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Ring-enhancing intracranial leions • MAGICAL DR mnemonic:
• • • • • • •
Adenoma, Aneurysm, Arachnoid cyst • Tuber cinerum hamartoma Craniopharyngioma, Rathke’s Hypothalamic glioma Meningioma, Metastasis Optic chiasm glioma Dermoid Epidermoid Lymphoma cleft cyst
• • • tumor)
Lymphoma Glioma Choristoma (granular cell
Abscess: AIDS, IVDA, immunocompromised state • Glioblastoma multiforme, high grade glioma • Infarct
• • • • •
Contusion/hematoma AIDS (toxoplasmosis) Lymphoma Demyelinating disease Radiation necrosis
Lesions crossing the corpus callosum • Glioblastoma multiforme • Lymphoma • Progressive multifocal leukoencephalopathy • Multiple sclerosis • Mimic: parafalcine meningioma Posterior fossa mass, child • Medulloblastoma • Cerebellar pilocytic astrocytoma • Ependymoma • Pontine glioma Posterior fossa mass, adult • Metastasis (most common) • Cerebellar pilocytic astrocytoma • Hemangioblastoma (von Hippel-Lindau disease • Medulloblastoma (cerebellar hemisphere) • Hemorrhage (hypertensive) Extra-axial mass • • • • • extension • epidural • Meningioma Arachnoid cyst Epidermoid cyst Dural metastasis Bone lesion with intracranial Empyema, subdural or Sarcoidosis
Suprasellar mass, adult (common) • Pituitary adenoma (prolactinoma > GH) • Craniopharyngioma (30-40 y/o) • Meningioma • Chiasmatic/hypothalamic glioma • Aneurysm Suprasellar mass, child (common) • Craniopharyngioma (4-5 y/o) • Chiasmatic/hypothalamic glioma (NF-1) • Germinoma Suprasellar mass, homogeneously enhancing • Macroadenoma • Meningioma (planum sphenoidale, clivus) • Aneurysm • Germinoma, teratoma Suprasellar mass, partially calcified • Meningioma • Craniopharyngioma • Aneurysm • Granuloma • Dermoid Suprasellar mass, high attenuation • Meningioma • Craniopharyngioma • Adenoma (hemorrhagic) • Aneurysm • Glioma • Germinoma Pituitary hemorrhage can occur with adenoma, bromocriptine therapy, pregnancy, XRT, anticoagulation, LP Suprasellar mass, Hyperintense T1/T2 • Adenoma (hemorrhagic) • Craniopharyngioma (cystic, proteinaceous material) • Rathke's cleft cyst Infundibular mass, child • Germinoma • Eosinophilic granuloma • Meningitis • Lymphoma • Glioma • Racemose cysticercosis Infundibular mass, adult • Metastasis • Sarcoid • Germinoma
Cavernous sinus mass • Meningioma • Schwannoma, neurofibroma • Aneurysm of ICA • Cavernous sinus thrombosis • Carotid-cavernous fistula • Metastasis • Lymphoma, sarcoid • Macroadenoma • Extension from bone tumors: metastasis, chordoma, chondrosarcoma Cavernous sinus mass, bilateral • Macroadenoma • Meningioma • Lymphoma • Metastases Cranial nerves 3, 4, 51, 52, 6 traverse the cavernous sinus, so a cavernous sinus mass may present with CN neuropathy. Standing Room Only: V1-Spinosum, V2-Rotundum, V3-Ovale Pineal region mass • Pineal cyst (NL <15 mm) • Germ cell tumor (germinoma) • Pineoblastoma (rare, child), pineocytoma (rare, adult) • Metastasis • Tectal glioma • Meningioma • Vein of Galen malformation Temporal lobe lesion, adult • GBM, metastasis • Ganglioglioma (young adult, also parietal lobe/cerebellum), DNET • HSV • Trauma • Mesial temporal sclerosis Absent posterior pituitary bright spot • EG • Diabetes insipidus Intraventricular mass • Meningioma (left atrium) • Metastases, lymphoma • Ependymoma (4th ventricle) • Subependymoma (rare, 4th ventricle or frontal horn) • Choroid plexus papilloma (child, left atrium; rare adult, 4th ventricle) • Colloid cyst • Astrocytoma (giant cell astrocytoma in Tuberous Sclerosis) • Central neurocytoma (rare, adult) • Medulloblastoma (child, 4th ventricle; adult, cerebellar hemisphere) • Racemose cysticercosis (mimics epidermoid cyst, arachnoid cyst) CSF seeding of tumor • Germinoma • PNET: medulloblastoma, pineoblastoma, retinoblastoma • Ependymoma • Choroid plexus carcinoma
Cerebellopontine angle mass • Vestibular schwannoma (bilateral, neurofibromatosis-2) • Meningioma • Arachnoid cyst • Epidermoid cyst (most common) • Other: ependymoma, schwannoma, glomus jugulare Sellar or suprasellar mass • GATCH MODE mnemonic:
Germ cell tumor, Granuloma
• Drugs: cyclosporine, MTX, FK506 (Tacrolimus) Hypertensive encephalopathy can occur in pregnancy, renal failure, TTP, hemolytic-uremic syndrome. It’s similar in appearance to cyclosporine, FK-506 therapy Dural venous sinus thrombosis • Infection: otomastoiditis • Pregnancy • Dehydration • Sepsis • Neoplasm: falx meningioma • Hypercoagulable states
• Aneurysm • Drug abuse: cocaine, amphetamine • Neoplasm Hemorrhage multifocal intra-axial • Trauma • Metastases • Amyloid angiopathy • Vasculitis • Venous infarction • Coagulopathy Hemorrhage, subarachnoid • Aneurysm • Trauma • AVM Hemorrhage, epidural/subdural • Trauma • Coagulopathy Leptomeningeal enhancement • Metastases: lung, breast, melanoma, lymphoma/leukemia, PNETs (child) • Meningitis: TB, fungal; otomastoiditis • Post-surgical • SAH • Meningeal (pial) angiomatosis in Sturge-Weber Meningitis bugs • (newborn) • • • Group B streptococcus H. infuenzae (child) N. meningititis (adolescent) S. pneumonia (adult)
Hyperacute blood (oxyhemoglobin) is diamagnetic (no unpaired electrons) on MRI, appearing T1 isointense/T2 hyperintense
White matter disease (multiple) • Ischemia • Multiple sclerosis Conditions associated with cerebral aneurysms • Acute disseminated • AVM encephalomyelitis: measles, mumps, • ADPCKD mononucleosis, varicella; post-vaccination • Fibromuscular dysplasia (basal ganglia/thalamus abnormalities • NF-1 differentiate from MS) • Collagen vascular disease • PML (classically • Marfan’s syndrome occipitoparietal regions) • Coarctation of the Aorta • Central pontine myelinolysis • SLE and other collagen Aneurysm in unusual location vascular diseases • Mycotic: bacterial endocarditis • Sarcoid • Vasculitis: PAN, SLE, • Lyme disease Wegener’s granulomatosis, Takayasu’s • Vitamin B12 deficiency disease • Radiation injury • AVM • Dysmyelinating disease: • Post-traumatic Canavan’s disease (diffuse, macrocephaly), Krabbe’s disease Which aneurysm is bleeding? (diffuse), Alexander’s disease (anterior), • Proximity to site of adrenal leukodystrophy (posterior), hemorrhage on CT metachromatic leukodystrophy (diffuse), • Large size Pelizaeus-Merzbacher disease (deficient • Adjacent spasm myelin-specific lipids) • Beaking of aneurysm contour • Frank extravasation of contrast Infarct, young adult (rare) • Dissection: post-traumatic, Marfan’s syndrome, FMD, extension of Hemorrhage, intraxial Type A thoracic aortic dissection into • Trauma common carotid artery • Hypertension (putamen, • Drug abuse: cocaine, thalamus, pons, cerebellum) amphetamine • Aneurysm (multiple in 15%) • Vasculitis: giant cell arteritis, • AVM, cryptic vascular PAN, temporal arteritis; sarcoidosis; SLE, malformation (cavernous hemangioma, Wegener’s disease, Behcet’s disease; capillary telangiectasia) methamphetamine, ergotism • Thromboembolic, venous • Basilar meningitis: bacterial, infarct (temporal lobe from transverse TB, fungal, syphilis sinus thrombosis, parasagittal subcortical • Fibromuscular dysplasia white matter from superior sagittal sinus • Migraine thrombosis, thalami from straight sinus or • Moyamoya disease (child): vein of Galen thrombosis) idiopathic; mimics include Sickle cell • Hemorrhagic metastasis: anemia, NF-1, connective tissue disorders melanoma, thyroid carcinoma, (Marfan’s syndrome, Ehlers-Danlos, choriocarcinoma, adenocarcinoma (breast, homocysteinuria), radiation injury, lung, renal, colon); GBM, Menke’s kinky hair syndrome, oligodendroglioma atherosclerosis (uncommon) • Amyloid angiopathy Traumatic dissection of the ICA usually occurs immediately above the carotid bifurcation, near the skull base, or at the level of the supraclinoid ICA. Dissection of the vertebral artery occurs at C6, where it enters the foramina transversarium Gyriform cortical enhancement • Stroke • Cerebritis • Postictal state • Hypertensive encephalopathy, eclampsia • Drugs abuse: cocaine, amphetamine • Other: coagulopathy, vasculitis, encephalitis
Dural enhancement/mass • Post-craniotomy or LP, CSF diversion • Neoplasm: meningioma, metastases (breast, prostate, lymphoma), direct extension of primary intracranial tumor, neuroblastoma (child) • Meningitis • Post-hemorrhagic: remote SDH, EDH • Spontaneous intracranial hypotension (CSF leak from lumbosacral root sleeve cyst) • Sarcoidosis Ependymal enhancement • Neoplasm: lymphoma, glioma, CSF spread of primary intracranial tumor or metastasis • Ventriculitis: meningitis, postshunting; CMV (AIDS) Hydrocephalus • Congenital: idiopathic, Chiari II malformation, Dandy-Walker malformation, aqueductal stenosis, perinatal hemorrhage or meningoencephalitis (STARCH) • Communicating: meningitis, SAH, meningeal carcinomatosis Parenchymal calcifications, neonate • CMV • Toxoplasmosis
Hemorrhage spontaneous intra-axial, elderly • HTN • Amyloid angiopathy • Metastasis Hemorrhage spontaneous intra-axial, young • AVM
• • •
Rubella infection Herpes Simplex infection HIV (basal ganglia) • STARCH mnemonic: Syphilis, Toxoplasmosis, AIDS, Rubella, CMV, Herpes simplex virus-2 T1 hyperintensity • Intracellular/extracellular methemoglobin • Fat • Proteinaceous fluid • Melanin • Slow blood flow on certain sequences • Calcification (hydrated) T2 hypointensity • Vascular flow voids • Deoxyhemoglobin (acute bleed), intracellular methemoglobin, ferritin, hemosiderin • Calcification or ossification • Proteinaceous fluid • Densely cellular mass: meningioma, lymphoma, PNET (pineoblastoma, medulloblastoma, neuroblastoma) • Iron deposition, physiologic (basal ganglia, substantia nigra, red nucleus, dentate nucleus), iron deposition, pathologic Calvarial button sequestrum O ME mnemonic: Osteomyelitis • Metastases
Arterial: atherosclerosis, Lipoma, dermoid
Calcified intracranial mass • Ca++ COME mnemonic:
• • • • • •
Craniopharyngioma Astrocytoma, aneurysm Choroid plexus papilloma Oligodendroglioma Meningioma Ependymoma (25%)
• Metastases to vertebrae: lung, breast, prostate, lymphoma • Other tumors: myeloma, chordoma, aneurysmal bone cyst, giant cell tumor, lymphoma/leukemia, osteoblastoma, eosinophilic granuloma, schwannoma, neurofibroma, ganglioneuroma, ganglioneuroblastoma, neuroblastoma • Epidural abscess: discitis, osteomyelitis • Hematoma Epidural lesion, child • Extension of paraspinal or vertebral tumor: neuroblastoma, ganglioneuroblastoma, ganglioneuroma; neurofibroma, schwannoma • Abscess • Ewing’s sarcoma • Lymphoma/leukemia • Eosinophilic granuloma • Other vertebral body tumors (above) Epidural extension over many levels • Abscess • Hematoma • Metastases • Lymphoma
Basal ganglia calcification • Idiopathic • Hypoparathyroidism, hyperparathyroidism • Fahr’s disease (familial idiopathic cerebral ferrocalcinosis) • Post-inflammatory, postanoxia • AIDS • Cockayne’s syndrome
Solitary lytic defect in skull • MT HOLE (“empty hole”) mnemonic: • Metastasis, multiple myeloma
• • • • • • • • • • •
TB, trauma Histiocytosis, hemangioma Osteomyelitis Leptomeningeal cyst Epidermoid
Intramedullary lesion • Neoplasm: ependymoma (adult, conus medullaris/filum, can be cystic or calcified or bloody), astrocytoma (child), hemangioblastoma, metastasis Destructive midline, skull-base lesion (rare) • Metastases • Infarct, ischemia • Myeloma • Hematoma • Nasopharyngeal carcinoma • Demyelinating disease: MS • Chordoma (midline) • Transverse myelitis: post-viral, • Chondrosarcoma (off midline) inflammatory, ischemia, MS, ADEM, • Meningioma SLE, XRT • Macroadenoma • Cryptic vascular malformation: • Lymphoma cavernous hemangioma, capillary • Esthesioneuroblastoma telangiectasia (cribiform plate) • Syrinx • Aggressive sinusitis: • Contusion aspergillus, mucormycosis • Abscess • Mucocele, polyposis Syringomyelia • • • • • surgery Trauma (myelomalacia) Neoplasm Chiari 1 or 2 malformation Infarct (myelomalacia) Arachnoiditis: meningitis, back Destructive skull-base lesion, frontal • Esthesioneuroblastoma • Metastasis • meningioma • Sinonasal carcinoma • Lymphoma • Rhabdomyosarcoma • Aggressive sinusitis • Mucocele, sinonasal polyposis Destructive skull-base lesion, basisphenoid • Nasopharyngeal carcinoma • Chordoma • Chondrosarcoma • Metastases, myeloma • Macroadenoma • Meningioma • Aggressive sinusitis: aspergillus, mucormycosis J-shaped sella • • • • • • • Cretinism Idiopathic Hydrocephalus Gargoylism Achondroplasia Optic glioma NF-1
Loss of lamina dura CHOMP mnemonic: Cushing’s disease Hyperparathyroidism Osteomalacia, osteoporosis Multiple myeloma Paget’s disease
Calcifications in brain • PINEAL mnemonic: • Physiologic: pineal gland, choroid plexus, basal ganglia • Infections: Cysticercosis, toxoplasmosis, TB, CMV • Neoplasm: craniopharyngioma, oligodendroglioma, meningioma, chordoma • Endocrine: hypervitaminosis D, hypoparathyroidism, hyperparathyroidism, Fahr’s disease
Intradural, extramedullary lesion • Meningioma (posterolateral) • Nerve sheath tumor (anterolateral): schwannoma, neurofibroma • Metastases (drop): germ cell tumors, ependymoma, PNET; adenocarcinoma, melanoma, lymphoma/leukemia • Dermoid, epidermoid • Lipoma • MANDELIN mnemonic: meningioma, metastasis (drop), arachnoiditis, arachnoid cyst, AVM, neurofibroma, dermoid, epidermoid, ependymoma, lipoma, infection (TB, cysticercosis) NL but tortuous nerve roots Extradural lesion • Degenerative disease: disc protrusion, osteophyte, synovial cyst
Jugular foramen mass • Glomus jugulare • Schwannoma • Metastasis • Meningioma • Asymmetrical or thrombosed jugular vein, ectatic carotid artery, carotid pseudoanuerysm Far lateral disc herniation mimics • Conjoined nerve root • Perineural cyst • Neurofibroma Tarlov cyst mimics • Intrasacral meningocele • Dural ectasia Arachnoiditis • • • • Trauma, surgery Intrathecal steroids, anesthesia Myelogram Infection
• Orbital cellulitis, pseudotumor • Varix, carotid-cavernous fistula • Lymphoma, rhabdomyosarcoma (child), metastasis (child: neuroblastoma to bone; adult: breast, lung, prostate, melanoma to uvea, rectus muscles, bone) Extraconal mass • Metastasis to bony orbit • Invasion by adjacent primary tumor: paranasal sinus or nasal SCC, sphenoid wing meningioma • Lacrimal fossa mass • Subperiosteal abscess or hematoma Orbital mass, child
Parapharyngeal space • Fat, branches of V3, salivary gland rests • SCC invading from pharyngeal mucosal , parotid, masticator spaces • Abscess from pharynx (tonsillar abscess), masticator space (odontogenic abscess) Pharyngeal mucosal space • Mucosa, Waldeyer’s ring, eustachian tube opening, minor salivary glands, muscles • SCC • Non-Hodgkin’s lymphoma, tonsillar abscess Masticator space • Muscles of mastication (pterygoids, masseter, temporalis), mandibular ramus, branches of V3 • Abscess (odontogenic) • Mandibular osteosarcoma • Rhabdomyosarcoma • SCC invasion from pharyngeal and parotid spaces • Non-Hodgkin’s lymphoma • Neurogenic tumor Retropharyngeal space • Fat, nodes • Abscess • Reactive adenopathy: NL in child, URI, tonsillitis • SCC invasion from pharyngeal and mucosal spaces • Nodal metastases from pharyngeal SCC, Non-Hodgkin’s lymphoma • Hemangioma • Neuroblastoma, rhabdomyosarcoma (child) Prevertebral space • Muscles (prevertebral, paraspinal, scalenes) • Brachial plexus roots, phrenic nerve, vertebrae, vertebral arteries • Discitis, osteomyelitis • Metastases • Primary vertebral body tumor Carotid space • ICA, internal jugular vein, cranial nerves 9, 10, 11, 12, nodes • Schwannoma, neurofibroma • Glomus jugulare, carotid body tumor • Meningioma of jugular foramen • Nodal metastases • Asymmetrical or thrombosed jugular vein, ectatic carotid artery, carotid pseudoaneurysm Remember: carotid body tumor usually splays the carotid bifurcation, while glomus vagale/jugulare displaces carotid anteriorly Parotid space • Parotid glands (with Stenson’s duct), intraparotid lymph nodes, branches of CN 7, external carotid artery
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LO VISHON mnemonic: Leukemia, lymphoma Optic nerve glioma
Vascular malformation (capillary hemangioma, lymphangioma) Inflammation (pre-, postSarcoma (rhabdomyosarcoma) Histiocytosis Orbital pseudotumor, osteoma Neuroblastoma septal)
Globe lesions • Uveal melanoma (lobular), uveal metastases (plaque-like) • Choroidal or retinal detachment • Vitreous hemorrhage • Pseudotumor • Retinoblastoma (child) • Optic disc Drusen, choroidal osteoma (lateral to optic disc) Optic nerve or nerve sheath enlargement • Optic glioma (child, NF-1), optic nerve sheath meningioma (adult), lymphoma/leukemia, metastasis • Pseudotumor • Optic neuritis • Sarcoidosis
Rectus muscle enlargement • Thyroid opthalmopathy Lesion causing pulsatile tinnitus (inferior>medial>superior>lateral) • Aberrant carotid artery, high • Pseudotumor jugular bulb or dehiscent jugular bulb • Myositis: extension from • Transverse sinus/internal paranasal sinus infection, pseudotumor jugular vein thrombosis, high grade • Metastasis, lymphoma, others carotid stenosis, dural AVF • Vascular congestion from mass • Glomus tympanicum, glomus at orbital apex, carotid-cavernous fistula, jugulare invading middle ear cavernous sinus thrombosis, dural AVM Lacrimal fossa mass • Viral infection • Benign neoplasm: dermoid, pleomorphic adenoma • Malignant neoplasm: adenoid cystic carcinoma, lymphoma, metastases • Pseudotumor • Sarcoidosis • Sjogren’s syndrome • Wegener’s granulomatosis Lacrimal fossa mass, bilateral • Lymphoma • Sarcoid Intraconal mass • Cavernous hemangioma (adult), capillary hemangioma (child), lymphangioma (child) Vascular retrotympanic mass • Congenital: aberrant carotid artery, high jugular bulb or dehiscent jugular bulb • Neoplasm: glomus tympanicum, glomus jugulare invading middle ear • Cholesterol granuloma, inflammatory debris/granulation tissue Paranasal sinus mass • Mucocele • Squamous cell carcinoma, adenocarcinoma, lymphoma, inverted papilloma, esthesioneuroblastoma, ameloblastoma, rhabdomyosarcoma, juvenile angiofibroma • Infectious sinusitis, granulomatous sinusitis • Osteoma
Middle ear mass • Cholesteatoma, cholesterol granuloma, inflammatory debris/granulation tissue • Vascular: aberrant carotid artery, dehiscent jugular bulb • Neoplasm: glomus tympanicum (cochlear promontory, ascending pharyngeal artery embolization), glomus jugulare invading middle ear (glomus jugulotympanicum), hemangioma, others
• Pleomorphic adenoma (adult, T2 bright), Warthin’s tumor (adult) • Mucoepidermoid carcinoma, adenoid cystic carcinoma, NHL • Nodal metastases from SCC, NHL, melanoma • Abscess • Lymphoepithelial cysts (AIDS) • Hemangioma or lymphangioma (child) • Lymphoma • 1st branchial cleft cyst Parotid lesions, multiple or bilateral • Warthin’s tumor • Nodal metastases from SCC, NHL, melanoma • Lymphoepithelial cysts (AIDS) Submandibular and sublingual spaces • Salivary glands, mylohyoid muscle, anterior tongue, nodes, branches of V3, CN 7, 9, 12 Submandibular space (with Wharton’s duct) • Nodal metastases • Direct invasion from SCC, NHL, salivary gland neoplasm • Dermoid or epidermoid, cystic hygroma, hemangioma, salivary gland neoplasm, lipoma • Abscess, lymphadenitis • Second branchial cleft cyst (anterior to sternocleidomastoid muscle) • Diving ranula Submandibular space, cystic mass • Second branchial cleft cyst • Cystic hygroma • Dermoid or epidermoid • Thyroglossal duct cyst • Diving ranula • Abscess or necrotic neoplasm Sublingual space • Invasive SCC of the tongue, salivary gland neoplasm • Dilated Wharton’s duct, abscess (odontogenic or sialoadenitis) • Dermoid or epidermoid • Ranula (dives below mylohyoid to submandibular space) • Cystic hygroma • Hemangioma, lingual thyroid posteriorly (child) Sublingual space, cystic mass • Dermoid or epidermoid • Ranula • Cystic hygroma • Abscess or necrotic neoplasm Oropharynx lesions include SCC, lymphoma, adenoid cystic carcinoma, mucoepidermoid carcinoma, adenocarcinoma; hemangioma, lymphangioma, abscess (child) Larynx extends from the valleculae to the space between cricoid cartilage/1st tracheal ring. Supraglottis is epiglottic tip to laryngeal ventricle (if lesion here only, voice sparing procedure). Lesions in
these areas: SCC, laryngocele, thyroglossal duct cyst, stenosis, trauma Infrahyoid neck • Same as suprahyoid neck Visceral space lesions • Thyroid and parathyroid glands, esophagus, larynx and trachea, recurrent laryngeal nerve, nodes • SCC of the larynx, thyroid neoplasm, esophageal carcinoma, nodal metastases or lymphoma, salivary gland neoplasm, dermoid or epidermoid • Reactive adenopathy, abscess • Laryngocele Bells palsy Ramsay-Hunt syndrome (herpes zoster infection) • Facial nerve schwannoma • Perineural tumor spread • Sarcoidosis • Lymphoma • Lyme disease Odontogenic cyst • • • • Radicular cyst Dentigerous cyst (tooth) Keratocyst Lateral periodontal cyst
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Hakeem Adams syndrome: NPH (gait ataxia, dementia, urinary incontinence) and may respond to VP shunt NAA should be highest peak; a 2:1 choline:creatine ratio suggests tumor CC/VV planes are carotid-cochlea (anterior)/vestibular-vein (posterior) Diffusion MR will be bright with metastatic collapse of vertebral body, but not with osteoporotic collapse Perimedullary and intramedullary AVMs are very difficult to treat with catheter. However, dural AVM is amenable to catheter treatment Cisternal portion of 7th cranial nerve normally enhances minimally Hangman fracture is hyperextension, distraction/compression forces at C2 Cerebral abscess may have thicker enhancing wall toward the cortical side, and a T2 hypointense rim (free radicals?) Expansile diploic space can occur in chronic anemias, dilantin therapy Odontoid type 1 fracture (dens tip) is rare, but mechanically STABLE. Type 2 (base of dens)
Enlarged vestibular aqueduct (>1.5 mm) • Sporadic • Mondini’s disease [cochlear hypoplasia or incomplete partition of cochlear turns (only 1-1.5x) with vestibular aqueduct enlargement] Cerebellar atrophy • ETOH • Anti-seizure medications Miscellaneous Facts: 1. In acute infarct, DWI is bright (restricted) and ADC map is dark. T2 shine through from chronic infarct or other process is bright on ADC map. ADC is calculated with at least 2 measurements of diffusion capacity with different b values. We use b=0, b=500 or 1000 2. For epidermoid vs. arachnoid cyst, try FLAIR (arachnoid cyst is dark) or DWI (restricted diffusion;bright with epidermoid cyst) 3. Methanol poisoning results in decreased density of lateral Putamina 4. CO poisoning causes hemorrhagic necrosis of Globus Pallidus 5. TPN and liver failure: increased T1 signal in basal ganglia (hydrated Ca++) 6. Wilson’s disease has increased T2 signal in basal ganglia (putamina) 7. Huntington’s disease: caudate atrophy 8. Amyotrophic lateral sclerosis: atrophy of frontal lobe, increased T2 signal posterior limb internal capsule 9. Parkinson’s disease: increased iron in BG, midbrain 10. Alzheimer’s disease: Diffuse atrophy, hippocampal atrophy, increased T2 signal in WM, temporal lobes 11. Pleomorphic Xanthoastrocytoma (young adult): supratentorial cystic mass with a mural nodule is the most common, may result in non-union, and is mechanically unstable. Type 3 can be mechanically stable or unstable
AVM bleed risk (2-3% per year) increases with intranidal aneurysm, deep periventricular location, deep venous drainage Cavernous angioma and developmental venous anomaly (most common malformation) often occur together. Cavernous angioma has no NL intervening brain, while capillary telangiectasia does A dural AVF may be due to occlusion of a dural venous sinus A C-C fistula can be high flow (young males, trauma, direct communication between carotid and cavernous sinus) or low flow (middle-aged female, spontaneous, communication between dural branches of ICA or ECA and cavernous sinus). Try balloon occlusion Hypertensive bleed occurs in basal ganglia, thalamus, pons, cerebellum Brain hypoxia/near drowning causes BG, posterior limb internal capsule, temperoparietal lobes hypodensity and corresponding T2 hyperintensity An acute hemorrhage may be due to an underlying mass or vascular malformation if there is enhancement and/or disorganized/different clot stages
carcinoma. sclerosing cholangitis. tumor. embryonal cell carcinoma. lymphoma/leukemia. 33. ganglioneuroma • Vertebral neoplasm: osteochondroma. histoplasmosis) • Tracheal neoplasms: adenoid cystic carcinoma. duplication cyst • Chronic mediastinitis (TB. choriocarcinoma. carcinoid. schwannoma. coughing. TB • Autoimmune disease (may be associated with retroperitoneal fibrosis. Morgagni’s hernia. Castleman’s disease Middle mediastinal masses • Lymph node enlargement: metastatic. histoplasmosis • Bronchogenic carcinoma • Lymphoma • Surgical shunt • Post-stenotic from pulmonary valvular stenosis. thymolipoma. MAI • Lymphoma • Cryptococcus Unilateral hilar enlargement • TB. there is anterior displacement of the C-spine Acceptable spine terminology • Disc bulge • Protrusion • Extrusion Branches of ECA • SALFOPSI mnemonic: Superior thyroid Ascending pharyngeal Lingual Facial Occipital Posterior auricular Superficial temporal Internal maxillary (middle • • • • • • • • meningeal) Cerebral angiography: Omnipaque 300 (full strength for cut-film.0. Grade 4 is probably due to hemorrhagic infarction from compression of the deep medullary veins (90% mortality) Ossification of the posterior longitudinal ligament (OPLL) is associated with DISH. spontaneous. endodermal sinus tumor • Lymphoma • Ascending aortic aneurysm • Rare: lymphangioma. seminoma. ABC. coccidiodomycosis. usually at C4-C6 Unilateral interfacetal dislocation is mechanically STABLE. trauma (esophageal rupture) Mediastinitis. adenocarcinoma • Castleman’s disease (usually hyaline vascular type). thymic cyst (congenital. Grades 1 & 2 have good prognoses. hyaline membrane disease. while hemorrhagic infarction (5%) occurs within 24 hours of ictus Germinal matrix hemorrhage occurs in 67% of 28-32 week premies. orbital pseudotumor) • Methysergide Bilateral hilar/mediastinal lymphadenopathy • Sarcoidosis • Bronchogenic carcinoma (usually unilateral) • Lymphoma • TB (usually unilateral) • Histoplasmosis • Coccidiodomycosis (usually unilateral) • Mycoplasma pneumonia • Viral disease • Bacterial infection (usually unilateral) • Leukemia • Metastases from extrathoracic primaries • Silicosis • Cystic fibrosis • Langerhan’s cell histiocytosis Hilar/mediastinal lymphadenopathy in AIDS • Kaposi’s sarcoma • TB. pulmonary artery coarctation • Pulmonary embolism • Partial absence of left pericardium Normal Basion-Dens distance: <12 mm. Boerhaave’s syndrome • Post-operative infection • Cervical infection spreading caudally Mediastinitis. 50% dilution for DSA). osteosarcoma. metastases • Abscess • Descending aortic aneurysm • Extramedullary hematopoiesis • Lateral thoracic meningocele: NF-1 Fatty mediastinal masses • Mediastinal lipomatosis • Lipoma/liposarcoma • Thymolipoma • Morgagni’s hernia with omentum • Epicardial fat pad • Paraesophageal hernia with fat • Extramedullary hematopoiesis (rarely fatty) • Chylolymphatic cyst • Teratoma Cystic Mediastinal masses • Thymic cyst • Cystic degeneration of thymic Hodgkin’s lymphoma • Germ cell tumors • Foregut cyst • Neurenteric cyst • Meningocele • Pancreatic pseudocyst • Lymphangioma • Abscess • Hematoma • Goiter. liposarcoma Posterior mediastinal masses • Neurogenic neoplasm: neurofibroma. sarcoid • Bronchogenic cyst • Bronchogenic carcinoma • Aortic aneurysm • Esophageal carcinoma. SCC. 5F-7F Simmons (elderly). then T2 hyperintense after 2-3 months • Germ cell neoplasms: teratocarcinoma. Berenstein catheter (young adult) or Head Hunter (general use). carcinoid. myeloma. granulomatous. mixed salivary gland tumor. neuroblastoma. Reidel’s thyroiditis. Hemorrhagic transformation (15-50%) occurs on days 2-14 after ictus. nodular hyperplasia. lymphoma. dermoid. parathyroid tumors. chest tube). AP/lateral/oblique views as necessary • CCA run: 10cc/sec for 12cc • ICA run: 8cc/sec for 10cc • ECA run: 4cc/sec for 6cc • VA run: 6cc/sec for 8cc with straight AP or Waters (basilar tip)/Towne view (PCA) • 2-4 frames/sec Differential Diagnoses Chest Radiology Anterior mediastinal masses • Retrosternal goiter • Elongated/aneurysmal dilatation of the innominate artery • Thymic masses: thymoma (>40 y/o). mesenchymal tumors.29. iatrogenic (surgery. 32. Power’s ratio: if the ratio of Basion to posterior arch C1/Opsthion to anterior arch C1 is >1. chondrosarcoma. ganglioneuroblastoma. 30. decompression during diving • Barotrauma • Tracheobronchial injury • Vomiting (Boerhaave’s syndrome) • Extension from retroperitoneum or neck • Post-operative (<1 week NL) • Positive-pressure ventilation • A SHIT mnemonic: asthma. cystic elements Diffuse mediastinal widening • Lipomatosis • Lymphoma • Small cell bronchogenic carcinoma • Mediastinitis • Anaplastic/poorly differentiated SCC • Hematoma Pneumomediastinum • Spontaneous: asthma. while 3 & 4 have poor prognoses. 31. Ewing’s sarcoma. s/p XRT in Hodgkin’s disease) . whereas bilateral is mechanically and neurologically UNSTABLE Wallerian degeneration is T2 hypointense the first month. fibrosing • Histoplasmosis. infectious • Esophageal perforation: endoscopy.
coccidiomycosis • Silicosis • Contrast material (pseudo calcification) • Sarcoidosis • Teratoma Overinflated ETT cuff Trauma Solitary metastasis XRT Rheumatoid nodule TE fistula Bronchogenic cyst Complication of surgical repair PMF Relapsing polychondritis Extrinsic mass effect Notable lung cancer stages • T1: <3 cm nodule Bronchial obstruction • T2: >3 cm mass. granulomatous disease (sarcoidosis. histoplasmosis. Place chest tube. malignant pleural • TB effusion. Wegener’s granulomatosis rheumatoid nodules. coccidiodomycosis. Wegener’s granulomatosis. fungal • Tracheal SCC. • Metastases: melanoma. asthma with ABPA. breast. trachea. N3: contralateral (bronchial) • Coronary arteries mediastinum/hilum. hemangiomas. IIIB=T4N3M0 (inoperable). colon. in 15%) or pulmonary sequestration • Traumatic stricture: postLangerhan’s cell histiocystosis • Caplan’s syndrome (RA & intubation or tracheotomy • Mucoid impaction coal worker’s pneumoconiosis) • Neoplasms • Trauma (hematomas) • Progressive massive fibrosis • Infectious/inflammatory • CMV. great vessels. histoplasmosis workers (rare) • T4: invasion of mediastinum. collagen vascular disease adenocarcinoma. breast. melanoma Remember: localized fibrous tumor of the pleura has • Lymphoma NO association with asbestos exposure! It affects the Solitary pulmonary nodule. syndrome (TB. ankylosing spondylitis) (fractured bronchus).or J-shaped) • Remember: IIIA=T3N2M0 • Endobronchial metastases: • Pericardium (constrictive (surgery). treated lymphoma • Granulomatous disease: histoplasmosis. bronchial metastasis Focal tracheal mass (RCC. hydatid cyst.• Pulmonary AVF • Congenital complete tracheal ring (rare) Tracheomalacia • • • • • • • Mediastinal calcification • Lymph node. spine. • Hematoma carcinoma risk increases 50-100x pleural fibroma. granulomatosis amyloidosis • Extrinsic compression: Solitary mass. ovary. trauma larynx. lung • Mucous plug • Sarcoidosis collapse. melanoma • Rare causes: Rheumatoid. >2 cm from Egg shell calcification • MEAT FACE mnemonic: carina • Silicosis • T3: <2cm from carina. carinii pneumonia. rheumatoid nodule • Saber-sheath trachea (COPD) histoplasmosis • Benign neoplasm: hamartoma. breast. measles • Pseudo mass: rib fracture with masses: TB. foreign body. pleural/chest • Endobronchial granulomatous • Pneumoconiosis of coal wall/pericardial/diaphragm invasion disease: broncholith in TB. lymphadenopathy colon. bronchial adenoma. hemangioma. • Intraluminal: foreign body. ovary cryptococcus. • Others: RA. histoplasmosis. sarcomas. erosion of bronchial artery in a lung cavity (bullae. small cell carcinoma (rheumatoid bronchostenosis). <3 cm • Other tumors: neurogenic. colon pericarditis) IV=distant metastases • Myocardium Lobar/segmental atelectasis • Endocardium (thrombus) Synchronous lung cancers occur in 1-2% cases. pulmonary sling • Tuberculoma. bronchocentric • Bronchogenic cyst (peripheral Focal tracheal narrowing granulomatosis. Diffuse tracheal narrowing • TB. TB. infectious mucoepidermoid carcinoma irrigation) granulomatous disease (TB. any size • Inflammation/infection: sarcoidosis. • Relapsing polychondritis • Broncoalveolar cell carcinoma lipoma. solitary metastasis from • Papillomatosis colon. >3cm vascular ring. stomach. subcarinal LNs. RCC. neurogenic tumor. Caplan’s syndrome • Infarct • Sarcoid. esophagus TB. lymphoma. tumor. RSV. middle lobe • Metastases: RCC. congenital Rasmussen’s aneurysm is secondary to mycetoma • Invasion from cancer of lung. pulmonary vein varix • Wegener’s granulomatosis. Cancer is most common in the RUL. neoplasm. rare) mucous plug (CF. plasma cell granuloma (child). MAI). • Adenoma • Lymphoma after radiation heart. coccidioidomycosis. scleroderma. hamartoma. bronchiectasis. adenoid cystic carcinoma. fibroma. coccidiodomycosis. breast. chondromas asbestos exposure and tobacco use. thyroid. • Tracheopathia • Hamartomas (rare) intraparenchymal lymph node osteochondroplastica (50 y/o male) • AVMs • Splenosis or endometrial tissue • Amyloidosis • Laryngeal papillomatosis • AVM. kidney. non-infectious • Mixed salivary gland tumor: disruption from extensive lymph node dissection). amyloidosis testes. bronchial atresia. bronchogenic sarcoma. carcinoid (peripheral in 20%). renal. carina. proximal ligation of bronchial artery. ipsilateral or • Carcinoma (primary) contralateral scalene/supraclavicular LNs • Annulus of aortic/mitral valves (C. atresia • Aortic/mitral valves LNs. and may present with hypoglycemia. testes. thyroid. vascular tumor. scleroderma. goiter • Brochogenic carcinoma • Vascular ring. Multiple nodules/masses. fibromas. • Malignant neoplasm: smooth muscle. visceral pleura. which happens • Tumors (myxoma. round • Lymphoma atelectasis. (rare) esophagus. foreign body granulomas. satellite nodules in same lobe • Foreign body Cardiac calcification • N2: ipsilateral mediastinal • Amyloidosis. carcinoid week due to ischemia (long bronchial stump. melanoma) Bronchopleural fistulae usually occur post-op >1 • Inflammatory polyp/papilloma: • Mural: non-small cell after instrumentation or tracheotomy carcinoma. granuloma from post-primary TB. hypertrophic pulmonary osteoarthropathy. histoplasmoma • • • • carcinoma • • • • Hydatid cyst (uncommon) Hamartoma Abscess Bronchoalveolar cell . melanoma. With bronchogenic carcinoma. Wegener’s callus. infections). pulmonary vein end-on • Nodular P. then Claget window (open drainage Wegener’s granulomatosis). colon. to be the most overlooked area on the CXR! post-operative).
Williams-Campbell syndrome. Chlamydia psittaci. CF. silicosis. BAC/adenocarcinoma (rare). CF. LAD. osteosarcoma • Inhalational lung disease: silicosis. AIDS• Resolving pulmonary edema related lymphoma AIDS with pleural effusion. EG. berylliosis • Viral pneumonias: varicella • Multifocal BAC • Sarcoidosis • Langerhan’s cell histiocytosis • Rare: microlithiasis. and carries a good prognosis • Chronic eosinophilic pneumonia AIDS. MAI. semiinvasive aspergillosis • Amebic abscess • Hydatid cyst • Paragonimiasis • Cavitating PMF: TB with silicosis • Wegener’s granulomatosis • Cavitating rheumatoid nodules • Septic emboli Cavities. Swyer-James syndrome. bronchogenic carcinoma) • AVM (50% occur in OWR. thin-walled • Blebs. Pseudomonas. bacterial • Hypersensitivity pneumonitis pneumonias (staphylococcus. while XRT fibrosis occurs at 9-12 months Tubular densities • Mucoid impaction (bronchocele): ABPA. volume overload. thick-walled • Bronchogenic carcinoma: SCC. <10mm • TB. or complex with multiple arteries and veins) • Pulmonary vein varix (left atrium) • Bronchiectasis: cylindrical. can be simple with a single feeding artery and single draining vein. others never • Primary lymphoma (rare) • Metastases: SCC of head and neck. mycoplasma. RUL with rupture of anterior mitral valve leaflet (MR) • Radiation • BAC • Lymphoma • Alveolar proteinosis • Hemorrhage Pulmonary Edema (PCWP in mmHg) • Vascular redistribution (12-17) • Interstitial edema (18-25) • Alveolar edema (>25) • Often occurs in CHF. amyloidosis • TEMPS BV mnemonic: TB/fungal. saccular. influenza. IPF. Whooping cough. Klebsiella. ABPA • Necrotizing infection: aspiration Bronchiolitis obliterans • Idiopathic • Infection • Toxic fumes inhalation • Drug toxicity • Dust exposure • GVHD • Autoimmune disease • S/p lung transplant • Connective tissue disorder Fleeting infiltrates • Allergic reactions • Drugs • Parasites • Inhaled antigens • Loeffler’s syndrome • Allergic aspergillosis • Recurrent edema • Chronic eosinophilic pneumonia with treatment • Pneumocystis pneumonia bleeding into the lung • • • Histoplasmosis. impaired mucocilliary clearance • Post-infectious: measles. congenital (bronchial atresia). alveolar cell carcinoma Mitral stenosis (pulmonary ossification). metastases (thyroid. • Vasculitis influenza. cervix. parainfluenza Bronchiectasis • Congenital: bronchial atresia. South American paracocci • Hematogenous metastases: thyroid. CD4 count and thoracic disease • Organizing pneumonia (BOOP) • >200: TB. Kartagener’s syndrome. melanoma. mucinous adenocarcinoma) • TB • • Varicella Silicosis Cavities. viral pneumonia Calcified pulmonary nodules • HAM TV’s mnemonic: • TB • Mycetoma • Pulmonary bullae. tumor (carcinoid. sarcoidosis. GI adenocarcinoma). 1/3rd OWR multiple.Milliary nodules. measles. viral pneumonia • Organizing pneumonia (BOOP) • PCP • Alveolar proteinosis • Eosinophilic pneumonia • Drugs • Pulmonary edema Bronchovascular distribution • Kaposi’s sarcoma • Sarcoidosis • Lymphangitic carcinomatosis • Lymphoma Increased lung volumes (chronic disease) • CF • COPD • EG • LAM/TS . legionella) • Fungal infections • 200-50: PCP. H. bullae • Traumatic lung cyst • Pneumatocele (pulmonary laceration) • Excavating bronchogenic cyst • Congenital lung cyst • Cavitating metastases • Parenchymal laryngopapillomatosis • Cystic bronchiectasis • Giant bullous emphysema (young male smokers) Cavities with air-fluid level • Cavitating bronchogenic carcinoma Peripheral infiltrates • Loeffler’s disease (acute eosinophilic pneumonia) Sarcoidosis with erythema nodosum and arthralgias is Lofgren’s syndrome. melanoma. pneumoconioses. esophagus. pneumoconiosis of coal workers. histoplasmosis. TB. choriocarcinoma. Coxiella burnetti Viral pneumonia: adenovirus. hamartoma Amyloidosis. varicella. TB. BAC. a-1antitrypsin disease. airspace consolidation: Kaposi’s sarcoma (201Tl positive) XRT pneumonitis occurs at 1-3 months. hypogammaglobulinemia. osteosarcoma. infected or non-infected • Infected lung cyst • Lung laceration with liquefied hematoma • Infected sequestration • Necrobiotic rheumatoid nodule • Cavitary pulmonary infarct • Infection of pre-existing cavity • Wegener’s granulomatosis Consolidation. choriocarcinoma. blastomycosis. Kaposi’s • Hemorrhagic metastases sarcoma • Septic emboli • <50: CMV. renal failure Atypical pneumonia: Mycoplasma. metastases (thyroid. lobar/segmental • Pneumonia • Infarction • Lung contusion • Focal edema: positional. adenocarcinoma • Abscess: Staphylcoccus. varicose Ground glass opacities • Hypersensitivity pneumonitis • Acute alveolitis: DIP. choriocarcinoma. coccidiodomycosis. Mournier-Kuhn syndrome. RSV. hemosiderosis.
collagen vascular disease. raised intracranial pressure • Rapid re-expansion of lung • SCHLITZ mnemonic: • Drug or transfusion reaction • Sarcoidosis • Inhalation of noxious agent: • Collagen vascular disease. SLE. and is the endstage histologic change of many things. lung • Stomach. tumor. fungus. silicoproteinosis. laryngeal carcinoma • Breast. such as ovarian. bronchitis • Proteinaceous material: alveolar proteinosis • Adult respiratory distress syndrome Chronic air space consolidation • Alveolar proteinosis • Lymphoma • Pseudolymphoma (small lymphocytic infiltrate similar to lymphoma but stains different immunohistochemically) • BAC • Sarcoidosis • Desquamative interstitial pneumonitis • TB. 2 chest. pancreas. bronchiectasis. DIP. colon • Prostate. breast. HSP). 2 pelvis mnemonic: • Thyroid. CF smoke. Stage 3 Hodgkin’s disease is below the diaphragm. GI Interstitial lung disease. RA Viral pneumonitis • Scleroderma. rheumatoid lung Upper lung fibrosis/hilar elevation • Post-primary TB • Radiation for breast or head and neck tumors • Sarcoidosis in chronic destructive phase • PMF • Histoplasmosis • Langerhan’s cell histiocytosis (uncommon) • Ankylosing spondylitis (rare) Upper lung interstitial disease CASSET P mnemonic: • CF Rheumatoid lung. gold therapy • PISSER mnemonic: pneumoconiosis. brochiolitis obliterans (Swyer-James/Macleod syndrome). 5–20mm • Non-infectious granulomatous disease: Langerhan’s cell histiocytosis. lung. drugs • Asbestosis. a-1-antitrypsin disease • Sarcoidosis • • • Scleroderma. asbestosis (crocidolite fibers). lymphoma/pseudolymphoma. radiation. alveolar proteinosis. coal workers pneumoconiosis • Langerhan’s cell histiocytosis • Sarcoidosis • Rheumatoid lung disease . Goodpasture’s syndrome. Diffuse interstitial disease trauma). silicosis. mixed connective tissue disease • Rare: amyloid. coccidiodomycosis. viral pneumonia • Metastases. Wegener’s disease • Infectious granulomatous disease: TB. sarcoidosis. aspiration • Hemorrhage: idiopathic pulmonary hemosiderosis (child). but this is controversial Hodgkin’s disease is 3x more likely to have solitary parenchymal disease than NHL. tumor. 2 abdomen. berylliosis (indistinguishable from sarcoidosis) • Sarcoidosis EG TB PCP Drug toxicity (chronic pneumonitis/fibrosis) • Bleomycin • Busulphan • BCNU Multifocal or diffuse transient air space • Nitrofurantoin consolidation • Amiodarone • Recurrent edema • Cyclophosphamide • Recurrent inhalation of toxins • MTX • Recurrent exposure to extrinsic allergens (hypersensitivity pneumonitis) Noncardiogenic pulmonary edema • Recurrent hemorrhage • Laryngospasm • Intermittent treatment of • Aspiration sarcoidosis • Neurologic (bleed. dermatomyositis/polymyositis Stages of sarcoidosis • • 0: NL CXR 1: mediastinal/hilar lymphadenopathy • 2: mediastinal/hilar lymphadenopathy and parenchymal disease • 3: parenchymal consolidation only • 4: honeycomb lung Dermatomyositis can be sporadic or occur with malignancy. bacteria. lipoid pneumonia Usual interstitial pneumonitis (UIP) has low lung volumes. DIP may be an early stage of UIP. fungus/TB. massive emboli • Central airway obstruction with air trapping. congenital absence of pectoral muscle (Poland syndrome) • Proximal interruption/hypoplasia of the pulmonary artery. BAC • Extrinsic allergic alveolitis • Pneumoconiosis • Drug reaction Interstitial lung disease with pneumothorax • Langerhan’s cell histiocytosis • Sarcoidosis • Any interstitial lung disease • CF • Lymphangioleiomyomatosis • PCP Unilateral hyperlucent lung • Mastectomy. histoplasmosis. rheumatoid lung. renal failure. scleroderma. congenital lobar emphysema. collagen vascular disease (SLE. scleroderma. • Lymphangitic carcinomatosis sepsis. alveolar cell carcinoma. anticoagulation therapy. chemicals • Histiocytosis • Heroin • Early ARDS due to shock. whereas stage 4 is solid organ involvement (lung.Diffuse air space consolidation • Edema: cardiogenic. trauma • Idiopathic pulmonary fibrosis Multiple ill-defined nodules. including IPF. bladder carcinoma • • • • • Ankylosing spondylitis Silicosis. IPF. EG. liver) • • Lymphangitic carcinomatosis Desquamative interstitial pneumonitis. scleroderma. atelectasis with compensatory hyperinflation • Pneumothorax (supine) • Giant bullous emphysema (young male) • Post-transplant native lung emphysema (pleural effusion opposite side) • • Tuberous sclerosis Pneumoconioses Basal interstitial disease • BALD ASS VR mnemonic: • • Bronchiectasis Aspiration (including mineral oil) Honeycomb lung • Idiopathic pulmonary fibrosis (fibrosing alveolitis) • Pneumoconiosis: asbestosis. chronic septal thickening • Chronic pulmonary edema • Lymphangitic carcinomatosis • Veno-occlusive disease (rare) • Congenital lymphangiectasia (rare) Lymphangitic carcinomatosis • 2 neck. fungus (rare) • Lipoid pneumonia (rare) • SAD FALL mnemonic: sarcoidosis. Sjogren’s disease. sarcoidosis. trauma. noncardiogenic • Pneumonia: PCP. Gaucher’s disease. bone. bleeding diathesis.
aureus. Cushing’s syndrome • Radiation Complete opacification of hemithorax • FAT CHANCE mnemonic: • • • • • • • • • Fibrothorax (TB) Adenomatoid malformation Trauma (hemothorax) Collapse Hernia Agenesis of lung Neoplasm: mesothelioma Consolidation Effusion Malignant chest wall tumor. loculated fluid. multiple myeloma. blastomycosis • Fracture with hematoma/callus: trauma. lung • TB • Collagen vascular disease: rheumatoid lung. mass • Traumatic rupture of diaphragm • Diaphragmatic tumor: lipoma. byssinosis (cotton). neuroblastoma • Bone tumor • Vascular tumor: metastases. nocardiasis. bronchogenic carcinoma. barytosis (barium) • Allergenic: berylliosis. healed bacterial or tuberculous empyema. desmoid. siderosis (iron). trauma • Hypoplastic lung (usually right side) . virus. Lung abscess may be due to s. fungal. fibrosarcoma • Hematoma • Infection: actinomycosis. nocardiasis. a chest tube is necessary (>25% or symptomatic patient). and others 3. fibrosis. patient emphysema/bullae Miscellaneous facts: 1. sequoiosis (tree protein) Pneumothorax with otherwise NL CXR • Blebs. pregnancy. lymphoma. increased depth of respiration. pneumoconiosis of coal workers. myasthenia gravis. eventration Bilateral elevated hemidiaphragm • Shallow inspiration • Restrictive lung disease • Obesity. amebic abscess • PE with infarct • Trauma with hydrothorax Pleural mass • Mesothelioma • Metastases from extrathoracic tumor • Metastatic lung adenocarcinoma • Resolving empyema. fibrobullous disease (AS). End-expiration is more reproducible. long biopsy time. bullae • TB • Trauma • Metastases: osteosarcoma • Asthma • Decompression (diving) • Langerhan’s cell histiocytosis • Spontaneous (tall. cadminosis • Organic dusts: farmer’s lung (fungi). child • Ewing’s sarcoma • Neuroblastoma • Askin’s tumor (neuroectodermal small cell tumor) • Rhabdomyosarcoma Transthoracic biopsy: FNA or Core with cutting needle. s. and cavitary neoplasms 2. Ewing’s sarcoma. hematoma Unilateral elevated hemidiaphragm • Subpulmonic effusion (pseudo elevation) • Lobar atelectasis • S/p resection • Congenital small lung • Phrenic nerve paralysis: iatrogenic. neurofibroma. chondrosarcoma. pneumoniae. Mycetoma forms within pre-existing cavities such as bullae. surgery. ascites. pneumoconioses). hemangioma or hemangiopericytoma. Klebsiella. organized hemothorax • Bilateral: asbestosis Pleural thickening • • • • • • • Healed empyema Resolved hemothorax Resolved asbestos pleuritis Confluent pleural plaques Extrapleural fat SLE S/p thoracic surgery • Subdiaphragmatic abscess. methylphenidate abuse Common pneumoconioses • With fibrosis: silcosis. fibroma. hernia (Bochdalek. renal osteodystrophy. Co-axial technique with 19g guide needle and 20-22g Chiba. bagassosis (sugar cane). mycosis. Lung abscesses and septic emboli can look similar. mesothelioma. amyotrophic lateral sclerosis Chest wall mass • Mesodermal tumor: lipoma. TB Rib lesion with surrounding soft tissue mass • Metastases • Multiple myeloma • Lymphoma • Fibrosarcoma • Neurofibroma • Osteitis: TB. Pleural thickening may be due to extrapleural fat. Morgagni). osteosarcoma. Increased risk PTX with large needle.Bilateral hyperlucent lungs • Emphysema • a-1-antitrypsin disease. mycoplasma. asbestosis • Without fibrosis: stannosis (tin). thin young male) Spontaneous pneumothorax • Blebs • TB • Metastasis • Asthma • Langerhan’s cell histiocytosis • Sarcoid • Any interstitial disease • CF • PCP Unilateral pleural effusion with NL lungs • Pleural metastases: adenocarcinoma of breast. fibrocavitary disease (TB. PTX in 30-50%. staphylococci. fungi. abdominal mass • Muscle weakness from SLE. anaerobes. muscle • Neurogenic tumor: schwannoma. In 5%. blastomycosis. bird fancier’s lung (bird proteins). tumor. pneumatocele. SLE • PE • Trauma • Chylothorax • Pancreatitis • Meig’s syndrome • Post-pericardiotomy syndromes • Subphrenic abscess • Asbestos-related pleuritis • Peritoneal dialysis • Viral pleuritis (rare) • Mesothelioma Left-sided pleural effusion • PE • Constrictive pericarditis • Aortic dissection with rupture • Trauma • Boerhaave’s syndrome • Pancreatitis • Trauma to upper thoracic duct • Apical left heart failure Right-sided pleural effusion • Left heart failure • Cirrhosis • S/p liver transplant • • Subphrenic abscess Ascites Pleural effusion with lung consolidation/mass • Bronchogenic carcinoma • Lymphoma • Metastases • Empyema • Pancreatitis • Pneumonia: anaerobes. increased number of visceral pleural punctures. hematoma • Rib lesion • Loculated effusion • Extrapleural lipoma • Post-inflammatory fibrin ball • Transpleural extension of invasive thymoma • Splenosis • Localized fibrous tumor of the pleura Pleural calcification • Unilateral: asbestos pleural plaques.
Note: AV canal may be an ostium primum with high VSD. if 1/3rd of lung opacified by pleural effusion: 1L. aortic dissection Dilated cardiomyopathy • Ischemic heart disease • Diagnosis of exclusion TAPVR drainage patterns • 1: left vertical vein to brachiocephalic vein to SVC to RA (snowman configuration) CYANOTIC with DECREASED pulmonary blood flow. 18. increased heart size (admixture shunt) • Elevated intracranial pressure • TGV • Truncus arteriosis Aortic stenosis • TAPVR Congenital • Tricuspid atresia • Degeneration of bicuspid • Single ventricle. single atrium aortic valve • Hypoplastic left heart • Rheumatic heart disease • DORV • HTN in elderly • AV canal • AVMs Large. single atrium Isolated pulmonary valvular stenosis has prominent main PA. aspirin overdose. pleural plaques. 15. 2cm deep: ~800cc. 12. as does Castleman’s disease. vasculitis). inhalation of noxious gases (N2O. Only 10% of myasthenia patients have thymoma Teratoma occurs in <30 y/o. valium. and is usually seen at the ventricular apex Partial absence of the left pericardium can result in cardiac torsion. difficult ETT intubation with intraoperative hypoxemia/atelectasis RUL. SO2. parenchymal (COPD. multiple pulmonary Constrictive pericarditis • Iatrogenic • Mediastinal radiation • Viral infection (repeated episodes) • Uremia • TB Restrictive cardiomyopathy • Idiopathic • Sarcoidosis • Hemochromatosis • Amyloidosis Aortic regurgitation Bacterial endocarditis • Rheumatic heart disease • Myxomatous degeneration of valve • Aortic root dilatation: Marfan’s syndrome. Fix by balloon valvulotomy. 1/3rd associated with myasthenia gravis. Luftsichel is the LUL collapse sign with hyperinflation of the LLL into the left lung apex On upright CXR. There are 3 types of Castleman’s disease. syphilitic aortitis. It results in mosaic perfusion on CT scan. 10. etc. • SV aneurysm idiopathic CYANOTIC with DECREASED pulmonary Noncardiogenic pulmonary edema blood flow. smoke) CYANOTIC with INCREASED pulmonary blood • Via nerves: high altitude flow. 7. bronchiectasis. and CXR with venous return rapidly tapering pulmonary arteries) • AP window (like PDA but • Increased pressure: pulmonary ascending aorta to main pulmonary artery) emboli (clots. The thymus begins to atrophy at puberty. 0-10.4. 100-400. Congenital aortic stenosis has LV enlargement. mitral stenosis. azygous continuation of the IVC Pulmonary arterial hypertension can be due to increased flow or increased pulmonary resistance. whole lung: ~3L. tricuspid insufficiency. with cyanosis of lower ½ of the body. constrictive pericarditis. malignant mesothelioma A “water bottle” configuration of the heart is classic for a pericardial effusion A false myocardial aneurysm is contained by pericardium only. Mimics include mediastinal lymphoma. sinus venosus. It occurs at three levels: pre-capillary (primary/idiopathic. Electron Beam CT/Multi-detector CT scores based on size & density of calcifications. Aortic coarctation is symptomatic with >50% lumen stenosis. talc). thyrotoxicosis. anomalous pulmonary venous drainage. prominent ascending aorta. outlet (supracristal. 5. 8. while a true aneurysm has all three cardiac layers. perimembranous (most common). Pseudocoarctation has no pressure gradient ASD: ostium primum (Down syndrome). If supravalvular stenosis. with or without increased heart size (left-to-right shunt) • ASD Pulmonary hypertension • VSD • Increased flow: reversal of • PDA flow in ASD/VSD with Eisenmenger’s • Endocardial cushion defect physiology (which presents clinically as • Partial anomalous pulmonary new-onset cyanosis. 13. asphyxia. and little remains (by CT) at age 30 Thymoma (>40 y/o): 1/3rd invasive. syncope Differential Diagnoses Heart & Great Vessels Imaging Postductal type may be associated with bicuspid aortic valve. a wide mouth. NL heart size (right-to-left shunt) • Via blood: sepsis. and post-capillary (LV failure. re• DORV with pulmonary expansion (lung must be atelectatic at stenosis least 72 hours) • TGV • cTGV with pulmonary stenosis • Via airway: near drowning. 6. SVC/IVC obstruction. obesity High output heart failure may be due to anemia. contrast. shistosomiasis. and compared to sex & age-matched controls. chronic pulmonary emboli. suspect William’s syndrome. 16. CCAM. antibiotics). • Pulmonary atresia methadone). infracristal) ACYANOTIC with INCREASED pulmonary blood flow. muscular. lipomatosis A tracheal bronchus (anatomic variant to RUL) may result in recurrent infection. 400-1000. 17. 9. obstructive/restrictive lung artery shunt disease (COPD. and is usually located along the posterior diaphragmatic surface. . has a narrow neck. RV. pregnancy Asbestos exposure may result in pleural effusions. if 2/3rds of lung: 2L. posterior/inferior types. any chronic interstitial lung disease). sarcoidosis. pulmonary venoocclusive disease). round atelectasis. 14. with hyaline vascular being the most common Saber sheath trachea in COPD has a coronal diameter that’s 2/3rds the sagittal diameter. diffuse pleural thickening. pulmonary vein stenosis. increased heart size • Ebstein anomaly • Tricuspid atresia (some types) • Pulmonary atresia (type 2) • Severe pulmonary stenosis with ASD CYANOTIC heart disease • 5 Ts mnemonic: • • • • • • TOF TAPVR Truncus arteriosis Tricuspid atresia TOGV Tingles: single ventricle. 11. tamponade). Can also be seen in obstructive sleep apnea. • Coronary artery-to-pulmonary vasculitis. heroin. etc. Preductal (infantile) type has R-L shunt via PDA. Cancer can cause obstruction of the RUL also A prominent azygous vein may be due to increased CVP (CHF. hypoxia/sleep apnea syndrome. anaphylactic reaction (blood. drugs • TOF (cocaine. poisons. interstitial • Systemic AVF fibrosis). 10-100. ASD has increased incidence of MVP VSD: inlet. 3cm deep: ~600cc. Decubitus film with 1 cm deep pleural effusion at mid thoracic level: ~400cc. postobstructive pneumonia. ostium secundum.
child (endocardial cushion defect) enlargement (rounded cardiac apex) more • Pericardial effusion marked than in AS. MR. • Vein of Galen malformation. overriding aorta. TOF has high VSD. neonates/child. RA (prominent right heart due to enlarged coronary sinus) • 3: portal vein. while LV is connected to pulmonary artery. stretching of valvular • Rheumatic heart disease • Coarctation of aorta proximal ring. There is LV cardiomyopathy enlargement. Acute MI shows NL CXR or CHF with NL • Infection: viral. XRT. DORV. while MR causes mild pulmonary 3-4 ribs operation side) • MR HTN/severe LA enlargement. • Autoimmune disease: Dressler interventricular septum. prominent cyanosis: TGV. If new onset cyanosis and In children. pleural effusion 3. PDA cause pulmonary overcirculation • MS Rhabdomyoma occurs in TS. Rib notching. aortitis cyanosis: ASD. • Aortic thrombosis (lower ribs) • Uremia Grade 1: 2. • Hypertrophic cardiomyopathy Shunt >2:1 is significant. AR. Ebstein’s anomaly 12. suspect coexisting aortic valvular disease. hypertrophic/obstructive with direct invasion (lung. RAO. restrictive (rare) with endocardial fibrosis. TOF has the “wooden shoe” appearance of CM due to RVH. TA. and is the most (pulmonary HTN) with prominent PA. infundibular pulmonic stenosis. In systemic HTN. unilateral right after MI. LA enlargement). 10. 4-8) • Trauma: hemopericardium mixed. often hemangioendothelioma • Decreased/NL vascularity with with LA enlargement • Large VSD. resulting in pulmonary undercirculation. acute marginals. SA node. bilateral SLE oligemia • Coarctation of the aorta (ribs • CHF 6. thymoma) the diaphragmatic surface of the LV and poor diastolic filling (MR. pulmonary congestion • NF-1 • Idiopathic. anemia. CHF. endocarditis. • Ischemic cardiomyopathy AFIP congenital heart disease eventual pulmonary venous HTN. Ebstein’s anomaly. TGA. unilateral left • Coarctation of aorta with 7. LV enlargement. resulting in globular-shaped CM. VSD. pulmonary Rib notching. Multivalvular disease usually involves MV. prominent tortuous aorta • Ebstein’s anomaly • Decreased vascularity with 11. then later • Cardiomyopathy Ebstein’s anomaly LV enlargement. RVH. RV • Acute MI common cardiac tumor to occur in enlargement. valve cm2. TA. diagonal branches. or PDA that connects the two circuits. RA enlargement. cardiac. RA enlargement. aortic dissection. Valvular heart disease: MS. shunt physiology aberrant right subclavian artery origin valve. small aorta • RV dysplasia to left subclavian artery origin (decreased LV output). cardiomyopathy CHD cardiomyopathy • Myocarditis: Coxsackie virus. MS occurs when valve area is <4-6 cm2. LV aneurysm • Malignancy: metastases 5. most common) are rare. IVC (usually obstructed at esophageal hiatus. Greater than a 2:1 shunt is necessary to see changes on CXR 2. A small aortic arch may be present. RCA is dominant in 85%. TOF. chest wall pulmonary hemosiderosis). Ebstein’s anomaly has “atrialized RV” and ASD/PFO.• 2: coronary sinus. AS can be due to RF. and pulmonary undercirculation. grade 2: 1 cm2. NL heart size with pulmonary edema) • 4: mixed pattern Mitral regurgitation • Rheumatic heart disease • MVP • Post-infarction papillary muscle dysfunction • Infectious endocarditis • Degenerative rupture of chordae tendineae • Marfan’s syndrome • Associated with annular calcification • LV dilatation in CHF. bacterial heart size (early). endocarditis. AV canal (syphilis). MI (longstanding pulmonary HTN causes • Pulmonary AVM. and later LA enlargement. breast. pulmonary congestion (occurs VERY LATE). Primary • Arterial hypertension tumors (myxoma. STARCH • Maternal diabetes • Ischemia • Absent coronary artery • Storage diseases • Hypoplastic left heart Coronary angiography • Judkins or Amplatz catheters: 4-8 cc by hand. AV node. a small PA with pulmonary undercirculation Miscellaneous facts: 1. LCA 8%. Rule of thumb: MS • Blalock procedure (subclavian Cardiomegaly causes severe pulmonary HTN/mild LA artery-to-PA) for TOF on right side (upper • AR enlargement. Cardiac • Constrictive pericarditis shunt reversal (Eisenmenger’s syndrome) . congenital bicuspid aortic thyrotoxicosis. TA. critical aortic ascending & descending aorta stenosis • Decreased/NL vascularity 9. Shunt vascularity is pulmonary overcirculation. • Pericardial effusion • Increased vascularity without 8. AR may be due to RF. carcinoid). Most regress by 4 years of age. circumflex (obtuse marginal branches. VSD. • High-output states: pregnancy. Dominance means which coronary artery supplies most common). There is CM with “egg-on-a-string” appearance of the mediastinum. 75% diameter decrease = 95% cross-sectional area decrease R-L shunt is seen in TOF. Hypocardia pulmonary atresia. TGV (uncorrected) has ASD. and may present with • Congestive (dilated) distal to coarctation angina. ASD. MS has LA enlargement (double density • SVC obstruction replacement frontal view). Remember: RV connected to aorta. ASD cyanosis: pulmonary stenosis.VSD. without cyanosis: pulmonary stenosis AV. co-dominance 7% syndrome CHF. Normal pericardial thickness is <4 mm cyanosis: pulmonary stenosis. There is LV Massive cardiomegaly. atherosclerosis. See LA. TAPVR hypoplastic left heart.5 cm2. fibroma and teratoma (epicardial) • Restrictive cardiomyopathy pruning of pulmonary arteries on CXR. posterior descending • LCA branches: LAD to septal. cranial and caudal angulation • RCA branches: conus. MR can be due to • Bacterial endocarditis (IVDA) ruptured chordae tendinae/papillary muscle Rib notching. PDA. cine 30-60 frames/sec • Various obliques of LAO. PDA. TOF. See a combination of both on CXR. RV enlargement AVM Tricuspid regurgitation with eventual right CHF /TR. If prominent • TR aorta. CXR may be NL. syncope. grade 3: <1 • Pulmonary atresia • Postsurgical: CABG. CHF shows CM. AS. • Increased vascularity with • Left ventricular outflow lesion: pulmonary venous HTN/edema. May see CM with/without pleural • Collagen vascular disease: effusion. Cardiomyopathy may be dilated (congestive. there may be are the next most frequent tumors. (lymphoma. Pericardial/myocardial tumors are usually • AS secondary to mediastinal invasion. melanoma. prominent ascending aorta. Ischemic heart disease shows NL CXR or LV enlargement Pericardial effusion 4. pulmonary edema. ramus intermedius) • 50% diameter decrease = 75% cross-sectional area decrease. LVH.
sebaceous/epidermal cysts • Oil cyst (rim Ca++. anasarca Diffusely increased breast density. chronic plasma cell mastitis related to extravasated secretions. collagen vascular disease. circumscribed margins • Hamartoma (fibroadenolipoma) • Cyst • Intramammary lymph node • Fibroadenoma • Steatocystoma multiplex (AD. fat-containing • Milk of calcium • Oil cyst • Adenosis • Fat necrosis • Foreign body • Lipoma (liposarcoma rare) • Dermatomyositis (rare) • Galactocele Mass. fibrous (may be fatal) mastopathy (thyroiditis. radiation (child). If it’s not palpable. contralateral breast be due to multiple causes. Surgery is • Medullary carcinoma (young). • Biopsy scar hypoproteinemia. surgical excision of breast bud (child). congenital mammary aplasia. warranted for lesions that cause obstruction or mucinous carcinoma (old). A pleural effusion is either a transudate (CHF. lung. distortion. inflammation. Poland’s syndrome. inflammatory carcinoma • Lumpectomy/surgical biopsies or axillary dissection (edema) • Radiation therapy (skin thickening. etc) • Hematoma: post-surgical. elastosis. Dilated cardiomyopathy (systolic/diastolic • Metastasis: lymphoma. medullary. Pulmonary sling (aberrant left pulmonary • Carcinoma: invasive ductal artery) is the ONLY vascular anomaly that NOS. plasma cell mastitis) neurofibromatosis. • Cysts (35-50 y/o) crystallization of processing chemicals • Fibroadenomas (<35 y/o) • Intramammary lymph nodes Calcifications. ASD and cardiac level TAPVR look alike Mass. nephrotic • Fat necrosis (mass-like. rare but Mammography may be seen after trauma/surgery or in Gardner’s syndrome) Calcifications. papillary valvular dysfunction carcinoma. adriamycin). talc. 16. ASD is most common entity to present in young autoimmune disorders) adults. sarcoidosis Single dilated duct/bloody nipple discharge • Duct ectasia • Papilloma • Malignancy Subtypes of ductal carcinoma • Invasive ductal NOS • Tubular • Medullary • Mucinous • Papillary Subtypes of DCIS • • • • Comedo Cribiform Micropapillary Solid Differential Diagnoses . • Abscess mets. fingerprints. primary. indurative edema can be due to infracardiac TAPVR or mastopathy) cor triatriatum (rare) • Biopsy scar • Fat necrosis • Breast abscess • Sclerosing adenosis • Granular cell tumor (anterior). including infection. 17. calcifications) pulmonary embolism. obscured margins • Ductal carcinoma in situ • Any of the previous entities • Fat necrosis • Early vascular disease Subareolar mass • Early fibroadenoma • Papillary carcinoma. then VSD>PDA>pulmonary stenosis 18. more • Intramammary lymph node: common in males) infection. nephrotic syndrome. egg shell calcification) Masses. diabetes mellitus. gold treatment for RA. beri beri. cystsyndrome) or exudate (parapneumonic.sarcomas are extremely rare. antiperspirant. trabecular thickening. lymphoma. and idiopathic Mass. engorged lymphatics) • Mastitis or inflammation: acute related to lactation. papillary. architectural pancreatitis. dust. ectasia. mass. AD. calcification) • Prior surgery (AD. indistinct margins 14. bronchogenic carcinoma. SLE. collagen vascular. maybe DCIS differentiates • Radial scar (sclerosing duct 19. lymphoma • Vascular (small “quirky”) • Multifocal or multicentric • Degenerating fibroadenoma breast cancer • Secretory calcification (duct • Skin lesions: moles. trabecular thickening. tatoos. it’s B9 • Carcinoma (especially invasive lobular) Diffusely increased breast density. but cyanosis ductal. skin thickening • Diffuse invasive carcinoma. Masses. TB (rare) • Dermatologic disorders: psoriasis • Generalized edema: CHF. RCC ischemia. complex degeneration cyst • Fibrous capsule adjacent to • Post-trauma (resolving seroma. malignant appearance • Invasive ductal carcinoma Mass. psoriatic arthritis. bleeding diathesis (IHSS) causes outflow obstruction. postreduction mammoplasty. pulmonary vascularity. desmoid tumor (pectoralis fascia. courses between the trachea and esophagus invasive lobular 15. Assumes a different appearance in two views. benign appearance • Papillomas • Skin (dermal) • Metastases. trabecular thickening • Interval weight loss • Hormone replacement therapy • Generalized edema • Endogenous hormone production from adrenal or ovarian tumors Axillary lymph nodes • Breast carcinoma metastatic to lymph node (contralateral or ipsilateral) • Lymphoma (mass. toxin (ETOH. invasive ductal carcinoma NOS 13. skin thickening) • Fibrocystic change Asymmetry • Asymmetric breast tissue: NL variant. arrhythmia • Sclerosing adenosis. keratosis. skin thickening) • Prior radiation (AD. primary breast carcinoma. spiculated margins with prominent right heart and increased • Invasive carcinoma: lobular. ovarian. static. diffuse increase in breast density) • Other malignancies • Reactive hyperplasia: infection or inflammation • Drugs or systemic diseases: gold therapy for RA. metastasis Architectural distortion • Papilloma • Carcinoma (especially tubular subtype) • Radial scar • Post-traumatic fat necrosis (oil cyst. multiple ECG paste. tubular. cirrhosis. dysfunction with pulmonary venous HTN) can melanoma. metabolic. Idiopathic hypertrophic subaortic stenosis blunt trauma. mucinous. gastric. A NL size heart with florid pulmonary hyperplasia. like with fat density. cirrhosis. trabecular thickening. • Phyllodes tumor multiple subcutaneous oil cysts. implant hematoma) • Fibrocystic change • Papilloma • Artifacts: scratches.
echogenic pseudocapsule Always correlate final pathologic diagnosis with US intermediate findings imaging appearance (check concordance): • Isoechoic • Low/intermediate suspicion • Mildly hypoechoic before biopsy with B9 pathology: 6-month follow up only to establish a new baseline • NL sound transmission • If B9 diagnosis. skin edema/ulceration. invasive cribiform. BI-RADS 3 with short-interval follow-up Diagnostic mammogram in symptomatic patients • If palpable but no US (nipple discharge. mucinous. DCIS. solitary dilated duct without nipple discharge. scar after lumpectomy/radiation • Evaluate dense breast tissue Spot compression to verify a density is a true mass and better define margins Spot magnification to evaluate margins of a mass and check for microcalcifications US echogenicity is relative to subcutaneous fat C MOI S (margins): Circumscribed. migration of implant.5-2x: sclerosing adenosis. if stable. skin changes. T4: any size with chest wall extension. reserpine. fatcontaining masses. Microlobulated. moderate florid ductal hyperplasia 4-5x: atypical ductal hyperplasia. Spiculated High density Equal density (isodense) Low density Fat-containing (radiolucent) Calcification distributions Clustered. Indistinct. exogenous estrogens for prostate CA • Tumor: testicular seminoma. intramammary lymph nodes. multiple similar lesions in both breasts) 3 Probably Benign (short-term follow-up) 4 Suspicious Abnormality (core biopsy) 5 Highly Suggestive (core or excisional biopsy) Probably Benign (~1. US to check for Screening mammogram for asymptomatic patients. Lobular. Obscured. T3: >5cm. linear. adenoid cystic. SCC. and Jewish background Skin lesions • Epidermal/sebaceous cyst • NF-1 • Mondor’s disease (thrombophlebitis of thoracoepigastric or lateral thoracic vein) • Steatocystoma multiplex • Inflammatory carcinoma Nipple-areolar complex • Nipple adenoma • Hidradenitis suppurativa • Leiomyoma • Paget’s disease Major ducts • • • Duct ectasia Solitary papilloma Papillary carcinoma US findings of benignity • Hyperechoic Core biopsy is contraindicated if lesion is too close • Macrolobulations to chest wall/skin. capsular contraction). peripheral papillomas. assess recurrence vs. NL tissue and bx. air gap (breast is moved away from film) Staging of breast cancer (TNM) • T1: <2cm. N3: ipsilateral internal mammary LNs • M1: distant metastases Notable breast cancer stages (0-4) • Stage 0: DCIS • • Stage 1: mass <2cm only Stage 2A: <2cm with or w/out mobile axillary LNs • Stage 2B: <5cm w/out mobile axillary LNs • Stage 3B: inflammatory carcinoma. spot compression. atypical ductal hyperplasia with positive family history (1st degree relative) Gynecomastia causes • Drugs: marijuana. choriocarcinoma • Cirrhosis MRI uses • Check extent of disease (multifocal) • Help staging • Evaluate implants (rupture.Increased risk marker lesions 1. medullary. regional. proliferation without atypia. bx is recommended retraction). no grid. but does not • Enhanced through correlate with imaging: excisional bx transmission • If pathology shows high risk • Heterogeneous echotexture lesion (atypical ductal hyperplasia. segmental. • Homogeneous echotexture atypical lobular hyperplasia. metaplastic.1mm. This has a similar • Microlobulation appearance in two views. Oval. consider patients with implants or prior lumpectomy discontinuing treatment and follow-up in 2-3 months ROLI (shape): Round. patient anxiety a factor. diffuse BI-RADS categories 0 Incomplete (needs additional imaging) 1 Negative 2 Benign Finding (round or oval calcifications. and • Duct extension correlate with physical exam. gel bleed. but not the defined margins • Microcalcifications of a true mass • If palpable. in a very small breast. mumps orchitis after age 20.4% malignancy): check prior studies for stability. then biopsy To avoid sampling error. cimetidine. lobular neoplasia. suspected radial scar/complex sclerosing lesions should have excisional biopsy. T2: 2-5cm. N2: fixed axillary LNs. • If on HRT. work-up of abnormal screening exam. or if throw • Oval (shorter than wide) of needle is greater than compression of tissue • Thin. secretory carcinoma Lobules • Cysts • Galactocele • Juvenile papillomatosis • Fibroadenoma • Complex fibroadenoma (cysts. redness. abnormality. and is more common in patients with Kleinfelter’s syndrome. circumscribed round or oval mass. If worrisome changes.8x): micro-focal spot 0. lateral). proliferative changes with atypia 8-10x: lobular neoplasia (LCIS). non-palpable FAD. embryonal cell carcinoma. AD at known biopsy site. if deemed necessary and should be either NL or possibly ABNL with • If not palpable and no US additional studies needed findings. sclerosing adenosis) • Juvenile fibroadenoma . and likely requires bx Magnification view (1. lump. well-differentiated DCIS. lobular neoplasia): excisional bx US findings suggesting malignancy • High suspicion before biopsy • Spiculated margins with DCIS pathology: excisional bx • Taller than wide • Angular margins • Any discordant finding should lead to excisional bx • Shadowing • Branching pattern Evaluate focal asymmetric density by additional • Markedly hypoechoic views (rolled. Developing density should be compared to oldest good quality film. pain. skin ulceration • Stage 4: distant metastases Male breast cancer is probably not related to gynecomastia. invasive ductal carcinoma. as they are difficult to differentiate from tubular carcinoma and may have adjacent atypical ductal hyperplasia. cardiac glycosides. or patient pregnant/planning pregnancy. Irregular Terminal duct • Hyperplasia • Multiple peripheral papillomas • Radial scar/complex sclerosis lesion (>1 cm) • Ductal adenoma • DCIS • Invasive ductal carcinoma • Tubular. inflammatory carcinoma • N1: mobile ipsilateral LN. it can be followed by 6month mammographic surveillance for 2-3 years. atypical lobular hyperplasia. patient unlikely to return.
spot compress. 1. 16. Steps: Sorry Always check patient chart. and an irregular contour. 15 cm) with hook wire. 7. 15. 3. needle length. arthropathy can be used to evaluate 13. fibroadenoma. homocysteinuria 11. sickle cell anemia. the subareolar region. and use tangential beam Mondor’s disease (superficial thrombophlebitis) usually involves the thoracoepigastric or lateral thoracic vein A radial scar is difficult to see on the orthogonal view Breast implants can be subglandular or subpectoral If a core biopsy shows radial scar. Ehlers-Danlos. ankylosing spondylitis) muscle in 20-40 cases. Always check the In acute traumatic aortic injury (ATAI). the glandular-fat diverticulum has obtuse margins. collagen vascular 7. papilloma Weight loss. Do pulse exam. delayed washout 9. j-wire or Hawkins retractable barb. lesion or to ensure 1-to-1 correlation with mammographic and clinical lesion. platelets (>50K NL). Tubular carcinoma is multicentric in ~28% • Pregnancy (high output) cases • Valvular aortic stenosis 12. edema. Fibrosis can be idiopathic or related to • CT. Use Conray 60 and 30g blunt-tipped • Cystic medial necrosis: sialography needle for ductagram Marfan’s. Pleomorphic microcalcifications with linear • Traumatic (pseudoaneurysm) and amorphous types predominating • Congenital (aortic sinuses) 5. immunosuppressive drugs • Constrictive pericarditis. 21. 22. A ductus view. Use compression paddle with fenestration and alphanumeric grid. The average glandular dose (with 4. while weight loss and tamoxifen (used in Europe to treat severe fibrocystic change) decrease breast density Mammography uses ~25 kV For tangential view. If not seen. tumor. AVM. US. the retroglandular area. pancreatitis or other process causing pseudoaneurysm. May include a Temporal arteritis small amount of abdomen. oral contraceptives • IVC membranes.coli. candida. an excisional biopsy should be performed DCIS presents as a mass in <5% of cases • Marfan’s syndrome • FMD • Extension of Type A thoracic aortic dissection Surgery in Type B dissection only when: • Ischemic extremity • Mesenteric ischemia. varices. bleeding time (<8 minutes NL). If a pneumocystogram is desired after an If there are islands of breast tissue in a nonanatomic distribution. IVUS diabetes. sclerosing adenosis giant cell arteritis. lung. stereotactic system. mastitis. ovary. peptic ulcer. the breast is pulled up and out general term comprising both Takayasu’s disease and to open the inframammary fold. On the CC view.• • • • • • Stroma Phyllodes tumor Tubular adenoma Lactating adenoma Sclerosing adenosis Lobular neoplasia Invasive lobular carcinoma 14. A biopsy site should remain stable or decrease syphilitic in size/density over time 4. NO delayed interface. and a smooth contour or spot compression for subareolar abnormalities Aortic dissection 10. MRI. Use mammography. consider reduction mammoplasty The differential diagnosis for inflammatory carcinoma is XRT. distortion at the site E. cervical cancer 17. 9. melanoma.3 rads/view using film-screen • Cystic medial necrosis: technique Marfan’s. HRT. post-lumpectomy. try selective thrombolysis and/or balloon thrombectomy Gastrointestinal bleeding • Upper GI tract: Mallory-Weiss tear. RCC. aspergillus. and lactation increase breast density. varices. A “complex fibroadenoma” has cysts. a monitor BP. folks I forgot to put them in here PT/PTT. iatrogenic from endoscopy • Lower GI tract: diverticulosis. pregnancy. descending thoracic aorta) Re-biopsy if there is increased density or • Infectious: staphylococcus. A follow-up mammogram is recommended 6 • Atherosclerotic (usually months post-biopsy to establish a new baseline. 23. 18. If patient has undergone a mastectomy. colon tumor. 20. salmonella. Preoperative needle localization in nonpalpable 24. • Aortitis: Takayasu’s disease. On MLO view. webs • Tumor growth into the IVC or hepatic veins: HCC. Always check the medial aspect of the CC of contrast. simply use 1/2 the amount of aspirated fluid Carotid artery dissection • Trauma . 5. atypical ductal hyperplasia. trauma. one sees the pectoralis disease (RA. For Miscellaneous facts: conscious sedation (midazolam. adrenal carcinoma • Chemotherapy. approach AP or Interventional Radiology parallel to chest wall). HR clinical breast exam is all that is necessary for follow-up Aortic aneurysms 2. angiodysplasia. a posterior nipple line pseudoaneurysm has acute margins. gastritis. Decide what type of needle-wire. lymphatic obstruction. homocysteinuria 6. thyroiditis. Use anterior washout of contrast. ECG. stomach. Needle-wire combination (lengths 3. 19. right heart failure For acute Budd-Chiari syndrome in a young female. pseudoaneurysm.2 cm • Hypertension compression) is 0. 11. retroglandular fat laterally Note: some authors consider Giant cell arteritis a 8. invasive lobular carcinoma Mimics of DCIS calcifications include sclerosing adenosis. Ehlers-Danlos. renal artery compromise • Rupture • Aneurysmal dilatation (false lumen) Pulmonary AVM (coil embolization) • Osler-Weber-Rendu • Sporadic • Trauma • Infection • Hepatogenic angiodysplasia • Pulmonary pseudoaneurysm (secondary to Swan-Ganz catheterization) Hypothenar-hammer syndrome mimics • Raynaud’s disease • Collagen vascular disease • Embolic disease • Beurger’s disease Budd-Chiari syndrome • Idiopathic • Hypercoagulable states: polycythemia vera. fentanyl). look for cleavage. • Fat necrosis • Lipoma • Hamartoma • Fibrosis • Mastitis/abscess • Pseudoangiomatous stromal hyperplasia • Sutural calcification • Hemangioma • Diabetic fibrous breast disease • Extra-abdominal desmoid • Lymphoma • Angiosarcoma • Metastases: contralateral breast. prior imaging studies. iatrogenic injury Differential Diagnoses atypical cyst aspiration. place BB over suspected location of calcification. but should have a convex pectoral muscle. oxygen saturation. Angiography.
glomerulonephritis. HTN Visceral/renal peripheral microaneurysms • PAN • IV drug abuse-associated vasculitis • SLE-associated vasculitis • Radiation vasculitis • Septic emboli Femoral graft occlusion • Anastomotic stricture • Intraoperative clamp injury • Poor outflow/run-off • Non-compliance with anticoagulation • Hypotensive condition (dehydration) • Hypercoagulable states: pregnancy. sarcoid. trauma.Mesenteric ishemia (occlusive/non-occlusive) • Embolic occlusion: cardiac source • Atherosclerotic plaques with ulceration • Low flow states: hypotension. Wilson’s disease. gallbladder cancer • Umbilical vein catheter (neonate) Portal hypertension • Pre-sinusoidal extrahepatic: portal vein thrombosis. maternal diabetes (child) Renal AVF • • • Penetrating trauma Iatrogenic (biopsy) Neoplasm: RCC. A category 1 lesion is a nonostial lesion with a short (3 cm) focal stenosis Main renal artery aneurysms • Atherosclerosis • FMD • NF-1 • AML • • Infectious cause Post-trauma Renal vein thrombosis • RCC with tumor invasion • Trauma • Amyloid.& postsinusoidal disease can result in falsely NL CSP. nephrotic syndrome • Sepsis. incarcerated hernia • Median arcuate ligament compression (celiac axis>SMA. pyelophlebitis. bleeding. ICA. splenic/mesenteric venous occlusion • Pre-sinusoidal intrahepatic: PBC. pancreas carcinoma. accentuated by expiration) • Dissection of abdominal aorta Non-occlusive mesenteric ishemia mimics • Ongoing hypotension or hypovolemia • Concurrent use of vasoconstrictive medications • Use of ergot alkaloids • Vasculitis Check spasm versus atherosclerosis • Test dose of Priscoline (25mg over 30-60 seconds) Papaverine therapy protocol for non-occlusive ischemia • Test dose of 30-60mg IA over 60-90 min • Then. BuddChiari syndrome • Tumor thrombus: HCC. vasovagal • Venous thrombosis seen in volvulus or intussusception. pancreatitis. NF-1 For renal PTA. 1mg/min for 12-24 hours Medications. septicemia. lymphocele Dialysis fistulagram with UE venogram A failing hemodialysis graft may cause increased venous pressures or abnormal urea circulation. dehydration. RCC. hepatitis). PAN. lupus coagulopathy Vascular graft complications • Perigraft infection. iliac source • Aneurysm • Adventitial cystic disease • Thromboangiitis obliterans (Beurger’s disease) with Martorell’s sign of corkscrew collaterals following course of occluded vessels • Jogger’s aneurysm (postchronic trauma) • Extrinsic compression by popliteal fossa mass Portal vein thrombosis • Idiopathic • Bland thrombus: portal hypertension. Use CO2 if possible. sclerosing cholangitis • Post-sinusoidal: Budd-Chiari syndrome Corrected sinusoidal pressure (CSP) • Wedge hepatic venous pressure – Free hepatic venous pressure (CSP= WHP-FHP) to approximate portal venous pressure • <5 NL • 5-10 mild • 10-15 moderate • >15 severe • Remember: pre. pancreatitis. Balloon should be 10-20% larger than NL vessel (except aorta where one should underdilate). congenital hepatic fibrosis. visceral. iliac. NTG to avoid spasm. PCV. The thrill may be diminished or newly pulsatile. Balloon length should be <1cm on either side of lesion. abdominal aorta and its major branch vessels • Type 3: types 1 & 2 • Atherosclerotic disease • Embolic occlusion: cardiac. as contrast can extravasate Renal artery disease • Atherosclerosis • Fibromuscular dysplasia • Arteritides: Takayasu’s disease. oral contraceptive use. poor cardiac output. perigraft leak • Anastomotic pseudoaneurysm • Aortoenteric fistula • Hematoma. dehydration. supravalvular/abdominal aortic stenosis) Takayasu’s disease • Type 1: aortic arch and brachiocephalic vessels • Type 2: descending thoracic aorta. perimedial. 4mm balloon in segmental artery. and rarely vertebral arteries Popliteal artery disease • Popliteal entrapment . AML For treatment of a renal transplant AVF or pseudoaneurysm or post-traumatic hemorrhage. aortic. An early RA bifurcation may be problematic. shistosomiasis • Sinusoidal: cirrhosis (alcoholic. vasculitis from radiation therapy or polyarteritis nodosa. protein c & s deficiency. pancreas carcinoma. cross lesion. lymphadenopathy. use heparin. reversal • Protamine sulfate for heparin • FFP for coumadin • Platelets for ASA Middle aortic syndrome • Atherosclerosis • Radiation vasculitis • Rubella-associated vasculitis • Takayasu’s disease • NF-1 • FMD • William’s syndrome (infantile idiopathic hypercalcemia. cholangiocarcinoma. A prosthetic forearm loop interposition graft (PTFE) • Type 4: pulmonary artery Fibromuscular dysplasia • Intimal. The patient may present with renal failure. use a 3F tracker (coaxial microcatheter system) and microcoils (1-20 mm diameter) for superselective embolization. use 6mm balloon in main RA. adventitial fibroplasia • Medial hyperplasia • Medial dissection • Remember: FMD occurs in long straight vessels such as the renal. FMD. Takayasu’s disease. hypercoagulable states. anti-thrombin III deficiency.
decrease to 0. Use a 12-14F chest tube for pleurodesis. diarrhea GI bleeding • Collateral pathways • Celiac axis to SMA: arc of Buehler In lower GI bleeds. A semi-permanent tunneled TESIO dialysis catheter can be placed. consider vasopressin initially. If distal embolization occurs. hyponatremia (seizure).2 units/min.1-0. tetracycline • Internal iliac: 5cc/sec for 25cc • Chemotherapeutic agents: bleomycin. celiac.2units • Complications: coronary artery spasm (MI). A central venous occlusion can cause dialysis graft malfunction. Simmons catheter for selective work with When <100 cc/day drainage. Further evaluation is needed once the patient is stable to determine the cause. then water seal. use an 8F chest tube. For a small a 3F tracker catheter for superselective pneumothorax. After infusion. CA. doxirubicin. Try PTA (10-12 mm balloon). increase to 0. or superselective microcoil embolization via a coaxial microcatheter system. Distal stenosis is usually the cause for graft occlusion. uncontrolled HTN. continue for 12-24 hours. soft tissue tumors or adenopathy • One-leg run-off: 4cc/sec for 48cc Pleurodesis agents • Two-leg run-off: 6cc/sec for • Antibiotics: doxycycline. fracture of clavicle or first Pelvic and lower extremity run off arteriogram rib. place on Pleurowork vac suction. IBD. continue infusion Typical infusion dose of tPA is 1 mg/hour Complications of thrombolysis • Distal embolization • Bleeding around the catheter • Pericatheter thrombus • Bleeding from a distant site GI Bleeding detection rates and Rx • Tagged red blood cell scan: 0. 72cc minocycline.1units/min. remote stroke or GI bleed Attempt thrombolysis via a multiple side hole/endhole Simmons. SOS or coaxial infusion catheter. hematuria • Recent stroke • Metastatic disease (intracranial) • Pregnancy • Use within 6 weeks of major surgery • Relative: recent chest/abdomen surgery. then celiac because contrast-filled bladder may obscure distal bleeding • Celiac axis: large particle or coil embolization • Distal esophagus/gastric fundus: left gastric artery embolization • Distal stomach or duodenum: gastroduodenal artery embolization Vasopressin (ADH) therapy • 0. Selective renal. Venous outflow stenosis and central graft stenosis are common.connects the brachial artery to cephalic vein. angiodysplasia. hemorrhoid/ulcer . SMA. Midstream aortogram for renal arteries (RPO) anomalous first rib.4 units/min at increments of 0. start pleurodesis (bleomycin is commonly used). study again in 20 minutes. then decrease 0. pectoralis • 2-3 frames/sec minor tunnel • IVC: 15cc/sec for 45cc • Compression by NL variants: cervical ribs. Common causes include diverticulosis. marginal artery of Drummond • Internal mammarysuperior/inferior epigastric-external iliac artery • IMA hemorrhoidal branchesinternal iliac artery • Intercostal-lumbar-deep circumflex-external iliac artery Contraindications to thrombolytic therapy • Active GI bleed. costoclavicular space. if necessary. polyp. • Use 5F Cobra. anomalous anterior • 5F Pigtail catheter: 20cc/sec scalene insertion for 40cc • Acquired lesions: muscular hypertrophy. exacerbation of HTN. do angiography through infusion catheter.5cc/min • Do IMA. • Celiac: 6cc/sec for 60cc (or corynebacterium 6/36) • Note: these agents cause • SMA: 6cc/sec for 60cc adhesions between pleural layers • IMA: 2cc/sec for 20cc For simple pleural effusion.1cc/min • Angiography: 0. bowel infarction. scalene minimus muscle. study in 20 minutes • If vasospasm.2 units/min over 8-12 hours • If still bleeding. SMA injection rates mitomycin C • Renal: 5cc/sec for 15cc • Bio agent: IL2. Place a 5F catheter towards the venous end and compress the venous end during injection to opacify the graft and arterial anastomosis. and possibly 12 x 60 Wallstent. an 8F chest tube should suffice. remove the chest tube 50cc Causes of decreased pulse at access site • Hypotension • Vasovagal reaction • Dissection • Hematoma formation • Catheter induced spasm • Embolus Acute arterial occlusion • Pulselessness • Pallor • Pain • Paresthesia • Paralysis Unsuccessful PTA: • Residual stenosis >30% • Residual gradient >10 mmHg or 10% systolic pressure • Large post-PTA dissection flap (flow limiting) • Hard Ca++ plaque Consider stent if: • dissection • • • • Post-PTA flow limiting Long segment stenosis Occlusion Recurrent stenosis after PTA Unsuccessful PTA Popliteal artery entrapment • Type 1: Popliteal artery medial to NL insertion of medial head gastrocnemious • Type 2: Popliteal artery medial to laterally positioned medial head gastrocnemious • Type 3: Compression by accessory slips of medial head gastrocnemious or plantaris muscle • Type 4: Compression by popliteus muscle • • • • • • Blush Encasement Displacement Puddling • SMA to IMA: arc of Riolan. Niemann. cisplatin. if residual stenosis • Ulcerated (complicated) stenosis Angiography tumor features • BEDPAN mnemonic: AV shunting Arch aortogram Neovascularity • 5F pigtail catheter: 20-25cc/sec for 40-50cc Thoracic outlet syndrome (effort thrombosis) • 6F pigtail catheter: 30cc/sec • Impingement at interscalene for 60cc triangle. if no air leak for 24 • Splenic/hepatic: 5cc/sec for hours.
For noninvasive vascular assessment. Popliteal artery aneurysms are bilateral in 60% cases. 3.• Wallstent (self-expanding) 20. 12 months postprocedure For venous access. IVC thrombosis 10%. pancreatitis. consider a transaxillary abdominal aortogram Distal profunda femoris branches to geniculate arteries to popliteal artery is a common pathway in SFA occlusion An aortic spindle is fusiform dilatation of the distal arch/proximal descending thoracic aorta that can simulate ATAI When performing a PAgram. thigh pressures are higher than brachial pressures but 24. air embolization. angioplasty. the goal is a portosystemic gradient of <12 mmHg. it is aneurysmal catheter • Hickman tunneled catheter for 17. IVC filter indications 25. do IVCgram to check IVC caliber. severe encephalopathy. Post-thrombolysis distal embolization can be 29. left-sided IVC. whereas rest pain is <0. but for chronic • S/p surgery for coarctation of changes IR does nothing the aorta 15. The SMA may give off inferior pancreaticoduodenal collaterals. 11. markedly elevated CVP. use microcoils alone or with gel foam For uterine artery embolization. there should be no sepsis or uncorrected coagulopathy. while in subacute/chronic DVT. check celiac/SMA for post. leg. A AAA can be fixed by either bifurcating 23. If no pulses in a posterior knee dislocation. there is a smooth filling defect in the tibial/popliteal vein (for example). velocity measures <50cc/sec. tumor. in cases of post-partum hemorrhage (bilateral internal iliac artery). aspergillus. in cases of bronchiectasis. If no results in 30 • Renal artery: 6 mm minutes. thrombolyse/stent • Atherosclerosis 14.5-0. Then. fixed by thrombolysis. Recanalization and collateral vessels may occur in chronic DVT An AVF occurs in 15-20% renal transplants. intercostal arteries.) 6. varices. Infection may necessitate hysterectomy LE run-off stations are thigh. Then. pseudoaneurysm. which is equal to >50% stenosis from myointimal hyperplasia. PUD with • Post-surgical gelfoam. thyrocervical trunk. For thoracic outlet syndrome. chemotherapy patient goes directly to surgery • TESIO semi-permanent 18. For pulmonary AVM. malposition). 6.6 indwelling catheter. hypervascular liver tumors. AVM. venous stenosis/thrombosis. use gelfoam pledgets for postpartum cases. associated with AAA in 33% cases coil collaterals. If malignant. Watch out for the non-target embolization to the spinal cord For foreign body retrieval. If popliteal artery >7 mm. ABI 26. Subclavian stenosis or occlusion leading to “steal” 30. do NOT stent iliac artery For bronchial artery embolization. For a malignant gastric • Gianturco ulcer. deploy • Use a 5F Cobra catheter in the SMA with a 3F tracker to supraselectively microcoil a jejunal bleed. May cause infarction or origin distal to aortic coarctation 32. “double ligation” Select stent types 19. • PE/DVT in patient with 0. and may present with bleeding. Do not stent these. ulcer. thrombosis. stroke) (16x60 mm) Wallstent • DVT in patient to undergo 9. pregnancy. or tumor. may PTA/thrombolyse or PTA alone. try selective microcoil Miscellaneous facts: embolization via a coaxial microcatheter system. If double 13. Powder causes necrosis leiomyoma. sheath. portal venous thrombosis. There is usually 1 right bronchial artery. AVM. embolize with gelfoam • Common iliac artery: 8 mm • Popliteal artery: 4-5 mm • For a duodenal ulcer or GDA 22. polycystic liver disease. Try vasopressin with gastritis. other measurements in lower extremity are • PE despite adequate lower than brachial pressure anticoagulation 7. Watch Select catheter types out for non-target embolization of spinal artery • Quinton temporary dialysis 34. Might 4. SVC stenosis/occlusion may be due to IVC. Meckel diverticulum. and for presence of IVC dissection. make sure you’re in the true lumen thrombus. do NOT stent. contrast reaction. 2 left bronchial arteries.0. delivery system) is MRI safe alloy XRT. For thrombosis. duodenal bleed with microcoil or PVA. You may get a transient AVF after arterial orthopedic procedure angioplasty. Radiofrequency ablation only works in a 28. PTX. symptomatic fibroids or menorrhagia (uterine artery). use a large surgery. Don’t forget a transjugular splenic venogram at the end to document hepatopedal flow and absent collateral filling For TIPS shunt malfunction. A splenic artery aneurysm (> 2 cm) occurs in 35. Delayed complications include infection. • Post-traumatic injury May thrombolyse acute disease. Typical PTA balloon sizes based on location Mallory-Weiss tear. metastases endoluminal tube graft or onlay graft (melanoma. the 36. give heparin and abx (if sepsis) Knee collaterals via geniculate & sural arteries If diffuse femoral disease. If benign. as they are • Free-floating caval thrombus transient and due to intimal dissection with vaso • History of PE/DVT with 27. dialysis catheter (increased infection rate. foot In an acute DVT. poor (shape) memory. place filters in both cavae. vessel etc. primarily stent with Gianturco or phenomenon 31. Mycotic aneurysms Usually left gastric artery in UGI bleeds 21. IBD. a Simmonnitonol filter (9F delivery system) if brachial vein. renal failure If there are no femoral pulses. 2. by running the wire/catheter down into NL circumaortic left renal vein. renal vein level. Use Brodel’s avascular line for renal biopsy consider vasopressin first in these cases (lateral in coronal plane of kidney) 5. Consider PVA (250-750 microns) for other etiologies. Recurrent mm Hg or >10% systolic pressure PE occurs in 2-4%. Do NOT perform in right CHF. maximum diameter of 5-6 cm Use a Bird’s nest filter if IVC >28 mm. fibrosing mediastinitis. start on the side of clinical/CXR abnormality and use nonionic contrast An iliofemoral graft occlusion reconstitutes via iliolumbar collaterals and the anterior . Immediate complications include hematoma. Kaposi’s sarcoma). use a snare and try to pull to the IVC For hepatic artery bleeding due to trauma. pull it. there is clot retraction with an irregular surface. external jugular or antecubital approach is necessary. catheter dysfunction (fibrin sheath. Venatech (14. Use a large coil or • Aberrant left subclavian artery detachable balloon. or possible active intrahepatic infection. severe hepatic failure. Before stenting for post-angioplasty For IVC filter.8. TB. GI bleed. venous anomalies (double IVC. For multiple renal AMLs. 16. ABI normally is >1. For symptomatic May-Thurner. Gel foam powder is NOT the same as gel foam Common UGI causes of bleeding include pledgets. vasorum communications to vein complication while on anticoagulation 10. try selective microcoil embolization via a coaxial microcatheter system. For claudication. PTA alone and/or place a new 8-12 mm stent. localize lesion. HTN. portal HTN. and may receive • Takayasu’s disease collaterals from internal mammary arteries. wound dehiscence. suction Simmon-nitonol has increased risk of migration. A significant gradient across a stenosis is >10 caval penetration. use platinum microcoils for AVM. Hepatic venous end is most common. • IVDA • Immunocompromised state • Specifically: embolize tumors • Endocarditis with microcoils or PVA. Bronchial arteries • Apical lung neoplasm usually come off at T4-T6. CF. systemic embolization. Use poor flow rate compared to surgical AVF) 8 mm embolization coils distal & proximal. 12.1. check IMA for other bleeding sites For TIPS shunt. Routine shunt surveillance should be at 3. use microcatheter • Palmaz (balloon-expandable): to embolize with PVA (500-700 microns) mount on PTA balloon. 33. place through 37. and PVA in bilateral uterine arteries in other etiologies.4 contraindication to anticoagulation (recent 8. FMD.
potassium aneurysm/tortuosity chloride. drug-induced esophagitis. 51. pemphigoid lymph node enlargement. Use a Simmons/SOS catheter with coaxial infusion catheter A persistent left SVC sweeps behind the left atrium to the coronary sinus or right atrium directly. 50. 46. amyloid. anterior herniation of intervertebral disc. gastric carcinoma. foreign body • Corrosive esophagitis • Inflammatory disease: TB. 45. The sciatic artery continues in the lower extremity to the popliteal. ABI. extrinsic impression • Cricopharyngeus Esophagus. radiation esophagitis • Infectious: candidiasis. lung. then snare it through a sheath. a small liver. arch. hematoma • NL variant in elderly • Anterior marginal osteophyte. narrowing neoplasm. refractory to ESWL.5 cm. left inferior • Inflammation: reflux pulmonary vein esophagitis. • Early achalasia infection. Blue toe syndrome Oncocytoma is bilateral in 6% cases. 39. 42.B. inflammatory esophagogastric polyp. fibrovascular polyp.38. breast or lung metastases. RA. dermatomyositis • Malignancy • Striated muscle disorders: myasthenia gravis • Presbyesophagus Esophageal cancer risk factors Abnormal esophageal motility • ETOH. 52. Crohn’s disease • Candidiasis • Reflux esophagitis • Glycogenic acanthosis • Superficial spreading esophageal carcinoma • Esophageal papillomatosis • Acanthosis nigricans (rare) • Cowden’s disease • Leukoplakia Esophagus. Doppler waveform analysis (velocities. duplication cyst. coarctation of aorta. lower esophageal Thoracic esophagus. post-nasogastric tube intubation. 47. is in the pulmonary artery. The SFA and PFA are usually hypoplastic. scoliosis • Pulmonary mass Esophagus. aberrant right subclavian artery. radiation injury cyst • Epidermolysis bullosa. internal-external. bullous • Mediastinal mass: tumor. 41. (adenocarcinoma) pseudoobstruction. double aortic Crohn’s disease. carcinoma). alcoholism • Head & neck cancer • Achalasia • Tylosis • Chagas disease • Plummer-Vinson syndrome • Scleroderma • Lye ingestion . Watch out for interposed bowel. 55. etc. aggregate stones >2. diverticula • Pharyngeal: Zenker’s (pulsion) • Midesophageal: traction • Distal: epiphrenic (pulsion) • Connective tissue disease: SLE. treadmill stress testing. ulceration • Inflammation: reflux esophagitis. fistula • Congenital. adenoma • Malignant tumor: SCC.5-3 cm A persistent sciatic artery is a branch of the internal iliac artery that is prone to trauma (pseudoaneurysm). tertiary contractions • Postcricoid impression • Presbyesophagus • Thyroid/parathyroid • Diffuse esophageal spasm enlargement • Esophagitis • Lymphoid hyperplasia: allergy. aortic • Drugs: tetracycline. discrete filling defect • Benign tumor: leiomyoma. spindle cell sarcoma. 53. gastric carcinoma with upward extension. or coagulopathy. 48. lymphoma TAPVR • Iatrogenic: post-surgical • Cardiac/pericardial structures: stricture. Barret’s esophagus. tumor. Crohn’s disease • Neoplasm: carcinoma. tobacco • Esophagitis • Achalasia (squamous • Neuropathy: CVA. laryngeal or thyroid carcinoma by direct extension • Varices • Foreign bodies Esophagus. 40. Usually occlusion is due to distal graft stenosis. suspect diabetes Try to position the free end of an intravascular foreign body in the SVC or IVC. effusion. IDDM. eternal Left side is often better due to a longer left intrahepatic duct Internal-external ureteral stent may be helpful as a trial period to see if patient will tolerate the catheter (especially if patient has XRT/chemotherapy cystitis) Most hemangioendotheliomas in children proliferate then involute by 18 months of age Post-XRT stenosis can be delayed several (510) years Transgluteal abscess drainage should be performed as close to the sacrum as possible. consider a transjugular approach PTC drain can be internal. If F. and as caudal as possible Might consider a Wallstent (16 x 60) in the trachea with symphony stents in the bronchi for relapsing polychondritis Might consider antegrade renal stone removal if single stone >2-2. Esophagus. 44. shift). 49. so if you inject the external iliac you won’t see the lower extremity “Restoration of NL lumen caliber without residual stenosis” Differential Diagnoses GI Radiology Cervical esophagus. eosinophilic esophagitis arch. division of the internal iliac artery to the CFA. and has the central stellate scar on imaging and a hypervascular spokewheel appearance on angiography Intimal cracking is expected with PTA If there is distal profunda femoris and multifocal distal tibial/pedal arterial disease. lymphoma. • Intramural esophageal neurenteric cyst with hemivertebrae. cervical aortic arch. spontaneous. adenocarcinoma. 43. bronchogenic carcinoma • Perforation: iatrogenic. then snare it For a percutaneous liver biopsy (22g CHIBA needle). TB. • Aortic structures: right aortic Barret’s esophagus (reticular mucosa). go through NL liver to avoid causing a large hematoma. papilloma. try a pigtail or SOS catheter to pull it into the SVC or IVC. quinidine • Nonaortic vascular structures: • Neoplasm: SCC. aberrant adenocarcinoma. A left vertical vein in supracardiac TAPVR is fused pulmonary veins that drain into the left brachiocephalic A transthoracic biopsy for suspected lymphoma should be done with a Shure cut biopsy needle to yield an adequate sample for subtyping Noninvasive vascular evaluation includes segmental limb pressures. breast left pulmonary artery (pulmonary sling). inflammation • Esophageal web (PlummerVinson syndrome). HIV. corrosive esophagitis. If there is significant ascites. 54. nodules Esophagus. lymphoma • Mimics: intramural pseudodiverticulosis. extrinsic impression ring/Schatzki ring • Normal structures: aortic arch. and lung metastases. polymyositis. • Infection: candidiasis left mainstem bronchus. ascorbic acid. spina pseudodiverticulosis bifida. for which balloon angioplasty can be performed. s/p TEF repair (neonates) • Malignancy: esophageal carcinoma after radiation therapy. scleroderma postvagotomy syndrome. CMV. left atrium and ventricle. Mallory-Weiss tear Esophagus. corrosive esophagitis. actinomycosis. histoplasmosis. post-tonsillectomy • Neuromuscular disorders • Abscess. herpes. or the gall bladder.
metastatic disease • Malignant tumor: pancreas or Crohn’s disease. acute ulcer mound. Kaposi’s sarcoma. obstruction • Gastroplasty (weight • Congenital: duodenal atresia. Cowden’s disease) strongyloidiasis. aspirin. Stomach. • PUD lipoma. Crohn’s Clostridium perfringens. foreign body diverticulum (wind sock deformity). ASA • Gastric pneumatosis • Varices. pancreatitis. • Intramural hematoma: child CMV Linitis plastica (leather bottle) abuse. diaphragm. lipoma. vagotomy. chronic granulomatous disease of childhood. obstruction • Benign tumor: leiomyoma. • Jejunogastric intussusception leiomyosarcoma. artery). • Prolapsed antral mucosa corrosive • Laryngocele • Brunner’s gland hyperplasia • Ischemia • S/p total laryngectomy • Benign lymphoid hyperplasia • PUD with intramural • Post-radiation therapy • Hypertrophic gastric mucosa perforation (focal) • Enlarged papilla Stomach. lymphoma. carcinoid. outpouching/ulceration chemotherapy (infusion into hepatic bulbar diverticulum • Benign: PUD. carcinoma • Varices • Extension of pancreas disease • Pseudolymphoma radiation-induced ulcer. granulomatous gastritis (TB. metastases (“bull’s eye” lesion with melanoma. pyloroplasty • Procedures for motility: cricopharyngeal myotomy. metastases amyloidosis. E. ampullary carcinoma. eosinophilic gastritis • Bezoars • Polyarteritis nodosa • Afferent loop syndrome Duodenum. clostridium). polyp. foreign body Pharyngeal mass Gas in wall of stomach • Ectopic pancreas (“bull’s eye” • Malignancy • Severe gastritis: infectious lesion) • Mucous retention cyst (hemolytic streptococci. Stomach. TB • Menetrier’s disease • Infiltrative processes: amyloidosis. other medications). lymphoma. duodenal carcinoma. intraluminal • Bezoar. chronic pancreatitis. • Duplication cyst gallbladder.Esophagus. Zollinger-Ellison syndrome • Neoplasm: lymphoma. reduction) Stomach. varices. hamartoma postbulbar ulcer. Belsey Mark 4 fundoplication. acute • Benign tumor: prolapsed antral • Malignant tumor: pancreatitis. Granulomatous disease (TB. Anisakis worm) • Chronic erosive gastritis • Granulomatous gastritis: Crohn’s disease. direct extension inflammatory mass • PUD from pancreas. candida. staphylococcus. Angelchik prosthesis (sialastic) • Antivarices: esophageal resection and reanastomosis with splenectomy. Complications of Bilroth procedure breast metastases prolapsed/intussuscepted antral polyp • Marginal ulcers • PUD • Variable malignant potential: • Carcinoma at gastric stump villous adenoma. pseudocyst • Inflammatory disorders: leiomyosarcoma. (breast. filling defects • Pseudo tumors: flexural pseudolesion. TB. Cronkite-Canada)/villous adenoma . Ladd’s bands. direct anastamosis (EA) • Antireflux: Nissan fundoplication. neurofibroma duplication cyst. pancreas carcinoma (Peutz-Jegher’s. leiomyoma. fold thickening • Carcinoma • Crohn’s disease • NL variant • Eosinophilic gastroenteritis • TB • Acute gastritis: ingested agents • Radiation • Aortoduodenal fistula (ETOH. pyloric stenosis. leiomyoma. Crohn’s disease) adenocarcinoma. preduodenal portal vein • Malignant tumor: • Polyps: hyperplastic (Cronkite• Inflammatory disorders: antral/pyloric channel carcinoma. corrosive agents (acid or alkali). • Malignant tumors: • Retained gastric antrum sarcoidosis. Kaposi's • Infiltrative processes: (Bilroth 2) sarcoma. lymph node and • Infection: TB hematogenous metastases Stomach. Hodgkin’s lymphoma > NHL. midgut volvulus. • Mimics: ectopic pancreas. pseudolymphoma. Heller myotomy (with Belsey 2700 fundoplication) Duodenum. • Ectopic pancreas • Superior mesenteric artery gastric duplication • Thickened folds simulating syndrome (rapid weight loss) • Gastric volvulus. (varioliform) erosions • Gastric outlet obstruction • Choledochocele • ETOH • Iatrogenic: endoscopy. Crohn’s disease. Streptococcus. colonic interposition. polyp adenocarcinoma. Proteus. carcinoid tumor • Acute gastritis (iron (bile reflux) intoxication). infection (a-hemolytic • GUTED mnemonic: granulomatous disease. breast. Kaposi’s sarcoma) Gastric cancer risk factors • Chronic atrophic gastritis • Pernicious anemia • Bilroth II • Adenomatous polyp (FAP. hypertrophic nodules: Menetrier’s disease. right colon. pneumococci. syphilis duodenal carcinoma. gastritis. mesenteric arterial • Crohn’s • Bulla ruptured into esophageal collaterals wall • Viral/fungal infection: candida. lymphoma. diverticula • Malignant: carcinoma. gastric bezoar inflammatory or infectious gastritis Postbulbar ulceration • Mimics: gastroparesis • Peptic ulcer disease • PUD (edematous mass) Gastric antral narrowing • Zollinger-Ellison syndrome • Eosinophilic granuloma • Benign tumors (inflammatory fibroid polyp) • SPICER mnemonic: • Malignant tumors: primary • Extrinsic cystic or • Sarcoidosis. Canada). nontropical sprue. leiomyosarcoma. metastases cholecystitis. melanoma. MVC • Mimics: barium precipitates • Malignant: scirrhous • Benign tumors: adenomatous carcinoma. right kidney.coli. steroids. eosinophilic gastroenteritis • PUD. surgical procedures • Reconstruction: gastric pullthrough. adenomatous. filling defects annular pancreas. surgery • Duplication cyst • NSAIDS. corrosive stricture lymphoma) • Intramural hematoma • Antral mucosal diaphragm. lymphoma. lung.
ascites. leiomyoma. giardiasis . uremia (chronic dialysis). proteinmastocytosis. metastatic replacement of pancreas. CHF). strongyloidiasis. amebiasis. Yersinia • Inflammation: appendicitis. MAC • Mastocytosis • Amyloidosis • Giardiasis • Typhoid Predominantly duodenal and/or jejunal • Sprue • Cystic fibrosis • Whipple’s disease • Giardiasis • Cryptosporidiosis • ZE syndrome • Strongyloidiasis Predominantly jejunal and/or ileal • Amyloid • Lymphoma • Graft-versus-host disease Predominantly ileal • Crohn’s disease • TB. melanoma. intraperitoneal seeding by ovarian. ZE syndrome. trauma. ovary. • Inflammatory disorders: PUD. ZE syndrome • Infiltrative: Eosinophilic Duodenum. parasitic infection (giardiasis. lymphoma. (nephrotic syndrome. Peutz-Jegher’s syndrome) • Metastases: hematogenously by breast. giardiasis. amyloid. pancreas pseudocyst. Henoch• WHILMA mnemonic: Schonlein purpura) • Whipple’s disease • Cystic fibrosis • Lymphoma. hypercoagulable states • Spontaneous DILATED small bowel with NL FOLDS • Obstruction • Post-vagotomy • Ileus • Scleroderma • Sprue (celiac. • Peritonitis Cryptosporidiosis. abetalipoproteinemia ZE syndrome. liver disease. pancreatic. ishemia (radiation. lymphoma. NODULES on folds collagen vascular disease. Paralytic ileus Abetalipoproteinemia • Ps mnemonic: • Other: Giardiasis. nontropical sprue • Neoplasm: lymphoma. cholecystitis. hamartomatous polyp • Malignant tumor: carcinoid. disease. Crohn’s disease. pancreatitis. • Neoplasm: lymphoma. ileal • Eosinophilic enteritis: stomach. angioneurotic edema. Yersinia. hemophilia). amyloidosis. • Vascular disorders: duodenal lymphangiectasia varices. Ulcer disease (PUD. lipoma. adrenal. • Macroglobulinemia. Whipple’s disease. hemangioma (TS. regular (fluid) • Blood: coagulation defects (anticoagulation. typhoid fever. direct extension by RCC. Brunner’s gland • Infectious: TB. intramural • Graft-versus-host disease hemorrhage. hyperplasia.disease). typhoid fever Other patterns • Sprue: duodenal. OWR. ZE syndrome). malignant. eosinophilic enteritis. metastatic). reactive • Cystic lymphangioma of the mesentery • Mesenteric arterial collaterals • Aortic aneurysm • Choledochal cyst DILATED small bowel with THICK FOLDS • Ischemia • Hemorrhage • Radiation therapy • Crohn’s disease • ZE syndrome • Lymphoma • Whipple’s disease • Amyloid • Abetalipoproteinemia Simplified small bowel folds. MAI. widened sweep • NL variant • Pancreatitis. leiomyosarcoma. emboli. pancreas carcinoma. TB. GI metastases to peripancreatic lymph nodes tumors). surgery). Tumor (benign. Mets • Amyloid. losing enteropathy). mesenteric arterial collaterals • Cystic fibrosis pancreaticodudenal arcade). appendix. mastocytosis. mesenteric lymphatic or venous obstruction. venous or lymphatic intestinal lymphangiectasis obstruction. abnormal folds enteritis. PCV. Turner’s syndrome. blue rubber bleb nevus syndrome). metastases (melanoma. Lymphangiectasia. diverticulitis. Yersinia. histoplasmosis. breast. ischemia. Kaposi’s sarcoma. • Edema (hypoproteinemia. typhlitis • Neoplasm: adenocarcinoma. infarction • Edema: hypoproteinemia (cirrhosis. • Pneumonia Eosinophilic gastroenteritis • PUD • Perforation Wet bowel (malabsorption) • Pancreatitis • Sprue • Pyelonephritis • ZE syndrome • Pregnancy • Menetrier’s disease • Pendix • Giardiasis • Porphyria • Whipple’s disease • Potassium deficiency • Post-operative Gastric and small bowel thickening Ischemic enterocolitis • VINTS mnemonic: • Vasculitis • Incarceration: hernia. Lymphoid hyperplasia venous or lymphatic obstruction. lymphoma • Ulcerative colitis NORMAL caliber small bowel with THICK FOLDS • Vascular: ischemia. carcinoid (ileum) • Diffuse infiltrative diseases: • Edema: hypoproteinemia Whipple’s disease. actinomycosis (history penetrating trauma. cirrhosis. MAI/CMV strongyloidiasis). all small bowel Terminal ileum narrow with abnormal cecum • TB • Crohn’s disease • Lymphoma • Carcinoid • Post-radiation • Ischemia Small bowel filling defect • Benign tumor: adenoma. Crohn’s cryptosporidiosis. Menetrier’s disease). CMV. lung. Diverticulum Duodenum. volvulus • Non-occlusive mesenteric ischemia: shock. hemorrhage. RCC. CHF • Thrombosis: atherosclerosis. chronic duodenal congestion (portal HTN. tropical) • • • • • • MALEZ mnemonic: Menetrier’s disease Amyloid Lymphoma Eosinophilic enteritis ZE syndrome Simplified small bowel folds. adenocarcinoma (rarely seen in sprue. angioneurotic edema Mastocytosis. irregular (cells) • Lymphoma • Metastases • Crohn’s disease • Whipple’s disease • CF • Cryptosporidium. colon carcinoma) • Intussusception: melanoma metastases Coned cecum • Crohn’s disease • Infection: TB. cystadenoma/cystadenocarcinoma • Lymph node enlargement: metastases. radiation therapy • Inflammatory: Crohn’s disease. Ectopic pancreas.
small (<1 cm). Gastric hyperplastic polyps are usually • Neoplasm: lymphoma.Colon. hyperplastic polyp. • Radiation colitis (late) thyroid disease) • Ischemic colitis (late) • Colitidies with inflammatory polyps: ulcerative colitis. infectious cholangitis (pyogenic cholangitis. All residents HATE doing GI exams Colon. hematogenous by melanoma. diverticular abscess • Other: intussusception. All residents HATE doing GI exams Yersinia. 2. lipoma. medullary sponge kidney (80% associated with Caroli’s disease) • Choledochal cyst (child) • Bacterial cholangitis • AIDS cholangitis: CMV. hemangioma Colon. lymphoma. lymphogranuloma venerum • Vascular: ischemia. All residents HATE doing GI exams • Amebiasis. breast. ulcerative colitis. All residents HATE doing GI exams • Lymphogranuloma venerum (Chlamydia) Colon. drugs adenomatous polyposis (Gardner’s syndrome. Mirizzi’s syndrome Intraluminal filling defect in CBD • Choledocholithiasis • Pseudocalculus: sphincter of Oddi spasm • Air bubble • Cholangiocarcinoma • Hemobilia: recent trauma or intervention (TIPS. hernia • Toxic megacolon: ulcerative colitis • Cirrhosis: hepatic. All residents HATE doing GI exams • Crohn’s disease 6. recurrent pyogenic cholangitis. All residents HATE doing GI exams Colitis cystica profunda. stricture (iatrogenic. Crohn’s disease. clonorchiasis). hemangioma • Malignant tumor: adenocarcinoma. Turcot’s syndrome. multiple. diverticulitis. CMV. segmental narrowing • Malignant tumor: adenocarcinoma. TB. ulcers 5. PTC) • Parasitic infection • Sludge ball Differential Diagnoses Abdominal Viscera Imaging Biliary tract/GB dilatation • Obstruction: stones. intramural hemorrhage. AIDS cholangitis. ampulla). lymphoma. appendix (inverted stump. All residents HATE doing GI exams • Ulcerative colitis 7. hepatic artery chemotherapy • Postinflammatory: sclerosing cholangitis. mucocele) Colon. adhesions. thumbprinting • Vascular: ischemia. amebiasis. kidney cancer. gallbladder. multiple • Ischemia (low flow states) • Polyposis syndromes: Familial • Ileus: metabolic. Peutz. hemolytic-uremic syndrome • Advanced colitis: ulcerative colitis. periportal adenopathy • Caroli’s disease: ARPCKD. volvulus. intussusception. radiation colitis • Other: endometriosis. ameboma. • Cathartic abuse Cronkite-Canada syndrome. noncontiguous spread by mesocolon in pancreas carcinoma and gastrocolic ligament in stomach cancer. Miscellaneous facts: pseudomembranous colitis 1. pseudomembraneous colitis • Neoplasm: lymphoma. Crohn’s colitis. dilated • Obstruction: carcinoma. postinflammatory). SCC. smooth (ahaustral) Jegher’s syndrome. lung). pancreatitis. clonorchiasis. s/p papillotomy during ERCP • Cholecystoenteric fistula from gallstone erosion (gallstone ileus) • Duodenal ulcer perforation into gallbladder • Gallbladder carcinoma perforation into GI tract • Septic cholangitis (uncommon) Choledochal cyst classification Type 1: fusiform dilatation of extrahepatic duct Type 2: mid-distal ductal diverticulum Type 3: choledococele Type 4: intra. Cowden’s disease (breast. prostate.Colon polyps. pancreatitis • Malignant neoplasm: cholangiocarcinoma. CMV • Behcet’s syndrome 9. Shigellosis. metastases • Other: pneumatosis cystoides coli • Amyloidosis Colon. Familial polyposis coli). 8. carcinoma (bile duct. diverticulitis. All residents HATE doing GI exams cystoides intestinalis 4. carcinoid • Inflammatory/infectious: Crohn’s disease. uterine. recurrent pyogenic cholangitis Pneumobilia • Iatrogenic: surgical fistulization. ovarian. primary biliary cirrhosis Biliary stricture • Iatrogenic: surgery. traumatic hematoma. cryptosporidiosis • Sclerosing cholangitis (diverticula) • Clonorchiasis (spares extrahepatic ducts) • Recurrent pyogenic cholangitis Narrowed or thick-walled ducts • Sclerosing cholangitis (diverticula with beaded ducts is classic) • AIDS cholangitis: CMV. cryptosporidiosis • Cholangiocarcinoma: bacterial cholangitis. on a background of Kaposi’s sarcoma chronic atrophic gastritis • Other: lymphoid follicles. cloacogenic carcinoma • Infection: ameboma.and extrahepatic duct involvement Type 5: Caroli’s disease (intrahepatic ducts) Gallbladder intraluminal filling defect/mass • Gallstones • Sludge • Hemobilia: trauma. pancreas. HCC • Extrinsic compression: periportal adenopathy. metastases (direct extension by cervical. Juvenile • Ulcerative colitis polyposis. bleeding diathesis • Parasitic infection: ascariasis • Cholesterol polyp . solitary filling defect • Benign tumor: adenoma. pneumatosis 3. carcinoid.
cholangiocarcinoma (lobar atrophy). metastases (mucinous adenocarcinoma of lung. macrocystic adenoma. islet cell tumor (insulinoma. tyrosinemia Portal hypertension • Extrahepatic presinusoidal: portal vein/splenic vein occlusion (pancreatitis. hepatic radiation therapy • Cirrhosis • Right-sided venous congestion: CHF. AVM. lung. cystic neoplasm (microcystic adenoma. amebic abscess. focal fatty infiltration. choledochal cyst (child) • Vascular: pseudoaneurysm (bx. gastrinoma. cystic metastases (lung. hematoma. lymphangioma • Mimics: splenic artery aneurysm Pancreas mass/focal abnormality • Neoplasm: epithelial (ductal Liver with echogenic parenchymal foci adenocarcinoma. acinar cell carcinoma. lymphoma. PCP. infection. ↓T2 • Posthepatic postsinusoidal: Budd-Chiari syndrome. • Intrahepatic sinusoidal: glycogen storage disease cirrhosis (ETOH. neuroblastoma) • Other: intrahepatic choledocholithiasis (recurrent pyogenic cholangitis). meconium peritonitis) Liver mass with central scar • Fibrolamellar HCC (calcified scar) • FNH • Hemangioma (giant >5cm) Liver with diffuse increased attenuation • Thorotrast • Hemochromatosis • Amiodarone therapy • Gold therapy • Wilson’s disease • Glycogen storage disease Liver cysts • Cystic neoplasm: metastases (choriocarcinoma. metastatic melanoma. histoplasmosis. AIDS. GI tract. FNH • Malignant neoplasm: HCC. adenoma • Sloughed mucosa: acute cholecystitis Gallbladder wall abnormality • Cholecystitis: acute. melanoma). focal fatty sparing. stomach. phleboliths/calcified thrombus (hemangioma). mucinous pancreatic carcinoma. intraabdominal sepsis (bacteroides in appendicitis. etc. VIPoma. while dysplastic nodules are ↑T1. trauma. colon. Liver calcifications • Infectious: Echinococcus. chronic ETOH abuse (cirrhosis) hepatitis Parasitic infection (shistosomiasis) • Aflatoxin. CMV solid and cystic papillary epithelial • Intrahepatic ductal stones: tumor). echinococcal cyst • Posttraumatic hematoma/biloma • Developmental: congenital cyst (ADPCKD). CF. hepatic infarct • Benign neoplasm: cavernous hemangioma. insulinoma. pancreatitis). intrahepatic cholangiocarcinoma. CBD by gallstone or duodenal ulcer prostate) • Portal venous gas: pneumatosis • Inflammatory: acute intestinalis (high amplitude spikes on pancreatitis. constrictive pericarditis Liver geographic lesion • Infarct: s/p transplant • Focal fatty infiltration • Focal fatty sparing • Radiation change Portal vein thrombosis • Idiopathic • Secondary: tumor (HCC). cancer. pseudocyst. recurrent pyogenic cholangitis pancreaticoblastoma. infection). sphincter of Oddi. chronic • Hyperplastic cholecystoses: adenomyomatosis. macrocystic adenoma/adenocarcinoma. RCC. parasitic abscess. hepatic artery aneurysm. hepatoblastoma. glucagonoma. cholesterolosis • Gallbladder carcinoma • Porcelain gallbladder (20% risk cancer) • Gallbladder varices • Metastatic melanoma • Non-specific wall thickening: cirrhosis. HCC) • Intrahepatic presinusoidal: congenital hepatic fibrosis. fibrolamellar HCC (in central scar). hepatitis. hepatitis. small cell carcinoma). hematologic disorders Livers masses (not cystic-appearing) • Non-neoplastic: pyogenic abscess. ovary. emphysematous. clotting disorder adenocarcinoma. granulomatous disease (TB. polycythemia vera. IVC obstruction Pancreas cystic lesions • Pseudocyst Liver with diffuse increase in echogenicity • Simple cyst: ADPCKD. arterioportal fistula (trauma. sclerosing cholangitis (IBD) hypointense. erosion into metastases (breast. solid and cystic papillary epithelial tumor. Caroli’s disease. a-1-antitrypsin deficiency • Thorotrast. • Fatty infiltration VHL • Cirrhosis • Abscess • Hepatic fibrosis • Neoplasm: necrotic • Gaucher’s disease • Hemochromatosis Liver with diffuse abnormal enhancement • Budd-Chiari • Hepatic venoocclusive disease: s/p BMT. peliosis hepatis (bacillary angiomatosis): TB. injury). • Pneumobilia: incompetent somatostatinoma. HCC. MAI. biliary cirrhosis. acalculous. mesenchymal hamartoma.• Polypoid tumor: gallbladder carcinoma. melanoma. • Prior infection: TB. CHF. hemochromatosis/Wilson’s Regenerating hepatic nodules are classically T1/T2 disease). surgery. regenerating nodule. microcystic adenoma. CMV • Tumors: cysts. shistosomiasis • Other: Wilson’s disease. renal failure. capsular calcification (hematoma. angiosarcoma (thorotrast) Hypervascular metastases in the liver • Choriocarcinoma • RCC • Carcinoid • Islet cell tumor • Thyroid carcinoma • Hepatitis (portal triads stand out in relief) HCC risk factors • • • • HEPATO mnemonic: Hemochromatosis. histoplasmosis). adenoma (OCP use). metastases. biliary cystadenoma/cystadenocarcinoma (rare). undifferentiated embryonal carcinoma • Infection: pyogenic abscess. adenoma/HCC with hemorrhage. abscess Doppler study) . leiomyosarcoma. primary biliary cirrhosis. PCP. MAI. trauma. ovary.
• Germ cell neoplasms: Klippel-Trenaunay-Weber syndrome teratoma. seminoma. LSD • Thyroid lesions • Idiopathic • Cystic hygroma • Large NL thymus in young • Radiation child • Tumors: lymphoma Low density retroperitoneal lymphadenopathy • Treated lymphoma • TB/MAI infection • Whipple’s disease • Testicular non-seminoma • Squamous cancer of the GI tract Miscellaneous facts: 1. 6. hemangioma • Calcified cyst: old hematoma. caustic ingestion. neonate • Chylothorax. Malrotation Bowel obstruction lead point may be due to a duplication cyst. lateral meningocele • Diaphragmatic hernia • Extramedullary hematopoiesis: thalassemia. Klebsiella). y/o usually) sansert.5T magnet Posterior mediastinal mass • Neurogenic tumors: neuroblastoma. • Hamartoma embryonal cell carcinoma. pseudocyst • Neoplasm: microcystic adenoma. macrocystic adenoma/adenocarcinoma. Chlamydia. ergots. ganglioneuroma. echinococcal cyst • TB. pneumonitis (AIDS) metastases like melanoma) • Varicella pneumonia • Langerhan’s cell histiocytosis Splenic solid mass • Sarcoma (angiosarcoma) Viral pneumonia in a child (RSV. newborn • Intestinal atresia • Hirschsprung’s disease (partial or total) • Meconium ileus • Meconium plug • Malrotation • Incarcerated inguinal hernia (thickened inguinoscrotal fold) • Intussusception • Imperforate anus (VACTERL) • AIM mnemonic: Atresia. melanoma Anterior mediastinal mass • Hemangioma: sporadic. >40 • Drugs: methysergide. staphylococcus. ovary.3 sec and its multiples (4. • Epidermoid cyst (congenital) coli. hemophilia • Epiglottic cyst. • Lymphoma pertussus) mimics include CF. meconium ileus. NHL) • Aneurysm • Thymoma (rare in child. other Therapeutic enema: meconium ileus. PCP • Vascular: infarct (SCD. pancreas) Cystic lung lesion • Congenital lobar emphysema Metastases that calcify • CCAM • CHOMP mnemonic: • Bronchopulmonary dysplasia. meconium plug syndrome. lung. E. splenic artery aneurysm Splenic calcifications • Infection: TB. pleural effusion • Congenital cystic adenomatoid malformation • Congenital lobar emphysema • Pulmonary agenesis/aplasia • Congenital diaphragmatic hernia • Neoplasm: neuroblastoma. ganglioneuroblastoma. GI) • Langerhan’s cell histiocytosis • Papillary thyroid carcinoma • Cystic fibrosis • Pneumatocele: postinfectious Splenic cystic mass (coccidiodomycosis. Chemical shift MRI (In/Opposed phase imaging) is in phase at 2. islet cell tumor • Vascular: splenic artery. echinococcal disease • Metastases: colon. BPD. lymphoma • Hemorrhage • Hemangioma Enlarged epiglottis • Epiglottitis (H. nerve sheath tumors • Dural ectasia.2. papilloma Gasless abdomen • Isolated esophageal atresia: sporadic. Meconium.Pancreas calcifications • Chronic pancreatitis: hereditary form. Imperforate anus. Meckel’s diverticulum. bacterial endocarditis). teratoma • Cervical neuroblastoma • Rhabdomyosarcoma • Cystic hygroma • Lymphadenopathy: reactive. intussusception (perform hydrostatic or air enema if no free air or peritoneal signs) Bubbly right lower quadrant • Meconium ileus • Ileal atresia • NEC • Hirschsprung’s disease Meckel’s diverticulum • Rule of 2’s: • 2% population • 2x male > female • 2 feet from ileocecal valve • 2 types mucosa (gastric. Wilson-Mikity syndrome • Chondrosarcoma • Congenital diaphragmatic • Osteosarcoma hernia • Mucinous adenocarcinoma • Papillomatosis (ovary. splenic artery (with or without aneurysm). histoplasmosis. Down’s syndrome • Severe peritonitis • Congenital diaphragmatic hernia (scaphoid abdomen) • CNS abnormality: intracranial hemorrhage • Vomiting • Paralysis (on ventilator) Double bubble • Duodenal atresia/stenosis • Malrotation with midgut volvulus or Ladd’s bands • Duodenal web • Preduodenal portal vein • Annular pancreas • Duodenal duplication Dilated bowel. choriocarcinoma. ovarian cancer Differential Diagnoses Pediatric Radiology Unilateral opacified hemithorax.3. cyst. fungal infections • Inflammation: pancreatic • Sarcoidosis pseudocyst • Lymphocytic interstitial • Cystic neoplasm (primary. endodermal sinus tumor (all less common) Retroperitoneal fibrosis • Lymphoma (Hodgkin’s • A DIRT mnemonic: disease. Intussusception. ingestion. aspiration pneumonia • Metastases: breast. etc) using a 1. Aganglionosis (Hirschsprung’s disease).1-2. trauma degenerated infarct Milliary interstitial disease • Infection: abscess. influenza) • Angioneurotic edema (AD) • Omega epiglottis (NL variant) • Trauma/hemorrhage: foreign body. post hydrocarbon • Posttraumatic: hematoma. hereditary spherocytosis • Neurenteric cysts (spinal dysraphism) Retropharyngeal mass • Retropharyngeal cellulitis/abscess . Incarcerated inguinal hernia.
• 2 cm diameter • You have to look at a SBFT 2x as hard because it’s 2 fucking small 2 see Extrinsic rectal mass • Duplication cyst • Sacrococcygeal teratoma • Anterior meningocele • Tumors: neuroblastoma. if thrombocytopenia. pheochromocytoma. • Pheochromocytoma: MEN • Bacterial hyperparathyroidism syndrome. Caffey’s disease. mimics • Trauma • Adrenal carcinoma rhabdomyosarcoma) • Adenoma Wormian bones • Neuroblastoma (if VIP. child Verner-Morrison syndrome) • I CHOP PORK mnemonic: • Rhabdomyosarcoma • Teratoma (retroperitoneal) • Hemangioma • Idiopathic (NL until 1y/o) • Abscess • Neurofibroma • Cleidocranial dysplasia • Pheochromocytoma • Hypothyroidism Adrenal calcification • Eosinophilic cystitis (due to • WHAT mnemonic: allergy. or as months old. child maternal diabetes. sepsis muscles. obstruction: abnormal muscle or fibrosis. hypoxemia. siblings of child with VUR. leptospirosis. mimics • Osteogenesis imperfecta rhabdomyosarcoma) • Waterhouse-Friedrickson • Pyknodysostosis. • Fanconi’s anemia (+/. • Pachydermoperiostosis Periosteal reaction lipoidosis. traumatic. Wolman’s syndrome (AR. check for intracranial bleed) • Mesenteric/omental cyst: • Ureteropelvic junction congenital. urinary tract dilatation. glycogen • Osteofibrous dysplasia disease) storage disease. Wimberger ring) • Hypervitaminosis A • Trauma: child abuse • Leukemia • Osteomyelitis • SCALP mnemonic: Scurvy. • Generalized dysplasias tyrosinemia (> 5 years) • Autosomal recessive • Osteogenesis imperfecta polycystic kidney disease • Mesenchymal hamartoma • Hypophosphatasia (cystic). • Choledochal cyst Cushing’s syndrome • Primary megaureter • Hydropic gallbladder: • Trauma • Prune-Belly syndrome Kawasaki’s disease. idiopathic. idiopathic. DIC: Tibial bowing follow-up in either sex (1/100th radiation of VCUG) Kassabach-Merrit syndrome. leukemia. can cause • NF-1 (anterior bowing) CHF) • Fibrous dysplasia Bilateral enlarged kidneys • Hepatoblastoma (< 3 years) • Congenital bowing • Nephroblastomatosis • Hepatocellular carcinoma: (posteromedial bowing) • Lymphoma (NHL>Hodgkin’s chronic hepatitis. acid • Gastroesophageal reflux (barium. adrenal cortical carcinoma Medullary nephrocalcinosis. Wilson’s disease. medial proximal tibia) • Prostaglandin therapy • Scurvy (white line of Frankel. child abuse. fatal) • Otopalatodigital syndrome • Physiologic • Hemorrhage • Rickets (healing) • PGE2 • Addison’s disease: TB • Metastatic disease: • Kinky hair syndrome adrenalitis neuroblastoma. • Eosinophilic cystitis (due to • Idiopathic NF-1 allergy. infectious. cirrhosis. • Steroids • Hemorrhagic (E. prolonged (deficient anterior abdominal wall • Metastases: neuroblastoma hyperalimentation. distal type • Hyperparathyroidism • William’s syndrome • Steroids • Immobilization • Hypophosphatasia Esophageal stricture • Caustic ingestion: lye.thumb) neoplastic crossing vessels or bands • Holt-Oram syndrome • Ovarian cyst (neonate) • Vesicoureteral reflux • Cornelia De Lange • Hepatic or renal cyst • Posterior urethral valves • Myositis Ossificans progressiva Focal hepatic lesion Start with US. Pelekan beak. sepsis. physiologic . Bladder mass. coli) hypovolemia • Cytoxan • Hypothyroidism. progeria disease. 24 hour pH probe. syphilis. undifferentiated embryonal • Bilateral Wilm’s tumors (5• Osteomalacia/rickets sarcoma (cystic. older child/adolescent) 10% cases) • Leukemia Slipped capital femoral epiphysis Adrenal masses • SHIT mnemonic: • Hemorrhage: birth trauma. Cystitis. hypervitaminosis A. Tc-labelled sulfur colloid) • Epidermolysis bullosa (rare) Echogenic renal pyramids • Chronic granulomatous disease • Renal failure with precipitation Vertebra plana of childhood • Langerhan’s cell histiocytosis of Tamm-Horsfall proteins • S/p esophageal atresia surgery • Leukemia (ALL)/lymphoma • Papillary necrosis • NG tube • Idiopathic juvenile • CMV. child • Lasix • Barter’s syndrome • RTA. then VCUG to exclude VUR and • Dystrophic dwarfism posterior urethral valves in males. Start with NUCS • Hemangioendothelioma (<6 study in females. steroids. Trummerfeld lucent band. candida infection osteoporosis • Chemotherapy/XRT • Early RVT • Infection: TB Right upper quadrant cystic mass Hydronephrosis • Steroids: exogenous. parasite. parasite. • Duplicated system with • Thrombocytopenia with absent CF. • Duodenal duplication cryptorchidism) Radial ray anomalies (absent radius) • Pancreatic pseudocyst: trauma. retinoblastoma (Menke’s) • Caffey’s disease • Down syndrome • Syphilis (Wimberger’s sign. hyperlipidemia obstructed upper pole radius syndrome (TAR syndrome. von Hippel-Lindau disease.
41. pulmonary lymphangiectasia. maternal MgSO4 and diabetes 4. 50. This is seen in Hurler’s disease. cerebellum. whereas multiple punched-out lesions more likely represent EG Chondroblastoma may be curettaged and filled with bone graft Coronal craniosynostosis (brachycephaly) is most commonly due to Crouzon’s disease. The differential is postural flattening. hypoplastic/absent patellae. May cause hyperinflation. Legg-Calve-Perthes disease is idiopathic AVN of the femoral heads. 43. a varus osteotomy and/or shelf acetabuloplasty can be performed 7. 48. Meconium ileus and ileal atresia look alike radiographically. Membraneous croup (bacterial tracheitis) is usually caused by staphylococcus 6. air trapping. but air-fluid levels are often present in the latter 3. neonatal pneumonia. 18. If it occurs only on one side. listeria). heart failure. and precipitous delivery. 40. subependymal. Hirschsprung’s disease. sacral deformity The clinical triad of tuberous sclerosis is adenoma sebaceum. 33. and it can be preoperatively embolized with PVA 15. cuboid 9. 46.Elbow ossification centers (age) • CRITOE mnemonic: 16. Can also be due to trauma. cerebral hemiatrophy A transtabular prone view shows if an anorectal malformation is above or below the pubococcygeal line. csection (no squeeze). 31. with carotid arteries being more anterior than the subclavian arteries Retained fetal lung fluid occurs in premies. elbow deformity. Treatment with pancreatic enzymes in CF may cause strictures in the terminal ileum or cecum 13. • • • • • • Capitellum (1) Radial head (5) Internal (medial) epicondyle Trochlea (7) Olecranon (11) External (lateral) epicondyle 17. and should be considered in any child with wheezing. dorsal midbrain. thalamus. 30. presacral mass. but increased perforation rate. 49. whereas extralobar is more common at birth. it is called plagiocephaly and may be nonhereditary. 36. whereas asplenia tends to have severe CHD (common atrium. (7) (12) Polydactyly • LETS mnemonic: Laurence-Moon-Biedl Ellis van Creveld syndrome Trisomies 13. Duodenal atresia is most likely due to failure of recanalization at 12 weeks in utero 11. and white matter changes which may represent hamartomas or gliomas. 51. VSD. 21. 27. For suspected epiglottitis. and is isointense to gray matter on all sequences NF-1 may have an acute angle kyphosis. CCAM A bowel loop is dilated if it is greater than one vertebral body wide Gray matter heterotopia can be focal subcortical. Alternatively. These babies will have asymmetric consolidation. Apert’s syndrome. 47. wide physis with “scooped out” metaphysis. hemorrhage The four-vessel sign indicates a double aortic arch. 42. A juvenile nasal angiofibroma usually involves the pterygopalatine fossa. BP foregut malformation. retained fetal lung fluid look alike on initial CXR . The differential is HMD. 25. Meconium plug syndrome can be seen in CF. If it has been present >48 hours. brainstem Lissencephaly may be due to STARCH (no severe genetic defects) or a syndrome. PTX/pneumomediastinum Exogenous surfactant may look like pneumonia because of asymmetric clearing of HMD. and should clear by 1-3 days. there is an increased risk of osteosarcoma at a later age. Treatment is aimed at containment of the femoral heads in the acetabulum. osteochondromatoses For meconium aspiration. 37. 54. consider hypoplastic left heart Fibromatosis colli (torticolis) develops in neonate at 2-8 weeks. 55. such as CDH. 39. 24. seizure disorder Leigh’s disease (subacute Necrotizing encephalomyelopathy) is the end-stage of many disease processes. Extreme prematurity can mimic lissencephaly Luckenschadel (lacunar skull) is due to a mesodermal bone dysplasia (NOT hydrocephalus) and may disappear by 3-6 months Holoprosencephaly is associated with trisomy 13 A solitary sclerotic lesion in the skull may be an epidermoid inclusion cyst. and may spontaneously disappear at 4-8 months Hamartoma of the tuber cinerum may present with precocious puberty. whereas Legg-Calve-Perthes disease occurs at 4-8 years. single ventricle. A retinal astrocytoma occurs in TS Retinopathy of prematurity and persistent primary hyperplastic vitreous both have micropthalmia Croup typically occurs in children ages 6 months-3 years. mental retardation. resulting in mastoid opacification and a wide ostium 14. 52. an anoplasty may be performed Congenital lobar emphysema is usually LUL>RML>RUL. idiopathic. pAPVR. hemoptysis unresponsive to treatment Meconium aspiration. Tarsal coalition of the talocalcaneal type usually occurs at or just posterior to the sustentaculum tali (at the middle facet) 10. 45. AVN and chondrolysis are known complications of SCFE 8. Transient (toxic) synovitis is a diagnosis of exclusion Hypophosphatasia consists of osteopenia. Consider GBBS (look for a pleural effusion. nail dysplasia Madelung’s deformity (AD) is progressive ulnar/volar tilt at the distal radial epiphysis articular surface with dorsal subluxation of the distal ulna. 22. Most cases that recur do so in the first week. band-like Vein of Galen malformation can be treated by both arterial/venous embolization The Currarino triad is an anorectal malformation. especially those of endocrine etiology (hypothyroidism. suspect shunt vascularity 5. It is bilateral in 10% cases. Do not perform a contrast enema in a patient with intussusception if there is free air. 44. check humeral ossification centers suggesting post-maturity. pulmonary edema Hyaline membrane disease (HMD) causes granular appearance of the lungs with symmetric underinflation. The pressure method has a better successful reduction rate. growth hormone deficiency). calcaneus. Miscellaneous facts: 2. it is important to know side of the aortic arch for surgical planning (thoracotomy will be on opposite side of arch) If NEC in first 24 hours of life. 32. 38. If it’s within 1 cm of the perineum. while epiglottitis occurs in children ages 3-6years. cerebral peduncles Septic joint occurs at 6 mos–2 years. meconium aspiration. Polysplenia may be associated with ASD. sepsis. 35. CMV. trauma. nephropathy. shock. neonatal pneumonia (GBBS. 19. it should be removed 12. 26. overweight. often in the extremity. Differential includes hypothyroidism. so premies without a thymus should NOT have HMD. 29. and may be associated with PDA. pulmonary edema. hypothalamus. pneumonia. Only 7% fail to reduce 23. while pulmonary aplasia has a short stump bronchus Intralobar sequestration is probably acquired. There is an increased incidence of astrocytomas of the optic nerve. more common in males (4:1). Differential includes neonatal pneumonia. infection. and often (98%) associated with other abnormalities. A toddler fracture can occur in the distal tibia. chest Most infantile neck hemangiomas regress spontaneously In patient with TE fistula. If it’s high-intermediate. The tibiofemoral angle is >150 Fong’s disease is iliac horns. then a diverting colostomy and later pullthrough may be performed. 34. VSD in 15-30% cases Pulmonary agenesis has no bronchus. If the descending right pulmonary artery is wider than the trachea. abdomen. If asymmetric. 53. and results in increased T2 signal in the BG. which should NOT occur in uncomplicated HMD) Foreign body aspiration usually occurs between 6 months-3 years of age. a portable lateral ST view of the neck should be performed with an ER physician present An extraosseous Ewing’s sarcoma usually occurs in older children. TGV) With retinoblastoma. CHD. 18 Simple polydactyly • • • • syndrome 20. and pathologic fractures Congenital tibia vara (Blount’s disease) occurs in obese black children. osteomyelitis. A button battery in the stomach may leak alkali or cause electrolysis. SCFE is bilateral in 20% cases. then consider superimposed pneumonia Steroids mature type 2 pneumocytes and decrease thymus size. 28. either by casting or an abduction brace. peritonitis. An antrochoanal polyp starts in the maxillary sinus and extends into the nasopharynx.
May occur with pulmonary stenosis instead of coarctation of the aorta number of fetuses. abdominal mass. check for fetal cardiac motion. pseudocyst secondary to VP shunt ADPCKD may be unilateral. For EV/TA ultrasound. cystic hygroma. Acute pyelonephritis poses a greater risk than VUR for scar formation If there is urinary ascites. collagen vascular disease. Post-dates. Monoamniotic is ARPCKD. abdominal wall defect. membranes diamniotic. DandyWalker malformation. the talocalcaneal angle is increased A Whitiker test allows you to simultaneously check pressure of the upper collecting system and bladder during a controlled percutaneous antegrade infusion of the upper collecting system UPJ obstruction may be due to crossing vessels. Valve ablation can be performed. hydrocephalus. 63. whereas a pseudogestational sac is present in an ECTOPIC pregnancy. consider Rhabdoid tumor of the kidney In congenital clubfoot. Turner’s syndrome ARPCKD can look like nephrocalcinosis. 60. If a typical Wilm’s tumor is present. Dichorionic twins have 2 GS. the talus and calcaneus assume a more parallel configuration with a decreased talocalcaneal angle. dysplasia. congenital heart disease. size less than dates and fetal occurs in monochorionic/monoamniotic weight <10%ile. overdistended • Asymmetric (late insult): bladder) uteroplacental insufficiency. whereas ectopic pregnancies will NOT. uterus cornua. hydrocephalus. microcephaly or anencephaly Oligohydramnios • Fetal demise • GU abnormality: posterior Monochorionic twins have 1 GS and 2 separate yolk urethral valves. seminal vesicle cyst. ureteral kinking. do temporary urinary diversion Primary megaureter is more common in males and on the left side. duodenal obstruction. Renal disease (polycystic kidney disease. number. asymmetric IUGR. Check the liver for dilated ducts (ARPCKD) to help differentiate Megacystis-microcolon-intestinalhypoperistalsis syndrome is likely related to degenerative smooth muscle disorder Cellules are created by mucosal protrusions into hypertrophied bladder wall muscle Infection or obstruction is necessary for a renal scar to form. If apparent single placenta. and the differential includes tuberous sclerosis. bilateral MCDK. teratoma. membranes poor nutrition. cardiac activity should be present. 58. abdomen (rare) Most accurate US parameters by dates • 1st trimester: CRL (<13 weeks) • • 2nd trimester: BPD 3rd trimester: FL. Rh incompatibility Differential Diagnoses Ultrasound First trimester bleeding • NL IUP: subchorionic hematoma • Abortion • Early pregnancy failure (anembryonic pregnancy) • Ectopic pregnancy • Gestational trophoblastic disease • For first trimester. document the . yolk sac seen at 8mm/20 mm MSD. consider Clear cell tumor of the kidney. evaluate the uterine anatomy and adnexae In early pregnancy. 61. renal abnormality • NL variant • GE MINER CO mnemonic: Gastroschisis. they are necessarily dizygotic (dichorionic. Embryo growth is 1mm/day A NL gestation will double b-HCG levels every 48 hours. determine • Premature rupture of number of placentas. 59. CRL not used after 13 weeks gestation. whereas diamniotic is each MCDK with contralateral agenesis or UPJ twin having a separate amniotic sac obstruction • IUGR Determine chorionicity by first checking sex of • Post-dates pregnancy twins. Molar pregnancies have very high b-HCG levels A double decidual sac is present in an early NL pregnancy. cervix. 62. MSD + 30 = gestational age (days). others Elevated maternal serum a-fetoprotein [>2. posterior urethral valves. 68. maternal • Premature rupture of smoking.56. sacs. unilateral both twins in 1 amnion. Differential includes ovarian cyst. but there are bone metastases. This is abnormal in maternal diabetes (macrosomia). check uterus and adnexae. subchorionic • Symmetric (early insult): hematoma STARCH. • Placenta previa (mimics: chromosomal abnormality uterine contraction. Polyhydramnios and presentation. The ectopic usually involves fallopian tube. Normally the calcaneus lines up with the base of the fourth metatarsal. Chorioangioma. Prune Belly syndrome. placental • Idiopathic (60%) location and appearance. always localize the GS. monoamniotic or dichorionic with Premature rupture of membranes. Neural tube defects. take standard measurements of embryo/fetus. while the talus lines up with the base of the first metatarsal. oligohydramnios of second twin (stuck) or diamniotic Syndromes with nonvisualization of intertwin membrane due to thinness/position. 67. ETOH In 2nd/3rd trimesters. significantly smaller fetal abdomen compared to other measurements Third trimester bleeding • Placenta abruption: IUGR retroplacental hematoma. bilateral renal agenesis. 66. and embryo at 16 mm/25 mm MSD. If the patient is too young and the scope won’t pass. evaluate fetal anatomy • Maternal diabetes. CHD. Cord entanglement compared to prior study. check for fetal life. If no intertwin membrane seen: Renal abnormality. stenosis. 1. Omphalocele Decreased AFP • • tissue) • • • Trisomies Molar pregnancy (no fetal Fetal demise Misdated pregnancy NL variant HC:AC should be 1. 64. functional muscle abnormality. dichorionicity. If CRL 5mm.0 in 3rd trimester. bands. In the less common congenital vertical talus. check for • Syndromes “chorionic peak” at intertwin membrane: • DRIPPS mnemonic: Demise. If opposite. Error by lab. diamniotic). HTN. If two placentas: dichorionic. ascites. If same sex. assess gestational age. If there are CNS metastases.2 in 2nd trimester. monochorionic. IUGR. 65. It’s bilateral in 20%. amniotic fluid volume. polyp Bladder diverticula in children may be due to neurogenic bladder. Twin-twin transfusion occurs in Suspect IUGR if interval growth less than expected monochorionic/diamniotic. 57. obstruction. Multiple gestations. Esophageal atresia. congenital nephrosis). or may be associated with contralateral renal agenesis in 9% cases Consider Noonan’s syndrome (male Turner’s syndrome) when lymphatic disorder is identified in a newborn. check for posterior urethral valves. Incorrect dates (most common).5 multiples of the mean (MOM)] • Incorrect dates: actual age of fetus is older • Twin gestation • Fetal demise • Fetal abnormality: neural tube defect. ovary. esophageal atresia.
The placental end is low resistance and is the desired location to sample. intrathoracic mass (CCAM. asymmetric). teratoma. arachnoid cyst. marginal • Myometrial contraction • Placenta accreta • Leiomyoma • Cervical change: shortening <2. If two vessels. The fetal end is high resistance. measured at cavum septum pallucidi and cisterna magna) • NL variant • Chromosomal abnormality: trisomy 21. A cord cyst can occur normally in 1st trimester. increased risk of chromosomal abnormality. congenital diaphragmatic hernia). mass (vein of Galen malformation.0 cm. hemorrhage (immune thrombocytopenia.• Fetus unable to swallow: CNS abnormality. cleft lip/palate. hydranencephaly • Malformation: holoprosencephaly. duodenal atresia (Down syndrome). cerebellar hypoplasia [<24 weeks transverse measurement of cerebellum (mm) equals gestation age (weeks)]. cystic degeneration. recommend an amniocentesis Cervical cancer risk factors include HPV/HSV infection. and hematomas can be seen after cord manipulation Early ultrasound milestones • Week 5: gestational sac • Week 5. non-immune hydrops (arrhythmia. off-midline with amniotic band syndrome • Soft tissue mass: hemangioma. subchorionic. partial. glioma) Nuchal thickening/abnormailty (>6mm. STARCH. prominent basal myometrial vascularity Central placental thickness (mm): should be <gestational age (weeks) + 10 Placental grading • 2: basilar plate Ca++ at junction of placenta/uterus (>30 weeks) • 3: Cotyledons or calcified compartments (rare before 36 weeks. aqueductal stenosis. PNET. Rh incompatibility (hydrops). severe maternal stress) • Non-communicating hydrocephalus: Chiari 2. small bowel obstruction. Turner’s syndrome • Cystic hygroma: Turner’s syndrome • Encephalocele: occiput. intervillous thrombosis • Infarct (usually not seen) • Hematoma: retroplacental. facial tumor • Swallowed fluid meets obstruction: esophageal atresia (VACTERL). infarction). Range of NL is 5-24 cm.5: yolk sac • Week 6: fetal pole. bilateral. or use the free cord. Dandy-Walker malformation. acute illness). agenesis of corpus callosum. thalamus • AC: left portal vein.0 at 30 weeks. thalamus • HC: occipital horns. chromosomal abnormality) • Twin gestation • TARDI mnemonic: Twins. GI). transiently NL variant Fetal posterior fossa abnormality • Effaced cisterna magna: Chiari malformation • Large cisterna magna: DandyWalker malformation. teratomas are rare. arachnoid cyst) • Destruction: porencephaly (parenchymal hemorrhage. being <3. hypertension • Mimics: uterine contraction. short-limed skeletal dysplasia. but if it is seen later. no Ca++ (1st 1: scattered small Ca++ (2nd trimester) trimester) . white matter dysgenesis.8 cm (premature labor. Reversal of diastolic flow is an ominous sign. it raises the possibility of IUGR. Hemangiomas occur at placental end. subchorionic fibrin deposition. frontal bone. Abnormal is >8cm or <2 cm in any quadrant Discriminatory b-HCG levels to identify IUP Endovaginal US: 1000 Transabdominal US: 1800 Umbilical artery S/D ratio should decrease over the course of the pregnancy. cardiac activity Abnormal placental echotexture • Clinically insignificant sonolucency: venous lake. and other abnormalities present. Fetal arrhythmia and breathing attempts can change the doppler signal Umbilical cord should have three vessels (2 arteries. suspect IUGR. If greater. cervical incompetence) • Vasa previa Obstructed uterus • • • Stricture: cervical stenosis Cervical/endometrial cancer Submucosal leiomyoma • Hemorrhage: fetal stress (maternal surgery. but also in up to 25% Trisomy 18 cases. immune thrombocytopenia • Arachnoid cyst • Vein of Galen malformation • High riding third ventricle (agenesis of corpus callosum) • Choroid plexus cyst: trisomy 18. oligohydramnios) Echogenic mass next to fetus • Molar pregnancy & NL twin • Partial molar pregnancy • Chorioangioma • Leiomyoma • Abruptio placenta Persistent transverse lie • Fetal mass: sacrococcygeal teratoma • Leiomyoma • Placenta previa • Nuchal cord tethering fetus • Roomy multiparous uterus Lower uterine segment abnormality • Placental previa: complete (symmetric. If present <36 weeks. immunosupression Fetal ventriculomegaly • Communicating hydrocephalus: infection. neuronal migration abnormality • NL variant (isolated mild ventriculomegaly) Fluid-filled fetal skull • Massive hydrocephalus (dangling choroid plexus) • Hydranencephaly • Holoprosencephaly Fetal supratentorial lesion • Tumor (rare): teratoma. thyroid goiter Standard fetal measurement levels • BPD: third ventricle. preplacental (Breus mole) • Chorioangioma (at cord insertion) • Infection • Molar pregnancy • Hydrops • Placental maturation (accelerated calcification of cotyledons): maternal smoking. twin-twin transfusion syndrome. increased number of partners (sexual not dance). Anomalies (CNS. If >1. 1 vein) and Wharton’s jelly. mega cisterna magna • NL cerebellar vermis is echogenic! Choroid plexus cysts may be seen in NL fetuses. maternal HTN. teratoma. Idiopathic AFI index: sum of largest AP fluid pockets in each of the four quadrants. Diabetes. look for other anomalies. megalencephaly. parietal bone. stomach • FL: should exclude distal femoral point (cartilaginous epiphysis) Fetal chest mass • CCAM • Congenital diaphragmatic hernia • Bronchopulmonary sequestration (extralobar only) • Bronchial atresia (left upper lobe) • Teratoma (pericardial sac) • • 0: homogeneous. burns.
hematoma • Parathyroid gland: cyst. adenoma Fetal hydronephrosis • UPJ obstruction • Apparent UVJ obstruction: ectopic ureterocele. malignant (seminoma. abscess. pancreas adenocarcinoma) Management guidelines for ovarian mass Cyst <2. <7 mm after 33 weeks gestation. VUR • Apparent urethral obstruction: posterior urethral valves. calcified) • Colon • Ovary • Breast • Stomach Thyroid nodule • Adenoma • Carcinoma: papillary. MAI. choriocarcinoma). urinoma (kidney displaced anteromedially). If abnormal.• Neuroblastoma (rare) Fetal abdominal wall abnormality • Omphalocele • Gastroschisis • Amniotic band syndrome • Limb-body wall complex (lateral chest/abdomen defects. didelphys. RCC. pyosalpinx • Paraovarian cyst. fluid in mesenteric/omental leaves • Pelvis/lower abdomen: ovarian cyst. colon) • Cyst (mediastinum. meconium pseudocyst. short umbilical cord) • Pentralogy of Cantrell Echogenic fetal bowel • Down syndrome • IUGR • Fetal demise • Intraluminal hemorrhage Cysts in fetal abdomen • Posterior midabdomen (touches spine): hydronephrosis. nonseminoma. reproductive age female • Ectopic pregnancy • Hemorrhagic cyst/endometrioma • Ovarian torsion • PID/TOA. hydrometrocolpos (tubular). caudal regression anomaly (VUR).5-5 cm F/U 4-6 weeks Atyp. PI <1. invasive mole. colon. The renal pelvis should be <50% transverse diameter of the kidney Uterus surrounded by ill-defined material in culde-sac or adnexae (“Frozen Uterus”) • Pelvic abscess. dilated bowel. sacococcygeal teratoma • NL third trimester colon Fetal ascites • • • Urinary source Bowel rupture Hydrops Thickened endometrium • Secretory phase of menstrual cycle (NL <15 mm) • Pregnancy related: IUP (double decidual sac). theca lutein • Benign neoplasm: dermoid (bilateral 15-20%) • Malignant neoplasm • Endometrioma (30-45 y/o) • Hydrosalpinx. Brenner tumor. appendicitis • Red degeneration of a fibroid (often a pregnant patient) Ovarian mass in an older patient is more suspicious of cancer when doppler shows RI <0. mixed. metastases such as prostate.4. follicular. adenofibroma. megacystismicrocolon-intestinal-hypoperistalsis syndrome. anaplastic./Surgery Enlarged ovaries • • • • • Stein-Leventhal syndrome PID Metastases Lymphoma Endometriosis . GTD (hydatidiform mole. megaureter. tunica) • Abscess • Hematoma • Adrenal rest Abnormality in testis. retained products of conception • Hyperplasia • Polyp • Carcinoma • Endometritis • HRT. other carcinomatosis • Exophytic leiomyomata Large premenopausal uterus (>10 x 5 x 5 cm) • Congenital malformation: bicornuate. ectopic pregnancy (pseudogestational sac). thecoma. CMV • Intrahepatic ductal stones: recurrent pyogenic cholangitis. disseminated PCP. persistent cloaca (female. Crohn’s disease. follow up at 3-4 weeks.0. lymphoma. surgery. Caroli’s disease • Pneumobilia: incompetent sphincter of Oddi. hemorrhage • Endometriosis • Ectopic pregnancy • Ovarian cancer. diverticulitis) Solid-appearing adnexal mass • Exophytic leiomyoma • Ovarian torsion • Hemorrhagic cyst • Endometrioma (30-45 y/o) • Abscess • Ectopic pregnancy • Dermoid • Solid ovarian tumor: primary (fibroma. urethral atresia (male or female). duplication cyst. tamoxifen Acute pelvic pain. histoplasmosis. The Pulsatility index: peak systolic velocity-end diastolic velocity/mean. urachal cyst (bladder dome). MCDK • Anterior abdomen: choledochal cyst (touches porta hepatis). erosion into common bile duct by stone/ulcer • Portal venous gas: pneumatosis intestinalis (high amplitude spikes on doppler exam) • Hepatitis (portal triads stand out in relief) Hyperechoic hepatic metastases (mucinous. follow up postnatally. not definitely a mass • Tumor • Infarct • Abscess • Tubular ectasia of rete testis • Sarcoidosis Diffuse abnormal testicular parenchyma • Atrophy: prior torsion. metastatic Krukenberg tumor (gastric. cyst <5 cm F/U 4-6 weeks Cyst >5 cm Lap. corpus luteum. while the Resistive index: peak systolic velocity-end diastolic velocity/peak systolic velocity Testicular mass • Tumor: benign (epidermoid cyst)./Surgery Any solid mass Lap. Hurthle cell (follicular subtype) • Colloid cyst.5 cm No F/U Cyst 2. lymphocele • Peritoneal inclusion cyst • Ectopic pregnancy • Abscess (TOA or regional process such as appendicitis. dysgerminoma). VUR) Grades of Vesicoureteral Reflux Measurement of NL renal pelvis: <4 mm before 33 weeks gestation. if abnormal in third trimester. medullary. septate • Leiomyomata • Adenomyosis • NL variant Cystic adnexal mass • Physiological ovarian cyst: follicular. inflammation • Torsion • Orchitis • Infiltrating tumor: lymphoma/leukemia • Testicular microlithiasis Hepatic visceral echogenic foci • Prior infection: TB.
base One may see hepatofugal vessels in portal vein tumor thrombus . 21. patient will benefit from CEA Parvus-tardus effect is dampening of a distal (arcuate) arterial waveform due to upstream stenosis. If <90 or >200. The ICA is located anomalies posterolaterally. if it’s incomplete suspect cancer On US. 19. In TIPS. and augmentation (squeezing calf) 16. 32. The CAS 26. 31. the peak systolic velocity should be 90-200 cm/sec in the shunt.7 Treat ectopic with MTX 13. Risk of cancer is 25% with serous Carotid Endarterectomy Trial) said if 70-99% cystadenoma and 5% with mucinous stenosis. multiple gestation. Systolic acceleration <300 cm/sec2 is abnormal. suspect endometrial cancer Aldosteronism is caused by adenoma (70% cases. increased an intratendinous hypoechoic area or LH:FSH ratio >2:1 dominant echogenic focus. consider arterial flow adenomyosis • Localized turbulent/arterialized 2. anembryonic pregnancy. US features of AVF • NL gray-scale imaging • Localized perivascular tissue vibration Miscellaneous facts: • Localized low-resistance 1. patient will benefit from CEA. fibroid The NASCET trial (North American Symptomatic 15. burns. 28. and thus is the major contributor to amniotic fluid thereafter Testicular seminomas do NOT have serum markers. Ovarian torsion may present as increased Rotator cuff US findings (axial & sagittal images) number of cortical follicles in an enlarged ovary • Preserved anterior echogenic 6. TB rarely causes a similar appearance Overlapping cranial bones suggests fetal demise A solid ovarian tumor in a young female suggests dysgerminoma A fetal chylous effusion is more common on the right A twin pregnancy can be NL twin with mole. 17. or there is a change of 50 cm/sec from baseline. hyperechoic • Cystic • Peripheral eggshell calcification US features of thyroid nodule (malignant) • Poorly defined margins • Hypoechoic • Microcalcifications • Cervical adenopathy US features of deep venous thrombosis (DVT) • Enlarged vein. 36. spontaneous (sepsis. 30. echogenic thrombus. medical therapy) Adrenal hemorrhage can be due to trauma (R>L). achieved by: • Using highest frequency transducer • Optimizing angle of interrogation (<600) • Decreasing PRF (scale). teratoma. if the hypoechoic inner myometrium is incomplete. malignant mesothelioma • Remember: be perfectly 9. 24. lymphoma (Asymptomatic Carotid Atherosclerosis Study) said if >60% stenosis. Also. partial molar pregnancy.8 >3. once the fetal lungs neck are mature: deliver 5. NL pregnancies. surgery) and hyperplasia (30% cases. <1. or NL fetus with hydrops of the placenta Ovarian granulosa cell tumor (usually B9) can liberate enough estrogen to cause endometrial hyperplasia or cancer A fetus begins to make urine at 14-20 weeks (mean 16 weeks). TB. adrenal venography.8 <1. 35. but not too low to cause aliasing. Abnormal lower uterine segment may be due changes in ECA waveform if confused to myometrial contraction. no flow • Doppler waveform phasicity changes with respiration.5 is also suggestive of RAS Doppler parameters optimization Doppler equation: 2fcosθ Vblood/Vsoft tissue Goal is to increase frequency shift. Peritoneal carcinomatosis mimics include with subdeltoid fascia approximating the humeral head pseudomyxoma peritonei.08]. It may cause ectopic pregnancy. it anteromedially. and has a NL velocity of >15 cm/sec. 27.• Metastasis. A massive tear leiomyoma (0. creating a hypoechoic focus that mimics a tear 10. then consider shunt malfunction. The differential diagnosis for a cervical Peak Systolic Velocity ratios (VICA/VCCA) ectopic is abortion in progress. 23.5% cases) shows non. Sudden increase in size of non-gravid uterus thickness tear shows discontinuity and may be due to sarcomatous degeneration of loss of the echogenic arc. embryonal carcinoma: afetoprotein). There may be increased T2 signal if degenerating US features of pseudoaneurysm • Swirling luminal flow 3. the native PV peak systolic velocity should be >30 cm/sec.8 <1. A complex mass in the testis is more likely a non-seminoma Testicular calcifications can be due to burned out neoplasm. 33. the endometrial stripe should be <12 mm GTD and retained products of conception are indistinguishable on US On MRI. thrombus Pergonal therapy. Fibroids are classically iso/decreased T1 and venous flow decreased T2 signal. it Peak Systolic Velocity values (cm/sec) should be done during the relatively quiescent NL Mild Mod Severe Critical second trimester. apex. nabothian cyst. and can undergo malignant degeneration in 1-2% cases Salpingitis isthmica nodosum (SIN) has diverticula and obstruction of fallopian tubes. peak velocity >180 cm/sec. Stein-Leventhal syndrome may present as arc increased size of ovaries (1/3rd are NL size). pseudogestational sac In a postmenopausal female on HRT. 29. Try a temporal tap to show 14. For the main renal artery. A malignant teratoma usually has more soft perpendicular to the tendon or the tissue and scattered Ca++ “anisotropy artifact” may occur. and peak renal arterial velocity/aortic velocity ratio >3. and slowed time to peak systole suggests RAS. In TIPS. but non-seminomas do (choriocarcinoma: b-HCG. lymphoma. infertility. endodermal sinus tumor. and is a high resistance vessel with may be associated with renal and cardiac multiple branches. PRF must be at least twice the frequency you are sampling (Nyquist theorem – thanks Helena!) • Decreasing wall filter • Increasing gain until low level noise occurs. Stenosis occurs more commonly at the hepatic vein end The hepatic vein has a triphasic waveform with 2 periods forward and 1 reverse (due to atrial contraction) US-guided biopsies of the prostate gland are sextant. post-infection or inflammation. A delayed systolic upstroke [acceleration time (T) >0. 37. the ECA is located 13/18. the cervix should have a dark complete stromal ring. • A partial thickness tear shows increased number of cortical follicles. Leiomyomata respond to GNRH by decreasing size or bleeding (treat anemia) CAROTID DOPPLER PARAMETERS 11. If surgery needs to be performed on mother. 22. NL • Variable amounts mural singleton pregnancy. done randomly in the peripheral zone. A two-vessel cord can be seen in trisomies At the carotid bifurcation. whereas a full 7. and is a low resistance vessel without branches. With abruptio placenta. surgery. valsalva. noncompressible. 18. and resolve weeks-months post-partum • May be multiple loculations • To-and-fro flow at aneurysm 4. anticoagulation. Microlithiasis (1-2 mm Ca++) may be associated with cancer Echogenic debris within the uterus may represent a missed AB. cystadenoma.visualization of the tendon 8. often with a history of PID. 20. neoplasm) The portal vein normally measures <13 mm. If the junctional zone is >12 mm. then decrease slightly US features of thyroid nodule (benign) • Clearly defined margins • Thin. Theca lutein cysts can occur in GTD.8 >1. 34. 25. Tocolytics are used to prevent 0% 1-39% 40-59% 60-79% 80-99% premature labor <110 <110 <110 >130 >250 12. twin gestations. Mucinous tumors can cause pseudomyxoma peritonei Disparity in twin sizes can occur in twin-twin transfusion and NL twins Mature cystic teratoma is bilateral in 15% cases. complete halo • Solid. abruptio placenta.
residual hydronephrosis after correction of VUR/obstruction • Acute trauma: hemorrhage (subcapsular. bilateral • Chronic medical renal disease: HTN nephrosclerosis. bleeding diathesis • Cystic RCC • Multilocular cystic nephroma (male child. • Agenesis or any parenchymal disease The fetal kidneys grow 1 mm for each week Delayed nephrogram by location gestation. sinus) • Calyceal diverticulum • Papillary necrosis cavity (focal or multifocal) Multiple bilateral renal cysts • ADPKD (cysts in liver. Do 3-. xanthogranulomatous pyelonephritis (focal. infection. Budd-Chiari syndrome. • Chronic transplant rejection sharp margination. • Collagen vascular disease lymphoma There may be increased flow in a recent Absent. 50% risk): thick/nodular septae. seminal vesicles. obstruction Striated nephrogram • Acute pyelonephritis • Acute RVT • Acute obstruction • Contusion • XRT nephritis • ARPCKD A shock nephrogram is a persistent dense nephrogram at 10 minutes with loss of pyelogram (it drains into bladder but no more contrast is filtered through the kidney) If patient having anaphylactic reaction. ischemia. or persistent nephrogram detorsion of the testis • Vascular: infarction. toxins. pheochromocytoma. islet cell tumor. glomerulonephritis • Post-renal: RVT. metastases • Acute renal infarction. no wall thickness or ++ Ca Renal medullary calcification • 2 (Minimally complicated cyst. multiloculated. regional LNs (3B). NL reversal of flow (below baseline). ischemia • Acute amyloidosis (rare) • ATN: several chemical and ischemic causes *Notice the word Acute in the above section Large kidneys. both • Abscess • Hematoma: neoplasm (RCC. cerebellar/spinal hemangioblastoma. The other dilution (1:1000) is given 0. • Pre-renal: RAS. more Ca++ in wall. Wilm’s tumor. distant metastases (4B) Synchronous TCC: 30% collecting system/renal pelvis TCC multiple at diagnosis. trauma. 41. enhancement Complex renal mass • Complicated cyst: hemorrhage. typically measuring 3. AML). myeloma. no hyperparathyroidism. solid vascular element. AML). call a code and administer epinephrine (1:10. or both (3C) • 4: extension into adjacent organs (4A).000) 3 cc IV. Only 2-3% of bladder TCC multiple at diagnosis Metachronous TCC: 40-80% upper tract TCC will at some time develop tumor elsewhere Renal cortical calcification (nephrocalcinosis) • Acute cortical necrosis: pregnancy. raise feet. fine Ca++. nonBosniak 2 hyperdense cyst. paraneoplastic enhancement. thyroid. retinal angioma. anticoagulation. >95% risk): irregular margins. MCDK (adult) • Page kidney *Notice the word Chronic in the above section Small kidneys. bilateral RAS. 43. female adolescent/adult) Solid renal mass • Benign neoplasm: AML. oncocytoma • Malignant neoplasm: RCC. • 3 (Moderately complicated cyst. IgA nephropathy. trauma. pyelonephritis hepatic venous waveform is non-specific and • Obstruction can occur in cirrhosis. • Hypercalcemic states: 5-10% risk): septae <2 mm. delayed. irregular Ca++. invasive urothelial tumor (TCC. transfusion reaction. ischemia. lymphoma (multiple. A blunted Goodpasture’s syndrome). VUR • Chronic radiation nephritis • Chronic amyloidosis (rare) • Congenital: hypoplasia. 0-1% syndrome risk): <20 HU. burns. trauma. then 6-. solitary mass). intraparenchymal) • Ureteral duplication • Compensatory hypertrophy • Xanthogranulomatous pyelonephritis • Neoplasm: RCC. sepsis. consider administering atropine 1 mg IV Solitary cystic renal mass • Simple cyst (cortical. short-gut • 1 (Simple benign cyst. then 12-month follow-up. sarcoidosis. 25% extending outside of kidney. adenocarcinoma). megaureter. SCC. peritonitis • Hereditary chronic nephritis (Alport’s syndrome) • Chronic glomerulonephritis: post-streptococcal. obstruction. minimal enhancement (MLCN) • 4 (Cystic carcinoma. milk-alkali cm. 40. analgesic nephropathy Large kidney.5-5 cm at birth. epididymal cystadenoma • Tuberous sclerosis (AML. renal artery The renal pyramids should be relatively dissection. hypotension hypoechoic at birth • Renal: ATN. no enhancement (<10 HU). cysts) • Acquired renal cystic disease of uremia (RCC. IgA nephropathy. contrast reaction and stenosis both cause biliary dilatation • ATN. diffuse) • Hematoma: neoplasm (RCC. A seminal vesicle cyst may be associated with renal vein thrombosis unilateral renal agenesis • Hypotension: severe cardiac Post-transplant hepatic arterial thrombosis disease. If vasovagal reaction. Differential Diagnoses GU Radiology • AIDS nephropathy (prognosis Hepatic veno-occlusive disease may be due to <6 months) chemotherapy in BMT patients or paroxysmal • Leukemia/lymphoma nocturnal hemoglobinuria • ARPCKD Hypoechoic renal lesions in children may • Vasculitis represent nephroblastomatosis. bleeding diathesis Stages of Renal Cell Carcinoma • 1: confined to renal capsule Small kidney. syndrome. dehydration. ovaries) • Von Hippel-Lindau disease (RCC. pancreas. some hyperdense cysts (<3 syndromes. pancreas cysts. anticoagulation. 44. bilateral • Diabetes mellitus (most common) • Acute glomerulonephritis • • 2: confined to Gerota’s fascia 3: extension into renal vein/IVC (3A). chronic glomerulonephritis. Goodpasture’s syndrome Bosniak CT renal cyst classification scheme • Oxalosis: IBD. slightly more complicated. unilateral* • Acute RVT • Acute pyelonephritis • Acute hydronephrosis: VUR. cysts) • 2F (Cyst that requires followup): Some hyperdense lesions. RVT • Chronic obstruction.3 cc IM. glomerulonephritis Hepatic venous waveforms are triphasic with (post-streptococcal. testes. 42. unilateral* • Chronic RAS. 39. lymphoma/leukemia. hypervitaminosis D homogeneous) .38. metastases • Inflammation/infection: focal pyelonephritis. start IV fluids.
tumor) (synechiae): surgery. interstitial endometriosis. TB • Submucosal uterine blood clot. corpus luteum. RCC with recruitment of vessels • Urolithiasis • Blood clot: tumor. neoplasm/adenopathy • Tuboovarian abscess • Stricture: infection. trauma. renal sinus cyst • Peritoneal inclusion cyst Male urethra (parapelvic. • SCRITT mnemonic: • Physiological ovarian cyst: obstructive • Shistosomiasis follicular. • Neoplasm: adenoma. • Fungus ball: diabetes. pregnancy Small capacity bladder with or without • Endometrial polyp (single. theca lutein • Residua from prior obstruction • Cytoxan • Benign neoplasm: dermoid or reflux • Radiation • Malignant neoplasm • Interstitial cystitis Collecting system/ureteral narrowing • Endometrioma • TB • Extrinsic: endometriosis • Hydrosalpinx. infection/inflammation. instrumentation. • Blood clot: tumor. rectosigmoid colon) • Psoas hypertrophy (distal ureters) • Retroperitoneal fibrosis Lateral ureteral deviation (>1 cm lateral to transverse process) • Aortic aneurysm • Aortocaval adenopathy • Pelvic mass • Psoas hypertrophy (proximal ureters) • Carcinoma: SCC (bulbous urethra) > TCC (posterior urethra) > adenocarcinoma Urethral trauma Collecting system/ureteral filling defects • Urothelial carcinoma (TCC. pituitary adenoma (Cushing disease). ureterocele. trauma. migrant • Adenomyosis • Cirrhosis renal stone • Pregnancy • Analgesics: phenacetin • Polyp • GTD (hydatidiform mole. stent • POSTCARD mnemonic: carcinoma. stone. • Pregnancy duplicated system. adenocarcinoma) • Leukoplakia (bladder > collecting system/pelvis > ureter): Adrenal calcification infection. • Glomerulonephritis ectopic) Intrauterine filling defect(s) • Goodpasture’s syndrome • Pseudoureterocele (secondary • Asherman’s syndrome • SLE to stone. > collecting system/pelvis): diabetes histoplasmosis. short-gut Papillary necrosis • Infection: TB. fungus ball. follow patient indwelling catheter (diffuse. stone • Malacoplakia (bladder > ureter > collecting system/pelvis): diabetes • Ureteritis cystica: infection. lymphoma • Hemorrhage (newborn. upper pole moiety of radiation Bladder. focal). urothelial • Chronic calcification infection: • Endometrial carcinoma tumor. stone. SCC. imperforate hymen. adults) • Infection: TB. instrumentation (penoscrotal junction). trauma. Fraley syndrome. extrinsic mass. If R/O ectopic exam is indeterminate. blastomycosis Papillary necrosis • Cysitis cystica: infection. indwelling catheter. • RVT invasive mole. myelolipoma. SCC. immunocompromised • Obstruction state Uterine enlargement or mass • Sickle cell anemia • Urolithiasis: stasis (outlet • Leiomyoma: intramural. diverticula. trauma. foreign body. exogenous hormone • Benign neoplasm: adenoma (nonfunctioning > functioning). RVT or compression. • Noninfectious cystitis: leiomyoma stricture. immunocompromised state • Collateral vessels: RAS or occlusion. pyosalpinx • TCC (bladder > ureter). choriocarcinoma) stone • Diabetes mellitus • Endometrial carcinoma • Papillary necrosis (sloughed • Obstruction: cervical papilla) Echogenic kidneys. bilateral tumor/stenosis. stent • Fungus ball: diabetes. neuroblastoma (child) • Pyelonephritis (child) indwelling catheter. blastomycosis Bladder filling defects • Urothelial carcinoma (TCC. pheochromocytoma. UPJ/UVJ. histoplasmosis. stone • Papillary necrosis (sloughed papilla) • • Type 1: stretch injury only Type 2: rupture above UG diaphragm at prostatomembranous junction • Type 3: rupture below UG diaphragm at membranobulbous urethra Adrenal gland • Hyperplasia: idiopathic. • Diabetes mellitus infection. cervical carcinoma). neurogenic • TB subserosal. Collecting system/ureteral dilatation calcification multiple) • Obstruction: stone. obstruction. • Benign prostate hypertrophy vaginal web/atresia • AIDS • Ureterocele (simple/orthotopic. shistosomiasis (bladder > ureter) Medial ureteral deviation • Iliac adenopathy • Iliac artery aneurysm • Retrocaval ureter • Pelvic lipomatosis • Pelvic surgery (absent uterus. adenocarcinoma) • Metastases • Leukoplakia (bladder > collecting system/pelvis > ureter): infection. retroperitoneal fibrosis • GTD ((hydatidiform mole. submucosal (least common) bladder). stone • Hemorrhage • Malacoplakia (bladder > ureter • Granulomatous disease: TB. renal sinus lipomatosis • Paraovarian cyst (elderly. infection. surgery/instrumentation with serial US and b-HCG levels congenital (web-like) . choriocarcinoma) • VUR • Megaureter Bladder wall calcification Cystic adnexal mass • Pregnancy: hormonal. papillary necrosis. • Stricture: radiation. retroperitoneal • Ectopic pregnancy • Trauma fibrosis. shistosomiasis. stone. chemical (cyclophosphamide).• type 1 • • syndrome • Distal renal tubular acidosis Medullary sponge kidney Oxalosis: IBD. pheochromocytoma • Malignant neoplasm: cortical carcinoma. peripelvic). metastases. obesity). cystitis invasive mole. inborn error of metabolism. ectopic hormone production.
chondroblastoma Ill-defined lytic lesion • Metastasis • Multiple myeloma • Ewing’s sarcoma • Acute osteomyelitis • Eosinophilic granuloma • Lymphoma/leukemia • Telangiectatic osteosarcoma (child. The peripheral zone of the prostate gland is where 85% of cancers occur. infection Multiple lesions • • • • • tumors) • Fibrous dysplasia EG Enchondromas Metastases. NL prostate volume <25 cc 4. bladder. The female urethra more commonly develops diverticula (though rare). multiple myeloma Hyperparathyroidism (brown Infection Hyperparathyroidism (Brown tumor). RCC • Multiple myeloma (plasmacytoma) • Giant cell tumor • Enchondroma (digits) • Clear cell chondrosarcoma • Desmoplastic fibroma (desmoid) • Fibrous dysplasia • Brown tumor • Hemophiliac pseudotumor • Subacute osteomyelitis (Brodie’s abscess) • Osteoblastoma Only in patients <30 years of age • Aneurysmal bone cyst • Solitary bone cyst • Nonossifying fibroma • Chondroblastoma • Chondromyxoid fibroma • Eosinophilic granuloma Automatics by age • <30 y/o: EG. CPPD. benzene compounds 2.52). senechiae 6. A small uterus can be seen in DES exposure. Brenner tumor). TB causes amputated calyx. adolescent) + clear cell chondrosarcoma (adult) • Chondromyxoid fibroma (calcified matrix is NOT seen) + NOF Bubbly lesion of bone • FEGNOMASHIC mnemonic: • Fibrous dysplasia Differential Diagnoses Musculoskeletal Radiology ABCD’s of MSK radiology • Alignment • • • • • • EG. tumor. Maffuci’s disease • NOF • Fibrous dysplasia Multiple lytic lesions • Metastases: breast. lung. RCC • Multiple myeloma (ribs) • ABC • GCT (no sclerosis) • Hemophiliac pseudotumor • Brown tumor • Enchondroma: Ollier’s disease. The neurovascular bundles enter/exit posterolaterally and are a site of capsular penetration. If the capsule is intact. thecoma. breast. colon. medulloblastoma • Bone island • Osteoid osteoma • Osteoblastoma . 7. adenofibroma. Maffuci’s syndrome Epiphyseal lytic lesion (apophysis) • Geode: OA. Outside the prostate gland. a mullerian duct cyst is midline (posterior/superior) • • • • Bone mineralization Cartilage Distribution Soft tissues • Well-defined lytic lesion • Metastasis: thyroid carcinoma. metastatic Krukenberg tumor (gastric adenocarcinoma) Intratesticular mass • Germ cell tumor • Stromal tumor: Leydig cell tumor. trauma. carcinoid. body. putty kidney 3. AVN • Intraosseous ganglion (classically the medial malleolus) • GCT • Chondroblastoma • Clear cell chondrosarcoma (similar to chondroblastoma) • EG • Infection (Brodie’s abscess) • Brown tumor Red marrow lesions • • • • Metastases Multiple myeloma Ewing’s sarcoma Lymphoma Lesions without associated pain • Fibrous dysplasia • Enchondroma • NOF • UBC Similar appearing lesions • ABC + osteoblastoma • Chondroblastoma (child. RCC • Multiple myeloma (ribs especially) • Osteomyelitis (hematogenous) • Fibrous dysplasia (unilateral polyostotic) • Brown tumor • Eosinophilic granuloma • Lymphoma/leukemia • Enchondroma: Ollier’s disease. the periprostatic fat in symmetric. a utricle cyst is midline. torsion • Trauma (hematocele) • Varicocele: idiopathic (left). cryptococcus) • Chondromyxoid fibroma. Risk factors for urothelial tumors include tobacco. enchondroma Giant cell tumor NOF Osteoblastoma Metastases. nulliparity. corkscrew ureter. tail) • Hydrocele: idiopathic. Prostate cancer in classically hypoechoic on US and hypointense on MRI 8. Hodgkin’s lymphoma. The volume of an ovoid organ can be determined by using the formula for a prolate ellipse: l x w x h (0. infundibular stricture. RA. Within the prostate gland. which may be associated with squamous carcinoma 5. gonadoblastoma • Orchitis • Trauma • “Burned out” tumor (echogenic focus) Extratesticular mass • Epididymitis • Spermatocele (epididymal head) • Epididymal cyst (head. while an ejaculatory duct cyst is paramedian. intra-abdominal mass causing venous obstruction/compression • Hernia Miscellaneous facts: 1. metaphysis) • Malignant fibrous histiocytoma • Fibrosarcoma (metaphysis) • Hemangioma Expansive lytic lesion • Metastasis: thyroid carcinoma. inflammation. while only 10% occur in the transitional zone. Sertoli cell tumor. coccidiodomycosis. hemangioma • Infection (Brodie’s abscess. infection • >40 y/o: metastases. multiple myeloma (plasmacytoma) • ABC Simple bone cyst Well-defined sclerotic lesion • Metastasis: prostate. multiple myeloma.Solid-appearing adnexal mass • Exophytic leiomyoma • Ovarian torsion • Hemorrhagic cyst • Endometrioma • Abscess • Ectopic pregnancy • Dermoid • Solid ovarian tumor: primary (fibroma.
adult • Cleidocranial dysplasia • Hypertrophic osteoarthropathy (dysostosis) (spares epiphyses): bronchogenic • Metastasis. bismuth. chronic osteomyelitis. neuroblastoma metastases. sacrum • Paget’s disease (pelvis. • Infection: IVDA localized fibrous tumor of the pleura. Wimberger ring) • Congenital infection (STARCH) • Juvenile chronic arthritis • Rickets (physeal widening. pubis. other pulmonary conditions. others Ill-defined sclerotic lesion • Metastasis: prostate. carcinoid. ilium. spine. metaphyseal cupping/fraying ) Juvenile chronic arthritis comprises Still’s disease (seronegative juvenile-onset RA). hypoparathyroidism • Hypervitaminosis D • Leukemia • Rickets (healed) • Scurvy (white line of Frankel. tibia. cardiac disease. arcs) • Hodgkin’s lymphoma • Chronic osteomyelitis • Stress fracture (metatarsal shafts. Gardner’s • Juvenile chronic arthritis syndrome • Turner’s syndrome • Osteoid osteoma • Pseudohypoparathyroidism. calcaneous. bladder. GI conditions • Scleroderma • • ASEPTIC mnemonic: Alcohol . skull. radiation osteitis • MFH • Desmoplastic fibroma (mandible. Cushing’s disease • Inadequate fracture immobilization • Paralysis: heterotopic ossification in SCI. Paget’s disease. Meyer’s dysplasia • Spondyloepiphyseal dysplasia • Trisomy 18. sacrum) • Involuting lytic lesion: NOF. seronegative spondyloarthropathy Dense metaphyseal bands • Growth arrest/stress lines • Heavy metal poisoning: lead. Pelekan beak. • Osteoblastoma pseudopseuodhypoparathyroidism • Brodie’s abscess • Trauma • Stress fracture • Sickle cell anemia • Parosteal osteosarcoma • Cortical desmoid Dactylitis (posteromedial suprachondylar linea • TB aspera of distal femur at adductor magnus • Sickle cell anemia insertion) • Psoriasis (sausage digit) • Parosteal lipoma (rare) • Melorheostosis Erosion of distal clavicle (cortical/endosteal hyperostosis in a spinal • Hyperparathyroidism nerve dermatomal distribution) • RA • Post-traumatic osteolysis Diffuse periostitis. osteofibrous Lymphoma. femur. SLE • Enchondroma • Low grade chondrosarcoma • Fibrous dysplasia • Healing stress fracture (metatarsal shafts. Osteogenesis imperfecta. tibia. osteopetrosis Epiphyseal irregularity • AVN • Congenital infection (STARCH) • Hypothyroidism • Dysplasia epiphysealis multiplex: chondrodysplasia punctata. multiple myeloma carcinoma. femur. Trummerfeld lucent zone. arsenic. usually after treatment) • Venous stasis • Fluorosis Diffuse periostitis. Trummerfeld lucent zone. mercury • Osteopetrosis • Hypothyroidism. 21 (accessory epiphyses) • NL variant Avascular necrosis Short metacarpal/metatarsal Focal periostitis/cortical hyperostosis • Idiopathic • Osteoma: sporadic. tibia) Stress fractures: Fatigue or Insufficiency fractures Lesion with sequestrum • Osteomyelitis (child) • EG • Fibrosarcoma: de novo. pubis. neuromuscular disorders • Osteogenesis imperfecta • NO SIR mnemonic: Neuromuscular disorders. Wimberger ring) • Congenital infection (STARCH) • Osteopathia striata (Vooerhoeve’s disease): coexists with osteopoikilosis. Infection. AVN. breast. colon. Steroids. other severe anemias • Niemann-Pick disease (rare) • Osteopetrosis (rare) • Metaphyseal dysplasia: Pyle’s disease (rare) Enlarged bone • • • • • (rare) Paget’s disease NF-1 Acromegaly Hemangioma Macrodystrophia lipomatosa High-riding shoulder (<1 cm from acromion) • Rheumatoid arthritis • Rotator cuff tear • CPPD Diaphyseal bone lesions • FEMALE mnemonic: • • • • • • Fibrous dysplasia EG Metastasis Adamantinoma. multicentric osteosarcoma • Congenital syphilis • Hypervitaminosis A (>6 months) • Scurvy (>6 months) • PGE2 Excessive callus formation • Steroids: exogenous. long bones) • Lymphoma • Metastasis (rare) • Osteoid osteoma (pseudosequestrum) Lesions with fluid-fluid levels • ABC • GCT • Chondroblastoma • Osteoblastoma • Telangiectatic osteosarcoma • Pachydermoperiostosis • Thyroid achropachy (feathery. Hodgkin’s lymphoma. cloud-like) • Chondrosarcoma (rings. femur. calcaneous. juvenile onset seropositive adult-type RA.• Mature bone infarct: SCD. medulloblastoma • Immature bone infarct/osteonecrosis • Osteosarcoma (amorphous. melorheostosis. child • Physiologic • Caffey’s disease • Child abuse • Malignancy: leukemia. Reduction (poor) Erlenmeyer flask deformity (undertubulation) • Gaucher’s disease (rare) • Thalassemia. Pelekan beak. leukemia Ewing’s sarcoma dysplasia Lucent metaphyseal bands • Severe illness (defective osteogenesis) • Leukemia • Neuroblastoma metastasis • NL variant • Scurvy (white line of Frankel.
Blastic metastases (breast. iatrogenic injury (ACL repair) • NF-1 (anterior) • Physiologic bowing of tibia (posteromedial) Premature closure of physis • Trauma: Salter-Harris 5 fracture • Juvenile chronic arthritis • Hemophilia • Accelerated skeletal maturation: McCune-Albright syndrome. Enigmas: pyknodysostosis. calcific tendinitis • Arthritis (periarticular osteopenia): RA. Osteitis. osteomyelitis Acroosteolysis • Scleroderma • Injury: frostbite. Anemia (Sickle cell). neoplasm (telangiectatic osteosarcoma). rickets • RA (severe) • Ankylosing spondylitis • Infection • OA (atypical medial migration) • Paget’s disease • Trauma • Prosthesis. Simulates Ewing’s sarcoma. Panner’s disease (capitellum). osteopetrosis. Pustulosis. Stage 5: secondary OA collapse Coarse trabeculation • Paget’s disease • Osteopenia • Hemangioma • Thalassemia • Gaucher’s disease (rare) Regional osteopenia • Disuse osteoporosis • Reflex sympathetic dystrophy: trauma. myxedema. melorheostosis. trauma • Neuropathic arthropathy: diabetes. burns. congenital indifference to pain • Distal embolism • Epidermolysis bullosa (rare) • Congenital erythropoietic porphyria • PVC exposure (thumb) • Pyknodysostosis • Idiopathic acroosteolysis of Hajdu and Cheney • Leisch-Nyan syndrome • • • • • • LEMON mnemonic: Lymphoma Ewing’s sarcoma. Gaucher’s disease AVN stages Acetabular protrusion • Osteomalacia. SLE.• Sickle cell anemia. Mastocytosis. RA. and is treated with NSAIDS. hypothyroidism). Iatrogenic: radiation. SLE • Transient regional osteoporosis: transient osteoporosis of the hip. Lymphoma. radiation • Familial acetabular protrusion (Otto’s disease) • • TB EG • • Stage 0: NL imaging Stage 1: NL x-ray/abn bone scan & MRI • Stage 2: mixed lysis & sclerosis • Stage 3: subchondral lucency • • Stage 4: fragmentation. MI. prostate). Keinbock’s disease. Sacroiliitis occurs in 1/3rd of patients. Renal osteodystrophy. syringomyelia. methysergide intoxication. steroids • Caisson’s disease (the “bends”). Hyperostosis. stroke. regional migratory osteoporosis • AVN • Ill-defined lytic lesion: osteomyelitis. electrical injury • Hyperparathyroidism • Psoriasis • Raynaud’s phenomenon/disease (white. EG. throacic outlet syndrome. fluorosis. a chronic disease of relapses/remissions. SLE. scleroderma • Exogenous or endogenous steroids • Pancreatitis • • Trauma Idiopathic: Legg-CalvePerthes disease. hyperthyroidism Well-formed bone spurs • Degenerative enthesopathy • DISH • Fluorosis • Acromegaly . Metabolic (hypervitaminosis D. red): primary. infection. prostate • Renal osteodystrophy • Sickle cell anemia • Osteopetrosis (sandwich vertebrae. septic arthritis. rare) • Pyknodysostosis • Paget’s disease • Mastocytosis (rare) • Myelofibrosis • Fluorosis • MARBLE mnemonic: Myelofibrosis. EG Multiple myeloma Osteomyelitis Neuroblastoma Diffuse osteosclerosis • Metastasis: breast. occurs in the clavicles of children. secondary to scleroderma. Tuberous sclerosis Expansive lytic posterior element lesion • Osteoblastoma • ABC Bone bowing • Paget’s disease • Osteogenesis imperfecta • Osteomalacia/rickets • Fibrous dysplasia • Growth plate injury: trauma (Salter-Harris 5 fracture). lytic phase of Paget’s disease Cortical striation/tunneling (rapid bone turnover) • Thyrotoxicosis • RSD • Disuse osteoporosis • Hyperparathyroidism • Paget’s disease (lytic phase) Pseudopermeative pattern with cortical holes • Hemangioma (ST phleboliths) • XRT • Aggressive disuse osteoporosis Permeative lesion Epiphyseal overgrowth • Hemophilia • Juvenile chronic arthritis • Paralysis Subchondral cyst • • • • • DRIP mnemonic: DJD RA Ischemic/avascular necrosis Pseudogout (CPPD) SAPHO: Synovitis. severe gout. blue. Acne. Blount’s disease. Paget’s disease.
CPPD. hemochromatosis • Ochronosis • Acromegaly • Articular dysplasia: spondyloepiphyseal dysplasia. milk-alkali syndrome. syringomyelia. Morquio’s syndrome. multiple epiphyseal dysplasia. DDH Destructive arthritis with sclerosis and debris • Neuropathic arthropathy: diabetes mellitus. MS. other seronegative spondyloarthropathies Poorly-defined bone spurs • Psoriatic spondyloarthropathy • Reiter’s syndrome • Ankylosing spondylitis • Avulsion injury Monoarticular arthritis • Trauma • Infection: pyogenic arthritis (gonococcus. seronegative arthritis. but plain film shows osteopenia in amyloidosis PVNS + giant cell tumor of tendon sheath are similar on MRI. Ehlers-Danlos syndrome Ribbon ribs Olecranon soft tissue swelling (extensor surface) Gout • RA • Bursitis • Trauma Ulnar deviation of metacarpophalangeal joints RA • SLE • Jaccoud’s arthropathy: ligamentous laxity due to rheumatic fever Radial deviation of metacarpophalangeal joints • Juvenile chronic arthritis Sacroiliitis • Ankylosing spondylitis • Psoriatic spondyloarthropathy • Reiter’s syndrome • Enteropathic arthropathy: IBD. tonsillitis • Congenital: Down syndrome. mixed connective disease • Tumoral calcinosis: hypercalcemia (renal failure. neoplasms. tarsal) • Muticentric reticulohistiocytosis Amyloidosis + PVNS similar on T2. leprosy. IBD Accelerated osteoarthritis • Articular trauma • CPPD. TB • Neoplasm: PVNS (rare). congenital hypoplasia of dens/os odontoideum (Down syndrome. SLE. Ehlers-Danlos syndrome Atlantoaxial subluxation • Trauma • Arthritis: RA. seronegative spondyloarthropathy. hypervitaminosis D.• Ankylosing spondylitis. Moroquio’s syndrome) • Occipitalization of C1 • Ligamentous laxity: Marfan’s syndrome. synovial osteochondromatosis • Inflammatory arthritis: RA. staphylococcus). fungal • Hyperparathyroidism (erosions) • Gout (less common) Arthropathy with soft tissue masses • Gout (Ca++ tophi only with concomitant renal disease) • Amyloidosis • Nodular RA (pressure points of extensor surfaces) • • • • • • Rib lesions • • HORNS mnemonic: Hyperparathyroidism Osteogenesis imperfecta RA NF-1 Scleroderma Fibrous dysplasia ABC . multicentric reticulohistiocytosis • Adjacent infection: pharyngitis. hyperparathyroidism. calcium hydroxyapatite deposition disease Purely erosive arthritis • RA • Pyogenic arthritis (acute) • TB (indolent) Erosive and proliferative arthritis • Psoriatic spondyloarthropathy • Reiter’s syndrome • Ankylosing spondylitis (can mimic RA) • Juvenile chronic arthritis • Pyogenic arthritis Arthritis with preserved joint space • Gout (until late) • TB (indolent course) • Juvenile chronic arthritis • Hemophilia • Amyloidosis • Synovial osteochondromatosis • Robust (cystic) RA (young male) • Reactive synovitis: infections. juvenile chronic arthritis • Crystal-induced arthritis: gout. syphilis. but GCTTS is located in the soft tissues near the joint Periarticular soft tissue calcifications • Hydroxyapatite deposition disease • Gout • Scleroderma (CREST syndrome). sarcoidosis) The anterior talofibular ligament is the most frequently injured ankle ligament CREST syndrome • • • • • Calcinosis Raynaud’s phenomenon Esophageal dysmotility Sclerodactyly Telangiectasia Chondrocalcinosis • CPPD • Hemochromatosis • Hyperparathyroidism (primary > secondary) • Gout Spine spondylolistheses • Spondylolysis • Facet degeneration • Degenerative disc disease (retrolisthesis) • Trauma • Ligamentous laxity: Marfan’s syndrome. congenital indifference to pain • CPPD • Chronic pyogenic arthritis • Ochronosis Neuropathic joint (5 D’s) • Destruction • Debris • Dense • Dislocation • Distension (effusion) Calcified intraarticular loose body • Synovial osteochondromatosis • Detached osteophyte (OA) • Acute osteochondral fracture • Osteochondritis dissecans (unstable fragment) • Ochronosis Joint effusion • • • • • • • • • Surgical arthrodesis Previous trauma Pyogenic arthritis Coalition Psoriatic spondyloarthropathy Reiter’s syndrome Ankylosing spondylitis Erosive OA RA (carpal. Whipple’s disease • Infection: pyogenic.
narrow interpediculate Anterior scalloping of vertebrae distance. lucent skull. thanatophoric dwarfism • Mesomelia: mesomelic dwarfism. tapered proximal metacarpals. RA. neuroblastoma • Paraganglia: pheochromocytoma. The differential includes child abuse. champagne pelvis with small sciatic notch. lymphoma Periapical abscess Neuroblastoma 10 mandibular tumor Floating teeth • • • • • • Achondroplasia • Mucopolysaccharidoses (middle/Moroqio’s. hypoplastic dens. Look like homozygous achondroplasia. Reiter’s syndrome • Symmetric: Ankylosing spondylitis. thick phalanges. (contralateral hypertrophy) short wide fingers. A ganglion occurs in the superior/posterior aspect of the shoulder in the spinoglenoid notch Grades of ligamentous SPRAINS • 1: perifascial edema/hemorrhage • 2: partial tear (increased T2 signal) • 3: complete tear (increased T2 signal with disruption) GRE sequences have low TR (20). Madelung deformity. Marfan’s cases syndrome. exuberant Calcaneus lesions (epiphysis equivalent) • GCT • Lipoma • UBC • Infection • Chondroblastoma . sporadic). chondroectodermal dysplasia (Ellis van Creveld syndrome). sarcoma • Sympathetic ganglia: ganglioneuroma. telephone receiver femurs • Metastasis with prominent spur of the inner proximal • ABC femur. short wide phalanges. • Aortic aneurysm square iliac bones (elephant ears). posterior vertebral scalloping. flared metaphyses • TB • Thanatophoric dwarfism: Absent pedicle narrow chest. small foramen magnum. flat femoral epiphyses. neurofibroma. syringomyelia. decreased T2). flat • Lymphadenopathy acetabulae. inferior/Hurler’s) • Down syndrome Posterior scalloping of vertebrae • Increased spinal pressure: neoplasm (lipoma. flared iliac wings. SLE. Cushing’s disease • Discogenic sclerosis • Osteopetrosis Increased interpediculate distance • Trauma • Syringomyelia • Intraspinal tumor • Dysraphism • AVM Expansive lesion of sternum • MAC mnemonic: callus. multiple myeloma ABC Chondrosarcoma Blow-out lesion of the posterior elements • ATOM mnemonic: Enlarged vertebrae • Paget’s disease • ABC • Acromegaly Bullet-shaped vertebrae • HAM D mnemonic: • Hypothyroidism • • • • ABC TB Osteoblastoma Metastasis EG Leukemia. platyspondyly. ependymoma). NF-1 (more severe than heterozygous): small foramen magnum. Fatal Dwarf syndromes . Ehlers-Danlos syndrome. tapered proximal metacarpals. low TE (15) MRI protocols to memorize! Shoulder Sag Obl STIR & PD Cor Obl STIR & PD Ax GRE & PD Knee Sag T1 & fat sat PD Cor STIR & PD Ax T2 & PD Elbow Sag STIR Cor T1 & STIR & 3D T1 GRE Ax PD & STIR Wrist Sag T1 Cor T1 & STIR & 3D T1 GRE Ax T2 & PD Metastasis: breast. platyspondyly. multiple myeloma EG Enchondroma Chondrosarcoma • Osteoblastoma Paravertebral ossification • Asymmetric: psoriatic spondyloarthropathy.Use Taybi’s book of hydrocephalus (long-standing) metabolic disorders & syndromes to look up • Dural ectasia: NF-1. posterior vertebral scalloping. juvenile osteoporosis • Hypophosphatasia: osteopenia. prostate Paget’s disease Hodgkin’s disease > NHL Chronic osteomyelitis Discogenic vertebral sclerosis Osteosarcoma • • • Metastases. scooped out metaphyses • Hurler’s disease: J-shaped sella. wormian bones. handle bar clavicles. Acromegaly. steroid osteoporosis.• • • • Metastases. so check if both parents Dense pedicle have achondroplasia • Congenital absence of • Osteogenesis imperfecta contralateral pedicle (congenita): osteopenia. neurofibroma. accordion shape femurs. beaked vertebrae (inferior). ganglioneuroblastoma. wide acetabular roof Dwarf syndromes based on site of extremity • Rhizomelia: achondroplasia (AD. short horizontal • Acromegaly ribs. glomus tumor A target appearance is seen with neurofibroma secondary to myxoid degeneration (increased T1. Marfan’s • Homozygous achondroplasia syndrome. Ehlers-Danlos syndrome • Jeune’s asphyxiating thoracic • Achondroplasia dystrophy: narrow chest. metaphyseal • Congenital absence flaring/widening. triradiate acetabulum • AMEN mnemonic: Achondroplasia. beaked vertebrae (middle). flared iliac wings. enteropathic arthropathy • Anterior: DISH (4 or more levels) • Focal mass: TB Disc calcification • Degenerative disc disease (dystrophic) • Ochronosis (young adult) • CPPD (chondrocalcinosis) • Surgical fusion • Ankylosing spondylitis • Hemochromatosis Ivory vertebrae • • • • • • Dense vertebral endplate • Degenerative disc disease • Renal osteodystrophy (Rugger jersey) • Excess steroids (marginal condensation): organ transplantation. multiple • Osteoblastic metastasis fractures. wide acetabular roof • Moroqio’s disease: vertebra plana. acrodysostosis Neurogenic tumors • Peripheral nerve: schwannoma. Cornelia de Lange syndrome • Acromelia: asphyxiating thoracic dystrophy. asthma.
Scleroderma has acroosteolysis. Ribbing’s disease (multiple hereditary diaphyseal sclerosis with thick diaphyseal cortices) are similar. torticollis. MCL and posterior horn of the lateral meniscus are commonly injured together. In RA. and is confined to the 41. Miscellaneous facts: 1. Spondylolisthesis grade 1 is <25%. osteofibrous dysplasia (ossifying fibroma). Differential includes traumatic myositis. fibular collateral ligament). Paravertebral ossification can be vertical (syndesmophytes) or horizontal (osteophytes) 7. osteomyelitis 18. Normally. knee. A bucket handle tear of the meniscus is suggested when only 1 bow tie is seen on sagittal view. AVM of the femoral head is usually anterior/superior in location with a serpiginous border 12. 43. metastases. the left widens 22. and is evident by >2 consecutive bow ties on sagittal images. pseudohypoparathyroidism is an end organ problem. TB spondylitis (calcified paraspinal mass). 34. 36. Distal soft tissue nodules of the digits with associated erosions may represent multicentric reticulohistiocytosis 11. and often is not repaired by orthopods The lateral ligamentous complex consists of a conjoined tendon posteriorly (biceps femoris tendon. wormian bones. Os odontoideum should have well-corticated margins. MFH/fibrosarcoma 20. Erosions in DJD can occur in the pubic symphysis. On coronal images. Sarcoidosis involving the digits has a lace-like osseous destruction with ST swelling 8. There may be fluid in the tendon sheath with or without tendonitis because it communicates with the joint The Achilles tendon has no sheath so no tenosynovitis. RA. 31. tapered terminal phalanges. or in older folks may occur with a rotator cuff tear Gadolinium arthrogram/MRI is done using 200:1 saline-to-GAD dilution Two mimics of a superior labral tear are the sublabral foramen (at the level of the middle glenohumeral ligament) and the Buford complex (absent anterior superior labrum with thick middle glenohumeral ligament) Biceps tendonitis appears as increased tendon size with increased signal. patellofemoral joint 3. hyperparathyroidism. coxa vera A giant cell tumor of the tendon sheath has a propensity for the foot. Discogenic vertebral sclerosis has a density abutting the end plate with narrow disc space and osteophytes 6. anemia. If large amount. fractures. cartilaginous Osteopetrosis has dense bones. consider GCT. 27. . it extends 53. short ribs. nor the end organs A Segond fracture is an avulsion of the lateral 50. These also cause diaphyseal overgrowth.cortical hypertrophy of the anterior arch of C1 19. On T2. 42. infection. Ribbing’s disease is milder and occurs in middle age 46. grade 3 <75% 24. HSM. hemophilia. SI joint. gracile diaphyses 13. and the iliotibial band anteriorly. Chondroectodermal dysplasia (Ellis VanCreveld disease) is ?mesomelic shortening with a trident acetabular roof and polydactyly. the anterior labrum in larger than the posterior labrum. except when located in the calcaneus 17. calcified larynx/sternum 26. Myositis ossificans progressiva is heterotopic ossification around multiple joints with a monophalangic great toe (synostosis between 1st metatarsal and proximal phalynx). muscular abnormalities. AC joint. 28. the right widens. parosteal osteosarcoma. Calcaneonavicular and talocalcaneal (middle facet) coalitions can be osseous. ossification of the pubic symphysis. C1-C2 move en masse with one side staying wide during rotation of the head to either side. and with turning to the left. to the interchondylar notch on the lateral tibial plateau and anteriorly on the lateral femoral condyle The transverse ligament extends between the anterior horns of the menisci and can simulate a tear. 37. With rotatory fixation. and pseudopseudohypoparathyroidism is neither a problem with the parathyroid glands 49. delayed 40. Normally a meniscus is seen on 2 images ACL. radiocarpal joint. CPPD may be associated with hemochromatosis. younger patients who have gait disturbance. hila) 39. A talar slant is seen in JRA. shoulder. Scheurmann’s disease is multiple AVM of the vertebral apophyseal rings +/. hyperparathyroidism Differential Diagnoses Nuclear Medicine 38. 30. suspect a full thickness tear The AC joint can be used as an anterior landmark to localize the critical zone. diagnosis. all of which look similar on plain film The superior glenohumeral ligament parallels the base of the coracoid process For the short 4th metacarpal differential 48. tendon (looks like PVNS). SLE of the digits has hypothenar ST wasting.• Brain (screening) Sag T1 Cor T2 GRE Ax T2 & FLAIR 25. CPPD likes the elbow. the ligament of Humphrey insertion may simulate a tear A torn PCL has uniform intermediate signal. hypoparathyroidism is a problem with the parathyroid glands. adamantinoma. fibrous.kyphosis 15. meniscal signal is OK Discoid meniscus occurs laterally in children. 33. ST Ca++ 10. osteopenia. Chondrodysplasia punctata (stippled epiphyses) has short humeri. Consider BMT Progressive diaphyseal dysplasia and 44. fracture 14. triangular fibrocartilage complex of the wrist 2. Increased T1 signal may be due to volume averaging with peritendinous fat or magic angle (supraspinatus tendon 55 degrees to bore of magnet) or degenerative tendinopathy In the shoulder. Cleidocranial dysostosis has delayed closure of the fontanelles. Mallet finger results from avulsion at the extensor digitorum tendon 23. but PDD occurs in 45. Often occurs with ACL tear Multiple hereditary exostoses has up to 20% 51. crystal deposition disease. 32. if you turn your head to the right. Labral tears occur anteriorly>posteriorly. A desmoid tumor can occur in the foot Up to 80% of tarsal coalitions are bilateral. Bone bruises (kissing contusions) occur posteriorly Modified Biello Criteria NL Low probability (3-5%) • Rat bites only • V/Q matches with NL CXR • Non-segmental Q abnormality (cardiomegaly. capitellum 16. or patients with collagen vascular disease. and least often superiorly A SLAP lesion is due to pull of the long head of the biceps during throwing motion. carpal fusion 47. bone-within-a-bone appearance. the so-called “plica syndrome” Fluid in the subdeltoid/subacromial bursa may be bursitis or related to a tear. Tibial lesions include fibrous dysplasia. some increased 52. which blends into the patellar retinaculum With patellar dislocation (usually lateral) the medial patellar retinaculum is disrupted with increased signal If the medial patellar plica thickens. At the meniscofemoral ligament insertion posteriorly. Destruction of a total hip arthroplasty can be secondary to particle disease (polyethylene). joint capsule at the tibial plateau. neuromuscular disease (paraplegia). tendinopathy or partial tear. tophi calcify only with associated renal disease 5. loss of corticomedullary junction. except in children where it represents hypervascularity. clavicle dysplasia (usually the middle 1/3rd). and may be due to RCT from impingement (anterior acromion on greater tuberosity). short tubular hand bones. 29. exostoses. coronal cleft of the vertebrae. grade 2 <50%. gout 4. it may mimic an MCL tear. In the 30-40 y/o group. TMJ 21. risk of malignant transformation On T1. Partial or complete tear of the Achilles tendon most often occurs in 40 y/o athletic males. Chondrocalcinosis in CPPD typically occurs in the pubic symphysis. UBC is usually curettaged and packed. ligamentous laxity (ulnar deviation) 9. any increased meniscal signal is ABNL. talus. aorta. osteomyelitis. 35. +/. Osteochondritis dissecans likes the knee. which is 2-3 cm long just proximal to the supraspinatus tendon insertion Only increased T2 signal in the critical zone is ABNL.
metastasis A superscan can be due to diffuse metastases (prostate. if it follows only red marrow. primary ST tumor. More focal liver uptake can occur with metastases. ESRD Increased MDP soft tissue uptake occurs in metastases. XRT. If PSA >8 ng. not enough lasix dose. Check time-activity curve pre. hyperparathyroidism. abdominal bruit with HTN • DMSA study with SPECT or glucoheptonate can be used to look for smooth renal contours and homogeneous cortical activity. immature renal function in a newborn. doxorubicin toxicity • • • • • For myositis ossificans surgery should be performed when the bone is mature. SCCa of head & neck. lung. osteoid osteoma. Normal time to peak (TTP) is <4-5 minutes. previously well-controlled HTN now difficult to manage. but can occur with chemotherapy. metastases. hematoma. angina. Use MAG3 (ERPF agent. Start with captopril exam by hydrating patient. Acute fractures can be seen <24 hours (young) or > 48-72 hours (elderly) Knee replacement may take >2 years to normalize.15 microCi/1 mCi 99m Tc Renal scintigraphy • A diuretic renogram checks for the presence of obstruction in a dilated collecting system. excess aluminum (antacids. and timeactivity curve. poor hydration. thyroid carcinoma. evidence of vascular disease elsewhere. while a ureteral leak occurs days 1-3 postop • Radionuclide cystogram for VUR is graded as minimal (ureter only). whereas 10-20 minutes is indeterminate and >21 minutes is obstruction. Give lasix at 20-30 minutes or when pelves are full. while MAG3 is preferred in a child and renal insufficiency. NO osteoblastic response. malignant pleural effusion. ST attenuation may cause false negative MDP. thyroid). lymphoma • A donut appearance may occur with MDP in GCT. stress fracture. Hypotension during the exam can cause a false negative study • Indications for ACEi study include new HTN >60 y/o or <20 y/o. metastases • Semarium-153 & Strontium-89 can be used for bone pain due to metastases if hot on MDP • Myocardial MDP uptake can occur in MI. leukemia • MDP imaging • Increased MDP uptake by kidneys is most commonly due to dehydration.• Stripe sign • Intermediate probability (20-50%) • Q = CXR abnormality (triple match) • COPD > 50% with abnormal CXR • Single moderate/large V/Q mismatch High probability (~90%) • At least 2 moderate/large V/Q mismatches with NL CXR • Significantly unmatched Q >> CXR Total lung perfusion abnormality • Tumor. use 111In & 99mTc sulfur colloid.3. artifact. renal insufficiency. then MDP may be helpful • Flare phenomenon occurs <6 months after therapy.and post-lasix. breast. unless there’s cortical retention. then give captopril and check BP every 15 minutes for 1 hour. Need good hydration and an empty bladder to promote diuresis. amyloid. orthopedic hardware. dehydration. hyperparathyroidism. severe HTN refractory to medical therapy. EG. pyelonephritis Cold defect on MDP may be due to metastases (renal. then metastases are more likely. primary tumor. while hip replacements take 6-12 months. hepatoblastoma. Wilm’s tumor. Check flow and functional images for 30 minutes. lymphadenopathy • Mediastinal fibrosis • Large central PE • Pulmonary agenesis. neuroblastoma • Osteomyelitis (early) • • Radiation. barium • Artifact: PMT/preamplifier • Diffuse increased uptake on bone scan (“Superscan”) • • Renal failure/secondary hyperparathyroidism • Hyperparathyroidism • Osteomalacia • Metastases: prostate. amyloidosis. prostate. colon. and is more common in cadavaric transplants. 10 mCi) and lasix (40 mg). dehydration. congestive cardiomyopathy. With DTPA (GFR agent). pacemaker. usually 2-3 months. dialysis Increased MDP uptake in muscle may be due to rhabdomyolysis. from Tc generator). necrosis. cellulitis. Acute rejection may take up sulfur colloid. MAG3 and DTPA are used. sarcoma. aplasia • Swyer-James syndrome • PTX • Large pleural effusion • • • • • • • Photopenic lesion on bone scan • Infarct/AVN (early) • • Certain metastases: RCC. but NOT ATN • ATN occurs during first week after transplant. anaplastic malignancies • • Neoplasms: multiple myeloma. nephrocalcinosis • Hyperparathyroidism may cause increased MDP uptake in the lungs and stomach due to metastatic calcification • Multiple myeloma. hypervitaminosis D. lung. shown by NL MDP study or when >2 successive 6 month MDP studies show improvement. lymphoma. but ATN will NOT • No flow may be due to renal artery occlusion or kinking. uterine cancer. hypercalcemia. breast. but poor function. electrical burn Cortical focus of MDP uptake may be Brodie’s abscess. multiple myeloma Increased diffuse liver MDP uptake may be due to excess ALUMINUM Fractures (90%) are NL by 24 months on MDP. neuroblastoma or osteosarcoma metastases. Paget’s disease with sarcomatous degeneration. Washout T1/2 (half time) should be <7-10 minutes (no obstruction). while infection occurs along whole prosthesis If MDP & 111In are incongruent. XRT. Also. bronchogenic carcinoma A sternal lesion in a breast cancer patient is metastatic disease in 76% cases Brown tumors are usually photopenic unless there is a pathologic fracture Shoulder or hip amyloidosis may show increased MDP uptake For a MDP superscan. consider metabolic causes Poor MDP uptake occurs in incorrect radiotracer/preparation. moderate (pelvicalyceal). cholangiocarcinoma Renal osteodystrophy (osteomalacia. trauma. Femoral component shows activity for 12 months (cemented) or up to 24 months (uncemented) If suspecting infection in prosthesis. checking for congruent uptake in marrow. a positive study will show asymmetry of split renal function. although chronic use without an additional dose at time of study is allowed at some institutions (decreased sensitivity). contamination. If abnormal [delayed time-topeak (>5 minutes) with cortical retention of radiotracer] do a baseline study. The 20 minute-topeak ratio should be <0. abscess. Mesoblastic nephroma can concentrate glucoheptonate • Interstitial nephritis can show gallium uptake. hepatoma. Cyclosporine toxicity mimics the appearance but occurs later • Acute rejection occurs during first few months and shows decreased perfusion but good function. At 1 hour void patient and image. Commonly occurs with breast. osteomyelitis • Increased liver activity on MDP may be secondary to faulty preparation of radiopharmaceutical with colloid formation. . hyperparathyroidism) may cause increased MDP uptake in the lungs. mastocytosis. AVN. lung. ACEi block conversion of angiotensin 1 to angiotensin 2. osteomalacia. hemangioma. May wish to give lasix 15 minutes prior to injection of agent to maximize flow to kidneys • An ACEi renogram requires the patient to be off ACEi for 48 hour for best results. liver amyloid (dialysis) can cause diffuse increased MDP uptake. stomach. suspect infection If there is diffuse increased MDP uptake by the liver. Etidronate (bisphosphonates) use. HCC. atherosclerotic heart disease. hyperparathyroidism. Mo breakthrough should be <0. osteomyelitis (increased pressure). kidneys • Aluminum breakthrough from Tc generator should be <10 micrograms/ml. lymphoma/leukemia). lymphoma. If the while skeleton is involved. This may take up to 2 years in some cases Increased pulmonary MDP uptake may occur in metastatic Ca++ of renal disease. A poor response to lasix can occur due to full bladder. There is less activity in medulla and no activity in collecting system (unless with Glucoheptonate you imaged early or there’s an obstruction). renal vein thrombosis or hyperacute rejection • Lymphocele occurs 1 week to 4 months postop. iron overload. bladder carcinoma • Hematologic disorders: myelofibrosis. polymyositis Increased MDP uptake in kidneys may be due to chemotherapy. iron overload. neuroblastoma. This shows good perfusion. Loosening occurs at tip and trochanter. myositis ossificans. ask if the patient had a recent 99mTc liver study.
mucous plug). and check % excreted (NL is 10-40% PO dose). In an infant. and cimetidine blocks secretion during Meckel scan. hemangioma. FNH. metastases (lung. hemangioma. FFA used). sarcoid. do FDG PET to show viable tumor. If 58Co-B12 is low and 57Co-B12-IF is NL. partial gastrectomy Doudenal cut of sign in HIDA imaging suggests acute pancreatitis (and GB won’t be seen at 60 minutes) Small bile leaks may require delayed images After Whipple procedure may use HIDA to check patency of bile ducts On HIDA. meningioma. duplication. paraganglioma. delayed (1-2 hours) imaging. lymphoma) • GI imaging • In the esophagus. If HIDA goes cold to hot on delayed images. inject MAA into peritoneum and check for lung uptake A 99mTc pertechnetate salivary scan (with lemon juice) shows hot area for Warthin’s tumor For tagged RBC bleeding scan. but NO DVT. Masses should be photopenic. Merkel cell. inflammation. pituitary adenoma (GH).5 cm for SPECT. bronchial obstruction (cancer. especially with in vivo method of labeling. pneumonectomy • If DTPA diffuses into lungs. adenoma. tumor emboli • The fissure sign can occur in COPD. HCC • May see focal intrahepatic hot spot in BuddChiari syndrome (increased caudate lobe relative to surrounding tissue) and SVC/IVC obstruction. IVDA. If low probability scan with low clinical likelihood and NO DVT. pleural thickening. chemotherapy. and if so.severe (pelvicalyceal with dilatation of the intrarenal collecting system and tortuous ureter Pulmonary imaging • Decrease dose/number of particles (1-2 mCi/100 K ) in pregnancy • The single breath image represents TOTAL LUNG CAPACITY. Don’t call it erosive gastritis! Check thyroid for uptake. Budd-Chiari syndrome. XRT. then take . Check FEV1 in ml x % of lung to be operated on. size. >1. COPD. Tumors >1 cm (primary. and amniotic fluid microthrombi. PTX. bowel fistula. SLE. toxic inhalation. Check for normalization of urinary 5-HIAA HIDA bile pooling may indicate partial obstruction (stricture. stone. TB. depending on age. Lesions should be >3 cm for planar imaging. is caused by tumor. abscess. vasculitis • Can perform a preoperative ventilation study for fractional assessment of lungs for bullae resection. likely there is intermittent bleeding from UGI tract. these patients are more likely to need . postvagotomy. ulcer. PE. lymphangitic carcinoma. or GI bleed. IVDA. or can be due to medications (MSO4) Increased uptake on liver-spleen study may occur in FNH. a mottled appearance of perfusion. Takayasu’s arteritis. primary pulmonary HTN. upper respiratory infection. Plus. aspiration pneumonia. HCC. pheo/neuroblastoma. GI bleed. collagen vascular disease. The washout images are the most sensitive for air trapping (NL <2-3 minutes) • Perfusion defects can occur in cancer. HCC. Does NOT occur in ATN • To visualize small accessory spleens or residual splenic tissue after splenectomy on sulfur colloid study. If suspect IBD. NO anticoagulation or pulmonary angiogram. suspect pleural effusion • A-1-antitrypsin disease causes retention at lung bases and poor perfusion at bases (loss of gradient from apex to base) • Bullae can simulate lobar matched defect. narcotics. coexisting cardiopulmonary disease. spontaneous GER > 4% is abnormal. IPF • If high probability scan with high clinical likelihood. but may show colloid shift when diffuse fatty infiltration is present • Hepatic blood pool scintigraphy (tagged RBC study) for hemangioma uses flow. bronchial carcinoid If CT shows scarring. obstruction. XRT. cancer. NO anticoagulation or pulmonary angiogram. CHD. Wegener’s). tumor. lung transplant. Swyer-James syndrome.4cc/sec. pleural effusion. regenerating nodules can take up HIDA. very rarely microemboli • The majority of PEs resolve in 2-3 months. False positive in metastases. Crohn's disease. melanoma) can mimic the appearance • Non-visualization of liver on sulfur colloid study may indicate end-stage liver disease. early (5-20 minutes). UE injection with SVC obstruction via the internal mammary vein to left umbilical vein to left portal vein 111 In octreotide scan is used in neuroendocrine tumors. Watch out for misleading appearance of ureteral activity. delayed excretion may be due to hepatic dysfunction or high-grade bile duct obstruction. edema. whereas > 7 % with provocative maneuver is abnormal. anticoagulate. angiosarcoma • May see renal uptake during sulfur colloid study due to CHF. enterogastric reflux may be NL (post-prandial. however. extrinsic compression). prolonged fasting. NL study NO anticoagulation. check doppler exam. and no bowel activity at 24 hours. ask is activity outside of NL blood pool. 810 keV) capsule and 57Co-B12-IF (122 keV) capsule. islet cell. SCCa lung. there is poor uptake and delayed visualization of biliary tree/bowel. surgery. fat. Branch photopenia may indicate chronic obstruction May have “preferential GB filling” without obstruction due to chronic cholecystitis (scarring of sphincter of Oddi?). breast. bronchiectasis • Contour mapping. fibrosing mediastinitis. suspect ARDS. With hepatic dysfunction. aortic dissection with hematoma compressing right pulmonary artery (also as complication to aortic valve replacement). in cirrhosis. Low probability scan with intermediate-high clinical likelihood. mucous plug. there is better/NL uptake by liver (especially Mebrofennin <20mg %). then pernicious anemia (not making IF in stomach). FNH. cirrhosis with regenerating nodules HCC may be mildly photopenic on HIDA. usually ETOH > other causes. contusion. used for intractable ascites) patency. can do somatostatin therapy. then malabsorption • Fatty infiltration should show NL sulfur colloid uptake. Collect urine for 24 hours (minimum 1L). May see NL renal activity and free pertechnetate in stomach. Example 31% R. Angiography 1cc/sec. or in a renal transplant due to chronic rejection (microthrombi). Stable patient with high probability scan and low-intermediate clinical likelihood. If colon activity increases at 3 & 24 hours. collagen vascular disease. HIDA may show uptake. do early (4 hour) and 24 hour imaging to check persistence over time For Laveen shunt (from peritoneum to jugular vein/SVC with catheter extending to near RA. XRT. Bowel uptake can occur from swallowed secretion of URI/pneumonia. s/p cholecystectomy) or pathologic in obstruction. Bilroth I/II. 69% L. but so can COPD. If physiologic myocardial uptake a concern. medullary carcinoma of the thyroid. pulmonary artery sarcoma. met. if negative do pulmonary angiogram • Posterior view shows decreased activity with NL anterior view. does it show antegrade/retrograde movement within bowel. LE injection with IVC obstruction • • • • • • • • • • • • • • • via the left umbilical vein to left portal vein. Try CCK to overcome functional obstruction at sphincter The GB will NOT be seen in acute cholecystitis or complete obstruction Biliary dyskinesis may show no response to CCK or an ejection fraction <35% Focal 111In colon uptake may occur in diverticulitis. If good uptake. >2% is abnormal • Use a salivagram/GER study to check for aspiration • Pentagastrin increases pertechnetate uptake. but if 58CoB12 is low and 57Co-B12-IF is low. AVM can cause false positive • A hemangioma shows decreased perfusion. Check for increased space between flank and liver edge that suggests ascites • HCC (>2-5 cm) shows increased activity on 67 Ga. tumor. Use cine scintigraphy. Should be >800 cc for survival • False positive FDG PET scans in granulomatous disease (TB. think HCC On HIDA. do 8-12 hour fast (glucose use is minimized. In young patients. With obstruction. pleural effusion (passive atelectasis) • A false positive study with perfusion mismatches can occur in cancer compressing the pulmonary artery. including carcinoid. cancer resection. pneumonia. SVC obstruction. Stable patient with high probability scan and high clinical likelihood. but lymphoma. XRT. NSCCA lung. pneumonia. smoking. you may need to increase intensity setting • FNH (40-70%) on sulfur colloid study show NL or increased uptake due to Kupfer cells. NUCS 0. abscess. intussusception. 80% clearance of 99mTc sulfur colloid occurs within 15 seconds • In GERD. adenoma. post-XRT. dilated bile duct • Dual isotope capsules for Schilling’s test consists of 58Co-B12 (510. • False negative study has been reported in BAC. pulmonary artery hypoplasia. pyloroplasty. while equilibrium (3-5 minutes) shows VOLUME of AERATED LUNG. intrahepatic GB. anticoagulate. increased blood pool activity • In vitro method of RBC tagging has a >95% labeling efficiency • A Meckel diverticulum should have the same intensity of uptake as the stomach • Colloid shift on liver-spleen study indicates diffuse liver disease. False positive in hamartoma. lymphoma. PEs may resolve in 3-7 days • Ventilation defects with good perfusion can occur in atelectasis.69 x FEV1 volume of lung to show amount remaining.
MEN II dedifferentiates. PCP. Faint uptake may be NL Increased gallium activity may occur in the thymus and salivary glands after XRT/chemotherapy Always hydrate with PET FDG to avoid confusing GU uptake FDG PET imaging for pulmonary nodule can be false negative in BAC and carcinoid. MIBG can be used in paraganglioma. but it is too medial and transient • A cold nodule in a euthyroid patient has 10% risk of cancer. neuroblastoma. try 111 In and SC bone marrow study to check for congruent uptake • False positive 111In study occurs in RA. usually 4 hours) renal activity. so NO talking during exam. due to edematous/hyperemic liver tissue with prolonged transit of HIDA. use • A hepatic arterial perfusion scan can be MIBG because renal uptake in kidneys during performed to show distribution of Octreoscan may be misleading chemotherapy • Can use an intraoperative gamma probe for • Chemoembolization of HCC (doxorubicin. Similar appearance can occur following recent cholecystectomy Non-visualization of the GB occurs in acute/chronic cholecystitis. dysembryogenesis (ectopia. . HCC • 131I NP-59 is used for adrenal cortical imaging. Try FDG PET for lymphoma defect) occur • After chemotherapy. suggests chronic cholecystitis. hyperalimentation. SUR > weeks.• • Tumor imaging • Use a Dual Head Gamma Camera in Coincidence Mode for PET. healing fracture. left ovarian vein. proliferative disease • A cold nodule is malignant in multinodular goiter in 1-6% cases • Somatostatin imaging is most useful with APUD tumor with type 2 SSR. Sulfur colloid nodule is call Marine-Lenhart disease shows photopenic HCC. post-XRT. If >liver. high-grade lymphoma. thrombus in pseudoaneurysm. histoplasmosis. wait 1 day before resuming (T1/2 110 minutes) • For medullary carcinoma of the thyroid. Do a Cytomel suppression test • MDP and FDG are better in skeletal lymphoma for 7 days. then it’s than gallium autonomous • FDG uptake in neck may be due to tumor. lymphoma hypernatremia. give MSO4. varices (caput madusa). such as Conn’s syndrome (metabolic acidosis. which indicates activity in • No IV contrast for 1-3 week. XRT. GI tract. while Octreoscan (50-75%) shows diffuse disease Medullary carcinoma of the thyroid has elevated calcitonin/CEA. sarcoidosis. Synthroid for 4-6 weight and FDG dose. may be due to increased uptake (Grave’s disease) angiography. then it’s pathologic thyroid study. or cancer thyroiditis. May see NL uptake in cecum lymphoid tissue or in the thymus after chemotherapy. (63%) hot on gallium. For a myocardial study. In >1 cm nodule. surgery. If sentinel LN is positive. False positives include TB. NF-1.5 suggests tumor • A solitary cold nodule is malignant in 15-25% • MIBI in breast cancer study may show false cases positive with fibroadenoma. but so are metastases. GDA aneurysm HIDA rim sign is seen in acute cholelithiasis. Hypermetabolic focus >1. Dilated cystic duct sign can occur after MSO4 due to increased pressure. consider hyperplasia. ATN. hypokalemia) due to • FDG can be used to differentiate malignant vs. FDG positive in Paget’s disease Bilateral uptake <5 days. TB.5 suggests benignity Chest tube needed after transthoracic biopsy in 5% cases FDG uptake in cecum. consider adenoma. FNH (70%) on sulfur colloid show NL/increased uptake • A cold area within a hot nodule is suspicious for cancer • If PET patient is breast feeding. If neuroblastoma shows avid MIBG uptake. prolonged fasting. functioning aldosteronomas. pelvic venous collaterals. vasculitis. suggests acute cholecystitis in appropriate clinical setting. Check delayed images. pancreatitis. Anxiety increases activity in paraspinal and trapezius muscles. drugs (bleomycin) • For sickle cell disease with suspected osteomyelitis. XRT. s/p cholecystectomy. pyogenic abscess. physical distention of GB At 60 minutes if no GB is seen. If hot nodule. and an intraoperative gamma probe can be used Use Octreoscan for bronchial carcinoid 131 I MIBG is used for neuroblastoma. Tuberous use intraoperative gamma probe with sclerosis Octreoscan • For pheochromocytoma/neuroblastoma. gelfoam) can be performed. while in Grave’s disease it’s higher • • • • • • • • • • • • • • • • • • • Gallium uptake in the pelvis of a child. so don’t be fooled. 2x transfusion requirement Decreased liver blood pool activity on tagged RBC study suggests liver disease False positive bleeding scans can occur in AAA. consider gallium scan first • 111In may be falsely negative if antibiotics have been given. Use semiquantitative standard Thyroid imaging uptake ratio (SUR). Carney syndrome. LAD • A discordant nodule may be multinodular goiter (metastatic). lymphangitic carcinomatosis. Uptake will be seen in all exercised muscles. gangrenous GB. spleen. inflammation. carcinoma. or in spine abnormality • For infection or loosening of a prosthesis. abscesses. SUR <2. pyelonephritis. use MIBG or Octreoscan • Octreoscan for carcinoid may change from positive to negative when tumor • Pheochromocytoma occurs in VHL. May see uptake in a renal transplant. Sjogren’s syndrome. chronic ETOH. follow-up gallium study • Hypertrophic and autonomous hot nodules are should wait at least 4-6 weeks to avoid false different. a TSH-dependent cold • HCC (50%) accumulate FDG. EARLY (<24 hours. Relative photopenia can agenesis) and dyshormogenesis (organification be seen I necrosis. lymphoma/leukemia. Hashimoto’s thyroiditis. multiple transfusions (iron deposition). Consider • physiologic renal activity with Octreoscan may a b-blocker before future studies using IV be misleading. and false positive in granulomatous disease (TB. lymphoma Increased gallium uptake in the kidneys at 24 hours occurs in obstruction. can use it as treatment. carcinoid. Waldeyer’s ring is NL. gallium. any pneumonitis. thyroid lymphoma • In Grave’s disease.5 cm • • Gallium uptake occurs in tumors and inflammation • Gallium salivary gland uptake occurs in sarcoidosis. parathyroid localization ethiodol. consider beware in diabetic patients dexamethasone-suppressible hyperplasia. then scan. and an intraoperative gamma probe can be used. sarcoid). which may also show increased uptake on MDP due to microcalcifications. a complete LN dissection will be performed FDG PET in occult breast cancer shows axillary LAD and breast lesion. whereas Kaposi’s sarcoma is thallium (+) only • FDG PET should be done after 8-12 hour fast. thus poor Octreoscan <1% cases uptake • Transient hyperthyroidism after IV contrast Use MIBG for pheochromocytoma because administration is called Jod-Basedow. Unilateral uptake osteopenic vertebral compression fracture <5 days. fungal disease. PTU (antithyroid lesion (microCuries/cc) corrected for patient medication) for 1 week. Hypertrophic nodule is due to negative study inflammatory insult or degenerative and is TSH-dependent. Insulinomas • Malignancy occurs in toxic nodule or goiter in have few SSR2 receptors. but mammogram/US is negative An occult primary adenocarcinoma is usually from lung. renal carcinoma. Cytomel (T3) for 2 weeks 2. thallium (for viability after chemotherapy or surgery). If don’t see GB over 30 minutes after MSO4. consider rhabdomyosarcoma. sarcoid. Use Octreoscan for ALL others! contrast • Gallium imaging is best for intermediate to • In children. MIBI Infection/Inflammation imaging • Increased diffuse gallium activity in the lungs may occur with IPF. consider cathartics Sarcomas can show increased uptake on FDG. use whole body Octreoscan to check for multiple tumors Gallium uptake in the abdomen can be due to liver. the patient is leukopenic. suture granuloma. give glucose load (with • or without insulin) to promote glucose use. If see GB. pancreas. May give booster HIDA at 60 minutes. FDG can show response to chemotherapy by decrease in uptake SCCa lung may have NL MDP. • • Hyperglycemia causes false negative FDG. FDG remains positive! May syndrome. • Always compare gallium uptake to liver • If salivary glands are NOT seen well on 99mTc (internal control). medullary thyroid carcinoma Mucinous GI tumors show increased MDP uptake For paraganglioma. TB • • Lymphoma id gallium (+) and thallium (+). Check for absent NL native kidney uptake Sentinel LN injections use sulfur colloid. so Bilateral uptake >5 days. and will be positive on Octreoscan and FDG SPECT Octreoscan lesion should be >9 mm.
The double product (HRxBP) should be >25. where flow is adequate to preserve cell viability but NOT function. rim around cold defect on static images. lymphoma shows increased FDG PET. with a lead strip over the median raphae on one image • • • • • progressive supranuclear palsy. tumor. perforated viscous. referred pain. MIBI underestimates viable myocardium to greater degree than thallium Use FDG (preferable) or 24-hour thallium to check for hibernating myocardium (82% for FDG vs. acute inflammatory arthritis. while chronic may cause decreased perfusion Thallium SPECT can be used for determining recurrent tumor vs. Check for regional wall motion abnormality. Always compare PET uptake to white matter. then later do without pain study. during a dual isoptope FDG/MIBI study To increase FDG uptake. then it may be Charcot joint 111 In likes neutrophils (ACUTE. diabetic arthropathy. no ventricles are seen. 2nd or 3rd degree heart block. then there is NO significant difference in risk compared to NL population. Wilson’s. bilateral hematomas. Obesity can cause global abnormalities. it may not change by 5%. Some institutions are doing sequential imaging or dual isotope simultaneous acquisition SPECT with FDG and MIBI. increased activity in epididymis on static images The torsion study uses immediate flow and delayed static imaging. Similar appearance in Parkinson’s. there may be global decrease in FDG uptake due to hyperglycemia • Decreased FDG uptake in the basal ganglia occurs in Huntington’s (caudate). Hibernating myocardium may fill in at 24 hours on thallium study. If same area as sulfur colloid. shunt tip migration. then low grade tumor. Breast attenuation can affect the anterior/septal wall. If FDG positive. Try Indium Acute testicle pain can be due to manual or spontaneous torsion. Torsion should be diagnosed <4 hours for best chance at salvage of testis. A pain defect • • • • • can be due to MI (acute or remote) or ischemia. so be cautious when calling defects. Early torsion shows photopenia of the affected testis with asymmetry of the scrotum. prone imaging may be helpful (artifact should disappear) ECG-gated myocardial perfusion imaging shows LV regional wall motion abnormality. Paget’s disease. Abnormal vessels do NOT dilate with Diamox. mimic signs of brain death with isoelectric EEG • For ictal injection. but low uptake with toxoplasmosis.). gallium will show other cause of FUO such as tumor Use 111In in suspected bowel infection. which may be misleading 111 In photpenia can be due to tumor. Cardiac imaging • Ejection fraction should increase by 5% during exercise. try MDP/gallium combination and look for incongruent uptake Gallium imaging is bad in neuropathic joint with suspected infection. LBBB can cause a reversible anteroseptal defect. torsion of the appendix testis. Late torsion shows a halo or bullseye appearance. leukemia.99:1 suggests low-grade glioma. or concomitant use Aminophylline or caffeine. consider doing thallium 24 hour imaging . using contralateral area of brain as reference. Revascularization is beneficial On thallium. low-grade glioma • • • • Brain imaging • Diamox challenge is used to check vascular reserve. and high dose (20-30 mCi) stress injection. but so can an abscess Testicular abscess has increased flow. it won’t work) • At peak exercise.000 for an adequate stress • We do thallium rest study because ST attenuation is worse and we don’t want the stress study to be subject to as much attenuation artifact • An exercise LVEF <30% has 62% 6-year survival • If previous MI or the patient cannot do strenuous activity. acute fracture. horizontal long axis inferior-anterior wall Can use cardiac imaging to assess preoperatively the risk for perioperative event. then risk of perioperative event increases 4-8x (10-30%) in low-intermediate risk patients (based on clinical data/ECG changes) Only thallium can show a reverse redistribution defect. Causes include adhesions. then hibernating myocardium. hematoma. multisystem atrophy Increased FDG uptake can occur in granulomatous disease (TB.• • • • • • • • • • prosthesis. In elderly woman. then high grade tumor • Hypothermia. vertical long axis septum-lateral wall. whereas distal obstruction shows ventricles but no peritoneal cavity. and unlikely to benefit from revascularization Short axis is filmed apex-base. RSD. vertebral osteomyelitis (20%). which may be due to prior revascularization. If proximal. peritonitis preventing CSF resorption Thallium.5:1 ratio. fungal disease. kinking. high-grade glioma. Delayed torsion has decreased flow. start imaging. Give Diamox 30’ before injection of perfusion agent. so do delayed imaging to sort it out Hibernating myocardium is chronically ischemic myocardium. If it’s the same. 68% with thallium improve with revascularization) If diaphragmatic attenuation is a possibility. Epididymitis has increased flow. <2 weeks). Target heart rate is >85% of the maximal predicted heart rate (220-age). XRT. global systolic function. so if FUO is presentation. Flow should increase 30% in NL patient. If it extends beyond margin of sulfur colloid activity. drug-induced coma. a patient with a high resting EF. suspect infection. If it’s higher (2x). Dobutamine) • Stress myocardial perfusion imaging • Can use MIBI in ER patient during chest pain. MIBI negative. then suspect exerciseinduced ischemia. while FDG takes 30-50 minutes to peak • In Alzheimer’s disease. thrombolytic therapy MIBI 1-day protocol use low dose (8mCi) at rest. GI bleed. cardiomyopathy. Check systolic wall thickening. If poor uptake in IDDM patient. there is decreased perfusion in bilateral posterior temperoparietal area. do Persantine or adenosine study • Perfusion-metabolism mismatch: viable myocardium. do a modified Bruce protocol where speed or grade are incrementally increased every 3 minutes (Bruce protocol increases both) • If patient unable to exercise. If FDG negative. do HMPAO. If NO reversible defects. may try gallium study first. If >3.5:1. Unilateral decrease perfusion can occur (usually on left) in Alzheimer’s disease and primary progressive aphasia • Pick’s disease or frontal lobe dementia • In a diabetic patient. For thallium. NPH. If it falls. MIBI can be used to differentiate XRT vs. may give insulin. then infarct. use HMPAO because uptake is rapid (maximum at 1 min. Perfusion-metabolism match: myocardial scar • No dipyridamole or adenosine in bronchospam disorder. If <3. hypotension. while >1. reinject at 2-4 hours (reinjection or restredistribution image). Rest image at 15-30 minutes. reversible metabolic coma. Low perfusion suggests XRT necrosis VP shunt malfunction occurs proximally & distally. then do pharmacologic stress test • If LBBB (reversible septal defect). XRT. metastases. recent stroke/TIA. Assess endocardial excursion and segmental wall thicken to help determine if something is artifact or ischemia/infarct • • Remember there is more ST attenuation with Tc 140 keV compared to FDG 511 keV. amyloid. or valvular disease. myelofibrosis Increased activity on MDP may be due to primary or metastatic tumor of bone. so less perfusion occurs in the corresponding territory (steal phenomenon) • In AIDS. a fixed defect at 3 hours may fill in at 24 hours. sarcoid) causing a false positive scan Acute herpes infection causes increased perfusion & FDG uptake. rim around cold defect on static images. infarction For 111In look for congruent activity in bone marrow with sulfur colloid study. Fixed defect (3050%) will fill in on delayed images • Diaphragm can cause basal inferior wall defect. or high grade vs. osteomyelitis For spine infection in adults (not good in child). MI. as gallium and HMPAO are excreted into bowel and kidneys. Give Dobutamine instead (but if patient on B-blocker. indicating viable myocardium. XRT necrosis. seen with significant tachycardia (exercise. Plus. MIBI negative. bilateral parietal strokes. Or try FDG. If reversible defect. especially in inferior wall. swallowed from sinonasal infection.
there is slow radiopharmaceutical by chromotography (>80% diastolic filling (slow upstroke) on time-activity is NL). hypertrophic cardiomyopathy. Do delayed images with MIBI or prone positioning to confirm that was the cause. then lateral view esophagram shows similar kind of middle mediastinal mass. and most with exercise A reversible defect can be due to ischemia. CT shows line clearly in the aortic arch. Retrocardiac density CXR left side. recalibrate • If background noise increases suddenly. An exercise study should show little splanchnic activity because it’s shunted away to muscle Increased thallium/MIBI uptake can be due to lactating breasts. saliva) • Use the correct pharmaceutical • Check MAA particle size. or is there a R-L shunt? Image brain • Clumping of MAA occurs when blood is drawn back into the syringe. HTN. Mass left heart border on CXR. LV aneurysm. button. the tip was not over the SVC but was more midline. CAD. For FDG PET wait 1 day EF is end diastolic counts – end systolic counts/end diastolic counts – background counts. inflammation. arterial spasm. 9. LV aneurysm. indicating diastolic dysfunction. medication T: trauma V: vascular A: artifact. 5. Check with flood source • Faint uptake throughout all images may be OFF-PEAK window. some management questions. flailed for a while. Mimics include myocarditis. Thallium cannot have delayed images because of redistribution. claustrophobic. For MIBI. Discussed drainage technique Pericardial cyst Acute LA enlargement. Normal LVEF : 50-80% (55-65% at our institution) If radionuclide ventriculogram looks bad. I flailed tremendously on these and surely failed them all. CT showed empyema. a low LVEF and multi-vessel disease The resting LVEF and pulmonary uptake on stress perfusion imaging are 2 parameters important for prognosis Thallium has certain advantages compared to MIBI. Of LVEF drops during treatment by >10% or to a EF <50% . worrisome for CA. abnormal original LCA. 247 keV) • A star artifact is due to septal penetration by high energy photons. Contaminants include free curve. Multiple cases of middle aged people with SOB and screwed up looking hearts. The 99MO generator creates 99mTc and free pertechnetate • In111 oxine-WBC can clump in the lungs. which is excreted RECALLS The following section was compiled by residents from another Midwest program.000 indicates adequate stress for detection of ischemia Increased RV uptake suggests RV overload or hypertrophy Radionuclide Ventriculogram (gated blood pool imaging) shows segmental wall motion abnormality and RV/LV chamber size • • • by the choroid plexus. neoplasm. then patient NOT treated with it. ddx. Portable chest with very hard to see right subclavian CVL. recent XRT For breast feeding after thallium. CXR with bilateral hilar adenopathy with several vague lung lesions. or poorly cooperative patients A double product >24. Use a high energy collimator with thick septae • When injecting lasix during a renogram. 4. hydrolyzed (reduced) Tc may be due to aortic stenosis. have patient wait 2-3 days. including less frequent/severe artifacts due to hot liver. amyloid. pericarditis. blood pool activity. 3. 7. Check the purity of the With decreased LV compliance. mets. however. jewelry. Discussed pressure measurements and different causes of pulmonary HTN Post trauma PTX. usually with hot spot in antecubital fossa/forearm • Prominent uptake in the ventricles on a HMPAO perfusion study may be due to increased free pertechnetate. Increased activity at the lung bases may be atelectasis • Infiltrated MDP can show axillary LN uptake. prosthetic eye! • In111 needs a medium energy collimator (172. cardiomyopathy. Activity decreases over 5-7 days unless MI is very large Radionuclide ventriculogram can be used prepost-doxorubicin therapy. Persistent air leak after tube placement. and can check stress induced pulmonary uptake and LV dilatation. halo artifact). allergic. so instead have patient drink water. Check with extrinsic flood (without collimator) to confirm • Mirror image artifact can occur with electronic malfunction • Overlap of organs may be due to the multiformat imager failing to advance (double exposure) • Increased lung and stomach activity can be seen in hyperparathyroidism (metastatic calcification) • Free pertechnetate can occur in any 99mTc study. creating hot spots. myocardial bridge. as well as a review book or CD! newly reversible defect in Post-PTCA patient suggests restenosis Remember… if you absolutely have NO idea what Multi-vessel disease is suggested by stress you’re looking at go through the various induced LV dilatation and thallium pulmonary disease categories: TIC MTV A uptake T: tumor (benign. 2. I included pericardial cyst in that location. A fixed defect is less likely viable with thallium compared to MIBI. I said that I would 10. If baseline LVEF <30%. CXR with left hilar mass. thyroid/parathyroid lesion. CXR with diffuse tubular lucencies. 12. worrisome for CA. aortic stenosis. CT with lingular lesion most likely CA. malignant) I: infection. XRT. included pericardial effusion. then showed head CT with ring enhancing lesion worrisome for abscess. syndrome X (angina without stenosis and NL coronary arteries) RVEF best determined by 1st pass method using Tc pertechnetate or MIBI. 11. which pertechnetate. Proceed at your own risk CHEST 1. autoimmune. Also you can do a 24 hour image because of longer T 1/2 to check for hibernating myocardium (FDG is only agent that’s better) Thallium. 14. Large heart w/o NL chest. iatrogenic C: congenital M: metabolic. If this is off (blurring. Higher activity will show up on the time-activity curve • Watch out for urine contamination (blood. it’s either PVCs or poor labeling Tc-pyrophosphate requires 24-48 hours (sometimes <12 hours) to be positive for myocardial infarction. has increased ST attenuation due to lower photon energy Planar cardiac imaging is only used today in morbidly obese. Do an ECHO Post-PTCA residual defects occur in 20-30%. 15. 13. ddx.• • • • • • • • • • • • • • • • • • LBBB shows a reversible anteroseptal wall defect because exercise increases delay between R & L ventricular activation relative to the duration of systole. causing multiple hot spots (labeled microemboli) in the lungs • Prior XRT may cause a cold defect • Collimator damage looks like a fine line across the image. Doxorubin toxicity. stop use of doxorubicin Diffuse pulmonary uptake on thallium (lung:ratio >0. sarcoid. wait 2 weeks. Cavitary lesion with A/F level. maybe intraarterial. what if patient just had MI?. inflammation. 8. zipper. it’s equipment malfunction or another patient/dose nearby • A photopenic area on all images in same place is PHOTOMULTIPLIER TUBE or preamplifier abnormality. Occurs less with adenosine & Persantine compared to Dobutamine. especially with stress reinjection. most c/w right to left shunt. or possibly too great distance from camera • Geometric cold areas may be extrinsic to the patient such as belt buckle. A Please refer to the protocols of your own institution. hiatal hernia.52) on PLANAR imaging indicates severe LV dysfunction. 6. Pleural plaques with mass in AE recess? mesothelioma Effusion with probable pseudotumor Enlarged central pulm arteries. extravascular. NL vessels. acquired Artifacts • Check daily the isotope peak calibration and intrinsic (without collimator)/extrinsic flood source • Heterogeneous activity on all images is a problem with UNIFORMITY • SPECT imaging requires CENTER of ROTATION checked monthly. . An equilibrium radionuclide ventriculogram can determine LVEF Increased splanchnic activity can cause increased inferior wall artifacts. he pushed a little further and I clammed up. I thought most c/w bronchiectasis. make sure no residual radiopharmaceutical is in the syringe by using saline. lymphoma.
Bitch. Bronchial lesion with post obstructive pneumonia 4. anatomy all distorted. 5. 8. Then she asked what Crohn’s would look like. PAST RECALLS: 1. 10. Collapse of LUL ?Mass Mitral Stenosis wit LA enlargement on CXR Aortic Laceration Persistent L SVC into Coronary Sinus Eisenmenger Physiology Apical massPancoast Intraparenchymal hematoma PE wit Hampton’s Hump 3. bx. There is a demineralized patient curled over upon himself into a ball.632 Hepatic Adenoma. Meckel’s. Right ventricular aneurysm with calcification. gave DDx 9. Sequestration. She showed me the images and proceeded to mis-identify them. likely cancer.Case 128 Next case was an IVP with dilated bowel loops. FNH Recurrent Sigmoid CA Ulcerated Esophageal CA Antral and Duodenal Narrowing due to scirrhous breast CA Esoph Stricture distal Gallstone ileus Thumbprinting in Colon. Posterior mediastinal mass 7. 6. Case 605 Large tubular low density structure RLQ on CT. Follow through in the pelvis. contained perf vs. 15. 12. 6. 8. RLL opacification on CXR. 20. The one straightforward case. It looked like a cecal volvulus. abnormal small bowel loop. 5. Classic chronic UC. Pericardial effusion on lateral CXR GI 1. 1998 Recalls: 1. I said I would do a decub to exclude perforation first. 22. 3. Dilated ascending aorta---give DDx. I said Upper GI. For the most part. 6. other pelvic structure filling. 7. everything I could think of about Crohn’s. Case 510 Long segment narrowing right colon and prox transverse colon with ulcerations and? extension into TI. met. 2. She didn’t ask the things we usually review like inheritance or associated tumors. this is GI”. Mitral stenosis 3. 6. 13. UC Caroli’s Disease wit ADPCK 5. Cystic fibrosis with focal infiltrate 10. 1. 24. 608. 5. 13. 13. 2. She asked what I would do next. 8. I look at it for a minute and then she says “Now remember this is a GI case”. ? abnormal loop of bowel vs.just tell the Drs of the location. 17. 9. 4. 8. 7. 9. esophagram with mass at GE junction. Large cystic mass left lobe liver with septation and ? nodule of wall. 7. 16. 23. 8. I have no idea what I was shown 1. Finally. primary tumor. 7. 10. Foreign body aspiration in kid 8. hemangioma. 18. Diffuse bilateral nodules---Histo. 1998 Recalls: 1. 14. 5. 19. Then she went into a long line of Questioning about polyposis. Looked like SBO. 5. 2. 607. 7. 8. Then she said “but Barium is inert. Instead she wanted to know about therapy for Cronkite-Canada and how long people with that syndrome live. arterial phase and called the arterial phase the venous. additional images given confirming mass. 11. she was nice and gave relatively unhelpful history. 11. bony dysplasia. She puts up a film that looks like your worst nightmare from Riley. likey met. 3. 4. he seemed unhappy with that approach. Carcinoid. 2. . 4. why are you worried?” I was trying real hard not to kill her and told her about barium peritonitis. She called a non-contrast image the 10. skip lesions. 7. She asked if I would use Barium. Crohn's vs. I said I wasn’t sure whether the abnormality was proximal or distal so I would do CT. 11.cystic with enhancing rim 1. likely carcinoid. Aortic transection on CXR and CT. other iatrogenic causes of perf. She asked about why the terminal ileum was abnormal and I described backwash ileitis. Severe scoli. 4. fistulae. 12. Then she says “so how do you tell the difference between UC and Crohn’s. mucosal thickening and cobblestoning. CHF. 15. Pleural rind soft tissue on CXR. 25. PAST RECALLS: 1. 3. Case 513.I’m not sure if that was in Peds or Chest… Chest. 14. “remember. UC. CT showed Spigalian hernia. BE with 2 cm irregular filling defect sigmoid colon. Anterior mediastinal mass 6. 4. 2. after all this she gives me the freaking CT I wanted in the first place. I told her about asymmetry. CXR status post pacemaker replacement with metal looking like pacer lead in LLL 5. I wanted to remind her this was a radiology exam. Case 626 Irregular smooth structure filling with contrast on sm. I saw one dilated loop in the RUQ and gave a differential. Duodenal CA. Swyer-James. infectious etiology. 6. I said PeutzJeghers. 6. DDx ischemic. 2. CA etc. fat density on CT: gave DDx 2. 12. then CT liver with enhancing mass. I chose to ignore her description and describe the hypervascular liver mass based on what I saw. Chest wall mass. 27. other infectious colitis discussed. She asked for a dif and I talked about other polyposis syndromes. ddx. I think Plain film superior mediastinal mass… MR showed it to be a massive aneurysm of one of the great vessels Asbestos plaques Discussion of asbestos exposure. I wanted to reply “then show me some freaking GI films. 3. 26. discussed types of colon polyps particularly the malignant ones. 5. Bwl. Case 319 Three phase CT. Case 636 linitis plastica Case 424 gastric ulcer with clot Case 412 vasculitis of SB in pt with SLE Case 525 NHL of SB Case 520 villous adenoma in duodenum Case 426 sprue scleroderma Case 525 Ca of gastric cardia spreading to distal esophagus Case 323 Crohn’s Case 514 Boerhaave’s Case 331 benign pneumatosis coli Case 628 intraluminal duodenal diverticulum Case 409 double channel pylorus SB lymphoma Case 520 giant fibrovascular polyp 2. Vydareny. invasive pulmonary aspergillosis (air crescent) TB fungus ball RLL sequestration eosinophilic pneumonia fibrosing mediastinitis with SVC obstruction mucoid impaction and metastatic renal cell Mournier Kuhn thymolipoma Castleman’s disease alveolar cell ca splenosis bilat diaphragmatic ruptures EG LAM IPF (remember association with adenoCa) lymphangitic carcinomatosis mosaic perfusion NF ATAI LUL collapse echinococcal cyst (pt presents with hemoptysis) mediastinal goiter (behind trachea with calcifications) bronchogenic cyst achalasia asbestosis (plaques not seen on lat) pleural lipoma 2000 Recalls: Dr. infection.Case616-617 Multiple duodenal polyps. 9. 8. 4. 2. 6. mucocele appendix. 3. She seemed angry and asked how else I might work it up. Case 320-325 Mesenteric mass with spiculations and calcification centrally and associated small bowel wall thickening. bitch” but I didn’t. Then when she got to the venous she got confused and had to start over and proceeded to mis-identify them in a whole new way. 7. 3. and the various diseases and risks Malignant mesthelioma. Causes of cardiogenic failure? Talked about guided biopsy and aspiration Bronchogenic cyst I had a case of a child with NF and neurofibromas. discussed Crohn's and fistula. 21. 1. Again. I just repeated everything again and she seemed angry again. 4.
then showed scapular Y-view confirming disloc. He occasionally asked what management I would recommend. 14. UGI: filling defect medial part of descending duodenum 2. 5. Focal area of jejunal edema with a tight segment of narrowing distally. what other study do you want?. 12. pelvis with right SI joint sclerosis and several enthesophytes. Unfortunately. U/S with mixed echo mass left kidney. 3. Gatenby. Adrenal mass vs. That started out with U/S. MR shows similar findings but more extensive appearance. pubic rami. 2. 6. came up with a synovial proliferative process. 9. MRI: uterine fibroid 10. 6. Shoulder MRI with classic rotator cuff tear distal supraspinatus tendon. 5. pap necrosis. Mucocele of appendix. 7. sort of looked like wadded up Penrose drains. most likely NOF. AML vs. anything else?. as well as other routes. I said could be VHL Papillary necrosis Bosniak 2 cyst. Led to CT and discussion of what information a surgeon might want to know. TCC vs shisto vs. 5. I asked for CT next. 7. 6. most c/w TCC Bladder wall calcification then IVP with filling defect bladder. 15. poor function Possibly a cloacal cyst that was adherent to bladder wall. air bubble vs. 7. Contrast reaction-treatment of hypotension/tachycardia mixed fatty mass upper pole right kidney vs. It was obvious on the ERCP… Some weird bilateral lower abd foreign bodies in a post-op patient.what the hey? Plain film: medullary nephrocalcinosis CT: extraperitoneal bladder rupture CT: renal cystic stx with faint wall enhancement. MRI. Xanthogranulomatous pyelonephritis with fistula to colon 2. what type of fracture might this be?. I didn’t know and said I would call the radiation safety officer and patient’s Dr. Gave typical dif then he asked “what if you saw the same thing in an adult” Pregnant woman with transient osteoporosis of hip focal cortical thickening prox humerus with central lucency.thin septa and calcs. 8. 4. CT: Splenic laceration 7. 13. she asked what else we could do. F/U a week later was NL. how much dose can a embryo take?. 5. effusion vs infection vs hemarthrosis. 9. 6. Hysterosalpingogram with contrast in uterus and fallopian tubes. 5. Ureteritis cystica Leaking AAA with extrav of contrast on CT. 16. Urethral stricture on retrograde with reflux of contrast into Cowper's glands. 15. 11. 5. 4. Myelolipoma. 1. ddx. 2. foreign object. Pelvis with healing left superior and inferior pubic ramus fractures and bones osteopenic. adenomyosis 2000 Recalls: Dr. Intussusception. Ram’s horn stomach Long discussion Infiltrative gastric cancer. maybe osteoid osteoma. 2. 6. 9. Retained sponge. maybe infection with sinus tract. I still thought hyperparathyroidism. CT.3. 8. Pyelonephritis. 10. XRT. polyp vs. 1. 14. lengthy discussion on shoulder dislocations. 11. IVP with filling defects in bladder and prox right collecting system. CT shows similar findings but there is a linear lucency going the cortex. no contrast: Elliptical fluid collection in base of penis……. Slightly expansile lytic lesion cortex distal tibia in younger patient. Pagets in spine Mets Osteopoikolosis Bone Infarct Exostosis SCFE Sub Ungual Exostosis Inclusion Cyst Perilunate disloc Lunate Disloc CPPD Lipohemarthrosis 7. Renal fracture with urinoma Splenic fracture. 2. 7. AP view shoulder with prob posterior shoulder disloc. a small filling defect present in uterine cavity. Emphysematous pyelo Adrenal Calcification. Pancreatic CA. most c/w psoriatic or Reiters. 7. what else?. she said patient just arrived from Cairo or somewhere. Cases were pretty easy and he didn’t ask for much in the way of differentials or management. I can’t remember if the beans were involved. 12. Testicular mets vs. It was pretty clear I didn’t know what this was… 11. 1. STOP. 2000 Recalls: Dr. CT with low density mass left kidney extending into the renal pelvis. ddx. 2. I said hyperparathyroidism. what else may appear like this. 12. 6. 4. SBFT/CT: Crohn’s 4. CT: Multiple pancreatic cystic stx: gave DDx 5. bx or surgical excision. CT: Hypervascular liver lesion 8. 8. CT. SB study showed a single loop that was about 15 cm in diameter. Younger patient with widening of right hip joint space. 2. Lymphoma Renal Lymphoma Enlarged Uterus. insufficiency fracture. ddx. CT and IVP with medullary nephrocalcinosis. 4. adrenal. UGI: Gastric volvulus 9. Pelvic fractures Ankylosing spondylitis OCD knee Calcaneus osteomyelitis MR Achilles tear Child with lytic metadiaphyseal lesion with surrounding periosteal rxn. 8. but must r/o infection. 12. He tried to help by telling me the patient had surgery a year ago. most likely RCCA with tumor thrombus and mets. 13. Transitional cell CA ureter with Bergman's sign on retrograde. (patient 17 y/o). DDX Pevlic Fracture with extraperitoneal Rupture Retrograde Urethrogram with anterior defectsChondyloma Traumatic UPJ transection RVT Periaortic LAD. 5. after some prompting I came up with a gestational sac—oh oh— what do you do now?. 3. MRI. AML with hemorrhage 4. where do these fractures occur in the pelvis?. 10. He seemed tired of the whole process and we flew through cases without much discussion. 11. Renal laceration 3. Plain film/CT: Pneumoretroperitoneum 10. 9. 9. 8. vs. Adenosis of uterus on MRI. 17. 6. myelolipoma. 4. 3. 7. 2. 4. CT: Pelvic lipomatosis 11. Discussion of causes of edematous pattern Klatskin tumor. 3. how would you work that up further?. which was no help. 3. Distal femur with classic parosteal osteosarcoma. small EM cancer. with a heterogeneous. 6. 1. Loosers zone scapula. bezoarlike filling defect. CT: Mesenteric adenopathy GU 1. which then led to a discussion of omental spread in particular. Cspine with anterior ankylosis. Asked for ultrasound solid mass Plain film/CT: MCDK CT: renal cell cancer CT: renal vein thrombosis MUSCULOSKELETAL 1. sacral arches. I blanked. Messinger. Fibroid vs. 1. pelvis with ? SI jt widening and Lspine with ? osteopenia. 3. 10. PAST RECALLS: 1. associated hemorrhage Polycystic kidneys with solid tumors. Bosniak grade 3 and grade 4 cysts Discussion of how to treat these Adult polycystic kidneys Renal TB ? Strictures. 7. Papillary necrosis on IVP. In the middle of one of the cases she stopped me and said a patient in the next room was getting a contrasted head CT and is now seizing! What are you going to do? 6. Retroperitoneal fibrosis. 1998 Recalls: 1. Classic SCFE. MRI: pheochromocytoma 5. CT: Portal vein thrombosis 6. asked for density measurements. 5. multilocular cystic nephroma but can’t tell that from RCCA. 3. . 4. SBFT: paraduodenal hernia 3. Papillary necrosis on IVP. Nasty right kidney mass with non-vis of IVC (probably tumor thrombus) and a liver lesion. 4. Bilateral angiomyolipomas with acute bleed on one side. 16.
but he told me lots of people couldn’t see the finding… 6. then switched cases before I even had time to discuss it. 6. I said it could be a glomus tumor. Strong start… 5. 3. 28. 12. No kidding. ? sinus thrombosis. That’s when I moved to the sag sinus. Psoriatic arthritis 5. 4. It wasn’t typical of anything. “If aliens came down and sat it these sessions. and listened to the discussions. I had mentioned EG during another case (which I can’t remember. 77. Distal metadiaphyseal bubbly lesion in forearm of 1-2 yo. 5. Multifocal bone infarcts. 48. effusion(hemophilia). MR with hyperintense mass on T1 and T2 most c/w cholesterol granuloma. 64. First case was an erosive arthritis. 68. so I discussed the findings and talked through my thinking. telangiectatic osteosarcoma vs EG on MR and plain film. 76. Multiple WM lesions C/W MS. Low density mass right sub mandibular gland. 9. sclerotic longitudinal strips involving ALL portions 11. leukemia Physis osteomyelitis 1998 Recalls: 46. ST calcification due to HPT. Fibrous dysplasia 8. DDXFracture. I offered up fibrous dysplasia and he asked what if the kid was from D. He gave me no histories even when I asked. Dense MCA/ infarct Intraventricular mass with hydro—I thought CP papilloma but gave a long dif. 14. 73. Maybe a tiny avulsion of base of distal phalanx of thumb.what it could be and why it wasn’t typical. but he didn’t seem happy. 2. 50. Segond fracture on MRI 3. Neuropathic joint. 74. The scaphoid. 56. 51. 10. 49. lymphoma. the carpal arcs of Gilula). DDX Reiter. fib. I said. 3. ABC vs. thin. diffuse and symmetric for infarcts…” and got “DON’T YOU THINK IT WOULD BE MORE SYMMETRICAL THAN 13. Gout Lymphangectatic Osteosarc on MR DISH. 11. He showed 7. 70. 17. 62. 42. I’m pretty sure it wasn’t EG. 16. 19. 10. 2. aliens. 15. MCA bifurcation aneurysm—CT then MRA. talked about possibility of spinal AVM. 20. not so much that the findings were hard but some of the stuff looked familiar but not classic. 2. 58. Meniscal cyst 6. 29. Gout 4. 24. 45. Anterior shoulder dislocation. 78. 39. osteo. Osteomyelitis. 23. osteoporotic female with bilateral sacral insufficiency fractures. “I agree it looks funny but there is something else”. Enhancing mass fourth ventricle. 72. agram with tortuous vessels at cord c/w AVM. 33. Something that started out looking like OCD of the femur. 7. additional images including MRV confirm. Hypertrophic osteoarthropathy 6. or so he led me to believe. 6.) The bell rang the second time. and I made a hasty exit. 2000 Recalls: Dr. 38. 31. but there was a lytic lesion in the prox tibia. 18. osteomyelitis 8. Pregnant or recently post-partum woman with HA. 32. 4. 5.He gave a history of “post-partum headache”. 55.13. At that point he launched into a discussion of 14. 43. 37. 83. mass. 69. 61. 21. He asked some basic questions about MRA Sagittal sinus thrombosis. He had to point out the most subtle tiny tubular filling defect at the very edge of the film to which I promptly agreed was real (yeah right). 53. . 44. I ran through the usual ddx list. He asked me. Lat view showed a large effusion or ST mass. 2. 1. Spondylolysis with reactive sclerosis Osteoid osteoma Stress FX Fongs disease Achondroplasia HPTH Enchondroma Neuropathic Joint AVN Myelomas Osteochondroma Butterfly Vert Body Sickle cell vert body Calcaneal Lipoma Scleroderma Hook of Hamate Fx OCD SONK Pagets in ileum Tarsal Coalition Frieberg's infraction th MT Myositis Ossificans B Facet lock NOF Post Humeral disloc Oss of Post Lig Ochronosis suprachondylar Process Madelung's deform Acromegaly Gout Cupids Bow…NL Variant PAST RECALLS: do you know what they would think is the most common disease? EG. Trauma case: two views wrist/hand. Medial collateral injury on MR. “this seems far too 12. carpal alignment. 82. arteriogram. Next case. 7. ddx. 52. 84. 1. 25. 65. what would you do next. 34. Spinal epidural abscess Temporal bone with mass posteriorly and inferiorly near jugular foramen. 80. asked what enhancement meant. Gilula ( ya know. 30. Pagets 9.C. 66. Osteosarcoma 7. 79. Rugger Jersey SpineROD Osteopetrosis in Vert Lead Poisoning Stylohyoid Ca++ Osteochondral Fx Game Keeper thumb Ca of Flexor Carpi Ulnaris Sarcoid Pelvic Finger Brodies Abscess Lupus Hemophilia in Knee Osteosarc SAPHO Avulsion Fax of PCL Avulsion Fx of inferior pubic Ramus Thyroid Acropachy Silastic Synovitis Hyperostosis Frontalis Insufficiency Fx Macrodystrophia Lipomatosa Condesans of Clavicle Ca++ in Gluteus Ollier’s Mehlorheostsis Lead Poisoning in spine Posterior Limbus Meniscal Cyst and Tear on MR Patellar Tendon Tear on MR ACL Tear on MR Medial Meniscal Tear on MR PVNS on MR Synovial Cyst on MR Osteochondral Fx on MR Segond Fx on MR Bone Bruise on MR Bone infarct on MR AVN of Hip on MR Transient osteoporosis on MR Tear of Supraspinatus Tendon on MR Perilateral Ganglion Cyst on MR OCD on MR Achilles Tendon tear on MR. and what I could see of distal fems of a child. though. MCs and phalanges looked NL. Young female with sag spine MRI increased T2 throughout distal cord with enhancement similarly. 85. 88. 7. asked about most common masses here in kids and adults. Bennet fracture 4. 22. eg. Gout. FIBROUS DYSPLASIA?!” as a reply. Path fx + periosteal rxn. 5. MRI with increased signal in region of straight sinus. 36. 1. “What’s your diagnosis?” I went with psoriasis. 67. 4. 75. ddx. 59. Fx of 5 Anterior fat pad sign in Elbow. I thought this section was the hardest overall. 1. 26. 71. two MR images that demonstrated a huge 8. 3. AS. NEURO 1. Psoriasis Gout Enchondroma OI Vertebra Plana Pagets Stress Fx of Calcaneus Ewing’s Neuroblastoma mets vs. Diffuse. 41. I obviously missed this case because the next case was… Classic glomus jugulare Degenerated facet with associated synovial cyst compressing nerve root. He bagged it and moved on.some strange expansile lytic lesion of prox humerus with periosteal reaction 2. He made a face. He said. 40. then showed myelogram which looked NL. 86. 3. 9. 35. 8. Braunstein won’t tell me what it was. 63. get MR. 81. Slightly expansile low density lesion petrous apex on CT. 54. 87. At first I thought the pituitary looked abnormal and was thinking Sheehan’s. 27. 57. of both tib. 47. 60.
15. 10. 6. 4. he kept asking for more. LE arteriogram showing tight stenosis of pop. I sent the guy to surgery. 13. Fractured catheter. 4. I said “that’s why we go straight to stent. angioplasty. 2. 2. She asked about catheter management. thoracic Ao dissection with aberrant R subclav a. Stab wound to shoulder. She said the guy has 14. 1. 16. and divertic of Kommerall pelvic hematoma displacing bladder treated with common iliac a. met vs trauma vs EG vs plasmacytoma. gradient less then 10 mmHg. peritoneal signs and lactic acidosis. 8. 10. 17. I said the guy’s gut is already dead so thrombolysis won’t help. 18. Pseudoaneurysm of one of the vessels arising from subclavian. Multiple pulmonary AVMs on CXR and pulmonary angio. asked about causes and management of emboli. 7. with the F/U showing marked increase in left/superior mediastinum. MRI 4. 11. Spinal cord ischemia due to aortic dissection on MRI 5. PTA air embolism to Ao and brain due to bx of lung nodules CABG aneurysm on CT (as ant mediastinal mass) pyogenic hepatic abscesses in pt with diverticulitis R psoas abscess cavernous transformation of PV with pseudoaneurysm of GDA and multiple hepatic abscesses effort thrombosis (Paget-Schroeder) pulm AVM UGI bleeding s/p B2 (Rx: with vasopressin instead of embo due to postop altered collateral supply) HCC with cavernous transformation and PV thrombosis (DO NOT DO TIPS) TIPS – puncture to IVC via R renal vein due to initial (mis)selection of inf. MRI 9. 8. when would you stop thrombolysis? And what is the time frame 18. 11. 16. 5. 1. phrenic injection of intralobar sequestration ATAI: avulsed R subclavian a. 6. 14. 6. Diverticular abscess. thrombolysis. could plasty. MRA or U/S. when would you pull drain?— essentially lots of questions on how to do procedure and manage patient. 7. 6. 7. Irregular lesion right CP angle isointense to CSF on all imaging sequences. 12. Angio showed mycotic aneurysm. Asked about treatment options. Disc free fragment. 8. 13. led to looking at rest of the head. asked about anatomy and all I knew regarding GI bleeding and angio. 9. 2000 Recalls: Dr. Dural sinus thrombosis: first non contrast CT then angio 2. MRI 8. a. how do you clinically follow patient?. Portal HTN. 6. Brain mass---discuss DDx. 3. likely stenosis from these multiple CVLs.15. 4. 3. Wished I knew all those vessels better. Sag MRI spine with collapsed single vertebrae with mass effect on cord and abnormal signal in cord at that level. options?. she asked about all the disease processes that can affect the pop. she showed a transvaginal drain and sinogram. Arachnoid cyst. c/w AV fistula. . Abd. Pelvic low density post-op female most c/w abscess. abdominal aortogram shows immediate filling of celiac. I said plasty and leave internal/external drainage catheter. atherosclerotic disease. transabdominal or transvaginal. Showed me a injection with persistent fistula. 9. CT with multiple wedge shaped defects spleen. Arteriogram of transplant kidney showing a tight stenosis and a ?pseudoaneurysm. CPA mass: gave DDx INTERVENTIONAL 1. 5. 3. coils. We talked about that. Thoracic outlet syndrome. Sure enough. Aortic Laceration Pseudo CoarctationAre there collaterals? Dialysis Graft Stenosis in Venous Limb Pancreatic Abscess drainage SMA occlusion What are the collateral Pathways? Biliary Stent occlusion with intrahepatic BDD. Orbital meningioma. Pelvic bleed s/p trauma. MS PICA infarct. CXR shows septic emboli. 12. should evaluate for other causes of SVC stenosis using CT. how manage?. 3. 4. Meningioma in Pineal Region Grey matter heterotopia TS Epidural Hematoma Macroadenoma of Pituitary Bilateral PCA infarcts and edema in BG Superior sagittal sinus thrombosis Leptomeningeal carcinomatosis Herpes encephalitis Arachnoid cyst 7. 8. Bovine arch with pseudoaneurysm at common origin. Thoracic outlet syndrome. 3. I said transgluteal drain. Ossification of Posterior Longitudinal Lig.. 2. PAST RECALLS: 1. 8. aspirate/drain. SMA embolus—discussed treatment options. what approach?. a. discussed treatment options including surgery vs embolization vs vasopressin. 5. Mark. related to a dissection? The guy was hit in the head Cavernous sinus mass. She asked what I would want to know about the patient. most c/w angiodysplasia. then asked a bunch of management questions regarding angioplasty. 17. 4. MRI brain: cryptococcus: young male with dilated perivascular spaces 6. c/w epidermoid. 7. 2. 1998 Recalls: 1. 1. 5. Hypothenar hammer syndrome. Optic neuritis. Was CN V schwannoma Another cavernous sinus mass. Risks?. angiodysplasia. what size?. Rasmussen's aneurysm ruptured Ao-bifem graft with contained leak 1. renals. SMA injection with filling defect at a branch point most c/w embolus. MCA stroke. CT then MRA: basilar tip aneurysm 7. Parenchymal AVM. any other options?. 3. Sequestered disk in L-spine. Patient with prior abdominal surgery for GSW now with fatigue. 9. 7. 10. I wasn’t sure and said between 6-24 hours. 6. aortic occlusion. discussed aneurysms. how would patient present?. What do I do now? What do I tell the patient are the risks for embolization? Heroin addict. 2.” Post procedure pseudoaneurysm. I said physical exam + labs. 1998 Recalls: 1. IMA bleed—She literally told me “this guy is bleeding out the ass” Discussed causes of bleeding and ways to embolize. Trauma Arch—Arch looked NL but great vessels were trash. 2. 3. Aneurysm. Another trip to surgery. L subdural. 5. to save the gut?. inflow/outflow. She showed me a post angioplasty image with dissection/disruption. 4. what result are you satisfied with?. discussed many things including CA. Asked what approach I would use to retrieve.I said we primarily stent these. 15. Renal artery stenosis (ostial). she focused on stenosis. 11. Petrous apex cholesterol granuloma. PAST RECALLS: 1. what to do?. I said leave the catheter in longer than you otherwise would. 4. SVCgram with stenosis in patient who had had multiple CVLs. Hepatic A. 16. 9. accessory R hepatic vein pelvic lymphocele drain placement s/p radical prostatectomy R colonic GI bleed via SMA angio bleed from jejunal diverticulum inf. Mesenteric angio with tangle of vessels in RLQ at cecum in patient with heme pos stool. My first case was dural sinus thrombosis on unenhanced CT (I thought first cases were supposed to be easy). how do you follow this patient?. Abnormal WM signal----discuss DDx. Aortic aneurysm causing recurrent laryngeal nerve paralysis. Dural AVM. 2. c/w Osler-WeberRendu. and IVC. diverticulosis. kidneys and an aorta that had mural thrombus. I nailed that case and the basilar tip aneurysm (2nd case) and he seemed very happy and gave me no grief the rest of the way. Bronchial artery bleed. probably embolic disease. Colloid cyst: CT 10. Median Arcuate compression Syndrome Pelvic Kidney and Replaced R. Hyperdense left MCA: CT 3. Anastomotic stricture post choledochojejunostomy. cystic medial necrosis. stenting. Pancreatic abscess. discussed management of “benign” vs “malignant” SVC stenosis. 5. 2. discussed surgical embolectomy. 19. creatinine.
spot with a encapsulated larger mass with fatty tissue c/w hamartoma. 6. he kept asking for more and seemed unsatisfied. 3) after I looked more carefully. 5) varices were better. there was slight increase in a nodular density. spots show better. Ferris. Simple cysts. 3. was nice and we flew thru the cases. Well circumscribed mass in L. there was still a tight area where the tract met the PV. OK she doesn’t get better and mammo looks same what do you do?. and the gradient fell to 10. PAST RECALLS 1. do nothing unless symptomatic then drain. 4. so we coiled the last of them Staghorn calculus with a smaller lower pole calyceal stone. 11. GI bleed on angio. Fibroadenoma. 3. Dystrophic calcification s/p XRT/lumpectomy. lesion moved up so it’s located medial. Port a cath central line headed up internal jugular: discussed grasping from below to reposition 3. most likely retained products of conception. 5. but I didn’t know anything about penile embolization. need to make sure additional views are positioned properly ULTRASOUND 1. 10. 12. He asked several non-film related questions: How much radiation from a mammo?. 1998 Recalls: 1.go figure. Discussed MSAFP Increased nunchal translucency Germinal matrix hemorrhage/hydrocephalus Complicated ovarian cystic mass. 5. Anencephaly . skin bx. Point out the anatomy case trans and long liver/porta hepatis. I said the options would be surgery or possible embolization. and other imaging options for implants Fibroadenomas 14. 8. Cholecystitis/Cholelithiasis DVT Tumor thrombus in portal view. discussed treatment options 10. 6. 12. 5. Bassett. Asymmetric density that went away on spot-mag Hamartoma Intramammary lymph node Intermediate calcifications 18. I know she showed me more but she went so fast it was a blur. 7. 16. 2. 4. calcified oil cysts) and a small irreg nodule. 3. Instead we talked about technique. Ovary in younger female with focal hyperechoic lesion. concerned for MMC. Discussed possibility of radial scar and biopsy options DCIS Mass with benign looking Calcs but poorly defined borders. 2. the other shows short videoclip of compression demonstrating complete compression of the venous structures. Slightly enlarged uterus with internal echoes. Fat necrosis Hamartoma Amorphous calcifications Spiculated mass Nodule seen only on MLO. 2. I said the borders still made it worrisome. Subclavian vein stenosis on angio. talk to her Dr. 7. some very bright. Venogram with retroaortic left renal vein 11. I’d want to look that up or discuss it with someone before doing anything to this guy’s schlong… (I think I worded it differently the first time. treatment is surgical BREAST 1. Inflammatory CA. Very subtle spiculated CA behind a bunch of dense FG tissue. 5. 3. Two wall stents already in place. 4) they put another wall in. 12. Gallstones with intra and extrahepatic bil dil. 6. had to work each one up Architectural distortion work up and DDx Cluster of suspicious microcalcifications Solid mass with indistinct borders Asymmetric density. 7. history given as recently post-partum. Spiculated mass 2. GB CA vs invading HCC vs tumefactive sludge. one shows art and vein. 8. 2. IVP with hydronephrosis and septic: discussed percutaneous neph tubes 2. DCIS vs Inv. c/w mastitis. Angio of portosystemic shunt: shunt was obviously malfunctioning and we discussed treatment 5. 1. 4. 5. Spiculated masses X4 cases. Focal pleomorphic calcifications. I’m still concerned about first area. 15. pulse wave with PSV=300 cm/sec and EDV=100 cm/sec. 4. 9. Post surgery patient Discussion of indications/contraindications for breast conserving therapy Breast asymmetry—right breast smaller but denser—discussed dif. 4. Showed a TIPS in progress. I’m concerned. bx. no DVT. he seemed grouchy and really tired of the whole process. almost missed this one. 6. Clustered pleomorphic calcifications Discussed various forms of biopsy Benign calcifications Spiculated mass Adenosis Plain film ruptured implant. 1. c/w high grade stenosis (70-99%). spot. 1. discussed causes and treatment. 4. Percutaneous cholangiogram with CBD stricture: this one due to surgery. Asked no difficult questions. 6. 7. 2000 Recalls: Dr. and. Asked “if this was CCAM what type would it be” Midline abdominal mass in fetus. Talked about that and other routes of shunting Guy with a urethral stricture undergoing a dilatation. This first study was called NL. 17.3. Simple cyst mammo and U/S. 6. 2. testicular torsion carotid stenosis MCDK ectopic pregnancy acute cholecystitis with gallstone duodenal atresia 9. Now has profuse bleeding. Focal spiculated mass with ?microcalcs. and contraindications to pulmonary angiography. Spiculated mass in R Milk of CA Asymmetric breast tissue Two regions of suspicious Ca. 6.) 9. Ductal CA. 3. 7. 13. As my session progressed. probably ruptured on other side as well Discussed implants. here’s the next study. Then showed me an angio and we discussed treatment. Talked about treatment options. Large filling defect in GB. “Tell me if we’re done. WOW. 3. what kvp do we use? Etc. pulled it together at last second. 4. DCIS. Angio showed the vessel which was the obvious source of the bleeding. to start antibiotics and f/u to make sure she gets better. Is that how you dx inflamm CA?. 1. Carotid color images with narrowing. what do you do now. yes. 19. I gave a long dif but couldn’t really decide. 2. 2) after I asked. Then I asked for a cleavage view which showed the lesion. 16. 5. Then showed me a midline image and asked what I thought of the other kidney. Discussed various doppler waveforms. 5. routine mammo. 18. 9. 11. worrisome. 6. real. Subtle area of arch dist. but I wasn’t sure the original area was there. L/S spine then shown showing dysraphic changes c/w MMC. what do you do now?. 4. 2000 Recalls: Dr. 5. likely CBD obstruction. we discussed treatment. that’s concerning for other causes of trabecular thickening such as inflammatory CA. Spiculated mass Architectural distortion. or specific concerns regarding its blood supply. Echogenic right kidney. 14. 3. 9. At first I thought he was a moron then I realized there was no L renal artery or vein and I said the patient probably doesn’t have one. External iliac/common femoral artery dissection. indications. Secretory calcifications . Two images groin trans. 17. bx. Fetus with lemon head and dilated lat vent. 8. Unilateral trabecular thickening in patient with mastitis symptoms. hemorrhagic cyst vs ectopic vs tumor vs met vs endometrioma. inv fibroadenoma. discussed treatment 6. Ulnar artery transection from trauma. my approach for the perc Portogram with recanalized umbilical vein. Asked for differential. Asked for XCC or straight ML and got an ML. Pelvic AVM on MRI. bx. he told me the gradient was 24. Ask how workup would differ pre and post menopause. 15. disappeared with compression views. 8. Double duct sign Diaphragmatic hernia. he became a bit more congenial and finally was philosophical at the end…. 19.” The bottom line was: 1) there were multiple varices. Axillary well circumscribed lesion Spiculated mass 13. 8. Breasts with multiple characteristically benign calcifications (vascular. PA gram: film had obvious PE but he never asked me to discuss the film. 10. 4. 3 nodules in one breast. ultimately. 10. 11.
RUQ U/S with tubular hypoechoic structure. 21. column of Bertin vs. it took 25. 17. then showed CXR which showed bilateral dense kidneys—no IV contrast was given. 12. she asked PAST RECALLS: about the eyes. 7. I thought 5. ?Salter 2 fracture. where I was 20. Ankle film with markedly irregular tibial physis showing widening and sclerosis. hands bilaterally. 3. Brochogenic cyst. 19. 16. 20. 8. 5. foreign body trachea. meconium ileus CXR with asymmetric vascularity and 4. thyroglossal duct cyst or Ranula a sling this morning?” Then he showed 7. echogenic mass in fetal thorax 3. 11. Jeune's compression upon the trachea. bowel edema. lobar emphysema At this point he started asking me what I 19. like what?.7. talocalcaneal coalition lesions and how they differ. and cystic collections near upper pole of one kid. I blanked. CF passed. hydrocarbon pneumonia (***on ddx for me a couple of minutes to remember that bibasilar infiltrates in kid) she did in fact say this is the peds section 26. Medullary nephrocalcinosis. Clubfoot. Discussed differences between adenomas and hyperplasia 12. 5. fractured pancreas. this had to have been the most painful silence ever. Discussed various admixture 1. 23. cystic hygroma Absent radius. ?para hilar infiltrates. NL anatomy at the porta hepatis. thumb present. CXR with hyperexpanded lungs. 30. 9. 13. 16. hepatoblastoma/hemangioendothelioma possibility. I can’t make 9. maybe bilat MCDK. 20. horseshoe kidney anything out of this picture either. Couldn’t figure out what it was Fetal u/s with oligo. 10. Canavan's / Alexander's out. 18. we had 6. double Ao arch (vasc ring) Started off with a head MRI!. 1. 28. I said it was abnormal. most c/w viral pneumonia. Abdomen CT with ascites. 15. ddx reactive airway disease. 11. 17. CDH. 29. 8. Caffey's when I came in. 3. 6. CLE. 7. ectopic pregnancy 6. PAST RECALLS 1. Then a bone case. Obstructed duplicated system on top of bladder outlet obstruction? 9. ABC there. 26. 1. Woodward. cong. deep venous thrombosis PEDS 1. This may have been a GU case… High-grade carotid stenosis. 18. septic L hip arthritis/osteomyelitis this was PA sling. Right Chest mass. 23. DDXTeratoma. 14. He said “sorry. TS Nodules in the trachea ? papillomatosis 12. 25. complex cystic pelvic mass 9. Gallstones with distal CBD stone and obstruction Pt with bleeding. There was a live intrauterine pregnancy with a crescentic hypoechoic area peripherally. 9. 10. 5. We started with some easier cases and eventually got to cases where I had no idea what I was looking at. keyhole bladder. Stenosis Carotid Stenosis Dermoid Endometrioma TOA Hydrosalpinx Endouterine Polyp Epididymitis Germinal Matrix hemorrhage NL Uterine serosal vasculature Choroid Plexus cyst Congenital diaphragmatic hernia Omphalocele IVC Thrombus Periaortic LAD 16. Patient who received pelvis radiation. Testicular microlithiasis. multiloc cystic nephroma PIE 11. Renal U/S with echogenic kidneys 9 mos old. 2. 9. 6. 13. hypoechoic adrenal lesion in 6 week old 8. Talked about complications in renal transplants Parathyroid hyperplasia. 1998 Recalls: 1. 2. 33. 2000 Recalls: Dr. yes THE Dr. 18. Renal cell CA. Then he said “you know. 17. She was nice and seemed to understand I was nervous. branchial cleft cyst thought I was in the wrong room. 14. Blount's to do that but I figure it means I had 22. lymphoma tuberous sclerosis (bilat renal angiomyolipomas) semilobar holoprosencephaly vasa previa Beckwith-Weideman 4. bilateral choroid plexus cysts 2. Renal U/S with hydro and dilated ureter to bladder bilaterally. multiple areas of expansile lytic destructive bone lesions in prox humeri. 31. 4. I don’t think he was supposed 21. discussed bilat UVJ obstruction possibly from ureteroceles. 19. I think there was also a linear lucency in metaphysis. 8. and near bladder. there was focal thickening of right optic nerve. 7. Intrauterine pregnancy. probably NF-1. this could be non-accidental trauma. enlarged and irregular yolk sac on ob ultrasound 11. Madelung deformity with TAR #1. pulm a stenosis from. then showed pelvis film with dysraphic changes in L/S spine. 2. medullary nephrocalcinosis 12. ratios and findings in stenoses Renal transplant u/s with reversal of diastolic flow. croup patient. 5. segmental biliary dilatation 5. then showed head CT with multiple skull fractures. etc. pseudoaneurysm in neck gestational trophoblastic disease pyloric stenosis Chiari II with MM subclavian steal ectasia of rete testes omphalocele appendicitis carotid dissection fetal demise testicular cancer with microlithiasis lupus nephritis biliary dilatation with stones anencephaly ovarian dermoid liver mets Gastroschisis tricuspid insufficiency with ascites anembryonic pregnancy R epididymo-orchitis posterior urethral valves incompetent cervix renal transplant rejection. c/w non-accidental trauma. can you connect the findings?. 14. what 1. 8. 21. 12. I thought I’ll fail for CCAM sure. She was very good at giving histories that directed your differentials. 14. Cyanotic patient with increased vascularity. ? bowel. Woodward. 11. 15. . Testicular CA. 15. SDH. 7. renal pelvic mass 7. Dandy Walker. First developed AVN then later film showed post irradiation osteochondroma. discussed simple and ectopic ureteroceles and duplication anomalies. We talked about this for a while… various velocities. 24.I gave a dif 13. 10. meconium aspiration US of cystic mass extending from pelvis 15. 2. 2. the case was still up 27. then showed IDA scan with large collection RUQ and bowel activity. I wasn’t sure but vaguely remembered an increase risk of leg fractures in MMC patients. 23. there were multiple T1 increased areas deep WM and GM areas. 6. I literally 24. Cholecystitis. 3. Physiologic Gut herniation Nuchal Cord Echogenic Bowel Single Umbilical Artery VSD Partial Mole IUFD Ectopic Renal A. tension PTX was going to do with my life. 22. 27. cerebral hemihypertrophy to umbilicus. discussed bilateral calcified kidneys. enlarged echogenic kidneys in 6 year old female 4. thickened endometrium in postmenopausal female 10. 22. 32. KUB unremarkable. maybe some kind of metaphyseal dysplasia I said. He wanted a dif for each 17. 6. I ask for the sex of the 16. asked if patient had had any trauma—no. Morquio's (ant beaking of spine) Thoracic paraspinal mass 3. no perfusion of spleen. 13. Beckwidth-Weidman me an esophagram which I couldn’t figure 8. 4.” 10. probably choledochal cyst. infarction. 4. 3. a start! lyphangioma.
then discussed what blood vessel supplies the inferior wall. 3. Low back pain. Ureteral Leak . Thallium study with ischemia. Mass in Hilum. 5. 3. Lung abscess. 4. 10. Case 2. 6. Little bit of funny uptake near one of the SI joints. Osteomyelitis on Bone-indium. Renovascular HTN imaging. wall infarct cardiomyopathy defect on brain SPECT – tumor bile leak Case 307 scar on DMSA scatter @ neck on bone scan from pt treated with I-131 lymphoma on Gallium scan Case 302 superscan due to osteomalacia Case 114 stress fracture Case 101. could do thyroid supression test. I felt totally gutted by the time I was done. 3. 7. shunt vascularity-give DDx for both cyanotic and acyanotic 6. He asked what “metabolic” imaging we could do. Jejunal atresia. Testicular CA with lung mets. Caffey’s dz. What else is it good for? That was a long discussion. 4. 7. he pushed me to show him where the ischemia was multiple times. 3. 2000 Recalls: Dr. Ask what else 14. Stress fx? Got SPECT. 5. I didn’t say anything. search for mets was unsuccessful except for a 24. 6. Gallium. how would you treat a hyperfunctioning nodule?.2. treadmill. Bone scan with solitary lesion in distal femur: gave DDx 2 Lung nodule on CXR then CT. child abuse 7. 10. hemiagenesis vs partial resection vs hyperfunctioning nodule on right. asked what can you use to stress a patient?. and a single static image instead of Iodine. Asked what 13. GI bleeding study with a left colon bleed. Graves dz. Cold Thyroid Nodule of calcific pericarditis. then he showed a cine in same patient showing apical akinesis. 3. Woo Hoo! 1. Case 115 CSF leak. I’m gonna kill this guy!. Asked how we de the exam. 7. adenosine. 4. keep looking he said. History was given as a young man status post cardiac arrest 8 Cine of child MAG-3 scan: duplex collecting system with lower pole reflux 9 SPECT of head with temporal lobe seizure focus 10 GI bleed 1. Triple match on V/Q. He kept asking for differentials when I couldn’t think of one thing most of the time. she showed Tc flow images. infarction. WBBS in patient with prostate CA. but didn’t get let out early. Bone scan AVN of femoral head in pt with renal transplant. He let me out at least 10 minutes early. 1. 3 Hepatobiliary scan with delayed activity in both gall bladder and bowel 4 Gallium scan with bilateral hot lungs: gave DDx 5 Neonatal hypothyroidism: discussed imaging techniques and etiologies 6 RL shunt on lung perfusion scan 7 IHSS and stress induced myocardial ischemia. Wilms tumor 9. Brown. agent we use for vent study. leukemia with osteoporosis. OK point to the ischemia in the inferior wall. about our protocol Case 203 Splenosis on sulfur colloid. and it became clear the bladder was masking a huge abnormality involving most of the sacrum. MUGA with dyskinetic apex. V/Q post trauma—fat emboli. 9. dipyridimole. 4. Fellows: This guy eviscerated me.430 inf. gave APmultiple nodules. Off the bat. stenosis pg 390 parathyroid adenoma (sestamibi) Case 713 CSF cisternogram (use In-111 DTPA) Case 602 osteomyelitis on 3phase bone scan (Brodie's abscess) Case 108 4. Lytic skull lesion on plain film then CT showed beveled edgesEG NUCLEAR 1. 1998 Recalls: 1. osteomyelitis 8. 6. I-131 20 mCi (I wasn’t completely sure). tiny area in the lateral skull. gave DDx 11. then angio 10. PCP on Gallium. of trauma. 1. weird area of sheet-like high density in soft tissue near ankle. back to the SPECT images. pulmonary sling. 8. big vessels 10. 5.Sarcoid. This guy was dehydrated last week. discussed possibility 1. Shocked bowel on CT. 2. 2. multiple pulmonary AVMs (I think). Oh well. 13. given AP and lateral chest then axial MRI 4. Meconium aspiration VATER. 4. she told me she wasn’t interested in hearing energies and half lives. (this guy must be getting billions in kickbacks from the cardiologists if he’s calling ischemia like this-WOW!). shouldn’t use adenosine or dipyridimole in patients with reactive airway disease or COPD. 6. Gallium Scan with cardiac activity ? 19. 2. when should you not use some of these?. 2. 9. We discussed cardiac imaging 3. might look like this if there was no history 15. else you might look for splenic tissue. What sorts of agents do we use? Any sort of pretreatment? I think she was looking for hydration. This was my last session and I didn’t let the door hit my rear on the way out. 2. low. Liver mass. all cases were straight forward and discussion was minimal. Inferior wall infarct. 1. Turns out the guy had a history of colon cancer… 4. 6. Meckel's. Case 415 Brain SPECT with right MCA distribution defects c/w infarcts. Asked a lot 21. However. Neonatal Group B Strep pneumonia. Renal scan with lasix showing obstruction. 11. 5. 4. Case 619 Thyroid scan with uptake only in right lobe. Oh well. 6. Colonic Bleed Testicular Torsion Discitis and Femur Fracture Pheochromocytoma Difference btwn HMPAO and DTPA Brain Death Study Myocardial Fixed Defect Lymphoma on Gallium Vesicoureteral Reflux V/Q scan with no perfusion to R Lung. Cardiac SPECT and corresponding CINE stress induced ischemia with secondary 17.604 12. finally after like an hour I saw uptake in the heart. Case 409 16. We discussed QA on SPECT cameras. 2. vertebral body compression fx. Lytic skull lesions---give DDx. 3. Case 705 off peak scan (blurry) multinodular goiter Case 706 subacute thyroiditis (ddx for low uptake) Case 709 osteosarcoma with met to chest pheochromocytoma on MIBG scan Page 28 Meckel's Case 317 lower GI bleed on RBC scan case 303 biliary atresia Pg 802 testicular torsion (pertech) Case 821 sarcoid. this was really frustrating because the perfusion was perfect everywhere. then showed Diamox study same patient showing similar findings. 107. he said images are sort of bad aren’t they. 11. Stress/rest cardiac perfusion study typical short and long axis views. what are the chances that that is a met?. 5. 12. 7. I thought I was doing really well in nukes. Breast CA mets to bone. 8. malrotaion with midgut volvulus 5. 5. then the study looked absolutely NL with no perfusion defects. I said PET and got one with a hot focus in chest.diffuse lung uptake on Gallium scan case 428. This was the only section where I stayed the entire 25 minutes. 6. OK now where’s the area of ischemia?. duodenal atresia U/S then CT of CMV calcifications Multifocal septic joints Newborn with cyanotic cardiac dz. vent dilatation. 8. dobutamine. 18. sit back in your chair he PAST RECALLS: said. amyloid 20. Would my interpretation change? She kept pushing me on that… 2. Hemangioendothelioma vs hepatoblastoma Caustic ingestion in Esopha Cleidocranial dysostosis Multiple enhancing lesions in brain??? Lytic Tibial lesion Coarc of the Aorta 9. Bile Leak 111 3. 1998 Recalls: 1. Hot solitary thyroid nodule. 7. 2000 Recalls: 11. 5. 5. Case 303 High prob V/Q scan with NL CXR. and lucent metaphyseal lines 3. Case 310 23. 108 alpha-1 antitrypsin on V/Q Pg 117 captopril on MAG-3 showing bilat renal a. 8. Dr. 12. leading to bone scan. Case 603. Asked how 22.