Top 100 Secrets

These secrets are 100 of the top board alerts. They summarize the concepts,
principles, and most salient details of radiology.
1. Increasing voltage (kV) decreases contrast and increases exposure,
making the film darker. Increasing milliampere-seconds (mAs)
increases exposure, making the film darker.
2. A scout film should always be obtained before performing a
fluoroscopy study with contrast. It allows the radiologist to
determine whether an object that appears white on a radiograph is
bone or metal versus contrast (the latter would not be on the scout
film).
3. Structures in the body that are very dense (such as those that contain
calcium) attenuate a large amount of the x-ray beam; thus the x-ray
beam is not able to reach the film and darken it, and such structures
appear white on a radiograph. Conversely, structures that are not
very dense (such as air) allow the x-ray beam to penetrate and

Top 100 Secrets

These secrets are 100 of the top board alerts. They summarize the concepts,
principles, and most salient details of radiology.
1. Increasing voltage (kV) decreases contrast and increases exposure,
making the film darker. Increasing milliampere-seconds (mAs)
increases exposure, making the film darker.
2. A scout film should always be obtained before performing a
fluoroscopy study with contrast. It allows the radiologist to
determine whether an object that appears white on a radiograph is
bone or metal versus contrast (the latter would not be on the scout
film).
3. Structures in the body that are very dense (such as those that contain
calcium) attenuate a large amount of the x-ray beam; thus the x-ray
beam is not able to reach the film and darken it, and such structures
appear white on a radiograph. Conversely, structures that are not
very dense (such as air) allow the x-ray beam to penetrate and

darken the film; thus such structures appear black.

4. Regions with many acoustic interfaces reflect a lot of sound back to
the transducer. These are termed echogenic or hyperechoic and by
convention are viewed as bright areas on ultrasound (US). Regions
with few acoustic interfaces do not reflect many sound waves; they
are termed hypoechoic and are viewed as dark areas.
5. Electron-dense structures, such as metal and bone, stop a large
number of x-rays and therefore are bright on computed tomography
(CT). Lower electron-density regions, such as air or fat, stop very
few x-rays and are rendered as dark. Since CT images are created
with x-rays, the same things that are bright and dark on plain films
are bright and dark on CT.
6. T1-weighted images have a short time to repetition (TR) (less than
1000 ms) and a short time to echo (TE) (less than 20 ms). T2weighted images have a long TR (more than 2000 ms) and a long
TE (more than 40 ms).
7. To differentiate between T1- and T2-weighted images, look for
simple fluid. Fluid tends to be hyperintense to virtually everything
else on T2-weighted images. On T1-weighted images, fluid is of low
intermediate signal. Good places to look for fluid include the urinary
bladder and the cerebral spinal fluid (CSF).
8. Nuclear medicine is unique in that its strength lies in portraying the
functional status of an organ rather than producing images that are
predominantly anatomic in content.
9. In nuclear medicine studies, the radiologist administers a radioactive
atom, either alone or coupled to a molecule, that is known to target a
certain organ or organs. Its distribution is then examined to
determine any pathologic condition in that particular organ.
10. PACS stands for picture archiving and communication systems.
These are the systems used by digital radiology departments to store,
network, and view imaging studies.
11. RIS stands for the radiology information system. The RIS manages
patient scheduling and tracking, examination billing, and
receipt/display of radiology reports.
12. The American College of Radiology recommends that women begin
getting mammograms at age 40 and annually thereafter.
13. The BIRADS (Breast Imaging Reporting and Dictation System)
lexicon was developed by the American College of Radiology to
provide a clear and concise way to report mammographic results: 1
= normal, 2 = benign finding, 3 = probably benign finding (6-month
follow-up mammogram recommended), 4 = suspicious finding
(biopsy recommended), 5 = high likelihood of malignancy (biopsy
recommended), and 6 = confirmed malignancy.
14. Breast US is useful in characterizing palpable masses or
mammographically detected masses as cystic or solid. Findings in a

15.

16.

17.

18.

19.

20.

21.
22.

solid lesion that are suspicious for malignancy include a hypoechoic

appearance, with posterior acoustic shadowing, angular margins,
spiculations, microlobulations, lesion morphology taller than
wide, and ductal extension of the mass.
Breast magnetic resonance imaging (MRI) findings suspicious for
malignancy in an enhancing lesion include avid arterial phase
enhancement, washout of contrast in a delayed phase, spiculated or
microlobulated margins, greater enhancement peripherally than
centrally, and architectural distortion.
Anomalous origin of the coronary arteries occurs rarely (about 1% of
cardiac catheterizations). Sudden death is associated with a left main
coronary artery that arises from the right sinus (particularly when the
artery courses between the aorta and pulmonary artery), a right
coronary artery that arises from the left sinus, and a single coronary
artery. The left main coronary artery may also arise from the
pulmonary trunk; this anomaly tends to present earlier, with
congestive heart failure or sudden death.
Aortic dissections that involve the ascending aorta are surgical
emergencies because the mortality rate is significantly greater in
medically managed patients (approximately 90% in the first 3
months) compared with surgically treated patients. This high
mortality rate is mostly due to hemopericardium, causing tamponade;
acute aortic regurgitation; or involvement of coronary artery origins,
causing myocardial infarction. Descending aortic dissections are
usually treated medically with antihypertensive agents.
The most specific finding of a pulmonary embolus is a partial or
complete intraluminal filling defect in a pulmonary artery. On CT
angiography (CTA), the filling defect should be present on at least
two contiguous sections. Abrupt cut-off of the artery also indicates a
pulmonary embolus.
A stenosis is generally considered significant if the luminal diameter
is reduced by 50% and the systolic pressure gradient is in excess of
10 mmHg across the lesion. A vessel lumen that is diminished by
50% will have a corresponding 75% reduction in a cross-sectional
area, which will likely reduce flow to a clinically significant level.
Contraindications to barium studies of the upper gastrointestinal (GI)
tract include known or suspected perforation (use water-soluble
agent) and the inability of the patient to swallow (use nasogastric
tube).
Focal hepatic lesions with T1 components that are isointense to
mildly hyperintense to the surrounding liver are almost always
hepatocellular in origin.
Almost all hepatic cysts and hemangiomas can be differentiated
from malignant liver disease by the use of heavily T2-weighted
(>180 msec) images.

23. On postcontrast images, the normal spleen displays alternating bands

of high and low attenuation (CT) or signal (MR) in the arterial
phase. The spleen appears more homogeneous in a more delayed
phase.
24. Splenic laceration can be differentiated from developmental splenic
cleft. Patients with laceration will have a trauma history, display a
low attenuation defect with sharp edges, and have perisplenic
hemoperitoneum.
25. Both MRI and CT are less specific in the characterization of splenic
lesions than they are in characterization of liver, adrenal, or renal
lesions.
26. The pseudocyst is the most common cystic lesion of the pancreas,
accounting for about 90% of all cystic lesions in the pancreas.
27. The pancreatic neck and body are the most common portions of this
organ to be injured in blunt trauma because they are compressed
against the spine in blunt traumatic injuries to the abdomen.
28. The most specific CT imaging finding of acute appendicitis is an
abnormal appendix that is typically dilated >=6 mm and fluid filled.
A calcified appendicolith with periappendiceal fat stranding is
another highly specific CT finding.
29. If bowel ischemia is suspected on CT, one should assess the patency
of the celiac artery, superior mesenteric artery, inferior mesenteric
artery, portal vein, superior mesenteric vein, and inferior mesenteric
vein. When the central superior mesenteric vessels are affected, the
entire small bowel, along with the large bowel proximal to the distal
third of the transverse colon, tend to be affected. When the central
inferior mesenteric vessels are affected, the distal third of the
transverse colon, the descending colon, and the sigmoid colon are
generally involved.
30. A fixed filling defect in the urinary collecting system is highly
suggestive of transitional cell carcinoma (TCC) and should be
further evaluated with brush biopsy.
31. In a male patient with pelvic trauma, the urethra should be evaluated
with a retrograde urethrogram before placement of a bladder
drainage catheter.
32. An enhancing renal mass that does not contain macroscopic fat is a
renal cell carcinoma until proven otherwise.
33. An enhancing renal lesion with macroscopic fat is a benign
angiomyolipoma.
34. Cystic renal lesions that contain thick internal septations, thick mural
calcification, or enhancing mural nodules are suggestive of cystic
renal cell carcinomas and should be excised.
35. Patients with limited renal function (creatinine 1.5 and greater)
generally should not receive iodinated intravenous contrast for CT.
Gadolinium chelate contrast agents used for MRI are generally safe

for these patients.

36. There are three ways to show that an adrenal lesion is a benign
adenoma: attenuation of less than 10 HU on unenhanced CT,
washout of greater than 50% on delayed CT, or signal loss of 10
15% on chemical shift MRI.
37. Most pheochromocytomas occur in the adrenal glands and enhance
avidly on CT and MRI.
38. In premenopausal women, since the normal dominant follicles can
range up to 3 cm (or sometimes greater), simple ovarian cysts
smaller than 3 cm need no follow-up and typically resolve
spontaneously.
39. MRI can generally distinguish between septate and bicornuate uteri.
A septate uterus will have a smooth outer contour and a fibrous
septum. A bicornuate uterus will display a depression, 1 cm or
greater of the outer contour of the fundus, and a thicker, more
muscular septum.
40. Most intratesticular masses are malignant. Most extratesticular
masses are benign.
41. The following equipment should be present when administering
conscious sedations: pharmacologic antagonists, appropriate
equipment to establish airway and provide positive pressure
ventilation, supplemental oxygen, and defibrillator.
42. Inferior vena cava (IVC) filters should be placed below the lowest
renal vein when possible.
43. Embolization on both sides of a pseudoaneurysm, aneurysm, or
arteriovenous (AV) fistula is necessary to prevent reconstitution of
flow via collaterals, which causes recurrence of the lesion.
44. The two most common indication for placement of a transjugular
intrahepatic portosystemic shunt (TIPS) are variceal bleeding related
to portal hypertension that is refractory to endoscopic therapy or for
ascites refractory to medical management. TIPS placement may act
as an effective bridge to liver transplantation for patients with endstage liver disease and the manifestations of portal hypertension.
45. There is high association between Segond fracture and anterior
cruciate ligament (ACL) tear and meniscal injury.
46. When you see a fracture of the medial malleolus, do not forget to
look at the proximal fibula for Maisonneuve fracture.
47. On a cervical spine radiograph, if you cannot visualize the lower
cervical spine, obtain either a swimmer's view or CT. You must
visualize C7T1 to clear the cervical spine.
48. Osteoporosis has many secondary causes. Medical evaluation for
multiple myeloma and endocrine diseases should be performed
before one assumes primary osteoporosis.
49. If you see multiple lytic bone lesions in an adult, think of metastatic
disease versus multiple myeloma. Primary tumors to consider in a

50.
51.
52.
53.

54.
55.
56.
57.

58.

59.

60.

61.

patient with metastatic bone lesions are lung, prostate, breast,

kidney, thyroid, and colorectal.
Patients with an osteoid osteoma classically present with pain at
night relieved by aspirin.
Primary bone tumors that are known to occur in the epiphyseal
region include giant cell tumor, chondroblastoma, and clear cell
chondrosarcoma.
Rotator cuff tears are rare in persons younger than 40 years, except
in athletes or in the setting of trauma.
MRI is the most sensitive modality for detection of early
osteonecrosis, before femoral head cortical collapse. Early detection
allows for possible joint-sparing therapies such as steroid reduction,
supportive therapies such as nonweight-bearing, and core
decompression.
A meniscal tear is diagnosed on MRI by identifying increased
internal meniscal signal intensity that extends to the articular surface.
After the Achilles tendon, the next most likely ankle tendon to tear is
the posterior tibial tendon (PTT).
The anterior talofibular ligament, part of the lateral ligamentous
complex, is the most commonly sprained and torn ankle ligament.
Early plain film findings of osteomyelitis include soft tissue swelling
and blurred fascial planes. After 710 days, bone lucencies and
periosteal reaction may be seen. On MRI, bone infection generally is
depicted as a region of abnormal marrow signal, which is T1
hypointense and short-tau inversion recovery (STIR) hyperintense to
normal marrow.
Epidural hematoma is a surgical emergency. It is usually caused by
an arterial injury (most commonly the middle meningeal artery),
often associated with temporal bone fracture, confined by the lateral
sutures, and usually lenticular in shape. Subdural hematoma is
usually caused by injury to the bridging cortical veins, is not
confined by the lateral sutures, and is usually crescentic in shape.
The differential diagnosis of an intracranial mass in a patient with
HIV includes toxoplasmosis, other brain abscess, and lymphoma.
Progressive multifocal leukoencephalopathy, a demyelinating
disease, can sometimes appear masslike.
Head CT is often normal in acute stroke. The earliest sign (within 6
hours) of an acute infarct on CT is loss of the gray-white
differentiation with obscuration of the lateral lentiform nucleus.
Acute ischemic changes can be seen within minutes of onset of the
ictus on diffusion-weighted MRI.
C8 is a nerve root without a body. It exits between C7 and T1. As a
result, cervical nerve roots exit above the pedicles of the samenumbered body; thoracic and lumbar nerve roots exit below the
pedicles of the same-numbered body.

62. One should be consistent in describing spinal degenerative disc

disease. A disc bulge is a diffuse, symmetric extension of the disc
beyond the end plate. A disc protrusion is a more focal extension of
the disc in which the neck is wider than the more distal portion. A
disc herniation is an extrusion of a portion of the disc in which the
neck is the narrowest part. A disc sequestrum is a free disc
fragment in the epidural space that has lost connection to the disc.
63. Inflammatory and vascular disorders of the spinal cord may mimic
neoplasms.
64. Low density in a lymph node in an adult with head and neck cancer
is characteristic of metastatic disease until proven otherwise.
65. The parotid glands are the only salivary glands that contain lymph
nodes.
66. Neck lesions above the hyoid bone should be studied first with MRI.
Pathologic findings of the neck below the hyoid bone should be
primarily imaged with CT scanning.
67. CT is the imaging modality of choice for conductive hearing loss.
MRI is the imaging modality of choice in adult-onset sensorineural
hearing loss.
68. Tumors and other lesions within the spinal canal may be classified as
extradural (outside the thecal sac), intradural-extramedullary (inside
the thecal sac, but outside the cord), or intramedullary (inside the
cord). Making this determination is the first step to selecting the
correct differential diagnosis for a lesion.
69. Fluorodeoxyglucose (FDG) positron emission tomography (PET)
changes the surgical management of patients in up to 40% of cases.
In some cases, distant metastases or restaging indicates that the
cancer is inoperable, thus preventing surgery that would have not
been useful. In as many as 20% of patients, PET shows that enlarged
nodes that may have prevented surgery from being considered were
actually benign, so that surgery can be performed.
70. A superscan on bone scan implies that so much of the methylene
diphosphate (MDP) is taken up by the bones that there is no
significant excretion in the kidneys and bladder or uptake in the soft
tissues. In a patient with cancer, a superscan implies widespread
osseous metastases that cannot be individually distinguished but
rather occupy almost the entire skeleton.
71. To classify a ventilation-perfusion (V/Q) scan as a high
probability for pulmonary embolism (PE), the scan must have the
equivalent of two or more large segmental perfusion defects (75
100% involvement of the segment) that are not matched by
ventilatory abnormalities. Four or more moderately sized perfusion
defects (2575% involvement of the segment) would also represent a
high probability for PE. The implication of a high probability scan
suggests a greater than 80% chance of having a PE.

72. Younger male patients with cold thyroid nodules are more likely to
have cancer than are older female patients with similar findings.
Exposure of the neck to radiation is also an important risk factor for
cancer in a cold nodule. Finally, US findings of mixed cystic and
solid components within a cold nodule are also more suggestive of
thyroid cancer. Cold nodules in the setting of a multinodular goiter
are substantially less likely to be cancer than other cold nodules.
73. After renal transplantation, acute tubular necrosis (ATN) occurs
almost immediately, whereas chronic rejection occurs over several
days to weeks or even longer. Patients with ATN have normal or
only slightly diminished perfusion of the kidney with a delayed
cortical transit time (how long it takes for urine to appear in the
collecting system). Rejection usually is associated with diminished
flow with mildly impaired cortical function.
74. An exercise stress test should be stopped when (1) the patient cannot
continue because of dyspnea, chest pain, fatigue, or musculoskeletal
problems; (2) the patient has a hypertensive response; (3) the patient
develops ST segment depressions of greater than 3 mm; (4) the
patient has ST segment elevation, heralding a possible myocardial
infarction; or (5) the patient experiences the onset of a potentially
dangerous arrhythmia such as ventricular tachycardia, ventricular
fibrillation, very rapid supraventricular tachycardia, or heart block.
75. A right-sided arch is associated with both tetralogy of Fallot (TOF)
and truncus arteriosus (TA), but is more closely associated with TA.
Since TOF is more common, however, you are more likely to see a
right-sided arch with TOF.
76. Thickened aryepiglottic folds with a thickened epiglottis are
indicative of epiglottitis and warrant emergent intubation.
77. If you suspect an aspirated foreign body, you should order bilateral
lateral decubitus films. A normal lung will lose volume, whereas an
obstructed lung will remain lucent and inflated.
78. The double-bubble sign on plain films represents an air- or fluidfilled distended stomach and duodenal bulb. It is seen in malrotation,
duodenal atresia, and jejunal atresia.
79. A fleck of calcium in a normal-sized globe of a child younger than 6
years is characteristic of retinoblastoma until proven otherwise.
80. In a pediatric elbow, the medial epicondyle ossification center
appears before the trochlear ossification center. If you see an ossific
density in the region of the trochlea in the absence of a medial
epicondylar ossification center, this is an avulsed fragment.
81. Metaphyseal corner fractures are highly sensitive and specific for
child abuse.
82. The most common cause of death of an abused child is injury to the
central nervous system.
83. If a pulmonary infiltrate does not resolve over time despite treatment

84.
85.
86.

87.

88.

89.

90.

91.
92.
93.
94.
95.

with antimicrobial agents, be suspicious of a potential

bronchoalveolar cell subtype of lung carcinoma.
Interstitial pulmonary edema, usually due to congestive heart failure,
is the most common interstitial abnormality encountered in daily
practice.
The majority of patients with asymptomatic mediastinal tumors have
benign tumors, whereas the majority of patients with symptomatic
mediastinal tumors have malignant tumors.
If you see a pneumothorax on chest radiography that is associated
with contralateral mediastinal shift and inferior displacement of the
ipsilateral hemidiaphragm, immediately notify the physician caring
for the patient because a tension pneumothorax may be present. This
requires emergent treatment to prevent rapid death.
If you see focal ovoid lucency surrounding an endotracheal tube
(ETT) or a tracheostomy tube with an associated bulge in the
adjacent tracheal walls, suspect overinflation of the cuff and notify
the clinical staff immediately.
If a nasogastric, orogastric, or feeding tube is seen to extend into a
distal bronchus, lung, or pleural space, notify the clinical staff
immediately and suggest that tube removal be performed only after a
thoracostomy tube set is at the bedside in case a significant
pneumothorax develops.
When air embolism is suspected during line placement or use, the
patient should immediately be placed in the left lateral position to
keep the air trapped in the right heart chambers, supplemental
oxygen should be administered, and vital signs should be monitored.
In a normal early pregnancy, the yolk sac should be visible
sonographically by a mean gestational sac diameter of 8 mm
transvaginally and 20 mm transabdominally. Similarly, an embryo
should be visible sonographically by a mean gestational sac diameter
of 16 mm transvaginally and 25 mm transabdominally.
If a pregnant patient presents with vaginal bleeding, pelvic pain, and
uterine tenderness, placental abruption must be excluded.
The most dreaded complication of oligohydramnios is pulmonary
hypoplasia.
Omphalocele has a worse prognosis than gastroschisis because the
former is associated with an increased incidence of chromosomal
abnormalities leading to other structural abnormalities.
Most strokes are due to emboli rather than carotid stenosis.
Therefore, it is important to identify irregular atherosclerotic
surfaces when examining the carotid circulation.
Sonographic findings in early or uncomplicated acute cholecystitis
may include gallstones (which may be impacted in the gallbladder
neck or cystic duct), gallbladder wall thickening, and gallbladder
distention. A sonographic Murphy's sign (focal tenderness over the

96.
97.

98.
99.

100.

gallbladder when compressed by the US transducer) may also be

elicited.
The combination of gallstones and a sonographic Murphy's sign has
a positive predictive value of 92% and a negative predictive value of
95% for acute cholecystitis.
For a physician to be found liable for malpractice, the following four
things must be demonstrated: (1) establishment of a duty of care
(i.e., doctor-patient relationship); (2) breach of the duty of care, or
negligence; (3) adverse outcome with injury or harm; and (4) direct
causality between the negligence and outcome.
The three most common reasons radiologists get sued are failure of
diagnosis, failure to communicate findings in an appropriate and
timely manner, and failure to suggest the next appropriate procedure.
To become board-certified in diagnostic radiology, you must pass
the written and oral examinations of the American Board of
Radiology (www.theabr.org). The written examination consists of a
physics portion and a clinical portion. You may take the physics
portion in your second, third, or fourth year of radiology training.
The clinical written portion is taken in the fall of the fourth year, and
the oral examination is taken in Louisville, Ky., in June of the fourth
year of residency.
The only thing worse than going to Louisville is going back to
Louisville.