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Required Diagnoses Image


! 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).

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


CTA I- and I+ images




Coronal Maximal Intensity

Projection (MIP) Image in
bone windows

Abdominal Aortic Aneurism

measuring up to 10 cm,
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.
" 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?


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

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






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?


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
" 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

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
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
" 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.

! Pneumothorax
! Lung

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


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

And persisting

Chest tube

Bulla in the right lower

lobe potential for
rupture and right-sided

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


Right mainstem bronchus intubation with left lung

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


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

Aortic balloon
pump used in

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)

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

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


Enteric tube

CHF volume overload: fullness of right hilum, left pleural

effusion, indistinct pulmonary vasculature


! Breast

! Lung cancer, pulmonary nodules
! Pleural effusion
! Pneumonia

45 year old female with palpable

breast lump.


What is the salient finding?

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

Diagnosis: DCIS (ductal

carcinoma in situ)

Atypical ductal epithelial cells thought to
represent the earliest form of breast cancer.
" Most common presentation is
microcalcifications as seen as previous
" 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


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

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
" Generally any nodule greater than 4mm is
followed based on the Fleishner criteria
" Nodules greater than 8mm require more
rigorous followup.

How would you describe the findings on this image?

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

65 year old male with shortness

of breath.

How would you describe the salient 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?

There is a lobar consolidation in
the left lower lobe.

On CXR, often seen as a focal parenchymal
abnormality in a patient with fever.
" Differential includes atelectasis, edema, and
" 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.

! Small

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

52M with abdominal distension


#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
" Causes

Adhesions 60%
Hernia 15%
Tumor 15%

69F with abdominal distension and


Best clue to diagnosis: a short segment of colon
wall thickening
Early cancer # irregular polyp or sessile
" 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%
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

" 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.
" 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


Each frame in the scan = 1 minute of recorded



Uses a gamma camera which detects

continuous radiation

Positive GI Bleeding Scans


Abnormal hot spot of radiotracer activity appears out of

nowhere as it enters the bowel lumen.


Activity must persist and may increase over time.


Activity must move with peristalsis anterograde,

retrograde, or in both directions.

Our patients Tc 99m RBC Bleeding Scan

Time = 0 min$



Common iliac a


47 min


Right upper quadrant bleed following the

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


Notice how many minutes it takes for the

tagged blood to travel in the colon.

84M with abdominal distension and




1. Air fluid levels from bowel stasis

2. Dilated haustra & colon (>9 cm)


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

# 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
b.Portal veins
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


Arrow Key:
for image
Zone of
Depth in cm
From skin
Type of US
probe used
Tech s initials






Dark shadow behind

objects reflecting US wave


Same patient. Diagnosis?

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


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

Scroll Through at the workstation


Scroll Through at the workstation


Scroll Through at the workstation


Scroll Through at the workstation


Scroll Through at the workstation


Scroll Through at the workstation


Scroll Through at the workstation


Scroll Through at the workstation


Scroll Through at the workstation


Scroll Through at the workstation


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


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

Prevent: high fiber diet, less processed foods

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

23F with midline abdominal pain


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

Reason for the right

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)


Dx: Obstructing right ureteral kidney

stone, with proximal

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.


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)


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


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


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

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
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



! 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


60F after fall

Dens (C2)
Fracture patterns

Type I:


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






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




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)


T1 weighted

T1 weighted
Do you recommend surgery?

T2 weighted

Treatment options

About 40% of asymptomatic people have disc



~90% treated conservatively: NSAID,

corticosteroid injection, or physical therapy


Discectomy if pain intractable, only 75%


Part 2: Hemorrhage

What type of bleed?



Subdural Hematoma
Typically venous
bridging vein tear in
extra-axial space #
Often spontaneous or low
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


69F new seizure

What is going on here?


Ans: Different densities in left subdural hematoma.

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

What type of bleed?

Subarachnoid hemorrhage


Can be diffuse or focal


Often layers dependently on tentorium or basal

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

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?

Tumors relatively chronic allowing the brain to remodel & adjust
EDH is acute giving the brain no time to adapt to mass effect

What does this mean?

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

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




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

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)



Bright on DWI, dark on ADC =

restricted diffusion ;
Differential for this classically includes CVA


Gyral swelling, sulcal effacement and

high FLAIR signal from edema in the
CVA region


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
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 &
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


(Degenerative Joint Disease)


Caused by trauma

(either overt or accumulation of



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



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

Soft tissue swelling

Joint space narrowing
Marginal erosions

RA Continued

Large joints
Marked joint space narrowing
" Osteoporosis


Proximal process
" Bilaterally symmetric
" Ulnar subluxation

Proximal > Distal

Ulnar Subluxation

ST Swelling and
Ulnar styloid erosion


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



Resoption of the distal phanlageal tufts

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
Mouse Ears Bone proliferation adjacent to

Mouse Ears

Sausage Digit


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

Often associated with perilunate dislocations of the


Triquetral Avulsion

22 YO F fell on outstretched

Colles Fracture


Caused by a fall on an outstretched hand

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
" Distal fracture fragment with volar

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

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




AP and Scapular-Y-View Post Reduction


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

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


Posterior dislocation results in a loss of the

cresent sign creating an absence of the bony

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

Absence of Crescent Sign

and Internal Rotation


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

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

fracture pre and post

Femoral neck fracture

pre and post fixation