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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 withextensive mural

thrombus

"

What imagingmodality would you

order next?





Findings:

"

CTA I- and I+ images

demonstrating:" Abdominal Aortic Aneurism

measuring up to 10 cm,

enlarged

" Extensive mural thrombus

with contrast filled lumen

measuring ~ 2 cm.

" No evidence of dissection

Coronal Maximal Intensity

Projection (MIP) Image in

bone windows



Discussion: AAAGeneral 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 cmin diameter.

" AAA can demonstrate fusiform or saccular morphology.

" Most common site for aortic aneurysm is in the infrarenal aorta, although aneurysm can occu anywherein the aorta.. Extension into the internal iliac artery is not uncommon, however extension into theexternal iliac artery is almost never seen.

" Surgical or endovascular repair is usually recommended for abdominal aortic aneurysm (AAA) > 5.5cm 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 thrombusmay 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 intimalaortic flap extending from proximal ascending

aorta to the right iliac artery (Type A

dissection).



Discussion: Thoracic Aortic Dissection" Definition:

"

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 radiographdemonstrating no acute findings.

"

Clear lungs; no pneumothorax, pleural effusion, pneumonia, or lobar atelectasis. Thecardiomediastinal silhouette is within normal limitsgiven portable technique.

"

Minimally displaced fractures of the left 6th and 7thanterolateral ribs.

" What is your concern at this time? What is your nextimaging 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 RVenlarges)

" 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 inthe 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, inthe 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

Pneumothorax (air in

pleural space)

Hyperinflation of lungs – pt

has emphysema with bullae



After chest tube placement

chest tube Diaphragmatic flattening & barrel

chest consistent with emphysema

N t D



Chest tube failureresulting in subcutaneous

emphysema

And persisting

pneumothorax

Next Day



Residual pneumothorax

Subcutaneous

emphysema

Bulla in the right lower

lobe – potential forrupture and right-sided

pneumothorax

Chest tube



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

Right middle lobe collapse

Minor fissure

Inferior/anterior portion

of major fissure



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

endotracheal

tube



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

lung should re-aerate with time

ETT



Congestive Heart Failure (CHF)

d h l b



CHF – low cardiac output results in blood backup in

pulmonary vessels and fluid leak from capillaries - wet

lungs

Endotracheal tube

(ETT) terminates

above carina

R subclavian

central line ends

in SVC

batwing appearance in CHF



Volume overload in CHF in this case results in:

Batwing appearance

Indistinct pulmonary vessels

Fluid in minor fissure on the right

Aortic balloon pump used in

hemodynamic

instability

8 f d i



78M found unresponsive

Bilateral pleural effusions on portable film – the fluid layers

posteriorly when the patient lies in bed with head raised 30°

BTW: Enteric tube should go into stomach

and not stop in throat – advance or pull!



Common tubes and lines and their

expected locations



29 year-old man

PICC (peripherally-inserted central catheter)

Terminates in superior vena cava

62M h k l li l



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



60M

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)

ETT ends above carina

R f h k D bh ff t b l t



Reason for exam: check Dobhoff tube placement

Dobhoff tube enters right-

sided bronchus

Dobhoff tube enters left-

sided bronchus

Dobhoff tubes are used for tube feeds – you want the liquid

to go in the stomach, not the lungs…

2nd try1st try

83M i ICU / VFIB d it ti



83M in ICU s/p VFIB and resuscitation

Endotracheal

tube

Enteric tube

Right internal

jugular centralline ends in

SVC

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?

!"# %&'(





DCIS

" Atypical ductal epithelial cells thought to

represent the earliest form of breast cancer.

" Most common presentation ismicrocalcifications as seen as previous

mammogram.

" Typically treated with lumpectomy/breastconserving 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 pulmonarynodule in the right upper lobe.

No lymphadenopathy is

identified.

Recommend contrast enhancedchest 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?

Fi di



Findings:

There is a 2.5 cm nodularopacity 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 lateralcostophrenic 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?





Pneumonia

" On CXR, often seen as a focal parenchymalabnormality in a patient with fever.

" Differential includes atelectasis, edema, andhemorrhage.

" In patients with lobar pneumonia, followup can be obtained in 6 weeks to ensure resolution. Ifnot resolved, a CT can be obtained to rule outobstructing 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 thickeningcreating an apple core apperance or lumenal

filling defect – can cause obstruction



2011 Estimated US Cancer Cases(excluding basal cell & squamous cell skin carcinoma)



(excluding basal cell & squamous cell skin carcinoma)





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 contrastexposure to patient while pinpointing the exact bleeding site.

Nuclear medicine GI Bleeding Scan



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 bleedingsites 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



Nuclear Medicine GI Bleeding Scan

" Draw patients blood and label w/ radioactivetracer (at BMC it is Technetium 99m) thenreinject.

"

Each frame in the scan = 1 minute of recordedactivity

" Uses a gamma camera which detectscontinuous radiation



Positive GI Bleeding Scans

1. Abnormal hot spot of radiotracer activity appearsout 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 patient’s Tc 99m RBC Bleeding Scan



Our patient s Tc 99m RBC Bleeding Scan

Time = 0 min

47 min

Liver Aorta

Common iliac a

Bladder



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)





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 orappendicitis) 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 vein

b. Portal vein

c. Biliary tree

d. Liver parenchyma

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 concerningfor bowel ischemia and necrosis.







Skin

Liver

Sagittal

Head

Posterior

Feet

Anterior

Gallbladder

Dark shadow behindobjects reflecting US wave

Same patient. Diagnosis?



p g



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 thestones: peripherally dense and centrally lucent





73F with bright red blood per rectum,

fever, and abdominal pain

Scroll Through at the workstation1/10






























Findings



Findings

" No oral contrast within colon lumen

" Pockets of air extending from sigmoid colon

"

Peri-colonic fatstranding

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?





23F with midline abdominal pain

Diagnosis?



Diagnosis?



A di iti t t t



Appendicitis treatment

" IV fluids

" Antibiotics

" Pain management" Bowel rest

" Surgery if no appendix perforation

5. GU & GYN



! Nephrolithiasis

! Intrauterine and ectopic Pregnancy





Why are the right kidneyfindings 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 righthydroureter/

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 alongthe transverse

processes on XR

(they lie on the

iliopsoas muscles for

much of their course)





Dx: Obstructing right ureteral kidney

stone, with proximal

hydroureteronephrosis

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




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.












Complex free fluid in cul-de-

sac, 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 colorDoppler flow



… Diagnosis?...



Dx: Suspicious for ruptured left

tubal ectopic pregnancy

Dont forget to always look for fluid in



abdomen too!

In this case, no free fluid seen

in Morrisons pouch between

liver and right kidney

Ectopic pregnancy



" 91% accurately dxd with TVUS + color Doppler

" Although 5-10% will be totally normal TVUS, just without IUP visualized

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

mIU/mL"

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, Morrisons pouch# if there, may suggest bad ruptured ectopic with a lot ofhemorrhage

" 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)



Normal intrauterine pregnancy (IUP)" Look for on transvaginal US (TVUS) [see next slides for example]:

" Gestational sac (GS)

"

Should be ROUND, not flattened/oblong (abnormal; if so, could be pseudogestational sacsuch as in ectopic pregnancy, could be abnormal pregnancy and suggest potential for earlyfetal demise)

"

Intradecidual sac sign# 4-4.5 wks post LMP, anechoic sac rimmed by echogenicendometrium

"

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

" 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

" 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



42+53' 6'7&6+*3 ,*7

(&-8 -(2 '7820'9&7 .&90,

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



6. BRAIN AND SPINE

! Normal Radiographic Anatomy

! Cervical Spine Fractures

! Lumbar Spine Disc Disease

! Subdural hematoma, epidural hematoma, andsubarachnoid hemorrhage

! Stroke

Normal C spine



C- spine: dens



C spine: Obliques



Alignment



60F after fall





78M pain after MVC



C2

C4

C6

C2

C4

C6

C i f K P i



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



p

"

C1- C8 nerve roots exit

above superior endplate of

the corresponding vertebra

"

T1- S5 nerve roots exit

below inferior endplate of

the corresponding vertebra

"

Cauda equina at T12-L1 so

lumbar disc disease does not

cause cord compression

"

Most common disorders:

"

Fracture

" Disc disease

" Metastasis

"

Infection

Normal L Spine



25F pain



T2 T1



S1

L5

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



T1 weighted

L5

S1

Do you recommend surgery?

T1 weighted 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?

Subdural Hematoma



EDHSDH

(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



Blue line=dura

Suture line

(e.g.

coronal)

Subdural hematoma

Can cross suture lines

Will not cross midline or tentorium

69F new seizure



What is going on here?RBCsediments

with



Ans: Different densities in left subdural hematoma.

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

with

gravity

What type of bleed?



Subarachnoid hemorrhage

SAH"

Can be diffuse or focal



Suture line

(e.g. coronal)

"

Often layers dependently on tentorium or basal

cisterns

" 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



Suture line

(e.g. coronal)

Usually does not cross

falx or tentorium

Epidural Hematoma



Typically arterial –

usually middle meningealartery AND post traumatic

ie. Younger patient

Most temporal ortemporoparietal lobes

Look for associated

fracture# 85-95%

Lucid interval then rapid

neurologic deterioration

Food for thought:



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





4:; "4< =/";>




This one is subtle and tough on the

CT, easier on the MRI!





4:; "4< =/";>

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



… 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

" GM cortex, normally denser on CT than WM, often affected by stroke first (higher metabolism thanWM)# 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 normallylooks like whiter, wavy ribbon line outlining the underlying WM

" 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)" 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 ofwater 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

adolinium 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





75 YO M with Hand and WristPain



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

OsteophytosisJoint Space Narrowing





Rheumatoid Arthritis



" Connective tissue disorder which may affect anysynovial 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



ST Swelling andUlnar styloid erosion

Ulnar Subluxation

Osteoporosis

Proximal > Distal





Psoriatic Arthiritis



"

Seroegative oligoarthritis most commonlyinvolves the hands followed by feet, SI jointsand spine

" Nearly always accompanied by skin disease

and nail bed pitting"

Involves the distal joints (DIPs) and iscommonly 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 articularsurface to form thin pencil-like bone. Concave

distal articular surface resembles a cup."

Sausage Digit Soft tissue swelling of a singledigit.

" Mouse Ears Bone proliferation adjacent to

erosions

Acroosteolysis



Pencil-in-Cup

Sausage Digit

Mouse Ears



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 thereforea negative exam doesnt 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 fracturesare the second most common fracture of the

carpal bones"

Patients often report dorsal hand pain

" Small bone chip off the dorsum of the wrist isvirtually pathognomonic for triquetral avulsion

fracture" Often associated with perilunate dislocations of the

wrist

Triquetral Avulsion



Triquetral Avulsion

Fracture



22 YO F fell on outstretchedhand



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



Volar angulation ofthe distal fragmentTransverse Fracture of

the distal radius



33 YO F w/ Arm Pain



Smith Fracture(Reverse Colles)



"

Caused by direct trauma to the dorsalforearm or falling onto a flexed wrist

"

Transverse fracture through the distalradius

"

Distal fracture fragment with volarangulation



20 YO F s/p mild trauma toleft arm



Pathologic FractureUnicameral (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 (pathognomonicfor UBC pathologic fracture)



Fallen Fragment Sign: Cortical bonefalling to the bottom of the fluid filled

Unicameral Cyst



44 YO M fell on elbow. Nowwith 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 bloodwhich displaces the posterior fat pad superiorly

" In the event of trauma, a visible posterior fat padindicates fracture"

Adult - radial head fx most common"

Child (epiphyses open) - supracondylar fx most common



Elevated Posterior Fat Pad w/Supracondylar Fx

Elevated Posterior Fat Padw/ Olecranon Fx

Radial Head Fx

Supracondylar Fx



18 YO Football Player s/ptackling another player.Shoulder now visibly

deformed.



Anterior Shoulder Dislocation



" Significantly more common than posteriorlocation (96% of shoulder dislocations)

" Occurs when the arm is forced into an externallyrotated 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 theglenoid on AP images

" Humeral head impacts on the inferior rim of theglenoid causing a Hill-Sachs deformity (see Hill-Sachs case)





38 YO M w/ RecurrentShoulder Dislocation



Hill-Sachs Deformity



" Depression fx of the posterolateral surface of thehumeral head

" Caused by anterior glenohumeral dislocation "

Impaction of the humeral head against the glenoidrim

" Best seen on AP projection in internal rotation

" Presence of Hill-Sachs may indicate a greaterlikelihood of recurrent dislocations

" Bony irregularity of the inferior glenoid rim mayalso be seen (Bankart Deformity)

External Rotation Internal Rotation





34 YO M with StuckShoulder 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 orelectroshock therapy

"

Cresent Sign AP view of a normal shoulderreveals overlap of the humeral head andglenoid" Posterior dislocation results in a loss of thecresent sign

creating an absence of the bonyoverlap

" light bulb Sign: Humeral head is fixed ininternal rotation



Normal Frontal Radiograph of theShoulder with a Crescent Sign





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 maybe utilized



Intertrochantericfracture pre and post

fixation

Femoral neck fracturepre and post fixation



Documents

requireRequired Diagnoses