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Required Diagnoses Image

Compendium

1. CRITICAL DIAGNOSES
! Abdominal

Aortic Aneurysm
! Abdominal trauma, including hepatic, splenic,
and renal injuries
! Aortic Dissection
! Pulmonary Embolism

73M with pulsatile abdominal mass on


physical exam and known history of
peripheral vascular disease status post
AKA (and previously known infrarenal
AAA to 6.6 cm).

Findings:
Aneurysmal AAA,
up to 8.0 x 9.0 cm
distally with
extensive mural
thrombus
" What imaging
modality would you
order next?
"

Findings:
"

CTA I- and I+ images


demonstrating:
"

"

"

Coronal Maximal Intensity


Projection (MIP) Image in
bone windows

Abdominal Aortic Aneurism


measuring up to 10 cm,
enlarged
Extensive mural thrombus
with contrast filled lumen
measuring ~ 2 cm.
No evidence of dissection

Discussion: AAA
General Features:
"Abdominal aorta is considered aneurysmal when its outer wall to outer wall diameter reaches 3 cm,
outer wall to outer wall diameter. Common iliac artery is considered aneurysmal when it exceeds 2 cm
in diameter.
"AAA can demonstrate fusiform or saccular morphology.
"Most common site for aortic aneurysm is in the infrarenal aorta, although aneurysm can occu anywhere
in the aorta.. Extension into the internal iliac artery is not uncommon, however extension into the
external iliac artery is almost never seen.
"Surgical or endovascular repair is usually recommended for abdominal aortic aneurysm (AAA) > 5.5
cm in diameter and iliac aneurysm > 3 cm.
"Imaging:
" Ultrasound is an excellent non invasive tool for aneurysm screening, follow-up and useful for
assessment of endoleak post endovascular repair. And may demonstrate:
" Bulbous or fusiform dilatation of the aorta/artery, Concentric layers of mural thrombus
may line the interior of large aneurysms, Membrane or intimal flap as present in
dissection, Retroperitoneal hematoma which is highly suggestive of aortic rupture.
" Color Doppler is useful for demonstration of aortic dissection and to confirm patency major
aortic branches, including celiac axis, superior mesenteric artery, renal arteries.
" CT remains the gold standard and preferred imaging modality::
" For evaluationt of possible aortic rupture
" For assessment of suitability for endovascular or surgical repair of the aortic aneurysm
" For post endovascular repair follow-up, particularly for assessment of endoleak

67-year-old obese female with acute


onset chest pain radiating to the back

What is your imaging study of choice?


" Which protocol?
"

- What is the finding? Is it


a surgical emergency?

Findings:
"

CTA of the Chest, Abdomen and Pelvis in


dissection protocol, demonstrating an
extensive aortic dissection with an intimal
aortic flap extending from proximal ascending
aorta to the right iliac artery (Type A
dissection).

Definition:
Discussion:
Thoracic Aortic Dissection

"

Aortic dissection: Spontaneous tear between the intima and media layers with
propagation of subintimal hematoma
Staging, Grading, or Classification Criteria:
Stanford classification (preferred classification)
" Type A: Originates in ascending thoracic aorta (60-70%), treated surgically
" Type B: Originates distal to left subclavian artery (30-40%), conservative
treatment with HTN management
DeBakey classification
" Type 1: Ascending and descending thoracic aorta (30-40%)
" Type 2: Ascending only (10-20%)
" Type 3: Descending only (40-50%) A: Extends to diaphragm, B: Descends
below diaphragm
"

"
"

"

"
"

Radiographic Findings: widened mediastinum, left apical cap


CT findings: hyperdense intramural hematoma on noncontrast images, displaced
intimal calcifications intraluminally, intimal flap (True vs False lumen with false
lumen usually larger and with delayed filling of contrast as seen on bolus images).

55M POD #1 s/p orthopedic procedure,


with sudden onset dyspnea, tachycardia
to 130s and desaturation to 80%

"

What is your first imaging examination of


choice?

Findings:
"

"

"

"

Single, portable, semi-upright chest radiograph


demonstrating no acute findings.
Clear lungs; no pneumothorax, pleural effusion,
pneumonia, or lobar atelectasis. The
cardiomediastinal silhouette is within normal limits
given portable technique.
Minimally displaced fractures of the left 6th and 7th
anterolateral ribs.
What is your concern at this time? What is your next
imaging study of choice?

Findings:
"

Contiguous coronal CTPA images


demonstrating large acute saddle embolus
involving the right and left pulmonary arteries

Discussion: Pulmonary Emboli


"

"

"

"

Definition: Embolization of thrombi to the pulmonary arteries, usually from deep


veins in lower extremities or pelvis
Radiographic findings: usually normal chest; rarely see wedge-shaped pulmonary
infarcts (Hampton hump: Pleural-based, cone-shaped opacity pointing toward the
hilum); focal areas of oligemia (Westermark sign).
CTPA findings:
" direct visualization of the thrombus (with central dark filling defects
surrounded by contrast usually indicative of acute PE; eccentric and adherent to
the vessel wall clot and webs indicative of chronic clot burden), evaluation for
right heart strain (i.e. leftward bowing of the interventricular septum as the RV
enlarges)
" Standard of care
Nuclear Medicine: V/Q scan
" Indirect indicator of clot; does not directly visualize the clot, only the
disruption of vascular perfusion.
" Combined with clinical Wells Criteria Score to assess propability.

30F with multiple stab wounds to


the abdomen

Left renal transverse laceration in


the interpolar region extending
toward the hilum
Perirenal fluid with high
attenuation areas suggestive
of active extravasation

Left upper quadrant anterior


abdominal stab wound
Extravasated rectal
contrast centered around
the splenic flexure, in
the region of the
visualized stab wound,
indicative of bowel
laceration

Discussion: Acute Abdominal Trauma


"

"
"

"

CT is the imaging modality of choice for diagnosis of intra-abdominal injury after blunt or penetrating
abdominal trauma, and is especially valuable when physical examination is unreliable (i.e. stuporous
patient) or equivocal.
CT is usually obtained for patients with significant abdominal trauma who are hemodynamically stable.
CT is performed WITH intravenous contrast, but WITHOUT oral contrast (at least in our institution).
Rectal contrast (in addition to IV) is reserved for cases with penetrating abdominal trauma (GSW,
stabbing). Delayed images may be obtained for evaluation of injury to the collecting system (higher level
of suspicion in setting of pelvic fractures) or to evaluate vascular injury and possibility of active vascular
extravasation.
Possible CT findings in the setting of acute abdominal trauma may include:
" Solid abdominal organ lacerations Splenic, liver, renal lacerations. These are usually linear areas
of hypodensity, potentially with surrounding fluid or hematoma. It is important to evaluate delayed
images for adjacent hyperdense foci which may represent active extravasation of intravenous
contrast (implies vascular injury), as this needs to be treated surgically. Shattered organs
demonstrated multiple lacerations and may demonstrate hypodense regions from devascularization
injury.
" Hemoperitoneum hyperdense fluid within the abdomen or pelvis, often ~ 30-45 HU. This is not
specific to any one particular injury, but a very hyper dense focal collection of fluid (sentinel clot)
can guide to the injured organ.
" Pneumoperitoneum- nonspecific finding which may be due to bowel laceration in penetrating trauma,
barotrauma, etc.
" Free contrast in peritoneal cavity may be seen with extravasation of rectal contrast through bowel
perforation as seen in above case or from leakage of contrast-opacified urine from the urinary tract.

2. CHEST
! Pneumothorax
! Lung

Collapse / Atelectasis
! Congestive Heart Failure
! Common Tubes and Lines

Pneumothorax

63M with shortness of breath

Hyperinflation of lungs pt
has emphysema with bullae

Pneumothorax (air in
pleural space)

After chest tube placement

chest tube

Diaphragmatic flattening & barrel


chest consistent with emphysema

Next Day

Chest tube failure


resulting in subcutaneous
emphysema

And persisting
pneumothorax

Subcutaneous
emphysema
Residual
pneumothorax
Chest tube

Bulla in the right lower


lobe potential for
rupture and right-sided
pneumothorax

Lung Collapse / Atelectasis

58M with fever and crackles

Plate-like atelectasis in the left lung base


(minimal airway collapse)

68F with shortness of breath s/p bronchoscopy

Minor fissure

Inferior/anterior portion
of major fissure

Right middle lobe collapse

52M with shortness of breath


endotracheal
tube

Right mainstem bronchus intubation with left lung


collapse the endotracheal tube needs to be retracted
so that it ends above the carina

ETT

s/p retraction of the endotracheal tube (ETT) the left


lung should re-aerate with time

Congestive Heart Failure (CHF)

Endotracheal tube
(ETT) terminates
above carina
R subclavian
central line ends
in SVC

batwing appearance in CHF


CHF low cardiac output results in blood backup in
pulmonary vessels and fluid leak from capillaries - wet
lungs

Aortic balloon
pump used in
hemodynamic
instability

Volume overload in CHF in this case results in:


Batwing appearance
Indistinct pulmonary vessels
Fluid in minor fissure on the right

78M found unresponsive

BTW: Enteric tube should go into stomach


and not stop in throat advance or pull!

Bilateral pleural effusions on portable film the fluid layers


posteriorly when the patient lies in bed with head raised 30

Common tubes and lines and their


expected locations

29 year-old man

PICC (peripherally-inserted central catheter)


Terminates in superior vena cava

62M: check central line placement

Right-sided central line crosses midline and enters


left subclavian vein, instead of terminating in
the desired location (SVC)

60M
ETT ends above carina
Enteric tube enters nose (NG)
or mouth (OG) and courses
through esophagus into the
stomach (for suction or tube
feeds)

Swan-Ganz catheter entering subclavian vein # SVC #


right atrium # right ventricle # pulmonary artery (to
measure pulmonary arterial wedge pressure)

Reason for exam: check Dobhoff tube placement


1st try

Dobhoff tube enters rightsided bronchus

2nd try

Dobhoff tube enters leftsided bronchus

Dobhoff tubes are used for tube feeds you want the liquid
to go in the stomach, not the lungs

83M in ICU s/p VFIB and resuscitation


Right internal
jugular central
line ends in
SVC

Endotracheal
tube

Enteric tube

CHF volume overload: fullness of right hilum, left pleural


effusion, indistinct pulmonary vasculature

3. BREAST AND CHEST


! Breast

Cancer
! Lung cancer, pulmonary nodules
! Pleural effusion
! Pneumonia

45 year old female with palpable


breast lump.

!"#$%&'($

What is the salient finding?

Findings:
There is a cluster of
microcalcifications in the left
mid breast. (hard to see, I
know).

Diagnosis: DCIS (ductal


carcinoma in situ)

DCIS
Atypical ductal epithelial cells thought to
represent the earliest form of breast cancer.
" Most common presentation is
microcalcifications as seen as previous
mammogram.
" Typically treated with lumpectomy/breast
conserving therapy.
"

45 year old female with 15 pound


unintentional weight loss and cough.

How would you describe the abnormality?

Do you need further imaging? If so, what would you


recommend?

Findings:
There is a 2.5 cm pulmonary
nodule in the right upper lobe.
No lymphadenopathy is
identified.

Recommend contrast enhanced


chest CT for further
characterization and to asses for
satellite lesions.

Pulmonary nodule
Lesions upto 3cm are considered pulmonary
nodules, greater than 3cm are considered
masses.
" Generally any nodule greater than 4mm is
followed based on the Fleishner criteria
guidelines.
" Nodules greater than 8mm require more
rigorous followup.
"

How would you describe the findings on this image?

Findings:
There is a 2.5 cm nodular
opacity in the right upper lobe
with lobulated borders.
No lymphadenopathy by CT
size criteria.
Path:
Pulmonary adenocarcinoma.

65 year old male with shortness


of breath.

How would you describe the salient findings?

FINDINGS:
There is an opacity in the right lower
lung zone, tracking up the right chest
wall with blunting of the right
costophrenic angle and a meniscus.

Pleural Effusion
"

Will show blunting of the costophrenic angle


in an upright chest xray.
200cc needed to show blunting of the lateral
costophrenic angle
" 50cc needed to show blunting of the posterior
costophrenic angle.
"

Larger effusions can develop a meniscus and track


up the chest wall.

45 year old female, smoker, with fever,


cough, chest pain with inspiration.

How would you describe the salient findings?

FINDINGS:
There is a lobar consolidation in
the left lower lobe.

Pneumonia
On CXR, often seen as a focal parenchymal
abnormality in a patient with fever.
" Differential includes atelectasis, edema, and
hemorrhage.
" In patients with lobar pneumonia, followup can
be obtained in 6 weeks to ensure resolution. If
not resolved, a CT can be obtained to rule out
obstructing lesion.
"

4. GASTROINTESTINAL
! Small

Bowel Obstruction
! Colorectal Cancer
! Large Bowel Obstruction
! GI bleed
! Cholecystitis and Biliary Obstruction
! Diverticulitis

52M with abdominal distension

Findings
"

#No gas in the left lower quadrant where you


would expect to see the descending colon

"

# Dilated loops of small bowel. The layering


or stair case appearance of the small bowel
loops is from lack of movement.

Small Bowel Obstruction (SBO)


Difficult to distinguish complete versus partial
SBO with imaging
" Bowel > 2.5 cm +/- air-fluid level within
bowel
" Causes
"

Adhesions 60%
Hernia 15%
Tumor 15%

69F with abdominal distension and


pain

Findings
Best clue to diagnosis: a short segment of colon
wall thickening
Early cancer # irregular polyp or sessile
plaque
" Advanced cancer # annular wall thickening
creating an apple core apperance or lumenal
filling defect can cause obstruction
"

Colon adenocarcinoma
Dukes Stage

5 yr Survival by Stage

A = mucosa & sub-mucosa only

A # 80 85%

B = serosa & local/direct soft


tissue spread

B # 64 78%

C = lymph node metastasis

C # 27 33%

D = distant metastasis (liver, lung,


D # 5 14%
bone)
Must aggressively search for metastatic disease

2011 Estimated US Cancer Cases


(excluding basal cell & squamous cell skin carcinoma)

68 year old woman with fatigue,


dark stool.
Fecal occult blood test + but
nothing found on colonoscopy
What do you want to do next?

Evaluation of Lower GI Bleed


Fast active bleed # colonoscopy or angiography
Slow intermittent bleed # may miss it on colonoscope! Need a
tagged RBC scan

Performed prior to IR procedure (embolization or coiling) so


angiographer can minimize time of procedure and IV contrast
exposure to patient while pinpointing the exact bleeding site.

Nuclear medicine GI Bleeding Scan


Advantages:
" Bleeding scan can detect bleeds as slow as 0.1 cc/min
(Angiography detects bleeds only as low as 1cc/min)
" Nonivasive compared to angiography
" Greater than 90% accuracy for localization of bleeding
sites in the setting of acute bleeding.
Disadvantages:
" Accuracy is not high for slow chronic bleeding.
" If ordered after all other evaluations are negative and
bleeding has slowed or stopped, accuracy is poorer.

Nuclear Medicine GI Bleeding Scan


"

Draw patient s blood and label w/ radioactive


tracer (at BMC it is Technetium 99m) then
reinject.

"

Each frame in the scan = 1 minute of recorded


activity

"

Uses a gamma camera which detects


continuous radiation

Positive GI Bleeding Scans


1.

Abnormal hot spot of radiotracer activity appears out of


nowhere as it enters the bowel lumen.

2.

Activity must persist and may increase over time.

3.

Activity must move with peristalsis anterograde,


retrograde, or in both directions.

Our patients Tc 99m RBC Bleeding Scan


Time = 0 min$

Liver

Aorta

Common iliac a

Bladder

47 min
$

Findings
"

Right upper quadrant bleed following the


course of the colon, starts to appear at 17-20
minutes.

"

Notice how many minutes it takes for the


tagged blood to travel in the colon.

84M with abdominal distension and


pain

/*.0'$12('3$
(*33$

)*+,-.*$

1. Air fluid levels from bowel stasis


2. Dilated haustra & colon (>9 cm)

Findings
"

Large bowel obstruction at the level of the


sigmoid colon

"

Haustra further apart 2/2 dilation

"

Coffee bean appearance of sigmoid colon as


bowel has loopedin a u-shape. Twisting of
bowel # sigmoid volvulus

Sigmoid Volvulus
"

Often elderly men / nursing home population

"

Pain out of proportion to exam

"

Emergent colonoscopy or surgery decompresssion

"

Concern for wall strangulation (like a hernia or


appendicitis) from obstructed venous/arterial flow

45M with nausea & pain

Findings:
# Dilated loops,
Stacking. Notice the
stagnant stool in the
small bowel is starting
to fecalize or become
more solid
# Stomach
dilated. Place an NG
Tube to decompress.
Q: What is going
on in the liver?

A: There is abnormal
air in the liver.

Q: Where is the air?


a.Hepatic veins
vein
b.Portal veins
vein
c.Biliary tree
d.Liver parenchyma

Portal venous gas in the setting of bowel obstruction is concerning


for bowel ischemia and necrosis.

50F with nausea, right upper quadrant


pain

Arrow Key:
Medical
record
number
Technical
Parameters
for image
acquisition
Zone of
optimum
Focus
Depth in cm
From skin
Type of US
probe used
Tech s initials

Skin

Anterior
Liver

Head

Feet

Posterior

Dark shadow behind


objects reflecting US wave
Sagittal

Gallbladder

Same patient. Diagnosis?

Findings
Stones in the gallbladder on ultrasound
" Shadow deep to gallbladder due to lack of
signal from reflected ultrasound waves.
"

Why does it reflect? Stones are dense!

String of pearl appearance of stones on xray


" Note that the laminated appearance of the
stones: peripherally dense and centrally lucent
"

Cholelithiasis
"

If unsure on ultrasound, move the patient to


watch the gallstones fall dependently!

"

Cholelithiasis =/= cholecystitis!


"

Look for fluid around gallbladder, edema in the


wall, dilated biliary tree, stone within the CBD to
diagnosis cholecystitis

73F with bright red blood per rectum,


fever, and abdominal pain

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Findings
No oral contrast within colon lumen
" Pockets of air extending from sigmoid colon
" Peri-colonic fat stranding or inflammation
(water density in the fat around the wall)
" Colon wall inflammation # progressed to a
mural abscess
"

water density in the wall


" thicker size of wall
" Arterial contrast enhancement of wall
"

Diagnosis?

Diverticulitis
Sigmoid colon involved in 95% of cases
" Fecal impaction at diverticula mouth with
subsequent ischemia. Similar mechanism to
appendicitis!
"

Prevent: high fiber diet, less processed foods


Treat amild case: IV fluids, antibiotics, bowel
rest
Treat severe case: Surgical resection

23F with midline abdominal pain

Diagnosis?

Appendicitis Findings
Fluid within the appendix
" Dilated appendix > 7 mm
" Wall thickening or vascular enhancement
" Edema or fat stranding around appendix
" +/- dense appendicolith at mouth of appendix
"

For thin pt, ultrasound may be better than CT!

Appendicitis treatment
IV fluids
" Antibiotics
" Pain management
" Bowel rest
" Surgery if no appendix perforation
"

5. GU & GYN
! Nephrolithiasis
! Intrauterine

and ectopic Pregnancy

34 y/o F, R flank pain

Why are the right kidney


findings present?

What are the Findings?...

US: Right hydronephrosis (large right renal


pelvis w/blunted calyces outlined in yellow;
compare to normal left kidney with bright
echogenic fatty renal hilum but no enlarged
pelvis/calyces, surrounded by the darker
normal renal parenchyma). Also right
hydroureter (lack of color Doppler flow in
large anechoic tubular structure in green #
therefore obstructed dilated ureter, not
vessel)

Reason for the right


hydroureter/
hydronephrosis?
A right 1.7 cm
calculus in the right
mid ureter
Note that renal
pelvises are
approximately at the
L2 level, and course
of ureters project
approximately along
the transverse
processes on XR
(they lie on the
iliopsoas muscles for
much of their course)

Diagnosis?...

Dx: Obstructing right ureteral kidney


stone, with proximal
hydroureteronephrosis

Previous CT Abd/Pelv

Previous CT Abd/Pelv

Pt has h/o right hydroureteronephrosis from stone!


Prior CT abd/pelvis showed obstructing distal stone at
ureterovesicular junction (see how the stone in red is at
the end of the dilated ureter outlined in green), as well as
a larger bladder calculus

Previous CT Abd/Pelv

Note that the renal stone CT protocol is performed in PRONE


position (belly on the table; flipped around here for viewing
convenience), in order to use gravity to better discern the
ureterovesicular junction from the bladder, to distinguish UVJ stone
from bladder stone if needed, as in this case. No contrast given, so
as not to obscure the radiodense stones.

Nephrolithiasis
"
"
"
"

Rate of spontaneous passage indirectly proportional to size (eg, 80% if < 4mm, 50%
if 4-6 mm, 20% > 8mm), often managed accordingly
If obstruction present (hydronephrosis, hydroureter) # affects management
Many types of stones: calcium (oxalate or phosphate, 75-80%), struvite (15-20%),
uric acid, cystine, matrix, xanthine, protease inhibitor-induced
Plain film (XR): misses many
"
"

"

CT: extremely sensitive


"
"

"

"

Radiopaque (visible if large): calcium, struvite or cystine (these two types can be
staghorn calculus that fill the pelvis/calyces to look like staghorns)
Radiolucent: uric acid, xanthine, protease inhibitor
Most stones uniformly dense except matrix and protease inhibitor-induced
If contrast enhanced (I+): could obscure stones. But if urographic phase is done, with
contrast excreted into collecting system, all of the types of stones will be represented by
filling defects in the collecting system
Secondary signs: hydronephrosis, hydroureter; ureteral wall swelling/edema around
stone, perinephric/periureteral stranding of fat (inflammatory changes)

US:
"
"
"

Stones = echogenic bright focus with posterior shadowing (acoustic waves blocked by
stone, unable to travel through to reflect off structures posterior to stone)
Best seen if in kidneys or ureterovesicular junction (UVJ), difficult to see if in ureter
Can see hydronephrosis/ureter, obstruction from potentially a stone (as in our case)

20 y/o F, pregnant, vaginal


bleeding, left adnexal tenderness
Serum beta-HCG of 2300

What are the Findings?...

Complex free fluid in cul-desac, with black anechoic fluid


within which there is
echogenic bright material
(possibly hemorrhage)
No IUP (empty uterus)

Normal left ovary,


with ring-shaped mass just
superior to the left ovary,
That demonstrates a ring of
fire hyperemia of color
Doppler flow

Diagnosis?...

Dx: Suspicious for ruptured left


tubal ectopic pregnancy

Don t forget to always look for fluid in


abdomen too!

In this case, no free fluid seen


in Morrison s pouch between
liver and right kidney

Ectopic pregnancy
"

91% accurately dx d with TVUS + color Doppler


"

"

When no IUP can be confirmed (empty uterus), and serum beta-HCG > 1000-2000
mIU/mL
"
"
"

"

Although 5-10% will be totally normal TVUS, just without IUP visualized
suspicion for ectopic MUST be raised
suspicion increases with adnexal/tubal mass
confirmed if see GS in tube

Other signs
"

Free fluid, especially complex (fluid contains echogenic material/debris, potentially


hemorrhagic from ruptured ectopic, not completely black anechoic simple free fluid)
"
"

"
"
"

Look in cul-de-sac
Look in abdomen, eg, Morrison s pouch # if there, may suggest bad ruptured ectopic with a lot of
hemorrhage

Adnexal/tubal mass/ring separate from ovary # +/- YS, +/- FHR


Ring of fire : tubal mass lights up on color Doppler
Corpus luteum: cystic structure WITHIN ovary that also can demonstrate a ring of fire ,
not to be confused with tubal ectopic ring of fire that is external to ovary
"

However, 85% of ectopics are seen on same side as ovarian corpus luteum!

"

Can use TVUS probe to palpate for area of pain # better localize ectopic

"

Heterotopic pregnancy (IUP AND ectopic at same time) = extremely rare

Normal intrauterine pregnancy (IUP)


"

Look for on transvaginal US (TVUS) [see next slides for example]:


"

Gestational sac (GS)


"

"
"
"

"

"
"

Yolk sac (YS): small ring/sac eccentrically within gestational sac, between
amnion and chorion, confirms IUP, usually at 5.5 wks when GS 5-6 mm,
definitely by GS 8mm (otherwise abnormal)
Fetal pole (embryo)
Fetal heart rate (FHR): should be seen by when fetal pole = 5 mm
"
"

"

Should be ROUND, not flattened/oblong (abnormal; if so, could be pseudogestational sac


such as in ectopic pregnancy, could be abnormal pregnancy and suggest potential for early
fetal demise)
Intradecidual sac sign # 4-4.5 wks post LMP, anechoic sac rimmed by echogenic
endometrium
Double decidual sac sign: 1st reliable sign of IUP, 5-5.5 wks post LMP # two echogenic
rings from endometrium surrounds gest sac
A thick-walled appearance is also typical of the GS

5.5-6.5 wks GA: <100 bpm OK


By 7 wks GA: <85 bpm is abnormal

Perigestational fluid/hemorrhage: identified by rim hypoechoic fluid around


portion of GS, often resolves on its own and is fine
"

if >50% of circumference of GS or misshapen GS, is more worrisome

Normal IUP

Normal IUP

Gestational sac (in yellow) in the uterus (in red)


with yolk sac
And fetal pole (crown-rump length corresponding
to gestational age of 6w 3d, with normal FHR

42+53'$6'7&6+*3$,*7$
(&-8$-(2$'7820'9&7$.&90,$

6. BRAIN AND SPINE


! Normal

Radiographic Anatomy

! Cervical

Spine Fractures
! Lumbar Spine Disc Disease
! Subdural hematoma, epidural hematoma, and
subarachnoid hemorrhage
! Stroke

Normal C spine

C- spine: dens

C spine: Obliques

Alignment

60F after fall

Dens (C2)
Fracture patterns

Type I:

III
II

Stable fracture # immobilize

Type II: Unstable fracture. Most likely to have non-union due to tenuous blood supply.
Type III: Stable # non-union uncommon after bracing.

78M pain after MVC

C2

C2

C4
C4

C6

C6

C-spine fracture Key Points


1. Evaluate alignment of spinal columns
2. Consider MR to evaluate cervical cord or to
better evaluate prevertebral soft tissues
3. Consider CT angiogram if suspect vertebral artery injury

Spine: How to Sound Smart


"

C1- C8 nerve roots exit


above superior endplate of
the corresponding vertebra

"

Cauda equina at T12-L1 so


lumbar disc disease does not
cause cord compression

"

T1- S5 nerve roots exit


below inferior endplate of
the corresponding vertebra

"

Most common disorders:


" Fracture
" Disc disease
" Metastasis
" Infection

Normal L Spine

25F pain

T2

T1

L5
S1

Lumbar disc disease


L4-L5 and L5-S1 most common areas in L-spine
# check the cone-down view!
Fibrocartilage replaces glycosaminoglycans #
decreased water content (dessicated)

LBP

L5
T1 weighted

S1
T1 weighted
Do you recommend surgery?

T2 weighted

Treatment options
"

About 40% of asymptomatic people have disc


bulges

"

~90% treated conservatively: NSAID,


corticosteroid injection, or physical therapy

"

Discectomy if pain intractable, only 75%


success

Part 2: Hemorrhage

What type of bleed?

EDH

SDH

Subdural Hematoma
(SDH)
Typically venous
bridging vein tear in
extra-axial space #
Elderly
Often spontaneous or low
trauma
Crescentic
Small or isodense may be
difficult to see

Epidural Hematoma (EDH) to be addressed later

Superior sagittal sinus

Suture line

Blue line=dura
Subdural hematoma
Can cross suture lines

Will not cross midline or tentorium

(e.g.
coronal)

69F new seizure

What is going on here?


RBC
sediments
with
gravity

Ans: Different densities in left subdural hematoma.


This indicates multiple ages of bleed, ie acute on chronic.

What type of bleed?

Subarachnoid hemorrhage

SAH
"

Can be diffuse or focal

"

Often layers dependently on tentorium or basal


cisterns
Suture line
(e.g. coronal)

"

Common causes: trauma >> aneurysm

"

Beware of vasospasm 7-10 d after bleed

"

May be epileptogenic focus

Elderly, fall down stairs

Intraparenchymal Hemorrhage
Subarachnoid Hemorrhage

What type of bleed?

Epidural Hematoma

EDH
Usually does not cross
falx or tentorium

Suture line
(e.g. coronal)

Epidural Hematoma
Typically arterial
usually middle meningeal
artery AND post traumatic
ie. Younger patient
Most temporal or
temporoparietal lobes
Look for associated
fracture # 85-95%
Lucid interval then rapid
neurologic deterioration

Food for thought:


Why can someone walk around with a large
asymptomatic brain tumor but a relatively small
epidural hematoma is fatal?

Answer:
Tumors relatively chronic allowing the brain to remodel & adjust
EDH is acute giving the brain no time to adapt to mass effect
SYMPTOMS = LOCATION + SIZE + GROWTH RATE

What does this mean?


Swirl Sign:
Hypoattenuating (darker)
area within bleed indicates
non-clotted blood, ie active
bleed
Even EDH with this sign do
not usually grow after being
imaged

85 y/o F, p/w
acute weakness and speech difficulty

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What are the Findings?...


This one is subtle and tough on the
CT, easier on the MRI!

Area of focal white matter


hypodensity on the right side

Hyperdense
linear thrombus in ipsilateral distal
MCA = hyperdense MCA sign

Loss of gray insular cortex, blending in with hypodense


underlying white matter = insular ribbon sign (normal
insula outlined in yellow bilaterally)

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Bright on DWI, dark on ADC =


restricted diffusion ;
Differential for this classically includes CVA

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Gyral swelling, sulcal effacement and


high FLAIR signal from edema in the
CVA region

Diagnosis?...

Dx: Acute Right MCA CVA

Cerebrovascular accident (CVA) aka Stroke


"
"

Classically @ Circle of Willis vascular territories (next slide); occasionally @


watershed zones between territories or scattered multifocal from embolic strokes
CT findings
"

Loss of gray-white matter (GM, WM) differentiation: 1st 3 hours post CVA
"
"

"
"
"

Hyperdense vessel sign: particularly in MCA strokes, asymmetric/unilateral dense


segment of vessel can suggest acute intravascular thrombus
Parenchymal edema # hypodensity, & gyral swelling/sulcal effacement (12-24 hrs post
CVA)
Hemorrhagic transformation can occur (24-48 hours post CVA)
"

"

"

GM cortex, normally denser on CT than WM, often affected by stroke first (higher metabolism than
WM) # becomes edematous, more hypodense # blends in with adjacent underlying white matter
Insular ribbon sign, aka loss of normal insular cortex, suggests stroke: GM insular cortex normally
looks like whiter, wavy ribbon line outlining the underlying WM

Can be related to reperfusion post thrombolysis

CTA can be performed to assess vessels for stenosis/occlusion if MR contraindicated

MRI findings
"
"

Can also see edema changes (swelling & loss of G-WM on T1, high signal on FLAIR &
T2)
Diffusion weighted imaging (DWI) = most sensitive imaging for acute stroke (95%)
"

"

Bright signal on DWI + dark signal on corresponding ADC map = restricted extracellular diffusion of
water protons (eg, from loss of function Na/K ATP pump)

MRI stroke protocol: +MRA (MR angiography) # identify vessel occlusions


"

Time-of-flight MRA can be performed based on flow of protons, WITHOUT needing to use
gadolinium contrast!

Figure 1. Drawings (top) illustrate the territories (blue) of the ACA, middle cerebral artery
(MCA) , and posterior cerebral artery.

de Lucas E M et al. Radiographics 2008;28:1673-1687


2008 by Radiological Society of North America

7. MSK Cases

75 YO M with Hand and Wrist


Pain

Osteoarthritis
(Degenerative Joint Disease)

"

Caused by trauma

(either overt or accumulation of

microtrauma)
"

"

Occurs in any joint but particularly common in


hands, knees, hips and spine
Hallmarks (All must be present or another diagnosis should
be considered)
"
"
"

Joint Space Narrowing


Sclerosis
Osteophytosis

Sclerosis
Osteophytosis

Joint Space Narrowing

45 YO F w/ joint pain and


stiffness in hands

Rheumatoid Arthritis
"

"

"

Connective tissue disorder which may affect any


synovial joint
Classically a bilaterally symmetric process that
involves the proximal joints
Hallmarks:
"
"
"
"

Soft tissue swelling


Osteoporosis
Joint space narrowing
Marginal erosions

RA Continued
"

Large joints
Marked joint space narrowing
" Osteoporosis
"

"

Hands:
Proximal process
" Bilaterally symmetric
" Ulnar subluxation
"

Proximal > Distal

Ulnar Subluxation

ST Swelling and
Ulnar styloid erosion

Osteoporosis

Skin and nail bed changes. Pain


in hands, feet and lower back.

Psoriatic Arthiritis
"

"

"

Seroegative oligoarthritis most commonly


involves the hands followed by feet, SI joints
and spine
Nearly always accompanied by skin disease
and nail bed pitting
Involves the distal joints (DIPs) and is
commonly asymmetric.
"

"

RA more proximal and symmetric.

No Osteoporosis

Imaging Features of Psoriatic


Arthritis
"
"

"
"

Resoption of the distal phanlageal tufts


(acroosteolysis)
Pencil-in-Cup Erosion of the proximal articular
surface to form thin pencil-like bone. Concave
distal articular surface resembles a cup.
Sausage Digit Soft tissue swelling of a single
digit.
Mouse Ears Bone proliferation adjacent to
erosions

Acroosteolysis
Mouse Ears

Sausage Digit

Pencil-in-Cup

30 YO M Slipped and Fell.


Now with Snuff Box pain
and swelling.

Scaphoid Fracture
"

"
"

Common status post fall on outstretch hand


(FOOSH) w/ snuffbox pain and swelling
Most common carpal bone fracture
Difficult to diagnose with radiographs therefore
a negative exam doesn t exclude the diagnosis
"
"

"

May cast patient and bring back in a week


May perform MRI for definitive diagnosis

High rate of avascular necrosis (AVN)


"

May require surgical intervention to avoid AVN

CT of the wrist reveals sclerosis of the proximal


scaphoid indicative of AVN

31 YO M fell on flexed wrist.


Now with tenderness over the
dorsal aspect of the wrist

Triquetral Fracture
"
"

"
"

Often due to forced hyperflexion


Next to scaphoid fractures triquetral fractures
are the second most common fracture of the
carpal bones
Patients often report dorsal hand pain
Small bone chip off the dorsum of the wrist is
virtually pathognomonic for triquetral avulsion
fracture
"

Often associated with perilunate dislocations of the


wrist

Triquetral Avulsion
Fracture

22 YO F fell on outstretched
hand

Colles Fracture
"

"

Caused by a fall on an outstretched hand


(FOOSH)
Fracture of the distal radius and often ulnar
styloid process
"
"

"

Classically a transverse fracture of the radius


Dorsal angulation of the distal forearm and wrist

One of the most common forearm fractures


"

Commonly seen in osteoporosis

Transverse Fracture of
the distal radius

Volar angulation of
the distal fragment

33 YO F w/ Arm Pain

Smith Fracture
(Reverse Colles)

Caused by direct trauma to the dorsal


forearm or falling onto a flexed wrist
" Transverse fracture through the distal
radius
" Distal fracture fragment with volar
angulation
"

20 YO F s/p mild trauma to


left arm

Pathologic Fracture

Unicameral (Simple) bone cyst

"

Unicameral Bone Cyst


"

"
"
"
"

"

Simple fluid filled cysts which are usually


asymptomatic (unless pathologic fx)
Always centrally located
Occur in patients < 30 yrs
Commonly occur in long bones (humerus, femur)
No periostitis (inflammation of the cortex)

Pathologic Fracture: Fx through abnormal


portion of bone such as a UBC
"

Fallen fragment sign: Fractured cortex sinks to the


bottom of the fluid filled cavity (pathognomonic
for UBC pathologic fracture)

Fallen Fragment Sign: Cortical bone


falling to the bottom of the fluid filled
Unicameral Cyst

44 YO M fell on elbow. Now


with pain and swelling.

Elbow Fracture (Olecranon)


"

Evaluate the posterior fat pad


"

"

"

Ordinarily the posterior fat pad is not visible as it is


tucked in the olecranon fossa
In the event of an elbow fx (olecranon, radial head or
supracondylar) the joint becomes filled with blood
which displaces the posterior fat pad superiorly
In the event of trauma, a visible posterior fat pad
indicates fracture
"
"

Adult - radial head fx most common


Child (epiphyses open) - supracondylar fx most common

Radial Head Fx

Elevated Posterior Fat Pad


w/ Olecranon Fx
Elevated Posterior Fat Pad w/
Supracondylar Fx

Supracondylar Fx

18 YO Football Player s/p


tackling another player.
Shoulder now visibly
deformed.

Anterior Shoulder Dislocation


"

"

Significantly more common than posterior


location (96% of shoulder dislocations)
Occurs when the arm is forced into an externally
rotated and abducted position
"

"

"

Commonly occurs in football players who arm


tackle and skiers whose uphill pole gets stuck

Humeral head lies inferiorly and medial to the


glenoid on AP images
Humeral head impacts on the inferior rim of the
glenoid causing a Hill-Sachs deformity (see HillSachs case)

AP View With Anterior Dislocation of


the Humeral Head

Scapular-Y-view w/ anterior dislocation

Coracoid

Acromion
Process
Glenoid

Anterior

AP and Scapular-Y-View Post Reduction

Posterior

38 YO M w/ Recurrent
Shoulder Dislocation

Hill-Sachs Deformity
"

"

Depression fx of the posterolateral surface of the


humeral head
Caused by anterior glenohumeral dislocation
"

"

"

"

Impaction of the humeral head against the glenoid


rim
Best seen on AP projection in internal rotation

Presence of Hill-Sachs may indicate a greater


likelihood of recurrent dislocations
Bony irregularity of the inferior glenoid rim may
also be seen (Bankart Deformity)

External Rotation

Internal Rotation

34 YO M with Stuck
Shoulder post trauma

Posterior Shoulder Dislocation


"

"

"

Significantly less common than Anterior


Shoulder dislocation (2-4%)
Caused by axial loading of an adducted and
internally rotated arm, convulsion disorder or
electroshock therapy
Cresent Sign AP view of a normal shoulder
reveals overlap of the humeral head and
glenoid
"

"

Posterior dislocation results in a loss of the


cresent sign creating an absence of the bony
overlap

light bulb Sign: Humeral head is fixed in


internal rotation

Normal Frontal Radiograph of the


Shoulder with a Crescent Sign

Axillary View

Acromion Process
Reverse Hill-Sachs
Deformity
Glenoid

Absence of Crescent Sign


and Internal Rotation

Coracoid

Two Separate Examples:


Elderly female slip and fell

Proximal Femur Fractures


"
"
"

High mortality (15-20% in 1 year)


Potential for vascular compromise which may
lead to AVN of the hip
Most often occur in the elderly (90%)
"

"
"

Caucasian females w/ osteoporosis

Young patients suffer hip fractures from high


impact/high velocity trauma
Radiographs are the initial study of choice
"

If non-diagnostic, MRI or nuclear medicine scans may


be utilized

Proximal Femur Fractures


"

Classified according to geopgraphy


"
"
"

"

"

Intracapsular vs Extracapsular
Intracapsular: Subcapital, transcervical and basicervical
Extracapsular: Intertrochanteric and subtrochanteric

Intracapsular Fx treated with prosthetic or replacement


device
Extracapsular Fx treated with a compression-type screw,
lateral side-plate or intramedullary nail

Intertrochanteric
fracture pre and post
fixation

Femoral neck fracture


pre and post fixation