Strategy Flashcards
1
Q
T1 Bright
A
Fat
melanin (melanoma)
blood (subacute)
protein rich fluid
calcification (hyalinized)
slow moving blood
laminar necrosis
2
Q
T2 Bright
A
Fat
Water
blood (extracellular methemogloving)
most tumors
3
Q
T1 and T2 dark
A
flow void
fibrosis/scar
metal
air
4
Q
REstricts diffusion
A
stroke
hypercellular tumor
epidermoid
abscess (bacterial)
acute demyelinations
CJD
T2 shine through
5
Q
PEDS neck looks cystic
A
Thyroglossal Duct Cyst Brachial cleft cyst Necrotic Level 2 Node Hemangioma of Infancy Cystic Hygroma Phlebectasia
6
Q
PEDS neck looks cystic
Thyroglossal Duct Cyst
A
*MIDLINE Ultrasound in Axial Planes C T / MRI in Sagital Planes Posterior to Tongue Anterior to Hyoid
7
Q
PEDS neck looks cystic
Brachial Cleft Cyst
A
‘ LATERAL
Axial Plane Most Likely
Anterior to the
Sternocleidomastoid (type 2)
8
Q
PEDS neck looks cystic
Necrotic Level 2 Node
A
Looks Just like BC Cyst - but the kid is too old (late teens / “young adult”)
Thyroid CA, or Nasopharyngeal HPV related CA
C T axial plane - most likely
9
Q
PEDS neck looks cystic
Hemangioma of Infancy
A
T2 Bright
Enhances
Will have flow in it on doppler
If you saw it you’d think to yourself “if that doesn’t involute that kid is never getting a date to prom”
10
Q
PEDS neck looks cystic
Cystic Hygroma
A
OB Ultrasound - most likely modality Cystic Hygroma . J2 Brjght DOES NOT Enhance Will NOT have flow in it on doppler Turners, Downs.
11
Q
PEDS neck looks cystic
Phlebectasia
A
Kinda looks like a big dilated jugular vein (because it is a big dilated jugular vein)
No stenosis or collaterals
12
Q
PEDS neck looks solid
A
Septic Thrombophlebitis Ectopic Thyroid Fibromatosis Coli Rhabdomyosarcoma Metastatic Neuroblastoma
13
Q
PEDS neck looks solid
Septic Thrombophlebitis
A
Jugular Vein with a clot - they will have to prove that has a clot in it - fprobably with doppler us Lemierre’s Syndrome Septic Emboli to the lungs Recent ENT procedure, or Infection Fusobacterium Necrophorum
14
Q
PEDS neck looks solid
Ectopic Thyroid
A
Back of the tongue or in front of the hyoid
Tc-MIBI, or 1-123
15
Q
PEDS neck looks solid
Fibromatosis Coli
A
Ultrasound
“Two Heads” of the Sternocleidomastoid
16
Q
PEDS neck looks solid
Rhabdomyosarcoma
A
MRI orCT
Seriously pissed off looking mass (probably in the orbit - maybe in the masticator mass)
Enhances heterogenous,
17
Q
PEDS neck looks solid
Metastatic Neuroblastoma
A
MRI orCT Soft Tissue Mass, Calcifications, Restricted Diffusion Classic is the orbit
18
Q
Cyanotic peds
A
TOF TAPVR Transposition truncus tricuspid atresi
19
Q
not cyaotic peds
A
ASD VSD PDA PAPVR AORTIC coarctation (adutl type - post ductul)
20
Q
Congenital Heart on C X R
cyanotic, right sided arch, incrased pulmonary vasculature
A
Truncus (types 1-3)
21
Q
Congenital Heart on C X R
cyanotic, right sided arch,normal pulmonary vasculature
A
TOF
22
Q
Congenital Heart on C X R
cyanotic, left arch, massive heart
A
Ebsteins or
Pulmonary Atresia without VSD
Non-Cardiac (wo n ’t be cyanotic)
- Infantile Hemangioendothelioma
- Vein o f Galen Malformation
23
Q
Congenital Heart on C X R
cyanotic, left sided arch, normal heart size, increased pulmonary blood flow
A
- TAPVR (especially type 3)
- D-Transposition -Ebsteins
- Truncus (look for R A rch)
- “Tingle Ventricle”
24
Q
Congenital Heart on C X R
cyanotic, left sided arch, normal heart size, decreased or normal pulmonary blood flow
A
- TOF
- Ebsteins
- Tricuspid Atresia
25
Neonatal Chest
high lung volume symmetric pattern ( looks like pulmonary edema)
Transient Tachypnea
“Pulmonary Edema + Effusions”
26
Neonatal Chest
high lung volume, less symmetric pattern (perihilar/streaky
Meconium Aspiration
or
Non GB Neonatal Pneumonia
27
Neonatal chest
low lung volumes, not usually pleural effusions
Surfactant- Deficient Disease (SDD)
| “Diffuse Granular”
28
Neonatal chest
low lung volumes, pleural effusions 25% of the time
Beta Hemolytic Pneumonia
| “Diffuse Granular
29
T H IS vs THAT: Meconium Asp ira tion o r Non Group B Strep Pneumonia
This is su p e r tough without any history, an d b e cau se o f that I f e e l like the te st w rite r has
two o p tion s: (J) Stop being an a ssh o le an d g iv e you some history, (2) not include both as
an sw e r ch o ices - assuming only one is co rre c t. Now, a long those lines i f you saw both as
choices an d the question h ea d e r g iv e s you no h isto ry you c o u ld eliminate them both as
d istra c to rs - b ecause they both c a n ’t be co rre c t.
30
Prematurity
u e s s in g th at the kid is p rem a tu re can be h e lp fu l fo r e lim in a tin g
ch o ic e s (M e co n ium A sp ira tio n is m o re o f a p o s t te rm th in g ), an d ra isin g y o u r p rete st
p ro b ab ility (SD D , o r N EC in a belly film). T h e re are two main clues:
(1) Humeral H ea d Ossification - T h is ten d s to o c c u r c lo s e r to term . I f th e h um era l
h e ad is N O T ossified y o u can a ssum e (in th e w o rld o f m u ltip le ch o ic e ) th at the kid
is lik e ly p rem a tu re .
(2) Lack o f Subcutaneous Fat - P rem a tu re k id s ten d to be very sk in n y , a lth o u g h I th in k
o f th is m o re o f a soft sign th at is u se fu l w h en ab sen t m o re th an p re sen t. I ’ll ju s t
say th a t if the kid a p p e a rs ch u b b y he is p ro b ab ly N O T p rem a tu re .
31
PEDs thing in the left upper lobe
Think Congenital Lobar Emphysema (CLE) first. But,
remember CCAM has no lobar prevalence, so it can be
anywhere
32
Peds thing in the lerft lower lobe
Think Sequestration First. Congenital Diaphragmatic
| Hernia (CDHs) favors this side too
33
Intralobar sequestration is seen
older kids
34
Extralobar sequestration
is seen
| in infants with comorbids
35
CLE is in the
upper lobe
36
The NG tube stops in the upper thoracic
| esophagus:
The NG tube stops in the upper thoracic
esophagus: Think esophageal atresia (probably in
the setting o f VACTERL).
37
The NG tube curling into the chest
it’s either (1) in the lung, or (2) it’s in a congenital diaphragmatic hernia. If 1 had to pick between the two (and it wasn’t obvious), I’d say left side hernia, right side lung - ju st because those are the more common sides.
38
T h e C la s s ic C o n g e n ita l L o b a r Em p h y s em a T ric k
They can show you a
series o f CXRs. The first one has an opacity in the lung (the affected lung is fluid filled). The
next x-ray will show the opacity resolved. The following x-ray will show it getting more
lucent, and more lucent. Until it’s actually pushing the heart over. This is the classic way to
show it in case conference, or case books
39
T h e School Aged CXR: Things to look for
Big Heart - Probably showing you a sickle cell case. Look for bone infarcts in shoulders.
Lucent Lung - Think foreign Body (air trapping). Remember you put the affected side down (if it remains lucent- that confirms it).
40
THIS vs THAT: Cystic Fibrosis vs Primary Ciliary Dyskinesia
CF
Abnormal Mucus - Cilia c an ’t clear it
Bronchiectasis (upper lobes)
Normal sperm, obliterated vas deferens
PCD
Normal Mucus - Cilia do n ’t work
Bronchiectasis (lower lobes)
Normal vas deferens, sperm cannot swim normally
41
PEDs mandiible
There are only a few things that a mandible will be shown for with
regards to Peds. Think Caffeys first - especially if the picture looks blurry and old (there
hasn’t been a case o f this in 50 years). If it’s osteonecrosis think about O.I. on
bisphosphonates. If it’s a dwarf case, think wide angled mandible with Pycnodysostosis. A
“floating tooth” could be EG.
42
The Abdominal Plain Film - on a newborn
Single Bubble:
In a newborn this is Gastric (antral or pyloric atresia). In an older child think gastric volvulus
43
The Abdominal Plain Film - on a newborn
Double Bubble
duodenal atresia
44
The Abdominal Plain Film - on a newborn
triple bubble
jejunal atresia
45
The Abdominal Plain Film - on a newborn
Single Bubble + Distal Gas
+ “Bilious Vomiting
concern for mid gut volvulus
next step = upper gi
46
The Abdominal Plain Film - on a newborn
Multiple Dilated Loops
concern for lower obstruction
next step = contrast enema
47
THIS vs THAT: Duodenal Atresia vs Jejunal Atresia
Duodenal Atresia
double bubble
failure to canalize (often isolated atresia)
associated with downs
Jejunal atresia
triple bubble
Vascular Insult * More likely associated with other atresias
48
THIS vs THAT: In tra lob a r vs E x tra lo b a r S eq u e stra tion
intralobar
No pleural covering
More Common
Presents later with recurrent infection
extralobar
Has its own pleural covering
Less Common
Presents early with other bad congenital things (heart, etc...)
49
Right sided heterotaxia
Two Fissures in Left Lung
Asplenia
Increased Cardiac Malformations
Reversed Aorta/I VC
50
Left sided heterotaxia
One Fissure in Right Lung
Polysplenia
Less Cardiac Malformations
Azygous Continuation o f the IVC
51
orbital calcs less than 3
retinoblastoma
cmv
colomoatous dyst
52
orbital calcs older than 3
toxo
| retinal astrocytoma
53
Peds Liver Masses
Infantile Hepatic Hemangioma
Hepatoblastoma
Mesenchymal Hamartoma
HCC
Fibrolamellar Subtvpe HCC
Undifferentiated Embryonal Sarcoma
Mets (Neuroblastoma, Wilms)
54
Peds Liver Masses
Infantile Hepatic
Hemangioma
Age 0-3
Endothelial growth factor is elevated
Progressively Calcify - as they involute
Associated:
High Output CHF
Skin Hemangiomas
55
Peds Liver Masses
Hepatoblastoma
Age 0-3
AFP is elevated
Calcifications are Common
Risk Factor = Prematurity
Many Association:
Wilms, Beckwith- Weidemann
may cause precocious puberty
56
Peds Liver Masses
Mesenchymal
Hamartoma
Age 0-3
AFP is negative
Calcification are RARE
CYSTIC MASS
Favors Right Lobe
“Developmental anomaly’’
57
Peds Liver Masses
HCC
Age > 5
AFP is elevated
Kids with cirrhosis (biliary atresia, Fanconi syndrome, glycogen storage disease)
58
Peds Liver Masses
Fibrolamellar Subtvpe
HCC
Age > 5
AFP is negative
Calcifies more often than conventional HCC
No Cirrhosis
Central Scar (scar does NOT enhance, and is T2 dark)
59
Peds Liver Masses
Undifferentiated Embryonal Sarcoma
Age > 5
AFP is negative
Cystic / Heterogeneously Solid Mass
Known to rupture
60
Peds Liver Masses
| Mets
Neuroblastoma, Wilms
Fetus - 4
6 - Early Teens
Multiple Masses in the Setting of Known Primary
61
Adult Benign Liver Masses
Hemangioma
FNH
Heptaic adenoma
hepatic angiomyolipoma
62
Adult Benign Liver Masses
hemangioma
Ultrasound - Hyperechoic
CT - Peripheral Nodular Discontinuous Enhancement
MR - T2 bright
Trivia - rare in cirrhotics
63
Adult Benign Liver Masses
FNH
Ultrasound - spoke wheel
CT - homogenous arterial enhancement
MR - stelath lesion - iso on t1 and t2
Trivia - central scar, bright on delayed eovist (gd-eob-dtpa)
64
Adult Benign Liver Masses
hepatic adenoma
Ultrasound - variable
CT - variable
MR - fat containing on in/out phase
Trivia - ocp use, glycogen storage idsease, can explode and bleed
65
Adult Benign Liver Masses
hepatic angiomyolipoma
Ultrasound - hyperechoic
CT - gross fat
MR - t1/t2 bright
Trivia - unlike renal aml 50% dont have fat, Tuberous sclerosis
66
Liver Sulfur Colloid HOT or COLD
hepatic adenoma
cold
67
Liver Sulfur Colloid HOT or COLD
FNH
40% HOT,
30% COLD,
30% Warm
68
Liver Sulfur Colloid HOT or COLD
cavernous hemangioma
cold
RBC Scan HOT
69
Liver Sulfur Colloid HOT or COLD
HCC
cold
70
Liver Sulfur Colloid HOT or COLD
cholangiocarcinoma
cold
71
Liver Sulfur Colloid HOT or COLD
mets
cold
72
Liver Sulfur Colloid HOT or COLD
abscess
cold
gallium hot
73
Liver Sulfur Colloid HOT or COLD
focal fat
cold
xenon hot
74
regenerative liver nodules
contains iron
t1 dark, t2 dark
dots not enhance
75
dysplastic liver nodules
contains fat, glycoprotein
ti bright, t2 dark
usually does not enhance
76
hcc
T2 bright
does enhance
77
This vs That: HCC vs
| Fibrolamellar Subtype HCC
```
HCC:
Cirrhosis
Older (50s-60s)
Rarely Calcifies
Elevated AFP
```
```
FL HCC:
No Cirrhosis
Young (30s)
Calcifies
Normal AFP
```
78
This vs That:
| Central Scars of FIN H and Fibrolamellar HCC
```
FNH:
T2 Bright
Enhances on Delays
Mass is Sulfur Colloid
Avid (sometimes)
```
FL HCC:
T2 Dark (usually)
Does NOT enhance
Mass is Gallium Avid
79
Multiple Low Density (NOT Cystic) Liver Lesions
METS
Think Colon First
| - unless they have a known primary
80
Multiple Low Density (NOT Cystic) Liver Lesions
HCC
Does the Liver look Cirrhotic?
81
Multiple Low Density (NOT Cystic) Liver Lesions
Regrnative nodules
Does the Liver look Cirrhotic?
82
Multiple Low Density (NOT Cystic) Liver Lesions
infections
Low Density Nodes - Think Mycobacterium
| Hyperenhancing Nodes - Think Bartonella
83
Multiple Low Density (NOT Cystic) Liver Lesions
sarcoid
Spleen Should be Involved Also
Gamesmanship - Probably gets some hints in the form of a CXR, or
Labs (elevated ACE)
84
Multiple Cystic Liver Lesions
AD Polycystic
Kidney
Different Size Cysts
(small and big)
Renal Cystic Disease
85
Multiple Cystic Liver Lesions
| Von
Meyenburg
Complex
Hamatromas
Small ( < 1.5 cm)
Will NOT connect with Ducts
Uniform distribution
86
Multiple Cystic Liver Lesions
```
Choledochal
Cysts (Caroli)
```
WILL communicate with duct
| Central “dot” Sign
87
Multiple Cystic Liver Lesions
Abscess
```
Bacterial and Fungal =
Multiple, R > L
Amoebic = Single and Subdiaphragmatic
Peripheral Enhancement
Necrotic center will not
enhance
```
88
Liver infection buzzwords
Starry Sky (US)
Viral Hepatitis
89
Liver infection buzzwords
Double Target (CT)
Pyogenic Abscess
90
Liver infection buzzwords
Bull’s Eye (US)
Candida
91
Liver infection buzzwords
“Extra Hepatic Extension”
Amoebic Abscess
92
Liver infection buzzwords
Water Lily (CT, Sand Storm US
Hydatid Disease
93
Liver infection buzzwords
tortoise shell
Schistosomiasis
94
Primary Hemochromatosis
Genetic - increased absorption
Liver, P an c re a s
Heart, Thyroid, Pituitary
95
Secondary Hemochromatosis
Acquired - chronic illness, and multiple
transfusions
Liver, S p le en
96
This vs That: AIDS Cholangiopathy vs Primary Sclerosing Cholangitis
AIDS:
Focal Strictures o f the extrahepatic duct > 2cm
Absent saccular deformities o f the ducts Papillary Stenosis
PSC:
Extrahepatic strictures rarely > 5mm
Has saccular deformities o f the ducts
97
Intrahepatic biliary dilation ddx
```
PSC
infection cholangitis
pancreatic head mass
cbd stone - late
biliary stricture
```
98
extrahepatic biliary dilation only ddx
post cholecystectoy
sphincter of oddi dysfucntion
type 1 choledochal cyst
cbd stone- early
99
THIS vs THAT: Chronic Pancreatitis Duct Dilation vs Pancreatic Malignancy Duct Dilation
CP:
Dilation is Irregular
Duct is < 50% o f the AP gland diameter
Cancer:
Dilation is uniform (usually)
Duct is > 50% o f the AP gland diameter (obstructive atrophy)
100
Uncommon Types and Causes o f Pancreatitis
Autoimmune
Pancreatitis
Groove
Pancreatitis
Tropic
Pancreatitis
Hereditary
Pancreatitis
Ascaris
Induced
101
Uncommon Types and Causes o f Pancreatitis
Autoimmune
Pancreatitis
Associated with elevated IgG4
Absence of Attack Symptoms
Responds to steroids
Sausage Shaped Pancreas, capsule like delayed rim enhancement around gland (like a scar). No duct dilation. No calcifications.
102
Uncommon Types and Causes o f Pancreatitis
Groove
Pancreatitis
Looks like a pancreatic head Cancer - but with little or no biliary obstruction.
Less likely to cause obstructive jaundice (relative to pancreatic CA)
Duodenal stenosis and /or strictures of the CBD in 50% of the cases
Soft tissue within the pancreaticoduodenal groove, with or without delayed enhancement
103
Uncommon Types and Causes o f Pancreatitis
Tropic
Pancreatitis
Young Age at onset, associated with malnutrition
Increased risk of adenocarcinoma
Multiple large calculi within a dilated pancreatic duct
104
Uncommon Types and Causes o f Pancreatitis
hereditary pancreatitis
Young Age at Onset
Increased risk of adenocarcinoma
SPINK-1 gene
Similar to Tropic Pancreatitis
105
Uncommon Types and Causes o f Pancreatitis
Ascaris
Induced
Most commonly implicated parasite in pancreatitis
Worm may be seen within the bile ducts
106
I Say Autoimmune Pancreatitis
You Say IgG4
107
I Say IgG4
```
Autoimmune Pancreatitis
Retroperitoneal Fibrosis
Sclerosing Cholangitis
Inflammatory Pseudotumor
Riedel’s Thyroiditis
```
108
THIS vs THAT:
| Autoimmune Pancreatitis vs Chronic Pancreatitis
Autoimmune pacreatitis:
no ductal dilation
no calcs
chroic pancreatitis:
ductal dilation
ductal calcifications
109
Cystic Pancreatic Lesions
Main Branch
IPMN
Side Branch
IPMN
Serous Cystic
Mucinous
Cystic
Solid Pseudo-
Papillarv
110
Cystic Pancreatic Lesions
Main Branch
IPMN
40s - 50s
Main Duct
High Malignant Potential (60%)
111
Cystic Pancreatic Lesions
Side Branch
IPMN
50s - 60s
Favor head, Uncinate
Typically Benign
(maybe 5% will develop malignancy)
Communicates with duct
112
Cystic Pancreatic Lesions
serous cystic
Grandma F > M >60
Favor Head
```
Does NOT Communicate with Main Duct
Central Calcifications
“Micro-Cystic” - “Honeycomb”
Benign
Glycogen Rich
Associated with von Hippel Lindau
```
113
Cystic Pancreatic Lesions
Mucinous
Cystic
Mother F > M 40s
Favor Body / Tail
Does NOT Communicate with Main Duct
Peripheral Calcifications
Larger Cysts (sometimes uni-locular)
Premalignant
114
Cystic Pancreatic Lesions
Solid Pseudo-
Papillarv
Daughter F > M 20s
Favor Tail
```
Large (5-10 cms)
Solid with Cystic Parts
Enhances like a Hemangioma
Has a Capsule
Asian or Black Female
```
115
Malignant Ulcer
```
Width > Depth
Located within Lumen
Nodular, Irregular Edges
Folds adjacent to ulcer
Aunt Minnie: Carmen
Meniscus Sign
```
116
Benign Ulcer
```
Depth > Width
Project behind the expected lumen
Sharp Contour
Folds radiate to ulcer
Aunt Minnie: Hampton’s Line
```
117
Direct Hernia
Less common
Medial to inferior Epigastric
Defect in Hesselbach triangle
NOT covered by internal spermatic fascia
118
Indirect Hernia
more common
lateral to inferio epigastric
failure of processus vaginalisu to close
coverved by internal spermatic fascia
119
Sigmoid volvulus
old person (constipated)
points to the RUQ
120
cecal volvulus
Younger Person (mass, prior surgery, or 3rd Trimester Pregnancy)
Points to the LUQ
121
Crohns
```
Slightly less common in the USA
Discontinuous “Skips”
Terminal Ileum - String Sign
Ileocecal Valve “Stenosed”
Mesenteric Fat Increased "creeping fat ”
Lymph nodes are usually enlarged
Makes Fistulae
```
122
Ulcerative Colitis
```
Slightly more common in
the USA
Continuous
Rectum
Ileocecal Valve “Open”
Perirectal fat Increased
Lymph nodes are NOT usually enlarged
Doesn’t Usually Make Fistulae
```
123
Tumor markers
cholangio
CEA and CA19-9 increased
124
Tumor markers
pancreatic CA
CA19-9 increased
125
Tumor markers
Colon CA
CEA increased
126
More Common In :
Crohns vs UC
gallstones
crohns
127
More Common In :
Crohns vs UC
PSC
UC
128
More Common In :
Crohns vs UC
Hepatic abscess
Chrohns
129
More Common In :
Crohns vs UC
pancreatitis
crohns
130
Multicystic Dysplastic Kidney
unilateral
- Neonate, No Renal Function (MAG 3)
- Associated with congenital UPJ obstruction
- Associated with reflux (VUR) -
131
Multilocular Cystic Nephroma
unilateral
- “Micheal Jackson - Young Boy, Older Woman"
- Multiple Cysts - Herniates into the Renal Pelvis”
132
cystic wilms
peds renal cyst mass, unilateral
133
AR- Polycystic Kidney Disease
bilateral
- enlarged, hyperechoic
- microcystic
134
Peds Tumor / Mass kidney
Mesoblastic
Nephroma
Nephroblastomatosis
wilms
Clear Cell - Wilms
Rhabdoid - Wilms
Multi-Cystic
Nephroma
RCC
Renal Lymphoma
135
Peds Tumor / Mass kidney
Mesoblastic
Nephroma
“Solid Tumor o f Infancy” (you can be born with it)
136
Peds Tumor / Mass kidney
Nephroblastomatosis
“Nephrogenic Rests” - left over embryologic crap that didn’t go away
Might turn into wilms (bilateral wilms especially)
“Next Step” - f/u ultrasound till 7-8 years old
Variable appearance
137
Peds Tumor / Mass kidney
wilms
90% + Renal Tumors
“Solid Tumor o f Childhood" - Never born with it
Grows like a solid ball (will invade rather than incase)
Met to the lung (most common)
138
Peds Tumor / Mass kidney
Clear Cell - Wilms
Met to Bone
139
Peds Tumor / Mass kidney
Rhabdoid - Wilms
Brain Tumors
| It fucks you up, it takes the money (it believes in nothing Lcbowski)
140
Peds Tumor / Mass kidney
Multi-Cystic
Nephroma
Micheal Jackson Tumor (Young Boys, Middle Age Women)
Big cysts that don’t communicate
Septal Enhancement
Can’t Tell it is not Cystic Wilms (next step = resection)
141
Peds Tumor / Mass kidney
RCC
“Solid Tumor o f Adolescent ”
| Syndromes - VHL, TS
142
Peds Tumor / Mass kidney
Renal Lymphoma
Non-Hodgkin
| Multifocal
143
Neuroblastoma v wilms
```
Neuroblastoma:
Age: usually less than 2 (can occur in utero)
Calcifies 90%
Encases Vessels (doesn’t invade)
Poorly Marginated
Mets to Bones
```
```
Wilms:
Age: Usually around age 4
(never before 2 months)
Calcifies Rarely (<10%)
Invades Vessels (doesn’t encase)
Well Circumscribed
Doesn’t usually met to bones (unless clear cell Wilms variant). Prefers lung.
```
144
Neuroblastoma vs Adrenal Hemorrhage
Neuroblastoma:
Heterogenous and vascular
High on T2 , Iso-Low on T1
Will grow on followup
Adrenal Hemorrhage
Centrally Hypoechoic and Avascular
High on T1 (7 days - 7 weeks)
Should shrink on followup
145
Adult RCC Associations
clear cell
Von Hippel-Lindau
146
Adult RCC Associations
papillary
Hereditary papillary renal.
| carcinoma
147
Adult RCC Associations
chromophobe
birt hogg dube
148
Adult RCC Associations
medullary
sickle cell trait
149
Bladder Cancer
Transitional Cell
CA
The “normal” kind Bladder CA » > Ureter CA
150
Bladder Cancer
Squamous Cell
CA
Calcifications
Chronic Catheter
Schistosomiasis (worm)
151
Bladder Cancer
adenocarcinoma
Midline
Urachus Association
Bladder Exstrophy
152
Urethra cancer
Prostatic Urethra
TCC
153
Urethra cancer
Bulbar / Penile Urethra
SCC
154
Urethra cancer
Urethral
Diverticulum
Adenocarcinoma
155
Renal Cyst Associations
ADPCKD
Cysts in Liver
Kidneys are BIG
156
Renal Cyst Associations
VHL
cysts in pancreas
157
Renal Cyst Associations
Acquired (uremic)
kidneys are small
158
Big Kidney with Lots o f Cysts
| Liver Cysts
AD Polycystic Kidney
159
```
Normal Sized Kidneys with Lots o f Cysts
Solid Renal Masses (RCCs)
Pancreatic Cysts (simple and serous cystic)
Pancreatic Masses
Adrenal Masses (paragangliomas)
```
von Hippel - Lindau
160
Renal Cysts
Multiple Fat Containing Renal Masses
(AMLs) - maybe bleeding
Lungs Cysts (LAM)
Tuberous Sclerosis
161
Small / Calcified Spleen
Gallstones (or absent GB)
Bone Infarcts
sickle cell
162
Severe Pancreatic Fatty Atrophy
Small bowel stool
Fatty Liver
CF
163
Big Liver, Big Spleen
Bone Infarcts
Extramedullary Hematopoiesis
Gaucher
164
Bilateral Adrenal Masses
(Pheochromocytoma - not adenoma)
Thyroid Cancer
MEN 2
165
Islet Cell Tumors
| Pituitary Adenoma
MEN 1
166
Renal Masses (Wilms, AML)
Adrenal Masses (Pheochromocytoma)
Skin Nodules
Scoliosis
NF-1
167
```
Vascular Malformation in the Liver
Bowel Angiodysplasia
Enlarged Hepatic Artery
Pulmonary AVM
Brain Abscess
```
Osier Weber Rendu
| Hereditary Hemorrhagic Telangiectasia
168
Cyst Morphology Trivia:
* ADPCKD - Round and Distributed Throughout Kidney
| * ARPCKD - Tubular Cysts which Spare Cortex
169
Anterior Mediastinal Mass
normal htymus
- Age < 10
- Homogenous
- No Mass Effect
170
Anterior Mediastinal Mass
lymphoma
- Age > 1 0
- Mass Effect
- Lymph Nodes
- SV C Compression
- Hodkin> NHL
171
Anterior Mediastinal Mass
teratoma
- Fat
- Cystic
- Calcifications
172
Anterior Mediastinal Mass
NS - Germ cell tumore
- Big
- Aggressive
- Hemorrhage
- Klinefelter
- Necrosis
173
Anterior Mediastinal Mass
Seminoma
- Straddle Midline
- Bulky
- Lobulated
174
DIP
```
- Apical Emphysema
(smoking related)
- Basilar Ground Glass
- Peripheral Basilar
Reticulation
- Smoker - Severe end of
RB-ILD
```
175
NSIP
Basilar Ground Glass
(sub-pleural sparing)
Traction Bronchiectasis
Scleroderma Association
(dilated esophagus)
176
UIP
Honeycombing - basilar
| predominant
177
LAM
* Thin walled cysts -
distributed evenly
' Tuberous sclerosis
178
LCH
```
■ Nodules with cavitation
(early)
* Apical - “B izarre” Cysts (late)
' Smoker -20s-30s
' Sparing of the costophrenic
recesses
```
179
LIP
```
■ Thin walled c ysts (less than
LAM)
" Ground Glass - clears with
treatment
" Sjogrens, RA, HIV
```
180
Eosinophilic pneumonia
Reverse Pulmonary
Edema Pattern
(peripheral)
Ground glass and
consolidation
181
COP
```
- Atoll / Reverse Halo Sign -
Consolidation around
Ground Glass
- Patchy, Peripheral
Consolidation
```
182
Aspergillosis
■ Halo Sign - Ground Glass
around consolidation
* Air Crescent - “invas ive”
183
Upper Lobe Predominant
Most inhaled stuff (not asbestosis). Coal
Workers, and Silicosis. This includes
progressive massive fibrosis.
CF
RB-ILD
Centrilobular emphysema
AS
SArcoid
184
Lower Lobe Predominant
asbestosis
primary cilia dyskinesia
Most Interstitial Lung Diseases
(UIP, NSIP, DIP)
Panlobular Emphysema (Alpha 1)
Rheumatoid Lung
Scleroderma (associated with NSIP)
185
Collagen Vascular Disease Pulmonary Manifestations
lupus
More pleural effusions and
pericardial effusions than
with other connective tissue
disease
Fibrosis is uncommon. Can
get a “shrinking lung.”
186
Collagen Vascular Disease Pulmonary Manifestations
RA
```
Looks like UIP and COP.
Lower lobes are favored.
Reticulations with or without
honeycombing, and
consolidative opacities which
are organizing pneumonia
```
187
Collagen Vascular Disease Pulmonary Manifestations
scleroderma
NSIP> UIP; lower lobe
predominant findings.
Look for the dilated fluid filled
esophagus.
188
Collagen Vascular Disease Pulmonary Manifestations
sjogrens
LIP
Extensive ground glass
attenuation with scattered thin
walled cysts.
189
Collagen Vascular Disease Pulmonary Manifestations
ankylosing spondylitis
Upper lobe fibrobullous
disease
Usually unilateral first, then
progresses to bilateral.
190
Infections in AIDS by CD4
>200 Bacterial Infections, TB
<200 PCP, Atypical Mycobacterial
< 100 CMV, Disseminated Fungal, Mycobacterial
191
ACR Appropriateness Criteria
First Line for Suspected Metastatic Disease
= CXR
Recommendation for patients on
mechanical ventilation = Daily CXR
First Line for Chest Pain and High
Suspicion for Aortic Dissection = CXR
192
Which Sequence(s) most useful?
Cardiac Myxoma
Low T l , High T2 (high myxoid content)
193
Which Sequence(s) most useful?
Acute vs Chronic MI
Look at T2 - Bright on Acute ; Dark on Chronic
| fibrous scar
194
Which Sequence(s) most useful?
Arrhythmogenic Right Ventricular
Dysplasia (ARVD)
T l Bright
195
Which Sequence(s) most useful?
Microvascular Obstruction
First Pass Perfusion (25 seconds post Gad)
196
Which Sequence(s) most useful?
infarct
Delayed Enhancement (10-12 mins post Gad)
197
Cardiac MRI Enhancement Patterns
subendocardial
infarct
198
Cardiac MRI Enhancement Patterns
transmural
infarct
199
Cardiac MRI Enhancement Patterns
Subendocardial Circumferential:
Amyloidosis *can also be transmural
200
Cardiac MRI Enhancement Patterns
midwall focal
HCM
201
Cardiac MRI Enhancement Patterns
Midwall septal linear
mycoraditis, idiopathic dilated cm
202
Cardiac MRI Enhancement Patterns
midwall outer linear
myocraditis, sarcoidosis
203
Cardiac MRI Enhancement Patterns
epicardial
myocarditis, sarcoidosis
204
C a rd ia c S u rg e ry T y p e s / In d ic a tio n s
CHF in Infancy, Single Ventricle
Pulmonary Artery Banding
205
C a rd ia c S u rg e ry T y p e s / In d ic a tio n s
Transposition, Pulmonary Outflow Obstruction
Rastelli (RV Baffle)
206
C a rd ia c S u rg e ry T y p e s / In d ic a tio n s
Transposition
Jatene (a type o f arterial switch)
207
C a rd ia c S u rg e ry T y p e s / In d ic a tio n s
Diseased Aortic Valves in Children
Ross
208
C a rd ia c S u rg e ry T y p e s / In d ic a tio n s
Aortic Root / Valve Replacement in Marfan
Bentall
209
Cardiac surgery
Glenn
Vein to Artery
(SV C to Pulmonary Artery)
Primary Purpose: Take
systemic blood directly to the
pulmonary circulation (it
bypasses the right heart).
Most Testable Complications:
- SVC Syndrome
- PA Aneurysms
210
Cardiac surgery
Blalock Taussig
Artery to Artery
(Subclavian Artery to Pulmonary
Artery)
Primary Purpose: Increase
pulmonary blood flow
Most Testable Complications:
-Stenosis at the sh u n t’s
pulmonary insertion site
211
Cardiac surgery
Fotan
It's complicated with multiple
versions - steps are unlikely to
be tested
Primary Purpose: Bypass the
right ventricle / direct systemic
circulation into the PAs.
Most Testable Complications:
-Enlarged Right Artium causing
arrhythmia
-Plastic Bronchitis
212
Large Vessel Vasulitis
Takayasu
giant cell
cogan syndrome
213
Takayasu
Large Vessel Vasulitis
Young Asian Female - thickened aneurysmal aorta
214
giant cell
Large Vessel Vasulitis
Old Person with involvement o f the “crutches” / armpit region
(Subclavian, axillary, brachial).
215
cogan syndrome
Large Vessel Vasulitis
Kid with eye and ear symptoms + Aortitis
216
Medium Vessel vasculitis
PAN
Kawasaki
217
PAN
Medium Vessel vasculitis
PAN is more common in a MAN (M > F). Renal Microaneurysm
(similar to speed kidney). Associated with Hep B.
218
KAwasaki
Medium Vessel vasculitis
Coronary Artery Aneurysm
219
Small Vessel (ANCA +) vasculitis
Wegeners
Churg Strauss
Microscopic Polyangiitis
220
Wegeners
Small Vessel (ANCA +) vasculitis
Nasal Septum Erosions, Cavitary Lung Lesions
221
Churg Strauss
Small Vessel (ANCA +) vasculitis
Transient peripheral lung consolidations.
222
Microscopic Polyangiitis
Small Vessel (ANCA +) vasculitis
Diffuse pulmonary hemorrhage
223
Small Vessel (ANCA -) vasculitis
HSP
Bechcets
buergers
224
HSP
Small Vessel (ANCA -) vasculitis
Kids. Intussusception. Massive scrotal edema.
225
behcets
Small Vessel (ANCA -) vasculitis
Pulmonary artery aneurysm
226
buergers
Small Vessel (ANCA -) vasculitis
Male smoker. Hand angiogram shows finger occlusions.
227
Tc-99m
Energy - “Low” - 140
Physical half life - 6 hours
228
Iodine - 123
Analog - iodine
Energy - low 159
Physical half life - 13 hours
229
Xenon - 133
Energy - low 81
Physical half life - 125 hours (biologic t l /2
30 seconds)
230
Thallium -201
Analog - Potassium
Energy - “Low” - 135 (2%), 167
(8%), use 71 ^01Hg
daughter x-rays
Physical half life -73 hours
231
Indium - 111
Energy - “Medium” - 173 (89%),
247 (94%)
Physical half life -67 hours
232
Gallium - 67
Analog - iron
Energy - Multiple; 93 (40%), 184
(20%), 300 (20%), 393
(5%)
Physical half life - 78 hours
233
Iodine -131
Analog - iodine
Energy - high 365
Physical half life - 8 days
234
Fluorine - 18
Analog - sugar
Energy - high 511
Physical half life - 110 mins
235
Strontium 89
physical half - life - 50.5 DAYS
| 14 days in bone
236
Samarium 153
physical half - life - 46 hours
237
Radium
physical half - life - 11 days
238
Yttrium 90
physical half - life - 64 hours
239
Rubidium 82
physical half - life - 75 seconds
240
Nitrogen 13
physical half - life - 10 mins
241
Probable Critical Organ
Tc - MDP
Bladder (some sources say bone)
242
Probable Critical Organ
Tc - Sulfur Colloid (IV)
Liver
243
Probable Critical Organ
Tc - Sulfur Colloid (Oral)
Proximal Colon
244
Probable Critical Organ
Tc - Pertechnetate
Stomach > Thyroid (some sources say colon)
245
Probable Critical Organ
Tc - Sestamibi
Proximal Colon
246
Probable Critical Organ
Tc - Heat Treated RBC
Spleen > Heart
247
Probable Critical Organ
Tagged RBC - MUGA
Heart
248
Probable Critical Organ
Tc - MAA
Lung
249
Probable Critical Organ
Tc - DMSA
Renal Cortex
250
Probable Critical Organ
Tc - MAG 3
Bladder
251
Probable Critical Organ
DTPA
Bladder
252
Probable Critical Organ
1-123 M1BG
Bladder (some sources say adrenal medulla)
253
Probable Critical Organ
1-131 M1BG
Liver (some sources say adrenal medulla)
254
Probable Critical Organ
1-131,1-123
Thyroid
255
Probable Critical Organ
In-111 WBC
Spleen
256
Probable Critical Organ
In-111 ProstaScint
Liver
257
Probable Critical Organ
In-111 Octreoscan
Spleen
258
Probable Critical Organ
Thallium 201
Renal Cortex
259
Probable Critical Organ
F I8 FDG
Bladder
260
Probable Critical Organ
Gallium
Distal Colon
261
Probable Critical Organ
HIDA
Gallbladder Wall
262
Mechanism o f Localization
Tc - Sestamibi
Passive Diffusion
Cross the cell membrane via lipophilic
diffusion
263
Mechanism o f Localization
Tc - Tetrofosmin
Passive Diffusion
Cross the cell membrane via lipophilic
diffusion
264
Mechanism o f Localization
Tc - HMPAO
Passive Diffusion
Delivery is flow related - then diffuse into
brain
265
Mechanism o f Localization
Tc - ECD
Passive Diffusion
Delivery is flow related - then diffuse into
brain
266
Mechanism o f Localization
DTPA
Filtration
267
Mechanism o f Localization
F18-FDG
Facilitated Diffusion
Carrier mediated transport across membrane
via GLUT
268
Mechanism o f Localization
1-123,1-131
Active Transport
Use ATP to move AGAINST concentration gradient
269
Mechanism o f Localization
Thallium
Active Transport (Na/K Pump)
270
Mechanism o f Localization
Rubidium
Active Transport (Na/K Pump)
271
Mechanism o f Localization
M1BG
```
Active Transport (Na facilitated
norepinephrine uptake system)
```
272
Mechanism o f Localization
DMSA
Active Transport
273
Mechanism o f Localization
Pertechnatate
Secretion
Active transport OUT of a gland or tissue
274
Mechanism o f Localization
MAG-3
Secretion
Secreted by peritubular capillaries
275
Mechanism o f Localization
Tc-99m IDA
Secretion
Secreted by hepatocytes
276
Mechanism o f Localization
Sulfur Colloid
Phagocytosis
RES eats the colloid particles
277
Mechanism o f Localization
Heat Treated RBCs
Sequestration
278
Mechanism o f Localization
MAA
Capillary Blockade
Lung Perfusion
279
Mechanism o f Localization
MDP
Chemisorption
Chemical Covalent + Hydrogen Bonding
280
Mechanism o f Localization
SM -153
Chemisorption
281
Mechanism o f Localization
Indium WBC
Cellular Migration
Cells migrate to the response of stimuli
282
Mechanism o f Localization
Octreotide
Receptor Binding
283
Mechanism o f Localization
| DAT Scan
1-123 Isoflupane
Receptor Binding
284
Tumors that are PET COLD
BAC (Adeno In Situ) - Lung Cancer
carcinoid
rcc
peritoeal bowlel/liver implants
anything mucinous
prostate
285
Not Cancer but PET HOT
infection
inflammation
ovaries in follicular phase
muscles
brown fat
thymus
286
FDG PET - Brain
alzheimer
Low posterior
temporoparietal cortical
activity
Identical to Parkinson
Dementia
287
FDG PET - Brain
multi infarct
Scattered areas o f decreased
| activity
288
FDG PET - Brain
dementia with lewy bodies
Low in lateral occipital
cortex
Preservation o f the mid
posterior cingulate gyrus
(Cingulate Island Sign)
289
FDG PET - Brain
picks/frontotemporal
low in frontal lobe
290
FDG PET - Brain
huntingtons
low activity in caudate nucleus and putamen
291
Tc DTPA
overview
Filtered (GFR)
Good For Native Kidneys with
Normal Renal Function
Critical Organ Bladder
292
Tc MAG 3
overview
Secreted (ERPF)
Concentrated better by kidneys
with poor renal function
Critical Organ Bladder
293
Tc GH
overview
filtered
Good for dynamic and cortical
imaging.
critical organ bladder
294
ATN
Immediate Post OP
(3-4 days post op)
Perfusion Normal
Excretion Delayed
295
Cyclosporin Toxicity
Long Standing
Perfusion Normal
Excretion Delayed
296
Acute Rejection - renal
immediate post op
poor perfusion
excretion delayed
297
Tc WBC vs In WBC
Tc WBC: renal and GI
| ln WBC: no renal or gi
298
Localization indium wbc
spleen
299
Localization indium wbc damaged
liver and bone marrow
300
Localization rbc tagged
heart
301
Localization rbc damaged
spleen
302
Tc WBC 4 hours
lung
303
Tc WBC 24 hours
lunc clear
bowel starting
304
Indium is BETTER than Gallium
| for Evaluating
Suspected abdominal-pelvic abscess due
to the lack o f a normal bowel excretory
pathway
305
Gallium is BETTER than Indium
| for Evaluating
```
• Spine
• Diffuse Pulmonary Processes: Gallium is
probably the agent o f choice for the
evaluation o f pulmonary inflammatory
abnormalities.
• Lymphocyte mediated infection
```
306
Tc HMPAO is BETTER than In WBC
| for Evaluating
```
• Children (lower Dose)
• Inflammatory Bowel - *but you have to
image early - like around an hour {or 30
mins - depending on who you ask).
• Osteomyelitis in Extremity
```
307
In WBC is BETTER than Tc HMPAO
| for Evaluating
fouo
308
Neuro toxo
ring enhancing
hemorrhage more common after treatment
thallium cold
pet cold
mr perfusion: decreased CBV
309
Lymphoma neuro
ring enhancing
hemorrhage less common after treatment
thallium hot
pet hot
mr perfusion: increased or decreased CBV
310
MR
AIDS
Encephalitis
Symmetric T2
| Bright
311
MR
PML
Asymmetric T2
Bright
T1 dark
312
MR
CMV
periventricular t2 bright
ependymal enhancement
313
MR
Toxo
ring enhancement
thallium cold
314
MR
Cryptococcus
dilated perivascular spaces
basilar meninginitis
315
Neuro Trivia
| nf1
Optic Nerve Gliomas
316
Neuro Trivia
| nf2
MSME; Multiple Schwannomas, Meningiomas, Ependymomas
317
Neuro Trivia
| vhl
Hemangioblastoma (brain and retina)
318
Neuro Trivia
| ts
Subependymal Giant Cell Astrocytoma, Cortical Tubers
319
Neuro Trivia
| nevoid basal cell syndrome (gorlin)
Medulloblastoma
320
Neuro Trivia
| turcot
GBM, Medulloblastoma
321
Neuro Trivia
| cowdens
Lhermitte-Dulcos (Dysplastic cerebellar gangliocytoma)
322
Maximum B le ed in g -A n eu r y sm Location
ACOM
Interhemispheric Fissure
323
Maximum B le ed in g -A n eu r y sm Location
PCOM
Ipsilateral Basal Cistern
324
Maximum B le ed in g -A n eu r y sm Location
MCA trifurcation
Sylvian Fissure
325
Maximum B le ed in g -A n eu r y sm Location
Basilar Tip
Interpeduncular Cistern, or Intraventricular
326
Maximum B le ed in g -A n eu r y sm Location
PICA
Posterior Fossa or Intraventricular
327
Neuro
Inverting Papilloma
Demographics: 40-70
M>F (4:1)
```
Typical Location: Lateral nasal wall
centered at the middle
meatus, with
occasional extension
into the antrum
```
```
Trivia: 40% show
"entrapped bone"
Cerebriform
Pattern
10% Harbor a
Squamous Cell
CA
```
Imaging Characteristics: Cerebriform Pattern
May have focal
hyperostosis on CT
328
Neuro
Esthesioneuroblastoma
Demographics: Bimodal 20s &
60s
Typical Location: Dumbbell shaped with
waist at the cribiform
plate
Imaging Characteristics: AVID homogeneous
enhancement
329
Neuro
SNUC
Demographics: Broad Range
(30s-90s)
Typical Location: Ethmoid origin more
common than
maxillary
Trivia: Large, typically >
4cm on
presentation
```
Imaging Characteristics: Fungating and
Poorly defined
Heterogeneous
enhancement with
necrosis
```
330
Neuro
Squamous Cell CA
Demographics: 95% > 40 years
old
Typical Location: Maxillary Antrum is
involved in 80%
Trivia: Most Common
Malignancy of
Sino-Nasal track
```
Imaging Characteristics: Aggressive Antral Soft
Tissue Mass, with
destruction of sinus
walls Low signal
on T2 (highly
cellular)
Enhances less than
some other sinus
malignancies
```
331
Neuro
JNA
(Juvenile
Nasopharyngeal
Angiofibroma)
```
Demographics: Nearly
Exclusively
Male
Rare < 8 or >
25
```
Typical Location: Origin in the
Spenopalantine
Foramen (SPF)
Trivia: Radiation alone
cures in 80%
```
Imaging Characteristics: Enhancing mass
arising from the SPF
in adolescent male
Dark Flow Voids on
Tl
Avidly Enhances
```
332
Neuro
Sinonasal Lymphoma
Demographics: Usually older,
peak is 60s
Typical Location: Nasal Cavity >
Sinuses
Trivia: Highly variable
appearance
```
Imaging Characteristics: Homogeneous mass in
nasal cavity with bony
destruction
Low Signal on T2
(highly cellular)
```
