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Click in the table below to view or print the notes that we put together for 2001 written boards: ultrasound vascular gastrointestinal cardiac genitourinary neuroradiology pediatrics head and neck (1 of 5) [5/29/2002 10:39:29 PM]

nuclear medicine miscellaneous





To download old exam recalls in zipped format, click the following links in the table: questions3 and get the pics for these by clicking here questions7





questions6 2001 recalls by our batch questions13 questions17





questions12 questions16

questions14 questions18

questions15 questions19 (2 of 5) [5/29/2002 10:39:29 PM]



GI notes that were made by one of our former GI radiologists. Click here to download them as a PDF file.

SEARCHING FOR RADIOLOGY INFO ON THE WWW (great site for a variety of neuroradiology cases) (the above neuro cases as unknowns) (more anatomy) (orthopedic radiology) (for Grays Anatomy with right clickable figures) (case of the day and board review questions) auntminnie cases presented as unknowns (3 of 5) [5/29/2002 10:39:29 PM] (good cases of the week) (general radiology site with written board review questions) (everything medical that you could ever want) (multimodality cross sectional imaging anatomy of the entire body) (cases and radiologic atlas) (anatomy sites on the internet) (hypertext of radiology) (multimedia textbook by Virtual Hospital) (Neuroanatomy on the internet) (many neuroanatomy sites on the internet) (radquiz written board recalls) (radiology websites organized by subject) (4 of 5) [5/29/2002 10:39:29 PM] (USUHS neuro differentials) Useful site for all of pediatric radiology pediatric cardiology 1 pediatric cardiology 2 pediatric cardiology 3 embryology of atrial partitioning click here for some nice pictures of the atrial septae coronary artery anatomy including angiograms (thousands of CT scans) board review questions from Crieghton University More radiology cases Board review notes from Indyrad Signs in musculoskeletal radiology (5 of 5) [5/29/2002 10:39:29 PM]


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There is no index for this so if you want to find something, press the Ctrl-F keys at the same time and type in the word you want to find in the find box! If someone would like to help make an index for this, let us know


figure 1: HV figure 2: CCA figure 3: SFA (1 of 13) [5/29/2002 10:41:13 PM]


figure 4: ICA figure 5: ECA figure 6: PV

ALIASING IN US: to decrease this artefact, increase prf, increase doppler angle, decrease transducer frequency

ANNULAR ARRAY: cannot be used in doppler

FIRST TRIMESTER ENDOVAGINAL US: earliest that IUP can be detected is 4.5 w (2 of 13) [5/29/2002 10:41:13 PM]


earliest that YS can be detected is with a MSD of 8mm cardiac activity is seen when CRL is 5 mm the embroyo should be seen when the MSD is 16mm

AVF: speckled pattern in ST's with increased venous proximal to the fistula

FETAL HYDONEPHROSIS: renal pelvis>4mm in a <20 w fetus renal pelvis >10mm in a >20 w fetus

AMNIOTIC FLUID: after 16w, MA, fetal urine production becomes the major source of amniotic fluid AFI<5 is considered oligohydramnios greatest depth of fluid >6 in any one quadrant or AFI>24 is polyhydramnios

PLACENTA: should not be > than 4 cm acreta: attached but does not invade myometrium (attaches) increta: invades myometrium (invades) percreta: penetrates beyond myometrium (penetrates)

CERVICAL LENGTH: (3 of 13) [5/29/2002 10:41:13 PM]


full bladder can artificially elongate cervical length to >3.5cm

DIZYGOTIC TWIN PREG: always dichorionic and diamniotic

DOWNS SYNDROME: prenatal US findings: increased nuchal skin fold thickness, echogenic bowel, mild pyelectasis, decreased ratio of measured to expected femur length, ventriculomegaly

TWO VESSEL CORD: associated with 25 to 50% fetal anomalies

RENAL ECHOGENICITY: early to mid 2nd trim: hypoechoic renal cortex mid 2nd term to late 2nd term: increased hyperechoic interfaces mid 3rd term: increased echogenicity involving the renal sinuses

NEONATAL ARPKD AND ADPKD: both look similar in the neonate with large echogenic kidneys. With ADPKD, there are associated cysts in other organs including: liver, spleen, pancreas, and epididymous

TESTICULAR MICROLITHIASIS: associated with Klinefelter, infertility, subfertility, testicular germ cell tumors (40%), male (4 of 13) [5/29/2002 10:41:13 PM]


pseudohermaphraditism, Downs, pulmonary alveolar microlithiasis. The ddx is post inflammatory, scar, granuloma, hemorrage with infarct, large calcifying sertoli tumor, benign adenomatoid tumor

CRYPTORCHIDISM: 90% in inguinal canal and proximal to internal ring. 10% are in abdomen, and bilateral in 33%. The testes are small and hypoechoic.

EPIDIDYMIS: isoechoic to hypoechoic to the testis

ECHOGENIC BOWEL: CF, perinatal death, CMV, trisomy 21

ECTOPIC PREGNANCY: most do not exhibit HCG>6500 prior to symptomatology. Most characteristic finding is beating heart, tubal ring (95% ppv), complex adnexal mass (92% ppv), with fluid (100% ppv)

TROPHOBLASTIC DISEASE: 1. complete or classic: 85% benign, and 15% malignant 2. complete plus fetus: 2% invasive 3. invasive: high association with previous missed abortion 4. partial: can occur with a triploid fetus

85% are complete moles. Note that partial moles have no malignant potential. Between 15 to 37% of moles have bilateral theca lutein cysts (5 of 13) [5/29/2002 10:41:13 PM]


ENDOMETRIOSIS: 8-18% menstruating women 30-40% are infertile internal: within uterus=adenomyosis external: most common in ovaries

BEST VIEW TO DETECT FETAL VSD: this is the subcostal 4 chamber view.

THYROMEGALY: if ap diameter of thyroid > 2 cm, then thyroid enlargement should be considered

THYROID NODULE: adenoma: true tumor, hypoechoic, peripheral halo of vessels adenomatous nodule: synonymous with hyperplastic nodule, also has peripheral halo of vessels

FETAL CORD DOPPLER US: doppler US should be at the fetal end of the cord, and blood sampling should be at the placental end

RING DOWN ARTEFACTS: when US beam strikes metal, stones, or cholesterol crystals in the GB wall the phenomenon of "ring (6 of 13) [5/29/2002 10:41:13 PM]


down" occurs. "Ring down" is the same thing as "comet tail". Please note that air can also give "ring down" and "comet tail" artefacts.

REVERBERATION: partial reflection seen at a boundary, eg the bright line seen in the bladder due to misregistration

GERMINAL MATRIX HEMORRAGE: There are 5 grades. Grade one is subependymal and 2 is hemorrage rupturing into a non dilated ventricle. 3 is intraventricular hemorrage with ventricular dilatation. Grade 4 is parenchymal involvement. The germinal matrix is in the floor of the entire ventricle. At 32 w it is found along the ventricular surface of the caudate up to the caudothalamic groove

BOSNIAK CLASSIFICATION OF RENAL CYSTS: 1=simple. 2=mildly complicated with thin septations. They can have Ca++. 3=indeterminate echos. They can have multiple septae and mural nodules. 4=solid mass component

FETAL VENTRICULOMEGALY: hydrocephalus in utero 3rd ventricle >2 mm and lateral ventricle>10mm

NUCHAL SKIN FOLD: if > 6mm at 24 weeks or mild ventricular dilatation suggests Trisomy 21

DIFFERENTIAL OF ANENCEPHALY: acrania, amniotic band syndrome; there are associated congenital abomalies suth as spinal dysraphism, cleft lip or palate, clubfoot, umbilical hernia. May see a cranial soft tissue mass which is angiomatous (7 of 13) [5/29/2002 10:41:13 PM]


stoma and short neck and bulging frog like eyes. There is polyhydramnios in 50 to 60 percent after 26 w due to failure of normal swallowing. The diagnosis can be made in 100% at 14 w

RENAL ARTERY STENOSIS: peak systolic>150 cc/min. The ratio of peak RA /aorta = 3.5 for RAS (ie 60% chance of having RAS). Tardus parvus is post stenotic and there may be absence of flow during diastole. Tardus parvus in its classical sense refers to slowed systolic acceleration with low amplitude of the systolic peak. To evaluate the delayed upstroke, 2 measurements are taken, the acceleration time which is the time from start of systole to peak systole and the accelaration index which is the slope of the systolic upstroke of less than 3 m/s2 (quoted from rumack). See schematic on p381 of rumack part 1 In looking at segmental renal arteries, it was noted that lack of the normal early systolic peak in the renal artery tracing was the best predictor of RAS with luminal narrowing greater than 60% (95% sensitivity and 97% specificity) This figure taken from Rumack may help to clarify the finding (8 of 13) [5/29/2002 10:41:13 PM]


BRADYCARDIA: causes increased stroke volume and increased systolic velocity. HTN causes increased velocity in a stenosis compared with a normotensive individual

UMBILICAL ARTERY US: ratio of S/D is always higher at the fetal end of the cord. S/D usually decreases to <4 as the pregnancy proceeds



INVOLUTION OF THE CORPUS LUTEUM: this occurs at 15w, but some say 16-20 w

CHOROID GLOMUS: most echogenic structure in neonatal brain

THE MOST COMMON FIBROIDS: those that are intramural (9 of 13) [5/29/2002 10:41:13 PM]


CAUSES OF INCREASED RENAL ECHOGENICITY: Acute and Chronic glomerulonephritis Renal transplant rejection Lupus nephritis Hypertensive nephrosclerosis Renal cortical necrosis Methemoglobulinuric renal failure Alport syndrome Renal amyloidosis Diabetic nephrosclerosis Nephrotoxin-induced acute tubular necrosis End-stage renal disease

MIXED ECHOGENICITY METS: breast, rectal, lung, anaplastic, cervical, carcinoid. Pancreatic generally gives hypoechoic mets

HYPOECHOIC LIVER METS: lung, breast and lyphoma are the big 3


NEONATAL BRAIN US: (10 of 13) [5/29/2002 10:41:13 PM]


The vermis is the most echogenic structure. The caudate is also echogenic. The corpus callosum is hypoechoic. When calcified, the corpus callosum is also echogenic

TESTICULAR TORSION: testicular torsion: bellclapper deformity resulting in intravaginal torsion is in teenagers. Extravaginal torsion is in infants.

OLIGOHYDRAMNIOS: differential is DRIPPC (demise, renal abnormality, infection, PROM, post dates, chorioamnionitis)

RENAL TRANSPLANT SONOGRAPHY: sonographically, hyperacute kidney rejection looks identical to RVT as there is no perfusion and no evidence of function. Acute rejection and accelerated acute rejection look the same with uptake adn excretion progressively reduced when compared with the baseline 5d post transplant. Acute rejection is 7d to 3 mo. ATN has normal perfusion but poor renal function and decreased renal excretion (appears worse 24h post transplant with pregressive improvement over the next few weeks).

LEMON SIGN: associated with encephalocele. usually disappears after 24 w.

DOWNS LAB VALUES: there is decreased afp, increased hcg, and decreased ue3; the ddx for increased hcg is Tris 18 and trophoblastic disease

PROSTATE SONOGRAPHY: (11 of 13) [5/29/2002 10:41:13 PM]


PZ: hyperechoic, TZ, CZ are hypoechoic. Cancer is hypoechoic in 60%

STRUCTURE OF THE PLACENTA: good pnemonic is CBP for capsularis, basilus, parietalis or check out the following figure:

VASA PREVIA: occues in 2 situations: (1) velamentous cord insertion and (2) succenturate placenta



APPROACH TO ABDOMINAL US (ISRAEL): long aorta long liver (L and R lobe) long GB, CBD, IVC (12 of 13) [5/29/2002 10:41:13 PM]


long PV long R kidney trv R kidney (u, m, l pole) trv liver (hepatic vein with flow, PV branches, lig ter, GB) long spleen trv spleen long L kidney trv L kidney (u, m, l pole) (13 of 13) [5/29/2002 10:41:13 PM]


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There is no index for this so if you want to find something, press the Ctrl-F keys at the same time and type in the word you want to find in the find box! If someone would like to help make an index for this, let us know

SPLENIC LYMPHOMA: lymphoma> leukemia HL>NHL

LESSER SAC HERNIA: 10%. These occur through the foramen of Winslow. Ileum>jejunum for foramen of Winslow. Paraduodenal hernias are the most common. These are the Waldeyer, and Lanzert hernias. Lanzert is on the left. Waldeyer is on the right. Lanzert is more common thanWaldeyer. Ie 3/4 are Lanzert and 1/4 are Waldeyer

ESOPHAGEAL STRICTURES: long segment: NGT, lye ingestion short segment: Baretts, squamous cell ca, epiderm bullosa

GLUCAGON: is absolutely contraindicated in pheo and in pts with insulinoma as it can cause hypertensive crisis in the former and precipitous glucose drop in the latter. It is also absolutely contraindicated in allergy. The anticholinergic buscopan is contraindicated in pts with glaucoma

ABDOMINAL TRAUMA: spleen is the most commonly injured organ

SOME MESENTERIC ANATOMY (1 of 39) [5/29/2002 10:46:18 PM]


first lets look at the neonateAt birth, when respiration is established, an increased amount of blood from the pulmonary artery passes through the lungs, and the placental circulation is cut off. The foramen ovale is closed by about the tenth day after birth: the valvular fold above mentioned adheres to the margin of the foramen for the greater part of its circumference, but a slit-like opening is left between the two atria above, and this sometimes persists. The ductus arteriosus begins to contract immediately after respiration is established, and is completely closed from the fourth to the tenth day; it ultimately degenerates into an impervious cord, the ligamentum arteriosum, which connects the left pulmonary artery to the arch of the aorta. (2 of 39) [5/29/2002 10:46:18 PM]


The right gastric artery arises from the hepatic, above the pylorus, descends to the pyloric end of the stomach, and passes from right to left along its lesser curvature, supplying it with branches, and anastomosing with the left gastric artery.

The gastroduodenal artery is a short but large branch, which descends, near the pylorus, between the superior part of the duodenum and the neck of the pancreas, and divides at the lower border of the duodenum into two branches, the right gastroepiploic and the superior pancreaticoduodenal. Previous to its division it gives off two or three small branches to the pyloric end of the stomach and to the pancreas.

The right gastroepiploic artery runs from right to left along the greater curvature of the stomach, between the layers of the greater omentum, anastomosing with the left gastroepiploic branch of the lienal artery. Except at the pylorus where it is in contact with the stomach, it lies about a finger's breadth from the greater curvature. This vessel gives off numerous branches, some of which ascend to supply both surfaces of the stomach, while others descend to supply the greater omentum and anastomose with branches of the middle colic.

The superior pancreaticoduodenal artery descends between the contiguous margins of the duodenum and pancreas. It supplies both these organs, and anastomoses with the inferior pancreaticoduodenal branch of the superior mesenteric artery, and with the pancreatic branches of the lienal artery.

The cystic artery usually a branch of the right hepatic, passes downward and forward along the neck of the gall-bladder, and divides into two branches, one of which ramifies on the free surface, the other on the attached surface of the gall-bladder.

The Lienal or Splenic Artery, the largest branch of the celiac artery, is remarkable for the tortuosity of its course. It passes horizontally to the left side, behind the stomach and the omental bursa of the peritoneum, and along the upper border of the pancreas, accompanied by the lienal vein, which lies below it; it crosses in front of the upper part of the left kidney, and, on arriving near the spleen, divides into branches, some of which enter the hilus of that organ between the two layers of the phrenicolienal ligament to be distributed to the tissues of the spleen; some are given to the pancreas, while others pass to the greater curvature of the stomach between the layers of the gastrolienal ligament. Its branches are pancreatic, short gastric, and left gastroepiploic.

The pancreatic branches are numerous small vessels derived from the lienal as it runs behind the upper border of the pancreas, supplying its body and tail. One of these, larger than the rest, is sometimes given off near the tail of the pancreas; it runs from left to right near the posterior surface of the gland, following the course of the pancreatic duct, and is called the arteria pancreatica magna. These vessels anastomose with the pancreatic branches of the pancreaticoduodenal and superior mesenteric arteries.

The short gastric arteries consist of from five to seven small branches, which arise from the end of the lienal artery, and from (3 of 39) [5/29/2002 10:46:18 PM]


its terminal divisions. They pass from left to right, between the layers of the gastrolienal ligament, and are distributed to the greater curvature of the stomach, anastomosing with branches of the left gastric and left gastroepiploic arteries.

The left gastroepiploic artery the largest branch of the lienal, runs from left to right about a fingers breadth or more from the greater curvature of the stomach, between the layers of the greater omentum, and anastomoses with the right gastroepiploic. In its course it distributes several ascending branches to both surfaces of the stomach; others descend to supply the greater omentum and anastomose with branches of the middle colic.

The superior mesenteric artery is a large vessel which supplies the whole length of the small intestine, except the superior part of the duodenum; it also supplies the cecum and the ascending part of the colon and about one-half of the transverse part of the colon. It arises from the front of the aorta, about 1.25 cm. below the celiac artery, and is crossed at its origin by the lienal vein and the neck of the pancreas. It passes downward and forward, anterior to the processus uncinatus of the head of the pancreas and inferior part of the duodenum, and descends between the layers of the mesentery to the right iliac fossa, where, considerably diminished in size, it anastomoses with one of its own branches, viz., the ileocolic. In its course it crosses in front of the inferior vena cava, the right ureter and Psoas major, and forms an arch, the convexity of which is directed foward and downward to the left side, the concavity backward and upward to the right. It is accompanied by the superior mesenteric vein, which lies to its right side, and it is surrounded by the superior mesenteric plexus of nerves. Branches.Its branches are: inferior pancreaticoduodenal, ileocolic, intestinal, right colic, middle colic.

The Inferior Pancreaticoduodenal Artery is given off from the superior mesenteric or from its first intestinal branch, opposite the upper border of the inferior part of the duodenum. It courses to the right between the head of the pancreas and duodenum, and then ascends to anastomose with the superior pancreaticoduodenal artery. It distributes branches to the head of the pancreas and to the descending and inferior parts of the duodenum.

The Intestinal Arteries arise from the convex side of the superior mesenteric artery. They are usually from twelve to fifteen in number, and are distributed to the jejunum and ileum. They run nearly parallel with one another between the layers of the mesentery, each vessel dividing into two branches, which unite with adjacent branches, forming a series of arches, the convexities of which are directed toward the intestine. From this first set of arches branches arise, which unite with similar branches from above and below and thus a second series of arches is formed; from the lower branches of the artery, a third, a fourth, or even a fifth series of arches may be formed, diminishing in size the nearer they approach the intestine. In the short, upper part of the mesentery only one set of arches exists, but as the depth of the mesentery increases, second, third, fourth, or even fifth groups are developed. From the terminal arches numerous small straight vessels arise which encircle the intestine, upon which they are distributed, ramifying between its coats. From the intestinal arteries small branches are given off to the lymph glands and other structures between the layers of the mesentery.

The Ileocolic Artery is the lowest branch arising from the concavity of the superior mesenteric artery. It passes downward and to the right behind the peritoneum toward the right iliac fossa, where it divides into a superior and an inferior branch; the inferior anastomoses with the end of the superior mesenteric artery, the superior with the right colic artery. The inferior branch of the ileocolic runs toward the upper border of the ileocolic junction and supplies the following branches: (a) colic, which pass upward on the ascending colon; (b) anterior and posterior cecal, which are distributed to the front and back of the cecum; (c) an appendicular artery, which descends behind the termination of the ileum and enters the mesenteriole of the vermiform process; it runs near the free margin of this mesenteriole and ends in branches which supply the vermiform process; and (d) ileal, which run upward and to the left on the lower part of the ileum, and anastomose with the termination of the superior mesenteric. (4 of 39) [5/29/2002 10:46:18 PM]

GASTROINTESTINAL RADIOLOGY (5 of 39) [5/29/2002 10:46:18 PM]


THINGS THAT KEEP ON GETTING ASKED ON THE EXAM (see representative CT scan images below): smv comes in front of sma and to the right of it 3rd part of duodenum passes behind sma (6 of 39) [5/29/2002 10:46:18 PM]


l renal vein also passes behind sma the uncinate process of the pancreas is posterior to the smv left renal vein is anterior to aorta right renal artery is posterior to the ivc renal vein and artery are anterior to the ureters (bridge over troubled waters) GDA is anterior to the portal vein gastroepiploic artery is anterior to the portal vein and the CBD the common hepatic duct is anterior to the right, left and common hepatic artery some things that are retrocaval include the right renal artery and medial right adrenal gland SVC is anterior to the R PA common iliac artery is anterior to the common iliac vein caudate lobe of liver is cephalad to the portal vein SVC (is anterior to the aorta and if u think vena cava which has 8 letters it reminds you of T8) is anterior to the esoph and aorta esophagus and vagus are the middle opening in the diaphragm (esophagus = 10 letters which is T10) most posterior is aorta/azygous/hemiazygous which enters the diaphragm at the T12 level (7 of 39) [5/29/2002 10:46:18 PM]


THE STORY ON LOBES AND LIGAMENTS OF THE LIVER: this is something that I keep on forgetting. LOBES: The right lobe is much larger than the left; the proportion between them being as six to one. It occupies the right hypochondrium, and is separated from the left lobe on its upper surface by the falciform ligament; on its under and posterior surfaces by the left sagittal fossa; and in front by the umbilical notch. It is of a somewhat quadrilateral form, its under and posterior surfaces being marked by three foss: the porta and the foss for the gall-bladder and inferior vena cava, which separate its left part into two smaller lobes; the quadrate and caudate lobes. The impressions on the right lobe have already been described.

The quadrate lobe is situated on the under surface of the right lobe, bounded in front by the anterior margin of the liver; behind by the porta; on the right, by the fossa for the gall-bladder; and on the left, by the fossa for the umbilical vein. It is oblong in shape, its antero-posterior diameter being greater than its transverse.

The caudate lobe is situated upon the posterior surface of the right lobe of the liver, opposite the tenth and eleventh thoracic vertebr. It is bounded, below, by the porta; on the right, by the fossa for the inferior vena cava; and, on the left, by the fossa for the ductus venosus. It looks backward, being nearly vertical in position; it is longer from above downward than from side to side, and is somewhat concave in the transverse direction. The caudate process is a small elevation of the hepatic substance extending obliquely lateralward, from the lower extremity of the caudate lobe to the under surface of the right lobe. It is situated behind the porta, and separates the fossa for the gall-bladder from the commencement of the fossa for the inferior vena cava.

The left lobe is smaller and more flattened than the right. It is situated in the epigastric and left hypochondriac regions. Its upper surface is slightly convex and is moulded on to the diaphragm; its under surface presents the gastric impression and omental tuberosity, already referred to page 1189. (8 of 39) [5/29/2002 10:46:18 PM]


LIGAMENTS: The liver is connected to the under surface of the diaphragm and to the anterior wall of the abdomen by five ligaments; four of thesethe falciform, the coronary, and the two lateralare peritoneal folds; the fifth, the round ligament, is a fibrous cord, the obliterated umbilical vein. The liver is also attached to the lesser curvature of the stomach by the hepatogastric and to the duodenum by the hepatoduodenal ligament.

The falciform ligament is a broad and thin antero-posterior peritoneal fold, falciform in shape, its base being directed downward and backward, its apex upward and backward. It is situated in an antero-posterior plane, but lies obliquely so that one surface faces forward and is in contact with the peritoneum behind the right Rectus and the diaphragm, while the other is directed backward and is in contact with the left lobe of the liver. It is attached by its left margin to the under surface of the diaphragm, and the posterior surface of the sheath of the right Rectus as low down as the umbilicus; by its right margin it extends from the notch on the anterior margin of the liver, as far back as the posterior surface. It is composed of two layers of peritoneum closely united together. Its base or free edge contains between its layers the round ligament and the parumbilical veins.

The coronary ligament consists of an upper and a lower layer. The upper layer is formed by the reflection of the peritoneum from the upper margin of the bare area of the liver to the under surface of the diaphragm, and is continuous with the right layer of the falciform ligament. The lower layer is reflected from the lower margin of the bare area on to the right kidney and suprarenal gland, and is termed the hepatorenal ligament.

The triangular ligaments are two in number, right and left. The right triangular ligament is situated at the right extremity of the bare area, and is a small fold which passes to the diaphragm, being formed by the apposition of the upper and lower layers of the coronary ligament. The left triangular ligament is a fold of some considerable size, which connects the posterior part of the upper surface of the left lobe to the diaphragm; its anterior layer is continuous with the left layer of the falciform ligament.

The round ligament is a fibrous cord resulting from the obliteration of the umbilical vein. It ascends from the umbilicus, in the free margin of the falciform ligament, to the umbilical notch of the liver, from which it may be traced in its proper fossa on the inferior surface of the liver to the porta, where it becomes continuous with the ligamentum venosum.

In the figure below, note that the caudate and IVC touch and are posteriorly located structures. They are also posterior in relation to the quadrate which happens to be an anterior structure (9 of 39) [5/29/2002 10:46:18 PM]


WHAT IS PELIOSIS HEPATITIS? Peliosis hepatitis: blood filed vascular lesion in the liver associated with baciliary angiomatosis in hiv patients: they have fever and jaundice

BIT ON HERNIAS right sided inguinal hernias usually contain small bowel whereas sigmoid colon usually prolapses into the left side

BARETTS ULCERATIONS: the fine reticular ulcerations are deep

HEPATIC ADENOMA ENHANCEMENT: hepatic adenomas enhance during the arterial phase of CECT (10 of 39) [5/29/2002 10:46:18 PM]


WHAT IS THE MOST COMMON FUNCTIONING ISLET CELL TUMOR? insulinoma. It demonstrates strong enhancement on CECT. Unlike the other functioning pancreatic islet cell tumors, insulinomas occur with equal frequency throughout the pancreas

MORE ON TOXIC MEGACOLON: toxic megacolon rarely ocurrs with pseudomembranous colitis

POLYPOSIS SYNDROMES while Peutz Jeghers is a disease with hamartomatous polyps, there is still a risk of malignancy as 2-3 percent have adenomatous polyps in the stomach, duodenum and colon. Think TGF for adenomas (ie Turcot, Gardners, Familial polyposis coli)

For the polyposis syndromes, this is helpful: hereditary turcot (AR) and Cronkite Canada (NH). All the rest are AD. Then I think of thank god its friday or TGF for turcot, gardeners and familial polyposis coli which are the ones that contain adenomatous polyps. All the rest contain hamartomatous polyps except juvenile polyposis coli which consists of a single inflammed polyp in the rectosigmoid region and presents with GI bleeding..

Other things useful are: Cowden (cow = milk=breast; women with this syndrome have an increased incidence of breast ca; also, women have more incidence of thyroid lesions so thyroid lesions). Also, in addition to breast carcinoma, Cowden's also has mucocutaneous lesions, and hamartomatous polyps of the gastrointestinal tract. For Cronkite Canada, they have more brownish hyperpigmentation of the skin and nail atrophy in addition to alopeciae. They end up dying soon after onset due to a severe protein losing enteropathy which results in thickened gastric folds among other things. CC is a disease of older adults (>60years) and it is rapidly fatal in women, but has a tendency to remission in men. Turcot have more brain tumors; usually supratentorial GBM and medulloblastoma. Peutz Jeghers, like Cowden's has multiple hamartomas and similarly they have pigmented mucocutaneous lesions ( I dont think the ones in Cowdens are pigmented though). Gardner syndrome is an autosomal dominant disease that is characterized by the triad of colonic polyps, osteomas (most commonly in the frontal sinus, but I need the check on this), and soft tissue tumors (eg. desmoid tumors, epidermoid inclusion cysts, fibroma, lipoma, leiomyoma).

MALIGNANCY IN ADENOMATOUS POLYPS: risk of malignancy of adenomatous polyps based on size: <5mm=0% 5-9mm=1% 10-20mm=10% >20mm=50%

HEMOCHROMATOSIS: 1 HC: get Fe in the hepatocytes of the liver. Also panc involved (11 of 39) [5/29/2002 10:46:18 PM]


In 2 HC: Kupffer cells of liver involved. Spleen, LN ie RES is involved

FOLDS AND RECESSES: The Valves of Houston is another term for rectal folds. The Twining recess also known as the "diamond sign" is a temporary triangular tent-like cleft in the midportion of the pyloric canal with its apex pointing inferiorly due to mucosal bulging between two separated hypertrophied muscle bundles on the greater curvature side of the pyloric channel. This sign is seen in hypertrophic pyloric stenosis. Morgagnis columns are a number of vertical ridges in the mucous membrane of the upper half of the anal canal. A Schatzkis ring is a contraction or incomplete diaphragm in the lower third of the esophagus which is occasionally symptomatic. The valves of Heister are a series of crescentic folds of the mucous membrane in the upper part of the cystic duct arranged in a spiral manner.

INFECTIOUS CAUSES OF CHOLANGITIS IN PTS WITH HIV: Cholangitis in a pt with hiv is caused by cryptosporidium or cmv or both. Can also be caused by hiv virus.

PSC VS PBC: Primary schlerosing cholangitis: strictures of both the intra and extrahepatic bile ducts Psc: Male > female. The differential for other conditions which cause an appearance similar to PSC is: recurrent biliary tract infections, post op patients with complications, and pts with hiv. The most common cause of this appearance worldwide is A. Lumbricoides infection. Things which are associated with PSC infection are: IBD usually CD, retroperitoneal fibrosis, ascending cholangitis after biliary surgery, aids and parasitic infection.

Pbc: Female>male. Pbc has classic "tree in winter" appearance.

SOME MORE CAUSES OF GB HYDROPS: Tpn, hiv and cholecystitis all cause hydrops

EFFECT OF PANCREATIC HORMONES ON SPHICTER OF ODDI: Glucagons relaxes the sphincter of oddi and causes relaxation of the bowel. It is contraindicated in pheochromocytoma CCK causes contraction of the gb but relaxes the sphincter (12 of 39) [5/29/2002 10:46:18 PM]


MALLORY WEISS VS VOORHAVE: 76% of Mallory weiss tears ocurr below the GEJ involving venous plexus. Single longitudinal tear. Voorhave do not have hematemesis. Bleed into chest. 2-5 cm rent 2-3 cm above the GEJ

BREAKDOWN ON ESOPHAGEAL CA: esophageal carcinoma: 81-95% scc and 4-19% adenoca

SMALL BOWEL LYMPHOMA: lymphoma: stomach>small bowel

ESOPHAGEAL VARICES: downhill varices develop when the SVC is obstructed below the level of the azygous vein takeoff so that the collaterals are most developed in the upper half of the esophagus

GI DUPLICATIONS: gi duplications are most common in the ileum and are on the mesenteric side

WHAT CAUSES NARROW SEGMENT ESOPH NARROWING? baretts and epidermolysis bullosa cause narrow segment narrowing

LIVER HEMANGIOMAS: hemangiomas are most common in the right lobe of the liver

CELL TYPE OF CHOLANGIOCARCINOMA: cholangio cas are adenocas (13 of 39) [5/29/2002 10:46:18 PM]


GI INFECTIONS IN HIV mai and cryptosporidium affects ileum>colon cmv and cocciomycosis affects colon>ileum

INFLAMMATORY AND INFECTIOUS INVOLVEMENT OF GUT AND ESOPHAGUS: in schleroderma, the proximal one third (striated) of the esophagus remains normal while the distal two thirds (smooth) becomes patulous giardiasis and whipples: involve mainly duodenum and jejunum and produce irregular fold thickening Behcets is a multisystem disease M>F that includes buccal and genital ulcerations, occular lesions and skin lesions. There can be GI ulcerations from mouth to anus. It is not associated with GI submucosal nodules

WHIPPLES: irregular fold thickening of prox SB and low density mesenteric lymph nodes is classic

HSP AND BOWEL WALL THICKENING: hsp is associated with regular bowel wall fold thickening due to mucosal hemorrage

regarding choledochal cysts: A choledochal cyst refers to a congenital dilatation of a segment of the biliary ducts. The pathogenesis of the dilatation is not clearly understood but may be related to abnormal reflux of pancreatic enzymes causing inflammation and bile duct dilatation. Type I is most common and appears as a rounded widening of the common bile duct. Type II is least common and appears as normal calibaer common bile duct with diverticula. Type III is a cystic dilatation at the ampulla of Vater, also known as a choledochocele. Type IVA are multiple cystic dilatations of the intra- and extrahepatic bile ducts. Type IVB appears as multiple dilations of extrahepatic bile ducts. Type V is also known as Carolis disease. The majority of cysts are diagnosed in patients during early childhood. Complications include cholangitis, biliary calculi, biliary obstruction and carcinoma. So in summary then: type 1 is the most common (80-90%) and involves fusiform dilatation of the CBD only Type 2 is a cbd diverticula and is the least common (2%) type 3 is a choledochocele and occurs in 3% type 4b is extrahepatic ductal cysts while 4a is both intra and extra. type 5 is Caroli disease which is intrahepatic involvement only

note there are 3 types of type 1: (14 of 39) [5/29/2002 10:46:18 PM]


and this figure (Weisleder) shows the type 2, 3, 4 and 5 lesions:

BILIARY CYSTADENOMAS: these are rare. F>M (4:1). Caucasian. Premalignant. 4.6% of all intrahepatic cysts of bile duct origin. The peak incidence is in the 5th decade. They are multiloculated with a thick capsule. They derive from ectopic rests of biliary tissue and have an appearance like mucinous tumors of pancreatic origin. They contain columnar epithelial gelatinous secretions (15 of 39) [5/29/2002 10:46:18 PM]


SPIGELIAN HERNIAS Spigelian hernias occur because of weakness in the posterior layer of the transversalis fascia

MOST COMMON CA++ LIVER LESION: Hydatid dz is the first consideration for any calcified lesion in the liver

PANCREATITIS: Ca++ can occur in acute pancreatitis from the breakdown of fat

Colonic obstruction: Ca 60-70 % Tics 20% Volvulus 5% Other is from hernia, impaction

PNEUMATOSIS WITHOUT PERITONITIS: Perforation of a jejunal tic can cause pneumatosis without peritonitis. It is associated with a high mortality

START OF THE CERVICAL ESOPHAGUS: The cricopharyngeus impression is at c56 which is the start of the cervical portion of the esophagus

CAUSTIC ESOPHAGITIS: The middle and lower third of the esophagus are affected more severely in caustic esophagitis as they are areas of holdup due to the aortic arch, l main bronchus and diaphragmatic hiatus etc

TUMOR SOURCES OF ACTH Acth is produced by smlc, carcinoid of the thymus, medullary thyroid ca, and pheochromocytoma (16 of 39) [5/29/2002 10:46:18 PM]



ORIGIN: 99% from exocrine portion of pancreas 1 % are from the acinar portion of the pancreatic gland a 0.1% are malignant ampullary tumor with ausually has a better prognosis than pancrreatic adenoca

CLASSIFICATION: 3 main types: (a) exocrine, (b) endocrine, and (c) nonepithelial

(A) EXOCRINE: these can be classified as either ductal, acinar, or indeterminate origin.

ductal: ductal adenocarcinoma makes up 90% of them of the exocrine pancreatic tumors. The second most common in the ductal category are cystic neoplasms (serous and mucinous) which make up 10-15%. The remainder comprise ductiectatic mucinous secreting tumor which synomymous with mucous hypersecreting carcinoma and solid and papillary neoplasm (found in young women with good prognosis). Incidentally, the cystic changes associated with vhl also fall under the "ductal" category

acinar: acinar cell carcinoma makes up 1% of the pancreatic tumors and occur in the acinar portion of the gland

indeterminate: the only one I know of is pancreaticoblastoma which is infantile pancreatic carcinoma

MORE DETAIL ON THE 2 MAIN DUCTAL EXOCRINE NEOPLASMS: cystic neoplasms (mucinous and serous): mucinous cystic neoplasm of panc (malig). less than 6 cysts that are greater than 20mm in diam. 20 % rim calcification. mucin. peripheral enhancement. younger patients. 95% in body or tail. serous is benign. has > 6 cysts that are < 20 mm. contains glycogen. central scar. amorphous starbursts of ca++. older pts. 70% in head of the pancreas.

ductal adenocarcinoma: 60% of them ductal adenocarcinomas occur in the head nd 35% are in the body and tail. The criteria for unresectability are if the sma, portal vein or proximal smv is encased, or if there is malignant ascites. (17 of 39) [5/29/2002 10:46:18 PM]


NOW ONTO THE ENDROCRINE VARIETY: (B) pancreatic islet cell (endocrine) tumors: first their cell of origin: Insulinomas: beta Glucagonomas: alpha Gastrinomas: alpha Somatostatinomas: delta vipoma: delta

85% are functioning and 15% are non functioning. The non fnctioning ones occur most commonly in the head of the pancreas

In order of frequency of occurence: insulinoma>gastrinoma>non functioning>glucagonoma>vipoma>somatostatinoma

Here is a breakdown on some of the features of the functioning islet tumors:

they are relatively vascular tumors and show homogeneous enhancement on gado enhanced T1 weighted images insulinoma (most common) F>M, no predilection for any part of pancreas. However, majority of insulinomas are in the distal 2/3 of the pancreas gastrinoma (second most common islet cell tumor): M>F, head/tail 1:1 glucagonoma F>M, body and tail somatastatinoma F>M, head VIPOMA F>M, body and tail (very rare)

location, location, location for the ones in the headof the pancreas, think GS for gastrinoma and somatostatinoma

Other features to note: the activity of glucagon is as follows d>j>s>c esophagus is not affected by glucagon Panc islet cell tumors are apud. They are usually hyperechoic on us. Presence of Ca++ suggests malignancy Somatostatinomas produce triad of steatorrea, diabetes melitis, and gallstones by inhibiting the pancreatic exocrine and (18 of 39) [5/29/2002 10:46:18 PM]


endocrine function. Glucagonomas produce diarrea, DM, and necrolytic rash

INCIDENCE OF MALIGNANT DEGEN OF PANCREATIC ISLET CELL TUMORS: Malignant transformation with insulinomas is the least common, occurring in 5% to 10% of cases. For all of the others, malignant transformation occurs in more than 50% of cases, with nonfunctioning islet cell tumor and glucagonoma being associated with the highest incidence (approaching 80%). There are reports that somatostatinoma can be up to 90% but the usual quoted figure is around 67%: insulinoma: 10 % vipoma: 60 % Gastrinoma: 60 % Somatastatinoma: 67 % Glucagonoma: 80 % non funtioning: 80%

NOW TO CONFUSE THINGS MORE, ONTO (C) NONEPITHELIAL PANCREATIC NEOPLASMS: the main types here are primary lymphoma, secondary lymphoma and mets. Primary lymphoma accounts for <1% of pancreatic neoplasms and secondary lymphoma appears as a large homogenous solid mass which may displace and stretch peripancreatic vessels. The main mets are rcc, melanoma, lung and breast

PANCREATIC LESION THAT IS CONFUSED WITH THE MUCINOUS CYSTIC NEOPLASM: Commonly confused with mucinous cystic lesions is the intraductal papillary mucinous tumor. In these lesions, neoplastic epithelium produces mucin which results in pancreatic ductal dilatation, which may cause obstructive jaundice. While intraductal lesions communicate with the pancreatic duct, mucinous lesions do not. As these are invasive tumors, treatment is surgical resection. this is what Micheal Steer MD from HMS has to say about them: Intraductal papillary mucinous tumors A ductal ectatic form of mucin-producing tumors can also occur. These tumors, referred to as intraductal papillary mucinous tumors or IPMTs, present as multifocal dilatations of smaller branch ducts that communicate with the main pancreatic duct. IPMTs can on occasion be diagnosed by the finding of thick mucin extruding from the papilla at the time of endoscopy. It can be found anywhere in pancreas; the area involved may range from several millimeters to several centimeters in size or even involve the entire ductal system. The cystic dilatations are lined by columnar epithelium which may show areas of papillary change, atypia, or obvious malignancy. IPMT is more common in men than women. Even if the initial lesion is benign, it has a high potential for malignant change

SOME THINGS THAT TS IS ASSOCIATED WITH: TS is associated with both amls and pheos in addition to other things such as osteomas (ie bone islands) (19 of 39) [5/29/2002 10:46:18 PM]


THINGS WHICH STIMULATE GASTRIC ACID PRODUCTION BY PARIETAL CELLS: Three endogenous chemicals stimulate the secretion of acid (HCL): acelycholine, gastrin and histamine. Gastrin is released from chief cells in the gastric antrum by the presence of food, alkanization of the gastric lumen, and gastrin releasing protein.

CAUSES OF PORTAL HTN: There are two separate and sometimes overlapping classification systems for the causes of portal hypertension, using either the liver or the hepatic sinusoid as the reference point. The former classifies conditions into pre-hepatic, intrahepatic and posthepatic causes, while the latter divides conditions into presinusoidal, sinusoidal and postsinusoidal causes. However, the exact site of increased resistance in many intrahepatic causes of portal hypertension has recently been questioned, and it is likely that the predominant resistance sites could change according to the stage of some disease processes. For example, early primary biliary cirrhosis is thought to produce mainly presinusoidal hypertension, but as dense cirrhosis supervenes, sinusoidal hypertension becomes more important. Similarly, an early lesion of alcoholic liver disease, the central or terminal hyaline sclerosis, characterized by zone 3 fibrosis, would cause postsinuoidal hypertension, with sinusoidal hypertension predominating as cirrhosis becomes established.

PRESINUSOIDAL: prehepatic: splenic av fistula splenic vein thrombosis massive splenomegaly

intrahepatic: sarcoidosis schistosomiasis nodular regenerative hypeplasia idiopathic portal fibrosis early PBC chronic active hepatitis myeloproliferative disorders graft vs host disease

SINUSOIDAL established cirrosis active hepatis (20 of 39) [5/29/2002 10:46:18 PM]


POSTSINUSOIDAL alcoholic terminal hyalin schlerosis venooclusive disease

posthepatic: budd chiari membranous web right heart failure constrictive pericarditis

SPLENIC VS HEPATIC ENHANCEMENT: splenic uptake precedes hepatic as splenic takes up during the arterial phase while hepatic is during the portal phase

HEPATIC LESION SCARS: fibrolamellar is a true scar so is dark, dark on T1, T2 while FNH has edema in the scar which gives dark,bright


fnh is more common than hepatic adenoma. hepatic hemangioma is the most common. fnh is not associated with OCP while hepatic adenoma is. The central scar of fnh contains bile ducts making it bright on T2 and low intensity on T1. Also the central scar of fnh is hypoechoic.In fnh, there are no normal portal venous structures and there is central and peripheral increased venous blood flow. The central scar of fnh enhances with contrast during the portal phase. 99mTcSC is the best for seeing fnh. 40% are cold, 50% are iso, and 10% are hotter than normal liver. It is interesting to note that 13% of fnh are multiple.

with adenoma, it shows as a defect on 99mTcSC, but 23% show mild increased uptake. Unlike fnh, this lesion is definitely associated with OCP. They are hypervascular and have low malignant potential and pain is usually from bleeding or rupture. They are also associated with glycogen storage diseases such as von Gierke. On HIDA, it is hotter than liver because it concentrates bile but does not contain any bile ducts to excrete the contrast so the contrast builds up to high concentrations. On MR, they are low signal on T1 and variable signal on T2 because of blood products.

WHERE DOES AIR IN THE BILIARY TREE GO TO: (21 of 39) [5/29/2002 10:46:18 PM]


in the supine patient, it rises into the left biliary tree which is the most superior location.

CALCIFIED LIVER METS: endocrine pancreatic ca mets, mucinous pancreatic ca, osteosarc, melanoma, papillary thyroid, serous ovarian ca, mucinous ovarian ca, medullary thyroid ca. Note that mets are 20x more common than primary liver ca.

INVOLVEMENT OF LIVER WITH LYMPHOMA: 60% is due to HL and 40% is due to NHL. The most common pattern of involvement is diffuse infiltrative.

APPEARANCE OF HCC: solitary (27-60%), multiple (15-25%) adn diffuse infiltative (10-15%). Ca++ in uncommon in HCC (2-9%) and more common in FLC (30-40%). The central scar of FLC is hypointense on T2 as it is true scar.

EMPHYSEMATOUS CHOLECYSTITIS: emphysematous is not gangrenous but is a precursor to it. Gallstones are absent in emphysematous cholecystitis. M>F (2:1). It is 5x more common than gangrenous. Gangrenous occurs in 2-38% of pts with acute cholecystitis. 10% have perforation. Murphy is postitive in only 30%

ONE CAUSE OF SPLENOMEGALY THAT I DID NOT KNOW: SLE. Other causes are portal htn, storage dz, lymphoma, leukemia, multiple myeloma, mets, thalassemia, early sickle dz, mononucleosis

MINOR PAPILLA: pancreatic embryology: minor papilla is present in 60%

PBC VS PSC: PBC has normal appearing extrahepatic ducts in contrast to PSC. Has tree in winter appearance of the intrahepatic ducts. Female>male. (22 of 39) [5/29/2002 10:46:18 PM]


RECTAL INVOLVEMENT BY IBD: UC: 100 % rectal involvement CD: 50% rectal involvement

PLUMMER VINSON:: Cervical esophageal webs


DIAPHRAGMATIC HERNIA: Patulous diaphragmatic hiatus: if > 3 cm

EVAC PROCTOGRAPHY: Anorectal angle inc from 95 degrees to 180 on straining


REGENERATING NODULES: Etoh=micro 3 mm Viral =macro 3-15 mm

ZOLLINGER ELLISON: ZE ulcerations: 75 percent in the duodenum, 20 in the stomach, and 11 in the jejunum (23 of 39) [5/29/2002 10:46:18 PM]


GRADING SYSTEM FOR PANCREATITIS: apache>8 or ransom > 4 is severe disease

CELIAC DZ: duodenum, jejunum > ileum

CAUSES OF BULKY LAN IN HIV: Kaposi is a cause of bulky retroperitoneal LAN in addition to lymphoma

GASTRIC ULCERS: increased risk in nsaid, menetrier, ze, h.pylori but not in alcoholism

VENOUS MESTENTERIC ANATOMY: R gastric goes to portal vein L gastric goes to paraumbilical vein to lumbar veins to IVC splenic vein goes to gastrorenal and splenorenal to renal vein to IVC

GI DUPLICATIONS: most common in the the distal ileum, distal esophagus, stomach, and duodenum. They are on mesenteric side and most are non communicating

ACHALASIA: in primary achalasia, symptom onset is insidious while in secondary eg to a esophageal or fundal tumor, it is characterized by more rapid onset of symptoms and odynophagia

INTERNAL vs EXTERNAL LARNGOCELE: within the confines of the thyroid cartilage and thyroid membrane. The external protrudes through the thyrohyoid membrane (24 of 39) [5/29/2002 10:46:18 PM]


COUINARDS SEGMENTS (SEE BELOW): Hepatic surgery, hepatic resection in particular, is based on a segmental anatomy described by Couinard in 1957. There are eight segments in all. The caudate lobe is segment I. The right and left liver are divided by the middle hepatic vein. The left liver segment II is divided from segments III and IV by the left hepatic vein. Segment II is posterior to the left hepatic vein. Segments III and IV are separated by the falciform ligament. Segments V through VIII compose the right liver. (25 of 39) [5/29/2002 10:46:18 PM]


LARYNGOCELE: represents a dilated appendix of the laryngeal ventricle and is usually confined to the perilaryngeal space. They are thin walled and can contain fluid

EFFECT OF HERPES AND DRUGS ON THE ESOPHAGUS: herpes and drug affect the upper and mid esophagus with superficial ulcer. Reflux causes shallow ulcers in the distal esophagus

GI INVOLVEMENT WITH LYMPHOMA: stomach (82%) ileum (15%) colon (6%) (26 of 39) [5/29/2002 10:46:18 PM]


duodenum (2%)

MALIGNANCY IN THE SMALL BOWEL: jejunum: adenocarcinoma is the most common ileum: carcinoid is the most common, and lymphoma is second mets can occur anywhere

DIVERTICULOSIS: diverticulosis in 50% of people 80y diverticulitis in 4-5% of people with diverticulosis bowel obstruction in 10% of people with diverticulitis

INCARCERATED VS STRANGULATED HERNIAS: incarcerated are irreducible and strangulated are ischemic and irreducible

CAVERNOUS HEMANGIOMA: iso to hypo on T1 and markedly hyper on T2

BRUNNERS GLAND HYPERPLASIA: in duodenal bulb, get brunners gland hyperplasis in a regular and nodular pattern. In heterotopic gastric mucosae, the nodules are varying sizes and polygonal

HCC TYPES: A: spreading B: expanding C: multifocal, diffuse

GI PATHOGENS IN AIDS: (27 of 39) [5/29/2002 10:46:18 PM]


CMV is the most common GI pathogen in AIDS and colitis is the most common GI manifestation of CMV

WHIPPLES AND MAI: can both look similar. Whipple has a fine nodularity in the small bowel with mesenteric LN's that are hypodense on CT. MAI has bulky retroperitoneal LN's like whipples.


GI LYMPHOMA (once again): stomach>small intestine>rectum>perianal>duodenum>colon

PHLEGMON VS ABSCESS: phlegmon is a ST density in omentum or mesentary. It is solid. abscess is liquid

MOST COMMON SITE OF BOWEL INJURY IN BLUNT ABDOMINAL TRAUMA: the most common site of GI injury is the jejunum. Most bowel injuries occur at points of fixation. Ie just beyond the ligament of Trietz

ANEURYSMS IN PANCREATITIS: GDA aneurysms are the most common of all of them

PANCREATIC TRAUMA: contusion, laceration, transection. The radiographic features are: hematoma, non enhancing regions, peripancreatic stranding. Delayed complications: abscess, pseudocyst, fistula, pancreatic necrosis

MORE ON PANCREATIC NEOPLASMS (SEE ABOVE): serous cystadenoma of panc has a capsule and is associated with VHL. It can have a central dense calcification. Solid and papillary neoplasm of the pancreas is found in adolescent girls and has a good prognosis (28 of 39) [5/29/2002 10:46:18 PM]


AGAIN MAJOR CAUSE OF BILE DUCT INJURY DURING LAPAROSCOPIC SURGERY: mainly occurs in pts with normal biliary anatomy

PHARYNGEAL POUCH: it is a lposterolateral outpouching through thyrohyoid membrane seen in trumpet blowers etc

LARYNGOCELE: lateral outpouching of larngeal ventricle seen in blowers

POST OP BILIARY STRICTURE: ischemia is the most common cause of post op biliary stricture from liver transplant. This is indicates HA thrombosis. It is more common in children than in adults due to the smaller size of the HA in children resulting in a more difficult anastomosis

LIVER STRAIGHT LINE SIGN: it is from portal segmental vein occlusion

COLONIC ANGIODYSPLASIA: it is antimesenteric. Telangiectasis with Rendu Osler Weber are in small bowel and not in colon. Note that ROW=HHT

CELLS IN THE STOMACH: antrum contains all the G cells. Fundus and body contain all the parietal or acid secretory cells.The chief cells which are also in the fundus and body make trypsinogen

CT DENSITY OF LIVER: on non enhanced CT, liver is more dense than spleen due to its high glycogen content (29 of 39) [5/29/2002 10:46:18 PM]


RADIOGRAPHIC IMITATOR OF UC: salmonella (think salmonella and uc or suc(k) )


DDX OF ACHALASIA: 1ary achalasia, chagas, central and peripheral neuropathy, malignancy

SCLERODERMA: the smooth muscle in the distal 1/2 to 2/3 of the esophagus is replaced by fibrous tissue, resulting in decreases esophageal motility. There is severely decreased LES tone resulting in reflux and peptic stricture formation

MENETRIERES: usually get antral sparing

GASTRIC VARICES W/O ESOPHAGEAL VARICES: this indicates splenic v thrombosis which is most commonly caused by pancreatitis or pancreatic ca. For downhill varices, mediastinal tumor or inflammatory dz are the usual cause

ORIGIN OF ZENKERS DIVERTICULUM: these arise in the midline posterior and just proximal to the cricopharyngeus muscle

GI WATERHED AREAS: the 2 areas are splenic flexure and rectosigmoid (30 of 39) [5/29/2002 10:46:18 PM]


VOORHAVE: the tear occurs along the L posterior esophageal wall near the L diaphragmatic crus

INTERNAL HERNIAS: majority are paraduodenal and result from failure of the mesentary to fuse with the peritoneum at the ligament of Trietz. Bowel herniation through the foramen of Winslow into the lesser sac is a less frequent occurrence

GASTRIC ADENOMATOUS POLY LOCATION: most are located in the antrum. Both the adenomatous and hyperplastic type are common in pts with achlorhydria and chronic atrophic gastritis

PNEUMATOSIS: 1ary: gas collections are predominantly cystic 2ary: gas collections are more linear

HYDATIC CYSTS: hydatid cysts from ecchinococcus are the most common cause of hepatic cysts worldwide. Can occur in the brain, lung, kidney, and bone. The risk of anaphylactic rxn from percutaneous aspiration is reduced with a very thin needle (22G). Ecchinococcus alveolaris is a solid, infiltrating, non specific mass and can look like a neoplasm

PRIMARY HC: they usually present with cirrosis, DM, and hyperpigmentation liver density seen in HC is also seen in amiodarone toxicity, glycogen storage dz, Wilsons. In 1 ary HC, the spleen is not involved

Good way to remember the position of the CBD, HV, and PV: (31 of 39) [5/29/2002 10:46:18 PM]


ie the CBD is on the same side as the GB

CONTENTS OF SMALL BOWEL MUCOSA: contain lamina propria, lymphoid follicles, and kultchinsky cells which are another name for the argentaffin cells that give rise to carcinoids. It does not contain myenteric plexus cells; these are in the muscularis

ASSOCIATIONS WITH PSC: usually involves fibrous obliteration of intra and extrahepatic bile ducts. Young M>F. It is associated with sicca complex, reidels struma, RPF, and mediastinal fibrosis

PNEUMATOSIS INTESTINALIS: it has a preference for the jejunum

INTRAMURAL ESOPH PSEUDODIVERTICULOSIS: m>f, 20% of pts are diabetic. 15% of pts are alcoholics. 34 - 48% are colonized with candida

ESOPHAGEAL TUMORS: esophageal ca 80% SCC and 20% adenoca. SCC is more common in the upper esoph. Need a double contrast esophagram to see the z line. Plummer vinson is dysphagia, Fe deficiency anemia, mucosal lesions of the mouth, pharynx and esophagus

LMYMPHGRANULOMA VENEREUM: is is caused by clamydia trachomatis in homosexual males. Gonococcal proctitis has a similar appearance

GI DUPLICATION: (32 of 39) [5/29/2002 10:46:19 PM]


most common in the teminal ileum on the mesenteric side

CARMEN MENISCUS SIGN AND KIRKLAND COMPLEX: ulcer crater straddling the lesser curvature of the stomach

SCLERODERMA: basal interstitial fibrosis and dilatation of the esophagus. The esophagus is involved in 90% and the lungs are the least likely to be involved. It is also associated with the CREST syndrome. The esop>small bowel>colon>stomach. There is an incompetent LES with decreased peristalsis and increased reflux into the dilated esophagus. There is small bowel atony, diln, malabsorption, pneumatosis, hidebound appearance, and pseudosacculations

SPRUE: in non tropical sprue, get jejunization of the ileum and ilealization of the jejunum. As mentioned earlier, there are transient intucusseptions of small bowel which becomes flaccid and dilated. A moulage pattern is seen with the older contrast suspensions

DIFFICULTY WITH REMBERING SOME OF THE FOLDS CAN BE HELPED AS FOLLOWS: anus = am = morgagni pylorus = pt = twinning

CAUSES OF PNEUMOPERITONEUM WITHOUT PERITONITIS: endoscopy, perforated jej tic (most common), therapeutic arterial embolization, perfed cyst or pneumatosis intestinalis, air tracking down form the mediastinum.

HAUSTRATION: there is no haustration from the mid transverse colon to the rectum. The descending colon is mainly supplied by the IMA

ZOLLINGER ELLISONS: the ulcerations occur in the proximal duodenum (75%), jejunum (11%), and stomach (20%). It is associated with the presence of gastrinoma (33 of 39) [5/29/2002 10:46:19 PM]


MORE ON TS: TS and ADPKD can have cysts in the liver but not in the pancreas. However, VHL has cysts in the liver, pancreas, and spleen

SUPERIOR RECTAL IS A CONTINUATION OF THE IMA: however, the middle and inferior rectal are branches which come off the anterior division of the internal iliac artery and anastomoses with the superior rectal artery see drawing adapted from Ann Agur book which is reproduced below from (34 of 39) [5/29/2002 10:46:19 PM]


SOME PANCREATIC DUCT ANATOMY: (pictures excerpted from Weissleder) (35 of 39) [5/29/2002 10:46:19 PM]


CHRONIC CHOLECYSTITIS: Rokitansky Ashoff sinuses failure to respond to CCK thick wall (36 of 39) [5/29/2002 10:46:19 PM]



ALCALCULOUS CHOLECYSTITIS: trauma, DM, burns, AIDS, prolonged fasting

US FINGINGS SUSPICIOUS FOR ACUTE CHOLECYSTITIS: >3 mm wall thickening, >4 cm of distension, positive Murphy sign, but can also have gangrene and nerve death giving a negative Murphy

SCLEROSING CHOLYCYSTITIS: extrahepatic: 80%. UC is more associated with it then crohns

ACCESSORY SPLEEN: seen in 40% of pts. They are <3 cm and located near the hilum

SPLENOMEGALY: >12 cm. To get the index, multiply the 3 dimensions. Most common cause is tumor, infection, metabolic

CAUSES OF SPLENIC TRAUMA: tumor: lymphoma, leukemia infection: histo, mono storage disease: gauchers, amyloid, hemochromatosis vascular: portal htn, ssd, thalassemia, trauma, myelofibrosis

SPLENIC TRAUMA: blunt vs penetrating: subscapular, intraparenchymal, laceration, fragmented, delayed splenic rupture. Note the sentinal clot sign (37 of 39) [5/29/2002 10:46:19 PM]


MOST COMMON SPLENIC METS: breast, lung, stomach, melanoma, ovarian ca

SPLENOSIS: S/P trauma, see it in the mesentary, diaphragm, dependent places such as the paracolic gutter, perihepatic space, and morrisons pouch. Note that Morrisons pouch is most dependent when the pt is in the dependent position. Morrisons pouch communicates with the lesser sac via the epiploic foramen. In the pelvis, the pouch of Douglas is the other dependent space

SPLENIC INFARCT: cardiovascular: valve dz, bacterial endocarditis tumor inflammatory eg pancreatitis other: eg SSD, polycythemia

PSEUDOMYXOMA PERITONEI: primary is ovarian or appendix. See scalloped indented liver, peritoneal Ca++, perotoneal thickening, pseudoascites (septated), inguinal hernias

GROIN HERNIA: direct is medial to the inferior epigastric vessels indirect is lateral to the inferior epigastric vessels through a patent processus vaginalus

DUODENAL FILLING DEFECTS: benign: adenoma, leiomyoma, carcinoid, villous adenoma

malignant: 90% of masses distal to the papilla are malignant, mets. They spread by direct invasion. bulb: 90% benign; 2nd and 3rd portions: 50% are malignant; 4th: 90% are malignant

bulb: ectopic gastric mucosa, varices, prolapsed antrum, brunner gland hyperplasia

distal: lymphoid hyperplasia, ectopic panc, annular panc, papilla, tumor, edema, choledochocele (38 of 39) [5/29/2002 10:46:19 PM]



MALABSORPTION PATTERNS: predominantly dilated loops: sprue, obstruction, scleroderma, other predominantly thickened loops: whipples, amyloid, giardiasis, cryptosporidiosis, lymphoma, EG, MAI thickened loops without malabsorption: tumor, hemorrage, edema the criteria for thickened folds is >3mm

PRIMARY BILIARY CIRROSIS: involves both intra and extrahepatic bile ducts

KILLIANS DEHISCENCE: it is immediately above the cricopharyngeus

LOCATION OF PARIETAL CELLS: in the fundus and body

COMMON CAUSES OF SWALLOWING ABNORMALITIES (Levine, Gore et al): leakage: weakness, atrophy, resection of tongue. Edentulous or missing teeth or ill fitting dentures. Paralysis of the soft palate. nasal regurgitation: weakness of the soft palate, or superior constrictor penetration o aspiration, or both: Poor or absent epiglottic tilt. Poor or absent elevation of the larynx. Poor or absent closure of the larynx Retention (in valleculae or piriform sinuses): Poor push. Weakness of stripping wave. Relative obstruction such as prominent cricopharyngeus or web (39 of 39) [5/29/2002 10:46:19 PM]


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There is no index for this so if you want to find something, press the Ctrl-F keys at the same time and type in the word you want to find in the find box! If someone would like to help make an index for this, let us know

Before we begin, here is the anatomy of the kidney, in terms of the vessels found within it: Here is the sequence from renal artery to renal vein (see figures): (1 of 37) [5/29/2002 10:47:48 PM]


Renal artery Segmental artery Lobar artery Interlobar artery Arcuate artery Interlobular artery Arcuate artery Interlobular artery Afferent arteriole Glomerulus Efferent arteriole Interlobular vein Arcuate vein Interlobar vein Segmental vein Renal vein (2 of 37) [5/29/2002 10:47:48 PM]


this is the Key for the model kidney: 1. Renal Vein 2. Renal Artery 3. Renal Calyx 4. Medullary Pyramid 5. Renal Cortex 6. Segmental Artery (3 of 37) [5/29/2002 10:47:48 PM]


7. Interlobar Artery 8. Arcuate Artery 9. Arcuate Vein 10. Interlobar Vein 11. Segmental Vein 12. Renal Column 13. Renal Papillae 14. Renal Pelvis 15. Ureter

TESTICULAR CA: germ call tumors: YES CT: yolk sac, embroyonal (2 yo and 2-3rd decade), seminoma, choriocarcinoma, teratoma Non germ cell: Leydig (3-6 yo, benign>malig by 9:1) and sertoli (1st year, benign >malig by 9:1). Leydig can cause precocious puberty yolk sac and teratoma are most common tumors in children. Seminoma are also germ cell and are more common in adults

TESTICULAR LYMPHOMA: child: leukemia>lymphoma adult: lymphoma>leukemia

TESTICULAR BLOOD SUPPLY: deferential, cremesteric, testicular

CAUSE OF STRIATED NEPHROGRAM: renal vein thrombosis, tamm horsfall protein, pyelonephritis, medullary sponge kidney (4 of 37) [5/29/2002 10:47:48 PM]


CAUSE OF NEPHROMEGALY: Glomerulonephritides, HIV nephropathy, diabetic glomerulosclerosis, amyloidosis, acute tubular and cortical necrosis, leukemia and lymphoma, ADPKD and ARPKD are all causes. Conditions that typically cause enlargement of one kidney, such as acute renal vein thrombosis, can also cause bilateral nephromegaly if the process is present in both sides. Medullary cystic disease which is inherited causes normal to small kidneys

TESTICULAR CYSTS: central is rete testes and peripheral is tunica albuginea

ADRENAL METS: 50% of adrenal masses in oncology pts will be mets. A unilateral adrenal met is most likely to be lung.

MALE URETHRA A little bit of the male urethal anatomy ( i always have trouble remembering this for more than 5 min): The prostate is a gland situated underneath the bladder (the bladder neck) and is perforated by the first portion of the urethra. The 2 ejaculatory ducts enter the upper part of the prostate from behind, travel through the gland and open into the urethra on a small protuberance (3-4 mm) of the urethral mucosa called the verumontanum ("veru"). (5 of 37) [5/29/2002 10:47:48 PM]


This is quoted from an article by Tartufus MD ( which may help to clafify some of the anatomy in this area. The veru is very critical because of the convergence of several other structures: Between the 2 openings of the ejaculatory ducts, we find the opening of the utricle, a remnant of our early life as embryo (a small duct representing the rests of the tissue which in the female develops into the uterus). The appearance of the utricle can vary widely from a tiny dimple in the veru to a long narrow duct extending deep into the prostatic tissue parallel to the ejaculatory ducts in the midline. In some individuals, this duct obliterates forming a cyst (utricular cyst) in the prostate, not rarely the cause of symptoms identical to those of "chronic prostatitis". The prostate is composed of 25-30 small glandular units (acini) located in the periphery of the prostate, and each glandular unit is connected to the outside world by a tiny duct which opens into the urethra at each side in direct proximity to the veru. The prostatic acini produce a fluid that, at orgasm, is expelled from the acini by contraction of the prostatic smooth muscle tissue surrounding these acini. The composition of the prostatic fluid is vital for the well-being of the spermatic cells outside the body and (6 of 37) [5/29/2002 10:47:48 PM]


severe alteration, like in certain forms of chronic prostatitis, can degrade fertility. Other important anatomical structures, mostly neglected in the literature, are the seminal vesicles (SV). These glands reside on the backside of the lower part of the bladder, their body (about 5-8 cm long, .6-1 cm wide) lies alongside the deferent duct (which carries the sperm cells from the testis to the urethra) and empties into this duct before the deferent duct enters the prostate to become the ejaculatory duct. The SVs are structurally hollow organs comparable to the gallbladder, but with multiple small saccular compartments (looking almost like a grape) interconnected with each-other. The wall of the SVs is composed of an internal cellular lining (glandular cells) which produces a fluid necessary for the extracorporeal survival of the sperm cells. This fluid, together with the fluid from the prostatic acini, constitutes a major part of the volume of the spermatic fluid; only a small part comes from the testicles. The outside muscular shell of the SVs contracts and expells the secretion at orgasm.

Non atrophy of Mullerian duct can cause cystic dilation of the vas deferens to the ejaculatory ducts. The utricle cysts can occur close to the prostate in the midline and can cause obstructive symptoms. These cysts lack sperm. They are associated with hypospadias and undescended testicle

PELVIC LIPOMATOSIS: associated with cystitis glandularis, renal failure, obstruction of the collecting system, no association with obesity, htn is an associated finding as is renal failure and renal stones

PRIMARY MEGAURETER: more common on the L than the R

GU INFECTION: In male<35 y, gonnorhea, clamydia are more common (7 of 37) [5/29/2002 10:47:48 PM]


In male>35 y, main organisma are E coli, staph, proteus


STRICTURE S/P TURP: most likely place to get a stricture is the bulbous urethra

MOST COMMON CAUSE OF URETERAL OBSTRUCTION: intrinsic ureteral abnormality


RENAL MASS WITH A CENTRAL SCAR? it is most likely RCC, just because RCC's show up more commonly than the others


RENINOMAS: (8 of 37) [5/29/2002 10:47:48 PM]


rare tumors but more common in females

REVERSED RENAL VEIN FLOW: most common cause of reversed renal vein flow in renal transplant is renal vein thrombosis

ECTOPIC URETROCELE IN A CHILD: can also present as an interlabial mass in addition to sarcom botyroides

RCC: 80-90% are clear cell type

MORE ON HUTCH DIVERTICULUM: hutch are not associated with hypospadias. They are associated with VUR. Hypospadias are associated with cryptorchidism

PROSTATITIS LOCATION: usually involves the peripheral zone

BPH: hypertrophy of the transitional zone is associated with bph

BLADDER CA RISK FACTORS: TCC: smoking, phenacetin, aniline, XRT, cyclophosphamide (9 of 37) [5/29/2002 10:47:48 PM]


SCC: leukoplakia, stone dz, infected tics, UTI, schistosomiasis (note that it is S hematobium that infects the bladder and not the others)

RENAL STONES: the most common one is Ca oxalate. #2 is struvite, and #3 is uric acid, 70% of people with renal stones have a metabolic disorder. RTA causes Ca oxalate stones. This is due to hypercalciuria without hypercalcemia. Sarcoid and HPT cause hypercalciuria with hypercalcemia. PCKD also causes an increased incidence of renal stones. Abnormal bowel mucosae from bowel resection or involvement with the terminal ileum with inflammatory bowel disease causes increase in oxalate absorption resulting in increased oxalate stones. Abnormal bowel mucosae also cause increased uric acid stones. The most common cause of uric acid stones is a primary as opposed to a secondary metabolic cause. Note that struvite is often laminated. Eswl is preferred when stone size is <25mm or when the stone is not branched or made of cystine. Also, it should not be used in cases of obstruction. Other contraindications to eswl are urosepsis, bleeding diathesis, pregnancy, and morbid obesity

TUBULE FUNCTION: Na reabsorbed: PCT Acid base balance: DCT and collecting duct Water reabsorption: PCT and CD ADH effect: CD

PYELORENAL BACKFLOW: pyelosinus (fornix rupture) pyelotubular (fan like streaks) pyelointerstitial (more amorphous than pyelotubular) pyelolymphatic (dilated lymphatics) pyelovenous (rare) the first 2 are the most common (10 of 37) [5/29/2002 10:47:48 PM]


VICARIOUS EXCRETION: ARF, ATN is the most common

CYSTITIS GLANDULARIS: mucin filled mucosal cysts with columnar cells (goblet) which appear as filling defects in the bladder. It is the precursor of adenocarcinoma

CYSTITIS CYSTICA: can progress to cystitis glandularis. Serous filled cysts. female > male. It is associated with chronic uti. Forms from Brunner nest degeneration in the lamina propria. (Bracco diagnostics sponsored Board review questions) state that cystitis cystica is not a premalignant lesion

PYELOURETERITIS CYSTICA: Pyeloureteritis cystica is hyperplastic transitional epithelium projecting into the ureteral lumen. It indicates past UTI. It is caused by chronic urinary tract stone or infection resulting in numerous submucosal lined cysts. Diabetics are predisposed. F>M. bladder>>proximal 1/3 of ureter>upj. Unilateral>bilateral. Multiple round small lucent filling defects in the ureter. 1-3 mm in size. Some sources say that there is an increased incidence of tcc, but the accepted view is that there is no increased incidence of malignancy (unlike in ureteral pseudiverticulitis)

MECKEL GRUBER: occipital encephalocele, microcephaly, polycystic kidney, post axial polydactyly

PCA INFARCT: affects ipsilateral thlamus, not the contralateral one (11 of 37) [5/29/2002 10:47:48 PM]


UNRUPTURED PCA ANEURYSM: classically gives an isolated and complete 3rd nerve palsy while this is not seen with a PICA aneurysm

AMYLOID ANGIOPATHY: this is deposition of amyloid in the media and adventitia of small and medium sized vessels of superficial layers of the cerebral cortex and leptomeninges with sparing of the deep grey nucei. It is not associated with systemic amyloidosis nor hypertension


MOST COMMON CAUSE OF CNS RHINORRHEA: trauma. Osteoma of the frontal sinus can cause cns rhinorrea, but a mucus retention cyst cannot

ANENCEPHALY: it is not associated with other major anomalies

HEMANGIOBLASTOMAS AND INTRACRANIAL BLEED: hemangioblastomas do not typically bleed

MOST COMMON POST FOSSA MASS: (12 of 37) [5/29/2002 10:47:48 PM]


if i did not already say so, it is an infarct. The most common post fossa mass is mets. Hemangioblastoma is the most common post fossa primary tumor

MOST COMMON SPINAL CORD TUMOR IN CHILD: astrocytoma (60%), ependymoma (30%), hemangioblastoma (3%)

ASK UPMARK KIDNEY: segmental renal hypoplasia. the appearance is the same as unifocal reflux nephropathy

HEMIATROPHY: assoc with wilms, MSK, congen hepatic fibrosis

URETEROCELES: orthotopic ureteroceles are frequently bilateral.

MALAKOPLAKIA VS LEUKOPLAKIA: malakoplakia: bladder > lower 2/3 of ureter > upper ureter > renal pelvis. Multifocal in 75%; bilateral in 50%. female > male for the urinary tract and male > female for other body parts (colon, rectum, etc) leukoplakia: bladder > renal pelvis > ureter

URETHRAL STRICTURES: 40% of urethral strictures in US are from gonorrea. mostly affects anterior urethra and one sees reflux into the glands of Littre. Foley catheters cause most strictures at the penoscrotal junction. Instrumentation causes most strictures at the external sphincter where it is difficult to pass an instrument through (13 of 37) [5/29/2002 10:47:48 PM]


URETHRAL TUMORS: most uretrhal tumors are SCC adn arise in the bulbous urethra

HEPATIC FIBROSIS ASSOCIATIONS: arpkd, adpkd, mdk, caroli, choledochocele

MLCN has > 10 cm cystic spaces. Young boys and older girls/women. They are taken out as cannot distinguish from Wilms. They can herniate into the renal pelvis. Incidence: F>M

NEPHROBLASTOMATOSIS: associated with Wilms; 30% unilateral wilms, and 100% bilateral wilms. Precursor to Wilms. The best test for it is contrast enhanced CT

MESOBLASTIC NEPHROMA: most common solid renal mass in the neonate. It is a hamartoma. it it treated with surgery due to uncertainty that it may contain areas of sarcomatous degeneration.

REFLUX: 5 grades. Grade 1 is reflux to ureter but not to kidney (14 of 37) [5/29/2002 10:47:48 PM]


NEONATAL ADRENAL HEMORRAGE: R (70%) > L (20%). Bilateral is 10%

RENAL ARTERY ANEURYSM: Ca++ 30 to 50% in the wall. They are associated with HTN in 15%. R>L. There is an increased risk of rupture in a pregnant woman. The indications for surgery are: rupture, distal embolization, RAS, causing HTN, woman of child bearing age and >2 cm. If they are not Ca++, then there is a greater risk of rupture.

FRALEY SYDROME: This is narrowing of renal pelvis due to crossing vessel

WHAT IS MEGACALICOSIS? Megacalicosis is nonprogressive caliceal dilatation caused by hypoplastic medullary pyramids. Mosaic-like arrangement of dilated calices (polygonal + faceted appearance, NOT globular as in obstruction)

SPECTRUM OF URETHRAL INJURIES: Urethral injury: type 1: stretching of posterior urethra without tear. Type 2: tear above UG diaphragm. Type 3: complete rupture at or below UG diaphragm. Straddle injury involves the anterior urethra in males, especially the bulbous portion where it is caused by compression of the urethra against the pelvis

INTRA VS EXTRAPERITONEAL BLADDER RUPTURE: extraperitoneal bladder rupture occurs 4 times more common than intraperitoneal rupture

HUTCH DIVERTICULUM Hutch diverticula are associated with reflux due to their location near the uvj which distorts the anatomy (15 of 37) [5/29/2002 10:47:48 PM]


in this region leading to reflux or obstruction

BLADDER CANCER: Bladder ca arising within a bladder tic usually metastasizes early due to no overlying muscle layer. With bladder outlet obstruction, most bladder tics develop near the base

POLYCYSTIC OVARIAN SYNDROME: stein leventhal: increased LH/FSH ratio

DRASH: male pseudohermaphaditism and progressive nephritis. Like vhl, hemihypertrophy is associated with rcc

BECKWITH WEIDMAN: EMG OR GOMPE: exomphalos, macroglossia, gigantism, organomegaly, diabetes, increased incidence of wilms

HORSESHOE KIDNEY: IMA stops kidney form ascending. there is an increased risk of rcc in the isthmus. Horseshoe kidney is 0.01 to 0.25%. It has an increased incidence of UPJ obstruction and increased incidence of infection. The incidence is UPJ obstruction > calculi and UTI's. Associated anomalies include omphalocele, cardiac, skeletal, anorectal, and GU

Here is some other information I ran into: Pathophysiology: The horseshoe kidney does not by itself produce symptoms. It is however, by virtue of its embryogenesis and anatomy, predisposed to a higher incidence of disease when compared to the (16 of 37) [5/29/2002 10:47:48 PM]


normal kidney. The variable blood supply, presence of the isthmus, high insertion and abnormal course of the ureters all contribute to these problems. Because of these embryogenic and anatomical factors there are higher rates of hydronephrosis, stone formation, infection and certain cancers which result in a diseased horseshoe kidney. The most common associated finding in horseshoe kidney is ureteropelvic junction obstruction which occurs in up to 35% of patients. It causes the majority of problems. Obstruction is due to the high insertion of the ureter into the renal pelvis. The crossing of the ureter over the isthmus may also contribute to obstruction. Nonobstructive dilatation must be distinguished from obstructive dilatation by diuresis radioisotope renal scans. The prevalence of stones in the horseshoe kidney ranges from 20% to 60%. Stone disease is thought to be due to the associated hydronephrosis or ureteropelvic junction obstruction that causes stasis of urine. This hinders stone passage. Metabolic factors as in the normal population have also been suggested as contributing to stone formation in these patients. Urinary stasis and stone disease also predispose the horseshoe kidney to infection present in 27% to 41%. Ascending infection from vesicoureteral reflux is another cause of infection in the horseshoe kidney. Certain cancers are more frequent in the horseshoe kidney. This is thought to be due to teratogenic factors present at birth as well as the susceptibility of the diseased horseshoe kidney to certain cancers. Renal cell carcinoma is the most common renal cancer in horseshoe kidney, accounting for 45% of tumors. The incidence of renal cell cancer in the horseshoe kidney is no different than that of the normal kidney.

Relevant Anatomy: Horseshoe kidneys may be found at any location along the path of normal renal ascent from the pelvis to the mid abdomen. The kidneys may be lower than normal as the isthmus is tethered during renal ascent by the inferior mesenteric artery. The isthmus usually lies anterior to the great vessels at the level of the 3rd-5th lumbar vertebra. It can rarely be posterior to these vessels or run between them. The vascular supply is variable and originates from the aorta, the iliac arteries, and the inferior mesenteric artery. Bilateral single renal hilar arteries occur in 30% of cases, various combinations of single and multiple renal hilar and isthmus vessels are seen in 70%. The isthmus of the kidney may not have a separate blood supply or may be supplied by a single vessel from the aorta in 65% of cases. The blood supply to the isthmus may arise from the common iliac, or inferior mesenteric arteries. The collecting system has a characteristic appearance on intravenous urogram due to an incomplete inward rotation of the renal pelvis, which faces anterior. The axis of the collecting system is deviated inward at the lower poles because of the lower pole's connection with the isthmus. The ureter may have a high insertion into the renal pelvis and cross anterior over the isthmus as it descends to the bladder.

MOST COMMON GU ABNORMALITY: (17 of 37) [5/29/2002 10:47:48 PM]


duplex collecting system is the most common GU anomaly. There is an associated increased incidence of UPJ obstruction and uterus didelphys. The lower pole refluxes and the upper obstructs, refluxes or both. The associated ectopic ureterocele is secondary to obstruction. It can also cause obstruction of the other side as well

UPJ OBSTRUCITION: men>women 2:1 and L>R. It is bilateral in 10-30%. It is associated with and increased incidence of contralateral dysplastic kidney and renal agenesis. It does not affect the lower ureter. In the fetus, it is most commonly due to muscular or intrinsic abnormality

RCC ASSOCIATIONS: aniridia, beckwith weidman, drash, nf, klippel trauneray, vhl, ts.

HYPERTROPHIED COLUMN OF BERTIN: It is a nl variant. It most commonly occurs at the juction of the upper and middle one third of the kidney

RETROPERITONEAL SPACES (quoted from board practice questions): The scrotum, if the processus vaginalis remains patent, communicates with the peritoneal cavity rather than with the retroperitoneum. The psoas muscle lies posterior to the posterior pararenal space, in what some refer to as the "retrofascial" space. The adrenal gland is in the perirenal space. Part of the lateroconal fascia courses in a plane parallel to the sagittal plane of the body. In patients with ample retroperitoneal fat, this fascia can be seen as a vertical line on x-ray examination of the kidneys, ureter, and bladder.

LIPIDOSIS OF THE ADRENAL GLAND: Wolman disease is a lipidosis of the adrenal gland. It is associated with ca++ of the adrenals. The affected infants usually die a few weeks after birth (18 of 37) [5/29/2002 10:47:48 PM]


ADRENAL GLAND SIZE: The medial limb of the r adrenal is bigger than the lateral limb. With agenesis of the kidney, the adrenal is still present but is cigar shaped

PHEO RULE OF TEN: Bilateral, multiple, malignant, familial, extraadrenal

URACHUS: a bit on the urachus: patent (ie communication) in 50%, urachal cyst in 30%, sinus in 15% and tic in 5% urachal cysts are susceptible to bleeding, ca, stones and obstruction. Infection with staph aureus is the most common complication of urachal cysts in adults. Bleeding is more common in children

ANORECTAL MALFORMATION: high (supralevator) anorectal malformation has a high (50%) association with GU and cardiac anomalies while a low malformation does not

ADRENAL CORTICAL HORMONES: concerning adrenal: cortex: gfr or mga while medulla: norepi, and epi only

RENAL BIOPSY: Brodels white line is in lateral kidney and is highly vascular. Brodels avascular plane is 1-2 cm posterolateral to the white line

CYSTIC KIDNEY DISEASES:: (19 of 37) [5/29/2002 10:47:48 PM]


arpkd 3 types, in the juvenile form, there is bilateral gross renal enlargement and faint nephrogram with blotchy opacification on initial images which then becomes increasingly dense. On US, the kidneys are hyperechoic and the cysts are not resolved.They consist of ectatic dilatation of the collecting tubules. There is a loss of the corticomedullary differentiation. On ob us, there is progressive renal enlargement as early as 17 w with hyperechoic renal parenchyma. There is non visualization of urine in the bladder in severe cases.

adpck mean age at dx is 43y. Assoc with cysts in liver, panc, lung, spleen, thyroid, seminal vesicles etc and cerebral berry aneurysms.There are bilateral large kidneys with multifocal round lesions and unilateral enlargement may be the first manifestation. The cysts may rim calcify. The kidneys shrink after the onset of renal failure. US shows multiple cortical cysts which are not seen prior to the teens. The kidneys are diffusely echogenic when the cysts are small in children. On Ob US, the kidneys can look large and echogenic similar to infantile PCKD usually in the 3rd trimester. The earliest sonographic dx is made at 14 w. It can be unilateral and macroscopic cysts are rare.

posterior urethral valves. Types 1 to 3. Type 1 is membranous, type 2 the folds consist of hypertrophied muscle and type 3 consists of an iris or diaphragm. The folds are wolffian duct remnants. Type 1 is the most common. Discovered in the first year and neonatal period in 70% (about 35% each). There is vur mainly on the L side. US shows oligohydramnios and hypoplastic multcystic dysplastic kidney if early occurrence. The ddx is upj or uvj obstruction or primary megaureter, megacystis microcolon sydrome, and massive vur More simply put, Type 1 PUR are slit like and type 3 are pinhole so type 3 are most likely to be associated with renal dysplasia. There is no association of PUV with Prune Belly syndrome

it is interesting to note that primary megaureter is more common on the L

mcdk second most common cause of an abdominal mass in neonate after hydronephrosis and it is the most common cause of an abdominal mass in a healthy neonate. M>F for unilateral and I believe M=F for bilateral. More common among infants of diabetic mothers. Most common cause of cystic dz in infants. Due to ureteral obstruction. Asymptomatic if unilateral. L>R for unilateral. Unilateral is most common form (80%) which is secondary to pelvoinfundibular atresia. Associated with other GU and ipsilateral anomalies. There are 2 forms. The multicystic kidney (potter 2a) is large kidney with multiple cysts and little visible parenchyma. the potter 2b form is hypoplastic or diminutive form with small echogenic kidney. in relation to site: upj causes large kidney with multiple large cysts. In distal ureter, small or no cysts in small kidney. Also, depending on time of insult, early (8-11w) --> atretic and small with few small cysts. Late causes large central cyst (pelvis) often communicating with small cysts. US shows no central sinus complex and no renal parenchyma. (20 of 37) [5/29/2002 10:47:48 PM]


Medullary cystic dz in adults and juveniles is AD while in children it is AR. Salt wasting uropathy. Medullary striations on ivp.Bilateral small kidneys with smooth contour and thin cortex. US shows increases echogenicity and small medullary cysts. There is loss of CM differentiation.

MSK dysplastic cystic dil of papillary and medullary portion of the collecting ducts. Young to middle aged adults. May be assoc with Ehlers Dan, hemihypertrophy, arpkd, Caroli dz. Medullary calcinosis may involve one or all pyramids. It is non hereditary.

RENAL CELL CA: presence of intralesional ca++ of a renal mass favors rcc especially if it is extensive. large solid component to the mass favors carcinoma and herniation of mass into renal pelvis suggests multilocular cystic nephroma

rcc staging: 1: confined to renal capsule. 2: penetrates beyond capsule but remains within gerota fascia. 3a: extends into the renal v or the ivc. 3b: in regional LN's. 3c: both venous extension and LN involvement. 4a: extension thoough Gerota into adjacent organs other than the ipsilateral adrenal. 4b: distant mets.

TS AND AML: people with TS: 80% have aml. In people with aml, only 20% have TS

BLADDER HYPERACTIVITY: cerebral lesion, eg parkinsons or stroke

DETRUSOR SPHINCTER DYSYNERGIA: lesion below pons and above T5. This results in external sphincter which obstructs emptying and causes thickened trabeculated bladder (21 of 37) [5/29/2002 10:47:48 PM]


FLACCID BLADDER: disc disease, diabetes, pelvic trauma, surgery disrupts nerves in sacral plexus and causes hyporeflexia of the bladder

SPONTANEOUS RENAL HEMORRAGE: rcc is the most common cause. for aml there is a much greater chance of bleeding with tumors greater than 4 cm

MORE ON TCC: trigone of bladder is the most common location and sessile tumors are of a higher grade than papillary tumors. for the bladder: tcc (90%), scc (5%) and adenoca (2%)

RENINOMA: young women, 2-3 cm at discovery, near poles of the kidneys, subcapsular, hyperechoic

RENAL ANOMALIES crossed fused ectopia is the second most common fusion anomaly of the kidney after horseshoe. the most common anomaly is partial duplication. in terms of ectopia: l--->r more than r--->l

RENAL AVF VS AVM: renal AVF is acquired while renal AVM is congenital (aqcuired is more common 75%)

ADRENAL BIOPSY: (22 of 37) [5/29/2002 10:47:48 PM]


right: posterior approach which has risk for ptx left: anterior which is to avoid spleen, but there is a risk to hit pancreas complications of adrenal bx are hemorrage and ptx. Some of the recalls say that hemorrage is more common than ptx

FEMALE GU CYSTIC LESIONS: Gartners cyst is a Wolffian duct remnant in the anterolateral wall of the vagina at the upper end. There is a 6% association with unilateral agenesis of the kidney Bartolins is in the lower end of the vagina and is associated with adenoca or scc (50/50). Ie it is lower in the vagina than gartners. A urethral diverticulum can occur from infected periuretral glands. Skenes are the largest ones and are paired; they are prostatic remnants (ie derived from Wolffian duct). Ureteral tic is more common in females. Skenes are in the distal 1/3 of the urethra

RETROCAVAL URETER: this occurs between the proximal 1/3 and distal 2/3 and causes proximal ureteral obstrucion adn results in flank pain. The classic sign is the "italic S" on the R

UVJ STONES the UVJ is the place of hangup of 75% of all stones.

PARAOVARIAN CYSTS: they often undergo torsion, typically they represent 10% of pelvic masses. They are located in the broad ligament. They are not responsive to hormonal therapy. They are Wolffian duct remnants and can grow to huge size (several liters). The clue to them is that they are in the adnexal region without being clearly connected to the ovary (23 of 37) [5/29/2002 10:47:48 PM]


CAUSE OF PERSISTENTLY DENSE NEPHROGRAM (=SAME AS INCREASING NEPHROGRAM): ras, rvt, atn, hypotension. acute pyelonephritis is not on the differential as 2/3 of pts have a normal nephrogram

CAUSES OF URETHRAL STRICTURES: Stricture - post trauma #1 cause, develop rapidly at anatomically restricted areas such as the penoscrotal junction and membranous urethra Congenital Stricture - do occur w short seg involved Inflam stricture #2 - Gonococcus, TB, Shisto, usually bulbous portion in 70% because of high concn of periurethral glands of littre in this area, beaded long seg strictures Squamous Cell Ca - rare, most commonly secondary to mult strictures

INCIDENCE OF VARICOCELES: a possible nutcracker effect of the sma and aorta on the left renal vein may be responsible for increased incidence of varicoceles on the left. Varicoceles occur in 10 to 20% of adult men. The valsalva maneuver increases the size of the varicocele

EMPHYSEMATOUS PYELONEPHRITIS AND CYSTITIS: emphysematous pyelonephritis and cystitis are more common in diabetic women. E. Coli is the main organism.

PROSTATE CA STAGING (JEWITT): A: no clinical manifestation B: palpable, has not invaded through the capsule C: invaded through the capsule, but assymptomatic D: distant mets (24 of 37) [5/29/2002 10:47:48 PM]


prostate ca: PZ (75%) > TZ (20%)> CZ (10%) note that prostate ca is hypointense on T2 relative to the peripheral zone which is bright on T2

GOODPASTURES DISEASE: these pts have antibasement membrane antibodies

GERM CELL TUMORS OF TESTICLE: testicular germ cell tumor mets: lung>liver>brain. Seminoma is 40-60% of all germ cell tumors. non seminomatous results in elevation of the HCG in 45% and AFP in 50%. Pure seminoma does not cause elevation of the HCG or AFP levels

MORE ON ESWL: in addition to cystine, also Ca oxalate is resistant to eswl

DELAYED CONTRAST RXNS: these are more common with non ionic than ionic contrast. For renal dysfunction, DM alone: no difference. DM + abnormal renal function: increased risk for contreast nephropathy. Intraarterial contrast shows a lower incidence of contrast nephropathy than intravenous by about 50%

RESPIRATORY DISTRESS: for expiratory stridor, use beta agonist eg albuterol and for inspirator stridor use epinephrine (25 of 37) [5/29/2002 10:47:48 PM]


SPERM GRANULOMA: most common cause of epididymal mass

PATENT URACHUS: patent (50%). urachal cyst 30% and urachal sinus 15%. Urachal tic is only 5%

NEPHROCALCINOSIS: 5% is cortical and 95% is medullary. Of the medullary, 40% is due to primary HPT and 20% is due to RTA. Today, most are due to MSK. Primary hpt causes increased Ca++ and 2ary hpt has less Ca++


ADRENAL INJURY: blunt trauma results in more injury to R adrenal ie R>L. This is due to R being connected directly to the IVC with better transmission of intraabdominal pressure to the adenal

SPLENIC CYSTS: #1 is endothelial and epithelial and #2 is parasitic and pseudocysts

PERINEPHRIC VS SUBCAPSULAR HEMATOMA: subcap hematoma deforms the kidney while perinephric does not (26 of 37) [5/29/2002 10:47:48 PM]


BLADDER TUMORS: tcc (90%)> scc (5%) > adenoca (2%)

EAGLE BARETT: this is synonymous with Prune Belly

EFFECT OF MAI ON THE SPLEEN: it causes massive splenomegaly

METABOLISM OF VASOPRESSIN: although it is made mainly in the hypothalamus, it is metabolized largely in the liver and kidney

STRIATED NEPHROGRAM: acute RVT, acute pyelonephritis, tamm horsfall protein, hypotension, MSK, kidney contusion

AFFECT OF TB ON URETER: pipestem, beaded, corksrew

ORGANISMS IN EPIDIDYMITIS: main ones are E coli, and pseudomonas or Staph. These make up 85%. Gonococcus is 12%. TB is 2 % (27 of 37) [5/29/2002 10:47:48 PM]


SPACE OF RETSIUS: this is located behind the umbilical fascia

PRIMARY MEGAURETER: this is due to slow emptying of the ureter. It is functional obstruction. It is more common on the L. It is associated with contralateral renal anomalies

RENAL VEIN THROMBOSIS: most common cause is nephrotic syndrome

ENTEROPATHIC RENAL STONES: uric acid and oxalate are increased in small bowel resection

UPJ OBSTRUCTION: L>R. Most are due to an intrinsic abnormality

RENAL TRANSPLANT: DM is #1 and chronic glomerulonephritis is #2 for renal transplant. #3 is PCKD and #4 is nephroschlerosis

FOCAL RENAL SCARRING: most common cause of this is pyelotubular backflow (28 of 37) [5/29/2002 10:47:48 PM]


MORE ON ASSOCIATIONS WITH WILMS: hemihypertrophy, NF, BW, Drash, spontaneous aniridia, cerebral gigantism (soto syndrome), klippel trenaunay

BOTTOM LINE ON BLADDER INSTABILITY: this is an excerpt from Hovespin which helped me to figure this out a bit better: there are 2 centers which control micturition, 1 is the pons and 2 is the sacral plexus. The pontine center is under the control of cerebral cortex. CVA, Parkinsonism, NPH etc release control and cause uninhibited bladder contractions. The resultant voiding process occurs as a normal sequence of reflexes and so the urinary tract is often normal radiographically. With a lesion below the pons, but above the sacrum (especially above T5), there is discoordination between voluntary control of the external sphincter by the CNS and the voiding reflex known as bladder - external sphincter dysynergia. Since the external sphincter obstructs normal emptying of the bladder, the bladder becomes thickened and trabeculated (called christmas tree bladder). The upper tracts suffer from high pressure/reflux. Common etiologies are MS, spinal cord tumors, trauma. The flaccid or atonic bladder occurs when the lesion involves the conus medullaris or sacral micturition center. Causes include disc dz, diabetic neuropathy, pelvic trauma, surgery. The bladder distends imperceptably until the intravesicular pressure builds up and causes overflow. AGain, the upper tracts may suffer too. Stress incontinence occurs because of improper vesicourethral angle which produces an incompetent sphicnter.

so in conclusion: note that there are 2 centers for micturition. One is the sacral micturition center and the other is the pontine micturition center. above pons: lose volitional control or get hyperreflexia with sphincter synergy below pons: loss of volitional control or have hyperreflexia with sphincter dysynergia sacral plexus or conus: get a combo of the above pelvic nerves: get loss of detrusor contraction ie bladder areflexia leading to a flaccid bladder (29 of 37) [5/29/2002 10:47:48 PM]


NEOPLASMS IN TRANSPLANT: liver and kidney transplant #1 is skin and #2 is NHL

OVARIAN VEIN SYNDROME: this is pain and dilatation of the R ureter from pressure due to a dilated ovarian vein

OBSTRETICAL SHOCK: causes cortical and not medullary necrosis

STRUVITE STONES: klebsiella, pseudomonas, E coli, Proteus

PROSTATE MR: homogenous intermediate signal on T1 and uniformly low signal on T2. On T1, the peripheral zone has slightly higher signal than the remainder of the prostate

BLADDER CA Note that T1 to T3a bladder tumor is confined to the bladder wall. T3b breaches the bladder wall and muscle and enters the pervesicle fat

ABDOMINAL NEUROBLASTOMA: >2/3 of abdominal neuroblastoma in childhood occur in the adrenals. > 50% of neuroblastomas are (30 of 37) [5/29/2002 10:47:48 PM]


calcified on plain film. Ca++ are seen in 25% of childhood RCC on AXR. They are not seen in rhabomyosarcoma on AXR

MORE ON PRUNE BELLY SYNDROME: the sigmoid ureters, the lower ureters are disproportionately dilated compared with the upper ureters. Also, they have prostate hypoplasia. PBS very rarely occurs in girls

URETEROCELES: simple are orthotopic and ectopic are not simple

MORE ON MCD: there is cystic dilatation of the DCT's and not the PCT's. Medullary cystic disease is AR in the juvernile form. The other name for it is juvenile nephronopthasis. The adult form is AD. Both have bilateral echogenic small kidneys with a thin cortex and smooth contour

MEDULLARY NEPHROCALCINOSIS: medullary nephrocalcinosis results from deposition of calcium salts in the distal collecting tubules near the papilla. In MSK, there are anatomically dilated DCT's causing stasis and resulting in Ca++ deposition, and dilated CD's (green book)

ATN AND CYCLOSPORIN: atn and cyclosporin toxicity present with preservation of renal perfusion but poor excretion

calcifications in tumors: Neuroblastoma >50% (31 of 37) [5/29/2002 10:47:48 PM]


rhabdomyosarcoma 0% renal cell ca 25% in renal lesions: rcc> wilms>tcc>mlcn>mets 10% of Ca++ renal masses are cystic

SEPTUM OF BERTIN: upper pole: 90% and bilateral in 60%

DROMEDARY HUMP: formed from compression of the L kidney due to the spleen

LYMPHOMA OF THE KIDNEY: incidence is 5%. NHL>HL. It spreads from direct extension from retroperitoneal disease and via hematogenous mets. Primary lymphoma of the kidney is rare as the kidneys do not have primary lymphatic tissue

FILLING DEFECT IN THE BLADDER: fungas ball (rare), blood clot, stone, ureterocele (rare), prostatic enlargement, cystitis, neoplasm. For neoplasm, the malignant is TCC (90%) and SCC (5%) which are common and adenocarcinoma (rare ie 2 %). The benign ones include leiomyoma, fibroepithelial polyp, hemangioma, pheo, adenoma

SIGNS FOR BLADDER OUTLET OBSTRUCTION AT THE LEVEL OF THE PROSTATE: bladder trabeculation, prostatic indentation at the base of the bladder, J shaped ureters as they enter the bladder, large PVR (32 of 37) [5/29/2002 10:47:48 PM]


MORE ON CORTICAL AND MEDULLARY CA++: cortical is tramline, and medullary is stippled. cortical Ca++: chronic glomerulonephritis, cortical necrosis, HIV nephropathy, others eg alport

medullary Ca++: medullary sponge kidney, hyperparathyroidism, RTA, papillary necrosis

RENAL PAPILLARY NECROSIS: lobster claw, clubbed calyxes, sloughed calyxes

INDICATIONS FOR ANGIOGRAPHY IN A PT AFTER TRAUMA: non visualization of kidneys on IVC, persistent hematuria, hypotension/hypertension or persistent hematuria following an interventional urologic procedure

RVT: adults: tumor>renal disease>postpartum state, hypercoagulable state infants: dehydration, shock, trauma, sepsis, SSD in the transplant situation, it most commonly occurs 3d post transplant

RENAL TRANSPLANT: resistive index: (Psys - Pdiast)/Psys < 0.7 non specific for rejection if >0.7 ATN is the most common cause of acute renal failure in transplant pts. Persistent dense nephrogram in smooth enlarged kidneys with normal perfusion is suggestive of acute ATN. Note that ATN is the only process with normal flow but decreased excretion (33 of 37) [5/29/2002 10:47:48 PM]


OVARIAN VEIN SYNDROME: ureteral notching with obstuction on R. The R gonadal vein crosses the ureter to drain into the IVC. The L renal vein drains into the L renal vein

ETIOL OF URETERAL DIVERTUCULUM: it is an aborted attempt at duplication

URETERAL PSEUDODIVERTICULUM: outward proliferation of epithelium into the laminal propria. It is premalignant

HUTCH DIVERTICULUM: congenital weakness of musculature near the UVJ

BENIGN AND MALIGNANT BLADDER TUMORS IN CHILDREN: malig: rhabdo (sarcoma botyroides projecting into the dome), leukemia/lymphoma mets to the wall

VUR: primary: congenital, ineffective valve mechanism such as a short tunnel, abnormal insertion angle secondary: submucosal, valve distorted by adjacent anatomic abnormality eg hutch diverticulum or ureterocele, cystitis

RENAL CALCIFICATIONS: (34 of 37) [5/29/2002 10:47:48 PM]


dystrophic, nephrocalcinosis (cortical and medullary), nephrolithiasis. Dystrophic refers to Ca++ in abnormal tissue such as tumor, vessels, TB etc. If see globular Ca++, than think dystrophic. Medullary nephrocalcinosis is much more common than cortical nephrocalcinosis

CAUSE SOF MEDULLARY NEPHROCALCINOSIS: hypercalcemic states, hpt, paraneoplastic sydromes, sarcoid, medullary sponge kidney (renal tubular ectasia may be unilateral or focal). RTA is bilateral symmetric because it is metabolic.

OXALOSIS: primary in children and secondary in adults (eg due to Crohns disease)

BIG FIVE OVARIAN CYSTS: toa, cystadenoca, adenoca, dermoid, hemorragic cyst, endometrioma, EP, ovarian torsion

PATIENTS AT HIGHER RISK FOR LATEX ALLERGY: those with myelomeningocele and bladder extrophy


MOST COMMON COMPLICATION OF ILEAL CONDUIT: not stones but pyelonephritis (35 of 37) [5/29/2002 10:47:48 PM]


STONE CHARATERISTICS: cystine is ground glass, strivits is lucent, matrix is lucent

RETROPERITONEAL FIBROSIS: may present with renal failure


LASIX TREATMENT: this can also be a cause of medullary nephrocalcinosis

CONTRAST INFUSION: causes transient increase in pulmonary arterial pressure but not in systemic arterial pressure

NEUROBLASTOMA VS WILMS: neuroblastoma is most likely to be bilateral

NEUROBLASTOMA: associated with opsoclonus, myoclonus, and cerebellar ataxia (36 of 37) [5/29/2002 10:47:48 PM]


IONIC AGENTS SODIUM VS NON SODIUM: there is a higher urinary flow with sodium agent than with a non sodium agent such as meglutamine. Ionic contrast agents are excreted primarily via glomerular filtration

STAUFFERS SYDROME: this is a paraneoplastic sydrome consisting of elevated LFT's in a patient with renal cell carcinoma. About 15% of pts with rcc and without mets have elevated lft's

KIDNEY METABOLISM: insulin, vasopressin, and GH are metabolized by the kidney but renin and erythropoeitin are not (37 of 37) [5/29/2002 10:47:48 PM]


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TURNERS SYDROME: 20% have cardiac abnormalities: bicuspid aortic valve and coarction

TORCH: CMV is the most common cause of in utero infection

PENTALOGY OF CANTRELL: deficiency of diaphragmatic pericardium, ectopia cordis, deficiency of anterior diaphragm, cardiac (vsd, asd, tof), sternal cleft, gastroschisis (check this). Associated with trisomy.

GASTROSHISIS: abnormal involution of umbilical vein results in area of abdominal wall weakness. The result is a full thickness abdominal fusion defect on R side of cord. There are thickened freely floating loops of bowel. There is associated non rotation or malrotation of bowel (1 of 18) [5/29/2002 10:48:17 PM]


OMPHALOCELE: midline defect in anterior abdominal wall due to failure to form umbilical ring during 3rd to 4th week of gestation with herniation of intraabdominal contents into the base of the cord. Can contain liver in 27%. High incidence of associated anomalies (45-88%).

OEIS COMPLEX: omphalocele, extrophy, imperforate anus, spinal abnormality

LIMB BODY COMPLEX: limb body wall complex: results from failure of closure of ventral abdominal wall. Can be due to early vascular insult or less likely, amniotic bands. The cord is absent or short, and the amniotic bands are an association.

PRUNE BELLY: Triad of (1) absent or hypoplastic abdominal wall muscle, (2) non obstructed markedly distended ureters plus or minus hydronephrosis and variable degree of renal dysplasia , (3) undescended testes due to bladder distension interfering with their descent. The urethra is elongated with dilated prostatic urethra and absence of the prostate

MOST COMMON CYSTIC LUNG MASS IN PEDS: ccam. Types 1-3. Types 2 and 3 have the worst prognosis due to 2ary abnormalities, while 1 has good prognosis after resection. M=F

INHALED FB: this happens 50% in <3 yo. 85% of the inhaled FB are vegetable matter. R>L (2:1). The main complication is bronciectasis (2 of 18) [5/29/2002 10:48:17 PM]


HYPOPHOSPATASIA: 3 forms: first 2 are AR (infantile lethal in >50% and childhood form whose first syptom is loss of teeth). The third form is the adult form which is AD. Alk phos deficiency leads to hypercalcemia and ethanolamine phospatemia and ethanolamine phosphaturia. The skull is lucent due to defective mineralization. It can look like OI, and likewise, there are blue schlera

CAFFEY DZ: mandible>clavicle>tubular bone diaphysis and ribs

CHILDHOOD MEDIASTINAL MASSES: the most common ones are: neuroblastoma, and lymphoma

NEUROBLASTOMA: two third of all cases are in the abdomen and 2/3 of these are in the adrenal. The most common extraadrenal location is in the organ of zuckerkandl

ATLANTOAXIAL SUBLUXATION IN KIDS: Downs, JRA, trauma, morquio syndrome

GROWTH PLATE PRESENT AT BIRTH: proximal femur (3 of 18) [5/29/2002 10:48:17 PM]


CDH: the barlow test is to see if the hip can be dislocated. It is performed by adducting and flexing the hip while pushing it posteriorly. The Ortolani test is extension of the hip which should lead to a click as the hip relocates. Ultrasound is not useful after 1 year of age due to shadowing from increased ossification of the hip. In terms of echogenicity, the acetabulum is more echogenic than the femoral head

IN MALROTATION: the sma and smv can be normally related in one third of cases

NON TRAUMATIC LIMP IN A CHILD: most common cause is toxic synovitis

CRITOE 1,5,7,10,10,11 years old

INTUSSUSCEPTION IN CHILDREN: 95% are idiopathic. Most common is ileocolic. 75% occur before age 3. 90% have no pathologic lead point. Lead points include meckels, lyphoma, polyp, HSP, inspissated meconium

SUTURE CLOSURE: divided into primary and secondary causes main secondary causes are due to hematological dz, metabolic dz, bone dysplasias, other sydromes scaphocephaly=dolicocephaly: premature closure of the sagital suture brachi: coronal (4 of 18) [5/29/2002 10:48:17 PM]


trigonal: metopic occicephaly: lambdoid clover leaf: coronal, lambdoid

MECKELS: remember rule of 2's and also that meckels frequently present as bleeding in kids and as intussusception or inflammation in adults

VACTERAL: in pts with TEF, cardiac (39%) > msk ( 24%) > gi (20%) > renal agenesis ( 12%). A better way to remember it is CLAR

INFANT OF DIABETIC MOTHER: Most specific sign in infant of diabetic mother is sacral agenesis. Also see bilateral adrenal hemorrage, renal vein thrombosis and small left colon

SMALL LEFT COLON: meconium plug sydrome: occurs in full term babies in the spectrum with small left colon. It is most associated with infants of diabetic mothers

However, according to other sources: meconium plug sydrome is seen in the newborn in the first 24 hours and is caused by CF (24%), Hirshprungs, prematurity, and maternal MgSO4 administration

MECKELS DIVERTICULUM: meckels diverticulum is an omphalomesenteric duct (vitelline) anomaly: there are 4 types-umbilicoenteric fistula, umbilical sinus, meckels diverticulum, and vitelline cyst. The urachus is the median umbilical ligament which is a thick fibrous cord as the remnant of the allantois (endodermal (5 of 18) [5/29/2002 10:48:17 PM]


outgrowth of yolk sac into stalk). It regresses by the 5th month of development. A patent urachus is a fistula between the bladder and the umbilicus. A urachal sinus is where the urachus is patent only at the umbilicus. A urachal diverticulum is where the urachus communicates only with the bladder dome and a urachal cyst is a gradually enlarging cyst due to closure of both ends of the urachus. Complications of a urachal cyst include infection (23%), intestinal obstruction, hemorrage into the cyst, and malignant degeneration (adenoca 84% and tcc 3%). The prognosis is poor with a 7-16% 5 year survival

BILIARY ATRESIA VS NEONATAL HEPATITIS IN NEONATE WITH HEPATITIS: biliary atresia is correctable in 12% and non correctable in 88%. This is what Dr. Cindy Miller at Yale gave us in her lecture: the gall bladder is norml in 10%. Liver echogenicity is normal or increased based on the appearance of the periportal triads. It is not possible to exclude or rule out neonatal hepatis by US exam. If you do a HIDA, first priming with phenobarbital, (5mg/kg for 5d prior) and if no excretion is seen into the small bowel than the diagnosis is biliary atresia. Can carry out the study to 24h to rule out hepatitis because biliary excretion would be slower even with phenobarbital induction. In neonatal hepatitis, the GB can be large or small. Liver echogenicity can be normal, increased, or decreased. Delayed excretion into the bowel and excretion into the bladder is seen. choledochal cyst, can also cause jaundice during the neonatal period. There is a cyst in the GB fossa.

PEDIATRIC LIVER TUMORS: hemangioendothelioma is the most common benign hepatic neoplasm in children hepatoblastoma is the most common malig hepatic neoplasm and is associated with ca++ in 50%; <5yo: hepatroblastoma; >5yo: hcc, mesenchymal sarcoma (can get chf); <2yo: mesechymal hamartoma

note that hcc is the second most common hepatic malig after hepatoblastoma. also note that hepatoblastoma is associated with precocious puberty, and in Rliver lobe > L lobe. There is also increased AFP and renal failure. Also associated with BW, hemihypertrophy

HEMANGIOENDOTHELIOMA: most common in first 6 mo of life. Have chf and cutaneous hemangiomas (6 of 18) [5/29/2002 10:48:17 PM]


DR MILLER NOTES ON PEDIATRIC LIVER TUMORS: hemangioendotheliomas occur at < 6 mo. They can be single or multiple. Occasionally Ca++. The aorta is decreased in caliber after the takeoff of the celiac axis. There are typically multiple hypoechoic lesions in the liver. These children also present with CHF. About 50% of them have hemangiomas of the skin. Hemangioendotheliomas are not malignant. If you support the child through the CHF, the lesion will go away by itself Mesenchymal hamartoma is a frequently pedunculated lesion hanging off the liver. It is a benign lesion. Occurs from 3 mo to 2 y typically. Hepatoblastoma can be seen in BW syndrome. It is less common than Wilms in Beckwith Weidmann. The lesions can be single or multiple and mixed in echogenicity. They can invade the hepatic, portal veins and IVC. There are Ca++ in up to 50% of them. Venous invasion cannot be assessed on CT. However, resectability can be assessed by CT

CYSTIC FIBROSIS: Tracheobronchial mucus, the Na and Cl is slightly elevated. In saliva, its normal. In sweat, the Na and Cl is elevated. Urinary excretion of PABA is decreased.

MORE ON CF: 97% of pts with mec ileus have CF and 10-20% of pts with CF have mec ileus.

PEDIATRIC TUMORS: wilms (15% ca++ on CT) is most common abdominal malig in children while neuroblastoma (85% ca++) is the most common intraabdominal malignancy in infancy

PULMONARY SEEQUESTRATION: (7 of 18) [5/29/2002 10:48:17 PM]

PEDIATRICS (8 of 18) [5/29/2002 10:48:17 PM]


PULMONARY SEQUESTRATION pulmonary sequestration is the triad of nonfuntioning lung segment, no communication with the TE tree, and systemic arterial supply. They are usually 6 cm is size and smooth, round or oval. This is usually near the diaphragm. Occasionally, a finger like projection is seen posteriorly and medially which usually represents the anomalous vessel. It is sometimes surrounded by recurrent pulmonary consolidation in a lower lobe that never really clears completely. It may communicate with the esophagus or bronchus. If it communicates with the GI tract, then it is called bronchopulmonary foregut malformation. The ddx is brochiectasis, lung absess, empyema, CCAM, intrapulmonary bronchogenic cyst, Swyer James, pneumonia, met, hernia of Bochdalek. There are 2 main types as follows:

Intralobar: prevalence 75%, surrounded by visceral pleura, drained by the pulmonary veins, become symptomatic in adulthood, and are usually acquired and are associated with congenital anomalies in 15%. They have a L to L shunt. The main complication is massive spontaneous non traumatic pleural hemorrage, chronic inflammation, and fibrosis. M=F. Can get recurrent pneumonia

Extralobar: they represent 25%. They have their own pleura, and are drained by systemic veins. They become symptomatic during the first 6 months of life and are considered developmental lesions and have a higher incidence of congenital anomalies (50%) compared with the extralobar variety. This has a L to R shunt. Can get infected in cases of communication with a bronchus or the GI tract. M>F

CCAM TYPES: 1: single or multiple air filled cysts 2: cysts < 2 cm with solid 3: solid, associated with maternal polyhydramnios 2 and 3 have the worse prognosis (9 of 18) [5/29/2002 10:48:17 PM]


MORGAGNI HERNIA: they are anteriomedially situated more commonly on the right. They often contain liver, fat, or transverse colon. The presentation is usually in older children as compared with bochdalek hernia

INTUSSUSCEPTION: perforation due to intuscusseption ocurrs at the proximal end

DUODENAL ATRESIA VS STENOSIS: DA is much more common than DS. 30% of DA have Downs. 20% of DA are preampullary so they dont have bilious vomiting

BIRTH ANOXIA: causes thalamic infarcts bilaterally

CONGENITAL RUBELLA: retinopathy, deafness, catarracts, mental deficiency, microcephaly, celery stalk sign, hepatosplenomegaly, congen HD (PDA), punctate Ca++ in the CNS

CHOANAL ATRESIA: 90% bony, 10% membranous, and children are obligate mouth breathers

RDS or HMD (older term): the peak for this is 3-5 d. The lungs have a ground glass appearance classically. There is hypoxemia and low lung volumes. Typical is the absence of pleural effusions. (10 of 18) [5/29/2002 10:48:17 PM]


TTN: Normal lung vols. Pulm edema pattern. Fluid in fissure. Pleural effusion

THYMUS: it is an expected finding up to the age of 2. It becomes progressively less visible up to the age of 8. After the age of 8, it is rarely seen. It presence is not necessarity abnormal

MOST COMMON CAUSE OF PNEUMATOCELES IN CHILDHOOD: staph is the most common. E coli and klebsiella are common causes in the older patient, along with trauma

LIP: this indicates the presence of AIDS in a young child and it can be mimicked by TB

SUBGLOTTIC EDEMA IN EPIGLOTTITIS: can be seen in up to 25% of pts. Note that epiglottitis occurs at an older age than croup

PANCREATIC INSUFFIENCY IN CF: only 2% of pts with CF experience endocrine insuffiency requiring insulin

SMALL CELL TUMORS IN KIDS: ewings, nhl, neuroblastoma, embryonal rhabdomyosarcoma. Note that Ewings metastasizes to lungs (11 of 18) [5/29/2002 10:48:17 PM]


(85%)>bones (69%)> pleura,>CNS

ELBOW DISLOCATION: 90% are posterior or posterolateral. Dislocation is associated with hyperextension. #1 is injury of medial condyl and #2 is separation of the radial head. Fx of the coronoid process is common in adults with posterior dislocation

NURSE MAID ELBOW: children: 2-5 y. Pull on the elbow results in dislocation with radial head slipping out of the annular ligament. This results in elbow held in pronation and it usually gets reduced be the tech during supine positioning for the X ray

CHROMOSOMAL ANOMALIES AND THEIR RELATION TO CHD: TOF: Downs peripheral pulmonary stenosis: Williams, congenital rubella septal defect: Ellis van Creveld PDA: isolated Tris 18 ( in addition to numerous other things has rocker bottom feet and choroid plexus cysts) Coarctation, VSD: Turners, NF, Sturge Weber ASD, VSD: Holt Oram

TURNER: short 4th MC, V shaped carpal row, osteopenia

CONGITAL RUBELLA: (12 of 18) [5/29/2002 10:48:17 PM]


80% cardiac, 20% osseous

MARFAN: aortic root abnormality, prolapsed MV, MR, 90% die of cardiovascular complications

CARPAL COALITION: LT is the most common CH is the 2nd most common and may be associated with Ellis Van Creveld

RETROPHARYNGEAL CELLULITIS IN CHILDREN: tonsillitis is the most common antecedent illness prededing cellulitis in the retropharngeal space. While we are talking about the RPS, note that the node of Rouvier is in the lateral RPS. Some RPS tumors include: lipoma, hemangioma, vascular malformations, plexiform NF

TUBULAR REABSORPTION IN CHILDREN: Na++ reabsorption in children is in DCT unlike in adults due to poor development of the PCT

XGP DIFFERENCES IN CHILDREN: in kids it is focal. In adults, it usually involves the whole kidney

URETHRAL INJURY: instrumentation usually injures the external sphincter and long term indwelling catheter causes erosions and structures at the penoscrotal junction (13 of 18) [5/29/2002 10:48:18 PM]


WATERHOUSE FRIEDRICHSON SYNDROME: this is caused by meningococcicemia which results in bilateral adrenal hemorrage leading to adreanal insufficiency known as WF syndrome


ESOPHAGEAL AND DUODENAL ATRESIA ASSOCIATION: EA is associated with DA and imperforate anus. DA is associated with Downs

CAUSES OF A LIMP IN A CHILD: 1-3Y: #1 is infection, #2 is tumor, #3 is trauma 3-10y: #1 is infection and toxic synovitis, #2 is perthes, and #3 is tarsal coalition >11y: #1 is SCFE, #2 is rheumatological condition, and #3 is trauma, #4 is tarsal coalition, #5 is neoplasia

ANORECTAL MALFORMATION: if high, ureteral reflux is more common, so there will be increased incidence of UTI

VASCULAR RINGS: double aortic arch is the most common one and also the most symptomatic. A pulm sling is also symptomatic, except that it is a sling and not a ring. You get ring-sling sydrome due to associated complete tracheal cartilage ring. The second most common vasc ring would be a R arch with an aberrant (14 of 18) [5/29/2002 10:48:18 PM]


L subclavian and a ductus

OLIGOHYDRAMNIOS: DRIPP C or demise, renal anomalies, infection, post dates, PROM, choramnionitis

POLYHYDRAMNIOS: TARDI (twins, anomalies, rh incompatability, diabetes, idiopathic)

INTUSSUSCEPTION: per Dr. Miller: 3 mo to 3 y. Crampy abdominal pain. Currant Jelly stool. Lethargy. Plain film shows SBO. There is presence of a palpable RLQ mass. Characteristic mass can be seen on US with concentric rings and a "pseudokidney sign." With pneumatic treatment, the success rate is 80% using about 80-120 mm of Hg. With hydraulic, there is a 70% success rate. Use the rule of 3's. Bag 3 feet above table, try 3 x, and wait 3 min to find it. This procedure can only be done in a facility with pediatric surgical backup. Using the pneumatic method, 18F foley catheter is inserted in the rectum. After taping it in place, 120 mmHg max, 3 min, make sure that you do not inflate the balloon. Try for 3 attempts

APPENDICITIS: per Dr. Miller: US of the appendix is sensitive in > 90% of cases. It is also >90% specific.Diameter of the appendix of >6mm from outer to outer, appendicolith, free fluid, color flow all help to improve specificity

MECKELS: 15-50% contain ectopic mucosa and of these, 50% contain gastric mucosa. Then use the rule of 2's ie 2 y, 2% of the population, 2 feet from the terminal ileum, 2 inches long etc (15 of 18) [5/29/2002 10:48:18 PM]


BONE MARROW DEVELOPMENT: conversion of red to yellow marrow takes place during growth and development. It begins immediately post natal in the diaphysis and progresses toward the metaphysis and axial skeleton. The epiphysis is not yet formed; however, once they ossify, rapid conversion to yellow marrow is the rule

TOO MUCH AIR IN THE STOMACH: baby crying, attempted NG intubation, antral web, pyloric stenosis, duodenal atresia, midgut volvulus. Other causes include: pylorospasm, antropyloric inflammation

TOO LITTLE AIR IN THE STOMACH: esophageal atresia, microgastria

DDX OF A HIGH OBSTRUCTION: malrotation, annular pancreas, duodenal or jejunal atresia, duodenal web, preduodenal portal vein. Note that atresia is much more common than stenosis. Ladd bands can obstruct the duodenum descending portion. Bile stained vomitus within the first 24 h of life is the hallmark of duodenal atresia

DDX OF LOW INTESTINAL OBSTRUCTION: imperforate anus, meconium plug syndrome, meconium plug sydrome, hirshprungs, meconium ileus, ilieal atresia, colonic atresia

NEONATAL BOWEL OBSTRUCTION: atresia>malrotation> meconium ileus (16 of 18) [5/29/2002 10:48:18 PM]


BLOUNTS: congenital tibia vara. 3 age groups: infantile (1-3y), juvenile (4-10), adolescent

CAFFEY DZ: cortical periostitis at multiple sites of unknown etiology. Could be viral. It is self limited, benign, and occurs before 6 mo of age. It affects the tibia, ulna and mandible as well as digits

DEFINITION OF DWARFISM: height 4 SD below the mean

EPIGLOTTITIS: supraglottic inflammatory process with thumb like epiglottis, thickened aryepiglottic folds, and subglottic edema in up to 25% of patients

COMMON PLACES FOR AN INGESTED F.B TO LODGE: thoracic inlet, aortic arch, L mainstem brochus, GEJ

RETROPHARYNGEAL CELLULITIS: increased ap diameter of the prevertebral ST's and straigtening of the normal cervical lordosis. Plain film is limited in its ability to distinguish retropharyngeal and parapharyngeal abscess

ORIGIN OF MECKELS DIVERTICULUM: vitelline duct. Male>female for symptomatic ones, and M=F for assymtomatic ones (17 of 18) [5/29/2002 10:48:18 PM]


MOST COMMON MEDIASTINAL MASS IN A CHILD: neuroblastoma>teratoma (18 of 18) [5/29/2002 10:48:18 PM]


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ANKLE BRACHIAL INDEX: ABI 1.0 normal 0.6-0.9 exercise claudication < or = 0.5 rest pain < 0.3 tissue loss

AXILLARY ARTERY BRANCHES: SALSAP (superior thoracic, acromiothoracic, lateral thoracic, subscapular, anterior circumflex humeral, posterior circumflex humeral). The thoracodorsal and circumflex scapular are branches of the subscapular. The axillary artery originates at the level of the clavicle proximal to the pectoralis minor muscle. The first branch of the axillary artery is the superior thoracic artery, next is the thoracoacromial artery which arises under the pectoralis minor muscle. The lateral thoracic artery is the next branch, in the axilla the subscapular artery is the next branch that gives off the circumflex scapular and the thoracodorsal artery. The circumflex humeral is the last branch of the axillary artery.

ANGIO OF ILIAC AND FEMORALS: best projection for iliac is ipsilateral oblique and for femorals is contralateral oblique

REVIEW OF ARTERIAL ANATOMY IN AP PROJECTION: (1 of 14) [5/29/2002 10:50:50 PM]


CONCERNING BRONCHIAL ARTERY EMBOLIZATION: The embolic agents chosen for bronchial artery embolization reflect the site of desired arterial occlusion. Absolute alcohol, boiling contrast or particulate powders produce occlusion at the level of the smallest vessels and accomplish tissue necrosis. This is to be avoided in bronchial artery embolization because of the risk of bronchial or esophageal infarction or spinal cord damage. Coils produce focal arterial occlusion at the large vessel level and invite peripheral collateralization and are therefore also inappropriate for bronchial artery embolization. Particulate emboli such as polyvinyl alcohol particles or Gelfoam in the 350 to 500 m size range are most appropriate for bronchial artery embolization. These agents will provide hemostasis without tissue necrosis. Particles of this size will likely be too large to enter small spinal radicular branches. Polyvinyl alcohol particles provide more long-term occlusion than Gelfoam particles which will be at least partially resorbed in 30 days. (ref: direct quote from:

ANATOMY OF THE BRONCHIAL ARTERIES (They originate most commonly from the proximal descending thoracic aorta anterolaterally between the level of the fourth and sixth thoracic vertebral bodies. In terms of their appearance, there are frequently multiple left and right bronchial arteries arising from the aorta, and often there is a common trunk from the anterior aspect of the thoracic aorta giving rise to both right and left branches). Single individual left and right bronhial arteries are the most common (30%). The next most common appearance (25%) is a common trunk giving rise to both right and left together with a single right (which results in 2 on the right and one on the left):

COMPARISON OF ANGIOPLASTY WITH SURGERY FOR FEM POP DISEASE Claudicants have 3 year patency 60%, patients with critical ischemia have 3 year patency of 40%. Restenosis secondary to intimal hyperplasia occurs months (early) after PTA, progression of arteriosclerotic disease is important cause of stenosis > 9 months. Most clinical failures are reported < one year. Surgery and PTA have shown to have identical results for patients with chronic limb ischemia for patients who are candidates for either. Surgery, however, is more effective in treating patients with long segment, diffuse stenosis or occlusions involving the origin of the SFA or distal popliteal artery or the trifurcation. (2 of 14) [5/29/2002 10:50:50 PM]


ACUTE COMPARTMENT SYNDROME: pressure in the compartment should not be > than 30mm. If you have normal blood pressure, than 40-45 mm is diagnostic.

CONTRAINDICATIONS TO ENZYMATIC FIBRINOLYSIS: recent intracranial, thoracic or abdominal surgery recent GI bleeding recent stroke or intracranial neoplasm recent major trauma pregnancy severe htn bleeding diathesis infected thrombus

ANOMALIES OF THE MESENTERIC ARTERIES: ARTERY replaced common hepatic replaced right hepatic accessory right hepatic replaced left hepatic accessory left hepatic inferior phrenic dorsal pancreatic gastroduodenal left gastric, splenic, or hepatic celiacomesenteric middle colic ANOMALOUS ORIGIN sma sma sma left gastic left gastric celiac celiac r or l hepatic aorta aorta dorsal pancreatic, splenic, hepatic FREQ % 2.5 10 6 10-12 8-13 35 22 18 <1 <1

COLLATERAL CIRCULATION: PATHWAY INTERCELIAC gastric arcade gastroepiploic arcade arc of barkow CELIAC AND SMA pancreatic arcade COMMUNICATION left and right gastric arteries left and right gastroepiploic arteries left and right epiploic arteries within the omentum gda and inferior pancreaticoduodenal arteries (3 of 14) [5/29/2002 10:50:50 PM]


arc of buehler SUPERIOR AND INFERIOR MESENTERIC ARTERIES marginal artery of drummond arc of riolan INFERIOR MESENTERIC AND ILIAC ARTERIES path of winslow (rectal hemorroidal arcade)

direct embryologic pathway

branches of middle and left colic arteries central vessel from middle to left colic artery

superior and middle/inferior rectal arteries

VENOUS COLLATERALS (there are quite a few of these): occlude suprarenal IVC: common iliac go to lumbars go to azygous go to SVC occlude SVC near junction with RA: azygous go to lumbar go to IVC occlude PV: SMV go to splenic v go to IMV go to hemorroidal go to internal iliac go to common iliac go to IVC

TRAUMATIC AORTIC RUPTURE: #1: isthmus (88-90%) #2: avulsion of arch just proximal to takeoff of brachiocepalic trunk (4-5%) #3: at diaphragmatic hiatus (1.8%) the pretest book (Hovespin) says that the most common place for traumatic aortic rupture is the isthmus and aortic root


note: ICA angio requires 6cc/s for 8 cc total volume ECA angio requires 3cc/s for 8 cc total

here is the ap and lateral projections of internal carotid artery injections (taken from you can can check out the dynamic angios by clicking on the above link (4 of 14) [5/29/2002 10:50:50 PM]


a: Pericallosal Artery; b: Anterior Cerebral Artery; c: Middle Cerebral Artery; d: Anterior Choroidal Artery; e: Ophthalmic Artery; f: Internal Carotid Artery; g: Posterior Cerebral Artery

these 2 images represent ap and lateral projections of vertebral artery injections (taken from: You can ckeck out the angios by clicking on the link:

H. Posterior Cerebral Artery I. Superior Cerebellar Artery J. Basilar Artery K. Antero-inferior Cerebellar Artery L. Postero-inferior Cerebellar Artery M. Vertebral Artery (5 of 14) [5/29/2002 10:50:50 PM]


MORE CEREBRAL ANATOMY (quoted from ANTERIOR CEREBRAL TERRITORY: the Heubner originates from the A1 one quarter and the A2 three quarters of the time. It is one of the important medial lenticulostriate branches. Note that the A1 supplies the medial lenticulostriates and the A2 supplies the recurrent artery of Heubner most of the time. Note also that the MCA supplies the lateral lenticulostriates

The anterior cerebral artery supplies most of the medial surface of the cerebral cortex (anterior three fourths), frontal pole (via cortical branches), and anterior portions of the corpus callosum. Perforating branches (including the recurrent artery of Heubner and Medial Lenticulostriate Arteries) supply the anterior limb of the internal capsule, the inferior portions of head of the caudate and anterior globus pallidus. Bilateral occlusion of Anterior Cerebral Arteries at their stems results in infarction of the anteromedial surface of the cerebral hemispheres: Paraplegia affecting lower extremities and sparing face/hands. Incontinence Abulic and motor aphasia Frontal lobe Symptoms: personality change, contralateral grasp reflex. Unilateral occlusion (distal to Ant. Comm. origin) of Anterior Cerebral Artery produces contralateral sensorimotor deficits mainly involving the lower extremity with sparing of face and hands (think of the humunculus).

MCA TERRRITORY: (6 of 14) [5/29/2002 10:50:50 PM]


The MCA supplies most of the temporal lobe, anterolateral frontal lobe, and parietal lobe. Perforating branches supply the posterior limb of the internal capsule, part of the head and body of the caudate and globus pallidus. Unilateral occlusion of Middle Cerebral Arteries at the stem (proximal M1 segment) results in: Contralateral hemiplegia affecting face, arm, and leg (lesser). Homonymous hemianopia - Ipsilateral head/eye deviation. If on left: global aphasia. Usually occlusion is embolic in nature - thrombotic occlusion more common in carotids.

BASILAR ARTERY BRANCHES: (7 of 14) [5/29/2002 10:50:50 PM]


1. Vertebral Artery. 2. Anterior Spinal Artery. 3. Posterior Inferior Cerebellar Artery (PICA). 4. Basilar Artery. 5. Anterior Inferior Cerebellar Artery (AICA). 6. Pontine Perforating Branches. 7. Posterior Cerebellar Artery (PCA)

INTERNAL CAROTID ARTERY TERRITORY: (8 of 14) [5/29/2002 10:50:50 PM]



1. Cervical ICA 2. Meningohypophyseal Trunk 3. Lateral Mainstem Artery 4. Opthalmic artery 5. PCOM ( Posterior Communicating Artery) 6. PCA (Posterior Cerebral Artery)

ICA OCCLUSION: in a pt with complete proximal ica occlusion, distal ica perfusion can occur via retrograde flow in the ipsilateral ophthalmic artery. (9 of 14) [5/29/2002 10:50:50 PM]


SUPRACLINOID CAROTID BRANCHES: the pnemonic for supraclinoid carotid segments is OPA (ophthalmic, posterior communicating and anterior choroidal)

CAROTID BASILAR ANASTOMOSES: Note that the carotid basilar pathway is through carotid-basilar anastomoses which develop during fetal life between the internal carotid and basilar arterial systems for the supply of the posterior cranial circulation. These include the trigeminal, hypoglossal, otic and pro-atlantal segmental arteries. With the development of the posterior communicating artery, these channels get obliterated but may rarely persist into adult life. The persistent trigeminal artery is the most common anomaly among the four, followed by the hypoglossal artery

MORE ON CAROTID-BASILAR ANASTAMOSES: persistent primitive trigeminal>primitive hypoglossal>persistant otic, proatlantal intersegmental artery


1. Internal Carotid. 2. Middle Cerebral Artery. 3. Horizontal (A1) segment of the (ACA). 4. Anterior Communicating Artery (ACOM). 5. Small ACOM branch to Basal ganglia, Corpus Callosum. 6. Medial Lenticulostriate Arteries. 7. Recurrent Artery Hebner. 8. A2 segment of ACA. 9. ACA Bifurcation. 10. Pericallosal Artery. 11. Calloosalmarginal Artery (ie at the marrgin of the brain)

TERRITORY OF THE ECA ( (ASLEOPS): (10 of 14) [5/29/2002 10:50:50 PM]


Oblique drawing of RCC bifurcation with external carotid artery and it's branches: 1. Superior thyrodial artery. 2. Ascending pharyngeal artery. 3. Lingual artery. 4. Facial artery. 5. Occipital artery. 6. Posterior auricular artery. 7. Superficial temporal artery. 8. Maxillary artery. 9. Internal carotid artery

LATERAL PROJECTION OF ICA AND ITS BRANCHES ( (11 of 14) [5/29/2002 10:50:50 PM]


1. External carotid artery. 2. Occipital artery. 3. Superficial temporal artery. 4. Maxillary artery. 5. Middle meningeal artery. 6. Ascending pharyngeal artery. 7. Vidian artery. 8. Artery of foramen rotundum. 9. Infraorbital artery. 10. Descending palatine artery. 11. Buccal artery

STENTING FOR BENIGN AND MALIGNANT BILIARY STRICTURES: Various types of biliary stents are commercially available. The plastic stents have two major problems: migration and occlusion. The metallic stents come in either balloon-expandable (ie, Palmaz stent, Strecker stent), or self-expanding types (ie, Wallstent, Gianturco stent). Metallic stents can be introduced in a contracted state through a small caliber tract. The gianturco stent is better for benign biliary strictures as tumor can grow in between the wires resulting in stent occlusion. Note that restenosis occurs in 20-30% of benign biliary strictures and requires re-ballooning This is what Valjii has to say on stents: They can be self expanding or balloon expandable the palmaz is a balloon expandable stent made of stainless steel. it shortens slightly as the balloon inflates. the device has minimal elastic deformation and has some longtidudinal flexibility and permanent plastic deformation. It should not be placed where intrinsic force could crush the stent the wallstent (Boston Scientific) is a flexible self-expanding stent composed of stainless steel filaments woven in a cross hatched pattern. It is available in a variety of fully deployed lengths and diameters. Its expanded length is considerably shorter than its compressed length. Placement is less precise than with other devices. It has almost no plastic deformity but considerable elastic deformity and longitudinal flexibility. These properties make it easy to pass through tortuous vessels and tight curves. the strecker stent i(Denmark) is made of tantalum monofilament woven into a mesh. the stent is deployed from a specially fashioned balloon and is very flexible and elastic. the Gianturco Rosch Z stent (Bloomington IN) is made of stainless steel wire in a zig zag pattern. It is self expanding and quite elastic. the Z stent is used primarily for esophageal strictures and long central venous stenoses. (12 of 14) [5/29/2002 10:50:51 PM]


HOW TO GO FROM THE IVC TO THE AORTA WITHOUT PASSING TROUGH THE LEFT VENTRICLE: first of all this question keeps on showing up on those dreaded boards: this is the official list: truncus arteriosus, tetralogy of Fallot, transposition, hypoplastic left heart, DORV. In hypoplastic L heart, the catheter has to pass through a patent PDA, which is necessary to maintain life.

EFFECT OF PULMONARY CAPILLARY WEDGE PRESSURE ON APPEARANCE OF THE LUNGS: PCWP: 8-12 normal 12-18 redistribution 19-25 interstitial pulmonary edema > 25 alveolar flooding

CONTRAINDICATION TO PULM ARTERIOGRAPHY: main one is pulm htn as this can lead to sudden death. a relative one is LBBB as manipulation of a catheter in the RV can cause RBBB leading to total heart block!

DRUGS IN VASCULAR IMAGING: vasodilators: papaverine: mesenteric ischemia. sm muscle relaxant, long acting tolazoline: peripheral spasm, direct sm muscle relaxant ntg: peripheral spasm, direct sm muscle relaxant, short acting nifedipine: peripheral spasm, for htn

vasoconstrictors: vasopressin, used for GIB, contraindicated in CAD, HTN, arrthymia epinephrine: renal vasoconstriction, used to differentiate tumor vessels from NL vessels

PTA SUCCESS RATES: iliac: 95% initial, 70-80% 5 year femoral: 90% initial, 70% five year renal: 95% initial, 70-90% five year (13 of 14) [5/29/2002 10:50:51 PM]


CYSTIC MEDIAL NECROSIS: tulip bulb appearance due to cystic medial necrosis. The causes are htn, marfans, ehlers danlos. There is involvement of the aortic sinuses and sinotubular junction which causes AI. Dissection is a frequent complication and Ca++ is rare.

SYPHILITIC ANEURYSM: In contrast to the above, syphilitic aneurysm has a tree bark appearance. Ca++ is common and dissection is rare (14 of 14) [5/29/2002 10:50:51 PM]


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There is no index for this so if you want to find something, press the Ctrl-F keys at the same time and type in the word you want to find in the find box! If someone would like to help make an index for this, let us know

CARDIAC MR: In cardiac MR, five different views of the heart: sagittal, coronal, axial (sometimes called transverse or transaxial), long axis and shortaxis. The views are presented according to the standard radiological convention of being viewed from below rather than the anatomical convention of being viewed from above. Of these five views the sagittal, coronal and axial views are classical cross-sectional views applied to all regions of the, body while the short and long axis views are standard cardiac views. Each image is planned from a scout view that is perpendicular to the view of interest. Thus the axial view is planned from a coronal scout, the coronal from an axial, the sagittal from a coronal, the short axis from a long, and the long axis from a short axis scout. The long axis image plane is determined by the line that runs from the apex of the heart to a midpoint at the base of the heart, often taken to be midway between the mitral valve leaflets. The short axis is perpendicular to it.

(Figure A: vertical long axis)

(Figure B: horizontal long axis)

(Figure C: short axis)

(Images taken from Lawson et al) (1 of 19) [5/29/2002 10:52:37 PM]


PENTALOGY OF CANTRELL: =tetralogy of fallot + asd

TRILOGY OF FALLOT: PS, RV hypertrophy, patent foramen ovale

VASCULAR RINGS: the most common cause is double aortic arch, second is R arch with aberrant L SCA, and third is pulmonary sling

HYPOPLASIA OF THE LEFT PA: concerning hypoplasia of the left PA, the following are true: Expiratory film is useful to differentiate from Swyer-James The left lung is hyperlucent Associated with a right aortic arch Most cases are associated with tetralogy of Fallot

CHANGE IN HEART SIZE WITH SYSTOLE AND DIASTOLE: In a study of 324 patients, comparison was made between systole & diastole. The change in diameter, was < 0.3 cm in 52 %, 0.4-0.9cm in 41 %, and 1-1.7 CM IN 7%

CORONARY ARTERY TERRITORIES: (2 of 19) [5/29/2002 10:52:37 PM]


LCA: anterior wall and superior 2/3 of the septum RCA: inferior wall and inferior 1/3 of the septum CX: lateral and posterior wall dominance refers to the artery that supplies the diaphragmatic aspect of the septum and LV and 85% of pts have R sided dominance

APPROACH TO CHD: approach to classification of CHD (Weissleder): see the figure below:

in D-TGA: there are 2 independant circulations, ie it is uncorrected. The following diagram from the Green Book can help determine the relative postions of the valves in TGA. NOTE: The orientation is looking down on it: (3 of 19) [5/29/2002 10:52:37 PM]


CARDIAC VALVULAR CALCIFICATIONS: in MR you do get ca++ of the annulus fibrosis (weissleder p 134). They are degen in pts > 70. For AS, valvular Ca++ is the most common. Get them in bicuspid and rheumatic. The radiographic appearance of valve calcs of the aorta correlates with the severity of dz. Subvalvular: 50% are AD and seen in IHSS. They can be congenital. Supravalvular: Williams and Rubella.

VALVE AREAS: mitral: 4-6 cm2 and aortic: 2-4 cm2 are considered normal

LV ANEURYSMS: 1. congenital: rare submitral and subaortic

2. acquired: MI, Chagas. True (70%): come from transmural MI, L anterior is most common while anterior apical is less common. (4 of 19) [5/29/2002 10:52:37 PM]


You see a focal bulge near the left heart border.Rim Ca++ are rare. There is a wide communication. They rarely rupture. Because of the large area of involvement of the LV, they are more likely to produce arrythmias and LV dysfunction then the false aneurysms False (30%): they are a contained rupture of the LV wall which is contained by pericardium----> these patients end up with pericarditis. Can be caused by trauma or s/p MI. They are located on the posterior lateral or posterior inferior diaphragmatic wall of the LV.The diameter of the mouth is small., and they have a greater risk of rupture. Thay are also called pseudoaneurysms. They involve the myocardium

CHD INCIDENCE: vsd> tof > pda > asd. note that asd is the most common chd in pts > 20 years old. VSD is still the most common for both infants and neonates combined

R ARCH ASSOCIATIONS: truncus arteriosus: 35%, tof: 25%. tga: 10% and ta: 5%

NEONATAL CYANOSES: tga>ta>truncus arteriosus and tapvr below the diaphragm

ORIGIN OF TOF: caused by abnormality in the embryology of the conal septum

EBSTEINS: get a huge heart (box shaped). The pathologic process is atrialization of the RV due to downward displacement of the tricuspid valve leaflets which reduces forward flow to the lungs. It is associated with maternal intake of lithium containing medications (5 of 19) [5/29/2002 10:52:37 PM]


CAUSES OF PULM EDEMA IN THE IMMEDIATE NEONATAL PERIOD: cor tritriatrium, tapvr below the diapragm, hypoplastic L heart

CAUSES OF CYANOSIS WITH DECREASED VASCULARITY: tof, ta, ps. of these, tof is the most common cause

TAPVR: type 1 or supracardiac is 52% of total and is drainage of pulmonary veins into L BCV, R and L persistent SVC/azygous type 2 is cardiac which is 30% of total. drainage is into the coronary sinus or RA the hemodynamics is a funtional L to R shunt. An ASD is required to restore oxygenated blood to the left side. there is cyanosis due to mixing of systemic and pulmonary venous blood in the RA type 3 is the subdiaphragmatic drainage type (12%) which is a functional R to L shunt. drainage is into the portal vein, IVC, ductus venosus, L gastric vein with constriction of the descending pulmonary vein by the diaphragm on route through the esop hiatus leading to pulmonary venous hypertension and RV pressure overload. death in a few days. it is associated with asplenia (80%) and polysplenia

VARIANT ANATOMY OF THE CORONARY ARTERIES: A TV star sued his cardiac surgeon because, in a by-pass operation, he negligently removed the healthy coronary artery leaving the defective one behind. The surgeon was an experienced cardiac surgeon. The attorney for the surgeon argued in court that the mix-up was a natural result of "abnormalities in the patient's heart". The lawyers put the patient's arteries on trial. Their defense was that the patient had "freakish anatomy". The case was settled out of court in favor of the patient. Information source: People (Weekly). 612/00. Variations of the coronary arteries are numerous, well known and are easily accessed.

NORMAL RELATIONSHIPS OF THE HEART VALVES: One more thing they might ask: pulmonary valve in relation to the aortic valve is anterior, inferior and left. Almost anything can possible be asked in terms of what is anterior or posterior to what so check this (6 of 19) [5/29/2002 10:52:37 PM]



Key: AC = anterior cusp, RC = right cusp, LC = left cusp, NC = non coronary cusp, PL = posterior leaflet, AL = anterior leaflet, SL = septal leaflet

ABERRANT VS ANOMALOUS CORONARY ARTERY: The aberrant coronary artery originates from the right cusp and usually presents in young adults during athletic activity. The anomalous coronary artery originates form the pulmonary artery and presents in infancy. In the case of an anomalous right coronary trunk, there are usually no dire consequences. In the case of an anomalous left coronary trunk, the patients usually die of myocardial ischemia at 13 months or longer (see below)

MORE ON ABERRANT CORONARY ARTERIES: Branches of the coronary arteries may vary in origin, distribution, number, and size. The left coronary artery is more variable than the right. The branches may arise as a common trunk, or both arise from the same aortic sinus. The anterior interventricular and terminal branches of the left coronary sometimes arise separately from the aortic sinus. In some cases, a single coronary artery serves the entire heart; either the right or the left coronary artery is absent. One coronary artery may be larger than usual and the (7 of 19) [5/29/2002 10:52:37 PM]


other correspondingly smaller. Very rarely, an extra coronary artery arises from the pulmonary artery. Occasionally, there are two interventricular branches, or two or more posterior interventricular branches. There may be three or even four independent coronary arteries which are, generally, quite small. A conus artery arising from the aorta was found in 50% of 651 subjects. Coronary artery preponderance occurs in about 30% of cases; left coronary is preponderant in 12% of cases and the right coronary in about 18%. Left coronary artery dominance is eight times more frequent in males (18.2%) than in females (2.6%), while right coronary artery preponderance is almost twice as common in females (23.1%) as in males (14.6%). In some unusual circumstances, the left coronary circumflex branch may be the dominant artery

MORE ON ANOMALOUS CORONARY ARTERIES: The right coronary artery occasionally arises from the pulmonary trunk, usually without adverse consequences. Cases have also been reported of the left coronary arising from the pulmonary trunk, but this is usually associated with myocardial ischemia, with patients dying at 13 months or younger. In one case, however, a female patient survived 60 years; in another case, a male survived 34 years (cause of death unrelated to heart disease). In 14,000 consecutive autopsies, this condition was found three times. When both coronary arteries arise from the pulmonary trunk, death occurs shortly after birth.

EVEN MORE ON ABERRANT VS ANOMALOUS CORONARY ARTERIES: Aberrant origin of either the right or left coronary artery occurs from the opposite sinus of Valsalva. The aberrant artery travels between the aorta and right ventricular outflow tract (RVOT) and may be hypoplastic and /or kinked. It may be mechanically compressed by the great vessels particularly during exercise or with hypertension.

Anomalous origin of the left coronary artery (LCA) from the pulmonary artery. This occurs in 1/300,000 births. The ectopic LCA has a variable number of intercoronary collaterals which connect to the otherwise normal RCA. There may be segmental left ventricular dysfunction and papillary muscle dysfunction with associated mitral regurgitation. As mentioned above, the condition is fatal in infancy if it involves the left coronary artery, but is not fatal if it involves the right ventricle Pulmonary hypertension with an intracardiac shunt may mask the presence of the ectopic LCA which then presents as mitral regurgitation. (8 of 19) [5/29/2002 10:52:38 PM]


The above figure 1 caption should say "aberrant origin of left main coronary....." The second diagram shows an unusual left coronary artery, with origin from right aortic sinus, and course between the bases of aorta and pulmonary artery. No circumflex branch. (9 of 19) [5/29/2002 10:52:38 PM]


SUPPLY OF THE SA AND AV NODES: It has been reported that in 50% of hearts, the sinoatrial and atrioventricular nodes were supplied by the right coronary, and in 7% of hearts, these nodes were supplied by the left coronary. In the remainder (43%), one artery supplied one node and the other artery supplied the other, in either combination. Spalteholz, however, reported the sinoatrial node to be supplied in 68% of cases by the right coronary, in about 32% by the left coronary, and very rarely by an extracardiac artery.

THE LCX: The left coronary circumflex branch may be larger and longer than usual, giving off the posterior interventricular artery before anastomosing with a smaller right coronary artery on the posterior surface of the heart.

SEPTAL BRANCH OF THE R CORONARY ARTERY: An infrequent branch of the right coronary is a septal branch that supplies the middle part of the septum and both limbs of the conduction system.

OTHER ORIGINS OF THE CORONARY ARTERIES: Occasionally, a coronary artery arises from the common carotid, later giving rise to right and left branches. "Large and direct" anastomoses between the right and left coronary arteries have been reported in 9% of individuals. Smaller anastomoses between the two vessels occur in most hearts. The absence of right/left coronary anastomoses was said to occur in 3% of hearts.

THE INTERVENTRICULAR OR DESCENDING CORONARY ARTERY: The anterior interventricular (descending) coronary artery and vein have been reported to arise from the left internal thoracic (mammary) artery and vein (Robicsek, et al.). (10 of 19) [5/29/2002 10:52:38 PM]


BENIGN CORONARY ANOMALIES: a) Separate origin of left anterior descending artery and left circumflex from the left sinus Valsalva (513 cases, 0.41% incidence, 30.4% of all anomalies). b) Absent left circumflex (with maximally dominant right coronary artery) (4 cases, 0.003% incidence, 0.24% of all anomalies). c) Origin of left circumflex from right coronary or right sinus of Valsalva (467 cases, 0.37% incidence, 27.7% of all anomalies). d) Ectopic origin of right coronary artery or left main trunk from posterior sinus of Valsalva (Left main trunk; 16 cases, 0.0008% incidence, 0.95% of all anomalies. Right coronary; 4 cases, 0.003%, 0.24% of all anomalies). e) Ectopic coronary origin from the ascending aorta (Left main trunk; 16 cases, 0.013% incidence, 0.95% of all anomalies. Right coronary; 188 cases, 0.15% incidence, 11.2% of all anomalies). f) Intercoronary communication (3 cases, 0.002% incidence, 0.18% of all anomalies). g) Small coronary artery fistulae (163 cases, 0.12% incidence, 9.7% of all anomalies). Total No. Anomalies...1359, Incidence...1.07%, Of all anomalies...80.6%.

POTENTIALLY MORE SERIOUS ANOMALIES: a) Ectopic coronary origin from the pulmonary artery (Bland-White-Garland syndrome) (Left main trunk from pulmonary; 10 cases, 0.008 % incidence, 0.59% of all anomalies). Left anterior descending; 1 case, 0.0008% incidence, 0.06% of all anomalies. Right coronary artery from pulmonary artery; 2 cases, 0.002% incidence, 0.12% of all anomalies). b) Ectopic origin of the left coronary artery from the right sinus of Valsalva Left main trunk from right sinus of Valsalva; 22 cases, 0.017 % incidence, 1.3% of all anomalies. Left anterior descending from right sinus of Valsalva; 38 cases, 0.03% incidence, 2.3% of all anomalies. Right coronary artery from left sinus of Valsalva; 136 cases, 0.107% incidence, 8.1% of all anomalies.

VARIATIONS IN CORONARY OSTEA: (11 of 19) [5/29/2002 10:52:38 PM]


MORE VARIATIONS IN THE OSTEA (upper left; The typical pattern of ostia and vessels. 1,2,3, pulmonary semilunar valve; 4,5,6, aortic semilunar valve; 7,8,9, tricuspid valve; 10,11, mitral valve; 4, origin of left coronary artery; 5, origin of right coroner artery): (12 of 19) [5/29/2002 10:52:38 PM]


DEBAKEY CLASSIFICATION OF AORTIC DISSECTION: type 1: 29-34% is ascending aorta and portion distal to arch type 2: 12 - 21% is ascending aorta only type 3: 50% is descending aorta only stanford A: 70%ascending aorta plus or minus arch in 4 cm (affects ascending aorta and arch) stanford B: 20-30% affects descending aorta only

surgical procedures for cardiac: ap window: side to side between ascending aorta and left pa for tof blalock taussig: end to side sca to pa for tof/ta/pulmonic stenosis pott: descending ao to l pa for tof (13 of 19) [5/29/2002 10:52:38 PM]


waterson cooley: ascending ao to r pa for tof blalock hanlon: surgical asd for tga mustard: septostomy and atrial baffle for tga rashkind: septostomy for tga rastelli: conduit rv to pa for tga jetene: arterial switch for tga fontan: conduit ra to pa for ta glenn: svc r pa for ta norwood: pa and descending ao conduit, followed by pa banding for palliation prior to heart transplant for hypoplastic l heart sydrome senning: this is the same as the mustard except it uses synthetic material pulmonary artery banding: multiple small VSDs and pulmonic stenosis ross: autologous transfer of pulm vein to aortic postition for aortic stenosis


One great artery arising from the heart giving rise to coronary, pulmonary, systemic arteries. It straddles a large vsd. It represents 2% of all CHD. (by comparison TGA is 10%). There are 4 types: see figure. Type 1 (50%) main PA and aorta arising from common trunk. Type 2 is 25%; both PA's come from the (14 of 19) [5/29/2002 10:52:38 PM]


back of the trunk. Type 3 (10%) both PA's come from the side of the trunk. Type 4 pseudotruncus or absent PA's. Pulmonary supply comes from collaterals arising from the descending aorta

COR TRITRIATRIUM: quick note on cortriatriatum since i keep on forgetting what this is: very rare, incomplete incorporation of PV into the LA causing obstruction to pulmonary venous return. It mimics congen mitral stenosis but has a normal LA size. It is associated with a parachute MV, mitral web and CHF

AORTIC STENOSIS-ANGIODYSPLASIA ASSOCIATION: aortic stenosis is associated with angiodysplasia in 20% of cases, and usually present as R colon GI bleed

MOST COMMON CHD CAUSING CENTRAL CYANOSIS SHORTLY AFTER BIRTH (GRAINGER AND ALLISON): uncorrected tga or d-tga is most common shortly after birth even though Fallot is more frequent than tga overall sue to its peak presentation at 2-6 y of age. d tga usually have a normal heart size at birth. dtga usually needs an additional anomaly for the circulations to mix. This is usually a vsd. d tga is only associated with R sided arch in 5%. d-tga has an egg on its side configuration. Corrected tga is only 15% of tga

SOME INPORTANT CAUSES OF A RIGHT SIDED ARCH (GRAINGER AND ALLISON): truncus arteriosus, tof, tricuspid atresia. All these are cyanotic

MOST COMMON CAUSE OF A VASULAR RING: this is right arch with aberrant L subclavian artery; however, this does not usually require surgery. The most common cause of a tight ring that requires surgery is type 1 double aortic arch there are 3 types of rings: (15 of 19) [5/29/2002 10:52:38 PM]


#1: DAA #2: R arch with aberrant L SCA and ductus arising from PA to descending aorta #3: R arch with mirror image branching and a ductus to the descending aorta sling L PA arisin from R PA

BICUSPID AORTIC VALVE: this is the most common cause of congenital valvular stenosis. Most cases of bicuspid aortic valve do not cause problems until until the valve thickens and calcifies in early adulthood. Supravalvular aortic stenosis is associated with peripheral pulm artery stenosis (Williams syndrome)

WILLIAMS SYNDROME: hypercalcemia, elfin facies, mental retardation, dwarfism, supravalvular aortic stenosis, and peripheral pulmonary artery stenosis

WHERE IS THE NARROWING IN TOF? before the valve ie rvot

EISENMENGERS: in rare cases of VSD, can get reversal of flow through a vsd called eisenmengers syndrome. Other causes are asd and pda in addition to vsd. It is usually caused by long standing shunts

OTHER CAUSES OF RIB NOTCHING: takayasu, tof, vena cava obstuction (16 of 19) [5/29/2002 10:52:38 PM]


VERTICAL VEIN IN SUPRACARDIAC AND SUPRADIAPHRAGMATIC TAPVR: it is on the L and behind the LA and ascends vertically in front of the L hilum to drain into the L BCV. PAPVR may also be associated with the vertical density on the L. This is scimitar sydrome: R>L

INFRACARDIAC DRAINAGE OF TAPVR: it is usually obstructed. There is pulm venous congestion, and edema. The heart size is not enlarged as there is RV pressure overload and not volume overload

MORE ON TAPVR: supradiaphragmatic: type 1: supracardiac (50%): L vertical vein going to SVC, non obstructed type 2: cardiac (30%): drains into the coronary sinus or RA. Also there is mixed (5%) which drains into both type 3: infracardiac (12%) which is obstructed most likely because it has to go through the liver and less likely because it has to go through the diaphragm. It drains into the PV, IVC, ductus venosus, left gastic vein leading to pulmonary venous hypertension and RV pressure overload. These infants usually die within a few days

PAPVR: 10X more common on the R side. The atrial septum is usually intact in papvr. In scimitar sydrome, the R inferior pulmonary vein drains into the IVC

CAUSES OF A BOOT SHAPED HEART: TOF and truncus (17 of 19) [5/29/2002 10:52:38 PM]


MOST COMMON TYPE OF VSD: membranous septum (80%)

CALCIFIED PDA: grainger and allison say that this usually indicates severe pulm hypertension. pda is the most common cause of an extracardiac L to R shunt

MR SPIN ECHO OF BLOOD: velocity of blood>3 cm/sec gives no signal. Slower moving blood can be isointense with surrounding tissue. Fibrous pericardium is low in T1 and T2. On T2, pericardial fluid would be bright, but due to motion, areas of signal loss occur which makes it difficult to distinguish from pericardium

PACER WIRE PROJECTING OVER THE RV ON A FRONTAL CXR: may be in left hepatic v, middle cardiac v, coronary sinus, or rv


ABERRANT R SCA ARISING BELOW A COARCTATION: it delivers low pressure blood to right axilla and arm and therefore cannot support a collateral circulation with reversed flow through the right intercostals, so it is does not cause unilateral rib notching

IN COARCTATION: kink in the aorta is towards the PA (18 of 19) [5/29/2002 10:52:38 PM]


HOLT ORAM: CHD (usually ASD) and upper limb abnormalities

VALVELESS VEINS: pulmonary vein, portal vein, cephalic vein, orbital veins, batsons plexus

FALSE LUMEN INVOLVEMENT OF BRANCH VESSELS: prefers L sided branches including L renal, L iliac, L subclavian (19 of 19) [5/29/2002 10:52:38 PM]


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There is no index for this so if you want to find something, press the Ctrl-F keys at the same time and type in the word you want to find in the find box! If someone would like to help make an index for this, let us know

EMBRYOLOGY: the telencephalon and diencephalon are part of the forebrain. The forebrain is derived from the prosencephalon. The midbrain originates from the mesencephalon. The hindbrain originates from the rhombencephalon

BIT ON REFLEXES: jaw: c5 biceps: c5-6 triceps: c7-8 finger: c7-t1 quads: L2-L4 hamstrings: L5-S2, ankle jerk: L5-S3, toe flexion reflex: s1-s2

CC fistula: can see retrograde flow in the superior ophthalmic vein and flow into the contralateral cavernous sinus

BASAL GANGLIA MR IN PTS WITH LIVER DISEASE: see increased T1 and decreased T2 (1 of 43) [5/29/2002 10:53:02 PM]


BUPHTHALMOS IN PTS WITH NF1: due to sphenoid wing dysplasia and herniation of temporal lobe

VEIN OF GALEN: posterior and superior to 3rd venticle

MOST COMMON CAUSE OF AN ENLARGED MASSA INTERMEDIA: only one that i know of is chiari 2

DOES POSTERIOR CHIASM LESION LEAD TO BITEMPORAL HEMIANOPSIA? need to check this. It looks like both anterior and posterior chiasmal lesions will produce bitemporal hemianopsia while lateral lesions will produce heteronymous hemianopsia

RETINAL LESIONS: vhl: retinal angiomas (von hippel tumor) sw: choroidal angiomas nf1: lisch nodules (pigmented iris hamartomas), Note that in nf2, there are no Lisch nodules ts: retinal hamartomas (phakomas) (astrocytic proliferation in the optic disc which is usually bilateral) downs: brushfield spots on the iris

VHL ASSOCIATIONS: von Hippel-Lindau disease is an autosomal-dominant disorder linked to a defect on the short arm of chromosome 3. It is a multisystem disease characterized by cysts, neoplasms of the abdominal viscera, (2 of 43) [5/29/2002 10:53:02 PM]


and hemangioblastomas of the central nervous system. Renal cell carcinoma is the most frequent malignant tumor. Pheochromocytomas are found in 10% to 15% of cases. Pancreatic manifestations include islet cell tumors and pancreatic cysts.

TUBEROUS SCLEROSIS: AD, chromosome 16 short arm, classic triad of zits, nitwits, fits, 95% of them have cortical tubers, subependymal GCT near foramen of monroe, retinal phakomas, facial angiofibromas, shagreen patches, kidney cysts, cardiac rhabdomyosarcoma, liver adenoma, bone islands

If you need more detail, here is the scoop in TS (quoted from Clinically these patients present with the triad of seizures (90%), mental retardation (50%), and adenoma sebaceum (90%). -autosomal dominant, 1/10,000-1/50,000 -chromosomes: TSC 1 9q, TSC 2 16p- forme fruste 5x more common -criteria (need 1) -facial angiofibromas -ungual fibroma (17%) -retinal hamartoma -cortical tubers (50%) -subependymal nodules -multiple renal AML -presumptive (need 2) -hypomelanotic nodules -shagreen patch -single AML -multicystic kidney -cardiac rhabdomyoma (30-50%) -LAM pattern, honeycomb lung -first degree relative with TS -subependymal giant cell astrocytoma in 15% (WHO grade I) -other findings: retinal benign astrocytic hamartoma, heterotopias, myelination disorder, ventriculomegaly

NEUROFIBROMATOSIS (3 of 43) [5/29/2002 10:53:02 PM]


NF1: nf of cn3-12 NF2: trigeminal > facial. There are bilateral 8th nerve masses at the origin of the superior and inferior division of the vestibular nerve. The olfactory and olfactory nerve have no schwann cells and so are not affected. NF is also associated with moya moya (puff of smoke) (see below)

MOYA MOYA ASSOCIATIONS: The Moya moya pattern of vessels seen on angiography is thought to be a phenomena secondary to intracranial large vessel narrowing or stenosis. The response of the cerebral vasculature to this type of narrowing is for more distal vessels to proliferate. There is debate as to whether the vascular abnormality represents a congenital problem or an acquired stenosis of intracranial vessels that occurs early in life. Moyamoya type changes have been found in a variety of diseases, including sickle-cell disease, neurofibromatosis, trisomy 21 and fibromuscular dysplasia. Other predisposing conditions for this problem include an auto immune process, cranial trauma, anaerobic bacteria or the use of oral contraceptive but none has been convincing.

WALLENBERG: also called lateral medullary sydrome. It is due to PICA or vert dissection or infarct. Note that Weber is from PCA infarct. Wallenberg produces pain and temp loss from the ipsilateral face and numbness and impaired sensation in the ipsilateral body. There is contralateral body pain and temperature loss and numbness (from the lateral thalamus)

For some more detail: classically as mentioned above it results from PICA infarct most usually due to vert artery occlusion. ipsilateral: preganglionic horners, face pain, numbness, and decreased sensation. Also dysphagia, hoarseness, decreased gag reflex, decreased taste, vertigo, nystagmus, n/v, diplopia, hiccups contralaterally: numbness, decreased pain and temperature sensation in trunk and extremities horners with meiosis, ptosis, anhydrosis

EFFECT OF STURGE WEBER ON THE CHOROID PLEXUS: ipsilateral choroid plexus enlargement is seen in Sturge Weber (4 of 43) [5/29/2002 10:53:02 PM]


PAPEZ MEMORY CIRCUIT (REMEMBER THIS ONE!): this circuit describes the connections that cause temporal lobe seizures. The following components comprise this circuit: 1. hippocampus, 2. parahippocampal gyrus, 3. fornix, 4. mamillary bodies

SKETCH OF THE CAVERNOUS SINUS (CORONAL) WITH CONTENTS SHOWN: the ica is most medial, and cn6 is the next most medial. The rest are in the wall. V2 is the most lateral

IN HIV CNS INFECTION: Involves oligodendroglia: PML Involves endothelial cells: herpes Involves perivascular spaces: cryptococcus Most common brain infection in HIV: HIV (5 of 43) [5/29/2002 10:53:02 PM]


Most common opportunistic infection: Toxo overall, the most common cns infection in hiv are as follows:#1 is cmv, #2 is hiv and #3 is jc virus (pml) for diffuse and for focal is toxo

BRIGHT BASAL GANGLIA ON T1: this is associated with liver disease, manganese toxicity, and tpn

HYPOINSTENSE BASAL GANGLIA ON T1: The bilateral basal ganglia lesions are similar in appearance to cyanide and carbon monoxide poisoning, two "acquired" mitochondrial cytopathies (which uncouple the cytochrome chain). Leigh's disease (also known as subacute necrotizing encephalomyelopathy) has an infantile, juvenile and adult type. (quoted from

THE LIPODYSTOPHIES (quoted from Adrenoleukodystrophy is an X-linked disease. The disease is caused by peroxisomal enzyme deficiency. The three major types are adrenoleukodystrophy, adrenomyeloneuropathy, and adrenoleukomyeloneuropathy. Adrenoleukodystrophy is associated with bilateral demyelination in the peritrigonal area and corpus callosum, which display marked enhancement post contrast. It is the most common form of the three and onset is usually at the age of three years. Adrenomyeloneuropathy is the second most common and is characterized by young adulthood onset. Adrenoleukomyeloneuropathy is characterized by peripheral nerve and spinal cord involvement. Krabbe's disease is autosomal recessive, and results from a lysosomal deficiency. Imaging studies demonstrated demyelination of centrum semiovale and corona radiata. Hyperdensity of the thalami on CT has also been described. Metachromatic Leukodystrophy, is an autosomal recessive disease, resulting from lysosomal deficiency of arylsulfatase A. It is characterized by symmetric periventricular white matter disease which is greatest seen in the frontal lobes. It is noteworthy because it is the most common leukodystrophy. Alexander's Disease often enhances but typically affects the white matter of frontal lobes preferentially. It is associated with macrocephaly. Canavan's Disease- (van Bogaert-Bertrand disease) results from a deficiency in N-acetylaspartylase. It is transmitted in an autosomal recessive manner. The disease is distinguished from other leukodystrophies in that it involves the subcortical U fibers and only the internal capsule is spared. Like Alexander's Disease, Canavan's Disease is associated with macrocephaly. The occipital lobes are preferentially involved. (6 of 43) [5/29/2002 10:53:02 PM]


This is what the neuro fellow at Yale had to say about the leukodystrophies: approach: in the infant there are only 3 to think about: canavan alexander krabbe of these 3, canavan and alexander have a big head and krabbe has a normal sized head

in the older child or adult: male: think about adrenoleukodystrophy and metachromatic leukodystrophy since these are all X linked recessive, if you see it in the female, then consider wrong karyotype of the above, only 2 enhance: canavan and adrenoleukodystrophy of the above, alexander has a frontal predominance adrenaleukodystrophy tends to edge enhance. Typically, posterior to anterior with sparing with the cortical U fibers which is pathognomonic. It is X linked ie males only.

Some other things that were mentioned are PVL in infant where you see WM thinning periventricularly with resultant enlargement of the ventricles PML does not enhance. Papovirus is the etiology MS classically involves the cerebellar peduncles. It has WM lesions that are perpendicular to the ventricles

SYRINGOMYELIA: involves spinal cord, while syringobulbia involves brainstem



Type 1) Granulation tissue--which gives signal of increased water: Hypo on T1, hyper on T2 Type 2) Fatty change--which gives signal of increased fat: Hyper on T1, hyper on T2 Type 3) Sclerotic change--which gives signal of increased calcium and decreased water and fat: Hypo on T1, hypo on T2.

ASSOCIATIONS WITH AGENESIS OF THE CORPUS CALLOSUM: Dandy Walker 11%, midline lipoma 10%, chiari two 7%. If it occurs by itself, it may be assymptomatic. It is associated with CNS anomalies (85%), cardiac and GU anomalies (15%), and karyotypes 13, 15, 18. If it is diagnosed after 22w than you see "teardrop ventricles". A high 3rd ventricle and radial array of gyri are associated

CHIARI MALFORMATION: C1 has herniated cerebellar tonsils and syringomyelia; Cerebellar tonsillar ectopia of > 5 mm (adults and children), syringomyelia 20-30%, hydro 25-44%, and Klippel feil 10% C2 has partial absence of the septum pellucidum, or complete absence in 40%. There is dysgenesis of the CC in 80%. Usually the splenium and rostrum is missing in 80-90%. Also there is an elevated 3rd ventricle. In addition, there is scalloping of the petrous bone and clivus. The massa intermedia and foramen magnum are both enlarged; skull and dura: small posterior fossa, luckenshadel skull, fenestrated falx, gaping foramen magnum, concave clivus and vents: hydro 90%, elongated tube like vents, high riding 3rd ventricle, absent or hypoplastic CC. The foramen magnum may be enlarged In C2 the brain shows inferior displacement of the vermis, medullary kink, large massa intermedia, tectal beaking, towering cerebellum through a wide tentorial incisura, associated polymicrogyria, callosal dysgenesis, interdigitating sulci, meningiomelole 100% which is usually consists of protrusion and exposure of the neural tissues through a spina bifida defect C3: there is herniation of the cerebellum into a high cervical or occipital encephalocele + all features of C2 C4: extreme cerebellar hypoplasia, no displacement. This includes hypoplasia of the pons in addition to agenesis of the cerebellum


CHIARI 1: 3mm below ="mild tonsillar ectopia"- no clinical significance, 3-5mm gray area, >5mm= Chiari I- may (8 of 43) [5/29/2002 10:53:02 PM]


have cranial neuropathy due to brainstem compression, central cord syndrome due to syrinx. Chiari I is by far the most common of the Chiari malformations. Etiologic theories include embyologic anomaly of craniocervical junction, intrauterine tonsillar herniation due to hydrocephalus, or acquired deformity from platybasia/basilar invagination. Associations include hydromyelia (25-60%), basilar invagination (25-50%), C2-3 fusion (18%), AO fusion (10%), cervical occulta (5%), Klippel-Feil (5%). No association with brain anomalies unlike Chiari II.

CHIARI 2: Chiari II malformation is a relatively common congenital CNS anomaly which represents an abnormality of neural tube closure at aproximately 4 weeks of gestation. The most common anomaly due to defective neural tube closure is anencephaly. The basic abnormality in Chiari II malformation is inadequate developmant of the fourth ventricle with a resultant small posterior fossa. The associated findings are largely due to the small posterior fossa. Myelomeningocele is almost universally present with this anomaly. The condition can be hereditary and familial. Chiari II is in no way related to Chiari I. Associated intracranial findings (variable and rarely all present): -hydrocephalus, narrow aqueduct, large foramen magnum -lacunar skull- inner table scalloping- resolves after about 6 mo -scalloped posterior petrous/clivus -low tent, wide hiatus -hypoplastic falx with gyral interdigitation -vertical straight sinus -lateral vents parallel with colpocephaly and squaring of frontal horns -80% absent septum pellucidum -hourglass 3rd vent with large massa intermedia -long, low and small 4th vent -beaked tectum with large QP cistern -large caudate heads -towering cerebellum Extracranial findings: ->99% with myelomeningocele -70% with deficient C1 posterior arch -restrictive dural band at craniocervical junction -20% with diastematomyelia (20%) -50% hydromyelia -thoracolumbar kyphosis

DANDY WALKER: (9 of 43) [5/29/2002 10:53:02 PM]


In DW, there is complete vermian agenesis while in DW variant , there is mild hypoplasia of the vermis. Agenesis of the corpus occurs in 20 to 25%

ETIOLOGY OF DWM: There is atresia of the foramina of Magendie and insults to the development of the cerebellum and 4th ventricle. Cisterna magna is insult to the developing 4th ventricle. DWV is insult to the developing cerebellar hemispheres and DW is a combination of both

HOLOPROSENCEPHALY: Septum pelucidum is always absent. Single ACA. The SS, SSS, internal cerebral veins as well as falx are absent. The ddx: severe hydro, DW cyst. hydrancephaly, agenesis of the CC with a midline cyst. Since the CC forms from anterior to posterior, and the posterior portion is present in holoprosencephaly, this implies that the anterior part is lost as opposed to not forming in the first place

It is common to all types is fusion of grey matter across the midline. Facial anomalies are frequently associated with the lobar type. The semilobar type may absence of the body and genu of the of the corpus callosum with an intact appearing splenium. Septooptic dysplasia is thought to be a mild form of holoprosencephaly

CAVUM SEPTUM: cavum sp: 5th ventricle, cavum vergae: 6th ventricle which is a posterior extension of the CSP behind the foramen of monro

CORPUS CALLOSUM: development is generally from front to back except for the rostrum. Note that callosal agenesis is associated with radial orientation of the gyri along the medial hemispheres. Partial agenesis is associated with Chiari 2, holoprosencephaly. In Dandy Walker, agenesis of the CC occurs in about 20% (10 of 43) [5/29/2002 10:53:02 PM]


MOST COMMON CPA MASS: Most common CPA mass: vestibular schwannoma

PINEAL REGION TUMORS: The majority of pineal region tumors are not of parenchymal cell (ie pinealoblastoma, pinealocytoma) origin. Most are of germ cell origin and occur in predominantly in teenagers

germ cell (>50% of pineal tumors, ie most common of pineal tumors): germinoma is #1 and has engulfed Ca++ teratoma is #2 (ie is the second most common pineal mass) and is heterogeneous with fat and cystic areas: The tumor elevates the internal cerebral veins and the patients present with Parinaud's syndrome

parenchymal: pineocytoma: looks like normal pineal parenchyma with exploding Ca++ pinealoblastoma: exploding Ca++ and also associated with trilateral retinoblastoma others: pineal cysts, astrocytomas, meningioma, vein of galen

PINEAL CA++ seen on 60-70% of plain skull films. Pineal Ca++ at < 6 years old is abnormal

FALCINE CA++: falx ca++ is more common in males. Dural Ca++ is more common in females.

BG CA++: normal if seen on CT but abnormal if seen on plain film (suggests hypoparathyroidism, (11 of 43) [5/29/2002 10:53:02 PM]


pseudohypoparathyroidism, cockayne, wilsons dz)

MAGNETIC SUSCEPTIBILITY: magnetic susceptibility is greater with conventional T2 than with FSE T2

WHAT IS THE FORAMEN OF VESALIUS?: it is posterior to the rotundum and contains the emissary veins. Note that the foramen lacerum is a fibrous structure through which nothing passes

JUGULAR FORAMEN: It contains 10 (medially), 11, and the jugular vein. Anterior, medial and smaller is CN9

THIRD NERVE PALSY: DM, MS, p.comm or basilar artery aneurysm (causes dilated or blown pupil in the case of unruptured aneurysm), migraine, lymphomatous memingitis. It is better to think of it as pupillary sparing=DM, and pupillary dilatation= unruptured p comm aneurysm. Weber syndrome is due to p comm infarct causing ipsilateral pupillary dilatation and contralateral hemiparesis


HOMONYMOUS HEMIANOPSIA: lateral geniculate and occipital lobe lesions (12 of 43) [5/29/2002 10:53:02 PM]


PITUITARY MICROADEMONA: by definition: <1cm

PINEAL TUMORS: germ cell tumors (eg germinomas, yolk sac tumors, choriocarcinomas) are more common than non germ cell tumors (eg pinealocytoma, pinealoblastoma). Germinomas almost always occur in the teens and are rarely seen after 30 years old. Males outnumber females by about 9:1

PERINAUD'S SYDROME: due to tectal compression by mass usually teratoma. There is loss of upward gaze due to pineal region tumor. Also there is deficiency of pupillary dilatation and reduced light response

PATTERNS OF MYELINATION OF THE BRAIN: Myelination on T1 imaging (months): 0 posterior limb of internal capsule and decussation of superior cerebellar peduncles 2 anterior limb of internal capsule 3 cerebellar WM 4 splenium 6 genu 8 adult pattern

on T2 imaging, myelination lags behind the appearance on the T1 images. For example, the adult pattern of myelination appears at 24 months instead of 8 months on T2 weighted imaging

SYNOVIAL CYST: (13 of 43) [5/29/2002 10:53:02 PM]


most common in the L spine

TARLOV CYST: These represent the most common type of arachnoid cyst. They arise from the posterior rootlet (S2 and S3 most common) and form a dilated nerve root sleeve as a normal variant. They can cause sacral erosion and may communicate with the thecal sac

CONGENITAL INRADURAL CYSTS: arachnoid cysts are the most common and are found in the thoracic region dorsal to the spinal cord. Neurenteric cysts are usually anterior or anterolateral to the cord. Spinal neurenteric cysts may enlarge the spinal canal

CHORDOMA: in the head and neck, spenoocipital sychondrosis is favored site of origin of chordomas. Chordomas are bright like csf on t2. They are calcified in up to 50%. The most common site of origin is the sacrococcygeal region

INTRAVENTRICULAR LESIONS: intraventricular lesion location: colloid cyst: anterior 3 vent subependymoma: posterior 3 vent craniopharyngioma: inferior to 3 vent choroid plexus papilloma: lateral vent (atrium)

this is how describes ependymomas vs subependymomas: subependymomas (also known as subependymal glomerate astrocytomas) are usually incidental fourth ventricular lesions in middle-aged or elderly men. Ependymomas are most commonly seen in children (14 of 43) [5/29/2002 10:53:02 PM]


and typically in the 4th ventricle. In spine of adult, ependymoma>astrocytoma. In spine of child, astocytoma>ependymoma. In brain of child, ependymoma is more common than in adults

MORE ON INTRAVENTRICULAR LESIONS: about 10% of cns neoplasms are partly or totally intraventricular. The most common lat vent mass is a CPP. The most common 3rd vent mass is a colloid cyst. The most common 4th vent mass is an ependymoma

COLLOID CYST: anterior 3rd vent originating from roof near foramen of monro. They may sometimes show peripheral capsular enhancement, and moderate hydrocephalus

CHOROID PLEXUS PAPILLOMAS: The body and atrium of the lateral ventricle are favorite loci for choroid plexus papillomas, particularly in young children. The 4th ventricle is most common in adults.

MENINGIOMA: most commonly supratentorial. parasagital>convexities>sphenoid wing>CPA>olfactory groove>planum sphenoidale. The most common intraventricular location is atria of lateral ventricles. Interestingly, ventricular meningiomas are always in the L lateral ventricle Meningiomas are supplied by the ECA. The dural tail sign is not specific for meningioma. Meningiomas are the most common benign intracranial tumors and the most common extraaxial tumor in adults. If seen in childhood, than they are frequently associated with NF2

MULTIPLE ENDOCRINE NEOPLASIA: men1 (wermer): pituitary adenoma, pancreatic islet cell tumor, parathyroid adenoma/hyperplasia. MEN 1 can have shwannomas, multiple lipomas, thymomas and carcinoids. (15 of 43) [5/29/2002 10:53:02 PM]


men2 (sipple): pheochromocytoma, thyroid medullary ca, parathyroid adenoma/hyperplasia. MEN 2a has associations with gliomas, GBM, meningiomas men3 (synonymous with 2b): pheochromocytoma, thyroid medullary ca, facial neuromas. MEN 2b can have associated marfanoid features and hypotonia Note that both Men 1 and Men2a and b are AD

BRAINSTEM CRANIAL NERVE ORIGINS: midbrain or above: cn1-4 pons: cn5-8 medulla: cn9-12

CALCIFIED POSTERIOR FOSSA MALIGNANCIES: calcifications in posterior fossa malignancies: medulloblastoma 10-20%, ependymoma 50% astrocytoma: 60% in posterior fossa are calcified and of these 40% in the cerebellum and 20% in the brainstem are calcified. 40% of supratentorial astro's are calcified

THE MOST COMMON PRIMARY LESION OF THE POSTERIOR FOSSA IN AN ADULT: hemangioblastoma. Multiple lesions are seen in pts with VHL. These tumors occur exclusively in the cerebellum, and they are solid in 30 to 40%. Signal voids can be seen adjacent to or within the solid nodule component

INTRACRANIAL TERATOMA: occur exclusively in males. They vary from benign to malignant. The pineal region is the most common site for teratomas. May contain fat. Associated with Parinauds (16 of 43) [5/29/2002 10:53:02 PM]


CHILDHOOD GLIOMAS: 10% of childhood gliomas are in the brainstem


SPINAL CORD LESIONS: ependymoma: 60-70% (it is the most common spinal glioma across all age groups) astrocytomas: 30% (it is the most common pediatric spinal glioma) hemangiomas: 2% note that in the spine of a child: asto 60%, ependymo 30% and in the spine of adult: astro 30%, ependymo 60%; note also that ependymomas are more common overall in children than adults the spinal cord is the second most common site for mets after brain note that in adult, spinal astrocytomas are more common than in children and in children, brain astrocytomas are more common than in adults

SPINAL MENINGIOMA: the most common site is the thoracic spine

SPINAL TERATOMA: most are congenital sacrococcygeal teratomas

MOST FREQUENT CAUSE OF INTRAMEDULLARY METS: lung ca (17 of 43) [5/29/2002 10:53:02 PM]


DEVIC SYNDROME: this is transeverse myelitis accompanied by blindness

SPINAL MS: most plaques involve the lateral columns and are not usually found in the anterior or posterior columns

SPINAL INFARCT: occlusion of the anterior spinal artery is more likely to be symptomatic than occlusion of the posterior spinal artery


THE DREADED ANTONI A AND ANTONI B STORY: this is somewhere in the depths of the AFIP notes which i have not yet opened. This story applies to schwannomas. The B cells are responsible for the cystic changes. Based on this, cyst formation is more common in shwannomas than in neurofibromas. In the absence of cyst formation, neurofibromas and schwannomas are indistinguishable by imaging

NERVE SHEATH TUMORS: involves thoracic and lumbar spine most commonly. The plexiform neurofibromas can undergo malignant degeneration (18 of 43) [5/29/2002 10:53:02 PM]


MORE ON SCHWANNOMAS: in spine, solitary benign neural tumors are almost always schwannomas. Schwannomas are common in sensory roots as single lesions. In NF, lesions are usually multiple and associated with NF1

LOCATION OF OPTHALMIC ARTERY: ophthalmic artery passes through the optic canal and not the superior orbital fissure

PCA VS HEUBNER: pca supplies thalamus via thalamic perforators. Does not supply cerebellum. Supplies occip, post temporal and parietal lobes Heubner supplies caudate and ant inf internal capsule (it is a branch of the aca)

THIRD NERVE PALSY: pupillary sparing 3rd n palsy is from DM. If pupil involved usually aneurysm or mass. Pupillary fibers run on outside of the third nerve

CIRCLE ANEURYMS: anterior circulation 90% A comm (35%)> ICA-Pcomm (35%) > MCA (20%) > basilar (5%) > other (5%) distal to the circle the prevalence is only 2% note that 20% of them are multiple and 25% of them are giant

CAROTID BRANCHES: (19 of 43) [5/29/2002 10:53:02 PM]


cervical: none petrous: tympanic, pterygoid cavernous: meningiohypophyseal, anterior meningeal, branch to trigeminal ganglion, dorsal meningeal, inferior hypoglossal, tentorial branch of bergorfundi supraclinoid: OPA or ophthalmic, Pcomm, anterior choroidal. The anterior choroidal supplies the medial globus pallidus, optic tract, temporal lobe, amygdaloid nucleus, choroid plexus of the lateral ventricle

STROKES: MCA (70%) > PCA (10%) > ACA (4%). The infratentorial vertebrobasilar PICA 10%

ARTERIAL TERRITORIES SEE THE FIGURES UNDER THE ANGIO SECTION ABOVE): ACA: -A1 segment: recurrent artery of Heubner comes off A1 and supplies the anterior limb of the internal capsule, putamen, anteror and inferior caudate head. One source says that the more common origin for the Heubner is A2 segment -acomm -A2: pericallosal and callosomarginal

MCA: -most lateral hemisphere. Most also supply the lentiform nucleus -M2: lateral brain (insular branches) -M1: lenticulostriates from the horizontal portion of the M1

PCA: -posterior third of inferior temporal lobe, and occipital lobe. It participates in the posterior limb of the internal capsule (20 of 43) [5/29/2002 10:53:02 PM]


HYPERDENSE TUMORS: lymphoma, medullo, meningioma

BLEEDING TUMORS: oligo, epend, gbm, medullo, pituitary adenoma

CALCIFIED TUMORS: 70% of intracranial oligodendrogliomas and 50% of medulloblastomas

CENTRAL NEUROCYTOMA: young adults and no gender preference. It is located in lateral ventricle adjacent to the foramen of Monro. It is a well circumscribed lobulated mass with necrotic and cystic changes commonly seen. The tumor is of neuronal origin. Calcification is common. Iso on T1 and iso to hyper on T2. The ddx is: oligo, subependymal gc astrocytoma, low grade astrocytoma, ependymoma

PILOCYTIC ASTROCYTOMA: nearly 50% of cerebellar astrocytomas are cystic with a mural nodule (enhancing)

RANGE OF CNS TUMORS IN TS: subependymal gc astrocytomas located near the foramen of monro (can cause obstruction of csf flow), hamartomatous cortical tubers, subependymal heterotopic nodules (these represent heterotopic grey matter and may enhance on gad enhanced mri). Note that the gc astrocytomas commonly show calcification

OLIGO'S: (21 of 43) [5/29/2002 10:53:02 PM]


involve cortex and subcortical wm in the fronto parietal region. They commonly show ca++ and hemorrage and can also have cytic degeneration

INTRACRANIAL EPENDYMOMAS: these are less common in adults than in children. Most are located in the parenchyma and not the ventricle. Have a fronto parietal predilection. Variable MR and CT contrast. Note that the majority of intracranial ependymomas are infratentorial. Posterior fossa ependymomas are most common in the first 5 years of life

METS: 4/5 are supratentorial, and 1/5 are infratentorial

MOST COMMON MASS IN THE ADULT BRAIN: infarct. However, most common primary brain tumor is a hemangioblastoma. Most common malignancy is mets

4th VENTRICULAR TUMORS: ependymoma, choroid plexus papilloma, medulloblastoma, astrocytoma

INTRAVENTRICULAR TUMORS: CPP, CP carcinoma, meningioma, teratoma, ependymoma, subependymoma, neurocytoma (septal), vascular malformation, heterotopic grey matter, cysticercosis and echinococcal cysts

CHOROID PLEXUS PAPILLOMA: seen more in the lateral vents more on the left side in children. In adults, they are seen more in the 4th (22 of 43) [5/29/2002 10:53:02 PM]



GANGLIOGLIOMA: more common in young pts, not elderly. They prefer the temporal lobes and the third ventricle. Clinically, the pts usually present with epilepsy. These tumors can be found as a posterior mediastinal mass in a child or young adult

CNS LYMPHOMA: primary cns lymphoma is more common than secondary cns lymphoma. Focal intraaxial lesions are the most common presentation. With recurrence, leptomeningeal dz is more common. This can present with cranial nerve palsies. Ring like enhancement is not seen in non AIDS lymphoma. Primary CNS lymphoma is frequently multiple (20 to 40% of cases) and the BG is a common location. The lesions may show hypointensity on T2 weighted MR. About 1/3 of pts with systemic lymphoma get cns disease

STURGE WEBER: V1 is associated with occipital angiomatosis, V2 is associated with parietal angiomatosis, and V3 is associated with frontal angiomatosis. In terms of which is most common: parietal > occipital > frontal. It is associated with hemiatrophy of the effected side of the brain. There is ipsilateral thickening of the skull, enlargement of the paranasal sinuses and mastoids (Dyke Davidoff)

MULTIPLE SCLEROSIS: Rudik Red Flag: no eye findings, no clinical remission, no bladder involvement, no sensory signs suggest another diagnosis. MR is 97% specific. The most frequent location for the brain involvement is the periventricular WM. Optic neuritis is called Devic disease. 12% show no intracranial dz, Marcus gunn pupil is central vision loss

MYCOTIC ANEURYSMS: s. viridans > s. aureus (23 of 43) [5/29/2002 10:53:02 PM]


for oncotic aneurysms: think atrial myxoma and chroriocarcinoma for sickle cell dz: staph aur > salmonella

PARASELLAR MASSES: #1: pituitary adenoma #2: craniopharyngioma #3: meningioma (rare) #4: paramedian carotid artery Microadenoma are more common then macroadenoma clinically but macroadenoma are more common then microadenoma pathologically. Macroadenomas are more common in children

In peds: craniopharyngioma > visual pathway glioma > hypothalamic astrocytoma adult: pituitary adenoma > craniopharyngioma > inflammatory pseudotumor from tolosa hunt

SUPRASELLAR: common: rathkes cleft cyst, craniopharyngioma, subacute hemorrage uncommon: lipoma, dermoid, congenital ectopic neurohypophysis

CHORDOMA: homogeneously bright on T2 and heterogeneous and low signal on T1. They show Ca++ in 30-70%

BLEEDS: with sdh and arachnoid cyts, the veins are pushed in against the brain, while in the elderly with atrophy, the veins bridge the csf space (24 of 43) [5/29/2002 10:53:02 PM]


FORMATION OF LIPOMOMYELOMENINGOCELE AND MYELOMENINGOCELE: non disjuction causes a big defect which forms a myelomeningocele ie it is more severe. Premature dysjunction forms a small defect and fat gets in forming a lipomyelomenigocele. The lipo is occult and is the most common form of the occult forms. So think fat = occult

TETHERED CORD: short fat cord below L2 in the adult by definition. At birth, the level is at L2,3 and in the adult, it is at L1,2

MR ARTEFACTS: phase encoding direction: motion, truncation (ring down artefact at high contrast interfaces which decreases the resolution of the image. Decreasing the contrast resolution of the image decreases this artefact. Also, fat suppression decreases this artefact frequency encoding direction: chemical shift artefact. FSE causes a decrease in contrast

PML VS HIV INFECTION OF THE BRAIN: PML affects the subcortical U fibers while HIV does not

CEREBELLUM: the nodulus is midline while the flocculus is not

SPHINGOLIPIDOSES: ADL: (see Lorenzo's oil) in the occiput and progresses anteriorly. The leading edge of dysmyelination is (25 of 43) [5/29/2002 10:53:02 PM]



Alexander: dysmyelination disorder affecting the anterior frontal WM. It is associated with macrocephaly (alexander the great big head)

Canavan: also have a big head. Affects the occipital lobes more commonly

Krabbe: hyperdense lesions in the thalami, caudate, and Korona Radiata. This is due to abnormal Fe retention in the globus pallidus

MELAS, MERRF: look these up

Leighs: This is not a sphingolipidosis. It is AR. There is abnormality in bilateral BG in particular putamen and lentiform nucleus. It is a grey mater lesion.

CONJOINED ROOTS: these are most commonly in the L5,S1 level


BG IN ALCOHOLIC LIVER DZ: increased manganese causes an increase in the T1 signal and a decrease in the T2 signal

CAUSES OF HYDROCEPHALUS: (26 of 43) [5/29/2002 10:53:02 PM]


overproduction, obstruction, communicating, normal pressure hydrocephalus (ventricular dilatation out of proportion to the degree of sulcal effacement)

EXTERNAL CAROTID TO INTERNAL CAROTID ARTERY COLLATERALS: vidian, artery of the foramen rotundum, facial and anterior deep temporal collaterals to the ophthalmic artery, meningolachrymal branch off the middle meningeal artery to the ophthalmic artery

EXTERNAL CAROTID TO VERTEBRAL ARTERY COLLATERALS: ascending pharyngeal neuromeningeal division to vertebral artery and muscular branches of occipital artery to distal vertebral artery

TENORIAL MENINGIOMA: must look at meningohypophyseal artery as this is most likely supplying it

CORTICOSPINAL TRACT: the fibers for this tract pass through the posterior limb of the internal capsule

ARACHNOID CYST: about 10% are infratentorial. The most common location in the posterior fossa is retrocerebellar. A suprasellar arachnoid cyst should be differentiated from an enlarged anterior 3rd ventricle. Scalloping of the bone adjacent to an arachnoid cyst is commonly seen

RATHKES CLEFT CYST: may show a thin rim of enhancement. Hemorrage may occur within the cyst. Most of them are intra and suprasellar in location (27 of 43) [5/29/2002 10:53:02 PM]


PITUITARY MICROADENOMA: enhance homogeneously with contrast. They are less than 1 cm in diameter by definition

CRANIOPHARYNGIOMA: originate form Rathke cleft pouch. most are located in the intrasellar and suprasellar location. Cystic changes and calcification are common. They can sometimes have hemorrage within them


CNS SARCOID: chronic basilar meningitis is the most common type. Basilar meningitis is also the most common CNS manifestation of coccidioidomycosis

MOST COMMON CAUSE OF MENINGITIS IN PTS WITH AIDS: cryptococcus neoformans. Infarction is a sequella of this infection


MOST COMMON CAUSE OF ENCEPHALITIS: (28 of 43) [5/29/2002 10:53:02 PM]


herpes simplex 1. It is usually a necrotizing encephalitis

FX OF PETROUS BONE: causes 7th and 8th nerve palsy

SAH: often associated with intraventricular blood. Traumatic SAH usually localizes in the interpeduncular fossa or subarachnoid space

SACCULAR ANREURYSM ASSOCIATIONS: fmd, marfans, coarct, ehlers-danlos

GIANT ANEURYSM: >25mm by definition. One half to 2/3 are found in the posterior fossa. About 20% of pts with aneurysm have multiple aneuryms

BEST WAY TO LOOK AT CAVERNOUS ANGIOMA: MRI with gradient echo technique

DURAL AVF: Cause symptoms related to intracranial venous hypertension, and may also be responsible for a thrombosed dural sinus (29 of 43) [5/29/2002 10:53:03 PM]


AVM'S: have a nidus, typically have enlarged feeding arteries, and draining veins with av shunting, and may have associated aneuryms and hemorrage

ENHANCEMENT FOLLOWING INFARCT: meningeal enhancement is seen within the first 3 days in large cortical infarcts and resolves after 1 week usually

CEREBRAL HEMORRAGE MRI APPEARANCE: in hyperacute clots, oxyhemoglobin is present and appears isointense on both T1 and T2 by 24 to 72 hours, most intracerebral hematomas contain intracellular deoxyhemoglobin which appears isointense on T1 and hypointense on T2 during the early subacute stage, deoxyhemoglobin is converted to intracellular methemaglobin which appears hyperintense on T1 and hypointense on T2 During the late subacute stage, cell lysis occurs and methemoglobin is released into the extracellular space and appears hyperintense on both T1 and T2 In the early chronic stage, there is a low signal ring on T1 and T2 due to the presence of macrophages containing ferritin nd hemosiderin

A good pnemonic to remember this is DD-BD-BB-DD

MRA: time of flight MRA relies on inflow of fully magnetized blood into the imaging plane and is encountered in flow compensated gradient echo images perpendicular to the axis of the blood vessel phase contrast MRA generates MR vascular images by detecting changes in the bloods transverse magnetization as it moves along a magnetic field gradient (30 of 43) [5/29/2002 10:53:03 PM]


MYELINATION: sensory fibers myelinate earlier than the motor fiber tracts

ADRENOLEUKODYSTROPHY: X linked, involves long chain fatty acids in the blood. Involves the posterior portion of the hemisphere, the occipital lobes and visual pathway

METACHROMIC LEUKODYSTROPHY: It is the most common inherited leukodystrophy it is AR. Have deficiency of arylsulfatase A. There is an infantile and adult form. It is associated with nonspecific wm abnormality with progressive loss of hemispheric brain tissue and symmetrc low density WM adjacent to the ventricles. There is no contrast enhancememt

LEIGHS: involves the putamen, caudate, and tegmentum which are increased in signal on T2. The pathologic changes are similar to Wernickes encephalopathy

ADEM: involves both cerebral and cerebellar wm. Long term f/u is needed to exclude MS. It is initiated by a previous viral infection. Optic neuritis can be seen which is why it is sometimes difficult to distinguish from MS. It is more common in children then in adults

PML: due to JC virus. M>F. Predilection for the occipital and parietal lobes. The spinal cord is rarely involved (31 of 43) [5/29/2002 10:53:03 PM]


DDX OF CENTRAL PONTINE MYELINOLYSIS: pontine infarct, MS, Lyme, brainstem glioma

BIG HEAD ASSOCIATIONS: canavan, alexander

MOST COMMON CAUSE OF DEMENTIA: alzheimers. The hallmark is atrophy disproportionately involving the hippocampus


TOXIC BRAIN DISORDERS: central pontine myelinolysis: electrolyte imbalance marchiafava bignami: tainted chianti causing necrosis of middle 2/3 of the corpus callosum; can also involve damage to the nearby subcortical wm and anterior commisure wernicke: thiamine deficiency with atrophy of the mamillary bodies pallidal necrosis: carbon monoxide poisoning

SOME SIGNS OF INCREASED ICP: dorsum sellae erosion and erosion of posterior clinoids

PITUITARY FOSSA DIMENSIONS: (32 of 43) [5/29/2002 10:53:03 PM]


high: not > than 13 mm ap diameter not > than 17 mm

TS AND AML: 80% of pts with TS have AML and 20% of pts with AML have TS. 75% of solitary AML occur in middle aged women

MENINGIOMA TYPES: 1: globular (this type is the most common) 2: meningioma en plaque (skull base) 3: multicentric (2-4%) location: convexity (lateral hemisphere) (20-34%) > parasagittal (medial hemisphere) (18-22%) > sphenoid ridge and middle cranial fossa (17-25%) > posterior fossa (9-15%) meningiomas exhibit the "mother in law" effect with contrast. Ie they come early and stay late

Supply is almost always ECA" vault (ie convexity): middle meningeal artery sphenoid plane and tuberculum: recurrent meningeal br of the opthalmic artery tentorium: meningeal br of meningohypophseal trunk of the ICA clivus and posterior fossa: vert and ascending pharyngeal artery falx: partly middle meningeal arteries and others

ICA supply is rare: intraventricular (choroidal vessels)

The hallmark of planum sphenoidale meningiomas is blistering adjacent to the sinus (33 of 43) [5/29/2002 10:53:03 PM]


SPINAL METS: in children, the initial site of spread is spinal canal via the neural foramen in adults, initial site is the vertebral body, typically posteriorly. Epidural space and pedicle are involved 2ary to vertebral involvement. Paraspinous ST changes are also frequently described. Distribution in the spine is according to distribution in the red marrow. Lower thoracic and lumbar spine are most frequently involved (source: Osborn)

SHEENAN: sheehan is postpartum infarction of the anterior pituitary

CALLOSAL LIPOMAS: 2 types: tubular nodular is anterior, ribbon like is posterior. Note that 30% of lipomas occur in the callosal area

ROW OR HHT: multiple cutaneous and visceral vascular abnormalities. Paradoxical embolie. Cerebral abscess. Epistaxis

KLIPPEL TRENAUNAY (KTS) angioosteohypertrophy is another name for this

MENINGIOMATOSIS: neurocutaneous angiodysplasia. Hamartomatous meningeal based lesions. Neurocutaneous melanosis. there is a 40% rate of developing primary malignant melanoma of the CNS (34 of 43) [5/29/2002 10:53:03 PM]


ETIOLOGY OF INTRACRANIAL ANEURYSMS: common: hemodynamic injury, atherosclerosis, vasculopathy, high flow state uncommon: trauma, infection, drug, neoplasm

INCREASED INCIDENCE OF INTRACRANIAL ANEURYSMS: coarctation, anomalous vessels, PCKD, FMD, CTD,s eg Marfans, high flow state

THE 4 TYPES OF INTRACRANIAL VASCULAR MALFORMATIONS: cavernous angiomas venous malformations capillary telangiectasia AVM's (parenchymal or pial, dural, pial-dural)

POSITION OF CONUS: tip of conus is at L1,2 while filum extends all the way to S1

CONCUSSIVE INJURY: most common points of injury are anterior temporal lobe, inferior frontal lobe, parasagittal hemisphere, inferior brain stem

HERNIATION: subfalcine: cingulate gyrus slips under the free margin of the falx and may result in contralateral ACA occlusion (35 of 43) [5/29/2002 10:53:03 PM]


transtentorial (uncal): ascending and descending. With descending, the parahippocampal gyrus is displaced medially over the tentorium and can result in PCA ischemia. the CPA cistern is enlarged and the suprasellar cistern is effaced. Can also get kernohans notch and Duret hemorrage

CONGENITAL ABNORMALITIES ASSOCIATED WITH DIFFERENT STAGES OF BRAIN DEVELOPMENT: dorsal and ventral induction: anencephaly, encephalocele, meningomyelocele, chiari, holoprosencephaly, cerebellar hypoplasia neuronal migration: lissencephaly, pachyhyria, schizencephaly, hemimegencephaly neuronal proliferation: congential tumors, hydrancephaly, macro and micro cephaly, vascular malformation neuronal histiogenesis: TS, NF, Sturge Weber, VHL

GLOMUS TUMORS: skull base: glomus jugulare below skull base: glomus vagale at carotid bifurcation: carotid body tumor

PILOCYSTIC ASTROCYTOMA: located most commonly in the 3rd and 4th ventrical. About half of them are in the optic chiasm or hypothalamus and one third of them are in the cerebellar vermis. They can cause obstructive hydro if in the 4th ventric or vermis

PLEIMORPHIC XANTHOASTROCYTOMA: rare, located int the inferior temporal lobe. Cystic changes are common, and there is an enhancing mural nodule (36 of 43) [5/29/2002 10:53:03 PM]


GIANT CELL ASTROCYTOMA: 10 to 15% of pts with TS. Found near the foramen of Monro. Virtually never found elsewhere in the brain. Show strong heterogeneous enhancement with mixed hypo and isodense regions

OLIGODENDROGLIOMA: most common intracranial neoplasm to calcify. They are almost exclusively tumors of adults. Pure ones are rare. Foci of cystic degeneration are common. They are predominantlu lesions of cerebral hemispheres and start in the white matter and grow towards the cortex. Theya re 85% supratentorial, with the frontal lobe being the most common location

GANGLION CELL TUMORS: they are the transition between glial and non glial cell tumors include ganglioglioma and ganglioneuroma as well as central neurocytoma. Ganglioglioma is more common than pure neural derived ganglioneuroma. Ganglioglioma is usually presenting as a cyst with mural Ca++ nodule; the most common clinical presentation is siezures. These occur most commonly in <30 yo, and most commonly supratentorially. The temporal lobe is more commonly involved then the frontal lobe

DDX OF INTRAVENTRICULAR TUMOR IN ADULT: neurocytoma, giant cell astrocytoma, ependymoma, subependymoma, oligodendroglioma, low grade pilocytic astrocytoma

WHO MENINGIOMA GRADES: 1: benign (typical) 2: atypical 3: anaplastic (malignant) (37 of 43) [5/29/2002 10:53:03 PM]


PNET TYPE TUMORS: medulloblastoma neuroblastoma pineoblastoma ependymoblastoma medulloepithelioma

BRAIN INFECTIONS: TB: base of brain herpes simplex: 2 is in neonates and is diffuse and 1 is in adults adn is in limbic sytem (temp, insular cortex, subfrontal, cingulate) HIV: frontal toxo: BG and cerebral hemispheres near the corticomedullary junction crypto: meninges, BG, midbrain is the most common location PML: multifocal areas of myelin and axonal loss involving the deep and superficial WM CMV: periventricular rim. Ca++ seen in neonatal CMV neurosyphilis: variable

an aside: primary lymphoma is periventricular. More than one lesion favors toxo. Periventricular location and subependymal spread favors lymphoma

TETHERED CORD: most common cause is is lipoma. A thickened filum is usually associated. Other causes are diastematomyelia adn myelomeningocele. The presentation is pain, neurogenic bladder, spasticity, scoliosis (38 of 43) [5/29/2002 10:53:03 PM]


SPLIT CORD: rare dorsal enteric fistula neuroenteric cyst diastematomyelia (T9 to S1) with diast, the hemicords are separate in 50% and common in 50%. Thoracic: 20%, lumbar: 50%, combined: 20%. Diast is associated with Chiari 2, tethered cord, hydromyelia, hemivert, block and butterfly verts. An osseous spur is seen in 50% of diastematomyelia. F>M

ORIGIN OF NEURAL ELEMENTS: ectoderm: skin and spinal cord mesoderm: myotomes and intervertebral discs endoderm: foregut, notocord (nuc of disc)

ENTEROGENOUS CYST: most common location is the T spine (42% ) followed by the C spine (32%). The L spine is rare to be involved

DDX OF HERNIATED NUCLEOUS PULPOSIS: conjoined nerve roots perineural cysts dilated root sleeve schwannoma or neurofibroma

ARACHNOIDITIS: (39 of 43) [5/29/2002 10:53:03 PM]


empty thecal sac sign, clumped nerve roots (causes by intradural fibrosis)

DIFFERENTIAL OF RING ENHANCING LESIONS: MAGIC DR: mets, abcess, gbm, infarct, contusion, demyelinating dz, resolving hematoma

BG CALCIFICATIONS: physiologic (aging) endocrine: hypo and hyperparathyroidism, hypothyroidism metabolic: leigh, melas (mito myopathy, encephalopathy, lactic acidosis, and stroke), merrf (ragged red fiber thing), fahr (familial cerebrovascular ferrocalcinosis) inflammation: histo, toxo, cmv toxin: meoh, CO, lead

INTRASELLAR MASS: pit adenoma, craniopharyngioma, mets, meningioma, aneurysm, rathke cleft cyst, pit hyperplasia, chordoma, pit abscess, empty sella, sarcoid

SUPRASELLAR MASS: meningioma, craniopharyngioma, optic n and optic chiasm glioma, epidermoid, dermoid, germinoma, arachnoid cyst, infundibular tumor (mets, primary), hamartoma of the tuber cinereum

SUPRASELLAR MASS WITH CALCIFICATIONS: giant carotid aneurysm, craniopharyngioma, meningioma, teratoma (40 of 43) [5/29/2002 10:53:03 PM]


PROCESSES PREDISPOSED TO CAROTID DISSECTION: ehlers danlos, marfan, trauma, chiropractic manipulations, fmd, cystic medial necrosis

COMPLICATIONS OF CAROTID DISSECTION: occlusion, embolus, aneurysm

MORE COMPLETE LIST OF INTRAVENTRICULAR NEOPLASMS: ependymoma, neurocytoma, CPP, subependymoma, subependymal giant cell astrocytoma, tubers, mets, lymphoma, meningioma, colloid cyst, epidermoid, dermoid, medulloblastoma, germ cell tumor

PRIMARY CNS LYMPHOMA: it will respond to steroids, while herpes encephalitis does not

NF AND MACROCRANIA: this is most common with NF1

BROMOCRIPTINE: pit fossa hemorrage is associated but it is not a common complication

MICROADENOMAS: they are eccentrically located in the pituitary (41 of 43) [5/29/2002 10:53:03 PM]


ENHANCEMENT AFTER CVA: you dont see meningeal or parenchmal enhancement 1 day s/p CVA. You see it after 4-7 d in non cortical infartions and after 6d in cortical infarctions

TUMORS THAT MIMIC ANEURYSMS: in the posterior fossa: extraaxial lesions that most likely mimic aneurysms are accoustic neuromas and meningiomas. intraaxial lesions that mimic an aneurysim are glioma, medulloblastoma, ependymoma, mets, and CPP

VENTRICULAR TEARDROP SIGN: associated with agenesis of the corpus callosum

WHAT IS A METACHROMIC LESION? it is a second lesion discovered subsequently and unrelated to the previous lesion

BINSWANGER DISEASE: this is subcortical WM disease (arterioschlerotic encephalopathy). The principle etiology is HTN. Dementia is the cardinal feature, and there is demyelinization or partial necrosis of the cerebral WM in an occipital and frontal distribution

PEDIATRIC BRAIN STEM GLIOMAS: common posterior fossa tumors. Mean age 10 years. 80% are anaplastic. 20% are low grade. pons>>midbrain>medulla (42 of 43) [5/29/2002 10:53:03 PM]


PILOCYTIC ASTROCYTOMA: most common location is optic chiasm. optic chiasm>cerebellum> brainstem

THE ABC OF SPINE MR (N Tishkoff): A: alignment B: bone marrow C: conus, cord D: discs E: endplates F: foramina

TYPICAL MR BRAIN PROTOCOL USED IN OUR INSTITUTION: sagital T1 flair diffusion 3D time of flight gad bolus neck axial T1 gad (43 of 43) [5/29/2002 10:53:03 PM]


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There is no index for this so if you want to find something, press the Ctrl-F keys at the same time and type in the word you want to find in the find box! If someone would like to help make an index for this, let us know



PARAPHARYNGEAL SPACE: note that the carotid space is posterior to the parapharyngeal space and therefore the carotid space is displaced posteriory by a parapharyngeal space mass (1 of 26) [5/29/2002 10:57:10 PM]


FACIAL NERVE TUMORS: most common facial nerve tumor is facial nerve schwannoma. the differential diagnosis of facial nerve schwannoma is: perineural extension of adenoid cystic carcinoma, hemangioma, glomus faciale tumor, cholesteatoma. concerning cranial nerve 8, the superior division of the vestibular nerve is the division most commonly affected by schwannoma

in the parapharyngeal space the vast majority of schwannomas arise from the vagus nerve. the third division of the trigeminal lies in the masticator space

the glomus faciale tumor can occur anywhere there is paraganglion cells. carotid region is #1 and jugular foramen is #2 in the head and neck region


the most common location for a shwannoma is the superior vestibular nerve

JUGULAR FORAMEN: the nerves contained within it can be summarized as follows: IX-Glossopharyngeal jugular foramen neck branchiomotor stylopharyngeus (2 of 26) [5/29/2002 10:57:10 PM]


pharynx, palate, carotid sinus, viscerosensory carotid body and posterior 1/3 tongue taste, special posterior sensory 1/3 tongue jugular formen-> tympanic branch-> tympanic caniculus-> middle ear jugular formen-> tympanic branch-> tympanic caniculus-> middle ear middle ear and viscerosensory auditory tube

middle ear

infratemporal fossa




jugular foramen

pharynx and larynx general auricle, external sensory auditory meatus mucosa of viscerosensory entire larynx preganglionic parasympathetic visceromotor to abdomen & thorax branchiomotor (3 of 26) [5/29/2002 10:57:10 PM]


XI-Spinal Accessory

enters by foramen magnum-> exits neck by jugular foramen


trapezius, sternocleidomastoid


the facial nerve labyrinthine segment (1) passes close to the cochlea and semicircular canals. This segment connects the IAC (not shown) with the geniculate area. The tympanic segment (2) extends along the medial wall of the middle ear. The mastoid or vertical segment (3) travels through region to the stylomastoid foramen. The stapedial muscle (arrow) marks the position of the pyramidal process. C is carotid artery. EAC is external auditory canal. GT is geniculate turn. HSC and SSC are the horizontal and superior semicircular canals. TM is the tympanic membrane

FACIAL NERVE SEGMENTS: they can be remembered by the following pnemonic CCL TMP this stands for cisternal, canalicular (7up), labyrinthine, temporal , mastoid, parotid (4 of 26) [5/29/2002 10:57:10 PM]


Here is another description of the coarse of the facial nerve just in case the above one is too cumbersome: 1: labyrinthine because of close relation to the labyrinth. It is called the first genu 2: tympanic segment; it passes just inferior to the horizontal SC canal and just superior to the oval window prior to the 2nd genu which dives and 3: becomes vertical in the mastoid segment. This second turn is called the pyramidal turn due to close proximity to the pyramidal eminence. The second turn or genu is posterior to the first turn or genu

pathway of the facial nerve(see above figure): intracranial: brainstem to porus accousticus IAC: anteriorsuperior portion Labyrinth: curls anteriorly over the cochlear and terminates at geniculate Tympanic: segment from anterior to posterior genu underneath lat SC canal Mastoid: posterior genu to stylomastoid foramen Parotid: extracranial between superficial and deep parotid lobes

CPA MASSES: schwannoma, aneurysm, arachnoid cyst, meningioma, epidermoid, ependymoma. Another way to remember it is AMEN (accoustic neurom, meningioma, epidermoid, non accoustic schwannoma)

OPENINGS TO CN5: standing room only or superior orbital fissure, rotundum, ovale

BRANCHIAL ARCHES: (5 of 26) [5/29/2002 10:57:10 PM]


branchial cleft cysts are second branchial arch anomalies (most common) and are found along the anterior margin of the sternocleidomastoid muscle in the lateral triangle of the neck third branchial arch anomalies are usually found in the posterior triangle of the neck thyroglossal duct cysts are second branchial arch remnants most commonly and are found in the anterior midline neck; they are the most common (90%) of the cystic neck masses

SOME MORE ON THE BRANCHIAL ARCHES: 1st: equal number of cysta and fistulae 2nd: cysts more common than fistulae; occur along anterior margin of the sternocleidomastoid

RANULA: simple ranula is in the sublingual space. A plunging ranula extends from the sublingual space into the submandibular space. It is a pseudocyst and so does not contain squamous epithelium

PARAGANGLION TUMORS OF THE H AND N: #1 is carotid body tumor and #2 is jugular foramen tumor


FACIAL NERVE PALSY: the most common cause of acute onset facial n palsy is Bells (6 of 26) [5/29/2002 10:57:11 PM]


WHICH WAY IS THE CAROTID DISPLACED BY A PPS TUMOR? the anwer is posterior (see above diagram of the h and n spaces)

SCUTUM scutum is called the lateral attic spur. it is at the junction of the middle and internal ear cavity

GRENADIGO SYNDROME: Gradenigo sydrome is petrous apicitis. it involves the 5th and 6th nerves

PRUSSAK SPACE: lateral part of epitympanic recess and incus. It is located between the lateral wall of the epitympanum and incus. The prussak space is considered part of the epitympanum. It is the most common place for axquired cholesteatoma. The petrous apex is the second most common place for developmental cholesteatoma

CHOLESTEATOMA: most common place for primary cholesteatoma is epitympanum and second most common place for primary is the petrous apex. It seems that the most common place for both primary and secondary cholesteatomas is the epitympanum. There are 2 types of acquired cholesteatoma. These are the pars tensa and pars flaccida varieties. The flaccid is the more common of the two

PULSATILE TINNITUS: dehiscence of the jugular bulb, aberrrant internal carotid artery, glomus tympanicum tumor, avm or avf in the region of the temporal bone. Note that cholesteatoma is not a cause of pulsatile tinnitus (7 of 26) [5/29/2002 10:57:11 PM]


GLOMUS TYPANICUM: glomus tympanicum: by definition arises in and is limited to the middle ear and like and aberrant carotid will present as a red mass behind the TM. A persistent stapedial artery is a common association with an aberrant carotid and it causes stapedial hearing loss in association with this artery. The glomus tympanicum is the most common tympanicum is the most common tympanic cavity neoplasm

CHOLESTEROL GRANULOMA: cholesterol granuloma almost exclusively occurs in the petrous apex in association with chronic inflammatory disease of the middle ear. Giant cholesterol cysts are petrous apex lesions which are uniquely hyperintense both on T1 and T2. Cholesterol cysts are lined with fibrous tissue and contain greenish brown liquid laden with cholesterol crystals

JUGULAR FORAMEN MASSES: paraganglioma, schwannoma, meningioma, hemangiopericytoma. Note that cholesteatoma is not a jugular foramen mass

TYMPANIC CAVITY MASSES: glomus tympanicum is the most common neoplasm. Both aberrant carotid artery or high jugular bulb with bony dehiscence can simulate a glomus tumor clinically. Both facial and chorda typani schwannomas may be seen

NERVES SUPPLYING THE TONGUE: nerves supplying tongue: anterior 2/3 is chorda tympani which is a division of the facial nerve and is responsible for taste in the anterior 2/3 of the tongue. The posterior 1/3 of the tongue is supplied by the glossopharyngeal nerve which as its name suggests is related to the tongue and the pharynx. The ninth cranial nerve exits the brain stem as a the most rostral of a series of nerve rootlets that protrude between the olive and inferior cerebellar peduncle. These nerve rootlets come together to form the ninth cranial nerve and leave the skull through the jugular foramen (8 of 26) [5/29/2002 10:57:11 PM]


GRENADIGO SYNDROME: Gradenigo's Syndrome is the complex of fifth and sixth nerve palsy, retroorbital pain and otorrhea seen with infection of the petrous apex. It is also known as petrous apicitis

MONDINI MALFORMATION: The triad consists of incomplete partition of the middle and apical cochlear coils, dilatation of the vestibule, and enlargement of the vestibular aqueduct. The mondini anomaly is a defect in the stapes foot plate leading to CSF leak. This predisposes to meningitis

SALIVARY GLAND TUMORS: Warthins tumor is second most common benign tumor of parotid and most common one to present bilaterally and M>F Pleomorphic adenoma are 80% (most common) of all parotid gland tumors and F>M 80% of all par gland tumors are benign. In the malignant category, mucoepidermoid is the most common. the rule of 80 for parotid tumors is as follows: 80% benign, pleomorphic, superficial lobe, parotid, stay benign if left untreated, 80% male, 80% bilateral adenoca is more common in the minor salivary glands. It is only in 2-3% in parotid gland

PAROTID TUMORS: pleiomorphic adenoma: 80% of all salivary gland tumors. Warthins is 80% male and 80% bilateral. Adenoid cystic is malignant and spreads perineurally In parotid, facial n lies laterally to the ECA laterally and retromandibular vein medially or another way of saying this is that the retromandibular vein and the ECA are medial to the facial nerve in the parotid space and the ECA is posterior and medial to the retromandibular vein. Most common benign tumors in kids is #1 hemangioma, #2 pleimorphic adenoma, and in the adult, #1 is pleomorphic adenoma > Warthin. As a general rule, most benign tumors are deep to the facial nerve

ORBITAL LYMPHOMA: (9 of 26) [5/29/2002 10:57:11 PM]


this usually occurs in the anterior portion of the orbit

INCIDENCE OF BENIGN TUMORS IN SALIVARY GLAND TUMORS BY GLAND: parotid: 80%, submandibular: 50%, sublingual: 30%, minor: 20% ie the smaller the gland, the greater the chance of malignancy

HEAD AND NECK TUMOR: cricoid in only complete cartilage ring in the airway if tumor goes beyond laryngeal ventricle, then voice sparing surgery is not possible thyroid cartilage is at level of both true and false cord anteriorly np carcinoma : more than 80% are SCC. Most begin in the fossa of rosenmuller lateral rps node is called node of rouvier. Is enlarged when lateral np recess (ie rosenmuller space fossa) is involved with tumor h and n is frequent site for extramedullary plasmacytoma 80% of these occur in the paranasal sinuses. Esthesioblastoma looks like scc. These remodel bone and do not destroy it. 2 age peaks: 10-20 and 50-60. they are unilateral nasal masses in most cases. Ca++ is uncommon. They are neural crest derived

OTITIS EXTERNA: necrotizing otitis externa: Pseudomonas almost exclusively

TEMPORAL BONE FX: longitudinal: 80% of temporal bone fx's. The facial nerve is affected in 10-20% which therefore causes facial paralysis in up to 20%. The 8th nerve typically remains intact. The ossicular chain is disrupted resulting in conductive hearing loss.

transverse fx: 20% incidence. There is a higher incidence of CN8 and CN7 (40-50%) injuries leading to sensorineural hearing loss (10 of 26) [5/29/2002 10:57:11 PM]


MR OF NASAL POLYP: in nasal polyp, get t1 shortening due to dehydration effect. They enhance at their periphery

EYE LESIONS: Retinoblastoma is most common cause of intraoccula ca++ in children. Coats disease of the eye is due to telangiectasia of retina which causes exudation resulting in retinal detachment. It is not associated with ca++ and is usually unilateral Phpv presents with a dense globe on CT. Rare ca++. Drusen clinically look like papilledema. There is well defined ca++ below the optic disk. It is usually bilateral. Coloboma is due to a failure of closure of an embryonic fissure. Get small globe with cyst coming out of ON and incomplete disk Rop (retinopathy of prematurity) presents with bilat small globes. It is due to oxygen toxicity. Ca++ is rare but can be seen late. Ddx of leukocoria in a child: Retinoblastoma>phpv>rop>toxocara

BILATERAL EXOPHTHALMOS: this is more common in bilateral exophthalmos in the adult. The most common cause of unilateral exophtalmos is orbital pseudotumor

CEREBELLAR ATROPHY: it is associated with the use of dilantin (11 of 26) [5/29/2002 10:57:11 PM]


DISSECTION: tends to involve the extracranial great vessels

SPINAL ACCESSORY NERVE: it goes through the jgular foramen

OPTIC CANAL: contains ON and optic artery

FIBROUS DYSPLASIA: Facial bone involvement with fd: Monostotic 20% and polyostotic 70% Sphenoid>frontal>maxillary>ethmoid


TMJ DISC DISLOCATION: (12 of 26) [5/29/2002 10:57:11 PM]


Normally the disc follows the condyl with mouth opening and moves forward with opening. Disc dislocation is usually anterior with associated perforation of the posterior disc attachment. The condyl impinges directly on the posterior disc neurovascular bundle causing pain on opening the mouth. In anterior dislocation, the posterior band (which is thicker) gets deformed. 70% of pts with meniscal problems have subluxation or dislocation. So in summary; subluxed tmj disk: looks normal with open mouth and remains anteriorly displaced with closed mouth. Dislocated: more anteriorly displaced with open mouth. Does not look normal. With closed mouth, the disk remains anteriorly displaced.

PLASMACYTOMA: The s of poems refers to skin changes

ONDONTOGENIC CYSTS: perodontal or radicular cyst is the most common type of odontogenic cyst while dentigerous is the second most common type. The dentigerous type usually developes around the crown of an unerupted tooth. the ratio is 25% maxilla and 75% mandible. a ranula originates in the sublingual glands. when a ranula ruptures, it is called a plunging ranula. the plunging variety rarely may extend into the masticator space. ranulas are located medial to the mylohyoid muscle typically.

NODAL STATIONS OF THE NECK: Neck node stations: 1 submental and submandibular 2,3,4 is internal jugular chain. 2 is the jugulodigastric ie above the bifurcation or hyoid 3 is below hyoid but above cricoid and 4 is below the cricoid 5 is spinal accessory (posterior triangle) 6 is related to the thyroid while 7 is in the tracheoesophageal groove

in some more detail: 1: submental, submandibular 2: IJ chain above hyoid bone, also includes the jugulodigastric node sitting along the posterior belly of (13 of 26) [5/29/2002 10:57:11 PM]


the digastric muscle at the upper pharyngeal level 3: jugular chain area between hyoid and cricoid cartilage 4: jugular chain below cricoid cartilage 5: LN of posterior triangle (deep and posterior to sternocleidomastoid and clavicle: also called the spinal accessory 6: LN in the anterior jugular chain and visceral chain in front of the hyoid and related to the thyroid 7: LN in tracheoesophageal groove extending to the superior mediastinum

SPACES OF THE HEAD AND NECK: parotid space: retromandibular vein (marker for the facial nerve), external carotid artery, facial nerve (divides the parotid into superficial and deep lobes), intraparotid nodes, and the parotid gland submandibular gland: submandibular space sublingual space: whartons duct (duct from submandibular gland). Note that the parotid duct is Stenson's duct masticator space: ramus and posterior body of the mandible, the muscles of mastication and the mandibular division (V3) of the trigeminal nerve as it exits the foramen ovale carotid space: the internal jugular vein, common and internal carotid arteries, nodes, sympathetic chain, cranial nerves IX, XI, XII superiorly, and cranial nerve X (the vagus)

TENSOR TYMPANI VS STAPEDIUS: stapedius nerve: is a branch of the facial nerve (to remember think of stap which rhymes with slap for slap on the face!) tensor tympani: when you are tense in the exam trying to remember this you will be gnawing on your pencil which requires the use of CN5

STAGING OF HEAD AND NECK TUMORS: The disease stage in the absence of nodal or distant metastasis is identical to the T stage. A single, small (<3 cm) metastatic node (N1) upgrades the patient to disease stage 3. Distant metastasis (M1) or anything more than (N1) upgrades the disease to stage 4. (14 of 26) [5/29/2002 10:57:11 PM]


BRANCHIAL CLEFT CYSTS: 2nd arch is the most common. They are anterior to the sternocleidomastoid, lateral to the thyroid. The ddx is tumor, necrotic nodes, lymphangioma

CYSTIC HYGROMA: most common in the posterior neck 75%. 20% in the axilla and 14% are in the chest wall. The microcystic variety is the most common. Also there is macrocystic. These lesions grow with the child. In terms of associations: turner (40%), noonans, roberts-curry, fas, chromosome 13, 18

CYSTIC LN METS IN NECK: for thyroid think papillary ca

THYROID CANCER: the most common is papillary thyroid carcinoma. the most common thyroid nodule is an adenoma. most are isoechoic. papillary thyroid ca has cystic cervical LN mets

HYPERPARATHYROIDISM: most common cause is adenoma, most commonly in the inferior gland . The inferior gland is derived from the 3rd branchial pouch and is the most likely to have an ectopic location which is most likely located in the mediastinum. The superior glands are derived from the 4th pouch. Most common location of ectopic superior parathyroid is in the retrotracheal area. 13% of the population who have hyperparathyroidism have a supernumary gland.

DEFINITION OF OMU: (15 of 26) [5/29/2002 10:57:11 PM]


The superior meatus is not associated with the OMU. The OMU involves drainage of the anterior and middle ethmoid air cells, frontal sinus, and maxillary sinus. The superior meatus is involved in drainage of the posterior ethmoid air cells which are not a part of the OMU

INFERIOR MEATUS: this drains the nasolachrymal duct. It has only one ostium

MIDDLE MEATUS: has an anteriorly located nasofrontal recess into which frontal sinus drains. The frontal can also drain into the anteriorly located nasofrontal recess via the anterior ethmoid cell.

OTOSCLEROSIS: 65% F>M and 80% bilateral. It occurs most commonly in the 2nd to 3rd decade. It is caused by replacement of the otic capsule by spongy bone. There are 2 types: #1 is stapedial (80%): progressive conductive hearing loss. There is early tinnitus and stapes fixation on the oval window. #2 is cochlear (20%) which causes progressive sensorineural hearing loss. The early stage of the stapedial type is demineralization

ORBITAL PSEUDOTUMOR: rapid onset of syptoms; multicompartmental involvement as follows: retrobulbar fat in 75% of cases, extraocular muscles in 57%, optic nerve in 38%, and uvea-sclera in 33%. Most cases respond to steroids. The superior rectus>medial rectus (see pnemonic for graves ophthalmopathy IM SLO). This might help to remember it ie S>M

GRAVES: IM SLO (16 of 26) [5/29/2002 10:57:11 PM]


TOLOSA HUNT: tolosa hunt has similar symptoms to orbital pseudotumor but involves the structures of the orbital apex, superior fissure, and cavernous sinus (see diagram with structures of cavernous sinus). The structures within the cavernous sinus are 3, 4, 5 (1), and 6

SUPERIOR ORBITAL FISSURE CONTENTS: 3,4,5(1), 6, superior ophthalmic vein, sympathetic fibers, orbital branch of middle meningeal artery. Note that 5(2) goes through the inferior orbital fissure

DACROCYSTITIS: inflammation of the sac which is medial

DACROADENITIS: inflammation of the lacrymal gland which is lateral

CAROTID SPACE CONTENTS: sheath contains CN 9, 10, 11, and 12

STRUCTURES IN THE LATERAL NECK REGION: Note that the ICA lies posterolaterally to the ECA as in the figure below: (17 of 26) [5/29/2002 10:57:11 PM]


BRANCHES OF THE ECA: the branches of the ECA in order of their occurrence are as follows: ASLEOPS ie: ascending pharyngeal, superior thyroidal, lingual, external maxillary (=facial), occipital, posterior auricular, superficial temporal (18 of 26) [5/29/2002 10:57:11 PM]


PTERYGOPALATINE FOSSA: tumors in the pterygopalatine fossa can invade: infratemporal fossa via the pterygomaxillary fissure oral cavity via the pterygopalatine canal orbit via the inferior orbital fissure middle cranial fossa via the foramen rotundum or vidian canal superior meatus via the spenopalatine canal

MOST COMMON EXTRAMEDULLARY SITE OF PLASMACYTOMA: nasopharynx or sinuses. Nasopharynx> sinuses

LOCATION OF THE CN5 BRANCHES: V1: travels through the cavernous sinus to the superior orbital fissure V2: through the cavernous sinus into the foramen rotundum V3: innervates the muscles of mastication (it passes through masticator space) and provides sensation to the lower jaw and face

CLASSIC LOCATION FOR JUVENILE ANGIOFIBROMA: pterygoid plate is the classic location. It originates near the spenopalatine foramen near the medial pterygoid plate. 5-15% have intracranial extension

INVERTED PAPILLOMA: 3 types: inverted, fungiform, cylindrical. 10% of inverted papillomas cause bony destruction via pressure erosion. In 10-20% of inverted papillomas, there is concomitant SCC (19 of 26) [5/29/2002 10:57:11 PM]


METS TO GLOBE: most common are breast and lung; involves the uveal layer and associated with subretinal fluid


TRACHEAL MALIGNANCIES: pnemonic is SAM ie in order of which is more common: squamous>adenoid cystic>mucoepidermoid. However, mucoepidermoid carcinoma is the most common salivary gland malignancy in children

DDX OF BENIGN TRACHEAL NEOPLASMS: q Cartilaginous tumors q Hamartoma q Benign mesenchymal tumors such as fibroma q If multiple: Juvenile laryngeal papillomatosis (having spread to the trachea and perhaps beyond).

SOLID ENHANCING H AND N MASS: esthesioblastoma, SCC, melanoma, extramedullary plasmacytoma. Esthesioblastoma remodels bone as opposed to destroying it. It can look like SCC. As already mentioned, esthesio has a bimodal age distribution 10 to 20 and 50 to 60 years old

MUCOCELE: (20 of 26) [5/29/2002 10:57:11 PM]


these can be associated with polyps that block the sinus ostea. The combination of mucocele and polyps occurs almost exclusively in atopic patients

EXTRAMEDULLARY PLASMACYTOMA IN THE H AND N: the following is a good rule: nasal cavity (80%), sinuses (3%). 35% of these pts will eventually get multiple myeloma

FIBROUS DYSPLASIA: results from failure of normal osteoblast differentiation and meturation. Monostotic 20% with 25% facial involvement. 70% are polyostotic with skull > face > pelvis and in the facial bones, the sphenoid > frontal > maxillary > ethmoid

RETINOBLASTOMA: There are 4 forms of this. 1: spontaneous. 2: AD. 3: deletion of chromosome 13 and 4 trilateral. All patients with bilateral retinoblastoma harbor the retinoblastoma gene. Note that Ca++ in an eye with micropthalmos is unlikely to be retinoblasoma as retinoblastoma is always seen in fully developed eyes. Ca++ in an eye < 3y old is #1 retinoblastoma, #2 colobomatous cyst. The ddx of leulokoria in a child is: #1 retinoblastoma (50%), #2 PHPV, #3 ROP, #4 toxocara

PARAPHARYNGEAL SPACE SHWANNOMA: these displace the internal carotid. A carotid body tumor splays the bifurcation while glomus vagale pushes the ICA anteriory (see figure): (21 of 26) [5/29/2002 10:57:11 PM]



DENTAL RELATED TUMORS: Dentigerous cyst of the mandible is more common than that in the maxilla. Ameloblastoma comes from remnants of dental enamel

SINUSITIS AND HEADACHE: only 3% of sinusitis causes headache so it is not going to be the most likely cause

NASOPHARYNGEAL CA: SCC: 80-90%. This is found in the antrum in 80% and men > 40y in > 95%

LOCATION OF THE SUBGLOTTIS FOR TUMOR RESECTABILITY ETC: may sound simple but not so easy when someone asks you in front of a bunch of experts! The subglottis is below the plane of the ventricle. The glottis refers to the true vocal cord. False cord is part of supraglottic region. If a tumor extends to or past the ventricle, then voice sparing surgery is not possible. If cancer involves the cricoid, need to do a total laryngectomy. However, if it involves the thyroid cartilage, then can do voice sparing surgery (22 of 26) [5/29/2002 10:57:11 PM]


RANULA DDX:: ranula most commonly originate from the sublingual glands. The ddx for ranula is lipoma, dermoid, epidermoid, . The ddx for plunging renula is epidermoid, dermoid, malignant LAN. The mylohyoid divides the mouth floor into sublingual and submandibular spaces

HALLER CELLS: these are air cells along medial wall of the orbit

ONODI CELLS: these are more posterior

AGER CELLS: ethmoid cells frequently pneumatize adjacent bone and form ager cells

CONCHA BULLOSA: along with haller cells etc, these can lead to obtruction of the OMC, septal deformity etc

RETENTION CYSTS VS MUCOCELE: retention cysts do not cause bony expansion while mucocele does

SALIVARY GLAND CA++ the most common is in the submandibular gland (80%) (23 of 26) [5/29/2002 10:57:11 PM]


MALIGNANT SALIVARY GLAND TUMORS: squamous cell ca is the most common: max (80%)>ethmoid (15%) less common ones are adenoid cystic ca and esthesioblastoma (comes from olfactory epithelial cells). Esthesio commonly extends through the cribiform plate into the brain. others are mesencymal eg fibrosarcoma, rhabdomyosarcoma, osteo and chondrosarcoma finally, mets

SALIVARY GLAND DUCTS: whartons (submandibular) stensons (parotid) bartholins (sublingual)

CYSTIC SALIVARY LESIONS: mucus retention cysts (true epithelial lining), ranula from sublingual glands in the floor of the mouth), mucocele (extravasation from duct rupture)

PAROTID TUMORS: benign: pleiomorphic adenoma (most common 70%), Warthins tumor, oncocytoma malignant: mucoepidermoid ca, ca arising from pleiomorphic adenoma, adenoid cystic ca, SCC, oncocytic carcinoma Ca++ are most commonly due to parathyroid adenoma and primary hpt. They are also from 2 hpt due to renal failure (24 of 26) [5/29/2002 10:57:11 PM]


MUCOCELE FREQUENCY: FEMS or frontal>ethmoid>maxillary>sphenoid


CAUSES OF SKULL THICKENING: pagets, FD, phenytoin, idiopathic, thalassemia, acromegaly, small brain, shunted hydrocephalus

LATERAL NECK MASS WITH EXTENSION INTO THE SUBLINGUAL SPACE: post inflammatory retention cyst. the ddx is cystic hygroma, epidermoid (see above)

MOST COMMON CAUSE OF INFLAMM DZ TO AFFECT THE CAROTID SPACE: thrombophlebitis of the jug vein. Others are pharyngitis and lymphadenitis

CAUSES OF OPTIC NERVE ENHANCEMENT: ms, syphilis, lyme, sarcoid, tb, glioma, mets, lymphoma, asculitis, ischemia, meningioma

CYSTIC LESION IN THE TONGUE: ranula (perforating vs non perforating), lymphangioma, dermoid, absexx, thyroglossal duct cyst (25 of 26) [5/29/2002 10:57:11 PM]


CYSTIC LESIONS IN THE TONGUE: first branchial cleft cyst, dermoid, epidermoid, sialocele, mucus retention cyst, cystic neoplasm, inclusion cysts, cystic hygromas (26 of 26) [5/29/2002 10:57:11 PM]


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Tc99mMAA: need to use a ratio of 10:1 for Tc based agents. Need to decrease the number of particles for the perfusion part of the imaging in pulm htn, pediatric patients, pregnancy, but not in prior PE

ERYTHROMYCIN: this compound increases the rate of gastric emptying

201Tl: this is an excellent tumor marker in addition to a myocardial perfusion agent. However, it does not label infectious and inflammatory processes

NUCS IN SPINAL INFECTIONS: 67Ga is good for intervertebral disc infection 111In WBC is good for spinal infection s/p instrumentation (1 of 7) [5/29/2002 10:57:17 PM]


RENAL IMAGING AGENTS: IOIP: 20% filtered. tubular is 80%. this is best for erpf DTPA: almost all is filtered. Best for GFR GH, DMSA: best for renal parenchyma; GH shows collecting system on early images. with GH, 15% is retained in the kidney and with DMSA, 42% is retained in the kidney. MAG3 has no significant filtration, ie almost all is by tubular secretion

TcDMSA gives the highest radiation dose to the kidney

67GA IN ANTIBIOTIC TREATED INFECTION: it is useful for following antibiotic treated osteomyelitis as Indium WBC give a false negative result in this situation

SOURCES FOR EXTRINSIC CAMERA FLOOD: 57Co sheet source flush with the camera or 99Tc point source 3 m away form the camera

PIOPED CRITERIA: high: 80% from 2 or more large segmental defects without CXR abnormalities low: <20% non segmental perfusion defects intemediate: one large, 2 moderate, 3 moderate, 1 large 1 moderate or triple match

MORE PIOPED CRITERIA: PIOPED: high probability is 2 or more large vq mismatches. A small perfusion defect comprises <25% of a lung segment and large defect comprises > 75% of a lung segment (2 of 7) [5/29/2002 10:57:17 PM]


GUIDELINES FOR 131I TOTAL BODY IMAGING: need to be off T4 for 6-8w and off T3 for 3w. Need to be off PTU for 2 w. No H2O soluble contrast for 4-8w

IN NUCS: stripe sign rules out PE, can be seen in COPD

NUCS AGENT FOR CARCINOID: Indium 111-octreaotide is preferred for carcinoids

MORPHINE AND PANCREATITIS: morphine administration can worsen pancreatitis

MORE ON RENAL IMAGING AGENTS IN NUCS: both dmsa and GH bind to tubules and GH is only 15% bound so both of these are cortical agents. DTPA is excreted almost all by GF. MAG3 and OIH are handled by tubular secretion and glomerular filtration in different proportions and can be used for plasma flow rate determination

GA67 UPTAKE IN THE LUNGS: lung uptake in IPF, PCP, mycobacteria infection, and bleomycin. In the UMDNJ notes 2000, it says that adriamycin does not cause increased gallium 67 uptake by the lungs

18F FDG UPTAKE IN ICTUS: (3 of 7) [5/29/2002 10:57:17 PM]


decreased interically and increased intrainctally

18F FDG UPTAKE IN ALZHEIMERS: bilateral parietal and posterior temporal decreased perfusion and decreased FDG utilization in these areas. There is sparing of the sensory, motor cortex, BG and thalami


18F FDG IN HUNTINGTONS: decreased metabolism and uptake in the BG

18F FDG IN SCHIZOPHRENIA: decreased metabolism in the frontal lobes

WARTHINS: shows increased uptake of 99mTcO4. Note that the superficial parotid lobe is bigger than the deep lobe

DOSIMETRY: Ga: bowel, DISIDA: bowel, 99m Tc pertechnetate: stomach, oral 99mTc SC: gut, IV 99mTc SC: liver and spleen, 99mTc disofenin: liver, damaged 99mTc RBC: spleen, 111 In WBC: spleen, 201Thallium: kidney, 99mTc sestamibi: bowel, 111In-octreatide: kidney, 123I IMP: lung, 99mTcRBC: heart wall, 99mTcHMPAO: lachrymal glands with 99mTc SC, smaller particles tend to localize in the bone marrow, while larger ones tend to localize (4 of 7) [5/29/2002 10:57:17 PM]


in the liver. Heat damaged 99mTcRBC specifically label spleen with minimal liver uptake

HARDWARE LOOSENING: scintigraphic finding of loosening of femoral component is focal skeletal phase uptake at the tip of the hardware. Scintigraphic finding of infected femoral component is intense flow and uptake around the prosthesis stem

CROSSED CEREBELLAR DIASCHISIS: in nucs, this is increase in the cerebellar uptake contralateral to a cerebral infarct. This is due to loss of suppressive neural activity from the contralateral infarcted cortex

201TL UPTAKE IN MALIG BRAIN TUMORS: it is proportional to the malignant grade of the tumors

SVC VS BUDD CHIARI: TcSC scanning shows hot quadrate with SVC obstruction and hot caudate with Budd Chiari

QUALITY CONTROL IN NUCS: mnemonic: CLAG C: constancy qd L: linearity qw A: accuracy qy G: geometric efficiency q repair (5 of 7) [5/29/2002 10:57:17 PM]


SCANNING IN AIDS: KS: gal - and thallium + lymphoma: gal + and thallium + infection: gal + and thal -

JUST TO RECAP: GH: 20% cort, 80% glom DTPA: 100% glom DMSA: 50% cortical IOH: 80% PCT, 20% glom MAG3: 95% PCT, < 5% glom

PARATHYROID ADENOMA: the combo of 99mTc and 201Tl with subtraction is useful for identifying parathyroid adenoma


111In: 67h 201Tl: 73h 67Ga: 78h

ARTEFACTS IN CARDIAC IMAGING: (6 of 7) [5/29/2002 10:57:17 PM]


breast attenuation: fixed lateral heart border diaphragm: inferior and posterolateral apex (thin): may mimic an infarct LBBB: reversible septal defect

CARDIAC NUCS: inferior wall: L lateral LA: LAO RV: shallow LAO

VENTILATION SCANNING: with 99mTcDTAA, particle size > 0.5 micometer behaves more like a gas so it is desirable for ventilation (7 of 7) [5/29/2002 10:57:17 PM]


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SOME THINGS THAT KEEP GETTING ASKED: The Right Bronchus, wider, shorter, and more vertical in direction than the left, is about 2.5 cm. long, and enters the right lung nearly opposite the fifth thoracic vertebra. The azygos vein arches over it from behind; and the right pulmonary artery lies at first below and then in front of it. About 2 cm. from its commencement it gives off a branch to the upper lobe of the right lung. This is termed the eparterial branch of the bronchus, because it arises above the right pulmonary artery. The bronchus now passes below the artery, and is known as the hyparterial branch; it divides into two branches for the middle and lower lobes. (Grays)

The Left Bronchus is smaller in caliber but longer than the right, being nearly 5 cm. long. It enters the root of the left lung opposite the sixth thoracic vertebra. It passes beneath the aortic arch, crosses in front of the esophagus, the thoracic duct, and the descending aorta, and has the left pulmonary artery lying at first above, and then in front of it. The left bronchus has no eparterial branch, and therefore it has been supposed by some that there is no upper lobe to the left lung, but that the so-called upper lobe corresponds to the middle lobe of the right lung. (Grays)

SOME SHUNTS: some of these keep getting asked on the exam: pulmonary varix (this is an abnormally dilated and tortuous pulm vein and does not produce a shunt): no shunt pulmonary avm (R to L) so this causes peripheral oxygen desaturaton intralobar sequestration (L to L) so no shunt (1 of 50) [5/29/2002 10:57:54 PM]


extralobar sequestration (L to R): no peripheral oxygen desaturation scimitar syndrome (hypoplastic pulmonary artery so lung is supplied by systemic artery and drained by anomalous pulmonary veins to the IVC which makes this a L to R (Weissleder says that the hyplastic lung is perfused from the aorta and drained by the IVC or portal vein. The vein has morphology similar to a sword). It is associated with bony abnormalities such as hemivertebrae, rib notching, rib hypoplasia, as well as CHD, and accessory diaphagm or diaphragmatic hernia as well as dextrapostion of the heart due to the small lung


LUNG FUNCTION: TVor tidal volume is amount of gas moving in and out of lungs without effort with each breathing cycle RV is amoount of gas remaining in the lung after a maximum expiration TLC or total lung capacity is gas contained in the lung at the end of a maximum inspiration VC or vital capacity is the amount of gas that can be expired after a maximum inspiration without force FRC is the amount of gas remaining in the lungs after the end of a quiet expiration (2 of 50) [5/29/2002 10:57:54 PM]


MUELLER MANEUVER: deep inspiration by the patient in the supine position is the best way to maximally distend to azygous vein

SIGNS OF PTX ON SUPINE CHEST FILM: deep sulcus sign, rounded epicardial fat pad, increased lucency at the lung base

TRACHEAL DISEASE: saber sheath, tracheopathia osteochondroplastica (distal 2/3 and proximal bronchi), relapsing polychondritis, tracheobroncomalacia, tracheobronchomegaly

BRONCHIAL ANATOMY: PA accompanies bronchi, PV runs independently of PA and bronchi, bronchial arteries accompany (3 of 50) [5/29/2002 10:57:54 PM]


bronchi, lymphatics accompany PV and do not run along side the bronchi (Grays Anatomy) Schematic longitudinal section of a primary lobule of the lung (anatomical unit); r. b., respiratory bronchiole; al. d., alveolar duct; at., atria; a. s., alveolar sac; a, alveolus or air cell; p. a.: pulmonary artery: p. v., pulmonary vein; l., lymphatic; l. n., lymph node. (Miller.)

SOME SIGNS IN THORACIC RADIOLOGY: air bronchogram - indicates a parenchymal process, including non-obstructive atelectasis, as distinguished from pleural or mediastinal process air crescent sign indicates a lung cavity, often due to fungal infection deep sulcus sign on a supine radiograph - indicates pneumothorax continuous diaphragm sign - indicates pneumomediastinum ring around the artery sign (around pulmonary artery on lateral chest radiograph) - indicates (4 of 50) [5/29/2002 10:57:54 PM]


pneumomediastinum fallen lung sign - indicates a fractured bronchus flat waist sign- indicates left lower lobe collapse gloved finger sign - indicates bronchial impaction, which can be seen in allergic bronchopulmonary aspergillosis Golden S sign - indicates lobar collapse with a central mass, suggesting an obstructing bronchogenic carcinoma in an adult luftsichel sign - indicates upper lobe collapse, potentially due to an obstructing bronchogenic carcinoma in an adult Hamptons hump - indicates a pulmonary infarct silhouette sign - loss of the contour of the heart or diaphragm used to localize a parenchymal process (e.g. a process involving the medial segment of the right middle lobe obscures the right heart border; a lingula process obscures the left heart border; a basilar segmental lower lobe process obscures the diaphragm) cervicothoracic sign a mediastinal opacity that projects above the clavicles is retrotracheal and posteriorly situated while an opacity effaced along its superior aspect and projecting at or below the clavicles is situated anteriorly tapered margins sign - a lesion in the chest wall, mediastinum or pleura will have smooth tapered borders and obtuse angles with the chest wall or mediastinum while parenchymal lesions usually form acute angles figure 3 sign abnormal contour of the descending aorta, indicating coarctation of the aorta fat pad sign or sandwich sign indicates pericardial effusion on lateral chest radiograph scimitar sign an abnormal pulmonary vein in venolobar syndrome double density sign contour projecting over the right side of the heart, indicating enlargement of the left atrium hilum overlay sign and hilum convergence sign used to distinguish a hilar mass from a non-hilar mass many more signs in chest radiology can be obtained from:

SEGMENTAL LUNG ANATOMY: rul: apical: B1 anterior: B2 (5 of 50) [5/29/2002 10:57:54 PM]


posterior: 3 ML: lateral: 4 medial: 5 LL: sup: 6 med: 7 ant: 8 lat: 9 post: 10

LUL: apicoposterior: B1,3 ant: 2 ling: sup: 4 inf: 5 LL: sup: 6 med: 7 ant: 8 lat: 9 post:10

ASBESTOSIS: Pleural plaques in asbestosis: posterolateral and diaphragmatic Benign mesothelioma: not associated with asbestos exposure, also, involves visceral pleura in 80%. Hypoglycemia associated

MOST COMMON PRESENTATION OF BAL: (6 of 50) [5/29/2002 10:57:54 PM]


BAL ca presents most commonly as a solitary pulm nodule. According to Dr. Westcott, a high % of persisitent solitary or focal ground glass density seen on high res CT turns out to be BAL carcinoma on subsequent bx. If there is a cystic component in the ground glass, then it is more likely to be adenoca. Multifocal ground glass is most likely inflammatory in nature

DEFINITION OF FRIEDLANDER PNEUMONIA The PA chest x-ray reveals a homogeneous opacity extending from the right heart border to the lateral chest wall. This opacity obscures the right atrial border placing it in the right middle lobe. This is known as the "silhouette" sign as described in Dr. Felson's textbook and it allows the process to be localized accurately from the PA chest x-ray alone. There is right middle lobe infiltrate producing convex bulging of the minor and major fissures. This is characteristic of Friedlander's pneumonia and can be seen with any acute exudative pulmonary infection. The organism classically associated with Friedlander's pneumonia is Klebsiella pneumoniae. Other organisms causing bulging of fissures include Streptococcus pneumoniae and Mycobacterium tuberculosis. This sign may also be seen with lung abcesses and bronchogenic carcinoma. The bulging fissure sign is known as the Fleishner sign like the Fleishner ring around the eye in Wilsons disease

INFECTIONS IN HEART TRANSPLANT PATIENTS: most common viral agent: CMV which usually appears in the 2 nd month after transplant



PLASMA ONCOTIC PRESSURE: 25mm Hg (7 of 50) [5/29/2002 10:57:54 PM]


VOLUME OF FLUID IN PLEURAL SPACE: 1-5 cc but may be up to 15 to 20 cc and still be normal

ACINUS: describes all structures distal to one terminal bronchiole. Acinus measures about 7mm and contains about 400 alveoli. So the acinus is the best term for the terminal bronchial subunit

SECONDARY PULMONARY LOBULE: polygonal structure which is 1.5 to 2 cm in diameter and contains about 3 to 5 acini per lobule and supplied by several terminal bronchioles

CARNEY TRIAD: carney triad=pulmonary chondroma, gastic leiomyosarcoma, and extraadrenal paraganglioma

CARNEY SYDROME: complex myoma, pituitary tumor, breast tumors, L atrial myxoma, pit adenoma, pigmented skin lesions

LUNG INVOLVEMENT WITH SCLERODERMA: schleroderma causes basal interstitial fibrosis

PULMONARY SARCOID (8 of 50) [5/29/2002 10:57:54 PM]


Staging of pulmonary sarcoidosis is based on the appearance demonstrated on chest x-ray. Stage 0 is a normal chest x-ray; stage I has nodal (especially hilar) enlargement only; stage II has nodal enlargement and parenchymal infiltrates; stage III demonstrates parenchymal shadowing only; and stage IV represents end-stage fibrosis. Isolated posterior adenopathy is rare in sarcoidosis. Sarcoidosis and tuberculosis are both common predisposing conditions for mycetoma formation. Laboratory findings associated with sarcoidosis include blood eosinophilia (up to 25%), hypercalcemia (10% to 20%), hypercalciuria, and elevated angiotensin-converting enzyme levels (50% to 60% of patients). Pleural effusion is a relatively rare finding in sarcoidosis.

MALIGNANT VS BENIGN LUNG TUMOR: best is difference in enhancement with and without contrast of 20 HU. this number gives the highest sensitivity and specificity

LUNG LESIONS: Sequestration: intralobar 60% L base and extralobar 80% L base or below diaphragm. Both are in the posteriomedial segments of the lower lobes CCAM: all lobes equally. Malignant degeneration is a potential complication CLE: LUL 40%, RML 35% and RUL 20% Bronchogenic cyst: mediastinum 85% (posterior>middle>anterior) and lung 15%. They like the medial third of the lung Scimitar syndrome: R>L Swyer James: whole lung, no preferences. Sometimes lobar or segmental

SCIMITAR SYNDROME: also called hypogenetic lung syndrome it is a special form of hypoplastic lung in which the lung is perfused from the aorta and drained by the portal vein or IVC. The anomalous vein has the morphology of a scimitar or sword. It is associated with an accessory diaphragm or diaphragmatic hernia. Bony abnormalities include rib notching, hemivertebrae, rib hypoplasia, CHD, ASD, VSD, PDA, TOF. The lung is usually small. R>L for incidence. There can be dextoposition (shift) of the heart because of the hypoplastic lung (9 of 50) [5/29/2002 10:57:54 PM]


DRUG TOXICITY ON LUNGS: drug tox affects lung bases most commonly

PCP LUNG: in pcp can have a normal cxr in 10%. Pneumatoceles in 10%

DDX OF UPPER LOBE INTERSTITIAL DISEASE (CASSET): Cystic fibrosis Ankylosing spondylitis Silicosis / Berryliosis Sarcoidosis Eosinophilic granuloma Tuberculosis, Fungus

DDX OF BASILAR DISEASE (BAD LASS RIF): bronchiectases aspiration dermatomyositis lymphangitic spread asbestosis sarcoidosis schleroderma rheumatoid (10 of 50) [5/29/2002 10:57:54 PM]


ipf furantin

SOME MORE THINGS WITH A UL PREDOMINANCE: AS, post 1ary TB, bronchocentric granulomatosis, CF, bronchial atresia

DIFFERENTIAL OF UNILATERAL HYPERLUCENT LUNG: faulty technique (patient rotation) chest wall defect (mastectomy, absent pec muscle) large airway obstruction (eg hilar mass compressing LLL bronchus, endobronchial obstruction with air trapping such as from foreign body, bronchogenic ca, carcinoid, bronchial mucocele) small airway obstruction (bronchiolitis obliterans, swyer james, emphsema particularly the bullous type, ptx) pulmonary vascular cause (pulm artery hypoplasia, pulm embolism, CLE, compensatory overinflation)

CONGEN ABSENCE OF THE PERICARDIUM: PA view looks like the rao view

PERICARDITIS: 50% of pts with Ca++ have constrictive pericarditis and 90% of pts with constrictive pericarditis have Ca++

ASSOCIATION OF PCP WITH CA++ extrapulmonary PCP infection is associated with Ca++ (11 of 50) [5/29/2002 10:57:54 PM]


most common location of Ca++ is in the LN's

LYMPHOID GRANULOMATOSIS: this is frequently a premalignant condition

PSEUDOLYMPHOMA VS LIP: they both share the same histologic features. In fact, pseudolymphoma is just another name for LIP and represents the localized form of LIP. However, LIP is diffuse, while pseudolymphoma tends to be a solitary mass. In pts with LIP, if LAN develops, lymphomatous change should be suspected

PANCOAST TUMOR IMAGING: coronal MR is mandatory. Note that the superior sulcus is the groove in the apex of the lung formed by the subclavian vessels

LARGE AND SMALL CELL LUNG CA: massive hilar lan is a well recognized feature of both

SQUAMOUS CELL CA: consolidation, and collapse is most commonly seen with SCC as they are frequently central lesions. Cavitation is seen in 6% of adenoca's and 12% of SCC's

BRONCHIAL CARCINOIDS: more likely to produce Cushings syndrome than non bronchial carcinoids (12 of 50) [5/29/2002 10:57:54 PM]


AN APPROACH TO ILD (temple U: this is one area that I really have a lot of trouble with: Establishing the diagnosis q Exact criteria vary from disease to disease q All Patients require good history and PE q Chest x-ray r Occasionally chest x-ray alone or in combination with other findings strongly suggests or is diagnostic of a given disorder. More often the chest x-ray is not diagnostic r When lesions are not diffuse, their location can can be of diagnostic utility s Lower Lobe Predominant s Collagen vascular: PSS, RA, MCTD s Acute hypersensitivity pneumonitis s Asbestosis s IPF s Mid Lung Predominant s Sarcoidosis s Uremia s CHF s Goodpasture's - look for anemia, renal dysfunction, hemoptysis s Upper Lung Predominant q Mnemonic = "A. S. S. E. T." ("like money in the bank") r A = Ankylosing spondylitis r S = Sarcoidosis r S = Silicosis r E = Eosinophilic granuloma r T = TB

If you add cystic fibrosis, then you get CASSETT

HERE IS THE DDX OF ILD: q Occupational and Environmental: Pneumoconiosis (13 of 50) [5/29/2002 10:57:54 PM]


Silica r Asbestos r Coal Dust Etc. Occupational and Environmental: Hypersensitivity Pneumonitis r Thermophilic actinomyces (Farmer's Lung) r Bird breeders lung r Woodworkers disease Drugs/Poisons r Chemotherapeutic agents (bleomycin, busulfan, methotrexate, chlorambucil, melphalan, ets.) r Antibiotics (nitrofurantoin) r Talc r Hydrochlorthiazide r Amiodarone Connective Tissue Associated r RA r PSS r MCTD r Polymyositis/dermatomyositis r SLE Idiopathic: Part of Multisystem Disease r Sarcoidosis r Vasculitis (interstitial disease is minor component) s Lung primarily involved s Wegener's s Lymphomatoid granulomatosis s Churg-Straus vasculitis s Lung secondarily involved s Systemic leukocytoclastic vasculitis r Eosinophilic granuloma Idiopathic: Pulmonary Only r Idiopathic pulmonary fibrosis r Eosinophilic Granuloma r Idiopathic pulmonary hemosiderosis r Chronic alveolar proteinosis Infectious r Residuae of active inflammation
r (14 of 50) [5/29/2002 10:57:54 PM]


r r r r q

Mycobacterial Fungal Pneumocystis Viral Lymphatic CA Chronic aspiration Uremia

r r r

ETIOLOGY OF ILD: no cause is identifiable in over 60% of pts with ild, and so this category is called idiopathic pulmonary fibrosis. In other forms of ild, the injury is introduced via the circulation or the airway. The following is the sequence of events that lead to ild: (1) primary insult by toxin, antigen or unknown (2) interstitial infiltration by polys, monos, macrophages, or eosinophils. Monos are usually predominant (3) alviolar cell ulceration and basal lamina destruction (4) persistent inflammation with abnormal repair mechanisms (5) alveoalar fibrosis and collapse (6) honeycombing and bronchiectasis

in terms of hypersensitivity connective tissue disorder associated lung disease, the following immune mechanisms are important: type 2 IgG mediated cytoxic reaction: Goodpastures (antibodies directed against glomerular basement membranes and alveolar walls) type 3 immune complex mediated: Wegeners and SLE. There are known or more commonly unknown immune complexes which deposit within the alveolar capillary bed and lead to endothelial complement activation resulting necrosis and thrombosis type 4 delayed type hypersensitivity associated with respiratory exposure to organic dusts. Antigen exposure activates T-helper cells (CD4+) and Cytotoxic T-cells (CD8+) which mediate the immune respose toward the offending antigen. Symptoms may present acutely or be slowly progressive. An intense lymphocytic alveolitis with or without granuloma formation is seen on histology. Example: Sarcoidosis (15 of 50) [5/29/2002 10:57:54 PM]


EXTRINSIC ALLERGIC ALVEOLITIS: acute affects the LL, and when chronic affects the UL (get fibrosis)


STAGING OF LUNG CANCER: here are the tumor and node descriptors: The stage of a lung cancer is very important in the clinical management of a patient. Staging is based on diagnostic evaluations as noted above. The currently accepted staging system for non-small cell lung cancer was adopted in 1997 by the American Joint Committee on Cancer and the Union Internationale Contre le Cancer, as a response to the need for more specific patient groupings. The four stages are based on the TNM descriptors as described below, and provides a consistent and reproducible classification for describing the extent of disease: Primary Tumor (T) TX Primary tumor cannot be assessed, or tumor proven by the presence of malignant cells in sputum or bronchial washings but not visualised by imaging or bronchoscopy. T0 No evidence of primary tumor T1 Tumor 3 cm in greatest dimension, surrounded by lung or visceral pleura, without bronchoscopic evidence of invasion more proximal than the lobar bronchus {ie not in the main bronchus} T2 Tumor with any of the following features of size or extent: > 3cm in greatest dimension Involves main bronchus, 2 cm distal to the carina Invades the visceral pleura Associated with atelectasis or obstructive pneumonitis that extends to the hilar region but does not involve the entire lung T3 Tumor of any size that directly invades any of the following: chest wall (including superior sulcus tumors), diaphragm, mediastinal pleura, parietal pericardium; or tumor in the main bronchus <2cm distal to the carina, but without involvement of the carina; or associated atelectasis or obstructive pneumonitis of the entire lung. (16 of 50) [5/29/2002 10:57:54 PM]



Tumor of any size that invades any of the following: mediastinum, heart, great vessels, trachea, oesophagus, vertebral body, carina; or tumor with a malignant pleural or pericardial effusionb, or with satellite tumor nodule(s) within the ipsilateral primary-tumor lobe of the lung.

Regional Lymph Nodes (N) NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Metastasis to ipsilateral peribronchial and/or ipsilateral hilar lymph nodes, and intrapulmonary nodes involved by direct extension of the primary tumor. N2 Metastasis to ipsilateral mediastinal, or subcarinal LN's N3 contralateral mediastinal or hilar nodes, supraclavicular or scalene nodes

Distant metastasis (M) MX presence of distant metastasis cannot be assessed M0 No distant metastasis M1 Distant metastasis presentc a) The uncommon superficial tumor of any size with its invasive component limited to the bronchial wall, which may extend proximal to the main bronchus, is also classified T1 b) Most pleural effusions associated with lung cancer are due to tumor. However, there are a few patients in whom multiple cytopathology examinations of pleural fluid show no tumor. In these cases, the fluid is non bloody and is not an exudate. When these elements and clinical judgement dictate that the effusion is not related to the tumor, the effusion is not related to the tumor, the effusion should be excluded as a staging element and the patients disease should be staged T1, T2 or T3. Pericardial effusion is classified according to the same rules. c) Separate metastatic tumor nodule(s) in the ipsilateral non-primary tumor lobe(s) of the lung are also classified M1. There are four stages, each corresponding to one or more TNM classification. Stage 1 reflecting the best prognosis and stage IV the worst. Stage 0 IA IB IIA IIB TNM subset Carcinoma in situ T1N0M0 T2N0M0 T1N1M0 T2N1M0, T3N0M0 (17 of 50) [5/29/2002 10:57:55 PM]



T3N1M0, T1N2M0 T2N2M0, T3N2M0 T4N0M0, T4N1M0 T4N2M0, T1N3M0 T2N3M0, T3N3M0, T4N3M0

IV Any T Any N M1 *Staging is not relevant for occult carcinoma, designated TXN0M0

The complex TNM system is not used in small cell lung cancer, a simple two stage system of limited and extensive disease. Limited disease is defined as disease confined to one hemithorax with or without ipsilateral mediastinal or supraclavicular lymphadenopathy, while extensive disease covers any disease spread outside this defined area.Recently patients with contralateral mediastinal and supraclavicular nodes and ipsilateral pleural effusion have been included in the limited disease category.


DEFINITION OF UNRESECTABLE LUNG CANCER: resectable is stage 0,1,2,3A, touching visceral pleura is resectable ie T2 unresectable is 3B or 4 another way of looking at unresectable lung cancer is T4. N3, or M1 (18 of 50) [5/29/2002 10:57:55 PM]


CHEST LN STAGING: 2R,L: paratracheal 4R,L: superior tracheobroncial 5,6: anterior mediastinum 7: subcarinal 8,9: posterior mediastinal 10R,L: bronchopulmonary 11 R,L: pulmonary 14: diaphragmatic

OSTIAL ANOMALIES: primum: lie immediately next to the AV valves. The defect is associated with Downs syndrome (ie it is "down" near the AV valves). It can cause asd, vsd, mitral incompetence, tricuspid incompetence, lv to ra shunt secundum: this is the most frequent type (60%) and involves the fossa ovale in the midseptal location. This defect is associated with Holt oram venosus: this is near the entry of the svc and is associated with anomalous entry of the pulmonary veins

HEMODYNAMICS OF ASD: enlarged RA and normal LA. Enlarged RV and normal LV. Inreased size of PA and not change in size of the aorta

THYMOMA: thymomas are invasive in 30 to 35% (they are heterogeneous and can spread by contiguity along pleural reflections). They can have pleural masses that surround and encase the lung circumferentially and may encroach on the vessels. Pleural effusions are uncommon 15% of pts with myesthenia gravis have thymoma and 30% of pts with thymoma have myesthenia gravis. The association is higher with thymic hyperplasis where 65% of pts with myestenia gravis have (19 of 50) [5/29/2002 10:57:55 PM]


thymic hyperplasia (source is Dahnert)

PLEURAL EFFUSION: left: voorhave: left sided esophageal perforation leading to L sided effusion pancreatitis: L ruptured thoracic duct in upper chest: L dissecting aortic aneurysm: L traumatic rupture of the aorta distal to the L subclavian artery: L SLE (L >R)

right: ruptured thoracic duct in lower chest: R CHF: R RA: R>L (ie R in 75%) Meigs: R sided effusions with ascites are seen in this condition

note the following: Diseases adjacent to the diaphragm: cause an effusion on that side: eg hepatic absess produces a R sided effusion note that on a PA view, the first 300 cc is not visualized. The left lateral decubitus may detect as litlle as 25 cc. In subpulmonic effusion, the peak of the diaphagm is laterally positioned note also that the most common cause of a unilateral pl effusion is malignancy (lymphoma, mets, primary lung ca) most bilateral effusions are transudates, the exceptions being SLE, mets, PE, lymphoma

ORIGIN OF PHRENIC NERVE: (20 of 50) [5/29/2002 10:57:55 PM]


brachial plexus; therefore, diaphragmatic paralysis can be a sequela of brachial plexus trauma. An important mimic of diaphragmatic paralysis is eventration of the diaphragm usually on the L

AIR LEAK: BPF usually occurs at 10-14 w. A small amount of air may reside within the hemothorax for months without any significance. A drop in the fluid level by >20mm or reappearance of air suggests a BPF. Early fistulae are due to poor surgical technique and late ones are due to recurrent tumor

NEUROBLASTOMA: can occur in the anterior mediastinum, but occurs most commonly in the posterior mediastinum. Nerve sheath tumors are spherical whereas ganglioneuromas tend to be sausage shaped

BRONCHOPNEUMONIA VS LOBAR PNEUMONIA: bronchopneumonia is a finding in Staph pneum and lobar pneumonia is a feature of Strep pneum

HYPOPLASTIC LUNG RELATIONS: TOF and TGA. There is agenesis of the PA

PULMONARY STENOSIS: the most common cause is valvular disease

PULMONARY GANGRENE: most common organisms are strep pneumonia and klebsiella (21 of 50) [5/29/2002 10:57:55 PM]


CENTRAL BRONCHIECTASIS: think aspergillus fumigatus

PCP IN AIDS: the miliary pattern is less common. Thin walled cysts (10%) occur due to parenchymal obstruction. If you see PTX in a pt with aids, the dx is pcp until proven otherwise

CF: the increased Cl and Na applies to sweat, not saliva. The disease affects the apical and posterior segments of the UL's with a RUL predominace. One complication of the lung involvement is ptx. Other findings are rectal prolapse and hypoplastic frontal sinuses

SWYER JAMES: bronchilitis obliterans. It occurs post viral infection, organ transplant, idiopathic. Classical is post viral. There is abrupt cut off of the airways at the 5th level. Air trapping occurs during expiration. With hypogenetic lung syndrome, there is no air trapping and small hemithorax. One sees pruned vessels on angio

CHF CAUSES: back pressure from the LV which is long standing, aortic valve dz, CAD, cardiomyopathy, MI obstructive phenomena: prox LV, MVD, LA myxoma, cor tritriatrium note that LA myxoma usually comes from the lower part of the intraatrial septum. This together with the fact that they usually occur on a stalk accounts for their propensity to protrude into the right or LV during atrial systole. Note also that myxomas rarely calcify (22 of 50) [5/29/2002 10:57:55 PM]


LATITUDE: cxr is low contrast and high latitide. By comparison, a mammogram would be high contrast and low latitude

LOEFFLERS: fleeting opacities in a pt with atopic hx. Frequently see it in ascariasis and filariasis. It can be unilat, bilat, segmental, nonsegmental. Typically it is periperal

CHRONIC EOSINOPHILIC PNEUMONIA: not fleeting. More serious. Insidious. Dense. Ill defined opacities. Reverse pulmonary edema pattern

LYMPHOID GRANULOMATOSIS: vasculitis in the same category as wegeners. Angiocentric distribution. Also involves kidney, skin, CNS. May be a frank lymphoma of B cells. M>F. Looks similar to wegeners. Multiple pulm nodules 1-10 mm. More numerus than wegeners. Cavitation is common

WEGENERS: it is more common in males

PTX IN ASTHMA: occurs more frequently in children than in adults

CATAMENIAL PTX: R>>L. It is associated with endometriosis of the diaphragm (23 of 50) [5/29/2002 10:57:55 PM]


SOME CAUSES OF TRACHEAL NARROWING: TPO, relapsing polychondritis, TB, amyloidosis, schleroma. Note that amyloidosis is a cause of parenchymal lung ca++ in 40%. A schleroma is caused by Klebsiella


SUPERIOR RIB NOTCHING: most likely non cardiogenic from rubbing of bones. HPT, polio, marfan, OI

INFERIOR RIB NOTCHING: blalock taussig (unilateral first 2 or 3 ribs), aortic obstruction, interupted aortic arch, tof, pulm atresia, svc obstruction, ebsteins, intercostal neuroma

CAUSES OF UNILATERAL RIB NOTCHING: coarct with L arch with aberrent R SCA coarct with R arch with aber L SCA AVM of arm BT shunt

AIDS CD4: mtb: <400 reinfection pattern (24 of 50) [5/29/2002 10:57:55 PM]


bacterial pneumonia: 175-250 AIDS definition: <200 PCP<200 primary pattern pulm TB: <200 Kaposi and fungi: <150 lymphoma, CMV, MAI <50

TB IN AIDS: primary tb pattern is infiltrate (<200) secondary tb pattern is ul predominant miliary pattern is not uncommon posterior seg of UL and superior seg of lower lobe are classic but TB can occur in the anterior segments of the upper and lower lobes

DDX OF LAN WITH CENTRAL HYPODENSITY IN HIV: aids related lymphoma, fungal, atypical mycobacterial

MEDIASTINAL MASSES IN CHILDREN: children: anterior 30%: lymphoma, leukemia, teratoma middle 30%: lymphoma, leukemia posterior 40%: neurogenic (most common), lymphoma, leukemia, teratoma note that thymoma is very rare in children. It is most common in the anterior mediastinum of adults (25 of 50) [5/29/2002 10:57:55 PM]


THYMOMA ASSOCIATIONS IN ADULTS: aplastic anemia, hypogammaglobinemia, red cell aplasia

PRIMARY VS SECONDARY TB: primary: lung bases, focal, no cavitation, LAN commonly seen as the only finding, effusion is common, miliary pattern, pleural effusion more common with primary than with secondary (Weisleder). In immunocomprimized, you see progressive primary disease where it spreads to all parts of the body. The occurrence of cavitation in primary disease indicates progressive disease secondary: Apicoposterior segment of UL and superior seg of LL predominant. Patchy, frequent cavitation, no LAN, effusion is uncommon, can have miliary pattern (same incidence as for primary). Note that miliary pattern is more commonly from primary than from secondarty TB

CAVITARY PNEUMONIA: most commonly in staph, gram negative (kleb, proteus, pseudomonas), anaerobic, mycobacterial. Less commonly from fungal, amebic, and helminth

PCP PNEUMONIA: pneumatoceles from pcp pneumonia resolve after treatment

PNEUMATOCELES: those in pts with S. Aureus usually resolve

BULLA: 1 cm cystic space in the lung parenchyma which is due to destruction of alveolar walls (26 of 50) [5/29/2002 10:57:55 PM]


TRANSUDATE VS EXUDATE: LDH>0.6, PROT>0.5, PLEUR LDH>200 is accurate in 99% for exudate. LDH is the most specific

PNEUMONIA IN AIDS: bacterial pneumonia is more common than pcp pneumonia

RIGHT MAIN BRONCHUS AND BRONCHUS INTERMEDIUS: both are normally outlined by air

RATIO OF ARTERY TO BRONCHUS IN UPPER AND LOWER LOBES: upper: 0.85, lower: 1.3. If a vessel is more than 1.5 times its accompanying bronchus, it should be considered abnormal

NORMAL RANGE OF EXCURSION OF THE DIAPHRAGM: as demonstrated by US: 2-8.6 cm (grainger and allison)

CONSOLIDATION: it respects lobes, not segments

SOME CAUSES OF AIR BRONCHOGRAM ON A CXR: non obstructive collapse, passive atelectasis, lymphoma, PMF, alveolar cell ca (27 of 50) [5/29/2002 10:57:55 PM]


SOME CAUSES OF EXPANSIVE LUNG CONSOLIDATION: consolidation 2ary to neoplasm (commonly SCC which obstructs the bronchus), klebsiella, pneumococcal pneumonia expansive consolidation is sometimes referred to as drowned lung but has nothing to do with drowning

LOWER VS UPPER ESOPHAGEAL RUPTURE: the upper 1/3 is adjacent to the mediastinal surface on the R and so upper esophageal rupture will give a R effusion. The lower 1/3 tends to lie next to the left and is adjacent to the L inferomedial surface which would give an effusion on the L

EGGSHELL CA++: silicosis, berylliosis, CWP, treated lymphoma, granulomatous dz such as histoplasmosis rarely contains eggshell ca++; diffuse ca++ are more common in granulomatous dz, sarcoid (rare and late in the disease) note that eggshell ca++ is not usually seen in TB

ASBESTOSIS: the short fibers of crocodilite are more likely to produce chest dz than the longer fibers of chrysotile note that malignant mesotheliomas arise independently from pleural plaques asbestosis is specific for the lungs and refers to pulmonary and not pleural fibrosis

IN ACUTE PE: fleishners sign is dilatation of the main pulmonary vessel by back pressure or clot, westermark sign is alteration of the pulmonary vasculature distal to the embolus, and hampton's hump is a shallow hump shaped lesion on the pleural surface near the pulmonary infarct

PULMONARY VASCULARITY: (28 of 50) [5/29/2002 10:57:55 PM]


grade 1: vascular redistribution 10-17mm grade 2: interstitial edema 18-25 mm grade 3: alveolar edema >25mm

PULMONARY CONTUSION: pulmonary contusion resolves in 5-10 days while localized pulmonary hematoma takes months or years to resolve

PULMONARY EDEMA WEDGE PRESSURE: the first signs of pulm edema (perihilar haze, kerley a and b lines, peribronchial cuffing, etc ) occur at a pulmonary capillary wedge pressure of 20-25 mm

LOWER LOBE COLLAPSE: causes an apparent reduction in the size of the hilum

LINGULAR COLLAPSE: has no minor fissure to give a clear upper border to the increased density

CASTLEMAN'S DISEASE: has mediastinal and not hilar LAN. M>F for the general type and M=F for the plasma cell type. There is angiofollicular LN proliferation. Unknown etiology. The LN's have muscle density. It is indistinguishable from lymphoma

GARLANDS TRIAD: (29 of 50) [5/29/2002 10:57:55 PM]


40% of pts with intrathoracic sarcoid have lan on the CXR at the time of diagnosis. Garlands triad is bilateral hilar and R paratracheal lan and is present in 75 to 95% of pts with intrathoracic sarcoid lan

CCAM: intralobar mass of disorganized pulmonary tissue. It communicates with the bronchial tree and has a normal vascular supply and drainage, but delayed clearance of fetal lung fluid. It is proliferation of bronchial structures at the expense of alveolar saccular development. The mass tends to compress the mediastinum and thus the esophagus resulting in polyhydramnios there are 3 types 1: multiple cysts up to 10 cm (50% ie type 1 is the most common); prognsosis is excellent following resection 2: multiple small cysts <1.5 cm (40%); px is poor due to associated abnormalities 3: solid lung (10%); px is poor secondary to pulmonary hypoplasia and hydrops

BRONCHIAL ATRESIA: most commonly involves the segmental UL bronchus, but may be seen in the LL. It usually affects an older child or adult

EMPYEMA NECESSITANS: chronic empyema attempting to decompress through chest wall. The common organisms that result in this are: actinomyces, TB, aspergillosis, norcardia, blastomycosis

KS IN AIDS: 10% overall. 30% pulmonary involvement if you have skin involvement. Get sub pleural nodule. Adenopathy is not common and if present is a late finding. Presence of ground glass density suggests hemorrage. 67Ga scan is negative which can be used to differentiate it from lymphoma (30 of 50) [5/29/2002 10:57:55 PM]



NON HODGKINS VS HODGKINS DISEASE IN THE CHEST: the main difference is that HL demonstrates a contiguous spread of disease to nodal chains while NHL skips adjacent nodes. For distribution, see below

DISTRIBUTION OF LYMPHOMA INVOLVEMENT WITH HD VS NHD for thorax: HD>NHD Lung parechymal involvemnt: HD (12%) >NHD (4%) for abdominal involvement: HD>NHD for splenic involvement: HD>NHD

AORTIC INVOLVEMENT BY LUNG CA: <90 degrees of circumferential involvement means the tumor is resectable. >90degrees of circumferential involvement=unresectable

CAUSES OF BRONCHOVASCULAR BEADING: sarcoid, lymphangitic carcinomatosis, kaposi, lymphoma, pulm edema

SILSBACH CLASSIFICATION OF SARCOID: (31 of 50) [5/29/2002 10:57:55 PM]


0: normal (10%) 1: adenopathy (50%) 2: adenopathy and lung dz (30%) 3: lung dz only (10%) 4: fibrosis

in terms of prognosis: 75% of stage 1 regresses to normal, and 10% remains enlarged and 15% progresses to stage 2 and 3


LUNG TRANSPLANT: acute rejection: occurs after the first 3 months in 60-80% and presents as edema and increased effusions without signs of LV dysfunction. Other things that can be seen are airway stricture and torsion

CAUSE OF AORTIC NIPPLE: left superior intercostal vein


PERCUTANEOUS NEEDLE BX PTX RATE: 25% (32 of 50) [5/29/2002 10:57:55 PM]


DRUG TOXICITY TO LUNGS: radiologic abnormalities commonly involve the lower lobes


LUNG ABCESS: it does not displace the lung vessels, it destroys them

MR VS CT: mr has better contrast resolution than ct

MILIARY LUNG DZ IN THYROID CA: suggests follicular

SPICULATED BORDER OF A SPN: hightly specific for malignant lesion

RADIATION PNEUMONITIS: most pronounced 1-6 mo post XRT. Fibrosis follows up to 18 mo post treatment. Acute reaction is confined to the radiation port. Chronic reaction extends outside the radiation port ( ie the radiation (33 of 50) [5/29/2002 10:57:55 PM]



PERIPHERAL LUNG OPACITIES: infarct, UIP, loefflers, hemophilus, influenza, sarcoid, amiodarone

NF: this can cause interstitial fibrosis in up to 20%

LOCALIZED MESOTHELIOMA: 75% arise from the visceral pleura, no association with asbestosis, pts are symptomatic with cough and CP, hypoglycemia

ENDOBRONCIAL LESIONS: breast, kidney, colon

ATYPICAL CARCINOID: it is more aggressive than typical carcinoid. ACTH, acromegaly, ZE are all paraneoplastic syndromes associated with bronchial carcinoid

DEFINITION OF TRACHEAL NARROWING: M: <13mm F: <10mm (34 of 50) [5/29/2002 10:57:55 PM]


ACCESSORY PLEURAL FISSURE (SOMETHING I AM REAL WEAK ON!) the best known of these in the azygous fissure in < 1% of the population minor fissure on the L separating the lingula from the rest of the upper lobe inferior accessory fissure or Twinings line: R>L, separates the medial and anterior basal segments, it runs obliquely upward and medially toward the hilum superior accessory fissure: R=L, horizontally oriented, separates the apical from the basal segments of either lower lobe

FALLEN LUNG SIGN: caused by tracheobronchial rupture

PTX: 40% LAM, 5-30% LCH, trauma (70% have rib fx)

CYSTS IN HIV: hiv by itself can cause cysts in 42% of pts independent of PCP. There is a UL predominance

MOST COMMON BACTERIAL PNEUMONIAS IN HIV: H. flu, Strep are the most common bacterial pneumonias and the most common lung infections in HIV. PCP pneumonia is the most common HIV related lung dz in adults and children. Another way of putting it is most common pneumonia in hiv is bacterial (h. flu, strep) while most common pneumonia in aids is pcp

ASBESTOS RELATED PLEURAL PLAQUES: (35 of 50) [5/29/2002 10:57:55 PM]


most commonly between the 6th to 10th ribs and no more than 4 ribs wide

MALIGNANT EFFUSIONS: lung 36%, breast 25%, lymphoma 10%

PULMONARY LIGAMENT: the L is more commonly visible on CT (72%). The phrenic n is located anteriorly to the pulm ligament

TWO TYPES OF ASBESTOS FIBERS (SEE ABOVE): serpentines which are long, curly and flexible, chrysotile is the main one used in the USA (90%) amphiboles which are straight and needle like and are more carcinogenic and fibrogenic (main ones here are crocidolite, amosite, anthropyllite). In terms of carcinogenicity: crododilite>chrysotile>amosite.

ASBESTOS PLEURAL DZ 20 yr latency, usually parietal, apices and costophrenic angles are spared. It affects the posterolateral chest wall. Not greater than 4 rib widths affected. Ca++ require a 30 to 40 year latency. They are called "holly leaf" ca++ when seen en face, rounded atelectasis with comet tail sign. Malig pleural dz is usually > 1cm thick, cirumferential, nodular, and the mediastinial pleura are involved.Visceral and parietal pleura are both involved in the case of malignancy

BENIGN ASBESTOS PLEURAL EFFUSION: no malignancy within 3 years of onset of the effusion by definition. Usually small effusion. Most common abnormality within 10 years of asbestos exposure

FIBROUS PLEURAL TUMOR (36 of 50) [5/29/2002 10:57:55 PM]


M=F, not related to asbestos. Arises from mesenchymal cells rather than epithelial cells and from the visceral pleura in 80% and parietal in 20% and 14-30% are malignant. Associated with HPO and hypoglycemia. Slow growing and pedunculateed and can change position

ASPIRATED FB: adult: presents as air trapping children: presents with hyperinflation

LOEFFLERS SYNDROME: most common inciting drugs are sulfonamides, ASA, methotrexate, penicillin, chlorpromazine, chlorpropamide

INCREASED RISK OF LUNG CA: predisposing: smoking, asbestos associated: tb, asbestos, ipf, scleroderma

BRONCHIOALVEOLAR CELL CA: a subtype of adenocarcinoma, like adeno, it is not associated with smoking. The most common presentation is a SPN

SCC: 2/3 are central endobronchial lesions. Most common type to cavitate. See earlier;

LARGE CELL CA: (37 of 50) [5/29/2002 10:57:55 PM]


strong association with smoking like small cell ca. It is a large tumor at presentation. Poor survival

PULMONARY VASCULITIS: most common cause is #1 wegeners, churg strauss, bronchocentric granuloma, (PAN is not a common cause) #2 is hypersensitivity, extrinsic alveolitis, drugs, malignancy #3 is CTD's #4 is behcets

TB IN AIDS: the miliary pattern is the most common pattern particulary when the CD4 is low

AIDS DEFINING ILLNESSES: in addition to PCP pneumonia, CNS lymphoma is also an AIDS defining illness

PRIMARY TRACHEAL TUMORS: malignant (90% of malignancies): SCC (50%), adenoid cystic (33%), mucoepidermoid

CAUSES OF BRONCHIECTASIS: tb, abpa, adenovirus, pertussis, chronic aspiration, neoplasm eg carcinoid, fb, inflammatory nodes as in RML sydrome, ciliary dyskinesia sydrome (quoted from UMDNJ) notes

KARTAGENERS: (38 of 50) [5/29/2002 10:57:55 PM]


50% of ciliary dyskinesia syndrome

DIVERTICULUM OF KOMMERALL: if diameter origin of aberrant R subclavian artery is dilated

THYMIC LYMPHOMA: usually secondary to HD

PNEUMOMEDIASTINUM: associated with asthma, dka, mechanical ventilation, severe cough, trauma, voorhave, instrumentation, air tracking into the mediastinum after perforation of a mediastinal structure or even the pharynx

MORE ON LV ANEURYSMS: congenital: usually young african american adults (submitral and subaortic)

acquired: true: s/p transmural MI located in L anterior and anteroapical and with a wide mouth. Less likely to rupture than a pseudoaneurysm pseudoaneursym: s/p MI or trauma. Involves the posterolateral or diaphagmatic wall of the LV. Has a narrow neck

CARDIAC TUMORS: (39 of 50) [5/29/2002 10:57:55 PM]


benign: #1: atrial myxoma L>R #2: rhabdomyoma (in TS) #3: ventricular fibroma (part of Gorlins syndrome); pedunculated note that mets are 40x more common than 1 ary cardiac tumors

malignant: the most common malignant cardiac tumor is angiosarcoma

HILUM OVERLAY SIGN: anteromediastinal mass will overlap with the hila. Cardiac enlargement or pericardial effusion will displace the hila laterally. It is used to distinguish a true hilar mass from a non hilar mass, or put another way: Differentiation of the true cardiomegaly from a large anterior mediastinal mass mimicking cardiac enlargement. An anterior mediastinal mass is indicated on a PA chest film whenever more than 1 cm of the right or left pulmonary artery is visualized within the lateral edge of what appears to be the cardiac silhouette.

ARCH ANOMALIES: L arch with aberrant R SCA is the most common R arch with mirrow image branching is the 2nd most common

ESOPHAGEAL AND TRACHEAL IMPRESSIONS ONCE MORE (FROM GLICKMAN and WEISLEDER): anterior trachea and posterior esopagus: DAA, R arch with aberrant L subclavian and L ductus anterior trachea: anomalous inominate which arises to the L of the trachea, anomalous L common carotid posterior esophageal: L arch and aberrant R SCA or mirror image to this (40 of 50) [5/29/2002 10:57:55 PM]


anterior esophageal and posterior tracheal: pulm sling with L PA arising from the R PA

MAS: an increase in the kvp of 20% will double the MAs. To maintain image quality between big and small patients, fix the KVP and vary the MAS

GRID RATIO: upright chest: 10:1 portable: 6:1

POSTERIOR MEDIASTINAL TUMOR MOST LIKELY TO BRIDGE THE NF: schwannomas are the ones that will do this

THYMOLIPOMAS: occur most often in children and young adults

MORGAGNI: most contain fat (omentum). Enema is usually diagnostic, not UGI. These are not usually diagnosed in childhood as are the bochdalek hernias

LUNG NODULE CA++ focal central CA++ is more suggestive of malignancy then focal eccentric Ca++ (according to ACR syllabus) (41 of 50) [5/29/2002 10:57:55 PM]



WHAT EXACTLY IS BOOP? this one still gets me even after 4 years of radiology training! main features are patchy, non segmental, predominantly subpleural with small effusions in 10-20%. It is not the same things as bronchiolitis obliterans and its name is unfortunate

PULMONARY ANGIITIDES AND GRANULOMATOSES: these range in spectrum from benign (necrotizing sarcoid granulomatosis) to malignant (lymphomatoid granulomatosis). Most pts respond to rx with steroids plus or minus cyclophosphamide. The lungs are most commonly involved because of the vascular network they contain. Wegeners and Churg Strauss are the only ones associated with a systemic vasculitis. Lymphomatoid gran. is considered to be a form of lymphoma with angioinvasive infiltrate. Bronchocentric angiomatosis has histo features in common with ABPA. It primarily involves the bronchi

ECTOPIC PARATHYROID ADENOMA: in the thymus posterior to the junction of the BCV's, adjacent to the aortic knob, and in the TE groove below the thyroid (this is a common location)


MORE ON THYMOMAS: the spindle cell variety is the one associated with hypogammaglobinemia. Eaton Lambert is not (42 of 50) [5/29/2002 10:57:55 PM]


associated with thymoma

ASKIN TUMOR: caucasian female. It arises from intercostal nerves and causes rib destruction and pleural effusion. It is a neuroectodermal small cell tumor

IF GET AIR IN THE LV DURING BX OF A LUNG NODULE: place pt on the L side and raise the legs ie trendelenberg

AORTIC RUPTURE: deviation of the NGT: 67% specific depression of the L mainstem bronchus: 53% spec mediastinal widening: not very spec but very sensitive (100%) aortic knob contour: less specific than deviation of the NGT and depression of the L mainstem

BRANHAM SIGN: this is bradycardia on closing a hemodynamically significant AVF

LUPUS: lung: effects on the lung are frequent (30-40%). This is due to chronic antibody damage to alveolar membrane. Lupus pneumonitis is patchy infiltrate with an alveolar pattern at lung bases peripherally secondary to infection, uremia. Get interstitial reticulations in lower lung fields in 30% (chronic). In infarct due to vasculitis, get fleeting plate like atelectases at both bases. Cavitary nodules represent vasculitis. (43 of 50) [5/29/2002 10:57:55 PM]


pleura: bilateral pleural thickening and pleural effusion. There is also pericardial effusion, and cardiomegaly from primary lupus cardiomyopathy

MOST COMMON CAUSES OF DIAPHRAGMATIC ELEVATION: eventration, atelectasis, abdominal mass, phrenic nerve paralysis


WHAT IS IN THE MIDDLE MEDIASTINUM: aorta, esophagus, trachea, bifurcation, great vessels, PA, paratracheal nodes

TYPES OF ATELECTASIS: obstructive, compressive, passive, cicratizing, adhesive

DIFFUSE FINE NODULAR OPACITIES: dust inhalation siderosis silicosis beryliosis infection eg viral, bacterial with norcardia, bronchopneumonia, and fungal (eg TB, histo, coccidio) EG sarcoid (44 of 50) [5/29/2002 10:57:55 PM]


TB neoplasm (thyroid, melanoma) other eg BOOP, Wegeners

MILIARY: considered 1-2 mm

CAUSES OF PRIMARY LUNG ABSCESS: aspiration, necrotizing pneumonia, septic emboli, complication of chronic lung dz

BOARDS APPROACH TO THE CXR: see lesion and decide what it is. Describe where lesion is. do a focussed ddx. Do a CT to decide on where the lesion is. If you see a medial mass in the lung, dont confuse it with a mediastinal mass. The ddx for a lung mass is ca, mets, granuloma, hamartoma, and dont forget carcinoid. The things which suggest carcinoid is a well marginated mass (indicating slow growth), which is partially endobroanchial or abutting the bronchus.

for anterior mediastinal mass, think the 4T's. Mature teratoma is seen in <40 and thymoma is in those >40. The mature teratoma is a cystic lesion with heterogeneous low attenuation areas due to the presence of fat inside. There can be Ca++ lobulated borders.

for posterior mediasinal mass, neurogenic tumor, neuroenteric cyst etc.

INCOMPLETE BORDER SIGN: think lesions of chest wall or pleura. Pressure erosions of the ribs in association with chest wall mass is highly specific for NF (45 of 50) [5/29/2002 10:57:55 PM]


ROUNDED ATX: aspesos exposure with pleural thickening. See vol loss, comet tail sign, swirling vessels. If no volume loss with rounded atx, then it is suspicious for carcinoma

LAM: increased volume, reticulonodular opacities, cysts, effusion on one side, prior h/o ptx. LCH can also present the same way with a high incidence of ptx

ASTHMA: increased vols, central airways thickened, centra bronchiectasis with areas of mucoid impaction, associated with abpa

TB LOCATION: most TB is apical and posterior and also in the superior seg of the RLL. If it is the anterior portion of the UL, then suspect malignancy

LADY WINDERMERE SYNDROME: MAI (chronic) in the inferior RML or lingula from chronic cough suppression. Get bronchiectasis,. They have no predisposing factors for MAI. The ddx is middle lobe sydrome (but no vol loss), ABPA, MTB, asthma, immunoglobulin deficiency sydrome

UIP: lower lobe predominance, fibrosis, with traction bronchiectasis distal to the airways out in the periphery. The ddx is asbestosis, coll vascular dz, hypersensitivity pnemonitis, sarcoidosis (46 of 50) [5/29/2002 10:57:55 PM]


BOOP: synonymous with cryptogenic organizing pneumonia. No infective organism found. Dense consolidation in 60%. Nodules regularly spaced. The ddx is wide and includes bacterial infection, vasculitis, BAL ca, lymphoma, eostinophilic pneumonia, and NSIP

FLOATING LILY SIGN: seen with echinococcal cyst in liver and lung

TRACHEAL LESIONS: only 10% of tracheal lesions are benign and 90% are malignant. Primary are squamous, adenoid cystic, mucoepidermoid. Mets are from local extenion eg from thyroid, and from distant sources eg breast, melanoma benign: papilloma, hemangioma, hamatoma (contains fat and popcorn Ca++), adenoma (rare) saber sheath: only intrathoracic. 95% of the pts have COPD. Ring Ca++ are common TPO: benign, rare. There are osteocartilagenous growths within the trachea. The lumen is narrowed and filled with calcified nodules. The distal 3/4 of the trachea and proximal bronchi are most commonly affected relapsing polychondritis: destruction and inflammation of cartilage throughout the body. The trachea is thick walled and with diffuse slit like intraluminal narrowing tracheobroncomalacia: primary or secondary. In the secondary form, there is compression of the trachea by vessels or a mediastinal mass. Can also be from copd or intubation tracheobronchomegaly: atrophy and dysplasia of trachea and proximal bronchi. Also known as Mounier Koun

TYPES OF EMPHYSEMA: panacinar: LL centriacinar: UL paraseptal: periphery of the lung along the septal lines overinflation: flattening of the diaphragms is the most reliable sign (47 of 50) [5/29/2002 10:57:55 PM]


TYPES OF BRONCHIECTASIS: congenital (CF, kartageners, pulm sequestration) post infectious: viral, bacterial bronchial obstruction: neoplasm, inflammatory nodes f.b. types: cylindrical, saccular (varicose), cystic. the bronchi appear larger than the accompanying vessels and appear thick walled

CAUSES OF CHYLOTHORAX: trauma, lac of thoracic duct, LAM, filariasis, idiopathic, tumor especially lyphoma

FIBROUS TUMOR OF THE PLEURA: comes from the visceral pleura in 70%. Has no relation to asbestos exposure

5T's OF ANTERIOR MEDIASTINAL MASS: thymoma, thymolipoma, thyroid hyperplasia, thyroid, terrible lymphoma note that terrible lymphoma includes the germ cell tumors: wihich can be remenbered by thinking of SECTE or seminoma, embryonal cell ca, choriocarcinoma, teratoma (20% malig), endodermal sinus tumor

BRONCHOPULMONARY FORGUT MALFORATIONS: bronchogenic cysts are ventral, subcarinal, mediastinal (75%), and pulmonary (25%). Enteric are posterior, supracarinal (48 of 50) [5/29/2002 10:57:55 PM]


CHURG STRAUSS: allergic granulomatosis. Presents as asthma, fever, necrotizing vasculitis, extravascular granuloma, eosinophilia

ANGIITIS GRANULOMATA: this is includes wegeners, allergic granulomatosis, and PAN, and is characterized by transient pulmonary shadows

HODGKINS: the LAN is almost always anterior

HYPOPLASTIC LEFT PA: it is associated with a R aortic arch

SOME CAUSES OF DIAPHRAGMATIC ELEVATION: hepatic mass or abscess interposition of colon diaphragmatic paralysis (phrenic nerve paralysis) subpulmonic abscess volume loss, atelectasis lobectomy diaphragmatic hernia eventration diaphragmatic rupture (49 of 50) [5/29/2002 10:57:55 PM]


diaphragmatic tumor

the most common causes of diaphragmatic elevation are: eventration, atelectasis, abdominial mass, and phrenic n paralysis (50 of 50) [5/29/2002 10:57:55 PM]


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BEFORE DOING ANYTHING FURTHER, CHECK THIS OUT: (1 of 14) [5/29/2002 10:58:41 PM]


BREAST ABSORBED DOSE ANNUALLY: not > than 300 mrem/breast/view

MAMMO RULES (dont ask me how many times I looked at this and still cant remember it): 1 d: processor qc and darkroom cleanliness 1w: phantom, viewboxes, screen cleanliness 1mo: visual checklist quarterly: fixer retention, repeat analysis, meetings with the radiologist 6mo: darkroom fog, film-screen contact, compression

INCIDENCE OF BREAST CANCER SUBTYPES: which is more common comedo, papillary, cribiform, medullary? Need to look these up!

BREAST CANCER STAGING: (2 of 14) [5/29/2002 10:58:41 PM]


tx cannot assess primary tumor t0 no evidence of primaryt tumor tis cis (ductal, lobular, pagets) t1 (<2 cm) a (<0.5 cm), b (>0.5 cm and <1 cm), c (>1 cm and < 2 cm) t2 >2 cm and < 5 cm t3 > 5 cm t4 any size with extension to the chest wall or skin: a: chest wall, b: skin, c: both, d: inflammatory

nx cannot assess n0 no regional nodal mets n1 met to moveable ipsilateral LN's n2 axillary LN's fixed to each other n3 mets to ipsilateral internal mammary chain

staging: 0 is tis n0 m0 1 is t1 n0 m0 2a is t0 n1 m0 or t1 n1 m0 or t2 n0 m0 2b is t2 n1 m0, or t3 n0 m0 3a is t0 n2 m0 or t1 n2 m0 or t2 n2 m0 or t3 n1 m0 or t3 n2 m0 3b is t4 any n and m0 or any t n3 m0 stage 4 is any t and any m with m1

THE POST SURGICAL BREAST: When malignant calcifications are present initially, it is advisable to obtain a mammogram of the breast shortly after surgery. Any residual calcifications indicate residual tumor and re-excision is indicated. Any increasing malignant calcifications on follow-up mammography indicate recurrent tumor. At times, it may be difficult to differentiate malignant from dystrophic calcifications. Recurrent tumor in a prior irradiated breast is treated with mastectomy. Increase in density and architectural distortion at the (3 of 14) [5/29/2002 10:58:41 PM]


lumpectomy site stabilizes 6 to 8 months following completion of therapy. Any later change is most likely due to recurrent tumor. Note that usually, post surgical changes to the breast stop changing by 2-5 years

RECALL RATE IN MAMMO: Svane cites a 4-5% recall rate at her institution and states that is a reasonable goal.

LOBULAR CA IN SITU: Lobular carcinoma in situ (LCIS) has no radiographic findings. The diagnosis is based on histologic findings following biopsy. LCIS is associated with an increased risk for the subsequent development of invasive carcinoma (>20% to 30% during the next 15 to 20 years). Interestingly, the invasive carcinoma may be either lobular or ductal. Both breasts are at equal risk. No treatment is indicated for LCIS, except close surveillance

While LCIS is typically not bilateral, its presence implies an increased risk of later developing invasive carcinoma (usually ductal) with equal risk (15%) in each breast. It is not a true carcinoma in a sense but a significant risk marker for subsequent CA

MONDORS: superficial thrombophlebitis

IF MAMMO WAS DONE WITHOUT A PHYSICAL EXAM: 5-10 % of breast ca would not be discovered

FOCAL CLUSTER OF MICROCALCEFICATIONS: then chance of malignancy is 20% (4 of 14) [5/29/2002 10:58:41 PM]


PAPILLOMATOSIS: the difference between this and the others is this lacks a fibrovascular core

MULTIFOCAL VS MULTICENTRIC: multifocal is all confined to one quadrant and multicentric is confined to multiple quadrants. Multicentric has the higher risk of recurrence with conservative management

BREAST CA PREVALENCE AND INCIDENCE: 6-10 per 1000 women for prevalence (ie initial screen) and 2-4 per 1000 in incidence (rescreen)


PERCENT CA IN ALL LESIONS WITH CA++: 20% incidence of cancer

S/P XRT AND CHEMO BREAST: <7y tumor occurs at or close to the lumpectomy site and > 7 y can occur in any quadrant. The mean time for recurrence is 3 years. Post lumpectomy changes resolve by 12 months and post lumpectomy plus XRT changes resolve by 12 m to 2 years

SPATIAL RESOLUTIONS: breast: 11 lp/mm cxr: 8 lp/mm (5 of 14) [5/29/2002 10:58:41 PM]


ct: 4 lp/mm mr: 2 lp/mm us: 0.5 lp/mm

LCIS: this is bilateral in 30% and IDC or invasive lobular ca is bilateral in 30%. Ie a 15% risk of ca per breast. This is because LCIS is a marker of ILC in addition to IDC

BREAST ECHOGENICITY: breast fat is hypoechoic and tumor is mostly hypoechoic so it would be difficult to pick out the tumor by US if it is located in the breast fat

NIPPLE PAPILLOMA OR JUST PAPILLOMA: is not the same as nipple adenoma. There is no risk of malignancy unless it is associated with atypical ductal hyperplasia. It has a fibrovascular core and is located within 2 to 3 cm of the nipple. It is also called a solitary papilloma. This is the most common source of nipple discharge

PAPILLOMATOSIS: Duct papillomatosis has no fibrovasuclar core. They have a 25% to 30% risk of malignancy (-recalls) and according to Dahnert a 5% risk of malignancy

MULTIPLE PAPILLOMAS: located in the periphery of the breast. Multiple circumscribed nodules sometimes with Ca++ and slight increase risk of CA even without the presence of atypical ductal hyperplasia (6 of 14) [5/29/2002 10:58:41 PM]


ADH: can present as a nodule or architectural distortion. It is a marker for 10% risk of breast ca in either breast within a 10 year period

FIBROID: involuting fibroid has Ca++ beginning peripherally (becomes popcorn like). Can also have Ca++ in the center

BREAST CA: 75% of breast Ca are taller than wide

BREAST CYST: Simple cysts do not have rim CA++. However, oil cysts from fat necrosis gave rim Ca++

BREAST LESION SAMPLING: 4 samples for breast vs 7 for the thyroid

THINGS WHICH INCREASE THE CHANCE OF A BREAST RECURRENCE: extensive intraductal component multicentric comedocarcinoma subtype



1.4% of people with a palpable focal assym density have breast ca. However, for assym breast tissue, the risk of ca is <1%

DEFINITION OF A CIRCUMSCRIBED MASS: need to have >75% of the margin visible

MEDULLARY AND COLLOID CA: medullary is younger pts and is faster growing. Colloid is in older pts (>65), and they are slower growing and hyper or mixed echogenicity

NATURAL HISTORY OF TRAUMA TO THE BREAST: the post traumatic changes that occur disappear completely in 50%, and remain stable in the remainder

XRT ON BREAST: the edema is most pronounced at 6 mo. It stabilizes at 12 mo

DEFINITION OF A MASS: it is a density seen on 2 projections

BREAST HAMARTOMAS: they rarely calcify (8 of 14) [5/29/2002 10:58:41 PM]


NIPPLE DISCHARGE: breast ca 83% bloody and 27% clear. Only 13% cases of breast ca have discharge.

UNILATERAL DISCHARGE: papilloma, fibrocystic changes, papillomatosis; the most common presentation of a solitary papilloma is nipple discharge

BREAST CA++: punctate < 0.5 mm and round >0.5 mm in malignant lesions: 70% of the Ca++ are confined to the tumor and 30% are adjacent to the tumor malig dz: calcium hydroxyapatite benign dz: calcium oxalate distribution of malig Ca++: clustered, linear, segmental

ORIGIN OF INVASIVE CA: 90% from TD and 10% from the lobular unit

GIANT FIBROADENOMA VS ADENOMA: in teenagers, no difference histologically, no true capsule on either of them. Cancer in a fibroadenoma is rare. The giant one is huge and can take up the whole breast as it is so fast growing

PHYLLOIDES the mean age is 45. They can be benign, low grade malignant, or malignant. Ca++ are uncommon. They contain cystic areas. There is a 5-10% potential for malignancy. Also, if non malignant, they can be locally aggressive (9 of 14) [5/29/2002 10:58:41 PM]


EFFECT OF ESTROGEN AND PROGESTERONE: estrogen causes cystic disease estrogen plus progesterone causes fibrocystic disease so the effect on breast density is increased with the combination

SMALL LESION: if <5mm, then excision or vacuum if >5mm, then can do a core bx

LEAD TIME VS SOJOURN TIME: lead time bias is interval that cancers are undetected at sreening ie it is false negative screening sojourn time is the duration of preclinical disease, ie it is a fixed time period the lead time can never be > than the sojourn time. The soujourn time is shorter in younger women due to denser breasts

Another way to explain it is point at which preclinically detected to time at which it would have presented. Based on this, slower growin tumors have a longer lead time bias

RELATION OF DCIS TO IDC: DCIS is not an obligate precursor to IDC because IDC can occur in the absence of DCIS. 10% of pts with DCIS have a palpable abnormality. For gado enhanced MRI, rapid wash in and wash out is more correlated with cancer

FDG VS SESTAMIBI: (10 of 14) [5/29/2002 10:58:41 PM]


they both have similar sensitivity for detection for malignant and benign breast lesions

RISK FROM 1 RAD TO THE BREAST: 6 cancers per million per year after a 10 to 15 year latency period (according to pretest Hovespin)

PINCH TECHNIQUE: this is also called the Eckland view. 25% of breast tissue is still obscured

STEATOCYTOMA MULTIPLEX: it is a familial disorder with multiple sebaceous cysts on the upper torso that affects both men and women

CANCER IN CALCIFIED LESIONS: 20 to 30% are malignant

MINIMAL CANCER LESIONS: lcis, dcis, invasive ca not > than 0.5 cm

PLASMA CELL MASTITIS: it is a type of secretory dz. It is a chronic inflammatory process. It occurs due to duct ectasia with accumulation of gummous material. The process is bilateral. There are smooth intraductal calcifications, and indurative mastopathy. Nipple discharge is not uncommon. It involves several ducts with white, yellow and green discharge (11 of 14) [5/29/2002 10:58:41 PM]


MANAGEMNT OF LCIS: bilateral mastectomy has been suggested. However, close clinical follow up of both breasts is the accepted clinical practice

OVERALL PREVALENCE OF BREAST CANCERS: medullary: 4% IDC nos: 80% colloid: 3% comedo: 5% papillary: 1% lobular 8% tubular: 4%

PROSTHESIS RUPTURE: intracapsular>extracapsular

BREAST SCREENING STATS: FN: 6%, FP: 5%, PPV: 10%, NPV: 90% likelyhood of ca in a <10 mm well circumscribed mass: <2% recall rate on initial screening: not >10% technical repeat: not >5% recall rate on subsequent (incidence screening): 5% biopsy PPV: 30% cancer detection rate: <1% cancers <2 cm in diameter and confined to the breast: >50% (12 of 14) [5/29/2002 10:58:41 PM]


mortality reduction: 30% prevalence screen: 6-10/1000 incidence screen: 2-4/1000

EFFECT OF HRT: has increased the recall rate and decreased the sensitivity and specificity of mammo screening

TO ESTABLISH A LESION AS BEING A REAL OR NOT: 90 degree view, compression view, compression plus magnification view, angled view, rolled view. Note that pec muscle can be seen in only 30% of CC. This means that can achieve better compression with CC than with MLO to help rule out summation lesions. Also note that sclerosis distorts the uniform round Ca++ of adenosis and makes them look more malignant

ALTERNATIVE NAME FOR PHYLLODES TUMOR: same as cystosarcoma named as such because it contains cyst like component

GRANULAR CELL MYOBLASTOMA: it is a spiculated mass that occurs in the tongue and breast, but is non malignant. It is a rare lesion

BREAST LYMPHOMA: primary lymphoma is 0.1% of all breast malignancies. The most common tumor met to the breast is melanoma

PHANTOM IN BREAST IMAGING: (13 of 14) [5/29/2002 10:58:41 PM]


q weekly, contains 6,5,5 and have to detect 4,3,3 fibers/speck groups/masses in 4.2 cm thick compressed breast. It it fails the test, than the processor chemistry is the first thing that is investigated

CHARACTERISTICS OF MALIGNANT LESION: PHYSICAL: hard, gritty, decreased mobility, skin thickening, retraction MAMMO: spiculated, mass, ill defined, microlobulation, clusters of Ca++ with a branching pattern, skin thickening, taller than wide, angular margins MAMMO CALCS: linear, branching, casting, pleiomorhic, multiple clusters US: marked hypoechogenicity, taller than wide, branch pattern, duct extension

OTHER TUMORS: extraabdominal desmoid: spiculated, related to prior trauma, local wide excision requred, with this there is a 20% recurrence rate. It occurs close to the pectoralis. It is also associated with Gardners syndrome

BREAST LYMPHOMA: primary is rare. Secondary is more common. The more common cell type is B cell. Burkitts is rapidly fatal

BREAST ANGIOSARCOMA: macrolobulated, cloud like, hematogenous mets, younger women, contralateral breast involvement is common

METS: most common is ca from the contralateral breast that spreads via the lymphatics (14 of 14) [5/29/2002 10:58:41 PM]


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TYPES OF JOINTS: synovial (diarthrosis or diarthodial): appendicular skeleton facet joints of spine atlantoaxial lower 2/3 of SI joint uncovertebral joints

cartilagenous joints (amphiarthosis): synchondrosis pubic symphysis intervertebral discs

fibrous joint: interosseus membranes tib-fib sydesmosis (1 of 61) [5/29/2002 11:01:42 PM]



CLASSIFICATION OF SOME ARTHRIDITES (see the figures below): (2 of 61) [5/29/2002 11:01:42 PM]


SEROPOSITIVE: adult RA: primarily affects synovial joints F>M can have seronegative RA early in the course of dz, RF may be positive in the joint spaces before being positive in the serum

Rheumatoid arthritis: RF (IgG) combines with antigen (IgG or IgM) to form immune complexes in the joint which activate the complement system attracting PMN's into the joint space resulting in diffuse multicompartment symmetric narrowing associated with marginal erosions, periarticular osteoporosis, and periarticular STS. It involves the large joints as well as small ones. In the knee, all compartments are involved. Involvement of the hip leads to axial or less commonly medial involvement. Get acetabulae protrusio in advanced cases. Get central or peripheral articular erosions. Resorpn of the ends of the clavicles. synovial cysts, and pseudocysts in close proximity to the joint. Also get joint effusion. Small joint involvement-wrist, MCP, PIP of hands and feet. DIP's of hand are spared. Get STS (periarticular) and joint effusion which is the earliest symptom. Also edema, and tenosynovitis. Joint deformities are Swan neck, Boutonniere, and Hitch Hiker thumb. In advanced stages, get subluxation, dislocation of the fingers, ankylosis particularly in mid carpal locations, (more common in sero negative RA). T and L spine are only rarely affected in RA. The C spine is involved in 50% (odontoid, (3 of 61) [5/29/2002 11:01:42 PM]


atlantoaxial, apophyseal joints). Transverse ligament laxity is the main problem here. Can also get SL ligament destruction.

Rheumatoid nodulosis: Very high RF. Nodules on the extensor surfaces. M>F. No joint involvement

JCA: this is a group of at least 3 chronic inflammatory synovial diseases that affect children. F>M: Still's: fever, LAN, salmon colored skin rash, sometimes hepatosplenomegaly, fatigue, anorexia, wt loss, most have chronic or recurrent arthralgias (4 of 61) [5/29/2002 11:01:42 PM]


Polyarticular JCA: inflammation of 4 or more joints c associated findings of anorexia, wt loss, fatigue, adenopathy,. Growth retardation is common. Hypoplasia of the mandible and early closure of the growth plates causes short metacarpals. There is overgrowth of the epiphyses of the knees, shoulders, and hips. If positive RF, there is a worse prognosis.

Pauciarticular JCA: <4 joints in the first 6 months. Involvement of the SI joints is not a feature of JCA. JCA shows many of teh features of adult RA, but some have other features that are almost pathognomonic ie periosteal rxn along the shafts of proximal phalanges and metacarpals, joint ankylosis in wrist and interphalangeal articulations. Fusion of the apophyseall joints of the C spine is also characteristic. Because onset of JCA occurs before completion of skeletal maturation, involvement of growth of bones is common, and epiphyseal involvement leads to fusion of the growth plate with resultant retardation of bone growth. Accelerated growth may occur secondary to hyperemia. Epiphyseal enlargement of the knee may lead to overgrowth of the condyls of the knee. (5 of 61) [5/29/2002 11:01:42 PM]


SERONEGATIVE SPONDYLARTHROPATHIES: AS principally affects the synovial joints of the spine as well as the SI joints. Peripheral joints such as the hips, shoulders, knees may be involved. M>F and younger age. Extraarticular features include iritis, pulm fibrosis, heart conduction defects, aortic regurge, cord compression, and amyloidosis. Pts may get low grade fever, wt loss, anorexia. 95% of pts are HLA B27 positive

One of the earliest radiographic features is squaring of anterior border of the lower thoracic and lumbar VB's. As the dz progresses, syndesmophytes form which bridge the VB's. They have a delicate appearance which distinguishes them from degenerative spine dz. Paravertebral ossifications are common. When apophyseal joints and VB's fuse late in the dz, the radiographic hallmark is bamboo spine. The SI joints are also affected. In the peripheral joints, inflammatory changes may distinguish them from those in RA. In the foot, get characteristic erosion at the tendon insertion-os calcis. Involvement of the ischial tuberosities and iliac crests with new bone formation causes whiskering.

Reiter: M>F. Clinically it is an infectious dz characterized by arthritis, conjuctivitis, and urethritis. Also, characteristically get a mucocutaneous rash. Like AS, eye involvement is common (conjuctivitis, iritis, uveitis, episcleritis). 60% of pts are HLA B27 positive. Unlike AS, reiters can affect SI joints unilaterally. There are 2 types of reiters, sporadic (more common in t he US associated with gonococcal urethritis, M>F) and epidemic (more common in Europe) associated with shiglla dysentry and yersinia. In reiters, get assymmetric, peripheral arthritis. It has a predilection for lower limb joints, most commonly the foot. MTP and heel. SI joint involvtcan be symmetric or assymetric. In the T and L spine, get course syndesmphytes characteristically bridging the VB's.

Psoriatic: there are 5 subgroups: type1: nail and terminal tuft of distal and occasionally proximal IP joints. type 2: opera glass hand deformity or arthritis mutilans due to extensive destruction of the phalanges, and MCP joints with pencil in cup deformity. These pts also have sacroileitis. type3: symmetric polyarthritis causing ankylosis of the PIP and DIP joints. Type 3 is frequently indestinuishable from RA. type 4: oligoarthritis. Unlike type 3, joint involvment is assymmetric and includes the PIP and DIP as well as the MCP joints. It is this subtype that most commonly has "sausage digits" Psoriasis involves mainly DIP of hands and feet but other sites ie PIP as well as hips, knees, ankles, shoulders, and spine may be found. There are few radiographic hallmarks to make the correct dx. The phalanges of the hand and foot may show fluffy new bone formation, which if periarticular is referred to as "mouse ears". In the advanced stage, can get "pencil in cup" deformity. In the heel, the late stage (6 of 61) [5/29/2002 11:01:42 PM]


changes are broad based osteophytes and periostitis. PA of the spine has a high incidence of sacroileitis which can be unilateral or bilateral. As in Reiters, can cause syndesmophytes and paraspinal ossification.

Enteropathic: it is associated with UC, CD, whipples (intesinal lipodystrophy). Most pts are HLA B27 positive. The spine, SI, and peripheral joints are affected in all three types. In the spine, there is squaring of VB's, formation of syndesmophytes bilatrally, and a radiograph looking identical to that from AS. The activity of the peripheral arthritis follows that of the bowel disease

Erosive Osteoarthritis: it affects typically middle aged women. It combines the clinical features of RA and OA. Can be recognizes by involvement of the PIP and the DIP, and a characteristic "gull wing" pattern of articular erosion. Spontaneous fusion of the IP joints may occur. It is limited the hands

MISCELLANEOUS: SLE: adolescent, M>F, B>W. these pts have malaise, weakness, anorexia, wt loss, positive ANA, rash the hands, hips, ankles, shoulder are affected. Hands are predominant site of involvement. The key feature is flexible joint contractures particularly at the MCP and PIP of the fingures and the IP of the thumb. These are due to loss of ligament and capsular support

Schleroderma: F>M, skin changes, edema, thickening. There are ST Ca++, acroosteolysis. Most pts develop CREST syndrome. 30 to 40% are RF and ANA positive. There is atrophy of the ST's of the tips of the fingers, resorption of the distal phalanges, subcutaneous and periarticular Ca++, and destructive changes of small articulations. Usually the IP joints.

Gout: M>F, great toe. Also goes for large joints such as knee, and elbow. There is articular erosion with preserved joint space and overhanging edges. They lack osteoporosis. There is tophi and periarticular swelling.

CPPD: M=F: variable joints: chondrocalcinosis of articular cartilage and menisci. Calcification of tendons, joints, ligaments, capsule. femoropatellar joint: joint space narrowing, subchondral sclerosis, osteophytosis the classic joints affected are the wrists, elbows, shoulders, ankles, with djd changes and chondrocalcinosis (7 of 61) [5/29/2002 11:01:42 PM]


hemophilia: M=F, large joints (hips, knees, shoulder), elbows and ankles. There is joint effusion, osteoporosis, symmetrical joint space narrowing, articular erosions, widened intercondylar notch, squared patella, it is very similar to the changes seen in JRA. In terms of frequency of joint involvement: knee>ankle>elbow>wrist>hip and shoulder. Hemophiliac pseudotumor most commonly occurs in the pelvis

hemochromatosis: M>F, hands, 2nd and 3rd MCP with beak like osteophytes and chondrocalcinosis

HPT: hands, multiple bones, skull, spine. There are destructive changes in the IP joints with subperiosteal resorption. Brown tumors. Salt and pepper appearance and rugger jersey spine

CAUSES OF ENTHESITIS: AS, enteropathy, arthritis, PA, reiters, DISH, acromegaly. To distinguish DISH from AS, look at the SI joints. They are usually not affected by DISH

OA: in OA, medial side of knee is affected which causes a varus deformity. The lateral aspect of the patellofemoral joint is also affected. In the wrist, involvement of the trapezio-scaphoid and the first CMC joints are the primary sites

CAUSES OF A HIGH T1: fat, flow, gado enhancement, extracellular methemoglobin, proteinaceous fluid, milk of Ca++, melanoma

AVASCULAR NECROSIS: Sinding-Larsen-Johansson disease is osteochondrosis of the inferior pole of the patella, age 10-14 yrs. Sever's disease is a normal variant associated with weight-bearing that results in sclerosis and fragmentation of the secondary calcaneal ossification center. Kohlers disease is avascular necrosis of the tarsal navicular, usually boys 3-10 yrs (8 of 61) [5/29/2002 11:01:42 PM]


COMPLICATIONS OF TIBIAL PLATEAU FX: lateral tibial plateau fx is the most common (85%) according to the Schatzker classification, there are 6 types 1-6 type 3 is a pure compressonn fx and also the most common (35%) type 5 is bicondylar overall, types 1-3 are the most common medial plateau fx's are associated with more violent injury

the complications are: peroneal n injury (due to lateral compartment being more commonly injured) OA no anterior compartment sydrome as there is no anterior compartment located here popliteal rupture and ligament injury

SLAC WRIST: occurs spontaneously or after trauma, similar pattern to CPPD, get associated SL widening

PERILUNATE DISLOCATION: this is the most common association with scaphoid waist fx

ULNAR CARPAL IMPACTION SYDROME: it is TFCC tear and dissassociation of the LT ligament

PATELLAR DISLOCATION: it is associated with patellar rim fx (9 of 61) [5/29/2002 11:01:42 PM]


LEGGE CALVE PERTHES: it is bilateral in only 10%. It is much more common in boys

FX DISLOCATION: Colles is not a fx dislocation whereas Barton is

OSTEOID OSTEIOMA: shows pooling of contrast in the nidus


HYPOPLASTIC TERMINAL TUFTS: get hypoplastic terminal tufts and not acroosteolysis in association with pyknodystocis

LIGAMENTS CONTRIBUTING TOWARDS PELVIC STABILITY: sacrospinous, sacrotuberous, sacroiliac ligaments all contribute toward pelvic stability

SYNOVIAL CYSTS: these are a will known manifestation of RA. They are common in the popliteal region (10 of 61) [5/29/2002 11:01:42 PM]


PARALYSIS: there is an increased incidence of osteomyelitis


WHICH OSSIFY IN MULTIPLE CENTERS: trochlear and capitellum

LEGGE CALVE PERTHS: the pain is rapid in onset

ONE THING THAT CHARACTERIZES TB: late preservation of the disc in spinal infections

SPONTANEOUS TENDON RUPTURE AND HOLES IN THE CARPAL BONES? this is one complication of renal failure


SSD DACTLYLITIS: (11 of 61) [5/29/2002 11:01:42 PM]


occurs in children 6 mo to 2 years. It is most common in the hands and feet


LIGAMENTS IN CHILDREN: they are stronger than the growth plate and therefore more likely to see growth plate injury than a tear in the ligament

SOME FEATURES OF PYKNODYSOSTOCIS: dystrophic nails, yellowed teeth, beaked nose, wormian bones, non segmental C1 and C2, non pneumatized parnasal sinuses,tapered terminal tufts

SIEZURES: you can see bilateral posterior shoulder dislocation

HILL SACH: it is posterolateral and is best seen on internal rotation

BONE AGE AND OBESITY: obesity can cause advanced bone age (12 of 61) [5/29/2002 11:01:43 PM]


OSSIFICATION OF THE ANNULUS FIBROSIS: patients with AS have ossification of the annulus fibrosis which may be confused with ossification of the anterior longitudinal ligament. Ca++ of the posterior longitudinal lig is seen in DISH

CHANCE FX: they are more commonly associated wtth seatbelt injury, but they can also occur with a fall from a height

CYSTIC ROBUST RA: seen in younger athletic people. Osteoporosis is not a feature

OSA VS EWINGS: OSA can met to bone more frequently than Ewings

ANTERIOR CLAVICLE DISLOCATION: more common than posterior dislocation. Posterior dislocation of the L sternoclavic joint can injure the L BCV

RSD: it is usually bilateral with involvement of one side more than the other

ACROMEGALY AND DISC CALCIFICATIONS: acromegaly causes disc space Ca++ while HPT does not (13 of 61) [5/29/2002 11:01:43 PM]


SYNOVIAL CYSTS AND JRA? rare in jra but common in ra

POST MENOPAUSAL OSTEOPOROSIS: see elevated urinary Ca++ but normal blood Ca++

EPIPHYSEAL CUPPING: trauma, rickets, scurvy, vit A toxicity

RUPTURED PT: it is the most common cause of acute foot pain in women>50

PAGETS MARKERS: urine hydroxyproline is elevated in pagets and so are blood alk phos levels. Note that bone resorption forms hydroxyproline and bone formation forms alk phos

GUYONS CANAL: is bordered by the pisiform medially and the hook of the hamate laterally and contains the ulnar artery and nerve

CARPAL TUNNEL CONTENTS: FCR (in a separate compartment) (14 of 61) [5/29/2002 11:01:43 PM]


FDP, FDS, FPL, median nerve

MAGIC ANGLE: is is most pronounced with short TE sequences

FOOT ANKLE ANATOMY: inferior to the sustentaculum tali is the FHL the most common injured tendon in the ankle is the TP, which is the one that inserts onto the navicular bone think of tom, dick, and very nervous harry and you come up with tp, fdl, artery, vein, nerve, and fhl (15 of 61) [5/29/2002 11:01:43 PM]


in the foot, TDH passes beneath flexor retinaculum on its way through the tarsal canal, joined by the PT artery and PT nerve. Since the FHL passes under the sustentaculum tali, it can get entrapped between a sustentaculum tali fragment and medial calcaneal cortex following a compression fx of the calcaneous. The peroneal tendon can get entrapped between fragments of the lateral cortex.

BIT ON SINUS TARSI: it is a cone shaped sinus which is larger medially and contains fat and neurovascular structures, and 5 ligaments including the ligament of the tarsal canal. Inversion injury causes sinus tarsi syndrome with lateral foot pain and loss of the fat signal. The 5 ligaments are medial, intermediate, lateral, and cervical ligament of the the tarsal canal

CONTENTS OF THE EXTENSOR RETINACULUM OF THE FOOT: TA ---> EHL ---> EDL --->pertertius (medial) (lateral)

TALAR BLOOD SUPPLY: most is carried in the interosseus ligament. The anterior and middle facets are in the subtalar joint, while the posterior is in the posteriior subtalar joint. Posterior is the largest and most important of the 3. Middle facet is part of the sustentaculum tali (16 of 61) [5/29/2002 11:01:43 PM]


FOOT PAIN IN ADOLESCENTS: the most comomon cause is tarsal coalition

RHABDOMYOSARCOMA: 1/3 arise in striated m. The remaining 2/3 is in sites where striated m is not found

FAILED BACK: 3 causes of pain after back surgery: 1 failed back. 2 segmental spine instability, 3 discogenic pain from mechanical overload on a disc

ISAROV PROCEDURE: 0.5 mm/day, uses membranous ossification to increase bone lengh

TENDON SHEATHS: long head of biceps and FHL communicate with joint space so fluid in the sheath can be normal. The peroneus longus t does not communicate with the joint space. The achilles has no tendon sheath. With tendon injury, you get increased T2 signal in the tendon from both partial tear and tenosynovitis. FHL and achilles are injured in ballet dancers. FHL uses sustentaculum tali as a pulley (see figure). In foot, although rare, the talonavicular joint is a target of CPPD

SESAMOIDS: these are in the FHB tendon, not the FHL (17 of 61) [5/29/2002 11:01:43 PM]


Hallux valgus: results form poor fitting footware. The angle between should be <20 degrees. In severe disease it is >35 degrees


FRACTURE CLASSIFICATION: maxilla: lefort AC joint: rockwoods Proximal humerus: Neer Epiphyseal: Salter Harris Acetabular column: Letornel Fem Neck: Garden Proximal tibial: Muller Patellar: Larsen Ankle: Weber

ANTERIOR AND POSTERIOR SHOULDER DISLOCATION: anterior: in shoulder, axillary a, brachial plexus, axillary and musculocutaneous branches lie anteroinferior to the glenoid so with first time anterior dislocation, the axillary n is the most likely to be injured (18 of 61) [5/29/2002 11:01:43 PM]


posterior: rotator cuff and neurovascular injury is less common. Posterior cortical rim of glenoid and lesser tuberosity are fxd

ROCKWOOD CLASSIFICATION OF AC SEPARATION: 1: NL, 2: AC separation, 3: AC and CC separation, 4: total disruption

INNERVATION OF THE HAND: dorsal: 2 1/2 to 2 1/2 volar 1 1/2 to 3 1/2 ulnar to radial nerve

CAUSES OF CARPAL TUNNEL SYNDROME: PRAGMATIC or pregnancy, ra, gout, mass, amyloid, trauma, idiopathic, collagen vascular

HOLT ORAM: it consists of a fingerized thumb and hypoplastic or absent radius, CHD, and an arched palette

PSEUDO AND PSEUDOPSEUDOHYPOPARATHYROIDISM: the 4th and 5th MC are smaller than normal pseudo are short, obese, mentally challenged, have skeletal resistance to PTH, hypocalcemia, and normal PTH the pseudopseudo have all labs normal. The features are otherwise the same as pseudo above

BUNKBED FX: (19 of 61) [5/29/2002 11:01:43 PM]


it is a salter 1 or 2 of the base of the first MT which is the pediatric equivalent of the lisfranc fx

MR OF RHEUMATOID NODULES: show increased SI on T2 while hyperlipidemia nodules show increased SI on T1

JOINT INVOLVMENT IN CPPD AND HEMOCHROMATOSIS: both show involvment of the 2nd and 3rd MCP

PES ANSERINUS: think SGT or sartorius, graculus, and semitendonosis

CAUSES OF METACARPAL SHORTENING: May occur with Turner's syndrome, Klinefelter's syndrome, trisomy 13 and 18, pseudohypoparathyroidism, pseudopseudohypoparathyroidism, trauma, basal cell nevus syndrome, melorheostosis, hereditary multiple exostoses, and ectodermal dsyplasia and also idiopathic

DWARFISM: rhizomelia: short femur, humerus mesomelia: short radius, ulna, tibia, fibula acromelia: hands and feet affected micromelia: entire limb affected

more on dwarfism quoted from Achondroplasia produces skull anomalies including brachycephaly and a hypoplastic skull base, (20 of 61) [5/29/2002 11:01:43 PM]


vertebral anomalies including posterior scalloping, scoliosis, laminar thickening, rounded anterior beaking of the lumbar vertebral bodies, and widened intervertebral foramina, yet lumbar spinal stenosis from ventrodorsal and interpediculate space narrowing. Achondroplasia is also associated with squared flattened iliac bones in the shape of a tombstone, also termed "champagne glass," as well as horizontal acetabula, brachydactyly, and metaphyseal flaring. Ovoid vertebral bodies with central anterior tongue at lower thoracic / upper lumbar vertebral bodies is a finding in Morquio's syndrome, as are hypertelorism, pectus carinatum, failure of fusion of sternal segments, hypoplasia or absence of odontoid, platyspondyly, widened intervertebral disk spaces, and elongated pelvic inlet and flared iliac wings termed "goblet" or "wineglass" shaped pelvis. H-shaped vertebral bodies are characteristic of sickle cell anemia. Congenital vertebral body fusions are found in Klippel-Feil syndrome. Ankylosing spondylitis gives osteitis of the anterior corners of the vertebral bodies and ossification of the annulus fibrosus. Trident hand, which is associated with achondroplasia, is characterized by fingers of nearly equal length. Cleido-cranial dysostosis is a syndrome noted for midline defects, including large head, decreased ossification of the skull, wormian bones, widened fontanelles and sutures with delayed closure, hypoplastic paranasal sinuses, hypoplastic clavicles, extra ribs, hemivertebrae, hypoplastic iliac bones, shortened radius, elongated second metacarpals, hypoplastic distal phalanges, pointed terminal tufts, coned epiphyses, and coxa vara. Ulna-minus variant has been associated with Keinbock's disease (avascular necrosis) of the lunate. In the vast majority of patients, the radial aspect of the lunate articular surface is even with the radial articular surface. An ulnar-plus deformity can result in tears of the triangular fibrocartilage and ulnar impingement syndrome. Holt-Oram syndrome is characterized by absence or hypoplasia of the thumb, 1st metacarpal, carpal bones, and radius. Nail-patella syndrome, also known as Fong disease, is characterized by hypoplastic nails of the 1st and second digits, abnormal iris pigmentation, renal dysfunction, bilateral posterior iliac horns (pathognomonic), hypoplasia of patella and radial head, and scoliosis.

FUSION ACROSS THE IP JOINTS: this can occur across the IP joints with psoriasis, reiters, erosive osteoarthritis, and ankylosing spondylitis. With RA, bones will fuse at the level of the tarsals and carpals; if there is more distant fusion than this, then it is not RA and may represent one of the overlap sydromes

DISI: it is associated with widened SL distance and horizontal configuration of the scaphoid

OSSIFICATION: (21 of 61) [5/29/2002 11:01:43 PM]


one bone where both membranous and enchondral take place together is the clavical

ACL TEAR: bone bruise involving the lateral femoral condyl is very specific for ACL tear. Buckled PCL or posteriorly dispaced lateral meniscus are less specific. It involves lateral contusion of the femoral condyl and posterolateral contusion of the tibial plateau in addition to medial meniscal tear etc

EFFECTS OF PARALYSIS: cartilage atrophy, osteomyelitis, osteonecrosis, heterotopic ossification

SHIN SPLINTS: they have nothing to do with stress fractures. On nuc med study with 99mTcMDP, there is increased uptake on the skeletal phase (not the vascular or blood pool phases) in the posteromedial tibial cortex in its mid to distal aspect

RSD: all 3 phases of the 3 phase bone scan are increased in 60%. It is associated with MI in 6%

VIEWS FOR PELVIC FX: 40 to 50 degree outlet view for showing posterior displacement of the iliium and SI joint oblique view (also called Judet) is for the acetabulum. Note that the outlet view is best for seeing vertical diastasis of the SI joint

AXILLARY NERVE DAMAGE: (22 of 61) [5/29/2002 11:01:43 PM]


occurs most commonly with anterior shoulder dislocation and can result in atrophy of the deltoid muscle. Note hat the radial nerve lies in the bicipital groove

ELBOW DISLOCATION: bone fragment in relocatid elbow joint space is usually from coronoid in an adult and from medial epicondyl in a child

SEGOND FX: bone chip just lateral to to lateral tibial plateau = ACL injury and lateral collateral ligament avulsion or tear

AMYLOID: it can cause lytic lesions, osteoporosis or osteonecrosis, fx, and carpal tunnel sydrome

IVORY PHALANX: can see it with psoriasis

TRANSIENT REGIONAL OSTEOPOROSIS: It is analogous to sudeks. In the female the L hip is worse in the 3rd trimester. In men it involves both R and L hips about equally. M>F and 4-5th decade most common. It has a duration of about 9 months. It is also known as BM edema sydroma with lots of marrow edema. There is patchy osteoporosis of the hip. On MR, there is high T2 signal and a small effusion. Note that hip infection causes a large effusion

AL TOXICITY: get spontaneous fx of the upper 2, 3, 4 ribs (23 of 61) [5/29/2002 11:01:43 PM]


PHEMISTERS TRIAD: (refers classically to TB arthritis): juxtaarticular osteoporosis, gradual joint space narrowing, and periarticular erosions

EROSIVE OSTEOARTHRITIS VS RA: EOA does not involve the MCP joints


CAUSES OF DISC SPACE CALCIFICATION: CPPD, acromegaly, hemochromatosis, HPT, neuropathic, ochronosis

WIDE SYMPHYSIS PUBIS: cleidocranial dysostocis, bladder extrophy, ehlers danlos, HPT

SEGOND FX: it is a fx of the margin of the anterolateral tibial condyl via avulsion fx of the insertion of lateral capsular ligament. The ddx is fx of Gerdy tubercle more posteriorly where the ITB attaches. It is associated with ACL tear (up to 100%), and MCL injury (24 of 61) [5/29/2002 11:01:43 PM]


POST MENOPAUSAL OSTEOPOROSIS: horizontal trabeculae are more thinned than the verticle ones

PRINCIPLE EVERTER OF THE FOOT: PT tendon. Patients with RA are more prone to rupture of the PT leading to painful flat foot


MR OF SPINAL DISCITIS: bright disc and bright endplate on T2

CAUSES OF CUPPED EPIPHYSIS: rickets, scurvy, trauma, XRT, infection, vit A, sickle cell, bone dysplasias

PARS DEFECT: secondary to degenerative change is most common at L4,5 and secondary to pars defect is most common at L5,S1. The defect is located just above the level of the disc space which is just above the level of the NF

ROTATOR CUFF INJURY: supraspinatus>infraspinatus>subscapularis>teres minor (SIST) when tendons degenerate, the result is decreased echogenicity on US (25 of 61) [5/29/2002 11:01:43 PM]


PILLAR FX VS UNILATERAL LOCKED FACET: flexion and rotation causes pillar fx extension and rotation causes unilateral locked facet

MYOSITIS OSSIFICANS ASSOCIATION: most closely with hip dislocation.

SUPRACONDLYAR FRACTURE: in the normal, the anterior humeral line passes through the middle 1/3 of the capitellum

AVULSION FRACTURE: ASIS is sartorius, AIIS is rectus femorus, pubic ramus is adductors and gracilus, lesser trochanter is iliopsoas

FRACTURE CLASSIFICATIONS: garden: femoral head tile: acetabulim weber: ankle schatzker: tibial plateau essex lopresti: calcaneus

CDH: most commonly affects L hip (70%). Bilateral is 5%. In CDH, < 50% of the head is covered by the (26 of 61) [5/29/2002 11:01:43 PM]


acetabulum. Note that the acetabular cartilage is more echogenic than the femoral head cartilage


BERQUIST TRIAD: spine/pelvis fx Diaphragmatic rupture Rib fx

MOST COMMON CAUSE OF HPT: Adenoma accounts for 80% of cases of hpt

PRIMARY HPT: see brown tumors, chondrocalcinosis

SECONDARY HPT: osteosclerosis, rugger jersey spine, soft tissue Ca++

HAND SCHULLER CHRISTIAN DISEASE: Hans schuller Christian disease is triad of diabetes insipitus, multiple lytic bone lesions, and exopthalmos (27 of 61) [5/29/2002 11:01:43 PM]


SOME ARTHRIDITES: Squared patella is a finding in hemophilia Pseudoarthrosis is associated with ankylosing spondylitis Protrusio acetabulae is associated with rheumatoid arthritis Mouse ears are associated with psoriatic arthritis

HYPERPARATHYROIDISM: In HPT, subperiosteal resorption occurs along the medial aspect of the proximal humerus and the tibia and along the radial aspect of the metacarpals

TARSAL COALITION: calcaneonavicular>talocalcaneal (middle facet)>talonavicular>calcaneocuboid. It is associated with peroneal flat foot in the 3rd decade. Talar beaking is more commonly seen in talocalcaneal with narrowing of the posterior subtalar joint. The etiology is congenital, acquired, infection, trauma, surgery

PERIOSTEAL VS PAROSTEAL OSTEOSARCOMA: periosteal: cleavage plain, looks like juxtacortical chondrosarcoma, worse px than parosteal. Periosteal OSA shows a saucerized cortex in the diaphysis and an associated ST mass. The differential dx is parosteal OSA and Ewings (5% of Ewings look like periosteal OSA) parosteal: looks like myositis ossificans and has a broad based attachment. The metaphyseal cortex is saucerized, and there is an associated ST mass in terms of location, 85% of periosteal OSA are in the femur, usually the diaphysis. The mean age is 22 (9-74) while parosteal is in posterior distal femur. The mean age is 30

STRESS SHIELDING: shielding of portion of bone or entire bone from mechanical stress due to internal fixation device resulting in demineralization and loss of intrinsic strength of the bone (28 of 61) [5/29/2002 11:01:43 PM]


STRESS RISER: bone has some flexibility compared with the orthopedic hardware. The portion of the bone with the hardware becomes stiffened. On either side of the IM rod, the bone maintains its normal flexibility resulting in a transition zone that is a common site for fx called a stress riser

ADAMANTINOMA: classic location is in the anterior 1/3 of the distal tibial diaphysis

OPLL: 20% of cases are found to have DISH. The C spine is most commonly affected site. It is not associated with AS

CAUSES OF NEURPATHIC JOINT: syringomyelia, DM, leprosy, neurosyphilis, myelomeningocele, sp cord injury, congenital insensitivity to pain

PAGETS: 1-5% or <1 % incidence of sarcomatous degeneration. Ivory vertebra (densely white). Also picture frame vertebra (also called bone within bone)

LINES OF ACETABULUM: (29 of 61) [5/29/2002 11:01:43 PM]


1: anterior column (iliopectineal line) 2: posterior column (ilioischial line) 3: roof 4: anterior lip 5: posterior lip 6: teardrop (seeing it does not tell you whether the quadrilateral surface is intact or not)

SLAC: this is scapholunate advanced collapse. It has an appearance also known as the stepladder configuration. It is most typial of CPPD. The radiocarpal joint is commonly affected in CPPD. Other things which help suggest CPPD are TFCC chondrocalcinosis, and or calcification of the SL ligament

LOOSENING OF PROSTHESIS: normally <2mm band of lucency surrounding a prosthesis which may be fibrous tissue or Mach effect. > 2 mm indicates loosening (30 of 61) [5/29/2002 11:01:43 PM]


TELANGIECTATIC OSA: it is highly lethal. Looks like ABC or SBC histologically

CLEAR CELL CHONDROSARCOMA: proximal femur or humerus. It has affinity for end of bone like GCT. It is a low grade malignancy clinically.

INVOLUCRUM: in osteomyelitis, involucrum is envelope of new bone . The dead cortical bone in the middle surrounded by the involucrum is called the sequestrum. Invulute=envelope ie surround

BRODIE ABSCESS: In children. They are subacute and well defined. Involve the metaphysis, rarely the epiphysis

OSTEOFIBROUS DYSPLASIA: formerly called ossifying fibroma. It differs from the classic FD in that the OD has bone spicules rimmed by osteoblasts. Lesion is usually in the anterior diaphyseal cortex of the tibia or fibula and have a rim of schlerosis. Anterior bowing of the involved bone is sommon, Most occur by 10 years old

FIBROUS DYSPLASIA: shepards crook deformity. Expansile lesion in distal fibula diaphysis. All polystotic dz have the tendency for one side of the body. With the polyostotic form, have polyendocrinopathy, sex precociousness, cushings, acromegaly, HPT, DM (31 of 61) [5/29/2002 11:01:43 PM]


EWINGS: histol resembles PNET, prefers metadiaphysis (44%), mid diaph (33%), mataph (15%), and epip (2%). Long bones 60% and flat bones 40%

HODGKINS: bimodial is peaking at 3rd to 5th decade. B symptoms are fever, night sweats, wt loss, superior LAN is the hallmark of HD. 10% initial involvement as lung involvement.

HPT: In addition to subperiosteal resorption in the hand both the medial proximal tibia and medial humerus are also affected. Also seen in superior and inferior edges of ribs, and undersurface of distal clavicle

ABC: some consider it to be an intraosseus or periosteal vascular malformation. It is thought to arise in response to trauma or a lesion. Underlying causes are GCT, chondroblastoma, FD, telangiectatic OSA. Sometimes, the ABC completely replaces the inciting tumor such that it can no longer be found. 75% of ABC are metaphyseal in long bones

H SHAPED VB: SS anemia, gaucher, thalassemia

MORE ON OPLL: it is seen in 50% of pts with DISH and 20% of pts with OPLL have DISH (32 of 61) [5/29/2002 11:01:43 PM]


MORE ON CPPD: it likes the medial tibial femoral joint space and the lateral patellofemoral joint space

CAUSES OF ACROOSTEOLYSIS: scleroderma, psoriasis, raynauds, thermal injury, hyperparathyroidism

LUNG FEATURES OF SARCOID: honeycombing or cystic changes involving the UL predominantly

CAUSES OF IP FUSION: psoriasis, AS, EOA, reiters, and not RA. Note that RA fuses at the level of the tarsals and carpals

SHOULDER: anterior dislocation 96%. The shoulder is in external rotation, and abduction. May be associated with fx of the greater tuberosity. There is risk of brachial plexus injury

posterior can be traumatic or atraumatic. The traumatic is due to ECT, convulsions etc and 50% are unrecognised intitially. They have the "rim sign" and the trough sign which is a reverse hill Sachs lesion.Ie a compression fx of the anteromedial humeral head. There is an associated avulsion of the lesser tuberosity. The light bulb sign is present due to internal rotation

DISI AND VISI (33 of 61) [5/29/2002 11:01:43 PM]


1=scapholunate dislocation (looks normal with widened SL interspace). There is a 3 mm gap between the lunate and scaphoid also called the Terry Thomas sign. there may be a ring sign on the PA view secondary to rotatory subluxation of the scaphoid 2=capitolunate dislocation (---> perilunate dislocation). The capitate is dislocated dorsally. While the lunate maintains its articulation with the radius 3=triquetrolunate dislocation (--->midcarpal or transcaphoid dislocation). The triquetral ligaments are ruptured and there is dorsal dislocation of the capitate and carpus and volar dislocation of the lunate 4=dorsal radiocarpal dislocation (--->lunate dislocation). The lunate dislocates volarly while the capitate appears to be aligned with the radius

BIT MORE ON NEGATIVE ULNAR VARIANCE: normally, there is a 80% to 20% ratio of distribution of forces on the radius and ulnar. Get 100% loading on the radius with negative ulnar variance. This results in malacia of the lunate. 80% of pts with (34 of 61) [5/29/2002 11:01:43 PM]


Kienbochs have negative ulnar variance. However, 20% of the normal population also have negative ulnar variance, so it is not specific for it. It is counted as negative or postitive if it is > or < than 2 mm

HIV ARTHROPATHY: looks like seronegative arthropathy with periostitis. There is LE predominance. Axial skeleton is spared. There is sacroileitis sometimes

TENNIS ELBOW: It is lateral epicondylitis. With golfers, the flexor muscles of the forearm cause medial epicondylitis

CENTER EDGE ACETABULAR ANGLE IS ANGLE OF WYBERG: it is normally> 20 degrees. In DDH, there are 3 types: Type 1 is dislocatable, unstable. Type 2 is partially dislocateable, subluxed. Type 3 shows flattening of the femoral head

TB OF THE JOINT: the hip is the most commonly affected joint

MM: 70% male predominance. 98% are > 40 years old. Most pts are assymptomatic. Bence Jones proteinuria in 50%. Thirty four percent are plasma cell type. There are uniform skull lesions

AMYLOIDOSIS: 1ary: no pre existing cause. Heart muscle, lungs, synovium, perivascular tissue. It is associated with plasma cell myeloma as the 2 disorders have similar onset (35 of 61) [5/29/2002 11:01:43 PM]


2ary: type is most associated with MSK involvement. Occurs in late coarse of chronic dz. Eg long term HD, osteomyelitis, infections.

3ary: familial, associated wiht nephropathy, neuropathy, cardiomyopathy

4ary: localized form in tracheo esophageal tree

amyloidosis causes lytic lesions in the femoral head and neck, shoulder, olecranon, wrists, bulky soft tissue masses. Also, in 8% of people, it causes carpal tunnel syndrome

OCHRONOSIS: it causes decreased disc spaces height. The Ca++ are laminated. There are Ca++ inner fibers of the annulus. Ochronosis and acromegaly Ca++ is HADD. All other is CPPD

CHONDROBLASTOMA VS GCT: chondro is dark on T1 and T2 while GCT is low or intermediate on T1 and bright on T2

MARROW DEVELOPMENT: distal ----> proximal. for hematopoietic being replaced by fat

FIRST CMC INVOLVEMENT: OA, gout, scleroderma, EOA, not reiters. It is classic for OA and EOA (36 of 61) [5/29/2002 11:01:43 PM]


LUPIS ARTHRITIS: the arthritis is non erosive. The ball catcher view is the best

ENTHESOPATHIES: AS, psoriasis, reiters, DISH. Shoulder is very infrequently affected by OA

SYNOVIAL OSTEOCHONDROMATOSIS: when synovial chondromatosis ossifies, it is caused synovial osteochondromatosis. Common locations are hip, knee, shoulder

ODONAHUE UNHAPPY TRIAD: medial collateral ligament tear, acl tear, medial meniscal injury note that an ACL tear is associated with meniscal injury. Lateral meniscal injury > medial in 65% note also that a PCL tear is most likely to be isolated

MORE MUSCULOTENDINOUS INSERTIONS: ACL: lateral femoral condyl PCL: medial femoral condyl biceps femorus: styloid process of fibula iliotibial band: gerdy tubercle on lateral tibia still more anteriorly is capsular attachment which is the site of segond fx

ULNAR VARIANCE IN TFCC TEARS VS KIENBOCHS: positive ulnar variance is associated with tfcc tears (37 of 61) [5/29/2002 11:01:43 PM]


negative ulnar variance is associated with kienbochs

POINT OF RUPTURE OF INFRAPATELLAR TENDON: it breaks at the tibia first

CAUSE OF OSTEOMYELITIS IN PTS WITH SSD: S. Aureus. This is also the most frequent pathogen to cause diskitis

SOME FRACTURE DISLOCATIONS: barton, galeazza, monteggia, bennett. Note that bennett is an intraarticular fx-dislocation of the base of the 1st MC while a rolando is a comminuted bennett

CAUSE OF OBLITERATED SINUSES: obliterated paranasal sinuses are from extramedullary hematopoiesis seen in thalassemia. It is not usually seen in SSD

CAUSE OF BIG DIGITS: NF, Maffucci, macrodystrophia lipomatosa, Klippel trenaunay (these can also have local gigantism)

ANKLE INJURY: eversion injury causes a tranverse fx of the medial malleolus and a spiral or transverse fx of the fibular inversion injury causes a transverse fibula fx and an oblique fx medial malleolus (38 of 61) [5/29/2002 11:01:43 PM]


HADD: most commonly affects the shoulder joint, usually monoarticular. Other name is milwaukee shoulder. It also affects the wrist, hand, foot, L spine. HADD causes calcific tendonitis. The supraspinatus tendon is the most frequent site. CPPD is commonly associated with HADD

CAUSES OF ST CA++: trauma, burns, neuro injury, calcific tendonitis, CVD, HPT, gout, CPPD, infection, sarcoid

SPINE DIVISIONS: for the purposes of injury, the spine is divided into 3 columns. Two of these have to be disrupted to get instability

LIPOSARCOMA: there are 4 types. well differentiated, myxoid, round cell, pleomorphic. The round cell is the most common. Both liposarc and lipoma can occur in muscle. Lipoma is not a precursor lesion of liposarc. It is the second most common tumor after MFH. It is commonly affecting 40 to 60 y old. It affects the leg, glut, and the thigh (42%) which also happens to be the most common site of involvement. The abdominal wall (42%) is also commonly affected

CPPD: wrists, hips, knees (particularly patellofemoral joint). Pseudogout is secondary to CPPD; chondrocalcinosis knee>symphysis>TFCC

SCFE: 12-14 yo M>F, B>W, if in girls, 20 to 25% bilateral. Slippage is posteriorly, medially and inferiorly (39 of 61) [5/29/2002 11:01:43 PM]


LCLC: anteriorly is ITB, medially is LCL which is thickening of the lateral retinaculum and posteriorly is biceps femorus tendon. Also included is the popliteus tendon, and lateral head of the gastrocnemius. It also includes the patellar retinaculum and the arcuate ligaments

VAN BUCHEM SYNDROME: AR and presents at an earlier age than Worths which is AD. It is endosteal hyperostosis of the cortex of the tubular bones. They are not expanded. There is mandibular enlargement however and it also affects the skull, clavicle, ribs, long bone diaphyses and can lead to cranial nerve palsy. The spinous processes also appear thickened and sclerotic

CHANCE FX: most common location is T12-L2


HIP DISLOCATION: femur in adduction with posterior hip dislocation and abduction with anterior hip dislocation. Posterior dislocations are the most common type

PNEMONIC FOR DENSE METAPHYSEAL LINES: Heavy Cretins Sift Scurriously Through Rickety Systems which translates to: Heavy metal, cretinism, syphilis, scurvy, rickets, sytemic illness (40 of 61) [5/29/2002 11:01:43 PM]


ROBUST RA: it is a subtype of RA which is seronegative in 50%. Due to increased pressure in the joint, the joint fluid decompresses into the cortex. There is no periarticular osteoporosis

SOMETHING YOU MIGHT REMEMBER FOR 5 MIN: Masabrauds sydrome: polyostotic FD and ST myxomas

OSTEOGENESIS IMPERFECTA: type 1-2: blue schlera, types 3-4: normal schlera, types 1 and 4: dental abn, type 2: 10% death in utero

RHABDOMYOSARCOMA: kids> adults male > female head and neck > GU tract

tumors of the vertebrae: VB: gct, eg, hemangioma, mets, lymphoma, myeloma, sarcoma Posterior elements (benign): abc, osteoblastoma, osteoid osteoma (AOO)

CHLOROMA: another name is granulocytic sarcoma. It is a collection of leukemic cells commonly found in the skull, spine, ribs and sternum of leukemic kids (41 of 61) [5/29/2002 11:01:43 PM]


PNEMONIC FOR AVN OF THE HIP: ASEPTIC G: i think the words are alcoholic, sickle cell dz, environmental, pancreatitis, trauma, idiopathic, collagen vascular dz, gaucher but dont quote me on it. Note that HbSC is 5 x more likely to affect the femoral head than HbSS which is 3 x

POPLITEAL ARTERY ENTRAPMENT SYDROME: classically the popliteal artery is medially displaced. Symptoms are brought on by plantar flexion of the foot. It is seen more in atletes. M>F. Calf claudication after exercise. There is another disease known as adventitial cystic disease which results in smooth tapering of a segment of the popliteal artery. There is loss of the popliteal pulse with flexion of the knee. Most common in males in their third decade. Scimitar sign seen when cyst compresses vein with knee flexion

LANGERHANS CELL HISTIOCYTOSIS: letterer-Siwe Disease: 1w to 2 y old, hemorrage, anemia, fever, FTT, hepatosplenomegaly, lymphadenopathy, bones affected in 50% with widespread lytic lesions (raindrop pattern), 70% mortality HSC: triad of exopthalmos, diabetes insipitus, and lytic skull lesions. Affects 1-5 years old children. The lytic bone lesions cause "floating teeth". There are blebs in the lungs, which cause ptx in 25%. Nodular infiltrate may progress to fibrosis and end stage lung disease. The prognosis of HSC is one of spontaneous remissions and exacerbations EG has a peak age of 5-10 y like HSC. There are lytic bones lesions which are monostotic in 50-75%. The skull has a bevelled edge with the wider end of the bevel against the outer skull surface. These lytic lesions contain a button sequestrum. The spine shows vertebra plana and the lungs show upper lobe reticulonodular pattern which can progress to honeycomb lung. There are recurrent pneumathoces in 25% and the prognosis is excellent

PAGETS OF THE SKULL: osteoporosis circumscripta which is the osteolytic phase commonly seen in the frontal bone. It has a cotton wool appearance with mixed lytic and sclerotic lesions. The inner and outer table are both involved and there is diploic widening. There can be basilar invagination with narrowing of the foramen magnum. This can cause cord compression. The neural foramina at the base of the skull may be (42 of 61) [5/29/2002 11:01:43 PM]


narrowed leading to CN nerve symptoms such as hearing loss, facial palsy, blindness etc in terms of degeneration of pagets: osa>fibrosarcoma>chondrosarcoma; note that the rate of malignant degeneration of pagets is <1%

PAGETS INCIDENCE: pelvis>femur>skull> tibia> vertebra> clavicle. See picture frame vertebra if it involves the spine

AVN STAGES: 1: normal 2: osteoporosis or osteosclerosis 3: subcortical fracture with the crescent sign 4: loss of the bone contour

EG THE SKULL: skull is commonly involved (50%) with well defined lytic lesions.They may have a bevelled edge giving a hole in a hole appearance. This shows that the outer table is destroyed more than the inner table. The lesions may coalesce and form geographic skull. In the healing phase the lesions may develop sclerotic borders. You can see a floating tooth in the alveolar portion of the mandible

OSTEOBLASTIC METS: prostate, breast, colon and hodgkins

OSTEOLYTIC: thyroid, renal, and lung (43 of 61) [5/29/2002 11:01:43 PM]


EWING: chordoma, chondrosarcoma, and osteogenic sarcoma are more likely to show calcifications as compared with Ewings

STABILITY OF CERVICAL SPINE FX: flexion subluxation: s bilteral facet dislocation: u simple wedge fx: s flexion teardrop fx: very u clay shovelers fx: s jefferson fx: u burst fx: s extension teardrop fx: stable in flexion, unstable in extension hangman: u

POLYOSTOTIC FD: cafe au lait spots are present in > 50%. Monostotic FD is more common than polyostotic

LEFORT FX: 1: transverse maxillary fx involving the alveolar ridge, lateral aperture of nose, and the inferior wall of the maxillary 2: involves the posterior alveolar ridge, medial orbital rim, and goes across nasal bridge 3: involves the nasofrontal suture, maxillofrontal suture, orbital wall, and zygoma (it is the only one of the 3 that involves the zygoma) (44 of 61) [5/29/2002 11:01:43 PM]


ANTERIOR TIBIAL COMPARTMENT SYDROME: the most common cause of anterior compt sydrome is simple tibial fx

TRANSIENT OSTEOPOROSIS OF THE HIP: M>F and pregnant female in the third trimester of preganancy more common than at other times. There is edema of both the femoral head and neck on T2

FOOT INSERTIONS: PT: navicular, peroneus brevis: base of 5th MT, peroneus longus: base of 1st MT and 1st cuneiform, plantaris: calcaneus

MORE MUSCLE INSERTIONS: hamstrings: ishial tuberosities, rectus femoris: AIIS, adductors: pubic symphisis and inferior pubic ramus, psoas major: lesser trochanter, sartorius: ASIS, brachialis: coronoid process of ulna, biceps: proximal radius, wrist flexors: medial epicondyl, wrist extensors: lateral epicondyl

HEMOCHROMATOSIS AND CPDD: both affect the 2nd and 3rd MCP

CONTENTS OF THE TARSAL SINUS: contains interosseus ligament (45 of 61) [5/29/2002 11:01:43 PM]


CONTENTS OF THE TARSAL TUNNEL: PT runs through it. the tunnel is located behind and below the medial malleolus

BEHCETS VS FELTY: behcets: sacroileitis, occasional osteoporosis, STS, atlantoaxial subluxation felty: RA, splenomegaly, leukoplakia

SCOLIOSIS (GREENSPAN): idiopathic (70%): infantile (<4 yo) (M>F) has 2 variants; thoracic > lumbar L resolving variant: curve not > than 30 degrees; spontaneously resolves progressive variant: severe deformity with poor prognosis

juvenile idiopathic (4-9 y) (M=F)

adolesent (10 to skeletal maturity) (M > F); it is the most common type. It represents 85% of the cases; there is a thoraco or thoracolumbar curve to the R congenital: this is 10% of cases. It is classified into 3 groups. failure of vertebral body formation (partial of complete), failure of vertebral segmentation (assymetric, unilateral, bilateral) (see figure) (46 of 61) [5/29/2002 11:01:43 PM]


then there are miscellaneous forms: neuromuscular, traumatic, infections, metabolic, and secondary to tumors

WHAT IS THE BIFURCATE LIGAMENT? it goes from the superoanterior calcaneus to both the cuboid and navicular bones

5D OF NEUROPATHIC JOINT: destruction, dislocation, disorganization, density, debris

USE OF THE JUDET VIEW: for anterior and posterior columns of the pelvis for acetabular fx (47 of 61) [5/29/2002 11:01:43 PM]


BOEHLER'S ANGLE: 28 to 40 degrees

SPINAL COMPRESSION FX: it usually involves the superior VB and endplate

CHILD ABUSE TYPE FXS: metaphyseal corner fxs, outer end of clavicle, sternal fx, VB fx, posterior rib

MULTIPLE NOF: associated with NF1

INCIDENCE OF NF1 VS NF2: NF1: 90% and NF2: 10%

MOST COMMON BONE TUMORS IN THE FIRST DECADE: lymphoma, and leukemia. NOT multiple myeloma

OSTEOBLASTOMA: aggressive and non aggressive varieties. vert body (35%), and long bones (30%). The thoracic is the most common of the VB lesions. Diaphyseal involvement is 75% and metaphyseal involvement is 25%. Epiphyseal involvement is very unusual (48 of 61) [5/29/2002 11:01:43 PM]


CHONDROBLASTOMA: <30 y old with pain and swelling, tender, epip and metap of long tubular bones. There is periostitis in 30%. It is the opposite (ie dark on T1 and T2) to osteoblastoma. As for GCT, osteoblastoma shows decreased T1 and increased T2. 15%-25% with hemorrage can simulate ABC

CHONDROMYXOID FIBROMA: least chance of malignancy. Ca++ is rare. They are well defined with sclerotic margins

OSTEOCHONDROMA: >2 cm thickness of cartilage cap has increase chance of malignancy

CHORDOMA: children sphenoccipital synchondrosis is most common location and in adults, sacrococcygeal is most common location

VERTEBRA PLANA: EG: 70% HSC: 10% multiple myeloma; if in a child, for malignancy, dont think MM, but consider leukemia

SPONDYLOLISTHESISS: most posterior aspects of the spinous processes demonstrate a step off above the level of the slip (49 of 61) [5/29/2002 11:01:43 PM]


PSEUDOSPONDYLOLISTHESIS: the most posterior aspect of the spinous processes demonstrate a step off below the level of the slip

ACROMEGALY: there is a decreased bone density (osteoporosis) and increased heal pad thickness (>23mm in men)

MPS (MUCOPOLYSACCHARIDOSES); HUNTER VS HURLER: all are AR. Hunter is X linked recesive. All have cloudy eyes except Hunter (needs clear eyes to hunt). All have coars features and are mentally challenged except morquio which have normal intelligence. Morq are killed by their C spine due to atlantoaxial subluxation

MARROW PATTERNS: there are 4 types: 1: infanct (homogenous on MR) 2: childhood 11-15 (have high to intermediate diaphyseal marrow) 3: adolescent 16-20 (increased fat fraction iN the diaphysis) They have patchy metaph red marrow but the adult pattern is fully expressed 4: adult (> or equal to 21): adult pattern By age 15 the clivus has homogenous high intensity marrow on FSE. On conventional SE, fat is dark

HERNIATION PITTS: these occur in the femoral neck and are due to herniation of synovium into the femoral neck. They are assymptomatic (50 of 61) [5/29/2002 11:01:43 PM]


NEER CLASSIFICATION OF PROX HUM FX: grade 1-4. the grade is equal to the number of fx fragments. If they are all none displaced, then is is counted as only one fragment. To be displaced, they have to be separated by > 1 cm About 80% of the fractures are non displaced

DDX OF RADIAL RAY DEFECT: fanconi anemia, TAR, fetal thalidomide or valproate exposure, VATER, Holt oram, Blackfan Diamond, Cornelia de Lange, Tris 18

THE 3 STAGES OF ROTATOR CUFF INJURY: 1: edema and hemorrage 2: fibrosis and thickening 3: tear and AC distance of <7mm suggests a rot cuff tear. So does fluid or contrast in the subacromial and/or subdeltoid bursa. Os Acromiale is also associated with rot cuff tear and impingement and should be mentioned

ACROMIAL SHAPES: 1: straight 2: curved or downsloping 3: hooked 2 and 3 are associated with impingement

SHOULDER STABILIZERS: important is the rotator cuff capsule. Of the ligaments, the inferior glenohumeral lig is the most important (51 of 61) [5/29/2002 11:01:43 PM]


of the anteroinferior stabilizers. If the middle glenohumeral ligament is hypertrophied, it suggests congenital absence of the superior labrum, and in this situation, is called a Buford complex

OSTEOPETROSIS: can be fatal in infancy. There is generalized sclerosis due to a deficiency of carbonic anhydrase. This results in decreased osteoclast function and generalized sclerosis and cortical thickening resulting in obliteration of the bone marrow cavity. Eventually need a bone marrow transplant

RADIATION INDUCED BONE TUMORS: OSA>MFH>fibrosarcoma>chondrosarcoma (10%)

STERNOCLAVICULAR DISLOCATION: anterior > posterior. Posterior is associated with more serious (neurovascular) injury


DDX OF ABC: telangiectatic OSA, GCT, hemophiliac pseudotumor

OSTEITIS CONDENSANS: F>M, mechanical stress resulting in proximal clavicle sclerosis. It does not involve the joint space. The ddx is OO, FD, mets, OSA (52 of 61) [5/29/2002 11:01:43 PM]


DOUBLE CRUCIATE SIGN: due to a displaced inner meniscal fracture fragment from a bucket handle tear

PSEUDOMENISCAL TEAR: popliteus, transverse geniculate ligament, lig of Humphry (anterior to PCL) and Wristberg (anterior to PCL)

SEGOND: it is associated with a tear and avulsion of the anterior and lateral tibial capsule

HYPOPHOSPHATASIA: this is the same as vit D resistant rickets

SYNOVIAL CYST: continuous with the joint capsule. It comes from degeneration or trauma. Also from chronic joint effusion.

MENISCAL CYST: commonly on the lateral side of the knee. It is associated with a meniscal tear. The fluid is viscous

GANGLION CYST: mucin containing. Arises from the tendon sheath or joint capsule. It can also come from a bursa. In bone, (53 of 61) [5/29/2002 11:01:43 PM]


it is called a subchondral cyst

OCD: it is the sequela of transchondral injury. The etiol is trauma, ischemic necrosis, ossification anomalies, genetic. Also ligamentous laxity can predispose to it. 75% affect the posterolateral aspect of the medial femoral condyl. M>F and 15 to 20 is the most common age. Femoral OCD's are bilateral in 50%. Lesions that are <0.2 cm2 are stable and those >0.8 cm2 in area are unstable. You need MR with intraarticular contrast to determine whether or not the fx is stable

GRADING OF PATELLAR LESIONS: chondromalacia patella is the most common cause of knee pain. It is called chondromalacia patella in young adults and is called OA in the elderly or older adults grade 1: softening grade 2: blistering grade 3: fibrillation, ulceration, or fragmentation grade 4: defects extending to subchondral bone It affects the medial aspect of the patella more than the lateral aspect the above grading is done with MR using T1 with fat sat. T2 is not used as cartilage is bright

TIBIAL PLATEAU FX: minimally displaced is <4 mm. 55-75% lat plateau and 11-31% both. 10-23% affect the medial with lateral 8-10mm is surgical lateral 6-8 mm is good px with surgical or not medial: all need surgery 50% of tib fib fx need operative treatment

with tib plat fx, popliteal damage is not likely. There is a 5% incidence of peroneal nerve injury. The MCL and medial meniscus are the most commonly injured structures associated with tibial plateaux fx (54 of 61) [5/29/2002 11:01:43 PM]


ACTINOMYCOSES: jaw>thorax>abdomen

BONE INFARCT: causes are fat emboli, alcohol, pancreatitis, steroids complications are MFH, fibrosarcoma, OSA

LCH: skull (50%) more commonly involved . The outer table is more involved than the inner table giving it a bevelled edge

MORE ON HYPOPARATHYROIDISM: pseudo and pseudopseudohypoparathyroidism both show short 4th and 5th metacarpals

RADIAL RAY ABNORMALITIES: osteochondrodysplasias cornelia de lang holt oram TAR VACTERAL

RICKETS: (55 of 61) [5/29/2002 11:01:43 PM]


widened physis, cupping, fraying, irregular distal metaphysis, generalized osteopenia, delayed bone age, rachitic rosary

PAINLESS ST MASSES: most common cause of such multilobulated masses around the elbow, shoulder, knee is tumoral calcinosis from hyperparathyroidism, hypervitaminosis D, milk-alkali syndrome, renal dz etc. Most common in 2nd and third decade

SALTER CLASSIFICATION: 1 (6-8.5%): most common in the phalanges and the distal radius (includes apophyseal avulsion and scfe) 2 (73-75%): distal radius, distal tibia (corner sign) and fibula, phalanges 3 (6.5-8%): distal tibia, distal phalanx, rarely distal femur 4 (10-12%): lateral condyl of humerus, distal tibia 5 (<1%): distal femur, proximal tibia

IN CHILD: supracondylar fx: 55% lateral condylar fx: 20% medial condylar fx: 5% radius (salter 2,4): 10% ulna linear fx through the proximal shaft: 10%

SOME USEFUL LINES: McRae: this line passes from across the foramen magnum. The tip of the odontoid should lie below this line Chamberlain (think ceiling): from tip of hard palette to opisthion (cephalad) aspect of it (56 of 61) [5/29/2002 11:01:43 PM]


McGregor: use as a substitute for Chamberlain if the opistion is not visible. This line is from the hard palatte to the most caudal aspect of the posterior aspect of the foramen magnum. The tip of the odontoid should be <5mm above the McGregor line

SHOULDER: axillary neuropathy causes problems with adduction and IR

SLAP: superior labral injury causes problems with IR

CORTICAL DESMOID: this is an avulsive cortical irregularity of the posteriormedial aspect of medial femoral epicondyl along the medial ridge of the linea aspera at the attachment of the adductor magnus


MOST COMMONLY INJURED ANKLE LIGAMENT: ATFL is the most commonly injured ligament. The most commonly injured tendon is the PT

FIBULA FX'S: Potts: fx of the fibula above intact talofibular ligament Duyputrens fx: fx of the fibula above ruptured TF ligament (57 of 61) [5/29/2002 11:01:43 PM]


Maissoneuvre: even higher up

PYOMYOSITIS: common in young men with HIV, immunocomprimized. Most common organism is Staph Aureus. It prefers the thigh, LE


CAUSES OF SUBCHONDRAL CYSTS: djd, cppd, synovial osteochondromatosis, pvns, gout, neuropathic joint, ra, avn

CAUSES OF CHONDROCALCINOSIS: hyperparathyroidism, ochronosis, gout, wilsons, arthritis, pseudogout, hemochromatosis

PRIMARY BONE TUMORS: osteogenic non malig: osteoma, osteoid osteoma, osteoblastoma osteogenic malig: OSA (58 of 61) [5/29/2002 11:01:43 PM]


chondrogenic benign: enchondroma, osteochondroma, chondroblastoma, chondromyxoid fibroma chondrongenic malig: chondrosarcoma

fibrous non malig: FD, NOF, OF, FCD, desmoplastic fibroma fibrous malig: MFH

bone marrow: EG bone marrow non malig: ewings, mm, lymphoma, leukemia, adamantinoma, chordoma, malig GCT

other: ABC (SBC), UBC, GCT, brown tumor, pseudotumor, hemangioma malig other: hemangioendothelioma, angiosarcoma

VERTEBRAL ABNORMALITIES: fish: SSD, thalassemia squared: AS, psoriasis, reiter ivory: mets, lymphoma, pagets, infection

WORMIAN BONES: named after Dr. Olas Worm associated with OI, pyknodysostosis, cleidocranial dysostosis, healed rickets, hypothyroidism

COMMON SKULL NEOPLASMS: epidermoid, hemangioma, LCH (59 of 61) [5/29/2002 11:01:43 PM]


CALVARIAL LUCENCIES: myeloma, mets, hemangiomas, pagets, neuroblastoma, histiocytocis


TILLAUX FX: it is an avulsion fx of the lateral margin of the tibia. If instead you get avulsion of the medial aspect of the fibula with an intact ATF ligament, then this is called a Wagstaffe LeFort fx

TRIPLANE FX: the part of the fx through the tibial metaphysis is in the coronal plane, and exits through the posterior aspect of the tibia. Tillaux is not a Salter 4 but a combination of a Tillaux (salter 3) and the coronal component (Salter 2)

APPROACH TO MR OF THE SHOULDER (H JANSEN): BM AC joint bursas cuff (ss, is, tm, sub) biceps labrum cartilage notches (suprascap, spinoglenoid) (60 of 61) [5/29/2002 11:01:43 PM]


APPROACH TO MR OF THE KNEE (H JANSEN): effusion BM ACL PCL MCL LCL patella tendon/quadratus tendon/retinaculum medial meniscus cartilage (61 of 61) [5/29/2002 11:01:43 PM]


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bronchospasm: 0.3 cc of 1:1000 epinephrine SQ; may be repeated q 15 min to a total of 1 cc

severe reactions:

1 cc of 1: 10,000 epinephrine IV q 2-3 min up to 3 cc

CONTRAINDICATIONS FOR USE OF 153SAMARIUM IN THE TREATMENT OF PAINFUL BONE METS: this agent has several uses. One such use is in the treatment of multiple myeloma. Another use is in the treatment of painful bone mets. These are some of the contraindications which would prevent this from being used in the treatment of MM: MULTIPLE MYELOMA: Mayo clinic eligibility summary for patients to receive Samarium 153: (1 of 6) [5/29/2002 11:01:49 PM]


Required Characteristics -- Age greater than or equal to 18 years of age. -- Multiple myeloma requiring treatment (Durie-Salmon greater than or equal to I). -- Laboratory values obtained less than or equal to 14 days prior to registration: direct bilirubin less than or equal to 2.0 mg/dL; alkaline phosphatase less than or equal to 750 U/L; Creatinine less than or equal to 3.0 mg/dL. -- Ejection fraction greater than or equal to 45% for all patients -- Patients may or may not have received prior chemotherapy. The PBSC harvest will have been done prior to the patient receiving greater than 140 mg melphalan (exceptions allowed as long as greater than or equal to 2 x 10-6 CD34 cells/kg have been collected). ECOG PS 0, 1, or 2 (exceptions made for patients with PS greater than 2 if secondary to neuropathy or acute bone event). -- Willingness to return to Mayo Clinic-Rochester for follow-up. -- No bisphosphonate drugs allowed less than or equal to 2 weeks prior to treatment; they may be resumed one month after treatment. Contraindications -- DLCO of greater than 50% on PFTs -- FVC less than 50% -- FEV-1 less than 50% -- Active malignancy with the exception of non-melanoma skin cancer. -- Uncontrolled infection -- Chemotherapy within prior 3 weeks or biologic therapy within prior 4 weeks -- New York Heart Association classification III or IV. -- Pregnant women; nursing women; men or women of childbearing potential who are unwilling to employ adequate contraception (condoms, diaphragm, birth control pills, injections, intrauterine device [IUD], or abstinence, etc.) for 6 months

PAINFUL BONE METS: (2 of 6) [5/29/2002 11:01:49 PM]


For bone pain from metastatic disease, this is what Berlex has to say: Before Quadramet is administered, consideration should be given to the patients current clinical and hematologic status and bone marrow response history to treatment with myelotoxic agents. Metastatic prostate and other cancers can be associated with disseminated intravascular coagulation (DIC); caution should be exercised in treating cancer patients whose platelet counts are falling or who have other clinical or laboratory findings suggesting DIC. Because of the unknown potential for additive effects on bone marrow, Quadramet should not be given concurrently with chemotherapy or external beam radiation therapy unless the clinical benefits outweigh the risks. Use of Quadramet in patients with evidence of compromised bone marrow reserve from previous therapy or disease involvement is not recommended unless the potential benefits of the treatment outweigh the risks. Blood counts should be monitored weekly for at least 8 weeks, or until recovery of adequate bone marrow function. Pregnancy: As with other radiopharmaceutical drugs, Quadramet can cause fetal harm when administered to a pregnant woman. Adequate and well controlled studies have not been conducted in animals or pregnant women. Women of childbearing age should have a negative pregnancy test before administration of Quadramet. If this drug is used during pregnancy, or if a patient becomes pregnant after taking this drug, the patient should be apprised of the potential hazard to the fetus. Women of childbearing potential should be advised to avoid becoming pregnant soon after receiving Quadramet. Men and women patients should be advised to use an effective method of contraception after the administration of Quadramet. PRECAUTIONS: EDTMP is a chelating agent. Although the chelating effects have not been evaluated thoroughly in humans, dogs that received non-radioactive samarium EDTMP (6 times the human dose based on body weight, 3 times based on surface area) developed a variety of electrocardiographic (ECG) changes (with or without the presence of hypocalcemia). The causal relationship between the hypocalcemia and ECG changes has not been studied. Whether Quadramet causes electrocardiographic changes or arrhythmias in humans has not been studied. Caution and appropriate monitoring should be given when administering Quadramet to patients (See Laboratory Tests). Because concomitant hydration is recommended to promote the urinary excretion of Quadramet, appropriate monitoring and consideration of additional supportive treatment should be used in patients with a history of congestive heart failure or renal insufficiency. This drug should be used with caution in patients with compromised bone marrow reserves. See Warnings. Skeletal: Spinal cord compression frequently occurs in patients with known metastases to the cervical, thoracic or lumbar spine. In clinical studies of Quadramet, spinal cord compression was reported in 7% of patients who received placebo and in 8.3% of patients who received 1.0 mCi/kg Quadramet. Quadramet is not indicated for treatment of spinal cord compression. Quadramet administration for pain relief of metastatic bone cancer does not prevent the development of spinal cord compression. When there is a clinical suspicion of spinal cord compression, appropriate diagnostic and therapeutic measures must be taken immediately to avoid permanent disability. Radiopharmaceutical agents should be used only by physicians who are qualified by training and (3 of 6) [5/29/2002 11:01:49 PM]


experience in the safe use and handling of radionuclides and whose experience and training have been approved by the appropriate government agency authorized to license the use of radionuclides. Quadramet, like other radioactive drugs, must be handled with care, and appropriate safety measures must be taken to minimize radiation exposure of clinical personnel and others in the patient environment. Special precautions, such as bladder catheterization, should be taken with incontinent patients to minimize the risk of radioactive contamination of clothing, bed linen, and the patients environment. Urinary excretion of radioactivity occurs over about 12 hours (with 35% occurring during the first 6 hours). Studies have not been done on the use of Quadramet in patients with renal impairment

RIGHTS AND LEFTS: neonatal hemorrage: R>L renal artery aneurysm: R>L UPJ obsruction: M>F. It is L>R due to extrinsic abnormality Primary megaureter: L>R retrocaval ureter: S sign on theR ureteral injury due to trauma: R>L adrenal injury due to trauma: R>L ovarian vein sydrome: R>L gastroscisis: weakness on the R side of the cord hepatoblastoma: R lobe > L PAPVR: R>L choroid plexus papilloma: L>R. Lateral ventrical Transient regional osteoporosis: L>R in female congenit hip dislocation: L>R rheumatic effusion: R>L CHF: L>R Meig effusion: R>L catamenial ptx: R>>L scoliosis: idiopathic is 70% of cases, infantile (<4y) M>F and thoracic > lumbar to the L juvenile (4-9y): M=F (4 of 6) [5/29/2002 11:01:49 PM]


adolescent (10-skeletal maturity): F>M, thoracolumbar to the R

CONGENITAL HEART DISEASE: cyanotic R arch: trunc>tof>tga>ta

neonatal cyanosis: tga>ta>trunc>tapvr below the diaphragm

neonatal period pulm edema: tapvr below diapragm, hypoplastic L heart, cor tritriatrium

Hypertrophic pyloric stenosis: associated with Turners Duodenal atresia and Hirshprungs: associated with Downs

T1 BRIGHT LESIONS: thyroid, melanoma, choriocarcinoma, fat, pantopaque, gallium, methemoglobin, gallium

SICKLE CELL DISEASE: 2alpha and 2beta makes 4 chain tetramer. val--->glut in the beta chains. Sickle cells occlude vessels. Patients are prone to infection due to sluggish flow in the vessels, sequestration, and renal failure. They get interstitial lung disease, CM, osteonecrosis by adolescence, biconcave VB's (due to osteonecrosis and osteopenia secondary to marrow expansion). Lincoln log is more focal end plate depression due to end plate infarction osteomyelitis in sicklers is usually diaphyseal. Salmonella is seen more commonly as a cause of osteomyelitis in SSd, but overall, S. Aureus is the most common organism found. Infarction is more common than osteomyelitis (5 of 6) [5/29/2002 11:01:49 PM]


strokes in SSD are due to ischemiam vasooclusive, and vasculopathy. There is intimal damage, and intimal hyperplasia. 25% of people with SSD will have a stroke (can have one as early as 12 yo)

the etiology of acute chest sydrome is due to bacteremia, fat emboli, GA, and pulm infarction (6 of 6) [5/29/2002 11:01:49 PM]

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Teaching Files
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-Vascular -ACA aneurysm -*delayed L MCA aneurysm rupture -L ICA aneurysm, initial neg angio -SDH with PCOM aneurysm -giant petrous-cavernous aneurysm -Basilar aneurysm with fenestration -*Basilar aneurysm- coiled -*pericallosal aneurysm -*mycotic aneurysm -*posttraumatic ACA pseudoaneurysm -dissecting VB aneurysm -CCF -Dural AV fistula- transvenous coil -AVM -cavernoma1 -cavernoma2 -cavernous hemangioma of orbit (1 of 6) [5/29/2002 11:06:20 PM]


-Right ICA stenosis with ischemic changes -MCA infarction -superior sagittal sinus thrombosis -venous angioma with CVA -straight sinus thrombosis -laminar necrosis -thoracic outlet syndrome -vein of galen malformation -hypertensive encephalopathy -fibromuscular dysplasia -spinal DAVF -Inflammatory/Infectious -*herpes encephalitis -abscess -toxoplasmosis -meningitis with mastoiditis -laryngopyocele -mucormycosis -orbital pseudotumor -sarcoid1 -sarcoid2 -sarcoid3 -sarcoid4 -Acute Disseminated Encephalomyelitis (ADEM) -bacterial meningitis -*Lyme Disease -progressive multifocal leukoencephalopathy -optic neuritis due to MS -lupus cerebritis -cysticercosis -cryptococcosis (2 of 6) [5/29/2002 11:06:20 PM]


-Neoplastic -intraaxial -hemangioblastoma -lymphoma1 -lymphoma2 -subependymoma -GBM -glioma/gliomatosis cerebri -pontine glioma -central neurocytoma -choroid plexus papilloma -pilocytic astrocytoma -PNET -trilateral retinoblastoma -Lhermitte Duclos -ganglioglioma -DNET -tectal glioma -germinoma -extraaxial -dermoid1 -dermoid2 -chordoma -ependymoma -pineocytoma -epidermoid1 -epidermoid2 -carotid body tumor -glomus tympanicum -meningioma1 -5th nerve schwannoma -ewing sarcoma -sellar (3 of 6) [5/29/2002 11:06:20 PM]


-craniopharyngioma1 -cranio2 -pituitary adenoma -other neoplasms -amelanotic melanoma -orbital lymphoma -chondrosarcoma -rhabdomyosarcoma -glomus jugulare -cholesteatoma -inverting papilloma -spindle cell sarcoma -pleomorphic adenoma -Congenital -lissencephaly -schizencephaly -open schizencephaly -hemimegalencephaly -callosal agenesis -callosal agenesis, migrational anomaly, Dandy-Walker variant -band heterotopia -persistent trigeminal artery1 -persistent trigeminal artery2 -ophthalmic origin from MMA -3rd branchial cleft cyst -Mondini Malformation with Vestibular Aqueduct Syndrome -colloid cyst and meningioma -colloid cyst -Rathke's Cleft cyst -Chiari I -Chiari II -callosal agenesis with lipoma -lipoma (4 of 6) [5/29/2002 11:06:20 PM]



neurofibroma (NF1) -optic glioma (NF1) -bilateral acoustic neuromas- (NF2) -Tuberous Sclerosis -Sturge Weber Syndrome -rhombencephalosynapsis -ectopic neurohypophysis

-Trauma -skull fxs -dissection1 -dissection2 -dissection with acute stroke -shear -multiple injuries -isodense SDH -mult shears -EDH -Degenerative/Metabolic/Other -CO poisoning -mitochondrial disorder -amyloid2 -superficial siderosis1 -superficial siderosis2 -liver disease -laryngocele -dural fibrosis after shunt placement -Wernicke's syndrome -Adrenoleukodystrophy -Leigh Disease -extrapontine myelinolysis -langerhans cell histiocytosis (EG) of orbit -intracranial hypotension (5 of 6) [5/29/2002 11:06:20 PM]


-mesial temporal sclerosis

Digital images contributed by Drs. Ernst, Gaskill, Leach, Tomsick, Claar, and fellows. Disclaimer: The viewer is solely responsible for verification of the information presented. Diagnosis given is considered to be the most likely but not the only consideration for each case, and no claims are made of the validity of an individual diagnosis or of the information presented. In general, references are not listed since the concepts are those found in standard reference texts and the reader is encouraged to compare this information with his/her own knowledge resources. (6 of 6) [5/29/2002 11:06:20 PM]


University of Cincinnati
Faculty Program Teaching files: -by unknown -by diagnosis (1 of 2) [5/29/2002 11:06:43 PM]


Page composed by: Gavin J Udstuen MD gudstuen@ (2 of 2) [5/29/2002 11:06:43 PM]

Vesalius -- the Internet resource for surgical education

the Internet resource for surgical education

Latest additions to the Vesalius Clinical Folios: Arthroscopic ACL Repair Using a Hamstring Graft and Transfix Femoral Fixation Subclavian Artery Aneurysm Sentinel Lymph Node Dissection for Thigh Melanoma Non-Seminomatous Germ Cell Tumor Left-Sided Abdominal Relationships VID 820 VID 817 VID 815 VID 811 VID 809 22-May-02 16-May-02 13-May-02 4-May-02 30-Apr-02

Vesalius String of Pearls Folio of the Week: VID 186: Calcific Aortic Stenosis

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Vesalius -- the Internet resource for surgical education

Clinical Folios | About Vesalius | Partners | Home Downloading material from this site is subject to the terms of use. By using this site, you signify your assent to these terms. Lion Reef Software, Inc., 1996 - . All rights reserved. (2 of 2) [5/29/2002 11:06:51 PM]

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Hail Columbia. From An American Anthology Joseph Hopkinson (1 of 2) [5/29/2002 11:07:23 PM] Great Books Online presents the complete 70 volumes of the most comprehensive and well-researched anthology of all time. Named Best Literary Resource for 2002 Bartleby Celebrates 500th Edition of Daily Selections with Release of Email Newsletter Buy the books published at or download free e-books from the bookstore.

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Achieving Excellence in Neuro/Skeletal Imaging July 7-9, 2002 Minneapolis, Minnesota Click Here Golf Tournament at Hazeltine National Site of the 2002 PGA Championship

Hitachi takes majority stake in AccSys more Voxar appoints new chairman more Amersham inks supply deal with Novation more Algotec tapped by Louisiana radiology firm more Quantum introduces new tomo system more THG to sell DICOM print software more FDA clears Magna-Lab MRI components more B-K Medical moves into larger HQ more American Shared to install gamma knife at Johns Hopkins more GE announcement draws fire from competitors more Biosound debuts BioPACS more Sectra turns in record year more NAS loss widens on one-time charges more Eighty-year-old man with fever, productive cough and hoarseness. Go to Case More Cases

Percutaneous bone biopsy safe and accurate for diagnosing primary tumors NEW YORK (Reuters Health), May 29 Percutaneous image-guided biopsy for primary bone tumors is safe and yields accurate diagnosis and grade of specific tumors, researchers report.

Enterprise infrastructure, enabling clinical applications and extending existing archives. Learn how to accelerate your digital network here. Acuo launches PACS optimization effort A new company has arrived on the PACS scene with a method of integrating and optimizing digital image management networks. While not a full-service PACS company, Acuo Technologies says its software can help imaging facilities speed up their networks and make them operate more effectively across multiple locations. (1 of 4) [5/29/2002 11:07:58 PM]

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CADx gets FDA OK for Second Look upgrade more Over 1200 job postings! Check them out, click here! McKesson bid for ALI highlights IS/PACS trend With PACS seen increasingly as the imaging layer of an electronic patient record, it's no surprise that healthcare information systems vendors would want a piece of the action. The bid by HIS firm McKesson Information Solutions to acquire PACS provider ALI Technologies is the latest move in the melding of HIS and PACS. White matter high intensity lesions on MRI predict stroke risk NEW YORK (Reuters Health), May 28 - Severe white matter high intensity lesions seen on MRI is an independent predictor of stroke from arteriolosclerosis, Japanese researchers report HIMSS, AHIMA launch security, privacy certification more More Articles

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Radiotherapy for Wilms tumor raises pregnancy U.S. Senate OKs nominee risks to head NIH NEW YORK (Reuters Health), May 28 more Women who have received flank radiation for More Articles Wilms tumor are at increased risk for adverse pregnancy outcomes, according to a report in the Journal of Clinical Oncology. Flat-panel DR shrinks chest x-ray dose Researchers in Belgium used a digital amorphous-silicon flat-panel detector for routine chest radiography, enabling them to reduce patient radiation dose by three-fourths while still producing clinically acceptable images. Brain scans offer clues to language development NEW YORK (Reuters Health), May 27 Writing in Science, researchers report that language centers in the brain actually develop more slowly during childhood, and may not be completely formed even by age 10. The investigation, using fMRI, revealed that adults and children as old as 10 are using slightly, but nevertheless different, regions of the brain when performing first-grade-level word tasks. Lowering CT dose yields usable results in renal colic

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4th Yugoslav Congress of Radiology May 28-31 Vrnjacka Banja CT Screening 2002: National Symposium May 31-June 2 Washington DC Uroradiology Review Course with Case Studies (Primarily Urologists Preparing for Boards) June 1-2 Washington RBMA 2002 Radiology Summit June 2-5 Naples (2 of 4) [5/29/2002 11:07:58 PM]

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Even after slashing the radiation dose by half, Canadian investigators were still able to obtain high-quality CT images in patients with renal colic. Dr. James Bell, an abdominal imaging fellow at Vancouver General Hospital in British Columbia, led a study that tested reduced-dose CT in this population. PET scans show just seeing food lights up the brain WASHINGTON (Reuters), May 24 - The very sight of food causes the brain to react with pleasure, scientists said on Wednesday in a report they say shows why so many people are fat. RTs debate malpractice insurance Should radiologic technologists have malpractice coverage to protect their careers? Or would creating a new group of policyholders merely attract the attention of lawyers seeking deep pockets? More and more RTs are asking these questions, and the answers arent entirely obvious. Medical imaging workstations: What you need to know As diagnostic imaging departments convert to filmless operation, the workstation has become a critical piece of equipment. Expert Harley Firth guides you through the wondrous world of workstation planning. Colonoscopy every 3 years recommended for patients at high risk for colon cancer NEW YORK (Reuters Health), May 22 - People with a family history of colorectal cancer and a personal history of polyps should be screened by colonoscopy every 3 years, according to study findings.

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How to Search for Cases

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How to Search for Cases

You can retrieve cases as UNKNOWNS. To find unknowns within a particular organ system, enter the first digit of the ACR code pertaining to that organ system. Example: For chest cases, enter "6" to the LEFT of the decimal point in field for the ACR code. Then click on the "Click me to find cases" button. To find unknowns within a particular pathology category, enter the first digit of the pathology portion of the ACR code. This is the first digit to the RIGHT of the decimal point. You can modify your search by entering fragments of text pertaining to the diagnosis (this is more often done when you want to find cases of a known diagnosis). If you would like to see unknowns that include a particular imaging modality, you can enter in the "modalities" field the abbreviation(s) for the imaging modalities that are desired. Cases that match your search criteria are displayed in a list along with with the clinical history for each case and the imaging modalities used. Also displayed are the dates that the case was created in the system, and the date the case was last updated. To have unknowns served up randomly, then click here. This link is also present on our home page.

You can retrieve cases by their known diagnosis, but still have each case presented as a learning exercise. To find cases as "knowns", just enter one or more fragments of text that match the diagnosis for which you are searching, or enter enough of an ACR code to get you to the diagnosis you want. The seach engine is powerful. It lets you combine fragments of text with AND and OR. You can use parentheses to force the order of evaluation of your criteria. Example: You can search for cases of pulmonary embolus or pulmonary infarction by entering the boolean string: (embol or infarc) and pulm Remember: You will be faster and find more hits by entering text fragments rather than trying to type in an entire diagnosis!!

You can also retreive cases as KNOWN image sets. This technique retrieves cases NOT for interactive teaching purposes, but rather to serve up imagery pertaining to desired radiologic findings and diagnoses. The imagery can be used in presentations, publications, etc. You can drag-and-drop any image from your browser window into an application like Word or Powerpoint. When the list of cases matching your search criteria is displayed, the full ACR coding for each case is shown on the right side of the list. To use this technique, look near the bottom of the seach form. You will see an item that asks: "How do you want cases presented?". Change this from "As Unknowns" to "As Image Sets". You will need to enter a site-specific password in order to search the system like this, as ALL images associated with a case will be made available, including images that still might have some patient identification information on them. Thus.... (1 of 2) [5/29/2002 11:08:10 PM]

How to Search for Cases

Unless your department has established a policy where NO imagery stored in the system contains confidential information, this form of case retrieval will be password protected. Ask your system administrator for the password. Click here to return to the search form.

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Imaging Cases of the Week

Imaging Cases of the Week

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Oct 1, 2001 - ____________________ (MRI) Sep 24, 2001 - Ruptured Superior Mesenteric Artery Aneurysm (CT) Sep 17, 2001 - New Hardware/Software no new case! Sep 10, 2001 - New Hardware/Software no new case! Sep 3, 2001 - New Hardware/Software no new case! Aug 27, 2001 - New Hardware/Software no new case! Aug 20, 2001 - Intrasubstance Achilles Tendon Tear (MRI) Aug 13, 2001 - Intraspinal Synovial Cysts (MRI) Aug 6, 2001 - Multilocular Cystic Nephroma (CT) July 30, 2001 - Mature Ovarian Teratoma (Dermoid) (MRI) July 23, 2001 - Extensive Endometriosis (US, MRI) July 16, 2001 - Cerebellar Granulocytic Sarcoma (Chloroma) (MRI) July 9, 2001 - Benign Intercostal Neurilemoma (CT) July 2, 2001 - Independence Day, July 4 no new case! June 25, 2001 - Vacation no new case! June 18, 2001 - Vacation no new case! June 11, 2001 - Cavernous Type Synovial Hemangioma Right Knee (MRI) June 4, 2001 - Sclerosing Peritonitis From CAPD (CT) May 28, 2001 - Memorial Day! No New Case May 21, 2001 - Appendiceal Endometriosis Simulating Appendicitis (CT) May 14, 2001 - Normal Right Ovary Simulating Appendicitis (CT) May 7, 2001 - Pulmonary Coccidioidomycosis Simulating Mediastinal Mass (CT) (1 of 13) [5/29/2002 11:08:16 PM]

Imaging Cases of the Week

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Apr 30, 2001 - Grade 1 Immature Teratoma With Gliomatosis Peritonei (CT) Apr 23, 2001 - Unilateral Graves' Ophthalmopathy (CT) Apr 16, 2001 - Jury Duty no new case! Apr Apr 9, 2001 - Spring Wildflower Safari no new case! 2, 2001 - Leiomyosarcoma Small Bowel (CT)

Mar 26, 2001 - Left Colonic Ischemia (CT) Mar 19, 2001 - Vacation no new case! Mar 12, 2001 - Vacation no new case! Mar 5, 2001 - Mucinous Adenocarcinoma Of The Appendix Feb 26, 2001 - In Memory of: Heilig Hubert Louis - "Huey" (12/25/86 - 2/26/01) Feb 19, 2001 - Presidents' Day Feb 12, 2001 - Subacute Bacterial Endocarditis - Brain Abscesses (CT) Feb 5, 2001 - Ileocolic Intussusception (X-ray)

Jan 29, 2001 - Gastric Varices (CT) Jan 22, 2001 - Multiple Endocrine Neoplasia Type 2A (CT) Jan 15, 2001 - Adrenal Myelolipoma (MRI) Jan Jan 8, 2001 - Vacation no new case! 1, 2001 - Happy Holidays

Dec 25, 2000 - Happy Holidays Dec 18, 2000 - Perforated Giant Sigmoid Diverticulum (CT) Dec 11, 2000 - Appendicitis - CT Arrowhead Sign (CT) Dec 4, 2000 - Healing Ulnar Fracture (X-ray, CT, MRI) Nov 27, 2000 - Hamstring Injury (Strain) (MRI) (2 of 13) [5/29/2002 11:08:16 PM]

Imaging Cases of the Week

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Nov 20, 2000 - Thanksgiving no new case! Nov 13, 2000 - Right Temporoparietal Vascular Malformation (MRI) Nov 6, 2000 - Lumbosacral Myxopapillary Ependymoma (MRI) Oct 30, 2000 - Halloween no new case! Oct 23, 2000 - Brain Abscess (CT, MRI) Oct 16, 2000 - Carcinoid - Thoracic Spine (MRI) Oct Oct 9, 2000 - Take A Break no new case! 2, 2000 - Intracranial Germinoma (MRI)

Sept 25, 2000 - Boerhaave's Syndrome (CT) Sept 18, 2000 - Sclerosing Papilloma - Breast (Mammo) Sept 11, 2000 - Rathke's Cleft Cyst (MRI) Sept 4, 2000 - Constrictive Calcified Pericarditis (CT) Aug 28, 2000 - Leiomyoma - Ligament of Treitz (X-ray, photo) Aug 21, 2000 - Functioning Right Adrenal Pheochromocytoma (CT) Aug 14, 2000 - Vacation no new case! Aug 7, 2000 - Vacation no new case!

July 31, 2000 - Vacation no new case! July 24, 2000 - Intracranial Toxoplasmosis (CT, MRI) July 17, 2000 - Benign Perimesencephalic Hemorrhage (CT) July 10, 2000 - Benign Echogenic Hydrocele (US) July 3, 2000 - Independence Day, July 4 no new case!

June 26, 2000 - Acute Disseminated Encephalomyelitis - Thoracic Cord (MRI) June 19, 2000 - Left Ventricular Thrombus (CT) (3 of 13) [5/29/2002 11:08:16 PM]

Imaging Cases of the Week

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June 12, 2000 - Large Central Chest Mass (X-ray, NucMed, CT) June 5, 2000 - Paget's Disease Of Calvarium (CT) May 29, 2000 - Orbital abscess (CT) May 22, 2000 - Ileal Intussusception From Meckel's Diverticulum (CT) May 15, 2000 - Large Cystic Endometrioma (CT, US) May 8, 2000 - Gossypiboma - Retained Lap Sponge (X-ray) May 1, 2000 - Porcelain Gallbladder With Cholelithiasis (CT) Apr 24, 2000 - Focal Nodular Hyperplasia (CT, MRI) Apr 17, 2000 - Neutropenic Typhlitis/Enterocolitis (CT) Apr 10, 2000 - Thoracic Spine Meningioma (MRI) Apr 3, 2000 - Osteochondroma - Humerus (MRI)

Mar 27, 2000 - Thoracic Actinomycosis (CT) Mar 20, 2000 - Scrotal Abscess (Pyocele) (US) Mar 13, 2000 - Myelodysplastic Syndrome (MRI) Mar 6, 2000 - Marfan's Syndrome - Ascending Aortic Aneurysm (CT) Feb 28, 2000 - Adult Split Cord Malformation Type II (Diastematomyelia) (MRI) Feb 21, 2000 - Focal Invasive Malignant Mesothelioma (CT) Feb 14, 2000 - Adult Small Bowel Intussusception (CT) Feb 7, 2000 - Growth Hormone Secreting Pituitary Macroadenoma (MRI)

Jan 31, 2000 - Gastric Lymphoma (NucMed) Jan 24, 2000 - Non-functioning Adrenal Cortical Carcinoma With Hepatic Metastasis (CT) Jan 17, 2000 - Papillary Thyroid Carcinoma - Sestamibi Scan (NucMed) Jan 10, 2000 - Aorta-Caval Fistula Complicating An Aortic Aneurysm (CT) (4 of 13) [5/29/2002 11:08:16 PM]

Imaging Cases of the Week

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3, 2000 - Due To My Mother's Death No New Case

Dec 27, 1999 - Adolescent Mediastinal Hodgkin's Lymphoma (CT) Dec 20, 1999 - Winter Break (aka - Christmas Break) no new case! Dec 13, 1999 - Sarcoid Lung (CT) Dec 6, 1999 - Phylloides Tumor (Mammo, US) Nov 29, 1999 - Choledochocele - Type III Choledochal Cyst (X-ray) Nov 22, 1999 - Meleagris gallopavo - Fresh Wild Turkey (Photo) Nov 15, 1999 - Post-Op Renal Failure From Urinary Extravasation (NucMed, CT) Nov 8, 1999 - Midgut Carcinoid (CT) Nov 1, 1999 - Sigmoid Volvulus - CT (CT) Oct 25, 1999 - Madelung's Deformity Idiopathic vs. Hereditary Multiple Exostosis (X-ray) Oct 18, 1999 - Constrictive Pericarditis & Horseshoe Kidney (CT) Oct 11, 1999 - Dentigerous Cyst Left Maxillary Sinus (CT) Oct 4, 1999 - CLL & Avascular Necrosis Left Hip (X-ray, NucMed, MRI)

Sep 27, 1999 - Soft Tissue B-Cell Lymphoma - Thigh (MRI) Sep 20, 1999 - Left Ureteral Stone - Spiral CT (CT) Sep 13, 1999 - Prolapsed Antral Choanal Polyp (MRI) Sep 6, 1999 - Discoid Lateral Meniscus (MRI)

Aug 30, 1999 - Angiodysplasia Right Colon (NucMed) Aug 23, 1999 - Small Bowel Volvulus & Lymphoma (CT) Aug 16, 1999 - Breast - PASH (PseudoAngiomatous Stromal Hyperplasia) (Mammo) Aug Aug 9, 1999 - Vacation no new case! 2, 1999 - Vacation no new case! (5 of 13) [5/29/2002 11:08:16 PM]

Imaging Cases of the Week

July 26, 1999 - Bronchiolitis Obliterans Organizing Pneumonia (BOOP) From Bleomycin (CT) July 19, 1999 - Moving no new case! July 12, 1999 - Moving no new case! July 5, 1999 - Solitary Plasmacytoma T-12 (CT)

q q q q q q q q q q q q q q q q q q q q q q

June 28, 1999 - Vacation no new case! June 21, 1999 - Vacation no new case! June 14, 1999 - Female Urethral Diverticulum (US) June 7, 1999 - Intracortical Chondromyxoid Fibroma Of Tibia (MRI, X-ray) May 31, 1999 - Adult Primary Pulmonary Tuberculosis (CT) May 24, 1999 - Pancreatic Islet Cell Tumor (CT) May 17, 1999 - Coccidioidal Pericarditis (NucMed, CT) May 10, 1999 - Testicular Seminoma (US) May 3, 1999 - Intracranial Cysticercosis (CT) Apr 26, 1999 - Sinusitis, Subdural Empyema & Left Frontal Lobe Abscess (CT, MRI) Apr 19, 1999 - Transitional Cell Carcinoma Infiltrating Kidney (X-ray, CT) Apr 12, 1999 - Spring Break no new case! Apr 5, 1999 - Nonfunctioning Neuroendocrine Carcinoma Of Pancreas (CT)

Mar 29, 1999 - Mandibular Ameloblastoma (CT) Mar 22, 1999 - Primary Duodenal Adenocarcinoma (CT) Mar 15, 1999 - Herpes Encephalitis (MRI) Mar 8, 1999 - MALT Lymphoma Of Breast (Mammo, US) Mar 1, 1999 - MALT Lymphoma Of Duodenum With Biliary Obstruction (CT) Feb 22, 1999 - Mature Cystic Ovarian Teratoma/Dermoid Cyst (US) (6 of 13) [5/29/2002 11:08:17 PM]

Imaging Cases of the Week

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Feb 15, 1999 - Papillary Thyroid Carcinoma (US) Feb Feb 8, 1999 - Gastrointestinal B-cell Lymphoma (CT) 1, 1999 - Gastrointestinal Stromal Sarcoma (CT)

Jan 25, 1999 - Take A Break no new case! Jan 18, 1999 - Grade II Papillary Transitional Cell Carcinoma Urinary Bladder (CT) Jan 11, 1999 - Multifocal Glioblastoma Multiforme (MRI) Jan 4, 1999 - Intracranial Epidermoid (MRI)

Dec 28, 1998 - Happy Holidays Dec 21, 1998 - Happy Holidays Dec 14, 1998 - Linitis Plastica Gastric Carcinoma (X-ray) Dec 7, 1998 - Invasive Intraductal Carcinoma Breast - Sestamibi Scan (NucMed) Nov 30, 1998 - RSNA (Radiological Society of North America) Meeting Nov 23, 1998 - Growth Hormone Deficiency & Osteochondritis Dissecans (X-ray) Nov 16, 1998 - Metastatic Papillary Serous Adenocarcinoma Ovary (CT) Nov 9, 1998 - Oligodendroglioma (CT) Nov 2, 1998 - Ascites & Secondary Bacterial Peritonitis (NucMed) Oct 26, 1998 - Common Bile Duct Stones & Lymphoma (CT) Oct 19, 1998 - Tibial Stress Fracture (X-ray, CT, MRI) Oct 12, 1998 - Hyperplastic Cholecystosis With Adenomyomatosis & Cholesterolosis (US) Oct 5, 1998 - Organo-Axial Gastric Volvulus (X-ray)

Sep 28, 1998 - Neuroblastoma (CT) Sep 21, 1998 - Intracanalicular Acoustic Neuroma (MRI) Sep 14, 1998 - Spermatic Cord Liposarcoma (MRI) (7 of 13) [5/29/2002 11:08:17 PM]

Imaging Cases of the Week

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7, 1998 - Gas In Retroperitoneal Abscess From Ruptured Colonic Diverticulum (CT)

Aug 31, 1998 - Vacation no new case! Aug 24, 1998 - Emphysematous Cystitis (X-ray) Aug 17, 1998 - Acute Suppurative Appendicitis - Ultrasound (X-ray, US) Aug 10, 1998 - Malignant Fibrous Histiocytoma - Thigh (CT) Aug 3, 1998 - Vacation no new case!

July 27, 1998 - Vacation no new case! July 20, 1998 - Vacation no new case! July 13, 1998 - Subacute Ulcerative Colitis (CT) July 6, 1998 - Benign Pleomorphic Parotid Adenoma (MRI)

June 29, 1998 - Hodgkin's Lymphoma Spleen & Pelvis (NucMed, CT) June 22, 1998 - Vacation no new case! June 15, 1998 - Vacation no new case! June 8, 1998 - Intracapsular Rupture of Breast Implant (MRI) June 1, 1998 - Infantile Hypertrophic Pyloric Stenosis (US) May 25, 1998 - Chronic Cocaine Abuse (CT) May 18, 1998 - Neonatal Pneumomediastinum & Pneumothorax (X-ray) May 11, 1998 - Acute Appendicitis - CT Scan (CT) May 4, 1998 - Ruptured Anterior Communicating Artery Aneurysm (CT, Angio) Apr 27, 1998 - Gastric Leiomyoma (UGI) Apr 20, 1998 - Tophaceous Gout & Gouty Arthritis of Foot (X-ray) Apr 13, 1998 - Subpleural Lipoma (CT) Apr 6, 1998 - Vacation no new case! (8 of 13) [5/29/2002 11:08:17 PM]

Imaging Cases of the Week

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Mar 30, 1998 - Adrenal Myelolipoma (CT) Mar 23, 1998 - Intracranial Germinoma (MRI) Mar 16, 1998 - Atypical Ectopic Mediastinal Parathyroid Adenoma (NucMed) Mar Mar 9, 1998 - Thymolipoma (CT, MRI) 2, 1998 - Early Lung Carcinoma In A Cigarette Smoker (CT)

Feb 23, 1998 - Early Middle Cerebral Artery Infarct (CT) Feb 16, 1998 - Thymoma (CT) Feb Feb 9, 1998 - Ruptured Basilar Tip Aneurysm (CT, Angio) 2, 1998 - Acute Mastoiditis With Epidural & Intracerebral Abscess (MRI)

Jan 26, 1998 - Osteochondritis Dissecans - Talus (X-ray) Jan 19, 1998 - Spinal Dural Arteriovenous Fistula (MRI) Jan 12, 1998 - Adrenal Pheochromocytoma (CT) Jan 5, 1998 - Atypical Glioblastoma Multiforme (MRI)

Dec 29, 1997 - Pseudomembranous (C. difficile) Colitis (CT) Dec 22, 1997 - Hypertrophic Pulmonary Osteoarthropathy (NucMed, X-ray) Dec 15, 1997 - Traumatic Liver Fracture/Laceration (CT) Dec Dec 8, 1997 - Intraosseous Fracture ("Bone Bruise") Calcaneus (X-ray, MRI) 1, 1997 - Giant Cell Tumor Cervical Spine (MRI)

Nov 24, 1997 - Tubo-Ovarian Abscess & Ovarian Teratoma (Dermoid) (CT) Nov 17, 1997 - Cecal Diverticulitis & Ruptured Cecal Diverticulum (US) Nov 10, 1997 - Pulmonary Embolism -- Spiral CT (CT) Nov 3, 1997 - Atypical Convexity Meningioma (CT, MRI)

Oct 27, 1997 - Ulnar Stress Fracture In A Body Builder (NucMed, X-ray) (9 of 13) [5/29/2002 11:08:17 PM]

Imaging Cases of the Week

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Oct 20, 1997 - Breast - Radial Scar (Mammo) Oct 13, 1997 - Large Cell Splenic Lymphoma (CT) Oct 6, 1997 - Khler's Disease Tarsal Navicular (X-ray)

Sept 29, 1997 - Appendicitis - Tc-99m HMPAO Labeled WBC Scan (NucMed) Sept 22, 1997 - Cranial Fibrous Dysplasia (MRI, CT) Sept 15, 1997 - Thyroid Carcinoma & Parathyroid Adenoma (NucMed) Sept Sept 8, 1997 - Massive Splenomegaly In CML (CT) 1, 1997 - Bilateral Persistent Sciatic Arteries (Angio)

Aug 25, 1997 - Ruptured Posterior Communicating Artery Aneurysm (MRI, Angio) Aug 18, 1997 - Ovarian Cystadenoma (CT) Aug 11, 1997 - Cholangiocarcinoma - Common Bile Duct (X-ray) Aug 4, 1997 - Cranial Chondrosarcoma With Proptosis (CT)

July 28, 1997 - Vacation no new case! July 21, 1997 - Vacation no new case! July 14, 1997 - Vacation no new case! July 7, 1997 - Dural Carotid-Cavernous Fistula (MRI)

June 30, 1997 - Femoral Chondrosarcoma In An Adult (X-ray, MRI) June 23, 1997 - Congenital Adrenal Hyperplasia In An Adult (CT, MRI) June 16, 1997 - Vacation no new case! June 9, 1997 - Vacation no new case! June 2, 1997 - Craniopharyngioma (MRI) May 26, 1997 - Renal Angiomyolipoma (CT) May 19, 1997 - Parathyroid Adenoma (US, NucMed) (10 of 13) [5/29/2002 11:08:17 PM]

Imaging Cases of the Week

q q q q q q q q q q q q q

May 12, 1997 - Osteomyelitis Fibula (MRI) May 5, 1997 - Cord Compression Due To T3 Fracture From Metastasis (MRI) Apr 28, 1997 - Multiple Myeloma & Compression Fracture T4 (MRI) Apr 21, 1997 - Crohn's Disease (CT) Apr 14, 1997 - Left Retro-orbital Metastasis From Breast (MRI) Apr 7, 1997 - Grade I Subependymal Hemmorhage (US)

Mar 31, 1997 - Type I (A) Thoracic Aortic Dissection (CT) Mar 24, 1997 - Adrenal Aldosteronoma (CT) Mar 17, 1997 - Subtle Right Renal Cell Carcinoma (CT, US) Mar 10, 1997 - Occult Fracture Right Hip (X-ray, NucMed, MRI) Mar 3, 1997 - IVC Thrombosis (CT) Feb 24, 1997 - Varicocele (US, Color Doppler) Feb 17, 1997 - Bile Leak Post Laparoscopic Cholecystectomy - Dx & Rx (NucMed, CT, X-ray) Feb 10, 1997 - Primary Intracranial Lymphoma (MRI) Feb 3, 1997 - Osteoid Osteoma Left Femur (X-ray, NucMed, MRI)

q q q q q q q q q

Jan 27, 1997 - Medial Orbital Blowout Fracture (CT) Jan 20, 1997 - Medullary Sponge Kidney (X-ray, IVP) Jan 13, 1997 - Colloid Cyst of Third Ventricle (CT) Jan 6, 1997 - Superior Vena Cava Syndrome (CT)

Dec 30, 1996 - Spontaneous Dissection Left ICA & Left MCA Thrombosis (CT, MRA) Dec 23, 1996 - Heterotopic Pregnancy - Tubal & Intrauterine (US) Dec 16, 1996 - Bacterial Epidural Abscess & Diskitis Thoracic Spine (X-ray, MRI) (11 of 13) [5/29/2002 11:08:17 PM]

Imaging Cases of the Week

q q q q q q q q q q q q q q q q q

Dec 9, 1996 - Fishbone In the Cervical Esophagus (X-ray, photo) Dec 2, 1996 - Lumbar Spinal Canal Meningioma (MRI) Nov 25, 1996 - Thyroglossal Duct Cyst (CT) Nov 18, 1996 - Ependymoma - Fourth Ventricle (MRI) Nov 11, 1996 - Ductus Arteriosus Aneurysm In An Adult (CT) Nov 4, 1996 - Pleural Asbestosis (CT) Oct 28, 1996 - Deep Venous Thrombosis - Indium-111 WBC Scan (NucMed) Oct 21, 1996 - Sigmoid Diverticulitis with Mesenteric Phlegmon (CT) Oct 14, 1996 - Calcified Chronic Subdural Hematoma (NucMed, X-ray) Oct 7, 1996 - Ruptured Giant Intracranial Aneurysm (CT)

Sept 30, 1996 - Testicular Carcinoma - Mixed Cell Type (US) Sept 23, 1996 - Sarcoidosis - Gallium Scan (NucMed) Sept 16, 1996 - Lymphocytic Adenohypophysitis (MRI) Sept 9, 1996 - Fractured Kidney From Blunt Abdominal Trauma (CT) Sept 2, 1996 - Cholesterolosis of the Gallbladder (US, OCG) Aug 26, 1996 - Spontaneous Splenic Rupture From Mononucleosis (CT) Aug 19, 1996 - Right Hemothorax From Ruptured Thoraco-abdominal Aortic Aneurysm (CT) Aug 12, 1996 - Vacation no new case! Aug 5, 1996 - Vacation no new case!

q q q q q q

July 29, 1996 - Vacation no new case! July 22, 1996 - Vacation no new case! July 15, 1996 - Bilateral Renal Oncocytomas (CT) July 8, 1996 - Intracerebral Cavernous Angioma (MRI) (12 of 13) [5/29/2002 11:08:17 PM]

Imaging Cases of the Week

q q q q q q q q


1, 1996 - Pancreatic Mucinous Cystadenocarcinoma (CT)

June 24, 1996 - Recurrent Pulmonary Embolus Rx'd with IVC Filter (NucMed, Angio, X-ray) June 17, 1996 - Diverticular Bleed Rx'd With Intra-arterial Vasopressin (NucMed, Angio) June 10, 1996 - Scapho-lunate Dissociation & Pisiform Fracture (X-ray) June 3, 1996 - Hook of Hamate Fracture (NucMed, CT) May 27, 1996 - Ramsay Hunt Syndrome (MRI) May 20, 1996 - Traumatic Dissection Right ICA & Right MCA Thrombosis (CT, Angio) May 13, 1996 - Traumatic Pneumorachis - Air in the Spinal Column (CT) (13 of 13) [5/29/2002 11:08:17 PM]

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Special Edition: One Physician's In my previous Left Corner article, I Response to the Attack... told the story of a resident in Pakistan How do we respond to the attack on America? Each of us has responded and the difficulties he encountered when trying to get copies of full-text out of our own unique experience and, through sharing our vicissitudes and articles for his research paper. Equally entertaining (well, I thought feelings with each other, we mourn and begin to heal. Here is a reflection so) is the story of the medical editor (me) and the from Bruce N. Cronstein, M.D., who is problem of full-text access. This story does not take place in an exotic third world country... Read more chairman of the Advisory Board of our sister site, RheumatologyWeb, and who volunteered to assist at Bellevue MRI of Spinal Epidermoids Hospital in New York City. From China, Drs. Dai, Zhu, and He probe the MRI characteristics of spinal cord epidermoids. Their report, in which eighteen cases of this rare benign tumor are evaluated, offers new conclusions about imaging and diagnosing these lesions. Question-and-Answer Radiology Review RadiologyWeb is publishing an updated series of review questions for studious residents and practitioners who wish to brush up! Our review questions adhere to the "single-best-answer" format and were created by experts in each subspecialty area. The 2001 series contains newly-minted questions in every category, and we have archived the 2000 series for those of you who are looking for extra practice! Mobile Pet Tatiana Kain, M.D. explains the value of mobile PET services. She focuses on the specific services that are (and are not) part of a typical agreement between a practitioner and the mobile PET company and looks at the future of expanded reimbursement for PET imaging. Visual Essay on Colitis

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the mouse will bring you the latest Table of Contents pages from select radiology journals chosen by our Medical Board. This one page connects you to articles recently published and journal homepages for links to abstracts. We keep you current with fewer clicks! CODING TIPS from BRACCO Bracco's Reimbursement Services Team describes and clarifies specific topics in radiological coding. The most recent tip covers the new coding requirements for vertebroplasty. Are you careful to include both radiological and surgical codes when billing for this procedure?

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DAVID, atlas of human anatomy

Go back to the CID HomePage

DAVID, Online Atlas of Human Anatomy

for Clinical Imaging Diagnosis
Developed by J.-C. Oberson MD. Copyright 1998.

Select the anatomical area you would like to examine by clicking on the corresponding lower designation.

Last update 11th May 2001

You are Visitor N

since May 1997 [5/29/2002 11:09:18 PM]

CID: online software tools to assist in imaging diagnosis

(Clinical Imaging Diagnosis)
This site is updated daily and is best viewed with Netscape browser 3.0 or more and MS-Internet Explorer 5.0 or more. What and Where is the CID? Purpose of this Web site We subscribe to the HONcode principles of the Health On the Net Foundation

On-line tools to assist in imaging diagnosis :

Internal tools: DAVID, atlas of human anatomy MINERVA, computer assistance in differential diagnosis GALLERY, teaching file Quick reference: Which imaging examination and when to order ? External tools and links: Biomedical Web Sites Search Engines or Directories Imaging teaching file sites Biomedical databases Radiological societies

You are Visitor N e-mail us (

since May 1997. Comments/suggestions/questions appreciated, please [5/29/2002 11:09:24 PM]

Anatomy on the Internet

Anatomy on the Internet

Here are some sites that include educational material for anatomy.
q q q q

Arkansas, University of Biomedical Sciences Interactive Emory University - Class in Anatomy - Cell Biology and MedWeb Harvard University s Vascular Anatomy

The Whole Brain Atlas

q q q q q q q q q q q q q q q

Johannes Gutenberg University - Workshop Anatomy for the Internet Medical College of Wisconsin - CHORUS National Library of Medicine - The Visible Human Project Preview the Heart Shimane Medical University - Radiological Images Southern California Orthopaedic Institute - Anatomy Review Stanford University - Medical Media and Information Technologies (SUMMIT) Uniformed Services University of the Health Sciences - Radiologic Anatomy Browser University of California Irvine - Virtual Anatomy and Histology Center University of Florida - Radiologic Anatomy and Office of Medical Informatics University of Hamburg - VOXEL-MAN Atlas Project University of Iowa - The Virtual Hospital University of Kansas - Study Guide in Anatomy University of Medicine and Dentistry at New Jersey - Practic Exams and Laurie Imaging Center University of Michigan s Thoracic Radiology

Advanced Tools for Learning Anatomical Structure (ATLAS)

q q q

University of North Carolina - Vertebral Body Anatomy University of Pennsylvania - Interactive Knee Demonstration University of Washington s Cases in Anatomy
s s s

The Digital Anatomist Program Anatomy Teaching Modules Radiology Cases (1 of 2) [5/29/2002 11:09:27 PM]

Anatomy on the Internet

q q

University of Wisconsin - Global Anatomy Wayne State University - Virtual Classroom

Loyola University Medical Education Network (LUMEN) homepage.

Other sites of interest

q q q q

Integrated Medical Curriculum - Gold Standard Media Neuroanatomy and Neuropathology on the Internet Braniac List of orthopedics websites from

Thanks to Ann Marie Kappil who helped compile this list.

John A. McNulty

Last Updated: Feb 26, 2002 Created: Jul 15, 1995 (2 of 2) [5/29/2002 11:09:27 PM]

CHORUS - Collaborative Hypertext of Radiology

Collaborative Hypertext of Radiology
q q

Nervous system Cardiovascular system Respiratory system Gastrointestinal system Genito-urinary system Musculoskeletal system Multisystem entities Technical stuff / Miscellany

Search for documents by title:

q q

About CHORUS Disclaimer Copyright Search Feedback

q q q q

Charles E. Kahn, Jr., MD, Editor 18 April 2002 "CHORUS To Go!" for palmtops: Supported in part by USPHS grant G08 LM05705 from the National Library of Medicine. Copyright 2002, Charles E. Kahn, Jr. Medical College of Wisconsin [5/29/2002 11:09:30 PM]

Virtual Hospital: Information by Department: Radiology

Information for Healthcare Providers

Information by Department: Radiology

Choose from the following custom views by specialty: Choose from the following multimedia textbooks: q Back Pain in Children
q q q q

Diagnosis of Disk Disease Diffuse Lung Disease Evaluation of Maxillofacial Neoplastic Lesions Using Computer Graphics from 3D-CT The Fetal and Young Child Nervous System - The Story of the Development and Maldevelopment of the Brain Imaging of Muscle Injuries Joint Fluoroscopy Lung Anatomy Lung Tumors: A Multidisciplinary Database Nuclear Medicine Imaging of the Gastrointestinal Tract Pediatric Abdominal Mass Imaging Pediatric Airway Disease Pediatric Non-Breath-Hold Cardiac MR Imaging Pelvis and Perineum Pulmonary Embolus 3D Reconstructed Images of Spiral CT for Maxillofacial Tumor Measurements Pulmonary Embolus Case Studies

q q q q q q q q q q q q

Choose from the following multimedia teaching files: q 3D Reconstructions

q q q q

Clinical Radiology Clerkship: Chest Exam Quizzes Correlapaedia - A Correlative Encyclopedia of Pediatric Imaging, Surgery, and Pathology International Thoracic Teaching Resource M3-M4 Teaching Modules: Section of Chest Radiology (1 of 3) [5/29/2002 11:09:41 PM]

Virtual Hospital: Information by Department: Radiology

q q q q q q q

MetaTextbook of Pediatric Radiology Normal Radiologic Anatomy: X-Ray, CT, MRI and Ultrasound Paediapaedia: An Imaging Encyclopedia of Pediatric Disease Pediatric Radiology Teaching File Radiology Resident's Case of the Week Thoracopaedia - An Imaging Encyclopedia of Pediatric Thoracic Disease Gastrointestinal Nuclear Medicine Case Studies

Choose from the following patient simulations: q Adult Pulmonary Case Studies
q q q

American Thoracic Society Case Studies Gastrointestinal Nuclear Medicine Case Studies Pediatric Airway Case Studies

Choose from the following lectures: q Interpretation of the Abdominal Plain Film provided in QuickTime video or RealVideo formats only. q Introduction to Clinical Medicine: Radiology Lectures
q q q q q q q q

Iowa Radiology On-call Handbook Pediatric Chest Department of Radiology Short Clerkship: Lectures Case Review Sessions of the Radiology Short Clerkship (074:006) Introduction of Skeletal Radiology (subset of former) Introduction to Chest Radiology (subset of former) Human Organ Systems Imaging in Medicine: Bone 2 Human Organ Systems Imaging in Medicine: Cardiovascular

Choose from the following clinical references: University of Iowa Department of Radiology Next Page | Previous Page | Section Top | Title Page Virtual Hospital Home | Virtual Children's Hospital Home | UI Health Care Home | Outline | Search | Help | Policies | Comments and Questions | E-mail This Page | Support Friends of Virtual Hospital
Search Quick Search: View this page at the Virtual Hospital location nearest you: Australia | Iceland | Japan | Korea | United States | Venezuela (2 of 3) [5/29/2002 11:09:41 PM]

Virtual Hospital: Information by Department: Radiology

Virtual Hospital International Locations: Australia | Iceland | Japan | Korea | United States | Venezuela
All contents copyright 1992-2002 the Author(s) and The University of Iowa. All rights reserved. Modified: Wed Apr 3 11:41:38 2002 Displayed: Wed May 29 21:59:32 2002 (3 of 3) [5/29/2002 11:09:41 PM]

Neuroanatomy & Neuropathology on the Internet

A searchable Directory compiled for Medical Students, Residents, and other Health Professionals

Original Contributions

Content: (click on the topics below)

Dementia * Demyelinating Diseases * Epilepsy * Impaired Consciousness, Sleep Disorders * Infection * Movement Disorders * Neurologic Examination * Neuromuscular Diseases * Pain * Signs and Symptoms * Stroke * Toxic, Metabolic, Nutritional Disorders * Trauma * Tumor

Compiled and designed by Katalin Hegeds, MD, PhD

* Search this site * Site Map *

May, 2002

Department of Neurology

University of Debrecen, Hungary

Other Resources: Medline | NeuroNames | OMIM | Dictionaries | Search Engines

New Links, May 2002

q q q q

Neuroanatomy Atlas Images - Columbia University, US Interactive Neuroanatomy Atlas - Columbia University, US Spinal Cord - Columbia University, US (flash required) Brachial Plexus - Columbia University, US

Histology Atlas of Microscopic Images - Columbia University, US (including nervous system)

q q q

Case Report: 13 month-old boy with history of nausea and vomiting - West Virginia University, US Pediatric Pathology Case Studies - Society for Pediatric Pathology, US Pathology Cases - Saint Louis University, US (1 of 4) [5/29/2002 11:10:30 PM]

Neuroanatomy & Neuropathology on the Internet


Neuromuscular Cases - University of Virginia, US

The last new item in our Online Neuropathology Atlas Subinsular Hemorrhage

q q

Wilder Penfield ... from the history of psychiatry - Ed Brown

Medical Neuroscience 2002 - Texas Tech University, US

q q q q

Human Brain Quiz Questions - Part I., US Human Brain Quiz Questions - Part II., US Neurology, Neuropathology and Neuropsychology Multiple Choice Questions - , UK Original Contributions r Neuroanatomy: Interactive Quiz
r r r

Neurology - Self-study Quiz 1. - University of Debrecen, HU (100 questions with answers) Neurology - Self-study Quiz 2. - University of Debrecen, HU (100 questions with answers) Neurology - Self-study Quiz 3. - University of Debrecen, HU (100 questions with answers)

q q q q q

Atlas of Neuroanatomy: With Systems Organization and Case Correlations Imaging of Orbital and Visual Pathway Pathology In Vivo Atlas of Deep Brain Structures Neurology PreTest Self-Assessment and Review Review Manual for Neurology in Clinical Practice

q q

Herpes free Pathology Case Reviews

Signs in Neurology CD-ROM

q q

7th Meeting of the European Society of Neurosonology and Cerebral Hemodynamics, May 26, 2002 - May 28, 2002, Berne, CH 8th International Conference on Alzheimer's Disease and Related Disorders, July 20, 2002 - July 25, 2002, Stockholm, SE

Neuroscience Resources - University of Wisconsin, US (2 of 4) [5/29/2002 11:10:30 PM]

Neuroanatomy & Neuropathology on the Internet


SearchOnline - Metasearch

High Quality Pictures: Artistic Photographs of Hungary

In Hungarian

In English

According to Web-Counter you are visitor number

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Member of the Medical Education Ring Linking medical education web sites worldwide [ Prev | Next | Skip One | Next 5 | List all | Random ]

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Below you can verify the spelling of a medical word: Enter medical word to spell check: Click here for helpful hints on looking up words.
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Neuroanatomy & Neuropathology on the Internet

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If you have any comments, please, contact Prof. Katalin Hegeds Last modified: May 11, 2002 Created: April 17, 1996

Copyright by Katalin Hegeds, 1996-2002, ALL RIGHTS RESERVED (4 of 4) [5/29/2002 11:10:30 PM]

Neuroradiology - A collection of the best educational sites

Neuroradiology Links

CT, MRI, PET, SPECT, angiography, ultrasound

q q

Normal Anatomy Case studies Teaching Files, Links

The best educational sites Normal Anatomy q Radiography of the Skull - Ohio State University, Columbus
q q q q q q q q

Radiography of the skull - XRAY2000, UK Radiologic Anatomy of Head - University of California, Davis Radiographic Anatomy of the Skeleton - University of Washington Cardinal features of the plain cervical spine Neuroradiology Tudor - University of Wisconsin Normal brain (sagittal, axial, coronal view) - Wayne State University Normal Cortical Anatomy - Massachusetts General Hospital, US (PPT) Atlases of the Brain - University of Utah, Salt Lake City
r r r

MRI - axial MRI - coronal MRI - sagittal

q q q

Normal Radiologic Anatomy : Head And Neck Imaging - Virtual Hospital, University of Iowa, US Radiological Anatomy of CNS - University of Connecticut MRI Head & Neck Atlases (including MR angiography and spectroscopy) - Laurie Imaging Center, University of Medicine and Dentistry, New Jersey MRI ATLAS OF THE BRAIN - Facult de Mdecine d'Angers, FR Angiography - Northeastern Ohio University, US Stereotactic Atlas Overlay on MRI

q q q

Neurological Diseases - Teaching Files, Case Studies, Image Galleries q The Whole Brain Atlas (normal and pathological) - Harvard Medical School
q q

Medpix: Medical Images: Brain and Neuro - Uniformed Services University, Bethesda, US Neuroradiology teaching files - University of Cincinnati
r r

by unknown by diagnosis (1 of 5) [5/29/2002 11:10:34 PM]

Neuroradiology - A collection of the best educational sites

q q q q q q q q q

Neuroradiology Teaching Files - University of Brescia, IT Neuroradiology Teaching Files - (UAB) University of Alabama at Birmingham NeuroRadiology Teaching Files - UNC University of North Carolina Neuroradiology Teaching Files - UCHSC University of Colorado, Denver Neuroradiology Teaching Files - Wayne State University Neuroradiology Teaching File - Harbor-UCLA Radiology Neuroradiology Teaching Files - University of Wisconsin Neuroradiology - American College of Radiology Learning File WEB Neuroradiological Teaching File - Laurie Imaging Center, University of Medicine and Dentistry, New Jersey Neuroradiology - New England Medical Center (pituitary tumor, subdural, epidural hematomas)

Interesting Cases: Neuroradiology - New England Medical Center

q q

Imaging of CNS Disease - University of Florida AuntMinnie's Teaching Files - Mark S. Frank, M.D.

Case of the Day

q q q

Neuroradiology Library - University of Iowa The Virtual Radiological Case Collection - Radiologische Universittsklinik, Homburg/Saar, DE Neuroradiology WEB - Neuroradiology Service Diagnosis Mdica, Barcelona, ES (in Spain) Brain Index, xray2000 Website, UK
r r r r

Skull Spine Cervical Spine Thoracic Spine Lumbar

q q q

Brain Lesions, CID Gallery, Diagnostic Imaging Center, Lausanne, CH Teaching Files - Bhatia General Hospital, Mumbai, IN Skull Case Index - Scottish Radiological Society, UK


Case of the Week: - NEURORADIOLOGY 2001 - American Journal of Roentgenology

r r r

Case of the Month - Taiwan Child Society, TW (2 of 5) [5/29/2002 11:10:34 PM]

Neuroradiology - A collection of the best educational sites

q q

MRI teaching files, brain cases by diagnosis - University of Florida, Gainesville MRI Teaching Files - Amar N. Gulati MD (oligodendroglioma, cystic hygroma, spinal ependymoma,
trigeminal Schwannoma)

q q q q q

UCSD - Neuroradiology Teaching File Database, University of California, San Diego, IMAGING OF STROKE: WHY, WHAT, WHERE, AND WHEN - AFIP Lecture Series Neuroradiology Case Studies - MT. SINAI MEDICAL SOCIETY LIBRARY Neuroradiology Teaching Cases - University of New Mexico Interesting Neuroradiology Cases - University of California, San Francisco

Interesting Cases Query form - mark Speciality, then Neurology (432 cases)

Neurology Clinical Cases - University of Rennes, FR (automatic translation from French to English

q q q q q q q q q q

Radiology Teaching Case Museum - South Bank University, UK BrightmanRad Cases - Harvard University (including neuroradiology) Case Database (including neuroradiology) - Belgian Journal of Radiology, BE Neuroradiology: UCLA Teaching Files - University of California, Los Angeles Neuroradiology Imaging Teaching Files ( - Case Western Reserve University Neuroradiology: Radiology Residency Teaching Collection - St. Joseph's Hospital, Phoenix Neuroimaging Case Challenges - American Society of Neuroimaging Residents' Case of the Week Archive - University of Pennsylvania Medifax - Neuroradiology: Brain, Spinal Cord, Normal, Diseases RadPa-Institute of Radiology, University of Palermo, IT
r r

Image Gallery Teaching Files

q q

Teaching Atlas of Brain Imaging: Online Case Studies (29) - PDF files Virtual Hospital: Radiology Resident's Case of the Week, 1995-1996

Virtual Hospital: Radiology Resident Case of the Week

q q q q q q q q

Emergency Neuroradiology - eMedicine Radiology (including neuroradiology) teaching files - University of Szeged, HU Radiology Teaching Files - Indiana University (including neuroradiology) Imaging Cases of the Week (including neuroradiology) - Doctor T, US Case of the Month including neuroradiology - King Edward Memorial Hospital, IN Case of the Month - The Belgian Radiology Link, BE Neuroradiology Case of the Month - University of Rochester, US Case Studies, Center for MR-guided Therapy - University of Minnesota, US (3 of 5) [5/29/2002 11:10:34 PM]

Neuroradiology - A collection of the best educational sites

q q

The Spine - University of California, Davis Three dimensional radiological imaging - Shimane University, JP

MRA neuro

q q q

CT Venography of Dural Sinus Thrombosis - Radiological Society of North America Neuroradiology of the Cavernous Sinus - Indiana University (ppt file) Superior Sagittal Sinus Thrombosis - Can. J. Neurol. Sci. 2001; 28: 346-348

Interventional Neuroradiology q Interventional Neuroradiology - Wake Forest University, Winston-Salem

r q q

Interventional Neuroradiology Procedures (with case illustrations)

Radiologie interventionnelle - Hopital de Rodez, FR (in French) Interventional Radiology - University of Strasbourg, FR

Nuclear Medicine q PET Brain Atlas - University of California, Los Angeles

q q q q

Atlas of Brain Perfusion SPECT - Harvard Medical School, Boston Let's Play PET! - University of California, Los Angeles Sample PET Neurology Cases - University of Tennesse, US Combined PET/CT: Physiologic/Anatomic Atlas of F-18 Fluorodeoxyglucose (FDG) Uptake on PET Imaging in the Head and Neck - American Society of Neuroradiology: Neurographics Nuclear Medicine Teaching File - Washington University Cases Related to Nuclear Medicine (including neurology cases) - Tokai University, JP Nuclear Medicine Teaching Files - University of North Carolina Nuclear Medicine - University of Kansas Skeletal System Imaging - University of Iowa

q q q q q

Ultrasound q Transcranial Doppler - An Overview of its clinical Application


Transcranial Doppler: An Overview of its Clinical Applications - The Internet Journal of Emergency and Intensive Care Medicine 2000 Vol4N1 Carotid Duplex Imaging, Online CME Course - GE Medical Systems Transcranial Color-coded Sonography (TCCS): A Helpful Tool In Clinical Neurology - Internet Journal of Neurology 2001

q q

Other Resources without Images q Basics of MRI: Joseph P. Hornak, Ph.D., Rochester Institute of Technology (4 of 5) [5/29/2002 11:10:34 PM]

Neuroradiology - A collection of the best educational sites

q q q q q

MRI Protocols - Massachusetts General Hospital MR Angiography - University of California, San Diego NEURORADIOLOGY - The Armed Forces Institute of Pathology Lecture Series Paediapaedia: Neuroradiological Procedure Descriptions - Virtual Hospital, University of Iowa Ultrasound Review


RSNALinks (Radiological Society of North America)


Education Resources

q q

Neuroradiologia en Internet Neuro Imaging -

Practice Questions q Brain MRI Practice Exams - Oregon Health Sciences University
q q q q

Brief Neuroanatomy Quiz - New England Medical Center Self-Assessment Quiz - Neuroradiology - University of Florida Neuroradiology Quiz - IndianRadiologist, IN Radiology Quiz, including Neuroradiology - Radiology Education Foundation, IN

Last modified: May 21, 2002 Links checked: May 21, 2002 Created: September 6, 2000 If you have any comments, please, contact Prof. Katalin Hegeds

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Differential Diagnosis in Neuroradiology

Neuroradiology Differential Diagnoses

(Original Text from Spencer Gay, MD, UVA)

James G. Smirniotopoulos, M.D.

Uniformed Services University of the Health Sciences Bethesda, Maryland

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POSTERIOR FOSSA MASS - CHILD Cerebellum/IVth Ventricle - Medulloblastoma - midline, vermian or roof - usually hyperdense on plain CT - often enhance homogeneously - Astrocytoma - usually PILOCYTIC ASTROCYTOMA - 2/3 are cystic with mural nodule - cyst fluid denser than CSF due to protein - Ependymoma - INTRA-ventricular - "cast" of lumen - 50% are calcified (1 of 18) [5/29/2002 11:11:08 PM]

Differential Diagnosis in Neuroradiology

Brainstem - Brainstem glioma - expands brainstem (infiltration w/o destruction) hydrocephalus (may be late) Extraaxial fluid collection - Large cisterna magna ("Mega Cisterna Magna") - Epidermoid inclusion cyst - Arachnoid cyst (may bevel inner table of skull) - Dandy Walker cyst of 4th ventricle (look for vermian abnormalities) - Vermian agenesis - Chronic subdural hematoma COMMENT: For a posterior fossa mass one should consider the direction of displacement of the 4th ventricle to assess from which compartment it arises POSTERIOR FOSSA MASS - ADULT Extraaxial: - Vestibular Schwannoma (CPA) - Meningioma - Ependymoma Intraaxial: Metastasis - most common intraaxial neoplastic post fossa mass in adult Hemangioblastoma - cystic or solid - angio shows hypervascularity & stain Astrocytoma - usually not vascular on angio Medulloblastoma - often more lateral in adults Lymphoma Abscess Infarct CEREBELLAR ATROPHY Drugs - Alcohol (vermis) - Dilantin (hemispheres) - Chemotherapeutic agents Vascular process (incl. infarction) Trauma Hyperthyroidism Paraneoplastic - lung, breast, lymphoma, ovary Olivopontocerebellar degeneration COMMENT: Cerebellar sulci > 1 mm, enlarged 4th ventricle, enlarged cisterns MASS IN CLIVUS Chordoma - bone destruction Meningioma - hyperostosis Local invasion - nasopharyngeal cancer - pituitary tumor Metastasis Chondrosarcoma (more often paramedian) COMMENT: A basilar artery aneurysm may appear to arise from the clivus - look for (2 of 18) [5/29/2002 11:11:09 PM]

Differential Diagnosis in Neuroradiology

pulsationartifact in the phase encoding direction BRAINSTEM LESION Brainstem glioma - present with cranial nerve palsies - hydrocephalus less common Infarction Hemorrhage - often hypertensive Pontine myelinolysis ("central", aka. "Osmotic Myelinolysis") Multiple sclerosis Metastasis Basilar artery aneursym/dolichoectasia may displace brainstem CEREBELLOPONTINE ANGLE TUMOR Vestibular Schwannoma (aka. "Acoustic neuroma") - enlarges IAC, rounded mass in cistern - enhances with IV contrast and Gadolinium DTPA - large (>2.5 cm) schwannomas heterogeneous - bilateral lesions in NF-2 Meningioma - does not enlarge IAC - enhances homogeneously Epidermoid - hypodense - enlarges cistern - serpentine margin - FLAIR sequence may distinguish from CSF (arachnoid cyst) Exophytic brainstem glioma - progressive cranial nerve palsies Acquired Epidermoid ("Cholesteatoma") -erupts from middle ear - signs of mastoiditis, Hx of ear infection Metastasis Basilar artery aneurysm Glomus jugulare Trigeminal schwannoma (may "dumbell" into middle fossa) Arachnoid cyst (homogeneous CSF density and signal) CT PROGRESSION OF INTRACRANIAL HEMATOMA (change from HYPER- to HYPO- dense over time) Initially - 60 - 90 Hounsfield Units (HU) 2 days - 70 HU 3 weeks - 30 HU >5 weeks - <30 HU 20% show enhancing rim at 2-6 weeks (3 of 18) [5/29/2002 11:11:09 PM]

Differential Diagnosis in Neuroradiology

MRI APPEARANCE OF INTRAPARENCHYMAL HEMATOMA (T1/T2: II, ID, BD, BB, DD (I-iso, D-dark, B-bright) Hyperacute - minutes to hours (DD => II) - T1WI - hematoma hypointense (deoxyHb) => isointense - T2WI - hematoma hypointense (deoxyHb) => isointense Acute - 0-2 days (ID => BD) - deoxyhemoglobin in intact RBCs with surrounding edema - T1WI - hematoma isointense, low signal intensity (SI) edema - T2WI - hematoma decreased SI at center, high SI edema Subacute - 2-14 days (BB) - deoxyhemoglobin changes to methemoglobin from outer to inner - T1WI - outer core shows increased SI - T2WI - Outer core shows increased SI due to shortened T1, longer T2 Chronic - 14 days (BB => DD) - hemosiderin laden macrophages at periphery - T1WI - inner core now also increased SI, rim has low SI - T2WI - inner core also has increased SI, rim has low SI Chronic - months later (DD) - hemosiderin laden macrophages at periphery - T1WI - mostly iso-/decreased SI, rim has lower SI - T2WI - markedly hypointense rim has low SI - "blooms" with greater T2-weighting COMMENT: T1WI = T 1 weighted image T2WI = T 2 weighted image SI = signal intensity CT PROGRESSION OF ISCHEMIC INFARCT Initially - 30 HU 1 day - <30 HU Enhance ~3 days till 6 weeks Mass effect peaks at 3-5 days - seen in 20 % of ischemic infarcts - a significant mass effect is a poor prognostic sign After 8th week - 50% have "negative mass effect" (atrophy) CAUSES OF SUBARACHNOID HEMORRHAGE Trauma (most common, but different clinical presentation) * Ruptured aneurysm (classic "Worst HA of my life!") * Arteriovenous malformation Neoplasm Hypertensive hemorrhage (after rupture through brain or ventricle) COMMENT: CT identifies a subarachnoid hemorrhage in upto 80 - 95% of cases. A negative CT does not rule out a small subarachnoid hemorrhage - therefore LP needed with classiscHx. SAH => angiogram. If 1st angio negative (spasm, clot, etc) then follow-up angio in 2-4 wks. After 2 normal angio => workup spine for source of blood (e.g. spinal AVM, spinal neoplasm (ependymoma)). (4 of 18) [5/29/2002 11:11:09 PM]

Differential Diagnosis in Neuroradiology

SUBDURAL vs. EPIDURAL Subdural - Crescentic shape - Can layer along falx or tentorium - Acute 1-7 d - dense on CT - MRI isointense on T1WI, decreased on T2W - Subacute 7-21 d - isodense on CT - MRI increased on T1WI and T2WI - Chronic >21 d - hypodense on CT, may have enhancing rim - MRI decreased intensity on T1WI, isointense on T2WI Epidural - Biconcave (lenticular) - Does not cross cranial sutures (unless Fx crosses or previous surgery) - OUTSIDE (external) to dural sinus - middle fossa common (laceration of middle meningeal artery) - may occur in posterior fossa after Fx lacerates transverse sinus INTRAVENTRICULAR TUMOR Colloid cyst - often at foramen of Munro (3rd ventricle) - hyperdense and enhancing Choroid plexus papilloma - usually in lateral ventricles in infants - more often in 4th ventricle in adults Meningioma - uncommonly Ependymoma - 4th ventricle Metastasis - to choroid plexus Subependymal Giant Cell Astrocytoma (f. of Monro, attach to caudate, 90% have Tuberous Sclerosis) Astrocytoma Central Neurocytoma (usually attached to septum pellucidum) COMMENT: Both CPP and Meningioma arise within choroid, and derive blood supply from choroid vessels. 3rd VENTRICULAR MASS Anterior - Colloid cyst - Meningioma - Ependymoma (5 of 18) [5/29/2002 11:11:09 PM]

Differential Diagnosis in Neuroradiology

- Choroid plexus papilloma (least common location) - AVM (unusual) - Basilar artery aneurysm (exotic) Posterior - Pineal region tumors (see below) - Tectal glioma - Epidermoid - Meningioma COMMENT: The 3rd ventricle is least common location for ependymoma and CPP. PINEAL REGION TUMOR Germ cell origin (about 60%) - Germinoma - 40 - 50% of ALL pineal region tumors - 2/3 of all Germ-cell origin tumors - tumor surrounds calcified gland - homogeneous, dense on plain CT - Teratoma - heterogeneous - may have fat/lipid - Teratocarcinoma - Embryonal cell/yolk sac/choriocarcinoma Pineal parenchymal tumors - exploded calcification - radiosensitive - Pineocytoma - hyperdense - Pineoblastoma - very malignant, a type of PNET Tectal glioma Meningioma (falx, tentorium) Metastasis Vein of Galen Malformation (including aneurysmal dilatation of vein of Galen) EXTRA-AXIAL TUMORS Meningioma - parasagittal > convexities > sphenoid ridge > subfrontal > juxtasellar > tentorial > posterior fossa > floor of middle cranial fossa Epidermoid - Dermoid - Lipoma (midline, ALL fat, may have callosal agenesis) Arachnoid cyst Bony lesion Meningeal infiltration by lymphoma or leukemia (may look epidural/subdural in shape) Carcinomatous meningitis (6 of 18) [5/29/2002 11:11:09 PM]

Differential Diagnosis in Neuroradiology

SUPRATENTORIAL TUMOR Glioma (30-40%) - Glioblastoma (astro grade IV) - Astrocytoma - Oligodendroglioma - Ependymoma Metastasis (20-30%) Meningioma (16%) Pineal gland tumors Lymphoma BASAL GANGLIA CALCIFICATIONS Birth anoxia Idiopathic (most common) bilateral and symmetrical Radiation TX Toxoplasmosis / CMV - usually not limited to basal ganglia Hypoparathyroidism / pseudohypoparathyroidism Infarct COMMENT: * BIRTH * SUPRASELLAR MASS ("SATCHMOE" - nickname for Louis Armstrong, deceased jazz musician extraordinaire) Sellar/Parasellar neoplasm - pituitary adenoma Aneurysm - sharply marginated - densely enhancing on CT, "pulsation artifact" on MR Germ Cell tumor ("ectopic pinealoma" - a misnomer) Teratoma - heterogeneosu,iso-/lipid - small - solid Craniopharyngioma - children>adults - calcified 75% - cystic 75% Hypothalamic glioma - children / Histiocytosis (Diabetes Insipidus) Meningioma / metastasis Optic glioma - erodes sphenoid - visual loss Epidermoid/Dermoid inclusion cyst COMMENT: For parasellar mass, add carotid-cavernous fistula and cavernous or other carotid aneurysm SELLAR MASS Pituitary adenoma Craniopharyngioma Meningioma Metastasis Epidermoid Abscess Aneurysm Pituitary bleed - apoplexy (post-partum or into adenoma) (7 of 18) [5/29/2002 11:11:09 PM]

Differential Diagnosis in Neuroradiology

Pituitary sarcoid Rathke cleft cyst (usually intrasellar, may extend out) Germinoma RING ENHANCING LESION (CT) Primary brain tumor (glioblastoma) - irregular thick ring Metastasis (especially if on ChemTx) Abscess - ring is more smooth and regula r - thinner on medial (WM) side Multiple sclerosis - in white matter Resolving hematoma - 10-21 days - usually has perilesional lucency Tuberculoma - associated extracranial TB often found - irregular ring Infarct Radiation necrosis - 9 months-3 years after Rtx > 4000 rads Postoperative change (at edges of resection) Aneurysm - due to intraluminal thrombus LOW DENSITY MASS LESION (CT) Lipoma - (-) CT # (- 60 -90 HU, not merely low, but very low) Epidermoid - due to inclusion of ectoderm - often lateral, occasional midline Arachnoid cyst - CSF density/intensity - most at temporal tip/ middle fossa P orencephalic cyst (brain defect) Infarct (acute from edema, chronic from encephalomalacia) Pilocytic astrocytoma (cyst fluid) Ventricle/cistern Chronic subdural HYPERDENSE LESION WITHOUT CONTRAST Meningioma - 20% also show hyperostosis - 2/3 show peritumoral edema Lymphoma (small round blue-cell tumor - densely cellular) - primary is usually intraaxial - secondary is often extraaxial Metastasis - * MRCT * Melanoma/Renal cell Ca/Choriocarcinoma/Thyroid Medulloblastoma (small round blue-cell tumor - densely cellular) Glioblastoma Ependymoma Colloid cyst (inspissated mucus) Hemorrhage (acute) / hemorrhagic infarct Craniopharyngioma Germinoma (pineal and suprasellar) (8 of 18) [5/29/2002 11:11:09 PM]

Differential Diagnosis in Neuroradiology

MULTIPLE ENHANCING LESIONS Hematogenous: Metastases - 45 -55% of CNS mets multiple - >2cm often cavitate - usually near gray-white junction (peripheral > central) Lymphoma - usually deeper, periventricular, may be rings in AIDS Disseminated infection (multiple abscesses) Multifocal infarction Inflammatory/Unknown Etiology: Multiple Sclerosis (white matter lesions) Vasculitis Hypertensive Crisis/Ecclampsia Inherited Mass Lesions/Neoplasms: Hemangioblastoma (von Hippel-Lindau) Arteriovenous malformations (cavernous hemangioma >> AVM) Meningiomas - 4% are multiple (some with NF-2, most without) Multicentric gliomas - 5% of all gliomas Tuberous sclerosis Neurofibromatosis (both types - NF1 (von Recklinhausen) and NF2 (MISME) GYRAL ENHANCEMENT: * Ischemia/Infarction (incl. seizures, migraines, etc.) * Cerebritis/Encephalitis (e.g. Herpes) Meningeal carcinomatosis (carcinomatous meningitis) Meningitis - chronic > acute AVM Cortical vein thrombosis Lymphoma Meningioangiomatosis (NF2) COMMENT: Sturge-Weber will be dense without contrast due to tram track calcification in cortex underlying a meningeal venous angioma CAUSES OF HYDROCEPHALUS (literally "water on the HEAD") Communicating (decreased reabsorption) - Normal pressure hydrocephalus - prominent temporal horns - s/p infection - meningitis - s/p subarachnoid hemorrhage - Dural vein thrombosis Non-communicating (mechanical obstruction to flow) - Aqueductal stenosis - postinflammatory or congenital (9 of 18) [5/29/2002 11:11:09 PM]

Differential Diagnosis in Neuroradiology

Tumors - especially colloid cyst Congenital anomalies Dandy-Walker cyst of 4th ventricle Arnold-Chiari malformation

Overproduction (increased production) - Choroid plexus papilloma COMMENT: Mimicked by atrophy - "hydrocephalus ex vacuo" MIDLINE SHIFT Intracranial mass - Tumor - Large infarct with edema - Intracerebral bleed Extracerebral collection - Epidural hematoma - Subdural hematoma - Empyema Unilateral atrophy HYDROCEPHALUS vs. ATROPHY (CT) Hydrocephalus (ventricles >> sulci) - Ballooned and tight frontal horns - Dilated temporal horns - Dilated 3rd (hourglass shape) with flow void on MR - decreased mammillopontine measurement (expanded 3rd pushes mammillary bodies post./inf. - Dilated 4th ventricle - Periventricular abnormal signal/density Atrophy (sulci and ventricles dilate proportionately) - Large cortical sulci - Less 3rd ventricular dilatation (with parallel sides NOT hourglass shape) - Increased with age COMMENT: Normal pressure hydrocephalus evaluated by nuclear cisternogram. No migration of activity over convexities/persistent intraventricular activity ... 50% aided by shunt ("shunt responsive NPH") APPROACH TO INTERPRETATION OF ANGIOGRAPHY What view (lateral, frontal, oblique, submental-vertex, etc)? What Vessel Was Injected? What phase (arterial, capillary, venous) of injection? Localize lesion (hypervascular/hypovascular, mass effect?, shift?) Check vessels for displacement - don't forget extracerebral lesions (10 of 18) [5/29/2002 11:11:09 PM]

Differential Diagnosis in Neuroradiology

AP - Anterior cerebral arteries, pericallosal - Internal cerebral veins - Sylvian point LAT - Sylvian triangle POSTERIOR CIRCULATION (verterbral injection) - Precentral cerebellar vein - PICA Characterize vascularity - increased (Hyper) or decreased (Hypo) BRANCHES OF INTERNAL CAROTID Meningohypophyseal trunk (that "Italian artery" Bernasconi-Casanari) Ophthalmic Superior hypophyseal Posterior communicating (infundibulum, connects to PCA) Anterior choroidal (AChoA - marker for temporal lobe herniation) Anterior cerebral (ACA) - Frontopolar - Callosomarginal - Pericallosal Middle cerebral (MCA) - Lenticulostriate (perforators to basal ganglia) Internal Carotid (ICA) - Cervical-Petrous-Cavernous-Supraclinoidsegments POSTERIOR CIRCULATION BRANCHES Vertebral - Muscular (occipital) branches - Meningeal branch - PICA Basilar - AICA - Superior cerebellar (SCA) - Posterior cerebral (PCA) - Posterior communicating - Posterior choroidal (medial/ and lateral branches) - Parietoccipital - Posterior temporal - Calcarine EXTERNAL CAROTID BRANCHES Superior thyroid Lingual Facial Ascending pharyngeal Occipital Posterior auricular (11 of 18) [5/29/2002 11:11:09 PM]

Differential Diagnosis in Neuroradiology

Superficial temporal Internal maxillary - Middle meningeal (f. spinosum) DEEP VENOUS DRAINAGE Anterior septal Thalamostriate Internal cerebral veins (paired) Basal vein(s) of Rosenthal (medial temporal lobe) Great vein of Galen Inferior sagittal sinus (free edge of Falx) Straight sinus Superior sagittal sinus (don't forget the "Torcular Herophilus") Transverse sinus Sigmoid sinus Internal jugular COMMENT: Superficial drainage is superficial middle cerebral vein, vein of Trolard and vein of Labbe to superior sagittal sinus CAUSES OF EARLY DRAINING VEIN - (rapid or short "transit time") * Neoplasms - primary or secondary * AVM Inflammatory lesion Trauma (hyperemia) Ischemia Epileptic focus Toxic encephalopathy COMMENT: Definition is vein seen < 3 sec after beginning of intracerebral contrast usually veins drain into Sup Sinus from anterior to posterior CRANIAL FORAMINA AND CONTENTS Cribiform plate - CNN-I - Olfactory nerve twigs to nasal vault Optic canal - CNN-II - Optic nerve and ophthalmic artery Superior orbital fissure - III - Oculomotor, IV - Trochlear, V1 - Ophthalmic , VI - Abducens, superior ophthalmic vein f. Rotundum - V2 Maxillary f. Ovale - V3 Mandibular and accessory meningeal artery f. Spinosum - Middle meningeal artery f. Internal auditory canal - VII (Facial), VIII (Vestibulo-Cochlear) f. Jugular - Jugular vein, IX -- Glossopharyngeal, X - Vagus, XI- Accessory f. Hypoglossal - XII Hypoglossal f. Magnum - Spinal cord, XI Accessory, vertebral arteries, spinal arteries APPROACH TO INTERPRETATION OF MYELOGRAPHY (12 of 18) [5/29/2002 11:11:09 PM]

Differential Diagnosis in Neuroradiology

Check plain films - for bone destruction, previous surgery, trauma, dysraphism Contrast used - water-soluble, oily Filling defects, displacement of sac, cord ? Compartment involved: CLASSIC: Intramedullary (cord lesion) Extramedullary/Intradural (subarachnoid space) Extradural (outside the thecal sac) Conus (How low?) Roots (Thickend, clumped, displaced?) Thecal sac (Narrowed? Stenosis?) INTRAMEDULLARY LESION Tumors - Ependymoma (most common, esp in adults) - Astrocytoma (more common in children/Cx location) - Medulloblastoma (CSF seeding) - Lipoma/Dermoid/Epidermoid - especially in dysraphism - Hemangioblastoma (Von Hippel-Lindau syndrome) - Metastasis - breast/lung/melanoma - Syringomyelia/Hydromyelia - Hematoma Inflammation - myelitis - AVM-Angioma Cervical - usually glioma or syrinx Thoracic - consider teratoma, dermoid, astrocytoma? EXTRAMEDULLARY/INTRADURAL LESION Meningioma (most thoracic) Schwannoma (more common than neurofibroma) Neurofibroma (erodes bone while extending through neural foramen, usually NF-1) Drop metastasis - medulloblastoma/ependymoma/pineal dysgerminoma/glioma Dermoid-Epidermoid (associated with dysraphism ?) Lipoma - most common location is caudal (also "fatty filum") COMMENT: Most tumors in this location are benign EXTRADURAL LESION Herniated disc (90% at L4-5 and L5-S1) Osteophyte Metastasis (Breast-Lung) Lymphoma Meningioma Primary Bone tumor: - Chordoma - Osteosarcoma/blastoma - Myeloma (13 of 18) [5/29/2002 11:11:09 PM]

Differential Diagnosis in Neuroradiology

- Aneurysmal bone cyst - Giant cell tumor Neurofibroma (often w/intradural component) Dermoid-Epidermoid/Lipoma SACRAL EXPANSILE LESION Sacrococcygeal Teratoma (often presents in newborn) Epidermoid cyst Chordoma (bulky, lobulated mass with bone destruction) Dural ectasia - meningocele Dermoid Lipoma Giant cell tumor Aneurysmal bone cyst OPTIC NERVE THICKENING Optic nerve glioma (usually pilocytic, often with NF1) Optic nerve sheath meningioma (tram track lesion outlines normal size nerve) Papilledema (dilations of SAS that surrounds nerve) Optic neuritis (MS-Sarcoid) Orbital pseudotumor - near globe - responds to steroid therapy - thickens muscles AND tendons Graves' disease - thickens extraocular muscles - no tendon involvement Vascular malformations - cavernous hemangioma > AVM - carotid-cavernous fistula Orbital cellulitis - may be 2nd to ethmoid sinusitis Leukemia Perineuritis Optic nerve hemorrhage COMMENT: Check optic chiasm for intracranial extension OCULAR MASS Child - Retinoblastoma - 2/3 "heritable", 1/3 w/Family Hx - multiple/bilateral if "heritable" - 90% Ca++ - staging (vitreous, choroidal, scleral, extension?) Adult - Choroidal melanoma - older patient, enhance (14 of 18) [5/29/2002 11:11:09 PM]

Differential Diagnosis in Neuroradiology

- Metastasis - breast, lung, extra-ocular melanoma - Intraocular lymphoma - Choroidal hemangioma RETRO-OCULAR MASS (Intraconal) Hemangioma - enhance - phleboliths seen in 10% Optic nerve glioma Optic nerve meningioma Angioma Lymphangioma AVM CONAL MASS Rhabdomyosarcoma - bone destruction - calcification Thyrotoxic ophthalmopathy - 88% bilateral - 80 % medial, inferior rectus muscles Myositic pseudotumor EXTRACONAL MASS Dermoid Mucocele - occurrence frontal > ethmoid > maxillary > sphenoid * FEMS * Lymphoma Pseudotumor LACRIMAL GLAND MASS Unilateral - Pleomorphic adenoma (histo similar to minor salivary gland tumors) - benign - Malignant epithelial cell tumors - Adenoid cystic carcinoma - bone destruction - Pseudotumor - Dacroadenitis Bilateral (systemic diseases) - Lymphoma - Sarcoid - Collagen vascular disease RADIOLUCENT SKULL LESION (15 of 18) [5/29/2002 11:11:09 PM]

Differential Diagnosis in Neuroradiology

Metastasis Normal variant Epidermoid (intradiploic) Eosinophilic granuloma ("beveled" margins) Plasmacytoma Paget's (widened diploic space) Burr hole Fibrous dysplasia (widened diploic space) Hemangioma (widened diploic space, radial or starburst trabeculae) Brown tumor of hyperparathyroidism Osteomyelitis Erosion from intracranial tumor (usu slow-growing, e.g. meningioma, oligodendroglioma) OPAQUE PARANASAL SINUS Acute sinusitis - FLUID Fracture (blood) Chronic sinusitis - MUCOSAL THICKENING Mucocele (obstructed sinus ostium => expanded sinus) Retention cyst (obstructed mucus gland => round mass) Polyp Normal hypoplastic - OTHER Cystic fibrosis Inverting papilloma (bone destruction) Malignant tumor EXPANSILE LESION OF SINUS Fibrous dysplasia Mucocele Ossifying fibroma Extensive polyposis (allergic history?) PHAKOMATOSES Tuberous sclerosis - Autosomal dominant - Adenoma sebaceum, seizures, mental retardation - Hamartomas involving many organs, angiomyolipomas of kidneys - Brain - periventricular subependymal nodules - Cortical tubers - 15% develop subependymal giant cell astrocytoma Sturge-Weber (Encephalotrigeminal angiomatosis ) - No inheritance pattern, congenital malformation - Port wine nevus of face - V1 distribution - Seizures, mental retardation, glaucoma (16 of 18) [5/29/2002 11:11:09 PM]

Differential Diagnosis in Neuroradiology

CT - gyral calcification and cerebral atrophy MR - gyriform enhancement - mass-like choroid plexus calvarial/facial thickening hemiatrophy and hemiparesis

Von Hippel-Lindau - Hemangioblastomas - cerebellum, retina, medulla, spinal cord - Pheochromocytoma (NIH Type 2a or 2b) - Renal cysts 60% - Renal cell carcinoma 45% - Pancreatic cysts, Islet cell tumors, serous adenomas Von Recklinghausen (Neurofibromatosis Type 1, NF1) - Autosomal dominant - Cafe-au-lait spots 6 or more, 15mmm in adult - fibroma molluscum (multiple cutaneous neurofibromas) - Sphenoid dysplasia - Acute kyphotic scoliosis - Lateral thoracic meningocele Type I - chromosome 17 - "peripheral" type (misnomer) - Peripheral neurofibromas - Other CNS tumors - glioma, optic glioma Wishart Neurofibromatosis (Bilateral Vestibular Schwannomas) Type II - chromosome 22 - "central" type (misnomer) (aka MISME Syndrome: Multiple Inherited Schwannomas, Meningiomas, and Ependymomas) - Bilateral vestibular schwannomas in "all" patients - Other CNS tumors - meningioma, spinal cord ependymoma, other cranial and spinal schwannomas COMMENT: The gliomas of NF-2 are ependymoma, those in NF-1 are astrocytoma (both pilocytic and glioblastoma)


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Differential Diagnosis in Neuroradiology

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Anatomy Atlas of Human Anatomy in Cross Section | Anatomy Tutorials | Digital Anatomist | Gray's Anatomy | The Human Brain: Dissections of the Real Brain | Illustrated Encyclopedia of Human Anatomic Variation | Instant Anatomy | LUMEN Structure of the Human Body | Musculoskeletal Atlas | Neuroanatomy Lab Resource | Pelvis and Perineum | University of Michigan | University of Utah Neuroanatomy Atlas | University of Utah Visible Human Radiology Anatomy Atlases of the Brain | Cardiac MRI Anatomical Atlas | Compare | David, Atlas of Human Anatomy | Emory Radiologic Anatomy | Joint Fluoroscopy | LUMEN Cross Section Tutorial | Lung Anatomy | McGill Radiologic Anatomy | MRI Anatomy Atlas | Neuroradiology Tutor | Normal Radiologic Anatomy | Musculoskeletal Radiologic Anatomy Modules | USUHS Radiologic Anatomy Browser | Whole Brain Atlas Surgical Anatomy Vesalius Embryology Cardiac Embryology | Development of the Human Heart | Embryology of the Central Nervous System | Fetal and Young Child Central Nervous System - the Story of the Development and Maldevelopment of the Brain | Genitourinary Development | Multi-Dimensional Human Embryo | University of New South Wales Embryology | Visible Embryo

Pediatric Textbooks
Critical Care ALL-NET Pediatric Critical Care Textbook General Pediatrics Cochrane Collaboration | eMedicine - Pediatrics | Evidence Based Medicine Resources from | Evidence Based Medicine Resources from the U.S. Navy | Merck Manual Pediatrics | PEDBASE | Pediatric Emergency Manual | University of Iowa Family Practice Handbook - (4 of 8) [5/29/2002 11:11:22 PM]

Pediatric Radiology | Pediatric Imaging | Paediatric Radiology | A pediatric radiology and pediatric imaging digital library

Pediatrics | Vanderbilt Pediatric Interactive Digital Library Genetics Clinical Genetics | Online Mendelian Inheritance in Man (OMIM) Hematology / Oncology Oncolink Orthopedics Electronic Orthopaedic Textbook | Wheeless' Textbook of Orthopedics Pathology Digital Slice of Life | Pediatric Pathology | WebPath - Pediatric Pathology Radiology MetaTextbook of Pediatric Radiology | Paediapaedia - an Imaging Encyclopedia of Pediatric Disease | Pediatric Radiology Normal Measurements Surgery Pediatric Surgery Handbook for Residents and Students | Vesalius Surgical Education

Digital Carousels
Formal Lectures Approach to Chest Infections | Approach to Chest Wall Masses | Approach to Lung Masses Beyond the Neonate | Approach to Mediastinal Masses | Overview of Pediatric Radiology Informal Lectures Approach to Abdominal Film Interpretation | Approach to Chest Film Interpretation

Patient Education / Consumer Health Information

See also: Patient Education / Consumer Health Information on Common Pediatric Radiology Procedures How to Evaluate Medical Information on the Internet Medical Library Association - Deciphering Medspeak Anatomy Information Human Anatomy Online | MEDLINEPlus Patient Education / Consumer Health Information Children's Hospital of Iowa | Children's Hospital Medical Center, Cincinnati | Duke University | MEDLINEPlus | Northside Alpharetta Medical Campus | Radiology Info | Society of Nuclear Medicine (5 of 8) [5/29/2002 11:11:22 PM]

Pediatric Radiology | Pediatric Imaging | Paediatric Radiology | A pediatric radiology and pediatric imaging digital library

Pediatric Radiology Guidelines

Radiology Clinical Practice Guidelines ACR Appropriateness Criteria | ACR Standards for Radiologic Practice | American Institute of Ultrasound in Medicine | British Society of Paediatric Radiology | Society of Cardiovascular and Interventional Radiology

Pediatric Radiology Continuing Medical Education Courses

ACR | American Society of Neuroradiology | ARRS | AuntMinnie | Diagnostic Imaging | eMedicine | Lumps, Bumps and Holes: a Primer on Spinal Dysraphism | Medscape Radiology | RSNA InteractED | Skolar | Society of Nuclear Medicine | Stanford Radiology

MEDLINE and Pediatric Radiology Journals and Mailing Lists

Journal Indices Index to Imaging Literature | PubMed (MEDLINE) | RadiologyLinx and Pediatric Radiology Linx Journals AJR | Applied Radiology | Diagnostic Imaging | JRAD | Pediatric Radiology | Radiographics | Radiology Mailing Lists Pediatric Nuclear Medicine Listserv

Pediatric Radiology Professional Societies

American Society of Pediatric Neuroradiology | Asian and Oceanic Society for Pediatric Radiology | British Society of Paediatric Radiology | European Society of Paediatric Radiology | French Society of Pediatric Imaging | Japanese Society of Pediatric Radiology | Russian Society of Pediatric Radiology | The Society for Pediatric Radiology (6 of 8) [5/29/2002 11:11:22 PM]

Pediatric Radiology | Pediatric Imaging | Paediatric Radiology | A pediatric radiology and pediatric imaging digital library

Internet Directories and Search Engines

Health Sciences and Pediatric Directories CliniWeb | | Hardin Meta Directory of Internet Health Sources | Harriet Lane Links | HealthWeb | MedWeb | MedWebPlus | Open Directory: Pediatrics | PedInfo | | Virtual Children's Hospital | WWW Virtual Library: Biosciences | WWW Virtual Library: Medicine | Yahoo: Pediatrics Health Sciences and Pediatric Search Engines MedHunt | OMNI Image Search Engines AltaVista | Ditto | Google Internet Directories | LookSmart | Open Directory | RealGuide | Yahoo Internet Search Engines AllTheWeb | AltaVista | AOL | AskJeeves | Excite | Google | Google Groups | HotBot | Lycos | MetaCrawler | MSN | Overture | | Webcrawler | WebTop

Overview is a pediatric radiology and pediatric imaging digital library. The goal of is to provide a starting point for entry into pediatric radiology places of enlightenment, entertainment and education on the Internet. identifies high quality pediatric radiology World-Wide Web sites that can teach, illuminate, and inspire. In essence, is meant to serve as a "pico portal" for users interested in pediatric radiology. Feel free to bookmark and / or link to uses the following criteria for World-Wide Web site selection: 1) The site is selected by a process of peer review by accreditation, because accreditation models are designed for works that change over time. To become accredited, a site must clearly display four core quality standards: a. Authorship, including the author's name, affiliation, and credentials. b. Attribution of facts through the listing of references. c. Disclosure of site ownership and sponsorship. d. Currency of the site by listing dates of content posting and updating. 2) The site must be free to use, in part or in whole. 3) The site's information must be primarily in Hypertext Markup Language format (HTML) so that it can be read by users with the lowest common denominator World-Wide Web browser. What's New / Weblog New sites are continuously being discovered and added to Here is a list of What's New in Pediatric Radiology on the Internet (7 of 8) [5/29/2002 11:11:22 PM]

Pediatric Radiology | Pediatric Imaging | Paediatric Radiology | A pediatric radiology and pediatric imaging digital library

If you would like to be automatically notified of new pediatric radiology web sites, you may subscribe to this mailing list. Comments We are interested in your comments about Please fill out our Comment form Awards, Reviews, Statistics, and Fan Mail has received acclaim from a number of sources. Please view our Awards, Reviews, Statistics, and Fan Mail. Tour Take a Tour of

Home | Search | Imaging Appearances of Common Pediatric Diseases | What's New | New Site Notification | Comments | Awards, Reviews, Statistics, and Fan Mail | Tour is curated by Michael P. D'Alessandro, M.D. We are interested in your comments about Please fill out our Comment form All contents copyright 1997-2002 Michael P. D'Alessandro, M.D. All rights reserved. "", the logo, and "A pediatric radiology and pediatric imaging digital library" are all Trademarks of Michael P. D'Alessandro, M.D. was funded in part by a grant from the Radiological Society of North America's Research and Education Foundation. is now funded in whole by Michael P. D'Alessandro, M.D. Advertising is not accepted. Your personal information remains confidential and is not sold, leased, or given to any third party be they reliable or not.

We subscribe to the HONcode principles of the Health On the Net Foundation The information contained in is not a substitute for the medical care and advice of your physician. There may be variations in treatment that your physician may recommend based on individual facts and circumstances. Last Revised: May 7, 2002 URL: (8 of 8) [5/29/2002 11:11:22 PM]

Congenital Heart Disease on the Web

Congenital Heart Disease

A multimedia review of the radiologic characteristics for radiology residents.

Increased Pulmonary Vascularity Without Cyanosis

Ventricular Septal Defect Patent Ductus Arteriosus Atrial Septal Defect Partial Anomalous Pulmonary Venous Return
Aorticopulmonary Window Atrioventricular Canal Left Ventricle to Right Atrium

Increased Pulmonary Vascularity With Cyanosis

D-Transposition of the Great Vessels Truncus Arteriosus Total Anomalous Pulmonary Venous Return Single Ventricle Tricuspid Atresia without Pulmonary Stenosis

Normal Pulmonary Vascularity (1 of 3) [5/29/2002 11:11:35 PM]

Congenital Heart Disease on the Web

Coarctation of Aorta Aortic Stenosis

Decreased Pulmonary Vascularity

Tetralogy of Fallot Ebstein's Malformation of the Tricuspid Valve Tricuspid Atresia with Pulmonary Stenosis Pulmonary Stenosis or Atresia

Increased Pulmonary Venous Vascularity

Scimitar and Stenosis of Individual Pulmonary Veins
Total Anomalous Pulmonary Venous Return (with Obstruction)

Hypoplastic Left Heart

Miscellaneous Lesions (2 of 3) [5/29/2002 11:11:35 PM]

Congenital Heart Disease on the Web

L-Transposition of the Great Vessels

(From Cardiovascular Radiology, 1985, Gedgaudas, Moller, Casteneda-Zuniga, Amplatz) (3 of 3) [5/29/2002 11:11:35 PM]

Virtual Children's Hospital: Metatextbook of Pediatric Radiology: Cardiovascular System

MetaTextbook of Pediatric Radiology

Cardiovascular System
Michael P. D'Alessandro M.D.
Peer Review Status: Internally Peer Reviewed

Imaging Modalities | Normal Variants | Congenital Heart Disease | Acquired Heart Disease | Cardiac Operations

I. Imaging Modalities
| Paediapaedia | A. Chest radiographs 1. Limitations B. Angiocardiography | Paediapaedia | 1. Indications 2. Projections C. Echocardiography 1. Standard views D. CT (including ultrafast and helical) E. MR 1. Indications 2. Anatomy F. Nuclear cardiology

II. Normal Variants

A. Cardiac embryology | Cardiac Embryology | Development of the Human Heart | (1 of 5) [5/29/2002 11:11:41 PM]

Virtual Children's Hospital: Metatextbook of Pediatric Radiology: Cardiovascular System

B. Cardiac anatomy | Cardiac MRI Anatomical Atlas | Illustrated Encyclopedia of Human Anatomic Variation | Introduction to Cardiothoracic Imaging |

III. Congenital Heart Disease

A. Congenital heart disease with decreased pulmonary blood flow (right-to-left shunt) 1. Tetralogy of Fallot (TOF) | Chiang Mai U | Loyola U - Heart | Paediapaedia | Ped Cardiology Almanac - 1 | Ped Cardiology Almanac - 2 | Ped Cardiology Almanac - 3 | Ped Cardiology Almanac - 4 | U of Hawaii | U of Kansas Cardiology - 1 | U of Kansas Cardiology - 2 | U of Kansas Cardiology - 3 | U of Kansas Cardiology - 4 | U of Kansas Cardiology - 5 | U of Minnesota CHD | 2. Ebstein anomaly | Paediapaedia | U of Kansas Cardiology - 1 | U of Kansas Cardiology - 2 | U of Kansas Cardiology - 3 | U of Minnesota CHD | 3. Tricuspid atresia | Paediapaedia | Paediapaedia - Hypoplastic Right Heart | Ped Cardiology Almanac | U of Kansas Cardiology | University of Minnesota CHD | B. Cyanotic congential heart disease with increased pulmonary blood flow (left-to-right shunt) 1. Truncus arteriosis | Cardiac MRI | Loyola U - Heart | Paediapaedia | U of Kansas Cardiology 1 | U of Kansas Cardiology - 2 | U of Kansas Cardiology - 3 | U of Minnesota CHD | 2. Transposition of the great arteries | Loyola U - Heart | Paediapaedia - D-TGA | Paediapaedia L-TGA | Ped Cardiology Almanac - L-TGA | Surgical Congenital Heart Disease - 1 | Surgical Congenital Heart Disease - 2 | U of Kansas Cardiology | U of Kansas Cardiology - D-TGA - 1 | U of Kansas Cardiology - D-TGA - 2 | U of Kansas Cardiology - D-TGA - 3 | U of Kansas Cardiology - D-TGA - 4 | U of Minnesota CHD - D-TGA | U of Minnesota CHD - L-TGA | 3. Single ventricle | U of Kansas Cardiology - 1 | U of Kansas Cardiology - 2 | U of Minnesota CHD | 4. Total anomalous pulmonary venous return above the diaphragm (TAPVR) | Chiang Mai U | Paediapaedia | Ped Cardiology Almanac - Supradiaphragmatic | U of Kansas Cardiology Supradiaphragmatic - 1 | U of Kansas Cardiology - 1 | U of Kansas Cardiology - 2 | U of Kansas Cardiology - 3 | U of Kansas Cardiology - 4 | U of Minnesota CHD | 5. Endocardial cushion defect (ECD) | CERF | Loyola U - Heart | Paediapaedia | U of Kansas Cardiology - 1 | U of Kansas Cardiology - 2 | U of Kansas Cardiology - 3 | U of Kansas Cardiology - 4 | U of Kansas Cardiology - 5 | U of Kansas Cardiology - 6 | U of Minnesota CHD | C. Acyanotic congenital heart disease with increased pulmonary blood flow (left-to-right shunt) 1. Atrial septal sefect (ASD) | Cardiac MRI | Loyola U - Heart | Paediapaedia | Surgical Congenital Heart Disease | U of Kansas Cardiology - 1 | U of Kansas Cardiology - 2 | U of Kansas Cardiology - 3 | U of Kansas Cardiology - 4 | U of Kansas Cardiology - 5 | U of Minnesota CHD | 2. Ventricular septal defect (VSD) | Loyola U - Heart | Paediapaedia | U of Kansas Cardiology - (2 of 5) [5/29/2002 11:11:41 PM]

Virtual Children's Hospital: Metatextbook of Pediatric Radiology: Cardiovascular System

1 | U of Kansas Cardiology - 2 | U of Kansas Cardiology - 3 | U of Kansas Cardiology - 4 | U of Minnesota CHD | U of Sydney | 3. Patent ductus arteriosus (PDA) | Chiang Mai U | Paediapaedia - 1 | Paediapaedia - 2 | U of Kansas Cardiology - 2 | U of Kansas Cardiology - 1 | U of Minnesota CHD | 4. Endocardial cushion defect (ECD) (See above III. B. 5. ) D. Congenital heart disease with pulmonary venous congestion or normal pulmonary blood flow 1. Coarctation of the aorta | Cardiac MRI | CERF - Abdominal | Paediapaedia - 1 | Paediapaedia 2 | Ped Cardiology Almanac | Ped Cardiology Almanac - Interrupted | U of Hawaii | U of Kansas Cardiology - 1 | U of Kansas Cardiology - 2 | U of Kansas Cardiology - 3 | U of Kansas Cardiology - Interrupted - 1 | U of Kansas Cardiology - Interrupted - 2 | U of Kansas Cardiology - Interrupted 3 | U of Minnesota CHD | 2. Hypoplastic left heart syndrome (HLHS) | Cardiac MRI | Paediapaedia | Surgical Congenital Heart Disease | U of Kansas Cardiology - 1 | U of Kansas Cardiology - 2 | U of Minnesota CHD | 3. Aortic stenosis (AS) | Paediapaedia | U of Kansas Cardiology - 1 | U of Kansas Cardiology - 2 | U of Kansas Cardiology - 3 | U of Kansas Cardiology - 4 | U of Kansas Cardiology - 5 | U of Minnesota CHD | 4. Mitral stenosis (MS) | U of Kansas Cardiology - 1 | U of Kansas Cardiology - 2 | 5. Total anomalous pulmonary venous return below the diaphragm (TAPVR) | Paediapaedia | Ped Cardiology Almanac - Infradiaphragmatic | U of Kansas Cardiology - Infradiaphragmatic - 1 | E. Anomalies of viscero-atrial situs | AFIP | Loyola U - Heart | Paediapaedia - Situs inversus | Paediapaedia - Situs solitus | U of Kansas Cardiology - Dextrocardia | U of Sydney - Dextrocardia | 1. Asplenia | Paediapaedia | Ped Cardiology Almanac | 2. Polysplenia | Cardiac MRI | Paediapaedia | Children's Hospital, Birmingham | F. Vascular rings and other congenital anomalies of the great vessels | U of Hawaii - Introduction | 1. Left arch with anomalous right subclavian artery | Paediapaedia | U of Kansas Cardiology | 2. Circumflex aorta (right aortic arch with left descending aorta) | Iowa Physiological Imaging | 3. Pulmonary sling (anomalous left pulmonary artery) | AuntMinnie | Paediapaedia | Rainbow Babies and Children's Hospital | 4. Right aortic arch | Correlapaedia | Iowa Physiological Imaging | Paediapaedia | Ped Cardiology Almanac | Rainbow Babies and Children's Hospital | 5. Double aortic arch | Cardiac MRI | Correlapaedia | Paediapaedia | Ped Cardiology Almanac | Rainbow Babies and Children's Hospital | U of Hawaii | G. Syndromes with congenital heart disease or vascular disease 1. Holt-Oram syndrome (3 of 5) [5/29/2002 11:11:41 PM]

Virtual Children's Hospital: Metatextbook of Pediatric Radiology: Cardiovascular System

2. Marfan syndrome | AuntMinnie | CERF | CERF - Dissection | CERF - Bones | Chiang Mai U | 3. Turner syndrome 4. William syndrome | Ped Cardiology Almanac | 5. Trisomy 21 (See above III. B. 5. ) 6. Schone's syndrome H. Miscellaneous 1. Congenital absence of the pericardium

IV. Acquired Heart Disease

A. Infectious/Inflammatory 1. Pericarditis | Ped Cardiology Almanac | U of Kansas Cardiology | 2. Myocarditis | U of Kansas Cardiology | 3. Rheumatic heart disease | Surgical Congenital Heart Disease | 4. Kawasaki disease | U of Hawaii - 1 | U of Hawaii - 2 | U of Kansas Cardiology - 1 | U of Kansas Cardiology - 2 | Virtual Pediatric Patients |

V. Cardiac Operations
A. Palliative 1. Glenn shunt | Ped Cardiology Almanac | U of Minnesota TF | 2. Blalock-Taussig shunt | Cardiac MRI - Hypoplastic left heart | Cardiac MRI - Hypoplastic right heart | Ped Cardiology Almanac | 3. Waterston shunt B. Operative repair 1. Norwood procedure | Cardiac MRI | 2. Arterial switch procedure | Surgical Congenital Heart Disease - 1 | Surgical Congenital Heart Disease - 2 | 3. Fontan procedure | Ped Cardiology Almanac | 4. Right ventricle-to-pulmonary artery conduit procedure C. Heart transplant Next Page | Previous Page | Section Top | Title Page (4 of 5) [5/29/2002 11:11:41 PM]

Virtual Children's Hospital: Metatextbook of Pediatric Radiology: Cardiovascular System

Home | Search | Imaging Appearances of Common Pediatric Diseases | What's New | New Site Notification | Comments | Awards, Reviews, Statistics, and Fan Mail | Tour Virtual Hospital Home | Virtual Children's Hospital Home | UI Health Care Home | Outline | Search | Help | Policies | Comments and Questions | E-mail This Page | Support Friends of Virtual Hospital
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All contents copyright 1992-2002 the Author(s) and The University of Iowa. All rights reserved. Modified: Thu Sep 20 09:30:57 2001 Displayed: Wed May 29 22:01:37 2002 (5 of 5) [5/29/2002 11:11:41 PM]


PLAIN RADIOGRAPHIC DIAGNOSIS OF CONGENITAL HEART DISEASE Colin McMahon, M.B.BCh. Edward Singleton, M.D. Texas Children's Hospital, Houston, Texas Texas Heart Institute Edward B. Singleton Diagnostic Imaging Service
Hypertext fomatting: Joseph Magee, Ph.D. 1. The normal chest radiograph Image and description. 2. Conditions with increased pulmonary vascularity. a. Atrial septal defect, secundum. A. Posteroanterior (PA) chest radiograph. Condition Description: Atrial Septal Defect (ASD) b. Ventricular septal defect. 1. Moderate left to right shunt A. PA chest radiograph. B. Right anterior oblique view. 2. Large left to right shunt. A. PA chest radiograph. 3. Large left to right shunt. A. PA chest radiograph. B. Right anterior oblique film and barium swallow. Condition Description: Ventricular Septal Defect (VSD) c. Atrioventricular septal defect. 1. Atrioventricular septal defect (Down syndrome). A. PA radiograph. 2. Atrioventricular septal defect (Down syndrome). A. PA radiograph. (1 of 10) [5/29/2002 11:11:49 PM]


Condition Description: Atrioventricular septal defect (AVSD) d. Patent ductus arteriosus. 1. Patent ductus arteriosus. A. PA radiograph. B. Right anterior oblique view. Condition Description: Patent Ductus Arteriosus (PDA) e. Total anomalous pulmonary venous connection. 1. Total anomalous pulmonary venous connection (Supracardiac) A. PA radiograph. 2. TAPVC (Supracardiac). A. PA chest radiograph. 3. Total anomalous pulmonary venous connection (infradiaphragmatic-obstructed). A. PA chest radiograph. 4. TAPVC (infradiaphragmatic-obstructed). A. PA chest radiograph. Condition Description: Total anomalous pulmonary venous connection (TAPVC) f. Scimitar syndrome. 1. Anomalous pulmonary venous connection (Scimitar sign). A. (Image and description). B. Left anterior oblique view. Condition Description: Scimitar syndrome g. Transposition of the Great Arteries. 1. Transposition of the Great Arteries (D-TGA). A. (Image and description). B. Right posterior oblique view. Condition Description: Transposition of the Great Arteries (D-TGA) h. Truncus arteriosus. 1. Truncus arteriosus. A. PA chest radiograph in the first week of life. B. PA chest radiograph of an older patient. Condition Description: Truncus arteriosus i. Corrected Transposition/ Ventricular inversion, L-TGA. 1. Corrected Transposition/ Ventricular inversion, L-TGA (2 of 10) [5/29/2002 11:11:49 PM]


A. PA chest radiograph B. (Image). C. (Image). Condition Description: Corrected transposition/ventricular inversion, L-TGA 3. Conditions with decreased pulmonary vascularity. a. Tetralogy of Fallot. 1. Tetralogy of Fallot A. PA chest radiograph B. Right anterior oblique views 2. Tetralogy of Fallot, right aortic arch. A. PA chest radiograph of a nine month old infant Condition Description: Tetralogy of Fallot b. Tetralogy/ absent pulmonary valve syndrome. 1. Tetralogy of Fallot/ Absent pulmonary valve syndrome. A. (Image and description) Condition Description: Tetralogy of Fallot c. Pulmonary atresia/ ventricular septal defect (pseudotruncus). 1. Pulmonary atresia with ventricular septal defect (Pseudotruncus). A. (Image and description) d. Tricuspid atresia. 1. Tricuspid atresia. A. (Image and description) Condition Description: Tricuspid atresia e. Ebsteins anomaly. 1. Ebsteins anomaly. A. (Image and descripion) Condition Description: Ebstein's Anomaly f. Transposition of the Great Arteries with pulmonary stenosis. 1. Transposition of the Great Arteries with Pulmonary stenosis. A. (Image and description). g. Pulmonary hypertension/ Eisenmengers syndrome. 1. Ventricular septal defect with pulmonary hypertension (Eisenmenger complex). (3 of 10) [5/29/2002 11:11:49 PM]


A. PA radiograph B. Right anterior oblique view. C. (Image and Description). Condition Description: Pulmonary hypertension/ Eisenmengers syndrome. 4. Conditions with normal pulmonary vascularity. a. Aortic stenosis. 1. Aortic stenosis. A. (Image and description) B. Right anterior oblique view Condition Description: Aortic valvular stenosis. 2. Aortic supravalvular stenosis. A. (Image and description) B. Angiocardiography PA view C. Angiocardiography lateral view Condition Description: Supravalvular aortic stenosis b. Coarctation of the Aorta. 1. Coarctation of the Aorta. A. Chest radiograph 2. Coarctation of the Aorta (severe). A. PA chest radiograph B. Left anterior oblique film 3. Coarctation of the Aorta. A. PA chest radiograph Condition Description: Coarctation of the Aorta. c. Interrupted Aortic Arch. 1. Interrupted Aortic Arch. A. Chest radiograph. Condition Description: Interrupted Aortic Arch. d. Endocardial fibroelastosis (Cardiomyopathy). 1. Endocardial fibroelastosis (Cardiomyopathy). A. PA view B. Right anterior oblique view Image Review: Endocardial fibroelastosis (Cardiomyopathy). (4 of 10) [5/29/2002 11:11:49 PM]


e. Pulmonary stenosis. 1. Pulmonary valvular stenosis A. PA chest film B. Right posterior oblique view Condition Description: Pulmonary valvular stenosis f. Mitral stenosis. 1. Mitral valve stenosis. A. PA chest radiograph B. Right anterior oblique view Condition Description: Mitral valve stenosis g. Cor triatriatum. 1. Cor triatriatum. A. (Image and Description) B. Angiocardiogram Condition Description: Cor triatriatum h. Hypoplastic left heart syndrome. 1. Hypoplastic left heart syndrome A. (Image and Description) 2. Hypoplastic left heart syndrome. A. (Image and Description) B. (Image and Description) Condition Description: Hypoplastic left heart syndrome i. Idiopathic pulmonary artery dilation. 1. Idiopathic pulmonary artery dilation. A. (Image and Description) B. (Image). Condition Description: Idiopathic pulmonary artery dilation 5. Aortic arch anomalies/ Vascular rings. (5 of 10) [5/29/2002 11:11:49 PM]


a. Double aortic arch. 1. Double aortic arch. A. - B. Cineangiograms Condition Description: Double aortic arch b. Right aortic arch with left ductus remnant. 1. Right aortic arch with left ductus arteriosus remnant. A. PA chest film B. Right lateral view Image Review: Right aortic arch with left ductus arteriosus remnant. c. Right aortic arch with abberant left subclavian artery. 1. Right aortic arch with anomalous left subclavian artery and left ductus. A. PA chest radiograph B. Left Posterior oblique film Condition Description: Right aortic arch with anomalous left subclavian artery and left ductus. 6. Malposition cardiac lesions. a. Dextrocardia. 1. Dextrocardia. Condition Description: Dextrocardia. b. Situs inversus totalis. 1. Situs inversus totalis. Condition Description: Situs inversus totalis. 7. Miscellaneous cardiac lesions. a. Congestive cardiac failure (non-cardiac aetiology). 1. Congestive cardiac failure secondary to glomerulonephritis. A. PA chest film B. Lateral chest film 2. Congestive cardiac failure secondary to sickle cell anemia. A. PA chest film B. Lateral chest film C. PA abdominal film Condition Description: Congestive cardiac failure (non-cardiac aetiology) (6 of 10) [5/29/2002 11:11:49 PM]


b. Absent/Hypoplastic pulmonary artery. 1. Hypoplastic pulmonary artery with hypoplastic lung. A. PA chest film c. Aneurysm of the pulmonary artery. 1. Aneurysm of the right pulmonary artery. A. PA chest radiograph B. Lateral chest radiograph 2. Aneurysm of the main pulmonary artery. A. PA chest radiograph Image Review: Aneurysm of the pulmonary artery. d. Partial/ complete absence of pericardium. 1. Partial absence of the Pericardium. A. PA chest radiograph B. Noncontrast CT Thorax 2. Congenital absence of Pericardium. A. PA chest radiograph Condition Description: Partial/ complete absence of pericardium. e. Pulmonary arteriovenous malformation. 1. Pulmonary arteriovenous malformation. A. (Image and Description) B. Lateral chest film Condition Description: Pulmonary arteriovenous malformation. f. Congenital ventricular diverticulum. 1. Congenital left ventricular diverticulum. A. PA chest radiograph B. - E. Systolic and diastolic PA and lateral cineangiograms Condition Description: Congenital ventricular diverticulum. g. Conjoined twins. 1. Conjoined twins. A. Plain film 2. Conjoined twins. A. PA chest radiograph (7 of 10) [5/29/2002 11:11:49 PM]


Condition Description: Conjoined twins. h. Pulmonary varix/varices. 1. Pulmonary varix/varices. A. (Image and Description) B. Lateral chest film 2. Pulmonary varix. A. PA chest radiograph B. Lateral radiograph Image Review: Pulmonary varix/varices. 8. Post-operative conditions. a. Atelectasis. 1. Atelectasis. A. (Image and Description). b. Pericardial effusion. 1. Pericardial effusion. A. PA chest radiograph c. Pleural effusion. 1. Pleural effusion. A. PA chest radiograph. d. Pneumothorax. 1. Pneumothorax. A. PA chest film B. (Image and Description) Image Review: Pneumothorax. e. Pneumopericardium. 1. Pneumopericardium. A. PA chest radiograph f. Phrenic nerve palsy. 1. Phrenic nerve palsy. A. PA chest radiograph. g. Pacemaker. 1. Pacemaker. (8 of 10) [5/29/2002 11:11:49 PM]


A. (Image and Description) 2. Pacemaker. A. (Image and Description) Condition Description: Pacemaker. h. Thoracotomy. 1. Thoracotomy. A. PA chest film i. Scoliosis (secondary to thoracotomy). 1. Scoliosis A. PA chest radiograph j. Aortic valve replacement. 1. Aortic valve replacement. A. PA chest radiograph. k. Mitral valve replacement. 1. Mitral valve replacement. A. PA chest radiograph. l. Calcified homograft. 1. Calcified homograft. A. PA chest film B. Lateral chest film Image Review: Calcified homograft. m. A.I.C.D. 1. Artificial implantable cardioverter device. A. PA chest radiograph 9. Post-interventional radiography. (9 of 10) [5/29/2002 11:11:49 PM]


a. Pulmonary artery stent implant. 1. Pulmonary artery stent implant. A. PA chest radiograph b. Coarctation stent implant. 1. Coarctation stent implant. A. PA and lateral chest radiograph c. Atrial septal defect device closure. 1. ASD occlusion device. A. PA chest radiograph d. Patent ductus arteriosus device closure. 1. PDA coil occlusion. A. PA chest radiograph 2. PDA sac occlusion. A. PA chest radiograph Image Review: Patent ductus arteriosus device closure. e. Aorto-pulmonary coil embolization. 1. Aorto-pulmonary collateral coil embolization. A. PA chest film f. SVC stent implant. 1. SVC stent implant. A. PA chest radiograph g. Femoral vein stent implant. 1. Femoral vein stent implant. A. Radiograph (10 of 10) [5/29/2002 11:11:49 PM]

Atrial Partitioning

Atrial Partitioning
Figure 1
By the time the heart tube has formed the bulboventricular loop , the two primitive right and left atria have fused to form a common atrium. Note that it now lies cranial to the primitive ventricle and dorsal to the bulbus cordis. The truncus arteriosus lies on the roof of the common atium causing a depression and indicates where septation of the atrium will occur. q AS = Aortic sac q BC = Bulbus cordis q CC = Conus cordis q LA = Left atrium q LV = Left ventricle q RA = Right atrium q SV = Sinus venosus q TA = Truncus arteriosus

Figure 2
The partitioning of the atrium begins with the appearance of septum primum at about the 28th day. This is a crest of tissue that grows from the dorsal wall of the atrium towards the endocardial cushions - - the ostium (opening) formed by the free edge of septum primum is the ostium primum.

Figure 3
Before the septum primum fuses with the endocardial cushions, perforations appear in the upper portion of the septum primum. These perforations will coelasce to form the ostium secundum. q SAO = Sinoatrial oriface q SS = Septum spurium q S1 = Septum primum q Perf = Perforations q O1 = Ostium primum q EC = Endocardial cushions

Figure 4
Unlike the septum primum, septum secundum does not fuse with the endocardial cushions. Its free edge forms the foramen ovale. The left venous valve and the septum spurium, located on the dorsal wall of the (1 of 2) [5/29/2002 11:11:50 PM]

Atrial Partitioning

right atrium, fuse with the septum secundum as it grows. q EC = Endocardial cushions q LVV = Left venous valve q O1 = Ostium primum q SS = Septum spurium q S1 = Septum primum q S2 = Septum secundum

Figure 5
At the end of the seventh week the human heart has reached its final stage of development. Because the fetus does not use its lungs, most of the blood is diverted to the systemic circulation. This is accomplished by a right to left shunting of blood that occurs between the two atria. The foramen ovale and the septum primum control this right and left communication. The septum primum acts as a valve over the foramen ovale. At birth the child will use its lungs for the first time and consequently more blood will flow into the pulmonary circulation. The pressure increase in the left atrium (where the pulmonary veins empty) will force septum primum to be pushed up against septum secundum. Shortly thereafter the two septa fuse to form a common atrial septum. q O1 = Ostium primum q S1 = Septum primum q FO = Foramen ovale q S2 = Septum secundum Return to Main Menu . (2 of 2) [5/29/2002 11:11:50 PM]

Virtual Hospital: Surgery: Atrial Septal Defect

Surgical Correction for Congential Heart Disease: Atrial Septal Defect

Figure 3: Secundum ASD

John T. Milleman, B.S. Christopher A. Caldarone, M.D. Thomas Fagan, M.D.
Creation Date: August 2000 Last Revision Date: August 2000 Peer Review Status: Internally Peer Reviewed

Note the excessive resorption of the septum primum causing a hole to exist in the atrial septum in the area of the fossa ovalis. (Compare with Normal Heart below) (1 of 3) [5/29/2002 11:12:11 PM]

Virtual Hospital: Surgery: Atrial Septal Defect

RA LA RV LV TV MV SASD Normal Heart Formation

right atrium left atrium right ventricle left ventricle tricuspid valve mitral valve secundum ASD


right atrium left atrium right ventricle left ventricle tricuspid valve (2 of 3) [5/29/2002 11:12:11 PM]

Virtual Hospital: Surgery: Atrial Septal Defect

MV mitral valve FO fossa ovalis

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LCA: AP view 1

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Left Coronary Angiogram AP View - 1

When you have completed review of this screen, please click the Next page blue arrow for the second portion of this section.

The AP view is not commonly obtained because the spine sits in the middle of the cineangiographic picture in this particular view and the coronaries lie directly in front of it. The similarity in radiolographic density between the spine and the contrast-filled coronaries interferes with the quality of the images. However, it is occasionally obtained when the location and severity of a stenosis cannot be clearly defined in the conventional views. The AP view may be of particular value in evaluating the ostium of the left main coronary artery and the shaft of the mid LAD. The AP view is of historical interest and goes back to the early days of cardiac catheterization, The x-ray tube, image intensifier and camera remained stationary, while the patient lay in a cradle that was rotated from the RAO to the LAO projections. Cranial or caudal angulation were not possible at those times. The AP view was often the first scouting view. The central or neutral position of the camera is known as the AP (anteroposterior) view, at which time the camera looks straight down the patients chest and heart. In other words, the xray camera is directly above the patients chest with the beam coming straight up from the x-ray tube and perpendicular to the patient (below, left). A cameras view of the patients heart in the AP view is shown on the right (below). The size of the heart has been purposely exaggerated for purposes of illustration.

The aortic valve has three cusps. The RCC or right coronary cusp, where the right coronary artery originates and the LCC or left coronary cusp where the the left main (LM) coronary artery arises. The NCC or non coronary cusp sits posterior to the other two cusps of the aortic valve. The LM divides or bifurcates into the left anterior descending (LAD) and the Circumflex (Cx) coronary arteries. In many cases there is a third artery (1 of 3) [5/29/2002 11:12:39 PM]

LCA: AP view 1

that originates from the LM and travels between the LAD and CX. This artery is known as the Ramus Intermediate (Ramus) or Optional diagonal coronary artery. In the AP view the LAD runs down the front of the heart along the side of the spine. The ramus and diagonal (Dx) moves diagonally and away from the LAD and the spine in this view. When more than one Dx is present, the first one is called the first Dx or Dx1, the second is called Dx2, etc. The septal perforators (SP) are smaller branches that come off the LAD. They supply blood to the interventricular septum.

The Circumflex (Cx), in the AP view, moves away from the spine at nearly a 90 degree angle and then wraps around the left atrioventricular groove to the back of the heart as was previously described. The Cx gives off one or more obtuse marginal (OM) and left postero-lateral branches (LPLA) that run downwards and away from the AV groove. When more than one OM branches are present, the first OM is called OM1, the second is called OM2, etc. (2 of 3) [5/29/2002 11:12:39 PM]

LCA: AP view 1

The picture on the left (above) shows the left coronary artery rotating back and forth between the right and left anterior oblique position (RAO and LAO) as the x-ray tube swings in a plane between the right and left sides of the patient (as shown on the right, above). Click on the buttons below the animation to see labels of the various views.
When you have completed review of this screen, please click the Next page blue arrow for the second portion of this section.

AP View - 1 (3 of 3) [5/29/2002 11:12:39 PM]

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Radiology Board Review Notes

Radiology Board Review Notes

Radiology Board Review Notes

This is a modification of a comprehensive series of notes outlining the essential elements of radiology -these notes were compiled by Dr. Jim Taylor from wide variety of sources during his Diagnostic Radiology Residency from 1992-1996. This page will act as the introduction for the catagorical version of the notes. The links lead to discussions of imaging findings catagorized by disease types. The "Differential Diagnosis" link leads to lists of the differential diagnosis of individual imaging findings. The sections are broken down by organ system. There is no seperate pediatric section at this time. All pediatric processes are included under the appropriate headings Hyperlinked references to sections within the notes will be found in case materials throughout the site. MUSCULOSKELETAL CHEST GASTROINTESTINAL GENITOURINARY OBSTETRICS--Some sections enhanced with linked Topic Discussion Modules NEURORADIOLOGY MAMMOGRAPHY NUCLEAR MEDICINE DIFFERENTIAL DIAGNOSIS STAGING OF NEOPLASMS PHYSICS (1 of 2) [5/29/2002 11:13:16 PM]

Radiology Board Review Notes

IV CONTRAST (2 of 2) [5/29/2002 11:13:16 PM]

Musculoskeletal Radiology Signs

Interactive Atlas of Signs in Musculoskeletal Radiology

A. Gentili,MD, M. Beller, MD, S. Masih, MD, L.L. Seeger, MD


Los Angeles, California
Multiple signs are described in the literature. The recognition of these signs allows the radiologist to make a specific diagnosis or give a brief differential diagnosis. We created an atlas of common and not so common signs used in Musculoskeletal Radiology. This atlas can be reviewed by sign name, pathological diagnosis or locations. These signs are illustrated with radiographs and diagrams. The references are linked to PubMed, allowing the user to have immediate access to the abstract, if available. This atlas includes: anterior drawer sign, blade of grass sign, bone in bone sign, bow tie sign, Boutonniere deformity, brim sign, cortical ring sign, cotton wool sign, crescent sign, double PCL sign, elbow fat pad sign, FBI sign, fish vertebra, heel pad sign, Hill-Sachs sign, inverted Napoleon hat sign, ivory vertebra sign, pneumoarthrogram sign, pronator sign, rim sign, Rugger Jersey sign, Scotty dog sign, swan neck deformity, tear drop sign, Terry-Thomas sign, tooth sign, track sign, vacuum phenomenon, and more.
Atlas of Signs in Musculoskeletal Radiology is approved by the ARRS (American Roentgen Ray Society) and is included in AJR Webreview
A. Gentili,MD, M. Beller, MD, S. Masih, MD, L.L. Seeger, MD [5/29/2002 11:13:20 PM]