RD 2018 August Flashcards

Question

Dwi abscess and methaem: - intracellular methaem May cause low dwi. - dwi around the abscess - is it normal ? - Normal diffusion restriction around an abscess - High ADC in infarct Methaemoglobin causes something…

Answer 1

*LW: Dwi abscess and methaem: intracellular methaem May cause low dwi: - early subacute (3 to 7 days) - intracellular methaemoglobin - T1 signal gradually increases (T1 shortening) to - become hyperintense - low signal on isotropic DWI and reduced ADC values dwi around the abscess - is it normal ? - peripheral or patchy restricted diffusion may also be seen; however not that constant with up to half of rim-enhancing lesions demonstrating some restriction not proving to be abscesses. High ADC in infarct: - Low in the first 7 days, with pseudonormalisation in 2nd week. - Becomes high after 3 weeks. Methaemoglobin causes something: - Late subacute (7 to 14-28 days) - extracellular methaemoglobin: over the next few weeks, as cells break down, extracellular methaemoglobin leads to an increase in T2 signal - high signal on isotropic DWI and reduced ADC values

Answer 2

*LW: unsure given low signals.... Petrous apex lesion. Bony destruction. Low T1, T2, enhancing. No DWI. Diagnosis: Petrous apicitis: boney destruction, enhancing thick dura, non enhancing pus which would be DWI bright. Metastases: bone destruction, intermediate T1 and T2, enhances, may restrict diffusion. Chondrosarcoma: invasive bony margins, should have chondroid matrix, high T2 signal, mixed enhancement. Cholesterol granuloma: Smooth expansile bone remodelling, High T1 and T2. Cholesteatoma: smooth expansile, low T1 and high T2, non enhancing, DWI bright. (seems odd as low on both..)

Answer 3

*LW: Favour thyroid eye disease given proptosis and lacrimal gland swelling. Unsure of pre septal swelling. *ESG Favour orbital sarcoidosis (maybe not recalled as an option) Multiple sites of orbital involvement Diffuse lacrimal gland infiltration Optic nerve-sheath thickening, enhancement Asymmetric extraocular muscle infiltration Intraorbital enhancing soft tissue masses Eyelid and periorbital preseptal infiltration Uveitis, especially anterior, but also posterior SCS: Radiopaedia. Lacimal gland swelling is seen in TED (lymphocytic infiltration). No mention of pre-septal swelling however.

Answer 4

*LW: Answer: Anterior into sinus - this is favoured option being least likely spread. medially: - nasal cavity via the sphenopalatine foramen laterally: - masticator space (or infratemporal fossa) via the pterygomaxillary fissure anteriorly: - orbit via the inferior orbital fissure (superiorly) posteriorly and superiorly: - Meckel cave and cavernous sinus (of the middle cranial fossa) via the foramen rotundum posteriorly and inferiorly: - middle cranial fossa via the vidian canal posteriorly and medially: - palatovaginal canal to the nasopharynx. inferiorly: - palate via the greater and lesser palatine canals Where will pterygopalatine lesion least likely spread Posterior into middle cranial fossa Medial into nose Lateral into subtemporal fossa Suprior into orbit

Answer 5

*LW: Inverting papilloma Associated with squamous cancer Inverted papillomas are a type of Schneiderian papilloma. Most commonly lateral wall of the nasal cavity, most frequently related to the middle turbinate/middle meatus and maxillary ostium Malignant transformation occurs in a variety of histologies, including keratinising and non-keratinising squamous cell carcinoma CT: Soft tissue density mass with some enhancement. The location of the mass is one of the few clues toward the correct diagnosis. As the mass enlarges, bony resorption and destruction may be present, with a similar pattern to that seen in patients with squamous cell carcinoma 2. Intralesional calcifications representing residual bone fragments are observed in ~40% of cases. The presence of a focal, often cone-shaped, hyperostosis correlate with the point of origin of the lesions.

Answer 6

*LW: Jaw cyst with enhancing nodule Ameloblastoma

Answer 7

Neck lymph node anterior to submandibular gland – what level? 1

Answer 8

*LW Sapres orbital roof. ZMC fracture = tripod fracture: - zygomatic arch - inferior orbital rim, and anterior and posterior maxillary sinus walls - lateral orbital rim

Answer 9

*LW: Laryngocele - Mixed laryngocele: Extends from paraglottic space through thyrohyoid membrane to low submandibular space (SMS)

Answer 10

Follicular met to nodes *LW: Thyroid cancer papillary which is least likely: Papillary Calcified nodes: false, usually cystic, septated, thick walled. *ESG disagree (statdx for nodal differentiated thyroid cancer - includes papillary and follicular: Nodes heterogeneous: Solid, cystic, calcified) Papillary Cystic nodes: true Papillary calcified: true Follicular met to nodes: likely false, as haematogenous spread more common early. Papillary thyroid cancer: - Most common - Solitary mass, with irregular margin, vascularity. - Mass may show Small punctate regions of echogenicity representing microcalcifications (psammoma bodies) may be present - Mets to nodes commonly - Nodal disease commonly shows cystic components, with thick nodular walls and septa. - Purely cystic nodes uncommon. Follicular thyroid cancer: - Haematogenous spread more common. - lesion lacks cystic change. - Concentrates pertechnetate, not radioiodine. * ESG - disagree, both papillary and follicular are radio-iodine avid, and neither medullary nor anaplastic are radio-iodine avid (Statdx)

Answer 11

*LW: Unsure of correct answer, likely need further discriminators Cystic lesions in neck of 40yo woman non-smoker, one in parotid two outside Most likely: Warthins: Unlikely as usually elderly male smoker Pleomorphic adenoma: Unlikely as Usually single lesion Sjogrens: possible, correct demogrpahics, usually multiple cystic lesions Mets: possible with other nodal station involvement. Lymphoepithelial lesions: also possible, bilateral solid cystic lesions, lack Ca++.

Answer 12

*LW: Torsion ; Vascularity excludes torsion: False Fallopian can twist with it or sometimes doesn’t: true.

Answer 13

*LW: Endometrial ca: endometrial atrophy is one of the commoners causes of post menopausal bleeding, accounting for 60-75% of cases: true

Answer 14

*LW: Per R.B: Preferred answer is A: VSD can be diagnosed by seeing unidirection flow across the septum 4 Chamber view of heart: VSD can be diagnosed by seeing unidirection flow across the septum: Likely not completely correct, as Right/left ventricular pressures similar in fetus → shunt bidirectional. If unidirectional shunt, look for other anomalies altering balance of ventricular pressures (e.g., outflow tract obstruction). VSD good to assess with septum verticle: False, image perpendicular to ventricular septum. LV anterior most to ventricle wall: False, right ventricle more commonly anterior to IVS. 2mm fluid both sides of heart is physiological: pericardial effusion is > 2mm in thickness. is thus FALSE.

Answer 15

*LW: Would favour CMV from probability, however other details may beable to distinguish as per below: CMV infection: 27% have microcephaly, ventriculomegaly, cotical dysplasia, intra parenchymal cysts. Hepatospleenomegaly, calcification both visceral and intra cranial. Hydrops. Most common congenital infection world wide. Congenital rubella: commonly associated with VSD and / or TOF. IUGR Congenital sensorneural hearing loss, cataract. Zika: Intracranial calcifications typically more florid than caused by the TORCH infections and also characteristically at the grey-white matter interface, which is unusual for other congenital viral diseases Corpus callosum abnormalities.

Answer 16

*LW: Toxo in utero infection: - first trimester: fetal death - second trimester: retinochoroiditis, microcephaly, and intellectual disability - third trimester: lymphadenopathy, hepatosplenomegaly, eye injuries, and brain calcifications, where most casesinfection transmitted in 3rd trimester. Suspected calcifications in 3rd trimester: Cannot have TORCH in 3rd trimester so if previous scans normal then infection excluded: FALSE If cephalic should do a transvaginal scan to further assess: Probably true.

Answer 17

*LW: Fetal hydronephrosis which is false Dilatation implies obstruction: False - other causes other than obstruction can cause dilation, e.g. reflux, megaureter, prune belly etc. Ectopic ureterocele, spefically in a female for some reason, implies duplex: TRUE. - Females more commonly affected by uretoceles, with most being congenitial secondary to ectopic insertion with associated duplex.

Answer 18

*LW: ``` Nuchal translucency late first trimester and early second trimester (11.3-13.6 weeks). a value of less than 2 mm in thickness is not associated with increased risk. Associations: - trisomies (including Down syndrome) - Turner syndrome - congenital diaphragmatic herniation - congenital heart disease - omphalocele - skeletal dysplasias - Smith-Lemli-Opitz syndrome - VACTERL association ``` Nuchal fold is a normal fold of skin seen at the back of the fetal neck during the second trimester of pregnancy Nuchal fold thickness of >6 mm is abnormal on a routine morphology ultrasound performed at 18-22 weeks. Associations: - t21 - Turner syndrome - congenital heart disease - Klippel-Feil syndrome

Answer 19

*LW In polyhydramnios which is true: Abdomen must be assessed for duodenal atresia: true Visible stomach excludes oesophageal atresia: false, although it may be suspected in the context of non visualisation of the stomach.

Answer 20

*LW: Options: - Deeply infiltrating endometriosis or adenomyosis. Likely deeply infiltrating endometriosis: - Deep involvement of pelvic organs with endometriosis - anterior cul de sac - Posterior cul de sac - uterine ligaments - Pelvic side wall - Bowel / bladder. Adenomyosis. Appearances: - generalised, affecting large portions of the uterus (typically the posterior wall), but sparing the cervix - Venetian blind - Irregular endometrial myometrial junction

Answer 21

*LW: Lymphocytic mastitis, also known as lymphocytic mastopathy, is a rare benign inflammatory disease of the breast that can mimic breast cancer. Diabetic mastopathy is a closely-related entity although it is sometimes used synonymously in the literature (radiopaedia). Lymphocytic mastitis is associated with autoimmune disease (such as Hashimoto’s thyroiditis, SLE, Sjogren). Thus DM-2 would not be associated with lymphocytic mastitis. Type 1 may be as is a auto immune condition. *SCS: radiopaedia says Lymphocytic mastitis is a similar condition to Diabetic mastopathy but occurs in non-diabetics (Diabetic mastopathy article)

Answer 22

Flame shaped retroareolar density unilateral pain man Gynaecomastia Pseudogynascomastia (this just means cancer) **LJS - Pseudogynaecomastia - increase in fat tissue only (no glandular tissue). i.e. flabby man boobs

Answer 23

*LW: Regarding lobular cancer: MRI good for local staging: true Usually shows non-mass enhancement: false Shows gradual enhancement: true Well seen on USS and Mammograms: true, but can be occult. Often calcifies: false, rarely calcifies. Lobular CA Most common mamm appearance is spiculated mass. 16% mm occult. Micro Ca++ < 10% MRI most sensitive for detection, and will identify additional occult lesions. Most common enhancement pattern is heterogenous enhanement. Non mass enhancement 20-40%. Slow initial phase kinetics, more likely to have persistent or plateau kinetics.

Answer 24

Breast ultrasound features most benign 2 questions, answer to both was the hyperechoic one

Answer 25

*LW: Radial scar management: Hookwire localization and open biopsy radial scar is a benign hyperplastic proliferative disease of breast. Stellate/spiculated appearance on mammo w central lucency. **WJI . Agree with logan cos they dont need a sentinel node biopsy so the surgical excision option is wrong. "Open biopsy" is nonspecific and presumably includes open excision biopsy which is what you are talking about. Incision biopsy would be wrong.

Answer 26

*LW: Radial scar: Completely obliterates central fat: false, lucent centre. Doesn’t relate to ischaemia: False, likely does to chronic ischaemia with slow infarction. Long spicules: true, longer and more gracile than carcinoma.

Answer 27

*LW: Large, fast growing mass that forms from the periductal stroma of the breast. benign, borderline, or malignant depending on histologic features including stromal cellularity, infiltration at the tumour edge, and mitotic activity. Fine needle aspiration is inaccurate, and even core biopsy has moderate sensitivity due to tumour heterogeneity causing inadequate sampling. non-specific large rounded oval or lobulated, generally well circumscribed, lesions with smooth margins. A radiolucent halo may be present. Calcification (typically coarse and plaque like) may be seen in a very small proportion. General sonographic features are non-specific and can mimic that of a fibroadenoma . On ultrasound, an inhomogeneous, solid-appearing mass is the most common manifestation. A solid mass containing single or multiple, round or cleft like cystic spaces and demonstrating posterior acoustic enhancement strongly suggests the diagnosis of phyllodes tumour. Vascularisation is usually present in the solid components. Treatment is usually with surgical excision.

Answer 28

*LW: Possible poor recall of all details: (*AJL subsequently changed an option so there was one correct option) Renal artery stenosis: 20% is caused by fibromuscular hyperplasia: TRUE- 20%, involves distal artery, younger population. An acceleration index >3m/s is significant: Likely false, an acceleration index LOWER than 3m/s is significant. Intra parenchymal acceleration time > 0.07s. Renal : Aortic ratio >2.5 significant: FALSE: > 3.5 is most commonly accepted value. Distal to stenosis usually shows high resistance waveform: FALSE - Parvus Tardus distal to stenosis.

Answer 29

*LW: Bilateral internal carotid artery beading or stenoses or something Fibromuscular dysplasia

Answer 30

*LW: ``` Which isn’t associated with carotid dissection: AV fistula: Likely false. Pseudoaneurysm: true Vessel enlarged: true Hyperdense crescent: true ```

Answer 31

**LJS - favour low T2 to be most incorrect. Enhancement is a differentiating feature from thrombus. Myxomatous components are T2 hyper Atrial myxoma which is false: Enhance homogeneously: FALSE - heterogenous low grade enhancement. Low T2: FALSE - Usually hyperintense T2, but can have low signal foci. Associated with carney complex: TRUE (beware of carney complex vs carney syndrome) - rare multiple endocrine neoplasia syndrome characterised by: cardiac myxoma, skin pigmentation, extracardiac myxoma, primary pigmented nodular adrenocortical disease (PPNAD), pituitary adenoma, Sertoli cell testicular tumours. Is 50% of benign tumours: TRUE.

Answer 32

*LW: Interarterial course of the right coronary artery, may occur if the right coronary artery (RCA) has an aberrant origin from the left coronary sinus. The interarterial course occurs because the artery passes between the ascending aorta and the pulmonary trunk. An interarterial course of the left coronary artery is defined as origination of the left main or left anterior descending coronary artery from the right coronary sinus of Valsalva, with a course between the ascending aorta and the pulmonary artery trunk.

Answer 33

*LW: | Fusion of leaflets

Answer 34

*LW: | Left atrial appendage thrombus easily diagnosed on TOE: TRUE

Answer 35

*LW: Chest: methotrexate and pneumatoceles: ?F = NSIP is the most common pattern of methotrexate-induced lung disease; also common is hypersensitivity reaction; usually cause diffuse reticulonodular opacities with lower zone predominance; usually subacute allergic response amiodarone and interstitial infiltrates T = 18% get lung toxicity, esp. chronic interstitial pneumonitis; upper zones cyclosporine and mass T = drug-induced lymphoproliferative disorder which may appear as solitary mass, multiple lung nodules & hilar nodes methotrexate and pneumatoceles ?F = NSIP is the most common pattern of methotrexate-induced lung disease; also common is hypersensitivity reaction; usually cause diffuse reticulonodular opacities with lower zone predominance; usually subacute allergic response phenytoin and pleural effusions = vasculitis, drug-induced SLE; Pleural effusion is a rare complication of phenytoin use that usually occurs early in the course [Chest 2009]. hypersensitivity reaction T: cromolyn sodium, erythromycin, nitrofurantoin, isoniazid, penicillin, sulfonamides, bleomycin, methotrexate, procarbazine, penicillamine; features incl. Interstitial and/or alveolar opacities, patchy peripheral airspace opacities, basilar reticulonodular interstitial opacities (opacities may be fleeting)

Answer 36

*LW: 7yo with 1 week SOB and non-productive cough, patchy consolidation and linear atelectasis: Mycoplasma IVM: considered the most common community-acquired pneumonia in 5 to 20-year-olds RP

Answer 37

*LW: Cf with haemoptysis Most likely finding on bronchial artery angiogram: Multiple small vessels: FALSE Dissection: FALSE Aneurysm: TRUE - shows bronchial artery aneurysms. May also see bronchial artery enlargement. SCS: bronchial artery dilation >2mm, tortuousity and aneurysms. Rarely see contrast extravasating. Aortobronchial collaterals from w chronic inflammation.

Answer 38

*LW: 8mm nodule in a man: If has been stable for 30 months, then the likelihood of malignancy is low (<2%): Favour this answer, likely testing Fleischner guidelines, and if was a solid nodule, if stable with follow up at 24 months, usually minimal risk. IVM - I think image in 12 months could equally be the right answer Notes: Solitary solid nodule 6-8 mm: low-risk patients: CT at 6-12 months, then consider CT at 18-24 months high-risk patients: CT at 6-12 months, then CT at 18-24 months Single ground glass nodule ≥6 m: CT at 6-12 months, then if persistent, CT every 2 years until 5 years Single part-solid nodule ≥6 mm: CT at 3-6 months, then if persistent and solid component remains <6 mm, annual CT until 5 years

Answer 39

*LW: Tcc papillary sessile: Which is true re TCC: Most renal TCC are sessile: FALSE - 85% are papillary. Most papillary lesions are high grade: FALSE - tend to be low grade. Most ureteric lesions are papillary: TRUE - 60%, and tend to be low grade. *AJL - for completeness, most bladder TCC are also papillary (70%)

Answer 40

*LW: Which is true: Testicular microlithiasis and klinefelters associated: TRUE. Testicular cyst uncommon: false Testicular lymphoma spares cord and epididymis: FALSE can involve the the epidymis.

Answer 41

*LW: Which do you get phaeos with: NF2 Carney triad - TRUE IVM: Carney triad (Assuming carney syndrome implies carney triad): extra-adrenal paraganglioma, gist and pulmonary chondroma. I wonder if it’s an incorrect recall, and NF1 should be an answer? *wji - syndrome is gi stromal sarcoma and paraganglioma Multiple endocrine neoplasia 2 Neuroectodermal disorders: Neurofibromatosis, Sturge-Weber syndrome, Carney triad

Answer 42

*LW: Echogenic cord seen. Diagnosis: Biliary atresia - TRUE. SD - https://radiopaedia.org/articles/triangular-cord-sign-biliary-atresia-1?lang=us

Answer 43

*LW: What supports a diagnosis of Biliary atresia on USS? - Dilated ducts - No - Increased vascularity peripherally : Favoured to be TRUE answer. - Larger hepatic artery calibre * AJL - and subcapsular hepatic arterial flow on doppler (RP).

Answer 44

*LW: Fat suppression by relaxation (I think) IVM agree

Answer 45

*LW: difficult question, unsure of exact answer.... Which of the following indicates significant neck trauma: Spinous process fracture: in isolation not necessary, such as Clay Shovlers fracture. However may also be associated with PLC rupture.... Rotatory subluxation of peg view: unsure.... *IVM ?referring to this https://www.orthobullets.com/spine/2050/atlantoaxial-rotatory-displacement-aard Atlantodental interval >2mm: debatable (StatDx states C1 arch to dens < 2mm in adults) (Radiopedia normal values, male < 3mm, female < 2.5mm) (Ortho bullets > 3.5mm considered unstable) 20mm prevertebral soft tissue at C7: upper limits of normal.