronephrosis/ureter, obstruction from potentially a stone (as in our case)
20 y/o F, pregnant, vaginal
bleeding, left adnexal tenderness
Serum beta-HCG of 2300
What are the findings?
Complex free fluid in cul-de-
sac, with black anechoic
fluid within which there is
echogenic bright material
(possibly hemorrhage)

No IUP (empty uterus)


Normal left ovary,
with ring-shaped mass just
superior to the left ovary,

That demonstrates a ring of


fire hyperemia of color
Doppler flow
Diagnosis?
Dx: Suspicious for ruptured left
tubal ectopic pregnancy
Dont forget to always look for fluid in
abdomen too!

In this case, no free fluid seen


in Morrisons pouch between
liver and right kidney
Ectopic pregnancy
91% accurately dxd with TVUS + color Doppler
Although 5-10% will be totally normal TVUS, just without IUP visualized
When no IUP can be confirmed (empty uterus), and serum beta-HCG > 1000-2000
mIU/mL
suspicion for ectopic MUST be raised
suspicion increases with adnexal/tubal mass
confirmed if see GS in tube
Other signs
Free fluid, especially complex (fluid contains echogenic material/debris, potentially
hemorrhagic from ruptured ectopic, not completely black anechoic simple free fluid)
Look in cul-de-sac
Look in abdomen, eg, Morrisons pouch if there, may suggest bad ruptured ectopic with a lot of
hemorrhage
Adnexal/tubal mass/ring separate from ovary +/- YS, +/- FHR
Ring of fire: tubal mass lights up on color Doppler
Corpus luteum: cystic structure WITHIN ovary that also can demonstrate a ring of fire,
not to be confused with tubal ectopic ring of fire that is external to ovary
However, 85% of ectopics are seen on same side as ovarian corpus luteum!
Can use TVUS probe to palpate for area of pain better localize ectopic

Heterotopic pregnancy (IUP AND ectopic at same time) = extremely rare


Normal intrauterine pregnancy (IUP)
Look for on transvaginal US (TVUS) [see next slides for example]:
Gestational sac (GS)
Should be ROUND, not flattened/oblong (abnormal; if so, could be pseudogestational sac
such as in ectopic pregnancy, could be abnormal pregnancy and suggest potential for early
fetal demise)
Intradecidual sac sign 4-4.5 wks post LMP, anechoic sac rimmed by echogenic
endometrium
Double decidual sac sign: 1st reliable sign of IUP, 5-5.5 wks post LMP two echogenic
rings from endometrium surrounds gest sac
A thick-walled appearance is also typical of the GS
Yolk sac (YS): small ring/sac eccentrically within gestational sac, between
amnion and chorion, confirms IUP, usually at 5.5 wks when GS 5-6 mm,
definitely by GS 8mm (otherwise abnormal)
Fetal pole (embryo)
Fetal heart rate (FHR): should be seen by when fetal pole = 5 mm
5.5-6.5 wks GA: <100 bpm OK
By 7 wks GA: <85 bpm is abnormal
Perigestational fluid/hemorrhage: identified by rim hypoechoic fluid around
portion of GS, often resolves on its own and is fine
if >50% of circumference of GS or misshapen GS, is more worrisome
Normal IUP
Normal IUP

Gestational sac (in yellow) in the uterus (in red)Double decidual sac
with yolk sac with two echogenic ring
And fetal pole (crown-rump length corresponding
to gestational age of 6w 3d, with normal FHR
6. BRAIN AND SPINE

Normal Radiographic Anatomy

Cervical Spine Fractures


Subdural hematoma, epidural hematoma, and

subarachnoid hemorrhage
Stroke
Normal C spine
C- spine: dens
C spine: Obliques
Alignment
60F after fall
I
Dens (C2)
Fracture patterns III
II

Type I: Stable fracture immobilize

Type II: Unstable fracture. Most likely to have non-union due to tenuous blood supply.

Type III: Stable non-union uncommon after bracing.


78M pain after MVC

C2 C2

C4
C4

C6 C6
C-spine fracture Key Points

1. Evaluate alignment of spinal columns

2. Consider MR to evaluate cervical cord or to


better evaluate prevertebral soft tissues

3. Consider CT angiogram if suspect vertebral artery injury


Spine: How to Sound Smart
C1- C8 nerve roots exit Cauda equina at T12-L1 so
above superior endplate of lumbar disc disease does not
the corresponding vertebra cause cord compression

T1- S5 nerve roots exit


Most common disorders:
Fracture
below inferior endplate of
the corresponding vertebra Disc disease

Metastasis

Infection
Normal L Spine
Part 2: Hemorrhage
What type of bleed?

Subdural Hematoma
(SDH)
Typically venous
bridging vein tear in
extra-axial space
Elderly
SDH
EDH
Often spontaneous or low
trauma

Crescentic

Small or isodense may be


difficult to see
Epidural Hematoma (EDH) to be addressed later
Superior sagittal sinus

Suture line

Blue line=dura (e.g.


coronal)

Subdural hematoma

Can cross suture lines

Will not cross midline or tentorium


69F new seizure
What is going on here?
RBC
sediments
with
gravity

Answer: Different densities in left subdural hematoma.

This indicates multiple ages of bleed, ie acute on chronic.


What type of bleed?

Subarachnoid hemorrhage
SAH
Can be diffuse or focal

Often layers dependently on tentorium or basal cisterns

Common causes: trauma >> aneurysm

Beware of vasospasm 7-10 d after bleed

May be epileptogenic focus


Elderly, fall down stairs

Intraparenchymal Hemorrhage
Subarachnoid Hemorrhage
What type of bleed?

Epidural Hematoma
EDH

Usually does not cross


sutures, but can cross
midline.

Suture line
(e.g. coronal)
Epidural Hematoma

Typically arterial
usually middle meningeal
artery AND post traumatic
ie. Younger patient

Most temporal or
temporoparietal lobes

Look for associated


fracture 85-95%

Lucid interval then rapid


neurologic deterioration
Food for thought:

Why can someone walk around with a large


asymptomatic brain tumor, but a relatively small
epidural hematoma is fatal?

Answer:

Tumors relatively chronic allowing the brain to remodel & adjust

EDH is acute giving the brain no time to adapt to mass effect

SYMPTOMS = LOCATION + SIZE + GROWTH RATE


What does this mean?

Swirl Sign:

Hypoattenuating (darker)
area within bleed indicates
non-clotted blood, ie active
bleed

Even EDH with this sign do


not usually grow after being
imaged
Epidural and Subdural Hematoma

EDH do not cross sutures but can cross midline.

SDH can and do cross sutures but do not cross midline (instead SDH layers along
the falx or tentorium)
85 y/o F, p/w
acute weakness and speech difficulty
DWI ADC FLAIR
What are the findings?

This one is subtle and tough on the


CT, easier on the MRI!
Area of focal white matter
hypodensity on the right side

Hyperdense Loss of gray insular cortex, blending in with hypodense


linear thrombus in ipsilateral distal underlying white matter = insular ribbon sign (normal
MCA = hyperdense MCA sign insula outlined in yellow bilaterally)
DWI ADC FLAIR
Bright on DWI, dark on ADC = Gyral swelling, sulcal effacement and
restricted diffusion; high FLAIR signal from edema in the
Differential for this classically includes CVA CVA region
Diagnosis?
Dx: Acute Right MCA CVA
Cerebrovascular accident (CVA) aka Stroke
Classically @ Circle of Willis vascular territories (next slide); occasionally @
watershed zones between territories or scattered multifocal from embolic strokes
CT findings
Loss of gray-white matter (GM, WM) differentiation: 1st 3 hours post CVA
GM cortex, normally denser on CT than WM, often affected by stroke first (higher metabolism than
WM) becomes edematous, more hypodense blends in with adjacent underlying white matter
Insular ribbon sign, aka loss of normal insular cortex, suggests stroke: GM insular cortex normally
looks like whiter, wavy ribbon line outlining the underlying WM
Hyperdense vessel sign: particularly in MCA strokes, asymmetric/unilateral dense
segment of vessel can suggest acute intravascular thrombus
Parenchymal edema hypodensity, & gyral swelling/sulcal effacement (12-24 hrs post
CVA)
Hemorrhagic transformation can occur (24-48 hours post CVA)
Can be related to reperfusion post thrombolysis
CTA can be performed to assess vessels for stenosis/occlusion if MR contraindicated
MRI findings
Can also see edema changes (swelling & loss of G-WM on T1, high signal on FLAIR &
T2)
Diffusion weighted imaging (DWI) = most sensitive imaging for acute stroke (95%)
Bright signal on DWI + dark signal on corresponding ADC map = restricted extracellular diffusion of
water protons (eg, from loss of function Na/K ATP pump)
MRI stroke protocol: +MRA (MR angiography) identify vessel occlusions
Time-of-flight MRA can be performed based on flow of protons, WITHOUT needing to use
gadolinium contrast!
Figure 1. Drawings (top) illustrate the territories (blue) of the ACA, middle cerebral artery
(MCA) , and posterior cerebral artery.

de Lucas E M et al. Radiographics 2008;28:1673-1687


2008 by Radiological Society of North America
7. MSK Cases
75 YO M with Hand and
Wrist Pain
Osteoarthritis
(Degenerative Joint Disease)

Caused by trauma (either overt or accumulation of


microtrauma)
Occurs in any joint but particularly
common in hands, knees, hips and spine
Hallmarks (All must be present or another diagnosis
should be considered)
Joint Space Narrowing
Sclerosis
Osteophytosis
Sclerosis

Joint Space Narrowing


Osteophytosis
45 YO F w/ joint pain and
stiffness in hands
Rheumatoid Arthritis
Connective tissue disorder which may
affect any synovial joint
Classically a bilaterally symmetric process
that involves the proximal joints
Hallmarks:
Soft tissue swelling
Osteoporosis
Joint space narrowing
Marginal erosions
RA Continued
Large joints
Marked joint space narrowing
Osteoporosis
Hands:
Proximal process
Bilaterally symmetric
Ulnar subluxation
Proximal > Distal

Ulnar Subluxation

Soft Tissue Swelling and


Ulnar styloid erosion Osteoporosis
30 YO M Slipped and Fell.
Now with Snuff Box pain
and swelling.
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Scaphoid Fracture
Common status post fall on outstretch hand
(FOOSH) w/ snuffbox pain and swelling
Most common carpal bone fracture
Difficult to diagnose with radiographs
therefore a negative exam doesnt exclude
the diagnosis
May cast patient and bring back in a week
May perform MRI for definitive diagnosis
High rate of avascular necrosis (AVN)
May require surgical intervention to avoid AVN
CT of the wrist reveals sclerosis of the proximal
scaphoid indicative of AVN
31 YO M fell on flexed
wrist. Now with
tenderness over the dorsal
aspect of the wrist
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Triquetral Fracture
Often due to forced hyperflexion
Next to scaphoid fractures triquetral
fractures are the second most common
fracture of the carpal bones
Patients often report dorsal hand pain
Small bone chip off the dorsum of the wrist
is virtually pathognomonic for triquetral
avulsion fracture
Often associated with perilunate dislocations of
the wrist
Triquetral Avulsion
Fracture

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decompressor
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22 YO F fell on
outstretched hand
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decompressor
are needed to see this picture.
Colles Fracture
Caused by a fall on an outstretched hand
(FOOSH)
Fracture of the distal radius and often ulnar
styloid process
Classically a transverse fracture of the radius
Dorsal angulation of the distal forearm and wrist
One of the most common forearm fractures
Commonly seen in osteoporosis
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decompressor
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Dorsal angulation
Transverse Fracture of of the distal
the distal radius fragment with
overlap /
foreshortening.
33 YO F w/ Arm Pain
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Smith Fracture
(Reverse Colles)

Caused by direct trauma to the


dorsal forearm or falling onto a flexed
wrist
Transverse fracture through the distal
radius
Distal fracture fragment with volar
angulation
20 YO F s/p mild trauma to
left arm
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Pathologic Fracture
Unicameral (Simple) bone cyst
Unicameral Bone Cyst (UBC)
Simple fluid filled cysts which are usually
asymptomatic (unless pathologic fx)
Always centrally located
Occur in patients < 30 yrs
Commonly occur in long bones (humerus, femur)
No periostitis (inflammation of the cortex)
Pathologic Fracture: Fx through abnormal
portion of bone such as a UBC
Fallen fragment sign: Fractured cortex sinks to the
bottom of the fluid filled cavity (pathognomonic for
UBC pathologic fracture)
Fallen Fragment Sign: Cortical bone
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decompress or
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falling to the bottom of the fluid filled
Unicameral Cyst
44 YO M fell on elbow. Now
with pain and swelling.
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decompressor QuickTime and a
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Elbow Fracture (Olecranon)
Evaluate the posterior fat pad
Ordinarily the posterior fat pad is not visible as it
is tucked in the olecranon fossa
In the event of an elbow fx (olecranon, radial
head or supracondylar) the joint becomes filled
with blood which displaces the posterior fat pad
superiorly
In the event of trauma, a visible posterior fat pad
indicates fracture
Adult - radial head fx most common
Child (epiphyses open) - supracondylar fx most common
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Radial Head Fx
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Elevated Posterior Fat Pad QuickTime and a


w/ Olecranon Fx decompressor
are needed to see this picture.

Elevated Posterior Fat Pad w/


Supracondylar Fx
Supracondylar Fx
18 YO Football Player s/p
tackling another player.
Shoulder now visibly
deformed.
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decompressor decompressor
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Anterior Shoulder
Dislocation
Significantly more common than posterior
location (96% of shoulder dislocations)
Occurs when the arm is forced into an externally
rotated and abducted position
Commonly occurs in football players who arm
tackle and skiers whose uphill pole gets stuck
Humeral head lies inferiorly and medial to the
glenoid on AP images
Humeral head impacts on the inferior rim of the
glenoid causing a Hill-Sachs deformity (see Hill-
Sachs case)
AP View With Anterior Dislocation of Scapular-Y-view w/ anterior dislocation
the Humeral Head
Acromion
Process
Coracoid
QuickTime and a QuickTime and a

Glenoid
decompressor decompressor
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Anterior Posterior

QuickTime an d a
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a re nee ded to s e e this pictu re .
deco mpress or
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AP and Scapular-Y-View Post Reduction


38 YO M w/ Recurrent
Shoulder Dislocation
Hill-Sachs Deformity
Depression fx of the posterolateral surface of
the humeral head
Caused by anterior glenohumeral dislocation
Impaction of the humeral head against the
glenoid rim
Best seen on AP projection in internal rotation
Presence of Hill-Sachs may indicate a greater
likelihood of recurrent dislocations
Bony irregularity of the inferior glenoid rim
may also be seen (Bankart Deformity)
External Rotation Internal Rotation
34 YO M with Stuck
Shoulder post trauma
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Posterior Shoulder

Dislocation
Significantly less common than Anterior
Shoulder dislocation (2-4%)
Caused by axial loading of an adducted and
internally rotated arm, convulsion disorder or
electroshock therapy
Cresent Sign AP view of a normal shoulder
reveals overlap of the humeral head and glenoid
Posterior dislocation results in a loss of the cresent
sign creating an absence of the bony overlap
light bulb Sign: Humeral head is fixed in
internal rotation
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decompressor
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Normal Frontal Radiograph of the


Shoulder with a Crescent Sign
Axillary View

Acromion Process

Reverse Hill-Sachs
QuickTime and a
decompressor Deformity
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Glenoid

Absence of Crescent Sign Coracoid


and Internal Rotation
Two Separate Examples:
Elderly female slip and fell
Proximal Femur Fractures
High mortality (15-20% in 1 year)
Potential for vascular compromise which
may lead to AVN of the hip
Most often occur in the elderly (90%)
Caucasian females w/ osteoporosis
Young patients suffer hip fractures from
high impact/high velocity trauma
Radiographs are the initial study of choice
If non-diagnostic, MRI or nuclear medicine
scans may be utilized
Proximal Femur Fractures
Classified according to geopgraphy
Intracapsular vs Extracapsular
Intracapsular: Subcapital, transcervical and basicervical
Extracapsular: Intertrochanteric and subtrochanteric

Intracapsular Fx treated with prosthetic or


replacement device
Extracapsular Fx treated with a compression-type
screw, lateral side-plate or intramedullary nail
Intertrochanteric Femoral neck fracture
fracture pre and post pre and post fixation
fixation
Osteomyelitis
48 YO MALE WITH RIGHT KNEE PAIN AND SWELLING
STATUS POST RIGHT TIBIAL PLATEAU AND PATELLA
FRACTURES AND ORIF.

CASE 1
Findings
Progressive osteolysis of the lateral
tibial plateau and lateral femoral
condyle.
9 YO MALE ARRIVED FROM HAITI WITH UNEXPLAINED
RIGHT KNEE PAIN/SWELLING

CASE 2
Cortical
breakthroug
h
Endosteal
scalloping
Periostea
l reaction
Findings
Multiple lytic lesions in the femoral diaphysis and distal
femoral metaphysis with regions of sclerosis and multiple
layers of periosteal reaction. Endosteal scalloping is
noted.
There are a few foci of apparent cortical breakthrough into
the adjacent soft tissues, including the posterior distal femoral
diaphysis (best seen on the lateral views of the knee and
femur), the lateral femoral diaphyis at the same level, and the
medial femoral diaphysis more proximally, near the junction of
the middle and distal femoral diaphyseal thirds.
Concerning for right femoral chronic osteomyelitis
T2 hyperintense (shown) and T1 hypointense (not
shown)
68 YO F WITH PULMONARY NODULES ON PRIOR CT, PAIN,
WEIGHT LOSS, AND HISTORY OF RECURRENT MRSA
BACTEREMIA

CASE 3
Findings
Destructive changes centered at the T10-T11
disc level with disruption of the inferior
endplate of T10 and superior endplate of T11
and associated lucency in the T10 and T11
vertebral bodies
Soft tissue density at the T10/T11 level which
abuts the descending thoracic aorta.
Anterior wedge compressive deformity of the
T11 vertebral body. These findings are
consistent with T10/T11 disciitis/osteomyelitis.
GENERAL CHARACTERISTICS
Inflammation of the bone that is almost always due to
infection, typically bacterial
Hematogenous spread in most cases, although direct
extension from trauma/ulcers is also common
Earliest changes are seen in adjacent soft tissues +/-
muscle outlineswith swelling and loss or blurring of
normal fat planes.
In general, osteomyelitis must extend at least 1 cm
and compromise 30 to 50% of bone mineral content to
produce noticeable changes in plain radiographs.
Early findings may be subtle, and changes may not be
obvious until 5 to 7 days in children and 10 to 14 days
in adults.
RADIOGRAPHIC FEATURES
regional osteopenia
periosteal reaction/thickening
focal bony lysis
endosteal scalloping
loss of bony trabecular architecture
new bone apposition
eventual peripheral sclerosis
In chronic or untreated cases, eventual
formation of a sequestrum, involucrum or
cloaca may be seen.
For your interest only:

Breast Cancer
Lumbar disc disease

Abdominal trauma
45 year old female with palpable
breast lump.
MAG View

What is the salient finding?


Findings:

There is a cluster of
microcalcifications in the left
mid breast. (hard to see, I
know).

Diagnosis: DCIS (ductal


carcinoma in situ)
DCIS
Atypical ductal epithelial cells thought to
represent the earliest form of breast cancer.
Most common presentation is
microcalcifications as seen as previous
mammogram.
Typically treated with lumpectomy/breast
conserving therapy.
25F pain
T2 T1

L5

S1
Lumbar disc disease

L4-L5 and L5-S1 most common areas in L-spine


check the cone-down view!

Fibrocartilage replaces glycosaminoglycans


decreased water content (dessicated)
LBP

L5

S1
T1 weighted
T1 weighted T2 weighted

Do you recommend surgery?


Treatment options

About 40% of asymptomatic people have disc


bulges

~90% treated conservatively: NSAID,


corticosteroid injection, or physical therapy

Discectomy if pain intractable, only 75% success


30F with multiple stab wounds to
the abdomen
Left renal transverse laceration in
the interpolar region extending
toward the hilum
Perirenal fluid with high
attenuation areas suggestive
of active extravasation
Left upper quadrant anterior
abdominal stab wound

Extravasated rectal
contrast centered around
the splenic flexure, in
the region of the
visualized stab wound,
indicative of bowel
laceration
Discussion: Acute Abdominal Trauma
CT is the imaging modality of choice for diagnosis of intra-abdominal injury after blunt or penetrating
abdominal trauma, and is especially valuable when physical examination is unreliable (i.e. stuporous
patient) or equivocal.
CT is usually obtained for patients with significant abdominal trauma who are hemodynamically stable.
CT is performed WITH intravenous contrast, but WITHOUT oral contrast (at least in our institution).
Rectal contrast (in addition to IV) is reserved for cases with penetrating abdominal trauma (GSW,
stabbing). Delayed images may be obtained for evaluation of injury to the collecting system (higher level
of suspicion in setting of pelvic fractures) or to evaluate vascular injury and possibility of active vascular
extravasation.
Possible CT findings in the setting of acute abdominal trauma may include:
Solid abdominal organ lacerations Splenic, liver, renal lacerations. These are usually linear areas
of hypodensity, potentially with surrounding fluid or hematoma. It is important to evaluate delayed
images for adjacent hyperdense foci which may represent active extravasation of intravenous
contrast (implies vascular injury), as this needs to be treated surgically. Shattered organs
demonstrated multiple lacerations and may demonstrate hypodense regions from devascularization
injury.
Hemoperitoneum hyperdense fluid within the abdomen or pelvis, often ~ 30-45 HU. This is not
specific to any one particular injury, but a very hyper dense focal collection of fluid (sentinel clot)
can guide to the injured organ.
Pneumoperitoneum- nonspecific finding which may be due to bowel laceration in penetrating trauma,
barotrauma, etc.
Free contrast in peritoneal cavity may be seen with extravasation of rectal contrast through bowel
perforation as seen in above case or from leakage of contrast-opacified urine from the urinary tract.

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