Everything Else Flashcards
Most common type of endoleak?
Type 2
Filling of sac by feeder artery eg IMA or lumbar artery
Type 4 endoleak
“4 is through the pores”
Doesn’t happen in modern stents.
Endoleak requiring urgent intervention
Type 1 & 3
High flow types. Most common type 2 often managed expectantly.
Choice of embolisation for embolising a tumour…
Liquid agent.
Blocks all end arterioles.
Why do you do angio run before placing IVC filter?
4 reasons…
- Confirm IVC patency
- Measure size needed
- Confirm no double (left sided) IVC
- Check renal vein position
*Infrarenal filter placement preferred
Contraindications for TIPS
Severe (right) heart failure. (Need an echocardiogram prior to undertaking).
Severe encephalopathy.
Best response to fibroid embolisation…
• Submucosal (subserosal do poorly).
• Enhancing “cellular” type (degenerated do poorly).
• Small fibroids.
particle embolisation usually (not coils or glue)
Fibroids which can’t be emobilised and need surgery
Pedunculated
Risk of detachment
Snowman sign on CXR
TAPVR
AKA figure of 8 sign.
Rheumatic heart disease:
What valves are affected?
Mitral stenosis
Aortic stenosis
“Rheu-MA-tic”
String of beads sign - brain MRI
Watershed infarcts
Massive splenomegaly
• CML
• Myelofibrosis
• Gaucher’s
• Malaria
Meigs syndrome
• Ovarian fibroma
• Ascites
• Pleural effusion
Most common site of ectopic pregnancy
Ampullary portion of fallopian tube
Cystic lesion anterolateral wall of the upper vagina
Gartner duct cyst
• May contain proteinaceous fluid with variable T1.
• Association with Wunderlich syndrome (renal agenesis/ectopia)
Feeding vessel or vascular pedicle
(Gynae)
Endometrial polyp
Breast cancer type with Paget’s disease of the breast
DCIS
PDOG lesions with drug resistant epilepsy (3)
PD-G
- PXA (pleomorphic xantho)
- DNET
- Ganglioglioma
*Oligo does not as grows too fast
Peripheral lobar microbleeds and convexity SAH
Cerebral amyloid angiopathy
• Friable leptomeningeal/cortical vessels.
• Common cause of lobar ICH in elderly.
• BP is NORMAL. Hypertensive angiopathy is CENTRAL.
Hypertensive vs amyloid angiopathy
Hypertensive is central.
———————————-
Amyloid is peripheral.
Old lady. Oestrogen producing ovarian tumour.
Thecoma
Ovarian tumour in child with precocious puberty
Granulosa cell tumour
• Subtype of sex cord stromal tumour.
• Sponge-like appearance on MRI.
• Association with Maffucci’s & Ollier’s
Brain tumours associated with Turcot’s syndrome
Medulloblastoma
Glioblastoma
Most common intramedullary spinal cord tumour in adults
Ependymoma
• 60% of adult spinal tumours
• Average 4 vertebral body lengths
• T2 hyperintense and enhances
Most common intramedullary spinal cord tumour in kids
Astrocytoma
• 60% of paeds spinal tumours (2nd most common overall)
• Peak age is 30 yrs
• Longer (average length 4-7 vertebrae)
Forceps delivery and neck swelling
Fibromatosis colli
Compartment syndrome > pressure necrosis > fibrosis of sternocleidomastoid
Present at few weeks of age. May be little to see on US.
Most common lesion in trigone of lateral ventricle in an adult
Meningioma
Triad of:
- Abdominal wall hypoplasia
- Bilateral cryptorchidism
- Pelvicalyceal dilatation and renal dysplasia
Prune belly syndrome
A.k.a Eagle-Barrett syndrome
Wrinkled/shrivelled abdomen - looks like a prune
Prune belly syndrome associations
Down’s syndrome
Malrotation
Wolman disease
Deposition of fat in multiple organs.
Hepatosplenomegaly and enlarged calcified adrenals.
Usually fatal with death in infancy.
Spinal lesion occurring at the conus or filum terminale
Myxopapillary ependymoma
Average age 35 yrs. Most common lumbar spinal tumour.
Low density in temporal lobe, insula and inferolateral frontal lobe but sparing of basal ganglia
HSV encephalitis
Stroke mimic but basal ganglia spared
WAGR syndrome
W - Wilms tumour
A - Aniridia (absence of iris)
G - Genitourinary anomalies
R - Retardation
Most common congenital diaphragmatic hernia
Bochdalek
Bochdalek hernia location
• Left sided in 85% (Bochda-L-ek)
• Posterolateral (Back-dalek)
• Pulmonary hypoplasia
Morgagni hernia
• Right sided 95%
• Anterior
• Rare
Gastroschisis
• Small right sided defect (~4cm)
• No surrounding membrane
• Malrotated
• Association with raised AFP
Omphalocele
A.k.a. Exomphalos
• Midline
• Larger defect
• Covering membrane (may be ascites)
• Liver herniation more common
• Association with other anomalies (Downs, Turners, Klinefelters, Beckwith-Wiedman and other issues)
• Worse prognosis
JC virus
Progressive multifocal leukoencephalopathy
Adult. Female. Retrobulbar mass with enopthalmos.
Breast cancer
Infiltrative retrobulbar mass. Enophthalmos is characteristic.
Lesion of mandible with tooth resorption
Ameloblastoma
Radiolucency around the CROWN of an unerupted/impacted tooth
DENTIGEROUS CYST
• Cyst encloses the crown
• Association with ameloblastoma and can become one
ADEM
(Acute disseminated encephalomyelitis)
Post-viral or vaccination. Typically 1-2 weeks.
Autoimmune demyelination that improves with steroids.
Very difficult to differentiate from MS.
Krabbe disease
Posterior white matter + cerebellum + spinal cord
Crabs are SLOW (posterior) and low (inferior)
Metabolic disturbance and mimic of infarct in pons
Osmotic demylination syndrome/central pontine myelinolysis
• Low density CROSSING MIDLINE
• Restricted diffusion
• High T2 trident shaped
May also be extrapontine which can occur simultaneously or in isolation.
Bilateral optic neuritis + transverse myelitis + aquaporin 4 antibodies
Neuromyelitis optica
Longitudinally extensive spinal cord lesion with expansion from swelling.
Empty thecal sac
Arachnoiditis
Nerve roots adhere to dura.
Can alternatively clump together mimicking a mass.
Iatrogenic and infectious eg TB causes.
Involvement of medial thalami, periaqueductal grey matter and mamillary bodies
Wernicke’s encephalopathy
Ashkenazi Jews are predisposed to…
Canavan’s
Gaucher’s disease
Tay-Sachs disease
Gaucher’s disease
• Accumulation of fatty substance in RETICULOENDOTHELIAL SYSTEM.
• ERLENMEYER flask deformity.
• Diagnosed by BONE MARROW ASPIRATE.
• Cause of MASSIVE SPLENOMEGALY. 95% have splenomegaly.
• Anaemia, large joint stiffness and pain if symptomatic.
Lytic bone mets
RCC (also expansile)
Lung Cancer
Thyroid Cancer
Melanoma
Breast Cancer (typically mixed)
NHL
Widened growth plate and metaphyseal cupping in child
Rickets
Also:
Delayed fontanelle closure
Poor epiphyseal mineralisation
Bowing deformity
Prostatic utricle cyst
Pear shaped
Communication with urethra
Intraprostatic
Order of occular muscle involvement in thyroid eye disease
I’M SLow
Inferior rectus
Medial rectus
Superior rectus
Lateral rectus
Tendinous insertions spared.
Mnemonic for calcified glial tumours
”Old Elephants Age Gracefully”
O - Oligodendroglioma
E - Ependymoma
A - Astrocytoma
G - Glioblastoma
(In order of decreasing incidence)
NF-1 mnemonic
CAFE SPOT
C: Café-au-lait spot (>6 in 1 yr)
A: Axillary or inguinal freckling
F: Fibromas (& FASI)
E: Eye hamartomas (Lisch nodules)
S: Skeletal abnormality eg sphenoid wing
P: Positive family history
OT: Optic Tumour
F: 2 neurofibromas or 1 plexiform neurofibroma
Most likely site of tear/transection of aorta?
Isthmus
(Distal to left subclavian artery origin)
Transient non-segmental peripheral consolidation with eosinophilia
Löeffler’s syndrome (simple pulmonary eosinophilia)
Fibrosing mediastinitis
• Cancer mimic in mediastinum. Often calcified.
• Compression or occlusion of mediastinal structures eg SVCO.
• Causes include:
- TB
- Histoplasmosis
- IgG4
Smoke inhalation imaging features
Pulmonary oedema
Child with calcified lung mets and pneumothorax
Metastatic osteosarcoma
Mnemonic for lymphangitis carcinomatosis
”Certain Cancers Spread By Plugging The Lymphatics”
C - cervix
C - colon
S - stomach
B - breast (2nd)
P - prostate and pancreas
T - thyroid
L - lung (1st) and larynx
Child presenting with LIP
HIV
Associated with LIP in an adult
Sjögren’s
*for this reason LIP is more common in women as Sjögren’s is 9x more common in females
*NSIP still most common pattern in Sjögren’s
Traumatic urethral stricture:
Anterior
Straddle injury
Traumatic urethral stricture:
Posterior
Pelvic fracture
“U hurt ur Pee Pee”
Pyloric stenosis measurements
Single muscle thickness >3mm
Longitudinal length >14/15
Pyloric volume >1.5cm 3
*remember Pi (3.1415)
Ground glass and cysts
PCP
LIP
PCP CD4 count
<200
Ground glass and cysts
Main pulmonary artery max diameter
29mm
If 30 or above = PAH
Lung cancer with cavitation
Squamous cell carcinoma
Scoring system for malignant probability of pulmonary nodules
Brock model
Herder score takes into account FDG PET findings too
Dilated thoracic duct
LAM
Gynaecomastia in a man
Central
Retroareolar
Flame shaped
An ECCENTRIC position is highly suspicious for cancer.
T4 RCC
Extension beyond Gerota’s fascia
T3 RCC
Extension beyond kidney but WITHIN Gerota’s fascia:
• T3a - renal vein
• T3b - IVC below diaphragm
• T3c - IVC above diaphragm or IVC wall
T4 renal pelvis cancer eg TCC
Invades perinephric fat or into adjacent organs
Penile calcification
Peyronie’s disease
Fibrous tissue plaques within tunica albuginea causing bent penis with painful erections
Bell clapper deformity
Testicular torsion
High insertion of tunica vaginalis on spermatic cord. Predisposes to torsion. Bilateral in 65-90%.
Nutcracker kidney
• Compression of left renal vein between overlying SMA and aorta.
• Haematuria and loin pain.
Superior quadrantanopia
Aka “pie in the sky”
Temporal lobe lesion
S is next to T
Inferior quadrantanopia
Parietal lobe
IP
Gradenigo syndrome
Triad of:
1. Otitis media
2. Retroorbital pain
3. Abducens (VI) nerve palsy - eye deviated medially
HIV vs PML
“U DON’T want HIV”
• U fibres spared in HIV. Involved in PML.
• Cortical atrophy in HIV.
• HIV is symmetrical. PML asymmetrical.
Pregnant pt with preeclampsia. Bilateral occipital hypo-attention.
PRES
Failure of posterior circulation to auto-regulate with acute changes in BP. Extensive cerebral oedema. Sometimes infarcts or haemorrhages.
*not always posterior or reversible
Most common thyroid cancer
Papillary
• Hypoechoic on US. Punctate calcification. Sometimes cystic.
• Association with bowel polyposis syndromes.
Parasitic infection from pigs
Neurocysticercosis
Adenomatous vs hamartomatous polyps
Get To Fuck | Chinese Communist Party
G - Gardner’s syndrome
T - Turcot syndrome
F - FAP
____________________________
C - Cowden’s syndrome
C - Cronkhite-Canada syndrome
P - Peutz-Jegher’s syndrome
Breast cancer screening age
50-70
*>70s can request screening every 3 years too
400-800 cancers detected for every cancer induced. 20% reduced mortality.
Lobster claw sign (kidney)
Papillary necrosis
Radiolucent renal calculi
HIV on indinavir
Antibiotics eg amoxicillin, cipro, nitro
Allopurinol
Schistosomiasis organism
Schistosoma haematobium affects urinary tract
Placenta accreta spectrum
• Accreta - villi ATTACH to myometrium
• Increta - villi partially INVADE myometrium
• Percreta - villi PENETRATE through beyond serosa
A-I-P
Single umbilical artery
Trisomy 18 (Edward’s syndrome)
Urethral cancer histology
Prostate - TCC
Elsewhere - SCC
Mayer-Rokitansky-Küster-Hauser syndrome (MRKH)
Congenital absence of the uterus and upper 2/3 vagina.
BUT
Normal ovaries and fallopian tubes
Tamoxifen associated endometrial changes
• Endometrial polyps (8-36%)
• Endometrial hyperplasia (1-20%)
• Cystic endometrial atrophy
• Endometriosis (increased risk endometrial carcinoma)
Name of first breast screening
PREVALENT
Screening starts at 50 so will be 50-53.
Incident is any subsequent screening.
Endometrial thickness in postmenopausal woman
<5mm
Serous vs mucinous cystadenocarcinoma of the ovary
Serous
• Most common malignant ovarian mass
• More likely bilateral
• Peritoneal carcinomatosis
Mucinous
• More likely unilateral & multiloculated.
• Stained glass appearance from varying mucin content of cysts.
• Pseudomyxoma peritonei
• Can rupture
SeHCAT scan
NM study for **bile salt malabsorption••. Used in investigation of diarrhoea.
MEN-1
PPP | Pi-Par-Panc
Pituitary adenoma
Parathyroid adenoma/hyperplasia
Pancreatic neuroendocrine tumour
MEN-2a
PPM
Phaeochromocytoma
Parathyroid hyperplasia
Medullary thyroid cancer
MEN-2b
PMMM
Phaeochromocytoma
Medullary thyroid cancer
Marfanoid habitus
Mucosal neuromas/ganglioneuromas
Fibrosing thyroiditis, IgG4, euthyroid, painless thyroid mass
Riedel thyroiditis
Weigert-Meyer law
UU | IR
Upper moiety - UU / UI
• Ureterocoele and obstruction.
• Ectopic insertion of ureter medial and inferiorly. Upper pole - inferior insertion.
Inferior moiety - IR
• Reflux
• Normal insertion
Penile cancer
SCC
• Associated with HPV
• Enhances but less so than corpus cavernosum & spongiosum
NF-2 mnemonic
MISME
Multiple Inherited Schwannomas, Meningiomas and Ependymomas
Megaureter
> 7mm diameter
Most common parasitic infection worldwide
Ascariasis
Intestinal worms with central alimentary tract. Will ingest barium.
Tapeworms are much longer and have no alimentary tract so cannot ingest barium.
Pattern of infant myelination
UFO
Up - Caudal to cranial
Forwards - Posterior to anterior
Outwards - Deep to superficial
*completes at ~9 months
Max aortic aneurysm diameter before intervention
> 5.5cm inner to inner
Refer to vascular.
> 3cm is abnormal.
Max aortic diameter before intervention needed
>5.5cm inner to inner
Refer to vascular.
>3cm is abnormal. If grown by >1cm in 1 yr may also intervene.
Cephalohaematoma
• Subperiosteal haematoma of the outer skull following birth trauma.
• Cannot cross sutures - this distinguishes them from subgaleal haematoma.
Vessel feeding nasopharyngeal juvenile angiofibroma
Internal maxillary artery - branch of ECA
Lateral neck cyst with beak pointing between ICA and ECA
2nd branchial cleft cyst
UAC position
”T10 to L3 - gets a NO from me!!”
• May be placed high or low as long as not around abdominal aorta branches.
• Dips down into pelvis through umbilical artery -> internal iliac.
UVC position
”T8 or T9? Everything’s FINE!”
• Umbilical vein -> left portal vein -> ductus venosus -> hepatic vein -> IVC
• Tip at junction of IVC and RA.
• Thrombus and liver injury possible.
Stroke window level
Width 8HU / Centred at 32 HU
Sensitivity increases from 57% to 71% compared to normal window setting.
Most common causes of temporal lobe epilepsy
- Medial temporal sclerosis (70%)
- Ganglioglioma (most common tumour)
Brain tumour post-radiotherapy
Meningioma
Intracranial lipoma:
Most common location
Pericallosal
Associated with corpus callosum agenesis.
Most common entrapment neuropathy of the elbow
Cubital tunnel syndrome
Seen in throwing sports, tennis, volleyball.
Thickened gastric folds. Low albumin.
MÉNÉTRIER’S DISEASE
• Present with symptoms of gastritis and oedema.
• ”GIANT rugal folds.”
Optic neuritis most commonly affects which portion of the optic nerve?
Intra-orbital retrobulbar segment
Thickened atrial septum >6mm
Cardiac Amyloid
Systemic process involving ALL 4 chambers.
Most common cause of RESTRICTIVE cardiomyopathy.
Most common site of MS in spinal cord
Cervical spine
*usually <2 vertebral lengths
*MS in spine usually peripheral
Most common type of choledochal cyst
Type I (80-90%)
Fusiform dilatation of extrahepatic bile duct.
Theorised result of reflux of pancreatic secretions. Pts may present with jaundice and palpable mass.
Type II choledochal cyst
Diverticulum
D = Duo = Type II
3% of bile duct cysts. Saccular outpouching.
Choledochocele
Type III choledochal cyst (~5%).
Protrusion of a dilated distal CBD into the duodenum.
May be repaired by ERCP or surgery if severe.
Type IV choledochal cyst
MULTIPLE intra AND extrahepatic cysts.
2nd most common ~10%.
Type V ONLY intrahepatic (Caroli disease). Will have cystic renal disease too.
Hyperdense renal cyst Bosniak classification
II if <3cm / IIF if >3cm
Type III endoleak
Leak through defect in graft wall. May be fracture or small hole.
Tracheobronchial abnormalities sparing posterior wall
Sparing of posterior wall = condition which is confined to the cartilage
Relapsing polychondritis
- smooth thickening
- dense tracheal cartilage calcification
Tracheobronchopathia osteochondroplastica
- irregular and nodular thickening
- often calcified nodules
Both cause SUBGLOTTIC STENOSIS
Tracheobronchial abnormalities that INVOLVE the posterior wall
• Post-intubation stenosis
- focal, HOURGLASS shaped
• GPA
- may cause ULCERS
• Tracheobronchial amyloidosis
- circumferential CALCIFICATION, focal or diffuse
Medications associated with drug induced lung injury/fibrosis
• Amiodarone - basal distribution, high density
• Ritalin lung - talcosis
• Nitrofurantoin - UIP/NSIP/OP/HP
• Methotrexate - NSIP
• Adalimumab and other immunomodulators
• Chemotherapy
Most common fibrotic pattern in CTD-related interstitial lung disease
NSIP
RA is UIP
Tetralogy of Fallot associations
• Right sided aortic arch (1 in 4)
• ASD/PDA
• Coronary artery anomalies
• Chromosomal anomalies eg Downs, DiGeorge, Alagille syndromes
Reduction of intussusception rules
Rule of 3s
3 attempts each lasting 3 mins. Less likely to be successful if <3 months.
120mmHg max pressure.
Most common TOF
Type C (85%)
Proximal oesophageal atresia with distal fistula from airway to distal oesophageal segment.
Wooden FB on CT
Hypoattenuating
Can mimic air with dry pine as low as -600HU. More water increases attenuation. Look for geometric shape.
Contraindications for liver biopsy
- Uncooperative
- Extrahepatic biliary dilatation (relative)
- Bacterial cholangitis (relative)
- Abnormal coagulation INR >1.5
- Thrombocytopenia <60 Plts
- Ascites
- Cystic lesion
Tortoiseshell liver
Schistosomiasis
Dystrophic calcification within polygonal network of fibrous septa.
Pathognomic for Japonicum and Mansoni types.
Denys-Drash syndrome
- Wilm’s tumour
- Male pseudohermaphroditism
- Progressive glomerulonephritis
2nd most common TOF
Type A (8%)
“A is for Atresia”
Isolated atresia. No fistula.
CHARGE syndrome
C - coloboma (may be visual impairment)
H - heart defects
A - atresia choanae (nasopharynx)
R - retarded growth and development
G - genital hypoplasia
E - ear abnormalities/deafness eg semicircular canal dysplasia/aplasia
Direct vs indirect inguinal hernia
Locate INFERIOR EPIGASTRIC artery
• DIRECT is MEDIAL to it. Passes through defect in Hesselbach’s triangle.
• INDIRECT is LATERAL to it. Passes through deep inguinal ring and down inguinal canal.
Role of US in skiers (gamekeepers) thumb
To look for STENER lesion. Will not heal without surgery.
Serpiginous cortical T1 hyper intensity after stroke
Cortical laminar necrosis.
Seen as early as 3-5 days but often ~2 weeks later. Usually resolves by 3 months.
Possible due to lipid laden macrophages.
Most common chamber of angiosarcoma in heart
Right atrium
Causes of unidentifiable spleen on US
• Sickle cell - autosplenectomy (infarcts)
• Polysplenia (multiple small spleens)
• Traumatic fragmentation
• Wandering spleen (wrong place)
Leukodystrophy with frontal distribution
Alexander disease
A is at the start of the alphabet
Leukodystrophy involving splenium of corpus callosum and parietal/peritrigonal white matter
X linked adrenoleukodystrophy
X at the back of the alphabet
Heel-toe manoeuvre during US biopsy
Reduces anisotropy artefacts as needle more perpendicular to beam so easier to see.
Pancreatic transplant
• Simultaneous renal transplantation (78%)
• Curative T1DM treatment
• Usually grafted to external iliac vessels
Liver lesion:
Increase in size during pregnancy
Hepatic adenoma
*subcapsular haematoma suggest haemorrhage or rupture
Angiography approach terminology
Antegrade = with the flow = down the leg
Retrograde = against the flow = up the leg - used for iliac/aortic intervention
Management of air embolism
High flow oxygen and left lateral positioning to keep air in right atrium.
IVC filter placement
Infrarenal
*exceptions may include:
• Pregnancy (avoids compression)
• Renal/gonadal vein clot (above clot)
• Duplicated IVCs
Mimic of HPOA in adolescent males with symmetrical bilateral tibial and fibular periosteal reaction
Pachydermoperiostosis
Self limiting condition that requires no treatment. Autosomal dominant inheritance.
Indications for splenic artery aneurysm intervention
• >25mm
• Portal hypertension
• Female of child bearing age with pseudoaneurysm (risk of rupture during pregnancy)
- coil embolisation usual Rx
Carney triad
PEG
P - pulmonary chondroma
E - extra-adrenal paraganglioma
G - GIST
- “T” in GIST = Triad
Mnemonic for intracranial hypotension
SEEPS
S - subdural hygromas > haemorrhage
E - enhancement of pachymeninges
E - engorgement of venous sinuses
P - pituitary hyperaemia & enlargement
S - sagging brain - midbrain & tonsils
Other clues:
• Postural/orthstatic headache which improves lying down (opposite to intracranial hypertension)
• CSF leak - lumbar puncture, trauma eg from sharp osteophyte, CSF/venous fistula, meningeal diverticulum
• Distended rounded venous sinuses
• Layer cake skull (hyperostosis)
Signs of perforation in kids
• Football sign
• Falciform ligament
• Lucency over liver
• Continuous diaphragm sign
• Rigler’s sign
• Triangular gas
*can do lateral shoot through/lateral decubitus
Management of lidocaine toxicity
Intralipid
Propofol
Benzodiazepines
*want to give drugs that lower seizure threshold and lipid emulsion to bind free circulating lidocaine
*cardiovascular toxicity eg arrhythmias
Management of lidocaine toxicity
Intralipid
Propofol
Benzodiazepines
*want to give drugs that lower seizure threshold and lipid emulsion to bind free circulating lidocaine
*cardiovascular toxicity eg arrhythmias
Rule of 2s Meckel’s diverticulum
2% of population
2 inches long
2 ft from IC valve (antimesenteric border)
*40% contain gastric mucosa - Tc pertechnetate scan
Buscopan contraindications
Recent ACS
Uncontrolled HF
Arrhythmia
Myasthenia gravis
Looks like bronchogenic cyst but has thicker walls
Foregut duplication cyst
Small bowel most common. Oesophageal duplication cyst 2nd most common .
Has muscular layer causing thicker wall.
Normal ETT position
Adults
5 cm (+/- 2cm) proximal to carina.
Approximately at T2
Neonates
1.5cm above carina OR T1 OR inferior clavicles
Mimics the presentation, PSA rise and MRI findings of prostate cancer including DWI & ADC
Granulomatous prostatitis
Biopsy needed to differentiate.
RFs: Intravesical BCG therapy for bladder Ca, TURP, sarcoid, TB
Gelatinous ascites
Pseudomyxoma peritonei
Look for the appendiceal mucocoele.
Intra vs extraperitoneal bladder rupture
Extraperitoneal - Conservative Rx
More common
Bladder base puncture - pelvic fracture
Contrast in retroperitoneum, thighs, scrotum, anterior abdominal wall
Intraperitoneal - Surgical Rx
Less common
Bladder dome from increased pressure
Contrast around bowel loops and collecting in paracolic gutters
Pneumobilia vs portal venous gas
Por tal venous gas = Per ipheral.
Imagine blood pushing gas from the hilum out to the periphery.
PHACE syndrome
Aka cutaneous haemangioma–vascular complex syndrome or Pascual-Castroviejo type II syndrome.
P - posterior fossa (e.g. Dandy-Walker malformation)
H - haemangiomas
A - arterial anomalies
C - coarctation and cardiac anomalies
E - eye (ocular) anomalies
Accordion sign (colitis)
Pseudomembranous (C. diff) colitis
Colitis affecting right colon and ileum
• Yersinia enterocolitica - non stenotic terminal ileal ulcers
• Salmonella
Obstructed cervical canal following fibroid embolisation
Fibroid detachment
May occur with superficial submucosal fibroids abutting the endometrial cavity.
Benign retro-areolar mass with dilated ducts and nipple discharge
Intraductal papilloma
Discharge may be slightly bloody.
Markedly dilated trachea and central airways, with recurrent infection
Mounier-Kuhn syndrome (Tracheobronchomegaly)
Tracheal diameter >3 cm
New renal cysts in dialysis patient
Acquired (uraemic) cystic kidney disease
> 3 simple appearing cysts in each kidney.
Trochlear nerve palsy
Long course around midbrain through ambient cistern, cavernous sinus.
Look for aneurysm.
Featureless stomach, B12 deficiency
Atrophic gastritis
• Linitis plastica usually nodular and have weight loss & IDA.
Thyroid eye disease
• ”I’M SLow” - spares tendinous insertion
• Usually develops within 1 year
• Increased density of orbital fat
• Superior ophthalmic vein may be dilated due to compression
Genital ambiguity
Congenital adrenal hypertrophy
21-Hydroxylase deficiency cause in >90% of cases.
Genital ambiguity in girls. Salt wasting in boys.
Adrenal limb >4 mm.
Hashimoto’s predisposes to…..
Thyroid lymphoma
Cardiac mass arising from valve
Papillary fibroelastoma
75% of valvular tumours. Aortic and mitral valve most common.
Intermediate to high T2 signal. ”Sea anemone” on echo.
Carney complex
Rare type of MEN syndrome
Cardiac myxoma
Skin lesions - blue naevi, skin myxomas
Pituitary adenoma
Sertoli cell testicular tumours
Ovarian masses
Thyroid disease
Fibroadenomas of the breast
Melanotic Schwannomas
Fibroadenoma with multiple round or cleft like cystic spaces
Phyllodes tumour (cystosarcoma phyllodes)
• Large, fast growing, oval or lobulated solid mass.
• Posterior acoustic enhancement.
• Radiolucent halo on mammography.
• Occasionally calcify.
• May undergo malignant degeneration.
Intussusception:
Child vs adult
Kids (6 months - 2 yrs)
Ileo-colic most common in kids
Usually idiopathic ie no lead point seen.
Adults and young neonates
In adults and very young infants (<3 months) no real pattern of distribution but will have a lead point.
Medium vessel vasculitis
Polyarteritis nodosa
Renal (~90%) - microaneurysms
Cardiac (70%)
GI tract, liver, spleen, pancreas
CNS
Kawasaki disease
Coronary vessels
Can affect any organ
Erythematous rash, fever, cervical lymphadenopathy & strawberry tongue
Brain MRI in a child with “eye of the tiger” sign
Hallervorden-Spatz disease
Now called pantothenate kinase-associated neurodegeneration (PKAN)
• Usually <6 yrs.
• Iron deposition in globi pallidi, substantia nigra, red nuclei - calcification on CT.
• Classic “eye of the the tiger” is central high T2 signal in otherwise low signal globus pallidus and can also be seen in Wilson’s and Parkinson plus in adults.
When is surgery performed for vesicoureteric reflux?
Grade IV and V
I - ureter only
II - reflux into kidney without dilatation
III - mild pelvicalyceal dilatation
IV - moderate dilatation & clubbed calyces
V - severe with a tortuous ureter
Stanford Type A aortic dissection
Proximal to the origin of left subclavian
Stanford Type B aortic dissection
Distal to the origin of the left subclavian
Debakey Type A aortic dissection
BAD
BAD
B = Both ascending and descending aorta
Debakey Type B aortic dissection
BAD
A = Ascending aorta
Debakey Type C aortic dissection
BAD
D = Descending aorta only
Only one which is Stanford type B
Most common site of TB after the lungs
Kidney and ureter
• Usually unilateral (75%)
• Putty kidney (autonephrectomy) - small, shrunken kidney with dystrophic or amorphous calcification
Other features:
• Infundibular strictures
• Amputated or moth eaten calyces
• Sawtooth, corkscrew or beaded calcified ureter
Arachnoid vs porencephalic cyst
Porencephalic cysts:
• Usually no mass effect
• Lined by white matter
• Often confined to a vascular territory
• Usually communicates with ventricles
“Mulberry shaped” cerebral vascular malformation
Cavernous angioma
• CT - hyperdense with speckled calcification. No mass effect or oedema.
• MRI - mulberry or popcorn appearance, hypointense T2 rim and blooming from blood products.
*AVMs will be serpiginous.
Renal artery stenosis
• Atherosclerosis (75%)
• Fibromuscular dysplasia (20%)
- younger
- distal renal artery
• Polyarteritis nodosa
- microaneurysms
• Takayasu
• NF-1
- involves ostium
• Coarctation
• Williams syndrome
VHL mnemonic
HIPPEL
H - haemangioblastoma
I - increased risk RCC
P - phaeochromocytoma
P - pancreatic cysts, tumours, NETs
E - eyes & ears - haemangioblastoma, endolymphatic sac tumours (deafness)
L - liver and renal cysts
CI-AKI
Creatinine peak occurs at 48-72 hrs.
Relative: 50% rise in Cr over baseline
Absolute: increase in Cr of >27
Evidence is weak and likely not even a thing.
Most common peri-graft fluid collection after renal transplant
Lymphocele
• Typically occur within 1-2 months.
• Well defined, anechoic and may have septations.
• Urine leaks are comparatively rare and usually in first week or two.
Dandy-Walker malformation triad
- Vermian hypoplasia
- Cystic dilatation of 4th ventricle
- Enlarged posterior fossa with torcular-lambdoid inversion (torcula above lamdoid suture due to superiority displaced tentorium)
Often secondary hydrocephalus (80%).
Scalloping of the occiput from pressure.
Hypoplastic cerebellar hemispheres.
MR enteroclysis vs enterography
MR enteroclysis requires nasoduodenal tube so is invasive.
Provides superior detection of mild superficial mucosal disease.
Phi angle gastric band
4-58°
Angle between axis of band and vertical line.
Stomal stenosis is the most common complication.
Beckwith-Wiedemann syndrome
Macroglossia
Omphalocele
Localised gigantism
Organomegaly
Ear pits
Associated with:
Wilm’s tumour
Neuroblastoma
Hepatoblastoma
Rhabdomyosarcoma
Management of anaphylaxis to contrast
Adult
• 0.5ml of 1:1000 adrenaline IM (0.5mg)
Child
• If 12+ same as adult
• If 6-12 yrs 0.3ml of 1:1000 (0.3mg)
• If <6 yrs 0.15ml of 1:1000 (0.15mg)
I.e. always 1:1000!
Increments 0.5 -> 0.3 -> 0.15.
Percutaneous renal intervention puncture sites
For drainage:
• Lower pole posterior calyx
For access to PUJ/ureters:
• Mid-upper pole posterior calyx
Always posterior. Brödel bloodless zone. Nephrostomies are on pt’s back.
Large tubes (12-14F) may be necessary for pus or gross haematuria with clots.
Further imaging via nephrostomy delayed by 24-48 hrs after placement in cases of infected urine.
Testicular fracture vs rupture
Fracture - tunica albuginea is intact, no surgery
Rupture - tunica albuginea disrupted, need surgery to salvage testicle
*Isolated epididymal injuries are rare.
TORCH infections
ToxOplasmosis = hydrOcephalus
HSV = Haemorrhage +/- infarction
CMV = Calcification (periventricular)
Rubella = microcephaly, periventricular calcification, cardiac anomalies
Intradural extramedullary spinal lesion
No More Spinal Masses
N - Neurofibroma
M - Meningioma
S - Schwannoma
M - Metastases
Order of frequency is MNM. Meningioma, nerve sheath tumour, mets.
Osler-Weber-Rendu syndrome (hereditary haemorrhagic telangiectasia)
• Multiple pulmonary AVMs which can cause cyanosis and high output heart failure due to shunting.
• Epistaxis due to nasal telangiectasia.
• Autosomal dominant inheritance.
Benign vs malignant gastric ulcers
Hampton’s line = Harmless
Carman meniscus = Carcinoma
Other malignant features:
Greater curve
Endoluminal (protrude into stomach)
Irregular gastric folds
Most common source of mets to the breast
Lymphoma (most common)
Melanoma (2nd most common)
More rarely:
Choriocarcinoma
RCC
Prostate
Junctional zone thickening
> 12mm is abnormal and suggests adenomyosis
Commonest gastric volvulus by age
O-O
Old = Organo-axial (2/3 of cases)
M-M
Midget (kids) = Mesentero-axial (60%)
Sigmoid vs caecal volvulus
Sigmoid volvulus
• Ahaustral in appearance
• Distal obstruction; ascending, transverse and descending colon may be dilated
• Few gas-fluid levels may be seen
Caecal volvulus
• Arises in the right lower quadrant
• Haustral pattern is maintained
• Distal colon usually collapsed and the small bowel is distended
• Single gas-fluid level may be seen
Zenker diverticulum
• Aka pharyngeal pouch
• Posterior and midline of hypopharynx
• Through Killian dehiscence
• Pulsion type pseudodiverticulum
Kartagener syndrome
Triad of:
Situs inversus
Chronic sinusitis or nasal polyps
Bronchiectasis
Similar presentation and appearance to CADASIL but younger patient
MELAS (mitochondrial encephalomalacia with lactic acidosis and stroke like episodes)
• Stroke-like episodes or dementia in kids/young adults.
• Parieto-occipital and parieto-temporal infarcts and secondary atrophy/encephalmomalacia.
• Elevated lactate peak on MR spectroscopy.
CADASIL
Cerebral autosomal dominant arteriolathy with subcortical infarctions and leukoencephalopathy
• Recurrent TIA/stroke in middle aged patients (30s-50s)
• Looks like small vessel disease beyond expected for age
• Occurs without vascular risk factors
• Anterior temporal lobe and external capsule most common
Congo red staining on histopathology
Amyloidosis
Maximum lidocaine dose that can be given safely
3mg/kg up to 200mg
Equates to:
20 mls of 1%
10mls of 2%
*max dose for lidocaine with adrenaline is 7mg/kg
Löfgren syndrome
• Acute clinical presentation of systemic sarcoidosis that manifests with:
- Lymphadenopathy
- Fevers
- Erythema nodosum
- Polyarticular arthritis.
*Not to be confused with Löffler syndrome (Simple pulmonary eosinophilia)
Most common metastasis to the spleen
Melanoma
Treatment option for unresectable HCC and intrahepatic cholangiocarcinoma
TACE (transcatheter arterial chemoembolisation)
• Either as palliative Rx or to bide time for curative transplant.
• Also used for hepatic mets.
• Not suitable for patients with severe cirrhosis (Child-Pugh C). Portal vein must be patent or normal liver can infarct.
Windsock appearance of D2 of duodenum
Duodenal web
May be complete or incomplete obstruction.
Most common causes of pneumonia in school aged kids
• Mycoplasma pneumoniae
• Strep pneumoniae (pneumococcus)
• Influenza A
Loeys-Dietz syndrome
• Rare Marfan-like connective tissue disorder
• Tortuous arteries, aneurysms, bifid uvula & hypertelorism
Alpha-1-antitrypsin deficiency
• Basal predominant panlobular emphysema (identical to Ritalin lung)
• Cirrhosis with expected increased risk of HCC
• Can be confirmed with blood test for a-1-a. Will be <1.1.
Causes of increased liver attenuation
Haemochromatosis
Amiodarone
Thorotrast
Wilson disease
Thalassaemia
NOT AMYLOID
Rubella vs CMV
Both cause periventricular calcification and microcephaly.
Rubella associated with congenital cardiac anomalies (VSD, TOF).
Neurocysticercosis stages
Vegans Can’t Get Neurocysticercosis
- Vesicular
- Colloidal vesicular
- Granular nodular
- Nodular calcified
• Tapeworm Taenia Solium found in pork (and humans)
• Cysts can appear in brain, CSF spaces, ventricles and spinal cord.
• Look for rice grain calcification in skeletal muscle.
1. Vesicular
Viable parasite with intact membrane so no host reaction.
Cyst with dot sign. No oedema.
2. Colloidal vesicular
Symptomatic stage. Parasite dies and membrane becomes leaky.
Cyst becomes thickened and hyperattenuating. Enhancement and oedema. May restrict on DWI.
3. Granular nodular
Cyst retracts into small enhancing nodule. Oedema reduces. Enhances but less marked.
4. Nodular calcified
Calcified nodule remains. No oedema or enhancement.
Neurocysticercosis organism
Taenia solium
(Species of tapeworm)
Chagas disease organism
Trypanosoma cruzi
Endemic to Central & South America.
• Myocarditis and eventually dilated cardiomyopathy.
• Meningoencephalitis
• Oesophageal dysmotility
• Skin lesions
• Conjunctivitis
Most common neuroimaging feature of NF-1
Focal areas of signal intensity (FASI)
Focal T2 hyperintensities found in up to 86% of patients.
2nd most common site of hydatid disease after the liver
Lung
Causative organism in hydatid disease
Echinococcosis granulosus
Most common species.
Hosts are dogs and wolves. Sheep become infected and pass on to humans.
- alveolaris & multilicularis from foxes is less common but more invasive
Most common type of CPAM
Type 1 (70% of cases)
1 or 2 large dominant cysts (2-10cm) surrounded by smaller cysts.
Types 2 and 3 CPAM
Type 2
• 2nd most common (15-25%)
• Smaller cysts (<2cm)
• Other lung, cardiac, renal anomalies
Type 3
• 10% cases
• Microcysts (<5mm)
• Poorer prognosis
*Type 0 is not compatible with life. Type 4 looks like 1 on imaging. Only epithelial lining which is different.
Congenital lobar overinflation locations
- LUL (45%)
- RML (30%)
- RUL (20%)
*CPAMs have no lobar predominance
Uplifted cardiac apex
Right ventricular hypertrophy
5 Ts of cyanotic congenital heart defects
Tetralogy of Fallot
Transposition of the great arteries
Truncus arteriosus
TAPVR
Tricuspid valve abnormalities and hypoplastic right heart syndrome
Wormian bones mnemonic
PORK CHOP
P - pyknodysostosis
O - osteogenesis imperfecta
R - rickets
K - kinky hair syndrome
C - cleidocranial dysostosis
H - hypothyroid, hypophosphatasia
O - one too many chromosomes (Downs)
P - primary acro-osteolysis
Progressive atrophy of half of the face
Parry-Romberg syndrome
Skin, soft tissues and bone.
Potter sequence mnemonic
POTTER
P - pulmonary hypoplasia
O - oligohydramnios
T - twisted skin (wrinkly skin)
T - twisted face (Potter facies: low set ears, retrognathia, hypertelorism)
E - extremity deformities (club hands and feet, joint contractures)
R - renal agenesis (bilateral); restricted growth (IUGR)
Tuberous sclerosis features
HAMARTOMA
H - hamartomas (CNS, retina, skin)
A - angiofibroma/adenoma sebaceum
M - mitral regurgitation
A - angiomyolipoma
R - rhabdomyoma
T - tubers (cortical, subcortical)
O - autOsomal dominant
M - mental impairment
A - ash leaf spots
S - Shagreen patches, seizures
Medullary calcinosis causes
HAM HOP
H - hyperparathyroidism
A - acidosis (renal tubular)
M - medullary sponge kidney, milk-alkali syndrome
H - hypercalcaemia, hypercalciuria
O - oxalosis
P - papillary necrosis
Cortical nephrocalcinosis causes
COAG
C - cortical necrosis
O - oxalosis
A - Alport syndrome
G - glomerulonephritis
Drop metastases mnemonic
Gruesome Masses Progressively Extend Caudally
G - GBM, germinoma
M - medulloblastoma
P - pineocytoma, PNET
E - ependymoma
C - choroid plexus carcinoma
Cavitating lung lesions
CAVITY
C - cancer (SCC primary/mets)
A - autoimmune (GPA, RA)
V - vascular (bland/septic emboli)
I - infection (TB, abscess)
T - trauma (pneumatocoele)
Y - young (CPAM, sequestration, cyst)
Mnemonics for the causes of renal papillary necrosis
POSTCARDS
P - pyelonephritis
O - obstruction
S - sickle cell disease
T - TB
C - cirrhosis
A - analgesics (NSAIDs, paracetamol)
R - renal vein thrombosis
D - diabetes mellitus
S - systemic vasculitides
Signs include:
• Ball on tee
• Lobster claw sign of forniceal excavation
• Signet ring
• Sloughed papilla with clubbed calyx
Extremely large lung mass in an infant
Pleuropulmonary blastoma
• Usually R sided & complete whiteout
• No rib invasion
• Association with CPAM
Differential would be Askin tumour
• Ewing’s sarcoma family of tumours
• Usually older (Ewing’s age)
• Rib invasion
Extremely large lung mass in an infant
Pleuropulmonary blastoma
• Usually R sided & complete whiteout
• No rib invasion
• Association with CPAM
Differential would be Askin tumour
• Ewing’s sarcoma family of tumours
• Usually older (Ewing’s age)
• Rib invasion
Vein of Galen malformation
Foetal cardiomegaly
• Cause of high output cardiac failure.
• High flow shunting from high pressure choroidal arteries to low pressure Veins of Galen.
Alcoholic with necrosis and demyelination of the corpus callosum
Marchiafava-Bignami disease
Starts at body then extends to genu and splenium.
Vitamin B deficiency.
Cystic ovarian lesions with ring of fire vascularity
Corpus luteal cyst
Thick walled with intense peripheral vascularity. No follow up.
Most commonly injured duodenal segment
D2/D3
Most common pancreatic neuroendocrine tumour
Most common overall: Insulinoma
Most common in MEN-1: Gastrinoma
Parinaud syndrome
Paralysis of upward gaze
Suggests pineal lesion.
Porencephaly vs schizencephaly
Both may communicate with the ventricles but…
• Porencephalic cysts are lined by white matter.
• Schizencephaly lined by cortical grey matter.
• Open vs closed lip refers only to the degree of apposition of the two walls.
Superior rib notching
• NF-1
• Hyperparathyroidism
• Osteogenesis imperfecta
• Connective tissue disease
- RA, SLE, Sjögren’s, Marfan’s, scleroderma
Inferior rib notching
• Enlarged collateral vessels
- coarctation, TOF, Takayasu, subclavian stenosis, SVCO, AVM
• Neurogenic tumours
- schwannoma, neurofibroma
• NF-1
• Hyperparathyroidism
Superior AND inferior rib notching
NF-1 (ribbon ribs)
Hyperparathyroidism
Pineal lesions by age
• Pineoblastoma - young children
• Germinoma - <20 yrs (most common)
• Pineocytoma - adults (20-60 yrs)
Primary vs secondary renal lymphoma
Primary is rare as kidneys don’t contain lymphoid tissue. Secondary (NHL) much more common.
Typically renal contour is preserved unlike RCC.
Smooth featureless brain contour
Lissencephaly
Calcifying oesophageal mass
Leiomyoma
Virtually pathognomic and benign.
Missing structure in holoprosencephaly
Septum pellucidum
Alobar type has no corpus callosum
Most common malignant parotid tumour
Mucoepidermoid carcinoma
• FS T1 + C to look for perineural spread
• Adenoid cystic carcinoma is 2nd most common
Worsening oxygenation and new ground glass/consolidation 48hrs after major trauma with multiple fractures
Fat embolism syndrome
Contusions/lacerations would be present on initial imaging
Dysphagia, upper oesophageal webs, iron deficiency anaemia
Plummer-Vinson syndrome
*IDA seems to be the cause and reduced incidence means PVS is now rare.
Fallen lung sign
Tracheobronchial injury
Usually near carina. Lung unable to inflate.
Paediatric temporal lobe cortical lesion with dural tail
Pleomorphic xanthoastrocytoma
Reactive rather than dural invasion.
Fat ring sign CT abdomen
Mesenteric panniculitis
Immediate perivascular sparing within region of haziness
“ADEM on steroids”
Acute haemorrhagic leukoencephalitis (Hurst disease)
• Most severe form of ADEM.
• Increased oedema, mass effect and microhaemmorhages.
• Usually fatal. Unlike ADEM which improves with steroids.
Age range for multilocular cystic nephroma
Bimodal age distribution
• Children and middle aged females.
• Partial nephrectomy usually performed.
“DOPE”
Gardner’s syndrome
D - Desmoid tumour
O - osteoma
P - papillary thyroid cancer
E - epidermoid cyst
Lynch syndrome
Hereditary non-polyposis colorectal cancer (HNPCC)
• Most common cancer syndrome
• 5x more common than FAP
• Adenomatous bowel polyps leading to colorectal cancer
• Associated with a huge list of malignancies including:
- endometrial
- ovarian
- GBM
- TCC
*if question mentions lots of different cancers in FH pick this!
Most common fungal infection of CNS in HIV
Cryptococcus
Toxoplasmosis is most common overall.
Empyema vs pulmonary abscess
Empyema
• Split pleura sign
• Obtuse angle with pleura
• Lenticular shape
• Pleural enhancement
• Smooth walled
• Hazy extrapleural fat
Abscess
• Acute angle with pleura
• Thick walls
• Abruptly interrupts bronchi/vessels
Neurosyphilis
• Often coexists with HIV
• Lepto & pachymeningitis
• Arteritis leading to infarcts
• Treponema pallidum causative species
Ureteric calculus vs phlebolith:
Comet tail sign
Phlebolith
Ureteric calculus vs phlebolith:
Soft tissue rim sign
Calculus
Rim represents the oedematous ureteric wall.
ARPKD vs ADPKD
ARPKD (affects kids)
• Smaller cysts (usually <1-2cm)
• Enlarged echogenic kidneys
• Reniform shape preserved
• Hepatic fibrosis & Caroli disease
• Poor prognosis due to pulmonary hypoplasia from oligohydramnios
ADPKD (affects adults)
• More common (10% of all ESRF)
• Kidneys normal at birth
• Gradually replaced by large cysts
• Berry aneurysms & hypertension
• Cysts in liver, pancreas, seminal vesicles
Ganglioglioma vs pleomorphic xanthoastrocytoma
Ganglioglioma more likely to calcify (35%). Rare with PXA.
Serous cystadenoma
(random trivia)
• No communication with duct
• Glycogen-rich cysts
• Association with VHL
• No malignant potential (unlike mucinous types eg mucinous cystadenoma, IPMN)
Signs of ovulation on US
Follicle suddenly disappears or regresses
Irregular margins
Internal echoes
Free fluid in pouch of Douglas
Increased perifollicular blood flow
• Follicular monitoring is a vital part of IVF.
• Clomiphene citrate used to induce ovulation.
Reducing MR artefact from hip prosthesis
• Reduce field strength
• Increase bandwidth
• Increase matrix size
• Use spin echo (FSE) over GRE
• Thinner slices
• Increase no. excitations (increases SNR)
Ovarian tumour containing thyroid tissue
Struma ovarii
• Type of teratoma and appear as such
• May also contain follicles and colloid
Most common cause of crazy paving pattern on HRCT
Pulmonary oedema
Although classically associated with pulmonary alveolar proteinosis
Kinky hair syndrome
• Fine, silvery and brittle hair
• Seizures and developmental delay
• Progressive cerebral & cerebellar atrophy
• Wormian bones, metaphyseal widening, tibial and femoral spurs
“Sack of marbles sign” in neck ultrasound
Dermoid cyst
“Bullseye/onion bulb” demyelination pattern on MRI head
Baló concentric sclerosis
• Rare, rapidly progressive and invariably fatal form of MS.
• Similar presentation to Marberg type MS which is typically seen in younger patients
Bilateral uptake in subscapular region on PET with poorly defined soft tissue masses
Elastofibroma dorsi
• Classically deep to serratus anterior and latissimus dorsi.
• Possibly caused by friction of scapula against chest wall.
• Mixed fibrous/fatty components.
• Often asymptomatic but may have pain.
• Mild-mod uptake on FDG PET.
