Aunt Minne and ACR Flashcards
Sjogren syndrome
- salivary gland, lacrimal gland
- keratoconjunctivitis sicca (dry eyes)
- xerostomia (dry mouth).
- LIP - lymphocytic interstitial pneumonia
- cysts
- GGO
- solid-appearance consolidations
- retroperitoneal fibrosis
- bilateral hydronephrosis or hydroureter
*
- bilateral hydronephrosis or hydroureter
Klippel-Feil syndrome
- Sprengel deformity of shoulder - hypoplastic scapula
- cervical fusion
- hemivertebrae
- kyphoscoliosis
- rib anomaly
- anamalies of aortic arch and branching vessels
Types of screws
How to protocol a CT for
lower GI bleed?
CT angiogram
- plain (rule out hyperdense bowel contents)
- arterial phase - active extrav
- venous phase - bleeding bigger?
Most common locations for
carotid artery
vertebral artery
dissection?
Carotid
- just below the skull base
Vertebral artery
- 4th portion as it coming out
Classification of segments of the VA:
V1 is proximal to entry into the transverse foramen of C6. V2 is within the transverse foramen from C6 to C2. V3 is from the transverse foramen of C2 but before entry into the dura. V4 is after entry into the dura.
IV contrast and GFR
GFR
normal > 60
lower limit for diabetics > 50
lower limit for normal pts > 30
Perimesencephalic SAH
Venous bleed
usually benign
Anterior choroidal artery arises superior/later
than take off of PCOMM
Anterior choroidal artery arises superior/later
than take off of PCOMM
Hangman’s fracture
A hangman’s fracture is the colloquial name given to a fracture of both pedicles or pars interarticularis of the axis vertebra (C2).
Unilateral opacification of mastoid air cells?
Look for obstructing tumor in the nasopharyngeal space
blocking the opening of the Eustachian tubes at the Fossa of Rosenmuller
If you see some apparent abnormality on GI fluroscopy
e.g. apparent esophageal narrowing
what do you do?
- Confirm its persistent (not transient)
- Comment on mucosal abnormality
Renal Calyceal Diverticulum
- focal eventration/outpouching of the renal calyx into the renal parenchyma
- usually incidental and asymptomatic
- may have stone formation due to stasis, infection, hematuria
- mimics renal cyst on unenhanced images
- delayed post contrast image - layering/pooling of contrast medium on delayed images - pathognomonic
Ovarian cyst follow up guidelines
In premenopausal women, follow-up of a simple cyst (thin-walled, round, and without internal echoes):
- < 5 cm, no follow-up;
- > 5 cm but < 7 cm, yearly follow-up.
In postmenopausal women with a simple ovarian cyst measuring > 1 cm but < 7 cm, yearly follow-up is recommended.
For patients of any age, further evaluation with MRI or surgical consultation should be considered for a simple cyst > 7 cm.
For any cyst containing septations (other than a single thin septation) or nodules, surgical consultation or further evaluation with MRI should be considered regardless of patient age.
- Thin septations (< 3 mm) and nodules without vascular flow suggest neoplasms that are likely benign;
- thick septations and nodules with vascular flow suggest malignancy.
Outlets of the
Pterygopalatine Fossa
- anterior - inferior orbital fissure - infraorbital nerve and artery (infraorbital canal)
- medial - sphenopalatine foramen - nasal cavity
- lateral - pterygomaxillary fissure - infratemporal fossa
- inferior - greater/lesser palatine canal
- posterior - foramen rotundum - V2 - middle cranial fossa
- posterior - pterygoid canal/Vidian canal - froamen lacerum/middle cranial fossa
- posterior - platovaginal canal (pharyngeal) - nasal cavity/nasopharynx
Contents of
Pterygopalatine Fossa
- terminal third of the maxillary artery
- maxillary (V2) of the trigeminal nerve
- pterygopalatine ganglion pass.
A young man presenting with epistaxis and a pterygopalatine mass
Dx?
Juvenile nasopharyngeal angiofibroma
- is the most common benign tumor of the nasopharynx
- Most commonly presenting in young men
- typically originates from the posterolateral wall of the nasal cavity and extends through the sphenopalatine foramen into the PPF.
- From the fossa, the tumor can then spread to the sphenoid, cavernous, or paranasal sinuses, or, rarely, to the parapharyngeal space or pterygoid muscle region.
DDx for persistent umbilical discharge
in a newborn?
- persistent urachal tract - urine leakage from bladder
- A voiding cystourethrogram would demonstrate if there is a fistulous connection from the bladder to the umbilicus
- persistent vitelline tract - fluid and feces leakage from the GI tract
- A Meckel diverticulum is a remnant of the vitelline duct protruding from the ileum.
Multiloculated cystic nephroma
- cystic mass
- may be septated and displacing the normal collecting system.
- compressed collecting system
DDx
- renal cyst
- cystic RCC
- cystic partially differentiated nephroblastoma (CPDN)
Most common breast neoplasm associated with
breast implants?
Anaplastic large cell lymphoma
- T-cell origin, indolent
- capsular mass
- peri-implant seroma
Mycotic aneurysm
- usually peripehral in location
- look for areas of infarction/hemorrhage
- only evident weeks out from endocarditis
- Rx: Abx +/- vessel sacrifice
Indications for V/Q scan
- contrast allergy
- renal failure
- to decrease dose to the breasts - pregnancy or postpartum
When to reduce Tc-99 MAA?
- pulmonary arterial hypertension
- only one lung
- pediatric patients
- right to left shunt
- usually only 1/1000 arterioles are occluded
Triple scan
abnormal matched
ventilation
perfusion
CXR
= very low probability
Reverse mismatch
ventilation defects
normal perfusion
= very low probability
causes
- bronchial obstruction, mucus plug
- COPD
- pleural effusion
- atelectasis
- pneumonia
PTC
percutaneous transhepatic cholangiography
Parallel ventricle configuration
racecar appearance
absence of corpus callosm
associated with lipoma
- curvilinear
- tubulonodular
Signs of intracranial hypotension
- diffuse pachy meningeal enhancement
- subdural effusions
- brain swelling
- sagging brain
- corpus callosum - drooping penis sign
- rounding of the dural venous sinuses
- tonsillar ectopia
- rounded pituitary gland
Enhancement pattern of CNS lymphoma
- immunocompetent - diffuse enhancement
- immunosuppressed - rim enhancement
Weber ankle fracture classification
Types of gastric volvulus
- organoaxial - higher risk of vascular compromise; associated with diaphragmatic defect
- mesenteroaxial - short axis
Techniques for upper GI series
- start with esophagus
- LAO swollow and follow
- lateral swallow and follow
- then do the stomach and duodenum
- pt prone first - shoot
- pt on to left lat decub and supine - shoot
- then roll another 360 and shoot
- then RAO - contrast in the fundus, duodenal cap double contrast!
- then LAO, double contrast of the gastric cardia and fundus
- lateral
Young patient with RCC
- meduallary RCC
- West African - Sickle cell
*
Intrahepatic portosystemic venous shunt
IPSVS
- IPSVS is an uncommon entity that can be incidentally discovered during imaging of an asymptomatic patient or during the work-up of a patient with cirrhosis and/or hepatic encephalopathy.
- IPSVS may be due to persistence of the vitelline and umbilical systems during early embryological development (congenital origin theory) or secondary to trauma, surgery, or cirrhosis (acquired theory).
- Treatment for the asymptomatic patient is not required. Diet control with restricted protein intake and lactulose supplementation is indicated in the symptomatic patient with hepatic encephalopathy. Surgical ligation or transcatheter embolization can be performed in the symptomatic patient refractory to medical management.
Localized fibrous tumor of the pleura
- rare
- women
- 50-70 years old
Leiomyosarcoma
Rhabdomyosarcoma
Chondrosarcoma
- Leiomyosarcoma - older adults
- Rhabdomyosarcoma - children and younger adults
- Chondrosarcoma - can show intratumoral mineralization best seen on CT
Askin Tumor of the Chest Wall
- rare tumor of the Ewing’s sarcoma family
- small blue cell tumor
- children and young adults
- heterogenous mass with pleural effusion and rib invasion/destruction
- Other members of the Ewing sarcoma family of tumors
- Ewing sarcoma
- peripheral primitive neuroectodermal tumor
- neuroepithelioma
- atypical Ewing sarcoma
- Askin tumor
Askin Tumor
- On chest CT, a heterogeneous mass is usually seen due to hemorrhage and necrosis.
- Pleural effusion, along with destructive invasion of the ribs, is also commonly seen.
- Given the nonspecific findings that are typical with Askin tumor, biopsy is necessary for diagnosis.
Pneumatosis intestinalis
- It is important to recognize pneumatosis intestinalis, however, its significance depends on etiology and clincial setting
- primary - 15%
- secondary - 85%
- Bowel necrosis (most common): Necrotizing enterocolitis, bowel infarction, caustic ingestion
- Mucosal disruption: Endoscopy, ulcers, obstruction, inflammatory bowel disease (IBD, bowel anastomoses
- Increased mucosal permeability: Steroids, chemotherapy, immunosuppressive therapy, immunodeficiency states
- Autoimmune: Systemic lupus erythematosus, scleroderma or other collagen vascular diseases
- Pulmonary: Asthma, chronic obstructive pulmonary disease, positive pressure ventilation, pneumothorax or trauma
- Portal venous gas
- Intestinal wall lesions: Ischemia, IBD
- Bowel distention: Endoscopy, obstruction, trauma
- Sepsis: Diverticulitis, cholecystitis, appendicitis, colitis including clostridium difficile infection
Most common primary malignant neoplam of the duodenum
- adenocarcinoma of the duodenum
- almost always 2nd, 3rd, and 4th portions
- distal to the ampulla of the Vater
Most common location for small bowel adenocarcinoma
Duodenum
Differential blood supply in the liver with HCC
- HCC - primarily supplied by hepatic artery; basis of transcatheter arterial chemoembolization (TACE)
- normal liver parenchyma - relies on portal vein supply; not affected majorly by TACE
Pituitary lymphocytic hypophysitis
- perpartum female
- M:F = 1:8
- head and vision changes
- thickened (>2mm) pituitary stalk, homogeneously enhancing, +/- pituitary mass
- 75% show posterior pituitary “bright spot”
- if left untreated, pan-pituitarism –> death
- Rx - Bx and steroids
DDx for pituitary mass
- pituitary hyperplasia
- sarcoidosis
- lymphocytic hypophysitis
- metastasis
- pituitary apoplexy
Influence of TIPS on live hemodynamics
- TIPS shunts portal vein to hepatic vein
- majority of the liver parenchyma supply switches from portal vein to hepatic artery
C-spine fracutre/injury
CT vs MR
- When a significant, acute, bony abnormality is identified by CT, further evaluation for ligamentous, spinal cord, or soft-tissue injury is best characterized by MRI.
- Traumatic vertebral artery injuries
- dissection
- occlusion
- transection
- psuedoaneurysm
Gastric cancer that has a scirrhous appearance?
Linitis Plastica
Risk factors for gastric adenocarcinoma
- H. Pylori
- atrophic gastritis
- pernicious anemia
- adenomatous polyps
- Ménétrier’s Disease
- smoking
Common cancers that metastasize to the stomach
- Breast ( #1)
- colon
- melanoma
- lung
- pancreas
Spread of gastric carcinoma
- local spread
- lymphatic spread - left supraclavicular node (Virchow node)
- hematogenous spread/transperitoneal - ovary Krukenberg tumor
Benign vs malignant
vertebral compression freactures
- Benign
- diffuse osteopenia
- other vertebral compression fractures
- intravertebral vacuum phenomenon - Kummel’s Sign
- Malignant
- associated soft tissue mass
- lytic destruction
- posterior element involvement
Types of cerebreal artery aneurysm?
- saccular - often at the artery bifurcation
- fusiform - often not at the artery bifurcation
- often associated with dissection
- blister aneurysm - often recur
- mycotic aneurysm
- often associated with infectious endocarditis
- often peripheral
*
Calcified bladder mass
- urachal carcinoma
- schistosomiasis
Hyperenhancing abdominal mass
Neuroendocrine tumors
- pancreas - islet cell tumor
- mesentery - carcinoid, paraganglioma (extraadrenal pheochromocytoma)
Most common pancreatic neuroendocrine tumor
i.e., islet cell tumor?
Insulinoma
Findings of cavernous sinus thrombosis
- Extraocular muscle enlargement
- induration of the retrobulbar fat
- narrowing or frank occlusion of the cavernous portion of the internal carotid artery
- asymmetric enhancement of the cavernous sinus
Where does trigeminal nerve trifurcate?
The trigeminal nerve trifurcates at the gasserian ganglion, which is located in Meckel’s cave.
Passage of V1, V2 and V3 cranial nerves
- Both V1, the ophthalmic nerve, and V2, the maxillary nerve, pass anteriorly through the cavernous sinus en route to their respective exits from the skull, the superior orbital fissure and the foramen rotundum, respectively.
- V3, the mandibular nerve, typically passes craniocaudally through the foramen ovale without traversing the cavernous sinus.
- S-R-O - standing room only
Causes of cavernous sinus thrombosis
- Invasive infection - fungal infection
- aspergillus
- candida
- mucoraceae
- Chemotherapy agent L-Asparaginase shows an increased incidence of cavernous sinus thrombosis by inactivating Antithrombin III
Risk factors for cavernous venous sinus thrombosis
- Periorbital infection-spread intracranially through the ophthalmic veins
- Otitis media - through internal carotid arterial plexus or the dural venous sinuses.
- Immunocompromised individuals - chemotherpay, diabetes, AIDS
GIST tumor does not have what?
GIST tumors do not have calcifications
GIST tumor
- CD117 or KIT receptor
- stomach > small bowel > large bowel
- heterogeneously enhancing hypervascular mass
- hemorrhage, cystic degeneration and necrosis common
- NO calcification
- NO lymphadenopathy
Findings of mesenteric vessels in volvulus
In volvulus of small bowel, SMA and SMV course upward (anticephalocaudal direction) instead of the normal downward course (cephalocaudal direction)
Jersey finger
- Disruption of the FDP tendon due to forced extension at the DIP joint
- Ring finger most often involved - as it is weakest
- often associated with avulsion injury of the distal phalanx
- Rx - surgery for all types of Jersey finger injury
Flash filling hemangioma
Flash filling hemangiomas are common but are usually smaller lesions.
However, these lesions may exhibit greater early arterial enhancement, although they will typically demonstrate delayed washout.
What is the most common persistent carotid-basilar anastomosis?
Trigeminal artery
Types of primitive carotid-basilar artery anastomoses
- otic artery
- hypoglossal artery
- trigeminal artery* (most common)
- proatlantal artery
Embryonic anastomotic vessels between the carotid and basilar arterial systems typically regress as the posterior communicating arteries develop
Significance of the presence of a proatalantal artery
- Increased risk of intracranial aneurysms and AVM.
- Important to document prior to surgical interventions (eg, carotid endarterectomy), as disruption of carotid flow may compromise the posterior circulation.
Biliary hamartomas
von Mayenburg complexes
- Benign biliary malformations that are considered part of the spectrum of fibropolycystic diseases of the liver.
- Asymptomatic and often incidental findings
- Significance: these lesions may be mistaken for metastatic carcinoma, microabscesses, or other lesions.
- US - innumerable, unifiorm, hyper- or hypo-echoic lesions throughout the liver
- CT - unenhancing cystic lesions
- MR - low T1, high T2
- DDx:
- polycystic liver disease
- cystic liver mets (more variable in size)
- candidiasis
- microabscesses
- extra-pulmonary PCP
- Caroli disease
- lymphoma/leukemia
Chondrodysplasia punctata
- A heterogenous group of disorders in which there are multiple radiographic calcifications within the cartilage of growing bone.
- This is a congenital defect in calcium deposition of endochondral bones.
What is the MR signal intensity of a dysplastic nodule?
- T1 hyper
- T2 hypo
- No arterial enhancement
- once T2 becomes hyperintense - worry about HCC!
Threshold for IV contrast
No diabetes - GFR > 30
Diabetes - GRF > 50
DWI bright liver lesions
- cysts
- hemangiomas
- mets
Signal characteristics of HCC
- T1 iso or hypo
- T2 hyper
Hypervascular liver mets
- MRCT
- neuroendocrine tumor - islet cell, paraganglioma
- carcinoid
Linitis plastica
- primary gastric adenocarcinoma
- metastatic cancer - lung, breast
Inguinal hernia
vs
Femoral hernia
- Inguinal hernia - through the inguinal canal, more anterior, more oblique course
- Femoral hernia - through the femoral triangle, more posterior, more vertical
Segond Fracture
- Avulsion of the lateral tibial condyle
- Associated with
- ACL
- medial meniscus
- lateral capsular ligament
Arnold-Chiari Malformation
- Type I
- tonsillar ectopia of > 3mm below foramen magnum
- syringomyelia of cervial or cervicothoracic spine
- medullary kinking and brainstem elongation
- acquired Chiari I malforation - occipitoatlantoaxial hypermobility with Ehler-Danlos syndrome or Marfan’s
- Type II
- larger cerebellar tonsillar displacement
- lumbar/lumbosacral myelomeningocele
- hydrocephalus
- Type III
- occipital encephalocele
- syringomyelia
- tethered cord
- hydrocephalus
- Type IV
- lack of cerebellar development/hypoplasia
Most common locations for cerebral aneurysms
- Anterior Communicating Artery: 30%
- Posterior Communicating Artery: 25%
- Middle Cerebral Artery: 20%
- Internal Carotid Artery Bifurcation: 7.5%
- Basilar Tip: 7%
Intussusception
intussusceptum
intussuscipien
- Tumoral calcinosis is autosomal dominant
- Multiple or solitary painless periarticular calcific masses with associated hyperphosphatemia
- Well-circumscribed, lobular, amorphous calcific masses in a bursal distribution, usually involving the extensor surfaces of large joints. A “sediment sign” can be seen from layering calcium, resulting in fluid-fluid levels. Pertinent negatives include lack of osseous involvement and lack of noncalcified soft-tissue masses.
- There are many mimics of tumoral calcinosis:
- chronic renal failure
- calcinosis universalis
- calcific tendinitis
- synovial osteochondromatosis
- myositis ossificans
- calcific myonecrosis
GIST
- arises from GI mesenchymal cells, Cajal
- most often stomach > small bowel, etc
- often have hemorrhage, necrosis, and calcifications
- A large GIST may appear as a nonspecific abdominal mass with the originating loop of bowel draped around the periphery or embedded within the mass. The presence of air-fluid levels can help to localize the abnormality to bowel.
- 50% are metastatic at the time of presentation
- can recur
- Gleevec reduces the chance of recurrence
- C-kit positive
Artery of Adamkiewicz
- arises from the left posterior intercostal artery
- supplies the lower 2/3 of the spinal cord via the anterior spinal artery
Posterior column syndrome
Subacute combined degeneration
- longitudinal on sagittal, inverted V-shape on transverse T2 hyper; may enhance on T1
- Vitamin B12 deficiency
- Tabes dorsalis
- Synergistic effect with nitrous oxide
chloromas
- aka: Granulocytic sarcoma
- named “chloroma” due to its green color
- soft tissue mass associated with AML, CML, or myeloproliferative disorders
- CT: iso or hypo dense to muscle
- MR: leukemic infiltration of the spine = hypo on T1, hyper on T2, enhancing post gad
Most common cause of hyper-parathyroidism
- parathyroid adenoma
- parathyroid hyperplasia
Incidence brown tumor in
primary, secondary, and tertiary
hyperparathyroidism
- Incidence of brown tumors is 4% in primary hyperparathyroidism and 1.5–1.7% in secondary hyperparathyroidism.
- However, the high prevalence of chronic kidney disease yields a higher incidence of brown tumors due to secondary disease overall.
Findings associated with
hyperparathyroidsim
- brown tumor
- bone resorption (subperiosteal resorption along the radial surface of the second or third middle phalanx
- resorption of distal clavicles
- osteopenia, osteosclerosis
- a “salt and pepper” appearance of the calvaria
- soft-tissue calcifications
- chondrocalcinosis
- dental radiographs may show loss of the lamina dura
Angiographic appearance of
angiodysplasia
- small tuft of abnormal vessels - veins, venules, and capillaries
- early, dense draining vein
Double PCL sign
Bucket handle tear
Cyclops lesion
- Focal synovial hypertrophy/arthrofibrosis after ACL reconstruction
- low T1 and low T2
What direction does ACL travel
From lateral to medial
Hemophilic arthropathy
- almost always male!
- symmetrical loss of joint cartilage involving all compartments equally
- periarticular erosions and subchondral cysts
- periarticular osteoporosis : from hyperaemia
- epiphyseal enlargement : from hyperaemia
- osteophytosis and sclerosis : due to secondary degenerative disease
appearances can be similar to juvenile rheumatoid arthritis - joint effusion seen in setting of haemarthrosis
- knee
- widened intercondylar notch
- squared inferior margin of patella
- bulbous femoral condyles
- flattened condylar surfaces
IT band friction band
Lateral
Lipoma arborenscens
- Some fat sat on FS sequences
Painful os peroneum syndrome
Rice Bodies
- Synovial infarctions encased by fibrin
- Hypo on T1 and T2
- Infection: TB, NTMB
- Chronic synovitis/bursitis: RA, JIA
- Synovial chondromatosis
What is the first branch of MCA?
Anterior temporal artery
