Main theory notes here:

https://docs.google.com/document/d/10_F-aa_XBvDRvCdoy0lebMW_5HYnxD7BZxGU
OJZaan0/edit?usp=sharing

Reading Chest X-rays: Respiratory

Increased opacity
- Blurred edges, ill defined, hazy, looks like infiltrate = ​Consolidation
- Lobar
- Lobar pneumonia
- Hemorrhage
- Ongoing pneumonia
- Infarction
- Sarcoidosis
- Diffuse
- HF (if bilateral - bat wings)
- Low albumin
- Renal failure
- Bronchopneumonia
- Hemorrhage
- Carcinoma (obstructive)
- Multifocal
- Bronchopneumonia

Where we see increased linings, look a bit fibrous, this is ​interstitial​.

- Reticular pattern
- Heart failure (look for Kerley B lines)
- Interstitial pneumonia
- Lymphangitic carcinoma
- Sarcoidosis
- Cystic
- Langerhans cell histiocytosis
- lymphagioleimy
 -

Atelectasis​ presents as a ‘solid’ opacity that covers a section of the lung field. Key findings
are a sharply defined opacity obscuring vessels ​without bronchogram​. It is caused by a
lack of air in the lung field.
- Diff dx
- Mucus plugging
- Tumor
- Foreign body
- Pleural effusion (look for displacement of central structures to ID between
absorbent atelectasis (above) vs pleural effusions
- Pneumothorax

Nodules and masses

Compare these opacities to that of infiltrate. The borders are more defined, although not
necessarily more regular. Look for ​specular ​(spiky) borders which may suggest malignancy
- Diff dx
- Granuloma
- Abscess
- Bronchial carcinoma (few opacities)
- Metastasis (multiple medium sized opacities)
- Organizing pneumonia
- Hamartoma (look for heterogeneity)
- Look for air/fluid level which would indicate partial drainage of an abscess
- Where fidning is ‘attached’ to plura or other structure, make sure to mention this.

Hilum enlargement
- If the hilum of the lung is enlarged, look for circular shapes, this would suggest
lymphoma​.
- Diff dx is Sarcoidosis
- If the ​vessels of the hilum ​look thickened (larger than 15mm) this may be due to
pulmonary hypertension as we are seeing the arteries.
- The hilum contains
- Principal bronchus
- Pulmonary artery
- Two pulmonary veins
- Bronchial arteries (one on one side, two on the other)
- Bronchial veins
- Lymphatics
- Lymph nodes

Black lung fields

- Look out for totally black lung fields, this suggests that the lung has fully collapsed,
try to find the true border of the lung in these cases.
- Also be aware that very dark lung fields can be a result of emphysema
Identifying TB
- Can be ‘miliary’ TB
- Look for ‘millions’ of tiny little nodules throughout the lung fields
- Or look for for parenchymal consolidation (especially in the apex)
- In CT look for lots of dotted bright sections in the axial segment
- TB vs Silicosis - Silicosis greater lymph node involvement

Broad mediastinum
- Consider lymphoma, most likely diagnosis. Also, aortic aneurysm and dissection
along with mass, cardiac tamponade and pericardial effusion
- The mediastinum contains
- Heart
- Vessels (aorta etc)
- Esophagus
- Trachea
- Phenic and cardiac nerves
- cardiac nerves
- Thoracic duct
- Thymus
- Lymph nodes

A note on pneumonia
There are five types of pneumonia, three you are most likely to see. We shall consider each
of the three:
- Bronchopneumonia
- Often staphylococcus, multifocal, patchy, sometimes without air
bronchograms
- Lobar
- Often pneumococcal pneumonia, affects entire lobe with air bronchograms
common.
- Interstitial
- Begins perihilar and can become patchy as disease progresses. No
bronchograms
These are shown left to right, top to bottom below.
Reading x-rays of the heart

- Aortic stenosis
- Narrowing of aorta, causes dilation of ascending aorta laterally. Look at the
additional contour on the right side of the mediastinum, and the dilation of the
Left ventricle. ​Known as aortic configuraiton of heart

- Aortic regurgitation
- Widening of aortic valve causes apex displacement left, with possible
cardiomegaly. US more detail

- Mitral stenosis
 - Narrowing of mitral valve causes left atrial enlargement with elevation of left
bronchus and increased lung markings in upper left. Can cause pulmonary
hypertension and pulmonary edema which may be visible. ​Look
enlargement and straightening of left heart border due to enlarged left
atria.

- Mitral regurgitation
- Leaking of mitral valve causes left atria and ventricular enlargement
- Hypertrophic cardiomyopathy
- Dilated cardiomyopathy

- Pericardial calcification
- Pericardial effusion
- Often a result of pericarditis, heart looks a bit like a water bottle

- Aortic dissection
- Look for mediastinal widening - blood enters medial layer of aortic wall,
tracking along forming a blood filled channel in a falls lumen (A or B, A=
affects ascending aorta and arch, B = affects other part). Observe extra
mediastinal shadow on left mediastinum of X-ray.

- Aortic stenosis
- Commonly uses CT
 - Aortic aneurysm
- Widening of the aorta (thoracic or abdominal (more common)).

- Cardiomegaly

Reading Abdominal Radiology

Many x-rays can be focal, prepositional, often with double (air and barium) contrast. Those
which are specifically of the colon will be a barium enema, those that are the whole intestine
are the barium meal.

Stomach

Note, the normal stomach has a wide range of anatomical variations as shown below, all of
these are normal!
- Hiatus hernia
- Always check diaphragmatic line, the stomach should rest up against it, if it
has gone through, think hernia
- Also, pay attention to where the gastric air bubble is, if it’s in the thorax, think
hernia

- Stomach ulcers
- Look for projecting shadow of the stomach, often on the lesser curvature
 - Neoplasia
- Benign = polyps, malignant = commonly adenocarcinoma
- Look for any kind of stricture around the body of the stomach, or a mass that
separates the stomach from the diaphragm.

- Cascade stomach
- Natural anatomical variation - look for two air-fluid levels

Large and small intestines

- Crohn's disease
- Look for ‘pavement like’ intestinal patterning
- Inguinal hernia
- Pay attention to where the intestine finishes, if it drops into the pelvis, think
inguinal hernia.

- Perforated hollow organ/iatrogenic/trauma = FREE AIR IN PERITONEUM

- If there is any air under the diaprhagm, you are looking at one of the above
three!

- Gas in small intestine + NO gas in large intestine

- This = obstruction at level of small intestine
- Obstruction of large intestine - massive colonic dilation

- Ileus = failure of peristalsis, often secondary to obstruction

- Look for dilation of small/large intestine
- Often comes with ​multiple air-fluid levels in abdomen

- Diverticulosis
- Look for small outpouchings of colon
- Coffee bean sign - huge dilation of sigmoid colon that looks like a coffee bean
- Due to volvulus of the sigmoid colon

- Apple core sign - common sign of neoplasia

- Most common neoplasia = adenocarcinoma

- Filling defects - indicative of growth inside of lumen - commonly neoplasia

(adenocarcinoma/polyp)
- Contrast is unable to move past blockage
Esophagus

Diverticula of the Esophagus

- Exactly what it says

- Ecclesia (paralysis) of the esophagus

- Look for distension and interpreted outline

- Esophageal varices
- Caused by portal hypertension
 - Filling defect of esophagus (malignant = adenocarcinoma or SCC, benign =
polyp)
- Observe pre-stenotic dilation and stenosis

Liver

CT/MRI modalities of choice

- Liver should always be the ​same​ density as the spleen (on MRI/CT same colour)
- If less dense (lighter) = fatty liver
- Liver should touch all the walls of the abdomen, if it doesn’t it is small
- Think liver cirrhosis​ (may also see dilation of portal veins) (below, cirrhosis
on left, normal on right)
- Metastasis
- Where you see multiple nodules in the liver (dark on CT often) these are likely
metastatic

- Neoplasia (malignant = hepatocellular carcinoma most common)

- Look for a well demarcated, possibly hyperdense, structure sitting in the
hepatic parenchyma. Note how the mass has jagged edges, not smooth like a
cyst (see below)
- Hepatic cyst
- Well demarcated, note how the contours are smooth

- Hydatid cyst - echinococcus

- Note the internal membrane in this, a dead give away
- These cysts can also calcify, if you see a calcified cyst is is likely hydatid

- Hemangioma
- A tumour of the vessels, is best observed in the late portal phase of contrast.

Remember, for CT we can have native, arterial

and venous (portal vein) stages! The
hemangioma will take up the blood later and
become more visible in the later stages.
 - Pneumo Portia + Pneumobilliary -
- Mechanisms for having air in the liver (one is air in portal system, other air in
biliary system (shown)).

Gallbladder

As well as X-ray, Ultrasound (useful for stones), MRI and CT we can also do some specific
visualisation of the ducts:
- ERCP
- Endoscopic retrograde cholangiopancreatogram - helps visualise distal biliary
tract
- PTC - percutaneous transhepatic cholangiogram
- Best visualisation of proximal biliary tract

- Porcelain gallbladder
- Calcification of gallbladder, look for mottled visage on x-ray

- Gallstones (cholelithiasis)
- Only calcium containing ones are visible
 - Cholecystitis
- Acute inflammation of the gallbladder, look for thickening of the gallbladder
wall.

Pancreas

The main these we look for in the pancreas are inflammation, cysts and tumours.

Acute Pancreatitis
- Best shown on contrast CT (arterial + portal protocol). US can be useful as well
- Typically show parenchymal enlargement with heterogeneous density due to edema.
Liquefactive necrosis may be present as may abscess formation and haemorrhage.
Normal pancreas (on far right), note how much thinner it is!
Chronic pancreatitis
- Typically has calcification included, this is the give away

Pancreatic neoplasia:
- Can be pancreatic ductal adenocarcinoma (most common malignancy) or cystic
neoplasm (top row are adenocarcinomas, bottom are cystic neoplasms)

Reading Urology scans

- Kidney stones
Look for opacities over the shadow of the kidney or on the path of the ureters.
 - Hydronephrosis
Caused by some form of blockage in the kidney which leads to buildup of fluid in the kidney,
look for dilation of the normal kidney anatomy.

- Horseshoe kidney
Kidneys have a large number of anatomical variants, a common example is the horseshoe
kidney.
 - Renal cell carcinoma/transitional cell carcinoma
The two most common types of cancer, RCCs found in renal parenchyma, TCC in the
ureters and the bladder. May be calcified.

Reading Musculoskeletal scans

- Osteophytosis
Angulation of corners of joints. Also known as bone spurs. Often a result of osteoarthritis,
Wilson’s disease, acromegaly, macrodystrophia lipomatosa progressiva, and others.
 - Osteoporosis
Bone jsut seems to vanish, look for decreased density. Can be due to old age or systemic
vitamin deficiencies/metabolic diseases.

- Osteochondrosis
Joint space narrowing, occurs in osteoarthritis, rheumatoid arthritis, inflammatory arthritis,
erosive osteoarthritis, gout

- Osteoarthritis
Affects all the joints, increasing the lucidity of the epiphyseal joints. Look for osteophytes and
narrowing of the joint space as well as structural deformities in the fingers,
 - Rheumatoid arthritis
Looks similar to osteoarthritis, however affects the metacarpal joints as opposed to the
phalangeal joints

- Aseptic necrosis of bone

Aseptic necrosis results from poor blood supply to an area of bone causing localised bone
death. It appears as a bright signal (T2) in MRI, with the signal coming from bone marrow
edema, or dark in T1.

- Osteomyelitis
Infection of the bone, creates a pus filled sequestrea. More dangerous in children as it can
more easily travel through the growth plate. Has two atypical forms, abscess of broady, and
Garre’s form (chronic).
 - Osteosclerosis
Look for calcified zones throughout the bone, diffuse.

- Osteonecrosis
Look for increased opacity on standard x-ray.

- Osteolysis
Resorption of the bone. Overactive osteoclast activity.
 - Periostosis
Abnormal deposition of periosteal bone, manifesting as periosteomas. Known as a
periosteal reaction, occurs with periosteal irritation. May be benign or aggressive.
Types:
- Single layer
- Can be caused b osteoid osteoma, ewing sarcoma, giant cell tumor,
osteomyelitis, osteosarcoma
- Multilayered
- Associated with osteosarcoma, osteomyelitis, ewing sarcoma and
others

- Speculated
- Classic indicator of malignancy
 - Codman’s triangle
- Another classic indicator of malignancy and aggressive lesions

- Osteoid-osteoma
Benign bone tumor that arises from osteoblasts. >1.5cm and commonly found in long bones,
are 10% of all benign bone tumors. Look for a small radiolucency on a long bone. May be
surrounded by mineralisation.
 - Osteoblastoma
Uncommon primary neoplasm, similar histologically to osteoid osteoma but larger (2-6cm).
Just look for a larger leucency

- Osteochondroma
An overgrowth of cartilage and bone that happens at the end of the bone
near the growth plate. Most commonly affects long bones in the leg, pelvis
or scapula. Most common benign tumor.

- Hemangioma
Benign tumor derived from blood vessel cells, most common is infantile
hemangioma (strawberry marks).

- Osteoclastoma/Giant-cell tumor of the bone

Generally begin benign but malignant degeneration does occur, likely to metastasize to the
lungs. Diff dx with aneurysmatic bone cyst.
 - Osteosarcoma
Aggressive neoplasm in the bone arising from transformed mesenchymal cells. Exhibits
osteoblastic differentiation producing malignant osteoid. Can have increased calcification
and lysis (so may appear as leucency or as increased density). Look for periosteal reaction,
very important.
 - Ewing Sarcoma
Malignant small, round, blue cell tumor. Found in bone or soft tissue, most commonly in
pelvis, femur, humerus, ribs, mandible and clavicle. Common in teenagers and young adults.
Usually presents as moth-eaten destruction permeative lucent lesions in the shaft of long
bones with onion skin periostitis.

- Multiple Myeloma
Most common primary malignant bone neoplasm in adults, arising from red marrow due to
monoclonal proliferation of plasma cells. Presents as many purely lytic lesions.
 - Chondrosarcoma
Cancer derived from chondrocytes. They are resistant to chemo and radiotherapy. Have a
ring-and-arc chondroid matrix mineralisation with aggressive features such as a lytic pattern.

Reading CNS scans

- Brain tumors
- Most common intracranial are Gliomas, if in contact with meningitis, think
meningioma, best spotted on MRI (below image T1, T2 and Flair)

-
- Sinus imaging
- We image the sinuses looking for fluid levels (indicating sinusitis) and cysts or
polyps
 - Ischemic stroke
This is the majority of strokes are ischaemic (80%, the remainder are haemorrhagic, 20%).
CT is the best method for investigation due to its speed. Occurs due to sudden cessation of
blood to brain. Can be defined by time of stroke:
- Early hyperacute (0-6hrs)
- Loss of grey-white matter differentiation, but limited findings on CT
- Late hyperacute (6-24hrs)
- Acute (24hrs - 1wk)
- Swelling becomes more marked, significant mass effect (pushes other
structures)
- Subacute (1-3 wks)
- Swelling subsides, small amounts of petechial haemorrhages
- Chronic (>3wks)

Make a note, is the affected artery anterior, middle or posterior cerebral artery?

- Extradural haemorrhage
Collection of blood between dura and skull. Pressents with headache, and possible loss of
cinsciousness, often due to trauma or tumor. CT image shows hyperdense biconvex
extra-axial collection with well-demarcated haemorrhage between brain and skull
- Active bleed has central dark areas
- Acute shows hyperdense region
 - Subdural haemorrhage
Collection of blood between dura and arachnoid layers of the meninges. Commonly related
to history of head trauma. Observe on CT with hyperdense crescent (central hypodensity
represents active bleeding). ​Bleed is not limited by any structures​.

- Subarachnoid hemorrhage
Bleeding into the subarachnoid space, usually central around the circle of willis. Often due to
rupture of an intracranial aneurysm, comes on with ‘thunderclap’ headache. CT imaging
shows hyperdense (bright) finding in the sulci of the brain, following central cerebral
structures.
 - Multiple sclerosis
Relatively common acquired, chronic, relapsing demyelinating disease involving the CNS.
Second most common cause of neurological impairment in young adults after trauma.
Images on CT are generally non specific, MRI is the best form of observation.
- T1 - lesions are hypointense (black holes)
- T2 - lesions are hyperintense (bright)
Looking for 2+ lesions in the CNS. In images left to right, Flair, T2, T1.

Just FYI, Flair is a setting where fluid is suppressed (FLAIR stands for Fluid-attenuated
inversion recovery).

How to present an image​:

- Title of examination (X-ray, CT, MRI, and location e.g. Anterior-posterior, Frontal,
Lateral etc)
- Abnormal findings
- Location
- Intensity
- Form (e.g. regular)
- Size
- Number
- Homogeneity
- Borders
- Type of processes
- Diff dx
When considering musculoskeletal images
- Adults have no epiphyseal plates
- Look around edges of all bones for fractures, displaced fractures = black lines,
trabeculation disruption = lucent and sclerotic lines
- Look for changes to joint (change of space, osteophytosis, subluxation or
dislocation), check periosteum, and soft tissue

Note:
Bulge on Left of heart, goes outside of atrial appendage, this is pulmonary trunk being
pushed out due to u=pulmonary trunk
Different types of pneumonia