APID
REVIEW
SHAHID HUSSAIN SHERIF A. A . LATIF ADR IAN D . HALL
Rapid Review of
Radiology Shahid Hussain MA, MB, BChir, MRCP, FRCR Consultant Radiologist Heart o f Eng land N HS Foundation Trust, Birming ham) UK
Sherif Aaron Abdel Latif MB , ChB, MRCS, FRCR Consul tant 1~1d i ologist Dudley Group of Hospitals NHS Foundatio n Trust, West Midlands, UK
Adrian David Hall MB , ChB , MRCP, FRCR Consultant Radiologist Dudley Group of H ospitals NHS Foundation Trust, West Midlands, UK
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"'f';ssible. Radiological atlases and film libraries provide ready access ro many of these classic cases, which can then be committed to memory. You can prepare a ready-made description of these cases for rhe viva. Ifro\! arc sure of the diagnosis, dispatch the film promptly with your preprepared 'speech' so that you can progress to the next case as soon as possible. Of course there may be 'Aunt Minnie' cases that yO ll haven't secn and rhis may present a problem, Such cases arc often not amenable to working out the diagnosis - you either know it or you don't . The o nly thing ro do is be methodical in your analysis and description of the findings so that at the very least you can suggest whether you feci an abnormality is li kely 10 be lo ngstanding and benign or orhenvise, and make appropriate suggestions on how you would proceed.
The 'test of observation' H ere, there is an abnormality prescnt that once seen, may wclllcad to an easy d iagnosis. The abnormality is subtle or hidden however, such that it tests the candidate's perception and approach [Q a case. Perceptual abi lity, however, is variable, not only between people bur also in the same obscn'er on diflcrcllt days (this is particularly [rue in examinat:ions where anxiety levels arc high). You must therefore be systematic in analysing each film if there is no ob\'io us abnormality [ 0 sec on firsr inspection. There arc mallYdiflerent s}'srcmatic approaches and it is beyond [he scope of this discussion to be morc prescriptive. Howcver, make sure you haye a system and usc it. Moreover, describe the process you are going through aloud in the viva so that the examiner knows that you arc practising safe radiology.
The 'jigsaw puzzle' This type of case presents several findings that once identified and considered together, lead to a specific or differential diagnosis. This nOt only tCSts perceptual skill and systematic approach, but also the ability ro mentally 'cross-reference' se\'eral diflcrential diagnosis lists for the various abnormalities identified , to find thc 'best fit' diagnosis. Whenever producing a differential diagnosis in an examination or real life, it is \'ital to produce a sensible list, not just a recital oflong lists learnt from books. To do this, you must use all clues available from the clinical histOry and film, and combine this information with knowled ge of the incidence of each possibility in a given patient population.
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Answer 38
Abdominal Imaging
ANSWER 38 Observations 138a)
Practical tips
Single AP image from a double cammst barium swallow examination shows a short, smoothly i.lpcrcd narrowing in rhe lower ocsophf small bowcl obstruction, pneumobilia and ectopic gallstOnes. Oncn, however, the gallstone is nor seen on plain film since rhe stoncs frequently have a predominant composition of cholcsterol with little
78
calcilication. An axial CT scan of the abdomen (41 e conlimled a gallstone ilcus \\;th a 5 em diameter laminated gallstone found in the distal ileum. The bowel was collapsed disral to rhe site of stone impaClion. At laparotomy, the stonc was milked back to thc jcjunum and rcmo\·cd.
Practical tips Always check for air in the biliary tree on the small bowd obstruction :lbdominal film . • Tilly loculcs of air in the biliary tree tend to be ccntl':llly located in the li\'(r (4Id ) compared with porral \'ein gas, which is seen in the periphery. • Bili::!')' tree gas can also be seen as a normal finding in paticlll~ who hal'l.: had a previous sphincterotomy or [allowing a recent ERe I' (end oscopic rctrogrndc cholangiopancrcatography),
Further management 1\ lcchanic;rl Sl11all bowel obstruclion is a sm gic&.. emergency.
Further reading Gurlcrik G, Gurlcyik E (2001 ). GallstOne ilclls: demographic and clinical criteria sllpponing preopcrati\'e diagnosis. UJI/S TrnJ'lIIn Derg 7 ( 1): 32- 34. Pangan JC, Estrada R, Rosales R ( 1984). Cholecystoduodenocolic fistula with recurrent gallstone ilcus. ArciJjJ'eJo/Surgery 11 9: 1201 - 1203.
Abdominal Imaging
Cases 42, 43
ry n;:ar-old male is admitted with -encephalopathy.
- SE43 ory llymptomatic 22 -),c;1r-old male nrcd w ith deTerioraTin g renal :rion
79
Answers 42, 43
Abdominal Imaging
ANSWER 42 Observations 142) Image from a double contrast barium meal examination shows multiple serpiginous filling defects in the lower oesophagus. Normal appearances of the g,tstric nmdus arc observed. Appcar:lllccs arc consistent with oesophageal varices and the distribution suggests that these arc 'uphill'. Diagnosis
to IVC/hcp;uic vein/splenic vein thrombosis or obstruction. Downhill \'ariccs (found in the mid and uppe r oesophagus); these arc characterized by coll:ncral blood flow from the SVC \'ia the :azygous vein into the IVe, and arise due to SVC obstruction from conditions such as IUllg tumour, lymphoma and rc[rasternal goi tre.
Ocsoph:agcal varices.
Differential diagnosis Fo r ocsophagcal ,·ariees: • Varicoid carcinoma of oesophagus. For gastric variccs (i.c. CJUSCS of thickened gastric folds): • Hypenrophie gastritis. Mcnctrier'sdiseasc. • Lymphoma. • Splenic \'cin thrombosis,
Discussion Oesophageal ,'a rices ha,'e a ,'cry typical appearancc o n contr;lst sw:tllow examination of dilated, smooth, se rpiginous filling defects. Varices collapse in the creer position and are beSt imaged with the patient pronto Thcre arc two types: • Uphill "arices (found in the lower oesophagus); these are charanerizcd by collatcral blood flow from the portal vein vb the azygous "ein to the superior \"ena cava (SVC ). These arise due to liver cirrhosis and duc
Gastric varices arc secn in combination with oesophageal "arices in patients with portal hypertension. When seen.tn the absence of oesophageal "arices, splenic vein thrombosis should be suspected. Again, appearances arc of smooth. serpiginous or grape -like filling defects; most commonl~ seen in the gastric fundus.
Practical tips Best images arc obtained with thc patient in a prone position, Further investigation with an ultrasound of the abdomen should be advised to look for cirrhosis and portal hypcrtension.
Further management Treatment is aimed at controlling poml hrpcrtension \Vim medical and surgical (transjugular intrahcp:ttic ponosy~temic shunt - T IPS) means. Treatment of bleeding ":trices and preemptive treatment of non bleeding varices is achie,-cd with endoscopic banding and sclerotherapy.
ANSWER 43 Observations (43) This pl:lin abdominal radiograph shows multiple small foci of calcification over both renal areas in thc region of the rCIl:J1 medulla rather than ren:J1 cort·ex. No stones arc seen elsewhere along the course of the renal tracrs.
Renal papill:t!), necrosis. Hypelyir:Jminosis D, Milk-alkali syndrome, M:Jlignancy - bone metastases, multiple myeloma, p:trnneopiastic syndrome. Primary hypcroxaluria,
Diagnosis Rell:J1 medullary llephrocalcinosis.
Discussion Mcdullary nephroc:Jlcinosis represcnrs calcific:Jrion in the distal con\'oluted tubules, i.e. in the renal pyramids, There arc m:Jny causcs :tnd the underlying pathology can rarely be determined on a plain rndiograph - clinical history is fur more important here. Tlte C:JlISCS arc: Renal tubular :Jcidosis ( RTA ), Endocrine causes - hyperparathyroidism, hyperthyroidism, C ushing's. Medulla!)· sponge k.idne~' . Idiopathic hypercalcuna,
80
Practi cal tips • The most common causcs of symmetrical medullary nephrocalcinosis are hyperparathyroidism and RTl'.. • T he most common cause of asymmetrical medullary nephrocalci nosis is medulla!)' sponge kidney".
Furth er manage ment Underlying causc must be identified - particubrly tre:ttJbk Furth er readi ng Dyer RB, Chen MY, Zagona RJ ( 1998 ). Abnorm:tl calcifications in the urina!)' trnct. RadioGraphies 18: 1405~ 1 424.
Abdominal Imaging
Cases 44, 45
E 45 ry ·n=Jr-old male presented with dial bloating.
81
Answers 44, 45
Abdominal Imaging
ANSWER 44 Observations (44) This is a single A I' image from a double contrast small bowel barium examination. T here is focal, eccentric n:lrrowing of the second part of the duodenum, with predominant notching of rhe latc",! wall. Appearances of the duodell um superior and inferior to this arc completely normal.
Clinical presentation can be with: • Pol)'hydramnios - i'l utero. • Persistent vomiting, "double bubble' - in neonates. • :-J:lUsca ~ ,'omiting and abdominal pain - in adults. The condition is complicated by 311 increased incidence 01 acute and chronic p3ncreatitis 3nd periampullary I"P';; ' J ulcer.
Diagnosis Practical tips
Ann ular pancreas.
Differential diagnosis For 3.nnubr pancreas: • Sphincter orOddi oedema (secondary to impacted none or pallcrc3tilis)/carcinoma - usually produces an eccentric lesion but this is prcdominantl~' medially located. • Duodenal ade nocarcinoma - usually presems with an annular concemric Il!cia., skin
piglllcOI'3.tion and nail atrophy.
Practical t ips • Images should oc carefull y inspected for a coexist colo nic tumour as well as cxtr:acolonic malignan . Intussusceprion in adu lts indicates an underhing. bowel pathology, whereas in children if can be idiopathic.
Furth er management Surgical refe rral is required for prophylactic cokcr is referr.tl for genetic screening of rclati\·es.
Further reading Galiatsatos P, Foulkes WD (2 006 ). Familial adcnOmatOllS polyposis. AmeriCfm jOllrnnl of
Gnstrotllurology 101 (2): 385-398.
Abdominal Imaging
Cases 50, 51
91
Answe rs 50, 51
Abdominal Imaging
ANSWER 50 Observations (50a)
Practical tips
This single TI weighted coronal image shows a striking reduction in signal intensity throughout the H"cr parenchyma. This is likely 10 indicate iron overload. II is notable that the spkcn re tains normal signal intensity so the li\'(:r abnonm.li[~' is most likely due to hacmochromatosis.
l\'l ultiplc transfusions for chronic haematological disordCG C:lnlead to iron overload, i.e. transfusion siderosis. j\IRJ wi ll show hypointensity in the liver find spleen in t condition. This helps diflerenti:lle it from haemo. eh romatosis where the spleen shows normal signal M IU.
Diagnosis
Further management
i-Iacmochromarosis.
In thc course offollow-up, ultl'J.sound monitoring may useful due to [he high risk of dC\'cloping cirrhosis hepatocellularcarcin0111a.
Discussion Pri mary hacmochrOlTl3[Qsis is an aurosomal recessive
condition characterized by increased absorption and ckposition of iro n within several organs illCluding [iva, pancreas, heart and pituitary gland. Patients arc usuall)' lsymptom:ttic until the 2nd dCC3dc, then they present with a varied clinical picture due [0 iron deposition in: • Skin - h)'PCrpiglllcllt:ttion. • U\'er - cirrhosis. lu:p:uomegaly. l)allcrc3S - diabetes. Heart - arrhythmias. dilated cardiomyopathy. Ml1sculoskclet31 - arthralgi:t. Pituira.ry - piruir-J.ry r.,ildrc with signs of impotence, tesf~eular atrophr. hair loss. Radiologically, imaging of the abdomen shows marked abllormality oCthe livcr. Accumulation of iron rcsults in the liver being of ditl'usel)' reduced signal on ;vIRl. The degree of iron deposition has been shown to correlate with the l\oIlU appearances. Uncnh:lIlced CT of the li\'cr demonstrates increascd :lUenuation (>75 HU). Follow-up in these patients is important due to the hepatic complication" of cirrhosis :tnd the ;nc.rc;eed risk. Oh hepatocellular carcinoma. Art.hropatAy of haemochromatosis is similar to that of calcium pyrophosphate deposition disease. Chondr~ calcinosis is a tcamre. T}VicaJl)', appearances arc of squaring of the mctacarpal he.lds due TO flatTening and peripheral small, hook-like SpUTS ( SOb ). Osteopenia is also common.
SOb Radiograph of both hands shows fl atteni ng of the 2nd and 3rd metacarpal heads w ith loss of joint space, giving a squared appea rance. Early spur formation is seen on the lateral aspect of th e 2nd metacarpal of left hand.
ANSWER 51 Observations (51 a, 51b)
Discussion
1111:1ges arc control and delayed prone abdo minal radiogra phs fro111 an [VU series. The control fi lm shows mediall y located appearance ofbolh kidneys and although the superior poles of both arc identifiable, inft:rior poles are not. The delayed IVU image (S ib) shows Illedial location of the pell'icalyeeal systems, which are anteriorly orientated. No filling defects arc identified.
This is the most COlllmon fusion abnormality of kidneys. It is 1110re cOIll111only found in male patients has an incidence of I in 300. The kidneys arc joined tht:ir lower poles in 90% of Ca$CS, by a parcnehymal/fi isthmus band ( S I c). The long axis of the k i dn~ medially oricntated with anterior rotation, such th.;n renal pclvisesi are anteriorly located. Thc condiri complicated by urinar), stasis with renal stone fornua. infection and reflux . Vesieoureteric reflux hydronephrosis sd:ondary to ureteropelvic jlln obstruction arc common. There is :I reported incrc~
Di agnosis H orseshoe kidney,
92
Abdominal Imaging
Case 52
enec of rCIl::ai adenocarcinoma, transitional cell m~
and Wilms' rumour. In :I.ddition the kidnc" is
cptib1c to injury following abdominal traUffi3. oc kidney is associated with: ourin:u)' ab'normaJitics: hypospadia, hidism, urctcr,ll duplication, bicornuate 'Jscular abnormalities .
. al tips .an IVU, check for filling defeCTs, which could nt
a retl;11 calculus or transitional cell
51c Axial CT image demonstrates the horseshoe kidney with a narrow isthmus of tissue extending anterior to the aorta and IVC.
-
~·old
male willI weight loss.
93
Answer 52
Abdominal Imaging
ANSWER 52 Observations (S2a)
Practical tips
Single AI' radiograph of the abdomen shows a metallic
• As with all radiographs that show e\'ide nce of likely primal)' malignancy. o nce this has been noted, look carefull y for metastatic disease elsewhere on the film , • Classicall~', coloreetal cancers metastasize to the li\'er due [0 the ,"enous drainage of bowel l"ia the portal \'enous system. Howe\,er, the \'enOliS drainage of therectum interfuces with the systemic ve nous drainage- . the 3nal canal and thus pulmona ry metastases are said 10 be more likely in rectal cancer than other colonic tumours. In reality, pullnonal)' metastases arc nOt :m uncommon finding in colon or rectal cancer.
stem within the (cmtal pel\'is, which presumably lies inlhc rectum or distal sigmoid colon. [t is likely thaI Ihis stent has been inserted to rdicve symptolllS from a (olarectal
1'lI1l1our. The rest of the bowd gas pattern is unremarkable wi t h no ("vidence of obslnlction. There arc, however, amorpholls, poorly marginated areas of calcification seen in the region of the liver and thc.:sc likely rcpn:scm calcified liver Illct:mascs. Ultrasound or cr
should be undcrt3kcn, and a contrast cnl13nccd CT (52b) of this patient docs confirm the presence of calcified liver
Further management Diagnosis Stcntcd rcct:l[ tumour with calcified liver mctast:tscs.
Differential diagnosis For calcified [h'cr mctast:J.scs: Mucinous adenocarcinomas - colon, rectum , ovarian, brc:l5[ and s[Omach. Osteosarcoma. Endocrine pancreatic carcinoma. Med ullal)' carcinoma ofthr ro id . LUllgcancer.
Discussion Colorcct:ll carcinoma is the third most COlllmon cancer diagnosed in the de"eloped world. Rectum and sigmoid arc the most common sites of1csio ns. When' surgical resection is not possible or appropriate, stems can provide symptomatic relief and prel'ent obstruction. The liver is the most common site for metastatic spread after regional lymph nodes,
T Ni\'1 ( tumour- node- metas tases) staging lllust be accomplished as lor most tumours. Tumour staging rectal cancer is done with MR.I (52c ) (along with loc.ll nod al staging). The primary reason for MRl is ro as proximity of nUllour to the llle$Oreetal fuscia - this is thr. plane along which the surgeon dissects in a [ot"J.imcsorc excision (TME ) procedure. This boundary is rhus referm. 10 as the eireumfercmial resection margin (CRM ), Ifloc.. tumour spread extends close to it, the surgical margin Il\.Io well be contaminated with tumour with the attendant . oflocal recurrence. ldentif)'ing patients where the CR.:\! threatened in this way means they can be selected preoperati\'e radiotherapy or chemotherapy to reduce r risk. Distal nodal disease and metastases can be ass!: with CT or MRI but if the chest is also to be imaged exclude pulmonary metastases, CT is required for 1 component at least.
52c Thin se~tion T2 weighted image shows a circumferential rectallumour with wall breach at the left anterolateral wall (12-2 o'clock) consistent with this being a T3 tumour.
94
Abdominal Imaging
Case 53
SE 53 c ry 35-year-old fe male presented \\~th inal pain and per rectal bleeding .3 months.
95
Answer 53
Abdominal Imaging
ANSWER 53 Observations (53a, 53b) Plain abdominal film of adult patielll shows marked wall
thickening of the transverse colon wi th thlllllb-printing. The sigmoid loops show no such abnormalities and the rc(mlll contains fucccs. The double contr:lSt b:lIium enema film confirms extensive mucosal ulccrmion and a somewhat cobblestone "pp·caranee rhat extends from caecum 10 the descending colon. The colon distal to this is 1l0fllllL The appearances :Ire in keeping with colitis, and sparing the
or
more distal colon makes Crohn's disease morc likely than ulcerative colilis. It is not:lblc that the sacroiliac joints arc normal.
Diagnosis Crohn'sdiscasc.
Differential diagnosis For [emlina] ileal disease: • TB - uSlIllly has morc severe il\\'olvement of the caecum ( 53c). Thnc is oHen evidence of pulmonary TB. Radiation ileitis. Ycrsinia .
53c T8 can also affect the bowel and appearances can mimic those of Crohn's disease. Caecal involvement w ith features of strictu ring and ulceration is more common than terminal ileal involvement.
96
For thumb·printing: • Inflammatol)' colitis - Crohn's, uJccl""Jtive colitis ( UC). Ischaemiccolitis. Infectious colitis/pseudomembranous colitis Divcrticulitis. Othcr causcs: cndometriosis, am)'loidosis, hereditary angioncurotic ocdcma, lymphoma.
Discussion Crohn's disease is a chronic, inflammatory, granulomatOUl disease that can aflcct any part of thc bowel trona oesophagus to recrum. Small bowel is most common~ im·olved and the tcrminal ileum is iJwolvcd in ovcr 95% cases (53£1 ). I'rcscnt:ltion is usually in the 2nd-4th decldo with s)'ml)\ollls uf abdominal pain, diarrhoea, pcr ren bleeding, weight loss and fearurcs ofmabbsorption Radiological fcatures arc: • Aphthous ulccrs - shallow ulccrs with surrounding oedema. Fissures, sinu~s and fistulae - Crohn 's is the third most (0111111011 cause offisrulae aftcr idiopathic causa and di\·crticulitis. Thc tistulae can be bctwcen loops
Ner 53
Abdominal Imaging
I, between inflamed bowel loops and otntcr nal "iscera, c.g. colo\'cskal or from bowel to tone mucosa - longirudinal and transverse
Sl!'par.ttcd by ocdematous mucosa, ning of small bowcllolds. lion of small bowclloops due
resection for C rohn's disease. There is noll' recurrence of
disease in the ncotcrminal ileum with features of: Thickening of the bowel wall. M3rkcd stranding of the surrounding (,1[ due to inflammation.
Engorged and dilated mesenteric \'csscls rclerrcd to as to
inflammation
or:dcmaofwalL gr:lIlubrity with < I 111m rounded mucosal
'yps - inflammatory or h ~verpl astic mucosa. - often multiple. Jc:sjons willI discontinuous disease 3TC seen in
of eases. g fea tures (53e ) are dcmollstr:ltcd in this case of _ male patie nt who has had a pre\'ious Terminal ileal
the 'comb sign' due 10 the similarity in appear:lllce to the teeth of a comb. Skip lesions with tWO im·oked segments shown on this single axial image. MR imaging (small bowel emerograph}') fearures arc demonstrated in Figures 53f- 53i . The fat suppressed coronal/axial images ( 53f, 53g) show bowd wal l lhickening in the proximal ileu m.
(eOlu. )
C- image shows recurrence of disease in the ina I ileum post surgical resection. There is bowel wa ll thickening and oedema with alery change in the surroundi ng tissues.
53f (coronal), 53g (axial) fat suppressed images showing bowel wall thickening of a loop of proximal ileum. Dynamic images are obtained and viewed in cine mode to see how this focus of bowel contracts.
97
Answer 53
Abdominal Imaging
The pre - :md post-contrast TI weighted corOlll! images (S3h, 53i) show cnhancmlcnt of an involvc.d loop of small bowel in the central lower abdomen. Treatment is both medical and surgical, with a high rate of fCCllTrcncc cI'cn alter resection (almost 40%), p;'1rticubrly in the ncotCfminal ileum following distal ileal resections
Practical tips Terminal ileal involvement, skip lesions and multiple strictures arc the best signs for Crohn's disease. When assessing colonic disease, rememocr that UC aimosl always involves the rectum and has a continuou' distribmion withom skip lesions. Ho\\"cl·er, if a UC patient has had steroid enemas, the rectum may look nonmtl. Always look for signs of complications of Crohn's, i.e ade nocarcinoma ( risk increased up to 20-lold ), lymphoma, toxic meg:lcolon, pertoration, abscess, fistulae. Always look for signs of extrailltestinal manifestations
53h (pre-contrast), 53i (post-contrast) coronal images of the colon showing enhancement in the thickened small bowel loops in the lower abdomen.
98
of disease all the film. Check lor sacroiliac joint disease, gallstones, hypcnrophic osteoarthropathy. Always look for signs of drug rfcatmcnr of disease on the film. Check femoral heads lor evidence of ;t,,:tscuhr necrosis from steroid trcatmclH. Further management Initial diagnosis in suspecTed cases is often confirmed with a Slllall oo\\'d barium study (iollow through Of emerod)'sis). Sometimes a more aCUTe presentation with abdominal pains mal' lcad to the diagnosis fim being suggested by CT. Capsule cndosco,,'~' is a !1 !:'1 illl"estigationllm Illay also first identify disease. OIKt" the diagnosis is made, follow-up imaging with MRI idea}.as this iucurs no rndiation risk oin what afC trequcntly young patients. CT imaging remains equally useful, howel·cr, when complications stich A abscess fonll~lrion arc suspccll:d. Trealllll:m includes medical and surgical discipli nes..
Abdominal Imaging
Cases 54, 55
SE 55 Dry '::9-year-old male presented with ivc d}'sphagia.
99
Answers 54, 55
Abdominal Imaging
ANSWER 54 Observations (541 Single image from a double conrr3st barium meal examination shows multiple, small dense foci ofconlr:J.$t wit hin the aIHrulll and bod\' of the slOmach. These are surrounded by a lucent halo' rcprc.sc m ing oedema. There
is some irregular thickening of the gastric folds, with thc targe t lesions appearing to be orientated along these.
Diag nosis Erosive gastritis.
Different ial diagnosis Fo r aphthous ulccr:Hion: Erosil'C gastritis. • C rohn 's disc;lSC. • Ihriurnprccipiralcancf.ICts .
For gastric fo ld thickening: Erosil'c S;lstritis. Zollinger- Ellison syndrome. Crohn'sdisease. Malign:lIlc), - lymphoma, carcinoma. Benign rcani,'e lymphoid hyperplasia, Mcncuier'sdiseasc, •
Discu ssio n Gastritis often has this apht hoid appearance ,,;da ":lriolirorm ulcers, consisting or a tin)' dense focus barium surrounded by a radiolucent halo or oedema gi,~ a ;rnrget lesion' appearance . Lesions arc usually multiple. The lntrum is preferentially affected with spread towarQ. the fundus, lesions appearing (Q be lon gitudin oriemated along the rugal rolds, Causes: In 50% or cases, no caus.ati,'e abnormality is identifi Peptic d iscasc, Dmgs - aspirin, NS AIDs, steroids, Alcohol. Infenion - herpes simplex, cytomcgalO\'irus (CM\' . C(mdidn, • Crohn's disease - lIslIall)' there arc signs ofCrohn's disease in other locations, most commonly the term inal ileum .
Pra cti ca l tips On the contraSt examination look fo r features in oesophagus of an infecti,'c cause for the gamic appca
o r for oesophageal varices pointing undcrlringcause.
TO
alcohol as
Further management Gastroemerology referral with a ,'iew (Q endoscopy.
ANSWER 55 Obse rvations (55) Single image trom a barium swallow examination shows a lesion in the lower oesophagus, just superior to the gastroocsophageal junction, The lesion is well defined with ;1 smooth edge, indenting lhe oesophageal IUlllen, No ulceration Of infiltration is seen. Ap pearances suggest a benign intramural mass, most likely a leiomyoma.
Diagnosis Lciomroma orthe oesophagus.
Differential diagnosis For smomh ocsophagel1 mass lesion: Neurofibroma. Li poma. • Hacmatoma, e.g. from instmmemation. • Duplication q'5t - can simulate an intramur::J.I mass,
presentation is with dysphagia, odynophagia and pos.. haematelllesis. Radiological features are: Well defined, large, smooth intramural mass extending into the oesophageallulllcn. Forms an obtuse angle wilh lhe adjacent mucosagood sign ofa benign lesion. Usuall), found in the mid and lowef oesophagus, Calcification is sometimes seen and is vi rruall v diagnostic since it is the only oesophageal nll~our ealcif)'. Ukerationisrarc. May be multiple in -3%. Uniform contraSt enhancement on CT,
Practica l tips Smooth, wdl defined, slow growing oesophageal afC likely 10 be benign.
Di scussio n This is dIe mOst com mon benign tumour of the oesophagus. It is usually fou nd in young adul ts, being slightl y more common in males. Growth is slow and
100
Further management Gastroenterology refe rral \\;th a I';ew to direct ,;su with endoscopy.
Abdominal Imaging
Case 56
101
Answer 56
Abdominal Imaging
ANSWER 56 Observatio ns 156a, 56b)
The All postmicturition imlge (56b) from 3n rvu series shows billteral dilat3tion of the disra.1 ureter with 3 ·cobra. held' lppelrlnce. There is a surrounding thick I1llo of lucency within the bbdder, represcnting oedema. These 3ppeara.nces are of bilatera.l ureterocelcs. The control film (56a ) demonsnates bilateral calculi in the peh'is that lie within these ureteroceles.
Diagnosis Bilatcra.l ureterocdes.
Differential diagnosis I:or radiolucent bladder filling defects on lVU: • Ureterocele. Hiaddertllmour. • Radiolucent calcu lus.
• Sloughed renal plpilla. • Gas secondary to fistula, cystitis, idiopathic causes and trauml. • Island prostate - enl3rged central zone Cln appear as ~ ccntra.l bladder lucency.
Discussion A simple or orthoropic ureterocele is a congenira.1 prolapse of the dist;!l ureter lnd its orifice into the bbddcr. It usu311 y an incidental ti nding in adu\[s and is bilatera.l in third of C3ses. Figure 56c shows how a ureterocele c produce l less spedfk type of filling defect when t.b.:. bladder is full and Figure 56d shows the typical ultra.sound. 3ppelra.nce. The main complication is of obstructi which can cause collecting system dibtatian and rc failure. There is also an increased risk of stone forma ' and it is therefore imperative to check the control film e,"ery patient-as in this case!
56d US image of the bladder s h ows protrusion of the distal urete r into the bladd er, indicating that these a re orthotopic urete roceles and no t pseudoureteroceles.
102
Abdominal Imaging
Case 57
urcrcrocclcs can haxc a ·similar appearance and d bv obslrucl;on of:l normal ufetef. Dificrcllbcn\:ccn the tWO types can be made using or oblique films, which show no prmnlsion of into the bladder lumen with pscudourc[crocelcs.
of pscudourcfcrocclcs include: .Jana ahhe distal ureter secondary to impacted • infection, radiothcrap~' . r tumour (56c:) ,
to
check the comrol film of an IVU.
management I asymptomatic ureterocele Ill;l}' not require rec urrent urinary tract infcnion ( UTI ), calculi, obsrruct;vc uropathy arc indications for surgical
56e Single axial T2 weighted image of the pelvis shows a pseudoureterocele secondary to a large bladder tumour.
103
Answer 57
Abdominal Imaging
ANSWER 57 Observations 157a) This frorHa] chest radiograph of an adult patient shows an added com'ex soft tissue density along the right mediastinal border and behind the heart. There is no normal gastric :ti l' bubble beneath the left hcmidiapllf:l.grn. The findings suggest d ilatation of the ocsoph:agus secondary to chronic distal ohstrunion, most likely due to achalasia. A barium swallow would confirm.
Diagnosis Achalasia.
Differential diagnosis Secondary achalasia due to a stricture at the gastrooesophageal junction, There will be normal pcristalsis however. C hagas' disease is esselltially the same as achalasia but the neurenteric plexus damage is due 10 Trypmlosomfl cYII::.iinfcction.
Discussion Achalasia is a lllmilily disorde r that is idiopathic in aetiology, characterized br degeneration of Auerbach's plexus. This results in a fai lure of relaxation of the caudal oesoph:lgus at the g:lstro-oesophageal sphincter.
Presentation is with progressivc dysphagia. investigat:ioe. is with a contrast swallow examination (57b), which mat" show featufes of: 'Vigorous achalasia' - multiplc tertiary contractions in the distal oesophagus Gill be the earliest sign. 'Bird's beak' deformity - symmetrical sLenotic segment of oesophagus at the gastro-ocsophageal junction. Imaging the patient erect allows best demonstration with contraSt forcing its way through the gastro-oesophageal sphincter when the hydrostatic pressure of the barium column in the oesophagus is sufiiciemly high . l'v lcga-oesophagus - dilatation of the oesophagus ttui call involve its emire length. Relaxation ofthe lo\\"er oesophageal sphinCler can be induced with amyl niTraTe inhalation. Achabsia is complicated by an increased risk of devcl~ an oesophageal squamous cell carcinoma.
Practical tips Check lungs for pulmonary changes of previous aspiration. Check for evidence of pulmonary metastases from secondary oesophageal malignancy (or indeed if the di!:ncd oesophagus is due to a primary malignancy rather than achalasia).
Further management • The condition is fi.lrther im'estigated with pressure measurements (manomet!)') and endoscopy. Treatment is most commonly by pneumatic dilatalil: of the gastro-ocsophageal sphincter. Surgical mrotomy is considered where there is disease
57b Two images from a barium swallow examination show a dilated oesophagus contai food debris, which 'narrows down to form the classical 'bird's bea'k' appearance at the gastrooesophageal junction.
104
Abdominal Imaging
Case 58
105
Answer 58
Abdominal Imaging
ANSWER 58 Observations (58a, 58b, SSc) Three im;lgcs from an JVU se ries arc provided bur no control film (which would normally be assessed prior 10 interpretation of the post -contrast films ). [Illages show uni lateral increasingly dense and persistent ncphrogr:un on the right'. The right kidney shows uniform smooth reduction in size when compared to the lefr. There is delayed excretion of comrasr by the right kidney on the 10 minute fi lm ( 58e ). These appcar:lI1ccs suggest unibtcTll
right renal :trtcry stenosis. The young age of the patient makes fibromuscuhr dysplasia more likely than atherosclerosis as the underlying pathology.
Diagnosis Renal artery stenosis.
Differential diagnosis For persistent dense ncphrogram: • UnilaTeral: Obstruction - acu te obstruction is the most common cause of this sign. Renal artery stenosis/ ischaemia. Renal vein thrombosis. Acutc bacterial pyelonephritis. Acute papillary necrosis.
Bi lateral: H }'potension/shock. Aelile tubular necrosis. • Acute glomerulonephritis . • Causes of un ilatera I change involving both kidneys.
Fibromuscular dysplasia ( 10-20%) - usually in the mid and distal renal arter)'; allccts young adults and .::hildrcn; more common in women; bilateral in twothirds. Less com mon causes include vascu litis, arterial dissection and thromboembolic disease. Hypertension in neurofibromatosis is a consequence 01 phaeochromocytoma and/ or renal artery stenosis, \\~th .11 smooth stenosis seen in proxim:al ren:al :arter)'. In this p:arielU, a renal angiogram was performed and showed a smooth n:arrow stenosis in the mid portion of rhe right rena! artery (58d ) and this would be in keeping with the underl ying diagnosis of fibromuscular dysplasia of the renal ;lrter'\'. The eonsequ~nee of renal artCr)' stenosis is systemic hypertension as a result of o\'er;lCtivit}, of the reninangiotensin system. Treatment is aimed :at medically controlling hypertension and with renal arter)' :angioplas~
Practical tips If there is bilateral delayed persistent nephrogram with absent or dec reased excretion, then the patient to ensure that contrast anaph ylactic sh"ock has not occurred. Magnetic resonance or CT angjogr~phy is the prcli:rred ilwesrig;ltion tor this condition in the moc\ernera.
t..... needs to be immediatclv checked
Further management Attempted renal arter)' angiography and angioplasry arc
usually
ad,~scd.
Discussion 'Illere arc two main causes of renal artery stenosis: • Atherosclerosis (80- 90%) - usually in the proximal 2 cm of the renal artery; afrects older population >50 years; more common in men; bibteral in one-third.
S8d Single image from a renal angiogram showing a ste nosis in the mid portion of the right renal artery.
106
Abdominal Imaging
Case 59
107
Answer 59
Abdominal Imaging
ANSWER 59 Observations (59a, 59b) Single image from a barium follow -through examination shows smooth thickelled small bowel folds. Selected axial
images from an IV comrast enhanced CT scm of the abdomen again dcmonsrr.l1cs smooth thickening ofbowcl folds in dilated loops offluid-fillcd small bowel. In addition, there is thrombus seen in the mid superior mesenteric vcill.
Diagnosis Small bowel ischaemia secondary to superior mesenteric vein (SMV) thrombosis.
Differential diagnosis For smooth thickened folds' Haemorrhage. Ischaemia: Acute - embolus, Hcnoch-Schonlcin purpura
( HSP). • Chronic - vasculitis, thromboangiitis obliterans, radiother.lPY· Oedema H ypoproteinaemia~ cirrhosis, nephrotic syndrome, protein -losing enteropathy. • Angioneurotic oedem,\.
Lymphatic obstruction ~ lymphoma, mesenn:ric fibrosis, intestinallymphangiecrasia.
Discussion Small bowel/mesenteric ischaemia can present very acutdy with symptoms of acute abdominal pain, ,'omiling, diarrhoea and recral blecding. This is usually due ro arterial thrombus, dissection or acute ,"enous Obstruction. Chronic ischaemia usually due to chronic arterial thrombus has a
more indolent symptomatology with longstandi ng grumbling abdominal cramps, postprandial pain, weight loss and malabsorption. Other causes of ischaemia include \"asculitis, bowel obstruction , radiotherapy and aCUle: abdominal inflammation, e.g. pancreatitis, appendicitis. Radiological features of acure small bowel ischaema include: Bowel \\'all thickening/oedema. Enhancement pattern of the bowel wall can be incre3sed or decreased (5ge). Stranding of the surrounding f.1L Pneuillatosis intestinal is, which is a late sign and indicati\'e of necrotic bowel. Free imra-abdominal gas due to perforation of necrosed bowel. Portal venous gas is seen in preillorbid patients. In chronic ischacmia, there call be additional complicati of strictures (which tend to be long, smooth a symmetrical), ulceration and atrophic valvulae connivenro. The splenic flexure and the proximal descending colon most cOlllmonly affected due to the transition fr superior to inferior mesenteric arterial supply at this poiIIL
Practical tips Look careftilly for linear gas shadows within the bowel wall indicative ofinrramllfal gas. Portal vein gas is usually seen in the pcriphery of the liYcr as well as centrally, in contrast to biliary gas, which is usually only central. This is a prcmorbid sip in adults.
Further management hll'cstigation with CT C:tll both diagnose and complications of ischaemia.
59c Axial CT image of the abdomen shows dilated flu id-fi ll ed loops of non-enhancing ischaemic small bowel.
108
idcnti~'
Abdominal Imaging
Cases 60, 61
SE 61 - tory 57 -year-old m:alc prcscillcd with 'Cr abdomi nal pain.
109
Answers 60, 61
Abdominal Imaging
ANSWER 60 Observations (60) Single oblique radiograph of the pelvis from an IVU shows a small, shrunken, spastic trabeculated bladder with multiple diverticula, with a superiorly pointed dome. This is the so· called 'pinc trce' appearance of a neurogenic bladder. Diagnosis Neurogenic bladder. Differential diagnosis For Slllall bladder: Infection - schistosoilliasis/TB. Iatrogenic - postsurgery/ radiotherapy. Neurogenic. Transitional cell carcinoma (TCC ) - awmilletric bladder contraction with thick wall and filling defects. Extrinsic compression - usually gi\'es a pear shaped bladder appearunee.
Discussion Bladder innervation is by the parasympathetic nervC$ 52-54. Injury to these nerves causes denervation oftbc detrusor muscle, giving this appearance of a shrunken. heavily trabeculated bladder, with an irregular thicken wall and multiple diverticula. Causes include: Congenital anomalies - myelomeningocele, spina bifida. • Spin:!1 trauilla. • Diabetes mellitus. • Infection - syphilis, herpes. • .Spinal neoplasm Practical tips Inspect IVU films carefully to look for asp' abnormality, which can help to determine the underl~ cause of the bladder abnormality. Further management In the absence of an easily identifiable cause, lumbo spine MIU can be useful.
ANSWER 61 Observations (61) Single image from a barium enema examination demonstrates a well defined, Sillooth, eccentric filling deft."(;t in the distal sigmoid colon. This appears to be extraluminal in origin and lies on the mesenteric aspect of the bowcl A similar lesion is seen in the pouch of Douglas. Multiple lesions centred in an intrJperitone3110carion suggest the diagnosis ofimraperitone31 metaS[3Ses. Diagnosis Colonic mctastascs. Discussion Tumours sprc~ld to the mesentcry via four rolltcs: • Direct invasion along thc mesenteric \'essels and fut scen with gastric, pancreatic, colonic and biliary cancers; 40% of patients with adenocarcinoma of the pancreas have tumour cxtending along the mcscntcric root at diagnosis Extension \~a mesenteric 1}'mph3tics - colonic, ovarian, breast, lung, c3rcinoid and melanoma cancers C3n spread to mesenteric lymph nodes, though lymphomJ is morc common. Haematogenolls spread - commonly from melanoma, hrCJS! :lild lung prim3ries, met3st'3ses invoke lhe anti mesenteric bordcr of the bowd via sm311 arteries. They can act as the lead point tor intussusception. Up to 7.5% ofmehnoma paticnts show st1l311 bowel involvcment
110
Intraperitoneal seeding - brc:lst, 0\'3rian, panctc:lOi: and gastric tumours arc the most common primaries responsible for intraperitone31 'drop' seeding. "Thot lesions involve the mesenteric borders. Appcaranas arc of a focal mass or ditfuse stellate appearance 011 CT, but on double contrast barium im3ging, Jppcarances arc of a foc31 extrinsic indentation of bowel. This involves the pouch of Dougl3s (50'\ commonly the superior/anterior border of the sigmoid. Thc distal ileum and mediJI border ofd:.: caecum arc also often invoked
Practical tips The most common underlying calise lor malignant diseJse is ovarian cancer. Further management Clinical review of patient to tty and loc3lize a likely tumour. CT sC3nning will confirm peritone31 di~ Illay well reycal the primary tumour. Further reading Shcth S, Horton KNt, Garland [\·tR, Fishman EK _ l'vlcsenteric neopl3sms; CT appe3rances of priffiX"l and secondary tumors and diffcrcntial diagno~ RndioGmphics 23: 457-473.
Abdominal Imaging
Cases 62, 63
SE 62 ory 46-year-old
Icmalc ,
recentl y
ted to the U K from Africa, - med with symptoms of urinary ncy and urgency.
E 63 ry - ::'-\~ar - old
diabetic presented with
and abdominal pain .
111
Answer 62
Abdominal Imaging
ANSWER 62 Observations (62a )
Practical tips
This single coned view of the pekis shows curvilinear wall calcificatio n of a relatively normal capaci ty bladder, No calcifiGlrion of the lower ureter.; is seen. No discontinuity in thc calcification is.scen. TIle history of residence in Africa raises the possibilities of bladder TB and schistOsomiasis. The absence of gross bladder contraction makes the laner more likcl}" but it would also be helpful to re,;ew a full length alxlominal film
~~n!:; n~~l:t L~j;:,e~t~~~;u~~l~~ficadon. Transitional cell ::r
Schistosomiasis il1\'ol\'("s bbdder and lower ureters and results in a calcified , nonshrunken bladder. Tn involves rhe kidneys and spreads via the ureters ro involve rhe bl:ldder. It is very unusual to have isolated bladder involvcment with TB and the degree of bladder contraction is more marked than in schistosomi:lsis Discontinuity of calcitic at ion in the bladder wall should arouse suspicion of bladder cancer,
Further manageme nt Diagnosis SchistOsomiasis.
Follow·up in these patients is required since the latency fw development of sq uamous cel l carcinoma of the bladder can be lip to 30- 35 rears.
Different ial diagnosis For calcified bladder wall: Cancer - prirnaril}' transitional cdl carcinoma (TCC) but also other rarer bladder tlImour.;. • Radiotherapy. • Inlection - Tn and schistosomiasis. D is.cussi o~ .. ,. .. SChlstOSOlmaSIS IS one of the mOSt common paraslilc infcctions, affecting 8% of the global populatio n. Schistosolllff l)(Illllntobilllll is the female parasitc which aflccts the genitou rinary system. Unlike TB , which tends to affect thc kidneys first and then spreads caudally, schistosomiasis has a re,'erse involvement and uSlIall}' is confined to bladder and lower ureters. (Another case of bladder schistOsomiasis [62b] is shown - note the absence of upper tract calci fication that one might sec in TB .) Classically, the patient presents with urinary frequen c)" urgency and dysuria. Imaging findings arc of: • Calcification of the bladder - which results in reduced bladder filling capacity and increased posnnicturition residual volume. Calcitlcatio n of the lower ureters. Lower ureteric strictures. Ureteritiscystica.
Complications of disease aAccting the genito urinary system include : Cystitis. Vesicourelerie reflux and subseq uent pyelonephritis. • Increased risk of squamous cell carci noma of the bladder. Other systems can be affected: Li\'er - oval migration results in portal hypertension and subsequent oesophageal varices. Respiratory system - diffuse granulomatous lung lesions.
11 2
62b Calcification of the bladder is seen in schistosomiasis with absence of upper tract calcification to help differentiate from TB.
Abdominal Imaging
Case 64
R 63 tions (63) biominal radiograph demonstrates gas within the ~.i lyccal system and upper ureter. No intraa1 renal gas is seen. No gas is seen in the right o r in the bladder.
There is an increased incidence of these conditions in patients with diabetes mellitus and women arc three times more: cOlllmonly affected than me n . Esc/)ericbia coli is the causative organism in 70%of cascs with Klehsiell", Proteus, Candida and PseudomOllflsorganisms also being found. In emphysematous pyelonephritis, small gas bubbles arc initially seen on plain radiographs in\"ol\'ing lhe renal parenchyma; this progresses to give a di ffuse mottling in morc ad,'anced disease and then progresses to produce a crescent of perinephric gas when there is extension into the perirenal fill.
Practical tips _ nie - urinary dive rsion procedures . .' tract fistula to bowel due to innalllillation, Crohn's, diverticulitis or spreading malignancy.
CT is the best imaging modality for assessing extent and location of gas.
Further management Depends on ca use but obviously infective causes require prompt, appropriate antibiotic treatment.
mamU5 pyelitis is a condition in which infective produce gas, which is confined within the renal :cc,aI system. In emphysematous pyelonephritis, gas JII'l
\\ithin the renal parenchyma - a lifc·thrcatcnirrg that requires prompt di:agnosis and tn:amlcnt.
Further reading Joseph RC, Amendola MA, Artze ME, et al. (1996 ). Genitourinary tract gas: imaging evaluation. RadioGrapbies 16: 295-308.
E 64 ;u·old female presented with and epigastric pain .
lIUlCty
11 3
Answ er 64
Abdominal Imaging
ANSWER 64 Observations (64a) Single image from :t double contrast barium meal cx:ulIi natio n shows :t lI'ell defined smooth walled ovoid mass lesion in lhe gastric JllIfIlm. A central smooth ulcer is present and no calcification is seen. Diagnosis Leiomyoma of the stomlcn. Differential diagnosis Fortargc! lesions: Ncurofibrolll3. Lipoma (64b). Ectopic pancreatic rest. MCl'3stascs - cOlll mon ly breast, IUllg, renal and malignant melanoma. H acm3ngioma
Di scussion T his is the second mOST common benign gastric tumour after gastric pol~'Ps. Ukc ocsophagcallciomyoma, these aTC slow growing lesions and arc usually asymptomatic umil
they incn:asc in size, when there may be epigastric p:lin and. bleedi ng. The gastric antrum and pylorus arc l he m common si tes "flected. T he majority of these lesio extend im raluminally (60%) and form well defi ned 0\' defects. They arc more likely ('Q ulcerate than ocsophag leiomyoma with ulceration scen in up to 50%. Calcifica . is rare. Complications include: Bleeding. Obstmction. Intussusception - tumour can act as a lead point. Malignant degeneration - s~cn in up to 15-20%m cases.
Practical tips Smooth, well defined, slow growing gastric lesions likely to be benign. Further management Although radiological appcarances suggest this to be benign lesion, referral for endoscop~' +/- biopsy should made.
64b Axial CT imag e demonstrating a well defined, smooth , rounded lesion in the stomach, which has clearly the same attenuation as intra·/extra·abominal fa t. This has appearances of a gastric lipoma .
11 4
Abdominal Imaging
Cases 65, 66
IJ8jorcnsenllsUler)
11 5
Answer 65
Abdominal Imaging
ANSWER 65 Observations (65a)
Thickc nin~
Single image from a double contrast bariulll enema exami nation shows :abnormalitv of the colon tha t extends from the rectum [0 the mid rrans\'crsc colon. There aTe (C3IUTes ofJuminal narrowing with mucosal irregularity, granulari ty ;1 11(\ shallow ukcr:ltion. The disease process appears cOll tinuous along the 3.flcctcd segment's with no fil rthcr lesions seen. Noml:!l appearances of the ikocacc:L1 region. Normal sacroiliac joints. T hc appearanccs arc in keeping with a colitis, most likely ulccrntive colitis.
Significant bowel wall thicke ning can 1c3d classical 'thumb-printing' appearance. Widening ar thc presacral space.
Diagnosi s Ulcc:rnti,'c colitis ( UC).
Di sc ussion Ulcerativc colitis is an idiopathic inf1ammator~' bowel disease \Iith invokemcnt predominamly of the mucosa and su bmucosa or thc l:trge bowel. There a rc tWO peaks of prcscntltion - 3rd-5th dccades and 7th- 8th dccldes. The most commo n presentation is with blood)' diarrhoel and abdominal plin. The rectum is almost always involved (96% of cases) with continuous, co~centrif and symr~lelri.c invo~\'~mcnt of the colon more proxlillally. The tcrmlllalrku1l1 IS 111I"01\'ed in 10- 25% due 10 backwash ileitis. In acute inflammation there arc findings of:
65b Single axial CT image shows continuous thickening of the colonic wall involving sigmOid colon. The surrounding fat is 'dirty' !i ncreased attenuation) due to inflammatory change. Appearances are of an acute active colitis though the appearances here are not specific for an underlying ca use.
11 6
o f bowd
W:I!l
(65b). to
tht:
Fine ll1ucS.11 granularity. Superficial ulceration. I'scudopolyps - islands of oedematous mucosa. Collar button ulcers (65c). Appcal'Jnces in the chronic stage: • Colon becomes ri gid with llllllinainarrowing due [( chronic inilamm:ltion, and loss or haustrations 'le3clpipc' colon. Coorsc grnn ul:tr mucosa. Inflam1l13tory polyps. Ibck\\'ashilcitis.
Abdominal Imaging
n is complicated by: n from toxic mcg~lCo[on in 5- 10% - thc ..:ommon cause of death (65d). .ldCIlOCarcinQm3 - this complicates Lip to 5% ~ ticnts with risk highest when there is or onsct at a young age( < 15 years) and \\;th chronicity of disease. The rectosigmoid 'TIOSI common location for ncopbstic [lOtlJlion. strictures - usually a single , shon, smomh is found, most cOlllmonly in the sigmoid . • .lS
with Crohn's disease, there arc a variety of
..u.: complications which include iritis, pyoderma ~ m,
chronic acrivc he patitis, sclerosing and seronegative arrhritis (Figure 65c ;lIes s;lcl'oiliiris with carly sclerosis of both oints).
I tips riJtion ofCrohn's from UC is often possible the imaging tindings: thn's characteristically has multiple, eccentric,
transmur:ll , skip lesions; preferential in\'ol\'ement of terminal ileum. FiStulae and deep ulcers afe common feature s . UC characteristicall\' has a continuous, concentric, symmetric i1l\'o l\,eniclH that eXl'ends proximally from the rectum :lIld only occasionally ilwokes the te rminal ileum. Fistulae, fissures and deep ulceration arc nOt fcatures. Remember that although the recnUll is always involved in UC, it Illa}, appear spared if steroid enemas have been used. Look for intestinal complicJtions of UC including malignancy, toxic megacolon, pneumatosis intestinalis and perforation . Look for exrJ";lim estinal complicat ions of UC such as sacroiliitis. Look lor compl ications oftreaUllellt, e,g. steroids causing avascular Ilecrosis (AV N ) Of osteoporosis.
Further management A combined medical/surgical approach to disease !lIanage· ment should be taken.
117
Answer 66
Abdominal Imaging
ANSWER 66 O bservations (66a) Single image from a double contrast barium examination is shown. There arc multiple slIb1l1LlCOS:l ] lesions seell
scattered throughout the (olon with no regional predominance. Close inspection shows that these aTC due to gas-filled cysts in the bowel wall. No free intraabdominal gas is seell to suggesT perforation. No linear gas collections ;\rc seen. No portal vein gas is seell.
Diagnosi s Pnc1I1l1arosis cysroi(ics intcstinalis. Discu ssion Pneumatosis cystoidcs imcsrillalis is usually a benign condiriori of middle aged people who tend to be asymptomatic but elll present with symptoms of vaguc abdominal pain, diarrhoea and lllUCOUS discharge. R.adiological findings arc of multi pic small \ - 5 mm gas· tilled cysts in a subserosal!sublllucosal distribution. They are more cOlllmonly found on the mescnteric rather than anti mesenteric sidc of the colon. The cysts can rupturc
leading to pneumoperitoneum but with no symptorm peritonitis. This cystic pneumatosis is usually a bem_ innocuolls condition and is associated with ch obstructivc pulmonary disease, perhaps dl,le to air t from ruptured alvcoli and along the mescntery \"i.l retropcritoncum. There is also an association with m disruption elsewherc in . the G I tract, e.g. peptic disease
Practical tips Air in tht: bowel wall due to infarction typically · more linear (66b) and may be associated with
gas in pre morbid cases. Further management Pncumatosis of the colon is usuallv not - the importance here is to trcat the patielll,
erechoic hepatic lesions on US: • Haemangioma. Focal nodular hypcrpl:asia (FNH ). !\dcnollla. t\'\c raSt:isis. Hep:atocell ular carcinolna. Lipom:l. Discussion Hepatic haemangioma is the most common benign tumour of tile liver, anccting up to 20% oCthe population. The~' :arc usually :asymptom:atic, being incidental findings 011 imaging studies, however large lesions c:an present with :acure haemorrhage and abdominal pain; 90% arc solitary
124
and 90% measure less than 4 em in diameter. Mul hacm:lIlgiorna may be associated ,\;th OsIcr-Wcbcrsyndrome. Some enlargement can be seen du pregnancy. • Imaging findings on ultrasound: well defined, uniform, h~l>Crcchok lesion is the Iypical ulmsou 3ppcar:lI1cc (71 d ). No Doppler signal is seen widUl' the lesion due [Q the low-,"c!ocity flow (7 1c). La lesions (;lll appear hn>occhoic and show flow ho\\'c,·cr. Imaging findings all cr: lobubtcd lowattcl1uati lesion, which is frequently peripheral in location. Calcification is not common. Following comr.m injection, there is peripheral nodubr cnhancelllcm with centripetal tilling. The lesion lIsuallj' fills in completely o\'(:r 3-30 min to become isodcnsc \\; II\'cr, though larger lesions ma~' show persisting central noncnhanccmcnt/ scar and small lesions Il\lII show immediate unitoml enhancement. Inllging findings on ~IRJ: haem:lIlgiomas show ~ signal on T2 weighted images [hat persist on mort" heavily T2 weighted scans. This is called the 'light bulb' sign and is indicative of cyst or haemangior-. The enhancemelU pattern with gadolinium is as described lor CT. • Imaging t1nding~on sulphm colloid lItan: cold
Usually imaging is sufliciclit to make thc di agnosi.) where :uypical features :afe present, biopsy CnI undertaken prO\·ided therc is normal livcr between lesion and li\·cr capsule to pre\·ent haemorrhage.
71
Abdominal Imaging
tips the illvcstig;ltion archaicc 10 characterize :ted hlcm:mgioma. A positive '\ight bulb' sign cs that the lesion is either a cyst or a gioma. However, depending on the specific iraj "t'
allccS,I)()SI-contraSI SGI1lS rnaysti11 be as necrotic or cystic neoplasms can yield a
'light bulb' sign.
)If TV CQnlr.IS( - obtlin pre -conTrast scans, then .n 30 s (arrcrial phase ), 60 s (ponal phase ) and min (equilibrium ph:lsc ). centripetal enhancement is intense and nodular, hi~hJy specific for the di:lgnosis of
Case 72
Fu rther management These arc essentially benign lesions and don't require any furrhcr follow-up.
Further reading
VihnO\'3 Je, Bl fccl6 J, Smimiotopoulos }G , ct fli. (2004 ). Hemangioma from head [0 toc: MR imaging WiTh pathologic correlation. RadioGraphies 24 :
367- 385 .
gl01113.
125
Answer 72
Abdominal Imaging
ANSWER 72 Obse rvations (72a, 72b, 72c, 72d)
cr
~
Several axial images of the abdomen with IV contraSt cnhancctm:nt in the portal venous phase arc shown. There is significant stranding of the pcrip:Ulcrc~ltic fat indicatil'e ofacutc inflammation, which is prcdominamly around the pancrc:Hic tail. \Virhill the pancreatic tail, there is a moderate sized fluid-filled C)'stic lesion, which would be consistent with a pancreatic pseudocyst in a patient with pancreatitis. The local inflammatory change appears to extend to involn! the distal transvcrsc colon at the splenic f1exurc. In addition, there is central low atlclU13tion within the panal ,'ein extending into the proximal splenic vein in \ ,.,' 'r' ~ keeping with I.'Ortaljsplcnic vein thrombosis. The 1 pancreatic duct IS d ilated al 4 mOl diameter. While the whole b"oral loocs arc often degraded by artefucr and pathology easily missed. The same to a lesser extent ill the posterior fossa. base and petrous bone - pathology GI.Il be easily JUiooked, especially on M Itl where there is a lot to
cr -
-
~.
signs of stroke - the
earl~'
changes ofinfurction
be \'ery subtle. Carefully check for subtle focal 'ng and reduced grey-white matter rcntiatio n. The Imer is beSt detected by using I11II:I'\' 'narrow windows' on • c:Oous sinus thrombosis and subdurnl empyema arc disorders with significant morbidity and mortality t can Ix easily overlooked. When presented with an ~ntly no rmal of a patient with a history of cDmincing acute imracrnnial pathology, always double .:Deck for increased density in the venous sinuses and mbtle subdural collections. Administrntion of IV ~urast may help confirm either. - Hxmorrhage - subtle subarachnoid or subdural tiood. must not be missed. C heck carefull~' for small
cr.
cr
amounts ofsubarachlloid blood layering in the ~> occipital horns or around the medulla close [0 the fornmen magnum. Pituitary - this is well sccn 011 sagittal MRI scallS, so do not forget to chcck it. A notc on mass lesions: \Vhen confronted ,\~th an intracr:lIlial mass lesion, assess the following: • Location - cemin tumours ha\"{~ a predilection for certain areas of the brain . • Age - this has a strong influence o n the differential diagnosis. Certain rumours are common in the paediatric age group while metaS[;lses always have to be considered in the older adult population. Is the mass intra- or eur.t-axial - that is, does it originate within brnin substance or nOt? The distinction is very important in fomling a differential diagnosis and though it seems obvious, can sometimes be difficult to establish on in particular. An eurn-axial mass causes crowding ofthc subcortical white matter fronds that extend between gyri. Com'erscly, an intrn-axi31 mass stretches the grey matter around it and consequently displaces the fronds of white maHer 3parr. Mass eflcer and oedema - check ror midline shift and effacement of normal CSF sp3ces such as sulci and cisterns. If extra-axial CS F spaces arc obliterated, there is risk or death due to br:lin herniation th rough dural al>c rt ures. !f rou see such features, then indic3te the degree of urgency required in seeking neurosurgical evaluation and intervention. • Assess the enhancement pattern of the lesion. This is often nonspecific but certain patterns such as the intense, homogeneous enhancement of meningioma ma~' allow a confident diagnosis.
cr
CT AND MRI NECK C ross-sectional imaging of the neck requires excellent an3tomical knowledge! Familiarize ~'oursclf with the anatomical divisions of the upper aerodigesth'e traer, the fascial Sp3Ces ofthe neck along which tumour and infection track, and the nodal stations of the neck. With this knowledge, you can make a meaningful interpretation for the E?-..TT surgeon . T2 weighted scans with fu! suppression arc particularly useful to eV31uate at first inspection if these arc avail3ble, for detecting both primary pathologr and
147
eNS, Head and Neck Imaging
nodal disease. Thereali-cr, sinmltaneous examination of the Tl weighted scans can help to better delineate the precise anatomical location of disease.
~~~IIN
RADIOGRAPHS
T here arc a very limited number of pathologies that arc likely to be shown on a skull radiograph:
~
Trauma As well as skull fractures, check for indirect signs of fixture such as fluid leyels in sinuses and intracranial air. Remember 10 look at all the bones on the film - the fracture of odontoid peg at the edge of the lateral skull film is a basic exam type of case. Calcificatio n Know the normal intracranial calcifications such as pineal and choroid plexus so that you can ditlerentiatc from pathological calcification such as that associated with meningioma. Pituitary Size and shape of the pituitarr fossa should be assessed.
~
Vault Several diffuse processes have characteristic changes on the skull radiog raph and make for 'spot diagnoses', e.g. acromegaly, fib rous dysplasi;l, th3lassacmia, hyperparathyroidism ;md myelon13.
Spine As always, there arc many potential pathologies to sec on plain films of the spine but trauma, infection and neoplasia arc particularl y common.
-0.
148
Tra uma When ;lssessing cen'ical spine films' • First ensure that the complete cervical spine has been imaged down to C7- Tl level On the lateral film, look at the anterior spinal, posterior spinal and spinolalllinar lines to ensure continuity (I.e. imaginary lines drawn along the anterior and posterior vertebral body cortices and along the anterior limits of the spinous processes).
Look at the sofi- tissues of the anterior cen'ical space. which should be no greater than a third of the width ofa vertebral bod" for C I- 3 and no more than the width ofa \'ertebr:al body for C4-7 . Check the imen'al between the anterior arch of atlas and the
~ ~~1~~1;ol~~n;~~ ~d~i:s s~~r~ 1~~~I~~a~~;i~r~I~. greater
On the AP film :J ]ook for misalignment of the vertebral spinous processes in a \'Crtical plane, which would suggest a flcet joint dislocation. Ensure that the AP 'peg' view adequately excludes a C2 peg fracture. When you arc suspicious of an unstable fracture, nak this clear so that adequate steps arc taken to prote..., the cervical spine until such time as this has been confirmed or excluded with CT. When assessing thoracic and lumbar films, carefully chco. alignment and \'ertebral body height. On the AP fil m the thoracic spine, look for widening of the paravcrte stripe suggestive ofhaematoma. Mali gnancy Bony involvement is one of the most common sites metasratic tumour spread along with the lungs and Ihu
,-~o~I~~rl~~~~ol~i~~II~~:'~I~~~~~~,i~;,n:e~~~~l~~~~~::e~~ spinous process for lytic deposits. As ever, pay attention the soft tissues - a paravertebral soft tissue mass may ~ you to a subtle bony lesion. Do not lorget that \\ mrcloma classically produces foc al bony lucencies possible resulting vertebral collapse, a significant nu . of cases show only diffuse oSleopenia, which can III osteoporOSIs. Infection Spinal infection is usually centred on the disc and the there will be a reduction in disc height with i1l\'olvc of the superior endplate of the vertebral body belo\\ inyoh·ement of the inferior endplate of the vertebral above. Added sofi- tissue d\le to abscess is likely to be and in the cervical spine will be seen as a preyertebral tisslle Im.SS on the lateral cervical spine film; in the [h spine this will be seen as a widening of the paravert stripe; and in the IUl11b::lf region there may be a abscess
eNS, Head and Neck Imaging
Cases 86, 87
~d presented with bilateral dcafilcss.
149
ANSWER 86 Observations (86a) Single high-resolution axial CT image of the skull at the level of the petrous bone. There is bilateral enlargement of t he vestibular aqueduct. Preci se measurements have not been documented but the aqueducts afC dearly significantly wider than the horizonta l semici rcular canal seen on the right.
Diagnosis Enlarged vestibular aqueduct syndrome. Discussion Enlarged vestibubr aqueduct syndrome presents clinicall)' with sensorineural hearing loss. Hearing is usually prescnt :\f
birth and then deteriorates from age of -3 years.
Deterioration is often in a stcP\\~SC manner, associated with episodes of minor head trauma. There is a suggestion of an inherited recessive genetic link and 50% of cases arc bilateral. A degree of cochlear dysplasia is present in 75% of cases. The normal endolymphatic duct o riginates from the vestibule, via the common crus and extends posterolaterally in the bony vestibular aqueduct to t he endolymphatic S.1C. The endolymphatic sac li ~s on the posterior aspect of the petrous temporal bone. Enlarged vestibular aq ued uct syndrome is diagnosed when the diameter at irs midpoint
exceeds 1.5 mm. Figure 86b indicates the dil:J.ted aqu in rhiscase. Diagnosis of the condition is important due to the _ results achie\'cd with cochlear implantation.
Practical tips A quick assessment of the vestibular aqueducts can made by comparing the diameter at midpoint to thc= diameter of the adjacent posterior semicircular ca~ the aqueduct should not be larger. When identified , check the cochlea for e"idence of dysplasia.
Further management Advise on a\'oiding head trauma where possible, t .~ no contact sports. • Hearing can be improved with cochlear implants.
Further reading Dahlen RT, H arnsberger HR, Gray SD etal. ( 1997 ). Overlapping thin -section f.1st spin-echo MR oftht large \'estibular aqueduct syndrome. American jOltrlml of Neuroradiology 18: 67- 75. Valvassori GE ( 1983). The I:J.rge vcstibul:J.r aqueduct associated anomalies of the inner car. Otola171lgo _ C/illicsofNortbAmeriCll 16: 95- 101 .
86b Axial CT image demonstratin g an enlarged
vestibu lar aqueduct.
150
eNS, Head and Neck Imaging
187) que image from a parotid sialogr-anl with no iiIm provided for comparison, The parotid duct is calibre with no obstructing stones or stricture. florid pUllerate dilatation of the _ _ _""'I" ",,,,,,,,1,,· and acini in keeping with punctate
Case 88
Althollgh sialography is the primary method of diagnosis, US is useful for tollow-up as it avoids thc radiation burden and invasive nature of sialography. At US, the gland is swollen with :I hettrogencous appearance and multiple hypo50%): Germinoma Teratoma - extremely heterogeneous mass. Occurs in young children Choriocarcinoma. Embryonal cell tumour. Pineal parenchymal tumours (25%): • Pineoeytoma - well demarcated, calcified, slow growing tumour in1middle ,'ged adults. • . Pineoblastoma - si milar to medulloblastoma. Allects young children. Enhances avidly :llld is nOl usually well circumscribed.
rn~lignant
Practical tips The pineal region is in the midline and masses in region may compress the aqueduct ofSyivius, so
~. ~t;;~~~ ~~~~~;n~~S~I~~~~~~~r~~h~l~~~~al gland
Others: • J'v lcningioma • Epidermoid or dermoid. • Arachnoid cyst - CSF density/signal • Pineal cySt - common; fluid density or signal though contents can be proteinaceous on MlU. • Lipoma
Discussion The pineal gland is a midline structure situated behind the 3rd ventricle and responsible for biorhythm. It is calcified in most people over the age of 15 years and in almost all
92 Pineal germinoma.
158
exceeds I em in diameter a pathological pineal p should be suspected. Calcification in germinoma when present is ccntnIL. pincobbst'Oma pniphaal. In ~'ollng children think of teratoma (which are \heterogeneous masses), pineoblastoma and a vein Galcnancurysm In young adults, the most common solid lesion is germinoma.
Further management Surgery is difiicult due to the central location in The main rolc for surgery is in obtaining a possibly debulkins of tumour to relieve symptoms. However, serminomas arc radiosensitive and therefore radiotherapy is the of treatment.
eNS, Head and Neck Imaging
Case 93
na PO and T2 weighted axial (top), T2 weighted coronal and T1 weighted sagittal (bottom) images.
159
Answe r 93
eNS, Head and Neck Imaging
ANSWER 93 Observations (93a) Selected J\Ht images of Ihe brain demonstrate hyperintel1sity in the righr trans\'ersc sinus on the T I and T2 weighted images \\lrh an abse nce oCthe nomlal \'enOliS sinus flow \'aids. There is high-signal abnormality seen withi n the right mastoid air cells on T2 weighred images, which is intermediate signal on Tl imaging - this is likely to indicate infection/innammato~' change, Appearances arc consistenr wirh a diagnosis of \'enous sinus thrombosis secondary to mastoiditis. No imracerebral/ccrcbellar h ~\emo rrh age or inlarer is demonstrated on these images.
Di ag nosi s Venous sinus thrombosis.
Discussion There arc a variet), of underl )'ing ellises of \'enous si nus thrombosis, which include trauma, in/ccrion, idiopathic and h)'percoagulablc states, i.e. oral contracepti\'e pill, anti phospholipid syndrome, parancoplastic tumour s)'ndromes, antithrombin III deficiency. Presenting srmptoms can often be \'ery nonspecific, meaning that diagnosis is often OI}ly made radiologically. Symptoms include headache, nausea, vomiting and drowsiness, The superior sagit tal sinus is most commonly aflccted, followed by trans\'ersc and sigmoid sinuses
IUdiological appearances :ITC: Uncontrastcd CT may show a hypcrdcnsc \ '(nOllS sinus due to thrombus (Figure 93b shows a thrombosed superior sagitt:J.J sinus). Contrast enhanced CT shows a filling delcct within the triangular lumen outlined by a sillall rim of (oml"$ the 'empty delta' sign. • MRI demonstrates :lIlabscncc afOaw \·oid within vcnous sinus, with local eflects of oedema, subcom infurction, suteal effacement and haemorrhage. • [n the acute phase, thrombus can appear as isoinrcnsc on Tl weighted imaging and hypointcnsc on 1'2 weighted imaging. TIlis hypointcnsity on T2 can sometimes be mistna. tor flow \'oid and thcn::forc phase-contrast MR.o\. which shows /low, is beneT at identification. • I n a chronic thrombosis, the venous sinus appea hypcrimcnsc on T I and '1'2 weighted images w extracellular methaemoglobin .
Venous infarcts arc idenrifiablc by their nonconformity \\ltb arterial territories and haemorrhagic tendency, Figure 93b demOIlstr.u a \'enous inf.,rct that docs nOt conform to the anatomical area sl1pplied by the vessels of posta. circulation,
93b Selected axia l CT images demo nstrate a fo cal area of low attenuation involving grey and with appearances consistent with an infarct. The distribution, however, does nol conform to arteria since this rep resents a venous infarct.
160
eNS, Head and Neck Imaging
Ca se 94
sinus thrombosis call present in a '"cry • manner and has signific3m morbidity and umrC31cd. When assessing scans of acutely _-call)' unwell' palicnts, alwa)'S keep it in mind the scan carefully. Similarly, beware of g infan':t$ that show features as described :itham questioning the possibility of an rutg wnous sinus thrombosis. J.ranccs oflhrombus o n MRl are complex ~ \\;th the age o[[hrombus. Moreover, patent sinuses can show absence of tlow \'oid when in certain planes. Making the diagnosis of smus thrombosis from MRI can therefore be 1('d. Modern Illultidctcctor CT scanners h3YC t speed and spatial rcso]urion to image the Sinuses and provide an allcrnari"c that (an be interpret, thromb us appearing as a filling Ul the lumen Oflhc otherwise enhanced '"CnOllS Figure 93c is a coronal reformat of a CT ~l showing thrombus in rhe lefi- tranS\'crsc ~ an ;cmpty dclt.l' sign. 93c Coronal reformat CT image shows thrombus in the left transverse sinus.
Answer 94
eNS. Head and Neck Imaging
ANSWER 94 Observations 194a)
Epidermoid ~ 5% ofCP angle lesions.
Single T2 weighted Mit image of [he brain at the kycl of the internal ;ludirol)' Illcarus. There is a large , well defined soft tissue mass lesion in the Tight ccrcbcllopontinc (C P) angle with extension intO the internal auditory canal. Widening of the canal is seen. No dural tai l is c\'idclH. Acoustic neuroma is m OST likely.
Arachnoid CYST. Posterio r circulation aneurysm. Metastases.
Di ag nosis Acousticncuroma.
Differe ntial diagnosis
orer angle lesions:
• Acoustic neuroma accounts tor 75% orcp angle
masses. Meningioma is the mosllikdy diHi.:rclltial at 10% (94b ). Lesions arc extra-axial and tend 10 be cxtracanalicular and commonl y calci!},. Dunl rails arc seen in up [0 6O'X.oftumours on MRJ.
Discussion Acoustic neuromas arc the most common tumours of C P angle and internal auditory (anal. They typicall~ from the \'estibular di\'ision of the 8th nefl,c and sh. p·erhaps be morc accurately termed \'cstibular sc llomas. These lesions prescll! in the 4th-7th decades arc more frequently seen in females. Prescntation at a rounger age in patients \lith type 2 neurofibro with prescntation in thc 2nd decade. Bilateral aCf' neuromas arc virtually pathognomonic of fibromatosis typc 2, whilc solimry tUlllours arc seen to 25% of cases. Presentation is with sympl scnsorincural hearing loss, tinnitus, vertigo and
94b Axial PO, T2 and T1 weig images w ith three post-contras: coronal images demonstrate a defined, extracanalicula r, enhanci ng lesion in the angle representing a
162
swer 94
eNS. Head and Neck Imaging
ging features: arise ill the internal auditOry canal (lAC).
cause ~nlargcmcnt/c:rosion oftlte lAC. LCSions extend imo rhe CP angle.
L.olt'gcr tumours (>3 em) have central areas of necrosis md haemorrhage. ~ificati on
n
is llOt a feature. cr lesions arc usually imensc with uniform anccmcnt. MRI, lesions arc low sigmll on TI, high signal on 30 years). l....'St
Scholl R., Kcllw H , Neumann D, Lurie A ( 1999). Cysts and c"sric lesions of the mandible: clinical and radioiogk-histopathologic review. RndioGrnplJics 19: 1107- 11 24 .
C\ost wit h no dcnral association:
~.n· _ OKC, simple bone cysr.
-
I~ars
- ameloblastoma, mct3stases o r myeloma.
Hacmangioblastoma.
Differential diagnosis • Juvcnilc pilocytic ;lstrocytoma - can be "cry difficult to diflcrentiatc from a haeillangioblastonll. This is the mOSt COlllnlon infratentorialtulllour in children. There is an association wi th ncurofibromatosis typc I , Lesions arc of an ident ical appearance, with a predominant cystic component and enhancing solid peripheral nodule. Metastasis. Arypical mcdulloblastoma,
Di scussion H aemangioblastoma is a benign vascular rumoull aflccting the CNS. It is the most common primary infratemorial nUllour in adults. The majority (80%) present in adults in the 3rd-6th decades, although there is an association '\ith "on H ippel- Lindau (V HL), which sees these tumours presenting in childhood and in this case may be multiple.
hacmangioblutoma. • Younger adults - hacmangioblasroma most com • Older adults - consider cystic mctaS[3sis
Furth er management When haemangioblastoma is suspected, do n't forg:... raise the possibility o f VH L (4-20% of haemangiob occur in the COllleX I of VH L and multiple lesi diagnostic ofVI-IL). VH L is an autosomal dominant inherited condition characterized
spectrUl:n:~:o~rl:~"'::~m:~o~"~,~,:i~~::~~~j~i~:~:
blastomas, develop a cardiac pheochromocytomas, pancreatic I cell mmours and haemangioblaslomas, li"er and retinal angiomas.
104 Enhancement of the solid posterior nodu le on post-gadolinium im ages.
182
eNS. Head and Neck Imaging
Case 105
183
Answer 105
eNS. Head and Neck Imaging
ANSWER 105 Observations (105) The selected images demonstrate diffuse cerebral atrophy exceeding that cxptctcd for the patient's young age. There is:I large focal area of signal abnonm.liry in the central pons Ih:1I is hyperintense on T2 weighted and hypointcnsc on TI wei glued sc:ms. 111crc is no associated mass effect. The signal changes would fil with central pontine myelinolysis and the clinical dCt3i1S and cerebral atrophy suggest that chronic alcohol abuse may Ix the underlying cause.
Clinically this results in pseudobulbar palsy, terraplc~ cOll\'uisioIlS, acute confusion and progression to comL is mOSt commonly confined to the pons but changes also be secn in the basal b>;lnglia, caudate, thalamus suocortkal white matter. Radiological presentation is fairly wdl defined low attenuation lesions on CT in central pons. On M IU , lesions aTe oflo\\' intensity on and high signal imensity on T2 imaging.
Practica l tips Diag nosis
Differenti al diagnosi s
Standard MR/CT im::aging (::an be normal for up to days after symptolll onset, lagging considerably behind clinical presentation. Rest ricted diffusion on D however, is found wirhin 24 hours.
• Pondnc glioma. • Inf.,rcrion.
Further management
Central pontine myelinolysis.
Di sc ussion Central ponline myelinolysis res ults from the des trllction of m~'c1in sheaths, dassicall~' in patients with rapidly corrected hypo n:ttracmia. Cases are reported in patients with: • Chronic alcohol abuse. • Chronic liver d isease. ' • $c"ere m::alnutrition. • Wilson's disease, chronic rell::al fitilure, diabetes, acute m)'clogcnous leukaemia . In the c::ase demonstrated there is diffilse glob::al (erebral ::atrophic ch::ange suggestive of chronic alcohol abuse.
• Early MIU appearances can be similar for a b::asibr inElrcr and M RA (::an be useful to look for :lrteri,;d thrombus. • Sc::arch for underlying cause if not readily app::arcOL
Furth er rea ding Ruzek KA, Campe::all NG, Miller GM (2003 ). Earf!; diagnosis of central pontine myelinolysis with diffusion-weighted imaging. American JOllnHlJ Nmrorndiolo!JY2 5 : 210-213. Stadnik nv, Demaerd P, Lurpae rt RR., It nl. ( 200.; Imaging tutori::al: differemi::al di::agnosis of bright lesions on diffusion-weighted MR images. RadioGraphies 23(1): e7.
105 Focal area of red uced Signal on T1 weighted (left) and increased signal o n T2 weig hted (right) images.
184
eNS, Head and Neck Imaging
Cases 106, 107
-old fCIll:a1c patient prescnted clles.
185
An swer 106
eNS, Head and Neck Imaging
ANSWER 106 Obse rvations (106a )
cr
This non contrast enhanced image demonstrates a large midli ne mass extending into the 3rd ventricle, which hlS both solid :lIld cystic compOllcnrs with central calcitication.
There is dibtation orthe temporal and anterior horns of the "cntridcs but normal :tppcarancc to the 4th ventricle findi ngs arc in keeping with obstructive hydrocephalus at the lc,"el of the. 3rd ventricle secondary to a mass lesion. The mixed density and calcification arc \ '(1)' suggcstive of a craniopharyngioma and M IU is suggested to further e"aluate.
Diagnos is Craniopharyngioma.
Differe ntial diagnos is
or suprascllar/intrascllar mass lesion:
c,wcrnolls sinus ( 3, 4, 53 and 6 ) and hypopitui resulting from compression of normal pituitary tissue Compared to craniopharyngioma, pitu itary adenomas arc predominantly solid and show morc i uniform enhancement. Calcification is rare, craniopharyngioma. Suprasellar ex tension produca 'snowman' configuration due to w:lining at the I the diaphragm sellae. Figure I 06b shows prc- and contrast Tl weighted images of a pituitary macroa with such features. lbthkc deft cyst is the other main diAcrcntiai di.a_ wi th 70% in\"olving sellar and suprasellar regions. benign cySt arising from remnants of Rathke's pouu can be differentiated by the following features' regular and ovoid shape, smaller size ( < ,...I. ,. W"
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A nswer 11 6
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CASE 124 History .\ , hllJ
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m
Answer 124
Musculoskeletal Imaging
ANSWER 124 Observations (124a)
Further management
There is difruse, coarse trabeculation of the visible bones causing a 'cobweb-l ike' appcar.:lllCC. Erlenmeyer fla sk deformity of the distal femurs is presen!. The features arc in keeping with thalassacmia major.
Death usu311y occurs within the first decade-. b)' multiple tra nsfusions, howe\'cr as exp discussion this tOO leads to skeletal abnorrn
Diagnosis
T yler P, Madani G, Chaudhuri R, ct (I/. (2006 radiological appearances ofth:llassnemia,
Further read ing Thalassacmia major.
Rndiology 6 1( 1):
Discussion Thabssacmia is an inherited disorder of haemoglobin synthesis charncfcristically seen in Mediterranean patients. The homozygous form, thalassacmia major, is mOTC sncrc. The radiological signs result from marrow hypcrpl:J.sia and expansion due [Q cnramcdullary h:u:rnatopoicsis. Evcry part of the skeleton may be aflcctcd in patients with untreated disease. R.1diologicaJ fcamrcs of the complications of treatment such as recurrent transfusions and iron chelation thcrapy may also be seen. In fuet, ab normalitit:s secondary to iron chelation therapy arc now more com mon than those due to lllarrow hyperplasia. T he radiological signs to look for depend on the site of the bod~' imaged' • Peripheral skelerun: Coarse trabeculation e3using 'cobweb' appearance ( 124a ). • Loss of conca\'ity ofwbular bones ( 124a). • Er1cnmerer flask deformity of metaphyses of long bones ( 124a). • Arthropathy and chondroca1cinosis as a result of haemochromarosis secondary to hypertral\sfllsion. • Fraying of metaphyscs and dense metaphyseal bands secondary ro iron chel3tion therapy. • Skull: 'Hair on cnd' appearance. Frontal bossing (124b) due to diploic expansion. O bliteration of paranasal sinuses (except for ethmoid sinuscs) due to marro\\' h)'pcrplasia ( 124b ). • A-.;i:tlskekton: Co3rsc trnbeculation causing 'cobweb' 3ppe3rance ( 124~'f
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Furth er reading Graham TS (2005 ). rhe ivory vertebra sign. R.adiology 23 5: 614-6 15.
245
An swer 138
Musculoskeletal Imaging
ANSWER 138 Observations (138a) There is marked abnormality at the midtarsal joint with dislocation. sclerosis and debris forma tion. Prominent vascular calcification is noted. The appearances arc those of a Charcot joint and the most likely cause in \'lew of the \'ascubr ca1cillc:ltion is diabetes mellitus.
Diagnosis Diabetic ncurop:llhic 100L
Differential diagnosis Of causes of neuropathic joint: • Shoulder and upper limb joints: • Syringomyelia. • Congcnit:ll insensitivity to p'lin
• uprosy. • Syph ilis.
Spine' • Trauma. • Tabes dorsalis.
Hip and knee: • Tabes dorsalis.
• Steroids. Ankle and foot: Di:lbctcsmcllitus. Alcoholism. • j\'lyclolllcningocdc. • Congenital inscnsiri\"ity to pain.
Discu ssion Neuropathic arthropathy is a traumatic arthritis associated with loss of sensation ;lnd proprioception of an affected limb. When encoun tered clinically it is also known as a C harcot joillt. The decreased pain sensation produces repetitil'e trauma leading to eventual destruction of the joint. T here is olien no history of trlullll and the patient Ill l}' present with a swollen Wlrrll joint with normll inflammatory markers. A third h:we pain at presentation although there is ustlllly a decreased response to deep pain and proprioception at this stage. Because the patient is still using the limb there is no juxta-articular osteoporosis, in fJct the bones arc sclerotic. The exccption to this rule is in patients with superadded infection, which is not uncommon in diabetics. Repeti tivc trauma leads to destmction, dislocation and dcfomlity \\irh multiple loose bodies within the joint. The likely underlying pathology depends upon the site of the joint and the age of the patient. When considering the ankle and foot, thc most common causes in adults arc diabetes mellitus and alcoholism, whereas in children the most common causes arc myelomeningocele and congenital insensitivity to pain. Examples arc shown of a Charcot joint secondary to diabetes mellitus ( 138b ) and a Charcot elbow in a patient with syringomyelia ( 138e).
246
Radiological features of a Charcot joint include: Dense (i.e. sclerotic) bones. Destmction and fragmentation of articular Degeneration. Debris (loose bodies). Dislocation. Deformity. Joint cffitsion. Exeessin:callus formation.
Practical tips Look for vascular calcification on the radiograpr will otten be present in patients with diabetes hence point to the underlying eausc. Fu rther management Trcatment is stl.pporril'e. Ampuration may be severe progress101l.
Musculoskeletal Imaging
Case 139
247
Answer 139
Musculoskeletal Imaging
ANSWER 139 Observations (139al Irregularity, sclerosis and loss ofhcight of the right femoral head arc seen on the pelvic radiograph. There is no signitic:l!lt abnormality ohhc acetabulum and the lefi: hip is unremarkable. The findings arc consistent with avascular necrosis of the right hip. Bilateral sacroiliac joint fusion is also present, though more prominclH 011 the riglH side. This suggests a background seronegative arrhropathy. It is therefore likely that the avascular necrosis is drug induced by treatment for the seronegative arthropathy, or perhaps associated inflanllllawrv bowel disease. No bowel abnormality is seen on tl;is plain film [0 confirm the latter hypothesis
Diagnosis Avascular necrosis (AVN ) in a patient on steroids for seronegative arthropathy. Differential diagnosis For causes of avascular necrosis (mnemonic - ' DRIED HI P' )' • Diaoctes and other metabolic conditions, e.g. hypedipidaemia, gout, pancreatitis. R.adiotherapy. ' l;ltlammatory disorders, e.g. rheumatoid, SLE, scleroderma . Endocrine disorders, e.g. Cushing'S. Drugs, e.g. steroids, anti-inflammatory and immunosuppressi\'e drugs, alcohol. Haematological disorders, e.g. sickle cell, hacmophilia, polycythaemia, Gaucher's. Infection and injury, e.g. fractures, burns and f.1t embolism. Penhe's disease (idiopathic AVN in children ). Discussion Avascular necrosis is a consequence of interrupted blood su pply [Q bone with death of cellular c1cmclHs. The many causcs arc listed in the difierential diagnosis and folloll" the mnemonic 'DRIED HIP'. The femor.tl head is the most common site at'tected. Other common locations include the humeral head and femoral condyles . The earliest radiological sign is subtle relative sclerosis seCOnd;H)' to resorption of surrounding bone. A radiolucent crescent par.tllel to the articular surface may appear. Flattening, fr.tgmentation and sclerosis then ensue. Subchondr.tl cysts and collapse lead to early osteoarthritis of the aflccred joint. An AP afthe pelvis ( 139 b ) shows the subtle crescent sign in the !cft hip of a child with early avaseubr necrosis. This is mo re clearly seen on the frog lateral vicw of the sallle patient ( 13ge).
248
Musculoskeletal Imaging
tips eOlia]
~auscs
for A \TN is long and,.of course,
toe- idiopathic Penhe's disease in children. The ~logical
IblUres arc worth checking for in
J. CJuse , but clinic31 history may be required For example, the child with AVN shown in leukaemia, and steroid trc:atmcnt was the
•
Case 140
Rhcutlllloid-typc arthropath y or changes of sdcrodcml:l. Vascular calcification, which may point to ulldcrl~-lng di:abctcs. Associations \\;Ih immunosupprcssh'cs, e.g. pelvic
transplant kidne y.
Further management The underlying cause should be sought and treated. Man ~' patients will de\'elop debilitating second ary arthritis and go on to require replacement of the affected joint. with steroid theral')'. e.g. thumb-printing presence ofa SrDm3 or sacroiliitis
249
Answer 140
Musculoskeletal Imaging
ANSWER 140 Observations 1140a)
Dis cu ssion
T here is diffilSC osteosclerosis 3Hccting the \'isibk skeleton. There is also ll1:tssivc splcllot1ll!galy making the likdy (iiagnosis That of myelofibrosis. Lymphoma is another possibility and less !ikcly, m:lslCX:YlOsis.
This rnrc1oprolifcrativc disorder results in progfC'1ll marrow n:placcmcm by tibmsis ;lIld consequent an extramedullary h3cm:lTop0ics;s and sp1cno mcga[ ~' massi,'c). T~vical age ofansc! is O\"er 50 )·cars.
Diagnos is
Practical t i ps
r.lyclofibrosis.
• Osteosclerosis is on-en missed when the appcaranct blamed on the qU31ity orthe film, i.e. when it is thought to be due to the I';1diograph being underpellCrrJted. Assessment of the intervertebra discs should be made - if the" arc visible then the: :lppearanee is likcl~' to be real. This is well demonstrated in Figure 14 0e: there is diffuse osteosclerosis aflcctin g all the bones on this exit patiellt with osteopetrosis. Note how the intervertebral discs arc clearly seen, reinforcing: f.let that the radiograph is Ilot underpcnelratcd. P.lticnrs with renal osteodrsrrophy may ha\'e a haemodialysis line on CXR or peritoneal di al~~ on A.XR. There may be evidence of subpcrioslcM bone resorption, soft tissue and vascular calci and 'nigger jersq" spine. When sclerotic met"JstJses 3Te suspected on a cheek rhe bre;lsr shadows: in female patienl5 may be 3 mastectomy, while in males enlarge breast tisslie Illay be seen due 10 hormone th prostatic carcinoma, Figure 140d shows sueh-:- sclerotic prostate lllet3St:lses and gynaeco
Differential diagnosis Of dimISI: bony sclerosis and splenomegaly: • Lymphoma.
• M:lStocyrosis. Of generalized osteosclerosis in ;Idults: • Sclerotic metastases (es pecially breiS! or prostate carcinoma).
Lymphoma. • A'lyclo/ibrosis.
• Paget's disease (140b). • Renal osteodystrophy. • Sickle (ell disease. M;lstocrtosis. Osteopetrosis. • L~rknodysostosis • Fluorosis Osteopetrosis and pyknodysosTOsis have onset in the paediatric age group.
140b Axial CT image of the pelvis shows sclerosis of the right hemipelvis with cortical thickening and thickened internal trabeculations typical for Paget's disease.
140c CXR of an adult with osteopetrosis demonstrates diffuse dense osteosclerosis.
250
Musculoskeletal Imaging
c splenomegaly on the AXR suggests -brosis atrophy (possibly with calcification ) sli ggest's cd] disease, and there may be mher signs of this ~ gallstones, avascular necrosis of the femoral .Ind cndphuc inf:lfClions causing H -shapcd I bodies. megal), and small bowel thickening suggest ·'osis. the" AX R of a patient with osteopetrosis a izcd 'bone within bone' lppcar.mcc Illay be md the \'encbral bodies may h;1\'( densely 'c cndplatcs producing 'sandwich \'crtcbr:J.c'. (,"cr flask dcfarmin' of the femurs should also cd for. Figure 140c is an orthopamomogr.un ad ult patient with osteopetrosis demonstrating osteosclerosis and supernume rary teeth '5 disease c;m also produce a 'bone within bone' nee, howe"er coarse trabeculatio n and cortkal ning normally diflcrcnti:lle this from other
Case 141
for spleniI.' enlargement that causes rC\:llrrc nt painful episodes, SC\'\:re thromlxxytope ni3 or an llnaccepmbly high red blood ce ll transfusion requirement. Median survival from time of diagnosis is approximatel y 5 years. End stage myelofibrosis is a wasting illness characterizcd by gencral disability, Ii,'cr failure and bleeding from thrombocytopenia.
is is associated with ligamentous insertion
management is no specifi c rreatillem for myelofibrosis. omy is not routinely performed, but is indicated
140e OPG of an adult with osteopetrosis; this demonstrates diffuse osteosclerosis and supernumerary teeth, which is an associated finding.
251
ANSWER 141 Observations (141a) There is a large, cxpansilc, mixed lytic/sclerotic destruct!,'C lesion involving t he right anterior hcmipclvis. There is marked cortical destruction with a soft tissue component. The lesion has a wide zone of transition. This is an aggn.:ssi"c lesion and the most likely diagnosis in a patient of this age is a primary malignancy such as lymphoma or chond rosarcoma. Metastasis should also be considered.
Diagnosis
greater than I.S cm then malignant transformation be suspected. Again, flocculent chondroid cakificao characteristic tor malignant degeneration.
Practical tips It call otten be diflicult to diflcrentiate an e ncho from an intr;\medullary chondrosarcoma, howc'a" larrer is more likely to present with pain and enchondroma will often demonstrate periosteal and cortical bre.\kthrough.
Chondrosarcoma.
Further management Differential diagnosis • Lymphoma • Metastasis.
Discussion Chondrosarcoma is the third most common primary bone malignancy with multiple myeloma being the mOSt common and osteosarcoma following second. Chondrosarcoma ca n be primary, or secondary following malignant translorrnation in ;1 pre -existing skeletal lesion such as an osteochondroma, enchondroma or a parosteal chondroma. C hondrosarcoma most commonly presents in the 4th or 5th decade of lite with a male predilection of 2: I. Radiographs typically re\·cal a mixed lytic and sclerotic appcarance. The scleroric areas represent chondroid matrix mineralization and arc seen in 60- 78% of lesions. The characteristic appearance of mineralized chondroid matrix is a 'ring and arc' pattern of calcific:uion that can co..11esce to form 'snowflake- type' calcification. T his characteristic chondroid calcification usually ;\lIows confident radiological di;\gnosis of a cartilaginous lesion. R.,diological signs· Mi xed lytic/sclerotic lesion. Wide z:onc of transition. 'Ring and arc' and 'snowflake' calcification. Cortical destruction. Soft tissue mass. C hondrosarcomas arc also characterized as central or peripheral. Central chondrosarcomas make up the majority and arc intramedullary in origin, although they may erode through the co rtex into the soft tissues . Central chondrosa rcomas lIsuall y arise in the pelvis or lemur and arc often expansile with the characteristic calcification described . Endosteal scalloping is often seen and call help diflcrcntiate low-gr;\de chondrosarcomas from enchondromas. Clinical sympwll1s arc nonspecific, with pain being the most frequent symptom . Peripheral chondrosarcoma is also termed exostotic chondrosarcoma and refers to malignant degeneration in an cxostosis (i.e. is a secondary chondrosarcoma). An cxample is shown in Figurc 141 bnote the flocculent calcification of the chondrosarcoma, which had arisen from the exostosis at the lateral femoral condyle. This should always be suspected when there is growth o f an exostosis after skeletal maturity or if an exostosis becomes painful. The cartilage cap of a suspicious exostosis can be measured 011 M lU, and if the thickness is
252
As with most primary bone t um ours, a su chondrosarcoma should only be biopsied in a bone tumour centrc so as nOt to seed tll contaminate the su rgical field.
Further reading Murphey lvi , Walker E, Wilsoll A, et at. (200 3). of prim.\!)' chondrosarcoma: radiologic-path correlation. /{ndioGmpbics 23: 1245- 1278.
141b Flocculent calcification from a chonrlrosarcoma that has arisen from the exostosis at the lateral femoral condyle.
Case 142 A 45-year-old male presented with severe back pain for several weeks.
253
Musculoskeletal Imaging
Answer 142
ANSWER 142 Observations (142a, 142b) AP and hlteral images ( 1423 ) ofthc thoracolumbar spine shol\' marked deformity at the TI2/ LI level with erosive destruction of the opposing ,"enebral endplates. There is anterior slip at this level with anterior angulation (gibbus deformity)_ Appearances arc in keeping \'ith a discitis. Axial and coronal T2 weighted MR images ( 142b) demonstrate high signal in the TI2/ Ll intel"Yertebral disc. Signal change extends throughout the adjacent ,·ertebrae, and there is endplate destruction and partial vertebral coll:tpse at T12. Til ,·ertebra has increased marrow signal suggesting it is also in\"ol\"ed. The axial image demonstrntes high -signal fluid collections in both psoas muscles consistent with bilateral psoas abscesses.
Diagnosis Tuberculous spond~'litis ( Pan's disease ) with associated psoas abscess.
Di scussion The spi ne is the most common bony location to be in,'olved in TH. Presentation is often late since initial sympl"oms :are of ,"aguc back pain and stiffness. The most common location IS the upper lumbar/ lower thor:acic region, particularly around L I leyel. The anterior aspect of the venebral body is mOSt typically aftectcd. The disk spacc thcn becomes involved via cxtension along the anterior or posterior longitudinalligamelll or directly through the endplatc.
R:adiological features of disci tis include: Reduction in height of the intervertebral disc, is usuall~' the first sign of a disciris. Erosion of the "ertcbral endplates. Involvement of the vcrtebrallxxlies leads to and resulting gibbus deformity. Spread of infection into adjacent soft tissues in psoas/ paraspinal abscesses. • Neurological im'ol\-ement arises due to intraspim. spread of infection and vertebral body colla~ occurs much more commonly whe n the infecri"fo_ organism is TH.
Practical tips • Discitis will cause bon)' abnormality of the su and inferior endplates of the adj:acent ,·enebral i.e. abnormalitv will be centred at" the level of • Thc vertebral disc space is m:aintained longer ill. spondylitis than in pyogenic discilis. • Look at the paraspinal regions to look for s infection. Infection can present as leg pain/s-duc 10 rracking of collections dOWI1 the iIi muscle. • Look at, and around the spinal cord for ex collcctions :and spinal in\"olvemem.
Further ma nagement Treatment is with antituberculous medication. of associated psoas or epidural abscesses may be
142b (left) Vertebral body collapse w ith abnormal marrow signal in the vertebral bodies above and below it. Bilateral psoas abscesses (right ).
254
Musculoskeletal Imaging
Cases 143, 144
male presented with hand following :J.
255
Answer 143
Musculoskeletal Imaging
ANSWER 143 Observations (143a) There is a bilaterul symmetrical erosive arthropathy ltlecting the distal interphabngell joints. BOlle density is preserved and there is 'pencil in cup' ddormity with bony proliferation. At the left little finger there arc signs of ankylosis of the distal interphalangell joint. The appearul1ces lre consistent with psoriatic arthroplthy.
Diagnosis Psoriltic arthropathy.
Differential diagnosis • Ankylosing spondylitis. • Rheumatoid arthritis (RAJ.
Discussion This is a seronegative arthropathy aflecting synovium and ligal11entous attachmcnts, and aflects fewer than 5% of psoriasis pltients. In approximately 15%, the arthrop~1thy Cln predate de\"clopmem of skin changes by SCI'aal years The pattern of disease is \'arilble, though the case illustruted is classical, i.e. asymmetric erosive oligoarthritis aflccting the distal joints of hands and feet. New bone formation is charucteristic, and Illay i"esult in ankylosis of interphalangcal jOllHs, as in this case. Resorption of the distal phalangcal tufts nu y Ix seen with accompln)'ing nlil changcs. Spondylolrthrop;lthy is another pattern of disease, often with sacroiliitis and parul"ertcbrul os.~iticltions. Other disease paTtefllS include symmetrical pol\'arthritis mimicking rheulllatoid, lllotloarthriris and arthritis mlltilans, a grossly destructivc pattcrn that may progress to forlll 'opera glass hand'
143b Radiograph of bot h hands of a patient with rheumatoid arthritis. Bilateral symmetrical erosive destruction is present affecting the metacarpophalangeal joints and the wrists. Note the telescoping of bone ends and the periarticular osteoporosis .
256
Practical tips When presented with a hand radiograph with C'\ of erosil'l' arthropathy, certain diflt~remiatill g can help identify the most likcly aetiology. T he mdiological differentiating learures of the more common crosive arthroplthies arc as tallows: • Psoriatic arthropathy: - Usually (/IyJllmctrical aosh"e. - lntaphalangeal joints, particularly the dist:a. interphalangeal joints, aTe a!lecred. - ROilY prolijcrfltioJl/ periostcal reactioll ani prcsCJ1'cd bom dCllsit'ycharacrerisric. - 'Pencil in cup' ddormity - Ankvlosis . It' - Bilateral symmetrical crorlJ'e arthropathy. - Metacarpophalangeal and proximal interphalangeal joi!HS affected, Le. prOD JIIlfll/joj'ltsojdigilJ. - Margillal erosions. - Subluxation with ulnar deviation of digiD. -
Decreased bone demity.
- Ankvlosis. . - Figure 143b is a rudiograph of both patient with rheumatoid arthritis bilateral synllnetrical crosil'c dcstructX.. llletacarpophabngeal joints. There is genemlized decreased bone density and arthropathy at rhe carpal joints and rail. joints. Figure 143c sholl'S similar ch _ feet of a rheumatoid patient with m~ erosions and symmetrical subluxation .. metara.rsophalangeal joints bilaterull~
143
Musculoskeletal Imaging
• Gomy arthropathy: - .\symmetrical crosh'c arthrop:llhy. - Erosions arc juxta-articular with DVttiJnllgj"g
("gu. - Preserved bone density and joint space. - Bony proliferation/periosTc:ll reaction. - Goltr) tophi causing sort tissue masses in 50%. - Figures 143d and 143c arc radiographs of goU[ de mo nstrating an asymmetrical eros;ve arthropath y with 'punched out' erosions. These ~rosions have o\'crhanging edges, which arc best seen at the proximal imerphalangeal joints orthe index fingers bilaterally and the mcucarpophlbngcal joint o f the right thumb. Further hrgc 'punched out' juna-articular erosions with associated tophi arc seen around the base of the right big toe in particular. Note the preservation of bone density.
•
It is impossible to distinguish thc sponrlyloonhropathy of psoriasis from Reiter's syndrome though it is notable that in psoriasis the hand is most affected and in Reiter's, the foot. Spond)'lo.1.rthropathy of psoriasis is diflcrcnt r:tdiographic~lll)' from ankylosing Sl)()nd)'litis - thc paravcrtebral ossification is asymmetrical and nOT d uc to true s)'ndesrnophytes.
Further manage ment Givcn thc inflammatory nature of the disease, treatment consists of anti -inflammatory and immunosuppressive drugs as for other infl3mmatory anhrop:lthic.::s.
Radiog ra ph o f both ha nds d e m o nstrates , 'punched out' e rosio ns w ith overhangi ng and associated soft tiss ue swelling in a patient gout.
'43e Radiograp h i gout with characteristic 'punched o ut' erosions aff ecting the big toes.
257
Answer 144
Musculoskeletal Imaging
ANSWER 144 Observations (144a) Il:adiogr.:tphs of the lett hand fCveal ::I lucent cxp:msik lesion ofthc diaphysis ofthc 5th Illcrac:upal. There is thinning of the cortex but no conical breakth rough or periosteal
reaction. No pathological fracture
hlS
occurred and no
fraCl11rc is seen elsewhere. The lesion has a narrow zone of tr:l.l1sition and nonaggrcssivc fcamrcs and is consistent \\ith
Pract ica l tips Chondroid pattern calcification, onen seen in enchondroma, is howe,"er frequelllly absent in of the tubular bones of the hands and feet. A painful enchondroml without pathological should be suspected of having undergone m tr:lnsformation IIntil pro\'en o therwise
an enchondroll1a.
Diagnosis Enchondroma.
Further manag ement There is no specilic treaTment for enchondronu .. benign bony le~ion That is oflen picked up inci when a pathological fr:lCture occurs.
Differential di agnosis For lytic lesion in the digits (mllemonic - 'SEGA GAME 1"), • Simple bone cyst - r;uc in the hand. Enchondroma is by fur the most likely lesion with this appcar;l1Iccat this site. sis w it h J 'bO lle wi {hiLl hOll e' ,1Pl'C.'1rJL1ce, The most likely cii.lgnosis is ostt'opelros is,
Dia gnosis Osteopetrosis cau sing a 'bone wit hin hellle'
ap~~Cdr;Ll1Ce,
Different ia l di ag nosis Of ' bone wit hin bOll e' appcJr;lIJcc (mJ1C'lll o nic ,- 'SHA RPS POOL ') : SicklC' cdl ,iiscasc, .. H ypervil~ Lllinosis D, • /\cromegaly, '" Rickets, '" r;lget's dis n~e Sc nrvy'" Post- radi,llioJl tberapY/Lh ol'Ouast/hell'Y metal
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MusculoskeletlOllmaglng
Answer 156
AN SWER 156 Ob" fYllio ns l l 56 1 ~
,.11 00_ No "'n~ up"" ofo.otop< ~ " " '. ho.~,~, tbe .. ~ >om, "r"h in to. bI.JJu , 11.. ' inoJin~, m ,h,,,,"", "",,"',n' ~ 1' 0 • ~>' Ii!." " ""'" i, wiJ.-""""' in ,'" "",,,,'" f""'lu< ing . ' t .. ",m"",', ,1101;, .... ,,,,,,",, .'~h ",.,"'1 ,~-dl i "~ .oJ duhh,,¥ '~'Cu0." ~"""'. >I.",
" f "" ph.l.ngarathyroidism in 3% ofc:lscs. Figure 160c sho\\"~ a pathological fracture through a bro\\TI
160b Left hand radiograph demonstrating lucent bands of resorption across the mid-portions of the distal phalanges of the first three digits.
La.mina dura of skull :Illd teeth producing 'fl
teeth' , 'Pepper-pot' skull due to trabecular n:sorplion ( 160d ). Pseudo-widening of joillls, e.g. sacroiliac jointi.. • Margill~\1 cro5ions of the h;lIlds.
Bone softening: Wedged I·ertebrae. • Kyphoscoliosis. • Bowing of long bones. Brown tumour ( 160e). Osteosclerosis (marc common in seconda/"}' h)"l>erp;lralhrroidism ). • 'Rugger jersey' spine. Soft tissuc calei/ication: Periarticular. • Chondroc:llcinosis. • Anerial. Ren:ll c:llculi. 1\ ledullary nephrocalcinosis.
""'l t
l~
160c AP radiograph of both knees demonstrates subperiosteal resorption at the medial aspect of both tibial metaphyses.
286
MuSculoskeletal Imaging
A nswer 160
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CASE 177 History ~onc ;lvaib blc.
3 13
Answer 177
Paediatric Imaging
ANSWER 177 Observations (177a) There is panial n lsion of an extra digit with the mct:lClrpal of the IinJc finger. This c ssc n tial1~' represents polys)'lldact)'ly, the possible causes of which include idiopathic, Ellis- van Crc\'c1d syndrome and C:arpcntcr syndrome. Diagnosis Ellis-van Crcn:ld syndrome.
Discuss ion There arc scveral causes ofsrndactyly (filsion of digits) and polydactyly (supernumerary digits ), which arc both congcnit:ll abnonnalitics. Ellis- van C rcvcld syndrome is also assOCiated with carpal fusion, as is Apcrr's syndrome. This is characterized bv features in the skull: notabk craniosynostosis of the ~oronal sutures, hypoplastic mid filee and enlargement of the sclb. . All of these features arc dt~lllonstratcd in the lateral skull radiogl':lph in a child with Apert's syndrome ( 177 b ).
Differential diagnosis
or causes of polydactyly:
• Idiopathic. Ellis- van Crevcld syndrome. • Carpenter syndrome. • Polysynd:lCtyly syndrome . O fca llscsof s),ndaCfyly: • Idiopathic. Apcrr's synd rome. Carpemer syndrome, Down's syndrome. Poland's syndrome . NClirofibrolllarosis.
Practi cal tips Some exam cases will have an obvious abnormality as part of a syndrome that you do n ' t know - Slating that you would seek help from a te.u book o r specialist colleague is a reasonable answer. You ca n't know everything! Further management Po ly/syndactyly will be parr of a syndrome with multiple ab norrll ~l 1ities.
177b Lateral skull radiograph of a child with Apert's syndrome demonstrating craniosynostosis of the coronal sutures, hypoplasia of the midface and enlargement of the sella.
314
Paediatric Imaging
Case 178
CASE 178 History ~onea\'ailablc.
315
Answ er 178
Paediatric Imaging
ANSWER 178 Observation s (178a, 178b) There is bowing deformity ohhc tibia, fibula and humcms The metaphyses of the bones arc widened producing an Erlenmeyer flask deformity. The metaphyses arc also rclati\'cly lucent when compared with the diaphysis, which is sclerotic. There 3fC no specific leatures 10 indicate lead poisoning, ostcopo.!tTOsis or thalassacmia, so the diflcrcnti:ll diagnosis lies between Pyle'S disease and lipidoses such 35 Gaucher's or Niemann- Pick disease.
Diagnosis Pyle's discasc.
Differential diagnosis [11 rhiscasc: Craniomct'aphyscai dysplasia. • Niemann-Pick disease. • Gauchcr'sdiscasc. Of Erlellmeyer flask deformity (mnemonic - 'Lead GNOME'): • Lead. G3uchcr's. Niemann- Pick disease - looks like Gaucher's but withouJ avascular necrosis. Osteopetrosis Mctaphyse;11 dyspbsia ( Pyle's) and craniollletaphyseal dysplasia (same as Pyle's discase: but there is a history of cranial nelyepalsies). 'E'malOlogical!! - thalassaemia.
Discussion Pyle's d isease is also known as metaphyseal dyspbsia. It is a rare autosomal reccssi,"c disordcr characterized by flaring of the ends of long bones with relative constriction and sclerosis of the ce mral ponion of the shafts. Affected patients arc usually as~' mptomatic and genu valgus
deformity is often a featu re:. The expanded metaphyses tend to be lucent and have the appearance of an Erlenmeyer flask (narned after the wide necked laboratory flask bearing the name of this German chemist). Craniometaphyseal dysplasia essentially has the samc features but in addition there arc cranial nCIYe palsies due to sclerosis of the skull base. Gaucher's disease is a hereditary disorder oflipid st.oragc common among Ashkenazi Jews. It is characterized by hepatosplenomegaly with flask-shaped long bones and generalized osteopenia with strikingly thin corticcs. Avascular necrosis is also a feature.
Practical tips Erlenmeyer flask deformity, the metaphyseal expansion of long bones, is also discussed in Chapter 5. AdditionaJ differentiating ICaturl..""S can be found on [he r:ldiograpn as to the specific underlying cause of Erlenmeyer flask. deformity: • Diftllsc sclerosis and sclerotic vertebr:ll endplates producing 'sandwich vcrtebrae' indicate osteopetrosis. With Pyle's disease, there will be relative sclerosis at the diaphysis and lucenc)' of tne metaphysis. Gaucher's disease will also be associated with lucency and osteopenia but there may be signs of anscular necrosis of the femoml or humeral hcads (loss of height and Ii-agmentation ) and on an AXR massi,"e hepatosplenomegaly may be seen. Thalassaemia is associated with coarsened trabeculation producing a 'cobweb' appearance. Lead poisoning causes dense metaphyseal bands as well as Erlenmeyer flask deformity. Further management This condition is usually asympromatic and requircs n... direct management.
1788 Metaphyseal widening with increased lucency.
3 16
Paediatric Imaging
CASE 179 Hist ory _'onc3vailabk,
Case 179
Answer 179
Paediatric Imaging
ANSWER 179 Observations (179a , 179b) The lateral skull radiograph ( 179 b ) demonstrates thinning of the calvaria with multiple wormian bones. Bowing dctormirics afC seen w atTcC[ the lim bs (1 79a ) and there Ut several frlcturcs of diHcring ages, mostly seen at the metaphyses of the long bOlles. Thac is geller,\iized oSTcopcnia of the skeleton with marked thinning of the con ices. The fcanm::s arc consistent with osteogenesis irnpcrfccT:t
Diagnosis Osteogenesis impcdccta Differential diagnosis Of lI'oTmian bones with common causes underlined ( mnemonic - 'PORKCH OPSI' ):
• P),knodysostosis Ostcogcm:sisinmcrfccra. Rickets in healing. Kinky hair s)'lldromc (I'''knkcs). Cleidocranial dysostosis. Hypothyroidism/hypophosphatasia. Otopalatodigital syndrome. Pach),dermoperioslosis. • Syndrome of Down. I~!iopa[hic nOrllwl in first ,"car of life.
318
Di scussion Osteogenesis imperfecta is a connective tissue disorder characterized by fi.lgile bones and blue sc1eme. Type I is comp:ltiblc with life. Type 2 is the lethal form associated with perinatal death. The principal radiological features include: Diffuse osteopcnia with thinning of cortices. Multiple fractures of differing ages with pseudarthroses and bowing deformity. Fractures arc associated with exubcmllt callus fOfmation. Biconcave yerrebi.ll bodies. Multiple wOTmian bones in the skull POOf dentition. Practical tips Multiple fractures in children should i.lise suspicion of non accidental injury (NAI) and sometimes diflcrentiating this from osteogenesis imperfecta can be difficult. Predomin:lJ1t1y osteogenesis fractures are diaphyseal compared with metaphyseal NAI fractures but this is nOt always the casco Further management Early medical inteIyention to increase bone mineral density and surgical intcrvention to treat/correct scoliosis and treat fractures mean that a multidisciplinary ap proach to the ongoing treatment is required
Paediatric Imaging
CASE 180 Hist ory A ch ild presented vomiti ng and .uaxi:!.
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CASE 181 Hist ory A 2-l11omh-old baby presented with cyanosis. (Ste pnge 322 [01- e(lse (lllslI'cr)
Cases 180, 181
Answer 180
Paediatric Imaging
ANSWER 180 Observations (180a) A series of axial MRI images of skull show a well defined hypcrdcnsc mass in the cerebellar ycrmis causing compression and anterior displacement of the 4th ventricle with obstmctil'c hydrocephalus. A small alllount ofocdcma su rrounds the mass. The teatures arc typical of a medulloblastoma Diagnos is Medulloblastoma. Differential diagnosis Of posterior fossa tumour in children: Medulloblastoma: Predominantly midline posterior to 4th vcmriclc. Hypcrdcnsc on CT with oedema. • Avid cnh:I.llCCl11CllL • 20%calc;!)', 50% necrose. Juvenile pilocytic astrocytoma: Typically paracentral, posterior to 4th ,'cntriclc Majority arc cystic with an enhancing mural nodule, the remainder arc solid. 20% calci!)'; oedema is rare. Epend)'llloma: Arises within 4th ve ntricle. Heterogeneous appearance and enhancemem • SO%c;\lcify.
H ydrocephalus is ott·en communicating type due to protein exudate obstructing CSF resorption Spreads through the exit foramen of fourth \"emride and wraps around brainstern ('plastic growth'). Sagittal and axial T2 weighted MR images (l 80b ) demonstrate a high signal lesion arising within the 4th Yemricle, wrapping around the brainstem and spreading via the foramina of Luschka and Magendie. Hydroceph.llus is present and a syrinx orthe upper cervical cord has de,-doped. Hrainstem glioma: Within pons, possibly causing pontine expansion or 4th 'Tntride displacement posteriorly_ Iso· or hypodense to brain so may be easily missed. Sagittal TI weighted MIl! with contrast ( i SOc) dcmonstrates a large pontine glioma. Note how the lesion is nonenhancing and almost the same signal as surroundi ng brain. Smaller such lesions can easily be missed due to such imaging characteristics. Enhancement often absent or minimal H),droccphalus uncommon (because present with focal neurology before this occurs).
Disc ussio n ,\kdulloblastoma is the second most common paediatric brain tumour and the most common in the posterior fossa. It is a tl'pe ofprimiti\"e neuroectodermal tumour ( PNET)
180b Sagittal and axial T2 MRI of the brain demonstrating an ependymoma in the 4t h ventricle, which extends into the foramina of l uschka and Magendie and causes obst ructive hydrocephalus. A syrinx of the upper cervical cord has developed .
320
Answer 180
Paediatric Imaging
arising from the roofofthe 4th,\·cntriclc. The majority of patients affected are under the age of 15 years, with 80% of lesions arising from the cerebellar vem}is, and the rest lying more laterally in the cerebellum. This lateral location is marc C01111110n in older ch ildren. They arc typically hyperdensc on CT due to dense cellularit)" and show avid, homogeneous enhancement. There is usually surrounding oedema, 20% show calcification and up to 50% show necrosis/cystic change. They arc highl~' malignant and spread occurs via the CSF in up to a third. Medulla· blastoma is rardy associated wi th Gorlin's syndrome - an autosomal dom inant disorder cha racterized by multiple Cluaneous basal cell carci nomas during childhood with mandibular ker:l.tocvsts and enensin: intracranial Gllcificarion of the fal~ and tentorium. At least 50%of primary brain IllmOUfS in children occur in the posterior fossa. Brainstem glioma tends to present with focal neurology due to invoh'ement oflhe long tr:J.cts and cr:J.nial nerve nuclei, while the olher three differential diagnoses listed present br way of mass effect and obstructive hydrocephalus with headache , vomiting and at3xia . The salient imaging reatures of each arc listed. Ir is important when staging paedi,lIric posterior fossa tumours to remember the potential ror CS F spread with medulloblastoma in particular, but sometimes with ependymoma too. POSt gadolinium scans should therefore include the whole spine as well as brain to pick up such deposits ('drop
metastases' ). A sagi nal TI MlU post-contrast ( l SOd ) demonstrates an enhancing medulloblastOma in the posterior fossa causing obstructi"e hydrocephalus. CSF spread of tumour has occurred with a metastasis in the prepontine cistern.
180e Sagittal T1 weighted MRI post IV contrast that shows a large pontine glioma.
180d Sagittal T1 MRI of the brain with gadolinium show ing an en hancing posterior fossa mass, w hich causes obstructive hydrocephalus. A metastasis is seen in the prepontine cistern. This proved to be a medulloblastoma.
Practical tips Make sure the post COntr:J.St scan looking for drop metastases is done preopcrarh'dy as postoper:J.ti\'e haemorrhage and granulation tissue can cause connlsion. Haemangioblastoma is primarily a tumour of adults but can be seen in adolescents in the posterior rossa when part of\'on Hippcl- Lindau syndrome. It is typically a cystic mass \\~th enhancing mUr:J.1 nodule, SO has similarities with pi lacyt ic astrocytoma.
Further management M RJ of the spine with intr:J.venous contrast enhancement should be undertaken to look ror 'drop metastases'. Neurosurgical assessment is then dearly appropriate.
Further reading Koeller K, Rushing E (2003 ). From the archives of the AF IP: medulloblastoma: a comprehensive review \\~Ih radiologic-pathologic correlation. RadioGraphies 23: 16 13- 1637.
321
Answer 181
Paediatric Imaging
ANSWER 181 Observations (181a) There is a right sided aortic arch, The heart is boot shaped indicating right ventricular hypertrophy. The lungs are not plethoric, in fun there is a reduction in the calibre of the pullllOnary vessels. Ol"crall, the !caturcs Jre suggestive of Ell10r'S Tetralogy
Diagnosis Tetralogy of FalJot. Differential diagnosis Of conditions associated with a right sided aortic arch: • Truncus arteriosus. • Tetralogy of Failor. • Transposition of great vessels. • Pulrnonarvatrcsia • VClltricul~r septal delcct (VSO ). Discussion Tctralob'Y of Failor is Olle afthc most common causes of c)lanotic congenital hean disease and is composed of the following: obstruction of right \"cntricular outflow, brgc VSD, right ventricular hypcnrophy and an o"erriding aorta. Radiological features on CXR arc· Conca"ity in tIle region of the pulmonary anery, which is small. Enlarged aona
Normal sized hean. Boot shaped hean due to right ventricular hypertrophy. Right sided aortic arch in 25% of cases Decreased calibre of pulmonary ,"essels. Right sided aortic :lfch may also be seen in paticnts with another cause of neonatal cyanotic congenital hean disease - transposition of the great ,·essels. However unlike Fallot's there is increased pulmonary vaseularity and the heart has an 'egg on its side' appearance on the CXR due 10 Ihe f::lct that the mediastinum is narrow because of the abnormal relationship of the great vessels. An example is shown ( 18 1 b ), though in this particular casc the aortic arch is left sided.
Practical tips • Fallot's tetralogy, pulmonary stcnosis and tricuspid atresia cause cyanosis with oligaemic lungs. Transposition ofthe great vessels, tmncus arteriosus and lotal anomalous pulmonary venous drainage cause cyanosis with plethoric lungs. Further management Cardiolo~' referral for echocardiography and consideraTion for a palliati,·c shunt or complete surgical repair.
181b CXR in a child with tra nsposition of the great vessels. There is pulmonary vascular congestion and the heart has an 'egg on its side' appearance.
322
Pae diatric Imaging
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CASE 186 History A 56~ycar· old woman with a firm mass in the ccmrallcft breast.
Case 186
ANSWER 186 Observations (186a, 18Gb) Bilateral mammograms show that in the upper central and hucral aspects of the left breast there is extensive pleomorphic microcalcification. Within the left axi lla there is a 21 mill diameter rounded node. The right breast appears normal. Ultrasound of the superior central left breast demonstraTes an irregular solid mass. The extensive microcalcification is of a configur:ltion suspicious for malignancy in the central left breast. There is possible metastatic spread ro the large axillary node. The ultrasound demonsrrates a probable malignancy. Furrhcr investigation with urgent biopsy of the lesion is required.
Diagnosis Ductal carcinoma ill situ ( DC IS ) with involved axillary nodes.
Differential diagnosis For pleomorphic calcification on mammograms: • DCIS. Atypical ductal hyperplasia. • Fat necrosis. • Fibrocystic change.
Look carefully for signs of an invasive focLis within the ca1cifieltion - search for a spiculate mass or stromal deformity. If not identified, assess further with ultrasound and possibly MR imlging.
Further management Further imaging assessment is suggested : mammographic magnification orthogonal views (typically craniocaudal and mediolateral ) may evaluate morphology and distribution of the microca1cification. Ultrasound guided biopsy of the solid lesion lnd mlmmographic stereotactic biopsics to Obtain a sample containing calcification should be performed. The sllspicious node should be sampled under ultr;l.sound guidance. In this case, the biopsies showed : ultrasound solid lesion - invasive carcinoma; stereotactic carl'S - DClS; axillary node - malignant cells. Once a diagnosis of malignancy has been established, surgical rcferral is required. In this case the pltien r underwent a mastecromy and axilbry lymph node clearance. Histological findings ,,·ere of a 12 mm I DC in thc superior ccntral breast with extensive (7 cm) intermedi,He grade DCIS; 4 Ollt of 15 axillary nodes were involved with tumour.
For enlarged axillary nodes: • Ipsilateral breast malignancy. Infection/inflammation of ipsilateral breast or arm. Collagen vascu lar discase/rheumatoid arthritis. Lymphoproliferative diseases: lymphoma and leukaemia . Metastases (melanoma, lung, contralateral breast). HIVadenopathy.
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pulmonaryarterim·enolls malform:uion 33 pulmonary asbestosis 3, 15 pulmonary embolus 31 pulmonary fibrosis dmg-induced 18 lowcrzone 15, 17 upper zone 15,17, 18 pulmonary haemosiderosis 23 pulmonary interstitial emphysema (PIE) 165 pulmona!)' malignancy asbestosis 15 systemic sckrosis 17 pulmona!)' metastases, cavitating 14 pulmona!)' nodules follo w-up 6 mitral vah'e disease 23 oesophageal tumour 14 rhcumatoid lung 6 sarcoidosis I pulmona!)' oedema 3 1 heart failure 29 pUlmOlla!)' opacity barium aspiration 20 ground glass 29 Icft upper lobe tumour \,~th lrmphangitis carcinomatosa 12 lung lobe collapS(: 14 metastatic calcinosis 20 pleural pscudotumour II puhnona!)' sarcoidosis 1 pulmonary \·cnous hypertension mi tral \'alvediscasc 23 pulmona!)' oedema due to heart failu re 29 pyelitis, emphyscmatous 63 pyclou reteritiscystica 77 pyknodysostosis ! 19, 168 Pyle's disease 119, 178
renin-angiotensin system, o\'eracrivity 58 rcspirarory distress, meconium aspiration syndrome 170 reversal sign 114, 163 rheumatic heart disease 23 rheumatoid arthritis 120,143 rheumatoid factor 17 rheumatoid lung 6 rheumarologic syndromes, histoplasmosis 25 rib. bilateral cervical 28 eXOStoses 130 lesions 9 notching 32 rickets 168, 175, 176 fig ht ventricular hypertrophy, mitral valve disease 23 Rigler sign 75, 167 Rigler's triad 41 Rokitansky nodule 84
Rathke cleft cyst 106 Raynaud's phenomeno n 17 thoracic Outlet syndrome 28 rectum st'ent'ed tumour with calcified liver metastases 52 ulcerative colitis 65 Rdter's synd rome 116, 143 renal adenocarcinoma 5 1 renal arte!)' stenosis 58 renal ectopia, crossed nlsed 68 renal lesions, fat 48 renal medullary nephrocalcinosis 43 renal obstmction, hydronephrosis
sialectasis, juvenile punctate 87 sicklccclidisease 129, 140, 155 siderosis, transfusion 50 sigmoid colon, displacement 84 sigmoid mlvulus 46 silicosis 18 simple bone cySt 115 Sj6grcn's syndrome 87 skin folds, lung edge art:efuct 35 skin nodules, neurofibromatosis type I 8 slipped upper femoral epiphysis (SUFE) 117 small bowel adenoma 49 ischaemia 59 loop dilatation 69 strictures 59 thickening in Crohn's disease 53 small bowel obstrucdon 4 1 adhesions 47 mechanical 4 1,47
S sign of Golden 14 sacral agenesis 173 sacroiliac joint disease Crohn's disease 53 ulcerative colitis 65 sacroiliac joint fusion 139 sacroiliitis 116,143 sandwich ,·enebrae 140 sarcoidosis cardiac sarcoid 22 pUinlOna!)' 1 schistosomiasis 62 schizcncephaly 169 sclerpdcrma 132, 152 sclerosis Charcot joint 138 dilYuS(: 119 sep~\1 thickening, interlobular 29
68 renal osteodystrophy 11 9, 140 renal papilla!)· necrosis 78 renal scarring, infections 68 renal stones, horseshoe kidney 5 1 renal lUberculosis with autonephrecromy 74 renal tubular acidosis 43
351
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