Mnemonics1 Flashcards

Question

SPINACH

Answer 1

S Scleroderma Soft tissue calcification Symmetrical erosive polyarthropathy Sclerodactyly – skin atrophy of the fingertips Flexion contractures of the fingers P Psoriasis Symmetrical erosive distal arthropathy of the hands Periostitis/bone proliferation “Pencil-in-cup” deformity Psoriatic nail changes may be seen on film Bony ankylosis of distal interphalangeal/proximal interphalangeal (PIP) joints I Injury (e.g. burns, frostbite) Infection N Neuropathy (e.g. diabetes, leprosy) C Congenital (Hajdu–Cheney’s syndrome) H Hyperparathyroidism Subperiosteal bone resorption, classically on radial aspect of the middle phalanges Brown tumours Osteosclerosis Dystrophic soft tissue calcification

Answer 2

P Paget’s disease Anterior bowing Cortical thickening Coarsened trabeculae Almost always involves the epiphyseal region “Banana” insufficiency fracture anteriorly Found in older people – rare in those <40 years of age R Rickets Frayed, splayed and cupped metaphyses Widened growth plates O Osteogenesis imperfecta Osteopenia Multiple fractures Involves whole skeleton B Blount’s disease (tibia vara) Depression and beaking of the proximal tibial metaphysis Medial deviation of the tibia distally I Idiopathic N NF-1 Anterolateral tibial bowing, at the junction of the middle and distal third Fibular hypoplasia Pathological fracture Pseudoarthrosis Also associated with many other skeletal abnormalities, e.g. sphenoid wing dysplasia, lambdoidal suture defect, “ribbon” ribs, posterior vertebral scalloping, kyphoscoliosis G abnormal Growth, e.g. achondroplasia Shortening of the long bones Flared metaphyses Typical spinal and pelvic features, e.g. posterior vertebral scalloping, decreased caudal interpedicular distance, “tombstone” iliac wings, horizontal sacrum

Answer 3

H HOA (secondary) Usually smooth, bilateral and symmetrical Diaphyseal and metaphyseal, sparing epiphyses Long bones, tubular bones of hands/feet Associated lytic bone lesions (metastases) Affects an older age group than pachydermoperiostosis P Pachydermoperiostosis (primary HOA) Can affect epiphyses (at tendon insertions) and metaphyses Rare; much less common than secondary HOA Presents in children and young adults T Thyroid acropachy Usually spiculated fluffy periostitis Asymmetrical distribution Hands and/or feet are involved, not long bones Soft tissue swelling V Venous insufficiency Lower limb Thick undulating periosteal reaction Phleboliths Soft tissue defects/bandages due to ulcers

Answer 4

S Steroids Renal transplant A Alcohol Pancreatic calcification (chronic pancreatitis) D Diabetes Vascular calcification G Gaucher’s disease Massive splenomegaly Bone marrow infiltration Long bone abnormalities – Erlenmeyer flask, osteopenia, osteosclerosis Pathological fractures Multiple bone infarcts H-shaped vertebrae I Infection Inflammation Idiopathic Idiopathic: Perthes’ disease in a child aged 4–8 years old – usually unilateral T Trauma Evidence of previous femoral neck fracture S Sickle cell anaemia “Codfish”/H-shaped vertebrae Calcified/absent spleen Gallstones Bone infarcts Sclerotic bones

Answer 5

M Metastasis (hypervascular) Peripheral ring enhancement in the arterial phase, most commonly Variable appearance F Focal nodular hyperplasia (FNH) Stellate central scar with high T2 signal Intense homogeneous enhancement of the mass in the arterial phase Mass becomes isointense to normal liver parenchyma (equilibrates) in the delayed phases Enhancement of the central scar in the delayed phase only A Adenoma Heterogeneous, with patchy high T1 signal (fat and acute haemorrhage) Homogeneous enhancement in the arterial phase Remains hyperintense to normal liver with heterogeneous enhancement in the more delayed phases May have an apparent capsule H Haemangioma Very high T2 signal Peripheral nodular enhancement in the arterial phase Subsequent centripetal infilling of contrast in the more delayed phases No delayed phase contrast washout H HCC Evidence of cirrhosis Homogeneous or heterogeneous arterial phase enhancement Rapid contrast washout (reduced enhancement on the more delayed phase images) May invade the portal vein – a tumour thrombus will enhance; a bland thrombus will not

Answer 6

G Gallstone ileus Small bowel dilatation/obstruction Gallstone within the terminal ileum S Surgery (biliary-enteric) Anastomosis between bowel and bile ducts (on CT scan) E Endoscopic retrograde cholangiopancreatography (ERCP) History of recent ERCP I Infection (emphysematous cholecystitis) Air in the gallbladder, sometimes with air in the bile ducts C Chronic pancreatitis Pancreatic calcification S Sphincterotomy

Answer 7

T TB Non-specific – cannot be reliably differentiated from Crohn’s disease Most commonly ileocaecal involvement Narrowed, thick-walled, cone-shaped caecum CT: pericaecal lymphadenopathy – nodes have low attenuation necrotic centres L Lymphoma Non-specific small bowel involvement Nodular, diffuse bowel wall thickening/ulceration Luminal narrowing Aneurysmal dilatation of bowel Polyps – may cause intussusception if large CT: variable – bowel wall thickening, mesenteric masses, lymphadenopathy C Crohn’s disease Terminal ileal involvement in the majority of cases Skip lesions Aphthous ulceration (irregular pools of barium) “Rose-thorn” and “cobblestone” ulceration Asymmetrical mucosal involvement – commonly at the mesenteric border, which can lead to pseudosacculations Fistulae (to bladder, bowel, skin) Intra-abdominal abscesses Strictures Separation of bowel loops – bowel wall thickening or fatty hypertrophy

Answer 8

I Inflammatory (ulcerative colitis [UC]/Crohn’s disease) Infective (pseudomembranous) Ischaemic UC: continuous disease extending proximally from rectum, no skip lesions small bowel normal, except in “backwash” ileitis symmetrical mucosal involvement granular mucosa progressive loss of haustral pattern over time “lead pipe” colon if chronic pseudopolyps (islands of normal mucosa) dilated transverse colon with “thumbprinting” (toxic megacolon) Crohn’s disease: skip lesions most commonly terminal ileal involvement aphthous ulceration (irregular pools of barium) “rose-thorn” and “cobblestone” ulceration asymmetrical mucosal involvement – commonly mesenteric border, which can lead to pseudosacculations fistulae (to bladder, bowel, skin) intra-abdominal abscesses strictures separation of bowel loops – bowel wall thickening or fatty hypertrophy Infective (pseudomembranous colitis): non-specific findings will vary bowel wall thickening, “thumbprinting” pericolic fat stranding bowel dilatation, pneumoperitoneum (on abdominal radiograph [AXR]) “accordion” sign (on CT) often left colon, but whole colon may be involved Ischaemic: most commonly around splenic flexure may see “thumbprinting” on AXR, segmental bowel wall thickening on CT, if acute may see strictures on barium enema, if chronic N Neoplastic (especially lymphoma) Neutropenic Neoplastic: non-specific wall thickening, luminal narrowing, strictures adjacent enlarged lymph nodes Neutropenic (typhlitis): wall thickening and pericolic inflammation of caecum ± ascending colon R Radiation Non-specific Confined to the radiation field, e.g. rectosigmoid with a history of radiotherapy for prostatic/cervical carcinoma

Answer 9

L Lymphoma Multiple masses Ill-defined confluent mass that encases structures but does not usually compress them Retroperitoneal lymph nodes Splenomegaly C Carcinoid Mass with focal calcifications within a thickened mesentery Stellate radiating pattern within surrounding mesentery (desmoplastic reaction) Tethering of small bowel loops Enhancing small bowel mass (the primary lesion) Hypervascular liver metastases F Fibromatosis (desmoid) Predominantly solid, soft tissue attenuation Well defined Retraction of the associated bowel Associated with Gardner’s syndrome: subcutaneous nodules multiple colonic polyps skull and mandibular osteomas other soft tissue tumours M Metastases Evidence of primary tumour Lymphadenopathy, which may be localised S Sclerosing mesenteritis Sarcoma Sclerosing mesenteritis: similar in appearance to carcinoid retraction and calcification Sarcoma: rare variable appearances

Answer 10

A Analgesics (especially non- steroidal anti-inflammatory drugs) Alcohol Analgesics: occasional renal papillary calcification (may be ring-shaped) signs of painful conditions requiring analgesic use include “bamboo spine”, sacroiliitis, sacroiliac joint ankylosis, femoral head osteonecrosis, advanced osteoarthritis D Diabetes Vascular calcification I Infection May be unilateral O Obstruction Renal/ureteric stones May be unilateral S Sickle cell disease Bone infarcts Gallstones Small, calcified or absent spleen Osteonecrosis of femoral heads H-shaped vertebrae

Answer 11

M Medullary sponge kidney Normal biochemistry “Paintbrush” or “bunch-of-flowers” appearance on IVU Kidney may be enlarged H Hyperparathyroidism (primary) Hyperoxaluria (rare) Hyperparathyroidism: serum calcium and phosphate abnormalities bone resorption osteosclerosis brown tumours soft tissue calcification Hyperoxaluria: dense homogenous nephrogram on plain film osteopenia and other skeletal abnormalities may present in childhood and have a renal transplant R Renal tubular acidosis Metabolic acidosis Osteopenia, fractures, Looser’s zones Most common cause of nephrocalcinosis in childhood C Calcium excess (sarcoid, vitamin D excess, immobilisation) Rare causes of nephrocalcinosis

Answer 12

M Metastasis Multiple or solitary Significant surrounding oedema Commonly at grey–white matter junction Most common infratentorial mass in an adult Thick and irregular wall (compared with an abscess) A Abscess Usually solitary Smooth thin walls with uniform enhancement Restricted diffusion on MRI Significant surrounding oedema G Glioma Usually solitary but sometimes multifocal May be large with irregular outline Irregular nodular ring enhancement Significant surrounding oedema (if high-grade) Mass effect Crossing the midline via corpus callosum is suggestive Commonly in the deep white matter I Infarct Corresponds to vascular territories Modest enhancement if subacute C Contusion A rare cause Associated haemorrhage, skull fracture, coup and contrecoup injuries D Demyelination Acute demyelinating plaques may demonstrate incomplete ring enhancement R Radiation Possible evidence of previous surgery

Answer 13

S Schwannoma (vestibular) Avid enhancement Intracanalicular component may expand the internal auditory meatus (IAM) Acute angle with petrous temporal bone May be heterogenous if large or have a cystic component A Arachnoid cyst No enhancement Isointense to cerebrospinal fluid (CSF) in all sequences No restricted diffusion M Meningioma Avid enhancement Dural tail Obtuse angle with petrous temporal bone Adjacent hyperostosis Calcifications E Epidermoid cyst No enhancement Isointense to CSF in most sequences Higher signal than CSF on fluid-attenuated inversion recovery (FLAIR) Restricted diffusion

Answer 14

C Craniopharyngioma Most commonly a suprasellar mass Intrasellar extension may occur Peak incidence in childhood and the fifth decade Multilobulated heterogeneous mass containing solid and cystic elements with calcification Variable T1 and T2 signal Vivid enhancement of solid components A Adenoma of the pituitary (micro- and macro-) Microadenoma: <10 mm in diameter displaces the pituitary gland enhances later than the normal pituitary gland Macroadenoma: >10 mm in diameter centred on intrasellar region, extending into the suprasellar cistern expansion of the pituitary fossa may invade the cavernous sinus and encase the internal carotid artery homogeneous enhancement calcification rare may haemorrhage or contain cysts R Rathke’s cleft cyst Intrasellar, with or without suprasellar extension – a purely suprasellar mass is very rare Thin-walled cyst No calcifications No enhancement, but surrounding normal pituitary tissue may mimic wall enhancement Variable MR signal – may show high (proteinaceous fluid) or low T1 signal M Meningioma Metastasis Meningioma: more commonly parasellar/suprasellar than intrasellar usually solid (may contain cysts) dural tail uniform enhancement Metastasis: rare often from breast or lung carcinoma evidence of other metastatic disease/known primary tumour enhancement may be indistinguishable from macroadenoma A Aneurysm Flow void on MRI G Glioma Suprasellar Optic chiasm and nerve gliomas are associated with NF-1 Usually enhance

Answer 15

Normal Normal variant Usually in the globus pallidus bilaterally Not usually extensive B Birth anoxia/hypoxia Variable calcification I Infection – congenital (toxoplasmosis) Inherited (Fahr’s disease) Toxoplasmosis: scattered focal irregular and/or curvilinear calcifications involving basal ganglia hydrocephalus abnormal brain parenchyma Inherited: bilateral extensive calcification R Radiotherapy Evidence of previous surgery Encephalomalacia T Toxins (carbon monoxide, lead) H Hypocalcaemia Bilateral extensive calcification

Answer 16

A cerebral Amyloid angiopathy Older age groups Cortical or subcortical location Spares deep white matter, basal ganglia, brainstem Often large haemorrhages Micro-haemorrhages: focal areas of low signal on gradient echo MR sequences Focal areas of encephalomalacia (from previous haemorrhage) Cerebral atrophy and leukoencephalopathy H Hypertensive Commonly in basal ganglia/thalamic location M Malignancy Metastases are more common than primary tumours Metastases are often multiple lesions, at the grey–white matter junction Vasogenic oedema and mass effect Enhancing lesions Primary tumours are usually a single lesion T Trauma (contusions) Small, often multiple parenchymal haemorrhages Especially in inferior frontal lobes and temporal poles – adjacent to bone Signs of trauma: scalp haematoma skull fracture associated extradural/subdural/subarachnoid haemorrhage V Vascular malformation Venous infarction Vascular malformation: AVMs – feeding arteries and draining veins post-contrast, nidus of abnormal vessels with calcified foci cavernous haemangiomas – “popcorn” appearance on MR with low signal rim, often difficult to see on CT scan Venous infarction: bilateral parasagittal or bithalamic infarction ± haemorrhage temporal lobe infarction ± haemorrhage sinus thrombosis – high attenuation in the superior sagittal or transverse sinuses on unenhanced CT, “empty delta” sign on CT venogram

Answer 17

S Stroke (acute infarct) Conforms to an arterial territory Relevant clinical history, acute onset E Epidermoid cyst T2 signal similar to CSF Increased signal on FLAIR No enhancement Most common at the cerebellopontine angles A Abscess Intraparenchymal Peripheral rim enhancement Surrounding vasogenic oedema Mass effect Very low ADC values Relevant clinical history: sepsis and rapid deterioration L Lymphoma Intermediate or low T2 signal relative to grey matter Avid homogenous enhancement May cross midline Relatively little mass effect

Answer 18

I Infarction High T2 signal Enhancement not a feature Mild cord expansion in the acute phase, but less so than tumours Restricted diffusion H Haemangioblastoma Usually discrete, avidly enhancing nodules High T2 signal mass Multiple flow voids from vessels Cystic component E Ependymoma Most common spinal tumour in adults Most common in the lumbar spine, conus/filum terminale and cervical spine Well defined Central location in the cord May be heterogeneous with focal cystic change and haemorrhage Well-defined, avid, homogeneous enhancement Bony remodelling is common A Astrocytoma Most common spinal tumour in children but also seen in adults Most commonly found in the thoracic and cervical spine Poorly defined Eccentric location in the cord Bony remodelling not a feature Haemorrhage uncommon L Lipoma (or dermoid cyst) Both are commonly found in the conus Presentation at >20 years of age Lipoma: high T1 signal – fat homogeneous Dermoid: contains variable proportions of fat, cystic areas and soft tissue components heterogeneous

Answer 19

N Neurofibroma Most commonly found in the cervical spine May be multiple “Dumbbell” appearance if they enter the neural foramen Low T1 and high T2 signal Contrast enhancement “Target” sign on T2-weighted imaging – low signal centre with peripheral high signal (also seen in schwannomas) Haemorrhage and cystic changes are rare Adjacent bony remodelling M Meningioma Usually in thoracic cord (75%) Lateral aspect of cord (90%) Broad-based dural attachment Dural tail Isointense to the cord on T1 and T2 Early avid enhancement S Schwannoma Most commonly found in the cervical and lumbar spine Usually solitary Rounded lesions ± “dumbbell” appearance if they enter the neural foramen Adjacent bony remodelling Low T1 and high T2 signal, contrast enhancement Haemorrhage and cystic changes may occur M Metastasis Commonly multiple, round and of varied sizes Enhancing nodular lesion on the cord and meninges “Sugar coating” of the cord “Drop” metastases – more common in paediatric patients Non-CNS primary tumour – more common in adult patients

Answer 20

D Disc Commonly multiple associated areas of degenerative disc disease A Abscess Long segment lobulated extradural collection Peripheral enhancement Usually secondary to a primary disc or vertebral infection M Metastasis Myeloma Associated vertebral marrow infiltration contiguous with the mass Commonly multiple N Neurofibroma Indents the theca laterally at the level of exit foramina May have a “dumbbell” appearance

Answer 21

C Caffey’s disease Onset <6 months of age; resolved by 1 year Thick irregular periosteal reaction Cortical thickening Commonly involves mandible, clavicle and ribs Less commonly involves long bones with asymmetrical involvement of diaphysis only Soft tissue swelling A juvenile idiopathic Arthritis Variable features including: osteopenia erosions soft tissue swelling T Tumour (leukaemia, metastatic neuroblastoma) Osteopenia Metaphyseal lucent bands (non-specific) N Normal (physiological) Occurs in those aged 1–6 months old Thin periosteal reaction Bilateral and symmetrical Diaphyseal, no metaphyseal involvement I Infection, e.g. congenital syphilis Metaphyseal dense/lucent bands Metaphyseal erosions Bilateral erosions of proximal medial tibial metaphyses (Wimberger’s sign) P Prostaglandin therapy Non-specific features May be similar in appearance to Caffey’s disease but history of cardiac abnormality

Answer 22

M Metastases Myeloma Abnormal marrow signal within affected vertebra Associated soft tissue mass May affect multiple vertebrae and involve posterior elements Evidence of primary malignancy elsewhere Less common in the young E Eosinophilic granuloma Uniform flattening of vertebra – “coin-on-edge” or “pancake” vertebra No involvement of posterior elements Preservation of disc space Most often a single vertebra affected Other skeletal features: lytic skull lesions with a double contour/bevelled edge long bone lesions, often ill-defined, lytic, diaphyseal L Leukaemia Lymphoma Similar features to metastases and myeloma Usually multiple vertebrae involved Underlying osteopenia in leukaemia T TB Vertebral body destruction, often not uniform May involve disc space (loss of disc height, endplate irregularity), usually at a later stage Abnormal bone marrow signal Epidural, subligamentous and paraspinal abscesses with thick enhancing rims Often affects multiple vertebrae Thoracolumbar kyphosis (gibbus deformity) Most often thoracolumbar spine

Answer 23

P Pyknodysostosis Wide skull sutures/fontanelles with delayed closure Small mandible Absent sinuses Absent/hypoplastic clavicles Osteosclerosis of skull base and elsewhere I Idiopathic N Normal variant T Hypothyroidism (congenital) Delayed closure of the fontanelles Small epiphyses with delayed closure D Down’s syndrome Hypoplasia of the facial bones and sinuses Atlanto-axial subluxation 11 pairs of ribs Clinodactyly (radial curvature of the little finger) O Osteogenesis imperfecta Osteopenia Deformed and gracile long bones Multiple fractures C Cleidocranial dysostosis Wide skull sutures/fontanelles with delayed closure Normal mandible Normal bone density Absent/hypoplastic clavicles Coxa vara/deformed femoral necks Wide pubic symphysis

Answer 24

G Glioma (of brainstem) Diffuse enlargement of the pons Anterior to the fourth ventricle Often no enhancement A Astrocytoma (pilocytic) Cerebellar lesion Well-defined cyst with a solid enhancing peripheral nodule Large lesions displace the fourth ventricle Hydrocephalus M Medulloblastoma Homogeneous well-defined round mass Hyperdense on pre-contrast CT Uniform enhancement Central – vermis of the cerebellum (80%) Compresses the fourth ventricle “Drop” metastases E Ependymoma Centred on the floor of the fourth ventricle Expands the fourth ventricle Extends through CSF foramina – “toothpaste” tumour Heterogeneous – calcification and cystic change

Answer 25

H Hydronephrosis Dilated renal pelvis and calyces If due to pelviureteric junction (PUJ) obstruction: normal calibre ureters Most commonly left-sided C Cystic kidney disease Multilocular cystic nephroma: multiloculated well-defined cystic mass arising from a pole of a kidney, usually lower pole thick fibrous capsule enhancing septations no solid components claw of distorted renal parenchyma calcification is rare does not metastasise – benign mass Multicystic dysplastic kidney: multiple renal cysts of varying sizes most commonly unilateral and asymptomatic fatal if bilateral no renal parenchyma visible non-functioning kidney on nuclear MAG3 renogram N Neuroblastoma More common at ages <2 years Large suprarenal/retroperitoneal mass Frequently crosses the midline Calcification typical Encasement of vessels, e.g. aorta, inferior vena cava (IVC), superior mesenteric artery Elevates the aorta anteriorly away from the vertebrae Displaces the kidneys May invade the spinal canal via the neural foramen W Wilms’ tumour More common at ages 2–4 years Well-defined, usually solid but sometimes cystic, renal tumour “Claw” sign (concavity of renal contour, distorted by tumour) Calcification may occur but not as often as in neuroblastoma Displacement of vessels Sometimes crosses midline May invade the renal vein and IVC O Ovarian cyst L Lymphoma Variable appearances: ileocaecal mass with bowel wall thickening ileocaecal mass with bowel wall thickening mesenteric and retroperitoneal nodal masses H Hepatoblastoma Age <5 years Right upper quadrant mass Soft tissue mass arising from the right lobe of the liver Often heterogeneous with necrosis/haemorrhage/calcifications Metastases to lung

Answer 26

H Hirschsprung’s disease Presents within the first 6 weeks of life in term infants Aganglionic bowel is of normal calibre A transition point may be seen and is typically conical Variable proximal dilatation of large bowel A Atresia (of ileum, colonic, anal) Ileal atresia: microcolon air-fluid levels in dilated small bowel no contrast reflux into dilated small bowel at contrast enema Colonic atresia: disproportionately enlarged colon distal to a competent ileocaecal valve Anal atresia: clinically apparent sacral agenesis associated with VACTERL abnormalities (i.e. vertebral anomalies, anal atresia, cardiovascular anomalies, tracheoesophageal fistula, renal and/or radial anomalies, limb defects) M Meconium ileus Meconium plug syndrome Meconium ileus: microcolon “soap-bubble” lucencies in the terminal ileum (meconium) air-fluid levels are rare reflux of contrast past distal ileum into dilated small bowel Meconium plug syndrome: no microcolon variable large bowel dilation left colon may be smaller than the right plugs of meconium often around splenic flexure

Mnemonics1 Flashcards

FRCR 2B mnemonics