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Compendium
1. CRITICAL DIAGNOSES
Pulmonary Embolism
73M with pulsatile abdominal mass on
physical exam and known history of
peripheral vascular disease status post Above
the Knee Amputation (AKA) (and previously
known infrarenal AAA to 6.6 cm).
Findings:
Aneurysmal AAA,
up to 8.0 x 9.0 cm
distally with
extensive mural
thrombus
What imaging
modality would you
order next?
Findings:
CTA I- and I+ images
demonstrating:
Abdominal Aortic Aneurism
measuring up to 10 cm,
enlarged
Extensive mural thrombus
with contrast filled lumen
measuring ~ 2 cm.
No evidence of dissection
diaphragm
Radiographic Findings: widened mediastinum, left apical cap
CT findings: hyperdense intramural hematoma on noncontrast images, displaced intimal
calcifications intraluminally, intimal flap (True vs False lumen with false lumen usually
larger and with delayed filling of contrast as seen on bolus images).
55M POD #1 s/p orthopedic procedure, with
sudden onset dyspnea, tachycardia to 130s
and desaturation to 80%
What is your first imaging examination of
choice?
Findings:
Single, portable, semi-upright chest radiograph
demonstrating no acute findings.
Clear lungs; no pneumothorax, pleural effusion,
pneumonia, or lobar atelectasis. The
cardiomediastinal silhouette is within normal limits
given portable technique.
Definition: Embolization of thrombi to the pulmonary arteries, usually from deep veins
in lower extremities or pelvis
Radiographic findings: usually normal chest; rarely see wedge-shaped pulmonary
infarcts (Hampton hump: Pleural-based, cone-shaped opacity pointing toward the
hilum); focal areas of oligemia (Westermark sign).
CTPA findings:
direct visualization of the thrombus (with central dark filling defects surrounded by
contrast usually indicative of acute PE; eccentric and adherent to the vessel wall clot
and webs indicative of chronic clot burden), evaluation for right heart strain (i.e.
leftward bowing of the interventricular septum as the RV enlarges)
Standard of care
Nuclear Medicine: V/Q scan
Indirect indicator of clot; does not directly visualize the clot, only the disruption of
vascular perfusion.
Combined with clinical Wells Criteria Score to assess propability.
Used for patients with contraindications to CTPA (contrast allergy, renal failure, and
in some institutions in pregnant females)
2. CHEST
Pneumothorax
Lung Collapse / Atelectasis
Hyperinflation of lungs
pt has emphysema with Pneumothorax (air in
bullae pleural space)
After chest tube placement
Residual
pneumothorax
Chest tube
Minor fissure
Inferior/anterior portion
of major fissure
R subclavian
central line ends
in SVC
Dobhoff tubes are used for tube feeds you want the liquid
to go in the stomach, not the lungs
83M in ICU s/p VFIB and resuscitation
Endotracheal
Right internal
tube
jugular central
line ends in
SVC
Enteric tube
Pneumonia
45 year old female with 15 pound
unintentional weight loss and cough.
How would you describe the abnormality?
Do you need further imaging? If so, what would you
recommend?
Findings:
No lymphadenopathy by CT
size criteria.
Path:
Pulmonary adenocarcinoma.
65 year old male with shortness
of breath.
How would you describe the salient findings?
FINDINGS:
There is an opacity in the right lower
lung zone, tracking up the right chest
wall with blunting of the right
costophrenic angle and a meniscus.
Pleural Effusion
Will show blunting of the costophrenic angle in an
upright chest xray.
200cc needed to show blunting of the lateral
costophrenic angle
50cc needed to show blunting of the posterior
costophrenic angle.
Colorectal Cancer
GI bleed
Diverticulitis
Appendicitis
52M with abdominal distension
Findings
No gas in the left lower quadrant where you
would expect to see the descending colon
Disadvantages:
Accuracy is not high for slow chronic bleeding.
If ordered after all other evaluations are negative and
bleeding has slowed or stopped, accuracy is poorer.
Nuclear Medicine GI Bleeding Scan
Bladder
47 min
Findings
Right upper quadrant bleed following the
course of the colon, starts to appear at 17-20
minutes.
Haustra
1. Air fluid levels from bowel stasis
2. Dilated haustra & colon (>9 cm)
Findings
Large bowel obstruction at the level of the
sigmoid colon
Dilated loops,
Stacking. Notice the
stagnant stool in the
small bowel is starting
to fecalize or become
more solid
Stomach
dilated. Place an NG
Tube to decompress.
Q: What is going
on in the liver?
A: There is abnormal
air in the liver.
a.Hepatic veins
vein
b.Portal veins
vein
c.Biliary tree
d.Liver parenchyma
Technical
Parameters
for image
acquisition
Zone of
optimum
Focus
Depth in cm
From skin
Type of US
probe used
Techs initials
Skin
Anterior
Liver
Head Feet
Posterior
Gallbladder
Sagittal
Same patient. Diagnosis?
Findings
Stones in the gallbladder on ultrasound
Shadow deep to gallbladder due to lack of
signal from reflected ultrasound waves.
Why does it reflect? Stones are dense!
String of pearl appearance of stones on xray
Note that the laminated appearance of the
stones: peripherally dense and centrally lucent
Cholelithiasis
If unsure on ultrasound, move the patient to
watch the gallstones fall dependently!
Nephrolithiasis
Intrauterine and ectopic Pregnancy
34 y/o F, R flank pain
Why are the right kidney
findings present?
What are the findings?
US: Right hydronephrosis (large right renal
pelvis w/blunted calyces outlined in
yellow; compare to normal left kidney with
bright echogenic fatty renal hilum but no
enlarged pelvis/calyces, surrounded by the
darker normal renal parenchyma). Also
right hydroureter (lack of color Doppler
flow in large anechoic tubular structure in
green therefore obstructed dilated ureter,
not vessel)
Reason for the right
hydroureter/hydronep
hrosis?
A right 1.7 cm
calculus in the right
mid ureter
Gestational sac (in yellow) in the uterus (in red)Double decidual sac
with yolk sac with two echogenic ring
And fetal pole (crown-rump length corresponding
to gestational age of 6w 3d, with normal FHR
6. BRAIN AND SPINE
subarachnoid hemorrhage
Stroke
Normal C spine
C- spine: dens
C spine: Obliques
Alignment
60F after fall
I
Dens (C2)
Fracture patterns III
II
Type II: Unstable fracture. Most likely to have non-union due to tenuous blood supply.
C2 C2
C4
C4
C6 C6
C-spine fracture Key Points
Metastasis
Infection
Normal L Spine
Part 2: Hemorrhage
What type of bleed?
Subdural Hematoma
(SDH)
Typically venous
bridging vein tear in
extra-axial space
Elderly
SDH
EDH
Often spontaneous or low
trauma
Crescentic
Suture line
Subdural hematoma
Subarachnoid hemorrhage
SAH
Can be diffuse or focal
Intraparenchymal Hemorrhage
Subarachnoid Hemorrhage
What type of bleed?
Epidural Hematoma
EDH
Suture line
(e.g. coronal)
Epidural Hematoma
Typically arterial
usually middle meningeal
artery AND post traumatic
ie. Younger patient
Most temporal or
temporoparietal lobes
Answer:
Swirl Sign:
Hypoattenuating (darker)
area within bleed indicates
non-clotted blood, ie active
bleed
SDH can and do cross sutures but do not cross midline (instead SDH layers along
the falx or tentorium)
85 y/o F, p/w
acute weakness and speech difficulty
DWI ADC FLAIR
What are the findings?
Ulnar Subluxation
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22 YO F fell on
outstretched hand
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Colles Fracture
Caused by a fall on an outstretched hand
(FOOSH)
Fracture of the distal radius and often ulnar
styloid process
Classically a transverse fracture of the radius
Dorsal angulation of the distal forearm and wrist
One of the most common forearm fractures
Commonly seen in osteoporosis
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Dorsal angulation
Transverse Fracture of of the distal
the distal radius fragment with
overlap /
foreshortening.
33 YO F w/ Arm Pain
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Smith Fracture
(Reverse Colles)
Radial Head Fx
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Glenoid
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Anterior Posterior
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Dislocation
Significantly less common than Anterior
Shoulder dislocation (2-4%)
Caused by axial loading of an adducted and
internally rotated arm, convulsion disorder or
electroshock therapy
Cresent Sign AP view of a normal shoulder
reveals overlap of the humeral head and glenoid
Posterior dislocation results in a loss of the cresent
sign creating an absence of the bony overlap
light bulb Sign: Humeral head is fixed in
internal rotation
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Acromion Process
Reverse Hill-Sachs
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Glenoid
CASE 1
Findings
Progressive osteolysis of the lateral
tibial plateau and lateral femoral
condyle.
9 YO MALE ARRIVED FROM HAITI WITH UNEXPLAINED
RIGHT KNEE PAIN/SWELLING
CASE 2
Cortical
breakthroug
h
Endosteal
scalloping
Periostea
l reaction
Findings
Multiple lytic lesions in the femoral diaphysis and distal
femoral metaphysis with regions of sclerosis and multiple
layers of periosteal reaction. Endosteal scalloping is
noted.
There are a few foci of apparent cortical breakthrough into
the adjacent soft tissues, including the posterior distal femoral
diaphysis (best seen on the lateral views of the knee and
femur), the lateral femoral diaphyis at the same level, and the
medial femoral diaphysis more proximally, near the junction of
the middle and distal femoral diaphyseal thirds.
Concerning for right femoral chronic osteomyelitis
T2 hyperintense (shown) and T1 hypointense (not
shown)
68 YO F WITH PULMONARY NODULES ON PRIOR CT, PAIN,
WEIGHT LOSS, AND HISTORY OF RECURRENT MRSA
BACTEREMIA
CASE 3
Findings
Destructive changes centered at the T10-T11
disc level with disruption of the inferior
endplate of T10 and superior endplate of T11
and associated lucency in the T10 and T11
vertebral bodies
Soft tissue density at the T10/T11 level which
abuts the descending thoracic aorta.
Anterior wedge compressive deformity of the
T11 vertebral body. These findings are
consistent with T10/T11 disciitis/osteomyelitis.
GENERAL CHARACTERISTICS
Inflammation of the bone that is almost always due to
infection, typically bacterial
Hematogenous spread in most cases, although direct
extension from trauma/ulcers is also common
Earliest changes are seen in adjacent soft tissues +/-
muscle outlineswith swelling and loss or blurring of
normal fat planes.
In general, osteomyelitis must extend at least 1 cm
and compromise 30 to 50% of bone mineral content to
produce noticeable changes in plain radiographs.
Early findings may be subtle, and changes may not be
obvious until 5 to 7 days in children and 10 to 14 days
in adults.
RADIOGRAPHIC FEATURES
regional osteopenia
periosteal reaction/thickening
focal bony lysis
endosteal scalloping
loss of bony trabecular architecture
new bone apposition
eventual peripheral sclerosis
In chronic or untreated cases, eventual
formation of a sequestrum, involucrum or
cloaca may be seen.
For your interest only:
Breast Cancer
Lumbar disc disease
Abdominal trauma
45 year old female with palpable
breast lump.
MAG View
There is a cluster of
microcalcifications in the left
mid breast. (hard to see, I
know).
L5
S1
Lumbar disc disease
L5
S1
T1 weighted
T1 weighted T2 weighted
Extravasated rectal
contrast centered around
the splenic flexure, in
the region of the
visualized stab wound,
indicative of bowel
laceration
Discussion: Acute Abdominal Trauma
CT is the imaging modality of choice for diagnosis of intra-abdominal injury after blunt or penetrating
abdominal trauma, and is especially valuable when physical examination is unreliable (i.e. stuporous
patient) or equivocal.
CT is usually obtained for patients with significant abdominal trauma who are hemodynamically stable.
CT is performed WITH intravenous contrast, but WITHOUT oral contrast (at least in our institution).
Rectal contrast (in addition to IV) is reserved for cases with penetrating abdominal trauma (GSW,
stabbing). Delayed images may be obtained for evaluation of injury to the collecting system (higher level
of suspicion in setting of pelvic fractures) or to evaluate vascular injury and possibility of active vascular
extravasation.
Possible CT findings in the setting of acute abdominal trauma may include:
Solid abdominal organ lacerations Splenic, liver, renal lacerations. These are usually linear areas
of hypodensity, potentially with surrounding fluid or hematoma. It is important to evaluate delayed
images for adjacent hyperdense foci which may represent active extravasation of intravenous
contrast (implies vascular injury), as this needs to be treated surgically. Shattered organs
demonstrated multiple lacerations and may demonstrate hypodense regions from devascularization
injury.
Hemoperitoneum hyperdense fluid within the abdomen or pelvis, often ~ 30-45 HU. This is not
specific to any one particular injury, but a very hyper dense focal collection of fluid (sentinel clot)
can guide to the injured organ.
Pneumoperitoneum- nonspecific finding which may be due to bowel laceration in penetrating trauma,
barotrauma, etc.
Free contrast in peritoneal cavity may be seen with extravasation of rectal contrast through bowel
perforation as seen in above case or from leakage of contrast-opacified urine from the urinary tract.