Radiology spotters

radiology spots

1. SPOTTERS Dr Priyanka Rana 19.6.18

2. 1 Presentation Pancreatic carcinoma metastatic to liver who underwent placement of a Port-A- Cath via the right subclavian vein. On last chemotherapy administration swelling and pain was noted in the soft tissue around the port reservoir and catheter associated with chemotherapy administration. Image guided evaluation of the Port-A- Cath has been requested.

3. 2.

4. 3

5. 4.

6. . A 25-year-old man with oculocutaneous albinism presented to the emergency department with multiple exophytic head and neck masses that had been developing for years. 5

7. 6

8. 15-year-old boy with a history of chronic swelling around the left eye 7

9. 8. A 5-month-old boy brought by his parents to the clinic for evaluation of bilateral leukokoria . Examination revealed bilateral retrolental masses. His elder brother was also blind by birth and developed hearing loss at the age of 12 years. His 2 elder sisters were completely normal

10. 9.

11. 10.

12. 11.

13. 12.

14. 13.

15. 14.

16. 15

17. 16.

18. 17.

19. 18.

20. 19.

21. 20.

22. 21.

23. 22

24. 23.

25. 24. Sign

26. 25.

27. K ey

28. 1 Presentation Pancreatic carcinoma metastatic to liver who underwent placement of a Port-A- Cath via the right subclavian vein. On last chemotherapy administration swelling and pain was noted in the soft tissue around the port reservoir and catheter associated with chemotherapy administration. Image guided evaluation of the Port-A- Cath has been requested.

29. There was difficulty to aspirate the port; contrast injection demonstrates 2 separate breaks in the catheter: In the catheter approximately 2 cm from the connection to the port reservoir and a larger break is noted near the right subclavian vein access site. In addition there is "pinch off" of the catheter at the right subclavian vein insertion site associated with movement of the medial right clavicle in respect to the right first rib. Pinch off syndrome

30. Pinch-off syndrome Pinch-off syndrome  is a spontaneous catheter fracture, which is seen as a complication of subclavian venous catheterisation . Chest radiograph Look for catheter deviation, luminal narrowing and discontinuity (fracture) of the tube Grades of abnormality grade 0 : no narrowing in the catheter's course grade 1 : deviation of the catheter with no luminal narrowing grade 2 : luminal narrowing as the catheter passes under the clavicle (pinch-off sign) grade 3 : transection of the catheter between the clavicle and the 1st rib with embolization of the distal catheter 1

31. 2.

32. Subpulmonic pleural effusion The left dome of diaphragm is higher than right with increased distance of diaphramatic outline to the fundal air bubble of stomach, suggestive of a subpulmonic pleural effusion.

33. Chest radiograph Apparent elevation and flattening of the diaphragm. What appears to be the diaphragm actually represents the visceral pleural, and the true diaphragm is obscured by the presence of intrapulmonary fluid. The peak of the pseudo-diaphragm will lie lateral to the normal position.   When located on the left, an increased distance may be seen between the pseudo-diaphragm and the gastric bubble. If required, a  decubitus projection can be performed to clarify the definite presence of a subpulmonic effusion.

34. 3

35. 3 unilateral grade II germinal matrix haemorrhage

36. G erminal matrix haemorrhage Classification grade I restricted to subependymal region/germinal matrix which is seen in the caudothalamic groove overall good prognosis 4 grade II extension into normal sized ventricles and typically filling less than 50% of the volume of the ventricle overall good prognosis 4 grade III extension into dilated ventricles ~20% mortality grade IV grade III with parenchymal haemorrhage 90% mortality 4

37. 4.

38. Mucinous cystadenoma of pancreas Radiographic features CT The tumour contour tends to be rounded or ovoid. Associated calcification tends to be more peripheral Contents of the lesion may be heterogenous is attenuation. Internal septations may be present and tend to be linear or curvilinear.

39. . A 25-year-old man with oculocutaneous albinism presented to the emergency department with multiple exophytic head and neck masses that had been developing for years. 5

40. 20.

41. 20.

42. 6

43. Radiation pneumonitis Radiation pneumonitis  is the acute manifestation of  radiation-induced lung disease (RILD)  and is relatively common following radiotherapy for chest wall or intrathoracic malignancies . Plain film Chest x-ray changes are non-specific, but confined to the irradiation port, with airspace opacities being most common. CT Change restricted to the irradiated field, making the diagnosis much easier. In cases of early or subtle radiation induced pneumonitis, areas of ground-glass opacity may be evident on CT. The two most common findings are  1-2 :  ground-glass opacities  and / or airspace consolidation Additional features that are sometimes seen include  1 :  focal or nodular opacities tree-in-bud appearances ipsilateral   pleural effusion atelectasis

44. 15-year-old boy with a history of chronic swelling around the left eye 7

45. Allergic fungal sinusitis is a disease process with a similar appearance to invasive fungal sinusitis, but one that occurs in an immunocompetent host. Imaging findings on CT include hyperdense opacification of the affected sinuses.  Expansion of the affected sinus is characteristic, and erosion is not uncommon.  Peripheral enhancement within the affected sinuses represents enhancement with the mucosa. 

46. 8. A 5-month-old boy brought by his parents to the clinic for evaluation of bilateral leukokoria . Examination revealed bilateral retrolental masses. His elder brother was also blind by birth and developed hearing loss at the age of 12 years. His 2 elder sisters were completely normal

47. 22.

48. 22.

49. 9.

50. Imaging Findings Increased lucency in the pelvis on conventional radiography due to fat deposition Inverted teardrop-shaped bladder (pear-shaped bladder) Ureters may be dilated and may be medially or laterally displaced distally Hydronephrosis , usually bilaterally The rectum is elongated and symmetrically compressed Rectum may be displaced cephalad (tower rectum) Increased distance between seminal vesicles and posterior bladder wall CT shows tissue surrounding bladder/rectum to be that of fat (-40 to -100 Hounsfield units) Pelvic Lipomatosis

51. 10.

52. Pellegrini-Stieda lesion Pellegrini-Stieda (PS) lesions  are ossified post-traumatic lesions at (or near) the medial femoral collateral ligament adjacent to the margin of the medial femoral condyle . One presumed mechanism of injury is a  Stieda fracture (avulsion injury of the medial collateral ligament at the medial femoral condyle ). Calcification usually begins to form a few weeks after the initial injury. Radiographic features Plain film Calcification adjacent to the medial femoral condyle , often linear in shape.

53. 11.

54. Imaging Findings Bilateral paraspinal masses with round,   lobulated margins Thoracic masses occur most often in patients with thalassemia or congenital hemolytic anemia Medullary expansion of the bony structures with widening of the ribs being the most pronounced bony finding Resorption of trabeculae produces coarsened appearance to bones Splenomegaly (or absent spleen) Masses to don’t calcify and do not usually cause bone erosion The lesions are usually of low-attenuation on non-contrast CT and may mildly enhance after contrast Extramedullary Hematopoiesis

55. 12.

56. Chest Hypoplasia or absence of clavicles Clavicle normally forms from three ossification centers: sternal , middle and distal One or more segments in any combination may be absent Usually of lateral portion R > L Clavicles completely absent in 10% Thorax may be narrowed and/or bell-shaped Small scapulae Supernumerary ribs Incompletely ossified sternum Cleidocranial Dysostosis

57. 13.

58. Pharyngoesophageal diverticulum ·           Occurs in older women ·           Posteriorly at site of Killian's dehiscence = superior boundary is thyropharyngeal muscle and inferior boundary is cricopharyngeal muscle ·           Pulsion diverticulum ·           False diverticulum = herniation of mucosa and submucosa through muscular layer Zenker’s Diverticulum

59. 14.

60. Imaging Findings In newborn, there may be a   double bubble sign from dilatation of the stomach and first portion of the duodenum  In, adult the diagnosis is usually suggested first by CT and can be confirmed with MRCP (magnetic resonance cholangio-pancreaticography ) or ERCP (endoscopic retrograde cholangio-pancreaticography ) UGI series     May show extrinsic compression on both lateral and medial walls of the  2 nd  portion of duodenum CT May be mistaken for thickening of the duodenal wall On MRCP or ERCP, the duct of the annular pancreas usually originates anterior to the duodenum sweeps posteriorly and opens into the main pancreatic duct or ampulla Annular pancreas

61. 15

62. Plexiform neurofibroma Plexiform neurofibroma  is a benign tumor of peripheral nerves (WHO grade I) arising from a proliferation of all neural elements, pathognomonic of neurofibromatosis type 1(NF1). MRI Reported signal characteristics include: T1:   hypointense T2:   hyperintense +/- hypointense central focus (target sign) T1 C+:  mild enhancemen

63. 16.

64. Liposarcoma Liposarcoma is the most common (33%) primary retroperitoneal sarcoma. Liposarcoma is usually large (average diameter, >20 cm) and is a slow-growing tumor . It is a predominantly hypoattenuating lesion on CT because of its fat content. At MR imaging, it follows fat signal. The appearance of liposarcoma may be similar to that of a lipoma , but liposarcoma has thicker, irregular, and nodular septa that show enhancement after contrast material administration.

65. 17.

66. Pathology It results from failure of fusion of dorsal and ventral pancreatic anlages . As a result, the dorsal pancreatic duct drains most of the pancreatic glandular parenchyma via the minor papilla. Although controversial, this variant is considered as a cause of pancreatitis. MRCP/MRI pancreas This is the standard method of evaluation in modern times. The key imaging features are: the dorsal pancreatic duct being in direct continuity with the duct of Santorini , which drains into the minor ampulla ventral duct, which does not communicate with the dorsal duct but joins with the distal bile duct to enter the major ampull Pancreas divisum

67. 18.

68. Imaging Findings On conventional radiographs or CT, curvilinear calcifications in segment of the wall or entire wall CT is more sensitive than conventional radiographs Thickness of calcification may vary On ultrasound, highly echogenic , shadowing, curvilinear structure in GB fossa DDx : stone-filled contracted GB Echogenic GB wall with little acoustic shadowing Porcelain Gallbladder Calcification of all or part of the gallbladder wall Flakes of dystrophic calcium within chronically inflamed and fibrotic muscular wall Wall is thickened and gallbladder is contracted Associated with gallstones in 90% Cystic duct is always obstructed 80% of patients with carcinoma of gallbladder have stones

69. 19.

70. Herpes Encephalitis Findings Bilateral temporal lobe FLAIR signal (post-seizure edema) HSV 2 in neonates HSV 1 in adults latent infection in the Gasserian ganglion (CN V) predilection for the limbic syste, cingulate gyrus, and subfrontal region late stage becomes bilateral, hemorrhage

71. TEMPORAL LOBE Tumor: Ganglioglioma Infection: Herpes Vascular: Transverse sinus thrombosis/infarct

72. 20.

73. Primary Intracerebral Lymphoma Findings: T2 bright lesion in the left frontal lobe and basal ganglia Crosses both gray and white matter Some mass effect No significant enhancement An unusual lesion in the non-HIV/ immunosuppred population ddx : Low –grade glioma

74. 21.

75. Homolateral Lisfranc farcture/dislocation Findings Widening between the base of 1 st and 2 nd metatarsals. lateral subluxation of the second through fifth metatarsals dislocation is relative to the cuneiforms: homolateral divergent (1st MT goes medial) can be due to trauma or in patients with diabetic neuropathy

76. 22

77. Prominent solid periosteal reaction affecting phalanges and distal of radius and ulna. There is also evidence of soft tissue swelling . Thyroid acropachy is an uncommon manifestation of autoimmune thyroid disease which presented with digital clubbing, swelling of digits and toes, and periosteal reaction of extremity bones (The term acropachy is a Greek word for thickening of the extremities). It is almost always associated with thyroid ophthalmopathy and dermopathy . Thyroid acropachy 22

78. 23.

79. Bennett Fracture Findings Intra-articular fracture-dislocation of proximal first metacarpal Mechanism is axial loading of a partially flexed first metacarpal (fistfight) Volar ligamentous fixation of first MC is very strong, so small volar bone fragment is avulsed and retains a normal position while the larger fragment subluxes or dislocates dorsally due to abductor pollicis longus Tx: internal fixation

80. 24. Sign

81. CT reveals a confluent mass which is encasing the abdominal aorta and its branches. These images two classic signs of lymphoma. The "sandwich sign" which refers to sandwiching of vessels by lymphoma and not narrowing them. The other sign is " floating aorta"  sign - the aorta is lifted away from the vertebral column by the lymphoma mass. sandwich sign

82. 25.

83. Rickets Vitamin D deficiency Liver or kidney disease (hydroxylation) GI malabsorption Dietary deficiency Findings Bowing in weight bearing long bones Metaphysis and physis widening, fraying, cupping, and slipping Generalized demineralization Coarse trabeculae

84. Thankyou