Shahid Hussain, Sharif Aaron Latif, Adrian Hall - Rapid Review of Radiology-Manson Publishing LTD (2010)

APID REVIEW
SHAHID HUSSAIN
SHERIF A. A . LATIF
ADR IAN D . HALL
Rapid Review of
Radiology
Shahid Hussain
MA, MB, BChir, MRCP, FRCR
Consultant Radiologist
Heart o f Eng land N HS Foundation Trust, Birming ham) UK
Sherif Aaron Abdel Latif

MB , ChB, MRCS, FRCR
Consul tant 1~1d i ologist
Dudley Group of Hospitals NHS Foundatio n Trust, West Midlands, UK
Adrian David Hall

MB , ChB , MRCP, FRCR
Consultant Radiologist
Dudley Group of H ospitals NHS Foundation Trust, West Midlands, UK
MANSON
PUB LI S HING - - - - - - - - - -
Dedications
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Contents
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Contri butors 5
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G,'nnJI Imrodllcl ion ,

Ch'l'tcr I - ChC51 1"'.ginS II
CI,.ptcr 2 - ,\bdomin.1 I""sing 71
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ell'plcr'; - " lll " \ll",kdct~ 1 Inug;nll 205
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Preface
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,
GENERAL
INTRODUCTION
This book has been written primarily for senior radiology exposure to as many ofthese cases as Ix>ssible. Radiological
ITJinces preparing for final radiology exams and in particular atlases and film libraries provide ready access ro many of
fo r trainees studying for the Fellowship of [he Royal these classic cases, which can then be committed to
College of R3diology. With Ihis in mind, the cases memory. You can prepare a ready-made description of
presented herewith have been presented in the exact these cases for rhe viva. Ifro\! arc sure of the diagnosis,
manner that the cases are presented in the Ro}'al College dispatch the film promptly with your preprepared 'speech'
of Radiology FRCR 2B exam. In the exam, long cases and so that you can progress to the next case as soon as
viva cases are presented with a very minimal bur highly possible. Of course there may be 'Aunt Minnie' cases that
relevant history and the required response is expected to yO ll haven't secn and rhis may present a problem, Such
be presented in a particular way. This format of reporting ' cases arc often not amenable to working out the diagnosis
involves giving a Description/ Interpretation of the images; - you either know it or you don't . The o nly thing ro do is
Diag nosis; Differential Diag nosis; and advice on Furrhcr be methodical in your analysis and description of the
Management. We have laid Ollt the answers here in exactly findings so that at the very least you can suggest whether
this manner and have included a Discussion [Q give in - you feci an abnormality is li kely 10 be lo ngstanding and
depth further information about each condition which wi ll benign or orhenvise, and make appropriate suggestions on
enable the sntdent to answer any qucstions directed to him how you would proceed.
or her in the viva situation, By tollowing the RCR exam
formal , thc candidate should be ideally prepared for t his The 'test of observation'
e.l:am and for [he future as a Consultant Radiologist. H ere, there is an abnormality prescnt that once seen, may
wclllcad to an easy d iagnosis. The abnormality is subtle or
hidden however, such that it tests the candidate's
FILM TECHNIQUE perception and approach [Q a case. Perceptual abi lity,
Whatever the imaging modality, the radiologist interprets however, is variable, not only between people bur also in
images using all the infonnation and clues available, to the same obscn'er on diflcrcllt days (this is particularly [rue
prod uce a differential diagnosis and/or advise on further in examinat:ions where anxiety levels arc high). You must
investigation and management. Above all else, this mUSt be therefore be systematic in analysing each film if there is no
done in a SAFE manner, and this often requires one [Q be ob\'io us abnormality [ 0 sec on firsr inspection. There arc
systematic in approach. Secondly, this process must be done mallYdiflerent s}'srcmatic approaches and it is beyond [he
in a SENSIBLE manner - it is easy to quote endless lists of scope of this discussion to be morc prescriptive. Howcver,
differential diagnoses but if these are not refined for each make sure you haye a system and usc it. Moreover, describe
individual case, the r.:tdiologisr's input is of little value.1l1e the process you are going through aloud in the viva so that
following discussion concentrates in particular o n the examiner knows that you arc practising safe radiology.
perfo rming these tasks in the examination viva scenario.
However, much of the advice is applicable to everyday The 'jigsaw puzzle'
practice [Qo, in particular the emphasis on a safe and This type of case presents several findings that once
sensible approach. identified and considered together, lead to a specific or
differential diagnosis. This nOt only tCSts perceptual skill
and systematic approach, but also the ability ro mentally
TYPES OF FILM 'cross-reference' se\'eral diflcrential diagnosis lists for the
The rypes of film one may enCounter in an exam/viva arc as various abnormalities identified , to find thc 'best fit'
fo llows: diagnosis. Whenever producing a differential diagnosis in
an examination or real life, it is \'ital to produce a sensible
The ' Aunt Minnie' list, not just a recital oflong lists learnt from books. To do
There arc certain disorders that have a characteristic this, you must use all clues available from the clinical
appearance on imaging that allows one to make an instant histOry and film, and combine this information with
'Spot diagnosis'. It \\~Il be assumed the candidate has come knowled ge of the incidence of each possibility in a given
across it before, and thus t he best preparation here is patient population.
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GENERAL VIVA CONS IDERATIONS

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Chest Imaging Cases \, 2
CASE 1
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Answe r 1 Chest Ima ging
ANSW ER 1
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Chest Imaging Cases 3, 4
CASE3
History
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CASE 4
History
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Answer 3 Chest Imll ging
ANSWER 3
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Answe r 5 Chest Imag in g
ANSWER 5
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A nswer 7 Chest Imaging Case 8
ANSWER 7
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AN SWER 9
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History
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Answe r 10 Chest Imag ing
ANSWER 10
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A nswers 10, 11 Chest ImO!lging
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ANSWER 11
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Chlst Imagin g Case 12
CASE 12
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ANSWER 12
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CASE 13
History
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A nswer 14 Chest Imaging
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CASE 15
ory
68-year-old male presented with
progrcssi\'c dyspnoca.
CASE 16
ory
--H)-year-old male presented with a
g progrcssi\'c history of dyspnoca
_more reecn! onset cyallosis.
37
Answer 15 Chest Imaging
ANSWER 15
Observations (15al thickened pleura, with linear bands extending from
This chest TJdiograph demonstrates bilateral lower zone the mass into the lung (craw's feet ) ( I Sb ).
imerstirial rcricular opacity with evidence of basal volume Malignant mesothelioma - - 90% arc related to
loss demonstrated b~' descent of bath hila. The interstitial previous asbestos exposure
opacit), gives the heart an irregular 'shaggy' border. These. Lung carcinoma - there is a brency of -30 years and
appearances arc in keeping with basal fibrosi6. There is a occurrence is related to the dose of asbestos exposure
calcified pleural plaque rcbred to the right hemidiaphragm. and to cigarette smoking - which can increase risk by
The combination of basal tibrosis with pleural disease 100-fold.
would suggest asbestos exposure with pulmonal)' asbestosis
and pleural plaques. Practical tips
Multiple pleur.l.l plaques arc characteristic tor previous
Diagnosis asbestos exposure ( I Sc).
PulmonarY;lsbcstosis. Look for signs of m:llignancy in patiems with asbestos
exposure - remember the increased risk of pleural and
Discussion pulmonary malignancy. Pulmonary masses should be
Pulmonary asbestosis is a chronic progressive fibrotic investigated with CT - ch:lfacteristic findings may
condition secondary to chronic asbestos exposure. permit a confident diagnosis of folded lung in some
eroeidol itc (blue ) asbestos fibres arc mOst commonly cases.
associated with malignant disease and pleural disease. Asbestosis is the 'odd one out' among the inorganic
Radiological features are of a fibrosing alveolitis that dusts causing pulmonary fibrosis. Thl: other
predominantly affects the bases and is indistinguishable fibrogenic dusts cause upper ZQlle fibr06is.
from other causes. Fibrosis can progress to result in
progressive massive fibrosis, but this again predominates Further management
at the lung bases. Pulmon:u), asbestosis has a latency period • Systemic sympwms, e.g. weight loss, shou ld be
of -40 years and therdore pleural changes are usually seen carditlly investigated to exclude mesothelioma or
prior to lung parenchymal changes. bronchogenic carcinoma, for which these patients are
Othcr features of asbestos exposure include: at increased risk.
Pleural efli.tsion - this is the earliest pleural In cases where there is still clinical concern abom an
abnormality, with a latency of - 10 years. area of possible tolded lung despitl: imaging,
Focal pleural plaques - have a btenc}' of 20-40 years. percutaneous biopsy may be requ ired to exclude a
DitTuse pleural thickening malignancy.
Pleural calcification.
Rounded atelectasis - this is also known as folded Further reading
lung and :uises due to infolding of thickened plcurtl. Akira M, Yamamoto S, Yokoyama K, etal. (19 90 ).
with associated subscgmental atelectasis.oMost Asbeswsis: high -resolution CT-pathologic
commonly seen in the lower lobes, it has the correlation. Radiolog'l 176: 389- 394.
appearance of a rounded subpleural mass abutting
15c Axial image shows a right anterior calcified

15b CT image of the chest demonstrating a large pleural 'plaque consistent with previous asbestos
intra parenchymal lung lesion that is abutting exposure . There is also subpleural reticulation
thickened pleura. Vessels appear to be radiating representing fitirosis and appearances would be of
towards the lesio n as though pulled towards it. asbestosis.
38
Answer 16 Chest Imaging Case 17
AN SWER 16
Observations (16) cardiovascular disease, either from an increase in overall
This frontal chest rJdiograph shows extreme cardiomcgal~' . pulmonary arterial resistance or from :In increase in the
There is marked dilatation of the central and main plll - o' ·erall circulatory '·olume going through the pulmonary
.anary arteries with 'pmning' of peripheral pulmonary circulation.
merics. No diffuse lung abnormality is seen Increased resistance - pulmonary veno-occlusil"e
T he findings arc indicative ofpuhnonary hypertension. dise:lse, chronic pulmonal)' thrombocmbolism, any
Gj,.-c n the gross cardiomegaly, a kft to right shunt is the chronic I'emil:ltory disorder leading to chronic
alIOS! likely cause. Howe\'er, cyanosis should not occur and hypoxi:l and resulting vasoconstriction in the
lIS presence suggests the shunt has rc\-crscd, that is, the puJmonal)' arteri:ll bed
p;1[ienr has developed Eisenmenger's syndrome. Increased flow - left to right shunts, i.e. ASO (atrial
septal defect ), VSO (vemricubr septJ.J defect ), rOA
Diagnosis (patent ductusarreriosus).
Pulmonary arterial hypertension from an undiagnosed In Eisenmenger's syndrome the pulmonary arterial
,"cntricular septal defect (VSD ) progressing to pressure climbs until it c,"elltually exceeds the pressure in
Eisenmenger's syndrome, the left heart and the shunt re'·crscs. It is seen in those with
pulmonary hypertension from :I left to right shunt.
Discussion
Pulmonary arterial hypertension is dilgnoscd by a sustained Practical tips
mean pressure >20 mml-lg (systolic >30 ITlITlHg, diasTOlic • On a pl:lin chest radiograph, hilar l}'mphadenopath~'
>1 5 ITlmHg ). Radiological fe:Hllfes on a plain chest can mimic pulmonar), aTlerial hypertension. Clinical
r.td iograph that suggest the diagnosis arc: history here is vital and cr should be subsequentl)'
• Increase in size orthe main pulmonary artery. undertaken in the right clinical sening.
• Reduction in size of peripheral pulmonary arteries The diameter of the m:lin pulmonal)' artery should bo
known as 'peripheral pruning'. less than that of the ascending thoracic aorta. Rc vc rsal
• Right heart enlargement of this ratio is a sign of pulmonary hypertension.
• Calcification ofthe central pulmonary arteries - a late
but characteristk sign. Furth er management
• Parenchymal mosaic attenuation pattern seen on Primary pulmonary hypertension has 110 cure :md a dism:ll
HRCT. prognosis. It is a diagnosis of exclusion so all underl ying
causes of secondal)' pulmonary hypertension m ust be
Primary pulmonary hypertension is idiopathic. The investigated. Cardiology referral with a I'icw to echo-
condition can also arise secondary to pulmon:lTY disease or cardiography would be required initially.
CASE 17
History
..\ 50-year-old female presented
with progressi,'e dyspnoea and
intermittelH cyanosis of the
fingcl1l.
39
ANSWER 17
Observations (17a) • Soft tissue calcification - systemic sclerosis.
This frontal chest film shows abnormal rcticuhr interstitial • Signs of malignancy including bony sclerosis from
op:Kiry at both lung bases, though there arc no features to myeloproliferative disorders - cyTOtoxic induced
indicate significant volume loss at the present time. A large • Sympathectomy clips - systemic sclerosis ( 17 b ).
area of calcinosis is noted in the soft tissues around the
upper right hUlllerus. The combination of find ings and Remember which disorders cause upper and lower
clinical history suggests a diagnosis of systemic sclerosis zone fibrosis ( reler to the differential diagnosis abovc,
with lower zone pulmonary fibrosis and Raynaud's and also that in Case 18 for npper zone fibrosis ):
phenomenon sarcoid is rhe classical upper zone disease, much as
IPF is the classical lower zone disea~. Thereafter,
Diagnosis remember that the upper zones arc better ae rated and
Lower zone pulmonary fibrosis due to systemic sclerosis. the lower zones better perfused. So, diseases caused
by inhaled dust (inorganic or organic, e.g. silicosis
Differential diagnosis ~ and extrinsic allergic akeolitis [EAA] respectively)
For lower zone pulmonary fibrosis: I ,,'" atlect the upper zones, while the lower zones will be
• Idiopathic pulmonary fibrosis (I PF) (cryptogenic '0"1 afkcted by blood ~orne disorders, i.e. drugs and
fibrosing alvcolitis - CFA). autoimmune conditions. Unfortunately, asbestos is an
• Connective tissue disorders - systemic sclerosis, exception and docs not obey this logic.
rheumatoid As with many fibrotic lung conditions, theft; is an
• Asbestosis. increased incidence of pulmonary malignancy in
• Drugs - especially certain cytotoxic;, e.g. systemic sclerosis associated pulmonary fibrosis -
cyclophosphamide, bleomycin, busulphan, etc. check for focalnodulcs/masses on the chest
radiograph. Alternatively, tOcal airspace opacities may
Discussion represent aspiration.
This autoimmune d isease has also been known as
scleroderma, \\~th a subgroup known as CREST syndrome Further management
Current nomenclature is systemic sclerosis wiTh diffuse or H RCT is the imaging choice in diagnosis and follow- up
limited scleroderma, the latter being The equivalent of ofinrcrstitiallung disease. cr imaging findings of fibrosis
CREST syndrome. The condition is three times as include lung volume reduction, subpleural reticulation,
common in females and typically presents in the 4th- 5th interlobular septal thickening and tJ":."letion bronchiect.1sis.
decades. A variety of autOantibodies may be present
including ANA and rheumatoid Factor. Clinical features
are many and varied bur include:
• Musculoskeletal - thickened skin, soft tissue
calcinosis, Raynaud's, erosi,·e arthritis (sec Case 152 ).
Lungs -loll"er zone pulmonary fibrosis, aspiration.
Oesophagus - hypotonia results in dilatation and
dysphagia. lncompetence of the gastfo-ocsophageal
sphincter results in reflux and consequent peptic
stricture, aspiration, etc.
Small bowel - dilatation and slow transit result in
bacterial overgrowth and malabsorption. Barium
studies show 'hidebound' appearance due to fibrosis
pulling the vah>ulae closer together.
Pscudosacculatiolls and pneumatosis in small and
large bowel.
T he CREST syndrome represents Calcinosis, Raynaud's,

oEsophageal dysmotility, Sclerodactyly, Telangiectasia.
Practical tips
Once lower zone pulmonary fibrosis has been noted
on the chest radiograph, examine the film for the
following features that may indicaTe a specific
diagnosis:
• Dilated oesophagus - systemic sclerosis (sec Case
152 ).
Erosions of the lateral ends of clavicles -
rheumatOid.
Pleural plaqucs - asbestOsis.
40
CASE1S
.... istory
.~3 r.:ar "Id 111J.1c I'n:scn1\:,j \\11h hol.:k
Jnd p"('grc"'I"c d\'~pnoc.1
:;'S E 19
"'11"Jlcprt"SCIllCd"1thkfl~rm
4'
ANSWER 18
Observations (18a) Apical bullae and cavit"Jtioli .
Plain radiograph of the chest shows changes of upper zone Paraseptal emphysema.
fibrosis with elevation of both hila and upper zone reticular Bronchiectasis .
opacit ies. In addition, there is a cavilY in the left uppe r
zone containing a soft tissue de nsity mass with surrounding Cardiac fC:ltll res include ao rtitif; involving the ascending
air crescent. These appearances would be consistent with aona with aortic \·alve insutlicielll'Y.
a mycetoma. T he patieTlt also has a marked kyphosis with P13ill radiographic featu res of uppe r zone fibrosis
the head obscuring the lung ::apices. Moreover, on close include:
inspection . there is a hint of syndcsmoph),tc formation EIc\':Ition of the hila.
along the right lateral aspeCT ofrhOr:lcic spine. Tenting of the hemidiaphragms.
T he combination of findings is consistent \\~th upper Ele\':Ition of the horizontal fissure on the right (a
zone fibrosis associated \\ith ankylosing spondylitis. T here good indicator).
is myceroma formation in the fib rotic C:IVil}, in the left Increased lucency of the lower zone due to
uppe r zone. hyperexpansion.
Reticular o pacilies ill the upper zones.
Diagnosis
Ankylosing spondylitis. Practical tips
Clues to help limit the diOercntial d iagnosis for upper
Differential diagnosis zone fibrosis include:
For uplX'r zone fibrosis (mnemonic - 'STRAD'): Kyphosi' and 'bamboo spine' indicate ankylosing
Sarcoidosis. spondylitis.
TB. Egg shell nodal caldficalion suggests silicosis or
R.1diation. S:trcoid.
Ankylosing spondylitis. Associated calcified grJnulomatn suggest T B.
Dust inha13tion - inorganic (e.g. silica) and organic
(i.e. chronic extrinsic allergic ah·eolitis). A l wa~'s look fo r signs of secondary
in fectio n/ mycetoma in fibrot ic cavities ( ISb ).
Discussion Whcn pulmona!), fi brosis due to ankylosing
Ankylosing spondylitis is an autoimmune disease that most spondylit is is suspected, look for signs of
commo n l~' manifests as a seronegative ;lfthropathy, complications of d mg treatmcnt on the film:
predominantly affecting the axia l skeleton (ini tially • Ihascular necrosis of humeral heads secondary to
sacroiliac joints then thoracic and lumbar spine). It usually steroids.
presents in the 2nd-4th decade and more fTcquently affects • Atypical dist ri bution of fibrosis may be secondary
men (sex mtio of - 5: I ). As well as bone involvement, there 10 drug treatment.
arc respiratOry and cardiac m:llliteslations. Respi ralo!)'
man itestations arc seen in - I % of cases and featu res Further manage ment
include: M ultidiscipl inary management is requ ired in this
UPlX'r lobe pu lmonary tibrosis. ll1ult isystem d isease .
• Relicular/ reticulonodular opacities in lUllg apices.
18b CT image in the same patient shows a cavitating

lesion in the left upper lobe apical segment
containing an Aspergillus fun gus bait.
42
ANSWER 19
Observations (19) SubcJa"ian insufficicncy - pain, numbness and
Two Spot images from an angiogram ;11I<cstigation at the weakness in the arm that is brought on by cxercising
Ie...el of the aortic arch lre prcscnt'cd. Both images show the thc limb. Necrosis ofthc fin gertips.
left shoulder joinr in an alxlucTcd position. The left hand Vertebrobasilar insuflicicncy - syncope can be
image shows contn st filling of the aortic arch with filling prccipitatcd by exercising the arm due to the stealing
of the brachioccphalic tru nk and left common CUQ[id of blood. Headaches, ataxia, vertigo, diplopia,
m ay. There is filli ng of the; proximal subda\~an artery but homon ymous hcmianopi::a ::and hemiparcsis have ::all
them there is a complete occlusion with no filling beyond been reported.
it. The right hand image shows a slightly delayed film \\;th
.:omr:ast seen in the left vcncbral artery (best seen at the Practical tips
k\'d of the C3/ 4 ) providing filling of the distal left Di::agnosis can be m::ade nonin\'asi\"d~' by US by idemif)~ng
wlxb.v;an anery. reversal of Doppler flow in the "cnebral arte ry.
Diagnosis Further management

Subclavian steal syndrome. CT can be useful to identify/characrcrizc c::alcificd
atherosclerotic plaque in the subcl:lvian artcry
Discussion (uncontrasted CT) and also the site/ degree of
This is a condition that is usually acq uired and caused by stenosis (arterial phase CT).
ahcrosdcrotic d isc:!$!:. Stenosis of the su\xla,·i3.n artery Surgical referral is required for treatment wil h either
results in stcaling of blood [Q the arm via rctrogradc flow balloon :mgioplast}' (+/ - stem insenion ) or surgical
m the ipsilateral "crlcbral artery. Othcr acquired causcs bypass (common carotid to subclavian artery).
-:Iudc "asculiti (T akarasu ), cmbolism, aortic disscction,
radiation fibrosis and chest trauma. Congenital causes arc Further reading
ancommon. Clinical features include: Chung ]W, Park JH , 1m JG, etnl. ( 1996). Spiral CT
lefT arm is more commonly im'oked than thc right. angiography ofthc thoracic aort:l. /{adioGmplJiCJ 16:
Reduced BP b~' up to 40 mmHg in the aflccted arm. 81 1- 824 .
• Delayed/wcak pulse in the aflccted arm.
CASE 20
History
\ -I4 ' ye:lT-old male having a pre -
cmplo)'mcnt chest radiograph.
43
ANSWER 20
Observations (20a) question to the clinician such as 'how unwell is this
This chest radiograph shows multiple fine, sand-like, tillY patient? ' can be most helpful.
calcified lesions measuring Jess than I mill in diameter,
spread throughout both lungs. Both lungs arc of normal Further management
\'olul11(. No olher abnormality is seen. No further m;lIlagement is required in this benign
condition.
Diagnosis
Ain:ol:lf microlithiasis. Further reading
Brown K, j\'lund OF, Aberle DR, Batra P, tt (I/. ( 1994 ).
Oifferential diagnosis Intrathoracic calcific3.tions; radiographic features and
With pin-poinr high-density nodules, rhe possibilities afC di ffe rential diagnoscs. RadioGraphiu 14; 1247-1261 .
Girl}' limited, as follows:
• Inhaled illO%'3nic dusts such as silicosis. Nodules tend
ro be a linle larger and arc predominantly in rhe
Illiddle and upper zones. CoaicscclKc \0 torm larger
lesions with cavir,uian and fibrosis occurs. Egg shell
calcification of nodes.
Other inoTbranic inhaled dusts such as tin oxide,
limestone and marble.
Slightly larger high -density opacities lead [0 a largcr

ditlercntial in addition to the above:
Varicclla pneumonia - pr~\lious inlection can appear
radiologically with multiple calcified nodules
measuring 1- 2 mm in size. No lymph node
calcification isscen.
Hist9plasmosis - hcaled inlection Gill also result in
multiple tiny calcifications throughom rhe lungs.
Associated 'I~rh mediastinal lymph node, liver and
spleen calcification.
Metasr:.uic calcinosis - focal calcification within the
alveolar septae due to elevated senun calcium and
phosphate b 'ds in conditions such as
h}'PCrparathyroidism, multiple myelo ma, sarcoidosis,
milk-alkali syndrome or hypervitaminosis D. There is
upper zone prcdominancc and disease can progress to
fOrtn airsp;lCc opacities, consolidatil'c appcarances and 20b Chest radiograph showing bilateral upper zone
fibrosis (20b). airspace opacities of metastatic calcinosis.
Pulmonary haemosidcrosis due to mitral vall-e disease.
Barium aspiration - hyperdense opacities in the lowcr
zoncs morc common o n the right (20c).
Discussio n
This is a rare condition that aflccts adults in the 4th- 6th
decades, resulting in calcification within the all'eoli. Usually
these paticnts arc asymptomatic, howcI'er thcy can prcsent
with dyspnoca on exenion. R.1diological appearances call
be quite striking with diffuse tin y calcit1ed nodules < I mm
in diamcter spread throughout borh lungs. The middle and
lowcr zoncs arc preferentially aHee!ed. Serum GI1cium and
phosphatc arc normal. DiAcrentiation from the causes
below is usually made by thc normal biochemistry,
characteriSlic radiological appearances and the p3.ucity of
clinical symptoms rci3.1il'c to the lll3.rked radiological
changes.
Practical tips
Clinical history is of vital imponance when narro"~ng down 20c Chest radiograph showing hyperdense airspace
3. list of ditlCrcnti3.1 diagnoses. Alveolar microlithiasis is 3. opacities in the lower zones predominating on the
good cX:1mple of where markcd r:ldio[ogical changes :1re right in a patient who aspirated during a barium
associatcd with a relative lack of symptoms. A simple swallow examination .
44
CASE 21
History
.\ 28-year-old pariem prcscnlcd with
oXrcriorating chronic d)'Spnoca.
CASE 22
History
A 45 -year-old 1n3ic presented with
':,udiac arrhythmia and shortness of
breath.
45
Answer 21 Chest Ima ging
ANSWER 21
Olao",atlo ns I2 I a) Prlt1 lc. ' l ip .
Th;' ... ,.,~ d",,, .., I,,,,,'ph . h ,, ~, '\'., h'f'<J · ~,~ ,;.-",. .. 'I'''' O\J ,,,to"" ,,, Th. ,,".I, rl ,;"" <..... "r ""--'n•.-I>"", "l-
or"';';" .""' ... ,I<,
k h hilum tI"" "" lik<~' ' 0 "r"'''o' '''' '" m ,J, f""" i" .1",,,10,,,,,,,, ' Od 1)'1'<'
"""' .... " r ' u~,;" J~."J " ",, ..I """"h •. :-;<> "g"",",., A~ r... _«",,,I. •"""/."~' '' ''' . .,...""";"""'r;" ,,.,
mlJ",!", ~ <ri.k",. Thi, .. pp."......" ~ .I<"nb<J ... 'Iin~" ~N'" 10",,_
;., "",,' ... J ~ .. d""'''' 'f'I'<" ~ K< uf .,k.po Ioro.,,,,," c )"'" fi~""", _ 1"'" """' •• ffi"" ,Ix urr")Qb"
r ul","" U}' .. po ,~ 'Iooi.. mo", ,h." ""'~ , 100<. (2 1d l
rv,.,-r<n '''''~ in"""," - 'l"i<. lin~'~. ;" i,i,N,
Oil gno. i. .tl;',,,J
AI',<I~i< "" .... hor<' I"''',.. ,.,. " I'<.pl~ ~~ (... BI"AI. HI ro-",,,," ," ~*, ' I , "<,,, ,, - <1"~I';,;" , 1,.-.. « H><
I""J"mi.,,,,,,
Om . ron ,i,( dl,gnos;,
F,,, •. n.. ;.,~ · r",.. um".i" Furth r m a nall"m~nt
~""""'!'"~,, I"""'~"" ~ Rd"u' <0 ,,,. ., r 0 Y'~; "" .. '~rro~,i>.1< with fu <t o"
• ",,,, ..,,,,," p,,,u",,,,,i •. im ,~"~ ""-""'.ur ~' i , ~ H RC r.
AR P....
• Qyr"";<"~ ""","", in ~ .""",non" ( COn Furth. readin g
Will;"., S_\ I. I,",,, f.T (1 99 71- (',,"" ~ .. '" ,~-, ,,, J'I'
Oi.cu •• io n ""k"",' (," hYr<"""'''~''~l l'''_''',!,''I ...... 'l'
Th~ ~ • h,I'<"""'";' i')' ",".Ih.,. ,...,,, ;,. k,,~ .... "'in~ " I",,¥i",,~ I "'~I'~ ) _ J!U;'''",/,hi<, 11, I ;~1_1600_
... h,n .. '" ~· 'h
I_a .>f ,,'hm"'"
"'"'.".oJ
i'l' "m'~'"J' ''I'<'1.ill i. I, .~·,·u " ;,.
.... "'mm,,,,ly 1·1 ""1 "'
r"""" ""h ,·)"i, 'ib",,". rU ',.,,",,)' f<'M" of 'h<
d;"_ ,..-
l'ul."",,,! ",fih,,,ion ~ ;, h ,,,,.><>ph
Wo. " h~'h
r"" "" .. , mif..-'t<><y/ ']ittins p","mQft"" of r'''h)'
."..~.,. in,~". ,.. " " ~, """ .. ,~y ",," .. ,,,. " . ~""
~.
C,,,~ I....,h""''''•• I,,, ,. " 1'1"" k""
p"'do..,,",....,< ,h" b ",U, U,' ...",,,..,, ,'ro.l,,", in~ ""'~
,hodo.,.·.· "" ph" ,oJ.W."""
• M",,,,,I "'r"""" i" dil",,1 "," 'll """"h ;lk"
f""'I""'S ,t-.. ""'S" in ~k",, ' 'rl'<"" .'" '1'1" , <on
""'." ; , "S" "",oI/'"b" ,on.po<
• LoN. "",,.,,;J,,,,,",
...,,., c r "'''~" of . '''''''~ "'m'" r,,;"n, wrth ABI'''' ' "
"""'" • 21b. 1 ' ,,_ ~;~ u " 2 1b .h .... J ;r ,,<J ." " " ,". _
f.U,d/plul'l',J up,,,, lob< "",,"'hi. ~h~h "" I" 1>< ..
..," " " ~,«.J •., "",. ,,1 '" f",," .. ~ 1'""," ", 11< .1< .."""",
,IK " l"" ~ .'" t" J iI.>!,J ''''''''hi ~ ith fu 1110,,, ,,'i<k,~"< "f
.""'''''- pl ,,u.'''~
"
A nswer 22 Ch est Imagi n g Case 23
ANSWER 22
Ob" ,"'lions (22) I m'll"~ "",ling. of <>,.1 ... _001 ..dud"
Th~ ~ ...... .. '"'~ "" ,"~· "f, t.. .. ,; '<n1";"-;' "dol .....! , Cmll " ",m"h ,,.. " , "', io ~ ,t.. '",n,n,,"'"I..
~.JoI ", ",m ."I" .",m"" 1'/ "'" Th< ,m",&, """,, .k l.)<d "P'""' (h ) '['"Oin,,"~ 'J' o. 1'1 ~' ; sh ,«l .... S'.).
I
<"h m,".. ' " ' ,,( 'h' ""," .. I. ' r "" .".! "..,,,1 "')'"
onl""" • " 1,,,,.... i.1 '" h.q"'"",.' "" ,ld.)",01 g'""-"io;' '"
.ith oporin. of tl>< , ...oo..,.. J;" , ~. 1b;'I"," m o f d " .)~d ,nhID"'",'" """'I""id". ' 0 ".". of6bruoio. ~i,h
.. " .... yu<..w .. <nh .....~m<" ' ~. ;u, ••"n"~ ,"""" .... ;.,'" "I' .... ~ .,ftlK ,.oo<•
.-.Ii" m . ....... ~ .,.
"'~. ".. .., inm,.. ' i ,~.r."wu m"o')' P""'<O•. d itf",nt;""q [.urn ,J-,., " f"""J '"lo<.ru;um .of
it< 10 ... ",", "" "" d;""K ,
Di.ynosis _ ~ "' .. "f h )",,,,",, ~ , "f '"" ,n),,,,.-.I ;, I ~ ., II.
(;.w~"" "",..I.
P,.ctIClllllps
Discussion SI''''''S ,"-rt>< ,"01,,,,.~, ;" ,, '"11&"''' " " ''''',"''''' """'l'
~, .. "' .... r <.. 01;..- "",·;'1 ~ .... n .. In _H" "f ",,;"n, • ,I.,., ,... ~ "n, 'n, ",,,,..I);" ~ ,I,'S"''';''
• ith _cu...._ HOH"", ,. t,.....
5" .. h>Nt ' ''!' d ...·..
,iV' •. CIi " "," r""'"'''"'" of ,,=id ;.
~·" k ,..,-J I" Furthe, mln_gem.nl
.,myth", i... wdk-ru!"I''''ky..-.l hu" f,, ",,_ lo.M " CXIl M r<'I'~""'l' ,h ", ~" of .omoiJ .
CASE 23
HillOry
A 50. )< ... ,~J ,.,k !'''.''''
p,.,,,,,,,,J ~;, n """",,'k><"
"
ANSWER 23
Observations (23a) ldt .anal "'PfICnd.agc CII\,U"ge lllenr. The norm;11 kIt
This chest radiograph shows evidence o f previous surgery mcdu!brul comour hJ.s tWO convcxities above th<.:
- there arc sternotom y wires and :l metallic mitr:!l v,ll\'e \'C:IIUldC - rhc X>nK: arell 3nd the main pulmo nal)'
replace m ent . The heart is enlarged with a cardio thor.lcic MttT\ Enbrgcmc::nt of the k ft 3tri313ppend3ge
ratio of 2 1:32 . There is a ' double de nsity' seen through produ.:cs.amlrd "bu mp' below the pulmon3ry
the right hean - a sign a flert atrial enlargement . Multiple, 23b n..s IS sometimes calk d the ' third mogul
small ( 1- 5 mill ) calcium density nodules arc seen in both [he term mogul is o ne uscd by skie rs to d escribe
lungs with mid and lower zone predominance. Upper ZOn e bumps In [he snow!).
venous diversion and a tiny light pleur:!] cffilsion suggest Caktfiarioo of thrOlll bus in lile !cll: 3trium ( 23c).
pulmonal)' veno us hypertension . Right "'cntricular hypertrophy,
Appearances ind icate that the patie nt has had surgical Pulmoru.n \~nous hypertensio n , intcrstitial and
lllitr:ll valve rcpi3cemcllt, but there arc persisting Icaturcs of pulnlOrUJ)" oedema.
mitral vake disease and signs o f left heart failure. He Pulfl"lOfUry h.lemosid<.:rosis - longstanding clev3tion
should undergo furt her asscssmcnr o f " ake and lefr heart of pulmonary "'eno us prl!ssure results in oozing o f
function . Th e high ·density pulllloll3ry nodules indicu c serum into the incerstitium. Blood products within
pu lmonary haemosidcrosis, a consequence of elevated this will ultimately be broke n d own to ,.
pulmon3ry ve no us pressure o ver many ye3rs.
Practical tips
Diagnosis h is diAicult to distinguish trom plain lilm
Mitral ,'al\'e discasc. is mitrJ.1 "3[\"e stenosis o r n:gurgi tation -
eonscqu<.: ncC$ and signs arc t he S3111e and
Discussio n coc x i ~t. Howe"er, if there is gross kfl atrial '
The most co mlllOIl GUIse of mirral valve dise:lse is rhcrc must he a component of stenosis prescnt.
rheumatic h<.:arr disease, widl presentatio n most cumnlo nly
seen in middk ,Igcd fcm;\k s. It results in kll ,ltriJI Further management
cnbrgemcnt J.nd pulmonary Vl!1l0US hypertension/heart Cardiac !'efen al with a " iew [(l c< h'"" "dio l~"'"
f-ailure assessmen t is required . Tr<.:almen£ il1\'ol\'es
Radiographic SigllS of mitral \'al"c disease arc: fo r arrh ythmi as (3£rial t"lbrillatio ll - AF ) and
' Double density' behind the rig ht heart border due to cardiac funnion . Surg ical intervcntion
left atrial enlargement. pCrelltall COllS v,llvc balloon dil at3tion (high
Splaying o rlhe carina by the large kft atrium . r.lrcs), valvotomy and v:llv<.: repbc<.:mcllt.
Oesophagus displaced to the right.
23b Chest radiograph shows enlargement of the left 23c lateral chest radiog raph shows curvilinear
atrial appendage in a patient w ith mitral stenosis. calcification of the left atrial wall.
48
Chest Imagin g Case 24
u r·old f1ule W:I,S rdured for

m"cstiguiofl rollowing m;!;:!.l
g showing a right lower lobe
k-I.iofl .
I,.,.'
.'
49
ANSWER 24
Observations (24) rET scans can be false negative for small lung
These PET scan images from 3. PET CT dcmonsnatc a metaStases or solitary lung nodules, False positivc diagnosis
1;lrgc right lower lobe highly FDG ( 18 fluoro-2-dcoxy- o n PET scanning also occurs due to infection and
glucose) avid lesion. There is a smaller lett upper lobe FDG intlammation - conditions that arc associated wid1 in -
avid lesion. Thc.rc is also rigln hilar uptake as well as uptake creased glucose turnover.
in the subcarinal region. Uptake in the region of the
oesophagus is also dcmonsu ;ucd. There is 110 FDG avid Practical tips
lesion in li"cr or adrcnals. No bony lesions arc In the UK, PET scanning is used mainly as a staging
demonstrated. tool. Neurological and cardiac applications arc not
utilized widely. Among others, PET is used for initial
Diagnosis ~:~~::~~I~ll~~ rcstaging of bronchogenic or oesophageal
l\'lct3static right lower lobe bronchogenic carcinoma.
Cancer networks arc increasingly utilizing PET prior
Differential diagnosis [Q planning for curati\'c surgel)', A growing
The left upper lobe lesion represent's either metastases or a application is the assessment of sol itary nodules. This
synchronous lesion. is particularly useful in centrallesiolls tor which
histological confirmation is more challenging and the
Di scussion complication rate is increased.
PET scanning rdics o n increased upl3kc of FDG in cell A well documcmed pitfull is a fu lsc negative scan for
populations with higher metabolic turno\'cr. The main small IUllg nodules or mcmsmscs. Lesions measuring
application is oncological imaging; other, less utilized less than 7-8 mm do ha,'c a higher fillse negati,'c rate.
applications include CNS and cardiac imaging. h is essemial Lymphoma staging is also widely undertaken. This is
that PET scans arc compared with cross-sectional imaging \'el)' useful for assessment of activity in residual
if no PET CT scan has been performed. Assessing only lymphoma masses and also for assessment of early
PC:f illl;lges alone can lead to diagnostic crrors, mainly rcsponse to chemotherapy. Inflammatol)' or infected
incorrect st:lging of malignant disease, The cr images (not nodal mediastinal masses (histoplasmosis) can also
shown ) of this PET/CT scan demonstrated a right sided give rise to false positive s~ans. Corrclation with cross·
pleural effusion that turned out to be malignant. Pleural sectional imaging is importallt in all cases where FDG
cffilsions do nOt demonstrate increased FDG activity. imaging is undertakcn.
Among Other areas, normal FDG uptake is
demonstrated in the brain , heart, sal ivary glands, liver, Further management
spleen as well as upper renal tracr and it is also excreted in PET CT resulrs should be discussed within a multi-
the urine, Nomlal bowel uptake is also often demonstrated. disciplinary team \,ith the purpose of deciding whether the
Pirfulls include increascd FDG uptake in fut (brown f.my patient would be a candidate for surgical disease clearance.
tissuc); this can simulatc malignant nodal diseasc. In the
current study, the increased oesophageal uptake is due to
a coexisting reflux ocsophagitis.
248 Right lower lobe bronchogenic

carcinoma (left) and likely metastasis (right).
50
25
fe male, prc\'iollsly
- the USA, presented for a
t chest mdiograph .
E 26
ry
:+-year-old male presented with
gia .
51
ANSWER 25
Observations (25a) and haematogenously to the spleen. Acme infection usually
This iron tal chest rndiograph demonstrates widespread 1- 3 presents with few nonspecific symptoms, and radiological
nUll diarnclcr miliary nodules seen Ihroughom barh lungs findings include gencralizcd lymphadenopathy, flitting
with no zonal predominance. The miliary nodules arc of nonscglllental bronchopneumoni:l, multiplc milia ry
cakifk density. Popcorn calcification ofthc kIt hilar lymph nodules, popcorn calcification ofhihlr/mediastinallymph
nodes is $Cen. In addition, there is amorphous calcification nodes and splcnic calcification. Chronic hislOpiasrnosis is
$Cen under the lell: hcmidiaphragm, which is likely to be in seen in patienrs with chronic obstructi\'c airways disease
the $plccn. and has r:l.diological features of peripheral consolidation
and apical fibrosis, Disseminated infcction can occur in
Diagnosis immunocompromised patients.
Histoplasmosis. Nonpulmonary features of hisroplasmosis include
pericarditis (5- 10%) and rheumatologic syndromes (-6%),
Differe ntial diagnosis c.g. arrhrnlgia, erythcma nodosum.
For increased density miliary opacities:
• MiliarYlllcrastascs Practical tips
Pneumoconiosis - silicosis, si.dcrosis, baritosis. In cases whcre there arc multiple radiolosical findings,
Varicclb-zostcr (25b ). consider the diflcrential diagnosis liST for each finding and
H:lcmosidcrosis - due to chronic pulmonary venous idemi!)' an ovcrlapping diagnosis (easier said than done in
hypertension, pu]mon:,uy haemorrhage, o r idiopathic. a \'h'asilllalion! ).
H istoplasmosis.
Further management
For popcorn calcification oflymph nodes: Clinicll/occupational history and I-IRCf can be useful to
• Sarcoidosis. dillcrcntiate the possible undcrlying d!;\gnoscs. Respiratory
• Silicosis. referral with a \'icw to antifunSll trcatmcnt would be
Hisropbsmosis. required ill the acute infcction.
• Coal workcr's pncumoconiosis «(,,,\VP).
• L}'lllphoma - post radiotherapy . Further reading
Brown K, Mund OF, Aberle DR, ct at. (1994 ).
Forsplcnic calcification: Imrathor;lcie calcifications: radiographic fcatures and
• Tuberculosis. diflCrential diagnoses. RndioGrnpIJies 14: 1247-1261.
Histoplasmosis. Whelt LJ, Wass J, Norton J ( 1984). Cavitary
In F.lrcts secondary to sickle cell discase. histoplasmosis occurring during tWO large urban
• H rd:nidcysts, outbrcaks, Analysis of elinical, epidemiologic,
• Haematoma. roentgcnographic, and Jaboratot)· fe:ltures. Mtdici"t
( Baltimore ) 63(4 ): 20 1-209.
Discu ssion 'Vilear LJ, Connolly-Stringfield PA, Bakcr RL ( 1990),
Histoplasma cnpSlllnwm is a fungus usually found in Disseminated histoplasmosis in the acquircd immune
temperate clim:tres and most commonly in thc northern ddiciellC)' syndrome: clinical findings, diagnosis and
USA. Infection is by inhalation of air bornc fungal sporcs. trcat'lllcllI,and rcvlcwof\hclil'erarurc. Mcdicim
These g..:rmin:ltc in the :l1vcoli and then spre;ld via the (Baltimore) 69( 6 ): 361.
pulmonary Iymph:llics [0 the hilar/Illediastinallymph nodes
25b Multiple calcified tiny nodules at

the left lung base in a patient with old
varicella pneumonia,
52
er 26 Chest Imaging Case 27
ations (26a) Practical tips

IIOntal chest radiogr-aph dcmons[r.ltcs a right sided Right sided aortic arch call gin: a notch in the posterior
.arch. No left sided aortic knuckle is seen . The hean aspect of the upper oesophagus on COntr:lSt swallow
enlarged. No IOcal1ung parenchymal abnonnaliry is examination .
Further management
No further managemem is required in this condition.
_ is can be contirmed wirh arterial phase contrast

-ed CT chest (26b ). Right sided aortic arch can be
ed with scveral congenital cardiac abnormalities but
.I.lso be see n in p:nicms without cardiac abnor-
The lau er grou p of p:l.IiclHS usually h:l\'c :J. right
.Ionic arch with :In aberrant Jeft subclavian artery
g as the most distal branch ort he ao rtic arch ), which
behi nd the ocsophagll~. This can be seen on a
swallow examination as a posterior indcmation in
t:wium column of the mid oesophagus. Patients with
sided aortic arch with mirror i1ll3gC branching, such
the leti: subclavian arises as a branch of the first ,"esse!
dlc Jo rtic arch, arc the group usually associated with
tic heart disease. The aorta descends in the right
crior mediastinum (although in a small proportion,
.;; this is 011 the lett).
26b Axial CT image demonstrates the right sided

aortic arch.
e ASE 27
to ry
34 -year-old smoker presents with
ressivel)' worsening shortness of
ath.
53
Answer 27 Chest Imil ging
AN SWER 27
ObH rvllions l27"1 " """ .. , .. "",,,,,,1 in uP"' .' ''''' . r""umn',"""", .. '"
Th, ,h,,' , .. I"5''I'h .t.~, !oi 1"",1 'hkl .",1 'hm ",1,,1 """,""" ""I <0" I'< ","""", \'1",,,1 .1Ii,,'." "" ,....
Ir
'l'" ' ""'. S""U' ""'h I. " S' ~ ;' " P"''''''' '''' afl.,,! ......·.."d. H ~CT "l'f""'''''''' '"" of ""'~ .oouk.
,,-,jo,,,<,, s,.,.,,, ' on.1I ",.jo'n.", .,,,, .. ," p .... "ul«l' ' orl ''''" el., , hin ~"k" '\'" 'h" ... ,0/",,..,..... ."" .....
wi,h .. ,I.. ,;~h ' .P I'" zoo ... ),'a pi, . .. , ,nu.;.," "' ~" I" on" .00.' .. I"", 'I"'in~ <of , he "1' '''' mJ
f"'<""""m."" ~ w,n. :rom,,0<i~ ' 0 'f'il< af 'h,
p.I<~"'" ''', '"' ~'.," ..... '" J;"rih,,,,,," ",d "''').'''''1 P•• OIic.llip.
w<o. 1J m' ~< I~"~,,h,", " II h ;"' ''l''''~ ,I" "M'" Iii-d)' On • CU, <)"'''' ""'I' J ....., _ .~ .. ....V""",.,.,j 1un3
J i '",,~~_ ,,,h.,,, "" he ,,,11<,,,,,, ~,,4 \>y io<"'i"~ " 1",,,,,,', ""'
"" I ",. Ok"'Wj'in, .","" ,,,I."',,,," "'I ", ~"
Oi.gnosl. 1.\ "'p"."~d<;,"" \ """""" ,."",, '" I "';w~' "
,,,,,,>;<',,,,", "u h"' ;' ~'!""'~ ' ~'""'"
)';,",,>fobmrn""'6 .h'"'8" on • eX k ""Iuok rih/-.on
Oiff".nti., dllgno.ls .n; ..,~ , ..... m . .... ( """,,,f,brom,,) ,«"
in
F", 'Y"" I . "~ ";0<," ~';,h "",,,,.1 0> ;n", ... J I.nt 1'''''<00, • ...t .... o,.'" and ,,;,,_
TO'",,,,,,, "k",,;, ;, ,..ill' o.kn,;tKJ lor ,n. hi>tu<y _
'''''L)m,~,.o
m<'' , ~ ' ,H ..,),..", ... _ "1<,.,, .... ""'" in b<io,~ ,h ...... " d"J lor ,\" ,Oi.OJ .. rm,,,'" ",,"'......
l nd---<>, ', ,I«~ k ~ n,,< ." m"l<;rk ')'" ""''' """"', .",1"'k...... "1'J«,,,n.
,,, .... """', '"' h.'3' "f ",1"", 1)' ,,,,;i,,,,, " " I ·~ IImo,h.",.,;, 1"'''''''''' , h" l . . .-. II, J ')'" ",.j '",
" " .) ' "" -.II.,...., ~·i'l> "', "oJLlk fv<on,,;'-.. , , " ~~,,,<d '''~''r ~"h '"'\' . bo , '" '-";~k '~ "I ,n."
O".'""y.o<~.n " ,,1 _on 'h, ~ .~ rI'.'" ,Ib,"" k,,~'"< '" '"..,., ""'inS'
.00 ",."'' '' pn<U""".....,,'"',
• ),;"'00';00-"",,,,,,,, - r ....Jomin."tlj· 'r"" 'lV>. F~rthr managemlnt
Tu"'''''''."k".... HK CT " " '" .«';" 1 ;" 'h, f"lID~ _ "P or ,,",,, r"'"""
• C)"" _ h ~<f"'" _·n.n iDo)';"~ r.,. 1"","6.01 "'"'pi ;'''..", of
..."'.', .... / ... )"',,,,,,, ;.,t<". ,~> ''';'.'' 'g ... .Iuk, ...I
Oi..,u.. ion r 0 ,.""""","",,,,
I.. "~"h,,,, " II h~"><p,,, i, " , mul';'I"" "
'"",.Ie n,,"m, ,I. ",,,, . _.""h 0« u n ""-'''' """"on I,' ., F~rthe, ,. .ding
I""~ p,J-..f," J " ·,,k>1 oJ." m l" . .okl h" ,n .'1""" ,,,,,) ... 'I>, .I I"!" SL." oJ
~ n, 11 9'~ ) .
... ~",i,,"'" ~'.h < ~"''''< ~'''/'''II . 1'11""''''''1' <h~I~'~ ,,' ''' '''''"'It)'I>'''i<'''~''~~ ~ : ''''''I'''''.' "r
C;H in,,-,j,,,, , "q"'"" ,f<h. "~,,_ inHW "S"' '" <ti ,..J"W.ph~ .00 cr find;"S' . ~""." 17),
""",u k' 'hn 1""&',,,;,, ly e....'''' ,~ ..... 0" ., ,h"· • ....J H9-:;~ _
,n." then ~-.lk..l,l" fiKm"""" L"" ~",ju.,... u. ",", Uy
CASE 28
Histo ry
A l~ · ",,,· ,~,, m.l, p" ... n"" .~h
""'m"... t r'" '' oc.h "m~ 1m"&,,
lAh,.,.. llk _.,., .. ..,,,;..,, I "' .. " ..
'p'" _ . ·h" h .. h'rp<n<J "'.u.
,I,,,,n'
CASE 29
History
A 65.)'<,,..~J ""I, I""""" J .;'h
~wJ«,,;,~lr .·""".i•• ~ ....."'».,{
,," .... h
Answe rs 28, 29 Chest Imag ing
ANSWER 28
OI>& ..".lIono i2b. b._I Di ......lon
><k"," ;",'s" "" .. ,n m~ "'''''N.m '1'1,,' fi", ;",,",' 'Jbo~,,;, ,~"k" .,....,,,..... •
~ ".,~, I "",,",,m. ", ...", ~"
P "") ~ • P"'-'""'''''' .."" ~hkh d.mo",,,,',, t.!",,,~ """. "'''1' '" ,·<in <Omf"<""'" .. tI" mot of, ... n"k
,,,",,.; n~" 1h< W,,'o" ... ,.,. p .... ) ,)",_., • p,g"i' "f"'" <,...,'"•.., "I d" '""~ 'n.. ,',,, "" , _ ,,( ')mr~'"'
",h"" io , ... "",h . hh "',",," ... """J . nJ "" ,, ~>l "i>< Ju. to "" " ",<UP"''''''' .. d ",,,,,,I,, ')'UP""''' >«
'r""""." uf ,I" ,.,rt;" ,,'~ ,n" ,... P'o,,,,,' m.;" ~"'nJ .... I<~' .. l'" or' ')mp'.... ""' r";'''!>' Th.
~''''''' ... ~ Th. ,hWol ""1'< {1& ) .00_" ""'",.; ""d","," ",1><1.0,,," .. ,,<r....v... n", ""' <r.... ~,,' I~ '-"<IuJ<J ~ ;,h
..... ,... ,,,lxl",10 ./t,,,",, " ,I><
k .. l ,,(,1>< ,"'~ .. ~ ,-""k,. """" "'''''' "'"' ",,,,,,,, rrobk,n,
, nb ",,_,,~"t<" ' .I>o,
G;,," ,... ,...,w,'"
of ",,~. I ';"', ~ ~ , "~,,~"d 'h" ,I", <.. , ."'" Ju< ,,, , ... "",,,<J "'"",, "1'0""1"'-..... ., _ ,~.>l
,",..I ",g,~", "-.IU~,J ~;,h ' h' .. ", " "~.,,, ""' ,I>< """"",1"-"""""';' ,iii.. ,,"," _, ''''"'pm ';''''''''',",
,hi,.! 1m •• , ~;,~ 'h, ..... , .k.',",,!. 11>< "",I, ,,[ d,;, ~ "r",' I"~ "'""m~ 'rmr"'"" ~ ;,~
1'" ~""'" h,.,Ik""", ""'" .~""n",,, r'''" ,,,"" ,,,,,,,.oJ ~'\'"''''''' ....... ""'n"". '""h"
'''ml'h''''~",' "I f'<""""''''~ ' n ">m~n' fu.m"",n '''''
Dll g"".I . 'u""' ~ """' ,m too';"" , ~, "',. ,
Tho,.,;" "",II" 'p.Jrom ••,,,onJ,,), '0 1kJ,t<," ""';',1
,;b> Prictioalllp'
Diffe r.nti, 1 di . gno."
<:.,,",~ rib> "w.... .. _J-I'" 0'''''' .......,I,,"," but "'" onil'
')"'1'''''''''''"' III"! ,of , ..... ,
0, """" "I tI ..."';, ".,k, ')"'I~ . It, :
C~ .'U"i'" _ 'mi.-" rh, fi~n .. , NoJ "• .oo."", ~ Furth e r m a nag e m e nl
I" "b. US ~ .>eM " , ,\\'" ....., ' "'' ~ ~ .>.><";n, .n,ml
• ""'"",,,,,1 _ r"" ,;~ ",.,,";.. , w ""-",,rr. "',.j~' I"'I'rk, , 'S".I ." n , Iv ''''' ; ~ • o. ,,", I • ",I ,." ',,,.1
>,r".u'. I""~.""
cr/M RI ..""" ""lUi ;' Ok n 'i~-;'s , .....,... of
"""r"""'" ;; ,.,. "I'I'""n' on rI>o. ,od"w ' I'"r,
ANSWER 29
ObSflrv •• lon.1 2So, 29bl ~'" ~"'.,," .""" .... "". "'1".1'h~ '''' .. ~,
'1".'" "" I cr ... ~" "' ,h. ,h,,' .h",,· ">1,,«,
or I.., I"""""r oro,,,, •.
•·'''!'' .. '"~r, ~".". .,r",,~ ,1\tl," .... ",,' ""'~~' .~ "h-wl., """' .. ~~
j<"' ... .n",,"'"
~ h u. ",tIo~YI" "1"01 'h"'h ,,"~. 1"1""",,,,· 6Ioro,;"
' j h~ ,0., ,,,1'; ... ;. .. "f i."~"~ r, ,, J"'i\> ."uIJ fi, . ·;o h •
J"~no'" oJf 1"""""'0<)'..00.,"" F", ""J"I " '""k>bul.. >< I~" ~,~"o. ,~
I. p.!'" "' ~~ ~ <U< , . . . " "• • _
Oi.gno. l. • s.."uOlo~ •.
\~""""''''Y ,,,,\fm, ,t,,, to, '''''IT f, ,,'" ,
Di.cu ..iDn
Diff. ,entlll dilgno.ls lA'""" " il.,«;'. d"S""'~ .""11,, m.J. ,hnblly "'"
............,'
•
."~' """-")'
l'ulmoooM)·",J.m.,
'''nro,m." ~' i,h en , rio,
r "'s" '" in "'l, .. n« .. ,h. <Ond~"",
';' II "~ ," ' f'""'"5' ,,",I '"
ok"""'>!,,.oo
1"(.,,".,,, r" I",,, ,, .~, ""'''' "..,," '" ...... _-" (0,,,,,,,,
H ..,""""',~., UPI'" WR< ,-",",,, I", Jom;'m«
1 , ,,«~.i, 1 '''''un'' ...... 1.,,,,,,,,,1 ,,,,J,,,,
,,;,10 I" ,;,'h ,,~ "'~"I .. ;,.,, ~.J
• E'.>,rin,., oIk,." ,[",,!;,"- 1«<1<)' R to,."
· ....""""'..
A~"~,, r ""';~"'"
f",," .... " nf ·s"x .. ' gI .... - >I>'<OI,,« ~

"h~'"" ,,,,km. ~i'h
• ",' '1'1'< ...... "" \.
, l"<IIIil..- I''''~''''''''''' (·10,,',
,·..... "" '/I)mph"'.. , 11>< '~I"~-;' ... ,,""" 1"''''Ok ~wm<""" "~I,",, ,,,
"'I'<"'''
,h. d ; '."'~K'
C"""",,''''~' ",.,11 ""'~"""--"~ "',, >." ""-
, l"m" ,!lin""
Tbcsc same lindings 3fe visible all CT. Alveolar Ollid often Practical tips
~ nrs as 'ground glass' opacity, which is an increased A combination of cardiomegaly, pleural clTusion and
::u.zincss/ attc.nuation in the lling - and which can be airspace opacity suggests cardiac f."tiluTe with pulmonary
chy in distribution. 'Ground glass' opacity is a relatively oedema.
..onspccific imaging finding due [0 many conditions that
.::aISC an overall increase in density within the segmellt of Further management
g displayed as a pixel on the CT image. There is a long Medica! management with eXR radiological tollow-up as
( remia! diagnosis including any cause of alveolar appropriate .
. j collsolidation.
CASE 30
iistory
~ 6 5 -vear-old male was referred tor :l
ardiac MRJ to assess cardiac viability.
57
ANSWER 30
Observations (3Da, 30b) Shorl a.'(is cine images arc acquired at first Pfl~ of a
The first image (3 0a ) is;t shorr <l.\:is scan through the left bolus injection of gadolinium to determine perfusion,
\'cmriclc during the firs t pass of contrast. There is no Infurcted myocardium shows no enhalll::ement on lint-pass
contrast enhancement orlhc thinned IeH \'cmricular septal imagin! (as demonstrated in this case), In addition, first -
:md anterior walls. The visualized posterior, lateral and pass imaging can show:
inferior walls show 110mlal enhancement and arc of nOnllal • Whether the infarct is transmural or subendocardiaL
thickness . The second im:agc (3 0b) is a delayed lour • Degrce of hypo/akinesia.
chamber ,-jew showing delayed, prolonged cnhanccmcm
of the septal, apical and 3lHcrohncr;11 wall of the left Delllycn..cnhancel1lenr sequences al approximately 5 min
ventricle. These appearances :HC of an extensive left show enhancement in infarcted tisslle sillce clear:lllce of
"cnrricular infurct wit h no evidence that inl"olved areas arc contrast from fibrotic tiSSlle is slower lh:lll from normal
viable. nH'ocardium.
· Ifthere is :lny uncert.linty regarding ditlercntiation of
Diagn osis ischaemic from inf.ucted mnxardi um then cardiac MRI
Left \'cntricubr inrnrct involving Ihe septal/apical! stress testing is per!armed \~'ithftNl-PIlJ1 images acquired
amcrolatcralwalls. at stress with adenosine and then repeated afTer 20 min al
rest. Areas of hypocnhancement at stress that show
Discussion recove!)' at rest represent areas of ischaemia rather than
Cardiac MRJ has 311 expanding rolc and current uses in&rction. .,\
include asscssmentof:
Cardiac viability prior to re\'ascubrization. Practical tips
Cardiac congenital heart detect Cardiac MR.I is a d~'namic test that requires assessment of
Cardiac tumours. cine inllges to make a subjecti\'e and objecti\'e assessment
Perieardialdiscasc. of1cfi \'enlricular function (ejection frnction ).
Canliomyopathics.
Further management
Assessing cardiac viability post 1l1~'ocardiaJ infarction is Coronary artery atherosclerotic disease is ch:lr,lCterized
important since re\'ascularization of li\'e tissue reduces using coronary angiography or corona!)' artery CT
morbidity and morraliry. Previously cardiac pcrfilsion was Patients with isehaemic but \'iable mYOi:ard iulll ma y be
assessed b~' cardiac nuclear medicine (lIHBG - Illeta- suitable for re\':lscularization with angioplasty or bypass
iooobenzylguanidinc [scintiscan }) stress resting but there is gl'Jfiing,
now an increased role for cardiac M ItI.
58
Chest Imaging Cases 31,32
:.ASE 31
Iis:ory
- ~ ~-old female patient prcscmcd
.:best pain.
tASE 32
ry
':'i-ycar-oJd Illale presented with
~ naftcrminortral1111a.
59
ANSWER 31
Observation s (31a) Discuss ion
This chest radiograph shows e\'idence of a pn:,'ious rigln '''ith breast cancer being such a common malisnan ~·.
llIastcctonw. !-lean :lIld mediastinal conrours are normal. complications will present frequemly on plain radiographs
No lung 3.b'llormaliry is seen. There is ditnlsc sclerosis of all so it is important to note :I mastectomy. Another 'tell tak'
visible bones, mOSt evident in Ihe ribs, Appearances arc of sign of pre\·iolts bre:lst cancer is the presence of a:;:illaTT
difli.Isc sclerotic mct:lSI":lSCS from a breast carcinoma primary. clips from node sampling.
The mastectomy may first be percei\'ed as a disparity
Diagnosis between the o"eral1 densities of the tWO hemithoraces..
"hstcctomy and sclerotic bone metastases, There arc many other causes for this, though sometimes
may not be e:ls), deciding which side is norm:ll.
Differential diagnosis
For causcs of unibtcraJ hypcrtr.lllsr.1dbncy: Practica l tips
• Chest wall abnormality - mastectomy, pecroral muscle In :lny c:lse with a history of breast cancer, the chcsr
atrophy (polio ) or absence (Pobnd's syndrome). radiograph should be scrutinized for features of recurrence.
Pleur-l1 almorm:tlit), - pncu1l1othor:lx, These ~lre classical "iva films for exams :lnd also presc
Lung abnormality - Swyer-James syndrome frequently in e"el)'ciay practice. Features to look fi
(consequence of bronchiolitis as a child resulting in a include:
hypoplastic lung with air tT:lpping on expiration ), Sclerotic/lytic bone metastases (31d ).
emphyscma, bulb!.', pulmon:ll)' embolus (3 I b ), Lung lllet~lstJses.
Lymph:lngitis C;J.rdnomafQsa.
For causes of unilater:tl hyperdensity: Pleural effusion.
Chest wall :lbnormalil)' - gynaecomastia (unilater:tl in A-.;illary lymphadenopathy.
40% of cases), breast impl:\l1I. Ri ght hemidiaphragm ele":ltion secondary to li,·er
• Pleural abnorm:llity - pleurJ.1 dfusion on supine film, metastases.
pleural thickening. • PUilllOnal)' pnelllllonitis/ ilbrosis from radiothcra~·
LUl\g abl\orma\it~, - ul\ilatera\ pu\mom.\}' oedema
from lying on one side (3 I c), consolidation, lobar Further management
collapse (especi:llly left upper lobe ). • In cases where clinical history and examin:ltion do
revcal an olwious cause lor the rdati,"c diftcrenccs
chest lucency - CT chest would be appropriate.
Isotope bone SCJn may ident"if)r distant bone
metastases.
31b There is a large central pulmonary embolus on 31c Unilateral pulmonary oedema with pleural
the right with marked reduction in vascula r markings effusion and airspace opacity on the right.
on this side.
60
An swers 31, 32 Chest Imaging
d Multiple poorly defined lytic lesions are seen

;;:TOug hout the ribs bilaterally .
SWER32
Observations (32a) Discussion
chest radiograph shows no ti.xallung abnormality and The most common cause of inferior rib notching is
rib fracture or pneumothorax from the recent trauma. coarctation of the aorta. This can be of [\vo types:
"e\"er, there is bilateral inferior rib notching involving • Preductal - the hypoplastic n~rro\\'ed segment is long
3rd- 8th ribs. The aortic knuckle is not well seen bllt These patients present in inf3ncy and early childhood
is no other mediastinal conto ur abnormality. The with congestive c~rdiac fJilurc. Prognosis is worse
..art is not cnl:lrgcd. There is no evidence of previous than lor those who present with t.he postduct"al type .
~Jiac surgery. No other specific bOlly or soft tissue I'ostductal - this Ilsuallv consists of a short narrowed
~rmaliticsarcsccl1. segment, immediately distal to the site of the
The most likely diagnosis is coarctation of the aorta - ligamentum arteno sulll (32b). Presentation is llsllally
p:nicnr's blood pressure should be checked in both in latef childhood, and is with hypertension,
and compared with that in the legs for confirmatory diftcrential blood pressures in the upper and lower
limbs and / or a heart IllUfmur.
( COIlt.)
:Jiagnosis
- 'or rib notching due to coarctation of the aorta.
- ere ntial diagnosis

inferior rib notching:
~\n:eriaJ :
Coarctation of the aorta .
• Subclavian obstruction after Blalock- Taussig shunt
fo r tetralogy of Fallot .
• \·cnous: SVC obstmction.

Arteriovenous malformations (AVlvl ).
:S-curogcnic, neurofibromatosis.
superior rib notching:

Rheumatoid arthritis, sckrodenna and SYSTemic lupus
crythcmarosus (SLE ).
H~~rparatbyroidism.
:S-curofibromatosis.
~larfu n's syndrome.
~uicti\'e IUllg disease. 32b Single angiographic im age shows postductal
stenosis of the descending thoracic aorta, with
postste notic dilatation.
On chest radiographs, the focal Il:J.ITowing of the aorta is When inferior rib nmching is noted check:
cbssically made more (vident because of pre- and The aortic comour for the 'figure of 3' sign.
posl'Stcnoric dilatation producing a classic ' tigure of 3' sign. Is therc evidence of previous repair, e.g.
Obscu ration orthe arch, as in this case, is also recognized. thoracotonw scar?
Ri b 1l00ching on the inferior surfucc of the 3rd-8th ribs can The hcart fo r e\'idence ofldi: ventricular
llsuall}, be seen in untrc:ltcd patients by 8 years. Rib hypertrophy, i.c. elevation of the apex .
notching occurs due [0 dilatation of the posterior Arc there features to indicate neurofibromatosis,
imcrcostal arteries, which act as collateral vessels. Since the e.g. cutaneous soft tisslle nodules?
1st and 2 nd posterior intercostal arteries arise from the When rib Ilmching is unilateral, suspect an aberrant
COsfoccl"l'ical trunk of subcbvian artery rather than $ulxla\'ian artery origin on the unaflected side.
descendi ng aorta, they do nOt form a collateral path and
hence do not cause rib erosion. Further ma nage ment
Coarctation of the :10m is associated with sc\'eral orher Surgical treatment for coarctation of the aorta in\,oh'es
congenital anomalies such as bicuspid aortic valve, patent resection and end to end anastomosis, prosthetic patch
ductus arteriosus (PDA), \'ctHricular septal dcfcC[ (VSD), graft, sulxlavian fbp aOrToplasry or balloon angioplasty.
tricuspid atrcsia and transposition of the gre;lt \·csscls. There
is also an association with Turner's syndrome.
Practica l t ips
When suspected from plain fi lms and clinical findings,
t.'IR or CT angiograph~' has now largely replaced
com'emional a n giograph~' as the next im'cstigatioll of
choice (3 2c).
32c A maximum intensity projection (MIP) image from an

MRA exam ination of the thoracic aorta.
62
SE 33
ory
38-year-old man was Ixing
tigatcd fo r transient neurological
".
CAS E 34
ory
51-year-old woman with oesophageal
er presented complaining of chest
63
Answers 33, 34 Chest Imaging
ANSWER 33
Observations (33a) Further management
There 3TC some incrc3.scd tubular sofi: tisslie dcnsitv Angiographic assessment and treatment with embolization
opJCitics in the right lower zone, suggcstiyc of abnormal or balloon occlusion is now the preferred management.
vessels, leading TO a faim pulmonary nodule. There is a
funhcr nodular opacity in the right lIplXT zone, again \Iith Further reading
Ihe suspicion of vessels running to it from the right hilum. Coley SC, Jackson JE ( 1998). Pulmonary arteriovenous
The left lung is CicJT and the mediastinal outline normal. maltormations. C/jIJicn/ Radi%gy 53(6): 396-404.
Given the clinical details, pulmonary ancrion:nous Pick A, Deschamps C, $tallSOIl AW ( 1999). Pulmonar)'
mallormations giving rise to paradoxical emboli and TIAs arteriovenous tistula: presentation, diagnosis, alld
l1msr be presumed. Contrast cllh:lllccd CT would confirm. treatment. World journal ofSllrgery 23( 11 ):
IIIS- II22.
Diagnosis
Pulmonary :lrtcrio\'cnOllS m3ltonm.tion (AVM ).
Single or multiple pulmon;uy nodules frOIll other causes.
Discussion
Pulmonary AVMs arc abnormal \'Jscular communications
between pulmonary arteries and \·eins (95%) or systemic
arteries and pulmon:lry veins. 1\10st commonl~', they arc of
the simple type, with :I single artery feeding :I focal
aneurysmal segment and a single dn)ining vein. Compkx
lesions ha\"e more than one artery and/or vein. Figure 33b
is a single angiographic image tll;lt demonstrates the large
feeding vessel to a solitary AVl'vl
Multiple pulmoll:lr)' AVMs may be associated with
Osler-Weber- Rcndu syndrome. They arc usuall~' asymp-
tomatic until the 3rd-4th decade when they can present
with local effects - haellloptysis, d)'spnoca on exertion and
cyanosis with clubbing (due to right LO lefi: shunt); or \\~lh
distal eflects - cerebrovascular accident (CVA ) or brain
abscess due TO paradoxical emboli. Lesions enlarge with
age.
Practical tips
The 'finger in glm·e' appearance from mucoid impaction 33b Single image from an angiographic
of cemfal ;lirways in allergic bronchopu lmonary asper- investigation demonstrating a large feeding
gillosis can look similar in some ways to the vessels vessel to the pulmonary AVM .
supplying an AVM. H owever, there is a nodule at the end
of these \·cssels in AVI'.,.\
ANSWER 34
Observations (34) Differential diagnosis
T his chc:st radiograph shows a normal sized heart and clear For causes of pneumomediastinul\J:
lungs. There is, however, c\·idcnce of air within the • Al,'eolar rupture in acute asthma.
mediastinum - best seen aTOund the leli heart border and • Oesophageal rupture due to malignancy, trauma,
aortic arch. Helow the medialldi: di;lphragm, a stent is just l"iolent vomiting ( Boerhaa\·..:>s syndrome - usually
about visibic across the gastro-ocsophageal junction. associated with a left sided pleural effusion).
It is likely that there has been oesophageal perforation Extension from peritoneum - pneumoperitoneum.
from the stemed oesophageal tumour Iatrogenic - following oesoph ageal balloon
dilatatioJl/stenting, bronchoscopy, ll1cdiastinoscopv.
Diagnosis positil·e pressure \'emiJalion. .
Pneumomediastinum from perforation of stented
oesophageal cancer.
64
Chest Imeging Case 35
• Look for an cffilsion to suggest oesophageal injury, or

n num is an uncommon condition that is oesophageal stem, as in this case .
m.nic but can present \I'ilh ncdcor ches!'
11 rarely leads to any complications bur it can Further manag ement
dUgnostic sign for an underlying medical Chcst CT after the patient has drunk some water-soluble
th.u does need trcarmen!. Although a ['an:: contraSt , o r a water-soluble contrast swallow, can confirm
_ ~iuhs, it is see n in children and masa an oesoph:ageal tear and leak and help to idcntif}' the site.
Further readi ng
Gcrazounis 1\.\, Arhanassiadi K, Kalantzi N, Mousr:m ias
M (2003 ). Spontaneous pneumomediastinum: a rare
benign entity. J01I'-"(I/ of711omcic alld Cnrdiol'aJw/flT
Surgery 126(3): 77~776.
tips
rlx' ribs for any sign of trauma.
lAX lung fields for a lesion that might hal·C
bronchoscopic/ surgical investigation.
4fr under the diap hragm to indicate
·toneum .
.old male presented to A& E

1'a:Urrenr acute-on -chronic
65
ANSWER 35
Obse rvations (3Sa) can have dire conscquences if an intercostal chest drain is
There is a large area of increased lucency in the right mid then mistakenl~' placed in the bulla! An expiratory fi lUl
and upper zone with no visible.:: lung markings. There is no makes a pneumothorax easier to de tect ( because it en-
visible lung edge, howeve r, to suggest this is a pneumo- hances the cont rast di ffe rem ial between pleural air and
thorax. Moreover, the re is crowding of"csscls in the lower lung parenchyma) but probably won't hel p resolve diag-
zone. The appearances arc likely ro indicate a large upper nostic confusion with a bulla. Patients with chronic lung
lobe bulla. There arc no focal pulmol131")' opacities to disease may well ha\'e pre\'ious filrns that show a bulla TO
indicate superadded infcClion . ComparisOI;I with an}' be longstanding.
;l\>;lilable old films should help confirm this interpretation.
A general reduction in density in the left uppe r zone Practi cal tips
suggcSlS rhal similar pathology is del'doping here tOO A pneumothorax leads to two findings: a visible lung edge
and hypodensity with absent lung markings ilteral to this
Diagnosis (35b). A bulla has absent lung markings but not the
Large right sided bulla. discre te lung edge. COIlI'ersciy, skin fo lds (seen mOST
freqlleml~' in babies and the elderly) can produce a pseudo
Discussion lung edge but the re \\~II be lung markings lateral to iT
A bulla is a large dila ted airspace within the hmg Witll a \\"JJl (35,).
less than I mill thick. They arc usuallY' produced byah'colar
dcstruction in "'mphyscUlII, Impaired ventilation ofrhe rest Further management
of the lung can result in dyspnoea, as well as that due to If diagnostic uncertainty continues after expert review of
rhe background chronic lung disease. the films, then occasionllly CT of the thorax may be
Confusion Cln lrise when the absence oflung mukings needed to diflerentiate bullae from pneumothorax.
leads to the erroneous diagnosis of pneumothorax. This
35b Image demonstrates a small pneumothorax 35c Chest radiog raph demonstrates a skin fold
with no lung markings lateral to the lung edge. giving an apparent lung edge but lung markings are
visible lateral to it.
66
Chest Imaging Case 36
. . . lib Sequential chest radiographs taken 4 months apart.
36c HRCT thorax of the same patient at a later dale.
6i
ANSWER 36
Observat io ns (36a, 36b, 36c) R:adiological features ofCF on a chest r.ldiograph arc:
This frontal chest rldiograph (36a ) demonstrates wide - Cystic/cylindrical bronchiectasis.
spreld, fairly symmetTicll lung plrcnchymll abnormality Peribronchial cuffing/thickening.
that is central in distribution and chnr.lo.:terized bv bronchial Mucous plugging with secondlry lte1cctlsis due to
\\'all thicken ing and cystic bronchiectatic chl;'ge, Some obstruction.
larger soft tissue density nodules arc seen in the lower • I-lilar lymphadenopafhy.
zones, which likely represent mucous plugs. Bibteral • Allergic bronchopul"lonaryilslX'rgil losis (ARPA).
lobull!ed hibr enbrgement is seen with the right sided
Ir mphadenopathy being more evident. Appearances arc of Respiratory complications or CF include pneumothorax.
cystic fibrosis. haemopt)'sis and cor pulmonale. Chronic pulmonary
Chest radiogrlph (36b) from the same plticnr t:l.ken at infecrion can lead to hypertrophic pulmonary osteo-
a latcr date demonSlrat"es more ad\'anced disease with more arthropathy ( H POA ).
mucous plugging and hyperinfbtcd lungs secondary to air • Cystic fibrosis is a multisystem disease: as wdl as causing
trapping. Peribronehill culling and thickencd 1.1Ontapering ~ meconium ileus (in, chi ldre n ) and meconium ileus
bronchi arc e\'idem. A right subclal'i;lIl central hne is noted, e(luivalent (in adults), It Clll also callse pancreatic insuffici-
presumabl}' for the administration of IV antibiotics, eney, biliary cirrhosis, portal hypel'lension, malabsorption
A c r image (36e) of the chest on lung windows shows due to gallbladder disease, cholelithiasis lnd dubbing
typical reatures o f CF with cylindrical brollchie([asis and a (36d).
central distribution, peribronchial euning. mucous plugging
:and lOCal :nclectasis. It also shows the most common Practica l tips
complic:ation of:a pneumothorax on the lci't side. • Typical presentation is of\\;despread pulmonary
disease in a young patient.
Di ag nosis • Tunnelled cenrrallines in patient's arc used for long
Cystic fibrosis (CF). term drllg treatment with antibiotics or ":i-
chemotherapy. Again this is a clue 1'0 the underlying
Di scussio n diagnosis,
Cystic fibrosis is an :autosolll:ll recessi\'e Illultisystem Look for complicltions ofCF - pneumothoraces and
condition that is chlrl(terized by exocrinr gbnd secondary infections.
dysrunction due to mucous plugging arising sccondlry to a Though nor a common site, I-I POA Clll occur in the
fuull in rell chloride transport. The condition aHects whites humerus and may thus be visible on the edge ofthr
with a geographical distribution :affecting Europeans and film.
Ashken:azi Jews. Di:agnosis is usually made in children, \\;th
the majority being diagnosed within the first year of life Fu rt her ma nage me nt
with the clinical presentation of meconium ileus and Follow-up in these patients is bc5t lX'rformed with HRCf
respiratory symptoms. Pulmonary complic:ations are the which can answer the important quest ions when lunf
predom inant cause of de:ath and sun'ival is limited to transplant is considered - is there coexistent Aspergill
-30-40 rears. infection? Arc there complicating felttlTeS, e.g. pneurrx
thomces?
36c HRCT thorax of the same patient at a later 36d Sing le axial CT image
date. d emonstrates significant splenomegaly
due to portal hypertension and
pancreatic calcificatio n secondary to
recurrent bouts of acute pancreatitis.
68
Chest Imaging Case 37
- rar-old IV d rug use r presented with cough and

rtncss ofbrcarh. He is nored to be signific:lOtly
- on prescluation. This series of chest radiographs
n at presentation, day 3 and day 7.
69
ANSWER 37
Observations (37a, 37b, 37e) Complications of PC P arc common, e.g- pneumothorax
The firs t chest film taken at presentation (373) shows no and superimposed TB/fungal infections.
obvious radiologic:tl 3bnorm3lity. The next radiograph Appearances on CT include a patchy mosaic/'ground
from 3 days later (37b) shows bilateral mid and lower zone glass' pattern with subsegmental sparing and coexistent
rcricu!ar/gr:lIlular inrcrstitial infiltrate with no evidence of thin walled cyStS and pneumatoceles. Appearance of
volume loss. The third film trom 7 days after presentation nodules on CT imaging is suggestive of a second disease
(3 7c) shows bilateral consolidarjvc change affecting both process being involved - metastases, l)'mphoma, septic
lungs. There is :J. pneumothorax on the left with subtotal emboli or Kaposi's sarcoma.
collapse of the left lung. Surgical emphysema is noted. Bilateral gallium uptake is seen prior to radiological
It is notable that the patiellt was initially vcry changes being evident.
symptomatic with a relatively normal chest film and then
showed rapid pulmonary changes over several days. The Practical tips
history of IV dmg abuse raises the possibility of background A strong index of suspicion for PCP should be maintained
HIV infection and the sequence of radiological appearances when an immunocompromised patient presents with
is typical for Pllwllloeystis e""illii pneumonia. dyspnoea. As in this case, symptoms can be OLit of
proportion to the initial radiographic changes.
Diagnosis
Pncumocystis carinii pneumonia (PCP). Further management
Diagnosis is confirmed with sputum cytology or
Discussion bronchoscopy and lavage. Treatment is with IV co-
P. carillii pneumonia is the mOSt common cause of trimoxazole.
interstitial pneumonia in immullocompromised patients
Radiological find ings can be very variable but the typical Further reading
pattern of development is as follows: Kuhlman JE, Kavum M, Fishman E K, Siegelman $S
• Normal chest radiograph is seen in up to 40% of ( 1990 ). PIIClllI/oeystis carinii pnellmonia: spectrum o f
patients, especially carlyon in the infection. parenchymal CT findings. Radiology 175: 7 11 -7 14.
Bilateral diffuse perihilar airspace/granular/reticular
opacities is the typical appearance.
Progression to diffuse airspace consolidation with air
bronchograms.
Pleural effusions arc seen in -20% of cases.
Response to treatment occurs over a period of - 1
week
Atypical features (seen in - 5%) include upper lobe thin
and thick walled cysts, IUllg nodules, mediastinal and
hilar lymphadenopathy.
Treatment with aerosolized pentamidine alone results
in the d isease af1ccting upper lobes.
70
Chapter 2
ABDOMINAL IMAGING
IN ABDOMINAL RADIOGRAPHS
ays, a s)'Stcmltic approach is required to be able to forget 10 check for bowel loops extending be low the < '-\
:t lhc mOSt information from a radiograph. T he order inguinal ligament indicative of hernia.
• led is a guide and should be adapted to your own Exclude bowel dilatation and wallthiekening. If there
lliettnccs and adjusted for each individual case. is dilatation, decide whether it is small or large bowel and
then try to cst:l.blish the 'cut ·oW point. wter ClSCS illustrate
- era l assessment specific features to check for when one suspeCtS small o r
r assess the qu:..ti t)' or the film, ensuring that there large bowel obstruction .
.kquarc cQ\'cragc - arc the hernial orifices cQ\'cred in
p.uicm who appears to h:wc small bowel oOOmtetian? Soft tissue organs
..dtition, make a quick assessment of the film to exclude Check the size and outline of the liver, spleen and kidnq'S.
important di:tgnoses that arc surgical emergencies and Also check the psoas outlines whic h ma ~' be obscured by ~'\.,
rt'qui rc immediate management: retroperitoneal pathology .
• PtttOration.
• Tone Illcgacolol.l , Calcification
Look at the rest of the film for calcified densities such as
es gallstones ( onl~' 5- 10% visible on plain radiographs) and
ufy any lines that arc present, e.g. postsurgical dnins, renal tract calculi (80-85% "isiblc on plain radiographs).
tu bes, urill:!r)' catheters and peritoneal dialysis Common incidental calciftc opacitics include mesenteric
ters. The pre$Cnce of peritOnea! dialysis catheters or nodes, phleboliths , ,·ascular calcification and uterine
rgical drains may offer a simple explanation for free fibroids. Calcification within the solid Ofb':lns may be more
.a.pcriwneal gas. significant howeve r. Unusual calcified opacities may allow
fOf a specific diagnosis such as a pelvic dermoid.
Gas pattern
erentiating sma ll from large bowel is \'ery difficult in Bones
ng chi ldren and one can usually only say whedler a Assess thc bones of the ve rtebral column and pe lvis fo r
k m is in d ll: pro.~i mal or distal bowel. In adults, incidental pathology or findings that might be rclc\'ant to
raures uscd to distinguish the two include position in the intra· abdominal disease s uch as sacroiliac joint changes
o men; d iameter (I:uge bowel <5 cm, small bowel <3 associated with inflammatory bowel disease.
; \'alvube conni\'t:ntcs travcrse the whole \\~dth of small
1::1 but this is nor so with the colonic haustralions; solid Periphery of the film
es onl\' scen in colon. Conclude by looking at peripheral stmcmrcs. For example,
The ra~ge of ' nor mal' bowd gas pattems is rather wide, patholog), at the lung bases that might mimic abdominal
t from experience, o ne should quickly know whether patholoID', incident:l.llcsions in the abdominal wall.
amount and dist ribution of bowel gas arc. \·cry
ormal. Unusually shaped collections of g:liS (e.g.
~ngular ) should raise suspicion of gas outside the GI ABDOMINAL CT
:no- and lead rou to examine thc area very dosely. Check The first qucstion to ask yourself when looking at all
.:Mefully for gas in areas of the abdomen where it is not abdominal cris what type of comrasr has the patient been
wormally seen, e.g. o\'er the liver (either as pockets of g3S gh'en, i.e. oral/IV/ both and during what phase has
'JI"\\;thin the biliary tree ) or in the relroperiwncum. Don't imaging been carried Out. T he typical phase for abdominal
71
Abc!ominal Imaging
imaging is portal-\'enous (60-70 seconds delay) bur other Pancreas - check lor calcification; the state of the
phases, e.g. pre-contrast, :mcrial, delayed, arc useful in pancreatic duct, pcripancreatic collections and
characterizing spedfic lesions. infl:lnlmatofY changes.
Axial im::agcs will commonly be presented and you can Spleen - check sizc and adjacent \'::Irices.
proceed in one of two ways - either :lSSCSS all stmctures on Kidneys - is the :menuation orthe kidneys correct for
each ax ial image then proceed to the next image, or, that phase of scan? Is there:: collecting s~'Stem
alternatively, assess each org:m in mm o\'er a series of slices dilamtion? Check the adrenals abo\'e.
before moving on to the next organ. in rcalit... , a
combination of the tWO is often used but the J:mcr ensures Then systematically evaluate the non·solid organs:
nothing is missed. • Aorta - as well as o\'erall size, du:ck for dissection and
As well as searching for tOcal lcsions within the organs, patency of main branches. Check major venous
other feature s to check include the fo llowing: patency at the same time, excluding deep vein
• Li\'cr: thrombus.
O verall attenuation (e.g. reduced in fatty change) Bladder, ovaries/ut erus.
and enhancement homogeneity. Lymphadenopathy.
Size :Illd comour (e.g. irregular contour in Intra -abdomi nal fat - peritoneal soft tisslle deposits
cirrhosis). arc easily overlooked unless the abdominal fur is
Patency of normal vascul::lrstrucrures. careful!vscrulinized.
$mte of intrahepatic bile ductS. Colon, 'ileum and stomach.
Gallbladder - check for stolles, the density ofbilc, Free gas/flui d.
wall thickening and perieholecystic fluid. Carefully Bones and lung bases.
assess the extrahepatic bile ducts.
72
Abdominal Imaging Cases 38, 39
- :car-old male presented with a

of gradually progressive
.,.
SE 39
ory
- -year-old female presellted with
bkcding.
73
GENERAL
INTRODUCTION
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Th. 'Aunt M'nn'. · Ih' ...... ;m' • ""it.o/ """",~ I... I<"n' ""'" book>. T" do
Th,,, ." .. ",in " ... "J,~ 'h" h.,·•• <h""""i>,,, ,hi>. )"" "''''' u" .11 <I"" ,,',~.bk r~"" tI", <Iin~"
"f'!""''''''' "" ""...... ~ , /W .uo... 0." '~IllO" .. " in,"n' hoto<y ,,,J [,I ... ,m J <"",b ...,hi, inro,,~""'" ~l, h
',...~ d~"";'· . I, ~·~I boo ........ ,~ ,I>< <.. >01;';,,, hlo "'""' ,,",'~kJ~, uf ,II< ""'''',"« ,of ,,' " ,...,.it>iJ ; ,~. ;., • ,o>< n
,h., 'he boo" r"r""''''''
.. ,"" i, t.<['-"<. ",J 1>< .. " r"" n' """" I"",n .
,
Answer 38 Abdominal Imaging
ANSWER 38
Observations 138a) Practical tips
Single AP image from a double cammst barium swallow Previous CXRs call ~ useful in identifying a cause for a
examination shows a short, smoothly i.lpcrcd narrowing stricture - look for a tlll110UT that might have been
in rhe lower ocsoph<lgus juSt superior to the gastro- irradiated or fratures of aspiration pneumonia/hiatus
oesophageal junction and a small hiatus hernia. The hernia.
OCsoph3guS proximal to rhis h:l.S delicate tr,Ulswrse mucosal
folds, the so-called fcline oesophagus. This 3.ppe31"311CC is Furth er management
35S0Ciatcd with gastro-ocsophagcal rdlux and leads to the GastrOenterology referral \\~th a view to direct \;sualization
conclusion that the shon stricrun: is a peptic stricmrc. and confirmation of diagnosis with endoscopy,
Di ag nosis Further reading

Peptic stricture fcline oesophagus. Luedtke P, Lc\-illc MS, Rubcsin SE, tt nl. (2003 ).
R.,diologic diagnosis ofbcnign esophageal strictures:
Differential diagnosi s a paltern approach. RadioGrnplJics 23: 897-909.
For oesophageal strictures:
• Lower oesophagus:
Peptic stricture secondary to gastro-oesophageal
renux,
Scleroderma - aflccted patients have an
incompetent lower oesophageal sphincter and
reduced pcrisl::Ilsis resulting in marked gastro-
oesophageal reflux.
NG intubation - pre\'cnrs'closure orthc lower
oesophageal sphincter.
Zollinger-Ellison syndrome_
Upper and mid oesophagus:

Harrett oesophagus - acquired condition
characterized b)' columnar Illel::lplasia secondary to
chronic gasrro-oesophageal rcflux/ oesophagitis.
Prcmalignam condition with an increased risk of
adenoearcinoma of the oesophagus.
Caustic ingestion - usually long, smooth
narrowing forms 1-3 months l)Osl ingestion.
Mediastinal rJdiOtherap), - usuaJJy long, smooth
narrowing forms 4-8 momhs post radiotherapy.
Skin diseases - epidermolysis bullosa, pemphigoid,
ery thema multi forme.
Other less common causes of strictures include Crohn's

disease, Candidn oesophagitis and Behr;el's disease.
Discussio n
Peptic strictures have this typical appearance of short (1-4
cm), smooth, tapered, concentric narrowing in the IOll'er
oesophagus. Associated radiological findings include
intramural pscudodi\'eniculosis (38b) and feline oesopha-
gus (so called occause this is the normal appearance in
cats). Longitudinal scarring can cause fixed [ranS\'ersc folds
but these can be diflerentiatcd from fcline oesophagus
sincc lhe), arc only seen in the region of the strictur;: and
do not extend more than half way ac ross the oesophagus,
giving a 'step bddcr' appearance.
38b Contrast barium swallow shows flask shaped

outpouchings with a narrow neck of intramural
pseudodiverticulosis.
74
swer 39 Abdominal Imaging Case 40
rvations (39) Di agnosis can be made with selective mesenteric

image from a mesen teric angiogram examination angiography or CT angiography. Both arc :a ble to idcnrif)'
an abnormal duster ofvcssds and contrast 'blush' bleeding when the rate is as little as I mljmin. Three levels
of abnormalit\, afC identified:
In carly disease, a densel)' contrast filled dilated \'ein is
seen within the bowel wall.
As the disease progresses, a vascular tuft can be seen
at the lesion site.
Fmther progression shows an early filling vein during
the arterial phase of scanning.
;vlcsenteric angiography has the adv,lntage of proceeding

directly to treatment with embolization. '1. ,
Practical tips y-r ;

J
CT is exce.Hem at ider.1tit~'ing the bleeding point when "\V;
there is actIve GI blcedll1g. Always perform a pre -contrast f
_ ysplasia is the most common cause of occult scan prior to the arterial phase scan so that high-
"ng in the large bowd, predominantly aflCcting the contrast intraluminal blood can be diftcrentiated from
y population. The condition is characterized by high -contrasT bowel tOad content/debris.
ar ectasia of the colonic circulation, most commonly
- :ring rhe caecum and ascending colon. The condition Further management
to chronic low-gr3dc blood loss but can also lead to Surgical resection is the definitive treatment when
cs of severe lower G I bleeding. There is an associa- endoscopic treatments have not controlled bleeding.
\\ith valvular heart disease, specifically aortic stenosis
SE 40
ory
35-year-old farmer presented with
ache in the right upper abdomen
sc...cralmonths.
75
ANSWER 40
Observations (40a) There is a predilection lor the lower lobes and disease is
There is a large, well defined lesion in the right upper Illore cOlllmonly seen on the right. CySts arc multiple in
quadr:l!ll, which has thin, curvilinear calcification of its wall. 2~ and bilateral in 2~ of cases. Figure 40b shows several
This is projected over the li,'cr and is probably inrrahcp3tic, left sided, well defined round intrapulmonary lesions.
though a calcified gallbladder cannot be excluded from this Calcification is rare. When air infiltrates between the layers
film. This is a solitary lesion with no orher abnormality of the cySt wall it can give the appearance of:a 'meniscus'
seen. Gi\'cn the appearances and paticnI's young 19C and sign, 'onion peel' sign and fin:atly thc 'watcr lily' sign, when
occupation, a hydatid q'Sl of the li\'cr is most likely. Funhcr there is complete separation of the endocyst from the
imaging with CT would help confirm the location of the pericysr. Rupture of the cySt can result in surrounding
lesion and the likcl~' diagnosis. Serological tests for hydatid consolidation.
disease should also be undertaken.
Practical tips
Diagnosis • Benign liver cysts afe common, but all cySts should be
Hydatid disease. closely inspected lor atypical features, e.g.
h)'l)cTattenllating wall Of wall calcification suggestive
Differential diagnosis of abscess/hydatid; poorly dcfined edgcs, which may
Ofca1citicd Ji\'crlcsion: suggest the lesion is in fact a metastasis.
Metastasis - especially colorcctal cancer. Cystic lesions involving lil"Cr and lungs should suggest
• Primaryli\'crlUmOl1T. infectivc/malignant underlying diagnosis until proven
• In fection - hydatid, TB. otherl\"ise.
Discussion Further management

Hyd~tid disease is ac~uired through infection by the )\bnagement can be cither medical (t\\"o benzimidazoles
parasitic tapeworm EcJllllO,o'CIIsgr(lllllloSlls. Dogs are the arc commonly used, albcndazole and mcbend:azolc) or
definite host with the human acting as an accidental host surgical (cystectomy or partial organ resection).
following lcddental ingestion of eggs from canine faeces.
The li,·er is the mOSt commonly im·oln:d organ and Further reading
presentation is with abdominal pain, jllllldice, bilia~' colic Pedrosa I, Saiz A, Arrazola 1, It nl. (2000). Hydatid
with eosinophilia in 20-50%. disease: radiologic and pathologic features and
In the lil'er, inlection results in the fomlltion ofa cyst, complications. RndioGrnphics 20: 795-817.
which is more commonly found in thc right lobe; the size Polat P, Kantard M, Alper F, It nl. (2003 ). Hydatid
of the cyst ranges up to 50 Clll bur is - 5 em on average and disease frolll head to toc. R..ndioGrnplJicJ 23:
mu lt iple in 20% of cases. The cyst is composed of three 475-494.
layers - the Outer pericyst, middle laminated ectocyst and
the inner endocyst.
Radiological features ;lfe:
Variable appearance ranging frOIll a simple unilocular
cyst to a complex hct"Cfogclleolls cystic mass.
D:lIlghtcr cysts arc char;lCterislic bllt arc a r;1re finding
Their presence is noted by a 'racemose' appearance.
Initially <hmghter cyStS arc \\'ell defined and round and
aTe seen at tile periphery of the mother cystS. They
progress to !orm large, irregular shaped cysts filling
the Illother cysl.
Can also contain debris (hyd.1tid sand), internal
septations and wall calcification.
• Calcification is seen in 20- 30% of hydatid cyStS and is
usua ll ~' cUrI·ilinear or ring like. Dense calcification is
seen as the e,·st Start.s to heal.
• On cr, the appearance is of a l~'st \\'ith a high
attenuation wall on Ilncnhanccd CT cvcn without
calcification.
• ,\·IRI appearance is of a cyst with a low signal rim.
• On C f /MRI!, thc wall and septac enhance with
contrast, which can aid in the diflercntiation betwecn
hydatid cyst and a simple liver cyst.
Complications arc of cySt rupture (50- 90% of cases) and

infection. 40b Patient with pulmonary hydatid presented with
The lun gs arc th e second most common site of several large. well defined nodules in the left lung
involvement in adu lts and the mOSt common in children. with no calcification.
76
Abdominal Imaging Case 41
CASE 41
History
.\ 67-year-old, o\'crwcight female
p,nicnt, with no past medical history,
pr('scnrcd with \'ague abdominal pain,
nausea and \·ol1li[lng.
77
ANSWER 41
Observations (41a, 41b) calcilication. An axial CT scan of the abdomen (41 e
AI' :abdominal radiograph shows distended loops of gas- conlimled a gallstone ilcus \\;th a 5 em diameter laminated
filled small bowd but absent colonic gas. TogClhcr with gallstone found in the distal ileum. The bowel was
the clinical history, appearances 3fC consistent with small collapsed disral to rhe site of stone impaClion. At
bowel obstruction. There is no evidence of free gas on laparotomy, the stonc was milked back to thc jcjunum and
these films but on the second image there is an abnormal rcmo\·cd.
collection of air o\'er the ce!Urnl liver that has a somewhat
li near/branching configuration. T his is consistent with air Practical tips
in the biliary tree. In the right side of pelvis, there is a Always check for air in the biliary tree on the small
round opacity showing peripheral calcification - this is likely bowd obstruction :lbdominal film .
to ind icate an obstructing gJ.llstone. • Tilly loculcs of air in the biliary tree tend to be
ccntl':llly located in the li\'(r (4Id ) compared with
Di agnosis porral \'ein gas, which is seen in the periphery.
Gallstone ilcus. • Bili::!')' tree gas can also be seen as a normal finding in
paticlll~ who hal'l.: had a previous sphincterotomy or
Discussion [allowing a recent ERe I' (end oscopic rctrogrndc
Gallstolle ileus is rchlti\'ely rare, accounting for 1-2% of all cholangiopancrcatography),
mcch;mic;ll obstructions (though more in the elderly). The
most common scenario is of a stone eroding through from Further management
gallbladder to duodenum - the cholecysroduodenal fistula 1\ lcchanic;rl Sl11all bowel obstruclion is a sm gic&..
leads to pneumobi lia and the Stone then impacts in the emergency.
Slllall bowel. T he fistula can also be !Tom the comOlon duct,
and can enend to thc colon or stomach instead of the small Further reading
bowel. Gurlcrik G, Gurlcyik E (2001 ). GallstOne ilclls:
Occasionally, the diagnosis can be made on plain films demographic and clinical criteria sllpponing
\\;th Rigler's triad t>f small bowcl obstruction, pneumobilia preopcrati\'e diagnosis. UJI/S TrnJ'lIIn Derg 7 ( 1):
and ectopic gallstOnes. Oncn, however, the gallstone is nor 32- 34.
seen on plain film since rhe stoncs frequently have a Pangan JC, Estrada R, Rosales R ( 1984).
predominant composition of cholcsterol with little Cholecystoduodenocolic fistula with recurrent
gallstone ilcus. ArciJjJ'eJo/Surgery 11 9: 1201 - 1203.
78
ry
n;:ar-old male is admitted with
-encephalopathy.
- SE43
ory
llymptomatic 22 -),c;1r-old male
nrcd w ith deTerioraTin g renal
:rion
79
Answers 42, 43 Abdominal Imaging
ANSWER 42
Observations 142) to IVC/hcp;uic vein/splenic vein thrombosis or
Image from a double contrast barium meal examination obstruction.
shows multiple serpiginous filling defects in the lower Downhill \'ariccs (found in the mid and uppe r
oesophagus. Normal appearances of the g,tstric nmdus arc oesophagus); these arc characterized by coll:ncral
observed. Appcar:lllccs arc consistent with oesophageal blood flow from the SVC \'ia the :azygous vein into
varices and the distribution suggests that these arc 'uphill'. the IVe, and arise due to SVC obstruction from
conditions such as IUllg tumour, lymphoma and
Diagnosis rc[rasternal goi tre.
Ocsoph:agcal varices.
Gastric varices arc secn in combination with oesophageal
Differential diagnosis "arices in patients with portal hypertension. When seen.tn
Fo r ocsophagcal ,·ariees: the absence of oesophageal "arices, splenic vein thrombosis
• Varicoid carcinoma of oesophagus. should be suspected. Again, appearances arc of smooth.
serpiginous or grape -like filling defects; most commonl~
For gastric variccs (i.c. CJUSCS of thickened gastric folds): seen in the gastric fundus.
• Hypenrophie gastritis.
Mcnctrier'sdiseasc. Practical tips
• Lymphoma. Best images arc obtained with thc patient in a prone
• Splenic \'cin thrombosis, position,
Further investigation with an ultrasound of the
Discussion abdomen should be advised to look for cirrhosis and
Oesophageal ,'a rices ha,'e a ,'cry typical appearancc o n portal hypcrtension.
contr;lst sw:tllow examination of dilated, smooth,
se rpiginous filling defects. Varices collapse in the creer Further management
position and are beSt imaged with the patient pronto Thcre Treatment is aimed at controlling poml hrpcrtension \Vim
arc two types: medical and surgical (transjugular intrahcp:ttic
• Uphill "arices (found in the lower oesophagus); these ponosy~temic shunt - T IPS) means. Treatment of bleeding
are charanerizcd by collatcral blood flow from the ":trices and preemptive treatment of non bleeding varices is
portal vein vb the azygous "ein to the superior \"ena achie,-cd with endoscopic banding and sclerotherapy.
cava (SVC ). These arise due to liver cirrhosis and duc
ANSWER 43
Observations (43) Renal papill:t!), necrosis.
This pl:lin abdominal radiograph shows multiple small foci Hypelyir:Jminosis D,
of calcification over both renal areas in thc region of the Milk-alkali syndrome,
rCIl:J1 medulla rather than ren:J1 cort·ex. No stones arc seen M:Jlignancy - bone metastases, multiple myeloma,
elsewhere along the course of the renal tracrs. p:trnneopiastic syndrome.
Primary hypcroxaluria,
Diagnosis
Rell:J1 medullary llephrocalcinosis. Practi cal tips
• The most common causcs of symmetrical medullary
Discussion nephrocalcinosis are hyperparathyroidism and RTl'..
Mcdullary nephroc:Jlcinosis represcnrs calcific:Jrion in the • T he most common cause of asymmetrical medullary
distal con\'oluted tubules, i.e. in the renal pyramids, There nephrocalci nosis is medulla!)' sponge kidney".
arc m:Jny causcs :tnd the underlying pathology can rarely
be determined on a plain rndiograph - clinical history is fur Furth er manage ment
more important here. Underlying causc must be identified - particubrly tre:ttJbk
Tlte C:JlISCS arc:
Renal tubular :Jcidosis ( RTA ),
Endocrine causes - hyperparathyroidism, Furth er readi ng
hyperthyroidism, C ushing's. Dyer RB, Chen MY, Zagona RJ ( 1998 ). Abnorm:tl
Medulla!)· sponge k.idne~' . calcifications in the urina!)' trnct. RadioGraphies 18:
Idiopathic hypercalcuna, 1405~ 1 424.
80
E 45
ry
·n=Jr-old male presented with
dial bloating.
81
ANSWER 44
Observations (44) Clinical presentation can be with:
This is a single A I' image from a double contrast small • Pol)'hydramnios - i'l utero.
bowel barium examination. T here is focal, eccentric • Persistent vomiting, "double bubble' - in neonates.
n:lrrowing of the second part of the duodenum, with • :-J:lUsca ~ ,'omiting and abdominal pain - in adults.
predominant notching of rhe latc",! wall. Appearances of
the duodell um superior and inferior to this arc completely The condition is complicated by 311 increased incidence 01
normal. acute and chronic p3ncreatitis 3nd periampullary I"P';; ' J
ulcer.
Diagnosis
Ann ular pancreas. Practical tips
Crtrcfully examine the fi lm for g:lllstones or sma ll
Differential diagnosis fe;)tu res of cocli3c disease (small bowel
For 3.nnubr pancreas: flocculation of contrast , featureless smooth small
• Sphincter orOddi oedema (secondary to impacted IUlllen/ folds, jeju nization of ileal loops and
none or pallcrc3tilis)/carcinoma - usually produces an peristalsis) to suggest :lI101her diagnosis.
eccentric lesion but this is prcdominantl~' medially
located. Further management
• Duodenal ade nocarcinoma - usually presems with an · cr \\ill confiml pancreatic tissue encircling the
annular concemric I<:sion \\;th shouldering and duodenum.
utccr:ltion. There is an association \\~th G:lrdncr ~ • ERCP (endoscopic retrograde
syndrome and coeliac d isca~. cholangiopanereatography) or I'vt RCP (magnetic
resonance cholangiopancre3togr:lphy) shows a
Discussion nomlally located main pancre3tic duct in the body 01·
Annular pancreas is a disOrder characterized by fuilure of the pancreas, :lIld 3 small duct in the head or the
rotation of the ventral bud of the pancreas resulting in pancreas encircling the duodenum.
pancreatic tissue encircling the duodenum. TIll: sccond pan
of the duodenum is inmh'ed in 85% of cases, Usually Further reading
patients are asymptomatic, but the condition can preSCn! Rizzo RJ, Szucs RA, Turner MA ( 1995 ). Congenital
at any age , with 48% of cases presenting in adulthood. abnormalities of the pancreas and biliary tree in
There is an association with other congenital abnormalities adults. l{nnioGmplJiu 15( 1 ): 49-68.
when the condition presents in chi ldhood - tracheo-
oesophageal atrcsi:l, duodenal atresia, irnperfor:ne anus,
Down 's syndrome.
ANSWER 45
Observations (45a) Discussio n
Single image from a percutaneous chol3ngiogram is shol\1l. Prim3!,)' sclerosing cholangi tis is a progressil·e fibr·",...
The percutaneous needle is seen with the tip in a proximal inflammatory condition 3fTecting both intrahepalic
intrahepatic bili3ry duct. There is clcar abnormalit), of the enrahepatic bile ducts. The condition is strongly as"""·,,,_
commo n d uct, which has several strictures with duc t with inflammatory bowel dise3se (ulecratil·c colitis [l"
dilatation and bead ing. No filling defects arc seen to round in 70%, Crohn's in 15%). Other assocbtions i'",""K
indic3te gallstones. Contrast is scen in the duodenum with re trope ritoncal and mediastinal fibrosis, chronic a
no obstnlcting lesion scen at the lel'cI ofthc sphincter of hepatitis, Riedel's thyroiditis, p3ncrcaritis and Sjogn=fl
Oddi. s)'ndrome.frescntal"ion is Wilh progressive fatigue, ,,"".
and jaundice . Biochemical changes :tn: round with clC"I
Diagnosis SCrulll bilinrbin and alkaline phosphatase.
Primary sclerosing cholangitis ( PSC). • Im3ging feat\rres on cholangiogi.lphy
(MRC P/ ERC P ): there arc mtrhifocal strictures
Differential diagnosis ' aflccting intra- and extra hepatic bile ducts wilh s~
For PSC: lesions. The classic p311em is or 3 'beaded' appe""...
• Sclerosing cholangiocarcinoma. with alternating segments of ste nosis and dilat":ltia.
• Acute ascending cholangitis. ( 45b),
• Bile duet carci noma - this G ill ran:I)' inl'oll'e the bili;u)' • Im3ging features on CT: ducts have the 3ppcaran.x
system in a difruse maImer producing multiple 1l1mour strictures, dilat;ltion, belding 3nd pruning.
stric1l1res. • Imaging on US: usually normal but may show d ua
1\';111 thickening,
82
•
of PSC include:
ma nagement
curative treatment for this condition is Ih'cr
rion. Medical palliath'c care in\,oh'cs treatment
toms of cirrhosis, parmi hypcrtension, chronic
(pruritus and malabsorption ) and ductal
ns such as strictures and ascending cholangitis.
'pHnary approach is therefore adopted requiring
"'gists, transplant surgeons and inrcn'cntional
45b Single image from an ERCP examination

showing multiple strictures with poststenotic
dilatation gi ... ing a beaded appearance.
- euoold male presented with

..n.aJ pain and vomiting.
83
ANSWER 46
Observations (46a ) vake and call usually be differentiated from sigmoid
This plain abdominal radiogr.lph shows a large, ahaustral volvulus bvsc\'eral teatures:
gas~fillcd viscus arising fi-om the left side of the pelvis :llld Caecal ~'olvulus usually occurs in a younger agt~
extending into the upper abdolllen. The loop is projected group: 30- 50 years
OWf the left side of pelvis and descending colon with its Dilated obstructed caecum often dilates to fill the left
apex under the left hcmidiaphragm. The medial walls of upper quadrant (although in many cases \'ertical
rhe loop form a sumrmuion line. There arc sc\'cral dilated rotation occurs with caecum still filling the right iliac
loops of descending colol1 cvidem with absence of g.ts in fossa ). The main axis will be opposite that of sigmoid
the rectum. The features an: typical of sigmoid volvulus and \'oh'ulus howe\'er, eXTending from the right iliac fossa
there is no frc.c intflpcritoncal gas seen to indic,Hc towards the left upper quadranL
pcrfor:uion. Some haustral markings arc still el'ident, un!ike
sigmoid \'okulus .
Diagnosis • There mav well be small bowel dilatation bUT lhe rcst
Sigmoid volvulus. of the colon will be undilated, unlike sigmoid
\'okulus,
For brgc bowel obstruction: Further management
• Colonic malignancy. Urgent surgical referral with a \'iew to insertion of a !latus
Inflammatory strictures: Crohn's, ischaemia, tube to decompress the bowel.
divcnicujiris.
Voll'lllus. Further reading
Infectious processes; TB, amocbiasis. Burrel! HC, Baker OM, Wardrop P, EvansAJ ( 1994).
Extrinsic lesions: abscqs, bJadder/prostate/merine Signiticant plain tilm findings in sigmoid \'olvulus.
tul~lour, endometriosis. CiiJlicnl Rndiolo,9.1' 4 9 : 317- 319.
Discussion
Volvulus account for - 10% of Jarge bowel obstructions in
the UK, the most common type being sigmoid volvulus
This occurs more commonl)' in the elderly. The twisting of
the sigmoid colon on its mesenteric axis is USU;\t!y a chronic
problem with supcrimposed acute episodes, and represents
a closed loop obstruction. Radiologically, the features arc
of large bowel obstruction with a markedly dilared loop of
colon seen arising from the left iliac fossa. The I'okulus is
characterized by an ahaustral inverted V-shaped loop of
colon. The media] walls produce a summ;uion line and
together with the lines ofthc lateral walls create the classic
'coffee bean' appearance. Se\'cral radiological features have
been doculllented as typical , though the most specific arc:
• Apex of the loop under the left hemidiaphragm.
Inferior convergence of the loop in the left side of the
pelvis - the main axis of the loop therefore eXTends
from left iliac fossa towards right upper quadrant.
'Left flank O\·erlap' sign - loop overlaps descending
colon,
Medial wall summation line.
Other features described include 'li\'er ovcrlap' and 'pckic

overlap' signs (where the loop overlaps li\'er and lefT iliac
bone, respectively); apex ofloop above T! 0; an air to fluid
ratio >2: 1.
Diagnostic confusion can be resolved with a barium
enema examination. This demonstrates a smooth, Tapered
beak-like end of the barium column termed the 'bini's
beak' sign. Treatment in\'olves the placing ofa rectal!latlls
tube.
46b CaecaLvolvulus with a dilated caecum
Practical tips extend ing up into the right upper quadrant. Small
Caecal volvulus (46 b ) can someti mes be a confusing bowel is dilated ' secondary to this obstruction but
ditlerential. It represents twisting JUST above the ileocaecal large bowel is collapsed helping to differentiate
caecal from sigmoid volvulus.
84
E 47
ry
::;·'-car-old female presented with
nal pain and vomiting.
SE 48
ory
38-\'car-old woman underwent
ruSt enhanced CT for further
uarion of a lesion noted
Ulld.
page 88forcnsc answer)
85
ANSWER 47
Observations (47a) Small bowd can be differemi:ated from large bowcJ using:
Multiple dilated loops of g3s-fillcd small bowel that the following fe:afUTes:
measure morc than 3 em in diameter arc seen within the • Presence of"al"ulae conni\'entes which extend :across
central abdomen. No gas is seen within the large bowel and the width of the bowel. Colonic haustf3 do not
appearances arc consistent with small bowel obstnlcrion. tran:rse the whole lumen.
Surgical clips arc noted in the right side of pelvis along with Dilated bowc! located in the centf31 abdomen f3ther
choicc),stcClomy clips in the rig ht upper quad ram . than the peripher)' (47d ).
Adhesions a TC therefore the most likely cause of the Diameter of loops is <5 em.
obstnlction. Absence of solid £leees.
Di ag nosis Practical tips

Small bowel obstmction from adhesions. Alw:ays check the film to tTy to identify the underlying:
cause of the obstruction:
Differential diagnosis Check herni:al orifices at the groin - there should Ix
For small bowel obstruction; no bowcJ gas extending below the position of the
• Adl1(:sions - account for up to 60% of s1l1:l11 bowel inguin'llligamcnt (3 line from public tubercle to
obstructions. anterior·superior iliac spine ) (47e, 47f, 47g, 4 7 h ).
• Hcrni::a. Look for evidence of previous surgery, as in this ca~
• Gallstone ileus. Look for air in the biliary tree and radio·opaque
• Small bowel or caecal malignancy. gallstOnes outside the TerritOry of the gallbladder as
• Intussusception. indicators of gallstOne ileus.
• Malrotation and volvulus. Examine bones for metastatic lesions, which can poim
to malignancy.
Discussion Alw:l.)'$ remember ro check for free gas secondary to
Small bowel obstruction can have a varied prcsenr:uion on perforation!
plain :abdominal f3diograph~'. The classical appeaf3nce is o f
central abdominal small bowel loops dilated to :>3 em in Further managem ent
diameter with :a paucity of gas in the large bowel. Other CT is the inl'estigation of choice for small bowd
appe:af3nces C:all be of: obstruction and it can identify both the site and c:ause 011
• 'String of beads' sign due to small:air·fluid b 'c!s in obstmction and also the complications. Mcchanical sm
fluid ·filled obstructed loops of small bowel (47b). bowel obstmetion is a surgical cmcrgency.
• Absence of gas in the small bowel due to compleTe
obstruction and complete fluid fillin g ofJoops (4 7e).
47b Plain abdominal radiograph 47c Plain abdominal radiograph

demonstrating the 'string of demonstrating complete absence of
beads' sign. small bowel gas due to fluid filling.
86
Abdominal Imaging
47e Axial CT image shows that there has been a

previous attempted hernia repair with a mesh
noted in situ. There has, however. been a
recurrence with dilated bowel going into the
hernia and completely collapsed bowel emerging
from it. This shows that this is the level of
obstruction.
479 Coronal CT reformatted image in

the same patient demonstrates a right
sided inguinal hernia.
47h Axial CT image of a patient w ith small

bowel obstruction.
87
ANSWER 48
Observations (48a) Appearance on CT: again, appeaT"J.nce is of a weI!
A l;ngc c(mral mass lesion is demonstraTed in th!.: left ddined fat -collt:l.ining lesion with some areas of
kidne y. This is slightly hctcrog..:ncous but hlS 3. prcdomi - higher attenuation tissue. Identific ltion off.1t (He
lllmly 6tty density. Appearances arc consistent with left <-20) within a renal lesion is highly specific for an
renal angiomyolipoma. angiol1l)·olipoma.
Appearances on ~·I RI: a En suppression sequence CaD
Diagnosis be very liseful in confirming intralesional fu t conrenl
Angiomyolipom3.
The main complication of these lesions is haemorrhage
Discussion the risk is rdated to size. Lesions greater than 4 cm
Angiom}"olipoma is a benign lesion containing fur, blood diameter ha'·e a risk of spontaneous bleeding
\'csscls and smooth muscle. They Tend to present in two approximately 50%.
groups of patients'
• Women in their 4th-7th decades where lesions arise Practical tips
spontaneously and tend to be iolitary allri I/J/I'/nfcml. hkntification of f.Jt in a renal lesion is very specific
Young paricms wirh TUberous sclerosis II'here lIIultiple angiom),olipoma.
nlld bilateral lesions an: seen in up to 75%of patients
(48b), Further management
Smail lesions « 4 cm ) arc usually asymptomatic but I
They arc also seen rarely in autosomal dominant polycystic >4 cm arc almost always sympromatic with pain and ..
kidney disease (ADPKD) and neurofibromatosis. of haemorrhage. Lesion resection or nephrectomy s
• Appearance 011 US: typical appearance is of a we!! be consid<:Ted in these patients. Transcatheter art
ddined edlObright lesion due to a high fin content embolization is;ll1alrernarive.
(48c). There 'can be a variable degree ofredm:ed
echogenicity depending on the ,unOUlH of smooth
muscle and/or haemorrhage
88
89
ANSWER 49
Observations (49a, 4gb) TurcOt syndromc is FAP with assocbted CNS malignan..-,
The twO CT images (493. ) demonstrate a large, well stich as medulloblastoma.
defined soft tissue mass in the central abdomen. This
displaces 3djaccm bowcl loops and most likely originates in Other polyposis conditio ns arc :
the mescntery. • Peutz-Jeghers - autosomal dominant (AD )
The si ngle imlgc (49b) from a double contrast barium hamartomatous polyposis condition with features
enema examination shows multiple small , well defined of mucQeulaneous pigmentation (usually brown
mucosal filli ng defecTS througho UT the colon consistent pigmented freckling on the mucous membranes
with widespread colonic po lyposis. Multiple polyps oflips and g ums) and multiple polyps found
throughout the colo n suggest an underlyi ng genetic prl!dominamly in the stomach and small bowel, \\ith
condition. lew also seen in rhe large bowel. Hamartomas ha\"e
malignant potential but the condition is associated
Diagnosis with all increased risk of lip per Gl tract malignancies..
Familial adenomalOus po lyposis ( FAP) wi t h mesenteric Complieal'ions of the cOll(lition include:
desrnoid tumour. • o\hbbsorprion.
• Transient intussusception
Discu ssion • Carcinoma of the G I tract.
Familial adcnomatous polyposis is an autosomal dominant • Carcinoma of breast, pancreas, ovary, endome
disease (chromosome 5 ) characte rized by multiple colonic and Testes.
adenol1latous polyps that inc\'it3bly progress to colorectal
cance r within 20 years of dia gnosis. Treatment invoh'es Cowden's s\'ndromc - AD condition char.lctcriud
prophylactic 1000al coleCTomy in carl)' ad ult life and genetic multiple ha;113rtOm:u ous polyps, breast and thyroid
screening of r."lIllily memocrs from the second decade with malignancy and skin lesions.
a \'iew to prophylactic surgery. All patients ha\'e colonic Cronkhite-Carmda syndrome - hamanomatous
polyps but small bowel and gastric adenomas arc also found colonic pol~'Ps arc a.ssoci:ltcd with alo(>l!cia., skin
(pcriampullaty cancer is the nltolsr COllllUOtl caliSC o(llcath piglllcOI'3.tion and nail atrophy.
o nce..col«tOftlY has-bccl1..pcrfunncd ).
Othe r associated features include: Practical t ips
Desmoid tUlllours. • Images should oc carefull y inspected for a coexist
Mesenteric fib rosis. colo nic tumour as well as cxtr:acolonic malignan .
Gastric harnano mas. Intussusceprion in adu lts indicates an underhing.
H ypen rophy of rctinal pigment epithelium. bowel pathology, whereas in children if can be
idiopathic.
Gardner and Tun:ol.$),ndrollles arc \'Miants of-fAP .
Gardncr syndrome also includes: Furth er management
O steomas of the skull and m ~l!ldibk. Surgical refe rral is required for prophylactic cokcr
Dental abnormalities - dentigerous cySts, odontoma, is referr.tl for genetic screening of rclati\·es.
hyperce mentollla, supernumerary tee t h.
Soft tissue tlImours stich as fibroma, lipoma, Further reading
leiom)'oma, neurofibroma. Galiatsatos P, Foulkes WD (2 006 ). Familial
• Epidermal cysts. adcnOmatOllS polyposis. AmeriCfm jOllrnnl of
• Association with lh)'roid canccr. Gnstrotllurology 101 (2): 385-398.
49b Multiple
polyps.
90
91
Answe rs 50, 51 Abdominal Imaging
ANSWER 50
Observations (50a) Practical tips
This single TI weighted coronal image shows a striking l\'l ultiplc transfusions for chronic haematological disordCG
reduction in signal intensity throughout the H"cr C:lnlead to iron overload, i.e. transfusion siderosis. j\IRJ
parenchyma. This is likely 10 indicate iron overload. II is wi ll show hypointensity in the liver find spleen in t
notable that the spkcn re tains normal signal intensity so condition. This helps diflerenti:lle it from haemo.
the li\'(:r abnonm.li[~' is most likely due to hacmo- eh romatosis where the spleen shows normal signal
chromatosis. M IU.
Diagnosis Further management

i-Iacmochromarosis. In thc course offollow-up, ultl'J.sound monitoring may
useful due to [he high risk of dC\'cloping cirrhosis
Discussion hepatocellularcarcin0111a.
Pri mary hacmochrOlTl3[Qsis is an aurosomal recessive
condition characterized by increased absorption and
ckposition of iro n within several organs illCluding [iva,
pancreas, heart and pituitary gland. Patients arc usuall)'
lsymptom:ttic until the 2nd dCC3dc, then they present with
a varied clinical picture due [0 iron deposition in:
• Skin - h)'PCrpiglllcllt:ttion.
• U\'er - cirrhosis. lu:p:uomegaly.
l)allcrc3S - diabetes.
Heart - arrhythmias. dilated cardiomyopathy.
Ml1sculoskclet31 - arthralgi:t.
Pituira.ry - piruir-J.ry r.,ildrc with signs of impotence,
tesf~eular atrophr. hair loss.
Radiologically, imaging of the abdomen shows marked

abllormality oCthe livcr. Accumulation of iron rcsults in the
liver being of ditl'usel)' reduced signal on ;vIRl. The degree
of iron deposition has been shown to correlate with the
l\oIlU appearances. Uncnh:lIlced CT of the li\'cr
demonstrates increascd :lUenuation (>75 HU). Follow-up
in these patients is important due to the hepatic
complication" of cirrhosis :tnd the ;nc.rc;eed risk. Oh
hepatocellular carcinoma.
Art.hropatAy of haemochromatosis is similar to that of SOb Radiograph of both hands shows fl atteni ng of
calcium pyrophosphate deposition disease. Chondr~ the 2nd and 3rd metacarpal heads w ith loss of joint
calcinosis is a tcamre. T}VicaJl)', appearances arc of squaring space, giving a squared appea rance. Early spur
of the mctacarpal he.lds due TO flatTening and peripheral formation is seen on the lateral aspect of th e 2nd
small, hook-like SpUTS ( SOb ). Osteopenia is also common. metacarpal of left hand.
ANSWER 51
Observations (51 a, 51b) Discussion
1111:1ges arc control and delayed prone abdo minal This is the most COlllmon fusion abnormality of
radiogra phs fro111 an [VU series. The control fi lm shows kidneys. It is 1110re cOIll111only found in male patients
mediall y located appearance ofbolh kidneys and although has an incidence of I in 300. The kidneys arc joined
the superior poles of both arc identifiable, inft:rior poles tht:ir lower poles in 90% of Ca$CS, by a parcnehymal/fi
are not. The delayed IVU image (S ib) shows Illedial isthmus band ( S I c). The long axis of the k i dn~
location of the pell'icalyeeal systems, which are anteriorly medially oricntated with anterior rotation, such th.;n
orientated. No filling defects arc identified. renal pclvisesi are anteriorly located. Thc condiri
complicated by urinar), stasis with renal stone fornua.
Di agnosis infection and reflux . Vesieoureteric reflux
H orseshoe kidney, hydronephrosis sd:ondary to ureteropelvic jlln
obstruction arc common. There is :I reported incrc~
92
enec of rCIl::ai adenocarcinoma, transitional cell

m~ and Wilms' rumour. In :I.ddition the kidnc" is
cptib1c to injury following abdominal traUffi3.
oc kidney is associated with:
ourin:u)' ab'normaJitics: hypospadia,
hidism, urctcr,ll duplication, bicornuate
'Jscular abnormalities .
. al tips
.an IVU, check for filling defeCTs, which could
nt a retl;11 calculus or transitional cell
51c Axial CT image demonstrates the horseshoe
kidney with a narrow isthmus of tissue extending
anterior to the aorta and IVC.
- ~·old male willI weight loss.
93
ANSWER 52
Observations (S2a) Practical tips
Single AI' radiograph of the abdomen shows a metallic • As with all radiographs that show e\'ide nce of likely
stem within the (cmtal pel\'is, which presumably lies inlhc primal)' malignancy. o nce this has been noted, look
rectum or distal sigmoid colon. [t is likely thaI Ihis stent carefull y for metastatic disease elsewhere on the film ,
has been inserted to rdicve symptolllS from a (olarectal • Classicall~', coloreetal cancers metastasize to the li\'er
1'lI1l1our. The rest of the bowd gas pattern is unremarkable due [0 the ,"enous drainage of bowel l"ia the portal
wi t h no ("vidence of obslnlction. \'enous system. Howe\,er, the \'enOliS drainage of the-
There arc, however, amorpholls, poorly marginated rectum interfuces with the systemic ve nous drainage- .
areas of calcification seen in the region of the liver and thc.:sc the 3nal canal and thus pulmona ry metastases are said
likely rcpn:scm calcified liver Illct:mascs. Ultrasound or cr 10 be more likely in rectal cancer than other colonic
should be undcrt3kcn, and a contrast cnl13nccd CT (52b) tumours. In reality, pullnonal)' metastases arc nOt :m
of this patient docs confirm the presence of calcified liver uncommon finding in colon or rectal cancer.
Further management
Diagnosis T Ni\'1 ( tumour- node- metas tases) staging lllust be
Stcntcd rcct:l[ tumour with calcified liver mctast:tscs. accomplished as lor most tumours. Tumour staging
rectal cancer is done with MR.I (52c ) (along with loc.ll
Differential diagnosis nod al staging). The primary reason for MRl is ro as
For calcified [h'cr mctast:J.scs: proximity of nUllour to the llle$Oreetal fuscia - this is thr.
Mucinous adenocarcinomas - colon, rectum , ovarian, plane along which the surgeon dissects in a [ot"J.imcsorc
brc:l5[ and s[Omach. excision (TME ) procedure. This boundary is rhus referm.
Osteosarcoma. 10 as the eireumfercmial resection margin (CRM ), Ifloc..
Endocrine pancreatic carcinoma. tumour spread extends close to it, the surgical margin Il\.Io
Med ullal)' carcinoma ofthr ro id . well be contaminated with tumour with the attendant .
LUllgcancer. oflocal recurrence. ldentif)'ing patients where the CR.:\!
threatened in this way means they can be selected
Discussion preoperati\'e radiotherapy or chemotherapy to reduce r
Colorcct:ll carcinoma is the third most COlllmon cancer risk. Distal nodal disease and metastases can be ass!:
diagnosed in the de"eloped world. Rectum and sigmoid arc with CT or MRI but if the chest is also to be imaged
the most common sites of1csio ns. When' surgical resection exclude pulmonary metastases, CT is required for 1
is not possible or appropriate, stems can provide component at least.
symptomatic relief and prel'ent obstruction.
The liver is the most common site for metastatic spread
after regional lymph nodes,
52c Thin se~tion T2 weighted image shows a

circumferential rectallumour with wall breach at
the left anterolateral wall (12-2 o'clock) consistent
with this being a T3 tumour.
94
SE 53
c ry
35-year-old fe male presented \\~th
inal pain and per rectal bleeding
.3 months.
95
ANSWER 53
Observations (53a, 53b) For thumb·printing:
Plain abdominal film of adult patielll shows marked wall • Inflammatol)' colitis - Crohn's, uJccl""Jtive colitis
thickening of the transverse colon wi th thlllllb-printing. ( UC).
The sigmoid loops show no such abnormalities and the Ischaemiccolitis.
rc(mlll contains fucccs. The double contr:lSt b:lIium enema Infectious colitis/pseudomembranous colitis
film confirms extensive mucosal ulccrmion and a somewhat Divcrticulitis.
cobblestone "pp·caranee rhat extends from caecum 10 the Othcr causcs: cndometriosis, am)'loidosis, hereditary
descending colon. The colon distal to this is 1l0fllllL The angioncurotic ocdcma, lymphoma.
appearances :Ire in keeping with colitis, and sparing or
the
more distal colon makes Crohn's disease morc likely than Discussion
ulcerative colilis. It is not:lblc that the sacroiliac joints arc Crohn's disease is a chronic, inflammatory, granulomatOUl
normal. disease that can aflcct any part of thc bowel trona
oesophagus to recrum. Small bowel is most common~
Diagnosis im·olved and the tcrminal ileum is iJwolvcd in ovcr 95%
Crohn'sdiscasc. cases (53£1 ). I'rcscnt:ltion is usually in the 2nd-4th decldo
with s)'ml)\ollls uf abdominal pain, diarrhoea, pcr ren
Differential diagnosis bleeding, weight loss and fearurcs ofmabbsorption
For [emlina] ileal disease: Radiological fcatures arc:
• TB - uSlIllly has morc severe il\\'olvement of the • Aphthous ulccrs - shallow ulccrs with surrounding
caecum ( 53c). Thnc is oHen evidence of pulmonary oedema.
TB. Fissures, sinu~s and fistulae - Crohn 's is the third
Radiation ileitis. most (0111111011 cause offisrulae aftcr idiopathic causa
Ycrsinia . and di\·crticulitis. Thc tistulae can be bctwcen loops
53c T8 can also affect the bowel and appearances

can mimic those of Crohn's disease. Caecal
involvement w ith features of strictu ring and
ulceration is more common than terminal ileal
involvement.
96
Ner 53 Abdominal Imaging
I, between inflamed bowel loops and otntcr resection for C rohn's disease. There is noll' recurrence of
nal "iscera, c.g. colo\'cskal or from bowel to disease in the ncotcrminal ileum with features of:
Thickening of the bowel wall.
tone mucosa - longirudinal and transverse M3rkcd stranding of the surrounding (,1[ due to
Sl!'par.ttcd by ocdematous mucosa, inflammation.
ning of small bowcllolds. Engorged and dilated mesenteric \'csscls rclerrcd to as
lion of small bowclloops due to inflammation the 'comb sign' due 10 the similarity in appear:lllce to
or:dcmaofwalL the teeth of a comb.
gr:lIlubrity with < I 111m rounded mucosal Skip lesions with tWO im·oked segments shown on this
single axial image.
'yps - inflammatory or h ~verpl astic mucosa.
- often multiple. MR imaging (small bowel emerograph}') fearures arc
Jc:sjons willI discontinuous disease 3TC seen in demonstrated in Figures 53f- 53i . The fat suppressed
of eases. coronal/axial images ( 53f, 53g) show bowd wal l
g fea tures (53e ) are dcmollstr:ltcd in this case of lhickening in the proximal ileu m.
_ male patie nt who has had a pre\'ious Terminal ileal
(eOlu. )
C- image shows recurrence of disease in the

ina I ileum post surgical resection. There is
bowel wa ll thickening and oedema with
alery change in the surroundi ng tissues.
53f (coronal), 53g (axial) fat suppressed images

showing bowel wall thickening of a loop of proximal
ileum. Dynamic images are obtained and viewed in
cine mode to see how this focus of bowel contracts.
97
The pre - :md post-contrast TI weighted corOlll! images of disease all the film. Check lor sacroiliac joint
(S3h, 53i) show cnhancmlcnt of an involvc.d loop of small disease, gallstones, hypcnrophic osteoarthropathy.
bowel in the central lower abdomen. Always look for signs of drug rfcatmcnr of disease on
Treatment is both medical and surgical, with a high rate the film. Check femoral heads lor evidence of
of fCCllTrcncc cI'cn alter resection (almost 40%), p;'1rticubrly ;t,,:tscuhr necrosis from steroid trcatmclH.
in the ncotCfminal ileum following distal ileal resections
Further management
Practical tips Initial diagnosis in suspecTed cases is often confirmed
Terminal ileal involvement, skip lesions and multiple with a Slllall oo\\'d barium study (iollow through Of
strictures arc the best signs for Crohn's disease. When emerod)'sis). Sometimes a more aCUTe presentation
assessing colonic disease, rememocr that UC aimosl with abdominal pains mal' lcad to the diagnosis fim
always involves the rectum and has a continuou' being suggested by CT. Capsule cndosco,,'~' is a !1 !:'1
distribmion withom skip lesions. Ho\\"cl·er, if a UC illl"estigationllm Illay also first identify disease. OIKt"
patient has had steroid enemas, the rectum may look the diagnosis is made, follow-up imaging with MRI
nonmtl. idea}.as this iucurs no rndiation risk oin what afC
Always look for signs of complications of Crohn's, i.e trequcntly young patients. CT imaging remains
ade nocarcinoma ( risk increased up to 20-lold ), equally useful, howel·cr, when complications stich A
lymphoma, toxic meg:lcolon, pertoration, abscess, abscess fonll~lrion arc suspccll:d.
fistulae. Trealllll:m includes medical and surgical discipli nes..
Always look for signs of extrailltestinal manifestations
53h (pre-contrast), 53i (post-contrast) coronal

images of the colon showing enhancement in the
thickened small bowel loops in the lower abdomen.
98
SE 55
Dry
'::9-year-old male presented with
ivc d}'sphagia.
99
ANSWER 54
Observations (541 Discu ssio n
Single image from a double conrr3st barium meal Gastritis often has this apht hoid appearance ,,;da
examination shows multiple, small dense foci ofconlr:J.$t ":lriolirorm ulcers, consisting or a tin)' dense focus
wit hin the aIHrulll and bod\' of the slOmach. These are barium surrounded by a radiolucent halo or oedema gi,~
surrounded by a lucent halo' rcprc.sc m ing oedema. There a ;rnrget lesion' appearance . Lesions arc usually multiple.
is some irregular thickening of the gastric folds, with thc The lntrum is preferentially affected with spread towarQ.
targe t lesions appearing to be orientated along these. the fundus, lesions appearing (Q be lon gitudin
oriemated along the rugal rolds,
Diag nosis Causes:
Erosive gastritis. In 50% or cases, no caus.ati,'e abnormality is identifi
Peptic d iscasc,
Different ial diagnosis Dmgs - aspirin, NS AIDs, steroids,
Fo r aphthous ulccr:Hion: Alcohol.
Erosil'C gastritis. Infenion - herpes simplex, cytomcgalO\'irus (CM\' .
• C rohn 's disc;lSC. C(mdidn,
• Ihriurnprccipiralcancf.ICts . • Crohn's disease - lIslIall)' there arc signs ofCrohn's
disease in other locations, most commonly the
For gastric fo ld thickening: term inal ileum .
Erosil'c S;lstritis.
Zollinger- Ellison syndrome. Pra cti ca l tips
Crohn'sdisease. On the contraSt examination look fo r features in
Malign:lIlc), - lymphoma, carcinoma. oesophagus of an infecti,'c cause for the gamic appca
Benign rcani,'e lymphoid hyperplasia, o r for oesophageal varices pointing TO alcohol as
Mcncuier'sdiseasc, • undcrlringcause.
Further management
Gastroemerology referral with a ,'iew (Q endoscopy.
ANSWER 55
Obse rvations (55) presentation is with dysphagia, odynophagia and pos..
Single image trom a barium swallow examination shows a haematelllesis.
lesion in the lower oesophagus, just superior to the gastro- Radiological features are:
ocsophageal junction, The lesion is well defined with ;1 Well defined, large, smooth intramural mass
smooth edge, indenting lhe oesophageal IUlllen, No extending into the oesophageallulllcn.
ulceration Of infiltration is seen. Ap pearances suggest a Forms an obtuse angle wilh lhe adjacent mucosa-
benign intramural mass, most likely a leiomyoma. good sign ofa benign lesion.
Usuall), found in the mid and lowef oesophagus,
Diagnosis Calcification is sometimes seen and is vi rruall v
Lciomroma orthe oesophagus. diagnostic since it is the only oesophageal nll~our
ealcif)'.
Differential diagnosis Ukerationisrarc.
For smomh ocsophagel1 mass lesion: May be multiple in -3%.
Neurofibroma. Uniform contraSt enhancement on CT,
Li poma.
• Hacmatoma, e.g. from instmmemation. Practica l tips
• Duplication q'5t - can simulate an intramur::J.I mass, Smooth, wdl defined, slow growing oesophageal
afC likely 10 be benign.
Di scussio n
This is dIe mOst com mon benign tumour of the Further management
oesophagus. It is usually fou nd in young adul ts, being Gastroenterology refe rral \\;th a I';ew to direct ,;su
slightl y more common in males. Growth is slow and with endoscopy.
100
101
ANSWER 56
Observatio ns 156a, 56b) • Sloughed renal plpilla.
The All postmicturition imlge (56b) from 3n rvu series • Gas secondary to fistula, cystitis, idiopathic causes and
shows billteral dilat3tion of the disra.1 ureter with 3 ·cobra. trauml.
held' lppelrlnce. There is a surrounding thick I1llo of • Island prostate - enl3rged central zone Cln appear as ~
lucency within the bbdder, represcnting oedema. These ccntra.l bladder lucency.
3ppeara.nces are of bilatera.l ureterocelcs. The control film
(56a ) demonsnates bilateral calculi in the peh'is that lie Discussion
within these ureteroceles. A simple or orthoropic ureterocele is a congenira.1 prolapse
of the dist;!l ureter lnd its orifice into the bbddcr. It
Diagnosis usu311 y an incidental ti nding in adu\[s and is bilatera.l in
Bilatcra.l ureterocdes. third of C3ses. Figure 56c shows how a ureterocele c
produce l less spedfk type of filling defect when t.b.:.
Differential diagnosis bladder is full and Figure 56d shows the typical ultra.sound.
I:or radiolucent bladder filling defects on lVU: 3ppelra.nce. The main complication is of obstructi
• Ureterocele. which can cause collecting system dibtatian and rc
Hiaddertllmour. failure. There is also an increased risk of stone forma '
• Radiolucent calcu lus. and it is therefore imperative to check the control film
e,"ery patient-as in this case!
56d US image of the bladder s h ows protrusion of

the distal urete r into the bladd er, indicating that
these a re orthotopic urete roceles and no t
pseudoureteroceles.
102
urcrcrocclcs can haxc a ·similar appearance and

d bv obslrucl;on of:l normal ufetef. Dificrcll-
bcn\:ccn the tWO types can be made using
or oblique films, which show no prmnlsion of
into the bladder lumen with pscudourc[crocelcs.
of pscudourcfcrocclcs include:
.Jana ahhe distal ureter secondary to impacted
• infection, radiothcrap~' .
r tumour (56c:) ,
to check the comrol film of an IVU.
management
I asymptomatic ureterocele Ill;l}' not require
rec urrent urinary tract infcnion ( UTI ), calculi,
obsrruct;vc uropathy arc indications for surgical
56e Single axial T2 weighted image of the pelvis

shows a pseudoureterocele secondary to a large
bladder tumour.
103
ANSWER 57
Observations 157a) Presentation is with progressivc dysphagia. investigat:ioe.
This frorHa] chest radiograph of an adult patient shows an is with a contrast swallow examination (57b), which mat"
added com'ex soft tissue density along the right mediastinal show featufes of:
border and behind the heart. There is no normal gastric 'Vigorous achalasia' - multiplc tertiary contractions in
:ti l' bubble beneath the left hcmidiapllf:l.grn. The findings the distal oesophagus Gill be the earliest sign.
suggest d ilatation of the ocsoph:agus secondary to chronic 'Bird's beak' deformity - symmetrical sLenotic
distal ohstrunion, most likely due to achalasia. A barium segment of oesophagus at the gastro-ocsophageal
swallow would confirm. junction. Imaging the patient erect allows best
demonstration with contraSt forcing its way through
Diagnosis the gastro-oesophageal sphincter when the
Achalasia. hydrostatic pressure of the barium column in the
oesophagus is sufiiciemly high .
Differential diagnosis l'v lcga-oesophagus - dilatation of the oesophagus ttui
Secondary achalasia due to a stricture at the gastro- call involve its emire length.
oesophageal junction, There will be normal pcristalsis Relaxation ofthe lo\\"er oesophageal sphinCler can be
however. induced with amyl niTraTe inhalation.
C hagas' disease is esselltially the same as achalasia but
the neurenteric plexus damage is due 10 Trypmlosomfl Achabsia is complicated by an increased risk of devcl~
cYII::.iinfcction. an oesophageal squamous cell carcinoma.
Discussion Practical tips

Achalasia is a lllmilily disorde r that is idiopathic in Check lungs for pulmonary changes of previous
aetiology, characterized br degeneration of Auerbach's aspiration.
plexus. This results in a fai lure of relaxation of the caudal Check for evidence of pulmonary metastases from
oesoph:lgus at the g:lstro-oesophageal sphincter. secondary oesophageal malignancy (or indeed if the
di!:ncd oesophagus is due to a primary malignancy
rather than achalasia).
Further management
• The condition is fi.lrther im'estigated with pressure
measurements (manomet!)') and endoscopy.
Treatment is most commonly by pneumatic dilatalil:
of the gastro-ocsophageal sphincter. Surgical
mrotomy is considered where there is disease
57b Two images from a barium swallow

examination show a dilated oesophagus contai
food debris, which 'narrows down to form the
classical 'bird's bea'k' appearance at the gastro-
oesophageal junction.
104
105
ANSWER 58
Observations (58a, 58b, SSc) Fibromuscular dysplasia ( 10-20%) - usually in the
Three im;lgcs from an JVU se ries arc provided bur no mid and distal renal arter)'; allccts young adults and
control film (which would normally be assessed prior 10 .::hildrcn; more common in women; bilateral in two-
interpretation of the post -contrast films ). [Illages show thirds.
uni lateral increasingly dense and persistent ncphrogr:un on
the right'. The right kidney shows uniform smooth Less com mon causes include vascu litis, arterial dissection
reduction in size when compared to the lefr. There is and thromboembolic disease.
delayed excretion of comrasr by the right kidney on the 10 Hypertension in neurofibromatosis is a consequence 01
minute fi lm ( 58e ). These appcar:lI1ccs suggest unibtcTll phaeochromocytoma and/ or renal artery stenosis, \\~th .11
right renal :trtcry stenosis. The young age of the patient smooth stenosis seen in proxim:al ren:al :arter)'.
makes fibromuscuhr dysplasia more likely than In this p:arielU, a renal angiogram was performed and
atherosclerosis as the underlying pathology. showed a smooth n:arrow stenosis in the mid portion of
rhe right rena! artery (58d ) and this would be in keeping
Diagnosis with the underl ying diagnosis of fibromuscular dysplasia
Renal artery stenosis. of the renal ;lrter'\'.
The eonsequ~nee of renal artCr)' stenosis is systemic
Differential diagnosis hypertension as a result of o\'er;lCtivit}, of the renin-
For persistent dense ncphrogram: angiotensin system. Treatment is aimed :at medically
• UnilaTeral: controlling hypertension and with renal arter)' :angioplas~
Obstruction - acu te obstruction is the most
common cause of this sign. Practical tips
Renal artery stenosis/ ischaemia. If there is bilateral delayed persistent nephrogram
Renal vein thrombosis. with absent or dec reased excretion, then the patient
Acutc bacterial pyelonephritis. t..... needs to be immediatclv checked to ensure that
Acute papillary necrosis. contrast anaph ylactic sh"ock has not occurred.
Magnetic resonance or CT angjogr~phy is the
Bi lateral: prcli:rred ilwesrig;ltion tor this condition in the
H }'potension/shock. moc\ernera.
Aelile tubular necrosis.
• Acute glomerulonephritis . Further management
• Causes of un ilatera I change involving both kidneys. Attempted renal arter)' angiography and angioplasry arc
usually ad,~scd.
Discussion
'Illere arc two main causes of renal artery stenosis:
• Atherosclerosis (80- 90%) - usually in the proximal
2 cm of the renal artery; afrects older population >50
years; more common in men; bibteral in one-third.
S8d Single image from a renal angiogram showing a

ste nosis in the mid portion of the right renal artery.
106
107
ANSWER 59
Observations (59a, 59b) more indolent symptomatology with longstandi ng
Single image from a barium follow -through examination grumbling abdominal cramps, postprandial pain, weight
shows smooth thickelled small bowel folds. Selected axial loss and malabsorption. Other causes of ischaemia include
images from an IV comrast enhanced CT scm of the \"asculitis, bowel obstruction , radiotherapy and aCUle:
abdomen again dcmonsrr.l1cs smooth thickening ofbowcl abdominal inflammation, e.g. pancreatitis, appendicitis.
folds in dilated loops offluid-fillcd small bowel. In addition, Radiological features of acure small bowel ischaema
there is thrombus seen in the mid superior mesenteric vcill. include:
Bowel \\'all thickening/oedema.
Diagnosis Enhancement pattern of the bowel wall can be
Small bowel ischaemia secondary to superior mesenteric incre3sed or decreased (5ge).
vein (SMV) thrombosis. Stranding of the surrounding f.1L
Pneuillatosis intestinal is, which is a late sign and
Differential diagnosis indicati\'e of necrotic bowel.
For smooth thickened folds' Free imra-abdominal gas due to perforation of
Haemorrhage. necrosed bowel.
Ischaemia: Portal venous gas is seen in preillorbid patients.
Acute - embolus, Hcnoch-Schonlcin purpura
( HSP). In chronic ischacmia, there call be additional complicati
• Chronic - vasculitis, thromboangiitis obliterans, of strictures (which tend to be long, smooth a
radiother.lPY· symmetrical), ulceration and atrophic valvulae connivenro.
The splenic flexure and the proximal descending colon
Oedema most cOlllmonly affected due to the transition fr
H ypoproteinaemia~ cirrhosis, nephrotic syndrome, superior to inferior mesenteric arterial supply at this poiIIL
protein -losing enteropathy.
• Angioneurotic oedem,\. Practical tips
Look careftilly for linear gas shadows within the
Lymphatic obstruction ~ lymphoma, mesenn:ric bowel wall indicative ofinrramllfal gas.
fibrosis, intestinallymphangiecrasia. Portal vein gas is usually seen in the pcriphery of the
liYcr as well as centrally, in contrast to biliary gas,
Discussion which is usually only central. This is a prcmorbid sip
Small bowel/mesenteric ischaemia can present very acutdy in adults.
with symptoms of acute abdominal pain, ,'omiling,
diarrhoea and recral blecding. This is usually due ro arterial Further management
thrombus, dissection or acute ,"enous Obstruction. Chronic hll'cstigation with CT C:tll both diagnose and idcnti~'
ischaemia usually due to chronic arterial thrombus has a complications of ischaemia.
59c Axial CT image of the abdomen shows

dilated flu id-fi ll ed loops of non-enhancing
ischaemic small bowel.
108
SE 61
- tory
57 -year-old m:alc prcscillcd with
'Cr abdomi nal pain.
109
ANSWER 60
Observations (60) Discussion
Single oblique radiograph of the pelvis from an IVU shows Bladder innervation is by the parasympathetic nervC$
a small, shrunken, spastic trabeculated bladder with 52-54. Injury to these nerves causes denervation oftbc
multiple diverticula, with a superiorly pointed dome. This detrusor muscle, giving this appearance of a shrunken.
is the so· called 'pinc trce' appearance of a neurogenic heavily trabeculated bladder, with an irregular thicken
bladder. wall and multiple diverticula. Causes include:
Congenital anomalies - myelomeningocele, spina
Diagnosis bifida.
Neurogenic bladder. • Spin:!1 trauilla.
• Diabetes mellitus.
Differential diagnosis • Infection - syphilis, herpes.
For Slllall bladder: • .Spinal neoplasm
Infection - schistosoilliasis/TB.
Iatrogenic - postsurgery/ radiotherapy. Practical tips
Neurogenic. Inspect IVU films carefully to look for asp'
Transitional cell carcinoma (TCC ) - awmilletric abnormality, which can help to determine the underl~
bladder contraction with thick wall and filling defects. cause of the bladder abnormality.
Extrinsic compression - usually gi\'es a pear shaped
bladder appearunee. Further management
In the absence of an easily identifiable cause, lumbo
spine MIU can be useful.
ANSWER 61
Observations (61) Intraperitoneal seeding - brc:lst, 0\'3rian, panctc:lOi:
Single image from a barium enema examination and gastric tumours arc the most common primaries
demonstrates a well defined, Sillooth, eccentric filling deft."(;t responsible for intraperitone31 'drop' seeding. "Thot
in the distal sigmoid colon. This appears to be extraluminal lesions involve the mesenteric borders. Appcaranas
in origin and lies on the mesenteric aspect of the bowcl A arc of a focal mass or ditfuse stellate appearance 011
similar lesion is seen in the pouch of Douglas. Multiple CT, but on double contrast barium im3ging,
lesions centred in an intrJperitone3110carion suggest the Jppcarances arc of a foc31 extrinsic indentation of
diagnosis ofimraperitone31 metaS[3Ses. bowel. This involves the pouch of Dougl3s (50'\
commonly the superior/anterior border of the
Diagnosis sigmoid. Thc distal ileum and mediJI border ofd:.:
Colonic mctastascs. caecum arc also often invoked

Tumours sprc~ld to the mesentcry via four rolltcs: The most common underlying calise lor
• Direct invasion along thc mesenteric \'essels and fut - malignant diseJse is ovarian cancer.
scen with gastric, pancreatic, colonic and biliary
cancers; 40% of patients with adenocarcinoma of the Further management
pancreas have tumour cxtending along the mcscntcric Clinical review of patient to tty and loc3lize a likely
root at diagnosis tumour. CT sC3nning will confirm peritone31 di~
Extension \~a mesenteric 1}'mph3tics - colonic, Illay well reycal the primary tumour.
ovarian, breast, lung, c3rcinoid and melanoma cancers
C3n spread to mesenteric lymph nodes, though Further reading
lymphomJ is morc common. Shcth S, Horton KNt, Garland [\·tR, Fishman EK _
Haematogenolls spread - commonly from melanoma, l'vlcsenteric neopl3sms; CT appe3rances of priffiX"l
hrCJS! :lild lung prim3ries, met3st'3ses invoke lhe and secondary tumors and diffcrcntial diagno~
anti mesenteric bordcr of the bowd via sm311 arteries. RndioGmphics 23: 457-473.
They can act as the lead point tor intussusception. Up
to 7.5% ofmehnoma paticnts show st1l311 bowel
involvcment
110
SE 62
ory
46-year-old Icmalc , recentl y
ted to the U K from Africa,
- med with symptoms of urinary
ncy and urgency.
E 63
ry
- ::'-\~ar - old diabetic presented with
and abdominal pain .
111
ANSWER 62
Observations (62a ) Practical tips
This single coned view of the pekis shows curvilinear wall Schistosomiasis il1\'ol\'("s bbdder and lower ureters
calcificatio n of a relatively normal capaci ty bladder, No and results in a calcified , nonshrunken bladder. Tn
calcifiGlrion of the lower ureter.; is seen. No discontinuity in involves rhe kidneys and spreads via the ureters ro
thc calcification is.scen. involve rhe bl:ldder. It is very unusual to have isolated
TIle history of residence in Africa raises the possibilities bladder involvcment with TB and the degree of
of bladder TB and schistOsomiasis. The absence of gross bladder contraction is more marked than in
bladder contraction makes the laner more likcl}" but it schistosomi:lsis
would also be helpful to re,;ew a full length alxlominal film Discontinuity of calcitic at ion in the bladder wall
~~n!:; n~~l:t L~j;:,e~t~~~;u~~l~~ficadon. Transitional cell ::r should arouse suspicion of bladder cancer,
Further manageme nt
Diagnosis Follow·up in these patients is required since the latency fw
SchistOsomiasis. development of sq uamous cel l carcinoma of the bladder
can be lip to 30- 35 rears.
Different ial diagnosis
For calcified bladder wall:
Cancer - prirnaril}' transitional cdl carcinoma (TCC)
but also other rarer bladder tlImour.;.
• Radiotherapy.
• Inlection - Tn and schistosomiasis.
D is.cussi o~ .. ,. ..
SChlstOSOlmaSIS IS one of the mOSt common paraslilc
infcctions, affecting 8% of the global populatio n.
Schistosolllff l)(Illllntobilllll is the female parasitc which
aflccts the genitou rinary system. Unlike TB , which tends
to affect thc kidneys first and then spreads caudally,
schistosomiasis has a re,'erse involvement and uSlIall}' is
confined to bladder and lower ureters. (Another case of
bladder schistOsomiasis [62b] is shown - note the absence
of upper tract calci fication that one might sec in TB .)
Classically, the patient presents with urinary frequen c)"
urgency and dysuria. Imaging findings arc of:
• Calcification of the bladder - which results in reduced
bladder filling capacity and increased posnnicturition
residual volume.
Calcitlcatio n of the lower ureters.
Lower ureteric strictures.
Ureteritiscystica.
Complications of disease aAccting the genito urinary system

include :
Cystitis.
Vesicourelerie reflux and subseq uent pyelonephritis.
• Increased risk of squamous cell carci noma of the
bladder.
Other systems can be affected:

Li\'er - oval migration results in portal hypertension
and subsequent oesophageal varices. 62b Calcification of the bladder is seen in
Respiratory system - diffuse granulomatous lung schistosomiasis with absence of upper tract
lesions. calcification to help differentiate from TB.
11 2
R 63
tions (63) There is an increased incidence of these conditions in
biominal radiograph demonstrates gas within the patients with diabetes mellitus and women arc three times
~.i lyccal system and upper ureter. No intra- more: cOlllmonly affected than me n . Esc/)ericbia coli is the
a1 renal gas is seen. No gas is seen in the right causative organism in 70%of cascs with Klehsiell", Proteus,
o r in the bladder. Candida and PseudomOllflsorganisms also being found. In
emphysematous pyelonephritis, small gas bubbles arc
initially seen on plain radiographs in\"ol\'ing lhe renal
parenchyma; this progresses to give a di ffuse mottling in
morc ad,'anced disease and then progresses to produce a
crescent of perinephric gas when there is extension into
the perirenal fill.
Practical tips
CT is the best imaging modality for assessing extent and
_ nie - urinary dive rsion procedures . location of gas.
.' tract fistula to bowel due to innalllillation,
Crohn's, diverticulitis or spreading malignancy. Further management
Depends on ca use but obviously infective causes require
prompt, appropriate antibiotic treatment.
mamU5 pyelitis is a condition in which infective
produce gas, which is confined within the renal Further reading
:cc,aI system. In emphysematous pyelonephritis, gas Joseph RC, Amendola MA, Artze ME, et al. (1996 ).
\\ithin the renal parenchyma - a lifc·thrcatcnirrg Genitourinary tract gas: imaging evaluation.
JII'l that requires prompt di:agnosis and tn:amlcnt. RadioGrapbies 16: 295-308.
E 64
;u·old female presented with

lIUlCty and epigastric pain .
11 3
Answ er 64 Abdominal Imaging
ANSWER 64
Observations (64a) they incn:asc in size, when there may be epigastric p:lin and.
Single image from :t double contrast barium meal bleedi ng. The gastric antrum and pylorus arc l he m
cx:ulIi natio n shows :t lI'ell defined smooth walled ovoid common si tes "flected. T he majority of these lesio
mass lesion in lhe gastric JllIfIlm. A central smooth ulcer extend im raluminally (60%) and form well defi ned 0\'
is present and no calcification is seen. defects. They arc more likely ('Q ulcerate than ocsophag
leiomyoma with ulceration scen in up to 50%. Calcifica .
Diagnosis is rare.
Leiomyoma of the stomlcn. Complications include:
Bleeding.
Differential diagnosis Obstmction.
Fortargc! lesions: Intussusception - tumour can act as a lead point.
Ncurofibrolll3. Malignant degeneration - s~cn in up to 15-20%m
Lipoma (64b). cases.
Ectopic pancreatic rest.
MCl'3stascs - cOlll mon ly breast, IUllg, renal and Practical tips
malignant melanoma. Smooth, well defined, slow growing gastric lesions
H acm3ngioma likely to be benign.
Di scussion Further management

T his is the second mOST common benign gastric tumour Although radiological appcarances suggest this to be
after gastric pol~'Ps. Ukc ocsophagcallciomyoma, these aTC benign lesion, referral for endoscop~' +/- biopsy should
slow growing lesions and arc usually asymptomatic umil made.
64b Axial CT imag e demonstrating a well defined,

smooth , rounded lesion in the stomach, which has
clearly the same attenuation as intra·/extra·abominal
fa t. This has appearances of a gastric lipoma .
11 4
IJ8jorcnsenllsUler)
11 5
ANSWER 65
Observations (65a) Thickc nin~ o f bowd W:I!l (65b).
Single image from a double contrast bariulll enema Significant bowel wall thicke ning can 1c3d to tht:
exami nation shows :abnormalitv of the colon tha t extends classical 'thumb-printing' appearance.
from the rectum [0 the mid rrans\'crsc colon. There aTe Widening ar thc presacral space.
(C3IUTes ofJuminal narrowing with mucosal irregularity, Fine ll1uc<>S.11 granularity.
granulari ty ;1 11(\ shallow ukcr:ltion. The disease process Superficial ulceration.
appears cOll tinuous along the 3.flcctcd segment's with no I'scudopolyps - islands of oedematous mucosa.
fil rthcr lesions seen. Noml:!l appearances of the ikocacc:L1 Collar button ulcers (65c).
region. Normal sacroiliac joints. T hc appearanccs arc in
keeping with a colitis, most likely ulccrntive colitis. Appcal'Jnces in the chronic stage:
• Colon becomes ri gid with llllllinainarrowing due [(
Diagnosi s chronic inilamm:ltion, and loss or haustrations -
Ulcc:rnti,'c colitis ( UC). 'le3clpipc' colon.
Coorsc grnn ul:tr mucosa.
Di sc ussion Inflam1l13tory polyps.
Ulcerativc colitis is an idiopathic inf1ammator~' bowel Ibck\\'ashilcitis.
disease \Iith invokemcnt predominamly of the mucosa and
su bmucosa or thc l:trge bowel. There a rc tWO peaks of
prcscntltion - 3rd-5th dccades and 7th- 8th dccldes. The
most commo n presentation is with blood)' diarrhoel and
abdominal plin.
The rectum is almost always involved (96% of cases)
with continuous, co~centrif and symr~lelri.c invo~\'~mcnt of
the colon more proxlillally. The tcrmlllalrku1l1 IS 111I"01\'ed
in 10- 25% due 10 backwash ileitis. In acute inflammation
there arc findings of:
65b Single axial CT image shows continuous

thickening of the colonic wall involving sigmOid
colon. The surrounding fat is 'dirty' !i ncreased
attenuation) due to inflammatory change.
Appearances are of an acute active colitis though
the appearances here are not specific for an
underlying ca use.
11 6
Abdominal Imaging
n is complicated by: transmur:ll , skip lesions; preferential in\'ol\'ement

n from toxic mcg~lCo[on in 5- 10% - thc of terminal ileum. FiStulae and deep ulcers afe
..:ommon cause of death (65d). common feature s .
.ldCIlOCarcinQm3 - this complicates Lip to 5% UC characteristicall\' has a continuous, concentric,
~ ticnts with risk highest when there is symmetric i1l\'o l\,eniclH that eXl'ends proximally
or onsct at a young age( < 15 years) and from the rectum :lIld only occasionally ilwokes the
\\;th chronicity of disease. The rectosigmoid te rminal ileum. Fistulae, fissures and deep
'TIOSI common location for ncopbstic ulceration arc nOt fcatures.
[lOtlJlion. Remember that although the recnUll is always
strictures - usually a single , shon, smomh involved in UC, it Illa}, appear spared if steroid
is found, most cOlllmonly in the enemas have been used.
sigmoid .
Look for intestinal complicJtions of UC including
• .lS with Crohn's disease, there arc a variety of malignancy, toxic megacolon, pneumatosis intestinalis
..u.: complications which include iritis, pyoderma and perforation .
~ m, chronic acrivc he patitis, sclerosing Look for exrJ";lim estinal complicat ions of UC such as
and seronegative arrhritis (Figure 65c sacroiliitis.
;lIes s;lcl'oiliiris with carly sclerosis of both Look lor compl ications oftreaUllellt, e,g. steroids
oints). causing avascular Ilecrosis (AV N ) Of osteoporosis.
I tips Further management

riJtion ofCrohn's from UC is often possible A combined medical/surgical approach to disease !lIanage·
the imaging tindings: ment should be taken.
thn's characteristically has multiple, eccentric,
117
ANSWER 66
O bservations (66a) leading to pneumoperitoneum but with no symptorm
Single image from a double contrast barium examination peritonitis. This cystic pneumatosis is usually a bem_
is shown. There arc multiple slIb1l1LlCOS:l ] lesions seell innocuolls condition and is associated with ch
scattered throughout the (olon with no regional obstructivc pulmonary disease, perhaps dl,le to air t
predominance. Close inspection shows that these aTC due from ruptured alvcoli and along the mescntery \"i.l
to gas-filled cysts in the bowel wall. No free intra- retropcritoncum. There is also an association with m
abdominal gas is seell to suggesT perforation. No linear gas disruption elsewherc in . the G I tract, e.g. peptic
collections ;\rc seen. No portal vein gas is seell. disease
Diagnosi s Practical tips

Pnc1I1l1arosis cysroi(ics intcstinalis. Air in tht: bowel wall due to infarction typically ·
more linear (66b) and may be associated with
Discu ssion gas in pre morbid cases.
Pneumatosis cystoidcs imcsrillalis is usually a benign
condiriori of middle aged people who tend to be Further management
asymptomatic but elll present with symptoms of vaguc
abdominal pain, diarrhoea and lllUCOUS discharge.
Pncumatosis of the colon is usuallv not <i" '' ' ,,,'..........
- the importance here is to trcat the patielll,
R.adiological findings arc of multi pic small \ - 5 mm gas·
tilled cysts in a subserosal!sublllucosal distribution. They Further reading
are more cOlllmonly found on the mescnteric rather than Pear BL ( \998 ). Pnnllllatosis intcstinalis: :l review.
anti mesenteric sidc of the colon. The cysts can rupturc /{nnio/Qgy 207 : 13- 19.
66b Abdominal radiograph shows linear gas

opacity withi n the w all of the transverse coler
a patient w ith ulcerative colitis.
118
119
ANSWER 67
Observations (67)
Selected 'in and ou[ ofphasc' T1 weighted axial images of early-delayed )
the abdomen arc provided, the ou[ ofphasc image lying to % washOllt .. x 100
( carly-ullcnhanced
the right. There is en largement of tile left adrenal gland
which appears of intermediate signal imcllsiry all Tl in
phase and shows signal 'drop out' 011 the TI Out of phase
image. Appearances on this chemical shift MRl art: Washout >60% has sensitivity and specificity - 9m.
consistent with fatty content and indicative of a benign the diagnosis of adenoma.
adenoma.
On chemical shift M JU - signal drop Oul on the OIl[
Diagnosis of phase imaging is seen with adenomas. Lesions
Adrenal adenoma. without significant intracellular fut (e.g. metastases
don't show any signal difference on in/our of phase:
Discussion imaging. The sensitivity and specificity arc similar
Adrcnal1csions arc found in - 9% ohhe general population. if nOt bener than, those of cOntrast enhanced CT.
Adrenal ldenomas arc the most common adrenal lesiol1. PET may be useful when CT and M lU fail to
Imag ing feamres can be used to ditTcrcntiatc benign characterize an adrenal mass. Malignant lesions s
adenomas from primary malignant (carcinoma, phaeo- increased uptake of FDG ( 18 fhroro -2 -deoxyglue
chromocytoma) or metastatic adrenal lesions. (>Ii,'er activity) while benign lesions do not (<li\·er
Imaging features for differentiation of an adenoma from activity).
metastasis are:
Adenomas are mostly <2.5 em in size; lesions >4 em in Practical tips
~~r~i~;~r;~~re likely to be ~etastases or adrenal An incidcmal enlarged adrenal picked up on US/ CT
should be furthe r irwestigated with a chest radiograpit.
Lesions showing no growth over 6 months arc usually look for a lung neoplasm.
benign.
On unenhanced cr - adenomas often contain Further management
intracellular f.1t", lowering the overall density on CT. Adrenal adenoma should be followed up after 6 m
When <10 Hounsficld units (HU ), this is highly Lesions that grow by over I ern in this time or those
specific for adenoma (96% specificity). Some measure over 4 ern should be considered for su
adenomas contain less fat and so a lesion with H U Hormonally active lesions may also be considered
> I 0 may represent adenoma or malignant lesion. surgery.
On IV contrast enhanced cr - both adenomas and
metaStases enhance, but adenomas washoUT more Further reading
rapidly. After a plain scan, acquire postcomrast scans Mayo-Smith WW, Boland GW, Nota RB , Lee MJ
at 60 s (early ) and 10 min (ddayed ). (2001 ). State-of-the-art adrenal imaging.
RndioGrnplJics 2 1: 995- 1012
ANSWER 68
Observations (68) It is associated with:
Single image from an JVU study is provided without a Renal calculi.
control film. It shows renal ectopia with both kidneys being Infection
located on the right side. This is crossed fused renal ectopia. Reflux.
There is no associated hydronephrosis. Megaureter.
Cryptorchidism.
Diagnosis Urethral valves.
Crossed fused renal ectopia. Multicystic dysplasia

Crossed re nal ectopia involves a kidney being located on Try to identify complications of the condition such as
the opposite side ofthe midline from its ureteral orifice. It scarring from recurrent infections, or hydronephrosis
is more common for the left kidne}' to have migrated to the to obstnrction from stones/urethral valves.
right, with the crossed kidney lying inferior to the normal
kidney. Usually the kidneys are fused and arc associated Further management
with aberrant renal ancries. No active management is required.
120
fC1ll::J.1c prcscnlcd with

Sfc::J.torrhoc::J. for 12 months.
ur-old 1l1::J.Ic W::J.$ involvcd in : J.

accident.
121
ANSWER 69
Observations (69) 'Moulage' sign - dilated smalJ bowel loops with
Single image from a small bowel enema examination is d&ccmcnt, particularly in the jejunum and
shown. The tip of the small bowd enema catheter is seen duodenum.
in the proximal duodenum. The examination dcmonstfltcs T ransicm intussusception - the cause of abdom'
a reversal of fold pattern with an increased Ilumbcroffolds pains.
seell ill The ileum and a reduction in the number of smalJ Floccubtion of the barium contrast due to
bowel folds seen in the proximal jejunum. These features
suggest malabsorption in dlC proximal s111311 bowel such as
coeliac disease.
Autoantibodies (e.g. antiendom),sial )
Diagnosis but diagnosis is made by demonstration
Cocli3cdiscasc. on jejunal biopsy. This abnormality
remo\·ed from the diet and recurs when it is
Discussion condition is complicated by an inerea!iCd .risk
Coeliac disease is a gluten-sensitive clltt:fopathy adenocarcinoma of the small bowel,
charaClt::rized histologically by villous atrophy. The carcinoma and pharyngeal carcinoma) (;1
duodenum and jejunum arc afl:ectcd more than the ileum
because some proximal gluten digestion means that less Practical tips
reaches the disul small bowel. It classically presents with Folds in the jejunum arc normally thicker and
steatorrhoea and diarrhoea, but more commonly presellts numerous than the ileum. Expect to sec seven fi
in less specific ways such as fatigue, weight loss and per inch in the jejunum lnd thrce to tour folds I:G
abdominal pain. Malabso rption can also n::sult in anaemia, inch in the ileum. A reversal of this pattern shaul..
osteomalacia, neuropathy and oedema. Age at presentation raise suspicion of coeliac disease.
call vary from early childhood to late middle age. If the radiological features deteriorate while on J
lmagiog features of coeliac disease include· glutcn-frce diet, raise the possibility Ii
Smlll bowd dilatation (due to reduced motility) is the such aslymphoml
most common imaging finding.
Reduced number of folds in the jejunum. Further management
'Jejunalization' of the ileum - an increased number of Confirmation of diagnosis is made with
ileal folds. This is a response to the reduced mucosal bowel biopsy.
arca in thcjcjullum.
ANSWER 70
Observations PO) Practical tips
Single image from an IVU series shows contrast in the Look for an underlying cause lor the abnormal
collecting systcms and in the bladder. The bladde.r has an bladder lppearance - pclvic fractures, i
abnomlal elongated configuration eXTcnding up om ohhe calcification in the walls of aneurysms, i
pelvis. There arc bilateral pelvic fractures through the ch;\nges in bone/small bowel to suggest un
acetabulum. No free COl11rast is seen leaking from the malignancy and l)'mphadcnopathy.
bladder.
Further management
Diagnosis Further treatment will depend on the underlying
Pe;lr shaped urinary bladder secondary to pelvic this is a secondary finding pointing towards an
hlematoma. problem.
For pear shalX'd bladdcr ( mnemonic - 'HELP' ):
• }-hematoma
External iliac artery aneurysms.
Lymphadenopathy.
Pelvic lipomatosis.
122
E 71
'"
rear-old ICl1lllc with 3.n incidental
kgo n de teCTed on ul trJsound.
71 a T2 weighted MRI scans with a normal and extended TE.
11b T1 weighted scans, in and out of phase.
123
ANSWER 71
Observations (71a, 71b, 71c) and 90% measure less than 4 em in diameter. Mul
T2 weighted im:ages demonstJ"3.te :a well defined, sligluly hacm:lIlgiorna may be associated ,\;th OsIcr-Wcbcr-
lobulated m:ass in the right lobe of liver, which is of syndrome. Some enlargement can be seen du
increased signal o n dIe normal T2 and UI[r.I-T2 weighted pregnancy.
seans (7 13). This is the so-c:llled 'light bulb' sign. Axi:ll TI • Imaging findings on ultrasound: well defined,
weighted images (7 Ib ) show thc lesion to be of reduced uniform, h~l>Crcchok lesion is the Iypical ulmsou
sign:al wit h no signal change in the Jj\·er on out of ph:asc 3ppcar:lI1cc (71 d ). No Doppler signal is seen widUl'
sc:allS to indicate that the lesion represents foca l t:-arty the lesion due [Q the low-,"c!ocity flow (7 1c). La
sparing. D}'namic post-contrast images (7 1c ) show lesions (;lll appear hn>occhoic and show flow
peripheral nodular enhancement with centripetal filling in ho\\'c,·cr.
o\·er time. These appearances arc diagnostic of cavernous Imaging findings all cr: lobubtcd lowattcl1uati
haemangioma. lesion, which is frequently peripheral in location.
Calcification is not common. Following comr.m
Diagnosis injection, there is peripheral nodubr cnhancelllcm
Cavcrnous haem:tngiom:l. with centripetal tilling. The lesion lIsuallj' fills in
completely o\'(:r 3-30 min to become isodcnsc \\;
Differentia l diagnosis II\'cr, though larger lesions ma~' show persisting
For hn>erechoic hepatic lesions on US: central noncnhanccmcnt/ scar and small lesions Il\lII
• Haemangioma. show immediate unitoml enhancement.
Focal nodular hypcrpl:asia (FNH ). Inllging findings on ~IRJ: haem:lIlgiomas show ~
!\dcnollla. signal on T2 weighted images [hat persist on mort"
t\'\c raSt:isis. heavily T2 weighted scans. This is called the 'light
Hep:atocell ular carcinolna. bulb' sign and is indicative of cyst or haemangior-.
Lipom:l. The enhancemelU pattern with gadolinium is as
described lor CT.
Discussion • Imaging t1nding~on sulphm colloid lItan: cold
Hepatic haemangioma is the most common benign tumour
of tile liver, anccting up to 20% oCthe population. The~' Usually imaging is sufliciclit to make thc di agnosi.)
:arc usually :asymptom:atic, being incidental findings 011 where :uypical features :afe present, biopsy CnI
imaging studies, however large lesions c:an present with undertaken prO\·ided therc is normal livcr between
:acure haemorrhage and abdominal pain; 90% arc solitary lesion and li\·cr capsule to pre\·ent haemorrhage.
124
71 Abdominal Imaging Case 72
tips Fu rther management

the illvcstig;ltion archaicc 10 characterize These arc essentially benign lesions and don't require any
:ted hlcm:mgioma. A positive '\ight bulb' sign furrhcr follow-up.
cs that the lesion is either a cyst or a
gioma. However, depending on the specific Further reading
allccS,I)()SI-contraSI SGI1lS rnaysti11 be VihnO\'3 Je, Bl fccl6 J, Smimiotopoulos }G , ct fli.
iraj as necrotic or cystic neoplasms can yield a (2004 ). Hemangioma from head [0 toc: MR imaging
"t' 'light bulb' sign. WiTh pathologic correlation. RadioGraphies 24 :
)If TV CQnlr.IS( - obtlin pre -conTrast scans, then 367- 385 .
.n 30 s (arrcrial phase ), 60 s (ponal phase ) and
min (equilibrium ph:lsc ).
centripetal enhancement is intense and nodular,
hi~hJy specific for the di:lgnosis of
gl01113.
125
ANSWER 72
Obse rvations (72a, 72b, 72c, 72d) In chronic pancrc:uitis (following sc\'CrJl bouts of 3(
Several axial cr images of the abdomen with IV contraSt episodes ), the pancreas becomes atrophic, there
cnhancctm:nt in the portal venous phase arc shown. There llluldtOcal calcificltion, the pancreatic duct becomes dilJt
is significant stranding of the pcrip:Ulcrc~ltic fat indicatil'e and chronic pscudocysts can form (7 2c ).
ofacutc inflammation, which is prcdominamly around the
pancrc:Hic tail. \Virhill the pancreatic tail, there is a Practical tips
moderate sized fluid-filled C)'stic lesion, which would be Look for the two main C:lUSCS ofpancre:ltitis - alco'"
consistent with a pancreatic pseudocyst in a patient with and gallstones. US is required to look for b"<lllstoncs
pancreatitis. The local inflammatory change appears to and can be used to look for complications, e.g.
extend to involn! the distal transvcrsc colon at the splenic pseudocyst formatioll and portal "cin thrombosis.
f1exurc. In addition, there is central low atlclU13tion within Look for the maill complications of pancreatitis .
the panal ,'ein extending into the proximal splenic vein in • Assessing the pancreas is beSt done by three phase
\ ,.,' 'r' ~ keeping with I.'Ortaljsplcnic vein thrombosis. The irn:lging \\'ith a pre·('ontT:lSt and 'pancrcatie' phase
~ 1 pancreatic duct IS d ilated al 4 mOl diameter. While the (~ 40 s) scan of the pancreas, followed by portal
whole b"<lllbladdcr h.\s not been im<lged - no g<lllsrones <Ire venous phase scans of the abdomen and pelvis. The:
seen on Ihese im<lges. The visualized liver edge is smooth pre ·contrast scan will allow lor assessment of
and liver has normal attenuation. calcification in the pancreas to determine whether
is an acute·on·chronic episode. Pancreatic phase sc
Diag nosis best assess for areas of necrosis and tixal mass ksi
Pancreatitis. Portal "enous imaging allo\\'s for assessment oflOQ(
disease and complications.
Disc ussion
Pancreatitis is an aCllte inflatnmatorv condition. There arc Further management
tWO main types of pancreatitis - oe<icmatOus and necrotic. Treatment is usually conserva tive although necrori
Oedem<ltous pancreatitis is the much morc common form, pancreatitis may well need more aggressive manage
eh;lr;ICtcrized by gland oedema, whereas necrotic panerea· involving surgery or percutaneous r:rdiologically gu
t:itis is rarer and is compliclted b)' pancreatic haemorrh<lge drainage.
and necrosis.
Appearances of the panercas in pancreatitis can therefore
\\ be variable, wi th the pancreas appearing normal, having
areas of nonenhancemcnt due to necrosis, ha"ing areas of
increased attenuation due to haemorrhage, or appearing
enlarged and oedematous. Universally, Streaking into the
surrounding fut due ro inflammation is obselyed.
Causes of pancreatitis include :
Alcoholism and g:lllstones :Ire the two most common
c:luses of acute pancreatitis. Assess for signs of alcohol
excess by looking for funy change in the li\'er (ditlilsc
low attenuation on cr, raised echogenicity on US),
cirrhosis (irregular nodular surfuce to the Ih'er which is
atrophic ) and portal hypertension (splenomegaly and
varices). Assess for gallstones with US initially, then
Mltep ifthere is still uncertainty.
Infections - hepatitis, IllUlllpS.
Trnuma.
Hypercalcaemia from multiple myeloma, sarcoidosis,
:lmyloidosis.
Drugs, e.g. steroids, diuretics (fruscmide, thiazides),
azathioprine.
Malignancy.
P,Hlcrearitis can be complicated by pseudocyst formatio n;

abscess formation (usually develops 2 weeks after acute
infl:J.mlllarion onset); spread of local inflammation to
in \'olvc bowel loops resulting in strictures, colitis and
pe rforation; portal ,"ein, splenic \'cin, Sl-'IV thrombosis;
ascites and chest complications - pleural effusion (usually
kft sided), empyema, unilateral pulmormry oedema.
126
M-old male presented with

-J. and chronic rcnal fuilurc _
127
ANSWER 73
Observations (73) Associations include:
Ultrasound longitudinal image of the right testicle Cryptorchidism.
demonstrates multiple sma!) hypcrcchoic foci, with no Infertility.
posttriar acoustic shadowing, disrribmed c\'cnl~' Klinefc!ter's.
throughout the. testicle. The testicle is otherwise of normal Down 's syndrome.
size and shape. No other focal mass lesion is identified. Male pseudohermaphrodism.
Al"eolar microlithiasis.
Diagnosis
Testicular microlithiasis. Practica l t ips
Identifying the disrriburion of calcific foci is im
Di scussion since a cluster of calcification within a hypocchOl"::
T esticular microlithiasis is a (ondition characterized by suggests nunour or chronic testicular infarction. I
failure of clearance of degenerated rubular epithelium from can be due to [Onion, trauma o r sc,'cre cpididymim..
the scminiferous tubules, which subscqucmly calcif)'. This
is an asymptomatic condition and is an uncommon Further management
incidental finding. [mage findings o n US arc of multi pic Urological referral with fo llow-up testicular US
small \ - 2 nlm hypc:rcchok foci with no acoustic sh:ad - monthly intervals to screen for malignancy.
owing, disuiblilcd throughout both teSles. Atypical
appearances of asymmetrical and unilateral foci arc also
seen. There is an increased risk of testicular gcrm cell
tumour in 40% and therefore follow-up \\~th 6 monthly-US
is oflen ath<iS'ctl.
ANSWER 74
Obse rv ati ons (74) Uretcral TB is found in 50% of gcnitourinary TB
Single AI' abdol11in ~11 r:ldiograph delllonstrntes amorphous, Radiographic features of involvement include
putty-like calcification within a shrunken right k.idney. filling defccts, calcification and strictures. Bladdtt
presents with a shrunken, scarred, calcified bladder
Diagnosis thick.ened wall and/or filling defects. Clinical p
Reml tuberculosis with autonephrectomy. is with frequency, urgency, dysuria, mic
haemaruria a.nd 'srcrilc' pyuria.
Discussion
The urogenital tract is the second most common site to be Practical ti ps
affcrted by TB, after the lungs. Renal TB is found in 5-1O'X. Urin;u)' tract TB spreads in an ante grade fashion.
of patients with pulmonary TB, bur there is only • Check chest radiograph for signs of pulmonary
rndiographic e"idence of pulmonary TB in fewer than 50%. but this is only seen in about 50% of cascio
The kidne y is usually affected first, via haematogenolls
spread from a lung/bone/GI focus. There can then be Furthe r m anagement
contiguous spread of inl~ction to im'ol\'e the ureters and Medical dmg therapy for TB should be initiated.
bladder. Renal TB is unilateral in 75% of cases and the most
common appearance is of a small, shnmken, scarred,
non fu nctioning kidney.
Less common appearances arc of:
• Cortical scarring.
• Rcnal pelvis/infundibular strictures rcsulting in
hrdrocalycosis and amputated calyx.
Ncphrolithiasis.
• Dystrophic parenchymal calcification.
128
cAr-old fe male presented with
129
ANSWER 75
Observations (75) Signs of free gas within the peritoneal ca"ity on a
Supine abdominal radiograph shows a positiyc 'Rigler sign' radiograph arc:
suggest ive OfpnClItllOpcrironclim. There is also outlining • 'rootb:l]] sign' - large round lucency in central
of the falciform ligamcm and the left lateral umbilical abdomen.
lig:amcnt wilh a large aTca of free gas seen overlying the 'Rigler sign' - air on both sides of the bowel w
liver. These findings arc consistent with pneumo- makes it unusually visible.
peritoneum. 'Triangle sign' - gas within bowd doesn't no
foml edges thercfo re such unusuall}' shaped
Diagnosis collections of air should arouse suspicion of ITtt _
Pncumopcriwilcum. 'Unchus sign' - olllline of median umbilical
ligament.
Differential diagnosis • Outlining off.:tlciform ligament as well as the IDe
Of causes ofpncumopcritoncum: and lateral umbilicallig-aments.
• Tr:lUllla.
• l:nTogcnic ClUSCS, e.g. laparotomy - usually gas should Practica l tips
hal'e resolved within 3 da)'s and its presence is If therc is an)' doubt about the diagnosis thcn m
suspicious after this; although it can take up to 3 chest radiograph or a left knera] decubitus film
weeks [0 resolve in some cases. Faster absorption abdomen should be acquired.
occurs with CO 2 :lIId in obese p:l.ticms.
Perforation of abdominal \iscus. Further management
Rupmrcd pneumatosis intcstinalis. Free intraperitoneal gas is suggestive of:a perforated
Rupture of an abscess. and is a surgical emergency - inform the surgiCJI
Exrcnsion from chest, i.e. pneumomediastinum, immediatcl~'.
broncnoplcural fistula,
Through femalc gcnital tract, e.g. intercourse, Further reading
waterskiing. Lc\'ine MS, Scheiner 10, Rubesin SE, n (II. (1991
Diagnosis of pneumoperitoneum on supine
Discussion abdominal radiographs. Amc";wn jOIIrlJII! of
T here :lfe a variety of signs th:lt aid in the detection of free Radiology 156: 731-735.
int raperitoneal gas.
ANSWER 76
Observations (76) Discu ss ion
Single image from a barium me:\l cxamination shows there Gastric carcinoma
is poor distension of the entire stomach, which is most lll:alignanc}' and shows an incre:lsed pre\'alcnce ill
evident in the bod}' and :lIltrum, with relative sparing of The scirrhous type of the tumour, which produco.
the cardia. Irregular gastric mucosa is seen within the plastica, accounts for 5- 10% of gastric cancer._
fundus and bod}'. The duodenum is normal. The infiltration of tumour causes fibrosis and rigi
appearances arc {hose of linitis plastica :and a gastric tumour reduction/ absence of peristalsis in affected area.
must be excluded in the first inst3.nce. fundus and body of the slOmach arc most
in\'olved.
Diagnosis
~::e~!:l~:l~tt~'~he st~lach
Linitis plastica due to brasrric carcinOllla.
on CT is often \'cry
Differential diagnosis due to poor distension; however, contrast
For linitis plastica appearance (m nemonic - 'CALM afe much better due TO their d}'llamic nature.
RAGE' ),
Cancer. Furth er management
Am~'loidosis. Referral to a gastroenterologist for endoscopy.
Lymphoma - usuall y non-Hodgkin'S type, most isappropriarc.
common pan ofGI tract ancCled.
Metasmscs - from lung, breast and melanoma. Further read ing
Radiation. B:a-Ssalam:ah A, Prokop M , U!'tinann!\i, tt (I/.
Alkalis and other corrosivcs. Dedicated multide[eetor cr of rhe sromach:
Granulomatous disorders, e.g. Crohn's, TB. spectrum of diseases. RadioGraphies 23 : 62-
Eosinophilic enteritis.
130
131
ANSWER 77
Observations (77a , 77b) Discussion
This fulllcngth film taken at 15 minutes in ;m JVU series This is ;\ condition characterized by multiple
shows multiple small, well defined, smooth rounded tilling subepithelial ftuid-nllcd CYSts in the wall of the renal
defects within both ureters. and ureters extending into the ureteric lumen. Theft'
association with recurrent urinary tract infections
Diagnosis obstmction, with a predisposition in diabetic patients..
Pyclonreteritis cystica. condition is asymptomatic and the lesions arc
premalignant. Occasionally it presents with haema
For radiolucent tilling defects in the ufeters: Practical tips
• Radiolucent calculi . Although any part of t.he ureter n1JY be invoked,
• Transitional cdl carcinoma (Tee). slight prcdilcction for the upper third.
Pycloufcrcritiscystica
Blood dots. Further management
Ureteric polyps ChJrJctcristic IVU JppeJrances may well pe ~
Sloughed renal papillae. confidcnt diagnosis. H owever, if there is diJgDI
uncertainty then ureteroscopy with biopsy may so
be required. Antibiotic treatment may be unde
though the response is variable.
77b Multiple round filling defects.
132
E 78
ry
fnr-ol d fe male with diabetes
trd \\1m renal failure.
133
ANSWER 78
Observations (78a, 78b) of the renal pyramids. There is a progression in
Two images from an IVU series arc shown. There is appearances as disease progresses. Phases of de\'cl
evidence of renal papillary swelling and enlargement. The Papillary swelling/enlargement .
intcrpoJar calyces on the right have a 'ball on ICC' Panial papilla')' sloughing - tract fomlation
appearance with 3 collection of contrast m~ucrial in the communicating with an irregular ca\·ity. On an I\
cemre of the papilla. A partial duplex system is also this is shown by the 'ball on tee' appearance \\itb
dcmonstr.ltcd on the right. There is a well defined contrast extending into a cemrall~' cavitated pa
intr:aluminal non-opaque filling defect in the upper ureter • Total papillary sloughing - which gives a 'signet
on the right, which repre$Cnts a sloughed papilla. appearance 011 IVU \\~ th the nonopacified slou_
papilla being surrounded by contrast in the
Diagnosis calyx/ ureter.
Renal papillary necrosis.
Practica l tips
Differential diagnosis To diflerentiate between the various causes, ide
Of causes ofrcnall':lpi llary necrosis (mnemonic - 'SAD whether the involvement is unilater-al (renal \'ein
ROPE'), thrombosis, obSITucri"e uropadly) or bilateral
• Sickle cell disease. (s}'sterniecauses).
• Analgesics. Diabetes is the most frequent cause (50%) .
Diabetes. A classic 'cx;lm type film' to be aware of is the 1\1.:
Renal ,-cin thrombosis. showing renal ,"'pillal)' necrosis and background
Obstructive uropathy. abnormalities ofa condition that has been treated
Pyelonephritis. with NSAlDs, e.g. ankylosing spondylitis, or boo!
Ethanol abuse. changes of sickle cell disease.
Discussion Furth er management

Renal papillary necrosis is caused by a variet), of disease Trcatmem ofthe condition requires identification (X
processes that rcsuh in ischaemia of the papillary portion unde rlying cause and control of this disease process
C'
"
7ab Sloughed papilla (left) and 'ball on tee' appearance (right).
134
CASE 80
History
A 28-year-old female presented \\;th tipper
abdominal pain , pyrexia and jaundice.
135
ANSWER 79
Observations (79) CytOmegalol·irus (CMV) <>esophagitis - presenrs
Single image from;} barium swallow examination shows a radiologicall)' with a single or multiple giant flat
shaggy, ulcerated Illllcosal pattern in the thoracic superfici;llulcer{s) ncar the gastro-ocsophageal
oesophagus typical of candidiasis. junction. Less commonly, it can present as discrete
small superficial ulcers as arc seen in herpes
Di agnosis oesophagitis.
Calldidn ocsophagitis. H IV ocsophagiris - chamcterized by giam
oesophageal ulcers, difficult to differentiate from
Discussion O .'IV <>esophagitis.
Cnlldidn ocsophagitis is the mOst COllllllon cause ot'
infectious ocsophagitis with C. (I/bicfllIS being the most All affect imlllunocompromiscd patientS :lIld arc mrcly
commonly ilWol\"cd org:lIlism. Immunocompromiscd in immunocompctents.
pariems have a predisposition to infection. Prcscmarion is
with gradual d)'Sphagia, odYllophagia and rCl.rostcrnal pain Practical tips
Association with oral infection is seen in up to 80%, Do 1l0tmistJke pseudodil'erticulosis of the oesophagus
characterized by SlTcral pltchy, white plaques cOI"cring the deep ulceration. This is a benign condition II
mucosa. In the oesophagus there is predilection for the oesophageal mucous glands become dilated and torm
IIpper 1J(f/fQ!tlJe oesopllflg/IJ with the appear-Jllcc of multiple, shaped outpouchings rrom the lumen. It is associated
shaggy, longitudinal mucosal plaques. There is reduction any $CI·ere ocsophagitis (sec Case 38 ).
in primary [Xrisf"Jlsis and some narroll;ng oCthe lumen due
to spasm and oedema. Stricture formation is a rare Further management
complication. Always consider immunocompromi~tion if not
Other infecti\·e causes of ocsophagitis include: alreadyapparenr.
Herpes ocsophagitis - the second most C0111mon cause Oropharyngeal candidiasis ma)' be a pointer to th~
of infectious ocsophagitis. Caused by herpes simplex nature of oesophageal ulceration but upper Gl
virus ( HSV) type I and most commonly presenting in endoscopy is still often needed to confirm via bi
males in 2nd-4th decades. Usuall)' involving the mid and brushings.
oesophagus, there arc multiple small discrete Antifungal or amiviml drugs tor treatment as
superficial punctate ulce rs. T he intervening mucos.:J. is appropriate.
usually of normal appearance.
ANSWER 80
Observations (80a, 80b) Associations orCaroli's disease:
Axial CT image and coronal reformats ofthc liver with IV Medullary sponge kidney (80'it).
contrast in portal ,·cnolls phase are shOll'n. There arc Polycystic kidney disease.
multiple, well defined low attcnuation cystic structures seen • Congenit;ll hepatic fibrosis.
throughout the liver. These appear to be communicating • Choledochal cyst.
lI'ith the bile ducts and are better demonstrated on the
coronal reformatted imagcs (SOb), No calculi are scen in Complications include biliary stasis, stoncs,
the ducts. The CT appearances arc highly suggcstil'e of hepatic abscess. There is an increased risk
Caroli's disease and the clinical detJils suggest cholangitis carcinoma in patients ,,;th Droli's disease. Biliary .
has de\'clopcd. and porral h)'I>Crtension arc 1/{Jf;complications.
Diagnosis Practical tips

Caroli'sdisease. Diagnosis is dependent on showing that the
communicate lI'ith the biliary tree - coronal and
Discussion reformats call be essential for this.
Caroli's disease is a rare autosomal recessive disorder
characterized by multifocal, cystic dilatation of the Further management
intrahepatic bile ducts. The differential diagnosis for this If there is anI' concern as to whclhcr the
condition is polycystic li\·er disease, however the two can communiCating, MRCP (magnetic resonance
be discriminated by identif)'ing the communication pancreatography) is a noninvasive method I
betwcen 'cysts' and bile ducts in Caroli's.
136
137
ANSWER 81
Observation (81a, 81b) on US to differentiate focal forms of the condition fr
Two MIU images are presented - T2 weighted sagittal and uterine fibroids.
axial images through the pelvis. TheS(: images show bulky US appearances afe of poorly defined hypoechoic area
enlargement offhc uterus. The junctional zone is widened within the myometrium with multiple small, 2-4 nu:a,
and poorly defined and the re aTC l11ultipk high signal fixi ectopic endometrial cysts seen withill the myometriu
within the myometrium in keeping with ccropic There is thickening of the anteriof and posterill
endometrial tissue These appearances arc typical of nwometrialwaiJs .
adenomyosis. . Ivl Rl appearances arc \'ery similar - myometrial \\
thic kening; high signal (on T2 weighted images) ect
Diagnosis endomctrial cySts in the myometrium and focal/di
Adenomyosis. thickening of the innermost layer of myometrium kn
as the junctional zone.
Di sc ussion Symptomatically pjticnts present with menorrhap.;..
Adenomyosis is a chronic condition affecting women pelvic pain and dysmenorrhoea and the condition can
during the re productive years. There is III incrclscd to infertility.
incidence in multiparous women, suggesting that uterine
trauma plays a role in the development of this disease. The Practical tips
disease is characterized by ectopic endomerrial tissue Widening of the junctional zone with eCTopic cndom
spreading into the myometrium resulting in myometrial cysts arc the best M RI features for diagnosis.
hyperplasia. The condition is benign and although it is
associated with endometriosis, there is no increased risk of Further management
de"cloping endometrial/utcrine malignancies. The disease Hysterectomy is the only management option to rc
can be either fOCal or difli.tsc. It can sometimes be difficult symptoms.
ANSWER 82
Observations (82a) Imaging features on US arc of curvilinear/pun
Single AP radiograph of the abdomen demonstrates a large calcification in the lhickened wall oflhe gallbbdder, \\
mass lesion in the right upper quadrant, which shows can be local or affecting the whole wall , wi th Illi
clllyilinear calcification of the wall. Appearances would best jcoustic shadowing. On oral cholecys tograph y_ -
fit with this being a calcified wall of the gallbladder. No gallbbdder is found to be 1l0nh.lIlctioning. The illl
discontinuous areas in calcification jre seell. of identiF,'ing the condi tion is the risk of den'l
gj!lbladdcr carcinollla, which occurs in 10-2 0% of
Diagnosis Appearances of galibladder carcinoma in this simation
Porcelain gallbladder. be of a luminal tilling defect, infiltration cjusing focal
thickening or a localized filllgating mass. Cholecyst
Differential diagnosis is therefore recommended e\"en if the paticlU
Similar appearalll.:es on US can be due to: asymptomatic.
• Emphysematolls cholecystitis.
• Gallbbdder filled with stones Practical tips
• Normal gas-filled bowel • Ultrasound and CT scans should be scrutinized far
secondary gallbladder malignancy when porcelain
Discussion gallbbdder is noted
This is an idiopathic condition that was coined to describe • A discontinuity in the calcification whcn the whole
the blue discolouration and brittle naUlre of the gallbladder gallbladder wall appears to be calcified may be a
at surgery. The condition is associated with gallstones in to gallbladder carcinoma.
90% of cases and is more frequently seen in women (sex
ratio of 5: 1). Patients are usually asymptomatic and Further management
diagnosis is made incidentjlly on plain films or US CholeeystectolllY is advised due to the high risk of tuml
imaging. Radiographic appearances mirror the histological
findings of dystrophic calcification in a chronically inflamed Further reading
gallbladder. T he caleification can be of twO types: Kane R, Jacobs R, Katz], Costello P ( 1984). Pore
• Curvilinear calcificjtion in the muscularis (82b). gallbladder: ultrasound jnd cr jppearances
• Punctate calcification in the mucosa/glandular spaces. Radi%gy 152: 1"37- 141.
138
139
An swer 83 Abdominal Imaging
ANSWER 83
Obs ervations (83a, 83b, 83cl Endometrial deposits can be focal or diffuse. In
Three MIU images arc shown - a sagittal T2 weighted case, the cbssical ap pear:mcc of an endometrioma
image (833 ), axial Tl (83 b ) and axial Tl weighted lilt 'chocolate cyst' is shown with a 1- 5 em cyst contai
suppressed image (8 3c ). There is a large 4 em lesion layered blood products of high signal on T l and _
idcnti licd within the left ol'ary, which is of high signal 011 weighted images. There is no signal loss on fut supprl!SSl(
both T I and T 2 weighted images and shows no fut sequences. The diffuse form is more common, how("l
suppression. On the sagittal T2 weighted image, there is with multiple smaller scattered cysts seen in se\
el'idence of layering of the contents of lhis mlSS. These locations.
appearances would be entirely consistent with blood Complications depend on the site of the deposin
produC[s and the lesion represents an cndomeniorna. can result in:
InfertiliTY (due to involvement of the fallopian tubes
Diagnosis causing adhesions/fibrosis ).
Endonletrioma. Bowel obstruction (due to fibrosis/stricturing oflbt:
bo\\'clwall).
Di scussion Pneurnothor.lx (due to spread to the pleura ).
End ometriosis is a chronic condition characterized by
ectopic deposits of endometrium outside the uterine cavity. Practical tips
It aflccts women in the 4th-6th decades and is Endometriomas can be diOcrcnriat'cd from de rmoid
characterized by chronic pe!\'k pain, dysmenorrhoea, by using 3. fur suppressed MRj sequence. Both will
menorrhagia and dyspareunia. Common sites for high signal on TI and T2 weighted images
endometrial deposits arc the ovaries, fallopian rubes, pouch endometriomas will still be high signal on fa t supp
of Douglas and uterosacralligarnents, however more dist'Jl sequences.
spread can occur to the bladder/bowel wall with even
further distal spread to the lungs and plcur.l. Spread to the Further management
G I tract most commonly occurs TO the distal sigmoid :llld This wndition can be difliculr 10 COntrol.
the rect'osigmoid wall and deposits can result in peritoneal management with hormonal suppression of menst
ad hesion and subsequent obstruction. Repeated bkeding is often attempted but surgical excision may be req
of the ectopic endomet.rial deposits results in fibrosis and
pain.
S3e l esion remai ns high signal on the T1 fa t

suppressed image suggesting that it represents blood .
140
-old female presenlcd

.tbdominal pain.
141
ANSWER 84
Observations (84a) Appearances on plain radiograph: teeth occur in 56
This single image from a double contrast barium enema of cases and arc readily identifiable. Mass effect \\ith
shows abnormality of the sigmoi d colon with poor bowel loop displacement is otten seen (84b). The
distension and apparent e:\ternal compression of the bowcl image shows a cemral lucent demit}' rcprcscntatin '
loops inferiorly. Thn:e well (Idined eakifie densities an: seen f:tt in the right side of the pelvis, which is dispbcing
adjacent to the affected segment and ha,'e the appearance of sigmoid colotl.
teeth. Appearances on us/crjf\'lIu ::t well delincd high
cchogcniciry lcsion is identified in the o\'ary due to
Diag nosis high fur content (84c). Again teeth arc easily
Ovarian dermoid. identified with posterior acoustic shadowing, \\idUII
the solid Rokit3nsky nodule. Fat is readily iclcntifiUo
Discussion 011 CT and J\'I RJ b~' virtue of its low density :lIld hi_
Ovarian dermoid cyStS arc benign lesions, which arc signal.
relali,'cly common, accounting for -20% of all o"arian
neoplasms. These mostly present during the reproductive Complications arc of torsion, rupture and mali~
years, with a mean age of presentation of 30 years. They degeneration (seen in 2% of cases).
contain tissue from all three germ cciliayers - ectodermal
(ski n, brain), meso<icrmai (muscle, f.lt ) and endodermal Practical tips
(mucinous/ciliated epithelium ). TUlllours arc bilateral in Some films uscd in radiological exams rely on the can
- 10%. nOling an incidental lesion at the edge of the film.
Trpical appearance is of a unilocular cyst, lined by in ovarian dermoids arc a classical example of an 'ed~
squamous epithelium and containing sebaceous, fatty the film'case!
material \\~th hair follicles and skin glands arising from the
wall . A proruocrance into thl: Cl.vit), known as a Rokitansky
nodule is usually the site ofbone/teelh material.
142
84 Abdominal Imaging
ma nagement Fu rther reading

the re is still clinical concern after l.lltrasound, OutW3tcr EK., Siegelman ES, HllIlI JL ( 2001 ). Ovarian
~ useful in completely characterizing these teratomas: tumor I)'pes and imaging characteristics.
Figures 84d-f arc axial T2 weighted (84d ), RndioGrnp/)jcs 2 1: 475- 490.
ghted (84c) and fut satur.llcd (84f) axial
_ of the pelvis showing dermoid cysts in both
. The right most cyst shows signal void
rly on all image sequences in keeping with
--,nion :l1ld complete f.1 t suppression confirms the
inam fat coment ofthcsc lesions.
ani to gynaecologist for surgical excision.
84d-84f Axial T2 weighted (84d), T1

weighted (84e) and fat saturated (84f)
axial images of the pelvis showing
dermoid cysts in both ovaries. Loss of
signal on the fat saturated image
confirms the high fat content.
143
CASE 85
History
Incidental li'"cr lesion W,\S nOfcd on
abdominal ul trasound scan ora 26-ycar-
old female
145
An swer 85 Abdominal Imaging
ANSWER 85
Observations (85a. 85b) Liver specific MRI contrast agents can help further..
Selected prc- and post-contrast l'vIlU images of the liver. In this case, a gadolinium agent with additional li,
Prc-contr:lSt images (853 ) demonstrate:l brge, well defined specific properties (Gd-BOPTA) has been used.,\[
lesion in segment 4 of the liver, which is of slightly reduced gadolinium chclates in current usc arc cxtraecll
signal on Tl weighted images. Out of phase Tl weighted agents that arc excreted \·ia the kidneys. Gd-BO PT.
images show 110 significant alteration of liver signal [0 and Gd-EOB-DTPA arc tll"O agents cUTrently in
suggest the area is due to focal f.ltty sparing. The lesion is that ;1]SO show a proportion ofhepatie excretion. Tbn-
slightly hyperintense on T2 weighted scans. beha'·e the same as conventional extracellular age
On dynamic post·conrrast imaging (85b ), the lesion during the arterial, portal and equilibrium phases of&.
ShOII'S marked enhancemem during early arterial (25 s) MRI, but also ilhlS[rate funcrioning hepatocyte ti
phase with a central hypointcnse scar ,·isible at this stage. on delayed illl;lges. Since FNH contains hepal00
There is subsequent wash out of contrast in the portal (60 and abnormal bile ductules, such agents arc rctai
s) and equilibrium (3 min ) phases to become isointense within FNH on delayed images {20 min to 2
with liver. The central scar shows enhancement in the depending on the agent}. Other non·gadolinium
equilibrium phase. liver specific MRI contrast agents can similarly
T he contrast agent used is gadolinium BOPTA (Gd- characterize FNH on the basis of the fu nctio
BOIYfA) and the image taken at 90 min shows persisting hepatic tissue elements it contains.
contrast uptake within the lesion indicative of hepatocyte Imaging features on angiography: these lesions
content. These appearances and pattern of enhancement usually ha'·e a central supplying artery with centri fu~
would best fit with the diagnosis of focal nodular filling giving a 'spoke wheel' appearance; this can
hyperplasia. difl"crcntiation from an adenoma, which has several
peripheral supply vessels.
Diagnosis Imaging features on sulphur colloid scan: usuall y
Focal nodular hyperplasia (FNH ). these lesions show normal activity due to the pre
ofKllpflercclls.
DiHe;e ntial diagnosis
For hepatic lesion with central scar: Practica l tips
• FNH. • Sulphur colloid SC:lllS h:w(' Tr:lditionally been used'
Adenoma. help confirm FNI-I suspected on CT and M IU by
Hepatocellular carcinoma virtue of the pn:scncc of Kuptler cells. Liver spccili.:
H aemangioma. contrast agcnts ,.1s described above lllaY .1l0W 0
Fibrolamellar carcinoma. this in many cases.
Hepatic adenoma is a cOlllmon ditlcrcntial when
Di sc ussion FN H is considered and there is evidence that ag~
Focal nodular hyperplasia is a benign hepatic lesion that such as Gd-BOPTA can help ditfcrcnti:J.tc FNH .
occurs mOst commonly in young/ middle aged \\"omen hepatic adenoma h), dClllonstr:lting the presence at
Usually these patients arc asymptomatic, with diagnosis functioning liver tissue in rhe fonner.
made as an incidental finding, although some patients can
present with vague abdominal pain. They are solitary Further management
(85-95%) vascular lesions containing normal hepatic Difl""erentiation frolll adenoma and hepatocC"
elements - Kupffer cells, hepatocytes and bile ducts carcinoma can sometimes be difiicult el·en Ilith histol
Imaging features arc very similar to those of hepatic inlormation. Excision is then carried out.
adcnomas. Unlikc hepatic adenomas, development is not
associated with the oral contraceptive pill, though Further reading
ocstrogens can exert trophic ctlccrs Schneider G, Grazioli L, Sai ni S (2005 ). MRI oftlJ(
Focal nodular hyperplasia is dil'ided into typical and Liller. Springer, Nell' York
atypical groups, with approximately 50% in each. Typical
lesions show the signal characteristics, enhancement pattern
and central scar as described below. Atypical lesions may
show signal heterogeneity, with more marked '1'1 and T2
hyperintensity, and no centr.ll scar .
• Imaging Icatures on cr and J\HU: classical FNH is
isodense on CT, while MRJ shows mild Tl
hypointensity and mild '1'2 hyperintensity. There is
prominenr enhancemellt in the arterial phase
following IV contrast, the central s..::ar being
conspicuous at this point due to nonenhancement.
Contrast washes out rapidl). in the portal and
equilibrium phases to become similar to normalli,·er,
though there may be scar enhancement in the
equilibrium phase.
146
Chapter 3
CENTRAL NERVOUS
SYSTEM, HEAD AND
NECK IMAGING
D MRI HEAD
imaging, if:ln abnormality is nOT obvious at first amounts ofsubarachlloid blood layering in the ~>
..Deck all arcassyst'cmatically: occipital horns or around the medulla close [0 the
h if IV contrast has been given. fornmen magnum.
les - check the configuration and size, ensuring Pituitary - this is well sccn 011 sagittal MRI scallS, so
is appropriate for the other CXf!.l-3.xi:J.1 CSF do not forget to chcck it.
such as the sulci.
hemispheres, brainstclll and cerebellum - on A notc on mass lesions:
in particular, there is a lot of information to \Vhen confronted ,\~th an intracr:lIlial mass lesion, assess
tc for focal masses, signal abnormalities and the following:
ral abnormalities! In examination \ 'iVa5, it may • Location - cemin tumours ha\"{~ a predilection for
lIIlrC'alistic to expect the candidate TO quickly detect certain areas of the brain .
.lhnormalitics so you may well be gi,"cn some • Age - this has a strong influence o n the differential
cc or JUSt presented with selected images. A diagnosis. Certain rumours are common in the
~",lluation of FU\JR (fluid anenuatcd inversion paediatric age group while metaS[;lses always have to
:) or PD (proton density) sequences may be considered in the older adult population.
.' lead you to pathology on M RI . Is the mass intra- or eur.t-axial - that is, does it
-axial spaces - carefully check for normal size, originate within brnin substance or nOt? The
c of blood or other collections. distinction is very important in fomling a differential
is - chcck for enhancemenr on cr and normal diagnosis and though it seems obvious, can
\Xtids on i\'IIU {including vessels at the skull sometimes be difficult to establish on cr in
particular. An eurn-axial mass causes crowding ofthc
periphery - assess orbits, sinuses, temporal subcortical white matter fronds that extend between
Iskull base and skull vault. gyri. Com'erscly, an intrn-axi31 mass stretches the grey
matter around it and consequently displaces the
e has their own blind spots bur here arc some fronds of white maHer 3parr.
ed areas 1'0 check when all else seems normal: Mass eflcer and oedema - check ror midline shift and
tempo ral lobes and posterior fossa 011 cr - effacement of normal CSF sp3ces such as sulci and
ges of the teml>oral loocs arc often degraded by cisterns. If extra-axial CS F spaces arc obliterated,
artefucr and pathology easily missed. The same there is risk or death due to br:lin herniation th rough
to a lesser extent ill the posterior fossa. dural al>c rt ures. !f rou see such features, then indic3te
base and petrous bone - pathology GI.Il be easily the degree of urgency required in seeking
JUiooked, especially on M Itl where there is a lot to neurosurgical evaluation and intervention.
• Assess the enhancement pattern of the lesion. This is
- ~. signs of stroke - the earl~' changes ofinfurction often nonspecific but certain patterns such as the
be \'ery subtle. Carefully check for subtle focal intense, homogeneous enhancement of meningioma
'ng and reduced grey-white matter ma~' allow a confident diagnosis.
rcntiatio n. The Imer is beSt detected by using
I11II:I'\' 'narrow windows' oncr.
• c:Oous sinus thrombosis and subdurnl empyema arc CT AND MRI NECK
disorders with significant morbidity and mortality C ross-sectional imaging of the neck requires excellent
t can Ix easily overlooked. When presented with an an3tomical knowledge! Familiarize ~'oursclf with the
~ntly no rmal cr of a patient with a history of anatomical divisions of the upper aerodigesth'e traer, the
cDmincing acute imracrnnial pathology, always double fascial Sp3Ces ofthe neck along which tumour and infection
.:Deck for increased density in the venous sinuses and track, and the nodal stations of the neck. With this
mbtle subdural collections. Administrntion of IV knowledge, you can make a meaningful interpretation for
~urast may help confirm either. the E?-..TT surgeon . T2 weighted scans with fu! suppression
- Hxmorrhage - subtle subarachnoid or subdural arc particularly useful to eV31uate at first inspection if these
tiood. must not be missed. C heck carefull~' for small arc avail3ble, for detecting both primary pathologr and
147
eNS, Head and Neck Imaging
nodal disease. Thereali-cr, sinmltaneous examination of the Look at the sofi- tissues of the anterior cen'ical space.
Tl weighted scans can help to better delineate the precise which should be no greater than a third of the width
anatomical location of disease. ofa vertebral bod" for C I- 3 and no more than the
width ofa \'ertebr:al body for C4-7 . Check the
imen'al between the anterior arch of atlas and the
~~~IIN RADIOGRAPHS ~ ~~1~~1;ol~~n;~~ ~d~i:s s~~r~ 1~~~I~~a~~;i~r~I~. greater
T here arc a very limited number of pathologies that arc On the AP film :J ]ook for misalignment of the
likely to be shown on a skull radiograph: vertebral spinous processes in a \'Crtical plane, which
would suggest a flcet joint dislocation. Ensure that
Trauma the AP 'peg' view adequately excludes a C2 peg
As well as skull fractures, check for indirect signs of fixture fracture.
such as fluid leyels in sinuses and intracranial air. Remember When you arc suspicious of an unstable fracture, nak
10 look at all the bones on the film - the fracture of this clear so that adequate steps arc taken to prote...,
~ odontoid peg at the edge of the lateral skull film is a basic the cervical spine until such time as this has been
exam type of case. confirmed or excluded with CT.
Calcificatio n When assessing thoracic and lumbar films, carefully chco.

Know the normal intracranial calcifications such as pineal alignment and \'ertebral body height. On the AP fil m
and choroid plexus so that you can ditlerentiatc from the thoracic spine, look for widening of the paravcrte
pathological calcification such as that associated with stripe suggestive ofhaematoma.
meningioma.
Mali gnancy
Pituitary Bony involvement is one of the most common sites
Size and shape of the pituitarr fossa should be assessed. metasratic tumour spread along with the lungs and Ihu
Vault ~ ,-~o~I~~rl~~~~ol~i~~II~~:'~I~~~~~~,i~;,n:e~~~~l~~~~~::e~~
Several diffuse processes have characteristic changes on the spinous process for lytic deposits. As ever, pay attention
skull radiog raph and make for 'spot diagnoses', e.g. the soft tissues - a paravertebral soft tissue mass may ~
acromegaly, fib rous dysplasi;l, th3lassacmia, you to a subtle bony lesion. Do not lorget that \\
hyperparathyroidism ;md myelon13. mrcloma classically produces foc al bony lucencies
possible resulting vertebral collapse, a significant nu .
Spine of cases show only diffuse oSleopenia, which can III
As always, there arc many potential pathologies to sec on osteoporOSIs.
plain films of the spine but trauma, infection and neoplasia
arc particularl y common. Infection
Spinal infection is usually centred on the disc and the
Tra uma there will be a reduction in disc height with i1l\'olvc
When ;lssessing cen'ical spine films' of the superior endplate of the vertebral body belo\\
-0. • First ensure that the complete cervical spine has been inyoh·ement of the inferior endplate of the vertebral
imaged down to C7- Tl level above. Added sofi- tissue d\le to abscess is likely to be
On the lateral film, look at the anterior spinal, and in the cervical spine will be seen as a preyertebral
posterior spinal and spinolalllinar lines to ensure tisslle Im.SS on the lateral cervical spine film; in the [h
continuity (I.e. imaginary lines drawn along the spine this will be seen as a widening of the paravert
anterior and posterior vertebral body cortices and stripe; and in the IUl11b::lf region there may be a
along the anterior limits of the spinous processes). abscess
148
eNS, Head and Neck Imaging Cases 86, 87
~d presented with bilateral

dcafilcss.
149
ANSWER 86
Observations (86a) exceeds 1.5 mm. Figure 86b indicates the dil:J.ted aqu
Single high-resolution axial CT image of the skull at the in rhiscase.
level of the petrous bone. There is bilateral enlargement of Diagnosis of the condition is important due to the _
t he vestibular aqueduct. Preci se measurements have not results achie\'cd with cochlear implantation.
been documented but the aqueducts afC dearly significantly
wider than the horizonta l semici rcular canal seen on the Practical tips
right. A quick assessment of the vestibular aqueducts can
made by comparing the diameter at midpoint to thc=
Diagnosis diameter of the adjacent posterior semicircular ca~
Enlarged vestibular aqueduct syndrome. the aqueduct should not be larger.
When identified , check the cochlea for e"idence of
Discussion dysplasia.
Enlarged vestibubr aqueduct syndrome presents clinicall)'
with sensorineural hearing loss. Hearing is usually prescnt Further management
:\f birth and then deteriorates from age of -3 years. Advise on a\'oiding head trauma where possible, t .~
Deterioration is often in a stcP\\~SC manner, associated with no contact sports.
episodes of minor head trauma. There is a suggestion of an • Hearing can be improved with cochlear implants.
inherited recessive genetic link and 50% of cases arc
bilateral. A degree of cochlear dysplasia is present in 75% Further reading
of cases. Dahlen RT, H arnsberger HR, Gray SD etal. ( 1997 ).
The normal endolymphatic duct o riginates from the Overlapping thin -section f.1st spin-echo MR oftht
vestibule, via the common crus and extends posterolaterally large \'estibular aqueduct syndrome. American
in the bony vestibular aqueduct to t he endolymphatic S.1C. jOltrlml of Neuroradiology 18: 67- 75.
The endolymphatic sac li ~s on the posterior aspect of the Valvassori GE ( 1983). The I:J.rge vcstibul:J.r aqueduct
petrous temporal bone. Enlarged vestibular aq ued uct associated anomalies of the inner car. Otola171lgo _
syndrome is diagnosed when the diameter at irs midpoint C/illicsofNortbAmeriCll 16: 95- 101 .
86b Axial CT image demonstratin g an enlarged

vestibu lar aqueduct.
150
eNS, Head and Neck Imaging Case 88
187) Althollgh sialography is the primary method of

que image from a parotid sialogr-anl with no diagnosis, US is useful for tollow-up as it avoids thc
iiIm provided for comparison, The parotid duct is radiation burden and invasive nature of sialography. At US,
calibre with no obstructing stones or stricture. the gland is swollen with :I hettrogencous appearance and
florid pUllerate dilatation of the multiple hypo<:choic tOci within it. lntraglandular reaerivc
_ _ _""'I" ",,,,,,,,1,,· and acini in keeping with punctate lymph nodcs may be noted
Practical tips
lnrraglandular lymph nodes arc seen in the parotid but not
the submandibubr gland, which becomes encapsulated
before lymph node de,"dopmellT occurs embryologically.
Further management
recurrent sialadcnitis is llSU;\lIy associated with Although sia1cctasis most commonly idiop;\thic, Sjogren's
,[rietllTc causing duct obstruction. These causes, syndrome can also cause this appearance and shou ld be
• Me rare in children and chronic infhlmmation is excluded with laboratory investigations. I'/J ?
JlTlmonJy idiopathic in nature. The parotid is
more than the submandibular gland, perhaps due Further reading
par.ltivcly smaller salivary Olltput. Clinically, Yam KL, L1U C, Li CK ( 1997 ). Primary Sjogren
present with repeated artacks of swelling of tile syndrome prescnring as rccurrclll parmitis. HOllg
associated fevcr. Age of onset is typically 3- 6 KOIIDJolmlal ofPaediarriu (Ncw Series) 2: 47-50.
symptoms usually rcsoh'ing sponranl"Ously after
151
Answer 88 eNS, Head and Neck Imaging
ANSWER 88
Observations (88a) Musele bellies arc ani..~cted with swollen appearance
CorOIl:ll Tl weighted MR il11agcsofthc orbit show llllrkcd and relative sparing of the tendinous insertions. Axix
bilateral swelling of the muscle bellies of the interior, medial CT images (88b) show swollen medial recti with
and superior rc([Us muscles with sparing of the tendinous t)'pical sp:lring of the tendinous insertions
insertions. This disrribution of extraocular Illuscle swelling Proptosis, lid retr:lctiOIl and reduced eye mo'"eIllCnlS
is typical ofth~'roid ophth:tlmoplthy. are features.
Diagnosis Usually rhe disease resolves spontaneously but ste

Thyroid ophthalmopatlw. trcatmCnt is prescribed to treat the swelling :lnd [0 red
intraorbit:ll pressure, which can otherwise cause optic n
Differential diagnosis and ophthalmic "ein compression. Surgical decompressil
Orbital pSCudotlllllOur - usually ilwokcs both muscic is sometimes required when there is acute swel ling
belly and tendillo/ls jmcrtioll; is pnillflll compared (0 threatellcd visual loss.
painless thyroid o pluhalmopathy and is morc commonly
IIlIilateral. Practical tips
The order of muscles involved in thyroid
Discussion ophthalmopathy is ( from most to least frequent )
Thyroid ophthalmopathy is a disease of the orbit IntCrior>]\kdial>Supcrior>LaterabOblique - Mllen
characterized by deposition ofmucopolys:tCcharidcs \\ithin - I'M SLO(w).
the muscle bellies of the intraorbital muscles. [t tlsu:tll y
presents in adults and is more common in \\·omel1. Thc Further management
paticllt is usually hyperthyroid (although 10% of cases arc Thyroid ophthalmopath)' with visual disturbance req
found in cuth yroid patients) with ocular presentation prompt evaluation and treatmcnt gi"cn the potential
within I year ofhypcrthyroid symptom onset. Se"erity of to visual function.
the cye disease, howcver, is not rela ted to thc sC"crity of
thc th yroid hormonc imbalancc. Further reading
Radiological fcatures arc as follows Hosten N, Sander B, Cordes M, etn/. (1989). Gr.JXCS
Majority of cases arc bilateral although therc is often ophthalmopathy: Mit imaging ofthc orbits.
asymilletrical diseasc. About 10% arc unilateral RfldiologJ' I72: 759- 762.
lnft~rior and medial rectus arc most coml11only
affected, with the lateral rectus being lc,\st likely to be
affected.
88b Selected axial CT images through the orbits show thickening of tbe medial rectus muscles with
their tendons.
152
89
\-car-old lll ale presented with

al headaches.
89a Axial PO (top left), axial and sagittal T1 weighted (left), axial and coronal T2 weighted
(right) MR images.
153
ANSWER 89
Observations (8ga) Practical tips
Selected MIU images demonstrate a round lesion in the A large basilar tip aneurysm can be mist:J.kcn for a
amcrosupcrior aspect of the 3rd ventricle. The lesion is colloid cyst on uncnhanccd CT scan Jnd this rcq
mildly hypcrimcnse on Tl weighted images, with variable carly identification and treatment.
signal on T 2 weighted images and a graduated fluid !clod Need to assess whether or nor there is hydroccp
appearance. It is likely that the COntents are proteinaceous - look at the degree ofdilarariotl of the temporal
flu id and the findings arc consistent with a colloid cyst of horns oCthe lateral ,·cntriclcs and look lor depT
rhe 3rd vcnrriclc ofthc brainstcm
Diagnosis Further man agement

Colloid C)'SL Although these arc benign lesions they can present
with CSF flow obstruction resulting in headache, k
Differential diagnosis consciousness al1d death, so a clinical review tor evi
For 3rd vcntricular lcsion: elevated intracranial pressure and neurosurgical re\~
lvleningioma - these arc not usually hyperintense on appropriate.
T I . Meningiomas commonly caJcit)r and show diffuse
enhancement with cOntraSL
Ar.lchnoid cyst - these arc usually isodense on CT and
isoimense with CSF 011 MRi
Dermoid cyst - usually found in the midline. These
contain fut and arc therefore usuall~' hypode115e on CT
and have mixed signal on J'vllU.
Ependymoma of the 3rd ventricle - these arc "ery
r.lre. Imaging featllres i'nclude cystic areas, necrosis
and calcification and the y show diffuse uniform
enhancement.
Basilar tip aneurysm.
Discussion
Colloid cysts account for approximately 0 .5-1 % ofCNS
'tll11l0u rs' . They usually present in young adults and arc
more commonly seen in males. T he cysts arise from the
interior aspect of the septum pellucidulll and extend into
the 3rd vCllIricle. Presentation is usually secondary to
obstructed CSF flow at the leld of the 3rd ventricle with
features of positional headache due to tr.lnSielll obstruction,
distllrb:lIlces of gait, reduced consciousness lcl'el and
papilloedcma. The lllajority of cysts ( 80%) contain
mucinous material while 20% contain fluid similar to CSF.
Typical features on CT: well defined thin walled cyst
in the 3rd veillride of slightly increased attenuation
with no en hancement (8 9 b ). Can cause erosion of the
sella
Typical features on MRI : mucinous material contained
within the cyst produces a well defined lesion of
increased signal intensity on TI and T2 weighted
images.
154
- '"Car-old male presented with

\isual field blurring.
155
Answ er 90 eNS, Head and Neck Imaging
ANSWER 90
Observations (90a) proceeds to capsulation/abscess lormation at 10-13
This contrast enhanced CT image of the brain with the ring enhancement illustr:Hed. When arising
demo!lStr;ncs mul tiple ring enhancing lesions with hacmatogenous spread, the classic3l location is at
surround ing ":lsagellic oedema in the left frontal lobe. grC)'-whire nlltter interflce, and most commonly in
Though no lesions arc seen in the right hemisphere on this middle ..:erebral artery territory. The me.dil l wlll is -
single image, JPparcnt vasagenic oedema in the right thinnest (due to better perfusion of the grey m
frontal lobe suggests that there may be fu rther lesions on laterally than the white matter medially) and results .
this side that arc not visualized. The diHcrcntial di:tgnosis tendency to rupture on this 3spect into the "cntricle
for ring enhancing lesions is long, but the history of pyrexi:t
points towards cerebral abscesses being most likely. Practical tips
Dif'tcremiation ofthc above list call be difficult and
Diagnosis history is "ery important to identify immune statm...
Cerebml abscesses. foreign travel and clini..:al presentation
Look for complications of absces$Cs such as rnpflln"
Differential diagnosis causing meningitis Of ventriculitis, radiologically
For ring enhancing CNS lesions: identified bv enhancement of these structures or
Cerebral abscess. sigl1,\1 in thi: sulci on FLAJ R MR images.
Metastases. (I Wall enhanccmcnt of cerebral abscess is typically
Toxoplasmosis. unifOfm - thick, im:gubr wall enhancement sho
Demyelination. raise suspicion of ..:erebral metastases.
Lymphoma. A peripheral ring on the unenha nced scan is more
Mu lticentric glioma common in metastasis than glioma
l'v lultip.le inrnrcts . • Assess paranas;"ll sinuses for a primary source of
Resolv1ng haematomas infection and ensure a chest radiograph has been
10 look for sourccs ofinfcct'ion and potential rigb;:
Discussion left shunts.
Patients who arc immullocompromised, on steroids or have
dbbctes aTC more susceptible to CNS abscess formation. Further management
The most common SOU Tee of infection is haematogenous J'vI!U with diffusion weighted imaging can solllcri mo
spread, though direct spread trom intected paranasal sinuses ditlcrcntiate tumour/metastases from abscess. Rest11'
can also occur. Clinical presentation is with headache, ditfusion of pus in an abscess cavity meJns that an
seizure and pyrexia. Focal infection pre..:eding abscess is high signal Oll OWl Jnd low signal on ADC
tormation is ceTcbritis, and appears as foeallow-density diffusion coefficient ) mapping. O pposite findings
change on CT or high T2 signal on MRJ (90b, 90c). This with llccrorictlllllours.
90b, 90c Axial T1 weighte d postcontrast a nd coronal T2 we i g ht ed~M RI im ag e s

of left tempo ral lo be abs ce sses . The ax ial T1 postContrast im age s hows a n
e n ha ncing rim w ith s ur rounding low s ignal oed e ma. The coro nal ima ge s ho ws
a h igh signa l abscess with s ignificant high sig na l s urro undi ng oedema c ausing
a m od e rate d eg ree of mas s effect a nd midline shift.
156
91
Di scussion
Optic drusen arc focal accumu lations of hyali ne material
in the region of the optic nerve head, which commonly
calcify. Aetiology is thought to be either a dc\'clopmcnral
abnor!ll;llit)' or a degene rative process and it is
histopathologically separate from retinal drusen deposits
that call be a nOTmallinding or associated with age related
macular degeneration. Clinically. patients arc usually
asymptomatk bur can present with reduced \'isu:al acuity,
migraine-like headaches and pscudopapillocdema. Di:ag-
nosis is made by the absence of ad\·ersc imaging features
such as abnormal cnhanccmcnt, optic nen'C thickening,
mass dlcCI or postcrior globe solid lesions. Ocular ultra-
sound can be particularly usefu l in evaluating, and
confirming this is not anuall). papilloedema. Optic disk
haemorrhage is a very rare complication. The majoriry of
cases (75%) arc bilateral.
Practica l tips
• \.omcg:a]ovirus (CMV). Bilateral calcification docs not necessarily suggest a
• Herpes simplex. benign disc::lsc process. The nonherirable form of
retinoblastoma (66") presents at - 24 months \\irh
usually unilatcnl disease; but the heritable form (33%)
• 'lpticdruscn. presents ::II - 12 months with often (66%) bil::atenl
• _ rhisis bulbi. disease.
• lninal detachment
• ~rinopathy of prematurity. Further management
• thpcrcalcacmic states - hyperparathyroidism, Ophthalmologica l assessment is required 10 confi rm the
..an:oidosis, chronic renal failure. diagnosis and check viSllal fields and acuity.
g ad ult m:lle prescnted with

and panlysis of upward b'"lZC.
157
ANSWER 92
Observations (92) elderly. Germ cell tumours arc the most common tum
This midline saginal Tl post-contrast ,'vIR image ofthe pineal region, accounting for over 50% of all p.
demonstrates a large, slightly lobulated but well defined masses. The most common subtype is germinoma, which
mass in the pineal region. The mass enhances homo- histological1y similar to testicular seminoma. Pi
geneously, compresses the superior colliculus and causes germinomas arc well defined midline masses that arc
dilatation of the 3rd velUride. The most likely diagnosis is more common in m3les than females. T hey afe norma
a pineal germinoma causing Parinaud's syndrome and seen in children and young adults. The lesion enh
obstructive hydrocephalus avidly. Oue to the anatomical location of the pineal
these lesions compress the aqueduct ofSylvius produ
Diagnosis hydrocephalus. The superior col1iculus of the brain
Pineal germinoma. ma~' also be compressed producing Parinaud's synd
paralysis of upward gaze. Less common germ cd! ttl
Differential diagnosis of the pineal gland include teratOmas, which are m
Of pineal region masses: seen in young children. Choriocarcinomas and emb~
• Germ cdl tumours (>50%): cell tumours arc even less common and arc hi_
Germinoma rn~lignant
Teratoma - extremely heterogeneous mass. Occurs
in young children Practical tips
Choriocarcinoma. The pineal region is in the midline and masses in
Embryonal cell tumour. region may compress the aqueduct ofSyivius, so
Pineal parenchymal tumours (25%): ~. ~t;;~~~ ~~~~~;n~~S~I~~~~~~~r~~h~l~~~~al gland

• Pineoeytoma - well demarcated, calcified, slow exceeds I em in diameter a pathological pineal p
growing tumour in1middle ,'ged adults. should be suspected.
• . Pineoblastoma - si milar to medulloblastoma. Calcification in germinoma when present is ccntnIL.
Allects young children. Enhances avidly :llld is nOl pincobbst'Oma pniphaal.
usually well circumscribed. In ~'ollng children think of teratoma (which are \-
heterogeneous masses), pineoblastoma and a vein
Others: Galcnancurysm
• J'v lcningioma In young adults, the most common solid lesion is
• Epidermoid or dermoid. germinoma.
• Arachnoid cyst - CSF density/signal
• Pineal cySt - common; fluid density or signal Further management
though contents can be proteinaceous on MlU. Surgery is difiicult due to the central location in
• Lipoma The main rolc for surgery is in obtaining a
possibly debulkins of tumour to relieve
Discussion symptoms. However, serminomas arc
The pineal gland is a midline structure situated behind the radiosensitive and therefore radiotherapy is the
3rd ventricle and responsible for biorhythm. It is calcified in of treatment.
most people over the age of 15 years and in almost all
92 Pineal germinoma.
158
na PO and T2 weighted axial (top), T2 weighted coronal and T1 weighted sagittal (bottom) images.
159
Answe r 93 eNS, Head and Neck Imaging
ANSWER 93
Observations (93a) IUdiological appearances :ITC:
Selected J\Ht images of Ihe brain demonstrate Uncontrastcd CT may show a hypcrdcnsc \ '(nOllS
hyperintel1sity in the righr trans\'ersc sinus on the T I and sinus due to thrombus (Figure 93b shows a
T2 weighted images \\lrh an abse nce oCthe nomlal \'enOliS thrombosed superior sagitt:J.J sinus). Contrast
sinus flow \'aids. There is high-signal abnormality seen enhanced CT shows a filling delcct within the
withi n the right mastoid air cells on T2 weighred images, triangular lumen outlined by a sillall rim of (oml"$
which is intermediate signal on Tl imaging - this is likely to the 'empty delta' sign.
indicate infection/innammato~' change, Appearances arc • MRI demonstrates :lIlabscncc afOaw \·oid within
consistenr wirh a diagnosis of \'enous sinus thrombosis vcnous sinus, with local eflects of oedema, subcom
secondary to mastoiditis. No imracerebral/ccrcbellar infurction, suteal effacement and haemorrhage.
h ~\emo rrh age or inlarer is demonstrated on these images. • [n the acute phase, thrombus can appear as
isoinrcnsc on Tl weighted imaging and
Di ag nosi s hypointcnsc on 1'2 weighted imaging. TIlis
Venous sinus thrombosis. hypointcnsity on T2 can sometimes be mistna.
tor flow \'oid and thcn::forc phase-contrast MR.o\.
Discussion which shows /low, is beneT at identification.
There arc a variet), of underl )'ing ellises of \'enous si nus • I n a chronic thrombosis, the venous sinus appea
thrombosis, which include trauma, in/ccrion, idiopathic and hypcrimcnsc on T I and '1'2 weighted images
h)'percoagulablc states, i.e. oral contracepti\'e pill, w extracellular methaemoglobin .
anti phospholipid syndrome, parancoplastic tumour
s)'ndromes, antithrombin III deficiency. Presenting Venous infarcts arc idenrifiablc by their
srmptoms can often be \'ery nonspecific, meaning that nonconformity \\ltb arterial territories and
diagnosis is often OI}ly made radiologically. Symptoms haemorrhagic tendency, Figure 93b demOIlstr.u
include headache, nausea, vomiting and drowsiness, The a \'enous inf.,rct that docs nOt conform to the
superior sagit tal sinus is most commonly aflccted, followed anatomical area sl1pplied by the vessels of posta.
by trans\'ersc and sigmoid sinuses circulation,
93b Selected axia l CT images demo nstrate a fo cal area of low attenuation involving grey and
with appearances consistent with an infarct. The distribution, however, does nol conform to arteria
since this rep resents a venous infarct.
160
eNS, Head and Neck Imaging Ca se 94
sinus thrombosis call present in a '"cry

• manner and has signific3m morbidity and
umrC31cd. When assessing scans of acutely
_-call)' unwell' palicnts, alwa)'S keep it in mind
the scan carefully. Similarly, beware of
g infan':t$ that show features as described
:itham questioning the possibility of an
rutg wnous sinus thrombosis.
J.ranccs oflhrombus o n MRl are complex
~ \\;th the age o[[hrombus. Moreover, patent
sinuses can show absence of tlow \'oid when
in certain planes. Making the diagnosis of
smus thrombosis from MRI can therefore be
1('d. Modern Illultidctcctor CT scanners h3YC
t speed and spatial rcso]urion to image the
Sinuses and provide an allcrnari"c that (an be
interpret, thromb us appearing as a filling
Ul the lumen Oflhc otherwise enhanced '"CnOllS
Figure 93c is a coronal reformat of a CT
~l showing thrombus in rhe lefi- tranS\'crsc
~ an ;cmpty dclt.l' sign.
93c Coronal reformat CT image shows thrombus in
the left transverse sinus.
Answer 94 eNS. Head and Neck Imaging
ANSWER 94
Observations 194a) Epidermoid ~ 5% ofCP angle lesions.
Single T2 weighted Mit image of [he brain at the kycl of Arachnoid CYST.
the internal ;ludirol)' Illcarus. There is a large , well defined Posterio r circulation aneurysm.
soft tissue mass lesion in the Tight ccrcbcllopontinc (C P) Metastases.
angle with extension intO the internal auditory canal.
Widening of the canal is seen. No dural tai l is c\'idclH. Discussion
Acoustic neuroma is m OST likely. Acoustic neuromas arc the most common tumours of
C P angle and internal auditory (anal. They typicall~
Di ag nosis from the \'estibular di\'ision of the 8th nefl,c and sh.
Acousticncuroma. p·erhaps be morc accurately termed \'cstibular sc
llomas. These lesions prescll! in the 4th-7th decades
Differe ntial diagnosis arc more frequently seen in females. Prescntation
orer angle lesions: at a rounger age in patients \lith type 2 neurofibro
• Acoustic neuroma accounts tor 75% orcp angle with prescntation in thc 2nd decade. Bilateral aCf'
masses. neuromas arc virtually pathognomonic of
Meningioma is the mosllikdy diHi.:rclltial at 10% fibromatosis typc 2, whilc solimry tUlllours arc seen
(94b ). Lesions arc extra-axial and tend 10 be to 25% of cases. Presentation is with sympl
cxtracanalicular and commonl y calci!},. Dunl rails arc scnsorincural hearing loss, tinnitus, vertigo and
seen in up [0 6O'X.oftumours on MRJ.
94b Axial PO, T2 and T1 weig

images w ith three post-contras:
coronal images demonstrate a
defined, extracanalicula r,
enhanci ng lesion in the
angle representing a
162
swer 94 eNS. Head and Neck Imaging Case 95
ging features: Detection of acoustic neuroma is largely done with

arise ill the internal auditOry canal (lAC). M RJ when possible - thin section T2 weighted
cause ~nlargcmcnt/c:rosion oftlte lAC. sequences are used in the main, with COntrast reserved
LCSions extend imo rhe CP angle. for difficult cases. When contT:lindicated, use contrast
L.olt'gcr tumours (>3 em) have central areas of necrosis enhanced CT.
md haemorrhage. A subgroup of acoustic neuroma show rel;llively rapid
~ificati on is llOt a feature. growtb that necessit3tes trea tment while others show
*
cr lesions arc usually imensc with uniform extremely slow growth and can be managed morc
anccmcnt. conservatively, Follo\\;ng initial diagnosis, a repeat
~~l~~~~~~~~~~~:i:l~:~~n~ ~~o~:~~\,n;;~i~~I~I~~e~~~~~
MRI, lesions arc low sigmll on TI, high signal on
n <lnd show uniform enhancement with gadolinium.
that can be managed more conservatively.
ieal tips Neurofibromatosis type 2: bil:lteral acoustic neuroma
'nguishing the main C P angle masses from each is a recognized diagnostic criterion for this condition.
Ilhcr: also known as the MlSME srndrome ( multiple
• Bmh acoustic neuroma and meningioma show inherited schwan noma, meningioma and
uniform enhancement so this is unhclphLI. ependymoma), In the 'real world' mos t acoustic
• Acoustic neuroma - expands the lAC, causing neuromas arc unrelated to neurofibromatosis typc 2.
flaring of the poms acousricus. May be bright 011 However, in exam "i\'as (and cenainl~' when bilateral),
T2 unlike meningioma. Makes an acute angle \\ith hal'e a high index of suspicion for the meningioma
petrous bone. elsewhere on the scan.
• Mcningiolll::l - dural rail of enhancement, obtuse!
anglCJwith petrOlls bone. Relatin:ly linle tissuc in Further management
the lAC compared to acoustic neuroma. Therapeutic options involve surgical excision, stereotactic
• Epidermoid vs arnchnoid cyst - both appear to radiation and conservative ma nagement. Which o ne
follow the density and signal ofCSF on CT and T I depends on the particubr circumstances of each patient,
md T2 weighted j\'IRJ. Howc\"er, the epidermoid but also whether the tumour is fast growing o r not. A
shows increased signal on PO, FLAIR and diffusionfl repea t sean a few months after the first can help identit}'
weightedMI{:l . the group of f.1Ster growing lesions that require a more
aggressivc approach.
SE 95
ory
30-ycar-old male:
-opanlomogram
) done for denral
163
ANSWER 95
Observations (95a) Dentition-associated cysts:
The OPG shows multiple missing teeth in the upper jaw Periapical/radicular cyst - secondary to pulp necrosis
and to a lesser extent the lower jaw LOO. In the riglu body of a carious tooth. V"i/ow/ay cyst associaud with thr
of the mandible, there is a well cin:ulllsuibcd, thin walled, Toot of a tooth. Can Ix dCStrucli~'e when large:, but noc
unilocular lucency measuring sen:ral ccmimclrcs in expansile. Most common lesion seen , Likely to be
diamete r. 111crc is no associated bon}' dC$truClion. The Ll'St painful.
is 3ssociatcd with the crown of an unerupted molar and Dentigerous cySt - IIlIilow/aT cyst associaud Il'ith lIlt
appcar:lIlccs afC consistent WiTh a dentigerous cyst. cyon", of all murllpted tooth
Diag nosis No visible association with teeth:

Dentigerous cyst. Ameloblastoma/ adamantinoma - rare, locally
aggrcssh'e (but non -merast:l.sizing) lytic [Umour th~1
Differenti al diagnosis is slow growing and often painless. This is all
Of cYStic mandibular lesion : t.'<pnmi/t, multi/ow/aud cyst witiJ 'bubbly' appenrn".,
P~riapical/radicular cyst. (though 20% unilocular). Can be associated with
Dentigerous cySt. unerupted molar tooth. Thinned cortex and no
OdonlOgenic kcratocyst. matrix mineralization . Contrast enhanced cr /~'I Rl
AmcloblaSIOlll:l. ma}' show enhancement of soft tissue elements and
Aneurysmal bone cyst. possibly an enhancing mural nodule. Five times m
Simple bone cyst. common in mandible than maxil!:t. T~'Pical age
Metastasis/ myeloma. 3(}-SO ,yeaYl. Figure 95b is an OPG in an adult pa
Brown tulllour. with ameloblastoma sho\\ing a lytic expansile lcsioa
Fibrous dysplasia. of the right side of the mandiblc with arcas ofinte
Man}' orher 'small print' lesions - nasopalatine cySt, septation producing a 'soap bubble' appearancc,
Pindborg's tumour, Statile's bone cyst, medi:tn lesion is locally aggressi\"e and has destroycd sevcral
mandibular cyst, etc. right lower teeth roots.
Odontogenic keratocyst (OKC) - "'Illti/ow/aud
Discussion lllli/owlay C,yst oftw 1ltay sitt of3rd lower /IIolar;
Dentigerous cysts arise from the ctown of an unerupted expallsilt extending along the mandible; sclerotic
tooth. The typicall}' aftccted age group is 10-30 years, with may displace teeth. Same age and sex group as
a male predominance. The cysts arc slow growing and dentigerous cySt; 50% arc symptomatic with swd
usually an incidental finding, but occasionally cause pain, growth rate is rapid and recurrence rate after
swelling or becomc secondarily infected. The majority curemgc is high. Multiple OKCs arc a feature of
occur in the posterior mandible. They arc \'ariable in size, Gorlin- Goltz (basal cell nac"tls) syndrome, an
and ha\'c a thin walled, unilocular appearance. TIlt autosomal dominant condition characterized b,'
associatio" ",ilh all ll1uyupud CYOII"1 is lilt key to diaguosis. multiple cutaneous basal cell carcinomas. .
The diAcrential diagnosis of cystic lesions of the • Aneurysmal bone cySt (ABC) - ","Itilow/ar c.m
mandible is vcry long bl![ most of the causes arc so r;tfe that 'soap bubble' appcnYIIllu i" polttrior mlllldible.
they can be dismissed most of the time. The emphasis will Appearances arc therefore very similar to
consequently be on common lesions and important rare ameloblastoma but ABC occurs primarily in those
ones. It is Ixst to assess lesions according to visible under 20 years of age.
association with demition, unilocular \"$ multilocular nature Fibrous dysplasia - 'ground glass' lIlatrix wirlJ
and age of the patient. Note that although not visibly calcijicarioll.
dentition related , lesions such as ameloblastOllla and Met:l.stas<:s and myeloma - don't forget these in
odolltogenic keratocysr do arise from dental-related tissue. older patienr.
95b OPG s hows large lytic ameloblastoma in the

right mandible with areas of internal septation
producing a 'soap bubble' appearance.
164
If brown tumour is suspected look. for other signs of

hypcrpar:uhyroidism such as resorption ofthc lamina dura
orthe teeth producing 'floating teeth' and generali zed
dcmincmlization ofrhc mandible and ll1;uilb .
Furth er management
Though often aS~'ll1ptomatic, dentigerolls cyst can cause
pain and swelling and may predispose to pathological
merure. Surgical excision (including the uncruprcd tooth)
may therefore be undertaken.
Further reading
Scholl R., Kcllw H , Neumann D, Lurie A ( 1999). Cysts
with demal associ,uian:
l....'St and c"sric lesions of the mandible: clinical and
tCd \Iith tooth apcx :md pain . I>crbpical cyst. radioiogk-histopathologic review. RndioGrnplJics 19:
tcd with unerupted tooth _ dentigerous cyst 1107- 11 24 .
\'Can and associated with crown ) or
JStO lll3 (>30 years).
C\ost wit h no dcnral association:

~.n· _ OKC, simple bone cysr.
- I~ars - ameloblastoma, mct3stases o r myeloma.
<Y
·year-old patient presented with
-hes and suspected sinusitis.
165
ANSWER 96
Observations (96a) Practica l tips
This occipiwn1cnral radiograph shows a large calcified • "Yhen multiple osteomas arc seen always consider
lesion in the right fromal sinus. The lesion has \'cry well Gardner's syndrome and irwcsligarc the fami ly hist
defined margins and a slightly lower density cemre. No and tor the presence of colonic polyposis.
fluid is seen within the sinus and there is no evidence of • Paran:lsal sinus osteomas may cause local pressure
local bony destruction. The appearances arc those of a erosion. A coronal CT rcconsmlCtion (96c)
frontal sinus 'iYory Ostt-oma', dcmonstrJtcs a left cdulloid sinus osteoma eroding:
the lamina papyracc;l and extending into the left
Diagno'sis orbit. Background sinus inOammatory changes 3«
h 'ol)' osteoma. present.
Discussio n Further management

Osteomas an:: benign tumours of membranous bone. These Incidental finding requiring no further management
arc round, well defined lesions of bony density that arc
usually found incidentally. They arc commonly found in
the paranasal sinuses, p:l1"ticularly the frontal and ethmoid
sinuses. Other coml11on si tes include the calvarium and
mandible. A CT coronal reconstruction (96b) in the same
patient confimls that the lesion lies within the right frontal
sinus.
96b Coronal CT reconstru ction demo nstrating a right

frontal sinus osteoma.
166
eNS. Head and Neck Imaging Ca se 97
lid fem ale presented with

w.l loss; and an episode of
mthsago.
167
ANSWER 97
Observations (97a . 97b) fi ndings on MRl with se\'eral aetiologies. Maki ng a
Selected MR images ofrhc brain - FLAIR axial and T2 specific diagnosis of dem),clination is often nor
weighted sag;!!al - arc presented. These scans show possible from imaging alone though multiple IcsiOOl.
multiple foc:!] O\'oid signal abnormalities in the il1\'ol\;ng lhe corpus callosum arc characteristic for
pcri\'ctltricubr white matter, which 3rc orientated 1.'15. Coexisting lesions in the brainsl'cm, cerebellum
perpendicular to the long ax is of dIe ventricles. Further and spinal cord also increase specificity.
lesions invoke the corpus callosum. No associated oedema. Be wary of making a conclusive diagnosis of M5
No evidence of hydroccph:tlus. Given the clinical derails, it M RI unless feat ures arc highly specific and there is J.
is likely that the patient has multiple sclerosis and is supporting history - the consequences for the pa
currentl y experiencing optic t~Cllli t is. arc significant. O ften , one can only offer a ditlcrcn
diagnosis for ' UBOs' that includes ,'v15.
Diagnosis
Multiple sclerosis (MS). Further m anagement
M RI of the spi nal cord is freq uently also undertak
Differential diagnosis complete assessment. Though MRl findings may be _
Of white matter lesions on MR]; suggesti\"e , careful neurological assessment is req uira.
Acute disseminated cnccphalolll),clitis (ADEM ). correlate the imaging findings \\~th clinical and Jahora.
Vasculitis. findings before making the diagnosis.
Ischaemic disease (97c).
M igraine. Further reading
Ncurosarcoid. Runge VM, Price AC, Kirshner H5, ct at. ( 1986). n.
evaluation of multiple sclerosis by magnetic reso
Discussion imaging. RfldioGrnpbiC!6: 203- 212.
This is the mOSt common chro nic demyelinating disease
and'is characterized by multiple lesions spread in tillle and
space. T ypically, it has a remitting /rdapsi ng course. The
onset of symptOms is usually in the 3rd-4th decades and
thcre is a sli ghtl y increased predominance in remales.
I ncrcascd prevalence is nOTed in areas of temperate climate.
Clinkal presentation is with focal neurological signs,
com monly including optic neuritis.
Imagingfcaru resare:
Lesions arc classicall~' ]x:ri\'entricular in location, O\'al
in shape, with their long axis perpendicular to the
lateral ventricle walls - 'Dawson's fin gers'.
Common locations for plaques include peri\'entricular
white matter, corpus callosum, internal capsule,
centrum scmiovale, optic ner'I'C/ tracts, cerebellu m.
Lesions on the inferior aspect ofrhe corpus ca llosulll
arc characteristic.
• Acute lesions can ha,'c mild surrounding oedema and
can enhance with com raSt.
• Chronic lesions ha"e no mass effect/ oedema and
don'tcnhancc.
• Lesions arc hyperintense o n T2 , hypo/ isointense o n
Tl.
Mull'ip1c sclerosis is also the most common demyelinating

process aflccting the spine - the cervical spine being most
frequently affected. It is characterized by plaques orientated
alo ng the axis or the spinal cord.
Funher clinical e\'3lua[ion im'ol\'es:
Lumbar punctme with CS F analysis for ol igoclon:tI
bands.
Electrophysiologic;).1 studies.
Practical tips 97c Sing(e axial MRI FLAIR image shows

Focal while matter signal ;).bnorm;).lities in cerebral periventricular high signal with scattered high
white marter (sometimes referred to as unidentified signal w hite matter foci. Appearances are of
bright objects - UBOs) are common incidental related small vessel disease.
168
169
ANSWER 98
Observations 198a, 98b) Plain radiogr:tphic image findings :l.rc:
This later:)l image of the skull (98a ) shows elongation of Enlargement of the sella (98c).
the jaw (prognathism ), frontal bossing, cnlargcl1lt:nr of the Mandibular enlargemcnt.
frontal sinuses and t hickening of the calvaria. There is Increase in sizc ofrhe frontal sinuses with promin
marked enlargement of the pituitary fOssa with e,·idcncc of afthc supraorbital ridge.
expansion bur no erosion. Enlarged hands with spade -like appearances o f the
Selected sagitt;'l] 1' 1 weighted illlages (98b ) of the br.l.in terminal phalanges (98d ).
connml the plain IiIIll findings of enlargement of the lTontal Thickening of the calvaria.
sin uses, frontal bossing ;'ind thickening of the c;l]"aria. Dur:tl ect:l.sia :l.nd posterior \"crtebr:l.1 body scallapln:-
There is a mass lesion within the pituitary fossa with Increased heel pad thickness( >25 tllm) (98c).
appearances consistent with pituitary macroadcllol1la. Prcm:lture ostcO:lrthritis (OA).
Enlargemen t of the tongue is also noted.
Pract ical tips
Diagnosis Normal dimcnsions of thc pitu itary fossa on lateral
Acrorncgal~' . films arc a length of < 15 mill and height of < 12 mm.

Excess growth hormo ne secretion by the anterior lobe of !\'ianagcmcnr of this condition is both medical (soma
the pituitary gland results in a variety of nlllsculoskclet;ll statin/brollloc riptine ) and surgical ( trallssphe n
abnOfm:l.litics. hypophysectomy).
98d Ra diogra
of the hand
shows marked
soft tissue
en largement
givi ng it a sp
like appeara nc:e.
In addition th
is w iden ing of
terminal tufts.
g8e Magnified image from plain skull radiograph

shows enlargement of the sella.
98e Soft tissue lateral radiograph demonstrates

thickening of the heel pad, which measu res >25 mm
in thickness. .
170
eNS. Head and Neck Imaging Case 99
-. weighted axial (top left). thin section T2 weighted axial orbits (top right), axial and coronal T2 weighted
I MR images.
171
ANSWER 99
Observations (99) intracranillly. Some optic nen'c gliomas haxc ext!:
The axial images of the orbit show fusitorm e nlargement associated thickening of rhe surrounding meninges, Ie
of the posterior righ t optic l1en'e, which also il1\"okes both ar.lchnoidal hyperplasia, which is often seen in patients 'Il
sidcs of the optic chiasm. The coronal scan confirms NF - on T 2W M IU , Ihis is seen as:I ccntrallow-si
thickening of the posTerior aspect of bOTh optic nen'es. tumour surrounded b~' a higher-signal rim that call M
Axial T2 weighted images also show a round tixus of high like a dilated perineural CSF space. p.
signal in The righ t cerebellar hemisphere and a second lesion Approximately 25% of paticlHs with optic glioma
in the posterior aspen of right midbrain that produces NFl and it is one of the diagnostic critcri:l listcd for
convexity to the margins of the cerebral peduncle. The condition, of which two or more arc required: six or IDI
appearances arc likely to indicate optic nerTe glioma 'cafe-au -lait' patches; twO or morc Lisch nodules; rn
involving the chiasm and both opril": nen'es along with more neurofibromas or one plexiform ncurofibr
hamartomas in the cerebellum and midbrain due to axillary freckling; optic glioma; bone dyspb.si~
neurofibromatosis type I. No cutaneous neurofibromas arc pseudarthrosis; fint degree relati,'c with NF l} In this
seen on these images. the coexisting lesions in the cerebellum and midbrJin
one to the overall diagnosis of NF l . These hig h T2 si~
Diagnosis toci arc seen in the brainsl'em, basal gangl ia, cerci
O pTic chiasm/nen'e glioma due LO neurofibromatosis type peduncles, cerebellum and the stLprarenrorb.1 whiTe
1 ( N F l ). They arc usually thought of lS I
lnd often decrease in size with .
Differential diagnosis to as[f(xyrom~ in the cerebmm,
ror optic nerve thickening: and telling the difference ma~' be i
• Optic nen'e glioma - 80% under 20 yean, variable enlarges O\'er time or shows
enhancement, calcifjcation I""Olre, buckling of nen"e, possibility of astrocytoma must be considered.
oflen asymptomatic. choroid plexus calcification and hydrocephalus
• 'Meningioma of optic nem: - middlc aged women, aqucduct stenosis arc o ther intrncranial features .
'tramtrac k' enhancemelll, calcification in 20- 50%, NFl is sporad ic in 50% and autosomal dominant'
straight nen"e, visu al impairment early. (chromosome 17).
Sarcoidosis.
Multiplcsclcrosis Practical tips
Lymphoma, kukaemia and metastatic disease. Tl weighted post-contraSt scans of the orbit sh
Intracranial hypertension - enlarges the perineural be performed with fut suppression in view of the
CSFspace. adjacemorbitai fur.
Meningioma is the main differential diagnosis for
Discussion optic ncn'e thickening and the features liSTed abo-
Optic nen'e glioma typically presents in childhood, only may help dis tinguish the tWO.
20% manifesting beyond the age of 20. Rclati\"cly slow Whenever NFl enters the diflc rential for anv
growing and benign ill children, lesions presenting in adults ~ I""Oldiological study, al\\':lYs check for evidence of
often show morc rapid malignant growth with intracranial cutaneous nodules that 'clinch thc diagnosis'.
spread. T hough often asymptom:uic, prescntaTion can bc
with visual loss and strabismus. BHater:!1 tumours herald Further management
NF l . The tumour causes fusiform or tubular cnlargement Treatment depcnds on the size ofnrl1lour along \\
of the optic nen"e sheaTh complex and shows variable age and gener:!] condition ofthc patient. Options
enhancement with IV contrasT. The majority of lesions surgcry, radiotherapy and chemotherapy.
occurring in the orbital portion of the nen·e do not extend
172
173
Answer lOa eNS, Head and Neck Imaging
ANSWER 100
Observations 1 11008) as thrombosis, infuretion can result from dissection of
Axial T2 weighted image demonstrates high signal in the ,'crtebral artery,
lateral aspect of right medulla. This is bright on dIe DWI Claude's syndrome is due TO a lesion of the red nu
indicating restricted water molecule: diffusion probably from of which inF.lrction is one example. T he consequences
cell swell ing due to leutc inf:lfction. Together with the ipsil:tteral oculomotor pals}' and contralateral tremor
clinical details, findings arc consistent with latcrallllcdllll~' araxia,
syndrome due to in furction in the territory of the right
posterior inferior cerebellar artery ( PICA). Practical tips
• T hese arc examples of comparati\'ely rare and \'e~
Observations 2 (100b) specific infarcts but they do make for an interestin....
These axial and coronal 1'2 weighted images show a focus test ofne uroonatomy understanding!
ofincrcascd signal in the right side of the midbr:l.in. Then: • OWl depicts reduction in Brownian motion of\\
is no associated mass dice! and the lesion lies in the region molecules, Cytotoxic oedema in acute infarction
of the red nucleus. The clinical symptoms arc compatible produce this and present high signal on the 0\\1
with 3n infurct affecting the red nucleus and causing scan. It is ,'cry sensitive, depicting infurclS JUSt 30
Claude's syndrome. or SO from onset.
• The DWI image also has inherent T2 weighting
Diagnosis' 'shine through' ), that is, thc signal is a combin.lD
Right PICA infarction (Wallenberg's syndrome). ofT2 weighted and reduced diffilsion , As such.
ma~' not distinguish an older infurcr (T2 hyperi
Diagnosis 2 from a recent one (reduced diffusion ) as both \\
Ri ght midbrain infarction :lflccting the red nucleus appear bright. An alternati\'e dep i~tion that can
(Claude's syndrome ), diflcrentiate acute and nonacute infurcts is the
apparent diffusion coefficient (ADC) map. Th~
Discussion no T2 component and shows reduccd diffusion
There arc various specific panems ofbrainstem infarction, acute infurct) as low signaL An older infarct th.Jl:
oftell having unusual eponyms. Othe rs include Weber's, also bright on DWI b}' virtue of T 2 'shine th ~
Nodlnagel's, "<lillard-Gubler and Foville's syndromes. will be bright on AOC.
Wallenberg's syndrome is due to PICA occlusion and Ischaemia is not the on l ~' cause of reduced di
presents with ipsilateral ataxia, d)'sphagia, fucial pain and Others include seizurc, trauma, h}'\>oglycaemi..l.
temperanlre sensory impairment and Homer's syndrome, abscess.
wi th contralateral irnpairrncnL of pain and tcmpcrature
scnsation in the bod)' and limbs. The PICA is the first Further management
major intracranial branch of the vertebrobasilar system :lIld DWI is !\lore scnsiti"e in thc carl}' d etection of '
supplies the dorsolateral medulla, cerebellar ,'ermis and when compared to CT. However, when throm
posterolatcral cerebellar hemisphere. It arises from the distal being considered, cr is more than adequate to
"ertebral :lrtery just below the basilar artery origin. As well haemorrhage alone.
100a High signal in latera l aspect of 100b Right midbrain high signal.
ri ght medulla.
174
101
C1r-old male presented with

_lIlrrollcd epilepsy_
175
ANSWER 101
Observations 1101a. 101b) • Distinguishing lubcrs/ h:lrnarto111as from giant c
The axial CT image of the [)",in ( lOla) showsscvcliIl small astrocytomas: tubers and subepend ymal hamar!
calcified lesions in the subepcnd ymaJ region of the txxIy of C:lll show some enhancement on MRI but CT is
the lateral \·cntricks. The T2 wciglucd MR im:agc of the usually sensith·e enough to show this. Because
brain ( 10 I b ) conlirms sc\'cml small subcpcndYlllalnodulcs cell astrocytom3S show more enh:lllcement, this
with associated low signal representing calcification. These be :lppreeiable on CT a.nd should a.rouse suspici
appearances arc consisTcm with slIbcpcndymal hamartomas.
There arc abnormal widened gyri in the left paricml lobe Further management
and right frontallobc seen on Ihe MR image, which arc Tuberous sclerosis has a high mortality with 70
likely to indicate cortical h:lI11lrtom3S. before the :lgc of 24 ~'ears. A multidisciplinan
approach is required with follow -up imaging im
Diag nosis Mltl brain, renal ultr3Sonography ( monitoring
Tuberous sclerosis. myolipom:ls :lnd looking for re nal cell c:lTcino
cchocardiography (50% of patients ha\·c rhabdom~
Discussion
TuberOLis sclerosis is an inheri ted autosomal domin:llll Further reading
disorde r of the neuroectoderm that is characterized bv AJtman Nit, Purser RK, Post MJ ( 1988 ). Tuberou.
mul[isystem abnormalities. The classical triad of features sclerosis: characteristics:lt CT and J\'IR imaging.
arc mental retardation, seizures and adenoma scbaceum. Radi%gy 167: 527-532.
CNSfcarures:
Subepcndymal hamartomas - most commonfy seen
along the ventricular surfuce of the caudate nucleus.
r...l ultiple small sy.bependymallcsions which calcify in
80%. Figure I Ol c shows another case where nodules
have not calcified, but produce :I 'w:lI'y' border to the
,·entriclcw:llls.
Corric:ll tubers - appearances arc of large widened
:ltypical gyri with reduced attenuation ce!lues on CT.
T he)' :Ire usuall}' multiple and can show rim 101c ..
. /~-" >"'"'" -.~ ,_
. U_'~
4' ~
calcification in 50%.
Heterotopic grey matter is13nds - these :lppcar as 13rge
hypodcnsc focal islands of tissue \\ithin the cerebral
whiremattcr.
Giant cell astrocytOlll:ls - occur around the foramcn of
J" lonro, and can cause hydrocephalus. J\-blign:l11t
potential is low.
Multisystem illvokement:
• Ocular - ocular phakomas, oplic nerve gliomas.
~
• Renal - angiomyolipoma, cysts, incre:lsed risk of re n:ll
ccllcarcinoma.
Respiratory - Iymphangiomyom:ltosis-like features --_,
with cystic lung disease, spontaneous pneumothoraces
~lnd chylothorax. . ,..,
i,
,
!
,
Cardio,"asctdar - rhabdomyoma, aonic aneurysms.
'.~.',; f f:-
Skin - :ldenoma sebaceum ( red/ brown small flat skin
lesions distribUled sylllme tricall ~' o\"er nose and
checks), sh:lgreen p:ltches, ash lcaflcsiolls, subungual
fibromas.
Practical tips
'. ' , .",.
The phakornatoses ( neurocutaneous disorders), o f

which tuberous sclerosis is an example, make great
eX:l111 G 1SCS because of the multitude of radiological
signs to 'piece together' - know them well!
176
177
ANSWER 102
Observations (102a) where flow ,ooids with complcx flow patterns aTe
Axial 1'2 (left) and gradient echo T2 (right ) images Figurc I 0 2c demonstr.ltes an example o n an axial _
dcrnonstr,nc a lesion in the lllcdi:ll right Icmporallobc with weightcd image with an AVM in the right frontal
a vcry low signal rim representing hacmosidcrin. This is producing the characteristic (';l1lglc of now voids.
ch:u :lctcristkally more prominent on the gradicm echo T2 C:wernous malformations (ca,"ernomas) arc thin
sequence with 'blooming' artcf.tcr. The cenlre of the k-sion walled sinusoidal vessels representing congenital
shows T2 hypcrimcnsity and the o\'crall shape is round. hamartomas. Unlike other vascular malforl11 atio~
The fcamrcs are consislcnr with a C:l\'crnoma. then: is no brain parenchyma Ixtwecn the \"3sculM
spaces. The appearancC$ on CT arc rathe r nons
Diagnosis but i\'IIU shows vcn' characteristic features, as
Ca\'crnoma (ca\"ernous angioma or ca'"crnous mal - illustrated. The celltral high signal represe nt's
formation )" lllcthaemogiobin and the outer low signal rim
haemosiderin. They presem with focal seizures (W
Discussion small parenchymal haemorrhages.
Vascular malformations arc a common cause of Venous angiomas arc uS ll all~' asymptomatic and
parenchymal brain haemorrhage and should be excluded anomalous ,"eins that dmin rhe normal brain.
when young patients present with spontaneous Classically, an enhancing stellate venous mallo
haemorrhage. They de,"elop from congenitally abnormal is seen extending TO the ventricular or conical
\'ascular connections, whieh may incrcasc in size. with rimc.
R..1diological features of\'ascular malformations arc: Practical tips
Arteriovenous malformations (AVMs) afe the most • AVMs typically h;1\'c ;t tangle oflow-signal flo\\
common type and arc eucntially an abnormal ":\ on ,\-IRI best seen on T2 and PD weighted ima_
collection of an cries connected dircctlv to ' "cins with • 10% of AVMs develop an :lssod:J.tcd :lllclll)'Sm OJ(
no imen'ening capillaries ( I 02b). Thc' vast majority alw:l\'S look. for this.
• afe supratentorial. On CT thc)' arc of mixed density Gradient ccho T2 is an excellent technique for
and mav have calcifications. Enhancement is also secn. idcntif)'ing haclllosidcrin 011 MIU, which is oltca
!-Iowcver, the classical appearance is found on MRl in vascular llultOrm:uions.
102b Large right cerebral AVM

demonstrated on a CT cerebral angiogram.
178
102 eNS. Head and Neck Imaging Case 103
idcrin will also be seen in an old haemorrhage gliosis resulting in some enlargemen t orlhe adjacent
KC~sari ly itwoking an underlying vascular [cft [atcra] vcntridc.
ation. Figure l02d dcmonSlrarts an old
age in the kft imernal capsule/thalamus Further manageme nt
.. would be cas}' to confuse this with c;;wcrnoma Often these arc aSYffipromatic and call be monitored with
the axial image. Howe"er, all old haemorrhage imaging to 3SSCSS change in growth. There is, however, an
to form ::I slit-like cavity unlike the rounded up to 2% risk of bleeding and surgcry/slcrcoractic
of cavernoma, and the coronal scan illustr.n cs radiosurgery arc treatment options.
diffe rence. NOte also the local \'olume loss due to
03 Axial and coronal T2 weighted scans of orbits (left/middle) and a 'time of flight' MR angiogram of the
rluacranial circulation !right),
179
ANSWER 103
Observations (103) Cranial nerve palsies - most commonly 6th and 3rd
T2 weighted images demonstrate dilatation of the left nervcs. This is thought to be due to either impaired
superior ophthalmic vein \\'ith presence of flow \'oid and \"cnous drainage of the ncn"c or direct compression
no focal compressi\'e mass lesion. The "time of flight' MRA Ilcr'I'CS bv distended ' "cins.
demonstrates normal arteri:!l intracranial anatOIlW \\'ith Contral~tcraJ srmptoms arc secn in - 10% duc to [h~
signal in the dilated left ophthalmic \"cin indicatil;g f.m presence of conllcniOtls between the two GI\"ernous
flow. The find ings arc in keeping with a kft carorico- sinuses.
C;ll'crnousfisrub.
Imaging features on h'IRI arc:
Diagnosis • Dilated superior ophthalmic vcin with flow ,·oid.
CaroriCOC3'I'CrIlOUS fistub. Enlargement of the ea,'ernous sinus.
• Swelling of the extraocular muscles, which can rcsuli
Differe nti a l diagnosis in limited ere mo,·ements.
For superior ophthalmic rein distension:
• Ca"ernous sinus thrombosis. Angiograph~' shows c;\fly opacification of the supe
Superior ophthalmic "ein thrombosis. ophthalmic rein when contrast is injected into intc
Pseudotllmour. carotid artery. Earl~' opacification of the veins C011llTI
Graves' disease. eating with cavcrnous sinus may also be noted.
Obstructi,'c orbital mass.
Practical tips
Discu ssion Early radiological changes arc of enlarged ocdemat
Fistulous communication betweell the internal carotid extraocular muscles and dilatation of the superior
artery and the ca"ern?us ~inus can ariS<,' secondary to head ophthalmic I·cin.
trauma or rupture 01 an mternal caroud artery aneurysm, More chronic changes arc of eniargeillent of the
The condition olien occurs spontaneously, however, due superior orbital tissure and scll:ar erosion.
[0 atherosclerosis. In addition, fisllllae can occur \\ith dural Clinically, pulsatile exophthalmos susgeslS this
branches of the external carotid artery. Orbital bruit is condition.
found in - 50% of patients due to turbulent arterial blood
flow, T he increased arterial pressure in the l'e!lOllS system Further management
and orbiral "cin congestion result in the symptoms of: When imaging features of a caroticQCa"ernous fistu.b
• Pulsatik proptosis. associated with decreased "isua! acuit,)" cmergency
Chemosis. mcnt is required to relieve intraoclllar pressure.
• Reduced visual acuity due to impaired retinal
perfusion - scvere/ rapid visual loss requires
angiographic im'cstigation and listula closure as an
emergency (0 preserve function.
103 Dilated left superior ophthalmic vein.
180
181
ANSWER 104
Observations (104) Typical appeara nce is of a well defined cystic I
SeleCTed '\'IR images ofthe brain show a large lesion in the containing fluid of CSF density with a solid perip
cerebellum, which is predominantly cystic in narure nodule, showing uniform a"id enhancement. Th~
(hn>erimcnsc on T2 and hypoimensc on Tl weighted commonly haemorrhage or necrosis in the solid n
images). Following IV colltrnsr there is cnhancemcm oftlle but it rarely calcifies. In up to 30% of cases the lesions
\\':1.11 of the cystic component and an associan:d solid nodule be emird)' solid wilh no cystic component.
posteriorly. S.1gittal image shows some filllncss of the btcral
"cmridcs and ObStTUcri\'c hydrocephalus is likely with Practical tips
compression at thc level of the 4th '·(lUride. When forming a differential for the posterior fossa
mass with enhancing peripheral nodule, the foil
Diagnosis generalizations apply:
Hacmangioblastoma. • Children - piloc)'tic astrocytoma>
hacmangioblutoma.
Differential diagnosis • Younger adults - hacmangioblasroma most com
• Juvcnilc pilocytic ;lstrocytoma - can be "cry difficult to • Older adults - consider cystic mctaS[3sis
diflcrentiatc from a haeillangioblastonll. This is the
mOSt COlllnlon infratentorialtulllour in children. Furth er management
There is an association wi th ncurofibromatosis typc I , When haemangioblastoma is suspected, do n't forg:...
Lesions arc of an ident ical appearance, with a raise the possibility o f VH L (4-20% of haemangiob
predominant cystic component and enhancing solid occur in the COllleX I of VH L and multiple lesi
peripheral nodule. diagnostic ofVI-IL). VH L is an autosomal dominant
Metastasis. inherited condition characterized
spectrUl:n:~:o~rl:~"'::~m:~o~"~,~,:i~~::~~~j~i~:~:
Arypical mcdulloblastoma,
blastomas,
develop a cardiac
Di scussion pheochromocytomas, pancreatic I
H aemangioblastoma is a benign vascular rumoull aflccting cell mmours and haemangioblaslomas, li"er
the CNS. It is the most common primary infratemorial and retinal angiomas.
nUllour in adults. The majority (80%) present in adults in
the 3rd-6th decades, although there is an association '\ith
"on H ippel- Lindau (V HL), which sees these tumours
presenting in childhood and in this case may be multiple.
104 Enhancement of the solid posterior nodu le on post-gadolinium im ages.
182
183
ANSWER 105
Observations (105) Clinically this results in pseudobulbar palsy, terraplc~
The selected images demonstrate diffuse cerebral atrophy cOll\'uisioIlS, acute confusion and progression to comL
exceeding that cxptctcd for the patient's young age. There is mOSt commonly confined to the pons but changes
is:I large focal area of signal abnonm.liry in the central pons also be secn in the basal b>;lnglia, caudate, thalamus
Ih:1I is hyperintense on T2 weighted and hypointcnsc on suocortkal white matter. Radiological presentation is
TI wei glued sc:ms. 111crc is no associated mass effect. The fairly wdl defined low attenuation lesions on CT in
signal changes would fil with central pontine myelinolysis central pons. On M IU , lesions aTe oflo\\' intensity on
and the clinical dCt3i1S and cerebral atrophy suggest that and high signal imensity on T2 imaging.
chronic alcohol abuse may Ix the underlying cause.
Practica l tips
Diag nosis Standard MR/CT im::aging (::an be normal for up to
Central pontine myelinolysis. days after symptolll onset, lagging considerably behind
clinical presentation. Rest ricted diffusion on D
Differenti al diagnosi s however, is found wirhin 24 hours.
• Pondnc glioma.
• Inf.,rcrion. Further management
• Early MIU appearances can be similar for a b::asibr
Di sc ussion inElrcr and M RA (::an be useful to look for :lrteri,;d
Central ponline myelinolysis res ults from the des trllction thrombus.
of m~'c1in sheaths, dassicall~' in patients with rapidly • Sc::arch for underlying cause if not readily app::arcOL
corrected hypo n:ttracmia. Cases are reported in patients
with: Furth er rea ding
• Chronic alcohol abuse. Ruzek KA, Campe::all NG, Miller GM (2003 ). Earf!;
• Chronic liver d isease. ' diagnosis of central pontine myelinolysis with
• $c"ere m::alnutrition. diffusion-weighted imaging. American JOllnHlJ
• Wilson's disease, chronic rell::al fitilure, diabetes, acute Nmrorndiolo!JY2 5 : 210-213.
m)'clogcnous leukaemia . Stadnik nv, Demaerd P, Lurpae rt RR., It nl. ( 200.;
Imaging tutori::al: differemi::al di::agnosis of bright
In the c::ase demonstrated there is diffilse glob::al (erebral lesions on diffusion-weighted MR images.
::atrophic ch::ange suggestive of chronic alcohol abuse. RadioGraphies 23(1): e7.
105 Focal area of red uced Signal on T1 weighted (left) and increased signal o n T2
weig hted (right) images.
184
-old fCIll:a1c patient prescnted

clles.
185
An swer 106 eNS, Head and Neck Imaging
ANSWER 106
Obse rvations (106a ) c,wcrnolls sinus ( 3, 4, 53 and 6 ) and hypopitui
This non contrast enhanced cr image demonstrates a large resulting from compression of normal pituitary tissue
midli ne mass extending into the 3rd ventricle, which hlS Compared to craniopharyngioma, pitu itary
both solid :lIld cystic compOllcnrs with central calcitication. adenomas arc predominantly solid and show morc i
There is dibtation orthe temporal and anterior horns of uniform enhancement. Calcification is rare,
the "cntridcs but normal :tppcarancc to the 4th ventricle - craniopharyngioma. Suprasellar ex tension produca
findi ngs arc in keeping with obstructive hydrocephalus at 'snowman' configuration due to w:lining at the I
the lc,"el of the. 3rd ventricle secondary to a mass lesion. the diaphragm sellae. Figure I 06b shows prc- and
The mixed density and calcification arc \ '(1)' suggcstive of contrast Tl weighted images of a pituitary macroa
a craniopharyngioma and M IU is suggested to further with such features.
e"aluate. lbthkc deft cyst is the other main diAcrcntiai di.a_
wi th 70% in\"olving sellar and suprasellar regions.
Diagnos is benign cySt arising from remnants of Rathke's pouu
Craniopharyngioma. can be differentiated by the following features'
regular and ovoid shape, smaller size ( <2 !TIl ), cystio;:
Differe ntial diagnos is 110, or minimll cnh:lllccmcnt ofthe thin wall.
or suprascllar/intrascllar mass lesion:
• Pituitary macroadcnoma. Discussion
• Craniopharyngioma Craniopharyngioma account for - 4% of int
• R.1thke cleft cysr. neoplasms, with a slight predominance in males,
peaks ofincrcascd incidence:
Other masst:s in the sellar region include meningioma, • Firstly in children in 1st-2nd decades, Wh("fC
metastases, chordoma and intenla!l'arOlid mer)' aneurysm. account for 50% of suprasellar turnouTS.
Pituitary macroadenor{KI is the most common lesion • Secondl y in adults in 5th - 6th decades.
involving the sellar and suprasellar regions. Microadenol1las
(20%) an: defined as being less [han 10 mm in size and These arc benign tumours arising fro m rem
usu:llly present with sympl"Oms due to hormonal secretion. 111thke's pouch. They grow from a suprasellar ori_
Macroadcnoll1as (80%) measure over 10 mill in size and the base of the 3rd vemricle. lmr:lsel lar extension
arc usually endocrinologieally inaeri,'e. The~' present with in 2 1%. Involvement of the bon)' sella can be seen
symptoms secondary to mass effeer such as hydrocephalus, radiographs and o n CT bOlle window imag("S
bitemporal hemianopia from optic c hiasm compression, demonstrate appearances or J-shaped sella, enl
involvement of cranial nerves tr:wdling in the adjacent and then ultimatel y erosion and destnJcrion.
106b Pre- and post-contrast T1 weighted MR sagittal images demonstrate a large pituitary
adenoma with uniform enhancement with contrast and with no cystic elements or signal
voids to suggest calcification.
186
106 eNS, Head and Neck Imaging
IT appca r,lIlccs arc 5ho'l\'11 in this casc \\;th Practical tips

,,:ystic clements and calci fi cuion (which is Look for the complications of masslcsions in this area:
-90% of cases). Following comrasl there is • H ydrocephalus :lIld optic chiasm compression.
amen! of the solid compOllcnrs and the CYSt • Lateral extension to invoke thc cavcrnous sinus ( seen
in up to 10 % of pituitary macro~dcnoma.s ) , which can
.\tRI findings reflect CT features with a cystic lead to thrombosis :lIld cranial nervc palsy. Lateral
InCn! following fluid signal (although high extension beyond the lateral wall of the internal
>my be seen on Tl weigh ted images depending carotid is rare wilh Rathke eleft cySt :lnd may help
Jttin/ blood content). The solid componcm is diflcremi:lte it frolll the other two conditions listed.
o n T 1 and shows cnhancclllcllI with
Fu rthe r management
+/- posropcrath'e radiotherapy.
Treatment is surgical
106c shows '1'1 sagittal pre- and post-IV contrast
d T2 axial and 53gitt.ll images (left). These Further rea ding
.I Lu-gc su prasellar lesion with intnsclb.r extension. Choi S H , Kwon 81, Na DG, ct al. (2007). i'imitary
solid and C}'stic clements wj th enhancement of adenoma, craniopharyngioma, and Rathke cleft cyst
component'S and cyst wall. Complications of ilwolving both intr.tsellar :lIld suprasellar regions:
'C hydrocephalus, pituitary st;}lk and optic chiasm ditlcrcntiation llsing 1-Ht!. CIi"icn! Radio!ogy62:
n can be appreciated. 453-462 .
106c T1 sagittal pre· and post-IV contrast and T2 axial and sagittal images demonstrate a
large suprasellar lesion w ith solid and cystic elements with enhancement of the solid
components and cyst wall. The lesion is causing obstructive hydrocephalus, pituitary stalk
and optic chiasm compression.
187
An swer 107 eNS. Head and Neck Imaging
ANSWER 107
Observat ions (107a) Prenatal detection can be made by US investigatic..
T1 sagittal and T2 axial and coronal images of the brain Diagnosis cannot usually be made before 22 wee
dcmonsu':uc: complete :agenesis of the corpus callosum \\ith gestation. Equivalelu image findings arc of:
no callosal [issue identified. There is increased separation • Absence ofthe septum pdlucidum.
of the 13tcral \'cmodes on the a.xial images crc;uing a 'b:J.t's • Dilated/elevated 3rd ,·cnrricle.
wing' appear-uKe. Coronal image demonstrates clc\'3tion • Enlargement of the occipitJI horns of the lateral
of the 3rd ventricle . ,·cntrides.
Di agnosis Practica l t ips

Agenesis ofthc corpus callosum. Ditlcrentiating bcrween dysgenesis and ischacmie da
is done b~' de("ermining which parts of the corpus call
Discussio n arc abnormal. With ischaemie injury the rostrum nill
The corpus callosum usually develops by 20 \\'ccks' present but :ltrophic.
gestation. T he genu and the body of the. corpus callosum
develop first and the posterior bod)' and spleniulll develop Fu rther ma nage ment
b ter. The rostrum is the last part of the corpus callosum TO Somctimcs this fin ding is made incidentally on
develop. Idcntil}'i ng the parts of the corpus callosuill imaging in later lire and no fu rther in\·estigatiOD
present call help to diflcrcntiatc octwccn dysgenesis (absent required.
genu/splenium ) and destruction, most commonly dlll~ 10
ischaemia (genu present but may be atrophic ). Corpus Fu rther reading
callosal agenesis is usually associated with reduced Babcock OS ( 1984 ). The normal, absent, and abno
intellectual function and can be associated with a varier\' of corpus callosum: sonographic findings. Rndioio..!!!
c;NS abnormalities in~ludin~ hydr~ephal.us, mid[il~e 15 1: 449-453.
itpoma , Oandy- 'Valker cySts, mterheilltsphenc arachnOId Oa\'idson HO, Abraham R, Steiner RE ( 1985 ).
cysts, neuronal migration disorders and Arnold- Chiari of the corVllS callosum: magnetic resonance
malformation. Rndiolog., 155: 371 - 373.
Classical imaging appearances on CT/M IU arc with:
' Bat 's wing' appcar""Jnce of the lateral ,'entriclcs due to
parallel lateral "entricles with marked separation
( 107b ).
' High riding' 3rd ventricle - can be seen at the b 'd of
the Jateml ventrieles.
Enlarged foramen of t-.'ionro.
107b Axial CT images of the brain demonstrating 'bat's wing' appearance of the lateral ventricles in a
with agenesis of the corpus callosum.
188
189
ANSWER 108
Observations (108a. 108b) destruction seen with skull base metasuses. Vasculu
Axial CT images ( 1 08a - axial C T scaJl at skull base with ,ooids and foci of haemorrhage are beller demonstnt
IV contrast, seen on bone and soft tissue windows) oflbe MRI - flow produces black signal I"oids and haem
brain demonstrate a poorl}' defined enhancing lesion in the produces hyperintensc foci on T I weighted images
jugular foramen, which is extending superiorly to in\'ol\'e combination of black holes and white dots leads to
rhe middle car and is causing permeative erosion aflbe called 'salt and pepper' aplXlrance commonly dcscril
pClrous temporal bone at the juguhlf foramen. The T2 Angiography is sometimes required for smaller
weighted MR image ( l OSb) confi rms this mass lesion, tha t don't demonstra te the classical imaging appe
which appears hrpcrintcnsc with serpiginous flow ,ooids and rel"eals a hypc r\'ascular lesion with a dense
indicating vascular flow. mmourstain.
The re is a small ris k of maligna nt transfo rmaci
Diagnos is in -2% of cases.
Glomus jugulorymp::lIlicum tumour.
Practica l tips
Description When suspected on MRI , cr can still help make.a
Glolllus jugulare rulllOUrs afC paragangliomas :lIld afC rhe conclusive d iagnosis in many cases by demonstra
most common jugular foramen lesion. Trpically, these classical permeati,", pattern of erosion at the
lesions arc soliury with a peak incidence in the 5th-6th foramen.
decad es and increased incidence in females. There are
fumi lial associations in which multiple paragangliomas Further management
present in conditions such as multiple endocrine neoplasia Depending on the size of the tumour and the in
( M EN). extension, a combined ENT / neurosurgieal proc
Glomus jugubre rumours usually extend imracranially pcrfomled.
and can inl"oh·e the m iddle car, as demonstrated here.
Clinifal presentation ma), be related to illl·oll'cment oCthe Further reading
9th, 10th and 11 th cranialnervcs. When there is extension Caldemeyer KS, l'-'lathews vr, AzzarclJi B, Smith
to im"oh"e the middle ear (glomus jugu10tympanicum ) then ( 1997). The jugular foramen: a rC\"1cwofan;a[
pulsatile tinnitus is the classical presentation. masses, and imaging ch:aracteristics. RadinG,..
These tumours arc highly vascular and enhance al·idly 17: 11 23- 1139.
wi th contrast on CT and MRI. O n CT , permeati\"(: bone
erosion is classical, differing from the coarser lytic
108b Hyperintense mass lesion w ith flow voids"
190
19 1
ANSWER 109
Observation s (109) Appc:ar.mccs on MRJ :lrC \'3rbbk depending 011
These sclcclcd MR im3gcs show an expanded sphenoid fluid/ protein CQrHcnt of the mucocele but impo
sinus filled with abnormal signal rather th:a11 air. The imaging findings arc of a nondcstructi\·c, slow gra...
(amelUS show mild uniform hyperintcnsiry on Tl weighted lesion.
and T2 weighted images. The walls of the sinus :appear
slllomh and intJct with no ob\iou$ evidence of dcstmctiOIl. Practical tips
The findings arc consistent with a mucocele of the CT is good lor showing bony expansion with the
sphenoid si nus, the signal indicative ofprotcinaccolls fluid absellce of bone erosion.
contents. Sagin;)'l Tl and coronll 1'2 inl:lgcs dcmonstr:I\C • ~'IlU is good for identil)'ing the exrelll/size of tile
displacement of the optic nerves br the expanded sinus, lesion and looking for complications of optic nel'\c
presumably causin g compression of the atHl:rior optic compression ( usually from postcrior ethmoid lesi<-
pathway gi\'en the hiSTOry of\'isuaJ disrurbance. and proptosis ( usuall~' from frontal and anterior
ethmoid sinuses).
Diagnosis Tl hypcrintensity \\ithin a lesion on an~' MRI s
Sphenoid sinus mucocele often helps to rnpid1r limit the diAcrential diagn
there are;\ limited number of things that arc brig.I:K
Discussion on TI imaging, i.e. fat, blood, proteinaceous f1uiQ.
A mucocele arises due to chronic obstruction of a sinus, paramagnetic contrast agents.
which then becomes filled with mucus. This collection acts
like a slow growing mass c:lUsing expansion of sinus bony Further management
walls withom frank bOil\' dl:slruction. Vessels and other Referral to ENT for consideration of endoscopic
srmcrures arc displaced ";ther than being encased, as with surgery.
a tumour. Usually these lesions are asyrnptomaric untillhcy
becomc large when the}' can cause optic nel""\'C compression,
proprosis and headache. Secondary infection of the
mucocele can supen'ene, but this is a rare complication.
Ninet), per cent of lesions arc found in rhe frontal and
ethmoid sinuses with sphenoid sinus rnucocdes being anI}'
rarely seen.
109 Superior displacement of optic nerve (left); lateral displacement of cavernous sinus
by large sinus mu cocele (right).
192
193
ANSWER 110
Observations (110a, 110b) Typical imaging appcarnnces of a butterfly gIl
The selected plain CT images ( iIOa) show a poorly of a poorly defined lesion that enhances uniformly
defined, hypcrdcnsc midline lesion eXTending across the fomlation, necrosis and haemorrhage are seen in a
body of the corpus callosum. There is no significant of C:1SCS and c:1kilication is rare and usu:llly :1SSOCiatcd
surrounding oedema. chemo/ r.ldiOlher.lpy. The corpus callosum is mack
Pre- and polit·contrast Tl weighted MRimagcs ( 1IOb ) dense, tightly packed white matter tr.lcrs and th
from the same patient show a multilobulatcd lesion with mass efleet and vasogenic oedema arc m
uniform cnhanccrncnr crossing the midline in the body of Hemispheric glioblastomas conversely have quite
the corpus callosum. No further lesions lre seen \\~thin the mass eHect and surroundin g oedema.
brain p arcnchym~1. Incidental note is made of cavum
sepnull pcllucidum. lllc findings arc of a 'buuerfly' tumour Practical tips
in t.hc corpus callosum. GBM and lymphoma arc the two likeliest diagnose..
bUrTerfl)' lesions ill\'olving the corpus callosum. Al
Diagnosis diflicult to diffe remiate radiologically, cavit:\tiOll
HutTcrfly g liobhlSloma multiformc (GBM ). necrosis arc rcl:ltivcl y uncommon in lymphoma (ex
AIDS patients).
For lesions crossing the midline in the corpus callosum: Further management
• GBi\·1. T2 hypoilltensiry is sometimes present with C:"S
• Lymphoma. lympholl1:1 and thereforc this imagc sequencc CD
• Dcmyclimuing disease - multiple selerosis. sometimes hclp to diffcrentiatc lymphoma from
glioblastoma.
Discussion Ncurosurgical c\·alu:ltion.
This is the mOSf common :ind the most malignant primary
brain (Umour. [\ accounts for >50% of brain tumours \\;th Further reading
:I \\~de :lge distriburion pc:alcing :It the 7lh-8th decades. The BOllrekas EC, Varakis K, Bnms D, et nf. (2002 ).
most common location is within the white muter of of the corpus callosum: ~'I R illl:lging and di!fe
centrum scmiovalc with increased incidence in the frontal considcrations in :ldults and children. Alllerimll
lobes. Other patterns of distribmion include callosal JOlln1n1 ofRndiology 179: 25 1- 257.
extension giving this appearance of a butterfly gHom:l, Rees JI-I, Smirniotopollios JG, Jones RV, Wong K
postcrior fossa lesions and multifocal distribution (seen in ( 1996). Glioblastoma multitormc: radiologic·
2-4%). pathologic correlation . RadioGrnphies 16: 6.
Tumours sprcad b), direct extension im·oh·ing white
maller traClS, such as the corpus callosum and cerebral
peduncles or vi:l the CSF « 2% of C:ISes). Haematogenous
spread can also very rnrcly occur.
110a lobulate d lesion crossing the mid line in the body of the corpus callosum.
194
eNS, Head and Neck Imaging Case 11 1
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195
An swer 111 eNS. Head and Neck Imaging
ANSWER 111
Observations (111a, 111b. 111c) Neurofibromas - enhancing dumbbell-shaped lesi
These STiRsagitt:l1 ( l il a), STIR coronal ( illb) and T2 Scoliosis and kyphosis.
weighted axial ( i l le) images of the spine demonstrate Enlarged vertebral foraminae - due to ne urofibrOI1ll
posterior vertebral scalloping, particularly at the T il , TI2 or lateral meningocele.
and L2 b'ds. There is also a thoracic scoliosis. AI H ypoplasia of the pedicles, Irans\'erse and spinous
approximately no le"el , coronal images show a right sided processes.
high·signallesion projecting laterally from the spinal canal,
presu mably through the intervertebral foramen. This Practical tips
follows CSF signal and is probably a lateral thoracic • Alwars look for the presence of subcutaneous nod
meningocele. The axial 1'2 weighted image shows a second on the image when NF l is suspectcd.
lateral thoracic meningocele on the Jeft side, in a similar • It Illa}' be difficult to diflCre.ntiate between a lateral
region ofthe spine. The combination of findings is strongly thoracic meningocele and a 'dumbbell' neurofib
suggestive of neurofibromatosis type I and multiple high- H owever, on MRI the former will be ofCSF de
signal cutaneous nodules on the sagittal images confinn this on all sequences, Le . high signal on T2, whe.reas
diagnosis. latter will have a hyperintense periphery on T2 mQ
hypointense core.
Diagnosis In a case such as this, one might also comment rn..
Neurofibromatosis type I (NFl ). there arc no obvious adrenal Illasses or renal
as)'mmetry (implying association with
Discussion phaeochromocytollla and renal artery stenosis,
Neurofibromatosis Iypc I is a neurocutaneous disorder, of respectively).
which 50% is inherited in an autosomal dominant manner
and 50% is sporadic. Classical features in the spine include: Further management
• L.1teral thoracic meningocele (dysplasia ohhe Neurofibromas can undergo malignant tr:l.Ilsform;!.tli
meninges resulting in di\"enicula of the thecal sac, 2-3%; therefore a rapid rone of growth or new onset
whieh extends through the neural foramina ). should be thoroughly investigated.
Posterior vertebral scalloping - also due to dural
ectasia.
1118 Posterior
vertebral
scalloping.
111b l ateral thoracic meningocele.
196
197
ANSWER 112
Observations (112a) Typical appearances on MR.I: well defined lesion
Selected uncnhanccd axial cr images ofrhc bi.lin show a which is high signal imensit),on T I weighted il1lagi •
well defined low attenuation lesion in the left fronrallobc \\ith signal \'oid at points of calcification. No
causing minimal mass effect. The contents arc oflowcr enhancement with comrast.
attenuation than CSF but gh'en the absence oftrauma it is
llnlikcl~' that this is due to intr.lcr:lnial air. It is likely that CySt rupture leading TO chemical meningitis is
instead, it represents fur, which could be easily confirmed occasional complication, as in this c:ase. Release of
by adjusting the CT windows or taking a direct dcnsit~, globules can produce f.u-Iluid levels WiTh CSF. Fi
measurement. A calcified nodule is seen at the posterior 112b demonstrates typlc:al appcar.mce of:a dcmlOid II;
aspect of the lesion with furthe r mural c:l.lcific:l.Iions 6t-containing lesion of high signal on TI weight
elsewhere. Further small loculcs of f'at arc seen in the im:aging. Some strands of mesodermal tissue arc n
:Interior hom of the left lateral ventricle and sc\'cr:al sulci. within it. A f.lI -fluid level is seen in the [:ateral \·emrick
to rupture into the subarachnoid space.
Diagnosis
Ruptured dermoid cyst Practical t ips
Posterior fossa dcrmoids arc usually found in the
Discussion midline and show no contrast enhanccmem on
Dermoid cYstS arc fairly Ullcommon CNS lesions, usu:ally CT/MIU.
presenting before the 4th decade. They arise due to On TI weighted MRI high signal is produced ~
inclusion of epithdial elements :at the time of closure of the: Fat.
neural rube and therefore contain ectodermal and Blood products ( methaemoglobin).
mesodermal components, i.e. hair, sebaceous glands and • Proteinaceous fluid.
skin . Derrnoids arc usually locpted ncar the midline and C:all • Contrast.
be found within hrain parench}'m:a , vcntricles, CSF sp:aces
or within·hom:. Dc\'elopmem :and g.rowth arc \'ery slow and Further management
presentation is therefoTt: late. MRI is bencr than cr
for identif)~ng nlprurc of a
• Typical appearances on Cf: low-densit), lesions CYSt and the consequent chemical meningitis.
containing fat with no contrast enhancemem. j\·l ural
or focal ccntral calcification can be seen.
198
eNS, Head and Neck Imaging Case 11 3
199
Answer 11 3 eNS, Head and Neck Imaging
ANSWER 113
Observations (113a) Bilateral temporal lobe im'okement is virtually
These T2 weighted axial brain images show :J. diffuse pathognomonic of HSV infection. Features that
increase in signal affecting the right Icmporallobc. This atypical and should arouse suspicion of other
in\'o!\'cs grey and wllite maner, eXTending to the cortical organisms include basal ganglia i1l\'ol\'ement and
surncc . Sulci in the aAcctcd aTea arc dfuccd. Similar signal isolated im'oh-ement of other lobes withom [c ~
changes extend along the cingulate gyrus ,md also affect lobe ilwolvemellr.
the contralateral temporal lobe to a lesser extem. The Cytotoxic oedema (seen in stroke and encephali
~' ~~~~:Ii~o~~el:,~:r~~~~' \~.:~~!l~lI~l~~~l~:I:~s~:sss,

duration of the history and distribudoll ofillvoil'cmcnt :lfe
in keeping wi th encephalitis, mos\ likely due to herpes
simpkxvims. atlects\\"hite matter only,
Without clinical history, one might mistake the :\
Diagnosis changes of HSV encephalitis for a middle ccrebr.JI
Herpes simplex (HSV) encephalitis. artery (MeA ) infarct. Howevcr, notc that the
posteromedial temporal lobe affecTed by HSV is
Differential diagnosis spared in an MCA infurct as this lerritory is sup
Right middle cerebral territory infilTct. by the posterior cerebral arIel)' ( PCA). Figure II
shows a typical MCA infJrct wilh lowanenuatioo
Discussion change in the right [emporallobe but sparing the
Encephalitis is the term generally u.sed to describe a diffuse described posteromedially (this scan also happem
cerebral inflammatory process of \'iral aetiology. Clinical show a hypcrdense MCA due to lhrombus). FOf"
presentation is with confusion , headache and seizures comparison, Figure 113c shows a PCA infurct \\
progressing to coma. Fe\'er is almost always prcsem . The the posteromedial rempomllobc affected.
most common organism is HSV. infection being either Neonatal herpes-related encephalitis is due to H
primary or due to vinls reacti\~ltion. The resulting cytotoxic type 2, probably acquired via the genital tract
oedema manifests as high signal on T2 weighted, FLAIR perinatally. The imaging features arc different fnr
and DWI t.'IRI. The temporal lobe is typically affected , those due to HSV type I described above.
often with the inferior frontal lobe and cingulate gyrus.
Unlike other viral infections, the basal g:mgli:!. arc usually Further ma nagement
spared. Urgent treatment with alHiviral drugs - mort
untreated I-ISV encephalitis can be as high as 65%,
Practica l t ips
• HSV encephalitis has high Illonalit}, and morbidity
rates bur is treatable with acyclovir SO a high index of
suspicion is needed, especially on cr, which may well
be the first imaging done - signs of oedema and
swelling arc likely to be comparati\'cI}' subtle
compared to MRI (if prcscllt at all).
11 3b Axial pla in C7
brain shows a ri
middle cerebral a:
territory infarct
hyperde nse artery
sign.
200
201
Answer 11 4 eNS, Head and Neck Imaging
ANSWER 114
Observations (114al is more resistant to hypoxia and therefore appears of hi_
This single CT im::agc shows diflusc low-attenuation change densit), in comparison with the low-density cerebral cona:
in the frontJl and tcmponl lobes and br:linstem with loss the so·called 'rC\"ersal sign' (sec also Case 163 ).
of the grey-white matter diflcrcllliation. The cerebellum is The conspicuity of the vessels and dura may lead
bener preserved. Generalized sulcal cff.1ccmcm indicates to the erroneous diagnosis of acute subarachn
ccrebr.tl swelling. haemorrhage (SAH ) on first inspection. An example or"_
This widespread reduction in brain density makes the real SAH is shown ( 1l4b ) - note high density in
normal ccrcbr:tl vessels and dural rcflccrions appear suprasellar cistern representing acute haemorrhage and
spuriousl ~' conspicuous. Close inspection confirms thal this nornlal density cerebral cortex with preserved grey-\\
is a pcrccplUal 'abnormality' - rhe basal cisterns arc of marter differentiation. There is also dilatation of
normal CSF density so there is not acute subarachnoid temporal horns of the lateral ventricles indicati ng e
haemorrhage. The ffndings arc suggcstil'c of global ccrcbr:l.l obstructive h~'drocephalus. Trauma is the most COIllrn.
ischaemia and oedema. cause of SAH. cr is 90% sensith'c in the detection of ;'\!..
in the first 24 hours following prcsentuion. Howcvcr.
Diagnosis decreases to 50% at I week and continues to fall ther
Global cerebral anoxia. Small SAH may not" be seen on CT and will onl~
This particular casc turned ou t to be secondary to deTected on lumbar puncture (LP) as xanthochromia. r.-
asthma· induced cardiorespiratory arrest. cause of75% of spontaneous SA H is berry ancurysms
these arc mostly found sprouting from the circle of\\
Discussion An exam pic of a large SAH in :I patient with :I rup
Global ischaemia can occur following prolonged hypoxia, aneurysm is shown ( 1 14 c). Note the cxtcnsi\'c amoWl[
which may be sccondary to litting, aspiration, smothering, blood filling the sulci and Sylvian fissures. Blood has
strangulation, etc. The CT,findings arc distinni\'e, with loss entered dlC vemricuiar svstcm and C.lIl be seen in the- '
of grey- white matter differcnriation and changes due to and 4th ventricles. The'large ;lIleurYSlll appears to
cercbr:al oedcllla including sulcal eflaccment. Generalized from the origin of lhe left middle cerebral artery.
low density of the cerebral COrTex de\"elops. The cerebellum
' 14b Axial plain CT of brain showing SAH with

blood in suprasellar and basal cisterns.
202
A nswer 114 eNS, Head and N eck Imaging
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114. 11><;.1 ~ . ;" CT b'';n

d"mon'Uatin9'orgb SAH wi,h
Ia<~ •• nOur",m .,i.ing ',om , he
left middle cofebnl . "ery.
Chapter 4
MUSCULOSKELETAL
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MU$culoskelelallmaging Case 115
CASE 115
Histo ry
A j h~"-oId "'..,
fN<" ""J ~."" ~
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Answer 115 Mu Scu los kelet al Imagi ng
ANSWER 11 5
Observatio ns II I !NIl id<n,;fi,hk with,n ,It< ')>' _ , n , ',alko '",!V",n<' . il"_
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Musculoskeletal Imaging Case 116
_ p and show benign features with

expansion, cortical thinning and fluid levels
)(R.I, However, the SBC has a more centra1
\\i thin the aRectcd bone, is less cxpansilc and
.bow a p:llhognomonic 'ful1cn fragment'.
_ in the !llscd skeletOn is subarticular and
'c wit h no marginal sclerosis - when all these
aTC presem in the correct age group, the
is is clear.
can look aggrcssi\'c or benign so is 3.1wars
bearing in mind depending on clinical history .
.'. fibrous dysplasia has such ' -:tried appc3!,;II1CeS
• fre quently enters the diflcrt;ntial diagnosis lor 11 Sd AP pelvis in a female with
. cal benign !>one lesion! w idespread lytic metastases and a
pathological fracture of the left femoral
neck. Note the cortical destruction and
the wide zone of transition of the
majority of the lesions.
209
Answe r 116 Mu Scul os ke let a l Imagi ng
ANSWER 116
Observatlo nS II I"'1 ".n .,,,' .n,h""r.,hr e."", "kifi"'"", " . il ... of
'i'h,,,, ~ ,~h' "m.",1 h"d " """"inS in ,hi. r""n'. Hp"",n',,'" ;""""..",. """" i\><,1 n" rl ... folm. "
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A nswer 11 6 MuSculoskeletal Imaging Case 117
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CASE 117
HiSlOI"1
~ 13_)"..,_,,1& ""I, ~""" ",J
~'"k p.oo in h ~ kit hip.
Answe r 117 MuSculoskeletal Imaging
ANSWER 117
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MuSc ulo s ke le tal Imaging Case 118
CASE 11 8
History
~ m.l. Pol;'"! p", .. "I<d . ';!h p';";"
.m!"'","" <lUmp .
Answer 118 Musculoskeletal Imaging
ANSWER 118
Observations (118a) Discussion
A below knee ~unpllt;ltion has previously been performed. Another example of a lymphoma is seen aAi:cri~
lllcrc is a pcrmcati\'c lucency with a ,\ide zone of transition tibia of a parielH in Figure 118b; a peTmeariH:
affecting the tibial stump. Periosteal reaction is visible along present with e\idence of cortkal destruction.
the posterior cortex ;lIld there is llso a hint of this along Permeative bone dest"mnion on radiogra~
the fibub. runhc:mlOTc, fuint luccncics arc suspected along the presence of aggressive p;nhology with fa
the :anterior cOrtex of the distal femur. These arc rhe potential. The pcrmcath'c lesion has a ditfusc:
appearances of an aggrcssi\'c lesion. eaten' appearance (l i Se). The zone oftransi
The reason for :Imputation and the time: inrerval since in other words the lesion is poorly dcmu.-
ha\'e nor been stared - this would help dari/)' the likely impaceptibly merges with uninvolved bone,
diagnosis. From the radiological findings alone, the main lesions where the zone of transition to no
possibilities arc that rhe amputation was for a distal narrow. PeriOStcal reaction rna)' or may not Ix
malignancy such as bone lymphoma that has now recurred, finding of a r~ef[m::ati\'e lesion on imaging usu.ll.
or that rhe current findings arc due 10 osteomyelitis in the malignant pathology; however. infection can
stump following amputation to r an unrelatcd reason. s,1me appearallce.
However, suspectcd im'olvcment of the distJI femur
without joint destmction f"lxOUI"S the former option. Practica l tips
This is an example of a \'i\"3 type film whel"(" •
Diagnosis definite or 'spot' diagnosis 10 be made - it is
Lymphoma recurrence following amputation. of preseming a reasoned approach to;1 sensible
diagnosis, thcn st"ating how [[lis could be natTC"
Differential diagnosis using dinkal inlormation or fi.lnher investig:n-r
Of permc:ui)'c bone lesions:
• Metastases. Further management
Myeloma. Recurrence of lymphoma may entail fu~
Lymphoma. and/or radiotherapy. MRI rna)' be helpful
Leukaemia. local extent more accurately.
Osteomyelitis
118b AP and lateral images of the tibia show a

permeative lesion is present with evidence of cortical
destruction.
2 14
Musculoskeletal Imaging Cases 119, 120
presented with :I
infection.
215
Answe r 119 Mu Scul os kelet al Imaging
ANSWER 11 9
Ob.. rvlti o n· 11 19~1 Dis. u sslon
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119,120 Musculoskeletal Imaging
....ith pyknodysostosis (11 9d ) demonstrates 119d

!iClcrosis with classicJ.] 'pointed chalk' tcrm;Jlli Pyknodysostosis
hand showing
osteosclerosis with
pOinting of the
distal phalanges
producing a
cycrflaskddormity: 'pointed chalk'
sclerosis indicatcs osteopetrosis. appearance.
. disease w;]I dcmOnStr.Hc sclerosis of the
is and lucency orlhc widened metaphys is.
r's disease will be associnlcd wi t h generalized
nil and pencil-thin cortices. There may also be
of avascular necrosis of IIle femoral o r hUllleral
md massh'C hepatospleno megal y m:l)' be seen
.oibdominal radiographs.
emia is associated with coarsened
brion producing a 'cobweb' appearance.
poisoning causes dense rnct;lphyscal bands.
11ge Forearm of a
management patient with
treatment 'l\'ailab1c tor osteopet rosis is bone fluorosis showing
trans plamation. Patients arc morc prone to diffuse
than the normal popul.uion. osteosclerosis and
prominent
ligamentous
insertion
calcification.
rvations (120a) Ankylosing spo ndylitis.

Aexion and extension views of the cel"\~cal spine arc Systemic lupus erythematosus (SLE ).
m. On flexion there is significant adanlOaxial joint Down's syndrome .
.ation. The odolHoid peg is not clearly demarcated J"lorquio's syndrome.
~ likely to be parti:J.II~' eroded. The remainder of the • Retropharyngeal abscess in a child .
- -..a.I spine is quitc wcll prcscn·cd. The most likely
is in a patiem of this age is rheumatoid arthritis. Discussion
Atlamo.uial subluxation occurs when the dist-lIlcc octween
the posterior aspect ohhe arch of the alias and the ;lIltcrior
toaxial subluxation in a patient \\"ith rheumatoid aspect of the odontoid peg exceeds 3 mill in adultS and 5
tis ( RA). mm in children. Erosion and destmction of the OOomoid
peg may also be seen, particularly when the process is
erential diagnosis caused by an inflammatol)' arthropathy. Several causts arc
mJ.moaxial subluxation: described in the differential diagnosis list but RA is the
.. Jt.-\. most common cause in adults. Synovitis with pannus
.. Psoriatic arthropathy. fo rmation causes erosion of the o dontoid peg and
.. ·U'·cnilc idiopathic anhritis. atlantoaxial ligamentS and consequcnt subluxation. This
(CO/It. )
2 17
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MuSculoskeletal Imaging Case 121
CASE 121
HiSla ry
~ Y''''"~ """·C,ri"',,,," r""'"'
p.... m,d .-i," k h kn<, p.i"_
ANSWER 121
Observations (121a, 121b) cause pain and limitation of mo\"ement, with o\·erl~· .::
AI' and l:ltem1 r.ldiographs of the left- knee show lobulated ulcer:nion and the de\·clopmelH of a sinus tract d
calcified masses in the soft tissues anterior to the left knee. (halk~' nuid. In fuct, the masses m3y contain fluid
Taking into consideration the age and cthnicity of the lel"cls on imaging that ha\"e a milk of eakiulll (on
paticm, ru!l1or.ll calcinosis is the most likely diagnosis. The periarticular region orlhe hip is the most COlllla
aHccted site. The masses can grow to 3 ,"cry large sill:
Diagnosis there is a tendency to r recurrence if the lesions
Tumoral calcinosis. complctelyexciscd.
Differential diagnosis Practical tips

Ofpcriarticular soft tissue calcification: The radiological appearances of the ,'arying CJ
• Hacmatoma. periarticular calcification can be quitc different:
Myositisossificans. • T umoral calcinosis - lobulated dense tl13sseS,
Crystal arthropathy. fluid le\"els.
Sclcrodcm13 ( I 21c - note the characteristic dist:ll tutt • Myositis ossific3llS and synovial sa rcoma may I
resorption in the index tinger). similar but withom fluid Ic\"els.
Dermatomyositis. • DefmatOll1l"0sitis - shects OfC:lkificatioll.
SyIlO\'ilJ osteochondromatosis. • S)'no\'ial oSTeochondromatosis - se\"eral foci of
• Tumornl calcinosis. calcification with lucent centres that 3fe essen
• SYIl0\;alurcom:t ( 121d, 121 e, 12 1f, 121 g ). loose bodies within the joim.

Tumonl calcinosis is a rare, 1x:nign condition characterized Patients with tumor31 calcinosis arc usuallv treat
b}' the presence of progressively enlarging perianieular phosphate depiction. Surgical excision is 3150 a
calcified soft tissue masses. It usually affects roung black option but needs to be meticulous as recurre na:
patients and there is a fumilial tendency. The masses Illay OCCLIrs with incomplete excision.
121c Radiograph of the

hand in a female adult
with scleroderma shows
the typical soh tissue
calcification . Note the
distal tuh resorption
affecting the index
finger, which is
characteristica lly see n in
this condition.
121e, 1211, 121g Axial n , T2 and fat saturated images of the synovial sarcoma shows a fairly well de
soft tissue lesion which is of tow signal on T1 and in homogeneously high signal on T2.
220
-_m p,,,,,,,,d with rigidity and
221
ANSWER 122
Observations (122a) Practica l tips
All and latCr:l1 radiographs of the right knee and upper tibia Ostcopoikilosis tends to be distriburcd around
and fibula demonstrate marked cortical thickening of the whereas multiple sclerolic !l\Clastlscs will not
diaphyses ohlle tibia and tibula, which has the appcarnncc confin<.!d.
of'dripping candle wax', This is typical ofmclorhcostosis.
There arc also multiple small sclerotic lOCi within thc Further management
mctJdi:tphysis of the distal femur and the proximal libi:! , No further mallagement is normally necessary.
which h:1I"c thc appearance of oSlcopoikilosis. conditions arc usually found incidenrall)•. The ~
is to ensu re thai a patielU with multiple sclerotic
Diagnosis has osteopoikilosis and not sclerotic metastases.
Mclorhcostosis and ostcopoikilosis.
Further readi ng
Differential diagnosis Levine S, Lambiasc It, Petchprapa C (2003 ). G::rT
$dcrQ[ic metastases in a paricllI with mclorhcostosis; this lesions of the tibia: characteristic appearances.
is much less likely. H owt:I'cr in patients with multiple coLII'entional r.ldiograph)'. RndioGmphics 23:
sclerotic foci alone, sclerotic metastases must always be 15 7- 177.
considered.
Di scussion
Melorheostosis is a nonhereditary disease of unknown
aetiology that often presents as an incident-al finding. II is
usually discovered in childhood where it has a rapid
progression, but it occasionally presents in adults where it
has a slow c.hronic course. The limb ill\"oked often
demonstrates joint pain , swelling and limitation of
movement. Males and fem:lles arc equally aficcted.
Radiological signs ofmclorheoslOsis arc as follows:
• Conical hyperostosis in one or multiple tubular bones
with streaks of sclerosis beginning at the proximal end
of the bone and extending distally, This produces the
chamcteristic 'dripping candle wax' appearance. This is
shown particularly well in Figure 122b, where the
right humerus and scapula arc aficcted in allother
patient.
Predominantly aflccts the diaph)'Sis of the bone,
The lower extremities arc mo re commonl\' aficcted
than the upper. .
Although a single bone may be involved, contiguous
bones of an extremity afe mOTe often aflccted.
Hilateral signs arc cxtremcly rare and should prompt
consideration of other causcs of sclerosis.
• Limb length discrepancy is also a feature and the
sclerosis may cross the joint and result in joint nLsion.
The skull, spine and ribs arc rarely invoh'ed. !\klorheostosis

is associated with osteopoikilosis, osteopathia striata
(asymptomatic disease consisting of lo ngitudinal striations
along the metaphyses of lo ng bones ) and arteriovenous
malformations,
OSleopoikilosis is an autosomal dominant disorder that
is more common in Lll~ks. II is asymptomatic and consists
of multiple o\'oid bone islands parallel to the h;:lJlg axis of
the bone. These bone islands normally measure 2- 10 mm
and arc found at the metaphysis and epiphysis, rarely
extending into the midshaft. It usually aficcts rhe peh'is, 122b AP radiograph of
wrist and ankle and Tarely affects the skull , ribs and melorheostosis affecting the
mandible . The differelltial diagnosis or this condition, humerus ~nd scapula
which often leads to clinical con fusion and concern, is demonstrating the typical
disseminated sclerotic metaStases. 'dripping candle wax' appearance,
222
A nswer 123 MuSculoskeletal Imaging Case 124
ANSWER 123
Olao,."ations 1123) H .If of ~" .. "" p ..,. n, hI' 'he ''''- .-.f : )'< . ", 'n;';, II ,
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CASE 124
History
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m
ANSWER 124
Observations (124a) Further management
There is difruse, coarse trabeculation of the visible bones Death usu311y occurs within the first decade-.
causing a 'cobweb-l ike' appcar.:lllCC. Erlenmeyer fla sk b)' multiple tra nsfusions, howe\'cr as exp
deformity of the distal femurs is presen!. The features arc discussion this tOO leads to skeletal abnorrn
in keeping with thalassacmia major.
Further read ing
Diagnosis T yler P, Madani G, Chaudhuri R, ct (I/. (2006
Thalassacmia major. radiological appearances ofth:llassnemia,
Rndiology 6 1( 1): 40~52.
Discussion
Thabssacmia is an inherited disorder of haemoglobin
synthesis charncfcristically seen in Mediterranean patients.
The homozygous form, thalassacmia major, is mOTC sncrc.
The radiological signs result from marrow hypcrpl:J.sia and
expansion due [Q cnramcdullary h:u:rnatopoicsis. Evcry part
of the skeleton may be aflcctcd in patients with untreated
disease. R.1diologicaJ fcamrcs of the complications of
treatment such as recurrent transfusions and iron chelation
thcrapy may also be seen. In fuet, ab normalitit:s secondary
to iron chelation therapy arc now more com mon than
those due to lllarrow hyperplasia.
T he radiological signs to look for depend on the site of
the bod~' imaged'
• Peripheral skelerun:
Coarse trabeculation e3using 'cobweb' appearance
( 124a ).
• Loss of conca\'ity ofwbular bones ( 124a).
• Er1cnmerer flask deformity of metaphyses of long
bones ( 124a).
• Arthropathy and chondroca1cinosis as a result of
haemochromarosis secondary to hypertral\sfllsion.
• Fraying of metaphyscs and dense metaphyseal
bands secondary ro iron chel3tion therapy.
• Skull:
'Hair on cnd' appearance.
Frontal bossing (124b) due to diploic expansion.
O bliteration of paranasal sinuses (except for
ethmoid sinuscs) due to marro\\' h)'pcrplasia
( 124b ).
• A-.;i:tlskekton:
Co3rsc trnbeculation causing 'cobweb' 3ppe3rance
( 124<).
BiconC3\'C "ertebr.lc.
'Bone within bone' appearance of spine and ribs.
Paraspinal masses (due to extramedullary
hacmatopoiesis).
Expansion of the ribs posteriorly, panicularly at the
costochondral junctions, due to marrow hyperplasia
( 124c).
Practical tips
• T he only sign may be a difruse but subtle coarsening
ofthe bony trabecu lae.
On an AX It look for evidence of hepatosplenomegaly
(a result of extramedullary haematopoiesis) and
gallstones.
On a exit look for cardiomcgaly secondary to
an3emia, 3S well as a paraspinal mass due to
eMr.lmedullary haematopoiesis.
224
CASE 125
History
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125 Musculoskelet';l Imaging Case 126
Furthe r ma nagement
i':lRI is helpful in assessing local spread :llld :lids planning
benig.n or aggressive? of surgical resection.
ysis, metaphysis or epiphysis?
old is the patient? Fu rther reading
~'Iurphcy M, Robbin M, i\kRac G, tt al. ( 1997 ). The
"olmg patient with an aggressive lesion such as many fuees of osteosarcoma. RadioGraphies 17:
m[cd, the twO main primary tumours to 1205':' 12 31.
Me Ewing's and osteOsarcoma. The tWO can
:ult to differentiate radiologically, and can also
1Ullilar clinical features such as fevcr and
'fosis. T he features shown in Table 2 may help,
_ none arc pathognomonic .
.able: 2 Dljji:YC1Iti(ltillgfCfl/IlYn of Ewillg'r S(lYCOIIJ(l «lid ortcosnYCOIII(l
Ewing's sarcoma O steosarcoma

Children Older children and young adults
More common in diaphysis 1\-10T": common in metaphysis
More commonly lucent or permeative More conHllOnl}' sclerotic
To bone To lung
227
ANSWER 126
There is a tnllswrsc fracture at the medial third of the Osteomalacia is related TO renal failure and
clavicle. which is li kcl\' to be an insufficienc\' fracturc as hyperparathyroidism therefore:
Ihere arc Looser ZOllC~ at the b \cral aspect oCthe cl:J.I'iclc On an abdominal radiograph look for a perit
:tnd the b tcr.tl border of the body ofth, scapula. T he bones dialysis catheter or a Hillnelled femoral haem
arc generally oSlcopcnic with marked thinning of the line.
coniccs. T he findings arc consistem with a diagnosis of On a chest radiogr.lph look for a centr.ll
osteomalacia line and eroded lateral cla"icles.
Promincnr vascular and soft tissue calcification
Diagnosis secn.
Osteomalacia. Brown TUmours ma~' be present and appear as
lesions, which mal' also be associated with
Discussion pathological fr.lc t ~Jre.
Ostcomabcia is a disorder of insuHkicnt osteoid
mineralization causing bone softening. Aetiology can be Further management
due to dictary deficiency, dccrclscd absorption or deficient Treatment involves rCI'ersing the cause of Ii
metabolism of vitamin D. deficiency.
Radiological fc;trurcs of ostcomalacia include.:
Generalized ostcopcni:t.
Cortical thinning.
Bowing of long bones.
Protmsio acetabuli.
Coarse trabecular patrc.rn ( 126 b ).
Looser zones:
• _ Pseudofra([ures that consist of tranS\'erse luct':nt
clefts \Iith sclerotic margins .
• These arc mostly seen in the pekis, femoral necks
( 126c) and scapula.
Insutlicicncy fraCTUres.
228
prcsclHcd with
ing dcform it), of right leg.
229
ANSWER 127
Observations (127a) Osteogenesis imperfecta - all four types can r
There is marked angulation deformity of the diaphyses of bowing of ,he long bones due to bone softening
the lower tibia and fibula with the formation of multipte fractures. Bowing typically involvC$ all the
pseudarthroses. The bones aTe also generally ostcopcnic. bones and can resull in pseudarthroses. Again OSt
The most likcl~' diagnoses arc nonunion of prc\'ious and pinning arc the preferred treatment alth:
fractures, ncurotibromatosis or osteogenesis impcrfccta. bisphosphonalcs n:l\'C been shown to produce
success.
Di agnosis Cleidocranial dysplasia is associated with (on_
Neurofibrom:ltosis. pseudarthrosis of the femur.
Ankylosing spondylitis can lead to pseudarthrosis
Differential diag nosis spine.
Nonunion of a fracture.
Osteogenesis imperfecra. Practical tips
• Fibrous d}'spbsil. Severe osteopenia and multiple fractures ofdi
• Congeniral. ;lges that hal·e exuberant callus fo rmation su&..£cIII
osteogenesis imperfecta. Remember that SOIlK
Discussion osteopenia may result trom disuse, howe"er, c!"
Congenit:ll - :lllcCls the middle to lower third ofthc tibia fracture nonunion.
and tibula. H alf of congenital pseudarthroses present in the Look for soft tissue nodules indicative of
first }'c:ar of life and later on there ma}, be cupping of thc neurofibromatosis.
proximal bone end and pointing ofthe distal bone end. A 'ground glass' density lesion associated \\ith
Neurofibromatosis rype I (NF l ) is a common genetic pscudarthrosis is suggestive offibrous dyspl.lSi.l.
disorder ;1I\d in addition 10 cutaneous and neurological
:abnormalities, osseous lesidns :are also seen. There rnav be Furthe r management
an terolateral bowing of the ribi:a with or witho~t a As in this case, osreotomy with bone g~'''''g """-....
hypoplastic fibula. Focal n:lrrowing and intramedullary is the treatment of choice.
sclerosis or cystic change:at the :apex of the angulation is
due to hanlarlOnlatOus fibrous tissue, typically at the Furth er reading
junction of the middle and distal third of tibia. Pathological Cheema 1, Grissom L, Harckc H (2003).
fracture with nonunion often results in pseudarthrosis of characteristics of lower·exrrcmit")' bowing in
the tibia and fibu la, with 'pencil pointing' of the bone RndioGrnpbics 23: 871 - 880.
fragments. Prophylactic bracing of limbs with bowing
deformit), may pre"ent the de\·clopment of pseudarthrosis.
OSleommy with bone grafting and pinning ( 127 b ) is the
treatment of choice if the pseudarthrosis has alread~'
occurred.
127b Radiog raph of the same patie nt pos

with pins.
230
dislocations. Hypoplasia orthe capitellum and !';ldial head

may also be pn::scm and this can kad to all increase in the
carrying angle: at the dbow. Similarly, genu valgus can
<x:eur due ro asymmetrical den:lopmcnt of the femoral
condyles. Some patients may ha\'e a short 5th metacarpal.
Practical tips
Look for a perironeal dialysis eMheler or femoral
'Aunt Minnie'. Fo ng's discasc, also known as runnelled dialysis line on the pclvic radiograph, :ls
and ostco-onychodysplasia, is a nTC Ihese palients ma ~' have rcnal failure.
[ disorder characterized by sym lllcrric:ll If the knecs arc included on the radiograph, look for
and mesodermal anomalies. Patients lend to hypoplastic or absent patellae and genu valgus
ab no rrn31ities of nai l dysplasia that Gill deformity.
spooning and splitting of the fingernails or ("\'ell
or aplasia. This particularl}' aflc cts the thumb Further management
finge rnails. Pat ient s lll;lY al so h:1.\"c lbnorm:tl The mOSI serious association of thi s condition is renal
of [he iris. dysfunction, which occurs secondary to abnormality of the
~ nce ofbilatcrnl poSTerior iliac horns is seen in glome ru lar basemenr membrane leading ro protei nuria ,
~ and is diagnostic ofdlC condition. Hypoplasia hacm3ruria and renal f.lil urc. The CX~lcr mechanism for this
JDtc:rior half of the ilia can result in drooping of the is unknown , bur renal f.1ilure tends to <x:ellr in later life ,
. The other major finding is aplasia or hypoplasia This is an important poim ro note when diagnosis of this
d bc, which frcqucntl~' results in recurrent lateral conditio n is made, often incidentally.
23 1
ANSWER 129
There is a 'hair on end' appcarnncc to the skull vault and • Thalassacmia major and sickle cell disease arc the
the diploic space is widened. This docs not aHe" the most common causes of'hair 011 end' skull. To
calvaria below the lel'el of the imcrnal occipital protuber- diflcrentiate the twO look at the maxillary sinuso-
ance. T he mlxilbry sinuses arc oblitcr.ttcd. The most likely they arc obliterated this suggests thalassaemia.
C:IllSC is thabSS3cmia major. docs not occur in sickle cell disease.
Is {he appearance diffuse or localized? IflocaJizo:.
Diagnosis consider neoplastic causes such as haemangiolll.l
TIIl13.ssacmi:J.major. ( 129b).
Haemangioma [ends to have a 'corduroy' ap
Differential diagnosis i.e. thickened and coarsened rather than thin \
Of'hair on end' appc ar;111CC of skull: trabeculation due t'O \'ascubr channels. This is
The mnemonic is 'STAN' and is c:\sy to remember when demonstrated in Figure 129b.
VOli think of Sun Laurc! 's hair!
. Sickle cell disease. Further management
Thalassacmia major. Thal:tssacmia major has a poor prognosis with
Anaemia (other an3cmias ): aHccted children not surviving past the first
Hereditary spherocytosis. Treatment is by repeated transfusions.
• Glucose-6-phosphatc dehydrogenase deficiency.
• Severe iron deficienc}' anaemia. Further reading
Hollar 1"1 ( 2001 ). The hair-on ·end sign. Rndi
Neoplastic: 347-348.
• Hacm:lIlgioma (J29b).
• Neuroblastoma metastases in children.
Discussion
The 'hair on end' sign is a finding that can be seen in the
diploic space ofthe skull on r:tdiogr:tphs, cr and MIU, and
has thc appearancc oflong, thin, venical striations. On plain
radiogl'.)phs and cr the appearance is caused by alternating
thickened tr:abeculae and radiolucent marrow hyperplasia.
On 1'\-\ RI, the alternating bands of h}'POintense tr:abe..:uiae
and h}'pcrimense marrow producc the distillct striated
p;\ttem . Es.scmially the effect is due to marrow hyperplasia.
The diploic space widens and the outer table thins and can
become obliterated. With regard TO anaemic causes, the
marrow hyperplasia begins in the frolHal region and can
aflcct the entire calvaria excluding that which is below the
internal occipital prolllbcr:tllce, since there is no marrow in
this area. Marrow hyperplasia in thalassaemia major is more
marked than in any other anaemia and may cause
hyperplasia of the fucial bones resulting in obliteration of
thc paranasal sinuses. Howc"cr the ethmoid sinuses arc
spared as they do not contain marrow. Thc 'hair on cnd'
appearance can also be seen in se"ere childhood cases of
iron deficiencyanacmia.
The medical literature is split as TO whethcr the 'hair on
end ' appea rance may be re"ersed following treatment of
the anaemia. Some authors have reported that resolution
of the appearance occurs with rrCatmelH, although the
diploic space may remain wider than normal. Howe\'er
others h:we reported that the appearances persist without
regression e\'en O\'cr a follow-up period of approximately
20 years.
232
auk presented wil It left

forsc\"crnlwccks. He
233
ANSWER 130
Observatio ns (130a) exostoses poillt away trom the nearest joint, as illustr;J..tel
,"Iultipk bony C.\ostoscs arc secn arising from the ribs on image 130b. A pscudo-Madclung ddormity may de\'
both sides of the chest. 011 the lett, there is a large ( 13 0b ), where there is ulnar shortening with bo\\ · _
associated soli tissue mass projected O\"er the btcr:tl thor.lx the radius, and ulnar tilt of the distal radial articular
Gi"cn the history of chest pain, sarcomatous tf:msformation [n tcwcr than 5% ofpatknts, malign:llll transform.m
must be suspected. Mon:oyer, there is a small leti: pleural into chondrosarcoma or ostcos:m:oma call occur. A
rc:tetion, a large pulmon:lI)' nodule in the left upper zone example is shown ( 1 30( ) where a patient with dia~
and possible pulmonary nodules ill the leti: lower zone and acbsis developed a chondrosarcoma aHccting the fi
rightcostophrenic recess. The exostoses may also cause neurological comp
The combination of findings suggests sarcomatous due to ncrve compression or entrapment.
tr.J.t1sformarion ill diaphyseal aclasis wirh pulmonary
Practical tips
'Diaph)"scaJ' aclasis is a misnomer as the exostoso
Diagnosis ;lTise from the metaphyses.
Diaphyseal aclasis with sarcomatous transformation. They are otten multiple and bilateral and point
from the nearest joint.
Discussion Thc carrilagc cap of the cxostosis Ill:!}' be calcificu.
Diaphyseal aclasis is an 3urosomal dominant condition
ch:!racterized by multiple exostoscs (osteochondromas). Further management
Osteochondromas 3fe benign cartilaginous tumours. In cases of neTye entrapmenr, surgical excision
Diaphyseal aclasis is usually discovered in ch ildhood and possible. The crucial f..1ctor is to f
short stature may occur due to the development of degeneration when iT occurs; sllspiciol1s signs i
exostoses :It the expense of nornul bone growth. The and growth of an exostosis :lfter physcal closun.
exostoses arc usually multiple and bilater.:ll and mostly afii:cT thickening of the cartibginotlS cap by greatcr than I :;.
the linlbs though ribs can be atli:CTed, as in this case. The This is best delincated 011 MRL
130b AP and lateral radiographs of the ulna 130c AP of rlght fem ur demonstrates
demonstrate multiple exostoses. Note how extensive flocculen t calci fication in a
they point away from the joint. huge chondrosarcoma, which arose
from the exostosis at the medial
femoral condyle.
234
131
. ... ""atii,' ns (1 31a , Practica l tips
lateral radiographs of the [cfi knee re"cal a well • In the adolescent knee with symptoms bur no obvious
in the l:lIcral aspect orthe medial femoral abnormality on first inspccrion, check for the subtle
. A scpantc bony fragment lies within the defect. osteochondl""J.l defec!. The' LAM E' mnemonic
_1"-"'""" rhose of osteochondritis dissccans. identities the classical location.
• When idemitied, check for radiological evidcncc of
joinr eflllsion and loose bodies.
• Suggest MRI forfurthere'"aluation.
Fu rther management
Identification and trcannent arc important to prevent the
dc\"eloprnem of osteoarthritis. Arthroscopy and remol·al
o r pinning of the detached fragment is the treatment of
KOC hondritis dissccans is svnon"mous with choice when conservative management with reST and
hondrosis dissccan s and ostcocho~dra! fracture
.,~.~
f
NSAIDs!:lils.
~lb ) . The cardinal fcaHirc is fragmentation ora portion
the articular cartilage and underlying bone, which may
Ie to fonn a loose body \\ithin the joint. It is thought
~~~~
o.:cur due to subchondral btiguc fr:tcturc as 3. result of
lUring from rotatory impacrion torees. Though
times asymplOmatic, presentation is often with p:lin 131b
<J.\"Jtcd by movement and/ or limited movement.
r,uients are mOSt cOlllmon!\, aficctl-d in adolescence with
aficctcd morc than fcn~ales. The ~"picallocation of
uochondritis dissecans at the knee is the Lateral Aspect
~lcdial fcmoral Epicondyle (usefully remembered by the
...\.\1£' mnemonic). The condition can be bilateral in up
30% of cases. Other commonly aflcctcd sites include the
eral head , capitellum and talus. ,vllU is useful in
cmlining whether the osteochondral fragment is loose 131b T1 and T2 weighted sagittal MRI images
("\;denced b~' a rim of fluid around it on T2 weighted of the knee show a traumatic osteochondral
_ or a rim of contrast around it on i'lIRl anhrography. fracture in the anterior aspect of the lateral
femoral condyle
CASE 132
istory
middle aged female prcselllcd lI'i[h
nful hands.
235
A nswer 132 Musculoskeletal Imaging
ANSWER 132
Observations {132aj distribution is olien bikuel'JI and symmetrical but t:bc
T his radiograph of both hands re\'eals soft tissue swelling f.tctor excluding rheumatoid arthritis is of co
at the meracarpopha!:mgeal joints bilarerally and to a lesser absence of erosions. Se\'eral difterent diseases m~
extent at the proximal interphalangeal joints, This is not similar appcal":lIlces as outlined in the differential _
associated with any erosions, ho\\'e\'cr there is subluxation Soft tissue calcification Illa\' be seen \\'ith sclerod
of sc\'eral joints including the metacarpophalangeal joint of Ehlcrs-Danlos sHldrome: )accoud's arthritis is
the right index linger and the right first carpometacarpal nonerosi\'e anhr~pathy aflccting the hands and
joint. Degencrati\'e ch'lllges arc also noted at both wrists. patients lollowing rheumatic \'ah'e disease. Figurt
In summary, there is a bibtcralnollcrosi\'c anhropathy \\ith shows an example of this demonstrating cha
evid ence of joint subluxation, The differen tial diagnosis subluxation at the metacarpophalangeal joints
includes collagen \'ascular disease, Early rheumatoid anhritis ulnar de\'i.uion orthe digits. T here is also subl
sholl id also be considered. the first carpometacarpal joint, Note the a
erosions.
Diag nosis
Systemic lupus erythematosus (SLE). Practica l tips
T he o nly find ing lI'ith the lIonero si\'e arthr
Differe ntia l diagnosis Illay be periartku b r soli tissue swelling in the
Of nonerosi\'c deforming arthropathy: stages.
• Collagen "asc uhlf disease. Subluxation of joints is the major linding and
• SLE. Illostly ;IAcCIS the metacarpophalangcal and
• Ehlers-Danlos syndrome. carpometacarpal joints bib tcrall}'.
• Scleroderma. The appearances tend to be bilateral and s~
Scleroderma ( 132c) and EhJcrs- Danlos syn
Jan:oud's arthropathy. may be associated with soli. tissue calcificatioo.
H}<pOsammaglobulinaemia. hand radiogra ph,
Discussion Further ma nage me nt

O \'cr 90% of paticnts with SLE dc\'clop arth ralgia, SLE is, as its name suggests, a systemic
Nonerosi\'c arthropathy is characteristically present, the although patiems can CXpeCi a long lifc death
main fcatures ofwhieh arc soft tissue swelling and joint occurs frOIll renal failurc or cardiomyopathy.
subluxation. In particular, the subluxation aftects the first supporti\'e with the aim of suppressing the .1.
carpometacarpal joi nts and ;llso the metacarpophalangeal element oftlte discase.
joints leading to u lnar de"iation of the fingers. T he
236
male prcS(:ntcd \\;rh left
237
ANSWER 133
Observations (133al importam to check whuher the paticm has unfuso:l.
AP and axial radiographs ofthc left shoulder demonstrate epiphyses 35 GeT will not normally be seen in this
a well defined lesion ill the upper hUllleral epiphysis. This group.
has a thick sclerotic borda and central lucency. T he lesion If doubt still c.~ists as to the nature of an cpiphya
has nonaggrcssi\'c features including a narrow zone of lesion, MR.! tl1J)' help. There is typiclll)' lTIarked
transition and the likely diagnosis consideri ng the agc of oedema seen surrounding a chondroblastoma bUi
the patiellt and the loc1tion of the lesion is rarclyaroundaGCT
chondroblastom:t.
Further management
Diagnosis Chondroblastoma is a benign tumour that m3Y bco:
Chondroblastom:l. loc3H), aggressive. Treatment is by curettage and bone
grafting.
Of epiphyseal lesions'
• Chondroblastorna - well defined sclerotic border,
calcification in 50%, may have periosteal re;letion.
Giant cell tumour (GCT) - closed epiphyses, abuts
articular surfuce, eccentric, no marginal sclerosis. No
periosteal reaction unless fracturc present
Geode - will be other signs of arthropath~' ; older
patients
• Metastases and myeloma
• Infection - llSUllI), :netaphyseal rather than epiphyseal.
Discussion
Chondrobbstoma is a rare, cartilage contlining tumour
that llmost always occurs in the epiphyses of long bones.
Patients aflccted arc under 30 years of age and tend to
present with localized plin. The lesion is usu311y well
defilled with" sclerotic border and occurs most commonl"
about the knee joinT. Calcification within the lesion is see;l
in approximately 50%. The tumour rardy metastasizes but
m3Y be locally aggressive ( 133b, 133c). 133b, 133c Plain radiograph of a lucent tibial
As with all focal bone lesions, an 3ssessment of benign epiphyseal lesion and axial T2 weighted MRI'
\"s aggressive tClTures, the patiem's age and the location of of the same case, which shows a well defi ned
the lesion within the bone arc criticli in forming a hypointense lesion in the tibial epiphysis co
meaningful differential diagnosis. Fortunately, the with a chondroblastoma . The high signal th
dilferenti31 for epiphyseal lesions is fairi)' short! One the tibial plateau is in keeping with marrow
condition that deserves brief discussion is GCT as this can This reactive oedema is a common feature d
somet.imes look similar. The \·ast majority occur in long chondrobfas toma and can lead to overesti
bones, most commonly ar the knee. Age at presentation is the aggressiveness of the lesion .
20-40 years, often with pain. Classical features ofGCT arc
presence in a fused skeleton, epiphyseal subanicular
location, ecee.ntric position and absence of margin31
sclerosis. Only when III these features are present can one
confidently predict GeT from rhe plain r.lciiogr.lph. What
is impossible to sa)', ho\\·e\·er, is whether the lesion is
benign or malignant.
Figure 133d is a radiograph of the knee in a patienr with
a GeL Note how tht· lesion 3buts the articular surfuce but
has no marginal sclerosis unlike the ehondroblastoma
illustrlted ( 133a ). The distinction l11;ly not always be this
clear howe\'er, and further 3.(h-ice is ollercd in rhe practical
tips section.
Practical tips
• With regard to epiphyseal lesions in yOllng p;nients,
the two main possibilities lre chondroblastoma and
GCT. However, man}' ehondroblastomas will not have 133d Radiograph of knee
the prominent internal calcifications and sclerotic demonstrating a lucent subarticular
border seen in Figure 133a. In such ClseS it is lesion typical of a GeT.
238
Musculoskeletal Imag ing Cases 134, 135
239
Answers 134, 135 MusculoskeletlOllmllglng
AN SWER 134
Obsarvllions l1341 ',h,t-I< I"",' ,II«,
m. ), t... «<" Oft 1"1 ""'W>"'" im.~...
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,0«
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ANSWER 135
Obsarvalionsl1351 oifl&.&ntial di~gno s is
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'"
A nswer 135 MU$c uloskeletallmaglng Case 136
,h;"',.", 11>< ,I;,,,,,",;,, 'h""""" h Ir<',"'" "~ P, .cti ", llip.

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CASE 136
HISlOIY
'" 31.)~".,~J m,k 1""<""" .~h
,h;~h 1";'"
'"
Answe r 136 Musculoskeletal Imaging
ANSWER 136
Observatio ns illaa l PrlOlic. 1 tip s
A, ,,,,. m;'l.h,ft "f, I>< I<m"' 'h "" ~ ,n "'" iii< m.n ~ i.h -r... '~'" ,.', ,' ' r ....",n« "fth ~ " .. '"" ~ 'h " ;, ~"ol,
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"""'S"r'< of , ,h~" ~· it h 0.1<0""""'. 1136<1 ,
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,''', ~·, I " " «)(I.-80!\ fo.- «KI' ., ," ion.1 "",........,.."' .. ), di".1 "di,," 01. ch ikl.
'"
Conventional osteosarcoma affecting the meta-

of the femur in a child.
ory
- -year-old female presented wilh
pain.
243
ANSWER 137
Observat ions (137a) disease is more frequent than the mher re ticu
There is homogeneous sclerosis of the L4 \"Crlchral body Howewr lymphoma is generally morc likely to
producing the appearance of an i\"ory vertebra. No in destructi\'e IVlic lesions than osteosclerosis,
significam expansion or trabeculation of the \"crtebral body Paget's disease' tends to cause expansion of the
is seen. The remaining n~rtcbr3C and bony skeleton 3TC vcrtebral bod)' with coarsening oft hc venical
nonn al in appearance. 111C most likely diagnosis in a female trabeculae, In fuct, the sclcrosis of Paget's tencb-
patient is SclCfOlic metastases from a breast carcinoma mostly at the periphery with relative lucency of
primary. T he diHcrcntial di:lg nosis includes lymphoma. centre owing to atrophy orthc spongiosa, This
produce a 'picture frame' or windowed double
Dia gnosis cOntour appearance,
Sclerotic metastases from breast carCin01ll3. As \\i th PagcI's disease, haemangioma callses
increased vertcbral trabccubtions and expansioa
Different ia l diagnosis sclerotic venebral body, The younger age groun
(J\'lncmonic - 'Mc:ts ... LP HI M' ): help to diflcremiate il from Paget's,
Lympho ma. Infection in the healing phase 1ll;IYcalise sclc~
l'agct'sdiscasc, ,'enebra, ho\\'c\'cr this ra.rcly ilwok es a single \
H acmangiorna. and endplatc destruction with decrease in disc
infection . height will point to the correct diagnosis,
M3StOCYlosis. Mastocytosis is a svstemie disease eharJcleriud
mast cdl prolifera.tion in skin and the
Discussion n:ticulocndothclial system, Release of histamine
The iI'o!)' \"(;rn:hrn sign refers to 311 increase in opacity of;) mast cells in bone promotes osteoblastic aCO\l:-
\'enchral body that rc rai ns its size and (amours. leading to sclerotic skeletal foci particu larly in
In adults: • spinc,
0steoblastic metastases elicit a sclerotic response that • Vcnebroplasty, the introduction of cement int
results in patchy replacement of the \'ertebra.l body collapsed \·cnebra.l body under imaging gui
spongi0S3 with dense new bone that may be confluent results in high density within the vencbra. '
( 137b , 1 37c), Sclermic metastases from prostate an i\'o!,)' \'enebra, This procedure is pcrformed
carcinoma in men and breast carcinoma in women arc patients with vertebral collapsc who ha"e snc:n:
the most common primaries, Occasionally unresponsil'c 10 mcdication, and is highly dfi
osteosarcoma and carcinoid are responsible, An example is shown (l 37d ) of an elderl)'
Lympho matous deposi ts can also elicit a marked who had painful osteoporotic collapse at two
osteoblastic response resulting in diffuse sclerosis, le\'cls and was successfiilly [realed with resol u
When considering lymphoma as a cause, Hodgkin's pain,
137c Sagittal fat

saturated MAl
imag e shows
multiple
sclerotic and
lytic m etastases
throughout the
visuallized
spine,
137b Sagittal fat

saturated MAl image
shows a sclerotic
metastasis in the T5
vertebral body.
244
thickcningjdil:muiorl and hepatosplenomegaly, which

\'crtcbra sign is less cOlllmon in children and may be sccn on the spine r.ldiogr.lph.
. the result oflymphollll, Decreased disc Sp:lCC height and cndplatc changes
nunonly, oslcobbslol1la, ncuroblaslOm:l, point 10 infection.
rna or medulloblastoma deposits can cause
nee. Fu rther management
The underlying Clllse G ill be dClcmlillcd from the age of
tips the patient, ancillary signs on the radiograph (as described
vertical lr;abccubtion and expansion suggeS[ abovc) and thc history and cxamination . An isotope bonc
or- hJcm:lI1gioma. The kute r :lAcels a younger scan may be required to loc:tre further dqx>sits in a p:tticllt
,whereas the former is seen in the cldcrl~' with mct"ast"ascs.
b<
mass 111:1}' be seen with lymphoma due to Furth er reading
thy, whic h may also cause alllenor scalloping Graham TS (2005 ). rhe ivory vertebra sign. R.adiology
~nc br.ll bodies. 23 5: 614-6 15.
tocyrosis, look for involvement of SCH:ral
:lIld bKkgrolllld small bowel
245
An swer 138 Musculoskeletal Imaging
ANSWER 138
Observations (138a) Radiological features of a Charcot joint include:
There is marked abnormality at the midtarsal joint with Dense (i.e. sclerotic) bones.
dislocation. sclerosis and debris forma tion. Prominent Destmction and fragmentation of articular
vascular calcification is noted. The appearances arc those of Degeneration.
a Charcot joint and the most likely cause in \'lew of the Debris (loose bodies).
\'ascubr ca1cillc:ltion is diabetes mellitus. Dislocation.
Deformity.
Diagnosis Joint cffitsion.
Diabetic ncurop:llhic 100L Exeessin:callus formation.

Of causes of neuropathic joint: Look for vascular calcification on the radiograpr
• Shoulder and upper limb joints: will otten be present in patients with diabetes
• Syringomyelia. hence point to the underlying eausc.
• Congcnit:ll insensitivity to p'lin
• uprosy. Fu rther management
• Syph ilis. Trcatment is stl.pporril'e. Ampuration may be
severe progress101l.
Spine'
• Trauma.
• Tabes dorsalis.
Hip and knee:

• Tabes dorsalis.
• Steroids.
Ankle and foot:

Di:lbctcsmcllitus.
Alcoholism.
• j\'lyclolllcningocdc.
• Congenital inscnsiri\"ity to pain.
Discu ssion
Neuropathic arthropathy is a traumatic arthritis associated
with loss of sensation ;lnd proprioception of an affected
limb. When encoun tered clinically it is also known as a
C harcot joillt. The decreased pain sensation produces
repetitil'e trauma leading to eventual destruction of the
joint. T here is olien no history of trlullll and the patient
Ill l}' present with a swollen Wlrrll joint with normll
inflammatory markers. A third h:we pain at presentation
although there is ustlllly a decreased response to deep pain
and proprioception at this stage. Because the patient is still
using the limb there is no juxta-articular osteoporosis, in
fJct the bones arc sclerotic. The exccption to this rule is in
patients with superadded infection, which is not
uncommon in diabetics. Repeti tivc trauma leads to
destmction, dislocation and dcfomlity \\irh multiple loose
bodies within the joint. The likely underlying pathology
depends upon the site of the joint and the age of the
patient. When considering the ankle and foot, thc most
common causes in adults arc diabetes mellitus and
alcoholism, whereas in children the most common causes
arc myelomeningocele and congenital insensitivity to pain.
Examples arc shown of a Charcot joint secondary to
diabetes mellitus ( 138b ) and a Charcot elbow in a patient
with syringomyelia ( 138e).
246
247
ANSWER 139
Observations (139al
Irregularity, sclerosis and loss ofhcight of the right femoral
head arc seen on the pelvic radiograph. There is no
signitic:l!lt abnormality ohhc acetabulum and the lefi: hip is
unremarkable. The findings arc consistent with avascular
necrosis of the right hip. Bilateral sacroiliac joint fusion is
also present, though more prominclH 011 the riglH side.
This suggests a background seronegative arrhropathy. It is
therefore likely that the avascular necrosis is drug induced
by treatment for the seronegative arthropathy, or perhaps
associated inflanllllawrv bowel disease. No bowel
abnormality is seen on tl;is plain film [0 confirm the latter
hypothesis
Diagnosis
Avascular necrosis (AVN ) in a patient on steroids for
seronegative arthropathy.
For causes of avascular necrosis (mnemonic - ' DRIED
HI P' )'
• Diaoctes and other metabolic conditions, e.g.
hypedipidaemia, gout, pancreatitis.
R.adiotherapy. '
l;ltlammatory disorders, e.g. rheumatoid, SLE,
scleroderma .
Endocrine disorders, e.g. Cushing'S.
Drugs, e.g. steroids, anti-inflammatory and
immunosuppressi\'e drugs, alcohol.
Haematological disorders, e.g. sickle cell, hacmophilia,
polycythaemia, Gaucher's.
Infection and injury, e.g. fractures, burns and f.1t
embolism.
Penhe's disease (idiopathic AVN in children ).
Discussion
Avascular necrosis is a consequence of interrupted blood
su pply [Q bone with death of cellular c1cmclHs. The many
causcs arc listed in the difierential diagnosis and folloll" the
mnemonic 'DRIED HIP'. The femor.tl head is the most
common site at'tected. Other common locations include the
humeral head and femoral condyles . The earliest
radiological sign is subtle relative sclerosis seCOnd;H)' to
resorption of surrounding bone. A radiolucent crescent
par.tllel to the articular surface may appear. Flattening,
fr.tgmentation and sclerosis then ensue. Subchondr.tl cysts
and collapse lead to early osteoarthritis of the aflccred joint.
An AP afthe pelvis ( 139 b ) shows the subtle crescent sign
in the !cft hip of a child with early avaseubr necrosis. This
is mo re clearly seen on the frog lateral vicw of the sallle
patient ( 13ge).
248
tips Rhcutlllloid-typc arthropath y or changes of

eOlia] ~auscs for A \TN is long and,.of course, sdcrodcml:l.
toe- idiopathic Penhe's disease in children. The Vascular calcification, which may point to ulldcrl~-lng
~logical IblUres arc worth checking for in di:abctcs.
• J. CJuse , but clinic31 history may be required Associations \\;Ih immunosupprcssh'cs, e.g. pelvic
For example, the child with AVN shown in transplant kidne y.
leukaemia, and steroid trc:atmcnt was the
Further management
The underlying cause should be sought and treated. Man ~'
patients will de\'elop debilitating second ary arthritis and
go on to require replacement of the affected joint.
with steroid theral')'. e.g. thumb-printing

presence ofa SrDm3 or sacroiliitis
249
ANSWER 140
Observations 1140a) Dis cu ssion
T here is diffilSC osteosclerosis 3Hccting the \'isibk skeleton. This rnrc1oprolifcrativc disorder results in progfC'1ll
There is also ll1:tssivc splcllot1ll!galy making the likdy marrow n:placcmcm by tibmsis ;lIld consequent an
(iiagnosis That of myelofibrosis. Lymphoma is another extramedullary h3cm:lTop0ics;s and sp1cno mcga[ ~'
possibility and less !ikcly, m:lslCX:YlOsis. massi,'c). T~vical age ofansc! is O\"er 50 )·cars.
Diagnos is Practical t i ps
r.lyclofibrosis. • Osteosclerosis is on-en missed when the appcaranct
blamed on the qU31ity orthe film, i.e. when it is
Differential diagnosis thought to be due to the I';1diograph being
Of dimISI: bony sclerosis and splenomegaly: underpellCrrJted. Assessment of the intervertebra
• Lymphoma. discs should be made - if the" arc visible then the:
• M:lStocyrosis. :lppearanee is likcl~' to be real. This is well
demonstrated in Figure 14 0e: there is diffuse
Of generalized osteosclerosis in ;Idults: osteosclerosis aflcctin g all the bones on this exit
• Sclerotic metastases (es pecially breiS! or prostate patiellt with osteopetrosis. Note how the
carcinoma). intervertebral discs arc clearly seen, reinforcing:
Lymphoma. f.let that the radiograph is Ilot underpcnelratcd.
• A'lyclo/ibrosis. P.lticnrs with renal osteodrsrrophy may ha\'e a
• Paget's disease (140b). haemodialysis line on CXR or peritoneal di al~~
• Renal osteodystrophy. on A.XR. There may be evidence of subpcrioslcM
• Sickle (ell disease. bone resorption, soft tissue and vascular calci
M;lstocrtosis. and 'nigger jersq" spine.
Osteopetrosis. When sclerotic met"JstJses 3Te suspected on a
• L~rknodysostosis cheek rhe bre;lsr shadows: in female patienl5
• Fluorosis may be 3 mastectomy, while in males enlarge
breast tisslie Illay be seen due 10 hormone th
Osteopetrosis and pyknodysosTOsis have onset in the prostatic carcinoma, Figure 140d shows sueh-:-
paediatric age group. - sclerotic prostate lllet3St:lses and gynaeco
140b Axial CT image of the

pelvis shows sclerosis of the
right hemipelvis with cortical
thickening and thickened internal
trabeculations typical for Paget's
disease.
140c CXR of an adult with

osteopetrosis demonstrates
diffuse dense osteosclerosis.
250
c splenomegaly on the AXR suggests for spleniI.' enlargement that causes rC\:llrrc nt painful
-brosis episodes, SC\'\:re thromlxxytope ni3 or an llnaccepmbly high
atrophy (possibly with calcification ) sli ggest's red blood ce ll transfusion requirement. Median survival
cd] disease, and there may be mher signs of this from time of diagnosis is approximatel y 5 years. End stage
~ gallstones, avascular necrosis of the femoral myelofibrosis is a wasting illness characterizcd by gencral
.Ind cndphuc inf:lfClions causing H -shapcd disability, Ii,'cr failure and bleeding from thrombo-
I bodies. cytopenia.
megal), and small bowel thickening suggest
·'osis.
the" AX R of a patient with osteopetrosis a
izcd 'bone within bone' lppcar.mcc Illay be
md the \'encbral bodies may h;1\'( densely
'c cndplatcs producing 'sandwich \'crtcbr:J.c'.
(,"cr flask dcfarmin' of the femurs should also
cd for. Figure 140c is an orthopamomogr.un
ad ult patient with osteopetrosis demonstrating
osteosclerosis and supernume rary teeth
'5 disease c;m also produce a 'bone within bone'
nee, howe"er coarse trabeculatio n and cortkal
ning normally diflcrcnti:lle this from other
is is associated with ligamentous insertion
management 140e OPG of an adult with osteopetrosis; this

is no specifi c rreatillem for myelofibrosis. demonstrates diffuse osteosclerosis and
omy is not routinely performed, but is indicated supernumerary teeth, which is an associated finding.
251
ANSWER 141
Observations (141a) greater than I.S cm then malignant transformation
There is a large, cxpansilc, mixed lytic/sclerotic destruct!,'C be suspected. Again, flocculent chondroid cakificao
lesion involving t he right anterior hcmipclvis. There is characteristic tor malignant degeneration.
marked cortical destruction with a soft tissue component.
The lesion has a wide zone of transition. This is an Practical tips
aggn.:ssi"c lesion and the most likely diagnosis in a patient It call otten be diflicult to diflcrentiate an e ncho
of this age is a primary malignancy such as lymphoma or from an intr;\medullary chondrosarcoma, howc'a"
chond rosarcoma. Metastasis should also be considered. larrer is more likely to present with pain and
enchondroma will often demonstrate periosteal
Diagnosis and cortical bre.\kthrough.
Chondrosarcoma.
Further management
Differential diagnosis As with most primary bone t um ours, a su
• Lymphoma chondrosarcoma should only be biopsied in a
• Metastasis. bone tumour centrc so as nOt to seed tll
contaminate the su rgical field.
Discussion
Chondrosarcoma is the third most common primary bone Further reading
malignancy with multiple myeloma being the mOSt Murphey lvi , Walker E, Wilsoll A, et at. (200 3).
common and osteosarcoma following second. Chondro- of prim.\!)' chondrosarcoma: radiologic-path
sarcoma ca n be primary, or secondary following malignant correlation. /{ndioGmpbics 23: 1245- 1278.
translorrnation in ;1 pre -existing skeletal lesion such as an
osteochondroma, enchondroma or a parosteal chondroma.
C hondrosarcoma most commonly presents in the 4th or
5th decade of lite with a male predilection of 2: I.
Radiographs typically re\·cal a mixed lytic and sclerotic
appcarance. The scleroric areas represent chondroid matrix
mineralization and arc seen in 60- 78% of lesions. The
characteristic appearance of mineralized chondroid matrix
is a 'ring and arc' pattern of calcific:uion that can co..11esce to
form 'snowflake- type' calcification. T his characteristic
chondroid calcification usually ;\lIows confident radiological
di;\gnosis of a cartilaginous lesion.
R.,diological signs·
Mi xed lytic/sclerotic lesion.
Wide z:onc of transition.
'Ring and arc' and 'snowflake' calcification.
Cortical destruction.
Soft tissue mass.
C hondrosarcomas arc also characterized as central or

peripheral. Central chondrosarcomas make up the majority
and arc intramedullary in origin, although they may erode
through the co rtex into the soft tissues . Central
chondrosa rcomas lIsuall y arise in the pelvis or lemur and
arc often expansile with the characteristic calcification
described . Endosteal scalloping is often seen and call help
diflcrcntiate low-gr;\de chondrosarcomas from enchond-
romas. Clinical sympwll1s arc nonspecific, with pain being
the most frequent symptom . Peripheral chondrosarcoma is
also termed exostotic chondrosarcoma and refers to
malignant degeneration in an cxostosis (i.e. is a secondary
chondrosarcoma). An cxample is shown in Figurc 141 b-
note the flocculent calcification of the chondrosarcoma,
which had arisen from the exostosis at the lateral femoral
condyle. This should always be suspected when there is 141b Flocculent calcification
growth o f an exostosis after skeletal maturity or if an from a chonrlrosarcoma that has
exostosis becomes painful. The cartilage cap of a suspicious arisen from the exostosis at the
exostosis can be measured 011 M lU, and if the thickness is lateral femoral condyle.
252
Case 142
A 45-year-old male presented with severe back pain for several weeks.
253
ANSWER 142
Observations (142a, 142b) R:adiological features of disci tis include:
AP and hlteral images ( 1423 ) ofthc thoracolumbar spine Reduction in height of the intervertebral disc,
shol\' marked deformity at the TI2/ LI level with erosive is usuall~' the first sign of a disciris.
destruction of the opposing ,"enebral endplates. There is Erosion of the "ertcbral endplates.
anterior slip at this level with anterior angulation (gibbus Involvement of the vcrtebrallxxlies leads to
deformity)_ Appearances arc in keeping \'ith a discitis. and resulting gibbus deformity.
Axial and coronal T2 weighted MR images ( 142b) Spread of infection into adjacent soft tissues
demonstrate high signal in the TI2/ Ll intel"Yertebral disc. in psoas/ paraspinal abscesses.
Signal change extends throughout the adjacent ,·ertebrae, • Neurological im'ol\-ement arises due to intraspim.
and there is endplate destruction and partial vertebral spread of infection and vertebral body colla~
coll:tpse at T12. Til ,·ertebra has increased marrow signal occurs much more commonly whe n the infecri"fo_
suggesting it is also in\"ol\"ed. The axial image demonstrntes organism is TH.
high -signal fluid collections in both psoas muscles
consistent with bilateral psoas abscesses. Practical tips
• Discitis will cause bon)' abnormality of the su
Diagnosis and inferior endplates of the adj:acent ,·enebral
Tuberculous spond~'litis ( Pan's disease ) with associated i.e. abnormalitv will be centred at" the level of
psoas abscess. • Thc vertebral disc space is m:aintained longer ill.
spondylitis than in pyogenic discilis.
Di scussion • Look at the paraspinal regions to look for s
The spi ne is the most common bony location to be infection. Infection can present as leg pain/s--
in,'olved in TH. Presentation is often late since initial duc 10 rracking of collections dOWI1 the iIi
sympl"oms :are of ,"aguc back pain and stiffness. The most muscle.
common location IS the upper lumbar/ lower thor:acic • Look at, and around the spinal cord for ex
region, particularly around L I leyel. The anterior aspect of collcctions :and spinal in\"olvemem.
the venebral body is mOSt typically aftectcd. The disk spacc
thcn becomes involved via cxtension along the anterior or Further ma nagement
posterior longitudinalligamelll or directly through the Treatment is with antituberculous medication.
endplatc. of associated psoas or epidural abscesses may be
142b (left) Vertebral body collapse w ith abnormal marrow signal

in the vertebral bodies above and below it. Bilateral psoas
abscesses (right ).
254
male presented with

hand following :J.
255
ANSWER 143
There is a bilaterul symmetrical erosive arthropathy ltlecting When presented with a hand radiograph with C'\
the distal interphabngell joints. BOlle density is preserved of erosil'l' arthropathy, certain diflt~remiatill g
and there is 'pencil in cup' ddormity with bony can help identify the most likcly aetiology. T he
proliferation. At the left little finger there arc signs of mdiological differentiating learures of the more
ankylosis of the distal interphalangell joint. The common crosive arthroplthies arc as tallows:
appearul1ces lre consistent with psoriatic arthroplthy. • Psoriatic arthropathy:
- Usually (/IyJllmctrical aosh"e.
Diagnosis - lntaphalangeal joints, particularly the dist:a.
Psoriltic arthropathy. interphalangeal joints, aTe a!lecred.
- ROilY prolijcrfltioJl/ periostcal reactioll ani
Differential diagnosis prcsCJ1'cd bom dCllsit'ycharacrerisric.
• Ankylosing spondylitis. - 'Pencil in cup' ddormity
• Rheumatoid arthritis (RAJ. - Ankvlosis .
Discussion It'
This is a seronegative arthropathy aflecting synovium and - Bilateral symmetrical crorlJ'e arthropathy.
ligal11entous attachmcnts, and aflects fewer than 5% of - Metacarpophalangeal and proximal
psoriasis pltients. In approximately 15%, the arthrop~1thy interphalangeal joi!HS affected, Le. prOD
Cln predate de\"clopmem of skin changes by SCI'aal years JIIlfll/joj'ltsojdigilJ.
The pattern of disease is \'arilble, though the case illustruted - Margillal erosions.
is classical, i.e. asymmetric erosive oligoarthritis aflccting - Subluxation with ulnar deviation of digiD.
the distal joints of hands and feet. New bone formation is - Decreased bone demity.
charucteristic, and Illay i"esult in ankylosis of interphalangcal - Ankvlosis. .
jOllHs, as in this case. Resorption of the distal phalangcal - Figure 143b is a rudiograph of both
tufts nu y Ix seen with accompln)'ing nlil changcs. patient with rheumatoid arthritis
Spondylolrthrop;lthy is another pattern of disease, often bilateral synllnetrical crosil'c dcstructX..
with sacroiliitis and parul"ertcbrul os.~iticltions. Other disease llletacarpophabngeal joints. There is
paTtefllS include symmetrical pol\'arthritis mimicking genemlized decreased bone density and
rheulllatoid, lllotloarthriris and arthritis mlltilans, a grossly arthropathy at rhe carpal joints and rail.
destructivc pattcrn that may progress to forlll 'opera glass joints. Figure 143c sholl'S similar ch _
hand' feet of a rheumatoid patient with m~
erosions and symmetrical subluxation ..
metara.rsophalangeal joints bilaterull~
143b Radiograph of bot h hands of a patient with

rheumatoid arthritis. Bilateral symmetrical erosive
destruction is present affecting the
metacarpophalangeal joints and the wrists. Note the
telescoping of bone ends and the periarticular
osteoporosis .
256
143 Musculoskeletal Imaging
• Gomy arthropathy: • It is impossible to distinguish thc

- .\symmetrical crosh'c arthrop:llhy. sponrlyloonhropathy of psoriasis from Reiter's
- Erosions arc juxta-articular with DVttiJnllgj"g syndrome though it is notable that in psoriasis the
("gu. hand is most affected and in Reiter's, the foot.
- Preserved bone density and joint space. Spond)'lo.1.rthropathy of psoriasis is diflcrcnt
- Bony proliferation/periosTc:ll reaction. r:tdiographic~lll)' from ankylosing Sl)()nd)'litis - thc
- Goltr) tophi causing sort tissue masses in 50%. paravcrtebral ossification is asymmetrical and nOT d uc
- Figures 143d and 143c arc radiographs of goU[ to true s)'ndesrnophytes.
de mo nstrating an asymmetrical eros;ve
arthropath y with 'punched out' erosions. These Further manage ment
~rosions have o\'crhanging edges, which arc best Givcn thc inflammatory nature of the disease, treatment
seen at the proximal imerphalangeal joints orthe consists of anti -inflammatory and immunosuppressive
index fingers bilaterally and the drugs as for other infl3mmatory anhrop:lthic.::s.
mcucarpophlbngcal joint o f the right thumb.
Further hrgc 'punched out' juna-articular
erosions with associated tophi arc seen around
the base of the right big toe in particular. Note
the preservation of bone density.
Radiog ra ph o f both ha nds d e m o nstrates

, 'punched out' e rosio ns w ith overhangi ng
and associated soft tiss ue swelling in a patient
gout.
'43e Radiograp h i gout
with characteristic 'punched o ut' erosions aff ecting
the big toes.
257
ANSWER 144
Observations (144a) Pract ica l tips
Il:adiogr.:tphs of the lett hand fCveal ::I lucent cxp:msik lesion Chondroid pattern calcification, onen seen in
ofthc diaphysis ofthc 5th Illcrac:upal. There is thinning of enchondroma, is howe,"er frequelllly absent in
the cortex but no conical breakth rough or periosteal of the tubular bones of the hands and feet.
reaction. No pathological fracture hlS occurred and no A painful enchondroml without pathological -
fraCl11rc is seen elsewhere. The lesion has a narrow zone of should be suspected of having undergone m
tr:l.l1sition and nonaggrcssivc fcamrcs and is consistent \\ith tr:lnsformation IIntil pro\'en o therwise
an enchondroll1a.
Further manag ement
Diagnosis There is no specilic treaTment for enchondronu ..
Enchondroma. benign bony le~ion That is oflen picked up inci
when a pathological fr:lCture occurs.
Differential di agnosis
For lytic lesion in the digits (mllemonic - 'SEGA GAME
1"),
• Simple bone cyst - r;uc in the hand.
Enchondroma is by fur the most likely lesion with this
appcar;l1Iccat this site.
<.Ibnt cell ttlrnQUT of tendon sheath.
Ancun'smaJ bone C"Sf - mrc in the hand.
GIOllll'IS tumour -I)ainful.
Abscess/ osteomyelitis.
Mcmstascsalldllwc!oma.
Epidermal inclusion cyst (imr:l.Osseous) - distal
ph3.bnx; history oftr:luma, e/,\·tlu:m3. 3.nd swelling m3.\'
be prescnt. . .
Fibrous d~'Splasi:J. - r:'Lre in the h3.nd.
Di scussion
Enchondroma is a common benign eartibginous tumour
most collllllonly seen in the tububr bones (50% in hands
and feet ) ofpatiellIs under the age of 30 years.
The C:J.Tdinal radiologicallCalmes arc listed below:
• Centr:'Lllesion within the medullary canal.
• LueelH expansion of bone.
• Narrow zone oftr:lnsition.
• Thinning of the cortex but no cortical breakthrough.
• No periosteal reaction unkss pathological fr:'Leture.
• Stippic(] calcific;ltion llKI)' be presem
• Cortical endoste;\1 scalloping.
• Alleets small tububr bones.
Oilier's disease occurs when multiple enchondromas arc

present ( l 44b). The enchondromas arc most commonly
see n in the (emur, tibia and hands in an asymmetrical
distribution. In the long bones, presentation is with
asymmetric limb shortening due 10 impairment of epi-
physeal fusio n. The lesions do nor incre3.se in size after
ccss.lrion of normal growth. Malignant rr:'Lnslormarion to
chondrosarcoma can occur in up to 25% of patients with
Oilier's disease by the age of 40. Malignant change is more
common in centr:'Llicsions and should be suspected when
there is abnormal cominued growth with pain 3.nd swelling
and /or imaging findings of growth in a pre\'iously stable 144b Multiple lucent expansile
lesion, bony erosion and new or increasing calcification lesions of the tubular bones of the
"·Ialli.lcd's s)'ndrome describes multiple enchondromas hand represent e nc hondromas in
wi th multiple soft tissue haemangiolll3.s, which presem on this patient with Oilier's disease.
imaging as multiple phlebolilhs in the soft tissues. It Note that the absence o f ph leboliths
prescnts bl"cr, usually after puberty, and has a much higher excludes the main d ifferential
incidence ofmalignalll tr:'Lllsfonmuion. diagnosis, Maffucc i's syndrome.
258
presented wilh heel pain.
259
A nswers 14 5, 146 Musculoskeletal Imaging
ANSWER 145
Observations (145 ) Pract ica l tips
Tllerc: i ~ diflllsc- osteoscicr(>sis w it h J 'bO lle wi {hiLl hOll e' The di ltcrt'11ti ,11 di ag nosis el 'bOI K \l'il'hin hOl K' <1lll),',d l-an cc
,1Pl'C.'1rJL1ce, The most likely cii.lgnosis is ostt'opelros is, is 1;1]-ge blll rh ere MC (('rr~ il\ fe ,l lllrcs or
lil e Llilderkin ..
di s(:a~e ~'r oc('ss that lll~ y poim 10 tile specitic Cduse:
Dia gnosis ~ O s r eo ~)nl'os is l1uy 11;1\'(: ErknnKyn' ihsk ddnnnit\' oj
Osteopetrosis cau sing a 'bone wit hin hellle' ap~~Cdr;Ll1Ce, the (' nd s of long bones and sclerotic vULL' bral '
endplalt's producing \;llJci" ie h vcrl'c brJt",
Different ia l di ag nosis ., T here lllay he ;m c iJl,llY Sigll<; of~ idd e (e lJ C\i:'e,lse Oil
Of ' bone wit hin bOll e' appcJr;lIJcc (mJ1C'lll o nic ,- 'SHA RPS the radi ugr:lp h sll ch as ;\\',lSC\t! ;lr n t'crm is of Ie men,)"
POOL ') : and hLim era l he.1ds, gdlbtollCS, H -s lu pcd vc:nehrac
<) SicklC' cdl ,iiscasc, du e rn en dphtc: intar([io l\ ,111d sl,lcnic arropliy Ol'
.. H ypervil~ Lllinosis D, ca\C iti c ~tivJl ,
• /\cromegaly, e Acromq;'l ly is ,w:;oci;1tcd WiLh rCClangular-s h<l l'eci
'" Rickets, veneh rae and ci1ondl'Oca kilJosis
'" r;lget's dis n~e . 0 I n children , cOll sici n I'ickn;; ;1l1d luo k for siliavill g and
Q Sc nrvy- fl;l)i Ilg of rbt JlJCLlp lwscs,
'" Post- radi,llioJl tberapY/Lh ol'Ouast/hell'Y metal o It th e p:ui e nr is deledv, ,'(lilsid er Paget 's ,met loo k t(x
poiso ning, inc:rl';1sed trJlxculariol1 Jild CO I't iClllhi ckcni ll g:,
G C)!'ieope tfos is ;md 0\;]1 05i5,
'" Osteol11vc liti.s, Further m an ageme nt
'" LeL1kaem id, The o lll v t reaimelli ,\\':lihb le Jor oqeopetfosis is bon e
Jl1.\lTOW 1r.1 1l " I '1.1J\t~lljOlL 1 );J[jel1r~ .1re ))lore pro n e rn
Di scussion Tr;lctl1reS rh dll th e nonn .lll)(>PL1LHitllL
' Bone \vithin bOll e' clcsc ribcs til,' r.ldi o logi cal ,1 ~'lxar .mcc
",hell' o ne bone ,1l' ~' CMS w ari,~ with in al1orh<:r , lL Cc\1l be Further re ading
seell ,IS P;UT ofnofnd dn'c lor 11l C\1t, espeCi ;llly in th c spinc, VVi lliam s H , Da\ies l\ , C hap man S (2004 ), HOll c wiThin
G I'c>wth ,\I:r esr may ;ll so C;HISt' xb e ,lppnr:1I1ci:: hlll' tile re ;He J hone', CIiIi1I:t7! }{,:r-iiirJ/ogr S9: 132 - 1.44 ,
5('\,('['.11 p,ltholos,iul ,all SCS as lislt:Ll , The di(Tll sc
os teosc lerosi s ;md :lgC o l'the pClticllt in rhi s (~\St' 114;; ) ],oilll
to t llC correct di ,l g ll os i ~ ,
ANSWER 146
Observation s (146) :\11 illtraoss(ouS li poma, "irh llO ge nrln I)lcdilcni oll , Thert'
"Vithin th e bu,iv oC lhe C;t!c'1J1 t llS thne i ~ 'J \\'d l ' LlcJll1cd is an assoc iari l)n w ich hypc rli popro[c in~eLlli.l, TIle: n'p i("i
ILlc~ nt Jesio L1 \\'i~ h.l Ilarrnw 'Z,(lne nl lTansi liOll , Th e les ion radi o log ic,ll Je-arllr,s are ;1/1 eX I'3 ns iJe , n Oll agg l-cssiYe
h,1 S ::t vcr y rhill sc leroti c bo rdt' l' ,1 11ci celllrJ ll v w itiJin the r;)d io lu,'(L1r Icsioll \I,ill! <l Lhill , \w ll dt'ilncd sc lemric bor,ieL
lesi,o ll i, a ( lu mp of L~ ;li ci tJ C ar l O n, Therc is 110 l'c ri os Lc.ll The re is no pcrio:;lc;l l 1'(,;l( [i 011 o r conica l ricsl rUC liOI1 ,
l'e;1Crion ur o verly ing soft [is~uc m ;lSS, T he lesion h,1 ~ ,1 Somcril11 cs rh e Icsio ll Jl\,l)' he scpr.m"d, A ('J Hr,, 1 CIUlllp 01
n O IJ~ggre ssiv e :tppeJl'<1l1ce dnd rile findillgs .liT n "p ical o t calciticarion is virru,l llv di;lgl1ostic dnd rq'!'(:.5eJ1lS d v~tn)11I1 i c
;lll iniLlOSStC1l1s lil' O Ill ~L c'l icitit'.J tiOI1 ti'om Ln necros is ,' l'atiCrl15 1ll ~1\' be
;) S)IIll~'tOm.Hic ur h;l ve lo c l1i zecl bone pJin. The 1"Jciio'
Dia gnosis gr.1phic .1p pClr.llh'cS Me, ~ i1l\ i b1' [() a lllJi cJIll Cr:l1 bone (\ ~ L
In traosscous iipolll J, O rher dine l'('llti ,li Lli;1 g nn$t'~ ;ll't' liste d ti) l cOlllp lett' ness ht1f
th e L'C1Hl;11 (,lic ifiCll'i o ll a nd ci1;1L';Kteri , ri, ,11)t'Ca l',1I1CCS or
Differenti al diagnosis th e lesioll ~ 146) m ;lk c ir vinuJ ll y tii,lg11 0 Slic of ;lJl
e l1ni ca l1lnal hone c"st intraosseom lip o \Jl;l
~ POsL -tfa Ulllari c CIf<;\' ,
~ Gia11l ce ll fl 1111 0 11i' \ GeT) , Pract ical tips
" D es moplastic Ii brOIll ,oL ,. l lltl'.I()~Se ()ll S Iq,o lll c\ ( ' lir'ol11'-l of bOllc ') ,' .\11 occ ur J[
~ln v .:l gc.

Di scussion ~ A ~~C l;lrJ l dU Jll I,' Ofc~lki fJ(,l tiol\ i.e, virm:dl)' di,lf:':llosric
The is t il e lli OSC CO lllDl ClLl IOCl rioll l() r all
CJ IC lll CliS
iiltI;lOSSCOlI S lip o mJ Ori1n sire' S o t inl' o lw:menr inclu d e Furth er management
rhe proximal te lllUL' , tib ia, hlli ll c ru~, pe lvis , 1ll.1l1,li bl. c alld T his i~ ,\ 1X: llig ll bt' ll )' Inil)ll and I ll) lll nil,r rn ,ll);l gern fnt
vend,]'«c , \Nhcn in\'o h' illg tllbllLtr bo nes, ir is Il <; l\.11 1\, i, n ccc ~<;,lI'\"
loca ted at rhe IllCUp l l\',~ i ' . P,lli" lltS L,f an y ag,c ill.1\' dn 'eioi,
260
CASE 147
History
~ .lO·}~,,·'~,1
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'"
ANSWER 147
ObsefVali"nsI147'1 l'wud""",..w.) T"'!'''"h) TOiJ~", h" ........-.. d",,,,~
'";.')' ~ «'n_ Tk' 'ruin& '" m_

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l.klr 'n b< . I"'r"h"
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,n<! ,~I'''''$".I b". "" k" """"" h,,~ "",m" <rh,,..
T.,~",,', ')".1"""" «>,,1.. """' non.d~i"""''''' ~(,h<
"', " "''"' ''''''''' ••'i" .fi'".-rl ""'", , h.,';"g 4'; X()
"",,h "To"",', .)"d "",,,,. 1"'0000)I"f'>'"h),,,;.!.m mJ d "orno. o",... r .. ", " " 10m .bo,n ' ... ",nd"l' ""'u"
I"'0.lor><udohr"<",...-,, n )~;'m ,],,,.Id ,100 b< , h ...",,,,;,,io .·ith ,""" ""U" •• ~bb<d ""k .oJ >mill
.""";&,,.1 . ,;.. •. ,,~~ A~,,", ,,,,,",,,,ion
i> .."n ., 10'" vf I"'~""
. ,,~ """",,nO< <"",""'" (""hn. , ~""<l"n,
, i,l",y ~.
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." .t~ ,
I<I;.-",,,ho< ,h".t< n'" ,j(.1>< ~ 'h ""''1,,,,,,,.1. """. """"••" ''''' ~ oh""""'I"")"" ,h"",,"in,; ohl><
'<N .n<! 5,h m<"''''T', I, .
Oifh •• nt l. 1 dl'U"",I,
.. ~ "".. 4,h m<'><"'"1',l/m"., "',I , p•• Cllcal tips
• r,~, _ ", .....
tio_ • "1"1", "",,' .,., """.'''''1',1 n "" • ~" "' .11 nn", ' ''''' ~u,
• r""inf"",;"" (. ~, !rom
• To,""', ')'nJ"",,,_
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• r""..J.'I'""u.J..,l'lM'"'' h)T<r..l ~m_ hYJ" , .... "h)",i.li ... .
• If, II< ~.•;" n . 1-<, , i"" Ii,«[, ,11«1 ~.. ,II< •"""''''' '"
Discussian .'I .J<I",,~ J<I;"",~)' _ Th~ w,,,,01 '"111\''' T ... ".,-,
,;,t,,,,.,, ";,~ ,,(,I" ~ 'h '" "'".",01 <>" n" UI. " ""' W' . '", ,)'''.1"""" ~ ,n"" li"ly.
".um,. r,,,,, . ~. n 1 . h" ",,,. ,... ~ '"" ~"'" rh pi'" ,h,""S • I,," ~ .. m."' uf ","I'irk ",,,,,,.,,,,,-, ~ .. " '1""'11,: ",
,·h'"'........ , r""d.,hn"'r""h)'", ..."",, ~ i ,,>ns'n~~ X- '''Y or ,..., • ifl<", ,, ,i.,. "l\'''''''' "", i.mk~m'''' flr
I...... 00m,""" ..... u. ~ of",".1 md ... 1<,,", ",,;-,,,,,, " . «h ...J ;,h m""' ''I' ~' ~ r""i",IMlr
'0 r.... hrroiJ ho,mon< .I"" to ",J '''''t'" "',;.,...." mJ ,h",,'" ri,,,", of l"'ud"h),rop""hrroi.J"",_
"'fo"i,~ hQn".,,,,,. r"~",, '",,"kwo h,," j)", ......
,· h..,,,,,,~,",, " , ~"" ~ ;'" h) •• ~,.,,, h)'<,"'~ .. b", "M' Funho. m.". s.m."t
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f.«, """"I "",J,,>O".
h) r""'~"" "i._""'." ninj; ur ,10.
...I
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'''.'''''"1)- iJ '>r"h~ ,. ",1 .. ,.1 ,,, I"."·..., ',,"m. ,nJ ~
.w " ",II'''''''' """"" ...., •• irh ~"""""'. 0(,11< trio ..... o~<" ;.><;&,,,. 1.
5,h m<"''''I''~ ....1 ~ ""'" .. "r ", 75'); ( I<Th)_
147b Ha"d ,a d;og .. ph of a pa,;"", w ith

p.eudohypopor .,hy!oidi1m dom o".tr." I
<"""e"i.,..
of ,10. J .d '0 5,h """ .'''pal"
'"
Answer 147 MuSculoskeletal Imaging Case 148
107< Rod;"g"ph ollne 1001 io 11>0 .. me po,;enl os in

Figu,. 147b demon"""" ,"",'. n"", 01 ,h. 3""0
511> me'.'.,..".
CASE 148
HISlory
" 00)- I""'ntN _..., t h,~h
1<_ )~ ,,_ oIJ
~.." ~hkh ~... """" dU""8 'h< "OS"'-

ANSWER 148
Observations (148a) or moderate and may be distant from t he lesion. C
or
There is an area of dense sclerosis aflccting the shaft the the classical cortical osteoid osteoma, the cancellous
femur with associated cOrtical thickening. Within this is an may not necessarily be situated at the centrc oj
area of ccmral111cency. This likely represents a nidus and sclerosis, making treatment more diflicult.
the tcatufcs arc therefore consistent with all osteoid The subperiosteal type is rarest, and typically I
osteoma. Depending 011 other clinical features, infection the medial aspect of the femoral neck or in the h~
might be considered as a diHcrential diagnosis. feet. It produces a soft tissue mass immediately adjao:::a
the affected bone rather than osteosclerosis. Can ...
Diagnosis and subperiosteal osteoid osteonl<1S typically arise
Osteoid osteoma. intra-articular or juxta-articular location.
O steoid osteomas most commonly occur in efl(-
Differential diagnosis and tibia, where they arc usually diaphysci
• Infixtion. metadiaphyseal. The most commonly affected area
• Eosinophilic granuloma. spine is the neural arch of the lumbar spine ..\;:
locations include the skull, ribs, mandible and
Discussion Intra-articular lesions arc most commonly found in
Osteoid osteoma is a rclati\'cly common, benign skeletal The affected population is young, with abol..
neoplasm composed of woven and osteoid bone, with loose presenting between the ages of 10 and 20 years._
intervening fibrovascular tissue. The lesion itself rarely all patients arc Caucasian with a male prcdominaocc
exceeds 1.5 em in maximum dimension and there arc three is the llsualmode of presentation and is worse at
main types: cortical, cancellolls and subperiosteal. is thought to be related to the vascularity of the
Cortical lesions arc the most common and have Symptoms may be present before the lesion is
characteriseic findings. Radiographs show dense reactive ica11), visible and approximately 75% of patients repm-
sclerosis that aHccts the sha'ft of a long bone, especially the of pain after salicylates. CT can aid plain radio_
tibia alld femur. The lesion itself, howc"er, is a radiolucent identifying tht: nidus. When the history is a~
area within this area of osteosclerosis known as the nidus. location unusual or radiographs unexpected l~
This is more clearly set::n on tht:: CT images of the same bone scinrigrapby can be very helpful. The
patit::nt (148b ). finding is a 'double dmsit}" sign, in which I
Cancellous osteoid osteomas have a sitc predilection for area of intense radionuclide activit), w'","'on,1inr
the femoral neck, posterior clements of the spine and the nidus, superimposed on a second larger area
small bones of the hands and feet. By comparison, the tracer accumulation due to reactive sclerosis.
sclerosis associated with a cancellolls lesion is usually mild
148b CT reconstruction in the same patient clearly

shows the lucent lesion with surrounding sclerosis
and central nidus.
264
Fu rt her reading
Gangi A, Guth S, Dictclllanll j, Roy C ( 2001 ).
Interventional Illuscu[oskclctll procedures.
RndioGrnplJics 2 1(3): I.
suggest 3.cr scan to confirm and Knnsdorf ,\>I, Stull M , Gilkey F, Moser R (199 1).
J the nidus. Osteoid osteoma. RndioGrnpbjCJ 11 (4 ): 67 1- 696.
pat'icnt's::J.gc arc strongly
__ ..'00."""
~ an isotope bone scan if
and CT arc unrc\·caling.
of com pi ere rClllO\,:t1 of the nidus.

treatment is su rgic31, however lllany cases 3rc
ted radiologically wi rh CT·suidcd laser
ublion. Greater than 90% Sllccess rates arc
";;th this technique.
265
Answ er 149 Musculoskeletal Imaging
ANSWER 149
Observations (149a) is thc primary site of in\'ol\'ement with extension into
There is all extensive, cxpansik [liceill lesion involving the diaphysis and the lesion may undergo calcitication_
length orlhe lett humerus, pn:dominJntl)' the mctlphyscs The crlniofucial torm is termed leontiasis ossel
and diJphysis. RClllo<klling orlhe bone is cI"idcl1l and th e hcmicranial, unlikc Paget's discase. Thc frontal
lesion has 'ground glass' density in some places. T here is, sphenoid bones arc most commonl y invoh·ed . Sclet"
however, no cortical break or perjosle:.l reaction 3nd th~' overgrowth of the fucial bones and cllvari:t results in
lesion has nonaggrcssiw fcamrcs. The most likely diagnosis deformity, cxophthalmos lnd visull implirmenl
is librous dysplasia. obliteration ofthe sinuses. Sclcrosis of the skull bast
nlrrow thc neurll toraminl clusi ng cranial
Diagnosis s~'mptoms. Frontal and lateral skull radiographs 1
Fibrous dysplasia. 149c) of l paticm \\;th leontiasis ossca show these Ii
Complications of fibrous dppiasia includc pat
Discussion frncmre, and malignant transformation into osteos.t!i
Fibrous dyspbsia is a benign tiura-osseous dc\-c!opmcllt'al fibrosarC01l1l or malignant fibrous hisliocytoml in
:l1lolll.l1y of bone whereby the medullary cavity becomes 1% of cases.
replaced by an im l11atlll'c matrix of .:ollagcn and \\"OI'CI1 Osteotibrous dysplasia is ;111 cmity that was Illis
bOllc. Males and females arc equally affected and 75% of the past lor fibrOllS dyspJasi:t. It is almost cxcl
patients develop the disease belore Ihe age of 30 years. The conlincd to thc diaphysis of the tibia and is seen in
monostotic form, which mOSI commonly lflects rhe ribs, children. The lpp~arallces are vcry simillr to
proximal femur and craniofacial bones, accoullIs lor 80% dysplasia with a nonaggressi\<e e <~pansilc.lucent/ ·_
ofcascs. glass'lcsion. Enlargcmcnt ofthc tibia occurs \\ith
Thc polyostotic fonn (i.e. in\'ohing more than one sire) bowing. As with fibrous dyspllsil, pathologic:t.l rn...
is seen in.ll~c n:mai.ning 2o:',~nd prcdominlntl~' aflec~ the c0111monly occur. The lesion often rcgresses spon
femur, tibia, pelvIS and 1;1clal boncs_ A subtyiX 01 the with age. An eXl1llpic is shown ( 149d ) that illus
pol)'oSlolic form is McCune- Alb right syndrome , where typical appearances ;11ld mid-di:lphyscallocation in",
polyostotic unil:tleral fibrous dysplasia is associlted with child.
'catc ·au -lait' SPOtS and precociollS puocrty in young girls. Th~ radiological featurcs of fibrous dysplasia ~
Radi ologicall~', a 'ground gbss' density !csion in the Lucent/'gro und glass' lesion in medullary CJ.\
medullary cavity is the characteristic fcaturc_ Thc 111ct;Jphysis • Expansilc.
14gb Occipitomental radiograph of skull in a

patient with leontiasis ossea demonstrating
hemicrania I sclerosis and expansion.
266
Answer 149 Musculoskeletal Imaging Case 150
• ;\ lctadiaphyscallocation. 149d Radiographs

Remodelling/alteration in bone architcaurc. of the leg in a child
Endosteal scalloping. demonstrate a
'Shepherd's crook' deformity when :aflCcting proximal lucenV'ground
femur. glass' lesion in the
Limb length discrepancy. diaphysis, which
Pathological fractun:. has nonaggressive
No cortical destruction. features and is
Nonaggrcssivc features. typical of
osteofibrous
Practical t ips dysplasia.
The appearances of fibrous dysphsia on'rlap with those of
many benign bone lesions and it is reasonable to include it
on rhe differential diagnosis list in many cases. As a result,
• is often the firsl differential prmidcd by r:ldiolog)' trainees
In a viva even when the lesion in question hlS characteristic
katu rcs of something clsc~ Only if a lesion has the
cturaCfcrisric features should fibrous dysplasia be the tirsl
Jiagnosis mentioned - morc often, il should be further
down the list.
Further management
There is no specific tre;lImelll for fibrous dysplasia.
uhologieal fracUlres often occur and may necessitate
urgieal fixation.
267
ANSWER 150
Observations (150a, 150b) On M RJ thcse same findings can be appreciated:
A'\:ial images oflhc wriSt with Tl weighting ( 1503) and T2 • Median nervc swelling proximal to the carp~
fur saruration ( l SOb) arc shown. Inflamed tcndon sheaths termed pscudoncuroma.
an: of high signal on T2 &t sattlr;lfCd images and low signal Palmar bowing of the flcxor retinaculum.
on Tl weighted images. In addition, there is palm:!f Featurcs of tcnosyno\"itis - which appear as
bowing of the flexor retinaculum. The median ncryc is of signal on 1'2 wcightcd images around the fI
increased signal on the T2 weighted imlge. This tcndons.
combination of features is consistent with a diagnosis of Increased signal in thc median nelYC on TI
carpal tunnel syndrome. imaging.
Median nervc enhancemcnt following contra
Diagnosis injection is va riable and thcre can be marked
Carpal tunnel syndrome. enhancement due to oedema or absence of
enhancemcmdue to ischae mia.
Discussion
Carpal W Hile! syndrome is a disease that arises due to Practical tips
chronic pressure on the median ncrve as it passl"S \\~thin the Assessment of nerve swelling can be made
carpal tunnel, usually associ:ttcd with repetitive wrist the size of the 111edbn nervI.' :It the level
Illovelllents. It is lllorc commonly seen in females with a radius and at the ham:lte.
ratio of 4:1 and is bilat eral in 50% of cases . Ustla]])'
d iagnosis is Illade by cli nicians with positi\·e findings o n Further management
clinical examination , electromyelography and nerye Methods to decrease oedema and swelling \\i
conduction studies. lt1diological ex;;ullina[ions havc a roll.' c:lrpal tIInnel such as treatment of hypo thy "
in the few cases where these ilwestigations are inconclusi\"c. restriction of fluid illlakc can help relieve sy
Ult rasou nd is usually the first examination undertaken Howeyer the gold standa rd treatment for carpoa
althoug h M IU has been s hown to bc morc specific and syndromc is surgical decompression .
sensitive. US findings arc of:
• Akdian nervc swelling in the proximal mnncljlc\"cl of
the distal radius.
Nervc flattening in the distal nlllncl .
Bowing of the flexor re tinaculum.
150b High signal of median nerv e on T2

weighted image (upper arrow); palmar
bowing of flexor retinaculum (lower arro,;",).
268
269
ANSWER 151
Observations (151a, 151b) p;uemal agc. Those \\1th thc homozygous form
AI' and lateral Tadiogr;\phs of dlC lumbar spine show still born or die in thc neonatal pcriod. Tho
posterior \'cttcbr.tl sGllloping of the lower lumbar vertebrae hcterozygolls :tchond roplasia can h;l\"e a long we
\\'ith a narrowed a nteroposterior canal diameter. The AI' normalill1elligcnce.
film ( 151a ) shows th:Jt the inrcrpcdicu lar dist:lIlcc is R.1diologicll fc:tturcs to look lor includc the
abnormally narrowed at L5 level and there is squaring of Macroccphlly with bulging forehead ( 151 c
the iliac wings. The features arc consistent with narrow fora men ntlgnum ma~' be associ.uc-d
achondroplasia. hydrocephllus.
Small J-shlpcd sella due to flarrcnin g ofru
Diagnosis sellae.
Acl1ondroplasia. Short flared ribs.
• llc)stcrior vertebrnl scalloping.
Differential diagnosis • Anterior-inferior \·enebr.tl body beaks.
O f posterior \'crtcbr:J.] scalloping: • Short pcdiclcs and caudal narrowing ofintc
• Prcssurt" dlccr - tUIllOurS in spinal c:l nal, distance (this should normally increasc in the
syringomyelia and cOllllllunicating hydrocephalus. dircction ). These abnormalities can Icad to
Dural cctasil. This occurs in ncurofibrolll:atosis. stenosis.
Mar/;IIl's and Ehlcrs- Danlos. Squared ilbc wings.
Acromegaly. 'Champagne glass' pchic inlet ( 15 Id ).
Achondroplasia. H orizontal sacrum.
Congenital disorde rs sllch as Illucopolysaccharidoscs, Shortening and bowinS of long bones with.l
e.g. Morquio's syndrome. 'trumpet' appearance due to disproportionate
mel"Jphyseal flarin g ( 15 1e).
Discussion Brac hydactyly leading to short smbb), fingers I ~
Achondropbsia is an autosomal dominant d isease of
defcctive enchondr.tl bone formation relatcd to advanced
151d AP pelvis in an achond ro plastic

typical 'champagne glass' pelvis with
iliac wings. The interpedicular distance nar
151c Macrocephaly and bulging forehead on lateral caudally and the sacrum is horizontal in orien
skull radiograph. and difficult to visualize.
270
Answer 151 Muscutosketetallmaging Case 152
P"<li""llip. 1$1 . 5 1>00.... "9 of

Ad. . .lnorl"" ~ ~, 'Au,,' ~I"n~ · _ h",il;";,,.. ith I>cth log. iO..,en in thi.
,11< ...... "" ma.. " • ,,,.oiJ>'~"',..,.t "", ,_ achondropl.stic with
Wh, " ,,", ""'''''' ~ "'. """.I"~,ih~ .... imhod< I",ing of t~o
.&'",.... de.moct"" .00 • ho."on , ~ f'<"hlon .... motap hv ••• ",odu."n~
" "" """"" .. ;. _ " " . ~ .wl"" "".~."., ..~ "~j<",, • " ","'pot' oppO"' "' •.
of 'h, 1"",_.",·h .. n ... ~ ••-"~ of ,,", "''''f'<'I.'.-"I"
~"'uK<" ,h. Iu.~, lo mb. "' ....
I'm","" ",,,lK.J "illorin~ on pol ... film _ d",k lOr.
~ ,,~'" ;"~ uf 'h" "''''I",J~ " w ,I ... "",,, ,."",11,
in
"''''N" ......''.
Cut""",,, "",tu 10:, of ,,,,,.. >fIl>r"""M~.
R«"n~"I" "".1><... i,h d,.. ndro<. l d",~;' in
><~)',
Furth . r mAnlglmlnt
Th"" ;, "" <1m 100- ,o. ,,,,,d"",,, but .A<""d in<!;';d • • h
-.
<On ""'m.Jl ~ "1"'" .lo"~ 1;1. 15 11 R..ti"llraph of ,h.
h.od d.mon.".ot;"g
Furth . r _ ding . !>o,~ ""bbV 'ub" l..
u.:"",, J. G,""-",, L. II"",,, II ( lOO3). R.oJ~Oj'hi<
' k ....."""'" ,>fk","."',,,",i')' 1>0. iot in <hil.l",n.
fIMI"(;...,h,,, ~J, 871_~~" .
CASE 152
History
A ". I.!JI. 'g,d ,""n.k
p«><""J .-i," ~.",'h ••".
Answer 152 MusculoskeletlOllmllglng
ANSWER 152
Obso ",atlo nsI 15h) Pr,Cl lc.' l ip.
1)""",<1;',,, ,,( 'h< d~,, ' n~h' i •• I" ting« ~ "e<n .'''h So ... ,~" .. "ki",'" . " ~ <h.".""~,;,, in "' ... ~.I,nn'
"..."... '«n~"'" ,...." of ,I>< J~,>I ph>l "". ",,,,,,,,,.., but ,',. ...., t... .. ,n .. ml><, "u""•.- ..,.0.",,«<1)";'
"i,I>< J~,, ' r~" ...... d mh, ,11<". ,",w", n"~- . f",",,,. ," ,~ .. h"I"'r""~)'''''"''''' " ... ~ ..'"."J',. "'~'"
,,"'" .,,,..bif th< ~h ...." Iin~" .
TM" .. ."" _->1<'1"""" r""'"'_ , h,, ' "" '''''''~ , ..... ~~. '''''". finS'"
"'" ,~'"< "ki"'''..... llK "'''"'', ...
",krook,"",
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of (. d",,,J"'llr) '" ,"011<" ';"P''' I ...".p' ';"1'.",) ;"
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Of K""''''''~I''~ (m.,m"". _ '~HA R1'~N' I ' r""m' "", ~ ,I<, "" I, ".n..m.ly,.~'''';,,~
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• " n.. 'l'" .. hrro Xl ... . of 11" rh .. , ...
'\"~"'I"'h)' _ p><>ri .. ~ . ''''' ..... ""<o"' h,i1 ~. I<krookm .. ,~, <'"'" ,rooio" of ,I« ,j;,,~ 'uti (h)'
, ", "m,wXI. "'. ."",..... '''''.., from ,;".h, ,u"l ... " 11" N.. of
R..)".uJ·, ,1.< "h.I,", (by ,inu< "f 'n ..... ' ... h"1'.II,, ).
T""",,, "XI ,"",n.1 .'i" ')', ~,~""';-~, ur,,,. 1"'",,,,1ph'''"' i" II<>!
• F.rid<nn'>I)'" ~ ul ', ... 'u'l',~ ;'<gIr. ,,, ... J b)' 'h, ",~i,'< ,,'I""I.. 'h~ •. ;"
• N,u"-",,,h\\ ' .S, '\" ng ' m'\~I " .nJ di. I ,<,,~ " "'''~I I'' f'>'->ri>t" .~h ~'r"h)' - k"" h 'n"" "
Ml h"'I"'hy .-.1',1« ""'f"h"'"S'" ~'in t' "o n
of r"'g,rtip ">10; i'~'''''''' : ~")k"i, ,"J 'I"""i in " 'I"
"'';-'''''';1)'.
• S<k...-.!<n... .\I"" of ,h. orh .. «,,,J~",", Ii,,," .ikrt "'" ,j~,"
R..)","J '. '"Ii.
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II) T'< 'l''' " hrroXi Om .
I>< ..,'''''." \'''''~, 'h'"~" ' ,g , I""~ f.hn ..... "'''1'h,~ ..1Ji .... " ..
(I~!b l _ ,,< Q,,. 17.
Oiscussi"n
M""""...,>i> ;,. ,I., "n" "".I '" ,jn<'~'< ,."'''',,.., m Furthr manageme nt
Jo:"n~";", "(,,,. ,jh' .. ,"' .... 'g<~ 'u"" n",,,, ' " m .. ,)' Th", ~ "',,-..., ~""''''ft>Jo:m .. T",,,",,,,,;, '"1'1'''';''
,"''' '"
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I""d . 'I'h< ,Iu-r, m.in r,",m. ,,; .. ,oo~m.n' ''''' ""..I
'un , ""1""'"'" ,"d I"", .. ;""b. (i". " 'he h.,,)
~~,~" ...
1',no.,,,1 .",,,",,, .. "," ",",lIy ,,,n " ,h. ,~, of
152b S"'9'" ' xi'"

CT im' g"
oj 'h ' ...... p' ti' '''
w;,h scl. ,od."" •• ho win ~ lung p " .n.h~ m. '
<h,~., gf I;b,g.~ wi'" , ""."" ,.1 ,. ticul.,ion,
T""" i, aI,o. dil.,. d ~o ph .~ " ,.
m
CASE 154
History
An 15-yc3r-old male presented with
back pain.
273
Answers 153, 154 MusculoskeletlOllmllglng
ANSWER 153
Obsorvatlo nsl153) J,inmoitr. ""'n .. ,tw J ,II<,,",;"] .1 i ,~~ IK' I,d",,".
Th,,.. ~ "h,;,~ , h"rtmin" .",1 .In" 'W'~ "f ,10, ,1;,.,.1 \\"10," kh. ",,,hi<', M. d<I" " ~ ,k!'.-mi',- ~ .... " m.. " I, ' ;'
,>.I ... ~"" ~~d&ns of .... "'1'''' t.c ...""n ,,,- d",>1 ",(i", ..x.o,,,.,", '" lOO"S .Jul, ~''''''''" ..... "oJ. ,,, t.c bil.<,,>1
,nJ "10,,. '1'10. h,""" ." ".-,,,.~,, " , ~"h ~h"'h " ,g .. ,.1 .,,' n ,""'~·>I, i.o-,,_W'il " I",." " '" ."",~,""I
ok"'mi'r, Th,,,, "" no ,,"""". to ind",,, J"rhr.. >1 Jom""'" ",.,Ji,i"" ~-h<" ,.iT"""
h,,~ bU", ..1
. <1 .. ;,_ ,00, m " " , 'f'<,;f" ",,'" ",,"""~, ,,,,I-I;""'J M""lu"~ J<loon;". ..... ""","KI" Ion~ .k>n< .tJort,"inf
f""" ,h~ f~m, ~ ith limi,oo .,,,,ion
of,ho <ibo ~ ,oJ ~',i>t.
Tu,,"'(, 'l""",t,.. ~ ."""',,,J ~ ' ;,h ~h,J'Iu" ,
Dilgno.i. J <I."",it)"., ~dl ~ "".. ".>t""" ~,hl><.l ",'". 10 "",>1>< ..
"' '''I<I'' "~ ,I<"'m' Oty, '''-''Kl·... ,,,~. _<.>0"'".'" MId ' '''''''"''8 "r 'h01 ", P"'''''''''' fu.",", ,,(
"f " "..-. .,f M~kl""" <k."",' ~ (m"'''''",'' _ ·nl.I",·) ' h<' "",>I ,,,1;'-'1 "" .. ,h pi" ,' ,,,,I rl',hi. ..~ "" , ..Iy "" ,ho
1'""",-, .yn d,,,,,,,. "I"" ><P<". ","" ~'ilI '" "",It;.t "In". t~, oftlo, oJi,,>I
• IJ;.,p,.thK. ,..I;" . .. ,'" '''"'~ ""'''' <>f,t-.. rh)'" olko., "",'m"J
L<,i · W,~ J;,....... (J)"KhonJ""'" ..... ). V"",h on , h~ .Ok. Th ... wl .. ; , , "J""oJ ""P~ "'&<
• D;, ,","><>I "",,~. ,nJ , r><""'" ~I-.J,,,,,,~ J, l.-m if" ,
T"u", , ~'" I"",,,.", "" k...! '" I""OO" . M ..kl" ,, ~
"",.,n.~. P"<:ti""l \ip.
L",l ,,~ """rh p.. ,I "'~" "'" 1"';" ,~ i", .•,. In."
Ol.cu .. lon ,n, .,in" ;""
i<" in,
di.lrh)'«>1 ><,""-
"' ",kl.", ~ ,k • .,n"y,"mp'"'" " h, ,., J~ .. I ",d.~ ~'h"h 1,.>1. h ~""'''''g "I ,h. ~, h m""'''r>l. ~hkh ~
h .. """"'" ~ """'-" . " d uI." '" "'"'" ...."lti". uI."
~ i. ."""i",J ~'ith l'"m,,', """"",,,.
rik "','" J~,~ "JioI """,,J..-
",rt..;., Th. d .. >1 "10,, ;,.
>I", ,""""00 Jo.....nr,.oo ,10, "i,"~~I.., .oh'f'<J ""1'''' .. Funh o, m o n o~.m. nl
,...d~,J .. ' 0 ,'" "cl .... J ,up.oI,"~ ""."J " ,,,- ~ ..... 110... ~ no """"" ",,"",n' l.- ,hi, """, ;,", • .
Th,,, "" """.1 """'1,••,,",~"i."J ~'i ,h M.J"",,~
ANSWER 154
ObH rvllionsl l!;4) Oiocuuion
T, ,-,", ~ "" il .... ,,~ I ., ' ''' "f, lo< IA ,~~d~.1
h<.Ir ~...".;" ~ \-'",,1:><. pI..,,, ~ ,10< '''''" "",J ,,, J,,,,,,;t.c ",,;f, .. m
,ho "">e. .
u,,.· of. " ,,,b,, ot.,,,. Th< ""m IiJ.dy <>"'" <ull .."" of. "~, b,,,) t...ly into , ,hi". A.. dO-l, TI., """"
i" • ,kaJ ~ .. , ",I;,,,}, ,,,/I'I,,,J ,,", b.. i, <",in< 'f'h II i, ".n ... '" .'", >< ; , ,"J"'" ",•••"
~ rh i i,. ~"""',,"". ~ ith
"",, " k.n', ,I" ,,,,-,,,,,, "'u>t
",,,<too.. "lo.'",J.
f"~"'''' ',,
,',,,,h ..1 "~ly ~ "'''''001 .. ""' ; o~ . 'w" "" <,lS"
TI"
Oi.~ n~l . 'r!""'"«. 11><".., '1'''''' "" r""'''~'' 'o-.J <0""' ",'
.",i'''rh,l ~ sr."'''"''''' ,,,,,i.~ ",,,10.. rI"'. 'r!"" 'hsh'ly .'iJ",d . l;.,, ~ lr
,10«< i. no k)l'oori<
." "'""~~ .~~-;""" , 1'h<' 1"""';''' ,km<n" of 'k,
Dlffltullll dllgnosls "<,,,1> .. "" "onn>ll)' '1""'1. f-'<l)' <on. ,ho >«"~,, wi ll
"'~ ,',,,<h,. pt."" ' Pl"" 1, ,;< .. -.J >,,,,,.,,,.1 in "'i~~' "'~,,.., g,.J ".lIr
IJiop.>,hk. " .ifoom ""11,,,>< ok""' I'" Sur, ,i""" ..,ok,u 0' ,
1"",,,,_,- 1'''''1,,,,.1 ~,Ii ,~."' """ ' " ~_,«,;,"" ,..'n. \\';,1.
• s ,or! ... i< (rn<"'''",,- ku',,,,,;'-'I. ", >I;,,~ tb<" ~ " ,,""'Out,,,,, "','" "",I-."
'u if,,~;" ;-..)
T"u .. " n'ig)1" , I, ,.,ugn ~"'" ,,,;,.,,,1«""1"<,,;,," "'~"""i< r
• ."",.1., ",~""Dy 1''''''<> n""." "'~'r ",I"" ~""," ",-,~ ,,,too,
H.<m"'& .... , r""" .. ""I""J i" ,ho .b"'",",i~ ,1;,~, 0", "f,"-"
~ " '_"',, """"~ . • 'h i<h ~,""" iJ i"r"h i< ~ !<n-nrJ
r ....,'f"""l)il'
l-o.-
• '110,",,"1'"''''' ,'w..f~m .
o."oyn<'~ ;n!","",
";.. ...,.
",,,,,",,1""«><"""J",,,~ '" ';'h"<--~ummd_\'''n,,, il
M''''I u • .-. d"'''''.

Sro"J)'Ioc"i, h)",>I J l' l't..~ "'''1>'n it>l.
• Mk" ',-n~," "'<.
'"
tips from binh. Pbtyspondyl)' may be generalized, aflixting all

ttncbral body affected has a uniformly flat 'coin the \'crlcbral bodies, multiple, affecting some but not all
edge' 3ppcarancc. the vcrtcbrnl bodies, or localized, in\"o]ving just one
;-encbral discs arc typically spared with normal \·crtcbn.l body.
~ccs.
posterior clements arc spared. Further management
generalized Os[copcnia suggests osteogenesis The underlying caUSe should be determined ifpossibk.
Eosinophilic granuloma is the most common cause in
children and usually n:sokes spontaneously wilh age.
\'ertcbra plana is the te rm used to describe

of a previously normal vertebral body,
refers to flattening of the venehral bodies
275
ANSWER 155
Observations (155al Practical tips
Three well defined densities in the right uppcr quadrant 3TC Ancillary signs of sickle cell disease on the radiogt2l'
projected outside the comour of the right kidney and arc depend on the area ofrhe body imaged:
likely to represent gallstones. There is mild, diffuse • Abdominal radiograph:
osteosclerosis and increased trabeculation of the bony H -shaped vertebrae due to endplate infurctiom..
skeleton with I'encbral cndplate infarctions causing H - Avascular necrosis ofthe femoral heads causim!:
shaped lumbar vertebrae. Sclerosis and flancning ofthc left flattening and fragmentation. -
femoral head suggest avascular necrosis. The spleen is noted Gallstones (secondary to haemolytic anaemia
to be atrophic :md calcificd. Ol-crall the features arc Splenic arroph)' and calcification .
consistcm with a diagnosis of sickle cell disease. Renal papillary necrosis may be caused by siekk-
cell disease due to slo ughing of papillae from
Diagnosis infurcrion; a sloughed papilla mal' be seen widm:
Sickle cell disease. the renal calyx (on an IVU) ( I SSc).
Discussion Chest radiograph:

Sickle cell disease is an inherited disorder mostly seen in H-shaped vertebrae due to endplate infurniom.
Afro-Caribbcans. The sickling arthc red blood cells leads to • Avascular necrosis of the humeral heads
increased blood viscosity, occlusion of small I'essels and • Cardiomegaly (due to chronic anaemia).
bone infarction leading to necrosis. Chronic haemol~,tic
anaemia also ensues. Marrow hyperplasia leads to Skull radiograph:
coarsen ing of the trabeculae and may cause diffuse 'Hair on end' appearance of skull vault due [0
osteosclerosis. A CXR in a l7-year-old female with sickle marrow h)'perplasia.
cell disease is shown ( I 55 b ). This demonstra tes diffuse • Widening of diploic space.
osteosclerosis with H -shaped thoracic vertcbrae (due to
endplate. infarctions) and cardiomegaly (secondary to Further management
chronic anaemia ). Treatment is genera lly supportive with m
transfusions being necessary. There is a high ineid
infection of bone and lung. Skeletal pain can occur
only from osteomyelitis but also from bone
inf..1rction
155b CXA in a patient with sickle cell

disease demonstrating diff use
osteosclerosis with cardiomegaly and H-
shaped thoracic vertebrae.
276
CASE 156
History
~"~o . )~" .<>IJ '·"m", I",... ",,,l.·.h
1,,'; llm~.J ';PH "t p..>tn .
• • •
m
Answer 156 MusculoskeletlOllmaglng
AN SWER 156
Ob" fYllio ns l l 56 1 1"" mo<' rom""., ,,"w ;, "'<lmJ """"""", ""'" of'h<
~ ,.11 0<><1,- """" ,,',n ~ r ",,< nI<J, Th",;" ~;o"r"''''. "'ins "",,,,",Ii< 10 ' " ~ ", ~i<"'" <'''-. ,h< ..'
", ... , <...... '
J I!IiH, in"",," ,kd"" "r"k< .'i,h mo", "'''' " '.. "f u" mul'i~k ,,,,,; of ..",,""'" " pt .... "" , ~ ... ""'" '>0_ No "'n~ up"" ofo.otop< ~ " " '. ho.~,~, tbe .. ~
,;I.<. re"'" ....' ",,',-c.,.,.! "" i,'or, h,,~'<,~, m" '" d"T"",, ~-,,<, .of
~.I""""'" might ""'" hoo ,~~,,,.,,.... """Ky , h.. ,.'".1.1
>om, "r"h in to. bI.JJu , 11.. ' inoJin~, m ,h,,,,"", 0. "OK 'uily ""obo"J , Th< di,l\a. "",,,,,,,, "' ", i""r
"",,"',n' ~ 1' 0 • ""r<''''''''
~>' Ii!." " ""'" i, ~ .",.Ilr """" r""""''''' ;'' ,be .. i.ol .1.01<'00, «1<-.. ;"
o,""'i~i<. """'''", <o>tn,I><"J ,,1
"'"..,io""" _"" ",,' ""'~
wiJ<,W oJ """" ••,:.,
0."", 1ft< " """.I w"~,, ,~ibk ,"J ,..... ;,
Oi_y n!»i. , I ~, ••,..." .., '""'rh""'~ "'~";,y,
__'" r< "",n' oj , .. , . . .,.1<'1",,,1 m" ,,' "'" R..J,,,,>v<.1"S.,;" '~'r<""-"" ..-,"
I>i","", ...,,,,«d ,I, ~~~ "' .. , i'r,
Oill.",nl;1 1d l. gnesls 1'.-."""",0' " .... h m.,i>I ')<h'n.lo-.n ~ '" .... ' ' 0"
or" ••,,, 0' , ""r<""""'. " .. m ...
• IMfu .. ,l,',,'" m<t"'.... , Abo<.,/lirtk up'''' "' ' h< k;.t"",• .
Il<n ~ o~""'"t "'l'hr_ V" " ~l","", ofbloJ.k,
• o,,,,,,,,"',,,i•. 10<"",,<1 hooK '" "'~ ';"0< ,,,.,,
I",,,,,,,J '""'1~"",oI~", r<,;''' ~ " I " "1"'"
• lin"''!''''''','·''''''''
•
It,,,,,..,,,,,...,,,",,
~I,<~ . f,"'<~~
\, i,;O:O, ",,,,,,,,I,.",;c.:"
• 1~ " lo<"". , P.lc:tlc. l lIps
• ArI",'i< ", ... mi" Ilm;",,~, ;,~'''' ,,.,1 ..,"i '" ;" ,I", '" • •« .., •
• \\'''''1'''',,1 ",S',', """"" .,"r<......,. ~ p"t","'" p'o>.-""""' in ,'" "",,,,'"
f""'lu< ing . ' t .. ",m"",',
Oiseuu ion ,11<1.00/", """" "nJ '0> ,''''''' ,.,," oJ;lfu", u p, ....
"_", ....".,.J "'''~' On , '" honn on .. iootor< """" ~ be",,, m""'," ~ ",n", m.y r....J"" """" "".1
..,'" "" " .... , "' ,n '01 .... ", liJ , ,,,, ~,,"' ~I .. ", , ' ,'" .. 1,,1, 'C<D "I in< ",,,,,,J , >,....
0.-n" ",'~'i<y in tt.. k.. ,,,,, but .uooJ , ;"'.I~,,"'" of,h,
",i"",- bI.JJ,,_ Tki, i, "".,J. ""1'''''''.'_ Th, .," Further m&n.gemenl
(,><lin. ;, ,t.. . W,"" of -""~ " " ,t.. ,;.t,,,,,, ~'h",h ""
Y " 1",,, • '", >"""..,' ~ ""',,t.. ,,,"" "n."""," roc,,~ ~ ,,,
"" .... r .. ~ ~"'" ,'" oJ"" .... in,:""" in 'l<kt'" " ,h;',' " , t.',m i"" Qh«I ... , 'h< e, "", ~ oJ,,, ", "",,,,",I;; '"
~ ,,,~,."",J. I" r"" """r ,,"h ',,,n, ."" "1''''''"'' ,n,h..",,,, J""N , Th j_ ,"., "" « '""", " "'" th< 0 ~" ~y
,""""I., t h, 1"" un, 11 'h, ,mrn,nn« ""',b,.<nt ",n,1 , nJ d.",-" ""m i." .... ,
..""it;, """"",t;' to d,;,;,,, ,h,,,-,, ''1'"'' "'" ",-" I,.",
1501 No ,.".1
uCtal . ,
MuSculoskeletal Imaging Case \57
CASE 157
History
An <IJ<~}' r""'"' f"<",",«1 ~ i , 1> 1<5
p. ....
ANSWER 157
Ob.. rvali o ns I 157~1 Prootic. 1 t ips
'I'h.", ~ 0011.. "" ""k f'< •• ",..1
m","",,,!, h),,,,, o/',h< ldi ,iN, "'"
""" n"
.I<ln ~
fihulo _",oJ'S" "" .....
,h. • n ••1, n' i~;"5 d;It"" )"<n. .... , ~ ,.." . ' n ""
,.J"'W'ph. ",-, ... Urn'" ""~)' ,.), "'" , e n .. ,hH
.. ~," .... oJ ' "' I.~ .. ,,' .., ""'11"'" ..-.j; , ...... ''I'-"'~!' On '''''S
' '" t~, ,I.. f"" '" '" .... " ... ; .. "f • rOm "',.
'"' "N"" "",Jw"~ ""r ~dl filk." •
mix. Th,,,, ~ no 'umou"
.... rio! <oki/i<" ..... of out. , TIK ""'" 1;Mlr , ... " uf,h. • ~""""I"' .nJ PhIt boh,h, ...... ' '" <h....,,, ,,"'-"',
p<';".,,~ ,.. "io. ~ ,h .... " " ,...... ; "ulf"'~"'r. ,rouGh , ,,ufto,~""r,,>01 ,~ ,,;,]" ld l;"', .. , to or'«;']
;, ;. ><ill "h-;"'bk '" ,.,., ... ".,,' ,o.Jiof,t'rh '" ,,,,luJ< d;",.>t.
hH""'~""" 1'"1.".. ,,), ,... ''''''"nT''h~ ,;,"" ,m ,><CuI, • l1...,~h.1I fn' , ....," " " . "'-~, ,t.. h ....... ","",mt..,
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• Ho<m .... " ~,.,,,' h in~ ,h.. ~ ""h~,~' ,.. t.. ""n
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,.,,. "" ."" ffi<~ " '~ . ",',n.-".", ~ ,.."",..",,,1
Oiffltentil l dilgnools Fut1h. m.nagomont
or JJffio", b...",J f'< n.....~ ",.,,,",,,;' .J"k" Th~ Jq.,.J , "" 'h< " " "' . H [>O.~ .. ,t.. M06' ,""'"",.
• lin'''''''''"'' ... 1" .... ..,. ..... ,....-t h"""'h, (III'VA). " u" .oj 'h, ""'" ;m",,","' ,""'.~.m'.' "1"''' ~ '0
• V.",ul .. ',,,,, If~",,,y_ ,,"uJ, ,t.. I""""''" ,,/ ,n ",.J<rl,",&I "n~ ,,,'"""' .
• r"It)""mt,,)"<r"~'~~ '
• Thl"'.;J ..",,,,,,hr-
• FlL""'-"~ .
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tt"";,,,," ,h" h,,, f Jilk",",~' " ~
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inJl.unm"'o,l' 00-. " di", "".
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.I~"" ,«n i" tI" ",~. " 1O"t,...
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a ubbing of,". ~ m'r t.. I"""n' An '''m~1< ~
"'"'W" ( 151bI, .... "'~,,.,n 'h, '"<lmh , oJ inJ" '"¥'''
or< .!l< ,~,J. i"""' '' ~ "'''-~ ....
~ oJ", "' " ...,.,~ m",'
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it, )"."~ hi..,.
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,,~'" «>0" 0>0" I.
,11<,,, 'h< I<w.« ..... fof'h< , .... .,.d log. '''''''tV<
",,,I, 157b Hond 'O<IlogfO ph ot 0 p ot;tnt w ;th
<In ,"', .... ,11""",1, 1',n.~, ..1""".. on hol, my th j'l"oid o<:,_hy dom""''''''''g
,;", .... .., HI'OA hu' t..~, wouoo 1";'M<n' md PO''''''''' ,..<:tion oIo"ll tho d,ophy ...
•
"".... "''''".... , ;,•. ,I,'" ,,, ,1,. <"ro,,;.,
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01 mo", ot ,I..
ph.I'''I/e •• " d IhO ' "
. nd 5th rnot3<o,po".
CASE 158
Histo ry
.\ 14 -ycar-oJd male presented with
.mll pain.
281
Answ er 158 Musculoskeletal Imaging
ANSWER 158
Observations (158) Radiographic aplX'aranccs arc \'aried. Lesions typi
Within the midshaft or the diaphysis of the humcms there appear lytic but may have reacti"e sclerosis. l"largins '
is a rdativciy well defined Irtic lesion that has a narrow zone oc well demarcated o r poorly defined and they may C"
of transition. T here is endosteal sca lloping and smooth ha\"e a pcnneati\'c appearance. A lamcllated periost
J:uncllalcd periosteal reaction. The lesion has nonaggrcssi\'c reaction is often seen. ilwasioll of overlying soft tissue
features and in this age group eosinophilic granuloma or result if rhe lesion penetrates through the corte.~. In
infcclion is the most likely diagnosis. skull, the lesion is often round with a punched
appearance and une\'en destruction of the inner and
Diagnosis skull tables results in a 'double contour' or 'ocvelled c
Eosinophilic gra nu l om~1. appearance. If the re is more than one lesion, these
coalesce producing 'geographical skull'. In the spine,
Differential diagnosis \'crtebral bod,' is thc most common site of lm'oke
Osteomyelitis. Lung in\'olvc~lelU occurs in 10%. Treatmcnt of the
Fibrous drsplasia. lesions consists of conscn'ati,'e therapy
• Leukaemia treatment such as curettage or excision .
• Lymphoma.
Practica l tips
Discussion AJways keep this cond ition in mind when fo
Langcrhans cell hisriocytosis is a spectrum of disease diflcrential diagnoses for lytic bone lesions in the ~
characterized by idiopathic proliferation of histioc),tcs patient - the appearances are varied and the clinical '
prod ucing focal or systemic manifestations. Eosinophilic may be confusing.
granuloma is the term used [0 describe the disease when
limited ro bone and is mostly seen in patients aged octween Further management
;; and 30 years, The elinical 'and radiological fC:Hurcs may The prognosis of eosinophilic granuloma is excellent
mimic infecrion as well as mher benign and malignam spontaneous resolution ofbon~' lesions occurring in b-1
diseases. The cause and pathogenesis of the condition arc months.
u nknown. Clinicli m:mitCSl'ations relate to thc atfected
bone with local pain, tende rness an d masses COlli manly Further reading
observed . Patients may ha\'c low'grade fe"er or ele"ated Lc\'inc S, Lambiase R, Pelchpr:tpa C (2003 ), ConiQ1
inflammatory markers, which eonnlscs the clinical picture lesions of the tibia: characteristic appearances at
with infection, The diseas~ may occur in any bone, conventional radiograph}', RtJdioGrnplJitJ 23:
although there is a predilection for the flat bones widl more 157- 177.
than half occurring in the skull, mandible, ribs and pelvis. Stull M, Kransdorf M , O,,'aney K ( 1992 ). L1ngerhm
Lesions arc solitary in 50- 75% of cases. Approximately one, cell histiocytosis of bone. RndioGrnphitJ 12( 4 );
third oflesions occur in the long bones, most commonly 801-823.
the femur followed bv the humerus and tibia. Most lesions
occur in the diaphysis, and in general the growth plan: acts
as a barrier to extension.
282
CASE 159
story
:!4-ycar-oJd male prcscms with knee inst:lbiJity
ing a football injury 2 l110mhs previously.
283
ANSWER 159
Observations (159a) mobile fragment that flips through approximately 18
S:lgillal T2 weighted imagcs or the knee demonstrate a much like a handle flipping from o ne side of a bucket
rupture orrhe anterior cruciate ligament, no imact fibres the other. In such circumstances, the residual pan:
being demonstrated . In keeping with this, there is mild meniscus will be reduced in thickness and will not be Stta
anterior tibial translocation. The posterior cmciate ligamcnr on the usuaillumbcr ofsagirral scans. If the 'bow tic'
(PCL)is intacr. seen on less than two contiguous SJgirral images, a 'bu
There is loss ohhc normal 'bow tic' appearance ohhe handle' tear must be excluded. The mobile fragmalll'
laterll meniscus with non-visualization or the bodv and should then be sought elsewhere in the joim, c.g. me
much orthe posterior horn. Funhcrmore, abnorm;llow in the intercondylar region ; anterior to the postCfl"
signal tissue is present in the intercondylar region just lateral entdatc ligament ( peL) producing the 'double pel'
10 the PCL. These findings are indicative or a 'bucket (I 59d ); in the anterior joim, in from of the anterior
handle' tcar of the lateral mcniseus with a fragment of of the meniscus.
mcniscus displaced mediall~' . A joint emLsion is also present. Other t}'PCS of mcniscal tear include:
Oblique and horizontal - linear signal change \\1m.
Diag nosis the meniscus th:lt extends to the inferior or superior
Anterior cruciate ligament (ACL) rupture with 'bucket surf.,cc.
h;mdle' tear of the lateral meniscus. R.1dial (also known as 'parrot beak' tear) - a vcrrial
(ear through the rrcc edge will produce an absent
Differenti al diagnosis 'bow lie' sign similar to a 'bucker handle' tcar.
Nonc. Howcn:r, the derect is only small and so the ddea
the 'bow tie' is much smaller.
Discussion
The ACL is best evaluated on Tl weighted images and As an aside, if the 'bow tic' appeamnce of the m
fibres shou ld run parallel to the roof of the intercondylar is seen on more than two saginll images this C.Do
notch (159b). ACL tears most commonly leave no nonm.l indicative of a discoid Illeniscus. This is prob
residuallibres visible on MIt! . Sometimes, residual fibres congenital abnormality where the meniscus has J
of the ACL arc seen, but following a more horizontal disc -like sh3pe than the normal 'e-shape' due to II
course than normal. thll1 nomlal body. They arc mon: prone to rcaring 3.IlIr.i
Sagittal images of normal menisci show a 'bow tic' be symptomatic e\'en without being torn.
lPI>carlrlce on at least two contiguous slices (159c). This
is because the normal meniscus is approximately 9 mill in Fu rther management
width and the sagi n al images arc 3-4 mill in thickness. • A complete ACL tcar causes instability that is
Thus, at least two sagittal slices should pass through a by surgical repair with a prosthetic o r tendon grwo..
contiguous section of meniscus. Menisclltears often require arthroscopic
'Hucket handle' tears constinHe about 10% of Illeniscal debridement.
tears. The vert ical tear through the inner edge produces a
284
CASE 160
istory
kma lc patient presented with joinr
n,.
285
ANSWER 160
Observations 1160a) Radiological features of h),pcrparathyroidism arc
T here is subperiosteal resorption of the r:ldial aspect ofthc 10110ws:
middle phalanges of the index and middle fingers. No BOlle resorption:
c\'idcncc of marginal erosions or brown tUllIours is seen Radial aspect middle ph,)Janx of211d and 3rd
though the trabecular pattern is coarsened. The findings fingers ( 160 .. ).
arc consistent with h)'perparathyroidism. Terminal phalangeal tufts ( 160b ).
Disral end of cla\"idcs and superior aspect of ribs
Diagnosis onCXIL
Hyperparathyroidism. "ledial aspect proxill1:l1 tibia ( 160c).
I'Ikdial tcmorll and humeral necks.
Discu ssion La.mina dura of skull :Illd teeth producing 'fl
The uneOnlrollcd production of parathyroid hormone in teeth' ,
h)'Pcflxtr:lthyroidism is primary, secondary or tertbry. 'Pepper-pot' skull due to trabecular n:sorplion
Primary hyperparathyroidism is causcd by a parathyroid ( 160d ).
adenoma. Thc raiscd parathyroid hormone lel·cls lead to Pseudo-widening of joillls, e.g. sacroiliac jointi..
reso rption of bone and hypercalcaemia. Secondary • Margill~\1 cro5ions of the h;lIlds.
h)'perp:Hathyroidism is usually a consequencc of renal
insuflicienc)" where chronic hypocalcaemia leads to Bone softening:
parathyroid hyperplasia. Some patients with secondary Wedged I·ertebrae.
hnxrp:lrathyroidisrn then go on to del·clop the tertiary • Kyphoscoliosis.
form , whereby a parathyroid adenoma :Irises within :I • Bowing of long bones.
chronically ol'erstinllliated hyperplastic parathyroid gbnd.
The cardinal radiological feature is subperiosteal bone Brown tumour ( 160e).
resorption. The dillerent sHes aflccted arc shown l>elow, Osteosclerosis (marc common in seconda/"}'
the d:lssical location being the radial aSlxct of the middle h)"l>erp;lralhrroidism ).
phalanx of the index and middle fingers. Figure 160b • 'Rugger jersey' spine.
shows :lnothcr pattern of erosion - band -like zones in the
middle orthe terminal rults. Bone soltening mal' result in Soft tissuc calei/ication:
wedged vertebrae, kyphoscoliosis :lnd bowing of long Periarticular.
bones. Parathyroid hormone-stinllllated focal osteoclastic • Chondroc:llcinosis.
activit)' can cause brown tumours, which arc characteris- • Anerial.
tieall)' expallsile, lytic, wdl demarcated lesions. These can
be the solit:I.TY sign ofhYlxfl>arathyroidism in 3% ofc:lscs. Ren:ll c:llculi.
Figure 160c sho\\"~ a pathological fracture through a bro\\TI 1\ ledullary nephrocalcinosis.
""'l t
160b Left hand
radiograph
demonstrating
lucent bands of
resorption across
the mid-portions
of the distal
phalanges of the
first three digits.
l~
160c AP radiograph of both knees
demonstrates subperiosteal resorption at
the medial aspect of both tibial metaphyses.
286
A nswer 160 MuSculoskeletal Imaging
Pro.li"", lip • Furthe r m en.ye me nl

• On CXk ~ ..~.~ '"Or<';""'" '"'''l~''' .. ,... j" ."'f}' h,l'<,p .... h~·",;.t,"" io I.. . "J I>y "''11",,1
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r><><""'" 1<;;' 71h ,..J " , h ,n" . A!oo look 10< ,,,,,ion 01 .. " "ubi «."W'pn, m'''' "'" i, O~'" I",""m«l,o
,"" I".,~ .."" "I d", " .... "" ( .""" I. k",." 'h, ..... """'.I~ "r""~"Y I ' ''''h). In ,""~.,,,"
H"p<'I'",'hyruid"~ ~ .. "";,"'" .·ith «n" f,o"", "" "'Uf>O< p"''''!'roid ,<I",om •. MRI 0< .dnt't;<'phr "a)' I><
,ho", m'~' '''' h .. ....!;,~,~ lin, on ,... (,1m onJ ,,~""'J to Iox , I< ,IK """'""'I.
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"'r I>< do< '0 "'-" """",,t>.
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m"l' I>< Ifn,l ,""'"\; ,.. 01,.1" n, f)' " ' r" " ..,,~ i",~;. , f-.
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.-.f'h' ,'"'
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1601 CXR in • potie nt wOh

hypo,po"thy""di.m with "b,l •
• ,o.ionI of th o .u".rio' .,,'.011
0( tt>e
I<flpooto,ior 7th on " 8 th lib •.
160<1 OiIfu • • bon. , • • orption 01 tho

O, ' • • n. p.-odu¢ in~ • 'pop","pOf okull
._"-'flC4.
1600;1 AP I~;ogl'ph 01 l;got

,lIoold .. domom" oting . , ,,,ion 01
,h. I.te ,ol ond of tho ~ ht ctoviolo.
1601> S .otomibi . c on with im . g •• ot 10

min.od 90 "'"' po" in jection._
let. i... d tr.ce, in • ri ght p ... th ~ r oid
od."""".
'"
Chapter 5
PAEDIATRIC IMAGING
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."""",,i,,< d .,;'~ ,.",,,1,,",,,,
Paediatric Imaging Cases 16 1, 162
CASE 161
History
S1i 1 1t.~n k,,~ .
CASE 162
History
A" I.)·, .... ~I J ,"h'd I"""""" . ·j,h
h<..J~h<, .
'"
Answers 161, 162 P aedi a tric Ima g ing
AN SWER 161
ObSflfYlli<>n' II&11 Oi .... . . ion
T I> ~ ,.o "'\O"' rh ~ ,,(, ,,~I",,", e, e,' " , I>< .. ~ "" •• '<'0 T)" """rh",;' J )'ri"i,. ~hl<h " ,Iq, ' "" ~n "
~'~ h ;,tI>< Iungo_ 11>< "" "m~~"'.01 00hl ~ "",n, ,,,,,",m , ,s th"" " ",,1-.oric Jw,,,,,",. ~ ,,...., of , t-", roo« """mon
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,I><", 5 "l""""S of 'h, i~." .in~ TIo< ", " "''' ''>j! •
o'-'h,
Ion~ ""'''' ~'~h "" in~ of ' h, m<1 ' r hl'''' " ro.lu<"~
"' t<<y" "~ ""l"riOCr.
, h.""" ... " '''kphon< h"hIl,' .h "" n,,,,;, ,"-' P,ootlc.' tip.
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)<" ."rt 1> " m ",'Um," ' ' '1'';''''
AN SW ER 162
ObSflovltions l 1621 OI ...... lon
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• I~"k"'m' . , , ",,,.,,,,,,,1'''' rl" n '~ m ' . ,. h "" ,.10<. "rl"""'",,
Lrml'hom"
• )<'''-''''''''''
M,,,"'''i<'
11 Yl"'I''' " h ) "'"'~"' .
• R><I" ,.
• H""-'I'",,,,, ! ,,t "~,
Paediatric Imaging Cases 163, 164
CASE 163
Histo ry
r.m<'l<"'''''-rl,'" cr "f ,t.. ~";n ... ,
' _ )~ ... o!d <hOl.! ~ ;.t, ..... , "iz ...... ,00
hH'''''·
CASE 164
Hi. tory
.\ n'~-bom r ""n"J w;,t. b" .. h;n£
J;"~ " I , ;"' .. 10 .. ,1,_
Answe rs 163, 164 Paediatric Imaging
ANSWER 163
ObH rv&lions ll&l1 d" ,,,,, H h, m.), , h,, ~- " , ~ , I, h)Y"""'""""" "f ,h,
" h, cr "''" ""'~, <h ,~, .h.T." ",,+,.,1'~' .I,m' ~"h to .....1 ",n"i ••••1 .""',, ",rt" ~'"h ,11'''",,'n' "f 'h,
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~ "h .ft:.,,,,,,",
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OIKUlSlon Furth" tlading

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i~. hi".' ''' ... '" 'hIT ,I", ,,,,btu",;' lit,.- .fk",J, (;T "
ANSWER 164
ObseovI,ions 11641 b""" ho.I"",I ... Jiff"'''''''' m ;., . " ... Th' ... to,.
An ,,,,~.,,,,I><.I 'ul>< ~;. rI'";'' ' ,,'~f ..,."l' i""~.'" 1<".,,, <On " ' ~ " X>', .,,",",.01 ,,, ,1-.".., ...-. Ju r h""",,,;,
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""" ~ • «"W.~,I J,orh"~"" ",m;'. oo..',m <)"'"
~.,,,,,,,,.,,,;,t ""IOHm""'" "" .. ~I " ".. ".I<"J,
P,"clicallip'
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"'''""'' .... ...-n; d(;DH .
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OiKU"lon Further manag emont

t,;''"t'"'''' ,ti'rh"s"'''"' h,m;. ""u'" f"on, i, ilu... ,,/ ,\I'''r n". ~m "" "r<",,1 " ,, '" ."" , ,,,, "'."' ,,~I
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m'''' '''mm''" '''''''''';'' .. ,.01 ",,,,,,,.Iy. ,'l,,, ," ~ I .. 15"" (0", "" '"' F"",,,j ~""" """-<1 ...", J• ." ...,,-.! .. ,h,
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h,)'UI'I .. i, 'h" 0''< " ,ol"d. Th,'"
~ ; II ~ '" , ... " i<""
n.. m,;" .liIf",",i>l ,Ii.~n'~" '" im,~;"~" "p';" , h..", .. ri'"'8 ' h< '"""m}' ,",I ~;A< .. nT ; "m~. ",mi,
oJ..,on,,'.-..J m,liom.. ';"" {aM ). T)' ~ <Ongo"" '" <)"tk frono CHI,
""".,.,,,1",' "fTh,' I",. """I" ,;.,-.. _" ,.,. ,... """,,,I
'"
Paediatric Imaging Case 165
CASE 165
Histo ry
~ l~ · ~·,,1 F", m""" ""''''''
~"", " ..,.j . ith ",,,",""OO).J~ ..... , ......
h"u " .~" h;"h .
'"
Answe r 165 Paediatric Imaglng
ANSWER 165
ObH <v, l l"ns . HIs..1 ;" ,,,>t ~i.", ( rulmon"r in,,,,,itW ,mr h,...m. - 1'1f.j ,
An 1<G ",I>< I;', On ,~, " "n,.,,~ , ,,,I 'h", ~.n ... MI... I Th~ " " 1< ..1 to . ,,"IJ,n '~''''''''''"'n ;" ,~, inf.n,·,
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f,,,, «'~uIOW, "u l,. I"",m . lfo" ",~ . lI l u,, ~ '""" ~ hh dong"'" bu"I<, ,,""J;" ~ to ,ho: lung 1"'. ;pI"'l""
... bron'hop.",~ I" ..;.~ ' ofth< h......,...,.j ,..J ~"f'hi< bil.",,,]. 'rmm,,,,,. 1 r,",m, P",""""",di."inum "'"
,ruinl-'. ,"" Ii~dy d;"f" ''' ~ ~ hyilin' m,mb.. " , Ji><.u<. P"' " mot .....'" "'" otl". """ Pli< " """ of J""ifh ~ r«""'"
Di1llnosi.
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,'"U"" of '''I,i"',,,!, J ~"". in ""~,"','" '. I, i, ''''''' kf! . i,j,d "n."", rn,"","""""" J;'rI"" i,, ~ ,b,
rom""", in p"m"",,, in.:.n" bu' o<'-";"" ~ l)' .no <>«Un <n«Jw.inum ' 0 'h< ,~" IOIo..p1<d 1<>«""" , du< ro ....
in ' "m inf..,,, uf JW><,;" " "', "" .. , " ~ Ju< '0 t.., k of '"d',~ don~ ,b,in""'''''m m.J I)'mph"'''' ... "'".
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\\"i,I"",,, i, ,I", . I ,~"i.o< """,I)' ,'i",", ;I>I, .,,01 ' '''''in P,"o:licel , ip.
w ll'p",J ".u,int '" 'p;, '''''Y " ~"". ''''~'Iy • f'" b,~ h, • s;g,,, ,of I"', m"u, ;,)" '"' 'f>< f,lm ' " ",d u,,"
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'5""''''' l'i"" "r .....,' ,~ • '"" "" ~,,~ 'II'"'" "I" "","m .00 ""''''.
... .... 'n'hog'~" ' " ,,,><lin! "'" m ,"" )" ng 1'<"."",,'1", • Sima" lung or"~'" .'" ' «" ~ ' ith ",on""
1'" <tm, " ' ,on, .. " "h"of",ton ' ,h",I'l' ",d r<"i'i'~ I""umon;" '" .""' ,, ... .. "inoJ Auk! 'rOO''''''''
1'<""""" ,.,~tcJ .~" , d <t ion. H",,,,,,., oJ.. ,1<""," wo•• )' !>o.m« unlik HMll, 'h< lung ',""m<' i" ,h<..
1"'''''''''' ." r k..J ,,, .r J","," in ~ ' h "", ~ in,,, 'h, I"'~" " ~-ilI b< nom..1 '" """", ..J,
165b Ch"1 ,odiog .. ph 01 • <Md"iln HMO one! 'of,

•• oond .. y to ve",il.lio" ,h.,Opy.
Q" •• "'OIhO ,'"
NO,,'he 1. lt , _ .1, ~ ,o"" h og,"m"
1&50 Ch .., ,0<11011'0"" 0' •
ohikl w i'h flMO who
d ... IoPOd pulm"",rv InW .. itioi empl>vum •• "" •
101. p""ufnO'ho," ...",.-.lO ,V '0 ""nlilotion ""'.. py.
No" the b ubbly i" .. "t~ iol. mphl".m l , odioting ro
"'" lung 0<190,
A nswer 165 Pae diatr ic Im ag ing Case 166
II;, I>o"",h.",,,,,, m ,<h"><,,,~ t ~ t<."", ofH,\1 P ,~
.oJ ," no" . ,,,,,;,, ,,>n<l~' ... ""h .. ",,"",",0' Aodiograph

"!'~ ... '" 'f"""""'" demo"",.';"g
C ....·~ , .. 1"..;,.... ,,(.1110",,, ,,,,I , ....., , .. 'h, 1>0';""" 01 on
"""""oJ t"" umb~ical
U",h~~. 1 """1 <., .. ' .. 116.... 1_ ~ .. ,h.,.,M. ri,,",
'U b<oJ' .. ;, p..... ;"kriot/), IT"", tho u •• bJ", ...
" oh.,.,.,
;n ,IK umb'"'' ""''I' ,IK. "",oJ, .. ,IK ;,,"'m"
,n" "'m..",, ~;.., "'<t." on<l thu, ;"'0 ........ , Th,
t'"
#o"oioJ I~ <;,1\" ",n,. ,I><
H - Il , .. I>< I,,~ '''m ..
U-+
"",>I "",." "
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IT"", urn..., .... p,,,,n$ in .onh ........... inw
,,,.,,", '~n,. 0' ,nJ i\'e ." ""n;".« ;., d>< 'OIh,
" nn m l l.'d).
Fu"~ " managoment

T,,,,,,,,,", ..,,,j,,. o')·~<O"';"'" .. <ntil ...... ....J
«1m;" .. ' ...... of wtft<,~" .
C.. "~Ii< .. ;,;'" "f II Mn ",","'"' ,h,,"1J .I~,), I",
""'~h', ".... '1)' ~"Ittt,," ..y .. "",;';.1".rh )""....
p.. u"" ....... anJ pn,u"""",",,,,,,, u,"
CASE 166
History
U"<OO1"' ..... ! . ",,~""_"" hot"
" 'n,...
Answer 166 Paediatric Imaging
ANSWER 166
Observations (166a) matter (thalami, putullin:t and br:tinstclll nuclei), the pcn
This axial comrast enhanced CT image shows bilarcrnl and rolandic g~'ri and conicospinal tr.tc[S. This case illustrate
symmetrical low density in the b::lsal g:lIlglia, in\'Oh-ing thc such a pattern .
putamina and thalami. T here arc scveral possible causcs for In oldcr childrt.'n, $t.',-erc hypoxic-ischaemic injury fill"
this appearance. Hypoxia and hypotension should be self- produce a diflcrent pattern, that of global cerebral injun-
evident. If not present, le\'l.'ls of glucose and carbon T he resulting cercbral oedcma :lIld loss of grcy-whl
mo noxide should be checked urgcllIly. marta diflcrcnti:ttion with sparing of tht.' brainstem
ccrcbdlulll GIll prod uce the acute rCl'crs:t1 sign on cr
Diagnosis descriocd elsewhcrc (sec Case 163 ).
Low-d ensity basal ga ngli3 secondary As a comparatil-c aside, high-dcnsity b:tsal ganglia d
hypoxia/ ischaemia. to calcification arc illustrated (l 66b ) and the diffcren
diagnosis listed.
Of low-density bas:tl g:l.Ilglil Practical tips
• H ypoxia Comparativc dcnsities of grey and whitc matter in tlr
H ypotension infJnt brain arc variablc on CT dcpc nding o n stage
HypogJycacmi:l myelill3lion. Norrnaliry ofthc basal g:mgli:t dcnsi~
Carbon monoxide poisoning can oc confirmcd by comp:trison wit h othcr grey
WiJson'sdiscasc matterstntcturcs.
MRI is thc most sensitivt.' mod:tlity for dctecti ng
Of basal g:lI1glia ca1cificltion (mnemonic 'PIE MAPS' ): hypoxic-ischaemic injury but may be logistically
• Physiological - rhe most common calise and difficult in the acutclr unwcll inf.mt. Ultrasound llUO
i ll crc;l ~ingl y so with agc, . • be practically the casiest imaging option bm has
InfectIon - c)'to1l1cgalOVlnlS (CMV), toxoplasma, reduccd scnsiti,"ity.
cong('ni~1 1 rubdla, HI V.
Endocrine - hypoparathryroidism (and Further management
pscudoj pseudopscudohypoparathyroidism ), Urgent correction of hypoxia, h)"potcnsion
hypcrparatllyroidism, hypothyroidism. hypoglycaemia is required followcd b~' exclusion of
lI'lceabolic - Leigh discase, Fain disease, Wilson's
disease.
Anoxia - at birth , ccrebro"ascular accidcnt (eVA).
Poisoning - Clrbon 1I10noxide, lead.
Syndromes - Down's, Cocbyne's syndrome,
ncu rofibromatosis.
Discu ssion
Apan from \Vilson's disease, the listed ditlrrcnti:J.I diagnoses
lor this :tppe:n:l1Ice afe of :tWIC disorders that ul timatcl}'
result in reduced cerebral oxygenation or glucosc provision.
T he dlcc t of hypoxi:tjh)'potension on the infant brain
dcpends on whcthcr the infant is tefm or prem3ture, and
whether the insuh is mild or scvere. In thc prem:tUlrc infant
up to about 34 "'cch, it is thc dccp whitc martel" Thai is
most vulnerable and hypoxie-ischacmie injury rcsults in
peri,"cnrricular Icu komalada (PV L) with sparing of sub-
cortical wh ite mane r and cortex. Since the cOfTicospinal
tr:\Ct fib res pass through this area, there is usually rcsulting
1Il0torimpairmcnt.
In the term inf:tn t , the pattern of susceptibility is
diftcrelH. A mild insult results in isch:tcmia of the
'watcrshed' :treas oftlie cerebrum where blood supply is
most tenuous_ These arc the boundaries OCfwcen the areas
supplied by the anterior, middle and postcrior cerebral
arteries. Vit:11 ;Ifeas of the brain arc protected by redistri-
butio n of blood flow. Aftc r a sc,'cre insu lt, howc"cr, "ieal
arcas of the brain can no longer be protcctt.'d, and it thc
most met.lbolicall)' actirt.' areas at this timt.' of lift.' that arc
aHccted. Thus, ischacmic damage occurs in the deep grcy
298
Paediatric Imaging Cases 167,168
ory
mature neonate prcscllIcd with
ina! distension and sepsis.
CASE 168
History
.\0 adolescent mate presented with a
hiswl)' oftralima.
299
ANSWER 167
Observations 1167a ) Pneumoperitoneum should be carefully looked for, as.
A cord c!:i mp is noted indicating that the neonate is no this necessitates immediate surgery. In the supine position.
morc than a few davs old. T he bowel is abnormal with free gas often collects anteriorly as a large rounded lucency
gaseous distension and a bubbly appearance to the bowe! in the central abdomen producing the 'football' sign.
wall indicating lllllrll gas. A brgc pneumoperitolleum is When perforation occurs ill utero, meconium within the
present with most of the gas adjacent to the li\'cr. The peritoneal cavity calcifies and can be seen on plain
features arc consistclH with necrotizing enterocolitis and radiography. An example is shown in a neonate ( 16 7b
perforation. No gas is seen within the portal veins. where there is peritoneal calcification (best seen over the
inferior tip of liver ) with a pneumoperitoneum causing ~
Diagnosis positive Rigler sign, i.e. visualization of both walls of tbc
Necrotizing enterocolitis (NEe ). bowel.

up to 80% of cases arc n:latcd to prematurity and NEe is The earliest radiological sign on plain film is bowel
the most COlllmon gastrointestinal emergency seen in di[,ltation (due to ileus).
premature blbics, lIsllaIly occurring in the tirst 2 weeks of If a cOntrast enema is required to exclude obstructioa
life. Ischaemia of the bowel is thought to occur secondary then water·soluble contrast should be used - barium
to perinatal stress, hypoxia or infection. Presentation is \\~th is contraindicated.
d iarrhoea or bloody stools. Radiographic features consist
of distended thick walled bowd which has a bubbly Further management
:lppearance due to submucosal gas, i.e. pneumatosis Mortality rates arc dependent on the degree
intestinalis. Gas mar track from the bowd into the portal prematurity, with rates quoted at 5% in term infunrs
ve no us .s~'s tem and can be ,seen on ~lain rad!ogra~h~' 12% in premature newborns. Initial treatment is supportJ\"
(branchlllg gas extends tow:lfds the penphery of the h\'er with bowel rcst bm if serial radiographs or clinical fea
unlike air in the biliary tre!,;, which is central ). Such a show progression or per/ofation then surgical resection
finding in adults is an ominous and usually premorbid sign, nccrotic bowel is required.
bur in NEe, this is nOt the case at all. Bowd strictures arc
a potem ial long term complication.
167b Abdominal radi ograph in a newborn

de mo nstrates visibility of both sid e s of the bowel
wall, i.e. a positive Rigle r s ign indicating
pneumoperito neum . Fle cks of calcification in the
right abdo men confirm the diag nosis of ante natal
meconium pe rito nitis .
300
swer 168 Paediatric Imaging Case 169
ervations (168) found in the lambdoid, posterior sagill3l :md tcmporo-

bonr injul)' is $Cen on this skull r.ldiogr:lph. There arc squ:lITIosal sutu rC$. The), arc consid ered abnormal when
pie wormian bones, which at this age is abnormal. seen after 1 rear or large ;\Ild numerous (> 10 ;n num ber
is a large differential di:agnosis but the most likely and larger than 6 x 4 01111).
is idiopathic.
Practica l tips
Because oflhc wide di lTcrential diagnosis, il is diilicult
to idemify a specific cause wilhout Ihe aid of a good
dinic:al hisrory.
- erential diagnosis Diffuse ostcopeni:a will be present on the skull
worrnian bones, with common causes underlined radiograph in cases o f rickets and ostcogenesis
cOlon ic ' PORKC HOPSI'): impcrlccta.
• Pyknodysoslosis. Pyknodysostosis, o n the other hand , will be 3ssociated
• Osteogenesis imprrtccrJ with diffuse osteosclerosis on rhe film.
• Rickets in healing.
• Kinky hair syndrome ( Menkes). Further management
• CleidOCranial dysostosis t.hnagcmelll is dependcllI on the underlying causc.
• HmOIhyroidjsm /hypophosphatasia.
• OLOpalatodigital syndrome , Further reading
• Pachydcrmopcriostosis. Cremin B, Goodman H , SprJllge r j, Beig hton P ( 1982 ).
• Syndrome of Down's. Wormian bones in osteogenesis iml>crfccta and other
• Idiopathic - norma] in first \'Car of Hti; disorders. Skeletnl Rndi%g:v 8( I ): 35-38.
Discussio n
'onni:an bones arc essentially small bones occurring in the
rures of the calvaria. These intrasururJ.1 ossic1cs arc usually
CASE 169
History
.l,. child with a hist0'1' of partial seizures.
301
ANSWER 169
Observations (169a) the cleft. It is not certain whether this condition is d ue -
Axial T2 weighted MR image at the level of thc latera] an ischaemic insult leading to germinal matrix infarcno.
vcnrric1cs. This demonstrates ;1 large cleft extending or whether it represents a focal cortical dysplasia.
through the full thickness of the left cerebral hemisphere There arc diHcrent manitcstations of the conge
from thc surface of the br~lin to the left lateral ventricle. neuronal migration anomalies which result in \'a ~ - _
The cleft is lined by grey matter and is filled with CSF. The degrees of mental retardation and/or seizures. 11It
findings arc consisten t with schizcnccphaly. following further patterns are recognized:
• Heterotopic g rey matter - when small collections of
Diagnosis the neurones arrest on their way to t he cortex the\'
Schizcncephaly. can be seell as discrete nodules '( most commonly in ~
subependyrnal location ) or as a subcortical band .
Discussion Thus there arc nodular and band heterotopias. Thor:
During gestation, Il('uranes migr3tc out\v,lrds from the are isointense to grey matter and show no
pcrivcntricular germinal matrix to form the norma] cerebral enhancement. \-Vbile so metimes asymptomatic,
cortices. This migration can be interfered with by several seizures and developmental delay can ensue, espe .
causes including chromosomal abnormalities, but mostly with band heterotopia. An example of nodular
the reason is unknown. The result is brain tisSLle lying in heterotopic grey matter is shown in an axial T2 MR
the wrong place, typically grey maner. image of the brain ( 169b ), where a small area of
Schizcnccphaly is a cleft extending through tbc full heTerOtopic gre~' maner is seCl1 in a subependymal
thickness of cerebral hemisphere from the ependyma-lined location adjacent to the occipiral horn ofrhe left
wall of ventricle to the brain surtaee. It is lined by pia ;md lateral ventricle.
grey matter that usually shows polymicrogyria, and is often P01Ylllicrogyria - sometimes neurolles may migrate
located around tile $ylvian fissure. The lateral end of tile the cortex but arc abnorm,\lly distributed, produ . _
cleft may be open and readily apparellt (open lip type ) but a bumpy appearance to the cortical gyri termed
can sometimes be closely opposed ;md easy to miss (dosed polymicrogyria. An example is shown in a coronal ~
lip type ). However, even the closed lip type will show a weighted MRI ( 16ge ), where polymicrogyria
small irregularity in the wall of the "entricle at the site of atlccting the right temporal lobe produces a burnp:r
16gb Axial T2 MRI of the brain shows a small area of

subependymal heterotopic grey matter adjacent to
the left occipital horn. Note how it is isointense to
the cortica l grey matter.
302
A nswer 169 Paediatric Imaging Case 170
In :-;or, I",~ ,h, oorm" k~ ,,"' .......ol ~"'"

,~, lI}";,
~,.""" J,,,...,, ,nJ <' ~r .
r",h),3),TI' - On """«.... ' ,.. ~,TI "'r" roony
~ ""'''I (1''' h)'.~,no I, ... '1""'" m "~,, .1'K",~~ "' 'h,
'""" "", .. 10m. 'h, ,",r",", "rthr ..... '1'1'''''
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,.... 1'''"'"'' h",~ ><"'< """,oJ ,,'mb,ion '""
w"n.J ,",,;,'01.
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",,"ul<,;,, ,hi;
'l>< w.~. (~"
"...J~"", ,ho~' .
'"".,. . "'"
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H'...·'''',
',n,l l" "1",,1 ", ~h",
I~'
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Funh l r mana g l me nt
,",d;'.ol "".'5''''''.' o" r;l<l"r,
169d C",""'" TI MAi o. on. bf" ~ 010 <hitd w;'"

h •• ncopl>oly: II>< lX>t1;co • • '0 .mooth w ith .Imoo.
ne "",mol ly 10,m,<I gyrI.
CASE 170
History
~ "'~"'~" ~h" ~., "'m" -I I ~"<'f"
f'",,,,",,J ~;,h h),.,..""
",
ANSWER 170
Observations (170a) The radiological features on CXR are:
An cndotr.lchcal rube has been pllecd juSt above the carina. Bilateral patchy atelectasis and consolidation.
There is also all NG tube passing inro the stOffilCh. There No air bronchograms.
arc bilateral diffi.1SC patchy opacities in both lungs indican,'c Hypcrinllation with areas of air trapping.
of widespread atelectasis and patchy consolidation. Small pleural effusions.
However, thc lungs appe3T hypcrinflatcd and there arc Spontaneous pneumothorax and
5111311 pleural cnusions. In vicw of the history, the pneumomediastinum ma~' result from the air trapping
:appearances arc likely 10 be due to meconium aspiration ( 170b).
syndrome.
Practical tips
Diagnosis Most common cause ofrespiratory distress in term
Meconium aspiration syndrome. babies: meconium aspiration.
• Most common cause of respiratory distress in preterm
Discussion babies: hyaline membrane disease.
A'\cconiulll aspiration syndrome is the most common cause
of respirator}' distress in ncwborns bom at 1'11][ or post reml. Furth er manag ement
T he brgc size oflhc fetus makes ddive,)' diAinLit. Perinatal Almost all neonates with meconium aspiL.ltion s~'ndrome
hypoxia and feral distress lead 10 meconium defecation ill make a full recovery of their pulmonary function. Upper
lIlero. Aspiration of the meconium into the ainl'ay suction may be employed and vcntilatory suppon
trac heobronchial tree then causes obstruction of small may be required in more scvere cases of rcspiL.ltory distress...
peripheral bronchioles (though only a minority of fetuses
exposed to meconium stained amniotic fluid develop
respiratory symptoms). This resu hs in une\'enly distributed
areas of subsegmental ateledasis with alternating areas of
air trappi.ng. The chest radiograph usually begins dearing
within a few days with no long teml radiographic sequelae
in the lungs.
HOb CXR in a neonate with a large

pneumomediasti num. Air outlines the
thymus producing an 'angel's wings'
appearance.
304
Paediatric imaging Cases 17 1, 172
CASE 171
History
~ ",,"""m r"·,,,",<>1 ~'"h
'<&''S''''''' of;.,.,.j,
CASE 172
History
,\1'''"'"''"'8 ,!",,,,,,,h,,'11'''.
1~ I CIi " 1 .'" ,,\'" in • m>k
; ,fon • • itt. • fM"" .",,1)' "",""""d
", .. ,')' ,,,,,' .. ht .....
Answe r 17 1 P~edl ~lri c Imuglng
ANSWER 171
Ob Hrv'lion' 117 1~1 Furth , m a n .~.m. n l
A I<,Ji"5 ,,,Ix ''''"
~ ,,;On.. . ~,, _ d"'. n,I.J N ...l-<"";"S S"'1Ii<, 1"'P';' ~ "'~" .... ". TIt ... ~'n '" I"" ' "mri"" ,,1
f"">'h "'f""'"nmg d>< "''''I'" 'llUL A ... no"" b<1=- , .... hr , .. ,,,amofi< k'k, """'Ph'S,,1 " ,;.,,,'" '" '~ n '''m,1
J ; 'I'h "",~. , ..... " ~ ,.-, ,~". "" .. ~ " .... ",~ ," '>ri,-.'"'" """ il;'1" ,,,.I, i, g .. J)' r ~'I\'" ' nJ/"" "r""""
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Oi.~nMi.
e"nt'""" , ..... 'l'wt,,1 ",,, ...
f",u l,("I'Ofl·
"i," ".. I"''''''I'h.~,1
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f.mt..y.-,lnS".nf ,h. r, im~". ~""~U, 'un. "'-r" "" " ,
"', m tIO< n""h< • ..,.j ",ooph,~,,,_ Ili",,"' .. of ,h i,
"rm'"," r n" n 'i"~ ;" ;"r,n'r ,,,.1, in ,-.m",
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"""f'h.pc. 1 "sm,n', '", d i,,01 "'V"'"' "' both). Tni,
...., "'"."",,,,,,,!h, ""'" <ommon 'U"'l"J'< ( ><'" '"
"""00 ~O'JO I "I>< .. ,"'''' '' ''''''I'h'F'' "'''' .. ...J • Jri,oI
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~hik , ~ , . i,,,1 TO~ ,-" .. k, .. 1"""'" u( , ~ f~"" ""'h"
int" "'"H",h ..,.j ,10,,, tn. n:_,", uf , ", ,,",.-d_
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''',''; •• 00 . " roo", l il ,I~' ,,, r""'"' ~i,h "",~h i , ~ '"
"hoI;,",~ '~""'g 1<-.-." -",,10k, " ",Iy .",~"",,, """"" 'n".
An ,u mri' i< ,00"",, {17 LbJ ~.... '" ~-.t<, _ """bk """,,,,,
h.. """" "j<mJ ,;. '" SG ,"b< in ,,,. """f'h'S"' ,..J i<
"'" '" I"'" ;"to ' "' "","" ' " th, ;;'tul.
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k<d .. ~ '""' '"'~- n. ".kJ "" loin it .It" "t<,"~',-J
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• Look fo.. ronooL;J"kon "'w-" .. s """;,,,J
"";"""'" p''''"'''''"''.
o.>Of'h,~, ~ ""' ..... ,", J TOF " " '" rut o r.
\'~CTHt ., ,,.,,,"'" ~, .I,,,, <I" en t<,.
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• ... ,,'-«<,.. .."....I ~, .
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R.,nol ""'"" 01 "'.
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'"'
Answe r 172 Paediatric Imaging Case 173
ANSWER 172
Observations (172) posterior urethra may be seen during voiding and
This MCUG study shows a transverse filli ng defca at the vesieouretera! reflux is present in 50%. Bladder
_ terio r urcthr:l. with distension of the proximal posterior trabeculation and a significant post void residual volume
;arcthra. The findings arc collsisrcnr \\~th posterior urethral may be noted. Prognosis depends on the duration of
lQh·cs. obstruction prior to corrective su rgery and is worse if
associated with \'esicoureteral reflux. Approximately rhrce-
Dia gnosis quarters of cases will have been discO\'ered in the first year
Posterior urethral vakes. of life, though occasionally it call be first noted in
adulthood.
Discussion
Congenital presence of thick folds of mucous membrane Practical tips
in the posterior urethra is the most common cause of Note how diagnosis is still possible when the catheter is ill
urinary tract obstrunion in boys. The condition is often sim during the. voiding phase of the MCUG ( 172).
suspected on prenatal US where it can lead to
oiigoh)'clramnios, hydronephrosis, prune belly and urine Further management
lSCitcs or urinoma due 10 leak. I f obstruction occurs carlv Urological surgical intervention is required with initial
in IItero then multicysti c dysplastic kidney may result. Aftc"r treatment aimed at relieving bladder outlet obstntction and
birth, MC UG is the investigation of choice to outline the abl:tting the valves. Secondary trcatment may be required
tr:Insvcrse fi lling defect caused by the thick mucosal folds. for vcsicoureteral reflux, urinary tract infections, urinary
Distension and elongation of the proximal part of the incontinence and renal dyshlilctioll.
CASE 173
History
A newborn presented with abdominal
distension and failure to pass
meconium.
307
ANSWER 173
Observations (173a) should be performed using Gastrograffin as this has a
An NG tube is in the stomach. There arc multiple dilated therapeutic eflect, helping to cle:tr the meconium b~
loops of bowel in the abdomen. No fluid lc,"cls arc seen drawing water into the gut.
within the bowel suggesting that the ;lppcaranccs 1l1:1~' be With Hirsehsprung's dise:tse, the contr:tst enema will
dlle to meconium ileus. However, mher p:uhoiogics such as demonstrate dilated bowel with :t transition zone to a dist1l.
Hirsc hsprung's discasl: ;lIld impcrfor:llc anliS should be aganglionic segment.
considered.
Practica l tips
Diagnosis • On all A...,{R of:t baby it is almost impossible TO tell if
,\.tcconiulll ileus. dil:tled loops ofbowcl arc l:uge or small bowel. The
presence or absence of ,·omirins/passage of
Differential diagnosis meconium are more helpful to know with regard to
Hirschspnlllg's disease. assessing if there is high or low bowel obstruction.
Impcrlor:uc3.nlls. The hernial orifices should be checked for :tir
· Ilcatatrcsia suggesting an inguin:tl hernia.
• Inguinal hernia. A 'soap bubble' appeamnce m;I ~' be seen on AXR in
llIeconium ileus due to the mixlllre of gas with
Discussion meconium.
Meconium ileus is the term used to describe small bowel Fluid levels arc not usually presem in meconium ileus
obsmu.:rion in neonat . :s secondary to inspiSS:J.tcd meconium because the bowel COntentS arc ,·ery viscous.
pellets impacted in the disnl ileum. The \'35t majority prm"c Look at the sacrum on the AXR, as imperforate anlU
to [m"e cystic fibrosis and this is the earliest manifcstation of is associated with sacral agenesis.
the disease. The diagnosis is confirmed by performing a
contrast enema, which demonstrates multiple round filling Furth er mana gement
defects (the inspissated meconium ) in the distal ileum and • 'V:tter-soluble contrast enema can be useful for both
proximal colon ( 173b ). The colon may be very narrow on diagnosis and treatnletH.
the contraST STUdy if it has been unused due to antenatal All patients with meconium ileus should have a 'SIl"CZ
ubsrnleTion, whereby it is Termed a microcolon. The enema test' to exclude underl ying cystic fibrosis.
173b Gastrograffin enema in a newborn shows

multiple filling defects in the ascending colon and
terminal ileum, which represent inspissated
meconium. Note the dilated small bowel loops.
308
Paediatric Imaging Cases 174,175
CASE 174
Hist ory
_\ 4-yur-old child presenred with
~'cr and abdominal pain.
CASE 175
Histo ry
.\ 4 -month o ld child presented
",lil pcr,;islent irrit'Jbilit)'.
309
ANSWER 174
Observations (174a) Almost all neuroblastomas contain calcification
Axial cr of the :abdomen with oral canTmst and IV contrast whereas 'Only up ro 10% of Wilms' rumours calcify.
in poml phase. There is a large slightly hcrcrogcl1wlls mass Both tumours call cross the midline and look
arising from the. right kidney. The mass docs not enhance as similar on imaging, appearing illsep3.fablc from the
much as the rellal parenchyma. There is local mass effect kidney; howcver, neuroblastoma rends to encase
with displacement, but no 100';'\siol1 ofthc right lobe ofli\'cr surrounding ,·esscls such as the aorta whilc Wilms'
or encasement of"csseJs. A small mass of similar density is tumours tend to displace surrounding tissucs and
seen ncar the hilum of the left kidney. The appearances stmcrures. An examplc of a neuroblastoma is
suggest bitateral Wilms' tumours. shown ( 174b) cncasing the aom and coeliac axis
vessels. Neuroblastoma may also extend into the
Diag nosis spinal canal through the neural f'Or."tmina.
Bilateral Wilms' [Umours.
Look for evidence of 1l1e[3static spread; 70% of
Differe nti al diagnosis neuroblastomas have malignant spread at presentation
Neuroblastoma. c'Ompared to just 10% of Wilms' tUlllOUrs. Also,
\-Vi!ms' tumours spread to lung, whereas
Discussio n neuroblastoma sprcads to bone.
Wilms' tumour (ncphroblastoma) is the most common
abdominal malignancy in young children, mOSt commonly Further management
prc.scming at ase 3-4 years. The most frequent presentation Treatment is ,lith radical nephrectomy and chemother."t~
is with abdominal mass, though hypertension, pain, IC\'er I'reopcrath'c chemotherapy is advocated in cases ofbilarer.al
and h:u:maturia also occur. The tumour usuall~' grows to a Wilms' tumours and whcn therc is IVe ex tension at
large size, often measurin~ over 10 cm. Radiological tumour (occurs in - 5%).
fcatures includc:
Exophytic mass displacing rather than encasing
adjacent structures.
Less contrast enhancement than norlllal rella]
parenchyma.
Cystic/necrotic areas give it a heterogeneous
appearance.
111\':1sion ofthc ren:1l \'ein and inferior ,'c na ca\':1 may
occur in up 1'0 10%.
Tumours arc bilateral in 10% and this indicates background

nephroblastomatosis, a state of persistent nephrogenic
blastema that is a precursor to Wilms'. Wilms' tumour is
associated with the Beckwith- Wiedem:lnn s}'ndromc
(macroglossia, visceromegaly and omphalocclc). Other
associations include aniridia and hemihypcrtroph}'.
The main differential diagnosis is neuroblastoma, a
comlllon malignant tumour of the neural crest that presents
in a similar way to Wilms' tumour ,lith a painful abdominal
mass and fe'·e r. Typical age of present'alion is slightly earlier
howe\'er (under 2 years). Hormone secretion from the
tumour (such as catecholamines) may cause o ther signs,
including hypertension and opsoclonus (chaotic jerky eye
mo\'eme[1[s). It can arise an~'whcre in lhe sympathC[ic
ncural chai n including the adrenal gland and the abdominal
s}'lllpathetic chain.
Practica l tips
• Always check for bilateral tumours when Wilms' is
suspected. 174b CT of a neuroblastoma. The huge mass
Differentiating between neuroblaStollla and Wilms' displaces the spleen and left kidney and shows
tumour can be difficult radiologically but then: are typical encasement of vessels, in this case the aOt:i
some specific features that can help: and coeliac axis.
310
Answer 175 Paediatric Imaging Case 176
ANSWER 175
Observations (175) 6 months. Irritability and fcn:r arc thc prcscnring
There is bilateral symmetricll thick, smooth periosteal symptoms and are associated with soft tissue swelling O\'cr
reaction aAccting the diaphyses of the long bones. There thc bones. Bilateral synll11ctrical thick periosteal reaction
is no fraying or splaying of rhe metaphyses to suggeSt is the cardinal radiological feature and most commonly
rickets. The most likely diagnosis at this age is Cail'{fs alleets the m,mdible, elal'icle and the long boIlCS. It usually
disease, ho\\'c\'cr other possibilities such as lcuk:".cmia need involvcs thc diaphysis ofthc bone. In the majority ofe:lSCS,
to be considered. [here is spontaneous complete reeon:ry by the age of 3
years.
Diagnosis
Caftcy's disc:lSC. Practica l tips
If there is ditfusc periOSTeal reaction with tractures of
Differential diagnosis <liBering ages, NA I must be considered .
Of bilateral dinusc periosteal rcacrion in childhood: • With rickcts, splaying and fraying ofthe mctaphrscs
• Norni:ll variant belare the age of 4 months_ will besccn.
C lflcy'sdiscasc.
Leukaemia. Further management
Scurvy. Whcn NAI is considered the n a (.-arcnli analrsis ofpn.:vious
Rickets. radiographs, the clinical presentation and consult":nion with
H ypcn"iraminosis A. a specialist paedi3trie radiologist must be carried our
Non accidcnt:ll injury (NAI ). because of the repercussions of a misdiagnosis.
Discussion
Inf.l.Iltilc conic:J.l hypcrostosis (Caffey's disease ) is a
prol ifcrJtivc bone disease seen in patients under the age of
CASE 176
History
None available.
311
ANSWER 176
Observations (176a) growth plate lead to the additional distinctive radiological
There is widespread bilateral decreased bone density with featmes of rickelS. Osteomalacia is discussed elsewhere in
healing insuflicicncy fractures of the r:tdius lnd ulna the book but the radiologieallcatuTes arc due to excessive
bilaterally. These arc associated \\~th thick smooth periosteal unminel"".llized osteoid producing Looser's zones,
rC;lcrioll and there is !Taying and spla)~ng of the mCl.lphyscs. osteopenia, cortical tunnelling, indistinct trabeculae and
The fcarurcsarc char.tctcristic ofrickclS. finally bowing and fl"".letures due to softened bones.
In addition, the following features arc seen in rickets:
Diagnos is Widened growth plate - loss of normal chondrocyte
Rickers. maturation and minel"".llization result in cdl build up
here .
Differential diagnosis Metaphysc:s arc irregular/ frayed , splayed and cupped
Hypophosph3t:J.sil. - impaired miner.1lizarion causes the frayed irregular
appear.1nce while build up of chondrocytes at the
Discussion physis indems the metaphysis producing cupping and
Ri ckets is mOST commonly due to insuflicicnt biologically splaying.
actil'c I'iumin D, though impaired calciulll absorption or Epiphysis oSleopcnic and irrcgubr.
excessive phosphate excretion call occasionally be to blame. I\:riarticularsofttissue. swelling.
In the western world, pure dicta!)' deficiency ofl'itamin 0 Apparent periostcal reaction due to subperiostcal
is ra rcl~' the sole cause; morc ofren it is due to ullminer.1lized osteoid.
malabsorption or impaired vitami n 0 mct:J.bolism in the Delayed maturation and growth.
Ih'cr or kidney.
RickelS is 'essc: ntially osteomalacia during enchondral Figure 176b demonstrates ricketS of the lower limbs -
bone growth, Portions of the skeleton that ha"e already note the typical changes around the metaphr~!s in the tiw
matured show features of osteomalacia, but loss of normal and also bowing of the fibula, Figure ] 76e is a CXR of.a
maturation and mineralization of cartilage cells at the child with rickets showing spla)'ing of the anterior ends 01
176b AP radiograph of both legs shows typical

features of rickets with fraying of the metaphyses.
312
Answer 176 Paediatric Imaging Case 177
the ribs and the metaphysis of the right humerus. The Further man age ment
~arancc of the anterior rib ends is due to changes at the Rickers is now usuall y idcllIificd early :llld treated with
cOSlochondr.d junction growth "blcs :and is tcnncd rhe I·iramin D supplements. Significant pch'is deformity and
'rachitic rosa')", gait disturbances arc now rarel y seen in the dC\'ciop<!d
world.
Practical tips
• The earliest sign of rickets on the plain film is a
widening of the growth plate .
• i..,(X)ser's zones aTC ..ire in rickets compared 10
ostcom:tbci:t in the filscd skeleton.
CASE 177
History
~onc ;lvaib blc.
3 13
ANSWER 177
Observations (177a) Discuss ion
There is panial n lsion of an extra digit with the mct:lClrpal There arc scveral causes ofsrndactyly (filsion of digits) and
of the IinJc finger. This c ssc n tial1~' represents polydactyly (supernumerary digits ), which arc both
polys)'lldact)'ly, the possible causes of which include congcnit:ll abnonnalitics. Ellis- van C rcvcld syndrome is
idiopathic, Ellis- van Crc\'c1d syndrome and C:arpcntcr also assOCiated with carpal fusion, as is Apcrr's syndrome.
syndrome. This is characterized bv features in the skull: notabk
craniosynostosis of the ~oronal sutures, hypoplastic mid
Diagnosis filee and enlargement of the sclb. . All of these features arc
Ellis-van Crcn:ld syndrome. dt~lllonstratcd in the lateral skull radiogl':lph in a child with
Apert's syndrome ( 177 b ).
or causes of polydactyly: Practi cal tips
• Idiopathic. Some exam cases will have an obvious abnormality as part
Ellis- van Crevcld syndrome. of a syndrome that you do n ' t know - Slating that you
• Carpenter syndrome. would seek help from a te.u book o r specialist colleague is
• Polysynd:lCtyly syndrome . a reasonable answer. You ca n't know everything!
O fca llscsof s),ndaCfyly: Further management

• Idiopathic. Po ly/syndactyly will be parr of a syndrome with multiple
Apcrr's synd rome. ab norrll ~l 1ities.
Carpemer syndrome,
Down's syndrome.
Poland's syndrome .
NClirofibrolllarosis.
177b Lateral skull radiograph of a child with Apert's

syndrome demonstrating craniosynostosis of the
coronal sutures, hypoplasia of the midface and
enlargement of the sella.
314
CASE 178
History
~onea\'ailablc.
315
Answ er 178 Paediatric Imaging
ANSWER 178
Observation s (178a, 178b) deformity is often a featu re:. The expanded metaphyses
There is bowing deformity ohhc tibia, fibula and humcms tend to be lucent and have the appearance of an
The metaphyses of the bones arc widened producing an Erlenmeyer flask (narned after the wide necked laboratory
Erlenmeyer flask deformity. The metaphyses arc also flask bearing the name of this German chemist).
rclati\'cly lucent when compared with the diaphysis, which Craniometaphyseal dysplasia essentially has the samc
is sclerotic. There 3fC no specific leatures 10 indicate lead features but in addition there arc cranial nCIYe palsies due
poisoning, ostcopo.!tTOsis or thalassacmia, so the diflcrcnti:ll to sclerosis of the skull base.
diagnosis lies between Pyle'S disease and lipidoses such 35 Gaucher's disease is a hereditary disorder oflipid st.oragc
Gaucher's or Niemann- Pick disease. common among Ashkenazi Jews. It is characterized by
hepatosplenomegaly with flask-shaped long bones and
Diagnosis generalized osteopenia with strikingly thin corticcs.
Pyle's discasc. Avascular necrosis is also a feature.

[11 rhiscasc: Erlenmeyer flask deformity, the metaphyseal expansion of
Craniomct'aphyscai dysplasia. long bones, is also discussed in Chapter 5. AdditionaJ
• Niemann-Pick disease. differentiating ICaturl..""S can be found on [he r:ldiograpn as
• Gauchcr'sdiscasc. to the specific underlying cause of Erlenmeyer flask.
deformity:
Of Erlellmeyer flask deformity (mnemonic - 'Lead • Diftllsc sclerosis and sclerotic vertebr:ll endplates
GNOME'): producing 'sandwich vcrtebrae' indicate osteopetrosis.
• Lead. With Pyle's disease, there will be relative sclerosis at
G3uchcr's. the diaphysis and lucenc)' of tne metaphysis.
Niemann- Pick disease - looks like Gaucher's but Gaucher's disease will also be associated with lucency
withouJ avascular necrosis. and osteopenia but there may be signs of anscular -
Osteopetrosis necrosis of the femoml or humeral hcads (loss of
Mctaphyse;11 dyspbsia ( Pyle's) and craniollletaphyseal height and Ii-agmentation ) and on an AXR massi,"e
dysplasia (same as Pyle's discase: but there is a history hepatosplenomegaly may be seen.
of cranial nelyepalsies). Thalassaemia is associated with coarsened
'E'malOlogical!! - thalassaemia. trabeculation producing a 'cobweb' appearance.
Lead poisoning causes dense metaphyseal bands as
Discussion well as Erlenmeyer flask deformity.
Pyle's d isease is also known as metaphyseal dyspbsia. It is
a rare autosomal reccssi,"c disordcr characterized by flaring Further management
of the ends of long bones with relative constriction and This condition is usually asympromatic and requircs n...
sclerosis of the ce mral ponion of the shafts. Affected direct management.
patients arc usually as~' mptomatic and genu valgus
1788 Metaphyseal widening with

increased lucency.
3 16
CASE 179
Hist ory
_'onc3vailabk,
ANSWER 179
Observations (179a , 179b) Di scussion
The lateral skull radiograph ( 179 b ) demonstrates thinning Osteogenesis imperfecta is a connective tissue disorder
of the calvaria with multiple wormian bones. Bowing characterized by fi.lgile bones and blue sc1eme. Type I is
dctormirics afC seen w atTcC[ the lim bs (1 79a ) and there comp:ltiblc with life. Type 2 is the lethal form associated
Ut several frlcturcs of diHcring ages, mostly seen at the with perinatal death.
metaphyses of the long bOlles. Thac is geller,\iized The principal radiological features include:
oSTcopcnia of the skeleton with marked thinning of the Diffuse osteopcnia with thinning of cortices.
con ices. The fcanm::s arc consistent with osteogenesis Multiple fractures of differing ages with
irnpcrfccT:t pseudarthroses and bowing deformity.
Fractures arc associated with exubcmllt callus
Diagnosis fOfmation.
Osteogenesis impcdccta Biconcave yerrebi.ll bodies.
Multiple wOTmian bones in the skull
Differential diagnosis POOf dentition.
Of lI'oTmian bones with common causes underlined
( mnemonic - 'PORKCH OPSI' ): Practical tips
• P),knodysostosis Multiple fractures in children should i.lise suspicion of non
Ostcogcm:sisinmcrfccra. accidental injury (NAI) and sometimes diflcrentiating this
Rickets in healing. from osteogenesis imperfecta can be difficult. Predomi-
Kinky hair s)'lldromc (I'''knkcs). n:lJ1t1y osteogenesis fractures are diaphyseal compared with
Cleidocranial dysostosis. metaphyseal NAI fractures but this is nOt always the casco
Hypothyroidism/hypophosphatasia.
Otopalatodigital syndrome. Further management
Pach),dermoperioslosis. • Early medical inteIyention to increase bone mineral density
Syndrome of Down. and surgical intcrvention to treat/correct scoliosis and treat
I~!iopa[hic nOrllwl in first ,"car of life. fractures mean that a multidisciplinary ap proach to the
ongoing treatment is required
318
Paediatric Imaging Cases 180, 181
CASE 180
Hist ory
A ch ild presented with
vomiti ng and .uaxi:!.
CASE 181
Hist ory
A 2-l11omh-old baby presented with
cyanosis.
(Ste pnge 322 [01- e(lse (lllslI'cr)

ANSWER 180
Observations (180a) H ydrocephalus is ott·en communicating type due
A series of axial MRI images of skull show a well defined to protein exudate obstructing CSF resorption
hypcrdcnsc mass in the cerebellar ycrmis causing Spreads through the exit foramen of fourth
compression and anterior displacement of the 4th ventricle \"emride and wraps around brainstern ('plastic
with obstmctil'c hydrocephalus. A small alllount ofocdcma growth'). Sagittal and axial T2 weighted MR
su rrounds the mass. The teatures arc typical of a images (l 80b ) demonstrate a high signal lesion
medulloblastoma arising within the 4th Yemricle, wrapping around
the brainstem and spreading via the foramina of
Diagnos is Luschka and Magendie. Hydroceph.llus is present
Medulloblastoma. and a syrinx orthe upper cervical cord has
de,-doped.
Differential diagnosis Hrainstem glioma:
Of posterior fossa tumour in children: Within pons, possibly causing pontine expansion
Medulloblastoma: or 4th 'Tntride displacement posteriorly_
Predominantly midline posterior to 4th vcmriclc. Iso· or hypodense to brain so may be easily missed.
Hypcrdcnsc on CT with oedema. Sagittal TI weighted MIl! with contrast ( i SOc)
• Avid cnh:I.llCCl11CllL dcmonstrates a large pontine glioma. Note how
• 20%calc;!)', 50% necrose. the lesion is nonenhancing and almost the same
signal as surroundi ng brain. Smaller such lesions
Juvenile pilocytic astrocytoma: can easily be missed due to such imaging
Typically paracentral, posterior to 4th ,'cntriclc characteristics.
Majority arc cystic with an enhancing mural Enhancement often absent or minimal
nodule, the remainder arc solid. H),droccphalus uncommon (because present with
20% calci!)'; oedema is rare. focal neurology before this occurs).
Epend)'llloma: Disc ussio n

Arises within 4th ve ntricle. ,\kdulloblastoma is the second most common paediatric
Heterogeneous appearance and enhancemem brain tumour and the most common in the posterior fossa.
• SO%c;\lcify. It is a tl'pe ofprimiti\"e neuroectodermal tumour ( PNET)
180b Sagittal and axial T2 MRI of

the brain demonstrating an
ependymoma in the 4t h ventricle,
which extends into the foramina of
l uschka and Magendie and causes
obst ructive hydrocephalus. A syrinx
of the upper cervical cord has
developed .
320
arising from the roofofthe 4th,\·cntriclc. The majority of metastases' ). A sagi nal TI MlU post-contrast ( l SOd )
patients affected are under the age of 15 years, with 80% of demonstrates an enhancing medulloblastOma in the
lesions arising from the cerebellar vem}is, and the rest lying posterior fossa causing obstructi"e hydrocephalus. CSF
more laterally in the cerebellum. This lateral location is spread of tumour has occurred with a metastasis in the
marc C01111110n in older ch ildren. They arc typically prepontine cistern.
hyperdensc on CT due to dense cellularit)" and show avid,
homogeneous enhancement. There is usually surrounding Practical tips
oedema, 20% show calcification and up to 50% show Make sure the post COntr:J.St scan looking for drop
necrosis/cystic change. They arc highl~' malignant and metastases is done preopcrarh'dy as postoper:J.ti\'e
spread occurs via the CSF in up to a third. Medulla· haemorrhage and granulation tissue can cause
blastoma is rardy associated wi th Gorlin's syndrome - an connlsion.
autosomal dom inant disorder cha racterized by multiple Haemangioblastoma is primarily a tumour of adults
Cluaneous basal cell carci nomas during childhood with but can be seen in adolescents in the posterior rossa
mandibular ker:l.tocvsts and enensin: intracranial when part of\'on Hippcl- Lindau syndrome. It is
Gllcificarion of the fal~ and tentorium. typically a cystic mass \\~th enhancing mUr:J.1 nodule,
At least 50%of primary brain IllmOUfS in children occur SO has similarities with pi lacyt ic astrocytoma.
in the posterior fossa. Brainstem glioma tends to present
with focal neurology due to invoh'ement oflhe long tr:J.cts Further management
and cr:J.nial nerve nuclei, while the olher three differential M RJ of the spine with intr:J.venous contrast enhancement
diagnoses listed present br way of mass effect and should be undertaken to look ror 'drop metastases'.
obstructive hydrocephalus with headache , vomiting and Neurosurgical assessment is then dearly appropriate.
at3xia . The salient imaging reatures of each arc listed. Ir is
important when staging paedi,lIric posterior fossa tumours Further reading
to remember the potential ror CS F spread with medullo- Koeller K, Rushing E (2003 ). From the archives of the
blastoma in particular, but sometimes with ependymoma AF IP: medulloblastoma: a comprehensive review \\~Ih
too. POSt gadolinium scans should therefore include the radiologic-pathologic correlation. RadioGraphies 23:
whole spine as well as brain to pick up such deposits ('drop 16 13- 1637.
180e Sagittal T1 weighted MRI post IV contrast that 180d Sagittal T1 MRI of the brain with gadolinium
shows a large pontine glioma. show ing an en hancing posterior fossa mass, w hich
causes obstructive hydrocephalus. A metastasis is
seen in the prepontine cistern. This proved to be a
medulloblastoma.
321
ANSWER 181
Observations (181a) Normal sized hean.
There is a right sided aortic arch, The heart is boot shaped Boot shaped hean due to right ventricular
indicating right ventricular hypertrophy. The lungs are not hypertrophy.
plethoric, in fun there is a reduction in the calibre of the Right sided aortic arch in 25% of cases
pullllOnary vessels. Ol"crall, the !caturcs Jre suggestive of Decreased calibre of pulmonary ,"essels.
Ell10r'S Tetralogy
Right sided aortic :lfch may also be seen in paticnts with
Diagnosis another cause of neonatal cyanotic congenital hean disease
Tetralogy of FalJot. - transposition of the great ,·essels. However unlike Fallot's
there is increased pulmonary vaseularity and the heart has
Differential diagnosis an 'egg on its side' appearance on the CXR due 10 Ihe f::lct
Of conditions associated with a right sided aortic arch: that the mediastinum is narrow because of the abnormal
• Truncus arteriosus. relationship of the great vessels. An example is shown
• Tetralogy of Failor. ( 18 1 b ), though in this particular casc the aortic arch is left
• Transposition of great vessels. sided.
• Pulrnonarvatrcsia
• VClltricul~r septal delcct (VSO ). Practical tips
• Fallot's tetralogy, pulmonary stcnosis and tricuspid
Discussion atresia cause cyanosis with oligaemic lungs.
Tctralob'Y of Failor is Olle afthc most common causes of Transposition ofthe great vessels, tmncus arteriosus
c)lanotic congenital hean disease and is composed of the and lotal anomalous pulmonary venous drainage
following: obstruction of right \"cntricular outflow, brgc cause cyanosis with plethoric lungs.
VSD, right ventricular hypcnrophy and an o"erriding aorta.
Radiological features on CXR arc· Further management
Conca"ity in tIle region of the pulmonary anery, Cardiolo~' referral for echocardiography and consideraTion
which is small. for a palliati,·c shunt or complete surgical repair.
Enlarged aona
181b CXR in a child with tra nsposition of the great

vessels. There is pulmonary vascular congestion and
the heart has an 'egg on its side' appearance.
322
Pae diatric Imaging Case 182
CASE 182
History
,\n II ·m,.., " ·,"1"" .. I ~-.h ",~ 1"1'"
.... J <><,.."s.,g~. 1 ,b,,,,,," . 1; ,;. ~
Answ er 182 Paediatric Imaging
ANSWER 182
Observations (182) There Jre numerous associated eNS anomalies, fo r
The posterior fossa is enlarged with absence of the example corpus callosum dysgenesis, holoproseneephaly,
cerebellar vermis, hypoplasia oCtile cerebellar hemispheres gyral dysplasia , grey matter migration anomalies and
and the presence of a large posTerior fossa cySt, which is in encephalocele. Associated anomalies outside the eNS
continuity with the 4th ventricle. A vcntriculopcritoncal include cleft palate, polydactyly and cardiac defe([s.
shunt is seen in the right l:trcral ventricle. There is
\'cntriculomcgaly but the sulci arc. not clfJccd. The features Practical tips
arc consistent with Dandy- Walker malformation • A mega cisterna magna may mimic Dandy- Walker
malformation, howe\'er there is no cerebellar vermis
Diagnosis abnormality, continuity with or abnormality of the
Dand).-Walkcr malformation 4th I"entricle.
• A posterior fossa arachnoid cySt may also mimic these
Discussion appearances.
The Dandy-Walker malformation is a congenital If the posterior fossa is not enlarged and the
malformation whcreb}' the posterior fossa is enlarged and cerebellar vermis is h~'poplastic rather than absent,
the tentorium ((rcbelli is elevated, howc"cr the cercbcll;u' consider Dandy- Walker variant rather than
hemispheres arc hypoplastic. Absence or hypoplasia of the malformaTion.
cerebellar vermis is present with a posterior fossa cyst
directly connecTed to the 4Th ventricle. Ventriculomegaly Further management
and dysgenesis of the corpus callosum arc associated The associated eNS abnormalities can be better identified
findings. Most affected patients die in infancy. The less on i\.j RI. T rearment often involves inscnion of a ventricular
severe form, Dandy- \Valker variant, is more common and shunt, as in this case, to relieve hydrocephalus. Genetic
is not associated with enlargemelH of the posterior fossa. counselling may be appropriaTe for the f.1mil)'.
T he associaTed posterior fossa cySt is smaller and the
cerebellar vermis is hypopl;lStic rJther thJn ;lbsent.
182 Absence of cerebellar vermis (left): sulci are not effaced (bottom
left); ventriculomegaly (right); hypoplasia of cerebellar hemispheres
(top right).
324
Pllediat,ic Imaging Case 183
CASE 183
History
mmmo&.
ANSWER 183
Observations (183) Duodenal atresia is associated with the VACTERL
Dextrocardia is present with situs solitus. A right femoral syndrome, a non-random association of congenital
line is noted. An NG tube is present in Ihe stomach, which abnormalities aftccting multiple systems, summarized by
is dilated with air. There is a 'double bubble' appearance the mnemonic 'VACTERL'. Three or more of the
of the dilated stomach and duodenal cap with no gas seen associated defects arc required to make the diagnosis. The
distally. T he findings afC consistent with duodenal atresia mnemonic is as follows·
• Vertebral anomalies
Diagnosis • Anorectal anomalies - imperforate anus.
Duodenal :nrcsi3, possibly pan ofVACTERL syndrome. • Cardiovascular :momalics - most commonly
endocardial cushion ddects.
Differential diagnosis • Tracheo- Esophageal fistula
Of ' double bubble' on abdominal radiograph: • Renal anomalies - ma}' be associated with a single
• An nuJarpancreas. umbilical artery.
• Duodenal diaphragm. • Limb anomalies - e.g. radial dysplasia, polydactyly,
• Peritoneal band. syndactyly.
• Choledochal cyst.
The characteristic cardiac abnormality is a septal defect but
Discussion dextrocardia, as in this case, has been described.
Duodenal atresia is due to failure of rccamllizatiOIl of the
duodenum at around 10 weeks and is the most common Practical tips
cause of congenital duodenal obstmction. The other major Always check the 'double bubble' radiograph for
cause is an nular pancreas, and both arc associated with VACTERL associations, e.g. vertebral anomalies on the
Down's syndrom~. The ob~ (ruct i on is just beyond the film
ampulla in the majority of cases and the 'double bubble'
results from gas-fluid levels in the first part of duodenum Further management
and stomach. Gas may be seen more distally in the bowel Fluid and electrolyte imbalance must be corrected along
if there is duode nal stenosis rather than complete atresia with decompression of the stomach \~a NG tube insertion.
(though atresia is twice as common). Surgical correction is then required, usually with good
326
CASE 184
Hist o ry
~ ,hdJ ~"h , I ~""""" .
ANSWER 184
Observat ions (184a) cervical spinc in the same p;]tienr (I 84b) shows mul tiple
Lateral spinal radiograp h shows ve rtebral bodies arc flattened vertebral bodies and abscnce of the peg.
fla ttened with ccnll':li bcaking anteriorly. There is also H urler's syndromc (another of the mucopol y-
widening of the intcrvcrtcbr.l! disc spaces and posterior S3ccharidoscs) and achondroplasia can have similar radio-
,'ertcb ral scalloping_ T he find ings arc suggestive of logical features; in particular, both ma y causc posterior
Morquia's synd rome. ,'enebral bod)' scallopin g and anterior venebral body
bcaking
Diag nosis T he radiologic;l l fca nlres of Morq uio's s)'l1drome arc
Morquia's ~yndrom c. described below:
Spine:
Differential diagnosis Posterior ,·crtebral sc;]lIoping.
• Hurler's syndrome. \Videning of intervene braI disc spaecs.
• Achondroplasia. Congenital flattening of the ,·enebral bodies
( plar)"spond)"l)').
Disc ussion Ante rior bcaking of ,·crtebral bodies.
Morquia's syndrome is a rare metabolic disorder classified Atlantoaxi;ll sublux;]lion.
as one of the rnuco polys3C(ha ridoscs. It is autosomal K~'phoscoliosis .
recessive and presents in childhood wi th characteristic
skeletal dcfonnity and dwarfism. Patients also ha\'c deafness Pelvis:
and card iac dysfunction, howc"cr Ihey may well Ii"c [Q • Fragmem";]tion and flatten ing offemoml hcads
adul thood . Atlantoaxial subluxation is a feature and there ( 1.4<).
may be absence o f thc odontoid peg. Radiograph of the • Flared ili;]c wings ( 184c).
184c AP radiograph of pelvis showing fragmentation

and flanening of the femo ral heads with fl aring of
the iliac wings.
184b Lateral cervical spine demons trating

absence of the peg w ith flattenin g and
posterior scalloping of the ve rtebral
bodies.
328
Lower limbs: If the spine radiograph includes the craniocer\'ical

• Sloping of superior margin of tibial plateau laterally junction always assess the peg as this ma ~' be absent in
( 184d ). ~'I orquio's and there may be atlantoaxial subluxation.
• Genu I'algus deformity ( 184d ). On a peh'ic radiograph flaring o flhe iliac wings "iJJ
be seen in achondroplasb and the
Hands and feet" mucopolysaceharidoses, howC\'er in achondroplasia
• Proxirm.l tapering o f the metacarpal bones the sacrum may be horizontal in orient-J.tion therefore
producing 'bullet-shaped' tllcrac3.rpJls ( 184e). appearing abscnt (see Case 15 1).
• Short \\;dcncd mbular bones with metaphyseal
irregularity ( 184e). Further management
Mortality/ morbidity arc related to atlantoaxial instability
Practical tips due to odonlOid peg hyperplasia. In addition, respirarory
It may be vcry difficult on imaging to diAcrcntiatc complications arc common due to chest wall deformity.
Morquio's from achondroplasia or dle olher mucopol~'
sacchlridoscs. Some featu res may help radiological Further reading
diflcrentiation: \Vakely S (2006). The posterior vertebral scalloping sign.
Cau(bl narrowi ng of the spinal callal is not a Icarmc of R.ndiology 239: 607- 609.
the mucopolysaccharidoscs however it is present in
ac hondroplasia; therefore assess the intcrpcdicubr
distance on the All of the spine .
• The 31ltcrior vertebral body beaks in 1\1orquio's tend
to be in the Middle of the "enthral body whereas in
Achondroplasia and Hurler's syndrome the y arc
Ameroinfcrior.
184d AP radiograph of both knees shows

genu valgum with sloping of the superior
margins of the tibial plateau.
329
Chapter 6
BREAST IMAGING
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Breast Imaging Case 185
CASE 185
History
';':""oj, . m.mm"..... m' ;n , . 1·,-",·
old ~ """n
Answer 185
AN SWER 185
ObSflrvllions IIB51 P.ltllc.ltip'
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CASE 186
History
A 56~ycar· old woman with a firm mass
in the ccmrallcft breast.
ANSWER 186
Observations (186a, 18Gb) Look carefully for signs of an invasive focLis within the
Bilateral mammograms show that in the upper central and ca1cifieltion - search for a spiculate mass or stromal
hucral aspects of the left breast there is extensive deformity. If not identified, assess further with
pleomorphic microcalcification. Within the left axi lla there ultrasound and possibly MR imlging.
is a 21 mill diameter rounded node. The right breast
appears normal. Ultrasound of the superior central left Further management
breast demonstraTes an irregular solid mass. Further imaging assessment is suggested : mammographic
The extensive microcalcification is of a configur:ltion magnification orthogonal views (typically craniocaudal and
suspicious for malignancy in the central left breast. There mediolateral ) may evaluate morphology and distribution
is possible metastatic spread ro the large axillary node. The of the microca1cification. Ultrasound guided biopsy of the
ultrasound demonsrrates a probable malignancy. Furrhcr solid lesion lnd mlmmographic stereotactic biopsics to
investigation with urgent biopsy of the lesion is required. Obtain a sample containing calcification should be
performed. The sllspicious node should be sampled under
Diagnosis ultr;l.sound guidance. In this case, the biopsies showed :
Ductal carcinoma ill situ ( DC IS ) with involved axillary ultrasound solid lesion - invasive carcinoma; stereotactic
nodes. carl'S - DClS; axillary node - malignant cells.
Once a diagnosis of malignancy has been established,
Differential diagnosis surgical rcferral is required. In this case the pltien r
For pleomorphic calcification on mammograms: underwent a mastecromy and axilbry lymph node
• DCIS. clearance. Histological findings ,,·ere of a 12 mm I DC in
Atypical ductal hyperplasia. thc superior ccntral breast with extensive (7 cm)
• Fat necrosis. intermedi,He grade DCIS; 4 Ollt of 15 axillary nodes were
• Fibrocystic change. involved with tumour.
For enlarged axillary nodes:

• Ipsilateral breast malignancy.
Infection/inflammation of ipsilateral breast or arm.
Collagen vascu lar discase/rheumatoid arthritis.
Lymphoproliferative diseases: lymphoma and
leukaemia .
Metastases (melanoma, lung, contralateral breast).
HIVadenopathy.
Discussi on
Pleomorphic microcalcification may be defined as irregular
calcifications of varying sizes and shapes, usually <:0.5 mm
in size. Orthogonal mammographic views may darif)' the
characteristics - for instance, lilH.:ar and segmental
distributions suggest that the calcification is ductal in
origin, whereas regional or diflilsc multiple bi!ater.ll groups
are less li kely to represent a ductal process.
A small percentage of mllignant lesions arise from the
stromal elements of the brelst. Ninety per cent of breaSt
cancers have cellular features thlt arc similar to ductal
epithelium and arc consequently classified as ductal cancers.
When confined ro the duct thev arc te rmcd ductal
carcinOllll ill sitll ( DCIS ). When the cells have breached
the basemenr membrane around the duct and invaded the
surrounding tissues, they arc termed invasivc ductal
carcinoma ( IDC).
The diagnosis of DCIS is associated with the possibility
of associated invasive disease. If no invasive focus is
identified on mammograph y further assessmenr with
ultrasound and possibly J\lR imaging with a view to
potentially finding an invasive component may be
performed.
Practical tips 186a Left MlO: axi llary lymph

Not infi·equently, microcaJcification is ofequi\·ocal node (upper arrow) and
configuration - if there is doubt there is a low extensive microcalcification
threshold to proceed to biopsy. (lower arrow).
336
Breast Imaging Cases 187, 188
CASE 187 CASE 188

Hi st ory Hi story
A 33-year-old woman with a soft A 64-\'car-old wom:all with a swollen
mobile smooth left breast lump. CI)1:hC;'l\:UOllSright breast.
33j
Answers 187, 188 Breast Imaging
ANSWER 187
Observations (187a. 187b) pc:rimc:nopausally in many women, but can be found in
The breasts arc heterogeneously dense. There arc scmi- women of all ages. Cysts may develop after commencing
ovoid low-density opacities in bmh breasts. There is a large oestrogen (hormone ) replacement therap~'.
dominant lesion in the upper Ollter left breast. On mammography, cysts appear as semi-ovoid masses
Ultrasound of the left breast lump demonstrates:I wel! with variable margins and density. There may be a
defined smooth margined anechoic mass with through peripheral halo and/or rim egg shell calcification. On
transmission. The appearance of the lesion assessed with ultrasound, cyStS usuall)' appear as well defined, anechoic
ultrasound is in keeping with a benign simple cyst. masses ,\~th posterior acoustic enhanccmem. In some, high
specular echoes shift in position as gain is increased
Diagnosis ('gurgling' cysts) . Posterior enhancement is not always
Benign simple cySts. demonstrable, particularly if the cyst is small or dose to the
chest wall. If there is an y question as to the cystic narure
Differential diagnosis of a lesion, aspiration is recommended. On occasion lesions
Of:l smooth low-densi ty lesion on mammography: appear cystic on ultrasound, but aspiration is unsuccessful
• Simple cyst. - thick prOTeinaceoUs fluid may be tOO gelatinous to be
· Oiteyst. aspirated.
Fibroadenoma.
• - 1.5% of circumscribed round lesions Illay be Practi ca l tips
malignancies. • Avoid satisfaction ofsul"\'ey: look for other, more
suspicious lesions.
Of an echoic lesion on ultrasound: CyStS often recur after aspiration.
• Simple cyst. If the lesion is dearly a simple: cyst, aspiration is not
Complicated (proteinaceous) cyst. required unless the symptoms of the mass arc
Duct ectasia. • distressing.
• illtr:J.dl!craljintracysric papilloma - look carefully on Irlhere is any doubt as to the nature or the cystic
ultrasou nd for a mural lesion. lesion, core bioI'S), is suggested.
Discussion Further manage ment

Cyst's arc asymptomatic in many women. Presentation is Ir there is any doubt about the mammographic
l'ariable. A palpable mass or masses may develop rapidly and appearances, further el'aluation with ultrasound should be
is/arc associated with tenderness. They del'elop undenaken.
ANSWER 188
Observatio ns (188) invasive focus which could be biopsied. The diagnosis
T here is diffilsc tr.lbecular prominence throughout the right could also be obtai ned from skin punch biopsy or rrom
breast which is or generalized increased density. T he skin image guided core biopsy of an axillary node.
is thickened. There arc enlarged nodes in the right a .~ iIla. Inflammatol)' breast cancer may be defined by clinical
The left breast is normal. diagnosis dependent on findings of oedema, el)'lhema and
'pcau d'orange' or on histological findings of metastatic
Di ag nosis breast cancer in dermal lymphatics. The definition is
Probable inflammatory right breast cancer \\~th axillary debatable: not all women with clinical findings suggcsti,'c
nodal illl'oll'emcm. or inflammatory breast cancer have iOl'olved dermal
lymphatics and ~ot all patientS with tumour cells in the
Differential diagnosis dermal lymphatics present wi th signs of inflammation .
For diffusc trabecular/skin thickening: Inflammatory malignancies account for 1%of all breast
• Post radiotherapy change. cancers and up to 40% of locally adl'anced breast cancers.
Progressive systemic sclerosis. The diflcrentiation between mastitis and inflammatol)'
Obstruction ortht' superior I'ena cava. carcinoma may be ditlicult.
Lymphoma.
infection/ inflammatol)' mastitis - most common in Practica l t ips
lactating women. Patients often undergo neoadjuvam chemothcrapy
• Tr:lllma. prior to mastectomy.
• Generalized oedema due to causes such as congesu"e Consider infla!J1matory breast cancer when an
hean f.l ilure or nephritic syndrome. inflamed breast fui ls to respond to a brief course of
antibiotics.
Di scussion
Uhr:lsound or MR imaging may be used to find a discrete
338
Breast Imaging Cases 189, 190
CASE 189 CASE 190

History History
A 42-rear-old mail with a soft mobile Screening mammograms in a 57 -rear-
tender Icft breast lump. old womall.
339
Answers 189, 190 Breast Imaging
ANSWER 189
Observations 1189) there arc characteristic mammographic features that ailow
In the left brC:lst there is l full shaped density emanating breast cancer in men to be recognized (round/spiculate
from the nipple which gradually blends into surrounding subareolar mass typically eccenTric to the nipple), there is
lany tissue. The right breast appears normal substantial overbp between these features and the
mammographic appearance ofbcnign lesions. Male breast
Diagnosis cancer is rare, accounting lor < I % of all male cancers.
Gynaccornasria. Gynaecomastia is characterized by hyperplasia of ductal
and stromal clements of the male breast . It manifests
Differential diagnosis clinically as a soft, mobile, tender mass in the retroareolar
O f a breast lump in a male: region. Gynaecomastia has been associated with an
• Gvnaccomastia. increased semm b·cI of oestradiol and a decreased level of
!\Ialc breast cancer (circuillscribed or spiculate mass teSTOsterone - this may occur with physiological changes
usually evident; often eccentric to the nipple ). at puberty and senescence and be caused by endocrine
Pscudog}'naccomasria (f.1rty cnbrgcmctlt with no disordcrs, systcmic diseases, neoplasms and certain drugs
ductal o r stromal prolitcration; secondary to obesity). including anabolic steroids, cimetidine, spironolactone and
Di:lbctic mastopathy (firm mass in patient with marijuana
longstanding type I diabetes mellitus ).
Abscess (cITthcma; acute histOry). Further management
On the diagnosis of gynaecomastia it is important to
Discussion corrdate the imaging findings with the clinical histOry.
Gynaccomastia usually appears as a fan shaped density Many cases of gynaecomastia are idiopathic bur
emanating from the nipple, gradually blending into underlying causes should be investigated - senUll hormone
surrounding fat. Three mammographic patterns of b ·cls should be taken. Ask for a drug history and the
gynaecomastia have bce.n described: nodular, dendritic and presence of signs of chronic renal insufficiency, cirrhosis
dirfuse. Tllere may be prom inent extensions into the and a testicular mass; other imaging im·estigations
surrou nding fu t and, in some cases, an appearance similar perr:a ining to the patient may raise one of these
to that ofa hetemgeneollsly dense tcmalc breast. Although possibilities.
ANSWER 190
Observations (190) system. T hese calcifications h:nd to be coarser and
1n the antelior aspects of both breasts there arc smooth \\"ell larger (usually >1 mill in diameter) than malignan t
defined spherical calcifications with lucent cen tres. No calcifications.
abnormal masses or distortion arc seen. Skin or dermal - usually spherical and lucent-centn:
calcifications at the periphery of the breast.
Diagnos is Suture - usually seen :at a known surgical site. The
Bilateral calcificatio n of benign configuration. calcifications ma~' be linear or tubular.
Differe ntial diagnosis Discussion

For benign calcification: Calcification is a frequent finding on mammograms. The
• Vascular - usually secondary to medial atherosclerosis . arrangement of calcification aids categorization as to
Mav be. associated with diabetes and whether it is benign or malign.ult. Clustered (occupying a
hYl;erparathyroidism. Often demonstrates a ,·olume <I pI oftisstle ), linear and segmental calcification
characteristic 'train track' configuration. may be secondary to benign or malignant processes.
Fat necrosis - peripheral calcification in a lucent mass; Regionally and diffusely distributed calcifications arc most
histOry oftraullla or surgery. likely due to benign p rocesses. T hese calcifications arc
Fibroadenoma involution - 'popcorn ~ like' scattered in a la rge volume of the breast and do not
calcifications usually beginning at the periphery and necessarily conform to a ductal distribution.
the n ill\'olvi ng the central portion.
'Milk of calcium' - a benign process that call be Practical tips
diagnosed with magnification views of orthogonal If calcification is of equivocal configuration, there is a low
projections: on the CC view, calcifications appear threshold to proceed to biopsy_
poorly defi ned and sllludgy; when imaged on the
MLO view, rhe calcifications are seen as sharply Further mana gement
defined and cresccnt shaped or linear. No intervention required. Routine recall lor screening.
Plasma cell mastitis an d duct ectasia - large rod-like
calcifications orienled along the axes of the duct:al
340
CASE 191
History
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Answer 191
AN SWER 191
Obu.vlli .. n' 11 91~. 191b. 19101 Di .... ssion
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,om!",'" to r"""''' m.mmogr.m •. ••J "'" P''''''''
," 'I"~ "''''' P"'''''' n,-'O ' """"""''' . oJ/' ~ _'"", ,,
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'"
Further Reading
AidJ to Radiological Diffirmtia/ Dif/gllosis NtIITOTfldi%m- TIJe ReqlliIiteJ
Stephen Chapman , Rich:ml Nakidny Robert I Grossman , D:a\'id M Youscm
\VB S;1UllrlCrs, 4th edn , 2003 Mosby, 2nd edn , 2003
Clillicnllmngillg: An Arlal of J)ijfirwtiai Diagnosis Pfledifltrit NtllTOiwflgi"g

Ronald L Eisenberg A Barko\'ich
Lippincott Williams and Wilkins, 4th cdn, 2002 Lippincott Willi:ams and Wilkins, 4th edn, 2005
Diagnostic lI"aging Head fllld Nuk Radi%m Rtl'itw M all lla/

ltic Harnsbcrgcr Wotfg:ang Dahncrt
Amirsys, 2004 Lippincott WitlianlS and Wilkins, 6th (dn, 2007
FlIlIdfllllClltnls o/Dif/gIlMt;, Radi%!J.Y Sc/f-Al!Cl!JIICllt C% m- Rtl!iew of NtIITOilll(Jgillg

William E Brant , CI),de A Helms Ki rsten Forbes, Sanjay Shetty, Michael Lev, Joseph
Lippincott Williams and Wilkins, 3rd cdn, 2006 H cis(rll1:an
J\'lanson Publishing Ltd , 2008.
Grail/oer (Illd AlliJon's Diagllostic R adiology: A Textbook
of Medical /lIJflgjllB Sdf-Al!el!lIItI" CO/OIIT Rel'iell' oj 'nJorfl cie Imflging
Ronald G Grainger, David J Allison , Adrian K Dixon Sue Copley, DJvid M . H ansell, Nestor L. Muller
Churchill Livingsto ne, 4th edn, 2001 Manso n Publishing Ltd, 2005
lmagill!] of DisenJeJ of tile Chest Textbook of Rfldi%g:y fllld Imflging

D~l\'id M H:mscll , Peter Armstrong, David A Lynch, H David Sutton, Ro dney Reznck, Janet Murfitt
Page McAdams Churchill Livingstone , 7th (dn, 2002
j\'losby, 4[h cdn , 2004
Mnglltlic Resollflll 'e IlIIng;II9 o/the Brf/ill and Spille

SconWAtias
Uppincorr-R.wen, 2nd edn, 1996
343
Index of Differential Diagnoses
, .1.;;f"'.. ..,. (" .,;. _JI •• ~,;.: U J •• ,"~ "",,, { '! . .i±
I;'" ,"","'..." 51 ~ . ~,J.; "'~~, 41
" 'h,I",;, !7 , ~ nl " 0 ' ~,~,,,.,,,,,,;.,, ~ .""' ~"ug, '9
"" ,>oJ.., ~7 ,,, ,,,,...,,,,,~ ... ,~,,,,, II I ."'" ,,,II '",,~ ... (GCT) ( .. ,hiIJ \
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"""'_"PI',,,,")i"" IU <pI<," l.5.
..,I<ri<,.. m<J~,,;",1 m", JjJ. "I;; "" ~ I;"', k"m ,10 h" m," ~ , h l "",",, I'"
"''''. " p,,,h.!< J 73 c...J;J , o"0I',,,~"6 II h.""",nJ,i~"ISr.\l' 1 119
..,.." _h, <W>' ,...., 18 1 <.: ... ~;'. J "'''' ij6 !tIll' (1"'" _h'r<J 0( .... ,,,\ 10
"1',><"...... uk"""., II '" it""S I....... ~,H' '''T II """,i,"'~"
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"",he IH k>''''''';' 'P"h''K "' ~ 90 ><~ Ii~, "1'''' ••''''''' "f 1.i
... " ~,,,,~ d' ...... , ~ ..... 13l """••"'' ' .\<",>.I"."nll~IO",\,~ 105 h,p"" "",. ,"
...."',,,,'.1 ," olu""" 110
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H i t'! 110
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"'' ' """. "'''
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iow-J",,,,y I .. ".,;':1..1.0,,," ,,'" ,,,,,,,,Nt Ii. llu,k' ''fnJ ,","" IS.
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N.,Ioj" (CllH I 1M hll'<"=f.'" ".,~ ,, ~ I.""" 71
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..... of,'{'<dI Hf.!.P) 70
, ..I'~"«n' limnS J"'", "" IVU
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•
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173
II
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IS1MJO.rsl'OOI.) 1<5 ')" ~ >ok"",,,,,,,oJ 'W".K'.""'" . ,,,,,~,oo l ,, "1" . 1 ' hkl.<" ;"~ 19
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lum p"""'" 189
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pk"" H "''''~<'''';';':''.'" 186 ,~i,'h),<" "'""" 1JJ I"., ,,,,,,,, "1»,,",, . . " ito.
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Gene.al Index
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JooJ""J ", I ~l
,o"~mit"'r<,,<f," lm~ri
r"'~'c ol "''''''"''''''''' I ,' .

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h.'"""",,", I""
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,," ' h .. u<)t ...... 17
,ibro<] )'.'",,
III
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J,,,, ..i,
F""f."";'"
58
~w;" . Oorn'" orif~"<, iZ
~' o " n J ~.~ ",o';'y
. ,."o<",m.>t;. HO.I89
k,...
109
I<~ "1'1'" ~ ,I« ' nn. ....... h '''''',",J)'1''''''' Ii.

~"' " >I,. ~~ w<"""" """
n
' it-h' ,>kJ ",,110 ,' 5
II 'io\l!« ..... J -C<> .u
f ... ,«Jk "I'~"'''' I~~.\) I.,
h<,,, ,, ,,,,.l"~ I " ' ,""'
h"""o,,",m, 119 .1!7
10'1. '"0
';,wl", ... ",.,', .1",.", '.l h"",.","" ,," ,,'~~ sa
t',oio' "''"'$_'/o''' ." ""o.... ~ I IY.W'.1!7 h"",,'I"l"~. ,,">t"' Ii I> ~";' lb.
HI< ~I"""" ,)"J"",", III h ·.. ..-.l.I" h)'f'<'pI,,;, (fSH I. h... "",ok",,~. ru''''''''''y II
E"" nm<nt.<''')...Jrom< lit
~ Ui... ,... L",,,,IJ '\"""""" 177
"'r"" ~;
"" " S'. J .."" 12 ~
h•• o"<oo.i~"
"''';"5 k_
119.1 • •
,m bol.", ;"". , ..""",, ""'" "'"' ..... 1I<."'n>< 161 aoow'" "'"""'" 9~
............"..." .n ",,,.1,,11 . ;" , n. 167 <",.. ",J ,', _~)I,"I" ,"",J""
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117
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f." ~ . 1
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(;PJJ• •.1. N
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,nodom" ........ 81.0.1 u '"fo..1
p'''''''"'''' c>r< " ""'"
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... n, tu f"'K'''' .. "" , ';,h h"""",hw.,,""" 50
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7'!
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'1"""),'"00" 89 _UO P""'''';';' 71 rrim.,,- ,"","""" i. .l.
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17l
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g"", "n ,u"~.,,, n hr'"'' """"" i"
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V"""' i"~.I,,'l'" r"""'·'" '""'"." "'0.1"""",,,..., 68
(HP) ." tloJ;, ", 15 l.l 60
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1 17. I ,'.I. 139
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General Index
pncumalOsis (tontinlled) pulmonaryarterim·enolls renin-angiotensin system,

cystoides intestinalis 66 malform:uion 33 o\'eracrivity 58
intestinalis 65, 167 pulmonary asbestosis 3, 15 rcspirarory distress, meconium
pneumobilia 41 ,.. pulmonary embolus 31 aspiration syndrome 170
pneumoconiosis 6, 7 pulmonary fibrosis reversal sign 114, 163
PlIelfmotystis tan"ii pneumonia dmg-induced 18 rheumatic heart disease 23
( PCP) 37 lowcrzone 15, 17 rheumatoid arthritis 120,143
pneumomediastinum 34,165 upper zone 15,17, 18 rheumatoid factor 17
meconium aspiration syndrome pulmonary haemosiderosis 23 rheumatoid lung 6
170 pulmonary interstitial emphysema rheumarologic syndromes,
pneumonia, aspiration 171 (PIE) 165 histoplasmosis 25
pneumoperitoneum 34,75 pulmona!)' malignancy rib.
necrotizing emerocolitis 167 asbestosis 15 bilateral cervical 28
pneumothorax 3 1 systemic sckrosis 17 eXOStoses 130
bulla diflerential diagnosis 35 pulmona!)' metastases, cavitating lesions 9
cystic fibrosis 36 14 notching 32
endometrioma 83 pulmona!)' nodules rickets 168, 175, 176
Langerhans cell histiocytosis 27 follo w-up 6 fig ht ventricular hypertrophy, mitral
meconium aspiration syndrome mitral vah'e disease 23 valve disease 23
170 oesophageal tumour 14 Rigler sign 75, 167
PllwmotyJtis tnrjlljj pneumonia rhcumatoid lung 6 Rigler's triad 41
37 sarcoidosis I Rokitansky nodule 84
positive pressure \·entilation pulmona!)' oedema 3 1
complication 165 heart failure 29 S sign of Golden 14
polycystic kidney diS(:asc 48 pUlmOlla!)' opacity sacral agenesis 173
polydactyly 177 barium aspiration 20 sacroiliac joint disease
polyhydramnios, annular pancreas ground glass 29 Crohn's disease 53
44 Icft upper lobe tumour \,~th ulcerative colitis 65
polymicrOb..yria 169 lrmphangitis carcinomatosa 12 sacroiliac joint fusion 139
portal hypertension, oesophageal lung lobe collapS(: 14 sacroiliitis 116,143
varices 42 metastatic calcinosis 20 sandwich ,·enebrae 140
positive pressure ventilation 165 pleural pscudotumour II sarcoidosis
positron emission tomography puhnona!)' sarcoidosis 1 cardiac sarcoid 22
(PET), merasl';nic bronchogenic pulmonary \·cnous hypertension pUinlOna!)' 1
carcinoma 24 mi tral \'alvediscasc 23 schistosomiasis 62
posterior cnlciate ligament 159 pulmona!)' oedema due to heart schizcncephaly 169
double PCL sign 159 failu re 29 sclerpdcrma 132, 152
postcrior inferior cerebellar artery pyelitis, emphyscmatous 63 sclerosis
infarction 100 pyclou reteritiscystica 77 Charcot joint 138
posterior urethra! vah·es 172 pyknodysostosis ! 19, 168 dilYuS(: 119
Po u 's disease 142 Pyle's disease 119, 178 sep~\1 thickening, interlobular
prematurity 29
hyaline membrane d isease 165, Rathke cleft cyst 106 sialectasis, juvenile punctate 87
170 Raynaud's phenomeno n 17 sicklccclidisease 129, 140, 155
necrotizing enterocolitis 167 thoracic Outlet syndrome 28 siderosis, transfusion 50
primary sclerosing cholangitis 45 rectum sigmoid colon, displacement 84
primitive neuroectodermal tumour st'ent'ed tumour with calcified liver sigmoid mlvulus 46
( PNET) 180 metastases 52 silicosis 18
progressive massive fibrosis 7 ulcerative colitis 65 simple bone cySt 115
prostate carcinoma, metastascs 140 Rdter's synd rome 116, 143 Sj6grcn's syndrome 87
Protws, emphysematous pyelitis 63 renal adenocarcinoma 5 1 skin folds, lung edge art:efuct 35
pmne belly, posterior urethral vah·es renal arte!)' stenosis 58 skin nodules, neurofibromatosis type
172 renal ectopia, crossed nlsed 68 I 8
pscudodi\·erticulosis, intr.lmural 38 renal lesions, fat 48 slipped upper femoral epiphysis
pseudohyperparathyroidism 147 renal medullary nephrocalcinosis 43 (SUFE) 117
pS(:udo-Maddung deformity 130, renal obstmction, hydronephrosis small bowel
153 68 adenoma 49
PsclldomollaJ, emphysematous renal osteodystrophy 11 9, 140 ischaemia 59
pyelitis 63 renal papilla!)· necrosis 78 loop dilatation 69
pseudoureteroceles 56 renal scarring, infections 68 strictures 59
psoas abseess 142 renal stones, horseshoe kidney 5 1 thickening in Crohn's disease 53
psoriasis 11 6 renal lUberculosis with small bowel obstrucdon 4 1
psoriatic arthropathy 143, 152 autonephrecromy 74 adhesions 47
pulmonary arterial hypertension 16 renal tubular acidosis 43 mechanical 4 1,47
351
General IndeJl
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Shahid Hussain, Sharif Aaron Latif, Adrian Hall - Rapid Review of Radiology-Manson Publishing LTD (2010)

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APID REVIEW

Sherif Aaron Abdel Latif

Adrian David Hall

t;"rl"lh, 0 lO I <1 M--.. r"N;./oW'>g LoJ

ISR.>; .7M I J.07. , I~O'

c..mm .....,",& «I;"",' IJI """,",,,,,

G,'nnJI Imrodllcl ion ,

CI,.ptcr 2 - ,\bdomin.1 I""sing 71

GII.!,"-' 6 - 1I,.,.j, l",agi"l1 b.y /~"frSllJr /trill l ..,/",n, 331

e, ...."" ...,,,,;,,.. O~ """"e'" ''''''''I'' ,",

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Th. ' di.<u .. ion· Furth. m. n l ~ . m e n l

GENERAL VIVA CONS IDERATIONS

~ = ,,~J [~. ~' ~ .~ ;..'~ ~

~., •. ;:-,,-,· 1~i.

Oiflllentil l dil gnosls

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= ''''-'" ...- ..~ 1 ::: U ::i

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Oiff" rontial d iagnolis OiSCUSlion

j~n i! ~""'1-~ ~ .. ::l-!, ,

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15c Axial image shows a right anterior calcified

T he CREST syndrome represents Calcinosis, Raynaud's,

18b CT image in the same patient shows a cavitating

Diagnosis Further management

Slightly larger high -density opacities lead [0 a largcr

u r·old f1ule W:I,S rdured for

248 Right lower lobe bronchogenic

25b Multiple calcified tiny nodules at

ations (26a) Practical tips

_ is can be contirmed wirh arterial phase contrast

26b Axial CT image demonstrates the right sided

f",," .... " nf ·s"x .. ' gI .... - >I>'<OI,,« ~

d Multiple poorly defined lytic lesions are seen

- ere ntial diagnosis

• \·cnous: SVC obstmction.

superior rib notching:

32c A maximum intensity projection (MIP) image from an

• Look for an cffilsion to suggest oesophageal injury, or

.old male presented to A& E

. . . lib Sequential chest radiographs taken 4 months apart.

36c HRCT thorax of the same patient at a later dale.

- rar-old IV d rug use r presented with cough and

- :car-old male presented with a

Di ag nosis Further reading

Upper and mid oesophagus:

Other less common causes of strictures include Crohn's

;;~;:;;;;~~~:; .no loft fomo,.1 h •• d