Mnemonics1

Question 1

STREP ABC

Answer 1

Upper lung fibrosis

S Sarcoidosis “Egg-shell” calcification of lymph nodes

Hilar/mediastinal adenopathy
Background lung nodularity
T Tuberculosis (TB; secondary) Cavitating lung lesions
R Radiation Well-defined non-anatomical border with normal lung
Evidence of previous surgery (mastectomy, surgical clips)

E Extrinsic allergic alveolitis (EAA)
P Pneumoconiosis
Progressive massive fibrosis (PMF)

Conglomerate upper lobe masses
“Egg-shell” calcification of lymph nodes
Background lung nodularity
A Ankylosing spondylitis Ankylosis of cervical spine
C Cystic fibrosis Young patient
Portacath

Question 2

LENT

Answer 2

Diffuse cystic insterstitial lung disease without volume loss

L Lymphangioleiomyomatosis (LAM) Females of childbearing age only

Pneumothorax
Pleural effusion

**E Eosinophilic granuloma ** (pulmonary Langerhans’ cell
histiocytosis [P-LCH])

Commonly affects young adult males
Nodules
Pneumothorax

**N Neurofibromatosis **type 1 (NF-1) Dysplastic “ribbon” or eroded ribs

Neurofibromas in the posterior mediastinum and
subcutaneous tissues

T Tuberous sclerosis (TS) Pulmonary features identical to LAM

Question 3

Sarcoidosis Does Like Producing Variable HRCT Findings

Answer 3

S Sarcoidosis Reticulonodular opacities in the mid and upper zones

Lobulated symmetrical hilar enlargement with right paratracheal stripe widening due to
lymphadenopathy – Garland’s triad
Nodules along subpleural surfaces and bronchovascular bundles
“Egg-shell” calcification of nodes
Upper lobe fibrosis and traction bronchiectasis in end-stage disease

D Drug reactions Non-specific
L Lymphangitis
carcinomatosis

Evidence of malignancy, e.g. pulmonary nodules or masses, rib lesions, mastectomy, neck
mass, mediastinal mass, surgical clips
Pleural effusions
Loss of lung volume
Hilar and mediastinal lymphadenopathy

P Pneumoconiosis Hilar lymphadenopathy
“Egg-shell” nodal calcification
Conglomerate upper lobe masses (PMF)
Upper lobe fibrosis
V Viral pneumonia Non-specific

Nodal enlargement in children

H Heart failure Cardiomegaly
Perihilar opacification
Upper lobe venous distension
Pleural effusions
Kerley’s lines
F Fibrosis Volume loss

Lower zone predominance (collagen vascular disease, idiopathic, asbestosis)
Pleural plaques (in asbestosis)

Question 4

CAVITIES

Answer 4

Multiple nodules

C Cancer (metastatic or primary lung) Features of malignancy

Mastectomy, evidence of other surgery (e.g. surgical clips),
lymphangitis, lymphadenopathy, bone lesions

A Autoimmune (Wegener’s granulomatosis, rheumatoid
nodules)

Wegener’s granulomatosis:
round lesions, which may show cavitation
no calcification
Rheumatoid nodules:
peripheral and lower zone predominance
basal lung fibrosis
arthropathy

V Vascular (infarcts, septic emboli) Infarcts:

pulmonary artery enlargement
pulmonary embolus on CT scan
Septic emboli:
cavitation
source of infection

I Infection
Inflammatory (granulomas, fungal, previous
chickenpox pneumonia, multiple lung abscesses)

Associated consolidation
Relevant clinical history

**T TB **Variable appearance

Possible findings include consolidation, lymphadenopathy,
upper lobe cavitation and pleural effusions

S Sarcoidosis, silicosis and Langerhans’ cell histiocytosis Sarcoidosis: check for Garland’s triad of lymphadenopathy
Silicosis or other pneumoconioses: small nodules that may
calcify
Langerhans’ cell histiocytosis: there may be cavitation of the
larger nodules

Question 5

Test Match Special

Answer 5

T TB (miliary) Superadded consolidation/cavitation

Lymphadenopathy
M Metastases Lytic/sclerotic bony lesions

Previous surgery (mastectomy, surgical clips in neck, axilla)
Lymphangitis

S Sarcoidosis
Simple silicosis

Sarcoidosis:
subpleural nodules – an HRCT feature
bilateral hilar and right paratracheal lymphadenopathy
“egg-shell” calcification of lymph nodes
Simple silicosis:
hilar and mediastinal lymphadenopathy
“egg-shell” calcification of lymph nodes

Question 6

SHAMPOO

Answer 6

S Silicosis Silicosis – chronic simple:
well-defined small nodules
mid and upper zone predominance
“egg-shell” calcification of hilar and/or mediastinal nodes
Silicosis – complicated:
irregular conglomerate lung masses (PMF)
initially peripheral mass, with migration towards the hilum

H Histoplasmosis
Hyperparathyroidism

Histoplasmosis (healed):
small, well-defined, acute nodules develop into multiple punctate calcifications
hilar and mediastinal lymphadenopathy
“popcorn” calcification of large mediastinal nodes
upper lobe fibrosis/cavitation (similar to TB)
punctate splenic calcifications (more visible on CT)
Hyperparathyroidism:
rare
ill-defined, may be large lung lesions
lateral clavicle resorption
superior/inferior rib notching
osteopenia/osteosclerosis
soft tissue calcification

A Alveolar microlithiasis Tiny, sand-like, diffuse calcifications that can obscure normal lung markings

Diffuse involvement of both lungs
Calcium uptake demonstrated on bone scan
Usually asymptomatic

M Metastases
Mitral stenosis

Metastases:
may be large, randomly distributed and of varying size
evidence of bony abnormality – lysis/sclerosis/absent limb, e.g. proximal
humerus (osteosarcoma)
neck mass/surgery (thyroid carcinoma)
Mitral stenosis:
small diffuse nodules
mid and lower zone predominance
cardiomegaly
double right heart border, splayed carina

P Previous chickenpox (VZV)
infection

Well-defined small nodules of similar size
No zonal predominance
No calcified lymph nodes

Question 7

CAT

Answer 7

Large Cavitating Lesion

C Cancer (primary more than
secondary)

Primary – more commonly solitary
Metastases – more commonly multiple
Lymphangitis carcinomatosis
Hilar/mediastinal lymphadenopathy
Rib lesions: sclerotic or lytic
Previous surgery: mastectomy, axillary clips, oesophageal stent, cervical clips
Thick- or thin-walled

A Abscess Usually a single cavitating lesion

Thick-walled
Air-fluid level
Lower lobe predominance – suggests aspiration

T TB (reactivation) Most commonly posterior segments of the upper lobe and apical segment of the

lower lobe
Other lung masses/nodules
Often bilateral
Cavity may contain an air-fluid level
May be surrounded by consolidation
“Tree-in-bud” nodularity on CT
Sometimes pleural effusion
Lymphadenopathy rare

Question 8

Four T’s

Answer 8

Anterior mediastinal mass

Thymic mass Pleural metastases if malignant
Teratoma (germ cell
tumour)

Younger age
Often contain fat and enhancing septa on CT
Calcification – rim or teeth/bone fragments
Thyroid (retrosternal) Continuity with neck and superior mediastinum

Deviation of the trachea

Terrible lymphoma Lymphadenopathy in middle and posterior mediastinum as well as axilla, neck, abdomen

and pelvis
Splenomegaly

Question 9

METAL

Answer 9

*Pleural lesion

M Mesothelioma Pleural effusion (often large and unilateral)
Pleural thickening, which may be multifocal or
circumferential
Often involves the mediastinal pleura and interlobar fissures
Ipsilateral volume loss
Calcified pleural plaques (previous asbestos exposure)
Chest wall invasion

E Empyema Pleural fluid with locules of gas
Pleural thickening and enhancement
Smooth margin, convex towards the lung
“Split pleura” sign
Adjacent pneumonia

T Thymic tumour (invasive thymoma or thymic
carcinoma)

Anterior mediastinal mass with lobulated contour
Encases mediastinal structures
Spreads along pleural surfaces
Unilateral nodular pleural thickening
A Adenocarcinoma metastases Evidence of metastatic disease:
lymphadenopathy
lymphangitis carcinomatosis
bone lesions
lung nodules/masses
pleural effusion

L Lymphoma
Loculated pleural effusion

Lymphoma:
variable – solitary nodule or diffuse pleural
thickening
pleural effusion
bilateral asymmetrical hilar enlargement
consolidation
lung nodules/masses
lymphangitis carcinomatosis
Loculated pleural effusion:
localised pleural fluid
smooth margin, concave towards the lung
no pleural thickening or enhancement

Question 10

CPAP

Answer 10

Hyperlucent hemi thorax

**C Chest wall **(Poland’s syndrome, polio,
mastectomy)

Asymmetry of thoracic wall soft tissues
Poland’s syndrome: rib/scapula hypoplasia, absent pectoralis major,
associated with ipsilateral breast aplasia
Polio: ipsilateral scapula/humeral hypoplasia
Mastectomy: surgical clips in the ipsilateral axilla may also be seen
P Positioning (rotation/scoliosis) Asymmetry of the distance between the spinous processes and medial ends
of the clavicles (this may be due to poor radiographic technique or an
unwell patient who cannot be adequately positioned)
Patients with thoracic scoliosis may have an inherent anatomical rotation

**A Airways disease **(airway obstruction,
emphysema, Swyer–James’ syndrome,
congenital lobar emphysema)

All: expiratory air trapping; this may result in increased ipsilateral lung
volume and contralateral mediastinal shift (the exception being Swyer–
James’ syndrome)
Swyer–James’ syndrome: normal or small volume lung with small
ipsilateral hilar vessels
Foreign body:
commonly seen in young children/toddlers
occasional radio-opaque foreign body seen in the ipsilateral bronchus
Congenital lobar emphysema:
babies/early childhood
hyperinflated lobe of lung

P Pneumothorax
Pulmonary embolus (PE)

Pneumothorax:
lung edge visible
absence of lung markings peripherally
always comment on mediastinal shift and a possible tension
pneumothorax
PE:
enlarged ipsilateral central pulmonary artery with paucity of the
peripheral pulmonary vasculature
peripheral lung opacities (infarcts)
pleural effusion

Question 11

Every CXR Aids Patient Management

Answer 11

E Effusion Tracheal deviation/mediastinal shift to the contralateral side

If secondary to malignancy – contralateral lung nodules, mastectomy, nodal enlargement, rib lesions

C Consolidation
Collapse

Consolidation:
air bronchograms
no tracheal deviation
Collapse:
tracheal deviation/mediastinal shift to the ipsilateral side
check endotracheal tube position – is it too near the carina or in the right main bronchus?
if secondary to central obstructing tumour/metastasis – assess for contralateral lung nodules,
mastectomy, nodal enlargement, rib lesions

A Agenesis Tracheal deviation to ipsilateral side

No change compared with previous CXRs (if available)

P Pneumonectomy Tracheal deviation to ipsilateral side

Fifth/sixth rib excision or signs of thoracotomy
Surgical clips

M Mesothelioma Calcified pleural plaques
Pleural effusion
Limited mediastinal shift due to encasement of the lung

Question 12

AEIOU

Answer 12

A Alveolar sarcoidosis Mid and upper zone distribution

Bilateral symmetrical reticulonodular pattern
Underlying nodules on CT – subpleural, fissural and bronchovascular distribution
Mediastinal lymphadenopathy

E Eosinophilic pneumonia
(chronic)

Blood eosinophilia
Nodules and reticular opacities uncommon
Classically affects young adult females

I Infarct Wedge-shaped opacities
Evidence of pulmonary embolus
Pleural effusions

O Cryptogenic Organising
pneumonia (COP)

Patchy peripheral consolidation with associated “ground-glass” shadowing
Predominantly lower zone
Reticular opacities
Nodules
Classically affects 40–70 year olds

U contUsion History/evidence of trauma, e.g. rib fractures, pneumothorax, subcutaneous

emphysema, aortic injury

Question 13

HARPIE

Answer 13

H Heart failure
Pulmonary haemorrhage

Heart failure: cardiac enlargement

A Acute respiratory distress syndrome (ARDS)
R Reaction to drugs
P Pneumocystis pneumonia (PCP) Pleural effusion and hilar lymphadenopathy are uncommon
I non-specific Interstitial pneumonia (NSIP)
E EAA

Question 14

SLIPS

Answer 14

S Sarcoidosis Lobulated symmetrical hilar enlargement with right paratracheal stripe widening due to

lymphadenopathy – Garland’s triad
Reticulonodular opacities in the mid and upper zone
Nodules along subpleural surfaces and bronchovascular bundles
“Egg-shell” calcification of nodes
Upper zone fibrosis and traction bronchiectasis in end-stage disease

L Lymphoma Bilateral but asymmetrical hilar enlargement
Enlarged hilar nodes usually abut the cardiac borders

I Infection (especially viral,
TB)

Unilateral or bilateral hilar lymphadenopathy with variable consolidation
Bilateral hilar enlargement is rare in TB

P Pulmonary artery
hypertension (PAH)

Enlarged main pulmonary artery
Enlarged left and right pulmonary arteries
Mural calcification of pulmonary arteries in long-standing severe PAH
Decreased peripheral vascular markings (“pruning”)
Cardiomegaly (especially right ventricle)
Lung parenchymal abnormalities, e.g. fibrosis, emphysema

S Small cell lung carcinoma Non-specific

Unilateral or asymmetrical hilar and/or mediastinal lymphadenopathy
Primary tumour may not be apparent

Question 15

AVN

Answer 15

A Arterial obstruction (Aortic coarctation, Blalock–
Taussig shunt, Takayasu’s arteritis)

Coarctation:
commonly bilateral, third to ninth ribs
abnormal aortic contour – prominent ascending and small
descending aorta
cardiomegaly with or without pulmonary oedema
“figure 3” sign on CXR
Blalock–Taussig shunt:
a procedure for the treatment of Tetralogy of Fallot
(subclavian-pulmonary artery anastomosis)
unilateral rib notching on the side of procedure – upper
three or four ribs
thoracotomy/median sternotomy wires
abnormal cardiac contour
Takayasu’s arteritis: unilateral rib notching on side of
subclavian artery occlusion – most commonly left

V Venous obstruction: superior vena cava obstruction Rarely seen

Evidence of malignancy (especially lung carcinoma, lymphoma)
Superior mediastinal widening
Hilar masses
Lung nodules/masses
Lytic rib lesions (metastases)
Reticulonodular shadowing (lymphangitis)

N Nerve (neurofibromatosis)
Normal variant

Neurofibromatosis:
large notches (from intercostal neurofibromas)
if severe, very thin attenuated “ribbon” ribs (from
pressure effects and rib dysplasia)
subcutaneous nodules
posterior mediastinal masses
kyphoscoliosis
interstitial lung disease with normal/increased volumes

Question 16

ROMPS

Answer 16

R Renal osteodystrophy Occurs in children or adults

“Rugger jersey” spine (ill-defined bands of endplate sclerosis)
Subperiosteal bone resorption
Secondary signs of renal failure:
haemodialysis or peritoneal dialysis lines
vascular fistulae
vascular and soft tissue calcifications

O Osteopetrosis Paediatric onset
Very dense bone
“Sandwich” vertebrae (well-defined endplate sclerosis)
Fractures
Sclerotic mandible with supernumerary teeth
Erlenmeyer flask deformity

M Metastases
Myelofibrosis

Metastases:
focal cortical destruction/lytic lesions
lung nodules
lymphangitis carcinomatosis
evidence of surgery, e.g. mastectomy, axillary clips
Myelofibrosis:
onset typically in those aged >50 years
narrowed medullary cavity
hepatosplenomegaly/splenectomy (surgical clips)

P Pyknodysostosis Paediatric onset
Fractures
Hypoplastic sclerotic mandible
Multiple wormian bones
“Pencil-sharpened” distal phalanges
S Sickle cell disease “Codfish”/H-shaped vertebrae

Avascular necrosis (AVN) humeral/femoral heads
Gallstones
Absent/atrophic calcified spleen
Cardiomegaly

Question 17

Metastases May Eventually Fracture Bones

Answer 17

M Metastases Generally occurs in those aged >40 years old

Variable appearances
Well or ill-defined but look for aggressive features
Non-expansile or expansile
May have a sclerotic component
M Myeloma Occurs in those aged >35 years old
Well-defined lytic lesions of uniform size
Endosteal scalloping (non-specific)
Rarely sclerotic

E Enchondromatosis (Ollier’s
disease/Mafucci’s syndrome)

Present in childhood
Commonly in hands and wrists
Multiple lytic, expansile, metaphyseal lesions
Chondroid matrix (punctate/curvilinear foci of calcification within lesion)
Abnormal growth, shortening and deformity of affected limbs
Ollier’s disease: many enchondromata
Mafucci’s syndrome: many enchondromata associated with soft tissue
haemangiomas (phleboliths seen on plain film)

F Fibrous dysplasia Occurs in those aged <30 years old

Especially ribs, pelvis and proximal femur, humerus, skull and mandible
Diaphyseal or metaphyseal
Usually well defined
Endosteal scalloping
Hazy, ground-glass internal matrix
Thick sclerotic rim (“rind” sign)
“Shepherd’s crook” deformity – bowed proximal femur

B Brown tumours Variable appearance

Well defined with some expansion
Secondary features of hyperparathyroidism, e.g. subperiosteal bone resorption,
“rugger jersey” spine, acro-osteolysis, osteopenia

Question 18

Politicians Always Make Grave Blunders

Answer 18

P Plasmacytoma/large
myeloma deposit

Occurs in those aged >35 years old
Well defined
Any location
May be multiple lesions if multiple myeloma

A Aneurysmal bone cyst
(ABC)

Occurs in those aged <30 years old
Most common in long bones around the knee, proximal femur and spine
Metaphyseal
Well defined

M Metastases Occurs in those aged >40 years old

Well or ill-defined, but look for aggressive features
May be multiple
Any location
G Giant cell tumour (GCT) Closed epiphysis

Well-defined non-sclerotic margin
Eccentric position
Epiphyseal – the lesion must abut the articular surface
Most commonly adjacent to the knee, the distal radius and sacrum

B Brown tumours Well defined
Any location
Look for evidence of hyperparathyroidism, e.g. subperiosteal bone resorption,
osteosclerosis, soft tissue calcification

Question 19

LOSE ME

Answer 19

L Leukaemia Variable appearance:
metaphyseal lucent lines
osteopenia
periosteal reaction
focal ill-defined lytic lesions
elevated erythrocyte sedimentation rate (ESR) and anaemia

O Osteomyelitis Variable appearance:
often metaphyseal
may have lucency, sclerosis, periosteal reaction and soft tissue mass

S Sarcoma (osteogenic) Generally occurs in those aged 10–20 years old

Metaphyseal
Lysis and sclerosis
Aggressive periosteal reaction
Soft tissue mass

E Eosinophilic granuloma Generally occurs in those aged <10 years old

Usually diaphyseal
Well or ill-defined
Periosteal reaction possible

M Metastasis (neuroblastoma) Generally occurs in those aged <2 years old

Ill-defined lytic lesions
May be multiple
Evidence of primary tumour on cross-sectional imaging
E Ewing’s sarcoma Generally occurs in those aged 10–20 years old

Diaphyseal
Ill-defined lysis, may be permeative
Sclerosis less common
Aggressive periosteal reaction
Soft tissue mass

Question 20

ACE GIG

Answer 20

A ABC Occurs in those aged 10–30 years old

Epiphyseal and metaphyseal in the fused skeleton
Most commonly metaphyseal in the unfused skeleton
Well defined
Expansile
Cortical thinning
Fluid–fluid levels (MRI)
Also occurs in vertebral posterior elements
C Chondroblastoma Occurs in those aged 10–20 years old

Eccentric epiphyseal lesion prior to skeletal fusion
May extend into metaphysis after fusion
Well defined
Sclerotic margin
Internal calcifications
Florid bone marrow oedema (MRI)
E Eosinophilic granuloma Occurs in those aged <30 years old

Variable appearance
More often diaphyseal/metaphyseal than epiphyseal
Well or ill-defined
Lytic or sclerotic
Periosteal reaction

G GCT Occurs in those aged 20–40 years old

Fused growth plates
Epiphyseal lesion expanding into the metaphysis
Must abut the articular surface
Eccentrically positioned lesion
Well-defined non-sclerotic margin
Expansile with cortical thinning
No marrow oedema on MRI

I Infection Occurs at any age
Variable appearance
Cortical sclerosis/breach
Soft tissue swelling
Periosteal reaction
Sequestrum
“Penumbra” sign on T1-weighted MRI

G Geode Less likely in a young patient

Background of degenerative joint disease

Question 21

MLML

Answer 21

M Metastases
Myeloma

Metastases:
more commonly focal rather than diffuse marrow involvement
usually low T1 and high T2/STIR signal. Sclerotic metastases are low signal on T1 and T2
sequences
may be evidence of a primary tumour – always check the localiser images
Myeloma:
more commonly diffuse than focal
variable T2 signal – high or low
L Lymphoma Marrow appearance as for metastases
More commonly focal than diffuse
Usually secondary to extraosseous disease: lymphadenopathy, splenomegaly

M Myelofibrosis
Mastocytosis

Diffuse abnormality
Splenomegaly – may be best seen on localiser images
Very low T1 (black marrow) signal
Low T2 signal

L Leukaemia Diffuse bone marrow abnormality

Variable T2 signal

Question 22

SALMON

Answer 22

S Spinal cord tumour Localised widening of the interpedicular distance at tumour site
A Achondroplasia
Acromegaly

Achondroplasia:
short pedicles resulting in sagittal spinal canal narrowing
progressive caudal narrowing of interpedicular distance
anterior vertebral body beaks
“champagne glass” pelvic inlet
horizontal sacrum
“tombstone” iliac wings
Acromegaly: enlarged vertebral bodies in both AP and lateral dimensions

M Marfan’s syndrome
Morquio’s syndrome

Marfan’s syndrome:
scoliosis
pectus excavatum/carinatum
Morquio’s syndrome:
platyspondyly/vertebra plana
central anterior vertebral body beaks
hypoplastic dens
atlanto-axial instability

O Osteogenesis imperfecta Osteopenia with multiple vertebral wedge fractures, resulting in biconcave vertebral bodies
N NF-1 Thoracolumbar kyphoscoliosis
Absent or eroded pedicles
Expansion of the intervertebral foramina due to “dumbbell” neurofibromas
Hypoplastic vertebrae

Question 23

SHIRT

Answer 23

S Scleroderma Dilated oesophagus
Lower lobe fibrosis
Soft tissue calcification
H Hyperparathyroidism Osteosclerosis

Other areas of osteolysis
Brown tumours
Soft tissue calcification

I Infection (osteomyelitis) Unilateral
R RA Glenohumeral erosions and joint space narrowing

Loss of the subacromial space
Lower lobe fibrosis
Signs of AVN due to steroid use, e.g. humeral head sclerosis

T Trauma (post-traumatic osteolysis) Old fracture
Unilateral

Question 24

TIPS

Answer 24

T Turner’s syndrome Madelung’s deformity
I Idiopathic
Injury
Iatrogenic
Infection

Bony deformity
Evidence of previous surgery

P Pseudohypoparathyroidism
Pseudopseudohypoparathyroidism

Intracranial calcification (pseudohypoparathyroidism)

S Sickle cell disease (post-dactylitis) Bone infarcts
Deformity

Question 25

SPINACH

Answer 25

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

Question 26

PROBING

Answer 26

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

Question 27

Healthy People Take Vitamins

Answer 27

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

Question 28

avascular necrosis) (SAD GITS

Answer 28

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

Question 29

Medical Families All Hate Hospitals

Answer 29

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

Question 30

(Grovelling Surgeons Expect Immediate CT Scans

Answer 30

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

Question 31

TLC

Answer 31

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

Question 32

INR

Answer 32

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

Question 33

Look Closely For Metastatic Spread

Answer 33

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

Question 34

ADIOS

Answer 34

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

Question 35

Medics Hate Renal Calculi

Answer 35

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

Question 36

MAGIC DR

Answer 36

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

Question 37

SAME, or Not all cerebellopontine angle masses are the SAME

Answer 37

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

Question 38

CAR MAG

Answer 38

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

Question 39

Normal BIRTH

Answer 39

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

Question 40

AH, MTV!

Answer 40

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

Question 41

SEAL

Answer 41

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

Question 42

I HEAL

Answer 42

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

Question 43

No More Spinal Masses

Answer 43

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

Question 44

DAMN

Answer 44

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

Question 45

CATNIP

Answer 45

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

Question 46

MELT

Answer 46

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

Question 47

PINT, DOC?

Answer 47

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

Question 48

GAME

Answer 48

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

Question 49

Happy Couples Never Work Over Long Holidays

Answer 49

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

Question 50

HAM

Answer 50

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